FIFTH CONFERENCE OF CENTRAL COUNCIL OF HEALTH & FAMILY WELFARE

Item

Title: FIFTH CONFERENCE OF CENTRAL COUNCIL OF HEALTH &
FAMILY WELFARE
extracted text: AGENDA NOTES

MW

CONFERENCE OF
CENTRAL COUNCIL OF
HEALTH 0 FAMILY WELFARE

PARLIAMENT HOUSE ANNEXE
JANUARY 8-10,1997

GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
NEW DELHI

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i?AGENDA NOTES

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PARLiram HOMSH fflESESE
JANUARY 8-10,1997
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GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
NEW DELHI
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CONTENTS
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AGENDA
ITEM NO.

I.

TARGET FREE APPROACH AND DECENTRALISED
PLANNING FOR FAMILY WELFARE PROGRAMME

1

II.

SHARING OF THE COST OF FAMILY WELFARE
PROGRAMME BY STATES AS RECOMMENDED
BY THE COMMITTEE ON POPULATION OF THE
NATIONAL DEVELOPMENT COUNCIL

3

III.

PULSE POLIO IMMUNIZATION - REVIEW OF
1995-96 AND PLANNING FOR 1996-97

5

IV.

REVIEW OF SPECIAL SCHOOL HEALTH CHECK UP
PROGRAMME OF 1996

8

V.

INCREASING THE EFFECTIVE AGE OF MARRIAGE
AND PROMOTION OF INFORMATION, EDUCATION
AND COMMUNICATION IN THE COMMUNITY TO
DELAY THE FIRST BIRTH

15

VI

STRENGTHENING OF PRIMARY, SECONDARY &
TERTIARY HEALTH CARE DELIVERY SYSTEM
IN COMPLIANCE OF ORDER OF HON’BLE
SUPREME COURT - MAY, 1996

18

VII

ALL INDIA HOSPITALS POST PARTUM
PROGRAMME, URBAN FAMILY WELFARE
CENTRES AND URBAN REVAMPING SCHEME
AND RURAL FAMILY WELFARE CENTRES

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VIII

INCENTIVESAND DISINCENTIVES RECOMMENDED
IN THE REPORT OF THE COMMITTEE ON POPULATION
OF THE NATIONAL DEVELOPMENT COUNCIL

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IX

REVIEW OF PREPARATION OF DISTRICT
TRAINING PLANS WITH SPECIAL EMPHASIS
ON TRAINING OF ANMs AS TRAINERS OF DAIS

39

COMMUNITY AWARD SCHEME AND FAMILY
WELFARE PLAN FOR WATERSHED PROJECT AREAS

45

OBSERVANCE OF “MATRI SURAKSHA ABHIYAN” ONCE
EVERY WEEK FOR IMPROVED HEALTH OF WOMEN
WITH SPECIAL EMPHASIS ON REPRODUCTIVE HEALTH

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PROGRAMMES CONCERNING FAMIL Y WELFARE SECTOR

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Dental Problems: National average 11.13%, 20 States/UTs are above the national
average.

The programmatic implications of this data will require an indepth analysis

after the detailed data from all districts is received. However, States were advised
to initiate action in the following areas immediately;

a)

The problems like anaemia, dental carries, worm infestation, night blindness
and scabies are preventable. Activities like health education with emphasis
on personal and food hygiene have to be taken up immediately by the
States. Role of teachers who were involved in the programme becomes

important in this activity and they have to be involved with the help of

material on prevention included in the training manual.
b)

The interventions at field level will have to be State specific and within the

States also the district wise incidence will have to be taken into account

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before deciding the same. States have been requested to analyse the

distnct/PHC wise data and institute immediate correctives for stepping up

Vitamin A and anaemia prophylaxis as these form a part of CSSM

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Programme.

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The States had to ensure that the referral system was put into place by the

States for taking care of the referrals emanating as a result of the school health
check up. Medical Officers have to keep a proper record of the referrals so that their

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findings can be used to corroborate the findings of the health check up done by the

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put into place.

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health workers. Monitoring system for cases referred to specialists also had to be

The initial feed back from the States during the visits of the officers suggests
that training of health workers and teachers was not uniform in all districts even in

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signal step for promotion of mother and child health. However, the Act did not bring
the desired results because of age old traditions and social pressures. To improve

social attitudes, all out efforts are needed to increase the level of consciousness

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about the bad effects of early marriage on the health of both mother and the child

and its impact on the population of the country. For this it is necessary to:-

(I)

Raise societal consciousness against the marriage at an early age,

(ii)

Effective implementation of the Child Marriage Restraint Act; and

(iii)

Delay the first birth. It is essential that States improve the delivery of
this message through different channels of communications on

consequence of early births and methods for preventing the same.

It is desirable to:

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(a)

Launch intensified interpersonal communication campaigns

&

for, communicating the message on the advantages of

marriage at a ripe age for the health of both the mother and
the child and methods for preventing early births.

(b)

NGOs and local bodies can also be effectively involved in this

movement.
(c)

Organisations like Nehru Yuvak Kendras, Mahila Swasthya

Sanghs, NSS and Bharat Scouts and Guides could also be
involved in this campaign.

(d)

Mass Media including electronic, print and traditional ones can
be made effective use of.

(e)

Preferential treatment under the various

development

programmes to those beneficiaries who conform to these
norms can also be considered.

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(f)
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Sensitisation of social and religions opinion leaders should be

taken up actively to promote marriages at higher age.

(g)

Doordarshan (National and regional level) may be persuaded

to give five minutes free time daily during prime times for
socially relevant messages on family welfare and compulsory
registration of marriages.

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Agenda Item No. VI

STRENGTHENING OF PRIMARY, SECONDARY &

TERTIARY HEALTH CARE DELIVERY SYSTEM IN
COMPLIANCE OF ORDER OF HON’BLE SUPREME COURT

MAY, 1996
The Common Minimum Programme:
As per the Common Minimum Programme 100% coverage of Primary Health
Service facility in rural and urban areas is to be ensured. We have at present a
service facility at the level of 5000 rural population named as Sub-Centre This is

staffed by one male and one female paramedical staff. A Sub-Centre is most
peripheral contact point between the Primary Health Care system and the

community. On an average six Sub-Centres are supervised and supported by a

Primary Health Centre headed by Medical Officer and supportive staff. For
specialist's services patients are referred to the Community Health Centre which

functions as a referral institution for in proximity to Primary Health Centres.

As on 30.06.1996, there are 132730 Sub-Centres, 21845 PHCs and 2424
CHCs functioning in the country.

REVISION

OF

FUNDING AND

STAFFING

PATTERN

FOR CENTRAL

ASSISTANCE TO STATE FOR IMPROVING RURAL HEALTH SERVICES.

A review of funding and staffing pattern for Central assistance to States is needed
to improve rural health services.

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Suggestions for the same are

placed as a

background material for

discussion(Annexure A).

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STRENGTHENING OF PRIMARY HEALTH CARE SERVICES AT 5000

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POPULATION LEVELS.

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(I)

Establishment of adequate number of Sub-Centres as per the population
coverage norms in vogue. Ignoring the States with surplus health

infrastructure, it is estimated that our country as on 30.6.96 would need an

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additional number of 10081 Sub-Centres, 2003 PHCs and 3133 CHCs to

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meet the norms for population coverage as per 1991 population.
(ii)

Provision of Safe Delivery Room (APNA GHAR) under Employment

Assurance Scheme of Ministry of Rural Development which can also act as

a meeting place for women's group for promotional activities.(Annexure 8)

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(iii)

Community participation

The involvement of individuals, families and communities in promotion of their own
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health and welfare, is an essential ingredient of primary Health Care. Therefore,

there must be a continuing effort to secure meaningful involvement of the
community in planning, implementation and maintenance of health services,

besides maximum reliance on local resources such as manpower, money and

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materials including indigenous system of medicine, if any, being practised in the
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region. A concept paper prepared by the Ministry of Health & Family Welfare is
enclosed as Annexure C.

(iv)

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Training of Heath Volunteers and Dais etc.
The programme aims at providing training to all the practising Traditional

Birth Attendants(Dais) in rural areas to enable them to conduct safe delivery

besides training volunteers from the community to act as Village Health Volunteers.

As on 1.4.1996 there are 660996 trained Dais ad 410904 trained Village Health

Guides in the rural areas.
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1.

ANNEXUREA

REVIEW OF PATTERN OF STAFFING AND CENTRAL ASSISTANCE TO

STATES IN THE NINTH FIVE YEAR PLAN

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I. STAFFING PATTERN:

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a) Sub-Centre:
It is presently staffed by an ANM, a Multipurpose Worker(Male) and a part-time

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helper.

It is recommended that an additional ANM be provided for sub-centres located in

remote, hilly and tribal areas and in poor performing districts.
a,

b) Primary Health Centres: Staffing pattern be modified to ensure institutional
deliveries at the PHCs.

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c) Community Health Centres:

Staffing pattern be modified to ensure its functioning as a First Referral Unit
capable of managing obstetric and other emergencies. Posting of an anaesthetist

and Gynaecologist and a Paediatrician be ensured so that Reproductive and Child
Health Services are delivered effectively.

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II. PATTERN OF CENTRAL ASSISTANCE TO STATES
The pattern of Central assistance to States was approved sometimes in

1980-81. There have been many suggestions from,the State Governments for

upward revision of the ceilings fixed as prices have gone up during the last 14-15
years. Keeping in view the price escalation and other factors, the following revised

pattern is suggested.
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1. Sub-Centre

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Non-recurring

Existing

Revised

Total addl. Expenditure

Rs. 3200

Rs. 5000

Depending on the Sanction

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for the opening of new Sub
centres.

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Recurring

The existing expenditure

Salary of ANM as per State Govt.

will vary from Time to time.
Helper

Rs. 600/-p.a.

Rs. 1200/-p.a.

Contingency

Rs. 600/-p.a.Rs. 1400/-p.a.

Rent(if Sub-Centre is in

Rs. 1000/-p.a. Rs. 3000/-p.a.

Rented building.)

Salary of LHV(1 LHV for 6 SCs) As per State Govt Scale of Pay

expenditure
will vary from
time to time

Medicine

£

Rs. 2000/-p.a. Rs. 5000/-p.a.
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Apart from salaries on ANM, LHV the proposed cost per unit(recurring) will be

10700+revised salary of ANM+LHV(1/6th) as per State Government Rates.

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2. Training of ANM/LHV

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There are 464 ANM(Female Health Workers) Training Centres with an admission

capacity of 21486 out of which 382 are funded by Government. Of India. There are
44 promotional LHV Training Centres with an admission capacity of 2718

functioning in the country. These training institutions are imparting training to

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prepare the required number of ANMs and LHVs to man the Sub-centres, Primary

Health Centres, Community Health Centres, Rural Family Welfare Training Centres

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and Health Courses in the country. The existing pattern of Central Assistance is as

under:1. Recurring

I. Staff(for admission capacity of 40)

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-Principal Nursing Officer

1

-Sister Tutor

2

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-Public Health Nurse

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-Senior Sanitary Inspector

1

-U.D. Clerk

1

-Domestic Staff

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-Warden

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ii) Stipend

Rs. 125/- per month per trainee.

iii) Contingency

Rs. 5000/- per anum

iv) POL

.

As per approved norm for Family Welfare vehicle.

v) Rent for school and hostel building

;;

Rs. 2500/-

(If it is functioning in rented building)

The pattern of assistance was fixed in 1978. The prices have gone up during
the last 12-13 years. Keeping in view the price escalation and other factors, the

following revised pattern is suggested:-

1. Recurring

Existing

Revised

Existing Exp.

I) Staff(for admission capacity of (40)

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Principal Nursing Officer

1

Sister Tutor

2

As per

The expenditure

Public Health Nurse

1

State

will vary from

Senior Sanitary Inspector 1

Govt.

Time to time

U.D. Clerk

1

Domestic Staff

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ii) Stipend

125/-

300/22

II

10,000/-

iii) Continency

5000/-

iv) POL

As per admissible rates needs to be revised.

v) Rent of school and hostel

2500/-

5000/-

building(if it is functioning in rented building.)

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3. Scheme of Training of MPW(Male)

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This scheme was started during 6th Five Year Plan in the year 1982. At
present, it provides free service of basic training of 1 year duration. On successful

completion of the training, the Health Workers(M) is posted at a Sub-centre along

with a Health Wcrker(F). There are 65 MPW(M) Training Centres which are
functioning in the country as on 1.4.96. Of these, 36 Health and Family Welfare
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Centres are imparting basic training to MPW(M) and there are 29 basic MPW(M)

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schools. The existing pattern of assistance was fixed in 1984. Due to escalation of
1 prices, the revised pattern of assistance is suggested.

1. Non-recurring

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I) Equipment and Furniture

for schools

Existing

Revised

Existing Exp.

@ Rs. 75,000/-per school with

New schools

Annual admission capacity of

not sanctioned

60 candidates

ii) Furniture, utensils etc.

For Hostel

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@Rs. 1500/- per seat

Rs. 90,000/-for 60
Candidates

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II. Recurring

I. Rent or Schools

Not exceeding

Rs. 10,000/-

Rs. 5000/- per month

ii) Rent for hostel

@Rs. 125 per month per

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Candidate in lieu of non
availability of hostel.

iii) Stipend for trainee.

@Rs.125/- per month per Rs. 300/-

)

Candidate, i.e. Rs. 90000/-

iv) Education aids,training
Material for training

for 60 candidates.
Rs. 5,000/-p.a.

Rs. 15,000

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Like models, flip charts etc.
v) Transportation(for

Rs. 15,000 per school

Rs. 30,000

vi) Contingency

@Rs. 15,000/-p.a.

Rs. 30,000

vii) Pay & allowance of staff

As per pay scales of State Govt. Will vary

K

Hiring bus)

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from time
to time.

Apart from the increase of salary of the staff, the proposed cost per unit will
be Rs. 3,10,000/-.

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4. Health & Family Welfare Training Centres

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There are 47 Health & Family Welfare Training Centres established in the
country to impart in-service training to the staff working at the sub-centres and

Primary Health Centres.These training centres were set up with 100% financial

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assistance by the Central Govt. Under the Family Welfare Programme. The existing
pattern of assistance as also the revised pattern, necessitated by the price
escalation and other factors as under:
Non-recurring

Existing

Revised

1. Vehicles(one bus, one mini bus &

Rs. 1,36,500/

Actual cost of

One jeep or two mini-bus & one jeep) (old expenditure)
& equipment including duplicating

vehicle

as no training centre has

Machine projector, typewriter and

been sanctioned after

Furniture.

1978.

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2. Construction

Cost of 20350-

As per approved

rates by CPWD/PWD

20450 Sq.ft. Plinth

Area as per the blue print of GOI.

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Recurring per annum

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3. Pay and allowances etc.of

As per State Govt's As per State Govt.

Staff(as per pattern)

Pay scale.

4. Contingencies including purchase

PaY sca'eRs. 15,000

Rs. 6,000/-p.a.

of educational materials books
for library, periodicals, postage,
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telephone charges, electricity and

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stationery and other charges.

5. Cost of petrol and maintenance of

(Revised from time

Vehicles@Rs. 12.000 and Rs. 9,000

to time)

(Petrol and Diesel reported driven

Rs. 36,000/-

to time

vehicles)

6. Rent for training centre and hostel

Revised from time

Rs. 18,000/-pa.

Rs. 40000

for trainees in case Govt.
accommodation is not available.

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7. Payment of Guest Faculty

Rs. 1500/-

Rs. 5000

The proposed cost per unit will be Rs. 60,000/-

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ANNEXURE B

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MULTI-PURPOSE ‘APNA GHAR’ MOTHER AND CHILD HEALTH CARE CENTRE
IN VILLAGE UNDER JAWAHAR ROJGAR YOJNA OF GOVERNMENT OF INDIA

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In order to provide on the spot quality ante-natal, natal and post-natal care

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to the pregnant women and new born, provision is being made under Jawahar

Rojgar Yojna(JRY) to construct a low cost room in every village.

2. Location

The room will be constructed within the village habitation using locally

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available suitable material blending with the architecture and local materials from

one village.

3. Construction

The room will be constructed by the Panchayat. Alternatively Mahila Mandals

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could be commissioned and they could employ contractors for this.

4. Upkaep

The upkeep of the room should be handled by community participation.

Ideally women's groups would be best suited for raising necessary contribution in
cash and in kind for this activity.
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5. Utilisation

The room would be used for multiple purpose.
(I)

Ante-natal, natal and post natal care to the pregnant women and new
born.

(ii)

Acceptors for users for Family Planning programme specially IUD

insertion.
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(iii)

Immunisation programme.

(iv)

Nutrition programmes under ICDS and

(v)

Mahila Mandal meeting for which adjacent arrangements will be

incorporated.
(Vi)

Screening for RTI/STD and organising referral.

6. Design of the room:

The room within an area of approximately 200 sq.feet will have two masonory
platforms for mother, counter top for the baby and trugh for the hand wash. The

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sanitary Sulabh water borne latrine will be built adjacent to the room but with access
from outside thus keeping the labour area clean. The liquid based waste will be

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disposed off in the latrine whereas the placenta waste will be buried in the fields
away from the room or as per local practice. A kitchen will be incorporated for

Anganwaris under ICDS programme who need to rent the place. This will be in
consultation with Department of Women and Child.

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This being a multi use centre, efforts are being proposed to make the

structure used as continuously as possible so that it is properly looked after,
maintained and becomes functional for the benefit of mother and child health of

village.
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ANNEXURE C

Community Involvement in Primary Health Care at 5,000 Population
Community involvement is a very complex social process and it requires

strong commitment, planning, sincerity of purpose and guidance at various levels
both in Govt, and community. Primary Health Care is essential health care made

universally accessible to individuals and acceptable to them through their
participation and at a cost the community and the country can afford. The concept

of Primary Health Care has been accepted by all the countries as the key to

attainment of Health for All by 2000 AD. Community participation is one of the
basic principles of Primary Health Care. Notwithstanding the overall responsibility
of the Central and the State Governments, the involvement of individuals, families
and community in promotion of their own health and welfare is an essential

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ingredient pf Primary Health Care.

Community involvement flows more naturally with provision for recognition,
sense of accomplishment, provision for community reward i.e. linking opening of

schools, roads, provision of hand pump etc. for the village and other schemes.
These would automatically lead to a sense of ownership and partnership in

schemes meant for the people. The capacity of individuals and families could thus

be enhanced through such involvement in planning, implementation and

maintenance of health services as direct benefits can be seen from their own
efforts.

To enable community village level structures to be established, existing
women’s groups like Mahila Swasthya Sanghs, Mahila Samakhyas, Mahila Kosh,
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Indira Mahila Yojna, Youth Mandals and Ex-servicemen groups, Mothers groups
etc. can be networked. Clusters and hamlets can be represented by volunteers.

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These groups could be mobilised and organised to work together for the

improvement in health seeking behaviour. Where only one or two groups of the
above mentioned category are available the expected functions of the other groups,

as established under Women and Child development, Education,

Rural

Development etc. could be taken over by the group currently existing in the village.

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The activities of this village level structure would be:

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Keeping the Village Water Points Clean.

2)

Ensuring village Health Sanitation.

3)

Ensuring provision of service for common illness.

4)

Inter-acting between service providers and community.

5)

In case of outbreaks of diseases to organise village level control
activities through health providers.

6)

in

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Mother and Child Health, Anti-natal Care, Post-natal care, Nutrition,

F

Controlling

vaccine

preventable

diseases

and

assisting

immunisation services.

7)

Counselling, Family Planning etc.
8)

Health Education and preventive and promotive services.

Planning
The above organised community groups will plan their activities for health

action twice a year after Rabi and Khariff ^pasons i.e. in June or December or in
any other months as may be convenient to them in view of their agricultural

activities and season ability of health problems. The initial meeting for planning of
activities would be attended by Government functionaries like ANMs, Anganwadi
Workers, Multi-purpose Workers, Block Extension Educators, Village Chowkidars,
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Ex-servicemen and NGOs. These Government officials will provide all information

about official health programmes and necessary coordination and help to convene
various activities in the community. These groups will also hold monthly meetings
for review of various community activities. Govt, functionaries will also participate

in monthly meetings as far as possible. Medical Officer of PHC will also participate
in planning meetings as far as possible.

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The members of the community will be regularly trained in various health

programmes and new initiatives taken up by the Government of India so as to seek

their active participation.

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Venue of a Meeting

Every village should identify a room either constructed by Govt./Panchayat
or donated by local community. These rooms will serve the purpose of delivery of
health services like Mother and child health, Immunisation etc. and for the meetings

of the village groups. Till such time this room becomes available, these group

activities of the community would be carried out in a room to be provided by the
Panchayat.

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Agenda Item No. VII

ALL INDIA HOSPITALS POST PARTUM PROGRAMME,URBAN

FAMILY WELFARE CENTRES AND URBAN REVAMPING
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SCHEME AND RURAL FAMILY WELFARE CENTRES
At present 550 Post Partum Centres are functioning at District Level and
1012 at Subdistrict Level. In addition 1083 Urban Family Welfare Centres, 871
Health Posts and 5435 Rural Family Welfare Centres are functioning in the country.

State-wise and scheme-wise distribution of these Centres is given in Annexure -1.

The achievement of these Family Welfare Schemes need to be made result
oriented. It is proposed that grant-in-aid in respect of the above Schemes may be

frozen at the 1996-97 level. However, additional grant in aid of 10% be given to

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those States which record at least a 5% reduction in Birth Rate and I.M.R. The
additional grant in aid will be made available after the relevant SRS figures are

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available.

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ANNEXURE-I
Statement showing State-wise number of Post Partum Centres, Urban Family
Welfare Centres, Urban Health Posts and Rural Family Welfare Centres
Number of Units

SI.

State/Union Territory

No.

FW
Subdistrict

District

11
37
4
33
13
11
11
39

55
20
22
6
64

22
47
52
3
3

60
75
69
1
1

2
1
19
19
35

4
1
60
35
100

10
23
61

1
32
1
72
27

2
87
3
147
55

1
65
9
81
111

6.

Gujarat

7.

Haryana

8.
9.
10.

Jammu & Kashmir

Himachal Pradesh
Karnataka

11.
12.

Kerala

13.

Maharashtra

14.
15.

Manipur

16.
17.
18.
19.
20.

Madhya Pradesh

,

Meghalaya

Mizoram
Nagaland

Orissa

Punjab
Rajasthan

21.
22.
23.
24.
25.

West Bengal

26.

A & N Islands

27.

Chandigarh

28.
29.
30.

D & N Haveli

31.
32.
33.

Sikkim
Tamil Nadu

Tripura

Uttar Pradesh

1
2

113
19
89*
12*
87

63
74
2
1

420
146
587
13

28
16

251
89
77

82
269

99
278

1

3

8
64
90

100

150

10

163
460
428
31
23
14
7
314
129
232

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5

9

69

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g

of

T otal:

3
12

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C(
5

1012

1083

871

l_€

ar

1

8

r

5435

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Reconciled figures not received.

et

wf

15
383
35
907
335

12

550

hf

oi

Lakshadweep
Pondicherry
Central Sector

0

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Daman & Diu
Delhi

T

Centres

131
6
10
42

Assam
Bihar
Goa

55
1
30
54

28

Arunachal Pradesh

Rural FW

Centres

1.
2.
3.
4.
5.

Andhra Pradesh

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Health
Posts

Urban

Post Partum Centres

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Agenda Item No.VIII

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INCENTIVES and disincentives recommended in
the report of the committee on population
of THE NATIONAL DEVELOPMENT COUNCIL.
The Committee on Population of the National Development Council (NDC)
had, in its Report, recommended a number of incentives and disincentives, both for

the general public and for Government./semi-Government. employees. This Report

was endorsed by the NDC in its 46th meeting held in September, 1993. An extract
ofthe relevant recommendations, contained in paragraphs 5.17 to 5.17.8 and 5.18

of the said Report, is given below :

The

incentives/disincentives currently applicable to

employees

of

Central/State/UT Governments, Autonomous Bodies, Public Sector Undertakings

etc. for adopting small family norm may be appropriately modified as follows :
’1

1

Leave Travel Concessions, free or concessional rail/bus or air jouneys

1

..

wherever applicable, CGHS facilities/reimbursement of medical expenses, Maternity

Leave benefit (excluding those directly affecting the health of the pregnant mother
and the foetus/new born), etc. are made available up to two children only.

Special increments for undergoing sterilisation, incentive of lower rate of
interest for house building advances, interest bearing advances viz. vehicle loans
should be available to the employees with two or less children only.

Priority in allotment of Government accommodation is given to employees

|

who have adopted 2-child norm.
33

I

17:

J-'

i./

r

1.
Any public servant violating the Child Marriage Restraint Act or who has
more than 2 children should be debarred from promotion for a period of five years

and birth of a child beyond three should result in dismissal from service.

II
■

I

Persons violating the Child Marriage Restraint Act or having more than 2

children may be debarred from recruitment in the Government/Autonomous Bodies/

I

Public Sector Undertakings.

Legal and administrative implications of the above recommendations should
be got examined before implementation, once these are accepted in principle by the

i
t

Government.

Regarding incentives available under the compensation of loss of wages to

I

the acceptors of sterilisation the States/UTs may be given flexibility of operation.

i

Special incentives and support to such programmes as involvement and

It
c‘.

continuation of schooling of female children, delaying the age at marriage, old age

pensions as already adopted by several States should be introduced in other States
also.
t:

Benefit of loans, advances, allotment of land/house sites, facilities of PDS
should be withdrawn from families violating the 2-child norm but may be restored

after the couple has undergone sterilisation operations.

Amendment to Panchayati Raj Act brought by the Rajasthan Government is

recommended to be emulated. The Central/State Governments should consider

bringing similar legislation for disqualifying the peoples' representatives at different

levels if they violate small family norm after getting elected
have useful demonstration effect on the people at large.
34

Such a step would

I

1

In pursuance of another recommendation of the Committee on Population of
the NDC, the Department of Family Welfare constituted a Group of Experts to

i

prepare a preliminary draft of the National Population Policy. In its Report, this

'i

Group of Experts recommended that " Incentives in cash or kind given by the

I

Central and State Governments for the acceptors of contraceptives as well as

1

motivators and service providers will be discontinued." In regard to employees in

>1

a

the organised sector (Central Govemment./State Government./ Local bodies/ Public

i

Sector) this group recommended modification of service rules and promotion

i

■;

policies to ensure that the small family norm is adopted by their employees. This
Group recommended that persons who marry below the legal minimum age of

ie

marriage be debarred from recruitment. The private organised sector was also
urged in this Report to take similar steps.
Currently, the Central Govt, does not have any scheme of incentives linked

>n.

to adoption of terminal contraception, or of the small family norm for the general
nd

-

public. There exists a scheme of "Cash Compensation for Acceptors of Sterilization
and IUD Insertion." Under this scheme, an amount of Rs.200/180/16 is given to the

State or Union Territory for every case of tubectomy/vasectomy/iUD insertion
ies

performed. The entire amount in the case of IUD insertions and about half of the
amount in the case of sterilisations goes to defray the cost of the surgical

procedure. In accordance with recommendation No. 5.17.6 of the Committee on
5

Population of the NDC, States/UTs : ‘we been given flexibility of operation, from the

*Qd

year 1996-97, to apportion the total amount between various items of expenditure,

i

subject to a few restrictions. Reports received from States/UTs indicate that they
are continuing to give a cash payment of about Rs. 100/- per case of sterilisation to

. .s

the acceptor, and also incentives to motivators and service providers. The payment

' ?r

to the acceptor is conceptually not an incentive. It is intended to compensate the

ent

acceptor for wages lost in the process of undergoing sterilisation.

Id

1; i0B
•
n

35

I

On account of inflation, this amount of about Rs. 100/- per case has no value

as an incentive, and is inadequate even to compensate for wages lost.

Non

i

I

disbursement of this amount to the acceptor or delayed disbursement are strong

z

possibilities. Keeping these factors in view, the States/UTs were urged to phase
■

out cash payments to acceptors, motivators and to Government. Sector service

Incentives do, however, exist for Central Government employees who (or
their spouses) undergo sterilisation after one, two or three children. States/UTs

and public sector undertakings have generally allowed these or similar incentives

to their employees. These incentives are as follows :

A special increment in the form of personal pay not to be absorbed in
future increases of pay.

Rebate of 1/2% on interest on House Building Advance.
Special’casual leave for undergoing sterilisation.

There are no disincentives, except a restriction of two living children
on eligibility for maternity leave, for female Government, employees.

Several States/UTs have introduced schemes of incentives, from their

of terminal contraception (sterilisation), or linked to education of female children,

n

delaying marriage of girls etc. The Department of Family Welfare has introduced
a 'Community Award Scheme', on pilot basis, in the year 1996-97.

International thinking on the subject is reflected in para 7.12 of the

1
h

Programme of Action of the International Conference on Population and

Development (ICPD), 1994; the relevant portion of which is reproduced below :

h
36

r
(

providers, while giving them flexibility in operation of the above mentioned scheme.

own funds, for the general public. Such incentives are linked either to acceptance

S

"Any form of coercion has no part to play. In every society there are many
social and economic incentives and disincentives that affect individual decisions

about child-bearing and family size. Over the past century, many Governments

have experimented with such schemes, including specific incentives and
disincentives, in order to lower or raise fertility. Most such schemes have had only

marginal impact on fertility and in some cases have been counterproductive."

With an ongoing constraint of resources, any policy of incentives linked to

!

• adoption of contraception is not likely to be sustainable. Incentives/disincentives

are also contrary to the tenet of voluntary and informed choice.
■

The Department of Family Welfare proposes the following policy formulation

!

for consideration by the Central Council of Health and Family Welfare on the issue
of incentives and disincentives.

Incentives
Incentives in cash or kind given by the Central and State Governments for
the acceptors of contraception as well as to motivators and service providers will

be discontinued in a time-bound manner.

Community incentives aimed at

■

encouraging the community to undertake activities resulting in reduction of birth
rate, infant and maternal mortality rates, increase in female literacy, increasing the

age of girls at marriage etc. have been introduced. The possibility of introducing
income tax concessions, in the form of higher tax exemption limit or in other forms
will be examined. Innovative schemes specifically directed to improve the status
■

•

of the girl child and eliminating adverse sex ratio would be developed. Special

attention will be given to the areas and States having a high TFR and IMR.

37

& .'■stiei..-

:

.. .

Organised Sector

The

employees

of the

Central

Government,

State

Governments,

Municipalities, and employees of various public sector undertakings must give the

lead in adopting the two child norm. The service rules in the Central and State

I r
i
>'

i1I

I
I

■

Governments and their undertakings would be suitably modified to ensure that the
two child norm is adopted by their employees. Similarly, all new entrants to the

government who are married before the legal age of marriage will be debarred from
recruitment. Promotion policies should be such that the adoption of the two child

norm is encouraged. The entire organised sector (public as well as private) must
also take similar steps in order to create an environment where the two child norm

is adopted by these relatively better off classes of society."

II I- 1
'.;L’;

I

• In accordance with para 5.18 of the Report of the Committee on

Population of the NDC, the Department of Family Welfare has introduced the

Constitution (Seventy-Ninth Amendment) Bill in Rajya Sabha, in the year 1992.

This Bill seeks to amend the Directive Principles of State Policy to provide that the
State shall endeavour to promote population control and to include in the

Fundamental Duties, a duty to promote and adopt the small family norm. It also
proposes to disqualify persons from being chosen as or holding office as, a member

of either House of Parliament or State Legislative, if he has more than two children.
The proposed amendment will have prospective effect only, in regard to the

disqualification for elective office. This Bill has been recommended for passage,

without any changes, by the Parliamentary Standing Committee on Human
Resource Development.

By virtue of Articles 243F(1) and 243V(1) of the

Constitution of India, these restrictions will apply to elective offices in Panchayats

and Municipalities also.

38

I

Agenda Item No.IX

review of preparation of district training

PLANS WITH SPECIAL EMPHASIS ON TRAINING OF

ANMs AS TRAINERS OF DAIS
Training Systems/Planning a'
Well developed training systems has to be evolved to take up training as an

ongoing and sustained activity. This is particularly critical as the current method of

conducting ad-hoc training under the different components of Family Welfare have

■

neither been cost effective nor have they brought about the desired behavioural
and attitudinal change in service providers.

I

ice Training at the District Level
Planning and Implementation of In-service
■

This training has thus to be seen as a responsibility of the district

administration. The district must ensure that all personnel are exposed to the
training programmes at regular specified intervals. Since the responsibility of

arranging for the training would be at the district level, stress will be laid on capacity

building at the district itself to train peripheral health providers. The district would
I

need to adhere to the uniform package of training but will have sufficient flexibility

I

to take into consideration their own training needs and particular conditions.

I

The initial training at the district may not be sufficient for required skill
development e.g. I.U.D. insertions, sterilization operations, and delivery cases. This
may require placement of the trainees to different health facilities at a later dat

39

...........

r

ensure quality, a minimum prescribed number of procedures will have to be carried
out by each trainee before she/he is certified as having been trained. District

training has to be flexible enough to allow this.

Action for States

The guidelines for developing in-service training plans at district level had

been circulated giving all the details required at each level. The State Secretaries
may issue suitable instructions to the districts to prepare the district training plans.
As a .first step, they may plan out training of ANMs for orientation under RCH, target

free approach and dai training. The details of the orientation training are given

below:

ORIENTATION

TRAINING

REPRODUCTIVE

AND

AUXILIARY

OF
OF

CHILD

HEALTH,

NURSE

TARGET

MIDWIFES

FREE

ON

I

APPROACH

COMMUNITY BASED MIDWIFERY AND TRAINING OF DAIS.

A six days orientation training has been proposed to orient the ANMs and

LHVs on reproductive and child health, target free approach, community based
midwifery and training of dais. This has been felt necessary as the these basic

grassroot level functionaries will play a major role to assess the service needs of

t

various RCH components at the community level through a process of participatory
assessment and plan delivery of services.

The trainees will be oriented on:

(i)

I

RCH
- concepts and

- components
40

1 .

F

r
(ii)

i

Target free approach

4

- need assessment/estimation

- planning service delivery

I

- monitoring

I
(iii).

Community based midwifery
;■

1

i
-essential care for all pregnant women

- identification of high risk cases

- management of complications
- infection control measures

- essential newborn care
*•

(iv).

Basic training skills in

|

imparting TBA training
|

- concepts
- methodology
- use of training material
- organizing monthly sessions
- contents and scheduling

I

The Item No 3 and 4 above has been included specially in view of large
numbe?: “of — being attended by
others. There has been no maior shift in this pattern oyer >as. few «

of dai training programme being in place since the Secon
ive
SRS estimates of ,993. s« more than 51% of -be de.ivenes are bemg attended
institutional with the
untrained birth attendants. Overall 23% of deliveries were
more than 90% in Kerala.
range of less than 5% in Rajasthan and Uttar Pradesh to
41

I1 J '

feOliiteTr.

I

F7 ^

II

In eight of the 15 large States for which information is available, less than 20% of

I trh

deliveries were institutional. The following figure shows that there are eight major
States where the attendance at delivery by untrained birth attendants are more than

1
<

the national average. In another four States percentage of deliveries attended by

f

o

«

■

untrained birth attendants ranges between 31.9 to 47.

h
a

Tabla II

J-

MEDICAL ATTENTION AT DELIVERY

tn

ATTENDED BY UNTRAINED BIRTH ATTENDANTS

at

st
KERALA
PUNJAB
HARYANA
TAMIL NADU
. KARNATAKA
ANDHRA PRADESH
GUJARAT
MAHARASHTRA
HIMACHAL PRADESH
WEST BENGAL
UTTAR PRADESH
ASSAM
ORISSA
MADHYA PRADESH
BIHAR
RAJASTHAN

a 2.2
I 2.4

;

id

OIRioy iM

"■

rwnwrot 10.6
31.0:

iSSiiSnSSHnri 0.1
i ifl i UHifsii i gn; p I 39.7

47

HI 11 III i I llimif; 1 III II III; III itllti III fi n I till 14|| 1111IT HM 5s i
fl Jll II III I: III 11 III: i III II H I; III I f|(| Ull in III |: III rf||| I. HI |(||fl 87 s
flf HI n III: 111 r 111 i III II III; III jJII li IIIIl11 III |. Ill 11 III I! III 1 HinfTW 05 3
flj.lil] I III i i III I i III:! Ill 11 III III 111[ 11 HI! Ill 11 hl I; III 111||]: III 11 III I. Illi11 limn 616
Ohm'• :Tiinii ■ ih~~hi 'ihi, hi.miiiira 53 a
flimill Illi Hill III! LllUil 111: Ul i3 Ifj,| |U;]J| |1||| |; ||| |j nt|, |]| |{||| |: |||; HinfflUIM 71 g:
£i;Hii.i m i; uii! 111;i,uife in■ iiniin 1 iif;,!ii ijmi; 11111111,1;m uni 1; m, mi; m;ppg 72
ILillllIII;mil: 111:41111 ||,j:H|IHinill:jJ|!(||ti:IU4|||,i!|||m||.|.mmUj|||iHlmiffi 76 2

INDIA

-HI ;lll

0

[{| I|! i niTIITirriiH: Uni (iiii hi inn 51.3

20

RGI::8R8 1993

40
60
PERCENT

80

■y

A

Pi
O

1.

-J
100

2.

It can also be observed that the perinatal, neonatal, and infant mortality are
significantly lower in the States where the deliveries by trained

personnel are

3.

I

42

■

r
higher. Attempts to train the traditional birth attendants through an intensified

itF

training programme was also started in 1994-95 in a time bound manner to train

one birth attendant in each village and to complete the training of the traditional

I

birth attendants by the end of the year 1996-97. The training so far organized were

hospital based which were away from the surrounding in which the traditional birth
attendants practice has resulted in not adopting the skills taught to them.

The present approach is to provide continued education/training to the

traditional birth attendants at the community level and orient the traditional birth

i

attendants on safe delivery practices through monthly interactions sessions at the
sub-centres with the ANM and LHV of the area. The 12 important issues have been

identified and one issue will be discussed by the ANM during this monthly meeting

with the TBAs.

I

a

In order to establish the linkage between the ANMs and the Traditional Birth
Jr

Attendants and to upgrade the trainer’s skills of ANM a six days' training is
proposed under the present scheme.

OBJECTIVE

1

To train ANMs as trainers for TBAs to impart training on safe delivery

I

practices.

2.

To orient the faculty members of SIHFW, HFWTC and ANM training schools

II

on community based midwifery so that this knowledge could be imparted to

I

future trainees in these institutions as well as impart training to ANMs on

L

TBA linked community based midwifery service.

To orient ANMs on participatory planning in target free approach.

t

43

1

1-31.

I

I

I

t

■
■

4.

To orient the ANMs on basic training skills.
il'.

The ANM training school shall organize training of inservice ANMs and LHVs

1

to impart training on the basic midwifery skills.
■

The faculty members of the ANM training centres will be trained at HFWTC/

SIHFW in a six days training.

The State MCH & Family Welfare Officers will be oriented on the above

training course in a meeting proposed to be held late in 1996.

I

44

I

i
Lx.

.

li

Agenda Item No.X

COMMUNITY AWARD SCHEME AND FAMILY
WELFARE PLAN FOR WATERSHED PROJECT AREAS
In order to secure greater involvement of the community in the National
Family Welfare Programme, the Department of Family Welfare introduced two new

schemes in 1996, to be implemented on pilot basis for one year in the first instance.

f

COMMUNITY AWARD SCHEME

I

The objective of the scheme is to involve the community at the village level
to take an active interest in the implementation of the Family Welfare Programme.

L

B

I

This scheme is operational in the calendar year 1996.

One revenue village with a population of more than 500 in each district of the

country, which registers the lowest birth rate, lowest infant and child mortality rate
!

and lowest maternal mortality rate in that district during the year, will be given an

award of Rs.2.00 lakhs. To become eligible for the award the village must record
■

100% civil registration of births and deaths.

4

All revenue villages with a population of over 500 will be eligible for the

Community Award Scheme. Villages which intend to participate in the scheme in
a year would have to register in the beginning of the year with the district

authorities. The eligibility of the village for the award will be decided by the District
Committee.
The award money will be presented to the village Pradhan/Sarpanch and will

be credited to the Village Panchayat account. The award money has to be used for
45
■

1

I
I

13

developmental activities in the revenue village itself and not in any of the other

village forming part of the same Panchayat. The utilisation of the award money
would be for developmental purposes in the village and not for the payment of

I

I

salaries of the staff of the Panchayat, maintenance of Panchayat amenities, office

expenses, acquisition of vehicles etc.

The scheme aims at promoting community participation in efforts to reduce
the infant, child and maternal mortality and birth rate and improve the general

health profile of the people of the village through creating community awareness

and better utilisation of the existing services. This scheme is applicable to all
States and UTs.

So far nine States viz. Uttar Pradesh, Assam, Andhra Pradesh, Goa, Punjab,

Gujarat, Kerala, Sikkim, Mizoram and two UTs viz. Daman & Diu and Andaman &
Nicobar Islands have sent their district wise proposals amounting to a total of
Rs.3.52 crores as of 20th November, 1996.

i

All other States/UTs have been

reminded to submit their detailed proposals.

FAMILY WELFARE PLAN FOR WATERSHED DEVELOPMENT PROJECT

I
I
I
I
I

AREAS OF NWDPRA

The Ministry of Agriculture and Cooperation has an ongoing scheme named
the "National Watershed Development Project for Rainfed Areas (NWDPRA)" for

watershed development, focusing on agricultural and environmental improvement,

scientific land use, increasing production of food-grains etc. through active

!

participation of groups of beneficiaries on order to bring about convergence of •
developmental programmes and to attain certain social and demographic objectives

in addition to the agricultural and environmental objectives.

46

I

. ’■'J'’ •

Strategy

I

I

Rural

The out reach established under the Pulse Polio Immunization (PPI)
Programme is proposed to be utilised to provide services to both women and

children. For the PPI Programme 6.5 lakh PPi booths were created. Since there

are approximately 1.5 lakh Sub-centres it is estimated that four PPI booths fell in
the jurisdiction of every Sub-centre. It is envisaged that each of these PPI booths

will function as an out reach point under the "Matri Suraksha Abhiyan" by rotation.
It is proposed that the booths be activated for service on Sundays by rotation so that

each booth gets activated at least once a month. The service will be provided by

I

I

the ANM. The schedule of operationalising the 4 booths in the jurisdiction of each

sub-centre ANM will be prepared by the LHV in consultation with the concerned

PHC doctor. The dates for activising each of the booths will be widely publicised
in the neighbouring areas. The ANMs will be provided a day off in the week in lieu
of work done on Sunday.

I
f
li

Urban

The urban areas are comparatively well served as regards secondary and

tertiary level institutions for reproductive and child health.

The focus of the

"Abhiyan" in urban areas will be on reaching the under served areas, specially

urban slums and peri-urban localities. It is assumed that about 20 per cent of the

PPI booths in urban areas were located in or near slum areas. It is proposed that
these posts be utilised under the "Matri Suraksha Abhiyan". Here again it should

be ensured that each post is activated at least once a month and that the

community are informed well in time.

49

• ••

t

I

“i

7

"During Nineth Plan, Family Welfare Programmes which include bringing
down Infant Mortality Rate (IMR), Child Mortality Rate (CMR), Maternal Mortality

Rate (MMR) and the Crude Birth Rate (CBR) to a level lower than the State or
National rate, whoever is lower may also be implemented in NWDPRA watersheds

i
I

I

in consultation with Ministry of Health and Family Welfare".

A new scheme 'Family Welfare Plan for Watershed Project Areas' has been

I

initiated on pilot basis for the financial year 1996-97 which aims to integrate family
welfare with development efforts in agriculture and soil conservation sector. Under

this scheme, every village having a micro-watershed project under the 'National

Watershed Project for Rainfed Areas’ will prepare a village level family welfare and
health care action plan. Rs.5000/- will be given to every village in the watershed

i;

for purchase of medicines required for essential MCH Care, for organising health

camps, and for emergency obstetric cases. This scheme has been taken up in
19612 watersheds of 12 selected States in the financial year 1996-97 on a pilot

basis. The estimated number of villages in these 19612 micro watershed projects

I

would be about 9,000.
Under the scheme, the Mitra Krishak Mandals (MKM) would be given an

amount of Rs.5,000/- for each village per year. The annual financial outlay required
for the scheme would be Rs.4.5 crores (Rs.5000 x 9000 villages).

Proposals

amounting to Rs.4.19 crores have been received from 11 States as on 2nd

December, 1996.

£

li
47

Agenda Item No.XI

Str

Ru

OBSERVANCE OF ”MATRI SURAKSHA ABHIYAN" ONCE

EVERY WEEK FOR IMPROVED HEALTH OF WOMEN
Pa

WITH SPECIAL EMPHASIS ON REPRODUCTIVE HEALTH

chi

are
Introduction

the
wil

The National Family Health Survey 1992-93 revealed that the Maternal

It i:

Mortality Rate in the country is 437 deaths per 100,000 live births. The rural MMR

ea

(448) is 13% higher than the urban MMR (397). It is matter of concern that inspite

the

of Safe Mothoerhood interventions the maternal mortality in the country is

I

su

unacceptably high. In addition to avoidable risks of mortality women suffer from a

Pt

very high morbidity specially reproductive health morbidity due to a variety of

in

reasons like poor status of women, inaccessibility of services and because of the

of

confidential nature of their problems.

|

I

Ui

To cater to the issues mentioned above it is proposed that all States and

Union Territories launch "Matri Suraksha Abhiyan" under which reproductive and
child health services will be provided to them very near their homes once every

te

week.

"A

uri
Analysis of service data for the year 1995-96 from 350 districts is annexed.

PF

As will be noticed the ante-natal registration of cases is low as is the proportion of

thi

deliveries conducted by trained personnel. The proposed Abhiyan will also aim at

be

achieving the National Health Policy Goal of achieving ante-natal care and

cc

deliveries by trained workers for all pregnant women.

n
48

.. i

Strategy

I

Rural

The out reach established under the Pulse Polio Immunization (PPI)
Programme is proposed to be utilised to provide services to both women and

I
£

!

children. For the PPI Programme 6.5 lakh PPi booths were created. Since there

are approximately 1.5 lakh Sub-centres it is estimated that four PPI booths fell in
the jurisdiction of every Sub-centre. It is envisaged that each of these PPI booths

will function as an out reach point under the "Matri Suraksha Abhiyan" by rotation.
It is proposed that the booths be activated for service on Sundays by rotation so that

I

each booth gets activated at least once a month. The service will be provided by

the ANM. The schedule of operationalising the 4 booths in the jurisdiction of each

sub-centre ANM will be prepared by the LHV in consultation with the concerned
)

I

PHC doctor. The dates for activising each of the booths will be widely publicised
in the neighbouring areas. The ANMs will be provided a day off in the week in lieu

of work done on Sunday.

Urban

The urban areas are comparatively well served as regards secondary and

tertiary level institutions for reproductive and child health.

The focus of the

"Abhiyan” in urban areas will be on reaching the under served areas, specially

■

urban slums and peri-urban localities. It is assumed that about 20 per cent of the

PPI booths in urban areas were located in or near slum areas. It is proposed that

these posts be utilised under the "Matri Suraksha Abhiyan . Here again it should

1

be ensured that each post is activated at least once a month and that the

community are informed well in time.

49

!

if

I;

I °

REFERRAL

o

It is expected that the check-up of women by ANMs would lead to

identification of cases which require interventions by doctors or specialists. It would

|

1

o
o

be important to identify institutions where cases which need specialist care are to
■' i

be referred. In the rural areas referral points will be the Primary Health Centres,

■W

Community Health Centres, First Referral Units, PP Centres and District Hospital.

I

In urban areas nearby PP centres, MCH Centres or hospitals could be

identified as referral points.

1

Coui

I1

o
o
o
o

Special care for referral cases : A special day for care of referred cases
should be designated in each of the identified referral institution.

On the day

services of specialist doctors should invariably be provided. Adequate publicity

I

about the venue and date for care of referred cases should be made.

j

SERVICES PROPOSED TO BE PROVIDED

I

Ante-natal Check-up and Services

o

o
o

Ider
lnfe<

I
o

Recording of medical and obstetrical history.

o

General physical examination to identify high risk features like pallor

o

(anaemia), swelling efface and feet, etc.

o

Breast examination.

o

Recording of

Height

Sen

Weight

Blood Pressure
o

Abdominal examination to monitor progress of pregnancy

o

Advice regarding food and rest

!

o
o
o

50

■

o

Prophylaxis against anaemia

o

Therapeutic doses of IFA for anaemic cases

'~ad to

o

TT immunization

. vould

o

Referral of cases of high risk cases to appropriate institution

are to

litres,

Counselling and Services for Fertility Regulation

>pital.

Id be

o

Advice ante-natal cases for spacing

o

Provide oral contraceptives

o

Provide condoms

o

Counsel women with young children for spacing with I.U.D. Inform women

who wish IUD insertion when and where services will be available.

I cases

i day

o

Refer couples who have completed their families for sterilisation

jblicity

o

Guide women who require MTP to appropriate health institution.

o

Refer couples with primary or secondary infertility to PHC MO/Gynaecologist

for management.

SdentificaUon and Referral of Women with Suspected Reproductive Tract
Infection

o

bailor

Women who complain of vaginal discharge, constant lower abdominal pain,
lesions on external genitalia should be referred to the medical officer for

I

examination and advice.

Services for Children

o

Immunization against all vaccine preventable diseases under UIP.

o

Vitamin A Prophylactic doses.

o

Advice/treatment/referral of cases of diarrhoea and pneumonia.
51

GflOv- 4 00

O 5%

o

Advice mothers about exclusive breastfeeding and appropriate weaning as
ar

applicable.
o

cc

Identify children with severe mal-nutrition for management at the PHC/FRU

ur

level.
b<
S
Equipment/drugs etc. which will be required

M
Basic equipment and drugs needed will be taken by the ANM to the booth.

She will provided with the services of a helper to carry these. The following would

be required :

m

1'

o

Weighing machine

o

BP instrument

o

Haemoglobinometeres

o

Fetoscope

o

Oral contraceptives

o

Condoms

o

Vaccine carrier with vials of all UIP antigens

c

o

Sterilised syringes and needles

r«

o

ORS packets

o

Cotrimoxazole tablets

o

Vitamin A solution

o

Stationery for recording history and referrals

I

h

lr
u

t

I

A

e
it

I
F

Resources

The Central Government will provide honorarium for the "helper" mentioned
in para above. In addition, a massive publicity campaign to orient and inform the

people about the Abhiyan will be undertaken utilising all media channels. States

52

I

ti
h

. ,"T
■

nd Union Territories wiil be expected to launch area specific campaign, m
„nL -h fire nalronai publicity campaign. The drugs and supplies provided

.
1

CXational Family Weifare Programme wil, be uti.ised for Services at the

1

under tne rvauu
rocnonsible for provision of
^s. States and Union Territories would be responsible

I

Specialist Services for referral cases.

I

I

matri suraksah divas

A

order to focus National attention on the issue of women's health and s

^erbood it is proposed that the day preceding the World Population Day ,.e.
tOth of July every year be observed as Matri Suraksha Drvas.

On this day a Health Meia specially focusing on reproductive and child
health issues -be observed in eye. Community Hea.,

count.

urban areas appropriate health institutions iike municp
mnnPW Centres should be identified for organising the Math Suraksha
urban F.W. Centres sno
rvnaeColoqist for management of

(

counselling and awareness generationJoe

reproductive and chiid health issues will also ^P-®^To atuact the people

activities like fun-fair, film shows, puppe
.
, b
incorporating the messages of reproductive and child heakhja a.so

rganised.
1

Wide publicity will be given by the Slate Govt, before the Mela

Resources
-

the State Government. Support for orgam g
Mela will be provided by the IEC Division of Department o

welfare

I
t.-

I
I

'Eft

53
I

.

1

■

The health Mela on Matri Suraksha Divas will culminate into World j

Population Day on the next day i.e. 11 th July of each year where the various mahila ■ ■
■

groups like mahila Swasthya Sanghs, ANMs, Women group involved in income
general activities will take pledge to dedicate their services for Matri Suraksha in

‘

i- ■

I •

their daily work.

■■

54

'5

1
MC REG 1 STRATI CX MO WLIYOULS REPOT TIB

TriXe to. 2

Id

• MX IWIA

11/12A6

1

Curvlitlv* ipto the rcnth of March, 1996

ie

Eetlmted
Prteywrcies

State

liUrtere

PWCCt

Estlnrted

(TTX)

Estloettd
Del I ver I e*

rained

InttlUXIcr»I By

IWOTHA
HOVOW. HVOESH

(torpl Icated Hcnth

Deliveries

Peracrrel

Pereomel
Peraomel

Case® as

Last

aaXcrfTDR

m X of

at
m X erf TOR

XcrfTDR)

Re^xjrled

(10)

(ID

TDR

(6)

(H

(8)

(9)

B74Z37

600164

61.99

23.59

56.65

19.76

1.74

War,96

1777

16.07

97.47

0.76

1.77

0.10

Hnr,96

129995

21.96

39.07

37.22

23.72

1.05

Mar,96

12B173

90.29
36.63
68.68
34.93

53568

U^O

T536

64.49

a.15

0.49

Mar.96

314450

278909

80.70

2U3O2

68.21

35.M

57.72

7.01

4.34

2 TWO

246100

57.93

179381

64.09

11.11

66.03

22.as

1.47

Mar.&S

92293

B4481

91.54

60422

65.47

23.13

58.37

18.50

0.94

Kar,96

59.78

23.76

16.46

1.25

Mar,96

39.16

5J.C6

7.79

2.22

Mar,96

12300

4505

592038

406627

Wot Avelleble

GOA
OJJ7MT

trained

(S)

366965

IIH5R

As X erf

(*)

966201

ASS7H

Total

□)

(1)

PVOESH

Index

As X erf
PTognnrclas

(Prcpotlcrate)

Referral

Deliveries Reported

AHC RAjl»tr«ticn

36098

10683

a.04

2710

1187875

1037968

87 J9

711532

7.11
59.91

343600

73.67

224113

65.22

96.64

0.79

2.57

0.90

Mar,96

KEPALA

253116

>varfA nwxsa

1554600

1351658

86.93

Kr-6417

67J0

22.A

56.60

a.66

0.82

Mar,95

742430

46.19

1817467

113.05

69.92

22.27

7.KJ

0.58

Mor,96

HVW’ASMTRA

1607500

AVW I KASW1R
K/V94A1MA

I

37630

59139

157.16

16436

43.68

67.84

26.30

5.87

1.01

Mar,%

h*WIHJL

18350

11827

64.45

6906

37_63

35.65

29.97

34.38

1.42

Mar,9$

FECJVLAYA

i

16602

71.56

UB72

68.46

39.56

33.74

21.70

1.17

For, 96

MI7CP/M

13533

19.95

8.30

0.00

Her,96

HVMMC

15774

1204

8.U

505

3.21

71.A

ORISSA

643907

533532

51.K>

244710

38.01

30.78

57.92

21.32

0.67

Mar, 96

111965

51.35

19.95

69.32

10.73

2.46

Mar,96

170108

78.0!

rvu’fl

216068

PA.IASTHM

597972

320078

53.53

29.80

32.51

50.84

16.65

4.08

sirxiM

1870

1135

60.70

178186
1KI7

Mor,96

59.20

39.48

57.45

3.07

0.45

H&r,96

WIIMOU

1109340

1150570

103.72

9578CP

87.23

74.99

19.54

5.47

5.a

Mor,96

TRiTERA

Not Available

LHTAfl FP/CESH

2957461

2519292

W.90

2256TP-5

76.03

12.29

80.18

7.53

0.15

Mar,96

65.80

8458^4

41.67

a.A

29.59

1.09

Mat,96

65.58

13.32

20.1!

3.68

Mar,96

69.78

8.19

2.03

1.59

Mar,96

1598200

1019634

wrwvw I MICCBA

7830

3572

45.79

3*05

52.92
53.41

nwoiGvm

3193

5306

165.19

25U

78.n

WEST POOl

I

HA

2?00

693

23.90

1729

59.62

23.66

50.14

26.20

0.12

Mar,95

227447

W.72

1KE99

43.75

65.62

22.09

11.29

6.55

1*r,95

17XSUWTP

730

729

99.05

6T3

•X.3

48.11

46.95

4.94

4.%

Mar,95

rODIOERRT

5500

15665

334.64

1T773

217^?

91.79

4.16

4.05

0.93

Mar,96

14£5g784

11272430

75.&S

9814952

65. (B

39.87

(7.55

iz.sa

1.42

Mar,9$

DELHI

Ml IHJIA

■I

j

Mot AvelletAe

253500

tWYX I Oil)

11

!

55

wgsr-.. ~

HHF~
j

i®f.
■ '
F‘r
Ik.

fet

:■ v>k-r

'

kS

'kwk ' ''J

I'It
■

PROGRAMMES CONCERNING
Ft '"
I"
fctw:

t ■■

HEALTH SECTOR

.r.

t

I
i-5 ■

few ■ ■
few
.
H ■''•?■■ f'}
■'

... '

3f8
' '.'3 .•;/.

.7

...
I

■:

I
■j

5^* ••'•■■ •

,’h.

-

.

'

'

' ■: •■■•kl
■•

••

■^■■■■■■■.

■

-

:

'

k

.
■>>:.

■:

/

■

.

-

'

-

..

i

Agenda Item No.XII

STATUS REPORT ON FEES FOR MEDICAL COLLEGES

FOLLOWING SUPREME COURT ORDER
The Supreme Court of India in its judgement dated 4.2.93 in Unnikrishnan
J.P. Vs. State of Andhra Pradesh while evolving a 'Scheme' regulating

admissions in professional colleges in the country, directed that each and every
State Government should constitute a Committee to fix the ceiling on fees

chargeable by a professional college or class of professional colleges, as the
case may be. The fee fixation by the State Committees was subject to final

■iM1

B-

fixation of fee by the Central Government/concerned professional councils.

The Government of India through concerned councils engaged
consultancy organisations to study and suggest a suitable fee structure for

private medical and dental colleges. While Medical Council of India engaged

M/s. A.F. Ferguson & Co., New Delhi, the Dental Council of India engaged M/s.

B.S. Raut & Co., New Delhi, for the purpose.

Based on the findings of the consultancy organisations and further
recommendations of the concerned professional councils and also taking into

account the increase in the intake of foreign students in private medical and
dental colleges, Central Government fixed the upper ceiling of fee for payment

seats as follows, which was effective for three years from 1993-94:-

Medical Colleges:-

An amount of Rs. 1,15,000/- per annum per student shall be payable as
fees. Out of this amount of Rs. 10,000/- per student in case of medical colleges

having partly own hospital facilities and Rs.20,000/- per student in case of

colleges which do not have their own hospital will be paid to the

Government/Authority running the hospitals, utilised by such medical colleges.

56

-

w.Dental Colleges:•L -

I

I

An amount of Rs.86,000/- per student shall be payable as fees. Out of

this,

amount of Rs. 10,000/- per student per year in case of colleges which do not

their own hospital facilities will be paid back to the Govenment/authonty
have
running the hospitals utilised by such colleges.
I-

However before the above fee structure could be implemented the

Supreme Court in its order dated 11.8.95 raised the fee for merit seats to
Rs 20 000/- per annum and Rs.15,000/- per annum and reduced the seat for
payment seats to Rs.75,000 to Rs.70,000/- and Rs.65,000/- for medical colleges

having own hospitals, partly own hospitals and partly Governments hospitals

and entirely dependent on Government hospitals respectively and Rs.50,000/per annum for dental colleges for the year 1995-96. The Supreme Court in Us
k

.subsequent order dated 9.8.96 while continuing the above fee for 1996-97
directed the Central Government/professional councils to fix a workable fee

J
!

'structure within three months which will be effective from 1997-98. Acting on the
above judgement the concerned professional councils have recommended the

I

following fee structure:-

I

Fee Structure for medical colleges

Rs. 1.5 lakh per professional course (18 months) per student for medical

(i)
institutions/medical colleges with their own hospitals

(ii)

Rs.1.3 lakh per professional course (18 months) per student for medical
institutions/medical colleges utilising the facilities of Government as well
as their own hsopitals,.

Rs.1.1 lakh per professional course (18 months) per student for medical
institutions/medical colleges utilising the facilties completely provide

ft

the Government hospitals.

57

y

i

(iv)

Rs. 15,000 for each professional course per student for free seats.

(v)

$75,000 to be charged from NRI/foreign students for the complete MBBS

’

I

Fee structure for dental colleges

(i)

Rs. 1.4 lakh per year for independent dental college

(ii)

Rs.1.0 lakh per year attached to medical college

(iii)

Rs. 15,000 for free seats.

(iv)

$30,000 as one time payment.

recommendations

I

I

course.

The

I
s

of the

professional councils

are under

consideration in consultation with the State Governments.

II
I

I
i
l

58

V.’' ’’
■

4
■

Agenda Item No. XIII

COMPULSORY RURAL SERVICE/FILLING UP OF

VACANCIES IN RURAL AREAS

I

In India, as per 1991 census, out of population of 846 million persons
29 48 per cent live in urban areas and 70.52 per cent living in rural areas have
inadequate health and medical care facilities. The large rural population is

scattered in 5.57 lakh villages. A good deal of imbalance exists between rural

J

and urban areas in the provision of medical care services.

J

Obligatory Service for 2-3 years for doctors in rural areas
At present it is not compulsory for doctors to serve in rural areas for 2-3

years immediately after joining State/Central Government service. The Central

i

Council of Health and Family Welfare in its meeting held on 11th October, 1995
passed the following resolutions to meet the shortage of allopathic doctors in

rural areas:(i)
"in order to meet the shortage of allopathic doctors in the rural

>1
I

areas, suitable amendments be brought into the M.C.I. regulation that a
permanent registration will be given to M.B.B S doctors only after they have
served at least for three years in rural areas notified by the State Governments.
i'

(ii)

The Council notes with great concern the above scarcity of doctors

in rural areas and recommends that rural posting for a specific period be made
compulsory and also a pre-requisite before admission to post-graduate

II

courses. .

I

The following recommendations were made at the Conference of Chief
Ministers on Basic Minimum Services held on 4th and Sth July, 1996:-

i?;; |

i

59

v

■

S

"In order to overcome the shortage of qualified doctors to man the

Primary Health Care System, 2-3 years service in the rural areas should be

■''

I fe- I

made obligatory for medical graduates/post-graduate before they are given
permanent registration”.

Si

The Medical Council of India has commented that there is no real

1

shortage of doctors of modern scientific system of medicine( allopathy) in the

country, but only mal-distribution. The State Governments may ensure rural

1

posting before appointing doctors to Government posts. Incentives should be
given for doctors in rural areas such as reservation in post-graduate courses.

Further, extending the period of pre-registration to another three years is not
practical/feasible and will not serve any purpose. If permanent registration is

withheld, unregistered doctors will be posted in rural areas while duly qualified

i
p
JIP
|

I ■

#■

»■

doctors will be available for urban areas. This disparity cannot be allowed. I he
MCI is of the view that the existing 6 months internship may be strengthened.

The MCI has questioned whether the State Government would be able to

provide jobs to all medical graduates passing out of the medical college in the

I

State after the long-drawn out process (a medical graduate will have to put in

five and a half years course plus a 3 year rural posting plus 3 years post

graduate course before completing his studies.).

Availability of Medical Manpower in PHCs, CHCs and Sub-Centres

i
At present the vacancies of Medical Officers and Specialists in the health

centres in the rural areas are very large. The State Governments are required
to place Gynaecologists, Paediatricians and women para-medical staff in vacant
posts. The vacancy position of doctors in PHCs and specialists in CHCs is as
under:-

iI
J
K-’’J

H i
■

60

■

>

I 1
■

'

■

•

■'

Doctors in PHCs:

Sanctioned

In position

Vacant

31,700

26,583

5,117

‘(Source : Rural Health Statictics, December, 1995)
Medical Specialists:-

(ii)

No. vacant

Name of specialist

No. of posts No. in position

i) Surgeons

1353

710

643

ii) Obst. and Gynae.

1139

548

591

iii) physicians

1104

574

490

iv) Paediatricians

845

498

347

‘(Source:

Rural Health Statictics, December, 1995)

Tamil Nadu Medical Service-compulsory rural service of doctors and

I

decentralised recruitment of doctors

As per the instructions

issued by the Government of Tamil Nadu on
■i

12.1.1987:-

I

■

(i)

The medical graduates immediately after their recruitment as
Asstt. Surgeons in Tamil Nadu Medical Service are posted in non

teaching medical institutions outside Madras City,

<■

(ii)

The Medical Officers, without any discrimination,

on first

appointment are posted in PHCs to serve there for a minimum

(iii)

I

period of 3 years;
In case of holders of post-graduate medical qualifications the

period of service in rural areas is one to two years;
(iv)

In case of Super-Specialists and holders of non-clinical post
graduates rural service is not insisted upon. Also relaxation is
given to post-graduate students and they are posted in District

Hospitals.

I
.

61

fcaa..

I

•1
Recruitment of Asstt. Surgeons to Tamil Nadu Medical Service-Selection

by Tamil Nadu Public Service Commission
The Government of Tamil Nadu found shortfalls in the procedure of filling
up of vacant posts of Asstt. Surgeons in Tamil Nadu Medical Service.

t
it'

Candidates selected for the post did not join duty or showed tendency of

I'iJ

t Js I

indifference to duty or adopted various methods for transfer to places near

Madras or of their choice. To provide uninterrupted medicare and health service
to the rural public the following decisions were taken by the Government of

Tamil Nadu:-

®

i

:i

S 2^ *
(i)

The State was divided into nine Zones and the Tamil Nadu Public

f

Service Commission called for application zone-wise.

(ii)

Those selected were stipulated to serve in the zone for 10 years.

(iii)

Zone-wise selection of 300 candidates are to be done every year.

(iv)

The selected candidates are to be given 30 days to join duty.

(v)

Though Medical Officers are selected zone-wise, their seniority
would be common in the merit list of TPSC.

Condition imposed by Government of Karnataka for Doctors to serve in

Rural Areas for Five Years

p >1

For filling up vacancies in rural hospitals, Government of Karnataka appoints

doctors on contract basis in rural areas and no transfer is allowed. While

recruiting doctors through Karnataka Public Service Commissioin, a conditiion

is imposed that doctor concerned would work in rural areas for five years.

The condition for contract appointment of doctor in rural areas in

Karnataka are as under:-

(1)

The contract appointment is for a maximum period of three years.

62

I

S'

t

b

.j

As this appointment is made to a particular dispensary in rural

(2)

areas, there is no scope for transfer to any other hospital or on

deputation.
The pay is fixed at Rs. 4000/- per month subject to discharge o
(3)

duty satisfactorily.

(4)

The contract doctors are eligible to

medical, leave facilities

available to officials of equal rank.
The contract doctors are not eligible for regularisation, pension,

(5)
gratuity, pay scale or any other allowances.
Such doctors give an undertaking to District Health Officers after

(6)

=.>

9

S

reporting for duty, etc.
Recruitment of Doctors in Rajasthan for Rural

The System of Ad-hoc

r

I

1
(

Areas

The Government ot Rajasthan for ensuring avaiiability of doctors m rural

'I

I

I

areas is adopting to a Centratised ad-hoc recruitment for peripheral rural hea h
The State Government has reserved 50 "7. of the seats in pos ■

! 1 I|

4

graduate courses for in-service doctors The eiigibility condition for jo.nrng post

nl

!

centres

graduate courses in Rajasthan rs 5 years service including ^-e yearsdh rura

areas An exception has been made in the case of doctors working n desed
and tribal areas where two years service is counted for the purpose of admission

•: 1

i
. Ml

^4I
?IM

to post-graduate courses.

■
S

i

ISSUES FOR CONSIDERATION BY THE STATE GOVERNMENTS/U.TS

a

The Ministry of Health 8 Family Welfare took initiative to call Hea

Secretaries of selected Slates, nameiy. Tamil Nadu. Ra.asthan, West Benga,
Karnataka and Secretary, MCI lo elicit their v.ews as to how

■k

ll

approaching the problem.
63

ey

i
a
■'I

I'
It is suggested that all other State Governments may consider introducing

the regional decentralised recruitment policy for doctors as is being done in
Tamil Nadu by filling up vacancies of doctors in rural areas and reserving a

K
I

certain percentage of post-graduate seats for inservice medical officers who

have put in 2 to 3 years service in rural areas.

At present every candidate is required to undergo after passing the final

M.B.B.S. examination compulsory rotational internship to the satisfaction of the

University for a period of 12 months so as to be eligible for the award of
M.B.B.S. degree and full registration to practice medicine.

The internship

S'

■

training includes training in medicine, surgery and Obst. and Gynae. and in

community health work in Rural Health Training Centres of upgraded PHCs.
The posting in rural health Centre is for a period of six months. The D.G.H.S.

is of the view that the entire period of one year should be spent in rural areas.
This issue is required to be decided in consultation with State Governments.

About 3000 post-graduate doctors are passing out of medical colleges in
the country every year. The Ministry of Health & FW is of the view that a
percentage of post-gradute seats may be reserved by State Governments for in

service medical officers as is being done in Rajasthan. The eligibility conditions
for joining post-graduate course for in-service doctors may be made 5 years

service including 2-3 years service in rural areas.

w
■

tI

tI

II

I

I11
I
I

I
i

i
64

I

I

I

Agenda item No.XFV

ang
3

1

EPIDEMIOLOGICAL SURVEILLANCE AND SUPPORT

9 a

SYSTEM

)

Disease causing microbes have threatened human health for centuries.
nal

Though the present health machinery responds better as compared to the

tr

situation decades earlier, yet the recent plague (1994) and dengue fever (1996)

of

outbreaks have demonstrated clearly that the executive health agencies need

h

to be better prepared to perceive, recognize and respond rapidly to public health

I in

threats arising out of disease outbreaks. The key to recognize new or emerging
infectious diseases and to tackle the resultant problems is surveillance.

S
Epidemiological surveillance is a prerequisite to modern, effective
control and prevention of communicable diseases. It means understanding a

disease as a dynamic process involving the ecology of the infectious agent, the

ir

host reservoir, the vectors and the environment as well as the complex

a

mechanism involved in the causation of the disease and its spread.

It also

implies follow up of specific diseases in terms of morbidity and mortality in time
IS

and place and keeping track of the circulation of etiological agents in man and

'S

the environment including animal population. This also includes all kinds of

laboratory' investigations, such as isolation, identification and typing of
etiological agents, investigation of the biological properties of the agents and

different serological studies of individual and population groups.

Attention also needs to be paid to other factors which may influence the

spread of infection and the incidence of disease, such as social and economic
changes in the country, population movements, large industrial and agricultural

investments like building of dams, irrigation etc. or international trade, export

and import of live animals, meat and meat products and poultry.

65

M

*

,p
r

National Institute of Communicable Diseases (N1CD) was established

in 1964 to provide technical expertise in the field of disease control activities and

t

act as a centre of excellence for building up man-power, providing technical
guidelines and advice to various health implementing agencies including

f
!

national authorities, undertaking surveillance for major communicable diseases

and

maintaining

watch

over

emerging

newer

health

problems

and

recommending appropriate measures to the Government to tackle the situation.

I'I

The number of outbreak of communicable diseases has been increasing

i

in recent years. There could be several reasons for this. Increased rapidity of
national and international travel and the greater distances travelled, extensive

deforestation and irrigation works, neglect of insect and vector control

programmes, explosive urbanisation and over crowding associated with

gatherings, frequent movement of population of refugees, large scale industrial
food processing etc. contribute to the same.

II
I
Ir

Disease surveillance activities shall cover mortality and morbidity

II

reporting, individual case investigation, epidemic case investigation, complete

laboratory investigation leading to detailed characterisation of the etiological
agents

involving molecular epidemiological

parameters,

investigation, epidemiological survey including immunological studies, animal

reservoir and vector distribution of diseases with natural foci, biological products

and drug utilisation, demographic and environmental data, guidelines for the
implementation agencies, feed back and dissemination of information,

identification of vulnerable areas,

I

epidemic field

ensuring community participation

i

i
I

I
■J

in

&■

surveillance, appropriate health education education and IEC activities and
collaboration with appropriate institutes inside and outside the country.
>

Diseases proposed to be covered for Surveillance
Organised surveillance machinery exists for malaria, leprosy and TB.

The surveillance machinery for JE, Kala-azar, cholera, rabies, leptospirosis,
66

f1

i

m-, - -

i

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i

iI

salmonellosis, dengue, typhus, viral encephalitis,
oiaque viral hepatitis, salmonellosis, aengue, typ.iuo,
meningococcal meningitis, measles, polio though exist but are Otten Inadequa e

I

t0 meet the needs of emergent response in the event of an outbreak.

I

r
H-

surveillance programme covering all important epidemic prone diseases so that

i
i

very early response could be instituted to prevent large scale morb.d.ty an
mLity. The diseases which are proposed to be covered under the proposed

There is an urgent need to establish an appropriate epidemiological

I

I
I

action p.an are: cho.era, p.ague, se.moneHosis, shige.losis. nckettssos.sa, dE.
kala-azar, dengue, leptospirosis, rabies. A.DS, poliomyelitis, measles, tetanus,

■ I

I B''■'

viral hepatitis, meningococcal meningitis, diphtheria, whoopmg cough, influe

1.

rubella, TORCH group of infections etc.

.

-k Expected outcome

of Disease Surveillance Programme
•i.

A well designed and well Implemented sumeillance programme can:
. detect unusual clustering of cases of a disease in time and space in

I

geographic area

i

I

- initiation of early and adequate response
- document the geographic and demographic spread o. an outbrea

I

- estimate the magnitude of problem

1

- help in describing natural history of disease

II
I
I
I

I

■'d

.■y

identify factors responsible for emergence of disease
facilitate laboratory and epidemiological research
■

67

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f.
r

S

<

■ — J
■

- assess the success of intervention efforts
-creation of public awareness through health education and IEC.
Issues

There have been a large number of drawbacks with the existing

mechanism of surveillance of communicable diseases.

Some of the major

issues are:
1.

Absence of a well defined, actively co-ordinated and effective
network of surveillance machinery.

i

2.

Non availability of appropriate guidelines for surveillance

3.

Inadequate laboratory support

4.

Lack of institutional support and appropriate linkages

5.

Poor primary health care infrastructure in urban areas

6.

Non-involvement of NGOs and private practitioners

7.

Inadequate health education to the community

8.

Absence of effective legislation and poor implementation of

1I
I

I

I

II

existing legislation

9.

Weak co-ordination between various agencies/institutions

10.

Resource constraints

The 4th Conference of Central Council of Health & Family Welfare had

recommended the launching of a National Disease Surveillance Programme
68

searm

SA "■

alongwith appropriate laboratory support services including entomological

1

services and the networking of disease reporting through a computerised HMIS

I

1

covering all States/UTs.

J

1
I

The Government of India has established National Apical Advisory
Committee and Response System under the Chairmanship of Union Secretary

!8

(Health). A Sub-Group has also been constituted under the Chairmanship of

Prof. V. Ramalingaswami to work the detailed modalities of the disease

I

surveillance programme.

Broad components of the disease surveillance programme as a centrally
sponsored scheme

1.

National Institute of Communicable Diseases (NICD) to be

redesignated as National Institute of Control of Diseases (NICD)

in the pattern of CDC, Atlanta and will be the nodal agency to
plan, monitor, review programme implementation and guide health

care

agencies

in

implementing the operation

of disease

surveillance programme.

2.

Existing laboratories should appropriately be networked through
electronic means like FAX, E-mail, NICNET etc., for harnessing
the information already available & generating appropriate

information to strengthen capability of detection of early warning

I1
1 us
F;

signal.

3.

Strengthening of National/State/District epidemiological capability
in

perceiving

threats,

detecting

threat

and

responding

J

appropriately.

wl'
4.

Uniform notification system in the country for diseases with

epidemic potentiality and instituting National health regulations to
69

..

i.
■

minimise spread of the disease from one area to another.

Computerised HMIS to be available all over the country.

F

It is urged that the Central Council of Health & Family Welfare takes

c

5.

cognisance of existing inadequate disease surveillance system and its resultant

adverse impact on the economy of the country and resolves to launch National

c

Disease Surveillance Programme as proposed above during the Ninth Five Year
(

Plan.

5

70

Agenda Item No. XV

1

national malaria eradication programme
Strengthening of MIS System for proper monitoring.

Malaria has been contained around 2 million cases in the country since

1984. However, from 1994 onwards it is being observed the Malarial focal

U

outbreak are being reported from some areas of the country which necessitates
timely alert of the States for undertaking appropriate preventive measures. All
the more such problems are emerging from the areas of low endemicity for

malaria wherein high casualties also occur because of unpreparedness of the

States facing such situation which.may be explained by the outbreak in
Rajasthan in 1994. It is important to notice that any fluctuation from earlier

Bi

i’

trends at the early stages for averting such exigencies is only possible by

developing proper information/reporting system at the district level with a malaria
epidemiologist and entomologist. It has been observed that the reports from the
States take on an average two months to reach the Directorate of NMEP. Even

with the best of efforts the same may not be useful to face an outbreak/epidemic
situation

since

malaria

is

a

local

and focal

disease. Therefore,

an

I
i
I

Epidemiological Cell should be established at the District level manned by

trained epidemiologists and entomologists for continuous monitoring and to

I

report any abnormal situation pertaining to all vector borne diseases including

i
malaria.
In order to strengthen the MIS system for proper monitoring of.the malaria
■■

situation to serve the purpose of early detection, the provision of appropriate

software programme at the district level

is a must. With the help of these

programmes, the epidemiologists at the district level will be able to up

II
I

malaria situation quickly and analyses the same in the most scientific manner

71

a

■fl

i
and inform the District and State Programme officers to take appropriate and

Ii ■' ■

timely control measures which are at present not possible with the time gap of

''WrZ'-" ■

2 months on an average spent over the consolidation of information.

The present infrastructure available with the NIC at the district level
including the NICNET facility should be made use of by the State/District Malaria

Officers so that at all the State headquarters consolidation is done. It should be

w

the responsibility of the State Headquarters to further communicate this to the

Directorate of NMEP and to share the information with the State Health

Authorities for under taking appropriate measures to control the situation.

CALENDER OF EVENTS AND ACTIVITIES FOR ALL VECTOR BORNE
DISEASES

Based on the information system proposed to be strengthened, a
calender of events and activities for each of the vector borne diseases would be
circulated wall in advance to all the State Governments for undertaking

preventive measures.

This would inter-alia include specific locations requiring attention both

from the point of view of prevention, spraying schedule, and transmission period.

The State shall be advised to strictly adhere to the action points

contained in the calender of events and activities proposed to be circulated to
them by the Directorate of NMEP.

CONTINGENCY PLAN FOR VECTOR BORNE DISEASES INCLUDING
DENGUE.
As a long term measure, a contingency plan giving specific details

relating to States' preparedness to contain any outbreak or epidemic situation
of vector borne diseases is under formulation by the Directorate of NMEP.

72

I ■'

t

lb

I
This contingency plan shall be specific to vector borne diseases and for

I

all the States highlighting the action points and calender of activities required

at each level of the Health functionaries in the States. Since the contingency

I

plan is still under formulation, the State Governments are requested to offer any

I

11
sliy
(• »

suggestions in this regard.

Strengthening of zonal and State level Entomological component for area

I'
I

specific vector control measures and forecasting.

II
I

The entomological component is very important as far as vector control

operations are concerned. This component is lacking. Presently, there are 72

I

zones in the States. Only 54 posts are filled up at the zonal level. There is,
therefore, an urgent need to fill up all the vacant posts.

t

I
I
I

The main function of the entomological team is to identify the present
XT?

transmission of vector borne diseases, particularly malaria and develop

integrated control strategy to prevent morbidity and mortality in addition to

!

forecasting the diseases situation. So far appreciable information has been

I

contributed by theses zones for entomological assessment for stratification of
areas requiring insecticide application and also for suggesting appropriate

control measures to reduce malaria and incidence of Japanese Encephalitis to

a tolerable level. These entomological teams do monitor susceptibility status of
vectors and other entomological indices. Depending on their findings, the

present control strategies have been finalised. Therefore, strengthening of these

component needs top priority under there present circumstances.

I

■

Strengthening of Basic Health Services by States.

With the introduction of Multi Purpose Workers Scheme, effective

implementation of National Health Programmes including NMEP is directly
related to the efficient functioning of the basic health services. These include

73

IH
H

11
I

surveillance and treatment of malaria cases, laboratory services and spraying
of insecticides. Keeping a sizeable number of Multi Purpose Workers (MPW)

and laboratory technicians posts vacant for a long period, as is observed in most

J®'

0

ti
e

of the States, adversely affects basic malaria work at the field level.. It

n

therefore, becomes imperative that the State Governments take immediate

v

action to fill up all the posts relating to malaria works and other posts coming
under the purview of basic health services without any further loss of time.

Development of skilled Manpower for Drug Sensitivity Tests at the state

level.
The drug resistance is also emerging as a major problem in tackling

malaria and incidence of P.faliciparum cases are increasing year by year. During
the lasts few years, foci outbreaks have been reported from various parts of the

country with an alarmingly high incidence of Pf. At present there are 258 (118
RIH, 71 RII) resistant foci in this country, although 13 P.falciparum monitoring
teams are working under the Regional Offices of Health & Family Welfare in

various States, it is difficult to cover the entire country. In such circumstances

these teams may impart training to the State officials for wide coverage.
Therefore, all the States should constitute Drug Monitoring Teams as per the Pf

situation, of their respective States.
EARLY ADOPTION OF MUNICIPAL BYE-LAWS BY THE STATES

Considering the fact that more and more people are migrating to urban

areas especially metropolitan cities the urban Malaria situation in the country is
also causing concern besides emergence of new vector borne diseases like

Dengue. Tools for control of vector borne diseases in urban situation have a

number of limitations. It therefore, becomes imperative to prevent creation of
Malariogenic conditions in urban areas.
74

I

*

■■

States were advised to frame and adopt suitable Municipal bye-laws on
the lines of Bombay Municipal Corporation Act, Comprehensive legal provisions

iI

exist in Bombay Municipal Corporation Act for slimination and avoidance of

mosquito breeding and for removal of cause that lead to mosquito breeding

within any premises.

I
This matter was also discussed at State Health Ministers Conference held

during February 1996, wherein the States were further advised to take early

1

action for framing and adopting suitable municipal bye-laws. No feed back has

I

Governments may be impressed upon the urgent need to take action for

.h,

I-

been received from the State on this important Public Health matter. State

adopting suitable Municipal bye-laws on the lines of Bombay Municipal
Corporation Act.

THE ROLE OF STATE GOVERNMENTS IN THE IMPLEMENTATION OF

I
i

NATIONAL MALARIA ERADICATION PROGRAMME

I

It has been observed that many states have not been able to effectively

!

implement the Malaria Eradication Programme as per the guidelines contained

I

I!

Hi

in Malaria Action Programme. Reportedly, the States due to their own financial

Hi

problems have not been in a position to fully contribute their mite to tackle the

II

Malaria situation and as a result local outbreaks have been occurring

The materials supplied by the Directorate of NMEP for undertaking Vector
Control measures which are crucial have not been utilised or lifted by certain
States leading to loss of human lives. This must be avoided at all costs.

In the name of matching contribution, some States have reportedly shown

expenditure on payment of salaries/wages. As per the guidelines of Planning

Commission, under the Centrally Sponsored Scheme (Cat-ll), 50% share of the

I

Hi

i

State has to be on Plan side, whereas, the payment of salaries and wages is

Non-Pian item.

75

ill

No exception can be made to the norms of Centrally Sponsored
Schemes, without the approval of full Planning Commission.

State Governments, should specifically earmark funds towards

operational costs and other incidentals, so that this becomes a truly Centrally

fI
I i
I1
F

Sponsored Programme implemented effectively.

c

11

III'

t
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4

(

I
I

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76
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■ L.-'

Fl
Agenda Item No. XVI

r

national aids control programme.
Review of Programme Implementation
Slow utilisation of funds:
i

I
!

Government-led efforts for control and prevention of HIV/AIDS in Indra

beqan in 1985 with the launching of a pilot project for screening hrgh risk
population, in 1991 a Strategic Plan for prevention and conlrol of HIV/AIDS was
developed in consultation with World Health Organisation and World Ban
'■

agreed to provide a Credit of US$ 84 million for the implementation of this

programme. The National AIDS Control Programme has been implemented

i!

-

llfi

ntiS

during the 8th Five Year Plan as a Centrally Sponsored Scheme with 100 per

cent financial assistance from the Central Government.
The programme is based on the following strategies identified for

■

I

prevention and1 control of HIV/AIDS in the country:
Strengthening Programme Management capabilities;
(a)
Surveillance and Research'

(b)

(c)

(d)

Information, Education and Communication (IEC);

Control of Sexually Transmitted Diseases (STDs);

1j'
I

(e)

Condom Programming;

(f)

Blood Safety; and

(g)

Reduction of impact on HIV/AIDS.

From 1992-93 onwards very few State Governments have utilised th

funds placed at their disposal for this Programme In fact, as and when

programme has been reviewed with the World Bank or with State AIDS

77

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i

Programme Officers, the main obstacle has been the slow utilisation of funds;
the slow release of funds from the State Finance Departments to the State AIDS

Programme Officers and the slow preparation of documents for enabling

I

National AIDS Control Organisation (NACO) to seek reimbursement from the
World Bank as per Agreement between Govt, of India and the World Bank.

The following steps have been taken by NACO to enable the State
Governments to make optimum utilisation of available resources:-

(i)

Union Minister of Health and Family Welfare has written to the Chief

Ministers of all the States for expediting the implementation of the
programme;

(ii)

Additional Secretary and Project Director, NACO, has written to Chief
Secretaries as well as Health Secretaries of all the States for speedier

utilisation of funds;

(iii)

Periodical meetings are held with State AIDS Programme Officers where

all the components of the programme including utilisation of funds are
reviewed in detail. The last meeting was held on November 20-21, 1996;
(iv)

The Programme Officers from NACO are constantly visiting the States to

ensure that the resources made available by the Govt, of India are fully
utilised.

Inspite of these efforts, the budgeted funds have not been used as
visualised in the scheme. The World Bank Credit is scheduled to come to a

close on 30th September 1997. It is essential that the Council considers afresh

steps to be taken by the State Governments for ensuring full utilisation of the

available credit.

Involvement of Non-Governmental Organisations (NGOs) in the implementation
of the National AIDS Control Programme

78

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II

f

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r

I

The National AIDS Control Programme visualises a very important role

?s
• J

for NGOs in the implementation of the scheme. In fact, the promotion of public
awareness and social mobilisation depends to a very large extent on the
activities of the NGOs to mobilise . Activities in HIV-related field which NGOs

could take up would include the following:-

lie

(i)

Cre.ation of awareness and preventive education;

(ii)

Service delivery through counselling, condom promotion and STD

curative services;

ie

(iii)

Enabling factors (skills);

(iv)

Care and support;

(v)

Advocacy; and

(vi)

Training.

9f

The Programme visualises that the NGOs would be selected in urban
areas for working amongst high risk behaviour groups and that the services of

a very large number of NGOs would be utilised in various States. However, the
experience of the last four years is that the role of NGOs in HIV control is

e

currently marginal and requires motivation and stimulation by the States. In fact,
very few of the State Governments have appointed an NGO Adviser or a nodal

3

agency for identifying NGOs in their respective States which could be provided
funds for creating awareness in the society. It is necessary that the State
Governments activate themselves in this respect as the disease is fast

spreading and needs to be tackled by mobilising community through NGOs.
Blood Safety

(a)

Setting up of National/State Blood Transfusion Councils:

In their judgement dated January 4, 1996 in the Writ Petition filed by

Common Cause concerning revamping of Blood Banking system in the country,

the Supreme Court, inter alia, directed the Union Government to establish a

79

■mp
P .7
National Council of Blood Transfusion as a Society registered under the
oocieties Registration Act. It has been envisaged in the judgement that the

Council would be a representative body having in it representatives from

Directorate General of Health Services of the Govt, of India; the Drugs Controller

General (India); Ministry of Finance in the Govt, of India; Indian Red Cross
Society; private blood banks; major medical and health institutions in the country
and NGOs active in the field of securing voluntary blood donations. It has also
been laid down that the Additional Secretary in the Ministry of Health who is

incharge of the operations of the National AIDS Control Programme would be
the President of the National Council. As envisaged in the judgement that each
State/Union Territory would set up a State/UT Blood Transfusion Council in their

respective State/UT on similar lines. The programme and activities of the
National and the State Councils are to cover the entire range of services related

to operation and requirements of blood banks including the launching of all
effective motivation campaigns through utilisation of all media for stimulating

voluntary blood donations, launching programmes for blood donation in
V

educational institutions, among the labour, industry and trade, establishments
and organisations of various services including civic bodies, training of

I

personnel in relation to all operations of blood collection, storage and utilisation,
separation of blood groups, proper labelling, proper storage and transport;
quality control and its achieving system, cross-matching of blood between donor
and recipients; separation and storage of components of blood and all basic

essentials of the operations of blood banking.

i

<1
The National Blood Transfusion Council was set up and registered as a
Society under the Societies Registration Act, 1860 on May 23, 1996. State Blood

Transfusion Councils have also been set up in the respective States and UTs.
The objective of including this agenda item is to sensitise the State/UT

Governments to undertake activities for revamping the blood banking
programme within their respective States/UTs. It may, however, be mentioned

here that the Hon'ble Supreme Court has to be kept informed on the progress
80
__

being made on various directives of the judgement from time to time through
ie

filing of affidavits by Director General of Health Services. The States may,

therefore, keep the Director General of Health Services informed about the
er

progress made by them in this direction at regular intervals.

(b)

Voluntary Blood Donation Programme

In 1989 the Govt, of India, Ministry of Health and Family Welfare,
engaged the services of M/s Ferguson & Co. to study the status of blood

banking programme in the country. One of the major shortcomings in the blood
banking system pointed out in their report relates to the source of blood.
According to this report, out of total quantity of 19.5 lakh units of blood being
generated per annum in the country, approximately 29 per cent was contributed

u

by professional donors. Over the years the demand for blood has increased due

to spurt of private hospitals and superspeciality nursing homes all over the

g

country. As the availability of blood has not shown parallel improvement, there

has been mushrooming of commercial blood banks. According to the Supreme

s

Court judgement, the Union Govt, and the Governments of the States and UTs
are required to discourage the prevalent system of professional donors so that

I,

this system is completely eliminated within a period of two years. States/UTs

are accordingly to draw up and implement time-bound programmes to generate

adequate quantities of blood from voluntary donors from all sections of the
society and to take steps to eliminate the system of professional donors.

a

(c)

Post-graduate Courses in Blood Transfusion

The blood transfusion services infrastructure in the country lacks many
critical resources, including acute shortage of adequately trained personnel. It

is also commonly agreed that the development of facilities for higher education

in Immunohaematology and Blood Transfusion in the country has not been
?

satisfactory. Taking note of this, the Supreme Court in their judgement dated

81

/

January 4, 1996 referred to above, has directed that steps should be taken for
starting postgraduate courses in blood collection, processing, storage and

transfusion and allied fields in various medical colleges and institutions in the
country.

1k

The Govt, of India have initiated a number of steps in this direction.
(

Curriculum for M.D. courses in Transfusion Medicine was got prepared and

(

forwarded to the Medical Council of India (MCI) for approval and to initiate the
(

process for inclusion of Blood Transfusion Medicine as a speciality for
1

postgraduate degree courses. The MCI approved the curriculum and the

Postgraduate Committee of the MCI

also decided to include M.D.

(Immunohaematology and Blood Transfusion) as an approved postgraduate MD
Degree in Blood Transfusion. The above mentioned developments were also

■.ii

brought to the notice of the State Governments with the request to initiate action
for starting the courses. It is urged upon the State Governments to take urgent
steps in this direction.

(d)

Income Tax Exemption to Donors in respect of donations made to
the National/State Blood Transfusion Councils.

1

While directing the State Governments to set up State Blood Transfusion
Councils, the Supreme Court had envisaged that the Councils are also
empowered to collect funds in the shape of contributions from the trade, industry
and individuals. In order to facilitate the collection of funds by the Councils, the

Govt, of India have amended Section 80-G of the Income Tax Act, 1961
providing for 100 per cent deduction from gross income of the donors in respect

of the donations made to the Councils.

82

I

Agenda Item No. XVII

I fe

NATIONAL TUBERCULOSIS CONTROL PROGRAMME

rI
Tuberculosis continues to be a major Public Health problem in India. The

disease affects primarily people in their most productive years of life and is
commonly associated with poverty, overcrowding and malnutrition.
education, environmental pollution

11

Lack of

and poor sanitation compound the

I

problem.The condition of relative deprivation among economically weaker

i

sections of the society and the high tuberculosis case rates in them seem to
form a vicious cycle, one aggravating the other.

In India 14 million people are estimated to be suffering from active
i

tuberculosis of which 2-2.5 million are highly infectious sputum positive cases.

rI

About 0.5 million die of the disease every year. Around 1.5 million TB cases are
detected every year of which about 20-25% are positive for sputum and rest of

|

are radiologically active sputum negative patients. It is estimated that almost an

■

equal number of TB cases are detected and treated by Non-Government

L

I ■
I

-h)>i

Organisations including Private Practitioners.

fe-'

To combat this problem, the scheme of National Tuberculosis Control

I

1

Programme (NTCP) was launched in 1962 on a 50:50 sharing basis with the

S1-’

States wherein the district was made the operational unit. The programme is

I

integrated with the Primary Health Care and provides services free for all

■ I

patients. So far Central assistance has been in kind (anti-TB drugs, equipments
r
i
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-I

i ■

and X-ray films etc.).

■
9
9J
9

At present District Tuberculosis Centres (DTC) have been established in
■

■-■’I-:

1iJfe-'

■J

446 districts out of 496 districts in the country. In addition to the DTCs there are

about 330 TB clinics which are mostly located in big towns and cities.

j ||

Short

83

I

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.

.

.

I

___

Course Chemotherapy (SCC) with potent anti-TB drugs was introduced in the
Programme since 1982. At present 292 districts have been covered with Short

Course Chemotherapy.

The objectives of the programme was to reduce suffering, disability and

w

1^3
J
..•3
I

death from TB. However, over the last 30 years achievement under the National

TB Control Programme are far short of the expectations. While reasons for such

I

shortfall are generally known and specifically identified by two Expert

Committees in 1975 and 1985, not much was done as a follow up to rectify them.

While other National Health Programme like NMEP, UIP, NLEP affected

substantial organisational and strategy changes and improved their overall
efficacy, National TB Control Programme did not make much headway largely

Mg/*1

’

1.3

for want of an appropriate strategy for reaching the peripheral areas and due to
gross under -funding.

The programme was last reviewed (1992) by a joint team from WHO and

■

I

W■

1

Govt, of India. Some of the important observations are:-

(a)

Gross under-funding of the programme resulting in inadequate

availability of drugs for treatment of cases.

(b)

Over-reliance on radiological diagnosis as a'gainst smear testing
through microscopy. Concentration of cases diagnosed at the
District TB Centres and non-utilisation of the facilities available in
the peripheral health institutions.

(c)

Infrequent supervision, partly due to lack of mobility and partly due
to inadequate number of supervisors.

(d)

Poor case holding because of poor accessibility, time and cost
factors involved in visiting health institutions, non-availability of
su

1

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drugs, neglect of treatment following disappearance of symptoms

L

and lack of awareness.

■ I

I rI
li

(e)

Inadequate facility and poor quality of sputum microscopy

(f)

Emphasis on case detection rather than cure

(g)

Multiplicity of treatment regimen and non-adherence to the
Regimen recommended under the National Control Programme.

-

In above context the country has adopted a revised strategy of Directly
Observed Treatment (DOTS) with SCC drugs in convenient patientwise boxes

1

being made available within easy walking distance with the objectives to achieve
85% cure rate necessary for sufficient impact on disease transmission. The

I’

strategy has been pilot tested in 6 rural districts and 10 metropolitan cities with
encouraging results.

The Government of India has sought World Bank

1

assistance for the following interventions.

NEW EMERGING AND RE-EMERGING ISSUES IN RELATION TO TB

CONTROL

I

ISSUES
Increasing disease Burden

I*
Estimated TB incidence in 1992 - 2005 are as under and activities of

National Programme remains at 1990 level.
■

r'■

I ■

F

1990

2064.000

1995

2350.000

2000

2678.000

2005

3045.000
85

W:
.....

I

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If

HIV-TB co-infection

■ afc -

The extent of dual HIV-TB infection in the country is at present unclear

g

but it seems reasonable to assume that there is a sizeable pool of dual infection

B

and this would increase without intervention. It is estimated that the incidence
i

of Tuberculosis will increase in the country during 1990 to 2005 by 0.4 additional
cases/lakh population per year. Due to increasing prevalence of the HIV
infection, dual infection is likely to increase resulting in increased morbidity and

|

mortality from tuberculosis. With dual HIV co-infection need for hospitalised
treatment will increase with the attendant cost liability.

'S

1

i-

Multi drug resistant TB (MDR-TB)

There is General impression that the pool of multi-drug resistant TB cases

;

are increasing. This is largely due to irregular and incomplete treatment. No

authentic survey report however.is available. Since treatment completion rate
• i ’©■

under National Programme has been below 40, there is high potential for
increase in drug resistance. Management of a multi drug resistant TB patients

is very expensive costing around Rs.50,000 to over 1000,000. MDR-TB patient
often needs sophisticated investigation and hospitalisation. Result of treatment

is also not very encouraging. The contacts are also at risk of getting MDR-TB. |
Prevention of MDR-TB to a large extent will be possible only if it is ensured that

I °

all the new patients put on treatment take drugs without interruption for fu

M

prescribed period.

Other important issues requiring immediate attention:-

(a)

ensuring timely procurement of adequate quantity of anti-TB drugs
and supply to the districts

(b)

■■

.

strengthening monitoring supervision at all level

86

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1

(C)

provide training and retraining at District level and development of

'I

training capabilities at State level

I

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I

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I

(d)

community participation and NGO involvement

(e)

(EC

(f)

i

filling-up of vacancies of Laboratory Technicians in the Peripheral

Health Institutions and Multi Purpose Workers.

II

Issue for Considration

Increasing disease burden and emergence of multi drug resistance TB

I

f

unless effectively controlled now will lead to a situation in which the

i

country will be forced to bear considerably higher expenditure in addition
to substantial economic loss due to disease and disability. This situation

■

can only be avoided by giving priority to the programme and providing

lit'
I

requisite funds. Both the Central Government and State Governments
need to increase their budget allocations to cover the critical activities,

>•

I

viz. Procurement and supply

4
II

of anti TB drugs and other essential

equipments and supplies.

Continuation of present policy of procurement of drugs on 50:50 sharing basis
has failed to ensure regular supply of drugs on a rational basis.

I
Following options may be considered:-

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(a)

?4I

100% procurement by Central Govt.

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However, in case of a

systems failure all the States will go without drugs. The

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programme in such a situation may suffer as it is going to be a all

I

or none phenomenon.

£

87

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■

■

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(b)

Decentralisation of drug purchase by State Government. The

State Health Authorities may be under pressure to spend the
money for other non plan activities.

(c)

The State Govt, may undertake procurement process and place
supply order. The payments may be made directly by P.A.O.,

DGHS.
For this activity State Govt, may determine their procurement
agency, call tender by National Competitive Bidding procedures
as per specifications given by the Central Govt. After a decision

is made on the bids, the State Govt, may place supply order within
the financial allocation communicated by the Central Govt. The

State Govt, may carry out quality testing as per laid down
procedure. The suppliers may submit their bills with certificates of
receipt by the State Store directly to the P.A.O., D.G.H.S. for

payment.
However, in view of the pre-condition by the World Bank that all drugs
should be procured by International Competitive Bidding for their re

imbursement, it may not be possible to decentralise the procurement of
drugs to the State level as the World Bank support for anti-TB drugs will

extend for all sputum positive cases in the country.
Regular supervision of D.T.C. key staff by the State level programme

officers and frequent supervision of field staff (Lab. Tech., MPWs) by

District officers (CMO, DTO) and by paramedical supervisors is critical for

maintaining quality of services at optimal level. Present state of poor
programme performance is largely due to inadequate supervision. One

of the major reasons for this lapse is lack of mobility which is the outcome
of poor transport facility, POL and maintenance fund.

A vehicle should be available to DTO and his key staff for which following
steps are necessary:

88

'Si f

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F"
(a)

Supply of vehicle from Central Govt, to all DTCs not having a
separate vehicle for D.T.C. work.

I
(b)

State Govt, may enhance the provision for POL & maintenance to

ensure visit of each PHI atleast once every quarter as per NTP

norms for supervision.

District TB Societies may be established in each district to monitor and

evaluate the Programme at District level and ensuring accountability and
coordination with NGOs.

State Governments may provide adequate fund for training and IEC at
District level.

Levy nominal charges on initial registration and issue of identity cards to

patients so as to imbibe a sense of participation and involvement in them.

Establish State TB Training and Demonstration Centrel in all States.

a
4

4
89

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Agenda Item No.XVIII

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There is urgent need to flush out all hidden cases of leprosy through
intensive public awareness campaign so that patients report voluntarily. This

should require involvement of both leprosy and GHC staff including the staff of

"fSM system and intensive use of media. State Governments, should issue a
circular to all district CMOs for giving further instructions for full cooperation of

GHC staff in districts and by the staff of ISM system for distributing leprosy drugs

Stai
and

NATIOANAL LEPROSY ERADICATION PROGRAMME
Intensified IEC Activities :

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act

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to the leprosy patients through their centers and for providing follow up
er

treatment to the leprosy patients. Circular should also be sent to the district
health training centres to include leprosy while orientation training of any

m

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category of GHC staff is organized. Vertical leprosy staff from the districts

should be invited for giving training to GHC staff. Similarly circular be sent to

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all regional Health & Family Welfare training centres and to ISM Medical

L

Colleges, Nursing Schools to include leprosy orientation training programme for

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all categories of health workers in their centres. Instructions should be sent to
all district magistrates to fill up the vacancies of contract staff sanctioned under

v

World Bank support and to utilize the funds released to districts societies for
i

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health education, orientation training etc.

e

I.

Disability and Ulcer Care

Training for disability and ulcer care needs to be strengthened in all the

districts of the country. States which have not completed disability care training

of four core trainers for each district should complete the same early and submit

I
■■

the report to Leprosy Division so that additional funds can be given for

■ i

90

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organizing further training of peripheral staff of the district. In each district the
State Governments should identify one orthopaedic surgeon/general surgeon

and one eye surgeon in district hospital as a nodal officer in the district who

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should be involved fortraining of field staff along with other four core trainers in

the district. The name of identified surgeons should be circulated in all health

r.

centres of the district so that they can refer the patient to them. Names of
surgeons identified in each district should be sent to Leprosy Division, Ministry
I

of Health & FW for monitoring and supervision on disabilities and ulcer care

I

I

I
I

activities.

Integration

Leprosy serviceswill be required to integrate with GHC services after the

end of 1998. Therefore, the process of integration must be started in a phased

manner. To start with all the Health & FW training centres, district training

centres and training centres under ISM are required to be instructed to include
leprosy in the course curriculum for all categories of staff including for

orientation training. The trainers can be involved from the locally available
Leprosy Trained Medical Officer/Supervisors. Such trainers should be allowed
to draw their TA/DA from the funds of District Leprosy Societies where they are

working. Once the orientation training of 80% of staff is completed in the district

with in next three years, the services can be integrated in the district after

following the transfer of records, reports and case cards. This is however

advisable to be done after verifying proper orientation training of atleast to 80
% of the staff.

1

11
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t"Agenda Item No.XIX(i):

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STATUS OF THE REPORT ON ENVIRONMENTAL

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HEALTH AND SANITATION

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The outbreak of Plague in 1994 and the resurgence of Malaria and

c

Dengue in some parts of the country has raised a serious concern with regard
to the capability of the existing Public Health System in the country. The newly
emerging and re-emerging health problems have been further accentuated by
deteriorating environmental health conditions

A Committee under the Chairmanship Of Shri M.S. Dayal, former Union

Health Secretary was constituted to formulate a comprehensive National

Programme of Sanitation and Environmental Hygiene on he lines of technology
mission for checking the fall in environmental standards.

The recommendations made by the Dayal Committee (1995) were

discussed in a meeting of Committee of Secretaries (COS) and it. was decided
that action on the priority areas identified in the Dayal Committee report may be

taken up by the concerned Ministries/Departments by including them in their
Ninth Plan proposal.

The concerned Ministries, viz., Urban Affairs and

Employment, Environment and Forests and Rural Areas and Employment have

been informed of the COS's decision for further necessary action.

The Dayal Committee had identified 6 priority areas for implementation
during the Ninth plan by the respective Ministries. These are (a) urban low cost
sanitation, (b)
management,

urban waste water management, (c) Urban solid waste
(d) rural environmental sanitation,

(e) industrial waste

management, (f) air pollution control and (g) strengthening of health surveillance

and support services.
92

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------ -

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The Working Group on "Environmental and Health; Health Education and

K

IEC constituted by the Planning Commission under the Chairmanship of

u
I

Secretary (Health) also examined issues related to Environmental Hygiene and
Sanitation Out of 15 action points identified by the Sub-Group of Environment

and Health, 7 points pertain to Ministry of Health & Family Welfare. These 7

I-

identified programmes broadly relate to environmental health surveillance, water
|

quality monitoring and surveillance, hospital waste management and

sensitisation of Panchayats and Nagar Palikas for planning and implementation
of environmental health activities at local level.

K
The 73rd and 74th Constitutional Amendment Acts, 1992 have provided

I

a framework for involvement of Panchayat Raj and Nagar Palikas in all

developmental programmes including public health and sanitation in the rural

and urban areas of the country respectively. These local bodies would thus

s

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t

have a tremendous role to play in upgrading the environmental health condition.
For effective implementation of health education activities in environmental

;

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Ii

health and sanitation, multi sectoral cooperation and coordination is necessary.

The Central Health Education Bureau should function as the nodal agency at

the Central level for health education, health awareness and community
participation in environmental health andsanitation activities,

Separate

Committees at village, block, district ad State level need to be constituted with
.

due representation from government and non-government agencies to monitor

I

the health education and awareness activities at the respective levels.

None of the available laws in the country takes into consideration health
and environment in a comprehensive manner. In view of this, constitution of an

intef-ministerial working group comprising the Ministry of Environment and

»!■

Forests and the Ministry of Health & Family Welfare has been suggested to

examine the existing Environmental (Protection) Act, 1986 and the Model Public
Health Act (Revised), 1978 and to frame a comprehensive Environment and

i

Health (Protection) Bill for consideration of the Government. The Panchayati

93

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1

Raj institutions and Nagar Palikas should also actively consider the model Public

'f

Health Act, 1978 for incorporating suitable provisions in their local health Acts,

OK?

The following points are for consideration and discussion in the meeting:1.

Constitution of an inter- ministerial group to examine the existing laws of
public health and environment and come out with appropriate

recommendations to enforce proper safeguards in the implementation of
development projects with due empowerment of local bodies.

2.

Strengthening of the Department of Health and Directorate General of
Health Services by establishing a Division of Environmental Health for

proper management and control of environmental health issues.

3.

The measures adopted by the Central Government on environment and
health may be adopted by the State Governments also for framing
suitable programmes in the area of environment, health and sanitation

and include them in the Ninth Plan.

4.

Sensitisation of Panchayat and Nagar Palikas is called for planning and

implementation of environmental health activities and implementing
health education activities through various Committees on a sustainable
basis.

5.

Appropriate schemes on drinking water quality monitoring and

surveillance and hospital waste management need to be initiated.

94

F

Agenda Item No.XlX(ii)

HOSPITAL WASTE MANAGEMENT
Factors which have brought the problem of hospital waste managQrri

t

into sharp focus have beeh -

(a)

The rapid increase in waste generated in hospitals mainly
increasing use of disposables as compared io recyclable or

due to

'"usable

devices.

(b)

The increase in complexity and technical advances in medical a d

surgical care resulting in a quantum increase in magnitude
complexity of waste generated from this activity. There has been q

and

rapid

mushrooming of health care facilities providing state-of-art, medical

care.
Unfortunately, at the same time, due attention has not been given t

providing

adequate

infrastructure

facilities

including

the

safe

management of waste generated.

(c)

The problem has been compounded by rag-pickers who sift through
waste and recycle certain elements for financial gains.

Thus the

recycling of bio-medical waste such as disposable syringes, intravenous
tubes, catheters, surgical gloves, etc. has undermined the drive to

treatment of patients safer through the use of disposable produc.ts

The following types of wastes are generated in the major hospitals in the country

i)

Mon-clinical or house hold waste;

ii)

Clinical or biological waste;

iii)

Solid, liquid waste and radio-active waste; and

iv)

Chemical waste.

95

t■

w’
In most of the major hospitals under the Central Government and State

Governments, incinerators have been installed for disposal of hospital waste.
Most of these hospitals have also introduced a system of segregation of

hospitals waste by use of different coloured plastic bags and destruction of

■
■

' ML

infectious items such as disposal syringes and needles. But there are gaps in
the system which has led to infectious items being thrown in refuse dumps and
which are picked up by rag-pickers.

In April, 1995, the Ministry of Environment & Forests, promulgated the

Draft Rules on Management of Bio-medical Wastes which provide for control
over generation, handling, treatment and disposal of medical waste.

The

■ 'I &W' i

appropriate authorities have been designated with the task of implementation
of these rules.

All persons handling such wastes are required to obtain

authorization from the appropriate authority.

j ||

A Schedule of Wastes has been listed to which these rules apply. The

segregation of waste at sources has been made mandatory for all institutions
dealing with these wastes. The rules also provide a general scheme for types

of containers to be used, colour coding and labelling. Options for treatment and
disposal are also provided in a broad way.

An important feature is the

prohibition on the import and export of bio-medical wastes. Biannual reports,

maintenance of records and returns have been made mandatory.

The rules were circulated to all health care establishments and their

comments invited. They are to be finalised by the end of 1996.

The Central Pollution Control Board (CPCB), has also developed

guidelines for management of hospital wastes and standards for incinerators.
According to the guidelines recommended by CPCB, the hospital wastes are to
be segregated in different categories and collection in colour-coded containers

so as to avoid mix up of the wastes. The infectious wastes should be subjected
96

I

•I

to incineration, while the needles, scalpel, blades, and discarded glasswares
should be disinfected by autoclaving. CPCB has recommended two types of

incinerators namely, for individual and common use.

Specification regarding temperature, emission levels, height of incinerator

and liquid effluent characteristics have been laid down.

Presently, incineration is being utilised for disposal of medical waste.
However, keeping in view the issues of environmental pollution, inherent

problems of production of ash and toxic emission, alternative strategies for

waste management need to be explored, such as

(a)

Waste Reduction : A lot of emphasis is being given to reduce the amount
of waste generated by return to recyclable devices. For example, use of
glass syringes instead of plastic syringes, etc.

(b)

Composting of organic faction of waste, particular trials are being made

in the use of vermi-composting in various parts of India.

(c)

Chemical processes which are eco-friendly.

(d)

Auto-claving and mechanical shredding.

During the current year 1996-97 an amount of Rs. 10 lakh has been kept

for initiating pilot projects on comprehensive waste management under the

Health Sector.

Various aspects of Hospital Waste Management in the country were
examined and a number of action points have emerged :

(i)

Comprehensive technical and management guidelines need to be issued.
Cost factors and economic considerations should be addressed in the

guidelines.

97

(i>)

Issue of instructions regarding the use of glass syringes after autoclaving.
Regarding needles it is felt that since virus may not be destroyed,

■

t

disposable needles could be used.

(iii)

Emphasis should be placed on creating awareness, motivating and

-m:.
■

educating staff. Training programmes should be formulated.
(iv)

It is necessary to prepare hospital waste manual which would cover the

following points :

(a)

Local collection of waste at site of waste generation.

(b)

Segregation of waste at local site.

(c)

Transportation of waste.

(d)

Disposal of waste (including radio-active waste).

(e)

Purchase of items such as shredders, coloured bags, needle

j

destroyers, etc.

(f)

Proper storage at the storage area of incinerator.

(g)

Disposal of ash generated by the incinerator.

(h)

Training of personnel handling waste.

(i)

Clear demarcation of tasks to be performed by different personnel.

0)

Duties of supervisory staff.

(k)

Instructions regarding protective clothing to be worn by personnel
handling hospital waste and periodic health check-up of such
personnel.

(I)

Security requirement to prevent illegal re-cycling.

(V)

Immunization of staff should be a priority.

(vi)

Each State/UT should formulate its plan of action for hospital waste
management and include this as apart of the State Plan discussion with

!I 1

the Planning Commission during the Annual Plan discussions for 1997-

98.

a fe-i '
98

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It is urged that the Central Council of Health & FW take cognisance of the
above stated facts relating to poor management of hospital waste and its

I 11
.■5

adverse impact on human health and resolve initiation of Hospital Waste

Management Programme during the Ninth Plan period.

99
sE,: •

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Agenda Item No.XX

Ob

STATUS REPORT ON RABIES INCLUDING USE OF

1

ARS IN SEVERE BITES

I

Approximately 30,000 deaths occur due to Rabies every year in India and

around one million persons take post-exposure treatment after dog bite, of which

■

around 0.5 million take painful 14 injections in the abdomen of the Semple

vaccine which is prepared in the sheep brain by 100 year old technology, only
0.5 million persons take more advanced, safer tissue culture vaccine for

treatment which costs about Rs.2000/- per treatment.

The nervous tissue

vaccine which is produced in the country at times is not of good quality and the

distribution in the States is not satisfactory (without proper cold chain) and in
remote areas sometime the patients do not get vaccine. Similarly, anti-rabic
serum which is given immediately after the bite to save the life of the patient is
not available in many hospitals and centres in the States, thus leading to deaths

in large number who are bitten by rabid dogs. Of late, the incidence of rabies
has increased not only in the stray dogs, but also in vaccinated dogs (70% dogs

developed Rabies). It has also been observed that a single rabid dog can bite
50-100 persons and cover 30-40 kms.

On the basis of the recommendations made at the Workshop on

Surveillance and Control of Rabies in 1985, which was attended by
representatives of States and UTs and National and International experts,

initiation of a national Rabies control programme was recommended. However,
same has not been implemented yet.

Anti-rabies vaccine production

’f

In India, by and large, neural anti-rabies vaccine is being used which is

; I'

manufactured in 12 public sector institutes. One of the public sector institutes

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100

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i.e. Pasteur Institute, Coonoor is also making efforts to produce Vero cell tissue

culture vaccine which may be made available shortly. Another public sector

undertaking is marketing tissue culture vaccine in small quantities. In private
sector Hoechst (India), Mumbai is manufacturing tissue culture vaccine in limited

SOT'-'-

quantity.

Anti-rabies serum is being manufactured by Central Research

Institute, Kasauli. In addition several institutes are involved in the production of
.
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■

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veterinary vaccines, both neural and tissue culture origin.

Rabies Control Programme:

The Rabies control activities should be through:-

(a)

Enhancing awareness among the general public through various

print and electronic media.
(b)

To reduce by humane methods maimed, obviously unhealthy and
unowned dogs with the aim to reduce the dog population to 80%

of the current population.
(c)

To compulsorily vaccinate this 80% dog population with a potent

■

tissue culture vaccine. The vaccine is to be administered free of
cost.

(d)

To effectively implement legislative measures for compulsorily
licensing the owned animals.

(e)

To provide pre-exposure tissue culture vaccine to persons

engaged in control activities.

(0

To strengthen the existing diagnostic services in the country.

Adoption of modern techniques for production of anti-rabies tissue culture
vaccine and phasing out the neural tissue vaccine.

To produce anti-rabies globulin through adoption of modern technologies.
101
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Strict quality assurance of the anti-rabies vaccines being produced.

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In view of the above it is urged that the Central Council of Health &

h

FW take cognisance of the facts related to Rabies problem causing

preventable mortality in man and animals and resolves to initiate Rabies

i

control activities in the country

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102

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Agenda Item No. XXI

NATIONAL PROGRAMME FOR CONTROL OF
BLINDNESS
The performance of cataract operations and other eye care services
needs to be improved in Government institutions viz. medical colleges, district

hospitals, district mobile units and upgraded PHCs.

To increase the performance, it would be necessary to upgrade the

targeted service units by filling up sanctioned posts of eye surgeons and
paramedical staff, supply of consumable items by the State, training of

personnel and support from PHC staff.

Funds released by Government of India are not efficiently utilized by the
States leading to accumulation of unspent balances over the plan period. This
not only hampers planned development of services in the State, but also

adversely affects disbursement of funds from the World Bank and DANIDA.

Delay in receipt of audited expenditure report slow down disbursements. These

shortcomings affect further release of funds to the States.

The State should judiciously draw a realistic plan of action for

development of services in each financial year well before the commencement

of the financial year. This plan of action should take into account equitable
distribution of eye care units in various districts of the State and should be
drawn in a need-based manner. Timely and complete reporting of performance,

development of services, component-wise expenditure and audit reports would
enable Government of India to release funds to the States and seek assistance

from the World Bank and DANIDA expeditiously. Proposals for revalidation of

unspent balances, if any, should be sent to Government of India in the first

103

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quarter of a financial year with details of component-wise savings, reasons

thereof and manner in which funds are proposed to be utilized.

The State Programme Cell needs strengthening to monitor activities
under National Programme for Control of Blindness including functioning of

District Blindness Control Societies in the States.

IF
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Funds are currently released to DBCS from Central Govt, on a performance

related basis, as recommended by Central Council of Health & Family Welfare
in their previous conference, in October, 1993. The State should assume the
responsibility of monitoring functioning of DBCS as per guidelines issued by
Government of India. However, main features of DBCS as outlined in GOI

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guidelines including its autonomous character, constitution, composition, pattern

■■

of expenditure etc. should be retained. To strengthen State Programme Cell,
the State Govt, should post full time State Programme Officer of Joint Director
rank and requisite support staff as sanctioned under NPCB.

/;

■

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■■i

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.■

Utilization of available services, both in fixed facilities and eye camps is

11

■

not optimal. The State Governments and respective District Blindness Control

Societies should plan and implement effective IEC activities to improve

I

awareness about eye care in general and treatment of cataract in particular,

,1

allay the misconceptions of public and inform availability of eye care services.

1 T

1

i

IEC activities should target not only beneficiaries but also community leaders,

Panchayat leaders, health staff and provide eye care services.

i

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Implementation of NPCB include collaboration between Government and

1

non-Govt. organizations. The State should extend full cooperation to NGOs in

■

■

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implementation of various schemes viz. organization of surgical eye
camps(reach out approach), organization of screening camps and surgery at

•'/I :•

base hospital (reach- in approach) expansion of or setting up of eye care units

.S-

in rural including tribal areas under World Bank assisted project, scheme for
104

11
:4

screening and motivation and eye banks/eye donation centres in voluntary

i'
■

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sector.

National Programme for Control of Blindness should be made

comprehensive eye care programme rather than a cataract centred programme.

The States should expand activities like school eye screening for
correction of refractive errors, eye donation and eye banking for reduction in

corneal blindness, management of glaucoma and other eye disorders. Follow
up of operated cases and provision of corrective glasses should also be

emphasized.

Additional activities under World Bank assisted project including
construction of dedicated eye operation theater, eye wards and dark rooms at
PHCs, schemes for cost recovery, training of district eye surgeons in IOL

surgery etc. should be undertaken. Additional posts under the project should be

created and filled by regular or temporary posts, through redeployment or
through contractual appointment.

105
i

Agenda Item No. XXII

NATIONAL CANCER CONTROL PROGRAMME

i
ii
i

It is estimated that there are 2.0 million cancer patients at any

given point of time and about seven lakh new cases come up every year in
the country. The disease has high morbidity and mortality.

1s
The Govt. Of India started the Cancer Control Programme on a

limited scale during the year 1975-76. There are schemes for

■J

(i)

Grant-in-aid to Regional Cancer Centres

si

(ii)

Financial assistance for setting up of Cobalt Therapy

T':

Units

(iii)

Development of oncology wings in medical

■W'
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colleges/hospitals.

(iv)

-I

District Project for health education, early detection and
pain relief measures

(v)

Financial assistance to voluntary organisations for health
education and cancer detection activities.

The Plan funds for National Cancer Control Programme during
The two years are as follows:-

IB
i

1995-96

Rs. 16.00 crores

1996-97

Rs. 18.00 crores

The points for discussion are:

(a)

li

Increase in Plan funds for strengthening of the programme and wide

coverage.

106

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(b)

■ T ?!

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Possibility of alternative sources of funding the programme so as to

augment the availability of resources. A Society may be formed which
may raise donations and loans apart from Central funding.

■s

(c)

The emphasis should be on comprehensive cancer centres for

prevention, diagnosis, treatment, pain relief and research activities. Thin

spreading of resources may not be desirable.

(d)

Emphasis on one time grants rather creating recurring liabilities under the
programme.

(e)

Regional Cancer Centres may increase their own resources so as to

reduce their dependence on Government Grants.

(0

There is a scheme for development of oncology wings in medical
colleges/hospitals. More institutions may be covered under the scheme

for augmentation of treatment facilities in the country.

(g)

Larger involvement of voluntary organisations in the programme

particularly for health education and cancer detection activities. Financial
■1

assistance may be provided to such organisations in consultation with the
concerned State Governments

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Agenda Item No. XXIII

Bp

NATIONAL IODINE DEFICIENCY DISORDERS

CONTROL PROGRAMME

i

MAGNITUDE OF THE PROBLEM:
As per information available more than 1.5 billion population of the
World are at the risk of Iodine Deficiency Disorders(IDD) out of which, it is
estimated that about 200 million people are living in our country. The survey

conducted by the Central & State Health Directorates, ICMR and. medical
institutes have clearly demonstrated that not even a single State/UT is free from

the problem of Iodine Deficiency Disorders.

Sample surveys have been

conducted in 25 States and 4 Union Territories of the country which have
revealed that out of 269 districts surveyed so far, IDD is a major public health
problem in 235 districts.
CONTROL PROGRAMME:

Realizing the magnitude of the problem the Government of India launched

a 100 per cent Centrally assisted National Goitre Control Programme(NGCP)
in 1962. The important objectives and components of the control programme
are as follows:(I)

Surveys to assess the magnitude of the Iodine Deficiency
Disorders.

(ii)

Supply of iodated salt in place of common salt.

(iii)

IDD Monitoring through analysis of salt and Urine samples.

(iv)

Resurveys to assess Iodine Deficiency Disorders and the impact
of iodated salt after every 5 years.

(v)

Health Education.

1
108

is

In August, 1992 the National Goitre Control Programme(NGCP) was
renamed as National Iodine Deficiency Disorders Control Programme(NIDDCP)
considering the wide spectrum of Iodine Deficiency Disorders.

ACHIEVEMENTS:

The achievements made under the major components of the existing
programme from its inception to date are as under:(i)

The policy of iodated salt production has been liberalized to private

sector.

641 private manufacturers have been licensed by Salt

Commissioner out of which nearly 532 units have commenced production
so far. They have annual production capacity of more than 60 lakh
tonnes for the entire country.

(ii)

The annual production of iodated salt has been raised from 5 lakh metric

tonnes in 1985-86 to 34 lakh metric tonnes in 1995-96. This is expected
to further rise to 50 lakh metric tonnes in near future.

(iii)

The Salt Commissioner in consultation with the Ministry of Railways

arranges for the transportation of iodated salt from the production centres
to the consuming States under priority category ‘B’ a priority second to

that for defence. Funds are provided to Salt Commissioner's Office for

maintaining the quality control of iodated salt at production level.

(iv)

To ensure use of only iodated salt, the sale of non-iodated salt has been

completely banned under Prevention of Food Adulteration Act, 1954, in
22 States and 5 Union Territories and partial in 2 States namely Andhra
Pradesh & Maharashtra. There is no ban in the State of Goa, Kerala and
Union Territory of Pondicherry.
(v)

For effective monitoring and proper implementation of NIDDCP all the
States and UTs have been advised to establish IDD control Cell in the

State Health Directorate and Central Government provides cash grants
for this purpose. Presently 27 States and Union Territories have
established such type of Cells.
109

t
(vi)

A National Reference Laboratory for monitoring of IDD has been set up
at the Bio-chemistry division of National Institute of Communicable
Diseases, Delhi for training medical and paramedical personnel and

monitoring the iodine content of salt and urine.

(vii)

It has been proposed to set up district level IDD monitoring labs for

■a

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iodine content of salt and urinary iodine excretion which are the most

effective tools for proper implementation of IDD Control Programme. For

the year 1996-97 budget provision has been made for setting up of at
least one IDD Monitoring Laboratory in each State/UT.

(viii)

Cash grants are provided by the Central Government for conducting
surveys/resurveys of IDD; Health Education and Publicity Campaign to

promote the consumption of iodated salt.
(ix)

The standards for iodated salt have been laid down under PFA Act, 1954.

j ■

These stipulate that the iodine content of salt at the production and
consumption level should be at least 30 and 15 ppm respectively.

(X)

Realising the importance of iodine deficiency in relation to Human
Resource Development, NIDDCP has been included in the 20 Point

■■

■1

11

fe-

Programme of the Prime Minister.

•t
(Xi)

For ensuring the quality control of iodated salt at consumption level,
testing kits for on the spot qualitative testing have been developed and

Ii

■

■

distributed to all District Health Officers in endemic States for awareness.

(xii)

GOI-UNICEF Project 1992, 1993-1995, is being implemented in 13
selected endemic States for extensive monitoring and IEC activities of
NIDDCP. The activities are to be strengthened in 106 selected districts
of 13 States including North-Eastern region. The project is also extended

I:
i

J

for the year 1996-97.
POINTS FOR CONSIDERATION OF CENTRAL COUNCIL OF HEALTH & F.W.

The major problems/action points of the programme for

consideration of the Council are as follows.110

L

__

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■ •ySl

I

(a)

To issue complete ban notification by the remaining States/UTs for
the sale of non-iodated salt.

(b)
(c)

To establish IDD Control Cell by remaining States/UTs.

To set up district IDD Monitoring Laboratories for estimation of

iodine content of salt by titration methods and urinary iodine
excretion by the remaining States and UTs. The Laboratory
personnel should be trained at National Reference Laboratory for

IDD monitoring at NICD Delhi. Complete guidelines, including

collection of samples from periphery, should be provided to the

Laboratory personnel.

(d)

To enforce the quality control of iodated salt supplied to the
consumers by the State/UT Governments.

(e)

(f)

To conduct IDD surveys in remaining districts.

To create awareness about IDD and consumption of iodated salt

for their prevention.

(h)

To develop trained medical and paramedical personnel for

implementation of NIDDCP

111

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Agenda Item No. XXIV(i)

MENTAL HEALTH PROGRAMMES-HIGHLIGHTING
DISTRICT COMPONENT
Mental Health problems have become a major public health problem in
recent times. Epidemiological surveys within the country have revealed that 5-

■'

111<1
1

-‘S

10% of general population are in need of psychiatric care at any given time and

<

also the most of them seek help through a general health facility for some

physical problems. General Practitioners are not sufficiently trained to detect

and manage these problems in their day to day practice.

I
3

The number of qualified mental health professionals is very small and
added to this is that most of them are concentrated in big cities. About 50
mental hospitals in the country are in a deplorable state to the extent that

1

Supreme Court had to ask the Central Government to intervene in at least five
of them. There are no mental health services or are only at a rudimentary level

in some States/U.T.s particularly in M.P., H.P. and in North East Region. Lack
of Psychiatric services at the periphery, lack of proper knowledge about mental

illness and their causes, myths, misconceptions and stigma surrounding mental
illness all result in untold suffering to the patients and their families calling for
a community based approach towards tackling mental health problems in the

country.
National Mental Health Programme (NMHP) though in existence since

31■I ■ ■

1982 failed to take off due to various reasons. After taking a decision to revamp
and revitalise the programme in the last Central Council of Health & Family

i

Welfare meeting, a National Workshop of State Health Administrators was held
at Indian Institute of Management, Bangalore in February, 1996, to give direction

.i
j

to the NMHP. One of the major recommendations of the Workshop was to adopt

J

community based approach in implementation of the NMHP in at least 25% of

a

the Districts in all the States of the country in the next Five Year Plan.

Parliamentary Standing Committee on Human Resource Development in its
latest Report (45th Report) has also emphasised that mental health services
need to be extended to all the districts of the country on priority and
112

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1

recommended appropriate increase in funding to achieve this target.
The District Mental Health Programme envisaged under NMHP will be
taken up with central assistance. As envisaged it will first be run on a pilot
basis in a few States on the model developed and successfully tried by

NIMHANS, Bangalore in Karnataka in the district, Bellary known as ‘Bellary

Model”. Training facilities for doctors, nurses and other workers required for the

District Mental Health team will be provided by identified institutions in the
States. These nodal institutions swill provide the necessary technical back-up
from time to time for developing and running the programme in district.

Monitoring of the programme will be done by the State through the nodal

institutions and by the Centre.

District Mental Health team is expected to

provide service to the needy mentally ill patients including persons suffering

from epilepsy and their families through Out-Patient Service, ten bedded in
patient facility, referral service, liaison with PHC and follow up service. The

programme also aims at creating awareness in the community to remove stigma
of mental illness.
Indian Lunacy Act, 1912 has been replaced by Mental Health Act, 1987
and is in force since April, ,1993 in all the States and UT’s. As per provisions

under this Act, in addition to setting up of a Mental Health Authority in their
respective States and UT’s, Mental Health Authority so established will take
necessary steps to ensure development and regulation of delivery of Mental

Health Services as per norms provided under the law.

The following points are for consideration and discussion :
General issues

(a)

In future, as a matter of policy, mental health may be integrated with

physical health as part of planning of health services in the country both in
States and the Centre. Peripheral services at the District and Sub-district level

have to be accorded due priority in planning.
(b)

Medical Council of India may be appropriately involved in improving the

undergraduate curriculum and training and also through introducing refresher
courses to update the knowledge and experience of practising physicians.
113

I
(c)

Improvement of mental hospitals and Departments of Psychiatry in

r

general and teaching hospitals in terms of adequate staff and services in all the
g.

States needs urgent attention.
District Mental Health Programme
(d)

States must take advantage of the training programmes of trainers offered

w
wfc-7*■
I

by the Centre through specialised institutions such as NIMHANS. They must in

turn undertake training programmes of other functionaries like PHC Doctors,
Nurses, Voluntary Social Workers, Anganwadi Workers, Community Health

I.

Workers, Teachers and family members of patients etc. so that patients can be

I

managed at the periphery itself within the community.
(e)

Appropriate IEC materials in all local languages may be developed for the

use of doctors and paramedics and the public to create awareness about the

II i-

disease and the much needed acceptance of the mentally ill in the society.

I
(f)

i

The States must provide adequate and regular supply of medicines meant

for mental illness etc. to the District and sub-District Health Centres.

(g)

More training institutes have to be identified in the States so that needs

of the District Mental Health Programme may be met with even in those States
which lack manpower resources.

(h)

.1

With the recognition and inclusion of disability arising out of Mental

■a

!"

illness as one of the disabilities eligible for benefits under the provisions in the
new Disability Act, 1955, rehabilitation of the mentally ill and their acceptance
within the community is an important area needing urgent attention by the States

State Mental Health Authorities

(D

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ji
■i -

Those States and U.T’s which have not yet formed or notified the Mental

Health Authority may do so at the earliest as establishment of Mental Health

Authority is the statutory requirement for every State & U.T. Once they start

functioning properly it will result in overall improvement in delivery of Mental
Health Services.
114

l

Sb

Agenda Item No. XXIV(ii)

it.

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’W

ROLE OF HEALTH SECTOR IN IMPLEMENTATION OF

PROGRAMMES FOR PERSONS WITH DISABILITIES
(EQUAL OPPORTUNITIES, PROTECTION OF RIGHTS
AND FULL PARTICIPATION)
It is to be noted that Act has come into force w.e.f. 7-2-1996 and is an
important landmark in the empowerment of persons with disability through

creation of equal opportunities and protection of their rights. Disabilities as per
this Act include (a) Blindness (b) Low Vision (c) Leprosy Cured (d) Hearing

impairment (e) Locomotor disability (f) Mental retardation and (g) Mental illness.
Even though Ministry' of Welfare is the nodal Ministry directly concerned with
rehabilitation of the disabled, Ministry of Health and Family Welfare plays an
important role in early detection and prevention of disability and has a number
of National Health Programmes in this connection. They are - (i) Leprosy
Eradication Programme (ii) Blindness Control Programme (iii) Iodine Deficiency

Disorders Control Programme and (iv) National Mental Health Programme .

Besides these, the Universal Immunisation Programme and Maternal Child

Health Programmes have a direct bearing on prevention of disabilities. There
is

a further need for development of inter-sectoral co-operation and

collaboration between various concerned Ministries, between Government and

N.G.O. Sectors and between Centre and States in the area.
Following Points are for consideration
1.

District Level Centres of Rehabilitation:

Health infrastructure in terms of PHC and District and Sub-District Centres at the

periphery already exits and can be advantageously used in the present context
for incorporating various aspects of prevention and rehabilitation.

2.

Mental illness:
As mental illness has also come under the purview of the Act. It has

115

J.

become all the more necessary to give further impetus to the National
Mental Health Programme with special emphasis on rehabilitation of
mentally ill and their acceptance back in the community.

Task of

assessment and grading of disability arising out of mental illness has to

be undertaken like in physical disability so that they are able to take

advantage under the provisions of the Act.
3.

Employment:

It need to be emphasised that 3% reservation for persons with disability
in jobs in Governments and Public Sector Undertakings is an extremely
important provision of this Act. and has to be quickly implemented by all
concerned including the Department of Health & Family Welfare in

various States and U.T.’s. The special employment exchange should

take care of this provision in the Act.
4.

Research:
Nation-wide surveys, investigations and research concerning the causes
of occurrence of disabilities and their prevalence in the community needs
to be undertaken if necessary in collaboration with other concerned

Ministries like Welfare. Also research needs to be undertaken in the
development of newer aids and devices and other cost effective socio
culturally acceptable methods of delivery of rehabilitation services within
the country.

5.

Establishment of Special Institutions or Identification of already existing

institutions :
The two special institutions dealing with disability under the Ministry of

Health & Family Welfare are:
1.

All India Institute of Physical Medicine & Rehabilitation, Mumbai,

2. All India Institute of Speech and Hearing, Mysore. Besides there are
departments of rehabilitation attached to hospitals. All these can be

further strengthened.

In the field of mental health, already existing

institutions of National character, like NIMHANS, Bangalore, CIP, Ranchi
and IHBAS, Delhi can be assigned key roles to develop cost effective

models of rehabilitation services for the mentally ill. There is need for

116

■'I

collaboration between various institutions run by other Ministries like

S'

Ministry of Welfare, Labour , Education and the NGO’s in the field.

Rehabilitation thus will be a collaborative effort.

1I
6

Training Programmes:

•v

Already existing training programmes under the various health

programmes have to cooperate and lay more stress on Preventive and
Rehabilitative aspects. There is also a need to develop suitable training

capsules in regional languages to transfer the technology at the grassroots
level of workers in the field.

Appropriate training programmes have to be

organised for training the PHC/CHC Doctors and other paramedics with the

assistance of specialised institutions in the area of Rehabilitation.
7.

Public Awareness Campaigns

These involve undertaking of IEC activities using the various available
methods of communication and media. It is to be noted that there is a lot of

stigma attached to certain illness like Leprosy and mental illness.

Myths,

misconceptions and prejudices surrounding these illnesses are a hindrance to
the rehabilitative efforts.

Correct and proper education about these illnesses need to be
undertaken and disseminated on a war footing to result in change of attitude.

117
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Agenda ItemNo.XXV

Tl
4

REGULATORY MEASURES FOR PRIVATE NURSING

HOMES
Problem

There are a great number of private and voluntary hospitals in the country
and several of them are running without qualified doctors, without adequate

equipment and infrastructure.

In addition many of those private nursing

homes/hospitals dump hazardous hospital waste in residential areas. The National

Human Rights Commission is considering the issue from the point of view of human

rights and has sought to know if any regulation has been framed to regulate the
functioning of private hospitals.

It has also been observed that there was no

categorisation for grading private hospitals with the view to enabling the public to
have readily available information of facilities with those hospitals.

Only a few

States have enacted legislation.

Laws enacted by State/U.Ts. to regulate private nursing

homes/hospitals

To regulate the functioning of the private hospitals, the Delhi Nursing Home

Registration Act, 1953 had been enacted to provide for registration and inspection
of nursing homes in the N.C.T. of Delhi. The Bombay Nursing Home Registration
Act, 1949 has been enacted by the Government of Maharashtra to provide for

registration and inspection of nursing homes in Maharashtra. The Government of

Andhra Pradesh, Karnataka and Uttar Pradesh are in the process of making similar
legislation.

118

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Brief Provisions of Delhi Nursing Home Act
The Delhi Nursing Home Registration Act, 1957 and the rules framed there
under provide for registration and inspection of nursing homes in the N.C.T. of
Delhi. This Act provides that no person shall carry on a Nursing Home without
registration and the nursing home is required to have qualified medical practitioners

and qualified nurses amongst others. In case of a maternity home, it should have

qualified mid-wives and qualified medical practitioners.

The construction,

accommodation of any premises used for a nursing home should be fit to be used
for a nursing home. The Government of N.C.T. of Delhi can cancel the registration

in respect of a nursing home on the grounds of violation of provisions of the Act.
The Act also provides for penalty for non-registratiion and imprisonment for a term

which may extend to three months.

Citizens' Charter Mark Scheme

The Ministry of Civil Supplies and Consumer Affairs and P.D. has formulated

a Citizens' Charter Mark Scheme for private as well as Government hospitals to

recognise and reward excellence in delivery of public service and to promote

improvement in public health services. It is a voluntary scheme. The providers of
public utility scheme will be invited to apply for Charter Mark - a Special Logo, that
signifies that the particular service has adopted the charter principle. The concept

of charter marks scheme has been borrowed from the U.K. model. However it has
been adopted to the Indian situation. The Citizens' Charter Mark can be provided

to those who provide the required services. Hospitals desireous of having a charter

mark should have the following facilities:-

(1)

X-ray, Tilted X-rays, Portable X-rays, Testing Labs., Ultra Sonogram,

3-T Scan, Whole body scan, Treadmill, E.C.G., E.E.G., Echo
cardiogram, Physiotherapy equipment.

119

(2)

Should offer centralisd air-conditioned rooms, intensive care unit

a

It

where 24 hours nursing attention is provided.

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(3)

A duty doctor is available throughout 24 hours.

(4)

24 hours electricity/generator, 24 hours water supply is available.

(5)

Engineers and technicians ensure 24 hours working of electronic and

'■■I

mechanical equipments.
(6)

The list of doctors on duty are displayed outside.

(7)

Canteen facility is available to provide hygienic food.

(8)

The hospital is open 24 hours and emergency cases are attended to

I‘i-

I

on priority.
(9)

The hospital has a pharmacy which is open 24 hours.

(10)

Telephone and STD facilities are available.

The hospital has a

telephone exchange with 10 lines.

(11)

Indoor patients will be provided with clean beds, bedsheets and kept
■

in hygienic environment, etc.

The implication of the Citizens' Charter Marks Scheme was examined in the
Ministry of Health and F.W. It was noted that the parameters of the Scheme would

entail almost quadrupling the strength of the hospital staff, and heavy investment
■

in other infrastructure for which there are no resources available either with the
Central Government or the State Government, except at the cost of disease control

programes and public health measures, which are their primary responsibility.

The Dte.G.H.S. after considering the Citizens’ Charter Mark Scheme had

concluded, inter-alia, as under:(1)

Health is a State subject and the State Government hospitals and

private hospitals are regulated by the State Governments. The Central Government
only lays down broad policies, and facilitates adoption of various measures for

improvement of health services.

'1
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(2)

An elaborate machinery would be required for examining the

applications under the proposed charter and for conducting inspections. According
to Government statistics, there were 4235 Government hospitals, 9457 private and
voluntary hospitals, 2401 Community Health Centres and 21,802 Primary Health

Centres.

' (3)

There are a multiplicity of practitioners practising in different systems

under Allopathy, Siddha, Ayurveda, Homoeopathy and Unani but the facilities

mentioned in the scheme relates to the allopathic system only.
(4)

The question of enforcing time limits is not realistic as the

infrastructure/support is weak. Government doctors in major hospitals hardly get

2-3 minutes to attend to a patient as they cannot turn away anybody who reports

at the hospital or a specific unit. Having no control over the numbers reporting, the
only way the situation can be remedied is to multiply the number of attending
doctors, which has financial implications and need sufficient budgetary provision.

(5)

The State Governments have inadequate enforcement staff to ensure

adequate deployment of resources, drugs, consumables, working equipments, staff
to adhere to the standards in private hospitals.
(6)

The Charter would have very limited applications as facilities like ultra

sonogram, C.T. Scan, Whole Body Scanner, Treadmill, EEG, etc. do not exist in
most hospitals.

Australian System of Accreditation

This Ministry on the other hand has been considering the idea of adopting the

Australian system of Accreditation under which professional associations like the
Association of Surgeons, Physicians, Paediatricians, Gynaecologists, etc. meet on
a common professional platform to give a star rating to hospitals according to the

facilities they provide. They obtain registration charges for the annual inspection
and award a star rating on the lines of hotel classification being done by the

121

Ministry of Tourism. The system appears to be more relevant to our needs since
this will provide for private hospitals to be assessed by a peer review voluntary

r.

group and accredited based on facilities provided.
.’i

POINTS FOR CONSIDERATION

(1)

Laws may be enacted on the lines of Delhi Nursing Homes

Registraion Act, 1953 and Bombay Nursing Homes Registration Act, 1949 to

provide for registration of private hospitals which have the minimum facilities for

different forms of treatment and grading them on the basis of facilities available and
services provided.

(2)

A monitoring mechanism should be available to ensure that the

facilities and services created are maintained at the desired level and continue to
be available.

I

(3)

Private hospitals in non-conforming areas which are posing health

hazards should be shifted to other areas.

(4)

Introduction of voluntary system of accreditation based on peer group

assessment.

122

Agenda Item No.XXVI

I
IMPROVEMENT OF EMERGENCY SERVICES IN
GOVERNMENT HOSPITALS
The emergency/casualty is the first encounter of the patient with the hospital
and there are a range of facilities which have to be provided to ensure that he gets
the best possible attention in the shortest possible time before he can be shifted to
the ICUs, specialised centres or wards.

In the case of Paschim Banga Khet Majdoor Samiti vs. State of West Bengal

and anothers The hon'ble Supreme Court of India in its judgment dated 6th May,
1996 has suggested remedial measures to ensure immediate medical attention and
treatment to persons in real need. The State Government of West Bengal had

appointed an Enquiry Committee headed by a retired judge who gave
recommendations, inter-alia, on measures that should be taken to ensure

immediate medical attention and treatment to critical patients. The Committee had
made the following recommendations in this regard:

(i)

The Primary Health Centres should attend the patient and give proper

medical aid, if equipped.

(ii)

At the hospitals the Emergency Medical Officer, in consultation with

the Specialist concerned on duty in the Emergency Department, should admit a

patient whose condition is moribund/serious. If necessary the patient concerned
may be kept on the floor or on the trolley beds and then loan can be taken from the

cold ward. Subsequent necessary adjustment should be made by the hospital
authorities by way of transfer/discharge.

123

(iii)

A Central Bed Bureau should be set up which should be equipped

with wireless or other communication facilities to find out where a particular

emergency patient can be accommodated when a particular hospital find itself
' iff

absolutely helpless to admit a patient because of physical limitations. In such
cases the hospital concerned should contact immediately the Central Bed Bureau

■a F

which will communicate with the other hospitals and decide in which hospital an

emergency moribund/serious patient is to be admitted.

(iv)

Some casualty hospitals or Traumatology Units should be set up at

some points on a regional basis.

(v)

The intermediate group of hospitals, viz., the District, the Sub-

Divisional and the State Government Hospitals should be upgraded so that a

patient in a serious condition may be given treatment locally.

The recommendations of the Committee have been accepted by the State

Government and the Government of West Bengal in its memorandum dated August
22, 1995 issued the following directions for dealing with patients approaching

health centres/O.P.D./Emergency Departments of hospitals:

(1)

Proper medical aid within the scope of the equipments and facilities

available at Health Centres and Hospitals should be provided to such patients and
proper records of such aid provided should be preserved in office. The guiding

principle should be to see that no emergency patient is denied medical care. All
possibilities should be explored to accommodate emergency patients in serious
condition.

(2)

Emergency

Medical

Officers

will

get

in

touch

with

Superintendent/Deputy Superintendent/Specialist Medical Officer for taking beds
on loans from cold wards for accommodating such patients as extra-temporary

measures.
J ■

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(3)

Superintendents of hospitals will issue regulatory guidelines for

admitting such patients on internal adjustments amongst various wards and

different kinds of beds including cold beds and will hold regular weekly meetings

for monitoring and reviewing the situation. A model of such guidelines would be
suitably amended before issue according to local arrangement prevailing in various
establishments.
(4)
If feasible, such patients should be accommodated in trolley beds and,

even, on the floor when it was absolutely necessary during the exercise towards
internal adjustments as referred to at (3) above.
Having regard to the drawbacks in the system of maintenance of admission

registers of patients in the hospitals it has been directed that the Superintendents

and Medical Officers of the hospitals should take the following actions to regularise
the system with a view to avoiding confusion in respect of Admission/Emergency

Attendance Registers:

(a)

Clear recording of the name, age,sex, address, disease of the patient
by the attending medical officers;

(b)

Clear

recording

of

date

and

time

of

attendance/examination/admission of the patient;
(c)

Clear indication whether and where the patient has been admitted,
transferred, referred;

(d)

Safe custody of the Registers;

(e)

Periodical inspection of the arrangement by the superintendent;

(f)

Fixing of responsibility of maintenance and safe custody of the
Registers.

With regard to identifying the individual medical officers attending to the

individual patient approaching Out Patients' Department/Emergency Department
of a hospital on the basis of consulting the hospital records, it has been directed by

the honourable court that the following procedure should be followed in future.

125

A.

"A copy of the Duty Roaster of Medical Officers should be preserved
in the office of the Superintendent incorporating the modifications

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done for unavoidable circumstances;

B.

Each Department shall maintain a register for recording the signature

of attending medical officers denoting their arrival and departure time;

C.

The attending medical officer shall write his full name clearly and put
his signature in the treatment document;

D.

The Superintendent of the hospital shall keep all such records in safe

custody;

E.

A copy of the ticket issued to the patient should be maintained or the

■

relevant data in this regard should be noted in an appropriate record
for future guidance.

It is appreciated that Hospital Superintendent/Medical Officers-in-charge may
have difficulty in implementing these guidelines due to various constraints at the
ground level and, as such, feed back is vital to enable Government to refine and

modify the order as will ensure a valid working plan to regulate admission on a just
basis. Detailed comments and, therefore, requested with constructive suggestions."

The honourable Supreme Court is also of the view that in order that proper

medical facilities are available for dealing with emergency cases it must be that:
1.

adequate facilities are available at the Primary Health centres where

the patient can be given immediate primary treatment so as to stablize his

condition;
2.

Hospitals at the district level and Sub-division level are upgraded so

that serious cases can be treated there;
3.

Facilities for giving specialist treatment are increased and available

at the hospitals at District level and Sub-division level having regard to the growing
needs.

126
4

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4.
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In order to ensure availability of bed in an emergency at State level

hospitals there is a centralised communication system so that the patient can be

sent immediately to the hospital where bed is available in respect of the treatment

which is required.
5.

Proper arrangement of ambulance is made for transport of a patient

from the Primary Health Centre to the District Hospital or Sub-Divisional hospital

and from the District hospital or Sub-Divisional Hospital to the State hospital.

6.

The ambulance is adequately provided with necessary equipment and

medical personnel.

7.

The Health Centres and the hospitals and the medical personnel

attached to those Centres and hospitals are geared to deal with larger number of

patients needing emergency treatment on account of higher risk of accidents on
certain occasions and in certain seasons.

The Government of West Bengal was party in the proceedings of the court.
Also, Union of India was a party. The honourable court has directed that other
States should also take necessary steps in the light of the recommendations made

by the Committee, the directions contained in the Memorandum of the Government

of West Bengal dated 22nd August, 1995 and directions given by hon'ble court.

The judgement of the apex court has been sent directly by the Registrar of
the hon'ble Supreme Court to State/U.T. Governments for compliance.

OTHER MAIN REQUIREMENTS

(I)

Establishing round-the-clock Central Room with a C.M.O. having

imprest funds for shouldering petty unforeseen expenses.
(ii)

Availability of specialists on call provided through long distance

pagers;
127

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I
(iii)

1

T

surgeons/physicians/anaesthetists for providing round the clock

fl

services in the emergency block. For this, posts will have to be

T |

Establishing

specialised

suitable

emergency

services

of

I

created as the present practice of leaving this important function to

interns and residents is neither safe nor advisable.
(iv)

Improving patient transportation by providing colour coded trolleys,

wheel-chairs, ambulances;
(V)

Improving man-power support by hiring private uniformed staff for

transporting the patients and maintaining sanitation;

(vi)

Bringing the emergency services for injuries, fractures, etc. within the
main casualty block; and

(vii)

Licensing a twenty-four hour drug shop and a small grocery store

selling essential patient utensils, bed-pans, hot water bottles and
other 'first day' needs near casualty.
POINTS FOR CONSIDERATION

1.

The Central Government is taking necessary steps to improve the

emergency facilities in the Central Government hospitals in Delhi. The State
Government/U.Ts. may also take similar necessary steps to improve the emergency
services facilities in State Government hospitals and consider making necessary

provisions in their State Plans for this purpose.
2.

The State Governments may take necessary remedial measures as

per the apex court judgement to ensure immediate medical attention and treatment

to the persons in real need, approaching health centres/O.P.D./Emergency
Departments of the hospitals.

3.

The State Governments may consider issuing instructions on the lines

issued by the State Government of West Bengal to ensure that immediate medical

attention is provided to patients in real need of treatment.

128

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Agenda Item N0.XXVII
1

NATIONAL AND STATE ILLNESS ASSISTANCE FUND
The proposal to create a National Catastrophic Illness Assistance Fund has
been under consideration of Ministry of Health & Family Welfare during the Eight
FiveYear Plan. A note was circulated to all the appraising agencies during March

1996. Since Planning Commission were of the view that no new schemes should
be started at the fag end of the Eight Five-Year Plan, it was decided to bring up this

scheme on the Non-Plan side, instead of deferring it to Ninth Five-Year Plan.

The genesis of this Fund is a recommendation in the 31st Report of the

Department relating Parliamentary Standing Committee on Human Resource

Development which expressed concern about inadequate facilities for treatment of
poor patients for major illnesses, especially those involving various complicated

procedures. The Committee had recommended that it was essential to explore all
appropriate sources of funds to assist poor patients coming to AllMS or other

Central Government hospitals for treatment of specific life threatening illnesses.
The Committee had further suggested that a National Fund could be set up in which

resources could flow from all sources, including private charities and international

agencies and organisations.

This sentiment was echoed by Hon’ble Prime Minister at the concluding
session of Chief Ministers held on 5th July, 1996. As a sequel to this, the Finance

Minister made a specific mention of a scheme to raise the National Illness
Assistance Fund for which a budget provision of Rs.5.00 crores was made in the

Budget Estimates of 1996-97. The Fund could be subscribed by private individuals,
corporate bodies in private or public sector, philanthropic organisations, national

129

or international and contributions made to this Fund were to be exempt from
payment of income-tax. A similar proposal was made for raising similar Funds at the
State level for which a Central Govt, assistance to an extent of Rs. 25.00 crores
during 1996-97 has also been made in the Budget Estimates. Since the provision
of Fund has been made under Non-Plan, it was decided to submit a detailed

scheme for activating the fund to Committee on Non-Plan Expenditure.

Primary objective of the Fund is as under

(1)

to provide assistance to poor persons below the poverty line of the
UTs without legislature in getting specialised treatment for life

threatening illness and treatment for injuries caused by industrial
accidents, accidents occurring while handling agricultural machines
and implements, bomb-blasts, natural calamities, etc, as a one-time

grant; and

(ii)

to provide assistance to patients from anywhere in the country on the
recommendations of the State Governments/UT Administrations in
cases where the treatment cost exceeds Rs. 1.50 lakhs.

The proposal was discussed in the Committee on Non-Plan Expenditure in
its meeting held on 17.10.1996. The proposal to set up a National Illness
Assistance Fund was approved, subject to the following conditions:-

(I)

The National Illness Assistance Fund is registered as a Society under
the Societies Registration Act.

(ii)

In respect of foreign contributions, clearance from MHA under foreign
contribution (Regulation) Act, 1976, is obtained.
130

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■

(iii)

Government hospitals may be given preference for the purpose of this

Fund.

(iv)

Government hospitals/lnstitutions which have availed of the facility of
customs duty exemption for the import of equipment also be asked to
participate in the scheme

(v)

The UTs without legislatures will be authorised to sanction cases upto

a ceiling of Rs. 1.50 lakhs for each individual case; the overall
budgetary ceiling under the National Illness Assistance Fund for each
Management Committee and communicated to the UT concerned.

(vi)

In case where treatment costs exceeds Rs.

Management

Committee

would

sanction

1.50 lakhs, the
cases

on

the

recommendation of State /UT Governments on first come first served
basis and maintain applications received in chronological order.

(vii)

The Central Government grant would be utilised for providing

treatment to the poor; however, efforts would be made to build up a
corpus of the Fund.

The proposal for providing assistance to State for setting up a similar Fund
was also approved, subject to the following conditions:-

(I)

The Central Government will make contribution to the extent of 50%
of the contribution made by the State Governments towards State

Fund/Society or Rs. 5 crores in respect of States with large number
and percentage of population below the poverty line, namely, Andhra
Pradesh, Bihar, Karnataka, Madhya Pradesh, Maharashtra, Orissa,

131

Rajasthan, Tamil Nadu, Uttar Pradesh and West Bengal and

• ■■

maxiumum of Rs. 2 crores to other States/UTs with legislatures,

whichever is less, in a year.

IB’'

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(ii)

The State government will have to furnish proof of the constitution of
State Fund as a Registered Society for availing assistance from the

■

Central Government.

i
(iii)

The bye-laws of the State/Society should adhere to the objective of
providing medical treatment to the poor below the poverty line.

(iv)

■

f'■

■ 11
5

The contribution of the Central Government towards the State
Medical Relief Fund would be kept in the fund of the Registered
Society which would be outside the State Government Funds.

i

In accordance with the approval of the Committee on Non-Plan Expenditure,
all Chief Secretaries have been apprised of the scheme.

The fund will be activated very soon.
The matter is also placed before CCH&FW for information.

■

132

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Agedna Item No.XXVIII

STRENGTHENING OF DRUGS/VACCINE/FOOD
QUALITY CONTROL

I. DRUG CONTROL

It had been agreed in the last Central Council of Health Meeting held on 1113, October, 1995 (Resolution No. 2, Page 33 of Proceedings) that the drugs

enforcement set up be strengthened both at the Centre and in the States, and the
capacity of drug testing in the analytical laboratories be augumented. The Ministry
of Health is negotiating with the World Bank for funding a project which aims to

attain the above objectives.

Presently, a central scheme providing 100% financial assistance to the State
Governments for setting up drug testing laboratories is in operation during Eight

Five Year Plan. Under this scheme, upto Rs. 7 crores was made available to the

States and many States benefitted from this funding. However, this scheme did not
envisage creation of additional posts in the laboratories and only covered cash

assistance towards the purchase of equipments, accessories and laboratory

chemicals.
Two National Consultants, appointed by WHO to assist the Drugs Controller

a

General (India), recently visited most of the State laboratories to ascertain the

actual requirements of each laboratory to increase the capacity to conduct drug

testing with the required improvement in the quality of testing. They have identified
the equipments and the manpower requirements of each laboratory and have
133

indicated that sophisticated equipments may improve the qulity of testing but the
improvement in capacity can be made only with the addition of laboratory workers

J?;;
■i

and the support of appropriate funds towards running expenses.

A 50:50 expense sharing scheme for increase in Drug Inspectorate staff
included in the Eighth Plan proposal never took off as funds could not be made
available for the same by the Planning Commission. Recognising the need to
increase the enforcement staff - both at the Centre and in the States - the project

under formulation for obtaining World Bank assistance includes a 100% assistance
scheme to strengthen the enforcement staff in the State Drug Control

Organisations. The National Consultants have also worked out the requirements
of the States who have expressed an interest to participate in this component of the

World Bank funded project. Some States have not indicated any interest in this

subject.

A condition for participating in the project is the State's commitment to

sustain the scheme at the close of five year project period. This would imply that
the salaries of all the additional posts created under the project and the recurring

expenses to support the additional activities generated shall be accepted as a State

liability by the participating States.

All State Governments are requested to agree to participate in this Project

and confirm their willingness to sustain the project after the five year period upto
which funding from the Centre will be available. This project would be in the larger

health interest of the people of this country as it would help in providing modem

testing and enforcement facilities so as to make quality and inexpensive drugs
available to the poor people of our country.

134

ii

II. VACCINES

The diseases for which drug resistance is already a matter of concern
(Respiratory Infection, TB, STD and Malaria) account for a large number of deaths.

Thus study/evaluation of drug resistance microbes pose a challenge for research

and health care.

Indigenous production of potent vaccines/drugs are to be

encouraged, for instance, replacement of the Nervous Tissue Anti Rabies Vaccine
by Vaccine based on Tissue Culture. Some institutions have shown interest in this

line and they are to be supported through all possible ways including Operational
Research. In addition, the manufacture of vaccine for Yellow Fever and Japanese

Encephalitis have to be undertaken for which steps have to be taken to augment

capacity and renovate and modernise the production units. The vaccine institutes
should be provided adequate funds for producing/strengthening the capacity of the
institutions for producing the vaccines as per needs. It is also desirable that there

should be upgradation/modernisation of the technology wherever necessary.

III.

Prevention of Food Adulteration Act, 1954 (Aims & Objectives)

Food Safely through Food Quality Control Programme is of paramount
importance in achieving the goal of “Health for all” by 2000 A.D. It can be achieved

through the combined efforts and cooperation of food industry (self disciplined
programmes and codes of practices) and the Government Authorities (legislative

measures). In all the cases, the co-operation of the Consumer Organisations/NonGovernmental Organisations (N.G.O.s) is a must.

The legislative measures adopted for food safety are provided under the

Prevention of Food Adulteration (PFA) Act- piece of Central Legislation

promulgated in 1954 which replaced all earlier Acts of the State Governments.

135

The Act which came into effect from 1 st June, 1955 has been amended

'I

■y

thrice, in 1964, 1976 and 1986 for plugging the loopholes and making the

punishments more stringent and empowering the Consumers and Voluntary

Organisations to play more effective role in its implementation.

II

Role of Central Government:-

(•)

To review the provisions of PFA Act, Rule & Standards in consultation

with the Central Committee for Food Standards, a statutory Advisory

Committee under the Act and its 9 Technical Sub-Committees.

(ii)

To conduct examination for the Chemists for their appointment as
Public Analysts under Act.

(iii)

To organise training programmes for various functionaries(viz. Senior

Level

Officers,

Food

Chemists,

Inspector

and

Consumer
>1

Organisations) under the Act.
(iv)

To approve the State PFA Rules.

(V)

To examine and approve the labels of Infant Foods.

(Vi)

To evaluate and monitor the progress of implementation of the Act in
the States/U.Ts.by collecting periodical reports and spot visits.

(Vii)

To liaise with National & International Food Quality Control

Organisation i.e. B.I.S. (associated with certification of processed
food articles), Directorate of Marketing and Inspection operating
Agmark

Scheme,

implementation

Ministry

of Fruits

of

Food

Products

Processing

order

(FPO)

Industries,

and

Codex

Alimentarius Commission.
(viii)

To ensure quality of food imported into India, under the provisions of

the Act.
(ix)

To create Consumer Awareness.

(x)

To augment the food testing Laboratries.

136

Central Food Laboratries:Four Central Food Laboratries. have been established under the Act, which

work as appellate Laboratries for the purpose of analysis of appeal samples of food
articles lifted by the Food Inspectors of States/U.Ts. and Local bodies. The two

labs. Viz. (I) Food Research & Standardization Laboratory, Ghaziabad and (ii)

Central Food Laboratory, Calcutta are under the Administrative Control of the
Directorate General of Health Services and other two viz. (I) Central Food Lab.,
Pune and (ii) Central Food Lab., Mysore are under the administrative control of

Government of Maharashtra and Council of Scientific & Industrial Research,
Government of India respectively.

State Food Laboratories:-

There are 81 Food Laboratories under the administrative control of
State/U.T. Governments and Local Bodies.

Achievements since the last meeting (I)

14 training programmes have been arranged for Senior level Officers/Public

Analysts/Food Inspectors as well as recognised Consumer Organisations so
as to acquaint them with the latest developments of the programme of Food

Safety and Quality Control.

(ii)

An amount of Rs. 1.44 Crores have been released by the Central
Government to the State/U.Ts during the year 1995-96 for purchase of

equipment by the State Food Laboratories.

(iii)

Survey on quality of plastic containers used in food packaging has been

carried out with the financial support from W.H.O.
(iv)

Survey on presence of pesticide residues in food articles was carried out,

which was also supported by W.H.O.

137

*

'■ 'w'

JOB

Deficiencies observed
(I)

Despite repeated resolutions of the Central Council of Health and Family
Welfare, no significant progress has been made in augmenting the

infrastructure for the Prevention of Food Adulteration Programme both at the
Central and State level.

(ii)

It has been observed that samples are drawn generally at the retail level.

The State/U.T. authorities need to pay special attention to curb adulteration
at source by directing the PFA enforcement machinery to concentrate their

attention at the manufacturers’/wholesalers’/distributors’ level.

(iii)

Efforts are required to be intensified on survey and investigation of source
of adulteration from large scale commercial places, like whole-sale/weekly

markets/slum areas.
(iv)

Strict vigilance needs to be kept on improving quality of street food sold in

and around Schools/Colleges/Market places/Fairs/Exhibitions.

(v)

Registered Consumer Organisations/N.G.Os need to be actively involved in
the programme of food safety and quality control.

(vi)

Strong Consumer movement need to be created by holding Radio Talks/T.V.
telecasts/Hoardings/Pamphlets etc. Importance of Food Safety and Quality

Control needs to be explained to the students of schools and colleges.

(vii)

It has been observed that a large number of cases launched under the
Prevention of Food Adulteration Act, 1954 by the States/U.Ts generally
result in acquittals. The progress of the cases subjudice in various courts

need to be monitored at every district headquarter.

(viii)

Licensing provisions under the Prevention of Food Adulteration Act/Rules
are yet to be enforced in a number of States/U.T.s, though the same is an
integral aspect of the food quality and safety programme.

138

Schemos for improving the Programme under World Bank Funded Capacity

Building Project on Food Safety and Quality Control

The following components of scheme are being contemplated for improving

the infrastructure at the Central/State level:-

(I)

Strengthening of PFA Unit in the Directorate General of Health Services so

as to set up a full fledged Secretariat for Central Committee For Food

Standards (C.C.F.S.) and National Codex Committee.
(ii)

Setting up of three Central Food Laboratories at Kandla, Mumbai and

Chennai and zonal offices/import quality control units in Mumbai, Calcutta,
Chennai and Chandigarh.

(iii)

Augmentation of laboratory facilities of Food Research and Standardization
Laboratory, Ghaziabad.

(iv)

Augmentation of laboratory facilities at Central Food Laboratory, Calcutta.

(v)

Financial assistance to States/UTs for strengthening their Food Testing
Laboratories working under the PFA Act, 1954 with staff and equipments
under Centrally Sponsored Scheme (100%).

(vi)

Setting up of District Food inspection Units in the States/U.ls. with
management information system providing 100 % central assistance.

(vii)

Active involvement of Consumer Organisations/NGOs in the programme by
providing financial assistance.

For the purpose of operation of schemes outlined at para (v),(vi) & (vii) above,
World Bank has been keen to extend financial assistance for a period of five years ■
provided the States/UTs give commitment to sustain the additional staff created

9

under the project after the period of five years.

Despite repeated persuasion from the Central level, confirmation regarding
139

11 II' :
sustainabilities has been received only from 13 States/U.Ts namely (1) Andaman

& Nicobar Islands (2) Andhra Pradesh (3) Bihar (4) Dadra & Nagar Haveli (5) Delhi
(6) Lakshdweep (7) Manipur (8) Mizoram (9) Orissa (10) Pondicherry (11) Sikkim

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■’ ■

(12) Tamil Nadu and (13) Tripura. Further, States/U.Ts are yet to identify any
consumer organisation/NGO who have been contributing effectively towards

programme of food safety and quality.

The Council may kindly ensure cooperation from all States/U.Ts for
implementation of schemes to be funded by World Bank by confirming their
commitment to sustain the additional staff after the project period of five years.

140

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Agenda Item N0.XXIX

INTRODUCTION OF YELLOW CARD SCHEME FOR

COMPULSORY HEALTH CHECK UP FOR SC/ST

POPULATION
It is proposed to introduce a scheme for compulsory health check up of
SC7ST population in rural areas in the country and to provide them free medical
treatment if necessary. This is considered desirable in view of the fact that a large

section of these communities continue to remain deprived of the health facilities and
do not have access to the facilities provided facilities through the existing outlets.

The Government of Karnataka has already launched a scheme known as the Yellow
Card Scheme for this purpose. Under the scheme, each member of every SC/ST
household would undergo a thorough medical examination annually which would

include:

1

Complete physical examination and identifying individuals requiring
diagnostic test/ or treatment;

2

Simple laboratory investigation like examination of urine, blood etc. for early

detection of diseases if any.

The medical examination would be conducted at health check up camps
which would be organised, according to a pre-determined schedule, at the sub

centers or in the villages covered by them for which prior publicity would be given.

In order to ensure that each member of the covered population attends the camps,
the assistance of the Gram Panchayat Members especially the SC/ST and Women

Panchayat Members, will be taken in making a house to house contact to give
141

publicity and to motivate the officers of the Primary Health Centers concerned and

other para medical personnel.

Services of the lady medical officers will also be

utilised for health check up of women members of the SC/ST households. Cases
requiring further examination or treatment would be referred to the nearest

Government hospital having the required facilities and such cases would be entitled
for free medical treatment on the basis of a referral card issued to them. Although
the scheme would be meant for SC/ST population , it would neither be feasible nor

appropriate to refuse attendance to the sick persons belonging to non SC/ST

households who might turn up at the camps. While such sick persons would also

be allowed to avail of the facilities provided in the health check up camps, they
would not be entitled to health cards.

The Government of Karnataka had launched the scheme initially in five
districts of the State and encouraged by the response and the impact of the
scheme, have decided to extend the scheme to the whole of Karnataka. It has been
intimated by the Government of Karnataka that the World Bank authorities have

also come forward to fund the scheme if it was introduced for covering the most

disadvantage sections of the Society in the entire State under the State Health
System Project. The scheme could be considered for adoption by other State/UTs

also

In this connection all States/UTs have been addressed vide the Ministry’s

letter No.Z.28015/126/96-H dated 7-12-96. The Council may, therefore, consider

the issue with reference to the following points:

a.

Adoption of the scheme in other States/UTs on a pilot project basis.

b.

The likely financial implications of introducing such a scheme and inclusion
of the scheme in the State Plans.

c.

Whether the existing infrastructure in the Primary Health Centers would be
adequate to take up the scheme and necessity of assisting the PHCs by
deputing teams from the District.

142

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Agenda Item No.XXX

AMALGAMATION OF STATE HEALTH EDUCATION

BUREAU AND LE.C. BUREAUX

State Health Education Bureaux and I.E.C. Bureaux are working as

independent functional units for dissemination of health education, information and
creating awareness on different issues of Health and Family Welfare to the masses

through existing primary health care approach and utilising the staff posted at the
grass-root.

I.E.C. Bureaux are being Centrally funded and they are taking care of
messages pretaining to reproductive and Family Welfare aspect where as State

Health Education Bureaux are functional on the funds provided by the National

Health Programme funds provided by the State Programme officer.

Keeping in view the similarities in the job functions of SHEBs and (EC

Bureaux it is suggested that the two kinds of institutions be amalgamated at
State/district/block/taluka and PHC levels. This will avoid financial over burdening

and optimum utilization of the equipments and existing staff like Mahila Swasth
Sangthan, ANM, AWW, BEE, DEMOS, Dy. DEMOS, Nehru Yuvak Kendras and

other Medical and Para-medical functionaries placed at the grass-root level.

Health Education provides motivation for self health care and community
participation for achieving the goal of health.

143

1

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b.

I

RESPONSIBILITIES OF AMALGAMATED BUREAUX

State Health Education Bureaux amalgamated with IEC Bureaux will have
to take up the problems of

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1.

Prevention and control of communicable diseases

2

Life style diseases

3

Reproductive health and child care

4

Health of Adolescent/Youth

5

Malnutrition and Micronutrient deficiency

6

Environmental health and sanitation

7

Occupational health

8

Geriatric health

9

Health related Vocational Courses

10

Health related Research

11

Training of medical and paramedical including NGOs

12

School Health Education

13

Disaster Control and Preparedness programme

14

All National Health Programmes and

15

Any other outbreak/epidemic

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DECENTRALIZATION OF THE ACTIVITIES

At present the programmes are conceived at Central level and implemented

through the States. It is envisaged that through decentralizing the planning at the
local government level and empowering them with financial support IEC strategies

shall meet the specific objectives at the grass-root level.

Active community participation delivery requires goals of preventive and

promotive health by empowering the community and individual by responsibilities

144

■'I

through proper training, assigning clear cut tasks to be performed with adequate
resource backing

COORDINATION WITH OTHER MINISTR1ES/DEPARTMENTS

Health Education is a multi disciplinary activity which can be achieved by
involvement of various disciplines like youth organisations, school and universities,

women organisations, Zila Panchayats, elected bodies at village/town levels and

non-governmental organizations; it is desirable and essential that these

organisations should be involved and utilized as they have the rapport with the
community.

Organisation of Swasth Melas free medical check-up observance of
“days”(Pulse Polio, World Health Day, Population Day etc) Child to child approach
has proved very useful and effective.

r

Right age of marriage, spacing between children and one or two.norms child
can be discussed in the colleges and ANC clinics. Female literacy, socio-economic

status of women has great bearing on the health of community, women participation
in planning of the programme shall go a long way in successful implementation of
the programmes.

Inter-Ministerial resources can be utilised during implementation of

programme by coordinated efforts and clear guidelines issued by the respective M
inistries for methods to be adopted for implementation of health programmes with

special efforts on maintaining healthy environment, inside the home and in the

neighbor hood with more stress on proper waste management.

145

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ROLE OF NGOs
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NGOs be involved in training, preparation of material and dissemination of

I

health messages

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IEC material should be programme, area specific and conform to the social
and cultural norms. Focal points should be identified for IEC activities at district

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and State levels.

I
Job responsibilities of IEC personnel will help in successful implementation

of programmes

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FINANCIAL AND TECHNICAL SUPPORT

The amalgamated Bureaux shall be 100% Centrally funded and seek

guidance and technical support from the Central Health Education Bureau. New
Delhi/IEC Bureau, Nirman Bhawan.

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PROGRAMMES CONCERNING
INDIAN SYSTEMS OF MEDICINE

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Agenda Item No. XXXI

EFFECTIVE USE OF ISM&H SYSTEM FOR HEALTH FOR

ALL FOR BETTER PATIENTS CARE SYSTEMS
The Indian Systems of Medicine and Homoeopathy (ISM&H) have not
received priority in the successive Plan periods. The example of development

of Allopathic System in the West has been so overpowering that all the
resources available have been channelised for developing an extensive and

modern allopathic system. Currently, the Plan Budget for the ISM&H at the
Central level is about 3% of the Plan Budget for allopathic system. In the States,

it is not substantially different, while there is some variation from State-to State.
With these inputs, the ISM&H systems cannot develop and the facility of ISM&H

treatment cannot be made available to people at a competent level. However,
at the National level, a new Department of ISM&H has been created in 1995 and

since the Ninth Five Year Plan is beginning in 1997-98, this is an opportunity for
restoring some priority to ISM&H sector and to redress some of the accumulate
deficiencies in these systems.
i

The large number of practitioners (6 lakhs) of ISM&H traditional health
promotional practices and readily assessable medicinal material of ISM need
to be utilised in National Health Care delivery system. Various NGOs and State

Governments are required to play active role. The Department of ISM&H and

Government of India also intend to support partially various schemes in this
regard.

ISM&H treatment facilities at Block Level

There are 23064 ISM&H dispensaries in the country. But these are not
uniformally distributed at a certain level of village throughout the country. It is

147

difficult to cover all the 5 lakh villages of the country by providing them a unit of

ISM&H dispensary. Therefore it is proposed to cover all the Block head quarters
by providing an ISM&H dispensary with the necessary infrastructure. This block

level centre will coordinate all the activities relating to ISM&H in the block.

District level Hospital of ISM&H

Out of 500 districts in the country only one hundred are having indoor
facilities of ISM&H. All the districts need to have an indoor and out door ISM&H
facilities of 30 beds which will include specialised treatment like Panchakarma,

Kshar-Sutra and Child and Mother Care facilities in ISM&H lines. These district

hospitals will serve as referral centres for ISM&H therapies.

Central Government Health Scheme Dispensaries

ISM&H facilities are available in 74 dispensaries/units whereas allopathic

treatment facilities are available in 242 dispensaries in the country. As per the
spirit of the scheme Ayurveda, Unani, Siddha, Homoeopathy and Yoga Units

needs to be extended in the remaining 168 CGHS dispensaries in the country,
in this way Delhi and all other major cities will have ISM&H facilities.

NGO Hospitals of specialised treatment of ISM&H

Government alone cannot make available specialised ISM&H Hospital in
the country. NGOs will be supported to establish 1-2 (50 bedded) specialised

treatment hospitals in each State. NGO/Societies will be supported upto the
extent of 80% for a plan period to establish these hospitals on chargeable basis.

Upgradation of ISM&H Educational Institutions for improving standards.

About

80%

teaching

institutions

of

ISM&H

do

not fulfil

the

norms/standards of Central Council of Indian Medicine and Homoeopathy.

148

Financial constraints are the main reasons.

Even the State Government

institutions are not following the CCIM norms. Therefore, States and Central
Governments need to allocate sufficient resources and take up ISM&H as a

priority item to produce trained ISM&H practitioners.

Unified Educational Authority for ISM&H

There is no competent regulatory and funding body like UGC to support
ISM&H education. Therefore it is highly necessary to establish a unified

education authority for ISM&H, through appropriate legislation which could
finance and monitor the educational standard of ISM&H. Sufficient funds also
need to be provided to this body for creating the required infrastructure as per

CCIM/CCH norms.

Training to the Para-Medical Personnel

Therefore, the training institutions of Pharmacists/Nurses and Technicians need

to be supported by the State and Central Governments.

Strengthening of Eminent ISM&H Graduate Colleges of Yoga and

Naturopathy.

Faculty of Ayurdeda, BHU, National Institute of Ayurveda, Jaipur, Institute

of PG Studies Jam Nagar, Hamdard University, Delhi, Aligarh Muslim University
and National Institute of Homoeopathy, Calcutta need to be strengthened to
develop as eminent institutes of ISM&H. Similarly some existing yoga institutes

like Vivekanand Kendra, Bangalore, Kaivalya Dham Samiti, Lonavala and Bihar

School of Yoga, Munger will be assisted for graduate level courses of Yoga.

Various reorientation training programmes for ISM&H professionals need

to be taken up to update the skill of ISM&H professionals.
149

Research and Development Proposals

Existing units of various Research Councils i.e. CCRAS, CCRUM, CCRH
need to be consolidated to manageable number (25% of the existing total
number).

Construction of buildings and provisions of the proper man and

materials is the priority for proper functioning of these research councils.

Specific in-house research in a time bound manner on diseases and treatments
of National priority, more in the areas where the existing allopathy do not have
the proper answer. There is need for research on minerals, metals, marine and

animal products extensively used in ISM&H. Collaborative research with the

other institutions is a right step to accelerate the research activities relating to

ISM&H.

Development of Medicinal Plants and other Raw materials used in ISM&H

The requirement of ISM&H plants/material is increasing and traditional

source of forest area is getting reduced.

To ensure the quality medicine,

conservation, propagation of medicinal plants is very necessary. The following
steps have been proposed:-

(i)

Development of Agro techniques of various medicinal plants;

(ii)

Establishment of Medicinal plants garden;

(iii)

Establishment of "Vanaspati Van" in the denuded forest areas.

(iv)

Setting up germ plasm banks

(v)

Publicity of common use of these medicinal plants in health care
and their cultivation practices.

Development of Pharmacopoeia and Drug Testing Laboratories of ISM&H

Pharmacopoeia of Ayurvdea, Siddha and Unani Drugs need to be
developed on priority for strengthening of existing Indian Pharmacopoeial

Laboratories of ISM&H. Similarly State and Central Governments need to
support the establishment of State Drug testing Laboratories which is also

necessary to implement the Drug Act provisions.
150

!

Strengthening of IMPCL and State Pharmacies of ISM

IMPCL, Mohan, a public sector undertaking of Government of India and
UP Government is producing medicines worth of Rs. 2 crores per annum

approximately to provide quality medicines. The strengthening of IMPCL and

other State Pharmacies by providing them assistance to update their
infrastructure is very necessary.

Intellectual Property Right Cell of ISM&H Medicines

In the present scenario of WTO and GATT it is necessary to set up a
patent cell which could take care of interest of patentable ISM&H researches.
*

The ISM&H sector is expected to receive higher priority in 9th Plan. While
the Government of India will attend to the remaining areas in a substantial
I

manner, the treatment facilities and ISM&H colleges will have to be the concern

of the State Governments. The ISM&H treatment facilities presently suffer from

lack, of buildings, infrastructure, non-sanction of doctors catering to different
branches of ISM disciplines and lack of medicines. The State Governments may
take this opportunity and provide adequate funds for improving the ISM&H
treatment facilities and ISM&H colleges in the Ninth Five Year Plan.

151
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Agenda Item No. XXXII

ROLE OF ISM&H DISPENSARIES (GOVERNMENT

SECTOR) IN NATIONAL HEALTH CARE DELIVERY
SYSTEM.
There are 23064 dispensaries in Government sector rendering ISM&H
facilities to the people. They are situated in far flung areas mainly at Gram

i

Panchayat or Village level. These are generally housed in two-rooms

accommodation. One Physician, one Pharmacist, one Class IV is the staffing
pattern for these dispensaries. Annua! quantum of medicines ranges from Rs.

4000 to Rs. 40,000. These ISM&H physicians are providing medical care
facilities in routine ailments as well as in emergency conditions. The total
number of patients attended through these dispensaries is quite significant
which shows the popularity and acceptance of these indigenous physicians.

These dispensaries have following problems in their functioning :
(')

Lack of proper building and accommodation to have the dispensary and
doctor in majority of the dispensaries in the country. For example in the

State of Himachal Pradesh, out of 650 dispensaries, only about 150 have
got accommodation, in the remaining either one or two rooms are

donated by Panchayat or local people. There is no provision of
residential accommodation for doctors. As a result the doctors are not

available round the clock.

In the State of Rajasthan, out of 2700

dispensaries of ISM&H 80% are running in donated one or two rooms

accommodation. The patient carry poor impression while getting service
in a totally unimpressive dispensary.

(ii)

The medicines supplied to ISM&H dispensaries are totally inadequate in

majority of the dispensaries. The annual expenditure ranges from

152

i

Rs. 4000 to 10000/- per year. Only a couple of States provide medicines
worth Rs. 20,000-40,000. In remote areas only the Government supply

is the source of medicines. Therefore, the shortage of medicines is a
general problem. In a large State like Uttar Pradesh where the number of

Ayurveda dispensaries and hospitals is 2207, there is no supply of
medicines for the last two years due to administrative problems and the

ISM&H doctors are sitting idle for want of medicines.

(iii)

The problem of availability of doctors of modern system in the rural areas
is wellknown.

Because of non-availability of allopathic doctors,

dispensary facilities created at considerable cost remain unutilised and

on the one hand, the investment made by the state governments remains

infructuous, on the other hand, the facility of treatment to public is not
available. It is worth considering in this context that ISM&H sector does
not suffer from this problem.

If dispensaries below block level are

converted into wholly ISM&H dispensaries, adequate infrastructure at no

additional cost will become available by ISM&H dispensaries. The ISM&H

doctors will willingly go to such places. In addition, the public will be able
to receive facility of treatment under ISM&H. The State Governments

will have to transfer the financial provision for such dispensaries to

ISM&H sector and convert the post of allopathic doctors into ISM&H
doctors. The Central Council may consider this suggestion.

j

]

153

Agenda Item No. XXXIII

INDIAN SYSTEMS OF MEDICINE AND
HOMOEOPATHY MEDICAL COLLEGES
The Government of India has set up the National Institute of
Homoeopathy at Calcutta, National Institute of Ayurveda at Jaipur and National
institute of Naturopathy at Pune. While the first two institutions are reasonably

well provided, the NIN is being taken up for creating infrastructure facilities now.

National institute of (Jnani System is being set up at Bangalore and it is
proposed to set up National Institute of Siddha at Madras and National Institute

of Yoga at Delhi soon. These National Institutes will provide leadership in terms

of standards and facilities in their respective disciplines. For Yoga, the
Government of India is planning to assist some eminent non-Governmental
organisations for starting a four year degree course.
I

In the country, there are 118 Ayurveda colleges, 30 Unani colleges and
130 Homoeopathy colleges.

However, the facilities in these colleges are

generally poor. Many of them are running in a few rooms and a large majority of
them do not fulfil even the minimum norms laid down by Central Council of
I

Indian Medicines and Central Council of Homoeopathy.

What is more

unfortunate is that many of the Government colleges suffer from such marked
deficiencies.

Admissions to these colleges are now through a combined

entrance test in which generally students who do not get selected for the modern

system are channelised for admission to ISM&H colleges. This results in too
many students having no aptitude for ISM&H being forced into these disciplines
and many of them either try to leave these colleges after one or two years or do
not show interest in studies.

154

Many of the ISM&H colleges do not even care to apply for recognition to
the CCIM/CCH in time. Some of them apply many years late and then exert

pressure on the Councils on the plea that the interest of the students will be hurt.
For example, Yashwant Shikshan Mandal Ayurvedic Mahavidyalya, Kadoli, was

set up in Sept., 1989 and applied for recognition only in June, 1993. Same was

the case of Ayurvedic Mahavidyalaya set up by this institution in Kolhapur.
Caitanya Ayurvedic Mahavidyalay, Bhusawai also was set up in 1989 and
■

applied for recognition only in May, 1993. Mai Bhago Ayurvedic Mahavidyalaya

Muktsar was set up in 1975 and it applied for recognition in Feb., 1976.
•;

Similarly, in Unani system, Jamia Tibia (UP) was set up in 1987 but applied for

recognition in October, 1990. Ibne Sinha Tibbi College, Azamgarh (UP) was set
up in 1980 but applied for recognition only in March, 1992. And Institute of

Medical Sciences, Srinagar (J&K) was set up in 1993 but it applied for
recognition in Sept., 1994. These are only some of the illustrations, the actual

phenomenon is more pervassive. The State Governments should see to it that
no unrecognised college starts admissions and similarly if a college has been
derecognised, it no longer continues to admit students. The Government of India

is considering amendments to the IMCC Act and CCH Act to provide penal
powers for such cases.
The State Governments are also requested to ensure observance of the

norms laid down by CCIM/CCH both in private and Government colleges. There
is need to urgently improve supervision of the functioning of such colleges.

In some States, the posts of teachers in ISM&H colleges are
interchangeable with those of doctors in dispensaries. This adversely affects
the quality of teaching because those who have aptitude for studies alone made
good teachers. The State Governments where such transferability exists need

to separate the cadre of teachers without delay. In regard to the admission of
students, a joint entrance examination needs to be given by, because the

experience shows that it is feeding indifferent and substandard students into the
155

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I
I

ISM&H Colleges. There are some students who are interested in ISM&H and

obviously admission must be made out of them only. In ISM there is another

special requirement that is for Ayurdeda, knowledge of Sanskrit has to be
acquired and the students must have a healthy respect for the traditions. In
Unani system knowledge of Urdu and persian has to be acquired. Such student
groups are quite distinct from the group that aspires to be doctors of modern

system. Therefore, the Central Council may consider recommendations to the
State Governments that admission tests for ISM&H colleges should be separate

so that only students who have interest in these disciplines and who have

aptitudes for these disciplines alone appear in the examinations and get
admitted. In such admission tests will also be worthwhile to agree to prescribe

that only those students who have done higher secondary with science are

considered eligible for these courses because without science background no
body can be a good doctor in any of the ISM&H disciplines. Students who have

done higher secondary only with Sanskrit or Urdu/Persian are apparently not
suitable, if they have not offered science also. The colleges will of course then

make arrangements for extensive study of Sanskrit during 4 1/2 years in
Ayurveda and of Urdu/Persian for Unani. These measures will improve the

management and standards of education in ISM&H colleges which in turn will
tum out good graduates who will be attuned to the ISM&H standards and will be
able to contribute to their development. It needs to be realised that the present

arrangement is leading to poor standard of education in ISM&H colleges and

poor quality of graduates coming out of the system are neither leading to deliver
competent medical service to the citizens nor to the development of ISM&H

disciplines.

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