Business Wealth Job Creation Personal Wealth Systems

You have been diligently saving into your 401K and looking forward to your retirement. You are 57 years old and you open your statement. You?ve lost half of your retirement investment. Suddenly retirement has been pushed back beyond age 65 and you will need a part-time job when you retire. You have been saving into your 529 college plan. Junior is about to turn 18; instead of the one hundred thousand dollars you expected based on what you were told were the historic returns of the market, you have less than half of that. Now you have to have the conversation with Junior, valedictorian of his class, about going to the Junior College.

What if your financial planner told you that you were about to embark on a great experiment? That the experiment would require you to set a consistent amount of money aside for 30 years in a lock box controlled by investment banks and the United States Federal Government, limit your investment options to mutual funds and bonds, and hope that certain beliefs about long term historical returns hold true until you need your money at the end of your working life.

That is exactly the first conversation that I had with my financial planner 7 years ago. She said to me, ?Ouida, these mutual funds, 401Ks and 529 college plans?this is all a great experiment Large groups of people have never retired or planned for college in this way before and we won?t know how this experiment is going to turn out for another 10 years or so.?

When I heard that,I realized television pundits and financial authors simply articulated unproven strategies in an overall experiment that began in the late 1970?s when corporations began to shift the responsibility for retirement planning and pension funding onto employees. I thought about the meaningless conversations that I had with my erstwhile plumber about the latest hot mutual fund and whether or not he should buy Google. The Great 401K Experiment has turned the majority of employees into investors and turned the man on the street or the salesman behind the desk into a financial guru.

Wikipedia defines an experiment in the following manner: In scientific inquiry, an experiment (Latin: ex- periri, “to try out”) is a method of investigating causal relationships among variables. An experiment is a cornerstone of the empirical approach to acquiring data about the world and is used in both natural sciences and social sciences. An experiment can be used to help solve practical problems and to support or negate theoretical assumptions.

I wonder who ever thought that by diligently placing money in their 401K that they were ?trying out? their retirement plan?

As a physician, I rely on the outcomes of well-designed experiments to determine the best therapeutic strategy for my patients. In health care, by the time an experiment involving a therapeutic intervention is carried out on human test subjects, basic assumptions about the therapeutic intervention have already been formulated and tested in the laboratory. In medicine, we know what the variables are and we control for them, we have specific outcome measures and, most importantly, we can stop the experiment if the outcome is out of line with expectations and proves to be harmful to patients.

Despite involving human test subjects, the goings on in the world of finance and retirement planning have nothing to do with a safe controlled experiment. No, in the world of personal finance and retirement planning, we have what is known as an observational study. In an observational study, people participate in a series of activities and we follow them long term to the end. Whatever that end is. We are simply along for the ride waiting to see what happens. In terms of retirement planning, that could mean a retirement lived in poverty or a retirement in which all of the financial needs are met. But this experiment does not guaranty the latter outcome.

Let?s look at the assumptions that financial planners and employees alike have made:

1) In retirement, expenses will go down. Therefore retirees will need only 75% of their pre-retirement income. This means that a person with an annual income of $100,000 during his working years, should set enough aside to generate an annual income of $75, 000 in retirement. This assumption has one basic flaw: it ignores inflation. Current estimates are that retirees will need $250,000 to $300,000 dollars just to handle health care expenditure. This basic tenet of retirement planning ignores the realities of many retirees, personal illness, the need to care for a sick spouse or adult children.

2) Stock market returns average 8% per year over the long haul. This is simply untrue. A quick trip to moneychimp.com shows that the S&P has returned 8.76% since 1871. However that percentage drops to 6.56% when adjusted for inflation. If you could have been invested in the markets for the past 137 years you could have done okay. But 137 years really does challenge the idea of just what the long haul is. The long haul is certainly more than 10 years. From January 1, 1998 to December 31, 2008 market returns were 0.96%. Inflation-adjusted returns were -1.44%. As I discuss in my article, The Stock Market: The Second Greatest Financial Scam of the 20th Century, the long haul for stocks is more like 30 years. It becomes obvious, then, what you should do if you are 50, intend to retire at 65 and are contemplating putting money in the markets as an investment.

3) Home prices will always go up. This assumption made home ownership tantamount to putting money away monthly into a super-charged savings account. I?ve never seen a savings account lose value the way the housing market did during the Savings and Loan crash and this most recent financial downturn.

4) Capital gains are better than cashflow. The current economic environment is a prime example of what happens when people invest for capital gains alone. When the capital gains party stops wealth is devastated. With cashflow, however, businesses can operate as usual. It is estimated that 20 percent of real estate loans made during the housing boom went to investors. What if all of those investors had invested for cashflow? Price appreciation made cashflow impossible for most of the investor purchases that were made in the last 4 years. Absent cash flow, investor money would have remained on the sidelines, fewer loans would have been made, property valuations would have remained in check and part of the speculation that drove the recent housing market would have been absent.

What happens when the basic assumptions of an experiment prove false? The experiment fails. In medicine, a failed experiment sends everyone back to the drawing board looking for answers. Not so in the world of personal finance. Personal Finance is called personal finance for a reason. You are the person and it is your finance. You are the only one who goes back to the drawing board usually with less money than you started with. The broker who sold you the stocks made his money. The fee-only planner that you were told to use by Smart Money Magazine made her money. The fund manager made his money.

What is the solution? Education. Education of the financial type. Every waking minute of every waking day. Yes this is work, but it is the only way. Those who don?t want to do this type of work should remain participants in the observational experiment to whatever end. My financial planner made sure that I stayed out of 529 plans, and that I did not invest in IRAs outside of my 401K plan. The way to wealth is simple and it is the following:

1) Live below your means
2) If housing prices in your area are too high, rent, but aim to keep total housing costs at less than 20% of income
3) Buy a quality car no more often than every 10 years and maintain that car. Car leases and frequent new car purchases are among the greatest drainers of household wealth
4) Eliminate consumer debt.
5) Obtain skills in writing, sales and marketing
6) Save
7) Invest savings into income-producing assets:
a) businesses such as network marketing
b) real-estate
Work with those assets once you do invest to make sure they produce income.
9) Protect all assets via entities
10) Find advisors and partners that you can trust who have your interests in mind. They are not hard to find.
11) Understand yourself and your tolerance for risk. For many putting money into bonds and not giving financial education another thought is the best strategy.
12) Read a financial book per month and attend one business development seminar per year that teaches a specific skill
13) Stay away from mainstream financial magazines. They only offer the same pabulum that has left many high and dry, stripped of their wealth.
14) Subscribe to Investors Business Daily, The Financial Times or The Wall Street Journal
15) Stay away from personal development seminars but read personal development books
16) Implement the strategies and skills from the seminars and books

Your time investment will be at least 10 hours per week. Are you ready to invest the time and get going?

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Health sector Reforms in Andhra Pradesh

    A review on Health sector reforms in India   The health sector reforms in India were started way back in 1970s .The Govt. of India identifies the need HSR and stated in the eighth five year plan. The Eighth Five Year Plan (1992-1997) was the first plan document to state the need for re-structuring of economic management systems, following the macro developments of the 1990s. During this period in the health sector, the concept of free medical care was revoked and people were required to pay, even if partially, for the health services (1). The Ninth Five Year Plan (1997-2002) emphasized the need to review the response of the public, voluntary and private sector health care providers as well as the population themselves to the changing health scenario, to reorganize health services to bring about greater efficiency and effectiveness and to introduce health system reforms to enable the population to obtain optimum care at affordable cost The Ninth Plan sought to increase the involvement of voluntary, private organizations and self-help groups in the provision of health care and ensure inter-sectoral coordination in implementation of health programmes and health-related activities as well as enable the Panchayati Raj Institutions (PRI) in planning and monitoring of health programmes at the local level so as to bring about greater responsiveness to health needs of the people and greater accountability; to promote inter-sectoral coordination and utilise local and community resources for health care(2) .The Tenth Five Year Plan (2002-2007) touches upon reforms at primary, secondary and tertiary level(3).                         Politics influence health systems in significant manner. The goals, priorities, and the strategies, variations in the commitment are largely decided through the political contingencies. There are competing demands on the health systems. The evolution of the health systems is largely shaped by the culture, history, and norms. Client satisfaction is very high. As per NFHS-2 data, an overwhelming majority of clients are satisfied by the services delivered by the public systems. May be the expectations are low or may be our people are so courteous. But on the hand, we have the report from Transparent International, ranked the health system in India is the most corrupt system (4)   The Government has taken several steps for improving the public health care institutions and Strengthening the primary health care infrastructure. However, the situation is compounded by severe resource constraints – financial, technical and human power related, which has resulted in policy makers as well as programme managers at differing levels being faced with difficult choices. In such a situation, attempts are being made through various reform initiatives to ensure that the health needs of the people are met One of the major reform initiatives underway is the Secondary Health System Strengthening Project funded by the World Bank in seven states (Andhra Pradesh, Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar Pradesh). The projects include strengthening FRUs/CHCs and district hospitals so as to improve the availability of emergency care services to patients, to reduce overcrowding at district and tertiary care hospitals, construction works, procurement of equipment, increased availability of ambulances, drugs; improvement in quality of services following skill up gradation training in clinical management, changes in attitudes and behavior of health care providers; reduction in mismatches in health personnel / infrastructure; improvement in hospital waste management, disease surveillance and response system. It is essential to assess both progress and problems in implementation of the reforms in each state and to appropriately modify the content and pace of implementation. Such an overview and analysis of all related issues is necessary to provide evidence to policy makers and other stakeholders in terms of the various dimensions and impact of health sector reform.(5) In the Indian Constitution, health is a state responsibility. During Adjustment, many state governments in India had recourse to Health Systems Development Project loans from the World Bank for carrying out health sector reforms (HSR), of which one of the key policies has been to raise public spending on health care from the abysmally low levels seen up to then. The Health Systems Development Project seeks to develop strategic management capacity; strengthen performance, accountability, and efficiency; and build implementation capacity. Further, it seeks to improve clinical service quality by renovating and expanding district, sub district, and community hospitals and improving access to services. In all seven reforming states, around 15% of the total project cost is borne by the state governments. All the project documents note the low levels of funding for secondary hospitals in the reforming states. This is attributed to the small share of overall public spending allotted to health, the limited portion of total health spending going to hospitals, and, within this, a skewed distribution of funds in favour of the tertiary hospitals. After analysis of the problems of the health sector, the governments of the reforming states have agreed-using terminology ranging from “assurances” to “commitments”-to several undertakings. These are: (i) to enhance the overall size of the health budget; (ii) to redress imbalances in public expenditure between secondary and tertiary care levels; (iii) to safeguard the operations and maintenance components of current expenditure allocations for the secondary health-care sector; (iv) to charge user fees for selected services; and (v) to address workforce issues. The Health Systems Development Project initiated in the seven states recognizes the need for enhanced public spending on health and identifies it as the foremost policy reform to be pursued. Nevertheless, such assurances and conditions have not succeeded in enhancing health sector budgets in states implementing HSR. Worse, HSR has not been able to arrest the decline in the share of health spending within total government spending. The Indian system is especially complicated, as the larger tax resources are controlled by the central government but the major responsibility for health-care spending is bestowed on the states (6).Andhra Pradesh is the first state to go with the HSR.               Health sector reforms in Andhra Pradesh   The state of Andhra Pradesh was formed on 1st November, 1956 under the States’ reorganization scheme. It is the fifth largest State with an area of 2, 76, 754 sq. km, accounting for 8.4 % of India’s territory and also the fifth most populous state with a Population of 75 crores. The state has varied physiographic features ranging from high hills, undulating plains to a coastal deltaic environment. Administratively, Andhra Pradesh is divided into 23 districts, 79 revenue divisions, 1123 mandals, about 27000 villages and 264 towns. AP’s economy grew at 7.2% during 2006-07 — the fourth consecutive year of 6% plus growth. The latest poverty headcount ratio stands at 16%, compared to 23% for India . the third-highest credit rating among the major Indian states; the third best investment climate in the country; and the fourth-lowest corruption level among Indian states Andhra Pradesh was the first Indian state to receive a multi-sector Bank operation – the Andhra Pradesh Economic Restructuring Program for US$ 550 million in 1997 – aimed at helping the state accelerate policy and institutional reforms across a wide range of sectors under a common fiscal framework. It is also the only Indian state where the Bank has disbursed three budget support operations – the First Andhra Pradesh Economic Reform Loan (APERL-1) in March 2002, the Second APERL in February 2004, and the Third APERL in January 2007 – that sought to support the state’s development program.(12) Within AP there are regional, social and gender disparities. Health outcomes are worst among Scheduled Castes (16% of population) and Scheduled Tribes (7% of population), especially those living in underserved areas in North tribal and South drought prone districts, and for women. Effective delivery of quality basic health services is hampered by demand and supply side issues, including poor health infrastructure and staffing.(15)     The reform history in health sector in the State can be traced to Andhra Pradesh First Referral Health System Project, one of the first World Bank aided health system projects in the country. This project, launched in 1995 had been implemented by AP Vaidya Vidhana Parishad (APVVP). Agencies like World Bank and DFID are supporting the reform process in the State. The Bank supported the AP Economic Restructuring Project which included improvement of primary health care as one of the component.(7) The priority reforms focus on improved access to quality and responsive health services, strengthened governance and management in health sector, improved institutional mechanisms for community participation and systems for accountability; and strengthened financial management systems.(15)  The government of Andhra Pradesh [GoAP 1999] Vision 2020 document identifies a seven-point set of priorities for health sector reform: providing universal access to primary healthcare; encouraging private investment in tertiary healthcare; focusing on specific programmes to promote family planning; focusing on improving health levels in disadvantaged groups and backward regions; ensuring a strong prevention focus; enhancing the performance of the public health system; and formulating a state information education and communication (IEC) programme to broadcast information on preventive healthcare.(13) The Government of Andhra Pradesh is embarking on a major health sector reforms to improve health care delivery in the State. D.F.I.D. has expressed its willingness to support these initiatives with a grant of 100 Million pounds over the next five years (2006-2011). The reform initiative will include measures to improve the effectiveness and accountability of public health services, measures to focus on community centric preventive healthcare system and enhance access to quality healthcare for the poorer sections of the population(14) DFID will provide up to £40 million health sector budget support to the DoHMFW, GoAP, over 3 years 2007 – 2010. The sector support will build synergy with National Rural Health Mission (NRHM) which is a health sector reform program of the central government for decentralisation, pro-poor focus, strengthening service delivery(15)     The health sector support will be provided over three years (2007-08 – 2009- 10). It aims at increased use of quality health services, especially by the poorest people and in underserved areas.(16) The main outputs will be: a) Improved access to quality and responsive services, especially in remote and interior areas; b) Governance and management of health sector strengthened; c) Institutional mechanisms for community participation and systems for accountability in functioning; and Financial management systems strengthened and improved public expenditure on health.   The performance of health services would be measured against(17)

* greater effectiveness and improved outcomes of existing programs;
* improved efficiency in the allocation of resources;
* greater access and equity; and
* consumer satisfacfion

Reforms underway in health sector   The major reforms underway are classified under these categories and the activities are noted below and we will look each of them in detail    (I) Reorganization and restructuring of existing government health care system

Establishment of Andhra Pradesh Vaidya Vidhana Parishad Strengthening of referral institutions and fixing of service norms Improvement in drug supplies Formation of Andhra Pradesh Health, Medical & Housing Infrastructure Development Corporation (APHM&HIDC) Strengthening of PHCs as 24-hour MCH centers Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres

(II) Changes in health system organisation, delivery and Management

Formation of Hospital Advisory Committee/ Hospital Development Societies for all PHCs and FRUs/ teaching hospitals Provision of free travel bus passes to pregnant women for antenatal check ups Public Private Partnership

(III) Changes in financing methods

Sukhibhava Scheme (Improvement of Institutional Delivery Services Scheme) User fees

(IV) Reforms related to human resources

Integration and responsibilities of functionaries for planning, implementation and monitoring of programmes of HM & FW department

(V) Involving community in health service delivery and Provision

Women Health Volunteers Scheme

(VI) Reforms to quality of care

Performance indicators for grading the PHCs Performance rating of secondary hospitals

    1.Reorganization and restructuring of existing government health care system   A)Andhra Pradesh Vaidya Vidhana Parishad   AP, has created the Andhra Pradesh Vaidya Vidhana Parishad (APVVP) by enacting an Act in the Legislative Assembly in 1986(8) This was done with the objective to lay greater emphasis on development of both preventive as well as curative health care  and to strengthen necessary linkages at appropriate levels to ensure comprehensive medical and health care services. APVVP has undertaken World Bank assisted Andhra Pradesh First Referral Health Systems Project (APFRHSP) in 1994 for a period of seven years. This has been one of the major projects undertaken by APVVP. The objectives of the project included improvement of efficiency in the allocation and use of health resources through policy and institutional developments and enhanced performance of health system by improving the quality, effectiveness and coverage of health services at the first referral level.   B)Strengthening of referral institutions and fixing of service norms   basic service norms for various categories of hospitals under the administrative control of APVVP have been fixed thereby creating a hierarchy of hospitals according to services and facilities. This system of service norms and referral linkages had been developed with a view to optimise utilisation of resources, avoid duplication and wastage of resources, regulate patient flow and reduce cost of treatment by reduction of patient burden at tertiary hospitals. the district hospital has been prescribed to provide services in eleven specialties for which 9 civil surgeon specialists, 18-20 civil assistant surgeons, 54-84 paramedical staff and other supporting staff have been Posted. C)Improvement in drug supplies To ensure regular supply of drugs at all times and in all situations, a system of three sources of drug supply has been put in place for the hospitals under APVVP: (a) centralised drug procurement system under which the institution has been allotted drugs worth a particular amount based on bed strength (Rs 2000 per bed per quarter); (b) an emergency provision for drugs (Rs 100 per bed per month) has been made to every institution from where emergency procurement of drugs is made; (c) drugs which are in short supply and for which regular rate contract suppliers are not available have been stocked at the office of District Coordinators of Health Service. Under the APFRHSP, const-ruction and repair of 160 hospitals including 81 CHCs, 58 area hospitals and 21 district hospitals had been undertaken.(10)         D)Formation of Andhra Pradesh Health, Medical & Housing Infrastructure Development Corporation (APHM&HIDC)   a separate corporation has been set up in 1987 exclusively for developing housing and other infrastructure for medical and paramedical staff and constructing sub centers, PHCs, hospitals, dispensaries, clinics and other health care centers One of the major projects undertaken by APHM&HIDC has been the World Bank assisted India Population Project-VIII launched for improving the medical care facilities in urban slums in 74 municipalities.   E)Strengthening of PHCs as 24-hour MCH centers   In a move to make available maternal and child health care at all times, 470 PHCs in backward districts have been designated as round the clock Mother and Child Health Centre (earlier called women health centres). One staff nurse, one ANM and three support staff have been appointed in each centre on contractual basis. Staff nurses have been trained to conduct normal deliveries and refer emergency cases. Additional facilities like telephone and vehicle have been provided to the PHCs in order to assist communication and transport for referral of emergency cases. Provision has been made to conduct fortnightly specialist clinics of gynaecology and paediatrics in these centres to detect high risk pregnancies and neonates for referral to FRUs.   F)Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres   The State Government has decided to establish 108, CEmONC centres spread across every district so that pregnant mothers requiring emergency care do not have to travel more than 40-50 kms to receive specialist care. Training of MBBS doctors in anaesthesia, neonatal care and blood transfusion is also planned to support this scheme.   2)Changes in health system organisation, delivery and Management A)Formation of Hospital Advisory Committee/ Hospital Development Societies for all PHCs and FRUs/ teaching hospitals   Hospital Development Societies have been constituted in all tertiary hospitals under the control of Directorate of Medical Education.(18) and after implementing NRHM rogi kalyam samithi at every PHC were formed to ensure the adequate participation of local institution,with an aim to improve effective and efficient services with allowed flexible financial powers. These societies are examples for decentralization . Activities of the society include maintenance of the hospital (including sanitation & water supply, electricity, building & civil works and equipment), purchase of drugs & medicine supplies and equipment. The government has set norms and limits for undertaking these works which are to be adhered to by the Society. The ‘system works’, observed an Unicef team which assessed the impact of RKS towards the end of 2000. The system, however, is not without any lacunae. For, it was pointed out that “overall control of the local RKS bodies remain in the hands of the collector and if he is not interested in health care then the whole thing might just drift(13)   B)Provision of free travel bus passes to pregnant women for antenatal check ups(19)   The Government of Andhra Pradesh has started an innovative scheme in order to enable pregnant women in rural areas to avail antenatal check ups at the nearest PHC/area hospital or FRU. It has tied up with the State Road and Transport Corporation to issue free transportation bus tickets pass to be utilised for three visits. The ANM issues the bus passes to the pregnant women on her house visits.       C)Public Private Partnership(20)   ·         Management of Urban Health Centers by NGOs   Under the World Bank assisted Andhra Pradesh Urban Slum Health Care Project (APUSHCP), 192 urban health centers (UHCs) have been established in 74 municipal towns in 21 districts covering 1848 slums. After withdrawal of support by the World Bank, the project has been funded by the state government since 2002. The outcomes of the project show marked improvement in ANC coverage, institutional deliveries, post natal care and immunisation in the slum population.   ·         108 emergency services                           Govt. has tied up with satyam computers to provide emergency transportation which proved to a most successful programme and many states are following the same like Gujarath. The objective of 108 Ambulances is to save people in life emergency . One ambulance is given for three mandals. Each ambulance fitted with equipment worth Rs.17 lakhs renders its services in life emergencies, road and fire accidents (22)   ·         Rajiv arogya sree    The innovative Govt. insurance scheme to serve people of  poor from the serious ailments now attracting the nation as this programme succeeded. this scheme provides financial support to families of BPL upto 2 lakhs per anum for treating serious ailments. it is proposed to cover the entire state by 2nd October 2008 with the govt. paying the insurance premium for all the beneficiaries .an amount of rs.450 crores are provided to implement the scheme during 2008-09. (21)       3)Changes in financing methods   A)Sukhibhava Scheme(23)   Under the Scheme, a cash assistance of Rs.300 (Rs 200 towards transportation charges and Rs 100 for food and incidental expenses) is paid to pregnant women belonging to below poverty line families who come to government hospitals/APVVP hospitals/ teaching hospitals/PHCs/CHCs for delivery serv-ices. This assistance is payable only to those women with no living children or with one living child.   B)User fees:-   If user fees are charged their main use may lie in optimization of expenditure patterns and better allocation between facilities and within facilities(24). Reddy and Vandemoortele (1996), based on a comprehensive review of user financing of basic social services carried out for UNICEF, point to three other discouraging features of user fees: (1) user financing can result in a sharp reduction in the utilization of services, particularly among the poor; (2) gender biases, seasonal variations and regional economic disparities can aggravate the effects of user financing on equity; (3) user financing  quires adequate capacities, effective decentralisation and continued government support; and (4) user financing can undermine political support for the goal of universal coverage of basic social services. In 2001, the Commission on Macroeconomics and Health (2001) also reached a similar conclusion that user fees end up excluding the poor from essential healthservices, in 2005, the Millennium Project’s recent Report to the UN Secretary General (2005) titled “Investing in Development – A Practical Plan to Achieve the Millennium Development Goals” also forcefully argues for abandoning user fees. The health sector in India has acquired a notorious reputation for inefficiency and corruption at all levels. There is little accountability in both the public and private sectors. Quality standards are practically non-existent as are performance measures and honest reporting. A recent report on human resources for health brought out by Harvard University’s Global Equity Initiative (2004) argues that it is people – health workers alone – who can produce an effective health system and deliver good ealth.(25) 4)Reforms related to human resources Integration and responsibilities of functionaries for planning, implementation and monitoring of programmes of HM & FW department At district level, District Health Coordination Committee (DHCC) has been constituted to ensure proper planning, implementation and monitoring of all programmes/activities of HM&FW Department in the district.  The Committee has been entrusted with the primary responsibility of planning, finalizing, implementing and monitoring the District Health Action Plans and institutionwise health plans in a participatory manner including all concerned officials, other concerned departments and NGOs.   5)Involving community in health service delivery and Provision  

Women Health Volunteers Scheme

  One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist – ‘ASHA’ or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. Following are the key components of ASHA(26) A woman, usually a daughter-in-law of a house who has studied upto 7th class and preferably from SC/ST community has been selected as WHV by the Gram Panchayat Health Committee. The selected WHV has been given one month training in health care aspects of pregnancy, antenatal, delivery, post natal and new born care, immunisation, diarrhoea, acute respiratory infections, first-aid and treatment of minor ailments. The training has been provided at Telugu Mahila Pranganams for three weeks and one week field level training at PHCs. Academy of Nursing Studies has been designated as the nodal agency for providing training to WHVs.   6)Reforms to quality of care   A)Performance indicators for grading the PHCs   One of the components of World Bank assisted AP Economic Restructuring Project is improvement of primary health care. In order to improve the quality of primary health care services, a system of performance rating has been developed to rate PHCs and CHCs. The grading has been accorded A to C in descending order   B)Performance rating of secondary hospitals   A performance rating system for secondary hospitals under APVVP has been  introduced. The indicators related to general services (outpatients, inpatients, bed occupancy), emergency services (emergency-OP, emergency-IP, emergency major operations, emergency minor operations), clinical services (major/minor operations, tubectomy, deliveries) and diagnostic services (X-ray, ECG, lab tests and USG) have been developed for the purpose. Normative targets for each type of hospital (district hospital, area hospital, community health center) have been fixed against which the performance is measured and rating assigned. Highest grading is A while lowest grading is C.(27)   Conclusion:-   Introduction of user charges and subcontracting of services to the private sector are the main elements of health sector reforms. The health sector reforms are only a part of drastic reforms in other major sectors undertaken as a part of Andhra Pradesh Economic Restructuring Project (APERP) and the overall impact on the health conditions of people and their access to medical care depend more on the changes proposed outside the health sector. For instance, while exempting the white ration card holders i.e. the poor from the user charges in the government hospitals, it proposes to drastically reduce the number of white card holders to half in the state. The net affect would be to reduce the percent of population eligible for free treatment.(29)   On the other hand the success of 108 EMRI services and overwhelming response from Rajiv Arogya sree scheme are the examples for HSR success. Just like every thing has gots its own pros and cons HSR should be done in such a way where the need exist and according to necessities .   Referances:-   (Note:-most part of the article was taken from ref.no 28 otherwise reference specified)

(Government of India, Eighth Five Year Plan, (1992-1997) Planning Commission, New Delhi.) (Government of India, Ninth Five Year Plan, (1997- 2002) Planning Commission, New Delhi ) ( Government of India, Tenth Five Year Plan (2002-2007) Planning Commission, New Delhi) ( D. Agarwal Health Sector Reforms: Relevance in India, Indian Journal of Community Medicine Vol. 31, No. 4, October-December, 2006) Health Sector Reforms in India, Initiatives from Nine States ( http://www.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html.The international development research centre) http://www.worldbank.org.in  (The Andhra Pradesh Vaidya Vidhana Parishad Act 1986 (Act No. 29 of 1986 with Amendaments upto 31.03.1989  Dr. MCR Human Resource Development Institute of Andhra Pradesh (Undated). “Andhra Pradesh Vaidya Vidhana Parishad Departmental Manual”  6http://www.aponline.gov.in/apportal/departments/ departments.asp?dep=16&org=98 GoAP (2006), Response to Questionnaire on Health Sector Reforms from MOHFW, GoI. http://www.worldbank.org.in/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/INDIAEXTN/0,,contentMDK:20970681~pagePK:141137~piPK:141127~theSitePK:295584,00.html#Ongoing_projects Grish kumar,promoting PPP in health services,EPW commentary,july19,2002  (G.O.Ms.No.130, HEALTH MEDICAL AND FAMILY WELFARE (K2) DEPARTMENT. Dated the 24th April, 2006)  ANDHRA PRADESH HEALTH SECTOR REFORM PROGRAMME (APHSRP) Terms of reference for Technical Cooperation (TC) to DoHMFW, GoAP  PRESS INFORMATION BUREAU GOVERNMENT OF INDIA, HEALTHCARE PROJECT IN AP FUNDED BY DFID, New Delhi, March 5, 2008) http://lnweb90.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/0CFD6217A8A5BDA2852567F5005D32BD  G.O.Ms.No.403, dated Sept 7th 1998  GoAP (2006), Response to Questionnaire on Health Sector Reforms from MOHFW, GoI. Power Point Presentation of Govt of AP at the 2nd Regional Workshop on Health Sector Reforms: Experiences of Select States at Hyderabad, 14-15th February 2005 and ECTA Working paper 2002/61 Public-Private Partnership: Operational Framework used in Andhra Pradesh and Assam http://www.scribd.com/doc/2208678/AP-Budget-Speech  http://pibhyd.ap.nic.in/er27070702.pdf  Dept. of Health Medical Family Welfare, GoAP (undated), “Sukhibhava (Improvement of Institutional Delivery Services Scheme): Implementation Guidelines to PHC/Hospital  http://mohfw.nic.in/NRHM/Documents/CRM_report_full_report_version.pdf   (A.K.Shiv Kumar,,Budgeting for health ,some considerations) Economic and Political Weekly April 2, 2005  http://mohfw.nic.in/NRHM/asha.htm#abt http://health.ap.nic.in/apvvp/apvvp_stat.html  (http://www.whoindia.org/linkfiles/health_sector_reform_hsr_vol_ii_-_andhra_pradesh.pdf)  (Impact Of Health Sector Reforms On Hospital Services In Andhra Pradesh – A Study Of Trends In The Structures Of Provision And Utilisation Pattern)(centre for economic and social studies) (http://www.cess.ac.in/cesshome/research6b.html)

Make Money Online Working From Home

Real Financial Return for Your Time Invested Online

Have you tried making money online using other websites only to find yourself at a dead-end? Then, searched again and just repeated this process until you finally quit? Well, I’m glad you’re ready to try again and I’m also glad you found me!

The process that I use to make money online is very straightforward, to the point, and actually has a cash return for your invested time. It’s too easy to stop doing, and works too well to not believe it!

It’s called CashCrate and this is the source for my extra monthly cash flow!

CashCrate is simply a company that allows people to take surveys and complete offers for different products that you probably use everyday anyways and get paid for it. Companies pay CashCrate to do this because in turn, they believe you will eventually buy their product. CashCrate takes this money and pays its members (me and 800,000 other people) a portion just for giving our opinion for those products. Think of it like a TV commercial, online!

Just a Few Reasons to Join CashCrate

- FREE to sign up and FREE to use
- Multiple ways to earn cash, all of which are optional
- No fees or charges to use the website or the forum
- No credit card or bank information
- No selling or making phone calls
- You can stop anytime with no charge
- Real cash return for your time
- FREE Forum right there on the site to blog and ask questions
- Excellent customer service from the staff
- Monthly payouts can be sent by check and now directly deposited through PayPal!
- Easy-to-Use, interactive website layout
- Your earnings and pending earnings displayed live at your members page

Different Ways To Make Money With CashCrate

CashCrate has 3 main ways to earn some extra cash.

First, they have a database full of offers, trials, and surveys to fill out and register for with a payout anywhere from $0.20 to $80.00! These usually only take a few minutes each and a lot of them are free to do. You can sort them to find all the free ones, all the highest payouts, or all the new ones. You are also free to do the ones you want, when you want, and do not have to complete all of them! A lot of these offers are for services you might use or want anyways like DirecTV, Blockbuster, a magazine subscription, and eBay!

Second, they offer 2 daily surveys per day with a payout of $0.80 each giving you the opportunity to make $24.00 a month minimum without any other offers or referrals!

Third is the referral program. This is also an option and I can honestly say, this is the most successful referral program on any GPT website. They give you your own banners to display throughout the internet, your own member link, and tips on how to start gaining referrals. The members of CashCrate have actually blogged 100 different ways to gain more referrals!

Personally, I have created 3 websites, numerous blogs including this one, posted to related articles, printed custom business cards, and stamp my member banners anywhere and everywhere!

Proof of CashCrate’s Effectiveness

The title above is a link to the page on my website that displays my PayPal payment sent on October 17!   The second screenshot was taken only 10 days after I began my membership! The results you will see are with no referrals and I haven’t spent a penny of my own money and never will!

Be sure to check out the second screenshot from September 24th when CashCrate notified me about confirmed offers that I submitted. There are 22 confirmation e-mails in a row! These offers alone got me $6.55! Do this on a daily basis and imagine the cash flow!

Frequently Asked Questions about CashCrate

Are there any requirements for participation? You must be atleast 13 years old. Members from the United States and other English speaking countries will have the most offers available to them, but members from other countries are welcome as well.

How much can I make? How much you can make is dependent on a few things such as what country you’re from and how much time you’re willing to devote to making money. As it is, most members have the opportunity to make more than a thousand dollars!

When do I get paid? Users who meet our minimum payout (only $20!) have their payments processed by the 20th of the following month So, if you earn $250 in June, you’ll get paid in mid-July.

How does the referral program work? The referral program has two levels. You get paid 20% of what your direct referrals make and 10% of what THEIR referrals make. Members can make hundreds a month just by referring other members to our free program!

What’s the best way to get started? After you sign-up, you’ll be presented with a short message on how to complete offers along with a “fast-track”, which is a list offers which you should complete right away because they are high paying and take little time to complete.

Borrowed from CashCrate’s FAQ’s Page

Can I Join CashCrate?

Are you 13 or older? — Do you want to make some extra money?

If you answered Yes to both of those questions, you can join CashCrate! It’s that easy!

If you’re wondering who CashCrate is for, here is a small list of who some of the members are:

- Stay-at-Home Moms and Dads
- Newly-weds
- College, High School, and Middle School Students
- People trying to get out of debt
- People saving for that new product
- Anyone just wanting a little extra cash

As you can see, CashCrate is for just about anyone! Just as long as your over 13 years of age. Remember, CashCrate will never ask for your social security number, bank account info, or credit card info. All they ask is your name and email to join! The staff are very friendly and always there when you need help or have a question.

You have no risks, no obligations, and nothing to lose! So give it a try! After you’ve completed a few offers, send me a message through CashCrate’s Message Center and let me know how you’re doing!

Thanks for reading, and I hope you join with me!

Ready to Make Some Extra Money?

If you’re ready to start making some extra money and join CashCrate, follow these easy steps.

1. Read the information on this blog or CashCraters to get informed.
2. Click this link to be taken to CashCrate’s website: I Want To Join!
3. Sign Up Free – All they ask is your name and email!
4. Set up if you want to get paid by check (will need mailing address) or by PayPal
5. Begin taking offers and surveys and watch your earnings grow!
6. Tell all your friends and family to join with you!

I hope all of this information has helped you in your quest to finding the right choice in making money online. CashCrate has over 800,000 members and growing rapidly every day. Make CashCrate your choice and take advantage of this opportunity.

I Want To Join CashCrate Now! Remember, you can email me through my website at CashCraters.com and ask me questions or feel free to post a comment or question on this blog.   . Thanks again and enjoy CashCrate!

If you write your goals and just hope to magically achieve them without committing yourself to it then you are just like most people. It is common for a majority of people to get stuck in an endless cycle of goal setting and giving up right away – and not accomplishing any goals at all.

Commitment plays a large part in getting goals achieved. If you do not commit to achieving your goals, then your goals will seem unimportant and since it is not important, you will just be tempted to quit before you even get started. However, show some commitment to your goals and set daily reminders to yourself about these goals and you will be encouraged to achieve them.

It is not that hard to commit to your goals as long as you set your mind to it. Here are some doable steps:

1) Make sure the goals you set are important to you. This is tricky as it is easy to fool yourself into thinking that you want one particular thing when in reality you want something else. Take your time in figuring out what it is that your heart wants to achieve. Know your reason behind a specific goal. How will achieving the goal benefit you? How will you feel after accomplishing your goal?

It is best to write it down in a journal and keep it close by so that you can easily go back and read it as often as you need to. Writing it and reading your goals and reasons behind them over and over again will help you commit to the goal.

Don’t forget to ask yourself if the benefits you will get outweigh any effort that you will go through to achieve the goal. If you believe that the benefits outweigh the sacrifices, then, go for it – work on achieving your goal.

2) Make sure to consider the “what if’s”. Think about the consequences if you do not continue on with achieving your goal. If the consequences are not all that grave, then perhaps you need to reconsider your goals. Make your goals top priority wherein if you don’t work on achieving them, you’ll be faced with an unfavorable consequence. Be creative. You can promise to give something up if you do not achieve your goal. This way, you will try your best to ensure that your goal gets accomplished.

3) Renew your commitment each day. When your goal is new and your motivation is high, it is so easy to be committed. However, you need to stay committed until your goal is achieved. Make a conscious effort to remember your goal and its importance to you each day when you wake up. That is why it helps to write your goals down in a journal so you can read it over and over and remember its importance. Make a vow to work on your goal each day until it is achieved.

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Also in college what would you have to major in ?

Emerging demand of professional writing has also developed the scope for grant writing. One of the most important writing forms in demand these days, grant writing is a great option for writers who are looking to expand their niches. Most important element that such form of writing requires is proper understanding of writing requirement.

In this regard, large number of grant writing workshops and seminars are being organized at various places. Such kind of grant writing training sessions sharpen your writing skills and teaches you all sort of trick that will help you stand out amongst other competitors.

Grant writing is a form of proposal writing. It includes all sorts of research support, statistics and the events to support your assertions. All the aspects and major requirements of such writing are clearly explained in the grant writing seminars. Suppose if you are writing for a homeless shelter, the writing should be persuasive enough to convince readers about why there is an actual need of your program.

You are taught everything right from selecting the type of language, keywords, sentence framing and other minor aspects in the grant writing seminars. These help you to write crisp and within word limit article for clients.

Along with grant writing workshops, there are major sites dedicated for such writing works. These websites teach you how to write detailed, informative, clear, concise and organized text for the readers. Inclusion of who, what, where and how is a must when it comes to grant writing. This not only makes the text more understandable but also makes it appear more convincing.

Grant writing is similar to scientific writing and require you to measure all the changes occurred in behavior and knowledge. Most of the grant writing trainings makes you focus on writing SMART goals that are specific, measurable, attainable, realistic and timely.

One thing that should always be considered while writing grants is you should never ask the organization to grant as much fund as you want. It depends upon the organization to give you money as per their consideration. Therefore, instead of spending time on convincing them to grant particular amount, writers should work on presenting all sort of aspects that will lead the organization to shed maximum money.

Different Types Of Diabetes

There are two main types of diabetes and they are: type 1 diabetes, which usually insulin occurs when the body cannot produce and allows glucose to provide the energy for the same. Type 2 diabetes occurs when the body cannot use they insulin available in the body.

Diabetes nutrition is very important as the disease can easily turn fatal and cause kidney and/or heart failure. Here are a few suggestions, which may help you improve your present health state and live your life as normally as possible under the circumstances.

Eat Well And Exercise

Diabetes nutrition is mostly directed around non-starchy foods, vegetable and fruits and high in fiber such as spinach, broccoli or green beans along with your regular meals. Whole grains is yet another item included in the diabetes nutrition along with brown rice, pasta, lentils, fish couple of times a week and lean meats.

Diabetes nutrition will depend from person to person and therefore it is recommended not to start any without consulting your doctor or dietician first.

Diabetes nutrition will work even better to ensure your good health if you include an exercise in your daily routine as well such as a half hour daily walk or something light done in the comfort of your home.

It is important to keep your weight under control when you suffer from diabetes as any other complication can create fatal effects for the same.

Helpful Tip

Checking your daily blood sugar as often as you feel is required is key when you have diabetes and thus, you can control your diabetes nutrition as well. Diabetes can be kept under control and you too can lead a healthy and normal life benefiting from its beauty and pleasure if you understand you disease and make all efforts to accommodate the same in the best possible way.

Check with your doctor for a diabetes nutrition plan and/or your dietician who will be happy to assist and help you with the same. The sooner you understand your disease the better will be for you and your body.

Effective leadership is essential for organizations in today’s competitive market. Business leadership coaching can recognize skill deficiencies and then provide the necessary support.

Even if you are a top performer in the technical aspect of your role, you may lack effective people and management skills to lead and inspire teams and individuals.

Rather than seeking new employees the focus for organizations today is managing the talent they have. Business leadership coaching helps to retain the intellectual capital of organizations. It improves employee confidence and skill, as well as significantly affecting bottom-line results.

Like with any coaching relationship, business leadership coaching must allow all parties to feel comfortable. Therefore, in addition to their business, clients are encouraged to choose coaches that offer a program that fit their personalit. Most business leadership coaches offer flexible and yet tailored programs that ensure action-oriented, result focused, practical programs.

Those typically involved in the program are the coach, the coached individual/team, the coachee’s team manager, and/or the client sponsors. This is to ensure that the business leadership coach provides optimal support by discussing the engagement process and quality check points with all the parties involved, thus enhancing the effectiveness for the individuals and organization.

Coaches help individuals define, create, and move forward toward their vision of what they want to be and how they want to be seen in the world through one-on-one coaching, facilitated learning and assessments. Business leadership coaching can be conducted in person, over the phone, or through the web. This helps to allow for travel, geography, and busy schedules,.

Business leadership coaching is for high-achieving individuals who are looking to get the next level of success. By asking questions that provoke deep thinking and being a sounding board self awareness is heightened. This leads to qualitative change by creating an inspiring and empowering environment which promotes action and self discovery.

Clients learn that leadership comes when they play their role authentically-in character, rather than out of character. Business leader coaching helps clients to find their leadership focus and redefine their leadership role. By stripping away non essentials and making way for new thinking and action they learn how to reshape their perceptions as a leader. Clients learn that achievement comes with clear defined goals and dedicated action.

Business leadership coaching helps to pave new ways of behaving, even with the many distractions that business people face such as multiple objectives, tough problems, day-to-day busyness and expectations of having to be an over-achiever in order to be a leader. Clients find ways to turn ordinary activities into business leadership opportunities. They learn to work with their strengths and tailor their work to fit with who they are rather than fighting with their own personality.

Business leader coaching helps individuals to become more powerful leaders.

Business leadership coaching can be the resource to help you get there if you are ready to create the life you want.