Kurukshetra March 2018 Summary: Budget - (Part - 2)

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Ayushman Bharat: Making Rural Health UniversalAyushman Bharat Program-potential game changer for Indian health care system. National Health Protection Scheme (NHPS) -newly proposed-targets a broader base of vulnerable and deprived population-designed to fulfill the legitimate expectations of people from any functioning health system, accessibility, affordability and appropriate care.

Budget: Kurukshetra March 2018 Summary (in English)
  • Implementation of ‘Ayushman Bharat’ supplemented by few complimentary initiatives can help achieving targets set by National Health Policy of India
  • Union budget-2018 - 19-allocation to health sector increased by 12 %

Ayushman Bharat Program has two major components

  1. Health and Wellness Centres-aim at provision of comprehensive primary health care services closer to the community
  2. National Health Protection Scheme (NHPS) -provide financial protection of upto ₹ 500,000 per family, per year for 10 crore families
  • Can Ayushman Bharat address key health challenges in India?
  • Vast network of primary healthcare system, these provide only 11 % of total health services.
  • Well-functioning ‘primary health-care system’ can cater upto 80 % to 90 % of health needs-80 % of outpatient consultations and 60 % of all hospitalization happen in private sector - patients need to pay huge amounts, much beyond their capacity-sell assets or borrow to pay health care bills-thus pushing themselves into deeper poverty or below the poverty line due to health expenditures-unhealthy workforce leads to absenteeism and reduced productivity
  • ‘Ayushman Bharat’ , National Health Policy (NHP) and Universal Health Coverage (UHC)
  • Ayushman Bharat would help India to stride towards UHC gradually.
  • Few steps are needed for successful implementation of Ayushman Bharat ProgramDetailed planning and sustained engagement with stakeholders
  1. Engage state government earnestly: 24 states have their own health insurance schemes-reluctance among states for the transition from their existing schemes-state government also need to contribute financial resources
  2. Strengthen administrative regulatory and capacity at all levels: state capacity to large scale insurance is limited-state governments to regulate health providers and health insurance sectors
  3. Build on the learnings from past and other ongoing schemes
  4. Sustain top level of political development

Ayushman Bharat program can be best utilized to strengthen and redesign health systems in India in a more integrated and people centric fashion.

Ayushman Bharat: Game changer in making because of the following reasons

  1. Irreversibly placed health higher on political agenda and public disclosure
  2. Successful implementation would ensure health challenges are met
  3. Brought attention back to primary health care and continuum of care
  4. NHPS approach to target vulnerable and deprived population is major policy shift from traditional approach.
  5. Launch of NHPS would introduce the concept of separation of provision and ‘financing/purchasing function’ and introduce ‘strategic purchasing’ .
  6. Linkage between good health and economic growth is explicitly acknowledged.

Proposed Health and Wellness Centres (HWC)

  • Target of making 11,000 HWCs functional-created by upgrading existing HSCs (Health sub Centres) to provide a comprehensive package of primary healthcare services, including preventive, promotive, curative and rehabilitative services and free essential drugs and diagnostic services

Proposed National Health Protection Scheme- 2018

NHPS 2018- would replace Rashtriya Swasthya Bima Yojana-target to cover 40 % of population.

Union budget 2018 - 19: Key health sector and related announcements

  • Ayushman Bharat Program
  • ₹ 500 per month for TB patients-a total of 600 crore
  • 24 district colleges upgraded to medical colleges
  • 3 % education cess changed to 4 % Health and Education cess
  • Continuation of Swachh Bharat Mission
  • Expansion of Ujjwala scheme from 50 million women to 80 million women
  • Allocation to National Nutritional Mission
  • Increase of nearly 10 % for Jan Aushadi Yojna, Swachch bharat Mission-Rural and Aanganwadi services

Ayushman Bharat Program: Possible considerations

  • There is supply deficiency in many states like North Eastern States also large Indian states ranked low in NITI Aayog՚s State Health Index 2018.
  • Even with state willingness, implementation of NHPS-2018 is likely to be a challenge.
  • States like Chhattisgarh, Karnataka, Andhra Pradesh, Himachal Pradesh and Rajasthan have broad range of health insurance scheme whose financial coverage is slightly less than offered in NHPS. These schemes in the states have good administrative capacity. These states could be prioritized for early adoption.
  • April 2020 onwards, ‘Ayushman Bharat’ program could be a suitable platform for transitioning from NHM.

Comprehensive primary healthcare: Health and Wellness Centres

12 essential services-HWCS to be linked to Block Level Primary Health Centres (referred as PHC) which would be a mid-level health care provider or MLHP. The services at HWCS are

  1. Care in pregnancy and child birth
  2. Neonatal and infant care services
  3. Childhood and adolescent health care services
  4. Family planning, contraceptive services and other reproductive healthcare services
  5. Management of communicable diseases: National Health Programs
  6. General out-patient care for acute simple illness and minor ailments
  7. Screening and management of Non-Communicable diseases
  8. Screening and basic management of mental illness
  9. Care for common Ophthalmic and ENT problems
  10. Basic Dental health care
  11. Geriatric and palliative health care services
  12. Trauma care and Emergency Medical services

Staff in the HWC are

  • ANM/Health worker (female)
  • Health Assistant- Male
  • Counsellor
  • Mid-Level healthcare provider (community health officer/Nurse/AYUSH)

The stated goal of NHP-2017 is in full alignment with UHC at global level

UHC is defined as “all people have access to needed promotive, preventive curative services and rehabilitative health services of sufficient quality to be effective, also ensuring that people do not suffer from financial hardship” .

Optimizing Implementation - ‘State of Health in India’ report released in 2017 says Indian health system needs to be changed to the need of people and not vice-versa

  • Strengthen PHC and referral linkage: Availability of physicians to provide outpatient consultations. In addition to HWCs, the primary health centres and community health centres need to be strengthened.
  • Consider progressive universalization: Expansion of NHPS beyond 10 crore families till entire population is covered should be a mid-term roadmap. Premium for poor can be paid by government and non-poor can join on basis of payment (preferably mandatory contribution) . NHPs can integrate all health insurance schemes. The outpatient consultation can be included in NHPS packages.
  • Strengthen health care regulation: Need to control the price of health care. India does not need any new regulations but effective implementation of existing regulatory mechanism can deliver a lot more

Full functioning of HWCs including establishing of additional HWCs (in urban areas) would require an additional expenditure of around ₹ 30,000 crore and annual recurrent expenditure of ₹ 20,000 crore. Ayusman Bharat would require ₹ 50,000 crore per annum. This is in alignment with NHP-2017 proposal to increase union government expenditure to the range of 2.5 % of GDP.

For new India by 2022, effective implementation of ′ Ayushman ′ (blessed with long life) Bharat program can ensure ′ Nirmaya (Healthy) bharat as well.

Rashtriya Swasthya Bima Yojana (RSBY) : launched in 2008 under the Ministry of Labor and Employment and aimed to cover 4 crore BPL families. Provided coverage upto ₹ 30,000 to 5 members of families. In late 2011, the scheme was transferred to Ministry of Health and Family Welfare

Proposed design and implementation plan for NHPS-2018

The design of NHPs-2018 is still being worked upon. NHPS-2016 would require a revision in light or revised package.

The ‘deprivation data’ from socio economic and caste census (SECC) will be used for eligibility of beneficiaries. The enrolment and identification to be linked to Aadhaar card.

The state government would be free to decide trust model or insurance model. NHPS 2018 would be implemented possibly from Aug-2018 and not later than 2 Oct 2018. Likely to be implemented in 5 - 7 states in first year, with additional states onboarding the following years.

What would achieving UHC mean to an ordinary citizen in India?

The day when an elderly tribal widow in a faraway remote village in India would not have to worry about access and utilization of health services that would be the day when Indian Government can claim to achieve Universal Health Coverage.

Thrust on Education

Key highlights of union budget in field of education are

  • Integration of existing schemes
  • Providing improved access to STs
  • Shifting from regular blackboards to digital blackboards
  • Revitalization of infrastructure of higher educational institutions
  • Fiscal accountability

National Policy of Education (NPE) initiated wide range of programs for achieving goal of Universalization of Elementary Education (UEE) . The schemes/programs introduced in 80s and 90s include

  • Operation Black Board (OBB)
  • Shiksha Karmi Project (SKP)
  • Mahila Samakhya (MS)
  • Lok Jumbish Project (LJP)
  • District Primary Education Program (DPEP)
  • Sarva Shiksha Abhiyan (SSA)

UEE was strengthened with the passage of Right of Children to Free and Compulsory education (RTE) Act 2009, which gave a legal mandate for free and compulsory education for children in the age group of 6 - 14 years.

National Program of Education (1986) emphasizes equitable access and enrolment of girls, SCs and STs. The NPE and Program of Action (1992) , recognized secondary education as critical instrument for social change, called for its phased expansion. POA laid emphasis on

  • Increase in access to secondary education
  • Increase in autonomy of Boards of Secondary Education
  • Introduction of technology in school curriculum
  • Vocationalization through specialized institutions

Rashtriya Madhyamik Shiksha Abhiyan (RMSA) initiated in 2009, government՚s intent for secondary education system that can support India՚s growth and development.

Centrally Sponsored Scheme of Restructuring and Reorganization of Teacher Education (CSSTE) initiated in 1978, it envisaged teacher education as continuous process with pre-service and in-service training being inseparable components

Merger of Schemes in School Education

SSA, RMSA, CSSTE are 3 major flagship school education development programs by MHRD being implemented in partnerships with states. SSA covers grade I to VIII, RMSA covers grade IX-X, (XI-XII for certain components) , CSSTE aims to provide infrastructural and institutional support toGovernment Teacher Education Institutions (TEIs) to enhance quality of teachers

The objectives of all schemes are to enhance access

  • To promote equity through inclusion of disadvantaged groups and weaker sections
  • Improve quality of education for all.

Intervention on SSA and RMSA are directed towards

  • Ensuring minimum standards in schooling provisions
  • Creating equal opportunities for schooling for all
  • Strengthen school based management for school improvement
  • Develop children grade specific competencies
  • Increase engagement of primary stakeholders in education.

The scope and coverage of these schemes remains segmented because of parallel institutional arrangements in national, state district and sub-district levels with little convergence with mainstream.

Suggestions by independent evaluation suggest increase in convergence and integration between the schemes through a single school education development program. This would help in efficient and optimal utilization of budgetary and human resource. The convergence of SSA and RMSA would facilitate productive synergies, better co-ordination and economies of administrative costs. Steps are being taken to create a single scheme for School Education by merging different Centrally Sponsored Schemes. The advantages of this merger are

  • Institutional capacity building
  • Exploration of new digital initiatives for strengthening in-service and pre-service teacher training innovative
  • Integration of training structures

This would strengthen the quality of teaching, which would be in line with Integrated B. Ed. program another highlight of Union budget 2018. It aims at making education a holistic process from pre-nursery to XII. This is a step to train 13 lakh-untrained teachers to make B. Ed. program more robust, practical, vibrant and more focused

DIKSHA- a portal, for teachers to train themselves to boost their skills and upgrade their knowledge.

Technology can act as an effective agent of change in classroom. Technology in class

  • Increases independent access and learning and provides greater choices for content delivery
  • Increase in confidence
  • Enhances communication
  • Provides flexibility in teaching, learning and evaluating
  • Gives immediate feedback

Digital blackboards are the need of hour as technology will be the driving force in improving quality of education. Technology might also help in enhancing the learning levels especially of children with significant learning challenges

The budget of all 3 schemes to be merged into single budget provision. This would be the Centre՚s share provided to states and UTs with sharing pattern of (60: 40) and 90: 10 for northeastern states and 3 Himalayan states and 100 for UTs.

The states to bring a single plan for entire school education, the Centre to provide assistance at all levels uniformly. The budget allocation for 2018 - 19 is higher than the revised budget estimate of the current year. Innovation in schools, mapping of learning outcomes and school assessments are key focus.

SSA allocated ₹ 26,128 crore; RMSA allocated ₹ 213 crore; Mid Day Meal to get ₹ 10,500 crore; allocation cut for KVs and Navodaya Vidyalayas.

Eklavya Model Residential Schools to be setup for ST students, Ministry of Tribal Affairs has recognized 163 priority districts. Government seeks to extend this facility but it is hard to find blocks with more than 50 % ST population other than NE states.

Revitalizing Infrastructure and Systems in Education (RISE) : New funding model. The Central Universities and Institutes will be able to borrow upto ₹ 1,00, 000 crore in next four years. The impact of RISE need to be assessed.

Promising Budget for Women

  • Government has proposed a series of structural reforms, which has potential to make India one of the fastest growing country of the world.
  • The dismal condition of women in the family is because of prevailing patriarchal mind set and lack of equal opportunities.

The government also increased the allocation to women specific program by 4 % .

Women and Child Development Ministry՚s share in the budget is increased to ₹ 24,700 crore. The ministry has introduced the outreach program of ICDS (Integrated Child Development Service) to

  • Improve the nutrition and health status of the children in the age group of 0 - 6.
  • Reduce the number of school drop outs
  • Fight malnutrition, mortality and morbidity existing among children

Expecting and lactating mothers needs have also been taken care of under this scheme. The following are the schemes under ICDS

Anganwadi Services: Introduced by the government in 1975, is a centre where mother and child health care services are provided. The services include providing information about

  • Modern family planning methods
  • Nutrition
  • Education
  • Supplementation
  • Immunization
  • Health checkups
  • Referral services

A 7 % increase for Anganwadi centre is a good sign for taking care of the need of the children. However, a case of ameliorating the working condition and remuneration of Anganwadi workers for greater motivation.

Pradhan Mantri Matru Vandana Yojna is a Maternity Benefit program introduced for pregnant women and Lactating Mothers. Partial compensation is provided to mothers for the wage loss in terms of cash incentives. It is restricted to only one child per woman.

Maternity leave has been increased up to 26 weeks

  1. Creches have been mandated in unorganized sector to provide day care facilities for children in the age group of 6 months-6 years. The allocation of fund under National Creche Scheme has also been doubled.
  2. National Nutrition Mission has been allocated ₹ 3,000 crore with an aim to reduce the occurrence of stunting and under nutrition among children and prevent anemia among adolescents, since a large number of children are severely underweight, severely stunted and wasted, mainly because of socio economic inequality.
  3. Child Protection Services: to prevent children from all type of abuse, exploitation, neglect discrimination, abandonment and separation from their families.
  4. SAG (Scheme for Adolescent Girls) : To provide nutrition, hygiene and awareness about reproductive health to adolescent girls to take care of their physical, mental and reproductive health. ₹ 500 crores were allocated.
  5. Sukanya Samridhi Yojana is a part of Beti Bachao, Beti Padao campaign. Parents are encouraged to open bank accounts for the education and marriage of their daughters.

    ₹ 280 crore in the present budget to generate awareness and improve the efficiency of welfare services intended for girls which can check the issues of female foeticide and infanticide

  6. Ujjawala: Comprehensive scheme for girls and women to prohibit trafficking of women and children by involving local communities, generate awareness and encouraging public participation. Forced labour, sexual slavery and sexual exploitation are the reasons for human trafficking. The scheme aims at rescuing the victims and repatriated to their family and society.
  7. To encourage women to join formal sector an amendment was proposed in Employees Provident Fund (EPF) and Miscellaneous Provisions Act. Women employee՚s contribution in provident fund was reduced to 8 % for first 3 years of employment, while the contribution of the employer was kept at 12 % .
  8. Under National Rural Livelihood program Women are encouraged to take up organic farming in clusters
  9. Mahila Shakti Kendra: to provide one stop convergent support services for empowering rural women with opportunities for skill development, employment, digital literacy, health and nutrition. It is a part of the umbrella scheme “Mission for Protection and Empowerment for Women” developed by Ministry of Women and Child Development. Main aim is to uplift the status of rural women.
  10. Pradhan Mantri MUDRA Yojana: Provides loans upto ₹ 100 lakh to non-cooperate, non-farm, small/micro enterprise. 76 % of MUDRA loans are given to women.
  11. Nirbhaya Fund: The allocation for this fund is ₹ 500 crore to create one-stop facility for survivors of rape and sexual violence. Medical, legal and psychological assistance to the victims at one-stop centre
  12. Swadhar Greh Scheme and Short Stay Home by Ministry of Women and Child Development provides emergency outreach services to women who do not have societal/family support or independent means of income. Free shelter, food, medical care counselling etc. to be provided at these centres. ₹ 95 crore been allocated
  13. Working Women Hostel Scheme: Safe and affordable accommodation to be provided for working women, those under training and girls attending professional courses.
  14. Swadhar Scheme under Ministry of Women and Child Development to provide food, clothing, shelter and care to vulnerable women/girls such as widows deserted by their families, women prisoners realized from jail without family support, women survivors of natural calamities, women victims of terrorist/extremist violence etc.
  15. Pradhan Mantri Ujjwala Yojna: Scheme by Ministry of Petroleum & Natural Gas. Free LPG connections for women below BPL. Proposal to increase to 8 crore women.
  16. National Social Assistance Program (NSAP) : Provides financial assistance to elderly, widow and persons with disabilities in the form of social security. It consists of sub schemes like
    • Indira Gandhi National Old Age Pension Scheme
    • Indira Gandhi National Widow Pension Scheme
    • Indira Gandhi National disability Pension Scheme
    • National Family Benefit Scheme
    • Annapurna Scheme

Almost an increase of 14 % in budget.

  1. Swachch Bharat Mission- 2 crore toilets, which would increase safety of girls and women.
  2. Pradhan Mantri Saubhagya Yojna: free electricity to 4 crore household.
  3. Mission for Protection and Empowerment for Women would get ₹ 1366 crores whereas the revised estimate in 2017 - 18 was 998 crores. The allocation for Women Helpline has been increased to 28.8 crores
Budget: Kurukshetra March 2018 Summary (in Hindi)

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