REPORT NO. 99

PARLIAMENT OF RAJYA SABHA

DEPARTMENT-RELATED PARLIAMENTARY STANDING COMMITTEE ON HEALTH AND FAMILY WELFARE

NINETY-NINTH REPORT Demands for Grants 2017-18 (Demand No.42) of the Department of Health and Family Welfare (Ministry of Health and Family Welfare)

(Presented to the Rajya Sabha on 20th March, 2017) (Laid on the Table of on 20th March, 2017)

Rajya Sabha Secretariat, New Delhi March, 2017/Phalguna, 1938 (Saka) Website : http://rajyasabha. nic. in E-mail : [email protected]. in Hindi version of this publication is also available

PARLIAMENT OF INDIA RAJYA SABHA

DEPARTMENT-RELATED PARLIAMENTARY STANDING COMMITTEE ON HEALTH AND FAMILY WELFARE

NINETY-NINTH REPORT Demands for Grants 2017-18 (Demand No.42) of the Department of Health and Family Welfare (Ministry of Health and Family Welfare)

(Presented to the Rajya Sabha on 20th March, 2017) (Laid on the Table of Lok Sabha on 20th March, 2017)

Rajya Sabha Secretariat, New Delhi March, 2017/Phalguna, 1938 (Saka)

CONTENTS

PAGES

1. COMPOSITION OF THE COMMITTEE...... (i)-(ii)

2. INTRODUCTION...... (iii)-(iv)

3. ACRONYMS (NHM, Health Sector)...... (V)-(X)

4. REPORT...... 1-66

Part-A (NHM)...... 1-33

Part-B (Health Sector)...... 34-66

5. RECOMMENDATIONS/OBSERVATIONS — AT A GLANCE...... 67-89

(Part A and B)......

6. MINUTES...... 91-97

7. ANNEXURES ...... 99-128

COMPOSITION OF THE COMMITTEE (2016-17)

1. Prof. Ram Gopal Yadav — Chairman RAJYA SABHA 2. Shrimati Renuka Chowdhury 3. Shri Rajkumar Dhoot 4. Dr. R. Lakshmanan 5. Dr. Vikas Mahatme 6. Shri Jairam Ramesh 7. Shri Ashok Siddharth 8. Shri Gopal Narayan Singh 9. Shri K. Somaprasad 10. Dr. C. P. Thakur LOK SABHA 11. Shri Thangso Baite $12. Shrimati Ranjanaben Bhatt %13. Shri Gyan Singh 14. Shri *15. Dr. Ratna De (Nag) ^16. Shri Dasrath Tirkey 17. Dr. (Smt.) Heena Vijay Gavit 18. Dr. Sanjay Jaiswal 19. Dr. K. Kamaraj 20. Shri Arjunlal Meena 21. Shri 22. Shri J. Jayasingh Thiyagaraj Natterjee 23. Shri Chirag Paswan

$ ceased to be member of the Committee w.e.f 20th October, 2016. % nominated as a member of the Committee w.e.f. 02nd January, 2017. * ceased to be member of the Committee w.e.f 02nd January, 2017. ^ nominated as a member of the Committee w.e.f. 02nd January, 2017.

(i) 24. Shri C. R. Patil 25. Shri M.K. Raghavan 26. Dr. Manoj Rajoria 27. Dr. Shrikant Eknath Shinde 28. Shri R.K. Singh (Arrah) 29. Shri Bharat Singh 30. Shri Kanwar Singh Tanwar 31. Shrimati Rita Tarai 32. Shri SECRETARIAT Shri P.P.K. Ramacharyulu, Additional Secretary Shrimati Arpana Mendiratta, Director Shri Rakesh Naithani, Joint Director Shri Dinesh Singh, Joint Director Shrimati Harshita Shankar, Assistant Director Shri Pratap Shenoy, Committee Officer Shrimati Gunjan Parashar, Research Officer

(ii) INTRODUCTION

I, the Chairman of the Department-related Parliamentary Standing Committee on Health and Family Welfare, having been authorized by the Committee to present the Report on its behalf, hereby present this 99th Report of the Committee on the Demands for Grants (Demand No.42) of the Department of Health and Family Welfare, Ministry of Health and Family Welfare, for the year 2017-18.

2. The Committee held one sitting on 2nd March, 2017 for examination of Demands for Grants (2017-18) of the Department of Health and Family Welfare and heard the Secretary (Ministry of Health and Family Welfare) and other officers thereon.

3. The Committee considered the Draft Report and adopted the same in its meeting held on 17th March, 2017.

4. The Committee while making its observations/recommendations has mainly relied upon the following documents:-

(i) Address by the President of India to both Houses of Parliament assembled together on 31st January, 2017;

(ii) Speech of Finance Minister on 1st February, 2017 while presenting the Union Budget 2017-18;

(iii) Implementation of Budget Announcements 2016-17;

(iv) Detailed Demands for Grants of the Department of Health and Family Welfare for the year 2017-18;

(v) Annual Report of the Department for the year 2016-17;

(vi) Detailed Explanatory Note on Demands for Grants of the Department of Health and Family Welfare for the year 2017-18;

(vii) Physical and financial targets fixed and achievements made so far during the Twelfth Plan period;

(viii) Projection of outlays for the schemes to be undertaken by the Department during the Financial Year 2017-18;

(ix) Details of under-utilization of the allocations made under different heads during the Twelfth Plan period;

(x) Written replies furnished by the Department to the Questionnaires sent to them by the Secretariat;

(iii) (xi) Presentation made by the Secretary (Ministry of Health and Family Welfare) and other concerned officers; and

(xii) Written clarifications furnished by the Department, on the points/issues raised by the Members during the deliberations of the Committee.

5. For facility of reference and convenience, observations and recommendations of the Committee have been printed in bold letters in the body of the Report.

NEW DELHI; PROF. RAM GOPAL YADAV 17 March, 2017 Chairman, Phalguna 26, 1938 (Saka) Department-related Parliamentary Standing Committee on Health and Family Welfare Rajya Sabha

(iv) ACORONYMS (NHM Sector)

AES : Acute Encephalitis Syndrome ANM : Auxiliary Nurse Midwife ASHAs : Accredited Social Health Activists BPL : Below Poverty Line BRICS : Brazil, Russia, India, China and South Africa CDs : Communicable Diseases CDSCO : Central Drugs Standard Control Organisation CEmOC : Comprehensive Emergency Obstetric Care CHCs : Community Health Centres DOTS : Directly Observed Treatment Short-course EAG : Empowered Action Group ECPs : Emergency Contraception Pills EFC : Expenditure Finance Committee FIPV : Fractional Inactivated Polio Vaccine GDP : Gross Domestic Product Gol : Government of India GNM : General Nursing and Midwifery HMIS : Health Mangement Information System IEC : Information, Education, Communication IMR : Infant Mortality Rate IPHS : Indian Public Health Standards IDSP : Integrated Disease Surveillance Programme IPV : Inactivated Polio Vaccine IUCD : Intrauterine Contraceptive Device JE : Japanese Encephalitis JSSK : Janani Shishu Suraksha Karyakaram JSY : Janani Suraksha Yojana LF : Lymphatic Filarisis MDA : Mass Drug Administration MMR : Maternal Mortality Ratio

(v) MoHFW : Ministry of Health and Family Welfare MDGs : Millennium Development Goals MO : Medical Officer MoU : Memorandum of Understanding MMEIG : Maternal Mortality Estimation Inter-Agency Group MSG : Mission Steering Group NACO : National AIDS Control Mission NE : North East NCDs : Non Communicable Diseases NHM : National Health Mission NRHM : National Rural Health Mission NGO : Non-Government Organization NLEP : National Leprosy Elimination Progaramme NMR : Neonatal Mortality Ratio NNMR : Neo Natal Mortality Rates NMSAP : National Multi-Sectoral Action Plan NTCP : National Tobacco Control Programme NUHM : National Urban Health Mission NPHCE : National Programme for health Care of Elderly NIDDCP : National Iodine Deficiency Disorders Control Programme NSSO : National Sample Survey Organisation NOHP : National Oral Health Programme NVBCP : National Vector Borne Disease Control Programme NTBCP : National Trachoma and Blindness Control Programme NPCDCS - : National Programme for Prevention and Control of Cancer, Diabetes, Cardio-Vascular Diseases and Stroke NVBDCP - : National Vector Borne Disease Control Programme OCPs : Oral Contraceptive Pills OOPE : Out of Pocket Expenditure PG : Post Graduate PHCs, : Primary Healthcare Centres PIPs : Programme Implementation Plans

(vi) POP : Progrsterone Only Pills PPFP : Post Partum Family Planning PPIUCD : Post Partum Intrauterine Contraceptive Device PPP : Public Private Partnership RBSK : Rashtriya Bal Swasthya Karyakaram RGI - SRS - : Registrar General of India - Sample Registration System RKSK : Rashtriya Kishore Swasthya Karyakaram RMNCH+A - : Reproductive Maternal Newborn Child and Adolescent Health RNTCP : Revised National Tuberculosis Control Programme RCH : Reproductive Child Health RHS : Rural Health Statistics RSBY : Rastriya Swasthya Bima Yojana SDGs : Sustainable Development Goals SHCs : Sub Health Centres SCs : Sub-Centres SHCs : Sub-Health Centres SHS : State Health Societies SN : Staff Nurse SPIP : State Programme Implementation Plan TB : Tuberculosis TFR : Total Fertility Rate TSP : Tribal Sub Pan U5MR : Under 5 Mortality Rate UIP : Universal Immunization Programme UCs : Utilization Certificates UHC : Universal Health Coverage ULBs : Urban Local Bodies UCHCs : Urban Community Health Centres UNICEF : United Nations International Children Education Fund UPHCs : Urban Primary Health Centres UTs : Union Territories WHO : World Health Organisation WHS : World Health Statistics

(vii) ACORONYMS (Health Sector) ASHA : Accredited Social Health Activities AIIMS : All India Institute of Medical Sciences AIDS : Acquired Immuno Deficiency Syndrome AD (HQ) : Additional Director (Headquarters) ANC : Anti natal care ART : Anti Retroviral therapy AIDS : Acquired Immuno-deficiency Syndrome BCGVL : Bacillus Calmette-Guerin (BCG) Vaccine Laboratory BAS : Building Automation System Cu375 : Copper 375 CRI : Central Research Institute CD4 : T-lymphocyte cell bearing CD4 receptor cGMP : Current Good Manufacturing Practice CoE : Centre of Excellence CBRI : Central Building Research Institute CCA : Chief Controller of Accounts CDL : Central Drug Laboratory DPT : Diptheria, Pertusis and Tetanus DCG(I) : Drug Controller General of India DNIT : Detailed Notice Inviting Tender MDoNER, : Ministry of Development of North Eastern Region, North East Ministry DUAC : Delhi Urban Art Commission DFG : Demands for Grants Dr. RML Hospital : Dr. Ram Manohar Lohia Hospital DGHS : Director General of Health Services DMRC : Delhi Metro Rail Corporation ETP & STP : Effluent Treatment Plant and Sewage Treatment Plant

(viii) ECG : Electro cardiography EFC : Expenditure Finance Committee FSWs : Female Sex Workers GAVI : Global Alliance for Vaccines and Immunization GNCTD : Government of National Capital Territory of Delhi HVPI : Haemo-vigilance Programme of India HVAC : Heating, Ventilation and Air Conditioning HSCC : Hospital Services Consultancy Corporation HSSC : Healthcare Section Skill Council HIV : Human Immuno-deficiency Virus HSS : HIV Sentinel Surveillance IVCD : Intrauterine Contraceptive Device INI : Institutions of National Importance IUI : Intrauterine Insemination IBBS : Integrated Behavioural and Biological Surveillance IDU : Injecting Drug Users JSY : Janani Suraksha Yojana JPNATC : Jai Prakash Narayan Apex Trauma Centre (AIIMS) KACH : Kalawati Saran Children's Hospital LHMC : Lady Hardinge Medical College MoHFW : Ministry of Health and Family Welfare MoU : Memorandum of Undertaking MSM : Men who have Sex with Men NBCC : National Buildings Construction Corporation NIB : National Institute of Biologicals NLCPR : Non-lapsable Central Pool of Resources NEIGRIHMS : North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences NCC : National Coordinating Centre NCA : National Centre of Ageing NABL : National Accreditation Board Laboratory

(ix) NCR : National Capital Region NCD : Non-Communicable Diseases NPCDCs : National Programme for Prevention and Control of Cancer, Diabetes, Cardio Vascular Disease and Stroke NACP : National AIDS Control Programme OT : Operation Theatre OPD : Out-patient Department PII : Pasteur Institute of India PPIUCD : Post-partum Intrauterine Contraceptive Devices PPFP : Post-partum Family Planning PSUs : Public Sector Units PFMS : Public Fund Management System PGI : Post-Graduate Institute PGIMER : Post-Graduate Institute of Medical Education & Research PORB : Pension and Other Retirement Benefit PLHIV : People Living with HIV/AIDS RIMS : Regional Institute of Medical Sciences SCI : State Cancer Institute SFC : Standing Finance Committee SJH & VMMC : Safdarjung Hospital and Vardhaman Mahavir Medical College SOFTel : Strengthening of Food Testing Laboratories SACS : State AIDS Prevention and Control Societies TCCC : Tertiary Cancer Care Centre TT : Tetanus Toxoid TG : Transgender UC : Utilization Certificat UIP : Universal Immunization Programme UPSC : Union Public Service Commission UTs : Union Territories

(x) REPORT

PART-A

NATIONAL HEALTH MISSION (NHM)

INTRODUCTION

1.1 The National Health Mission (NHM) encompasses two sub-missions, the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). The main programmatic components include Health System Strengthening in rural and urban areas, Reproductive-Maternal-Neonatal-Child and Adolescent Health (RMNCH+A) and Communicable and Non-Communicable Diseases. The NHM envisages achievement of universal access to equitable, affordable and quality healthcare services that are accountable and responsive to people's needs.

National Rural Health Mission (NRHM)

1.2 As per information given in the Annual Report 2016-17 of the Ministry of Health and Family Welfare, NRHM seeks to provide accessible, affordable and quality health care to the rural population, especially the vulnerable groups. Under the NRHM, the Empowered Action Group (EAG) States as well as North Eastern States, Jammu and Kashmir and Himachal Pradesh have been given special focus. The thrust of the mission is to establish a fully functional, community owned, decentralized health delivery system with inter-sectoral convergence at all levels and to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social and gender equality.

National Urban Health Mission (NUHM)

1.3 As per the Annual Report 2016-17, NUHM seeks to improve the health status of the urban population particularly urban poor and other vulnerable sections by facilitating the access to quality primary healthcare. NUHM covers all State capitals, district headquarters and other cities/towns with a population of 50,000 and above (as per Census 2011) in a phased manner. Cities and towns with population below 50,000 will continue to be covered under NRHM.

II. BUDGETARY ALLOCATION

2.1 ` 26,690.70 crore has been provided in BE 2017-18 in Demand No. 42 for the National Health Mission. This consists of ` 26,675.70 crore under revenue account and ` 15.00 crore under capital account.

2.2 As per Demand No. 42, ` 22,197.95 crore had been provided in RE 2016-17 for the National Health Mission. This consisted of ` 22197.45 crore under revenue account and ` 0.50 crore under capital account. 2

2.3 Allocation made for the following Heads of NHM for 2017-18 is as below:-

Budget 2017-18

Revenue Capital Total

1 2 3 4 5

National Health Mission 45. National Rural Health Mission 45.01.RCH Flexible Pool including Routine Immunization 5966.60 -- 5966.60 Programme, Pulse Polio Immunization Programme, National Iodine Deficiency Disorders Control -1400.00 -- -1400.00 Progrmme etc.

Net 4566.60 -- 4566.60 45.02.Health System Strengthening under NRHM 8383.26 -- 8383.26 45.03.Flexible Pool for Communicable Diseases 2838.48 -- 2838.48 -1478.48 -1478.48 1360.00 1360.00 45.04 Flexible Pool for Non-Communicable Diseases, 955.00 -- 955.00 Injury and Trauma 45.05 Infrastructure Maintenance 5517.54 -- 5517.54 45.06 Forward Linkages to NRHM 26.18 -- 26.18 45.07 Strengthening of State Drug Regulatory System 52.35 -- 52.35 45.08 Pilot Schemes (Sports Medicine, Deafness, Leptospirosis 39.79 -- 39.79 Control, Control of Human Rabies, Medical Rehabilitation, Oral Health, Fluorosis) 45.09 Human Resources for Health ------45.10 Prime Minister's Development Plan for Jammu and 287.93 -- 287.93 Kashmir Total- National Rural Health Mission 21188.65 -- 21188.65 46. National Urban Health Mission 752.05 -- 752.05 47. Tertiary Care Programs 47.01 National Mental Health Programme 35.00 -- 35.00 47.02 Capacity Building for Trauma Centres 190.00 -- 190.00 47.03 National Programme for prevention and control of 300.00 -- 300.00 Cancer, Diabetes, cardio-vascular Disease and Stroke 3

1 2 3 4 5 47.04 National Programme for Health Care for the Elderly 110.00 -- 110.00 47.05 National Programme for Control of Blindness 25.00 -- 25.00 47.06 Telemedicine 40.00 -- 40.00 47.07 Tobacco Control Programme 10.00 15.00 25.00 Total- Tertiary Care Programs 710.00 15.00 725.00 48. Human Resources for Health and Medical Education 48.01 Upgradation/Strengthening of Nursing Services 60.00 -- 60.00 (ANM/GNM) 48.02 Strengthening/Upgradation of Pharmacy School/College 5.00 -- 5.00 48.03 District Hospital -Upgradation of State Government 165.00 -- 165.00 Medical Colleges (PG Seats) 48.04 Strengthening Government Medical Colleges (UG Seats) 480.00 -- 480.00 and Central Government Health Institutions 48.05 Establishing New Medical Colleges (upgrading District 3300.00 -- 3300.00 Hospitals) 48.06 Setting up of State Institutions of Para-medical Sciences 15.00 -- 15.00 in States and Setting up of College of Para-medical Education Total- Human Resources for Health and Medical 4025.00 -- 4025.00 Education Total National Health Mission 26675.70 15.00 26690.70 2.4 Allocations and expenditures for 2016-17 under Demand No.42 is given below:- Budget 2016-17 Revised 2016-17 Revenue Capital Total Revenue Capital Total 1234567 National Health Mission 45. National Rural Health Mission 45.01 RCH Flexible Pool 7774.89 -- 7774.89 7884.99 -- 7884.99 including Routine Immunization Programme, -1841.90 -- -1841.90 -1651.00 -- -1651.00 Pulse Polio Immunization Programme, National Iodine Deficiency Disorders Control Programme etc. Net 5932.699 -- 5932.699 6233.99 -- 6233.99 4

1234567 45.02 Health System 5226.00 -- 5226.00 5513.26 -- 5513.26 Strengthening under NRHM 45.03 Flexible Pool for 2730.75 -- 2730.75 2781.04 -- 2781.04 Communicable Diseases -1457.75 -- -1457.75 -1408.04 -- -1408.04 Net 1273.00 -- 1273.00 1373.00 -- 1373.00 45.04 Flexible Pool for Non- 555.00 -- 555.00 555.00 -- 555.00 Communicable Diseases, Injury and Trauma

45.05 Infrastructure Maintenance 4997.00 -- 4997.00 5367.05 -- 5367.05

45.06 Forward Linkages to NRHM 25.00 -- 25.00 25.00 -- 25.00

45.07 Strengthening of State Drug 0.01 -- 0.01 50.01 -- 50.01 Regulatory System

45.08 Pilot Schemes (Sports 38.00 -- 38.00 38.00 -- 38.00 Medicine, Deafness, Leptospirosis Control, Control of Human Rabies, Medical Rehabilitation, Oral Health, Fluorosis)

45.09 Human Resources for Health 40.00 -- 40.00 31.69 -- 31.69

45.10 Prime Minister's Development ------275.00 -- 275.00 Plan for Jammu and Kashmir

Total- National Rural Health 18087.00 -- 18087.00 19462.00 -- 19462.00 Mission

46. National Urban Health 950.00 -- 950.00 575.00 -- 575.00 Mission

47. Tertiary Care Programs

47.01 National Mental Health 35.00 -- 35.00 35.00 -- 35.00 Programme

47.02 Capacity Building for 200.00 -- 200.00 174.08 -- 174.08 Trauma Centres

47.03 National Programme for 300.00 -- 300.00 283.87 -- 283.87 prevention and control of Cancer, Diabetes, cardio- vascular Disease and Stroke 5

1234567

47.04 National Programme for 110.00 -- 110.00 98.00 -- 98.00 Healthcare for the Elderly

47.05 National Programme for 15.00 -- 15.00 15.00 -- 15.00 Control of Blindness

47.06 Telemedicine 40.00 -- 40.00 30.00 -- 30.00

47.07 Tobacco Control Programme 25.00 -- 25.00 24.50 0.50 25.00

Total-Tertiary Care Programs 725.00 -- 725.00 660.45 0.50 660.95

48. Human Resources for Health and Medical Education

48.01 Upgradation/Strengthening of 25.00 -- 25.00 25.00 -- 25.00 Nursing Services (ANM/GNM)

48.02 Strengthening/Upgradation of 5.00 -- 5.00 5.00 -- 5.00 Pharmacy School/College

48.03 District Hospital -Upgradation 10.00 -- 10.00 20.00 -- 20.00 of State Government Medical Colleges (PG Seats)

48.04 Strengthening Government 110.00 -- 110.00 155.00 -- 155.00 Medical Colleges (UG Seats) and Central Government Health Institutions

48.05 Establishing New Medical 445.00 -- 445.00 1293.70 -- 1293.70 Colleges (upgrading District Hospitals)

48.06 Setting up of State 5.00 -- 5.00 1.30 -- 1.30 Institutions of Para-medical Sciences in States and Setting up of College of Para-medical Education

Total- Human Resources for Health 600.00 -- 600.00 1500.00 -- 1500.00 and Medical Education

Total National Health Mission 20362.00 -- 20362.00 22197.45 0.50 22197.95

2.5 The Department has informed that the allocation for different components under NHM for 2017-18 is not as per the projected requirements. The Committee notes that against the projected outlay 6 of ` 34,315.66 crore under NHM, only ` 26690.70 crore has been allocated for the F.Y. 2017-18, leaving a shortfall of ` 7624.96 crore. As informed by the Secretary during his deposition before the Committee, the reduction in outlay will affect the following:

1. Upscaling of existing initiatives e.g. strengthening of Health facilities to IPHS standards,

2. Establishing SHCs, PHCs and CHCs as per the norms,

3. Strengthening of Sub Health Centres as Health and Wellness centres to deliver a package of comprehensive primary health care,

4. Implementation of new interventions relating to Non Communicable Diseases,

5. Strengthening of District Hospitals,

6. Roll out of Universal Health Coverage (UHC) Pilots,

7. Scale up of free drugs and free diagnostics initiatives,

8. Expansion of Routine Immunisation and strengthening of major communicable Diseases control programmes including for TB.

2.6 The Department has further informed that the following measures have been taken to offset the effect of shortfall of funds:

• Due to the revised Centre-State funding under NHM, the total outlay for Centre and State would be ` 34,025.16 crore for the F.Y. 2017-18 with Central share of ` 26,690.70 crore. This enhanced outlay would certainly help in sustaining and taking a few more activities under NHM.

• Advocating with the States to increase their Health budget, many States have increased their health budget beyond mandatory 10% indicating more investment in health sector.

• The Fourteenth Finance Commission has more than doubled the grant for local bodies and recommended that nearly all of this money should be spent on improving basic services. The Commission has fixed the grant of ` 2.87 lakh crore which would go directly to the Gram Panchayats and Municipalities, without any share for other levels. Provision of appropriate matching support to local bodies could be made under NHM (based on proposals in PIP) if the local bodies invested in strengthening healthcare delivery.

• Efforts will be made to get more resources at the supplementary stage.

2.7 The Department in its written reply has informed that the reduction in Central Plan allocation for NHM has not been fully compensated by the increase in State Health Budgets due to revised Centre-State funding pattern from 75:25 to 60:40. As against the Twelfth Plan allocation of `1,93,405.71 crore, funds to the tune of `91,022.00 crore only was made available towards allocation under NHM i.e. 47%. Resultantly, the increase in State share has been inadequate to compensate against the Twelfth plan allocation. However, as a result of revision in Centre-State funding pattern the resource availability due 7 to State Share increased from `4,570.00 crore in F.Y. 2012-13 to `10,522.00 Crore in 2016-17 and `12,150 Crore in 2017-18.

The Statement showing State-wise aggregate figure of State Health Budget is furnished at Annexure-IV.

Recommendation

2.8 The Committee notes that against the projected demand of ` 34,315.66 crore for 2017-18 under the National Health Mission, the total allocation in BE 2017-18 is only ` 26,690.70 crore leaving a shortfall of ` 7624.96 crore. In comparison to the RE 2016-17 allocation of ` 22197.95 crore, the increase in BE 2017-18 is only ` 4492.75 crore which, in the opinion of the Committee, is insufficient. The Committee notes the admission of the Department in its written submissions that though the resource availability from State share has increased from ` 4570.00 crore in Financial Year 2012-13 to ` 10,522.00 crore in 2016-17, the reduction in Central Plan allocation for NHM has not been fully compensated by the increase in State Health Budgets due to revised Centre-State funding pattern from 75:25 to 60:40 post hike of the share of States in the Central Taxes divisible pool from 32% to 42% in the form of untied funds. The Committee also notes the submission of the Department that the shortfall in allocations for NHM for 2017-18 vis-a-vis its projected demand for funds will adversely impact a number of health initiatives/programmes like upscaling of health facilities to Indian Public Health Standards; establishing Sub-Health Centres, Primary Health Centres and Community Health Centres as per norms; rolling out of Universal Health Coverage Pilots; scaling up of free drugs and free diagnostics initiatives, etc. It would be pertinent to point out that though in his Budget speech, the Finance Minister has proposed to transform 1,50,000 Health Sub-Centres into Health and Wellness Centres and "promote use of generic drugs", there is no solid roadmap for ensuring adequate financial resources for these initiatives and this is where the dichotomy of the Budget announcements gets reflected. It needs to be highlighted that as per the latest National Health Accounts estimates (2013-14), 35.7% of the total health expenditure is on medicine purchase and as per the NSSO data nearly 71% of the out-of-pocket (OOP) burden is due to expenditure on medicines. The Committee is therefore of the view that the BE 2017-18 allocation of ` 26690.70 crore is grossly inadequate. It is in this context that allocation of additional financial resources for NHM for 2017-18 makes a compelling case.

2.9 Taking into consideration the submission of the Health Secretary made before it on 2nd March, 2017 that in order to undertake new initiative like Universal Health Coverage Pilots and scale up existing initiatives, the minimum required increase in allocation for 2017-18 would be ` 4000.00 crore, the Committee lends its support to the allocation of additional ` 4000.00 crore for NHM.

2.10 The Committee observes that the Fourteenth Finance Commission has radically enhanced share of the States in the Central divisible pool from 32% to 42% and according to the Ministry of Finance, all States stand to gain in absolute terms from the new devolution formula. After the 8

Fourteenth Finance Commission award, the Government has instituted sharp cuts in the Central allocation for the Health Sector assuming that 42 per cent transfer of Central taxes to the States in the form of untied funds would compensate for the shortfall in Central funds for Health. The Committee recognizes the fact that the increased devolution of tax revenue to States is not bad in principle in a federal fiscal structure such as ours and offers an excellent opportunity for the States to increase their health spending and implement schemes as per aspirations of people. The Committee is, however, concerned to note from Annexure - IV that despite the enhanced share in Central taxes divisible pool, all States/UTs have not increased their health budgets commensurately in 2016-17. Albeit some of the State Health Budgets for 2016-17 have registered negative growth as compared to 2015-16 {i.e. Assam (-7%), Chandigarh (-3%), Daman & Diu (-15%), Karnataka (-2%), Manipur (-31%), Pondicherry (-1%)}. Some of the State Health Budgets for 2016-17 have shown marginal increase in health allocation as compared to 2015-16. The Committee on a perusal of Twelfth Plan average of State Health Budgets finds that States like Andhra Pradesh, Jammu and Kashmir, Manipur, Nagaland and Sikkim have registered only single digit increase in percentage terms. Thus the assumption that the enhanced share of the States/UTs in the Central divisible pool would compensate for the sharp reduction in the Central allocation for Health has not been validated. The Committee feels that unless all States increase their health budgets in commensurate with the enhanced Central transfers, it would be difficult to attain affordable and equitable healthcare. The Committee would, therefore, like the Ministry of Health and Family Welfare to hand-hold the laggard States and find out the underlying reasons for marginal or negative increase in their State Health Budgets and take remedial measures accordingly so that the desired outcomes on health parameters are achieved and the desired level of flow of funds to the Health Sector is ensured. The Committee would also like the Ministry to develop a suitable Health Information System for tracking and reporting on health expenditures in States on a real time basis and ensure that the additional State Health financing indeed gets allocated and spent during 2017-18. The Committee desires to be kept apprised of the action taken in this regard.

2.11 The Department further informed that in 2014, the per capita health expenditure in terms of purchasing power parity (PPP) for India stands at $267 as compared to Brazil ($1,318) China ($731) Russia ($1,836) South Africa ($1,148) (Source: WHO Global Health Expenditure database)

2.12 In reply to a pointed query about the health expenditure, the Committee has been informed that as per the above WHO database, the total health expenditure as percentage of GDP in 2014 for India is 4.7% as compared to BRICS countries i.e. Brazil 8.3%, China 5.5%, Russia, 7.1% and South Africa 8.8%.

2.13 On being asked as to what is the quantum of government expenditure on health as a proportion of GDP the Department in its written reply informed that as per Economic Survey 2016-17, the expenditure by Government (Central and State Governments combined) on health as percentage of GDP for 2016-17 (BE) was 1.4 per cent. 9

2.14 On being asked as to what is the Centre-State ratio in total government health allocations and whether the Government has fixed any target for increase in public health expenditure as a percentage of GDP the Department in its written reply informed that the ratio of Union and State Governments is estimated as 34%: 66% of Total Government Health Expenditure. Further, the Government has formulated Draft National Health Policy 2015, which envisages raising public health expenditure progressively to 2.5% of the GDP in a time-bound manner. As per the Twelfth Five Year Plan document, the core health expenditure was to be raised to 1.87% of GDP by 2017.

2.15 On being asked about what is the quantum of the out-of-pocket expenditure on health in the country and whether the out-of-pocket expenditure on health in India is one of the highest, even among low income countries and whether it is a fact that the high out-of-Pocket expenditure on healthcare forms a barrier to accessing good healthcare and cause households to incur huge expenditure, which in turn push them to indebtedness and poverty and how the vision of moving towards universalization of affordable healthcare can be translated into reality, given the low level of government expenditure on health, the Department in its written reply informed that the out-of-pocket expenditure in India is 64% of the total health expenditure. (Source: National Health Accounts 2013-2014). Out of 192 countries ranked in terms of Out of Pocket Expenditure as a percentage of Total Health Expenditure in 2014, India is placed at 183 just above neighboring countries of Bangladesh (187 rank) and Afghanistan (184 rank) while Brazil (84 rank), China (108 rank) Russia (151 rank ) and South Africa (15 rank) perform better than India. (Source: WHO Global Health Expenditure database)

2.16 The Department has also furnished the following information:-

• India ranks 183rd out of 192 countries in terms of percentage OOPE out of total health expenditure. (Source: WHO, 2014) countries like Brazil (25%) Russia (46%) China (32%) S. Africa (06%) Sri Lanka (42%) Thailand (08%) that have similar socio-economic indicators have much lesser OOPE than India.

• Public Heath is a State subject. Under the National Health Mission (NHM), support is provided to States/UTs to strengthen their healthcare system for provision of accessible, affordable and quality healthcare in public health facilities.

• Under NHM, the Government is providing support to States for provision of a host of free services such as for maternal health, child health, adolescent health, family planning, universal immunization programme, and for major diseases such as TB, vector borne diseases such as Malaria, Dengue and Kala Azar, Leprosy, etc. Other major initiatives for which States are being supported include Janani Shishu Suraksha Karyakram (JSSK), Rashtriya Bal Swasthya Karyakam (RBSK), Rashtriya Kishor Swasthya Karyakram (RKSK).

• To reduce OOPE, under NHM, support is available to States for provision of free essential drugs and diagnostics. Support is also being provided to States for provision of dialysis service free of cost to poor and vulnerable population.

• The Central Government is also implementing the Rashtriya Swasthya Bima Yojana (RSBY) which provides health cover up to `30,000/-for secondary care hospitalizations on a family 10

floater basis as per the approved package rates to BPL population and 11 other defined categories of unorganized workers.

2.17 Further, about 7% population is pushed into poverty as per National Sample Survey Office (NSSO) data every year. High Out of Pocket Expenditure (OOPE) on healthcare forms a barrier to accessing good healthcare. That is why, movement towards Universal Health Coverage (UHC) was a key goal of 12th Five Year Plan by improving efficiency of available resources and requesting States to increase healthcare expenditure.

Recommendation

2.18 The Committee observes that despite India's healthcare falling way below the global benchmark and the country lagging behind on health goals such as maternal and infant mortality and having a lowly ranking even among the developing countries on healthcare parameters, our level of public spending on health is one of the lowest in the world which has further exacerbated the dismal state of the healthcare sector. Despite all key policy documents like the National Health Policy of 2002, the draft National Health Policy of 2015, the Twelfth Five Year Plan and the Report of the High Level Expert Committee emphasizing the need to reach 2.5% of GDP, India's total government expenditure on health languishes at 1.15% (as per the National Health Accounts 2013-14, a rigorous estimate on health expenditures in the country) and is way less than the world average of 5.99% (Economic Survey-2016-17). The squeeze of public finances has resulted in the appalling state of our healthcare system and given birth to impoverishing out- of-pocket healthcare expenditure which is as high as 64% of the total health expenditure due to which about 7% population is pushed below poverty threshold every year (NSSO 71st Round data). India ranks 183 among 192 countries in terms of out-of-pocket healthcare Expenditure as a per cent of Total Health Expenditure and is just above Bangladesh (187) and Afghanistan (184). The 12th Plan is concluding by 2016-17 end but India is nowhere near the target of 2.5%. It is, therefore, no surprise that India continues to be an extreme outlier in terms of public health spend despite the sustained high economic growth in the past two decades. The Committee is constrained to observe that despite India being the fastest growing major economy in the world today with its economic growth pegged at around 7% in the current fiscal year, it has squandered the opportunity to turn its economic success into a better healthcare system for its population. This only goes to show that in the prioritization matrix of the successive Governments, health has been accorded a lower priority. The Committee observes that acceleration in economic growth by itself will not translate into higher public spending on health. The Government will also have to demonstrate a strong political will to value health as societal imperative for development and alter the government health financing landscape in a fundamental way by way of providing a much larger resource envelope for health financing. If countries like Thailand and Brazil are close to achieving Universal Health Coverage for their population (Source : draft National Health Policy, 2015) there is no reason why India cannot accomplish this goal. But for that to happen, the urgency of raising public health expenditure to 2.5 % should not be lost sight of. In this 11 context the Committee would like to draw the attention of the Government to its draft National Health Policy of 2015 which states that global evidence shows that unless a country spends at least 5-6% of its GDP on health and major part of it is from Government expenditure, basic healthcare needs are seldom met. The Committee would therefore like the Government to address this critical policy challenge of raising the government health spend to 2.5% of GDP and chalk out a solid roadmap for earmarking more financial resources for the Health Sector.

2.19 The Committee is aware that in a federal fiscal structure such as India's, the goal of increasing public spending on health to 2.5% of GDP would not be possible without the active involvement of State Governments. The Committee would, therefore, like the Government to make an assessment as to how much the Centre and States would need to increase their respective health spending to achieve the target of 2.5% of GDP within a designated timeline and also suggest where the extra-resources for achieving this level of health financing should come from. The Committee may be apprised of the assessment made.

2.20 On being asked about the approved outlay of Twelfth Five Year Plan, approved BE and RE for each year and actual release and the trend of expenditure in these Five Years for NHM, the Department in its written reply informed that the approved outlay under National Health Mission (NHM) during the Twelfth Five Year Plan was `1,93,405.71 Crore. The details is placed at Annexure-I. However, against the approved outlay, only `91,022.82 crore has been allocated which is 47%.

2.21 The trend of expenditure during the Twelfth Five Year Plan Period is as under: (` in crore) Year Budget Revised Actual Expenditure in Percentage Estimate Estimate Expenditure wrt BE wrt RE (B.E.) (R.E.) 2012-13 20542.00 17000.00 16762.77 82% 99% 2013-14 20999.00 18100.00 18215.44 87% 101% 2014-15 21912.00 17627.82 18037.99 82% 102% 2015-16 18295.00 18295.00 18282.40 100% 100% 2016-17 19000.00 20000.00 15412.16* 79% 75%

TOTAL 100,748.00 91,022.82 86,346.24 86% 95%

* Release is updated up to 09.02.2017.

The Department has informed that the salient achievements vis-a-vis the targets set in Twelfth Five Year Plan is at Annexure-II.

Recommendation

2.22 The Committee notes that against the approved outlay of ` 193405.71 crore for the National Health Mission in the Twelfth Plan, only ` 91022.00 crore has been allocated which in percentage 12 terms works out to measly 47% of the funding originally envisaged for the NHM in the Twelfth Plan. The Committee also notes that the trend of expenditure in the first four years of the Twelfth Plan has been excellent and the release made have been utilized to the fullest, implying that the allocated amounts have been utilized effectively. Even in the current fiscal (i.e. 2016- 17), 75% expenditure has been incurred as on 31st January, 2017 and it is hoped that the entire amount will be spent by the time the financial year ends. The Committee observes that had the Government allocated the entire Twelfth Plan approved outlays for NHM, the country would have seen much improved health outcomes in terms of quality primary healthcare services and reduced out-of-pocket health expenditure.

2.23 The Committee observes that just committing resources for health financing is not enough and it is equally important to ensure that the committed resources indeed get allocated and spent for the intended purposes. The Committee would therefore like the Government to ensure that such an anomalous situation does not recur in future and funds approved on paper for the National Health Mission are released and utilized also.

Delay in Transfer of Funds

2.24 As regards the recurrent delay in transfer of funds through the Treasury route, the Department in its written reply has informed that the recurrent delay in transfer of funds has been addressed by the Ministry to a fair extent by constantly monitoring release of funds from States Health Treasuries. There is an improvement in delay in transfer of funds from State Treasury to State Health Society in comparison to previous years. It may be noted that the average delay in transfer of funds were reduced from 117 days to 72 days in 2016-17 due to regular monitoring.

2.25 Replying to a query regarding the reverting back to society mode of fund transfer, it was informed that requests have been made to Ministry of Finance to allow the transfer of funds directly to State Health Societies under the NHM. However, the same has not been agreed to.

2.26 Regarding the quantum of funds lying with the State treasury, the Department has submitted that during the F.Y. 2016-17, the funds to the tune of ` 2012.54 crore still were parked with Treasury as on 31.01.2017 out of `8145.03 crore under NRHM-RCH Flexible Pool of NHM.

2.27 On what are the problem areas identified in implementation of various programmes/components of NRHM and NUHM during 2016-17, the Department in its written reply has informed that the problem areas identified in implementation of various programmes/components of NRHM and NUHM during 2016-17 are as follows:

• Transfer of Central grants through treasury route has been implemented from the F.Y. 2014-15. It is noted that there continue to be considerable delays in transferring of funds from State Treasury to State Health Society, through there is a reduction in average delay in transfer of funds in comparison to last year.

• Public Health being a State subject, implementation of approved plan under NHM depends upon implementation capacities of the State/UT Governments. 13

• Implementation capacity of many States is slow particularly in respect of civil construction, procurement of drugs and equipment, engagement and management of human resources, paucity of health human resource such as doctors & specialists, and convergence with other sectors that impact on health, etc.

2.28 The Committee while noting the reduction in time period for transfer of funds to State Health Society through treasury route, finds that there is still a time lag of 72 days in transfer of funds through the Treasury mode and out of ` 8145.03 crore released under the RCH Flexible Pool of NRHM during 2016-17, an amount of ` 2012.54 crore was still lying idle with State Treasury as on 31.01.2017. Taking note of the unnecessary delay in transfer of funds through the Treasury route, and keeping in view the fact that timely transfer of funds is extremely important as delayed transfers hamper fund utilization, the Committee in its 93rd Report had recommended that if the current fund flow architecture i.e. Treasury Route continues to result in delay in transfer of funds, the Society route of funds should replace the Treasury system. However, the Ministry of Finance has not agreed to reverting to the society mode of transfer of funds. The Committee desires to be apprised of the reasons adduced by Ministry of Finance for persisting with the Treasury Route.

2.29 The Committee also recommends that the Department should ensure close and sustained monitoring of the transfer of funds to State Health Societies and ensure that the current mechanism of fund transfer does not result in low fund utilization because further delay would lead to reduction in funds allocation in the coming years which in turn would adversely affect vital health programmes to be implemented. The Committee takes note of the Department's submission that implementation capacity of many States is slow and observes that this may be due to their low absorptive capacity which in turn may be an outcome of chronic lack of investment on health infrastructure and lack of institutional capacities. The Committee would, therefore, like the Department to work in close coordination with such States so that their developmental deficits are removed and low utilization does not become a stumbling block in increasing allocation to them.

Utilization Certificates

2.30 On what is the total number of Utilization Certificate pending and the amount involved therein, Year-wise and State-wise, the Department has informed that the total number of Utilization Certificate pending and the amount involved therein along with Year wise(2010-15) and State Wise information for NRHM is furnished on Annexure- IV. For NUHM, the total amount of pending UCs is 1621.05crore for the period 2013-14 to 2015-16. However, it may be noted that as per General Finance Rules (GFR), the UCs in respect of particular financial year can be received in the next financial year. In view of this, the funds released in F.Y. 2014-15 would get settled through the Audit report of 2015-16. The Audit report along with Audited UCs for the F.Y. 2015-16 are in the process of submission by the States and on settlement of Audit UCs for all 36 States/UTs, there will be no significant pendency in Utilization Certificates (UCs). 14

Recommendation

2.31 The Committee recommends that the Department should adopt a multi-pronged strategy to ensure that there is no pendency of Utilization Certificates by the end of this financial year. The Committee desires to be kept updated on pending Utilization Certificates (UCs).

III. NATIONAL RURAL HEALTH MISSION

A. RCH Flexible Pool including Routine Immunization Programme, Pulse Polio Immunization Programme, Immunization Programme, National Iodine Deficiency Disorders Control Programme.

3.1 The objective of RCH Flexible Pool is to reduce Total Fertility Rate (TFR), Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR) and assure reproductive health and choice to citizens and contribute thereby to stabilization of population consistent with the goals enshrined in the National Population Policy 2000 and Eleventh & Twelfth Five Year Plan. It aims at providing need based, client centered, demand driven, quality services to the beneficiaries with a view to improve the health status of Infant, Women and Children, Establishment of AFHCs.

3.2 The financial performance under RCH Flexible Pool including Routine Immunization, Pulse Polio Immunization Programme and National Iodine Deficiency Disorders Control Programme up to 09/02/ 2017 is as follows:

(` in Crore)

Pool B.E. R.E. Expenditure* % of Utilisation

RCH Flexible 5932.99 6233.99 4871.70 78.14% Pool including Immunisation, NIDDCP

('*Status as on 09/02/2017)

Recommendation

3.3 The Committee finds that out of ` 6233.99 crore an amount of ` 4871.70 crore has been spent (upto 9th February, 2017) which comes to about 78% utilization. The Committee observes that RCH is a critical area of intervention for the maternal and child health and therefore it is imperative that the funds allocated are made an effective policy tool and used gainfully and optimally. The Committee, therefore, desires to be updated on the actual expenditure figures for 2016-17.

3.4 As per the Demand No. 42 of Expenditure Budget the revenue allocation for RCH Flexible Pool was ` 5932.99 crore in BE 2016-17 which was increased to ` 6233.99 crore in RE 2016-17. The revenue allocation has been drastically reduced to ` 4566.60 crore in BE 2017-18. The Department in 15 its written reply has informed that the increase in revenue allocation from ` 5932.99 crore in B.E. 2016-17 to ` 6233.99 crore in RE 2016-17 has been done keeping in view introduction of 4 life saving vaccines under Immunization. Further, in view of the query raised in respect of reasons for drastic decrease of revenue allocation to ` 4566.60 crore in B.E. 2017-18, the Ministry has submitted that there is no reduction in B.E. 2017-18 for activities that have been undertaken through RCH Flexible Pool. In view of the decision of Mission Steering Group (MSG) of NHM and on account of rationalization of components of Human Resources and Drugs, these components are now being reflected under the flexible pool of Health Systems Strengthening under NRHM and NUHM. There was a provision of about `2600 crores (approx) for Health Human Resource and drugs in BE/RE of 2016-17, which is getting reflected in Health systems component in 2017-18. So, there is no reduction of funds for activities concerning RCH Flexible Pool including Routine Immunization Programme, Pulse Polio Immunization Programme, Immunization Programme, and National Iodine Deficiency Disorders Control Programme. In fact, there is decent increase in budget for RCH activities.

Recommendation

3.5 The Committee notes from Demand No. 42 that as compared to Revenue allocation of ` 6233.00 crore in RE 2016-17, ` 4566.00 crore has been allocated in BE 2017-18 for RCH Flexible Pool. When asked to clarify, the Department has stated that on account of rationalization of components of Human Resources for Health and Drugs, these components are now being reflected under the Health System Strengthening under NRHM and NUHM. The Committee observes that there is an element of obfuscation and non-transparency in the manner of presenting budget estimates for such an important component i.e. RCH. The Committee apprehends that the desired outcomes of RCH, which a focused grant could yield, may not be forthcoming due to such subsuming of specific schemes. The Committee therefore desires that the Government should have a relook in the matter and address these concerns appropriately.

3.6 The Committee also feels that there is a crucial need for the States to ramp up their investment for reproductive and child health and the higher devolution recommended by the Fourteenth Finance Commission to fill the resource gaps of the States, can certainly be deployed to good effect. It is pertinent to mention here that the Ministry of Health and Family Welfare in a report titled 'A Strategic Approach to Reproductive, Maternal, Newborn Child and Adolescent Health in India' published in 2013 had estimated that "if the current unmet need for family planning could be fulfilled within the next five years, India can avert 35,000 maternal deaths and 12 lakh infant deaths while saving more than 4450 crore of Indian currency. If safe abortion services are coupled with increase in family planning services, the savings made to the country could be to the tune of ` 6500 crore." It is thus evident that more government investments in RCH will give one of the best returns to society. The Committee would therefore like the Department to impress upon States the immense benefits from enhanced spending on RCH and devise arrangements for the States to step up their funding for RCH. 16

3.7 On the physical progress under RCH Programme in 2016-17, the Department has informed that:-

Family Planning:

The physical progress under Family Planning during 2016-17 is as follows:

During the Female Male Total IUCD PPIUCD year Sterilization Sterilization Sterilization

2016-17* 27,27,046 58,883 27,85,929 46,74,315 12,93,314 (Apr-Feb)

*Up to Feb 2017

Newer interventions under Family Planning Programme:

• Mission Parivar Vikas: The Government has launched Mission Parivar Vikas for substantially increasing the access to contraceptives and family planning services in the high fertility districts of seven high focus states with TFR of 3 and above. These 146 districts are from the seven high focus, high TFR states (Uttar Pradesh, Bihar, Rajasthan, , Chhattisgarh, Jharkhand and Assam) that itself constitutes 44% of the country's population.

• New Contraceptive Choices: The current basket of choice has been expanded to include the new contraceptives viz. Injectable contraceptive, Centchroman and Progrsterone Only Pills (POP).

• Redesigned Contraceptive Packaging: The packaging for Condoms, OCPs and ECPs has now been improved and redesigned so as to influence the demand for these commodities.

• New Family Planning Media Campaign: A360 degree media campaign has been launched to generate contraceptive demand.

• Enhanced Compensation Scheme for Sterilization- The sterilization compensation scheme has been enhanced in 11 high focus states (8 EAG, Assam, Gujarat, Haryana).

• A new IUCD (Cu 375) with 5 years effectivity has been introduced in the programme as an alternative to the existing IUCD (Cu 380A with effectivity of 10 years).

• A new method of IUCD insertion i.e. PPIUCD has been introduced.

• Emphasis on Postpartum Family Planning (PPFP) services with PPIUCD and promotion of minilap as the main mode of providing sterilization in the form of post-partum sterilization to capitalize on the huge cases coming in for institutional delivery under JSY.

Recommendation

3.8 The Committee notes that out of 27,85,929 sterilizations carried out in 2016-17 (upto February, 2017), the number of female sterilization (27,27,046) far outnumber male sterilization (58,883). The Committee is of the opinion that sterilization does not only mean female sterilization 17 but also includes male sterilization. The Committee desires that Government should take positive steps towards achieving the objective of at least 10% of sterilization being male sterilization as indicated in the Twelfth Five Year Plan Report.

Institutional Deliveries: As per HMIS, a total 1.26 crores institutional deliveries took place in 2016-17 (April-December 2016), which comes out to be 89.5% of Institutional deliveries against total reported deliveries.

Under Janani Suraksha Yojana (JSY), a total of 46.15 lakhs beneficiaries have been covered in 2016-17 (April-September 2016).

Recommendation

3.9 The Committee is happy to note that as compared to total reported deliveries, institutional deliveries account for 89.5%. The Committee would, however, exhort the Department to focus on uncovered areas where home deliveries cannot be avoided due to difficult terrain or some other cultural reasons/tribal practices to ensure access to minimum standards of care is facilitated to the most underprivileged and deprived sections of our population through ANM assisted home deliveries.

Universal Immunization Programme:

3.10 The Department has informed that:-

• Full immunization coverage of the country has reached 87. 26 % as per HMIS data (till December month for 2016-17 updated on 27th January, 2017).

• Introduced injectable Inactivated Polio Vaccine (IPV) across the country in 2015-16 to provide additional protection against polio. Till January, 2017, nearly 137 lakh doses of IPV have been given across the country.

• Introduced Rotavirus Vaccine in 4 States (Haryana, Odisha, Himachal Pradesh and Andhra Pradesh) in 2016 and has planned further expansion in 5 additional states in 2017. Till January, 2017, nearly 38 lakh doses of Rotavirus vaccine have been given in country.

• Strengthening of routine immunization through three phases of Mission Indradhanush conducted since April, 2015. During 2016-17, third phase of Mission Indradhanush was conducted between April, 2016 and July, 2016 wherein 61.8 lakh children were reached of which 16.3 lakh children were fully immunized. In addition, 17.8 lakh pregnant women were also vaccinated with Tetanus toxoid.

• Inactivated Polio Vaccine (IPV) was introduced in 8 States/UTs in November, 2015. The vaccine was expanded to 28 States/UTs between April 2016 and June 2016.

• Initiated Measles - Rubella campaign recently in February, 2017 in 5 States (Goa, Lakshadweep, Puducherry, Tamil Nadu and Karnataka). The campaign is ongoing. 18

• In 2016-17, JE vaccination campaign for children aged 1-15 years has been completed in 9 districts, covering 36.6 lakh children and is planned to cover 9 more districts by March, 2017. JE vaccine has been included in Routine immunization in these districts after completion of the campaign.

• Adult JE campaign for adult population (15-65 years) is ongoing in 6 newly identified JE endemic districts of West Bengal and the same will be conducted in four districts of Assam by March, 2017.

Recommendation

3.11 The Committee notes that though the country has made considerable improvement in immunization under the Universal Immunization Programme and the full immunization coverage has reached 87.26% as per Health Management Information System (HMIS) data as on 27th January, 2017, the country accounts for 7.4 million children (as per UNICEF) who are not immunized and more than 20% of all child mortality worldwide. The Committee, therefore, recommends that the Department should identify the challenges to immunization and chalk out a multi-pronged strategy to overcome them. The Committee desires to be kept apprised in this regard. The Committee would also like to be apprised of the status of full immunization in rural areas and urban areas separately.

Pulse Polio Immunization

3.12 On whether domestic manufacturers have been able to ramp up production of IPV vaccines in 2016 and if not, what is the extent of imported IPV vaccines vis-a-vis the country's requirement, the Department in its written reply has informed that since January 27, 2017 all the supplies of IPV for the programme are done through domestic manufacturers only. However there is a global shortage of bulk ingredient required to produce IPV, therefore the domestic manufacturers have not been able to supply chain of IPV for immunization. For this fractional IPV ( FIPV) is being introduced across the country which is equally efficacious as single dose IPV.

Recommendation

3.13 The Committee observes that though India has been declared as Polio free by WHO in March, 2014 and has since maintained the status, ordinary prudence demands that all necessary precautions need to be taken to obviate the possibilities of disruption of the supplies on account of an unforeseen crises in commercial production of IPV. The Committee, therefore, desires to know the action plan of the Department to tackle such an eventuality. The Committee desires to know the contribution of the public and private sector in the supply of IPV to Pulse Polio Programme. The Committee also recommends that the Government should keep a close watch on the immunization programme to ensure that Polio does not resurface due to shortage of bulk ingredient required to produce the vaccine. 19

Adolescent Health

3.14 The physical performance under Rashtriya Kishor Swasthya Karyakram (RKSK) is as below:

Physical Performance

No. of AFHCs as on WIFS Coverage (%) No. of PE No. of Peer 30th Sept '16 (April to Nov '16) to be Educators In School Out of School Total selected selected as on 30th Nov '16

7210 33.6 22.2 31.6 236700 165218

*Note: Data given in all India Figure

Maternal Mortality Ratio (MMR)

3.15 The Department has informed that Maternal Mortality Ratio (MMR) in India was exceptionally high in 1990 with 556 women dying during child birth per hundred thousand live births. Approximately 1.38 lakh women were dying every year on account of complications related to pregnancy and child birth. Millennium Development Goal (MDG) 5 pertains to Maternal Health where target is to reduce the Maternal Mortality Ratio (MMR) by three quarters between 1990 & 2015. Based on the UN Inter-Agency Expert Group's MMR estimates in the publication "Trends in Maternal Mortality: 1990 to 2015", the target for MMR is estimated to be 139 per 1,00,000 live births by the year 2015 taking a baseline of 556 per 100,000 live births in 1990. As per the latest report of the Registrar General of India, Sample Registration System (RGI-SRS), MMR of India has shown a decline from 178 per 100,000 live births in the period 2010- 12 to 167 per 100,000 live births in the period 2011-13. State-wise MMR is placed at Annexure-V. The annual rate of decline of MMR during the period 2010-12 and 2011-13 is 6.2%. Assuming, the same pace of decline continues, India's MMR is likely to reach the MDG -5 targets of 139. The decline of MMR in India is greater than its global decline. However, as per the Maternal Mortality Estimation Inter-Agency Group (MMEIG), estimates 2015, India accounts for 15% of all maternal deaths worldwide.

States' progress on MMR

3.16 Assam continues to be the State with the highest MMR (300) followed by Uttar Pradesh/Uttarakhand (285) and Rajasthan (244). States of Maharashtra (21.8%), Andhra Pradesh (16.4%), Haryana (13%), Tamil Nadu (12.2%), Assam (8.5%), Gujarat (8.2%), Punjab (9.0%), Karnataka (7.6%), Kerala (7.6%), and have registered equal or higher decline as compared to the national decline. States which have achieved an MMR of 100 per 100,000 live-births in 2011-13 are Kerala, Tamil Nadu, Maharashtra and Andhra Pradesh. The States of Gujarat, Haryana, Karnataka, West Bengal have also reached the MDG- 5 target. Additional efforts will be required for lowering the MMR, especially, in the States of Assam (300), Uttar Pradesh (285), Rajasthan (244), Odisha (222), Madhya Pradesh/Chhattisgarh (221) and 20

Bihar/Jharkhand (208), which have quite high MMR as compared to the national level, if the MDG target is to be achieved in an equitable manner.

3.17 India has also committed to the latest UN target for the Sustainable Development Goals (SDGs) for MMR at 70 per 100,000 live births by 2030.

Recommendation

3.18 The Committee notes from the submission of the Department that the current pace of decline of MMR indicates that India is likely to achieve the target of the Millennium Development Goal-5 (set by WHO) of reducing MMR to 139 per 100000 live births. However, the fact that India still accounts for 15% of all maternal deaths worldwide is unacceptable. Equally disturbing is the fact that there are wide interstate disparities in terms of MMR. The Committee is of the view that a differential approach would need to be taken to address MMR differentials across geographical region. The Committee desires to be apprised of the strategy devised to overcome widespread inequities in MMR. The Committee also desires to know as to how India compares with neighbouring countries like Sri Lanka, Bangladesh and Nepal on MMR indicators.

3.19 The Committee hopes that the target of MMR under (Sustainable Development Goals) SDG's has factored into account the States where MMR is quite high. The Committee recommends that the Department should make 'special efforts' in order to achieve the target it has fixed under SDG's for MMR.

Status of Child Mortality in India

3.20 As per information furnished by the Department:

• As per the SRS 2014, the under five mortality rate (U5MR) is 45 per 1000 live births which has sharply declined by 4 point from 2013.

• About 44% of under-five deaths take place within the first 7 days of birth.

• About 58% of under-five deaths take place within first one month of birth.

• Approximately 87% of under-five child mortality takes place within one year of the birth.

• As estimated 1,26,200 under five deaths are being averted in 2014 as compared to 2013 whereas almost 89,500 under five deaths could be averted in 2013 as compared to 2012.

• Infant Mortality Rate (IMR) is 39 per 1000 live births in 2014.

• 56,000 infant deaths (as per estimates) are being averted in 2014 as compared to 2013.

• Neonatal Mortality Rate (NMR) in the country is 26 per 1000 live births.

• Almost 64,850 newborn deaths are being averted in 2014 as compared to 2013 which is two-fold improvement in 2013 as compared to 2012. 21

3.21 Further the trends of Decline in Infant Mortality Rate in India is as under:-

• IMR has declined only 1 points in 2014 from 2013.

• IMR has shown a marginal decline from 2013 to 2014, however NMR has shown 2 points decline in the same point. Thus, post-neonatal mortality is cause of concern and concentrated efforts are required to address post-NMR as well.

• Rural-Urban differential is 17 points in 2014 which is the same as observed in 2013. Therefore, no reduction in rural-urban differential of IMR from 2013 to 2014 took place.

• Gender differential has remained constant of 3 points at National level. Highest gender differential observed in Lakshadweep (12 point) followed by Chandigarh (8 point) and Bihar (7 point).

• Female infants experienced a higher mortality than male infants in all States except Tamil Nadu and Assam where both are the same.

Recommendation

3.22 The Committee notes that the Rural-Urban differential of IMR was 17 points in 2014 which is same as in 2013. Therefore, there is no reduction in rural-urban differential of IMR from 2013 to 2014. The Committee notes that the Gender differential has remained constant at 3 points at National Level. The Committee observes that till there is a forward movement in Rural-Urban differential and Gender differential, the gains achieved would not be enough to reach the target set. The Committee, therefore, recommends that the Department should regularly monitor the Rural-Urban Differential and Gender Differential to ensure that the targets set are achieved at the ground level.

Under-5 Mortality Rate (U5MR)

3.23 Further as per Annual Report (2016-17) of the Department of Health and Family Welfare, the following are the trends of decline in under-5-Mortality Rate:-

• Under 5 Child Mortality has declined from 64 in 2009 to 45 in 2014 thus showing a 19 points drop in last six years.

• Compound annual rate of decline for U5MR is 6.8% during 2009-14.

• As per SRS 2014, 14 States have achieved MDG4 (<45 per 1000 live births) namely Andhra Pradesh, Delhi, Haryana, Gujarat, Himachal Pradesh, Jammu and Kashmir, Karnataka, Kerala, Maharashtra, Punjab, Tamil Nadu, Telangana, Uttarakhand and West Bengal.

• Addtionally, 4 States have also achieved SDG (<25 per 1000 live births) namely Delhi, Kerala, Maharashtra and Tamil Nadu.

• 7 high focus States have higher Under 5 mortality rate than national average (45) namely Assam (66), Madhya Pradesh (65), Odisha (60), Uttar Pradesh (57), Bihar (53), Rajasthan (51) and Chhattisgarh (49). 22

• Maximum decline of U5MR was observed in Assam and Uttar Pradesh which have shown 7 point decline in 2014 as compared to 2013, while Andhra Pradesh and Bihar have shown one point decline and Kerala has shown 1 point increase in U5MR.

• Andhra Pradesh has shown increase (+1point) in NMR, stagnant IMR and one point declined in U5MR. However, it may be noted that the figures previously available were for undivided State of Andhra Pradesh.

• 58% of under five death is contributed by 4 States namely; Uttar Pradesh (3.1 lakhs), Bihar (1.4 lakhs), Madhya Pradesh (1.2 lakhs) and Rajasthan (0.87 lakh).

• Decline in Rural U5MR is higher to the decline in urban areas, thereby narrowing Rural- Urban Gap.

• Rural-Urban differential of under 5 mortality is much higher (43 points) in Assam however it has been observed that urban U5MR is higher (R:36, U:38) than rural areas in the State of Uttarakhand.

• Gender differential in U5MR is 7 (Male-42, Female-49). Chattisgarh and Uttar Pradesh have highest (11 point) gender differential of U5MR followed by Madhya Pradesh (10 points), Rajasthan (10 points) and Bihar (9 points).

• Gender differential in U5MR has either increased or is stagnant in most of the States in 2014 as compared to 2013.

• All the bigger States have higher Under-five mortality rates of female than that of male except Tamil Nadu.

Causes of Neonatal Mortality

• The major causes of neonatal deaths are infections (33%) such as Penumonia, Septicemia and Umbilical Cord Infection; Prematurity (35%) i.e. birth of newborn before 37 weeks of gestation and Asphyxia (20%) i.e. inability to breathe immediately after birth leading to lack of oxygen.

• Factors contributing to above causes are as under:-

• Home delivery by unskilled persons

• Lack of essential new born care for asphyxia and hypothermia

• Poor child care practices

• Lack of early detection of sick newborn

• Inadequate/Delayed referral mechanism

• Inadequate infrastructure at health care facilities for specialized care of sick newborn. 23

Recommendation

3.24 The Committee is of the view that the success of 18 States in U5MR can be replicated in the High Focus States. The Committee, therefore, recommends that the Department should ensure that 'template' for ensuring U5MR in 18 States are formulated and implemented in these High Focus States to ensure that these 'States' also achieve SDG goals.

B. Health System Strengthening under NRHM

3.25 A revenue allocation of ` 5226.00 crore was made in BE 2016-17 which was increased to ` 5513.26 crore at RE stage. Asked about the reasons for the increases at RE stage alongwith the actual expenditure incurred, the Department informed that the increase in RE stage has been proposed to support free drugs and diagnostics and PM National Dialysis Programme. During the F.Y. 2016-17, the expenditure under Health System Strengthening of NRHM up to 09/02/2017 is `3974.96 crore i.e.72% of the budgetary allocation in RE Stage. The entire allocation of Health System Strengthening under NRHM of ` 5513.26 crore at RE stage is expected to be fully utilized.

3.26 ` 8383.26 crore has been allocated in the revenue allocation in 2017-18 under this head. On how the Department proposes to utilise this increased allocation and the activities proposed to be undertaken under this head, the Department informed that the steep increase in revenue allocation for BE 2017-18 is due to the decision for rationalization of activities pertaining to Health Human Resources, IEC and Drugs and Diagnostics. As per the decision, all such activities under all the programmes under NHM are to be brought together under Health Systems Strengthening component under NRHM/NUHM. All activities relating to strengthening of health systems including provision of technical health human resource at facility level, free drugs and diagnostics, IEC, strengthening infrastructure will be undertaken under this head.

3.27 On being asked of the proposal that has been made in the Budget 2017-18 for conversion of Sub- Centres into Health and Wellness Centres and what will be the mandate of these centres and what component of allocation has been made for this proposal, the Department has informed that Health and Wellness Centres are expected to provide Comprehensive Primary Health care. This would include the delivery of a package of preventive, promotive, curative and rehabilitative services delivered close to communities by health care providers that are responsive to local health needs, and are able to provide care for most common ailments, enable referral for doctor or specialist consultations and can undertake follow-up.

Recommendation

3.28 The Committee fully supports the initiative taken by the Government to ensure 'last mile connectivity' in health and wellness, by converting sub-centres into Health and Wellness Centres as this would provide easy and timely access to quality healthcare and take the healthcare closer to people. The Committee is however concerned about the fact that there are huge constraints of skilled manpower and it would be very difficult to bridge this gap. The Committee would therefore like the Department to indicate a roadmap to address the huge gap in terms of availability of skilled manpower for the proposed Health and Wellness Centres. 24

3.29 The Committee also observes that all States may not have additional fiscal space for mobilizing resources for Health and Wellness Centres. The Committee, therefore, desires that the Department should hold deliberations especially with the more needy and backward states which are also weak on health parameters and ensure that such states are provided 'additional support' to ensure the success of this intervention.

C. Flexible Pool for Communicable Diseases

3.30 The Department in its written reply has informed that a revenue allocation of ` 1273.00 crore was made in B.E. 2016-17 which was increased to ` 1373.00 crore in R.E. 2016-17. The reasons for increase and actual expenditure are as under:-

(i) Excess allocation of ` 100.00 crore was made in R.E. 2016-17 under Flexible Pool for Communicable Diseases specially for RNTCP for 1st line anti TB and 2nd line anti TB Drugs.

(ii) Actual expenditures under Flexible Pool for Communicable Diseases against R.E. 2016-17 are as under:-

(` in crore)

Programme R.E. 2016-17 (Plan) Actual Expenditure till 10.02.2017

RNTCP 740.00 491.83

NVBDCP

Plan 505.65 337.13

Non-Plan 13.00 10.81

NLEP 46.00 22.52

IDSP 68.35 41.96

TOTAL 1373.00 904.25

3.31 Further on being asked as to how is the revenue allocation of ` 1360.00 crore for 2017-18 proposed to be utilized and whether the allocation is sufficient, and if not, which component of the Pool would be adversely affected, the Department in its written reply has informed that in 2017-18, most of the programme activities shall be carried from previous year, which are under process since Twelfth Five Year Plan. Markedly, Communicable Diseases programmes are major disease specific programmes and all programme activities are having sensitivities and specificities. All efforts shall be made to achieve the target of reducing/eliminating diseases. However, the allocation of ` 1360.00 crore for Communicable Diseases programmes i.e. RNTCP, NVBDCP, NLEP and IDSP for financial year 2017-18 is inadequate.

3.32 Notably, low allocation is seen even in EAP component under NVBDCP (wherein allocation is not 25 being made as per Grant signing agreement), which may adversely affect the programme implementation. The details are as under:-

Programme Proposed for RE 2016-17 Allocated for RE 2016-17 (Plan) & BE 2017-18 (Plan) (Plan) & BE 2017-18 (Plan)

RE 2016-17 BE 2017-18 RE 2016-17 BE 2017-18

RNTCP 1000.00 1100.00 740.00 740.00

NVBDCP 784.87 1065.78 505.65 505.65

NLEP 51.51 121.00 46.00 46.00

IDSP 75.00 110.00 68.35 68.35

TOTAL 1911.38 2396.78 1360.00 1360.00

Recommendation

3.33 The Committee in the earlier part of this Report has lent its support to an additional allocation of ` 4000.00 crore for NHM for 2017-18 which the Committee hopes would take care of the shortfall of funds under Flexible Pool for Communicable Diseases. According to some reports, communicable diseases contribute 52% of all disease burden and more than 60% of deaths in the country. The Committee, therefore, recommends even at the cost of repetition that a sufficiently higher magnitude of funds should be allocated for this Pool.

3.34 The Committee notes that out of ` 1373.00 crore allocated at RE 2016-17, an expenditure of only ` 904.25 crore has been spent till 10th February, 2017. While, the Committee is all with the Department for the need for increasing funds in its fight against communicable diseases, it simultaneously recommends that the Department should ensure expenditure monitoring and fiscal discipline and avoid rush of expenditure before the fiscal end.

Lymphatic Filariasis

3.35 On how many districts in the country are JE/AES endemic and by when the Department would be able to completely eliminate JE/AES, the Department in its written reply informed that 256 districts are so far endemic for lymphatic Filariasis, out of these 86 districts have stopped MDA after validation through TAS. The programme is scaled up to reach about 600 million population achieving 100% geographical coverage in all 256 endemic districts. The efforts to scale MDA and tackle LF have shown success but not up to the desired level. All efforts will be made to achieve the target of reducing microfilaria rate below 1% by the end of 2017.

Kala-azar

3.36 The Department in its written reply has informed that the strategies adopted for elimination of Kala-azar elimination have shown significant results as the number of blocks reporting less than one case per 10,000 populations at block level which is the target of elimination has gone upto 539 during 2016 26 as against 492 reported during 2015. Similarly 6221 cases have been reported 2016 as compared to 8500 cases reported during the corresponding period of last year, a reduction of 28%. No death was reported during 2016 as compared to 5 deaths reported during 2015. The target for elimination of Kala-azar has been revised to 2017.

Leprosy

3.37 As per the budget speech 2017, the target year for elimination of Leprosy is 2018.

Recommendation

3.38 The Committee notes that though ambitions targets have been fixed for elimination of Kala-azar and Filariosis by 2017 and Leprosy by 2018, the allocated resources do not match the intent and give rise to an apprehension that desired outcomes may not be forthcoming. The Committee would like to highlight the fact that Kala-azar was targeted to be eliminated by 2010 which was revised to 2015 and further revised to 2017. This cannot be condoned. The Committee, therefore, desires that the Department should be clear headed in its goals and should not keep on revising its targets. There appears to be some inadequacy in implementing the plans due to which targets have not been achieved. The Committee strongly recommends that practicable targets may be fixed and efforts may be made to achieve them.

Revised National Tuberculosis Control Programme (RNTCP)

3.39 The financial performance of RNTCP during the 2015-16 and 2016-17 (till 31-01-2017 ) is as under:

Financial Year Total Allocation State Allocation Release (Cash + Total (Cash+Commodity) Commodity) Expenditure

2015-16 640.00 603.20 617.20 639.86

2016-17 640.00 598.19 451.77 469.50*

*Expenditure till 31-01-2017

Physical Performance

Financial Year Total T B Cases Notified New Smear Positive (NSP) Cure Rate

2015-16 1436343 87%

2016-17 761738 88%

Up to September 2016.

3.40 As per the Annual Report 2016-17 of the Department, "The Revised National TB Control Programme (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, was launched in 1997 and expanded across the country in a phased manner. As per the Budget 27

Speech 2017 of the Finance Minister, Government has prepared an action plan to eliminate tuberculosis by 2025.

Recommendation

3.41 The Committee observes that the main challenges confronting RNTCP are prevalence of high levels of disease transmission and increase in incidence of drug resistant TB. The Committee is of the view that this is due to poor primary healthcare infrastructure in rural areas and unregulated private healthcare leading to irrational use of first-line and second-line anti- tuberculosis drugs. Though in the Budget Speech, 2017, the Government has set targets for elimination of TB by 2025, visible progress towards eliminating TB would not be possible without addressing these issues of poor primary healthcare infrastructure and unregulated private healthcare. The Committee would therefore like the Government to focus their strategy on addressing these issues.

3.42 As per information given in the Annual Report 2016-17, one of the new initiatives in 2016 was introduction of Bedaquiline for treatment of MDR-TB as conditional Access Programme in six sites. Further as per the Global TB Report, 2016, approximately 4% of T.B patients are estimated to be co- infected with HIV. Drug resistant - TB is estimated to be 2.5% in new cases and 16% in previously treated T.B. Cases.

Recommendation

3.43 The Committee is concerned to note that despite passage of so much time since the launch of RNTCP India continues to have the highest TB burden in the world and drug-resistant TB is 2.5% in new cases and 16% in previously treated TB cases. The Committee is aware that the Ministry of Health and Family Welfare has rolled out a new TB drug- Bedaquiline to combat extremely drug resistant TB which has been discovered after 40 years. The administration of Bedaquiline is however tightly controlled and restricted to six Government hospitals, two at New Delhi and one each at Mumbai, Chennai, Ahmedabad and Guwahati and access is decided by domicile. The Committee desires that the trials may be completed at the earliest and if found effective, it may be rolled out for wider coverage.

D. Flexible Pool for Non-Communicable Diseases, Injury and Trauma

3.44 The Committee has been informed that the revenue allocation for the Non-Communicable Diseases, Injury and Trauma in 2016-17 was ` 555.00.crore. With the available fund allocation of ` 555.00 crore it was not feasible to scale up the activities for the F.Y. 2016-17 under NCD Flexible Pool.

3.45 The Department has informed in its written reply that the increase in revenue allocation for F.Y. 2017-18 to the tune of ` 955.00 crore has been done keeping in view launch of Programme for Screening, referral and management of common NCDs such as Hypertension, Diabetes, 3 common cancers and Chronic Obstructive Pulmonary Disease (COPD). The amount allocated will be insufficient as against the proposed budget of `3,498.00 crore, only ` 955.00 crore has been allocated for the said 28 pool. However, it may be noted that beside the NCD flexipool, the health systems strengthening under the NRHM and NUHM is helping address the NCD disease conditions.

Recommendation

3.46 The Committee notes from the Department's reply that the revenue allocation of ` 955.00 crore for financial year (2017-18) falls woefully short of the proposed budget of ` 3498.00 crore. Even though the Department has stated that besides NCD flexi pool, the health systems strengthening under the NRHM and NUHM is helping to address the NCD diseases, the Committee strongly feels that in view of the increasing burden of non-communicable diseases in the country, fund constraint should not be the reason for increase in disease burden. The Committee therefore strongly supports the Department's contention to increase the budget allocation and recommends that the Department may approach the Ministry of Finance for seeking the desired allocation at RE stage.

E. Strengthening of State Drug Regulatory System

3.47 Revenue allocation for the Strengthening of State Drug Regulatory System was ` 0.01 crore in BE 2016-17 which has been substantially increased to ` 52.35 crore in BE 2017-18. On what are the reasons for massive increase from ` 0.01 crore in BE 2016-17 to ` 50.01 crore in RE 2016-17 and what are the actual expenditure figures, the Department in its written reply has informed that the Government had approved a proposal for strengthening of the drug regulatory system in the country, both at the Central and State levels at a cost of `1750 crore. Out of this, ` 850 crore has been approved as the Central Government's contribution for upgrading and strengthening the State's Drug Regulatory System. The share of the Centre and the States would be in the ratio of 60:40 for all States except Jammu and Kashmir, Himachal Pradesh, Uttarakhand, Sikkim and seven North Eastern States for which the ratio is fixed at 90:10. The State Governments are required to sign a Memorandum of Understanding (MoU) with the Government of India before the funds would be released to them. Accordingly, proposals were asked for from the States. Out of the 36 States/UTs, the following 21 States/UTs have since submitted proposals for release of funds along with the MoU duly signed by the respective States/UTs. These are: (i) Karnataka (ii) Delhi, (iii) Goa, (iv) Jharkhand, (v) Odisha, (vi), Gujarat, (vii) Kerala, (viii) Andhra Pradesh, (ix) Telangana, (x) Punjab, (xi) Jammu and Kashmir, (xii) Bihar, (xiii) Madhya Pradesh, (xiv) Dadra and Nagar Havelli, (xv) Tripura, (xvi) Mizoram, (xvii) Sikkim, (xvii) Arunachal Pradesh, (xix) Himachal Pradesh, (xx) Meghalaya and (xxi) Maharashtra.

3.48 Initially, despite projection by the Ministry of Health and Family Welfare, no funds were made available for Strengthening of State Regulatory System and only a token amount of ` 1 lakh was kept in the budget. An amount of ` 50 crore has since been provided for making it available to the States as the first instalment. Sanctions have been issued and the funds are being transferred to the States.

3.49 On how is the revenue allocation of ` 52. 35 crores in BE 2017-18 proposed to be utilized and whether the proposed amount is sufficient and if not, what would be the bare minimum requirement of funds under this head, the Department in its written reply has informed that the allocation of ` 52.35 29 crore for 2017-18 will be used for making it available to the States. The amount is not considered sufficient and more funds will be requested for during the course of the year.

Recommendation

3.50 The Committee observes that the present drug laboratories in the country are not fully equipped with the state-of-the-art facilities for testing and analyzing complex formulations and detect spurious, misbranded, substandard and adulterated drugs. Keeping in view the fact that India is the manufacturing hub and pharmacy of the world, it is essential to put in place a vibrant and dynamic regulatory regime so that the public could be safeguarded from substandard or unsafe drugs. It is in this context that strengthening of testing and surveillance capacities in Centre and States is the need of the hour. Since monitoring of the quality of drugs is primarily the responsibility of the State Drugs authorities supplemented by CDSCO, without manpower augmentation and upgradation of State Drug Testing Laboratories, the objective of ensuring availability of quality drugs to the people cannot be realized. The Committee, therefore, recommends that the Department should process all the proposals received from State Governments with a sense of urgency and promptitude and speed up their approval and help build regulatory systems at par with international standards. The Committee desires to be kept apprised of the physical progress made in this regard.

IV. NATIONAL URBAN HEALTH MISSION

4.1 The Department has informed that the allocation in BE 2016-17 of `950.00 crore was reduced to `575.00 crore in RE of 2016-17 on account of high unspent balances available with the States under NUHM and due to low absorption capacity at the States. Since the programme was launched by Cabinet in May, 2013, most of the activities in States are at take off/implementation stage. The actual expenditure incurred under NUHM is ` 480.07 crore (i.e. 84% of RE) upto 31st January, 2017 during FY 2016-17.

4.2 On being asked about the specific problems related to NUHM, the Department informed that:-

• NUHM is a recently launched programme involving different stakeholders like ULBs in case of metro cities where NUHM implementation is mandated through the Urban Local Bodies in Metro cities of Ahmedabad, Bangalore, Chennai, Hyderabad, Kolkata, Mumbai and New Delhi. The coordination mechanism between State Health departments and the Urban Local Bodies needs to be strengthened and not well established in most places.

• Mostly contractual staff is posted at the urban health facilities thus impacting the utilization of funds at these facilities. Besides for regular staff posted at most of the facilities, the expenditure is booked under Corporation/ULB budget.

• The financial system of accounting, budgeting and reporting needs to be strengthened for expediting the pace of utilization of funds.

• The Urban Health institutional arrangement is not robust in metro cities. There is lack of availability of land and space for setting up of new health facilities in urban areas. 30

• There is lack of capacity and expertise in urban health, and retention and availability of Medical and Paramedical Staff i.e. MO, SN, ANM etc. in urban areas is an issue.

• Inadequate PPP capacities are also an area of concern.

4.3 A revenue allocation of `752.05 crore has been made in 2017-18 and is proposed to be utilised as per the activities proposed by the States in its annual State Programme Implementation Plan (SPIP) under NUHM for the FY 2017-18. The allocation of `752.05 crore is less that the projected demand of `1100.00 crore with the shortfall of `347.95 crore i.e. 32%. With regard to shortfall of funds, additional demand for funds can be projected by the Ministry in the supplementary demand for grants in case of improved pace of utilization of funds. Besides, the extent of shortfall in budget can be met by the State from the proportional state share contribution.

Recommendation

4.4 The Committee has been closely following the implementation of NUHM since its take off in 2013 after a protracted and long winding process. The Committee notes that the NUHM programme is a vital component for meeting healthcare needs of the urban population with a focus on urban poor and is oriented towards making available primary healthcare services and reducing their out-of-pocket expenditure on health. The Committee therefore views with serious concern the reduction in allocation for NUHM for 2017-18 (` 752.05 crores) vis-a-vis 2016-17 (` 950.00 Crore). The Committee, therefore, would like the Government to devise the strategy in coordination with States to not only remove absorptive capacity constraints but also focus on capacity building of the States to ensure effective utilization of the NUHM funds.

V. TERTIARY CARE PROGRAMS

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDS)

5.1 As per information given in the Annual Report 2016-17, the Non-Communicable Diseases account for 60% of all deaths. The Department has informed that the draft National Multisectoral Action Plan (NMAP) for prevention and control of common NCDs (2016-2022) was circulated to 39 departments for the comments on the roles suggested and requested to nominate a Nodal Officer at the rank of Joint Secretary to coordinate the actions. 28 Departments have submitted their response on the action points and 35 departments have nominated nodal officers. The comments received from various Departments were synthesized and revised NMAP has been prepared. The revised documents are being shared with Nodal Departments for taking necessary action in the matter. The Department of Health and Family Welfare coordinates with the departments and other Stakeholders through multiple mechanisms.

Recommendation

5.2 The Committee observes that the diseases like cardiovascular diseases, cancer, chronic respiratory diseases, diabetes etc. are the leading causes of deaths in India and despite the launch of NPCDS in 2010, the efforts against the growing burden of these diseases are grossly 31 insufficient and a lot more needs to be done to cater to these challenges. The Committee would therefore like the Department to quickly move towards implementation of the National Multi- sectoral Action Plan so that the outreach of NPCDS could be made universal.

5.3 Since the above diseases often require life-long management, the Committee is of the view that AYUSH has huge potential for safe and cost-effective management of NCDs. The Committee, therefore, recommends that the Department should exploit AYUSH strengths for the management of above NCDs.

VI. HUMAN RESOURCES FOR HEALTH AND MEDICAL EDUCATION

(i) District Hospital - Upgradation of State Government Medical College (PG seats)

6.1 The scheme was launched in Eleventh Five Year Plan with the objective of increasing postgraduate seats in Government Medical Colleges. Funds are provided to the Government Medical Colleges for infrastructure development. Fund sharing between the Central and State Government is in the ratio of 90:10 for NE/special category States and 60:40 for other States under the scheme. Central share amounting to ` 736.94 crore has been released to 72 State Government Medical Colleges in 20 States till date.

6.2 On the actual utilization figures for the allocation made in 2016-17 and the reasons for massive increase in allocation from ` 20.00 crore in RE 2016-17 to ` 165.00 crore in the 2017-18, the Department informed that `10.00 crore was allocated in BE-2016-17 and the entire amount has been released under the scheme. Since the scheme was launched in Eleventh Five Year Plan, the proposal is to release 50% of the balance amount under the scheme in 2017-18 so as to wind up the scheme by 2018-19.

6.3 Regarding the physical performance, the Department informed that as per information furnished by the States/UTs, approximately 800 PG seats have increased so far.

Recommendation

6.4 The Committee notes that the Finance Minister in his Budget Speech has made a call for 5000 more postgraduate seats. India is witnessing the rapidly rising burden of communicable and non-communicable diseases. Besides, several new medical institutions are facing challenges in getting faculty to train doctors. The Committee is therefore baffled to note the submission of the Department that the Scheme is to be wound up by 2018-19. The Committee desires that the scheme be reviewed and assessed and revamped instead of being closed.

(ii) Establishing New Medical Colleges (upgrading District Hospitals)

6.5 As per information given in the Annual Report, under the scheme Establishing New Medical Colleges (upgrading District Hospitals), it is proposed to open 58 medical colleges in underserved areas of the country with intake capacity of 100 MBBS seats in each medical college; increasing annual intake capacity to 5800 seats at undergraduate level in Government sector. The objective is to utilize the existing infrastructure of district hospitals for increasing additional undergraduate seats in a cost effective manner by attachment of new medical college with existing district/referral hospitals. Fund sharing between the 32

Central Government and States is in the ratio of 90:10 for NE/special category States and 60:40 for other States. Upto 30-11-2016, 51 proposals had been approved under the scheme. Funds to the tune of ` 1504.73 crore have been released to the States/UTs till date. ` 1293.70 crore had been allocated in RE 2016-17 for this scheme, which has been substantially increased to ` 3300.00 crore in BE 2017-18. On what are the reasons for a quantum increase in revenue allocation of ` 3300.00 crore made in 2017-18 and in what manner the same is proposed to be utilized and whether the allocation of ` 3300.00 crore is as per projected demand and if not, what is the extent of shortfall, the Department has informed that as per the decision taken in the meeting held in PMO dated 9.6.2016, the target date for completion of ongoing works of 58 medical colleges is 31.12.2018. Against the central share of `7541 crores, only `1504 crores has been released till date. Enhanced allocation is required to expedite the completion of works.

6.6 The Department has informed that Five Medical Colleges i.e. at Port Blair (A&N Islands); Rajnandgaon (Chhattisgarh); Sarguja (Chhattisgarh); Gondia (Maharashtra); and Nahan (Himachal Pradesh) under the Centrally Sponsored Scheme namely, 'Establishment of new Medical Colleges attached with existing district/referral hospitals' are functional.

6.7 An EFC note for upgradation of 82 District Hospitals in to Medical Colleges in Phase-II of the Scheme has been circulated.

Recommendation

6.8 The Committee observes that there is a huge shortfall in the number of MBBS doctors in the country and at the present rate of production, the shortfall will not be met for many years. The Committee, therefore, welcomes the substantial increase in allocation to ` 3300.00 crore under "Establishment of New Medical Colleges (upgradating District Hospitals)’ as the increase in allocation would help augment human resources in the health sector and improve the quality of healthcare delivery. The Committee is however, concerned at the snail's pace of progress made in adding 82 more medical colleges in Phase II of the Scheme. A year has passed since the Phase II was conceptualized, but the Expenditure Finance Committee is yet to accord its approval to Phase II. The Committee, therefore, recommends that the Department should sort out all the pending issues within a specified time-frame and hasten the formulation of a policy.

VII. Deficiency of Health Infra-structure and Manpower in Rural Areas

7.1 On what are the latest figures concerning the shortfall of doctors, specialists and surgeons in rural health setting and whether the steps taken by the Department of Health and Family Welfare to augment the supply of doctors in rural areas have produced the intended results the Department has informed that as per Rural Health Statistics (RHS) 2015-16, shortfall of doctors at PHCs, specialists (including surgeons) at CHCs and surgeons at CHCs are at Annexure VI.

7.2 Public health being a State subject, the primary responsibility to ensure availability of doctors in public health facilities lies with the State Governments. However, under the National Health Mission (NHM), financial and technical support is provided to States/UTs to strengthen their healthcare systems 33 including support for engagement of doctors on contractual basis, based on the requirements posed by the States/UTs in their Programme Implementation Plans (PIPs). Support is also provided to States/UTs by giving hard area allowance to doctors for serving in rural and remote areas and for their residential quarters so that they find it attractive to serve in public health facilities in such areas. As the posts required for health facilities are filled up by respective State/UT Governments, they are impressed upon from time to time to fill up the vacant posts.

Recommendation

7.3 From the data supplied by the Department, out of 11262 sanctioned posts for specialists at Community Health Centres (CHCs), 7359 are lying vacant; out of 2657 posts for Surgeons at CHCs, 1811 are lying vacant; out of 34068 doctors at Primary Health Centres, 8774 are lying vacant. The Committee notes that there are a large number of vacancies with respect to the specialists at CHCs and Doctors at Primary Health Centres. The Department has informed that 'Public Health' being a State subject, the primary responsibility to ensure doctors in public health facilities lies with the State Governments. The Committee while agreeing with the view that 'Public Health' is a State subject, feels that the Centre cannot absolve itself of the responsibility of ensuring accessibility and affordability of health to all citizens, which can only happen when the Centre monitors the availability of manpower in States. The Committee, therefore recommends, that the Department should encourage the States to carry out the reforms in the recruitment process and fill the vacant posts. The Committee desires to be apprised of the efforts made and progress achieved in this regard. 34

PART-B

HEALTH SECTOR

BUDGETARY ALLOCATION

1.1 The projected demand of the Department of Health and Family Welfare for 2017-18 for both Capital and Revenue funds and extent of shortfall is as under:

(` in crore)

Projection of estimate Actual allocation Shortfall in allocation 2017-18 2017-18

Revenue Capital Total Revenue Capital Total Revenue Capital Total

24809.29 4692.05 29501.34 21239.47 3483.81 24723.28 3569.82 1208.24 4778.06

1.2 The Department has informed that owing to shortfall in allocation, implementation of the Programmes/ Schemes in the Health Sector shall not be affected as the same would be offset by way of projection of Supplementary Demands for Grants in the first batch of the Supplementary demands. Further, it has also been submitted that to ensure optimal utilization of funds for different development activities, utilization of funds is reviewed by various committees formed at different levels to ensure fiscal discipline. Meetings are also held regularly to review utilization of funds and these are attended by implementing agencies. During review, the physical and financial progress is taken into account and realistic assessment is done. Budget is revised in accordance with this assessment during the first Supplementary, during RE/ BE exercise, Second Supplementary, Third Supplementary and Final Estimates Stage. All efforts are made to utilize all funds and to ensure that least funds are surrendered.

1.3 It can be seen from the above table that for the year 2017-18, ` 24723.28 crore has been allocated against the projected demand of ` 29501.34 crore leaving a shortfall of ` 4778.06 crore. The Department has committed that shortage of funds would not impact the implementation of projects/schemes in the Health Sector and fiscal discipline would be maintained while utilization of funds and all efforts would be made to ensure optimum utilization. The Committee, however, is of the view that since there has been consistent underutilization of funds during the preceding years, the Department should ensure the completion of administrative pre-requisites for the implementation of projects/schemes in a time bound manner and design an action plan using financial yardsticks to achieve the targets set for the year 2017-18. Also, stringent monitoring machinery be evolved to keep track of the activities being undertaken within a set timeline.

1.4 The Committee's attention has been drawn to media reports stating that India ranks very low on basic health parameters as around 400 million people do not have access to essential

34 35 health services with the problem becoming acute in rural India. Health care in India continues to be a major challenge even when compared to many developing nations as India has just over 0.9 hospital beds per 1,000 people, which is abysmally low when compared to the world average of around 4 hospital beds per 1,000 people which is a pointer to the inadequate public health system. These gross deficiencies in health infrastructure and qualified health care providers are result of low spending on the health sector for decades. Public health care facilities do not cover the country extensively and most of them are poorly equipped and understaffed, while a few relatively better ones are overcrowded with the problem getting aggravated by non-availability of secondary or tertiary care services in rural areas. National Sample Survey numbers show a decrease in the use of public hospitals over the past two decades. More than half of Indian's rural population depends upon private healthcare, which is four times as expensive as public healthcare. Also, the shortage of expert medical professionals in public health centres has arisen posing another challenge to the Indian health care sector. It would also be pertinent to mention here that the expenditure in healthcare technology is considerably low in India and hospitals in India need to increase their spending on technology upgradation considerably to provide for improved patient-centric services. Investment in Indian healthcare sector is the need of the hour alongwith appropriate audit and financial monitoring, capacity building and judicious resource allocations. The Committee is of the view that the health sector should get substantially more allocations and, therefore, the Committee strongly recommends the Department to approach the Ministry of Finance with their proper planning and synergized action plans to seek enhanced allocations in coming years.

1.5 The Secretary, Department of Health and Family stated that a total budgetary allocation of ` 47,353.00 crore has been given to the Ministry of Health and Family Welfare which is an increase of around ` 10,000.00 crore as compared to last year's BE, which was ` 37,000.00 crore. Besides this, the National Health Mission gets an additional quantum of about ` 1900.00 crore, Pradhan Mantri Swasthaya Suraksha Yojana : ` 1500.00 crore and the Human Resource Sector which is medical education and upgradation of district hospital : ` 3425.00 crore. The Secretary also stated that this year States' capacity to spend has increased considerably which has led to enhanced spending in health sector in the country than previous years. He also added that additional resources of ` 300-400 crore are required in CGHS where outstanding bills from the hospitals are close to ` 350.00 crore which need to be cleared to maintain the association of CGHS with the empanelled hospitals. Similarly, an additional amount of ` 400.00 crore is required for drug procurement by NACO.

1.6 Further, the Secretary apprised the Committee about the achievements in medical education sector wherein in the last two academic sessions, 68 new medical colleges have been opened and 11835 MBBS and 1004 Post Graduate seats have been added. Also, NEET has been introduced for UG and PG courses and combined counselling has been adopted by many States. There has been a gradual increase in number of nursing institutions from 1619 in 2013 to 1831 in 2016. Also, the upgradation of existing State Government medical colleges has been done by adding 1715 new MBBS seats in 22 medical colleges and the budgetary provision of ` 480.00 crore is given in 2017-18 to accelerate their performance. 36

1.7 The Secretary also informed the Committee about the Department's focus on mental health for elderly and cancer care wherein 11 Centre of Excellence (COE) and 27 PG Department have been established while 10 COEs and 12 PG Department are underway for manpower development in Mental Health. Also, two National Centres of Ageing (NCAs) have been approved for AIIMS, New Delhi and Madras Medical College, Chennai at cost of ` 30.00 crore each for Mental Health Sector; 20 Regional Geriatric Centres are proposed to be established to assess health, social and economic status of elderly population under Geriatric care. Besides this, setting up of 13 Tertiary Care Cancer Centre (TCCC) and 11 State Cancer Institute (SCI) to strengthen all cancer related activities in respective regions have been approved under cancer care.

1.8 Coming back to overall health scenario and respective outlays, it has been informed that an outlay of `75, 145.29 crore was made under the 12th Five Year Plan (2012-17) for Health Sector. Against this, only `40,538.00 crore was allocated on Annual Plan basis during the Plan Period, which amounted to 53.95% of the 12th Five Year Plan Outlay. Year wise approved allocation for both Revenue and Capital expenditure vis-a-vis actual expenditure during this respective year is as detailed below:-

(` in crore) (upto 02/02/2017)

Sl. No. Year Budget Estimates Actual Expenditure

Revenue Capital Total Revenue Capital Total

1 2012-13 4293.70 2291.30 6585.00 2845.72 1299.71 4145.43

2 2013-14 5311.07 2854.93 8166.00 2984.06 1277.16 4261.22

3 2014-15 6813.51 1919.49 8733.00 4773.10 872.35 5645.45

4 2015-16 5386.65 867.35 6254.00 6298.36 891.14 7189.50

5 2016-17 9092.14 1707.86 10800.00 7640.38 723.50 8363.88

TOTAL 30897.07 9640.93 40538.00 24541.62 5063.86 29605.48

1.9 The Committee observes that out of the total outlay for the 12th FYP of ` 75,145.29 crore, only 53.95% of total outlay was given to the Department. The Committee on perusal of the trend of expenditure during the last five years notes that the Department has not been able to utilize even the allotted funds optimally. Out of BE of ` 40538.00 crore for 2012-17, actual expenditure amounted to ` 29605.48 crore which is approximately 73% of the allocated funds. For the year 2016-17, the expenditure w.r.t. RE of ` 11447.07 crore was 73.07 % only, amounting to ` 8364.37 crore leaving a shortfall of ` 3082.70 crore, except for the year 2015-16. This trend of under utilization indicates the lack of proper planning by the Department in assessing the fund requirements vis-a-vis the targets set which has led to consistent underutilization during each year of the Five Year of Plan period. 37

1.10 The trend of expenditure during each year in percentage is as under: (` in crores) (*upto 2.2.2017) Financial year BE RE AE Trend of expenditure Trend of expenditure in % wrt BE in % wrt RE 2012-13 6585.00 5000.00 4145.43 62.95 82.91 2013-14 8166.00 5065.00 4261.22 52.18 84.13 2014-15 8733.00 6772.18 5645.45 64.65 83.36 2015-16 6254.00 7504.00 7189.50 114.96 95.81 2016-17 10800.00 11447.07 *8363.88 77.44 73.07

1.11 On analysis of the expenditure trends, the Committee finds a substantial mismatch in the financial projections leading to sub-optimum utilization. The Committee is dismayed to note the casual approach of the Department in framing the unrealistic financial projections vis-a-vis targets set for the 12th Plan period. The Committee recommends that the Department undertake a thorough analysis of the fund requirements for implementation of projects/schemes, identify bottlenecks and reassess them so as to avoid any under utilization of the allocated funds in future. Besides, there is strong need to prioritize various projects/schemes so that funds which could be deployed elsewhere do not lapse due to underutilization.

1.12 From the information furnished by the Department about the extent of expenditure vis-a-vis allocations made in BEs and REs for 2015-16 and 2016-17 under different schemes, the attention of the Committee has been drawn towards the few schemes wherein there has been erratic trend of utilization of funds:-

(` in crores)

2015-16 2016-17 Schemes BE AE % of AE BE AE % of AE w.r.t BE w.r.t. BE PMSSY 2206.00 1577.83 71.52 2450.00 1402.08** 57.23 CNCI 67.00 37.00 55.22 70.00 12.50* 17.86 RIPANS, Aizwal 65.00 29.00 44.62 75.00 28.60** 38.13 FSSAI 72.00 54.88 76.22 72.00 30.01** 41.68 CDSCO 122.50 76.86 62.74 184.70 63.20* 34.22 NOTP 10.00 06.35 63.50 15.00 03.00** 20.00 Development of 13.00 01.03 07.92 06.00 01.74** 29.00 Nursing Services

*upto 5th January, 2017, ** upto 2nd Feb., 2017 38

1.13 As regards PMSSY; RIPANS, Aizwal; FSSAI; CDSCO, the percentage of expenditure with respect to BE has been reduced in 2016-17 as compared to the year 2015-16. As regards CNCI & NOTP there has been a drastic reduction in utilization of allocated funds. For Development of Nursing Services, no marked improvement is seen. The Committee would like to know the reasons for the flaws in planning and the corrective steps taken by Department to improve its budgetary analysis.

1.14 The Chittaranjan National Cancer Institute (CNCI), Kolkata, an important Regional Cancer Center working has been working in the area of biology of cancer particularly oral cancer and uterine cancer for more than six decades. The Committee is dismayed at the underutilization of funds by CNCI and recommends that the Institute should draw up a clear roadmap to emerge as a global cancer research facility and treatment center for the entire Eastern India and streamline its administrative processes which have been primarily responsible for the underutilization of allocated resources.

1.15 As regards the Annual Action Plan 2017-18 for major schemes in Health Sector, the Committee has noted the following allocations:

(` in crores)

Sl. No. Name of scheme 2016-17 2017-18 BE RE AE BE (Financial outlays) 1. CGHS 115.00 148.00 89.22 1276.65 2. AIIMS 1000.00 1005.00 1000.00 2400.00 3. PMSSY 2450.00 1953.24 1402.08 2500.00 4. Major Central Medical 2383.00 2693.08 1850.08 4984.22 Institutions/ Hospital 5. NACO 1700.00 1753.00 1474.98 2000.00 6. National Centre of 28.20 27.03 26.51 55.54 Disease Control (NCDC)

1.16 From the scrutiny of the above table, it is evident that during 2016-17, there has been considerable under-utilization of funds in almost all the major schemes except AIIMS and NCDC. In view of this trend of under-utilization of funds, the Department needs to justify seeking enhanced funds for 2017-18 especially when the allocated funds at RE 2016-17 have not been fully utilized. The Committee is surprised to note the increase in funds of ` 4984.22 crore allocated to major Central Medical Institutes & Hospitals despite the fact that in the year 2016-17, a sum of Rs 2383.00 crore at BE was enhanced to ` 2693.08 crore at RE stage and only ` 1850.08 crore could be utilized as on 2nd February, 2017 leaving a considerable shortfall in expenditure. Similarly, for CGHS, only 60% of the funds have been used and yet an increase in allocation has been sought for 2017-18. The Committee recommends that the Department should formulate an pragmatic action plan for 39 ensuring judicious utilization of financial resources vis-a-vis set physical targets along with a robust monitoring mechanism to ensure that allocated funds do not remain idly parked and to minimize the amount of savings. The Committee would also like to suggest to the Department to set realistic targets that can be achieved in a time bound manner so as to ensure that spillover of the activities is avoided.

1.17 On response to a query regarding the details of pending Utilisation Certificates (UCs) of the last 10 years with a year-wise break up and the amount involved therein, the Department has furnished the following information:-

Last 10 Year Summary of Outstanding UCs as on 31/01/2017

M/o Health & Family Welfare

Year Deptt. of Health Deptt. of Family Deptt. of AIDS Welfare Control

No. of Amount No. of Amount No. of Amount Ucs (` in Lakhs) Ucs (` in Lakhs) Ucs (` in Lakhs)

2005-06 99 6588.97 94 10300.18 0 0.00

2006-07 193 8541.85 78 24693.32 0 0.00

2007-08 137 10649.59 39 4062.19 0 0.00

2008-09 127 19360.22 18 7229.51 36 2097.52

2009-10 89 6001.84 29 711.54 15 357.54

2010-11 139 24551.36 25 210.80 1 0.30

2011-12 613 74401.43 32 4288.79 0 0.00

2012-13 411 51449.75 66 98454.22 6 862.17

2013-14 545 61194.76 212 314487.58 8 2919.91

2014-15 57 41134.81 10 869.31 0 0

TOTAL 2410 303874.58 603 465307.44 66 6237.44

*the oldest Utilization Certificates pending is from 1993-94.

1.18 It was further apprised that the office of the Chief Controller of Accounts (CCA) has developed a Web-portal for monitoring of pending UCs. Whenever any proposal for release for Grant-in-Aid to any institute is made, it is checked whether any UC is pending against the institution or not. In case any UC is pending, no release is made until the institution settles the pending UCs.

1.19 As regard the progress made in clearance of large number of pending Utilization Certificates, it is informed that the Ministry of Finance is now also providing the facility of monitoring of UCs through 40

Public Fund Management System (PFMS). After implementation of PFMS for Autonomous Bodies, the respective Institutes will be able to generate Utilization Certificates (UCs) through the system and also can send it through PFMS. As per the Action Plan, all Central Ministries/Departments were required to complete the full roll-out in respect of its attached/subordinate offices by 31st October, 2016. All six attached/subordinate offices of the Ministry have been covered on PFMS platform much before this date. The due date for implementation of PFMS in all Grantee Institutions (Autonomous Bodies) is 31st March, 2017. The Institutions of National Importance (INI) are being taken first. Accordingly, all six AIIMS like Institutions (under PMSSY), AIIMS, Delhi and PGI, Chandigarh have already been brought on the PFMS Platform.

1.20 The Committee notes that out of a total 2410 Utilization Certificates in health sector, 66 UCs pertaining to NACO have been pending for an amount of ` 303874.58 lakh and ` 6237.44 lakhs respectively with the oldest pending UCs dating back to 1993-94. The Committee also notes that during DFG 2016-17, the Department had furnished that the oldest UCs dates back to 2005-06 with an amount of ` 67.40 crore involved therein. The Committee takes serious exception to the manner in which the information is furnished to the Committee and impresses upon the Department to provide correct and factual information. The Committee is deeply concerned about the huge amount of funds involved therein as this would adversely impact the implementation of the various schemes and developmental projects. The Committee appreciates the Department's efforts in implementing PFMS and is hopeful that with this, pendency of UCs would come down and funds can be utilized appropriately. The Committee also suggests that having an exercise of continuous monitoring of the performance of PFMS to find gaps, if any, in the implementation of this software may also be evolved. The Committee would like to be apprised in this regard on a regular basis.

II. SAFDARJUNG HOSPITAL & VARDHMAN MAHAVIR MEDICAL COLLEGE (SJH & VMMC), NEW DELHI

2.1 As per the information given by Department, the allocation of funds and expenditure thereon for the year 2016-17 is as under:

(` in crore)

2016-17

BE RE AE (11/02/2017)

Plan 592.00 918.58 494.51

Non Plan 337.00 343.00 333.71

2.2 It was found that the fund allocation in BE was ` 592.00 crore which was further enhanced to ` 918.58 crore but the actual expenditure upto 11/02/2017 remained at ` 494.51 crore, leaving substantial funds unutilized.

2.3 The Committee is dismayed to observe the considerable amount of unutilized funds in view of various developmental activities going on at SJH & VMMC as this clearly indicates poor fiscal 41 planning and execution on the part of the Department leading to a large amount of allotted funds lying idle, resulting in cost escalation. The Committee recommends that the Department should take corrective measures to arrest the shortfall in utilization of budgeted funds and monitor the activities being undertaken to ensure their timely completion.

2.4 The Department has further informed that the projected demand under Capital & Revenue head was `130.50 crore and `1127.44 crore, respectively in the financial year 2017-18. However, the funds allotted to it was `200.50 crore & `905.19 crore respectively. The allocated funds will be utilized for the smooth functioning of the hospital for patient care services including the procurement of equipments, completion of project (re-development plan), procurement of vehicles for the hospital, and construction/ upgradation/repair of staff quarters. It has also been informed that after implementation of Emergency Block there may be a shortage of funds.

2.5 The Committee notes that the budgeted funds for the financial year 2017-18 would be utilized to complete the ongoing civil and procurement activities only as no new projects are in the pipeline for the hospital. The Committee, therefore, recommends that the Department should make all out efforts to achieve the physical targets in time to avoid their spillage to the next year. Moreover, in case of the implementation of the Emergency Block, in case additional funds are required then the Department should approach the Ministry of Finance for enhanced allocation at RE stage.

2.6 As regards the ongoing projects at VMMC, the Committee has been apprised that the ongoing projects are consequent to the creation of additional infrastructure and it has been delayed due to late statutory clearances. The permission for additional infrastructure from statutory bodies like Delhi Urban Art Commission (DUAC), Fire Department and Delhi Police has been obtained and submitted to NDMC for obtaining approval. A revised cost estimates has also been prepared and approval of competent authority is being obtained.

2.7 The Committee is disappointed to note that the creation of additional infrastructure at VMMC is still on paper and is pending for approvals from concerned authorities. The Committee would like to know the details of these activities and the progress made in this regard.

2.8 On the issue of the vacancy positions in SJH & VMMC, the Committee notes that out of sanctioned strength of 5457 posts under various categories, 1543 posts are lying vacant. In Group A & B categories, out of 3408 sanctioned posts, 1015 posts are lying vacant. The Committee is aware of the fact that Safdarjung Hospital witnesses a huge number of OPD patients and with such heavy patient load along with persistent shortage of workforce, the smooth functioning of the hospital is bound to get affected. The Committee would like to know the reasons for the persistent shortage of staff and strongly recommends that the Department should expedite the process of filing up of the vacancies on priority basis.

2.9 On the issue of the progress made towards operationalization of IVF Lab at Safdarjung Hospital, the Department has informed that technical bid for equipment was opened and evaluated by external 42 experts but it stands rejected as none of the bids were technically responsive. It is also noted that the recruitment of Embryologist and Asst. Embryologist is under process and these being regular posts, recruitments are to be made through UPSC. Meanwhile, recruitment of Embryologist and Asst. Embryologist is being done on contractual basis and performing of Intrauterine Insemination (IUI) is being done regularly.

2.10 The Committee notes that Intrauterine Insemination (IUI) is not a time bound procedure and requires constant monitoring under a team of experts. Given the high incidence of people opting for IVF and simultaneous mushrooming of IVF centers in private sector, patients are taken for a ride and exploited in terms of money and physical well being. Therefore, IVF facility in a government set up would certainly be a boon for childless couples where they can undergo the treatment at a comparatively low cost. Therefore, strengthening of the IVF lab and making it fully functional should be on utmost priority.

III. DR. RAM MANOHAR LOHIYA HOSPITAL (RML), NEW DELHI AND PGIMER, DR.RML HOSPITAL

3.1 The Plan and Non Plan funds allotted for the year 2016-17 are as under:-

(Rs in crore)

2016-17

Dr. RML Hospital

BE RE AE (20/01/2017)

Plan 182.00 182.00 147.87

Non Plan 280.00 255.00 223.11

PGIMER, Dr. RML Hospital

Plan 28.00 34.50 29.345 (31/1/17)

3.2 The Department has informed that the physical targets have been achieved and the projects are running as per schedule, and the PGIMER has been fully functional with 141 PG seats including the specialist, super specialty and diploma courses. It has also been informed that the capital allocation of ` 60.00 crore made in BE 2017-18 as per the projected demand of the Institute would be utilized for construction of the Resident Doctor's Hostel.

3.3 With respect to the ongoing and new projects in Dr. RML Hospital (Annexure VII), the Committee notes that out of 4 projects at Dr. RML Hospital, only the Dharamshala project has been completed and made operational w.e.f. 5th Jan, 2017. The project of construction of Super Specialty Block, is still at examination stage, Modern Maternal Center is dwelling in process of vacation of land and the construction of doctors' hostel is waiting for administrative clearances from the competent authorities. The dates for commencement for these projects have not been decided yet. 43

3.4 The Committee expresses its displeasure at the tardy progress of execution of the above projects and recommends the Department to identify and resolve the factors responsible for the inordinate delays in getting departmental approvals and in eviction of land for maternal center at the earliest so as to move forward in implementing such critical projects as delay in execution of projects would ultimately lead to time and cost escalations. Therefore, the Committee suggests to the Department to analyze the timeframes along with deliverables for implementation of the projects so as to avoid financial and physical slippages.

3.5 In reply to a query regarding updated status of vacancies in RML Hospital, the Department has informed that efforts are being made to fill up the various vacant posts in Dr. RML Hospital. The recruitment of nursing staff, Sr. radiograph, radiographer, X-ray assistant, pharmaceutical staff has already been initiated. The recruitment process for filling up the post of Jr. ECG technician (10) has been final but posts are withheld by order of Hon'ble Court. Physiotherapist (8), Occupational Therapists (3) and OT Assistants (16) have joined recently through written examination conducted by Institution itself. It has also been stated that the recruitment for filling of other posts could not be initiated due to amendment in Recruitment Rules, framed long time back in 1973/1974, which lost its significance due to up-gradation in technology and higher qualifications.

3.6 The Committee notes that despite efforts made to fill up the vacant posts at the hospital; vacancies still exists in various categories which would be having adverse impact on the functioning of the hospital. The Committee notes with concern the non revision of the Recruitment Rules since 1973-74 and recommends for immediate revision in context of present day requirements. Also, abolition of the vacant Group 'C' (Ministerial) category with 96 vacancies posts and erstwhile Group D posts with 415 vacancies may be considered so that the funds could be utilized to create more technical/para-medical vacancies viz. physiotherapist, occupational therapist, dialysis technician, optometrists, speech pathologist, respiratory therapists and prosthetic technicians emerging medical technical professionals so as to offer a wider variety of human resource trained to fulfil present day health care needs. The Committee, therefore, also recommends that the matter be taken up on priority basis to expedite the administrative procedures and process of getting approvals so as to step up the efforts to fill up the various posts at the Dr. RML Hospital. The Committee would like to be apprised of the action taken in this regard. To save on the administrative process, the Committee strongly recommends for a collaborative approach with the Ministry of Skill Development and Entrepreneurship which is running a successful flagship programme through the Healthcare Sector Skill Council (HSSC).

IV. LADY HARDING MEDICAL COLLEGE (LHMC)

4.1 The Redevelopment Plan of LHMC and associated hospitals which was initiated in March, 2012 by M/s Unity Infraprojects Ltd. and M/s SAM Built Well (I) Ltd; it was to be completed by May/ June, 2014, but due to breaches of terms and conditions and delay on part of M/s Unity Infraprojects Ltd., the contract was terminated on 19th August, 2015 by LHMC on the recommendation of HSCC with approval of the Ministry of Health and Family Welfare. Subsequent to this, HSCC was asked to submit 44 their proposal for execution of balance work with cost implication and estimated cost of balance works left out by M/s Unity.

4.2 On being asked about the progress made with respect to phase I of the Comprehensive Redevelopment Plan and maintenance work of Lady Harding Medical College and its associated hospitals till date, the Department has furnished that the revised cost estimates of the remaining work prepared by HSCC (I) Ltd, (Project Consultant) have been prepared and the proposal is under examination in the Ministry. Once the revised proposal is approved by the competent authority, the process for award of work with time line will be initiated. In the meantime, the Central Building Research Institute (CBRI), Roorkee has been asked to examine the proposal from fire and other safety aspects.

4.3 On review of the chain of events that occurred at LHMC with respect to the Redevelopment Plan, the Committee notes that that there must have been cost escalations and wastage of budgeted funds. The Committee is dismayed to note that the Department has not taken Committee's recommendation in 93rd report of DFG (2016-17) seriously as under and the project is still hanging fire for approvals even after a gap of one year.

"The Committee observes that the originally approved cost of the Redevelopment Plan of LHMC and associated hospitals was ` 586.49 crore and the project was targeted to be completed by May/June 2014. But due to breaches of terms and conditions and delay on the part of M/s. Unity Infraprojects Ltd., the contract has been terminated. Much delay has already taken place and it is, therefore, imperative on the part of the Department to resolve at the highest level all procedural and operational matters including approval of cost estimates expeditiously, and execute the Redevelopment Plan within the approved cost and shortest possible time frame. The Committee also recommends that a fool-proof mechanism be devised to address operational performance of the contractor and take appropriate policy decision to address the critical issues concerning the execution of the Redevelopment Plan. The Committee desires to be kept apprised of the progress made towards executing the Redevelopment Plan."

4.4 The Committee is dismayed at the lackadaisical approach of the Department with respect to the Comprehensive Redevelopment Plan and maintenance work of LHMC and associated hospitals. The Committee is concerned to note that wrong selection of the company. i.e. M/s Unity Infraprojects and M/s SAM Buillt (I) is the prime reasons for the delay, cost escalations and execution related difficulties. This sort of arrangement and consequential delays has been noted in several other projects. In these circumstances, the Committee recommends that reputed infrastructure companies with a proven track record should be roped in to execute construction and infrastructure related projects. The Committee also recommends for blacklisting of the errant companies. The Committee is disappointed to note that as such no progress has been made in the Redevelopment Plan of the Institute and the likelihood of its completion in near future seems very bleak. The Committee, therefore, strongly recommends that the Department should make all out efforts to complete the procedural issues involved therein and make the concerned authorities accountable for timely completion of the project. The Committee may be updated of the progress made in this regard. 45

4.5 To the query regarding actual expenditure incurred in 2016-17 alongwith status of the physical targets and achievements, the Committee notes that four projects are a spill over activity from the last financial year viz. Establishment of Human Milk Bank; Renovation of Female Surgical Ward; New toilets as part of Swaach Bharat Abhiyan Public address system in Auditorium; Provision of lifts for disabled person. And the remaining other projects viz. provision lifts for disable person, addition of horticulture services, additional parking space in KSCH and Student cafe are new proposals to be started in the financial year (2017-18). The Committee has also been informed that the allocation of ` 382.069 crore (Revenue Head) and ` 24.40 crore (Capital Head) at BE 2017-18 is as per the projected demand.

4.6 In view of the spillover activities from the previous year and new initiatives proposed for the year 2017-18, the Committee observes that the Hospital has substantial number of projects to be completed for the current year. The Committee is of the opinion that the Department should do prudent assessment of fund requirements and expedite pre-project formalities for operationalization of various projects as envisaged.

4.7 On the query regarding vacancy position at LHMC, the Committee has noted the following information:-

Name of Sanctioned In-position Vacancy Posts Reasons the post Strength deemed abolished

Faculty 298 245 53 - -

Technical 299 104 195 40 Proposal for framing/ amendment of Recuritment Rules is under consideration of DGHS.

Non-Technical 226 107 119 38 Proposal for revival of non-technical post is under consideration of DGHS

Erstwhile 739 505 234 - As per the Govt. of India's decision Group 'D' after 6th CPC, no group 'D' Staff is to be recruited in the Govt. Office. Posts of erstwhile group 'D' employees have been upgraded as group 'C' and designated as Multi-Tasking Staff. Post will be filled up once the RRs for the post are finalized.

Cadre of Nursing 831 502 320 09 -

4.8 The Committee has observed that 53 faculty posts are vacant out of the sanctioned strength of 298. As regard the vacancies in other categories like technical and non-technical, the Department has informed that the matter is under consideration of DGHS. In Nursing Cadre, out of 831 sanctioned posts, 46

320 posts are vacant in various categories. The Committee is concerned to note such a huge gap in the nursing workforce and its likely impact on the functioning of the hospital. Although vacancies in faculty posts are less but any extent of shortfall in faculty and other staff would overburden the existing workforce. The Committee strongly recommends for a collaborative approach with the Ministry of Skill Development and Entrepreneurship which runs a successful flagship programme under the Healthcare Sector Skill Council (HSSC) for meeting paramedical/ technical manpower requirements.

V. ALL INDIA INSTITUTE OF MEDICAL SCIENCES (AIIMS), NEW DELHI

5.1 The Committee notes that the budgetary support of ` 2293.00 crore was provided to AIIMS during 2016-17. However, the expenditure upto January, 2017 was ` 1867.50 crore. The BE 2017-18 reflects ` 2400.00 crore under Revenue head.

5.2 As regards the status of physical targets set and achieved in various projects, the updated information is at Annexure VIII. From the perusal of the furnished information, the Committee notes that out of 17 projects at AIIMS; only in three projects viz. Construction of Housing and Hostel at Ballabgarh Fatehpur Billach; Construction of Nallah (Balance Work) and Construction of a Motorable Tunnel (DMRC), the physical work has been completed. In other projects namely OPD Block of Masjid Moth, vertical expansion of trauma care, construction of cafeteria and facade work for Gate No 1, the physical progress is at 46%, 89%, 90% and 15% of completion respectively. Also, there are other projects with almost nil physical progress made owing to delay in civil works and under planning on the part of Department. It is noted that for the construction of paid ward, ` 70.00 crore has been allocated for 2017-18 and the contract has been terminated and the work is now likely to be awarded to L1 Bidder. Besides, funds to the tune of ` 98.00 crore and ` 25.00 crore have been allocated for construction of Burns Unit and Hostel No. 4 at Masjid Moth respectively and work has been awarded to L1 Bidder in August, 2016.

5.3 The Department has stated that for all major projects, the implementation is monitored by a committee headed by the Health Secretary. The said committee meets on a periodical basis to ensure that adequate budget is available for timely completion of civil works.

5.4 The Committee recommends that all out efforts should be made for the projects under planning stage to be brought to take off stage expeditiously and measures should be taken to expedite the process of getting departmental approvals from concerned authorities to increase the pace of implementation of the projects. The Department should also set in place an intensive monitoring mechanism to ensure successful execution of the projects within the approved cost and designated timelines. The Committee is extremely concerned to note that the faulty tendering process led to selection of the wrong executing agency, and thus caused execution cost overruns and other delays. The Committee recommends that the track record of the company especially in case of construction related projects should be made an important criterion to avoid recurrence of such instances. The Committee recommends for roping in of reputed construction companies with a proven track record for execution of such projects within a time frame. 47

5.5 On being asked about the vacancies as on date in the Institute, the Department has informed that at present, 73 Professors and 106 Assistant Professors seats are vacant at the All India Institute of Medical Sciences, New Delhi. As regards recruitment process for the posts of Professor, a litigation on the issue of seniority between the Professors appointed under the mode of Direct Recruitment vis-a-vis those who were promoted under Assessment Promotion Scheme is pending before the High Court of Delhi. Unless, the issue of seniority is resolved, the process of filling up of the vacant posts of Professor could not be initiated. However, efforts are constantly being made to fill up the vacant faculty posts of Assistant Professor. In the year 2016, appointments letters were issued to 85 candidates, out of which, 74 candidates have already joined. Process for filling up the vacant posts of Assistant Professor will be initiated once the previously recruited candidates join their posts. The Committee notes that though the number of vacant faculty posts has reduced from 232 to 179 as compared to last year, the Department needs to put in additional efforts for further reducing the number of vacancies keeping in view the increasing workload at the Institute. The Committee is of the view that a complete team of paramedical professionals including technical staff is sine-qua-non for the efficient functioning of any hospital set up. For a premier institute like AIIMS, gaps in the workforce would definitely affect the smooth running of the hospital. The Committee therefore recommends that to maintain the status of Institute of national importance, the Department should strive to plug these gaps in the medical/paramedical sanctioned posts by expeditious filling up of all vacancies in various categories. A collaborative approach with the Ministry of Skill Development and Entrepreneurship may also be considered for manpower requirements.

5.6 As regard the updated status of Burns Unit at JPNATC, the Department has stated that the work has been awarded to L1 bidder on 25th May, 2016. The Committee notes that matter has been hanging fire since last 2 years and no forward movement has taken place. The Committee is apprehensive that if this is the pace of progress, the project may not be initiated even during the financial year 2017-18 unless the issue is taken up at a higher level. The Committee, therefore, strongly recommends that the Department should firm up all pre and post-project approvals and ensure that the project is initiated before the end of this financial year.

VI. POSTGRADUATE INSTITUTE OF MEDICAL SCIENCES AND RESEARCH (PGI), CHANDIGARH

6.1 It has been informed that as on 31.01.2017 the actual expenditure was ` 68.00 crore under Plan Head and ` 773.00 crore was under Non-Plan.

6.2 The updated details of the ongoing projects in PGI, Chandigarh is given at Annexure IX. The Committee notes that out of nine ongoing projects, three projects viz. setting up of Satellite Centre of PGIMER at Sangrur (Punjab); Replacement of Air Cooling System with Air Conditioning (HVAC) system in New OPD Block; Upgradation of HVAC System of Operation theatre Complex, Nehru Hospital, PGIMER, Chandigarh have shown some progress. However, the remaining six projects have been progressing at a snails' pace. 48

6.3 The Committee notes that out of the remaining six projects, except for upgradation of HVAC system of the operation theater complex, Nehru Hospital, no expenditure has been reported till December, 2016. All these projects are still at formulation stage and in waiting for approvals from the concerned authorities.

6.4 The Committee notes that despite the availability of financial and physical resources, the projects at PGI, Chandigarh could not be pushed ahead due to inordinate delays caused due to bureaucratic procedures. Moreover, as per canons of financial propriety, the more quickly a project gets implemented, the lesser it results in cost and time overruns. The Committee while deprecating this slow progress in the six projects recommends that the Department should closely monitor the activities being undertaken and fast track these projects to ensure that no cost or time overruns are reported.

6.5 As regards the progress made towards the three projects i.e. Advance Cardiac Centre (Phase I); Modernization of Research 'A' and 'B' Block and Modernization of Nehru Hospitals the details are as under:-

Sl. Name of Project Expenditure Updated status with corrective measure No. Project Outlay/ Upto Dec. taken for implementation of project. Estimated 2016 cost (` in (` in Cr.) Crore)

1. Advanced Cardiac 13.67 3.06 Awarded work of Civil, Electrical & HVAC Centre (Phase-II) component has been completed. The work of installation of Lifts has been awarded. Detailed Estimate and DNIT of Medical gases are under approval of the competent authority.

2. Modernization of 48.33 4.83 After finalization of schemes submitted by Research A and B NBCC for Upgradation of External Engineering Block. Services of Research Block A & B by Monitoring Committee, the tender documents submitted by NBCC were scrutinized & deficiencies were pointed out. NBCC has submitted final tender documents of Electrical work & documents of other services are awaited from them.

3. Modernization of 87.82 8.78 The scheme submitted by NBCC has been Nehru Hospital finalized by Monitoring Committee. The tender documents are being prepared at the end of NBCC. Further action shall be initiated after receipt of tender documents from them. 49

6.6 The Committee notes the progress made in these three projects and observes that all these projects are at nascent stage and under approvals of the competent authorities. In this regard, the Committee would like to reiterate its recommendation made in its 93rd Report on DFG (2016-17) which is as under:-

"The Committee is constrained to observe that all the three projects, i.e. Advance Cardiac Centre (Phase II), Modernisation of Research 'A' and 'B' Block and Modernisation of Nehru Hospital were targeted to be completed during the 11th Five Year Plan but are nowhere close to execution even after the lapse of four years of the 12th Plan period. The Committee expresses its displeasure at the tardy progress of implementation of the above projects and recommends that the factors responsible for the inordinate delay in the implementation of the projects may be gone into in detail and corrective measures taken accordingly so that the implementation of projects is speeded up with sustained monitoring."

6.7 On query regarding vacancy position vis-a-vis sanctioned strength, the Committee notes that nearly twenty percent seats are vacant in the institute as out of 8771 sanctioned strength under various categories, 1616 posts are lying vacant.

6.8 The Committee strongly recommends that the Department should undertake a time-bound exercise to fill the vacancies of medical/paramedical/nursing/technical staff. The Committee is of the opinion that with increasing automation, there is a distinct possibility for reduction in requirement of the administrative staff and the resources can be channelized in favour of paramedical/technical staff.

VII. REGIONAL INSTITUTE OF MEDICAL SCIENCES (RIMS), IMPHAL

7.1 The Department has informed that the fund allocation of ` 190.00 crore under Revenue Head in BE 2017-18 is not as per the projected demand of the Institute which was ` 460.57 crore. The reason for reduced allocation as compared to ` 269.00 crore during 2016-17 is not known to the Institute. It has been informed that the allotted fund of ` 190.00 crore under BE 2017-18 will not be sufficient for the activities at the Institute. Projected salary amount for the year 2017-18 alone is ` 250.01 crore after taking into account the implementation of 7th Pay Commission recommendations. If the allotted amount of ` 190.00 crore under BE 2017-18 is not enhanced, no fund will be available with the Institute for any expenditure for creation of capital assets and hospital related expenditure.

7.2 The Committee notes the list of projects and proposed initiatives at the Institute. The work of construction of PG Gents and Ladies Hostel, Nursing Hostel and Internee Hostel and construction of OPD Block is at standstill and there has been time and cost overruns too. The present status of work is only 38%. As regards the construction activities for increase of UG seats from 100 to 154, the Committee is informed that only 5% of the work has been done. The slow progress is due to prolonged economic blockade in the National Highways of Manipur for the last three months. The Committee was given to understand that there is no time and cost escalations for this programme. It has also been stated that no separate funds are allocated for these programmes but expenditure is met from routine Grant- in-aid provided by the Ministry. 50

7.3 The Committee feels that the present status of constructional activities at RIMS, Imphal appears to be worrisome since the work was started in 2012 and the stipulated time of completion was October, 2013. The work was stopped after the agreement between HSCC and the work agency was declared null and void in March, 2015. This sorry state of affairs indicates a lackadaisical attitude of Department towards healthcare needs of the North-eastern Region. The Committee strongly recommends that Department should take up the matter on priority basis and resolve all the administrative and technical bottlenecks to resume the projects and complete them in the shortest possible time. Since the funds as per the projected demand has not been given to the Institute, the Committee is of the view that the ongoing and proposed initiatives at the Institute would bear the brunt of shortfall of funds. Therefore, the Committee supports the Department to call for more funds at RE stage to meet the demands of the Institute. The Committee also advocates for greater coordination with the DONER Ministry so that plan schemes (capital outlay) for RIMS, Imphal can be supported through Non-lapsable Central Pool of resources (NLCPR). The Committee is concerned to note the opaque administrative process followed in the procurement process during the last few years by RIMS, Imphal and strongly recommends for greater central scrutiny and monitoring with respect to capital spending by RIMS, Imphal specifically in context of procurement of medical equipments.

VIII. NORTH EASTERN INDIRA GANDHI REGIONAL INSTITUTE OF HEALTH AND MEDICAL SCIENCES (NEIGRIHMS), SHILLONG

8.1 The utilization status of funds during 2016-17 is as under:

(` in crores)

B E RE AE (upto 02/02/2017)

300.00 260.20 188.84

8.2 The allocation of ` 200.00 crore for the year 2017-18 is against the projected demand of ` 360.00 crore. The increased demand for funds is due to projects of Under Graduate Medical College, Regional Cancer Centre and Expansion of the Nursing College with associated Hostels and Guest House.

8.3 As regards the status of the new projects, the Committee notes that the 38th Standing Finance Committee (SFC) meeting held on 4th August 2016 accorded approval for the projects, namely, Construction of 100 intake Medical College with Hostel facilities of 650; State of the Art Regional Cancer Center with 250 bedded ward and a patient Guest House of 28 Rooms; and Expansion of the Nursing College for 100 intake with hostel facilities, at a total cost of Rs 363.98 crore.

8.4 As regards the status of recruitment of faculty Group A, B, C posts at the Institute, the Committee notes that out of sanctioned strength of 1332 posts in various categories, 934 posts are filled and 398 posts are lying vacant. The vacancies are mainly due to delay in administrative procedures and approvals.

8.5 The Committee is constrained to note the huge shortage of staff and feels that this would eventually cripple the functioning of the Institute while over burdening the existing workforce. 51

The Committee, therefore, recommends that the Department should take up this matter on a priority basis and fill up the posts at the earliest.

IX. FAMILY WELFARE SCHEMES (FWS)

9.1 The Department has elaborated on initiatives under the Family Programme of India and submitted that it has launched various schemes like the Mission Parivar Vikas; New Contraceptive Choices; Redesigned Contraceptive Packaging; New Family Planning Media Campaign; Enhanced Compensation Scheme for Sterilization etc. under the Family Programme of India. Besides this, a new IUCD (Cu 375) with 5 years effectivity has been introduced in the programme as an alternative to the existing IUCD (Cu 380A with effectivity of 10 years). A new method of IUCD insertion i.e. PPIUCD has also been introduced. Emphasis on Postpartum Family Planning (PPFP) services with PPIUCD and promotion of minilap as the main mode of providing sterilization in the form of post-partum sterilization to capitalize on the huge cases coming in for institutional delivery under JSY was also under taken.

9.2 It has been further informed that there are schemes for ASHAs to ensure spacing in births. Under the scheme, services of ASHAs are being utilized for counselling newly married couples to ensure delay of two years in birth after marriage and couples with one child to have spacing of three years after the birth of 1st child. The scheme is being implemented in 18 states of the country. Celebration of World Population Day & fortnight (July 11 - July 24) is another milestone in this field. The World Population Day celebration is a step to boost Family Planning efforts all over the country. The event is observed over a month long period, split into an initial fortnight of mobilization/sensitization followed by a fortnight of assured family planning service delivery. Besides there are several on-going Interventions are being undertaken under Family Planning Programme.

9.3 The programme wise details of BE and AE as on 08.02.2017 is as follows:-

(` in crore)

Programme B E RE (2016-17) AE (Approved) (08.02.2017)

Training in sterilization/Recanalization 0.05 0.05 0.0421

Male Participation 0.95 0.95 0.6219

Technology in Family Welfare 1.5 01** 0

Total Family Welfare Programme through 0.01 0.01 0 Indian Medical Association

Grand Total 2.51 2.01 0.664

** An amount of ` 1.50 crore was allocated to be released to IIT Kharagpur for NCTFW Project. In the meantime a decision was taken to transfer the NCTFW project to DHR in view of fact they have full fledged advisory/technical committees who are able to evaluate the research work of NCTFW project. Hence in the Revised Estimate for the year 2016-17, ` 50 lac has been surrendered. 52

9.4 On scrutiny of the budgetary allocation, the Committee is concerned to note that out of ` 02.51crore at BE stage, only an amount of ` 0.664 crore has been spent which is a merely 33% of the budgetary fund with respect to RE. The Committee is disappointed to find the substantial mismatch between the activities proposed and funds actually spent. As family planning is an integral component of the population control programme, the Committee is of the view that there must be a proactive approach on the part of the Department to properly monitor the utilization of funds for various activities as envisaged under the programme. The Committee, therefore, strongly recommends that the Department should shed its lackadaisical attitude and closely monitor the utilization of funds.

X. NATIONAL ORGAN TRANSPLANT PROGRAMME (NOTP)

10.1 The actual expenditure vis-a-vis allocation made in 2015-16 and 2016-17 under NOTP is as under:- (` in crore) Year Budget allocation Actual expenditure B.E. R.E. 2015-16 10.00 10.00 6.3521 2016-17 15.00 7.13 4.12 as on 13.02.2017.

10.2 As regards the evaluation of scheme done by the Department, it was stated that the scheme is giving positive results in terms of increased awareness about organ donation and increase in number of cadaver organ donations. The Department has also informed that for the scheme to be more effective, it needs to be continued and expanded.

10.3 The Committee observes that actual expenditure during 2015-16 was just 63% with respect to RE of ` 10.00 crore only leaving unutilized resources. During 2016-17, funds at RE was further reduced to ` 7.13 crore from ` 15.00 crore at BE stage, wherein the actual expenditure as on 13/2/2017 was just ` 4.12 crore. The Committee takes a serious note of the under-utilization of funds under the scheme in both the yea` The Committee is of the view that Department should evaluate the scheme and its scope of expansion to utilize the available physical and financial resources to avoid under-utilization of funds.

XI. SERA AND VACCINE MANUFACTURING UNITS

11.1 The trend of fund utilization at BCGVL, Guindy; PII, Coonor and CRI, Kasauli during last three years in as under: (` in crores) PII, Coonor Year B E RE AE 2014-15 40.00 40.00 40.00 2015-16 45.00 45.00 36.00 2016-17 54.50 54.50 50.50(2/2/17) 53

Year BE RE AE

BCGVL, Guindy 2014-15 12.02 12.64 8.68 2015-16 12.40 8.64 6.83 2016-17 5.50 5.50 4.57 (2/2/17) CRI, Kasauli 2014-15 10.00 6.27 4.85 2015-16 16.00 14.58 8.44

2016-17 14.66 10.85 4.96 (2/2/17)

11.2 On being asked about the latest update on the progress made with respect to upgradation work at BCGVL, Guindy; PII, Coonor and CRI, Kasauli and making these sera and vaccine manufacturing units GMP compliant and operational, the Department has furnished the following information:

(i) Central Research Institute, Kasauli : cGMP compliance achieved for DPT group of vaccines; Bulk production of DPT and Commercial productions of TT Vaccines commenced.The new DPT facility has been completed and made GMP compliant in January, 2014. After the installation qualification and operational qualifications of DPT blocks have been completed, the staff engaged in the production units has been trained to operate the newly installed machinery and equipment. The bulk for Consistency/Commercial batches of TT has been successfully produced after achieving cGMP compliance.

(ii) BCG, Vaccine Laboratory, Guindy: All the work of new cGMP facility completed; Manufacturing of BCG vaccine on trial basis has commenced; Commercial production of BCG vaccine is being initiated. The work of up-gradation of BCG Vaccine manufacturing facility has been completed and GMP compliant achieved in August, 2016. After installation qualification and operational qualifications of the installed equipment, the production of BCG Vaccine on trial basis has been started. The Consistency/Commercial batches of BCG vaccine are being initiated.

(iii) Pasteur Institute of India, Coonoor: 98% of civil construction and other work have been completed; Mechanical installation work i.e. HVAC & BAS, Modular, Water System, Fire Safety Work, ETP&STP, Insulation & Electrical fitting work of various Blocks ranging from 70% to 96% completed. The civil construction work on the project was started in June, 2013. 99.5 % of civil construction and other work of the new cGMP compliant facility completed. Mechanical equipment installation in all the blocks is in progress. 75% mechanical work on water system and process equipment like ware house equipment, packaging equipment, lab equipment, clean room equipment and SS furniture is completed. The validation work of the equipments of the new cGMP compliant facility would be completed by June, 2017. 54

11.3 The Committee notes the consistent trend of substantial amount of funds remaining unutilized at CRI, Kasauli in the last three years. When the facility is producing commercial batches of TT in bulk after achieving cGMP compliance, unutilized funds indicates some lacunae in the process of bulk production. The Committee would suggest the Department to undertake an assessment of the unit and identify the shortcomings and take remedial measures to ensure the smooth running of the vaccine production unit.

11.4 The Committee also observes that at CRI, Kasauli and BCGVL, Guindy, upgradation work has been completed and both the units have been made cGMP compliant since long. The commercial production of TT vaccines and BCG vaccines has already commenced at the respective units. As regards, PII, Coonoor, civil construction is nearing completion and cGMP compliant facility would be fully completed by June, 2017. The Committee would like to suggest the Department to speed up the activities to make PII, Coonoor, cGMP compliant unit to utilize its vaccine production output to make Universal Immunization Coverage a success with increased supply of vaccines at low cost.

11.5 The Committee notes that the public sector vaccine manufacturing units are established to supply quality vaccines for the Universal Immunization Programme (UIP) of the Government of India. The production capacity of these units is barely able to meet the requirement of the programme. The Committee is dismayed to note that the production of yellow fever vaccine has been suspended in CRI Kasauli since 2012. The Committee notes with concern that a premier vaccine manufacturing unit like the CRI has been relegated to the sidelines by stopping its production on one ground or the other. The Committee is appalled at this state of affairs which ultimately led to our dependency on private vaccine manufacturers for meeting the demand for vaccine under UIP. The Committee also notes that once GMP specifications to manufacture DPT vaccine were achieved by CRI Kasauli, it is being replaced by Pentavalent Vaccine.

11.6 Besides the Committee is concerned to note that the DCG (I) has been repeatedly not approving the GMP facilities of CRI on one pretext or another. The Committee would like to draw the attention of the Government to its 38th report on major issues concerning the three vaccine producing PSUs, namely CRI Kasauli, The Pasteur Institute of India (PII) Coonoor and the BCG Vaccine laboratory (BCGVL), Chennai and would like to reiterate its earlier recommendations so that the dependency on private vaccine manufacturing units can be reduced by utilizing the installed capacity at public sector vaccine manufacturing units to their optimum. The Committee is also concerned to note the evasive manner in which the department has avoided giving details of the market share of public sector vaccine manufacturing units vis a vis the private sector vaccine manufacturers.

11.7 National Institute of Biological (NIB)

11.7 National Institute of Biologicals is an autonomous Institution under the Ministry of Health & Family Welfare (MOHFW), Government of India. One of the main functions of the NIB is to undertake research, establish linkages and exchange personnel with different institutions in India and abroad for furtherance 55 of its mandate. The Institute is the National Coordinating Centre (NCC) for the Haemo-vigilance Programme of India (HvPI), at the national level which aims to track adverse reactions associated with blood transfusion and blood donation.

11.8 The Committee undertook an in depth analysis of the increasing dependence of NIB on budgetary support even though when NIB was expected to generate 80% of its recurring expenditure from internal resources. The Committee is concerned to note the ever increasing requirement of budgetary support to NIB specifically during the last five years. The Committee is of the opinion that NIB is exceeding its mandate by duplicating the work done by CDL Kasauli resulting in wastage of scarce public funds as CDL Kasauli is already engaged in the testing of vaccines, sera, solution of serum proteins for injections, toxins, antigens, anti toxins, surgical ligatures, bacteriophages and oral vaccines. The Committee recommends for greater scrutiny of the functioning of NIB by ICMR specifically in context of its role and achievements in the area of research. The Committee is also concerned to note the involvement of private sector vaccine manufacturers in the general body of the NIB and recommends for suitable amendments in the NIB bye laws so that there is no involvement of private sector vaccine or biological manufacturer. The Committee recommends for NIB to ensure that there is no duplication in the setting up of laboratories/ testing infrastructure with the already existing facilities available within the same ministry. The Committee also recommends that NIB should adhere to its original mandate instead of trying to be another regulator.

XII CENTRAL GOVERNMENT HEALTH SCHEME (CGHS)

12.1 CGHS is a Health Scheme mainly for serving/ retired Central Government employees and their families. The scheme was started in 1954 in Delhi and now it has spread to 26 cities and will cover more cities soon. The utilization status of funds both Capital and Revenue allocated in 2016-17 is as under:-

(` in crore)

Allocation Expenditure as on 9.02.2017

Revenue 988.00 858.83

Capital 50.00 10.68

PORB 1116.49 1021.46

12.2 The Department has informed that CGHS being mainly welfare scheme no specific targets can be fixed. However, CGHS has opened new Wellness Centres at Shimla, Indore, Pondicherry and Visakhapatnam. Under Capital Section, sanction of funds to the tune of ` 46 crore have been issued for construction of CGHS buildings at AD(HQ), Sector-13, Shakurbasti, Dwarka 9 & 23, Prasad Nagar, Mayur Vihar-Ph-1, Rohini and renovation at Raipur.

12.3 The Department has also informed that the allocations for the year 2017-18 as follows are largely as per the projections and the shortfall if any, would be met at RE stage. 56

(` in crore)

Projection Allocation

Revenue 1376.66 1202.95

Capital Work 43.70 43.70

PORB 1410.75 1402.79

12.4 It has been also informed that the allocations in the Capital shall be spent for the completion of the Wellness Centre buildings under construction and to augment the infrastructure facilities at new Wellness Centres proposed to be opened at Agartala, Aizawl, Imphal, Itanagar, Gangtok, Kohima and Goa. As regards new initiatives/projects are proposed under CGHS during 2017-18, CGHS will take over 33 Postal dispensaries and opens atleast one Wellness Centres in each State Capital, viz., Agartala, Aizawl, Imphal, Itanagar, Gangtok, Kohima and Goa during 2017-18.

12.5 As regards the updated status on expanding Yoga and AYUSH dispensaries/ units in CGHS and status of vacancies with respect to AYUSH in CGHS, the Department has submitted that after 1985-86, no more regular AYUSH facility could be added in CGHS. The matter regarding expansion of AYUSH Wellness Centres was discussed by Secretary, AYUSH in a meeting on 18.07.2016 with officers of CGHS.

12.6 The Committee is surprised to note that after year 1985-86, no regular AYUSH facility has been added to CGHS. However, the Committee appreciates that the Department has taken up this matter with Ministry of AYUSH. But still, no concrete action has been taken. The Committee, therefore, recommends that the Department should firm up and complete the proposal regarding strengthening of infrastructure, manpower, and maintenance of AYUSH facility in CGHS.

12.7 Further, in reply to a query regarding updated status on NABL accreditation of labs and diagnostic centres under CGHS and progress made in consolidation of in-house labs and restricting the diagnostic labs, the Department has informed that CGHS has no NABL accreditated in-house laboratories. There are 36 NABL accreditated labs and 19 non-NABL empanelled under CGHS in Delhi /NCR.In addition, it has also been stated that CGHS is not in favour of adding more infrastructure at in-house laboratories as the demand of beneficiaries is not very large and several diagnostic labs are empanelled under CGHS.

12.8 On being asked about the status of pendency of hospital bills till date in CGHS, Department has informed that Hospital bills of about `250.00 crore are pending for settlement due to lack of funds under PORB. During current financial year about `400 crores have been paid to the empanelled hospitals. To expedite the settlement of hospital bills subject to availability of funds under PORB, the Committee was informed that the Department has adopted modified system of payment to hospitals since May 2015, under which the Bill Processing Agency, viz., UTI-ITSL would process the hospital bills without initial provisional payment and the processing of the hospital bills has been made online. The financial power of Addl. Directors for settlement of hospital bills has been enhanced from Rs 5 Lakhs to ` 7 Lakhs w.e.f. 5th October 2016. 57

12.9 The Committee notes that many hospitals have de-empanelled themselves from CGHS. The Committee is of the view that the de-empanelment of some very good CGHS approved Hospitals is a major cause of concern and inconvenience to the CGHS patients. The Committee observes that the de-empanelment of these hospitals is mainly due to non-settlement of their dues by the Government. The recent decision of the Department to allow online processing by UTI-TSL is a welcome step but it needs to regulated and checked from time-to-time for desired results. The Committee also recommends introduction of a dedicated CGHS wing in all Government Hospitals and also to ensure that there should be CGHS empanelled hospital in each district of the country. It also recommends putting in place an effective mechanism of quality assurance of the drugs supplied through CGHS.

XIII. CENTRAL DRUGS STANDARD CONTROL ORGANISATION (CDSCO)

13.1 CDSCO regulates the import, manufacture, distribution and sale of drugs, cosmetics and notified medical devices in the country under the provisions of the Drugs and Cosmetics Act, 1940 and the Drugs Standard Control Organisation (CDSCO) and the State Drug Regulators to ensure availability of drugs, cosmetics and medical devices that meet the parameters of quality, safety, efficacy or performance. The Drugs Controller General (India) is the head of Central Drugs Standard Control Organisation (CDSCO).

13.2 On being asked about the progress made w.r.t. strengthening of drug regulatory system of the States uptill now, the Committee has been informed that the Government had approved a proposal for strengthening of the drug regulatory system in the country, both at the Central and State levels at a cost of ` 1750.00 crore. Out of this, ` 850.00 crore has been approved as the Central Government's contribution for upgrading and strengthening the State's Drug Regulatory System. The share of the Centre and the States would be in the ratio of 60:40 for all States except Jammu & Kashmir, Himachal Pradesh, Uttarakhand, Sikkim and seven North Eastern States for which the ratio is fixed at 90:10. The State Governments are required to sign a Memorandum of Understanding (MoU) with the Government of India before the funds would be released to them. Accordingly, proposals were asked for from the States. Out of the 36 States/UTs, the following 21 States/UTs have since submitted proposals for release of funds along with the MoU duly signed by the respective States/UTs. An amount of ` 50.00 crore has been provided for making it available to the States. Sanctions have been issued and the funds are being transferred.

13.3 The Committee strongly recommends that the execution of the project for strengthening of the drug regulatory system be done immediately in accordance of the approvals given by the Expenditure Finance Committee (EFC) in a strict time bound manner. The Committee recommends for setting up a regular consultative mechanism with the State Governments so as to prevent inordinate delays. Efforts may be done to sign MoUs with the remaining States/ UTs.

13.4 The Committee would like to draw attention of the Government to its 93rd Report on the DFG (2016-17) wherein the status of vacancies in CDSCO has been reflected in Table No. 30. The Committee recommends for immediate filling up of vacancies in CDSCO especially in context of the enhanced role as a regulatory body for medical devices consequent to the recent notification 58 of Medical Devices Rules 2017 which shall come into force w.e.f. 01/01/2018. The Committee is concerned to note that the topmost head of CDSCO i.e the DCG (I) continues to function in a very adhoc manner with additional charge. The Committee strongly recommends for a suitable full time DCG (I) and also would like to be updated about the status of action taken in this regard. The Committee recommends for a quarterly update on the progress made in the strengthening of the drug regulatory framework, vacancy position and engagement of a full time DCG (I). The Committee suggests that the entire regulatory framework for regulating the Medical Device industry should be in place in CDSCO before 1st January, 2018.

XIV. FOOD SAFETY AND STANDARD AUTHORITY OF INDIA (FSSAI)

14.1 The Food Safety and Standards Authority of India (FSSAI) have been established under the Food Safety & Standards Act (FSS Act), 2006. It is a statutory body for laying down of science based standards for articles of food and regulating manufacturing processing, distribution, sale and import of food so as to ensure safe and wholesome food for human consumption.

14.2 The trend of utilization status of funds in the last three years is as below: (` in crores) BE RE AE (upto 2/2/17) 2014-15 60.00 60.00 41.11 2015-16 72.00 72.00 54.88 2016-17 72.00 72.00 52.00 (upto 14/02/2017)

14.3 The Department has also informed that the Central Sector Scheme for strengthening of the Food Testing System in the country includes provision for Mobile Food Testing Labs with a cost of `481.95 crore, was approved by the competent authority in September, 2016. FSSAI is the implementing agency of the Scheme. A demand for `114.20 crore for FSSAI, including `48.00 crore under the Grant-in-aid (Capital) for the said scheme was made in Revised Estimates (2016-17). However, `72.00 crore was allocated as RE (2016-17). The amount of ` 133.58 crore have been provided as against the projected demand of ` 324.75 crore in BE (2017-18) and additional funds will be sought depending upon the implementation of the scheme in due course of time.

14.4 The Committee observes that there is consistent trend of under utilization of funds during the years 2014-15, 2015-16 and 2016-17. The Committee is of the view that safety and standardization of food is a neglected area in India and the Department needs to focus more in this field. The Food Safety and Standard Authority of India was established in 2006. The status of safety, regulation, manufacturing, processing, distribution, sale and import of food items for human consumption shows a dreary picture in the country. Slow progress of the developmental activities and initiatives would hamper the quality of work being rendered in context of safety and standardization of food items across the country. Since there are numerous domains under the Food safety and Standard Authority of India, under utilization of budgeted funds indicates negligence in this area and poor financial planning on the part of the concerned authority. 59

14.5 The Committee expects the Department to take appropriate measures to arrest shortfall in utilization of budgetary funds and ensure that the strengthening of Food Testing Systems/ laboratories is done in a time-bound manner.

14.6 The Committee would like to emphasize upon the need for ample provisioning of Mobile Food Testing Labs (SOFTeL) in the country. This would certainly go a long way in ensuring awareness regarding precautionary measures so that diseases spreading through contaminated/ sub-standard food are minimized. Therefore, to improvise the food testing across the country, more number of food testing labs need to be started.

14.7 The Committee recommends that the results of all the food items being tested should be made public through advertisement, newspaper and other electronic, print and social media to make public aware about the same. The Committee, also recommends the Department to set desirable and achievable targets and seek additional funds depending upon the implementation of the scheme at later stage.

XV. PRADHAN MANTRI SWASTHAYA SURAKSHA YOJANA (PMSSY)

15.1 The PMSSY has been launched in 2006 with the objectives of correcting regional imbalances in the availability of affordable/reliable tertiary healthcare services and to augment facilities for quality medical education in the country. It has two components-setting up of AIIMS like Institutions and upgradation of existing State Government Medical Colleges/Institutions.

15.2 As per the information furnished by the Department, the Twelfth Plan Approved Outlay for PMSSY is ` 12000.00 crore and allocation of funds and expenditure during the five years period is as under:-

(` in crores)

Financial B E RE Actual release Balance Year 2012 - 13 1544.21 1010.00 993.47 16.53 2013 - 14 1975.00 1377.00 1282.11 94.89 2014 - 15 1456.00 891.00 812.39 78.61 2015 - 16 2156.00 1621.03 1578.12 42.91

2016 - 17 2450.00 1953.24 1586.4 6(as on 14.02.17)

15.3 The Committee observes that there has been a shortfall in the utilization of the budgeted funds majorly in 2016-17. Out of allocated funds of ` 2450.00 only ` 1586.00 crore has been utilised upto 14.02.17. With multiple project related activities in pipeline, the funds remaining unutilized shows imprudent attitude of the Department in financial planning vis-a-vis physical targets. Had the Department paid heed to the Committee's earlier recommendations, the achievement at the 60 end of the 12th Five Year Plan would have been different. It has been noted that six AIIMS in the Phase I are still underway and are at various stages of their completion and it would take some time to make them fully functional with regard to construction of medical college, hospital complex, residential complex, electrical services, estate services and procurement of equipments. This indicates poor assessment of time and cost by the Department that has left the funds unused.

15.4 As regards the upgradation of existing Government Medical Colleges under PMSSY, the Secretary, Health apprised the Committee that a total of 73 Government medical colleges have been notified under PMSSY for upgradation. Out of the 73 colleges, only 13 colleges have been upgraded and 6 are in progress under Phase I&II and rest of the colleges are at various level of tendering and approval stages. In the written replies of the Department, the Committee noted that under phase I & II, civil works at 09 Institutes have already been completed; civil work at 03 Institutes are in advance stage of completion and upgradation work at 04 Institutes that mainly involved procurement of medical equipment, procurement for SVIMS, Tirupati has been completed and at 03 Institutes, it is in advance stage of completion. The construction work at AIIMS, Rae Bareli is also being undertaken under Phase II of PMSSY wherein the OPD complex and majority part of Housing complex has been completed.

15.5 The Secretary during his deposition before the Committee informed the Committee that 5 new AIIMS at Mangalgiri in Andhra Pradesh, Nagpur in Maharashtra, Kalyani in West Bengal, Bhatinda in Punjab and Gorakhpur in Uttar Pradesh have been approved by the Cabinet; sites for 3 new AIIMS at Tamil Nadu, Himachal Pradesh and Bihar are under finalization and two new AIIMS at Jharkhand and Gujarat have been announced in the budget 2017-18.

15.6 On the perusal of the reply furnished by the Department regarding the reasons for delay and the measures taken to remedy the situation in PMSSY, the Committee finds that there is no tangible progress and the status remains the same as was reported earlier to the Committee. The Committee, therefore, is of the view that had the Department taken steps to seriously monitor the performance of the committees formed at local level, tangible progress would have taken place in the completion of Phase I and II. Keeping in view the status of six AIIMS in Phase I & II, the Committee recommends that the Department should strive towards concluding the civil and up gradation work at all the six AIIMS like Institutions under Phase I & II for making them fully operational so that the focus of the Department can be shifted on the activities pertaining to Phase III & IV of PMSSY. Completion of Phase I & II brooks no delay and year 2017-18 should see the institutes functioning.

15.7 The Committee is distressed to note that the tendering process in almost all PMSSY process has lead to a situation where projects remain incomplete. Besides this, the Ministry in itself lacks the expertise to execute such projects. The Committee recommends that large hospital projects be handled by reputed companies with a past track record of on time and quality delivery. The Committee is of the opinion that to tackle the issue of L1 rates in tenders reputed companies may be roped in on the same terms and transfer prices as quoted by the in-house agencies. 61

15.8 The Committee is also concerned to note that a large number of medical equipments are bought routinely by regional AIIMS on the basis of proprietary technology and proprietary certificate. The Committee recommends for more transparent mechanism for purchase of capital equipment. The Committee also recommends that proper upkeep of capital equipment be ensured in all AIIMS.

15.9 The updated status of manpower available in the 6 AIIMS as furnished by the Department is as under:

AIIMS Faculty Posts Non-Faculty Post

Sanctioned Filled up Filled Total Sanctioned Filled up Filled Total on regular up on posts on regular up on posts basis contractual filled up basis contractual filled up basis basis

Bhopal 305 54 02 56 3776 03 65 68

Bhubaneswar 305 142 00 142 3776 180 105 285

Jodhpur 305 104 00 104 3776 00 98 98

Patna 305 55 00 55 3776 306 196 502

Raipur 305 78 00 78 3776 208 261 469

Rishikesh 305 84 00 84 3776 00 174 174

15.10 The Committee observes that out of 305 sanctioned faculty posts at each of these AIIMS, not even half are filled up in any of these Institutes. As regards the non-faculty posts, the no of posts filled on regular basis is pathetically poor. At Jodhpur and Rishikesh, out of sanctioned strength of 3776, no regular posts are filled and contractual arrangements have been done by filling 98 and 174 posts, respectively. The Committee feels that infrastructure and manpower go hand in hand for running of any institute/hospital successfully. A sound mix of manpower from all areas of expertise and fields including faculty, paramedical, technicians and support staff are required for all the Institutes. The Committee, therefore, recommends that the Department should fill up the sanctioned posts under all categories at the earliest so that a permanent and adequate manpower is in place in a premier institute like AIIMS. The Committee would also like to voice its concern regarding the students who have joined the courses and are suffering due to shortage of faculty and non- faculty staff.

XVI. NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF CANCER, DIABETES, CARDIOVASCULAR DISEASE AND STROKE (NPCDCS)

16.1 The Non-Communicable diseases (NCD) like cardiovascular disease, cancer, chronic respiratory diseases, diabetes, and other NCDs are estimated to account for 60% of all deaths. The NPCDCS was launched in 2010 with focus on strengthening infrastructure, human resource development, health promotion, early diagnosis, management and referral. 62

16.2 The Secretary while deposing before the Committee stated that the proposed Universal Screening Programme is likely to be launched for screening the entire population above 30 years of age for five basic problems, namely, hypertension, diabetes, common cancers like oral cancer, cervical cancer and breast cancer. The Department in its reply regarding the pending proposals received from various State Governments for establishment of State Cancer Institute/TCCC pending with the Government has stated that the proposals are examined as per scheme guidelines by the Standing Committee, chaired by DGHS. The proposals received but not placed before the Standing Committee due to deficiencies are communicated to the State Government/Institutions for fulfillment.

16.3 The Committee notes that there are still several States which do not even have any single State Cancer Institute/TCCC, despite the pressure that is faced by Tertiary Care hospitals. The Committee strongly recommends for regular follow up with the State Governments/Institutions for rectifications of deficiencies if any in the proposals sent by them so that the cancer treatment infrastructure in the country is strengthened.

16.4 The Committee also recommends that priority be given to States which do not have a single State Cancer Centre/TCCC. The Committee would like to be updated about the progress made in this regard.

XVII NATIONAL AIDS CONTROL ORGANISATION (NACO)

17.1 As per information given in the Annual Report (2016-17) of the Department, the National AIDS Control Programme (NACP) has been implemented by Government of India as 100% centrally sponsored scheme through State AIDS Control Societies in the States for prevention and Control of HIV/AIDS in the country. The NACP has evolved through three phases of implementation and is currently in its fourth phase and is globally acclaimed as one of the most successful programmes.

Overview of HIV Epidemic in India

17.2 As per the India HIV Estimation 2015 report, adult (15-49 years) HIV prevalence in India was estimated at 0.26% in 2015. In 2015, adult HIV prevalence was estimated at 0.30% among males and at 0.22% among females.

17.3 Among the States / UTs, in 2015, Manipur has shown the highest estimated adult HIV prevalence of 1.15%, followed by Mizoram (0.80%), Nagaland (0.78%), Andhra Pradesh and Telangana (0.66%), Karnataka (0.45%), Gujarat (0.42%) and Goa (0.40%). Besides these States, Maharashtra, Chandigarh, Tripura and Tamil Nadu have shown an estimated adult HIV prevalence greater than the national prevalence (0.26%), while Odisha, Bihar, Sikkim, Delhi, Rajasthan and West Bengal have shown an estimated adult HIV prevalence in the range of 0.21 - 0.25%. All other States / UTs have adult HIV prevalence below 0.20%.

17.4 The adult HIV prevalence at national level has continued its steady decline from an estimated peak of 0.38% in 2001-2003 through 0.34% in 2007 and 0.28% in 2012 to 0.26% in 2015. Similar consistent declines were noted among males and females at the national level. 63

17.5 According to HIV Sentinel Surveillance (HSS) 2014-15, the overall HIV prevalence among ANC clinic attendees, considered a proxy for prevalence among the general population, continues to be low at 0.29% in the country, with an overall declining trend at the national level. The highest prevalence was recorded in Nagaland (1.29%), followed by Mizoram (0.81%), Manipur (0.60%), Gujarat (0.56%) and Chhattisgarh (0.41%), Telangana (0.39%), Bihar (0.37%), Karnataka (0.36%) and Andhra Pradesh (0.35) were other States which recorded HIV prevalence of more than the national average. 17.6 India continues to portray a concentrated epidemic. National Integrated Behavioural and Biological Surveillance (IBBS) has estimated HIV prevalence among Female Sex Workers (FSWs), at national level at 2.2%. HIV Prevalence among Men who have Sex with Men (MSM) recorded at the national level was 4.3% while among Injecting Drug Users (IDU), the prevalence of HIV recorded among IDU at the national level was 9.9%. Also, HIV Prevalence among Transgender/Hijras (TG) was recorded to be 7.5% as per the IBBS data. New Initiatives in NACP IV 17.7 The Department has informed about the new initiatives in NACP IV as given below: (i) HIV testing guidelines revised to increase testing • Step towards reaching 90% testing coverage • Community based testing (ii) Elimination of mother to child transmission • ART to HIV+ve Pregnant women irrespective of CD 4 count & clinical stage of HIV (iii) CD4 guidelines - ART initiated at CD4 500 • More than 10 lakhs PLHIV on ART as on December'16 • 100,000 additional PLHIVs on ART in 2016-17 (iv) 3rd line ART rolled out in 2016-17 Budgetary allocation 17.8 The total Twelfth Plan Outlay (2012-17) for the National AIDS Control Organisation (NACO) was `11394.00 crore. Out of total outlay, BE allocation from 2012-13 to 2016-17 was `8386.00 crore which was further reduced to `7944.61 crore at RE stage. The actual expenditure was `7140.43crore for the entire Twelfth Plan Period. The year-wise BE, RE and actual expenditure during the Twelfth Plan Period are given below:-

(` in Crores)

Year Budget Estimates Revised Actual Expenditure in Estimates expenditure Percentage

wrt BE wrt RE

123456

2012-13 1700.00 1759.56 1316.07 77.42 74.80

2013-14 1785.00 1500.00 1473.16 82.53 98.21 64

123456

2014-15 1785.00 1300.00 1287.39 72.12 99.03

2015-16 1397.00 1615.00 1605.72 114.94 99.43

2016-17 1719.00 1770.05 1458.09* 84.82 82.37

TOTAL 8386.00 7944.61 7140.43 85.15 89.88

* Booked figure only up to 30th Jan, 2017

17.9 The Committee is constrained to note that while the Planning Commission had recommended total outlay of `11394.00 crore for the NACO for the 12th Plan Period, the total RE allocation made by the Union Government in the five years of the 12th Plan period (i.e. 2012-13 to 2016-17) was `7944.61 crore only which works out to 69.72% of the funding envisaged by the Planning Commission. Given the fact that overall NACO expenditures are reasonably high with about 90% of the funds released for the NACO between 2012-13 and 2016-17 being utilised as on 31st January, 2017, the Committee observes that the actual allocation of funds for NACO was done in an arbitrary fashion. Despite India's progress in reduction of HIV prevalence, the country still had an estimated 21.17 lakh HIV infected people in 2015 which is third largest in the world. Hence, it is evident that the budgetary cuts instituted by the Government would have impacted the various interventions under National AIDS Control Programme. The Committee would exhort the Government to ensure that such a trend does not recur in future and the funds approved on paper get allocated and spent also.

17.10 The Department has informed the Committee that `2000.00 crore has been allocated for National AIDS Control Organisation for the year 2017-18. On being asked about the adequacy of the budgetary allocation for 2017-18, the Secretary of the Department of Health and Family Welfare during his oral evidence on 2nd March, 2017, informed that `400 crore more would be required for drug procurement in NACO. He also submitted that :

"..... One is the expenditure on immunization because of increase in vaccines and vaccine coverage, because as Global Alliance for Vaccines and Immunization (GAVI)'s support goes down, we would have to step up our financial support."

"....As a country, we cannot afford to withdraw that. Secondly, so far, there was no allocation to NACO because much of it or almost all of it was external funding. For the last two years, we are on our own. So, our domestic budget support will have to go up. There is no other option."

17.11 The Committee observes that funding from external sources has contributed substantially in supporting the NACP interventions. But in the light of the global economic slowdown, external funding for the Programme is certain to shrink considerably and there is, therefore, an imperative need to balance the financing strategy of NACP IV by way of generating more funds from domestic sources so that the reach of existing NACP interventions is sustained and the cost of clinical care and treatment to people living with HIV is provided for. Though the recent HIV 65 estimates highlight an overall reduction in HIV prevalence, there are significant inter-state variations and some States like Maharashtra, Chandigarh, Tripura and Tamil Nadu have shown estimated adult prevalence greater than the national average (i.e. 0.26%). Besides HIV epidemic due to MSM, transgender, migration and IDU are being identified in greater number across the country and hence pose enormous challenges. Taking all these facts into consideration, the Committee lends its support to the Department's demand for additional funds and recommends that an additional amount of ` 400.00 crore be allocated for NACO for 2017-18.

Utilisation Certificates

17.12 The position of the unspent balances during 2014-15, 2015-16 and 2016-17 is as under:

Consolidated Year wise statement for the release, expenditure and unspent balance (cash-in hand) with all SACS as on 30th January 2017

* Figures in Lakh

Years Release Expenditure Unspent Balance (Cash in Hand)

2014-15 93587 92385.69 13685.47

2015-16 77010 79111.71 11141.05

2016-17# 83500.95 52090.47 23806.17

# Figures as on 30.01.17

17.13 On being asked about the steps/actions taken by NACO towards utilizing unspent balances available with SACS during 2015-16 and 2016-17, the Department has submitted that close monitoring of cash balances with SACS is undertaken and position is reviewed to direct the SACS to liquidate the cash balances with them. Review meetings with SACS officials/personal intervention of SACS Project Directors for liquidating the cash balances were held. Releases made to SACS from NACO were after adjusting the unspent balance pending with them.

17.14 The Committee is constrained to note the unspent cash balances with SACS. The Committee believes that unspent balances indicate poor financial planning and discipline. The Committee strongly recommends that NACO should direct all SACS to undertake a quarterly review of unspent cash balances and initiate steps to liquidate the unspent cash balances on quarterly basis instead of reviewing it at the end of the financial year. The Committee would also like the Department to ensure proper fiscal planning and discipline.

Metro Blood Bank Project

17.15 As per information given in the Annual Report (2017-18) of the Department, it is proposed to set up four state-of-the-art Centres of excellence in Transfusion Medicine in Chennai, Delhi, Kolkata and Mumbai. First Phase of project has been approved by the Ministry for Health and Family Welfare for 66 two such centres and Memorandum of Understanding is to be signed with respective State Governments. MoU with Government of Tamil Nadu has been signed to establish one such centre in Chennai.

17.16 On being asked about the progress made towards establishing Metro Blood Banks, the Department has submitted that Metro Blood Bank Project was approved by Finance Minister for a total outlay of ` 404 crores in Chennai & Delhi in 2016-17. HLL Lifecare Ltd. has been engaged as the Project Management Committee. MoU was signed with Tamil Nadu Govt. on 14th June, 2016. Government of National Capital Territory of Delhi (GNCTD) is yet to sign MOU. There is so far nil expenditure in the FY 2016-17.

17.17 Attention of the Committee has been drawn to the observation and recommendation made by the Committee in its 93rd Report on Demands for Grants (2016-17) which is as follows:

"The Committee observes that the budgetary provisions to the tune of ` 83.00 crore had been made in BE-2014-15 for setting up of Metro Blood Banks, but the entire amount had to be surrendered due to non-approval of the project by Expenditure Finance Committee (EFC). The EFC has now approved the Project as Central Sector Scheme with budget outlay of ` 404.00 crore to be implemented over 7 years. The Committee notes the assertion made by the Department that MoUs with States should be signed shortly and financial outflow shall start soon after. However, given the fact that the revised MoU was shared with States in December 2015, the Committee doubts that the funds would be drawn from this head in financial year 2015-16. Evidently, the NACO appears to be oblivious to the ground reality on the implementation of this project. There should be no further delay in implementing this programme".

17.18 The Committee is constrained to note the tardy progress made towards establishing Metro Blood Banks in Chennai and Delhi. The Department had made a provision of `404.00 crore in RE 2015-16 and ` 404.00 crore in RE 2016-17 but nothing was spent, leading to idle parking of the funds and the eventual surrendering of the entire budgeted funds for this Scheme for 2015-16 and 2016-17. The surrendering of the budgeted funds is indicative of the fact that the Department has not played its role as a facilitator well in implementing the Scheme that has a significant bearing on improving the NACP interventions. Also, at a time when the Government is striving for fiscal consolidation, such ritualistic allocations which remain on paper only, are unacceptable to the Committee. The Committee, therefore, recommends that all hindrances in establishing Metro Blood Banks be ironed out early so that such instances of blockage of funds earmarked for this Scheme do not recur. The Committee desires to be kept apprised of the progress made towards operationalizing this Scheme. 67

RECOMMENDATIONS/OBSERVATIONS — AT A GLANCE

PART-A

NATIONAL HEALTH MISSION (NHM)

II. BUDGETARY ALLOCATION

The Committee notes that against the projected demand of ` 34,315.66 crore for 2017-18 under the National Health Mission, the total allocation in BE 2017-18 is only ` 26,690.70 crore leaving a shortfall of ` 7624.96 crore. In comparison to the RE 2016-17 allocation of ` 22197.95 crore, the increase in BE 2017-18 is only ` 4492.75 crore which, in the opinion of the Committee, is insufficient. The Committee notes the admission of the Department in its written submissions that though the resource availability from State share has increased from ` 4570.00 crore in Financial Year 2012-13 to ` 10,522.00 crore in 2016-17, the reduction in Central Plan allocation for NHM has not been fully compensated by the increase in State Health Budgets due to revised Centre-State funding pattern from 75:25 to 60:40 post hike of the share of States in the Central Taxes divisible pool from 32% to 42% in the form of untied funds. The Committee also notes the submission of the Department that the shortfall in allocations for NHM for 2017-18 vis-a- vis its projected demand for funds will adversely impact a number of health initiatives / programmes like upscaling of health facilities to Indian Public Health Standards; establishing Sub-Health Centres, Primary Health Centres and Community Health Centres as per norms; rolling out of Universal Health Coverage Pilots; scaling up of free drugs and free diagnostics initiatives, etc. It would be pertinent to point out that though in his Budget speech, the Finance Minister has proposed to transform 1,50,000 Health Sub-Centres into Health and Wellness Centres and "promote use of generic drugs", there is no solid roadmap for ensuring adequate financial resources for these initiatives and this is where the dichotomy of the Budget announcements gets reflected. It needs to be highlighted that as per the latest National Health Accounts estimates (2013-14), 35.7% of the total health expenditure is on medicine purchase and as per the NSSO data nearly 71% of the out-of-pocket (OOP) burden is due to expenditure on medicines. The Committee is therefore of the view that the BE 2017-18 allocation of ` 26690.70 crore is grossly inadequate. It is in this context that allocation of additional financial resources for NHM for 2017-18 makes a compelling case. (para 2.8)

Taking into consideration the submission of the Health Secretary made before it on 2nd March, 2017 that in order to undertake new initiative like Universal Health Coverage Pilots and scaling up of existing initiatives, the minimum required increase in allocation for 2017-18 would be ` 4000.00 crore, the Committee lends its support to the allocation of additional ` 4000.00 crore for NHM. (para 2.9)

The Committee observes that the Fourteenth Finance Commission has radically enhanced share of the States in the Central divisible pool from 32% to 42% and according to the Ministry

67 68 of Finance, all States stand to gain in absolute terms from the new devolution formula. After the Fourteenth Finance Commission award, the Government has instituted sharp cuts in the Central allocation for the Health Sector assuming that 42 per cent transfer of Central taxes to the States in the form of untied funds would compensate for the shortfall in Central funds for Health. The Committee recognizes the fact that the increased devolution of tax revenue to States is not bad in principle in a federal fiscal structure such as ours and offers an excellent opportunity for the States to increase their health spending and implement schemes as per aspirations of people. The Committee is, however, concerned to note from Annexure - III that despite the enhanced share in Central taxes divisible pool, all States/ UTs have not increased their health budgets commensurately in 2016-17. Albeit some of the State Health Budgets for 2016-17 have registered negative growth as compared to 2015-16 (i.e. Assam (-7%), Chandigarh (-3%), Daman & Diu (- 15%), Karnataka (-2%), Manipur (-31%), Pondicherry (-1%)}. Some of the State Health Budgets for 2016-17 have shown marginal increase in health allocation as compared to 2015-16. The Committee on a perusal of 12th Plan average of State Health Budgets finds that States like Andhra Pradesh, Jammu and Kashmir, Manipur, Nagaland and Sikkim have registered only single digit increase in percentage terms. Thus the assumption that the enhanced share of the States/ UTs in the Central divisible pool would compensate for the sharp reduction in the Central allocation for Health has not been validated. The Committee feels that unless all States increase their health budgets in commensurate with the enhanced Central transfers, it would be difficult to attain affordable and equitable health care. The Committee would, therefore, like the Ministry of Health and Family Welfare to hand-hold the laggard States and find out the underlying reasons for marginal or negative increase in their State Health Budgets and take remedial measures accordingly so that the desired outcomes on health parameters are achieved and the desired level of flow of funds to the Health Sector is ensured. The Committee would also like the Ministry to develop a suitable Health Information System for tracking and reporting on health expenditures in States on a real time basis and ensure that the additional State Health financing indeed gets allocated and spent during 2017-18. The Committee desires to be kept apprised of the action taken in this regard. (para 2.10)

The Committee observes that despite India's healthcare falling way below the global benchmark and the country lagging behind on health goals such as maternal and infant mortality and having a lowly ranking even among the developing countries on healthcare parameters, our level of public spending on health is one of the lowest in the world which has further exacerbated the dismal state of the healthcare sector. Despite all key policy documents like the National Health Policy of 2002, the draft National Health Policy of 2015, the 12th Five Year Plan and the Report of the High Level Expert Committee emphasizing the need to reach 2.5% of GDP, India's total government expenditure on health languishes at 1.15% (as per the National Health Accounts 2013-14, a rigorous estimate on health expenditures in the country) and is way less than the world average of 5.99% (Economic Survey-2016-17). The squeeze of public finances has resulted in the appalling state of our healthcare system and given birth to impoverishing Out-of-Pocket 69 healthcare expenditure which is as high as 64% of the total health expenditure due to which about 7% population is pushed below poverty threshold every year (NSSO 71st Round data). India ranks 183 among 192 countries in terms of out-of-pocket healthcare Expenditure as a percent of Total Health Expenditure and is just above Bangladesh (187) and Afghanistan (184). The 12th Plan is concluding by 2016-17 end but India is nowhere near the target of 2.5%. It is, therefore, no surprise that India continues to be an extreme outlier in terms of public health spend despite the sustained high economic growth in the past two decades. The Committee is constrained to observe that despite India being the fastest growing major economy in the world today with its economic growth pegged at around 7% in the current fiscal year, it has squandered the opportunity to turn its economic success into a better healthcare system for its population. This only goes to show that in the prioritization matrix of the successive governments, health has been accorded a lower priority. The Committee observes that acceleration in economic growth by itself will not translate into higher public spending on health. The Government will also have to demonstrate a strong political will to value health as societal imperative for development and alter the government health financing landscape in a fundamental way by way of providing a much larger resource envelope for health financing. If countries like Thailand and Brazil are close to achieving Universal Health Coverage for their population (Source : draft National Health Policy, 2015) there is no reason why India cannot accomplish this goal. But for that to happen, the urgency of raising public health expenditure to 2.5 % should not be lost sight of. In this context the Committee would like to draw the attention of the Government to its draft National Health Policy of 2015 which states that global evidence shows that unless a country spends at least 5-6% of its GDP on health and major part of it is from Government expenditure, basic healthcare needs are seldom met. The Committee would therefore like the Government to address this critical policy challenge of raising the government health spend to 2.5% of GDP and chalk out a solid roadmap for earmarking more financial resources for the Health Sector. (para 2.18)

The Committee is aware that in a federal fiscal structure such as India's, the goal of increasing public spending on health to 2.5% of GDP would not be possible without the active involvement of State Governments. The Committee would, therefore, like the Government to make an assessment as to how much the Centre and States would need to increase their respective health spending to achieve the target of 2.5% of GDP within a designated timeline and also suggest where the extra-resources for achieving this level of health financing should come from. The Committee may be apprised of the assessment made. (para 2.19)

The Committee notes that against the approved outlay of ` 1,93,405.71 crore for the National Health Mission in the 12th Plan, only ` 91022.00 crore has been allocated which in percentage terms works out to measly 47% of the funding originally envisaged for the NHM in the Twelfth Plan. The Committee also notes that the trend of expenditure in the first four years of the 12th Plan has been excellent and the release made have been utilized to the fullest, implying that the allocated amounts have been utilized effectively. Even in the current fiscal (i.e. 70

2016-17), 75% expenditure has been incurred as on 31st January, 2017 and it is hoped that the entire amount will be spent by the time the financial year ends. The Committee observes that had the Government allocated the entire Twelfth Plan approved outlays for NHM, the country would have seen much improved health outcomes in terms of quality primary healthcare services and reduced out-of-pocket health expenditure. (para 2.22)

The Committee observes that just committing resources for health financing is not enough and it is equally important to ensure that the committed resources indeed get allocated and spent for the intended purposes. The Committee would therefore like the Government to ensure that such an anomalous situation does not recur in future and funds approved on paper for the National Health Mission are released and utilized also. (para 2.23)

Delay in Transfer of Funds

The Committee while noting the reduction in time period for transfer of funds to State Health Society through treasury route, finds that there is still a time lag of 72 days in transfer of funds through the Treasury mode and out of ` 8145.03 crore released under the RCH Flexible Pool of NRHM during 2016-17, an amount of ` 2012.54 crore was still lying idle with State Treasury as on 31.01.2017. Taking note of the unnecessary delay in transfer of funds through the Treasury route, and keeping in view the fact that timely transfer of funds is extremely important as delayed transfers hamper fund utilization, the Committee in its 93rd Report had recommended that if the current fund flow architecture i.e. Treasury Route continues to result in delay in transfer of funds, the Society route of funds should replace the Treasury system. However, the Ministry of Finance has not agreed to reverting to the society mode of transfer of funds. The Committee desires to be apprised of the reasons adduced by Ministry of Finance for persisting with the Treasury Route. (para 2.28)

The Committee also recommends that the Department should ensure close and sustained monitoring of the transfer of funds to State Health Societies and ensure that the current mechanism of fund transfer does not result in low fund utilization because further delay would lead to reduction in funds allocation in the coming years which in turn would adversely affect vital health programmes to be implemented. The Committee takes note of the Department's submission that implementation capacity of many States is slow and observes that this may be due to their low absorptive capacity which in turn may be an outcome of chronic lack of investment on health infrastructure and lack of institutional capacities. The Committee would, therefore, like the Department to work in close coordination with such States so that their developmental deficits are removed and low utilization does not become a stumbling block in increasing allocation to them. (para 2.29)

Utilization Certificates

The Committee recommends that the Department should adopt a multi-pronged strategy to ensure that there is no pendency of Utilization Certificates by the end of this financial year. The Committee desires to be kept updated on pending Utilization Certificates (UCs). (para 2.31) 71

III. NATIONAL RURAL HEALTH MISSION

A. RCH Flexible Pool including Routine Immunization Programme, Pulse Polio Immunization Programme, Immunization Programme, National Iodine Deficiency Disorders Control Programme.

The Committee finds that out of ` 6233.99 crore an amount of ` 4871.70 crore has been spent (upto 9th February, 2017) which comes to about 78% utilization. The Committee observes that RCH is a critical area of intervention for the maternal and child health and therefore it is imperative that the funds allocated are made an effective policy tool and used gainfully and optimally. The Committee, therefore, desires to be updated on the actual expenditure figures for 2016-17. (Para 3.3)

The Committee notes from Demand No. 42 that as compared to Revenue allocation of ` 6233.00 crore in RE 2016-17, ` 4566.00 crore has been allocated in BE 2017-18 for RCH Flexible Pool. When asked to clarify, the Department has stated that on account of rationalization of components of Human Resources for Health and Drugs, these components are now being reflected under the Health System Strengthening under NRHM and NUHM. The Committee observes that there is an element of obfuscation and non-transparency in the manner of presenting budget estimates for such an important component i.e. RCH. The Committee apprehends that the desired outcomes of RCH, which a focused grant could yield, may not be forthcoming due to such subsuming of specific schemes. The Committee therefore desires that the Government should have a retook in the matter and address these concerns appropriately. (Para 3.5)

The Committee also feels that there is a crucial need for the States to ramp up their investment for reproductive and child health and the higher devolution recommended by the Fourteenth Finance Commission to fill the resource gaps of the States, can certainly be deployed to good effect. It is pertinent to mention here that the Ministry of Health and Family Welfare in a report titled 'A Strategic Approach to Reproductive, Maternal, Newborn Child and Adolescent Health in India' published in 2013 had estimated that "if the current unmet need for family planning could be fulfilled within the next five years, India can avert 35,000 maternal deaths and 12 lakh infant deaths while saving more than 4450 crore of Indian currency. If safe abortion services are coupled with increase in family planning services, the savings made to the country could be to the tune of ` 6500 crore." It is thus evident that more government investments in RCH will give one of the best returns to society. The Committee would therefore like the Department to impress upon States the immense benefits from enhanced spending on RCH and devise arrangements for the States to step up their funding for RCH. (Para 3.6)

The Committee notes that out of 27,85,929 sterilizations carried out in 2016-17 (upto February, 2017), the number of female sterilization (27,27,046) far outnumber male sterilization (58,883). The Committee is of the opinion that sterilization does not only mean female sterilization but also includes male sterilization. The Committee desires that Government should take positive steps towards achieving the objective of at least 10% of sterilization being male sterilization as indicated in the Twelfth Five Year Plan Report. (Para 3.8) 72

The Committee is happy to note that as compared to total reported deliveries, institutional deliveries account for 89.5%. The Committee would, however, exhort the Department to focus on uncovered areas where home deliveries cannot be avoided due to difficult terrain or some other cultural reasons/tribal practices to ensure access to minimum standards of care is facilitated to the most underprivileged and deprived sections of our population through ANM assisted home deliveries. (Para 3.9)

Universal Immunization Programme

The Committee notes that though the country has made considerable improvement in immunization under the Universal Immunization Programme and the full immunization coverage has reached 87.26% as per Health Management Information System (HMIS) data as on 27th January, 2017, the country accounts for 7.4 million children (as per UNICEF) who are not immunized and more than 20% of all child mortality worldwide. The Committee, therefore, recommends that the Department should identify the challenges to immunization and chalk out a multi-pronged strategy to overcome them. The Committee desires to be kept apprised in this regard. The Committee would also like to be apprised of the status of full immunization in rural areas and urban areas separately. (Para 3.11)

Pulse Polio Immunization

The Committee observes that though India has been declared as Polio free by WHO in March, 2014 and has since maintained the status, ordinary prudence demands that all necessary precautions need to be taken to obviate the possibilities of disruption of the supplies on account of an unforeseen crises in commercial production of IPV. The Committee, therefore, desires to know the action plan of the Department to tackle such an eventuality. The Committee desires to know the contribution of the public and private sector in the supply of IPV to Pulse Polio Programme. The Committee also recommends that the Government should keep a close watch on the immunization programme to ensure that Polio does not resurface due to shortage of bulk ingredient required to produce the vaccine. (Para 3.13)

Maternal Mortality Ratio (MMR)

The Committee notes from the submission of the Department that the current pace of decline of MMR indicates that India is likely to achieve the target of the Millennium Development Goal-5 (set by WHO) of reducing MMR to 139 per 100000 live births. However, the fact that India still accounts for 15% of all maternal deaths worldwide is unacceptable. Equally disturbing is the fact that there are wide interstate disparities in terms of MMR. The Committee is of the view that a differential approach would need to be taken to address MMR differentials across geographical region. The Committee desires to be apprised of the strategy devised to overcome widespread inequities in MMR. The Committee also desires to know as to how India compares with neighbouring countries like Sri Lanka, Bangladesh and Nepal on MMR indicators. (Para 3.18) 73

The Committee hopes that the target of MMR under (Sustainable Development Goals) SDGs has factored into account the States where MMR is quite high. The Committee recommends that the Department should make 'special efforts' in order to achieve the target it has fixed under SDGs for MMR. (Para 3.19)

Status of Child Mortality in India

The Committee notes that the Rural-Urban differential of IMR was 17 points in 2014 which is same as in 2013. Therefore, there is no reduction in rural-urban differential of IMR from 2013 to 2014. The Committee notes that the Gender differential has remained constant at 3 points at National Level. The Committee observes that till there is a forward movement in Rural-Urban differential and Gender differential, the gains achieved would not be enough to reach the target set. The Committee, therefore, recommends that the Department should regularly monitor the Rural-Urban Differential and Gender Differential to ensure that the targets set are achieved at the ground level. (Para 3.22)

Under-5 Mortality Rate (U5MR)

The Committee is of the view that the success of 18 States in U5MR can be replicated in the High Focus States. The Committee, therefore, recommends that the Department should ensure that 'template' for ensuring U5MR in 18 States are formulated and implemented in these High Focus States to ensure that these 'States' also achieve SDG goals. (Para 3.24)

B. Health System Strengthening under NRHM

The Committee fully supports the initiative taken by the Government to ensure 'last mile connectivity' in health and wellness, by converting sub-centres into Health and Wellness Centres as this would provide easy and timely access to quality healthcare and take the healthcare closer to people. The Committee is however concerned about the fact that there are huge constraints of skilled manpower and it would be very difficult to bridge this gap. The Committee would therefore like the Department to indicate a roadmap to address the huge gap in terms of availability of skilled manpower for the proposed Health and Wellness Centres. (Para 3.28)

The Committee also observes that all States may not have additional fiscal space for mobilizing resources for Health and Wellness Centres. The Committee, therefore, desires that the Department should hold deliberations especially with the more needy and backward states which are also weak on health parameters and ensure that such states are provided 'additional support' to ensure the success of this intervention. (Para 3.29)

C. Flexible Pool for Communicable Diseases

The Committee in the earlier part of this Report has lent its support to an additional allocation of ` 4000.00 crore for NHM for 2017-18 which the Committee hopes would take care of the shortfall of funds under Flexible Pool for Communicable Diseases. According to some reports, communicable diseases contribute 52% of all disease burden and more than 60% of 74 deaths in the country. The Committee, therefore, recommends even at the cost of repetition that a sufficiently higher magnitude of funds should be allocated for this Pool. (Para 3.33)

The Committee notes that out of ` 1373.00 crore allocated in RE 2016-17, an expenditure of only ` 904.25 crore has been spent till 10th February, 2017. While, the Committee is all with the Department for the need for increasing funds in its fight against communicable diseases, it simultaneously recommends that the Department should ensure expenditure monitoring and fiscal discipline and avoid rush of expenditure before the fiscal end. (Para 3.34)

The Committee notes that though ambitions targets have been fixed for elimination of Kala-azar and Filariosis by 2017 and Leprosy by 2018, the allocated resources do not match the intent and give rise to an apprehension that desired outcomes may not be forthcoming. The Committee would like to highlight the fact that Kala-azar was targeted to be eliminated by 2010 which was revised to 2015 and further revised to 2017. This cannot be condoned. The Committee, therefore, desires that the Department should be clear headed in its goals and should not keep on revising its targets. There appears to be some inadequacy in implementing the plans due to which targets have not been achieved. The Committee strongly recommends that practicable targets may be fixed and efforts may be made to achieve them. (Para 3.38)

Revised National Tuberculosis Control Programme (RNTCP)

The Committee observes that the main challenges confronting RNTCP are prevalence of high levels of disease transmission and increase in incidence of drug resistant TB. The Committee is of the view that this is due to poor primary healthcare infrastructure in rural areas and unregulated private healthcare leading to irrational use of first-line and second-line anti- tuberculosis drugs. Though in the Budget Speech, 2017, the Government has set targets for elimination of TB by 2025, visible progress towards eliminating TB would not be possible without addressing these issues of poor primary healthcare infrastructure and unregulated private healthcare. The Committee would therefore like the Government to focus their strategy on addressing these issues. (Para 3.41)

The Committee is concerned to note that despite passage of so much time since the launch of RNTCP India continues to have the highest TB burden in the world and drug-resistant TB is 2.5% in new cases and 16% in previously treated TB cases. The Committee is aware that the Ministry of Health and Family Welfare has rolled out a new TB drug- Bedaquiline to combat extremely drug resistant TB which has been discovered after 40 years. The administration of Bedaquiline is however tightly controlled and restricted to six Government hospitals, two at New Delhi and one each at Mumbai, Chennai, Ahmedabad and Guwahati and access is decided by domicile. The Committee desires that the trials may be completed at the earliest and if found effective, it may be rolled out for wider coverage, (Para 3.43)

D. Flexible Pool for Non-Communicable Diseases, Injury and Trauma

The Committee notes from the Department's reply that the revenue allocation of ` 955.00 crore for financial year (2017-18) falls woefully short of the proposed budget of ` 3498.00 crore. 75

Even though the Department has stated that besides NCD flexi pool, the health systems strengthening under the NRHM and NUHM is helping to address the NCD diseases, the Committee strongly feels that in view of the increasing burden of non-communicable diseases in the country, fund constraint should not be the reason for increase in disease burden. The Committee therefore strongly supports the Department's contention to increase the budget allocation and recommends that the Department may approach the Ministry of Finance for seeking the desired allocation at RE stage. (Para 3.46)

E. Strengthening of State Drug Regulatory System

The Committee observes that the present drug laboratories in the country are not fully equipped with the state-of-the-art facilities for testing and analyzing complex formulations and detect spurious, misbranded, substandard and adulterated drugs. Keeping in view the fact that India is the manufacturing hub and pharmacy of the world, it is essential to put in place a vibrant and dynamic regulatory regime so that the public could be safeguarded from substandard or unsafe drugs. It is in this context that strengthening of testing and surveillance capacities in Centre and States is the need of the hour. Since monitoring of the quality of drugs is primarily the responsibility of the State Drugs authorities supplemented by CDSCO, without manpower augmentation and upgradation of State Drug Testing Laboratories, the objective of ensuring availability of quality drugs to the people cannot be realized. The Committee, therefore, recommends that the Department should process all the proposals received from State Governments with a sense of urgency and promptitude and speed up their approval and help build regulatory systems at par with international standards. The Committee desires to be kept apprised of the physical progress made in this regard. (Para 3.50)

IV. NATIONAL URBAN HEALTH MISSION

The Committee has been closely following the implementation of NUHM since its take off in 2013 after a protracted and long winding process. The Committee notes that the NUHM programme is a vital component for meeting healthcare needs of the urban population with a focus on urban poor and is oriented towards making available primary healthcare services and reducing their out-of-pocket expenditure on health. The Committee therefore views with serious concern the reduction in allocation for NUHM for 2017-18 (` 752.05 crores) vis-a-vis 2016-17 (` 950.00 Crore). The Committee, therefore, would like the Government to devise the strategy in coordination with States to not only remove absorptive capacity constraints but also focus on capacity building of the States to ensure effective utilization of the NUHM funds. (Para 4.4)

V. TERTIARY CARE PROGRAMS

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDS)

The Committee observes that the diseases like cardiovascular diseases, cancer, chronic respiratory diseases, diabetes etc. are the leading causes of deaths in India and despite the 76 launch of NPCDS in 2010, the efforts against the growing burden of these diseases are grossly insufficient and a lot more needs to be done to cater to these challenges. The Committee would therefore like the Department to quickly move towards implementation of the National Multi- sectoral Action Plan so that the outreach of NPCDS could be made universal. (Para 5.2) Since the above diseases often require life-long management, the Committee is of the view that AYUSH has huge potential for safe and cost-effective management of NCDs. The Committee, therefore, recommends that the Department should exploit AYUSH strengths for the management of above NCDs. (Para 5.3) VI. HUMAN RESOURCES FOR HEALTH AND MEDICAL EDUCATION (i) District Hospital - Upgradation of State Government Medical College (PG seats) The Committee notes that the Finance Minister in his Budget Speech has made a call for 5000 more postgraduate seats. India is witnessing the rapidly rising burden of communicable and non-communicable diseases. Besides, several new medical institutions are facing challenges in getting faculty to train doctors. The Committee is therefore baffled to note the submission of the Department that the Scheme is to be wound up by 2018-19. The Committee desires that the scheme be reviewed and assessed and revamped instead of being closed. (Para 6.4) (ii) Establishing New Medical Colleges (upgrading District Hospitals) The Committee observes that there is a huge shortfall in the number of MBBS doctors in the country and at the present rate of production, the shortfall will not be met for many years. The Committee, therefore, welcomes the substantial increase in allocation to ` 3300.00 crore under "Establishment of New Medical Colleges (upgradating District Hospitals)" as the increase in allocation would help augment human resources in the health sector and improve the quality of healthcare delivery. The Committee is however, concerned at the snail's pace of progress made in adding 82 more medical colleges in Phase II of the Scheme. A year has passed since the Phase II was conceptualized, but the Expenditure Finance Committee is yet to accord its approval to Phase II. The Committee, therefore, recommends that the Department should sort out all the pending issues within a specified time-frame and hasten the formulation of a policy. (Para 6.8) VII. DEFICIENCY OF HEALTH INFRA-STRUCTURE AND MANPOWER IN RURAL AREAS From the data supplied by the Department, out of 11262 sanctioned posts for specialists at Community Health Centres (CHCs), 7359 are lying vacant; out of 2657 posts for Surgeons at CHCs, 1811 are lying vacant; out of 34068 doctors at Primary Health Centres, 8774 are lying vacant. The Committee notes that there are a large number of vacancies with respect to the specialists at CHCs and Doctors at Primary Health Centres. The Department has informed that 'Public Health' being a State subject, the primary responsibility to ensure doctors in public health facilities lies with the State Governments. The Committee while agreeing with the view that 'Public Health' is a State subject, feels that the Centre cannot absolve itself of the responsibility of ensuring accessibility and affordability of health to all citizens, which can only happen when the Centre monitors the availability of manpower in States. The Committee, therefore recommends, that the Department should encourage the States to carry out the reforms in the recruitment process and fill the vacant posts. The Committee desires to be apprised of the efforts made and progress achieved in this regard. (Para 7.3) 77

REPORT

PART-B

HEALTH SECTOR

BUDGETARY ALLOCATION

It can be seen from the above table that for the year 2017-18, ` 24723.28 crore has been allocated against the projected demand of ` 29501.34 crore leaving a shortfall of ` 4778.06 crore. The Department has committed that shortage of funds would not impact the implementation of projects/schemes in the Health Sector and fiscal discipline would be maintained while utilization of funds and all efforts would be made to ensure optimum utilization. The Committee, however, is of the view that since there has been consistent underutilization of funds during the preceding years, the Department should ensure the completion of administrative pre-requisites for the implementation of projects/schemes in a time bound manner and design an action plan using financial yardsticks to achieve the targets set for the year 2017-18. Also, stringent monitoring machinery be evolved to keep track of the activities being undertaken within a set timeline. (Para 1.3)

The Committee's attention has been drawn to media reports stating that India ranks very low on basic health parameters as around 400 million people do not have access to essential health services with the problem becoming acute in rural India. Health care in India continues to be a major challenge even when compared to many developing nations as India has just over 0.9 hospital beds per 1,000 people, which is abysmally low when compared to the world average of around 4 hospital beds per 1,000 people which is a pointer to the inadequate public health system. These gross deficiencies in health infrastructure and qualified health care providers are result of low spending on the health sector for decades. Public health care facilities do not cover the country extensively and most of them are poorly equipped and understaffed, while a few relatively better ones are overcrowded with the problem getting aggravated by non-availability of secondary or tertiary care services in rural areas. National Sample Survey numbers show a decrease in the use of public hospitals over the past two decades. More than half of Indian's rural population depends upon private healthcare, which is four times as expensive as public healthcare. Also, the shortage of expert medical professionals in public health centres has arisen posing another challenge to the Indian health care sector. It would also be pertinent to mention here that the expenditure in healthcare technology is considerably low in India and hospitals in India need to increase their spending on technology upgradation considerably to provide for improved patient-centric services. Investment in Indian healthcare sector is the need of the hour alongwith appropriate audit and financial monitoring, capacity building and judicious resource allocations. The Committee is of the view that the health sector should get substantially more allocations and, therefore, the Committee strongly recommends the Department to approach the Ministry of Finance with their proper planning and synergized action plans to seek enhanced allocations in coming years. (Para 1.4)

77 78

On analysis of the expenditure trends, the Committee finds a substantial mismatch in the financial projections leading to sub-optimum utilization. The Committee is dismayed to note the casual approach of the Department in framing the unrealistic financial projections vis-a-vis targets set for the Twelfth Plan period. The Committee recommends that the Department undertake a thorough analysis of the fund requirements for implementation of projects/schemes, identify bottlenecks and reassess them so as to avoid any under utilization of the allocated funds in future. Besides, there is strong need to prioritize various projects/schemes so that funds which could be deployed elsewhere do not lapse due to underutilization. (Para 1.11)

As regards PMSSY; RIPANS, Aizwal; FSSAI; CDSCO, the percentage of expenditure with respect to BE has been reduced in 2016-17 as compared to the year 2015-16. As regards CNCI and NOTP there has been a drastic reduction in utilization of allocated funds. For Development of Nursing Services, no marked improvement is seen. The Committee would like to know the reasons for the flaws in planning and the corrective steps taken by Department to improve its budgetary analysis. (Para 1.13)

The Committee is dismayed at the underutilization of funds by CNCI and recommends that the Institute should draw up a clear roadmap to emerge as a global cancer research facility and treatment centre for the entire Eastern India and streamline its administrative processes which have been primarily responsible for the underutilization of allocated resources. (Para 1.14)

The Committee is surprised to note the increase in funds of ` 4984.22 crore allocated to major Central Medical Institutes and Hospitals despite the fact that in the year 2016-17, a sum of ` 2383.00 crore at BE was enhanced to ` 2693.08 crore at RE stage and only ` 1850.08 crore could be utilized as on 2nd February, 2017 leaving a considerable shortfall in expenditure. Similarly, for CGHS, only 60% of the funds have been used and yet an increase in allocation has been sought for 2017-18. The Committee recommends that the Department should formulate an pragmatic action plan for ensuring judicious utilization of financial resources vis-a-vis set physical targets along with a robust monitoring mechanism to ensure that allocated funds do not remain idly parked and to minimize the amount of savings. The Committee would also like to suggest to the Department to set realistic targets that can be achieved in a time bound manner so as to ensure that spillover of the activities is avoided. (Para 1.16)

The Committee notes that out of a total 2410 Utilization Certificates in health sector, 66 UCs pertaining to NACO have been pending for an amount of ` 303874.58 lakh and ` 6237.44 lakhs respectively with the oldest pending UCs dating back to 1993-94. The Committee also notes that during DFG 2016-17, the Department had furnished that the oldest UCs dates back to 2005-06 with an amount of ` 67.40 crore involved therein. The Committee takes serious exception to the manner in which the information is furnished to the Committee and impresses upon the Department to provide correct and factual information. The Committee is deeply concerned about the huge amount of funds involved therein as this would adversely impact the implementation of the various schemes and developmental projects. The Committee appreciates the Department's 79 efforts in implementing PFMS and is hopeful that with this, pendency of UCs would come down and funds can be utilized appropriately. The Committee also suggests that having an exercise of continuous monitoring of the performance of PFMS to find gaps, if any, in the implementation of this software may also be evolved. The Committee would like to be apprised in this regard on a regular basis. (Para 1.20)

II. SAFDARJUNG HOSPITAL AND VARDHMAN MAHAVIR MEDICAL COLLEGE (SJH & VMMC), NEW DELHI

The Committee is dismayed to observe the considerable amount of unutilized funds in view of various developmental activities going on at SJH & VMMC as this clearly indicates poor fiscal planning and execution on the part of the Department leading to a large amount of allotted funds lying idle, resulting in cost escalation. The Committee recommends that the Department should take corrective measures to arrest the shortfall in utilization of budgeted funds and monitor the activities being undertaken to ensure their timely completion. (Para 2.3)

The Committee notes that the budgeted funds for the financial year 2017-18 would be utilized to complete the ongoing civil and procurement activities only as no new projects are in the pipeline for the hospital. The Committee, therefore, recommends that the Department should make all out efforts to achieve the physical targets in time to avoid their spillage to the next year. Moreover, in case of the implementation of the Emergency Block, in case additional funds are required then the Department should approach the Ministry of Finance for enhanced allocation at RE stage. (Para 2.5)

The Committee is disappointed to note that the creation of additional infrastructure at VMMC is still on paper and is pending for approvals from concerned authorities. The Committee would like to know the details of these activities and the progress made in this regard. (Para 2.7)

On the issue of the vacancy positions in SJH & VMMC, the Committee notes that out of sanctioned strength of 5457 posts under various categories, 1543 posts are lying vacant. In Group A & B categories, out of 3408 sanctioned posts, 1015 posts are lying vacant. The Committee is aware of the fact that Safdarjung Hospital witnesses a huge number of OPD patients and with such heavy patient load along with persistent shortage of workforce, the smooth functioning of the hospital is bound to get affected. The Committee would like to know the reasons for the persistent shortage of staff and strongly recommends that the Department should expedite the process of filing up of the vacancies on priority basis. (Para 2.8)

The Committee notes that Intrauterine Insemination (IUI) is not a time bound procedure and requires constant monitoring under a team of experts. Given the high incidence of people opting for IVF and simultaneous mushrooming of IVF centres in private sector, patients are taken for a ride and exploited in terms of money and physical well being. Therefore, IVF facility in a Government set up would certainly be a boon for childless couples where they can undergo 80 the treatment at a comparatively low cost. Therefore, strengthening of the IVF lab and making it fully functional should be on utmost priority. (Para 2.10)

III. DR. RAM MANOHAR LOHIA HOSPITAL (RML), NEW DELHI AND PGIMER, DR. RML HOSPITAL

The Committee expresses its displeasure at the tardy progress of execution of the above projects and recommends the Department to identify and resolve the factors responsible for the inordinate delays in getting departmental approvals and in eviction of land for maternal centre at the earliest so as to move forward in implementing such critical projects as delay in execution of projects would ultimately lead to time and cost escalations. Therefore, the Committee suggests to the Department to analyze the timeframes along with deliverables for implementation of the projects so as to avoid financial and physical slippages. (Para 3.4)

The Committee notes that despite efforts made to fill up the vacant posts at the hospital; vacancies still exists in various categories which would be having adverse impact on the functioning of the hospital. The Committee notes with concern the non revision of the Recruitment Rules since 1973-74 and recommends for immediate revision in context of present day requirements. Also, abolition of the vacant Group ‘C’ (Ministerial) category with 96 vacancies posts and erstwhile Group D posts with 415 vacancies may be considered so that the funds could be utilized to create more technical/para-medical vacancies viz. physiotherapist, occupational therapist, dialysis technician, optometrists, speech pathologist, respiratory therapists and prosthetic technicians emerging medical technical professionals so as to offer a wider variety of human resource trained to fulfil present day health care needs. The Committee, therefore, also recommends that the matter be taken up on priority basis to expedite the administrative procedures and process of getting approvals so as to step up the efforts to fill up the various posts at the Dr. RML Hospital. The Committee would like to be apprised of the action taken in this regard. To save on the administrative process, the Committee strongly recommends for a collaborative approach with the Ministry of Skill Development and Entrepreneurship which is running a successful flagship programme through the Healthcare Sector Skill Council (HSSC). (Para 3.6)

IV. LADY HARDING MEDICAL COLLEGE (LHMC)

On review of the chain of events that occurred at LHMC with respect to the Redevelopment Plan, the Committee notes that that there must have been cost escalations and wastage of budgeted funds. The Committee is dismayed to note that the Department has not taken Committee's recommendation in 93rd report of DFG (2016-17) seriously as under and the project is still hanging fire for approvals even after a gap of one year.

"The Committee observes that the originally approved cost of the Redevelopment Plan of LHMC and associated hospitals was ` 586.49 crore and the project was targeted to be completed by May/June 2014. But due to breaches of terms and conditions and delay on the part of M/s. Unity Infraprojects Ltd., the contract has been terminated. Much delay has already taken 81

place and it is, therefore, imperative on the part of the Department to resolve at the highest level all procedural and operational matters including approval of cost estimates expeditiously, and execute the Redevelopment Plan within the approved cost and shortest possible time frame. The Committee also recommends that a fool-proof mechanism be devised to address operational performance of the contractor and take appropriate policy decision to address the critical issues concerning the execution of the Redevelopment Plan. The Committee desires to be kept apprised of the progress made towards executing the Redevelopment Plan." (Para 4.3)

The Committee is dismayed at the lackadaisical approach of the Department with respect to the Comprehensive Redevelopment Plan and maintenance work of LHMC and associated hospitals. The Committee is concerned to note that wrong selection of the company, i.e. M/s Unity Infraprojects and M/s SAM Buillt (I) is the prime reasons for the delay, cost escalations and execution related difficulties. This sort of arrangement and consequential delays has been noted in several other projects. In these circumstances, the Committee recommends that reputed infrastructure companies with a proven track record should be roped in to execute construction and infrastructure related projects. The Committee also recommends for blacklisting of the errant companies. The Committee is disappointed to note that as such no progress has been made in the Redevelopment Plan of the Institute and the likelihood of its completion in near future seems very bleak. The Committee, therefore, strongly recommends that the Department should make all out efforts to complete the procedural issues involved therein and make the concerned authorities accountable for timely completion of the project. The Committee may be updated of the progress made in this regard. (Para 4.4)

In view of the spillover activities from the previous year and new initiatives proposed for the year 2017-18, the Committee observes that the Hospital has substantial number of projects to be completed for the current year. The Committee is of the opinion that the Department should do prudent assessment of 115 fund requirements and expedite pre-project formalities for operationalization of various projects as envisaged. (Para 4.6)

The Committee is concerned to note such a hug huge gap in the nursing workforce and its likely impact on the functioning of the hospital. Although vacancies in faculty posts are less but any extent of shortfall in faculty and other staff would overburden the existing workforce. The Committee strongly recommends for a collaborative approach with the Ministry of Skill Development and Entrepreneurship which runs a successful flagship programme under the Healthcare Sector Skill Council (HSSC) for meeting paramedical/ technical manpower requirements. (Para 4.8)

V. ALL INDIA INSTITUTE OF MEDICAL SCIENCES (AIIMS), NEW DELHI

The Committee recommends that all out efforts should be made for the projects under planning stage to be brought to take off stage expeditiously and measures should be taken to expedite the process of getting departmental approvals from concerned authorities to increase the pace of implementation of the projects. The Department should also set in place an intensive 82 monitoring mechanism to ensure successful execution of the projects within the approved cost and designated timelines. The Committee is extremely concerned to note that the faulty tendering process led to selection of the wrong executing agency, and thus caused execution cost overruns and other delays. The Committee recommends that the track record of the company especially in case of construction related projects should be made an important criterion to avoid recurrence of such instances. The Committee recommends for roping in of reputed construction companies with a proven track record for execution of such projects within a time frame. (Para 5.4)

The Committee notes that though the number of vacant faculty posts has reduced from 232 to 179 as compared to last year, the Department needs to put in additional efforts for further reducing the number of vacancies keeping in view the increasing workload at the Institute. The Committee is of the view that a complete team of paramedical professionals including technical staff is sine-qua-non for the efficient functioning of any hospital set up. For a premier institute like AIIMS, gaps in the workforce would definitely affect the smooth running of the hospital. The Committee therefore recommends that to maintain the status of Institute of national importance, the Department should strive to plug these gaps in the medical/paramedical sanctioned posts by expeditious filling up of all vacancies in various categories. A collaborative approach with the Ministry of Skill Development and Entrepreneurship may also be considered for manpower requirements. (Para 5.5)

The Committee is apprehensive that if this is the pace of progress, the project may not be initiated even during the financial year 2017-18 unless the issue is taken up at a higher level. The Committee, therefore, strongly recommends that the Department should firm up all pre and post-project approvals and ensure that the project is initiated before the end of this financial year. (Para 5.6)

VI. POSTGRADUATE INSTITUTE OF MEDICAL SCIENCES AND RESEARCH (PGP), CHANDIGARH

The Committee notes that despite the availability of financial and physical resources, the projects at PGI, Chandigarh could not be pushed ahead due to inordinate delays caused due to bureaucratic procedures. Moreover, as per canons of financial propriety, the more quickly a project gets implemented, the lesser it results in cost and time overruns. The Committee while deprecating this slow progress in the six projects recommends that the Department should closely monitor the activities being undertaken and fast track these projects to ensure that no cost or time overruns are reported. (Para 6.4)

The Committee notes the progress made in these three projects and observes that all these projects are at nascent stage and under approvals of the competent authorities. In this regard, the Committee would like to reiterate its recommendation made in its 93rd Report on DFG (2016-17) which is as under:-

"The Committee is constrained to observe that all the three projects, i.e. Advance Cardiac Centre (Phase II), Modernisation of Research fA' and 'B' Block and Modernisation of Nehru 83

Hospital were targeted to be completed during the Eleventh Five Year Plan but are nowhere close to execution even after the lapse of four years of the Twelfth Plan period. The Committee expresses its displeasure at the tardy progress of implementation of the above projects and recommends that the factors responsible for the inordinate delay in the implementation of the projects may be gone into in detail and corrective measures taken accordingly so that the implementation of projects is speeded up with sustained monitoring." (Para 6.6)

The Committee strongly recommends that the Department should undertake a time-bound exercise to fill the vacancies of medical/paramedical/nursing/technical staff. The Committee is of the opinion that with increasing automation, there is a distinct possibility for reduction in requirement of the administrative staff and the resources can be channelized in favour of paramedical/technical staff. (Para 6.8)

VII. REGIONAL INSTITUTE OF MEDICAL SCIENCES (RIMS), IMPHAL

The Committee feels that the present status of constructional activities at RIMS, Imphal appears to be worrisome since the work was started in 2012 and the stipulated time of completion was October, 2013. The work was stopped after the agreement between HSCC and the work agency was declared null and void in March, 2015. This sorry state of affairs indicates a lackadaisical attitude of Department towards healthcare needs of the North-eastern Region. The Committee strongly recommends that Department should take up the matter on priority basis and resolve all the administrative and technical bottlenecks to resume the projects and complete them in the shortest possible time. Since the funds as per the projected demand has not been given to the Institute, the Committee is of the view that the ongoing and proposed initiatives at the Institute would bear the brunt of shortfall of funds. Therefore, the Committee supports the Department to call for more funds at RE stage to meet the demands of the Institute. The Committee also advocates for greater coordination with the DONER Ministry so that plan schemes (capital outlay) for RIMS, Imphal can be supported through Non-lapsable Central Pool of resources (NLCPR). The Committee is concerned to note the opaque administrative process followed in the procurement process during the last few years by RIMS, Imphal and strongly recommends for greater central scrutiny and monitoring with respect to capital spending by RIMS, Imphal specifically in context of procurement of medical equipments. (Para 7.3)

VIII. NORTH EASTERN INDIRA GANDHI REGIONAL INSTITUTE OF HEALTH AND MEDICAL SCIENCES (NEIGRIHMS), SHILLONG

The Committee is constrained to note the huge shortage of staff and feels that this would eventually cripple the functioning of the Institute while over burdening the existing workforce. The Committee, therefore, recommends that the Department should take up this matter on a priority basis and fill up the posts at the earliest. (Para 8.5)

IX. FAMILY WELFARE SCHEMES (FWS)

On scrutiny of the budgetary allocation, the Committee is concerned to note that out of ` 02.51 crore at BE stage, only an amount of ` 0.664 crore has been spent which is a merely 84

33% of the budgetary fund with respect to RE. The Committee is disappointed to find the substantial mismatch between the activities proposed and funds actually spent. As family planning is an integral component of the population control programme, the Committee is of the view that there must be a proactive approach on the part of the Department to properly monitor the utilization of funds for various activities as envisaged under the programme. The Committee, therefore, strongly recommends that the Department should shed its lackadaisical attitude and closely monitor the utilization of funds. (Para 9.4)

X. NATIONAL ORGAN TRANSPLANT PROGRAMME (NOTP)

The Committee observes that actual expenditure during 2015-16 was just 63% with respect to RE of ` 10.00 crore only leaving unutilized resources. During 2016-17, funds at RE was further reduced to ` 7.13 crore from ` 15.00 crore at BE stage, wherein the actual expenditure as on 13/2/2017 was just ` 4.12 crore. The Committee takes a serious note of the under-utilization of funds under the scheme in both the years. The Committee is of the view that Department should evaluate the scheme and its scope of expansion to utilize the available physical and financial resources to avoid under-utilization of funds. (Para 10.3)

XI. SERA AND VACCINE MANUFACTURING UNITS

The Committee notes the consistent trend of substantial amount of funds remaining unutilized at CRI, Kasauli in the last three years. When the facility is producing commercial batches of TT in bulk after achieving cGMP compliance, unutilized funds indicates some lacunae in the process of bulk production. The Committee would suggest the Department to undertake an assessment of the unit and identify the shortcomings and take remedial measures to ensure the smooth running of the vaccine production unit. (Para 11.3)

The Committee also observes that at CRI, Kasauli and BCGVL, Guindy, upgradation work has been completed and both the units have been made cGMP compliant since long. The commercial production of TT vaccines and BCG vaccines has already commenced at the respective units. As regards, PII, Coonoor, civil construction is nearing completion and cGMP compliant facility would be fully completed by June, 2017. The Committee would like to suggest the Department to speed up the activities to make PII, Coonoor, cGMP compliant unit to utilize its vaccine production output to make Universal Immunization Coverage a success with increased supply of vaccines at low cost. (Para 11.4)

The Committee notes that the public sector vaccine manufacturing units are established to supply quality vaccines for the Universal Immunization Programme (UIP) of the Government of India. The production capacity of these units is barely able to meet the requirement of the programme. The Committee is dismayed to note that the production of yellow fever vaccine has been suspended in CRI Kasauli since 2012. The Committee notes with concern that a premier vaccine manufacturing unit like the CRI has been relegated to the sidelines by stopping its production on one ground or the other. The Committee is appalled at this state of affairs which 85 ultimately led to our dependency on private vaccine manufacturers for meeting the demand for vaccine under UIP. The Committee also notes that once GMP specifications to manufacture DPT vaccine were achieved by CRI Kasauli, it is being replaced by Pentavalent Vaccine. (Para 11.5)

Besides the Committee is concerned to note that the DCG (I) has been repeatedly not approving the GMP facilities of CRI on one pretext or another. The Committee would like to draw the attention of the Government to its 38th report on major issues concerning the three vaccine producing PSUs, namely CRI Kasauli, The Pasteur Institute of India (PII) Coonoor and the BCG Vaccine laboratory (BCGVL), Chennai and would like to reiterate its earlier recommendations so that the dependency on private vaccine manufacturing units can be reduced by utilizing the installed capacity at public sector vaccine manufacturing units to their optimum. The Committee is also concerned to note the evasive manner in which the department has avoided giving details of the market share of public sector vaccine manufacturing units vis-a-vis the private sector vaccine manufacturers. (Para 11.6)

National Institute of Biological (NIB)

The Committee is concerned to note the ever increasing requirement of budgetary support to NIB specifically during the last five years. The Committee is of the opinion that NIB is exceeding its mandate by duplicating the work done by CDL Kasauli resulting in wastage of scarce public funds as CDL Kasauli is already engaged in the testing of vaccines, sera, solution of serum proteins for injections, toxins, antigens, anti toxins, surgical ligatures, bacteriophages and oral vaccines. The Committee recommends for greater scrutiny of the functioning of NIB by ICMR specifically in context of its role and achievements in the area of research. The Committee is also concerned to note the involvement of private sector vaccine manufacturers in the general body of the NIB and recommends for suitable amendments in the NIB bye laws so that there is no involvement of private sector vaccine or biological manufacturer. The Committee recommends for NIB to ensure that there is no duplication in the setting up of laboratories/ testing infrastructure with the already existing facilities available within the same ministry. The Committee also recommends that NIB should adhere to its original mandate instead of trying to be another regulator. (Para 11.8)

XII CENTRAL GOVERNMENT HEALTH SCHEME (CGHS)

The Committee is surprised to note that after year 1985-86, no regular AYUSH facility has been added to CGHS. However, the Committee appreciates that the Department has taken up this matter with Ministry of AYUSH. But still, no concrete action has been taken. The Committee, therefore, recommends that the Department should firm up and complete the proposal regarding strengthening of infrastructure facility, manpower, and maintenance of AYUSH facility in CGHS. (Para 12.6)

The Committee notes that many hospitals have de-empanelled themselves from CGHS. The Committee is of the view that the de-empanelment of some very good CGHS approved 86

Hospitals is a major cause of concern and inconvenience to the CGHS patients. The Committee observes that the de-empanelment of these Hospitals is mainly due to non-settlement of their dues by the Government. The recent decision of the Department to allow online processing by UTI-TSL is a welcome step but it needs to regulated and checked from time-to-time for desired results. The Committee also recommends introduction of a dedicated CGHS wing in all Government Hospitals and also to ensure that there should be CGHS empanelled hospital in each district of the country. It also recommends putting in place an effective mechanism of quality assurance of the drugs supplied through CGHS. (Para 12.9)

XIII. CENTRAL DRUGS STANDARD CONTROL ORGANISATION (CDSCO)

The Committee strongly recommends that the execution of the project for strengthening of the drug regulatory system be done immediately in accordance of the approvals given by the Expenditure Finance Committee (EFC) in a strict time bound manner. The Committee recommends for setting up a regular consultative mechanism with the State Governments so as to prevent inordinate delays. Efforts may be done to sign MoUs with the remaining States/UTs. (Para 13.3)

The Committee would like to draw attention of the Government to its 93rd Report on the DFG (2016-17) wherein the status of vacancies in CDSCO has been reflected in Table No. 30. The Committee recommends for immediate filling up of vacancies in CDSCO especially in context of the enhanced role as a regulatory body for medical devices consequent to the recent notification of Medical Devices Rules 2017 which shall come into force w.e.f. 01/01/2018. The Committee is concerned to note that the topmost head of CDSCO i.e. the DCG (I) continues to function in a very adhoc manner with additional charge. The Committee strongly recommends for a suitable full time DCG (I) and also would like to be updated about the status of action taken in this regard. The Committee recommends for a quarterly update on the progress made in the strengthening of the drug regulatory framework, vacancy position and engagement of a full time DCG(I). The Committee suggests that the entire regulatory framework for regulating the Medical Device industry should be in place in CDSCO before 1st January, 2018. (Para 13.4)

XIV. FOOD SAFETY AND STANDARD AUTHORITY OF INDIA (FSSAI)

The Committee observes that there is consistent trend of under utilization of funds during the years 2014-15, 2015-16 and 2016-17. The Committee is of the view that safety and standardization of food is a neglected area in India and the Department needs to focus more in this field. The Food Safety and Standard Authority of India was established in 2006. The status of safety, regulation, manufacturing, processing, distribution, sale and import of food items for human consumption shows a dreary picture in the country. Slow progress of the developmental activities and initiatives would hamper the quality of work being rendered in context of safety and standardization of food items across the country. Since there are numerous domains under the Food safety and Standard Authority of India, under utilization of budgeted funds indicates negligence in this area and poor financial planning on the part of the concerned authority. (Para 14.4) 87

The Committee expects the Department to take appropriate measures to arrest shortfall in utilization of budgetary funds and ensure that the strengthening of Food Testing Systems/ laboratories is done in a time-bound manner. (Para 14.5)

The Committee would like to emphasize upon the need for ample provisioning of Mobile Food Testing Labs (SOFTeL) in the country. This would certainly go a long way in ensuring awareness regarding precautionary measures so that diseases spreading through contaminated/ sub-standard food are minimized. Therefore, to improvise the food testing across the country, more number of food testing labs need to be started. (Para 14.6)

The Committee recommends that the results of all the food items being tested should be made public through advertisement, newspaper and other electronic, print and social media to make public aware about the same. The Committee, also recommends the Department to set desirable and achievable targets and seek additional funds depending upon the implementation of the scheme at later stage. (Para 14.7)

XV. PRADHAN MANTRI SWASTHAYA SURAKSHA YOJANA (PMSSY)

With multiple project related activities in pipeline, the funds remaining unutilized shows imprudent attitude of the Department in financial planning vis-a-vis physical targets. Had the Department paid heed to the Committee's earlier recommendations, the achievement at the end of the Twelfth Five Year Plan would have been different. It has been noted that six AIIMS in the Phase I are still underway and are at various stages of their completion and it would take some time to make them fully functional with regard to construction of medical college, hospital complex, residential complex, electrical services, estate services and procurement of equipments. This indicates poor assessment of time and cost by the Department that has left the funds unused. (Para 15.3)

On the perusal of the reply furnished by the Department regarding the reasons for delay and the measures taken to remedy the situation in PMSSY, the Committee finds that there is no tangible progress and the status remains the same as was reported earlier to the Committee. The Committee, therefore, is of the view that had the Department taken steps to seriously monitor the performance of the committees formed at local level, tangible progress would have taken place in the completion of Phase I and II. Keeping in view the status of six AIIMS in Phase I & II, the Committee recommends that the Department should strive towards concluding the civil and up gradation work at all the six AIIMS like Institutions under Phase I & II for making them fully operational so that the focus of the Department can be shifted on the activities pertaining to Phase III & IV of PMSSY. Completion of Phase I & II brooks no delay and year 2017-18 should see the institutes functioning. (Para 15.6)

The Committee is distressed to note that the tendering process in almost all PMSSY process has lead to a situation where projects remain incomplete. Besides this, the Ministry in itself lacks the expertise to execute such projects. The Committee recommends that large 88 hospital projects be handled by reputed companies with a past track record of on time and quality delivery. The Committee is of the opinion that to tackle the issue of LI rates in tenders reputed companies may be roped in on the same terms and transfer prices as quoted by the in-house agencies. (Para 15.7)

The Committee is also concerned to note that a large number of medical equipments are bought routinely by regional AIIMS on the basis of proprietary technology and proprietary certificate. The Committee recommends for more transparent mechanism for purchase of capital equipment. The Committee also recommends that proper upkeep of capital equipment be ensured in all AIIMS. (Para 15.8)

The Committee feels that infrastructure and manpower go hand in hand for running of any institute/hospital successfully. A sound mix of manpower from all areas of expertise and fields including faculty, paramedical, technicians and support staff are required for all the Institutes. The Committee, therefore, recommends that the Department should fill up the sanctioned posts under all categories at the earliest so that a permanent and adequate manpower is in place in a premier institute like AIIMS. The Committee would also like to voice its concern regarding the students who have joined the courses and are suffering due to shortage of faculty and non- faculty staff. (Para 15.10)

XVI. NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF CANCER, DIABETES, CARDIOVASCULAR DISEASES AND STROKE (NPCDCS)

The Committee notes that there are still several States which do not even have any single State Cancer Institute/TCCC, despite the pressure that is faced by Tertiary Care hospitals. The Committee strongly recommends for regular follow up with the State Governments/Institutions for rectifications of deficiencies if any in the proposals sent by them so that the cancer treatment infrastructure in the country is strengthened. (Para 16.3)

The Committee also recommends that priority be given to States which do not have a single State Cancer Centre/TCCC. The Committee would like to be updated about the progress made in this regard. (Para 16.4)

National AIDS Control Organisation (NACO)

Budgetary allocation

The Committee is constrained to note that while the Planning Commission had recommended total outlay of `11394.00 crore for the NACO for the Twelfth Plan Period, the total RE allocation made by the Union Government in the five years of the Twelfth Plan period (i.e. 2012-13 to 2016-17) was ` 7944.61 crore only which works out to 69.72% of the funding envisaged by the Planning Commission. Given the fact that overall NACO expenditures are reasonably high with about 90% of the funds released for the NACO between 2012-13 and 2016-17 being utilised as on 31st January, 2017, the Committee observes that the actual allocation of funds for NACO was 89 done in an arbitrary fashion. Despite India's progress in reduction of HIV prevalence, the country still had an estimated 21.17 lakh HIV infected people in 2015 which is third largest in the world. Hence, it is evident that the budgetary cuts instituted by the Government would have impacted the various interventions under National AIDS Control Programme. The Committee would exhort the Government to ensure that such a trend does not recur in future and the funds approved on paper get allocated and spent also. (para 17.9)

The Committee observes that funding from external sources has contributed substantially in supporting the NACP interventions. But in the light of the global economic slowdown, external funding for the Programme is certain to shrink considerably and there is, therefore, an imperative need to balance the financing strategy of NACP IV by way of generating more funds from domestic sources so that the reach of existing NACP interventions is sustained and the cost of clinical care and treatment to people living with HIV is provided for. Though the recent HIV estimates highlight an overall reduction in HIV prevalence, there are significant inter-state variations and some States like Maharashtra, Chandigarh, Tripura and Tamil Nadu have shown estimated adult prevalence greater than the national average (i.e. 0.26%). Besides HIV epidemic due to MSM, transgender, migration and IDU are being identified in greater number across the country and hence pose enormous challenges. Taking all these facts into consideration, the Committee lends its support to the Department's demand for additional funds and recommends that an additional amount of ` 400.00 crore be allocated for NACO for 2017-18. (para 17.11)

Utilisation Certificates

The Committee is constrained to note the unspent cash balances with SACS. The Committee believes that unspent balances indicate poor financial planning and discipline. The Committee strongly recommends that NACO should direct all SACS to undertake a quarterly review of unspent cash balances and initiate steps to liquidate the unspent cash balances on quarterly basis instead of reviewing it at the end of the financial year. The Committee would also like the Department to ensure proper fiscal planning and discipline. (para 17.14)

Metro Blood Bank Project

The Committee is constrained to note the tardy progress made towards establishing Metro Blood Banks in Chennai and Delhi. The Department had made a provision of `404.00 crore in RE 2015-16 and ` 404.00 crore in RE 2016-17 but nothing was spent, leading to idle parking of the funds and the eventual surrendering of the entire budgeted funds for this Scheme for 2015- 16 and 2016-17. The surrendering of the budgeted funds is indicative of the fact that the Department has not played its role as a facilitator well in implementing the Scheme that has a significant bearing on improving the NACP interventions. Also, at a time when the Government is striving for fiscal consolidation, such ritualistic allocations which remain on paper only, are unacceptable to the Committee. The Committee, therefore, recommends that all hindrances in establishing Metro Blood Banks be ironed out early so that such instances of blockage of funds earmarked for this Scheme do not recur. The Committee desires to be kept apprised of the progress made towards operationalizing this Scheme. (para 17.18)

MINUTES

V*

FIFTH MEETING

The Committee met at 2.30 P.M. on Thursday, the 2nd March, 2017 in Main Committee Room, Ground Floor, Parliament House Annexe, New Delhi.

MEMBERS PRESENT

1. Prof. Ram Gopal Yadav — Chairman

RAJYA SABHA 2. Shri Rajkumar Dhoot 3. Dr. Vikas Mahatme 4. Shri Jairam Ramesh 5. Shri Ashok Siddharth 6. Shri Gopal Narayan Singh 7. Dr. C. P. Thakur LOK SABHA 8. Shri Dasrath Tirkey 9. Dr. Sanjay Jaiswal 10. Dr. K. Kamaraj 11. Shri Arjunlal Meena 12. Shri J. Jayasingh Thiyagaraj Natterjee 13. Shri M. K. Raghavan 14. Dr. Manoj Rajoria 15. Dr. Shrikant Eknath Shinde 16. Shri Kanwar Singh Tanwar 17. Shrimati Rita Tarai 18. Shri Manohar Untwal SECRETARIAT Shri P.P.K. Ramacharyulu, Additional Secretary Shrimati Arpana Mendiratta, Director Shri Rakesh Naithani, Joint Director

* Minutes of Ist to IVth meetings relate to other matters.

93 94

Shri Dinesh Singh, Joint Director Shrimati Harshita Shankar, Assistant Director Shri Pratap Shenoy, Committee Officer Shrimati Gunjan Parashar, Research Officer WITNESSES Representatives from the Department of Health and Family Welfare 1. Shri C. K. Mishra, Secretary 2. Dr. Jagdish Prasad, Director General of Health Services (DGHS) 3. Dr. Arun K. Panda, Additional Secretary & Mission Director, National Health Mission (NHM) 4. Sh. Sanjeeva Kumar, Additional Secretary 5. Dr. R. K. Vats, Additional Secretary & Director General (CGHS) 6. Shri Manoj Jhalani, Joint Secretary 7. Shri Arun Singhal, Joint Secretary 8. Shri K. L. Sharma, Joint Secretary 9. Shri Sunil Sharma, Joint Secretary 10. Ms. Sheela Prasad, Economic Adviser

11. Ms. Bharathi Das, Chief Controller of Accounts

Opening Remarks

2. At the outset, the Chairman welcomed the Members * * * Thereafter, he briefed the Members about the agenda of the meeting i.e., examination of Demands for Grants (2017-18) of the Department of Health and Family Welfare pertaining to National Health Mission (NHM) and Health Sector (Ministry of Health and Family Welfare) and having a presentation of the Secretary of the Department of Health and Family Welfare on the same.

Oral Evidence of the Health Secretary on Demands for Grants (2017-18) (Demand No. 42)

3. The Committee heard the Secretary and other representatives of the Department of Health and Family Welfare on Demands for Grants (2017-18) pertaining to National Health Mission and Health Sector. At the outset, the Secretary presented an overall macro picture of the Department before the Committee, stating that an allocation of ` 47,353.00 crore has been made under NHM and Health Sector in BE 2017-18 as compared to last year's BE of ` 37,000.00 crore indicating an increase of about ` 10000.00 crore. He also informed that the increase of the budget for 2017-18 has been made mainly for National Health Mission, PMSSY, Human Resource Sector in Medical Education and Upgradation of district hospitals. He also highlighted the fact that the Department had done well with respect to achievement of Millennium Development Goal (MDG) targets with decline in Infant Mortality Rate (IMR) and under-5 mortality rate.

*** Relate to other matters. 95

4. Thereafter, the Additional Secretary, Department of Health and Family Welfare made a power-point presentation on NHM and Health Sector and inter alia highlighted the following points (i) actual allocation for NHM and Health Sector in the 12th Plan Period was much less than the approved Twelfth Plan Outlays therefor; (ii) the trend of expenditure vis-a-vis budgetary allocations made in the five years of the 12 Five Year Plan (iii) Progress made under National Health Mission components i.e. NRHM-RCH Pool, National Urban Health Mission, Communicable diseases; Achievement under MDG-6 to reverse the incidence of Malaria; TB and HIV/AIDS; (iv) allocation from 2015-16 to 2017-18 in AIIMS, PGIMER and JIPMER; (v) growth of Nursing Institutions; (vi) Focus on Non-Communicable Diseases (NCD); (vii) Cancer care; (viii) Status of fund flow for NACP-IV during the 12th Five Year Plan; (ix) allocation and under-utilization status of budget under CGHS; etc.

5. The Members then raised certain queries on Demands for Grants (2017-18) pertaining to NHM and Health Sector. The Secretary, Department of Health and Family Welfare and other officials replied to some of the queries raised by the Members. The Chairman directed the Secretary to furnish detailed written replies to the queries left unanswered within a week.

6. A verbatim record of the proceedings of the meeting was kept.

7. The Committee then adjourned at 4.53 P.M. to meet again at 11.00 A.M. on 3rd March, 2017. 96

VII

SEVENTH MEETING

The Committee met at 10.00 A.M. on Friday, the 17th March, 2017 in Room "62", First Floor, Parliament House, New Delhi.

MEMBERS PRESENT

1. Prof. Ram Gopal Yadav — Chairman RAJYA SABHA 2. Shrimati Renuka Chowdhury 3. Dr. R. Lakshmanan 4. Dr. Vikas Mahatme 5. Shri Jairam Ramesh 6. Shri Ashok Siddharth 8. Shri Gopal Narayan Singh 9. Shri K. Somaprasad LOK SABHA 10. Shri Thangso Baite 11. Shri Nandkumar Singh Chauhan 12. Dr. (Smt.) Heena Vijay Gavit 13. Dr. Sanjay Jaiswal 14. Dr. K. Kamaraj 15. Shri Arjunlal Meena 16. Shri M.K. Raghavan 17. Dr. Shrikant Eknath Shinde 18. Shri R.K. Singh (Arrah) 19. Shrimati Rita Tarai SECRETARIAT Shri P.P.K. Ramacharyulu, Additional Secretary Shrimati Arpana Mendiratta, Director Shri Dinesh Singh, Joint Director Shri Rakesh Naithani, Joint Director

96 97

Shrimati Harshita Shankar, Assistant Director Shri Pratap Shenoy, Committee Officer

Shrimati Gunjan Parashar, Research Officer

Opening Remarks

2. At the outset, the Chairman welcomed the Members of the Committee and briefed them about the agenda of the meeting i.e., to consider and adopt draft 99th * * * Reports of the Committee on Demands for Grants (2017-18) of the Departments of Health and Family Welfare, * * * (Ministry of Health and Family Welfare) and * * *.

Consideration and adoption of draft 99th, * * *Reports of the Committee

3. The Committee then considered and discussed the draft 99th, * * *Reports of the Committee on Demands for Grants (2017-18) of the Ministry of Health and Family Welfare pertaining to Departments of Health and Family Welfare and * * *. After some discussion, the Committee adopted the said Reports with minor changes. The Committee, thereafter, decided that the Reports may be presented to the Rajya Sabha and laid on the Table of the Lok Sabha on Monday, the 20th March, 2017. The Committee authorized its Chairman, Shri Jairam Ramesh and Dr. Vikas Mahatme to present the Reports in Rajya Sabha, and Dr. Sanjay Jaiswal and Dr. Shrikant Eknath Shinde to lay the Reports on the Table of the Lok Sabha.

4. * * *

5. * * *

6. * * *

7. The Committee then adjourned at 10:30 A.M.

*** Relate to other matters.

ANNEXURES

ANNEXURE-1

Department of Health & Family Welfare Scheme wise proposed outlays for 12th Plan under National Health Mission & Family Welfare

(` in crores)

Sl. No. Name of the Scheme 12th Plan (2012-17) Outlay including domestic and EAP components

12 3

I NATIONAL HEALTH MISSION 184806.27

A. NRHM -RCH Flexible Pool** 115285.69

1. RCH Flexible Pool 35121.60

2. Mission Flexible Pool 45000.00

3. Routine Immunisation 3200.00

4. Pulse Polio Immunisation 3900.00

5. Iodine Deficiency Disorder Control Programme 350.00

6. Strengthening of District hospitals for providing advanced secondary 11714.09 care

7. Providing free generic medicines in all public health institutions 16000.00 in the country

B. National Urban Health Mission-Flexible Pool 15143.00

C. Flexible pool for Communicable Diseases*** 10551.87

l. National Vector borne Control Programme 4912.72

2. National T.B. Control Programme 4500.15

3. National Leprosy Eradication Programme 500.00

4. Integrated Disease Surveillance Programme 639.00

D. Flexible pool for Non-communicable diseases, injury & trauma # 12325.71

101 102

1 2 3

1. National Programme for Control of Blindness 2506.90

2. National Mental Health Programme 1577.46

3. Health care for Elderly 1147.56

4. National Programme for prevention and control of Deafness 304.79

5. National Tobacco Control Programme 429.00

6. National Oral Health Programme 10.00

7. Assistance to States for capacity Building (Burns) 50.00

8. National programme for Prevention and control of Cancer, Diabetes, 6000.00 Cardiovascular Diseases and stroke (NPCDCS)

9. Other New initiatives under non communicable diseases 300.00

E Infrastructure Maintenance 31500.00

II Family Welfare -Central sector 8599.44

1. Social Marketing Area Projects 0.80

2. Social Marketing of Contraceptives 650.00

3. Funding to Institutions 553.7

(i) Population Research Centres 90.00

(ii) CDRI, Lucknow 34.50

(iii) NIHFW, New Delhi 143.30

(iv) IIPS, Mumbai 215.00

(v) NPSF/National Commission on Population 22.60

(vi) Funding to Training institutions 48.32

(a) F.W. Training and Res. Centre, Bombay 41.50

(b) Rural Health Training Centre, Najafgarh 1.02

(c) Travel of Experts/Conf./Meetings etc. (Melas) 5.80

4. Central Procurement Agency # # 50.00

5. International Co-operation 15.00

6. FW Linked Health Insurance Plan 185.00 103

1 2 3

7. Free distribution of contraceptives 720.00

8. Procurement of Supplies & Materials 1820.00

9. IEC (Inf., Edu. and Communication) 1800.00

10. Area Projects 20.02

11. Forward Linkages to NRHM 748.00

12. Strengthening National Programme Management of the NRHM 918.40.

13. National Drug De-Addiction Control Programme 151.10

14. Other CSS activities 967.40

(i) Other Family Welfare Activities 29.00

(a) Role of Men in Planned Parenthood 5.00

(b) Training in Recanalisation 8.00

(c) FW Programme in Other Ministries 7.50

(d) Technology in Family welfare 8.50

(ii) Gandhigram Institute 12.50

(iii) Assistance to IMA 1.50

(iv) Expenditure at HQs (RCH) 60.50

(v) Research and study activties under RCH 9.00

(vi) Regional Offices 130.90

(vii) RCH training 51.50

(viii)Information technology 12.50

(ix) NGO (PPP) 10.00 %

(x) Management Information System (MIS) 650.00

Grand total 193405.71

* For domestic + external component; ** RCH and Mission flexi pool and other related schemes merged into one; *** Infectious diseases merged into one flexi pool; # for 12th Five year plan and for annual plan 2013-14 the Outlay has been bifurcated-Tertiary care is reflected under the Health sheet while the flexi pool component is reflected under 'Flexipool For non communicable diseases' in the NHM & Family Welfare sheet. # #Central procurement agency shown under NHM for 2012-13 and under Health from 2013-14 104

ANNEXURE-II

Targets & Achievements for 12th Five Year Plan are as follows :

Targets & Achievements for NHM/12th FY Plan

Sl. No. 12th Plan Targets Achievements (by 31.03.2017)

1. Reduce IMR to 25/1000 live births IMR has reduced to 37 in 2015 (SRS).

2. Reduce MMR to 1/1000 live births MMR has reduced to 1.67/1000 live births in 2012-13.

3. Reduce TFR to 2.1 TFR has reduced to 2.3 in 2014 (SRS).

4. Reduce annual prevalence and mortality Tuberculosis Prevalence and mortality reduced to from Tuberculosis by half half as compared to 1990 level. Incidence reduced from 300 / lakh in 1990 to 217/ lakh in 2015 Mortality reduced from 76/ lakh in 1990 to 32/ lakh in 2015 Data Source : WHO Global TB report 2016

5. Reduce prevalence rate of Leprosy to Prevalence rate of Leprosy reduced to Less than <1/10000 population in all districts. 1/10000 population in 551 Districts as on 31st March 2016.

6. Annual Malaria Incidence to be < 1/1000 Annual Malaria Incidence is 0.67 in 2016.(Prov.)

7. Less than 1 per cent microfilaria Out of 256 LF endemic districts, 222 districts prevalence in all districts have reported Mf rate less than 1% as per reports of 2016.

8. Kala-Azar Elimination by 2015, Out of 628 endemic blocks 492 (78%) have <1 case per 10000 population already achieved elimination till 2016. in all blocks

Statement showing salient targets/ Outcome goals set for 12th Five Year Plan

Sl. No. Targets/ Outcome goals Achievements

1. Reduction of Infant Mortality Rate 37 [Source- Sample Registration System-2015] (IMR) to 25

2. Reduction of Maternal Mortality Ratio 167 [Source- Sample Registration System (MMR) to 100 2011-13]

3. Reduction of Total Fertility Rate 2.3 [Source- Sample Registration System-2014] (TFR) to 2.1

104 105

Sl. No. Targets/ Outcome goals Achievements

4. Prevention and reduction of Under-nutrition % children aged 0-59 months who are under- in children under 3 years to half of NFHS-3 weight: 29.4 [Source- Rapid Survey on (2005-06) levels Children (RSOC): 2013-14]

5. Prevention and reduction of anaemia among 55.3%[Source-NFHS-3] women aged 15-49 years to 28 per cent

6. Raising child sex ratio in the 0-6 year age 919 [Source-Census-2011] group from 914 to 950

7. Prevention and reduction of burden of Malaria: 1.17 million cases with 384 deaths - 2015 Communicable and Non-Communicable Estimated TB Burden in India: Incidence: 167 diseases (including mental illnesses) and cases per 100000 population, Prevalence: 195 injuries cases per 100000 population, Deaths: 17 deaths 100000 population, Leprosy: Annual New cases detection ratio (ANCDR) -9.71 per 100000 population (2015-16) [Source- respective Programmes]

8. Reduction of poor households' out-of- 64.21% OoPE as % of total health expenditure pocket expenditure (OoPE) [Source- NHA (Estimates for India)-2013-14] 106

ANNEXURE-III

State Health Budget

(` in Crore)

Sl. No. States 2015-16 2016-17 % of 12th Plan Non-Plan Total Plan Non-Plan Total Increase Plan Avg. 1 2 3 4 5 6 7 8 9 10

1. Andaman and 205.83 73.24 279.07 199.89 80.91 280.80 1% 16% Nicobar Islands

2. Andhra 1,986.81 3,741.42 5,728.23 3,170.03 2,933.73 6,103.76 7% 6% Pradesh

3. Arunachal 302.52 337.59 640.11 465.87 426.10 891.97 39% 33% Pradesh

4. Assam 2,656.52 1,374.33 4,030.85 2,270.53 1,490.72 3,761.25 -7% 22%

5. Bihar 2,363.00 2,621.93 4,984.93 5,337.18 2,897.52 8,234.70 65% 27%

6. Chandigarh 167.07 193.07 360.14 135.77 215.12 350.89 -3% 11%

7. Chhattisgarh 2,542.01 697.40 3,239.41 3,163.05 810.43 3,973.48 23% 27%

8. Dadra & Nagar 67.35 9.89 77.24 89.82 - 89.82 16% 36% Haveli

9. Daman & Diu 52.60 10.09 62.69 42.43 11.15 53.58 -15% 13%

10. Delhi 3,138.00 1,649.00 4,787.00 3,200.00 2,059.00 5,259.00 10% 16%

11. Goa 178.29 205.21 383.50 391.71 236.51 628.21 64% 27%

12. Gujarat 6,193.85 1,627.78 7,821.63 6,505.00 1,707.05 8,212.05 5% 20%

13. Haryana 1,845.88 1,182.73 3,028.61 2,595.43 1,321.51 3,916.94 29% 21%

14. Himachal 309.01 1,099.48 1,408.49 312.91 1,251.69 1,564.60 11% 10% Pradesh

15. Jammu & 144.26 1,822.10 1,966.36 264.00 2,004.31 2,268.31 15% 9% Kashmir

16. Jharkhand 1,875.43 838.14 2,713.57 2,129.18 920.49 3,049.67 12% 22%

17. Karnataka 4,026.90 2,421.10 6,448.00 4,237.82 2,065.23 6,303.05 -2% 14%

18. Kerala 1,457.31 3,707.48 5,164.79 1,524.06 4,171.72 5,695.78 10% 17%

19. Lakshadweep 36.50 19.97 56.47 40.00 24.16 64.16 14% 5%

20. Madhya 2,418.69 2,289.37 4,708.06 2,985.89 2,623.61 5,609.50 19% 22% Pradesh

21. Maharashtra 4,557.21 3,490.50 8,047.71 4,561.65 3,837.19 8,398.84 4% 19%

106 107

1 2 3 4 5 6 7 8 9 10

22. Manipur 304.04 213.75 517.79 131.78 224.32 356.10 -31% 4%

23. Meghalaya 380.74 202.12 582.86 470.00 258.88 728.88 25% 35%

24. Mizoram 211.25 166.81 378.06 226.25 188.03 414.28 10% 21%

25. Nagaland 2.00 316.12 318.12 4.50 334.45 338.95 7% 7%

26. Odisha 2,107.44 1,774.90 3,882.34 3,252.98 1,983.83 5,236.81 35% 31%

27. Pondicherry 309.50 212.91 522.41 297.10 219.00 516.10 -1% 12%

28. Punjab 990.43 2,013.53 3,003.96 1,308.28 2,100.88 3,409.16 13% 12%

29. Rajasthan 4,975.88 3,265.27 8,241.15 6,046.14 3,491.25 9,537.39 16% 24%

30. Sikkim 199.23 108.60 307.83 192.61 119.52 312.13 1% 7%

31. Tamil Nadu 3,837.37 5,234.25 9,071.62 4,098.19 4,974.53 9,072.72 0% 14%

32. Telangana 2,459.00 2,472.54 4,931.54 2,462.83 3,504.05 5,966.88 21% #DIV/0!

33. Tripura 497.20 410.89 908.09 572.66 425.98 998.64 10% 23%

34. Uttar Pradesh 9,073.84 6,854.27 15,928.11 11,667.92 7,877.66 19,545.58 23% 23%

35. Uttarakhand 677.22 811.54 1,488.75 786.88 893.67 1,680.55 13% 24%

36. West Bengal 2,588.90 3,536.03 6,124.93 2,999.22 3,936.73 6,935.95 13% 11%

TOTAL 65,139.08 57,005.35 1,22,144.42 78,139.57 61,620.92 1,39,760.49 14% 19% 108

ANNEXURE-IV

Department of NRHM

State wise UCs Pending Report Post 2010 (2010-2015)

as on 03.02.2017

Sl. No. State No. of UC Pending Amount (Rs)

1. Andaman and Nicobar 4 27,28,000

2. Andhra Pradesh 26 97782,55,000

3. Assam 14 3918,15,000

4. Bihar 15 30206,59,304

5. Chandigarh 18 7992,81,525

6. Chhattisgarh 5 200,34,000

7. Dadra and Nagar Haveli 2 56,00,000

8. Daman and Diu 5 14,61,000

9. Delhi 21 1254,15,014

10. Goa 1 6,52,000

11. Gujarat 8 7826,03,250

12. Haryana 2 12,00,000

13. Himachal Pradesh 4 2349,64,000

14. Jammu and Kashmir 9 7011,88,000

15. Jharkhand 12 25816,20,081

16. Karnataka 15 47690,00,000

17. Kerala 10 11242,62,000

18. Lakshadweep 3 4,29,000

19. Madhya Pradesh 13 12047,94,000

20. Maharashtra 15 1097,07,642

21. Manipur 3 112,20,000

22. Meghalaya 14 3986,04,197

23. Mizoram 7 1941,39,000

108 109

Sl. No. State No. of UC Pending Amount (Rs)

24. Nagaland 5 3195,52,000

25. Odisha 13 21806,00,000

26. Puducherry 3 26,38,000

27. Punjab 7 5504,85,000

28. Rajasthan 3 27,40,000

29. Sikkim 2 8,13,000

30. Tamil Nadu 21 52954,68,120

31. Tripura 6 2010,55,000

32. Uttar Pradesh 20 16665,55,378

33. Uttaranchal 19 7545,12,128

34. West Bengal 18 45959,68,286

TOTAL 343 418300,18,925 110

ANNEXURE-V

Maternal Mortality Ratio: India and State wise

(Source: RGI (SRS 1997-98, 1999-01, 2001-03, 2004-06, 2007-09, 2010-12 and 2011-13)

States 1997-98 1999-01 2001-03 2004-06 2007-09 2010-12 2011-13

India 398 327 301 254 212 178 167

Andhra Pradesh 197 220 195 154 134 110 92

Assam 568 398 490 480 390 328 300

Bihar/Jharkhand 531 400 371 312 261 219 208

Gujarat 46 202 172 160 148 122 112

Haryana 136 176 162 186 153 146 127

Karnataka 245 266 228 213 178 144 133

Kerala 150 149 110 95 81 66 61

Madhya Pradesh/ 441 407 379 335 269 230 221 Chhattisgarh

Maharashtra 166 169 149 130 104 87 68

Odisha 346 424 358 303 258 235 222

Punjab 280 177 178 192 172 155 141

Rajasthan 508 501 445 388 318 255 244

Tamil Nadu 131 167 134 111 97 90 79

Uttar Pradesh/ 606 539 517 440 359 292 285 Uttarakhand

West Bengal 303 218 194 141 145 117 113

IMR & U5MR

As per Sample Registration System (SRS) of Registrar General of India, Infant Mortality Rate of country is 37 (SRS, 2015) whereas Under Five Mortality Rate is 45 at National level as per SRS, 2014.

U5MR IMR

India 45 (SRS, 2014) 37 (SRS, 2015)

Global*(2015) 44 32

* Status of World's Children 2016 report by UNICEF

110 111

State-wise information on Infant Mortality Rate (as per SRS, 2015) and Under-5 Mortality Rate (as per SRS, 2014) are placed at annexure 1 and annexure 2 respectively.

The Government of India is implementing the following interventions under the National Health Mission (NHM) all across the country to reduce child mortality rate in country:

i. Promotion of Institutional deliveries through cash incentive under Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) which entitles all pregnant women delivering in public health institutions to absolutely free delivery including Caesarean section, post-natal care and treatment of sick infants till one year of age.

ii. Strengthening of delivery points for providing comprehensive and quality Reproductive, maternal, newborn, Child and Adolescent Health (RMNCH+A) Services, establishment of Maternal and Child Health (MCH) Wings at high caseload facilities, ensuring essential newborn care at all delivery points, establishment of Special Newborn Care Units (SNCU), Newborn Stabilization Units (NBSU) and Kangaroo Mother Care (KMC) units for care of sick and small babies. As on date, 495 MCH wings, 661 SNCUs, 2321 NBSUs and 18323 NBCCs are functional in the country.

iii. Early initiation and exclusive breastfeeding for first six months and appropriate Infant and Young Child Feeding (IYCF) practices are promoted in convergence with Ministry of Women and Child Development. Village Health and Nutrition Days (VHNDs) are observed for provision of maternal and child health services and creating awareness on maternal and child care including health and nutrition education. Ministry of Health and Family Welfare launched MAA-Mothers' Absolute Affection programme in August 2016 for improving breastfeeding practices (Initial Breastfeeding within one hour, Exclusive Breastfeeding up to six months and complementary Breastfeeding up to two years)through mass media and capacity building of health care providers in health facilities as well as in communities.

iv. Universal Immunization Programme (UIP) is being supported to provide vaccination to children against many life threatening diseases such as Diphtheria, Pertusis, Tetanus, Poliomyelitis, Tuberculosis, Measles, Hepatitis B, Meningitis and Pneumonia due to Haemophilus Influenza type B. The Government of India has also launched Mission Indradhanush in April 2015 to reach unreached children. In addition, vaccination against Japanese Encephalitis is carried out in endemic districts and vaccination against Rotavirus diarrhoea is provided in four states (Odisha, Himachal Pradesh, Haryana and Andhra Pradesh).

v. Name based tracking of mothers and children till two years of age is done to ensure complete antenatal, intranatal, postnatal care and complete immunization as per schedule.

vi. Rashtriya Bal Swasthya Karyakram (RBSK) for health screening, early detection of birth defects, diseases, deficiencies, development delays including disability and early intervention services has been operationalized to provide comprehensive care to all the children in the age group of 0-18 years in the community. During the Financial Year 2015-16, 18.7 Crore 112

children were screened for 4Ds under this programme. More than 87 lakh children were referred to secondary tertiary facilities by team, out of this around 45.6 lakhs children availed services in referred facilities

vii. Some other important interventions are Iron and Folic Acid (IFA) supplementation for the prevention of anaemia among the vulnerable age groups, annual deworming on National Deworming Day (NDD), home visits by ASHAs under Home Based Newborn Care to promote community care practices and early referral of sick newborns and promote use of ORS and Zinc for management of diarrhoea in children.

viii. Various trainings are being conducted to train doctors, nurses and ANMs for antenatal, intranatal and post-natal care, essential newborn care, early diagnosis and case management of common ailments of children.

ix. To sharpen the focus on the low performing districts, 184 High Priority Districts (HPDs) have been prioritized for Reproductive Maternal Newborn Child Health+ Adolescent (RMNCH+A) interventions for achieving improved maternal and child health outcomes.

State-wise Infant Mortality Rate (Source: Sample Registration System 2015 Bulletin)

Sl. No. State/ UT Infant Mortality Rate (per 1,000 Live Births)

12 3

India 37

1. Bihar 42 2. Chhattisgarh 41 3. Himachal Pradesh 28 4. Jammu and Kashmir 26 5. Jharkhand 32 6. Madhya Pradesh 50 7. Odisha 46 8. Rajasthan 43 9. Uttar Pradesh 46 10. Uttarakhand 34 11. Arunachal Pradesh 30 12. Assam 47 13. Manipur 9 14. Meghalaya 42 113

12 3 15. Mizoram 32 16. Nagaland 12 17. Sikkim 18 18. Tripura 20 19. Andhra Pradesh 37 20. Goa 9 21 Gujarat 33 22. Haryana 36 23. Karnataka 28 24. Kerala 12 25. Maharashtra 21 26. Punjab 23 27. Tamil Nadu 19 28. Telangana 34 29. West Bengal 26 30. Andaman and Nicobar Islands 20 31. Chandigarh 21 32. Dadra and Nagar Haveli 21 33. Daman and Diu 18 34. Delhi 18 35. Lakshadweep 20

36. Puducherry 11

State-wise Under-5 Mortality Rate (Source: Sample Registration System 2014 Report)

Sl. No. State/ UT Under-5 Mortality Rate (per 1,000 Live Births) 12 3 India 45 1. Andhra Pradesh 40 2. Assam 66 3. Bihar 53 4. Chhattisgarh 49 114

12 3 5. Delhi 21 6. Gujarat 41 7. Haryana 40 8. Himachal Pradesh 36 9. Jammu and Kashmir 35 10. Jharkhand 44 11. Karnataka 31 12. Kerala 13 13. Madhya Pradesh 65 14. Maharashtra 23 15. Odisha 60 16. Punjab 27 17. Rajasthan 51 18. Tamil Nadu 21 19. Telangana 37 20. Uttar Pradesh 57 21. Uttarakhand 36 22. West Bengal 30 Total Fertility Rate (TFR) TFR India 2.3 (SRS 2014) Global*( PRB 2015) 2.5

State-wise TFR based on the SRS 2014 is provided below

Interventions of Ministry of Health Family Welfare to reduce TFR are as follows:

New interventions under Family Planning

• Mission Parivar Vikas: The Government has launched Mission Parivar Vikas for substantially increasing the access to contraceptives and family planning services in the high fertility districts of seven high focus states with TFR of 3 and above. These 146 districts are from the seven high focus, high TFR states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand and Assam) that itself constitutes 44% of the country's population.

• New Contraceptive Choices: The current basket of choice has been expanded to include the new contraceptives viz. Injectable contraceptive, Centchroman and Progrsterone Only Pills (POP). 115

• Redesigned Contraceptive Packaging: The packaging for Condoms, OCPs and ECPs has now been improved and redesigned so as to influence the demand for these commodities

• New Family Planning Media Campaign: A360 degree media campaign has been launched to generate contraceptive demand.

• Enhanced Compensation Scheme for Sterilization- The sterilization compensation scheme has been enhanced in 11 high focus states (8 EAG, Assam, Gujarat, Haryana)

• A new IUCD (Cu 375) with 5 years effectivity has been introduced in the programme as an alternative to the exiting IUCD (Cu 380A with effectivity of 10 years).

• A new method of IUCD insertion i.e. PPIUCD has been introduced.

• Emphasis on Postpartum Family Planning (PPFP) services with PPIUCD and promotion of minilap as the main mode of providing sterilization in the form of post-partum sterilization to capitalize on the huge cases coming in for institutional delivery under JSY.

• Scheme for ensuring drop back services to sterilization clients

• Appointment of dedicated RMNCH+A counsellors at high case load facilities.

• Assured delivery of family planning services - In last four years states have shown their commitment to strengthen fixed day family planning services for both IUCD and sterilization.

• Scheme for Home delivery of contraceptives by ASHAs at doorstep of beneficiaries.

• Scheme for ASHAs to ensure spacing in births:

- Under the scheme, services of ASHAs are being utilized for counselling newly married couples to ensure delay of 2 years in birth after marriage and couples with 1 child to have spacing of 3 years after the birth of 1st child.

- The scheme is being implemented in 18 states of the country (8 EAG, 8 North East, Gujarat and Haryana). Additionally the spacing component has been approved in West Bengal, Karnataka, Andhra Pradesh, Telangana, Punjab, Maharashtra, Daman Diu and Dadra and Nagar Haveli

• Celebration of World Population Day & fortnight (July 11 - July 24):

- The World Population Day celebration is a step to boost Family Planning efforts all over the country.

- The event is observed over a month long period, split into an initial fortnight of mobilization/sensitization followed by a fortnight of assured family planning service delivery.

- June 27 to July 10: "Dampati Sampark Pakhwada" or "Mobilisation Fortnight"

- July 11 to July 24 "Jansankhya Sthirtha Pakhwada" or "Population Stabilisation Fortnight" 116

On-going Interventions under Family Planning Programme

• Ensuring quality of care in Family Planning services by establishing Quality Assurance Committees in all state and districts. • Increasing male participation and promotion of 'Non Scalpel Vasectomy''. • Operating the 'National Family Planning Indemnity Scheme' (NFPIS) under which clients are insured in the eventualities of deaths, complications and failures following sterilization and the providers/ accredited institutions are indemnified against litigations in those eventualities. • Compensation scheme for sterilization acceptors - under the scheme MoHFW provides compensation for loss of wages to the beneficiaries on account of undergoing sterilisation. • Accreditation of more private/ NGO facilities to increase the provider base for family planning services under PPP. • Improving contraceptives supply management up to peripheral facilities • A rational human resource development plan is in place for provision of IUCD, Minilap and NSV to empower the facilities (DH, CHC, PHC, SHC) with at least one provider each for each of the services and Sub Centres with ANMs trained in IUCD insertion • Emphasis on Minilap Tubectomy services because of its logistical simplicity with less failure rates. • Demand generation activities in the form of display of posters, billboards and other audio and video materials in the various facilities Strategies adopted by Jansankhya Sthirata Kosh/National Population Stabilization for Population Control Prerna Strategy:- JSK has launched this strategy for helping to push up the age of marriage of girls and delay in first child and spacing in second child birth in the interest of health of young mothers and infants. The couple who adopt this strategy awarded suitably. This helps to change the mindsets of the community. Santushti Strategy:- Under this strategy, Jansankhya Sthirata Kosh, invites private sector gynaecologists and vasectomy surgeons to conduct sterilization operations in Public Private Partnership mode. The private hospitals/nursing home who achieved target of 10 or more are suitably awarded as per strategy. National Helpline:- JSK is also running a call centers for providing free advice on reproductive health, family planning, maternal health and child health etc. Toll free no. is 1800116555

State wise Total Fertility Rate (Source: SRS 2014) 1 2 SRS 2014 India 2.3 Andaman 1.6* Andhra Pradesh 1.8 117

1 2 SRS 2014 Arunachal Pradesh 2.3* Assam 2.3 Bihar 3.2 Chandigarh 1.7* Chhattisgarh 2.6 Dadra and Nagar Haveli 2.9* Daman & Diu 2.0* Delhi 1.7 Goa 1.4* Gujarat 2.3 Haryana 2.3 Himachal Pradesh 1.7 Jammu and Kashmir 1.9 Jharkhand 2.8 Karnataka 1.8 Kerala 1.9 Lakshadweep 1.6* Madhya Pradesh 2.8 Maharashtra 1.8 Manipur 1.5* Meghalaya 2.9* Mizoram 1.7* Nagaland 1.8* Odisha 2.1 Puducherry 1.8* Punjab 1.7 Rajasthan 2.8 Sikkim 1.7* Tamil Nadu 1.7 Tripura 1.4* Uttar Pradesh 3.2 Uttarakhand 2.1 West Bengal 1.6 118

ANNEXURE-VI

Total Specialists at CHCs

Total Specialists [Surgeons, OB&GY, Physicians & Paediatricians]

(As on 31st March, 2016)

Sl. No. State/UT Required1 Sanctioned In Position Vacant Shortfall [R] [SI [PI [S-P] [R-P] 12 3 4 5 67 1. Andhra Pradesh 772 384 159 225 613 2. Arunachal Pradesh 252 NA 4 NA 248 3. Assam 604 NA 131 NA 473 4. Bihar 592 NA 40 NA 552 5. Chhattisgarh 620 620 61 559 559 6. Goa 16 5 5 0 11 7. Gujarat 1288 186 148 38 1140 8. Haryana 440 153 30 123 410 9. Himachal Pradesh 316 NA 7 NA 309 10. Jammu and Kashmir 336 344 190 154 146 11. Jharkhand 752 131 122 9 630 12. Karnataka 824 824 498 326 326 13. Kerala 900 30 40 * 860 14. Madhya Pradesh 1336 1336 289 1047 1047 15. Maharashtra 1440 823 505 318 935 16. Manipur 68 4 3 1 65 17. Meghalaya## 108 3 12 * 96 18. Mizoram### 36 0 0 0 36 19. Nagaland 84 NA 8 NA 76 20. Odisha 1508 908 354 554 1154 21. Punjab 600 578 196 382 404 22. Rajasthan 2284 1654 497 1157 1787 23. Sikkim 8 NA 0 NA 8 24. Tamil Nadu 1540 NA 76 NA 1464 25. Telangana 456 284 147 137 309

118 119

12 3 4 5 67 26. Tripura 80 0 1 * 79 27. Uttarakhand 236 200 41 159 195 28. Uttar Pradesh 3092 2099 484 1615 2608 29. West Bengal 1396 669 125 544 1271 30. Andaman and Nicobar 16 9 0 9 16 Islands 31. Chandigarh** 8 11 14 * * 32. Dadra and Nagar Haveli 0 0 0 0 0 33. Daman and Diu 8 2 0 2 8 34. Delhi 0 0 0 0 0 35. Lakshadweep 12 0 0 0 12 36. Puducherry 12 5 5 0 7

All India2/Total 22040 11262 4192 7359 17854

Notes: **sanctioned data for 2013-14 used ##Sanctioned data for 2015 used ### Data for 2015 repeated NA: Not Available. 1 Four per Community Health Centre All India figures for Vacancy and Shortfall are the totals of State-wise Vacancy and Shortfall ignoring surplus in some States / UTs *: Surplus. 2 For calculating the overall percentages of vacancy and shortfall, the States/UTs for which manpower position is not available, are excluded

Surgeons at CHCs

(As on 31st March, 2016)

Sl. No. State/UT Required1 Sanctioned In Position Vacant Shortfall [R] [SI [P] [S-P] [R-P] 1 2 3 4 5 6 7 1. Andhra Pradesh 193 96 19 77 174 2. Arunachal Pradesh 63 NA 0 NA 63 3. Assam 151 NA 14 NA 137 4. Bihar** 148 NA 13 NA 135 5. Chhattisgarh 155 155 19 136 136 6. Goa 4 2 1 1 3 7. Gujarat 322 62 41 21 281 8. Haryana 110 40 6 34 104 120

1 2 3 4 5 6 7 9. Himachal Pradesh 79 NA 1 NA 78 10. Jammu and Kashmir 84 89 48 41 36 11. Jharkhand 188 31 36 * 152 12. Karnataka 206 206 128 78 78 13. Kerala 225 NA 1 NA 224 14. Madhya Pradesh 334 334 83 251 251 15. Maharashtra 360 202 87 115 273 16. Manipur 17 0 0 0 17 17. Meghalaya# 27 0 0 0 27 18. Mizoram## 9 0 0 0 9 19. Nagaland 21 NA 2 NA 19 20. Odisha 377 133 75 58 302 21. Punjab 150 147 48 99 102 22. Rajasthan 571 505 127 378 444 23. Sikkim 2 NA 0 NA 2 24. Tamil Nadu# 385 0 2 * 383 25. Telangana 114 71 14 57 100 26. Tripura 20 0 0 0 20 27. Uttarakhand 59 50 6 44 53 28. Uttar Pradesh 773 529 112 417 661 29. West Bengal 349 0 0 0 349 30. Andaman and Nicobar 4 3 0 3 4 Islands 31. Chandigarh# 2 2 1 1 1 32. Dadra and Nagar Haveli 0 0 0 0 0 33. Daman and Diu 2 0 0 0 2 34. Delhi 0 0 0 0 0 35. Lakshadweep 3 0 0 0 3 36. Puducherry 3 0 0 0 3 All India/ Total 5510 2657 884 1811 4626

Notes: # Sanction data for 2015 used ## Data for 2015 used ** Sanctioned data for 2011 used NA: Not Available. All India figures for Vacancy and Shortfall are the totals of State-wise Vacancy and Shortfall ignoring surplus in some States / UTs *: Surplus. 1 One per Community Health Centre 121

Doctors + At Primary Health Centres

(As on 31st March, 2016)

Sl. No. State/UT Required1 Sanctioned In Position Vacant Shortfall

[R] [S] [P] [S-P] [R-P]

1 2 3 4 5 6 7

1. Andhra Pradesh 1075 2270 1412 858 * 2. Arunachal Pradesh 143 NA 122 NA 21 3. Assam 1014 NA 932 NA 82 4. Bihar** 1802 2078 1786 292 16 5. Chhattisgarh 790 777 344 433 446 6. Goa 22 48 56 * * 7. Gujarat 1314 1697 1105 592 209 8. Haryana 474 635 489 146 * 9. Himachal Pradesh 518 636 424 212 94 10. Jammu and Kashmir 637 1347 761 586 * 11. Jharkhand 327 327 271 56 56 12. Karnataka 2353 2353 2133 220 220 13. Kerala 824 1120 1169 * * 14. Madhya Pradesh 1171 1771 946 825 225 15. Maharashtra 1811 3009 2927 82 * 16. Manipur 85 238 194 44 * 17. Meghalaya## 109 128 105 23 4 18. Mizoram^ 57 152 71 81 * 19. Nagaland 126 108 120 * 6 20. Odisha 1305 1312 959 353 346 21. Punjab 427 518 494 24 * 22. Rajasthan 2080 2807 2422 385 * 23. Sikkim 24 NA 26 NA * 24. Tamil Nadu 1368 2927 2751 176 * 25. Telangana 668 1318 1024 294 * 26. Tripura ## 94 158 147 11 * 27. Uttarakhand 257 386 215 171 42 122

1 2 3 4 5 6 7 28. Uttar Pradesh 3497 4509 2209 2300 1288 29. West Bengal 909 1324 721 603 188 30. Andaman and Nicobar 22 42 36 6 * Islands 31. Chandigarh## 3 0 2 * 1 32. Dadra and Nagar Haveli 11 6 11 * 0 33. Daman and Diu 4 3 7 * * 34. Delhi 5 21 20 1 * 35. Lakshadweep 4 5 7 * * 36. Puducherry 24 38 46 * * All India2/Total 25354 34068 26464 8774 3244

Notes: ## Sanctioned data for 2015 used ** Sanctioned data for 2011 used ^ Sanctioned data for 2013-14 used NA: Not Available. +: Allopathic Doctors All India figures for Vacancy and Shortfall are the totals of State-wise Vacancy and Shortfall ignoring surplus in some States / UTs *: Surplus. 1 One per Primary Health Centre 2 For calculating the overall percentages of vacancy, the States/UTs for which manpower position is not available, are excluded 123 -VII 181 crore. NNEXURE ` A Remarks roachment on the land. A joint survey A roachment on the land. Allocation is Rs 10 Crore has been made for Further action in the current financial year. inviting bids and their evaluation is in progress. Timeline for the completion of project is 36 months from the date of approval. Standing Finance Committee approved the project with estimate cost of Action is in progress for vacation of August, 2016 was conducted on 9th and 10th 14 OTs + OTs 14 The proposal alongwith Detailed beds ength Married) (single + Status/Report 725 Cr. To 959.78Cr To Cr. 725 (116.66 cr is for wages& O&M for one year. It is not include in the 959.78 cr capital) (area Acre revised from 3.99 Acres) to 2.20 Cath 3 Lab Project Report (DPR) is under examination in the Ministry. Date budget Total Bed ICU OT oning ement functi Date of Not YetNot - Budget revised from 400 63 Not Yet - Not yet - 181 Cr (178+3) 824 finalised finalised finalised enc Commenc- of str HSCC HSCC (I) LTD Agency nominated Agency Modern Maternal 123456789 Super Speciality Name of Building Block (Area-2.20LTD (I) acres) Doctors Hostel care centre (Area2.01 acres) not

123 124 by Dr. RML Hospital and Delhi Urban Shelter RML by Dr. Improvement Board (DUSIB) authority for the provisional A identification of eligible dwellers. demand has been sent to the Executive Engineer (Civil), H, Division 4-6, Pandit Pant Marg, New Delhi vide letter No. D/265/DD (Rehab)/1/2016 dated 02.12.2016 in which they have demanded Rsl.83 crores to vacate the Jhuggies out of which 50% the amount to the tune of Rs91.5 lakh has been released to DUSIB to initiate the process of vacation. 5th Jan., 2017. CPWD -rooms 42 Completed and also made operational w.e.f. 1 2 3 45 (0.981 Acres) 6 7 8 9 Dharmshala 125

ANNEXURE-VIII

All India Institute of Medical Sciences

Engineering Services Department

Revised Budget Estimate for FY 2016-17 & BE 2017-18

(Projects under Plan Head)

Fig. in crore

Sl. No. Name of Project Construction work Physical Progress Remarks

Revised Budget Budget Estimate 2016-17 2017-18

12 345 6

A. PLAN 2016-17 2017-18

1. OPD Block of Masjid Moth 150.00 82.80 Physical Progress Expenditure is likely 46% completed @ 15.00 Crore for five months

2. Vertical Expansion of 56.00 15.50 Physical Progress ` 55.80 is considered Trauma Centre 89% completed for Equipment cost.

3. Paid Ward 0.00 70.00 Contract terminated Expenditure is likely Work is likely to be to be done in Dec- awarded to LI bidder March 2017

4. 33 KVA Substation at 5.00 1.00 Physical Progress 0% Expenditure may Masjid Moth completed incurred construction of STP/Road work in Masjid Moth

5. Construction of Housing and 0.00 20.00 Physical Progress Substantially Hostel at Ballabgarh Fatehpur 100% Completed & completed Billach Recurring Cost

6. Miscellaneous works (A/c, etc.) 1.00 2.00 For procurement A/C

7. Construction of Burn Unit 5.00 98.00 Work awarded in Aug. Expenditure is likely 2016 to LI bidder to be done in Dec- March 2017

8. Trauma Expansion 0.00 210.00 Physical Progress 0% Expenditure towards (Additional Land) completed additional land of 2 Acres to L&DO and other works.

125 126

12 345 6 9. Construction of Service Block 0.00 20.00 Physical Progress 0% completed 10. Construction of Emergency 0.00 20.00 Physical Progress Block cum Diagnostic Block 0% completed 11. Construction of Hostel No.4 7.00 25.00 Work awarded in Aug. Expenditure is likely at Masjid Moth 2016 to LI bidder to be done in Dec- March 2017 @ ` 1.50 Crore 12. Construction of Cafeteria 9.00 0.50 Physical Progress Substantially 90% completed completed 13. Construction of Guest House 0.00 1.00 Physical Progress Under Planning 0% completed 14. Construction of Nallah 0.00 0.00 Physical Progress Completed (Balance work) 100% completed 15. Construction of Motorable 5.10 2.00 Physical Progress Balance payment to Tunnel (DMRC) 100% completed be made to DMRC for additional work taken up by them 16. Facade work for Gate No.l 1.50 0.50 Physical Progress Likely to completed 15% completed by the end of March 2017 17. Master Plan/Site development 5.00 7.50 Physical Progress Under Planning etc of Ansari Nagar East & 0% completed Masjid Moth

TOTAL (A) 244.60 575.80 B. 1. National Cancer Institute of 256.00 816.00 Physical Progress Expenditure is i/o other packages 20% structure likely @ 35.00 competed & Work Crores & other awarded for associated work Residential package bridge construction work in progress 5% structure completed 2. Cardio Vascular Institute 0.00 260.00 Consultant has been appointed Total (B) 256.00 1076.00 Total (A) + (B) 500.60 1651.80 Machinery & Equipment 250.00 268.20

TOTAL 750.60 1920.00 127

ANNEXURE-IX

Sl. No. Name of Project Expenditure Updated status with corrective measure Project Outlay/ Upto Dec. taken for implementation Estimated 2016 of project. cost (In Cr.) (` in Cr.)

12 34 5

1. Setting up of Satellite 449.00 48.12 The work of Phase-IA i.e. Temporary OPD Centre of PGIMER at & Guest House have been completed. OPD Sangrur (Punjab) services have been made operational on trial basis and 300-350 (approx.) numbers of patients are visiting daily.The work of Phase I- B i.e. Hospital, Administrative Block, OPD and Residential Complex has been awarded to M/s NKG Infrastructure Limited on 08.07.2016 amounting to ` 152.95 Crores. The agency has started the work and foundation work is under progress. 2. Expansion of Nehru 182.05 47.16 An agenda for the work of Additional Services Hospital (250 bedded) under Phase-II was placed in the 120th SFC at PGIMER, Chandigarh meeting held on 24.01.2017 and the Committee approved the proposal amounting to ` 67.75 crores under General Plan Grant. The same is being conveyed to CPWD.

3. Replacement of Air 33.00 0.35 The agenda was placed in the 120th SFC Cooling System with meeting held on 24.01.2017 for award of Air conditioning work to the L-1 agency M/s ETA Engineering (HVAC) System in Pvt. Ltd. and the Committee approved the New OPD Block proposal. The work is being awarded.

4. Up-gradation and 3.93 Nil After approval of the DNIT and Detailed Special Repair of Estimate from the competent authority, the Residential houses % age rate tenders have been invited. The of PGIMER, Sector eligibility bid has been opened which is 12, Chandigarh under scrutiny. 5. Revised Estimate for 211.34 Nil As per decision of the SFC, the proposal is Construction of being submitted for the approval of the SFC Residential Complex & of the Ministry. Hostels at PGIMER Campus, Sector-12, Chandigarh under OBC Implementation Scheme

127 128

12 34 5

6. Re-construction/ raising 3.40 Nil The agenda was placed in the 120th SFC of Boundary Wall, meeting held on 24.01.2017 for award of Replacement of Entry work to the L-1 agency M/s Rattan Gate & Reconstruction Constructions. The Committee approved the of Driveway etc. in proposal. The work is being awarded. Type-VI & VII houses, Sector-24, Chandigarh.

7. Expansion of existing 63.08 Nil After approval of the Request For Proposal Multi-level Parking, (RFP) for appointment of consultant by the Construction of new competent authority, the RFP have been Multilevel parking and floated. The technical bid has been opened connecting passage and is being evaluated. from Multi Level Parking to New OPD, PGIMER, Sector-12 Chandigarh.

8. Up-gradation and Special 17.85 Nil After approval of the DNIT and Detailed Repair of Residential Estimate of Module-I, II & III from the houses of PGIMER, competent authority, the %age rate e-tenders Sector 24, Chandigarh have been floated. The status is as under: (Module-I, II & III) Module-I: The agenda was placed in the 120th SFC meeting held on 24.01.2017 for award of work to the L-1 agency M/s Sohan LAI Mehta. The Committee approved the proposal. The work is being awarded. Module-II: After approval of the eligibility bid from the competent authority, the price bids have been opened, the agenda shall be placed before the SFC for award of work. Module-Ill: The tenders are being re-invited.

9. Upgradation of HVAC 6.53 1.34 The work was awarded to lowest bidder M/s System of Operation Blue star Ltd. vide letter No. 399 dated Theater Complex, 01.06.2016 amounting to `4,37,48,899.00.As Nehru Hospital, per present status, the low side work in OT PGIMER, Chandigarh. Complex at Level-4 & 5 has been completed and the complex has been handed over to the user department and the system is working satisfactorily whereas the high side work is under execution at Main AC plant. The work is likely to be completed by end of March, 2017.