KAMLA NAGAR, DELHI - 110007 ANIMATION | VFX tel. - CHANGE
KAMLA NAGAR, DELHI - 110007 ANIMATION | VFX tel. - CHANGE
KAMLA NAGAR, DELHI - 110007 ANIMATION | VFX tel. - CHANGE
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DECEMBER 2011<br />
The draft Approach Paper of the 12th Plan was approved by the<br />
cabinet and presented to the National Development Council on<br />
October 22, 2011. The paper, which projects a growth rate of 9%<br />
for the 12th Plan, envisages that inclusiveness, an idea carried<br />
over from the 11th Plan, should lead to poverty reduction, increase<br />
in health outcomes and universal access of children to schools.<br />
It further states that inclusiveness should include providing<br />
opportunities for wage employment and livelihoods, and improved<br />
provision of water, sanitation and housing. All these have<br />
implications for improving child health and reducing childhood<br />
poverty.<br />
HEALTH<br />
The observation of the paper that the National Rural Health<br />
Mission (NRHM) focused on child health and pre-natal care and<br />
that it was now necessary to expand to a wider range of conditions<br />
gives the impression that targets in child health have already<br />
been achieved and therefore we can move on. Though offering a<br />
broader set of services is important given our changing<br />
epidemiological profile, the focus on child health cannot be<br />
diminished as India still accounts for the highest proportion of<br />
child deaths in the world.<br />
The Approach Paper states that central and state government<br />
expenditure on health has increased to 1.4% of GDP in 2011-12<br />
from less than 1% at the beginning of the 11th Plan. This<br />
calculation is based on Budget Estimates of 2011-12, whereas<br />
actual expenditures would be lower. Even otherwise, the estimated<br />
increased expenditure on health mentioned in the paper is way<br />
below the UPA government’s commitment to raise it to 3% of<br />
GDP. The paper agrees only to a rise of up to 2.5% of GDP, that<br />
too by the end of the 12th Plan, ie 2017.<br />
The paper mentions the High Level Expert Group (HLEG) on<br />
Universal Health Coverage constituted by the Planning<br />
Commission but does not give any clear commitment on the<br />
provision of universal healthcare. It says instead that the<br />
recommendations of this group will be an input for defining a<br />
“comprehensive health strategy for the next 10 years”.<br />
The accountability matrix defining the responsibilities of<br />
functionaries of the health, women and child development, water<br />
and sanitation departments at the block and habitation levels is<br />
a welcome step towards convergence of health and related<br />
services. However, to make it functional there must be a<br />
convergence in the performance of various functions at the state<br />
and district levels also.<br />
On the positive side, the 12th Plan does envisage a convergence<br />
of health and childcare services; but it is aimed at the lower<br />
levels of health and nutrition services, ie the anganwadi centre<br />
and sub-centre. In operational terms it will amount to having one<br />
ARTICLES<br />
1. 12th Five year Plan and the Health<br />
Accredited Social Health Activist (ASHA) positioned at every<br />
anganwadi centre (AWC), who will connect the AWC to the<br />
Auxiliary Nurse Midwife (ANM) at the sub-centre. The idea to<br />
have a sub-centre in every panchayat does not appear to be<br />
offering anything new as a sub-centre is anyway supposed to<br />
exist for every 5,000 population in the plains and for every 3,000<br />
population in the tribal and hilly areas, which works out to one<br />
for every panchayat already.<br />
The paper also promises to set up sub-centres and Integrated<br />
Child Development Services (ICDS) centres in all slums to provide<br />
primary healthcare to the urban poor, which is lacking at present.<br />
This step is welcome, but the provision of primary healthcare in<br />
urban areas requires a broader urban primary healthcare system<br />
and not just sub-centres and ICDS centres.<br />
The Approach Paper promises to make healthcare delivery more<br />
consultative and inclusive of the community by increasing users’<br />
participation through institutionalised audits, again a welcome<br />
move. But we should not forget that the community monitoring<br />
exercise under NRHM in the 11th Plan was carried out only in a<br />
few areas with strong civil society presence.<br />
A reduction of regional disparities in maternal and child health,<br />
in particular in the 264 high-focus districts, is also a programme<br />
focus already. The offer to provide funds for upgradation of<br />
primary healthcare centres (PHCs) and community healthcare<br />
centres (CHCs) to IPHS norms is also an already existing<br />
commitment of the government.<br />
The Approach Paper also mentions making district hospitals<br />
district knowledge centres for training health workers like nurses,<br />
mid-level health workers and offering courses like Bachelor of<br />
Rural Healthcare/Primary Practice. This would help provide a<br />
cadre of qualified health professionals to attend to a defined set<br />
of basic healthcare services. This is one way to get qualified<br />
practitioners in allopathy to reach India’s remote rural areas.<br />
Several examples of NGOs providing community healthcare using<br />
trained rural health workers have shown the effectiveness of<br />
such an approach.<br />
It should be implemented across the spectrum for all levels of<br />
health functionaries including medical professionals and applied<br />
to men from these communities also.<br />
In terms of financing healthcare, the paper acknowledges the<br />
high out-of-pocket health expenses of Indians and offers a twopronged<br />
approach of expanding public provisioning of<br />
healthcare and public financing of care using the private sector,<br />
but subject to appropriate regulations and oversight. Once the<br />
government becomes a buyer of a set of services from the private<br />
sector it will be in a commanding position to ensure that the<br />
private sector functions according to state regulations.<br />
In addition to expanding public provisioning and bringing publicly<br />
financed private players under a regulatory regime, the paper<br />
also envisages establishing a health insurance plan for every<br />
citizen. The details in this regard are likely to emerge from the<br />
report of the HLEG which is due in November.<br />
NUTRITION<br />
The need to restructure the ICDS focusing on the 0-3 age-group,<br />
promoting decentralisation of administration, ensuring quality,<br />
participation of women’s/mother’s groups and strengthening<br />
convergence with related schemes is clearly articulated in the<br />
paper, though the roadmap is not spelt out. The paper states that<br />
the recommendations of the inter-ministerial working group on<br />
ICDS constituted under the PM’s Nutrition Council are awaited.<br />
A shift towards family- and community-based interventions such<br />
as breastfeeding is also mentioned. In this regard a national<br />
campaign on universal breastfeeding linked to a programme for<br />
wider and enhanced provision of nutrition to breastfeeding<br />
mothers, should be taken up on a scale comparable to the<br />
erstwhile family planning programme, as this intervention is<br />
crucial for the survival of 0-6-month- old children.<br />
CONCLUSION<br />
The paper points out that India’s labour force will increase by<br />
32% in the next two decades, while that of industrialised countries<br />
and China will decline by 4% and 5% respectively and that<br />
therefore we should reap the benefits of this demographic<br />
dividend. This would however demand that we ensure the health,<br />
nutrition and education of children who will form the labour force<br />
The paper’s emphasis on local production of drugs is a very for the coming decades. On the contrary we find that the Infant<br />
important measure as public sector drug companies have not Mortality Rate, a key indicator of health status, is at 50/1,000 live<br />
been given encouragement for several years. Drug self- births according to Sample Registration Survey (SRS) 2009,<br />
sufficiency is important in the context of the IPR regime and a published in early-2011 and is still higher at 70 and 66<br />
declining public sector in this field, coupled with the fact that respectively in UP and MP according to the recent Annual Health<br />
several Indian private sector giants have been taken over by Survey (AHS) 2010-11. The AHS was conducted in the nine states<br />
foreign multinationals.<br />
of Rajasthan, Uttar Pradesh, Uttarakhand, Bihar, Jharkhand,<br />
Orissa, Madhya Pradesh, Chhattisgarh and Assam. These states<br />
The paper also deals with training and hiring women from alone account for 70% of infant deaths, 75% of under-5 deaths<br />
marginalised communities in the healthcare workforce. But this and 62% of maternal deaths in India, which demand urgent<br />
approach should not be only for ASHAs, ANMs and AWWs. attention. �<br />
2. Euro Zone Crisis Clouds Recovery in Europe & Central Asia<br />
Economic recovery is underway in the Emerging Europe and<br />
Central Asia (ECA) region, but at a slow pace and is at risk from<br />
the troubled Eurozone, according to the World Bank at a press<br />
briefing during the World Bank/IMF Annual Meetings 2011.<br />
“Most countries in Emerging Europe and Central Asia have<br />
recovered from the global economic crisis, but growth has<br />
returned at lower rates than pre-crisis trends in most of the<br />
region. The region is expected to record a real growth rate of 4.3<br />
percent in 2011, which is one of the lowest of any developing<br />
region,” said Philippe Le Houérou, World Bank Vice President<br />
for the Europe and Central Asia Region. ”The slow recovery in<br />
the region may be establishing a ‘new normal’ of lower economic<br />
growth rates in many of the region’s countries.”<br />
Le Houérou cautioned, ”The sovereign debt problems in<br />
Western Europe pose challenges to the sustainability of this<br />
relatively tepid recovery. The Eastern Europe and Central Asia<br />
region is especially dependent on Western Europe as an export<br />
market and a source of finance and migrant remittances, so slower<br />
growth in the West will hurt. The region’s strong financial<br />
linkages to Western Europe, which were a source of growth during<br />
the boom years in Central and Eastern Europe, are now a source<br />
of vulnerability for some countries.”<br />
According to the briefing, most countries in the region have<br />
recovered the output losses suffered during the 2008-9 global<br />
economic crisis. In fact, GDP remains below its 2007 level in<br />
only eight out of 30 ECA countries. Helped by high commodity<br />
prices, the countries farther to the east in the region have done<br />
much better since the crisis than those to the west.<br />
But ECA’s recovery signals a lower growth gradient than the<br />
pre-crisis rates. There has been a noticeable reduction in growth<br />
prospects: countries in the region may need to prepare for growth<br />
rates that are 2 percentage points of GDP less than what they<br />
were before the global crisis.<br />
Job losses remain a concern throughout the region<br />
Unemployment increased significantly during the crisis ¯ in 2008<br />
it was about 10 percent, while as of about early 2011, the overall<br />
unemployment rate for the region is at 13 percent. Meanwhile,<br />
youth unemployment remains a particular concern at 27 percent.<br />
To address this, governments have been trying to limit the effects<br />
of the crisis on labor markets through a wide range of employment<br />
programs. Some jobs are returning and unemployment has<br />
dropped since the early 2010 peak, with only a few exceptions<br />
(Bulgaria, Croatia, Slovenia, Moldova, and Hungary). But the<br />
job turnaround will remain gradual even if the economic recovery<br />
is sustained. Increases in output per worker are driven by<br />
increases in hours worked, but these are still below their precrisis<br />
levels. Therefore, the room for further increases in<br />
productivity and hours worked could delay the recovery in<br />
employment.<br />
Public finances have weakened, especially in the west<br />
The global crisis has had a severe negative impact on public<br />
finances. During pre-crisis times, structural fiscal imbalances were<br />
masked by revenue over-performance, as buoyant economies<br />
yielded more taxes than governments often expected. During<br />
the crisis, there was sharp fiscal deterioration in most countries<br />
in the region. Public debt has gone up in many countries, leaving<br />
governments less room to counter any economic slowdown than<br />
they had in 2007.<br />
Fiscal adjustment has often been in the form of ad hoc expenditure<br />
cuts. The immediate challenge in many countries is to begin<br />
more systematic fiscal consolidations that are socially sustainable<br />
and growth-friendly. Most countries in the region have to<br />
prepare for aging populations, which are adding to the fiscal<br />
pressures in health care and pension expenditures even as the<br />
economic turbulence over the last three years has left<br />
governments deeper in debt.<br />
Banking flows have been stable in the west but have<br />
fallen in the east<br />
According the briefing, financial flows have been stable in<br />
Central and Southeastern Europe, but have not been<br />
growing. Western European banks have so far maintained<br />
operations in the member and candidate countries of the European<br />
Union. In the countries further to the east, including oil and<br />
commodity exporters, there have been pullbacks, with the<br />
developments in these economies mimicking those in East Asia<br />
during the 1997-98 crisis.<br />
The decline in credit to firms and households from pre-crisis<br />
levels was sharp, but necessary in some countries. While credit<br />
has been slow to recover, there are encouraging signs in most<br />
countries in the region. Only five countries in the region are still<br />
experiencing contractions in credit.<br />
Risks are rising again<br />
The main risk is that of spillovers from the sovereign debt crisis<br />
in some of the Euro area economies. The rescue packages have<br />
not assured markets, and uncertainty has spread to larger<br />
economies. The sovereign debt problems in southern Europe<br />
and Ireland can affect the region in both direct and indirect ways,<br />
operating through both financial and nonfinancial transmission<br />
channels.<br />
Given the importance of Greek banks in the Balkans and Italian<br />
banks in Central Europe, any problems they have would have<br />
direct effects in those countries. Some of the banks most active<br />
in emerging Europe ¯ especially those based in Austria and<br />
Sweden ¯ have limited exposure in Greece, Italy, Ireland, Portugal,<br />
and Spain, but interconnectedness on funding markets could<br />
result in adverse consequences.<br />
Western European countries are the most important trade partners<br />
for most countries in the region, and weaker economic prospects<br />
in Europe will dampen their recovery. There are already signs of<br />
declines in export demand. Export levels in 2011 were expected<br />
to be above those reached in 2008, but recovery of exports has<br />
so far been sluggish. Now a slowdown in global activity has<br />
increased the downside risks, most sharply for countries with<br />
close economic linkages with the Eurozone.<br />
According to Indermit Gill, World Bank Chief Economist for<br />
the Europe and Central Asia Region, ”Governments in Emerging<br />
Europe have to again become fiscally resilient. Public debt<br />
buffers have shrunk in most of the region. With the sovereign<br />
debt crisis in advanced economies, markets are paying more<br />
attention to fiscal vulnerabilities. They have to do this now, both<br />
to prepare for a possible economic slowdown and to deal with<br />
the rising fiscal burden of pensions and healthcare of aging<br />
populations. Much of the region needs to make transparent plans<br />
for reforming public expenditures, and begin implementing them<br />
soon.”<br />
Gill emphasized that, “The most pressing problem facing many<br />
countries is persistently pervasive joblessness. The private<br />
sector has to be freed to generate economic growth and jobs ¯ the<br />
rules and regulatory structures for doing business can be greatly<br />
improved with no additional expense for taxpayers. With almost<br />
a third of all young adults out of work, governments in the region<br />
should put the modernization of labor market regulations and<br />
social welfare systems at the top of their reform agenda. Such<br />
structural reforms to increase entrepreneurship and inclusion<br />
are simultaneously an immediate, medium-term, and long-run<br />
priority.”<br />
The World Bank is supporting the recovery<br />
World Bank support reached $6.1 billion this fiscal year, including<br />
$5.5 billion from the International Bank for Reconstruction and<br />
Development (IBRD) and $650 million from the International<br />
Development Association (IDA). Turkey ($1.4 billion), Romania<br />
($1.1 billion), and Poland ($1.1 billion) were the largest borrowers.<br />
The sectors receiving the most funding were energy and mining<br />
($1.9 billion), public administration ($1.7 billion), and health and<br />
social services ($1.2 billion).<br />
Along with funding, the Bank provides over 180 economic and<br />
technical reports every year in the Emerging Europe and Central<br />
Asia region to inform government reform efforts and prioritize its<br />
own financial support. It offers analytical support and<br />
encouragement to governments to improve labor market and<br />
social security systems and expand selected social safety net<br />
programs. The Bank is advising governments on how to fix less<br />
efficient public programs and improve social services so that<br />
their benefits reach those who need them most. �<br />
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