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Subject: Health

  • National Health Accounts Estimates: 2017-18

    Out-of-pocket expenditure (OOPE) as a share of total health expenditure and foreign aid for health has both come down as per the findings of the National Health Accounts (NHA) estimates for India for 2017-18.

    What is National Health Accounts (NHA)?

    • The NHA estimates are prepared by using an accounting framework based on internationally accepted System of Health Accounts 2011, provided by the World Health Organization (WHO).
    • It is released by Ministry of Health & Family Welfare.
    • It describes health expenditures and flow of funds in the country’s health system over a financial year of India.
    • It answers important policy questions such as what are the sources of healthcare expenditures, who manages these, who provides health care services, and which services are utilized.
    • It is a practice to describe the health expenditure estimates according to a global standard framework, System of Health Accounts 2011 (SHA 2011), to facilitate comparison of estimates across countries.

    Objective of the NHA

    • To describe the Current Health Expenditures (CHE).

    The details of CHE are presented according to

    • Revenues of healthcare financing schemes: – entities that provide resources to spend for health goods and services in the health system;
    • Healthcare financing schemes: entities receiving and managing funds from financing sources to pay for or to purchase health goods and services;
    • Healthcare providers: entities receiving finances to produce/ provide health goods and services;
    • Healthcare functions: It describes the use of funds across various health care services.

    About NHA (2017-2018)

    • The 2017-18 NHA estimates shows government expenditure on health exhibiting an increasing trend and growing trust in public health care system.
    • With the present estimate of NHA 2017-18, India has a continuous Time Series on NHA estimates for both government and private sources for five years since 2013-14.
    • These estimates are not only comparable internationally, but also enable the policy makers to monitor progress towards universal health coverage as envisaged in the National Health Policy, 2017.

    Key Highlights

    Increase in GDP share: The NHA estimates for 2017-18 clearly show that there has been an increase in the share of government health expenditure in the total GDP from 1.15% in 2013-14 to 1.35% in 2017-18.

    Increase in govt share in expenditures: In 2017-18, the share of government expenditure was 40.8%, which is much higher than 28.6% in 2013-14.

    Per-Capita increase in expenditure: In per capita terms, the government health expenditure has increased from Rs 1042 to Rs.1753 between 2013-14 to 2017-18.

    Focus on total healthcare: The primary and secondary care accounts for more than 80% of the current Government health expenditure.

    Social security expenditure: The share of social security expenditure on health, which includes the social health insurance program, Government financed health insurance schemes, and medical reimbursements made to Government employees, has increased.

    Decline in foreign aid: The findings also depict that the foreign aid for health has come down to 0.5%, showcasing India’s economic self-reliance.

    Decline in OOPE: The government’s efforts to improve public health care are evident with out-of-pocket expenditure (OOPE) as a share of total health expenditure coming down to 48.8% in 2017-18 from 64.2% in 2013-14.

    Way forward

    • After 18 months of Covid-19, financial year 2017-18 appears to be from another era.
    • However, learnings from that year’s NHA help us to plan for health system strengthening in the post-Covid years.
    • The special financing packages for Covid emergency response, announced by the central government in 2020 and 2021, represent an extraordinary situation.
    • The resolve to increase public financing for health must remain strong even after Covid.

     

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  • Key Demographic Transitions captured by 5th round of NFHS

    The Union health ministry released the summary findings of the fifth round of the National Family and Health Survey (NFHS-5), conducted in two phases between 2019 and 2021.

    About NFHS

    • The NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India.
    • The previous four rounds of the NFHS were conducted in 1992-93, 1998-99, 2005-06 and 2015-16.
    • The survey provides state and national information for India on:

    Fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services etc.

    Objectives of the survey

    Each successive round of the NFHS has had two specific goals:

    • To provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes
    • To provide information on important emerging health and family welfare issues.

    Key highlights of the NFHS-5

    [1] Women outnumbering men

    • NFHS-5 data shows that there were 1,020 women for 1000 men in the country in 2019-2021.
    • This is the highest sex ratio for any NFHS survey as well as since the first modern synchronous census conducted in 1881.
    • To be sure, in the 2005-06 NFHS, the sex ratio was 1,000 or women and men were equal in number.

    [2] Fertility has decreased

    • The Total Fertility Rate (TFR) has also come down below the threshold at which the population is expected to replace itself from one generation to next.
    • TFR was 2 in 2019-2021, just below the replacement fertility rate of 2.1. To be sure, in rural areas, the TFR is still 2.1.
    • In urban areas, TFR had gone below the replacement fertility rate in the 2015-16 NFHS itself.

    [3] Population is ageing

    • A decline in TFR, which implies that lower number of children are being born, also entails that India’s population would become older.
    • Sure enough, the survey shows that the share of under-15 population in the country has therefore further declined from 28.6% in 2015-16 to 26.5% in 2019-21.

    [4] Children’s nutrition has improved

    • The share of stunted (low height for age), wasted (low weight for height), and underweight (low weight for age) children have all come down since the last NFHS conducted in 2015-16.
    • However, the share of severely wasted children has not, nor has the share of overweight (high weight for height) or anaemic children.
    • The share of overweight children has increased from 2.1% to 3.4%.

    [5] Nutrition problem for adults

    • For children and their mothers, there are at least government schemes such as Integrated Child Development Services (ICDS) that seek to address the nutritional needs at the time of childbirth and infancy.
    • However, there is a need to address the nutritional needs of adults too.
    • The survey has shown that though India might have achieved food security, 60% of Indians cannot afford nutritious diets.
    • While the share of women and men with below-normal Body Mass Index (BMI) has decreased, the share of overweight and obese (those with above-normal BMI) and the share of anaemic has increased.

    [6] Basic sanitation challenges

    • Availability of basic amenities such as improved sanitation facilities clean fuel for cooking, or menstrual hygiene products can improve health outcomes.
    • There has been an improvement on indicators for all three since the last NFHS. However, the degree of improvement might be less than claimed by the government.
    • For example, only 70% population had access to an improved sanitation facility.
    • While not exactly an indicator of open defecation, it means that the remaining 30% of the population has a flush or pour-flush toilet not connected to a sewer, septic tank or pit latrine.

    [7] Use of clean fuel

    • The share of households that use clean cooking fuel is also just 59%.

    [8] Financial inclusion

    • The share of women having a bank account that they themselves use has increased from 53% to 79%.
    • Households’ coverage by health insurance or financing scheme also has increased 1.4 times to 41%, a clear indication of the impact of the government’s health insurance scheme.

     

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  • HomoSEP: Robot for cleaning Septic Tanks

    IIT Madras has developed a robot that can, if deployed extensively, put an end to this practice of sending people into septic tanks.

    HomoSEP

    • HomoSEP stands for “homogenizer of septic tanks”.
    • It has a shaft attached to blades that can open like an inverted umbrella when introduced into a septic tank.
    • This is helpful as the openings of the septic tanks are small and the tank interiors are bigger.
    • The sludge inside a septic tank contains faecal matter that has thickened like hard clay and settled at the bottom.
    • This needs to be shredded and homogenized so that it can be sucked out and the septic tank cleaned. The whirring blades of the robot achieve precisely this.

    Manual scavenging deaths in India

    • A statement by the Social Justice and Empowerment Ministry conveyed that in the five years till December 31, 2020, there have been 340 deaths due to manual scavenging.
    • Uttar Pradesh (52), Tamil Nadu (43) and Delhi (36) leads in the list. Maharashtra had 34 and Gujarat and Haryana had 31 each.
    • This is despite bans and prohibitory orders.

    Various policy initiatives

    • Prohibition of Employment as Manual Scavengers and their Rehabilitation (Amendment) Bill, 2020: It proposes to completely mechanise sewer cleaning, introduce ways for ‘on-site’ protection and provide compensation to manual scavengers in case of sewer deaths.
    • Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013: Superseding the 1993 Act, the 2013 Act goes beyond prohibitions on dry latrines, and outlaws all manual excrement cleaning of insanitary latrines, open drains, or pits.
    • Rashtriya Garima Abhiyan: It started national wide march “Maila Mukti Yatra” for total eradication of manual scavenging from 30th November 2012 from Bhopal.
    • Prevention of Atrocities Act: In 1989, the Prevention of Atrocities Act became an integrated guard for sanitation workers since majority of the manual scavengers belonged to the Scheduled Caste.
    • Judicial intervention: In 2014, a Supreme Court order made it mandatory for the government to identify all those who died in sewage work since 1993 and provide Rs. 10 lakh each as compensation to their families.

     

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  • Health Care Equity in Urban India

    The report on ‘Health Care Equity in Urban India’ exploring health vulnerabilities and inequalities in cities in India was recently released.

    About the report

    • The report is released recently by Azim Premji University in collaboration with 17 regional NGOs across India.
    • It notes that a third of India’s people now live in urban areas, with this segment seeing rapid growth from about 18% (1960) to 28.53% (2001) to 34% (in 2019).
    • The study draws insights from data collected through detailed interactions with civil society organizations in major cities and towns.
    • This also included an analysis of the National Family and Health Surveys (NHFS), the Census of India, and inputs from State-level health officials on the provision of health care.
    • It also looks at the availability, accessibility, and cost of healthcare facilities, and possibilities in future-proofing services in the next decade.

    Key highlights of the report

    • Urban poverty on rise: Close to 30% of people living in urban areas are poor.
    • Declining life expectancy: Life expectancy among the poorest is lower by 9.1 years and 6.2 years among men and women, respectively, compared to the richest in urban areas.
    • Chaotic health governance: The report, besides finding disproportionate disease burden on the poor, also pointed to a chaotic urban health governance.
    • Multiplicity and non-coordination: The multiplicity of healthcare providers both within and outside the government without coordination challenges to urban health governance.
    • Lack of political attention: Urban healthcare has received relatively less research and policy attention.

    Major recommendations

    The report calls for:

    • Strengthening community participation and governance
    • Building a comprehensive and dynamic database on the health and nutrition status, including co-morbidities of the diverse, vulnerable populations
    • Strengthening healthcare provisioning through the National Urban Health Mission, especially for primary healthcare services
    • Putting in place policy measures to reduce the financial burden of the poor
    • A better mechanism for coordinated public healthcare services and better governed private healthcare institutions

    Conclusion

    • As urbanization is happening rapidly, the number of the urban poor is only expected to increase.
    • A well-functioning, better coordinated, and governed health care system is crucial at this point.
    • The pandemic has brought to attention the need for a robust and resourced healthcare system.
    • Addressing this will benefit the most vulnerable and offer critical services to city dwellers across income groups.

     

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  • More a private sector primer than health-care pathway

    Context

    NITI Aayog recently published a road map document entitled “Health Insurance for India’s Missing Middle”.

    About missing middle and provision in the NITI Aayog report

    • The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), aims to extend hospitalisation cover of up to ₹5 lakh per family per annum to a poor and vulnerable population of nearly 50 crore people.
    • Left out segment: Covering the left out segment of the population, commonly termed the ‘missing middle’ sandwiched between the poor and the affluent, has been discussed by the Government recently.
    • Towards this, NITI Aayog recently published a road map document entitled “Health Insurance for India’s Missing Middle”.
    • Primary role for private commercial health insurer: The report proposes voluntary, contributory health insurance dispensed mainly by private commercial health insurers as the prime instrument for extending health insurance to the ‘missing middle’.

    Issues with the provision in the NITI Aayog report

    • Narrow coverage: Government subsidies, if any at all, will be reserved for the very poor within the ‘missing middle’ and only at a later stage of development of voluntary contributory insurance.
    • This is a major swerve from the vision espoused by the high-level expert group on UHC a decade ago, which was sceptical about such a health insurance model.
    • No country has ever achieved UHC by relying predominantly on private sources of financing health care.
    • Contributory insurance not best way: Evidence shows that in developing countries such as India, with a gargantuan informal sector, contributory health insurance is not the best way forward and can be replete with problems.
    • Issues with low premium model: For hospitalisation insurance, the report proposes a model similar to the Arogya Sanjeevani scheme, albeit with lower projected premiums of around ₹4,000-₹6,000 per family per annum.
    • This model is a little different from commercial private insurance, except for somewhat lower premiums.
    • Low premiums are achieved by reducing administrative costs of insurers through an array of measures, including private use of government infrastructure.
    • This model is vulnerable to nearly every vice that characterises conventional private insurance.
    • Insufficient measures to deal with adverse selection: The report suggests enrolment in groups as a means to counter adverse selection.
    • The prevailing per capita expenditure on hospital care is used to reflect affordability of hospital insurance, and thereby, a possible willingness to pay for insurance.
    • Both these notions are likely to be far-fetched in practice, and the model is likely to be characterised by widespread adverse selection notwithstanding.
    • OPD insurance on a subscription basis: The report proposes an OPD insurance with an insured sum of ₹5,000 per family per annum, and again uses average per capita OPD spending to justify the ability to pay.
    • However, the OPD insurance is envisaged on a subscription basis, which means that insured families would need to pay nearly the entire insured sum in advance to obtain the benefits.
    • Clearly, this route is unlikely to result in any significant reduction of out-of-pocket expenditure on OPD care.
    • Role of government:The NITI report defies the universally accepted logic that UHC invariably entails a strong and overarching role for the Government in health care, particularly in developing countries.

    Consider the question “What are the challenges in achieving universal health coverage? What are the issues with private sources  financing health care to achieve UHC?”

    Conclusion

    The National Health Policy 2017 envisaged increasing public health spending to 2.5% of GDP by 2025. Let us not contradict ourselves so early and at this crucial juncture of an unprecedented pandemic.

  • Project Sampoorna: A successful measure against malnutrition

    Project Sampoorna’s success in reducing child malnutrition is a model that can be easily implemented anywhere.

    What is Project Sampoorna?

    • Project Sampoorna has been implemented in the Bongaigaon district of Assam.
    • It aims to target Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM).
    • It was launched to target the mothers of SAM/ MAM children with the tagline being ‘Empowered Mothers, Healthy Children’.
    • It was based on the success of the community-based COVID-19 management model (Project Mili Juli).

    Key features of the project

    • Under this project, the mother of a healthy child of an Anganwadi Centre was paired with the target mother and they would be Buddy Mothers.
    • They were usually neighbours and shared similar socioeconomic backgrounds.
    • They were given diet charts to indicate the daily food intake of their children and would have discussions on all Tuesdays at the Anganwadi centres.
    • 100 millilitres of milk and an egg on alternate days for the children for the first 3 months were provided so that their mothers could stabilise themselves in the newly found jobs.
    • Children who had not improved were checked and treated by doctors under the Rashtriya Bal Swasthya Karyakram (RBSK).

    Success of the project

    • This project has prevented at least 1,200 children from becoming malnourished over the last year.
    • National Nutrition Mission and the State government recognised this project in the ‘Innovation Category’.
    • The mothers were enrolled in Self Help Groups (SHGs) under the National Rural Livelihoods Mission (NRLM) and were thus working.

     

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  • Global Drug Policy Index inaugurated

    The first-ever Global Drug Policy Index was recently inaugurated.

    Global Drug Policy Index

    • It is released by the Harm Reduction Consortium, ranks Norway, New Zealand, Portugal, the UK and Australia as the five leading countries on humane and health-driven drug policies.
    • It is a data-driven global analysis of drug policies and their implementation.
    • It is composed of 75 indicators running across five broad dimensions of drug policy:
    1. Criminal justice
    2. Extreme responses
    3. Health and harm reduction
    4. Access to internationally controlled medicines and
    5. Development

    Highlights of the 2021 ranking

    • The five lowest-ranking countries are Brazil, Uganda, Indonesia, Kenya, and Mexico.
    • Norway, despite topping the Index, only managed a score of 74/100.
    • And the median score across all 30 countries and dimensions is just 48/100.

    India’s performance

    • India’s rank is 18 out of 30 countries
    • It has an overall score of 46/100.

     

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  • Should the NDPS Act be amended?

    • The Union Ministry of Social Justice and Empowerment has proposed certain changes to some provisions of the Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985.
    • The recommendations have assumed importance in the backdrop of some high-profile drug cases including the recent arrest of Bollywood actor’s son.

    What is NDPS Act?

    • The NDPS Act, 1985 is the principal legislation through which the state regulates the operations of narcotic drugs and psychotropic substances.
    • It provides a stringent framework for punishing offenses related to illicit traffic in narcotic drugs and psychotropic substances through imprisonments and forfeiture of property.
    • This is a stringent law where the death penalty can be prescribed for repeat offenders.

    Key amendments suggested

    • To decriminalise the possession of narcotic drugs in smaller quantities for personal purposes.
    • Persons using drugs in smaller quantities be treated as victims.

    Issues with the NDPS Act

    Ans. First arrest and then investigate

    • First arrest and then investigate seems to be the principle for investigations under the NDPS Act.
    • Section 50 of the Act (conditions under which search of persons shall be conducted) needs to be followed scrupulously.
    • When officials stumble upon a person carrying drugs during raids or a routine check, the drugs must be seized in front of a Gazetted Officer or a Magistrate.

    Why such provision?

    • In cases of sudden development, the suspect is taken to the nearby Magistrate or the latter is brought to the spot and then only drugs are seized.
    • If this is not adhered to, the court acquits the accused persons. Only then the next stage of investigation commences.
    • While tracking drugs cases, investigators go from consumers to drug suppliers.

    Is there any scope of mi-use?

    • It is not possible at all. Once cannot manage all the people all the time.
    • Since the seizure procedure is to be followed, there could be one Magistrate at the time of seizing drugs, another during further investigation and a different Magistrate at the time of trial.
    • Moreover, governments can change.

    Challenges in enforcing the NDPS Act

    (a) Peddling

    • Since drug peddling is an organised crime, it is challenging for the police to catch the persons involved from the point of source to the point of destination.
    • Identifying drugs that are being transported is a challenge since we cannot stop each and every vehicle that plies on Indian roads.

    (b) Transportation

    • Most drug bust cases are made possible with specific information leads.
    • Unless we check every vehicle with specially trained sniffer dogs, it is difficult to check narcotic drugs transportation.

    (c) Production

    • The main challenge is to catch those producing these substances. Secret cultivation are mostly carried on in LWE affected areas.
    • Going beyond State jurisdiction, finding the source of narcotic substances and destroying them is another big challenge.

    (d) Delay in trials

    • Securing conviction for the accused in drugs cases is yet another arduous task. There are frequent delays in court procedures.
    • Sometimes, cases do not come up for trial even after two years of having registered them.
    • By then, the accused are out on bail and do not turn up for trial.
    • Bringing them back from their States to trial is quite difficult let alone getting them convicted.

    Other Challenges

    (a) Growing hopelessness in society

    • The COVID-19 pandemic, for instance, has aggravated anxieties among the youth.
    • Joblessness and livelihood losses are the major push factors.

    (b) Issues in rehabilitation

    • The proposal to send persons to rehabilitation centres is good on paper but we do not have the infrastructure to ensure that it is properly implemented.
    • We don’t have adequate de-addiction centre counsellors. We face an acute shortage of psychiatrists and counsellors.

    Issues in legalization of drugs

    • Legalisation of drugs usage will only compound the problem.
    • It could lead to the proliferation of drugs.
    • It is dangerous. More and more people may start using them.

    Way forward

    • We need to thoroughly examine why and how people are getting addicted to narcotic drugs.
    • No doubt the NDPS Act is stringent, but we need to make a distinction between the drug peddler and the end user.
    • The person using it in smaller quantities for personal use cannot be bracketed with the person producing narcotic drugs.
    • We need to make a clear distinction between a drug supplier and an end user.
    • A drug user needs to be seen as a patient. The Act as of now prescribes jail for everyone — the end user and the drug supplier.
    • Instead of suggesting proposals to change sections of the law for the entire country, it would be advisable to introduce this on a pilot basis in one State that faces an acute drugs-related problem.

    Conclusion

    • We should examine the root cause of the problem.
    • Relying only on law-enforcing agencies, however hard they are at work to address the problem, is not going to solve it.
    • Civil society and governments will have to work together to create an enabling environment to address the issue.

     

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  • Strengthening healthcare through ABHIM

    Context

    The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (ABHIM), announced recently, seeks to realise greater investment in the health system as proposed in the Budget, implement the Fifteenth Finance Commission recommendations such as strengthening of urban and rural primary care, stronger surveillance systems and laboratory capacity.

    Measures of ABHIM

    • It will support infrastructure development of 17,788 rural health and wellness centres (HWCs) in seven high-focus States and three north-eastern States.
    • In addition, 11,044 urban HWCs will be established in close collaboration with Urban Local Bodies.
    • The various measures of this scheme will extend primary healthcare services across India.
    • Areas like hypertension, diabetes and mental health will be covered, in addition to existing services.
    • Support for 3,382 block public health units (BPHUs) in 11 high-focus States and establishment of integrated district public health laboratories in all 730 districts will strengthen capacity for information technology-enabled disease surveillance.
    • To enhance the capabilities for microbial surveillance, a National Platform for One Health will be established.
    • Four Regional National Institutes of Virology will be established.
    • Laboratory capacity under the National Centre for Disease Control, the Indian Council of Medical Research and national research institutions will be strengthened.
    • Fifteen bio-safety level III labs will augment the capacity for infectious disease control and bio-security.

    Way forward

    • There is a need to train and deploy a larger and better skilled health workforce.
    • We must scale up institutional capacity for training public health professionals.
    • Private sector participation in service delivery may be invited by States, as per need and availability.
    • ABHIM, if financed and implemented efficiently, can strengthen India’s health system by augmenting capacity in several areas and creating a framework for coordinated functioning at district, state and national levels.
    • Many independently functioning programmes will have to work with a common purpose by leaping across boundaries of separate budget lines and reporting structures.
    • That calls for a change of bureaucratic mindsets and a cultural shift in Centre-State relations.

    Conclusion

    The ABHIM can fix the weaknesses in India’s healthcare system.

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  • Preparing for outbreaks

    Context

    Prime Minister Narendra Modi launched the Ayushman Bharat Health Infrastructure Mission, one of the largest pan-India schemes for strengthening healthcare infrastructure, in his parliamentary constituency Varanasi in Uttar Pradesh.

    Aims of Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (ABHIM) and how it seeks to achieve it

    • This was launched with an outlay of ₹64,180 crore over a period of five years.
    •  In addition to the National Health Mission, this scheme will work towards strengthening public health institutions and governance capacities for wide-ranging diagnostics and treatment, including critical care services.
    • The latter goal would be met with the establishment of critical care hospital blocks in 12 central institutions such as the All India Institute of Medical Sciences, and in government medical colleges and district hospitals in 602 districts.
    • Laboratories and their preparedness: The government will be establishing integrated district public health labs in 730 districts to provide comprehensive laboratory services.
    • Research: ABHIM will focus on supporting research on COVID-19 and other infectious diseases, including biomedical research to generate evidence to inform short-term and medium-term responses to such pandemics.
    • One health approach: The government also aims to develop a core capacity to deliver the ‘one health’ approach to prevent, detect, and respond to infectious disease outbreaks in humans and animals.
    • Surveillance labs: A network of surveillance labs will be developed at the block, district, regional and national levels for detecting, investigating, preventing, and combating health emergencies and outbreaks.
    • Local capacities in urban areas: A major highlight of the current pandemic has been the requirement of local capacities in urban areas.
    • The services from the existing urban primary health centres will be expanded to smaller units – Ayushman Bharat Urban Health and Wellness Centres and polyclinics or specialist clinics.

    Conclusion

    The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (ABHIM) is another addition to the arsenal we have to prepare for such oubreaks in the future.

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