Education and Health

Here are detailed notes based on the provided sources, formatted as requested.

Notes on Education and Health in India

1. Social Infrastructure and Social Sector

• Social infrastructure, including educational and health infrastructure, along with safe drinking water and sanitation, is essential for the growth of skilled and educated manpower.

• This manpower helps the process of growth by providing impetus to social sector development.

• At the time of independence, India had very poor social infrastructure.

• The planning process over six decades has made efforts to strengthen social infrastructure at various levels.

• It is important to assess the achievements, shortcomings, and failures in this regard.

2. Development of Education in India

• The Constitution of India resolved to provide elementary education for everyone.

• Article 45 stated that the state shall endeavor to provide free and compulsory education for all children until they complete the age of fourteen years, within a period of ten years from the commencement of the Constitution.

• The Government set up the Education Commission (1966), headed by Dr. D.S. Kothari, to determine the need and estimate the required Gross Domestic Product (GDP) for promoting education.

• The Commission emphasized the critical relationship between education and productivity and the critical role of education in national and economic development.

• It stated that education as investment in human resources plays an important role among factors contributing to economic growth.

• The Commission recommended that expenditure on education should be stepped up to 6 per cent of GDP during the next 20 years.

• The 42nd amendment of the Constitution in 1976 brought education onto the concurrent list, making it the responsibility of both the Central and State Governments.

• Education was previously largely a responsibility of State Government.

• The 86th Amendment of the Constitution led to the inclusion of Article 21-A.

• Article 21-A made free and compulsory education to all children of 6-14 years of age a Fundamental Right.

• In pursuance of this legislation, the central government enacted the Right to Education Act in 2009.

• Government has issued National Policy Statements on education in 1968, 1986, and 1992.

• These policies emphasized eradicating illiteracy altogether and providing universal elementary education to all in the shortest possible time.

• Another major emphasis was the need to expand vocational and technical education at the secondary level.

• Improvement in quality and relevance of higher education and expansion for the age group 17-23 years were also emphasized.

• Equity in education by gender, caste, and socio-economic groups (scheduled castes and scheduled tribes) has been a key principle.

• More recently, the Government reserved 27 per cent seats in institutions of higher education for Other Backward Castes (OBCs) from 2007-08.

• This is in addition to existing reservations of 15% for Scheduled Castes (SCs) and 7.5% for Scheduled Tribes (STs).

• Reduction in regional disparities has been another major objective of educational planning in India.

Summary of Education Development: (1 minute summary) Education development in India began with a constitutional commitment to free and compulsory elementary education. Influential commissions highlighted education's link to economic growth and recommended increased spending. Legislation moved education to the concurrent list and made elementary education a fundamental right. Policies have aimed for universal elementary education, illiteracy eradication, expansion of vocational/technical education, quality higher education, and equity across social groups and regions.

3. Progress of Elementary Education

• Between 2001-02 and 2013-14, the number of Primary Schools (Class I to V) increased from 6.64 lakhs to 8.59 lakhs.

• Total enrolment at the primary level increased from 11.4 crores to 13.0 crores during the same period.

• At the Upper Primary Level (Class VI to VIII), the number of schools increased significantly from 2.20 lakhs in 2001-02 to 5.9 lakhs in 2013-14.

• Total enrolment at the upper primary level increased from 4.5 crores in 2001-02 to 6.58 crores in 2013-14. Note: Source text initially mentions 2004-05 for 6.58 crores, but the table shows this figure for 2013-14. I will use the table data as primary.

• Total enrolment at the Elementary Level (Class I to VIII) increased from 15.87 crores in 2001-02 to 19.58 crores in 2013-14, an addition of 3.7 crores.

• Despite achieving a Gross Enrolment Rate (GER) of over 96 per cent, the drop-out rate remains quite high.

• The drop-out rate for the primary level (I to V) was 22.3 per cent (2011-12).

• The drop-out rate for the entire elementary education (Class I to VIII) was about 40.8 per cent (2011-12).

• Drop-out rates vary by social composition.

• For SCs, the drop-out rate (I-VIII) was 40.2% and for STs it was 57.2% (2011-12).

• In both SC and ST categories, the drop-out rate among girls was higher than among boys (2011-12). Example: SC girls 36.4% vs SC boys 43.3% (Note: Source text states drop-out rate among girls is higher, but table 8 shows SC boys 43.3% and SC girls 36.4%. For STs, girls are 57.1% and boys 57.3%. Overall girls 40.0% and boys 41.5%. The text seems to contradict the table for overall and SCs. I will include the text statement but note the table data). The Eleventh Five Year Plan attributed the higher drop-out among girls to the opportunity cost of girl-child education, where they are often neither in school nor the labor force but doing domestic work, mostly sibling care.

• High drop-out rates among weaker sections of society have contributed to the failure in universalizing elementary education (UEE).

• Other contributing factors include lower teacher attendance, lack of adequate facilities (rooms, blackboards, educational aids), virtual absence of separate toilets for girls, and lack of an environment to retain children in studies.

• The retention rate in 2004-05 was low: out of 100 children enrolled in Class I, only 49 reached Class VIII.

• Retention rates among SCs was 43% and among STs was 34%.

• The goal of UEE was set by the Constitution framers to be achieved by 1960.

• Nearly 60 years later, the country is still far from achieving the goal of UEE.

• The Constitution was amended in 2002 to make elementary education a justiciable Fundamental Right.

• Despite this, in 2004-05, 7.1 million children were out of school, and over 50 per cent were dropping out at the elementary level, reflecting a gross failure.

• The Mid-day Meal Scheme (MDMS) was introduced to improve retention rates.

• It was implemented after the success in Tamil Nadu.

• MDMS expenditure increased from ₹ 441 crores covering 3.34 crore children in 1995-96 to ₹ 1375 crores for 10.56 crore students in 2003-04.

• Per student expenditure under MDMS fluctuated, reaching a low of ₹ 99 in 2001-02, then increasing to ₹ 3.59 per meal for primary and ₹ 5.38 for upper primary students in 2013-14.

• MDMS prescribes specific nutritional content: for primary classes (I-V), 100g food grain, 20g pulses, 50g vegetables, 5g oil/fat for 450 calories and 12g protein; for upper primary (VI-VIII), 150g food grain, 30g pulses, 75g vegetables, 7.5g oil/fat for 700 calories and 20g protein.

• The scheme was extended to upper primary schools from April 2008.

• Total children covered by MDMS was 10.80 crores in 2013-14.

• Assessments of MDMS have highlighted weaknesses: sub-standard meals, poor cooking arrangements, and prevalence of corruption.

• Quality improved in states where stakeholders, especially mothers, were associated.

• Association of parents in vigilance committees also helped improve effectiveness.

• There is a need to strengthen transparency and improve vigilance by actively associating parents, especially mothers.

• MDMS has been well-documented to improve retention rates, especially among weaker sections.

• Measures to reduce private cost in education include providing free uniforms, free textbooks, and stationery to students from below the poverty line families.

• Provision of free transport in state roads also helps improve attendance, particularly for rural children.

• These measures reduce the private costs of education for parents, increasing attendance and retention rates.

• The government provides special incentives for girl children to counter parental apathy towards their education.

Summary of Elementary Education Progress: (1 minute summary) Significant growth in elementary schools and enrolment has occurred. However, despite high gross enrolment, drop-out rates, particularly for Class I-VIII, remain a major challenge, exacerbated for Scheduled Castes and Tribes and girls. Factors contributing to drop-outs include inadequate facilities, teacher attendance issues, and lack of separate toilets. The Mid-day Meal Scheme aims to boost retention, showing success, but faces issues with quality and corruption. Measures like free uniforms, books, transport, and girl-child incentives are also used to reduce private costs and improve attendance/retention. Achieving universal elementary education, a long-standing goal, remains elusive.

4. Performance in Secondary Education

• The enrolment rate in secondary education (IX-X) is 76.6 per cent, and in higher secondary (XI-XII) is 52.2 per cent (2013-14).

• While these rates provide partial satisfaction, the high drop-out rate of 52.7 per cent (Class I-X, 2009-10 data used as example) is a cause of worry.

• Drop-out rates (I-X) for boys were 53.3% and for girls 51.8% (2009-10 data).

• There are glaring inter-state variations in enrolment, drop-out rates, and access to secondary and higher secondary education.

• Example: In 2004-05, the national average drop-out rate (I-X) was 61.9%, but it was much higher in Bihar (83.1%), Nagaland (97.3%), West Bengal (78%), Rajasthan (73.9%), Assam (75%), and Arunachal Pradesh (70.8%).

• Even today, the national average of drop-outs is much higher than desired, requiring big effort to move towards universalization of secondary education in the knowledge economy.

• There is a structural change in the management pattern of secondary schools.

• In 1993-94, government, local bodies, and aided private schools accounted for 85 per cent of schools.

• Private unaided schools have shown a significant increase in share, from 15% in 1993-94 to 30% in 2004-05.

• This doubling of the share of private unaided schools indicates that parents are willing to pay more for education if they perceive good quality education in such schools.

• This implies that public sector investment in government and aided secondary schools should be increased to improve their quality and attract more students.

• Mathematics, Science, and English are three core subjects where a large majority of students do not perform well.

• Nearly 50% fail in these subjects, highlighting the need to focus on them to improve quality in secondary schools.

• Achieving universal access to secondary education requires substantially strengthening school infrastructure, both physical and human.

• The Eleventh Plan proposed measures for secondary education:

  • Provide a secondary school within 5 km and a higher secondary school within 7-8 km of every habitation.

  • Improve the Gross Enrolment Ratio (GER) for secondary (from 15% in 2004-05 to 75% by 2011-12) and combined secondary/higher secondary (from 40% to 65% during the same period). (Note: The GER target for secondary seems unusually high, potentially a typo, as combined GER target is lower).

  • Strengthen infrastructure in existing schools with 3.43 lakh additional rooms and 5.14 lakh additional teachers.

  • Achieve 100 percent trained teachers and a pupil-teacher ratio of 25:1 by 2011-12.

  • Set up 6,000 quality model schools at the block level.

  • Upgrade 15,000 existing primary schools to secondary schools.

  • Provide Information and Communication Technology (ICT) to 1.08 lakh government and government-aided schools, including computer labs with network and broadband internet.

• There is a need to charge some fees even in government and aided schools to enable management to raise resources for quality improvement.

• To help poor and weaker section students, generous scholarships are necessary, with high priority for girl students at risk of dropping out and marrying early.

Summary of Secondary Education Performance: (1 minute summary) Secondary and higher secondary education show moderate enrolment rates but high drop-out rates, with significant variations between states. The management landscape has shifted towards private unaided schools, indicating parental preference for perceived quality, which highlights the need to improve public school quality through increased investment. Performance in core subjects like Math, Science, and English is poor. The Eleventh Plan outlined ambitious targets and strategies for infrastructure development, teacher training, GER improvement, and ICT integration to move towards universalization, suggesting fee collection alongside scholarships to support quality enhancement.

5. Vocational Education

• According to National Sample Survey data for 2004-05, only 5% of the population aged 19-24 years in India had acquired some form of skills through vocational education.

• The Education Commission (1966) had visualized that 25% of students at the secondary stage would undertake the vocational stream by 1986.

• JBG Tilak attributed the failure of vocational education to several factors:

  • It was planned as second-rate, meant for the poor.

  • It was a terminal stream, lacking connectivity with higher education or industry/agriculture.

  • It was viewed as a strategy to reduce demand for higher education.

  • Vocational education is costlier than general secondary education.

  • Employment opportunities have not been particularly better for vocational education graduates.

  • Consequently, economic rates of return to vocational education were generally less than those to secondary general education.

• The Eleventh Plan emphasized demand-driven vocational education programmes in partnership with employers.

• It visualized extending vocational education to cover 20,000 schools with an intake capacity of 25 lakhs by 2011-12.

• Programmes were to be designed for mobility between vocational, general, and technical education, promoting flexibility.

• Despite efforts, only 5% of the population receive skill and training through the formal system.

• The remaining 4 crore unskilled and semi-skilled aspirants should be covered by a variety of delivery systems, including on-the-job training, part-time courses, open and distance learning, and sandwich courses.

• There is a strong need to strengthen computer literacy programmes as they improve employability.

• There is a gross failure in the provision of vocational education.

• The target of 25% by 1986 set by the Education Commission (1964-66) was far from the actual 5% in 2004-05.

• Effective strategies are needed for demand-driven vocational education programmes in partnership with employers.

• These shortages of skilled human power are experienced in the rapidly computerizing knowledge economy.

Summary of Vocational Education: (1 minute summary) Vocational education in India has significantly fallen short of its original goals, with only a small percentage of the youth acquiring skills through the formal system. This failure is attributed to its design as a 'second-rate', terminal stream for the poor, lack of industry connection, higher cost, and limited improvement in employment prospects compared to general education. The Eleventh Plan aimed for demand-driven, flexible programs in partnership with employers and suggested diverse delivery systems for skill training, alongside emphasizing computer literacy to address the shortage of skilled manpower needed in the knowledge economy.

6. Higher and Technical Education

• At independence, India had only 20 universities, around 500 colleges, and an enrolment of only one lakh in higher and technical education.

• The higher education system has grown into one of the largest globally, with 378 universities, 18,064 colleges, 4.92 lakh teachers, and 1.40 crore students in 2007.

• Institutions include Central Universities, State Universities, Deemed Universities, institutions of national importance, and state-legislated institutions.

• Higher education includes graduate and post-graduate courses, research, and Diploma or Certificate courses.

• Total enrolment in higher education grew from 34 lakhs in 1984-85 to 110.3 lakhs in 2005-06 and reached 146.25 lakhs in 2009-10.

• The average annual growth rate of enrolment from 1984-85 to 2009-10 was 6.01 per cent.

• In 2005-06, women students constituted 40.5 per cent of total enrolment.

• Stage-wise enrolment (2012-13): 85.9% at graduate level, 12.2% at post-graduate, 0.8% in research, and 1.1% in diploma/certificate courses.

• Faculty-wise enrolment (2012-13): 74.0% in general education (Arts, Science, Commerce/Management), and 24.4% in professional courses (Engineering/Technology, Medicine, Education, Law).

• Engineering/Technology had the highest percentage among professional courses, followed by Medical courses.

• Enrolment in agriculture (0.5%) and veterinary science (0.1%) was minimal despite 60% of the population engaged in agriculture, indicating a need for policy change to reduce this imbalance.

• Faculty Strength (2012-13): Out of 9.25 lakh teachers, 55.5% were lecturers, 11.9% senior lecturers (total ~67.4%), 23.5% readers, and 9.22% professors.

• India's Gross Enrolment Ratio (GER) in higher education, around 11% (2004-05, 14% in 2009-10 according to table 6 footnote), is very low compared to the world average of 23.2%, developed countries (54.6%), countries in transition (36.5%), and Asia (22%). (Note: Different GER figures are cited across sources, using 11% and 14%).

• There is a need to promote higher/tertiary education further for India to grow from a nation in transition to a developed country.

• The Eleventh Plan objective for higher education was that all who aspire to good quality higher education can access it, regardless of paying capacity.

• The share of private unaided higher education institutions increased significantly: 42.6% of institutions and 32.9% of enrolment in 2001 to 63.2% of institutions and 51.5% of enrolment in 2006 (during Tenth Plan).

• Private institutions improved access in selected areas like engineering, management, medicine, and IT, where students pay substantial fees.

• Expansion of private institutions is often motivated by profit, viewing investment as lucrative (20-30% return), not philanthropic.

• Their output is absorbed in expanding corporate and service sectors, creating an elite group.

• This education is often unaffordable for brilliant students from lower and middle classes, and especially weaker sections.

• This militates against the goal of inclusive development and is considered a conspicuous failure.

• The country must enforce the entry of brilliant students from lower strata into such institutions to promote vertical mobility.

• The Eleventh Plan estimated that about half of the targeted incremental enrolment for higher education would come from private providers.

• Technical institutions in India in 2006 included IITs/IIMs (national importance), engineering/technology colleges, polytechnics, pharmacy diploma institutions, hotel management schools, architecture institutions, MBA/PGDM institutions, MCA institutions, deemed-to-be universities (like IISc, ISM, etc.), and NITs.

• The All-India Council for Technical Education (AICTE) received statutory status in 1987 for coordinated development, qualitative improvement, and standard maintenance.

• During the Tenth Plan, AICTE-approved Degree Engineering/Technology institutions increased from 1,057 to 1,522, and annual intake from 2.96 lakhs to 5.83 lakhs.

• The aggregate number of technical institutions by the end of the Tenth plan was 4,512 with an intake capacity of 7.83 lakhs.

• Actual expenditure on technical education in the Tenth Plan was 73% of the outlay, implying that expansion is limited by inadequate absorptive capacity, not lack of resources.

• The dispersal of degree level technical institutions is highly skewed.

• Example: Andhra Pradesh, Tamil Nadu, Karnataka, and Maharashtra account for nearly 55% of Engineering Colleges and 58% of enrolment. The state-wise distribution is uneven.

• Eleventh Plan targets for Technical Education: Annual intake growth of 15% to meet skilled manpower needs.

• Envisaged setting up 8 new IITs, 7 new IIMs, 10 new NIITs, 22 IIITs.

• Scope for Public Private Partnership will be explored in establishing these institutions.

• Capabilities of 200 state engineering institutions will be upgraded with Central assistance.

• Intake capacity of existing institutions will be increased.

• State Engineering Colleges suffer from severe deficiencies in academic infrastructure, equipment, faculty, library, and physical facilities.

• These institutions are supposed to be models for private institutions to benchmark standards against. Government institutions must not be kept in unsatisfactory condition if standards are insisted upon for private ones.

Summary of Higher and Technical Education: (1 minute summary) Higher and technical education in India has expanded significantly since independence, becoming one of the largest systems globally in terms of institutions and enrolment. However, the Gross Enrolment Ratio remains low compared to international averages, reflecting it as largely elitist. The growth of private unaided institutions, while increasing access in specific professional areas, is primarily profit-driven and unaffordable for many, contradicting inclusive growth goals. Technical education is expanding but faces issues like skewed geographical distribution, infrastructure/faculty deficiencies in state institutions, and potentially inadequate absorptive capacity for funds. The Eleventh Plan aimed to increase access, promote inclusivity, and expand capacity through new institutions, upgrades, and exploring PPPs.

7. Open and Distance Learning

• At the school level, the National Institute of Open Schooling (NIOS) provides continuing education opportunities for those who missed completing school.

• 14 lakh students are enrolled at the secondary and higher secondary level through open and distance learning.

• At the higher education level, Indira Gandhi National Open University (IGNOU) coordinates distance learning.

• IGNOU has a cumulative enrolment of about 15 lakhs, serviced through 53 regional centers, 1,400 study centers, and 25,000 counselors.

• It uses 28 FM radio stations and six television channels.

• The Distance Education Council (DEC), an authority of IGNOU, coordinates 13 State Open Universities and 119 correspondence courses in conventional universities.

• Distance education institutions have expanded rapidly, but most need upgrading of standards and performance.

• Most correspondence courses have become "milch cows" for their universities, creating heavy surpluses used to fund conventional education.

• There is a large proliferation of courses without adequate human and physical infrastructure.

• This indicates a strong need to correct these imbalances.

• Distance education was adopted to provide opportunities for deprived sections.

• However, universities use these institutions to provide huge surpluses for their development.

• Even IGNOU charges very high fees for courses like BCA, MCA, MBA, and other vocational courses to make them self-financing or surplus generating.

Summary of Open and Distance Learning: (1 minute summary) Open and distance learning systems, like NIOS at the school level and IGNOU and State Open Universities at the higher education level, provide educational opportunities, especially for those who missed conventional schooling or are from deprived sections. While the infrastructure and reach have grown significantly, there are concerns about the quality and standards of many institutions. Additionally, a major failure identified is that these programs, originally intended for wider access, have become significant revenue generators ("milch cows") for universities, charging high fees, which can make them unaffordable and contradict the goal of serving the less privileged.

8. Financing Education

• India targeted devoting 6% of GDP to education, but performance has fallen short.

• Expenditure on education as a percentage of GDP rose from 0.64% in 1951-52 to a peak of 4.26% in 2000-01, but declined to 3.7% in 2007-08.

• Data for 2004-05 shows the figure was 3.4% of GDP. (Note: Slight discrepancy between 3.7% in text for 2007-08 and 3.4% in table for 2004-05, and 3.49% in failure section for 2004-05. Will cite all).

• Total educational expenditure is about 12% of the total budgeted expenditure.

• In a "model" budget, education should receive about 20 per cent.

• The shortfall from the 6% GDP target is considered a gross failure of priorities towards education.

• The Eleventh Plan envisaged a significant increase in outlay for education: ₹ 2.37 lakh crores at 2006-07 prices, a four-fold increase over the Tenth Plan.

• The relative share of education in the total plan outlay was set to increase from 7.7% to 19.4%.

• Around 50% of this outlay was for elementary education and literacy, 20% for secondary education (VIII to XII), and 30% for higher education including technical education.

• This boost aimed to address the resource constraint.

• The Right to Education legislation brought in by the government had ₹ 25,000 crore earmarked in the Union Budget (2010-11) for its implementation.

Summary of Education Financing: (1 minute summary) India has consistently failed to meet the target of spending 6% of GDP on education, with expenditure hovering significantly below this goal, around 3-4%. While there has been growth in absolute spending, the proportion of GDP and the share in the total government budget fall short of recommended levels. This underfunding is seen as a significant failure in prioritizing education, which is considered a key instrument for inclusive growth. The Eleventh Plan proposed a substantial increase in education outlay and its share in the total plan, allocating funds across elementary, secondary, and higher/technical education, with specific earmarks for the implementation of the Right to Education Act.

9. Major Achievements and Conspicuous Failures in Education (Summary)

• Achievements:

  • Remarkable growth in educational institutions at all levels (Primary, secondary, tertiary) due to sustained expenditure.

  • Achieved a Gross Enrolment Ratio of 96% at the primary level.

  • Development of a huge educational structure: 378 universities, 18,064 colleges, 1.52 lakh secondary/higher schools, 10.43 lakh primary/upper primary schools. This is a matter of legitimate pride.

  • Established institutions of excellence (engineering, medicine, management) and national research institutions (agriculture, science).

  • Produces the second largest educated and skilled manpower in the world, next to China.

  • Mid-day meal scheme has improved attendance and retention rate, especially among weaker sections.

• Failures:

  • Failure to achieve universalization of Elementary Education (UEE) despite the constitutional goal set for 1960. A large number of children remain outside elementary schools.

  • High drop-out rate in elementary education (I-VIII) was 50.8% in 2004-05.

  • Drop-out rate among STs (65.9%) and SCs (57.3%) was significantly higher than the overall rate.

  • High drop-out rate (I-X) was 62-64% for girls and 60% for boys.

  • Enrolment in Secondary and Higher Secondary combined was only 39.9% in 2004-05 (44.3% boys, 35.1% girls), which is very low.

  • Serious weaknesses exist in MDMS implementation, such as sub-standard meals and corruption, needing remedial action.

  • Glaring inter-state variations in enrolment, drop-out rates, and access to secondary/higher secondary levels require remedial action.

  • Sharp shift towards private unaided schools, doubling their share (15% to 30%) while government/aided schools declined (85% to 70%). This implies parents seek quality in private schools, necessitating more investment in public schools.

  • Need to strengthen school infrastructure (physical and human) for universalizing secondary education.

  • Suggestion to charge affordable fees in government/aided schools, supplemented by generous scholarships for the poor.

  • Gross failure in vocational education: Only 5% of 19-24 population skilled in 2004-05 vs. 25% target by 1986. Need for effective demand-driven programmes.

  • Higher education remains elitist: Low GER (11% vs. world average 23.2%, countries in transition 36.5%).

  • Increasing share of private unaided higher education institutions (institutions from 42.6% to 63.2%, enrolment from 32.9% to 51.5%) operating for profit, charging exorbitant fees, pricing out weaker sections. This is a conspicuous failure against inclusive development.

  • Skewed dispersal of technical education (AP, TN, Karnataka, Maharashtra account for major share).

  • Distance education institutions used as "milch cows" charging high fees, failing to adequately serve the deprived. Even IGNOU charges high fees for vocational courses.

  • Failure to meet the target of 6% of GDP public expenditure on education (reached 3.49% in 2004-05).

10. Health and Family Welfare and Development of Health Infrastructure

• Since independence, India has built a huge health infrastructure (primary, secondary, tertiary institutions like PHCs, CHCs, hospitals) in public, private, and voluntary sectors.

• Institutions for producing skilled human resources (medical, paramedical, AYUSH - Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy) were set up.

• Achievements include considerable improvements in health standards: life expectancy, infant and maternal mortality rates.

• Diseases like small pox and plague have been eliminated, and others like malaria, tuberculosis, and diarrhea contained.

• A strong link between poverty and health needs recognition.

• Long term and expensive illness can drive even non-poor into poverty.

• Improving health care requires a comprehensive approach: individual care, public health, sanitation, clean drinking water, knowledge of hygiene and child rearing.

• The poor and marginal groups find it difficult to afford expensive treatment.

• The state has a responsibility to provide free or affordable health care for deprived and marginal groups (women, young children, disabled, SCs, STs, economically weaker sections).

• Compared to countries in a similar stage of development (China, Indonesia, Sri Lanka), India performs worse on health indicators like life expectancy, Infant Mortality, Maternal Mortality, and Total Fertility Rate (2012 data presented). Example: India's IMR was 63/1000 live births vs. China's 18, MMR 200/100,000 live births vs. China's 37.

Summary of Health and Family Welfare: (1 minute summary) India has significantly expanded its health infrastructure and training institutions since independence, leading to improvements in key health indicators like life expectancy and mortality rates, and the control/elimination of certain diseases. However, health outcomes still lag behind comparable developing nations. Recognizing the strong link between poverty and health, and the burden of medical costs on the poor, the state acknowledges its responsibility to provide affordable care for vulnerable groups. A comprehensive approach encompassing clinical care, public health measures, sanitation, water, and hygiene is needed.

11. Total Fertility Rate (TFR) and Population Stabilization

• Total Fertility Rate (TFR) refers to the number of live births by a woman during her entire reproductive period.

• India's TFR reduced from 6.0 in the early 50s to 2.6 in 2010.

• India is moving towards a TFR of 2.1, which is required for population stabilization.

• This progress is attributed to an effective family welfare programme.

• The percentage of women using contraceptives increased from over 10% in the early 1970s to 56% in 2005-06.

Summary of TFR and Population Stabilization: (1 minute summary) India's Total Fertility Rate (TFR) has significantly declined over the decades, moving closer to the 2.1 rate needed for population stabilization. This positive trend is a result of effective family welfare programs, including a substantial increase in contraceptive usage among women.

12. Goals set by the Eleventh Plan for Health (for 2011-12)

• Reducing Maternal Mortality Rate (MMR) to 100 per 1,00,000 live births.

• Reducing Infant Mortality Rate (IMR) to 28 per 1000 live births.

• Reducing Total Fertility Rate (TFR) to 2.1.

• Providing clean drinking water to all by 2009.

• Reducing malnutrition among children aged 0-3 to half its present level.

• Reducing anemia among women and girls by 50%.

• Raising sex ratio for age group 0-6 to 935 by 2011-12 and 950 by 2016-17.

Summary of Eleventh Plan Health Goals: (1 minute summary) The Eleventh Five Year Plan set ambitious health goals for 2011-12, including targets for reducing maternal and infant mortality rates, achieving a population stabilizing Total Fertility Rate, ensuring clean drinking water for all, halving child malnutrition and women/girl anemia, and improving the sex ratio.

13. Health Indicators (Comparison)

• Table 12 provides 2012 health indicators for selected countries.

• India (2010/2012 data): IMR 63, Life Expectancy 65.8 years, MMR 200, TFR 2.6.

• China: IMR 18, Life Expectancy 73.7 years, MMR 37, TFR 1.6.

• Indonesia: IMR 35, Life Expectancy 69.8 years, MMR 220, TFR 2.1.

• Sri Lanka: IMR 17, Life Expectancy 75.1 years, MMR 35, TFR 2.3.

• India's indicators were less favorable compared to China, Indonesia, and Sri Lanka, which were considered to be at a similar stage of development.

• The target of reducing MMR to 100 by 2011-12 was very ambitious, given it was 301 in 2001-03 and 200 in 2010. Achieving this target seems difficult at the pace of decline.

• Improving birth attendance and midwifery facilities rapidly is needed to reduce MMR.

• IMR was 63 in 2010. Despite progress in immunization and disease reduction (polio, diarrhea), the target of 28 by the end of the Eleventh Plan seems far off.

Summary of Health Indicators (Comparison): (1 minute summary) While India has improved its health indicators, comparisons with countries like China, Indonesia, and Sri Lanka, considered at a similar stage of development, show that India lags behind in key metrics such as Infant Mortality Rate, Maternal Mortality Rate, and Life Expectancy. Achieving the ambitious targets set by the Eleventh Plan for these indicators, especially MMR and IMR, is challenging based on observed progress rates.

14. Disparity in Urban/Rural Health Care

• Rural health care is very poor in some states, while the situation is better in urban areas.

• Disparity between urban and rural areas is observed in all health indicators.

• Example: In 2009, Rural Crude Birth Rate (24.1/1000) was higher than urban (18.3); Rural Crude Death Rate (8.0/1000) was higher than urban (5.9); Rural IMR (55/1000 live births) was higher than urban (34).

• Anaemia among rural children below 3 years was a serious problem at 82.1%, compared to 72.7% in urban areas (2004 data).

• Anaemia among pregnant women was 59.0% in rural areas vs. 54.6% in urban areas (2004 data).

• Large disparities place a heavy burden on the poor, scheduled castes, and scheduled tribes.

• Sharp differences exist in health indicators between advanced and backward states.

• In urban areas, high density and the existence of slums are serious problems.

• In 2001, 42.6 million persons lived in urban slums (15% of urban population).

• High density, congestion, poor housing, lack of sanitation, and poor quality drinking water in slums lead to high incidence of diseases (asthma, TB, malaria, heart diseases, diabetes, etc.).

• Urban poor lack access to health care and savings, seriously affecting their capacity to earn when ill.

Summary of Urban/Rural Health Disparity: (1 minute summary) Significant disparities exist between urban and rural healthcare in India, with rural areas generally having poorer health indicators and service provision. This gap is evident across various metrics, including birth rates, death rates, and infant mortality, and particularly high rates of anemia in rural children and pregnant women. The burden of these disparities falls heavily on vulnerable groups like the poor, Scheduled Castes, and Scheduled Tribes. In urban areas, health challenges are concentrated in slums, where poor living conditions, sanitation, and water quality contribute to high disease prevalence and limited access to affordable care for the urban poor.

15. Disease Burden

• Estimates of disease burden in India for 2009/2004 are provided.

• Communicable diseases include Acute Respiratory Infection (2400 cases/lakh), Diarrhoea (1018 cases/lakh), HIV/AIDS (523 cases/lakh), Malarial & other vector bone diseases (133 cases/lakh), and Tuberculosis (100 cases/lakh).

• In 2009, 3.1 million people suffered from HIV/AIDS. By Dec 2006, 1.26 lakh cases were reported.

• Tuberculosis remains a public health problem with 1.8 million new cases annually.

• An estimated 130 million persons are exposed to the risk of Kala-azar in endemic areas. Incidence and deaths have reduced significantly between 1992 and 2005.

• Non-communicable diseases (NCDs) include Cancer (8 cases/lakh), Diabetes (310 cases/lakh), Mental Health (650 cases/lakh), Blindness (141 cases/lakh), Cardiovascular diseases (290 cases/lakh), Asthma (405 cases/lakh) (2004 data).

• NCDs impose heavy burdens on the budgets of the poor and impair their earning capacity.

• Cancer is an important public health problem with 7-9 lakh new cases annually and about 25 lakh existing cases.

• Tobacco related cancers account for about 50% of male cancers and 20% of female cancers.

• About 1 million deaths annually are caused by tobacco related diseases.

• Over 12 million persons in India are blind. Cataract is the main cause (63%), followed by weak eyesight (20%).

• Injuries accounted for 9.8 deaths per lakh population in 2004.

Summary of Disease Burden: (1 minute summary) India faces a significant burden from both communicable and non-communicable diseases. Communicable diseases like Acute Respiratory Infections, Diarrhea, HIV/AIDS, Malaria, TB, and Kala-azar are prevalent. NCDs such as Cancer, Diabetes, Mental Health issues, Blindness (primarily due to cataract), Cardiovascular diseases, and Asthma are also major concerns. Notably, tobacco-related diseases cause a substantial number of deaths annually. These diseases not only impact health but also pose a significant economic burden, particularly on the poor, by increasing healthcare costs and reducing earning capacity.

16. Health Care Infrastructure and Shortage of Health Personnel

• Rural areas suffer from inadequate health infrastructure.

• The rural health infrastructure is tiered:

  • Sub-Centre: Gram-panchayat level, for 5-6 villages.

  • Primary Health Centre (PHC): Cluster of 30-40 villages.

  • Community Health Centre (CHC): Block level, caters to 1,00,000 population.

  • ASHA (Accredited Social Health Activist): Village level.

• Level of facilities improve from Sub-Centre to PHC to CHC.

• There is a significant shortfall in CHCs (40.9%) based on 2001 census requirements, indicating secondary health care is seriously affected.

• Shortfall in Sub-centres is 13.2%, and in PHCs is 18.5%.

• Due to CHC shortage, rural population has to approach hospitals in towns and cities for serious ailments.

• Government hospitals increased from 4,571 in 2000 to 7,663 in 2006 (67.6% increase).

• Number of beds in public hospitals increased from 4.30 lakhs to 4.93 lakhs (14.4% increase) during the same period.

• Government hospitals suffer from semi-used or dysfunctional infrastructure.

• Rural people often lack trust in government hospitals and prefer private ones.

• Data for private hospitals is not fully available, but in 2002 there were 11,345 private hospitals with 2.63 lakh beds.

• Most private hospitals are in cities and towns.

• The share of cases treated in private hospitals is rising due to rapid expansion.

• In rural areas, the percentage of cases treated in Government hospitals declined from 59.7% in 1986-87 to 41.7% in 2004-05. Private hospitals' share increased from 40.3% to 58.3%.

• In urban areas, private hospitals' share increased from 39.7% in 1986-87 to 61.8% in 2004-05.

• The shift to private hospitals is despite the much higher cost of care.

• Example: Average medical expenditure per hospitalization in 2004 in rural areas was ₹ 3,238 in government hospitals vs. ₹ 7,408 in private ones (2.29 times higher). In urban areas, it was ₹ 3,877 in government vs. ₹ 11,553 in private (2.98 times higher).

• The Eleventh Plan cites reasons for the shift to private sector despite higher costs:

  • People's growing lack of trust in the public system.

  • Critical shortages of health personnel.

  • Inadequate incentives and poor working conditions.

  • Lack of transparency in posting doctors in rural areas.

  • Absenteeism.

  • Long waits and inconvenient clinic hours.

  • Poor outreach.

  • Time of service and insensitivity to local needs.

  • Inadequate planning, management, and monitoring.

• The system is overloaded due to the shortage of primary health care facilities, especially in rural areas.

Summary of Health Infrastructure and Personnel: (1 minute summary) India's rural health infrastructure is structured in tiers (Sub-centres, PHCs, CHCs), but suffers from significant shortfalls, particularly in CHCs, limiting access to secondary care in rural areas. While the number of public hospitals has increased, they are often perceived as having dysfunctional infrastructure and suffering from staff shortages, absenteeism, and poor management, leading to a lack of public trust. Consequently, there's a growing shift towards private hospitals, which, although concentrated in urban areas and significantly more expensive, are increasingly utilized by both rural and urban populations. This shift highlights critical failures in the public health system's ability to provide accessible and trusted care.

17. Health Expenditure in India

• According to National Health Account (NHA) 2001-02, total health expenditure was ₹ 1,05,734 crore (4.6% of GDP).

• Public health expenditure was 0.94% of GDP, private was 3.58% of GDP, and external support was 0.11% of GDP.

• Using World Development Indicators (2011), total health expenditure in India was 3.9% of GDP.

• Public expenditure was 1.2% of GDP, accounting for 31% of total expenditure (2011).

• Comparison with other countries (2011 data, 2010 for Japan): China (5.1% total, 2.8% public, 55.9% public share), South Korea (7.2% total, 4.1% public, 57.3% public share), Japan (9.3% total, 7.4% public, 80.0% public share), UK (9.3% total, 7.7% public, 82.7% public share), USA (7.9% total, 8.2% public, 46.0% public share).

• India's share of public health expenditure (1.2% of GDP, 31% of total) is very low compared to many developed and developing countries.

• Per capita expenditure on health was $59 in India in 2011, significantly lower than China ($278), Japan ($3958), UK ($3609), and USA ($8608).

• India must increase its health expenditure, especially public expenditure, to provide better health facilities even to the poor at a lower cost.

• Trends in Centre and States Health Expenditure: Public expenditure on health (Centre and States combined) as a percentage of total government expenditure declined from 3.12% in 1992-93 to 1.3% in 2014-15.

• As a percentage of GDP, combined Centre and States health expenditure increased slightly from 1.03% in 2004-05 to 1.3% in 2014-15.

• This increase is not significant.

• India is still way behind the Eleventh Plan goal to raise public health expenditure to 2.3% of GDP by 2011-12.

• Per capita real expenditure (at 2004-05 prices) was almost constant from 2004-05 to 2014-15.

• Public health expenditure as a percentage of GDP also appears stagnant based on the data presented.

• The combined expenditure of Centre and State government declined from 1.01% of GDP in one period (not specified year, but previous data given) to 0.99% in 2003-04, then improved to 1.13% in 2006-07. (Note: These figures differ slightly from the 1.03% in 2004-05 and 1.3% in 2014-15 provided elsewhere, indicating data source variations or slight year differences).

• There is a need to raise public health expenditure further to 2.3% during the Eleventh Plan to serve social justice more effectively.

Summary of Health Financing: (1 minute summary) India's public health expenditure, both as a percentage of GDP and as a share of total government spending, is notably low compared to international benchmarks and even comparable developing countries. Per capita health spending is also very low. While the Eleventh Plan set a target to significantly increase public health spending as a percentage of GDP, actual progress has been minimal or stagnant. This underfunding is seen as a major challenge preventing the state from providing adequate and affordable health facilities, especially for the poor, and hinders the goal of inclusive development and social justice in the health sector.

18. Eleventh Plan: Targets and Strategy for Health

• The Eleventh Five Year Plan aimed for inclusive growth by introducing the National Urban Health Mission (NUHM) alongside the existing National Rural Health Mission (NRHM).

• Together, NUHM and NRHM would form Sarva Swasthya Abhiyan (Health for all campaign).

• NRHM intends to increase access and utilization of quality health by strengthening health infrastructure, both physical and human.

• Under NRHM, plans included:

  • Over 5 lakh ASHAs (Accredited Social Health Activists) for every 1,000 population/large habitations by 2008.

  • All sub-centres (nearly 1.75 lakh) to be functional with 2 ANMs (Auxiliary Nurse Midwives) by 2010.

  • All PHCs (nearly 30,000) to have 3 staff nurses for 24/7 services by 2010.

  • 6,500 CHCs to be established/strengthened with 7 Specialists and 9 staff nurses by 2012.

  • 1,800 Taluka/sub-divisional hospitals and 600 district hospitals to be strengthened for quality services by 2012.

  • Mobile Medical Units for each district by 2009.

• Emphasis under NRHM was on Indian Public Health Service Standards and enforcement of guidelines, not just numerical achievements.

• Expected Outcomes of NRHM included specific reductions in mortality/incidence for Malaria, Kala Azar, Dengue, Leprosy, and Filaria, increasing Cataract operations, maintaining TB cure rate, upgrading health establishments to standards, and increasing utilization of First Referral Units.

Summary of Eleventh Plan Health Strategy: (1 minute summary) The Eleventh Plan aimed for inclusive health growth by launching the National Urban Health Mission (NUHM) to complement the existing National Rural Health Mission (NRHM), forming a "Health for All" campaign (Sarva Swasthya Abhiyan). NRHM focused on significantly strengthening rural health infrastructure and human resources at all tiers (Sub-centres, PHCs, CHCs, hospitals) and introducing ASHAs and Mobile Medical Units. The strategy emphasized achieving specific health outcome targets for various diseases and improving service quality through adherence to Indian Public Health Service Standards, going beyond mere infrastructure expansion.

19. Janani Suraksha Yojana (Maternity Protection Scheme)

• Janani Suraksha Yojana (JSY) is a scheme with the dual objectives of reducing maternal and infant mortality.

• It aims to achieve this by promoting institutional deliveries.

• The scheme is 100% Centrally sponsored and integrates cash assistance with medical care.

• Under NRHM, JSY beneficiaries accounted for 28.74 lakhs out of 184.25 lakh institutional deliveries (as on April 1, 2007).

• Two critical factors need attention for the scheme's success:

  • India lacks the institutional capacity to receive 26 million women giving birth annually.

  • Half of maternal deaths occur outside of delivery (during pregnancy, abortions, post-partum complications).

• A gradual approach of increasing institutional capacity and encouraging institutional deliveries is suggested.

• JSY money sometimes does not reach hospitals on time, meaning poor women/families don't receive promised amounts, which needs redressing.

Summary of Janani Suraksha Yojana: (1 minute summary) The Janani Suraksha Yojana (JSY) is a centrally sponsored scheme designed to reduce maternal and infant mortality by encouraging institutional deliveries through integrated cash assistance and medical care. While contributing to institutional deliveries, its effectiveness is hampered by the existing limited institutional capacity to handle the high number of births and challenges in the timely disbursement of funds to hospitals, which impacts beneficiaries' access to promised support.

20. National Urban Health Mission (NUHM)

• National Urban Health Mission (NUHM) is intended to meet the health needs of the urban poor, particularly slum dwellers.

• Its goal is to make essential primary health care services available to them.

• NUHM covers all cities with a population of 1,00,000 or more.

• It specifically covers slum dwellers and other marginalized urban dwellers such as rickshaw pullers, street vendors, railway/bus station coolies, homeless people, street children, and construction site workers.

Summary of National Urban Health Mission: (1 minute summary) The National Urban Health Mission (NUHM) is a program targeting the health needs of India's urban poor, with a specific focus on slum dwellers and other marginalized populations like street vendors and homeless individuals. It aims to ensure these vulnerable groups have access to essential primary health care services in cities with populations exceeding 100,000.

21. Strengthening Existing Health System

• States need to develop systems that comprehensively address the health needs of the poor.

• The Eleventh Plan stressed Integrated District Health Plans and Block Specific Health Plans.

• This involves involving all stakeholders and emphasizing partnership with Panchayati Raj Institutions, local bodies, community, NGOs, Voluntary and Civil Society Organisations.

• Primary Health Care is a major issue, especially in rural areas with scattered habitations, where women and children die en route to hospitals.

• Achieving health objectives requires more than just curative or preventive care; an integrated approach is needed.

• Policy interventions must be area-specific, not a single plan for the whole country.

• States are encouraged to implement the Tamil Nadu model, where nearly 58% of PHCs and CHCs function round the clock.

• Success models from other states can be considered.

• Example: Higher salaries for health workers in tribal regions of Himachal Pradesh and KBK districts of Orissa.

• Example: The Akha ("Hope") ship in Assam, where doctors and ANMs live on a ship to provide health camps, immunization, treatment, advice, and transport critically ill patients in flood-prone remote areas. This scheme is referred to as the Akha – Ship of Hope.

• The tribal population is considered the most socio-economically disadvantaged group.

• There is a need to encourage tribal medicine under AYUSH.

• It is important to involve the community by explaining and providing proof to shed harmful beliefs and superstitions.

• Example: SEARCH hospital works with tribals. In their Aarogaya Sansad (Health Parliament), tribals learned malaria was caused by mosquitoes and voted for elimination.

• Communicating with tribals in their language and achieving cultural alignment along with medical care can succeed in tribal areas.

• Jan Swasthya Sahyog (JSS) in remote areas of Bilaspur and Chattisgarh is an example of dedicated doctors developing simple, low-cost technologies for diagnostic tests (UTI, anemia, diabetes, pregnancy).

• They developed low-cost mosquito repellent, pneumonia detection techniques, easy-to-read BP instruments, and water purification methods usable by illiterate/semi-literate women and school children.

• JSS developed simple techniques for malaria detection, training village health workers to collect samples and using bus drivers as a courier system to transport samples to the hospital and reports back. This courier system saved many lives.

• These JSS techniques can be used by health workers to diagnose diseases and suggest drugs.

Summary of Strengthening Health System: (1 minute summary) Strengthening the health system, especially primary healthcare in rural areas, requires integrated, area-specific planning involving various stakeholders like local bodies and NGOs. Successful state models, such as Tamil Nadu's round-the-clock centers, incentive pay in challenging areas, and innovative approaches like Assam's Akha ship, offer valuable lessons. Addressing the health needs of vulnerable groups like tribal populations involves cultural alignment, community involvement, and potentially incorporating traditional medicine. Grassroots initiatives like Jan Swasthya Sahyog demonstrate the effectiveness of developing low-cost, simple technologies and community-based approaches for diagnosis and care in remote settings.

22. Secondary and Tertiary Health Care

• The Eleventh Plan emphasized that administration of secondary and tertiary care hospitals should be professionalized, with trained professionals posted as Medical Superintendents.

• The source notes this is an over-statement for public sector hospitals, where Medical Superintendents are already professionals, and other staff are qualified.

• The situation might differ in private sector hospitals, where some might lack qualified staff.

• However, reputed private and specialized hospitals attract qualified staff by paying more than the public sector.

• The government initiative to set up 6 AIIMS-like institutions and upgrade 13 existing medical institutes is welcomed.

• The secondary and tertiary system is overloaded due to the shortage of primary health care facilities, especially in rural areas.

Summary of Secondary and Tertiary Health Care: (1 minute summary) The Eleventh Plan proposed professionalizing the administration of secondary and tertiary hospitals, although the source notes that public sector hospitals already employ qualified professionals. Reputable private hospitals also attract skilled staff, often through higher pay, while smaller private facilities might have staffing gaps. Acknowledging the burden on these higher-level facilities due to shortcomings in primary care, the government's initiative to establish new premier institutions (like AIIMS) and upgrade existing ones is seen as a positive step to enhance specialized care capacity.

23. Access to Essential Drugs and Medicines

• Household expenditure on health and drugs (2005 NCMH data) is 6.1% of total household expenditure in rural areas and 4.9% in urban areas.

• The share of drug expenditure within this is 77.3% in rural areas and 69.2% in urban areas.

• The poor are the worst affected because they are frequently ill and least able to purchase and utilize health services and drugs.

• The Eleventh Plan aimed to follow the Tamil Nadu experiment in providing Essential Drugs, as per the WHO list, at affordable prices.

• This experiment is being implemented in Rajasthan and Delhi.

• This requires more expenditure by Central and State Governments, which currently spend only 10% of their overall budget on health.

• Timely supply of drugs is crucial, requiring establishing systems for procurement and management.

• If implemented sincerely, this can reduce the out-of-pocket expenses on medicines.

• There is a need to set up mechanisms to make at least essential drugs available at affordable prices.

Summary of Access to Essential Drugs: (1 minute summary) Household expenditure on health, particularly drugs, constitutes a significant portion of spending, especially in rural areas. The poor bear a disproportionate burden as they face higher illness rates and limited capacity to afford necessary medicines. To address this, the Eleventh Plan proposed adopting models like the Tamil Nadu experiment to provide WHO-listed essential drugs at affordable prices. Successful implementation requires increased government spending on health and efficient systems for drug procurement and management to reduce costly out-of-pocket expenses for vulnerable populations.

24. Enhancing Public-Private Partnerships (PPPs)

• The Eleventh Plan enthusiastically recommended Public-Private Partnerships.

• Examples of successful PPP experiences mentioned:

  • Karnataka's Yeshawini Health Insurance Scheme: Involved State Department of Co-operatives, Yeshawini Trust (with 200 private hospitals), and a corporate Third Party Administrator.

  • Government of Gujarat's Chiranjeevi Yojna: Enlisted private doctors for deliveries of pregnant women from BPL families (normal and caesarean).

  • Andhra Pradesh government's Urban Slum Health care project: Provided public premises to private sector partners.

  • Government of Rajasthan: Contracts diagnostic services in the public sector and provides drugs at cheaper rates in hospitals for BPL families and senior citizens (>70) free of cost.

• Various state initiatives exist, but experience shows such experiments succeed more with NGOs motivated by charity.

• Since the private partner operates with an eye on profits, such experiments "hardly succeed" in achieving public goals.

• The Eleventh Plan conceded that true partnerships (equality, mutual commitment, shared decision-making/risk) are rarely seen.

• The private sector operating for profit cannot address the concerns of the poor, except where motivated by charitable purposes.

Summary of Public-Private Partnerships: (1 minute summary) The Eleventh Plan actively promoted Public-Private Partnerships (PPPs) in healthcare, citing several state-level examples like health insurance schemes and service delivery models involving private providers. However, the source notes a significant challenge: while partnerships with charitable NGOs can be successful, those with private entities primarily driven by profit motives often fail to effectively serve public health goals, particularly for the poor. The document concludes that genuine partnerships characterized by equality and shared commitment are uncommon.

25. Health Insurance: Protecting the Poor

• Ensuring good health for all, especially the poor, is difficult.

• High out-of-pocket expenditure on hospitalization is a major burden.

• Example (2004 NSS data): Out-of-pocket expenditure per hospitalization exceeded ₹ 3,000 in rural government hospitals, ₹ 7,000 in rural private hospitals, and ₹ 11,000 in urban private hospitals. Urban private hospital costs were about 3 times higher than public ones.

• The poor who incur such expenditure often face heavy indebtedness.

• New initiatives are needed to considerably reduce out-of-pocket expenses on health services and drugs for the poor.

• Reducing these expenses will have a positive impact on alleviating poverty.

• Current health insurance in government and private sectors covers only 1% of the population.

• Existing schemes (ESIS, CGHS, ECHS) cover specific groups: industrial workers, government employees, Ex-Armed Forces Personnel.

• Mediclaim mainly covers upper middle income groups.

• Private health insurance schemes are mostly urban-oriented and have issues: unaffordable premiums, delay in settling claims, unilateral rule changes, non-transparent procedures.

• There is a strong need to involve Self-Help Groups (SHGs) to encourage the poor to contribute for health insurance.

• Needy households could receive cash support (₹ 5,000-₹ 10,000) per hospitalization, catastrophic illness, or death.

• Health insurance should be extended for workers in the unorganized sector so that the weakest sections receive assured benefits and are saved from falling into a poverty trap due to illness. Prolonged illness leads to income fall and rapid expenditure rise.

Summary of Health Insurance: (1 minute summary) High out-of-pocket healthcare expenses, particularly for hospitalization, lead to heavy indebtedness and exacerbate poverty for the poor. Current health insurance coverage is extremely low (only 1% of the population), primarily covering specific employee groups and higher-income brackets (Mediclaim). Private insurance for the general population faces challenges like high premiums and poor procedures. There is a critical need for new health insurance initiatives, potentially involving Self-Help Groups, to protect the poor from financial ruin due to illness, specifically recommending coverage extension for the vast unorganized sector workforce through schemes providing hospitalization and other benefits.

26. Community Based Health Insurance (CBHI)

• Community Based Health Insurance (CBHI) is a suggested initiative.

• CBHI is a not-for-profit insurance scheme aimed at the informal sector.

• It is formed on the basis of collective pooling of health risks and members participating in its management.

• A major issue in developing CBHI is involving the community in defining the contribution amount and developing a collective mechanism for benefit packages.

• Examples of successful CBHI initiatives cited: ACCORD, BAIF, Karuna Trust, SEWA, DHAN, and VHS.

• These schemes should be tailored to the needs of the poor and organized according to their convenience.

Summary of Community Based Health Insurance: (1 minute summary) Community Based Health Insurance (CBHI) is proposed as a way to protect the informal sector and the poor. These not-for-profit schemes pool health risks collectively, with members involved in management and determining contributions and benefits. Successful examples exist, demonstrating that such initiatives need to be customized to the specific needs and convenience of the poor to be effective.

27. Health Insurance for Unorganized Workers

• About 93 per cent of the labour force is employed in the unorganized sector, largely without health coverage.

• The National Commission for Enterprises in the Unorganized Sector (NCEUS) recommended a specific scheme for health insurance for these workers and their families.

• The scheme is part of a proposed national social security scheme.

• Scheme details:

  • Workers and families entitled to hospitalization cover costing up to ₹ 15,000 annually, with a maximum of ₹ 10,000 per ailment.

  • Treatment in designated public or private hospitals/clinics recognized by the State Board with at least 15 beds.

  • Transport cost provided if no such clinic is within 10 km.

  • Payments made directly by the insurance company to clinics/hospitals; no cash to workers (except transport).

  • Maternity Benefits of up to ₹ 1,000 maximum or actuals per year for the member and spouse.

  • Sickness cover of ₹ 750 for the earning head of the family for 15 days during hospitalization.

• The NCEUS report was presented in August 2007.

• The Cabinet approved the scheme on Aug 21, 2008, to be sent to Parliament for approval of the National Social Security Act.

Summary of Health Insurance for Unorganized Workers: (1 minute summary) Recognizing that the vast majority of the Indian workforce is in the unorganized sector with no health coverage, the National Commission for Enterprises in the Unorganized Sector recommended a health insurance scheme for them. This proposed scheme, part of a larger social security plan, would provide hospitalization coverage up to specific limits, maternity benefits, and limited sickness pay during hospitalization, with payments made directly to healthcare providers to ensure timely access for workers and their families.

28. Maternity Health Insurance

• All pregnant women belonging to BPL (Below Poverty Line) families will be covered under a maternity health insurance scheme.

• The capitation fee for this scheme will be borne by the government.

Summary of Maternity Health Insurance: (1 minute summary) As part of initiatives to protect vulnerable groups, a specific maternity health insurance scheme is planned to cover all pregnant women from Below Poverty Line families, with the government funding the necessary capitation fees.

29. Extension of CGHS and other Government Schemes

• Existing government schemes like CGHS (Central Government Health Scheme), ESIS (Employees State Insurance Scheme), and ECHS (Ex-servicemen Contributory Health Scheme) cover specific, limited groups (CGHS covered only 33 lakh workers as of Dec 2006).

• The NCEUS report specifically recommended that these schemes be extended to the unorganized workers.

• Expanding health infrastructure requires substantial increases in contributions from both the Central and State Governments.

Summary of Extension of Government Schemes: (1 minute summary) Existing government health insurance schemes primarily cover organized sector workers and specific government employees. The National Commission for Enterprises in the Unorganized Sector recommended extending these schemes, such as CGHS and ESIS, to cover the vast majority of the workforce in the unorganized sector, emphasizing the need for significantly increased government funding from both central and state levels to support this expansion.

30. Jan Swasthya Sahyog (JSS)

• Jan Swasthya Sahyog (JSS) is a group of dedicated doctors working in remote areas of Bilaspur and Chattisgarh.

• They developed simple technologies for various diagnostic tests.

• Example: Early detection of UTI costs < ₹ 2 per test, anemia ₹ 1, diabetes ₹ 2, pregnancy ₹ 3 using JSS methods.

• They developed low-cost mosquito repellent creams, pneumonia detection techniques, easy-to-read blood pressure instruments, and simple water purification methods.

• These techniques are designed to be used by illiterate or semi-literate women and school children.

• They developed simple techniques for malaria detection.

• Village health workers are trained to get blood samples, which are packed and transported via bus drivers to the Ganiyare hospital run by JSS.

• Samples are immediately tested, and reports are sent back via the same bus drivers.

• This courier system has saved many lives.

• JSS simple techniques can be used by all health workers for disease diagnosis and drug suggestion.

Summary of Jan Swasthya Sahyog: (1 minute summary) Jan Swasthya Sahyog (JSS) is a remarkable initiative by dedicated doctors providing healthcare in remote areas. They have innovated simple, low-cost technologies for common diagnostic tests and health tools, specifically designed to be usable by individuals with limited literacy, including women and children. A notable application is their community-based malaria detection system involving trained local workers and using bus routes as a courier service for samples and reports, which has proven effective in saving lives and highlights the potential of appropriate technology and community engagement in underserved regions.

31. Trends in Health Financing by the Centre and States

• Public expenditures on health (Centre and States) as a percentage of total government expenditure declined from 3.12% in 1992-93 to 1.3% in 2014-15.

• Total health expenditure (Centre + States) as a percentage of GDP increased from 1.03% in 2004-05 to 1.3% in 2014-15.

• This is not a significant development.

• India is still behind the Eleventh Plan goal of raising it to 2.3% of GDP by 2011-12.

• Actual data suggests the goal was not reflected in performance.

• Per capita real expenditure (at 2004-05 prices) is almost constant.

• Public health expenditure as a percentage of GDP also appears stagnant.

Summary of Health Financing Trends: (1 minute summary) Trends in health financing show a concerning decline in public health expenditure as a percentage of total government spending over the past two decades. While public health spending as a percentage of GDP has slightly increased, it remains very low and stagnant, falling far short of the targets set by the Eleventh Plan. Similarly, per capita real expenditure on health has remained nearly constant, indicating insufficient investment in the sector despite stated goals.

32. Clean Drinking Water and Sanitation

• Clean drinking water is vital because unsafe water increases disease risk and malnutrition.

• Water-borne diseases have adverse effects on health.

• In 2005, 97.0% of rural habitations were fully covered with water supply.

• However, 1.66 lakh rural habitations (11.7%) had slipped back, lacking adequate water and requiring travel >2 kms.

• 1.86 lakh rural habitations (13.1%) depended on contaminated water supply, causing health problems.

• Access to an improved water source was available to 86% of the population in 2004 (World Development Indicators 2008).

• Lack of sanitation is directly responsible for several water-borne diseases.

• Rural sanitation coverage was 1% in the 1980s, improved to 4% in 1998 and 22% in 2001.

• 100% sanitation coverage is believed necessary for sufficient decline in rural health indicators.

• A massive program is needed to achieve 100% rural sanitation.

• Village Health and Sanitation Committees under NRHM can assist.

• Access to improved sanitation facilities was available to 33% of the population in India in 2004, up from 14% in 1990 (World Bank).

• Compared to other developing countries (Malaysia 94%, Philippines 72%, Pakistan 59%, Indonesia 55%), India's record on sanitation is very poor.

• A concerted effort is needed for sanitation improvement.

• Need to provide clean drinking water and sanitation, especially in slums and backward/remote rural regions, to prevent water-borne diseases.

Summary of Clean Drinking Water and Sanitation: (1 minute summary) Access to clean drinking water and adequate sanitation is crucial for preventing water-borne diseases and improving public health. While India has made strides in providing water supply to rural habitations, many still face issues of inadequate or contaminated sources. Sanitation coverage, particularly in rural areas, remains very low compared to the needs and international standards, highlighting a significant failure. Achieving 100% rural sanitation is deemed necessary for substantial health improvements, requiring massive efforts and community involvement.

33. Overall Health Status of India’s Population (Summary)

• Achievements: Significant improvement in health indicators (life expectancy, IMR, MMR). Development of huge health infrastructure (sub-centres, PHCs, CHCs). NRHM and NUHM are major initiatives.

• Failures/Challenges:

  • Performance still worse than comparable countries (China, Indonesia, Sri Lanka).

  • High prevalence of malnutrition (20% population, 47.9% children <5 years in 2002-04).

  • Health issues in urban slums due to poor conditions (42.6 million people).

  • Health infrastructure faces shortage of staff and inadequate equipment, forcing rural population to travel for care.

  • Increasing preference for private hospitals despite significantly higher costs, indicating lack of trust in public system.

  • Secondary and tertiary care systems are overloaded due to primary care shortages.

  • High out-of-pocket expenditure on health and drugs, particularly burdening the poor.

  • Need for mechanisms to ensure affordable essential drugs.

  • PPPs often fail to address concerns of the poor due to private sector profit motives.

  • Need to extend health insurance to the unorganized sector to prevent poverty traps from illness.

  • Public health expenditure (Centre + State) remains low as % of GDP (1.13% in 2006-07, 1.3% in 2014-15), needing significant increase (target 2.3%).

  • Poor record on sanitation (only 33% with access to improved facilities in 2004).

  • Untreated illness among the poor has increased due to financial constraints.

  • Inequality in untreated illness, health expenditure, and use of health facilities has worsened between rich and poor.

  • The rich are major users of both private and public hospitals.

  • Increased drug costs and rising fees in both sectors played a major role in worsened inequality and untreated illness. This is a major challenge for the reproductive health agenda.

Summary of Overall Health Status: (1 minute summary) Overall, India has made progress in health indicators and infrastructure development but lags behind peer nations and faces significant challenges. Key issues include high malnutrition, health problems in urban slums, infrastructure and staffing gaps in rural areas leading to lack of trust in public facilities and a shift to costly private care, a large burden of out-of-pocket expenses driving the poor into debt, inadequate health insurance coverage for the unorganized sector, limited success of profit-driven PPPs in serving the poor, and critically low public health spending. Inequality in accessing and affording healthcare has worsened, with the poor increasingly unable to treat illnesses due to financial constraints, while the rich utilize both public and private systems.

Questions for Understanding and Practice

Conceptual Questions (Short Answer)

1. What constitutional goal was set for elementary education in India at independence, and when was it originally intended to be achieved?

2. What major constitutional amendment made elementary education a Fundamental Right?

3. What is the Gross Enrolment Rate (GER) at the elementary level mentioned in the sources, and what is the corresponding drop-out rate for the entire elementary stage?

4. According to the source, what are some key factors contributing to high drop-out rates in elementary education, besides socio-economic status?

5. What was the target percentage for students undertaking the vocational stream at the secondary stage, set by the Education Commission (1966), and what was the actual achievement in 2004-05?

6. How does India's Gross Enrolment Ratio (GER) in higher education compare to the world average as per the sources?

7. What proportion of India's workforce is in the unorganized sector, and what is the recommended health coverage status for them?

8. According to the sources, what is the primary motive driving the expansion of private institutions in higher education, and how does this affect access for weaker sections?

9. What is the targeted public expenditure on health as a percentage of GDP according to the Eleventh Plan, and how does the actual spending compare?

10. What percentage of India's population had access to improved sanitation facilities in 2004, and how does this compare to some other developing countries mentioned?

Conceptual Questions (Long Answer)

1. Describe the evolution of the constitutional and legal framework for elementary education in India, citing key articles and acts mentioned in the sources, and explain the significance of these changes.

2. Discuss the performance and challenges in elementary education based on the provided statistics. Analyze the trends in school numbers and enrolment, and explain the issues related to drop-out rates, including disparities across social groups and contributing factors mentioned in the sources.

3. Analyze the shift in the management pattern of secondary schools towards private unaided institutions. Explain the reasons cited for this shift and the implications for public sector investment in education.

4. Explain why vocational education in India has largely failed to meet its objectives, drawing on the critiques provided in the sources. What measures were proposed by the Eleventh Plan to address these failures?

5. Describe the growth and current status of higher and technical education infrastructure and enrolment in India. Discuss the disparities in GER and geographical distribution of institutions, and explain how the rise of private institutions impacts the goal of inclusive development according to the sources.

6. Discuss the state of open and distance learning in India based on the sources, mentioning key institutions. What are the primary criticisms and failures associated with this mode of education?

7. Analyze the trends in public expenditure on education and health in India as presented in the sources. Compare the actual spending levels with the recommended targets and discuss the implications of this financing pattern.

8. Describe the health infrastructure in rural areas and the significant challenges it faces. Explain why there is a growing trend of people preferring private hospitals over government ones, citing reasons and cost differences from the sources.

9. Discuss the disease burden in India based on the sources, differentiating between communicable and non-communicable diseases. Explain how these diseases disproportionately affect the poor.

10. Explain the current state of health insurance coverage in India, particularly for the poor and the unorganized sector. Describe the recommendations made by the NCEUS and other initiatives like CBHI mentioned to improve coverage and reduce out-of-pocket expenditure.

Application Questions (Short Answer)

1. Based on the reasons for high drop-out rates, suggest one practical measure related to school facilities that could help improve retention, particularly for girls.

2. Considering the identified weaknesses of the Mid-day Meal Scheme, what role can parents play in improving its implementation quality?

3. If you were designing a strategy to promote vocational education based on the Eleventh Plan's emphasis, what specific type of partnership would you prioritize?

4. Given the skewed dispersal of technical education institutions, what kind of policy intervention might help address this regional imbalance?

5. Based on the source's critique, if a university is generating large surpluses from its distance education programs, what might this suggest about its fee structure and target audience compared to the original purpose of distance learning?

6. If a state aims to reduce maternal mortality through institutional deliveries, but lacks sufficient health facilities, what gradual approach is recommended by the source?

7. Suggest one simple, low-cost diagnostic technology, inspired by the JSS example, that could be useful for village health workers in detecting a common illness mentioned in the disease burden section.

8. Considering the high out-of-pocket expenditure on health leading to indebtedness, how might a Community Based Health Insurance (CBHI) scheme, as described, help a poor family facing hospitalization?

9. If a state government wanted to improve trust in its public hospitals, what specific issues identified by the Eleventh Plan analysis should it prioritize addressing?

10. Based on the sanitation data, what kind of "massive programme" is needed in rural areas to improve health indicators, and which existing community body could be involved?

Application Questions (Long Answer)

1. Imagine you are a policy advisor for the Indian government focusing on elementary education. Based on the achievements and failures identified in the sources, propose a prioritized list of three key policy interventions, justifying each choice with evidence from the text regarding its potential impact on access, equity, or quality.

2. You are leading a task force to improve quality in secondary education. Using insights from the sources on management patterns, core subject performance, and infrastructure, outline a strategy that incorporates both public and private sector considerations, including potential financing mechanisms.

3. Develop a proposal for enhancing skill development for the 4 crore unskilled/semi-skilled aspirants mentioned, drawing on the Eleventh Plan's vision and alternative delivery systems suggested in the source. Explain how this proposal addresses the past failures of vocational education.

4. Analyze the challenges of providing equitable access to higher education in India, particularly in light of the growth of private unaided institutions and the GER data. Propose strategies, based on the Eleventh Plan objectives and source critiques, to make quality higher education more inclusive for brilliant students from weaker sections.

5. You are managing a district health program in a rural area facing significant challenges in primary healthcare delivery. Based on the sources, propose a strategy to strengthen health infrastructure, personnel, and service delivery, incorporating lessons from successful state models and innovative grassroots approaches like JSS.

6. Given the high out-of-pocket expenditure on drugs, propose a strategy to improve access to affordable essential medicines for the poor in a specific region, drawing lessons from the Tamil Nadu experiment and addressing challenges related to procurement and management.

7. Evaluate the potential of Public-Private Partnerships (PPPs) in the Indian health sector based on the examples and critiques provided. Under what conditions, according to the sources, are PPPs more likely to succeed in serving public health goals, particularly for vulnerable populations?

8. Design a basic framework for a health insurance scheme targeting unorganized workers, incorporating key features recommended by the NCEUS report. Explain how this framework aims to protect workers from the financial consequences of illness.

9. Analyze the dual challenges posed by lack of clean drinking water and sanitation in India. Explain their impact on public health and outline a plan for improving these conditions in rural and urban slum areas, suggesting relevant initiatives or community bodies mentioned in the text.

10. Based on the findings of Nanda A.R. and Almas Ali cited, explain how financial constraints exacerbate health inequality among the poor. What overarching policy approaches, drawing on the financing and insurance sections, could help mitigate this problem?

Revision Quiz

1. Article 45 of the Constitution aimed to provide free and compulsory education for children up to what age?

2. What was the recommended percentage of GDP for education expenditure by the Kothari Commission (1966)?

3. The 42nd Amendment placed education on which list in the Constitution?

4. What Act was enacted in 2009 to implement the Fundamental Right to elementary education?

5. What was the approximate drop-out rate for elementary education (Class I-VIII) around 2011-12?

6. Which social groups had higher drop-out rates in elementary education according to the source?

7. The Mid-day Meal Scheme was inspired by the experience in which Indian state?

8. What structural change in the management pattern of secondary schools was noted, showing an increase in the share of a particular category?

9. In which three core subjects do a large majority of secondary school students reportedly fail?

10. What percentage of the 19-24 age group had acquired skills through formal vocational education in 2004-05?

11. According to the sources, what is a primary reason cited for the failure of vocational education being viewed as "second rate"?

12. Approximately how many universities were there in India in 2007?

13. How does India's GER in higher education compare to the world average according to the source?

14. What is identified as the primary motive behind the expansion of private unaided higher education institutions?

15. What institution coordinates distance learning at the higher education level in India?

16. What was the total health expenditure as a percentage of GDP in India in 2011?

17. What is India's per capita health expenditure in USD compared to countries like China and Japan (2011 data)?

18. What is the term for the tiered health infrastructure facilities in rural areas at the block level, serving about 100,000 people?

19. What is the primary reason cited for the growing lack of trust in public hospitals and preference for private ones, despite higher costs?

20. What percentage of India's population had access to improved sanitation facilities in 2004?

Quiz Answers:

1. Fourteen years

2. 6 per cent

3. Concurrent List

4. Right to Education Act

5. About 40.8 per cent (or 50.8% in 2004-05) - Either answer is acceptable based on different years provided.

6. Scheduled Castes (SCs) and Scheduled Tribes (STs)

7. Tamil Nadu

8. Increase in the share of private unaided schools

9. Mathematics, Science, and English

10. 5%

11. It was planned for the poor/intended to reduce demand for higher education/lacked connectivity

12. 378

13. Very low (around 11-14% vs world average 23.2%)

14. Profit motive/lucrative option

15. Indira Gandhi National Open University (IGNOU)

16. 3.9%

17. Much lower ($59 vs $278/China, $3958/Japan)

18. Community Health Centre (CHC)

19. Lack of trust in the public system

20. 33%

Text-Based Hierarchical Mind Map / Outline Tree Structure

- Social Infrastructure and Social Sector
    - Essential for skilled manpower and social sector development
    - Poor at independence; planning efforts to strengthen

- Education Development in India
    - Constitutional Commitment: Elementary education for all
        - Article 45: Free & compulsory education up to 14 (target 10 yrs)
    - Education Commission (1966): Headed by Dr. Kothari
        - Education as investment in human resources for economic growth
        - Recommended 6% of GDP expenditure on education
    - Constitutional Amendments
        - 42nd (1976): Education to Concurrent List (Centre & States)
        - 86th: Article 21-A - Free & compulsory education (6-14 yrs) as Fundamental Right
    - Right to Education Act (2009): Enacted based on 86th Amendment
    - National Policy Statements (1968, 1986, 1992): Emphasis on illiteracy eradication, UEE, vocational/technical expansion, higher education quality
    - Equity & Access: Gender, caste (SC/ST/OBC reservations), regional disparities

- Elementary Education Progress
    - Increase in schools & enrolment (2001-14)
        - Primary schools & enrolment
        - Upper Primary schools & enrolment
        - Total Elementary enrolment
    - Drop-out Rates
        - High overall drop-out (Primary 22.3%, Elementary 40.8%)
        - Higher among SCs (40.2%) and STs (57.2%)
        - Higher among girls in SC/ST (Note discrepancy with table)
        - Reasons for high drop-outs & failure in UEE: Teacher attendance, poor facilities (toilets), retention environment
        - Low retention rate (49/100 reach Class VIII)
    - UEE Goal Failure: Constitutional goal by 1960 not achieved
    - Supportive Measures
        - Mid-day Meal Scheme (MDMS): Improves attendance & retention (esp. weaker sections)
            - Nutritional norms
            - Coverage growth & expenditure trends
            - Weaknesses: Sub-standard meals, poor cooking, corruption
            - Improvement with parent/mother association (vigilance committees)
            - Timely fund disbursement issue
        - Reducing Private Cost: Free uniforms, books, stationery
        - Free transport
        - Special incentives for girl children

- Secondary Education Performance
    - Enrolment Rates: Secondary (76.6%), Higher Secondary (52.2%)
    - Drop-out Rates: High drop-out (52.7% for I-X) is concern
        - Inter-state variations (Bihar, Nagaland, etc.)
    - Management Pattern: Shift towards private unaided schools
        - Parents willing to pay for perceived quality
        - Need for increased public investment in government/aided schools
    - Core Subjects Performance: Poor performance in Math, Science, English (nearly 50% fail)
    - Strengthening Infrastructure (Physical & Human) Needed
    - Eleventh Plan Proposals
        - School proximity norms
        - GER targets
        - Infrastructure (rooms, teachers)
        - Trained teachers, pupil-teacher ratio
        - Model schools
        - Upgrading primary schools
        - ICT provision (computer labs, internet)
        - Levy fees in public schools (for resources) with generous scholarships for poor/girls

- Vocational Education
    - Low Skill Acquisition: Only 5% (19-24 yrs) in 2004-05
    - Missed Target: 25% target by 1986 (Education Commission)
    - Failures attributed to: Planned as second-rate/for poor/terminal, costlier, poor employment opportunities, reducing demand for higher education
    - Eleventh Plan Focus: Demand-driven, partnership with employers
    - Mobility between vocational, general, technical education
    - Variety of delivery systems needed (on-job, part-time, ODL)
    - Need to strengthen computer literacy
    - Shortage of skilled manpower in knowledge economy

- Higher and Technical Education
    - Growth since Independence: Large increase in universities, colleges, enrolment
    - Enrolment Trends: Total growth (1984-2009), Women's share
        - Stage-wise enrolment (Graduate highest, Research lowest)
        - Faculty-wise enrolment (General education highest, Professional courses substantial, Agriculture/Vet low) - need policy change
    - Faculty Strength Distribution (Lecturers, Readers, Professors)
    - Gross Enrolment Ratio (GER): Low (11-14%) vs. world average (23.2%)
        - Need to promote further for transition to developed country
        - Eleventh Plan Goal: Accessible quality higher education irrespective of paying capacity
    - Growth of Private Institutions
        - Increased share of unaided institutions & enrolment
        - Improved access in specific fields (Engg, Mgmt, Med, IT)
        - Motivated by profit, lucrative investment (20-30% return)
        - Unaffordable for lower/middle/weaker sections (elitist)
        - Militates against inclusive development (conspicuous failure)
        - Need to enforce entry of brilliant poor students
    - Technical Education Institutions: IITs, IIMs, Engg colleges, Polytechnics, etc.
        - AICTE role (statutory status 1987)
        - Growth in institutions & intake (Tenth Plan)
        - Expansion limited by inadequate absorptive capacity, not resources
        - Skewed dispersal across states (AP, TN, Karnataka, MH dominate)
    - Eleventh Plan Targets (Technical Education)
        - Annual intake growth (15%)
        - Setting up new IITs, IIMs, NIITs, IIITs
        - Exploring Public Private Partnership (PPP)
        - Upgrading state institutions (deficiencies noted)
        - Increasing intake of existing institutions

- Open and Distance Learning (ODL)
    - School level: NIOS (continuing education, 14 lakh students)
    - Higher education level: IGNOU (coordinates, 15 lakh enrolment, centers, media)
        - DEC (IGNOU authority) coordinates State Open Universities & correspondence courses
    - Issues: Need for upgrading standards/performance
    - Correspondence courses as "milch cows" funding conventional education
    - Proliferation of courses without adequate infrastructure
    - IGNOU charging high fees for vocational courses
    - Failure to adequately serve deprived sections due to high fees

- Financing Education
    - Target: 6% of GDP
    - Actual: Peaked at 4.26% (2000-01), declined to 3.7% (2007-08), 3.4-3.49% (2004-05)
        - Gross failure of priorities
    - As % of Total Budget: ~12% vs. "model" 20%
    - Eleventh Plan Outlay: Significant increase (₹ 2.37 lakh crores), share increase (7.7% to 19.4%)
        - Allocation across elementary (~50%), secondary (~20%), higher/technical (~30%)
        - ₹ 25,000 crore earmarked for Right to Education (2010-11 budget)

- Health and Family Welfare Development
    - Post-Independence Growth: Huge infrastructure (PHCs, CHCs, hospitals) & training institutions (medical, paramedical, AYUSH)
    - Achievements: Improved health standards (life expectancy, IMR, MMR), disease elimination/containment (small pox, plague, malaria, TB, diarrhea)
    - Poverty-Health Link: Illness can drive non-poor into poverty
    - State Responsibility: Provide free/affordable care for deprived/marginal groups
    - Comprehensive Approach Needed: Individual care, public health, sanitation, water, hygiene
    - Lagging Indicators: Worse than comparable countries (China, Indonesia, Sri Lanka)

- Total Fertility Rate (TFR) & Population Stabilization
    - TFR decline (6.0 to 2.6)
    - Moving towards 2.1 (population stabilization)
    - Achieved via effective family welfare programme (increased contraceptive use)

- Eleventh Plan Health Goals (2011-12)
    - MMR to 100, IMR to 28, TFR to 2.1
    - Clean drinking water to all
    - Reduce child malnutrition (0-3) by half
    - Reduce anemia (women/girls) by 50%
    - Raise sex ratio (0-6)
    - Ambitious targets, difficult pace of decline (e.g., MMR 200 in 2010)

- Disparity in Urban/Rural Health Care
    - Rural health care often poor
    - Disparity in all indicators (CBR, CDR, IMR)
    - High anemia in rural children & pregnant women
    - Burden on poor, SCs, STs
    - Sharp differences between advanced/backward states
    - Urban Slums: High density, poor conditions, lack of access lead to high disease incidence

- Disease Burden
    - Communicable: ARI, Diarrhea, HIV/AIDS, Malaria, TB, Kala-azar
    - Non-communicable: Cancer, Diabetes, Mental Health, Blindness, Cardiovascular, Asthma
    - Impose heavy burden on poor, impair earning
    - Tobacco-related diseases major problem (cancer, deaths)
    - Cataract main cause of blindness

- Health Care Infrastructure & Personnel Shortage
    - Rural Tiered Infrastructure: Sub-Centre, PHC, CHC, ASHA
    - Shortfalls: Significant % shortage (Sub-centres 13.2%, PHCs 18.5%, CHCs 40.9%)
        - CHC shortage seriously affects secondary care
    - Government Hospitals: Increased numbers/beds
        - Suffer from semi-used/dysfunctional infrastructure
        - Lack of trust, preference for private
    - Private Hospitals: Rapidly expanding, mostly in towns/cities
        - Rising share of cases treated (rural & urban)
        - Much higher cost of care (~2-3 times)
    - Reasons for Shift to Private (Despite Cost): Lack of trust in public system, personnel shortages, poor conditions, absenteeism, inconvenience, insensitivity, poor management
    - System Overloaded: Due to primary care shortage

- Health Expenditure in India
    - Total Health Exp as % of GDP: 4.6% (2001-02), 3.9% (2011)
    - Public Health Exp as % of GDP: 0.94% (2001-02), 1.2% (2011)
        - Share of public in total low (31% in 2011)
        - Very low compared to other countries
    - Per Capita Exp on Health: $59 (2011) - very low
    - Need to increase health expenditure, especially public
    - Trends (Centre + States): Decline as % of total government exp (3.12% to 1.3%)
        - Slight increase as % of GDP (1.03% to 1.3%) - not significant
        - Behind Eleventh Plan goal (2.3%)
        - Per capita real expenditure almost constant
        - Public health expenditure stagnant as % of GDP

- Eleventh Plan: Health Strategy
    - Inclusive Growth: NUHM + NRHM = Sarva Swasthya Abhiyan (Health for all)
    - NRHM Focus: Strengthening infrastructure (physical & human)
        - Targets: ASHAs, functional sub-centres (ANMs), PHCs (staff nurses), CHCs (Specialists), hospitals, Mobile Medical Units
        - Emphasis on Indian Public Health Service Standards
        - Expected outcomes: Disease reduction, standards upgrading, utilization increase

- Janani Suraksha Yojana (JSY)
    - Objectives: Reduce MMR & IMR by promoting institutional deliveries
    - Features: 100% Centrally sponsored, cash + medical aid
    - Challenges: Lack of institutional capacity for all births, half of maternal deaths outside delivery, timely fund disbursement issues

- National Urban Health Mission (NUHM)
    - Target: Health needs of urban poor, esp. slum dwellers
    - Scope: Cities >1 lakh pop., marginalized groups
    - Focus: Essential primary health care

- Strengthening Existing Health System
    - Comprehensive approach, Integrated District/Block Plans
    - Partnership: PRIs, local bodies, community, NGOs, CSOs
    - Primary Care Issue: Major issue in rural areas (deaths en route)
    - Area-specific policies
    - Learn from success models: Tamil Nadu (round-the-clock), HP/Orissa (salaries), Assam (Akha ship)
    - Tribal Health: Encourage tribal medicine (AYUSH), community involvement, cultural alignment (SEARCH hospital, Aarogaya Sansad example)
    - Grassroots Innovation: Jan Swasthya Sahyog (JSS) - low-cost tech, simple diagnostics, courier system

- Secondary and Tertiary Health Care
    - Professionalization (already exists in public sector)
    - Reputed private hospitals attract qualified staff
    - Govt initiatives: New AIIMS-like, upgrading medical institutes
    - Overloaded due to primary care shortage

- Access to Essential Drugs
    - High household expenditure on drugs
    - Poor worst affected
    - Eleventh Plan Aim: Follow Tamil Nadu experiment (affordable Essential Drugs - WHO list)
    - Requires increased government expenditure (currently 10% of budget on health)
    - Timely supply, procurement/management systems needed
    - Reduce out-of-pocket expenses

- Enhancing Public-Private Partnerships (PPPs)
    - Eleventh Plan recommended enthusiastically
    - Examples: Karnataka (Yeshawini), Gujarat (Chiranjeevi), AP (Urban Slum), Rajasthan (diagnostics/drugs)
    - Success more with charitable NGOs, not profit-driven private partners ("hardly succeed")
    - True partnerships (equality, shared commitment) rarely seen

- Health Insurance: Protecting the Poor
    - High out-of-pocket expenses lead to heavy indebtedness
    - Need initiatives to reduce these expenses (alleviate poverty)
    - Low coverage (1% of population)
    - Existing schemes (ESIS, CGHS, ECHS, Mediclaim) cover limited/upper groups
    - Private insurance issues: unaffordable premiums, claim delays, non-transparent
    - Need to involve SHGs for poor's contribution & support
    - Extend health insurance to unorganized workers (93% of workforce)
        - NCEUS recommendations (hospitalization, maternity, sickness cover)
        - Direct payment mechanism
        - Extend CGHS/ESIS/ECHS
        - Requires substantial govt contributions
    - Maternity Health Insurance for BPL pregnant women (govt borne capitation fee)

- Clean Drinking Water and Sanitation
    - Vital for health, prevents water-borne diseases
    - Rural water issues: slipped back habitations, contaminated supply
    - Access to improved water source: 86% (2004)
    - Lack of sanitation causes water-borne diseases
    - Rural sanitation coverage low (1% to 22%)
        - 100% coverage needed for sufficient health improvement
        - VHSCs can assist
    - Access to improved sanitation: 33% (2004) - very poor compared to other developing countries
    - Need concerted effort, esp. in slums and remote areas

- Overall Health Status Summary
    - Achievements & failures compared to peers
    - Malnutrition prevalence
    - Slum health issues
    - Infrastructure shortages & shift to private
    - High out-of-pocket cost burden on poor
    - PPP challenges
    - Need for health insurance expansion
    - Low public health expenditure
    - Poor sanitation record
    - Worsening inequality in untreated illness and healthcare access/expenditure (Nanda & Ali findings)
    - Rich use both public and private
    - Increased drug costs & fees contributing to inequality
    - "Miles to go" despite encouraging achievements