Health Planning with national health scenario

Health Planning in India
and
National Policies related to Health and Health Planning

NATIONAL HEALTH PLANNING
• Health planning is an integral part of national socio-economic
planning.
• “the orderly process of defining community health problems,
identifying unmet needs and surveying the resources to meet
them, establishing priority goals that are realistic and feasible
and projecting administrative action to accomplish the purpose
of the proposed programme”

• Guidelines for National Health Planning were provided by number of
committees, which are appointed by Government of India to review
the existing health situation and recommend measures for further
action.
• The Goal for National Health Planning in India was to attain
“Health for all by the year 2000”

1. Bhore Committee, 1946
2. Mudaliar Committee,1962
3. Chadah Committee , 1963
4. Mukerji Committee,1965
5. Mukerji Committee, 1966
6. Jungalwalla Committee,1967
7. Kartar Singh Committee,1973
8. Shrivastav Committee ,1975
9. Rural Health Scheme ,1977
10. Health for all by 2000 AD- Report of the working group,1981

BHORE COMMITTEE,1946
Sir Joseph Bhore as Chairman

BHORE COMMITTEE,1946
• The most comprehensive health policy and plan document ever
prepared in India was the `Health Survey and Development
Committee Report’ (1943) popularly referred to as the Bhore
Committee. Submitted report in 1946 (4 volumes)
• “if the nation’s health is to be built, the health programme
should be developed on a foundation of preventive health work
and that such activities should proceed side by side with those
concerned with treatment of patients.”
• It made comprehensive recommendations for remodelling of
health services in India.

Objectives:
• The services should make adequate provision for the medical care of
the individual in the curative and preventive fields and for the active
promotion of positive health;
• These services should be placed as close to the people as possible, in
order to ensure their maximum use by the community, which they are
meant to serve;
• The health organization should provide for the widest possible basis of
cooperation between the health personnel and the people;
• Provisions should be made for enabling the representatives of medical
and auxiliary professions to influence the health policy of the country.

5. “Group” practice, should be made available
– In view of the complexity of modern medical practice, from the standpoint of
diagnosis and treatment, consultant, laboratory and institutional facilities of a
varied character, which together constitute;
6. Special provision will be required for certain sections of the
population, e.g. mothers, children, elderly etc.,
7. No individual should fail to secure adequate medical care, curative
and preventive, because of inability to pay for it and
8. The creation and maintenance of as healthy an environment as
possible in the homes of the people as well as at work.

Recommendations
1. Integration of preventive and curative services of all
administrative levels.
2. Major changes in medical education which includes three
months training in preventive and social medicine to prepare
“social physicians”.

Recommendations
3. Development of Primary Health Centres in 2 stages :
a) Short term measure –One primary health centre
‐
for a 40,000 population.
b) 2 doctors, 1 nurse, 4 PHN, four midwives, four trained dais, two SI,
two HA, one pharmacist and 15 class IV employees.
4. A long term programme (also called the
‐ 3 million plan) of setting up
a) primary health units with 75 bedded hospitals for each 10,000 to
20,000 population and
b) secondary units with 650 bedded hospital, again regionalised
around district hospitals with 2500 beds.

• In the fifties and sixties the entire focus of the health
sector in India was to manage epidemics.
• Mass campaigns were started to eradicate the various
diseases.
• These separate countrywide campaigns with a technocentric
approach were launched against malaria, smallpox,
tuberculosis, leprosy, filaria, trachoma and cholera.
• Cadres of workers were trained in each of the vertical
programmes.

• The policy of going in for mass campaigns was in continuation of the
policy of colonialists who subscribed to the percepts of modern
medicine that health could be looked after if the germs which were
causing it were removed.
• But the basic cause of the various diseases is social, i.e. inadequate
nutrition, clothing, and housing, and the lack of a proper environment.
These were ignored.

• National programs were launched to eradicate the diseases.
• The NMEP was started in 1953 with aid from the Technical Cooperation Mission of
the U.S.A. and technical advice of the W.H.O. Malaria at that period was
considered an international threat.
• The tuberculosis programme involved vaccination with BCG, T.B. clinics,
and domiciliary services and after care. The emphasis however was on
prevention through BCG. These programmes depended on international
agencies like UNICEF, WHO and the Rockefeller Foundation for supplies of
necessary chemicals and vaccines.
• The policy with regard to communicable diseases was dictated by the
imperialist powers as in the other sectors of the economy.

• During the first two Five Year Plans the basic structural framework of the
public health care delivery system remained unchanged.
• Urban areas continued to get over three fourth of the medical care
‐
resources whereas rural areas received "special attention" under the
Community Development Program (CDP). History stands in evidence to
what this special attention meant.
• The CDP was failing even before the Second Five Year Plan began.

MUDALIAR COMMITTEE,1962
• known as the “Health Survey and Planning
Committee”, headed by Dr. A.L. Mudaliar.
• Survey the progress made since submission of Bhore report
and to make further recommendations.
• Advised strengthening of existing PHC’s and subdivisional &
district hospitals so that they function as referral centres

RECOMMENDATIONS
1.Consolidation of advances made in the first two 5yr plans
2.Strengthening of district hospital with specialist services
3.Regional organizations in each state for 2-3 districts.
4. PHC should not be made to cater to more than 40,000
population
5.Improve quality of health care provided by PHCs.
6.Constitution of an All India Health Service on the pattern of
Indian Administrative Service.

CHADAH COMMITTEE,1963
• This committee was appointed
under chairmanship of
Dr. M.S. Chadah
• To advise about the necessary
arrangements for the
maintenance phase of
National Malaria Eradication
Programme.

RECOMMENDATIONS
• NMEP Vigilance should be responsibility of general
health services ie PHC at block level.
• Monthly home visits should be carried out by
basic health workers(one basic health worker per
10,000 population )
• These workers were also as “multipurpose”
workers to look after collection of vital statistics
and family planning.

MUKERJI COMMITTEE,1965
• The basic health workers, with their multiple
functions could do justice neither to malaria work
nor to family planning work.
• Shri Mukerji,(Secretary of Health to the government
of India) was appointed to review the strategy in the
area of family planning.

RECOMMENDATIONS
• Separate staff for the family planning programme.
The family planning assistants were to undertake
family planning duties only.
• Basic Health workers for other than family
planning.
• Delink Malaria activities from Family Planning.
• Accepted by Government of India.

MUKERJI COMMITTEE,1966
• Multiple activities of the mass programmes like family
planning, small pox, leprosy, trachoma, NMEP
(maintenance phase), etc. were making it difficult for
the states to undertake these effectively because of
shortage of funds.
• A committee of state health secretaries, headed by the
Union Health Secretary, Shri Mukerji, was set up to look
into this problem.
• Committee worked on the details of Basic Health
Service to be provided at Block level and strengthening
required at higher level of administration

JUNGALWALLA COMMITTEE,1967
• This committee, known as the “Committee on Integration of
Health Services” was set up in 1964 under the chairmanship
of Dr. N Jungalwalla
• Look into various problems related to integration of health
services, abolition of private practice by doctors in
government services, and the service conditions of Doctors.
• The committee defined “integrated health services” as :-
a) A service with a unified approach for all problems instead
of a segmented approach for different problems.
b) Medical care and public health programmes should be put
under charge of a single administrator at all levels of
hierarchy.

RECOMMENDATIONS
Integration at all service , organization and personal levels
1.Unified Cadre
2.Common Seniority
3.Recognition of extra
qualifications
4. Equal pay for equal
work
5. Special pay for special
work
6. Abolition of private
practice by government
doctors
7. Improvement in their
service conditions

KARTAR SINGH COMMITTEE,1973
• This committee, headed by kartar singh was titled the
“Committee on multipurpose workers under Health
and Family Planning.”
a) the structure for integrated services at the periphery n
supervisory levels.
b) feasibility of having multipurpose workers in the field
c) training requirements for such workers
d) utilization of mobile service units set up under family
planning programme for integrated medical, public
health and family planning services operating on field.

RECOMMENDATIONS
• Auxiliary nurse midwives replaced by female health
workers(FHW).
• Basic health workers,vaccinators,family planning health
assistants by MHWs.
• Multipurpose workers first introduced.
• 1 PHC for 50000 population.Each PHC divided into 16
sub-centres(1 for 3000-3500 people), each having
1MHW and 1FHW.
• Male n female health supervisors incharge of MHWs
and FHWs.
• Doctor has overall charge of all supervisors.
• Introduced in 5th
Five year plan.

SHRIVASTAV COMMITTEE,1975
• Set up in 1974 as “Group on Medical Education and Support
Manpower”
• To determine steps to
a) develop a curriculum for health assistants who were to function as
a link between medical officers and MPWs.
b) reorient medical education in accordance with national needs &
priorities
c) to make any other suggestions to achieve the above

RECOMMENDATIONS
• Creation of bands of paraprofessional and
semiprofessional(school teachers , post masters etc.) health
workers from within the community itself
• Establishment of 2 cadres of health workers namely –
multipurpose health workers and health assistants between the
community level workers and doctors at PHC.
• Development of a “Referal Services Complex”
• 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.

RURAL HEALTH SCHEME,1977
• Launched after acceptance of shrivastav committee
report.
• Steps were initiated
a) Training of community health workers
b) Involvement of medical colleges in total health care of
selected PHCs and reorientation of medical education to
the needs of the rural people.
c) Reorientation training of MPWs

HEALTH FOR ALL BY 2000 AD-REPORT OF WORKING
GROUP,1981
• Constituted by planning commission in 1980 with Secretary for
MOHFW as Chairman.
• To identify the goal for Health For All by 2000 AD
• To outline the specific programmes for 6th
five year plan
• Evolved Indices and targets to be achieved in the country by
2000AD.

• Government of India has set up Planning commission in 1950 (Prime
minister –Chairman)
“ for assessment of material , capital and human resources of the
country and to draft developmental plans for effective utilization of
resources”
“Perspective Planning Division”

Consists of Chairman , Deputy chairman and 5 members.
3 major Divisions- Programme advisors , General secretariats, Technical
divisions.
Planning commission has been formulating 5 years plans.
reviews from time to time progress made in various directions and
makes recommendations

Health sector Planning
• Planning commission gave considerable importance in Health programmes in
five year plans
• For the purpose of planning, Health sector has been divided in to following
subsections-
1.Water supply and sanitation
2. Control of communicable diseases
3.Medical education , training and research
4.Medical care –Hospitals, clinics, PHCs etc.
5.Public health services
6.Famil planning
7.Indiginous system of medicine

• All the above subsectors were considered in five year plans based on
felt needs and technical considerations.
• A Bureau of planning was constituted in 1965 for better coordination
of central and state governments .
• Main function of this bureau is compilation of National Health Five
year plans which is implemented at center, state, district and village
level.

Broad objectives of health programmes during Five year plan
are
1. Control or eradication of major communicable diseases.
2. Strengthening of Basic Health services through PHCs and
Subcenters.
3. Population control
4. Development of Health Manpower resources

• 1 First plan (1951-1956)
• 2 Second plan (1956-1961)
• 3 Third plan (1961-1966)
• 4 Fourth plan (1969-1974)
• 5 Fifth plan (1974-1979)
• 6 Sixth plan (1980-1985)
• 7 Seventh plan (1985-1989)
• 8 Period between 1989-91
• 9 Eighth plan (1992-1997)
• 10 Ninth plan (1997-2002)
• 11 Tenth plan (2002-2007)
• 12 Eleventh plan (2007-2012)
• 13. Twelfth five year Plan(2012-
2017)

Twelfth Five year plan (2012-17)
• Health of the nation is essential component of development and
economic stability.
• There is a strong link between Poverty and Ill health.
• There is need for quality Health services in remote rural areas.
• There is need to transform public health in to accountable,
accessible ,affordable and quality services during 12th
Five year plan.

• 12th
plan seeks to strengthen initiative taken during 11th
plan that is
“Universal Health coverage” in the country.
• “Ensuring equitable access for all Indian citizens ,regardless of
Income level , social status, gender, Caste or Religion , to affordable,
accountable and appropriate assured quality health services as well
as services addressing wider determinants of health delivering to
Individuals and populations, with the government being Guarantor
and enabler although not necessary the only provider of Health and
related services”

• For UHC , there should be universal access to services of health and
other determinants.
• Goal of UHC in 2 parallel steps
1. Clinical services at different levels through public health system
and supplemented by contract in private providers.
2. Universal provision of high impact preventive and public health
interventions by the Government.

List of Preventive and public health interventions
1. Full Immunization for <3 years and Pregnant
2. Full antenatal , natal and post natal care
3. Skilled Birth attendance and Emoc facility
4. IFA supplementation for children , adolescent and pregnant
5. Regular treatment of Intestinal worms for children and reproductive age
women
6. Access to Iodine and Iron fortified salts
7. Vit A supplementation (9-59 months)
8. Access to basket of contraceptives and safe abortion services
9. Preventive and promotive health education services
10. Home based new born care and encouraging breast feeding.

List of Preventive and public health interventions
11.Community based care and referral of sick children
12. HIV testing and counselling during Antenatal care
13. Free drugs for HIV positive and PPTCT.
14. Malaria prophylaxis , LLIT bed nets , Rapid diagnostic kits and
appropriate treatment.
15. School health check up s
16. Management of Diarrhea using ORS
17. Diagnosis and treatment of Tuberculosis and leprosy
18. Vaccines for Hepatitis B for high risk groups
19. Patients transport system including emergency dial 108 model.

Outcome Health Indicators of 12th
Five year
Plan
1. Infant mortality rate to 25/1000LBs (NFHS 5-35.2)
2. Maternal mortality ratio to 100/1000 LBs (sample registration
system-103/1000 LBs)
3. Total Fertility rate to 2.1 (NFHS 5- 2.3 )
4. Prevention and reduction of undernutrition in children under 3
years to half of NFHS-3(2005-06- 58% and 46% ) levels , 27% by
2017.
5. Prevention and reduction of anemia among women aged 15-19
years to 28%.(59.1%-NFHS 5)

6. Raising Child sex ratio in the 0-6 years age group from 914 to 950 .
7. Prevention and reduction of burden of communicable and non
communicable diseases including Mental illness and injuries.
8. Reduction of poor household’s out of pocket expenditure – increase
in public health spending to 1.87 % of GDP by 12th
plan.
Outcome Health Indicators of 12th
Five year
Plan

Post-2017 (No 13th Plan – new framework)
• Planning Commission abolished → NITI Aayog (2015)
• No 13th Five-Year Plan: replaced by Three-Year Action Agenda (2017–20), Strategy for New
India @75 (2018–22), and alignment with SDGs 2030
• National Health Policy 2017:
• Aim: Universal Health Coverage
• Public health expenditure → 2.5% of GDP target
• Stronger focus on primary care, NCDs, equity
• Ayushman Bharat (2018):
• Health & Wellness Centres (HWCs) for primary health care
• PM-JAY for secondary/tertiary care coverage
• Current status:
• IMR, MMR, TFR goals broadly achieved
• Undernutrition & anemia remain persistent challenges

12th
five year plan goals for communicable diseases
Disease 12th
plan goal
Tuberculosis Reduce annual incidence and mortality to half
Leprosy Reduce prevalence to <1 / 10,000 and Incidence to
zero
Malaria Annual Malaria incidence to less than 1/1000
Filariasis <1 percent microfilaria prevalence in all districts
Dengue Sustaining case fatality rate of less than 1 percent
Chikungunya Containment of out breaks
Japanese encephalitis Reduction in Mortality by 30 percent
Kala Azar Elimination by 2015, <1/10,000 population in all
blocks
HIV/AIDs Reduction of new infections to zero and
comprehensive support and treatment to all cases

Achievements during plan period
First Plan (1951-56) 12th
plan (2012-2017)
1. PHCS 725 25,650
2.Subcenters NA 156,231
3.Community Health centers - 5624
4. Total beds(2002) 125000 710,761
5.Medical colleges 42 476
6.Annual admissions in Medical colleges 3500 52,646
7.Dental colleges 7 313
8.Allopathic Doctors 65,000 1,041,395
9.Nurses(registered) 18,500 1,980,526
10.ANMS(Registered) 12,780 841,276
11.Health Visitors 578 55675
12.Health workers(F) in position - 220,707
13.Health workers(M) in Position - 56,163
14.Block Extension educator - 3512
15. Health Assistant (M) in Position - 12,288
16. Health Assistant female in position - 14267

Planning Commission dissolved on 17th
August 2014 and replaced by
NITI Aayog on 15th
March 2015.
Bottom to Top Approach
Plan formed and advised by both state and center

With the Prime Minister as the Chairperson, presently NITI Aayog consists of:
Vice Chairperson: Suman Bery
Ex-Officio Members: Amit Shah, Rajnath Singh, Nirmala Sitaraman and Narendra Singh Tomar
Special Invitees: Nitin Gadkari, Piyush Goyal, Virendra Kumar, Ashwini Vaishnaw and Rao
Inderjit Singh
Full-time Members: V. K. Saraswat (former DRDO Chief), Ramesh Chand (Agriculture Expert)
[19]
and Dr. V. K. Paul (Public Health expert)
Chief Executive Officer (CEO): Parameswaran Iyer
Governing Council: All Chief Ministers of States (and Delhi and Puducherry),
Lieutenant Governor of Andaman & Nicobar Islands, and Special Invites

NITI Aayog
• Governments Premier Thick tank (Knowledge , Innovation and
Communication)
• It was told to prepare 15 years vision, seven year strategy and three
year action agenda documents.
• Three years action Agenda(2017-18,19 and 20) proposed specific
health related goals to be achieved by 2020.

Specific Health related Goals by three years action agenda ,NITI
Aayog.
1. Reduce Maternal Mortality Ratio to 120/100000 LBs(2013-167)
2. Reduce IMR to 30/1000 LBs(2013-40)
3. Reduce under 5 Mortality rate to 38/1000 LBs(2015-48)
4. Reduce TFR to 2.1(2.3 in 2013)
5. Reduce Incidence of Tb to 130/100000(2015-217/100000)
6. Reduce Incidence of Malaria(API) to less than 1/1000 in 90% of districts(74% in
2016)
7. Eliminate Kala azar(80%-2015) and Lymphatic filariasis(87%-2015)
8. Reduce premature mortality from CVDs, Cancer, Diabetes or COPDs by 1/4th
of
NFHS 4 levels.
9. Reduce out of pocket spending to 50% of the total health expenditure(2014- 62.4%)

National Health Policy 2017
• Ministry of Health & Family Welfare, Govt. of India
• Tagline: “Health for All, All for Health”

Background
• Previous policy: NHP 2002
• Need for update → changing disease burden, rising NCDs, health
financing gaps
• Global commitments → SDGs, Universal Health Coverage (UHC)

Vision & Goals
• Vision: Attain highest possible level of health & well-
being for all
• Key Goals by 2025:
• Increase life expectancy to 70 years
• Reduce Total Fertility Rate (TFR) to 2.1
• Achieve Universal Health Coverage (UHC)
• Reduce mortality (IMR, MMR, U5MR)
• Eliminate leprosy, kala-azar, filariasis

Major Policy Thrusts
• Strengthening primary health care – Health & Wellness Centres
• Free essential drugs, diagnostics & emergency care
• Focus on preventive & promotive health
• Mainstreaming AYUSH
• Public health management cadre
• Digital health technology & surveillance

Financing & Implementation
• Target: 2.5% of GDP on health by 2025
• Strategic purchasing from private sector
• Health assurance through insurance schemes (Ayushman Bharat)
• Decentralized planning → states as key implementers
• Monitoring & accountability with measurable indicators

Health Indicators: India vs Bihar (Current & 2030 Targets)
Indicator India (Current) India 2030
Target
Bihar (Current) Bihar 2030 Target
MMR (per 100,000) 88 ≤70 104 ≤70
IMR (per 1,000) 25 ≤25 23 Align with national
U5MR (per 1,000) 31 ≤25 30 Align with national
NMR (per 1,000) 19 ≤12 19 ≤12
TFR ≈2.0 Stabilise ≤2.1 3 Align with national
Stunting (<5 yrs, %) 35.5% <25% 43% <30%
Wasting (<5 yrs, %) 19.3% <12% 21% <15%
Anaemia (women 15–49
yrs, %)
57% <30–40% 63.6% Reduce substantially
TB incidence (per
100,000)
195 Eliminate by
2030
≈294 Align with national
Fully immunized
children (9–11 mo, %)
93% ≥95% ≈95% ≥95%

National Policies related to Health and Health
Planning

National Health Policy 2017
AIM- “ Inform, Clarify, strengthen and prioritize the role of government in
shaping health systems in all its dimensions”
-Investment in health
-Organization of Health care services
-Prevention of diseases and promotion of good health
-Cross sectoral actions
-access to technologies
-developing Human resources
-Encouraging Medical Pluralism
-Building Knowledge base
-developing better financial protection strategies
-strengthening regulation and health assurance

Specific quantitative Goals and objectives
Three broad components
1.Health status and programme impact
2. Health system performance
3.Health system strengthening

Health status and Programme Impact
1. Life expectancy and Healthy Life
a. Increase Life expectancy to 70 by 2025(67.5)
b. Establishment of regular tracking of DALYs index as a measure of
Burden of disease and its Trends by major categories by 2022.
c. Reduction of TFR to 2.1 by 2025.

2. Mortality by age /Cause
a. Reduce Under5 mortality to 23 by 2025 and MMR to 100 by 2020.
b. Reduce IMR to 28 by 2019
c. Reduce NMR to 16 and still birth rate to 16 by 2025.

Reduce disease prevalence or Incidence
a. Achieve global target of 90:90:90 for HIV/AIDS
b. Achieve and maintain elimination status of leprosy by 2018,Kla azar
by 2017, lymphatic filariasis in Endemic pockets by 2017.
c. Achieve and maintain cure rate by >85% and reduce Incidence to
reach elimination by 2025.
d. To reduce prevalence of Blindness by 0.25/1000 by 2025 and
disease burden by 1/3rd
from current levels .
e. To reduce premature mortality from cardiovascular diseases, cancer,
Diabetes or Chronic respiratory diseases by 25% by 2025

B. Health System Performance
1. Coverage of Health services-
a. Increase utilization of Public health facilities by 50% (2025)
b. Antenatal care and skilled Birth attendance to be sustained above
90%(2025)
c. Full immunization by more than 90% by one year of age(2025)
d. Meet need of Family planning by 90%(2025)
e. 80% of known Diabetic and Hypertensives will maintain controlled
status by 2025.

2. Cross sectoral goals related to Health
a. Relative reduction of prevalence of current Tobacco use by
15%(2020) and 30% by 2025.
b. Reduction f 40% stunting in under5 children by 2025.
c. Access to safe water and sanitation to all by 2020
d. Reduction of occupational Injury by half from current levels of 334
per lakh agricultural workers by 2020.
e. National/state level tracking of current health behaviour.
B. Health System Performance

C. Health system strengthening
1.Health Finance
a. Increase health expenditure in percentage of GDP from 1.15% to
2.5% by 2025.
b. Increase state sector health spending to >8% by 2020.
c. Decrease in proportion of families facing catastrophic health
expenditure from current levels to 25% by 2025.

2. Health Infrastructure and Human resource
a. Ensure availability of paramedics and Doctors as per IPHS norms in
high priority districts by 2020.
b. Increase community health volunteers to population ratio as per
IPHS norms in high priority districts by 2025.
c. Establish Primary and secondary care facility as per norms in high
priority districts by 2025.

3. Health Management Information system
a. Ensure electronic database of information on health system
components by 2020.
b. Strengthen the Health surveillance system and establish registries
for diseases of Public health importance by 2020.
c. Establish health information architecture , exchanges , National
health information network by 2025

Health Planning with national health scenario

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