Role of ASHA and ANM

One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist  'ASHA'  or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. Following are the key components of ASHA: 

• ASHA must primarily be a woman resident of the village  married/ widowed/ divorced, preferably in the age group of 25 to 45 years.
• She should be a literate woman with formal education up to class eight. This may be relaxed only if no suitable person with this qualification is available.
• ASHA will be chosen through a rigorous process of selection involving various community groups, self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village Health Committee and the Gram Sabha.
• Capacity building of ASHA is being seen as a continuous process. ASHA will have to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles.
• The ASHAs will receive performance-based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets.
• Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is expected to be a fountainhead of community participation in public health programmes in her village.
• ASHA will be the first port of call for any health related demands of deprived sections of the population, especially women and children, who find it difficult to access health services.
• ASHA will be a health activist in the community who will create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.
• She would be a promoter of good health practices and will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals.
• ASHA will provide information to the community on determinants  of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services.
• She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
• ASHA will mobilise the community and facilitate them in accessing health and health related services available at the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.
• She will act as a depot older for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc.
• At the village level it is recognised that ASHA cannot function without adequate institutional support. Women's committees (like self-help groups or women's health committees), village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, and the trainers of ASHA and in-service periodic training would be a major source of support to ASHA.

Support Mechanism for ASHA 

• The Government of India has set up an ASHA Mentoring Group comprising of leading NGOs and well known experts on community health. Similar mentoring groups at the State/District/Block levels could be set up by the States to provide guidance and advise on matter relating to selection, training and support for ASHA.
• As ASHA will be in the village on a permanent basis, she should be selected carefully through the process laid down in the first set of ASHA guidelines. 
• The guidelines already issued on ASHA envisage a total period of 23 days training in five episodes. 
• Now, that ASHAs have been selected, the next step would be to familiarize her with the health status of the villagers and facilitate her adoption to the village conditions. 
• The Gram Panchayat will be involved in supporting ASHAs in her work. 
• A village health register is maintained by the AWW which is not always complete.
• All State Governments are presently organizing monthly Health and Nutrition day in every village (Anganwadi centers) with the help of AWW/ANM. ASHA along with AWW should mobilize women, children and vulnerable population for the monthly health day activities like immunization, careful assessment of nutritional status of pregnant/lactating women, newborn & children, ANC/PNC and other health check-ups of women and children, taking weight of babies and pregnant women etc. and all range of other health activities. 
• ASHA would be required to interact with SHG Groups, if available in the villages, along with AWW, so that a work force of women will be available in all the villages. 
• ANM should have a monthly meeting with the ASHAs stationed (5-6 ASHAs) in the villages of her work area at the Anganwadi Centre during the monthly Health and Nutrition Day to assess the quality of their work and provide them guidance.
• The Medical Officer In-charge of the PHC will hold a monthly meeting which would be attended by ANM and ASHAs, LHVs and Block Facilitator. 
• A meeting of ASHA could be organized on the day monthly meetings are organized at the PHC level to avoid unnecessary travel expenditure and wastage of time.
• In addition to monthly meetings at PHC, periodic retraining of ASHAs may be held for two days once in every alternate month where interactive sessions will be held to help then to refresh and upgrade their knowledge and skills, as provided for in the original guidelines for ASHA.
• At the block level, the BMO will be in overall charge of ASHA related activities.
• Officials in the ICDS should be fully involved in ASHAs activities and their support should be provided for at every level i.e. PHCs, CHCs, District Society etc. 
• Periodic surveys are envisaged under NHM in every village to assess the improvement brought about by ASHA and other interventions. 
• The District Health Mission in its meetings will specially assess the progress of selection of ASHAs, their training and orientation, usefulness to the villages etc. 
• The success of NHM to great extent depends on performance of ASHA and her linkage with functional health system. 
• The States may take appropriate steps to locally adopt these guidelines and make the ASHA scheme a complete success.

ROLE of  Auxilliary Nurse Midwives (ANM)

• Holding weekly / fortnightly meeting with ASHA to discuss the activities undertaken during the week/fortnight.
• Acting as a resource person, along with Anganwadi Worker (AWW), for the training of ASHA.
• Informing ASHA about date and time of the outreach session and also guiding her to bring the prospective beneficiaries to the outreach session.
• Participating and guiding in organising Health Days at Anganwadi Centre.
• Taking help of ASHA in updating eligible couples register of the village concerned.
• Utilising ASHA in motivating the pregnant women for coming to Sub-Centre for initial check-ups.
• ASHA helps ANMs in bringing married couples to Sub-Centres for adopting family planning.
• Guiding ASHA in motivating pregnant women for taking full course of iron folic acid (IFA) tablets and TT injections, etc.
• Orienting ASHA on the dose schedule and side affects of oral pills.
• Educating ASHA on danger signs of pregnancy and labour so that she can timely identify and help beneficiary in getting further treatment.
• Informing ASHA about date, time and place for initial and periodic training schedule. ANM would also ensure that during the training ASHA gets the compensation for performance and also TA/DA for attending the training.....

The NRHM  seeks to provide minimum two ANMs (against one at present) at each Sub-Centre, as one ANM at a sub-centre has not been found adequate to attend to the complete needs of maternal and child care in any village. The Government of India would support the second ANM for appointment on contract basis and apart from fulfilling the other criteria she must be a resident of a village falling under the jurisdiction of the Sub-Centre. The intention is to improve accountability at the local level..

The second ANM would not be transferred before completion of 10 years at the same Sub-Centre and would not be a substitute for Male Health Worker (MHW). An untied fund of Rs.10,000/- per Sub-Centre per annum is being provided by opening a joint account of the ANM and Sarpanch, to meet the emergency type expenditures and to ensure that lack of drugs and other consumables is not an issue.

HUMAN GENOME PROJECT

The concept of genomics began with the concept of Human Genome Project in the mid 1980s. The $3 billion project-The Human Genome organization (HUGO) was set up in 1990 to co-ordinate the work of scientists in a number of countries-the USA, Japan, UK, France, Germany, Canada, Israel, Russia, Italy and others- in a project to map all of the genes on human chromosomes. The Human Genome Project started on 1st Oct, 1990 in US to map and sequence the complete set of human chromosomes, as well as those of some of the model organisms.

According to a 1986 report submitted by Department of Energy (USA) " The ultimate goal of this initiative is to understand the human genome" and "knowledge" of the human genome is as necessary to the continuing progress of medicine and other health sciences as knowledge of human anatomy has been for the present state of medicine." 

The funding for this project came from the US government through the National Institutes of Health, USA and a UK charity organization, The Wellcome Trust (which funded the Sanger Institute in Great Britain), and some other groups around the world.

The aim of the Human Genome Project was to identify all the genes (approx. 25,000) in human DNA and to determine the sequence of the three billion chemical base pairs that make up human DNA. Efforts were made to create databases to store this information and develop tools to do comprehensive data analysis.

Another important aspect of this project was the decision taken to address the ethical, legal and social issues arising as a outcome of this project. In order to have comparative data, research work was carried out simultaneously on three other organisms namely bacteria- E.Coli, the fruit fly-Drosophila melanogaster, and laboratory mouse.

Another big step forward was the transfer of the technology to the private sector. This approach lead to tremendous progress in the biotechnological field in the later years. The procedure adopted involved the breaking down of genomes into smaller pieces approximately 150,000 base pairs in length also known as BACs or "bacteria artificial chromosomes". They can be inserted into bacteria where they are copied by the bacterial DNA replication. These pieces are then sequenced separately as a small "shotgun" project and then assembled. The larger (150,000 base pairs) together create chromosomes. This is known as "the Hierarchical shotgun" approach because in this method first the genome is broken into relatively large chunks, which are then mapped to chromosomes before being selected for sequencing.

Every individual has a unique gene sequence therefore the data published by the Human Genome Project does not essentially represent the exact sequence of each and every individual’s genome. The results represent the combined genome of a small number of anonymous donors. In order to have more information about the human genome project, the readers can visit the following web site:www.ornl.gov/techresources/Human_Genome/home.shtml

The Impact of Human Genome Project

After the human genome project the world has changed and it is going to change even more. The Human Genome project is going to impact our lives in a tremendous way. It took 15 years and about 4 billions US dollars to sequence the human genome which was completed in 2003. There are 4 bases in the DNA. A,T, G, C and if we add them up then the total is approx 3 billion. Further, the average gene consists of 3000 bases, and the sizes vary greatly. The largest known human gene is dystrophin about 2.4 million bases. The total number of genes is estimated at around 30,000. Almost all (99.9%) nucleotide bases are exactly the same in all people. So far the functions of over 50% of discovered genes are unknown.  Chromosome 1 has the most genes about 2968, and the Y chromosome has the fewest (231) as chromosome 1 is the longest and Y chromosome is the smallest. The Human Genome Project also revealed that genes appear to be concentrated in random areas along the genome, with vast expanses of non coding DNA between. Stretches of up to 30,000 C and G bases repeating over and over often occur adjacent to gene-rich areas, forming a barrier between the genes and the "junk DNA." These CpG islands are believed to help regulate gene activity. The ratio of germ line (sperm or egg cell) mutations is 2:1 in males v/s females.  Researchers point to several reasons for the higher mutation rate in the male germ line, including the greater number of cell divisions required for sperm formation than for eggs.

The information that was revealed by the Human Genome Project can be used to improve diagnosis of disease. The risk associated with genetic predisposition to diseases can be calculated and based on the results new strategies can be used to treat these diseases such as gene therapy, customized drugs based on individual patients genetic profiles. The information from Human genome Project is also being used in microbial Genomics to detect and treat pathogens, use microorganisms in bio-remediation where environment can be monitored to detect pollution levels and clean up toxic waste. New energy sources as biofuels are also being developed. 

With the help of Genome Sequencing machines, it is now possible to sequence a genome in a record period of time. The human genome is about 3 giga bases and with the present available models of the Genome Sequencing machine, it is possible to sequence 200 giga bases in a week’s time. As far as the price of sequencing is concerned, the price of sequencing a base has already fallen 100 million times. A few years back, it was used to cost $100,000, today it is $1000 and in the coming years it is going to be  $100.

 The world’ s capacity to sequence the human genome is something like 50,000 to 100, 000 human genomes this year. This is based on the present model of the machines available. This is going to double, triple or quadruple year over year. In fact, the Beijing Genomics Institute is far ahead then others with a capacity that is almost 20% of the total genome sequencing capacity of the world. The sequencing of the genes is continuously giving us valuable information regarding human health and treatment of diseases that were difficult to understand and therefore had no cure. The most important being Cancer hitherto still with no cure. It has been possible to correlate the relation between the deletion of TP 53 gene and occurrence of cervical and breast cancer. If there happens to be a deletion mutation in this gene, there is almost 90% chance of getting cancer in these individuals.  If one can get the genetic test done, and if they have the same deletions, the family or the individual can go for regular screenings to catch the cancer early.

There is other very interesting information getting revealed, such as explaining marital infidelity due to the presence of “Cheating genes.” Already there are labs to tests for allele 334 of the AVPR1 gene that is also called “Cheating gene”. This test is being used to find out the compatibility between the couples which in turn will help to lower down the divorce rates and emotional trauma caused due to broken relationships. Arginine vasopressin receptor 1 A (AVPR1A) is one of the three major receptor types, others being AVPR1B and AVPR2, for arginine vasopressin which is present through out the brain, liver, and kidney. Variation in the gene for one of the receptors for the hormone vasopressin is reported to be associated with the bonding of human males with their partners/spouses. It was reported that the 334 allele of a common AVPR1A variation seemed to have negative effects on the men’s relationship with their spouses.

"Our findings are particularly interesting because they show that men who are in a relatively stable relationship of five years of more who have one or two copies of allele 334 appear to be less bonded to their partners than men with other forms of this gene," says Jenae Neiderhiser, Professor of psychology, Penn State. "We also found that the female partners of men with one or two copies of allele 334 reported less affection, consensus and cohesion in the marriage, but interestingly, did not report lower levels of marital satisfaction than women whose male partners had no copies of allele 334." 

The prospect of using the genome as a universal diagnostic is upon us today. Just like other diagnostic tools being used in the hospitals, very soon we are going to have Whole Genome sequencing machines in the pathology labs as routine healthcare tools.

It means is that everybody who is alive today can live an extra 5, 10, 20 years. Very soon, we will have our entire genome copy on a pen drive or on the laptop with an easy access to your personal physician or family doctor. The doctor by looking at your genome can do the risk assessment for you as to which diseases you are prone to due to your genes. This assessment will help the doctor to suggest precautions and preventions and early interventions that will not only ultimately save millions of lives but also increase the life span of individuals.

Beyond Human Genome…….

The International HAP MAP Project

After sequencing the Human Genome, the next goal on which the biotechnologists and researchers are working is to map the SNPs in the entire genome, which is known as “HAP map”. This is a $ 100 M public- private effort, which will take almost 3 years to complete. The project involves collecting DNA samples from the blood samples of researchers from Nigeria, Japan, China and US. The aim is to create the next generation map of the human genome. This information is going to help us understand the .1% (100-99.9) difference that makes humans different from each other. These differences are due to Single Nucleotide Polymorphisms.  By locating the SNPs a Haplotype is created. A Haplotype is a set of single nucleotide polymorphisms (SNPs) on a single chromosome pair that are statistically associated. A Haplotype has also been defined as a combination of alleles (DNA sequence) at adjacent locations on the chromosomes that are transmitted together. A haplotype could be one locus, several loci, or an entire chromosome depending on the number of recombination events that have occurred between a given set of loci. The identification of a few alleles of a haplotype block can identify all other polymorphic sites in its region. This information will help to understand the genetics behind the common diseases.

The findings of the Human genome project, has opened vistas for new fields such as “Systems Biology” which explores life at the ultimate level. The whole organism is taken in to consideration instead of individual components such as single genes or proteins. This novel approach combines DNA sequences with advanced technologies to study how proteins carry out all the activities of a living cell.

Besides this the novel field of Consumer Genetics is going to define the business model and commercial enterprises. Consumer Genetics is now being used to customize personal care and nutritional supplement products. You can get skin care and supplements customized to meet the needs of your DNA. The Life insurance policy is going to be based on your personal genome copy.

One of the other products, fungi, is being also used as a rich source of protein. Since 1960s, a European bread producer spent over $45 million on a fungus that can be formed into acceptable food substitutes and started its commercial production in early 1984. For example a mycoprotein (protein derived from fungi), Fusarium graminearum which is a mold related to mushrooms and truffles. It is odorless and tasteless and contains about 45% protein, and 13% fat with a dietary composition same as beef. This mycoprotein has an amino acid content that is close to that recommended by the Food and Agriculture Organization of the United Nations as “ideal” for human consumption.

REGULATIONS ON SURROGACY

• While the new Assisted Reproductive Technology (ART) Regulation Bill and Rules, 2010, are still in the womb, the non-statutory Indian Council of Medical Research (ICMR) Guidelines, 2005, are being followed.
• As per the latest and new Indian visa regulations, effective November 15, 2012, all foreigners visiting India for commissioning surrogacy will be required to apply for medical visas and cannot avail of simple tourist visas for surrogacy purposes. 

 NEW REGULATIONS:

• Foreigners visiting India for commissioning surrogacy must apply for medical visa

• The man and woman should be duly married and the marriage should have sustained for at least two years
• A letter from the embassy should be enclosed with the visa application stating that the country recognizes surrogacy and the child born thereof will be treated as a biological child of the couple
• The couple will furnish an undertaking that they would take care of the child
• The treatment would be done only at registered ART clinics recognized by the ICMR
• The couple should produce a notarized agreement between the applicant couple and the prospective surrogate mother
•  For return journey, the couple will need exit permission from FRRO/FRO
• The couple can be permitted to visit India on a reconnaissance trip on tourist visa, but no samples can be given to any clinic during such visit 

  RECOMMENDATIONS OF LAW COMMISSION:

• Surrogacy arrangement will continue to be governed by contract among parties, which will contain all the terms requiring consent of surrogate mother, medical procedures, reimbursement, willingness to hand over the baby, etc. This arrangement should not be for commercial purposes.
• Surrogacy arrangement should provide for financial support for surrogate baby in the event of death of the commissioning couple or individual before delivery, or divorce between the intended parents and subsequent unwillingness to take the baby.
• Life insurance covers for surrogate mother.
• One of the intended parents should be a donor to foster the bond of love and check chances of child abuse.
• Legislation should recognize a surrogate child to be the legitimate child of the commissioning parent(s) without there being any need for adoption or even declaration of guardian.
• The birth certificate of the child should contain the name(s) of the commissioning parent(s) only.
• Right to privacy of the donor as well as surrogate mother should be protected.
• Sex-selective surrogacy should be prohibited.
• Cases of abortions should be governed by the Medical Termination of Pregnancy Act.
• The ART Bill, 2010, has legal lacunae and lacks creation of a specialist legal authority for determination and adjudication of legal rights of parties, in addition to falling in conflict with existing family laws. These pitfalls should not become a graveyard for a law yet to be born. Surrogacy needs to be regulated by a proper statutory law. Till then, the visa regulations will provide succor and relief.

NATIONAL CHILD POLICY

• For the first time since Independence, India has adopted a policy document at the highest level to recognize every child’s right to survival, development, protection and participation and define a child as a person below 18 years of age.
• The Policy approved by the Cabinet will inform all existing laws related to children and prevent future conflicts on the issue of child’s definition
• The change in child’s definition stems from India’s commitment to the UN Convention on Rights of the Child which it ratified long ago but failed to bring its laws in line with the UNCRC.

 HIGHLIGHTS:

• The National Policy for Children 2030 states for the first time that a child will be any person below the age of 18 years. It adds that all existing legislations will have to change to honour the policy.
• The Prohibition of Child Marriage Act 2006 will have to be amended to define all children below 18 years. At present, this law differentiates between male and female children defining a child as anyone below 21 years in case of “males” and “anyone below 18 years in case of “females”.
• The Prohibition of Child Labour Act will have to change as it currently defines a child as someone below 14 years for the purpose of child labour
• The Policy for the first time recognizes the children’s right to life, survival and development and goes beyond their physical existence.
• India adopted the last National Child Policy way back in 1974. The old policy stressed Integrated Child Development Services, immunization and child labour. But since the advent of globalization, rise in crimes against children and strides in mass media, the Government had not revised its policy which could guide the national plans properly.

JAN AUSHADHI

Over the years India, has developed a strong capability in producing quality branded and generic medicines in most of the therapeutic categories, evolving from an mere Rs 1500 crores industry in 1980 to a more than Rs 68,000 crores industry in 2008. However,although these medicines are reasonably priced, as compared to the prices of their equivalent medicines in most other countries, yet a large population of poor people in the country, find it difficult to afford the more expensive branded category of medicines. Accordingly, ‘ensuring availability of quality medicines at affordable prices to all’, has been a key objective of the Government. some of the important steps taken to enable this are:

Price control of Scheduled Drugs through the National Pharmaceutical pricing authority (NPPA): Under the

1. Drug Price Control Order, 1995, NPPA): Under the Drug Price Control Order, 1995, NPPA has been given the mandate to control and fix the maximum retail prices of a number of scheduled/listed bulk drugs and their formulations, in accordance with well defined criteria and methods of accounting, relating to costs of production and marketing Notably therefore, the prices of these medicines have remained quite stable and affordable.
2. Price regulation of Non-Scheduled Drugs: Apart from the scheduled medicines under DPCO,1995, the NPPA monitors the prices of other medicines not listed in the DPCO schedule, such that they do not have a price variation of more than 10% per annum. This has further helped in keeping the prices of most of the non-scheduled medicines stable and affordable.
3. Uniform VAT of 4% on medicines: Government has fixed a uniform and low rate of 4% VAT on medicines in the country. This policy has been adopted, in almost all the States in the country, and has reduced the incidence of sales tax on medicines and thereby assisted in keeping their prices low.
4. Reduction in Excise duty from 16% to 4% Further and in addition to above low, VAT rates, the [present government had, as part of the Budget for the year 2008-09 reduced the excise duty on medicines from 16% to 8%. This has been further reduced to 4 percent as from 8th December, 2008. This has again, played a crucial role in keeping the prices of most of the medicines at reasonable levels.

Not satisfied with the above regulatory and financial steps for ensuring greater availability of medicines at affordable prices to all, specially the poorer masses, the government has decided to launch a country wide Jan Aushadhi Campaign. It is well known that due to market led consumer awareness and availability, branded medicines are sold by drug manufacturers at higher prices than their unbranded generic equivalents, which are as good in therapeutic value. Therefore, if generic medicines are made more accessible and available in the market, everyone would benefit. Seizing this opportunity, the Pharma Advisory Forum in its meeting held on 23rd April, 2008 under the Chairmanship of Shri Ram Vilas Paswan, Hon’ble Union Minister of Chemicals & Fertilizers and Steel, Decided to launch a Jan Aushadhi Campaign. A key initiative under the campaign would involve opening of jan aushadhi stores where, unbranded quality generic medicines would be sold which are available at lower prices, but are equivalent in potency to branded expensive drugs.

Jan Aushadhi Campaign: Key Objectives

The Jan Aushadhi Campaign would:

1. Make quality the hallmark of medicine availability in the country, by ensuring, access to quality medicines through the CPSU supplies and through GMP Compliant manufacturers in the private sector.
2. Despite constraints of budget in the Central and State governments, extend coverage of quality generic medicines which would reduce and thereby redefine the unit cost of treatment per person. For example branded Diclofenac tablets are available at the average market rate of Rs 36.70* for a pack of 10 tablets.
3. Jan Aushadhi Stores would be sell this at Rs 3.10* which is less than 10% of the market price of the branded category. Thus with the same cost 10 times more persons could be treated with same efficacy and cure.
4. Develop a model which can be replicated not only in India but also in other less developed countries in their common goal of improving quality affordable health care by improving access to quality medicines at affordable prices for all.
5. Not be just restricted to the Public Health System but be adopted with zeal and conviction by the Private Sector and thereby spread its coverage to every village of this country. The jan aushadhi campaign is open for all. Since generic equivalents are available for all branded drugs, the campaign will provide access to any prescription drug or Over The Counter (OTC) drug for anybody. It will be as much available to the disadvantaged sections of the society as much to the advantaged richer population segment of the country.
6. Create awareness through education and publicity so that quality is not synonymous with high price but less is more that is to say that, with a lesser price, more medicines would be available, more patients would be treated and more people will lead a healthier life.
7. Be a public program involving State governments, the Central government, Public Sector enterprises, private Sector, NGOs, Cooperative bodies and other institutions.
8. Create a demand for generic medicines By All for All by improving access to better healthcare through low treatment costs and easy availability wherever needed in All therapeutic categories.

The Jan Aushadhi Campaign will accordingly:

1. Promote greater awareness about cost effective drugs and their prescription.
2. Make available unbranded quality generic medicines at affordable prices through public-private partnership.
3. Encourage doctors, more specifically in government hospital to prescribe generic medicines.
4. Enable substantial savings in health care more particularly in the case of poor patients and those suffering from chronic ailments requiring long periods of drug use.

Important Next Steps

1. A list of Unbranded Generic medicines, commonly used by patients for chronic and other diseases, has been prepared. The National List of Essential Medicines, 2003 (NLEM, 2003) has also been used for this purpose.
2. This will be considered as Common List (CL). Each State would be able to have an add-on list called the State List (SL) based on the use of any specific medicine in the area.
3. The State Governments/NGOs/Charitable/cooperative/Government bodies will be encouraged to establish jan aushadhi stores in Government hospital premises or at other suitable location in all the Districts of all the States and union Territories.
4. Under the jan aushadhi campaign jan aushadhi stores will be opened in al the districts in the country in phases. Accordingly, States have been identified for opening of the jan aushadhi stores in the first phase along with the proposed nodal organizations responsible for coordinating the activities. After successful operationalisation of the program in these districts, other districts in other States would be considered in subsequent phases.

INTEGRATED CHILD PROTECTION SCHEME

India is home to almost 19% of the world’s children. More than one third of the country’s population, around 440 million, is below 18 years. The future and strength of the nation lies in a healthy, protected, educated and well-developed child population that will grow up to be productive citizens of the country. It is alarming that, in 2011, the Crimes against children reported a 24% increase from the previous year with a total of 33,098 cases of crimes against Children reported in the country during 2011 as compared to 26,694 cases during 2010. The State of Uttar Pradesh accounted for 16.6% of total crimes against children at national level in 2011, followed by Madhya Pradesh (13.2%), Delhi (12.8%), Maharashtra (10.2%), Bihar (6.7%) and Andhra Pradesh (6.7%).

Thus there is an urgent case for increasing expenditure on child protection. so that the rights of the children of India are protected. The neglect of child protection issues not only violates the rights of the children but also increases their vulnerability to abuse, neglect and exploitation.

GOI has launched the Integrated Child Protection Scheme (ICPS) aimed at building a protective environment for children in difficult circumstances, as well as other vulnerable children, through Government-Civil Society Partnership.

Objectives of the scheme are:

1. To create a safety net for children in need of care and protection and children in conflict with law by building a protective environment for them, keeping their best interests in mind;
2. To promote preventive measures to protect children from falling in the situations of vulnerability, risk and abuse;
3. To promote preventive measure to address the vulnerabilities of families and build their ability and capacity protect their children;
4. To supplement and strengthen the infrastructure established under the Juvenile Justice (Care and Protection) Act 2000;
5. To build capacities of families, communities, and NGOs to strengthen care, protection and response to children;
6. To create State and District Child Protection Units as well as State Adoption Cells;
7. To promote in-country adoption and regulate inter-country adoption as well as ensure minimum standards;
8. To provide services to the more vulnerable categories of children through specialized programmes;
9. To establish linkages for restoration of children to their biological families and placement with adoptive families or foster families, where necessary;
10. To provide specialized institutional care to infants and children up to 6 years of age who are either abandoned or orphaned/destitute;
11. To check and end female foeticide and infanticide in the country;
12. To provide services to street and destitute children, including child beggars;
13. To provide for care and support services for children affected by HIV/AIDS;
14. To establish CHILDLINE in every district, for creating access in emergencies by providing counseling, restoration and rehabilitative services to children along with linkages to other available services under various schemes of the Government of India/State Governments;
15. To train and sensitize local bodies, police, judiciary and other concerned departments of State Governments to undertake related responsibilities;
16. To strengthen the knowledge base by undertaking research and documentation, resource mapping of services, the creation of a Management Information System (MIS) for tracking vulnerable children, and database management;
17. To carry out advocacy and spread awareness about child and family-related issues for supporting the family;
18. To network with the Allied Systems i.e. Government departments and Non-Government agencies;
19. To initiate any other need-based specialized innovative services through families, community and panchayats/local bodies, including child guidance and counseling especially to combat drug abuse, sexual abuse, child marriage, and discrimination against the girl child.

Department of AYUSH

AYUSH is a department of Indian Systems of Medicine i.e. Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH). It has been set up with a view to provide focused attention to development of Education & Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy systems. The Department continues to lay emphasis on upgradation of AYUSH educational standards, quality control and standardization of drugs, improving the availability of medicinal plant material, research and development and awareness generation about the efficacy of the systems domestically and internationally.
The Indian systems of medicine include all the non-allopathic systems of medicine like:
• Ayurveda: Ayurvedic, a Sanskrit word which means 'the science of life', is one of the oldest recorded healing sciences in the world. Ayurvedic practitioners use diet, herbs, minerals, colour, gems, yoga, and pranayama (scientific breathing) in treating patients; they also consider exercise, life-habits, seasons of the year, and individual temperament. Their purification treatments include therapeutic emesis, purgation, medicated enemas, diaphoresis, and medicated massage. They also classify foods according to temperature, and give hot foods for certain problems and cold foods for others.
• Sidha: Sidha is the most ancient Indian System of medicine practiced in India. The basic principles and doctrines of Sidha system are similar to those of Ayurveda. Both Ayurveda and Sidha are holistic system of medicines dealing with preventive, primitive and curative concepts of health and are holistic systems of medicine covering, body, mind, soul and phenomena of nature. But Sidha is usually practiced in Southern part of India.
• Unani: Unani Medicine is an ancient form of system of medicine first developed and based on the teachings of Hippocrates in 460 BC, who freed medicine from the realm of superstition and magic and gave it the status of science. This system of medicine originated in Greece but was brought to India by Arabs and Persians. It adopts holistic approach i.e. the human body is composed of seven natural and basic components called Umoor-e-Tabaiyah which is mainly responsible to maintain health.   They are Arkan (elements), Mizaj (temperament), Akhlat (humours), Aaza (organs), Arwah (spirit/vital forces), Quwa (faculty/energy), Afal (functions/actions).
• Homeopathy: This system of medicine was discovered by German physician Dr. Samuel Hahnemann. It is a system of medicine that cures natural disease by administering drugs which have been experimentally proved to possess the power of producing similar artificial symptoms on healthy human beings. It has also wide acceptability because of its holistic and intrinsic values, low cost and absence of any side effects of the drug.
• Yoga: Yoga is a way of life propounded by Yajyavalkya and later systematized by Patanjali. The history of yoga is about 2500 years when Patanjali provided it systematic forms which consists of eight components. This yoga helps in improving physical, mental and social-well being and provides relief from stress and strain, increases resistance power of the body, etc.
• Naturopathy: Naturopathy like yoga is a way of life and believes in the practice of applying the simple laws of nature to life. It is commonly known for drugless treatment of disease and an organized way of life is the key to health energy and happiness. It lays special emphasis on eating and living habits, adoption of purification measures, use of hydrotherapy, cold packs, mud packs, massage, etc.
• Sowa-Rigpa: It is commonly known as Amchi system of medicine is one of the oldest, Living and well documented medical tradition of the world. It has been popularly practice in Tibet, Magnolia, Bhutan, some parts of China, Nepal, Himalayan regions of India and few parts of former Soviet Union, etc. It has been recently added to the medical system of India.
There are more than four lakhs registered practitioners under these systems particularly in rural areas. There are many Ayurvedic, Unani and Sidha colleges both in government and non government sectors.

VACCINE AND ITS TYPES

Vaccine is a biological preparation that improves immunity to a particular disease. A vaccine typically contains an agent that resembles a disease-causing microorganism, and is often made from weakened or killed forms of the microbe or its toxins. The agent stimulates the body's immune system to recognize the agent as foreign, destroy it, and "remember" it, so that the immune system can more easily recognize and destroy any of these microorganisms if it encounters in future.

Types of vaccines:

a) Inactivated vaccines: When inactivated vaccines are made, the bacteria are completely killed using a chemical, usually formaldehyde. Dead pieces of disease-causing microorganisms (usually bacteria) are put into the vaccine. Because the antigens are dead, the strength of these vaccines tends to wear off over time, resulting in less long-lasting immunity. So, multiple doses of inactivated vaccines are usually necessary to provide the best protection. The benefit of inactivated vaccines is that there is zero chance of developing any disease-related symptoms -- allergic reactions are possible but extremely rare.

Examples of inactivated vaccines are hepatitis A, hepatitis B, poliovirus, hemophilic influenza type b, meningococcal, pneumococcal and the injected form of influenza.

b) Live-attenuated vaccines: Live-attenuated basically means alive, but very weak. These vaccines are made when the virus is weakened to such a level that they reproduce only about 20 times in the body. 

When the vaccine is made, the virus or bacteria is weakened in a laboratory to the point where it's alive and able to reproduce, but can't cause serious illness. Its presence is enough to cause the immune system to produce antibodies to fight off the particular disease in the future. They typically provoke more durable immunological responses and are preferred for healthy adults.

Examples include the viral diseases yellow fever, measles, rubella, and mumps and the bacterial disease typhoid. 

c) Recombinant Vector vaccine – by combining the physiology of one micro-organism and the DNA of the other, immunity can be created against diseases that have complex infection processes.

d) DNA vaccination – in recent years a new type of vaccine called DNA vaccination has been created from an infectious agent's DNA. As in complex diseases the DNA quality of the infection changes thus no vaccine works on it.DNA vaccine works by insertion and expression, triggering immune system recognition of viral or bacterial DNA into human or animal cells. Some cells of the immune system that recognize the proteins expressed will mount an attack against these proteins and cells expressing them. 

MEDICAL TOURISM IN INDIA

Medical tourism can be generally defined as provision of 'cost effective' personal health care in association with the tourism industry for patients needing surgical healthcare and other forms of dedicated treatment.

This process is being facilitated by the corporate sector concerned in health care as well as the tourism industry - both personal and public.

Offering some of the best medical treatment in the world and with an excellent reputation in its private hospitals India's health care sector has undergone an enormous boom in recent years and it has become a global health destination, with its medical tourism area growing by 30 per cent each year. With the developed countries finding themselves over-burdened with the task of providing cost effective healthcare, India has emerged as a popular global health tourism destination.

India's private hospitals offer highly sophisticated and specialized medical services at very affordable prices, and a growing trend has emerged for patients from the UK to consider India for their private healthcare. India has one of the largest pharmaceutical industries in the world. It is self sufficient in drug production and exports drugs to more than 180 countries.

In fact, Indian doctors are considered to be among the best in the world and their high level of surgical expertise evolves by many years of training - after studying in India many doctors train and work in many developed countries. Interestingly apart from the specific health care issues Indian approach is a holistic approach. India is well known for alternative therapies and post treatment travel destinations.

India offers services in -

1. Bone Marrow Transplant

2. Cardiac Care

3. Cosmetic Surgery package 

4. Dialysis and Kidney Transplant package 

5. Orthopaedic surgery

6. Joint Replacement Surgery package etc.

Some characteristics:

a) India offers speciality & super-speciality treatments at 5-10 times less cost as compared to US & UK, despite providing world class quality treatment.

b) India offers highly advanced medical treatments not available in Middle East, Africa & SAARC countries (Afghanistan, Nepal, Bangladesh) at cost effective prices. 

c) India offers best mix of Western & Eastern health care systems. Besides Allopathic treatment, India offers various traditional treatment options like Ayurveda & Homeopathy.

d) India has become Medical Tourism capital of the modern world. Medical Tourism is expected to generate revenue of US $ 350 million by 2013 in India. 

e) Medical Tourism in India is expected to grow at an annual growth rate of 37 per cent from 2009-2012. 

f) Highly skilled medical fraternity, low treatment costs, cutting edge technological advancements & rich cultural heritage have made India the most sought after Medical Tourism destination.

MID-DAY MEAL SCHEME

The Mid Day Meal is the world’s largest school feeding programme reaching out to about 12 crore children in over 12.65 lakh schools/EGS centres across the country.

Mid Day Meal in schools has had a long history in India. In 1925, a Mid Day Meal Programme was introduced for disadvantaged children in Madras Municipal Corporation. By the mid 1980s three States viz. Gujarat, Kerala and Tamil Nadu and the UT of Pondicherry had universalized a cooked Mid Day Meal Programme with their own resources for children studying at the primary stage By 1990-91 the number of States implementing the mid day meal programme with their own resources on a universal or a large scale had increased to twelve states.

With a view to enhancing enrollment, retention and attendance and simultaneously improving nutritional levels among children all over India, the National Programme of Nutritional Support to Primary Education (NP-NSPE) was launched as a Centrally Sponsored Scheme on 15 August 1995, initially in 2408 blocks in the country. By the year 1997- 98 the NP-NSPE was introduced in all blocks of the country. It was further extended in 2002 to cover not only children in class I-V of government, government aided and local body schools, but also children studying in Education Guarantee Scheme and Alternative and Innovative Education centres.

Central Assistance under the scheme consisted of free supply of food grains @ 100 grams per child per school day, and subsidy for transportation of food grains up to a maximum of Rs 50 per quintal.

In September 2004 the scheme was revised to provide cooked mid day meal with 300 calories and 8-12 grams of protein to all children studying in classes I-V in Government and aided schools and EGS/AIE centres. In addition to free supply of food grains, the revised scheme provided Central Assistance for (a) Cooking cost @ 1 per child per school day, (b) Transport subsidy was raised from the earlier maximum of 50 per quintal to 100 per quintal for special category states, and  75 per quintal for other states, (c) Management, monitoring and evaluation costs @ 2 per cent of the cost of foodgrains, transport subsidy and cooking assistance, and (d) Provision of mid day meal during summer vacation in drought affected areas.

In July 2006 the nutritional norm has increased from existing 300 calories and 8-12 gram protein to minimum 450 Calories and 12 gram of protein. Assistance for cooking / kitchen devices (gas stove with connection, stainless steel water storage tank, cooking and serving utensils etc.) in a phased manner @ _ 5,000 per school.

In September 2007, the name of the Scheme was changed from 'National Programme of Nutritional Support to Primary Education 'to 'National Programme of Mid Day Meal in Schools' and the Scheme was extended to cover children of upper primary classes (i.e. class VI to VIII) studying in 3,479 Educationally Backward Blocks. The calorific value of the Mid Day Meal for upper primary stage was fixed at 700 Calories and 20 grams of protein.

The Scheme was further revised in April 2008 to cover all upper primary schools of country and also to include recognized Madrasas / Maqtabs supported under SSA as Government Aided schools as well as those Madrasas / Maqtabs which may not be registered or recognized but supported under SSA as EGS / AIE intervention in coordination with State Project Directors of SSA.

During the year 2009 the following changes have been made to improve the implementation of the scheme: Food norms have been revised to ensure balanced and nutritious diet to children of upper primary group by increasing the quantity of pulses from 25 to 30 grams, vegetables from 65 to 75 grams and by decreasing the quantity of oil and fat from 10 grams to 7.5 grams.

Monitoring Mechanism

The Department of School Education and Literacy, Ministry of Human Resource Development has prescribed a comprehensive and elaborate mechanism for monitoring and supervision of the Mid Day Meal Scheme. The monitoring mechanism includes the following:

• Representatives of Gram Panchayats/Gram Sabhas, as well as Mothers' Committees are required to monitor the (i) regularity and wholesomeness of the mid day meal served to children, (ii) cleanliness in cooking and serving of the mid day meal, (iii) timeliness in procurement of good quality ingredients, fuel, etc. (iv) implementation of varied menu and (v) social and gender equity. This is required to be done on a daily basis.

• In order to ensure that there is transparency and accountability, all schools and centres where the programme is being implemented are required to display information suo-moto. This includes information on:
a) Quality of foodgrains received, date of receipt.
b) Quantity of foodgrains utilized.
c) Other ingredients purchased, utilized
d) Number of children given mid day meal.
e) Daily Menu
f) Roster of Community Members involved in the programme.

• Officers of the State Government/UTs belonging to the Departments of Revenue, Rural Development, Education and other related sectors, such as Women and Child Development, Food, Health are also required to inspect schools and centres where the programme is being implemented.

• The FCI is responsible for the continuous availability of adequate food grains in its Depots. It allows lifting of food grains for any month/quarter up to one month in advance so that supply chain of food grains remains uninterrupted. The District Collector/CEO of Zila Panchayat ensures that food grains of at least Fair Average Quality are issued by FCI.

Accredited Social Health Activists (ASHAs)

Recognizing the importance of health in social and economic development and improving the quality of life of the people, Government of India has launched the National Rural Health Mission, (NRHM), in the year 2005. The mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, hygiene, sanitation and safe drinking process.

The main purpose is to provide effective health care to the entire rural population in the country. The core strategy of the mission is to provide well trained female health activist (Accredited Social Health Activist- ASHA) in each village (1/1000 population) to fill the gap of unequal distribution of health services in rural area.

ASHAs are expected to create awareness on health and its determinants, mobilize the community towards local health planning, and increase utilization of the existing health services.

Read this article for comparision between ASHA and ANM

Role of ASHA:

Create awareness
They create awareness about the Health, Nutrition, basic sanitation, hygienic practices, healthy living and working conditions, information on existing health services and need for timely utilization of health, nutrition and family welfare services.

Counseling.

ASHAs counsel people for Birth preparedness, importance of safe and institutional delivery, breast-feeding, immunization, contraception, prevention of RTI/STI, Nutrition and other health issues.

Mobilization

Facilitate to access and avail the health services available in the public health system at Anganwadi Centers, Sub Center, Primary Health Centre and district hospitals.

Village health plan

Work with the village Health and sanitation Committee to develop the village health plan.

Escorts/ Accompany

They escort the needy patients to the institution for care and treatment.

• Accompany the woman in labor to the institution and promote institutional delivery
• Provision of Primary Medical Health Care
• Minor ailments such as fever, first aid for minor injuries, diarrhea.
• Provider for DOTS
• Depot Holder ORS, IFA, DDK, chloroquine, oral pills and condoms
• Care of new born and management of a range of common ailments
• Inform Births, deaths and unusual health problem or disease out break
• Promote Construction of household toilets

Recently the Mission Steering Group (the highest decision making body of the NRHM)has approved the proposal for involving ASHAs in activities such as spacing between births, promoting iodised salt and village sanitation.

Thus the accredited social health activists (ASHAs) — the first port of call for health cares under the National Rural Health Mission (NRHM) — will be entrusted with additional responsibilities, albeit with better monetary incentives.

The ASHAs will now have to work as a counseller for the newly-married couples and those with one child to have their first child after two years of marriage and space their children for at least three years. For this, the ASHAs would be paid an incentive of Rs. 500 per couple she manages to convince for spacing between births.

It has also been decided to involve ASHAs in organising the monthly village health sanitation and nutrition committee (VHSNC) meeting for which she will be paid an incentive of Rs. 150 a month. This meeting will be followed by the meeting of women and adolescent girls where the health and sanitation needs of adolescent girls would be discussed.

Importantly, it has also been decided to further incentivise ASHAs by providing an additional Rs. 100 for every child who receives complete first year immunisation and Rs. 50 for every child who further completes two years of immunisation as per the stipulated schedule. As of now, ASHA gets Rs. 150 for mobilising children to immunisation session sites.

The Centre has also identified 303 anaemia endemic districts in the country where each ASHA will be given an honorarium of Rs. 25 a month for testing 50 salt samples for checking iodine content.

Thus the additional responsibilities along with the monetary incentives have been proposed to encourage and motivate ASHAs for better work.

NATIONAL RURAL HEALTH MISSION

Recognizing the importance of Health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has launched the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. 

The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care.

National Rural Health Mission was launched on 12th April, 2005 with an objective to provide effective health care to the rural population, the disadvantaged groups including women and children by improving access, enabling community ownership, strengthening public health systems for efficient service delivery, enhancing equity and accountability and promoting decentralization

The scheme proposes a number of new mechanisms for healthcare delivery including training local residents as Accredited Social Health Activists (ASHA) and the Janani Surakshay Yojana (motherhood protection program). It also aims at improving hygiene and sanitation infrastructure. It is the most ambitious rural health initiative ever.

The mission has a special focus on 18 states Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh.

Goals of NHRM

a) Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR) 

b) Universal access to public health services such as Women’s health, child health, water, sanitation &hygiene, immunization, and Nutrition

c) Prevention and control of communicable and non-communicable diseases, including locally endemic diseases 

d) Access to integrated comprehensive primary healthcare 

e) Population stabilization, gender and demographic balance.

f) Revitalize local health traditions and mainstream AYUSH.

g) Promotion of healthy life styles.

Salient features of NHRM:

• Innovation in Human Resource Management

Promote access to improved healthcare at household level through the Accredited Social Health Activist (ASHA). ASHA would act as a bridge between the Auxiliary Nurse and the village Midwives and be accountable to the Panchayat. ASHA would facilitate in the implementation of the Village Health Plan along with Anganwadi worker, ANM, functionaries of other Departments, and Self Help Group members, under the leadership of the Village Health Committee of the Panchayat.

• Strengthening Public Health Delivery in India

New concept of Indian Public Health Standards introduced. They are set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission.

• Strengthening PHCs

Mission aims at Strengthening PHC for quality preventive, promotive, curative, and supervisory and Outreach services through adequate and regular supply of essential quality drugs and equipment (including Supply of Auto Disabled Syringes for immunization) to PHCs. Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus States, through mainstreaming AYUSH manpower.

• Strengthen CHCs

Infrastructure strengthening of CHCs by implementation of IPHS standards which includes Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management and developing standards of services and costs in hospital care.

• Decentralized Planning

This includes “District Health Mission” at the District level and the “State Health Mission” at the state level. District Health Plan would be a reflection of synergy between Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition. It also includes involvement of PRIs in planning process to improve access of facilities.

• Strengthening Disease Control Mechanisms

National Disease Control Programmes for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme has been integrated under the Mission, for improved programme delivery and new Initiatives have been launched for control of Non Communicable Diseases. Further disease surveillance system at village level would be strengthened. Supply of generic drugs (both AYUSH & Allopathic) for common ailments at village, SC, PHC/CHC level will also be included.

Janani Shishu Suraksha Karyakram

Health is a State Subject and State Governments are providing health care including drugs to the patients. In order to strengthen the hands of the State Governments, the Ministry of Health and Family Welfare is providing additional support under the National Rural Health Mission (NRHM) for overall health system strengthening including support for provision of free drugs in public health facilities.

Janani Suraksha Yojana was launched in 2005. The scheme is intervention for safe motherhood and seeks to reduce maternal and neo-natal mortality by promoting institutional delivery, i.e. by providing a cash incentive to mothers who deliver their babies in a health facility. The scheme is fully sponsored by the Central Government and is implemented in all states and Union Territories (UTs), with special focus on low performing states. With the launch of JSY the number of institutional deliveries has increased manifold. There are however more than 25% pregnant women who still hesitate to access facilities. Important factors affecting access include: 

a) User charges for OPD, admissions, blood etc.

b) Expense on medicines and other consumables.

c) Cost can be very high in case of caesarean operations. 

Thus under NRHM, a new initiative called Janani Shishu Suraksha Karyakram (JSSK) has been launched in 2011 for providing free and cashless maternity services  and newborn care in all Government healthcare institutions including diet, no out-of-pocket expenditure for drugs, disposables, diagnostics, blood transfusion, referral transport and drop back facility. Janani-Shishu Suraksha Karyakram supplements the cash assistance given to a pregnant woman under Janani Suraksha Yojana and is aimed at mitigating the burden of out of pocket expenses incurred by pregnant women and sick newborns. Besides it would be a major factor in enhancing access to public health institutions and help bring down the Maternal Mortality and Infant mortality rates.

The Free Entitlements under JSSK would include:

1. Free and Cashless Delivery

2. Free C-Section

3. Free treatment of sick-new-born up to 30 days

4. Exemption from User Charges

5. Free Drugs and Consumables

6. Free Diagnostics

7. Free Diet during stay in the health institutions – 3 days in case of normal delivery and 7 days in case of caesarean section

8. Free Provision of Blood

9. Free Transport from Home to Health Institutions

10. Free Transport between facilities in case of referral as also Drop Back from Institutions to home after 48hrs stay.

11. Free Entitlements for Sick newborns till 30 days after birth similarly include Free treatment, Free drugs and consumables, Free diagnostics, Free provision of blood, Exemption from user charges, Free Transport from Home to Health Institutions, Free Transport between facilities in case of referral and Free drop Back from Institutions to home.

Eligibility for Cash Assistance:

• Low Performing States-All pregnant women delivering in Government health centres or accredited private institutions.

• High Performing States-BPL pregnant women, aged 19 years and above.

• Low and High both-All SC and ST women delivering in a government health centre or accredited private institutions

Uttar Pradesh,Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir have been identified as Low Performing States while all others are High Performing States.