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• Ayushman Bharat – Pradhan Mantri Jan Aryogya Yojna (AB-PMJAY)
• Ayushman Bharat – Digital Health Mission (AB-DHM)
• Pm Ayushman Bharat Health Infrastructure Mission (PMAB-HIM)
• Decriminalization of Medical Negligence
• Immunization Program in India/ Vaccination
• BCG Vaccine – 100 years and Counting
• Maternal health – Schemes

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1) AYUSHMAN BHARAT – PRADHAN MANTRI JAN ARYOGYA YOJNA (AB-PMJAY)

• About AB-PMJAY (Pradhan Mantri Jan Arogya Yojana)
  • Ministry: MoH&FW
  • AB-PMJAY is an entitlement based scheme that aims to provide health insurance cover of upto 5 lakh rupees per family to over 10 crore poor families (about 50 crore population) for secondary and tertiary care hospitalization. There is no cap on the size of the family or age of the beneficiary.
    • All pre-existing conditions are also covered from day 1 of implementation of PM-JAY in respective states/UT.
  • It is the world’s largest government funded health care program.
  • The eligible poor families are decided on the basis of SECC, 2011 data and include poor, deprived rural families and occupational category of urban worker’s families (Roughly 8.03 crore rural families and 2.33 crore urban families (11 occupational criteria)).
    • In addition the beneficiary of RSBY are also included.
    • Further, there is no capping on number of family members or age of members -> this ensures that senior citizens and girl children also get good health services.
  • The scheme provides cashless and paperless access to services for the beneficiary at the point of service. Eligible people can avail the benefits at both government and listed (empanelled) private hospitals.
    • In case of hospitalization, members of the beneficiary families don’t need to pay anything under the scheme, provided one goes to a government or an empanelled private hospital.
  • It is a centrally sponsored scheme, so, there is a state component too (60:40).
  • It is a portable scheme, which means beneficiary can avail benefits in any of the states that is implementing the scheme.
  • It subsumes Rashtriya Swastha Bima Yojana and the Senior Citizen Health Insurance Scheme (SCHIS).
  • Adhaar card is not mandatory – identity to avail benefit can be established through ration card or election ID card.

2) AYUSHMAN BHARAT – DIGITAL HEALTH MISSION (AB-DHM)

• Details
  • The missions aim to create a complete Digital Health Ecosystem which will connect the digital health solutions of hospitals across the country with each other.
    • This digital ecosystem will enable a host of other facilities like Digital Consultation; Consent of Patients in letting medical practitioners access their records, etc. This will ensure that all medical records are stored digitally and are thus not lost. They would be accessible through app or web-portal.
    • All this will help in improving the quality, access, and affordability of health services by making the service delivery “quicker, less expensive, and more robust”.
  • Unique Health ID:
    • Any person wanting to be part of ABDHM will get a health ID, which is a randomly generated 14-digit number. It will be used for three purposes – Unique Identification; Authentication; and Threading of the beneficiary’s health records, only with their informed consent, across multiple systems and stakeholders.
  • Facilities:
    • You can access your digital records right from admission through treatment and discharge.
    • You can access and linkyourpersonal health records with yourhealth IDto create a longitudinal health history.
  • NDHM Sandbox
    • It is a digital architecture that allows private players to be part of the National Digital Health Ecosystem as health information providers or health information users.
  • Privacy:
    • Citizen’s consent is vital for all access.
    • Users can delete or exit the services anytime he wants.
  • Upcoming features:
    • Future features will enable access to verified doctors across the country.
    • The beneficiary can also create health ID for her child, a digital health records right from birth.
    • She can add a nominee to access her health ID and view or help manage the personal health records.
    • Also, there will be much inclusive access with the health ID available to people who don’t have phones, using assisted methods.
• Why can’t Adhaar be used as Digital ID:
  • The Adhaar Act and Supreme Court verdict restrict the use of Adhaar ID for welfare schemes promoting government subsidies.
• Significance: (ease of living; optimal treatment; reduce re-testing; increased accountability; easy identification of specialists, doctors, labs; Big Data, Data Mining and Artificial intelligence-based solution etc.

A) E-SANJEEVANI – NATIONAL TELEMEDICINE SERVICE

• Ministry: MoH&FW
• It is an innovative, indigenous, cost-effective, and integrated cloud based telemedicine system application to enable patient to doctor teleconsultation to ensure a continuum of care and facilitate health services to all citizens in the confines of their home.
• Two verticals of eSanjeevani
  • eSanjeevaniAB-HWC: It endeavors to bridge rural-urban digital health divide by providing assisted teleconsultation, and ensuring that e-beneficiaries of AB Scheme are able to avail the benefits that they are able to entitled to.
    • It operates on Hub and Spoke Model wherein the ‘Ayushman Bharat – Health and Wellness Centre’ are set up at the state level, act as spokes, which are mapped with the hub (comprising MBBS/ Specialty/ Super Specialty doctors) at zonal level.
  • eSanjeevaniOPD is the latter vertical which caters to citizens in both rural and urban alike. It leverages technology via smartphones, tablets, laptops etc. enabling doctor consultation to be accessible from the patient’s residence regardless of location.
• Progress So far:
  • As of Jan 2023, 1,12,553 HWC in rural areas and 15465 Hubs at tertiary level hospitals, and medical colleges in the states have been enabled in the eSanjeevani.
  • Patients Served: It has served 9.3 crore patients so far and is serving around 4 lakh patients daily.
• E-Sanjeevani is evolved into the world’s largest outpatient Services system.
• It is a cohesive part of Ayushman Bharat Digital Health Mission (ABDM) and more than 45,000 ABHA IDs have been generated using eSanjeevani Portal.

3) PM AYUSHMAN BHARAT HEALTH INFRASTRUCTURE MISSION (PMAB-HIM)

• PMABHIM, announced in the Budget 2021-22, is the largest pan-India Health Infrastructure Scheme which aims to strengthen the PAN-India health infrastructure.
• It is a centrally sponsored scheme with a budgetary outlay of Rs 64,180 crore for the FY 2021-22 to 2025-26 and will improve health care facilities from village to national level in this period.
• There are three major aspects of the ABHIM – Augmenting Healthcare facilities for treatment; Setting up of integrated public health labs for diagnosis of diseases; and Expansion of existing research institutions that study pandemics.

4) DECRIMINALIZATION OF MEDICAL NEGLIGENCE

• Why in news?
  • Bhartiya Nyaya Samhita has kept the punishment for medical negligence lower than the punishment for causign death by other kinds of negligence (Dec 2023).
• Introduction
  • As per the Section 106(1) of the Bhartiya Nyaya (Second) Sanhita (BNSS), doctors will continue to face a two year imprisonment and/or fine if convicted. This is lesser than the Sanhita’s recommended punishment of five years for other cases of death by negligence (for e.g. by rash driving).
• Note: The maximum imprisonment of doctors with this amendment remain the same as it was under IPC section 304A – upto 2 years of imprisonment or fine or both.
  • Medical negligence has not been clubbed with other accidental deaths where punishment has been kept higher.
• Need of lower punishment for medical negligence:
  • Doctor’s shouldn’t be punished for honest mistakes and negligence is a complex issue in medical field and therefore this shouldn’t be clubbed with other kinds of negligence.
  • It will also reduce harassment of doctors from frivolous lawsuits and harassment.
  • It will ensure that doctors will be able to provide care without fear of persecution and patients can be assured of quality care.
• Criticisms:
  • Critiques argue that doctors should be more careful and the scope of negligence should be lesser here.
  • Owing to the “power imbalance” in the doctor-patient relationship, an act of negligence on the part of the doctor calls not for a lower punishment but a higher one.

5) IMMUNIZATION PROGRAM IN INDIA/ VACCINATION

• Various Initiatives
  • The government had launched Expanded Program for Immunization in 1978 which was further replaced by Universal Immunization Program (UIP) in 1985. It is the largest Immunization Program in the world, with the annual coverage of 2.6 crore infants and 2.9 crore pregnant women. Through this India has achieved ground breaking success in eradicating/ eliminating life threatening vaccine preventable diseases like small pox, Polio, Maternal Neonatal Tetanus etc.
    • But despitea lot of efforts and improvements, the immunization coverage had been slow to increase with a coverage of 62% according to NFHS-4 released in 2015-16.
• Key Factors behind low Immunization Coverage
  • Rapid and Unplanned urbanization.
  • Large migrating and isolated population is difficult to cover.
    • Difficult terrains, areas under LWE etc. are also difficult to cover.
  • Lack of awareness among uninformed masses and unaware population leads to low demand of immunization.
• Other problems with vaccination system in India
  • Inequality in vaccine administration – Socio-economic status-based vaccine disparity with the disadvantaged and underserved groups being left out.
  • Vaccine Hesitancy: Rumor Mongering/ Misinformation among some population also prevents full coverage.
• Negative Impact of COVID-19 on routine vaccination
• Various Efforts to deal with above challenges:
  • MoH&FW have employed an effective approach – such as involving the community, seeking the support from other ministries and partner agencies, establishing an organized surveillance system, and employing mass campaign management strategies to reach every unreached child for vaccination.
  • Mission Indradhanush was launched by the MoH&FW in 2014. It is a strategic endeavor under UIP with an aim to target under-served, vulnerable and inaccessible populations.
    • It covers 8 vaccines (Diphtheria, Whooping Cough, Tetanus, Polio, Measles, Childhood TB, Hepatitis B and Meningitis) across the country, 2 vaccines (Pneumonia and Hemophilus influenza type B) in selected states and 2 vaccines (Rotavirus Diarrhea and Japanese Encephalitis) in selected districts.
    • MI contributed to an increase of 6.7% in full immunization coverage after the first two phases of Mission Indradhanush.
  • Intensified Mission Indradhanush (IMI) was launched in Oct 2017 – to achieve a coverage of 90% with focus towards districts and urban areas with persistently low levels.
  • In Dec 2019, Government had launched Intensified Mission Indradhanush 2.0 (IMI 2.0) to be implemented between Dec 2019 – March 2020 that seeks to escalate efforts to achieve the goal of attaining a 90% national immunization coverage across the country.
  • Intensified Mission Indradhanush 3.0 aimed to reach those children and pregnant women who have been missed out of the routine immunization program. The first phase ran from 22nd Feb 2021 for 15 days.
  • Intensified Mission Indradhanush 4.0 launched in Feb 2022.
    • Three rounds of IMI 4.0 was planned to catchup on the gaps that might have emerged due to COVID-19 pandemic. The activity will be conducted in 416 districts across 33 states/Uts.
    • These districts were identified based on vaccination coverage as per the latest National Family Health Survey-5 report, Health Management Information System (HMIS) data and burden of vaccine preventable diseases.
  • Intensified Mission Indradhanush 5.0 (IMI 5.0) campaign was being conducted in three rounds:
    • 7-12 Aug 2023; 11-16 Sep 2023; and 9-14 Oct 2023 (6 days every month)
    • It aims to ensure immunization coverage of all vaccines provided under the UIP as per the National Immunization schedule.
    • Special focus is on improvement of Measles and Rubella vaccination coverage with the aim of Measles and Rubella elimination by 2023.
    • It ensures that routine immunization services reach the missed-out and dropped out children and pregnant women across country. This year, for the first time the campaign was conducted across all districts in the country and include children upto 5 years of age (previous campaigns included children upto 2 years of age)
    • It saw participation from Jan pratinidhis and Social media influencers have come in large numbers across all states/ Uts to appeal to people to visit nearest vaccination centres.
  • Since 2014, 11 phases of Mission Indradhanush have been completed.

6) BCG VACCINE – 100 YEARS AND COUNTING

• BCG was first used in humans in 1921.
• Details about BCG vaccine (bacilli Calmette-Guerin)
  • BCG was developed by two Frenchmen, Albert Calmette and Camille Guerin.
    • It is a live attenuated strain derived from an isolate of Mycobacterium bovis and has been used widely across the world as a vaccine for tuberculosis. Currently, it is the only licensed vaccine available for the prevention of TB. It is the world’s most widely used vaccine with about 120 million doses every year.
  • Interesting Fact: Works well in some geographical locations and not so well in others. Generally, the farther a country is from equator, the higher is the efficacy. Therefore, it has high efficacy in UK, Norway, Sweden, and Denmark; and little or no efficacy in countries on or near the equator like India, Kenya, and Malawi, where the burden of TB is higher. These regions also have higher prevalence of environmental mycobacteria.
    • However, in children BCG provides strong protection against severe forms of TB. This protective effect appears to wane with age and is far more variable in adolescents and adults, ranging from 0-80%.
    • A large clinical trial between 1968-1983 by ICMR’s National Institute for Research in TB in Chengalpattu district of TN, indicated that BCG offered no protection against pulmonary TB in adults, and a low level of protection (27%) in children.
• Other uses of BCG
  • BCG also protect against respiratory and bacterial infections of the newborns, and other mycobacterial diseases like leprosy and Buruli’s ulcer.
  • It is also used as an immunotherapy agent in cancer of the urinary bladder and malignant melanoma.
• BCG in India
  • BCG vaccinations were first conducted in India in 1948 and it became part of the National TB control program in 1962.
  • It remains a part of basket of vaccines included under the Universal Immunization Program.
• Other TB vaccines:
  • Over the last ten years, 14 new Vaccines have been developed for TB and are in clinical trials. Of particular interest is a Phase-3 clinical trial by the ICMR, of two vaccines:
    • A Recombinant BCG called VPM 1002
      • Currently, IAVI is partnering with study sponsor Serum Institute of India Pvt. Ltd. (SIIPL) and Vakzine Projekt Management GmbH (VPM), a German development consulting firm to conduct the “priMe Study”. “priME is a multicenter, double-blind, randomized, active controlled Phase-III study to evaluate the efficacy and safety of the vaccine candidate in comparison to BCG.
      • VPM1002 is a recombinant BCG and include a gene from Listeria monocytogenes, that codes for the production of a protein called listeriolysin O. This protein ensures better availability of TB antigens so that the immune system can mount what may be more effective response.
  • Mycobacterium Indicus Pranii (MIP) – It was identified and developed into a vaccine in India.
    • MIP is a non-pathogenic mycobacterial species.
    • The name is based on the site of isolation of the bacterial species from India (indicus), discovery by Pran Talwar (pranii) and characterization at the National Institute of Immunology, India (pranii).

7) MATERNAL HEALTH – SCHEMES

A) UNDERSTANDING MATERNAL MORTALITY RATE

• Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
• Maternal Mortality Rate (MMR) provides a measure of the quality of safe deliveries and maternal care and India’s healthcare services have lagged in this respect in comparison to neighbours like China, Sri Lanka and Maldives.

Trends in Mortality indicators

	2014	2016	2018	2020
Maternal Mortality Ratio (per lakh live births)	167 (2011-13)	130 (2014-16)	113 (2016-18)	97 (2018-20)
Infant Mortality Rate (per 1000 live births)	39	34	32	28
Neonatal Mortality Rate (per 1000 live births)	26	24	23	20
Under 5 Mortality Rate (per 1000 live births)	45	39	36	32
Early Neonatal Mortality Rate - 0-7 days (per 1000 live births)	20	18	18	15

Source: Sample Registration System

With concerted efforts made under the Reproductive, Maternal, New-born, Child, Adolescent Health Plus Nutrition (RMNCAH+N) strategy, India has made considerable progress in health in improving the health status of both mothers and Children.

• As per the Sample Registration Survey (SRS) data, India has successfully achieved the major milestones to bring Maternal Mortality Ratio (MMR) to below 100 per lakh live births by 2020 [laid down in the National Health Policy, 2017]
• Eight states have already achieved the 2030 SDG targets to reduce MMR to less than 70 per lakh live births by 2030. These include Kerala (19), Maharashtra (33), Telangana (43), Andhra Pradesh (45), Tamil Nadu (54), Jharkhand (56), Gujarat (57), and Karnataka (69).

 

B) NATIONAL HEALTH MISSION 2013

• With respect to mother’s health, the NHM includes following initiatives:
  • Reproductive Maternal Neonatal Child and Adolescent Health (RMNCH+A) Program.
  • Janani Surakha Yojna (JSY) to promote institutional delivery which is expected to reduce neo-natal and maternal mortality.

 

C) JANANI SURAKHA YOJANA (2005 SCHEME)

• The JSY is a safe motherhood intervention launched in 2005 as part of the NRHM to improve maternal and neonatal health by promotion of institutional deliveries (childbirth in hospitals).
• It is a 100% centrally sponsored scheme which integrates cash assistance with delivery and post-delivery care
• Key Features
  • Financial assistance under JSY is available to all pregnant women in states that have low institutional delivery rates namely, UP, UK, Bihar, Jharkhand, MP, Chhattisgarh, Orissa, Assam, Rajasthan & J&K (categorized as low performing states).
  • In remaining states (where institutional delivery are satisfactory, pregnant women from BPL/SC/ST households only are entitled for JSY benefits.
  • It is implemented through ASHA, the accredited social health activists, acting as an effective link between the Government and poor pregnant women under the scheme.

 

D) JANANI SHISHU SURAKSHA KARYAKRAM

• The program launched in 2011 entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery including Caesarean section.
  • The program stipulates free drugs, diagnostics, blood and diet, besides free transport from home to institution, between facilities in case of a referral and drop back home.
  • Similar entitlement has been put in place for all sick infants accessing public health institutions for treatment.

 

E) MATERNITY BENEFIT SCHEME (MBS) / PRADHAN MANTRI MATRITVA VANDANA YOJANA (PMMVY)

• Details of the Scheme:
  • Under PMMVY a ‘cash incentive of Rs 5,000 is provided directly to the bank account of the pregnant or lactating mothers for the first living child of the family.
  • It is aimed at improving health seeking behavior, arresting MMR, ensuring proper nutrition and offsetting wage loss.
  • The scheme is being implemented from 1st Jan 2017.
• Target Women
  • Eligible PW&LM, excluding women in regular employment who are in receipt of similar benefits under any law for the time being.
• Other key provisions of the scheme:
  • Center: State Share: 60: 40
  • The benefit of Rs 5000 to PW&LM in three installments for the birth of first live child by MWCD and remaining incentives as per the approved norms towards maternity benefit under existing programs after institutional deliveries so that on an average women would receive Rs 6,000.
  • Conditional cash transfer scheme would be in DBT mode.
• Limitation of the Scheme
  • Only for first child
  • Amount too small
  • Several conditions attached
  • Subsuming of Janani Surakha Yojana: JSY which is a cash based incentive of Rs 14,00 for institutional deliveries, has been subsumed under this scheme. JSY is an older scheme started for a different purpose and should not be confused with maternity benefits for wage compensation.

 

F) STATE GOVERNMENTS RUNNING THEIR EFFECTIVE SCHEMES (TN AND ODISHA)

• Dr. Muthulakshmi Reddy Maternity Benefit Scheme in TN provides for financial assistance of Rs 18,000 per child for the first two children.
• MAMATA Scheme of Odisha provides Rs 5,000 for first two children.
  • These two schemes are working reasonably well due to their wider coverage and simplerprocess.
  • In 2020-21, MAMATA showcased a 57% increase in women who received all installments, and PMMVY showcased a decrease.

 

G) SUMAN (SAFE MOTHERHOOD ASSURANCE / SURAKSHIT MATRITVA INITIATIVE

• Launched by MoH&FW in 2019.
• The initiative is aimed at zero preventable maternal and new born deaths.
• It brings all the services, which are currently being provided to pregnant woman, under one umbrella from ante-natal registration upto delivery to strengthen the services to prevent maternal deaths.
• It will also strengthen the system of grievance redressal and ensure greater accountability and transparency.
  • It is a center’s initiative that will ensure fully responsive and accountable health system.
• Suman would be implemented in a phased wise manner throughout the country.