Dr Sundarraman

Scroll Top Right to Health Resources | RTH Resources Primary Menu Home About Us Conversations on Health Policy Thematic Areas Contact Us 0 0   By Prof. T. Sundararaman Conversations on Health Policy June 30, 2024 Getting reliable mortality and burden of disease estimates – So near but yet so far!!! Conversation between Dr Chalapathi Rao (CR) and Prof T Sundararaman (TS Reliable mortality data is essential for measuring the health outcomes of Universal Health Coverage (UHC) and for health planning in general. In this conversation, we discuss the sources of information on mortality and note that while there is ongoing work to improve death reporting and Medical Certification of Cause of Death (MCCD), and this includes digitization of data, we have not arrived at a situation where any of this can be used for guiding policy or action. The only information readily available is the Global Burden of Disease and preventable mortality indicators generated by IHME, but these have considerable limitations, but our focus should be on why it is feasible and desirable to do much better with the data and data systems we already have. Much improvement can happen if the states assisted by the public health community take the lead in this area of public health practice and research. TS: I’ll get to the larger question of measuring Universal Health Coverage (UHC) a bit later. But I’m going to start with this what do we know about the sources of information on adult mortality? There is mortality data available in the census, the NSSO health rounds, the National Family Health Survey (NFHS), and the Sample Registration System (SRS). Then there is the registration of deaths in the Civil Registration System (CRS) and Medical Certification of Cause of Deaths (MCCD). Would you give me a sense of what are the pros and cons of each source? We are talking of mortality from all causes and not just maternal mortality. CR: Let’s start with the census. The census does have information on under 5-year-old child survival. There is a series of questions on birth history, from women from 15 to 49 years, asking about how many children were ever born and how many of them are still surviving. To that information, they apply a series of equations, which are known as the Brass methods by which they can calculate the risk of dying between birth and five years. I am not aware of whether the census includes a specific question on maternal mortality or all-cause mortality. I don’t think so, because I haven’t seen a published report on that, but one needs to check. In some other Asian countries, in the census, they also ask a question about whether there has been a household death in the last year or three years and they use that data to estimate mortality, but in the Indian census, they don’t. Census-based child survival estimates have several disadvantages- related to low periodicity, recall bias especially with regard to still births, and issues on statistical methodology. So, although this data is available in the census, this has not been taken seriously, and even now other sources have better information. The NSSO health rounds are also not reliable for mortality data. There is a recall bias, and the sample size is not adequate for measuring adult mortality rates, or life expectancy at birth and anything related to the causes of death. Even the Sample Registration System (SRS) and the NFHS themselves are hopelessly inadequate in terms of sample size, to be able to estimate an adult mortality rate with any degree of precision, which can be put to use for either assessing cross-sectional scenario at a point in time or to measure trends over time. The confidence intervals are so wide that they will always overlap, and you’ll never be able to interpret differentials. I have the data published on this for SRS1, which has a sample size several times higher than the CRS. So, if the confidence interval is wide for the SRS, it will be even wider for the NFHS TS: SRS publishes data on all-cause mortality. NFHS does not. Both SRS and NFHS publish data on child mortality, but they seldom match. So when you compare the SRS and NFHS, which is the more reliable source and why do you think so? CR: I would actually not rely on either of them, but if you want me to compare them, then we need to actually go a little deeper into the methodology of each source. The sample size in SRS is designed to measure the infant mortality rate (IMR) at the level of the “natural division” within 15% relative standard error. A natural division is a big geographical region somewhat made up of a cluster of districts, so each large state has 2-4 natural divisions. We see these natural divisions used in weather reporting- an area like Cooch Behar in West Bengal, or say Vidarbha in Maharashtra. Now, based on the sample size, SRS is precise enough to measure the IMR. But in that same cluster, which has been selected to measure IMR the SRS is also recording the mortality at all ages. But obviously, because adult mortality is rarer than infant mortality in most populations, the confidence intervals will be much wider than 15% as a relative standard. ​​So, that is the reason why there is no substitute to the Civil Registration System (CRS), in terms of sample size given the vast population and the wide dispersion that we have and the need for precise mortality measurement at least at the natural division of the state level, if not at the district level. For our population size, if we accurately measure mortality through the CRS, we can get very robust estimates even at the district level and we are actually looking into some of those analyses as we speak. TS: Yes. So this is one big message that we have arrived at. The civil registration system (CRS) cannot be substituted. But before we leave SRS, could we agree that SRS would be reliable in a larger state, and perhaps the current practice of giving mortality estimates of a five-year period instead of one year will provide more reliability? CR: There is one more drawback we can say of the sample registration system, even for the under-five mortality. Although they may be doing a fair job for the under-five mortality at the state level, stillbirths are under-reported and we need further attention to measuring stillbirths and perinatal mortality rates. SRS does publish a 5-year aggregate of deaths. The life tables from the sample registration system are grouped for those 5 years. They are useful and I have used some of those reports for my comparative analysis. The most recent of these is the 2015 to 2019 report. But we need to check them. In principle, aggregating the data would yield a stronger state-level estimate. And we might also conjecture that the mortality may not change so much over a period of five years. But this is still a lame excuse. In states which have a population of at least 40 to 50 million population, we definitely need indicators at the sub-state level because there are going to be differentials and you can’t apply a uniform rate for such a large population. So, that is something we have to keep in mind when we aggregate data across years. It is, statistically, somewhat like cheating in doing that. Note also that SRS involves an additional supervisor who visits all households in each sample cluster every six months, and independently records vital events that had occurred during this period; which is then compared with the records maintained by the local enumerator. A reconciled list of events is then prepared, based on the matching, thereby providing more reliable data for the villages in this sample. So the data collection methodology of the SRS is sound, the problem is with the limited sample size. TS: So let us come back to Civil Registration System (CRS) which is where we will focus the rest of our discussion. In CRS, the basic data is from form 2 which is a death report filed by a non-medical notifier. If the death is attended by a medical officer they will fill form 4, which is the MCCD form, and if the death is elsewhere or brought dead in an ambulance to a doctor, then Form 4a is filled. Am I correct? Can you fine-tune me on this? CR: All deaths are to be reported using a form 2. Whether the death happened at home or in a hospital or anywhere, it is to be reported using form 2. There is a list of notifiers and registrars for local level on who can fill in the form and to whom they must submit it to at district and sub-district level and state level that is issued by the registrar-general of births and deaths. On form 2, the notifier also records the names of the informant from the household and they are supposed to get the signature or thumbprint of the informant because in official terms this data is being reported by the household to the government. [Of the total 36 states and UTs, in about 20 states/UTs it is the panchayats or general administration which notifies and registers in local and the district level. In about 15 states/UTs it is the health department which does so at the local level and in about 10 of these it also has the registrar-function at the district level as well. Before independence and for many years after, in most states it was the police department which was the registrar, with the village kotwal playing the notifier. Now that arrangement exists in only J &K. In all other states it is the panchayat system and general administration or the health system which is in charge. Earlier, as inherited from the colonial state, registration was a citizen duty and the state bestowed it or denied it as part of the exercise of its powers. Now registration is increasingly perceived as an entitlement- which is a welcome development]. Deaths which have been in a health facility or hospital, are to be issued both form 2 and form 4 by the hospital. So, when they are filling in the form 2, they get the signature of the person who is taking the body and they give him one copy. They also send one copy of form 2 and one of form 4 which is the Medical Certification of Cause of Death (MCCD) to the Registrar’s office directly. The third type of deaths are those that were ‘brought dead’ to a physician or which happened outside the health facility, but which was attended to by a physician and for these he/she issues the form 4a. The family is then required to go to the Registrar and report the death, where they will fill in a form 2. And this form 4a is not given to the family. It comes directly to the Registrar’s Department and sent to the Health Department for further processing of all MCCDs. I’m not really sure about the extent to which form 4 and 4a is implemented across the country. There may be some data from the Registrar General’s report. I know, that in Tamil Nadu about 30% of deaths are reported with a form 4 and 13% across the state are reported with a form 4a, so an so the total MCCD coverage is 44%, which is quite good. Situation is similar in Goa, Maharashtra, Kerala- but these are high compared to other states. I also know that in Maharashtra and Goa (a much smaller state), the coverage of MCCD is quite high compared to other states, but across the country, there is a lot of shortfall in the availability of this information. TS: If I remember right, MCCD coverage of deaths would be about 25% across the country? CR: Yes. I suspect that there are likely to be a lot of hospitals, where they are actually filling in the MCCD form, but the form is not progressing into the Registrar’s system for some reason or the other. So, if we pay a little more attention to compiling with greater efficiency, whatever forms are already being filled, and we might be able to have a much larger MCCD coverage. To substantiate this, note that from SRS, nearly 50+ % of deaths in the whole country were hospital-based. Since 2015-16, MCCD reporting has been made mandatory across all hospitals in the country. And Central Bureau of Health Intelligence (CBHI) have conducted a lot of training programmes and distributed materials on MCCD. TS: I understand that before 2015, MCCD was by policy limited to medical colleges hospitals and larger hospitals, and even district or much less private hospitals were not required to fill it. But today has MCCD expanded even to primary health centres? CR: It is expanded to all clinical establishments with an inpatient facility providing treatment where a death can take place. So, unless our primary health centre has a delivery unit or something like that, around the clock, it won’t be implemented. In other words primary health centres, and private outpatient clinics do not fill form 4. But to both public and private hospitals it is a mandatory and a legal requirement. TS: is there a chance of duplication of data from form 2 and form 4, where a hospital files the death and so does field level functionary? CR: There may be, but I think that they in the existing system. when this form comes to the local registrar’s office they will check in and ensure that there is no double counting of events. This is unlikely to be a significant problem. TS: The MCCD records only hospital deaths, which is about 25 percent and there is no clear denominator for these deaths. So, other than the legal requirement of certification of death, what public health value does it have currently? CR: True. It does not, by itself, have public health value, since one cannot, estimate population-based mortality rates or even the leading causes of death. Those who die in hospitals are not representative of deaths in the general population. If we could combine it with data from form 2 we would do better. TS: So back to CRS and form 2 as the main source of reliable public health data on mortality. What would be the amount of completion of form 2 across the country and in Tamil Nadu in particular? CR: We were getting an annual Civil Registration System report based on this form 2 data. The most recent report as we have seen is for 2020, which was published around mid-2022. Since then, we haven’t had a report because of various administrative reasons related to the covid pandemic. We are expecting the reports to resume in the near future. In the latest, report, the level of completeness is estimated at 92% across the country and in several states, it is 100%. But there is a problem in how they arrived at this number. I have done some analysis for the data for 2019 and previously also, in which we have estimated the completeness at national level and for each state and we have published this along with its methodology on which it is based2. It was about 79% for males, and around 72% for females, and if you put both together, it’s about 75%2. We generally do not publish or discuss mortality statistics for both sexes together, because it doesn’t have any relevance. So, we always calculate it separately. The shortfall is mostly in the counting of infant deaths, even for state like Tamil Nadu where completeness is 98 percent for men and 95 percent for women. For Andhra Pradesh, the completeness estimate based on form 2, is 94% per males and 85% for females. And the other end for Bihar, it is 48% for males and 35% for females. Karnataka is 96% males and 88% females, and Kerala is 98% and 97 %. And Tamil Nadu is 98 and 95. Gujarat is 89% for females and about 90% for males. In fact, I would say that, except for a few states, the completeness is sufficient for us to start thinking of generating state and district level data with population denominators. (the latter needs the next census which is now many years overdue). TS: Now I’m going to go into my main question. What we have understood till now is that of all the data sources, form 2 is the most robust and for many states we do have this report with high reliability and completeness. What prevents us from presenting this information annually and putting this data up in the public domain? Not as yet by cause of death, but definitely by age and gender. If from smaller research studies we can have an age and gender-wise cause of death and we could apply this to the CRS age and sex-related mortality rates, and we then would have a fairly robust measurement of important UHC outcome indicators at the district level. So why don’t we have a district-wise annual report of mortality? Do other countries have that and can we have that? CR: So, rather than answering the question of why we don’t have that, maybe we can focus on whether and how we can have that? The first enabling factors is this circular3 issued in November 2017 by the office of the Registrar General that empowers the state governments and their registrar generals to calculate the vital rates through data from the CRS in all states, at both the district and at state level beginning 1st January 2018. This authorization of the states means that the public health community can inform and work with states to close this gap. Need not wait for the center. Secondly, if we look at the civil registration system report of 2019 4. we see the details of number of deaths registered by state, union territory and district and they also have deaths by age and gender (pages 62 through the 69). So clearly the deaths by age and gender for each district is available. TS: So it is clear that age and sex-wise data is available by district in most districts, and even the other states can catch up. Lack of digitization has been mentioned as a problem, but in my understanding most states have already digitized. This would mean almost real-time availability of this information. The goal is so very near, even for presumptive cause of death. But the digitized information is not used. Form 2, captures data on paper form and then the data is entered into computers. But after the data is entered, the aggregate of that disappears. There is no output from that path. There is a manual aggregation process that happens in parallel and that seems to be actually be data that is on flow. But even this is not used for state and sub-state information and action. CR: Yes, Form 2 is a manual process- but this is essential. Because form 2 is an official paper record, which has to be maintained at the local registrar level as an archive. Then the data from form 2 is entered into the death register which is now becoming electronic. So they have this dual process of data entry and transmission, but also the paper archives, and totals at the local registrar level. I am aware that in both Tamil Nadu as well as Punjab, all the variables of form 2 (including the presumptive cause of death) are entered in the computer and they are submitted to the state vital statistics unit. However, the cause of death data from form 2 is unavailable in the reports. Till this computerization started, such data was not available for analysis. The information was only on that paper record which is kept at the local registrar level. Now this data is available and adequate for analysis for all age and gender specific mortality rates at state and district level. However, with regard to the data on presumptive cause of death, though its availability now is a huge step forward, it still has a major problem of reliability. Form 2 is technically data as reported by the family, and the quality of presumptive cause of death reported depends on whether a documents with proper medical diagnosis or prescriptions are available, or it is only the family’s knowledge and interpretation and what it wants to share. Often family statements would be very broad like heart disease or lung disease. I presume that a lot of the data will be unreliable because the purpose of that presumptive cause of death column on form 2 is only to distinguish as to whether the death was from natural causes or was it associated with any medical, or legal, issue. Neither notifier nor local registrar is trained to understand the technical terms that are present in reports from a hospital and derive a proper diagnosis on that. And we cannot blame them. You know, their function is not epidemiologic. You know, their function is from a social and government perspective that if a person has died, then their death has to be registered and the form has to be given to them for them to carry on with all other things. TS: But should we not be able to address this gap. We note that the SRS itself is a way of going deeper and putting another layer of verbal autopsy inquiry over the presumptive cause of death reporting and thereby improving the counting of births and deaths. There have been very good pilots run by people like Yogesh Jain, in JSS where they have used interactive voice recording with notifiers to also get a better quality of death reporting. We know that standardizing symptomatic, presumptive reporting is possible and this would add great value to CRS reporting on deaths. There is a WHO standardisation of around 128 diagnoses or even less that was suggested for verbal autopsy backed presumptive diagnosis of cause of death. Even the HMIS under NRHM had way back standardized about 12 diagnosis entities on which till today HMIS reports deaths. These categories are broad like fever related deaths, trauma related deaths, cardiovascular related deaths etc which in combination with age, sex and geography is enough for quite a lot of district and sub-state health planning and actions. . Even if causes are relatively unknown, one can unpack it with information from surveillance sites. The other way to do it is to, like for IMR, use information from research studies to look at the nature of deaths in a specific age group and then apply it to the other figures elsewhere. So why aren’t we able to make these presumptive causes talk more? By standardizing protocols and giving training we should be able to achieve this almost immediately. I believe the CBHI and the mainstream departments are focused on Form 4 and MCCD, which have inherent limitations even if we get it correct. On the other hand, information from form 2 is reaching universal coverage and is digitized. Just a little bit more is required. CR: I completely agree we could do get an adequate quality of mortality report with CRS data if we do this. There have been, to my mind two barriers to doing so: neglect and disconnect. Neglect because nobody paid attention to try and strengthen this cause of death reporting in form 2 through any kind of standardization. But what I want you to focus now is on the disconnect, in that research projects in this area are few and have never really translated into proper action which is integrated with the regular death reporting program under the CRS. Because there has to a proof of that concept on scale, and only then can it be considered to be scaled up and strengthened across all state populations. We can get reliable data with numerators based on defined denominators even now, but the reasons we have not done so can be attributed to neglect and the disconnect. TS: Right. So, what is being done by the government to address this challenge in Tamil Nadu? CR: So as opposed to neglect, the TN government has been paying attention. And as opposed to disconnect, an implementation research project is underway, which connects research on data quality improvement with the routine operations of the CRS system. The project us led by the Director of Public Health, with technical support from the WHO. I am aware that field work is being undertaken in two districts Karur and Krishnagiri to record causes for all the deaths in these districts. The district population is the denominator. MCCD forms (form 4) are assured for all the deaths in facilities, and form 4A for deaths which happen at home and certified by a physician. And for the rest of the home deaths which is around 55 %, the WHO verbal autopsy questionnaire is being used to investigate the causes of death. A detailed presentation of the project aims, design, methodology and progress till April 2024 was delivered to the Verbal Autopsy Reference Group Community of Practice, on 25th April 2024. The field methods for home deaths are quite straightforward. The health inspectors who are positioned in each PHC get the list of deaths for which there is no form 4. They get that list from the local registrar. The have been trained in conducting VA interviews. The health inspector goes to the identified household with a tablet and does the verbal autopsy interview and this gets uploaded to the server. As of now, much progress has been made for deaths in 2023, And recently, training was provided to a team of doctors to review these questionnaires and assign the cause of death based on the information from the questionnaire. The training team includes staff from the Madras Medical College, Nation Institute of Epidemiology and myself. Academics from medical colleges in Krishnagiri and Karur are also involved in the project to help build local capacity, support field supervision, guide local monitoring & evaluation, and other technical support. The cause of death from VA will be ascertained by a local PHC medical officer. It is anticipated that by the end of the year, a detailed analysis of mortality by age, sex and cause for these 2 districts for 2023 could be available. TS: Are you using this process to upgrade form 2 to form 4? CR: Yes. Rather, form 2 will stay as the official death report, but will now be supplemented by a VA-derived cause of death to be used for health statistics, instead of the presumptive cause noted on Form 2. But this VA COD will not be called a form 4. Because Form 4 is legally the medical certification by the physician who has observed the death. Here, the physician is basing his opinion on a derived diagnosis in retrospect. So, we are calling it, verbal autopsy cause of death, but the format and the structure is similar to the form 4 of a hospital. TS: How many diagnostic categories do you have in the verbal autopsy cause of death? What is the level of standardization of this? CR: Diagnosis can be of different levels of granularity, as it is based on information that is provided by the household in the form of a medical reports and this varies. Broadly it conforms to the International Classification of Diseases – and we go that level of granularity which the information provided allows us. We could for example say a 5-year- old female child died of pneumonia if we have such a diagnosis or we could state that the 5-year-old female child developed fever acutely and died at home if only that is available. If other the other hand we have information that child had fever, cough, breathlessness and chest pain, they will diagnose it as pneumonia. They will not list these four symptoms. The WHO VA standards include a list of about 65 or 70 cause categories of public health importance, which could be used by physicians to assign the COD. TS: Now onto the big question and this should have been the starting point. Now given all the problems we’ve discussed, should we place our greater reliance on the Global Burden of Disease estimates and the UHC indicators like deaths in the 30 to 70 age group generated for all countries including India by the Institute for Health Metrics and Evaluation (IHME)? Are these reasonable alternatives to reports based on our own mortality data given the problems we are facing? CR: The Global Burden of Disease estimate is based on statistical models where all available information from whatever sources of data are available for India are said to be used. This information is used and estimates are provided at both the national and at the state level. The convergence between local data based on projections and Global burden of disease estimates have been studied and published for all-cause mortality as well as cause specific mortality and for a range of indicators. In this publication4 we show that the global burden of disease overestimates life expectancy at birth at the state level. We note that the GBD estimates do not use CRS data, but use only SRS data and for under-five mortality they use the NFHS data. And they claim some other methods, which I am not going into, but which I do not find convincing. When you overestimate life expectancy, you are underestimating mortality. When you underestimate mortality, your health programs will not be sufficiently powered to make decisions and study trends, and even the resource allocation to and within the health sector may get undermined. This overestimation of life expectancy is true for both males and females. I had previously collaborated with the Institute of Public Health in Malaysia5 for cause-specific mortality, using similar methods as being implemented now in Tamil Nadu. In that study, the age-standardised mortality rates from the study, based on country’s mortality data, were compared with those from the GBD for the 10 leading causes of death in males and female. And we found that in 7 out of 10 of the leading causes in males and females, the causes were statistically significantly different. So GBD is either under-estimating or over-estimating. In many smaller countries, GBD and preventable mortality estimates are based on mortality data from other countries. These are of little use for either planning or measuring progress. Some governments accept the GBD data, but at times, as with Covid 19 deaths, they are not seen to be acceptable. My point of view is just pointing fingers at GBD is not going to get us anywhere. We have to pull up our socks and produce our own reliable mortality data and compare it with the GBD and see which one is more plausible. If we just take GBD estimates at face value or if we outsource our analyses by giving them whatever data is available without trying to do anything ourselves, then we might end up with an estimate which is not reflecting the truth and which we ourselves do not have confidence in. So in conclusion, what I’d like to say is. Ensuring reliable CRS mortality data is feasible in the short term. If you look at what is happening in Tamil Nadu’s they have made a lot of groundbreaking progress with data on mortality in the two study districts, covering a population of approximately 4 million (about 28,000 deaths in 2023). There is also an intention to use available resources and the critical capacity from these two districts to be able to scale up in other districts next year. The methodology is not rocket science. And my view is, given that UHC is related to the Sustainable Development Goals that need to be achieved by 2030, there is enough time for India to build up the required capacity over the next 3-5 years and implement a sufficient number of activities covering larger numbers of states to be able to have their own data and be able to draw inferences and conclusions based on local data and analysis, rather than depending on external agencies. If you remember, I met you in 2013 in NHSRC when you were then its executive director, and we had discussed this topic. Even now it is the NHSRC for example, with its current leadership, and its many state avatars which can take the lead in building up the capacity required for this across the states. Given the fact that the Registrar General’s November 2017, order has empowered state governments to generate their health outcome indicators from CRS it is an urgent need to draw the attention of public health researchers and practitioners to help the government close this gap. TS: Would you like to comment on the million-death study? CR: That is a topic in itself. And quite controversial. We should learn from it. But Ill like to take a pass on that. Perhaps its best left for another conversation. TS: Just another minor detail to conclude with. In the measure of UHC, other than certain disease-specific outcome measures, the indicator that you have talked a lot about is preventable mortality in the 30 to 70 age group. You have a number of papers on that. This is one reliable indicator which we would be able to generate at the district level from an improved CRS to measure progress towards UHC? Could you help us understand this indicator better? CR: In 2014, WHO developed an indicator for non-communicable disease (NCD) mortality as an important indicator for measuring UHC progress. This indicator for non-communicable disease mortality was defined as the unconditional probability of dying between the ages of 30 and 70 from diabetes, cardiovascular disease, cancers and chronic obstructive lung diseases. The rationale for this age group was that normally deaths from these causes would not happen below the age of 30. And, after the age of 70, there are challenges in accurately measuring what was the actual underlying cause of death because there can be multiple morbidities and age has a leading contribution to make. But we don’t have data on causes of death to be able to filter out how many have died from these four causes as compared to others. So, in my studies, total all-cause mortality in between age 30 and 70 is taken as a proxy.6 The bulk of it would be from NCDs, but even other common causes like road traffic accidents, or injuries or alcohol, or tuberculosis HIV and hepatitis-B are preventable. The term amenable or avoidable mortality has been used to refer to those who could be saved because of healthcare and preventable includes those saved by healthcare as well as prevented by larger public health interventions. So “preventable mortality” term can be used as the unconditional probability of dying between the age of 30 and 70 and the estimated population in this age group is the denominator. But I would caution that such definitions and terms are still evolving. TS: Thanks for this interview. I know that we have kept to the overview and not gone into the much greater depths that you are capable of. Much of this information is basic, but just impossible to access elsewhere. So, thank you. One reason why we have chosen this topic, is also as an appeal to all our schools of public health and departments of preventive and social medicine, to get engaged in providing support to state governments to generate reliable all-cause mortality data at the state and district level, which would immensely benefit public health action by the government and civil society and enhance their own efforts in public health research. This also makes for data sovereignty and federalism. Where the countries and states have the capacity to generate, own and use their own high-quality public health data and not become dependent on block-boxed estimates which are difficult to verify or replicate. Dr Chalapati Rao is a research academic at the Australian National University. His key interests lie in the collection and analysis of cause-specific mortality statistics for health policy and research. His experience covers field projects for implementing or strengthening mortality data collection & validation, as well as secondary data analysis, for countries in the Indo-Pacific region. His work in India includes previous research on causes of death in Andhra Pradesh, verbal autopsy validation in Delhi and surrounding areas, CRS system analysis/evaluation, and subnational mortality estimation. His current work focuses on the design and implementation of activities to strengthen cause-specific mortality measurement at the district and state levels. Reference List Rao, C., & Gupta, M. (2020). The civil registration system is a potentially viable data source for reliable subnational mortality measurement in India. BMJ global health, 5(8), e002586. Rao, C., John, A. J., Yadav, A. K., & Siraj, M. (2021). Subnational mortality estimates for India in 2019: a baseline for evaluating excess deaths due to the COVID-19 pandemic. BMJ Global Health, 6(11), e007399. Office of the Registrar General of India. Monitoring vital rates: Action to be taken. Ministry of Home Affairs, Government of India.; New Delhi. 2017 3rd November 2017.: Circular No. 2/6/2017 – VS (CRS). Available from: http://crsorgi.gov.in/web/uploads/download/CRS_Circular_Monthly.pdf Vital Statistics of India Based on the Civil Registration System (2019). New Delhi: Office of the Registrar General of India, Ministry of Home Affairs, Government of India. Omar A, Ganapathy SS, Anuar MFM, Khoo YY, Jeevananthan C, Maria Awaluddin S, Rao C. Cause-specific mortality estimates for Malaysia in 2013: results from a national sample verification study using medical record review and verbal autopsy. BMC Public Health. 2019;19(1):110. Rao, C., Gupta, A., Gupta, M., & Yadav, A. K. (2021). Premature adult mortality in India: what is the size of the matter?. BMJ Global Health, 6(6), e004451. Prof. T. Sundararaman / ABOUT AUTHOR More posts by Prof. T. Sundararaman Leave A COMMENT Message * Name * Mail * Website Save my name, email, and website in this browser for the next time I comment. Send Comment Recent posts Getting reliable mortality and burden of disease estimates – So near but yet so far!!! June 30, 2024 Why is Progress towards Universal Health Coverage so far off track? Implementation Failure or Gaps in the Strategy? June 10, 2024 What is happening at the 77th World Health Assembly- 2024? ......And an Introduction to the WHO Tracker May 24, 2024 Recent Posts Getting reliable mortality and burden of disease estimates – So near but yet so far!!! Why is Progress towards Universal Health Coverage so far off track? Implementation Failure or Gaps in the Strategy? 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(जे एस ए) जन स्वास्थ्य अभियान हरियाणा ने एन.ई.ई.टी परीक्षा में हुए घोटाले एवं कुप्रबंधन की उच्च स्तरीय निष्पक्ष जांच की मांग की है। हमने यह कहा है कि 4 जून को NEET-UG परीक्षा परिणाम घोषित होने के बाद अनेकों शिकायतें सामने आ रही हैं, जो एन.टी.ए. द्वारा संचालित परीक्षाओं की पारदर्शिता पर गंभीर सवाल उठाती हैं। गौरतलब है कि एन.टी.ए. का गठन किए जाने के बाद से महत्वपूर्ण परीक्षाओं में  निरंतर गंभीर भ्रष्टाचार एवं कुप्रबंधन की श्रृंखला सामने आई है जिससे यह साबित होता है कि एक केंद्रीकृत संस्था एन.टी.ए. नीट जैसी प्रवेश परीक्षा आयोजित करवाने में अक्षम और अयोग्य है। हमारा मानना है कि एमबीबीएस-बीडीएस स्नातक स्तरीय प्रवेश परीक्षा में कुल अंक 720 होते हैं। प्रत्येक सही उत्तर के लिए 4 अंक दिए जाते हैं, जबकि प्रत्येक गलत उत्तर के लिए कुल अंकों में से 1 अंक काटा जाता है, जबकि अनुत्तरित प्रश्नों छोड़ दिया जाता है। अंक प्रदान करने की एक ऐसी व्यवस्था में 719 और 718 अंक प्राप्त करना किसी भी रूप में संभव नहीं है। लेकिन परिणामों में ऐसे मामले कई देखे गए हैं। एन.टी.ए. ने एक बयान में गैरजिम्मेदाराना रूप से कहा है कि इस साल के रिजल्ट में ग्रेस मार्किंग भी हुई है जबकि इस साल परीक्षा से पहले एन.टी.ए. द्वारा प्रकाशित दिशानिर्देशों में कहीं भी इस ग्रेस मार्किंग योजना का कोई उल्लेख नहीं किया गया है। इसके अलावा, ऐसी शिकायतें भी मिली हैं कि एक ही केंद्र से एक ही क्रम में लगातार रोल नंबर वाले छात्रों को समान अंक मिले हैं, जो की संयोगवश 720 में से 720 अंक हैं। यह स्थिति पेपर लीक होने का स्पष्ट संकेत देती है। इसके अलावा रैंक प्राप्त उम्मीदवारों की इस गंभीर संख्या वृद्धि के कारण उम्मीदवारों को अब निजी कॉलेजों में प्रवेश लेने के लिए मजबूर होना पड़ रहा है। रैंक प्राप्त विद्यार्थियों की संख्या में वृद्धि का कारण सीधे तौर पर एन.टी.ए. की नीतियाँ जैसे कि पाठ्यक्रम में उल्लेखनीय कमी किया जाना है। हमारा मानना है कि मोदी सरकार में जिस तरह से एनएमसी और एन.टी.ए. मिलकर मेडिकल शिक्षा का निजीकरण कर रहे हैं, वह देश के भविष्य के लिए खतरनाक है। मेडिकल क्षेत्र में राज्य-आधारित संयुक्त प्रवेश परीक्षा प्रणाली को बदलने के लिए अंतहीन भ्रष्टाचार व्याप्त होने का तर्क दिया गया था, अब यही अंतहीन भ्रष्टाचार का आरोप NEET-UG को लेकर भी सामने आ रहा है। हम इस बार की नीट-यूटी परीक्षा की तुरन्त उच्च स्तरीय निष्पक्ष जांच की मांग करती है ताकि विद्यार्थियों के साथ न्याय किया जा सके। जेएसए इसके साथ ही एन.टी.ए को खत्म करने और इसके अब तक के सभी घोटालों की तुरन्त पारदर्शी जांच करने की भी मांग करता है। R S Dahiya Member Haryana JSA State Committee

Population and Household Profile Urban Rural Total

Population and Household Profile Urban Rural Total Total 1. Female population age 6 years and above who ever attended school (%) 82.3 69.6 73.8 70.3 2. Population below age 15 years (%) 23.2 26.3 25.3 27.8 3. Sex ratio of the total population (females per 1,000 males) 911 933 926 876 4. Sex ratio at birth for children born in the last five years (females per 1,000 males) 943 873 893 836 5. Children under age 5 years whose birth was registered with the civil authority (%) 95.7 94.9 95.1 94.2 6. Deaths in the last 3 years registered with the civil authority (%) 88.8 85.5 86.4 na 7. Population living in households with electricity (%) 99.8 99.5 99.6 98.9 8. Population living in households with an improved drinking-water source1 (%) 99.3 98.2 98.6 98.3 9. Population living in households that use an improved sanitation facility2 (%) 86.0 84.6 85.0 80.6 10. Households using clean fuel for cooking3 (%) 90.5 42.6 59.5 52.2 11. Households using iodized salt (%) 95.1 96.6 96.1 92.8 12. Households with any usual member covered under a health insurance/financing scheme (%) 28.3 24.2 25.7 12.2 13. Children age 5 years who attended pre-primary school during the school year 2019-20 (%) 8.1 7.4 7.6 na Characteristics of Adults (age 15-49 years) 14. Women who are literate4 (%) 85.7 76.7 79.7 na 15. Men who are literate4 (%) 93.3 90.6 91.5 na 16. Women with 10 or more years of schooling (%) 60.1 44.1 49.5 45.8 17. Men with 10 or more years of schooling (%) 65.0 60.8 62.2 61.1 18. Women who have ever used the internet (%) 60.2 42.8 48.4 na 19. Men who have ever used the internet (%) 79.7 68.8 72.4 na Marriage and Fertility 20. Women age 20-24 years married before age 18 years (%) 9.9 13.7 12.5 19.4 21. Men age 25-29 years married before age 21 years (%) 17.6 15.2 16.0 23.9 22. Total fertility rate (children per woman) 1.7 2.0 1.9 2.1 23. Women age 15-19 years who were already mothers or pregnant at the time of the survey (%) 3.0 4.3 3.9 5.8 24. Adolescent fertility rate for women age 15-19 years5 21 29 27 41 Infant and Child Mortality Rates (per 1,000 live births) 25. Neonatal mortality rate (NNMR) 19.0 22.7 21.6 22.1 26. Infant mortality rate (IMR) 28.6 35.3 33.3 32.8 27. Under-five mortality rate (U5MR) 36.0 39.8 38.7 41.1 Current Use of Family Planning Methods (currently married women age 15–49 years) 28. Any method6 (%) 73.5 72.9 73.1 63.7 29. Any modern method6 (%) 59.0 61.3 60.5 59.4 30. Female sterilization (%) 24.1 36.3 32.3 38.1 31. Male sterilization (%) 0.7 1.1 0.9 0.6 32. IUD/PPIUD (%) 5.0 4.9 5.0 5.7 33. Pill (%) 2.9 2.8 2.8 2.7 34. Condom (%) 24.6 14.9 18.1 12.0 35. Injectables (%) 0.4 0.4 0.4 0.2 Quality of Family Planning Services 38. Health worker ever talked to female non-users about family planning (%) 21.2 26.9 24.9 23.0 39. Current users ever told about side effects of current method8 (%) 71.6 68.2 69.1 63.5 LHV = Lady health visitor; ANM = Auxiliary nurse midwife; na = Not available ( ) Based on 25-49 unweighted cases 1Piped water into dwelling/yard/plot, piped to neighbour, public tap/standpipe, tube well or borehole, protected dug well, protected spring, rainwater, tanker truck, cart with small tank, bottled water, community RO plant. 2Flush to piped sewer system, flush to septic tank, flush to pit latrine, flush to don't know where, ventilated improved pit (VIP)/biogas latrine, pit latrine with slab, twin pit/composting toilet, which is not shared with any other household. This indicator does not denote access to toilet facility. 3Electricity, LPG/natural gas, biogas. 4Refers to women/men who completed standard 9 or higher and women/men who can read a whole sentence or part of a sentence. 5Equivalent to the age-specific fertility rate for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19. 6Any method includes other methods that are not shown separately; Any modern method includes other modern methods that are not shown separately. 7Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone the next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have unmet need for spacing if they are: · At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years, or are unsure if or when they want to become pregnant. · Pregnant with a mistimed pregnancy. · Postpartum amenorrhoeic for up to two years following a mistimed birth and not using contraception. Women are considered to have unmet need for limiting if they are: · At risk of becoming pregnant, not using contraception, and want no (more) children. · Pregnant with an unwanted pregnancy. · Postpartum amenorrhoeic for up to two years following an unwanted birth and not using contraception. Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Unmet need for family planning is the sum of unmet need for spacing plus unmet need for limiting. 8Based on current users of female sterilization, IUD/PPIUD, injectables, and pills who started using that method in the past 5 years Haryana - Key Indicators Indicators NFHS-5 (2019-21) NFHS-4 (2015-16) Maternal and Child Health Urban Rural Total Total Maternity Care (for last birth in the 5 years before the survey) 40. Mothers who had an antenatal check-up in the first trimester (%) 85.0 85.3 85.2 63.2 41. Mothers who had at least 4 antenatal care visits (%) 63.1 59.2 60.4 45.1 42. Mothers whose last birth was protected against neonatal tetanus9 (%) 88.6 91.7 90.7 92.3 43. Mothers who consumed iron folic acid for 100 days or more when they were pregnant (%) 50.7 51.5 51.2 32.5 44. Mothers who consumed iron folic acid for 180 days or more when they were pregnant (%) 31.7 32.0 32.0 14.3 45. Registered pregnancies for which the mother received a Mother and Child Protection (MCP) card (%) 94.9 97.6 96.8 92.0 46. Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within 2 days of delivery (%) 92.4 90.8 91.3 67.3 47. Average out-of-pocket expenditure per delivery in a public health facility (Rs.) 1,768 1,631 1,666 1,569 48. Children born at home who were taken to a health facility for a check-up within 24 hours of birth (%) (7.3) 2.9 3.8 1.4 49. Children who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within 2 days of delivery (%) 92.3 90.4 91.0 na Delivery Care (for births in the 5 years before the survey) 50. Institutional births (%) 96.1 94.4 94.9 80.4 51. Institutional births in public facility (%) 48.6 61.1 57.5 52.0 52. Home births that were conducted by skilled health personnel10 (%) 0.7 1.3 1.1 5.8 53. Births attended by skilled health personnel10 (%) 95.5 94.0 94.4 84.6 54. Births delivered by caesarean section (%) 23.5 17.8 19.5 11.7 55. Births in a private health facility that were delivered by caesarean section (%) 34.9 33.4 33.9 25.3 56. Births in a public health facility that were delivered by caesarean section (%) 14.4 10.9 11.7 8.6 Child Vaccinations and Vitamin A Supplementation 57. Children age 12-23 months fully vaccinated based on information from either vaccination card or mother's recall11 (%) 74.3 77.9 76.9 62.2 58. Children age 12-23 months fully vaccinated based on information from vaccination card only12 (%) 82.0 80.8 81.1 79.4 59. Children age 12-23 months who have received BCG (%) 95.9 94.6 95.0 92.8 60. Children age 12-23 months who have received 3 doses of polio vaccine13 (%) 77.8 81.6 80.6 75.3 61. Children age 12-23 months who have received 3 doses of penta or DPT vaccine (%) 88.9 88.3 88.5 76.5 62. Children age 12-23 months who have received the first dose of measles-containing vaccine (MCV) (%) 89.4 89.4 89.4 79.0 63. Children age 24-35 months who have received a second dose of measles-containing vaccine (MCV) (%) 33.5 31.4 32.0 na 64. Children age 12-23 months who have received 3 doses of rotavirus vaccine14 (%) 79.5 80.0 79.8 na 65. Children age 12-23 months who have received 3 doses of penta or hepatitis B vaccine (%) 87.8 87.3 87.4 54.3 66. Children age 9-35 months who received a vitamin A dose in the last 6 months (%) 62.2 66.0 64.9 71.3 67. Children age 12-23 months who received most of their vaccinations in a public health facility (%) 92.1 98.8 96.9 94.8 68. Children age 12-23 months who received most of their vaccinations in a private health facility (%) 6.5 0.7 2.4 5.1 Treatment of Childhood Diseases (children under age 5 years) 69. Prevalence of diarrhoea in the 2 weeks preceding the survey (%) 4.8 5.0 4.9 7.7 70. Children with diarrhoea in the 2 weeks preceding the survey who received oral rehydration salts (ORS) (%) 52.2 44.4 46.6 60.6 71. Children with diarrhoea in the 2 weeks preceding the survey who received zinc (%) 26.0 26.3 26.2 21.9 72. Children with diarrhoea in the 2 weeks preceding the survey taken to a health facility or health provider (%) 70.8 78.3 76.1 77.3 73. Prevalence of symptoms of acute respiratory infection (ARI) in the 2 weeks preceding the survey (%) 1.8 2.4 2.3 3.2 74. Children with fever or symptoms of ARI in the 2 weeks preceding the survey taken to a health facility or health provider (%) 70.7 74.6 73.5 80.1 9 Includes mothers with two injections during the pregnancy for their last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within 10 years of the last live birth), or five or more injections at any time prior to the last birth. 10Doctor/nurse/LHV/ANM/midwife/other health personnel. 11Vaccinated with BCG, measles-containing vaccine (MCV)/MR/MMR/Measles, and 3 doses each of polio (excluding polio vaccine given at birth) and DPT or penta vaccine. 12Among children whose vaccination card was shown to the interviewer, percentage vaccinated with BCG, measles-containing vaccine (MCV)/MR/MMR/Measles, and 3 doses each of polio (excluding polio vaccine given at birth) and DPT or penta vaccine. 13Not including polio vaccination given at birth. 14Since rotavirus is not being provided across all states and districts, the levels should not be compared. Haryana - Key Indicators Indicators NFHS-5 (2019-21) NFHS-4 (2015-16) Child Feeding Practices and Nutritional Status of Children Urban Rural Total Total 75. Children under age 3 years breastfed within one hour of birth15 (%) 37.7 43.3 41.6 42.4 76. Children under age 6 months exclusively breastfed16 (%) 70.3 69.1 69.5 50.3 77. Children age 6-8 months receiving solid or semi-solid food and breastmilk16 (%) 51.8 39.2 43.0 35.9 78. Breastfeeding children age 6-23 months receiving an adequate diet16, 17 (%) 9.3 13.0 11.9 7.0 79. Non-breastfeeding children age 6-23 months receiving an adequate diet16, 17 (%) 10.6 11.3 11.1 10.0 80. Total children age 6-23 months receiving an adequate diet16, 17 (%) 9.6 12.7 11.8 7.5 81. Children under 5 years who are stunted (height-for-age)18 (%) 26.1 28.1 27.5 34.0 82. Children under 5 years who are wasted (weight-for-height)18 (%) 10.8 11.8 11.5 21.2 83. Children under 5 years who are severely wasted (weight-for-height)19 (%) 4.3 4.4 4.4 9.0 84. Children under 5 years who are underweight (weight-for-age)18 (%) 20.5 21.8 21.5 29.4 85. Children under 5 years who are overweight (weight-for-height)20 (%) 3.3 3.3 3.3 3.1 Nutritional Status of Adults (age 15-49 years) 86. Women whose Body Mass Index (BMI) is below normal (BMI <18.5 kg/m2 ) 21 (%) 11.4 16.9 15.1 15.8 87. Men whose Body Mass Index (BMI) is below normal (BMI <18.5 kg/m2 ) (%) 15.0 14.3 14.5 11.3 88. Women who are overweight or obese (BMI ≥25.0 kg/m2 ) 21 (%) 37.5 30.9 33.1 21.0 89. Men who are overweight or obese (BMI ≥25.0 kg/m2 ) (%) 30.2 27.4 28.3 20.0 90. Women who have high risk waist-to-hip ratio (≥0.85) (%) 64.6 61.7 62.6 na 91. Men who have high risk waist-to-hip ratio (≥0.90) (%) 59.5 57.7 58.3 na Anaemia among Children and Adults 92. Children age 6-59 months who are anaemic (<11.0 g/dl)22 (%) 68.1 71.5 70.4 71.7 93. Non-pregnant women age 15-49 years who are anaemic (<12.0 g/dl)22 (%) 57.5 62.1 60.6 63.1 94. Pregnant women age 15-49 years who are anaemic (<11.0 g/dl)22 (%) 54.6 57.2 56.5 55.0 95. All women age 15-49 years who are anaemic22 (%) 57.4 61.9 60.4 62.7 96. All women age 15-19 years who are anaemic22 (%) 59.3 63.5 62.3 62.7 97. Men age 15-49 years who are anaemic (<13.0 g/dl)22 (%) 16.0 20.4 18.9 20.9 98. Men age 15-19 years who are anaemic (<13.0 g/dl)22 (%) 26.7 31.5 29.9 29.7 Blood Sugar Level among Adults (age 15 years and above) Women 99. Blood sugar level - high (141-160 mg/dl)23 (%) 5.3 5.4 5.4 na 100. Blood sugar level - very high (>160 mg/dl)23 (%) 7.0 5.1 5.7 na 101. Blood sugar level - high or very high (>140 mg/dl) or taking medicine to control blood sugar level23 (%) 13.5 11.2 11.9 na Men 102. Blood sugar level - high (141-160 mg/dl)23 (%) 7.0 6.1 6.4 na 103. Blood sugar level - very high (>160 mg/dl)23 (%) 6.9 5.9 6.2 na 104. Blood sugar level - high or very high (>140 mg/dl) or taking medicine to control blood sugar level23 (%) 15.1 12.6 13.5 na Hypertension among Adults (age 15 years and above) Women 105. Mildly elevated blood pressure (Systolic 140-159 mm of Hg and/or Diastolic 90-99 mm of Hg) (%) 13.6 11.7 12.3 na 106. Moderately or severely elevated blood pressure (Systolic ≥160 mm of Hg and/or Diastolic ≥100 mm of Hg) (%) 5.7 5.3 5.4 na 107. Elevated blood pressure (Systolic ≥140 mm of Hg and/or Diastolic ≥90 mm of Hg) or taking medicine to control blood pressure (%) 22.9 20.1 21.0 na Men 108. Mildly elevated blood pressure (Systolic 140-159 mm of Hg and/or Diastolic 90-99 mm of Hg) (%) 17.2 16.2 16.6 na 109. Moderately or severely elevated blood pressure (Systolic ≥160 mm of Hg and/or Diastolic ≥100 mm of Hg) (%) 7.0 6.9 6.9 na 110. Elevated blood pressure (Systolic ≥140 mm of Hg and/or Diastolic ≥90 mm of Hg) or taking medicine to control blood pressure (%) 26.2 24.6 25.1 na 15Based on the last child born in the 3 years before the survey. 16Based on the youngest child living with the mother. 17Breastfed children receiving 4 or more food groups and a minimum meal frequency, non-breastfed children fed with a minimum of 3 Infant and Young Child Feeding Practices (fed with other milk or milk products at least twice a day, a minimum meal frequency that is, receiving solid or semi-solid food at least twice a day for breastfed infants 6-8 months and at least three times a day for breastfed children 9-23 months, and solid or semi-solid foods from at least four food groups not including the milk or milk products food group). 18Below -2 standard deviations, based on the WHO standard. 19Below -3 standard deviations, based on the WHO standard. 20Above +2 standard deviations, based on the WHO standard. 21Excludes pregnant women and women with a birth in the preceding 2 months. 22Haemoglobin in grams per decilitre (g/dl). Among children, prevalence is adjusted for altitude. Among adults, prevalence is adjusted for altitude and for smoking status, if known. As NFHS uses the capillary blood for estimation of anaemia, the results of NFHS-5 need not be compared with other surveys using venous blood. 23Random blood sugar measurement. Haryana - Key Indicators Indicators NFHS-5 (2019-21) NFHS-4 (2015-16) Screening for Cancer among Adults (age 30-49 years) Urban Rural Total Total Women 111. Ever undergone a screening test for cervical cancer (%) 1.0 0.7 0.8 na 112. Ever undergone a breast examination for breast cancer (%) 0.3 0.3 0.3 na 113. Ever undergone an oral cavity examination for oral cancer (%) 0.4 0.3 0.3 na Men 114. Ever undergone an oral cavity examination for oral cancer (%) 1.6 1.3 1.4 na Knowledge of HIV/AIDS among Adults (age 15-49 years) 115. Women who have comprehensive knowledge24 of HIV/AIDS (%) 22.0 18.7 19.7 31.1 116. Men who have comprehensive knowledge24 of HIV/AIDS (%) 39.4 35.0 36.4 48.5 117. Women who know that consistent condom use can reduce the chance of getting HIV/AIDS (%) 71.4 70.7 70.9 71.6 118. Men who know that consistent condom use can reduce the chance of getting HIV/AIDS (%) 86.8 89.4 88.5 87.8 Women's Empowerment (women age 15-49 years) 119. Currently married women who usually participate in three household decisions25 (%) 90.7 86.2 87.5 76.7 120. Women who worked in the last 12 months and were paid in cash (%) 22.6 17.0 18.8 17.6 121. Women owning a house and/or land (alone or jointly with others) (%) 35.7 41.0 39.3 35.8 122. Women having a bank or savings account that they themselves use (%) 76.3 72.4 73.6 45.6 123. Women having a mobile phone that they themselves use (%) 65.1 43.4 50.4 50.5 124. Women age 15-24 years who use hygienic methods of protection during their menstrual period26 (%) 96.7 91.6 93.2 78.3 Gender Based Violence (age 18-49 years) 125. Ever-married women age 18-49 years who have ever experienced spousal violence27 (%) 18.0 18.2 18.2 32.0 126. Ever-married women age 18-49 years who have experienced physical violence during any pregnancy (%) 2.5 1.2 1.6 4.9 127. Young women age 18-29 years who experienced sexual violence by age 18 (%) 0.2 0.5 0.4 1.5 Tobacco Use and Alcohol Consumption among Adults (age 15 years and above) 128. Women age 15 years and above who use any kind of tobacco (%) 1.7 3.0 2.5 na 129. Men age 15 years and above who use any kind of tobacco (%) 23.3 32.1 29.1 na 130. Women age 15 years and above who consume alcohol (%) 0.3 0.2 0.3 na 131. Men age 15 years and above who consume alcohol (%) 15.7 16.2 16.1 na 24Comprehensive knowledge means knowing that consistent use of condoms every time they have sex and having just one uninfected faithful sex partner can reduce the chance of getting HIV/AIDS, knowing that a healthy-looking person can have HIV/AIDS, and rejecting two common misconceptions about transmission or prevention of HIV/AIDS. 25Decisions about health care for herself, making major household purchases, and visits to her family or relatives. 26Locally prepared napkins, sanitary napkins, tampons, and menstrual cups are considered to be hygienic methods of protection. 27Spousal violence is defined as physical and/or sexual violence INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES Vision: “To position IIPS as a premier teaching and research institution in population sciences responsive to emerging national and global needs based on values of inclusion, sensitivity and rights protection.” Mission: “The Institute will strive to be a centre of excellence on population, health and development issues through high quality education, teaching and research. This will be achieved by (a) creating competent professionals, (b) generating and disseminating scientific knowledge and evidence, (c) collaboration and exchange of knowledge, and (d) advocacy and awareness.” For additional information, please contact: Director/Principal Investigator (NFHS-5) International Institute for Population Sciences Govandi Station Road, Deonar Mumbai - 400 088 (India) Telephone: 022 - 42372467 Email: nfhs52017@gmail.com, director@iipsindia.ac.in Website: http://www.iipsindia.ac.in http://www.rchiips.org/nfhs/index.shtml Director General (Stats.) Ministry of Health and Family Welfare Government of India Statistics Division Indian Red Cross Society Building New Delhi 110 001 (India) Telephone: 011 - 23736979 or 23350003 Email: sandhya.k@nic.in Deputy Director General (Stats.) Ministry of Health and Family Welfare Government of India Statistics Division Indian Red Cross Society Building New Delhi 110 001 (India) Telephone: 011 - 23736982 Email: dk.ojha@gov.in Website: http://www.mohfw.gov.in Technical assistance and additional funding for NFHS-5 was provided by the USAID-supported Demographic and Health Surveys (DHS) Program, ICF, USA. The contents of this publication do not necessarily reflect the views of USAID or the United States Government. The opinions in this publication do not necessarily reflect the views of the funding agencies. For additional information on NFHS-5, visit http://www.iipsindia.ac.in or http://www.mohfw.gov.in

Health Manifesto

 Jan Swasthya Abhiyan: People’s Manifesto on Right to Health and Healthcare - 2024

Addressing the health system crisis - Urgent need to advance people’s 

Right to health and healthcare through transformation of health systems

As India approaches the 2024 Lok Sabha elections, Jan Swasthya Abhiyan circulates this memorandum with a charter of policy proposals, appealing to all the political parties and independents in the election fray to commit to these by incorporating them in their election manifesto.  This is essential because of the critical state of our country's health system, since more than 80 crore people of this country who today depend on free ration also require protection for their health related vulnerabilities. Despite the COVID experience, people’s health still remains very low on priority for the Union government. Increasing commercialisation and decrease in the government’s role has placed quality healthcare out of reach of the majority of Indians.

The Union government's handling of the COVID pandemic was marked by serious mismanagement on various fronts, exacerbating an already critical situation. Although the pandemic underlined the outstanding need for stronger public health systems, the Union government’s spending on health remains dismal. It continues to restrict funds, along with neglecting the National Health Mission, while eroding federalism and imposing hyper-centralised decision making. Refusal to regulate profiteering by the commercialised private healthcare sector, accelerated privatisation of health services, and failures of the much-hyped PMJAY health insurance scheme have further worsened the situation, leaving the vast majority of the population, especially marginalised communities at risk. 

Key Demands Concerning Right to Health and Healthcare

Our Health, Our Right! - Right to Healthcare legislation must be passed to ensure guaranteed availability of free quality treatment of all conditions, in close proximity to place of residence. Expand, improve & strengthen public healthcare infrastructure to provide such essential care. Denial, delay and incomplete treatment to be strictly prevented.

Increase Budgetary Allocation for Health – Increase Health Spending to 3.5% of GDP, with 1% of GDP coming from Centre; States should get special financial envelopes for raised health expenditure. 

No one should face financial hardship due to Out-of-Pocket (OOP) Spending on health – Reduce OOP to less than 25% of Total Health Expenditure.

Fill Vacant Posts and Ensure Justice to Health workers  – No health facility should have a vacant position. No public health establishment should engage contractual staff, it is essential to regularise all scheme based and contractual health workers. Ensure adequate wages and protection under labour laws. A Human resources for health policy would be enforced to ensure these measures. 

Devolve administrative and financial powers to local bodies and state governments to enable them to conceptualise and manage health systems in their jurisdictions, with support from national and regional bodies.

Immediately reverse the rebranding of Health and Wellness Centres as ‘Arogya mandirs’, in keeping with the constitutional values of secularism and inclusivity.

Ensure availability of affordable and quality essential drugs & diagnostics – Implement effective and rational price control; return to cost-based pricing. Ensure availability of medicines as per the NLEM 2022, eliminate all irrational medicines and Fixed Dose Combinations (FDCs).  

Healthcare is primarily the government’s responsibility – Phase out Government-funded health insurance schemes such as PMJAY and Public Private Partnerships.

Regulate Private healthcare sector by ensuring effective implementation of an improved Clinical Establishment Act. All states must ensure effective regulation of private healthcare while implementing the Patients Rights Charter, along with transparency and regulation of rates, and grievance redressal systems for patients. 

Stop Commercialisation of Medical Education – Review & reform National Medical Commission and National Eligibility cum Entrance Test (NEET). Ensure highest standard of medical, nursing and other allied medical services education and one common uniform system of admissions and fee structures

Protect Workers’ Health – Properly implement National Policy on Safety, Health and Environment at Work. Ensure effective implementation of laws and related measures to prevent serious diseases like silicosis caused due to hazardous occupations, ensure full rehabilitation of families affected by ailments. Strengthen, reform and expand the ESI system. 

A public-centred system for universal health care, ensuring a common system to provide health care for all residents of India, must be developed in the foreseeable future.

Jan Swasthya Abhiyan proposes the following range of policy actions in the health sector, which should be committed to by all political parties and candidates in context of upcoming Lok Sabha elections. JSA will mobilize and campaign among different sections of the people around these proposals, and call upon all social movements, civil society organisations and people to build a consensus around these actions, which must become the highest political priority in India today. 

Make the Right to healthcare a justiciable right through the enactment of appropriate legislations at Union and State levels. Retain health services as a state subject with strong emphasis on federalism

There is a need to ensure all-encompassing healthcare access from primary to tertiary services, for the entire population by enacting Right to healthcare legislations at State level. This should be supported by an appropriate legal, financial and operational framework at national level. In a complementary manner, public health laws must secure access to health determinants, protecting people’s health from various influences. The overall direction should be to establish healthcare as a fundamental right in the Indian Constitution. Health services should remain with the State List as enshrined in the Constitution and should not be made part of the concurrent list.

Rapidly increase public expenditure on Healthcare to reach 3.5% of GDP, with at least 1% of GDP being spent by the Union Government. 

Overall public health expenditure must be majorly increased to reach 3.5% in the short term. While enabling this, the Union government should transfer a much larger share of resources to states through the Finance Commission (FC), and a special financial envelope for states should be created for implementation of Right to Health and Healthcare under the XVI Finance Commission. Special grants under XV FC to local bodies should be augmented further, to foster decentralised governance and delivery of healthcare services. Allocation towards the National Health Mission should be enhanced to facilitate upgradation and expansion of rural and urban health services, and dealing with communicable as well as non-communicable diseases and climate related health challenges. Greater flexibility should be accorded to states to decide on the priorities within NHM and the process of participatory, decentralised planning should be strengthened. 

Out-of-pocket expenditure on health must be minimised and brought down to below 25% of health spending in next five years

Out-of-pocket (OOP) spending on healthcare should be minimised so that no one is pushed into poverty, or faces catastrophic health spending and indebtedness due to healthcare expenses. Current decline in utilisation of health services due to high spending by households is unacceptable and must be reversed to ensure that no one has to forgo healthcare due to unaffordable costs. The objective of reducing OOP to less than 25% of health spending should be adopted as a national goal.

Expand and strengthen the public healthcare system to ensure free availability of quality health care at all levels, including entire range of medicines, diagnostics and vaccines

Strengthen and enable public health systems at all levels in rural and urban areas to provide free comprehensive services, essential drugs and diagnostics, expanding both quantity and quality based on health services standards. This would require upgradation of public health facilities, with matching human resource policy and improved governance and management. Combined with this, it is important to ensure nationwide access to essential medicines and diagnostics in all public facilities, based on models of successful state level schemes such as those operating in Tamil Nadu, Kerala and Rajasthan. Along with ensuring genuinely autonomous public corporations with adequate and competent staff and various measures for transparency and responsiveness, public budgets on medicines must be substantially upscaled to meet the requirements. The government must provide all essential medicines, diagnostics, and medical devices, free of charge, in publicly run hospitals for life-threatening diseases, in order to fulfill its constitutional obligations under Article 21. Ensure regular, adequate availability of essential vaccines through the public health system.

 

Eliminate corruption, ensure community accountability and democratise the health system

It is essential to ensure transparency and social accountability while eradicating corruption in the Public health system, based on processes for broad based participation and democratisation. Ensure empowered participation of people through generalisation of community-based planning and monitoring, with involvement of public representatives, people’s organizations, women's groups and health sector CSOs at all levels from village to state. Develop a community-driven health system with active, diversified participation and strong grievance redressal mechanisms. 

Replace Government funded health insurance schemes with a Public centred system for Universal Health Care, eliminate PPPs and privatisation of health services

Phase out the Pradhan Mantri Jan Arogya Yojana - based on the discredited insurance model - in a phased manner, and replace this with a Public centred system for Universal Health Care. In the interim, all admissions under the scheme in private facilities must be based on gatekeeping by public health facilities, regarding those conditions where services are not available within the public system. There is clear need as well as potential to develop a public centred system for Universal Health Care, based on major expansion and strengthening of public services, while engaging regulated private providers to address current gaps. This system will provide ready access to quality healthcare, which will be available free of charge to everyone. Eliminate existing PPPs which weaken public services, abolish privatization of government health services, no government hospitals or services should be handed over to private companies. 

Reverse the rebranding of Health and Wellness Centres as ‘Arogya mandirs’

Without any significant expansion in number of SCs and HWCs and augmenting the provision of services in those facilities, the Union government has arbitrarily renamed these public institutions built over the last several decades, as ‘Arogya mandirs’ with religious connotations. This is clearly a violation of principles of secularism enshrined under the constitution, and must be immediately reversed. It must be ensured that public institutions remain secular and inclusive, focusing on the overall well-being of all citizens. Instead of making such negative and superficial changes, efforts should be made to substantially strengthen and upgrade the Sub-centres and PHCs now designated as HWCs, to provide comprehensive primary care.

Ensure justice for all health workers, upgrading and regulating training of health force 

All scheme based and contractual health workers, including ASHAs and Anganwadi workers, must be regularised while ensuring them adequate wages and protection under labour laws. The policy of contractualisation must be replaced by systematic regularisation of all types of contractual employees in health services. All vacancies in Health Departments must be filled and new posts created as per requirement. All health workers including ANMs, Nurses, Doctors and Paramedics must be paid decent wages while working in a supportive environment. There must be complete transparency in the processes of recruitment, transfers and promotions of officers and employees in the health system. Increase public investment in health professional education and training and regulate private institutions providing training for healthcare personnel. 

Need for major reforms in medical education and National Medical Council

  There is an urgent need to control commercialized private medical colleges, while not sanctioning further such private colleges and mandating their fees to be not higher than government medical colleges. There is need for independent, multi-stakeholder review and reform of the structure and functioning of the National Medical Commission, which has come under major criticism for lack of representation of diverse stakeholders, promoting high degree of centralisation in decision-making with erosion of state autonomy, and promotion of further commercialisation of medical education. There is a particular need to review and restructure the National Eligibility cum Entrance Test (NEET) which tends to place candidates from rural areas, those from non-English medium schools and less privileged backgrounds at a disadvantage. NEET encroaches on the autonomy of states in determining their own medical admission processes, and the imposition of NEET is perceived as an infringement on state level educational policies.

Adopt a people-centred, rational pharmaceutical policy and make medicines affordable for all

A pro-people pharmaceutical policy must be implemented which would bring all essential medicines and devices under effective and rational price control. The comprehensive price control regime should restore cost-based pricing for all medicines, along with banning irrational drugs and combinations, regulating pharma marketing practices, and promoting generic medicine outlets. It is important to implement a comprehensive generic medicine policy, which covers labelling as well as prescribing of all medicines. 

Resist dilution of Patent Law provisions that protect national interests and use public health safeguards in the Indian Patent Act. Reject provisions being pushed through Free Trade Agreements which affect the production of low-cost generic drugs. Utilize compulsory licensing provisions to reduce the costs of high-cost treatments for diseases such as cancer and rare diseases. Additionally, address regulatory barriers to the entry of costly biosimilar medicines. Monitor online medicine trade, and effectively promote fair-priced drug outlets. 

Strengthen public pharmaceutical industries and public sector vaccine production units, while rolling back their privatisation. Addressing Intellectual Property Rights (IPR) issues, coupled with scaling up production through Indian public sector companies would enhance vaccine accessibility. Reinstate funding for Open-Source Drug Discovery (OSDD) initiatives, promoting collaborative research for affordable and accessible medications. It is also recommended to abolish GST imposed on sale of medicines, as part of the wider spectrum of measures required to ensure affordability of medicines, which are essential life-saving products.

Protect workers health

Ensure health protection for all workers in unorganised as well as organised sectors. Formulate and enforce a comprehensive occupational health and safety (OHS) policy, while integrating OHS into the medical curriculum. Properly implement the National policy on safety, health and environment at work (2009), adopt all ILO conventions concerning workers health and safety. It is important to integrate occupational health services with general health services at all levels. Strictly implement laws and related measures to prevent occupational diseases like silicosis and other occupational lung diseases. Ensure full rehabilitation of families affected by these ailments as done in the instance of the Bonded Labour System Abolition Act. Implement health impact assessments for all corporate projects, ensuring transparency and participation. Majorly strengthen and reform the ESI system, expanding this system to provide healthcare protection for all workers in both organized and unorganized sectors.

Regulate the Private healthcare sector and safeguard patients’ rights

Effectively regulate the private healthcare sector by amending the Clinical Establishment Act-2010, towards ensuring patient rights, quality of care, transparency and standardisation of rates. To check irrational and unnecessary interventions, treatment practices need to be more standardised, with these measures people will not have to pay huge bills in private hospitals. States should adopt such improved regulation or should enact their own acts with similar positive provisions. It is important to establish well-staffed, dedicated mechanisms for effective implementation of these regulations, which include people’s representation. The complete 'Patient Rights Charter' must be strictly enforced in all hospitals and health facilities, display of indicative rates will be mandatory and user-friendly grievance redressal system should be operationalised. Rates for diagnostics also must be regulated, and “cut practice” should be effectively banned. It is also important to implement a publicly managed admission system for charitable hospital beds, so that referrals from government facilities to charitable trust hospitals can optimize utilisation of beds for economically weaker sections.

Promote medical pluralism and AYUSH systems of healing

It is necessary to support medical pluralism so that people have a choice to access non-allopathic systems of healing, including safe home-based birthing practices. Substantial encouragement and funds must be given to research and documentation, to promote evidence-based use of AYUSH and traditional community-based systems of healing. At the same time, certain commercialised Ayurvedic companies have been found to make exaggerated health claims about their products, although these claims may not be demonstrated. There have also been concerns about some Ayurvedic products related to quality control and safety issues. Hence there is need for effective, appropriate regulatory oversight of Ayurvedic and other AYUSH systems of medicine in context of growing commercialisation and certain kind of political patronage to specific companies. 

Ensure gender sensitive health services and social support systems

Recognize gender-based violence as an important public health concern, providing prompt rescue, comprehensive medical care, and sustained support. Address gender-based violence and harassment concerning health workers urgently. Ensure equitable, quality healthcare for women, adolescents, children, and LGBTQ individuals from all backgrounds, including those experiencing violence. Universalize maternity benefits for all, including contractual and daily wage workers, and provide workplace creche and restrooms for working mothers with small children.

Ensure comprehensive healthcare for vulnerable groups and sections with special health needs, eliminate all forms of discrimination and exclusion in health care 

Implement special measures to provide comprehensive, quality health services for vulnerable populations and those with special needs, addressing vulnerabilities related to social background, health status, lifecycle position, occupation and other factors. This must address the health needs of women, dalits, adivasis, Muslims and minority communities, particularly vulnerable tribal groups, LGBTQ persons, refugee and migrant populations, people in conflict areas, people living with HIV, manual scavengers, waste  pickers, differently abled persons, children and elderly persons, and all other vulnerable groups. Urgently eliminate all forms of discrimination including caste, community, religion, tribe, or ethnicity-based discrimination in the health sector, while ensuring the right to healthcare for all with dignity. Remove mandatory Aadhar linking for accessing health services, and ensure access to healthcare for all without barriers based on state domicile, citizenship proof, etc.

Address mental health in comprehensive manner, upgrade disease control and preventive health programmes

Ensure comprehensive treatment for mental health problems, community-oriented care and wider promotion of mental health, through enhanced implementation of an expanded District Mental Health Programme within the National Mental Health Policy framework. Address inadequacies in dealing with major diseases, like HIV-AIDS and Tuberculosis through expanded and reoriented health programs. Upgrade preventive health programmes and enhance mechanisms to handle communicable diseases based on a review of current systems.

Regulation of clinical trials, promoting people-oriented health research

Implement strict regulation and fair compensation for clinical trial participants, which would be effectively monitored by CDSCO. Develop a justiciable charter of rights for clinical trial participants. Upgrade public health research capacity, while facilitating the use of findings to guide action and improve health systems. Ensure effective regulation of conflicts of interest, ensure adequate national sources of funding for Indian research institutions to prevent dependence on transnational agencies and corporations. 

Multi-dimensional initiatives to ensure social determinants of health

Enhance the capacity of the Public health system to monitor and advocate for multi-pronged action on social determinants of health, involving various concerned departments. Foster inter-sectoral coordination to improve social determinants, considering factors like food security, nutrition, sanitation, environmental pollution, climate change, working conditions, road safety, substance abuse, and violence. Ensure effective implementation and amendment of various laws for people's rights and gender justice. Universalize and expand ICDS to cover under-3 children and establish community-owned programs and daycare services for majorly improved nutrition, health and well-being of women and children.

Reclaiming public health as part of the broader movement for defending democracy

Today India faces a critical juncture in our history, with democracy coming under unprecedented attack, growing communalisation and social exclusion, and an aggressively pro-corporate political economy. Expanding democracy and overturning the pro-corporate policy framework is now crucial to ensure people’s health rights and strengthen public health systems. As Jan Swasthya Abhiyan we resolve to integrate our actions for advancing public health with various broader movements for defending and expanding democracy and secularism, while promoting peace and social harmony in India and our region. 

We strongly appeal to all political parties believing in democracy and social justice, 

to place Right to health and healthcare centrally on their agenda for elections in 2024!

Health manifesto

 Jan Swasthya Abhiyan: People’s Manifesto on Right to Health and Healthcare - 2024

Addressing the health system crisis - Urgent need to advance people’s 

Right to health and healthcare through transformation of health systems

As India approaches the 2024 Lok Sabha elections, Jan Swasthya Abhiyan circulates this memorandum with a charter of policy proposals, appealing to all the political parties and independents in the election fray to commit to these by incorporating them in their election manifesto.  This is essential because of the critical state of our country's health system, since more than 80 crore people of this country who today depend on free ration also require protection for their health related vulnerabilities. Despite the COVID experience, people’s health still remains very low on priority for the Union government. Increasing commercialisation and decrease in the government’s role has placed quality healthcare out of reach of the majority of Indians.

The Union government's handling of the COVID pandemic was marked by serious mismanagement on various fronts, exacerbating an already critical situation. Although the pandemic underlined the outstanding need for stronger public health systems, the Union government’s spending on health remains dismal. It continues to restrict funds, along with neglecting the National Health Mission, while eroding federalism and imposing hyper-centralised decision making. Refusal to regulate profiteering by the commercialised private healthcare sector, accelerated privatisation of health services, and failures of the much-hyped PMJAY health insurance scheme have further worsened the situation, leaving the vast majority of the population, especially marginalised communities at risk. 

Key Demands Concerning Right to Health and Healthcare

1. Our Health, Our Right! - Right to Healthcare legislation must be passed to ensure guaranteed availability of free quality treatment of all conditions, in close proximity to place of residence. Expand, improve & strengthen public healthcare infrastructure to provide such essential care. Denial, delay and incomplete treatment to be strictly prevented.

2. Increase Budgetary Allocation for Health – Increase Health Spending to 3.5% of GDP, with 1% of GDP coming from Centre; States should get special financial envelopes for raised health expenditure. 

3. No one should face financial hardship due to Out-of-Pocket (OOP) Spending on health – Reduce OOP to less than 25% of Total Health Expenditure.

4. Fill Vacant Posts and Ensure Justice to Health workers  – No health facility should have a vacant position. No public health establishment should engage contractual staff, it is essential to regularise all scheme based and contractual health workers. Ensure adequate wages and protection under labour laws. A Human resources for health policy would be enforced to ensure these measures. 

5. Devolve administrative and financial powers to local bodies and state governments to enable them to conceptualise and manage health systems in their jurisdictions, with support from national and regional bodies.

6. Immediately reverse the rebranding of Health and Wellness Centres as ‘Arogya mandirs’, in keeping with the constitutional values of secularism and inclusivity.

7. Ensure availability of affordable and quality essential drugs & diagnostics – Implement effective and rational price control; return to cost-based pricing. Ensure availability of medicines as per the NLEM 2022, eliminate all irrational medicines and Fixed Dose Combinations (FDCs).  

8. Healthcare is primarily the government’s responsibility – Phase out Government-funded health insurance schemes such as PMJAY and Public Private Partnerships.

9. Regulate Private healthcare sector by ensuring effective implementation of an improved Clinical Establishment Act. All states must ensure effective regulation of private healthcare while implementing the Patients Rights Charter, along with transparency and regulation of rates, and grievance redressal systems for patients. 

10. Stop Commercialisation of Medical Education – Review & reform National Medical Commission and National Eligibility cum Entrance Test (NEET). Ensure highest standard of medical, nursing and other allied medical services education and one common uniform system of admissions and fee structures

11. Protect Workers’ Health – Properly implement National Policy on Safety, Health and Environment at Work. Ensure effective implementation of laws and related measures to prevent serious diseases like silicosis caused due to hazardous occupations, ensure full rehabilitation of families affected by ailments. Strengthen, reform and expand the ESI system. 

12. A public-centred system for universal health care, ensuring a common system to provide health care for all residents of India, must be developed in the foreseeable future.

Jan Swasthya Abhiyan proposes the following range of policy actions in the health sector, which should be committed to by all political parties and candidates in context of upcoming Lok Sabha elections. JSA will mobilize and campaign among different sections of the people around these proposals, and call upon all social movements, civil society organisations and people to build a consensus around these actions, which must become the highest political priority in India today. 

1. Make the Right to healthcare a justiciable right through the enactment of appropriate legislations at Union and State levels. Retain health services as a state subject with strong emphasis on federalism

There is a need to ensure all-encompassing healthcare access from primary to tertiary services, for the entire population by enacting Right to healthcare legislations at State level. This should be supported by an appropriate legal, financial and operational framework at national level. In a complementary manner, public health laws must secure access to health determinants, protecting people’s health from various influences. The overall direction should be to establish healthcare as a fundamental right in the Indian Constitution. Health services should remain with the State List as enshrined in the Constitution and should not be made part of the concurrent list.

2. Rapidly increase public expenditure on Healthcare to reach 3.5% of GDP, with at least 1% of GDP being spent by the Union Government. 

Overall public health expenditure must be majorly increased to reach 3.5% in the short term. While enabling this, the Union government should transfer a much larger share of resources to states through the Finance Commission (FC), and a special financial envelope for states should be created for implementation of Right to Health and Healthcare under the XVI Finance Commission. Special grants under XV FC to local bodies should be augmented further, to foster decentralised governance and delivery of healthcare services. Allocation towards the National Health Mission should be enhanced to facilitate upgradation and expansion of rural and urban health services, and dealing with communicable as well as non-communicable diseases and climate related health challenges. Greater flexibility should be accorded to states to decide on the priorities within NHM and the process of participatory, decentralised planning should be strengthened. 

3. Out-of-pocket expenditure on health must be minimised and brought down to below 25% of health spending in next five years

Out-of-pocket (OOP) spending on healthcare should be minimised so that no one is pushed into poverty, or faces catastrophic health spending and indebtedness due to healthcare expenses. Current decline in utilisation of health services due to high spending by households is unacceptable and must be reversed to ensure that no one has to forgo healthcare due to unaffordable costs. The objective of reducing OOP to less than 25% of health spending should be adopted as a national goal.

4. Expand and strengthen the public healthcare system to ensure free availability of quality health care at all levels, including entire range of medicines, diagnostics and vaccines

Strengthen and enable public health systems at all levels in rural and urban areas to provide free comprehensive services, essential drugs and diagnostics, expanding both quantity and quality based on health services standards. This would require upgradation of public health facilities, with matching human resource policy and improved governance and management. Combined with this, it is important to ensure nationwide access to essential medicines and diagnostics in all public facilities, based on models of successful state level schemes such as those operating in Tamil Nadu, Kerala and Rajasthan. Along with ensuring genuinely autonomous public corporations with adequate and competent staff and various measures for transparency and responsiveness, public budgets on medicines must be substantially upscaled to meet the requirements. The government must provide all essential medicines, diagnostics, and medical devices, free of charge, in publicly run hospitals for life-threatening diseases, in order to fulfill its constitutional obligations under Article 21. Ensure regular, adequate availability of essential vaccines through the public health system.

 

5. Eliminate corruption, ensure community accountability and democratise the health system

It is essential to ensure transparency and social accountability while eradicating corruption in the Public health system, based on processes for broad based participation and democratisation. Ensure empowered participation of people through generalisation of community-based planning and monitoring, with involvement of public representatives, people’s organizations, women's groups and health sector CSOs at all levels from village to state. Develop a community-driven health system with active, diversified participation and strong grievance redressal mechanisms. 

6. Replace Government funded health insurance schemes with a Public centred system for Universal Health Care, eliminate PPPs and privatisation of health services

Phase out the Pradhan Mantri Jan Arogya Yojana - based on the discredited insurance model - in a phased manner, and replace this with a Public centred system for Universal Health Care. In the interim, all admissions under the scheme in private facilities must be based on gatekeeping by public health facilities, regarding those conditions where services are not available within the public system. There is clear need as well as potential to develop a public centred system for Universal Health Care, based on major expansion and strengthening of public services, while engaging regulated private providers to address current gaps. This system will provide ready access to quality healthcare, which will be available free of charge to everyone. Eliminate existing PPPs which weaken public services, abolish privatization of government health services, no government hospitals or services should be handed over to private companies. 

7. Reverse the rebranding of Health and Wellness Centres as ‘Arogya mandirs’

Without any significant expansion in number of SCs and HWCs and augmenting the provision of services in those facilities, the Union government has arbitrarily renamed these public institutions built over the last several decades, as ‘Arogya mandirs’ with religious connotations. This is clearly a violation of principles of secularism enshrined under the constitution, and must be immediately reversed. It must be ensured that public institutions remain secular and inclusive, focusing on the overall well-being of all citizens. Instead of making such negative and superficial changes, efforts should be made to substantially strengthen and upgrade the Sub-centres and PHCs now designated as HWCs, to provide comprehensive primary care.

8. Ensure justice for all health workers, upgrading and regulating training of health force 

All scheme based and contractual health workers, including ASHAs and Anganwadi workers, must be regularised while ensuring them adequate wages and protection under labour laws. The policy of contractualisation must be replaced by systematic regularisation of all types of contractual employees in health services. All vacancies in Health Departments must be filled and new posts created as per requirement. All health workers including ANMs, Nurses, Doctors and Paramedics must be paid decent wages while working in a supportive environment. There must be complete transparency in the processes of recruitment, transfers and promotions of officers and employees in the health system. Increase public investment in health professional education and training and regulate private institutions providing training for healthcare personnel. 

9. Need for major reforms in medical education and National Medical Council

  There is an urgent need to control commercialized private medical colleges, while not sanctioning further such private colleges and mandating their fees to be not higher than government medical colleges. There is need for independent, multi-stakeholder review and reform of the structure and functioning of the National Medical Commission, which has come under major criticism for lack of representation of diverse stakeholders, promoting high degree of centralisation in decision-making with erosion of state autonomy, and promotion of further commercialisation of medical education. There is a particular need to review and restructure the National Eligibility cum Entrance Test (NEET) which tends to place candidates from rural areas, those from non-English medium schools and less privileged backgrounds at a disadvantage. NEET encroaches on the autonomy of states in determining their own medical admission processes, and the imposition of NEET is perceived as an infringement on state level educational policies.

10. Adopt a people-centred, rational pharmaceutical policy and make medicines affordable for all

A pro-people pharmaceutical policy must be implemented which would bring all essential medicines and devices under effective and rational price control. The comprehensive price control regime should restore cost-based pricing for all medicines, along with banning irrational drugs and combinations, regulating pharma marketing practices, and promoting generic medicine outlets. It is important to implement a comprehensive generic medicine policy, which covers labelling as well as prescribing of all medicines. 

Resist dilution of Patent Law provisions that protect national interests and use public health safeguards in the Indian Patent Act. Reject provisions being pushed through Free Trade Agreements which affect the production of low-cost generic drugs. Utilize compulsory licensing provisions to reduce the costs of high-cost treatments for diseases such as cancer and rare diseases. Additionally, address regulatory barriers to the entry of costly biosimilar medicines. Monitor online medicine trade, and effectively promote fair-priced drug outlets. 

Strengthen public pharmaceutical industries and public sector vaccine production units, while rolling back their privatisation. Addressing Intellectual Property Rights (IPR) issues, coupled with scaling up production through Indian public sector companies would enhance vaccine accessibility. Reinstate funding for Open-Source Drug Discovery (OSDD) initiatives, promoting collaborative research for affordable and accessible medications. It is also recommended to abolish GST imposed on sale of medicines, as part of the wider spectrum of measures required to ensure affordability of medicines, which are essential life-saving products.

11. Protect workers health

Ensure health protection for all workers in unorganised as well as organised sectors. Formulate and enforce a comprehensive occupational health and safety (OHS) policy, while integrating OHS into the medical curriculum. Properly implement the National policy on safety, health and environment at work (2009), adopt all ILO conventions concerning workers health and safety. It is important to integrate occupational health services with general health services at all levels. Strictly implement laws and related measures to prevent occupational diseases like silicosis and other occupational lung diseases. Ensure full rehabilitation of families affected by these ailments as done in the instance of the Bonded Labour System Abolition Act. Implement health impact assessments for all corporate projects, ensuring transparency and participation. Majorly strengthen and reform the ESI system, expanding this system to provide healthcare protection for all workers in both organized and unorganized sectors.

12. Regulate the Private healthcare sector and safeguard patients’ rights

Effectively regulate the private healthcare sector by amending the Clinical Establishment Act-2010, towards ensuring patient rights, quality of care, transparency and standardisation of rates. To check irrational and unnecessary interventions, treatment practices need to be more standardised, with these measures people will not have to pay huge bills in private hospitals. States should adopt such improved regulation or should enact their own acts with similar positive provisions. It is important to establish well-staffed, dedicated mechanisms for effective implementation of these regulations, which include people’s representation. The complete 'Patient Rights Charter' must be strictly enforced in all hospitals and health facilities, display of indicative rates will be mandatory and user-friendly grievance redressal system should be operationalised. Rates for diagnostics also must be regulated, and “cut practice” should be effectively banned. It is also important to implement a publicly managed admission system for charitable hospital beds, so that referrals from government facilities to charitable trust hospitals can optimize utilisation of beds for economically weaker sections.

13. Promote medical pluralism and AYUSH systems of healing

It is necessary to support medical pluralism so that people have a choice to access non-allopathic systems of healing, including safe home-based birthing practices. Substantial encouragement and funds must be given to research and documentation, to promote evidence-based use of AYUSH and traditional community-based systems of healing. At the same time, certain commercialised Ayurvedic companies have been found to make exaggerated health claims about their products, although these claims may not be demonstrated. There have also been concerns about some Ayurvedic products related to quality control and safety issues. Hence there is need for effective, appropriate regulatory oversight of Ayurvedic and other AYUSH systems of medicine in context of growing commercialisation and certain kind of political patronage to specific companies. 

14. Ensure gender sensitive health services and social support systems

Recognize gender-based violence as an important public health concern, providing prompt rescue, comprehensive medical care, and sustained support. Address gender-based violence and harassment concerning health workers urgently. Ensure equitable, quality healthcare for women, adolescents, children, and LGBTQ individuals from all backgrounds, including those experiencing violence. Universalize maternity benefits for all, including contractual and daily wage workers, and provide workplace creche and restrooms for working mothers with small children.

15. Ensure comprehensive healthcare for vulnerable groups and sections with special health needs, eliminate all forms of discrimination and exclusion in health care 

Implement special measures to provide comprehensive, quality health services for vulnerable populations and those with special needs, addressing vulnerabilities related to social background, health status, lifecycle position, occupation and other factors. This must address the health needs of women, dalits, adivasis, Muslims and minority communities, particularly vulnerable tribal groups, LGBTQ persons, refugee and migrant populations, people in conflict areas, people living with HIV, manual scavengers, waste  pickers, differently abled persons, children and elderly persons, and all other vulnerable groups. Urgently eliminate all forms of discrimination including caste, community, religion, tribe, or ethnicity-based discrimination in the health sector, while ensuring the right to healthcare for all with dignity. Remove mandatory Aadhar linking for accessing health services, and ensure access to healthcare for all without barriers based on state domicile, citizenship proof, etc.

16. Address mental health in comprehensive manner, upgrade disease control and preventive health programmes

Ensure comprehensive treatment for mental health problems, community-oriented care and wider promotion of mental health, through enhanced implementation of an expanded District Mental Health Programme within the National Mental Health Policy framework. Address inadequacies in dealing with major diseases, like HIV-AIDS and Tuberculosis through expanded and reoriented health programs. Upgrade preventive health programmes and enhance mechanisms to handle communicable diseases based on a review of current systems.

17. Regulation of clinical trials, promoting people-oriented health research

Implement strict regulation and fair compensation for clinical trial participants, which would be effectively monitored by CDSCO. Develop a justiciable charter of rights for clinical trial participants. Upgrade public health research capacity, while facilitating the use of findings to guide action and improve health systems. Ensure effective regulation of conflicts of interest, ensure adequate national sources of funding for Indian research institutions to prevent dependence on transnational agencies and corporations. 

18. Multi-dimensional initiatives to ensure social determinants of health

Enhance the capacity of the Public health system to monitor and advocate for multi-pronged action on social determinants of health, involving various concerned departments. Foster inter-sectoral coordination to improve social determinants, considering factors like food security, nutrition, sanitation, environmental pollution, climate change, working conditions, road safety, substance abuse, and violence. Ensure effective implementation and amendment of various laws for people's rights and gender justice. Universalize and expand ICDS to cover under-3 children and establish community-owned programs and daycare services for majorly improved nutrition, health and well-being of women and children.

Reclaiming public health as part of the broader movement for defending democracy

Today India faces a critical juncture in our history, with democracy coming under unprecedented attack, growing communalisation and social exclusion, and an aggressively pro-corporate political economy. Expanding democracy and overturning the pro-corporate policy framework is now crucial to ensure people’s health rights and strengthen public health systems. As Jan Swasthya Abhiyan we resolve to integrate our actions for advancing public health with various broader movements for defending and expanding democracy and secularism, while promoting peace and social harmony in India and our region. 

We strongly appeal to all political parties believing in democracy and social justice, 

to place Right to health and healthcare centrally on their agenda for elections in 2024!