NATIONAL HEALTH MISSION: ACHIEVEMENTS & CHALLENGES

1. NATIONAL HEALTH MISSION:
ACHIEVEMENTS AND CHALLENGES
Dr. Pragyan Paramita Parija
VMMC & Safdarjung Hospital
1

2. Contents
Introduction of NHM
Achievements and challenges of NHM in following
headings;
 RMNCH+A
 Communicable Disease
Control Programmes
 Non- communicable
Disease Control
Programmes
 Service Delivery :
 Human Resources for
Health and Training
 Community Processes
and Convergence
 Information and
Knowledge
 Healthcare Financing
 Quality Assurance
 National Urban Health
Mission
 Governance and
Management
2

3. VISION:
 Attainment of universal access to
equitable
affordable
quality health care services
accountable responsive to people’s needs
with effective inter-sectoral convergent action
To address wider social determinants of health.
3

4. Goals:
Goals (2012-17) Target Achieved
1.MMR 100/1Lakh LB 167/1 Lakh LB( SRS-2016)
2.IMR 25/1000 LB 34/1000 LB(SRS Sept 2017)
3.TFR 2.1 2.2( NFHS-2015-16)
4. Prevent and reduction of anemia in women aged 15-49yrs(53%-2016)
5. Prevent and reduce mortality and morbidity from
Communicable, non-communicable, injuries and emerging diseases
6. Reduce household OOPE on total health care expenditure (from 72% to 60%)
7. TB: Reduce annual incidence and mortality by half ( AI- 2.17, MOR- 32 [2015])
8. Leprosy: Reduce prevalence to <1/10,000 ( PR- 0.66[2017] in 551 districts)
Incidence to zero in all districts
9. Malaria: Reduce Annual incidence to <1/1,000 [1.10 – 2011 to 0.84 – 2016]
10.Filariasis: Mf Prevalence <1% in all districts [222/256 districts- 2016]
11. Kala-azar: Elimination by 2015; <1/10,000 in all blocks
[636 endemic blocks– 562(88%) achieved elimination]
4

5. ORGANOGRAM
5

6. 1. TRENDS OF MMR IN INDIA: SRS
398
327
301
254
212
178 167
0
50
100
150
200
250
300
350
400
450
MMR
6

7. 2. TRENDS OF IMR IN INDIA: SRS
58 58 57
55
53
50
47
44
42
40 39
37
34
0
10
20
30
40
50
60
70
IMR
7

8. 3. TFR TRENDS IN INDIA:
2.8
2.7
2.6 2.6
2.5
2.4 2.4
2.3 2.3
2.2
0
0.5
1
1.5
2
2.5
3
TFR
8

9. TIME LINE:
9
1992
CSSM
1997
RCH I
2005
RCH II
2013
RMNCH+A
• Centralised
• Target
oriented
• FP
• Decentralised
• Target free
• Life cycle
approach
• Full range
MCH+RTI/STI
• Outreach
• State based
planning
• Pro-poor
focus
• Skilled
attendance
• Focused on
EAG states
• Focus on
adolescent
• HPD
• RCH Portal
to track

10. 5×5 MATRIX RMNCH+A
Reproductive Maternal Neonatal Child Adolescent
1. PPIUCD at
high case
load centres
2. Interval IUCD
at subcentre
3. Door step
delivery of
contraceptive
by ASHA
4. Ensure access
to PTKs &
Safe abortion
strengthening
5. Maintain
sterilisation
quality
1. MCTS-
early & full
ANC regd
2. Detect
High risk
pregnancy
& line list
severe
anaemic &
trt
3. Equip
delivery
points with
trained HR
4. Review
MMR, IMR
& CMR
5. High Home
deliveries-
Distribute
Misoprostol
in 8th
Month
1. Early
initiation &
EBF
2. HBNC
3. Essential
Newborn
care
4. SNCU
5. Community
level
Gentamycin
by ANM
1. Complementa
ry feeding,
IFA &
nutrition
2. Diarrhoea –
ORS & Zinc
3. Pneumonia
mgt
4. Full
immunisation
coverage
5. RBSK
1. Address
Teenage
pregnancy
& increase
Contracept
ive
prevalence
2. Peer
education
3. ARSH
clinics
4. NIPI
including
WIFS
5. MHS
10 Health system strengthening Cross cutting intervention

11. 1. RMNCH+A: ACHIEVEMENTS
1. Maternal:
A) PMSMA : Most of the states started this scheme.
Private practitioners are also involved actively in some of
states. (5,50,000 women found out to be high risk
pregnancy) (more than 10 million check ups being
done for High Risk Pregnancy)
B) MDR: Good mechanism of maternal death review
was observed in most of the states. Some states are in
process of establishing Maternal Near Miss Review.
11

12. MCH Indicators NFHS-4
2015-16(%)
1st trimester registration 59
≥4 ANC visits 51.2
Institutional Delivery 79
Skilled birth attendance 81
100 IFA 77.7(30.3% only
took)
Tetanus 83%
PNC within 2days 65.1
C- section 17
12

13. MCH Indicators NFHS-4
2015-16(%)
Breast feeding <1hr 42
Exclusive Breast feeding 55
LBW Child 18.2
Full immunisation 62
Underweight <5yrs 35.7
13

14. 2. CHILD:
A) Diarrhea: Adequate supplies of zinc & ORS were
available in most of the centres.
Any ORT-60%, ORS- 51%(NFHS-4)
3. IMMUNISATION:
Routine immunisation coverage is increasing
gradually.(62%- NFHS4)
Through IT enabled platforms; eVIN & ANMOL,
immunisation system is strengthened.
14

15. 4.PTKs reported to be available at all sub centres.
5.IUCD insertion and withdrawl done by trained personell
(available at all health facilities)
6. Good planning and organisation of VHNDs.
15

16. 1. RMNCH+A : CHALLENGES
 Challenges in RMNCH+A planning and implementation
are due to
A) inadequate orientation of district hospitals
B) inadequate functionality of FRUs
C) lack of essential drugs
D) inadequate monitoring of RMNCH+A services
16

17. A. MATERNAL:
a) ANC:
 Subcentres are deficient in
terms of range of services
available.
 Challenges in identifying and
line listing of High risk
pregnancies and anaemia.
 Lack of orientation on newer
guidelines
 Incomplete record on MCP
cards
17

18. b) INTRANATAL & POSTNATAL:
c)JSY: Delay in payment of JSY incentives
d) JSSK: Low awareness in tribal population
Lack of assured drop back services
 Partographs are not used at district level or
below.
 Institutional deliveries were being conducted
only 10-30% below district level, thus
overloading higher centres.
 Distribution of Misoprostol yet to be
instituitionalised in high home delivery areas
18

19.  B. CHILD:
a) KMC wards are lacking
below district level
b) Shortage of SNCUs and
NBSUs
c) MAA initiative;
unreached to people
d) Shortage of iron-folic
acid syrup/tab
(deterent to NIPI)
19

20. e) RBSK:
f) CDR: Yet to be implemented( MP started in SNCU)
 Non adherence to guidelines while
screening
 lack of microplanning
 poor referal and follow up
mechanism
 limited involvement of schools
 limited involvement of DEIC at
various district hospitals
20

21. C. FAMILY PLANNING:
a) Shortage relate to spacing
methods( OCPs & Condoms)
b) NSV:
c) Counselling: protocols are weak
d) Comprehensive Abortion Care: Available above DH
 Awareness
level low
 Done at very
few DH
 shortage of
human
resources for
conducting
NSV
21
indicators NFHS-4
(%)
Contraceptive
prevalence rate
54
Unmet need for FP 13
Female sterilisation 36
Condom 9
OCP 3.6

22. 22
TFR-2.2
NFHS4

23. D. IMMUNISATION:
AEFI- Challenges regarding
identification, management & reporting
10612 deaths associated with AEFI since 2008
AEFI Kits are not available
E. ADOLESCENT:
 Under utilisation of AFHC
 Lack of visibility of IEC at health
centres
 Peer education component not yet
addressed
 Stock out of sanitary napkins
 Sensitisation under MHS was low
23
% of using
hygienic
method for
Menstrual
protection-
57.6
(sanitary
napkin-
41.8%)

24. 2. COMMUNICABLE DISEASE CONTROL
PROGRAMME: ACHIEVEMENTS
A. IDSP: Reporting was done from all states (71-90%)
Regular analysis of data
B. NVBDCP:
a) MALARIA: Consistent decline in malaria incidence
(0.84 IN 2016)
RDT kits were available at all level
40 millioons LLINs are distributed and
used by the community
Active case surviellance
b) KALA AZAR: Declining trend was observed with
decreased mortality
29000 cases- 5743 cases
105 deaths- 0 deaths
(88% achieved elimination)
Incentives given to patients and ASHAs24
2010 2017

25. C. RNTCP: Use of CBNAAT helps in rifampicin resitance
TB-HIV colocation at most of the public
institutes
ATT drugs available at all DOTS Centre
Notification system through NIKSHAY
25

26. c) FILARIASIS: Declining trends was seen.
(222/256- <1%Mf)
TAS was carried out.
Special night clinics are functional
in high endemic areas.
D. NLEP: Decreasing trend of prevalence
(0.66%)
Adequate Drugs available
Intensive case detection
RCS scaled up
SPARSH awareness campaign
begun
26

27. 2. COMMUNICABLE DISEASE CONTROL
PROGRAMME: CHALLENGES
A. IDSP: Inadequate human resources
Reporting from private health facilities is a
concern.
B. NVBDCP:
a)MALARIA: Genetic changes in pathogens
Drug & Insecticide Resistance
Poor Urban Planning
Low utilisation of Fund
27

28. b)JE: Increasing Incidence of JE cases (231 districts)
Coverage of vaccination is low
(42.8% 2nd Dose of JE vaccine)
Mortality was reported. (11.6% CFR from JE)
c) CHICKUNGUNYA:
Increasing trend of prevalence
48176(2010)- 62268(2017)
Diagnostic services are not available at all
facilities
28

29. d) DENGUE:
Increasing case load[28292(2010)- 157220(2017)]
Mortality due to dengue is a concern
[110(2010)- 250(2017)]
C. RNTCP: Increasing burden of MDR & XDR
Shortage of Human Resources
Delay in payment of salary of staff
Notification from private providers is a concern
Isoniazid prophylaxis for contacts is still a concern29

30. D. NLEP: Increasing trend of child notification rate
School programme is yet to integrated.
Shortage of Physiotherapists
30

31. 3. NCD CONTROL
PROGRAMME:ACHIEVEMENTS
A. NPCDCS: Oppurtunistic screening for >30years for DM, HTN
were available at all facilities.
Tele stroke project in HP
Guidelines on management – simple
Single programme for combating multiple diseases
31

32. B. NPCB & VI:
Screening activities were carried out at all
public health facilities.
Integration of School health programme
Active involvement of NGOs in screening and
cataract surgeries
Infective Trachoma elimination(<10yrs- 0.7%)
Tele-opthalmology services are available in Tripura
32

33. C. NTCP: Graphic warnings have been notified.
Rules for depiction of Tobacco products in films and TV.
National consultation on economics on Tobacco
D.NMHP: Integration with general health services
Man power Development Scheme
Wider availability of psychotropic medications
33

34. E. NPCHE: Weekly Geriatric clinic at PHC proposed.
Indoor services are available at 6/8 regional
centres
F. NIDDCP: Universalisation of Iodinisation of salt
(93.1% households using iodised salt)
Monitoring of Salt quality at consumption level
NRL & Regional IDD monitoring labs
34

35. 3.NCD CONTROL
PROGRAMME:CHALLENGES
1. NPCDCS: Despite epidemiologic transition, NCD is not a major
priority
Lack of NCD clinics
Less Specialists are available
Poor IEC
Population based screening yet to be implemented.
Respiratory component weakly addressed.
35

36. 2. NPCB & VI: Lack of involvement of private opthalmic
surgeons in programme
Vit A def prevalence is a serious concern
Lack of orientation to community opthalmic
practices
36

37. 3. NTCP: COTPA Not yet implemented properly
Lack of integration between NTCP & NPCDCS
4. NMHP: More emphasis was given on curative rather than
preventive
Lack of counselling services
Referal system not integrated properly
involvement of private sector is poor
Complex Training manual
37

38. E. NPCHE: Health education related to healthy ageing not
conveyed properly
Suitable calipers & supportive devices are not available
Lack of Counselling services
Lack of Physiotherapy services
F. NIDDCP: Low funding of the programme
Despite of universalisation of iodised salt, prevalence of
goitre has not gone down(263 districts are endemic)
38

39. 4. SERVICE DELIVERY:
ACHIEVEMENTS
1. Increase access to drugs:
 All states have free drug policy to decrease
OOPE ( 72% to 60%)(2010-11 to 2015-16)
 NABL accredited lab ensure quality of drugs
 Increase access to drugs at affordable prices at
Jan Asaudhi, AMRIT, Sanjivani (Bihar)
39

40. 2. Free diagnostics services are
available in all states:
40

41. 3. Pradhan Mantri National Dialysis
Programme:
• BPL populations have been exempted from user
charges for availing dialysis services across the
states.
4. Strengthening of district hospitals as
training centres
5. Better functioning of blood services in
Tamil Nadu, Andhra Pradesh where blood
is provided free of cost to pregnant
women and for others 500rs – 750rs
charged
• Blood on call in Nasik Public hospitals
• E blood bank also started in Odisha
41

42. 6. Increase in service utilization: (2016-17)(baseline 2009-10)
 OPD attendance increase 68%
 IPD attendance increase 98%
 General surgery increase 109%
 Cesaeran Section increase 41%
Debatable
42

43. 6. Biomedical Equipment Maintenance Programme(BMMP) has
improved functionality of equipments and helped in assured
diagnostics services.
e.g. e-Upakaran in Rajasthan, Gemportal in Delhi
7. Strategized IEC activities as per local needs and local languages in
most of the states.
8. E initiatives: DAWAapp
Matritva app
Chetna app(MP)
ANMOL (AP)
Esmart(AP)
43

44. 9. Initiatives involving Community Health Volunteers:
Participatory Learning Action(PLA) at block/District level
Social Security Scheme For Sahiyas and Sahiya help Desks
(Jharkhand)
10. Initiative for AYUSH system; AYUSH Gardens in Maharastra
where Health related herbs and plants are planted and used.
44

45. 11. Financial protective Initiative:
 TN Chief Minister’s Comprehensive Health Insurance Scheme
 Dr.Muthuswamy Reddy Maternity Benefit scheme
 Arunachal Pradesh Chief Minister’s Universal Health Insurance
Scheme
 Rajiv Arogyashree in AP
 Migrant worker’s screening camps at Border- Kerala
 Private Pay clinics At Itanagar
45

46. 12. Call centres linked Ambulance services are available in many
states
108- ERTS- Critical care, Trauma & Accident victims etc
( 8061 vans)( capital expenditure- NHM, Operational- 60% in 1st
year, 40% in 2nd year, 20% in subsequent years by NHM)
102- NAS- Pregnant women & Child
(8252 vans)( Fully supported by NHM)
Empanelled vehicles; Janani Express- MP, Odisha
Vahan- Jharkhand, Nischay Yan Prakalp- WB,
Khusiyo Ki Sawari- UK
46

47. 4. SERVICE DELIVERY: CHALLENGES
1. Health Infrastructure: Inspite of surplus Infrastructure in
many states, the country still has a shortage of Health
Centres.(SC-6%, PHC- 9%, CHC-65%)
2. Sub health centre- New norm- 30 mins by walk from a
habitation
Sub centre- 20% short fall
PHC- 22% short fall
CHC – 30% Short fall
47

48. INFRASTRUCTURE: RHS-2017
48

49. 49

50. 50

51. 4. Drugs and Vaccines distribution system(DVDMS) is a web based supply
chain management upto PHC level yet to be operationalized in many states
5. Under utilisation of services in North eastern states( Arunachal Pradesh &
Nagaland)
6. Availability of blood still become a challenge;
limited functioning of Blood Storage units
lack of trained Human resources
non linkage with a mother blood bank
51

52. 7. Inspite of improvement of AYUSH provision, protocols for
Internal Referral between AYUSH and other departments are non-
existent
8. Mobile medical unit(MMU) are underutilised for outreach
activities.(MMU- 2062- 424 districts)
9. Out of pocket expenditure on blood services, transportation
and drugs (The cost incurred towards blood services ranged from
Rs 300 to Rs 3000).
Catastrophic Health expenditure->2%52

53. 5. HUMAN RESOURCES:
ACHIEVEMENTS
A. AVAILABILTIY OF HR:
a)To fill service gaps
b) Prefrence to in service NHM staff in recuirment for regular positions
c) Relaxation in higher education to in service MOs
Contracting specialists on call
Appointing AYUSH MOs
Mobility support, fixed posting of specialist
53

54. B. TRAINING & CAPACITY BUILDNIG:
Conducting
post
training
evaluation
of skills of
trained
staff
CPS in MH,
fellowships,
Diploma,
certificates
in clinical
specilaities
Integrated
multiskilling
of LTs
54

55. C. WORK FORCE MANAGEMENT:
HRMIS has been established .
Public health cadre have been established.(MH & TN)
Programme officers at all level
Skill Based Competency tests for identifying
Skillgap
Annual performance appraisal has been linked with
renewal of contracts of staff.
55

56. 5. HUMAN RESOURCES: CHALLENGES
A. AVAILABIITY OF HR:
Significant vacancies of service providers, shortage of specific HR
Sanctioned posts are less than required numbers
Less RMNCHA counsellors were available
B. TRAINING & CAPACITY BUILDNIG:
Training need assessment is lacking
Shortage of trained HR & Training Infrastructure
Low utilisation of specialised skills was reportedly due to
nonrelevant postings.
MPW trainings shut down.
56

57. SHORTFALL OF HR: RHS 2017
57

58. 58

59. SHORTFALL OF SPECIALISTS AT CHC:
59

60. 60
87%
SF
SURG
EONS
81%
SF
PEDS
74%
SF
OG

61. C. WORKFORCE MANAGEMENT:
Pay disparity for data entry operator & LTs under all
programme
Pay disparity among regular & contractual staffs as a
cause of Resentment
Lack of Robust HR policies
Delayed recuirment process
61

62. 6. COMMUNITY PROCESS &
CONVERGENCE: ACHIEVEMENTS
SELECTION
• ASHAs are in place except Goa, Rural areas of Puducherry,
non tribal areas of TN.
• 91% ASHAs in Rural, 60% in Urban
SUPPORT
• ASHA Selection exceeds 90% of the target in most of the
states
• Kudumbashree Volunteers help to existing ASHAs in Kerala
INCENTIVE
• Incentives are now streamlined due to PFMS & RTGS(J&K)
• Mobile talk time/phone are distributed in some states
• ASHA Awards in MP& UP
62

63. • ASHA uniforms in MP & J&K
• Insurance cover(social security scheme) in MP
& Bihar
• Preferential Selection of ASHA in ANM/GNM
training
• Promotion as ASHA Facilitator/ Block mobiliser
• Increasing ownership by ASHAs
• Improving in RMNCHA indicators
63

64. 6. COMMUNITY PROCESS &
CONVERGENCE: CHALLENGES
Lack of
drug &
equipm
ents
Weak
triple
AAA
converge
nce
Weak
skills
Slow
pace of
training
Lack of
capacity
building
of VHSNC
MAS – Underway
RKS- Functionality was
different in each state
VHSNC-
Delay in
fund
release,
utilisation
CAH- Poor
utilisation
64

65. 7. INFORMATION & TECHNOLOGY:
ACHIEVEMENTS
94% of health facilities reporting data on HMIS portal
RCH portal operationalised in almost all states
Most states are utilising HMIS data for planning and
monitoring
Mapping of Urban health facilities by HMIS portal
Multiple e-initiatives: ANMOL, SNCU Online,
Computerized Accidents & Trauma Services and Hospital
Management Information System (Delhi), Ecman
(Kerala), Matritva and EpiMetrics (Maharashtra), PICME
and National Oral Health Mobile app (in Tamil Nadu)
65

66. 7. INFORMATION &
TECHNOLOGY: CHALLENGES
Data entry, incomplete data collection & uploading,
lack of standardised registers
Poor internet connectivity, inconsistent power supply
Reporting from private sector is poor.
Delhi (MIS), Himachal Pradesh (Hospital Information
System) and Tamil Nadu (PICME) have reported their
own HMIS- not interoperable.66

67. 8. HEALTH CARE FINANCING:
ACHIEVEMENTS
Systems of transfer of money
through online
(DBT using PFMS/ RTGS)
Vaccancies in state finance HR
largely overcome in almost all
states67
Different Flexipools-
NRHM-RCH Flexipool
NUHM-RCH Flexipool
CD-Flexipool
NCD-Flexipool
Infrastructure maintenance
13.5%
increase
budget
allocation

68. 8. HEALTH CARE FINANCING:
CHALLENGES
Delay in
transfer of
funds from
State treasury
to State Health
Societies (SHS)
Low Fund
utilization
under NUHM
and NCD
programs
No information
on State
Health
Insurance
programme
68
Federal Finance ministry in August renewed NHM with $20
billion between 2017-20 against Health ministry’s requirement
25$ billion.

69. 9. QUALITY ASSURANCE:
ACHIEVEMENTS
SQAC & DQAC constituted in almost all states
Baseline assessment of facilities started
Training under NQAS & Kayakalp
69

70. 9. QUALITY
ASSURANCE:CHALLENGES
Slow progress after
gap detection
Patient satisfaction survey
yet to be started
Grievance redressal- 104-
nascent stage
SOPs are not applicable to
many facilities & Staffs –
not well versed
BMW- new & old guideline
posters are displayed
Mixing of wastes
70

71. URBAN HEALTH CARE FACILITIES
71

72. 10. NUHM: ACHIEVEMENTS
Mapping of urban
slums(78%), urban health
facilities in cities(57%)
74% UPHCs sanctioned
under NUHM have been
operationalised.
Efficient UHND micro
planning(but outreach
irregular)
PPP mode adopted to
extend services
e.g. APOLLO in AP, RED
CROSS SOCIETY in GUJ
72

73. 10. NUHM: CHALLENGES
Lack of
convergence
between ULBs &
state Health Dept
ULBs still to take
up implementation
to city level
Acquiring land in
crowded urban
slums - difficult
Not inducted
into Qualty
assurance
programme
Inconvinient
OPD timings-
working ppl
excluded
Low utilisation of
funds due to delay
in RKS formation
73

74. 11. GOVERNANCE &
MANAGEMENT: ACHIEVEMENTS
 Clearly defined organogram, functions and job
descriptions of various Programme Management Units
 Good performance assessment systems for PMU staff
 Convergence with line departments like WCD, Education,
Sanitation, Urban development was observed.
74

75. 11. GOVERNANCE & MANAGEMENT:
CHALLENGES
 State Health Mission meetings have decreased ( 54 in 2006-07 to 34 in
2015-16)
 Lack of proper integration between NHM and Directorates.
 Capacity development initiatives for PMU staff not seen.
 SPIP and budget allocation not done as per DHAP. Eg. Andhra Pradesh,
Arunachal Pradesh, Bihar, Jammu & Kashmir.
 Death reviews (MDR/CDR); HMIS; and Centralised Procurement
Management Information Systems struggling to pick up.
75

76. SUMMARY
 STRENGTH:
1. Strong Political will
2. Three tier Health system
3. Districts are divided on the priorities; HPD- 184
4. Finance- Different Flexipool-
NRHM, NUHM,CD,NCD,INFRASTRUCTURE
5. Integration of various programmes(CD, NCD, RMNCHA)
6. Strengthening of Infrastructure
7. E- initiatives
76

77.  Weakness:
1. Shortage of Skilled personell and Specialists
2. Low utilisation of Funds
3. Delayed payment of staffs & disparity among regular
and contractual staffs
4. Weak supervision
5. Lack of orientation to new guidelines & infrequent
training
77

78.  Oppurtunities:
1. Integration with AYUSH
2. Involvement of private sectors
3. Utilisation of data from HMIS for local improvement
4. Availability of funds
5. Rapid procurement of drugs, vaccines and materials
through E-initiatives
6. Active involvement of PRIs & NGOs
78

79.  Threats:
1. Lack of motivation of contractual staffs
2. Improper facilities for Doctors & paramedics
3. Frequent change of bureaucrats
4. Availability of Sub-standard Drugs & Equipments in
market
79

80. SWASTH BHARAT
SAMRIDDHA BHARAT
80

81. 81

82. REFERENCES
1.Govt. of India(2017). Press Release. Ministry of Health and Family Welfare
2. National Family Health Survey-4(2015-16)
3. Govt. of India(2016). Annual report. Ministry of Health and Family Welfare
4. WHO (2015). Global Tuberculosis Report 2015.
5. National Leprosy Eradication Programme. Annual report.2016
6. National vector borne disease control programme. Annual report.2016
7. 10th Common Review Mission, 2017. MoHFW
8. National Health Programme. J. Kishore 2017
9. Health policies, Programmes in India, D.K. Taneja, 2017
10. Rural Health Statistics 2017
11. K.Park, 24th edition
82