Lok Sabha Question No. 836 (UNSTARRED), answered on 2021-02-05
Subject: Medical facilities in rural areas
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Devji Mansingram Patel, Ranjeetsingh Naik Nimbalkar

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

LOK SABHA UNSTARRED QUESTION NO. 836 TO BE ANSWERED ON 5 TH FEBRUARY, 2021

## MEDICAL FACILITIES I N RURAL AREAS

## 836. SHRI DEVJI M. PATEL: SHRI RANJEETSINGH HINDURA O NAIK NIMBALKAR:

Will the Minister of HEALTH AND FAMILY WE LFARE be pleased to state:

(a) whether the Government has taken note of the fact that the people living in rural areas in mos parts  of the  country  including  Maharashtra  and  Ra jasthan  do not  have  adequate  medical facilities, if so, the details thereof;

(b) the extent to which the National Rural Health Mission has achieved its targets;

- (c) whether the Government proposes to set up Superspeciality Healthcare Centres in the rural areas particularly in Madha, Maharashtra and Jalore/Sirohi districts in Rajasthan; and
- (d) if so, the details thereof and if not, the reasons therefor?

## ANSWER

## THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI ASHWINI KUMAR CHOUBEY)

(a):  'Public Health & Hospitals' being a State subject the primary responsibility for ensuring healthcare services including establishing more public health care facilities lies with State Government.

To  address  the  healthcare  ch allenges,  particularly  in  rural  areas,  the  National  Rur Health  Mission  (NRHM)  was  launched  in  2005  to  supplement  the  efforts  of  the  State/U governments  to  provide  accessible,  affordable  and  quality  healthcare  to  all  those  who public health facili ties. Currently, NRHM is a sub - mission of National Health Mission (NHM). NHM support is provided to States/ UTs including Maharashtra and Rajasthan for setting u new facilities as per norms and upgradation of existing facilities for bridging the inf tructure gaps based on the requirement posed by them.

NHM support is also provided for provision of a range of free services related to maternal health, child health, adolescent health, family planning, universal immunisation programm , and for major diseases such as Tuberculosis, vector borne diseases like Malaria, Dengue and Azar, Leprosy etc.

Other  major  initiatives  supported  under  NHM  include  Janani  Shishu  Suraksha Karyakram (JSSK) (under which free drugs, free diagnostics, fr ee blood and diet, free transport from  home  to  institution,  between  facilities  in  case  of  a  referral  and  drop  back  h provided),  Rashtriya  Bal  Swasthya  Karyakram  (RBSK)  (which  provides  newborn  and  child health  screening  and  early  interventions  service s  free  of  cost  for  birth  defects,  diseases, deficiencies and developmental delays to improve the quality of survival), implementati Free  Drugs  and  Free  Diagnostics  Service  Initiatives,  PM  National  Dialysis  Programme  a implementation  of  National  Qual ity  Assurance  Framework  in  all  public  health  facilities including in rural areas.

Mobile Medical Units (MMUs) & Telemedicine are also being implemented to improve access to healthcare particularly in rural areas.

As  part  of  Ayushman  Bharat,  the  States  are supported  for  establishment  of 1.5  lakh Health  and  Wellness  Centres  across  the  country  by  December,  2022  for  provision  o comprehensive primary  care that includes preventive healthcare and health promotion at community level with continuum of care app roach . Further Ayushman Bharat, Pradhan Mantri Jan Arogya Yojana (AB -PMJAY) provides health coverage up to Rs 5 Lakh per family per year to  around  1074  crore  poor  and  vulnerable  families  as  per  Socio  Economic  Caste  Censu (SECC).

(b): In the 15 years o f implementation, the NHM has enabled achievement of the Millennium Development Goals (MDGs) for health. It has also led to significant improvements in mate new - born, and child health indicators, particularly for maternal mortality ratio, infant nder five  mortality  rates,  wherein  the  rates  of  decline  in  India  are  much  higher  than  th averages and these declines have accelerated during the period of implementation of NHM. major achivements under NHM are given at Annexure- 1.

(c) &(d): As per the information received from the Health Department of Rajasthan, Provi Super - speciality Healthcare facilities in the rural areas is not contemplated presently a -speciality  Healthcare  facilities  are  being  provided  at  Medical  Colleg es  level  in  State  of Rajasthan.

As  per  the  information  received  from  the  Health  department  of  Maharashtra,  as  St Government has set up super - speciality hospital in Pune which is 200 km from Madha, there is no planning to establish separate super - speci ality hospital at Madha. Further, under Department of Medical Education, presently, Super Speciality Hospitals are functional in medical col Pune,  Aurangabad  and  Nagpur  and  are  being  set  up  at  Mumbai  and  Sindhudurg.    Similarly under  Public  Health Department  of  Maharashtra,  Super  Speciality  Hospitals  are  functional Nashik and Amravti and are also being set up at at Thane.

## Achievements of NHM

## A. Improvements in Core Health Outcomes:

- (1) Reduction in  OOPE: The  average  medical  expenditure  per  hospitalization  and childbirth also declined in this period, from Rs. 5636 to Rs. 4290 in rural areas, and Rs. 7670 to Rs. 4837 in urban areas for hospitalization and from Rs. 1587 to Rs. 1324 in rural areas and Rs. 2117 to Rs. 1919 in urban areas for institutional delivery, indicating the impact of NHM in reduction of Out of Pocket Expenditures for health care.
- (7) The  number  of  districts  that  achieved  the  target  of leprosy  elimination increased  from  543  districts  in  2011-2012  to  554  by  March  2017  and  to  571 districts  by  March  2018.  The  prevalence  rate  of  Leprosy  reduced  to  less  than 1/10000 population in 610 Districts in 2020.
- (2) Maternal Mortality Rate (MMR) has declined from 556/lakh live births in 1990 to 113/lakh live births in 2016-2017. Rate of decline of MMR in India at 77% is much higher than global average decline of 44% over the same period. (3) I nfant Mortality Rate (IMR), declined from 80 in 1990 to 32 in the year 2018 1 . (4) Under 5 Mortality Rate (U5MR), declined from 52 in 2012 to 36 in 2018, (5) Total Fertility Rate (TFR) declined from 2.3 in 2013 to 2.2 in the year 2018 1 . (6) The  incidence  of  Tuberculosis per  1,00,000  population  reduced  from  234  in 2012  to  193  in  2019.  The  mortality  due  to  TB  per  1,00,000  population  also reduced from 42 in 2012 to 33 in 2019.
- (8) For Malaria, Annual Parasitic Index (API) was sustained at levels of less than 1 and declined from 0.89 in 2014 to 0.32 in 2018, and 0.25, in 2019. Malaria cases and deaths declined from 21.27% and 20% respectively in 2019 from 2018.
- (9) By the end of December 2019, 94% Kala-azar endemic blocks have achieved the elimination target of <1 KA case per 10,000 population at block level.
- (10) The National target for sustaining Dengue related case fatality rate to less than 1% was met. Dengue related case fatality rate in 2014 was 0.3% and reduced to 0.1% in 2019.

## Annexure-I

- (11) The  prevalence  of blindness (visual  acuity  <3/60)  has  reduced  to  0.36%  in 2019) from 0.68% in 2010.
- (12) There is a 17.3% relative reduction in prevalence of tobacco use from 34.6% to 28.6% from 2009-10 to 2016-17.

## B. Increased Access to Health Services:

1. As  a  result  of  the  health  systems  strengthening  efforts  of  NHM,  the  proportion  of those seeking care from public health facilities, increased from 28.3% to 32.5% in rural  areas  and  21.2%  to  26.2%  in  urban  areas  between  2014  to  2017.;  and utilization of public health facilities for institutional deliveries increased from 56% to 69.2% in rural areas and from 42% to 48.3% in urban areas.

2. Growth in Public Health Facilities : NHM adopts a  health  system  approach  and  targets  to  build  a  network  for  public health facilities with Health & Wellness Centres at the grassroot level and District Hospitals,  with  robust  referral  linkage,  to  offer  Comprehensive  primary  and secondary care services to citizens. The growth in the number of facilities at various levels since 2025 is given in Table 1 -

| S. No.                                                                      | Type of facility                                                            | Status 2005   | Status 2020   |
|-----------------------------------------------------------------------------|-----------------------------------------------------------------------------|---------------|---------------|
| Facilities as per classification in 2005                                    | Facilities as per classification in 2005                                    | 146026        | 157411        |
| 1 2                                                                         | Sub Health Centres Primary Health                                           | 23236         |               |
|                                                                             |                                                                             |               | 24855         |
| 3 4                                                                         | Centres Health Centres                                                      | 3346          | 5335 756      |
|                                                                             | Community                                                                   | 635 940       |               |
| 5                                                                           | District Hospitals First Referral Units (FRU)                               |               | 3,122         |
| 6 24 x 7 Delivery Points Facilities conceptualised and implemented underNHM | 6 24 x 7 Delivery Points Facilities conceptualised and implemented underNHM | 2,243         | 15494         |

7

Ayushman

Bharat

Health  &

-

55898

Wellness Centres

Dental Care Units

It may be seen from the above that implementation of NHM has not only contributed to  increase  in  the  institutional  capacities  for  service  delivery  but  also  has  led  to

|         |                                                                            |     | 4,660                                           |
|---------|----------------------------------------------------------------------------|-----|-------------------------------------------------|
| 8       |                                                                            | - - |                                                 |
|         | Urban PHCs                                                                 |     | 650 278                                         |
| 9 10 11 | MCHWings                                                                   |     | 894                                             |
|         | Obstetric ICUs/HDUs Sick New-born Care Units (SNCU) / Neonatal ICUs (NICU) | - - |                                                 |
| 12      | New-Born Stabilization Units (NBSU)                                        | -   | 2,571                                           |
| 13      | New Born Care Corners (NBCC)                                               | -   | 20,337                                          |
|         |                                                                            |     | 42                                              |
| 14 15   | Paediatric ICUs (PICU) Nutritional Rehabilitation Centres (NRC)            | - - | 1072                                            |
| 16      | NCD Clinics                                                                | -   | Dt NCD Clinics: 638 CHC NCD clinics: 4464 3,470 |
| 17      | Molecular Diagnostic facilities for TB                                     | -   |                                                 |
| 18      | Geriatric wards in District Hospitals                                      | -   | 578                                             |
| 19      | Geriatric services in District Hospitals and CHCs Service                  | -   | DHs: 578 CHCs: 2,704 20,990                     |
| 20      | National Ambulance (ALS\BLS ambulances                                     | -   |                                                 |
| 21      | Adolescent Friendly Health Clinics (AFHCs)                                 | -   | 7,980                                           |
| 22      | Treatment Centres for Viral Hepatitis                                      | -   | 792                                             |
|         | PMNDP Dialysis Centres                                                     |     |                                                 |
| 23      |                                                                            | -   | 862                                             |

24

-

1,759

- development  of  capacities  for  targeted  interventions  of  the  various  National Programmes under the NHM.
4. National Ambulance Services : At the time of launch of NRHM (2005), ambulance networks were non-existent. So far, 20,990 Emergency Response Service Vehicles are  operational  under  NRHM.  Besides  5,499  patient  transport  vehicles  are  also deployed,  particularly  for  providing  'free  pickup  and  drop  back'  facilities  to pregnant women and sick infants.
3. Equitable development :  There was also a sustained focus on the health of tribal populations, those in Left Wing Extremism areas, and the urban poor. A more recent effort at ensuring equity in access and use, is the Aspirational district initiative, in which  115  districts  across  28  states,  with  weak  social  and  human  development indicators have been identified for allocation of additional resources and capacity enhancement to catch up with more progressive districts.
5. Human  Resource  Augmentation : NHM  supports  states  for  engaging  of  service delivery  HR  such  as  doctors,  nurses  and  health  workers  and  also  implements  the world's largest community health volunteer programme through the ASHAs. More than 10 lakhs ASHAs and ASHA facilitators are engaged under NHM. NHM has also supported  states  to  acquire  staff  with  skills  in  public  health,  finance,  planning, management and M&E to plan and implement interventions, freeing up clinical staff to  deliver  health  services.  Differential  remuneration  and  incentives  linked  to remote/underserved  areas of posting, resulted in increased availability  and retention of HR in difficult and remote areas. Human Resource Information System (HRIS) is a key administrative HR reform implemented under NHM for regular and contractual staff, providing comprehensive real time information on the HR posted in  facilities  and  in  managerial  positions,  facilitating  salary  payments  and  transfer postings.  NHM  invests  in  capacity  building  and  mentoring  for  all  cadres  of personnel, with a focus on multi-skilling and task sharing to address HR shortages.
6. Health  Sector  Reforms: The  National  Health  Mission  (NHM)  enabled  the  design and implementation of reforms specifically related to Governance (Decentralized

Management Units, and creation of flexibility in administrative and fund management decisions, creation of Rogi Kalyan Samitis, establishment of community collectives for accountability, such as the Village Health, Sanitation and Nutrition  Committees  and  Mahila  Arogya  Samitis), Procurement (creating  the institutional mechanisms needed for effective procurement modalities such as the Medical services Corporations in several states,  improve supply chain and logistics management,  and  expand  procurement  capacity),  and Technology (to  facilitate reporting,  follow  up  of  mothers  and  children  in  need  of  services,  IEC  and  for tracking vaccine use).

NHM supported health system reforms have  resulted  in  development  of  resilient  health systems, albeit at different stages of maturity that enable successful scaling up of existing interventions and the addition of newer reforms given the rapid transitions from rural to urban, gradual demographic transition to aging populations, increasing burden of chronic diseases, and the emergence of newer infectious diseases.

7. Addressing high Out-of-Pocket Expenditure (OOPE) : Recognising the need for reducing the current high levels OOPE, and that, almost 70% of the OOPE is on account of drugs and diagnostics, the Free Drugs and Free Diagnostics Services Initiatives have been implemented  under  the NHM.  The  Essential Drugs Lists (EDL) and the Essential Diagnostics Lists have been notified and are periodically updated to include more essential drugs based on new initiatives undertaken. These interventions coupled with strengthening of health facilities' capacities to deliver an expanded range of services, closer to communities, teleconsultation services are leading to significant reduction in OOPE (Ref. para (1) of 3.3.1).

Of  note  is  that  the  NHM  reforms  were  oriented  towards  addressing  inequity,  across  and within states. A study done in 2020 by the National Institute of Public Finance and Policy (NIPFP)  on  health  spending  in  states  under  NHM,  suggests  that  NHM  contributed  to reduction of inequality in health spending across states and added funds to the lower tiers of the health pyramid.