Healthcare

Powering rural healthcare

http://www.thehindu.com/opinion/op-ed/powering-rural-healthcare/article21419655.ece

Providing solar-powered systems across primary health centres can improve health outcomes

Around 38 million Indians rely on health facilities without electricity. Without access to

regular power supply, numerous life-saving interventions cannot be undertaken.

Ground report

A study, ‘Powering Primary Healthcare through Solar in India: Lessons from Chhattisgarh’,

published recently by the Council on Energy, Environment and Water (CEEW) and

supported by Oxfam India, evaluated 147 primary healthcare centres (PHCs) across 15

DAILY NEWS BULLETINLEADING HEALTH, POPULATION AND FAMILY WELFARE STORIES OF THE DayTuesday 20171212

districts in Chhattisgarh. It highlights the role of solar energy in bridging the gaps in

electricity access in rural healthcare facilities. In rural India, PHCs provide the last-mile

delivery of healthcare services. The Rural Health Statistics 2016 data find that India has

around 25,000 PHCs, and of the functional PHCs, 4.6% are not electrified. Further, the fourth

round of District Level Household and Facility Survey data indicates that one in every two

PHCs in rural India is either unelectrified or suffers from irregular power supply.

The use of renewable energy sources such as solar could help PHCs augment or even

substitute traditional grid-based power systems. This would also help the transition towards a

low-carbon, climate-smart healthcare system. Moreover, solar systems can facilitate reliable

and uninterrupted electricity supply critical for 24/7 emergency services, deliveries and

neonatal care, as well as inpatient and outpatient services.

In order to augment electricity supply across PHCs in power-surplus Chhattisgarh, the

Chhattisgarh Renewable Energy Development Agency (CREDA), between 2012 and 2016,

installed off-grid solar photovoltaic (PV) systems of 2kW each in 570 PHCs. Districts in

Chhattisgarh with a higher share of power-deficit PHCs (with less than 20 hours of electricity

supply per day from the grid), showed a higher infant mortality rate, a higher under-five

mortality rate, and a lower proportion of fully immunised children. The CEEW study found

that the solar-powered PHCs in Chhattisgarh admitted over 50% more patients and conducted

almost twice the number of child deliveries in a month compared to the power-deficit PHCs

without a solar system.

The ability of solar-powered PHCs to maintain cold chains to store vaccines and drugs and

operate new-born care equipment has significantly improved. Almost one-fourth of the

power-deficit PHCs in Chhattisgarh relied exclusively on solar as a backup to run cold chain

equipment. Continuous electricity supply must be ensured to cold chains at PHCs, especially

in rural Chhattisgarh, which has an infant mortality rate that is higher than the average for

rural India. Further, patients showed more willingness to get admitted for treatment at the

solar-powered PHCs due to facilities like running fans. Also, 90% of PHCs with solar

systems reported cost savings due to lower electricity bills or reduced expenditure on diesel.

Can solar systems be scaled up?

Scaling-up solar-powered systems across PHCs in rural India is dependent on three factors.

The first is to recognise the critical nature of electricity access in the entire health system

infrastructure. The Indian Public Health Standards has set minimum service-level

benchmarks for all activities of PHCs, indicating that every PHC should have power supply

with a back-up option. The National Health Policy 2017 reiterates the commitment to

improve primary healthcare by strengthening infrastructure. The second is the ability to adapt

solar systems around the local needs and considerations of PHCs including the burden of

disease, weather, terrain, and power availability. For example, disaster-prone areas that need

blood storage units and other health services could invest in higher capacity systems or

greater storage capacity. Third, there must be a focus on making ‘Solar for Health’ a national

priority. Scaling solar systems (5kW) across PHCs to power healthcare services could

contribute to about 160 MW of decentralised energy capacity. Solar power can be extended

to cover subcentres (1kW systems) and community health centres (8kW systems), where the

total potential would be around 415 MW.

Significant opportunities exist to simultaneously address the multisectoral goals of energy

access, energy security, resource management, and health outcomes, often competing for

resources and political attention. Solar power for healthcare in Chhattisgarh is a crucial

opportunity, with evidence that scaling this initiative can meet national and regional

ambitions for energy access and improved health outcomes.

Sunil Mani is Research Analyst and Hem H. Dholakia a Senior Research Associate at CEEW

Positive thinking

Positive thinking and wheatgrass (The Hindu: 20171212)

http://www.thehindu.com/opinion/open-page/positive-thinking-and-

wheatgrass/article21381855.ece

The secret of overcoming disease spells and running on hope and courage — and antioxidants

I was in my mid-teens, running on hormones, sarcasm and teenage angst. There were regular

showdowns at home, and the sound of my room door being banged shut resonated as often as

the doorbell.

My mother was a worry-wart. If ever news of a fire or an explosion reached her, which,

sadly, was not very rare, my outings to crowded places such as a cinema hall — the only

release those pre-cafe days — would stop. There would be an immediate clampdown on my

already scatty social life, and it wasn’t fun.

In addition to these frequent denials, I was rarely allowed out at night. On the few occasions

my parents caved in, they would insist my friends ride up in the lift and drop me off at my

doorstep on the 23rd floor, despite the fact that dropping someone at the lift lobby inside the

building gates was the norm. My friends, well aware of the tigress my mother was, asked no

questions; this was a minor compromise. It just mirrored her paranoia.

One evening my mother and I had a particularly harsh fight. A friend’s older sister was

having a huge party for her birthday at a nightclub, and I had been invited. We were

breathless with excitement, never having been inside one before. I had borrowed someone’s

dress since I didn’t possess any nightclub-worthy clothes, and tentatively broached the

subject with my mother. I knew permission would not be easily granted, but was unprepared

for this sudden and immediate denial, this blank refusal to discuss it further.

I threw a fit. My brother had just returned from a nightclub the previous weekend smelling of

cigarette smoke. “The fumes hang in the air,” my brother had informed us, swearing he

hadn’t touched a cigarette. I was eager to test this theory, but my mother was not about to

give me that chance. Anger spilled out of me, and as I started to rant about how unfair it was

that my parents gave in to sexist societal pressures, my mother raised a hand.

“I have cancer.”

Instantly, without even fully processing what she had just said, I burst into tears. My mother

had developed a lump in her breast, which had been discovered to be malignant. She

underwent a mastectomy. The good news is, she recovered, remarkably well.

Nevertheless, back then, none of us knew how things would turn out, and the fear was

crushing.

But my mother was a fighter. She fought her cancer with a good diet, exercise, positive

thinking, and wheatgrass, which grew in abundance in pots all over the house, the juice of

which my brother and I were also, under protest, forced to swallow. Life bounced back to

normal soon enough, but I found I couldn’t talk about my mother’s cancer, not even with my

best friend. I tried to broach the subject with her many times, but at every attempt I felt my

throat tighten, my head pound with the pressure of containing my tears. I gave up.

Days, packed with studies, exams, family vacations, and a lot of laughter, slipped by. I tried

to be a better daughter, to reduce her stress levels, which I was convinced had contributed to

her cancer.

The disease was soon relegated to the background. Before long, but for the ever-green

wheatgrass pots, there were no visible reminders of the scars it had left behind.

One day I stumbled upon an article on breast cancer, which detailed the prognosis and the

percentage of women who survive post-five years. I started calculating how many years had

passed. It had been more than five.

“What does this mean,” I had asked my mother, wondering if she had reached the end of her

rope. My mother explained how if it hadn’t returned in so many years, chances were she was

cancer-free. “If it doesn’t return in 10 years, consider me completely cured!” It didn’t return

in 10 years, it didn’t return in 15. The wheatgrass pots vanished.

A little over 20 years later, she was diagnosed with another lump in her breast, which also

turned out to be malignant. She had been going for regular check-ups, and thankfully, caught

it early. It hadn’t spread. Out came the wheatgrass pots.

It has been close to seven years since she had her second mastectomy, and her blood-work

has been perfect.

Over the years, countless people have called on my mother for support. She has given many

hope, courage and strength. Today she is over 70. She grows stronger and more beautiful,

inside and out, every day.

“What is your secret,” people often ask.

“Positive thinking,” she says. “A daily walk and…” she pauses (for effect or emphasis, I’ll

never know), “wheatgrass.”

Misleading Hunger Index

Flawed economics? (The Hindu: 20171212)

http://www.thehindu.com/opinion/op-ed/flawed-economics/article21419055.ece

Hunger is not related as much to food production as to access and distribution

The article “A misleading hunger index” (Dec. 4) could have been ignored for its wrong

understanding of both epidemiology and nutrition if it wasn’t for the fact that its authors are

members of the NITI Aayog. The authors, unhappy about the Global Hunger Index (GHI) put

out by the International Food Policy Research Institute, ranking India 100 out of 119

countries, said we should have been somewhere around 77, as though that would make India

proud.

The first flaw in the article is the assumption that, with a 26% increase in per capita food

production in the last decade, and a doubling in the last 50 years, hunger must have

automatically come down. In reality, hunger is not related as much to the production of food

as to access and distribution. Do the urban poor, who depend predominantly on PDS, have

the same access as the urban rich? There is also a gender, caste, religion, regional variation in

access.

The authors say that the GHI is neither appropriate nor representative of hunger since more

weightage (70.5%) is assigned to children less than five years, who constitute only a minor

population. Children’s requirement for calories is 2-3 times (80 calories/kg/day for children

versus 35-45 calories/kg/day for adults) the adult requirement. This makes them more

vulnerable to undernutrition and its consequences.

The statement that “weight and height of children are not solely determined by food intake

but are an outcome of a complex interaction of genetics, environment, sanitation and

utilisation of food intake” is mischievous at best and dangerous at worst. The role of genetics

in determining adult height is significant only after two or three generations of adequate food

availability. When children have deficits of 600 calories (they are recommended 1200-1500

calories), neither can the argument for wholesome food be ignored nor the fact that these

children are more vulnerable to infections due to lowered immunity and possibly

malabsorption.

For data to be comparable, representative indicators are chosen. The nutrition status of

children under five is a sensitive measure of the overall nutrition of a country. Similarly,

maternal mortality rate as an acceptable indicator of health system function does not mean

that pregnant women constitute the largest share of the population. The authors need to

understand the difference between bias and representation before they level charges of bias

against the GHI.

They claim that “there is still inconclusive debate on the cut-off for minimum energy

requirement calculation” and suggest that a lower Food and Agriculture Organisation norm of

1,800 kcal should suffice for calculating hunger. Why should India settle for a ‘minimum’

energy requirements when it has worked out a recommended dietary allowance that addresses

the energy needs of all populations based on gender, occupation, weight and special

conditions like weight gain during pregnancy and growth of children?

Veena Shatrugna is a clinical nutritionist and former deputy director of the National Institute

of Nutrition and Sylvia Karpagam is a public health doctor and researcher

Pollution

For clean air, India needs a policy leap(The Hindu: 20171212)

http://www.thehindu.com/opinion/op-ed/for-clean-air-india-needs-a-policy-

leap/article21419755.ece

The way to curb pollution is to tax carbon. Only then will households look for greener

substitutes

It wouldn’t be an exaggeration to say that air pollution is one of the biggest public concerns

in India today. Its implications are many but just two will suffice here. A report of the Lancet

Commission on pollution and health states that around 19 lakh people die prematurely every

year from diseases caused by outdoor and indoor air pollution. A study by the Indian Journal

of Pediatrics shows that the lungs of children who grow up in polluted environments like

Delhi are 10% smaller compared to the lungs of children who grow up in the U.S. This is

nothing short of a public health emergency. What is needed, therefore, is a comprehensive

policy to curb pollution. We need to act now.

At the heart of the problem of pollution are carbon dioxide (CO2) emissions. About 75% of

all greenhouse gas emissions are CO2 emissions produced through burning fossil fuels — oil,

coal and natural gas — to generate energy. Since the early 2000s, carbon emissions have

increased because of high growth in the Indian economy. In 2014, India’s total carbon

emissions were more than three times the levels in 1990, as per World Bank data. This is

because of India’s heavy dependence on fossil fuels and a dramatically low level of energy

efficiency.

Remodel the energy mix

Emissions can be curbed only if people are persuaded to move away from fossil fuels and

adopt greener forms of energy. But how do we achieve that? Tax carbon, period.

A part of the carbon revenue thus generated can be used for a systemic overhaul of the energy

mix, which, to a large extent, would address the pressing problem of environmental

degradation. The Indian economy’s energy mix needs to be remodelled through investments

in clean renewable sources of energy like solar, wind, hydro, geothermal and low-emissions

bioenergy, and by raising the level of energy efficiency through investments in building

retrofits, grid upgrades, and industrial efficiency. According to our estimates, this energy mix

overhaul requires an additional 1.5% of GDP (to the current annual level of 0.6%) annually

over the next two decades. Assuming that the Indian economy grows at 6% per annum and

the population is likely to rise from 1.3 billion to 1.5 billion over the next two decades, the

per capita emissions will still fall as a result of this policy, from the International Energy

Agency’s 2035 Current Policy Scenario of 3.1 metric tonnes to 1.5 metric tonnes — a 52%

decline. Since this expenditure is financed by the carbon tax revenue, it will be a revenue-

neutral policy with no implications on the fiscal deficit.

There is, however, a problem with carbon tax. It’s regressive in nature — it affects the poor

more than the rich. Fortunately, there’s a way out. Economists in the West have argued for a

‘tax and dividend’ policy according to which the revenue thus generated is distributed equally

across its citizens and as a result, the poor are more than compensated for the loss, since in

absolute amounts the rich pay more carbon tax than the poor. Such a policy of cash transfer,

which might work in the West, however, has a problem in the Indian context, which has been

discussed in the context of the Right to Food debate.

Instead of a cash transfer, the other part of the carbon revenue can be used for an in-kind

transfer of free electricity to the population that contributes less carbon than the economy

average, and universal travel passes to compensate for the rise in transport costs and to

encourage the use of green public transport. Such a policy justly addresses the widening

schism between Bharat, which bears the climate impact burden, and India, which is imposing

that burden because of its lifestyle choices.

As of 2014, more than 20% of India’s population did not have access to electricity. In July

2012, India experienced a blackout affecting roughly 70 crore people. Through this Right to

Energy programme, every household in India will have access to electricity, a feat that almost

all the governments since Independence have dreamt of but have failed to deliver. The free

entitlement of fuel and electricity for a household works out to 189 kWh per month based on

our calculations from the National Sample Survey data. Anything above this limit will be

charged in full to control misuse of this policy. Travel passes with a pre-loaded balance

amount of around ₹4,600 per household per annum, which can be used in any mode of public

transport — private and government alike — will be available for every household.

The level of carbon tax required for this policy to come into effect is ₹2,818 per metric tonne

of CO2. It will be levied upstream, namely, at ports, mine-heads, and so on. While the prices

of almost all the commodities will rise, the highest rise in price will be in fuel and energy

since the carbon content is the highest in this category. To give an idea about the pinch that

will be felt, the average price of electricity will rise from its current value of ₹3.73 to ₹4.67

per kWh.

Other benefits

This policy not only curbs emissions but also delivers on providing more employment since

the employment elasticity in greener forms of energy is higher than those in fossil fuel-based

energy. Higher prices of commodities according to their carbon content will induce

households, including the rich, to look for greener substitutes. They have the effect of

enticing even the poor to move away from traditional forms of energy consumption because

the price of energy will be zero for them (provided they consume less than the cut-off limit)

as compared to a shadow positive price in terms of the time used for collection of wood or

cow dung cakes. Availability of free energy also addresses the issue of stealing of electricity,

since there will be no incentive left for those who steal. In India, even in 2014, the value of

electricity stolen through corrupt means amounts to about 0.8% of GDP. It’s difficult to put a

figure on the health benefits that such a policy will entail, but as a rough measure, a

significant part of more than 3% of India’s GDP currently spent on pollution-induced

diseases will surely come down.

If we want to breathe to live, India needs to make such a policy leap.

Rohit Azad teaches economics at JNU, New Delhi, and Shouvik Chakraborty is a research

fellow at the Political Economy Research Institute, Amherst, U.S.

Abortions

1.6cr abortions a yr in India, 81% at home: Study (The Times of India:

20171212)

http://epaper.timesgroup.com/Olive/ODN/TimesOfIndia/#

Mumbai: A total of 1.56 crore abortions took place across India in 2015, 22 times the 7 lakh

figure that the government has been putting out every year for the last 15 years, according to

a research paper published in The Lancet Global Health medical journal on Monday.

Not only do a lot more Indian women than previously thought undergo abortions every year,

an overwhelming number — 81% — take medicines at home instead of going to hospitals,

the study has said.

“The government figure talked of surgical abortions carried out in its own hospitals. The

private sector was not counted, nor were medical abortions,” said the main author, Dr

Chandra Shekhar of International Institute of Population Sciences in Mumbai.

Overall, 1.27 crore (81%) abortions were medication abortions, 22 lakh (14%) were surgical,

and 8 lakh (5%) were through other methods, probably unsafe.

Medical abortions using mifepristone and mifepristone-misoprostol combipacks need a

doctor’s prescription.

‘50% of pregnancies unintended’

Doctors whom TOI spoke to said the revised number of abortions caried out in India wasn’t

asurprise. “Smaller studies done previously in Mumbai and Chennai indicated abortions were

higher than thought,” said a doctor with a government hospital. “Sale of medicines for

abortion also gave us an indication,” said gynecologist Dr Nozer Sheriar, who was a part of

the study.

The new study also estimated that half of the total 48.1 million pregnancies in India in 2015

were unintended. “Abortions accounted for one-third of all pregnancies, and nearly half of

pregnancies were unintended,” said the study, adding that India’s abortion rate is 47 per

1,000 women of reproductive age, which is similar to rates in Pakistan

(50), Nepal (42) and Bangladesh (39). Dr Shekhar said the unintended pregnancies pointed to

the need for better contraception and family planning programmes.

Around 53% Indians use modern contraception, but the expert said studies have shown that

half the couples surveyed didn’t know how to use the condom correctly. The study —

conducted jointly by IIPS, the Delhi-based Population Council and the New York–based

Guttmacher Institute — compiled national sales and distribution data of medical abortion

pills and conducted surveys of various public and private health facilities in six Indian states.

It estimated that close to three in four abortions are achieved using drugs from chemists and

informal vendors. WHO says abortion medicines are safe and effective when used correctly

and within a nineweek gestational limit.

Unfortunately, only a quarter of the abortions occur in the public sector, which is the main

source of healthcare for the poor. Dr Sheriar said abortions are the third leading cause for

maternal mortality in India. “The use of medicines for abortions has brought down this

number from 12% to 8% in recent years, but it is still huge,” he said, underlining the need to

make access to abortion easier for women. The results show abortions don’t need to take

place in hospitals, nor do they need highly trained doctors. The study proposed recommended

permitting nurses, AYUSH doctors (practitioners of indigenous medicine) and auxiliary nurse

midwives to provide abortion medicines. This would expand the number of providers—and

facilities—qualified to offer safe abortion services.

Immunotherapy (The Asian Age: 20171212)

http://onlineepaper.asianage.com/articledetailpage.aspx?id=9593123

Total Health Expenditure

INDIA’S HEALTH SPENDING (Hindustan Times: 20171212)

http://paper.hindustantimes.com/epaper/viewer.aspx

New National Health Accounts data reveals medicines are the biggest financial burden on

Indian households

Air quality

Air quality improves marginally with rain (Hindustan Times: 20171212)

http://paper.hindustantimes.com/epaper/viewer.aspx

THE IMPROVEMENT, BECAUSE OF THE RAIN, WAS REFLECTED BETTER IN THE

LEVELS OF PM10 AND PM2.5 WHICH STARTED DIPPING SOON AFTER THE

DRIZZLE

The air quality in Delhi, which spiked throughout Monday, showed signs of marginal

improvement from late Monday evening, as rain lashed the National Capital bringing down

the concentration of particulate matter – the dominant pollutants in Delhi’s air.

SANCHIT KHANNA/HT PHOTO

n Delhi received light rain on Monday. The meteorological department has forecast rain on

Tuesday as well. The rain helped bring down levels of particulate matters in Delhi’s air.

Experts said that pollution levels are likely to dip further on Tuesday as light rain and drizzle,

triggered by a western disturbance, is expected to continue till Tuesday morning.

The day’s average Air Quality Index (AQI) dropped to 361 on Monday from 377 on Sunday.

But this improvement was not because of the drizzle. The average AQI is calculated around 4

pm and the rain started around 6 pm.

The improvement, because of the rain, was reflected better in the levels of PM10 and PM2.5

which started dipping soon after the drizzle started. Till 8.30pm on Monday, Delhi received

2mm rain.

While PM10 concentration dropped from around 422 at 2 pm to around 400 around 9pm, the

level of PM2.5 also came down from around 245 at 5 pm to 238 at 9pm

“There will be further improvement on Tuesday as the rain will wash away some more

pollutants in the air. The layer of dust on the roads, trees and constructions sites will also be

washed away. The dust particles, which used to rise from these surfaces and mix with the air,

will not be able to do so, allowing Delhiites to breathe some cleaner air,” said D Saha head of

the air quality laboratory at CPCB.

But pollution levels could spike marginally once again from Wednesday and continue to

deteriorate till Friday because of the calm winds and high moisture levels left back by the

rains.

“We are expecting some shallow fog on Wednesday and Thursday morning as there would be

a lot of moisture in the air. The winds would be calm too,” said Kuldeep Srivastava, a senior

scientist with the RWFC.

MeT experts, however, said that the sky is likely to clear up from Friday as the cold and dry

north westerly winds are expected to pick up speed.

“Once we get a clear sky, a good sunshine and some strong winds from the north and

northwest, air quality would definitely improve,” said Saha.

The Indian Medical Association (IMA

IMA to form state-level panels to look at quality of healthcare (Hindustan

Times: 20171212)

http://paper.hindustantimes.com/epaper/viewer.aspx

The Indian Medical Association (IMA), the national voluntary organisation of doctors, has

announced the creation of a state-level Medical Redressal Commission that can look into the

quality and social and financial aspect of healthcare practices – either on demand or suo

moto.

The commission will be constituted of a prominent public figure, an IMA office bearer, one

former state medical representative and two subject experts.

The move came in the light of two private hospitals in the national capital region being

accused of negligence and overcharging. The association urged all doctors to follow the

ALERT policy (Acknowledge, Listen in detail, Explain, Review and Thank you) to develop

doctor-patient trust. “This will help in bringing down the increasing incidents of violence

against doctors,” said Dr KK Aggarwal, president of the IMA.

The IMA also urged doctors, hospitals and the healthcare industry to employ self-regulation

to increase the doctor-patient trust. Steps recommended by the IMA include doctors

preferably prescribing drugs from the National List of Essential Medicines, promoting the

Janaushadhi Kendras, transparent billings, provide options for cost-effective treatment at the

time of admission.

“Doctors should actively participate in ensuring that no hospital sells any item priced higher

than the MRP. No service charges should be added to procure drugs from outside. MRP shall

not be dictated by the purchaser,” said Dr Agarwal.

The organisation urged the state government to subsidise the cost of emergency care, even at

private hospitals.

Health insurance

Only 27 per cent Indians have health insurance: report(Indian Express:

20171212)

http://indianexpress.com/article/india/only-27-per-cent-indians-have-health-insurance-report-

4978687/

Thus, of India’s 135 crore people, 100 crore have no cover against catastrophic health

expenses.

The NDA government is “committed to UHC”, Health Minister J P Nadda asserted at an

event on Monday, the eve of Universal Health Coverage (UHC) Day. However, only 27 per

cent Indians or approximately 35 crore people have health cover, according to data from the

National Health Profile (NHP) released in April.

Thus, of India’s 135 crore people, 100 crore have no cover against catastrophic health

expenses.

“We are committed to advancing the agenda of Universal Health Coverage in the country,”

Nadda said. He was speaking at an event where he launched a mobile application to help

health workers in peripheral areas through complicated deliveries, a scheme for quality

certification of labour rooms and guidelines for critical obstetric care.

NHP data, which is compiled by the Central Bureau of Health Intelligence (CBHI) that

reports to the Union Health Ministry and, therefore, uses government figures to compile all

its reports, also says that between 2009-10 and 2014-15, public expenditure on health as a

percentage of GDP has remained constant at 0.98 per cent. Interestingly, a scheme that would

provide some health cover to 10 crore families requiring an annual government commitment

of Rs 6,000 crore, which was to be the precursor to a full-blown nationwide health protection

scheme, has been with the Union cabinet for more than a year now.

The 2017 NHP report on the CBHI website says: “Around 35 crore individuals were covered

under any insurance in 2015-16. This amounts to 27% of the total population of India. 77% of

them were covered by public insurance companies. Overall 80% of all persons covered with

insurance fall under government sponsored schemes… Compared to other countries that have

either Universal Health Coverage or moving towards it, India’s per capita public spending on

health is low.”

In 2014-15, average per capita public health expenditure ranged from Rs 940-2,532, the

spending being the highest in the northeastern states and lowest in what are known as the

Empowered Action Group states of Bihar, Jharkhand, MP, Chhattisgarh, Odisha, Rajasthan,

UP and Uttarakhand.

Health Care Services ( Dainik Gagaran: 20171212)

http://epaper.jagran.com/ePaperArticle/12-dec-2017-edition-Delhi-City-page_6-3450-4862-

4.html

Clinical establishment Act ( Dainik Gagaran: 20171212)

http://epaper.jagran.com/ePaperArticle/12-dec-2017-edition-Delhi-City-page_12-3436-4592-

4.html

Health (Hindustan: 20171212)

http://epaper.livehindustan.com/story.aspx?id=2412632&boxid=100409316&ed_date=2017-

12-12&ed_code=1&ed_page=7

Cauliflowers (Hindustan: 20171212)

http://epaper.livehindustan.com/story.aspx?id=2412641&boxid=99066332&ed_date=2017-

12-12&ed_code=1&ed_page=16

Imagery (Hindustan: 20171212)

http://epaper.livehindustan.com/story.aspx?id=2412641&boxid=99247380&ed_date=2017-

12-12&ed_code=1&ed_page=16