Title : Further discussion on the motion for consideration of the Constitution (Amendment) Bill, 2004 (Insertion of new article 47A) moved by Suravaram Sudhakar Reddy on 12th August, 2005. (Bill with drawn).
MR. DEPUTY-SPEAKER: The House shall now take up Item No.32. Shri Hansraj G. Ahir to continue. He is not present.
The hon. Minister of Health to reply now.
THE MINISTER OF HEALTH AND FAMILY WELFARE (DR. ANBUMANI RAMADOSS): Thank you, Sir, for giving me an opportunity to reply to the Private Member’s Bill moved by hon. Member, Shri Suvaram Sudhakar Reddy. I would like to say that I have been literally waiting for six to seven months to reply to this.
I would like to thank the hon. Member first for putting up this very important issue to the House. I have heard the views of the entire spectrum of this august House. It was unanimous that the services in the rural areas need to be upgraded. I would like to share my concern with them and I also accept the feelings, the emotions of the entire House on this issue.
Sir, we have come a long way, 58 years after Independence and 73 per cent of our population lives in rural areas and villages; like the Father of our nation, Mahatma Gandhi said India lives in villages, rightly Sir. But all these years, have we provided the right infrastructure in the health sector? Frankly speaking, we need to do a lot more. Our aim, our goal, our mission, the UPA Government’s mission, even though it may be far fetched, is to provide health care facilities to everyone. As the hon. President of India has said that ‘equal health care facilities should go out to rural areas, to the people who live in the villages, to the last person living in the last village. On those lines, we are charting out a huge programme to fill up this gap in the rural areas in the health care sector.
Sir, we have been having a national Health Policy 2000 and a National Population Policy 2001 on which we are putting up this huge infrastructure down these years in the villages, in the rural areas.
Today, we have approximately 145,000 sub-centres and each sub-centre caters to a population of about 3,000 in the hill areas and 5,000 in the plain areas. We have approximately 23,000 primary health centres, which catre to a population of about 20,000 in the hill areas and 40,000 in the plain areas. We have approximately 3,222 community health centres which cater to a population of about 80,000 in the hill areas and 120,000 in the plain areas. Adding to this, we have an entire spectrum of colleges. We have approximately 242 medical colleges in this country. But unfortunately, out of 242 medical colleges, 152 are only in six States, almost the Southern States, including Maharashtra and Gujarat. So, we have a lot of need there in the rural areas and all this infrastructure, all these years has been only about 18 per cent to 20 per cent.
It is very unfortunate and I accept and I concur to the entire House that we need more facilities, more infrastructure. When we say that, the entire gamut of sub-centres, primary health centres, community health centres and all these figures put together comprises of only 20 per cent of the public health infrastructure in the country. We definitely need more. That is why, the UPA Government, under our hon. Prime Minister, Dr. Manmohan Singh, has promised that. Madam Sonia Gandhi, through the Common Minimum Programme of UPA has also said that.
Today’s meagre investment in the public health infrastructure is only 0.9 per cent of the total GDP. We have promised that we will increase it to minimum two per cent in the next three to four years. Rightly so, we are trying to do our best and in fact, we have an unprecedented 32 per cent increase in the health budget over the last year’s health budget. We are going on those lines.
But then, again coming back to the issue of rural areas where there is not much facilities today and rightly so I will be replying individually to what the hon. Members have said. I would like to again say that today the second highest cause of concern is spending on health. The highest cause is spending on agriculture. So, we are in the knowledge of things. But since it is nearly 20 months that we have taken over, we are trying to do our best. A very big programme, in fact, I would like to say that the biggest programme, in the health sector in the post-Independence period, is National Rural Health Mission, which again I will be coming to when I come to other parts of the reply[r30] .
In fact, in the National Rural Health Mission (NRHM) we are concentrating on the North-East where it has been neglected all these years. In fact, I have been a very frequent visitor to the North-Eastern areas. I see very loving people there where there are not much facilities. That is why we are trying to provide more and concentrate more on the North-East where there are a lot of people who require lot of infrastructural facilities and they have to come all the way. Some of them go to Chennai, some go to Calcutta, some go to Mumbai and some go to Hyderabad for treatment. So we said that not even one individual there in the North-East should move out of the North-East for treatment. Everything we will be providing completely to the North-East. We are concentrating on those lines also.
Of course, now we have our own system called the Indian system of medicine. We have Ayurveda, we have Siddha and we have Yoga. In fact, we have Unani and the traditional system of Homeopathy. So, we are trying to use this system, the cost-effective system, which has been followed for centuries, literally since time immemorial. The system of Siddha is as old as Tamil language. So, we are trying to take the system and put it into the mainstream. We are trying to incorporate both the Indian system as well as the modern system whereby some hospitals and some doctors will be there in the Primary Health Centres and we are trying to provide medicines.
We are also trying to have the second Programe of the RPH that is Reproductive Health Programme (RPH) Part II. In fact, we are trying to literally spend approximately Rs. 40 crore in the next five years only on this Programme and this comes under the National Rural Health Mission which I will be explaining. Once again, I would like to share the concerns of all the Members and individually I will try to go into the queries put up by the hon. Members. In fact, once again, I would like to thank Shri S. Sudhakar Reddy for having brought out this Constitution (Amendment) Bill. He has queried about the budget not there for the Common Minimum Programme. Budget is not a constraint. Our Prime Minister has promised me in health sector that we have a commitment of increasing it from 0.9 per cent to a minimum of 2 per cent. Budget is not a constraint at all. The only problem is that ‘Health’ is a State Subject. We do the policies, the implementation is there by the State Governments. Some States do well and some States do not. We all know that. We know which are the States which are doing well and we also know which are the States which are not doing well all these years. That is why, budget is not a problem, it is only the absorption capacity and the functioning. We give a quantum of money to the States, but then we do not get the utilisation certificate. So, there are a lot of problems with that and there are a lot of administrative problems in some States which we are trying to rectify. I am going personally to all the States coming under the National Rural Health Mission; I am talking with the Chief Ministers and coordinating with the officers. In fact, I had visited Bihar two days ago just to meet the Chief Minister. I was there only for two hours. I met the Chief Minister, discussed the health issues and said that we are going to provide them what they wanted. That is why we are trying to go there and have a lot of things done in the health sector.
Of course, my good friend, Shri S. Sudhakar Reddy said that we need more infrastructure. Government can build infrastructure. That is not a problem. But, then where is the manpower? Who mans it? Where are the technical personnel? Where are the doctors? Where are the nurses? Where is the para-medical staff? We need to train them. We need more of them. India has been producing quite some of them but that is not enough. It is not enough to build infrastructure.
My good friend says that each village should have one Primary Health Centre. To maintain, to build up Primary Health Centre, it costs anywhere between Rs. 25 lakh and Rs. 50 lakh, and to maintain it for one year, it costs anywhere between Rs. 13 lakh and Rs. 15 lakh. I do not think building one Primary Health Centre in each and every village – we have literally six lakh villages in the country – is a rational approach. Logically also, I do not think we could have built up Primary Health Centres in every village. The thing that we are trying to do is firstly to improve the existing facilities, improve and modernise the existing Primary Health Centres, have blood storage capacity, make some of these Primary Health Centres run for 24 hours, and make some of them First referral (FR) units. That is what we are trying to do in the National Rural Health Mission.
I would like to elaborate some more points about the National Rural Health Mission. This is a very big programe which, as I said, was inaugurated by the hon. Prime Minister on 12th April last year. The entire country comes under the gamut of this National Rural Health Programme. We are trying to focus on 18 States which have very low infrastructure and which have low parameters on health indices like the highest infant mortality, highest maternal mortality, high population, highest crude death rate, highest disease burden and all these issues. So, we have taken 18 States of the lowest strata and we have identified them. We are focussing more on these States.[r31]
These States are UP, Bihar, Madhya Pradesh, Rajasthan, Orissa, three newly formed States – Uttaranchal, Jharkhand and Chhatisgarh, the entire North Eastern States, Jammu & Kashmir and Himachal Pradesh. In fact, in the first phase we are putting out ASHA called Accredited Social Health Activist. Every single village with a population of 500 or 1,000 will be given ASHA. ASHA will be selected for each village. ASHA will live in that village. So, ASHA cannot work in any other village. So, ASHA has to compulsorily live in that village. We are giving training to ASHA for a period ranging from 28 days to one year. The training comprises courses like immunization. In the morning ASHA gets up and see how many children are there in that village and she has to know all the children by heart and immunize the children according the date schedule. Every woman will be screened. Every pregnant woman will be taken for anti-natal check up. Every pregnant woman will be compulsorily taken for institutional delivery. That is the mandate of ASHA. That is one of the most important works. We are giving her some corpus money for her emergency travel. So, she will be taking the pregnant woman to the nearest recognized centre to conduct a delivery. That centre could even be a private hospital. So, we are not differentiating between a private hospital and a public hospital. We are going to pay money through Janani Suraksha Yojana. It is a new programme, which we have put out through the Government of India. Of course, ASHA’s other work is post-natal check up. She has to take any eligible couple for sterilization. We are trying to make it more accessible. Not one individual is going to be coerced in any of these procedures. In fact, ASHA will be given condoms to keep with her. ASHA will be trained in such a way that she will guide the village women to build household latrine in every house. We are going to give money through the Ministry of Rural Development. ASHA will be trained and also she will be given medicines so that she can treat patients with common ailments like headache or diarrhoea or vomiting. Earlier there were no medicines in the village and everybody had to go to a sub-centre, which is eight or 10 kilometres away. Now, ASHA will be living in the village, she will trained and will be given medicines to treat common ailments. I am sure, a lot of problems of the village people could be solved now. For each Centre we will be giving Rs. 10,000 as corpus money every year to replenish their resources, to upgrade their facilities and to have all the essential medicines that they want or any other commodity which the village wants. ASHA will be selected by village headman, Anganwadi worker and Self-Help Group. They come together and select ASHA. ASHA is not going to be paid money as a salary. She is going to be paid money according to the work she does. If she does immunization, she is going to be paid certain money; if she does anti-natal check up, she is going to be paid certain money; and for conducting a delivery, some quantum of money is going to be given to her. That is why, the more work she does the more money she is going to be paid.
As regards the Sub-centres, they are going to be provided with medicines. We are going to modernize the Primary Health Centres. We are going to upgrade them. We are going to spend a lot of money for modernizing the existing facilities first in all these Primary Health Centres and then we will be going on to take up newer facilities as an when they are necessary. Today we have a lot of problems with regard to the existing facilities. Some of them are dilapidated. There is no water, there is no power, there is no electricity, there are no quarters, and there are no medicines. Nothing is there. So, we are trying to first improve the existing infrastructure and then we will be going in for providing the new infrastructure.
Coming to the Community Health Centres, Block Hospitals and Taluk Headquarters Hospitals, we are trying to upgrade them. Every year we are trying to upgrade two Community Health Centres in one district. We are going to spend anywhere between ten lakhs of rupees and one crore of rupees depending on the requirement. We are modernizing the operation theatres in all these Community Health Centres. Modern labour rooms are going to be put up in all these Community Health Centres. Blood storage capacity has to be provided. Ultra sound machines are going to be provided. We are going to build quarters in each Community Health Centre whereby the doctors, nurses and employees could stay so that they need not move out of the campus and we have a holistic health care. We try to follow the Indian public health standard whereby there will be an anesthetist, a gynecologist and a surgeon in these Centres. We are trying to increase the number of pediatrician and also see that all other specialists come under one umbrella. We are also giving a medical mobile unit in each district initially. In each block we want to have a medical mobile unit and in due course of time we will be giving it. Initially we are trying to provide this in each district.
So, we will try to take the patient to the Community Health Centre which we are trying to refurbish and modernize so that it can have all the facilities[lh32] .
That is our aim and we are trying to do it at that point of time.
As I said, we are trying to integrate the Indian system of medicine as well as the modern system. We have doctors prevalent in both the systems, and on these lines, each district is going to have a District Health Society chaired by the Collector, and, of course, co-chaired by the District Chairman, the Panchayat representative because in our entire gamut of network, the PR, Panchayati Raj representative will be an essential part of that. They will plan what they want for the village or for their town or for their region. It is not like we are going to plan for them. They will plan for us. There is going to be a Village Health Society and a District Health Society. They will plan and send it to us and we will put the money.
Also, we are going to have Chartered Accountants in each district. They are going to monitor the programme, implement the programme and, of course, try to guide the entire network as to how the programme could be implemented. They will act both the ways. They will be informing us as well as guiding them.
At the State level also, the State Steering Mission will be chaired by the hon. Chief Minister and the Health Minister will be part of the Mission. At the Central level, the Health Minister is chairing this Mission. We are having a lot of Steering Mission meetings. A lot of discussions are going on. For this programme, the National Rural Health Mission, you give me a little more time because it has taken 10 months to conceptualise. Day and night we are working out. We have our officers. Earlier we had a lot of health programmes but I do not see much success in these programmes. I will definitely say that it will take one-and-a-half years just to implement this programme. I am not promising you that the heaven and earth results are going to come in the next one or two years. For me, it will take one-and-a-half years just to implement this programme.
In the next three years we are going to see some results trickling in. In the next five years, we are going to have a lot of results. In the next seven years, I could see that all the infant mortality coming down dramatically. Maternal mortality will come down. There will be population stabilisation and other improvements because this programme is not only a health programme but this is also going to be a holistic programme of health, sanitation, drinking water and nutrition. So, all the Ministries are involved, namely the Panchayati Raj Ministry, the Ministry of Rural Development and the Ministry of Water Resources. All are involved in this programme which we are trying to do.
Today, out of 250,000 ASHAs to be envisaged in 250,000 villages in 18 States, literally about 110,000 ASHAs are being put into place. We have been giving the training module and we are going all out to train them. Training is the most essential part of it. We are going on those lines.
Coming back to his query about the problems of HIV, I would like to say this.
MR. DEPUTY-SPEAKER: Has Punjab also been included in those 18 States?
DR. ANBUMANI RAMADOSS: Punjab will be included in the next phase because we are taking the States which have a lower parameter. This NRHM comprises the entire country. But more focus is on 18 States. The entire country is going to come in the network. We are going to modernize the PHCs. We are going to modernize the CHCs in all the States but then focus is on these 18 States because these States represent 60 per cent of India’s population but if you see the infant mortality and maternal mortality they are very, very backward in health statistics.
Of course, I would very proudly say that yesterday we had the first meeting of the National Council on HIV/AIDS. I would proudly say that India is the first country in the world where the Prime Minister chairs the National Council on HIV/AIDS. No other country in the world does it. India does it.
Also, another issue is that in this Council, all my Cabinet colleagues are members. We have about four to five Chief Ministers who are members. The Health Ministers are also members of this Council. We have civil societies and NGOs. We have a whole gamut of network, and a lot of people are there as members in that. We had the first meeting. We had sorted out a lot of issues. We are trying our very best to eradicate this huge menace of HIV/AIDS in this country and we are taking it very seriously. We are concentrating more on prevention. Regarding caring support, in fact, we are trying to support 100,000 people free of cost through minimum 100 hospitals. But today we are doing about 26,000 people. We are supporting them but there is no limit. If there are more people, then they will be involved in to the system of treating them.
Coming back to malaria in Andhra Pradesh, it has been very rampant. The hon. Member is from Andhra Pradesh. In fact, there are seven tribal districts. There have been a lot of issues in these districts. They are mostly tribal districts of Andhra Pradesh. I have asked my officers to go there and co-ordinate. In fact, the Government of Andhra Pradesh have been doing well in supplying and giving mosquito nets or spraying insecticides, and they are taking care of the treatment course. When they get malaria, they are trying to take care of this[m33] .
16.00 hrs.
Another issue he has raised is about heart diseases. I would concur with him. This morning we had a conference in the All India Institute of Medical Sciences. There, the WHO representative had come from Geneva and he was also saying that India is going to face a huge problem in the next 40 to 50 years in cardio-vascular diseases, diabetes and strokes and we are trying to chalk out the entire future on these programmes.
Today, we are moving from a phase of communicable diseases to a phase of non-communicable diseases like in the case of tuberculosis, it is coming down and likewise in the case of leprosy. We have eliminated leprosy. We have not eradicated it but we have eliminated it and these sorts of things are coming down.
On the other side, India has become a diabetic capital of the world. Cardio-vascular disease problems are there. In the coming financial year, we are having a new programme called `the Integrated Programme on Diabetes Cardio-vascular Diseases and Strokes.’ There, we are trying to have a massive awareness programme, massive awareness campaign amongst the different strata of the society especially in the rural areas. There is going to be screening campaign as to how we could prevent the lifestyles. Today we are in the age of globalisation, junk food and sedentary life styles. There is no mobility. People sit in front of TV and see mega serials literally the whole day. So, there are a lot of issues in that. We are trying to educate people in that.
Coming back to what the hon. Member, Shri K. S. Rao, has said about the health care insurance, `yes’, it is a good suggestion. Today, the State and the Central Governments are spending on health. This is just one-third of what the individuals spend. Putting the State and the Central Government together, the quantum of money which the State and the Central Government spends, what the individuals spend is to be seen collectively. All the individuals in India spend about two-thirds of what the Government spends. So, the only way is health insurance. That is the only way where we could avoid health-spending by individuals and we are trying to have a very comprehensive programme on health insurance. We have had programmes earlier. … (Interruptions)
SHRI VIJAYENDRA PAL SINGH (BHILWARA): Is Baba Ram Dev also helping you out in this cause? … (Interruptions)
DR. ANBUMANI RAMADOSS: Can I finish? Why do you want to interrupt me? I am talking on health insurance. Can I finish on health insurance? This is a very important topic. Why do you want to go to Baba Ram Dev issue now? … (Interruptions)
Health insurance is the only way. In fact, we are trying to have a comprehensive health policy. We have had health insurance schemes earlier. But these were not successful. I also acknowledge that. Even the Government has the universal health insurance policy where we are trying to induct about one million people who are below the poverty line. But I do not see the programme going. There is the point of reimbursement. I do not see a poor man spending money during emergency and getting his reimbursement. So, all these issues we are trying to sort out and we are trying to have a comprehensive policy, having a private-public participation in both the insurance sectors and insurance providing and health care providing also. Of course, there are two sectors– organised and unorganised sectors in the health insurance which we are trying to do.
Of course, my good friend, Shri K. S. Rao, has said also of use of Ayurveda and Siddha. I have already mentioned that we are trying to integrate because this is our own system, founded by our forefathers. It is our duty to propagate this system and this system is not only propagated in India but also worldwide.
Sir, in the last year and a half, literally, about six to seven Ministers of different countries had met me personally, coming here in India. They said that they want to propagate it in their own country, right from Chily to Hungary to South Africa. We have been getting a lot of queries and we are trying to do it within our own country first and then we are trying to do it worldwide. We are also having a lot of issues on this.
Another issue which was raised was about the Diploma of Medicine. They call them barefoot doctors. In the early 60s, there was a concept of barefoot doctors. They were doing short training in medicine and they were asked to go to the villages and take care. Then, they have become full-fledged so-called `quake’ doctors in the later half. So, we had a huge issue on that. We do not recognise this system at all. Of course, on the condition of MBBS doctors for rural posting, we are trying to bring in a comprehensive policy. We are going to make it mandatory for Internship for medical students who have finished their House Surgeon course, that they will mandatarily work for one year in the rural areas after finishing their Internship. That is what we are trying to bring in and after that compulsory one-year rural posting, he will be given his permanent registration so that he could go out and practise.
The hon. Member had asked about the incentives for nursing homes in rural areas. We are trying for it. In fact, the hon. Minister of Finance last year had announced that for anybody having a 100-bedded hospital in rural areas, there will be some tax exemption and there will be a lot of sops in the taxation network[R34] also .
16.05 hrs. (Shri Varkala Radhakrishnan in the Chair[krr35] )
Hon. Member Shri Bachi Singh Rawat raised an issue about the problems of posts. He said machines are there in the hospitals. Rightly, in some hospitals there are machines, there are beds; but there are no posts. We need to do more of this. In fact, I depend on the State Governments. We try to request them, we try to cajole them, I go there and I talk to them and that is the only thing I could do with the State Governments. Some are responding well and some are not. Again, I cannot penalise the States which do not respond because if I penalise them, by not giving any funds etc. it will be more worse. So, the only way for me is to ask them and request them to put up more workers. In fact, for the Auxiliary Nurse Midwives, ANMs, in the sub-centres the Central Government is paying their salaries. We are trying to do a lot more on these issues.
Of course, there was this issue about mobile health centres. Through the Rural Health Mission we are trying to have one mobile medical unit in each district in the first phase which will go around the entire area. In fact, he has queried about encouraging herbal cultivation. It is a very valid point. We are trying to do it. We have a National Medicinal Plant Board established. India has got a very right tropical climatic conditions and good environment to cultivate these medicinal plants. My experts say that in the next 40 years these medicinal plants will be a trillion dollar industry and all our farmers could take it up. There is no need of much water or pesticide and, in fact, we are trying to propagate it. In fact, today evening at 5.30 p.m. we have a discussion with the Minister of State for Commerce at my office only on this issue of how we could still propagate it and have more zones etc.
Shri Ramji Lal Suman mentioned about doctor-patient ratio and asked are there enough doctors in this country. No, sir. They are not enough. We have both the Indian system and the modern system doctors. In the Indian system doctors, we have approximately 7,00,000 doctors and in the modern system we have about 6,90,000 doctors. These doctors put together, the doctor-patient ratio comes to about 700 people per one doctor. But then if you take only the modern system, it comes to about 1,700. We need more doctors. Unfortunately, these medical colleges are concentrated only in most of the Southern States. I have been asking the State Governments to start more medical colleges. When I went to Bihar I asked the Chief Minister to start ten more colleges. We need more colleges in the Government sector and not exactly in the private sector. The Government should invest more money and produce more doctors; and not only doctors but nurses also. They have to start the nursing schools also and along with that, schools for paramedicals also. That is what we are trying to do.
Of course, population is one of the biggest problems for this. I could say that this is one of the very important problems for us. We have to stabilise the population. We are trying to do it without any coercion or forcing anybody to do anything; but we are trying to do it through the NRHM also.
On the point of spending by the State Government, earlier, as I said, ten years ago, the State Governments were literally spending about 7.5 to 8 per cent of their total budget on health. But now it has come down to just 5.5 per cent on an average and some States just spend three per cent of their total budget on health. We are trying to ask them to increase its spending. I have been talking to the Planning Commission also to ask and request the States to spend more.
Hon. Member Shri Mahtab was mentioning about the issues in Orissa. Orissa has pretty bad figures in the health sector. I could say Orissa could be compared with Bihar. The crude birth rate, crude death rate and the infant mortality is very high in that region. We need to do more. Through NRHM, I am sure, we are going to do it.
He was asking that like the Sarva Shiksha Abhiyan can we have a Sarva Swasthya Abhiyan. It is a good suggestion. I have suggested this to the hon. Minister of Finance. I hope he takes the suggestion and gives us the two per cent health cess and we can call it whatever he wants later on.
He was querying about Medical Council of India and Orissa medical colleges. We have been having lot of issues. Only in Orissa State, earlier if I am not wrong, there were 600 medical seats. But today, I think, there are only 350 seats[krr36] .
So, it has come down in Orissa because the infrastructure and the doctors are not there. When the Council go and inspect, they have to have certain parameters. So, they have reduced it for them. We are trying to help them out and we are trying our best to see that the Government sector gets more seats in that because Orissa is a State which requires badly a lot of doctors, a lot of infrastructure and a lot of inputs into the health system.
SHRI BRAJA KISHORE TRIPATHY (PURI): All are Government colleges.
DR. ANBUMANI RAMADOSS: Yes, they are all Government colleges. That is why, I am trying to help the Government. Last year, they wanted to close one more college, but I said ‘No. Nothing doing.’ When I visited there, I talked to the Chief Minister and told him to employ more doctors and more paramedics, nurses etc. For these things, we are co-ordinating and trying to help them out.
Another issue of brain drain was put up. In fact, after taking over, I had put up a Committee under the Chairmanship of former Health Secretary, Mr. Ranjit Roy Chaudhary, and they have given the recommendations just ten days ago on how we could prevent brain drain because lot of doctors and specialists leave the country and go to greener pastures like UK and USA. We want to stop them going and we are trying to do it.
Shri Appadurai was raising issues in Tamil. Can I reply in my mother tongue because he said it in Tamil? I want to reply in Tamil. … (Interruptions)
SHRI BRAJA KISHORE TRIPATHY : You can do so if we get interpretation.
DR. ANBUMANI RAMADOSS : I have not informed about interpretation. Okay, he is not there.
He was generally querying about sub-centres and primary health centres. His general query was about lack of attention in the rural areas. Of course, we are trying to do it under NRHM.
Shri Jai Prakash said that the norms about doctors should comprise of work in rural areas, which I have already answered. We are trying to bring in a legislation whereby they have to have one-year compulsory posting in rural areas. Of course, Government is not employing health workers. We have abundant amount of health workers in this country. We have about 1.2 million health workers in this country doing lot of health activities from immunisation to DOTS providers like TB medicines, and going house to house surveying people. There are lot of issues and we are trying to look into them. All these years, the training module was not good. So, now we are concentrating on what is the quantum of training, what is the quality of training, the module that we need to do. In America, you could see that a nurse is an 80 per cent doctor. After a patient comes and stabilises, then a nurse can take care of him, but here, they do not and they cannot. That is why, we need to increase our training modules and increase our curriculum.
Then, Shri Jai Prakash has said that the health workers are not living in villages. Absolutely, and that is why, in NRHM, we have said that ASHA has to live in a village and she cannot live in any other village. The first criterion for her selection is that she has to live in that specific village and she cannot move out of the village.
Then, the issue of adulteration and spurious drugs was raised, which time and again I have addressed in this august House and told what steps the Government is taking. We are trying to bring in a very stringent legislation which is with the Standing Committee on Health.
Of course, Shri Hanumanthappa had said about infant mortality and MMR. Today India has about 60 per thousand live births of infant mortality and approximately 400 per thousand live births of maternal mortality, which is definitely on the higher side and we are definitely trying to take steps to reduce it. That is why, in NRHM, we have brought out saying that the main three rates – IMR, MMR and TFR – will be brought down after this NRHM is fully implemented and goes through the entire gamut of seven years.
He raised another issue of diploma in health and medicine. You cannot have a diploma in medicine. That is literally like a barefoot doctor after a three-year course. Some States like Assam and Chhattisgarh have a three-year medicine course, but the Central Government is not going to recognise these courses. We have a national pattern and these persons, who are doing these courses in Chhattisgarh and Assam, could work only in those States because the State Government recognises it. We do not have any problem on that. If some States want to have, they can go ahead and have it provided that they will not be recognised nationally. Any of these people cannot join post-graduate national-oriented courses also.
Shri Karunakara Reddy from Bellary said about no information available about NRHM. I would say that we have all the information on the website and I would even personally give more information to the hon. Member about the complete NRHM[reporter37] .
He was saying that an ASHA is not qualified. We should make an ASHA qualified. We have to make her trained and we are training ASHAs. So far as the criteria of selecting an ASHA is concerned, she should be at least Eighth standard or Tenth standard. That is the basic qualification. The success depends on the quantum of training, the module of training we do.
He referred to six new AIIMS-like institutions, which all the Members of the august House have been querying time and again. We are bringing it. In fact, it has been now put up back to the Cabinet. The Committee of Secretaries had gone through that. They have recommended the inclusion of some more States. Some States were left out. We are adding some more States like Kerala, Karnataka, Maharashtra and Gujarat. These States have been added on. We are now trying to bring it. In the next few months, we will be announcing that. We will be starting these works in all these six new AIIMS and also upgrading other structures in other States.
Of course, Mr. Ram Kripal Yadav talked about anaemia in women and that they have been suffering in the rural areas. I accept, Sir, this has been the fall out of malnutrition. It is a basic factor that there has been a lot of malnutrition. Of course, women, particularly pregnant women in this country have been severely affected, and the statistics literally show that about 75 per cent to 80 per cent of the pregnant women have some sort of anaemia. Anaemia could be categorised like moderate, severe and mild anaemia. Women are suffering. We have a lot of programmes on those lines, like in all the ANMs, they go to the women and do anti-natal check ups. They do three anti-natal check ups where they are giving 100 iron tablets to each one of them. If they have severe anaemia, they will give 200 tablets. They are also giving iron and folic acid tablets to prevent anaemia and they have to take one each. We guide them on these lines.
Of course, he was mentioning about some Government doctors doing private practice. Individual States take up individual policies on this. The Central Government policy is that no Central Government doctor should do private practice. However, Sir, some States do allow private practice for their doctors. On one side, we have issues of brain drain, doctors going out of the country. These doctors get a salary of about Rs. 30,000 to Rs. 40,000 per month. If they go to the private sector, they will earn about Rs. 5 lakh to Rs. 6 lakh a month easily. We have to give them some more incentives. Myself being a doctor, I know about their problems also. We have to recognise their services and also try to give more incentives to them. At the same time, those doctors who are erring on the wrong side, who are usurping the patients coming to the Government hospitals by asking them to come to the private clinics, should be severely punished. Definitely, we will punish them, if we know who are these people.
Shrimati Paramjit Kaur Gulshan said that there was no quality in Government hospitals. Some of them have. In the Government sector, we have a whole lot of patients coming. Take for example, Safdarjung Hospital. We have literally 6,000 OPD patients coming to the Hospital every day, and it is a very big number. We are trying to have more cleanliness, and we are trying to have more sanitation. However, when you take into account the load of patients coming to the hospital, the doctors are not able to take care of these 6,000 patients. Some Government hospitals might have witnessed a decline in quality. However, there is our commitment that where all there has been a problem, we are supporting them, we are complementing them, and we are trying to modernise the entire infrastructure. We have a very ambitious plan of modernising the complete Safdarjung Hospital as an entity. Safdarjung Hospital buildings, during the British period, were used as barracks. Still, some of those barracks are being used to run this Hospital. We are now having a Mega-Plan for Safdarjung Hospital. We are trying to raze all the old structures in a phased manner, build new hospitals and build new structures, modernise them and give them to the public.
She was also complaining that there were no medicines and no doctors in Punjab. Definitely, I will look into this issue. Maybe, if she brings any specific issue to my notice, I will be happy to help them out. In fact, he was saying that in Malwa region, the prevalence of cancer is on the increase. We will definitely look into that issue to find out as to why cancer is prevalent in Malwa region and we will also look into other issues.
Of course, Shri Sandeep Dikshit had put out very valuable points and he had also articulated all his concerns. In fact, Shri Sandeep has been very right in saying that we do not need an amendment, that it is the fundamental duty of the Government to provide them and that it is the fundamental duty of the public to demand proper quality healthcare. On one side, he says, the country has been making progress. Yes, Sir, absolutely, on one side, we are making progress. On the economic front, there is 7.5 per cent to 8 per cent growth. Ours is the second fastest growing economy in the world[R38] .
On the other hand, I accept what he says that our rank in the Human Development Indices of the United Nations Development Project is 127 out of 177 countries. We have to definitely think over this. We have to think of economy on the one side and the social parameters on the other side. My Prime Minister in the last two years has been working to close the gap between the growth of economy and the social sector. He is trying to address the problems of health, education, agriculture, employment, drinking water, etc. They are the main areas of his concentration.
The hon. Member said that there are differences among the States as far as health care facilities are concerned. He is absolutely right when he says that different States have different levels of health care indices. Kerala’s health care indices are compared to some of the developed countries in the world. At the same
time we have certain States, which I do not want to mention in this august House, where we have some of the worst health indices in the world. So, we have huge disparities. Most of the southern States are doing well in health care. This is directly linked to literacy rate. Why Kerala does well is because of its literacy rate. Women’s literacy rate is very high in Kerala. That is why there is more awareness created there. That is what the Government is trying to do. The Government is trying to go into preventive mode.
Life expectancy is increasing in the country and rightly so. Life expectancy is 63 years today and it is expected to go up to 75 years in the next 15 to 20 years because of availability of better health care, more infrastructure and more facilities out there. The hon. Member referred to the attention that is needed to be given to primary health care by bringing more personnel and more money into the system. We are doing that through NRHM. He talked about the health insurance scheme and advised us not to emulate the American system of health insurance. We would definitely not do that because that is not the system we are looking at. We are looking at an Indianised system, a rural-oriented system, a cashless system of health insurance. We do not want the farmer to go from pillar to post in getting reimbursement of money. We want a cashless system wherein a farmer just goes and gives his health card or insurance card and then gets the medicines and treatment. That is the system that we want and that is what we are trying to do.
The hon. Member said that he could not cite any example of a world class public hospital in India like Apollo. I would like to deny that. We have wonderful public hospitals in the country like AIIMS, PGI Chandigarh, JIPMER, NIMHANS, etc. We have some of the world class public hospitals in the country. Some of the magazines have categorised the AIIMS as number one hospital in the country. This is a world class hospital. Most of the countries in the world want to have tie-ups with the AIIMS. I do acknowledge that it is not enough and we need more of them to come up in the country.
Shri Shailendra Kumar talked about doctors not being available in rural areas. I said what we are trying to do for that. He referred to population explosion. I have already stated what we are trying to do in that regard. He said that a lot of nurses in Uttar Pradesh are from Kerala. I would like to congratulate the nurses from Kerala for going out not only to Uttar Pradesh but to different places in the entire world. They are doing a great service. They are very bold sisters. You have to have social orientation; you have to have service orientation. That is what they are doing. The nursing job is a thankless job because you do all the hard work and all the dirty work. That is why I would like to congratulate the nurses and sisters from Kerala who are going out to different parts of the country.
Taking this opportunity, I would like to ask Shri Shailendra Kumar to urge upon his leaders to start more medical and nursing colleges in Uttar Pradesh. We need a lot more doctors and nurses in Uttar Pradesh. I met the Chief Minister of Uttar Pradesh when launching the National Rural Health Mission and I mentioned this to him. He had promised that he would look into this and start more colleges.
The hon. Member talked about vaccination for the Japanese Encephalitis. We would be vaccinating most of the children in Uttar Pradesh before this season. This year we will be preventing Japanese Encephalitis deaths. Shri Shailendra Kumar talked about providing clean water for drinking in rural areas. The objective of the NRHM is that we should have drinking water, sanitation, nutrition, etc, in the rural areas and we are trying to do it[KMR39] .
Shri A.K.S. Vijayan has mentioned about doctors not being available in the villages. Shri Vijayakrishnan has mentioned about facilities not available in the rural areas, which I have already addressed. There is a demand for one hospital in each village. Yes, everybody wants good, functioning and quality hospital in a village. But for the Government to implement it, it has to maintain and build a hospital and to have more personnel and infrastructure. That is why we are trying to improve the existing facility. According to the National Population Policy criteria, one Primary Health Centre should be provided to a certain thousand people.
Shri T.K. Hamza from Kerala expressed worry about PHCs in block levels. In fact, Kerala Government is already doing well in the health sector. Steps under the NRHM should be taken to fill up these infrastructure vacuum. Shri Panda from Orissa mentioned about no facilities in tribal and interior parts. I accept that there are no facilities in Orissa, especially in tribal and interior parts. That is why the National Rural Health Mission is going to concentrate a lot in Orissa, Bihar and Uttar Pradesh. Of course, Madhya Pradesh and Rajasthan also need attention. But we are going to concentrate tremendously in Orissa, Bihar and Uttar Pradesh because when I travelled to these States, I could see that not much facilities are available in these States. In Orissa, we need more mobile facilities also. These States have a lot of problems. Hence, we would increase the number of medical mobile units in these States. We would like to provide a medical mobile unit in each district all over the country. But in these difficult States, we may even think of having two or even three medical mobile units so that they could go around different corners of the villages and States.
Of course, there is a need for maternal care. Yes, there is no maternal care. That is why, I would say that once ASHA is fully implemented, ASHA would be taking responsibility in the case of delivery and ante-natal care which would bring down maternal mortality. If there is no facility in a village, ASHA could take the lady to a private doctor and extend all help in delivery and would pay the private doctor whatever be the charges. We are trying to implement Janani Suraksha Yojana also. I have already talked about the issue of private practice of doctors which concerns both the doctors and the public.
About giving special attention to Orissa, I would like to tell that we would give very special attention to Orissa. We have to definitely improve the national figures and the national average, which we are trying to do. Shri Manoranjan Bhakta has mentioned about health centres. We are trying to improve. He had also mentioned about medicines supplied through CGHS and the quality of such medicines is not good. That is different issue, which again we would try to improve. We already have a good formulary and medicines are being made available now.
There is a query about the National Illness Fund and the same has to be increased. We are trying to work out on this. There are some issues and complaints about the Prime Minister’s Relief Fund and that not many people are accessing that. We are trying to take up the issue with the hon. Prime Minister’s Office and we are trying to access this Fund. This needs equal participation from the State Governments also. As State Governments increase their share, we would also increase. Of course, he had advised to hold the meeting of the Health Ministers and to have a new Health Policy. I think, this suggestion is well taken. We would consider that also. About new Insurance Policy, they say that if we spend on health care, spending on individual’s health could be avoided. There was a mention about specialists in Andaman & Nicobar Islands. During my visit, I have not seen many specialists in hospitals. Specialists are not going to Andaman & Nicobar Islands. We need them in Andaman & Nicobar Islands. We are trying to work out the ways and means to get them. In this connection, I have been talking to the different Ministries to start a medical college in Andaman & Nicobar Islands. The DG of Armed Forces Medical College had met me and informed me that he would convey this to the different ministries. There is a G.B. Pant hospital in Andaman Islands with 300-beds. They could start a medical college there. If they start, there will be more Specialists. We are trying to solve the issue in Andaman & Nicobar Islands also.
Of course, Punnu Lal Mohale has mentioned about non-availability of doctors in villages and Shri C.K. Chandrappan has given interesting statistics – he has mentioned about 94 per cent doctors in the urban areas; 68.5 per cent hospital in urban areas; and 60.5 per cent are not getting any type of facilities; and the spending on health care is about 0.9 per cent. He has also mentioned about the CMP. We have already addressed these issues. To address these issues, under the National Rural Health Mission, we are starting schemes in the rural areas[R40] .
He has said that all panchayats in Kerala have PHCs. It depends on the size of the panchayat. We are going with a population ratio. Every 20,000 to 40,000 population will have a PHC.
Dr. Koya from Lakshadweep, himself is a doctor. He has drawn the attention to the Indian Systems of Medicine. We are trying to do it at the highest level. He had a query about the manpower for running the health services. In UK, about 35 to 40 per cent of the doctors in the National Health Services are from Asia and mostly from India. I have also brought this to the attention of the British High Commissioner asking him to leave the specialists, as we need them here. I think, that has proved a little positive. Now, we have less number of doctors going there. We cannot prevent them totally. He was talking about the five-star hospitals. India today is going to have the concept of health tourism where we have hundreds of thousands of patients coming to India for treatment. But my entire focus is going to be on rural areas. Health tourism is going on by itself. Private sector is trying to involve in this. We will be very very careful to see that this health tourism does not rub on the rural people. People in the rural areas should not suffer. There should not be any price hike due to health tourism.
Prof. Ramadass talked about the preventive aspect. The main focus of the UPA Government in health sector is going to be on promoting preventive mode. We do not have money to cure more than a billion population. The only thing we can do is to focus on the preventive aspects, the basic public health issues like hygiene, sanitation, cleanliness, environmental protection and so on. He has said that the success of Kerala should be emulated elsewhere in this country. That is absolutely true. We are trying to do it. We do not see much in Kerala as far as infrastructure is concerned. Infrastructure is better in Tamil Nadu than in Kerala. But Kerala is much better in terms of health parameters, like, awareness, education, women’s awareness and so on.
Health is not an individual subject. It has a social implication. Where the literacy is high, health is high and health care is high. That is what we are trying to do. My good friends and colleagues in this august House have raised very serious issues. I acknowledge this. I would like to say that I am on their side on this issue because I also feel that there is not much infrastructure, not much care available in the rural areas. Infrastructure needs to be improved tremendously for more than a billion population on a war-footing. We are trying to do it under the National Rural Health Mission. I ask you to give me a time for another one or two years, I will improve the health parameters, like the infrastructure, providing doctors with rural postings, increasing the number of nursing colleges and to start more medical colleges in the under-privileged States. Once we do that, I am sure, we would address the needs of the entire country and especially of the rural areas.
As I said earlier, we have got 600,000 villages in the country. We would need Rs.25 lakh to Rs.50 lakh for starting a primary health centre and we would need another Rs.15 lakh for running it. Therefore, the money that we would need to start these centres is very high. With these words, I would like my friend Shri Sudhakar Reddy to withdraw his Bill.
MR. CHAIRMAN : Hon. Minister, there are a number of primary health centres in every State. These Centres get closed by 1.00 p.m. Nobody is available after that. Is there any remedy?
DR. ANBUMANI RAMADOSS: We are trying to have 24-hour functional PHCs under the NRHM.
MR. CHAIRMAN: I would like to know why no medical aid is available in the afternoon.
DR. ANBUMANI RAMADOSS: Under the NRHM, we are envisaging to have 24-hour functional PHCs and CHCs. Once we have mobile medical unit, this will not be a problem. Today, every village has a telephone. Every village has a cell phone. My colleague Dr. Maran has now made ‘one rupee one call’. We are going to provide one telephone to each unit. We are going to take up the task of modernising the block hospitals[p41] .
We are trying to concentrate on block hospitals where we are going to have specialists. Specialists would not be in PHCs. They can be there where there are facilities.
With these words, I would say that the Private Member’s Bill moved by my good friend might be withdrawn.
MR. CHAIRMAN : Now, Shri Sudhakar Reddy. You are fortunate in having a very exhaustive reply which is unusual. He has made a very exhaustive reply.
DR. PRASANNA KUMAR PATASANI (BHUBANESWAR): Sir, I want to put one question, through you.
Last time, the hon. Minister had committed before the House saying that he would accord sanction for one AIIMS sort of a hospital at Bhubaneswar because most of the people from Orissa were coming to Delhi for treatment, spending a lot of money. He had already accorded sanction and already the work of AIIMS had started at Bhubaneswar. But we need some more money to be allotted in this year’s budget. I would like to remind him about the commitment he made last time.
The second question is relating to private health sector. We are grateful to him that he had already given concurrence to a hi-tec Tirupati Panigrahi Medical College Hospital; the work had already started there. Another thing he had committed is for Achuta Samanta’s Medical College Hospital of KITTS, which has been delayed. It has already complied with all the facilities and appended doctors and full-fledged equipment are there. So, I appeal that it must also be accorded permission immediately. This is my appeal.
SHRI SURAVARAM SUDHAKAR REDDY Sir, I compliment the hon. Minister, Dr. Anbumani Ramadoss for giving a very elaborate reply to all the questions that have been raised during the debate.
I proposed an amendment to the Constitution of India, inserting a new article 45A so that there is a right for the rural India to have one Primary Health Centre in every village with all basic facilities.
During the debate, cutting across political barriers, all the Members have supported this. I am thankful to all the hon. Members who supported the amendment. Three hon. Members who felt that there is no necessity of an amendment have supported the spirit of the amendment. All the other speakers have totally supported the amendment.
The hon. Minister has also agreed that the rural area is unfortunately denied the basic medical facilities. It is true that the National Rural Health Mission is advancing very well and I compliment the present Government for taking initiatives to start this, for the first time, taking into consideration, the inadequacies and the discrimination shown towards rural India.
But in spite of the elaborate reply, I feel that the National Rural Health Mission is not going to solve all the problems. Still, there are several problems which could not be totally explained. The hon. Minister said that there is no problem of money, and that in the next seven years, it is planned to spend about Rs.40,000 crore. But during the last year, an amount of Rs.2,000 crore only has been given additionally. In this way, I believe that even after a century, these facilities cannot be provided to them.
Sir, I may be allowed to make a few points which the hon. Minister has explained. In the recent period, it is true that with all the facilities, we were able to control some very important diseases like polio, leprosy and even TB, to some extent[R42] .
At the same time, some of the old problems like Malaria are coming up in a very big scale. A number of our friends from Orissa have explained the problems in tribal areas. In my parliamentary constituency Malaria is a very serious problem. In Chintapalli, in Visakhapatnam district about 1000 tribal people died in a single year because the Government did not provide even the basic medicines.
In these circumstances I felt that the rural areas should have the primary health centres. The Government is doing contrary to it. It is true that on the one side more Budgetary allocation is made and on the other side privatisation is being encouraged. Nowadays, new words, ‘health industry’ are being used. Health is being commercialised. It is very unfortunate. The hon. Minister has rightly said that there is a necessity to have infrastructure, money and manpower. As far as manpower is concerned, there is definitely a dearth of manpower because of lack of medical colleges. A large number of private medical colleges are being allowed and the Government is escaping from its responsibility. It is becoming so costly for an ordinary person to get admission to a medical college. Only rich and super rich can now become doctors. It is the most unfortunate thing. In these circumstances when about Rs.25-40 lakh is being paid for getting admission in the medical colleges, you cannot expect doctors to work in Primary Health Centres. So, the Government should take into consideration all these things. It is the primary responsibility of the Government of India to provide medicines, basic health care to its citizens. That is why I feel that not as a reward or as a relief but as a right under the Constitution the rural areas should have Primary Health Centres. Of course, private doctors will always have some limitation.
I cannot insist on this but it would have been better if the hon. Minister would have said that he would initiate a proposal to bring an amendment to the Constitution. In that case I would have happily withdrawn my Bill. I would like to know from Dr.Ramadoss whether the Government is prepared or is he in a position to initiate such a proposal if not now, maybe after the next Budget. If the hon. Minister is prepared to initiate such a proposal then I would happily withdraw my proposal. My purpose of bringing this Bill was to bring it to the notice of the nation, through Parliament, bring it to the notice of the Government and that purpose is solved. At the same time, I would like an assurance from the Minister that the Government itself would introduce such an amendment.
DR. ANBUMANI RAMADOSS What the hon. Member has said, the entire House including me accepts the general feelings of the hon. Members. Nobody has said that the facility is not there but they said that it is lacking and it needs improvement. It is the fundamental right of the individual to demand good health care. It is the fundamental duty of the Government to do so and that is what we are trying to do by bringing a lot of programmes under Rural Health Mission. I have given an extensive reply and I am sure in the days to come we are going to spend more money. This year we have spent about Rs.7000 crore under the NRHM and next year it is going to be minimum Rs.10,000 crore. We are going to increase it every year. We just cannot build infrastructure. Today, there are complaints.… (Interruptions)
MR. CHAIRMAN : There is a lot of unemployment among the doctors.
DR. ANBUMANI RAMADOSS: It is a specialised subject. Unemployment is a general problem. Any doctor is either self-employed or Government-employed. It is the either way[R43] .
Either he can self-employ himself and practice or he can work in the Government sector. That is a different issue. But then we are trying to provide the infrastructure. We are trying to improve the manpower. My good friend has mentioned private medical colleges. We are not allowing private medical colleges. According to the requirement, the State Governments want them. They give the essential certificate. So, they are the ones who want more colleges and doctors. But again I am insisting that the State Governments should start more colleges rather than the private sector starting them. That is what I have been saying to the Chief Ministers in my meeting with them. We are saying that you should invest money into your own infrastructure, have more colleges and produce more doctors. That is why, I am for the Government sector. I want to have more Government colleges. That is my premier focus and that is what we are going to do. We are providing this infrastructure. The UPA Government has its own commitment. As per the CMP, it is for 0.9 per cent in the public sector. We are trying to provide a minimum of 0.2 per cent and in the four years 0.2 per cent is going to be a huge amount of money. We are trying to do it. My good friend will also accept the Governments serious commitment on the health sector.
With these words, I would kindly request him to withdraw the Bill.
MR. CHAIRMAN : Are you withdrawing?
SHRI SURAVARAM SUDHAKAR REDDY I do not insist. There are very less friends from the Opposition side also.
I hope that the hon. Minister will take into consideration all the views that have been given including the proposal for compulsory service in the rural areas for the medical graduates.
With these words, I beg to move for leave to withdraw the Bill further to amend the Constitution.
MR. CHAIRMAN: The question is:
“That leave be granted to withdraw the Bill further to amend the Constitution of India.”
The motion was adopted.
SHRI SURAVARAM SUDHAKAR REDDY : Sir, I withdraw the Bill.