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Human resources section3c-textbook_on_public_health_and_community_medicine


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AFMC WHO Textbook Community Medicine

AFMC WHO Textbook Community Medicine

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  • 1. Organization of Health Care in Community level 84 India For a successful primary health care programme, effective referral support is to be provided. For this purpose one Community Health Centre (CHC) has been established for every Leo S. Vaz 80, 000 to 1, 20, 000 population, and this centre provides the basic specialty services in general medicine, pediatrics, surgery,The Health Care Services Organization in the country extends obstetrics and gynecology.from the national level to village level. Community Health Centres (CHCs)Central level CHCs are being established and maintained by the StateThe organization at the national level consists of the Union Government. It is manned by four medical specialists i.e.Ministry of Health and Family Welfare. The Ministry has three Surgeon, Physician, Gynecologist and Pediatrician supporteddepartments, viz. - Department of Health & Family Welfare, by 21 paramedical and other staff. It has 30 in-door beds withDepartment of Ayurveda, Yoga-Naturopathy, Unani, Sidha & one OT, Xray, Labour Room and Laboratory facilities. It servesHomeopathy (AYUSH) and Department of Health Research. as a referral centre for 4 PHCs and also provides facilities forEach of these departments is headed by respective secretaries obstetric care and specialist consultations. As on March, 2007,to Govt of India. The department of Health & Family Welfare there are 4, 045 CHCs functioning in the country. The presentis supported by a technical wing, the Directorate General of staffing pattern of CHCs is as in Box - 1.Health Services, headed by Director General of Health Services(DGHS). Box - 1 : Staffing Community Health Centre S. Staff For Community Existing IPHSState level No Health Centre proposedThe organization at State level is under the State Department of 1 Medical Officer# 4 7Health and Family Welfare in each State headed by Minister andwith a Secretariat under the charge of Secretary/Commissioner 2 Nurse Mid-Wife (staff Nurse) 7 9(Health and Family Welfare). The State Directorate of Health 3 Dresser 1 1Services, as the technical wing, is an attached office of the 4 Pharmacist/Compounder 1 1State Department of Health and Family Welfare and is headedby a Director of Health Services. The area of medical education 5 Laboratory Technician 1 1which is with the Directorate of Health Services at the State, 6 Radiographer 1 1is known as Directorate of Medical Education and Research. 7 Ward Boys 2 2This Directorate is under the charge of Director of MedicalEducation, who is answerable directly to the Health Secretary/ 8 Dhobi 1 -Commissioner of the State. Some states have created the posts 9 Sweepers 3 3of Director (Ayurveda) and Director (Homeopathy). Theseofficers enjoy a larger autonomy, although sometimes they still 10 Mali 1 -fall under the Directorate of Health Services of the State. 11 Chowkidar 1Regional level 12 Aya 1 -In some states like Bihar, Madhya Pradesh, Uttar Pradesh, 13 Peon 1 -Andhra Pradesh, Karnataka and others, zonal or regional 14 OPD Attendant 5*or divisional set-ups have been created between the 15 Stat Asst. / Data Entry OperatorState Directorate of Health Services and District HealthAdministration. Each regional/zonal set-up covers three to 16 OT attendantfive districts and acts under authority delegated by the State 17 Registration clerkDirectorate of Health Services. 18 Ophthalmic Asst. 1District level Total : 25 31All health care programmes in a district are placed under a # : Surgeon, Obstetrician, Physician, Pediatrician, Anaesthetist, Public healthunified control. It is a link between the State/ regional structure programme manager, Eye surgeon.on one side and the peripheral level structures such as PHC/ * Sr No. 11, and 14 - 17 - total 5, flexibility rests with State for recruitmentsub-centre on the other side. The district officer with the overall as per needcontrol is designated as the Chief Medical and Health Officer(CM & HO) or as the District Medical and Health Officer (DM Primary Health Centre (PHC)& HO). These officers are popularly known as DMOs or CMOs, PHCs are the cornerstone of rural health services- a first port ofand are overall in-charge of the health and family welfare call to a qualified doctor of the public sector in rural areas for theprogrammes in the district. These DMOs/CMOs are assisted by sick and those who directly report or referred from Sub-centresDy. CMOs and programme officers. for curative, preventive and promotive health care. The Bhore • 457 •
  • 2. Committee in 1946 gave the concept of a PHC as a basic health Sub-Centreunit to provide as close to the people as possible, an integrated The Sub-Centre is the most peripheral and first contact pointcurative and preventive health care to the rural population with between the primary health care system and the community.emphasis on preventive and promotive aspects of health care. Sub-Centres are assigned tasks relating to interpersonalThe health planners in India have visualized the PHC and its communication in order to bring about behavioral change andSub-Centres (SCs) as the proper infrastructure to provide health provide services in relation to maternal and child health, familyservices to the rural population. The central Council of Health welfare, nutrition, immunization, diarrhoea control and controlat its first meeting held in January 1953 had recommended of communicable diseases programmes. The Sub-Centres arethe establishment of PHCs in Community Development Blocks. provided with basic drugs for minor ailments needed for takingThese centres were functioning as peripheral health service care of essential health needs of men, women and children.institutions with little or no community involvement. They There are 1,45,272 Sub Centres functioning in the countrywere not able to provide adequate health coverage, partly, as on March 2007. Currently a Sub-centre is staffed by onebecause they were poorly staffed and equipped and lacked Female Health Worker commonly known as Auxiliary Nursebasic amenities. The 6th Five year Plan (1983-88) proposed Midwife (ANM) and one Male Health Worker commonly knownreorganization of PHCs on the basis of one PHC for every as Multi Purpose Worker (Male). One Health Assistant (Female)30,000 rural population in the plains and one PHC for every commonly known as Lady Health Visitor (LHV) and one Health20,000 population in hilly, tribal and backward areas for more Assistant (Male) located at the PHC level are entrusted witheffective coverage. the task of supervision of all the Sub-centres (generally sixPHC is the first contact point between village community and subcentres) under a PHC. The Ministry of Health & FW, GOIthe Medical Officer. The PHCs were envisaged to provide an provides assistance to all the Sub-centres in the country sinceintegrated curative and preventive health care to the rural April 2002 in the form of salary of ANMs and LHVs, rent (ifpopulation with emphasis on curative, preventive, Family located in a rented building) and contingency, in addition toWelfare Services and promotive aspects of health care. One drugs and equipment kits. The salary of Male Health Worker isPrimary Health Centre covers about 30,000 (20,000 in hilly, borne by the State Governments. The staffing pattern of sub-desert and difficult terrains) or more population. Many rural centre is depicted in Box - 3.dispensaries have been upgraded to create these PHCs. Atpresent, a PHC is manned by a Medical Officer supported by Box - 3 : Staffing Sub centre14 paramedical and other staff. It acts as a referral unit for 6 S. IPHSsub-centres and refer out cases to Community Health Centres Staff For Sub-Centre Existing No proposed(CHCs-30 bedded hospital)/sub-district/district hospitals. It has4-6 indoor beds for patients. There are 22, 370 PHCs functioning 1. Health Worker(Female)/ANM 1 2as on March 2007 in the country. The staffing pattern of new 2. Health Worker (Male) 1 1primary health centre is shown in Box - 2. Voluntary Worker (optional on 3. 1 1 honorarium) Box - 2 : Staffing Primary Health Centre Total 2/3 3/4 S. Staff for New Primary IPHS Existing No. Health Centre proposed The shortfall in the rural health infrastructure, based on 1. Medical Officer 1 2 2001 population census, has been depicted in Box - 4. 2. Pharmacist 1 1 Box - 4 : Shortfall in Rural Health Infrastructure All 3. Nurse Mid-wife (Staff Nurse) 1 3 India 4. Health Worker (Female)/ANM 1 1 As per Existing % 5. Health Educator 1 1 2001 Required (as on 31 Shortfall Shortfall 6. Health Assistant (Male) 1 1 Population Mar 2007) Health Assistant Female)/ Sub-Centres 158792 145272 20855 13. 13 7. 1 1 LHV PHCs 26022 22370 4833 18. 57 8. Upper Division Clerk 1 1 CHCs 6491 4045 2525 38. 90 9. Lower Division Clerk 1 1 Note : All India shortfall is derived by adding state-wise figures of shortfall ignoring the existing surplus in some of the states. 10. Laboratory Technician 1 1 Source : Bulletin of Rural Health Statistics in India, MOHFW (GOI), 2007. Driver (Subject to availability 11. 1 * of Vehicle) Indian Public Health Standards (IPHS) 12. Class IV 4 4 The overall objective of IPHS is to provide health care that is Total 15 17/18 quality oriented and sensitive to the needs of the community. *Optional / vehicle may be outsourced In order to provide optimal level of quality health care, a set of standards are being recommended for Community Health • 458 •
  • 3. Centre /Primary Health Centre/sub centre. The IPHS for Primary 8. Promotion of Safe Drinking Water and Basic SanitationHealth Centres has been prepared keeping in view the resources 9. Prevention and control of locally endemic diseases likeavailable with respect to functional requirement for Primary malaria, Kalaazar, Japanese Encephalitis, etc.Health Centre with minimum standards such as building 10. Disease Surveillance and Control of Epidemics :manpower, instruments, and equipments, drugs and other Disinfection of water sources and Promotion of sanitation.facilities etc. These standards would help monitor and improvethe functioning of the PHCs. The objectives of IPHS for PHCs 11. Collection and reporting of vital eventsare : 12. Education about health / Behaviour Changei. To provide comprehensive primary health care to the Communication (BCC) community through the Primary Health Centres. 13. National Health Programmes including Reproductiveii. To achieve and maintain an acceptable standard of quality and Child Health Programme (RCH), HIV/AIDS control of care. programme, Non communicable disease control programme,iii. To make the services more responsive and sensitive to the Revised National Tuberculosis Control Programme needs of the community. (RNTCP)Minimum Requirements at the Primary Health Centre for 14. Referral Services : Appropriate and prompt referral ofmeeting the IPHS : cases needing specialist care.1. Medical care : 15. Training : Training of Health workers and traditional(a) OPD services : 4 hours in the morning and 2 hours in the birth attendants; Initial and periodic training of paramedicsafternoon / evening. Minimum OPD attendance should be 40 in treatment of minor ailments; Training of ASHAs. Periodicpatients per doctor per day. training of Doctors through Continuing Medical Education,(b) 24 hours emergency services : Appropriate management Training of ANM and LHV in antenatal care and skilled birthof injuries and accident, First Aid, Dog bite/snake bite/scorpion attendance.bite cases, and other emergency conditions 16. Basic Laboratory Services : Essential Laboratory services(c) Referral services 17. Monitoring and Supervision : Monitoring and supervision(d) In-patient services (6 beds) of activities of sub-centre.2. Maternal and Child Health Care including family 18. AYUSH services as per local people’s preference :planning: (Mainstreaming of AYUSH).a) Antenatal care : Early registration of all pregnancies and 19. Rehabilitation : Disability prevention, early detection,minimum 3 antenatal checkups with minimum laboratory intervention and referral.investigations. 20. Selected Surgical Procedures : The vasectomy, tubectomyb) Intra-natal care : (24-hour delivery services both normal (including laparoscopic tubectomy), MTP hydrocelectomy and ,and assisted) Promotion of institutional deliveries, appropriate cataract surgeries as a camp/fixed day approach have to beand prompt referral for cases needing specialist care. carried out in a PHC having facilities of O.T.c) Postnatal Care : Two postpartum home visits, first within 21. Record of Vital Events and Reporting48 hours of delivery, 2nd within 7 days through Sub-centre Charter of Patients’ Rights for Primary Health Centres :staff, essential new born care, provision of facilities under Primary Health Centres exist to provide health care to everyJanani Suraksha Yojana (JSY). citizen of India within the allocated resources and availabled) New Born care facilities.e) Care of the child : Emergency care of sick children including 1. The Charter seeks to provide a framework, which enablesIntegrated Management of Neonatal and Childhood Illness citizens to know(IMNCI), full Immunization of all infants and children against ●● What services are available and users’ charges if any.vaccine preventable diseases, Vitamin A prophylaxis to the ●● The quality of services they are entitled to.children. ●● The means through which complaints regarding denial orf) Family Planning : Education, Motivation and counseling poor qualities of services will be addressed.towards family planning, Provision of contraceptives. 2. Objectives3. Medical Termination of Pregnancies using Manual ●● To make available health care services and the relatedVacuum Aspiration (MVA) technique. (wherever trained facilities for citizens.personnel and facility exists) ●● To provide appropriate advice, treatment, referral and support that would help to cure the ailment to the extent4. Management of Reproductive Tract Infections / Sexually medically possible.Transmitted Infections ●● To redress any grievances in this regard.5. Nutrition Services (coordinated with ICDS) 3. Commitments of the Charter6. School Health : Regular check ups, appropriate treatment ●● To provide access to available facilities withoutincluding deworming, referral and follow-ups. discrimination.7. Adolescent Health Care : Life style education, counseling, ●● To provide emergency care, if needed on reaching the PHC.treatment. • 459 •
  • 4. ●● To provide adequate number of notice boards detailing 5. Universal Immunization Programme (UIP) : He/she will the location of all the facilities and the schedule of field plan and implement UIP in line with the latest policy and visits. ensure cent percent coverage of the target population in●● To provide written information on diagnosis, treatment the PHC (i.e. pregnant mothers and new born infants). being administered. 6. National Vector Borne Disease Control Programme (NVBDCP)●● To record complaints and respond at an appointed time. : He/she will be responsible for all NVBDCP operations for4. Grievance redressal : Grievances that citizens have will Malaria, Kala Azar and JE in his/her PHC area and will bebe recorded. Aggrieved user after his/her complaint recorded responsible for all administrative and technical matters.would be allowed to seek a second opinion at CHC. 7. Control of Communicable Diseases : He/she will ensure5. Responsibilities of the users : Users of PHC would attempt that all the steps are being taken for the control ofto understand the commitments made in the charter and would communicable diseases and for the proper maintenance ofnot insist on service above the standard set in the charter sanitation in the villages.because it could negatively affect the provision of the minimum 8. Leprosy : He/she will provide facilities for early detectionacceptable level of service to another user. Instructions of of cases of Leprosy and confirmation of their diagnosisthe PHC personnel would be followed sincerely, and in case and treatment.of grievances, the redressal mechanism machinery would be 9. Tuberculosis : He/she will provide facilities for earlyaddressed by users without delay. detection of cases of Tuberculosis, confirmation of their diagnosis and treatment and also ensure functioning6. Performance audit and review of the charter : Performance of Microscopic Centre (if the PHC is designated so) andaudit may be conducted through a peer review every two or provision of DOTS.three years after covering the areas where the standards have 10. Sexually Transmitted Diseases (STD) : He/she will ensurebeen specified. that all cases of STD are diagnosed and properly treatedDuties of Medical Officer, Primary Health Centre and their contacts are traced for early detection.The Medical Officer of Primary Health Centre (PHC) is responsible 11. School Health : He/she will visit schools in the PHC areafor implementing all activities grouped under Health and Family at regular intervals and arrange for Medical Checkups,Welfare delivery system in PHC area. He/she is responsible in immunization and treatment with proper follow up ofhis individual capacity, as well as over all in charge. those students found to have defects.I. Curative Work 12. National Programme for Prevention of Visual Impairment and Control of Blindness : He/she will make arrangements1. The Medical Officer will organize the dispensary, outpatient for rendering treatment for minor ailments and testing of department and will allot duties to the ancillary staff to vision. ensure smooth running of the OPD.2. He/she will attend to cases referred to him/her. III. Training : He/she will organize training programmes3. He/she will screen cases needing specialized medical including continuing education for the staff of PHC and ASHA attention including dental care and nursing care and refer under the guidance of the district health authorities and Health them to referral institutions. & Family Welfare Training centres.4. He/she will provide guidance to the Health Assistants, IV. Administrative Work : He/She will carry out all Health Workers, Health Guides and School Teachers in the administrative activities required for smooth running of the treatment of minor ailments. PHC.5. He/she will visit each Sub-centre in his/her area at least Job Responsibilities of Health Educator once in a fortnight on a fixed day not only to check the The Health Educator will function under the technical work of the staff but also to provide curative services. supervision and guidance of the Block Extension Educator.6. Organize and participate in the “health day” at Anganwadi However, he/she will be under the immediate administrative Centre once in a month. control of the PHC Medical Officer. He/she will be responsible forII. Preventive and Promotive Work providing support to all health and family welfare programmes1. The Medical Officer will ensure that all the members of in the block. His duties and functions are : his/her Health Team are fully conversant with the various 1) He/she will have with him/her all information relevant to National Health & Family Welfare Programs including development activities in the block, particularly concerning NRHM to be implemented in the area allotted to each health and family welfare, and will utilize the same for Health functionary. He/she will further supervise their programme planning. work periodically both in the clinics and in the community setting to give them the necessary guidance and direction. 2) He/she will develop his/her work plan in consultation with2. He/she will keep close liaison with Block Development the medical officer of his/her PHC and the concerned Block Officer and his/her staff, community leaders and various Extension Educator. social welfare agencies in his/her area. 3) He/she will collect and interpret the data in respect of3. He/she will coordinate and facilitate the functioning of extension education work in his/her PHC area. AYUSH doctor in the PHC. 4) He/she will be responsible for regular maintenance of records4. He will plan and implement the Reproductive and Child of educational activities, tour programmes, daily dairies and Health Programme. other registers, and will ensure preparation and display of • 460 •
  • 5. relevant maps and charts in the PHC. ●● Participate as a member of the health team in mass camps5) He/she will assist the Medical Officer, PHC in conducting and campaigns in health of health workers under the MPW and ASHA and other ●● Help the health workers to work as part of the healthschemes under NRHM. team.6) He/she will organize the celebration of health days and 3. Supplies, equipment and maintenance of Sub-centres : Inweeks and publicity programmes at local fairs, on market days, collaboration with the health assistant male, check at regularetc. intervals the stores available at the sub-centre and help in the procurement of supplies and equipment.7) He/she will organize orientation training for health and familywelfare workers, opinion leaders, local medical practitioners, 4. Records and Reports :school teachers, dais and other involved in health and family ●● Scrutinize the maintenance of records by the Health Workerwelfare work. Female and guide her in their proper maintenance. ●● She will carry with her the proper record forms, diary and8) He/she will assist the organizing of mass communication guidelines for identifying suspected Kala-Azar and JEprogrammes like film shows, exhibition, lecturers and dramas. cases.9) He/she will supervise the work of field workers in the area of ●● She will be responsible along with Health Assistant Maleeducation and motivation. for ensuring complete treatment of Kala-Azar and JE10) He/she will supply education material on health and family patients in his area.welfare to health workers in the block. ●● She will be responsible along with health assistant male11) While on tour he/she will verify entries in the eligible for ensuring complete coverage during the spray activitiescouple register for every village and do random checking of and search welfare acceptors. 5. Training12) While on tour he/she will check the available stock of ●● Organize and conduct training for dais/ASHA with theconventional contraceptive with the depot holders and the kits assistance of the health worker female.with MPHWs and ASHAs. ●● Assist the medical officer of the primary health centre in conducting training programme for various categories of13) He/she will help field workers in winning over resistant cases health personnel.and drop-outs in the health and family welfare programmes. 6. Maternal and Child Health :14) He/she will maintain a complete set of educational aids on ●● Conduct weekly MCH clinics at each Sub-centre with thehealth and family welfare for his/her own use and for training assistance of the health worker female and dais.purpose. ●● Conduct deliveries when required at PHC level and provide15) He/she will organize population education and health domiciliary and midwifery sessions in schools and for out-of school youth. 7. Family Planning and Medical Termination of Pregnancy16) He/she will maintain a list of prominent acceptors of family ●● She will ensure that health worker female maintains up-toplanning method and opinion leaders village wise and will try date eligible couple registers all the involve them in the promotion of health and family welfare ●● Conduct weekly family planning clinics along with the MCHprogrammes. clinics at each Sub-centre with the assistance of the health17) He/she will prepare a monthly report on the progress of worker female. Provide information on the availability ofeducational activities in the block and send it to the higher services for medical termination of pregnancy and referauthority. suitable cases to the approved institutions.Job Responsibilities of Health Assistant Female (LHV - Lady ●● Personally motivate resistant case for family planning.Health Visitor) (Female Supervisor) 8. NutritionUnder the Multipurpose Workers Scheme, a Health Assistant ●● Ensure that all cases of malnutrition among infantsFemale is expected to cover a population of 30,000 (20,000 in and young children (0-5 years) are given the necessarytribal and hilly areas) in which there are six Sub-centres, each treatment and advice and refer serious cases to the primarywith the health worker female. The health assistant female will health centre.carry out the following duties : ●● Ensure that iron and folic acid, vitamin A are distributed to1. Supervise and guide the beneficiaries as prescribed.●● Supervise and guide the Health Worker Female, Dais and 9. Universal Immunization Programme : Supervise the guide ASHA in the delivery of health care service to the immunization of all pregnant women and children (0-5 years). community. 10. Acute Respiratory Infection :●● Visit each sub-centre at least once a week on a fixed day to ●● Ensure early diagnosis of pneumonia cases. observe and guide the Health Worker Female in her day to ●● Provide suitable treatment to mid/moderate cases of ARI. day activities under various National Health Programmes. ●● Ensure early referral in doubtful/severe cases.2. Team Work 11. School Health : Help medical officers in school health●● Assist the Medical Officer of the primary health centre in services. the organization of the different health services in the 12. Primary Medical Care : Ensure treatment for minor area. ailments provide ORS & first aid for accidents and emergencies • 461 •
  • 6. and refer cases beyond her competence to the primary health during his visit to the field and collect thick and thincentre or nearest hospital. smears from any fever case he comes across and he will13. Health Education : Carry out educational activities for administer presumptive treatment of prescribed dosage ofMCH, Family Planning, Nutrition and Immunization, Control of Anti-malarial drugs.blindness, Dental care and other National Health Programmes ●● He will be responsible for prompt radical treatment tolike leprosy and Tuberculosis with the assistance of the Health positive cases in his area.Worker Female. ●● Supervise the spraying of insecticides during local spraying along with the Health Worker Male. Where Kala-Azar andJob Responsibilities of Health Assistant Male (Supervisor) JE is endemic he will supervise the work of Health WorkerUnder the Multipurpose workers scheme, a health assistant Female.male is expected to cover a population of 30,000 (20,000 in ●● He should verify that the Health Worker Male really visitedtribal and hilly areas) in which there are six Sub-centres, each those houses and identified suspected Kala-Azar and JEwith the health worker male. The Health Assistant Male will cases and ensured complete treatment has been donecarry out the following duties : properly.1. Supervise and guide ●● He will carry with him the proper record forms, diary and●● Strengthen the knowledge and skills of the health worker guidelines for identifying suspected Kala-Azar and JE male and supervise and guide him in the delivery of health cases. care service to the community. ●● He will be responsible for ensuring complete coverage●● Visit each Health Worker Male and at least once a week to treatment of Kala-Azar and JE patients in his area. observe and guide him in his day to day activities. ●● He will be responsible for ensuring complete coverage●● Assess monthly the progress of work of the Health Worker during the spray activities and search operation. Male. ●● He will also undertake health education activities●● Carry out supervisory home visits in the area of the health particularly through interpersonal communication, worker male. arranging group meetings with leaders and organizing2. Team Work and conducting training of community leaders with the●● Help the health workers to work as part of the health assistance of health team. team. 6. Communicable Disease●● Coordinate his activities with those of the Health Assistant ●● Be alert to the sudden outbreak of epidemics of diseases, Female and other health personnel including the dais and such as diarrhoea/dysentery, fever with rash, jaundice, health guide. encephalitis, diphtheria, whooping cough or tetanus●● Coordinate the health activities in his area with the poliomyelitis, tetanus neonatorum, acute eye infections activities of workers of other departments and agencies and take all possible remedial measures. and attend meeting at PHC level. ●● Take the necessary control measures when any noticeable●● Conduct staff meetings fort nightly with the health workers disease is reported to him. in coordination with the Health Assistant Female at one of ●● Carryout the destruction of stray dogs with the help of the the Sub-centres by rotation. Health Worker Male.●● Attend staff meetings at the Primary Health Centre. 7. Leprosy●● Assist the medical officer of the Primary Health Centre ●● In cases suspected of having leprosy take skin smears and in the organization of the different health services and send them for examination. conducting training programmes for various categories of ●● Ensure that all case of leprosy take regular and complete health personnel. treatment and inform the medical officer PHC about any●● Participate as a member of the health team in mass camps defaulters to treatment. and campaigns in health programmes. 8. Tuberculosis3. Supplies, equipment and maintenance of Sub-centres ●● Check whether all cases under treatment for Tuberculosis●● In collaboration with the Health Assistant Female, check are taking regular treatment, motivate defaulters to take at regular intervals the stores available at the Sub-centre regular treatment and bring them to the notice of the and ensure timely placement of indent for and procure the Medical Officer, PHC. supplies and equipment in good time. ●● Ensure that all cases of Tuberculosis take regular and●● Check that the drugs at the Sub-centre are properly stored complete treatment and inform the Medical Officer, PHC and that the equipment is well maintained. about any defaulters to treatment.4. Records and Reports : Scrutinize the maintenance of 9. Environmental Sanitationrecords by the Health Worker Male and guide him in their ●● Help the community sanitation for safe water sources,proper maintenance. Soakage pits, Manure pits, Compost pits, Sanitary latrines,5. Malaria Smokeless chullas and supervise their construction.●● He will supervise the work of Health Worker Male. He ●● Supervise the chlorination of water sources including should check minimum of 100 of the houses in a village to wells. verify the work of the Health Worker Male. 10. Universal Immunization Programme : Conduct●● He will carry with him a kit for collection of blood smears immunization of all school going children with the help of the • 462 •
  • 7. Health Workers Female. and refer them to nearest approved institution. Educate the11. Family Planning community of the consequences of septic abortion and inform●● Personally motivate resistant case for family planning. them about the availability of services for medical termination●● Guide the Health Worker Male in establishing female depot of pregnancy. holders. 4. Nutrition : She will identify cases of malnutrition among●● Assist M.O. PHC in organization of family planning camps infants and young children (zero to five years) give the and drives. necessary treatment and advice and refer serious cases to the●● Provide information on the availability of services for Primary Health Centre. She will distribute Iron and Folic Acid medical termination of pregnancy and refer suitable cases (IFA) tablets as prescribed to pregnant nursing mothers and to the approved institutions. administer Vitamin A solution to children. She will educate the●● Ensure follow up of all cases of vasectomy, tubectomy, IUD community about nutritious diet for mothers and children in and other family planning acceptors. coordination with Anganwadi Workers.Job Responsibilities of Health Worker Female (ANM) 5. Universal Programme on Immunization (UIP) : She will1. Maternal and Child Health : She will register and provide immunize pregnant women with tetanus toxoid, administercare to pregnant women throughout the period of pregnancy. She DPT, oral polio, measles and BCG vaccine to all infants andwill ensure that every pregnant woman makes at least 3 (three) children, (Hepatitis-B in pilot areas) as per immunizationvisits for ante natal check-up, estimate their haemoglobin level schedule.and test urine of these women for albumin and sugar. She will 6. Dai Training : She will list Dais in her area and involve themrefer all pregnant women to PHC for RPR test for syphilis and in promoting Family Welfare and help the Health Assistantrefer cases of abnormal pregnancy and cases with medical and Female / LHV in the training programme of Dais.gynaecological problems to Health Assistant Female (LHV) or 7. Communicable Diseases : She will notify the Health Workerthe Primary Health Centre. She will conduct deliveries in her Male/MO PHC immediately about any abnormal increase inarea when called for and supervise deliveries conducted by cases of diarrhoea/dysentery, fever with rigors, fever withDais and assist them whenever called in. She will refer cases rash, fever with jaundice or fever with unconsciousness whichof difficult labour and newborns with abnormalities, help them she comes across during her home visits, take the necessaryto get institutional care and provide follow up to the patients measures to prevent their spread. If she comes across a casereferred to or discharged from hospital. She will identify the of fever during her home visits she will take blood smear,ultimate beneficiaries, complete necessary formalities and administer presumptive treatment and inform Health Workerobtain necessary approvals of the competent authority before male for further action. She will Identify cases of skin patches,disbursement to the beneficiaries under Janani Suraksha especially if accompanied by loss of sensation, which sheYojana. She will make at least two post-natal visits for each comes across during her homes visits and bring them to thedelivery in her areas and render advice regarding care of the notice of the Health Worker Male/MO (PHC). She will givemother and care and feed of the newborn. She will also assess oral rehydration solution to all cases of diarrhoea/dysentery/the growth and development of the infant and take necessary vomiting and identify and refer all cases of blindness includingaction required to rectify the defect. She will educate mothers suspected cases of cataract to MO PHC.individually and in groups in better family health includingmaternal and child health, family planning, nutrition, 8. Vital Events : She will record and report to the healthimmunization, control of communicable diseases, personal and authority of vital events including births and deaths,environmental hygiene. particularly of mothers and infants.2. Family Planning : She will utilise the information from 9. Record Keeping : She will register (a) pregnant women fromthe eligible couple and child register for the family planning three months of pregnancy onward (b) infants zero to one yearprogramme. She will be responsible for maintaining eligible of age; and (c) women aged 15 to 44 years. She will maintaincouple registers and updating at all times. She will spread the the pre-natal and maternity records and child care records andmessage of family planning to the couples and motivate them for prepare the eligible couple and child register. She will maintainfamily planning individually and in groups. She will distribute the records as regards contraceptive distribution, IUD insertion,conventional contraceptives and oral contraceptives to the couples sterilized, clinics held at the sub-centre and suppliescouples, provide facilities and to help prospective acceptors in received and issued. While maintaining passive surveillancegetting family planning services, if necessary, by accompanying register for malaria cases, she will record : No. of fever cases,them or arranging for the Dai/ASHA to accompany them to No. of blood slides prepared, No. of malaria positive caseshospital. Provide follow-up services to female family planning reported, No. of cases given radical treatment.acceptors, identify side effects, give treatment on the spot for 10. Treatment of minor ailments : She will provide treatmentside effects and minor complaints and refer those cases that for minor ailments, provide first-aid for accidents andneed attention by the physician to the PHC/Hospital. She will emergencies and refer cases beyond her competence to the PHC/establish female depot holders, help the Health Assistant CHC/hospital.Female in training them, and provide a continuous supply of 11. Team Activities : She will attend and participate in staffconventional contraceptives to the depot holders. meetings at PHC/Community Development Block or both. She3. Medical Termination of Pregnancy : She will identify the will coordinate her activities with the Health Worker Male andwomen requiring help for medical termination of pregnancy other health workers including the Health volunteers/ASHA • 463 •
  • 8. and Dais. confirmatory diagnosis. He will guide the suspected cases to12. Role of ANM as a facilitator of ASHA : Auxiliary Nurse the nearest diagnostic and treatment centre for diagnosis andMidwife (ANM) will guide ASHA in performing the following treatment by the MO. He will keep a record of all such cases andactivities : shall verify from PHC about their diagnosis during the monthly meeting or through health supervisor during his visit. He willShe will hold weekly / fortnightly meeting with ASHA and carry a list of all Kala-azar/JE cases in his area for follow updiscuss the activities undertaken during the week/fortnight. and will ensure administration of complete treatment. He willShe will guide her in case ASHA had encountered any problem assist during the spray activities in his area. He will conduct allduring the performance of her activity. She will act as a resource health education activities particularly through interpersonalperson for the training of ASHA. She will take help of ASHA in communication by carrying proper charts etc. and also assistupdating eligible couple register of the village concerned. She health supervisors and other functionaries in their educationwill utilize ASHA in motivating the pregnant women for coming subcentre for initial checkups and bringing married couplesto sub centres for adopting family planning. She will guide (B) National Leprosy Eradication Programme : He willASHA in motivating pregnant women for taking full course of identify cases of skin patches especially if accompanied byIFA Tablets and TT injections etc. ANMs will educate ASHA on loss of sensation, refer the above cases to PHC Medical Officerdanger signs of pregnancy and labour so that she can timely for diagnosis. If Leprosy patients want to take MDT from sub-identify and help beneficiary in getting further treatment. centre, he will provide treatment and maintain patient card.Job Responsibilities of Health Worker (Male) (C) National Blindness Control Programme : He will identify and refer all cases of blindness including suspected cases ofThe Health worker Male will make a visit to each family once cataract to Medical Officer, PHC.a fortnight. He will record his visit on the main entrance to thehouse according to the instructions of the State/UT. His duties (D) Revised National Tuberculosis Control Programme :pertaining to different National Health Programme are : He will identify persons especially with fever for 15 days and above with prolonged cough or spitting blood and take sputum(A) Malaria and other diseases under NVBDCP : From each smears from these individuals and refer these cases to the M., he shall enquire about presence of any fever cases; PHC for further investigations. He will check whether all caseswhether there was any fever case in the family in between his under treatment for Tuberculosis are taking regular treatment,fortnightly visits; whether any guest had come to the family motivate defaulters to take regular treatment and bring themand had fever ; whether any member of the family who had to the notice of the medical officer PHC.fever in between his fortnightly visit had left the village. Heshall collect thick and thin blood smears on one glass slide (E) Universal Immunization Programme : He will administerfrom case having fever or giving history of fever. He shall DPT, oral Polio, measles and BCG vaccine to all infants andbegin presumptive treatment for Malaria after blood smear children in his area in collaboration with health workerhas been collected. He will follow the instructions given female and assist her in administration of tetanus toxoid toto him regarding administration of presumptive treatment all pregnant women. He will assist the health supervisor male/under NVBDCP He shall contact the ASHA, FTD during their . health supervisor female in the school health programme.fortnightly visit to the village and (i) collect blood smears (F) Reproductive and Child Health Programme : He willalready taken by the ASHA, FTD (ii) also collect details of utilize the information from the eligible couple and childeach case in MF-2 (iii) replenish both drugs and glass-slides register for the family planning programme. He will distributeand Rapid Diagnostic Kits (RDKs) and look into the account conventional contraceptives and oral contraceptives to theof consumption of Anti malarial drugs and use of RDKs. He couples and provide follow up services to male family planningshall dispatch blood smears along with MF-2 collected from the acceptors, and refer those cases that need attention by theASHA, FTD, multipurpose worker female and those collected physician to PHC/Hospital. He will assist the health supervisorduring their visit in his area to the PHC Laboratory twice a male in training the community and its leaders in familyweek. He shall see the results obtained by the use of RDKs and welfare. He will identify the women requiring help for medicalverify the radical treatment administered by the ASHA, FTD if termination of pregnancy, refer them to the nearest approvedany during his visit. He shall administer radical treatment to institution and inform the health worker female.the positive cases as per drug schedule prescribed and as per (G) Other Communicable Diseases : He will identify casesinstructions issued by the Medical Officer PHC and take laid of diarrhoea/dysentery, fever with rash, jaundice encephalitis,down action if toxic manifestations are observed in a patient diphtheria, whooping cough and tetanus, poliomyelitis, neo-receiving radical treatment with primaquine. He shall contact natal tetanus, acute eye infections and notify the healththe ASHA and FTD and inform him of the spray dates and assist supervisor male and MO PHC immediately about these cases.the Health Supervisor Male in supervising spraying operations He will carry out control measures until the arrival of theand training of field spraying staff. health supervisor male and assist him in carrying out theseWhere Kala-Azar / Japanese Encephalitis is endemic : measures.From each family he shall enquire about presence of any fever (H) Environment Sanitation : He will chlorinate the publiccases of more than 15 days duration or fever with encephalitic water sources including wells at regular intervals. Educatepresentation. He will identify the fever cases detected by him the community on (a) The method of disposal of liquid wastesduring his visits and direct such a case to report to PHC for (b) The method of disposal of solid waste (c) Home sanitation • 464 •
  • 9. (d) Advantage and use of sanitary type of latrines At present, Health Day’s are organized every month at the(e) Construction and use of smokeless chulhas. Anganwadi level in each village in which immunization, ante/(I) Primary Medical Care : He will provide treatment for minor post natal check ups and services related to mother and childailments provide first aid for accidents and emergencies and health care including nutrition are being provided. Space atrefer cases beyond his competence to the PHC/hospital. each Anganwadi to serve as the hub of health activities in the village could be considered under other Rural Development(J) Health Education : He will educate the community about Programmes. This space could also serve as depot for medicinesvarious health services. and contraceptives.(K) Nutrition : He will identify cases of malnutrition among A revolving fund would be set up at the village level for providinginfants and young children (0-5 years) in his area, give the referral and transport facilities for emergency deliveries asnecessary treatment and advice or refer them to the anganwadi well as immediate financial needs for hospitalization. Thefor supplementary feeding and refer serious cases to the PHC. fund would be operated by the VHSC. Untied fund wouldEducate the community about the nutrition diet for mothers also be made available to VHSC for various health activitiesand children from locally available food. including IEC, household survey, preparation of health register,(L) Vital Events : He will Enquire about births and deaths organization of meetings at the village level etc. Since VHSCoccurring in his area, record them in the births and deaths would be asked to play a leading role in the health matters ofregister and report them to the Health Supervisor Male / ANM the village, its members would be given orientation training toand educate the community on the importance of registration equip them to provide leadership as well as plan and monitorof births and deaths. the health activities at the village level.Accredited Social Health Activists (ASHA) For those villages which are far away from the Sub-Centre,A trained female community health worker - ASHA - is being a TBA with requisite educational qualifications would beprovided in each village in the ratio of one per 1000 population. identified for training and support. She would assist the ANMFor tribal, hilly, desert areas, the norm could be relaxed for one at the Sub Centre. ASHAs willing to play this role would beASHA per habitation depending on the workload. ASHA must given preference. In places where even an ANM’s servicesbe a primary resident of the village with formal education upto are not reaching and there is no accredited ASHA available,Class VIII and preferably in the age group 25-45. She would be the RMPs would be identified for training so that they couldselected by the Gram Sabha following an intense community upgrade their skills and get accredited. Efforts would alsomobilization process. She would be fully accountable to be made to regulate quacks and untrained dais. ASHA willPanchayat. Induction training of ASHA is to be of 23 days in assist the villagers in referral services for AYUSH/testing HIV/all (five modules), spread over 12 months. On the job training AIDs, STI, RTI, also preventive, promotive health already withwould continue throughout the year. AWW/SHGs etc. ASHA will provide them information on theThough she would not be paid any honorarium, she would be treatments available under AYUSH.entitled for performance based compensation. It is expectedthat on an average an ASHA working with reasonable efficiency Summarywould be able to earn Rs. 1000 per month. Since as per the The health care services’ organization in the country extendsexisting approval, the compensation for ASHA is not factored in from the national level to village level. At the national level itthe scheme, it is proposed to modify the programmes mentioned consists of the Union Ministry of Health and Family Welfare,in the ASHA compensation package, wherever necessary, to which has three departments, viz. - Department of Health &enable the payment of compensation to her. The cost of training Family Welfare, Department of AYUSH and Department ofand drug kits to ASHAs would be supported by the Centre in the Health Research. Each of these departments is headed by18 high focus states. The other states would have the flexibility respective secretaries to Govt of India. The department ofto have Health link workers to support it out of the RCH II Health & Family Welfare is supported by a technical wing,flexible fund. As a special case, ASHAs could be supported in the Directorate General of Health Services, headed by Directorvery remote backward regions in non-focus States. General of Health Services (DGHS). At State level it is under the State Department of Health and Family Welfare in each StateASHAs would reinforce community action for universal headed by Minister and with a Secretariat under the chargeimmunization, safe delivery, newborn care, prevention of of Secretary/Commissioner (Health and Family Welfare). Thewater-borne and other communicable diseases, nutrition and State Directorate of Health Services, as the technical wing,sanitation. She will also help the villagers promote preventive is an attached office of the State Department of Health andhealth by converging activities of nutrition, education, Family Welfare and is headed by a Director of Health Services.drinking water, sanitation etc. In order that ASHAs work in At Regional level, in some states each regional/zonal set-upclose coordination with the AWW, she would be fully anchored covers three to five districts and acts under authority delegatedin the Anganwadi system. ASHAs would also be provided with by the State Directorate of Health Services. At District level,a ‘drug kit’ which would help her in providing immediate and all health care programmes are placed under a unified controleasy access for the rural population to essential health supplies and is a link between the State/ regional structure on one sidelike ORS, contraceptives, a set of ten basic drugs. She would and the peripheral level structures such as PHC/Sub-centre onalso have a health communication kit and other IEC materials the other side. The district officer with the overall control isdeveloped for villages. designated as the Chief Medical and Health Officer (CM & HO) • 465 •
  • 10. or as the District Medical and Health Officer (DM & HO). service to the community; and visit each Health Worker Male atOne Community Health Centre (CHC) has been established for least once a week. They maintain records and carry out a teamevery 80, 000 to 1, 20, 000 population, and this centre provides work at PHC.the basic specialty services in general medicine, pediatrics, Health Worker Female (ANM) provides MCH care, Familysurgery, obstetrics and gynecology. CHCs are being established planning, identify the women requiring help for MTP andand maintained by the State Government. It is manned by identify cases of malnutrition among infants and youngfour medical specialists i.e. Surgeon, Physician, Gynecologist children and refer them. She will immunize pregnant womenand Pediatrician supported by 21 paramedical and other staff. with tetanus toxoid, administer DPT, oral polio, measles andIt has 30 in-door beds with one OT, Xray, Labour Room and BCG vaccine to all infants and children, (Hepatitis-B in pilotLaboratory facilities. It serves as a referral centre for 4 PHCs. areas) as per immunization schedule. Dai Training, identifying,PHCs are the cornerstone of rural health services- a first port notifying and referring various Communicable Diseases andof call to a qualified doctor of the public sector in rural areas recording the vital events are some of her important jobs. Thefor the sick and those who directly report or referred from Sub- Health worker Male will make a visit to each family once acentres for curative, preventive and promotive health care. fortnight and performs the prescribed duties pertaining toOne Primary Health Centre covers about 30, 000 (20, 000 different National Health Programmes like NVBDCP NLEP , ,in hilly, desert and difficult terrains) or more population. At RNTCP UIP National Blindness Control Programme and others. , ,present, a PHC is manned by a Medical Officer supported by He will chlorinate the public water sources including wells at14 paramedical and other staff. It acts as a referral unit for 6 regular intervals and educate the community.sub-centres and refer out cases to Community Health Centres A trained female community health worker - ASHA - is being(CHCs-30 bedded hospital)/sub-district/district hospitals. It has provided in each village in the ratio of one per 1000 population.4-6 indoor beds for patients. She must be a primary resident of the village with formalThe Sub-centre is the most peripheral and first contact point education upto Class VIII and preferably in the age group 25-between the primary health care system and the community. 45. She would be selected by the Gram Sabha and would beSub-centres are assigned tasks relating to interpersonal fully accountable to Panchayat. Though she would not be paidcommunication in order to bring about behavioral change and any honorarium, she would be entitled for performance basedprovide services in relation to maternal and child health, family compensation. ASHAs would reinforce community actionwelfare, nutrition, immunization, diarrhoea control and control for universal immunization, safe delivery, newborn care,of communicable diseases programmes. The Sub-centres are prevention of water-borne and other communicable diseases,provided with basic drugs for minor ailments needed for taking nutrition and of essential health needs of men, women and children. Study ExercisesCurrently a Sub-centre is staffed by one Female Health Workercommonly known as Auxiliary Nurse Midwife (ANM) and one Long Questions : (1) Describe the Health care organization inMale Health Worker commonly known as Multi Purpose Worker India. Explain how “Primary Health Care” is provided to all.(Male). One Health Assistant (Female) commonly known as Lady (2) Describe the Staffing and functioning of PHC. (3) DescribeHealth Visitor (LHV) and one Health Assistant (Male) located the duties of Medical Officer at the PHC level are entrusted with the task of supervision of Short Notes : (1) ASHA (2) Duties of Health worker Maleall the Sub-centres (generally six sub centres) under a PHC. (3) Duties of Health worker Female (ANM) (4) Duties ofThe overall objective of Indian Public Health Standards (IPHS) Health Assistant Female (5) Duties of Health Assistant to provide health care that is quality oriented and sensitive (6) Staffing pattern of PHC (7) Functioning of CHCto the needs of the community. In order to provide optimal (8) Functioning of Sub-centrelevel of quality health care, a set of standards are being MCQsrecommended for Community Health Centre /Primary Health (1) According to the national health policy, one sub-centre forCentre/Sub centre with reference to Infrastructure, Functioning the hilly areas covers a population of (a) 3000 (b) 5000and Staffing including responsibilities of each. (c) 1000 (d) 4000The Medical Officer of Primary Health Centre (PHC) is responsible (2) All are grass root workers except (a) Anganwadi workersfor implementing all activities grouped under Health and Family (b) Traditional birth attendants (c) Village health guideWelfare delivery system in PHC area. He/she is responsible in (d) Health assistants.his individual capacity, as well as over all in charge for his (3) A female multipurpose worker should be able to detectcurative, preventive and promotive care of the patients. He will all of the following except (a) Anemia (b) Renal diseaseorganize training programmes including continuing education (c) Hydramnios (d) Malpresentationfor the staff and carry out all administrative activities required (4) Which is true about Community health centre :for smooth running of the PHC. (a) It covers a population of one lakh (b) It has 60 beds with specialties in surgery, medicine and gynecologyThe health assistant female will supervise, guide and train the (c) Community health officer is selected with a minimumHealth Worker Female, Dais and ASHAs; and also visit each of 5 years of exposure (d) New medical post of communitySub-centre at least once a week. The Health Assistant Male health officer is createdwill strengthen the knowledge and skills of the health worker (5) One PHC should be present in hilly areas for everymale and supervise and guide him in the delivery of health care • 466 •
  • 11. (a) 10,000 people (b) 20,000 people (c) 30,000 people (10) The minimum number of beds recommended for CHC by (d) 50,000 people IPHS is (a) 30 (b) 35 (c) 40 (d) 60(6) Guideline for selection of village health guide are all except (11) Health Assistants visit Sub-centre / Health Workers once in (a) They should be permanent resident of local community every (a) week (b) 2 weeks (c) 3 weeks (d) month (b) They should have minimum formal education at least (12) One Health Assistant (Male) is entrusted with the task upto 10th standard (c) Acceptable to all sections of society of supervision of ____ Sub centres (a) 2-3 (b) 5-6 (c) 7-8 (d) They should be able to spare at least 2-3 hrs daily for (d) only 2 community health work (13) Which is false regarding ASHA : (a) Provided in each village(7) A dai is trained for (a) 30 working days (b) 90 working in the ratio of one per 1000 population (b) A primary days (c) four months (d) six months resident of the village with formal education upto Class(8) Govt trains a health guide from a village (a) every year IV (c) Preferably in the age group 25-45 (d) Selected by the (b) once in three years (c) once in five years (d) only once Gram Sabha(9) Which is not a duty of a traditional birth attendant Answers : (1) a; (2) d; (3) b; (4) a; (5) b; (6) b; (7) a; (8) b; (a) Aseptic delivery (b) Health education (c) Injection of (9) c; (10) a; (11) a; (12) b; (13) b. Tetanus toxoid (d) Registration of birth Bhore Committee (1943-1946) 85 Reports of Health Committees During pre independence era, to improve the preventive, promotive and curative heath services of country, a National Sunil Agrawal Planning Commission was set up by the Indian National Congress in 1938. The rulers of that time, the British EmpireIn the pre-independence period, the British had started a realised the importance of Public Health and instituted thenumber of Public Health initiatives. Quarantine act was passed ‘Health Survey and Development Committee,’ in the year 1943in 1825. Commission of Public Health in 1859 had pointed out under the chairmanship of Sir Joseph Bhore. The committeethe need of safe water and environmental sanitation to prevent was tasked to survey the then health conditions and healthoccurrence of epidemics. In 1864, Sanitary commissioners organisations in the country, and to make recommendationswere appointed in all three provinces of Bombay, Madras and for future development. The committee submitted its report inBengal to study the health problems and initiate measures for 1946. The integration of preventive, promotive and curativeimprovement. Local self government act was passed in 1885. health services and establishment of Primary Health CentresDecentralization of health administration had begun in 1919 in rural areas were the major recommendations made by thiswith Montague- Chelmsford constitutional reforms. The colonial committee (Box - 1).era was marked by the dichotomy which continues to operatein the country’s health policy to date. They acknowledged Box-1 : Important recommendations of the Bhorethe existence of the gaps in coverage of health services, committeeproclaiming the responsibility for the same and recommending ●● Integration of Preventive, Promotive and Curativesuitable action while simultaneously not providing resources services at all administrative levels.for implementation. This trend was unfortunately perpetuated ●● The development of Primary Health Centres for theeven in free India. delivery of comprehensive health services to the ruralIn 1940, the resolution adopted by the National Planning India. Each PHC should cater to a population of 40, 000Committee based on the Sokheys Committee’s recommendations with a Secondry Health Centre (now called Communityrecommended integration of preventive and curative functions Health Centre) to serve as a supervisory, coordinatingand the training of a large number of health workers. Bhore and referral institution.committee constituted in 1943 laid the framework on which ●● In the long term (3 million plan), the PHC would havethe health care was eventually built in the independent India. a 75 bedded hospital for a population of 10,000 toThe health care in India has since moved from bureaucratic 20,000.government based top down approach to decentralized ●● It also reviewed the system of medical education andcommunity based bottom- up system after the Panchayati Raj research and included compulsory 3 months training incame into being. This model was long ago propagated by the Community Medicine.Father of the nation “Mahatma Gandhi”. ●● Committee proposed the development of National Programmes of health services for the country. • 467 •
  • 12. This document laid the utmost emphasis on primary health Box - 3 : Important recommendations of the Chadahcare; it needs no emphasis that primary health care was later committeeon recognised as the key strategy to achieve Health for All (HFA)by 2000 during Alma-Ata conference. The Bhore committee ●● Strict monitoring and vigilance of implementation ofmodel was based on the allopathic system of medicine. The NMEP is responsibility of general health services at alltraditional health practices and indigenous system of medicine levels i.e. health workers of PHC, CHC, ZP .prevalent in rural India, which had great influence and were ●● One basic health worker (now called Multi Purpose worker)part of their socio-cultural milieu were not included in the for every 10, 000 population was recommended.model proposed by Bhore committee. The approach was not ●● Basic health workers should visit house to house once inentirely decentralized but had a top down approach. However a month to implement malaria provided a ready-made model at the time of independence ●● Basic Health worker should take additional duties ofand thus was adopted as a blueprint for both health policy and collection of vital statistics, family planning etc.development of the country.Post Independence Era : Since, the dawn of independence, Mukerji Committee, 1965rapid strides have been made in effecting improvements By recommending basic health workers to take on additionalin the quality and out reach of health care services to the responsibilities and work as multi purpose worker, bothpeople. After Independence in 1947, the Indian Government NMEP and family planning programme got a major set back.constituted Planning Commission in 1950, and started Five A committee under the chairmanship of Shri Mukerji, thenyear plan system for socioeconomic development of the country Health Secretary to GOI was appointed to review the healthof which health was the important and integral part. Besides system at different levels from the point of manpower andthe planning commission the government also set up various financial planning. Important recommendations of the Mukerjicommittees to plan specific public health services or review committee are in Box - 4.existing health situations.Mudaliar committee (1962) Box - 4 : Important recommendations of the Mukerji committeeDuring second five year plan, Government decided to relookat the health needs and resources of the country to provide ●● Strengthening of the administrative set up at differentnecessary guidelines to national health planning. Also to levels from PHC to state health the progress made since submission of Bhore committee ●● Separate staff was recommended for family planningreport, Government appointed “Health Survey and Planning program.Committee” under the chairmanship of Dr A Lakshmanswami ●● Basic health worker to be utilised for all duties except forMudaliar in 1959 to make future recommendations for family planning.development and expansion of health services. It admitted thatthe basic health facilities had not reached at least half the nation Jungalwalla Committee, 1967and there was gross mal distribution of hospitals and beds in In 1967, Central Council of Health appointed “Committee onfavour of urban areas. The committee found that the quality of integration of Health Services” headed by Dr N. Jungalwalla,services provided by PHCs were grossly inadequate with poor then Director, National Institute of Health Administration andfunctioning, lack of referral system, and gross under staffing Education. Important recommendations of the Jungalwalladue to insufficient resources. Important recommendations of committee are represented in Box - 5.the Mudaliar committee are depicted in Box - 2. Box - 5 : Important recommendations of the Jungalwalla Box - 2 : Important recommendations of the Mudaliar committee committee ●● Integrated health services with : ●● Strengthening of existing PHCs and development of - Unified cadre referral centres before new centres were established. - Common seniority ●● Strengthening of subdivisional and district hospitals. - Recognition of extra qualifications ●● Integration of medical and health services. - Equal pay for equal work ●● It also suggested constitution of an All India Health - No private practise Service in the pattern of Indian Administrative service. - Special pay for specialised service - Improvement in their service conditions ●● Medical care of the sick and conventional public healthChadah Committee (1963) programmes functioning under single administrator.Dr MS Chadha, the then DGHS, was appointed to study thedetails of the necessary requirements related to PHCs andmaintenance of National Malaria Eradication Program. Kartar Singh Committee, 1973Important recommendations of the Chadah committee are The Committee headed by then additional secretary, MOH andshown in Box - 3. Family planning, Shri Kartar Singh, was constituted to study and make recommendations on the structure for integrated health services at peripheral and supervisory levels. It was to • 468 •
  • 13. study the feasibility of bi purpose and multipurpose workers Shivaraman Committee health reportin the field. Important recommendations of the Kartar Singh A Committee on Basic Rural Doctors was framed under thecommittee are shown in Box - 6. guidance of Shri Shivaraman, then member of planningShrivastav Committee (1974-75) commission. The committee recommended establishment of countrywide cadre of basic rural doctors consisting of trainedThis is known as “Group on Medical Education and Support paraprofessionals to extend comprehensive health care deliveryManpower” constituted in 1974 by the Government. The to rural community.concept of community participation in the health sectororiginated which has given concept of “people’s health in V Ramalingaswamy Committee Healthpeople’s hand”. Convened under the chairmanship of Dr J BShrivastav, Director General Health Services, this committee Reportmade the recommendations as in Box - 7. This committee under the chairmanship of Dr V Ramalingaswamy, then DGHS, recommended as in Box-8. Box - 6 : Important recommendations of the Kartar Singh committee Box - 8 : Important recommendations of the Ramalingaswamy committee ●● It recommended “Female Health Worker” in place of ANM and “Male Health Worker” in place of malaria ●● Involvement of community for health planning and surveillance worker, vaccinators, health education health programme implementation assistants and family planning health assistants. ●● 30 bedded hospital for every 1 lakh population ●● The committee proposed a PHC per 50, 000 population ●● Integration of health services at all levels with 16 subcentres, each covering a population of 3000- ●● Redefined the role of doctor in the community 3500. (4) ●● Recommended that PHC and District health centres ●● Each subcentre to have one male and one female health should be under the control of three tier Panchayati Raj worker. System. ●● There should be one male and one female health supervisor at PHC to monitor and supervise the activities Bajaj Committee health report 1986 of staffs of 3-4 sub centres. A expert committee for ‘health manpower planning, production ●● The MO i/c PHC will be the overall in charge of all and management’ was constituted under the chairmanship peripheral staff. of Dr JS Bajaj, then member of planning commission, to ●● Training for all workers engaged in the field of health, tackle the problem of health manpower planning, production family planning and nutrition should be integrated. and management. Important recommendations of the Bajaj committee are in Box - 9. Box - 7 : Important recommendations of the Shrivastav committee Box-9 : Important recommendations of the Bajaj committee ●● Creation of Village Health Guide (VHG) or community health volunteers from the community itself like ●● Recommended for Formulation of National Health teachers, postmasters, gram sevaks who can provide Manpower planning based on realistic survey. comprehensive health services as paraprofessionals. ●● Educational Commission for health sciences should be ●● Primary health care be provided within the community developed on the lines of UGC. itself through specially trained workers so that the ●● Recommended for National and Medical education policy health of the people is placed in the hands of people in which teachers are trained in health education science themselves. technology. ●● Creation of MPW and Health Assistants (HA) in between ●● Uniform standard of medical and health science the VHG and MO i/c PHC. education by establishing universities of health sciences in all states.Based on these recommendations “Rural Health Scheme” was ●● Establishment of health manpower cells both at statelaunched by the government in 1977-78. The programme of and central of community health workers was initiated during ●● Vocational courses in paramedical sciences to get more1977-78. The major steps initiated were : health manpower.a) Involvement of medical colleges in health care of selected PHCs with the objective of reorienting medical education Krishnan Committee Health Report 1992 according to rural population called Re Orientation of The committee under the chairmanship of Dr Krishnan Medical education (ROME). It led to teaching and training reviewed the achievements and progress of previous health of undergraduate students and Interns at PHCs. committee reports and also made comments on shortfalls. Theb) Training of Village Health Guides and utilising their committee address the problems of urban health and devised services in the general health service system. the health post scheme for urban slum areas. The committee had recommended one voluntary health worker (VHW) per • 469 •
  • 14. 2, 000 population with an honorarium of Rs 100. Its report in charge of all peripheral staff. Srivastava committe (1974)specifically outlines which services have to be provided by the recommended Creation of Village Health Guide (VHG) orhealth post. These services have been divided into outreach, community health volunteers based on its recommendation ruralpreventive, family planning, curative, support (referral) health scheme was launched. It recommended establishmentservices and reporting and record keeping. Outreach services of countrywide cadre of basic rural doctors consisting ofinclude population education, motivation for family planning, trained paraprofessionals to extend comprehensive health careand health education. In the present context, very few outreach delivery to rural community. Important recommendations ofservices are being provided to urban slums. the Ramalingaswamy committee were 30 bedded hospital for every 1 lakh population, PHC and District health centres shouldSummary be under the control of three tier Panchayati Raj System. APublic Health initiatives like Quarantine act, safe water and expert committee for ‘health manpower planning, productionenvironment sanitation, appointment of sanitary inspectors and management’ was constituted under the chairmanship ofwere stared in the pre-independence era. Bhore committee Dr JS Bajaj and recommended (1986) Formulation of Nationallaid the framework on which the Indian health care is built in Health Manpower planning based on realistic survey etc. Theindependent India. The health care in India has since moved committee under the chairmanship of Dr Krishnan (1992)from top down approach to bottom- up approach. The ‘Health reviewed the achievements and progress of previous healthSurvey and Development Committee, ’ was instituted in the committee reports and also made comments on shortfalls.year 1943 under the chairmanship of Sir Joseph Bhore. Thecommittee submitted its report in 1946 with following important Study Exercisesrecommendations like the integration of preventive, promotive Long Question : Describe various health committees in post-and curative health services and establishment of Primary independent era.Health Centres (for 40, 000 population) in rural areas. Later Short Notes : (1) Recommendation of Bhore committeeon it forms the key strategy to achieve Health for All (HFA) by (2) Recommendation of Jungalwala committee2000 during Alma-Ata conference. It was based on allopathic (3) Recommendation of Kartar Singh committee.system. It provided a ready-made model adopted as a blueprint MCQs :for both health policy and development of the country. 1. Quarantine act was passed in_______ (a) 1840 (b) 1825 (c)In post independent era planning commission and several 1852 (d) 1882committees were set up to plan specific public health services 2. Bhore committee was formed in_______ (a)1943 (b)1934or review existing health situations. Mudaliar committee (c) 1948 (d)1938(1962) found that the quality of services provided by PHCs 3. According to Bhore committee each PHC cater for________were grossly inadequate with poor functioning, lack of referral population (a) 20,000 (b) 40,000 (c) 25,000 (d) 30, 000system, and gross under staffing due to insufficient resources 4. Which committee recommended a Basic Health workerand its major recommendations were strengthening of existing per 10, 000 population (a) Bhore committee (b) MudaliarPHCs and development of referral centres, strengthening of committee (c) Chadha committee (d) Kartar Singhsubdivisional and district hospitals, integration of medical committeeand health services, and suggested constitution of an All 5. Which committee recommended ‘No private practise’ forIndia Health Service in the pattern of Indian Administrative govt. Doctor (a) Mudaliar committee (b) Chadha committee,service etc. Chadah committee (1963) was appointed to study (c) Kartar Singh committee (d) Jungalwalla committeethe details of the necessary requirements related to PHCs and 6. Rural health scheme was based on recommendation ofmaintenance of National Malaria Eradication Program. Main which committee (a) Srivastav committee (b) Chadharecommendations were basic health worker for every 10, 000 committee (c) Kartar Singh committee (d) Jungalwallapopulation who will supervise malaria activities along with committeeadditional duties of family planning. Due to set back in both 7. Which committee proposed a PHC per 50,000 populationmalaria and family planning Mukerji committee (1965) was with 16 subcentres, each covering a population of 3000-appointed. It recommended separate staff for family planning. 3500 (a) Mudaliar committee (b) Chadha committeeIn 1967, Central Council of Health appointed “Committee on (c) Kartar Singh committee (d) Jungalwalla committeeintegration of Health Services” headed by Dr N. Jungalwalla 8. Which committee suggested constitution of an All India(1967) which recommended no private practice for govt Health Service in the pattern of Indian Administrativedoctors. The Committee (1973) headed by Shri Kartar Singh, Service (a) Mudaliar committee (b) Chadha committeewas constituted to study and make recommendations on the (c) Kartar Singh committee (d) Jungalwalla committeestructure for integrated health services at peripheral and 9. Which committee recommended establishment ofsupervisory levels. The committee proposed a PHC per 50, 000 countrywide cadre of basic rural doctors consisting ofpopulation with 16 sub-centres, each covering a population of trained paraprofessionals to extend comprehensive health3000-3500. Each sub-centre to have one male and one female care delivery to rural community (a) Shivaraman committeehealth worker. There should be one male and one female health (b) Chadha committee (c) Kartar Singh committeesupervisor at PHC to monitor and supervise the activities of (d) Jungalwalla committeestaffs of 3-4 sub centres, The MO i/c PHC will be the overall • 470 •
  • 15. 10. Match the following Further Suggested Reading 1. Govt. of India (1946). Report of the Health Survey and Development 1. Bhore committee a. 1963 Committee, Govt of India Press, Simla. 2. Govt. of India (1962). Report of the Health Survey and Planning Committee, 2. Chadah committee b. 1967 Ministry of Health, Delhi. 3. Govt of India (1973). Report of the Committee on Multipurpose Workers 3. Mudaliar committee c. 1943 Under Health and Family Planning Programme, Department of Family 4. Jungalwala committee d. 1973 Planning, Ministry of Health and Family Planning, New Delhi. 4. Govt of India (1976). Swasth Hind, 20, 233 5. Kartar Singh committee e. 1962 5. National Health Reports. G N Prabhakaran. In : Policies and Programmes of Health in India. Jaypee Brothers, New Delhi 2005Answers : (1) b; (2) a (3) b; (4) c; (5) d; (6) a; (7) c; (8) a; (9) a;(10) 1-c; 2-a; 3-e; 4-b; 5-d. appointed by the British, with Sir Joseph Bhore as Chairman, 86 Health Planning Process in India for survey and planning; their report is a major event in the history of Indian Health Planning. Sunil Agrawal As on today, India is the world’s 12th largest economy and the third largest in Asia behind Japan and China, with total GDP of around 1 trillion ( $1,000 billion). Nearly two-thirdsHealth of a nation is an essential component of development, of the population depends on agriculture for its livelihood.vital to a nation’s economic growth and internal stability. 700 million Indians live on Rs.42 per day or less, but thereAssuring a minimal level of health care to the population is a large and growing middle class of 325-350 million withis a critical constituent of the development process. Since disposable income for consumer goods. Real GDP growth forIndependence, India has built up a vast health infrastructure the fiscal year ending March 31, 2007 was 9.4% up from 9.0%and health personnel at primary, secondary, and tertiary care growth in the previous year. Growth for the year ending Marchin public, voluntary, and private sectors. For producing skilled 31, 2008 is expected to be between 8.5-9.0%.human resources, a number of medical and paramedicalinstitutions including Ayurveda, Yoga and Naturopathy, Unani, The Planning CommissionSiddha & Homeopathy (AYUSH) institutions have been set up. After independence in 1950 the present Planning CommissionThe strong link between poverty and ill health needs to be was established, which launched first five year plan in 1951.recognized. The onset of a long and expensive illness can drive The Planning Commission was set up to make an assessment ofthe non-poor into poverty. Ill health creates immense stress the material, capital and human resources of the country, andeven among those who are financially secure. High health to draft developmental plans for the most effective utilisationcare costs can lead to entry into or exacerbation of poverty. of these resources addressing the needs of the community andThe importance of public provisioning of quality health care country at large. It gives suggestions and recommendations toto enable access to affordable and reliable heath services the cabinet on the various issues of the country’s development incannot be underestimated. This is specially so, in the context consultation with ministers of the state and central government.of preventing the non-poor from entering into poverty or in There are 29 divisions in the Planning Commission liketerms of reducing the suffering of those who are already below agriculture, health, nutrition, education, environment, familypoverty line. The country has to deal with rising costs of health welfare, housing, water supply, manpower, rural development,care and growing expectations of the people. The challenge multilevel planning and monitoring, etc. In 1957, the Planningof quality health services in remote rural regions has to be Commission was provided with a Perspective Planning Divisionurgently met. Given the magnitude of the problem, we need to which makes projections into the future over a period of 20-25transform public health care into an accountable, accessible, years.and affordable system of quality services. The role of scientific The membership of the planning commission is highlyhealth planning at the national level, to achieve this goal, distinguished and from the very beginning it is chaired byneeds no highlighting. the Prime Minister of the country. The planning commissionAmong socialist countries, India is the first and foremost consists of Chairman, Deputy Chairman and 5 members. Thecountry to show tradition of health planning. During British Planning Commission works through 3 major divisions :India, the National congress had a planning committee under ●● Programme Advisorsthe chairmanship of Pandit Jawaharlal Nehru. A committee was ●● General Secretariat ●● Technical Divisions • 471 •
  • 16. Planning Commission reviews, from time to time, the progress is 75.2%. Public spending on health has increased from 0.22%made in various directions and makes recommendations to of GDP in 1950-51 to 1.05% of GDP during the mid 1980s andGovernment on problems and policies relevant to rapid and stagnated at around 0.9% of GDP during the later years. Indiabalanced economic development. spent approx Rs 1,08,732 Crores on health and health relatedHealth Sector Planning expenditure during 2001-02. This amounted to about 4.8% of the estimated GDP at market prices in 2001-02. National healthThe Planning Commission gave considerable importance to expenditures, when taken as a proportion of GDP at factor cost,health programmes in overall development of the country. The were 5.2%. Since 1995-96 household expenditure on healthhealth sector is divided into the following subsectors: has been growing at the current rate of approx 14% overall. In 1995-96, households in India spends an estimated Rs 33,253 Subsectors of Health in Planning Commission crores at nominal prices which is estimated to have increased ●● Water supply and sanitation to Rs 72,759 crores in 2001-02. With an overall growth rate of ●● Communicable diseases 14% household spending, it is likely to be close to Rs 1,00,000 ●● Medical education, training and research crores in nominal terms during 2003-04. ●● Curative services i.e., Hospitals, PHCs, etc. ●● Public Health Services Table - 1 : Allocations for Selected Key Programs in the ●● Family Planning Union Health Budget (Rs Crores) ●● Indigenous Systems of Medicine Programme 2004-05 2005-06 2006-07All the above subsectors receive due importance in five Hospitals & Dispensaries 240.75 268.70 263.25year plans, however the priority changes from plan to plan Medical edn & Research 912.82 1397.33 1436.64depending upon the felt needs of the community, technicalconsiderations and the progresses made. A Bureau of Planning AYUSH 225.73 405.98 447.89was constituted in 1965 in the Ministry of Health to have NACO - HIV/AIDS 232.00 476.50 636.67better coordination between Centre and State Governments. RCH 710.51 881.73 1765.83The working of the national plans is reviewed time to time byNational Development Council (NDC), which decides the social Pulse Polio 832.00 1004.00and economic policy affecting national development. Routine Immunisation 1186.40 472.60 326.50Health Finance Indicators FW services & 1948.71 2412.41 1942.61Health finance indicators include allocations under five contraceptionyear plans, expenditure on health, trends in public and Area Projects 123.01 501.26 205.57private spending. It provides an understanding of patterns ofinvestments, expenditure, sources of funding and proportion of NRH Mission 1530.88allocation in the health sector, vis a vis other total allocations. Flexible FundsBudgetary Allocations : Health in India, like most social sectors, Source: Demand for Grants, respective Budget years, Ministryis a state subject and the contribution of the state governments of Finance, GOI, New Delhito health spending is between 80 and 85 per cent. While in therecent years the Union government has substantially hiked its Table -1 looks at and summarises some of the key programmaticcontribution to the health budget increasing at 30 per cent per allocations in the Union Health Budget. Here we see thatannum, in itself this makes a very small impact on the overall traditional sectors like hospitals, medical education and familyhealth budget. Presently, the health budget of state and central planning services are now receiving a smaller chunk of thegovernments combined is less than one percent of GDP . health budget in comparison to the “new” sectors like RCH, HIV/AIDS, immunization (especially pulse polio). From theIn India there has been a growing analysis of health budgets 2005-06 budget onwards, NRHM has taken a large share ofand health expenditures. The economic reforms of the 90’s the RCH and Family Planning budgets giving a boost to ruralhave created a trajectory of public health spending that shows health allocations.a downward trend both in terms of share of the governmentbudget as well as a proportion of the Gross Domestic Product. Five Year PlansPrior to economic reforms in the mid- 80s, public health The five year plans were conceived for organised developmentexpenditures had peaked 1.6 per cent of the GDP and was 3.95 of the country by planning a long term road map focussing onper cent of government’s budget. By 2001, these figures read a sustained development instead of short term gains. It lays maindismal 0.9 per cent and 2.7 per cent, respectively, and further emphasis on rebuilding rural India, industrial development,down to 0.8 and 2.4 per cent in 2005. What was worse was health for all and balanced development in all sectors. Planningthe decline in new investments by the Ministry of Health as Commission laid special emphasis on health programmes withreflected in the decline in capital expenditures from a robust 12 the broad objectives of:per cent in 1986-87 to a mere four per cent in 2000-01 and only a) Control and eradication of major communicable diseasesa slight improvement in 2004-05 at five per cent. of public health importance.Government expenditure on health as percentage of total b) Strengthening basic rural health services by establishingexpenditure on health is 24.8% while that of Private Expenditure • 472 •
  • 17. Sub-centres and Primary Health Centres. and community development (17.4 percent), transport andc) Population Control. communications (24 percent), industry (8.4 percent), sociald) Development of health manpower resources. services (16.64 percent), land rehabilitation (4.1 percent), andHealth planning has been ensured of proper investment other (2.5 percent).through successive five year plans, which is as under showing The target growth rate was 2.1 percent annual gross domesticpattern of allocation since inception. The overall outlays product (GDP) growth; the achieved growth rate was 3.6during the various plan periods are shown in Fig. - 1 & Table-2 percent. During the first five-year plan the net domestic productrespectively. went up by 15 percent. Lower increase of per capita income as compared to national income was due to rapid population Fig. - 1 : Five Year Plan Outlays growth. The World Health Organization, with the Indian 70000 government, addressed children’s health and reduced infant mortality, contributing to population growth. 60000 Second plan (1956-1961) 50000 The second five-year plan focused on industry, especiallyRs. in crores 40000 heavy industry. Domestic production of industrial products was encouraged, particularly in the development of the public 30000 sector. 20000 Third plan (1961-1966) 10000 The third plan stressed on agriculture and improving 0 production of rice, but the brief Sino-Indian War in 1962 exposed weaknesses in the economy and shifted the focus 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th towards defence. In 1965-1966, the Green Revolution in India Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan advanced agriculture. The war led to inflation and the priority Period was shifted to price stabilization.First plan (1951-1956) In an effort to bring democracy to the grassroot level, Panchayat elections were started and the states were givenThe first Indian Prime Minister, Shri Jawaharlal Nehru presented more development responsibilities.the first five-year plan to the Parliament of India on December8, 1951. The total plan budget of 206.8 billion INR (23.6 Gross Domestic Product rate during this duration was lower atbillion USD in the 1950 exchange rate) was allocated to seven 2.7% due to 1962 Sino-Indian War and Indo-Pakistani War ofbroad areas: irrigation and energy (27.2 percent), agriculture 1965. Table - 2 : Pattern of central Allocation (Rs in Crores) in Five Year Plans S Total Family Period Health AYUSH SubTotal No Investment Welfare 1 First Plan (1951-56) 1960.00 65.2 (3.3) 0.1(0.1) 65.3(3.4) 2 Second Plan (1956-61) 4672.00 140.8 (3.0) 5.0 (0.1) 145.8 (3.1) 3 Third Plan (1961-66) 8576.5 225.9 (2.6) 24.9 (0.3) 250.8 (2.9) 4 Annual Plans (1966-69) 6625.4 140.2 (2.1) 70.4 (1.1) 210.6 (3.2) 5 Fourth Plan (1969-74) 15778.8 335.5 (2.1) 278.0 (1.8) 613.5 (3.9) 6 Fifth Plan (1974-79) 39426.2 760.8 (1.9) 491.8 (1.2) 1252.6 (3.1) 7 Annual Plan (1979-80) 12176.5 223.1 (1.8) 118.5 (1.0) 341.6 (2.8) 8 Sixth Plan (1980-85) 109291.7 2025.2 (1.8) 1387.0 (1.3) 3412.2 (3.1) 9 Seventh Plan (1985-90) 218729.6 3688.6 (1.7) 3120.8 (1.4) 6809.4 (3.1) 10 Annual Plan (1990-91) 61518.1 960.9 (1.6) 784.9 (1.3) 1745.8 (2.9) 11 Annual Plan (1991-92) 65855.8 1042.2 (1.6) 856.6 (1.3) 1898.8 (2.9) 12 Eight Plan (1992-97) 434100.0 7494.2 (1.7) 6500.0 (1.5) 108.0 (0.02) 14102.2 (3.2) 13 Ninth Plan (1997-02) 859200.0 19818.4 (2.31) 15120.2 (1.76) 266.35 (0.03) 35204.95 (4.09) 14 Tenth Plan (2002-07) 1484131.3 31020.3 (2.09) 27125.0 (1.83) 775.0 (0.05) 58920.3 (3.97) 15 Eleventh Plan (2007-12) 2156571.0 136147.0 (6.3%) 3988.0 (0.18%) 140135.0 (6.5%) Notes:- (a) Dept of ISM & H (now AYUSH) was created during 8th plan period (b) Figures in bracket indicate percentage to total plan investment outlay (c) Deptt of Health and Family Welfare were merged from 2005 • 473 •
  • 18. Fourth plan (1969-1974) complete 5 years of schooling by 2007;At this time Smt Indira Gandhi was the Prime Minister. The ●● Reduction in gender gaps in literacy and wage rates by atIndira Gandhi government nationalized 19 major Indian banks. least 50% by 2007;In addition, the situation in East Pakistan (now independent ●● Reduction in the decadal rate of population growth betweenBangladesh) was becoming dire as the Indo-Pakistani War of 2001 and 2011 to 16.2%;1971 and Bangladesh Liberation War took place. ●● Increase in Literacy Rates to 75 per cent within the Tenth Plan period (2002-3 to 2006-7);Fifth plan (1974-1979) ●● Reduction of Infant mortality rate (IMR) to 45 per 1000Stress was laid on employment, poverty alleviation, and live births by 2007 and to 28 by 2012;justice. The plan also focused on self-reliance in agricultural ●● Reduction of Maternal Mortality Ratio (MMR) to 2 per 1000production and defense. In 1978, the newly elected Morarji live births by 2007 and to 1 by 2012;Desai government rejected the plan. ●● All villages to have sustained access to potable drinkingSixth plan (1980-1985) water within the Plan period. Goals & Achievements during Tenth Plan are given in Table-3.Called the Janata government plan, the sixth plan marked areversal of the Nehruvian model. When Rajiv Gandhi was electedas the prime minister, the young prime minister aimed for rapid Table - 3 : Goals and Achievements during Tenth Planindustrial development, especially in the area of information Goal for Indicator Achievementstechnology. Family planning was expanded in order to prevent Tenth Planoverpopulation. In contrast to China’s harshly-enforced one- Decadal Rate of 15.9% for 2001-child policy, Indian policy did not rely on the threat of force. 16.2% Population Growth 11 (Projected)1More prosperous areas of India adopted family planning morerapidly than less prosperous areas, which continued to have a Infant Mortality Rate 45 per 1000 58 per 1000high birth rate. live births live births2Seventh plan (1985-1989) Maternal Mortality Ratio 2 per 1000 3.01 per 1000 live births live births3The Seventh Plan marked the comeback of the Congress Party Source: 1. Technical Group on Population Projections set up by Nationalto power. The plan lay stress on improving the productivity Commission on Population (Dec 2006), RGI, GOI; 2. SRS 2005; 3. 2001-03level of industries by up gradation of technology. Special Survey of Deaths using RHIME (routine, resampled, household interview of mortality with medical evaluation), RGI (2006) GOI.Period between 1989-911989-91 was a period of political instability in India and hence Review of Tenth Plan Schemes : The Tenth Five-Year Planno five year plan was implemented. Between 1990 and 1992, (2002-07) indicated the dismal picture of the health servicesthere were only Annual Plans. At that time Dr. Manmohan infrastructure and emphasized the need to invest more onSingh (currently, Prime Minister of India) launched India’s building good primary-level care and referral services. Tofree market reforms that brought the economic stability in the review the health services framework, design, and approachcountry. It was the beginning of privatization and liberalization within which the policies were formulated the National Ruralin India. Health Mission was launched.Eighth plan (1992-1997) The original approved health and family welfare outlay for theModernization of industries was a major highlight of the Tenth Plan centrally sponsored and central sector schemes wasEighth Plan. This plan can be termed as Rao and Manmohan Rs 36,378 crore. However, the sum of annual outlay increasedmodel of Economic development. The major objectives include to Rs 41,585 crore. Against this, the actual expenditure hasContaining population growth, poverty reduction, employment been Rs 34,950.45 crore, that is, 84.05% of the sum of annualgeneration, strengthening the infrastructure, institutional outlay. In 2005-06, all family welfare schemes and majorbuilding, HUMAN RESOURCE DEVELOPMENT, Involvement of disease control programmes were put under the umbrella ofPanchayat raj, Nagarapalikas, NGOs and Decentralisation and the National Rural Health Mission.people’s participation. Review of the National Rural Health Mission at the end of theNinth plan (1997-2002) Tenth Plan reveals that in order to improve the public health delivery, the situation needs to change on a fast track mode atDuring the Ninth Plan period, the growth rate was 5.35 per the grassroots.cent, a percentage point lower than the target GDP growth of6.5 per cent. The status as on 30 April, 2008 is as under: (a) State Health Missions have been constituted in all states.Tenth plan (2002-2007) (b) ASHA training modules developed and revised.The main objectives of the 10th Five-Year Plan were: (c) Over 1500 management professionals (CA/MBA) appointed●● Reduction of poverty ratio by 5 percentage points by in Program Management Units (PMU) to support the 2007; programme management. This is being planed at the level●● Providing gainful and high-quality employment to the of the block also. labour force; (d) RCH- II launched and under implementation.●● All children in India in school by 2003; all children to (e) IMNCI started in 142 districts. • 474 •
  • 19. (f) Legal changes brought about to allow ANMs to dispense ●● Reduce Total Fertility Rate to 2.1 medication and MBBS doctors to dispense anesthesia. ●● Provide clean drinking water for all by 2009 and ensure(g) At 1,611 PHCs AYUSH doctors have been co-located that there are no slip-backs(h) 228413 Village Health & Sanitation Committees (VHSCs) ●● Reduce malnutrition among children of age group 0-3 to have been constituted and operational by 30 April 2008. half its present level(j) Against the target of 5 lakh fully trained Accredited Social ●● Reduce anaemia among women and girls by 50% by the Health Activists (ASHAs) by 2008, the initial phase of end of the plan training (first module) has been imparted to 5.36 lakh. 4. Women and Children ASHAs in position with drug kits are 224951 in number. ●● Raise the sex ratio for age group 0-6 to 935 by 2011-12(k) Out of the 145272 Sub-centres (SCs) expected to be and to 950 by 2016-17 functional with 2 Auxiliary Nurse Midwives (ANMs) by ●● Ensure that all children enjoy a safe childhood, without 2008, only 22471 had the same. any compulsion to work(l) 22,370 Primary Health Centres (PHCs) are functional and 5. Infrastructure out of which 3450 PHCs are functional with three staff ●● Provide homestead sites to all by 2012 and step up the nurses by 2008. pace of house construction for rural poor to cover all the(m) There has been a shortfall of 5,498 (>50%) specialists poor by 2016-17 at the Community Health Centres (CHCs). Total CHCs functional are 4,045 out of which 2,966 have been selected 6. Environment to be upgraded to IPHS. ●● Attain WHO standards of air quality in all major cities by(n) Number of Districts where annual integrated action plan 2011-12 under NRHM have been prepared for 2007-08 are 485. ●● Treat all urban waste water by 2011-12 to clean river watersEleventh plan (2007-2012) Eleventh Five Year Plan Agenda in Health Sector : ThrustThe Eleventh Five Year Plan provides an opportunity to areas to be pursued during the Eleventh Five Year Plan arerestructure policies to achieve a New Vision based on faster, summarized below:broad-based, and inclusive growth. 1. Improving Health EquityGoal : To achieve good health for people, especially the poor i. National Rural Health Mission (NRHM)and the underprivileged. ii. National Urban Health Mission (NUHM)Strategies 2. Adopting a system-centric approach rather than a1. A comprehensive approach that encompasses individual disease-centric approach health care, public health, sanitation, clean drinking water, i. Strengthening Health System through upgradation of access to food, and knowledge of hygiene and feeding infrastructure and public private partnership practices. ii. Converging all programmes and not allowing vertical2. To increase aggregate spending on health by the Centre structures below district level under different programmes and the states.3. The contribution of the private sector in providing primary, 3. Increasing Survival secondary, and tertiary services. i. Reducing Maternal mortality and improving Child Sex ratio4. Good governance, transparency, and accountability in the through Gender Responsive Health care delivery of health services. ii. Reducing Infant and Child mortality through Home Based5. Health as a right for all citizens is the goal that the Plan Neonatal Care (HBNC) and Integrated Management of will strive towards. Neonatal and Childhood Illnesses (IMNCI)Time-Bound Goals for the Eleventh Five Year Plan 4. Taking full advantage of local enterprise for solving1. Income & Poverty local health problems●● Accelerate GDP growth from 8% to 10% and then maintain i. Integrating AYUSH in Health System at 10% in the 12th Plan in order to double per capita income ii. Increasing the role of Registered Medical Practitioners by 2016-17. iii. Training the Traditional Birth Attendants (TBAs) to make them Skilled Birth Attendants (SBAs)2. Education iv. Propagating low cost and indigenous technology●● Reduce dropout rates of children from elementary school 5. Preventing indebtedness due to expenditure on health/ from 52.2% in 2003-04 to 20% by 2011-12 protecting the poor from health expenditures●● Increase literacy rate for persons of age ≥ 7 years to 85%●● Lower gender gap in literacy to 10 percentage points i. Creating mechanisms for Health Insurance●● Increase the percentage of each cohort going to higher ii. Health Insurance for the unorganized sector education from the present 10% to 15% by the end of the 6. Decentralizing Governance plan i. Increasing the role of PRIs, NGOs, and Civil Society3. Health ii. Creating and empowering Health committees at various●● Reduce infant mortality rate to 28 and maternal mortality levels ratio to 1 per 1000 live births • 475 •
  • 20. 7. Establishing e-Health The country has to deal with rising costs of health care andi. Adapting IT for governance growing expectations of the people. The role of scientific healthii. Establishing e-enabled Health Management Information planning at the national level, to achieve this goal, needs System no highlighting. Among socialist countries, India is the firstiii. Increasing role of telemedicine and foremost country to show tradition of health planning.8. Improving access to and utilization of essential and During British India, the National congress had a planningquality health care committee under the chairmanship of Pandit Jawaharlal Nehru.i. Implementing flexible norms for health care facilities A committee was appointed by the British, with Sir Joseph (based on population, distance and terrain) Bhore as Chairman, for survey and planning; their report isii. Reducing travel time to two hrs for emergency obstetric a major event in the history of Indian Health Planning. After care independence in 1950 the present Planning Commission wasiii. Implementing Indian Public Health Service Standards for established, which launched first five year plan in 1951. The health care institutions at all levels Planning Commission was set up to make an assessment ofiv. Accrediting private health care facilities and providers the material, capital and human resources of the country, andv. Redeveloping hospitals/institutions to draft developmental plans for the most effective utilisationvi. Mirroring of centres of excellence like AIIMS of these resources addressing the needs of the community and country at large. There are 29 divisions in the Planning9. Increasing focus on Health Human Resources Commission In 1957, the Planning Commission was providedi. Improving Medical, Paramedical, Nursing, and Dental with a Perspective Planning Division which makes projections education and availability into the future over a period of 20-25 years. The membershipii. Reorienting AYUSH education and utilization of the planning commission is highly distinguished and fromiii. Reintroducing licentiate course in medicine the very beginning it is chaired by the Prime Minister of theiv. Making India a hub for health care and related tourism country. The planning commission consists of Chairman,10. Focusing on excluded/neglected areas Deputy Chairman and 5 members. The Planning Commissioni. Taking care of the Older persons works through 3 major divisions: Programme Advisors; Generalii. Reducing Disability and integrating disabled Secretariat & Technical Divisions. The health sector is dividediii. Providing humane Mental Health services into the following subsectors: Water supply and sanitation,iv. Providing Oral health services Communicable diseases, Medical education, training and11. Enhancing efforts at disease reduction research; Curative services i.e., Hospitals, PHCs, etc, Publici. Reversing trend of major diseases Health Services, Family Planning & Indigenous Systems ofii. Launching new initiatives (Rabies, Fluorosis, Medicine. A Bureau of Planning was constituted in 1965 in the Leptospirosis) Ministry of Health to have better coordination between Centre12. Providing focus to Health System and Bio-Medical and State Governments. The working of the national plansresearch is reviewed time to time by National Development Council (NDC), which decides the social and economic policy affectingi. Focusing on conditions specific to our country national development. The five year plans were conceivedii. Making research accountable for organised development of the country by planning a longiii. Translating research into application for improving health term road map focusing on sustained development instead ofSchemes and Outlays for Eleventh Five Year Plan : To achieve short term gains. It lays main emphasis on rebuilding ruralthe desired outcomes in the health sector, a substantially India, industrial development, health for all and balancedenhanced outlay for the Department of Health and Family development in all sectors. Planning Commission laid specialWelfare has been earmarked during the Eleventh Five Year Plan emphasis on health programmes with the broad objectives of:(2007-12). The total projected GBS for the Eleventh Plan is Rs a) Control and eradication of major communicable diseases1,20,374.00 crore (at 2006-07 prices) and Rs 1,36,147.00 crore of public health importance, b) Strengthening basic rural(at current prices). This enhanced outlay is about four times the health services by establishing Subcentres and Primary Healthinitial outlay for the Tenth Plan (Rs 36,378.00 crore). A large Centres, c) Population Control, d) Development of healthproportion of this amount i.e. Rs 89,478.00 crore (65.72 %) is manpower resources. Health planning has been ensured offor NRHM, the flagship of the Government of India. Another proper investment through successive five year plans, which isRs 625 crore is to be contributed by the Dept. of AYUSH to as under showing pattern of allocation since inception.make a total of Rs 90,103 crore for NRHM during the EleventhFive Year Plan. For the other ongoing schemes, a total of Rs Study Exercises23,995.05 crore has been earmarked. For the new initiatives Long Question : Discuss the strategies, time bound goals &it is Rs. 20,846.95 crore. Rs. 1,827.00 crore has also been schemes of 11th five yr plan.earmarked for Oversight Committee. Short Notes : (1) Planning commission (2) Health sectorSummary planning (3) Achievements of 10 five yr plan.Since Independence, India has built up a vast health MCQs:infrastructure and health personnel at primary, secondary, 1. The 3 major divisions of Planning Commission are alland tertiary care in public, voluntary, and private sectors. except: (a) Programme Advisors (b) General Secretariat • 476 •
  • 21. (c) Technical Divisions (d) Executive Division social and economic policy affecting national development.2. All are the sub-sectors of health in planning commission True / False except (a) Water supply and sanitation (b) Medical 11. Contribution of the state governments to health spending education, training and research (c) Indigenous Systems is between 80 and 85 per cent. True / False of Medicine (d) Agriculture 12. Presently, the health budget of state and central3. Broad objectives of Five year plan are: (a) Control and governments combined is less than one percent of GDP . eradication of major communicable diseases of public True / False health importance (b) Strengthening basic rural health 13. Traditional sectors like hospitals, medical education and services by establishing Sub-centres and Primary Health family planning services are now receiving a greater chunk Centres (c) Population Control (d) All of the health budget in comparison to the “new” sectors4. One of the following is not the strategies of 11th plan: like RCH, HIV/AIDS, immunization (especially pulse polio). (a) To increase aggregate spending on health by the Centre True / False and the states (b) The contribution of the private sector 14. From the 2005-06 budget onwards, NRHM has taken a in providing primary, secondary, and tertiary services large share of the RCH and Family Planning budgets giving (c) To establish medical colleges in rural sectors of country a boost to rural health allocations. True / False (d) Health as a right for all citizens is the goal. 15. Government expenditure on health as percentage of total5. 11th Plan will strive towards: (a) Accelerate GDP growth expenditure on health is 24.8% while that of Private from 8% to 10% and then maintain at 10% in the 12th Plan Expenditure is 75.2%. True / False in order to double per capita income by 2016-17 (b) Raise 16. Public spending on health has increased from 0.22% of GDP the sex ratio for age group 0-6 to 935 by 2011-12 and to in 1950-51 and stagnated at around 10% of GDP during the 950 by 2016-17 (c) Attain WHO standards of air quality in later years. True / False all major cities by 2011-12 (d) All 17. Planning Commission was provided with a Perspective6. India is the world’s 10th largest economy and the third Planning Division which makes projections into the future largest in Asia behind Japan and China, with total GDP of over a period of 20-25 years. True / False around 1 trillion. True / False Answers : (1) d; (2) d; (3) d; (4) c; (5) d; (6) False; (7) True;7. Growth for the year ending March 31, 2008 is expected to (8) False; (9) True; (10) True; (11) True; (12) True; (13) False; be between 8.5-9.0%. True / False (14) True; (15) True; (16) False; (17) True.8. There are 22 divisions in the Planning Commission. True / False Further Suggested Reading 1. India’s Five Year Plans. Complete Documents, Academic Foundation, New9. A Bureau of Planning was constituted in 1965 in the Delhi. Ministry of Health to have better coordination between 2. Govt of India (2006), Annual Report 2005-06, Ministry of Health and Family Centre and State Governments. True / False Welfare, New Delhi.10. The working of the national plans is reviewed time to time 3. League of Nations Health Organisation, European Conference on Rural Hygiene (1931), Recommendations on the principles governing the by National Development Council (NDC), which decides the organization of Medical Assistance, the Public Health Services and Sanitation in Rural Districts, Geneva. • 477 •
  • 22. secondly, Report of the working group on ‘ Health For All by Public Health & Community 2000 AD’ sponsored by Ministry of Health and Family Welfare 87 Medicine Related Policies in (MOHFW), Government Of India. These reports formed the India basis of the National Health Policy formulated by MOHFW, GOI in 1983. Sunil Agrawal Since, the inception of National Health Policy there have been marked changes in the determinants of health. Some of the policy initiatives outlined in the NHP-1983 yielded results,National Health Policy (NHP) - 2002 while in several other areas, the outcome was not as expected.Policies are “courses” or “principles” of action adopted or These include remarkable successes like eradication of Guineaproposed by a Government. In the developing countries Worm. Polio is on the verge of being eradicated. Leprosy,like India, resources often fall short of requirements, the Kala Azar, and Filariasis can be expected to be eliminated inGovernment policies then guide us to set priorities and allocate the foreseeable future. There has been a substantial drop inresources to achieve our objectives. Health policies are intended the total fertility rate and infant mortality rate. The successto achieve a level of health status for most of the persons in the of the initiatives taken in the public health field is reflectedcommunity. The policies enacted by various Government bodies in the progressive improvements of many demographic,have formal framework with legal backup. Health policy aims epidemiological and infrastructural indicators over the periodat the improvement of the conditions under which people live, 1951 to 2007 (Box - 1).including housing, education, nutrition, child care, reproductive Improvement of these health indicators were the outcomehealth, transportation, information and communication. of several complementary initiatives of development sectorBackground covering rural development, agriculture, food production, animal husbandry, drinking water, sanitation, education etc.In 1977, the World Health Assembly at Alma Ata decided to Despite the impressive public health gains, the morbiditylaunch an ambitious movement known as, “Health for All and mortality levels in the country were high as compared to(HFA) by 2000 AD”. This broadly means attainment of level developed countries. Over the years the incidence of some ofof health that will permit all people to lead economically and the communicable diseases like Malaria, Tuberculosis, HIV/socially productive life. As a signatory to HFA strategy, the AIDS, hepatitis and non communicable diseases like Cancers,Government of India was committed to frame its own policy and life style diseases, diabetes etc were on the rise and much moreimplement to attain Health For All by 2000 AD. In pursuance of dedicated efforts were required to achieve goal of, “Health Forthis objective, two important committees were framed to study All by 2000 AD”. After the passage of year 2000, it was the timethis strategy in detail keeping in view local percept. These to take stock of situation and progress ahead with extra zeal towere, firstly, the Report of the study Group on ‘Health for All achieve ultimate goal of Health For All. Accordingly, the NHP -- an alternative strategy’, Sponsored by ICSSR and ICMR, and, Box - 1 Indicator 1951 1981 2000 2006 Life Expectancy 36.7 54 61 (M), 62.7 (F) 62.3 (M), 63.9 (F) Crude Birth Rate per 1000 40.8 33.9(SRS) 26.1(99 SRS) 23.5 Crude Death Rate per 1000 25 12.5(SRS) 8.7(99 SRS) 7.5 IMR per 1000 live births 146 110 70 (99 SRS) 57 Total Fertility Rate 6 - 3.8 2.9 Malaria (cases in million) 75 2.7 2.2 1.78 Leprosy cases per 10,000 population 38.1 57.3 3.74 0.72 Small Pox (no of cases) >44,887 Eradicated  Guineaworm ( no. of cases) >39,792 Eradicated Polio 29709 265 116 SC/PHC/CHC 725 57,363 1,63,181 1,71,567 Dispensaries &Hospitals 43,322 (95- 9209 23,555 96-CBHI) Beds (Pvt & Public) 117,198 569,495 8,70,161 Doctors (Allopathy) 61,800 2,68,700 5,03,900 6,96,747 Nursing Personnel 18,054 1,43,887 7,37,000 15,09,196 (Sources : 1 - 3) • 478 •
  • 23. 1983 was revised and a new, extensive NHP was enunciated by services would be much enhanced.the Govt of India in 2002. (e) Primacy to preventive and first-line curative initiative atObjective of National Health Policy (NHP) 2002 the primary health level. (f) Emphasis will be laid on rational use of drugs within theThe main objective of this policy is to achieve an acceptable allopathic system.standard of good health amongst the general population of the (g) Increased access to tried and tested systems of traditionalcountry. The noteworthy initiatives are presented in Box - 2 medicine. The endeavour of NHP-2002 is to achieve the time-bound Box - 2 : Noteworthy initiatives under the National Health goals mentioned in Box - 3, within the framework of strategies Policy 2002 mentioned above. ●● Comprehensive primary health care services On a short term basis, within the context of the NHP the , ●● Health volunteers Important health related targets for the eleventh five year plan ●● Well worked out referral system (2007 - 2012) are : ●● Integrated network of evenly spread speciality and super ●● Reducing Maternal Mortality Ratio (MMR) to 1 per 1,000 speciality services live births. ●● Reducing Infant Mortality Rate (IMR) to 28 per 1,000 liveStrategies births.The revised strategies adopted by GOI to achieve above objective ●● Reducing Total Fertility Rate to 2.1.are : ●● Providing clean drinking water for all by 2009 and ensuring(a) Increase access to the decentralized public health system by no slip-backs. establishing new infrastructure in deficient areas, and by ●● Reducing malnutrition among children of age group 0-3 to upgrading the infrastructure in the existing institutions. half its present level.(b) Ensuring a more equitable access to health services across ●● Reducing anaemia among women and girls by 50%. the social and geographical expanse of the country. ●● Raising the sex ratio for age group 0-6 to 935 by 2011-12(c) Increasing the aggregate public health investment and 950 by 2016-17. through a substantially increased contribution by the Major Strategies of NHP-2002 Central Government. It is expected that this initiative will (a) Financial Resources : It is concerning that Public Health strengthen the capacity of the public health administration expenditure has declined from 1.5% of GDP in 1990 to 0.9% at the state level to render effective service delivery. of GDP in 1999. Given the difficult fiscal position of the State(d) The contribution of the private sector in providing health Governments, the Central Government will have to play a key Box - 3 : Goals to be achieved by 2000 - 2015 Goals for which the target year is already over Target Year Result Eradicate Polio 2005 Not achieved Eradicate Yaws 2005 Achieved Eliminate Leprosy 2005 Achieved Achieve Zero level growth of HIV/AIDS 2007 Not achieved Establish an integrated system of surveillance, National Health Accounts and Health 2005 IDSP has been Statistics. launched Increase State Sector Health spending from 5.5% to 7% of the total budget 2005 Not achieved Goals for which time is available Target Year Eliminate Kala Azar 2010 Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne 2010 diseases Reduce Prevalence of Blindness to 0.5% 2010 Reduce IMR to 30/1000 and MMR to 100/Lakh 2010 Increase utilization of public health facilities from current Level of <20 to >75% 2010 Increase health expenditure by Government from the existing 0.9 % to 2.0% of GDP 2010 Increase share of Central grants to Constitute at least 25% of total health expenditure 2010 Increase State Sector Health spending from 5.5% to 7% of the budget and further 2010 increase to 8% Eliminate Lymphatic Filariasis 2015 • 479 •
  • 24. role in augmenting public investments. It is planned, under the by nurse practitioners in several developed countries.policy, to increase health sector expenditure by both central and (f) Role of Local Self-Government Institutions : NHP-2002state government as stated in Box 3 above. However, the higher lays great emphasis upon the implementation of public healthpublic health investment should also be gainfully utilised by programmes through local self government institutions. Thethe public health administration for upliftment of health status financial incentives will be provided by Central Government.of the community. (g) Norms for Health Care Personnel : Minimal statutory(b) Equitable distribution : To meet the objective of reducing norms for the development of doctors and nurses in medicalvarious types of inequities and imbalances, i.e., interregional; institutions need to be introduced urgently under the provisionsacross the rural - urban divide; and between economic classes - of the respective MCI and INC acts.the most cost-effective method would be to increase the sectoral (h) Education of Health Care Professionals : Keeping in viewoutlay in the primary health sector. Such outlets afford access the uneven distribution of colleges in the country, the policyto a number of individuals, and also facilitate preventive and envisages the setting up of a Medical Grants Commission forearly stage curative initiative. NHP-2002 sets out an increased funding new Government Medical and Dental Colleges andallocation of 55 percent of the public health investment for the upgradation of existing colleges in different parts of the country.primary health sector, the secondary and tertiary health sectors The existing curriculum can be modified to a more need-being targeted for 35 percent and 10 percent respectively, for based, realistic, skill oriented syllabus, at undergraduate levelstrengthening existing facilities and opening additional public with a more significant component of practical training. Thisservice outlets. would make fresh doctors contribute effectively to providing(c) Delivery of National Public Health Programmes : The of primary health services immediately after graduation. Thepolicy envisages a key role for the Central Government in policy recommends periodic skill updating through Continuingdesigning national programmes with the active participation Medical Education (CME) programmes on important healthof the State Governments. Also, the policy ensures the issues.provisioning of financial resources, in addition to technical (j) Need for Specialists In Public Health and Familysupport, monitoring and evaluation at the national level by Medicine : In order to alleviate the acute shortage of medicalthe Centre. However, to optimize the utilization of the public personnel in public health, the policy envisages to raise thehealth infrastructure at the primary level, NHP-2002 envisages proportion of postgraduate seats in the field of ‘Public Health’the gradual convergence of all health programmes under a and ‘Family Medicine’ progressively to reach a stage whereinsingle field administration. Vertical programmes for control 1/4th of the seats are earmarked for these disciplines. Sinceof major diseases like TB, Malaria, HIV/AIDS, as also the RCH the public health discipline has an interface with many otherand Universal Immunization programmes, would need to be developmental sectors, specialization in public health maycontinued till these diseases are no more a public health threat. be encouraged not only for medical doctors, but also forThe major change in programme implementation is through non-medical graduates from the allied fields of public healthautonomous bodies at State and district levels whereas the engineering, microbiology and other natural sciences.role of district and state health departments will be limited tooverall monitoring of achievements of programme targets and (k) Nursing Personnel : In the interest of patient care, thetechnical aspects. This will give better planning and operational policy emphasises the need for an improvement in the ratio offlexibility and public health projects will be more suited to the nurses vis-à-vis doctors/beds and an increase in degree holdinglocal needs. nurses vis-a-vis diploma holding nurses and training of super speciality nurses.(d) The State of Public Health Infrastructure : The NHP2002 envisages kick-starting the revival of the Primary Health (l) Use of Generic Drugs and Vaccines : NHP emphasizes theSystem by providing some essential drugs under Central need for basing treatment regimens on generic drugs ratherGovernment funding. This policy recognizes the need for more than proprietary drugs, except in special circumstances. Thisfrequent in service training of public health medical personnel, is a pre-requisite for cost effective public health care andat the level of medical officers as well as paramedics. Further, it production and sale of irrational combination of drugs wouldalso recognizes the practical need for levying reasonable user- be prohibited through the drug standard statute. The UIPcharges for certain secondary and tertiary public health care should be assured of uninterrupted supply of vaccines mainlyservices for those who can afford to pay. from public sector institutions so that they are available at an affordable price.(e) Extending Public Health Services : For better availabilityand distribution of medical personnel in their jurisdiction, State (m) Urban Health : NHP-2002 envisages the setting up ofGovernments will expand the pool of medical practitioners to an organized urban primary health care structure based oninclude a cadre of licentiates of medical practice, practitioners of appropriate population norms. The structure conceived underIndian Systems of Medicine and Homoeopathy. Simple services/ NHP-2002 is a two-tiered one; the Primary centre covering aprocedures can be provided by such practitioners even outside population of one lakh, with a dispensary providing an OPDtheir disciplines, as part of the basic primary health services in facility and essential drugs, to enable access to all the nationalunder-served areas after adequate training and subject to the health programmes, and a second-tier of the urban healthmonitoring of their performance through professional councils. organization at the level of the Government general hospital,The scope of expanding services of paramedical personnel from where referral is made from the primary centre. The fundingexisting usage will be examined on lines of services rendered of UHC will be jointly borne by state and centre. The policy • 480 •
  • 25. also recommends establishment of fully equipped trauma care (u) Women’s Health : The policy envisages the increasednetworks to reduce accidental mortality and morbidity. access of women and underprivileged groups to basic health(n) Mental Health : NHP-2002 envisages a network of care of primary health sector and gives highest priority to thedecentralized mental health services and the diagnosis of identified programmes relating to women’s health.common disorders, and the prescription of common therapeutic (v) Regulation of standards of Para Medical Disciplinesdrugs by general duty medical staff. Central Government has and Medical Ethics : The NHP 2002 recognises the needalso committed to upgrade physical infrastructure of mental for the establishment of statutory professional councils forhealth institutions for indoor treatment of patients. paramedical disciplines to register paramedic practitioners,(o) Information, Education And Communication (IEC) : maintain standards of training, and monitor performance. TheNHP-2002 envisages an IEC policy, which maximizes the policy also recommends that a contemporary code of ethics bedissemination of information to those population groups notified and rigorously implemented by the Medical Councilwhich cannot be effectively approached by using only the of India as well as the need to watch newer areas like genemass media. The focus would therefore be on the interpersonal manipulation, and stem cell research.communication of information and on folk and other traditional (w) Enforcement of Quality Standards for Food and Drugs :media to bring about behavioral change. Dispelling of myths The NHP-2002 envisages that the food and drug administrationand misconceptions about religious and ethical issues by will be progressively strengthened, in terms of both laboratorythe community leaders, particularly religious leaders is an facilities and technical expertise. Food standards will be similareffective way for behavioural change in the community. NHP to Codex specifications and drug standards will be at par with2002 also gives priority to school health programmes which the most rigorous ones adopted elsewhere.aim at preventive health education, providing regular health (x) Environmental and Occupational Health : The policies andcheck ups and promotion of health seeking behaviour amongst programmes of the environment related sectors be smoothlychildren. interfaced with the policies and the programmes of the health(p) Health Research : The policy envisages an increase in sector.Government funded health research to a level of 2 percent by (y) Providing Medical Facilities to Users from Overseas :2010. Domestic medical research would be focused on new The policy strongly encourages the provision of secondary andtherapeutic drugs and vaccines for tropical diseases, such as TB tertiary health services on a payment basis to service seekersand Malaria, as also on the sub-types of HIV / AIDS prevalent in from overseas (Medical Tourism), due to comparatively cheaperthe country. Private entrepreneurship will be encouraged in the cost.field of medical research. (z) Impact of Globalisation on the Health Sector : The policy(q) Role of The Private Sector : In principle, this policy envisages a national patent regime for the future, which availswelcomes the participation of the private sector in all areas of of all opportunities to secure for the country under its patenthealth activities - primary, secondary or tertiary. It envisages laws, affordable access to the latest medical and therapeuticthe enactment of suitable legislation for regulating minimum discoveries.infrastructure and quality standards in private clinicalestablishments / medical institutions along with statutory National Population Policy (NPP) - 2000guidelines for the conduct of clinical practise. The NHP In 1952, India became the first country in the world to launchenvisages the co-operation of private practitioners and NGOs a national program, emphasizing family planning to the extentin the national disease control programmes. necessary for reducing birth rates “to stabilize the population at(r) The Role of the Civil Society : The policy emphasizes a level consistent with the requirement of national economy”.the need to simplify procedures for government - civil society The evolution of the national family planning programme isinterfacing in order to enhance the involvement of civil society presented in Box - public health programmes. The National Health Policy, 1983, stated that replacement(s) National Disease Surveillance Network : This Policy levels of fertility rate (TFR) should be achieved by the yearenvisages the setting up of an integrated disease control 2000. On 11 May 2000, India had 1 billion (100 crore) people,network from the lowest rung of public health administration i.e., 16 percent of the world’s population on 2.4 percent ofto the Central Government. This public health surveillance the globe’s land area. If current trends continue, India maynetwork will also encompass information from private health overtake China in 2045, to become the most populated countrycare institutions and practitioners. It is expected that real-time in the world. While global population has increased threefoldinformation will greatly strengthen the capacity of the public during 20th century, from 2 billion to approximately 6 billion,health system to counter local outbreaks of seasonal diseases. the population of India has increased nearly five times from 238 million (23 crores) to 1 billion in the same period. India’s(t) Health Statistics : The policy envisages the compilation of current yearly increase in population of 15.5 million is enoughbaseline estimates for the incidence of the common diseases. to neutralize efforts to conserve our efforts towards resourceThe policy proposes to enable the periodic updating of these endowment and environment.baseline estimates through representative sampling, under anappropriate statistical methodology, so that the public health The National Population Policy (NPP) 2000 provides a policysystem would move closer to the objective of evidence-based framework for advancing goals and prioritizing strategiespolicy-making. during the next decade, to meet the reproductive and child • 481 •
  • 26. Box - 4: Evolution of Family Planning Programme in India Year Remarks 1925 Prof Raghunath Dhondo Karve opened the first birth control clinic in Mumbai 1938 National Planning Committee of the Indian National Congress set up in 1938 strongly supported Family Planning as a state policy First five-year India was the first country to have officially launched a well-defined family planning programme in 1951 plan (1951-56) Third five year Extension wing was added to the existing programme, introduction of intrauterine device, integrated plan (1961-66) approach was adopted in 1966 and family planning formed an integral part of maternal and child health and nutritional services. 1968 Social marketing for condoms was introduced under which condoms or Nirodh were made available at highly subsidized price. And at this stage Lippies loop was introduced. Fourth five year Family planning services were integrated with Primary health care at this stage. 1970-All India Hospital plan (1969-74) Post Partum Programme (AIHHP) was launched. 1971-liberalisation of abortions by the govt. by passing MTP act. Fifth five-year The programme took the recourse in this time period with Mass Vasectomy Camp Approach leading to plan (1974-79) national emergency in 1975. The programme was renamed at this stage as Family Welfare Programme. Family welfare basket was filled with nutrition and child health programmes. 1975-Integrated Child Development Scheme. 1978-Child Marriage Restraint Act. India became signatory of Alma Ata declaration in 1978. Sixth five-year The national health policy diluted family planning and it became a part of concept of positive health and plan (1980-85) one of the means to achieve Health for All by 2000. Seventh five-year There was strengthening of Mother and child (MCH) services along with family welfare services. Other plan (1986-90) programmes as Oral Rehydration Therapy (ORT), control of respiratory group of infections and universal immunization programme were also included. Eighth five-year The programme was renamed again as Child survival and Safe Motherhood programme (CSSM) in plan (1992-97) 1992(7). Ninth five-year Reproductive and Child Health programme was launched in 1997 comprising of Child Survival and Safe plan (1997-2002) Motherhood (CSSM), Sexually transmitted infections (STI) and other components. Tenth five year RCH II was launched with few modifications after evaluating RCH I plan (2002-2007)health needs of the people in India, and to achieve net health services, supplies and infrastructure.replacement levels (TFR) by 2010. It is based upon the need (b) Make school education up to age 14 free and compulsory,to simultaneously address issues of child survival, maternal and reduce drop outs at primary and secondary schoolhealth and contraception, while increasing outreach and levels to below 20 percent for both boys and girls.coverage of a comprehensive package of reproductive and child (c) Reduce infant mortality rate to below 30 per 1000 livehealth service by government, industry and voluntary non- births.government sector, working in partnership. The NPP affirms the (d) Reduce maternal mortality ratio to below 100 per 100,000commitment of government towards voluntary and informed live births.choice and consent of citizens while availing reproductive health (e) Achieve universal immunization of children against allcare services, and continuation of the target free approach in vaccine preventable diseases.administering family planning services. The objectives of NPP (f) Promote delayed marriage for girls, not earlier than age 18- 2000 are shown in Box - 5. and preferably after 20 years of age.The major differences between the earlier approach and the (g) Achieve 80 percent institutional deliveries and 100 percentnewer approach, based on NPP - 2000 and RCH-II programme deliveries by trained persons.are shown in Box - 6. (h) Achieve universal access to information / counselling, and services for fertility regulation and contraception with aNational Socio Demographic Goals wide basket of choices.In pursuance of these objectives, the following National Socio- (j) Achieve 100 percent registration of births, deaths,Demographic Goals to be achieved by 2010 are formulated: marriages and pregnancies.(a) Address the unmet needs for basic reproductive and child (k) Prevent and control communicable diseases. • 482 •
  • 27. Box - 5 : Objectives of NPP - 2000 ●● To address the unmet needs for contraception Immediate ●● Strengthen health care infrastructure, and health personnel objective ●● Provide integrated service delivery for basic reproductive and child health care. Medium-term ●● To bring the TFR to replacement levels by 2010 objective ●● Vigorous implementation of inter-sectoral operational strategies. Long-term ●● To achieve a stable population by 2045, at a level consistent with the requirements of sustainable economic objective growth, social development, and environmental protection Box - 6 : Differences between older and newer approach (8). Old Approach (Family Planning) New Approach (Reproductive and Child Health) Population-Centered People-centered Over-emphasis on sterilization Informed Choice of contraceptives Quantitative targets Qualitative targets Family Planning in a separate basket FP merged with Health: One package for Health, MCH & FP Focus on 30 + women with 3 or 4 children Focus on new operation, in particular, adolescents (15-25 years) Focus on gender issues and concern for gender equity Insensitive to gender issues and elimination of discrimination against women No linkage with basic needs of the poor Priority for fulfilling the Minimum Needs Programme No consultation with people Decentralised programme run through panchayats & nagarpalikas at the grassroot level Family Welfare Department- the sole Abolish the Department and establish a Population and custodian of population matters Social Development Communion and Fund(l) Integrate Indian System of Medicine (ISM) in the provision - too frequent- too many’. of RCH services, and in reaching out to households. (e) Preference of male child.(m) Promote vigorously the small family norm to achieve (f) More children are preferred by poor parents as more work replacement level of TFR. force.(n) Contain the spread of Acquired Immuno Deficiency Major Strategies in NPP - 2000 Syndrome (AIDS), and promote greater integration between There are 12 strategic themes in order to achieve the socio the management of RTI and STI. demographic goals by 2010. These are enumerated below:(o) Bring about convergence in implementation of related social sector programmes so that family welfare becomes a (a) Decentralized Planning and Program Implementation. people centered programme. (b) Convergence of Service Delivery at Village Levels. (c) Empowering Women for Improved Health and Nutrition.Targets set by NPP 2000 and Current Scenario (d) Meeting the Unmet Needs for Family Welfare Services.These are shown in Box - 7 and 8. (e) Focus on Under-Served Population Groups.If the NPP - 2000 is fully implemented, we anticipate a - Urban Slumspopulation of 1107 million (110 crores) in 2010, instead of - Tribal communities, hill areas, displaced/migrant1162 million (116 crores) projected by Technical Group on populationspopulation Projections. - Adolescents (f) Involvement of men in planned parenthoodCauses of High Population Growth in India (g) Action through diverse Health Care Providers.Population growth in India continues to be high on account of (h) Collaboration with and Commitments from Non-following - Government Organizations and the Private Sector.(a) Large size of population in the reproductive age group (i) Mainstreaming Indian System of Medicine and (estimated contribution 58 percent). Homeopathy.(b) Higher fertility due to unmet needs of contraception. (j) Contraceptive Technology and Research on Reproductive (estimated contribution 20 percent). and Child Health.(c) High desire for fertility due to high Infant Mortality Rate (k) Providing for the Older Population. (estimated contribution about 20 percent). (l) Information, Education and Communication.(d) Approximately 50 percent of girls marry below the age of Operational Strategies 18, resulting in a typical reproductive pattern of ‘too early These include the following : • 483 •
  • 28. Box - 7 : Targets set by NPP - 2000 and current scenario. Indicators Target by 2010 Current status (2007) Population 1107 Million 1103 Million (2005) School attendance: Reduce drop outs at primary ●● 6-10 yrs - 83% < 20 percent for both boys and girls and secondary school levels ●● 11-14 yrs - 75% ●● 15-17 yrs - 41% (NFHS-3) Infant mortality rate <30 per 1000 live births 57 per 1000 live births Maternal Mortality Rate <100 per 100,000 live births 301 per 100,000 live births (2001-2003) Marriage : Marriage for girls, not Promote delayed marriage ●● Girls (Before 18yrs) - 46% earlier than age 18 ●● Boys (before 21 yrs) - 27% (NFHS-3) Achieve universal 44% of children fully immunization of children. vaccinated (NFHS-3) Deliveries by trained persons. 100% 48% CBR 21 23.5 TFR 2.1 2.9 Box - 8 : Targets under various plans. National Population Tenth Plan Goals RCH II Goals Millennium Indicator Policy 2000 Goals (2002-2007) (2005-2010) Development Goals (By 2010) Infant Mortality Rate <45/1000 <30/1000 <30/1000 - Under Five Mortality Rate Reduce by 2/3 from - - - 1990 levels by 2015 Maternal Mortality Ratio Reduce by 3/4 from 200/100000 <100/100000 <100/100000 1990 levels by 2015 Total Fertility Ratio 2.3 2.1 2.1 - Couple Protection Ratio 65% 65% 100% -(a) Utilize village self help groups to organize and provide with kits for midwifery, ante-natal care, and delivery; basic basic services for reproductive and child health care, medication for obstetric emergency aid; contraceptives, combined with the ongoing ICDS scheme. drugs and medicines for common aliments.(b) Implement, at village levels, a one-stop integrated and (f) Trained birth attendants as well as the vast pool of coordinated service delivery package for basic health traditional dais should be trained and made familiar with care, family planning and maternal and child health emergency and referral procedures. related services, provided by the community and for the (g) Provide wider basket of choices in contraception, through community. innovative social marketing schemes to reach household(c) Wherever these village self-help groups have not developed levels. for any reason, community midwives, practitioners of ISM, (h) Improve district, sub-district and panchayat-level health retired school teachers and ex-defence personnel may be management with coordination and collaboration between organized to perform similar functions. district health officer, sub-district health officer and the(d) At village levels, the Anganwadi centre may become the pivot panchayat for planning and implementation activities. of basic health care activities, contraceptive counselling (j) Strengthen Community Health Centres (CHCs) and PHCs to and supply, nutrition education and supplementation, provide comprehensive essential and emergency obstetric as well as preschool activities. The Anganwadi centres and neo-natal care. can also function as depots for ORS/basic medicines and (k) Strengthening skills of health personnel and health contraceptives. providers through classroom and on-the-job training.(e) A maternity hut should be established in each village to (l) Focus attention on men in the information and education be used as the village delivery room with storage space for campaigns to promote the small family norm. supplies and medicines. It should be adequately equipped (m) Sensitize, train and equip rural and urban health centres and hospitals towards providing geriatric health care. • 484 •
  • 29. Promotional and Motivational Steps for Adopting GoalsSmall Family Norm in NPP The National Nutrition Policy had following goals :(a) Rewards for Panchayats and Zila Parishads for exemplary 1. Reduction in the incidence of malnutrition and stunted performance. growth among children.(b) Balika Samridhi Yojana - A cash incentive of Rs 500 is 2. Reduction in the incidence of low birth weight to less than awarded at the birth of the girl child of birth order 1 or 2 to 10 percent. promote survival and care of girl child. 3. Elimination of blindness due to Vit A deficiency.(c) Maternity Benefit Scheme - A cash incentive of Rs 500 is 4. Reduction in the iron deficiency anemia among pregnant awarded to mothers who have their first child after 19 women to 25 percent. years of age for the birth of first or second child only. 5. Universal iodisation of salt for reduction of iodine(d) Family Welfare - linked Health Insurance Plan. deficiency disorders to below endemic level.(e) Couples below the poverty line, who marry and produce 6. Special emphasis to geriatric nutrition. two children after age of 21 are rewarded. 7. Annual production of 250 million tonnes of food grain.(f) Opening/Establishing creches and child care centres in 8. Improving household food security through poverty rural areas and urban slums, to promote participation of alleviation programme. women in paid employment. 9. Promoting appropriate diets and healthy life style.(g) Provision of wider and affordable choices of The Strategy contraceptives.(h) Strengthening and expansion of safe abortion facilities. Nutrition is a multi-sectoral issue and needs to be tackled at(j) Increased vocational training schemes for girls leading to various levels. It is important to tackle the problem of nutrition self-employment. both through direct nutrition intervention for specially(k) Villagers will be provided soft loans and encouraged to run vulnerable groups as well as through various development ambulance services for referrals. policy instruments which will create conditions for improved(l) Village level self help groups will be set up. nutrition. A. Direct Short Term InterventionsNational Nutrition Policy (i) This envisages Nutrition Intervention for speciallyThe adoption of National Nutrition Policy (NNP) by the vulnerable groups:Government under the aegis of the Deptt. of Women & (a) Expanding the Safety Net through the UniversalChild Development in 1993 has been one of the significant immunization Programme, oral rehydration therapy andachievements on Nutrition scene in the country. The Nutrition the Integrated Child Development Services (ICDS)Policy recognized that “Nutrition affects development as (b) With the objective of reducing the incidence of severe andmuch as development effects nutrition”. The Policy advocates moderate malnutrition by half by the year 2000 A.D.a series of actions in different spheres like food production, (c) Reaching the Adolescent Girls : The Government’s recentfood distribution, education, health and family welfare, people initiative of including the adolescent girl within ‘the ambitwith special needs and nutritional surveillance. The direct and of’ ICDS should be intensified so that they are made readyindirect instruments of Nutrition Policy were recommended for a safe be institutionalized through inter-sectoral co-ordination (d) Ensuring better coverage of expectant women in order tomechanism at Central and State levels. It gives an integrated achieve a target of 10% incidence of low birth weight byapproach between broad sectors of agriculture, food and 2000 A.D.nutrition, Environment, animal husbandry etc and thereby (ii) Fortification of Essential Foods : Essential food itemsimproving the nutritional status of the society. shall be fortified with appropriate nutrients. e.g. salt withThe major nutrition problems of India can be classified as iodine and/or iron.follows : (iii) Popularisation of Low Cost Nutritious Food : Efforts(1) Under-nutrition resulting in: to produce and popularise low cost nutritious foods from (a) Protein Energy Malnutrition (PEM); indigenous and locally available raw material shall be (b) Iron deficiency; intensified. (c) Iodine deficiency (d) Vitamin A deficiency and other hypovitaminoses. (iv) Control of Micro-Nutrient Deficiency amongst (e) Low Birth Weight children vulnerable Groups : Deficiencies of Vitamin A, iron and folic(2) Seasonal dimensions of Nutrition; acid and iodine among children, pregnant women and nursing(3) Natural calamities & the landless. mothers shall be controlled through intensified programmes.(4) Market Distortion and Disinformation; B. Indirect Policy Instruments : Long Term Institutional &(5) Urbanisation. Structural Changes :(6) Special Nutritional Problems of Hill People, Industrial (i) Food Security: In order to ensure aggregate food security Workers, Migrant Workers, and other special categories; a per capita availability of 215 kg/person/year of foodgrains(7) Problems of over nutrition, overweight and obesity for a needs to be attained. small section of urban population. • 485 •
  • 30. (ii) Improvement of Dietary pattern through Production (xvi) Improvement of the Status of Women : The mostand Demonstration effective way to implement Nutrition with mainstream activities(iii) Policies for Effecting Income transfers so as to improve in Agriculture, Health, Education and Rural Development isthe entitlement package of the rural and urban poor. to focus on improving the status of women, particularly the(a) Improving the purchasing power: Poverty alleviation economic status. programmes, like the Integrated Rural Development Administration and Monitoring Programme (IRDP) and employment generation schemes The policy have been implemented and administered by several like Jawahar Rozgar Yojana, Nehru Rozgar Yojana and ministries and departments of Government of India and NGOs. DWCRA are to be re-oriented and restructured to make The administration and monitoring of the programme is as a forceful dent on the purchasing power of the lowest under: economic segments of the population. 1. Implementation of National Nutrition Policy(b) Public Distribution System: Ensuring an equitable (a) The measures enumerated above have to be administered food distribution, through the expansion of the public- by several ministries/departments of the Government of distribution system. India and various governmental and non-governmental(iv) Land Reforms: Implementing land reform measures so organisations. There should be a close collaborationthat the vulnerability of the landless and the landed poor could between the Food Policy, the Agricultural Policy the Healthbe reduced. Policy, the Education Policy, the Rural Development(v) Health & Family Welfare: The health and family welfare Programme and the Nutrition Policy as each complementsprogrammes are an inseparable part of the strategy through the other.“Health for All by 2000AD”. (b) An Inter-Ministerial Co-ordination Committee will function(vi) Basic Health and Nutrition Knowledge: Basic health and. in the Ministry of Human Resource Development under thenutrition knowledge. With special focus on wholesome infant Chairmanship of Secretary, Department of Women and Childfeeding practices, shall be imparted to the people extensively Development, to oversee and review the implementation ofand effectively. nutrition intervention measures.(vii) Prevention of Food Adulteration: Prevention of (c) A National Nutrition Council will be constituted infood adulteration must be strengthened by gearing up the the Planning Commission, with Prime Minister asenforcement machinery. chairperson. 2. Monitoring of Nutrition situation : Nutritional(viii) Nutrition Surveillance: Nutritional surveillance is surveillance of the country’s population especially children andanother weak area requiring immediate attention. mothers, shall be the responsibility of the National Institute of(ix) Monitoring of Nutrition Programmes: Monitoring of Nutrition.Nutrition Programmes (viz ICDS), and of Nutrition Education 3. Role of State Governments : In a federal polity like ours,and Demonstration by the Food & Nutrition Board, through all the cutting edge of governmental interventions commencesits 67 centres & field units, should be continued. from the state level. Full implementation of various special(x) Research: Research into various aspects of nutrition, both programmes being run for upliftment of nutritional statuson the consumption side as well as the supply side, is another of country, will go a long way in ensuring success of theessential aspect nutritional policy. The programmes have been discussed in(xi) Equal Remuneration: Special efforts should be made to detail in the section on nutrition in this book and include ICDS,improve the effectiveness of programmes related to women. Special Nutrition Programme, Balwadi Nutrition Programme,(xii) Communication: Communication through established Wheat Based Supplementary Nutrition Programme, Tamil Nadumedia is one of the most important strategies to be adopted for Integrated Nutrition Programme, Mid Day Meals Programme,the effective implementation of the Nutrition Policy. Nutritional Anaemia Prophylaxis Programme, Goitre Control Programme and Programme for Prevention of Nutritional(xiii) Minimum Wage Administration: Closely related to the Blindness due to Vitamin A, is the need to ensure an effective minimum wageadministration to ensure its strict enforcement and timely Functions of the Food & Nutrition Boardrevision and linking it with price rise through a suitable The Food & Nutrition Board’, as reconstituted on 26 July 1990,nutrition formula. advises Government, coordinates and reviews the activities in(xiv) Community Participation: The active involvement of the regard to food and nutrition extension/education; development,community is essential not only in terms of being aware of the production & popularisation of nutritious Foods and Beverages;services available to the community but also for deriving the measures required to combat deficiency diseases; andmaximum benefit from such services by giving timely feedback ‘Conservation and efficient utilisation as well as augmentationnecessary at all levels. of food resources by way of food preservation and processing.(xv) Education and Literacy: It has been shown that Education National Nutrition Mission (NNM) was set up in 2002 with& Literacy particularly that of women, is a key determinant for overall responsibility of reducing both macro and microbetter nutritional status. nutritional deficiency in the country. As part of NNM, a new programme for adolescent girls and expectant and nursing • 486 •
  • 31. mothers is being launched by Department of Women and 5. Trading in blood i.e. Sale & purchase of blood shall beChild Development during 2002-03. Under this programme grains are supplied free of cost through targeted public 6. The practice of replacement donors shall be graduallydistribution system (PDS) directly to identified families. phased out in a time bound programme to achieve 100% voluntary non-remunerated blood donation programme.National Blood Policy 7. State Blood Transfusion Councils shall organise the bloodA well organised Blood Transfusion Service (BTS) is a vital transfusion service through the network of Regional Bloodcomponent of any health care delivery system. An integrated Centres and Satellite Centres and other Government, Indianstrategy for Blood Safety is required for elimination of Red Cross Society & NGO run blood centres and monitortransfusion transmitted infections and for provision of safe and their functioning.adequate blood transfusion services to the people. The main 8. The Regional Centres shall be autonomous for their day tocomponent of an integrated strategy include collection of blood day functioning and shall act as a referral centre for theonly from voluntary, non-remunerated blood donors, screening region assigned to it.for all transfusion transmitted infections and reduction of 9. Due to the special requirement of Armed Forces in remoteunnecessary transfusion. border areas, necessary amendments shall be made in theThe Blood Transfusion Service in our country is quite Drugs & Cosmetics Act/Rules to provide special licences todecentralised and lacks resources and good management. In small garrison units. These units shall also be responsiblespite of hospital based system, many large hospitals and nursing for the civilian blood needs of the do not have their own blood banks and this has led Objective - 2 : To make available adequate resources to developto proliferation of stand-alone private blood banks. The blood and re-organise the blood transfusion service in the entirecomponent production/availability and utilisation is extremely There is shortage of trained health-care professionals Strategyin the field of transfusion medicine and the requirements of 1. National & State/UT Blood Transfusion Councils shall begood manufacturing practices and implementation of quality supported/ strengthened financially.system management. 2. Efforts shall be directed to make the blood transfusionThus, a need for modification and change in the blood service viable through non-profit recovery system.transfusion service has necessitated formulation of a National 3. Efforts shall be made to raise funds for the blood transfusionBlood Policy and development of a National Blood Programme service for making it self-sufficient.which will also ensure implementation of the directives 4. The mechanism shall be introduced in government sectorof Supreme Court of India in 1996. Hon’able Supreme court to route the amounts received through cost recovery ofdirected to phase out unlicensed blood banks by May 2007 and blood/blood components to the blood banks for improvingprofessionals blood donors by December 1997. their services.Mission Statement : The policy aims to ensure easily Objective - 3 : To make latest technology available for operatingaccessible and adequate supply of safe and quality blood the blood transfusion services and ensure its functioning in anand blood components and transfusion under supervision of updated manner.trained personnel for all who need it through comprehensive, Strategyefficient and a total quality management approach. The broad 1. Minimum standards for testing, processing and storageobjectives and strategies to achieve as given in National Blood shall be set and ensured.Policy are as under : 2. All mandatory tests as laid down under provisions of DrugsObjective - 1 : To reiterate firmly the Govt. commitment to & Cosmetics Act/Rules shall be enforced.provide safe and adequate quantity of blood, blood components 3. Inspectorate of Drugs Controller of India and State FDAand blood products. shall be strengthened to ensure effective monitoring and aStrategy vigilance cell shall be created under Central/State Licensing1. A National Blood Transfusion Programme (NBTP) shall be Authorities. developed to ensure establishment of non-profit integrated 4. Quality Assurance Manager shall be designated at each National and State Blood Transfusion Services in the Regional Blood Centre/any blood centre collecting more country. than 15,000 units per year.2. National Blood Transfusion Council (NBTC) shall be the 5. An External Quality Assessment Scheme (EQAS) through policy formulating apex body in relation to all matters the referral laboratories approved by the National pertaining to operation of blood centres. National AIDS Blood Transfusion Council shall be introduced to assist Control Organisation (NACO) shall allocate a budget to participating centres in achieving higher standards and NBTC for strengthening Blood Transfusion Service. uniformity.3. State/UT Blood Transfusion Councils shall be responsible 6. NBTC shall identify a centre of national repute for quality for implementation of the Blood Programme at State/UT control of indigenous as well as imported consumables, level. reagents and plasma products.4. The enforcement of the blood and blood products standards 7. Each blood centre shall develop its own Standard Operating shall be the responsibility of Drugs Controller General Procedures on various aspects of Blood Banking. India. • 487 •
  • 32. 8. All blood centres shall adhere to bio-safety guidelines as Objective - 6 : To strengthen the manpower through Human provided in the Ministry of Health & Family Welfare manual Resource Development. “Hospital-acquired Infections : Guidelines for Control” and Strategy disposal of bio-hazardous waste as per the provisions of 1. Transfusion Medicine shall be treated as a speciality. the existing Biomedical Wastes(Management & Handling) 2. A separate Department of Transfusion Medicine shall be Rules - 1996 under the Environmental Protection Act - established in Medical Colleges. 1986. 3. Medical Colleges/Universities in all States shall beObjective - 4 : To launch extensive awareness programmes for encouraged to start PG degree (MD in transfusion medicine)blood banking services including donor motivation, so as to and diploma courses in Transfusion Medicine.ensure adequate availability of safe blood. 4. In all the existing courses for nurses, technicians andStrategy pharmacists, Transfusion Medicine shall be incorporated1. Efforts shall be directed towards recruitment and retention as one of the subjects. of voluntary, non-remunerated blood donors through 5. In-service training programmes shall be organised for all education and awareness programmes. categories of personnel working in blood centres as well2. Activities of NGOs shall be encouraged to increase as drug inspectors and other officers from regulatory awareness about blood donation amongst masses. agencies.3. All blood banks shall have donor recruitment officer/donor 6. Short orientation training cum advocacy programmes on organizer and shall create and update a blood donor’s donor motivation and recruitment shall be organised for directory which shall be kept confidential. Community Based Organisations(CBOs)/NGOs who wish4. Enrolment of safe donors shall be ensured. to participate in Voluntary Blood Donor Recruitment5. A Counsellor in each blood centre shall be appointed for Programme. pre and post donation counselling. 7. States/UTs shall create a separate cadre and opportunities6. State/UT Blood Transfusion Councils shall recognise the for promotions for suitably trained medical and para services of regular voluntary non-remunerated blood medical personnel working in blood transfusion services. donors and donor organisers appropriately. Objective - 7: To encourage Research & Development in the7. National/State/UT Blood Transfusion Councils shall field of Transfusion Medicine and related technology. develop and launch an IEC campaign using all channels Strategy of communication including mass-media for promotion 1. A corpus of funds shall be made available to NBTC/SBTCs to of voluntary blood donation and generation of awareness facilitate research in transfusion medicine and technology regarding dangers of blood from paid donors and related to blood banking. procurement of blood from unauthorised blood banks/ 2. A technical resource core group at national level shall be laboratories. created to co-ordinate research and development in theObjective - 5: To encourage appropriate clinical use of blood country.and blood products. Objective - 8: To take adequate legislative and educationalStrategy steps to eliminate profiteering in blood banks.1. Blood shall be used only when necessary. Blood and blood Strategy products shall be transfused only to treat conditions 1. For grant/renewal of blood bank licenses including plan leading to significant morbidity and mortality that cannot of a blood bank, a committee, comprising of members be prevented or treated effectively by other means. from State/UT Blood Transfusion Councils including2. National Guidelines on “Clinical use of Blood” shall be Transfusion Medicine expert, Central & State/UT FDAs made available and updated as required from time to shall be constituted which will scrutinise all applications time. as per the guidelines provided by Drugs Controller General3. State/UT Governments shall ensure that the Hospital India. Transfusion Committees are established in all hospitals to 2. Fresh licenses to stand-alone blood banks in private sector guide, monitor and audit clinical use of blood. shall not be granted.4. Medical Council of India shall be requested to take following 3. Approved regional blood centres/government blood centres/ initiatives: Indian reduction cross blood centres shall be permitted to a) To introduce Transfusion Medicine as a subject at supply blood and blood products to satellite centres which undergraduate and all post graduate medical courses. are approved by the committee. The Regional Centre shall b) To introduce posting for at least 15 days in the be responsible for transportation, storage, cross-matching department of transfusion medicine during internship. and distribution of blood and blood products through c) Blood and its components shall be prescribed only by satellite centres. a medical practitioner registered as per the provisions of 4. A separate blood bank cell shall be created under a Medical Council Act - 1956. senior officer not below the rank of DDC(I) in the office5. Adequate facilities for transporting blood and blood of the DC(I) at the headquarter. State/UT Drugs Control products including proper cold-chain maintenance shall Department shall create such similar cells with the trained be made available to ensure appropriate management of officers including inspectors for proper inspection and blood supply. enforcement. • 488 •
  • 33. 5. The existing provisions of drugs & Cosmetics Rules will be services. In pursuance of these objectives, the National Socio- periodically reviewed to introduce stringent penalties for Demographic Goals to be achieved by 2010 are formulated. If unauthorised/irregular practices in blood banking system. the NPP - 2000 is fully implemented, we anticipate a population of 1107 million (110 crores) in 2010, instead of 1162 millionSummary (116 crores) projected by Technical Group on populationIn 1978, the World Health Assembly at Alma Ata launched an Projections.ambitious movement known as, “Health for All (HFA) by 2000AD”. As a signatory to HFA strategy, the Government of India Study Exerciseswas committed to frame its own policy and implement to attain Long Question: Discuss the objectives and strategies adoptedHealth For All by 2000 AD. This formed the basis of the National in National Health Policy 2000Health Policy formulated by MOHFW, GOI in 1983. Since its Short Notes : National Socio Demographic Goals to be achievedinception, there have been marked changes in the determinants by 2010.of health. Improvement of these health indicators were theoutcome of several complementary initiatives of development MCQssector covering rural development, agriculture, food production, 1. World Health Assembly at Alma Ata launched movementanimal husbandry, drinking water, sanitation, education etc. known as, “Health for All (HFA) by 2000 AD” in the yearDespite the impressive public health gains, the morbidity and (a) 1988 (b) 1998 (c) 1978 (d) 1983.mortality levels in the country were high. In the year 2000, 2. The remarkable success of NHP 1983 includes eliminationit was the time to take stock of situation and progress ahead of : (a) Leprosy (b) Kala Azar (c) Filariasis (d) All.with extra zeal to achieve ultimate goal of Health For All. 3. Noteworthy initiatives under the National Health PolicyAccordingly, the NHP - 1983 was revised and a new, extensive 2002 includes all except : (a) Comprehensive primary healthNHP was enunciated by the Govt of India in 2002. The main care services (b) Non involvement of health volunteersobjective of this policy is to achieve an acceptable standard of (c) Well worked out referral system (d) Integrated networkgood health amongst the general population of the country. The of evenly spread speciality and super speciality services.revised strategies adopted by GOI to achieve above objective 4. Important health related targets for the eleventh five yearare : (a) Increase access to the decentralized public health plan (2007 - 2012) are: (a) Reducing Maternal Mortalitysystem. (b) Ensuring a more equitable access to health services Ratio (MMR) to 1 per 1,000 live births (b) Reducingacross the country. (c) Increasing the aggregate public health Infant Mortality Rate (IMR) to 28 per 1,000 live birthsinvestment through a substantially increased contribution by (c) Reducing Total Fertility Rate to 2.1 (d) All.the Central Government. (d) The contribution of the private 5. The immediate/ short term objectives of NPP 2000 are: (a) Tosector in providing health services would be much enhanced. address the unmet needs for contraception (b) Strengthen(e) Primacy to preventive and first-line curative initiative at health care infrastructure, and health personnel (c) Providethe primary health level. (f) Emphasis will laid on rational use integrated service delivery for basic reproductive and childof drugs within the allopathic system. (g) Increased access to health care (d) All.tried and tested systems of traditional medicine. 6. The major strategies under NPP 2000 include all except: (a) Empowering Women for Improved Health and NutritionOn a short term basis, within the context of the NHP the , (b) Meeting the Unmet Needs for Family Welfare Servicesimportant health related targets for the eleventh five year plan (c) Providing Medical Facilities to Users from Overseas(2007 - 2012) are: Reducing Maternal Mortality Ratio (MMR) (d) Focus on Under-Served Population 1 per 1,000 live births; Reducing Infant Mortality Rate (IMR)to 28 per 1,000 live births; Reducing Total Fertility Rate to 2.1; Fill in the blanksProviding clean drinking water for all by 2009 and ensuring no 1. NHP - 1983 was revised and a new, extensive NHP wasslip-backs; Reducing malnutrition among children of age group enunciated by the Govt of India in ______________.0-3 to half its present level; Reducing anaemia among women 2. In 2006 nation’s CBR was at __________ & CDR wasand girls by 50% ; and Raising the sex ratio for age group 0-6 935 by 2011-12 and 950 by 2016-17. 3. One of the targets for the eleventh five year plan (2007 - 2012) is to raise the sex ratio for age group 0-6 to _______In 1952, India became the first country in the world to launch by 2011-12 and ______by 2016-17.a national program, emphasizing family planning to the extent 4. NHP 2002 envisages to raise the proportion of postgraduatenecessary for reducing birth rates. The National Health Policy, seats in the field of ‘Public Health’ and ‘Family Medicine’1983, stated that replacement levels of fertility rate (TFR) wherein _________of the seats are earmarked for theseshould be achieved by the year 2000. The National population disciplines.Policy (NPP) 2000 provides a policy framework for advancing 5. By 2010 the NHP 2002 envisages an increase in Governmentgoals and prioritizing strategies during the next decade, to funded health research to a level of ____________ the reproductive and child health needs of the people in 6. India’s current yearly increase in population is _______India, and to achieve net replacement levels (TFR) by 2010. million.The NPP affirms the commitment of government towards 7. NPP 2000 aims at Promote delayed marriage for girls, notvoluntary and informed choice and consent of citizens while earlier than age _________ and preferably after 20 years ofavailing reproductive health care services, and continuation age.of the target free approach in administering family planning • 489 •
  • 34. 8. A cash incentive of Rs 500 is awarded at the birth of the Further Suggested Reading girl child of birth order 1 or 2 to promote survival and care 1. Govt of India, Ministry of Health & Family Welfare. National Health Policy of girl child. Name the yojna _____________________. Document. New Delhi 2002. 2. Govt of India, Ministry of Health & Family Welfare. National PopulationAnswers : MCQs : (1) c; (2) d; (3) b; (4) d; (5) d; (6) c ; Fill in the Policy Document. New Delhi 2000.blanks: (1) 2002; (2) 23.5, 7.5; (3) 935, 950; (4) one-fourth; (5) 3. ational Nutrition Policy. Department of Women and Child Development, N2; (6)15.5; (7) 18; (8) Balika Samiridhi Yojna. Ministry of Human Resource Development, Government of India, New Delhi, 1993.References 4. leventh Five Year Plan 2007-2012. Planning Commission, Government of E India, New Delhi.1. Sample Registration System Bulletin October 2007, Registrar General of India (Latest). 5. ishore J. National Nutrition Policy in National Health Programmes of India, K 7th ed. Century Publications, New Delhi, 2007.2. National Leprosy Eradication Programme 6. http://www.naco.nic.in3. Bulletin on Rural Health Statistics in India 2006. Infrastructure Division MOHFW/GOI. 7. National Blood Policy. Department of Women and Child Development, Ministry of Human Resource Development, Government of India, New Delhi, 1993. 8. ishore J. National Blood Policy. In : National Health Programmes of India, K 7th ed. Century Publications, New Delhi, 2007. organizational structures, optimization of health manpower, National Rural Health Mission 88 (NRHM) decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into Sunil Agrawal district health system, and operationalizing community health centers into functional hospitals meeting Indian Public Health Standards in each Block of the Country.Recognizing the importance of Health in the process of economicand social development and improving the quality of life of National Rural Health Mission (NRHM) : Will It Makeour citizens, the Government of India has resolved to launch A Difference?the National Rural Health Mission to carry out necessary Since independence, our country has created a vast publicarchitectural correction in the basic health care delivery health infrastructure of Sub - centres, Public Health Centressystem. The Goal of the Mission is to improve the availability (PHCs) and Community Health Centres (CHCs). There is also aof, and access to, quality health care by people, especially for large cadre of health care providers (Auxiliary Nurse Midwives,those residing in rural areas, the poor, women and children. Male Health workers, Lady Health Visitors and Health AssistantUnder the Common Minimum Programme, health care system Male). Yet, this vast infrastructure is able to cater to only 20%of the country was given prime importance in which the UPA of the population, while 80% of health care needs are still beinggovernment had pledged to increase public spending on health provided by the private sector. Rural India is suffering from ato at least 2 - 3 % of the Gross Domestic Product (GDP) over the long - standing health care problem. Studies have shown thatnext five years of its term with a focus on primary health care. only one trained health care provider including a doctor withThe National Rural Health Mission was launched by the Hon’ble any degree is available per every 16 villages. Although, morePrime Minister on 12th April 2005, to provide accessible, than 70% of its population lives in rural areas, but only 20%affordable and accountable quality health services even to the of the total hospital beds are located there. Most of the healthpoorest households in the remotest rural regions. The difficult problems that people suffer in the rural community and inareas with unsatisfactory health indicators were classified as urban slums are preventable and easily treatable. In view ofspecial focus states to ensure greatest attention where needed. the above issues, the National Rural Health Mission (NRHM)The thrust of the Mission was on establishing a fully functional, has been launched by Government of India (GOI).community owned, decentralized health delivery system with What is NRHM ?inter sectoral convergence at all levels, to ensure simultaneous The National Rural Health Mission (2005 - 12) was launched inaction on a wide range of determinants of health like water, April 2005 to provide effective health care to rural populationsanitation, education, nutrition, social and gender equality.   throughout the country with special focus on 18 states, whichIt also aims at mainstreaming the Indian systems of medicine have weak public health indicators and/or weak facilitate health care. The Plan of Action includes increasing These states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh,public expenditure on health, reducing regional imbalance Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur,in health infrastructure, pooling resources, integration of Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, • 490 •
  • 35. Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. ●● TFR - to be reduced to 2.1 by 2012.Principles ●● Malaria Mortality - 50% reduction by 2010, additional 10% by 2012.The NRHM is conceived within the following set of guiding ●● Kala Azar Mortality Reduction - 100% by 2010 andprinciples : sustaining elimination until 2012.1. Promote equity, access, efficiency, quality and accountability ●● Filaria/Microfilaria Reduction - 70% by 2010, 80% by 2012, in Public Health System. and elimination by 2015.2. Enhance people oriented and community based ●● Dengue Mortality Reduction - 50% by 2010 and sustaining approaches. at that level until 2012.3. Decentralize and involve local bodies. ●● Cataract operations - increasing to 46 lakh until 2012.4. Ensure Public Health Focus. ●● Leprosy Prevalence Rate - reduce from 1.8 per 10,000 in5. Recognized value of traditional knowledge base of 2005 to less that 1 per 10,000 thereafter. communities. ●● Tuberculosis DOTS - maintain 85% cure rate through entire6. Promote new innovations, method and process Mission Period and also sustain planned case detection development. rate.The NRHM will cover all the villages in these 18 states through ●● Upgrading all health establishments in the districts toapproximately 2.5 lakh village - based “Accredited Social Health Indian Public Health Standards (IPHS).Activists” (ASHA) who would act as a link between the health ●● Increase utilization of First Referral units from bedcenters and the villagers. One ASHA will be raised from every occupancy by referred cases of less than 20% to over 75%.village, who would be trained to advise village populations ●● Over 5 lakh ASHAs, one for every 1,000 population/largeabout Sanitation, Hygiene, Contraception, and Immunization habitation, in 18 Special Focus States and in tribal pocketsto provide Primary Medical Care for Diarrhoea, Minor Injuries, of all states by 2008.and Fevers; and to escort patients to Medical Centers. They ●● All Sub - centres (nearly 1.75 lakh) functional with twowould also be expected to deliver direct observed short course ANMs by 2010.therapy for tuberculosis and oral rehydration, to give folic acid ●● All Primary Health Centres (nearly 30,000) with three stafftablets and chloroquine to patients and to alert authorities to nurses to provide 24x7 services by 2010.unusual outbreaks. ASHA will receive performance - based ●● 6,500 Community Health Centres strengthened/establishedcompensation for promoting universal immunization, referral with seven specialists and nine staff nurses by 2012.and escort services for RCH, construction of house - hold toilets, ●● 1,800 Taluka/Sub Divisional Hospitals and 600 Districtand other health care delivery programs (See Box - 1). Hospitals strengthened to provide quality health services by 2012. Box - 1 : Key Components of NRHM ●● Mobile Medical Units for each District by 2009. ●● Provision of health activist in each village ●● Functional Hospital Development Committees in all CHCs, ●● Village health plan to be prepared by village panchayat Sub Divisional Hospitals, and District Hospitals by 2009. ●● Strengthening of rural hospitals ●● Untied grants and annual maintenance grants to every ●● Integration of vertical health and family welfare programs SC, PHC, and CHC released regularly and utilized for local at district level health action by 2008. ●● Strengthening delivery of Primary Health Care ●● All District Health Action Plans completed by 2008. ObjectivesGoals - The major goals of NRHM are : a)  Train and enhance the capacity of Panchayati Raj(a) Reduction in Infant Mortality Rate (IMR) and Maternal Institutions (PRIs) to own, control and manage public Mortality Ratio (MMR). health services(b) Universal access to public health services such as b) Preparation of Health plan for each village through Village women’s health, child health, water, sanitation & hygiene, Health Committee of the Panchayat immunization, and nutrition. c) Strengthening sub - centers through an untied fund to(c) Prevention and control of communicable and non - enable local planning and action (each sub - center will communicable diseases, including locally endemic have an Untied Fund of Rs. 10,000 per annum). This Fund diseases. will be deposited in a joint Bank Account of the ANM and(d) Access to integrated comprehensive primary health care. Sarpanch and operated by the ANM, in consultation with(e) Population stabilization, gender and demographic the Village Health Committee. balance. d) Provision of 24 hour service in 50% PHCs by addressing(f) Revitalize local health traditions and mainstream AYUSH. shortage of doctors, especially in high focus States,(g) Promotion of healthy life styles. through mainstreaming AYUSH manpower.Specific Targets e) Preparation and implementation of an intersectoral District Health Plan prepared by the District Health Mission,The expected outcomes of NRHM are listed below : including drinking water, sanitation and hygiene and●● IMR - to be reduced to 30/1,000 live births by 2012. nutrition;●● Maternal Mortality - to be reduced to 100/100,000 live f) Integrating vertical Health and Family Welfare programs at births by 2012. National, State, Block, & District levels. • 491 •
  • 36. Duration of NRHM (g) Prompting non - profit factor to increase social participation,The duration of NRHM will be from 2005 to 2012. The total promoting health behaviors and improving intersectoralallocation for the Departments of Health and Family Welfare convergence.has been hiked from Rs. 8,420 crores to Rs. 90,103 crores in Supplementary Strategiesthe budget proposals for the year 2007 - 08. (a) Regulation of private sector to improve equity and reduceCore Strategies “out of pocket” expenses. (b) Foster Public Private Partnership (PPP) to meet nationalThe main focus in NRHM would be on the following issues : public health goals.(a) Decentralized village and district level health planning. (c) Re - Orientation of Medical Education (ROME).(b) Appointment of Accredited Social Health Activist (ASHA): (d) Raising health security / insurance for the poor. The selection criteria would be “women, resident of the Organisational Structure concerned village, married / widow / divorced, 25 - 45 years age, formal education up to 8th, to be selected out Organisational structure of NRHM from the apex till district of a panel by village health and action committee of Gram level is shown in Box - 2. Sabha”. Norm would be 1 per 1000 population, but this To support the District Health Mission, every district will have norm may be changed for different areas. There would be an integrated District Health Society (DHS) and all the existing NO pay or honorarium but she will be given compensation societies as vertical support structures for different national for various health and sanitation services provided. They and state health programmes will be merged in the DHS. The will be given a kit of suitable drugs. They would be guided DHS will be responsible for planning and managing all health by Anganwadi Workers (AWW) and ANM. In 4 years, 2.5 and family welfare programmes in the district, both in the rural lakh ASHAs will be deployed. as well as urban areas.(c) Strengthening the public health service delivery system, The Delivery System particularly at village, primary and secondary level, by developing and implementing the Indian Public Health A generic public health delivery system envisioned under NRHM Standards; Developing CHCs as the First Referral Units from the village to block level is illustrated in Figure - 1 (FRUs) by providing special care in the specialities of Progress Under NRHM Medicine, Surgery, Obs & Gyn, and Pediatrics. Presently The status as on 30 April, 2008 is as under : minimum standards of Indian Public Health for CHCs have (a) State Health Missions have been constituted in all states. been developed; later they will be developed for PHCs & (b) ASHA training modules developed and revised. subcentres also. (c) Over 1500 management professionals (CA/MBA) appointed(d) Mainstreaming of AYUSH (Indian Systems of Medicine). in program management units (PMU) to support the(e) Improved management capacity to organise health systems programme management. This is being planned at the and services in public health. level of the block also.(f) Emphasizing evidence based planning and (d) RCH - II launched and under implementation. implementation. (e) IMNCI started in 142 districts. Box - 2 : Organisational structure of NRHM Level Organisation Mission Steering Group (MSG) headed by the Union Minister for Health & Family Welfare and an Empowered Central level Programme Committee (EPC) headed by the Union Secretary for Health & FW. State Health Mission and State Health Society State Health Mission headed by the Chief Minister of the State. The functions under the Mission would be carried out through the State Health & Family Welfare Society State level Composition ●● Chairperson : Chief Minister ●● Co - Chairperson : Minister of Health and Family Welfare, State Government ●● Convener : Principal Secretary/ Secretary (Family Welfare) ●● Nominated non - official members (5 to 8 members) such as health experts, representatives of medical associations, NGOs and Representatives of Development Partners Frequency of meetings : At least once in every six months District Health Mission Chairperson : Chairman, Zilla Parishad District level Co - Chairperson : District Collector/DM Vice Chairperson : CEO Zilla Parishad Mission Director : Chief Medical Officer/ CMHO/ Civil Surgeon • 492 •
  • 37. in Box - 3. Fig. - 1 : NRHM - Illustrative Structure NRHM – ILLUSTRATIVE STRUCTURE Box - 3 : Eligibility criteria for JSY Health Manager Category of states & BLOCK LEVEL HEALTH OFFICE Accountant Beneficiaries Store Keeper cash assistance Accredit private 100,000 BLOCK Low Performing States (LPS) providers for public Population LEVEL All pregnant women / All health goals 100 Villages HOSPITAL Ambulance Strengthen Ambulance/ (Cash assistance in rural areas SC/ST Women delivering transport Services Telephone Increase availability of Nurses is Rs 1400 and Rs 600 for the in SC/PHC/CHC/ FRU/ Obstetric/Surgical Medical mother & ASHA respectively; Provide Telephones Emergencies 24 X 7 Round the Clock Services; Encourage fixed day clinics Distt or state hospital or 30-40 Villages in urban areas it is Rs. 1000 accredited private hospital CLUSTER OF GPs – PHC LEVEL 3 Staff Nurses; 1 LHV for 4 SHCs; -5 and Rs 200 respectively). Ambulance/hired vehicle; Fixed Day MCH/Immunization Clinics; Telephone; MOi/c; Ayush Doctor; High Performing States (HPS) BPL pregnant women aged Emergencies that can be handled by Nurses 24 X 7; – Round the Clock Services; Drugs; TB / Malaria etc. tests 19 yrs and above/ All SC/ 5-6 Villages GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL (Cash assistance for the ST Women delivering Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR -6 Villages; 5 mother in rural areas in SC/PHC/CHC/FRU/ Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic is Rs 700 and in urban Distt or state hospital or VILLAGE LEVEL – ASHA, AWW, VH & SC areas it is Rs. 600). accredited private hospital 1 ASHA, AWWs in every village; Village Health Day 8 Drug Kit, Referral chains National Urban Health Mission (NUHM)(f) Legal changes brought about to allow ANMs to dispense The National Urban Health Mission (NUHM) will meet health medication and MBBS doctors to dispense anaesthesia. needs of the urban poor, particularly the slum dwellers by(g) At 1,611 PHCs, AYUSH doctors have been co - located. making available to them essential primary health care(h) 2,28,413 Village Health & Sanitation Committees (VHSCs) services. This will be done by investing in high - caliber health have been constituted and operational by 30 April 2008. professionals, appropriate technology through public - private(j) Against the target of 5 lakh fully trained Accredited Social partnership, and health insurance for urban poor. Recognizing Health Activists (ASHAs) by 2008, the initial phase of the seriousness of the problem, urban health will be taken training (first module) has been imparted to 5.36 lakh. up as a thrust area for the Eleventh Five Year Plan. NUHM ASHAs in position with drug kits are 224951 in number. will be launched with focus on slums and other urban poor.(k) Out of the 145272 Sub - centres (SCs) expected to be The Eleventh Five Year Plan will aim for inclusive growth by functional with 2 Auxiliary Nurse Midwives (ANMs) by introducing National Urban Health Mission (NUHM), which 2008, only 22471 had the same. along with NRHM, will form Sarva Swasthya Abhiyan. The(l) 22,370 Primary Health Centres (PHCs) are functional and organisation would be : out of which 3450 PHCs are functional with three staff nurses by 2008. At the state level : Besides the State Health Mission and State(m) There has been a shortfall of 5,498 (>50%) specialists Health Society and Directorate, there would be a State Urban at the Community Health Centres (CHCs). Total CHCs Health Programme Committee. functional are 4,045 out of which 2,966 have been selected At the district level : There would be a District Urban Health to be upgraded to IPHS. Committee(n) Number of Districts where annual integrated action plan At the city level : A Health and Sanitation Planning under NRHM have been prepared for 2007 - 08 are 485. Committee.Janani Suraksha Yojana At the ward slum level : There will be a Slum Cluster Health,To change the behaviour of the community towards institutional Water and Sanitation, the Government of India, under NRHM in 2005, For promoting public health and cleanliness in urban slums,modified the National Maternity Benefit Scheme (NMBS) from the Eleventh Five Year Plan will also encompass experiences ofthat of a nutrition - improving initiative to the Janani Suraksha civil society organizations working in urban slum clusters. ItYojana (JSY). The Yojana has identified the Accredited Social will seek to build a bridge of NGO - GO partnership and developHealth Activist (ASHA) as an effective link between the community level monitoring of resources and their rightful use.Government and the poor pregnant women. NUHM would ensure the following :The scheme has the dual objectives of reducing maternal and ●● Resources for addressing the health problems in urbaninfant mortality by promoting institutional deliveries. Though areas, especially among urban poor.the JSY is implemented in all states and UTs, its focus is on ●● Need based city specific urban health care system to meet10 low performing states having low institutional delivery the diverse health needs of the urban poor and otherrate. The scheme is 100% centrally sponsored and integrates vulnerable assistance with maternal care. It is funded through the ●● Partnership with community for a more proactiveflexi - pool mechanism. Under the NRHM, out of 184.25 lakh involvement in planning, implementation, and monitoringinstitutional deliveries in the country (as on 1 April 2007), JSY of health activities.beneficiaries were 28.74 lakh. The eligibility criteria are shown • 493 •
  • 38. ●● Institutional mechanism and management systems to Plans, mandate involvement of all health related sectors and meet the health - related challenges of a rapidly growing emphasize partnership with PRIs, local bodies, communities, urban population. NGOs, Voluntary and Civil Society Organizations.●● Framework for partnerships with NGOs, charitable hospitals, and other stakeholders. Summary●● Two - tier system of risk pooling : (a) Women’s Mahila Arogya The National Rural Health Mission was launched by the Hon’ble Samiti to fulfil urgent hard - cash needs for treatments; Prime Minister on 12th April 2005, to provide accessible, (b) A Health Insurance Scheme for enabling urban poor to affordable and accountable quality health services even to meet medical treatment needs. the poorest households in the remotest rural regions. NRHMNUHM would cover all cities with a population of more than will give special focus to 18 states, which have weak public100,000. It would cover slum dwellers and other marginalized health indicators and/or weak infrastructure. The duration ofurban dwellers like rickshaw pullers, street vendors, railway NRHM will be from 2005 to 2012. The total allocation for theand bus station coolies, homeless people, street children, Departments of Health and Family Welfare has been hiked fromconstruction site workers, who may be in slums or on sites. Rs. 8,420 crores to Rs. 90,103 crores in the budget proposals for the year 2007 - 08.The existing Urban Health Posts (UHPs) and Urban FamilyWelfare Centres (UFWCs) would continue under NUHM. They Key component of NRHM are provision of health activist in eachwill be marked on a map and classified as the Urban Health village, village health plan to be prepared by village panchayat,Centres on the basis of their current population coverage. All strengthening of rural hospitals, integration of vertical healththe existing human resources will then be suitably reorganized and family welfare programs at district level, strengtheningand rationalized. These centres will also be considered for delivery of Primary Health Care.upgradation. Intersectoral coordination mechanism and The major goals of NRHM are (a) Reduction in Infant Mortalityconvergence will be planned between the Jawaharlal Nehru Rate (IMR) and Maternal Mortality Ratio (MMR), (b) UniversalNational Urban Renewal Mission (JNNURM) and the National access to public health services, (c) Prevention and control ofUrban Health Mission. communicable and non - communicable diseases, includingThe Challenges before NRHM and its key approaches: locally endemic diseases, (d) Access to integrated comprehensiveA Critique primary health care (e) Population stabilization, gender and demographic balance (f) Revitalize local health traditions andIt is clearly a gigantic task to bring about major changes mainstream AYUSH (g) Promotion of healthy life outcomes by simultaneous action on a wide range ofdeterminants of health. NRHM has identified communitization, The expected outcomes of NRHM are by 2012 reduction inflexible financing, innovations in human resource management, IMR and MMR to 30/1000 live births and 100/100,000 livemonitoring against IPH Standards, and building capacities at birth respectively, reduction of TFR to 2.1 by 2012, Malariaall levels as the principal approaches to ensure quality service Mortality - 50% reduction by 2010, additional 10% by, efficient utilization of scarce resources, and most of Kala Azar Mortality Reduction - 100% by 2010 and sustainingall, to ensure service guarantees to local households. elimination until 2012, Filaria / Microfilaria Reduction - 70% by 2010, 80% by 2012, and elimination by 2015, DengueHealth is a state subject and the NRHM will build partnership Mortality Reduction - 50% by 2010 and sustaining at that levelwith the States to ensure meaningful reforms with more until 2012,Cataract operations - increasing to 46 lakh untilresources. Ultimately, the success of NRHM will depend on 2012,Leprosy Prevalence Rate - reduce from 1.8 per 10,000 inthe ability of the Mission interventions to galvanize State 2005 to less that 1 per 10,000 thereafter, Tuberculosis DOTSGovernments into action, pursuing innovations and flexibility - maintain 85% cure rate through entire Mission Period andin all spheres of public health action. Ensuring availability of also sustain planned case detection rate, Upgrading all healthfully trained and equipped resident health functionaries at all establishments in the district to Indian Public Health Standardslevels and large scale financing under initiatives like the Janani (IPHS),Increase utilization of First Referral units from bedSuraksha Yojana for institutional deliveries are a few priorities occupancy by referred cases of less than 20% to over 75%, Overfor action. Partnerships with non governmental providers to 5 lakh ASHAs, one for every 1,000 population/large habitation,strengthen pubic health delivery are also an important need in 18 Special Focus States and in tribal pockets of all statesgiven the distribution of Specialist doctors in India. While we by 2008,All Sub - centres (nearly 1.75 lakh) functional withhave 30,000 MBBS graduates coming out of our Colleges every two ANMs by 2010,All Primary Health Centres (nearly 30,000)year, the entire rural health system for more than 750 million with three staff nurses to provide 24x7 services by 2010,6,500people never has more than 26000 doctors. Community Health Centres strengthened/established with sevenThere is need to shift to decentralization of functions to specialists and nine staff nurses by 2012,1,800 Taluka/Subhospital units/health centres and local bodies. The States need Divisional Hospitals and 600 District Hospitals strengthened toto move away from the narrow focus on the implementation provide quality health services by 2012,Mobile Medical Unitsof budgeted programmes and vertical schemes. They need for each District by 2009, Functional Hospital Developmentto develop systems that comprehensively address the health Committees in all CHCs, Sub Divisional Hospitals, and Districtneeds of all citizens. Thus, in order to improve the health care Hospitals by 2009,Untied grants and annual maintenanceservices in the country, the Eleventh Five Year Plan will insist grants to every SC, PHC, and CHC released regularly and utilizedon Integrated District Health Plans and Block Specific Health for local health action by 2008, All District Health Action Plans • 494 •
  • 39. completed by 2008. State and Urban Health Programme Committee. At the districtThe main focus in NRHM would be on (a) Decentralized level - District Urban Health Committee At the city level - Avillage and district level health planning, (b) Appointment of Health and Sanitation Planning Committee. At the ward slumAccredited Social Health Activist (ASHA) - “women, resident of level - Slum Cluster Health, Water and Sanitation Committee.the concerned village, married / widow / divorced, 25 - 45 years NUHM would ensure Resources for addressing the healthage, formal education up to 8th, to be selected out of a panel problems in urban areas, especially among urban poor, needby village health and action committee of Gram Sabha”. Norm based city specific urban health care system to meet thewould be 1 per 1000 population, (c) Strengthening the public diverse health needs of the urban poor and other vulnerablehealth service delivery system, particularly at village, primary sections, Partnership with community for a more proactiveand secondary level, (d) Mainstreaming of AYUSH (Indian involvement in planning, implementation, and monitoring ofSystems of Medicine), (e) Improved management capacity in health activities, Institutional mechanism and managementhealth systems, (f) Emphasizing evidence based planning and systems to meet the health - related challenges of a rapidlyimplementation, (g) Prompting non - profit factor to increase growing urban population, Framework for partnerships withsocial participation, promoting health behaviors and improving NGOs, charitable hospitals and other stakeholders, Two - tierintersectoral convergence. Supplementary Strategies are (a) system of risk pooling : (i) women’s Mahila Arogya Samiti toRegulation of private sector to improve equity and reduce “out fulfil urgent hard - cash needs for treatments; (ii) a Healthof pocket” expenses, (b) Foster Public - Private Partnership Insurance Scheme for enabling urban poor to meet medical(PPP) to meet national public health goals, (c) Re - orientation treatment needs.Of Medical Education (ROME), (d) Raising health security /insurance for the poor. Study ExercisesAt centre level there will be Mission Steering Group (MSG) Long Question : How does NRHM envisage to achieve goalsheaded by the Union Minister for Health & Family Welfare and of NHP - 2002 ?an Empowered Programme Committee (EPC) headed by the Short Notes : (1) Key components of NRHM (2) Specific targetsUnion Secretary for Health & FW. At state level State Health of NRHM (3) JSY (4)Functions of ASHA.Mission headed by the Chief Minister of the State and will have MCQsminister of health and family welfare, state government and 1. NRHM was launched in (a) Apr 2005 (b) Mar 2006 (c) Novprincipal secretary (Family Welfare) plus 5 - 8 non - official 2003 (d) Dec 2004members. At district level, district health mission with Chairman 2. According to NRHM IMR should be less than ___ per 1000Zilla Parishad, District Collector / DM, CEO Zilla Parishad and live births by 2012 (a) 30 (b) 28 (c) 32 (d) 35Chief Medical Officer/ CMHO/ Civil Surgeon as its members. The 3. According to NRHM MMR should be less than ___ per 1000delivery system is through strengthening health system. live births by 2012 (a) 1 (b) 2 (c) 1.5 (d) 3Janani Suraksha Yojana is 100% centrally sponsored and 4. According to NRHM Dengue mortality should be reducedintegrates cash assistance with maternal care. It is funded by ____ by 2010 (a) 40% (b) 50% (c) 75% (d) 60%through the flexi - pool mechanism. Low Performing States 5. According to NRHM target for cataract operation by the(LPS) beneficiaries are all pregnant women; cash assistance year 2012 (a) 40 lakh (b)46 lakh (c) 51 lakh (d) 55 lakhin rural areas is Rs 1400 and Rs 600 for the mother & ASHA 6. One ASHA is for ______ population in plain areas (a) 700respectively; in urban areas it is Rs. 1000 & Rs 200 respectively. (b) 1000 (c) 300 (d) 1500High Performing States (HPS) : cash assistance for the mother Answers : (1)a; (2)a; (3)a; (4)b; (5)b; (6) rural areas is Rs 700 and in urban areas it is Rs. 600.Beneficiaries are all pregnant ladies below poverty line. References & Further Suggested reading 1. Indian Journal of Public Health, 2007.The National Urban Health Mission (NUHM) will meet health 2. NRHM Newsletter, Govt of India, Ministry of Health & Family Welfare.needs of the urban poor, particularly the slum dwellers, National Health Policy Document. New Delhi Jan making available to them essential primary health care 3. National Rural Health Mission 2005-2012, Mission document, Ministry of Health and Family welfare, Government of India The organisation would be At the state level : the 4. Mudur G. India launches national rural health mission. BMJ 2005; 23: 330:State Health Mission, State Health Society and Directorate; and 920. • 495 •
  • 40. Reproductive and Child Health Essential Components of RCH-II Programme 89 (RCH) Programme The essential components of RCH - II programme (8) are illustrated in Fig. - 1. The individual components are discussed in detail herewith (See Table - 1). Puja Dudeja & Ashok K. Jindal Fig. - 1 : Essential Components of RCH - IIThe International Conference of Population and Development(ICPD) at Cairo in 1994 was the basis for the launch of RCHprogramme in our country in 1997. The RCH Programme is an Population Strengtheningumbrella programme to provide need based, client centered, Systems and Stabilizationdemand driven, high quality services the beneficiaries with Partnershipsa view to enhancing the quality of reproductive life of thepopulation and enabling country to achieve the populationstabilization. The vision is to bring about outcomes as Mainstreaming Maternal Healthenvisioned in the Millennium Development Goals, the National gender and equityPopulation Policy 2000 (NPP 2000), the Tenth Plan document, RCH II Reproductive Tractthe National Health Policy 2002 and Vision 2020 India, Infections (RTIs) andminimizing the regional variations in the areas of reproductive Initiatives for Sexually Transmitted vulnerable groupsand child health and population stabilization through an Infections (STIs)integrated, focused, participatory program, meeting the unmetdemands of the target population and provision of assured, Adolescent health Newborn andequitable, responsive quality services. The programme now child healthintends to gradually make a shift to address the entire gamutof women’s health issues. The program will pay substantiallymore attention on the 8 states, (Empowered Action Group:EAG states) lagging behind in population stabilisation effortsviz. Bihar, Chattisgarh, Jharkhand, Madhya Pradesh, Orissa, Population StabilizationRajasthan, Uttar Pradesh & Uttaranchal. The programmealso focuses on universalisation of immunization, ante-natal The details of national family planning programme have beencare, skilled attendance during delivery and other features of given in another chapter, in this book, on national health policycommon childhood care. and national population policy (1-6) and you are advised to refer to the same.Definition Unmet need for family planning, ‘which refers to the conditionWorld Health Organization (WHO) has defined reproductive of wanting to avoid or postpone childbearing but not usinghealth as follows: any method of contraception’ has been a core concept inWithin the framework of WHO’s definition of health as a state international population for more than three decades(10).of complete physical, mental, and social well-being, and not Unmet need for contraception arises from several reasons, suchmerely the absence of disease or infirmity; reproductive health as weak motivation, low female autonomy, perceived healthaddresses the reproductive processes, functions and systems risks, and moral objection to the use of contraception. On aat all stages of life. Reproductive health therefore implies that nationwide basis the family planning program currently offerspeople are able to have a responsible, satisfying and safe sex five modern contraceptive options. The methods currentlylife and that they have the capability to reproduce and the available for spacing are - oral contraceptive pills, condomsfreedom to decide, if when, and how often to do so(1). This and intra-uterine devices. Male and female sterilization is oftendefinition focuses on right of men and women to be informed of used for limiting family size.and to have access to safe, effective, affordable, and acceptable Expanding contraceptive choices in RCH Phase II :methods of fertility regulation of their choice, and the right International evidence shows that increasing the availability ofto access to appropriate health care services that will enable method choice increases acceptance rates. It is estimated thatwomen to go safely through pregnancy and childbirth and every additional method increases the contraceptive prevalenceprovide couples with the best chance of having a healthy rate by 12%. A wider contraceptive choice, including naturalinfant. methods, helps meet the changing needs of couples duringAccordingly, RCH - I was launched in 1997 as a part of 9th plan, their lives. Multiple methods make switching easier, reducewhile RCH - II was launched in 2002 as a part of 10th five year method-specific discontinuation, and improve user satisfaction.plan. Many lessons have been learned from RCH Phase I. The Contraceptive choice can be expanded both by adding newdesign of RCH Phase II specifically seeks to address the lessons methods to the existing range as well as increasing access tolearnt from RCH Phase I to effectively reach the national long- the services providing the choice. The details of contraceptivesterm goals through flexible, cohesive and strategic planning. are dealt with in an exclusive chapter in the section on family health. • 496 •
  • 41. Table- 1: RCH Phase II - Improvements over RCH Phase I (9) Lessons learnt from RCH I Corrective Measures in RCH II Limited involvement of states and States will prepare plans linked to clear outcomes after assessing their own priorities, limited ownership by states of RCH allowing a needs-based state-specific plan to be developed. Phase Pace of implementation slow Bottlenecks to fund flows will be removed by simplifying processes. Low utilization of public health This has been diagnosed as being due to users’ perceptions of low quality, frequent facilities service unavailability and low acceptability of some services. This will be addressed through preservice and in-service training, with a particular focus on provider attitudes and making services more users friendly. Infrastructure to be completed within Outsourcing will be undertaken with agreed institutional mechanisms to manage the project time frame infrastructure and to ensure accountability and delivery of reliable and quality services. The processes of managing and construction of infrastructure will be simplified. Limited management capacity There will be a lateral infusion of skilled personnel to improve the management capacity structure at the national, state and district levels, with clearly defined functional responsibilities and roles. Need to incorporate the system of Financial management systems will be built into the program management structure. smooth flow of funds RCH Phase I was implemented as a RCH is visualized as a long-term program, oriented towards achieving ambitious, but project; there was a need to incorporate realistic health outcomes and improvements well-defined outcome indicators RCH Phase I had a “one size fits all” States will have different requirements, levels of performance and capacities and will design be able to take these into account when designing their state PIPs. Such a differential approach may be extended to the district level depending upon the performance of districts. Need to move away from “stand alone” RCH Phase II will adopt a program approach, bringing in key elements of sector public health approach management and reform and strengthening of systems. RCH Phase I focused almost exclusively Whilst RCH Phase II necessarily includes supply side strategies, these will be on the supply side complemented by an integrated and robust strategy to stimulate demand for services. RCH Phase I was centrally designed RCH Phase II has been designed after wider consultation. with little consultationStrategies to expand contraceptive choice in RCH Phase II by increasing compensation and by using media.1. Expanding the range of FP services: Each CHC and PHC 7. Involving Panchayati Raj Institutions, Urban Localhaving an OT (operation theatre) facility will have at least one Bodies and NGOs.Medical Officer trained in one method of sterilization. Maternal Health2. Improving and integrating RCH services in PHCs and The programme envisages a holistic strategy for bringing aboutsub-centers: The capacity of Lady Health Visitors (LHVs) and a total intersectoral coordination at the grass root level andAuxiliary Nurse Midwives (ANMs) will be built through skill- involving the NGOs, Civil Societies, Panchayati Raj Institutionsbased clinical training for spacing methods including IUCD and Womens’ group in bringing down maternal mortality rate.insertion and removal, lactational amenorrhea method (LAM), The National Population Policy 2000 and National Healthstandard days method (SDM) and emergency contraception (EC). Policy 2002 have set the goal of reducing MMR to less thanThey will also be trained in infection prevention, counseling 10 per 100,000 live births by the year 2010(11). The maternaland follow-up for different family planning methods. mortality rate in India is 301 per 100,000 live births (SRS, RGI3. Training of District Hospital/CHC/PHC staff to offer an 2001-03 Maternal Mortality Report). Various schemes underexpanded choice of services: Training providers to offer LAM, the programme are as under:SDM, EC and injectables will help to increase the range of choice Essential Obstetric Care : The complete package of essentialand ensure quality services and follow-up for clients. obstetric care includes antenatal care, institutional/ safe4. Forging linkages with the ICDS division of women and delivery services & postnatal care. It has been seen that achild development department. total of three antenatal checkups to be conducted where all5. Engaging the private sector to provide quality family components of essential obstetric care can be provided.planning services. Provision of 24 hrs Delivery Services at PHC : Under RCH II6. Stimulating demand for quality family planning services all the CHCs and 50% of the proposed PHCs will be providing • 497 •
  • 42. round the clock delivery services. ●● Enhance access to confidential counseling foe safe MTP ,Postnatal care for mother and new born: To ensure postnatal train ANMs, AWWs and link workers/ ASHA and AWWscare within 24hours of delivery and subsequent home visits on while maintain confidentialityday 3 and 7 are the important components for identification Facility Leveland management of emergencies occurring during post natal ●● Provide quality Manual Vaccum Aspiration ) facilities at allperiod. The ANMs, LHVs and the staff nurses are being made CHCs and at least 50% of PHCs that are being strengthenedaware of and also oriented for tackling these emergencies for 24 hrs deliveriesidentified during these visits. ●● Provide comprehensive and high quality MTP services atSkilled Attendance at Birth: To manage and handle some all FRUscommon obstetric emergencies at the time of birth the staff ●● Encourage private and NGO sectors to establish qualityhas been trained to give certain injections and perform certain MTP servicesinterventions in emergency to save life. Other interventions for improving maternal healthProvision of Emergency Obstetric and Neonatal Care at National Nutritional Anemia Prophylaxis Program (NowFirst Referral Unit (FRU) : There are three critical elements under RCH) : As per NFHS III, 56.1% of ever married womenof a facility being declared as FRU. They are availability of aged 15-49 yrs are anemic. The problem is more severesurgical interventions, newborn care and blood storage facility during pregnancy with 57.8% being anemic. A program foron a 24 hr basis. prophylaxis and treatment of nutritional anemia has beenReferral Services at both Community and Institutional under implementation in the country since 1997-98. Under thislevel: Establishing referral linkages between the community programme all pregnant and lactating women are provided withand FRUs is an essential component for utilization of services one tablet (containing 100 mg of elemental iron and 0.5mg Folicparticularly during emergencies. Since emergencies during the acid) for 100 days. Those who have severe anemia are providedprocess of birth can not be predicted, it is essential to place with double dose of these tablets; and health education aparteffective referral linkages which can be accessed by all pregnant from other services.women in case of emergency. Village Health and Nutrition Day : Organizing village healthSetting of Blood Storage Centers at FRUs : Timely treatment and nutrition day at Anganwadi center at least once a monthof complications associated with pregnancy is sometimes to provide antenatal / postpartum care for pregnant women,hampered due to non availability of Blood Transfusion services promote institutional delivery and health education apart fromat FRUs. The drugs and cosmetics act has been amended to other services.facilitate establishment of Blood Storage Centers at such Janani Suraksha Yojana (JSY) : It is a safe motherhoodFRUs. intervention under NRHM being implemented with the objectiveTraining of MBBS Doctors in Life Saving Anesthetics Skills of reducing maternal and neonatal mortality by promotingfor Emergency Obstetric Care : Provision of adequate and institutional delivery among the poor pregnant women. It wastimely Emergency obstetric care has been recognized globally launched on 12 April 2005 and is being implemented in allas the most important intervention for saving lives of pregnant states and is a 100 % centrally sponsored scheme. The mainwomen who may develop complications during pregnancy and element in the yojana is ASHA who will act as a link betweenchild birth. It has not been possible till now due to lack of govt and the poor pregnant woman. She is to facilitate pregnantspecialist man power gynecologist and anesthetist particularly women to avail services of maternal care and to arrange forat the district and subdistrict level. In view of above, a 18 transport services. Cash assistance will be given both to theweeks programme for training MBBS doctors in anesthetic mother and ASHA worker on getting an institutional delivery.skills has been started by govt. but at the same time it will not Reproductive Tract Infections (RTIs) and Sexuallybe a replacement of specialist. Transmitted Diseases (STDs)Obstetric Management skills : GOI has also introduced RTIs and STDs were not recognized as a public health problemtraining of MBBS doctors in obstetric management skills and till recently. The spread of HIV infection and the role that RTIhas prepared a 16 weeks training programme in obstetric / STD play in the transmission of HIV have brought urgency tomanagement skills including cesarean section operation. the problem. Strategies under RCH II are :Safe Abortion Services/ Medical Termination of Pregnancy 1. The prevention, early detection and effective management(MTP) : Two thirds of all abortions take place outside the of common lower reproductive tract infections have beenauthorized health services by unauthorized often unskilled included as a component of essential care through theproviders. Eight percent of all maternal deaths are due to existing primary health care infrastructure.complicated abortions. This is a preventable tragedy and an 2. Convergence with National AIDS Control Programmeindication of unmet need for abortion. Provision of 24x7 MTP is envisaged in provision of these services, in termsservices at PHCs, CHCs and FRUs are being strengthened by of utilization of these services for case management,training of medical manpower in techniques of MTP by the laboratory services, counseling services, drugs, equipment,states. Following Strategies are being implemented: blood safety etc.Community Level 3. Under RCH II programme there is a commitment for●● Spread awareness regarding safe MTP in the community implementing the RTI/STI services at the sub district level and the availability of services thereof i.e. in 50% of the PHCs and all FRUs, including drugs, • 498 •
  • 43. training, disposable equipment and provision of laboratory The differences are given in Table-2. technicians. Components:4. National Guidelines for management of RTIs and STDs 1. Improvements in the case-management skills of health have been developed and disseminated to the states. staff through the provision of locally-adapted guidelinesNewborn and Child Health on Integrated Management of Neonatal and ChildhoodUnder RCH II, the activities being undertaken to achieve the Illness and activities to promote their use;NRHM goals under newborn and child health are: 2. Improvements in the overall health system required for1. Integrated Management of newborn and childhood effective management of neonatal and childhood illness; illnesses 3. Improvements in family and community health care2. Home Based Newborn Care(HBNC) practices.3. Promotion of breastfeeding and complementary feeding (Details of IMNCI are discussed in a chapter exclusively in the4. Control of deaths due to ARI section on family health)5. Control of Deaths due to Diarrhoeal Diseases Home Based New Born Care : The Govt of India has approved6. Supplementation with micronutrients the implementation of home based new born care where ASHAs7. Universal Immunization Programme will be trained in identified aspects of new born care during theIntegrated Management of newborn and childhood second year training. The underlying principle of effective careillnesses: India is faced with an unparalleled challenge in the at birth is that wherever an infant is born, home or facility,area of child survival and health. The country contributes 2.4 he/ she is provided clean care, warmth, resuscitation, andmillion of the global burden of 10.8 million under-five child exclusive breastfeeding. He/she is weighed and examined, anddeaths, which is the highest for any nation in the world. Nearly if the clinical needs are not manageable at the place of delivery,26 million infants are born each year, of whom 1.2 million die he/she is referred and managed at an appropriate facility. Abefore completing the first four weeks of life and 1.7 million die large proportion of deliveries would continue to occur at homesbefore reaching the first birthday. by the TBAs for some more years to come, especially in theWhy integrated approach? : Many well-known prevention and EAG states. It is therefore, considered desirable to continue totreatment strategies have already proven effective for saving impart newborn care skills to TBAs in areas with high ratesyoung lives like Childhood vaccinations, Oral rehydration of home deliveries. They will also be provided clean deliverytherapy, Effective antibiotics for pneumonia, Prompt treatment kits. At the same time, the overall effort would be to promoteof malaria, breastfeeding practices etc have reduced childhood childbirth by skilled birth attendants and in institutions, bothdeaths. While each of these interventions has been successful, in the public and private sector. Interventions for newborn haveaccumulating evidence suggests that an integrated approach been summarized in needed to manage sick children to achieve better outcomes. Promotion of Breast Feeding and Complementary Feeding: Because many children present with overlapping signs and Revival of the Baby Friendly Hospital initiative (BFHI) has beensymptoms of diseases, a single diagnosis can be difficult, and approved and implementation shall be initiated.may not be feasible or appropriate. This is especially true for Control of Deaths due to Acute Respiratory Infectionsfirst-level health facilities where examinations involve few (ARI): Acute respiratory infections (ARI) in children caninstruments, negligible laboratory tests, and no X-ray. involve the upper respiratory tract (nose, throat) or the lowerHistory : During the mid-1990s, the World Health Organization respiratory tract (bronchi, lungs). The lower respiratory tract(WHO), in collaboration with UNICEF developed a strategy infections (broadly termed as pneumonias) are a major causeknown as the Integrated Management of Childhood Illness of deaths of infants and children in India accounting for about(IMCI). This strategy has been expanded in India to include all 30% of under-five deaths. The actual deaths are much higherneonates and renamed as ‘Integrated Management of Neonatal as many children die at home (12). Timely treatment based onand Childhood Illness (IMNCI)’. India has included care of new well-researched algorithms can save most children with ARI.born and has modified generic IMCI and named it as IMNCI. The ARI control program was initiated as a pilot project in Table 2 : Differences in generic IMCI and IMNCI Features Generic IMCI India IMNCI Coverage of 0-6 days (early new born period) No Yes Basic health worker module No Yes Home visit module by provider for care of newborn and young infant No Yes Child first then New born/Young Sequence of training young infant infant first then child Home-based training No Yes Duration of training on Newborn/young infant 2 to 11 days 4 to 8 days Child first then New born/Young Sequence of training young infant infant first then child • 499 •
  • 44. Table-3: Interventions for newborn care Level Interventions Key Players ANC : Focus to be on enhancing coverage among the poor and marginalized women, improving quality and promoting institutional deliveries, birth preparedness and care seeking for danger ANMs, AWWs signs. Skilled care at birth : Institutional deliveries to be promoted through Janani Suraksha Yojana involving TBA; deliveries by ANMs to be encouraged ; piloting Community Skilled ANMs, C-SBAs Birth Attendant (C-SBA) program to be completed; in populations where access to skilled TBAs birth attendants or institutional deliveries not available, clean deliveries by trained TBAs to be accepted. Home - based newborn and post-partum care : Using IMNCI protocol, AWWs to provide home-based care neonates with emphasis on warmth, breastfeeding, prevention of infection, extra care of LBW infants, early detection of sickness; at least three contacts in the first AWWs Home and week of life stipulated starting with the first day, extra contracts for LBW and sick neonates supervised by Community ; maternal post-partum care also provided healthy family practices; TBAs to reach neonates ANMs ; TBAs level and mothers and promote healthy family practices; ANMs to supervise, especially the care of LBW and sick babies and mothers. Community - based management of sick neonates : Using IMNCI protocols, ANMs to assess ANMs neonates with sickness and manage mild/moderate sickness. Referral of sick mothers and neonates : Funds for referral transport to be made available at Families village level, communities to be encouraged to map facilities and development mechanisms, communities, AWWs and TBAs to facilitate referrals. AWWs, TBAs Behaviour Change Communication (BCC) : BCC strategy to aim at promoting early and Community, complete ANC, institutional deliveries birth preparedness recognition and early care-seeking media, ANMs, for maternal and neonatal danger signs, healthy newborn and maternal care practices. AWWs, TBAs PHCs/CHCs ●● 50% of PHCs (1000) and all CHCs ( 600) to be upgraded to provide ; 24 hour basic emergency obstetric care (EmOC) and inpatient care to inborn and outborn sick neonates Facility Nurse, ANMs and children; outpatient IMNCI to be implemented, neonatal, antenatal and post-partum level LHVs, MOs care to be strengthened. ●● Rest of the PHCs to provide antenatal care ANC, outpatient IMNCI and post-partum care.14 districts in the country in 1990. In 1992, the ARI control Supplementation with micronutrients : National Programmestrategy became a part of CSSM program, which continued for Prophylaxis against Blindness in Children caused due tointo the RCH Phase I project in 1997. Co-trimoxazole tablets Vitamin A deficiency is being implemented through RCHare being provided at subcenters and above. ANMs are being programme (See Box - 1). The objectives are to decrease thetrained to treat children with ARI. prevalence of Vit A deficiency to 0.3%.Control of Deaths due to Diarrhoeal Diseases : Diarrhoeal Anemia among Children : Iron deficiency anaemia is widelydiseases account for 17 percent of under five mortality in post prevalent in young children. NFHS II (1998-99) revealed thatneonatal period, and 3 percent of neonatal deaths(13). The Oral 74.3% children under the age of three years are anemic. UnderRehydration Therapy (ORT) program was started in 1986-1987. the National Nutritional Anemia Prophylaxis Program (now partThe main objective of the program was to prevent deaths due of RCH) Iron & Folic acid tablet containing 20 mg of elementalto dehydration caused by diarrhoeal disease. Health education Iron and 0.1mg of Folic acid are provided at sub center level.aimed at rapid recognition and appropriate management of 100 tablets are given to children who are clinically anemic.diarrhoea has been a major component of the CSSM and RCH As per the revised policy, infants between 6-12months of agePhase I project. ORS packets are provided at sub-centers as part are also included in the program as a significant proportionof the drug kit-A, under the RCH program. The use of home of these infants are anemic. For children aged 6-60 months,available fluids and ORS has resulted in a substantial decline Ferrous sulphate and Folic acid is to be provided in a liquidin the mortality associated with diarrhoea from an estimated formulation. For safety sake liquid formulation should be1.0 -1.5 million children every year prior to 1985 to six to seven dispensed in bottles so designed that only 1ml can be dispensedlakh deaths in 1996. In addition, social marketing and supply each time. School children 6-10yrs of age are also included inof ORS through the public distribution system is being done in the programme. Children 6-10 yrs are to be provided 30 mg ofsome states. elemental Iron 250mcg and Folic acid per child per day for 100 • 500 •
  • 45. Box - 1 : Strategy for National Programme for Prophylaxis against Blindness in Children due to Vit ‘A’ deficiency Infancy Childhood Sick Children Health and nutrition education ●● Health education efforts to ensure adequate ●● All children with xerophthalmia to be is being taken up to encourage intake of vitamin A rich food throughout treated at health facilities colostrums feeding, exclusive childhood ●● All children suffering from measles to breastfeeding for the first six ●● Early detection and prompt treatment of be given one dose of vitamin A if they months and the introduction infections have not received it in the previous one of complimentary feeding ●● Vitamin A dose of 1,00,000IU at nine month thereafter 1,00,000IU of Vitamin months and 2,00,000IU thereafter at six ●● All cases of severe malnutrition to be A is being given at nine months monthly intervals up to three years of age given one additional dose of vitamin Adays. Adolescents are to be supplemented in the same dosage risk of maternal and infant mortality, sexually transmittedand duration as adults. infections and reproductive tract infections in adolescence, andUniversal Immunization Programme : National Immunization the rapidly rising incidence of HIV in this age group. In contextschedule is given in Table - 4. The impact of the UIP is measured of the RCH program goals, with special reference to reductionin terms of Vaccine Preventable Diseases (VPD) burden. Over the in IMR, MMR and TFR, addressing adolescents in the programlast 15 years there has also been a general decline in the reported framework will yield dividends in terms of delaying the agenumber of cases of the six main VPD, Despite the improvement at marriage, reducing the incidence of teenage pregnancy,indicated above, the stated goals were not fully achieved, thus the prevention and management of obstetric complicationsthere is an urgent need to address the immunization system including safe abortion services and the reduction of unsafedeficiencies and emphasize the need for strengthening the sex.system and vigilant monitoring and surveillance. Strategy for addressing Adolescent Reproductive and Sexual Health (ARSH) in RCH Phase II : It is proposed to provide Table - 4 : National Immunization schedule adolescent health services through the existing subcenters/ PHCs and CHCs (See Table-5). Age Vaccines Initiatives for vulnerable groups Birth BCG, OPV Vulnerable communities include those groups who are under- 6 Weeks DPT, OPV, Hepatitis B served due to problems of geographical access, (even in better 10 Weeks DPT, OPV, Hepatitis B off states) and those who suffer from social and economic 14 Weeks DPT, OPV, Hepatitis B disadvantages such as Scheduled Castes/Scheduled Tribes (SCs/STs) and the urban poor. Scheduled caste people (166.6 9 months Measles million) and scheduled tribe people (84.3 million) in India 16-24 months DPT (1 st Booster), OPV are considered to be socially and economically the most 5 years DPT (2nd Booster) disadvantaged group. The SCs constitute 16.2% and STs 8.2% of the country’s population (as per the 2001 Census). The RCH 10 years TT indicators for these groups of people are worse than the urban Pregnant unimmunized 2 doses of TT with one month average due to following reasons: interval 1. Poor connectivity to health centers because of distance, Pregnant immunized One booster dose of TT topography, and lack of public transport 2. Lack of flexibility and reduced responsiveness to localUrban Measles Campaign : A special campaign was stated diversity and needsfor slum areas in 1998 with assistance from UNICEF. In 1999- 3. Lack of appropriate Human Resource Development (HRD)2000, 50 cities were covered. The emphasis is on covering all policy to encourage/motivate the service providers to workunprotected children up to age of 3 years with single dose of in remote and tribal areasmeasles vaccine. Goals : To improve the health status of the vulnerableNeonatal Tetanus elimination : All women in reproductive population by ensuring accessibility and availability of qualityage group should be covered with three doses of tetanus toxoid primary health care and family welfare services to them.vaccine through a campaign approach. Such campaigns have Objectives : The objectives of the Vulnerable Plan are :been implemented in Rajasthan and Madhya Pradesh to achieve (i) To improve accessibility, availability and acceptability ofearly elimination of neonatal tetanus. health services including RCH services by strengtheningAdolescent Health infrastructure including training and skill development of service providers, improving the supply of equipment,Adolescents (10-19 years) in India represent almost one-third drugs etc. in an integrated and participatory mannerof the population. A large number of them are out of school, (ii) To bring them at par in this respect with the rest of theget married early, work in vulnerable situations, are sexually population, and thus improving the aggregate indicatorsactive, and are exposed to peer pressure. Some of the public towards achieving the expected results set under RCHhealth challenges for adolescents include pregnancy, excess Phase II by the end of 2010. • 501 •
  • 46. Table - 5: Services to adolescents under RCH II challenges of maternal and child health. The umbrella of RCH covers family Level of Service planning, ORT, RTI, STD and CSSM. Target Group Services Care Provider It has a participatory approach of all Sub center HW (F) Unmarried & ●● Enroll newly married couples communities including ISM practitioners, Married Females ●● Provision of spacing methods Dais, opinion leaders, NGOs apart from and males ●● ANC care & institutional delivery intersectoral coordination of Govt. ●● STIs/HIV prevention The programme lays great emphasis ●● Anemia prevention on training, IEC and research and development activities related to RCH. PHC/CHC Health Unmarried & ●● Contraceptives Procurement procedures and audit Assistant Married Females ●● Management of menstrual disorders arrangements have been streamlined (F)/ LHV/ and males ●● RTIs education and management to ensure uniformity in accounting. MO ●● Nutritional counseling and The modern system of Management management of anemia Information and evaluation will ensure ●● Counseling and services for MTP accountability, especially at districtFor tribal population and urban poor, separate health plans level. Lessons learnt from RCH I haveaddressing specific needs of these groups have been made. been tackled well in RCH II. There is a scope for a separate plan for each state. The services are client-centered, demand drivenMainstreaming Gender and Equity in RCH Phase II and based on the needs of the community. Up gradations ofIn India there is significant disparity in health care utilization level of facilities will contribute in reducing maternal and childand health status between women and men. Poor women mortality. Successful implementation will also provide out reachconsume less health care resources and suffer worse health services to the vulnerable groups of population such as urbanthan men and a large and increasing share of health expenditure slums, tribal population and adolescents. Due to overlapping ofby poor people is taking place outside of the public sector. The expenditures there will be a reduction in costs inputs.aim of mainstreaming gender is to correct imbalances betweenthe position of men and women in terms of access to resources Critical appraisaland benefits as well as to understand the differences in terms The goals set up in RCH II to be met by 2010 seem difficultof health status and health determinants. The RCH Phase II to be met. It is well known that socioeconomic developmentequity objective is to reduce the health inequities both between is the biggest contraceptive. There has been no mentiongeographical areas and between social groups, and to respond of socioeconomic development in population the needs of vulnerable populations. Implementation of such a vast program on ground seems difficult. The contraceptive basket has very little to offer forFunds Flow Arrangement for RCH Program and the males. The appropriate technology of seven cleans duringManagement of Funds delivery has lost its importance. There is actually physicalThere are two routes through which the MoH&FW, GoI shortage of manpower in health institutions at the periphery.transfers funds to the state/Union Territory governments for To add to this there is also shortage of kits, drugs, vaccines andimplementation of the RCH program. Funds mainly for salary contraceptives. Referral system and feedback are not smoothand grants-in-aid to institutions and purchase of contraceptives when real time implementation on ground takes place. Withfor social marketing are routed through state treasuries, while the launch of National Rural Health Mission (NRHM) the govtfunds for other activities and a few selective components are desires that RCH II to be implemented under NRHM which hasprovided through the State Committee on Voluntary Action created lot of confusion in the minds of middle level managers..(SCOVA) / state RCH /FW/Health Society, most of the funds for The algorithm for implementing IMNCI is very exhaustive andthe day-to-day running and implementation of the RCH program it will be difficult to be implemented by the grass root levelare passed on to these societies directly by the MoH&FW, GoI. worker.Monitoring and Evaluation SummaryA comprehensive integrated Health management information India was the first country to have launched a Familysystem will be functional in RCH - II. Community Need Planning Programme in 1951and again it is the first one toAssessment and Monitoring Approach (CNAMA) will be used. have converted the guidelines of International ConferenceThe work plans for a particular year will originate from the sub of Population Development at Cairo in 1994 in the form ofcenter level under each PHC and are subsequently aggregate Reproductive and Child Health Programme (RCH) in 1997. RCHwith appropriate additions at the CHC and district levels. Based finished its Phase I and entered Phase II in 2002. The goals ofon district action plans, aggregated state action plans are RCH II are to reduce Infant Mortality rate to < 30/1000 andprepared at the state headquarters with appropriate additions. Maternal Mortality Ratio to <100/100,000 and attain a TotalA similar reporting system will be followed for the monthly Fertility Ratio of 2.1. The immediate objective is to meet theprogress reports. unmet need of contraception, health care infrastructure andStrengths health personnel; medium term objective of attaining a TotalRCH II is an integrated and vast programme to address the Fertility Ratio of replacement level by 2010 : long term objective • 502 •
  • 47. of achieving population stabilization by 2045. School children aged 6-10 yrs of age are also included in theRCH II has been planned on the basis of lessons learnt from programme. Children aged 6-10 yrs are to be provided 30 mg ofRCH I. Components of RCH II are Population Stabilization, elemental Iron and 250 mcg Folic acid per child per day for 100Maternal Health, Reproductive Tract Infections (RTIs) and days. Adolescents are to be supplemented in the same dosageSexually Transmitted Infections (STIs), Newborn and child and duration as, Adolescent health, Initiatives for vulnerable groups, Universal immunization programme is also being implementedMainstreaming gender and equity, Strengthening Systems and through RCH and targets 6 vaccine preventable diseases.Partnerships. Recently Hepatitis B vaccination has been included and supplyTo attain population stabilisation RCH II offers Expanding of auto disabled syringes is being ensured for immunisation.contraceptive choices in the form of injectables, non steroidal Adolescents have been included and are being providedoral contraceptive, female condoms, Lactational amenorrhoea, services as dividends in terms of delaying the age at marriage,safe days method and Non scalpel Vasectomy. reducing the incidence of teenage pregnancy, the prevention and management of obstetric complications including accessFor improving maternal health, various schemes as Essential to early and safe abortion services and the reduction of unsafeObstetric care, Provision of Emergency Obstetric and Neonatal sexual behavior.Care at First Referral Unit (FRU), Safe Abortion Services/Medical Termination of Pregnancy (MTP) and Janani Suraksha Vulnerable communities include those groups who are under-Yojana (JSY) have been started. served due to problems of geographical access, (even in better off states) and those who suffer from social and economicPrevention, early detection and effective management of disadvantages such as Scheduled Castes/Scheduled Tribescommon lower reproductive tract infections have been (SCs/STs) and the urban poor. These have been included in RCHincluded. Guidelines for same have been made. Under RCH with specific goals and objectives to plans addressing specificII, the activities being undertaken to achieve the NRHM goals needs of these groups. The RCH Phase II equity objective isunder newborn and child health are : Integrated Management to reduce the health inequities both between geographicalof newborn and childhood illnesses, Home Based Newborn areas and between social groups, and to respond to the needsCare (HBNC), Promotion of breast feeding and complementary of vulnerable populations. RCH II is an integrated and vastfeeding, Control of deaths due to ARI, Control of Deaths due programme to address the challenges of maternal and childto Diarrhoeal Diseases, Supplementation with micronutrients, health.Universal Immunization Programme. Integrated Managementof newborn and childhood illnesses aims at training the health Referencesstaff to refer/treat patient at out patient facility/ home based 1. Govt of India. Reproductive and child health Programme, schemes forcare, of neonates and children up to five years of age. Co- Implementation. October 1997.Department of Family Welfare. Ministry of Health and Family Welfare. New Delhi.trimoxazole tablets are being provided at subcenters to control 2. Chandrasekaran C, Kuder K. Family planning through clinics. Mumbai:deaths due to Acute Respiratory Infections (ARI) and ORS Allied publishers; 1965.packets are being provided to Control Deaths due to Diarrhoeal 3. Banerjee D. Health and family planning services in India. An epidemiological, sociocultural and political analysis and perspective. Calcutta: Lok Paksh;Diseases. 1985.National Programme for Prophylaxis against Blindness in 4. Government of India. First Five-Year Plan (1951-56). New Delhi: Planning Commission; 1951 p. 22.Children caused due to Vitamin A deficiency is being implemented 5. Irudaya RS, Padmavathi R. India’s family planning program: A criticalthrough RCH programme. The objectives are to decrease the appraisal. Econ J Nepal 1990; 13(3): 21-42.prevalence of Vit A deficiency to 0.3%. National Nutritional 6. Government of India. The Medical Termination of Pregnancy Act, 1971 (ActAnemia Prophylaxis Program is also now part of RCH. Iron and No. 34 of 1971), 10th August 1971, New Delhi: Ministry of Health and Family Welfare: 1971.Folic acid tablets are being distributed to Children, adolescents 7. Park K. Indicators of MCH care. Park’s textbook of Preventive and Socialand pregnant ladies. Under this programme all pregnant and medicine. 18th ed. Jabalpur: Banarsidas Bhanot, 2005.lactating women are provided with one tablet (containing 100 8. Bose A. The Family Welfare Programme in India: Changing of elemental iron and 0.5mg Folic acid) for 100 days. Those In: Mathur HM, editor. The Family Welfare Programme in India. Vikas Publishing; 1995. p. 1-29who have severe anemia are provided with double dose of these 9. National Program Implementation Plan. RCH Phase II - Program Document.tablets health education apart from other services. For children Ministry of Health and Family Welfare. New DelhiIron and Folic acid tablet containing 20 mg of elemental iron 10. France Donnay, Children in the tropics, Controlling Fertility, 1991 No 193- 194.and 0.1mg of Folic acid are provided at sub center level. 100 11. Govt of India (2000), National population Policy, Ministry of Health andtablets are given to children who are clinically anemic. As per Family Welfare. New Delhithe revised policy, infants between 6-12months of age are also 12. Epidemiology of diseases, Edited by Miller, D.L. and farmer, R.D, Blackwelincluded in the program as a significant proportion of these Scientific Publications. 13. WHO (2005), The World Health Report 2005, Make every mother and childinfants are anemic. For children 6-60 months, ferrous sulphate count.and Folic acid is to be provided in a liquid formulation. For 14. GOI (2004). Annual Report 2003-2004. Ministry of Health and Familysafety sake liquid formulation should be dispensed in bottles ‘welfare. New designed that only 1ml can be dispensed each time. • 503 •
  • 48. The Goal and Objectives of the RNTCP Revised National Tuberculosis 90 Control Programme (RNTCP) Goal : The goal of TB Control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India. Puja Dudeja & Ashok K. Jindal Objectives : ●● To achieve at least 85 percent cure rate of the newlyIn India today, two deaths occur every three minutes from diagnosed sputum smear-positive TB patients; andtuberculosis (TB). But these deaths can be prevented. With ●● To detect at least 70 percent of new sputum smear-positiveproper care and treatment, TB patients can be cured and the patients after the first goal is met.battle against TB can be won. Strategy : DOTS is a systematic strategy which has fiveEvolution of Tuberculosis Control in India : See Table - 1 components (See Box - 1).RNTCP : Launch, Expansion and Coverage ‘DOTS’ - remains the core strategy; however all components ofNational Tuberculosis Control Programme launched in 1962, new Stop TB Strategy are incorporated in the second phase ofsuffered from weakness in the form of poor managerial control, RNTCP These are: .inadequate funding, over-reliance on x-ray, non-standard 1. Pursue quality DOTS expansion and enhancement, bytreatment regimens, low rates of treatment completion, improving the case finding and cure through an effectiveand lack of systematic information on treatment outcomes patient-centered approach to reach all patients, especially(Evolution of Tuberculosis Control in India is given in Table-1) the poor.(1). Program reviews showed that only 30% of estimated 2. Address TB-HIV, MDR-TB and other challenges by scalingtuberculosis patients were diagnosed and only 30% of those up TB-HIV joint activities, DOTS Plus and other relevantwere treated successfully. The Revised National Tuberculosis approaches. The guidelines for management of MDR-TBControl Programme (RNTCP), based on the DOTS strategy, under DOTS-Plus strategy have been developed.  took its roots in India in 1993 by pilot testing as Phase I 3. Contribute to health system strengthening, by collaboratingproject covering a population of about 18 million and was with other health programmes and general services.launched as a national Programme in 1997. The expansion 4. Involve all health care providers, public, nongovernmentalbegan in late 1998 and at end of 2000, 30%of the country’s and private, by scaling up approaches based on a public-population was covered, and by the end of 2002, 50%of the private mix (PPM), to ensure adherence to the Internationalcountry’s population was covered under the RNTCP (2). By the Standards of TB care.end of 2003, 778 million and at the end of year 2004, 997 5. Engage people with TB, and affected communities tomillion population was covered. By December 2005, around demand, and contribute to effective care. This will involve97% (about 1080 million) of the population had been covered, scaling-up of community TB care; creating demandand the entire country was covered under Directly Observed through context-specific advocacy, communication andTreatment Short course (DOTS) by 24th March 2006(3). In the social mobilization.first phase of RNTCP (1998-2005), the programme’s focus was 6. Enable and promote research for the development of newon ensuring expansion of quality DOTS services to the entire drugs, diagnostics and vaccines. Operational Research willcountry. The RNTCP has now entered its second phase in which also be needed to improve programme performance.the programme aims to firstly consolidate the gains made to RNTCP Structure and Service Delivery Mechanismsdate, to widen services both in terms of activities and access, At the center : The Central TB Division (CTD) is responsibleand to sustain the achievements for decades to come in order for developing technical policies, procuring drugs, preparingto achieve ultimate objective of TB control in the country. Phase training modules, programme and financial monitoring,II of the RNTCP is a step towards achieving the TB-related quality assurance, advocacy, operational research prioritiesMillennium Development Goal (MDG) targets. Directly Observed and mobilising funds.Treatment Short Course - ‘DOTS’ - remains the core strategy. Table 1: Evolution of Tuberculosis Control in India Year Remarks 1962 The National TB Control Programme (NTCP) launched. The strategy was based on early detection and treatment thereby converting infectious cases to noninfectious and preventing noninfectious cases from becoming infectious with treatment, Diagnosis through radiology and sputum microscopy, Free Domiciliary treatment through Primary Health Care Services, Establishing District Tuberculosis Centre in every district, Extend coverage under Short Course Chemotherapy (SCC),Strengthen state TB training and demonstration centers 1992 Government of India, together with the WHO and SIDA, reviewed the national programme and concluded that it suffered from various managerial and operational weaknesses. As a result, a Revised National Tuberculosis Control Programme (RNTCP) was designed 1993 -2005 Era of Directly Observed Treatment Short course(DOTS), RNTCP launched 2006-2010 RNTCP Phase II • 504 •
  • 49. Box - 1 : Components of DOTS 1 Political and administrative commitment : It warrants the topmost priority, which it has been accorded by the Government of India. This priority must be continued and expanded at the state, district and local levels. 2 Good quality diagnosis : Good quality microscopy allows health workers to see the tubercle bacilli and is essential to identify the infectious patients who need treatment the most. 3 Good quality drugs and an uninterrupted supply of good quality anti TB drugs : In the RNTCP a box of medications for , the entire treatment is earmarked for every patient registered, ensuring the availability of the full course of treatment the moment the patient is initiated on treatment. 4 Supervise treatment to ensure right treatment : The heart of the DOTS programme is “directly observed treatment” in which a health worker, or another trained person who is not a family member, watches as the patient swallows the anti- TB medicines in their presence. 5 Systematic monitoring and accountability : The programme is accountable for the outcome of every patient treated. This is done using standard recording and reporting system, and the technique of ‘cohort analysis’. The cure rate and other key indicators are monitored at every level of the health system, and if any area is not meeting expectations, supervision is intensified. The RNTCP shifts the responsibility for cure from the patient to the health system.At the State : The RNTCP is integrated with the general health treatment services, RNTCP Designated Microscopy Centrescare delivery systems in the states. At the State level, the State (DMCs) have been established for every 1, 00,000 population.Tuberculosis Officer (STO) is responsible for planning, training, Norms for the establishments of TUs and DMCs are relaxed tosupervising and monitoring the programme in their respective 2, 50,000 and 50,000 population respectively in hilly/difficultstates as per the guidelines of the State TB Control Society or its and tribal areas. In addition, a vast network of DOT centresequivalent (STCS or its equivalent). The STO based at the State (treatment centres), all with trained DOT providers, haveTB Cell is administratively answerable to the State Government been established in all RNTCP areas so that patients can haveand technically follows the instructions of the CTD, and easy access to TB treatment. In addition, there are 17 Statecoordinates with CTD and the districts for executing the duties TB Training and Demonstration Centres (STDCs) which act asmentioned above. The State TB Cell (STC) is responsible for the technical support units to the respective STC. Responsibilitiessupervision and monitoring of the programme throughout the of the STDCs include assisting the STC in training, supervisionstate. and monitoring of the programme, quality assurance of theAt the District : District TB Centre (DTC) is the key organisational RNTCP sputum microscopy services, advocacy and IEC, andunit responsible for the implementation of the programme operational research. The level of involvement of the STDCs,in the respective districts. The district is the key level for the however, varies from state to state. Release of programmemanagement of primary health care services. The district level funds from the centre to the state and districts is channeled(or municipal corporation level) performs functions similar to via the state and district TB control societies. State and districtthose of the state level in its respective area. The Chief District societies make decisions on budget formulation according toHealth Officer (CDHO) / Chief District Medical Officer (CDMO) guidelines from the centre, hire contractual staff, purchaseor an equivalent functionary in the district is responsible for necessary items, oversee programme planning, implementationall medical and public health activities including control of and monitoring, and perform other functions which greatlyTB. The District Tuberculosis Centre (DTC) is the nodal point facilitate programme implementation.for TB control activities in the district. In RNTCP the primary , Tuberculosis unit : A major organizational change in RNTCProle of the DTC has shifted from a clinical one to a managerial is the creation of a sub-district level Tuberculosis Unit. Theone. The District TB Officer (DTO) at the DTC has the overall Tuberculosis unit (TU) consists of a designated Medicalresponsibility of management of RNTCP at the district level Officer-Tuberculosis Control (MO-TC) who does tuberculosisas per the programme guidelines. The DTO is also responsible work in addition to his/her other responsibilities, as wellfor involvement of other sectors in RNTCP and is assisted by as two full-time supervisory staff for tuberculosis work-aan MO, Statistical Assistant and other paramedical staff. For Senior Treatment Supervisor (STS) and a Senior Tuberculosiseach district, there should be a full-time DTO, who is trained in Laboratory Supervisor (STLS). TUs are generally based in aRNTCP at a central level institution. Community Health Centre (CHC), Taluk Hospital (TH) or BlockThe DTC is supported by sub-district TB Units (TUs) established Primary Health Centre (BPHC). The team of STS and STLS at thefor every 5, 00,000 population to serve as a link between the Tuberculosis Unit level (TU level) are under the administrativedistrict level and the periphery. The TU is the lowest reporting supervision of the DTO / MO-TC. The TU covers a populationunit under the RNTCP At the TUs, a special cadre of dedicated . of approximately 500,000 (250,000 in tribal, desert, remoteTB supervisory staff, the Senior Treatment Supervisor (STS) and hilly regions). The TU will have one Microscopy Centreand the Senior Tuberculosis Laboratory Supervisor (STLS), for every 100,000 population (50,000 in tribal, desert, remotehave been appointed on a contractual basis for carrying out and hilly regions) referred to as the Designated Microscopysupervisory work in the field under the charge of a Medical Centre (DMC). DMCs are also provided in Medical Colleges,Officer-TB Control. To further decentralise the diagnostic and Corporate hospitals, ESI, Railways, NGOs, private hospitals, • 505 •
  • 50. etc, depending upon requirements. The TU is responsible for Definitions : Treatment Outcomesaccurate maintenance of the Tuberculosis Register and timely Cured : Initially sputum smear-positive patient who hassubmission of quarterly reports to the district level. The TU is completed treatment and had negative sputum smears, on twothe nodal point for TB control activities in the sub-district. occasions, one of which was at the end of treatment.Definitions - Types of Disease Treatment completed : Sputum smear-positive patient whoPulmonary Tuberculosis, Smear-Positive : TB in a patient has completed treatment, with negative smears at the end ofwith at least 2 initial sputum smear examinations (direct the intensive phase but none at the end of treatment or Sputumsmear microscopy) positive for AFB or TB in a patient with one smear-negative TB patient who has received a full course ofsputum smear examination positive for AFB and radiographic treatment and has not become smear-positive during or atabnormalities consistent with active pulmonary TB as the end of treatment or Extra-pulmonary TB patient who hasdetermined by the treating MO or TB in a patient with one received a full course of treatment and has not become smearsputum smear specimen positive for AFB and culture positive positive during or at the end of treatment.for M.tuberculosis. Died : Patient who died during the course of treatmentPulmonary tuberculosis, Smear-negative : TB in a patient regardless of cause.with symptoms suggestive of TB with at least 3 sputum smear Failure : Any TB patient who is smear positive at 5 months orexaminations negative for AFB, and radiographic abnormalities more after starting treatment. Failure also includes a patientconsistent with active pulmonary TB as determined by the who was treated with Category III regimen but who becomestreating MO followed by a decision to treat the patient with smear positive during treatment.a full course of anti-tuberculosis therapy or Diagnosis Defaulted : A patient who has not taken anti-TB drugs for 2based on positive culture but negative AFB sputum smear months or more consecutively after starting treatment.examinations. Transferred out : A patient who has been transferred toExtra Pulmonary tuberculosis : TB of any organ other than another Tuberculosis Unit/District and his/her treatment resultthe lungs, such as the pleura (TB pleurisy), lymph nodes, (outcome) is not known.intestines, genitourinary tract, skin, joints and bones, meningesof the brain, etc. Diagnosis should be based on culture- Tuberculous infection : It is the presence of viable but notpositive specimen from the extra-pulmonary site, histological, multiplying virulent tubercular bacilli within the cells of theradiological, or strong clinical evidence consistent with active human being without any manifestation of clinical symptoms.extra pulmonary TB followed by decision of the treating MO to Tuberculous disease : It is the presence of viable, multiplying,treat with a full course of anti-TB therapy. Pleurisy is classified virulent tubercular bacilli within the cells or tissues, with theas extra pulmonary TB. A patient diagnosed with both sputum presence of clinical symptoms.smear positive pulmonary and extra pulmonary TB should be Diagnosisclassified as pulmonary TB. Three samples of sputum are collected on two daysDefinitions : Types of cases [spot (I day), overnight/early morning (II Day), spot (II Day)] andNew: A case who has never had treatment for tuberculosis or are examined under microscope. Results of sputum microscopyhas taken anti-tuberculosis drugs for less than one month. are given in Table - 2. Algorithm for diagnosis and treatmentRelapse: A TB patient who was declared cured or treatment is given as Fig. -1.completed by a physician, but who reports back to the healthservice and is now found to be sputum smear positive. Table - 2 : Results of sputum microscopyTransferred in : A TB patient who has been received for No oftreatment into a Tuberculosis Unit, after starting treatment in If the slide has Result Grading fields to beanother unit where s/he has been registered. examinedTreatment after default : A TB patient who received anti- More than 10 AFB per Pos 3+ 20tuberculosis treatment for one month or more from any source oil immersion fieldand returns to treatment after having defaulted, i.e., not takenanti-TB drugs consecutively for two months or more, and is 1-10 AFB per oil Pos 2+ 50found to be sputum smear positive. immersion fieldFailure : Any TB patient who is smear positive at 5 months or 10-00 AFB per 100 oil Pos 1+ 100more after starting treatment. Failure also includes a patient immersion fieldwho was treated with Category III regimen but who becomessmear positive during treatment. 1-9 AFB per 100 oil Pos Scanty 100Chronic : A TB patient who remains smear positive after immersion fields -B*completing a re-treatment regimen. No AFB in 100 oil Neg 100Others : TB patients who do not fit into the above mentioned immersion fieldstypes. Reasons for putting a patient in this type must be * Record actual number of bacilli seen in 100 fields - e.g “ Scanty 4”specified. • 506 •
  • 51. Fig. - 1: Algorithm for diagnosis of a tuberculosis Diagnosis Cough for 3 weeks or more 3 Sputum smears 3 or 2 Positives 1 Positive 3 Negatives Antibiotics 10-14 days Cough persisits Repeat 3 Sputum Examinations 1 Positive 3 Negatives 3 or 2 Positives X-ray X-ray Negative Suggestive Suggestive Negative for TB of TB of TB for TB Smear Smear Smear Positive TB Negative TB Positive TB Anti TB Treatment Non TB Anti TB TreatmentFluorescent microscopes have been provided to the state Table - 3 : Classification of categories, types of patients,designated Intermediate Reference Laboratories (IRLs) under regimens adopted under RNTCPRNTCP and at present, the use of fluorescence microscopyis linked to the culture and Drug Sensitivity Testing (DST) Duration Cat Type of patient Regimensactivities of the IRLs. The most important advantage of the in monthsfluorescence technique is that slides can be examined at a New sputum smear +velower magnification, thus allowing the examination of a much 2(HRZE)3 Seriously ill sputum -velarger area per unit of time. I 6 Seriously ill sputum 4(HR)3Treatment under RNTCP extra-pulmonaryTreatment in RNTCP is under two phases : Intensive and Sputum +ve relapse 2(HRZE)3continuation phase. Categorization of patients is given inTable - 3. Duration of treatment alongwith phases is given for 1(HRZE)3 Sputum +ve failureeach category in Table - 4. Duration of treatment if patient is II 5(HRE)3 8still sputum positive at end of intensive phase (IP) is given Sputum +ve treatmentin Table - 5, while details of anti-tubercular drugs are given after defaultin Table - 6 and 7. Treatment categories and their relation tosputum examination schedule is given in Table - 8. Sputum -ve Extra 2(HRZ)3Management of patients who interrupt treatment : The III pulmonary not 6 seriously ill 4(HR)3details are given in Table - 9 and 10. 4(KOCZEEt) IV MDR TB 12-18(OCEEt) 18-24 • 507 •
  • 52. Table - 4: Phase and duration of treatment Table 5 : Duration if sputum is +ve at end of Intensive Duration (number of doses) Phase* Cat Intensive Continuation Total Duration (number of doses) Phase (IP) Phase (CP) Cat Intensive Continuation Total 18 weeks 26 weeks Phase (IP) Phase (CP) I 8 weeks (24 doses) (54 doses) (78 doses) 18 weeks 26 weeks I 12 weeks (36 doses) 12 weeks (36 22 weeks 34 weeks (54 doses) (90 does) II doses) (66 doses) (102 doses) 22weeks 34 weeks II 16 weeks (48 doses) 18 weeks 26 weeks (66 doses) (144 doses) III 8 weeks (24 doses) (54 doses) (78 doses) * Cat I - at the end of 2 months; Cat II - at the end of 3 months Table - 6: Dosages of Anti tubercular drugs Dose (thrice Number of pills Medication Drug Action Dose in children (mg/Kg) a week) *** in combipack Isoniazid Bactericidal 600mg 10-15 2 Rifampicin Bactericidal 450mg* 10 1 Pyrazinamide Bactericidal 1500mg 25 2 Ethambutol Bacteriostatic 1200mg 15 2 Streptomycin Bactericidal 0.75g** 15 - * Patients who weigh 60 kg or more at the start of treatment are given an extra 150mg dose of rifampicin. ** Patients over 50 years of age & those who weigh <30 kg are given 0.5g of streptomycin. *** Adult patients weighing <30kg receive drugs in patients-wise from the weight band suggested for pediatric patients. Table - 7 : Side effects of Anti tubercular drugs Drug Side Effects Isoniazid Hepatitis, peripheral neuropathy, pellagra, like syndrome, skin rash, drowsiness, fatigue Rifampicin Hepatitis, flu-like syndrome, skin rash, gastritis, respiratory and hemolytic syndromes, orange discoloration of urine, sweat, saliva Pyrazinamide Hepatitis, joint pains like gout due to hyperuricemia Ethambutol Ocular toxicity, decreased visual acuity, blurring and red green colour blindness, gastrointestinal toxicity and peripheral neuropathy, not recommended in children less than 6 yrs of age. Streptomycin Vestibular damage leading to nystagmus, unsteadiness of gait, reduces hearing, hypersensitivity reaction, impairment in excretory functions of kidney. Contraindicated in pregnancy. Use of unsterile needles can transmit Hepatitis B and HIV. O f l o x a c i n / GI symptoms like nausea, vomiting, anorexia, anxiety, dizziness, headache, convulsion, rupture of Achilles Ciprofloxacin tendon Kanamycin Vestibular and auditory symptoms, cutaneous hypersensitivity Ethionamide GI symptoms like diarrhoea, abdominal pain, hepatotoxicity, convulsion, mental symptoms, impotency, gynecomastiaChemoprophylaxis for Children Hospitalization of TB patientsHousehold contacts of smear-positive TB cases, especially Some TB patients may need hospitalization during their illness.those below 6 years of age, must be screened for symptoms of All indoor patients are to be treated with RNTCP regimens. Thetuberculosis. In case of symptoms being present, the diagnostic treatment is given using prolongation pouches which will bealgorithm for pediatric TB should be followed and the child supplied by District TB Officer through the STS of that TU. Onshould be given a full course of anti TB treatment if he is discharge, patients may be given a maximum of three doses (1diagnosed as a TB case. For asymptomatic children and those week drug supply) to cover the intervening period prior to theirwho are not found to be suffering from TB, chemoprophylaxis continuation of treatment at their respective DOT Centre, whichwith Isoniazid (5 mg per kg body wt) should be administered may/not be in the same district, hence ensuring no interruptiondaily for a period of six months. This is regardless of the BCG in treatment. All indoor patients treated under RNTCP should be ,vaccination status. registered under the local TU in which the hospital is located. • 508 •
  • 53. Table - 8 : Treatment categories and sputum examination schedule Treatment Regimen Sputum Examination For Pulmonary Tb Pre- Test at If Cat Type of patient Regimen* Treatment month result Then sputum (end IP) is Start continuation phase, test sputum again at 2 - month in CP ( 4 months) and at the end of treatment (6 months) New Sputum + 2 Continue intensive phase for one more month, test smear-positive sputum again at end of extended IP (3 months), end + then at 2 months in CP (5 months) and at the end of 2H3R3Z3E3 I treatment (7 months) # +4H3R3 Start continuation phase, test sputum again at the Seriously ill - end of treatment (6 months) ** Sputum smear-negative - 2 Continue intensive phase for one more month, test Seriously ill ** sputum again at end of extended IP ( 3 months), + extra pulmonary and then at 2 months in CP (5 months) and at the end of treatment ( 7 months) # Sputum smear- Start continuation phase, test sputum again positive Relapse - at 2 month in CP and at the end of treatment (8 Sputum smear- 2H3R3Z3E3S3 months) positive Failure II +1H3R3Z3 + 3 Continue intensive phase for one more month, test Sputum smear - positive Treatment +4H3R3E3 sputum again at end of extended IP (3 months), end + after default then at 2 months in CP (6 months) at the end of Others*** treatment ( 9 months) New Sputum Start continuation phase, test sputum again at the smear-negative, - end of treatment (6 months) not seriously ill 2H3R3Z3 III - 2 New extra- + 4H3R3 Re-register the patient and begin Category II pulmonary, not + treatment # seriously ill * The number before the letters refers to the number of months of treatment. The subscript after the letters refers to the number of doses per week. The dosage strengths are as follows: H : Isoniazid (600mg), R: Rifampicin (450mg), Z : Pyrazinamide (1500mg), E: Ethambutol (1200mg), S : Streptomycin (750mg), Patients who weigh 60 kg or more receive additional rifampicin 150 mg. Patients who are more than 50 years old receive streptomycin 500mg. Patients who weigh less than 30 kg, receive drugs as per body weight. Patients in Categories I and II who have a positive sputum smear at the end of the initial intensive phase receive an additional month of intensive phase treatment. ** Seriously ill also includes, any patient, pulmonary or extra pulmonary who is HIV positive and declares his sero-status to the categorizing/treating medical officer. For the purpose of categorization, HIV testing should not be done. *** In rare and exceptional cases, patients who are sputum smear-negative or who have extra-pulmonary disease can have Relapse or Failure. This diagnosis in all such cases should always be made by an MO and should be supported by culture or histological evidence of current, active TB. In these cases, the patient should be categorized as ‘others’ and given Category II treatment. # Any patient treated with Category I who has a positive smear at 5 months or later should be considered a Failure and started on Category II treatment afresh. Any patient on Category III who has a positive smear anytime during the treatment is also considered as Failure and started on Category II treatment.DOTS plus evidence have emerged regarding services for MDR-TB. DOTS-DOTS-Plus is an integral component of RNTCP to manage MDR- Plus programmes can and should strengthen the basic DOTSTB and is being implemented through programme infrastructure strategy. XDR TB (extensive drug resistant tuberculosis) is(4). The first WHO endorsed DOTS-Plus programmes began defined as MDR TB with further resistance to 3 of 6 classes ofin 2000. At that time, the Green Light Committee (GLC) was second line drugs. DOTS plus which is handling MDR Tb has aestablished to promote access to high quality second-line drugs serious threat from XDR TB.for appropriate use in TB control programmes. DOTS-Plus pilot Involvement of Private Practitioners in RNTCPprojects have demonstrated the feasibility and effectiveness of Private Practitioners (PPs) are generally the first point ofMDR-TB treatment in less affluent countries. In 2002, the Global contact for significant proportion of patients with tuberculosisFund to fight AIDS, TB, and Malaria (GFATM) started financing (5). All PPs can support and encourage effective tuberculosisTB control programmes, including MDR-TB, greatly reducing control by:the economic barrier to MDR-TB control. Based on data and ●● Ensuring prompt referral of patients with cough for 3experience from these projects, practices and further scientific • 509 •
  • 54. Table - 9 : Management of patients who were smear -negative at diagnosis and who interrupt treatment Treatment DO a sputum Result of Length of Re-received before Smear sputum Smear Outcome Treatment interruption registration interruption examination examination Less than Resume Treatment and No - - - 2 months Complete All dosesLess than 2 months Neg - - Resume Treatment Yes1 month or more Pos Default New Begin CAT I afresh Less than Resume Treatment and No - - - 2 month Complete All does Resume Treatment and Neg - -More than More than Complete All doses Yes1 month 2 months Treatment Begin CAT II Treatment Pos Default After Default afreshTable - 10 : Management of New smear-positive cases who interrupt treatment (Category I) Result of Treatment DO a sputum Length of sputum Re-received before Smear Outcome Treatment interruption Smear registration interruption examination examination Less than 2 Weeks No - - - Continue CAT I*Less than 2-7 Weeks No - - - Start again on CAT I *1 month Positive Default New Start again on CAT I** 8 Weeks or more Yes Negative - - Continue CAT I *1-2 Months Less than 2 weeks No - - - Continue CAT I * 1 extra month of intensive 2-7 Weeks Yes Positive - - phase of CAT I * Negative - - Continue CAT I * 8 Weeks or more Yes Treatment Positive Default Start on CAT II* after DefaultMore than Default Positive Other Start on CAT II*2 months 2-7 Weeks Yes *** Negative - - Continue CAT I * Treatment Positive Default After Start on CAT II* 8 Weeks or more Yes Default Negative - - Continue CAT I ** A patient must complete all 24 doses of the initial intensive phase. For example, if a patient has to continue his previous treatment and he took 1 month oftreatment and he took 1 month of treatment (12 doses) before interrupting. He will have to take 1 more month (12 doses) of the intensive treatment. The patientwill then start the continuation phase of treatment.** A patient who must start again will restart treatment from the beginning.*** Although this patient does not strictly fit the definition of default. Default most closely describes the outcome of this patient, although at re-registration thepatient should be categorized as ‘Other’.* Patients with extra-pulmonary TB should receive Category III treatment unless they are seriously ill, in which case they should receive Category I treatment.** Examples of seriously ill patients are those suffering from meningitis, disseminated TB, tuberculous pericarditis, peritonitis, bilateral or extensive pleurisy, spinalTB with neurological complications, smearnegative pulmonary TB with extensive parenchymal involvement, intestinal, genito-urinary TB and co-infection withHIV. All forms of pediatric smear negative TB except primary complex and pediatric extrapulmonary lymph node TB and unilateral pleural effusion. • 510 •
  • 55. weeks or more for sputum smears. under RNTCP which is implementing the DOTS strategy of●● Providing reassurance that tuberculosis can be cured. diagnosis and treatment for TB nationwide (11).In 2007-08,●● Giving only RNTCP recommended drug regimens. TB-HIV collaborative activities are to be extended to the entire●● Starting treatment with rifampicin-containing regimens country and have been included as an integral part of NACP III only if it can be ensured that treatment can be completed and RNTCP II. under observation. The goal of the National framework is to further enhanceInvolvement of NGOs in RNTCP collaboration between RNTCP and NACP and reducing the ,Involvement of Non-Governmental Organizations (NGOs) in burden of TB and HIV in India. The objectives are-RNTCP is of vital importance. NGOs have an active role in health 1. To establish mechanisms for coordination between RNTCPpromotion in the community and many patients seek treatment and NACP at National, State and District levels.from/through them. Depending on the capacity of the NGOs, 2. To decrease morbidity and mortality due to tuberculosistheir possible areas of involvement can be health education, among persons living with HIV/AIDS.service delivery, planning, programming, implementation, 3. To decrease the impact of HIV in tuberculosis patients andtraining and evaluation(6). provide access to HIV related care and support to HIV- infected TB patients.Quality Assurance in RNTCP ConclusionSputum examination is the mainstay for diagnosis ofTuberculosis under RNTCP Poor quality microscopy services . RNTCP is the second largest programme of the country and hashave serious implications for the programme, including the strengthened the existing NTP structure and created TB unit atfailure to detect persons with infectious TB who will continue the sub district level. RNTCP has expanded in a systematic wayto spread infection in the community, or leading to unnecessary covering the whole of country by March 2006. There has beentreatment for “non-cases.” The quality assurance activities take intensified Public private mix in scaling up the initiatives toplace at the National reference laboratories, intermediate level strengthen case detection and treatment. Political commitmentreference laboratories and TB unit. is one of the main components of DOTS. DOTS have been made responsible for carrying out defaulter retrieval activity aboutIn addition, Internal Quality Assurance includes all means by the patients put on treatment. This is ensures completion ofwhich the laboratory personnel performing TB smear microscopy treatment by the patients. Various NGOs are also playing usefulcontrol the process, including checking of instrument, new lots role by providing man power or financial assistance (13).of staining solutions smear preparation, grading etc. It is asystematic internal monitoring of working practices, technical Critical appraisalprocedures, equipment, and materials, including quality of There has been poor coverage due to gaps in primary healthstains. care infrastructure and manpower in difficult to assess areas.RNTCP Tribal Action plan Quality of sputum examination is not up to the mark. The private practitioners at many places use non standard treatmentTribal constitute 8.08% of the country’s population, which makes regimens. The problem of drug resistant TB is emerging very fastIndia the second largest concentration of tribal communities in which is virtually untreatable and spreading all over the worldthe world (8). There are 635 tribes in India located in five major including India (12). Given the problems of number of drugstribal belts across the country. The RNTCP Tribal Action Plan to be used, their cost, adverse effect, the duration of therapyhas the following objectives (9) : and accessibility of treatment, this group is going to pose a1. Encourage tribal populations to report early in the course big problem for the RNTCP in particular and the community of illness for diagnosis. at large. Direct supervision is the corner stone for the success2. Enhance treatment outcomes amongst tribal populations of RNTCP but in our country, lot of stigma is still attached to3. Promote closer supervision of tribal areas by RNTCP staff TB. As a result, many patients, especially young females, whoIEC in RNTCP want to hide their ailment, do not go to DOTS-provider thriceAdvocacy and communication is a central and integral part of or even once a week. Such patients often resort to influence thethe Phase II RNTCP (10). Communication plans are directed DOTS-provider and get medicines in bulk. In this process, directtowards scaling up the current level of communication activities supervision is lost.through good mass media campaigns to creating a supportiveand enabling environment for grassroot level participatory Summaryprocesses and community empowerment. National Tuberculosis Control Programme was launched in 1962 and suffered from weakness in the form of poor managerialTB and HIV control, inadequate funding, over-reliance on x-ray, non-As per NACO sentinel surveillance report of 2006, the standard treatment regimens, low rates of treatment completion,prevalence of HIV infection is estimated to be 0.36 % of the and lack of systematic information on treatment outcomes. Thepopulation, which translates to 2.5 million people living with Revised National Tuberculosis Control Programme (RNTCP),HIV/AIDS in India. Tuberculosis (TB) continues to be a public based on the DOTS strategy, took its roots in India in 1993health challenge in India and it is estimated that 1.8 million with the goal of decreasing mortality and morbidity due tocases of TB occur in India annually. Active TB disease is the TB and cut transmission of infection until TB ceases to be acommonest opportunistic infection amongst HIV-infected major public health problem in India. It progressed in a phasedindividuals. A low cost and high quality cure for TB is provided • 511 •
  • 56. manner and by 24th March 2006 entire country was covered by Another important aspect for success of RNTCP is involvementit and entered its second phase (2006-2010). of private practitioners and NGOs in the programme. RNTCPThe objectives of the RNTCP are to achieve at least 85 percent also has a tribal action plan to Encourage tribal populationscure rate of the newly diagnosed sputum smear-positive to report early in the course of illness for diagnosis, EnhanceTB patients and to detect at least 70 percent of new sputum treatment outcomes amongst tribal populations, and Promotesmear-positive patients after the first goal is met. Directly closer supervision of tribal areas by RNTCP staff. TuberculosisObserved Treatment Short course (DOTS) strategy has five is the commonest opportunistic infection in HIV cases. Therecomponents: Political and administrative commitment, Good is a strong collaboration between RNTCP and National AIDSquality drugs & an uninterrupted supply of good quality anti- Control Programme to decrease morbidity and mortality dueTB drugs, Good quality diagnosis using sputum microscopy, to tuberculosis among persons living with HIV/AIDS and toSystematic monitoring and accountability and supervised decrease the impact of HIV in tuberculosis patients and providetreatment to ensure the right treatment. DOTS remain the core access to HIV related care and support to HIV-infected TBstrategy of RNTCP II however few additional components in patients.the form of DOTS expansion and enhancement, addressing TB- ReferencesHIV, collaboration with other health programmes and general 1. .aspservices and involvement of private practitioners have been 2. Journey Of Tuberculosis Control Movement In India: National Tuberculosisemphasized. Programme To Revised National Tuberculosis Control Programme Prahlad Kumarindian J Tuberc 2005; 52:63-71The structure of RNTCP has The Central TB Division (CTD) at the 3. RNTCP India: Journey from 1996-2002.g. R. Khatri. Indian J Tuberc 2006;top, State TB Cell (STC) at the state and District TB Centre (DTC) 53:64-68at the district level. The TB Units (TUs) at the subdistrict level 4. Revised National Tuberculosis Control Programme DOTS-Plus Guidelines. 2006. Central TB Division, Directorate General of Health Services, Ministryis the lowest reporting unit under the RNTCP The Tuberculosis . of Health & Family Welfare, Nirman Bhavan, New Delhiunit (TU) consist of a designated Medical Officer-Tuberculosis 5. Involvement of Private Practitioners in the Revised National TuberculosisControl (MO-TC) who does tuberculosis work in addition to his/ Control Programme. 2005. Central TB Division Directorate General of Health Services, Ministry of Health and Family Welfare Nirman Bhavan, New Delhiher other responsibilities, as well as two full-time supervisory 6. Involvement of Non-Governmental Organizations in the Revised Nationalstaff for tuberculosis work - a Senior Treatment Supervisor Tuberculosis Control Programme October 2005 Central TB Division,(STS) and a Senior Tuberculosis Laboratory Supervisor (STLS). Directorate General of Health Services Ministry of Health and Family Welfare, Nirman Bhavan,The TU covers a population of approximately 500,000 (250,000 7. Revised National Tuberculosis Control Programme Environmental and Bio-in tribal, desert, remote and hilly regions). The TU will have medical Waste Management plan for RNTCP- II. 2005. Central TB Division,one Microscopy Centre for every 100,000 population (50,000 Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhavan, New Delhiin tribal, desert, remote and hilly regions) referred to as the 8. Census of India. 1991 Part II B (i) PCA- General Population (Vol. I & II).Designated Microscopy Centre (DMC). Downloaded from htpp:// on 11th January 2004.Diagnosis of a case is based on sputum microscopy where 9. Revised National Tuberculosis Control Programme TRIBAL ACTION PLANthree samples over two days are taken and ZN method of (Proposed for the World Bank assisted RNTCP II Project). 2005.Central TBstaining is used. For treatment the patient is classified into a Division, Directorate General of Health Services, Ministry of Health & Familycategory based on the definitions given in the programme and Welfare, Nirman Bhavan, New Delhi. 10. IEC -baseline document central TB division. 2007. Report compilation: Newtreatment of that particular category is started for the patient. Concept Information Systems, New Delhi.The treatment is divided into two phases intensive phase 11. National framework for joint TB/HIV collaborative activities. 2008. Centraland continuation phase. Antitubercular drugs being used in TB Division and National AIDS Control Organization Ministry of Health and Family Welfare Government of India New Delhi.RNTCP are H : Isoniazid R : Rifampicin, Z : Pyrazinamide E : 12. Singh MM. XDR-TB - Danger ahead. Indian J Tuberc 2007; 54:1-2.Ethambutol, S : Streptomycin. Household contacts of smear- 13. Rajinder Singh Bedi, RNTCP : Observations, doubts and suggestions. Lungpositive TB cases, especially those below 6 years of age, must India 2007; 24 : 81-82be screened for symptoms of tuberculosis. For asymptomaticchildren and those who are not found to be suffering from TB, Further Suggested Reading 14. The Global Plan to Stop TB, 2006-2015. Actions for life-towards a worldchemoprophylaxis with isoniazid (5 mg per kg body wt) should free of tuberculosis..Geneva World Health Organization, 2006 (WHO/HTM/be administered daily for a period of six months. STB/2006.35). 15. Toman’s Tuberculosis, Second Edition.DOTS-Plus is an integral component of RNTCP to manage 16. Status report on RNTCP DDG (TB), Directorate General of Health Services, .MDR-TB and is being implemented through programme Ministry of Health and Family Welfare, Government of India, New Delhi.infrastructure. XDR TB (extensive drug resistant tuberculosis) Indian J Tuberc 2008; 55: 91-93is defined as MDR TB with further resistance to 3 of 6 classes 17. Technical and operational guidelines for tuberculosis control.2005. Central TB Division Directorate General of Health Services Ministry of Health andof second line drugs. Family Welfare, Nirman Bhavan New Delhi - 110 011. • 512 •
  • 57. Strategy National Vector Borne Disease 91 Control Programme (NVBDCP) During the Tenth Plan (2002-2007), NVBDCP was planned to be implemented through the existing health care infrastructure and was planned to focus on improved training of health care Puja Dudeja & Ashok K. Jindal workers, reporting and monitoring of VBDs, insecticide and drug resistance, involvement of Panchayati Raj Institutions (PRIs),NVBDCP is an umbrella programme for prevention and control improved IEC and community acceptance and availability ofof major vector borne diseases of public health importance ITBNs (4). During the eleventh five year plan (2007-2012) thenamely Malaria, Filaria, Japanese encephalitis(JE), Kala existing strategies of vector borne diseases would be furtherazar and Dengue/Dengue Hemorrhagic Fever (DHF)(1). The continued and further strengthened with special emphasis onprogramme lays special focus on the vulnerable groups of the surveillance, human resource development, behavior changesociety namely, children, women, Scheduled Castes (SC) and communication, supervision and monitoring, quality assuranceScheduled Tribes (ST). Under the programme, it is ensured and quality control of diagnostics & drugs and operationalthat the disadvantaged and marginalized sections benefit from research (5).the delivery of services so that the desired National Health ImplementationPolicy and National Rural Health Mission (NRHM) goals are The programme runs under the Union Ministry of Health andachieved. Family Welfare. The execution of the programme at variousBefore 2003, various centrally sponsored schemes namely levels is given in Table 1.National Anti Malaria Programme, National Filarial Control There is also a strong link up between NVBDP and NRHM (6).Programme and Kala Azar Control Programme were fighting NRHM will focus on all diseases of NVBDCP ASHA is envisaged . with menace of malaria, filariasis and kala azar respectively on to play a key role in the grass-root level implementation ofa cost sharing basis between center and state(2). There was no NVBDP Actions to be taken under the NRHM are: .centrally sponsored programme for JE, dengue, chikungunia. ●● ASHA and Village Health Team to be oriented to communityThe states were managing these with their own resources based vector control strategies.  Convergence with Waterwithout any financial and technical assistance. From the year and Sanitation Mission will facilitate this process. 2003-2004, Government of India decided to fight the peril of all ●● ASHA to be able to give presumptive treatment forvector borne diseases on a common platform as NVBDCP . malariaMission Statement ●● Enhanced surveillance capacity (human resources andIntegrated accelerated action towards reducing mortality on infrastructure) at PHC and CHC levelsaccount of malaria, dengue, Japanese Encephalitis by half ●● Enhancing laboratory capacity at CHC and PHCand elimination of Kala-azar by year 2010 and elimination ofLymphatic Filariasis by 2015(3). Malaria Malaria is major public health trepidation in our country. At the Table - 1 : Organisational structure of NVBDCP Level Agency Action Framing technical guidelines & policies as to guide the states for implementation of Programme Directorate of National National Vector Borne Diseases Budgeting and planning the logistics pertaining to central sector Control Programme Monitoring of implementation through regular reports and returns Evaluation of Programme implementation Conduct the entomological studies in collaboration with zonal entomological setup of Regional Offices for the state Health and Family Drug resistance studies Welfare (ROH & FW) located at state HQ Cross checking of blood slides for quality control State Capacity building of the states Responsible for implementation of Programme strategies and monitoring in accordance Directorate of Health to Programme guidelines Services Development of infrastructure Coordination between the state and centre for effective implementation and monitoring District District Malaria Offices Key unit for planning and monitoring of Programme under a technical officer Village Primary Health Centres Passive surveillance for malaria • 513 •
  • 58. time of independence of the country, there were an estimated As per the data from National Health Profile 2007, there75 million malaria cases and 0.8 million deaths annually. High were 1.78 million cases of malaria and 1704 deaths in themalaria burden had adverse effects on agriculture, industrial year 2006. The largest numbers of cases in the country weredevelopment and national economy. Use of insecticides reported by Orissa, followed by Jharkhand, West Bengal,for malaria control became available in fifties and global Assam, Chhattisgarh, Rajasthan, Gujarat & Uttar Pradesh andexperience in malaria control indicated then that malaria the largest numbers of deaths were reported by Assam followedcould be controlled or even eradicated within a short period, if by Orissa, West Bengal, Arunachal Pradesh, Meghalaya,available measures were implemented effectively. Maharashtra, Mizoram, Gujarat and Karnataka.Magnitude of the problem Evolution of the ProgrammeTrend of Malaria Cases and Deaths Due to Malaria in India is The National Malaria Control Program (NMCP) was launched indepicted in Fig - 1a & 1b respectively. 1953 and was redesignated as Eradication Program (NMEP) in 1958. The NMEP made an excellent progress till 1965, bringing Fig. - 1a & 1b : Trend of Malaria Cases and Deaths Due to down the malaria incidence to almost nil. However, thereafter Malaria in India (Source : National Health Profile 2007) setbacks started due to various operational, administrative and technical reasons. Against this background, in 1977, the Modified Plan of Operations (MPO) was started. The evolution is presented in Table - 2. In 1995 the Malaria Action Plan (MAP) was launched. It envisaged decentralized planning (akin to RCH), covering a total of 199 million (20.6%) population living in high risk areas. The criteria for defining a high risk area are as follows: (A) Rural / Tribal areas 1. Death due to malaria (Pf) - last 3 years 2. Doubling SPR in last 3 years 3. No doubling but average SPR in 3 years > 4% 4. P. falciparum > 30 % ith SPR > 3 % in 3 years w 5. Chloroquine resistant Pf. 6. Aggregation of labor in project areas. 7. New settlement in endemic/receptive and vulnerable area. (B) Urban Areas 1. SPR>10% during any of last 3 years 2. Population > 50000 & 5% with ration malaria: fever cases > 1/3 Year In 1997 the Enhanced Malaria Control Project (EMCP) was Table - 2 : Evolution of National Malaria Control / Eradication Programme S. No Year Programme Remarks 1 National Malaria 1953 Strategy - Residual insecticide spray; 75 million cases Control Programme 2 Residual Spray+ Active search of cases & Radical Treatment National Malaria following reduction of cases to 2 million 1958 Eradication Programme Brought down annual malaria incidence to 0.1 million cases by 1965 Could not sustain for various technical, administrative and financial constraints 3 1965-66 Minimum no of cases 0.1million with no deaths. Resurgence of malaria with 6.47m cases in 1976 1970’s 4 Urban Malaria Passive treatment of malaria cases, antilarval measures, minor engineering 1971 Scheme (UMS) methods like closing ditches, biological control and awareness camps. 5 The programme was integrated with primary health Modified Plan of care delivery system in rural areas. Operation (MPO) (also Successfully brought down the annual incidence of malaria substantially, 1977 included P. falciparum viz., reduction to a level of 2 million cases per annum by 1984 containment programme) Strategies were selective insecticide spray API>2, Active Surveillance- Fortnightly visits- blood smear collection, antilarval operations in urban areas. • 514 •
  • 59. launched covering a total of 1045 PHCs in 100 districts of AP, 4. Community ParticipationJharkhand, Gujarat, MP Maharashtra, Orissa and Rajasthan , ●● Sensitizing and involving the community for detection ofthrough World Bank assistance. The components were Early Anopheles breeding places and their eliminationdetection and prompt treatment through a Link worker for ●● NGO schemes involving them in programme strategiesevery 2000 population and selective vector control using ●● Collaboration with CII/ASSOCHAM/FICCITemephos (Abate) for anti-larval and DDT / malathion for ●● Observance of anti malaria month in June and intensifyresidual applications. activitiesIn 1998, World Health Organization and other partners initiated 5. Environmental Management & Source Reductionthe “Roll Back Malaria” (RBM) plan. The key interventions were MethodsVector Control through Insecticide Treated Nets (ITN) and Indoor ●● Source reduction i.e. filling of the breeding placesResidual Spray (IRS); Intermittent Preventive Therapy during ●● Proper covering of stored waterpregnancy (IPT); and prompt and effective case management, ●● Channelization of breeding sourcein particular Artemisinin based combination therapy. 6. Monitoring and Evaluation of the programmeIn 2003, the NVBDCP was launched, integrating the various ●● Monthly Computerized Management Information Systemcomponents of control strategies for common vector borne (CMIS)diseases. In 2005, the programme was made a important ●● Field visits by state by State National Programme Officersstrategic part of NRHM. ●● Field visits by Malaria Research Centres and other ICMR InstitutesMalaria control strategies in NVBDCP ●● Feedback to states on field observations for corrective1. Early case Detection and Prompt Treatment (EDPT) actions.●● EDPT is the main strategy of malaria control - radical National Antimalaria Drug Policy treatment is necessary for all the cases of malaria to prevent transmission of malaria. National antimalaria drug policy essentially provides a●● Chloroquine is the main anti-malaria drug for uncomplicated framework for the safe and effective treatment of uncomplicated malaria. and severe malaria as well as prevention of malaria in vulnerable●● Drug Distribution Centres (DDCs) and Fever Treatment groups, such as pregnant women and young children. The Depots (FTDs) have been established in the rural areas policy is as follows : for providing easy access to anti-malarial drugs to the Presumptive Treatment (PT) - Low Risk Areas : PT comprises community. of a single dose of chloroquine phosphate 10 mg/kg. body●● Alternative drugs for chloroquine resistant malaria are weight to all fever / suspected malaria cases (Table - 3). recommended as per the drug policy of malaria. NVBDCP drug policy recommends the use of combination therapy i.e Table - 3 Artesunate plus Sulfadoxine Pyrimethamine as a second line of treatment for P. falciparum cases in chloroquine Çhloroquine Phosphate resistant areas. Age in Years No. of Tablets●● All fever cases should preferably be investigated for mg. Base (150 mg) malaria by microscopy or Rapid Diagnostic Kit (RDK). RDK is a immunochromatographic test. It detects Plasmodium <1 75 ½ falciparum histidine rich protein in blood. 1-4 150 12. Vector Control (i) Chemical Control 5-8 300 2●● Use of Indoor Residual Spray (IRS) with insecticides 9-14 450 3 recommended under the programme.●● Use of chemical larvicides like Abate in potable water 15 & above 600 4●● Aerosol space spray during day time●● Malathion fogging during outbreaks Presumptive Treatment (PT) - High Risk Areas : As per(ii) Biological Control revised policy of NVBDCP presumptive treatment of all suspected malaria cases, up to sub-centre level only, in “high risk areas”●● Use of larvivorous fish in ornamental tanks, fountains is as shown in Table - 4. etc.●● Use of biocides. Table - 43. Personal Prophylatic Measures that individuals/communities can take up Chloroquine Base Day 1 10 mg/kg (600 mg adult)●● Use of mosquito repellent creams, liquids, coils, mats etc.●● Screening of the houses with wire mesh Primaquine Day 1 0.75 mg/kg (45 mg adult)●● Use of bednets treated with insecticide●● Wearing clothes that cover maximum surface area of the Chloroquine base Day 2 10 mg/ kg (600 mg adult) body Chloroquine base Day 3 5 mg/kg (300 mg adult) • 515 •
  • 60. Radical Treatment - Low Risk Areas -ACT) in confirmed chloroquine resistant cases. This must beFor Plasmodium vivax (Table - 5) followed with Primaquine (45 mg). The age-wise dosage is as shown in Table - 7. Table - 5 Table - 7 Chloroquine Primaquine 2.5 Age in Artesunate (AS) Phosphate 150 mg mg base Daily Age I day II day III day year Sulfadoxine+ base Single dose dose for 5 days in (no. of (no. of (no. of pyrimethamine No. of No. of year tablets) tablets) tablets) mg base mg base (SP) tablets tablets AS ½ ½ ½ <1 75 1/2 Nil Nil <1 SP ¼ Nil Nil 1-4 150 1 2.5 1 AS 1 1 1 5-8 300 2 5.0 2 1-4 SP 1 Nil Nil 9 -14 450 3 10.0 4 AS 2 2 2 15 & 5-8 600 4 15.0 6 SP 1½ Nil Nil above AS 3 3 3 9-14For Plasmodium falciparum : In “Low Risk Areas” where SP 2 Nil Nilpresumptive treatment with 600 mg chloroquine alone (adult 15 & AS 4 4 4dose) has been given and later blood smear is found positivefor Pf, the complete radical treatment should be given with a above SP 3 Nil Nilsingle dose of tablet chloroquine 10 mg/kg bw combined with ●● Dose of Artesunate is 4 mg /kg body weight for 3 days.0.75 mg/kg bw of primaquine. Strength of the tablet is 50 mg.Radical Treatment - High Risk Areas ●● Dose of SP is 25 mg /kg body weight of sulfadoxine plusFor Plasmodium vivax : In high risk areas where presumptive 1.25 mg /kg body weight of pyrimethamine single dose.treatment with 1500 mg chloroquine base spread over three The strength of SP tablet is 500 mg sulfadoxine and 25 mgdays and 45 mg primaquine (adult dose) has been given, of pyrimethamine.chloroquine need not be administered again, but primaquine Note: Sulfalene / Sulphadoxine and Pyrimethamine combinationmust be given for 5 days (Table - 6). does not take care of P vivax cases. Where SP - ACT is not available, SP alone should be given. Table - 6 Chemoprophylaxis : In chloroquine sensitive areas chloroquine Tablets Primaquine 2.5 mg is to be given. In chloroquine resistant areas it is to be Age in year base Daily dose for 5 days supplemented by proguanil. mg base No. of tablets Regimen <1 Nil Nil ●● Chemoprophylaxis is to be started a week before arriving at malarious area for visitors. 1-4 2.5 1 ●● For pregnant women in high risk area prophylaxis should 5-8 5.0 2 be initiated from second trimester. 9-14 10.0 4 ●● Start with loading dose of 10 mg/kg bw and followed by a weekly dose of 5 mg/kg bw. This is to continue till 1 month 15 & above 15.0 6 after delivery in case of pregnancy and in travelers till one month after return from endemic area. The terminatingFor Plasmodium falciparum : In “High Risk Areas”, fever cases dose should be 10 mg/kg bw along with 0.25 mg/kg bw ofare given presumptive treatment with 1500 mg Chloroquine primaquine for five days.(over 3 days) and 45 mg Primaquine (adult single dose). ●● Chemoprophylaxis with chloroquine is not recommendedTherefore radical treatment with primaquine is not required if beyond 3 years because of its cumulative toxicity.they are found positive for Pf microscopically. ●● In chloroquine resistant areas chemoprophylaxis isChloroquine resistant P falciparum cases : The radical recommended with chloroquine 5 mg/kg bw weekly andtreatment of Pf cases in chloroquine resistant areas, which proguanil 100mg daily.are under alternate drug schedule, and in specific cases not Vector controlresponding to chloroquine, is by second line of treatment.Resistance should be suspected if in spite of full treatment and In our country, control of vectors is actually control ofno history of vomiting, diarrhoea, patient does not respond An. culicifacies as 60-70% of new cases of malaria are due to itwithin 72 hours parasitologically or deteriorate clinically. and rest 15-20%. by An. fluviatilis. Approx 70% of the allottedNational Anti Malaria Drug Policy has recently recommended budget is spent for control of malaria in those areas whereArtesunate + sulfadoxine/ sulfalene combination therapy (SP An. culicifacies is the vector species for malaria transmission. • 516 •
  • 61. Except for An. stephensi all other malaria vectors exist as Insecticide Resistance in Malaria vectors : Malaria vectorsspecies complexes comprising several sibling species that in India are resistant to DDT alone or double resistant to HCHresult in considerable impact on the transmission of malaria or triple resistant to DDT, HCH, malathion and quadrupleincluding susceptibility to commonly used insecticides in resistant to DDT, HCH, malathion and Deltamethrin (syntheticpublic health programme. pyrethroid). HCH has been phased out in 1997. In the yearsInsecticides : Wettable Powder (WP) formulations are used to come development of resistance to synthetic pyrethroidfor indoor residual sprays and Emulsifiable Concentrate (EC) warrants a caution of impending possibility of wide spreadformulations are used for larval control. For Indoor Residual resistance to other compounds of this group that are introducedSpray (IRS) insecticides in use are DDT 50% WP malathion 25% , in public health programme for indoor residual spray as well asWP and synthetic Pyrethroid (WP). Synthetic Pyrethroids include insecticide treated bed nets. Strategies for delaying / avoidingdeltamethrin 2.5% WP Cyfluthrin 10% WP lambdacyhalothrin , , the onset of resistance include:10% WP alphacypermethrin 5% WP Etofenprox 10% WP and , , ●● Avoid indiscriminate use of insecticidesBifenthrin 10% WP Synthetic pyrethroid insecticides are also . ●● Avoid use of insecticides that simultaneously selectused for impregnation of bed nets. resistance to other chemically related insecticides.Change of Insecticide : The change of insecticide is warranted ●● Avoid use of insecticides that induce development of moreafter production of data on vector resistance studies and field than one type of resistance mechanism of broad spectrumobservations on epidemiological impact of spray in respect of resistance.of insecticide in use by State Govt. The change of insecticide ●● Avoid use of the same insecticide for both against adultswill always be decided in mutual consultation between State and larvae.Programme Officer for NVBDCP ROH&FW and the Dte. of , ●● Use of non chemical control methods, e.g. biopesticides,NVBDCP with concurrences of State and Central Govts. larvivorous fish. ●● Use of synergist with insecticides to reduce physiologicalInsecticide formulations used under NVBDCP : The resistance.formulations/compounds used under the NVBDCP for control ofmalaria are DDT; Malathion 25% WP (used under the progamme Malaria Surveillance Under NVBDCPin areas with DDT resistance); and, Synthetic Pyrethoids. As The aim of surveillance is to detect changes in trends orregards synthetic pyrethroids, the cost of these insecticides is distribution in malaria and other vector borne diseases inmuch higher than the cost of DDT and Malathion. Currently order to initiate investigative or control measures. Malariathere are five insecticides of this group registered with surveillance presumes that every malaria case will presentCentral Insecticide Board for use in the programme. These itself with symptoms of fever at some point of time during theare (i) Deltamethrin2.5% WP (ii) Cyfluthrin 10% WP (iii) , , course of infection. Surveillance activities are summarized inAlphacypermethrin 5% WP (iv) Lambdacyhalothrin 10% WP and Table - 8.(v) Bifenthrin 10% WP. Table - 8 : Surveillance activities under NVBDCP S.No Component Remarks 1 Fortnightly Active case detection (ACD)is carried out by multipurpose health workers (male) under Primary Domiciliary visits Health Care System. He carries out search for a fever case or who had fever in between the visits of MPW, collects blood smear from such cases, administers appropriate anti-malarial(s). The rationale is that the “incubation interval” i.e., the full life cycle of malaria for the development of the parasite in the mosquito and that in the human being in case of P vivax is approximately 22 days while for P falciparum it is 35 days. Thus, surveillance cycle of less than one incubation interval will catch most of the secondary cases before the commencement of next cycle. Through this activity, the malaria surveillance can be measured. 2 Fever Treatment To avoid delay in detection of cases which occur in between visits of MPW, establishment of Depots (FTDs) Fever Treatment Depots in villages especially in areas which are remote/ inaccessible and have low population density collection of blood smears, administration of presumptive treatment, impregnation of bed nets, promotion of larvivorous fish etc, 3 Passive Case By Allopathic, Ayurvedic, Homeopathic, Siddha medicine dispensaries in the health sector, local Detection (PCD) residents or voluntary agencies operating locally, Anganwadi workers, private practitioners etc. 4 Rapid Fever In case of an epidemic outbreak, the suspected epidemic zone is covered in a short duration and all Survey fever cases are screened by taking blood smears 5 Mass survey Mass survey of the entire population may be carried out in the suspected epidemic zone. Here all the population irrespective of age, sex or fever status is screened by taking blood smear. Specially children must be included in survey. 6 Drug Distribution The functions of DDCs are the same as those of FTDs, except that the DDCs do not take blood slides Centre (DDC) but administer drugs to fever cases. • 517 •
  • 62. Rationale behind surveillance : Malaria surveillance utilized for assessment of the impact of control operations.presumes that every malaria case will present itself with The SPR of blood slides collected from cases currently havingsymptoms of fever at some point of time during the course fever will be higher than the SPR of the slides collected fromof infection. Therefore, if all fever cases occurring in the cases with history of fever. Therefore, higher positivity ratescommunity are kept under surveillance over a period of time are obtained in blood smears collected at the PCD. Trends inand their blood smears are examined for malaria parasite, SPR can be utilized for predicting epidemic situations in thethe total malaria parasite load can be examined. For accurate area. If monthly SPR exceeds by 2½ times of the standardestimates of malaria endemicity, the blood smear examination deviation observed in SPR of the preceding 3 years or precedingrate specially the Monthly Blood Examination Rate (MBER 3 months of the same year, an epidemic build up in the area canshould be equal to fever rate of the month in the community. be suspected. Monthly or yearly trends of SPR are utilized toTherefore it is necessary to ensure that all persons having fever study the impact of control operations.during malaria transmission months are included in the total SPR is measured as follows:blood slides examined during the year. The MBER norms of0.8 percent during non-transmission season and 1.2 to 1.8 SPR = No. of blood smears found +ve for MP x 100percent during transmission season (or approximately 1% per No. of blood smears examinedmonth) were laid down in the Malaria Eradication Programme.MBER should be monitored MPW-wise by the medical officer- Accelerated Urban Malaria Control Projectin-charge during monthly meeting at the PHC in order to assess To address the malaria problem in urban areas, an Urbanthe surveillance operation in the PHC area. In both the cases Malaria Scheme (UMS) was launched in 1971 with the objectivei.e. ABER and MBER the denominator is common because the to control malaria by reducing the vector population by way ofentire population is covered during each fortnightly domiciliary recurrent anti-larval measures and detection and treatment ofvisit by MPW (male). ABER is the cumulative sum of monthly cases through the existing health services of the State/Urbanrates during the year. ABER/ MBER is an index of operational Local Bodies. In this context, an “Accelerated Urban Malariaefficacy of the programme. The Annual Parasite Incidence (API) Control Project” is proposed in high endemic 28 towns/cities withdepends upon the ABER. A sufficient number of blood slides GFATM support. The proposed project will be implemented byshould be systematically obtained and examined for malaria the Urban Local Self Govt, viz., Municipalities in collaborationparasite to work out accurate API. with the local NGOs. The project goal is to reduce malariaAs a rough guide, MBER should be 1% and ABER should be morbidity and mortality in the project population (in 28 townsat least 10%. If it is less than this figure it indicates a poor in 12 states) by 50% by 2015.surveillance coverage and in this situation, API may not remain Project Objectives : Increasing the access to diagnosis anda good index of malaria incidence. In such situations, SPR, treatment in project areas, with particular focus on slums,rather than API should be considered. While collecting ABER construction sites/industrial estates/market areas with floatingor MBER, blood slides collected by all agencies are taken into population. Majority of the population at risk at focused sitesaccount, i.e blood smears collected through ACD, PCD, FTD or are poor and marginalized families, living below poverty line.any other voluntary agency during the same period. However, 1. Malaria Transmission Risk Reduction through Integratednumber of blood smears collected and examined during a Vector Management mode (IVM).mass survey and their results should not be included while 2. Enhancing awareness towards behavioural impact aboutcalculating ABER or MBER. malaria prevention and control and promoting community, NGO and private sector participation. No. of blood smears collected during the year Kala-azarABER = x 100 Population covered under surveillance Kala-azar, a disease transmitted by sand fly vector is a cause No. of blood smears collected during the month of high morbidity and mortality in the 4 states of Bihar,MBER = x 100 Jharkhand, Uttar Pradesh and West Bengal, with 165.4 million Population covered under surveillance population living in these endemic areas (7). A total of 48 No. of blood smears found +ve during the Year districts are endemic, with sporadic cases being reported fromAPI = x 1000 Population covered under surveillance few other districts. The burden of disease since 2004 is given in Table - 9.The Slide Positivity Rate (SPR) among the blood smearscollected through both active and passive surveillance gives Table - 9more accurate information on distribution of malaria infectionin the community over a period of time. Monthly SPR can be S.No Year Cases Deathscalculated to find out the seasonal rise and fall in malaria 1 2004 24340 156prevalence in the community. SPR among children 2-9 yearsof age can be utilized for comparison with pre-control Child 2 2005 31217 157Parasite Rates to assess the impact of control measures on 3 2006 39178 187local malaria endemicity and transmission. SPR in the agegroup of less than one year (Infant Parasite Rate) can be 4 2007(Provisional) 22751 101 • 518 •
  • 63. Kala-azar Elimination Initiative : The National Health Policy The subsequent land marks in filarial control are given in(2002) has set the goal for elimination of Kala-azar by year 2010. Table - 11.Elimination Programme is 100 per cent Centrally Supported Strategy for Elimination of Lymphatic Filariasis : The(except regular staff of State governments & infrastructure). strategy for achieving the goal of elimination is by annualIn addition to kala-azar medicines and insecticides, cash mass drug administration of DEC for 5 years or more to theassistance is being provided to endemic states since December population excluding children below two years, pregnant2003 to facilitate effective strategy implementation by states. women and seriously ill persons in affected areas to interruptStrategy transmission of disease(8). Under the programme, Mass Drug●● Interruption of transmission through vector control by Administration (MDA) campaign is organized and an annual undertaking residual indoor insecticide spraying in affected single dose of Diethylcarbamazine citrate (DEC) tablets is areas, with DDT up to 6 feet height from the ground twice administered to the eligible population in the affected areas annually. on a single day designated as National Filaria Day. The drug●● Early diagnosis and complete treatment (Table - 10). distribution is made by door-to-door campaign. In addition,●● IEC and community mobilization. booths are established at health facilities, both in public and private sectors. Co-administration of DEC and Albendazole free Table - 10 : Treatment guidelines for Kala-azar of cost to be implemented in all the endemic districts by 2008 Name of Dosages in a phased manner ( Albendazole kills intestinal helminthic the Drug infections also). The transmission of infection can be stopped by treating the Ist line 20 mg per kg. body entire eligible population living in filarial endemic areas with Injection SSG drug for weight daily for 20 days Mass Drug Administration (MDA) with DEC given once a year for treatment Maximum 8.5 ml per day 5-7 years i.e. during the life span of adult filarial worm which Injection II nd line 1 mg. per kg. body weight gives birth to millions of micorfilariae. With every treatment Amphotericin-B drug alternate days 15 injections there will be a heavy reduction in the circulating microfilariae. 50 mg. bd below 12 years This will markedly reduce or stop the transmission of the infection by the mosquitoes to other healthy persons. 100 mg. bd above 12 years Tablet DEC is available as 50 mg or 100mg tablets. The drug has been 2.5 mg/kg body weight bd Miltefosine is use in India for more than five decades. It is a safe drug (56 tablets) for 28 at the recommended does. The dose of DEC is 6 mg/kg body days (adult Dose) weight. The dose schedule which was being followed is shown in Table - 12.FilariasisFilariasis has been a major public health problem in India Table - 12 : Conventional Drug Schedulenext only to malaria. India accounts for about 40% of the 120 Age (in year) Dose of DECmillion estimated cases globally with either disease or infection <2 Nil(Microfilaria cases).Cases of filariasis have been recorded fromAndhra Pradesh, Assam, Bihar, Chattisgarh, Goa, Jharkhand, 2-3 50 mgKarnataka, Gujarat, Kerala, Madhya Pradesh, Maharashtra, 4-5 100 mgOrissa, Tamil Nadu, Uttar Pradesh, West Bengal, Pondicherry, 6 - 11 150 mgAndaman & Nicobar Islands, Daman & Diu, Dadra & NagarHaveli and Lakshadweep. It is a disabling & disfiguring disease 12 - 17 200 mgand causes immense personalized trauma of the affected > 18 300 mgpersons, even though it is not fatal. In 1955, the nationalfilarial control programme was launched. The main control However, a simplified dose schedule was administered inmeasures were mass DEC administration, antilarval measures Tamil Nadu for the mass drug administration urban areas and indoor residual spray in rural areas. This was monitored by the state government and the Vector Table - 11 S. No Year Activity Remarks 1. 1996-97 Annual Mass Drug Covered 41m population, extended to 77m population in 2002 and 400m in 2004 Admini-stration Strategy is to be continued for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease. 2. 2002 National Health Policy Elimination of Lymphatic Filariasis (ELF) by the year 2015 3. 2003 NVBDCP Convergence with other vector borne diseases • 519 •
  • 64. Control Research Centre (VCRC), ICMR and found to be safe and Fig. - 2 : Dengue cases & deaths in India : 1996 to 2006effective. The results were discussed by the National Task Force Cases Deathson Lymphatic Filariasis and the following simplified schedule 18000 600has been recommended for MDA in the country (Table - 13). 16000 500 14000 12000 400 Table - 13 D e aths C as e s 10000 300 8000 Age (in year) DEC Dose DEC (Tablet of 100 mg) 6000 200 4000 100 <2 Nil Nil 2000 0 0 2-5 100mg 1 tablet 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Y e ar 6-14 200mg 2 tablets Guidelines for Integrated Vector Management for 15 & above 300mg 3 tablets Control of Dengue / Dengue Haemorrhagic Fever under NVBDCP (10)Side effects of DEC : DEC at the above doses is safe. Person The key to control DF/DHF is adoption of a comprehensivewith high mf density may experience general side effects in approach by way of regular vector surveillance and integratedthe form of headache, body ache, nausea and vomiting which management of the Aedes mosquitoes through biological andresult from the death of the Microfilariae. The side effects chemical control that are safe, cost effective; and environmentalare temporary and subside in a day or two after symptomatic management,legislations as well as action at household andtreatment. Rarely, localized reactions in the form swelling and community levels.tenderness of lymph nodes may occur. Temporary side effectsthat may occur in 1 to 10% of the population who may be Vector Surveillancecarriers of microfilariae. Both larval and adult surveys to be carried out.Contraindications of DEC : DEC is safe. However, as a matterof precaution, it should not be given to children under two Larval surveys Adult Surveysyears and to pregnant women. Severely ill patients may also i) House Index (HI) i) Landing/biting collectionavoid taking the drug. ii) Container Index (CI) ii) Resting collectionThe disease has been targeted for global elimination by 2020.Transmission control and disability alleviation are two pillars of iii) Breteau Index (BI) iii) Oviposition trapsthe Global Elimination Strategy for Lymphatic Filariasis (GELF). iv) Pupae Index (PI)Interruption of transmission can be achieved by mass annualdrug administration of Diethylcarbamazine Citrate (DEC) toentire communities at risk of infection when community drug Environmental Management : The major environmentalconsumption rates are adequate. This is expected to result in management methods used for control of immature stages ofreduction of transmission of lymphatic Filariasis to low levels dengue vector are:and ultimately in the elimination of Filariasis, preventing new (i) Environmental modification: Long lasting physicalinfections from occurring and protecting future generations transformation of vector habitats. For example, improvedfrom the disease. water supply, mosquito proofing of overhead tanks, cisterns orDengue underground reservoirs.Dengue Fever (DF) is an acute viral infection with the potential (ii) Environmental manipulation: Temporary changes toof causing large outbreaks. Death can occur in dengue vector habitats that involve the management of essential andhaemorrhagic fever (DHF), which is a severe from of the disease. non-essential containers and management of or removal ofThe National Health Policy (2002) has set the goal of reduction natural breeding sites.of mortality on account of Dengue by 50% by year 2010. (iii) Changes in human habitations: Efforts are made toMagnitude of the Problem reduce man-virus contact by mosquito proofing of houses with screens on doors/windows.This is shown in the Fig. - 2. Personal Protection : Insecticide treated mosquito nets haveUntil June 2007 there were 256 cases and 2 deaths (9). limited utility in dengue control, since the vector species biteStrategy for Control during the day time. However, insecticide treated bed nets cana. Disease and vector surveillance be effectively used to protect infants and night workers whileb. Vector management through source reduction with sleeping in daytime. community participation Biological Controlc. Case management (i) Larvivorous fish are recommended for control of Ae.d. IEC initiatives aegypti in large water bodies or large water containers.e. Epidemic preparedness and early response. • 520 •
  • 65. (ii) Endotoxin-producing bacteria, Bacillus thuringiensis Strategy serotype H-14 (Bt H-14) has been found to be an effective Early case detection and treatment : Early diagnosis & proper mosquito control agent. management of JE cases is of prime importance to reduceChemical Control : Chemical control measures (larvicides, case fatality through strengthening of diagnostic and clinicaladulticides) are recommended in permanent big water management of JE cases, at PHCs/CHCs and District Hospitals.containers where water has to be conserved or stored because JE burden can be estimated satisfactorily if the facilities for JEof scarcity of water or irregular and unreliable water supply. confirmation are made available at least in referral hospitals.Larvicide : Since Ae. aegypti breeds in clean water, which Considering the merits and demerits of each diagnostic test andis stored and used forhousehold purposes, as such all the the patients representing different clinical phases of infection,larvicides, which are safe, without any odour or colour, have establishment of two diagnostic tests, one for detection of JEresidual effect with low mammalian toxicity and do not pose any Reverse Transcriptase - Polymer Chain Reaction (RTPCR) andhealth hazard should be used. Temephos, an organophosphate one for detection of virus antigen/virus genome is necessary.compound meets all the above mentioned requirements and this Vector Controlinsecticide is being used under the public health programme. Chemical control : Vector control is a serious challenge forThe recommended dose for application of Temephos (50 EC) is JE control because of exophilic and exophagic behaviour of JE1 ppm (1 mg per liter of water). vectors, which limits effectiveness of conventional insecticides.Adulticide : The following methods are recommended for the IRS is not recommended for prevention and control for JE.control of adult Ae. aegypti mosquitoes: However, in areas where vector is endophilic like Mansoniaa) Pyrethrum spray annulifera, IRS may be considered for vector control in highb) Malathion fogging or Ultra Low Volume (ULV) spray risk pockets. Fogging is a very cost intensive vector controlLegislative Measures tool but with limited effect and therefore, not recommended asModel civic byelaws : Under this act, fine/punishment is a routine vector control measure. In case of JE outbreaks, sinceimparted, if breeding is detected. These measures are being the vectors are mainly outdoor resting and outdoor feeding,strictly enforced by Mumbai, Navi Mumbai, Chandigarh and peri-domestic fogging could be resorted to very carefully forDelhi Municipal Corporations. containment of outbreaks. It has been suggested that most of the states may resort to fogging whenever there is any JEBuilding Construction Regulation Act : Building byelaws outbreak so that they can make their efforts visible in theshould be made for appropriate overhead / under ground tanks, community besides its impact on adult population of vectormosquito proof buildings, designs of sunshades, porticos, mosquitoes. Personnel protection methods and anti larvaletc for not allowing stagnation of water vis-à-vis breeding of operations should also be taken.mosquitoes. In Mumbai, prior to any construction activity, theowners/builders deposit a fee for controlling mosquitogenic Reduction of breeding sources for larvae : Two feasibleconditions at site by the Municipal Corporation methodologies have been demonstrated to control breeding of mosquitoes in rice fields. They are (i) water management systemEnvironmental Health Act : Suitable byelaws should be made with intermittent irrigation system and (ii) incorporation of neemfor the proper disposal/storage of junk, discarded tins, old tyres products in rice field. The water management is nothing but aand other debris, which can withhold rain water. strategy of alternate drying and wetting water managementBehavior Change Communication (BCC) campaign : The system in the rice fields. By using neem products as fertilisercommunity needs to be educated to prevent breeding of in rice fields, they not only enhance the grain production butmosquitoes. also suppress the breeding of culicine vector of JE.Chikungunya Larvivorous fish : Introduction of composite fish culture for mosquito control in rice fields has been evaluated and provedChikungunya is a relatively rare form of viral fever caused by to be successful. In other large and small water bodies releasean alpha virus that is spread by bite of Aedes aegypti mosquito. of larvivorous fish will prevent the JE vectors breeding.The name is derived from the Swahili word meaning ‘thatwhich bends up’ in reference to the stopped posture developed Biolarvicides : Biocides like Bacillus thuringiensis a result of the arthritic symptoms of the disease. israelensis and Bascillus sphaericus were promoted and anticipated to have great implications as biological larvicidesThe preventive and control strategies are same as for dengue against different mosquito species. Lack of suitable deliveryfever. Surveillance of fever cases with joint pains should be system and short duration of larvicide effect restricted its useemphasized. in vector control strategy.Japanese Encephalitis Reduction in man-vector contact : Pyrethroid-impregnatedDirectorate of National Vector Borne Disease Control Programme bed nets and curtains have shown to reduce man-mosquito(NVBDCP) is a nodal agency for control and prevention of contact. However people may not prefer to use bed nets due toJapanese Encephalitis (JE) in the country (12). Reduction of high temperature and humidity. In such areas, people do acceptmortality on account of Japanese Encephalitis by 50% by year impregnated curtains instead of bednets. The limitation with2010 has been envisaged under the National Health Policy this technology is the repeated impregnation of the curtains(2002). once in 6 to 9 months and periodic assessment of vectors for development of insecticide resistance to this product • 521 •
  • 66. Control of Pigs : Pigs constitute the amplifying host of JE existing facilities available both in public & private sectors.and mosquitoes when bite pigs get infected that later infect Urban Malaria : It is perceived as a major threat; no structuredhumans. In JE endemic areas, pigs are found associated with health care delivery system like the primary health care systemhuman habitations. Control methods can include immunizing, as in rural areas has been established. Funds are also allocatedslaughtering pigs, use of mosquito proof piggeries, etc. for larvicides / adulticides only and the operational costs ofSegregating pigs at least 4-5 km away from human habitations malaria control activities are met by the State/Urban Localcan be used wherever it is possible by implementing some by- Bodies. The coverage by anti larval measures however, limitedlaws by local administration. Several studies conducted in Japan and do not extend to the entire towns/city limits. The sourceshowed that pig immunization was effective in eliminating reduction drives in domestic areas are hampered by denial ofdisease in pigs, which may reduce animal transmission and entry to public health personnel on security reasons, limitedpossibly lower human incidence. But it has not been used at the community mobilization and multi-sectoral collaboration andnational level because pig immunization requires large number absence of appropriate civic legislations.of newborn pigs to be immunized each year and because the Monitoring & Evaluation : Enactment and enforcement ofperiod of vaccine effectiveness is limited. legislatures to prevent mosquito breeding in domestic andBehaviour Change Communication (BCC) or (Information peri-domestic areas or work places, government/commercialEducation Communication) : Health Education should buildings, construction sites, etc. are the responsibility ofbe imparted through all probable approaches on personal multiple authorities and often not implemented in a coordinatedprophylaxis against vector, segregation of amplifier hosts manner. No proper resource allocation is also made for most ofby mosquito proofing and for early reporting of cases. Each these components, even though these are extremely critical toendemic state should conduct a media advocacy and health achieve the desired health objectives of health and well-beingeducation workshop a month prior to the expected season in urban educate media about the upcoming JE season and enlisttheir support in dissemination of messages on self protection Use of insecticides for vector control : Using insecticidesmethods and early case reporting at nearest medical facilities, in improper dosage and schedule promotes vector resistance.etc., thereby avoiding any uninformed, adverse publicity. There is shortage of insecticides due to which incorrect chemical is used as an alternative or the same is diluted to meet theImmunization against JE : There are three types of JE vaccine widespread production and in worldwide use for control ofJE. These are (i) inactivated mouse brain derived vaccine; (ii) Community participation : It is inadequate.inactivated primary hamster kidney cell-derived vaccine, and Non Uniformity in treatment : No uniformity in medical(iii) live attenuated vaccine. Under immunization protocol, practitioners regarding treatment of vector borne diseases.immunization of pigs is to be considered which may reduceviral transmission by limiting or preventing viraemia in pigs. SummaryJE vaccines for pigs and equines have been used in various NVBDCP is an umbrella programme for prevention and controlareas of China. of major vector borne diseases of public health importance namely Malaria, Filaria, Japanese encephalitis (JE), Kala azarJE vaccine used in India is a formalin-inactivated product and Dengue / Dengue Hemorrhagic Fever (DHF). It came intoprepared from mouse brains infected with Nakayama JE existence in 2003.virus manufactured at Central Research Institute, Kasauli,and Himachal Pradesh. The virus is purified with protamine The Mission is to have Integrated accelerated action towardssulphate treatment and ultra centrifugation. The final vaccine reducing mortality on account of malaria, dengue, Japaneseis supplied in a freeze dried form and reconstituted in 5.4 ml of Encephalitis by half and elimination of Kala-azar by year 2010sterile pyrogen free distilled water supplied by the laboratory. and elimination of Lymphatic Filariasis by 2015. The strategyPilot projects for JE vaccination have already started in few lays emphasis on Training of health personnel in the diagnosisstates in the country. of vector-borne diseases and appropriate treatment including referral, Improved reporting, recording and monitoring of vector-Critical Appraisal of NVBDCP borne diseases, Monitoring drug and insecticide resistance, UseTechnical manpower : There is shortage of MPWs in all the of standardised protocol for the diagnosis and management ofstates. In some states the shortage may be as high as 60% or these diseases, Involvement of PRIs and research studies inmore of the sanctioned strength. For the timely and regular vector borne diseases. The implementation at the national levelsurveillance these field level functionaries are crucial. is by Directorate of National Vector Borne Diseases ControlExamination of blood smears : The blood smears collected by Programme, at the state level by Regional Offices for HealthACD & PCD are to be examined expeditiously. Under the current and Family Welfare (ROH & FW) located at state HQ, districtsituation, in most of the places, there is considerable time lag level by District Malaria Offices and Primary Health Centres atbetween collection and examination of blood smears due to the village level.National Rural Health Mission will focus on allinadequate facilities. The laboratory for malaria microscopy the diseases covered under NVBDCP .should be decentralized and brought as near to the community The strategies for malaria control under the programme has beenas possible. All efforts should be made to reduce the time lag Early case Detection and Prompt Treatment (EDPT), Vector controlbetween blood smear collection and examination by utilizing (Chemical, Biological Control methods), Personal Prophylatic • 522 •
  • 67. Measures, Community Participation and Environmental of disease. The National Health Policy (2002) has set the goalManagement & Source Reduction Methods. National antimalaria of reduction of mortality on account of Dengue by 50% bydrug policy essentially provides a framework for the safe and year 2010. Strategy for dengue control comprise of Diseaseeffective treatment of uncomplicated and severe malaria as and Vector Surveillance, Vector management through sourcewell as prevention of malaria in vulnerable groups, such as reduction with community participation, Case management,pregnant women and young children. All fever cases should IEC initiatives and epidemic preparedness and early response.preferably be investigated for malaria by microscopy or Rapid Reduction of mortality on account of Japanese EncephalitisDiagnostic Kit (RDK). RDK is a immunochromatographic test. It by 50% by year 2010 has been envisaged under the Nationaldetects Plasmodium falciparum histidine rich protein in blood. Health Policy (2002). The strategy includes Early case detectionThe first line of treatment is Chloroquine and the second line for and treatment, Vector Control (Reduction of breeding sourcesP falciparum is Artesunate combination therapy (ACT) consisting for larvae, use of Larvivorous fish, Biolarvicides), Reduction inof Artesunate+ Sulphadoxine/Sulphalene+Pyrimethamine. man-vector contact and control of Pigs. JE vaccine used in IndiaIn case of resistance to these formulations quinine would be is a formalin-inactivated product prepared from mouse brainsthe drug of choice. ACT is not to be used against treatment of infected with Nakayama JE virus manufactured at CentralP vivax cases as it is not effective against it. Chemoprophylaxis Research Institute, Kasauli, and Himachal Pradesh.for malaria: In chloroquine sensitive areas chloroquine is to begiven and in Chloroquine resistant areas it is to be supplemented Referencesby proguanil. 1. National vector Borne Disease control Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of IndiaInsecticides under NVBDCP for malaria control are DDT, available at compounds (Malathion), Synthetic 2. Park K: National Health Programmes. In Park’s text book of Preventive and Social Medicine. 19th ed. Banarsidas Bhanot, 2007Pyrethoids(i) Deltamethrin2.5% WP (ii) Cyfluthrin 10% WP (iii) , , 3. Jugal Kishore. National Health Programmes of India.7th ed. CenturyAlphacypermethrin 5% WP (iv) Lambdacyhalothrin 10% WP and Publications. New Delhi. 2007(v) Bifenthrin 10 WP) Wettable powder (WP) formulations are 4. Tenth Five Year Plan 2002-2007, chapter 2.8.Govt. of Indiaused for indoor residual sprays and emulsion concentrate (EC) 5. Report of working Group on communicable and Non Communicable Diseases For the Eleventh Five Year Plan September 2006formulations are used for larval control. Malaria vectors in India 6. Health bulletin for ASHA on prevention and control of vector borne diseasesare resistant to DDT alone or double resistant to HCH or triple bulletin 1. January 2007resistant to DDT, HCH, malathion and quadruple resistant to 7. CD Alert January 2006 Vol 10: No. 1DDT, HCH, malathion and Deltamethrin (synthetic pyrethroid), 8. Elimination Of Lymphatic Filariasis Training Manual On Mass Drug Administration & Morbidity Management. National vector Borne Diseasehowever HCH has been phased out in 1997. control Programme, Directorate General of Health Services, Ministry ofMalaria surveillance under NVBDCP is done through Fortnightly Health and Family Welfare, Government of India 2004. 9. Directorate of National Vector Borne Disease Control Programme StatusDomiciliary visits by MPW (male), Fever Treatment Depots Report On Dengue And Chikungunya As On 12.06.2007(FTDs), Passive Case Detection (PCD), Rapid Fever Survey, Mass 10. Guidelines For Integrated Vector Management For Control Of Dengue /survey and Drug Distribution Centre (DDC). The National Health Dengue Haemorrhagic Fever Govt Of India National Vector Borne DiseasePolicy (2002) has set the goal for elimination of Kala-azar by Control Programme, Directorate General Of Health Services, Ministry Of Health & Family Welfareyear 2010. Strategy under NVBDCP includes Interruption of 11. CD Alert January 2006 Vol 10: No. 2transmission through vector control by undertaking residual 12. Guidelines For Prevention And Control Of Japanese Encephalitis Zoonosisindoor insecticide spraying in affected areas, with DDT up to 6 Division National Institute Of Communicable Diseases (Directorate General Of Health Services) 22-SHAM NATH MARG, DELHI - 110 054feet height from the ground twice annually, Early diagnosis &complete treatment and IEC & community mobilization. Further Suggested ReadingThe National Health Policy (2002) has set the goal for elimination 1. The clinical management of acute malaria 1990. WHO regional publications, South-East Asia Series No.9of Lymphatic Filariasis (ELF) by the year 2015. The strategy 2. Epidemiology and control of malaria in India 1996. R.S. Sharma, G.K.for achieving the goal of elimination is by Annual Mass Drug Sharma and G.P Dhillon .S.Administration of DEC for 5 years or more to the population 3. The use of Antimalarial drugs 2000. Report of a informal consultation.excluding children below two years, pregnant women and WHO/CDS/RBM/2001.33 4. Malaria vector control and personal protection who technical report seriesseriously ill persons in affected areas to interrupt transmission - 936 • 523 •
  • 68. large about leprosy. National Leprosy Eradication 92 Programme 5. Correction of deformities through deformity care programme. Treatment with MDT was introduced under NLEP in phased Puja Dudeja & Ashok K. Jindal manner in the year 1983 and programme was renamed as National Leprosy Eradication Programme. At the 44th“Leprosy work is not merely medical relief, it is transforming World Health Assembly held in 1991, WHO and its Memberfrustration in life into the joy of dedication, personal ambition States committed themselves to eliminate leprosy as a publicinto selfless service.” Mahatma Gandhi health problem by the year 2000, elimination being defined as prevalence below one case per 10,000 population. The Government of India was also a signatory to this commitment. To enhance the process of elimination, the first World Bank The NLEP Emblem symbolizes beauty supported project on NLEP was started in the year 1993-94 and and purity in lotus. The Emblem MDT made available to all the registered cases. The Second captures the spirit of hope positive World Bank supported National Leprosy Elimination Project action in the eradication of Leprosy. was started for a period of 3 years and was implemented with the following objectives. Objectives of NLEP II (2001 onwards)Evolution of Leprosy control in India 1. To decentralize the NLEP responsibilities to the states/The details are given in Table - 1 UT: State level societies will be formed in 24 states and fundingThe National Leprosy Control Programme (NLCP) was launched to the districts will be done by state societies. State societiesin 1954 (3). The strategy of NLEP was based on controlling the will not be needed in the 8 smaller states/ Union Territoriesdisease through reduction in the quantum of infection in the since the district societies there are adequate for channelingpopulation, and reduction in infective source, thus breaking funds.the chain of disease transmission. The program, therefore, had 2. Integration of Leprosy Control Activities with the generalbeen planned on the following basic activities : health services : To accomplish integration of leprosy services1. Survey and case detection. with general health care system in 27 low endemic states and2. Registration of cases for treatment. proceed with integration as rapidly as possible in the 27 low3. Provision of continuous treatment with Dapsone to all endemic states. In the 27 low endemic states/ UTs integration cases, as close to their homes as possible. will be affected in all districts during the first project year4. Education of patients, their families and community at Table 1: Evolution of leprosy control in India Year Remarks Initially Leprosy patients were isolated and segregated. Several statutory acts and laws were also enacted Pre during this time against them. In India ‘The Lepers Act 1898’ was enacted, which discriminated against the independence Leprosy patients and segregated them socially. This act has since been repealed by Union Government & all the States & UTs. Government of India launched National Leprosy Control Programme with the objective of controlling leprosy 1955 with Dapsone. 1983 Launched National Leprosy Eradication Programme(NLEP) and introduced MDT for treatment 1991 WHO declaration to eliminate leprosy at global level by 2000 1993 - 2000 World Bank supported NLEP - I After integration of leprosy services with GHC system in 2002-03, leprosy diagnosis and treatment services are 1998 to 2003 available free of cost at all the Primary Health Centres (PHCs) in all the districts in India. National Health Policy had set the goal of elimination of leprosy (i.e., to reduce the number of cases to < 2002 1/10,000 population) by the year 2005 2001 - 2004 World Bank supported NLEP - II 2005 National programme continues with GOI funds India achieved elimination of leprosy at National Level in December’ 05, when the recorded Prevalence Rate (PR) in the country was 0.95/10,000 (<1/10,000) population.(1,2). By March 2007, the prevalence rate of leprosy in the country had declined to 0.72 per 10,000 population and 28 states/UTs have achieved the goal of 2005 leprosy elimination. The remaining 7 States/UTs viz. Bihar, Chhattisgarh, Jharkhand, West Bengal, Chandigarh, D&N Haveli and Delhi are having PR of >1 per 10,000 population and are progressing towards elimination. Out of 611 districts, 487 (79.71%) districts have achieved the elimination status • 524 •
  • 69. itself. In the 8 high endemic states a mixed approach has been same guidelines of GOI but will conform to Indian Public Healthfollowed from the first year onward with the general health Standards as laid own under the mission. The minimum servicesservice staff offering leprosy services that included case finding available at the community health center should be diagnosisand treatment. The vertical staff is focusing on covering of leprosy, treatment of cases, management of reactions andpreviously un-reached areas as well as providing support to advice to patients on disability prevention & care.general health service. MDT : The details are given in Table - 2, 3 and 43. To achieve elimination at national levelStrategies Table - 2 : MDT Regimen1. Special Action Project for Elimination of Leprosy (SAPEL) Type of leprosy/ Type offor rural and Leprosy Elimination campaigns for urban Duration of Characteristics regimenareas: It is an initiative aimed at providing MDT services in treatmentdifficult to reach areas. PB (Pauci - bacillary) PB (Adult) / 1-5 patches &/2. Modified Leprosy Elimination Campaign (MLEC): It is Six pulses in 6-9 PB (child) or involvementorganizing camps which include a package of teaching, training, consecutive months Less severe of one nerveintensified IEC, case detection and prompt MDT. Wide publicity typeis given prior to camp. Five such nation wide campaigns have MB (Multi bacillary) MB (Adult)/ More severe typebeen carried out. Twelve pulses in MB (child) 6 or more skinActivities 12-18 consecutive patches & or1. Early detection through active surveillance by the trained months involvement of two health workers or more nerves2. Regular treatment of cases by providing Multi-Drug Therapy (MDT) at fixed in or centers a nearby village of Surveillance after treatment moderate to low endemic areas/district ●● PB cases are clinically examined once a year for minimum3. Intensified health education and public awareness two years after completion of treatment. campaigns to remove social stigma attached to the ●● MB cases are clinically examined once a year for a minimum disease. period of five years after completion of treatment.4. Prevention of Disability & Medical Rehabilitation5. Leprosy Training of General Health Services functionaries Table - 3 : Dosage in Adults6. Information Education and Communication (IEC) Rifampicin 600mg monthly using Local & Mass Media for reduction of Stigma & given under supervision Discrimination.7. Monitoring & Evaluation Dapsone 100mg daily self administered8. Inter-sectoral collaboration Multibacillary Clofazimine 300mg once monthlyInfrastructure (Adult) supervised; 50mg daily, self administeredNLEP was implemented through the establishment of Leprosy (When clofazimine is totally unacceptablecontrol units (LCU), Survey Education and Treatment centers owing to discoloration of skin, 250-(SET) and urban leprosy centers. The leprosy control units were 375mg of ethionamide or propionamideestablished in endemic areas with one medical officer, two non can be administered as daily dose).medical supervisors and twenty para medical workers. Each Pauci bacillary Rifampicin 600 mg monthlyLCU covered a population of 4.5 lacs. The staff at SET center (Adult) given under supervisioncomprised of one paramedical worker for 20-25 thousand Dapsone 100mg daily self administeredpopulation and one non medical supervisor for 5 paramedicalworkers. The SET centers were attached to the PHCs and were Table 4 : Dosage for children 10-14 yearsunder the medical officer in charge of PHC. Mobile leprosytreatment units provide services to leprosy patients in non Rifampicin 450mg monthly given underendemic areas. Each mobile unit consisted of one medical supervision; Dapsone 50mg daily self Multibacillaryofficer, one non medical supervisor, two paramedical workers administered; Clofazimine 150mg (Child)and a driver. There were two MLTU for moderately endemic and once monthly supervise and 50mg onone for low endemic states. alternate day, self administeredAt state level state leprosy officer was the chief coordinator Pauci bacillary Rifampicin 450mg monthly givenand technical advisor to the concerned state govt. At the (Child) under supervision; Dapsonecenter, leprosy division of directorate general health services 50mg daily self administeredwas responsible for planning, supervision and monitoringof the program. The division is under the control of Deputy Information, Education and Communication (IEC)Director General who advised govt on all anti leprosy activities. Objectives of IEC in moderately/low endemic states : ThisPresently NLEP has been integrated into the general health would be to encourage greater voluntary self-reporting, as theservices system under NRHM. The program will run under the strategy for case detection in these states. • 525 •
  • 70. Objectives of IEC in high endemic states : In five high and providing re-constructive surgery services and supportendemic states, where active search is conducted during to various NGOs in the country carrying out leprosy relatedMLEC, the objective of IEC is to create general awareness of activities.MLEC and signs and symptoms of leprosy to provide support Leprosy Institutions : Four premier Leprosy Institutes arefor and prepare the ground for MLEC. The targets are clients, working under Directorate General of Health Services, Ministryinfluencers, and providers, particularly from general health of Health & F.W., Government of India viz. CLTRI, Chengalpattu,services and private providers. Special client focus groups of RLTRI, at Aska, Raipur and Gouripur are involved in researchIEC in the next phase are women, children, difficult to reach (basic and applied ) in Leprosy and Training of differentgroups-urban remote areas, etc. categories of staff involved for Leprosy elimination. TheseTraining Institutes also play important role in management of referralAll staff of the general health services in general health services patients, providing quality care to chronic ulcer and disabledin government hospitals, PHCs, CHCs, are expected to be trained patients with the help of Minor & Major Reconstructiveto detect, treat, refer and to prevent and rehabilitate disability. Surgeries.Monitoring and Evaluation of NLEP Urban Leprosy Control ProgrammeNLEP has an inbuilt information system for monitoring and To address the complex problem like larger population size,supervision of the programme activities at Central, State, migration, poor health infrastructure and increasing prevalenceDistrict & Peripheral level. in urban areas, there was a need for Urban Leprosy Programme. Urban Leprosy Control Programme has been implemented sinceSimplified Information System (SIS) : SIS was introduced in 2005 under which assistance is being provided by Govt. of India2002 under which simplification of information system was to urban areas having population size of more than 1 lakh. Fordone, so that the newly involved GHC service personnel can the purpose of providing graded assistance, the urban areaseasily adapt to the system of record keeping, validation of are grouped in four categories i.e. Township-I, Medium Cities-I,records, reporting and monitoring of the programme at PHC/ Medium Cities-II, Mega Cities.Hospital, District and State level. This system has drasticallyimproved recording, reporting and its transmission. The Post Elimination Period - NLEPprogramme is monitored routinely at District, State and Central In the Post elimination period, NLEP needs to expand the scopelevel through scrutiny of regular monthly reports. The system of leprosy services provided to the patients, their families andhas been computerized for compilation of district reports at community at large. The aims and objective under the 11thstate level. Plan (2007-2012) are as below. These objectives are also inLeprosy Elimination Monitoring (LEM) : LEM exercise was conformity with the global strategy issued by WHO (2006-undertaken with WHO support through the NIH&FW, New Delhi, 2010).to assess the programme achievement in identified indicators 1. Further reducing the leprosy burden in the country.during the year 2002, 2003 and 2004(5). Immediate actions 2. Provide good quality leprosy services.were initiated on the deficiencies observed. 3. Enhance Disability Prevention and Medical Rehabilitation. 4. Increase advocacy towards reduction of stigma andInvolvement of NGOs stop discrimination and Strengthen monitoring andNGOs are involved in leprosy elimination activities for many supervision.years and their contribution has been a positive impact in New Paradigm : In view of the need to sustain leprosy servicesreducing the prevalence of leprosy. There are 285 NGOs for many years to come, there has to be a shift from a campaignworking in the field of leprosy throughout the country and 54 like elimination approach, towards the long term process ofNGOs are getting grant-in-aid from government of India for sustaining integrated high quality leprosy services, whichSurvey, Education and Treatment (SET) scheme. Beside routine in addition to case detection and treatment with Multi Drugactivities, some are also providing facilities for hospitalization Therapy, also include prevention of disability and rehabilitation.and disability and ulcer care. Few NGOs are involved in To get the programme move in the desired direction, the Newconducting reconstruction surgeries. The NGOs serve in remote, Paradigms in NLEP have been detailed as below:inaccessible, uncovered, urban slums, industrial / labourpopulation and other marginalized population groups. The Burden of leprosy : The burden of leprosy can be looked at invarious activities undertaken by the NGOs are, IEC, Prevention three ways:of Impairments and Deformities, Case Detection and MDT ●● Firstly, the most relevant epidemiological measure of theDelivery. burden of leprosy is the incidence of disease, which is the number of people developing leprosy during a definedILEP Agencies : International Federation of Anti-leprosy period usually one year. Because leprosy is an insidiousAssociation (ILEP) is actively involved as partner in NLEP . disease, number of cases detected/ registered for treatmentIn India ILEP is constituted by 10 Agencies viz. The Leprosy is generally lower than the actual number of incident casesMission, Damien Foundation of India Trust, Netherland Leprosy for that time. Hence, incidence is difficult to measureRelief, German Leprosy Relief Association, Lepra India, ALES, directly and New Case Detection Rate (NCDR) is used as aAIFO, Fontilles - India, AERF - India and American Leprosy proxy for incidence rate.Mission. Activities carried out by ILEP are - capacity building ●● Secondly, the burden may be related to the registeredof GHC staff, provision of technical support at various level prevalence of disease, which is the number of people on • 526 •
  • 71. treatment at a certain point of time. Although registered Critical Appraisal prevalence was a useful indicator to achieve the leprosy Leprosy in present day scenario is still associated with social elimination milestone, it is not adequate indicator to reflect stigma. There are various myths related to the disease which changes in the epidemiological trend of leprosy. interfere with health seeking behavior particularly early●● Thirdly, the burden of leprosy can be viewed as disability detection and treatment. Resistance to anti leprosy drugs i.e and deformity produced by leprosy. Dapsone, Rifampicin and Clofazimine has already been reportedImproving the quality of services : The quality of care depends in few studies. No alternative regime is presently available foron the quality of technical supervision provided by the program such cases. Achieving elimination will give a false sense ofand availability of strong back up from an effective referral security against transmission of infection. Leprosy is a socialsystem. Quality leprosy services means treatment by MDT is disease however no efforts have been made for elimination ofavailable at all the health units without any geographical, social factors related to the disease. There are many problemseconomic or gender barriers. Services provided are patient- related to integration of program with general health services.centred; observe patient’s rights, including the rights to Leprosy has always received low priority when compared totimely and appropriate treatment, privacy and confidentiality. HIV/AIDS. Very little has been done in the area of rehabilitationThe quality leprosy services addressing each aspect of case of leprosy, based on firm scientific evidence like diagnosisis carried out timely and accurate with supportive counselling, Summarytimely treatment with MDT, free of charge in a user friendly The National Leprosy control programme (NLCP) was launchedenvironment; appropriate disability prevention interventions; in 1954. Treatment with MDT was introduced under NLEP inreferral for complications and appropriate rehabilitation phased manner in the year 1983 and programme was renamedand maintaining simple records and encourage review and as National Leprosy Eradication Programme. The objectives ofevaluation. NLEP II (2001 onwards) have been To decentralize the NLEPPrevention and management of impairments and disabilities: responsibilities to the states/UT, Integration of Leprosy ControlThe current situation with regard to the number of persons Activities with the general health services and To achieveliving with leprosy - related disabilities and impairments may elimination at national level. India achieved eliminationneed reassessment, particularly at national level. In addition, of leprosy at National Level in December’ 05, when theprogramme should ensure that persons affected by leprosy recorded Prevalence Rate (PR) in the country was 0.95/10,000have access to services by other programmes dealing with population.other disabling diseases or conditions. Interventions aimed The main activities are - Early detection through activeat preventing disabilities / impairments from occurring and/or surveillance by the trained health workers, Regular treatmentworsening include early detection and effective management of of cases by providing Multi-Drug Therapy (MDT) at fixed inleprosy-related reactions and nerve damage, proper counselling or centers a nearby village of moderate to low endemic areas/on self care, participation of household members in home based district, Intensified health education and public awarenesscare, development and use of locally produced and culturally campaigns to remove social stigma attached to the disease andand aesthetically acceptable footwear and other appliances. Prevention of Disability & Medical RehabilitationImproving community awareness and involvement : The The other strategies followed were Special Action Projectmajor theme of community awareness is to provide accurate for Elimination of Leprosy (SAPEL) for rural and Leprosyinformation about the disease, its curability and availability Elimination campaigns for urban areas: It is an initiative aimedof services at the nearest health facility. The objective of such at providing MDT services in difficult to reach areas. ModifiedIEC efforts should be to encourage self - reporting of new cases Leprosy Elimination Campaign (MLEC): It is organizing campsand to reduce stigma and discrimination. There are four key which include a package of teaching, training, intensified IEC,messages for the general public include early signs of leprosy, case detection and prompt MDT Modified Leprosy Eliminationits Curability, encourage people to support leprosy affected Campaign (MLEC): It is organizing camps which include apeople to live a normal a life and no need to fear as disease can package of teaching, training, intensified IEC, case detectionbe managed just like any of other diseases; can be expressed in and prompt MDT.many different ways. NLEP was implemented through the establishment ofSupport of National Rural Health Mission : ASHA could Leprosy control units (LCU), Survey education an Treatmentbe utilized for early detection of suspected cases of leprosy, centers(SET) and urban leprosy centers. Presently NLEP hasreferral of such cases to nearest health centre for confirmation been integrated into the general health services system under& completion of treatment. Rogi Kalyan Samities at PHC, NRHM. The program will run under the same guidelines ofCHC and district hospitals are autonomous registered bodies GOI but will conform to Indian Public Health Standards as laidconstituted at each level to facilitate in management of own under the mission. The minimum services available athospitals and delivery of quality care to patients. The NLEP will the community health center should be diagnosis of leprosy,be benefited by working in coordination with other programs treatment of cases, management of reactions and advice tounder the NRHM. District Health Mission which is chaired by patients on disability prevention and care.the president of Zila Parishad may be helpful for advocacy of For Treatment leprosy cases are divided into Paucibacillarythe program. (Less severe type 1-5 patches &/or involvement of one nerve ) and Multibacillary (More severe type 6 or more skin patches & • 527 •
  • 72. or involvement of two or more nerves). PB cases are clinically of leprosy services provided to the patients, their families andexamined once a year for minimum two years after completion community at large. The aims and objective under the 11thof treatment. MB cases are clinically examined once a year for a Plan (2007-2012) are to further reduce the leprosy burden inminimum period of five years after completion of treatment. the country, Provide good quality leprosy services, EnhanceMonitoring and Evaluation of NLEP is through Simplified Disability Prevention and Medical Rehabilitation, IncreaseInformation System (SIS) was introduced in 2002 under which advocacy towards reduction of stigma and stop discriminationsimplification of information system was done, so that the and Strengthen monitoring and supervision.newly involved GHC service personnel can easily adapt to the Referencessystem of record keeping, validation of records, reporting and 1. Indian Journal of Leprosy, vol 78, No1, Jan- March2006monitoring of the programme at PHC/ Hospital, District and 2. WHO (2006), the works of WHO in SEAR, Report of Regional Director, 1 JulyState level. was introduced in 2002 under which simplification 2005-30 June 2006.of information system was done, so that the newly involved 3. National Leprosy Eradication Programme. Directorate general of health Services. Ministry of Health and Family Welfare. Available at htpp://mohfw.GHC service personnel can easily adapt to the system of record _Leprosy_Eradication_Programmekeeping, validation of records, reporting and monitoring of the 4. Annual Health Report 2006-2007. Ministry of Health and Family Welfare.programme at PHC/ Hospital, District and State level. Govt. of India. 5. WHO (1982). Tech. Rep. Ser., No 675.In the Post elimination period, NLEP needs to expand the scope control of rabies as the Nodal Agency. The committee will be Pilot Project On Prevention and chaired by DGHS with Animal husbandry Commissioner, Joint 93 Control Of Human Rabies Under Commissioner, Live Stock and Health; Joint Commissioner, 11th Five Year Plan Ministry of Information and Broadcasting, Govt of India; Director NICD; Director IVRI Izzatnagar; Director PII, Coonor as members and HOD, Zoonosis Division NICD as member secretary. Puja Dudeja & Ashok K. Jindal Initially the programme is proposed to be implemented on pilot basis in two major cities i.e. Delhi and Pune.Rabies is an acute viral encephalomyelitis which is invariably Components of the programme : There will be 2 components,fatal but can be easily prevented. Dog is the principal reservoir as follows :of Rabies in India. The goal of rabies control is to preventhuman death and control dog rabies so that it no longer Human Componentremains a major public health problem. This will reduce the 1. Local Health Authorities will make available infrastructuresocioeconomic losses from the disease. In India, cases of rabies and logistics in the pilot project area, areas for postoccur throughout the year and in all parts of the country with the exposure treatment.exception of Andaman and Nicobar Islands. It is estimated that 2. Facilities of wound wash will be provided at anti rabiesabout 20,000 people die of rabies every year. This figure may clinic by the local health authorities.not be exact as there is on organized system of surveillance of 3. Surveillance system will be strengthened to generate reliablerabies cases and hence lack of reliable data. There is at present data. Attempts will be make to integrate surveillance underno comprehensive National Rabies control Programme in India. IDSP work.Various organizations are currently involved in control activities 4. Development of trained manpower.without any intersectoral coordination. Existing rabies control 5. Ensuring community participation in IEC activities.activities are being carried out by Municipal Corporations/ 6. Involvement of NGOs and private sector.Committees, Cantonments etc. in their respective areas. 7. Strengthening the Nodal agency for human rabies control (NICD, Delhi) for monitoring and evaluation of humanObjectives : The broad objectives of the proposed pilot rabies component.control programme are firstly, prevention of Human deaths due 8. Operational Research with focus on study of factors leadingto rabies and secondly, reducing the transmission of disease to rabies deaths and minimizing animal animals. Animal ComponentTarget : The specific target is reduction of rabies deaths in 1. Vaccination of stray dogshuman beings by at least 50% by the end of Five year plan 2. Sterlization of dogs and population managementin the pilot project areas. For verification, the retrospective 3. Waste managementdata will be collected from pilot project areas and continuous 4. Dog movement restriction etc.surveillance will be maintained till the end of XI five yearplan. Further Suggested ReadingImplementation : The programme will be implemented as a 1. Working gps/Steering Committees/Task Force for the 11th five year plan2007- 2012.Plg Com.GOI.Available at htpp:/ planning project, with National Apex Committee for prevention and htm. • 528 •
  • 73. The important strategies adopted to eradicate the Guinea Guinea Worm Eradication 94 Programme Worm (GW) were (2) : 1. GW case detection and continuous surveillance through active case search operations and regular monthly Puja Dudeja & Ashok K. Jindal reporting. 2. GW case management.India is the first country in the world to establish the National 3. Vector Control by the application of Tempos in unsafe waterGuinea Worm Eradication Programme in 1983-84 as a centrally sources eight times a year and use of fine nylon mesh/sponsored scheme on 50-50 sharing between Centre and States double layered cloth strainers by the community to filterwith the objective of eradicating guinea worm disease from Cyclops in all the affected villages.the country. The objective of the Guinea Worm Eradication 4. Health education.Programme was to achieve zero guinea worm disease incidence 5. Trained manpower the country. The programme achieved zero guinea worm 6. Provision and maintenance of safe drinking water supplydisease status in 1997, against 40,000 cases occurring annually on priority in GW endemic 1984. Banwari Lal, 25 years old, from Jodhpur in Rajasthan, 7. Concurrent evaluation and operational research.was the last case in India in 1996 (1). “Zero” incidence has Referencesbeen maintained since August 1996 through active surveillance 1. Lancet 2000;355:212(News)and intensified field monitoring in the endemic areas. In the 2. Ministry of Health & Family Welfare. GOI, New Delhi, India.Meeting of WHO in February 2000, India has been certified forthe elimination of Guinea Worm Disease and on 15th February2001, declared India as “Guinea Worm Disease Free (2)”. Identifying the causes of upsurge; Strengthening diagnostic 95 Leptospirosis Control Programme facilities; and, Improving management facilities. Initiatives : The three major factors responsible for leptospirosis Puja Dudeja & Ashok K. Jindal are salinity of soil, adequate moisture and presence of microorganisms in reservoir / carrier hosts. IntersectoralDue to rapid ecological changes, many zoonoses have emerged coordination among the departments of National Bureau ofas epidemics. Leptospirosis causes significant morbidity and Soil Survey and Land Resource Management, Department ofmortality in human beings especially in coastal region of the Meteorology, Rodent control Board of India and department ofcountry. The objectives of the programme are to establish Animal Husbandry of endemic states will be taken. The areassurveillance in the country and to reduce morbidity and from where the disease has not been reported but where similarmortality due to leptospirosis in India. The control programme ecological factors prevail will be separately earmarked aswill be implemented in a phased manner. In the first phase ‘Leptospira Prone Areas’. A monitoring and evaluation systemit will be conducted in Kottayam district of Kerala and South for above activities will be set up (1).Gujrat. The reduction in Morbidity and Mortality would be an Referencesindicator of successful implementation of the programmme. 1. Working gps/Steering Committees/Task Force for the 11th five year plan2007-Strategy : The strategy includes Development of Data Base 2012.Plg Com.GOI. Available at htpp:/planning htm.through routine and IDSP system; Identifying vehicle oftransmission; Identification of serovar in prevalent states; • 529 •
  • 74. National AIDS Control Programme Phase II 96 National Aids Control Programme (1999-2004) The Phase II of the National AIDS Control Programme has Puja Dudeja & Ashok K. Jindal become effective in 1999. It is a 100% Centrally sponsored scheme implemented in 32 States/UTs and 3 Municipal Corporations namely Ahmedabad, Chennai and Mumbai The Red Ribbon is an international through AIDS Control Societies.The focus in this phase was to symbol of AIDS awareness that is slow the spread of HIV infection, decrease the mortality and worn by people all year round and morbidity associated with HIV infection and minimize the particularly on World AIDS Day socioeconomic impact resulting from HIV infection(3,4). (December 1) to demonstrate care National AIDS Control Programme Phase III and concern about people living (2006-12) with HIV/AIDS and to remind others of the need for their support NACP-III is based on the experiences and lessons drawn from and commitment. The concept of a NACP-I and II, and is built upon their strengths. World AIDS Day originated at the Goal : To halt and reverse the epidemic in India over the next 1988 World Summit of Ministers five years by integrating programmes for prevention, care and of Health on programs for AIDS support and treatment. prevention. Since then, it has been Objectives : To reduce the rate of incidence by 60 per cent in taken up by Govts., International the first year of the programme in high prevalence states to organisations and charities around obtain the reversal of the epidemic, and by 40 percent in the the world. vulnerable states to stabilise the epidemic. StrategyEvolution : Evolution of National AIDS control programme is ●● Prevent infections through saturation of coverage of high-given in Table - 1. risk groups with targeted interventions (TIs) and scaled up interventions in the general population. Table 1 ●● Provide greater care, support and treatment to larger Year Remarks number of People Living with HIV/AIDS (PLHA). 1986 First HIV case reported in India ●● Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment 1987 AIDS control programme was launched programmes at district, state and national levels. 1992 Ministry of Health and Family Welfare set up a ●● Strengthen the nationwide Strategic Information National AIDS Control Organization (NACO) Management System. 1986-1992 Surveillance launched in 55 cities in the three Programme Implementation states and the programme activities were left to Intensive coverage of High Risk Groups through targeted the states without a strong central guidance interventions : Surveys conducted under NACP II indicated 1992-1997 National AIDS Control Project (Phase I), presence of high risk groups in all parts of the country and extended to 1999(1) a focused strategy was launched to raise their awareness, motivating them to adopt safe behavior, improving their 1999-2004 National AIDS Control Programme (Phase II), access to preventive services and tools such as condoms. extended to 2007 NACP III will aim at increasing the coverage of such services 2002 National AIDS Prevention & Control Policy (2) especially for high risk groups, identified as sex workers and 2002 National Health Policy : Zero level growth of their clients, transgender population, men having sex with new HIV/AIDS by 2007 men (MSM) and IV drug users in urban and rural areas. The ‘bridge population’ identified as truck drivers, street children, 2007-2012 National AIDS Control Programme (Phase III) prison inmates and migrant workers would also receive special attention under NACP III. The essential elements of targetNational AIDS Control Programme Phase I interventions proposed under NACP III are access to behaviours(1992-99) change communication, prevention services such as condoms,During this phase, the National AIDS Control Project was STI services, needles and syringes, treatment services in formdeveloped for prevention and control of AIDS in the country. of STI clinics, drug substitutions for IV drugs, antiretroviralThe ultimate objective of the project was to slow the spread therapy and creation of an enabling environment under allof HIV to reduce future morbidity, mortality, and the impact project sites.of AIDS by initiating a major effort in the prevention of HIV Intensification of interventions among general populations:transmission. There was a nation wide capacity building in Although 99 % of Indian population is not infected, a highmanagerial and technical aspects of the programme. It also level of vulnerability exists, especially, among young people,aimed at increasing awareness and condom usage in targeted women, migrant workers and marginalized populations. NACPhigh risk population. • 530 •
  • 75. III aims at reducing risk, vulnerability and stigma through Family Health Awareness Campaign (FHAC)increased awareness and targeted behavior change. The These are campaigns for 15 days, organized by the states toprogram is considered to be effective when 99 % of population address the issue of RTIs/STDs and HIV/AIDS. The objectives ofcan recall three modes of HIV transmission and two methods of the campaign are :prevention. This is to be achieved through increased awareness 1. To raise awareness levels regarding HIV/AIDS in rural andthrough communication, social mobilization & advocacy and slim area and other vulnerable groups of the population.through integration and expansion of integrated HIV related 2. To make people aware about the services available underservices like HIV counseling, testing, STI treatment, Prevention the public sector for management of HIV/AIDS.of Parent To Child Transmission and Post Exposure Prophylaxis 3. To facilitate early detection and prompt treatment of RTI/(PEP) at sub district hospital, community health centers and STD cases by utilizing the infrastructure available underPHCs. primary health care system including provision of drugs.Sexually Transmitted Disease (STD) Control Program : 4. To strengthen the capacity of medical and paramedicalEvidence suggests that likelihood of contracting HIV infection professionals working under health care system to respondis 8-10 times higher in presence of other STDs, particularly to HIV/AIDS epidemic adequately.genital ulcers. In view of the established relationship between 5. To use safe blood from licensed blood banks and bloodHIV and STIs, Min of Health & Family welfare adopted a policy storage centers.of integrating HIV/AIDS and STD control within the existing 6. To be aware that HIV can be transmitted from the infectedhealth care system. Under the program, emphasis is given mother to her baby during pregnancy, delivery and breastto comprehensive treatment of STIs at primary health care feeding.level and integration of non-stigmatized services with greater Voluntary Counseling and Testing (VCT) : VCT specificallyaccessibility and acceptability by patients and community, involves increasing availability an demand for voluntarywhile maintaining confidentiality and privacy of the patients. testing including joint testing of couples, training grassrootsNACO took over the STD control program (in operation since health workers in HIV counseling and providing counseling1946) in 1992 and made it an integral component of AIDS through blood banks and through STI clinics. Under NACP III,control policy. After overcoming the shortcomings of the it is envisaged that at least one voluntary testing centre woulderstwhile STD control program (like poor accessibility, stigma), be established in every district. Pretesting counseling (beforeNACP III continues to provide STI services based on syndromic HIV testing) essentially prepares an individual for undergoingapproach, with the aim to improve etiological management HIV test, identifying high risk behavior. Post test counselingof STIs (5). The broad objective of STI control program under helps the client to understand the importance and meaning ofNACP III are to reduce STD infections, thereby controlling HIV negative or positive HIV test, benefits of changing the high risktransmission by minimizing a risk factor and to prevent short behavior and constructively handling the marital and sexualand long term morbidity & mortality due to STDs. This is to be needs.achieved through the following strategies : HIV testing : Under the present HIV testing policy of Govt of(i) Development of adequate & effective program management India, there is no rationale for mandatory HIV testing of any by strengthening existing STD clinics, appointing STD individual. It is established that any form of mandatory testing program officers in State AIDS control societies and usually drives ‘underground’ those who are at highest risk due identification of district nodal officers who would supervise to stigma & discrimination and is thus counter-productive in working of STD clinics. the long term. According to present HIV policy, HIV testing is(ii) Promotion of IEC activities for prevention of transmission carried out on voluntary basis with adequate pretest and post of STD & HIV infections in form of activities to educate -test counseling. Govt of India has formulated a comprehensive people for responsible sexual behavior, safer sex and HIV testing policy, in accordance to WHO guidelines, which greater condom usage. states that :(iii) mproving case management including diagnosis, I (i) No individual shall be made to undergo any form of treatment, counseling, partner notification and screening mandatory HIV testing. for other diseases, in form of two sets of guidelines for PHC (ii) HIV testing shall not be imposed as a precondition to level and for referral of STD specialists. employment or for providing health care facilities during(iv) Increasing access to health care for STD by strengthening employment. existing STD clinics, increasing heath seeking behavior (iii) Adequate facilities for voluntary testing with pretest and through IEC & NGOs and establishing first Referral Units post - test facilities will be made available throughout the in collaboration with Dept of Family welfare. country in a phased manner, so as to have at least one HIV(v) Creating facilities for diagnosis & treatment of testing centre in every district. asymptomatic infections by providing trained lady medical (iv) Disclosure of HIV status to spouse of the person will depend officer and sensitizing community through family Health entirely on willingness to part with such informations. Awareness Campaigns for early detection and referral to However, all efforts should be made so that the individual PHCs. voluntarily shares such information with family, to ensure(Details of syndromic approach to management of STDs is proper home based care.given in detail in the chapter on STDs). (v) Different testing strategies are to be adopted under different circumstances, as under : • 531 •
  • 76. ●● Mandatory testing : Screening in blood banks for blood (iv) Chemoprophylaxis should be reviewed on 1, 3 and 6 safety. However, testing in all blood banks will be months interval. undertaken on collected blood samples in an unlinked & (v) Under NACP III, only following drugs are approved for post anonymous manner so as to only identify the status of exposure prophylaxis : blood sample and not of the donor. ●● Zidovudine - 300 mg twice daily for 4 weeks●● Unlinked and anonymous testing : To be undertaken for ●● Lamivudine - 150 mg twice daily for 4 weeks epidemiological surveys and HIV surveillance to monitor ●● Indinavir - 800 mg thrice daily (only as part of expanded the trend of HIV infection in community. regime)●● Voluntary and confidential testing : To be undertaken ●● Saquinavir - 600 mg thrice daily. as confirmatory testing for subclinical infections/clinical Blood Safety Program : In India, blood banking infrastructure management and as voluntary testing. is highly decentralized and there is acute shortage of trained●● Need based testing : To be undertaken with explicit manpower, equipment and financial resources necessary to consent, for research purpose, after ensuring all ethical provide the desired quality of blood. In addition, there is often considerations. shortage of blood which encourages private blood banks withFor screening of donated blood, a single test by either Rapid inadequate infrastructure and quality control.or ELISA method is enough to eliminate possibility of HIV Blood safety has remained an integral part of NACP since itsinfected blood. For epidemiological surveys, the same procedure inception an NACP III has included the objectives of :is adopted with one or two of Rapid/ELISA/Simple, which (i) Ensuring organized blood banking services at State/Districthas high sensitivity. In such cases, testing is unlinked and levelanonymous and result is not given to the person. For clinical (ii) Educating & motivating community about importance ofmanagement and for confirmation of HIV status of individuals voluntary blood donationwho voluntarily ask for it, testing using different antigen (iii) Enforcing quality control for all units of blood to bepreparation. The result of HIV testing in such cases has to be infused.disclosed only after proper pre-test and post-test counseling of Condom Promotion Program : In India, heterosexualthe concerned individual. transmission constitutes the major transmission route ofPrevention of Parent To Child Transmission (PPTCT) : Various HIV and condom usage remains the single most effective andstudies have indicated that chemoprophylaxis (in the form of practical method to prevent HIV transmission. Accordingly,Nevirapine) before delivery in case of HIBV-infected pregnant Condom Promotion program under NACP III proposed that therewoman significantly reduces mother-to-child transmission rate should be no moral, religious or ethical inhibition in promotingfrom 33 % to 8.4 % at birth or 10.1% at age of two months. The condom usage among sexually active individuals, especiallyintervention cost has been worked out to Rs.175 per women, those who practice high risk behavior(6). Under NACP III, it iswhich is a very cost effective method to prevent perinatal HIV envisaged to convince people to use condom not only for familyinfection. NACP III envisages that antenatal clinics will be planning but also as the best preventive measure against HIV,used for imparting HIV education to pregnant women through convince commercial sex workers and their clients to usetrained counselors. Special emphasis would also be given to condoms as means to prevent sexually transmitted diseasesdrug prophylaxis linked with infant feeding, nutritional support including HIV and to make available low cost, good qualityand contraception. Drug regimes used for chemoprophylaxis condoms to people all over the country easily at the time andwould be modified according to emerging evidence of efficacy place where they will need them. The objective of Condomof the drugs. Promotion Program is to ensure easy access to acceptable, goodOccupational Health and HIV/AIDS : NACP III has addressed quality and affordable condoms with the view to promote safethe issue of expanding HIV/AIDS response at work place. sex. The following are used as indicators for success of CondomUnder NACP III, specific guidelines have been formulated Promotion Program under NACP III :in collaboration with employers, workers organizations, (i) Percentage of persons who report easy availability ofministries and civil society, with the aim to strengthen response condoms within 500 meters of the place where they needto HIV and mitigate the effect of the diseases at work place. them.The key areas for intervention at work place are prevention of (ii) Percentage of persons reporting consistent use of condomHIV/AIDS, management & mitigation of impact at work place, in sexual encounters with non- regular partners in last 30care & support for infected workers and reducing stigma and days.discrimination at work place. (iii) Percentage increase in number of non-traditional outletsUniversal Protection & Post Exposure Prophylaxis (PEP) : for condoms, like post offices, shopping malls etc.Under NACP III, health care worker will be provided specific University Talk AIDS Project (UTA) : UTA Project began asprotection against occupational exposure to HIV. NACP III early as Oct 1991 with partnership between National Servicerecommends following measure after occupational exposure : Scheme (NSS), Dept of Youth Affairs & Sports and NACO. The(i) Rapid testing facility for HIV testing. project aims to generate awareness among students on HIV(ii) Exposure with HIV should be considered a medical related issues through seminars, talks workshops and written emergency. material. The program also deals with related issues pertinent(iii) Chemoprophylaxis should be started within 4 hours after to youth like drug abuse, relationship, courtships, marriage exposure. and thus aims to enhance life style skills among the youth. • 532 •
  • 77. Treatment for opportunistic infections : It was previously HIV Sentinel Surveillance : HIV Sentinel Survillance isavailable at district level; would be now available at CHC and undertaken every year jointly by National AIDS ControlPHC levels. Drugs would be given free at all govt hospitals and Organisation (NACO) and Min of Health & Family Welfare sincefew NGOs with good track record in providing HIV care would 1998, with the aim of updating HIV estimates for the country.also be incorporated for treating HIV. NACP III also proposes Under this program, HIV prevalence in the country is estimatedclose linkage between NACP and RNTCP since tuberculosis based on HIV prevalence recorded at designated sentinelremains the most common and most lethal opportunistic surveillance sites (such as STD clinics, de-addiction centersinfection among HIV infected individuals. and intervention centers for female sex workers) for different(a) Anti retroviral therapy to as many infected individuals risk groups. Women attending antenatal clinics are taken to has been attempted under NACP III. NACP III proposes be representative of the general population. Blood samples partnerships and through community partnership and collected (between 01 Aug - 31 Oct) by unlinked anonymous ownership. Serpositive women who have participated in method are tested at regular intervals annually and the data PPTCT program, children below 15 years with HIV/AIDS, is used for epidemiological analysis and estimation of HIV PLHA referred under targeted interventions (such as for prevalence in the country. The HIV Sentinel Surveillance System commercial sex workers, truck drivers or migrant workers) of India has greatly evolved over time covering all the districts and AIDS patients getting treatment from govt ART centres of the country as well as all the high risk population groups. will be given priority for ART. It is proposed that by 2010, Annual HIV Sentinel Surveillance is conducted among Pregnant as many as 1,84,000 individuals would be on ART. women attending Antenatal clinics, Patients attending STI(b) NACP III also proposes to establish DNA PCR facility for Clinics, Female Sex Workers, Injecting Drug Users, Men who diagnosis of HIV in children through selected national have Sex with Men, Migrant Population, Long distance Truckers, referral centres, to meet the requirement due to increasing Eunuchs and Fisher folk. Based on HIV Sentinel Surveillance number of infected children. data, all the districts in the country are categorised into fourCapacity Building : Under NACP III, capacity building at categories for priority attention in the programme.national, state and district levels is envisaged through Behaviour Surveillance Survey ( BSS) : BSS throws lightmultiple strategies to meet the fast evolving challenges of on the knowledge, awareness and behaviours related to HIV/HIV epidemic in the country. Possible centres for imparting AIDS among general population, youth as well as amongtraining, identified by a multidisciplinary standing committee different high risk group communities. It also provides rich(including an epidemiologist, economist, microbiologist and inputs to understand the impact of the intervention effortspublic health, marketing, communication specialists among being undertaken through NACP (7). BSS is undertaken toothers), will identify training needs at various levels and also provide behavioural measurement for recording trends of highhelp states to plan their training. In addition, capacity building risk behavior among selected population groups. A set of 9under NACP III will include issues of program management, indicators, as under were used on three occasions to assessfinance and procurement of infrastructure human resource and the trends.medicines at various levels. (a) Knowledge indicators : These include Proportion ofMonitoring & Evaluation respondents who know the following : 2 acceptable ways toHIV Surveillance : Effective and accurate HIV surveillance prevent STDs; that condoms prevent STDs; 2 acceptable waysis essential to monitor progress of the control program. NACP to prevent HIV; and, that condoms prevent HIV.III undertakes HIV surveillance with the objective to estimate (b) Behaviour Indicators : These include proportion ofincidence, prevalence, morbidity and mortality due to HIV and respondents who report heterosexual intercourse with non-also to identify behavioural and biological markers on progress regular partner in the last year and proportion of respondentsof preventive program. who report condom usage during last sexual intercourse withOne of the significant achievements of NACP is a credible HIV non regular partner in the last yearsentinel surveillance system. Information gathered through HIV (c) Prevalence of Urethritis among male respondents who reportsentinel surveillance, behavioural sentinel surveillance and STD symptoms of urethritis during last one year or proportion ofsurveillance helps in tracking the epidemic and provides the male respondents who sought treatment from qualified medicaldirection to the programme. Under NACP-III, PPTCT surveillance practitioners for urethritis in the last year.and ANC surveillance system are planned to be included in the (d) Appropriate perception of risk indicators : This pertains toprogramme. Surveillance for HIV infection comprises of four proportion of respondents with high risk behavior who perceivebroad areas : HIV Sentinel Surveillance, AIDS Case Surveillance, that they can get infected with HIV.Behavioural Surveillance and Sexually Transmitted Infections(STI) Surveillance. HIV Surveillance closely monitors and tracks India’s response to HIV epidemic is influenced by the availablethe level, spread and trends of the epidemic as well as the risk surveillance data, implementation capacities and politicalbehaviours that predispose the growth of epidemic. Inputs commitment at state and national level. Apart from thefrom the robust sentinel surveillance system of India, routine sentinel surveillance, nationwide Computerised ManagementAIDS Case reporting, and periodic behavioural surveillance Information System (CMIS) provides strategic informationsurveys give direction to the programmatic efforts by showing on programme monitoring and evaluation. However, inthe impact of the interventions and areas that need focus of the planning of NACP-III it was felt that data from sentineldifferent initiatives. surveillance and CMIS are not sensitive enough to detect the • 533 •
  • 78. emerging hot spots of the epidemic. To overcome this, NACO, in AIDS better access to treatment.its third HIV/AIDS programme introduced Strategic Information Paediatric Care and Support : The primary goal of paediatricManagement System (SIMS) at national and state levels to focus prevention, care and treatment programme is to prevent HIVon strategic planning, monitoring, evaluation, surveillance and infection to newborns through Prevention of Parent To Childresearch. It is aimed to provide effective tracking and response Transmission (PPTCT) and provide treatment and care to allto HIV epidemic. The system assigns clear responsibilities to children infected by HIV.all programme officers and facilitates data flow and feedback Research : Beginning NACP-III, NACO has positioned itself asat various levels. the promoter and coordinator of research on HIV/AIDS not onlyCore Services at District level in India, but the entire South Asia region through partnershipIn packaging of services, care is taken for the special needs and networking with national academic and other institutionsof the region and availability of complementary health care in the region. This initiative will enhance NACO’s knowledgesystem. In high prevalence districts, the full spectrum of and evidence base of the various aspects of the epidemic.preventive, supportive and curative services are available in Strengthening decentralization and expanding healthmedical colleges or district hospitals. These hospitals provide systems : Under the NACP-III, decentralization of HIV servicesHIV/AIDS prevention services including treatment and cure for and convergence of services with the Reproductive Child Healthsexually transmitted infections, psycho-social counselling and Programme is envisaged; with strengthening of the capacitiessupport for people infected or affected by HIV, management of the districts to manage prevention, treatment, care andof opportunistic infections and anti-retroviral therapy for support programmes.people living with HIV/AIDS, counselling and testing facility Prioritization of districts for programme implementation:for prevention of parent to child transmission of HIV infection, National AIDS Control Programme - III envisages districtspecialised paediatric HIV care and treatment / referral for level planning and implementation of all the programmaticspecialist needs such as surgery, ENT and ophthalmology etc. initiatives. For the purpose of planning and implementationCare and Support for Children : Approximately 50,000 children of NACP-III, all the districts in the country are classified intobelow 15 years are infected by HIV every year. So far, care and four categories based on HIV prevalence in the districts amongsupport response to these children was at a very minimal level. different population groups for three consecutive years. TheNACP-III plans to improve this through early diagnosis and definitions of the four categories are as follows :treatment of HIV exposed children; comprehensive guidelines Category A : More than 1% ANC prevalence in district in any ofon paediatric HIV care for each level of the health system; the sites in the last 3 years.special training to counsellors for counselling HIV positive Category B : Less than 1% ANC prevalence in all the siteschildren; linkages with social sector programmes for accessing during last 3 years with more than 5% prevalence in any Highsocial support for infected children; outreach and transportation Risk Group (HRG) site (STD/FSW/MSM/IDU).subsidy to facilitate ART and follow up, nutritional, educational,recreational and skill development support, and by establishing Category C : Less than 1% ANC prevalence in all sites duringand enforcing minimum standards of care and protection in last 3 years with less than 5% in all HRG sites, with known hotinstitutional, foster care and community-based care systems. spots (Migrants, truckers, large aggregation of factory workers, tourist etc).Treatment : HIV infection is not the end of life. People can leada  healthy life  for a long time  with appropriate medical care. Category D : Less than 1% ANC prevalence in all sites duringAnti-retroviral therapy (ART)  effectively suppresses replication, last 3 years with less than 5% in all HRG sites with no knownif taken at the right time. Successful viral suppression restores hot spots or no or poor HIV data.the immune system and halts onset and progression of disease Critical appraisalas well as reduces chances of getting opportunistic infections Due to stigma attached with HIV/AIDS, people living with the- this is how ART is aimed to work. Medication thus enhances disease face a lot of discrimination. The program does notboth quality of life and longevity. Adherence to ART regimen lay much emphasis to this important issue. Rehabilitation ofis therefore very vital in this treatment. Any irregularity in sex workers who are HIV positives has been neglected in thefollowing the prescribed regimen can lead to resistance to program and needs special budgetary allocation. When theHIV drugs, and therefore can weaken or negate its effect. ART program started no targets were fixed and the program couldis now available free  to all those who need it. Public health not be evaluated properly due to non existence of indicators.facilities are mandated to ensure that ART is provided to people Provision of free ART may eat the budget of other importantliving with HIV/AIDS (PLHA). Special emphasis is given to the communicable diseases. NACP has been conspicuously silenttreatment of sero-positive women and infected children.  ART on structural socioeconomic vulnerabilities and the rootis initiated depending upon the stage of infection. PLHA with cause of continuing flow of subpopulation into situationsless than 200 CD4 (white blood cells/ mm3) require treatment involving high risk behavior. It offers nothing to address theseirrespective of the clinical stage. For PLHA with 200-350 CD4, vulnerabilities through creating viable, holistic alternativesART is offered to symptomatic patients. Among those with for those presently entrapped. The concept of voluntary andCD4 of more than 350, treatment is deferred for asymptomatic confidential testing is not being implemented in true spirit.persons. There are 127 ART centres operating in the country as Many Indians are tested for HIV without their knowledge andof June 2007. By 2012, 250 ART centres will become functional consent especially for those undergoing surgeries.across the country in order to provide people living with HIV/ • 534 •
  • 79. Summary For care and support of children, NACP-III plan envisages early diagnosis and treatment of HIV exposed children; comprehensiveThe first HIV case was reported in 1986. National AIDS Control guidelines on paediatric HIV care for each level of the healthProgramme was launched in 1987. The programme was in system; special training to counsellors for counselling HIVphase I from 1992-1997(extended to 1999), phase II (1999- positive children; linkages with social sector programmes for2004) and is presently in phase III from 2007-2012. The Goal accessing social support for infected children; outreach andof NACP is to halt and reverse the epidemic in India over the transportation subsidy to facilitate ART and follow five years by integrating programmes for prevention, care,support and treatment. The Objectives are to To reduce the rate ART is initiated depending upon the stage of infection. PLHAof incidence by 60 per cent in the first year of the programme with less than 200 CD4 (white blood cells/ mm3) requirein high prevalence states to obtain the reversal of the epidemic, treatment irrespective of the clinical stage. For PLHA withand by 40 percent in the vulnerable states to stabilise the 200-350 CD4, ART is offered to symptomatic patients. Amongepidemic. those with CD4 of more than 350, treatment is deferred for asymptomatic persons.The Strategy in phase III has been to prevent infections throughsaturation of coverage of high-risk groups with targeted National AIDS Control Programme - III envisages districtinterventions (TIs) and scaled up interventions in the general level planning and implementation of all the programmaticpopulation, Provide greater care, support and treatment to larger initiatives. For the purpose of planning and implementationnumber of People Living with HIV/AIDS(PLHA), Strengthen the of NACP-III, all the districts in the country are classified intoinfrastructure, systems and human resources in prevention, four categories based on HIV prevalence in the districts amongcare, support and treatment programmes at district, state and different population groups for three consecutive years. Thenational levels and to Strengthen the nationwide Strategic definitions of the four categories are as follows : Category A :Information Management System. More than 1% ANC prevalence in district in any of the sites in the last 3 years. Category B : Less than 1% ANC prevalence inThe activities which are included are - Intensive coverage all the sites during last 3 years with more than 5% prevalenceof High Risk Groups through targeted interventions, in any HRG site (STD/FSW/MSM/IDU). Category C : Less thanIntensification of interventions among general populations, 1% ANC prevalence in all sites during last 3 years with less thanSexually Transmitted Disease (STD) Control Program, Family 5% in all HRG sites, with known hot spots (Migrants, truckers,Health Awareness Campaign (FHAC), Voluntary Counseling large aggregation of factory workers, tourist etc). Category D:and Testing (VCT), Prevention of Parent to Child Transmission Less than 1% ANC prevalence in all sites during last 3 years(PPTCT), Universal Protection & Post Exposure Prophylaxis with less than 5% in all HRG sites with no known hot spots or(PEP), Blood Safety Program, Condom Promotion Program, no or poor HIV data.University Talk AIDS Project (UTA), Treatment for opportunisticinfections and Monitoring & Evaluation. ReferencesFor HIV testing different strategies have been adopted for 1. Govt of India, Annual Health Report 1999-2000. Ministry of Health and Family Welfare. New Delhi.different situations such as (a) Mandatory testing : screening 2. Govt. of India (2002), National AIDS Prevention and Control Policy, NACO,in blood banks for blood safety. However, testing in all blood Ministry of Health an family Welfare, New Delhi.banks will be undertaken on collected blood samples in an 3. Govt. of India(2002), Combating HIV/AIDS in India 2000-2001, NACO,unlinked & anonymous manner so as to only identify the Ministry of Health and Family Welfare, New Delhi. 4. Govt of India, Annual Health Report 2004-2005. Ministry of Health andstatus of blood sample and not of the donor. (b) Unlinked and Family Welfare. New Delhi.anonymous testing : To be undertaken for epidemiological 5. NACO Website, National AIDS Prevention and Control Policy.surveys and HIV surveillance to monitor the trend of HIV 6. Govt of India, country scenario 1997-98, NACO, Ministry of Health andinfection in community. (c) Voluntary and confidential testing: Family Welfare. New Delhi. 7. Population Foundation of India and Population Reference Bureau (2003),To be undertaken as confirmatory testing for subclinical HIV/AIDS in India, New Delhi.infections/clinical management and as voluntary testing. 8. Strategy and Information Plan. National AIDS Control Programme Phase III(d) Need based testing : To be undertaken with explicit consent, (2006-2011). 2006. National AIDS control Organisation. New Delhi.for research purpose, after ensuring all ethical considerations. • 535 •
  • 80. was adopted. The strategy consisted of four nation-wide PPI 97 Polio Immunization Programme rounds in the months of October, November, December 2000 and January 2001; followed by two sub-national rounds in 8 States of Assam, Bihar, Gujarat, Madhya Pradesh, Orissa, Puja Dudeja & Ashok K. Jindal Rajasthan, Uttar Pradesh and West Bengal and routine immunization, especially in the poor performing States. DuringIn May 1988, the World Health Assembly committed the 1999, Supplementary Immunisation Activities (SIAs) weremember nations of the World Health Organization (WHO) to intensified, with the addition of house-to-house vaccinationachieving the goal of global eradication of poliomyelitis. This after an initial day of fixed-site activity (2).goal is defined as (1):●● No cases of clinical poliomyelitis associated with wild Table - 1 poliovirus, and●● No wild poliovirus found worldwide despite intensive Year Remarks efforts to do so. 1978 Vaccination against polio was initiated underWHO Regions that have been certified as polio-free are the Expanded Programme on Immunization (EPI)Americas (last case in 1991, Peru; Region certified polio-free in 1984 Coverage achieved was around 40% of all infants1994), the Western Pacific Region (last case in 1997, Cambodia; with 3 doses of Oral Polio Vaccine (OPV)Region certified 2000), and the European Region (last case in 1985 Universal Immunization Programme (UIP) was1998, Turkey; Region certified 2001). launchedStrategy 1995 The number of reported cases of polio declined fromThe primary strategies for achieving this goal are: 28757 during 1987 to 3265 in 1995. Pulse PolioAttaining high routine immunization : By immunizing every Immunization (PPI) Programme was launched inchild aged <1 year with at least 3 doses of oral poliovirus 1995-96 to cover all children below the age of 3vaccine (OPV). Paralytic polio can be caused by any of 3 closely- yearsrelated strains (serotypes) of poliovirus. Trivalent OPV (OPV3) 1996-97 To accelerate the pace of polio eradication, theprovides immunity against all 3 types. Three routine OPV doses target age group was increased to all childrenshould be received by infants at ages 6, 10 and 14 weeks. under the age of 5 yearsNational Immunization Days (NIDs) : By conducting Pulse 1997 National Polio Surveillance Project was launchedPolio Immunization (PPI) programme by providing additional by Govt. of India & World Health OrganizationOPV doses to every child aged <5 years at intervals of 4-6weeks. The aim of NIDs/PPI is to “flood” the community with Summary of cases : Decadal trend of polio cases is given inOPV within a very short period of time, thereby interrupting Table - 2 (3).transmission of virus throughout the community. Intensificationof the PPI programme is accomplished by the addition of Table - 2extra immunization rounds, adding a house-to-house “searchand vaccinate” component in addition to providing vaccine Year No. of casesat a fixed post. The number of PPI rounds conducted during 1998 1934any particular year is determined by the extent of poliovirus 1999 1126transmission in the country. The modified IPPI (IntensifiedPulse Polio Immunization) strategy included vaccination of 2000 265children through fixed booth approach on first day, followed 2001 268by extensive house-to-house search of missed children for 2002 1600vaccination.Surveillance of Acute Flaccid Paralysis (AFP) : Identify 2003 225all reservoirs of wild poliovirus transmission. This includes 2004 134AFP case investigation and laboratory investigation of stool 2005 66specimens collected from AFP cases, which are tested forpolioviruses in specialized laboratories. 2006 676Mopping-up immunization : When poliovirus transmission 2007 874has been reduced to well-defined and focal geographic areas, 2008 420 (P1:25, P3:325)intensive house-to-house, child-to-child immunization Source : See reference (3)campaigns are conducted over a period of days to break thefinal chains of virus transmission. AFP SurveillanceEvolution of Polio vaccination in India The strategy to eradicate wild poliovirus is two-fold, viz.,This is presented in Table - 1 immunization and surveillance. The objective of AFPIn 1999 - 2000, with a view to reach the global goal of reaching surveillance is to detect the exact geographic locations wherezero incidence of polio by 2000 AD, a strategy to intensify PPI wild polioviruses are circulating in the human population. All • 536 •
  • 81. cases of acute flaccid paralysis in children aged <15 years specimen form AFP cases and its shipment to laboratories.are rigorously investigated by a trained medical officer, with AFP Surveillance at the local level is institution based throughcollection of stool specimens to determine if poliovirus is the a comprehensive network of reporting sites which includescause of the paralysis. Analysis of the location of polioviruses health facility reporting units & informers.isolated from AFP cases allows programme managers to plan Critical appraisal (4)immunization campaigns (Pulse Polio Immunization). A critical juncture has been reached in eradication ofCase Definition : Acute flaccid paralysis is defined as any poliomyelitis in India. The tools are available which are provencase of AFP in a child aged <15 years, or any case of paralytic to be effective across the world. The large disparity in routineillness in a person of any age when polio is suspected. vaccine coverage among various regions of the country isAcute : Rapid progression of paralysis from onset to maximum hampering the eradication efforts. Compounding the problemparalysis; Flaccid : Loss of muscle tone, “floppy” - as opposed is the social mobility from migrant labour moving to urbanto spastic or rigid; Paralysis : Weakness, loss of voluntary conglomerates. Eradication efforts need to be focused on thesemovement. Any case meeting this definition undergoes a high risk groups, including mop-up activity for absentee andthorough investigation to determine if the paralysis is caused defaulter immunisation. Community participation remains theby polio. key to success and has to be ensured for better complianceComponents of AFP Surveillance The importance of ensuring cold chain has to be stressed to1. Case Notification maintain vaccine potency. Potency checking of OPV is hardly2. Case and laboratory investigation done after the inception of the Vaccine Vial Monitor (VVM)3. Outbreak Response Immunization (ORI) and active search into IPPI. A review of this may be necessary to ensure that a of cases in community potent vaccine is used. As we near the control of wild-virus4. 60 days follow up, cross notification & tracking of cases transmission, Vaccine Associated Paralytic Polio (VAPP) is aAn AFP case detected by health workers is reported to local real danger. The introduction of Injectable Polio Vaccine mayhealth authorities and to state and national bodies. Case be an option, at least in the better performing areas like Keralainvestigators are sent to confirm the diagnosis and collect faecal and the North East. Combination of DPT with IPV in the UIP hassamples that are transported to the nearest laboratory for virus been suggested and may have to be done in the near future.culture. This is followed by Outbreak Response Immunization Summary(ORI), wherein all children less than 59 months in the area Polio eradication is defined as - No cases of clinical poliomyelitisare given an additional dose of OPV. At least 500 children are associated with wild poliovirus, and No wild poliovirusvaccinated under ORI. Along with ORI, an intensive search is found worldwide despite intensive efforts to do so. Thecarried out for more cases of AFP The case definition includes . primary strategies for achieving this goal are attaining highany child less than 15 years with history of flaccid/floppy routine immunization, National Immunization Days (NIDs),paralysis. The AFP cases are revisited after 60 days of onset of Surveillance of Acute Flaccid Paralysis (AFP) and Mopping-upparalysis to check for residual weakness/neurological deficit. immunization. On NID, OPV doses to every child aged <5 yearsThe confirmation of paralytic polio is based on the review after at intervals of 4-6 weeks. The aim of NIDs/PPI is to “flood” the60 days and the laboratory report of the stool specimen. The community with OPV within a very short period of time, therebysuspected stool samples are sent to WHO recognized National interrupting transmission of virus throughout the community.Laboratories where poliovirus culture and identification arecarried out. If poliovirus is found, the samples are forwarded AFP Surveillance: The objective of AFP surveillance is toto one of the Regional Reference Laboratories where VDPV and detect the exact geographic locations where wild polioviruseswild poliovirus are differentiated. are circulating in the human population. The Components of AFP Surveillance are Case Notification, Case and laboratoryNational Polio Surveillance Project investigation, out break response immunization and activeThe National Polio Surveillance Project is a collaborative project search of cases in community and 60 days follow up, crossof Govt. of India & the World Health Organization and managed notification and tracking of the latter. Currently a team of more than 250 Surveillance The National Polio Surveillance Project is a collaborative projectMedical Officer (SMO), Sub-Regional Coordinator (SRC) and of Govt. of India & the World Health Organization and managedRegional Coordinator (RC) are spread across the country who by the later for active surveillance of Acute Flaccid Paralysis;comprise the field staff of project. They are supported by a was established to meet the demands of Polio of 9 Polio National Laboratories, which undertake theVirological Investigation of AFP (Acute Flaccid Paralysis) cases. ReferencesThe central headquarter unit of the project - The National Polio 1. Polio Eradication Initiative, Office of the Director-General and DepartmentSurveillance Unit (NPSU) provides logistical & technical backup of Immunisation, Vaccines and Biologicals, Family and Community Health. The Global Polio Eradication Initiative Strategic Plan 2004-2008. Geneva,to the field staff. Switzerland: World Health Organization, 2004; 37-43.In October 1997, active surveillance of Acute Flaccid Paralysis 2. CDC. Progress toward poliomyelitis eradication-India, 2003.MMWR 2004; 53:238-41.was established to meet the demands of Polio Eradication. SMOs 3. AFP Surveillance Bulletin - IndiaReport for week 37, ending 13th Septemberwith Government counterparts established Reporting Units for 2008 GOI, National Polio Surveillance Projectreporting of occurrence of AFP cases to the District, State & 4. Wg Cdr S Mukherji, Lt Col AK Jindal, Brig Zile Singh, Maj Swati Bajaj. PolioNational levels; timely case investigation & collection of stool Eradication in India: Myth or Reality. MJAFI 2005; 61 : 364-366 • 537 •
  • 82. Activities & Components Integrated Disease Surveillance 98 Project (IDSP) 1. Establish and Operate a Central-level Disease Surveillance Unit. 2. Integrate and strengthen disease surveillance at the state Puja Dudeja & Ashok K. Jindal and district levels. 3. Improve laboratory support.Surveillance is essential for the early detection of emerging 4. Training for disease surveillance and action.(new) or re-emerging (resurgent) infectious diseases. In the The details are shown in the Table - 1absence of surveillance, disease may spread unrecognized by Implementation : IDSP will monitor a limited number ofthose responsible for health care or public health agencies, conditions based on state perceptions including 13 core andbecause sick people would be seen in small numbers by many 5 state priority conditions for which pubic health response isindividual health care workers. By the time the outbreak is available. District, State & Central Surveillance units will be setrecognized, it may be too late for intervention measures. up so that the program is able to respond in a timely mannerContinuous monitoring is essential for detecting the ‘early to surveillance challenges in the country including emergingsignals’ of outbreak of any epidemic of a new or resurgent epidemics. It will integrate surveillance activities in the countrydisease. Surveillance data can be effectively used for the under various programs and use existing infrastructure forpurpose of social mobilization to help the public participate its function. Private practitioners / Private hospitals / Privateactively in controlling important diseases. This will go a long laboratories and medical colleges will be inducted into theway in reducing the burden of disease in the community. program as sentinel units. Uniform high quality surveillanceIDSP is a decentralized; state based Surveillance Project (IDSP) activities will be ensured at all levels. Following actions will bewhich will be able to detect early warning signals of impending taken for successful implementation :outbreaks and help initiate an effective response in a timely (i) Limiting the total number of diseases under surveillancemanner. It will also be expected to provide essential data to and reducing overload at the periphery.monitor progress of on-going disease control programs and (ii) Developing standard case allocate health resources more optimally. IDSP will also (iii) eveloping formats for reporting. Dfacilitate the study of disease patterns in the country and (iv) Developing user friendly manuals.identify new emerging diseases (1). (v) Providing training to all essential personnel.Aim & Objectives : The aim is to improve the information (vi) Setting a system of regular feed back to the participants onavailable to the government health services and private health the quality of surveillance activity. District Public Healthcare providers on a set of high-priority diseases and risk factors, Laboratory will be strengthened to enhance capacity forwith a view to improving the on-the-ground responses to such diagnosis and investigations of epidemics and confirmationdiseases and risk factors. The objectives are : of disease conditions. Use of information technology will be done for communication, data entry, analysis, reporting,1. To establish a decentralized state based system of feedback and actions. A national level surveillance network surveillance for communicable and non-communicable will be established up to the district level. diseases, so that timely and effective public health actions can be initiated in response to health challenges in the Disease conditions under the surveillance program : country at the state and national level. Integration of Surveillance under various disease control2. To improve the efficiency of the existing surveillance programme : Under IDSP surveillance activities carried out activities of disease control programs and facilitate sharing under National Disease Control Programmes relating to Malaria, of relevant information with the health administration, Tuberculosis, HIV/AIDS, Diseases under RCH (Measles, Polio, community and other stakeholders so as to detect disease Acute Diarrhoeal Diseases) and state specific diseases would trends over time and evaluate control strategies. be integrated (See Table - 2). Table - 1 Compo- Activities nent 1. Ministry of Health and Family Welfare (MOHFW) will establish a new Disease Surveillance Unit. It will give support to states surveillance units and help in coordination. It will also help in change of diseases in the system. 2. It will integrate and strengthen disease surveillance at the state and district levels, and involve communities and other stakeholders, in particular, the private sector. 3. This involves upgrading laboratories at the state level, in order to improve laboratory support for surveillance activities. Adequate laboratory support is essential for providing on-time and reliable confirmation of suspected cases; monitoring drug resistance; and monitoring changes in disease agents. It also includes introducing a quality assurance system for assessing and improving the quality of laboratory data. 4. The first three components will require a large and coordinated training effort to reorient health staff to an integrated surveillance system and provide the new skills needed. • 538 •
  • 83. Table - 2 : Disease conditions under the IDSP Surveillance Group of diseases Examples Regular Surveillance Vector Borne Malaria Water Borne Acute Diarrhoeal Disease (Cholera), Typhoid Respiratory Diseases Tuberculosis Vaccine Preventable Diseases Measles Diseases under eradication Polio Others Road Traffic Accidents Other International commitments Plague Unusual clinical syndromes Menigoencephalitis / Respiratory (Causing death / hospitalization) Distress Hemorrhagic fevers, other undiagnosed conditions Sentinel Surveillance Sexually transmitted diseases/Blood borne: HIV/HBV, HCV Other Conditions Water Quality, Outdoor Air Quality (Large Urban Centers) Regular periodic surveys NCD Risk Factors Anthropometry, Physical activity, Blood Pressure, Tobacco, Nutrition, Blindness Additional State Priorities Each state may identify up to five additional conditions for surveillanceResponse to the Surveillance Information at various 4. At CHC / PHC Level : The response functions at the MO i/clevels (Fig. - 1) CHC and MO i/c PHC level will include Verification of reports of outbreaks from health worker (within 24 hours), verification of1. At Central Level : The response functions at the central reports of Outbreaks in the rumor registry (within 48 hours),surveillance committee level will include Development of disease-specific control activities (immediately), collection andnational guidelines for case definitions and disease control, transport of biological samples to lab, reporting of suspected andcompilation and analysis of SSU reports (quarterly), reporting confirmed cases to DSU (within 24 hours), IEC and integrationto World Bank, coordinate external quality assurance activities. with Village health committee, and outbreak investigation,The CSU will also advise SSUs on disease control measures, under DSU directions. The actions will also include verificationMonitor situation and response (continuously), notify of local health worker case reports (weekly), verification ofinternational public health agencies, seek and coordinate laboratory reports (weekly), and Feedback to local healthinternational assistance if necessary. workers (weekly).2. At State Level : The response functions at the state 5. At Local Health Worker Level : The response functionssurveillance committee level will include : Advise to DSUs on will include : Informing MO PHC/CHC, Active search for similardisease control measures, monitor situation and response, Cases, Collection and transport of biological samples to lab,notify CSU, and deployment of state rapid response team and IEC activities. The actions will also include monitoring ofif necessary, Compilation of DSU reports (monthly), assess illnesses and reporting to CHC, and to refer patients to PHC /reporting performance of DSUs (monthly), reporting to CSU CHC.(monthly) and feedback to DSUs (monthly). Phasing : IDSP will be implemented in three phases (2) as3. At District Level : The response functions at the District follows : Phase I (FY 2004-05), Phase II (FY 2005-06) andsurveillance committee level will include : Initiation of outbreak Phase III (FY 2006-07).investigation through Rapid Response Teams (RRT), providecoordination to Outbreak response activities involving CHCs, Conclusion : Surveillance is the essence of a disease controlinitiate disease control measures and treatment, notify SSU, program. By setting up a decentralized, action oriented,facilitate private / public Partnership in outbreak response. It integrated and responsive program, it is expected that IDSP willwill also include Data entry of sentinel data from institutions avert a sufficient number of disease outbreaks and epidemicsnot linked directly (weekly), analysis including calculation of and reduce human suffering and improve the efficiency ofcase counts and descriptive epidemiology (weekly), monitoring all existing health programs. Such a program will also allowand evaluation including assess accuracy and completeness monitoring of resource allocation and form a tool to enhanceof submitted reports (weekly), collection and trend analysis of equity in health delivery.water quality, air quality, and road accident data. • 539 •
  • 84. Fig. -1 : Structural Framework Of Integrated Disease Surveillance Project RURAL SURVEILLANCE URBAN SURVEILLANCE CSU CSU- Central Surveillance Unit SSPS - Selected Sentinel Private Sites SSU- State Surveillance Unit DSU- District Surveillance Unit SSU District/HIV/AIDS Rural SSPS - 15 District TB Lab ESI District Hospital Railway Hosp PHC , Sub-centres Water Dept. ID Hospitals Informers Dispensaries CGHS DSU Corporation Hosp Informers Pollution Control ICMR Labs Rural Medical Colleges Medical Colleges Police District Malaria Urban SSPS-15 Un itSummary The components are to Establish and Operate a Central-level Disease Surveillance Unit, Integrate and strengthen diseaseIDSP is a decentralized, state based Surveillance Project which surveillance at the state and district levels, Improve laboratorywill be able to detect early warning signals of impending support and Training for disease surveillance and action.outbreaks and help initiate an effective response in a timelymanner. It will also be expected to provide essential data to The implementation is through District, State & Centralmonitor progress of on-going disease control programs and Surveillance units. There will be Regular Surveillance (Vectorhelp allocate health resources more optimally. Borne, Water Borne, Respiratory Diseases, Vaccine Preventable Diseases and Diseases under eradication), Sentinel SurveillanceThe aim is to improve the information available to the (Sexually transmitted diseases/Blood borne conditions),government health services and private health care providers Regular periodic surveys (NCD Risk Factors )and each stateon a set of high-priority diseases and risk factors, with a view may identify up to five additional conditions for improving the on-the-ground responses to such diseases andrisk factors. The objectives are : To establish a decentralized The flow of information will be from Local Health Worker tostate based system of surveillance for communicable and CHC MO / PHC MO, to District Surveillance Committee, to Statenon-communicable diseases, so that timely and effective Surveillance Committee and finally to Centre Surveillancepublic health actions can be initiated in response to health Committee. IDSP will be implemented in three phases : Phasechallenges in the country at the state and national level; To I (FY 2004-2005); Phase II (FY 2005-2006); and Phase IIIimprove the efficiency of the existing surveillance activities (FY 2006-2007).of disease control programs and facilitate sharing of relevantinformation with the health administration, community and References 1. Integrated Disease Surveillance Project (IDSP). Government of India Ministryother stakeholders so as to detect disease trends over time and of Health And Family Welfare 14 May 2004.evaluate control strategies. 2. Annual health report 2006-07. Ministry of Health And Family Welfare. Government of India. • 540 •
  • 85. 3. Up gradation of Psychiatry wings in the General Hospitals/ National Mental Health 99 Programme (NMHP) Medical Colleges. 4. IEC Activities. 5. Research & Training in Mental Health for improving service Puja Dudeja & Ashok K. Jindal delivery. District Mental Health ProgrammeMental disorders form an important public health priority, Its main objective is to provide basic mental health services toboth in terms of the numbers of people suffering from mental the community & to integrate these with other health services.disorders and due to the burden of these disorders in the The programme envisages a community based approach to thecommunity (1, 2). These conditions include the severe forms of problem, which includes:mental disorders like psychoses, substance abuse and mental 1. Training of mental health team at the identified nodalretardation. Of the health conditions contributing to the institutions.disability adjusted life years (DALYs), of the top 10 conditions, 2. Increase awareness about Mental Health problems.four are mental disorders. 3. Provide service for early detection & treatment of mentalObjectives : NMHP was started in 1982 with the following illnesses in the community (OPD/Indoor & follow up).objectives (3): 4. Provide valuable data & experience at the level of1. To ensure availability and accessibility of minimum mental community at the state & center for future planning & health care for all in the near foreseeable future, particularly improvement in service & research. to the most vulnerable sections of the population. 5. Strengthening and Modernization of Mental Hospitals.2. To encourage mental health knowledge and skills in Identified thrust areas based on experience gained general health care and social development. during 10th Five Year Plan3. To promote community participation in mental health 1. To expand DMHP in an enlarged & more effective form. service development and to stimulate self-help in the 2. Strengthening/modernization of remaining mental community. hospitals in order to modify from largely custodial role toNMHP envisaged integration of mental health care with general therapeutic care and welfare (4). 3. Upgrading Departments of Psychiatry in Medical CollegesImplementation : A model for delivery of community based & enhancing the Psychiatric content of the medicalmental health care at the level of district was evolved and curriculum at the UG/PG level.field-tested in Bellary district of Karnataka by NIMHANS 4. Information, Education and Communication activities forbetween 1986-1995. This model was adapted as the District creating awareness and reducing stigma.Mental Health Programme (DMHP) and it was implemented 5. Research & Training in Mental 27 Districts across 22 states/UTs in the 9th five year plan 6. School Mental Health Programme.beginning in the year 1996. 7. Involvement of NGOs & Public Private Partnership in Community based care of mentally ill patients to fill theBarriers to Implementation of the Programme: service gap in mental health delivery.1. Shortage of trained manpower in the field of mental health. Revised Framework of 11th Five Year Plan2. Social stigma & lack of knowledge of psychiatric patients The revised approach for the programme in eleventh five year & their families. plan will recognize the importance of mental health care and3. Negative attitude of general practitioners, primary care will concentrate on providing counselling, medical services, physicians & other specialists. and establishing helplines for all, especially people affected4. NGOs/Voluntary Organizations do not find this field by calamities, riots and violence(5). The following actions are attractive. envisaged :5. Inadequate staff & infrastructure of mental hospitals and 1. There is a need to empower the PHC doctor to offer care to psychiatric wings of medical colleges. mentally ill persons at the PHC.6. Uneven distribution of sparse resources limiting the 2. There is a need to improve public awareness and facilitate availability of mental health care to those living in urban community participation. areas. 3. The psychiatric departments of Medical Colleges have to beNMHP during the 10th Five Year Plan upgraded to enhance better training opportunities. 4. Mental Hospitals that offer tertiary care to be improved toAn evaluation of the NMHP was undertaken in 2003 and the make treatment acceptable to the patients.programme was re-strategised to incorporate the following Indicators in 11th planchanges and it became from single pronged to a multi-prongedprogramme for effective reach and impact on mental illnesses. 1. No of districts that have successfully implemented DMHPMain strategies of NMHP during the 10th plan period are as 2. Improvement in service care in mental hospitalsfollows: 3. Lowering of stigma attached to mental illnesses 4. Increased awareness of mental disorders1. Expansion of DMHP to 100 districts all over the country.2. Strengthening and Modernization of Mental Hospitals. • 541 •
  • 86. Strategies vulnerable sections of the population, To encourage mental1. Integrating mental health with primary health care through health knowledge and skills in general health care and social NMHP . development, To promote community participation in mental2. Providing of tertiary care institutions for treatment of health service development and to stimulate self-help in the mental disorders. community. NMHP envisaged integration of mental health care3. Eradicating stigmatization of mentally ill patients and with general health care and welfare. protecting their rights through regulatory institutions like central and state mental health authorities. The objectives of the programme in the eleventh five year plan are to empower the PHC doctor to offer care to mentallyCritical Appraisal ill persons at the PHC, improve public awareness andSuccessful implementation of mental health is a big challenge facilitate community participation, upgradation of psychiatricfor all. With a large population of mentally ill in our country departments of Medical Colleges have to be upgraded toand very few psychiatrists being available, less than one enhance better training opportunities.psychiatrist is available for every 3 lacs population. The The strategies in the eleventh plan include integrating mentalpsychiatrist / population ratio in rural areas that account for health with primary health care through NMHP Providing of ,70% of country’s population, could well be under one for every tertiary care institutions for treatment of mental disordersmillion. There is a need to strengthen district mental health and eradicating stigmatization of mentally ill patients andprogrammes and enhance its visibility at the grass root level. protecting their rights through regulatory institutions likeThe man power gaps in the field of psychiatry are required to central and state mental health filled up. The NGOs have to join hands in this programmeand help in Community Based care of mentally ill. Preventive Referencesand promotive aspects of the programme have to be focused 1. The World Health Report 2001- Mental health: New Understanding, Newand looked in addition to treatment of serious mental ailments. Hope. Geneva: World Health Organization; 2001. 2. Gururaj G, Issac MK. Psychiatric epidemiology in India: Moving beyondIEC activities have to be strengthened and training of general numbers. In: Agarwaal SP Goel DS, Salhan RN,Ichhpujani RL, Shrivatsava ,practitioners in mental health is required to be emphasized S, editors. Mental health- An Indian perspective (1946- 2003), Newupon. Optimal mix of different mental health care services is Delhi:Directorate General of Health Services, Ministry of Health and Family Welfare; 2004 p. 37-61.given in Table1(6,7). There is a need for integrating the mental 3. National Mental Health Programme for India. New Delhi: Government ofhealth components in national level programmes like the ICDS, India, Nirman Bhavan; system, and use of traditional systems like yoga, 4. Reddy GNN; Channabasavanna SM; Murthy RS; Narayana Reddy GN;meditation, so that the mental health promotive activities Srinivasa Murthy R. Implementation of national mental health programme for India. NIMHANS Journal. 1986 Jul; 4(2): 77-84become part of the programme. 5. Planning Commission. Towards a faster and more inclusive growth - an approach to the 11 Five Year Plan. New Delhi: Government of India, YojanaSummary Bhavan; November 2006 p. 72.NMHP was started in 1982 with the objective of ensuring 6. Organisation of services for mental health. Mental health policy and service guidance package. Geneva: World Health Organization; 2003 p. 34.availability and accessibility of minimum mental health care 7. World Health Report-2006, Working together for health, Geneva: Worldfor all in the near foreseeable future, particularly to the most Health Organization; 2006 p. 26. launched in 1975-76. In view of the magnitude of the problem National Cancer Control 100 Programme and the requirement to bridge the geographical gaps in the availability of cancer treatment facilities across the country; the programme was revised in 1984-85 and subsequently in Puja Dudeja & Ashok K. Jindal December 2004. Goals & Objectives : The goals and objectives are (2) :Cancer is an important public health problem in India with 1. Primary prevention of cancers by health educationnearly 7-9 lakh new cases occurring every year in the country. regarding hazards of tobacco consumption and necessityIt is estimated that there are 20-25 lakh cases of cancer in the of genital hygiene for prevention of cervical at any given point of time. In India over 70% of the cases 2. Secondary prevention i.e. early detection and diagnosis ofreport for diagnostic and treatment services in advanced stages cancers, for example, cancer of cervix, breast cancer andof the disease, resulting in poor survival and high mortality of the oro-pharyngeal cancer by screening methods andrates (1). With the objectives of prevention, early diagnosis and patients’ education on self examination methods.treatment, the National Cancer Control Programme (NCCP) was • 542 •
  • 87. 3. Strengthening of existing cancer treatment facilities, which 4. District Cancer Control Programme (DCCP) : The DCCP were inadequate. will be implemented by the Nodal Agency, which may be an4. Palliative care in terminal stage cancer. RCC or an Oncology Wing. The aim is to strengthen District Hospitals in 2-3 congruent districts for early detection and Global appropriate treatment or referral. ●● Cancers cause 12 per cent of deaths 5. Decentralized NGO Scheme : This scheme has been ●● Second leading cause of death in developed countries devised to promote prevention and early detection of cancers. accounting 21 % (2.5m) of all deaths Non- Governmental Organizations (NGO) will implement these ●● Second leading cause of death in developing countries activities under the coordination of the Nodal Agency, which accounting for 9.5% of all deaths (3.8m) will be an RCC or an Oncology Wing. India District Cancer Control Programme ●● One of the ten leading causes of death This programme was launched in 1990-91 and under this ●● There are 1.5-2 million cancer cases at any given point programme each state and union territory is advised to prepare of time their projects on health education, early detection, and pain ●● 7 lakh new cases of cancer and 3 lakh deaths occur relief measures. For this they can get up to Rs. 15 lakhs one annually due to cancer time assistance and Rs. 10 lakhs for four years recurring ●● The common sites for cancer in India are oral cavity, assistance. The district programme has five elements: lungs, oesophagus and stomach in males and cervix, 1. Health education. breast and oral cavity among females 2. Early detection. 3. Training of medical & paramedical personnel.Existing Schemes under National Cancer Control Programme 4. Palliative treatment and pain relief.(3) : This is shown in Table - 1. 5. Coordination and monitoring.The programme was revised in December 2004.There are 5 The District programmes are linked with Regional Cancerschemes under the revised programme (4) Centres/ Government Hospitals/ Medical Colleges. For effective1. Recognition of New Regional Cancer Centres (RCCs) : In functioning each district where programme has started to haveorder to augment comprehensive cancer care facilities in regions one District Cancer Society that is chaired by local Collector/of the country lacking them, new RCCs are being recognized. Chief Medical Officer. Other members are Dean of medical college, Zila parishad representative, NGO representative etc.2. Strengthening of Existing RCCs : A one-time grant of Rs.3.00 crores is provided to the existing RCCs in order to further National Cancer Registry Programme (NCRP)strengthen the cancer treatment facilities in the existing National Cancer Registry Programme was launched in 1982centres. by Indian Council of Medical Research (ICMR) to provide true3. Development of Oncology wing : The scheme aims to information on cancer prevalence and incidence. There arecorrect the geographical imbalance by providing financial five population-based urban cancer registries in Mumbai,assistance to Government institutions (Medical Colleges as Bangalore, Chennai, Bhopal, Delhi and a rural registry at Barsiwell as Government Hospitals) for enhancing the cancer care in Maharashtra and six hospital-based registries at Chandigarh,facilities. Dibrugarh, Thiruvananthapuram, Bangalore, Mumbai and Chennai. The NCRP provides data on regional difference and time Table - 1 : Existing Schemes under National Cancer Control Programme Scheme Remarks Financial Assistance to Voluntary Organisations For IEC activities and early detection of cancer District Cancer Control Scheme District projects are given financial assistance to carry out health education, early detection and pain relief measures. Under this scheme one time financial assistance of Rs.15.00 lakhs is provided to the concerned State Government for each district project with a provision of Rs.10.00 lakhs every year for the remaining four years of the project period. Cobalt Therapy Installation To strengthen the cancer treatment facilities, the financial assistance of Rs. 1.0 crore is given to charitable organisations and 1.5 crores for government institutions is provided for procurement of teletherapy and brachytherapy equipments etc. This is one time grant as at present. Development of Oncology Wings in Govt. Medical The aim is to fill geographical gaps. One time financial assistance of College Hospitals Rs.2.00 crores is provided by the centre for purchase of equipment. Regional cancer institutes There are 25 Regional Cancer Research and Treatment Centres recognised by Government of India and recurring grant of Rs.75 lakhs is being given to these Regional Cancer Centres. • 543 •
  • 88. trends in cancer prevalence so that appropriate modifications and diagnosis of cancers, for example, cancer of cervix,in the ongoing programmes could be made. breast cancer and of the oro-pharyngeal cancer by screeningObjectives of NCRP methods and patients’ education on self examination methods,1. To generate authentic data on the magnitude of cancer Strengthening of existing cancer treatment facilities and problem in India. palliative care in terminal stage cancer.2. To undertake epidemiological investigations and advice Existing Schemes under National Cancer Control Programme are control measures. Financial Assistance to Voluntary Organisations, District Cancer3. Promote human resource development in cancer Control Scheme, Cobalt Therapy Installation, Development epidemiology. of Oncology Wings in Govt. Medical College Hospitals andIn the XI five year plan, the focus will be on community based Recognition of New Regional Cancer Centres. The elementscancer prevention and control strategies. We are in the process of of district programme are Health education, Early detection,establishing OncoNET India, a network connecting 25 Regional Training of medical & paramedical personnel, PalliativeCancer Centres and 100 peripheral centres thus facilitating treatment and pain relief and coordination and monitoring.telemedicine services and continued medical education. National Cancer Registry Programme was launched in 1982Critical appraisal by Indian Council of Medical Research (ICMR) to provide true information on cancer prevalence and incidence. The NCRPThe programme however has mainly contributed to the provides data on regional difference and time trends in cancerdevelopment of radiation oncology services rather than making prevalence so that appropriate modifications in the ongoingany headway in the direction of prevention and early detection programmes could be made.(5). There is no organised screening programme for any of thecommon cancers in the country. Most cancer centers provide References: 1. KA Dinshaw, SS Shastri, SS Patil. Community Intervention For Canceronly opportunistic screening services. Research and training Control & Prevention: Lessons Learnt Indian Journal Of Medical & Paediatricwas one of the objectives of the programme but was neglected Oncology Vol. 25 No. 2, 2004.during implementation of the programme. 2. Y. N. Rao, Sudhir Gupta and S. P Agarwal. National Cancer Control Programme: . Current Status & Strategies: 50 years of cancer control in India.Summary 3. Ministry of Health and Family Welfare. GOI 4. Annual Health Report 2007-2008. Minisrty of Health and Family Welfare.National Cancer Control Programme (NCCP) was launched GOIin 1975-76. The goals & objectives are primary prevention 5. Dinshaw KA, Shastri SS, Patil SS Cancer Control Programme In India:of cancers by health education regarding hazards of tobacco Challenges for the new millennium Health Administrator Vol: XVII, Number 1: 10-13consumption and necessity of genital hygiene for preventionof cervical cancer; Secondary prevention i.e. early detection cardiovascular disease in people aged 35-64 years (9.2 million National Programme for years lost in 2000). The common risk factors are Tobacco, 101 Prevention & Control of Diabetes, Alcohol, Diet and Physical inactivity. Cardiovascular Diseases & Stroke Rationale for Having a Common Programme for the Prevention and Control of Diabetes, CVD and Stroke Puja Dudeja & Ashok K. Jindal 1. Diabetes is an important risk factor for both the major forms of cardiovascular disease (coronary heart diseaseThe World Health Report of 2002 states that Cardiovascular and stroke).Diseases (CVD) will be the largest cause of death and disability 2. CVD is the major cause of death and disability in personsin India by 2020. Non Communicable Diseases (NCDs), with diabetes.especially Cardiovascular Diseases (CVDs), Diabetes Mellitus, 3. Common risk factors underlie CVD and diabetes: unhealthyCancer, Stroke and Chronic Lung Diseases have emerged diets, physical inactivity and over weight are common toas major public health problems in India, due to an ageing both.population and environmentally driven changes in behaviour. 4. High blood pressure often precedes and predicts theIt is estimated that in 2005, NCDs accounted for 5,466,000 onset of clinical diabetes by several years. This has led to(53%) of all deaths (10,362,000) in India. The estimated burden ‘hypertension’ being regarded as a pre-diabetic condition.of common NCDs are; 2.4 million Ischemic Heart Diseases, 37.8 5. Clinical trials have shown that, mortality reduction andmillion diabetes, 2.4 million cancers and 0.93 million stroke. increased survival are better achieved by blood pressureCompared with all other countries, India suffers the highest control than even by blood sugar control, in persons withloss in potentially productive years of life, due to deaths from diabetes. • 544 •
  • 89. 6. Persons with CVD or diabetes require similar lifestyle Immediate objectives therapy and often similar drug therapy for prevention of 1. Primary prevention of major Non Communicable Diseases complications (diet; physical activity; smoking cessation; through Health Promotion. cholesterol lowering drugs; aspirin; ACE inhibitors; other 2. Surveillance of NCDs and their risk factors in the blood pressure lowering drugs). population.7. Persons with diabetes frequently need to be screened for 3. Capacity enhancement of health professionals and health CVD and risk factors of CVD. systems for diagnosis and appropriate management of8. Proven lifestyle interventions which can prevent the onset NCDs and their risk factors. of diabetes (diet and physical activity) are similar to those 4. Reduction of risk factors of NCDs in the population. proven to reduce the risk of developing hypertension, 5. Establish National Guidelines for management of NCDs. coronary heart disease or stroke. 6. Development of strategies/ policies for prevention of NCDsThe strategic approaches and operational elements for in the country through Inter ministerial collaborations/prevention and control of CVD and diabetes are thus similar coordination.or closely interlinked, whether it is primordial prevention, 7. Community empowerment for prevention of NCDs.primary prevention or secondary prevention (reducing the riskof complications after the onset of disease). Summary The NPDCS will be implemented in a phased manner with a pilotImplementation : The NPDCS will be implemented in a phased being done in the Preparatory Phase 2006-07. Subsequently, themanner with a pilot being done in the Preparatory Phase programme would be implemented across the country through2006-07. Subsequently, the programme would be implemented select institutions over the XI Five Year Plan. The aim of theacross the country through select institutions over the XI Five Programme Prevention and control of common NCD risk factorsYear Plan. through an integrated approach and reduction of prematureAim of the Programme : Prevention and control of common morbidity and mortality from DM, CVD and Stroke. In theNCD risk factors through an integrated approach and reduction long term the programme envisages, reduction in prevalenceof premature morbidity and mortality from DM, CVD and Stroke of risk factors of common NCDs, reduction in morbidity and(1). mortality due to Diabetes, Cardiovascular diseases and StrokeLong term objectives and building capacity of health systems to tackle NCDs and1. Reduce prevalence of risk factors of common NCDs. improvement of quality of care.2. Reduce morbidity and mortality due to Diabetes, Cardiovascular diseases and Stroke. References 1. Annual Health Report 2006-07. Ministry of Health and Family Welfare. Govt.3. Building capacity of health systems to tackle NCDs and of India. improvement of quality of care. National Iodine Deficiency Table 1 102 Diseases Control Programme S. Year Event No. Puja Dudeja & Ashok K. Jindal 1. 1954- Prospective study on iodine deficiency 1962 disorders in Kangra valleyIodine, an essential micronutrient with daily requirement 2. National Goitre Control 1962of 100-150 mg, plays an important role in normal human Programme (NGCP)growth and development. It has been widely recognized that 3. Technical goitre control reviewdeficiency of iodine not only contributes to goitre but also is 1982 committee recommended to declarean important risk factor for preventable mental retardation; entire country goitre proneit affects reproductive functions and impairs child’s learning 4. Universal iodisation ofability. The disorders produced as a result of nutritional iodine 1983 salt in the countrydeficiency are classified as “Iodine Deficiency Disorders (IDD)or IDD syndromes” (1). 5. NGCP was redesignated as NationalThe History of Iodine Deficiency Control Programme in our 1992 Iodine Deficiency Disorderscountry is given in Table1. Control Programme* (NIDDCP) * The title has been changed in view of the wide spectrum of Iodine Deficiency Disorders like mental and physical retardation, deaf mutism, cretinism, high rates of abortion etc. and the Govt. commitment to overcome all other Iodine Deficiency Disorders apart from Goitre, through Universal lodisation of salt. • 545 •
  • 90. Programme Implementation (2) Benefits of IDD control (3) : IDD is one of the threeResponsibilities : It is a 100 percent centrally assisted micronutrient deficiencies declared to be eliminated by WHO,programme. The Ministry of health and Family Welfare is the the other two being vitamin A deficiency and iron deficiency.nodal ministry for policy decisions on NIDDCP The central . Apart from minimizing human misery, IDD control makes itNutrition and Iodine Deficiency Disorders Cell at the Directorate possible to have better education to the children, high labourGeneral of Health Services is responsible for the implementation productivity and better quality of life. See Table - 2.of NIDDCP The Salt Commissioner’s office under the Ministry of .Industry is responsible for licensing, production and distribution Table - 2of iodated salt to States/UTs. This office is also responsible for S. No. Reduction Benefitsmonitoring the quality of iodated salt at production level and Mental Higher work output indistribution of same in the country. The Salt Commissioner 1 deficiency school and work placein consultation with the Ministry of Railways arranges formovement of iodated salt from production centres to the states/ Reduced cost of custodial 2 AutismUTs on a priority basis. The best indicator for monitoring the and medical careimpact of iodine Deficiency Disorders Control Programme is Reduced educational cost fromneonatal hypothyroidism. reduced absenteeism and grade 3 Spastic diplegiaThe Government’s goal of NIDDCP is to reduce the prevalence repetition and higher academicof iodine deficiency disorders below 10 percent in the entire achievement by the studentcountry by 2012 AD. Critical Appraisal : IDD control cells have not been establishedThe Objectives of NIDDCP are as under in all the states. The process of setting up iodine monitoring1. Survey to assess the magnitude of the IDD laboratory for estimation of iodine content of salt and urinary2. Supply of iodated salt in place of common salt iodine excretion is slow. Lack of resources and trained3. Resurvey after every 5 years to assess the magnitude of manpower restricts the quality control of iodated salt at the the IDD and the impact of iodated salt on it consumer level. A lot needs to be done to create a felt need for4. Laboratory monitoring of iodated salt and urinary iodine the programme activities among the masses. Medical and para excretion medical manpower needs to be trained on the subject.5. Health education and publicityOther components of the strategy are Summary(i) Testing of salt at manufacturing level. The disorders produced as a result of nutritional iodine(ii) Testing of salt at Consumption level. deficiency are classified as “Iodine Deficiency Disorders (IDD)(iii) esting of Urine samples at District/State level. T or IDD syndromes”. In 1962 National Goitre Control Programme(iv) Monitoring the Thyroid status of new borns through was launched, however the title has been changed in 1992 screening of cord Blood samples. to NIDDCP to cover the wide spectrum of Iodine Deficiency(v) Strengthening of Central Iodine Deficiency Disorder Control Disorders. Cell at the Headquarters. The goal of NIDDCP are to reduce the prevalence of iodine(vi) Strengthening of Training including establishment of deficiency disorders below 10 percent in the entire country by Iodine Deficiency Disorder Training Programme. 2012 AD. The Objectives of NIDDCP are to survey to assess the(vii) Information, Education and Communication. magnitude of the IDD, supply of iodated salt in place of commonIDD Control Cell : Each state has an IDD Control Cell which salt, resurvey after every 5 years to assess the magnitude of thecarries out periodic surveys regarding the prevalence of IDD IDD and the impact of iodated salt on it, laboratory monitoringand coordinates with central IDD cell. The functions of this cell of iodated salt and urinary iodine excretion and Healthare as under: education and publicity. IDD Control Cell in each state has been1. Checking iodine levels of the salt with wholesalers and established which carries out periodic surveys regarding the retailers within the state and coordinating with food and prevalence of IDD and coordinates with central IDD cell. civil supplies department.2. The distribution of iodated salt within the state through References 1. CD Alert June 2005 Vol.9: No.6 open market and public distribution system. 2. Tiwari BK. Revised guidelines on National Iodine Deficiency Disorders3. Creating demand for iodated salt. Control Programme. Directorate General of Health Services. Ministry of4. Monitoring consumption of iodated salt. Health and Family Welfare. October 2006.5. Conducting IDD surveys to identify the magnitude of IDD 3. T Jaya Krishnan, M. C. Jeeja. Iodine deficiency disorders in school children in kanur district. Discussion paper no 41. 2002. June 2005 Vol.9: No.6. Kerala in various districts. research programme on local development. Centre for development studies.6. Conducting training. Tiruvantapuram.7. Dissemination of information, education and communication. • 546 •
  • 91. workers. The training of PHC doctors and health functionaries National Programme for 103 Prevention & Control of Deafness would be provided by Rehabilitation Council of India.  2. Capacity building : for the district hospital, community health centers and primary health center in respect of ENT/ Puja Dudeja & Ashok K. Jindal Audiology infrastructure. 3. Service provision including rehabilitation : ScreeningHearing loss is the most common sensory deficit in humans camps for early detection of hearing impairment and deafness,today. As per WHO estimates in India, there are approximately management of hearing and speech impaired cases and63 million people, who are suffering from significant auditory rehabilitation (including provision of hearing aids ), at differentimpairment; this places the estimated prevalence at 6.3% in levels of health care delivery system. Indian population; of these, a large percentage is children 4. Awareness generation through IEC activities : For earlybetween the ages of 0 to 14 years. With such a large number of identification of hearing impaired, especially children so thathearing impaired young Indians, it amounts to a severe loss of timely management of such cases is possible and to remove theproductivity, both physical and economic.  stigma attached to deafness.Objectives  Expected Benefits of the Programme1. To prevent the avoidable hearing loss on account of disease The programme is expected to generate the following benefits or injury. in the short as well as in the long run :2. Early identification, diagnosis and treatment of ear 1. Large scale direct benefit of various services like prevention, problems responsible for hearing loss and deafness. early identification, treatment, referral, rehabilitation etc.3. To medically rehabilitate persons of all age groups, for hearing impairment and deafness as the primary health suffering with deafness. center/community health centers/district hospitals largely4. To strengthen the existing inter-sectoral linkages for cater to their need. continuity of the rehabilitation programme, for persons 2. Decrease in the magnitude of hearing impaired persons. with deafness. 3. Decrease in the severity/extent of ear morbidity or hearing5. To develop institutional capacity for ear care services by impairment in large number of cases. providing support for equipment & material and training 4. Improved service network for the persons with ear personnel. morbidity/hearing impairment in the states and districtsLong term objective : To prevent and control major causes covered under the project.of hearing impairment and deafness, so as to reduce the total 5. Awareness creation among the health workers/grassrootdisease burden by 25% of the existing burden by the end of level workers through the primary health centre medicaleleventh five year plan. officers and district officers which will percolate to theStrategies lowest level as the lower level health workers function1. To strengthen the service delivery including within the community. rehabilitation. 6. Larger community participation to prevent hearing loss2. To develop human resource for ear care. through panchyati raj institutions, mahila mandals, village3. To promote outreach activities and public awareness bodies and also creation of a collective responsibility through appropriate and effective IEC strategies with framework in the broad spectrum of the society. special emphasis on prevention of deafness. 7. Leadership building in the primary health centre medical4. To develop institutional capacity of the district hospitals, officers to help create better sensitization in the grassroot community health centers and primary health centers, level which will ultimately ensure better implementation selected under the project. of the programme.Programme Execution & Expansion (1) SummaryA pilot project, to be conducted in 25 districts derived from The programme is a part of eleventh five year plan with the10 states and one union territory, is already in the first phase objective of preventing and controlling major causes of hearingof implementation. This will run from 2006 to 2008. In the impairment and deafness, so as to reduce the total diseaseremaining four years of the 11th Five year plan, it is proposed burden by 25% of the existing burden by the end of eleventh fiveto expand this programme to include a total of 203 districts year plan. The  Components of the Programme are Manpowercovering all the states and Union territories of India by 2012. training and development to grass root level workers, CapacityThe expansion will be done in a phased manner, with inclusion building - for the district hospital, community health centersof 45 new districts each year. At the end of the plan, it is and primary health center in respect of ENT/ Audiologyproposed to cover 50% of the districts in all the pilot states infrastructure, Service provision including rehabilitation in the(except Uttar Pradesh) and 25% of the districts in all the other form of Screening camps, management of hearing and speechstates/UTs. impaired cases and rehabilitation (including provision of hearing aids), at different levels of health care delivery systemComponents of the Programme and awareness generation through IEC activities.1. Manpower training and development : For prevention,early identification and management of hearing impaired References:and deafness cases, training would be provided from medical 1. Working gps/Steering Committees/Task Force for the 11th five year plan2007- 2012.Plg Com.GOI.Available at htpp:/planning level specialists (ENT and Audiology) to grass root level htm. • 547 •
  • 92. been decentralized up to the district level where District National Programme for Control 104 of Blindness Blindness Control Societies (DBCS) have been set up as the nodal agencies. Members of the DBCS include officials from District Administration, Health, Education and Social Welfare Departments, media, community leaders and NGOs/Private Puja Dudeja & Ashok K. Jindal Sectors involved in eye care. These societies directly receive funds from the Government. The concept is to establish a bottomNational Programme for Control of Blindness was launched in up approach in dealing with blindness through multisectoralthe year 1976 as a 100% centrally sponsored scheme with the and coordinated efforts. These societies are responsible forgoal to reduce the prevalence of blindness from 1.4% to 0.3%. identifying blind in every village, organize diagnostic screeningIndia was the first country to launch the National Programme camps at suitable locations, arrange transportation of patientsfor Control of Blindness. Due to a large population base and to the designated facilities, and ensure follow up. The statesincreased life expectancy, the number of blind particularly have State ophthalmic cell under directorate of health servicesdue to senile disorders like Cataract, Glaucoma, Diabetic and state health societies. At the apex National institute ofRetinopathy etc. is expected to increase. Among the emerging ophthalmology (Dr. Rajendra Prasad Centre for ophthalmiccause of blindness, diabetic retinopathy and glaucoma need sciences in AIIMS, New Delhi) has been established. Variousspecial mention. 2 percent of India’s population is expected to other regional institutes have been developed. Medical collegesbe diabetic. 20 percent of diabetics have diabetic retinopathy have been upgraded under NPCB and few of them are providingand this number is likely to grow in future. India is committed training to ophthalmic reduce the burden of avoidable blindness by the year 2020by adopting strategies advocated for Vision 2020: The Right to School Eye Screening Programme : Under this the childrenSight. The prevalence and causes of blindness and future goals aged 10-14 years are being screened by trained teachers andare given in Table - 1. those suspected to have refractory error are seen by ophthalmic assistants and corrective spectacles are prescribed.Objectives ConstraintsThe objectives of the programme are (1) : 1. Inequitable distribution of eye surgeons : There are an1. To reduce the backlog of blindness through identification estimated 12,000 eye surgeons in India with an average of and treatment of blind. 1 surgeon for 1,00,000 population. There is a wide disparity2. To develop Eye Care facilities in every district. between urban and rural areas. This disparity has led to3. To develop human resources for providing Eye Care significant differences in services offered / sought by the Services. public.4. To improve quality of service delivery.5. To secure participation of Voluntary Organizations in eye 2. Suboptimal utilization of human resources: It is care. estimated that about 40 percent of eye surgeons in government section are non operating surgeons. They are either practicing Table - 1 : Prevalence and causes of Blindness & Future medical ophthalmology/ refraction services or providing general Goals medical care. Population 3. Inadequate number of paramedical eye personnel Year Remarks Prevalence (%) 4. Suboptimal coverage : Govt. facilities, NGO and private Cataract was leading cause (75% sector are usually located in urban/ periurban areas. Geo- 1971-74 1.38 physically remote and socioeconomically backward population of blindness) remains underserved. Cataract blindness increased to 5. Over emphasis on cataract : The problem of corneal 1986-89 1.49 80%. Trachoma and Vitamin A blindness, Glaucoma and diabetic retinopathy has not been related blindness reduced. adequately addressed. Similarly pediatric ophthalmology and Cataract reduced to 63%. low vision has received low priority. Refractive error second leading 6. Lack of public awareness : Rural, illiterate and under 2001-04 1.10 cause (20%). Glaucoma and privileged population are not fully aware about various diabetic retinopathy emerging interventions that are available to restore vision. Integration causes. of the programme is limited and therefore rural health workers 2007 -- Goal for 10th plan : 0.8% are also not motivating potential beneficiaries. Goal under “Vision 2020 Major challenges ahead 2010 -- Initiative”: 0.5% 1. In-depth study of epidemiology of blindness 2. Comprehensive eye care programmeProgramme Implementation 3. Reaching the underserved populationIndia is a vast country having 28 States and 7 Union Territories 4. Development of sustainable infrastructurewith 593 districts, with an average population of nearly two 5. Technological advancement in eye caremillion per district. The programme implementation has 6. Human resource development 7. Quality of care • 548 •
  • 93. Strategies during XI plan Environmental improvement (E of SAFE), including1. Strengthening advocacy and motivation by involvement of personal hygiene and community sanitation as part of village panchayat, local bodies, grass root NGOs, women primary health care. group and formal and informal leaders. Childhood Blindness2. Human resource development. Vitamin A deficiency : To achieve and sustain the elimination3. Infrastructure development. of blindness due to vitamin A deficiency.4. Grant in aid to state blindness control societies and district Surgically avoidable causes : To control blindness in children blindness control societies.5. Involvement of private practitioners. from cataract, glaucoma and retinopathy of prematurity (ROP)6. Increased IEC activities. Refractive Errors and Low Vision : Spectacles are an essentialVision 2020 - The Right to Sight Initiative : The global part of the treatment of many eye patients. Their provision isinitiative, “VISION 2020: The Right to Sight” is a collaborative therefore an integral part of eye care delivery. Elimination ofresponse initiated by the World Health Organization (WHO) and visual impairment (vision less than 6/18) and blindness due tothe International Agency for the Prevention of Blindness (IAPB) refractive errors or other causes of low vision. This aim goesto combat the gigantic problem of blindness in the world. It beyond the elimination of blindness and also includes thewas launched in Geneva in 1999. The diseases covered under provision of services for individuals with low vision.Vision 2020 are (2) : Implementation : The proposed structure for implementation1. Cataract of Vision 2020 is vision centre at the primary level, Service2. Trachoma centre at the secondary level and Training centre and centre of3. Onchocerciasis (not a problem in India) excellence at the tertiary level.4. Childhood blindness5. Refractive Errors and Low Vision SummaryThese conditions have been chosen on the basis of their National Programme for Control of Blindness was launchedcontribution to the burden of blindness and the feasibility and in the year 1976. India was the first country to launch theaffordability of interventions to control them. Each country National Programme for Control of Blindness. The objectiveswill decide on its priorities based on the magnitude of specific are to reduce the backlog of blindness through identificationblinding conditions in that country. Under this initiative, five and treatment of blind, to develop Eye Care facilities in everybasic strategies to combat blindness are : district, to develop human resources for providing Eye Care1. Disease prevention and control. Services, to improve quality of service delivery and to secure2. Training of personnel. participation of Voluntary Organizations in eye care.3. Strengthening the existing eye care infrastructure. The programme implementation has been decentralized upto4. Use of appropriate and affordable technology. the district level where District Blindness Control Societies5. Mobilization of resources. (DBCS) have been set up as the nodal agencies. These societiesVision 2020 will serve as a common platform to facilitate a are responsible for identifying blind in every village, organizefocused and coordinated functioning of all the partners in diagnostic screening camps at suitable locations, arrangeeliminating avoidable blindness by the year 2020. It will further transportation of patients to the designated facilities, anddevelop and strengthen the primary health/eye care approach ensure follow the problem of avoidable blindness. Broad regional alliances The Constraints for implementation are inequitable distributionwill be sought to eventually develop a global partnership for of eye surgeons, suboptimal utilization of human resources,eye health. suboptimal coverage, over emphasis on cataract and lack ofCataract : Cataract is the major cause of blindness in the public awareness. The global initiative, “VISION 2020: Theworld. The aim is Elimination of cataract blindness (person Right to Sight” is a collaborative response initiated by thewith vision less than 3/60 in both eyes). World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) to combat the giganticTrachoma : Trachoma is the second cause of blindness in sub- problem of blindness in the world. It was launched in GenevaSaharan Africa, China and the Middle-Eastern countries. The in 1999. The diseases covered under Vision 2020 are Cataract,aim is to eliminate blindness due to trachoma. Trachoma is to Trachoma, Onchocerciasis, Childhood blindness and Refractivebe controlled through the implementation of the SAFE strategy Errors and Low Vision.integrated within primary health care in all communitiesidentified as having blinding trachoma within a country. This Under this initiative, five basic strategies to combat blindnessincludes the following: are disease prevention and control, training of personnel,i) Assessment to identify communities with blinding strengthening the existing eye care infrastructure, use of trachoma. appropriate and affordable technology and mobilization ofii) Delivery of community-based trichiasis Surgery by trained resources. paramedical staff (S of SAFE). Further Suggested Readingiii) Antibiotic treatment (either tetracycline eye ointment or 1. Annual Health Report 2006-07. Ministry of Health And Family Welfare. oral azithromycin) for children with active disease (A of Government of India. SAFE). 2. Working gps/Steering Committees/Task Force for the 11th five year plan 2007-2012.Plg Com.GOI.Available at htpp:/planning Promotion of Facial cleanliness (F of SAFE) and plans/11thf.htm. • 549 •
  • 94. Institute of Mass communication, media division of Other Important National Health 105 Programmes MoHFW. The messages of oral and dental health should be merged with other IEC materials being developed by the centre and state governments. Puja Dudeja & Ashok K. Jindal Strategies for future 1. Oral Health Education : Use of primary health care approach: It is recommended to spread the messages of oral(A) National Oral Health Programme health care and strengthening of existing infrastructure.Oral diseases such as dental caries, periodontal diseases, Health care workers to be an important part of the programmemalocclusion and oral cancers constitute an important public in spreading health awareness. Health care workers to behealth problem in India today. Oral diseases have a great impact trained in providing pain relief and refer the case for furtheron systemic health and is now established that periodontal investigation and treatment.diseases has far reaching effects on various systemic diseases ●● Development of IEC material and use of masss media inlike low birth weight, Diabetes, Heart disease, Respiratory spreading awareness.diseases, Stroke, Atherosclerosis etc. Oral cancer prevalence ●● Involvement of NGOs in delivery of oral health highest in India, causing high morbidity and mortality. ●● etworking with other departments like Dept. of Education NNational oral health program is a pilot project on oral health and Social Welfare in imparting oral health education tostarted in the year 1999 by DGHS and the Ministry of Health the school children.and Family Welfare. Under this project, All India Institute of 2. Manpower and infrastructre development for primaryMedical Sciences has been made a nodal agency. and secondary prevention of oral diseases : Mobile DentalProgramme targets : These are given in Table - 1. Clinics to provide on the spot diagnostic, preventive, interceptive and curative services to the people and school children in far Table - 1 flung rural areas of the state, should be made available. Oral Prevalence Status by 3. Strengthening school health services : Good oral habits Age Group Diseases (%) 2005 2012(%) and practices learnt early in life would help reduce the disease Dental Caries All 40-50 <30 burden later in life. Periodontal Critical Appraisal 15+ 45 <35 diseases Oral health care has not been given sufficient importance in Malocclusion 9-14 32. 5 25 our country. Most of the district hospitals have the post of a dental surgeon but they lack in equipment, machinery and Oral cancer 35+ 0. 03 0. 02 material. Even when the equipment exists, the maintenance Fluorosis All 5. 5 4 is poor. Oral health has not been discussed in National Health Policy 2002 and National Rural Health Mission also does notComponents have any mention of oral health services either. The treatment1. Oral Health Education by involving health workers, school of Oro-dental diseases is enormously expensive and no Govt. children, teachers and mass media. across the globe can bear the cost for dental treatment for its2. Production of IEC Material for awareness generation. entire population. It is suggested that Govt. should bear the3. Formulation of modules for trainers (Dental surgeons), cost for primary and secondary prevention completely and may Health Workers and School Teachers. impose cost to cost pricing for the treatment part at all levels.The main focus of this project is on primary prevention which (B) National Programme for Prevention ofis the most cost effective, appropriate and desirable. FluorosisThe project was reviewed by National Institute for Health and Fluorosis, a public health problem, is caused by excess intakeFamily Welfare in 2004 and following recommendations were of fluorides through drinking water/food products/industrialmade: pollutants, over a long period. It results in major health1. The program to be divided into several implementation disorders like dental fluorosis, skeletal fluorosis and non phases giving reasonable time frames and goals to be skeletal fluorosis besides inducing ageing. achieved in each phase.2. Centre to provide technical support to the states by forming Level of fluoride : The fluoride content in drinking water various committees and one time financial support. in India is about 0.5mg/l but in fluorosis endemic areas, the3. The states to be responsible for implementation of the natural water have been found to contain as much as 3-12 mg/l programme by involving the education department, school of fluoride. A concentration of 0.5 - 0.8 mg/l is considered safe teachers, health workers and by developing adequate limit in India. In temperate climate where intake of water is infrastructure and facilities. low, the optimum level of fluorine in drinking water is accepted4. Modification of the existing IEC material with respect to as 1mg/l (2). the local situation in the states and in consultation with Problem statement : Fluoride endemicity has been reported agencies like Central Health Education Bureau, Indian in 196 districts of 19 states & UTs of the country. The affected • 550 •
  • 95. population with fluorosis is about 66 million in the country. etc. on a pilot basis.Based on excess level of fluoride content in No. of district, the (a) Southern Zone (One district)States/UTs have been classified as mild, moderate and severe (b) Western Zone (One district)endemic State/UTs of Fluorosis. States like Andhra Pradesh, (c) Northern zone (One district)Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Haryana, Jharkhand (d) Eastern zone (One district)Karnataka, Kerala, Jammu & Kashmir, Madhya Pradesh, (e) Central zone (One district)Maharashtra, Orissa, Punjab, Rajasthan, Uttar Pradesh, Tamil The Pilot Programme will be implemented in first two years timeNadu, West Bengal are affected from fluorosis. In all these including impact evaluation of various strategies/componentsstates, the drinking water has high fluorine content. of the programme. Third year onwards, the Programme will beWhy a National Programme? expanded to cover about 100 districts of 19 States dependingAt present there is no National level Programme for Fluorosis on availability of funds.Control. Data regarding prevalence of Fluorosis is based on (C) Programme for the Elderlystudies conducted by different groups over a period of time. India, as the second most populous country, has 76. 6 millionSurveys at a National level regarding prevalence have not people at or over the age of sixty ( 2001 Census) constitutingbeen conducted so far. For provision of safe drinking water, about 7. 7 % of its total population. Life expectancy hasGovernment of India supplements the efforts of State Government increased from around 59 years in the 1970s to 63 yearsand UTs by providing funds under the Accelerated Rural Water currently, and is expected to cross 70 years by the year 2020.Supply Programme (ARWSP). The chairman of National Human The proportion of elderly in India is set to rise dramatically inRights Commission reviewed the fluorosis situation in the the next few and recommended a National Programme for the samein the XI plan(3). Care of elderly : The Health of the elderly requires comprehensiveObjectives care with preventive, curative & rehabilitative services. Unlike the developed countries, India does not have a well structured1. To assess the intake of fluoride by assessing its presence Geriatric Health services, thus leading to a relatively ad hoc in all sources of drinking water, consumption of foods rich system of health care delivery for the elderly. In this scenario, in fluoride and intake through industrial emissions at the there is a need for a specialized geriatric health service, which district in the endemic states. recognizes the elderly as being a vulnerable population.2. To coordinate the activities in relation to fluorosis being carried out in various departments/Ministries like M/o rural Programme Vision : A society where persons aged 60 years Development, D/o Drinking Water, RGNDWM, Education, and above will have the peace of mind and sense of security Social Welfare, NICD, M/o H & FW. that arises from the knowledge that they have access to quality3. To impart training to medical doctors and paramedicals of health care at all times. the districts for early diagnosis of Fluorosis. Programme Mission : A community based holistic care4. To develop IEC material from Policy Level to the community system, which offers every citizen above the age of 60 years personnel. the opportunity to participate in a health care programme,Strategies : The following strategies are to be adopted : which includes preventive, curative and emergency health care1. Conducting fluoride survey regarding fluoride level in services of high quality. all drinking water sources, food product sources, and Goal : To improve the access to promotive, preventive, curative industrial emissions if there is industry in the project and emergency health care among elderly persons. district. Objectives2. Launching of extensive Fluorosis prevention and control 1. Provide comprehensive health care to the elderly by programme in coordination with Dept. of drinking water, preventive, curative and rehabilitative services. Ministry of Environment, Ministry of Information and 2. Train Health professionals in Geriatrics, including Broad casting, Ministry of Social Justice and Empowerment supportive care and Rehabilitation. and Ministry of Health & Family Welfare. 3. Develop scientific solutions to specific elderly health3. Establishment of testing of fluoride facility in water, food problems by research into Geriatric and Gerontology. and blood in each district of programme area. Programme Implementation : The national program for health4. Imparting training programme to medical and paramedicals care of the elderly will be a centrally funded program. The of the programme districts to diagnose Fluorosis cases entire Geriatric population will be covered by the 2 national including deformity cases. institutes of Ageing, one in North India and the other in south5. To develop extensive IEC material in relation of Fluorosis. India, eight identified regional centres (each implementing6. To implement the decision of Central Programme Geriatric Health Care in about 3 to 4 states). Under the control Implementation Committee under DGHS. of these two institutes, one teaching medical college/TertiaryProject Area : In the beginning, the programme for prevention level hospital in each state to develop the Geriatric Unit whichand control of Fluorosis, can be implemented in 5 districts will include the Outpatient services, Acute care, Subacute Careselected from each of the following zones of the country based and Long term care units. The health professionals trainedon prevalence of fluorosis, geographical distribution, weather, here will be sent to the district level centres for Geriatric Health Care delivery. • 551 •
  • 96. (D) Nutritional Programmes & Integrated artificial recharge etc. State Governments also use funds under Sub-Mission. Powers have been delegated to the States forChild Development Services (ICDS) sanctioning Sub-Mission projects.Details of various National Nutritional Programmes and ICDSprogramme are discussed in an exclusive chapter in the section Prime Minister’s Gramodaya Yojana (Rural Drinkingon nutrition. Water) Prime Minister’s Gramodaya Yojana (PMGY) was launched by(E) Water Supply and Sanitation Programme the Prime Minister in 2000-01.Evolution : The Ministry of Rural Development has been Goal : To provide basic necessities to the people in rural areastaking initiatives to provide safe drinking water in all rural for improvement of the physical quality of life.habitations. The National Water Supply and Sanitation Components : Primary education, Primary health, Rural shelter,Programme was initiated in 1954 with the objective of Rural drinking water, nutrition and rural electrification are theproviding safe water supply and adequate drainage facilities to six components of PMGY. 10 per cent of the PMGY funds havethe entire urban and rural population of the country. In 1972 a been earmarked for rural water supply.special programme known as Accelerated Rural Water SupplyProgramme (ARWSP) was started to supplement the national Objectiveswater supply and sanitation programme. The Govt of India 1. Emphasize on taking up projects and schemes for waterlaunched International Drinking water Supply and Sanitation conservation, rainwater harvesting, water recharge andDecade Programme in 1981. Other programmes like Prime sustainability of drinking water sources in areas underMinister’s Gramodaya Yojana - Rural Drinking Water (PMGY- Drought Prone Areas Programme (DPAP) and DesertRDW), have been implemented to resolve drinking water crisis Development Programme (DDP); overexploited dark andin rural habitations. These programmes also give importance to grey Blocks and other water stress and drought affectedrainwater harvesting, sustainability of sources and community areasparticipation. 2. Take up projects/schemes to tackle quality related problems and for providing safe drinking water to uncovered andAccelerated Rural Water Supply Programme (ARWSP) partially covered habitations.Objectives Swajaldhara : It is a community led participatory programme1. To ensure coverage of all rural habitations and especially launched in 2002, aimed at providing safe drinking water in reach the unreached with access to safe drinking water; rural areas. It also includes building awareness among the2. To ensure sustainability of the systems and sources; village community on the management of drinking water3. To tackle the problems of water quality in affected projects, including better hygiene practices and encouraging habitations; water conservation practices along with rain water harvesting.4. To institutionalize the sector reform initiative in rural It has two components. The first is for a gram panchayat or a water supply sector. group of panchayats at the block/tehsil level and the second atProgramme Implementation the district level.Rural water supply is a State subject. States have been takingup projects and schemes from their own resources for the (F) Rural Sanitationprovision of safe drinking water. State Governments decide the The concept of sanitation connotes a comprehensive definition,implementing agencies for the programme. The agencies may which includes liquid and solid waste disposal, food hygiene,be the Public Health and Engineering Department (PHED), Rural personal, domestic and environmental hygiene. AlthoughDevelopment Department or the Panchayati Raj Department. the concept of sanitation has undergone qualitative changesImplementation is also taken up by the Government Boards / during the years, there has been a very limited change in theNigams / Agencies in a few States. All projects and schemes sanitation condition of rural India.proposed under ARWSP are approved by the State Level Scheme Central Rural Sanitation Programme (CRSP)Sanctioning Committee. CRSP was launched in 1986 and aims at improving the qualityRole of Panchayats : As per the 73rd Amendment to the of life of the rural people and to provide privacy and dignity toConstitution of India, the subject of rural water supply is vested women in particular.with the Panchayati Raj Institutions (PRIs). The Panchayats Objectivesare to play a major role in providing safe drinking water andmanaging the systems and sources in their respective areas. 1. Improving the general quality of life in rural areas.They can be involved in the implementation of schemes, 2. Accelerating coverage in rural areas.particularly in selecting the location of handpumps, standposts 3. Generating demand through awareness creation and healthand spot sources. education. 4. Controlling incidence of water and sanitation relatedSub-Mission : Sub-Mission programmes of the Government diseases.of India were launched with the objective to provide safe Programme componentsdrinking water facilities in rural habitations affected by water 1. To construct individual sanitary latrines for householdsquality problems like fluorosis, arsenic, brackishness, excess Below Poverty Line (BPL) with subsidy, where demandiron, nitrate etc. The States undertake these projects. For exists.ensuring source sustainability through rainwater harvesting, • 552 •
  • 97. 2. To encourage other households to buy facilities through htm. markets including sanitary marts. 2. Ravindranathan I. Essential trace elements in food. Nutrition 2001, 35(3): 9-323. To assist in setting up of sanitary marts. 3. Working gps/Steering Committees/Task Force for the 11th five year plan2007-4. To launch awareness campaigns in selected areas. 2012. Plg Com. GOI. Available at htpp:/planning omm.. nic. in/plans/11thf.5. To establish sanitary complex for women. htm. 4. Working gps/Steering Committees/Task Force for the 11th five year plan2007-6. To encourage locally suitable and acceptable models of 2012. Plg Com. GOI. Available at htpp:/planning omm.. nic. in/plans/11thf. latrines. htm. Study Exercises7. To promote total sanitation in villages through construction of drains, soakage pits for liquid and solid waste disposal. Study ExercisesSubsidy for household latrines : Subsidy is given for simple MCQs & Exercises on National Health Programmesand less expensive latrines. A duly completed householdsanitary latrine comprises only a Basic Low Cost Unit (BLCU) Puja Dudeja & Ashok K Jindalwithout any super structure. 1. Which of the following is true with respect to goals of RCHStrategy for School Sanitation : School Sanitation is a vital - II? (a) IMR< 45/1000 (b) MMR< 100/100000 (c) Both ofcomponent of sanitation. It is proposed to construct toilets in all above (d) None of above rural schools (separate complex for boys and girls) by the end 2. The long term objective of RCH - II is to achieve a stableGovernment machinery, NGO participation and IEC campaigns, population by (a) 2045 (b) 2050 (c) 2015 (d) 2055provision for an alternate delivery system and more flexible 3. Centchroman (non steroidal contraceptive) has beendemand-oriented construction norms are also stressed. developed by (a) Indian Institute of Population Sciences (b) National Institute of Health and Family Welfare(G) Minimum Needs Programme (c) All India Institute of Medical Sciences (d) Central DrugIt started in 1975 with the objective of providing certain basic Research Laboratory, Lucknowminimum needs and improve the living standards of the 4. Reducing MMR<200/100000 is a goal of (a) N a t i o n a lpeople. Its bigger objective is social and economic development Health Policy 2002 (b) National Population Policyof the community, particularly the underprivileged and under- (c) Tenth five year plan (d) RCH IIserved population. The programme includes the following 5. Home visits for postnatal care for mother and new borncomponents. under RCH II are done on (a) Day 2 and 5 (b) Day 3 and 7(a) Rural Heath (c) Day 1and 3 (d) Day 3 and 5(b) Rural Water Supply 6. Which of the following is not a critical element of First(c) Rural Electrification Referral Unit in RCH II? (a) Availability of surgical(d) Elementary Education interventions (b) Newborn care (c ) Blood storage facility(e) Adult Education on a 24 hr basis (d) Easy accessibility(f) Nutrition 7. A total number of ________ tablets of iron with folic acid(g) Environmental improvement of Urban Slums are given to a pregnant woman by health worker (a) 100(h) Houses for landless labourers (b) 70 (c) 150 (d) 200 8. Under National Nutritional Anemia Prophylaxis ProgramIt laid emphasis on establishment of PHC, subcentres to the strength of iron and folic acid in tablets is (a) 60 mgimprove rural health. To improve the nutritional status, it elemental iron and 0.5 mg folic acid (b) 100 mg of elementalaimed at providing nutritional support to eligible persons, to iron and 0.5 mg folic acid (c) 100 mg of elemental iron andexpand “Special nutrition programme” to all the ICDS projects, 0.1mg folic acid (d) 60 mg elemental iron and 0.1 mg folicand to consolidate the mid-day meal programme and link it to acidhealth, potable water and sanitation. 9. Janani Suraksha Yojana (JSY) aims at reducing maternal(H) 20 - Point Programme and neonatal mortality rate by (a) Promoting institutional delivery (b) Health education (c) Distribution of iron andIt is an agenda for national action to promote social justice folic acid tablets to the mothers (d) All of the aboveand economic growth. It was restructured in 1986 with the 10. Under IMNCI the pink colour chart refers to a treatmentobjective of “eradication of poverty, raising productivity, at (a) Out patient facility (b) Home management (c) Givereducing inequalities, removing social and economic disparities injection/oral drops (d) Urgent referral and improving the quality of life”. At least 8 of the 20 points 11. The objective of national programme for prophylaxisare related, directly or indirectly, to health. These are: Point against blindness in children due to vitamin A deficiency1 - Attack on rural poverty; Point 7 - Clean drinking water; is to decrease the prevalence of Vitamin A deficiency toPoint 8 - Health for all; Point 9 - Two - child norm; Point 10 (a) 0.1 % (b) 0.2 % (c) 0.3 % (d) 0.001%- Expansion of education; Point 14 - Housing for the people; 12. The objective of national programme for prophylaxisPoint 15 - Improvement of slums; and Point 17 - Protection of against blindness in children due to vitamin A deficiencythe environment. is being implemented through (a) RCH programmeReferences (b) National programme for control of blindness (c) UIP (d)1. Working gps/Steering Committees/Task Force for the 11th five year plan2007- None of above 2012. Plg Com. GOI. Available at htpp:/planning comm. nic. in/plans/11thf. 13. Goal of National tuberculosis control programme is • 553 •
  • 98. (a) To eradicate TB (b) To decrease the transmission of TB (d) June (c) To treat all sputum +ve patients (d) To decrease the 30. Which of the following statements is false? (a) Lymphatic incidence of TB to such a low level that is no longer a major filariasis has been targeted for elimination in 2015 public health problem (e) BCG vaccination of all infants (b) Strategy for elimination is by Annual Mass Drug14. Which of the following is an objective of RNTCP? (a) To Administration of DEC for 5 years or more (c) Children achieve at least 70 percent cure rate of the newly diagnosed less than 2 ys are not included in Annual Mass Drug sputum smear-positive TB patients (b) To detect at least 85 Administration (d) DEC is safe in Pregnancy percent of new sputum smear-positive patients after the 31. Which one of the following strategies is aimed at AIDS first goal is met (c) To achieve at least 85 percent cure rate control in India ? (a) Detection and treatment of AIDS of the newly diagnosed sputum smear-positive TB patients cases in the community (b) Detection and isolation of HIV (d) Both A & B infected persons in the community (c) Immune-prophylaxis15. Which of the following is not a component of DOTS ? of the risk groups (d) Community education behavioral (a) Political and administrative commitment (b) Systematic change monitoring and accountability (c) Supervised treatment to 32. AIDS was first detected in India in the year (a) 1975 (b) ensure the right treatment (d) Health education 1981 (c) 1986 (d) 199116. Which of the following statement is false? (a) Duration of 33. Which of the following is not true about National AIDS Intensive phase of Category I is 8 weeks (b) Duration of control Programme? (a) Sentinel surveillance methodology Continuation phase of Category II is 22 weeks (c) Duration have adopted (b) Community based screening for prevalence of Intensive phase of Category II is 12 weeks (d) None of of HIV taken up (c) Early diagnosis and treatment of STD is the above a major strategy to control spread of HIV (d) Formulating17. The total number of doses in category II is (a) 78 doses guidelines for blood banks donors & dialysis units (b) 102 doses (c) 108 doses (d) 76 doses 34. National Leprosy Eradication programme was started in18. Which of the following Anti tubercular drug is bacteriostatic? (a) 1949 (b) 1955 (c) 1973 (d) 1983 (a) Streptomycin (b) Ethambutol (c) INH (d) Rifampicin 35. Elimination in leprosy stands for (a) Reduce the number19. DOTS plus strategy is for treatment of (a) HIV with TB of cases to < 1/10,000 population (b) Reduce the number (b) Malaria with TB (c) MDR TB (d) All the above of cases to < 1/1000 population (c) No case of leprosy in a20. Drug used in chemoprophylaxis of TB is (a) INH region for 5 years (d) 100 percent treatment of all cases (b) Rifampicin (c) Both of above (d) None of above 36. Which one of the following statements is not correct21. Under NAMP radical treatment of falciparum malaria is , regarding National Leprosy Eradication Programme (NLEP) given for (a) 1 day (b) 5 days (c) 7 days (d) 14 days (a) Multibacillary leprosy treatment is recommended22. All of the following statements about NAMP are true for one year (b) Skin smear examination is done for except: (a) MBER should be equal to fever rate of the classification into paucibacillary and multibacillary month in the community (b) Trends in SPR can be utilized (c) Special Action Project for Elimination of leprosy is for for predicting epidemic situations in the area (c) Annual rural areas (d) Surveillance for two years for a treated case blood examination rate is calculated from the number of of paucibacillary leprosy to be carried out slides examined per 100 cases of fever (d) For calculating 37. India was declared ‘Guinea Worm disease free’ in the year ABER and MBER the denominator is common (a) 1996 (b) 2000 (c) 2001 (d) 200223. Function of FTD is best denoted by: (a) Diagnosis of cases 38. National Mental Health programme was started in + spraying (b) Collection of slides + treatment of fever (a) 1992 (b) 1983 (c) 1994 (d) 1985 (c) Only treating fever cases (d) Treatment + slide collection 39. Which of the following is not a component of AFP + spraying SURVEILLANCE? (a) Case notification (b) Case in Laboratory24. Which of the following diseases are not included under investigation (c) Out break response and active search in NVBDCP ? (a) Malaria (b) Japanese Encephalitis (c) Viral community (d) Attaining high routine immunization encephalitis (d) Dengue 40. Which of the following is not a strategy for achieving Polio25. Choice of insecticide for Kala Azar elimination under Eradication? (a) Attaining high routine immunization NVBDCP is (a) Malathion (b) DDT (c) Malathion+ DDT (b) National Immunization Days (NIDs) (c) Surveillance of (d) DDT Acute Flaccid Paralysis (AFP) (d) Mopping-up immunization26. A person wants to visit a malaria endemic area of low (e) None of the above level chlorquine resistant falciparum malaria The best 41. National Mental Health Programme is (a) Vertical chemoprophylaxis is : (a) Chloroquine (b) Proguanil+ programme (b) Integrated Programme (c) None of the Chloroquine (c) Sulphadoxin + pyrimethamine above (d) Mefloquine 42. National Caner Control Programme was started in (a) 197627. A malaria survey is conducted in 50 villages having a (b) 1986 (c) 1970 (d) 1992 population of one lakh. Out of 20000 slides examined, 43. Under National Cancer Control Programme, oncology 500 turned out to be MP positive. The SPR is (a) 20% wings were sanctioned to - (a) Regional Cancer Institutes (b) 5% (c) 25% (d) 0.4% (b) District Hospital (c) Medical College Hospitals28. Which of the following is an indicator for operational (d) Voluntary Agencies treating cancer patients efficacy? (a) API (b) ABER (c) AFI (d) SPR 44. National Cancer Registry Programme (NCRP) was started29. Anti- malarial month is (a) April (b) May (c) September by (a) Ministry of Health and Family Welfare (b) Indian • 554 •
  • 99. Council of Medical Research (c) Collaboration of (a) and (b) 48. SAFE strategy in vision 2020 is for which eye condition (d) None of the above (a) Trachoma (b) Cataract (c) Onchocerciasis (d) Childhood45. The goal of NIDDCP is (a) To reduce the prevalence of blindness iodine deficiency disorders below 10 percent in the entire 49. Vision 2020 ‘The right to sight’ includes all except country by 2012 AD (b) To reduce the prevalence of iodine (a) Trachoma (b) Epidemic conjunctivitis (c) Cataract deficiency disorders below 5 percent in the entire country (d) Onchocerciasis by 2012 AD (c) To reduce the prevalence of iodine deficiency 50. ICDS is running under (a) Ministry of health and Family disorders below 10 percent in the entire country by 2010 Welfare (b) Ministry of Women and child development AD (d) None of the above (c) Collaboration of both of above (d) None of above46. The best indicator for monitoring the impact of Iodine Answers : (1) b; (2) a; (3) d; (4) c; (5) b; (6) d; (7) a; (8) b; Deficiency Disorders Control Programme is (a) Prevalence (9) a; (10) d; (11) c; (12) a; (13) d; (14) c; (15) d; (16) b; (17) b; of goiter among school children (b) Urinary iodine levels (18) b; (19) c; (20) a; (21) b; (22) c; (23) b; (24) c; (25) d; among pregnant women (c) Neonatal hypothyroidism (26) b; (27) c; (28) b; (29) d; (30) d; (31) d; (32) c; (33) b; (34) d; (d) Iodine level in soil (35) a; (36) b; (37) c; (38) a; (39) d; (40) e; (41) b; (42) a;47. Which one of the following is not a target disease under (43) c; (44) c; (45) a; (46) c; (47) d; (48) a; (49) b; (50) b. ‘Vision 2020: The Right to Sight’ (a) Refractive error (b) Trachoma (c) Corneal blindness (d) Diabetic retinopathy purpose of better understanding: 106 Health Legislations in India 1. Health Facilities and Services 2. Disease Control and Medical Care Sunil Agrawal 3. Human Resources 4. Ethics and Patients Rights 5. Pharmaceutical and Medical DevicesAn important aspect of Preventive Medicine and Public Health 6. Radiation Protectionis legislative control or legislative power. These laws protect 7. Hazardous Substancespublic health at large but it should maintain the balance 8. Occupational Health and Accident Preventionbetween individual autonomy and community protection and 9. Health of the Elderly, Disabled, Rehabilitation and Mentalits actions should be directed to improve the health status in Healththe community. The characteristics of public health laws are: 10. Families, Women and Children1. Responsibility of government as a right to provide adequate 11. Smoking, Alcoholism and Drug Abuse health and health services to all citizens. 12. Social Security and Health Insurance2. Public health laws protect community health rather than 13. Environmental Protection individual’s health. 14. Nutrition and Food Safety3. Public Health contemplates the relationship between the 15. Health Information and Statistics state and the population. 16. Intellectual Property Rights4. Public health laws deals with the delivery of public services 17. Custody, Civil and Human Rights based on scientific methodologies e.g. Purification of 18. Other Aspects not covered by any heading above water. Under the constitutional provisions, the government of India5. The laws acts as important guidelines for the state, owes its population social security, health services, safety, community and individuals. environmental protection, equal opportunity and justice. TheTo achieve the fundamental goals of our constitution various methods adopted by the government to deliver these servicesacts and rules are enacted. are through framing policies, execution of legislation andAct : Act means statutes or laws adopted (enacted) by a national implementation of programs. The provision of an act is furtheror state legislative assembly or other governing body. explained in detail in rules and regulations. Public healthRules: Rules are explicit statements that tell an individual officials enforce rules through following ways:what he or she ought to do or ought not to do. a) Permits, licenses and registrationsImportant legislations in India pertaining to public health and b) Administrative ordersits protection are grouped in the following categories for the c) Civil penalties d) Injunctions • 555 •
  • 100. Legislations are not an end in themselves. They have to ●● Dental Council of India Regulations, 1955, 1956, 1984,be executed in letter and spirit by a responsible society 2006and the officials responsible for their implementation. ●● Dental Council (Election) Regulations, 1952Often these legislations may not be able to bring about the ●● BDS, MDS Course Regulations, 1983desired result. There are many factors responsible for lack of ●● Establishment of Dental Colleges, 1993effectiveness of these legislations, viz., Lack of awareness, PharmacyLack of implementation, Corruption, Lack of infrastructure, ●● Pharmacy Act, 1948Inconsistency and, Inadequacy. To overcome these problems ●● Pharmacy Council of India - RegulationsGovernment of India has initiated National Legal Literacy NursingMission in 2005 to impart knowledge and education on various ●● Indian Nursing Council Act, 1947legal aspects including those related to Public Health. This ●● Indian Nursing Council Regulationsprogramme seeks to sensitise, and create awareness among Rehabilitationpeople about their legal rights, acts and regulations and ●● Rehabilitation Council of India Act and Regulations, 1992,interpretation of legal jargon. 1997, 1998Laws in relation to Health Facilities and Services Laws in relation to Ethics and Patients Rights●● Indian Red Cross Society Act, 1920 ●● Consumer Protection Act and Rules, 1986, 1987, 2002●● All India Institute of Medical Sciences Act, 1956 ●● Ethical Guidelines for Biomedical Research on Human●● Post Graduate Institute of Medical Education and Research, Subjects, 2000 Chandigarh, Act, 1966 ●● Right to Information Act and Rules, 2005●● Bureau of Indian Standards Act and Rules, 1986, 1987 ●● Central Information Commission (Appeal Procedure) Rules,●● National Institute of Pharmaceutical Education and 2005 Research Act, 1998●● Clinical Establishment Acts Laws in relation to Pharmaceutical and Medical a. Nursing Homes Registration Acts Devices b. State Clinical Establishment Acts and Rules ●● Drugs and Cosmetics Act, 1940, 2005, 2006Laws in relation to Disease Control and Medical Care ●● Drugs Control Act, 1950 ●● Drug and Magic Remedies (Objectionable Advertisement)●● Epidemic Diseases Act, 1897 Act, 1954●● Indian Aircraft Act and Rules, 1934, 1954 ●● Department of Ayurveda, Yoga and Naturopathy, Unani,●● Indian Port Health Rules, 1955 Siddha and Homeopathy (Ayush) Orders, 2005●● Medical Termination of Pregnancy Act, 1971, 1975●● Transplantation of Human Organs Act and Rules, 1994, Laws in relation to Radiation Protection 1995, 2002 ●● Atomic Energy Act and Rules, 1962, 1984●● Prenatal Diagnostic Techniques (Regulation and Prevention ●● Radiation Protection Rules, 1971 of Misuse) Act and Rules, 1994, 1996, 2002, 2003 ●● Radiation Surveillance Procedures for Medical Application of Radiation, 1980, 1989Laws in relation to Human Health Care Resources ●● Atomic Energy (Working of the Mines, Minerals andThe professional ethics, quality control of education Handling of Prescribed Substance) Rules, 1984, 1987programmes, standards etc. are important for all the systems ●● Safety Code for Medical Diagnostic X-Ray Equipment andof medicine, hence there are acts and regulations which are Installationsenumerated below: Laws in relation to Hazardous SubstancesAllopathy ●● Narcotic Drugs and Psychotropic Substances Act and●● Indian Medical Council Act and Rules, 1956, 1957, 1965, Rules, 1985 1993, 2001, 2002. ●● Prevention of Illicit Traffic in Narcotic Drugs and●● Medical Council of India 1994, 1998, 2000, 2001 Psychotropic Substances Act, 1988●● Establishment of New Medical Colleges, Higher Course ●● Hazardous Wastes (Management and Handling) Rules, Regulations, 1993. 1989, 2002●● Eligibility Requirement for Taking Admission in Undergraduate Medical Course in a Foreign Medical Laws in relation to Occupational Health and Accident Institution Regulations, 2002. PreventionIndian System of Medicine and Homeopathy India is signatory to many International treatise and ILOs●● Indian Medicine Central Council Act and Regulations, convention on occupational health. To bridge the large gap in 1970, 1989, 2005 health status of workers and provide a safe and secure work●● Homeopathy Central Council Act, 1973, 2002 place certain legislations are required to be enacted to ensure●● Homeopathy Education Courses, Standards, 1983 health and safety of the workers, these legislations are as●● Homeopathy Practitioners (Professional Conduct, Etiquettes under: and Code of Ethics) Regulations, 1982 ●● Workmen’s Compensation Act, 1923Dentistry ●● Factories Act 1948, 1987●● Dentist Act, 1948, 1993 ●● Mines Act, 1952, 1957 • 556 •
  • 101. ●● Motor Transport Workers Act, 1961 ●● Air (Prevention and Control of Pollution) Act and Rules,●● Personal Injuries (Emergency Provisions) Act, 1962, 1963 1981, 1982, 1983●● Beedi and Cigar Workers Act, 1966 ●● Environment (Protection) Act, 1986, 2002●● Child Labour (Prohibition and Regulation) Act, 1986 ●● Bhopal Gas Leak Disaster Act, 1985, 1992●● Dock Workers (Safety, Health and Welfare) Rules, 1990 ●● Central Board for the Prevention and Control of Water●● Public Liability Insurance Act and Rules, 1991 Pollution (Procedure for Transaction of Business) Rules,●● Building and Other Construction Workers Act, 1996 1975●● Fatal Accidents Act, 1855 Laws in relation to Nutrition and Food Safety●● Contract Labour (Regulation and Abolition) Central Rules, ●● Prevention of Food Adulteration Act and Rules, 1954, 1971 1955, 2001, 2002Laws in relation to Elderly, Disabled, Rehabilitation ●● Infant Milk Substitutes, Feeding Bottles and Infant Foodsand Mental Health Act and Rules, 1992, 1993, 2003●● Mental Health Act, 1987 ●● Atomic Energy (Control of Irradiation of Food) Rules,●● Central and State Mental Health Rules, 1990 1996●● Persons with Disabilities (Equal Opportunities, Protection ●● Food Safety and Standards Act, 2006 of Rights and Full Participation) Act, 1995, 1996 Laws in relation to Health Information and Statistics●● National Trust for Welfare of Persons with Autism, Cerebral ●● Births, Deaths and Marriages Registration Act, 1886 Palsy, Mental Retardation and Multiple Disabilities Act, ●● Registration of Births and Deaths Act, 1969 1999, 2000 ●● Collection of Statistics Act and Rules, 1953, 1959Laws in relation to Family, Women and Children ●● Census Act, 1948, 1993●● Special Marriage Act, 1954 Laws in relation to Intellectual Property Rights●● Hindu Marriage Act, 1955 ●● Patents Act and Rules, 1970, 1972, 2005●● Children Act, 1960 ●● Arbitration and Conciliation Act, 1996●● Dowry Prohibition Act, 1961 ●● Trade Marks Act, 1999●● Suppression of Traffic in Women and Girls Act, 1956 ●● Laws in relation to Custody, Civil and Human Rights●● National Commission for Women Act, 1990 ●● Indian Penal Code, 1860●● Juvenile Justice (Care and Protection of Children) Act, ●● Unlawful Activities (Prevention) Act, 1967 2000 ●● Protection of Human Rights Act, 1993Laws in relation to Smoking, Alcoholism and Drug Laws in relation to Other (Miscellaneous) IssuesAbuse ●● Essential Commodities Act, 1955●● Cigarettes (Regulation of Production, Supply and ●● Standards and Weights Measures Act, 1976 Distribution) Act, 1975●● Cigarettes and Other Tobacco Products (Prohibition of The Consumer Protection Act (CPA), 1986 Advertisement and Regulation of Trade and Commerce, The CPA is a comprehensive legislation in which consumers Production, Supply and Distribution) Act and Rules, 2003, can approach with complaints to Commissions at the District, 2004 state and central level without any lawyers and there is no●● Cigarettes and Other Tobacco Products (Prohibition of court fee. Sale on Cigarettes and Other Tobacco Products around The CPA protects following consumer rights Educational Institutions) Rules, 2004 1. Right to safetyLaws in relation to Social Security and Health 2. Right to be informedInsurance 3. Right to choose●● Minimum Wages Act, 1948 4. Right to be heard●● Employees State Insurance Act and Rules, 1948, 1950 5. Right to seek redressal●● Life Insurance Corporation Act, 1956 6. Right to consumer education●● Maternity Benefit Act, 1961, 1963 Under this Act a complainant can file any allegation in writing●● Insurance Regulatory and Development Authority Act, about: 1999, 2000, 2001, 2002 a) A loss or damage suffered as a result of any unfair tradeLaws in relation to Environmental Protection practice adopted by the traderEnvironmental protection is one of the most important global b) The goods / service suffers from one or more defectsrequirements of today. There are many provisions in the c) An excess price is charged than the one displayed for theconstitution of India to safeguard the environment and state is goods or servicemade responsible for this. There are many Acts in the country The Supreme Court declared that like other service providersto protect the environment and mankind. These are as under: under contract, doctors who offer services for the price●● Insecticides Act and Rules, 1968, 1971, 1993, 2000 offered are also under the same obligation to compensate the●● Water (Prevention and Control of Pollution) Act and Rules, purchaser (patient) for any deficiency in the quality of their 1974, 1975, 1977, 1978, 2003 services. Doctors in government service, charitable clinics providing free service are exempted from CPA. If the cost of the • 557 •
  • 102. services or goods and compensation is less than 5 lakhs then to mobilise infected persons or community to prevent spreadthe complaint can be filed in the district forum. If the cost is up of epidemic. State or Central Government can inspect any shipto 10 lakhs then the complaint is filed with State Commission or vessel leaving or arriving at any port in the territories andand for higher amounts the case is registered with National take appropriate action as prescribed. Violation of this Act isCommission at New Delhi. punishable under sec 188 of the IPC.The punishment for the guilty under the Act is imprisonment The Drugs and Cosmetics Act, 1940 (Amendedfor minimum one month extendable up to three years or finenot less than Rs 2000/- extendable up to Rs 10,000/- or both. in 1964, 1983, 1995)Negligence means that, ‘a person who holds himself ready to The Drugs and Cosmetics Act is mainly aimed to regulategive medical advice and treatment implied undertakes that the import, manufacture, distribution and sale of Drugs andhe possesses the skills and knowledge for that purpose. Such Cosmetics, presumably for maintaining high standards ofperson when consulted by a patient owes him certain duties medical treatment. Substandard medicines / drugs may causenamely a duty of care in deciding what treatment to give or a severe damage to lives of people.duty of care in the administration of that treatment. A breach The Act extends to the whole of India. In this Act the drug isof any of those duties gives a right of action for negligence to defined as, ‘All Medicines (Ayurveda, Siddha, and Unani) forthe patient’. internal or external use of human being or animals and all substances (other than food) intended to be used for or in theRegistration of Births and Deaths Act, 1969 diagnosis, treatment, mitigation or prevention of any diseaseIn India, vital statistics are generated through Civil Registration or disorder in human beings or animals including preparationSystem (Registration of births and deaths), sample registration applied on human body or to destroy insects’.system, decennial population census, rural survey of cause of The Central or State government have power to make rules anddeath, medical certification of causes of death from hospitals appoint inspector to control or inspect any drug or cosmeticand health centres and adhoc surveys conducted by national for its standardization and safety which can be tested in theand international research organizations. Central or State Drug laboratory. The Government can prohibitThe Registration of Births and Deaths Act was implemented in manufacturing, importing or selling of any drug or cosmetic.1969 with the aim to collect and compile vital statistics which Violation of law by any person or corporate manager or owneris necessary for planning and administration. The Act has given is liable for punishment for a term which may extend to 3-10statutory authority to the Registrar General, India to coordinate years and shall also be liable to fine which could be fivethe work of civil registration through out the country. In rural hundred or ten thousand rupees or with both.areas, the local registrars are mainly drawn from panchayat, Drugs and Cosmetic Rules 1995 contains the list of drugs forpolice, health or revenue departments. In urban areas, health which license is required by manufacturer, importers, andofficers of the municipalities or corporations or the executive exporters. Recently ‘in vitro’ blood groups, sera and in vitroofficers are the Registrars. diagnostic devices for HIV, HBsAg, and HCV are also includedEvery registrar has to register births and deaths, occurring in schedule CI. All imported drugs in indigenous manufacturerswithin his/her administrative areas. The information regarding have to register to control over the quality of imported as welloccurrence is to be given within 21 days in both the events of as locally manufacturing kits.births and deaths. Delayed registration requires late fee andaffidavit from notary public. Every registering authority sends The Medical Termination of Pregnancy Act,periodical returns to the Chief Registrar who in turn sends it to 1971Registrar General of India. Registrar General brings out every (It extends to the whole of India except the State of Jammu andyear annual report called ‘Vital Statistics of India”. Kashmir.)The Act also provides for medical certification of cause of death. Registered Medical Practitioners who may terminateA medical officer has to certify free of cost in the prescribed Pregnancies : A pregnancy may be terminated by a Registeredformat, the cause of death if he/she is attending the deceased Medical Practitioner (RMP) registered under the MCI Act, andduring his last breath or illness. those who have undergone 6 months housemanship or 3 years post graduate training in obstetrics and gynaecology or anyEpidemic Diseases Act, 1897 registered medical practitioner who have conducted 25 cases ofThe Act provides power to exercise for the control and to MTP in approved institution. Where the length of the pregnancyprevent any epidemic or spread of epidemic in the States or does not exceed twelve weeks, then one RMP can conduct MTPCountry. The states may authorise any of its officers or agency and if the length of the pregnancy exceeds twelve weeks butto take such measures if the state feels that the public at large does not exceed twenty weeks, opinion of not less than twois threatened with an outbreak of any dangerous epidemic registered medical practitioners are required to certify the valid(Sec. 2). Person who is inspecting, is empowered to determine reasons as per the law for discontinuation of pregnancy.about the process and authority to take responsibility of all Conditions under which MTP can be carried out :expenses incurred in compensation, travelling, temporaryaccommodation, segregation of infected person, etc. The State (i) Therapeutic : The continuance of the pregnancy wouldGovernment can authorise the Dist. Magistrate or other officials involve a risk to the life of the pregnant woman or of graveto utilise any resources in terms of man, money and material injury to physical or mental health. • 558 •
  • 103. (ii) Eugenic : There is a substantial risk that if the child were Further details of Workmen Compensation Act and other lawsborn, it would suffer from such physical or mental abnormalities in relation to industrial health are discussed in detail in theas to be seriously handicapped. section on Occupational health in this book.(iii) Social : When economic and social environment is not The Water (Prevention and Control ofsuitable for continuation of pregnancy or due to failure ofany method used by couple for the purpose of limitation of Pollution) Act 1974children. This Act was passed by the Parliament in 1974 to counter and(iv) Humanitarian : It involves pregnancy due to rape. contain ever growing pollution of natural water resources. This Act is comprehensive in providing the legal basis for prevention(v) Lunatic : When pregnant women is mentally not sound or and control of water pollution, maintenance and restoration oflunatic. wholesomeness of water sources in the country.Note : No pregnancy shall be terminated except with the Definitionsconsent of the pregnant woman. Under the Act important definitions are:Place where pregnancy may be terminated : No terminationof pregnancy shall be made in accordance with this Act at any a) Pollution : Pollution means contamination of water or suchplace other than : alteration of the physical, chemical or biological properties of(a) a hospital established or maintained by Government, or water or such discharge of any sewage or trade effluent or of(b) a place for the time being approved for the purpose of this any other liquid, gaseous or solid substance into water as may, Act by Government. or is likely to create a nuisance or render such water harmful or injurious to public health or safety, or to domestic, commercial,Punishment : Termination of pregnancy not falling under the industrial, agricultural or other legitimate uses, or to the lifepurview of MTP Act is an offence punishable with rigorous and health of animals or plants or of aquatic organisms.imprisonment for a term which shall not be less than 2 yearsup to maximum 7 years. b) Sewage Effluent : Sewage Effluent means effluent from any sewerage system or sewage disposal works and includesThe Workmen’s Compensation Act, 1923, sullage from open drains.1984, 2000 c) Trade Effluent : Trade Effluent includes any liquid, gaseousAs per the Workmen’s Compensation Act, any worker employed or solid substance which is discharged from any premises usedin wide varieties of hazardous occupations by an employer, for carrying on any industry, operation or process, or treatmentif suffers an injury, he/she is eligible for compensation. If he and disposal system, other than domestic sewage.dies then legal dependents can claim the benefits provided by To execute the aforesaid purposes, the Act provides forthe Act. The ‘employer’ includes any body of persons whether the constitution of Central, State and Joint Boards havingincorporated or not and any managing agent of an employer prescribed powers and functions. These boards are to be calledand the legal representative of a deceased employer and when Pollution Control Boards. The main function of the Centralthe services of a workman are temporarily lent or let on hire Board shall be to promote cleanliness of watercourses into another person by the person with whom the workman has different areas of the States. The Board has been conferred theentered into a contract of service or apprenticeship means such power to perform several functions i. e., advisory to the Centralother person while the workman is working for him; Govt; co-ordinating the activities of the State Boards; provideThe disablement means the loss in the earning capacity of technical assistance and guidance to the state board, carry outa workman in every employment which he was capable of and sponsor investigations and research relating to problemsdoing at the time of accident. Its effect may be temporary or of water pollution and their abatement; plan and organizepermanent. To enter into contract of Workmen’s Compensation training of persons engaged or to be engaged in programmes forAct, and claim for an occupational disease, he or she should prevention and control; collect, compile and publish technicalhave been employed in the specified occupation for at least 6 and statistical data related to the subject; to lay down, modifymonths. or annul the standards for a water course; plan and cause to be executed, nationwide programmes and so on.The compensation is paid to the workers according to thedamage: The Board may establish or recognize laboratories to enable1. In case of death, compensation is paid to the dependents; it to perform its functions including the analysis of samples 40 percent of the monthly wage, multiplied by factor or Rs of water, sewage or trade effluents. The State Boards, under 20,000/- whichever is more. the guidance of Central Board, are similarly responsible to plan2. In case of permanent disablement; 50 percent of the monthly and execute comprehensive programmes in their respective wage, multiplied by factor, or Rs.24,000/- whichever is territories. They have also been conferred the powers of entry more. into any premises after giving due notice to the owner and collect3. In case of partial permanent disablement; the compensation samples of water, sewage and trade effluents for analysis and is percentage of that payable in case of total permanent recommend necessary legal steps. The State Governments, under disability as given in schedule I. advice from the Board, are also authorised to take emergency4. In case of total or partial temporary disablement; a sum measures when pollutants have entered or threatened to enter equal to 25 percent of the monthly wages of the workman the watercourse due to accidental or unforeseen event or act of shall be paid half yearly. omission or commission. A joint Board is set up on subjects of • 559 •
  • 104. common interest by mutual agreement either between adjacent Functions of Central Boardstates or between the states(s) and the Central Govt. when (1) To improve the quality of air and to prevent, control orthe latter has been appointed as the executing agency for the abate air pollution in the country.Union Territories. (2) To advise the Central Government on any matter concerningPunishments : Any person or organisations which fail to comply the improvement of the quality of air and the prevention,with regulations of this Act can be convicted and punished with control or abatement of air pollution.imprisonment of 3 months or fine up to Rs 10,000/ or with (3) Plan and cause to be executed a nationwide programme forboth. If offender repeats the offence then additional fine up to the prevention, control or abatement of air pollution.Rs 5,000/ for everyday, during which such failure continues (4) Co-ordinate the activities of the State Boards and resolveafter the conviction for the first such failure. disputes among them.If the failure continues beyond a period of 1 year after the date (5) Provide technical assistance and guidance to the Stateof conviction, the offender shall, on conviction, is punishable Boards, carry out and sponsor investigations and researchwith imprisonment for a term which shall not be less than 2 relating to problems of air-pollution and prevention,years but which may extend to 7 years and with fine. control or abatement of air pollution. (6) Plan and organise the training of persons engaged or toAir (Prevention and Control of Pollution) Act, be engaged in programmes for the prevention, control or1981 abatement of air pollution on such terms and conditions as the Central Board may specify.The Air (Prevention and Control of Pollution) Act, 1981 is (7) Organise through mass media a comprehensive programmean Act to provide for prevention, control and abatement of regarding the prevention, control or abatement of airair pollution. The Act is an outcome of the United Nations pollution.Conference on the Human Environment held in Stockholm in (8) Collect, compile and publish technical and statistical dataJune, 1972. The Act extends to whole of India. relating to air pollution and the measures devised for itsDefinitions effective prevention, control or abatement and prepareIn this Act, important definitions are - manuals, codes or guides relating to prevention, control or abatement of air pollution.(a) Air Pollution : Air Pollution means any solid, liquid or (9) Lay down standards for the quality of air.gaseous substance (including noise) present in the atmosphere (10) The Central Board may establish or recognise a laboratoryin such concentration as may be or tend to be injurious to or laboratories to enable the Central Board to perform itshuman beings or other living creatures or plants or property functions under this section efficiently.or environment. (11) The Central Board may delegate any of its functions under(b) Automobile : Automobile means any vehicle powered either this Act generally or specially to any of the committeesby internal combustion engine or by any method of generating appointed by it.power to drive such vehicle by burning fuel. CPCB has power to restrict use of any area, automobile,(c) Control Equipment : Control Equipment means any or industry having or causing air pollution. Any personapparatus, device, equipment or system to control the quality empowered by pollution control boards shall have right to enter,and manner of emission of any air pollutant and includes any at all reasonable times as he considers necessary, any place fordevice used for securing the efficient operation of any industrial seizing or examining and testing any control equipment, airplant. sampling, industrial plant, record, register, document or any(d) Emission : Emission means any solid or liquid or gaseous other material object or for conducting a search of any place insubstance coming out of any chimney, duct or fuel or any other which he has reason to believe that an offence under this Actoutlet. or the rules has been made.(e) Industrial Plant : Industrial Plant means any plant used for Punishmentany industrial or trade purposes and emitting any air pollutant Whoever fails to comply with the provisions shall be punishedinto the atmosphere. with imprisonment for a term which shall not be less than one(f) Occupier : Occupier, in relation to any factory or premises, year and six months but which may extend to six years andmeans the person who has control over the affairs of the factory with fine, and in case failure to comply continues, an additionalor the premises, and includes, in relation to any substance, the fine may be imposed which may extend to Rs 5,000/- for everyperson in possession of the substance. day during which such failure continues after the convictionCentral Pollution Control Board (CPCB) for the first such failure.The Central Pollution Control Board constituted under Section If the failure continues beyond a period of 1 year after the date3 of the Water (Prevention and Control of Pollution) Act, of conviction, the offender shall, on conviction, is punishable1974 (6 of 1974), shall, without prejudice to the exercise with imprisonment for a term which shall not be less than 2and performance of its powers and functions under that Act, years but which may extend to 7 years and with fine.exercise the powers and perform the functions of the CentralPollution Control Board for the prevention and control of airpollution under this Act. • 560 •
  • 105. The Transplantation of Human Organs Act, therapeutic after the commencement of this Act unless such hospital is duly registered under this Act.1994An Act to provide for the regulation of removal, storage and Punishment for Removal of Human Organ withouttransplantation of human organs for therapeutic purposes and Authorityfor the prevention of commercial dealings in human organs. (1) Any person who renders his services to or any hospital and who, for purposes of transplantation, conducts, associatesDefinitions with, or help in any manner in, the removal of anyIn this Act, some important definitions are : human organ without authority, shall be punishable with(a) Brain-stem death : Brain-stem death means the stage at imprisonment for a term which may extend to five yearswhich all functions of the brain-stem have permanently and and with fine which may extend to ten thousand rupees.irreversibly ceased. (2) Where any person convicted under sub-section (1) is a(b) Deceased Person : Deceased Person means a person in registered medical practitioner, his name shall be reportedwhom permanent disappearance of all evidence of life occurs, by the Appropriate Authority to the respective State Medicalby reason of brain-stem death or in a cardio-pulmonary sense, Council for taking necessary action including the removalat any time after live birth has taken place. of his name from the register of the Council for a period of two years for the first offence and permanently for the(c) Donor : Donor means any person, not less than eighteen subsequent offence.years of age, who voluntarily authorises the removal of any ofhis human organs for therapeutic purposes. Punishment for Commercial Dealings in Human Organs(d) Human Organ : Human Organ means any part of a humanbody consisting of a structured arrangement of tissues which, Whoeverif wholly removed, cannot be replicated by the body. (a) makes or receives any payment for the supply of, or for an(e) Near Relative : Near Relative means spouse, son, daughter, offer to supply, any human organ; (b) seeks to find a personfather, mother, brother or sister. willing to supply for payment any human organ; (c) offers to supply any human organ for payment; (d) initiates or negotiates(f) Transplantation : Transplantation means the grafting of any arrangement involving the making of any payment forany human organ from any living person or deceased person to the supply of, or for an offer to supply, any human organ; (e)some other living person for therapeutic purposes. takes part in the management or control of a body of persons,Authority for Removal of Human Organs whether a society, firm or company, whose activities consistAny donor may, in such manner and subject to such conditions of or include the initiation or negotiation of any arrangementas may be prescribed, authorise the removal, before his death, referred to in clause (d); or (f) publishes or distributes or causesof any human organ of his body for therapeutic purposes in to be published or distributed any advertisement.writing and in the presence of two or more witnesses use for Shall betherapeutic purposes. And no such removal shall be made by Punishable with imprisonment for a term which shall not beany person other than the registered medical practitioner. less than two years but which may extend to seven years andAuthority for Removal of Human Organs in Case of shall be liable to fine which shall not be less than ten thousandUnclaimed Bodies in Hospital or Prison rupees but may extend to twenty thousand rupees.In the case of a dead body lying in a hospital or prison and not Punishment for Contravention of any other Provisionclaimed by any of the near relatives of the deceased person of this Act.within forty-eight hours from the time of the death of the Whoever contravenes any provision of this Act or any ruleconcerned person, the authority for the removal of any human made, or any condition of the registration granted, thereunderorgan from the dead body which so remains unclaimed may be for which no punishment is separately provided in this Act,given, in the prescribed form, by the person in-charge, for the shall be punishable with imprisonment for a term which maytime being, of the management or control of the hospital or extend to three years or with fine which may extend to fiveprison, or by an employee of such hospital or prison authorised thousand this behalf by the person in charge of the management orcontrol thereof. The Immoral Traffic (Prevention) Act, 1956Restrictions on Removal and Transplantation of An Act to provide in pursuance of the International ConventionHuman Organs signed at New York on the 9th day of May, 1950, for theNo human organ removed from the body of a donor before his prevention of immoral traffic. Any person who keeps ordeath shall be transplanted into a recipient unless the donor is maintains or acts or assists in the keeping and management ora near relative of the recipient. a brothel, is liable to be punished under this section.Registration of Hospitals Engaged in Removal, DefinitionsStorage or Transportation of Human Organs. Some of the definitions in this Act are :No hospital shall commence any activity relating to the (a) Brothel : Brothel includes any house, room, conveyance orremoval, storage or transplantation of any human organs for place, or any portion of any house, room, conveyance or place, • 561 •
  • 106. which is used for purposes of sexual exploitation or abuse for (a) imprisonment upto 6 months or fine upto Rs. 500/- orthe gain of another person or for the mutual gain of two or both, on first conviction; and (b) imprisonment upto 1more prostitutes. year and fine upto Rs. 500/-, in the event of a second or(b) Prostitution : Prostitution means the sexual exploitation or subsequent conviction.abuse of persons for commercial purposes or for consideration But, a man who commits any of offences under this section,in money or in any other kind, and the expression “prostitute” shall be punishable with imprisonment for not less than 7shall be construed accordingly. days but upto 3 months.(c) Child : Child means a person who has not completed the Prostitution is a social evil and indicates poverty, weak socialage of 16 years. fabric, alcoholism and lower status of women. Immoral traffic will not only lead to lower social morals but also spread of(d) Major : Major means a person who has completed the age certain killer diseases like STIs, HIV/AIDS etc. There is aof 18 years. increasing prevalence of HIV/AIDS noticed in commercials sex(e) Minor : Minor means a person who has completed the age workers.of 16 years but has not completed the age of 18 years. The Child Marriage Restraint Act, 1929Offences and Punishments in this Act are: The Act extends to whole of India except state of J & K. the Act1. Any person who keeps, or manages, or acts or assists in is expedient to restrain the solemnisation of child marriages. the keeping or management of, a brothel, shall be liable to be punished with - Definitions (a) rigorous imprisonment for not less than 1 year but upto Under this Act some definitions are : 3 years and also fine upto Rs.2,000/-, on first conviction; (a) Child : Child means a person who, if a male, has not and completed twenty one years of age, and if a female, has not (b) rigorous imprisonment for not less than 2 years but completed eighteen years of age. upto 5 years and also fine upto Rs. 2000/-2. Any person who procures or induces any person for the (b) Child Marriage : Child Marriage means a marriage to which purpose of prostitution; or takes, causes or induces any either of the contracting parties is a child. person to carry on prostitution, shall be punishable with- (c) Minor : Minor means a person of either sex who is under (a) rigorous imprisonment for not less than 3 years but eighteen years of age. upto 7 years; and Punishments (b) fine upto Rs. 2,000/- a) Any male above eighteen years of age and below 21 years,3. Any person over the age of 18 years who knowingly lives contracts a child marriage shall be punishable with simple on the earnings of the prostitution of any other person, imprisonment which may extend to 15 days, or with fine shall be liable to be punished with imprisonment upto 2 which may extend to Rs 1,000/- or with both. years, or fine upto Rs. 1,000/-, or both. b) Any male above 21 years of age contracts a child marriage But, where such earnings relate to the prostitution of a shall be punishable with simple imprisonment, which may child or a minor, the offender shall be liable to be punished extend to 3 months and shall also be liable to fine. with imprisonment for a term of not less than 7 years c) Where a minor contracts a child marriage, any person and not more than 14 years. having charge of the minor, whether as parent or guardian4. Any person who detains any other person in any brothel, or in any other capacity, lawful or unlawful, who does not or in or upon any premises, for the purpose of prostitution, act to promote the marriage or permits it to be solemnised shall be liable to be punished with imprisonment for not shall be punishable with simple imprisonment up to 3 less than 7 years but upto for life; or imprisonment upto 10 months and shall also be liable to fine. It is a cognisable years and also fine. offence and person can be arrested without the warrant or5. Any person who carries on prostitution in or in the vicinity without the orders of a Magistrate. of public places which are within a distance of two hundred metres of any place of public religious worship, educational Bio Medical Waste (Management and institution, hostel, hospital, nursing home or such other Handling) Rules 1998 public place of any kind as may be notified in this behalf This is dealt in detail in an exclusive chapter in this book. by the Commissioner of Police or Magistrate in the manner prescribed. Any person who commits an offence shall be Municipal Solid Waste (Management and punishable with - Handling) Rules, 2000 (a) imprisonment for not less than 7 years but for life; or (b) imprisonment upto10 years and also fine. The solid waste generated in urban areas is increasing everyday.6. Any woman who tempts, or attracts, or endeavours The characteristics of the waste generation are changing with to tempt or attract the attention of, any person for more disposable plastic items being wasted along with other the purpose of prostitution; or solicits or molests non decomposable low combustible items. On an average 0.2- any person, or loiters or acts to cause obstruction or 0.5 kg of solid waste per capita per day is generated in the annoyance to persons or to offend against public decency, Indian cities and the civic authorities collect about 35 million for the purpose of prostitution, shall be punishable with - tons of municipal solid waste every year. There are various reasons for poor management of solid waste in urban areas • 562 •
  • 107. such as lack of fund, lack of technology, lack of awareness and Executive Officer : For every cantonment there shall be anpeople’s participation, inadequate staff etc. Under the EPA 1986 Executive Officer appointed by the Central Government or byto safeguard the environment and human health government of such person as the Central Government may authorise in thisIndia has laid down Municipal solid waste management rules. behalf. The Executive Officer shall have the following duties :-These rules lay down the responsibility of management of solid (a) exercise all the powers and perform all the duties conferredwaste disposal and various standards for disposal of treated or imposed upon him by or under this Act or any other law forleachate. The management of solid waste has been made the the time being in force; (b) prescribe the duties of, and exerciseresponsibility of municipal authority. The district magistrate / supervision and control over the acts and proceedings of, officersdeputy commissioner shall have the over all responsibility for and other employees of the Board, other than medical officerthe enforcement of the provisions under these rules. Refuse in charge of the cantonment general hospital or dispensary;based fuel technology has been advocated by the government (c) be responsible for the custody of all records of the Board;and wastes like plastic generate energy but also emits (d) arrange for the performance of such duties relative to thecarcinogens such as dioxins into air. By 2020, it is decided that proceedings of the Board or of any Committee of the Board or50 percent of municipal solid waste and 70 percent of the other of any Committee of Arbitration constituted under this Act, aswaste must be recycled. those bodies may respectively impose on him; (e) comply with every requisition of the Board on any matter pertaining to theCantonments Act 1924 administration of the cantonment.An Act to consolidate and amend the law relating to theadministration of cantonments. Summary The Public Health Legislations aims to improve the healthIt extends to the whole of India. The important definitions in status of the community by maintaining the balance betweenthis Act are:- individual autonomy and community protection. GovernmentDefinitions of India has initiated, National Legal Literacy Mission in 2005(a) Assistant Health Officer : Assistant Health Officer means to impart knowledge and education on various legal aspects.the medical officer appointed by the officer Commanding-in- The CPA is a comprehensive legislation in which consumers canChief to be the Assistant Health Officer for a cantonment. approach with complaints to Commissions at the District, state(b) Board : Board means a Cantonment Board constituted and central level without any lawyers and court fee. Doctorsunder this Act. in government service, charitable clinics providing free service(c) Civil Area : Civil Area means an area declared to be a civil are exempted from CPA.area by the Central Government. The Registration of Births and Deaths Act was implemented(d) Executive Officer : Executive Officer means the person in 1969 with the aim to collect and compile vital statisticsappointed under this Act to be the Executive Officer of a which is necessary for planning and administration. The Actcantonment. has given statutory authority to the Registrar General, India to coordinate the work of civil registration throughout the(e) Health Officer : Health Officer means the senior executive country. Every registrar has to register births and deaths,medical officer in military employed on duty in a cantonment. occurring within his/her administrative areas. The informationConstitution of Cantonment Boards regarding occurrence is to be given within 21 days in both theIn Class I cantonments (population exceeding 10,000) & class events o