NHP-2015 V

1 Goal:
The attainment of the highest possible level of good health and well-being, through a
preventive and promotive health care orientation in all developmental policies, and universal
access to good quality health care services without anyone having to face financial hardship as a
consequence.

3.2.Key Policy Principles:
Equity: Public expenditure in health care, prioritizing the needs of the most vulnerable, who
suffer the largest burden of disease, would imply greater investment in access and financial
protection measures for the poor. Reducing inequity would also mean affirmative action to
reach the poorest and minimizing disparity on account of gender, poverty, caste, disability,
other forms of social exclusion and geographical barriers.

Universality: Systems and services are designed to cater to the entire population- not only a
targeted sub-group. Care to be taken to prevent exclusions on social or economic grounds.
Patient Centered & Quality of Care: Health Care services would be effective, safe, and
convenient, provided with dignity and confidentiality with all facilities across all sectors being
assessed, certified and incentivized to maintain quality of care.

Inclusive Partnerships: The task of providing health care for all cannot be undertaken by
Government, acting alone. It would also require the participation of communities – who view
this participation as a means and a goal, as a right and as a duty. It would also require the
widest level of partnerships with academic institutions, not for profit agencies and with the
commercial private sector and health care industry to achieve these goals.

Pluralism: Patients who so choose and when appropriate, would have access to AYUSH care
providers based on validated local health traditions. These systems would also have Government support and supervision to develop and enrich their contribution to meeting the
national health goals and objectives. Research, development of models of integrative practice,
efforts at documentation, validation of traditional practices and engagement with such
practitioners would form important elements of enabling medical pluralism.
Subsidiarity: For ensuring responsiveness and greater participation, increasing transfer of
decision making to as decentralized a level as is consistent with practical considerations and
institutional capacity would be promoted. (Nothing should be done by a larger and more
complex organization which can be done as well by a smaller and simpler organization.)
Accountability: Financial and performance accountability, transparency in decision making,
and elimination of corruption in health care systems, both in the public systems and in the
private health care industry, would be essential.
Professionalism, Integrity and Ethics: Health workers and managers shall perform their
work with the highest level of professionalism, integrity and trust and be supported by a
systems and regulatory environment that enables this.
Learning and Adaptive System: constantly improving dynamic organization of health care
which is knowledge and evidence based, reflective and learning from the communities they
serve, the experience of implementation itself, and from national and international knowledge
partners.
Affordability: As costs of care rise, affordability, as distinct from equity, requires emphasis.
Health care costs of a household exceeding 10% of its total monthly consumption expenditures
or 40% of its non-food consumption expenditure- is designated catastrophic health
expenditures- and is declared as an unacceptable level of health care costs. Impoverishment
due to health care costs is of course, even more unacceptable.

3.3.Objectives:3.3.1. Improve population health status through concerted policy action in all sectors and
expand preventive, promotive, curative, palliative and rehabilitative services provided by the
public health sector.
3.3.2. Achieve a significant reduction in out of pocket expenditure due to health care costs and
reduction in proportion of households experiencing catastrophic health expenditures and
consequent impoverishment.
3.3.3. Assure universal availability of free, comprehensive primary health care services, as an
entitlement, for all aspects of reproductive, maternal, child and adolescent health and for the
most prevalent communicable and non-communicable diseases in the populationEnable universal access to free essential drugs, diagnostics, emergency ambulance
services, and emergency medical and surgical care services in public health facilities, so as to
enhance the financial protection role of public facilities for all sections of the population.
3.3.5. Ensure improved access and affordability of secondary and tertiary care services through
a combination of public hospitals and strategic purchasing of services from the private health
sector.
3.3.6. Influence the growth of the private health care industry and medical technologies to
ensure alignment with public health goals, and enable contribution to making health care
systems more effective, efficient, rational, safe, affordable and ethical. .

EXPENDITURE
The National Health Policy accepts and endorses the understanding that a full achievement of
the goals and principles as defined would require an increased public health expenditure to 4 to
5% of the GDP. However, given that the NHP, 2002 target of 2% was not met, and taking
into account the financial capacity of the country to provide this amount and the institutional
capacity to utilize the increased funding in an effective manner, this policy proposes a
potentially achievable target of raising public health expenditure to 2.5 % of the GDP. It also
notes that 40% of this would need to come from Central expenditures. At current prices, a
target of 2.5% of GDP translates to Rs. 3800 per capita, representing an almost four fold
increase in five years. Thus a longer time frame may be appropriate to even reach this modest
target.
4.1.2. The major source of financing would remain general taxation. With the projection of a
promising economic growth, the fiscal capacity to provide this level of financing should
become available. The Government would explore the creation of a health cess on the lines of
the education cess for raising the necessary resources. Other than general taxation, this cess
could mobilise contributions from specific commodity taxes- such as the taxes on tobacco, and
alcohol, from specific industries and innovative forms of resource mobilization. Extractive
industries and development projects that result in displacement, or those that have negative
impacts on natural habitats or the resource base can be considered for special taxation thereby
allowing investment and job opportunities in education and health for affected communities.
4.1.3. Since about 50% of health expenditure goes into human resources for health, an equitous
growth of health and education sectors would also lead to increased employment in many areas
and communities, which do not otherwise benefit from the economic growth rate, particularly
where jobless growth is a phenomenon. High public investment in health care is one of the
most efficient ways of ameliorating inequities, and for this reason, this commitment to higher

public expenditures is essential. 

India lost 66 wild tigers in 2014

Tamil Nadu with 15 had the highest number of deaths

: Sixty-six wild tiger deaths were reported in the country in 2014. Two tiger deaths occurred on the last day of the year. It was the only day in 2014 when two wild tiger deaths were reported. One was at Bandipur in Karnataka and the other at Tadoba Andhari in Maharashtra.

As per statistics provided by Tigernet, the official database of the National Tiger Conservation Authority, the highest number of wild tiger deaths was reported from the forests of Tamil Nadu —15, followed by Madhya Pradesh —14. Six of the deaths in Tamil Nadu were from the Mudumalai Tiger Reserve.

The majority of wild tiger deaths was caused by poaching. The data do not give a clear figure on the number of tigers killed by poachers, but it is estimated that about 50 tigers could have been killed in this manner.

Of the 66 deaths, only one death was due to natural causes — reported from the Valmiki Tiger Reserve, Bihar. Fights between tigers, possibly for territory control, caused three deaths.

Two tigers, suspected to be man-eaters, were shot dead by police personnel. One was near Udhagamandalam on January 23 and the other near Chandrapur in Maharashtra on July 19

In the Valmiki Tiger Reserve, one cub was found dead. Wild tiger deaths were also reported from Andhra Pradesh, Assam, Kerala, Karnataka and Uttarakhand. Thirty-two deaths were reported in the first six months of the year.

The highest number of deaths was in December — 10. Wild tiger deaths had taken place during all months of the year. The first tiger death of the year was reported from the Melghat Tiger Reserve in Maharashtra on January 10.

During the year, 12 cases of seizure of tiger parts were registered. This included seizure of seven tiger skins. While three tiger skins were seized from Maharashtra, two were seized from Andhra Pradesh and one each from Tamil Nadu and Kerala.

In 2013, the number of wild tiger deaths was 63 and the highest number was reported from the forests of Karnataka —16, followed by Maharashtra, 9.

Nuclear logjam: India, U.S. to work on new proposals

Revised insurance scheme to reduce suppliers’ risk

Indian and U.S. officials are expected to meet in Delhi next week to discuss two proposals made by India to clear the nuclear logjam, with an added push coming from U.S. President Obama’s impending visit on January 24.

The Hindu has learnt that the proposals were put forward during the first contact group meeting on civil nuclear issues held on December 16-17 that had been tasked by President Obama and Prime Minister Modi with finding a way around U.S. objections to India’s supplier liability law.

According to one official present at the meeting, India put up a revised proposal of an “insurance pool” using General Insurance Company (GIC) to alleviate the risk to U.S. suppliers. An earlier proposal had been made during the UPA government’s tenure in March 2014, but had been rejected. Officials say the new offer would include a pool of GIC, New India Assurance, Oriental Insurance, National Insurance and United India, that would generate a risk cover of about $242 million.

A second proposal, that U.S. officials have taken back to discuss with lawyers and representatives of American companies GE-Hitachi and Westinghouse, would entail a “clarification of Section 46” of the law that has been described as “vague” . At present, Section 46 says that nothing in the law will “exempt the operator from any proceeding which might, apart from the act, be instituted against the operator.” This has been read to mean that U.S. suppliers could face tort claims, that is, be sued by victims of an accident where the nuclear parts are deemed faulty. U.S. officials will bring both proposals back to Delhi next week.

India’s proposals to U.S. face resistance

U.S. officials have said they were “hopeful” of some movement in the nuclear deal that has been hanging fire since it was signed in 2008. Although India has allotted project sites for two 1000 mw nuclear reactors each by U.S. companies Westinghouse and GE-Hitachi in Gujarat and Andhra Pradesh respectively, no work has started on either.

Indian and U.S. officials are expected to meet in Delhi next week to discuss two proposals made by India to clear the nuclear logjam. India put up a revised proposal of an “insurance pool” to reduce the risk to U.S. suppliers. A second proposal would entail a “clarification of Section 46” of the law on supplier liability that has been described as “vague.”

R.K. Sinha, Chairman of India's Atomic Energy Commission, told Reuters agency last month that India was working fast to address the concerns of suppliers.

“We are working on a solution with the insurance companies.” A similar pool is available to nuclear operators in the U.S., under the ‘Price-Anderson’ act. But India’s liability law includes suppliers as well.

While the insurance pool proposal would help Indian nuclear parts suppliers like L&T, Gammon and BHEL, officials said U.S. company representatives present at the contact group meeting in December found the insurance pool proposal “inadequate” as it would accept supplier liability that the U.S. says is in contravention of the International Convention on Supplementary Compensation.

Former nuclear officials, who have vocally protested any “dilution” of the supplier liability law, say the second proposal may run into trouble in India. “There can be no side arrangement with the U.S.,” former Atomic Energy Regulatory Board Chairman A. Gopalakrishnan told The Hindu. “If any clarification on Section 46 is to the U.S.’s satisfaction, it will certainly be violation of India’s act.”

Mr. Gopalakrishnan also questioned why Indian officials were proposing solutions to the logjam at all. “Why all the eagerness to procure American reactors, some of which like GE’s 1000 MW reactor haven’t been used anywhere else? Indian reactors already developed, like the 700 MWe heavy water reactors, could easily be scaled up to similar capacities.”

Publicly Financed Health Insurance:

A number of publicly financed health insurance schemes were introduced to improve access to
hospitalization services and to protect households from high medical expenses. Eight states
introduced health insurance programmes for covering tertiary care need and over time as
expenditures increased, many of these States (Andhra Pradesh, Karnataka, Tamilnadu,
Maharashtra, etc.) moved to direct purchasing of care through Trusts and reserving some
services to be delivered only through public hospitals. The Central Government under the
Ministry of Labour & Employment, launched the Rashtriya Swasthya Bima Yojana (RSBY) in
2008. The population coverage under these various schemes increased from almost 55 million
people in 2003-04 to about 370 million in 2014 (almost one-fourth of the population). Nearly
two thirds (180 million) of this population are those in the Below Poverty Line (BPL) category.
Evaluations show that schemes such as the RSBY, have improved utilization of hospital services,
especially in private sector and among the poorest 20% of households and SC/ST households.
However there are other problems. One problem is low awareness among the beneficiaries
about the entitlement and how and when to use the RSBY card. Another is related to denial of
services by private hospitals for many categories of illnesses, and over supply of some services

Some hospitals, insurance companies and administrators have also resorted to various fraudulent
measures, including charging informal payments. Schemes that are governed and managed by
independent bodies have performed better than other schemes that are located in informal cells
within existing departments or when managed by insurance companies. The insurance schemes
vary widely in terms of benefit packages and have resulted in fragmentation of funds available
for health care; especially selective allocation to secondary and tertiary care over primary care
services. All National and State health insurance schemes need to be aligned into a single
insurance scheme and a single fund pool reducing fragmentation. The RSBY scheme has now
been shifted to the Ministry of Health & Family Welfare, helping the State and Central Ministry
move to a tax financed single payer system approach. The Ministry could now compare the
relative costs per patient for alternative routes of financing viz. purchase through insurance, or
direct purchase from private sector and from public sector or free care by public sector as a form
of tax based financing, and take the best decision for a given context.

Investment in Health Care:

Despite years of strong economic growth and increased Government health spending in the
11th Five Year plan period, the total spending on healthcare in 2011 in the country is about
4.1% of GDP. Global evidence on health spending shows that unless a country spends at least
5–6% of its GDP on health and the major part of it is from Government expenditure, basic
health care needs are seldom met. The Government spending on healthcare in India is only
1.04% of GDP which is about 4 % of total Government expenditure, less than 30% of total
health spending. This translates in absolute terms to Rs. 957 per capita at current market prices.
The Central Government share of this is Rs. 325 (0.34% GDP) while State Government share
translates to about Rs. 632 on per capita basis at base line scenario. Perhaps the single most
important policy pronouncement of the National Health Policy 2002 articulated in the 10th
, 11th
and 12th Five Year Plans, and the NRHM framework was the decision to increase public health
expenditure to 2 to 3 % of the GDP. Public health expenditure rose briskly in the first years of
the NRHM, but at the peak of its performance it started stagnating at about 1.04 % of the
GDP. The pinch of such stagnation is felt in the failure to expand workforce, even to train and
retain them. This reluctance to provide for regular employment affects service delivery,
regulatory functions, management functions and research and development functions of the
Government. Though there is always space to generate some more value for the money
provided, it is unrealistic to expect to achieve key goals in a Five Year Plan on half the
estimated and sanctioned budget. The failure to attain minimum levels of public health
expenditure remains the single most important constraint. While it is important to recognize
the growth and potential of a rapidly expanding private sector, international experience (as
evidenced from the table below) shows that health outcomes and financial protection are
closely related to absolute and relative levels of public health expenditure.
Country Total Health Exp per
capita (USD) - 2011

Country Total Health Exp per
capita (USD) - 2011
Total Health Exp as %
of GDP - 2011
Govt. Health Exp as
% of Total Health Exp
- 2011
Life Expectancy at
birth (years) 2012
India $62 3.9% 30.5% 66
Thailand $214 4.1% 77.7% 75
Sri Lanka $ 93 3.3% 42.1% 75
BRIC Countries
Brazil $ 1119 8.9% 45.7% 74
China $ 274 5.1% 55.9% 75
Russia $803 6.1% 59.8% 69
South Africa $670 8.7% 47.7% 59
OECD Countries
USA $ 8,467 17.7% 47.8% 79
United Kingdom $ 3,659 9.4% 82.8% 81
Germany $ 4,996 11.3% 76.5% 81
France $ 4,968 11.6% 76.8% 82
Norway $ 9,908 9.9% 85.1% 82
Sweden $ 5,419 9.5% 81.6% 82
Denmark $ 6,521 10.9% 85.3% 80
Japan $ 4,656 10% 82.1% 84

NHP-2015IV

Developments under the National Rural Health Mission:
The National Rural Health Mission (NRHM) led to a significant strengthening of public health
systems. It brought in a workforce of close to 900,000 community health volunteers, the
ASHAs, who brought the community closer to public services, improving utilization of services
and health behaviors. The NRHM deployed over 18,000 ambulances for free emergency
response and patient transport services to over a million patients monthly, added over 178,000
health workers to a public system that had depleted its workforce to sub-critical levels over a
long period of neglect, provided cash transfers to over one crore pregnant women annually,
empowering and facilitating them to seek free care in the institutions and began to address
infrastructure gaps. Across States, there were major increases in outpatient attendance, bed
occupancy and institutional delivery. However these developments were uneven and more
than 80% of the increase in services is likely to have been contributed by less than 20% of the
public health facilities. Further, States with better capacity at baseline were able to take
advantage of NRHM financing sooner, while high focus States had first to revive or expand
their nursing and medical schools and revitalize their management systems. Larger gaps in
baselines and more time taken to develop capacity to absorb the funds meant that gaps
between the desired norms and actual levels of achievement were worse in high focus states.
Inefficiencies in fund utilization, poor governance and leakages have been a greater problem in
some of the weaker states. Much of the increase in service delivery was related to select
reproductive and child health services and to the national disease control programmes, and not
to the wider range of health care services that were needed. Action on social determinants of
health was even weaker.

The almost exclusive focus of policy and implementation often masks the fact that all the
disease conditions for which national programmes provide universal coverage account for less
than 10% of all mortalities and only for about 15% of all morbidities. Over 75% of
communicable diseases are not part of existing national programmes. Overall, communicable
diseases contribute to 24. 4% of the entire disease burden while maternal and neonatal ailments
contribute to 13.8%. Non-communicable diseases (39.1%) and injuries (11.8%) now constitute
the bulk of the country‟s disease burden. National Health Programmes for non-communicable
diseases are very limited in coverage and scope, except perhaps in the case of the Blindness
control programme.
2.8. NRHM as an instrument for strengthening state health systems:
The National Rural Health Mission was intended to strengthen State health systems to cover all
health needs, not just those of the national health programme. In practice, however, it
remained confined largely to national programme priorities. While such a limited scope
enabled progress in a few indicators, this was a poor strategy. Beyond a point, such selective
facility development is neither sustainable nor efficient. For example female sterilization
operations or surgery for Emergency Obstetrics Care is safest if performed in an operation
theatre, that is functional throughout the year, and undertaken by professional teams with
support systems that are in constant use. But if such operations are undertaken on a few days
per year, in a camp mode or during an occasional emergency sustaining the quality of care for
such sporadic events is much more difficult. Strengthening health systems for providing
comprehensive care required higher levels of investment and human resources than were made
available. The budget received and the expenditure thereunder was only about 40% of what
was envisaged for a full re-vitalization in the NRHM Framework.

Urban Health:
Rapid and unplanned urbanization has led to massive growth in the number of the urban poor
population, especially those living in slums. This section of the population has poorer health
outcomes due to adverse social determinants and poor access to health care facilities, despite
living in close proximity to many hospitals - public and private. There is almost no
arrangement for primary care in many cities and towns. The National Urban Health Mission,
sanctioned in 2013 has a strong focus on strengthening primary health care- through additional
ANMs, urban ASHAs, women‟s health committees and a network of primary health centers. A
technical resource group has examined the urban health situation at length and suggested
measures needed to address the most vulnerable and marginalized sections of the urban poor
and the way forward in convergence. NUHM needs substantial expansion of funding on a
sustained basis in order to establish and operationalize a well functional primary health care
system in the urban areas.

NHP-2015 III

Inequities in Health Outcomes:
While acknowledging these achievements we need to be mindful and confront the high degree
of health inequity in health outcomes and access to health care services as evidenced by
indicators disaggregated for vulnerable groups. There are urban-rural inequities and there are 5
inequities across states. (Table 1). A number of districts, many in tribal areas, perform poorly
even in those states where overall averages are improving. Marginalized communities and
poorer economic quintiles of the population continue to fare poorly. Outreach and service
delivery for the urban poor, even for immunization services has been inadequate.

Table 1 : Disparities in health outcomes:
Indicator India
Total Rural Urban % differential
TFR (2012) 2.4 2.6 1.8 44% difference
IMR (2012) 40 44 27 63% difference 

Concerns on Quality of Care:
The situation in quality of care is also a matter of serious concern and this seriously
compromises the effectiveness of care. For example though over 90% of pregnant women
receive one antenatal check up and 87 % received full TT immunization, only about 68.7 % of
women have received the mandatory three antenatal check-ups. Again whereas most women had
received iron and folic acid tablets, only 31% of pregnant women had consumed more than 100
IFA tablets. For institutional delivery standard protocols are often not followed during labour
and the postpartum period. Sterilization related deaths a preventable tragedy, are often a direct
consequence of poor quality of care. Only 61% of children (12 -23 months) have been fully
immunized. There are gaps in access to safe abortion services too, and in care for the sick
neonate.
2.5. Performance in Disease Control Programmes:
India‟s progress on communicable disease control is mixed. The most acclaimed success of
this period is the complete elimination of polio. In Leprosy too there have been significant
reductions, but after a reduction of an annual incidence of 120,000 cases, there is stagnation,
with new infective cases and disabilities being reported. Kala-azar and Lymphatic filariasis are
expected to decline below the threshold for certifying by 2015, but as in leprosy there are likely

to be Blocks where the prevalence is above this threshold. In many more Blocks, which have achieved elimination, continuing attention to identifying and managing low levels of disease
incidence is required for some time to come. In AIDS control, progress has been good with a
decline from a 0.41 % prevalence rate in 2001 to 0.27% in 2011- but this still leaves about 21
lakh persons living with HIV, with about 1.16 lakh new cases and 1.48 deaths in 2011. In
tuberculosis the challenge is a prevalence of close to 211 cases and 19 deaths per 100,000
population and rising problems of multi-drug resistant tuberculosis. Though these are
significant declines from the MDG baseline, India still contributes to 24% of all global new
case detection. In malaria there has been a significant decline, but there are also the challenges,
of resistant strains developing and of sustaining the gains, in a disease known for its cyclical
reemergence and focal outbreaks. Viral Encephalitis, Dengue and Chikungunya are on the
increase, particularly in urban areas and as of now we do not have effective measures to address
them. Performance in disease control programmes is largely a function and reflection of the
strengths of the public health systems. Where there are sub-critical human resource
deployment, weak logistics and inadequate infrastructure, all national health programmes do
badly. This was one of the important reasons of the launch of the National Rural Health
Mission, which was geared to strengthen health systems.