INSIGHTS INTO YOJANA FEBRUARY 2016 · Insights into Yojana: February ‐ 2016 6 The declaration of...

INSIGHTS INTO YOJANA FEBRUARY 2016

An Insights Initiative

Analysis & Simplification of important Articles published in Yojana Magazine

Insights into Yojana: February ‐ 2016

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http://www.insightsonindia.com | INSIGHTS IAS

http://www.insightsonindia.com/


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Table of Contents

Health Sector in India: Perspective and Way Forward:

Evolution of National Health Policy in India

Health Care in Tribal Areas: Present and the Future

Realizing the Power and Promise of Health Communication

Universal Health Coverage

Reducing Malnutrition: Women’s Health Holds The Key

Adolescent Health in India

MDGs: What are they?

A boost to promote entrepreneurship among SC/ST and Women

Mission Indradhanush

Rashtriya Kishor Swasthya Karyakram (RKSK)

Kilkari




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Health Sector in India: Perspective and Way Forward:

The health sector in India is said to be at the crossroads.

Why? It is partly due to an interesting relationship between development and health, which is known

as the ‘Preston Curve’.

What is it?

In 1975, Samuel Preston showed that if the health of nations as measured by life expectancy is

plotted against the wealth of nations as measured by GDP per capita, then up to a point, even

for a modest increase in GDP per capita, there is a sharp increase in life expectancy. After

certain point, the curve flattens out, where, even large increases in public health expenditure

lead to very low/modest increase in life expectancy.




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India’s position:

As explained by Nobel Prize winning Economist Angus Deaton (In his book ‘The Great Escape’), India’s position is peculiar compared to developed countries and some developing countries.

With the past problems of infant mortality and maternal mortality still persisting, the country is witnessing increase in the number of noncommunicable diseases.

This places India at or near the bend on the Preston Curve, which has major policy implications.

What needs to be done?

Along with the increased public expenditure, encourage private investment in the health sector for better health outcomes.

For private investment to increase, the existing public health system should be strengthened.

Purchasing care from private sector may also be considered. If private involvement is being considered, it should be preceded by a strong regulatory

regime and increased expenditure far above the 2.5% of GDP that the current national health policy draft calls for.

Progress in Reproductive and Child Health:

In the past decade, India has been successful in bringing down the infant mortality rate, maternal mortality, death of children below the age of 5 and other pregnancy related deaths.

This has been possible because of the focused attention on these matters by successive governments at the centre (starting from child survival and safe motherhood programme in 1990s to National Rural Health Mission).




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The declaration of the Millennium Development Goals and India’s race to reach these goals has also contributed to the success.

On two social determinants supply of safe drinking water and women’s literacy India has fared well.

Government’s timely interventions have also helped reduce decadal population growth rate. Many states have already achieved crude birth rate compatible with population stabilization.

Also helped is the combination of health systems strengthening and maternity focused programs like the JSY, ASHA, Dial 108 and 104, and appointment of additional nurses among others.

What’s left behind?

However, the above mentioned accomplishments were made without comparable improvements in sanitation and child nutrition, which are two of the most important social determinants of health.

Seven states still continue to face high fertility rate. These include UP, Bihar, MP and Rajasthan.

The country still faces about 46, 500 maternal deaths and about 1.5 million deaths of children under 5 every year. This constitutes a high proportion of global maternal and child deaths.

Quality and safety of healthcare in the country is also an issue. Last but not the least, poor financial outlay remains a major concern. Most deaths due to infectious disease are due to diarrhea and respiratory infections

especially in children. Deaths due to communicable diseases account for 30% of mortality in the country.

Increasing share of deaths due to noncommunicable diseases. This accounts for over 70% of all deaths.

India witnesses about 785 male deaths per 100, 000 due to main 4 NCDs cancer, diabetes, chronic respiratory disease and cardiovascular disease.




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What’s the main concern?

When it comes to NCD, India is no exception. In fact, major risk factors for NCD whether it is overweight, obesity, physical inactivity, alcohol or smoking are all more prevalent in the prevalent world. But, the absence of primary healthcare is worrisome in developing countries like India. Private sector has no doubt expanded to fill these gaps but market forces largely promote curative and preferably tertiary care.

Market driven growth is unable to address the needs of primary and secondary prevention. This makes the government’s role more significant.

What’s been done so far?

The government has initiated a National Disease Control Programme against non communicable diseases.

Health, though a state subject, got a push from the centre under the 11th five year plan. National Rural Health Mission was merged with National Urban Mission it form the National Health Mission. Centre’s intervention was necessary both in terms of financing and ideas.

Creation of over 900,000 workforce called community health volunteers or ASHAs. They have made a major contribution by bringing health services closer to the community and increasing its utilization.

Approval of National Urban Health Mission in 2013. Introduction of publicly finance health insurance schemes that cover the cost of

hospitalization of the poor.

What else is required?

Fund allocations should keep pace with requirements. Efficient utilization of funds has to be ensured. Along with private industry, policy should also concentrate on strengthening public

health care system.




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State budgetary mechanisms have to be strengthened. The centre has to make sure that the funds allocated are not misused or routed for any other purpose.

Invest more to increase the skilled public health workforce on a regular and reliable terms of employment.

Reduce out of pocket expenditure. Consider bringing all the government sponsored insurance schemes under one roof. Engaging notforprofit sections in partnerships that require a less rigorous regulation

can also provide considerable benefits.

Conclusion:

Initiative, so far have definitely helped India achieve better heights in this regard. But, time has come to intensify and expand these efforts and make sure that benefits out of these reach more and more number of people. Inclusion of private sections in this sector has to be carefully considered. A premature and unprepared shift without first putting in place, the regulatory mechanisms and getting politically ready for much higher levels of public investment is fraught with danger.

Glossary:

The crude birth rate is the number of live births occurring among the population of a given geographical area during a given year, per 1,000 midyear total population of the given geographical area during the same year.

Total fertility rate represents the number of children that would be born to a woman if she were to live to the end of her childbearing years and bear children in accordance with current agespecific fertility rates.




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Evolution of National Health Policy in India

The draft National Health Policy 2014 is the third to be announced in the last six decades of governance of health sector in India.

Background:

National Health Policy of 1983:

The National Health Policy of 1983 was formulated with the global vision of 'Health for All by 2000' set in the aftermath of the Alma Ata Declaration.

It laid strong emphasis on infrastructure development, primary health care and development of a well trained cadre of health care professionals.

But it remained more as a vision document as it fell short of defining clearly the achievable targets matched by requirement of resources. And by 2000, the country was nowhere near achieving the objective of health for all.

National Health Policy in 2002:

The Millennium Declaration 2000 and adoption of a number of health related Millennium Development Goals (MDGs) at global level gave impetus for formulation of a new National Health Policy in 2002.

The NHP 2002 clearly identified the shortcomings and challenges in attaining the goal of health for all and adopted a more practical approach to improve the health standards of the people.




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It has broken new ground in identifying suboptimal resource base as a serious impediment to secure minimum health standards for the people.

It recommended that the health spending as a proportion of GDP should be doubled from 1% to 2% within a period of 10 years.

It laid emphasis on primary health care suggesting that at least 50% of health expenditure should be incurred on primary health care.

It has for the first time listed out clearly the identified targets for various health outcomes to be achieved within the next 10 years.

What’s worrisome?

Despite its strong push for greater emphasis on public spending on health, public expenditure on health remained stationary for the next 10 years at around 1% of GDP only.

Even though, the country has done well in achieving some of the targets set in the Policy in the areas of disease control and maternal and child health, it has fallen short of achievements in a number of areas like control of noncommunicable diseases, securing equitable access to health care services for the poor and marginalised sectors of population and meeting the chronic shortage of qualified health care professionals in the country.

What’s in the new policy?

The government, in January 2015, came out with the draft National Health Policy. The new draft National Health Policy has been refreshingly different in its approach in many ways.

What’s so special about this policy?

Government has adopted the principle of transparency in policy formulation by putting it in public domain for extensive feedback from experts and general population alike.

The draft Policy has taken into consideration the change of context for health sector in many ways. Most importantly, it has recognised that incidence of catastrophic




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expenditure due to health care costs is growing and is now estimated to be one of the major contributors to poverty.

'The drain on family incomes due to health care costs can neutralize the gains of income increases and every Government scheme aimed to reduce poverty ' the Policy acknowledges.

It observes that an increasing number of households are facing catastrophic expenditures due to health costs (18% t of all households in 201112 as compared to 15% in 200405).

It has also recognised that much of the increase in service delivery was related to select reproductive and child health services and to the national disease control programmes, and not to the wider range of health care services that were needed to improve the health standards of general population.

The major shifts in disease burden from communicable diseases and maternal and neo natal ailments to noncommunicable diseases and injuries have been given due weightage in the new draft Policy which attempts to balance the emphasis between the twoo.

The primary aim of the new National Health Policy draft is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions by following certain key principles including equity, universality and inclusive partnerships.

What’s needed?

The objectives set in the present draft are aspirational like in a vision document. They need to be transformed into a Policy which should have clear cut goals and targets to achieve, a time frame in which these will be achieved and resources, financial and technical that would be needed to achieve the goals.

The Policy should aim at a 10 to 15 year time frame and the goals should be harmonised with the Sustainable Development Goal on Health (SDG 3) adopted by India along with other countries in the UN General Assembly in September 2015. The SDG 3 should be adopted as an overall objective for various components of the health goals to be achieved by 2030.




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There should be stronger emphasis on equity as a basic principle. The global principle of 'no one should be left behind' as a post 2015 development agenda needs to find its echo in the national policy framework.

The National Health Policy 2002 for the first time, indicated the level of investment that is needed to deliver optimum level of health services as a percentage of GDP. The policy reiterates the commitment to increase investments to 2.5% of GDP but no specific time frame has been set to reach this target. Hence, a time limit has to be specified.

There should also be a target set for the state governments as well on the health expenditure as a percentage of total government expenditure.

Improved governance mechanisms and a legal framework for creating an enabling environment for providing accessibility to health services should be important components of an effective health policy.

The responsibilities of central and state governments need to be more clearly delineated and lines of accountability clearly drawn for performance. With the Government at the Centre devolving more resources to states for social sector programmes, accountability of states for delivering health care services to people has to be greater.

Decentralisation of programme implementation to the lowest level of effective service delivery should be an important feature of the new National Health Policy.

The present legal environment surrounding health sector is very confusing with a plethora of laws at different levels of adoption and implementation by the centre and the states. It is necessary to harmonise and align them to the overall objective of providing equitable access to health services, especially to poor and socially disadvantaged sections of the society.

The policy focus on providing Universal Health Coverage (UHC) is in line with the globally agreed target of UHC as a part of SDG on Health. Government of India agreed in principle to adopt UHC as a national goal, but is yet to provide adequate resources to make it happen on the ground. Providing universal access to fully funded health care services including provision of drugs and diagnostics to poor and marginalised populations coupled with financial risk protection schemes like medical insurance for lower and middle income groups would be the right formula mix to universalise health coverage for the entire population.

India should reassess its role in the international arena as a leader in pharmaceutical production, as a major supplier of life saving medicines to countries in Africa and Asia,




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and as a major advocate for developing trade and intellectual property regimes which are supportive of development of national economic growth and improved health standards.

Health as a Fundamental Right:

The Union Ministry of Health and Family Welfare suggested, in January 2015, making health a fundamental right, similar to education. This key proposal in the draft National Health Policy, 2015, suggests making denial of health an offence.

The draft policy proposes that “the Centre shall enact, after due discussion and on the request of three or more States (using the same legal clause as used for the Clinical Establishments Bill), a National Health Rights Act, which will make ensuring health as a fundamental right, whose denial will be justiciable.

The States would voluntarily opt to adopt this by a resolution of their Legislative Assembly.

Many of the developing nations that have made significant progress towards universal health coverage, such as Brazil and Thailand, have made it a Fundamental Right, and such a law is a major contributory factor.

Conclusion:

India is passing through a period of transition in its own developmental path, built on the three pillars of economic development, social inclusion and environmental sustainability. The new National Health Policy should be visionary in its approach to fulfil these objectives, and at the same time, be practical in goal setting and providing financial, technical and administrative support to achieve those goals.




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Health Care in Tribal Areas: Present and the Future

As per the Census 2011, the ‘tribals’ constitute around 8.6% of the total Indian population, and almost 90% (89.97%) of them live in rural areas.

Broadly the STs inhabit two distinct geographical areas a large segment inhabiting nine (9) Central Indian states of Madhya Pradesh, Chhattisgarh, Jharkhand, Andhra Pradesh, Maharashtra, Odisha, Gujarat and Rajasthan) and the other distinct area being the North East (Assam, Nagaland, Mizoram, Manipur, Meghalaya, Tripura , Sikkim and Arunachal Pradesh).

Main concerns:

In spite of the efforts of the government, these Tribal areas continue to suffer from poor maternal and child health services and ineffective coverage under national health and nutrition programmes.

Being among the poorest and most marginalised groups in India, tribals experience extreme levels of health deprivation. The tribal community lags behind the national average on several vital public health indicators, with women and children being the most vulnerable.

Several studies on maternal health show poorer nutritional status, higher levels of morbidity and mortality, and lower utilisation of antenatal and postnatal services among tribals.

Underfive mortality rates among rural tribal children remain startlingly high, at 95 deaths per 1,000 live births in 2006 compared with 70 among all children.

Health problems prevalent in tribal areas include endemic infectious diseases like malaria, tuberculosis, and diarrhoeal diseases, apart from malnutrition and anaemia.

What is worrying is that the prevalence of chronic diseases such as hypertension and diabetes mellitus, hitherto rare in these populations, is rising, and stroke and heart disease are now the leading causes of death.




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Research and data available through surveys have found that infrastructure like SubCentres, Community Health Centres (CHCs), Public Health Centres (PHCs) and others are less than required in the tribal areas.

Reasons for poor health:

Research has shown that 75% of India’s tribal population defecates in the open and 33% does not have access to a clean source of drinking water. Insanitary conditions, ignorance, lack of health education and poor access to healthcare facilities are the main factors responsible for the poor health of tribals.

Further, displacement from their traditional forest homes and natural source of food and lack of livelihoods makes them dependent on the public distribution system (PDS) and other government handouts for survival. Most tribal groups are traditionally huntergatherers and not accustomed to agriculture — their diets, therefore, are now severely limited in fruits and vegetables as well as good sources of protein (including fish and meat). Polished rice and cereals available through the PDS have replaced diverse dietary food baskets.

Although the government has provided for the establishment of Primary Health Centres (PHCs) in tribal areas for every 20,000 population and subcentres for every 3,000 population, quality healthcare is not available to the majority of tribals. Posts of doctors and paramedicals are often vacant. Additionally, the nonavailability of essential drugs and equipment, inadequate infrastructure, difficult terrain and constraints of distance and time, and the lack of transport and communication facilities further hinder healthcare delivery.

The geographical and infrastructural challenges to public health and the lack of healthrelated knowledge among tribals are exploited by quacks, who are often available at the doorstep.

Though successive Five Year Plans have provided for the needs of tribal populations within different schemes, and a large amount of funds are allocated, little improvement has been noted on the ground.

Also, scarcity of trained manpower for health is a major problem and an obstacle to the extension of health services to rural and tribal areas.




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How can the situation be improved?

Traditional healers, who are often the first point of care, can be sensitised and trained to deliver simple interventions like ORS for diarrhoea and antimalarials as well as to refer patients to the PHC in a timely manner.

Tribal boys and girls (who complete school but often have no further opportunities) could be trained as community health workers or nurses and incentivised to stay and work in their own communities.

Nutritional counselling and education, establishment of kitchen gardens and provision of a more diverse range of food items through the PDS would help in curtailing macro and micronutrient deficiencies.

More research needs to be done on the traditional herbal medicines used by tribal people and their use encouraged, wherever beneficial.

Health care delivery system to ST population should be culture sensitive and in the local language to overcome the physical distance.

Data on ST population is a basic ingredient for planning, monitoring and evaluating health programmes in the scheduled areas. Hence, it should be made available as and when required.

The Tribal Sub Plan (TSP) budget, in proportion to the ST population, should be an additional input and not a substitute to the regular budget for the routine activities of the health department in the scheduled areas.

Conclusion:

A total health programme for the tribal villages is a prerequisite to check and eradicate vectorborne and waterborne diseases. Facilities may be created in the tribal areas so as to attract hundred percent deliveries in the hospitals. All preventive vaccinations and injections may be given free of cost to the tribal people including Hepatitis B and antimeasles vaccines. It is, therefore, essential to update and provide 24hours hospital facility to the people in the tribal area. It is necessary to conduct frequent surveys on the food habits, nutrition, health




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practices of the tribals. It will help the authorities to take suitable measures to improve the health of the tribals.

Realizing the Power and Promise of Health Communication Communication for Social and Behavioral change has been accepted as one of the critical strategies for improving health status and performance of the health programmes.

The power and potential of the communication has long been understood since early days by the government of India in its plans and actions.

Although, a lot has been achieved over the years in a number of health programs and interventions but even today, India faces huge challenges as far as key health status and indicators are concerned.

Significance of Health Communication:

The development in medical science has led to longevity of life and India has found answers to many dreadful diseases. However, communication will play a major role to communicate the treatment available to many disorders across our country.

Despite the availability of medical facilities, 8085% of blind people in India could have been treated had proper communication reached them.

This percentage is hardly 5% in developed economies, only due to nonavailability of treatment and not lack of appropriate communication.

What’s the problem?

There are several factors for the current situation which are related to supply side including inadequate infrastructure, gaps in human resources, challenges to funding release and utilization, quality of services, access, and managerial and operational challenges and health being a state subject.




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The challenges from demand side have also been enormous which includes a very large and diverse population, tradition and customs, myths and misconceptions, beliefs and perceptions, habits and attitudes, values and norms and gaps in information and knowledge and awareness issues.

Besides, policy makers and program planners rarely view engaging the most vulnerable creatively on issues of prevention and health seeking behaviour as a priority. This negligence to health communication is the result of overly medicalised approaches to health where the focus is to treat the patient but not to prevent the disease. The underlying assumption is that the individual is incapable of health seeking behaviour. Thus, the patient is at the receiving end of choices made about their health by a group of doctors.

Disinterest among public health officials about health communication is not the only reason for deprioritised or poor health communication. These activities are supervised not by communication professionals but by doctors who understand and know nothing of health communication. These doctors are often at a loss with no training on the subject. As result, these activities are at best unimaginative, instructive and unengaging with little or no impact.

Moreover, health messaging is viewed as a soft aspect of public health programming. ‘Real’ doctors are reluctant to do health communications.

Previous experiences:

In India, two examples of successful health communication that had considerable impact are polio and HIV. In either case, a host of agencies worked together to develop a multipronged strategy led by communication professionals. This helped in creating multiple strategies that were used to engage diverse audiences.

Polio messaging for example was built on simple idea — two drops that could save your child’s life. This message was everywhere — from print, TV and radio from the more urban and semiurban audiences and on roadsides, on the back of buses and lorries and in small village fairs.

HIV was perhaps India’s most complex disease communication exercise. In a society with ingrained double standards, limited women’s rights and a complete lack of




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conversation on sexuality and sexual diversity talking about HIV may have been impossible. However, HIV program managers within the government understood the importance of prevention and sought help from external agencies creating what was perhaps the most elaborate and effective health communication campaign in recent history.

The HIV campaign used every possible medium and celebrities to transmit messages on prevention, on treatment and on stigma. An important aspect of this campaign was it consciously focused on being entertaining and connecting with the audience. It also consciously avoided being judgmental of lifestyle choices. HIV programming in particular was relevant as it emphasized the notion of choice — an idea that was empowering to an audience used to directive messaging.

Public health authorities across highburden countries need to reorder their approach to public health communication. For starters, this communication needs to be managed by communication professionals and not doctors. Public health communication must be multipronged, regionally suitable and easy too absorb. Finally, public health authorities need to take up public health communications as a priority.


There has to be strategic shift in terms of how the budgetary provisions are made for the communication efforts at the center and states. Presently, the funding for the communication efforts is grossly inadequate.

The capacity of the communication department personnel and training institutions should be thoroughly augmented.

Improved monitoring, tracking, assessment, evaluation and research efforts for health communication need to be well in place for better outcomes and accountability.

The health communication efforts need to forge and harness partnerships at all levels.

Conclusion:

Public health authorities need to understand that if we expect people to change lifestyle choices, we need to engage them with health messages that are persuasive. Clearly, this is a job for communication professionals not doctors. Strategic health communication efforts need to




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be strengthened in order to significantly accelerate the results and impact of the health mission actions.

Universal Health Coverage

A critical component of the United Nations' 2030 agenda for Sustainable Development Goals is health for all. However, despite a decadelong work under the National Rural Health Mission, a vast majority of Indians remains out of the heath careforall umbrella. The more recent National Urban Health Mission of 2013 and the Rashtriya Swasthya Bima Yojana have only just begun.

It is being said that Universal Health Coverage (UHC) is the single most powerful concept that public health has to offer.

What is Universal Health Coverage (UHC)?

UHC refers to a goal for each nation, whereby all citizens have access to quality health services they need, and don't suffer financial hardship when they pay for them.

Universal coverage three dimensions:

UHC has three dimensions population coverage, health services coverage and financial protection coverage and is often presented by a cube, referred as ‘UHC Cube’.

The inside cube reflects the existing status in the countries, where only a proportion of the population has access to health services, only a few services are available and not all who receive services can afford the cost.

The outer cube is the aspirational goal for the countries, as defined by UHC, and proposes that all countries should fill the box by extending coverage of quality services with affordable cost.




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UHC and SDGs:

UHC assumes greater importance in the context of the recent adoption by the United Nations of the 2030 agenda for Sustainable Development Goals (SDGs). It is a key element for the success of healthrelated SDG (SDG 3); it also underpins other SDGs.

UHC and India:

India has made rapid strides towards increasing access to health services in the past few years through a number of initiatives, including the flagship National Rural Health Mission (NRHM), launched in 2005. This was expanded to the urban population through the National Urban Health Mission (NUHM) in 2013.

To provide financial protection to targeted populations, including those below the poverty line, the government has implemented the Rashtriya Swasthya Bima Yojana (RSBY). It covers the cost of secondarylevel hospitalisation.

In addition, there are a number of statespecific schemes. Some involve running free diagnostics facilities and offering free medicines; others are governmentfunded health insurance schemes in several states. Evidence suggests that these can reduce the financial burden on patients and increase attendance at public health facilities.

The need to accelerate UHC in India:

While these initiatives provide some financial protection to those seeking health care, tens of millions still fall into poverty after an illness or abstain from accessing the health services they need.

At 60%, India's outofpocket expenditure (OOP) for health is one of the highest in the world. This exacerbates health inequities. To sustain its economic growth, India will need to have a healthy population and address health inequities. In this context, UHC can be the driver and benefit the entire population.

Accelerating UHC is the key to successfully addressing the new public health challenges and inequities in health outcomes.




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It is important to define and agree on the vision and goals for 2030. This involves agreeing on a process for developing such a vision. This will entail development of a national framework and roadmap that define roles of the Centre and the states, besides that of both public and private sectors. This goal needs to be operationalized.

As the states are at varying levels of development, the UHC vision for the country needs to be cognizant of these diversities. In this context, there are opportunities for the states to accelerate the process of moving towards UHC. They could choose a model that they can follow for 510 years to develop their own path and determine their own pace. The overall national framework ensures convergence in the long term.

Highlevel political commitment to invest in the health sector is essential for advancing the UHC agenda at both the Centre and the states. This commitment is also needed beyond the Ministry of Health, notably the ministries of finance, skill development and human resources development, and the NITI Aayog. A similar commitment is needed in the states also.

Along with political commitment is a must, community involvement is equally essential for moving towards UHC. Institutions, both in the government as well as NGOs, including thinktanks and private sector players, have an important role to play in advocating UHC and pushing for its effective implementation.

Intrinsically related to efficiency in government health spending is the need for a robust health system. A weak health system cannot produce a healthy population.

Progress towards UHC entails developing a monitoring and accountability framework as part of the same process that defines the UHC vision for India. This can be achieved through defining a set of indicators and timebound goals, including IMR, MMR, life expectancy, OOP and access to services.

Finally, it is important to build mechanisms for regular review and adaption based on ongoing monitoring and accountability processes.

Conclusion:

UHC is considered a journey rather than a destination. Experiences from other countries show that it takes 1015 years to make reasonable progress in this direction and UHC s not possible




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in a year. While Uhc is the aim, the health system reforms and strengthening are foundation and tools, on which progress in the direction of UHC could be made.

Reducing Malnutrition: Women’s Health Holds The Key

According to UNSCN, malnutrition and disease have close links. In many ways, malnutrition is the largest single contributor to disease in the world. In some instances, ill health or disease could be a direct consequence of malnutrition, while in others, a key contribution.

Although malnutrition's effects on women and adolescent girls have been recognized for decades, there has been little measurable progress in addressing the specific nutritional problems of women and adolescent girls.

What is Malnutrition?

It is defined as ill health caused by deficiencies of calories, protein, vitamins, and minerals.

How it affects?

Malnutrition interacting with infections and other poor health and social conditions, saps the strength and wellbeing of millions of women and adolescent girls around the world.

Why we need to reduce malnutrition?

Malnutrition poses a variety of threats to women. It weakens women's ability to survive childbirth, makes them more susceptible to infections, and leaves them with fewer reserves to recover from illness.

HIVinfected mothers who are malnourished may be more likely to transmit the virus to their infants and to experience a more rapid transition from HIV to fullblown AIDS.




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Malnutrition undermines women's productivity, capacity to generate income, and ability to care for their families.

Addressing women's malnutrition has a range of positive effects because healthy women can fulfill their multiple roles — generating income, ensuring their families' nutrition, and having healthy children — more effectively and thereby help advance countries' socioeconomic development.

Women are more likely to suffer from nutritional deficiencies than men are, for reasons including women's reproductive biology, low social status, poverty, and lack of education. Sociocultural traditions and disparities in household work patterns can also increase women's chances of being malnourished.

How Women's Nutrition Affects National Economies?

Malnutrition in women leads to economic losses for families, communities, and countries because malnutrition reduces women's ability to work and can create ripple effects that stretch through generations.

Countries where malnutrition is common must deal with its immediate costs, including reduced income from malnourished citizens, and face longterm problems that may be related to low birth weight, including high rates of cardiac disease and diabetes in adults.

Recent research indicates that 60% of deaths of children under age 5 are associated with malnutrition — and children's malnutrition is strongly correlated with mothers' poor nutritional status.

By improving the nutrition of adolescent girls and women, nations can reduce health care costs, increase intellectual capacity, and improve adult productivity.

India: Situation and Response

Despite its commitment to reduce malnutrition levels and its sustained economic growth, India lags behind on all key nutrition indicators.

The Rapid Survey in Children shows that 38.7% children the age of 5 are stunted, 19.85% are wasted and 42.5% are underweight. Stunting is a measure of chronic under




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nutrition, wasting indicates acute undernutrition and underweight is a composite of these two conditions.

Many efforts are underway to address malnutrition in the country. Notably, the ICDS, a flagship programme of the Ministry of Women and Child Development, works towards improving the nutrition and health status of children and expectant mothers through a package of servicessupplementary nutrition, immunization, health check ups etc. through a cadre of frontline workers at the Anganawadi centres.

Other such measures include PDS, MGNREGA and Midday meal scheme.


Preventing malnutrition requires a political commitment. Public health systems need to prevent and treat micronutrient deficiencies, encourage households to meet the dietary needs of women and adolescent girls throughout their lives, and ensure their access to highquality health services, clean water, and adequate sanitation.

Policymakers should also address women's low social status and ensure that girls have access to education — which should include information on nutrition.

Such policy measures can help increase women's age at first pregnancy, an important determinant of maternal health and child survival, and can encourage women to space their births.

Involve the community in developing and supporting the interventions and developing policies.

Policymakers can help improve women and children's nutrition by addressing women's low status in society. Gender inequalities are often greatest among the poor, particularly in terms of household investments in health and education. Addressing gender inequalities can help ensure that women can get the nutrition they need, improving their own health and that of their families and, ultimately, contributing to their societies' development.

Microfinance programs, which provide women with small loans for their businesses, are another way to raise women's status and improve their ability to provide for themselves and for their families.




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Data on women's nutritional status can be a powerful tool for informing communities and governments about the nature, extent, and consequences of female malnutrition, but data need to be collected regularly, analyzed, and disseminated.

Policymakers can also make the government and program managers accountable for improving outcomes.

Conclusion:

Adequate nutrition is important for women not only because it helps them be productive members of society but also because of the direct effect maternal nutrition has on the health and development of the next generation. There is also increasing concern about the possibility that maternal malnutrition may contribute to the growing burden of cardiovascular and other noncommunicable diseases of adults in less developed countries. Finally, maternal malnutrition's toll on maternal and infant survival stands in the way of countries' work toward key global development goals.

Adolescent Health in India

According to 2001 census data, there are 253 million adolescents, which comprise nearly onefifth (22%) of India's total population (Census 2001). Of the total adolescent population, 12% belong to the 1014 years age group and nearly 10% are in the 1519 years age group.

This age group comprises of individuals in a transient phase of life requiring nutrition, education, counselling and guidance to ensure their development into healthy adults. However, data on adolescents from national surveys including NFHS III, DLHS III and SRS call for focused attention with respect to health for this age group.




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Given the above scenario, Government of India has recognized the importance of influencing healthseeking behaviour of adolescents.

Significance of Adolescent Health:

The health situation of this age group is a key determinant of India's overall health, mortality, morbidity and population growth scenario. Therefore, investments in adolescent reproductive and sexual health will yield dividends in terms of delaying age at marriage, reducing incidence of teenage pregnancy, meeting unmet contraception need, reducing the maternal mortality, reducing STI incidence and reducing HIV prevalence in.

It will also help India realize its demographic bonus, as healthy adolescents are an important resource for the economy.

The adolescent period provides a second chance to improve the health and wellbeing of a child in the second decade of his life. While what happens during the early years of life impacts adolescents’ health and development, what takes place during the adolescent period affects health during the adult years and even influences the health and wellbeing of the next generation.

Also health and wellbeing issues like teenage pregnancy, nutrition, alcohol and tobacco consumption, mental health, suicides and road accidents, there are certain interventions which if not applied during the adolescent period can be missed forever. Immunisation of adolescent girls using human papillomavirus (HPV) vaccine can cut deaths from cervical cancer.

Concerns:

As per the National Family Health Survey (NFHS)3, adolescents in India suffer from both undernutrition and overweight issues. In the 15–19 age group, nearly half the girls and nearly threefifths of the boys (58%) are underweight. At the same time, 2.4% of the girls and 1.7% of the boys in this age group are overweight.




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Early sexual activity is another area of focus. Findings from NFHS–3 show that births in the age group of 15–19 years account for 17% of the total fertility rate (the average number of children born to a woman) in India.

What has been done so far?

India has demonstrated very strong leadership in positioning adolescent health as part of continuum of care. India has taken the lead to present to the rest of the world why it is important to have a discussion on adolescent health.

Overlooking the health of the adolescents has been one of the main reasons why India has failed to reach MDG goals.

However, programmes in India targeted at adolescents are not as advanced as in the case of child health and survival. Programmes targeted at adolescents are not so well established. Besides, knowledge and capacity to drive those programmes are not well established.

Conclusion:

Adolescent health in India is still in an infant stage, and at risk of infanticide. If we want to deliver a comprehensive services package to our adolescents, then we have first to overcome a range of obstacles: traditional society, cultural restricttions—especially for girls—and the politicalreligious context. Only government action can put these hindrances aside.




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MDGs: What are they?

These are eight international development goals that were established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. They were set to be achieved by 2015.

They are the world’s timebound and quantified targets for addressing extreme poverty in its many dimensionsincome poverty, hunger, disease, lack of adequate shelter, and exclusionwhile promoting gender equality, education, and environmental sustainability.

They are also basic human rightsthe rights of each person on the planet to health, education, shelter, and security.

The eight millennium development goals are:

1. Eradicate Extreme Hunger and Poverty. 2. Achieve Universal Primary Education. 3. Promote Gender Equality and Empower Women. 4. Reduce Child Mortality. 5. Improve Maternal Health. 6. Combat HIV/AIDS, Malaria and Other Diseases. 7. Ensure Environmental Sustainability. 8. Develop a Global Partnership for Development

Each goal has specific targets, and dates for achieving those targets.

2010 Summit on the Millennium Development Goals:

The 2010 MDG Summit concluded with the adoption of a global action plan – Keeping the Promise: United to Achieve the Millennium Development Goals — and the announcement of a number of initiatives against poverty, hunger and disease.




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A $40 billion pledge in resources over the next five years was also made to accelerate progress on women’s and children’s health.

MDG fund:

The MDGFund was established in 2007 through a landmark agreement signed between the Government of Spain and the UN system with the aim of accelerating progress on the MDGs.

With a total contribution of approximately $US 900 Million, the MDGFund financed 130 joint programmes in eight programmatic areas in 50 countries around the world, in addition to global partnerships, thematic knowledge management initiatives and the JPO and SARC young development professionals training programmes.

The MDGFund also led a social justice initiative to put the issue of social exclusion and inequality firmly at the centre of the fight against poverty and all efforts to achieve the MDGs.

The MDGF has three main objectives: to spur achievement of the MDGs by working across multiple sectors within target countries; to boost the effectiveness of international aid by increasing national leadership and ownership of development programmes; and to promote the “One UN” concept, the consolidation and streamlining of the UN’s work at country level to speed up development operations and avoid duplication.

New SDGs:

In September 2015, the 193Member United Nations General Assembly formally adopted the 2030 Agenda for Sustainable Development, along with a set of bold new Global Goals.

These new SDGs replace the Millennium Development Goals (MDGs) which were adopted in 2000 and expired in 2015.

These new set of global goals aim to combat poverty, inequality and climate change over the next 15 years in the most comprehensive international effort ever to tackle the world’s ills.




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What are the SDGs?

The SDGs are a set of 17 goals and 169 targets aimed at resolving global social, economic and environmental problems.

Aiming to encompass almost every aspect of human life, the main themes of the SDGs are ending poverty, tackling inequality and combating climate change.

According to the UN’s own estimates, achieving the 17 Sustainable Development Goals and 169 targets meant to transform the world will require over 250 billion dollars annually for the next 15 years.

What did the MDGs accomplish?

The United Nations says the MDGs – a set of eight goals with 21 targets – led to achievements including:

More than halving the number of people living in extreme poverty, to 836 million in 2015 from 1.9 billion in 1990.

Gender parity in primary schools in the majority of countries. Reducing the rate of children dying before their fifth birthday to 43 deaths per 1,000 live

births from 90. A fall of 45% in the maternal mortality ratio worldwide. Some 37 million lives saved by tuberculosis prevention and treatment, over 6.2 million

malaria deaths averted, and new HIV infection rates down by around 40%. Access to improved sanitation for 2.1 billion people.

Why do we need SDGs?

Some 795 million people around the world still go hungry and around 800 million people live in extreme poverty, with fragile and conflicttorn states experiencing the highest poverty rates.

Between 2008 and 2012, 144 million people were displaced from their homes by natural disasters, a number predicted to rise as the planet warms, bringing more extreme weather and rising seas.




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Water scarcity affects 40% of the global population and is projected to increase. Some 946 million people still practice open defecation. Gender inequality persists in spite of more representation for women in parliaments

and more girls going to school. 57 million children still denied right to primary education.

However, please note that these SDGs are non binding.

What is sustainable development?

The United Nations defines sustainable development as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs”.

A boost to promote entrepreneurship among SC/ST and Women

The Union Cabinet, chaired by the Prime Minister Shri Narendra Modi, in January 2016 approved the “Stand Up India Scheme” to promote entrepreneurship among SC/ST and Women entrepreneurs.

The Scheme is intended to facilitate at least two such projects per bank branch, on an average one for eachcategory of entrepreneur. It is expected to benefit atleast 2.5 lakh borrowers.

The Stand Up India Scheme provides for:

Refinance window through Small Industries Development Bank of India (SIDBI) with an initial amount of Rs. 10,000 crore.




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Creation of a credit guarantee mechanism through the National Credit Guarantee Trustee Company (NCGTC).

Handholding support for borrowers both at the pre loan stage and during operations. This would include increasing their familiarity with factoring services, registration with online platforms and emarket places as well as sessions on best practices and problem solving.

The details of the scheme are as follows:

Focus is on handholding support for both SC/ST and Women borrowers. The overall intent of the approval is to leverage the institutional credit structure to reach

out to these underserved sectors of the population by facilitating bank loans repayable up to 7 years and between Rs. 10 lakh to Rs. 100 lakh for greenfield enterprises in the non farm sector set up by such SC, ST and Women borrowers.

The loan under the scheme would be appropriately secured and backed by a credit guarantee through a credit guarantee scheme for which Department of Financial Services would be the settler and National Credit Guarantee Trustee Company Ltd. (NCGTC) would be the operating agency.

Margin money of the composite loan would be up to 25%. Convergence with state schemes is expected to reduce the actual requirement of margin money for a number of borrowers.

Over a period of time, it is proposed that a credit history of the borrower be built up through Credit Bureaus.

Background:

The "Start up India Stand up India" initiative was announced by the PrimeMinister in his address to the nation on 15th August, 2015. The Stand up India component is anchored by Department of Financial Services (DFS) to encourage greenfield enterprises by SC/ST and Women entrepreneurs.




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Mission Indradhanush

Mission Indradhanush was launched by the Health & Family Welfare Ministry in April 2015.

Aim:

The Mission Indradhanush, depicting seven colours of the rainbow, aims to cover all those children by 2020 who are either unvaccinated, or are partially vaccinated against seven vaccine preventable diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B.

Details:

The Mission will be implemented in 201 high focus districts in the country in the first phase which have nearly 50% of all unvaccinated or partially vaccinated children (Of the 201 districts, 82 districts are in just four states of UP, Bihar, Madhya Pradesh and Rajasthan and nearly 25% of the unvaccinated or partially vaccinated children of India are in these 82 districts of 4 states).

These districts will be targeted by intensive efforts to improve the routine immunization coverage.

Between 20092013 immunization coverage has increased from 61% to 65%, indicating only 1% increase in coverage every year. To accelerate the process of immunization by covering 5% and more children every year, the Mission Mode has been adopted to achieve target of full coverage by 2020.

The focused and systematic immunization drive will be through a “catchup” campaign mode where the aim is to cover all the children who have been left out or missed out for immunization.

Under Mission Indradhanush, four special vaccination campaigns will be conducted between January and June 2015 with intensive planning and monitoring of these campaigns.

The learnings from the successful implementation of the polio programme will be applied in planning and implementation of the mission.




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The Ministry will be technically supported by WHO, UNICEF, Rotary International and other donor partners. Mass media, interpersonal communication, and sturdy mechanisms of monitoring and evaluating the scheme are crucial components of Mission Indradhanush.

Rashtriya Kishor Swasthya Karyakram (RKSK)

The Ministry of Health & Family Welfare, in April 2014, launched Rashtriya Kishor Swasthya Karyakram for adolescents, in the age group of 1019 years, which would target their nutrition, reproductive health and substance abuse, among other issues.

Key facts:

The key principles of this programme is adolescent participation and leadership, Equity and inclusion, Gender Equity and strategic partnerships with other sectors and stakeholders.

The programme envisions enabling all adolescents in India to realize their full potential by making informed and responsible decisions related to their health and well being and by accessing the services and support they need to do so.

To guide the implementation of this programme, MOHFW in collaboration with UNFPA has developed a National Adolescent Health Strategy. It realigns the existing clinicbased curative approach to focus on a more holistic model based on a continuum of care for adolescent health and developmental needs.

Besides its focus on sexual and reproductive health as well as gender bias, the programme, called the Rashtriya Kishor Swasthya Karyakram (RKSK), marks a significant step in efforts to curb India’s rising burden of noncommunicable diseases.

The programme will use social media networks like Facebook, Twitter and Whatsapp to reach urban adolescents with correct information on safe sex practices.




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A crucial part of the outreach programme is to have an “adolescentfriendly” health clinic in every district of the country, offering a range of clinical services, including contraceptives.

Objectives:

1. Improve Nutrition. 2. Improve Sexual and Reproductive Health. 3. Enhance Mental Health. 4. Prevent Injuries and violence. 5. Prevent substance misuse.

Strategies/interventions to achieve objectives can be broadly grouped as:

1. Community based interventions Peer Education (PE). Quarterly Adolescent Health Day (AHD). Weekly Iron and Folic Acid Supplementation Programme (WIFS). Menstrual Hygiene Scheme (MHS). 2. Facility based interventions Strengthening of Adolescent Friendly Health Clinics (AFHC). 3. Convergence Within Health & Family Welfare FP, MH (incl VHND), RBSK, NACP, National

Tobacco Control Programme, National Mental Health Programme, NCDs and IEC. With other departments/schemes WCD (ICDS, KSY, BSY, SABLA), HRD (AEP, MDM),

Youth Affairs and Sports (Adolescent Empowerment Scheme, National Service Scheme, NYKS, NPYAD).

4. Social and Behaviour Change Communication with focus on Inter Personal Communication

Significance of this programme:

According to the health ministry, more than 33% of the disease burden and nearly 60% of premature deaths among adults in India are associated with behaviours or conditions




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that began or occurred during adolescence. These include tobacco and alcohol use, gender violence and sexual abuse.

Many of communicabledisease conditions have a beginning in adolescence and this programme aims to improve health outcomes by investing in adolescent health today. The large and increasing share of adolescents and youth in India’s population can translate into a demographic dividend only if policies and programmes focus on their health and wellbeing.

The significance of RKSK is underpinned by evidence that adolescence is the most important stage of the life cycle for health interventions. Adolescents aged between 10 and 19 years number around 253 million in India—about a fifth of the population.

The programme marks a major shift from existing clinicbased services and aims to reach adolescents in their own spaces, such as schools and communities. It focuses heavily on strategies of social and behaviour change, especially in order to encourage young men to be more sensitive toward adolescent girls.

Kilkari

The government has launched Kilkari (literally baby noises), a mobile voice message service that delivers weekly messages to families about pregnancy, family planning, nutrition, childbirth and maternal and child care.

The database for the Kilkari programme will be taken from the successful Mother and Child Tracking System (MCTS) to monitor pregnant women and babies.

As per plans, every woman registered with MCTS will receive weekly messages relevant to the stage of pregnancy and age of the infant.

In all, 72 free audio messages, each of about twominute duration, will reach targeted beneficiaries from the fourth month of pregnancy until the child is a year old.

In the first phase, the Kilkari application is expected to benefit 1.84 crore pregnant women/newborns in Jharkhand, Odisha, UP, Uttarakhand and in some districts of Madhya Pradesh and Rajasthan.




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The Bill and Melinda Gates Foundation has provided the mobile phone application for Kilkari and mobile academy; the latter is a 240minute free training module for ASHAs.

RailTel Corporation of India Ltd, a mini ratna company, has been selected to provide data centre services for hosting the apps, while Reliance Communications will provide connectivity.



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