THE EXPERT COMMITTEE ON PUBLIC HEALTH SYSTEM
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- THE EXPERT COMMITTEE ON PUBLIC HEALTH SYSTEM
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CWZ
REPORT
OF
THE EXPERT COMMITTEE
ON
PUBLIC HEALTH SYSTEM
GOVERNMENT OF INDIA
ministry of health & family Welfare
NIRMAN BHAVAN, NEW DELHI-110 011.
JUNE, 1996
Y
M-
PREFACE
Centuries old rich Indian heritage of holistic health care practice
as detailed in Ayurveda and as evidenced from the relics of Indus
valley civilisation was lost through gradual deterioration of quality of
medical and health care during the successive centuries following
invasions of alien culture, inappropriate uses of scientific discoveries,
industrial and agricultural revolution which while contributing to
human development in various spheres also created the enormous
problem like large pockets of poverty, slums, overcrowding with all its
ill-effects, and gross unhygienic sanitary environment in cities and
towns. At the time of Independence the status of public health was
low as shown through high rates of infant and under - five mortality,
high fertility rate and very low life expectancy against the backdrop of
low literacy rate, a large segment of population below the poverty line
subjected to economic deprivation and hunger, indicating poor quality
of human existence. It was at that time that the first major review of
Indian health care delivery system with its recommendations in the
form of Bhore Committee became available which not only acted as a
historical landmark in the development of public health system of the
country but also laid down the blue-print of future health planning
and development.
During the subsequent decades the development of Indian public
health system essentially followed the pattern envisaged by the Bhore
Committee. Over the years, several additional committees namely
Mudaliar Committee, Chadha Committee, Madhok Committee,
Mukherjee Committee, Shrivastav Committee, Kartar Singh
Committee, Bajaj Committee, etc. internalised cumulative experiences
and further contributed in developing the public health system.
National Health Policy came into existence in 1983 and provided
strong policy directives for the development of health care delivery
system. Unfortunately many of the recommendations made by these
committees could not be implemented largely due to non-availability
of resources and also to a certain extent due to varying perceptions by
the implementing agencies.
Though phenomenal gains have been made in the health status
of the people as seen from an increase in life expectancy; reduction in
infant mortality, death rate, and fertility rate, yet much more needs to
be done to improve the quality of life of the people for meeting the
challenges of the new, emerging and reemerging human pathogens
and also the rising morbidity and mortality from non-communicable
IF
and lifestyle-related diseases. Increasing evidence of public health
emergencies as seen from frequent reports of outbreak of diseases is
indicative of declining standard of public health in several parts of.the
country, thus posing a serious concern amongst health
administrators. Responding to such concerns, the Ministry of Health
and Family Welfare constituted this Committee to comprehensively
review the public health system in the country and to offer
appropriate recommendations.
After detailed deliberations the Committee has prepared its report
which inter alia deals mainly with the current status of public health
system, epidemiological surveillance system, status of control
strategies for epidemic diseases, existing health schemes,
environmental health and sanitation, role of state and local health
authorities in epidemic remedial measures, health manpower
planning, and health management information system. A series of
remedial actions are proposed to impart a greater degree of
responsiveness in the public health system, An appropriate action
plan has accordingly been formulated.
It is a pleasure to record deep appreciation to all Members of the
Committee for their contributions. Dr.K.K.Datta, Member-Secretary
of the Committee deserves a special mention for his most valuable
efforts in preparing the report. The inputs of Adviser(Health), officials
of Health and Family Welfare Division of the Planning Commission
and of the National Institute of Communicable Diseases in the
preparation of the Report are also acknowledged.
(J.S.Bajaj )
Chairman,
Expert Committee on
Public Health System
Dated : June
, 1996
CONTENTS
Description
Sl.No.
1.
EXECUTIVE SUMMARY
2.
INTRODUCTORY CHAPTER
Page
Nos.
1-20
21
22
1.0 Background
2.0 Introduction
CURRENT STATUS OF PUBLIC HEALTH
SYSTEM IN INDIA
3.
3.1
3.2
3.3
3.4
3.5
3.6
History
Federal Set-up
Union Ministry of Health & Family Welfare
Department of Health
Department of Family Welfare
Department of Indian System of Medicine and
Homoeopathy
*3.7 Function
3.8 Department of Health
3.9 Computerisation
3.10 Medical Education, Training and Research
3.11 International CO-operation for Health and Family
Welfare
3.12 Facilities for Scheduled Castes and Scheduled
Tribes under special component plan
3.13 Directorate General of Health Services
3.14 Functions of Department of Indian System of
Medicine and Homoeopathy
3.15 Department of Family Welfare
3.16 Planning Commission
3.17 State Level
3.18 District Level
3.19 Community Health Centre / Primary Health
Centre/Sub-Centre
3.20 Observations, Suggestions and Overview
3.21 State Level
3.22 District Level
3.23 Community Health Centres
3.24 PHC/Sub-centre Level
i
43
44
44
45
45
45
46
48
49
50
51
51
53
58
60
63
64
65
66
66
72
72
73
74
EPIDEMIOLOGICAL SURVEILLANCE SYSTEM
INCLUDING INSTITUTIONAL SUPPORT
SERVICES
4.
General Introduction
Notification System
Diseases that are notifiable
Legal Provisions for Notification
Reporting Agency
Defects in Notification
Epidemiological Units and Investigations
Public Health Laboratories
Isolation and treatment facilities
Quarantine Administration
Anti-Mosquito and anti-rodent measures at Ports
and Airports
4.12 Collection and dissemination of Statistics
4.13 Observations, Suggestions and Overviews
4.14 Institutional Supprt Services
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
76
77
78
78
79
79
81
81
82
82
83
83
96
99
STATUS OF CONTROL STRATEGIES FOR
EPIDEMIC DISEASES
5.
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
General Introduction
Malaria
Kala-azar
Japanese Encephalitis
Dengue
Diarrhoeal Diseases including Cholera
Poliomyelitis
Measles
Viral Hepatitis
Strategy for Control of Epidemic Diseases
Observations, Suggestions and Overviews
103
105
109
110
111
112
113
114
114
114
116
EXISTING HEALTH SCHEME
6.
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
Rural Health Service Scheme
Health Manpower in Rural areas as on 31.03.95
Health Manpower in Tribal areas as on 31.03.95
Training of professionals and para-professionals
Village Health Guide Scheme
Mini Health Centre Scheme of Tamil Nadu
Rehbar-i-Sehat Scheme in J & K
Child Survival and Safe Motherhood Scheme
Universal Immunisation Programme
Surveillance of Vaccine Preventable Diseases
ii
118
123
123
125
126
128
129
129
130
131
6.11 Testing of Oral Poliovaccine
6.12 Oral Rehydration Therapy for Diarrhoea control
among children
6.13 Programme of Acute Respiratory Infection
6.14 Iron Deficiency
6.15 Vitamin A Deficiency
6.16 Safe Motherhood Services for Pregnant Women
6.17 Care of Newborn and infants
6.18 National Malaria Eradication Programme
6.19 National Leprosy Eradication Programme
6.20 National Tuberculosis Control Programme
6.21 National Filaria Control Programme
6.22 National Guineaworm Eradication Programme
6.23 National AIDS Control Programme
6.24 National Kala-azar Control Programme
6.25 National Programme for Control of Blindness
6.26 National Iodine Deficiency Disorders Control
Programme
6.27 National Diabetes Control Programme
6.28 National Cancer Control Programme
6.29 Observations, Suggestions and Overviews
7.
135
135
136
136
137
139
144
145
146
147
148
150
150
152
154
155
157
NATIONAL FAMILY WELFARE PROGRAMME
7.1 Introduction
7.2 Family Welfare Programme During the First
Seven Five Year Plans
7.3 Observations, Suggestions and Overviews
8.
131
133
161
161
177
ENVIRONMENTAL HEALTH AND SANITATION
8.1 Introduction
8.2 Constitutional Obligations for Environmental
Health and Sanitation
8.3 Water Supply
8.4 Sanitation
8.5 Hospital Waste Management
8.6 Drinking Water Quality Surveillance - Legislation
and Standards
8.7 Operation and Maintenance
8.8 Industrial Waste Management and Air Pollution
Control
8.9 Air Pollution control in India
8.10 Observations, Suggestions and Overviews
iii
183
185
186
187
191
191
192
192
195
198
9.
EPIDEMIC REMEDIAL MEASURED - ROLE OF
STATE AND LOCAL HEALTH AUTHORITIES
9.1
9.2
9.3
9.4
9.5
9.6
9.7
Introduction
State Health Directorates
Municipal Health Authorities
District Health Authorities
Primary Health Centre Infrastructure
Panchayati Raj System
Observations, Suggestions and Overviews
201
201
202
203
203
204
204
CURRENT STATUS OF HEALTH
MANAGEMENT INFORMATION SYSTEM AND
ITS ROLE
10.
10.1 Introduction
10.2 Evolution of HMIS in India & its current Status
10.3 Current Status of HMIS implementation in
various states
10.4 Observations
206
206
211
211
RECOMMENDATIONS
11.
11.1
11.1.1
11.1.2
11.1.3
11.1.4
11.1.5
11.1.6
11.1.7
11.1.8
11.1.9
11.1.10
11.1.11
11.1.12
11.1.13
11.1.14
11.1.15
11.1.16
11.1.17
11.1.18
Short Term
Policy Initiatives
Administrative Restructuring
Health Manpower Planning
Opening of Regional Schools of Public Health
Strenthening & Upgradation of the Departments
of Preventive and Social Medicine in Idetified
Medical Colleges
Reorganised functioning of the Department of
PSM in Medical Colleges
Establishment of a Centre for Diseases Control
Primary Health Care Infrastructure in Urban
Areas
State Level
District Level
Establishment of a supervisory mechanism at,
Sub-district level
Community Health Centres
PHC/ sub-centre level
Village level
Prevention of Epidemics
Upgradation of Infectious Diseases Hospitals .
Water Quality Monitoring
Urban Solid Waste
iv
213
213
216
216
217
217
218
218
218
219
219
219
220
220
221
221
224
224
224
11.1.19
11.1.20
11.1.21
11.1.22
11.1.23
11.2
11.2.1
11.3
Inter-sectoral co-operation
Nutrition
Decentralised uniform funding pattern
Non Governmental Organisations (NGOs)
Involvement of ISM & Homoeopathy
Long Term
Broad set-up of Ministry
Funding
225
225
226
226
227
227
227
228
12.
ACTION PLAN FOR STRENGTHENING OF
PUBLIC HEALTH SYSTEM
229
13.
ACKNOWLDGEMENT
238
14.
BIBLIOGRAPHY
239
15.
ANNEXURES
i-lii
v
EXECUTIVE SUMMARY
E-1.0 INTRODUCTION
India is a large country with around 900 million population in 25 states
and 7 Union Territories. Historically India had a rich public heath system as
evidenced from the relics of Indus Valley civilisation demonstrating a holistic
approach towards care of human and disease. The public health system
declined through the successive invasions through the centuries, intrusion of
modern culture and growing contamination of soil, air and water from
population growth. With the establishment of British rule and the initiation
of practice of Western medicines in India strong traditional holistic public
health practice in India went into disuse bringing disease-doctor-drug
orientation. The so-called modern public health practice of the advanced
European and industrialised countries was primarily set up around
cantonments, district and State Headquarters in British India.
E-l.l By the time India achieved independence socio-political and economic
degradation reached to an extent where hunger and mal-nutrition were
almost universal; 50% of the children died before the age of five, primary
health care was very rudimentary or non existent and the state of public
health was utterly poor as evidenced through life expectancy at birth around
26, infant mortality rate 162, crude death rate around 22, maternal mortality
rate around 20. Only 4.5% of the total population had access to safe water
and only 2% of the people had sewerage facility. Number of medical
institutions were few and trained para professionals like nurses, midwives,
sanitary inspectors were barely skeletal in numbers. The picture on the
nutrition front was very grave. Food production, its distribution and
availability of food per capita were all unsatisfactory. MCH services, school
health services, health care facilities for the industrial workers, environmental
health were all far from satisfactory.
E-1.2 Under the Constitution, health is a state subject and each state has its
health care delivery system. The federal government's responsibility consists
of policy making, planning, guiding, assisting, evaluating and co-ordinating
the work of various provincial health authorities and also supporting various
on-going schemes through several funding mechanisms. By and large health
care delivery system in India in different states has developed following
independence on the lines of suggestions of the Bhore Committee which
recommended delivery of comprehensive health care at the door step of the
population through the infrastructure of primary health centres and sub
centres. During the last eight 5 year plans following independence a large
network of primary health care infrastructure covering the entire country has
been established. In addition, several national health and disease control
programmes were initiated to cover a wide range of communicable diseases
namely, malaria, filaria, tuberculosis, several vaccine preventable diseases like
diphtheria, pertussis, tetanus, polio, measles etc. and to also cover some
important non-communicable diseases like iodine deficiency disorders,
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control of blindness, cancer, diabetes etc. The progress was periodically
reviewed through constitution of several committees like Mudaliar
Committee, School Health Committee, Chadha Committee, Mukherjee
Committee etc.
To provide more thrust on the improvement of
environmental health and sanitation the responsibilities pertaining to water
supply, sanitation and environmental related issues were transferred to the
concerned ministries of Urban Development, Rural Development and
Environment and Forests. Major initiatives were taken up in our efforts to
reach Health for All by 2000 A.D. on the lines of policy directives enunciated
in National Health Policy. Eighth plan starting in 1992-93 clearly emphasised
that the health facilities must reach the entire population by the end of Sth
plan and that the health for all paradigm must not only take info account the
high risk vulnerable group i.e. mothers and children but also focus on the
under privileged segments both within and outside the vulnerable group. All
the efforts put through the last four and a half decades following
independence made significant dent in the improvement of health indices
viz. IMR 74 (1994), water supply urban area 84.9%, rural area 79.2% (1993),
sanitation urban area 47.9% (1993), rural 14% (1994), crude death rate 9.2%
(1994), expectation of life at birth Male 60.4% (1992-93) and female 61.2%
(1992-93). Significant number of doctors and para medical staff are available
and the food productions have been raised from 50 million tonnes in 1950 to
182 million tonnes in 1993-94 increasing the per capita availability even in
spite of large population growth from 394.9 gm in 1951 to 474.2 gm in 1994.
E-1.3 In spite of this significant development and impressive growth in
health care, enormous health problems still remain to be tackled and
addressed to. Though mortality has declined appreciably yet survival
standards are comparable to the poorest of the nations of the world. Even
within the country wide differences exist in the health status in the states like
Bihar, Orissa, Madhya Pradesh, Rajasthan to that of Karnataka, Maharashtra
and Punjab which have done exceedingly well in terms of quality of human
life. Major problems facing the health sectors are, lack of resources, lack of
multi-sectoral approach, inadequate IEC support, poor involvement of NGOs,
unsatisfactory laboratory support services, poor quality of disease
surveillance and health management information system, inadequate
institutional support and poor flexibility in disease control strategy etc.
E-1.4 In the background of the above and also in the light of the observations
in recent times following review of the rural health services, national
programmes like malaria, tuberculosis, UIP etc. concern has been expressed
that whether our efforts will succeed in achieving the goal for reaching
Health for All by 2000 A.D. In fact experts are of the opinion that Health for
All by 2000 A.D. is not a distinct possibility. It may have to be revised
backwards by a decade or two. The concern has been further compounded
following the recent outbreaks of malaria and plague indicating poor
response capability of the existing public health system in meeting the
emergent challenges of the modern days particularly the threat posed by new.
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In this context, the
emerging and re-emerging human pathogens.
committee to comprehensively
Government of India constituted an expert
< x
review the public health system in the country under the chairmanship of
Prof. J.S. Bajai, Member, Planning Commission to undertake a comprehensive
review of (a) public health system in general and the quality of epidemic
surveillance and control strategy in particular, (b) the effectiveness of the
existing health scheme, institutional arrangements, role of states and local
authorities in improving public health system, (c) the status of primary health
infrastructure, sub centres and primary health centres in rural areas specially
their role in providing intelligence and alerting system to respond to the
science of outbreaks of disease and effectiveness of district level
administration for timely remedial action and (d) the existing health
management information system and its capability to provide up-to-date
intelligence for effective surveillance, prevention and remedial action. The
committee had four meetings in addition to interaction between the members
of the expert committee.
The summary of the observations and
recommendations suggested by the committee are summarised here.
E-2.0 PUBLIC HEALTH SYSTEM IN INDIA
E-2.1 Federal Set up
The federal set up of public health system consists of Ministry of
Health & Family Welfare, the Directorate General of Health Services with a
network of subordinate offices & attached institutions and the Central
Council of Health & Family Welfare. The Union Ministry of Health & Family
Welfare is headed by a cabinet minister who is assisted by a Minister of State.
It has three departments namely. Department of Health, Department of
Family Welfare and Department of Indian Systems of Medicines. The
Department of Health deals with the medical and public health
including drug control and prevention of food adulteration through the
Directorate General of Health Services and its supporting offices. Director
General of Health Services renders technical advice on all medical and public
health matters and monitors various health schemes. Director General of
Health Services also renders technical advice on family welfare programmes.
The functions of the Union Ministry of Health and Family Welfare are to carry
out activities to fulfil the obligations set out in the 7th Schedule of the Article
246 of the Constitution of India under Union and Concurrent list.
The federal government has set up several regulatory bodies for
monitoring the standards of medical education, promoting training and
research activities namely. Medical Council of India, Indian Nursing Counci,
Pharmaceutical Council etc. In addition to the Union Ministry of Health &
Family Welfare, Planning Commission has a Member (Health) of the rank of a
Minister of State who assists the Ministry of Health in formulation of plan
through advice and guidance and the expert guidance is also available for
monitoring and evaluation of the plan projects and schemes.
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E-2.2 State level
The State governments have full authority and responsibility for all the
health services in their territory. The State Ministry of Health & Family
Welfare is headed by a Minister of Health & Family Welfare either of a
cabinet rank or a Minister of State. Often he/ they is/are assisted by a Deputy
Minister depending upon the political situation. The Health Secretariat is the
official organ of the State Ministry of Health & Family Welfare and is headed
by a Secretary/Principal Secretary/Commissioner as the case may be. State
Health Secretariat is assisted by a technical wing called the State Health
Directorate. Earlier all the functions pertaining to health and family welfare
and medical education were integrated. However, now in many states
directorates of public health services, posts of Director of Public Health,
Director of Family Welfare and Director of Medical Education have been
separated and they report directly to the Secretary.
E-2.3 District Level
The principal unit of administration in India is the district which is
under.a Collector/ District Magistrate/Deputy Commissioner. The size of the
districts vary widely from less than 0.1 million to more than 3 million and the
district public health system is headed by the Chief Medical and Health
Officer/District Health Officer.
E-2.4 Community Health Centre/Primary Health Centre/Sub Centre
Apart from the headquarters of the district having district hospitals
and the office of the Chief Medical and Health Officer, the district has a
network of hospitals, dispensaries, community health centres, primary health
centres and sub centres to cover the entire population of the district with
regard to health care delivery services. It has also the network of hospitals
and dispensaries under the Indian Systems of Medicine and Homoeopathy.
E-2.5 Health is a multi-ministerial responsibility. Many of the activities
undertaken by the other ministries have tremendous impact on the health of
the people.
Several policy initiatives related to agriculture, urban
development, industrial packages have far reaching health linkages involving
higher morbidity and mortality. The same need to be analysed through
appropriate health impact assessment studies for guidance of policy makers.
E-2.6 Many of the areas under the National Health Policy have not yet been
implemented. During the last decade massive changes have occurred
through destruction of ecological system, rapid urbanisation, large population
growth, industrial revolutions etc. leading to changes in health and
demographic scenario. Appearance of new, emerging and re-emerging health
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problems has been causing concern. This calls for review of the National
Health Policy.
E-2.7 India is a large country with diverse socio economic situations.
Therefore, uniform health care delivery system is not likely to yield the
desired results. Therefore, continued efforts to develop alternate strategies
should be there so that the same could be appropriately dovetailed within the
overall framework of the health care delivery system to obtain better results.
E-2.8 73rd and 74 Constitutional amendments have provided immense
administrative and managerial authorities to the Panchayats and
municipalities. The same should be fully exploited with appropriate
delegation of financial authorities to improve the public health system.
E-2.9 Several ministries are involved in public health related activities.
Hardly any appropriate inter-sectoral co-ordination and co-operation
mechanism exists.
E-2.10 In the present organisational set up of the Ministry of Health & Family
Welfare there are several areas of duplications and there is excessive
bureaucracy. Not enough number of senior public health positions exist.
Many of the important positions requiring public health responsibility are
being managed through non-Public health professionals. For several key
areas like environmental health & sanitation, manpower planning hardly any
component exists in the DGHS.
E-2.11 Indian Systems of Medicine & Homoeopathy has large number of
professionals. They are not being appropriately exploited to supplement the
modern health care delivery services particularly in the area of awareness,
community participation etc.
E-2.12 Rapid urbanisation has led to phenomenal growth in urban
population. 25-30% live now in urban area. Though tertiary care services are
available but primary care is grossly neglected here leading to higher
morbidity & higher mortality amongst urban poor and slum dwellers and to
also over straining of tertiary care health services.
E-2.13 Earlier practice of integrated delivery of health care services is being
eroded through creation of separate directorates in several states leading to
disintegrated pattern of medical and health administration. Growth of
bureaucracy as evidenced through placement of bureaucrats as Directors of
Health Services or as heads of primarily medical and health organisations is
also responsible for erosion of public health machinery.
E-2.14 Epidemiological support services and public health laboratory facilities
at the district level is grossly inadequate.
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E-2.15 Referral services in the community health centre is poor. Public health
specialised services in the community health centre is totally lacking.
E-3.0 EPIDEMIOLOGICAL SURVEILLANCE SYSTEM
E-3.1 Epidemiological services were grossly inadequate prior to
independence but have since developed to a great extent, concurrently with
the national control/eradication programmes for various diseases like
malaria, tuberculosis, leprosy, cholera, vaccine preventable diseases, filaria
etc. However, there is a conspicuous lack of uniformity in the lists of diseases
which are notifiable in different states and also from the view point of
primary agency responsible for reporting. Cholera, yellow fever and plague
which are under International Health Regulations are notifiable throughout
the country. The other important diseases which are notifiable in one state or
the other are viral hepatitis, enteric fever tuberculosis, influenza, meningitis,
Japanese Encephalitis, rabies, diphtheria, leprosy, measles, poliomyelitis etc.
Notification system in operation in various states is usually supported
through certain legal provisions. The position with regard to legal provisions
also varies from state to state and some state governments do not have any
specific act excepting invoking the Epidemic Diseases Act 1897. In urban areas
the responsibility lies with the municipal health authorities. Common defects
in notification are delay and inaccuracy in reporting the cases and under
reporting.
E-3.2 Epidemiological investigations have a key role to play in effective
control of diseases. For co-ordinating and carrying out such investigations,
epidemiological units/cells have been established in a number of states but
there are states where such units have not been established yet. Public health
laboratories play a premier role in verification of diagnosis, in assisting
epidemiological tracing of the spread of the outbreak and in understanding
the natural cycle of the disease. In most of the states, public health
laboratories are not functioning very efficiently and there is hardly any
facilities for virus isolation work in these public health laboratories.
E-3.3 Wide variation in the notification system being implemented by
various states/UTs make the data lack in epidemiological quality and thus
hardly offers inputs for an effective response. The data generated through the
massive rural health infrastructure and hospitals and dispensaries are
received late and are non-uniform with scanty laboratory support. It includes
also no reporting and truncated reporting from several areas due to complete
blackout of surveillance in time & space due to variety of reasons viz. non
availability of health personnel, apathy of health personnel, poor
management, errors in reporting etc.
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E-3.4 Surveillance data generated through the system and through various
programmes are considered at best indicative of trend rather than the actual
situation in the community and mortality and morbidity numbers reported
are grossly under estimated.
E-3.5 Though major national health and family welfare programmes have
institutional support services but such support mechanism is grossly
inadequate to meet the challenging needs of the modern programme
management. With large amount of information being generated covering
various areas of development and various scientific disciplines, there is an
urgent need for their appropriate analysis, understanding and dovetailing to
make the on-going programmes more modern and updated. Unfortunately,
in several of the programmes such formal mechanism does not exist. Though
a large number of medical colleges, national and referral institutions are there
not much has been done in the context of harnessing the expertise through a
formal linkage mechanism.
E-4.0 STATUS OF CONTROL STRATEGIES FOR EPIDEMIC DISEASES
E-4.1 Appropriate guidelines for detection of outbreak and early warning
signal mechanism for epidemic prone diseases are not nationally available. It
is usually provided by NICD on ad hoc basis.
E-4.2 Though several diseases with epidemic potentiality are covered
through national disease control/eradication programmes like National
Malaria Eradication Programme, Universal Immunisation Programme, there
is no centrally sponsored or central scheme to tackle epidemic prone diseases
in general. National Malaria Eradication Programme provides guidelines
with respect to detection and containment of epidemic of malaria and kalaazar and so also several of EPI targeted diseases have appropriate guidelines
for epidemiological investigations. Guidelines have provisions of initiating
control measures but none of the guidelines have a component of generating
early warning signal and thus helping in identification of outbreaks early.
For many of the diseases like poliomyelitis, cholera, viral hepatitis, adequate
diagnostic support services are not available as a result many of them are not
detected and reported. Even in most of the medical colleges facilities for
identifying new sero types of cholera are not available.
E-5.0 EXISTING HEALTH SCHEME
E-5.1 There are large number of schemes functioning in the country like
Development of health infrastructure. Training of professionals and para
professionals. Village health guide, Mini health centre, Rehbar-i-Sehat
scheme. Child survival and safe motherhood scheme including UIP,
Programme of Acute Respiratory Infection, ORT, etc. in addition to several
major diseases control/eradication programmes covering diseases of public
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health importance like malaria, leprosy, tuberculosis etc. under communicable
diseases and blindness control, iodine deficiency disorders, cancer and
diabetes etc. under chronic diseases. In addition to the above programmes
under the Ministry of Health and Family Welfare there are several schemes
under other ministries like Ministry of Rural Development, Ministry of Urban
Development, Ministry of Environment & Forests and Ministry of Welfare to
cover wide areas of environmental health, water supply, sanitation and child
health.
E-5.2 All the schemes have been aimed to improve the public health system.
Large number of agencies are involved. Co-operation and co-ordination
between these agencies are grossly inadequate and thus many of the
programmes do not give satisfying performance.
E-5.3 Multiplicity of funding mechanism, poor administrative &• financial
authority at the peripheral points, multiplicity in administrative authority
lead to poor performance.
E-6.0 NATIONAL FAMILY WELFARE PROGRAMME
E-6.1 *India was the first country to have an official family welfare
programme which was initiated in 1952. Since then, during the subsequent
eight five year plans, family planning as a measure of population control has
been receiving high priority attention in each of the five year plans. During
the 3rd five year plan (1961-66), family planning received a major boost and it
was declared the very centre of plan development and in the year 1966 a
separate Department of Family Planning was established in the Ministry of
Health and the extension approach was further modified into an integrated
approach and thus family planning became an integral part of MCH and
nutrition services. The National Health Policy has indicated a long-term
demographic goal of achieving replacement level fertility (net reproduction
rate of 1.0) by the year 2000 A.D. which would necessitate achieving a birth
rate of 21 per thousand, death rate of 9 per thousand and annual population
growth rate of 1.2 per cent. The 7th plan document visualised the goal of
reaching the same by 2006-11. However, keeping in view the level of
achievement the Sth plan document has envisaged to achieve the same by
2011-16.
E-6.2 The family planning programme has not been able to achieve fully the
demographic goals which are vitally linked with improvement of public
health system in the country. States which have done exceedingly well on
the demographic front have also done well on the health front.
E-6.3 Creation of a separate department leading to disintegration of earlier
integrated way of functioning has not improved performance.
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E-6.4 Poor referral services to a great extent are responsible for high
maternal and infant mortality Only few first referral units are functional.
E-6.5 India is a vast country. Efforts of the government alone can not meet
the needs. Though a large number of NGOs are functioning well in the
country, not much efforts have been made in that direction to involve them
more effectively in the delivery of health & family welfare services.
E-7.0 ENVIRONMENTAL HEALTH AND SANITATION
Though environmental health and sanitation received priority
attention in all the successive plans but level of environmental health and
sanitation both in rural areas and in urban areas continues to be poor in spite
of significant achievements in terms of coverage and quality of service. This
has been largely due to large population growth, urbanisation,
industrialisation, population movements and ecological changes. Following
the Bhore Committee recommendations an Environmental Hygiene
Committee was constituted in 1948-49 and in 1953 a national level technical
body (Central Public Health Engineering Organisation) was established in the
Ministry of Health to undertake national water supply and sanitation
programme. In 1973 the subject of water supply and sanitation was
transferred from Ministry of Health to Ministry of Works and Housing and
local self government (presently redesignated as the Ministry of Urban Affairs
and Employment). The Water (Prevention and Control of Pollution) Act of
1974 was another milestone in the prevention and control of water pollution
in the country. For implementation of the Act, a Central Pollution Control
Board at the national level and State Pollution Control Boards at the state
level were established in 1974. The Act was amended in 1988. The Air
(Prevention and Control of Pollution) Act, 1981 amended further in 1987 has
provided an instrumentation to improve the environment. In 1981
International Drinking Water Supply and Sanitation Decade was launched. In
addition to that centrally sponsored rural sanitation programme and several
other programmes were also initiated by different ministries. In spite of all
these efforts, recurring outbreaks of gastrointestinal disorders and
haemorrhagic dengue fever etc. and large scale outbreaks of malaria and
plague in recent years point towards insufficiency in our efforts in improving
environmental health and sanitation. The low level of urban, peri-urban and
rural sanitation is a matter of deep concern. Multiple operating agencies with
poor co-ordination between them have added to poor programme efficiency.
E-8.0 ROLE OF HEALTH AUTHORITIES IN EPIDEMIC REMEDIAL
MEASURES
E-8.1 Health is a state subject and the entire health care delivery services
including epidemic remedial measures are primarily through the State
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governments who have the constitutional authority and obligations to
implement the health care delivery services. The municipalities and the local
authorities and the State governments though have the constitutional
authority and obligations to effectively implement the public health
programmes but they are unable to function satisfactorily in that direction
because of paucity of resources, non-availability of the expertise in terms of
personnel and institutional support etc. and also due to appropriate
perception of public health problems. Many of these local bodies do not have
requisite financial authorities.
E-8.2 Municipal Bye-laws and the local bye-laws are widely in variation
from one and another and many of them are outdated. Many of the
provisions of municipal bye-laws and local bye-laws though technically
sound but do not yield desired results because of poor implementation.
E-9.0 CURRENT STATUS OF HMIS & ITS ROLE
9.1
Initially HMIS was started in the states of Haryana, Gujarat, Rajasthan
and Maharashtra on pilot basis in one district each of the states. The system
was manual and the data which was generated as a result of implementation
of the pilot project proved very useful. On the basis of the achievement of
HMIS which was known as HMIS Version 1.0, the programme officers of
various State Governments and experts from the related fields were consulted
and the inputs for each level of institution responsible for health care delivery
were designed and developed.
E-9.2 During the year 1988-89 National Informatics Centre set up Satellite
based computer communication network called NICNET and the HMIS was
again modified and modified computerised formats designed and developed
in the shape of Version 2.0 were implemented. It has become fully
operational in Haryana, Sikkim and in several other states it is in different
stages of implementation.
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E-10
RECOMMENDATIONS
E-10.1 Short-term
E-10.1.1
Policy Initiatives
E-10.1.1.1
Review of National Health Policy
The National Health Policy was formulated and adopted in
1983. During the years since then major changes have occurred
occurrea
through continuing population growth, rapid urbanisation, industrial
revolution, changing health and demographic scenario, appearance of
new, emerging and re-emerging health problems etc.
Newer
technologies are also available. In view of the same, the National
Health Policy needs a careful and critical reappraisal. The committee,
therefore, recommends constitution of a Group of Experts to prepare
the draft of the new National Health Policy by the end of 1996.
E-10.1.1.2
Establishment of health impact assessment cell
There is a need to enhance the capacity and capability of the
. Ministry of Health & F.W. to undertake health impact assessment for
major development projects, industrial units etc. so that the
project/industrial authorities could be appropriately advised & guided
to incorporate proper intervention measures/changes as the case may
be. All large projects of different ministries should invariably have
health component in the proposal itself and this should be examined
and approved by the Ministry of Health & Family Welfare. Regular
analysis of various public policies and practices of other ministries viz.
agriculture, industry, urban development, rural development and
environment, which have direct link with the health of the people,
must be considered as an essential prerequisite for a meaningful interministerial co-ordination.
E-10.1.1.3
Surveillance of critically polluted areas
Health impact and environmental epidemiology related to air,
water, and soil pollution need to be monitored 'and evaluated
particularly in the critically polluted areas in the country. Ministry of
Health and Family Welfare should initiate actions in this regard
urgently, in co-ordination with the Ministries of Environment, Industry
and Urban Development. Measures such as a properly maintained
data-base, mapping of the vulnerable areas, immediate intervention
where possible and continuing surveillance need to be initiated as a
well structured programme of action.
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E-10.1.1.4
Search for alternative Strategy/ strengthening of health
services/system research
Uniform health care strategy for the entire country is not likely
to succeed because of a variety of reasons: geographic, socio cultural,
ethnic, educational, economic etc. The committee recommends that
allocation of adequate funds to the Centre, UTs and State Directorate of
Health Services enabling them to undertake or commission Health
Services/System Research and Intervention Studies and to ensure that
such research results are utilised to improve the health care delivery
services.
E-10.1.1.5
Uniform adoption of Public Health Act by the local health
authorities
Model Public Health Act revised and circulated in 1987 should
be examined by all State health authorities, municipalities and local
health authorities carefully and adopted/enacted to suit local and
•national needs.
E-10.1.1.6
Establishing National Notification System/National Health
Regulations
The notification system as it exists today varies widely from
state to state and within the state from area to area. The Committee
recommends uniform National Health Regulations for adoption by all
states.
E-10.1.1.7
Joint Council of Health, Family Welfare and ISM &
Homoeopathy
The existing Joint Council of Health & Family Welfare should
be further broad based to make a Joint Council of Health, Family
Welfare and Indian Systems of Medicine & Homoeopathy.
E-10.1.1.8
Establishing an Apex Technical Advisory Body
In order to ensure a mechanism of continuing review and
appraisal of public health issues, policies, programmes and services,
the committee recommends establishment of broad . based Apex
Technical Advisory Body to advise the Ministry of Health & Family
Welfare.
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E-10.1.1.9
Constitution of Indian Medical & Health Services
The Committee reinforces in the strongest terms the need to
constitute Indian Medical & Health Services without any further
delay.
E-10.1.1.10
Administrative restructuring
E-10.1.1.10.1 Organisational set up of the ministry
Most of the functions of the Union Ministry of Health and
E-10.1.1.10.1.1
Family Welfare are highly technical in nature and, therefore, require
technical leadership of a high quality. The committee therefore,
strongly recommends that the union Ministry of Health & Family
Welfare may consider merger of the two departments of Health
Family Welfare and the single department so created benefits from
technical leadership as indicated above. The department of ISM and
Homeopathy may also have to be similarly restructured.
E-10.1.1.10.1.2
The Department of Health & Family Welfare and DGHS
should be restructured and reorganised and while doing so emphasis
should be given to strengthen Planning Division of DGHS, Food and
Drug Division. New Divisions of Environmental Health & Sanitation
Health impact assessment Cell and Health Manpower Division should
also be established.
E-10.1.1.10.1.3
All the major technical divisions under the Union
’ Ministry
of
Health
&
Family
Welfare
and
major
institutions/organisations should have an advisory body to
periodically review the functioning of these divisions/institutions and
suggest appropriate corrective step or steps for improving their
various activities.
E-10.1.1.11
Health Manpower Planning
“ - - 'Manpo'
>Wer Planning
E-10.1.1.11.1 The DGHS should have a strong Health
also be
Division; appropriate institutional support: mechanism
u.__h—:
a
National
Institute
of
Health
established through establishment of
Manpower Development.
' ; that recommendations contained in
E-10.1.1.11.2 The committee reiterates
of
1987
on health manpower planning
Bajaj committee report
-production and management should be implemented in right
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earnestness which will greatly strengthen public health system in the
country.
E-10.1.1.11.3 The committee recommends that positions requiring public
health tasks should be filled by appropriate qualified public health
professionals and until these professionals are available, these could be
operated by general category health professionals through appropriate
training in health services administration, management and
epidemiology.
E-10.1.1.12
Opening of Regional Schools of Public Health:
The committee recommends that at least four more regional
schools of public health are set up in Central, Northern, Western and
Southern regions. Duly modernised schools could be in the pattern of
All India Institute of Hygiene and Public Health, Calcutta and School
of Tropical Medicine, Calcutta.
E-10.1.1.13
Strengthening and upgradation of the Departments of
Preventive and Social Medicine in identified medical colleges
The committee recommends that some of the existing medical
colleges who have very significant expertise in teaching of preventive
and social medicine/community medicine be further strengthened by
establishing within the department an advanced centre for teaching of
public health or through upgrading the existing department so that it
can take up additional responsibilities of continuing education in
public health subjects for health professionals and can also undertake
responsibilites for producing more public health professionals to meet
the demands of the country. In this context, it is strongly suggested
that a centrally sponsored programme of upgradation of few identified
departments of preventive and social medicine in the medical colleges
could be taken up during the last financial year of this Plan and during
the 9th Plan period at least 25% of existing departments may be
similarly upgraded through availability of additional funds by the
Planning Commission to the Ministry of Health & F.W. in this regard.
These centres could be linked through a network so that the facilities
could be maximally utilised.
«
E-10.1.1.14
Reorganised functioning of the Department of PSM in
Medical Colleges:
The committee suggests that some of the positions of the
Department of Preventive and Social Medicine should be periodically
rotated between the State/District National health programme
management focal points so that the programme managers get the
benefit of updated academic and technical skills and the students are
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benefited from the practical experience of the programme managers at
the field level.
E-10.1.1.15
Establishing a Centre for Disease Control
The committee is of the view that National Institute of
Communicable Diseases, Delhi should be substantially strengthened
through capacity building into a National Centre of excellence for
Disease Control on the pattern of similar advanced centres such as
CDC, Atlanta.
E-10.1.1.16
Primary Health Care infrastructure in urban areas:
The committee recommends that an Expert Group be
constituted to suggest restructuring or even redesigning of health care
infrastructure linking existing primary health care infrastructure to
secondary and tertiary care in urban areas in a geographically defined
area and developing appropriate referral system.
E-10.1:1.17
State Level:
Creation of several positions of Directors at the State level has
led to disintegration of earlier integrated pattern of medical and health
administration. Earlier practice needs to be restored. It is also
recommended that functioning of the Department of Health being
mostly that of technical nature a technical man should be the head of
the Department of Health instead of a bureaucrat.
E-10.1.1.18
District level:
The committee recommends to establish epidemiological unit if
not already existing under the National Disease Surveillance
Programme.
E-10.1.1.19
Establishment of a supervisory mechanism at the Sub-district
level:
The committee is of the view that there is an urgent need to
institute appropriate supervisory mechanism at the sub district level.
E-10.1.1.20
Community Health Centres:
Community Health Centre is regarded as the first referral unit.
The National Education Policy in Health Sciences as approved by the
Central Council of Health & Family Welfare in 1993 has recommended
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placement of one public health specialist at the community health
centre (CHC) level and if this is implemented the same will contribute
immensely in strengthening the public health system.
Until such time as a Public health expert is available at CHC
level, it is suggested that each of the specialists take up the
responsibility of monitoring the public health programme pertaining to
their speciality in the population covered by CHC e.g. obstetrician will
supervise collection and reporting of data pertaining to Reproductive
Health and Family Planning, Paediatrician for immunization and child
survival, physician for communicable and non-communicable disease
control programme, surgeon for disability limitation rehabilitation and
blindness control programmes.
E-10.1.1.21
PHC/Sub-Centre level:
To ensure participatory management by the community the
organisational structure of the health services at PHC/Sub
centre/village level should be entrusted to the Panchayat! Raj
institutions which should decide the nature, structure, and priorities of
•the organisation of the health care delivery services at the village level
depending upon the local situation, resource availability etc.
E-10.1.1.22
Village level
The committee is of the considered opinion that the Village
Health Guide in the new envisaged role as Panchayat Swastha Rakshak
will provide useful support to the Panchayat system at the village level
in enhancing community awareness and participation.
E-10.1.1.23
Prevention of Epidemics:
E-10.1.1.23.1 It may not be possible to completely prevent outbreak of
diseases. However, epidemics can be prevented if an appropriate
surveillance mechanism is established. In fact price of freedom from
disease is appropriate surveillance. The Committee agrees with the
recommendations of the Fourth Conference of the Central Council of
Health & Family Welfare (1995) proposing initiation of a National
Disease Surveillance Programme for strengthening of health
surveillance and support services and recommends that this
programme should be initiated as a centrally sponsored scheme within
the existing health infrastructure with appropriate laboratory support
involving already existing expertise in various national institutes,
medical colleges, and district public health laboratories.
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E-10.1.1.23.2 With the establishment of National Disease Surveillance
Programme, several national institutes at the national, regional and
state level alongwith several medical colleges and important public
health laboratories will be appropriately linked so that the response
capability becomes faster and expertise available in these institutes
promptly could be harnessed by the executive health authorities at the
district level to respond to an epidemic situation.
E-10.1.1.23.3 The committee recommends that National Institute of
Communicable Diseases should prepare guidelines for surveillance
regularly under the supervison of a National Task Force, update the
guidelines at predetermined interval and send to all health
implementing agencies. The guidelines should include details of the
mechanism of detection of outbreak and detection of early warning
signal.
E-10.1.1.23.4 The system of civil registration of deaths. Model Registration
Scheme, Sample Registration Scheme subsequently renamed as Survey
of Causes of Death (Rural), certification of causes of death should be
continuously improved by enlarging its scope and coverage so that it
- gives more relevant data in the context of the entire country.
E-10.1.1.23.5 The processing of weekly epidemiological statistics being
provided by CBHI lacks an appropriate feed back channel to the
various peripheral agencies. The: same need to be developed in the
■' i of MMWR (Morbidity Mortality Weekly Report) published by
pattern
CDC and National Institute of Communicable Diseases may take up
the responsibility for the same. CBHI may continue to act as a nodal
agency for diseases which are being reported on a monthly basis. The
diseases under International Health Regulations and the diseases
under National Health Regulations having epidemic potentiality
should be the responsibility of NICD which has the due expertise in
appreciating the problem and initiating action accordingly.
With the expansion of HMIS to other states and its
establishment on a firm basis the epidemic intelligence component
could be appropriately dovetailed within the HMIS and a few districts
in some states be taken up where HMIS has been satisfactorily
established incorporating the epidemic intelligence component in the
light of the experiences of NICD epidemic prone disease surveillance
project and NADHI Projects of CMC, Vellore on a pilot basis. If found
successful, it will further strengthen the HMIS in its response
capability. This could form part of operational research support to the
proposed National Disease Surveillance Programme.
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E-10.1.1.23.6 The committee recommends that the Epidemic Diseases Act
provisions should be made available to all the health authorities and
the provisions under the Act could be continuously reviewed by a
designated group to make it more comprehensive in the light of the
latest scientific information available.
E-10.1.1.24
Upgradation of Infectious Diseases Hospitals
Every State has got one or more ID Hospitals. Most of these
hospitals are inadequately staffed with poor maintenance. Many of
them lack the basic diagnostic support services. There is an urgent
need that facilities in these hospitals are appropriately reviewed and
modernised to meet the requirements of infectious diseases
management.
E-10.1.1.25
Water quality monitoring
Ministry of Health & Family Welfare should take up the issue of
water quality monitoring with the Ministries of Rural Areas and
Employment and Urban Affairs and Employment and initiate a few
pilot studies in different locations in the country to examine the
•feasibility of implementing a community based and affordable model
of water quality monitoring and develop National Action Plan in this
regard based on pilot study results.
E-10.1.1.26
Urban Solid Waste
The committee endorses the recommendations of the 1995 Bajaj
Committee Report of the High Power Committee on Urban Solid
Waste Management in India, constituted by the Planning Commission
with regard to collection, transportation and safe disposal of municipal
wastes including industrial and hospital wastes etc. The committee
also endorses the suggestion of the Bajaj Committee, that it is essential
to evolve a National Policy as well as an action plan for management of
solid waste.
E-10.1.1.27
Inter-sectoral Co-operation:
E-l0.1.1.27.1 Large number of health schemes are implemented through the
Ministry of Health & Family Welfare. In addition, there are large
number of schemes having tremendous impact on human health and
quality of life. These schemes are being implemented through several
other ministries. But as different agencies are involved and co
ordination between these agencies is not so easily achieved, the
Committee is of the opinion that until and unless a formal mechanism
of co-ordination and co-operation is established involving all
concerned and guidelines indicating detailed responsibilities in respect
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of all participating units precisely defined, even inspite of individual
schemes appearing to be technically sound, the same will not be able to
deliver what is expected of them in terms of effective improvement in
the Public Health System.
E-10.1.1.28
Non-Governmental Organisations (NGOs):
The committee recommends that the NGOs should be
increasingly involved through an appropriately developed action plan
with suitable funding.
E-10.1.1.29
Involvement of ISM & Homoeopathy:
The practitioners of Indian System of Medicine can be gainfully
employed in the area of National Health Programmes like the National
Malaria Eradication Programme, National Leprosy Eradication
Programme, Blindness Control Programme, Family Welfare and
universal immunisation, nutrition programme etc. Within the health
care system, these practitioners can strengthen the components of (i)
.health education, (ii) drug distribution for national disease control
programmes, (hi) motivation for family welfare, and (vi) motivation for
immunisation, control of environment etc.
E-10.2 Long-term
Broad set up of Ministry:
The recommendations of the Bhore Committee that the Ministry
of Health should be under the charge of a separate Minister is being
followed and is currently in practice. However, the members of the
committee are of the opinion that the several activities linked with the
human health are presently undertaken by Ministry of Welfare,
Ministry of Human Resource Development, Ministry of Urban
Development, Ministry of Environment, Ministry of Rural
Development etc. The work of sanitation and environmental health
was earlier with the Ministry of Health but now it is being undertaken
by several ministries viz. Ministry of Environment' and Forests,
Ministry of Rural Areas and Employment, Ministry of Urban Affairs
and Employment and Ministry of Chemicals. It has been further seen
that the inter-sectoral co-ordination which is very vital in successful
implementation of various programmes is not readily available
through a formalised mechanism resulting in poor achievements under
various programmes. Therefore, involving all the activities pertaining
to human health, creation of a new ministry such as Human Welfare
may require serious consideration. Alternatively a National Council of
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Human Welfare be constituted under the chairmanship of Prime
Minister of India, and other members being Deputy Chairman,
Planning Commission, Ministers of concerned Ministries, eminent
medical and health professionals and representatives of professional
organisations and NGOs etc.
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INTRODUCTORY CHAPTER
1.0
BACKGROUND
The Ministry of Health & Family Welfare, Government of India
constituted a Committee to comprehensively review the public health
system in the country with major emphasis on quality of epidemic
surveillance, its role in alerting the health system to respond to the
signs of outbreak of disease and the effectiveness of the district level
administration and the existing Health Management Information
System (HMIS) for mounting timely remedial action vide Order
No.T.21011/13/94-PH dated the Sth March, 1995 with the following
composition1:
1.
Prof. J S Bajaj, Member, Planning Commission.
Chairman
2.
Dr Jai Prakash Muliyil,
Deptt. of Community Medicine,
Christian Medical College, Vellore.
Member
Dr Harcharan Singh, Ex-Adviser (Health), Planning
Commission.
Member
Dr N S Deodhar, Ex-Officer on Special Duty,
MOH&FW, 134/1/20, Baner Road, Aundh, Pune.
Member
3.
4.
5.
Dr K J Nath, Director, All India Institute of Hygiene &
Public Health, Calcutta.
Member
6.
Dr K K Datta, Director, NICD, Delhi.
1.
The Terms of Reference of the committee were as follows:
The Committee will comprehensively review:-
Member-Secretary
a) the public health system in general and the quality of epidemic
surveillance and control strategies in particular;
b) the effectiveness of the existing health schemes, the institutional
arrangements and the role of the States and local authorities in
improving the public health system;
c) the status of the Primary Health infrastructure (sub-centres and
primary health centres) in rural areas, especially their role in
providing intelligence and alerting the system to respond to the signs
1 Ministry of Health & Family Welfare’s order No.21011/13/94-PH dated the Sth March. 1995.
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of outbreaks of disease, and the effectiveness of the district level
administration for timely remedial action; and
d)
the existing Health Management Information System and its
capability to provide up-to-date intelligence for effective
surveillance, prevention and remedial action.
2.
The committee while giving the report would also recommend the
short term and long term measures to prevent recurrence of epidemic
and generally improve the standards of hygiene in the country and
inter alia delineate the financial management to be adopted for
achieving the goals set out in their recommendations.
1.1
The Committee commenced its work on 4th May, 1995 when it had its
first meeting. The meeting started with review of large number of
documents covering recommendations of the Central Council of
Health on related issues from the year 1955 till date, recommendations
of the Central Council of Health pertaining to various National Health
Programmes, existing Heajth Management Information System,
relevant portion of the 8th Plan document, interim report of the
Technical Advisory Committee on Plague, Paper on epidemiological
intelligence system in India and various papers submitted by the
members on related issues. The list of various papers and their authors
is given in Annex-1.
The second and third meetings of the committee were held on '
7th June and 9th August,1995 respectively.
In addition to the
members, senior officials of the Planning Commission and NICD
assisted the committee in its work. Their names are given in the
Annex-IA.
2.0
INTRODUCTION
Historically India had a rich public health system as evidenced
from the relics of the Indus Valley civilisation. The medical and health
practice as detailed in Ayurveda and the surgical skills demonstrated
by Charak and Sushrat bear testimony to rich centuries old heritage of
medical and health care practice in India indicating a holistic approach
towards care of human health and disease2'3. This, deteriorated
through successive invasions through the centuries, intrusion of
alien culture, inappropriate uses of scientific discoveries, industrial
and agricultural revolution, etc. which while contributing to human
D. Banarjee: Social & Cultural foundation of health services system - Economic & Political Weekly.
Vol. 9, No.32-34, 1974, p. 1333.
3 K.N.Rao: “Public Health and Health Services”; Encyclopedia of social work Vol.l, (New Delhi
publication division) p.364 (1968).
22
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development in various spheres, created enormous problems like
large pockets of poverty, slums, over crowding with all its ill effects,
unhygienic sanitary conditions in cities and towns, high sickness and
death rates especially among women and children, continuing high
morbidity due to infectious diseases like malaria, tuberculosis,
industrial health hazards and problems of social pathology which
had an adverse impact over community health.
In the Western world the industrial revolution during 18th19th century that vastly improved the socio-economic conditions of
the people but also contributed immensely to over-crowding in the
cities and towns and creation of slums. With increase in population,
the environment suffered through growing contamination of soil, air
and water resulting in several pandemics of plague, cholera etc.
which ragaved the nations during the period. The State was then
made responsible to institute good health laws and look after the
health of the people in several countries in eighteenth century giving
rise to modern concept and practice of 'Public Health' around 1840.
2.1
Public Health has been defined as the science and art of
preventing disease, prolonging life and promoting health and
efficiency through organised community efforts. Public Health aims
*to achieve healthy environment, control of communicable and noncommunicable diseases, education of the individual in personal
hygiene, organising medical and nursing services for early diagnosis
and prevention and control. It also aims for development of a social
milieu for promotion and maintenance of health thus ensuring
health and longevity as a basic human right. In short public health is
organised application of resources to achieve Health enabling man
to lead a socially and economically productive life.
2.2
In India during the colonial period State sponsored health
services were initiated. During this period health and sanitation
measures primarily were centred around the cantonment and district
headquarters. However, when it was realised that the health of the
working population was closely linked with the productivity of the
nation, some preventive services and basic curative services were
made available through all state hospitals. This laid the foundation
of western medicine in India. While doing so the strong traditional
holistic public health was relegated to the background.
2.3
The modern concept of simultaneous application of
preventive and curative measures to maintain the health of the
individual and of the community was yet to emerge as there was a
lack of recognition of the role that environmental hygiene played in
the preservation of health. The concept that the State is responsible
for the establishment and maintenance of the facilities required for
23
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community health protection on a wider basis laid the foundation of
modern public health practice. Though the industrialised societies
in the West made tremendous progress in that direction the public
health practice in India was mainly centred around medical relief,
the only exception being cantonments and district and State
Headquarters wherein health, sanitation and hygiene measures were
co-ordinated. This trend continued till it was realised that the health
of the people is closely linked with the productivity of the nation
and its capacity to generate revenue.
Some of the important
landmarks in the history of public health system of the country before
Second World War were:
1. Appointment of a Royal Commission to enquire into the health of the
army in India in 1859.
2. Epidemic Diseases Act, 1897.
3. Plague Commission following the outbreak of Plague in 1896/Kalaazar Commission.
4. Reforms introduced by the Government of India Act 1919 and
Government of India Act 1935.
5. Establishment of Institutes like Malaria Institute of India (formerly
Central Malaria Bureau) in 1909, Central Research Institute, Kasauli in
1905 and All India Institute of Hygiene and Public Health, Calcutta
(1928).
6. Madras Public Health Act, 1939.
2.4
The foundation of public health practice in India was laid
through commissions of public health, decentralisation of the health
administration, greater autonomy to the provinces pertaining to the
matters relating to health. The emergence of an organised public
health system in fact dates back to the appointment in 1859 of a special
Royal Commission to enquire into the causes of poor physical
conditions of the Sepoy in the British Indian Army. Local bodies were
responsible for health administration in their respective territories and
as regards expenditure on local health administration/municipalities
were required to set aside 30% and District Boards 12.5% of their
respective annual revenues to spend on public health activities4.
However, allocations were insufficient to meet the demands of
essential public health practices.
4 Report of Health Survey and Development Committee - Sir Joseph Shore, Vol. 1-4, 1946, p.22&34.
24
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2.5
At the time when India achieved independence literacy rate was
low, the economic deprivation rampant, socio-economic and health
status poor as shown by IMR, under five mortality, fertility rate, life
expectancy and sex ratio (shown subsequently). The health care was
predominantly urban hospital based and the primary health care and
outreach services were extremely deficient, both in their quality and
outreach.
2.6
Status of Public Health in India prior to independence4-5
Table showing some of the health indicators during that period
Crude death rate (1937)
IMR
(1937)
Life expectancy at birth
(1921-30)
MMR
(1938)
Fertility rate (1931-41)
Sex ratio
(1941)
22.4
162
26.91 (M)
26.56 (F)
20/1000 Live birth
45
945/1000
JVater Supply:
1939 4.5% of the total population had access to safe water.
Sanitation:
1939 2% of the people had sewerage facility.
Morbidity and mortality from diseases of public health importance
Average Annual Deaths in British India during 1932-1941
Diseases
Average Annual
Deaths
Percentages of Total
Deaths
Cholera______________
Smallpox____________
Plague_______________
Fevers_______________
Dysentery & Diarrhoea
Respiratory Diseases
Other Causes
144,924
69,474
30,932
3,622,869
261, 924
471,802
1,599,490
2.4
1.1
0.5
58.4
4.2
7.6
25.8
Total
6,201,434
100.0
5 Compendium of recommendations of various committees on Health & Development 1943-1975,
CBHI, DGHS, Government of India.
25
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Malaria
Estimated number of cases in a year
100 million
Estimated number of deaths in a year
1 million
Average Annual Dealths due to Malaria
37% of total dealths
Tuberculosis
Estimated number of active cases
2.5 million
Estimated number of deaths in a year
0.5 million
Mortality Rate in cities
200 - 450 per 100,000
Population
It was estimated that 10-20% of deaths with fever and 20% of
deaths with respiratory diseases were due to Pulmonary Tuberculosis.
Personnel4In 1941-42, health personnel population ratio was grossly
unsatisfactory (one doctor for 6,300, one nurse for 43,000 and one
midwife for 60,000, one lady health visitor for 400,000, one pharmacist
for 40,00,000 and one dentist for 300,000). Hospital bed was only 0.24
per thousand population. Number of medical institutions was small
and annual turn out of trained para-professionals like nurses,
midwives, sanitary inspectors was totally inadequate to impart any
vigour to the requisite public health activities.
2.6.1
Health legislations4:
Legal provisions regarding health matters were .scattered over
more than 40 and odd enactment dealing with diverse subjects viz.
Quarantine Act, 1825; Vaccination Act, 1880; Medical Act, 1886; Birth,
Death and Marriage Registration Act, 1896; The Epidemic Diseases Act,
1897; Indian Factory Act, 1911; Indian Lunacy Act 1912; Indian Leper
Act. These legal provisions were made on different occasions to meet
varying requirements under different administrative authorities. It
was always felt that all these Acts should be put together in a
comprehensive model Public Health Act for better administration.
26
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Only Madras province was having comprehensive public health Act
satisfying reasonably the requirement of health administration of those
years.
2.6.2
Nutrition including supervision
maintenance of standard4:
for
food
supply
to
ensure
Bengal famine of 1943 only exemplified and amplified the food
production, its distribution and generally unsatisfactory state of its
availability per capita. Total food production was grossly insufficient
in quantity and cereals and pulses had to be imported to meet the
requirement. Annual production of Pulses 7-9 million tonnes
providing only 3 ozs per capita per day, annual production of sugar 5.3
million tonnes providing only 1.3 ozs per capita per day (1943)6 were
indicative of scarcity of food. Against the dietary requirements of
2100-2400 calories, a typical Indian diet had only 1750 calories and that
too ill balanced, deficient in essential nutrients like proteins, vitamins
and minerals. The provincial governments were responsible for
prevention of food adulteration. However, in respect of the majority of
the local authorities the control exercised was inadequate and
unsatisfactory and the conditions under which food production and
-Sale was occurring often constituted grave menace to the health of the
people.
2.6.3
MCH Services4:
Both MMR and IMR were high. Even in Madras province
where efforts were made to provide maternity services by qualified
midwives, only about 3% of the total births were conducted by them.
In rest of the country the situation was worse.
2.6.4
School Health Services4:
School health services did not exist in most parts of the country.
Even where it existed the quality of services had been very poor and
far from satisfactory. Most of the schools had very low standard of
sanitation, health education about personal hygiene did not have any
impact on the students because facilities for these did not exist even in
the school environment. The report on School Medical Inspection of the
joint committee of the Central Advisory Boards of Health and
Education (1941) concluded school health work in British India barring
a few was carried on in a perfunctory manner.6A
6 Food Grain Policy Committee (1943).
6A School Medical Inspection of the joint Committee of the Central Advisory Boards of Health and
Education (1941).
27
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2.6.5. Industrial health4:
Many industrial establishments were even without dispensaries.
The facilities available with regard to sanitation, light, ventilation,
drinking water supply, urinal, latrines, clothing, housing, nutrition etc.
were far from satisfactory and at times even non-existent. The
prevalence of hook-worm infestation among colliery workers was
68.8% as against 37.1% and 18.6% for the rural areas and towns
respectively. Little information was available regarding incidence of
occupational diseases in India. In England, medical practitioners were
required to notify under section 3 of Factory and Workshop Act, 1938,
certain diseases contracted in the factory or workshop. In India no such
provision existed under the Factory Act. Number of compensations
claimed under Factory Act were so low that they hardly gave any
indication of burden of Industrial diseases.
2.6.6.
Industrial and occupational health hazards were not taken into
account either while planning expansion of industries or in
employment of appropriate work force. Data base on occupational
health problems was not available and several of potentially hazards
situations remained completely unidentified.
2.6.7. Environmental Health4:
Housing, water supply, general sanitation were far from
satisfactory. Over-crowding in urban areas was very common. In
rural areas there has been no planning and control of housing. In
municipal areas though the legal provisions existed for enforcing
desirable standard of housing but these powers were not used
satisfactorily. Only 4.5% population had access to safe water and only
2% had sewerage facility. Industries developed haphazardly in urban
areas. Environmental pollution by industries continued unabated with
utter disregard with its impact not only on the health of workers but
also on the living conditions of the population/habitats around such
establishments.
The health conditions of the people and the state of health
services became an issue of national movement. The Indian National
Congress in 1930 set-up the National Planning Committee (NPC)
under the Chairmanship of Shri Jawahar Lal Nehru. The sub
committee on National Health of the NPC was formed to assess the
health situation and services of the country under the Chairmanship of
Col. Santok Singh Sokhey. It submitted an interim report in 1940 and
its final report in 19487. National Planning Committee adopted a
7 National Planning Committee, Sub-committe on National Health(Sokhey Committee) report.
Bombay; Vora, 1948.
28
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resolution on August 31, 1940, based on the interim report urging the
integration of preventive and curative functions in a single state
agency and responsibility of the State in the maintenance of the health
of the people.8
2.7.
Immediate Post Second World War period:
2.7.1
Bhore Committee4:
Immediately prior to independence of India a committee
headed by Sir Joseph Bhore made significant contribution in laying
down the public health policy relevant to the then existing health
priorities & requirements. Their recommendations flowed from the
concept that expenditure of money and effort on improving nation's
health is a gilt-edged investment which will yield not only deferred
dividends to be collected years later but would also ensure immediate
and steady returns in terms of substantially increased capacity for
growth and productivity thus contributing to the national economy
and human development. The committee recommended establishment
of a well structured and comprehensive health service with a sound
primary health care infrastructure. The thrust areas included housing,
-environmental sanitation, safe drinking water supply, waste disposal,
communicable diseases control, maternal and child care, nutrition,
health education to facilitate community participation and optimal and
effective use of available facilities and resources was also
recommended.
Bhore Committee report pinpointed attention to the lack of safe
water supply and sanitation measures on country wide basis. The
Madras Government followed-up by appointing a committee in 1947 to
examine and report on the question of safe water supply and drainage
in the urban and rural areas of the entire state and the committee came
out with very far reaching recommendations with regard to
organisation, finance and priorities.
The Bhore Committee report also observed that overwhelming
majority of the people of India at that time had been receiving medical
care only from indigenous practitioners of Ayurveda and Unani
systems etc. and in fact indigenous medicine played ah important role
in the life of the Indian people and, therefore, the practitioners of
Indian systems of medicine should be involved in development of
basic health services.
8 Health Status of the Indian People- The foundation for Research in Community Health, December,
1987, p.4.
29
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2.8
Post independence period:
2.8.1. Health Infrastructure
After independence the Government of India implemented the
recommendations of the Bhore Committee with the resources that were
available and continued to develop its public health system through
establishment of large network of primary health care infrastructure
covering the entire country. Simultaneously soon after independence.
Ministry of Health,
Government of India constituted the
Environmental Hygiene Committee9 for an overall assessment of the
country-wide problem in the entire field of environmental hygiene.
The committee recommended specifically a comprehensive plan to
provide water supply and sanitation facilities for 90% of the population
within a period of next 40 years incorporating initiation of some
priority schemes in selected areas. In 1953 Central Public Health
Engineering Organisation (CPHEO) was established within the
Ministry of Health and in 1954 Union Health Ministry announced the
National Water Supply and Sanitation Programme as a part of health
schemes under the 1st five year plan and made specific provisions to
assist the States in its implementation - both in rural and in urban
*areas9’A.
2.8.2
In 1960, Ministry of Health, Government of India constituted a
National Water Supply and Sanitation Committee (Simon Committee)
to make a critical review of the progress made and assess the future
requirements in the field of water supply and sanitation both in rural
and urban areas. The committee made a critical review, assessed the
problem and suggested effective measures with special reference to
Government organisations, tax structure and finance, legislation,
training facilities and related matter.
2.9
Model Public Health Act 195510:
A Model Public Health Act was prepared by the Ministry of
Health. The same was circulated to all the States for its adoption with
requisite modifications, if necessary. The Model Public Health Act was
prepared to act as a guide for framing the public health acts by the
States, municipal corporations and municipalities and-to serve as a
source reference for public health practitioners. The Act had wide
ranging provisions covering the entire gamut of public health activities
viz. water supply, drainage, sanitation facilities, buildings, food
sanitation, control of offensive trade, prevention and control of
9 Report of the Environmental Hygiene Committee (B.C. Gupta), Oct. 1949, Govt, of India, Ministry of
Health.
9‘A First Five Year Plan. Planning Commission (1951-56).
10 Model Public Health Act, 1955 prepared by the committee headed by Dr. B.C. Dasgupta.
30
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communicable diseases including vector borne diseases, control of
insects, sanitary and health regulations during fairs and festivals and
special provisions for lodging houses, health resorts, health camps,
parks, play grounds and green spaces, slaughter houses, markets, etc.
The same was modified and circulated to all the States in 198711 .
However, the same has not been appropriately followed up with
various local health authorities and, therefore, each and every local
health authority has its own public health laws. Major deficiencies in
this regard are: though the provisions exist under the municipal/local
area Act, hardly the same are implemented and penalty imposed for
defaulter to make the public health system more effective: Thus public
health system has not been able to develop and respond to the desired
extent.
2.9.1
During the subsequent decades a vast network of primary
health care institutions has been developed covering the entire country
and the entire planning process through the five years plan was an
effort to strengthen the public health practice through launching of
national control/eradication programme of major communicable
diseases, integration of the Indian systems of medicine, population
control, launching of sanitation and drinking water supply programme
.through mission approach, ICDS programme, multipurpose health
workers scheme, scheme of community health guides etc. Large
number of committees were subsequently established to periodically
review various components of public health system like Mudaliar
Chaddha
Committee,1962;
School
Health
Committee,! 961;
Madhok
Committee,1965;
Mukherjee
Committee,1963;
Singh
Committee,!967;
Kartar
Jungalwalla
Committee,!967;
Committee,!973; Shrivastava Committee,1975; Bajaj Committee,!987;
etc. during the subsequent period. All primarily recommended
strengthening of public health system through primary health care
approach strengthening its various components be it infrastructure, be
it manpower, be it training, be it medical education, etc. The Mudaliar
Committee in particular stated in unequivocal terms that no change in
constitutional provisions with regard to health being a State subject
was necessary.11A
The Mudaliar Committee observed in terms of mortality and
morbidity in respect of diseases of public health importance as under:
11 Model Public Health Act, Central Bureau of Health Intelligence, Directorate General of Health
Services, Ministry of Health and family Welfare,Government of India, 1987.
11A Health Survey & Planning Committee (Mudaliar), 1961.
31
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Morbidity rates per 100,000 population
1.
2.
3.
4.
5.
6.
7.
8.
9.
2.9.2
Smallpox
Snake bite
Tetanus
Throat diseases
Tuberculosis
Typhoid and para typhoid
Venereal diseases
Ill-defined causes
Unknown causes
99
99
66
132
66
2119
99
199
166
Central Council of Health and Central Council of Family
Welfare the two erstwhile highest policy making bodies for health and
family welfare activities (now integrated into one) have time and again
recommended strengthening of public health system by providing
effective support for the control of diseases, strengthening of
epidemiological surveillance, making determined efforts to ensure
people's co-operation in the implementation of the programme
involving Panchayat, youth organisations, women organisations,
^indigenous medical practitioners, institution of integrated health
information system, enforcement of suitable legislation measures for
reporting common epidemic diseases and expeditious provision of safe
drinking water supply, drainage and sanitation in the urban and rural
areas. Specific recommendations from the Central Council of Health
for different related areas are in Annex-2.
2.9.3
In 1973 major development took place transferring subjects of
water supply and sanitation from the Ministry of Health to Ministry of
Works and Housing and local self government and in the area of water
supply and sanitation several important developments took place
during the subsequent years. Some of the important ones were: The
Water (Prevention and Control of Pollution) Act 1974 which was
amended further in 1988; establishment of Ministry of Environment
and Forests; the Air (Prevention and Control of Pollution) Act 1981
which was further amended in 1987; establishment of Central and State
Pollution Control Boards; initiation of international drinking water
supply and sanitation decade in 1981; the Environment Protection Act
1986; initiation of the Rajiv Gandhi National Drinking Water Mission in
1986.
2.9.4
Launching a centrally sponsored rural sanitation programme by
the Department of Rural Development (presently under the newly
organised and re-designated Ministry of Rural Areas & Employment)
in 1986 and the centrally sponsored low cost sanitation programme in
1991 by conversion of dry latrines and rehabilitation of scavengers by
32
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•
the Sth five year plan (1992-97) by the Ministry of Urban Development
re-designated as Ministry of Urban Affairs and Employment
(MOUA&E) indicate the concern of Government of India and the State
Governments for tackling the problems of sanitation in rural and
urban areas.
2.9.5
The National Seminar on Rural Sanitation (16-17 September,
1992) organised by the Ministry of Rural Development, Government
of India (MORA&E) and providing a forum for new directions in
hygiene and sanitary problems alongwith the report of the expert
committee on rural sanitation programme 1994 reflect the continuing
concern of Government of India for promotion of sanitation.
Similarly the National Conference on Urban Water Supply and
Sanitation Policy (11-13 March, 1993), urban basic services for the
poor by the Ministry of Urban Development (presently Ministry of
Urban Affairs & Employment) indicate a similar concern for
promotion of sanitation in urban areas11'8.
2.9.6
In spite of these efforts, recurrent episodes of outbreaks from
sanitation linked diseases indicate inadequacy of efforts in this
direction. The low level of urban, peri-urban, rural sanitation is a
.matter of deep concern.
2.10
National Health Policy12:
National Health Policy which came into existence in December,
1983, provided directives to strengthen public health system for
achieving Health for All by 2000 AD
through the universal
comprehensive provision of health care services. It clearly stated that
considering the large variety of inputs into the health, it is necessary to
secure the complete integration of all plans for health and human
development with the overall national socio-economic development
process especially in the more closely health related sectors viz. drugs
and pharmaceuticals, agriculture and food production, rural
development, education and social welfare, housing, water supply and
sanitation, prevention of food adulteration, maintenance of prescribed
standards in the manufacture and sale of drugs and the conservation of
environment. It further stated that the comprehensive primary health
care services should be relevant to the actual needs and priorities of the
community at a cost which the people can afford and implementation
should involve participation of the community adequately utilising the
services available in the NGO sector.
"’B Report of the National Mission on Environmental Health and Sanitation, Department of Health.
Govt, of India. (1995).
12 National Health Policy, Ministry of Health and Family Welfare.Govemment of India, 1983.
33
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2.11
Inadequate Human Resource Development:
For development of any system the man behind the system is
very important. Health professionals constitute an essential input for
the development of the public health system in the country. In this
context, inter-linkages between the health and education policies are
very important. The National Policy on Education in 198613 stated that
health planning and health service management are optimally
interlocked with the education and training of appropriate categories
of health manpower through health related vocational courses. Health
education at the primary and middle levels will ensure commitment of
the individual to family and community health and lead to health
related vocational courses at the Plus 2 stage of higher secondary
education. Graduates of vocational courses will be given opportunities
under pre-determined conditions for professional growth, career
improvement and lateral entry into courses of general technical and
professional education through appropriate bridge courses. National
Health Policy also stated that the public health education programme
should be supplemented by health, nutrition and population education
programmes in all educational institutions at various levels.
Simultaneously efforts would require to be made to promote universal
.education especially adult and family education without which the
various efforts to organise preventive and promotive health activities,
family planning and improved maternal and child health can not bear
fruit.
2.11.1
The National Health Policy as passed by the Parliament assigns
to the Indian System of Medicine and Homeopathy an important role
in the delivery of Primary Health Care and envisages its integration
with modern system of medicine. Bajaj Committee (1987)14
recommended also that within the health care system these ISM
practitioners can strengthen the components of (i) health education (ii)
drug distribution for national control programme (iii) motivation for
family welfare (iv) motivation for immunisation, control of
environment etc.
2.11.2
The growth and development of health services and manpower
over the Five Year Plan period reveals that (a) health services and
health manpower have been developing in isolated- manner and
without any proper linkage in temporal and spatial dimensions, (b) the
process of health manpower development has not been as rational as it
should have been, due probably to less concern for appropriate
manpower as compared to concern for physical, technical and
13 National Policy on Education, 1986.
14 Health Manpower Planning, Production and Management: Report of expert committee (Bajaj
Committee), Ministry of Health and Family Welfare,Govt, of India, 1987, Page 16
34
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technological facilities, (c) there has not been a proper balancing
between planning, production and management dimensions of
health manpower development process and (d) there has been far
less a concern, almost amounting to negligence, for the planning and
production of allied health professionals, as compared to that for
medical manpower. Indeed, the primary reason for this being the
medical bias in the entire process of health system planning and
health manpower development.
2.11.3 Though a vast network of health infrastructure has been developed,
and 146 medical colleges have been established we are still far away
from total requirement of manpower taking into consideration the vast
population of our country. Due to paucity of resources and paucity of
adequate number of trained personnel many of the sub centres are
without male multipurpose health workers. Population nurses ratio,
the doctor para-medical professional ratio are still far from satisfactory.
Even in spite of availability of large number of practitioners under the
Indian System of Medicine, they have not been appropriately
dovetailed within the health care delivery system.
2.12
Constitutional obligations for Public Health and Sanitation:
Public Health and Sanitation is a State subject as given in the
Seventh Schedule, Article 246, list II-6 of the Indian Constitution. At
the National Level, the Department of Health of the Ministry of
Health and Family Welfare, Government of India is the nodal agency
for public health.
2.12.1
The 73rd and 74th Constitutional Amendments Act, 1992
provide for involvement of Panchayati Raj Institutions and Nagar
Palikas in all developmental Programmes including Public Health
and Sanitation, in rural and in urban area in the Country.
The 73rd Constitutional Amendment Act 1992 provides for
involvement of Panchayati Raj institutions in all developmental
programme in rural areas. With regard to public health it covers
rural housing, drinking water, roads & culverts, non-conventional
energy sources, markets & fairs, health & sanitation including
hospitals, primary health centres and dispensaries.
The 74th Constitutional Amendment Act 1992 provides for
involvement of municipalities/Nagar Palikas in all developmental
programmes in urban areas. With regard to public health it covers
water supply for domestic, industrial & commercial purposes, public
health, sanitation, conservancy and solid waste management, slum
improvement and upgradation, burials & burial grounds, cremations.
35
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cremation grounds and electric crematoriums, regulation of slaughter
houses & tanneries.
2.13
Demographic scenario:
One of the most crucial problems facing the public health
system is the high growth rate of Indian population. In 1991, India's
population was 846.3 million and by the turn of the century the figures
are expected to cross over one billion. The problem has been further
compounded by higher male ratio (1000:929) which is indicative of
lower status of women in the society and its resultant implications on
human development particularly the child population. Below 15 years
population (39.6%) is indicative of high dependency on adult
population. This higher growth of the Indian population basically is
the result of steep decline of mortality and much slower decline of
fertility. The national family welfare programme which is more than
four decades old has not given the desired results in controlling
growth of population. Future National Population Policy must aim to
lay emphasis on programmes and activities directed towards the
ensuring survival and sound development of children which means
emphasis on the need of a co-ordinated and convergent programme of
•action at the peripheral point covering the entire area of health care
activities including nutrition, immunisation. Acute Respiratory
Infection control, diarrhoeal diseases control, water supply and
sanitation, education, etc.
2.14
Current State of Health:
IMR
73: Rural 82 and Urban 45 (1994)15
Age-specific death rate 0-4 yrs 33.3 (1988). 16
MMR
3.77 in rural area. (1990)16
4.37 in India (1992-93)16A
Water supply
Urban
Rural
84.9% (November, 1993)16B
79.2% (1993)16B
Sanitation
Urban
Rural
47.9% (1993)16B
14% (1994)11B
15 Sample Registration System (SRS), Registrar General of India (1994).
16 Bulletin on Rural Health Statistics in India for the quarter ending March 1995- Rural Health
Division, Directorate General of Health Services, Ministry of Health and Family Welfare,Government
of India, New Delhi.
,6A National Family Health Survey (1992-93), International Institute of Population Sciences, Bombay.
16B Economic Survey, 1994-95, Government of India.
36
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Crude death rate
9.2
(1994)16B
Expectation of life at birth M = 60.4 (1992-93)16B
F = 61.2 (1992-93)16B
Health Personnel17
46 Doctors for 100 thousand population
22
I
37 Nurses for 100 thousand population
40 ANM/Midwives for 100 thousand population
» k.
Number as on 31.12.92168 Doctors = 410825
Nurses = 385410
Dentists = 11300
2.15
Availability of Food:
India has made significant improvement in food grain
production, registering an increase from 50 million tonnes in 1950 to
152.37 million tonnes in 1983-84 and to about 188 million tonnes in
1994-95. The Per capita availability of food grains in 1951 was only
394.9 gm per day as compared to 474.2 gm per day in 1994. Though the
. per capita net availability of food production has gone up in respect of
cereals but has declined in respect of pulses from 60.7 gm in 1951 to
37.8 gm in 1994. Overall figures for food production provide a rather
misleading picture of the actual situation as they tend to mask certain
striking regional imbalances. The phenomenal success of the Green
Revolution in Punjab and Haryana is not seen in other States. Besides,
in other States food production is not satisfactory because of the
substitution of food crops with cash crops meant primarily for exports.
2.16
Uneven Socio-economic development18:
In spite of significant development and impressive growth in
the infrastructure and personnel for health care, the enormity and
complexity of problems remain a continuing challenge. The impressive
gains include a significant decline in mortality and a continuing
increase in life expectancy. However, within the country wide
differences exist in the health status of States like Bihar, Uttar
Pradesh, Orissa, Madhya Pradesh, Rajasthan to that of Kerala,
Maharashtra and Punjab. Health is intricately linked with social,
economic and political systems. Kerala though not economically as
advanced like Maharashtra and Punjab but has achieved much more
in terms of health status due to a variety of factors like literacy, status
17 Health Graphics of India, 1993- Central Bureau of Health Intelligence, Directorate general of Health
Services, Ministry of Health and Family Welfare.Government of India, New Delhi.
18 State of India’s Health-Voluntary Health Association of India. 1992.
37
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O
v>
of women etc. In several states, districts similarly did not perform
uniformly. Some did very well and some dismally poor.
Some of the other factors which might also have contributed in
the states for low performances are:
•
Often higher allocations are made on high cost technology oriented
health interventions of low cost effectiveness in tertiary health care
set up in urban areas. At the same time critical and cost effective
interventions in rural areas remain under-funded.
•
Procurement of brand name pharmaceuticals instead of generic
drugs often leads to higher expenditure thus denying essential
drugs to many.
•
Non-availability of personnel, diagnostic support services, drugs
etc. improper locations & poor maintenance of the facilities, poor
supervision of staff often contribute to under-utilisation of the
facility.
•
Growing number of urban slums with rudimentary or non-existent
health care facilities.
However, the Sth plan18-A has laid adequate emphasis on
consolidation of primary health care services in rural areas,
strengthening of secondary care services and optimisation of tertiary
care services.
2.17
Poor quality of Disease Surveillance:
Though the disease burden with particular reference to
malaria, kala-azar, plague, yaws and the vaccine preventable diseases
like measles, poliomyelitis, tetanus, diphtheria etc. has been reduced
tremendously and smallpox eradicated, yet resurgence of some
diseases like malaria, kala-azar, plague are indicative of poor
epidemic intelligence in the country. If the surveillance mechanism
would have been appropriate this could have been avoided to a large
extent. Malaria surveillance though supposed to be active in nature
and functioning, but largely the information is presently collected
through passive surveillance because of non functioning/poor
functioning of the active surveillance mechanism.
Diagnostic
support services for Kala-azar, Plague for making the surveillance
machinery more appropriate for early intervention also are not
adequate and in addition there have been emerging problems like
appearance of newer strains of cholera, spread of dengue
18 A Sth Five Year Plan, Planning Commission (1992-97).
38
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haemorrhagic fever, spread of Japanese Encephalitis, outbreak of
meningitis and viral hepatitis etc. For these the surveillance
machinery needs to be reoriented and updated and further
decentralised so that appropriate and timely intervention can be
made to prevent large scale morbidity and mortality.
2.18
Lack of flexibility in Disease Control Strategy:
2.18.1
Though health is a state subject, the State Governments are
not given adequate flexibility to modify the programme depending
upon the needs of the disease control. Too much dependence on
centralised disease control strategy gradually eroded the provincial
regional or peripheral initiative in adopting situation specific disease
control mechanism for a given situation.
2.18.2
Most of the disease control/eradication strategies the country
followed though appear to be in right direction at the time of the
initiation of the programme but it did not have the element of
continuing programme development dovetailing the newer
technologies and interventions available and as a result many of the
newer technologies/intervention methodologies were in fact
implemented much later in the evolution of the programme leading
’to longer time frame in achieving the control/eradication.
2.18.3
With regard to important national programme of control
Tuberculosis, the problem continues to remain almost at the same
level as it used to be excepting perhaps mortality from Tuberculosis
has come down which is primarily due to use of modern
chemotherapeutic drugs.
The disease control strategy for
Tuberculosis lacked appropriate directives. Thrust area in diagnosis
for Tuberculosis till recently remained on radiological findings.
Review of radiological findings have indicated that quite often errors
creep in diagnosis leading to use of unnecessary drugs.
Professionals do not give much emphasis on sputum diagnosis
leading to many a sputum positive cases being given conventional
anti-Tuberculosis drugs which lead to continuing morbidity and
transmission of the disease. However, in recent times emphasis is on
detection of sputum positive cases through improved sputum
microscopy. The recommendations of Central Council of Health &
Family Welfare meeting in 1993 provided a clear directive in that
area. Accordingly the National TB Control Programme strategy is
being revised for implementation with World Bank assistance.
2.19
Lack of Institutional Support:
The country has been implementing several health schemes.
Most of the schemes, in fact, all have been well prepared keeping in
view the country's socio-economic and political set up. However,
39
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while implementing these health schemes, the institutional back up
support to the schemes are not often well laid out. In India,
fortunately a large number of institutions either under the health
sector or in welfare or human resource development sector have
been established. However, it is observed that the institutional
support mechanism to the health programmes are not often
appropriately worked out. If the operational manuals of the existing
national health programmes are critically examined, it will be
observed that the appropriate institutional support component to the
programmes is one of the weakest links. 146 medical colleges, a
large number of national research and referral institutions are
available. A large number of institutions under the NGO sector are
also functional. If the expertise available within these institutes are
appropriately harnessed and the programme operational details are
worked out giving due recognition and responsibilities to these
institutions, much more could be achieved in terms of reduction of
disease morbidity and mortality within the available resources.
Though these institutes may have wide variation in their mandates
but appreciable convergence could be achieved through well
structured operational guidelines linking them by appropriate
networking mechanism.
One area of major concern is that though large number of
medical colleges have come into existence, there is hardly any
additional public health schools established. Even though the
approach paper for 7th Plan clearly stated to establish six more
schools of public health, nothing much has been done. In fact the
only composite school of public health (All India Institute of
Hygiene and Public Health, Calcutta) needs substantial input and
strengthening. Similarly the institutes like NICD (National Institute
of Communicable Diseases), NIH&FW (National Institute of Health
& Family Welfare) working in specialised areas of public health and
the departments of Preventive & Social Medicine in medical colleges
need substantial strengthening.
Training facilities for epidemiology and health management,
the two disciplines which contribute to a great extent to efficient
functioning of health services including that of hospitals are
required to be augmented in medical colleges and created in
specialised institutions where training of teachers can be undertaken.
2.20
Too much centralisation of administrative machinery:
The administrative machinery both at the centre and States is highly
centralised. Poor administrative and financial authority at the
peripheral levels often contribute to inadequate or delayed
responses. Therefore, the administrative authorities both at the
Centre and the State need to be decentralised. Once Panchayati Raj
40
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system becomes fully operational, this will have local authorities
more involved in understanding their problems so that they can
participate better in the health care delivery services.
2.21
Poor Laboratory Support Services:
Though a vast network of primary health infrastructure is
available but because of poor public health laboratory support
services except that for malaria and tuberculosis, primary health care
infrastructure can not respond appropriately in identifying cluster of
cases in time and space through laboratory diagnosis. Even the
laboratory support services for malaria and tuberculosis are far from
satisfactory. If for some diseases like measles when laboratory
confirmation may not be very essential the mechanism of obtaining
information from the field and its upward flow does not give an
effective clue in identifying clustering of cases in time and space and
thus only when the situation assumes proportion of concern in terms
of morbidity and mortality health authorities come to know about it
through the mass media. The laboratory support services even at the
district level are not adequate. The laboratory support services at the
district level are inadequate as most often it covers only clinico
jjathological services for diagnostic purposes. Only rudimentary
microbiological support services are available.
2.22
Poor implementation of HMIS:
The existing Health Management Information System
(HMIS)19 has been under implementation recently. Only in two
states viz. Haryana and Sikkim it is fully operational. Data from
these two states also have not helped the authorities in effective
surveillance, prevention and remedial action because the programme
is not appropriately implemented.
Establishment of appropriate epidemiological analytic
capability at the peripheral health care delivery level is the key for
proper and effective response for a given health situation and
therefore, if the same is achieved it will strengthen the health system.
2.23
NGOs:
We have got large number of health institutions under the
NGO sector. Not only they provide service of very committed nature
but also many of them have updated expertise in disease
management, diagnosis and its prevention & control. There is a need
to harness the expertise available with these institutions under the
19 Health Management Information System (Version 2.0) CBHI, Dte. General of Health Services,
Planning Commission, Nationa Informatics Centre - 1990.
41
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NGO sector so that health care delivery services can improve further
to meet the needs of the people. NGOs also provide models for
alternatives in health care delivery system. The same could be
appropriately dovetailed wherever applicable and feasible.
2.24
Inadequate IEC support:
Health education has always been considered as one of the
very important components of health care delivery system.
However, this component does not receive priority attention to make
this tool more responsive to the needs of the people at large. A large
chunk of our population is still illiterate. Therefore, appropriate IEC
input will be necessary to make the people aware of their health
needs so that they can participate better in health care delivery
services. Organised community effort is a key component in public
health system. The same needs appropriate attention.
2.25
Lack of multi-sectoral approach:
Health can not be delivered in isolation. It is part of overall
human development. Therefore, health services need to be a part of
total package of other developmental activities. A co-ordinated
’approach involving different sectors is necessary. This is particularly
so in sanitation and environmental health activities where other
sectors like Ministry of Urban Development, Ministry of Rural
Development, Ministry of Environment etc. are involved. At present
this area is rather weak and almost non-existent.
2.26
Lack of resources:
Resources available in the health care sector has been far from
satisfactory because of many other priorities of a developing nation.
Only in recent times there is a growing realisation that health is an
asset and it significantly contributes to the economic development of
the country. It also is an area of good investment which will provide
a substantial cost effective returns. The financial institutions like
World Bank etc. are coming forward to invest in the health sector
resulting in availability of more resources.
42
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CURRENT STATUS OF
PUBLIC HEALTH SYSTEM IN INDIA
3.0
CURRENT STATUS OF PUBLIC HEALTH SYSTEM IN INDIA:
3.1
History
India is a large country consisting of 25 States and 7 Union
Territories. Under the Constitution, health is a State subject and each
State has its health care delivery system. By and large the health care
delivery systems in India in different provinces have primarily
developed as per the recommendations of the Bhore Committee4 which
recommended delivery of comprehensive health care through the
infrastructure of primary health centres and sub-centres. The Federal
government's responsibility consists of policy making, planning,
guiding, assisting, evaluating and co-ordinating the work of the
various provincial health authorities. The first important land mark of
modern public health system in the country was the appointment of a
Royal Commission to enquire into health of the Army in India in 1859.
On the basis of the recommendations. Commissions of public health
were established in Madras, Bombay and Bengal in 1864. However,
the recommendations of the Royal Commission for employment of
public health staff in towns and districts were not fully carried out and
no comprehensive policy in regard to development of preventive
.health services was laid down. The Plague Commission in 190419A
recommended strengthening of the public health services and the
establishment of laboratories for research and for the preparation of
vaccines and sera.
The action taken to implement those
recommendations included (i) the creation of a medical research
department under the Central Government, (ii) establishment of the
Indian Research Fund Association for promoting research into medical
problems (iii) provision of grants to the provinces to assist in the
execution of public health work such as drainage and water supply
and (iv) strengthening of public health personnel by additions to the
existing post of Deputy Sanitary Commissioners under the provincial
governments and to health officers under the local bodies. However,
the total effect of such measures was very small. The Government of
India Act 1919 gave statutory sanction to the transfer of functions from
the Centre to the provinces namely medical administration including
hospitals, dispensaries and asylums and provision for medical
education, public health and sanitation and vital statistics etc. which
would be the responsibility of the State. The reforms introduced by
Government of India Act 1935 provided further autonomy to the
provinces in the matters of functioning of health. Health function at
the central level was through a composite Department of Education,
Health and Lands before 1945 when a separate health department was
created in September 1945 though the Minister continued to take care
of health in addition to education and lands affairs. The Bhore
l9A Plague Commission, 1904
43
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Committee recommended that the portfolio of health should be with a
Minister who can devote undivided attention to the health alone and
the same is in practice now.
3.1.2
In the Department of Health on the technical side, two advisers
i.e. one Director General of Indian Medical Services and one Public
Health Commissioner existed. The Director General of Indian Medical
Services was to advise on medical matters and the Public Health
Commissioner on public health matters.
The Shore Committee
recommended that these posts be merged into one to bring integration
in medical and health care services which was subsequently
implemented. The public health system in India has three tiers.
Federal, State and District.
3.2
Federal set-up:
The official organs of the public health system at the national
level consist primarily of Ministry of Health & Family Welfare, the
Directorate General of Health Services with a network of supporting
sub-ordinate offices and attached institutions providing health care
services and the Central Councils of Health and Family Welfare. In
addition to the above, other Ministries namely Ministry of Rural Areas
and Employment (MORA&E) and Ministry of Urban Affairs and
Employment (MOUA&E), Ministry of Environment and Forests
(MOE&F), Ministry of Welfare (MOW), Agriculture, Industry, Human
Resources Development, Ministry of Information & Broadcasting,
Department of Electronics, Ministry of Labour, Ministry of Chemicals
& Furtilizers, Ministry of Home Affairs, Registrar General of Vital
Statistics and Census Commissioner, National Sample Survey
Organisation and Ministry of Science & Technology also undertake
directly or indirectly activities pertaining to public health viz. water
supply, sanitation, environment protection and human resource
development etc. The Planning Commission and Ministry of Planning
and plan implementation provide over arching mechanisms for policy
planning, co-ordination and implementation. In this report, the areas
falling primarily under the Ministry of Health & Family Welfare have
been discussed.
3.3
Union Ministry of Health & Family Welfare:
The Union Ministry of Health & Family Welfare is generally
headed by a Cabinet Minister who is assisted by a Minister of State.
These are political appointments. In addition to the above. Planning
Commission chaired by the Prime Minister has a Member (Health) of
the rank of a Minister of State.
44
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The Union Ministry of Health & Family Welfare has three
departments. The Department of Health, Department of Family
Welfare and the newly created Department of Indian Systems of
Medicine.
Department of Health:20
3.4
The Department of Health is headed by the Secretary to the
Government of India who is assisted by two Additional Secretaries,
three Joint Secretaries and several Directors/Deputy Secretaries, and
other administrative staff. In addition, a Joint Secretary (FA) caters to
all the three departments viz. Department of Health, Department of
Family Welfare and Department of Indian Systems of Medicines. The
organogram is in Annex-3.
Department of Family Welfare:20
3.5
The Department of Family Welfare, was created in 1966 and is
headed by a Union Secretary who is assisted by three Joint Secretaries,
several Directors/Deputy Secretaries and a large number of
supporting staff. The Department of Family Welfare also has three
Deputy Commissioners holding similar positions of a Joint Secretary
*and are from the technical side. These Deputy Commissioners are also
assisted by several Assistant Commissioners and other technical and
administrative staff. Recently on 30th August, 95, the Ministry has
issued orders stating that the work of the Department of Family
Welfare will be also through Director General of Health Services.
Organogram is in the Annex-4.
Department of Indian System of Medicine and Homoeopathy 20
3.6
The National Health Policy of 1983 envisages the necessity to
initiate organised measures to enable each of the Indian Systems of
Medicine including Ayurveda, Siddha, Unani, as well as Homeopathy
to develop in accordance with its genius.
3.6.1
20
In view of the above thrust has been laid on ISM during the
Eighth Plan and recently the Government of India has created a
separate department of
Indian Systems of Medicine and
Homoeopathy within Ministry of Health and Family Welfare with a
view to develop and promote ISM&H. In addition to the Secretary one
Joint Secretary and several technical advisers/Dy. Advisers etc.,
covering various fields of Indian systems of medicine namely.
Homeopathy, Ayurvedic and Unani, etc., constitute the department.
The organogram is given in Annex 5.
Annual Report 1994-95, Ministry of Health and Family Welfare, Government of India.
45
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3.6.2
India currently has a large resource of 4.05 lakhs practitioners of
ISM and 1.56 lakhs practitioners of homeopathy who provide the
medical/curative services. Most of them is for the primary health care
level treatment of ailments. Beyond that their contribution to public
health system is negligible. There are about 236 ISM&H colleges
producing about 10,927 graduate/diploma holders every year20. Their
services have to be fully utilised for health care delivery system in the
country.
3.7
Functions:
The functions of the Union Ministry of Health & Family Welfare
are to carry out activities to fulfil the obligations set out in the 7th
schedule of the article 246 of the Constitution of India21 under (a)
Union List, (b) Concurrent List and (c) State List.
3.7.1
Union List:
Some of the functions given in the Union List are:
1. International health relations and administration of Port Quarantine.
2. Administration of institutes for scientific and technical education
financed by the Government of India only or in part or declared by the
parliament as institutes of national importance viz.. AIIMS (All India
Institute of Medical Sciences), New Delhi; PGI (Postgraduate Institute),
Chandigarh; ICMR (Indian Council of Medical Research), New Delhi;
All India Institute of Hygiene and Public Health, Calcutta; National
Institute of Communicable Diseases, Delhi; National Tuberculosis
Institute, Bangalore; Central Leprosy Training and Research Institute,
Chingleput and a large number of support organisations including
Central Government Health Scheme. All India Institute of Medical
Sciences, New Delhi, National Institute of Communicable Diseases,
Delhi, PGI, Chandigarh and JIPMER (Jawahar Lal Institute of
Postgraduate Medical Education and Research), Pondicherry are
medical institutes essentially for tertiary medical care.
3. Co-ordination with States and other ministries for promotion of health.
Functions listed under the union list are the responsibility of the
federal government.
21
Constitution of India, 1991, Government of India.
46
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3.7.2
Concurrent List:
Functions listed under concurrent list are the responsibility of
both the Union and the State Governments. Either the Central
Government or the State Government or both have powers of
legislation in matter related to the affairs under the concurrent list.
Some of the important functions under the concurrent list are:
1. Regulation and Development of medical, pharmacy, dental and
nursing provision through their respective councils.
2. Establishment and maintenance of drugs standards.
3. Spread of communicable diseases from one State to another State i.e.
Prevention of the extension from one State to another of infections or
contagious diseases or pests affecting men, animals or plants.
4. Vital statistics including registration of births and deaths.
5. Ports other than those declared major ports.
6. Adulteration of food stuffs and other goods.
7. Population control and family planning.
8. Lunacy and mental deficiency.
9. Items like population control, family planning, medical education,
adulteration of food stuffs and other goods, drugs and poisons,
medical profession, vital statistics including registration of births and
deaths, lunacy and mental deficiency are in the concurrent list.
3.7.2.1
State List
1. Public Health and sanitation; hospitals and dispensaries.
2. Pilgrimages, other than pilgrimages to places outside India.
3. Burials and burial grounds; cremations and cremation grounds.
4. Preservation, protection and improvement of stock and prevention of
animal diseases; veterinary training and practice.
5. Water, that is to say, water supplies, irrigation and canals, drainage
and embankments, water storage and water power subject to the
provisions of entry 56 of List I.
47
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6. Markets and fairs.
As per the scheme of allocation of subjects in the constitution,
the items public health, sanitation, hospital and dispensaries fall in the
State list.
3.7.2.2
Ministry of Health and Family Welfare at the Centre20 is
responsible for co-ordination of a large number of programmes of
national importance like family welfare, primary health care,
prevention, control and eradication of major diseases, etc. The
Ministry has several centrally sponsored schemes which are
implemented through the States. There are also central-sector schemes
which are implemented by the States. However, funding is totally from
Government of India for these Central Sector Schemes. All the schemes
aim at fulfilling national health priorities as identified from time to
time and also enunciated in the National Health Policy Statement.
In addition to the Directorate General of Health Services with its
97 subordinate offices, the ministry is also administratively concerned
with 29 statutory/autonomous bodies. There are also three public
-sector undertakings under the administrative control of the ministry20.
3.7.2.3
3.8
Department of Health:
The Department of Health deals with medical and public health
matter including drug control, prevention of food adulteration and
receives technical advice through DGHS on all medical and public
health matter and monitors various health schemes.
3.8.1
The public expenditure on health sector, both in centre and State
put together has been little over 1.5% of the GDP. The NDC Committee
on population constituted by the Prime Minister have recommended a
gradual increase in financial outlay for family welfare to about 3% of
the public sector plan out lay. This, is combination with increased
outlay for health, would aim at public health expenditure of at least 5%
of GDP22 . The annual plan outlay for 1995-96 for central health sector
is Rs.670 crore. The plan investment in health is givdn in the table
below:-
22 Report of the Committee on the National Development Council on Population: Planning
Commission (1992).
48
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Table showing investment in different plan periods
(Rupees in crores)
Water
Family
Welfare
Supply &
. Sanitation
Period
Total Plan
Investment
Health
I Plan (1951-56)
1960.00
65.20
0.1
N.A.
II Plan (1956-61)
4672.00
140.80
2.20
N.A.
III Plan (1966-66)
8576.00
225.00
24.90
10.70
Annual Plans (1966-69)
6625.40
140.20
70.50
102.70
IV Plan (1969-74)
15778.80
335.50
284.40
458.90
V Plan (1974-79)
39322.00
682.00
497.40
971.00
1979-80 Outlay
11650.00
268.20
116.20
429.50
VI Plan (1980-85)
97500.00
1821.05
1010.00
3922.02
VII Plan (1985-90)
180000.00
3392.89
3256.26
6522.47
Two Annual Plans
(1991-92)
137033.55
2253.86
1805.52
4427.29
VIII Plan (1992-97)
434100.00
7575.92
6500.00
16486.93
Several national health programmes viz. National AIDS Control
Programme,
Malaria
Control
Programme, Leprosy
Control
Programme, etc. being carried out by the Ministry will be detailed out
subsequently.
3.9
Computerisation:20
Health Informatics Division (HID) of the National Informatics
Centre (NIC) under the aegis of Planning Commission provides
computer and MIS support to the Ministry of Health and Family
Welfare. Towards this, HID is running a full fledged computer centre
in the Ministry of Health and Family Welfare and is equipped with a
full range of computer system, software and manned by computers
professionals. The 486 based mini computer system is operational
through 45 terminals connected to it in a star network. International
and national Electronic Mail (NICMAIL) facilities are available through
sent across/receive information to and from various districts and other
NIC Centres spread all over the country.
49
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3.10
Medical Education, Training and Research:20
The Centre has set-up regulatory bodies for monitoring the
standards of medical education, promoting training and research
activities. This is being done with a view to sustaining the production
of medical & para medical manpower to meet the requirements of
health care delivery system at the primary, secondary and tertiary
levels.
3.10.1
Medical Education:
Medical Council of India is the statutory regulatory body
established under the provisions of the Indian Medical Council
Act,1933 which was later replaced by Indian Council Act,1956. The
same was amended in 1958 and in 1964. However, a major amendment
was made in 1993 to stop mushrooming of new medical colleges,
increase of seats and introduction of new courses without the approval
of MCI/Govt.of India. To institute an Education Commission on
Health Sciences is under consideration for quite some time. The
recently concluded 4th Conference of Central Council of Health and
Family Welfare (11-13 October,1995) urged the Government to
.establish the commission immediately after necessary legislation. Two
states namely Andhra Pradesh and Tamil Nadu have established
Universities of Health Sciences. Several States like Madhya Pradesh,
Maharashtra, Bihar and Karnataka are on the way of establishing such •
Universities of Health Sciences/Medical Universities.
Similar councils like Dental Council, Nursing Council,
Pharmacy Council etc. also have been established for maintaining
regulation on paramedical education. Organisations like National
Board of examinations; National Academy of Medical Sciences, New
Delhi; All India Institute of Medical Sciences, New Delhi; PostGraduate Institute, Chandigarh; Jawaharlal Nehru Institute of
Postgraduate Medical Education & Research, Pondicherry; All India
Institute of Hygiene & Public Health, Calcutta; National Institute of
Communicable Diseases, Delhi; etc. are contributing immensely in
building up health manpower.
3.10.2 Training: Almost all the national institutes and research facilities in
the health sectors including medical colleges. Regional Health &
Family Welfare Training Centres etc. are involved in training of health
professionals. A continuing medical education (CME) cell was set up
in the Medical Council of India in 1985. National Academy of Medical
Sciences also conducts CME programmes and supports such
programmes. National Institute of Communicable Diseases conducts
specilised training in epidemiology and disease control and All India
50
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«
Institute of Hygiene & Public Health, Calcutta provides specilised
training for public health professonals.
3.10.3 Research: Indian Council of Medical Research is the nodal agency for
promotion, formulation, conduction and co-ordination of biomedical
research in the country. At present Health System/Services Research
receive very inadequate support and poor response from the Health
Directorate. In spite of several efforts little headway has been made in
strengthening the health system research as a part of priority activity of
ICMR. Response from Directorate of Health Services is equally poor.
3.11
International Co-operation for Health and Family Welfare:20
Various International Organisations such as World Bank as well
as United Nations Agencies like WHO/UNICEF, UNFP and several
other continue to provide significant technical and material assistance
for many health and family welfare programmes in the country In
addition, there are bilateral programme of assistance such as DANIDA,
SIDA, NORAD, JAICA, ODA etc. All these agencies provide for the
development and strengthening of health care facilities through
supplies and equipment, fellowships, training, short-term group
educational activities, workshops, meetings, and conferences. In
‘addition, several bilateral agreement also exist in form of cultural
exchange programmes through visits of scientists, and co-operation in
various health related fields.
3.12
Facilities for Scheduled Caste and Scheduled Tribes under special
component plan:20
The scheduled Caste and Scheduled Tribes constitutes 16.48%
and 8.08% respectively of the total population of the country as per
1991 Census.
The constitution provide for a comprehensive
framework for the socio-economic development of Scheduled Caste
and Scheduled Tribes. Article 46 of Constitution requires both State
and Federal governments to promote with special care the educationa
and economic interests of the weaker sections and in particular of
SC/ST and to protect them from social injustice and all forms ot
exploitation.
3.12.1
The concept of Tribal sub-plan and special component plan for
Scheduled Castes were adopted during fifth and sixth five year plans
respectively and have been continued during the seventh and eighth
five year plans. This constitutes the main instrument for all round
development and welfare of Scheduled Tribes and Scheduled Castes
respectively.
05646
51
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3.12.2
The National Health Policy (1983)13 provides high priority foi
health care delivery services in the tribal, hilly and backward areas
through relaxation of norms for rural health infrastructure.
<
3.12.3
The Eighth Plan consciously and consistently focused the
attention on promoting the health care to the under-privileged
segments of vulnerable population through consolidation and
operationalising the Primary Health Care infrastructure ano
strengthening referral system through district Health Care models.
Thrust areas include:
a)
Major investment in development and strengthening of primary
health care infrastructure aimed at improving the quality and
out reach of services.
b)
Consolidation and expansion of the secondary health care
infrastructure upto and including the district level services.
c)
Optimisation of the functioning of the tertiary care.
d)
Building up of referral and linkage system so that optimal
utilisation of available facilities at each level is possible.
e)
Control of communicable diseases which continue to dominati
major public health concerns in the country.
f)
Tackling the emerging problem of non-communicable diseases.
g)
Improving the utilisation of Indian Systems of Medicine and
Homoeopathy (ISM&H).
h)
Creation of well trained skilled medical and paramedical
manpower, adequate in quantity and appropriate in quality, tc
take care of the health needs of the population.
Specific efforts have been made to ensure that the ongoing
economic restructuring does not lead to any adverse effect or
provision of essential care to meet the health needs of the most need5’
segments of the population. Some of the major efforts in this direction
include allocation of funds under the Social Safety Net Scheme to
improve Maternal and Child Health (MCH) infrastructure in a phased
manner, beginning with the 90 poorly performing districts. Specific
efforts are also being made to promote Indian Systems of Medicine
especially in view of the fact that these are traditionally well accepter
by the population, personnel belonging to these systems are available
in the remote and rural areas and provide treatment at affordable cos..
Involvement of voluntary organisations and improved Informatio
52
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Education and Communication (IEC) activities are supported so that
there is adequate community participation and improved utilisation of
the available health facilities.
3.13
Directorate General of Health Services:
The Directorate General of Health Services is the principal
source of technical advice to the Union Government in both medical
and public health matters. Its organogram is given in Annex-6. Some
of the major functions are:
3.13.1
Central drug standard Control Organisation: The drug control
organisation is a part of the Directorate General of Health Services
(DGHS) and is headed by Drugs Controller of India and is assisted by
four zonal officers at Madras, Bombay, Calcutta and Ghaziabad. There
are four sub-zonal offices, six port offices and four drug testing
laboratories.
The import, manufacture, sale and distribution of the drugs in
3.13.1.1
the country is controlled by Drug Controller of India as per the
provision of Drugs and Cosmetics Act, 1940 and rules thereunder23 .
.The main objective of the Act is to ensure that drugs available to the
consumers are safe and efficacious and cosmetics are safe.
The major functions are:
23
•
Control of the quality of the drug imported in the country.
•
Co-ordination activities of the State and Union Territories drug
control authorities and to advise them on uniform
administration of Drugs and Cosmetic Act.
•
Approve new drugs to be imported or manufactured in the
country.
•
Lay down regulatory measure and standard of drug to act as
Central Licensing approving authorities in respect of whole
human blood, blood products, intravenous fluids, sera and
vaccine. This function is being implemented through Indian
Pharmacopoeia Committee.
•
To assist in the implementation of the above functions Drug
Advisory Board has also been constituted which is a statutory
body under Drugs and Cosmetics Act to advise the State
Drugs and Cosmetics Act, 1940.
53
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governments on technical guidelines arising out of the
administration of this Act.
Hathi Committee Report (1975)24 was a historical land mark in
3.13.1.2
the field of drug development in India. It recognised that to ensure
availability of essential medicines, a list of essential drugs has to be
made and that to prevent price hike, profits on drugs must be curtailed
with least profitability on essential and life saving drugs. It also
recommended withdrawal of hazardous and irrational drugs.
Subsequently, a National Drug Policy (NDP) was formulated in 1978
which was further revised in 1984 and consequent upon the
announcement of new drug policy25 in September 1994, a draft bill has
been prepared for bringing out an enactment for establishing a
national drug authority to ensure quality control and rational use of
the drug in the country. Even after lapsed of 10 years after the report
the List of Essential Drugs has not been prepared and large number of
hazardous and irrational drugs remain to be withdrawn from the
market.
3.13.2
International
Health
Affairs/Port-Airport
Health
Prganisation:20 Arrangement for Health clearance and Quarantine
.administration at the eight major ports and five International Airports *
in the country are made by the Central Government under the Indian
Port Health Rules, 1955 and Aircraft (PH) Rules, 1954 which are based
on the International Health Regulation 1969. The objective of these
Port and Airport Health Prganisations is to prevent spread of
communicable diseases, prevention of entry of Yellow Fever into the
country through passengers coming from or transmitting through
notified endemic countries.
Arrangements also exist for health
clearance of aircraft at Amritsar Raja Sansi Airport, Hyderabad,
Trivandrum and Dabolim Airports. Similar arrangements are also
made as and when necessary at Lucknow, Varanasi, Gaya, Nagpur,
Ahmedabad, Agra, Pune, Bangalore and Andaman & Nicobar Island.
Arrangements exist for health clearance of ships at various minor ports
and special arrangements regarding health clearance of ships arriving
at Tuticorin Port and Bangalore are also made with the help of State
Government staff.
Health checks have been established since 1976 at Attari in
Punjab for India Pakistan Rail and Road Traffic.
3.13.3
Medical Stores Organisation (MSP):20 Procurement of drugs and
other supplies and their distribution are through the MSP at Bombay,
Madras, Calcutta, Kamal, Guwahati and Hyderabad.
This
24 Hathi Committee Report (1975).
25 New Drug Policy, 1994.
54
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organisation supplies the civil medical requirements of the Central
Government and various State Governments including supplies from
foreign agencies like UNICEF, SID A, WHO, USAID.
Various drugs and other commodities required for running the
national health programmes like NLEP, NMEP, TB, etc. are handled by
the MSO. It also caters to the supplies of the medical stores for CGHS.
It arranges also relief supplies during disasters.
3.13.4
Central Government Health Scheme:20 The Central Government
Health Scheme (CGHS) is a large organisation taking care of the central
government servants and their family members. Members of
Parliament and their family members, central government pensioners,
etc. It has hospitals, dispensaries in major cities of the country
wherever large chunk of central government employees are stationed.
The existing number of dispensaries, system-wise as on 31.03.1994 is
given in Annex-7. Facilities provided under the scheme include
outpatient care services, through a network of allopathic, ayurvedic,
homeopathy, unani dispensaries and units, supply of medicine,
laboratory and x-ray investigations, domicilliary visits, emergency
treatment, antenatal care, confinement, postnatal care, advise on family
•welfare, specialist consultation, hospitalisation facilities in government
and private hospitals recognised under CGHS.
3.13.5
Medical Education:20 In addition to governing directly some of
the medical colleges like Lady Hardinge Medical College, JIPMER,
Pondicherry, it also provides support to medical colleges in Delhi like
Maulana Azad Medical College, GTB Medical College and Hospital
through provision of personnel. It is also responsible for distribution
of the medical seats for undergraduates and postgraduates which fall
under the category of Central Quota covering the entire country. It
also co-ordinates the functioning of the various councils - medical,
dental, nursing, pharmacy, etc.
3.13.6
Governance of Central/National Institutes/Institutions: Several
central and national institutions are directly governed by the DGHS
namely. National Institute of Communicable Diseases, Delhi; All India
Institute of Hygiene and Public Health, Calcutta; Central Research
Institute, Kasauli; National Tuberculosis Institute, Bangalore; Central
Leprosy Training and Research, Chingleput; Ram Manohar Lohia
Hospital, New Delhi; Safdarjang Hospital, New Delhi; Central
Institute of Psychiatry, Ranchi, etc. National Medical Library is directly
under the DGHS. The National Medical Library aims to help in the
advancement of medical and health and related sciences through
collection, dissemination and exchange of information.
55
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3.13.7
Central Bureau of Health Intelligence: This acts as a nodal
agency for collection, collation, analysis and dissemination of
information on health conditions in the country. It also conducts
training programmes for various categories of health statistical
personnel and also undertakes field studies on the priority health
problems. The Bureau acts as a nodal agency for development and
operation of Health Management Information System in the country.
The obligations under the international health regulations are
being observed. The morbidity and mortality figures in respect of
internationally quarantinable diseases including cholera are processed
by CBHI on the basis of report from all over the country for onward
transmission to World Health Organisation.
3.13.8
Central Health Education Bureau: This is responsible for the
preparation of educational material in creating health awareness
among the people. It also caters to the needs of the health education
activities of various disease control programme managers. It has
recently established a centre for promotion of health related vocational
studies. It also conducts a post graduate diploma course in health
education affiliated to Delhi University.
3.13.9
National Health Programmes: A large number of national
health programmes are in operation covering both communicable and
non-communicable diseases namely National Malaria Eradication
Programme (NMEP), National Leprosy Eradication Programme
(NLEP), National Tuberculosis Control Programme (NTCP), Guinea
Worm Eradication Programme (GWEP), National Programme for
Control of Blindness (NPPB), Cancer Control Programme (CCP),
Iodine Deficiency Disorders control programme (IDD), Diabetes
Control Programme (DCP), National AIDS Control Programme
(NACP), etc. Basic implementation is the responsibility of the State.
The Central Government is involved in formulation of strategies co
ordination, monitoring evaluation and providing appropriate guidance
to the States.
3.13.10
Food Adulteration26 : The prevention of Food Adulteration Act
was enacted in 1954. The aims envisaged under this Act are (i) to
ensure quality food to the consumers; (ii) to protect 'the consumers
from fraud and deception; and (iii) to encourage fair trade practices.
The Act, which came into effect from 1st June,1955 has been amended
thrice, in 1964, 1976 and 1986 for plugging the loopholes and for
making the punishments more stringent and empowering the
consumer and voluntary organisations to play effective role in its
implementation. The subject of Prevention of Food Adulteration is in
26
Prevention of Food Adulteration Act 1954.
56
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the concurrent list of the constitution. However, in general the
enforcement of the Act rests with the State/UT Governments. The
Central Government primarily plays an advisory role in its
implementation
besides
carrying
out
various
statutory
functions/duties assigned to it under the various provisions of the Act.
Four Central Food Laboratories have been established/ specified under
the Act, which work as appellate laboratories for the purpose of
samples lifted by food inspectors of States/UTs and local bodies. The
two laboratories viz. (i) Food Research and Standardisation
Laboratory, Ghaziabad and (ii) Central Food Laboratory, Calcutta are
under the Administrative Control of the Directorate General of Health
Services and the other two viz. (iii) Central Food Laboratory, Pune and
Central Food Laboratory, Mysore are under the Administrative control
of Government of Maharashtra and Council of Scientific and Industrial
Research, Government of India, respectively. There are 81 Food
Laboratories under the administrative control of State/UT
governments and local bodies.
Ministry of Health and Family Welfare has launched a centrally
sponsored scheme for providing funds to the State/UTs governments
for purchase of equipment for strengthening their food laboratories
-during the Eighth Five Year Plan. A proposal to augment the food
quality control infrastructure at the Central/State level with World
Bank assistance is also under active consideration of Central
Government. Some of the deficiencies observed in the enactment of the
PF A are (i) The existing set up for food quality control at the
central/State level is hardly adequate to fulfil the responsibilities
assigned under the Act. (ii) A total of approx. 3500 Food Inspectors
have been working against the minimum norm of 16000 (1 Food
Inspector per 50,000 population), (iii) The food laboratories need to be
augmented with trained manpower and equipment, (iv) Most of the
State PFA Rules are outdated, (v) Licensing provisions are not being
properly enforced, and (vi) PFA cases have been pending in the Courts
of Law due to paucity of adequate technical/legal assistance to the
Prosecution agencies.
3.13.11
>
5
Vaccine Production: India is self-sufficient with the production
of EPI vaccines except BCG. The polio vaccine is imported in bulk in a
concentrated form then it is diluted and ampoule. This is done by
Haffkine Biopharma, M/s Radicura Pharma. Indigenous production of
polio vaccine is likely to start soon. Both Haffkine Biopharma & M/ s
Radicura Pharma are making efforts in this direction. Serum Institute
of India, Pune is a major manufacturer of vaccine in the country in the
private sector contributing immensely in attaining self sufficiency in
indigenous capability of several vaccines. Central Research Institute,
Kasauli is directly under the administrative control of DGHS and
DGHS also supports other vaccine production institutions like
57
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Haffkine Biopharma, Bombay; Pasteur Institute, Coonoor, etc. through
some form or the other. The average production of vaccine vis a vis
requirement of different vaccines are in Annex-8.
3.13.12
Central Council of Health: The Central Council of Health was
set up by a presidential order in 1952 under article 263 of the
Constitution of India for promoting co-ordination between Centre and
the States in the implementation of the various activities involving
health of the nation. Union Minister of Health and Family Welfare is
the Chairman and the State Health Ministers are the members.
Central Council of Family Welfare: With the creation of the
Department of Family Welfare and in view of the top priority being
given to the population control. Central Council of Family Welfare also
has been established with the Union Minister of Health and Family
Welfare as the Chairperson. The councils used to meet jointly and
sometimes independently to review various activities pertaining to the
health and family welfare and give appropriate policy directives to the
Central ministry and State governments. The first joint meeting of CCH
and CCFW was held in 1974. The councils were officially merged in to
one in 1986 and first meeting of the new joint council was in 1988. The
• broad functions of the joint council are:
3.13.13
1. To consider and recommend broad lines of policy in regard to matters
concerning health and population control in all its aspects.
2. To examine issues for legislation in fields of activities relating to the
health and population control and to lay down the pattern of health
development and population control in the country.
3. To examine all the national programmes under Grant-in-Aid scheme
and to recommend appropriate steps to the Central government and
the State governments for initiating corrective measures.
3.14
Functions of Department of Indian Systems of Medicine and
Homoeopathy20
Ayurved based on Athervaved, was developed more than 3,000
years ago by sages like Agnivesh and Sushruta. Thefe is mention of
about 15,000 drugs in the classical texts. Of these, 1,500 drugs are in
wide use. 'Siddhas' seem to have contributed towards development of
Siddha Medical System which is in wide use in Tamil speaking areas.
The Unani System of Medicine had its origin in Greece, it was
extensively adopted and developed by the Arabs after assimilating
medical knowledge from India and Iran and ultimately it developed
strong root in India. The basic concept in all the three systems relates to
maintaining a balance in the body between different elements or
58
phsfinal.doc (
€
humours of which the body is functioning. Any disturbance in the
balance leads to disease and the therapy lies in restoring the balance
through use of medicines of natural origin based on herbs and
minerals.
Yoga and Naturopathy, which are being practised in the country
as a way of living for maintenance of health have also been included
under Indian Systems of Medicine.
Dr. Samuel Hahnemann, a German Physician based on his
experimental conclusion that the curative power of the drug lay in its
disease producing power, propounded the basic principle of
Homoeopathy "Similia Similibus Curentur".
The department has following functions:
3.14.1
Institutional development: Before independence these systems
were left to develop on their own with practically no government
support. After independence, institutions paralleling those existing in
Allopathy were formed and these were Central Council of Indian
Medicine and Central Council of Homoeopathy. Central Council for
.research in Ayurveda and Siddha, Central Council for research in
Unani Medicine, and Central Council for research in Homoeopathy,
National Institute for Ayurveda at Jaipur, National Institute of
Homoeopathy at Calcutta, National Institute of Unani Medicine at
Bangalore and National Institute of Naturopathy at Pune were also set
up as apex bodies for research and training. In order to formulate
standards for drugs, Pharmacopoeial Committees for each system
were set up.
3.14.2
Regulation of Educational Standards and Professional Practices:
Two Central Councils are responsible for laying down and maintaining
uniform standard of education and regulate the professional practices
of the practitioners in the field of ISM & H.
3.14.3
Administration of National Institutes: Four National Institutes
one each for Ayurveda, Homeopathy, Unani and Naturopathy have
been established as autonomous organisations under the department.
3.14.4
Pharmacopoeial Standards and Drug Testing Facilities: Four
Pharmacopoeial committees are working for preparing official
formularies/pharmacopoeias to maintain uniform standards in
preparation of drugs of Ayurveda, Unani, Siddha and Homeopathy
and to prescribe working standards for single drugs as well as
compound formulations.
59
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3-14.5
Drug Control Cell (ISM): The drug control cell for Indian
Systems of Medicine was established in May 1992 to assist the drug
controller (I) for matters related to ISM.
3.14.6
Drug Testing Laboratories: Pharmacopoeial laboratories for
Indian
Medicine,
Ghaziabad,
Homeopathic
Pharmacopoeial
laboratory, Ghaziabad are high technology based standard settingcum-drug testing laboratory have been established for ISM at national
level.
3.14.7
Apex bodies for Research: The four research councils viz.
Central Council for Research in Ayurveda and Siddha, Central Council
for Research in Unani Medicine, Central Council for Research in
Homeopathy and Central Council for Research in Yoga and
Naturopathy are the apex bodies for research in concerned system of
medicine and these councils initiate, aid, guide, develop and co
ordinate scientific research in different aspects of the system, both
fundamental and allied.
3.14.8
Development of Medicinal Plants: Medicinal Plants are a great
source of raw material for drug production. A separate cell was created
<in the ministry to look into the various aspects of development of
medicinal plants required by the pharmaceutical industry for
preparation of ISM & H drugs.
3.15
Department of Family Welfare:20
3.15.1
3.15.2
The department has ten technical divisions viz.
i.
Programme Appraisal and Special Schemes;
ii.
Technical Operations;
iii.
Maternal and Child Health;
iv.
Evaluation and Intelligence;
v.
Information, Education and Communication;
vi.
Supply Division;
vii.
Transport;
viii. Universal Immunisation Programme;
ix.
Area Projects; and
x.
Rural Health Division.
The National Family Welfare Programme was launched in India
in 1951 with the objective of "reducing the birth rate to the extent
necessary to stabilise the population at level consistent with the
requirement of the national economy". In keeping with the democratic
traditions of the country, the Family Welfare Programme seeks to
promote responsible and planned parenthood through voluntary and
informed choice of family planning methods, best suited to individual
acceptors.
60
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3.15.3
The long term demographic goal, as laid down in the National
Health Policy (1983) is to achieve a Net Reproduction Rate of Unity by
the year 2000 AD.
3.15.4
Keeping in view the present levels of achievement. Eighth Five
Year Plan has visualised that NRR-1 would iou be achievable by the
year 2011-16 AD. The goals to be achieved by the end of the Eighth
Plan and achievements are given in following table:
Indicator
Eighth Plan Goals
Achievements 1993 (Prov.)
Crude Birth Rate
(per 1000 population)
26.0
28.5*
Infant Mortality Rate
(per 1000 live births)
70
74.0*
45.4**
56%
Couple Protection Rate
* Sample Registration Survey (SRS) data.
** As on 31.03.1994
3.15.5 •
The population of India is expected to cross one billion mark by
2001. There are sizeable differences in the achievements under the
family welfare programme. On one end of the spectrum are states like
Kerala, Tamil Nadu and Goa which have already achieved replacement
level of fertility. On the other hand, in the large northern states of
Uttar Pradesh , Madhya Pradesh, Rajasthan and Bihar fertility levels
and birth rates continue to be higher than the national average. The
experience of implementing the family welfare programme over the
last four decades has clearly demonstrated the need for adopting a
holistic and multisectoral approach towards population stabilisation.
3.15.6
Female literacy, age at marriage of girls, status of women,
poverty etc. directly influence the fertility behaviour implying that
various departments in the central and state government, social and
voluntary organisations need to play a positive role. A Group of
Experts has prepared a draft on National Population Policy which has
been tabled in the Parliament.
3.15.7
National Development Council (NDC) committee on
populations' recommendations endorsed by the NDC in its 46th
meeting on 18 September,!993 is under active consideration of the
Government.
61
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3.15.8
The Pre-natal Diagnostic Techniques (Regulations and
Prevention of Misuse) Act 199427 has been Gazette notified. It gives
permission for undertaking diagnostic techniques on a woman only in
certain specified circumstances and in registered institutions.
3.15.9
The 79th Constitutional Amendment 1992 for ensuring strong
political commitment has been introduced in Parliament in December
1992 seeking promotion of population control and small family norm
within the framework of Article 47 having the provision under which a
person shall be disqualified for being elected if he/ she has more than
two children. However, the proposed amendment has prospective
effect and will not apply to any person who has more than two
children on the date of commencement of the proposed amendment or
within a period of one year of a such commencement.
Functions:
3.15.10
The department of family welfare in consultation with states,
has evolved an action plan having the following key features:i)
Improving the quality and outreach of family welfare services;
ii)
Differential strategy for special focus on 90 poor performing
districts (birth rate of 39 and above per one thousand population
as per 1981 census);
iii)
Developing a mechanism to make available funds to States and
UTs, on the basis of reduction in birth rate;
iv)
Increasing the coverage of younger couples;
v)
Introducing new contraceptives and improving the quality of
contraceptives;
vi)
Strengthening family welfare schemes in urban areas, especially
in slum pockets;
vii)
Revitalising training activities of medical and para-medical
personnel with emphasis on motivational arid counselling
aspects;
viii)
Sustaining the good work done under the
Immunisation Programme and strengthening
interventions for maternal and child health care;
Universal
of other
27 The Pre-natal Diagnostic Techniques (Regulations & Prevention of Misuse) Act 1974.
62
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3.16
ix)
Re-orientation of information, education and communication
efforts to focus on the quality of life issues and inter-personal
communication;
X)
Involving voluntary and non-governmental organisations in a
big way to promote active community participation in the
programme;
xi)
Gearing up of the implementation machinery in the States and
Union Territories; and
xii)
Evolving high level inter-sectoral co-ordination mechanism at
the national, state and district levels.
Planning Commission:
The Planning Commission was established in 1950 and through
the formulation of Five Year Plans it has contributed immensely in
building modern India.
The Prime Minister in his capacity as Chairman of the Planning
^Commission, participates and gives direction to the Commission on all
major issues of policy.
i
The Deputy Chairman and nine full time Members of the
Planning Commission function as a composite body in the matter of
detailed plan formulation. They provide advice and guidance to the
subject Divisions in the Commission in the various exercises
undertaken for the formulation of approach to the plan. Five Year
Plans and Annual Plan. Their expert guidance is also available to the
subject Divisions for monitoring and evaluation of the Plan
programmes, projects and schemes.
The
Commission
functions
through
29
General/
technical/subject Divisions apart from the division of house keeping.
Each division is headed by a senior officer designated as
Principal/Adviser/Adviser/Addl.
Adviser/Joint
Secretary/Joint
Adviser who functions under the overall supervision and guidance of
the Secretary, who at this time has been also designated as MemberSecretary.
The Eighth Plan has, recognised "human development" as the
core of all development effort. The Plan, has therefore, identified
health, education, literacy and basic needs including drinking water,
housing and welfare programme for weaker sections as sectors which
contribute to human well being. In fact the Directional Paper of the
Eighth Plan has identified health and population control as among
63
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six most important objectives of the Plan. The organogram is given
in Annex-9.
3.17
State Level:
The provincial governments have the full authority and
responsibility for all the health services in their territory. Historically
the Montegau Chelmsford Reforms came in operation in 1919 when
State health administration was given autonomy by the Central
government in matters of public health. The Government of India Act
1935 gives further autonomy to the States. Under the constitution the
subjects under the health have been divided under three broad lists i.e.
Union List, Concurrent List and the State List. State List includes
provision of medical care, preventive health care services and matters
of public health and, therefore, the States have got absolute authority
and responsibility for all health care services. At present, there are 25
States and 7 Union Territories. However, all of them follow almost
similar pattern of governance and have the following :
3.17.1
3.17.2
State Ministry of Health: The State Ministry of Health is headed
by a Minister of Health & Family Welfare either of Cabinet rank or of
-Minister of State. Often the State Minister is assisted by a Deputy
Minister depending upon the political situation at a particular point of
time. The Health Secretariat is the official organ of the State Ministry
of Health and is headed by a Secretary, Principal Secretary,
Commissioner as the case may be who is assisted by Additional, Joint
and the Deputy Secretaries and a large number of other administrative
staff. In a couple of States, Director of Health Services is also Ex-officio
Secretary to the State Government as recommended by the Bhore
Committee but in majority of the States the same has not been
implemented. State Health Secretariat is assisted by the technical wing
called State Health Directorate.
State Health Directorate:
For a long time two separate
departments namely Medical and Public Health were functioning in
the States. The heads of these departments were known as Surgeon
General/Inspector General of Civil Hospital and Director of Public
Health respectively.
Following Bhore Committee reports which
specifically recommended integration of medical and * public health
wing, these posts were merged together in many States and the post of
Director of Health Services was created. Over a period of time all the
States created this post who acted as the Chief Technical Adviser to the
State government on all matters relating to medicine and public health.
He was also responsible for all the organisational and other activities
related to the health of the province. All the functions pertaining to
health and family welfare and medical education were integrated.
However, with passing of time now in many States Directorates of
64
phsfinal.doc
f
Public Health Services, Posts of Director of Public Health, Director of
Family Welfare and Director of Medical Education are again being
separated and they report directly and separately to the Health
Secretary of the State. In some of the States even the State Health
Secretaries have got two separate departments like Secretary Family
Welfare and Secretary Medical Education. The Director of Health
Services is assisted by Additional, Joint, Deputy Directors and other
supporting staff. Directors of Health Services are not necessarily from
the Public Health discipline. In fact, in most of the States it is not from
the public health discipline and therefore often they are not adequately
sensitive/oriented towards public health needs. The public health
engineering organisation is under the public health works department
of the State Governments and not under the State Health Directors.
With the promotion of Indian Systems of Medicine, many of the States
have also established the post of Director of Indigenous Systems of
Medicine.
3.17.3
In the Directorate of Health Services focal points for various
disease control programmes at various levels namely the Additional
Director/Joint Director/Deputy Director/Assistant Director exist. In
the Directorate also exists the State Bureau of Health Intelligence
•which is the nodal agency for collecting all information pertaining to
morbidity and mortality from diseases. All related information with
regard to health services are collected, collated and tabulated for the
use of the health authority and also for onward transmission to the
Central Bureau of Health Intelligence. Organogram in respect of some
States of India is given in Annex 10-A to 10-R.
3.18
District Level:
The principle unit of administration in India is the district which
is either under a Collector/District Magistrate/Deputy Commissioner.
As on date there are 460 districts and the size of the district vary
widely from less than 0.1 million to more than 3 million. Within each
district, there can be six administrative areas (I) Sub Division, (ii)
Tehsil/Taluka, (iii) Municipalities and Corporation, (iv) Community
Development Block, (v) Panchayat and (vi) Village.
3.18.1
The district public health system is headed by Chi£f Medical and
Health Officer/Chief Medical Officer of Health/District Health
Officer/Chief District Medical Officer who is assisted by several
deputy chief medical and health officers/district health
officers/additional deputy health officers/district programme officers
in various states depending upon the designations used in various
states. The chief of the district hospital is often designated as Medical
Superintendent of the district hospital or Civil Surgeon. In some of the
states, he functions independently of the CMOH but in most of states
65
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CMOH is the overall in charge of the entire district and medical health
administration
including
district hospital.
The
district
collector/deputy commissioner/district magistrate co-ordinate all
activities pertaining to the district and, therefore, the Chief Medical
and Health Officer of the district though technically is under the Dte. of
Health Services for all technical matters but in times of health
emergencies the district collector/the district magistrate can
appropriately direct the CMOH for any specific prevention and control
measures. The organogram of some districts in the country is given in
Annex 11-A to 11-C.
3.19
Community Health Centre/Primary Health Centre/Sub-Centre:
Apart from the infrastructure as indicated at the district level it
has a network of hospitals, dispensaries, community health centres,
primary health centres and sub centres to cover the entire population
of the country with regard to the heath care delivery services. It also
has a network of hospitals and dispensaries under the Indian Systems
of Medicine. Detailed functions including the numbers established will
be described under the chapter Existing Health Scheme.
3.20
3.20.1
-OBSERVATIONS, SUGGESTIONS & OVERVIEW
Health Policy
3.20.1.1
People generally believe that development programmes and
projects, especially economic ones, would automatically improve
health status. While the link between economic growth and better
health is a strong one, growth in income and a developing economy do
not necessarily ensure improved health status. Many developing
countries are concerned with the possible health impact of economic
restructuring and development policies. The essence and essentials of
health programmes include control of communicable diseases and
reduction of health risks from environmental pollution and hazards.
The interdigitation of primary environmental care and primary health
care is therefore obvious. The Inter-Agency Regional Conference on
Health Development held in New Delhi, India from 20-24 March, 1989
recommended that the capacity of Ministry of Health be strengthened
to analyse development projects to ensure that they'do not have
negative impact on health status. Regular analysis of various public
policies and practices of other ministries viz. agriculture, industry,
urban development, rural development and environment, which have
direct link with the health of the people, must be considered as an
essential prerequisite for a meaningful inter-ministerial co-ordination.
3.20.1.2
National Health Policy was formulated and endorsed by
Parliament in 1983. Many of the recommendations covering nutrition.
66
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prevention of food adulteration & maintenance of the quality of drugs,
immunisation, Maternal & Child health services, environmental
protection, water supply & sanitation, management information
system, health education, medical research etc. have been implemented
which had paid dividend in terms of reduction in infant mortality,
crude death rate, increased life expectancy etc. However, some of the
recommendations have either not been implemented or have been
partially implemented viz. to establish a nation-wide chain of sanitary cum - epidemiological stations between the primary and secondary
levels of the hierarchical structure, depending upon the local situations
& other relevant considerations having suitably trained staff equipped
to identify plan and provide preventive, promotive and mental health
care services, to establish epidemiological units at district levels, to
restructure the health services, to establish a well worked out referral
system, to review all existing health legislations, full utilisation of
untapped resources by encouraging practice by private medical
professionals, increased investment by non-governmental agencies in
establishing curative health centre and by offering organised logistic,
financial and technical support to the voluntary agencies active in the
field etc. During the decade following the policy statement many
changes have occurred viz. erosion of ecological system, rapid
.urbanisation, large population growth, economic liberalisation policy
leading to major changes in industrial sector, change in health and
demographic scenario, appearance of new, emerging and re-emerging
health problems like HIV, Plague, Dengue, Malaria, Hepatitis, Japanese
encephalitis. Dengue Haemorrhagic fever etc., declining appreciation
of the public health problems by the health managers and Medical
professionals etc.
In the context of the above, there is an urgent need to review
the National Health Policy both in terms of reformulation of strategies
and re-setting of targets. Results of several field studies are now
available which need to be considered and if feasible, incorporated in
the policy.
3.20.1.3
Several alternative strategies have been tried or are being tried
under research studies or by the voluntary organisations and many of
them have been found to be highly satisfactory in their results.
However, it may be noted that those alternative strategies are being
implemented by either very committed research workers or by NGOs
and that too in a very limited area and there is no consensus on an
alternative strategy to be implemented all over the country and experts
and professionals all still continue to recommend comprehensive
health care delivery services through the vast network of primary
health care infrastructure developed in the country ensuring
community awareness and participation in the general model of Bhore
Committee. However, provision of adopting a situation specific
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measure within the overall guidelines of health care services should
also exist. The search for an alternative strategy should continue and
individual researcher and institution should undertake studies on
various aspects of health care to continuously provide newer
observations and recommendations to update the health care delivery
system.
3.20.1.4
Public Health Act: need & rational
With the decentralisation of administrative system through the
recent constitutional 73rd28 and 74th29 constitutional amendments
providing more power to the municipal health authorities and local
authorities, an urgent need has arisen to review all the existing public
health laws. All the local health authorities need to be appropriately
guided in adopting the Model Public Health Act revised in 1987 and
already circulated and every effort should be made to monitor its
enactment with appropriate modification depending upon the local
situation.
3.20.2
Broad set up of Ministry:
The recommendations of the Bhore Committee that the Ministry
of Health should be under the charge of a separate Minister is being
followed and is currently in practice. However, the members of the
committee are of the opinion that the several activities linked with the
human health are presently undertaken by Ministry of Welfare,
Ministry of Human Resource Development, Ministry of Urban
Development, Ministry of Environment, Ministry of Rural
Development etc. The work of sanitation and environmental health
was earlier with the Ministry of Health but now it is being undertaken
by several ministries viz. Ministry of Environment and Forests,
Ministry of Rural Areas and Employment, Ministry of Urban Affairs
and Employment. It has been further seen that the inter-sectoral co
ordination which is very vital in successful implementation of various
programmes is not readily available through a formalised mechanism
resulting in poor achievements under various programmes. Therefore,
convergence of all these activities pertaining to human health & family
welfare may be considered through the creation of a new over-arching
ministry like that of Human Welfare.
28 The constitution (Seventy-Third Amendment) Act, 1992. Gazette of India, Extraordinary, Part II
Sec.3(ii) dated 24.04.93.
29 The constitution (Seventy-Fourth Amendment) Act. Gazette of India, Extraordinary, Part II Sec.3(ii)
dated 01.06.93
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3.20.3
Broad organisational set up of the Union Ministry:
There are three departments in the ministry headed by
3.20.3.1
bureaucrats and the Directorate General of Health Services is headed
by a technocrat. Co-ordination between the departments is not
satisfactory and often compartmentalised adversely affecting the
linkage between different programme. Even between the working of
Directorate General of Health Services and Department of Health there
are several areas of duplication. Most of the functions of the Union
Ministry of Health and Family Welfare are a blend of social action and
actions requiring highly technical support. Therefore, a technical expert
will be more suitable to provide the requisite support & leadership.
There has been growing concern about erosion of technical hierarchy
which has been noted in some States. It is essential that the technical
hierarchy is maintained so as to provide appropriate technical inputs at
various levels of management and administration. Replacement of
technical personnel with bureaucrats should be avoided.
The functioning of the Family Welfare and Health Departments
3.20.3.2
are complimentary in nature and the two departments could be easily
merged into a single department avoiding duplication of work and
•bringing co-ordination and uniformity in the functioning of the
Ministry.
3.20.3.3
Several recommendations were made earlier on various national
platforms including that of Central Council of Health urging initiation
of Indian Medical and Health Services but the same has not yet been
implemented because of a variety of reasons. However, keeping in
mind the growing complexity in tackling health conditions it is once
again urged that the Indian Medical and Health Services should be
introduced in the country. If some of the States do not agree to do so
the same may be implemented in those states which agree to
implement the same. This will strengthen the capability of the public
health svstem.
Over a period of time, the discipline of public health has
3.20.3.4
deteriorated because it does not draw adequate talent nor it is able to
provide adequate recognition to specialities such as epidemiology,
MCH, health education, occupational health, public health
administration etc. There is only one composite school of public health
is available in the country. Other schools of public health like National
Institute of Health & Family Welfare and National Institute of
Communicable Diseases function in specific areas of public health.
Therefore, there is a need to open new schools of public health so that
more public health professionals could be trained. The existing public
health schools also be appropriately strengthened. Public Health has
strong component of clinical medicine. Unless the felt needs of the
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community are fulfilled by appropriate curative measures it will not be
possible for the community to be educated on/or brought to accept
long term prophylactic measures including environmental health,
sanitation and immunisation and contraception. In this context it
might essential to ensure that curricula for training in public health
have a strong clinical component as well as health administration,
health management and preventive medicine.
Positions requiring public health background should be filled by
3.20.3.5
appropriate qualified public health professionals and till those
professionals are available, it could be operated by general category
health professionals through appropriate training in health services
administration, management and epidemiology.
Many of the Central programme managers have never worked
3.20.3.6
in the state as a result they do not have appropriate perception of the
problems of the states and their functioning leading to poor
professional communication and understanding between the central
and state health programme managers. Creation of Indian Medical
and Health Services will automatically take care of this. Till the same is
done, there should be identified exchangeable posts on deputation
*basis between the state and central health services so that functioning
of the Centre and State health set up improves.
3.20.4
Restructuring of the Department of Health & DGHS:
An exercise for restructuring the Department of Health, Family
3.20.4.1
Welfare and DGHS should be taken up keeping in view the above
observations.
3.20.4.2
It has been felt that though our major national health
programme have been planned well, the lack of adequate supervision,
monitoring and timely mid course connection have resulted in poor
implementation.
There is an urgent need to build within the
implementing machinery at all levels, a mechanism for data collection
on process and impact indicators and reporting of problems
encountered during implementation. The district. State and Central
level programme managers should have access to these data on a real
time basis, so that the timely supervision and corrective action will
ensure smooth implementation of the programme.
3.20.5
Advisory Body:
Planning Commission sets-up Steering Committee and various
working group in connection with plan formulation. If the Steering
Committee can function on a continuing basis it not only can overview
the progress of the planned activities, it will also have better feed back
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through periodic review and monitoring which will provide added
inputs for subsequent plan formulation.
3.20.6
Joint Council of Health & Family Welfare:
should be
3.20.6.1
The Joint Council of Health and Family
family Welfare
weirare snouiu
ue
further broad based to make it a Joint Council of Health, Family
Welfare and ISM & Homoeopathy. This will provide further strong
policy initiative to strengthen ISM & Homoeopathy.
of me
the DGHS
and major
3.20.6.2
Functioning of the major divisions oi
uons ana
institutes and autonomous bodies could be periodically reviewed by
constituting a special technical advisory group/committee so that the
Ministry can initiate appropriate corrective action.
3.20.7
Health manpower planning:
3.20.7.1
Health manpower planning has been grossly neglected and
there is neither an institution nor any institutional approach for the
same. There is undoubtedly a need for an appropriate institutional
mechanism to assess the requirements of various categories of health
* manpower now and over the next few decades at various levels so that
appropriate action for training of these categories of personnel as well
as creation of posts and career planning for these individuals could be
taken up as a serious time-bound activity essential for proper
development of health care delivery in this country. The committee
reiterate that recommendations contained in health manpower
planning production and management expert committee report of
198714 should be implemented in right earnestness which will greatly
strengthen public health system in the country.
3.20.7.2
Primary health care delivery services being a team approach, the
training and continuing medical education (CME) of the professional
and para professionals should have components of training/ education
of the entire team together in addition to training of the individuals.
This multi professional approach will provide cohesive functioning of
the team and improve quality and coverage of primary health care.
3.20.7.3
The system of providing an exposure to the community health
care to the physicians through the Department of Preventive and Social
Medicine at the medical college under the ROME scheme has not
proved very successful as it provides very limited exposure in
community health care. One of the issues is that the teachers of social
and preventive medicine do not practise adequately the science of
preventive and social medicine because of their limited responsibility
for community health care practice. It is suggested that the faculty
members from various specialities in the Medical College should be
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posted to PHCs along with the students, so that the have an insight
into the problems at delivery of health services at primary health care
level. They may come up with appropriate technology or innovative
strategy to solve the local problems. The PHC/CHC staff in town
might get posted for a short period in appropriate department in
medical colleges as a part of their inservice training. This two way
linkage will not only help in problem solving but also help the vital
support between institutions establish successful functional referral
system for patient care. Managers of health care programmes require
not only management skills and knowledge of preventive medicine but
also in-depth understanding of the various components of diagnosis
and management of problems as related to the national programmes.
Without this knowledge and skills they may not be able to quickly find
out problems in delivery of essential services needed for the national
programme at the peripheral level and initiate appropriate corrective
action. The posting in medical colleges will provide the opportunities
to acquire these skills.
3.20.7.4
To make the public health system more responsive to the new,
emerging and re-emerging health problem and also to meet the
challenges of esclating epidemic of the non-communicable diseases, the
•need for establishing a Centre for Disease Control at the national level
should be considered.
3.21
State Level:
3.21.1
In recent times it has been seen that the several positions of
directors in the erstwhile directorate of health services have been
created namely, the director of family welfare, the director of health
services, the director of ISM, the director of medical education etc.
They all report to the Secretary of the Department of Health. The
functioning of the Department of Health being mostly that of technical
nature a technical man with managerial competence should be the
head of the Department of Health.
3.21.2
To provide an exposure to the functioning of the central health
set up some identified exchangeable posts on deputation basis between
the Centre and the State should be created. This will improve
functioning of health care delivery system.
3.22
District level:
At the district level epidemiological services input to the various
programme managers is essential. Until and unless appropriate
information is collected, tabulated, analysed and interpreted,
intervention measures suffer leading to poor implementation of the
programme.
Therefore, every district should have a strong
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epidemiological services input through establishment of an
epidemiological unit headed by an officer of the level of district
epidemiologist and supporting staff. Establishment of this type of unit
will also help initiating disease surveillance programme including
early warning signal system with strengthening of epidemiological
services will also include enhancing laboratory diagnostic capabilities
for human pathogens of public health importance.
3.23
Community Health Centres:
3.23.1
Community Health Centre is regarded as the first referral unit.
However, facilities for the referral centre such as operation theatre, Xray facilities, laboratory, etc. are not available in many CHCs. Even
where theatre facilities are available the requisite specialists have not
yet been posted. In the absence of anaesthetist neither the surgeon nor
obstetrician can undertake emergency surgery in high risk patients.
Thus the lack of essential physical infrastructure as well as personnel
required for carrying out the assigned task has come in the way of
CHCs functioning as first referral units. The National Education Policy
in Health Sciences which provides for the educational needs and
training requirements of all major health care professionals and para
•professionals and which has been approved at the meeting of the
Central Council of Health and Family Welfare, (1993) should be
implemented through properly developed action plan in a time bound
manner.
The Council also recommended placement of one public health
specialist at the community health centre (CHC) level and if this is
implemented the same will contribute immensely in strengthening the
public health system and will offer suitable correction to our present
hospital based disease cure emphasis in health care delivery to make it
disease prevention and health promotion oriented as enshrined in the
National Health Policy statement. The availability of additional
manpower in form of one public health specialist in all the CHCs may
not appear immediately feasible at this stage of available public health
specialist manpower. However, once a beginning is made and
National Education Policy in Health Sciences is implemented in a time
bound manner through an appropriate action programme, this will be
possible in foreseeable future and thus disease corltrol activities
channelled through CHC will have more updated professionally
competent support for better management of disease control
programme and transfer of newer technologies for various disease
control activities at the grass root level.
Establishments of the Community Health Centres were major
steps in providing higher level expertise in health care practices
covering promotive, curative and preventive services. However, the
73
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same did not develop to that direction. National Health Policy also
envisaged establishing nationwide chain of sanitary cum
epidemiological stations. The location and functioning of these
stations were intended to be between primary and secondary of the
hierarchical structure depending upon the local situation and other
relevant considerations. Each such station is required to have suitably
trained staff equipped to identify, plan and provide preventive,
promotive and mental health care services. The community health
centres should have been the ideal location. However, the same has
not been established.
3.23.2
Till such time that a public health expert is not available at the
CHC level, any generalist can be appropriately trained for delivery of
the public health services and given the responsibility of the same till
the appropriate manpower is available.
3.23.3
If public health system has to succeed emphasis should be
given to decentralised health planning, more allocation to the health
sector, strengthening health information system and capability of
generating early warning signal for quick responses to health
emergencies, strengthening inter-sectoral co-ordination, achieving
community participation, augmenting continuing medical education
for all categories of health professional and para-professionals,
health service research, more involvement of Indian Systems of
Medicine practitioners etc.
3.24
PHC/Sub-Centre level:
The organisational structure of the health services at village
level should be entrusted to the Panchayati Raj institutions which
should decide the nature structure, and priorities of the organisation
of the health care delivery services at the village level depending
upon the local situation, resource availability etc. This would ensure
decentralised area specific microplanning. Only the functional
components of the health care delivery system at the village level
should be detailed out so that primary health care delivery services
can move towards the objective of achieving the goal of Health For
All. Within such a framework, further co-ordination must develop at
all levels of local self-governance.
3.25
Primary health care infrastructure in the urban area which
caters to the needs of 25 - 30% of the population is grossly deficient.
Immediate attention need to be given to develop the primary health
care infrastructure in urban area. It is essential to build up
appropriate primary and secondary level care infrastructure in urban
areas to take care of essential needs for simple ailments of growing
74
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urban poor population. Creation of such facilities and appropriate
referral linkages with secondary and tertiary hospitals will
substantially reduce over-crowding in tertiary facilities and to ensure
that these facilities are used only by people requiring care for
complicated ailments which cannot be tackled at primary and
secondary level care level.
*
n-
-
r
/*X
r
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F
9
i
EPIDEMIOLOGICAL SURVEILLANCE
SYSTEM INCLUDING INSTITUTIONAL
SUPPORT SERVICES
I .
”■01 ni 0
■Illi I
III
4.0
EPIDEMIOLOGICAL SURVEILLANCE
INSTITUTIONAL SUPPORT SERVICES
4.1
General Introduction
SYSTEM
INCLUDING
Epidemiological surveillance is an essential per-requisite to
effective control and prevention of communicable diseases. It means
understanding a disease as a dynamic process involving the ecology of
the infectious agent, the host, the reservoir, the vectors and the
environment as well as the complex mechanism involved in the
causation of the disease and its spread.
It implies follow up of specific diseases in terms of morbidity
and mortality in time and place and keeping track of the circulation of
etiological agents in man and the environment including animal
population.
Supportive facilities for diagnosis and further
epidemiological services include 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.
'
For diseases with zoonotic foci of infection like plague, rabies,
arbovirus infections, it is important to study the condition which
favours the spread of infection like over multiplication of animal
reservoirs or vectors as well as their biological properties like
resistance to infection in the reservoirs or to insecticides in the vectors.
Attention should also be paid to other factors which may
influence the spread of infection and the incidence of disease, such as,
social and economic changes, population movements, large industrial
and agricultural investments like building of dams, irrigation projects
etc. or international trade, road and building construction work, export
and import of live animals, meat and meat products and poultry.
The collection of epidemiological information from a variety of
sources requires the full use of existing knowledge and involves co
operation with several other scientific disciplines and agencies.
A
On efficient procedures of case detection, notification, isolation
and treatment of cases and epidemiological investigation depends
success of the system. Success of a control or eradication programme
requires promptness in reporting of cases, reliable diagnosis and
subsequent treatment of cases along with timely initiation of available
prophylactic measures amongst the population exposed to risk of
infection. This depends largely on the facilities available for each of
these facets of epidemiological service in the country. Such services
were inadequate prior to Independence but have since developed to a
76
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great extent, concommitantly with the national control/eradication
programmes for various diseases like malaria, tuberculosis, trachoma,
leprosy, cholera, filaria, etc.
The consolidated picture of the existing epidemiological
intelligence system in the country is as under:
4.2
Notification System30
Reporting of the occurrence of a disease is a fundamental pre
requisite for a disease control programme. Reporting of individual case
is a useful method particularly for diseases in which effective control
measures are known and are provided by the health agencies.
Notification provides a day-to-day number of cases occurring in a
community and this information can be used to study the geographical
prevalence/incidence, differential morbidity and mortality rates for
different age-groups, sexes and relevant sub-groups of population. It
is clear that reliability, completeness and speed of notification are
important not only for introduction of effective control measures but
also for evaluating the progress of a disease control programme by
way of measuring decline in incidence or prevalence.
There is a conspicuous lack of uniformity in the lists of diseases
which are notifiable in different States and also from the view point of
primary agency responsible for reporting. The practice as to which
and how diseases are to be notified varies greatly from State to State.
Each local authority responsible for reporting in conformity with the
regulations determines as to which diseases are to be notified, their
nature and the manner of forwarding the reports to higher levels. List
of notifiable diseases vary from country to country and also within the
same country between the States and between urban and rural areas.
Usually diseases which are considered to be serious menaces to public
health are included in the list of notifiable diseases.
The notification process is initiated on diagnosis of the case.
Appropriate containment measures follow notification. For diseases
with short incubation period and where diagnosis could be quickly
made as in case of cholera, plague, meninogococcal, meningitis,
diphtheria, etc. this is extremely useful to the health authorities. In
contrast where diagnosis is not easy and takes longtime or where the
patient may remain asymptomatic for long notification may not
provide adequate tool for prompt control measures.
30 Epidemiological Surveillance System in India Dr.S.K. Sengupta and Shri P.N.Kapoor; CBHI, DGHS
Publication, February, 1971.
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>
4.3
Diseases that are notifiable
Cholera, yellow fever and plague which are internationally
qurantinable diseases are notifiable throughout the country as required
under International Health Regulations. The other important diseases
which are notifiable in some of the States are viral hepatitis, enteric
fever, tuberculosis, influenza, meningitis, Japanese encephalitis. Rabies,
diphtheria, leprosy, measles, poliomyelitis, scarlet fever, typhus, viral
encephalitis, relapsing fever, whooping cough, etc. It may also be
mentioned that some States have declared certain diseases notifiable
only in the urban areas. Further, some diseases are declared notifiable
only in the event of an epidemic or threatened epidemic. The fact that
most of the important diseases other than cholera, yellow fever and
plague are not uniformly notifiable in all the States has resulted in the
non-availability of a complete picture of morbidity and mortality
pattern of such diseases for India as a whole. In addition notification is
generally grossly incomplete and not accurate. To improve upon this,
all important communicable and occupational diseases that are
required to be controlled/prevented should be made nationally
notifiable and the system should be implemented well.
4.4
< Legal Provisions for Notification
Notification is usually in operation through certain legal
requirements. Legal provision for notification of diseases varies from
State to State. Some State Governments in India do not have any
specific act, except invoking the epidemic diseases Act 1897 and
extending the same depending upon the situation.
In the event of threatened outbreak of a notifiable disease in any
place or area, Government have conferred powers on the Collectors of
the District to declare the entire District of the concerned area as
threatened with the outbreak of the disease. When a declaration is in
operation and until it is withdrawn the collector of the district or any
persons duly authorised by him by general or special order or if
empowered in this behalf under this Act the Health Officer or any
other officer of the local authority concerned is vested with special
powers for the prompt prevention and control of the disease. In
accordance with the powers delegated by the Government, the Health
staff in the concerned areas undertake preventive and control measures
to check the disease.
In some States notification of the specific communicable diseases
to the Health Officer is compulsory and non-compliance is punishable
with monetory fine. However, that is very poorly implemented.
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4.5
Reporting Agency
Under the traditional system of notification and registration, the
village chowkidar (watchman) is the person responsible for reporting
of cases in the rural areas. The Chowkidar may be an illiterate person
and is also involved in duties other than notification. As such the
notification has been defective in reliability, promptness and
completeness. In some States, the primary reporting agency is village
panchayat or village headman. However, now with the establishment
of primary health centres and sub-centres throughout the country, the
health personnel like basic health workers and other para-medical staff
are being increasingly involved in the notification so as to improve the
situation.
The usual channel of notification starting from village
chowkidar or panchayat is the police station, primary health centre,
and district health officer. The Medical Officer-in-charge of the
Primary Health Centre is the authority responsible for coordination
and control of the disease under the overall charge of district health
officer/chief medical and health officer.
In urban areas, the responsibility of the notification of the
disease rests with the municipal authority or the staff designated by it.
Municipal health authorities notify the cases to the District Health
Officer.
Apart from municipal authorities the hospitals and
dispensaries are also required in most States to notify the cases of
notifiable diseases to the local authorities and to district health officer.
Private practitioners have not yet effectively been involved in the
notification system except in some States. Efforts have also been made
in few States to elicit co-operation of the general public, particularly the
head of the family in which a case of notifiable disease occurs.
Christian Medical College, Vellore, in collaboration with the
Directorate of Health Services, Tamil Nadu, has developed a good
system of voluntary notification of selected diseases and traffic
accidents in the North Arcot, Ambedkar and Tiruvannamalai
Sambuvarayar Districts. Cases are regularly reported by both the
Government and private doctors and hospitals voluntarily.
Confirmation is done by medical college.
4.6
Defects in Notification
Common defects in notification are under or over reporting,
delay and inaccuracy in the reporting of cases. Sometimes the cases are
notified only during the epidemic peaks or when it has already caused
significant morbidity and mortality. Delay is an indirect cause of
spread of the disease and occurrence of cases which could be otherwise
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prevented. Similarly, it is often observed that causes of morbidity or
mortality are wrongly reported, classical examples being mis-reporting
of chickenpox as smallpox, and of cholera as of gastroenteritis, or vice
versa. Stray cases are seldom reported. The usual practice is to report
cases when the epidemic is fully established and a large number of
cases have occurred with some deaths. Besides, cases are often grossly
under reported as well as mis-reported. Efforts are, however, being
made to remedy these defects as far as possible.
For prompt notification many States were using the procedure
of notification through pre-paid postcards distributed amongst the
health personnel. This system was already in vogue in some States like
Andhra Pradesh, Mysore, Uttar Pradesh, Delhi etc. but now it is hardly
practised.
Central Council of Health in its 14th Meeting held in October,
196731 in Delhi studied the problem of delayed reporting of the
primary outbreaks of epidemic diseases in the rural areas and
recommended that the present system of reporting through the agency
of panchayats should be improved and revitalised. The Council also
recommended that the staff of P.H.Cs., particularly the basic health
‘workers now the multipurpose health workers should be made
responsible for reporting of outbreaks of epidemic diseases in their
areas and Medical Officer of the PHC should co-ordinate the reporting
system at the Block level. It was also recommended that self addressed
and prepaid postcard of different colours for different disease should
be supplied to all workers at the periphery not only to those of health
department but also to panchayat, revenue department and teachers of
the primary schools. It was hoped that with the implementation of
these recommendations, the notification system would improve to the
extent that a regular flow of accurate statistics of communicable
diseases is ensured.
The Central Council of Health in its 16th Meeting held in
November, 196932 in Bhopal recommended that a Committee be
constituted consisting of representatives of Ministry of Health,
Ministry of Home Affairs (Registrar General of India), Ministry of
Defence, Ministry of Railways, Indian Council of Medical Research,
Indian Medical Council, Indian Medical Association, Employees' State
Insurance Corporation and State Governments. This Committee
would go into the problem of notifications of communicable disease on
a uniform pattern throughout the country. However, the same did not
31
32
Proceedings of the 14th meeting of Central Council of Health, October, 1967.
Summary proceedings of the 16th Meeting of the Central Council of Health: Govt, of India,
Ministry of Health & Family Planning and works. Housing and Urban Development - 4th-5th
Nov.. 1969.
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materialise,
ineffective.
4.7
In brief, the system of notification in India is largely
Epidemiological Units and Investigations
Epidemiological investigations should have a key role to play in
effective control of a disease. These investigations have become an
integral part of various disease control and. eradication programmes.
For checking spread of any epidemic, prompt epidemiological
investigation towards determination of focal points, the route of
dissemination, source of infection, and groups of population exposed
to immediate risk of infection, is absolutely necessary.
For
coordinating and carrying out such investigations, epidemiological
units/cells have already been established in a number of States.
Particular mention may be made of epidemiological units that have
been established in Andhra Pradesh, Tamil Nadu, Karnataka and
Maharashtra, etc. In the States where no epidemiological unit has yet
been established epidemiological investigations are carried out by the
State Epidemiologists or the individual programme officers.
Investigations are also carried out by national institutes/centres
dike National Institute of Communicable diseases, Delhi; All Indie
Institute of Hygiene and Public Health, Calcutta; National Institute o
Virology, Pune; School of Tropical Medicine and some medical colleges
etc. Besides coordinating the control measures under the Plague and
Guineaworm Eradication Programmes, National Institute of
Communicable Diseases has been carrying out regularly
epidemiological investigations for Cholera, haemorrhagic and dengue
fevers, viral hepatitis, Japanese encephalitis, Kala-azar, Malaria.
Plague, Poliomyelitis, meningitis, typhoid, food poisoning, typhus, ano
other communicable diseases to assist the States in the control o.
epidemics.
National institute of Communicable Diseases also undertake
surveillance of several communicable diseases viz. Cholera, Japanes
encephalitis, Kala-azar, Guineaworm, viral hepatitis, AIDS
poliomyelitis etc.
Medical Colleges and teaching hospitals are also involved
whenever necessary in the conduct of investigations of local epidemics.
4.8
Public Health Laboratories
Public Health Laboratories play a prominent role in tK
verification and confirmation of diagnosis. Laboratory services ca
help in the following ways:-
81
plisfmal.doc
a)
confirming the aetiological agent responsible for the
disease causation;
b)
tracing of the spread of the outbreak;
c)
studying the natural cycle of the disease;
d)
examining epidemiological character of the aetiological
agent with reference to changing pathogenicity,
invasiveness, drug resistance etc.
Public Health Laboratories also play an important role in
determining the control strategy, based on finding of systematic
studies done in regard to the pattern of disease prevalence and the
immunity status of different groups of population. In fact, efficient co
ordination between local laboratory services and the epidemiological
unit is imperative for assessment of the problem, initiation of effective
containment measures and evaluation of the control steps undertaken.
In these public health laboratories usually facilities for Bacteriological
isolation work, water analysis, food analysis, etc. exist. There is usually
no facility for virus isolation work though some of them carry out
•serological work.
In most of the States public health laboratories are not
functioning very satisfactorily. In some States like Tamil Nadu,
Maharashtra, Karnataka, Gujarat, etc. some of the public health
laboratories are well equipped and functioning well.
4.9
Isolation and treatment facilities
Subsequent to case detection and notification, isolation and
treatment is important. For this purpose, infectious diseases hospitals
are functioning in the important towns and cities of various States.
Besides, in many general hospitals, provision has been made for
separate infectious diseases wards. In case of sudden outbreak of
epidemics or during important festivals and fairs, temporary isolation
and treatment camps are also established wherever necessary.
4.10
Quarantine Administration
’International Quarantine1 being a central subject, quarantine
administration at the six major ports, viz. Calcutta, Visakhapatnam,
Madras, Cochine, Bombay and Cochin and five international airports
viz. Bombay (Santa Cruz), Calcutta (Dum Dum), Madras
(Meenambakkam), Delhi (LG.I.A), and Tiruchirapalli is carried out by
the Central Government under the Indian Port Health Rules, 1955, and
the Indian Aircraft (Public Health) Rules, 1954, which are based on the
82
phsfinai.doc
International Health Regulations.
Arrangements for the health
clearance of aircraft exist at the diversionary airports of Lucknow,
Gaya, Nagpur, Begumpet, Ahmedabad, Pune and Bangalore and also
at Car Nicobar, Trivandrum and Amritsar airports.
The Indian Port Health Rules, 1955 are also applicable to minor
ports having international traffic. Since the volume of traffic at minor
ports does not warrant the appointment of whole time port health
officers, local medical officers of the State Government are appointed
as part time Port Health Officers by the Maritime State Governments
concerned under powers conferred on them by the Central
Government in regard to the functions under Section 17 of the Indian
Ports Act, 1908.
Introduction of faster and more frequent traffic between India
and yellow fever infected areas in Africa and America, and favourable
meteorological conditions for the growth of Aedes aegypti mosquitoes
poses a serious threat of India from this disease. The Government of
India is taking special measures to prevent introduction of the disease
into the country through aerial and maritime traffic. All persons
including children arriving in India within 9 days of their departure
Jrom yellow fever infected areas without valid vaccination certificates
are detained in quarantine.
4.11
Anti-Mosquito and anti-rodent measures at Ports and Airports
Intensive anti-mosquito anti-rodent and other sanitary measures
are taken in all the major ports and International Airports. In the Ports
these measures are undertaken by the Port Authorities, while in the
Airports by the Government of India. At the instance of the Ministry
of Health & Family Welfare and Urban affairs & Employment, the
Director General, Civil Aviation has issued instructions to Aerodrome
authorities to incorporate Standard Health Clauses in the agreements
pertaining to lease of Airports land by them to other parties, for the
purpose of maintenance of public health of the Airports including
sanitation, control and prevention of nuisance from insects, rodents or
any other sources and prevention of abuse of the water sources and
drainage facilities provided in the areas of the respective Airports.
4.12
Collection and dissemination of Statistics
4.12.1 Weekly Epidemiological Statistics:
Central Bureau of Health Intelligence, Directorate General of
Health Services, is receiving periodical statements on weekly basis in
respect of incidence of communicable diseases, especially cholera,
yellow fever, and plague (which are iinternationally quarantinable
83
phsfinal.doc
diseases) from various States and Union Territories of the country. The
States and Union Territories furnish the weekly statements showing
figures of cholera, plague etc. for each district, first provisionally
through telegrams followed by final statements within another two
weeks. In final weekly statements, the district-wise figures are given
with rural/urban break-up. The information about the names of sub
divisions, villages or towns affected in the district are also included in
the final statements.
The information on declaration of fresh outbreaks from any of
the quarantinable diseases or freedom from infection due to these
diseases is also regularly received from the local areas i.e., districts and
major airports and seaport towns. The same is communicated to
WHO, Geneva through cablegrams. A consolidated weekly
epidemiological record is prepared, containing information on (i) cases
and deaths of cholera, plague, yellow fever in each of the affected local
areas; (ii) declaration of fresh infection from quarantinable diseases or
freedom therefrom and (iii) names of affected tehsils/ taluks, villages or
towns in each local area. The weekly epidemiological record is widely
disseminated to national and international agencies including WHO.
This is also published in the Supplement to the Gazette of India every
*week.
4.12.2 Monthly Surveillance Report:
Till recently statistics of cases and deaths of communicable
diseases other than cholera, yellow fever and plague were not being
collected on regular basis. The Central Bureau of Health Intelligence
made an attempt to collect such statistics for some important
communicable diseases from all the States and Union Territories in
1966. The information is now being collected in a monthly proforma.
The response is quite encouraging although the figures suffer from
incompleteness of coverage. In fact, most of the States are furnishing
the cases and deaths of these communicable diseases covering only
indoor and out door patients treated in medical institutions and indoor
deaths among them. Computerised HMIS is under implementation in
some States. The same will be covered in details subsequently.
*
Central Bureau of Health Intelligence started bringing out a
consolidated monthly report entitled. "Monthly Surveillance Report" in
1968. Detailed analysis of statistics of cholera, plague and other
communicable disease alongwith control measures is included in this
monthly report. Special reports on epidemics whenever reported are
also incorporated. Besides, reports on progress of various national
disease control/eradication programmes are also quite often included
in the Monthly Surveillance Report.
84
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4.12.3 Inter-State exchange of epidemiological information:
Realising that inter-State exchange of epidemiological
information helps in checking the inter-State spread of the diseases the
States have been requested to send the copies of their weekly
epidemiological statements as well as telegraphic declarations of fresh
infection or freedom therefrom , to the neighbouring States. The inter
state exchange of epidemiological information covers all
communicable diseases especially cholera, plague, haemorrhagic fever,
and dengue fever. The State have also been requested that if on
investigation it is found that a case or cases of cholera, plague or other
communicable diseases have been reported from some other districts
in the same State or from any other State the concerned district as well
as State authorities should be informed immediately. Most States have
made arrangements for inter State exchange of epidemiological
information on the above lines.
4.12.4 National Disease Control/Eradication Programmes:
Other important sources of information on morbidity and
mortality are the National disease control and eradication
.programmes. National Malaria Eradication Programme has yielded a
continuous series of morbidity data on the basis of active and passive
surveillance procedures. National Leprosy Eradication Programme
also yields figures of prevalence on the basis of the surveys which are
aimed at case detection for subsequent treatment. Programmes for
other diseases like Tuberculosis, Filariasis, Cholera, and Plague also
yield useful information on morbidity and mortality. A sample survey
was conducted under the assessment of prevalence of Tuberculosis
during 1955-5833. The reports on the various diseases regarding their
prevalence and control are brought out by Central Bureau of Health
Intelligence, other sections of the Directorate General of Health
Services and also by the institutions that carry out the studies. It may
be mentioned that the CBHI has conducted a number of
epidemiological studies using the routinely collected data or data
collected specially on ad-hoc basis. National Institute of Health &
Family Welfare also has undertaken studies on Institutional morbidity,
and mortality pattern in India based on available information though^
various sources like CBHI, Institutions, hospitals, etc.34
33
Tuberculosis in India - A sample survey 1955-58. Indian Council of Medical Research. New
34
Institutional Morbidity and Mortality Pattern in India: U.Dosaju, M Kataria and P P Talwar’
Statistics and Demography Department, NIH&FW, New Delhi, 1985.
85
phsfinal.de.
4.12.5 Registration of deaths:
The continuous and compulsory registration of vital events is
very useful as a source for vital statistics and as a legal document. India
has a long tradition of registration of vital events particularly births
and deaths; and the administrative machinery for the purpose has been
in existence for over a century.
In 1873, the Government of India had passed the Births, Deaths
and Marriages Registration Act, but the Act provided only for
voluntary registration. Subsequently, individual States like the Tamil
Nadu, Karnataka and Assam passed their own Acts.
The system of civil registration as it obtains today, however,
leaves much to be desired in matters of coverage, quality timeliness of
data and availability of final results for administration and research.
However, many steps for improvement and upgrading of system of
registration have been and are being taken by the office of the Registrar
General of India. The Planning Commission had taken note of the
pressing need for strengthening the vital statistics system on a priority
basis. Certain short-term schemes, such as, the sample registration
•scheme with adequate supervision and model registration in areas
close to the rural health centres, to provide immediately reliable birth
and death rates, and also some long-term schemes for strengthening
and steadily improving the normal registration systems are in
operation. In an effort to improve the civil registration system, the
Government of India promulgated the Central Births and Deaths
Registration Act in 1969. The Act came into force on 1st April 1970.
The Act provides for compulsory registration of births and deaths
throughout the country and compilation of vital statistics in the States
so as to ensure uniformity and comparability of data.
The
implementation of the Act required adoption of rules for which also,
model guidelines have been provided. The Act also fixes the
responsibility for reporting births and deaths. In the Act provision of
fine also exists.
4.12.6 Model Registration:35
The Registrar General of India initiated in early sixties a scheme
called Model Registration Scheme pursuant to recommendations made
in the Conference on Improvement of Vital Statistics held in 1961. The
scheme has been renamed in 1982 as Survey of Causes of Death
(Rural). Initially taken up on a very limited scale and later on it has
been extended to larger number of States. Subsequently, the coverage
35
Survey of Causes of Death (Rural): Annual Report. 1992. Registrar General of India, Ministry of
Home Affairs.
86
phsfinal.doc
has been further enhanced and the number of sample PHC villages was
increased to 1200. In 1992 the survey was conducted for 1305 sample
villages of selected PHC spread over to 23 States and 2 Union
Territories. Information was being collected through the Medical
Officer of the PHC who is the guardian of work at PHC level. He
guided the para medical staff in ascertaining the causes of death
through lay diagnosis technique.
During 1988-92 the ten leading causes of death were : Senility,
disorders of respiratory system, disorders of circulatory system, causes
peculiar to infancy, accidents and injuries, fevers, digestive disorders,
disorders of the central nervous system, child birth and pregnancy and
others. Six important leading causes of death in infants (causes
peculiar to infancy) were pre-maturity, respiratory infection, diarrhoea,
congenital mal formation, cord infection (including tetanus) and birth
injury. Six major causes of maternal death (child birth and pregnancy)
were bleeding of pregnancy and puerperium, anaemia, abortion,
toxaemia, puerperal sepsis and mal-position of the child.
A Technical Advisory Committee on Vital Statistics was
appointed by the Registrar General of India in 1991 which studied in•depth the system. Some of the observations were:
*
All the events of births and deaths of usual residents of the
sample villages of selected PHCs should be recorded,
irrespective of their place of occurrence alongwith the events of
visitors in the sample villages.
*
All the missed events should be recorded through half-yearly
survey to ensure completeness of coverage.
*
To cover more population under this survey, the population of
the sample village should be between 2000 and 5000.
*
A nearby village at a distance of 3 to 5 Kms. from the PHC may
be selected for the survey.
*
Intensive monitoring of the survey work in the field may be
introduced by the State implementing agencies and the office of
the Registrar General, India.
A team of international experts under USAID visited and
studied the scheme in 1993.
Based on their recommendations,
population at risk is now being collected for further analysis of survey
data. The coverage under the scheme is being further enhanced to at
least 1 % of the total rural population of India.
87
phsfinal.doc
4.12.7 Medical certification of cause of death:
To improve the cause of death statistics, the scheme of medical
certification of cause of death according to international list of causes of
death has been functioning in most of the States in collaboration with
the Registrar General of India. This scheme yields very useful
information on cause of death statistics. It may be mentioned that the
deaths for which this information (i.e., medical certification of cause of
death) is available represents only a small proportion of total deaths. It
covers urban areas and the government hospitals etc are mostly
covered. Seven leading causes of deaths were diseases of circulatory
system, infectious and parasite diseases, ill-defined conditions, injury
and poisoning, certain conditions originating in perinatal period,
diseases of respiratory system, and diseases of digestive system36.
4.12.8 Morbidity Surveys:
Role of morbidity surveys in yielding an integrated picture of
morbidity pattern in the community can hardly be over emphasized.
.So far, only very few systematic morbidity surveys have been carried
out37 - 40 General Health Surveys in some community development
Blocks were carried out during 1955-5841 under the auspices of
Directorate General of Health Services. Another important morbidity
survey was carried out in 1961 among Central Government Health
Scheme beneficiaries42 in Delhi. Morbidity surveys with limited scope
have also been carried out in various States. However as the same has
not been taken up in right earnestness, it has not generated very useful
country wide data. The following reasons could be attributed to:
a)
b)
c)
d)
e)
36
37
38
39
40
41
42
Confined to certain specified and restricted area
Varied in their objectives
Covering different population
Heterogenous in their design and type of information
Ad-hoc in nature.
Mortality Statistics of Causes of Death 1988: Registrar General of India (Sept., 1'992).
Report on the Short Medical and Health Survey of the Sikkim State: Seal S.C. and Bhattacharya
L.M.; Govt, of India Press, Calcutta-1954.
Report of the Resurvey of Singur Health Centre Area 1957-58: S.C. Seal, K C Patnaik, R.C.Sen,
L.M. Bhattacharya & others, Govt, of India Press, Nasik (1966).
National Sample Survey, Report on Morbidity: No.63-49; Cabinet Secretariat 1960,1961.
Studies on Morbidity Pattern of Children in an Urban Community. A. Chowdhury & K..C.
Chowdhury: Indian Jr. of Paediatirics; Vol.29, 1962.
Report of Short General Health Survey in nine Community Development Blocks: DGHS
Report on the Contributing Health Service Scheme for 1961, Ministry of Health, Government of
India,(vol.l-3).
88
phsfinal.doc
4.12.9 Sample Registration
The sample Registration System (SRS) is a dual record system
with the main objective of providing reliable estimates of birth and
death rates at the national and sub-national levels. The SRS was
initiated by the Registrar General of India on a pilot basis in few
selected states in 1964-65. It now covers almost the entire country
except Mizoram.
The field investigation consists of continuous
enumeration of births and deaths by a resident enumerator, generally a
teacher and an independent survey every six months by a computer
supervisor. The data obtained through these two operations are
matched. The unmatched and partially matched events are re-verified
in the field and thereafter and unduplicated count of births and deaths
is obtained. During 1994 SRS operated in 6,300 sampling units selected
from 1991 census from of which 4149 were in rural areas and 2151 were
in urban areas. The sample unit in the rural areas is a village or a
segment of a village. In the urban area the ultimate sampling unit is a
census block. The birth rate in India was 28.7/1000 (Urban-23.7/1000,
Rural-30.4/1000) and the death rate was 9.3/1000 (Urban-10.6/1000,
.Rural-5.8/1000)43.
The Central Bureau of Health Intelligence (CBHI) of the
Directorate General of Health Services is responsible for:
♦ collection and processing of health statistics and dissemination
of information.
♦ epidemic intelligence for diseases covered under International
Health Regulations and other communicable diseases.
♦ Morbidity and mortality statistics, vital statistics, population
statistics, programme statistics etc.
♦ Field studies in priority areas of health information indicators
and health services research through field survey units located
at Bangalore, Bhubaneswar, Patna, Bhopal and Jaipur in the
regional offices for Health and Family Welfare.
♦ Development and strengthening
Information System (HMIS).
43
of
Health
Management
Sample Registration Bulletin, July 1995; Vol.29, No.2, Registrar General of India
89
phsfinal.doc
♦ Monitoring of health situations and important events in health
and related sectors by establishing control room during
emergencies.
♦ Conducting training programmes for medical and para-medical
staff in vital and health statistics and medical records.
♦ Monitoring and evaluation of strategies for health for all.
In addition to the above work by CBHI, vital statistics are
collected by the Registrar General of India through various schemes
like Sample Registration scheme. Model Registration Scheme, Medical
Certification of Cause of Deaths etc. Department of Family Welfare
also has got an Evaluation and Intelligence Division which collects
information relating to family planning.
4.12.10
Disease Surveillance
National Institute of Communicable Diseases (NICD) assists in
disease surveillance of those diseases which have got epidemic
•potentials like Cholera, Japanese Encephalitis, Dengue Haemorrhagic
Fever, Kala-azar, Viral Hepatitis, Poliomyelitis, AIDS, Plague etc.
However, the infrastructure that is available for the purpose is skeletal
and very inadequate and, therefore, the disease surveillance data are
grossly inadequate. Through all available the machinery, the data that
are available particularly in relation to epidemic diseases have been
further reviewed and some of the observations are as under:
4.12.10.1
MALARIA:
MALARIA CASES IN INDIA:1961-1994
YEAR
CASES
DEATHS
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
49151
59575
87306
112942
99667
145012
278214
274634
347975
694017
1322398
1428649
1930273
3167658
5166142
6467215
3
99
59
90
phsfmal.doc
YEAR
CASES
DEATHS
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
(PROV) 1993
(PROV) 1994
4740900
4144385
3064697
2898140
2701141
2182302
2018605
2184446
1864380
1792167
1663284
1854830
2017823
2018783
2117472
2125826
2274804
2200829
55
74
196
207
170
187
239
247
213
323
188
209
268
353
421
422
329
1069
CASES OF MALARIA
1961-1994
7000000
6000000
5000000
4000000
3000000
♦
2000000
1000000
.,■■■■..........
... i ....... .
0 Hmm!
19 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 9s
61
YEAR
Malaria surveillance was initiated primarily based on active
surveillance through regular fortnightly home visits but over a period
of time the system of surveillance has weakened and now it is
functioning primarily through passive surveillance. Data are obtained
through the vast network of infrastructure consisting of District
Health Offices, CHCs, PHCs and sub-centres. The programme has
recently been reviewed in 1985, 1992 and 1994-9544 45 46 . Some of the
observations are: NMEP data is indicative of trend and problem of
malaria is grossly underestimated. Surveillance is inadequate and
wanting in many areas. Laboratory services are not fully dependable
and lack supervision. Treatment is delayed and drug resistance is
increasing.
A strong epidemiological component needs to be
established in NMEP for effectively handling the problem at the
44
In-depth evaluation of modified plan of operation on NMEP 1985.
Task Force on Malaria 1992.
46
Expert Committee report on Malaria, 1995.
45
91
phsfinal.doc
periphery and generating appropriate surveillance data for meaningful
situation specific intervention.
The vector mosquitoes have also posed problems such as
insecticide resistance, change in bionomics, and finding new breeding
places due to ecological changes as a result of development, e.g.
irrigation canals in Rajasthan. The quality of spraying operations have
also gone down considerably.
Community participation and
involvement in NMEP is minimal.
Though appropriate technology for control of malaria is
available for different epidemiological paradigms of Malaria, the
administrative indifference, the organisational weakness and apathy of
middle level and peripheral workers in the States have led to periodic
epidemics and high mortality. Instead of piecemeal changes in the
strategy of Malaria control, the Central Government should appoint a
team of administrative and technical experts in planning, finance,
information, education and communication, epidemiology and
malariology to review the entire malaria problem vis-a-vis health care
delivery system in the country.
4.12.1Q.2
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS IN INDIA: 1984-1994
YEAR
CASES
DEATHS
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
3370
2490
7500
3315
6867
6489
2916
4071
2432
2291
786
2627
916
2627
1346
2404
2422
1291
1530
888
923
415
The vaccine against Japanese Encephalitis is effective. In fact
Japan has controlled JE through vaccination programme and changing
its agricultural practices.
Central Research Institute, Kasauli
manufactures limited quantity of vaccine. Pilot studies with JE vaccine
showed encouraging results. However, once the epidemic starts, role
of JE vaccine in aborting an epidemic is minimal47. Protecting large
number of people periodically with the JE vaccine with 3 doses needs
large resources. However, if proper surveillance can be undertaken
with appropriate entomological and laboratory support facilities in
47 Japanese Encephalitis, NICD, 1988.
92
phsfinal.doc
high risk areas, epidemics could be predicted to mount appropriate
intervention measures for aborting the outbreak.
4.12.10.3
KALA-AZAR
KALA-AZAR IN INDIA:1981-1994
YEAR
CASES
DEATHS
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
15075
12336
14551
17224
17277
17806
23685
22739
34489
57742
61670
77102
45459
24096
N.A.
N.A.
N.A.
67
44
72
94
131
497
606
838
1419
710
364
Resurgence of kala-azar in a big way has been primarily due to
inadequate surveillance and timely intervention. Diagnostic support is
grossly inadequate in the periphery and paucity of drugs has forced
people to take treatment from private sector resulting in increasing
number of cases though prevailing in the community go unreported.
Non availability of funds have contributed significantly in enhancing
the problem.
The current programme also does not have an
appropriate surveillance machinery and experts are of the view that it
is grossly underestimated48.
4.12.10.4
DENGUE
There is evidence that India has experienced outbreaks of
dengue and dengue haemorrhagic fever in recent years; however,
information regarding these outbreaks has not been well documented
or formally presented in the scientific literature. Though dengue has
been known to exist in India for over a century, two strains of dengue 1
virus were first isolated in 1945. Despite frequent outbreaks of dengue,
no report of heamorrhagic fever associated with dengue was made
until 1963. The epidemic lasted from 1963 to 65 and an estimated
100,000 cases occurred from Calcutta & Vizag. DHF & DSS were both
documented during the epidemic. More recently severe outbreaks of
dengue occurred in Delhi in 1988, Madras 1989, Calcutta 1990 and
again in Delhi in 1991. As dengue is not a notifiable disease.
48
Report of the Group on Experts on Kala-azar (Harcharan Singh Committee) - 1986.
93
phsfmal.doc
surveillance is not in place and expert opine several outbreaks go
unrecognised and unreported. Concern has further been aggravated
by the fact that dengue considered primarily an urban disease is being
increasingly reported from rural areas49 and there has been increasing
reports of Dengue haemorrhagic fever and Dengue shock syndrom
from different parts of India.
4.12.10.5
CHOLERA
CHOLERA IN INDIA: 1961-1994
YEAR
1961
1962
1963
1964
1965
1966
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
(PROV.)1991
(PROV.)1992
(PROV.)1993
(PROV.)1994
CASES
47637
27165
56988
56436
43285
13027
22587
19280
17268
17140
21344
40855
30997
21955
17492
9091
10708
5638
8717
6073
4693
9202
2642
5813
4211
11423
8957
5044
3704
7088
6911
9437
4958
DEATHS
16334
9403
20309
19836
12947
2788
4472
3757
3801
3595
2908
5308
2189
2320
861
538
263
312
309
200
217
432
68
154
71
224
215
72
87
150
55
53
52
49
WHO International Conference on DHF and National Brain Storming Session on Dengue 7-8 Feb..
1993 at Pune, India.
94
phsfinal.doc
NOTIFIED CASES OF CHOLERA
1961-1994
CASES (Thousands)
60000
50000
40000
30000
20000
10000
0
,
,
,
,
,
,
,
,
.
T
I
,
I
r—■
T
T
r
.
.
>
.
T
r
r
T
T
,
.
I
.
.
19 62 63 64 65 66 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94
61
YEAR
Though Cholera is notifiable all over the country and is covered
under International Health Regulation, number of cases are not
uniformly reported. Some states report only bacteriologically positive
cases and some report only clinical cases as laboratory support is not
available.
There is gross under reporting of cholera cases and deaths in the
-country. This is due to all patients with severe gastro enterities not
seeking medical care, poor diagnostic facilities and poor reporting
system from the private practitioners.
The recent finding of V.cholerae 0139 spreading to other parts
of the country is an area of major concern. It is further stated that
diagnostic support for this is also not widely available.
4.12.10.6
VIRAL HEPATITIS
VIRAL HEPATITIS IN INDIA: 1986-1994
YEAR
1986
1987
1988
1989
1990
1991
1992
1993
1994
CASES
154533
179862
145903
134948
124531
93497
98047
117789
86134
95
DEATHS
2246
1923
2022
1856
1793
1449
1268
N.A.
N.A.
phsfinal.doc
Viral hepatitis information is available through the institutional
framework and the data is grossly an underestimate. Many of the
jaundice cases particularly viral hepatitis A are milder in nature and
do not report to the institution and a significant chunk of jaundice
cases receive treatment through the private sector.
There is substantial under reporting of viral hepatitis in India.
Majority of viral hepatitis patients especially in rural areas do not
report to the practitioners of modern system of medicine and hence do
not get reported. Only when viral hepatitis outbreaks occur especially
in urban areas does the notification system provide some measure of
accurate information on the number of cases in the outbreak.
On a very skeletal basis NICD has initiated Viral Hepatitis
Surveillance and has established 13 regional Viral Hepatitis
Surveillance Centres. These centres have developed expertise for
laboratory investigations for Hepatitis A to E. Moreover, as scanty
resources for diagnostic reagents are available, the surveillance
machinery has not developed to a desired extent. However, it has
undertaken several focal studies.
Focal community based studies carried out by different
institution indicate that the number of hepatitis cases reported through
institutional frame work is just a tip of the iceberg. ' In addition,
appropriate laboratory support is not available for identifying the
causative organism in most of the areas.
From the above, it is clear that existing health surveillance
system mechanism is grossly deficient in its nature and content and
does not generate an effective immediate response activity for better
control of communicable diseases particularly epidemic-prone
diseases.
4.13
OBSERVATIONS, SUGGESTIONS & OVERVIEW:
4.13.1
The notification system varies widely in states and within the
state from area to area. Even diseases which are covered under the
International Health Regulations, uniform case definition is not
followed. Some states provide information based on bacteriological
diagnosis and some states provide information based on clinical
diagnosis. So the data are not comparable. Many States and local
areas do not report cholera because of possible punitive/regulatory
measures associated with reporting of their number of cases. There is
an urgent need that system of notification is reviewed by constituting
a Committee immediately which should finalise the diseases to be
covered under notification under various categories viz. diseases
under International Health Regulations which should be mandatory by
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all States, Union Territories and local areas. Diseases under National
Health Regulations which should also be mandatory by all States and
Union Territories and local areas. In view of the very nature of these
diseases being covered under International Health Regulations and
National Health Regulations even nil reporting should be resorted to.
4.13.2
Diseases under International Health Regulations and other
identified epidemic prone diseases under National Health Regulations
should be reported once in a week. During the epidemic time, daily
reporting should be resorted to. Other diseases being covered under
the National Health Regulations should be reported once in a month.
4.13.3
Diseases under Provincial Health Regulations. In addition to
the diseases mentioned under items 1 & 2 above, some more diseases
could be added depending upon the local situation.
4.13.4
Diseases under Local Health Regulations:
In addition to
diseases under 1, 2 & 3 above, some local areas might require addition
of certain more diseases depending upon situation. The same should
be included under this category.
1
It may be stated that 16th meeting of the Central Council of
Health recommended for constitution of a committee to review the
notification system and examine a uniform pattern of notification
through out the country. However, the same never materialised34.
4.13.5
The notification system should be appropriately backed by legal
provisions all over the country. Unfortunately, the legal provisions are
very variable and punitive measures are non existent and even if it is
there, it is hardly implemented. Until and unless the notification
system has got legal backing it is not likely to generate relevant
epidemiological data for an appropriate response mechanism to be
mounted. Therefore, the committee strongly recommends that a
uniform notification system duly supported by legal provisions should
be implemented. Implementation of Model Public Health Act all over
the country by various local authorities will enable the notification
mechanism to greatly strengthen the Public Health System.
Epidemiological services and support system in various States are
grossly inadequate because of non-availability of appropriate
laboratory investigative facilities. Though most of the States have got
Public Health laboratories but not adequate facilities are available in
those laboratories to provide appropriate laboratory investigative
facilities for identifying the nature and the spread of the disease.
Virological investigations are not undertaken and bacteriological
examinations are of routine nature. Rapid diagnostic techniques are
hardly available. Non-availability of resources for procurement of
appropriate reagents, disposables etc. has led to cessation of practice of
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several conventional techniques of bacteriological isolation and
procedures in many laboratories.
4.13.6
Due to non-availability of qualified personnel many of the
Public Health laboratories are run by General Duty Medical Officers
and the technical expertise in most of these laboratories are much short
of the minimum necessary inputs which can provide a good support to
the epidemiological intelligence services. The recommendations of the
Health Manpower Planning, Production and Management Committee
should be followed in right earnestness so that appropriate manpower
is available in these areas.
4.13.7
With the 73rd and 74th constitutional amendments giving more
autonomy to the Panchayati Raj system and urban local authority
could be appropriately revitalised in channelling the information
generated and this will vastly improve quick health intervention in the
areas being affected.
4.13.8
National Institute of Communicable Diseases, Delhi and
Christian Medical College, Vellore have worked on Models of
obtaining information involving peripheral health workers and
.physicians in the private sector respectively and if both the models can
be appropriately dovetailed within the existing HMIS, the same will
provide early warning signals for detecting an impending epidemic.
NICD may, therefore, in collaboration with CBHI prepare an
appropriate protocol for initiating a suitable epidemic disease
surveillance programme in few States within the HMIS on a pilot
basis.
4.13.9
The diseases that are to be covered under the notification system
should consider adequately the problems of new, emerging and reemerging infections so that appropriate response could be generated to
tackle the situation.
4.13.10i
The weekly epidemiological statistics being provided by CBHI
does not have an appropriate feed back channel to the various
peripheral agencies. The same need to be developed in the pattern of
MMWR (Morbidity Mortality Weekly Report) published by CDC and
National Institute of Communicable Diseases may ' take up the
responsibility for the same and initiate action in this regard to prepare
an MMWR type of Bulletin for rapid feed back to all participating
agencies, experts etc. CBHI may continue to act as a nodal agency for
diseases which are being reported on a monthly basis. The diseases
under International Health Regulations and the diseases under
National Health Regulations having epidemic potentiality should be
the responsibility of NICD which has the due expertise in appreciating
the problem and initiating action accordingly.
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4.13.11
The system of civil registration of deaths. Model Registration
Scheme, Sample Registration Scheme subsequently renamed as Survey
of Causes of Death (Rural), certification of causes of death should be
continuously improved by enlarging its scope and coverage so that it
gives more relevant data in the context of the entire country.
4.13.12
Morbidity survey is highly expensive and is often considered
not cost effective. However, it generates very good data. If on an
appropriate national sample basis morbidity survey could be orgaised
through the existing health care services once in lOor 20 years, it may
provide meaningful data on changing health and disease scenario.
4.13.13>
National Institute of Communicable Diseases has recently
proposed a centrally sponsored National Disease Surveillance
Programme within the existing health infrastructure to generate
appropriate epidemiological data with particular reference to epidemic
diseases and having emphasis on new, emerging and re-emerging
health problems with appropriate laboratory support involving
already existing expertise in various national institutes, medical
colleges, district public health laboratories and modernising the
laboratory support system.
Fourth Conference of the Central Council of Health & Family
Welfare held in 1995 recommended initiation of a National Disease
Surveillance Programme for strengthening of health surveillance and
support services as a centrally sponsored scheme within the existing
health infrastructure with appropriate laboratory support involving
already existing expertise in various national institutes, medical
colleges and district public health laboratories. Additional support
needs to be provided to modernise laboratory support system through
strengthening of conventional techniques and procedures, induction of
rapid diagnostic tests, molecular epidemiology capability so that the
public health system is updated and modernised to respond to any
eventual public health emergency. Initiation of a national disease
surveillance programme will improve notification system, institution
of early warning signal mechanism and would enhance prompt
response capability.
4.14
INSTITUTIONAL SUPPORT SERVICES
All the major national health and family welfare programmes
have some institutional support services like National Tuberculosis
Control Programme is supported by National Tuberculosis Institute^
Bangalore, National Malaria Eradication Programme is supported by
National Institute of Communicable Diseases, Delhi & Malaria
Research Centre, Delhi, National Leprosy Eradication Programme by
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the Central Leprosy Training and Research Institute, Chingleput and
its other regional centres. National Family Welfare Programme by
National Institute of Health & Family Welfare, New Delhi etc. to name
a few.
0
In the country, we have 146 medical colleges. Large number of
national institutes covering various fields of activities in medical and
health care also exist. These institutes are either under the Ministry of
Health & Family Welfare or Indian Council of Medical Research or
under Department of Biotechnology or Council of Scientific and
Industrial Research or Department of Science and Technology etc. In
addition, a large number of voluntary organisations are also active in
the field of public health, sanitation, health and family welfare
activities.
There is no formal mechanism as on date which enlists support
from these organisations through a well designed guideline for flow of
information, exchange of expertise though it is undeniably true that
most of these institutes have reasonably sound, modern, sophisticated
diagnostic support services and the technical expertise in supporting
various health care activities. It is a matter of concern that even in spite
-of the availability of such expertise within the health care system, the
same are not being harnessed through an appropriately drawn out well
structured mechanism and as a result even in spite of having the
expertise in terms of personnel, procedures etc. often the same are
imported at exorbitant cost thus straining the resources available. This
has been evident in the recent outbreak of plague where international
experts were called to assist the national health authorities in seeking
solution to the problem.
Many institutions are established. However, they are not
appropriately utilised to their full potential. This is primarily due to
the inappropriate linkages with the health care delivery system. With
modern communication facility like E-mail, fax, computers, satellite
linkages it is neither difficult nor impossible to harness information
generated in these institutions, national laboratories, medical colleges
through an appropriate linkage mechanism for use in the national or
provincial level. In fact, this is highly essential so that expertise in any
part of the country could be harnessed by other agencies in times of
need. Only what is needed an appropriate programme of linking these
national institutions and laboratories through a well designed protocol
of collecting and transmitting the information. This will reduce
unnecessary duplication of resources and help better utilisation of the
existing facilities.
Continuing education is very important in updating the
expertise for more effective health care delivery services. If all the
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available institutions including medical colleges and national
laboratories are appropriately linked together for enhancing the
capacity of the health care delivery services this will tremendously
improve the functioning of the public health system.
The development of public health laboratory services has not
been up to the mark. We have expertise in different institutions for
study of microbes at sub cellular and molecular levels but we have
inadequate facilities in isolation and characterisation of common
infectious agents at the peripheral health care system49A .
Poor referral system under the primary health care
infrastructure has led to less than satisfactory performance of several
programmes. To establish proper referral services means development
of a linkage mechanism between the different institutions from sub
centre/primary health centre/community health centre to sub district
and district level institutions, the regional institutions, the medical
colleges and the national centres. This linkage mechanism should also
try to involve institutions in the NGO sectors to make the system more
responsive to the situation.
The success of public health system will depend on its
surveillance and response capability through quick access to epidemic
situations and mobilisation of experts within the health care delivery
system in arriving at a diagnosis and mounting appropriate control
measures through investigation of outbreaks.
Technical Advisory Committee on Plague has observed that
some attempts are being made to develop the national disease
surveillance system with an appropriate network of various
institutions, medical colleges and the implementing agencies and the
committee recommended initiation of such disease surveillance system
with focus of attention on new, emerging and re-emerging
infections111. Such a system must develop effective linkage mechanism
at the national level and if necessary may be come a part of the regional
or even global networking mechanism.
Indian Medical Association (IMA) has a membership of
approximately 100,000 doctors. They can play an active role in disease
surveillance mechanism. IMA has been involved under the Family
Welfare Programme, AIDS Control Programme and various other
health programmes but their involvement needs to be augmented
significantly. In addition all those practitioners of modern medicine
who are on the registers of Medical Council of India and state medical
councils (number more than 400,000) need to be sensitised to such a
49A Technical Advisory Committee on Plague 1995.
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vital national need. So, the linkage mechanism of the disease
surveillance system should involve medical practioners adequately to
strengthen response capability of the public health system. In this
context, it is stated that if the notification system proposed under the
National Disease Surveillance Programme is appropriately backed by
legal provisions the same will strengthen the response capability of the
public health system further.
While developing the linkage mechanism with various
institutions and medical colleges, the thrust area of involvement will be
in the area community diagnosis. Presently, diagnostic support
services in the medical colleges are mostly to meet the individual
patient's needs. The same needs to be extended through appropriate
inputs and linkage mechanism for flow of various clinical materials
from the periphery so that diagnositic support services could be
further widened and public health system gets further strengthened.
In the recently concluded meetings with the national institutions
and medical colleges it has been strongly recommended that initiation
of a nation-wide disease surveillance system with emphasis on new,
emerging and re-emerging health problems involving an appropriate
-referral system and linkage mechanism from the periphery to the
national level should receive priority attention to make the response
capability of the public health system more updated and modern.
The institutional linkage mechanism should be such that the
institutes involved converge appropriately in relation to provision of
dignostic services, collection, tabulation, interpretation and
dissemination of information and its appropriate feed back.
The committee under the convenorship of Union Secretary of
Health on National Mission of Environmental Health and Sanitation in
its report in July, 95 has recommended initiation of a Sub-mission on
Strengthening of Health Surveillance and Support Services which
not only includes a national disease surveillance system covering
infectious diseases but also other health conditions.
Com H 5V2-
05648
>-'*1I
•
102
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STATUS OF CONTROL STRATEGIES
FOR EPIDEMIC DISEASES
5.0
STATUS OF CONTROL STRATEGIES FOR EPIDEMIC DISEASES
5.1
General Introduction:
Without thorough understanding of what constitutes an
epidemic, one cannot develop strategy for its control. Most recent
definition of epidemic is the occurrence in a community or region of
cases of illness, specific health related behaviour, or other healthrelated events clearly in excess of normal expectancy. The community
or region, and the time period in which the cases occur, are specified
precisely. The number of cases indicating the presence of an epidemic
will vary according to the agent, size and type of population exposed,
previous experience or lack of exposure to the disease, and time and
place of occurrence; epidemicity is thus relative to usual frequency of
the disease in the same area, among the specified population, at the
same season of the year. A single case of a communicable disease long
absent from a population or first invasion by a disease not previously
recognised in that area requires immediate reporting and full field
investigation; two cases of such a disease associated in time and place
may be sufficient evidence to be considered an epidemic. However, it
is necessary to consider what constitutes an impending or actual
.emergency for public health services and to identify early warning
indicators. Even the selection of disease that can cause epidemic often
poses a problem. Some diseases such as, influenza, cholera, malaria,
plague, dengue, Japanese encephalitis etc. are well known to cause
epidemic. There are also diseases which can cause an epidemic or a
focal outbreak in an unusual circumstances like a refugee camp, man
made or natural calamity, among a large group of pilgrims/tourists,
following importation of disease viz. rickettsial infection,
schistosomiasis, Legionnaire disease etc.
In the past the term epidemic was used almost exclusively to
describe an acute outbreak of infectious diseases. Now in recent
decades, the term epidemic has been broadened to include infections or
chronic degenerative diseases occurring at an unusual frequency.
The key words in the definition of epidemics are "in excess of
expected occurrence". In developed countries like the USA, even one
case of cholera would cause a potential epidemic whereas in countries
like India and Bangladesh, a few hundred cases of cholera is usual
expected occurrence. An arbitrary limit of two standard deviations
from its endemic frequency is used to define epidemic threshold. By
and large in usual practice communicable diseases with epidemic
potential having short incubation period are considered epidemic
prone diseases.
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An epidemic of a communicable disease is occurrence of a
number of cases of the communicable disease known or suspected to
be of communicable nature i.e. unusual in number or unexpected for
the given place and time. It often evolves very rapidly needing a quick
response.
A health emergency can be defined only within the context of
the social, political and epidemiological circumstances in which it
occurs. Since such circumstances significantly affect the urgency of a
problem the following need to be taken into consideration in initiating
health emergency measures:
A. There is a risk of introduction and spread of the disease in the
population.
B. A large number of cases may reasonably be expected to occur.
C. The disease involved is of such severity as to lead to high
morbidity, disability or death.
D. There is a risk of social and/or economic disruption resulting
from the presence of the disease.
E. The national authorities are unable to cope adequately with the
situation because of lack or insufficiency of technical or
professional personnel, organisational experience, necessary
supplies of equipment and material and material like drugs,
vaccines, diagnostic materials, vector control agents.
F. There is a danger of international transmission.
G. Health emergencies often result in human and economic losses
and often lead to political problems. It is the responsibility of
the health services to control or preferably to prevent such
situation by organising an effective action plan for
epidemiological services.'
There is no centrally sponsored/central scheme to tackle
epidemic prone diseases in the above context in India, though, there
are several diseases which have epidemic potentiality viz. malaria,
kala-azar, measles, poliomyelitis, etc. which are covered through
National Disease Control Programmes.
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5.2
Malaria:
5.2.1
NMEP guidelines with respect to detection and containment of
epidemics states50:
5.2.2
The drier parts of north west India consisting of Punjab,
Haryana, Delhi, north western section of Uttar Pradesh, semi arid
climatic zone with annual rainfall upto 100 mm. Indo Gangagetic
plains are known major epidemic prone areas contributing to periodic
fulminating malaria epidemics resulting in large number of malaria
deaths. This is particularly so with unusual monsoon rainfall and
other favourable conditions. It used to occur every 7-9 years with high
mortality. The prediction of such epidemics was worked out by
Christophers and brought to high degree of accuracy by Gill50. These
epidemics resulted periodically in absolute catastrophe as seen by the
figures of general morbidity and by general mortality and by number
of cases of malaria admitted to hospitals. In terms of its fulminating
characteristics it often surpassed plague and cholera epidemics.
5.2.3
Surveillance for malaria implies search for sporadic, imported,
introduced, induced or indigenous residual cases of malaria and the
assessment of their epidemiological significance during the process of
*an eradication campaign or after eradication has been achieved. The
treatment of such cases and to take measures to prevent recrudescence
of local transmission from them are also part of the surveillance
procedure50.
5.2.4
Specific age groups for cases detected as envisaged of attack
phase are not applicable to the surveillance phase. It is expected that
as a result of interruption of transmission through three continuous
years the immunity status of the community will be low and children
upto three years of age would have no experience of malaria at all.
5.2.5
The surveillance procedure consists of a house to house visit
every fortnight to search for parasite positive cases; each individual
should be contacted for enquiry. Since it will not be practical to
examine the blood of every individual in every home during each visit
and since it is reasonable to expect that the parasite positive individual
will manifest fever at some one or other of the fortnightly visit,
therefore, enquiry is restricted to individual having fever in between
the last visit and the present visit and from each such case the blood
smear is obtained for detection of malaria parasites.
5.2.6
Entomological observations in the surveillance phase was to
know the rate of build up of vector population and their behaviour
50
Manual of the Malaria Eradication Operation, NMEP Directorate 1960.
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characteristics. After the spray is withdrawn the vector is expected to
increase and with the achievement of interruption of transmission it is
expected that the parasite reservoir will be low or altogether absent
and transmission of malaria will not be possible even if the vector
population is high.
5.2.7
District Malaria Officers were instructed to report occurrence of
falciparum cases through telegram to all concerned within 24 hours.
For investigation of outbreak and initiating control measures,
operational guidelines were to take situation specific measures like
mass treatment, mass radical therapy, insecticide spray both residual
and space etc.
5.2.8
During 1963-6451 a few focal outbreaks occurred in the
consolidation areas which were promptly contained through
immediate spray, mass blood survey and treatment.
However,
subsequently especially after 1966 much larger outbreaks have
occurred because of the inability to take prompt remedial measures on
account of acute shortage of insecticides. Thus the foci extended over
.wider areas making it more difficult to control the situation in view of
the short comings in the existing logistic problem. In depth study team
of NMEP in 1974 observed that the Indian NMEP has suffered mainly
due to non availability of adequate quantity of insecticides from 1965.52
5.2.9
The Modified Plan of Operation53 stressed that all areas within
an API of two and above (from 1976) must be brought under spraying
programme. The point at which the spraying activities are to be
discontinued was, however, unclear because that was linked with the
efficiency of the case detection system and the response capability of
the district programme of dealing with the situation promptly after the
interruption of intervention measures. The MPO relied on the routine
case detection procedures and stipulated that for technical reasons the
two-weekly frequency pattern of the domiciliary visits for case
detection should continue. However, with the introduction of MPW
scheme surveillance mechanism of malaria was eroded.
5.2.10
When malaria continues to be highly endemic surveillance
machinery should be able to detect cases early for their treatment,
identify epidemic prone areas, detect outbreak early, monitor drug
resistance, insecticide resistance, etc.
No specific guidelines
particularly with regard to detection of outbreak was there.
51 PfCP (Plasmodium falciparum containment programme) 10 years of operation in India 1978-88, A P
Ray et al, Dte. of NMEP/WHO/SIDA, Delhi 1988.
52 In-depth Study Report on Malaria 1974.
53 The Modified Plan of Operation, NMEP Directorate, 1976.
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The above surveillance mechanism viz. fortnightly visit,
collection of blood slides from fever cases and its transportation to
PHC/CHC, communication of the results for radical treatment is
considered to be the best of all disease surveillance mechanisms in the
country within the existing resources. But from technical point of view
even this surveillance mechanism may miss many an impending
outbreak in its very early stages. However, if it is implemented with
right earnestness, most of the outbreaks could be detected within a
reasonable time frame for mounting appropriate action. However, a
variety of reasons like large scale vacancy existing among male
multipurpose workers leading to complete black out of surveillance in
several pockets, delay in transportation of slides and their examination
because of poor mobility, difficult terrain, non-availability of the
technicians, poor quality of microscopes, lack of supervision
contributed largely to failure in detection of outbreaks early resulting
in situations of high mortality and morbidity which could be easily
averted through proper surveillance.
5.2.11
With the introduction of PfCP within the PfCP areas
surveillance was strengthened and specific instructions were given for
epidemiological surveillance through:
a) Appearance of foci, time and size (population involved in the
locality).
b) Undertaking mass blood (usually fever) surveys if not done by
the organisation.
c) Vulnerability of the area/projects to large-scale importation of
cases.
d) Volume and proportion of falciparum cases.
e) Deaths, if any, due to malaria: Complete investigation by district
epidemiologists as per instructions and scrutiny and analysis of
reports at co-ordinator's level as well as by the HQ PfCP Cell.
f) Immediate reporting of such cases by telegram to all concerned
followed by special reports.
5.2.12 The Operational Manual for Malaria Action Programme 1995 by
Directorate of NMEP54 has clearly stated that the malaria incidence
should be properly monitored through analysis of the data in MF-9
(village register of the PHC). It should analyse the trends of incidence
54 The Operational Manual for Malaria Action Programme 1995 by Directorate of NMEP.
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in different villages vis-a-vis number of fever cases from the same area
reporting to the PHC OPD. The information of cyclic epidemic and
seasonal epidemics should be carefully looked into. Other factors
which should be properly monitored to assist in early warning
signalling are:
•
Parasite rate: Look for variation/increase in number of fever cases,
species distribution.
•
Vector dynamics through increase in mosquito density, vector
density.
•
Through population dynamics, influx of migrants from known
endemic to non-endemic areas and vice versa, tropical congregation
of population in projects, large labour movement to population
migration through floods and droughts.
•
Environmental and climatic conditions like early and heavy rainfall
in pre-transmission period, increased humidity during the above
period, natural disasters like floods, droughts, drying of river bed
leading to pool formation, earthquake etc.
Other information should be carefully examined like rise in
malaria positivity rate, rise in fever incidence reported by FTD
holder/MPW, community leaders, press, legislators, medical
practitioners of the area and their reports should be carefully assessed
along with laboratory positivity rate and time frame of the area.
5.2.13
If an epidemic predominantly of P.vivax infection is there, it is
certain that the first round of insecticide had not been done in time as
scheduled or coverage was poor and case detection, drug distribution
was not done for at least 2-3 months. If an epidemic with P.falciparum
predominance is seen, both rounds of insecticidal spray were either not
given or coverage was extremely poor and case detection and drug
distribution was not done for at least 4-5 months. In case of an
epidemic, control measures are to be enforced through delineation of
affected areas by rapid survey, rapid fever survey, mass survey. Blood
smear should be examined within 24 hours. All persons from whom
blood smears are taken should be given presumptive treatment or
mass radical treatment depending upon the situation. Measures are
also to be taken for liquidation of foci through space spray, residual
insecticidal spray etc. In urban area, community level operation in
addition to indoor spray, entomological investigations and the control
measures should be effectively implemented within 7-10 days in any
case not later than exceeding the fortnight to prevent a secondary case.
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5.2.14
From the above it is clear that the surveillance mechanism and
the control measures that are recommended though appear to be
technically sound yet due to a variety of operational failures epidemics
occur and most of the times it could be attributed to operational
failures like non-availability of insecticides, very poor surveillance,
poor interpretation of the available data etc. Efforts were made to
develop malaria forecasting model by several authors55 . However, the
same was not implemented under the programme and these models
are based on the data mostly available outside the country and no
serious attempts have been made to develop malaria forecasting model
in the context of our country.
5.3
Kala-azar:
The first recorded outbreak of Kala-azar was in the year 1824 at
Mohammadpur of Jessore district of Bengal. Later it spread Nadia
district in 1832 or 1833 and then to other parts. Bihar recorded its first
Kala-azar outbreak in 1882 and subsequently it is to have periodic
outbreaks of Kala-azar. With the introduction of NMEP, Kala-azar
started disappearing as a collateral benefit as Kala-azar vector is highly
susceptible to DDT. However, with the cessation of insecticide
operation when most of the units in North Bihar went into
‘consolidation phase, the slow build up of sandfly population leading to
report from several institutions admission of Kala-azar cases signalling
a simmering epidemic outbreak in early 70's. Institution of emergency
control measures under the guidance of National Institute of
Communicable Diseases when it was estimated that 70,000 cases of
Kala-azar occurred with 4500 deaths in 197756 resulted in significant
reduction of kala-azar mortality and morbidity during the period 197779 with ad hoc assistance from UNDP. Kala-azar control operation
undertaken by NMEP from 1980 had no separate funding provision
for kala-azar control apart from use of insecticides on ad hoc basis on a
limited scale and the federal government used to provide some drugs
like pentamidine (Ilnd line drug) and provide insecticide through
NMEP.
The Expert Committee on Kala-azar48 recommended initiation
of a Kala-azar Control Programme in Bihar and West Bengal giving
several options for funding viz. 100% central assistance^ 50:50 sharing
basis, partial sharing of some items, one time grant plus 50:50 sharing
etc. However, the same was not implemented. Then, in the year 199091 with the approval of Planning Commission, kala-azar control
scheme was initiated on a 50:50 sharing basis and from the very next
year the federal government has been providing total requirements of
55 The Biomathematics of Malaria, Norman T.J. Bailey, 1982.
56Sanyal, R.K. etal 1979.
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insecticides and drugs for Bihar and from 94-95 for both the states of
West Bengal and Bihar. The strategies and the operational guidelines
so far do not have any specific areas detailed out for detection of focal
outbreaks and its containment measures57 . However, if all the areas
pertaining to disease surveillance are appropriately implemented, the
same will provide sufficient lead in identifying outbreaks within a
reasonable time frame for control of Kala-azar. The Expert Committee
on Kala-azar58 in 1991 outlined the necessity of community
participation and generating awareness among the common mass for
seeking early detection through laboratory tests so that appropriate
treatment could be initiated leading to recovery from the disease.
The diagnostic support services that are available in the affected
areas under the programme are very inadequate and often causes
enormous delay in the detection of cases. Fortunately, now very good
rapid diagnostic tests are available which can lead to very early
diagnosis. Availability of this procedure will significantly improve
kala-azar disease surveillance particularly identification of outbreak
early.
5.4
Japanese Encephalitis:
Japanese Encephalitis has been prevalent in Eastern, South East
Asian countries since long. It has emerged as a major public health
problem in Indian since early 1970 when a series of outbreaks occurred
in various parts of the country 47'59 . Japanese Encephalitis activity has
been detected in early 1950s. However, the reports of outbreaks
occurring in different parts of the country after 1970 have caused
tremendous concern to the health authorities.
There is no separate prevention and control programme for
Japanese Encephalitis. National Institute of Virology, Pune provides
useful information with regard to Japanese Encephalitis through
investigation of outbreaks, sero-epidemiological studies, etc. National
Institute of Communicable Diseases, Delhi responds to the
investigation of outbreaks of Japanese Encephalitis in different parts of
the country and provides useful information on Japanese Encephalitis.
School of Tropical Medicine, Calcutta also provides very useful
information with regard to Japanese Encephalitis in West Bengal and
North Eastern States through epidemic investigations and serological
studies. Directorate of NMEP receives information on Japanese
Encephalitis from various State health authorities on the number of JE
cases detected and the number died, month-wise and district-wise
57 Model District Plan - NMEP, 1989.
58 Report of Expert Committee on Kala-azar in Bihar, DGHS, 1991.
59 ICMR Bulletin vol. 18, August 1988.
110
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from the different States. However, as laboratory diagnostic facilities
for Japanese Encephalitis are very scanty and inadequate most of the
cases reported are on clinical diagnosis.
However, during the
epidemic, investigative teams from NICD, Delhi, NIV, Pune, School of
Tropical Medicine, Calcutta collect materials which provide laboratory
diagnostic support services. Therefore, by and large the surveillance
data are grossly deficient with regard to virological diagnosis. The
current surveillance data indicate that an increasing number of districts
are reporting Japanese Encephalitis cases and outbreaks are also being
reported from these districts indicating establishment of newer
ecological situations favourable for the vectors of Japanese
Encephalitis. Guidelines for the control of JE circulated by NMEP do
not have specific provision of identifying outbreaks early. However,
measures to be taken in the event of an outbreak have been detailed
out. Information on prevention and control is periodically provided by
NICD, NIV, School of Tropical Medicine and Directorate of NMEP. A
meeting was convened under the chairmanship of DG, ICMR with
Director, NMEP as the Member-Secretary to review the strategy and
control of JE held at ICMR HQ60 . The meeting recommended several
action plan for JE control covering case detection and management,
prophylactic measures such as, vaccination and vector control
^(insecticidal spray in hyper-endemic areas), establishment of a system
of surveillance for JE, vaccination on incidence of JE, research, efforts to
evolve better vaccine, effective vector control measures and methods
for forecasting of JE epidemic. However, not much has been achieved
in this direction. CRI, Kasauli manufactured JE vaccine and the
vaccine was found to be very highly protective but because of paucity
of funds many State Governments did not procure the vaccine for
protection of high risk groups. Japanese encephalitis is also not
uniformly notifiable in the country and hence many cases/out breaks
go unrecognised.
5.5
Dengue:
The first recorded outbreak of Dengue fever in India was in
181261 . Serological survey was first carried out in 1954 and later
indicated that Dengue is quite widespread in India62 . Dengue with
haemorrhagic manifestations was first noticed in Calcutta in 1963.
Since then in fact, from mid fifties numerous outbreaks of Dengue have
occurred and have been investigated63 . Analysis of 54 outbreaks
during the period from 1956-95 indicates increasing frequency of
60 Minutes of the meeting on strategy for control of JE held at ICMR HQ, New Delhi on 19th
December, 1988.
61 Dengue Fever and Dengue Haemorrhagic Fever in India by Prof.J K Sarkar, Dengue News Letter
Vol.5, No. 1, Jan. 1979, P-12.
62 Monograph on Dengue/Dengue Haemorrhagic Fever Regional Publications, SEARO WHO No.22.
63 ICMR Bulletin Vol.24 No.5? 1994.
111
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haemorrhagic manifestation from Dengue. This is a very disturbing
fact. There is no separate programme of disease control for prevention
and control on Dengue fever in India. One very disturbed observation
is that favourable conditions for Dengue vectors are being increasingly
observed both from urban as well as rural areas. Dengue outbreaks
have been reported from most of the States. It was mainly from urban
areas but from 1987 rural areas also in some States were involved. All
the four known Dengue viruses were found involved with different
frequency and proper entomological surveillance can offer clue to
identify early impending danger from Dengue outbreak. Dengue is
not reportable disease in India uniformly and no active surveillance
exists and therefore, outbreaks of Dengue and Dengue Haemorrhagic
Fever are often not reported or documented. Specific guidelines for
Dengue and Dengue Haemorrhagic Fever including emergency
preparations and response are available with many countries64.
No guidelines for Dengue surveillance with specific provisions
of identifying outbreaks of Dengue early in India is available till date.
WHO International Conference on Dengue and Dengue Haemorrhagic
Fever and National Brain Storming Session during 7-8 February, 199349
at Pune, India, recommended that NICD shall prepare the guidelines
Jor Dengue surveillance in the country. NICD has prepared the
guidelines in consultation with other experts and the same guidelines
are being finalised in consultation with various States.
The
surveillance mechanism of Dengue and Dengue Haemorrhagic Fever
developed by NICD has been discussed also in the Regional
Consultation on Strategy for Prevention and Control of Dengue and
Dengue Haemorrhagic Fever in South Asian Region held in New Delhi
from 10-13 October, 199565 which has broadly endorsed the same.
5.6
Diarrhoeal Diseases including Cholera:
5.6.1
The Central Expert Committee Report for 1958-59 and the
Health Survey and Planning Committee 196111A'66 and the State
Officers meeting held in 1964 and 1967 recommended initiation of
Cholera Control Programme and National Cholera Control
Programme was initiated during the Fourth Five Year Plan (1969-74)
with establishment of a Cholera Control Cell at different levels
envisaging elimination of endemic foci through surveillance and
appropriate control measures with emphasis on provision of safe
drinking water supply and improvement of environmental sanitation.
64 Dengue and Dengue Haemorrhagic Fever in the Americas, Guidelines for Prevention and Control,
PAHO Scientific Publication No.548.
65 Regional Consultation on Strategy for Prevention and Control of Dengue and Dengue Haemorrhagic
Fever in South Asian Region held in New Delhi from 10-13 October, 1995.
66 National Programme on Control of Diarrhoeal Diseases, National Health Programme Series 9,
NIH&FW, 1988.
112
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With the decline of Cholera cases considerably, the scheme was
discontinued during the Sixth Five Year Plan as a centrally aided
scheme and was transferred to the States. A nominal allocation of
Rs.14 lacs was made during the Sixth Five Year Plan which was
primarily used for health education activities.
The Oral Rhydration Therapy (ORT) Programme was started in
1986-87 in a phased manner with the objective of preventing associated
deaths in children due to dehydration. Diarrhoeal diseases are major
health problems specially in children under five years of age. It has
also been estimated by WHO/UNICEF that approximately 25% of all
deaths in these age groups are due to diarrhoea or diarrhoea related
causes. ORS is most important in bringing down the diarrhoea
mortality. Diarrhoea treatment and training centres have been set up
in about 90 medical colleges and these act as centre for propagating
standard case management of diarrhoea to provide training to medical
students, interns and health workers. The network is being further
expanded to district hospitals also. However, the programme strategy
does not have provision of identifying diarrhoeal disease outbreaks
early and the guidelines for prevention and control in the event of an
outbreak are usually provided within the health care delivery system.
5.6.2
Cholera:
Cholera is nationally notifiable and is covered under
international health regulation^ WHO guidelines for cholera control
exist67 . However, the same is not adequately followed by the
programme management in India. Even though Cholera is covered by
International Health Regulations but due to non-availability of
appropriate diagnostic support facilities many outbreaks go
undetected.
i
The present programme of diarrhoeal disease control
programme is primarily around oral rehydration therapy (ORT)
programme. Poor surveillance coupled with appearance of new
serotype 0139 is a matter of concern.
5.7
Poliomyelitis:
Poliomyelitis is one of the EPI targeted diseases under the
Universal Immunisation Programme which was launched in 1985 and
declared as one of the Technology Missions in 1986 as part of the
overall National strategy to bring down infant mortality and freedom
from Poliomyelitis and other EPI target diseases. It may be mentioned
here that with the eradication of smallpox in 1977 the vaccination
67 Guidelines for Cholera Control, WHO, Geneva, 1993.
113
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programme was expanded into Expanded Programme on
Immunisation. The scope of EPI was further enlarged through
initiation of UIP in 1985 and the coverage of Polio has improved
significantly to around 95% in the country.
Guidelines under UIP state that immediate reporting of cases of
Neonatal tetanus and Poliomyelitis are mandatory. However, due to
non-availability of laboratory support services many of the cases go
unrecognised. The programme management provides guidelines for
investigation of poliomyelitis outbreak and procedures of surveillance.
However, it does not have specific guidelines for identifying the
outbreaks early. The programme has provisions of monitoring the
cold chain of the vaccine and the monitoring mechanism indicates
steady improvement in efficacy of the cold chain system from 60% to
90%20.
5.8
Measles:
Measles Immunisation Programme has improved vastly and the
coverage has gone upto almost 90%. The guidelines for measles
surveillance do not have specific provisions of identifying the outbreak
.early.
However, in the event of an outbreak, procedures of
investigation have been detailed out.
5.9
Viral Hepatitis:
There is no National programme on Viral Hepatitis prevention
and control. NICD has developed a surveillance mechanism through
development of diagnostic/ surveillance capability in 13 regional
surveillance centres. However, as no separate funds are available, no
specific guidelines for the prevention and control of viral hepatitis
have been made available uniformly to the States though specific
information on its prevention and control is provided to the States as
and when required in the event of an outbreak. The surveillance
mechanism does not have any provision for detecting an outbreak
early because adequate diagnostic kits and reagents are not available
for the same.
5.10
Strategy for Control of Epidemic Diseases
5.10.1
There is no centrally sponsored/central scheme to tackle
epidemic prone diseases as one single group and, therefore, no
separate budget is available for epidemic control. For control of
epidemics of diseases for which national health programmes are in
operation, funds are available through the programme but for diseases
for which no national programme is in operation, funds are usually
114
phsfinal.doc
provided on ad hoc basis within the resources of the health care
delivery system.
1
5.10.2
There is no national focal point to tackle epidemic prone
diseases. However, National Institute of Communicable Diseases,
Delhi; National Institute of Virology, Pune; All India Institute of
Hygiene and Public Health, Calcutta; National Institute of Cholera &
Enteric Diseases, Calcutta offer assistance to the State governments in
investigation of outbreaks and also providing appropriate guidelines
for its control. By and large the major responsibility is borne by
National Institute of Communicable Diseases, Delhi. It is responsible
also for providing appropriate guidelines for prevention and control of
any epidemic diseases in any part of the country. For diseases like
malaria, kala-azar, Japanese Encephalitis, National Malaria Eradication
Programme directorate also shares substantial responsibility.
5.10.3
Most of the State Health Directorates have a focal point in
handling epidemic diseases in the State and at the district. District
Health Officer or the Chief Health Officer is responsible for
management of epidemics/outbreaks. Collectors/District Magistrates
or local health authorities at the municipalities are authorised to invoke
•Epidemic Diseses Act whenever needed.
5.10.4
Though the surveillance machinery is not geared up to detect
early warning signal yet once the epidemic is detected and identified
the entire health care delivery system gears up and tackle the situation
on a war footing to minimise mortality and morbidity. Being an one
time activity for a short duration time frame usually response is mostly
quick and co-operation and collaboration from all concerned are easily
secured and even experts from the medical colleges or other health
establishments are rushed to the place to assist the local set up in
containing the outbreak early.
5.10.5
Though on a routine basis diagnostic support services may not
be available but during the epidemic the diagnostic support services
are provided drawing experts and resources from wherever it is
available.
5.10.6
As there is no separate programme for epidemic diseases the
guidelines for prevention and control are not regularly available on a
continuing basis. However, during epidemic every efforts are made to
reach everyone concerned with appropriate information for prevention
and control.
115
phsfinal.doc
5.11
OBSERVATIONS, SUGGESTIONS & OVERVIEW:
5.11.1
In summary it could be said that appropriate guidelines for
detection of outbreak and early warning signal mechanism for
epidemic prone diseases are not nationally available. The same are
usually provided on ad hoc basis to the implementing agencies by
NICD and in respect of some specific diseases like Dengue and JE by
National Institute of Virology, Pune.
5.11.2
Even for the diseases which are covered under the National
Health Programmes though guidelines for prevention and control are
available but the surveillance mechanism does not have provision for
identifying outbreak early so that quick response could be initiated.
However, if the guidelines for surveillance are implemented properly,
the same will generate sufficient data for mounting an appropriate
response within a reasonable time frame. However, for epidemic
prone diseases detailed guidelines for surveillance including provision
of detecting outbreaks early and appreciating early warning signal to
mount proper and effective response are though available but the same
is not available in the country uniformly as there is no specific disease
surveillance programme. CBHI guidelines do not cover early detection
of outbreaks and responses thereto.
5.11.3
NICD prepares guidelines and procedures for outbreak J
investigations and epidemic disease surveillance but the same is not
available through out the country under a regularly monitored
programme. The same is usually provided on requests to various
health agencies on request. Neither these guidelines are regularly
updated. The entire mechanism is an ad hoc basis.
5.11.4
The notification system in the country is not uniform. The same
requires to be updated keeping in view the new, emerging and reemerging diseases and local situation and immediate efforts need to be
made to make the system uniformly implemented through appropriate
guidelines.
In this context the committee agrees with the
recommendations made in this regard by the Central Council of Health
in 1969 and reiterated by the Central Council of Health and Family
Welfare in its recently held meeting from 11-13 October, 19956® .
5.11.5
Initiation of a national disease surveillance programme will
improve notification system, institution of early warning signal
mechanism and prompt response capability and the Committee agrees
68 Resolution of the 4th Meeting of Central Council of Health and Family Welfare, 11-13 October,95.
116
phsfinal.doc
i
with the recommendations of the Central Council of Health and Family
Welfare in this regard.
5.11.6
Every State has got ID Hospital. Most of these ID Hospitals are
inadequately staffed with poor maintenance. Many of them lack in
having the basic diagnostic support services. There is an urgent need
that facilities in these ID Hospitals are appropriately reviewed and
they are modernised to meet the requirements of infectious diseases
management. These hospitals should also have some provisions
particularly in the major metropolitan cities for management of cases
suffering from dangerous human pathogens.
117
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EXISTING HEALTH SCHEMES
6.0
EXISTING HEALTH SCHEMES
6.1
Rural health service scheme (Health component of minimum needs
programme)
6.1.1
Development of health infrastructure:
Health infrastructure in rural areas is of prime importance to
realise the objectives set forth in the National Health Policy and for
attaining the goal of health for all by the year 2000 AD. Primary health
care is accepted as one of the main approach through which
comprehensive health care delivery is envisaged and also as the
government's concerted efforts to reach the vast rural mass and thus
priority has been accorded to the extension, expansion and
consolidation of rural health infrastructure.
There are a number of schemes under the Minimum Needs
Programme to provide primary health care relevant to the actual needs
of the community of the rural areas. The number of health institutions
and health manpower in rural area as on 31 March 1995 is as under:
6.1.2 ^Primary health care infrastructure in India as on 31.03.1995
INSTITUTIONS
1.
2.
3.
4.
5.
6.
6.1.3
Village Health Committees
Sub-centres
Primary Health Centres
Community Health Centres
Rural Dispensaries
Rural Hospitals
2,20,545
1,31,900
22,156
2,377
11,670
3,568
Number of PHCs & Sub-centres required & in position in tribal
area69
776.84 Lakhs
A. Total Population in TSP Area as per 81 Census
B. Total Population in Tribal pocket as per 81 Census 414.89 Lakhs
444
C. Total CHCs in position (in Tribal Area)
3653
D. Total PHCs required for Tribal Area
3243
E. Total PHCs in position (in Tribal Area)
25440
F. Total Sub-Centres required for Tribal Area
19891
G. Total Sub-Centres in position in Tribal Area
69 Bulletin on Rural Health Statistics in India, Government of India, March,95.
I
118
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6.1.4
Level of Achievement of some norms all India position as on
31.03.199569
S.No.
Parameters/indicators
National Norms
1.
Rural Population covered by a Sub
centre__________________________
Rural Population covered by a PHC
Rural Population covered by a
Community Health Centre________
No. of sub centres for each PHC
No. of Primary Health Centres for
each Community Health Centre
Trained Village Health Guide
3000-5000 Pop.
Norms
achieved/established
_____ (Approx.)_______ |
4766
20000-30000 Pop.
About 1 Lakh Pop.
28375
2.64 Lakhs
I
I
6 Sub-Centres
4PHCs
5.9 Sub-Centres
9.3 PHCs
i
2.
3.
4.
5.
6.
7.
Trained Dai
8.
Rural Population served by Health
Workers (Male and Female)______
Ratio of HA (M): HW (M)_______
Ratio of HA (F) : HW (F)_________
Average Rural Area Covered by a
Sub-centre_____________________
Average Rural Area Covered by a
PHC___________________________
Average Rural Area covered by a
CHC
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
1
I
One VHG for each
Village/1000
population
At least one for each
village/1000
Population
M : 3000-5000
F : 3000-5000
_______ 1:6_______
1:6
1.42 Villages/1512
Population
I
I
1.00 Village 1027
Population
i
10038
2728
1 :3.9
1 : 6.9
23.83 Sq.km.
141.86 Sq.km.
1322.35 Sq.Km.
2.75 Km.
Max. radial distance covered by a Subcentre (in km.)______________________
Max. radial distance covered by a
PHC (in km.)_______________________
Max. radial distance covered by a
CHC (in km.)______________________
Average number of villages covered
by a sub-centre_____________________
Average number of villages covered
by a PHC__________________________
Average number of villages covered
by a CHC
6.71 Km.
20.51 Km.
4-7
I
25-27
247-248
I
Note: The national or state averges often give misleading impression. Due to
regional imbalances and variation, local situation in several places is
unsatisfactory.
6.1.5
Sub-centres:2069
119
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I
Sub-centre is established on the basis of one centre for every
5000 population in plain area and 3000 population in hilly and tribal
areas. Each sub-centre is required to be manned by a trained female
health worker (ANM) and a trained male health worker. The sub
centres were established on the basis of mid 1987 projected population.
Department of Family Welfare has not sanctioned additional sub
centre since 1990-91 onwards. Up to 31 March 1995, a total of 1,31,900
sub-centres have been established. Upto end of March'95, 6,476 (4.9%)
sub-centres are without any ANMs. 23,004 (17.4%) sub-centres are
without any health worker (male). 4,956 (3.8%) sub-centres are without
any ANM and health worker (male).
6.1.6
Primary Health Centres:20 69
Primary health centres are established on basis of one primary
health centre for every 30,000 population in plain area
and
20,000
population in hilly, tribal and backward areas. Primary health centre
are manned by Medical Officer and other para medical staff. Each
primary health centre provides supportive supervision to 6 sub-centres
and serve as referral centre for these sub-centres. Up to 31 March 1995
.a total of 22,156 primary health centres have been established. 1,139
(5.1%) PHCs are without any doctor. 7083 (32%) PHCs are without any
laboratory technician and 1196 (5.4%) are without any pharmacist.
1
/
/
(
c
t
L
6.1.7
Community Health Centre:20 69
Community health centres are rural institutions which are being
established by upgradation of primary health centres having 30 beds
with basic speciality services like medicine, surgery, mid-wifery, and
paediatrics covering a population of 80,000 to 1,20,000. It acts as a
referral centre for four primary health centres of the block. Up to 31
March 1995 a total of 2,377 community health centres have been
established.
i
<
(
6.1.8
Building for sub-centres, PHCs, and CHCs:69
Health
Institutions
Sub-centre
No.
functioning as
on 31.3.95
131900
No. of bldgs,
constructed / functioning
in Go Panchayat Buildg.
68112
No. of bldgs,
under
construction
10740
No. of bldgs, yet
.to be constructed
54031
PHCs
22156
14091
1295
6989
CHCs
2377
1572
516
197
120
phsfinal.doc
The status of primary health care infrastructure related to
MCH&FW though appears to be good but the actual programme
implementation is poor. There are deficiencies with regard to skill and
knowledge of health personnel, lack of basic facilities and simple
equipment for ensuring minimal essential maternal health care.
A recently concluded ICMR evaluation indicates that maternal
component of the family welfare component is the weakest and
requires maximum attention.70
Discriminatory attitude toward female from birth through her
life contributes largely to the poor quality of MCH care. Our women
folk are burdened with care of large families, are largely illiterate, have
poor access to education, good food, nutrition and health thus inspite
of the massive infrastructure available quality of MCH care is far from
satisfactory which has contributed immensely in weakening the public
health system.
In India the health care services delivery is almost entirely
through the government channel and it is often not available in remote
and inaccessible areas which contributes towards limiting the out reach
.of the public health system; sometimes the services are not utilised by
the people because of improper location of the facility and/or poor
quality of the services offered and thus the system gets further
crippled.
Large number of sub-centres are still functioning from the MPW
female residence or rented building with inadequate space for proper
delivery of service. The same needs priority attention.
Though the Sub-centre is required to serve 3000-5000 population
it does not take into account the distance and travel time. In some of
the Sub-centres ANM is required to cover 10-15 kms and sometimes
more. To improve the efficiency of the health care delivery services in
these centres, special travel allowance needs to be provided; the same
was recommended by the working group on health care delivery
service in rural and urban areas.71
Distance based norm could be
thought of in identified areas.
I
The districts which have high maternal mortality, infant
mortality and low■ couple protection rate should be provided with two
female health workers and one male health worker. The same was
70 Working Group Report on Safe Motherhood Activities for the Eighth Year Plan (90-95) Planning
Commission, June,89.
.
71 The Working Group Report of the Planning Commission, Health Care Delivery Services in rural and
urban areas - policies and perspectives, June, 1989.
121
phsfinai.doc
recommended by the working group on health care delivery services.71
However, the same has not been implemented.
The group also recommended 100% assistance only for those
centres which have both male and female workers. Alternatively, of the
funding 50% of both male or female workers could be implemented.
The same will improve positioning of both health workers at the
subcentre. However, nothing has been done in this direction.
Many of the PHCs are not functioning in the government
buildings and, therefore, adequate space is not there for effective
functioning.
The working group71 recommended positioning of a record
clerk or a clerk with training in statistics at PHCs to improve HMIS
but the same has not been implemented.
The group further recommended that the post of the Medical
Officer at PHC should be made non practicing one but many of the
states have not done so.
The group also recommended creation of a post of Public Health
Nurse at PHC. The same has not been done by the implementing
agencies.
The group also recommended positioning of a public health
specialist in the PHC but the same has not been implemented so far.
There is need to review the staffing pattern of new PHCs and
Sub-centres taking into consideration geographic situation,
infrastructural facilities, available work load under various national
health programme, convergence of various developmental activities
having direct bearing on health and environment etc.
6.1.9
Urban Health Services
More than one quarter of the population in the country now
lives in urban areas. In metropolitan and large cities about 40-50% of
the urban dwellers are estimated to be living in slum areas where the
health status of the people is as bad as, if not worse than, in rural areas.
But infrastructure for primary health care in urban areas hardly exists.
6.1.10 Secondary and Tertiary Care Services
The sub-divisional and district hospitals which are the
secondary level medical care institutions, lack adequate manpower and
facilities, to be able to discharge their responsibilities satisfactorily.
122
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6.2
Health manpower in rural areas as on 31.03.95:69
1. (a) No. of Village Health Guides reported to
be working
(b) No. of volunteers trained under
Alternative Health Guide Scheme
6.3
3,22,609
948
2. Traditional Dais trained
6,12,124
3. ANM/HW (F)
1,32,045
4. Health Workers (Male)
62,629
5. LHV/HA(F)
19,045
6. Health Assistant (Male)
15,916
7. Block Extension Educator
5,658
8. Pharmacist
20,172
9. Lab. Technician
10,715
10. Nurse Mid-wives
11,653
11. Radiographer
1,200
12. Doctors at PHCs
28,135
13. Paediatricians
436
14. Obst.& Gynae.
576
15. Physicians
658
16. Surgeons
703
Health Manpower in Tribal areas as on 31.03.1992:69
sanctioned
In Position
Percentage
Medical Personnel
2568
1986
77.30
Para-medical
personnel
16765
13988
83.40
Category
123
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Man power development is essential for delivery of health
services. Right man in right place and in right time is essential. More
TBAs need to be trained. The para medicals and other health care
providers are more curative oriented rather than public health oriented
involved in preventive and promotive health aspects.
The ANM who is the main person for delivery for MCH&FW
services is not available in several sub-centres20'69. This contributes to
less than satisfactory qualitative performance of services. The male
health workers are grossly inadequate in number as evidenced by large
vacancies in several states. This also has contributed significantly in
poor performance of the public health system.
Lack of participation of medical college teachers in clinical
practice under rural setting, and failure of PSM department in
successful co-ordination between community medicine and other
departments result in non-exposure of integrated approach to practice
of medicine.
6.3.2
Additional assistance to poorly performing districts
Available information indicates that investment in health
especially in the primary health care infrastructure is low in many
poorly performing states. Recognising the need for special attention
and necessity for additional inputs to improve the performance in
poorly performing states, one half of the total funds for social safety
Net Scheme have been provided to the department of Health and
Family Welfare. On the basis of data from 1981 census, 90 districts with
crude Birth Rates of over 39 per thousand population, high Infant
Mortality Rate and low literacy among women have been chosen and
interventions aimed at reduction in maternal and infant mortality and
increase in institutional delivery have been initiated in 1992-93. The
CSSM programme was also initiated first in the poorly performing
districts. Besides Area Development Projects aimed at establishing
primary health care infrastructure for providing family planning and
MCH services have also been taken up in some poorly performing
states. A project aimed at revitalising the Family Welfare Programme
in Uttar Pradesh was initiated with assistance from USAID in 1993.
Through these projects efforts are made to ensure • that funding
constraints do not come in the way of achieving the needed
improvement in the infrastructure and quality and coverage health and
Family Welfare programmes to the population in dire need of it. The
progress of work in these projects through process and impact
indicators are being assessed and monitored.
124
phsfinal.doc
6.4
Training of professionals and para-professionals:69
6.4.1
Dais Training Programme
Dais training programme aims at imparting training to all
traditional practising Dais in the country and is receiving priority
attention in order to reduce the maternal and infant mortality rates by
conducting aseptic deliveries and providing better ante-natal and
postnatal care. The duration of training is one month. A total of
6,12,124 Dais have been trained so far.
The Working Group Report of the Planning Commission,
Health Care Delivery Services in rural and urban areas - policies and
perspectives, June,198971 recommended the programme to be reviewed
by all the State governments and all untrained practising Dais should
be trained and if already trained need to be retrained expanding their
role to:
•
•
•
•
•
•
Early registration of pregnancy
Identifying high risk pregnant
Referral to the health workers
Conducting aseptic and hygienic delivery
Detection of low birth weight babies
Getting mothers and children immunised
Several States have not done such reviews. The same need to be
undertaken as still most of the deliveries in rural areas are being
conducted by Dais.
6.4.2
ANM Training Programme:20
Each sub-centre is manned by one male and one female health
worker. In order to train required number of ANMs in rural areas,
there are 461 ANMs training schools functioning in the country with an
annual capacity of 20,156. The duration of training is 18 months. These
training institutions are also being utilised to provide continuing
education/training in addition to provide basic training.
6.4.3
Lady Health
Programme:20
Visitor(LHV)/Female
Health
Assistant
Training
One female health assistant has to supervise the work of six sub
centres in the rural areas. She provides techmeal guidance, supervision
and support to the ANMs who work at the sub-centre. The senior
ANM trained for further six months can take up the post of LHV,
which is a promotional post. 44 LHV training schools are functioning
the country with an annual admission capacity of 2,768. These training
125
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schools are also utilised for giving continuing education to female
health assistants besides providing training programmes of six months
duration.
6.4.4
Multi-purpose Worker (Male):20
As per the norms each sub-centre is required to be manned by a
trained female health worker (ANM) and a trained male health worker
known as multi-purpose worker (male).
Uni-purpose workers
working under various disease control and health programmes were
converted to multi-purpose worker in 1978 which continued till 1990.
However, due to acute shortage of male MPWs, a scheme of basic
training for MPW (male) was initiated during the Seventh Plan period.
Under this scheme, 10th pass candidates were selected and trained for
a period of one year before they were inducted into service.
The basic training of MPW (male) was initiated in 47 health and
family welfare training centres (HFWTC) in various States as 100%
centrally sponsored scheme. As these schools were found to be
inadequate, financial sanction to 50 new basic MPW (male) schools
were given by the Government of India. At present, there are 44
•HFWTCs and 28 new basic MPW (male) schools which provide basic
training to MPW (male).
6.4.5
Orientation Training of Medical and Para-Medical Personnel:20
This is a centrally sponsored scheme under the family welfare
programme to provide training to both medical and para-medical
personnel (medical officers, health assistants, health workers, block
extension educators, key trainers of ANM training schools) working at
the CHCs, PHCs and SCs and is provided mostly at HFWTCs.
6.5
Village Health Guide Scheme:
On the recommendation of the Shrivastava Committee on
Medical Education and Support Manpower in 197572, the Community
Health Workers Scheme was launched on 2nd October, 197720 as a
Centrally sponsored scheme in all the States except Tamil Nadu,
Jammu & Kashmir and Arunachal Pradesh. The scheme was renamed
as Village Health Guide (VHG) Scheme in 1981 when it was made
100% centrally sponsored scheme under family welfare programme.
According to the scheme, the community selects the volunteer as VHG
who after training for three months at the primary health centre acts as
a link between the community and the government health
functionaries. During the training period a stipend of Rs.200/- p.m.
72
Shrivastava Committee of Medical Education and Support Manpower in 1975.
126
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was paid to the workers and on completion of training these workers
were provided a kit containing common articles of uses and medicines
and the manual for functioning as a VHG. The VHG was given an
honorarium of Rs.50/- p.m. and medicines worth Rs.50/- p.m. for
carrying out their function as VHG. About 4.16 lacs VHG have been
trained till now and about 3.24 lacs VHG are under the roll of State
governments/UTs. The scheme has been studied intensively and
extensively by Government of India and by independent agencies73 '74.
Following review in 1984 it was decided to dispense with the existing
male health guide to be replaced by female health guide and the State
governments were advised accordingly. Honorarium to the male
health guide was advised to be discontinued from July, 1986.
Following the above decision, a number of writ petitions were filed in
various courts of the country. Due to a variety of reasons, the scheme
had not been functioning well and accordingly it was reviewed by the
State health secretaries in January, 1993 where most of the states except
West Bengal, Mizoram, Punjab and Maharashtra opined that the
scheme had not served any useful purpose. However, reports of
evaluation of scheme by National Institute of Health & Family Welfare
in collaboration with other institutions. Planning Commission and
Department of Health were in favour of continuation of the scheme
•and it was stated that the scheme is a major asset to the Panchayati Raj
system with respect to fulfilment of health related function assigned to
the Panchayats and accordingly an Expert Committee under the
chairmanship of Director General of Health Services was constituted
which recommended to initiate a new scheme Panchayat Swasthya Seva
Scheme on a pilot basis in two district of each state and one district each
of Union Territory in the current plan and to cover the entire country
in phases by the end of the 9th plan. One Panchayat Swasthya Sevak will
be for a population not exceeding 1000 in plain areas, and 700 in hilly,
tribal and difficult areas and they are to be provided an honorarium of
Rs.300/- p.m. and medicines worth Rs.100/- p.m. However, the
Central Council of Health & Family Welfare in its fourth meeting held
recently from 11-13 October, 199568 recommended not to introduce the
new Village Health Guide Scheme. Insofar as the existing Village
Health Guide Scheme is concerned, it is left to the State governments to
take a decision. It recommended further that available resources be
used to strengthen the health infrastructure and not to introduce new
agencies. However, the Chairman of the Council advised that this is to
be reconciled..
73 Evaluation of Community Health Workers on Peripheral Level - ICMR sponsored study, University
College of Medical Sciences, New Delhi.
74 Repeat Evaluation of Community Health Volunteer Scheme, National Institute of Health & Family
Welfare, 1979.
127
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6.6
Mini Health Centre Scheme of Tamil Nadu:
The need for re-orienting the health care delivery scheme and
making it community based and family centred prompted launching of
the village health volunteer scheme in October, 1977 in the central
sector. Tamil Nadu being in a favourable situation with regard to
availability of medical manpower, rural roads and transport and
having large number of satisfactory functioning voluntary
organisations opted for Mini Health Centre Scheme. Basically the
scheme provided an opportunity for voluntary organisations
interested in health to collaborate with the government and
supplement its efforts in the delivery of community based health care
to the rural population. It also encouraged medical practitioners to
start voluntary organisations for this purpose75 . The state of Tamil
Nadu has been implementing Mini Health Centre Scheme as an
alternative to VHG Scheme since 1977-78 with the approval of the
Central Government. A mini health centre is a multi-purpose unit
organised by voluntary organisation in collaboration with government
for the delivery of curative, preventive and promotive services to the
rural population catering to around 5000 population and starting with
a part-time doctor, two para-medical workers and three lay first aiders
^chosen from the village community. Evaluation carried out by
National Institute of Health & Family Welfare in 1991-9275 concluded
that the Mini Health Centre Scheme being the first attempt by the
Tamil Nadu government to involve voluntary sector in delivery of
health care had certain in-built rigidity regarding budgetary allocations
and pattern of expenditure which do not suit the ground reality in
different parts of Tamil Nadu and also the diverse pattern in the
background and the capabilities of voluntary organisation. Therefore,
in its present form it should be concluded and replaced by a projectised
approach with a time frame of 3-5 years to initiate integrated
community development scheme with primary health care activities
with appropriate Grants-in-aid support. This new mini health centre
project should heavily rely on family health volunteers with
appropriate training with honorarium not lower than statutory daily
wages prevailing in the State. In order that the voluntary sector
contribute in a big way the new projects should include outreach
physical facilities by way of village level labour rooms and 1-2 beds for
lying in facility for maternity cases. Dependence on*government's
grants should be gradually reduced with increasing involvement and
participation of the community by appropriately dovetailing the health
component within the integrated approach for rural development
having aspects of income generation, employment, water supply, basic
sanitation, increased production and availability of foods and,
75 Report on the Evaluation Study of Mini Health Centre Scheme in the State of Tamil Nadu, National
Institute of Health & Family Welfare, 1991-92.
128
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therefore, while screening the new mini health centre project
preference will be given to those who adopt multi-sectoral approach.
♦ For effective functioning close referral linkage should be developed
through proper guidelines for laboratory and other investigations and
also for treatment beyond the scope of mini health centres.
♦ As the voluntary organisation has different backgrounds and
capabilities, uniform funding pattern may not work very satisfactorily
and, therefore, provision of modifying at the local level within the
overall funding limit should be available.
♦ Staff of the mini health centres should be uniformly trained through
identified institutions in Tamil Nadu so that the new mini health
centres can function satisfactorily.
♦ Financial monitoring of the new MCH projects should be carefully
done and reliable selected private chartered accountants firms may be
nominated for the same.
6.7
Rehbar-i-Sehat Scheme in J & K:
The State of Jammu & Kashmir has been implementing Rehbari-Sehat Scheme in place of Village Health Guide Scheme. Large
number of Rehbar-i-Sehat Scheme workers are teachers and the
services rendered by them in first aid, curative services in common
ailments, health education about common health problems were found
to be very satisfactory and the major strength of the project was with
the health care services at the door step of the community, care for the
poor and neglected, provision of spraying, treatment and promotion of
health education. The Scheme was reviewed by National Institute of
Health & Family Welfare in 198576 and this evaluation indicated that
this has been functioning satisfactorily. During the recent problems in
J & K with enhanced terrorist activities it is the Rehbar-i-Sehat Scheme
which has been found to be functioning satisfactorily compared to any
other health care activities which are often found utterly absent.
6.8
Child Survival and Safe Motherhood Scheme:
The Child Survival and Safe Motherhood Scheme was launched
on 20th August, 1992 by the President of India. The programme is
directed at achieving 9 of the 17 goals of the National Health Policy
which are related to maternal and child health77.
76 Research Studies of National Institute of Health & Family Welfare, 1977-90.
77 National Child Survival and Safe Motherhood Programme, Ministry of Health & Family Welfare,
Government of India, June, 1994.
129
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The Central and State governments have accorded a high
priority to this programme as it addresses the major causes of
morbidity and mortality in women and children which are preventable
by readily available cost effective interventions. The programme has
the following components:
6.9
•
Sustaining and strengthening the on-going immunisation, oral
rehydration therapy and prophylaxis scheme for Iron and Vit.A.
•
Improving maternal care at the community level by providing
training to the traditional birth attendants and desirable delivery
kits.
•
Expanding in a phased manner the programme for acute
respiratory infections in children below five years of age.
•
Set up in a phased manner a network of sub district level first
referral units for improving the emergency obstetric care.
Universal Immunisation Programme:20
r
Universal Immunisation Programme was launched in 1985
which was converted as one of the technology missions in 1986 as a
part of overall national strategy to bring down infant and maternal
mortality in the country20. At the beginning of the programme in 198586 the vaccine coverage levels ranged between 29% for BCG and 41%
for DPT. By the end of March, 1994 coverage levels have improved
significantly and they ranged 82% for tetanus toxoid and 97% for BCG.
The year-wise and the vaccine-wise achievement during the last
decade 1985-86 to 1993-94 given in Table.
Table
Achievement as percentage of annual targets
(compiled on the basis of reports of states/UTs)
Targets (in lakh)
DPT
YEAR
INF
P.Women
OPV
BCG
MSL
41.12
35.66
28.84
1.34
1985- 86
128.55
128.55
48.41
52.19
152.00
1986- 87
152.00
56.55
16.17
60.46
70.70
44.06
1987- 88
169.32
169.32
72.23
55.17
74.83
79.29
1988- 89
180.44
226.64
79.61
82.30
89.04
69.32
1989- 90
191.41
251.24
82.93
90.85
100.72* 101.54* 102.99*
1990-91
223.39
252.66
90.84
91.22
92.93
85.07
1991- 92
233.34
261.31
90.88
96.47
85.75
270.08
90.28
242.90
1992-93
96.69
88.30
93.23
92.85
1993- 94
275.55
247.90
Note: Measles vaccine was introduced in the programme from 1986-87.
* Due to inclusion of children over one year of age.
130
TT(PW)
39.85
45.27
56.48
65.15
58.83
79.70
77.51
79.40
82.12
phsfinal.doc
6.10
Surveillance of Vaccine Preventable Diseases:
Immediate reporting of Polio and Neonatal tetanus has been
made mandatory. There has been a significant decline in the reported
disease incidence of these diseases as shown in Table.
Table
Reported incidence of vaccine preventable diseases : India
YEAR
1985
1986
1987
1988
1989
1990
1991
1992
1993
Dip.
Per
Tet*
Neo
natal
Tetanus*
Polio
Measles
15686
184368
37647
9426
167225
30994
12952
163786
31844
17146
145469
24343
11849
9790
137374
17762
11114
8425
113016
14043
9313
12550
73520
15036
11241
6810
61648
12023
6687
7131
476120
1535'
6606
22584
160216
20169
155072
28257
247519
24257
157800
13307
162560
10408
87446
8670
79655
@8801
92297
@405.
6507r
* : Tet includes cases in adults and NNT upto 1987 (Source: CBHI, Directorate General of
Health Services)
As reported by district to MCH Division.
The programme of Universal Immunisation made significant
contribution towards reduction of vaccine preventable diseases. In fact
polio eradication and neonatal elimination are expected in very near
future. The programme also contributed immensely towards decline in
infant mortality rate.
The country is self sufficient in all vaccines except BCG and Oral
Polio. The Oral Poliovaccine is being made available from the
imported concentrate.
6.11
Testing of Oral Poliovaccine:
The testing of field samples for Oral Poliovaccine for potency so
as to check quality and effectiveness of cold chain system under Universal
Immunisation Programme was started in 1985 with three OPV centres at
NICD, Delhi, CRI, Kasauli and Enterovirus Research Centre, Bombay and at
present 13 testing centres in the country are functioning and few more centres
will become functional in near future. During the last several years, testing
of OPV results indicate phenomenal improvement in cold chain system as
shown in Table given below:
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TABLE
POTENCY TEST REPORTS OF FIELD SAMPLES OF OPV
Year
Samples Tested
1987
1988
1989
1990
1991
1992
1993
1994
1290
2196
5423
8148
9208
13936
16513
17281
Samples
Satisfactory
790
1454
4580
7550
8354
12287
14781
15621
% age Sample
Satisfactory
61
66
84
93
91
88
90
90
POTENCY TEST RESULT IN INDIA DURING 1994
Name of Institute
No. of Samples
received
% age
Satisfactory
NICD, Delhi
EVRC, Bombay
CR1, Kasauli______
STM, Calcutta____
1PM, Hyderabad
BJMC, Ahmedabad
PII, Coonoor______
K1PM, Madras
BHU, Varanasi
RMRCT, Jabalpur*
NIV, Bangalore
PH, Shillong
2561/2554
3065/3062
1559/1538
1088/1088
940/939
1703/1703
1354/1354
3078/3078
699/699
193/147
773/773
348/346
63.4
92.0
99.74
83.73
93.2
99.0
99.0
98.9
90.0
94.55
90.0
95.72
S.No.
K
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
* Centre have become non-functional in 1995.
The programme was reviewed jointly by a large number of
experts from Government of India, WHO and UNICEF in 1992.78
Some Salient observations:•
The UIP has been in operation for a varying length of time in
different parts of the country resulting in unequal impact of the
programme in different areas. Therefore, the goals of polio
78 Review of the Universal Immunization Programme: Country Overview, September-1992,
MOH&FW, GOI.
132
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eradication & NNT elimination will have to be phased
accordingly.
•
The States of Maharashtra, Haryana and Tamil Nadu as a whole
have done extremely well and have high levels of development,
easy access and well-developed physical and managerial
infrastructure and are capable of taking up additional measures
for polio eradication and NNT elimination. Some districts
within other states are also capable for the same.
•
With surveillance of polio getting augmented effective use of
improved clinical and laboratory criteria for confirmation of
cases and discarding non-polio cases should be emphasised.
•
In less developed States poor infrastructure, lower awareness
amongst the people, areas of difficult physical access,
considerable distances, less motivations and commitment
amongst key staff are important problems.
Several recommendations made by the team like strong active
surveillance, wider laboratory support, identification of high risk areas
jmd their elimination through focused mass vaccination, close
monitoring of surveillance through state level computerisation of data
compilation and analysis, using software designed specifically for that
purpose etc. have been poorly implemented.
Following big success of polio plus programme of Rotary
International and Pulse Immunisation in Delhi, Bombay, the
government introduced National Immunisation days covering the
entire country during 1995-96.
6.12
Oral Rehydration Therapy for Diarrhoea control among children:
The Oral Rehydration Therapy (ORT) programme was started in
1986-87 with the objective of preventing diarrhoea associated deaths in
children due to dehydration. Studies have revealed that 90% of the
children suffer from diarrhoea can be managed successfully at home by
mothers by administering home-made or home available fluids at the
onset of diarrhoea. Only 10% of the cases need oral rehydration salts79.
The goal set under the programme is reduction of deaths due to
diarrhoeal diseases in children by 30% by 1995 and 70% by the year
2000 AD The coverage envisaged were:
79 Child Survival and Safe Motherhood Programme - India, Ministry of Health & Family Welfare, July,
1991.
133
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1. Improve use of ORT plus feeding rate to 50% by 1995 and 80% by 2000
AD
2. Improve access to ORS by making available ORS in every
village/urban slums by 1995; access to ORS to be improved to 80% of
the population by 1995 and 100% by 2000 AD
3. Improve maternal knowledge on home case management from existing
level to 80% by 1995 and 100% by 2000 AD
4. Improve access to case management at health facilities or providers
from existing level to 80% by 1995 and 95% by 2000 AD
Strategies used were : Increase in use of home made fluids and
ORS at home levels plus continued feeding, improve maternal
knowledge, increase in accessibility of ORS through government
channels and private sector by appropriate social marketing,
standardisation of ORS packets, better case management by the
workers as well as medical practitioners at all service facilities and
surveillance of cases and deaths from diarrhoea.
ORS supplies are being organised by the Government of India
centrally and 379.3 lacs packets were procured and supplied to the
states and union territories during 1993-94. The districts covered by
Child Survival and Safe Motherhood Programme are receiving ORS as
a part of the sub centre kit.
Considering 135 million children population below 5 years and
at least 2-3 episodes of diarrhoea each child will be having per year,
27-40 million episodes will require ORS packets. Therefore, ORS
supply still falls short of our requirement. With the promotion of ORS
many episodes of diarrhoea will be treated with ORS even if home
made fluids would have been sufficient to take care of. Therefore,
actual shortage of ORS compared to the total needs is much more than
what the figure shows. The success of ORT is basically linked with its
appropriate and uniform distribution through social marketing where
mothers are involved in administration of ORS through high profile
community awareness programme and in this context literacy plays a
major role.
Though some smaller studies have been undertaken but large
impact assessment study has not been done so far. The same is needed
to be undertaken. The programme has been designed to prevent
deaths from diarrhoea and it does not reduce incidence of diarrhoea
which is linked with sanitation, water supply, environment,
knowledge, attitude and practice pattern of the people.
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6.13
Programme of Acute Respiratory Infection:
Pneumonia is another leading cause of death in infants and
young children accounted for 20% of the under 5 deaths. The Acute
Respiratory Infection (ARI) control strategy developed during 1989
and implemented in 24 districts on pilot basis during 1991. The review
carried out during 1991 indicated that the ARI could be implemented
through the trained health workers at the sub centre level . Now, the
rational treatment of ARI and prevention of deaths due to Pneumonia
is an integral part of Child Survival and Safe Motherhood Programme
and the health workers are being imparted training in ARI
management. Cotrimoxazol the important drug in ARI is supplied
through the CSSM drug kit. The programme has a goal of reducing
deaths due to ARI by 20% by 1995 and 40% by 2000 AD Specific
objectives are: reduction of deaths due to Pneumonia in children under
5 years through standard case management, reduction of inappropriate
use of antibiotics in treating ARI other than pneumonia, prevention of
deaths due to pneumonia by developing linkage with immunisation,
diarrhoeal diseases control, nutrition and MCH. Strategies of the
programme are primarily home care for coughs and colds, access to
standard case management through health facilities, enhancing
jnaternal knowledge when to seek care, referral of severe cases to
hospitals, promotion of immunisation to cover all eligible children,
training of staff including doctors and para medical staff and
surveillance of cases and deaths from pneumonia in children.
Prophylaxis programme against Iron deficiency and Anaemia
in mothers and Vit.A deficiency in children:
6.14
Iron Deficiency:
Anaemia is one of the leading causes of maternal mortality
contributing towards 20% of the maternal deaths in the country in
1990-9120.
Deficiency of anaemia also aggravates in conditions of
eclampsia, sepsis and haemorrhage. Though the programme is in
operation for quite sometime but it received high priority under the
programme of Child Survival and Safe Motherhood Programme.
During 1993-94 as many as 18.3 million pregnant women were
provided with recommended doses of iron and folic acid.
The major problems related to National Anaemia Prophylaxis
Programme has been poor reach and inadequate utilisation of services
and lack of strategy that addresses additional needs of moderate and
severe anaemic cases79. Iron and folic acid is administered to pregnant
women to prevent as well as control anaemia. Prior to 1990,100 tablets
(each 60 mg of iron and 0.5 mg folic acid) were given but iron and folic
acid in those doses can not control anaemia from therapeutic point of
135
phsfmal.doc
view in cases having anaemia and the programme did not have the
component to provide additional doses of iron and folic acid to
anaemic women. Taking into consideration the crude birth rate of
around 28-29 more than 25 million pregnant women will be requiring
iron and folic acid tablets and, therefore, the actual coverage through
iron and folic acid is still far from satisfactory. In many women iron
and folic acid needs to be supplemented by deworming in places of
high intestinal parasitic infections. But in several areas that is not
being done contributing to the less than satisfactory performance of the
scheme.
6.15
Vitamin A deficiency:
Vit.A deficiency which can lead to blindness has been widely
prevalent in our country because nutritional deficiency is widely
prevalent amongst pre-school children. The programme has been in
operation for quite sometime but with the initiation of Child Survival
and Safe Motherhood Programme, the programme has been further
strengthened. Earlier the strategy for control of blindness due to Vit.A
deficiency has been to cover children of the age group of 1-5 years with
administration of 0.2 million international units twice a year to each
•child having the eligible target population of more than 100 million a
year. Due to resource constraints and limited reach of services only
around 30 million children could be covered annually. Therefore, most
of the children could not be reached with appropriate Vit.A at the
recommended frequency. For the prevention of Vit.A deficiency in
children under the Child Survival and Safe Motherhood Programme
priority was given to the children of age group of 1-3 years and during
1993-94, 15.5 million infants were administered the measles linked
doses while DPT, OPV booster linked dose was given to 5.6 million
children in the age group of 1-2 years. In the present strategy, two
dimensions have been included. The recent stduies have indicated that
the prevalence of Vit.A deficiency is most in children below 3 years of
age and the programme now visualises mega doses of Vit.A in children
between 9 months and 3 years. Secondly, therapeutic measures for
Vit.A deficiency have also been included in the programme. Children
with Vit.A deficiency will be treated. Five per cent of children of 1-3
years age will suffer from signs of Vit.A deficiency and will require
therapeutic doses. The programme needs evaluation.
6.16
Safe Motherhood Services for Pregnant Women:
The SRS data indicates that the proportion of deliveries attended
by the untrained hands is still very high particularly in the rural areas
of Assam, Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh
which contributes to the higher maternal mortality. Therefore, in
addition to strengthening the traditional birth attendants through
136
phsfinal.doc
training and re-training and promoting dean and safe deliveries
actions have also been initiated with emphasis on essential obstetric
care for all, early detection of complications and emergency services for
those who need it. Essential obstetric care for all shall include early
registration at 12-16 weeks, check up at least 3 times, anaemia
prevention and control, immunisation and care at birth, early detection
of complications, attention on clinical examination to detect anaemia,
bleeding to know APH/PPH, blood pressure examination to detect
toxaemia, weight gain to detect toxaemia, fever to detect sepsis and
prolonged labour (more than 24 hours). For emergency services for
those who need it in a health institution selected rural health facilites
are being upgraded as the first referral centre with a post of
Gynaecologist and a operation theatre. One such first referral unit will
be established for a population of 3-5 lacs in addition to the district
hospital hospital in each district. 6-12 such first referral units are being
established in six high IMR/MMR states viz. Uttar Pradesh, Madhya
Pradesh, Rajasthan, Bihar, Orissa and Assam. Other states are being
asked to mobilise their own resources for upgrading the health
facilities for providing emergency obstetrics care and medical
treatment of maternal complications. Such referral centres should have
the facilities for vacuum extraction, administration of anaesthesia,
Jjlood transfusion, caesarean section, manual removal of placenta,
suction evacuation, dilatation and curettage for incomplete abortion,
inserting intra-uterine devices and perform operations.
Many more such referral units are required. Such marginal
input will hardly have an impact on the total scene of the country.
6.17
Care of newborn and infants:
Almost 50% of the infant deaths occur within one month of birth
and half of the same occurs in the early neonatal period. Over 30%
ofthe babies born in India are of low birth weight (less than 2500 gms)
which are at enhanced risk to such mortality. It is estimated that 80%
of neonatal deaths are associated with low birth weight. Therefore,
high priority is being accorded to the care of new boms and infants
through identification of low birth weight babies, teaching the mothers
and families to take appropriate care of new boms at homes with
particular reference to proper feeding, warmth and .prevention of
infections. Babies requiring hospitalisation and special care should be
taken care by the referral units. The training of medical and para
medical personnel should have a component of new bom care,
immunisation, early establishment of exclusive breast feeding,
continued feeding during the illness particularly when dealing with
episodes of diarrhoea and ARI, proper hospital practices to facilitate
rooming-in practice and maternal counselling etc.
137
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Though the Child Survival and Safe Motherhood Programme
has sound components of intervention measures of achieving the goal
set for under the programme in our giant efforts to reach health for all
by 2000 AD yet the programme has not yielded the desired results due
to a variety of factors. The attempt to improve the health of women
should have strong components of changing unfavourable cultural
norms to more favourable ones in the light of available scientific
information like attitude to marriage, age at marriage, the values
attached to fertility and sex of the child, the pattern of family
organisaton and ideal role demanded by women by social conventions
because this determines the status of the women in the family
influencing immensely her access to medical care, education, nutrition
and health. This calls for more attention from early childhood to
adolescent for the female child.
Amongst the poorest section women are all the more vulnerable
and they are forced to work for a longer period that too in a very low
paid occupation. In addition early marriage and early motherhood are
all contributing to the poorer health of mother leading to a serious
impact on the public health system.
National Health Policy document clearly outlines the need for
‘securing health and strength of workers men and women, adult and
children through proper opportunities and facilities which is only
possible through establishment of a new social order based on equality,
freedom, justice and the dignity of individual as enshrined in our
Constitution.
Though effective delivery of health care services are dependent
largely on the nature of medical education, training and proper
orientation towards community health and all categories of medical
and health personnel and their capacity to function as an integrated
team, the same has not been achieved because of poor coordination
between different programme managements between the centre and
the States, between states and the districts, between districts and the
community health centre and between community health centres and
the sub centres.
Delivery of health has a major component of caring with a
human approach which requires emotional involvemenit and personal
commitment apart from providing only a professional service devoid
of personal touch. Unfortunately the exisitng public health system has
not been able to develop in that direction making the system more
acceptable to the people. Though a very elaborate health care delivery
infrastructure has been developed and several important
professionally managed programmes are being implemented still the
health care delivery remains under-utilised to a major extent and many
a primary health centres/community health centres are unable to
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function as a cohesive team. If the primary health centre/community
health centre does not function properly referral system almost
becomes non-functional leading to no referral or delayed referral
contributing towards high morbidity and mortality which indirectly
creates non appreciation of the health facilities leading to poorer
utilisation of the facilities.
6.18
National Malaria Eradication Programme:
Before the National Malaria Eradication Programme was
initiated malaria was a major public health problem in India with 75
million cases and 0.8 million deaths leading to large scale human
misery. To tackle the problem of malaria. National Malaria Eradication
Programme was launched in 1958 with the objective to eradicate
malaria from India in 7-9 years i.e. 1966-6780 . During the attack phase,
the strategy was indoor residual spray to interrupt the transmission.
After three years of spray and on satisfying the criteria laid down by
the WHO and assessment by the Independent Appraisal Team area
would enter into the consolidation phase81 . During the consolidation
phase the surveillance operations were carried out through active and
passive case detection services. On two years of successful completion
the consolidation phase units entered into maintenance phase the
Responsibility for which rested with the general public health service.
The Indian campaign was considered to be the largest public health
endeavour in the world and it contributed immensely towards the
global eradication of malaria in 1965. Only 0.1 million cases with no t
deaths due to malaria was in India which facilitated immensely
agricultural, industrial and other developmental activities. Afterwards
the set back started due to a variety of technical, administrative and
financial reasons. Increasing number of outbreaks were reported and
the number of malaria cases started rising which stood 1.32 million in
1971 and went upto 6.46 million in 1976 and malaria deaths started
reporting from 1974. Concerned by the reappearance of malaria in the
country, several committees were constituted and then ultimately on
the recommendations of the Consultative Committee of Experts, the
Modified Plan of Operation was introduced with effect from 1.4.77.
During the years 1960-74, several committees were constituted namely,
Hinman Committee (I960)82 , Chadha Committee (1963)83 , Mukherjee
Committee (1966)84 , Madhok Committee (1967)85, In-depth Evaluation
80 Malaria and its control, Directorate of National Malaria Eradication Programme.
81 National Institute of Health & Family Welfare, National Malaria Eradication Programme, National
Health Programme Series 4, reprinted May, 1990.
82 A critical review of the NMEP in India (Hinman Committee), November, 1960.
83 Special Committee of the Preparation for Entry of the NMEP into the Maintenance phase (Chadha
Committee), Ministry of Health, November, 1963
84 Committee to recommended the staffing pattern of the PHC Complex (Mukherjee Committee),
Ministry of Health, 1966
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Comittee (1970)86 , Second In-depth Evaluation Committee (1974)87 and
Consultative Committee of Experts (1974)88.
The large number of committees established duing that period
but without major impact on the malaria situation indicated several of
the recommendations of these committees were not fully implemented
and the major problem with the NMEP was shortage of insecticides
from 1965. Close studies of the situation show that compared to the
1970 rate of increase was three times in the maintenance phase
obviously on account of the inability of the health network under the
general health services89 to tackle malaria. However, when the malaria
incidence became worse the Modified Plan of Operation was
implemented which provided immediate relief in terms of i eduction of
malaria cases and deaths. It may be stated here that based on the
recommendations of the Madhok Committee in 1969 which observed
more and more urban areas had been contributing to malaria cases
urban malaria scheme came into existence in 1971 covering 23 towns
initially and later on expanded to cover more areas.. A special
programme of P.falcipcirum Containment Programme was also initiated
in 1977 in view of the facts of the increase of P.falciparum incidence,
development of P.falciparum resistance and spread to other areas of the
.country. Initially started with 55 district later on it was extended to 110
'districts. In 1983 the programme was rephased and ultimately the
programme was wound up in 1989 with the withdrawal of SIDA
assistance. The programme continued for sometimes on a skeletal scale
till the available SIDA funds were exhausted. The Modified Plan of
Operation paid rich dividend and the number of cases came down to
around 2 million in 1983 and thereafter it almost remained stationary
and the Government of India appointed the Third In-depth Evaluation
Committee with national and international experts in 198544 which
observed that:
•
The problem of malaria in India is grossly underestimated.
•
The MPO which was intended as a strategic approach to avert country
wide epidemics of malaria, is not able to project itself in the framework
of a sound long-term control programme.
85 Special Committee constituted to review with working of the NMEP and to recommend measures for
improvement (Madhok Committee), Ministry of Health, October, 1969.
86 Evaluation in-depth of the NMEP of India, November, 1970.
87 Committee to study in-depth all relevant aspects of NMEP (1974), Ministry of Health & Family
Welfare, January, 1974.
88 Consultative Committee of Experts to determine alternative strategies under NMEP, Ministry of
Health & Family Welfare, August, 1974
89 Ray, A.P. (1976) - Resurgence of Malaria after achieving eradication, Swasthya Hind, Central
Health Education Bureau, Vol.20 No. 12, page 373.
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•
The effective control of malaria has been seriously jeopardised due to
lack of adequate professional support and varied commitment on the
part of the state Governments.
•
The increasing extent of the technical problem i.e., vector resistance to
insecticides and resistance of Pfalciparum to antimalarial drugs have
substantially reduced the efficacy of the tools available to the
programme.
•
The low level knowledge generating capability through research,
stands in no proportion to the financial outlays and operational
complexity of the programme.
•
The total lack of inter-sectoral co-ordination has led to a dramatic
increase of malaria such as in urban areas and development projects.
•
Active community participation and health education has neither been
promoted adequately nor supported in spite of being laid down as a
basic approach in the MPO.
•
Due to indifferent implementation, the present standard of vector
.control measures are largely suboptimal and subject to diminishing
returns.
•
The drug distribution by volunteers and Government institutions has
had a significant positive impact in reducing mortality and morbidity
due to malaria.
•
The inadequacy of the epidemiological services in their ability to guide
operations in the face of a constant and rapidly changing malaria
situation is resulting in the gradual loss of sense of direction of the
programme.
•
The PfCP has made an effective contribution towards control of
malaria in most of its original areas of operations; however, it has been
unable to keep up with the changing distribution of Pfalciparum
malaria in the country and the potentials of the PfCP have not been
adequately exploited in increasing the professional standards of the
programme as a whole.
Some of the recommendations were malariogenic stratification
of the country, training in malariology and allied fields by creation of
more training centres at the national and state level, ensuring
community participation and health education, establishing Division of
Planning and Epidemiological Assessment and Operational Research
and Training at the national headquarters of NMEP and also at the
State headquarter of NMEP by the end of 1986 and to reduce continued
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dependence on insecticidal spray and promote environmental
measures through effective inter and intra sectoral co-ordination.
For malariogenic stratification of the country, Government of
India constituted a committee which submitted its report in 1987 and
also the training activities were enhanced and more efforts were put to
ensure community participation in health education. However, the
Divisions of Planning and Epidemiological Assessment and
Operational Research and Training have not been established. To
secure inter-sectoral co-ordination in anti-malaria activities various
ministries and departments were approached by the Union Ministry of
Health for creating an in-built infrastructure to combat malaria but
there was no useful response in this direction. Taking broader area into
view recently the matter was discussed in the Fourth meeting of the
Central Council of Health & Family Welfare which has recommended
that a formal co-ordination mechanism should be evolved at all levels
involving all other related ministries namely. Ministry of Environment
and Forests, Ministry of Rural and Urban Development, Human
Resource Development, Chemicals and Fertilizers, Industries, Railways
etc. and such mechanisms should not only be established at the centre,
it should also be established at the State, district, taluka and Panchayat
Jevels. As the situation is still not improving as evidenced from the
surveillance data and in view of the recent large scale outbreak of
malaria a committee has been constituted by the government under the
Chairmanship of Dr S Pattanayak. The report was submitted in 199546
which observed that though proper technology for control of malaria is
available in different epidemiological paradigms of malaria, the
administrative indifference, the organisational weakness, the low
prioritization to malaria under the health services and apathy of
middle level and periphral workers in the states have led to periodic
epidemic and high mortality. The committee identified four high risk
areas namely epidemic prone areas covering 141 million population in
Punjab, Haryana, Western Uttar Pradesh, Rajasthan, Madhya Pradesh,
and a few pockets in other States, tribal areas in 7 North Eastern states,
and North Indian peninsular areas covering 69 million population and
project areas which require special dispensation. The committee also
reviewed urban malaria situation and identified 29 worst affected cities
contributing over 80% of the urban malaria problem.
The drug distribution centres and the fever treatment depots
which were established under MPO and gave very good results in
containing the rising trend of malaria have over a period of time have
become non-functional. The same needs to be re-established in all
epidemic prone areas with proper support of link workers between the
DDCs/FTDs to the government functionary and these link workers
should be compensated for their travel which will facilitate early
detection of cases and hence the detection of the outbreaks.
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Under the MPO the laboratory services have been decentralised
to the block level PHCs but with the establishment of PHCs for 30
thousand population many of these PHCs are without a microscope
and the microscopist. Therefore, urgent action needs to be taken to
provide this laboratory microscopy service in these Primary Health
Centres.
The Committee also observed that the insecticidal spray is
erratic with poor coverage and timing of spray does not match the
actual technical time frame resulting in poor results from the spray.
That is why the committee wants to put a word of caution as
vehemently as possible that the strategy as laid down will not lead to
any impact on malaria situation until and unless the organisation,
administration and execution at the state and peripheral level are
strengthened with appropriate responsibility at every level in making
available the right type of insecticide, release of funds in time,
undertaking spray in right time as per the epidemiological needs,
proper supervision of the spray with appropriate community
awareness and participation, the desired impact of malaria reduction
will not be achieved. The committee suggested that the District
Malaria Officer/district health authorities should continuously
monitor the efficiency of the case detection and timely intervention
measures vis-a-vis the malaria incidence in the community including
vector resistance for increase in transmission potential so that the
advance action can be appropriately undertaken. The committee also
suggested establishment of mobile teams to combat outbreaks at the
district level with proper supervision of insecticides spray equipment,
spraymen and anti-malarials for immediate containment of outbreaks.
•
The committee also suggested that in place of piecemeal changes
in malaria control, the Central government should appoint a team of
administrative and technical experts in planning, finance, information,
education, communication, epidemiology and malariology to review
the entire malaria problem vis-a-vis the health care care delivery system
in the country. However, it is stated that malaria control has very
serious linkages with the socio economic development of the country
through industrial and agricultural revolutions and the tempo of
progress may come to a grinding halt if the adequate attention is not
given in malaria control and, therefore, until and unless resources are
made available, proper decisive changes are made on emergent basis
on the recommendations of the committee backed by proper political
will, the public health system will continue to remain as suspect with
chances of break down whenever intervention measures slackens
either through faulty surveillance, non-availability of anti-malarials or
insecticides etc. The P.falciparum Containment Programme review90
90 Evaluation Report of the P.falciparum Containment Programme under NMEP of India January/February, 1989.
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indicated that the active surveillance under NMEP can not be
maintained because of large scale vacancies in the number of male
multi-purpose workers and after the introduction of multi purpose
workers scheme the surveillance mechanism has been severely
strained.
6.19
NATIONAL LEPROSY ERADICATION PROGRAMME:
The Leprosy is an age old scourge of mankind and a few
decades ago the disease was one of neglect; the affected were put in
leprosarium maintained by charitable trust and organisations. With
the establishment of Indian Council of British Empire Leprosy Relief
Organisation in 1925 renamed as Hind Kushth Nivaran Sangh in 1949
the foundations were laid for the beginning of organised leprosy work
in India91 . The National Leprosy Control Programme was initiated by
Government of India in 1955 which was later on converted into
National Leprosy Eradication Programme (NLEP) in 1983 with the
objective of elimination of leprosy by the year 2000 A.D. based on early
detection of cases and their regular treatment with multi drug therapy.
Before eradication programme was initiated the estimated case load
was about 4 million. The same has been brought down to only 0.70
million at the end of June, 199592 . Elimination of Leprosy in numerical
terms has been placed at a level where leprosy case load will be less
than 0.1 per thousand population because it is expected that with the
prevalence at that level, there will be no active transmission of the
disease. The programme strategy is around domiciliary treatment with
multi-drug therapy, mobile leprosy treatment services in
moderate/low endemic districts, early case detection and treatment,
health education to patients and their families and the community
rehabilitation of those. The organisational structure of the programme
management is the National Leprosy Eradication Commission which
functions as a policy making body to guide the National Leprosy
Eradication Board to implement the plan and policies as laid down
through the Directorate General of Health Services, Directrors of
Health Services, Leprosy Bureaus in States and Union Territories;
district and zonal leprosy officers implement the programme. The
leprosy prevalence has been brought down to a significant level and
now elimination by 2000 A.D. is a distinct possibility. The Government
of India and all State governments have already . repealed the
discriminatory Lepers Act. The programme has been reviewed in the
recently concluded fourth Conference of Central Council of Health &
Family Welfare from 11-13 October,1995 which has observed the
efficiency of the multi drug therapy in leprosy and, therefore.
91 National Leprosy Eradication Programme, NHP Series 6, National Institute of Health & Family
Welfare, 1990.
90
“ Agenda Notes of the Conference of Central Council of Health & Family Welfare, October 11-13,
1995.
144
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recommended MDT to all leprosy cases all over the country and to
initiate special efforts for rehabilitation and to recognise greater
involvement of NGOs, VOs and joint sector in the field of
reconstructive surgery and rehabilitation of the affected persons. The
Council also has recommended that all discriminatory provisions
under various marriage Acts in the country against leprosy should
immediately be repealed.
6.20
NATIONAL TUBERCULOSIS CONTROL PROGRAMME:
Tuberculosis continues to be a major public health problem in
India. As per the National Sample Survey conducted by ICMR in 19555833, nearly 1.5 per cent population
has been suffering from
radiologically active Tuberculosis of lungs of which l/4th i.e. 0.4% are
sputum positive or infectious. Afterwards several similar surveys have
been carried out though none of them were representative of the entire
country93 ,94 ,95 but no reduction in the incidence/prevalence has been
noticed excepting reduction in mortality from over 80 per 100
thousand to nearly 53 per 100 thousand due to Tuberculosis.
Tuberculosis is a staggering public health problem globally and
WHO has declared tuberculosis as a global emergency in 199392.
It is estimated that 12-14 million tuberculosis patients are in the
country of which about 3 million cases are highly infectious and
sputum positive. About 2-2.5 million tuberculosis cases occur in the
country every year and 0.5 million die of tuberculosis every year. The
problem is equally prevalent in rural and urban areas. Only 1.5 million
tuberculosis patients are being detected and treated under the
programme and it is estimated that an equal number are treated by
NGOs and private practitioners. Experts are of the opinion that with
the spread of HIV, the problem of tuberculosis will worsen.
The National Tuberculosis Control Programme has been in
operation since 1962 with the aim to reduce morbidity and mortality
from tuberculosis and reduce the transmission of the disease by
detecting as large number of tuberculosis patients as possible and
treating them, establishing tuberculosis centres in every district of the
country, short course chemotherapy for the sputum positive cases and
strengthening of training capability and augmenting health education.
The key strategy is diagnosis of patients through sputum testing and
chest X-ray.
93 National Tuberculosis Institute, Bangalore 1974 Bulletin WHO 51, 437-487.
94 Raj Narain, Bulletin WHO, 29, 1963, 641-664.
95 Pamra, S.P. 1973, Indian Journal of Tuberculosis, 20.
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As on date district tuberculosis programme is being
implemented in 391 districts and short course chemotherapy has been
made available in 253 districts. Most of the DTBC are fully equipped
with laboratory equipment. In addition there were about 330
tuberculosis clinics in big towns and cities and a total of 47,600 beds are
available for treatment of tuberculosis patients. There are 17 State
Tuberculosis Demonstration and Training Centres established under
the programme. But no tangible decline of incidence of tuberculosis
has been noticed over the last three decades and with the spread of
HIV, experts opine that the situation will worsen. A review was
undertaken by Government of India through an expert committee with
assistance from WHO and SID A96 . The committee observed that less
than 30% complete treatment. Inadequate budgetary allocation,
shortage of drugs, undue continuing emphasis on X-ray diagnosis,
poor quality of sputum microscopy, thrust on case detection rather
than cure, poor organisational set up, and advocacy for tuberculosis,
multiplicity of treatment regime were other observations and
suggested a revised strategy with emphasis on high quality sputum
microscopy, standard treatment regime, creation of a sub-district
supervisory unit, ensuring regular uninterrupted supply of drugs upto
the most peripheral point through enhanced outlay and directly
observed treatment of multi drug therapy and high profile education
campaign and operational research and enhanced involvement of
NGOs.
Based on the above, the revised strategy is under
implementation in 15 sites with the assistance of SIDA, World Bank
and ODA and it is expected that the revised strategy will be extended
to larger areas with World Bank/ODA assistance soon. Tuberculosis
Control Programme faltered because of improper programme strategy,
having emphasis on X-ray diagnosis, inadequate resources and poor
advocacy for the programme, poor quality of microscopy, emphasis on
detection rather than cure etc.
7
'■
t
•n
6.21
NATIONAL FILARIA CONTROL PROGRAMME:
Filariasis is a global problem with more than one billion people
at risk of infection and numerically the public health problem of
lymphatic filariasis is high in China, India and Indonesia which
contribute to over 2/3rd of the total estimated persons affected in the
globe97. All the States and Uts except Arunachal Pradesh, Chandigarh,
Delhi, Haryana, Himachal Pradesh, J & K, Manipur, Meghalaya,
Mizoram, Punjab, Rajasthan, Sikkim, Nagaland and Tripura are
endemic for filariasis. Present estimate indicates 412 million people are
living in known endemic areas of which 109 million are in urban areas
and rest are in rural areas. At present only 46 million urban
96 Review of National Tuberculosis Programme in the Country by Govt, of India, 1992.
97 WHO Technical Report Series No.702, 4th Report of the WHO Expert Committee on Lymphatic
Filariasis, 1984.
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population is being protected through recurring anti-larval measures
by 206 control units and 198 clinics98 . NFCP operates mainly in the
urban areas and hardly anything exists for rural areas.
The
programme was initiated in 1955. However, during the last four
decades nothing much has been achieved. The programme has been
periodically assessed by experts through the ICMR in 1960s, 1970s and
1980s. Low priority, poor allocation of funds, growing rapid
urbanisation and poor intersectoral co-ordination and non
implementation of the specific bye-laws by the municipal bodies
resulted in very poor functioning of the programme99 . Though newer
technology for control of filariasis is available and considered to be
effective but the same is yet to be implemented. The programme
receives so low priority that even in the recently concluded Conference
of Central Council of Health & Family, there is no agenda item on
filaria.
6.22
*
NATIONAL GUINEAWORM ERADICATION PROGRAMME:
Encouraged with the success of smallpox eradication, the
Ministry of Health launched National Guineaworm Eradication Programme in 1983-84 with the objective of eradicating the
M guineaworm disease from the country with NICD functioning as nodal
agency for planning, co-ordination, guiding and evaluating the
guineaworm eradication programme in seven endemic States namely, '
Andhra Pradesh, Gujarat, Karnataka, Madhya Pradesh, Rajasthan and
Tamil Nadu. The strategies followed are guineaworm case detection *
and continuous surveillance through regular periodic active search
operation and monthly reporting, case management, control of vector
through application of insecticides in unsafe water sources eight times
in a year, use of fine nylon mesh/ double layered cloth strainers, health
education and provision and maintenance of safe drinking water on
priority in guineaworm endemic villages through the Public Health
Engineering departments under Rajiv Gandhi National Drinking
Water Mission. When the programme was initiated in 1984100 , the
number of cases recorded were 39,792 in seven States in 89 districts
which was reduced to 371 in 1994 and as on date 59 till September that
too from only 3 districts of Rajasthan and the rest of the endemic
districts/states are free and it is expected that no further transmissions
will occur after 1995. The programme succeeded primarily due to wel^
designed programme strategy in collaboration with Public Health/Engineering departments. The collateral benefits of this programme
has been in the improvement of public health system through^
98 Annual Review of National Filaria Control Programme 1991, NMEP, India.
99 Operational Constraints and their Feasible Solutions for efficient functioning of National Filaria
Control Programme (NFCP) Units in the country - Report of National Workshop - 10-12 December,
1991, NICD, Delhi.
100 Guinea Worm Eradication Programme in India - Operational Manual, NICD, 1989.
147
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provision of safe drinking water in large number of districts and large
number of villages. The strength of the programme has been its
regular periodic monitoring and evaluation through the programme
management as well as through independent evaluation. The Sth
Independent Evaluation was undertaken in 1993101. The programme is
periodically reviewed by the Task Force and the 17th Task Force
Review was held in January, 1995 which recommended preparatory
work for certification of eradication, holding of an international
evaluation which is currently being processed and accorded top
priority to achieve zero transmission.
6.23
NATIONAL AIDS CONTROL PROGRAMME:
Human deficiency virus has spread all over the world cutting
across all the barriers of geographical, economic, social and ethnic
distinctions and this pandemic during the last one and a half decade
has posed a grave health challenge in this century and the way it is
spreading, if appropriate and specific preventive measures and drugs
are not available, the situation will pose a grave danger to the human
civilisation. Rightly, therefore, WHO has taken up a wide and
determined global effort to prevent and contain the further spread of
infection. According to WHO estimates around 2 million were infected
‘with HIV in 1993 raising the total infected since the start of the
pandemic to more than 15 million including one million children102.
The evidence of HIV infection was first recorded in May, 1986 in India
when HIV infection was found amongst six prostitutes in Tamil Nadu.
Since then over the years it has spread to the different parts of the
country and it has assumed a major public health problem. Upto the
end of 30th September, 1994, the total number of HIV sero positive
cases detected in India is 15,619 and the number of AIDS cases detected
so far are 849 from 21 States and UTs102.
National AIDS Control Cell established in the DGHS in 1986 has
grown into National AIDS Control Organisation (NACO) and the
current prevention of AIDS under National AIDS Control Programme
was launched with World Bank assistance on 23rd September, 1992
and the budgetary allocation for 1992-97 is 220.60 crore. Since AIDS
has no cure the scheme mainly aims at slowing down the infection,
creation of awareness, ensuring blood safety and STD control. The
organisational component of the programme is a National AIDS
Committee under the chairmanship of Hon'ble Union Minister of
Health & Family Welfare and Multi-sectoral Committee under the
chairmanship of Secretary (Health) who provide policy directives in
order to ensure efficient programme management. A National AIDS
101 Guinea Worm Eradication Programme in India - Report and Recommendations, NICD, 1993.
102 National AIDS Control Programme in India - Country Scenario - An update - September, 1994,
NACO, Ministry of Health & F.W., Govt, of India.
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Control Board has also been constituted under the chairmanship of the
Secretary. Besides the above the Technical Advisory Committee has
also been established under the chairmanship of Director General of
Health Services. Similarly co-ordinating/management bodies have
been created in the States in order to form Empowered Committee,
State AIDS Cell and State Technical Advisory Committee. The
Empowered Committee has been constituted by the States either under
the chairmanship of Chief Secretary or Additional Chief Secretary as
per the National AIDS Control Board. Review of the programme
indicates that utilisation of funds during the last three years has been
very little and huge unspent balance remained with the State. The
Standing Committee of Parliament also has expressed a concern over
the slow utilisation of huge unspent balance lying with the States100.
Slow utilisation of funds is mainly due to non-release of funds by the
State Finance departments. There is a strong view that the grants
released under the programme are being diverted to meet
requirements in other areas. The issue of ensuring the safety of blood
is also not getting adequate attention. Many of the States have
indicated that they have more number of STD clinics and blood banks
than that indicated by NACO. However, NACO has already conveyed
government's approval covering STD clinics under the programme
*and covering of the additional number of blood banks is awaiting
clearance92.
The growing gap between the number of HIV cases being
detected and the number of AIDS cases reported indicate poor efficacy
of the surveillance mechanism with particular reference to detection of
AIDS cases. For strengthening surveillance mechanism there is an
urgent need for manufacture of HIV testing kits indigenously. Even
after 10 years of AIDS/HIV detection in the country no significant
progress in generating indigenous capability in manufacturing of HIV
kits has been noticed. All the major National Health programmes get
appropriate institutional support to assist the programme management
in various operational research, training, evaluation etc.
The
programme management is yet to generate adequate institutional
support and no formal national evaluation/ independent appraisal has
been undertaken for the programme. There is an urgent need for the
same. The programme has been recently reviewed by the Central
Council of Health & Family Welfare in its Conference held in New
Delhi from October 11-13, 1995 which observed that the Empowered
Committee at the Sate level is not adequately functional and hence be
re-constituted under the Secretary, Department of Health. Poor
utilisation of funds under the programme could be improved through
channelising the funds directly through district health societies. To
ensure blood safety the blood bank system should be improved to the
extent that not only blood is tested for HIV but it is also tested for
syphilis and hepatitis.
IEC activities need to be stepped up
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appropriately to generate awareness amongst all sections of society
and known discriminatory attitude of the health care facilities should
be immediately dispensed with for treatment of HIV cases.
6.24
NATIONAL KALA-AZAR CONTROL PROGRAMME:
Kala-azar was endemic in Bihar, Assam, Tamil Nadu and was
responsible for considerable morbidity and mortality during pre DDT
era. However, with the launching of National Malaria Control
Programme in 1953 and National Malaria Eradication Programme in
1958 mass insecticidal spraying was undertaken for malaria control
and as a collateral benefit Kala-azar control was achieved and in fact
the disease almost disappeared80. With the withdrawal of insecticidal
spraying from the maintenance areas of NMEP, Kala-azar reappeared
with built up of vector population and subsequently kala-azar
transmission was established in Bihar and West Bengal. Initially it was
in few districts of Bihar in early seventies and now 31 districts of Bihar
and 9 districts of West Bengal have become endemic for kala-azar
having 75 million people living at the risk of kala-azar. Before 1991 the
assistance for the kala-azar was being provided by the Government of
India out of the NMEP budget provision. However, separate funds for
kala-azar control was provided from 1991 with an allocation of 4.06
*crore. Since then the Government of India has considerably enhanced
the inputs raising the allocation in 1994-95 to 20 crore. The strategy is
broadly through interruption of transmission, reducing vector
population by undertaking indoor residual insecticidal spray twice
annually, early diagnosis and complete treatment of kala-azar cases
and health education for community awareness. In view of the
financial constraints faced by the State government the Government of
India provides the total cost on medicines and insecticides for kala-azar
in Bihar. Similar facilities are also being provided for West Bengal from
this year. The programme has been reviewed recently by the Central
Council of Health & Family Welfare in its fourth Conference held in
New Delhi from 11-13 October, 199568 which observed that the
appreciable decline had occurred compared to 1992. However, it has
come to the notice that in recent times the timely budgetary release is
not being obtained which is very essential in appropriate functioning
of the programme.
6.25
NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS:
Of the total estimated 30 million blind persons (visual aquity
less than 3/60) for the world 6 million are in India. Two major surveys
were conducted to find out the prevalence of blindness in the country.
The first survey was carried out by ICMR on a National Sample in 1974
and arrived at a figure of 1.38% prevalence rate for the economically
blind. For the second and the latest NPCV/WHO survey (1986-89) the
prevalence rate has been found to be 1.49%. The increase being
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attributed to change in age structure and also due to mounting
backlog103 . Prevalence of blindness is high in States like J & K,
Madhya Pradesh and Rajasthan. In absolute terms more than 2/3rd of
blind persons are in Andhra Pradesh, Bihar, Madhya Pradesh,
Maharashtra, Rajasthan, Tamil Nadu and Uttar Pradesh. No major
survey has been conducted in India to know about the incidence rate.
However, a survey by ICMR has estimated that about 2.2 million
sujects turned economically blind (visual aquity 6/60) every year in
India. Studies show that poor suffer more than the affluent because of
low nutritional status, longer hours of working outside the houses and
gross negligence of the disease in the early stage and little access to
health services. With the launching of the National Programme of
Trachoma in 1963 the first organisational effort to control blindness at
national level started. The programme continued for a decade without
much change in the strategy. Then on better appreciation of the survey
results carried out by ICMR the Central Council of Health & Family
Welfare in its meeting held in 1975 resolved that one of the basic
human rights was the right to see and, therefore, it has to be ensured
that no citizen go blind nutritionally or being blind does not remain so
if by reasonable deployment of skill and resources his eye-sight could
be prevented from deteriorating and if already lost could be
.restored104. Based on the recommendations made by the Central
Council of Health, National Programme on Trachoma was renamed as
National Programme for Visual Impairment and Control of Blindness
and launched in 1976 as a 100% centrally sponsored programme.
Various activities of this programme included establishment of
regional institutes of ophthalmology, upgradation of medical colleges
and district hospitals, development of mobile eye units, recruitment of
required ophthalmology manpower and provision of various
ophthalmoligcal services. National survey was conducted during the
period 1986-89 to evaluate the programme.
The prevalence of
blindness revealed by the survey was 1.49%. The survey also showed
that 80.1% of these blind people are blind on account of cataract. The
survey observed that activities under this programme are yet to show
an impact in reducing the prevalence of blindness to the goal level of
0.3% by the year 2000 A.D92.
In the year!994-95 the budgetary
allocation got a quantum leap from 25 crore in 1993-94 to 40 crore. In
1995-96, it has been further enhanced to 94 crore.
Voluntary organisations are playing very significant role in the
programme. With the success achieved and experienced through pilot
district projects, district blindness societies have been established
through out the country and 411 societies have already been
established100. During 1994-95, 21.64 lacs cataract operations have been
103 The Present Status of National Programme for Control of Blindness, DGHS, 1993.
104 Proceedings of the Joint Meeting of the Central Council of Health & Central Family Planning
Council, 17-19 April, 1975.
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undertaken. WHO and Danish International Development Agency
have been assisting the programme significantly through development
of manpower, supply of equipment to mobile units, PHCs and district
hospitals, preparation of health education materials etc. During the
first phase of the Danish assistance (1978-88) an assistance of 10.12
crore was provided and during the phase second (1989-94) 34.53 crore
was provided. Apart from the external assistance provided by the
above two organisations to strengthen the programme. World Bank
has been assisting blindness control project since 1994-95. Accordingly
some specific guidelines have been provided105 '106 . The proposed
expenditure of the project is 554.56 crore for a period of seven years.
The project is being implemented in seven major states namely,
Andhra Pradesh, Madhya Pradesh, Maharashtra, Tamil Nadu, Orissa,
Uttar Pradesh and Rajasthan. Major inputs will be for upgrading the
ophthalmolgical services expanding the coverage in rural and tribal
areas, establishment and functioning of district blindness control
societies, training of ophthalmology manpower, improving the
management information system, and creating awareness about the
programme. The programme has been reviewed in the recently
concluded Conference of the Central Council of Health & Family
Welfare from 11-13 October, 1995. The council observed that the
•decentralisation of the programme has been one of the remarkable
feature which has improved the functioning of the programme and
suggested to strengthen the programme through establishment of
district societies, establishing identified eye beds and detecting
operation theatre in district hospitals and medical college hospitals,
establishment of at least one mobile unit in each district centre,
emphasis on quality of cataract operation, mass awareness campaign
particularly for the remote and tribal areas and more attention to the
urban slums and establishing a co-ordinaton mechanism with the
social welfare ministry for the rehabilitation of the visually
handicapped.
6.26
NATIONAL IODINE
PROGRAMME:
DEFICIENCY
DISORDERS
CONTROL
It has been estimated that 1.5 billion people in the developing
countries are at risk for living in iodine deficient environment. About
90 million people suffer from goitre, more than 3 million are overt
cretins and millions more suffer from intellectual deficiency92. Iodine
is an essential micronutrient which is required 100-150 mgms daily for
normal human growth and development. There is an increasing
incidence of widespread distribution of environmental iodine
105 National Programme for Control of Blindness - Guidelines for District Blindness Control Society Revised - August, 1995, DGHS, Minitry of Health & F.W.
106 National Programme for Control of Blindness, Schemes for Participation of Voluntary
Organisations (Part I) 1995, DGHS, Ministry of Health & F.W.
AV ■
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deficiency not only in the Himalayan regions but also in the sub
Himalayan terai areas, reverine areas and even the coastal regions. It
affects from development of foetus to all ages of human beings. It
results in abortion, still birth, mental retardation, deaf mutism, squint,
dwarfism etc. It is estimated that 167 million people are at risk of
iodine deficiency disorders and the study conducted by ICMR and
medical institute has demonstrated that not a single state/UT is free
from the problem of iodine deficiency disorders. It has been estimated
that 54.4 million people are suffering from endemic goitre and about
8.8 million are mental/motor handicapped. Sample survey carried out
in 25 States and 4 Uts of the country have revealed that out of 245
districts surveyed, iodine deficiency disorders is a major public health
problem in 211 districts92.
Government of India launched a 100% centrally sponsored
Goitre Control Programme in 1962 which was renamed as National
Iodine Deficiency Disorders Control Programme in view of wide
spectrum IDD. On the recommendations of the Central Council of
Health in 1984107 , the Government of India took a policy decision to
iodize the entire salts in the country by 1992. The programme started
in April, 1986 and today the annual production of iodized salt is 34 lac
MT.
In order to ensure use of only iodized salt all the States and Uts
have been advised to issue notification banning sale of salts other than
iodized salts for edible purposes under PFA Act. So far 24 States/UTs
have completely banned the same while another 5 has banned
partially20.
The Salt Commissioner in consultation with the Ministry of
Railways arranges transportation of iodized salt from the production
centres to the consuming states under priority category B, a priority
second to Defence. 25 States and Uts have established IDD Control
Cell at the Directorate and a National Reference Laboratory for
monitoring has also been established at NICD.
Government of India/UNICEF project 1993-95 has been in
operation in 17 selected endemic districts for extensive monitoring and
IEC activities and the same are going to be expanded to 106 selected
districts of 13 States including North Eastern States. This programme
is also included in the 20 point programme of the Prime Minister. The
programme has been reviewed in the recently concluded Conference of
the Central Council of Health & Family Welfare. All States/UTs
should ban sale of non-iodized salts and set up IDD Control Cell and
establish IDD Monitoring Laboratories. The Council also suggested
107 Proceedings of the 10th Conference of Central Council of Health & Central Family Welfare
Council. 9-11 July, 1984.
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examining providing subsidy to the manufacture and distribution of
iodized salts.
6.27
NATIONAL DIABETES CONTROL PROGRAMME:
In pursuance of the recommendations of the Working Group
and the Expert Sub Group on Diabetes Mellitus the National Diabetes
Control Programme was included in the 7th Five Year Plan as one of
the central health sector programmes and a sum of Rs.25 lacs was
allocated to initiate district Diabetes Control Programme in five
districts of the country108 . It was envisaged that infrastructure for
monitoring and evaluation at the national level (under the National
Co-ordinator) be created during 1986-87 and initiate the programme in
two districts during 1987-88, two additional districts in 1988-89 and
finally one district in 1989-90. Two districts viz. Salem and South Arcot
in Tamil Nadu were taken up. The Working Group found satisfactory
performance of clinical and laboratory facilities at 69 community health
centres and the efforts made at strengthening diabetes care
infrastructure, education and training of requisite health manpower,
preparation of learning resource materials, dissemination of
information with a view to generate community awareness and
leadership satisfactory. One district in J & K also was taken up and
*Rehbar-i-Sehat scheme contributed immensely in the implementation
of the programme. A sub committee set up in 1989 recommended
establishment of the National Documentation Centre with the objective
of collation and dissemination of data relating to epidemiology,
pathophysiology, etiology, drug management, nutrition, counselling,
care of complication etc. and suggested that the centre be located in
close proximity to the co-ordination, monitoring and evaluation centre
located at AIIMS. The Working Group further recommended to extend
the district diabetes control programme to 25 districts.
During the Sth Plan period some of the states have initiated
State Diabetes Control Programme as a part of the State Plan scheme.
The State of Karnataka has initiated the programme in two districts
and now proposes to extend to three more districts. Andhra Pradesh,
Rajasthan, Maharashtra, Himachal Pradesh and Punjab have indicated
that they intend to initiate District Diabetes Control Programme
during 1995-96. Training material and health education materials in
local language is available in Tamil Nadu, Karnataka, Maharashtra and
J & K.
The programme does not receive the priority that it should have
and there is no agenda item to discuss this important issue in the
108 Working Group Report on Containment of Non-communicable Diseases for the Sth Five Year Plan
(1990-95).
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recently concluded Conference of the Central Council of Health &
Family Welfare.
6.28
NATIONAL CANCER CONTROL PROGRAMME:
Cancer is increasingly becoming a major health problem.
Around 7 lacs new cases of cancer occur in India every year and nearly
'll 3rd are advance and incurable at the time of diagnosis92. Nearly half
of this die of the disease each year. It has been estimated that by 2026
the cancer deaths will increase nearly threefold. Considering the
gigantic problem the Government of India launched National Cancer
Control Programme in 1975-76 through provision of Central assistance
for purchases of cobalt therapy for treatment of cancer patients.
Subsequently 10 major institutions were recognised as regional cancer
centres with grants-in-aid from the government. During the 7th five
year plan 19.34 crore were released by Government of India and
strategies are around primary prevention through detection, secondary
prevention through early diagnosis and treatment, strengthening of
existing therapeutical services and provision of palliative care in
terminal cancers.
Though 11 centres have been established so far but they cover
•hardly 10% of the population and the level of expertise in these
regional centres need further upgradation. A large proportion of the
cancer cases are being cared for by the medical colleges and private
hospitals which often lack expertise, manpower and facilities. Against
the required norm of one cobalt unit per million population only 200
cobalt units are available in the country. During the Eighth Plan,
emphasis has been placed on primary prevention, early diagnosis of
cancer and augmentation of treatment facilities through:
a) Development of Oncology wings in medical colleges and hospitals
to fill up geographical gaps in the availability of the cancer
treatment facilities. So far financial assistance has been provided
for development of Oncology wing in 23 medical colleges/hospitals
in the country under the scheme.
b) Scheme of district cancer control programme for preventive health
education, early detection and pain relief. The project is linked
with regional cancer centre and 24 projects have been undertaken
so far in ten States.
c) Assistance to voluntary organisations for undertaking health
education and early detection. So far 15 VOs have been brought
under the scheme.
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d) Supply of Palliative medicines like Morphine. So far 26 districts
have been identified by the Government of India. In identified
districts five beds are kept for Palliative care.
A National Cancer Board has also been constituted and similar
boards were also suggested at the State level and the Working Group
reported that 14 states/2 Uts have constituted their Cancer Control
Board.
The Working Group108 reviewed the programme and suggested
three operational levels of the cancer control. Level 1: which includes
sub centre PHC and community health centre and district hospitals not
having the facilities for treatment of cancer. Level 2: which includes
district hospitals having facilities for treatment of cancer, medical
colleges and dental colleges and Level 3: which includes regional
cancer research and treatment centres.
During the 7th five year plan only levels II & III were involved
in cancer control so the group recommended that level 1 also to be
utilised during the Sth plan. The group also recommended that the
regional cancer research and training centres should not only act as a
referral centre but for complicated and difficult cases it should also act
*as an apex body for taking up activities such as development of
diagnostic test, development of health education, dissemination health
education materials, training of professional and para professional
personnel. In states where no regional centre is available, medical
college hospitals should be identified and developed. Indian System of
Medicine professionals should be appropriately involved in primary
prevention. Early detection of cancer through organised oncology
screening programme, has brought down incidence and mortality from
cervical cancer in developed countries. Towards this end the Institute
of Cytology & Preventive oncology has done very good work and
found the following interventions like raising the marriage age beyond
18 years, observing small family norms, maintaining successful and
obstetric hygiene, control and containment of genital infection through
control promiscuity using various contraceptives will provide very
good dividend in reduction of cervical cancer and, therefore, the same
should be field tested widely to realise their actual potential. The
District Cancer Control Programme has been initiated in 27 districts to
undertake level-1 Cancer Prevention activities. The programme has
been recently reviewed by the Central Council of Health & Family
Welfare in its fourth Conference held in New Delhi from 11-13 October,
1995. The council noted with concern and disappointment that its
earlier recommendations specifying measures administration and
legislative for curbing consumption of tobacco and tobacco products
have not been implemented. The same should be immediately
implemented.
The council also recommended strengthening of
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national cancer registration programme of ICMR to generate more
useful epidemiological data, strengthening of the cancer control cell of
the DGHS, augmenting the district cancer control programme by
covering more districts, and augmenting coverage of more medical
colleges to develop oncology wings for providing therapeutical
services.
The council also recommended more involvement of the NGOs
in cancer control programme.
6.29
OBSERVATIONS, SUGGESTIONS & OVERVIEW:
6.29.1
In the chapter large number of health schemes implemented
through the Ministry of Health & Family Welfare have been described.
In addition to that there are large number of schemes having
tremendous impact on human health and quality of life. These schemes
are being implemented through several other ministries. Some of the
important ones which have a direct bearing on the Public Health
System are Rajiv Gandhi National Drinking Water Mission
(RGNDWM), Rural Sanitation, Accelerated Urban Water Supply
Programme, Urban Sanitation, Urban Basic Services for the Poor,
.Urban Solid Waste Management, Sewerage and Sewage Treatment,
Prevention of Water and Air Pollution, Nutritional Programmes like
Integrated Child Development Services, Special Nutritional
Programme, Balwadi Nutritional Programme, Midday Meal
Programme etc. All these schemes have been conceptualised to
improve the Public Health System. But as different agencies are
involved and co-ordination between different agencies are not so easily
achieved, experts are of the opinion that until and unless a formal
mechanism of co-ordination and co-operation are established involving
all concerned and having guidelines indicating detailed responsibilities
in respect of all participating units, even inspite of individual schemes
appearing to be technically sound, the same have not been able to
deliver what is expected of them in improving the Public Health
System. Experts opine that such mechanism is very vital in the
implementation of the health schemes and will strengthen Public
Health response capability significantly.
In this context it is stated that the recently concluded Central
Council of Health & Family Welfare (CCH&FW) in its meeting on 1113 October, 95 resolved that such mechanism should be established
immediately at all levels and as it pertains to human health, the
Ministry of Health & Family Welfare should be the nodal agency for
such mechanism.
The committee has deliberated at length on this issue and is of
the opinion that to establish such mechanism of collaboration and co
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operation should be a priority area of action on part of the
Government. As all the schemes are linked to human health, creation
of a new Ministry of Human Welfare could be conceptualised giving
the responsibility of undertaking all such activities. In this context
decentralisation of the administrative mechanism through the
Panchayati Raj will provide a very good operative tool for co
ordinating all the activities pertaining to the human health and thus
strengthening Public Health System.
6.29.2
For all the schemes funding are separate and hardly there is
authority which allow at the delivery point adjustments of funds from
one to the other depending upon the local situation. Delegating
financial and administrative responsibilities to the Panchayati Raj
systems to adjust funds from one another through a predetermined
flexible operating financial accounting & expenditure scheme will
allow in a given local situation administrative and operational tools to
utilise the funds more effectively and thus the impact of the various
health schemes on the Public Health System could be reviewed in its
totality.
6.29.3
Public Health System requires expertise from a variety of
•disciplines. Sometimes experts responsible for different schemes do not
appreciate its impact on the Public Health System covering expertise of
another discipline; for example Public Health Engineering Department
is responsible for supply of potable water for drinking. The department
also is to take care of establishing an appropriate drainage mechanism
for the waste water. In case the same is not being attended to, it will
create potent source of vector breeding and insanitary environments,
leading to vector/water borne and thus putting strains on the
resources of another department. Therefore, while providing the
specific services where several disciplines are involved, the leadership
of undertaking such jobs should preferably be task oriented and other
concerned should provide the requisite support through a well
designed programme guidelines.
6.29.4
Though a huge health infrastructure and a large number of
schemes are in operation in the country, yet the same has not been able
to improve the Public Health System as envisaged because of poor
coverage, poor infrastructure, poor monitoring & evaluation and host
of other factors. Many schemes have been initiated on pilot basis in a
limited areas and there after extended. For the successful functioning
of several of these schemes, several complementary health schemes are
required. For example : When Kala-azar epidemic struck Bihar efforts
were made to undertake Kala-azar control through NMEP but the area
where the Kala-azar epidemic was spreading there was hardly any
NMEP organisational structure/expertise left for undertaking spray
because Malaria entered in the maintenance phase long before in these
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areas. As a result though the insecticides were available there was no
operative infrastructure present. This necessitated establishing these
operative infrastructure and thus delaying greatly in initiating Kalaazar control scheme.
6.29.5
Several schemes are in operation and health workers are given
operative guidelines in implementing various intervention measures
under different scheme and some of these guidelines often do not
provide simplified uniform instructions and often act as a factor in
enhancing confusion amongst them - thus affecting the quality of
Public Health System. Therefore channelising all the schemes through
the Panchayati Raj Administration for providing uniform set of
instructions in simple manner will go a long way in strengthening the
Public Health System.
6.29.6
Large number of vacancies exist in Medical/Para-Medical
personnel in PHC/CHC. Dearth of several specialists also is present in
CHC. Orientation in Public Health is also poor. This has resulted in
poor technical capacity of the existing rural health service. Therefore
the national education policy in health sciences should be implemented
through a time bound programme. In that case appropriate experts
•will be available in the concerned health sector with more updated
professional competent support for better management of disease
control programme and transfer of new technologies for controlling
various emerging diseases/health problems at the grass root level.
6.29.7
Powers and responsibilities in the health & family welfare sector
should be transferred to Panchayat bodies and Nagar Palikas
alongwith financial resources for better management of various
schemes. Adequate flexibility also needs to be provided to them
through the states.
6.29.8
Serious attempts will have to be made to develop urban health
services. Organic linkages need to be forged with the urban
development schemes including Urban Basic Services for a
comprehensive development of health and welfare services. Local
hospitals should be made responsible to run these centres and treat
them as their extension counters for providing health services to the
community. Voluntary organisations and local bodies would be
encouraged to develop partnership and ultimately taking full
responsibility for carrying out these programmes. Health system
research to develop a model of urban primary health care services is
also required.
6.29.9.
The medical college hospitals and specialised hospitals have to
be used exclusively as tertiary care centres and for health manpower
development. Important pre-requisites for this would be improvement
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in the facilities and standards of care available at secondary care level
and development of strong referral system.
6.29.10I
There is a need to review the staffing pattern of new PHCs and
they need to be adequately strengthened to enable them effectively
functioning for delivering comprehensive health care services.
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NATIONAL FAMILY WELFARE
PROGRAMME
7.0
NATIONAL FAMILY WELFARE PROGRAMME
7.1
Introduction
One of the crucial problems facing the nation today is the
increasing population, which has been growing at an alarming rate.
Census of 1991 had indicated the population of India as 846.3 million,
up from 342 million in 1947. During the decade 1981-91 the All India
average annual exponential growth rate has been of the order of 2.14%,
marginally lower than 2.22% during the preceding decade but is still
very high in comparison to the developed nations of the world. On
2.4% of the world's land area, India supports more than 16% of the
world's total population. The rapid increase in population has serious
implications on the over all socio-economic development of the
country. Therefore the containment of population growth is one of the
priority objectives.
7.2
Family Welfare Programme During The First Seven Five Year Plans
With a view to check the growth of population the Family
Planning Programme (since renamed Family Welfare Programme) was
taken up in the country since 1952. The programme aims to provide
family planning services within the broader context of maternal and
child health care. It disseminates information and education to enable
couples to make voluntary and informed choice regarding the size of
the family and spacing through contraception. A large scale variations
and diversities in the demographic situation, socio-economic and
cultural milieu between and within the states and regions of the
country made the task of population control a challenging and
formidable one.
7.2.1
The approach under the programme during the First and
Second Five Year Plans was mainly "Clinical" under which facilities for
provision of services were created. However, on the basis of data
brought out by the 1961 census, the clinical approach adopted in the
first two plans was replaced by "Extension and Education approach"
which envisaged expansion of service facilities along with spread of
message of small family norm.
7.2.2
In the Fourth Plan, high priority was accorded to the
programme and it was proposed to reduce birth rate from 35 per
thousand in 1968-69 to 32 per thousand by the end of Plan. For
achieving this objective, 16 million sterilisations and 8.6 million IUD
insertions would have to be performed, and the level of conventional
contraceptive users was to be raised to 10 million. To accomplish this,
concerted efforts were made to establish and strengthen the basic
infrastructure needed for provision of services especially in the rural
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areas. However, despite these efforts, including the strategy of holding
mass vasectomy camps, higher compensations to acceptors and greater
expenditure on media and publicity, only 16.5 million couples,
constituting about 16.5% of the couples in the reproductive age group,
could be protected against conception by the end of Fourth Plan.
7.2.3
In the Fifth Five Year Plan, the objective before the programme
was to bring down the birth rate to 30 per thousand by the end of 197879. For achieving this goal, it was envisaged to raise the level of
couples protected against conception to 40 million by 1978-79. The
programme was included as a priority sector programme during the
Fifth Plan with increasing integration of family planing services with
those of Health, MCH and Nutrition to make the programme became
more readily acceptable. A new project was also planned under which
unipurpose workers working in various health programmes were to be
converted into multi-purpose workers following suitable orientation
training. During the period the family planning programme had
received a set back and the effective couple protection rate came down
from 23.9% in 1976-77 to 22.5% in 1980.
7.2.4
In the Sixth Five Year Plan, the working Group on population
.and Policy set up by the Planning Commission recommended the
adoption of long-term demographic goal of reaching net reproduction
rate of unity by 1996. However, in the National Health Policy (1983) the
long term demographic goal of reaching net reproduction rate of unity
was postponed to be achieved by 2000 A.D. The implications of this
were to achieve the following by the year 2000 A.D.
1. Reduction of average size of family from 4.4 children in 1975 to 2.3
children.
2. Reduction of birth rate to 21 from the level of 33 in 1978 and death
rate from 14 to 9 and infant mortality rate from 127 to below 60.
3. Increasing the couple protection level from 22% to 60%.
Keeping in view the long term objective of reaching the NRR of
1 by 1996 and also the past performance, present capacity and future
potential, a target of 24 million sterilisations, 7.9 million IUD insertions
and raising the level of CC users to 11 million during 1984-85 was fixed
for the Sixth Five Year Plan (1980-85) for which an outlay of Rs. 1010
crores was agreed to by the Planning Commission against an
expenditure of Rs. 493.94 crores during the Fifth Plan (1974-78). The
achievement was 17 million sterilisations & 7 million IUD insertions,
9.31 million CC users were enrolled during 1984-85.
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7.2.5
The Seventh Five Year Plan envisaged a target of 31 million
sterilisations, 21.25 million IUD insertion and increasing the annual
number of CC, OP users to 14.50 million in the last year of the Plan.
With the achievement of these targets, the Couple Protection rate was
expected to increase from 37.5% in March, 1987 to 42% in March, 1990.
The Seventh Five Year Plan was formulated on the basis of the
report of Steering Group on " Population Stabilisation and Maternal
and Child Health Care". The Programme during this period carried
out on a purely voluntary basis with emphasis on promoting spacing
methods, securing maximum community participation and promoting
maternal and child health care. The strategy of implementation of the
Family Welfare Programme was reviewed during 1985-86, under the
direction of the Prime Minister so as to redesign the programme and
draw up a time bound Action Plan to bring about a swift decline in the
birth rate.
In order to provide facilities/services nearer to the door steps of
population, the following steps/initiatives were taken during the
Seventh Plan period:-
J.
It was envisaged to have one sub-centre for every 5000 population
in plain areas and for 3000 population in hilly and tribal areas. At
the end of Seventh Plan i.e. 31.3.90, 1.30 lakhs sub-centres were
established in the country.
II.
The Post Partum programme was progressively extended to sub
district level hospitals. At the end of Seventh Plan, 1075 sub
district level hospitals and 936 Health Posts were sanctioned in
the country, out of which the number functioning were 1012 and
870 respectively.
III.
The Universal Immunisation Programme started in 30 districts in
1985-86 was extended to cover 448 districts in the country by the
end of the Seventh Plan.
IV.
A project for improving Primary Health Care in Urban slums in
the cities of Bombay and Madras was taken up with assistance
from the World Bank.
V.
Area Development Projects were implemented in selected
districts of 15 major states with assistance from various donor
agencies.
The broad achievements of the Family Welfare Programme
ending the Seventh Five Year Plan (March, 1990) are summarised
below:-
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I.
Reduction in crude birth rate from 41.7 (1951-61) to 30.2 (SRS:90).
II.
Reduction in total fertility rate from 5.97 (1950-55) to 3.8 (SRS:90).
III. Reduction in infant mortality rate from 146 (1951) to 80 (SRS:90)
IV. Increase in Couple Protection Rate from 10.4% (1970-71) to 43.3%
(31.3.1990).
V. Setting up of a large network of service delivery infrastructure,
which was virtually non-existent at the inception of the
programme.
VI. Aversion of over 118 million births by the end of March, 1990.
The approach adopted during the Seventh Five Year Plan was
continued during 1990-92. A major new initiative undertaken during
1991-92 is the Child Survival and Safe Motherhood Project, an
integration of Universal Immunization Programme
with
expanded/intensified MCH activities in high IMR states/Districts of
the country. World Bank assisted Area Development projects IPP VI
.(U.P., M.P. and Andhra Pradesh) and IPP VII (Punjab, Haryana,
Gujarat, Bihar and J & K) and UNFPA assisted Area Development
projects for Himachal Pradesh and Maharashtra were operationalised,
starting of indigenous production of Cu-T, an important birth-spacing
contraceptive device, and introduction of non-steroidal weekly oral
contraceptive pill, a product of indigenous research were important
landmarks during this period. IEC efforts were intensified to improve
the capacity and skill of Population research Centres(PRCs).
7.2.6
Achievement under family welfare programme
The achievements of the Family Welfare Programme since its inception
are summarised below:
Parameter
S. No
1981
1951-61
1994
1.
Birth Rate
41.7
37.2*
28.6 (SRS 94)
2.
Death Rate
22.8
15.0*
9.2 (SRS 94)
3.
Total Fertility Rate
5.97
4.5
3.6 (SRS 92)
4.
Net Reproduction Rate
Infant Mortality Rate (Per 1000
live births)__________________
Couples Protection Rate
6.
(Percent)____________________
Cumulative Number of births
7.
averted (in million)__________
* refers to period 1971-81.
5.
146
110
73 (SRS 94)
10.4
(1970-71)
0.04
22.8
45.8 (Prog. Data
31.3.94)_________
182.76 (Prog. Data
31.3.94)
164
9
1
1.48
43.4
NHP Goals by
2000
21
Less than 60
60
phsfinal.doc
It is estimated that if the averted births had taken place, the
average annual exponential growth rate of population during the 198191 decade would have been of the order of 2.72%, as against 2.14%
actually registered in 1991 census.
7.2.7
Eligible couples and per cent effectively protected is given in the
table below:Year
No. of Eligible couples
______ (millions)______
1951
1961
1971
__________ 65__________
__________ 79__________
__________ 94__________
_________ 116_________
_________ 118_________
_________ 121__________
_________ 124_________
_________ 126_________
_________ 129_________
_________ 132_________
_________ 135_________
_________ 138_________
_________ 141__________
145
1980- 81
1981- 82
1982- 83
1983- 84
1984- 85
1985-86
1986-87
1987- 88
1988- 89
1989- 90
1990- 91
1991-92
1992- 93
1993- 94
1994- 95
1995- 96
7.2.8
152
155
Percent effectively
protected (CPR)
NA
NA
10.4
22.8
23.7
25.9
29.5
32.1
34.9
37.5
39.9
41.9
43.3
44.1
43.4
45.1
45.1
45.3
Year-wise medical termination of pregnancies performed since
inception of the Programme is given in the table below:Number of facilities
___________ Year
_______ 1877_______
__________1972-76
_______ 2149_______
_________ 1976-77
_________ 1977-78
_______ 2746_______
_________ 1978-79
_______ 2765_______
_________ 1979-80
_______ 2942_______
_________ 1980-81
_______3294_______
_________ 1981-82
3908
_________ 1982-83
4170
4553_______
_________ 1983-84
4921
_________ 1984-85
_______5528_______
_________ 1985-86
_________ 1986-87
_______5820_______
_________ 1987-88
6126
______ 6291______
_________ 1988-89
______ 6681______
__________1989-90
________ 1990-91
6859
Cummulative total since inception of the Programme upto
march, 91
165
Number of abortions
_________381,111
__________ 278,870
__________247,049
_________317,732
__________360,838
_________ 388,405
_________ 433,527
_________516,142
__________547,323
_________ 577,931
__________583,704
__________588,406
__________584,870
_________582,161
__________596,357
__________580,744
7,565,170
phsfinal.doc
7.2.9
In order to give new thrust and dynamism to Family Welfare
Programme, an area specific microplanning was suggested in a
background document submitted by the Planning Commission, as a
result of which, a sub-committee of National Development Council on
Population was constituted. The report of the Sub-Committee was
considered and endorsed in the meeting of the National Development
Council held on 18th September, 1993. The Department of family
Welfare has initiated follow-up action to implement the
recommendations. The major recommendations of the NDC are:
I.
Strengthening of infrastructure of the delivery of primary health
care and family welfare services both in rural and urban areas by
providing physical facilities, filling up of vacant posts and
ensuring supply of essential drugs, dressing and other
consumables.
II.
Providing facilities for medical termination of pregnancy
sterilisation should be created at every primary health care.
JII.
An integrated programme for all developmental activities
including family welfare should be worked out to achieve inter
sectoral co-ordination.
IV.
Panchayats should be involved in planning and implementation
of different developmental activities aiming towards achieving
combined goals with special reference to programmes aimed at
women development and family planning.
V.
Mechanism should be developed for the purpose of formulation
of National Population Policy directives, plan of action, over
viewing and monitoring the programme and obtaining support
from all sections from within and outside the Government.
Similar mechanisms should be developed at state and districts
levels.
VI.
Differential approach in programme formulation and
implementation should be adopted to meet ’area specific
requirements with particular reference to poorly performing
districts.
VII. Mechanism for securing commitment and support of leadership,
including people's elected representatives and religious leaders,
should be developed. The organised sector and associations of
professionals, trade and industry, journalists, NGQs, etc. should
be involved for population control efforts.
166
phsfinai.doc
VIII. Steps should be taken to raise the age at marriage and literacy
status of women and to remove the gender gap in selective
demographic determinants.
IX.
The quality and outreach of Maternal & Child Health Services
should be further strengthened.
X.
Poverty alleviation schemes administered by central and state
Governments should be used as effective instruments for
propagating family welfare programme.
XI.
A set of incentives and disincentives have also been
recommended by the Committee with the provision that legal and
administrative implications of these be got examined once these
are accepted in principle. NDC desired in-depth discussion prior
to implementation.
XII. A National Population Policy and Development of necessary
mechanisms for its expeditious and effective implementation may
be formulated.
Recognising the fact that reduction in infant and child mortality
is an essential prerequisite for acceptance of small family norm.
Government of India has attempted to integrate MCH and FP care as a
part of Family Welfare Services at all levels. The NDC in 1991
approved the modified Gadgil Mukherjee Formula, which for the first
time gives equal weightage to performance in MCH sector (IMR
reduction) and FP sector (CBR reduction) as part basis for computing
central assistance to nonspecial category states (Table). At secondary
and tertiary care level FP services are closely integrated with Obst/gyn
and paediatric care. At the primary health care level the PHC Doctor
and the ANM provide both MCH and FP services.
167
phsfinal.doc
TABLE
1% ALLOCATION OF CENTRAL ASSISTANCE UNDER GADGIL
MUKERJEE FORMULA TO NON-SPECIAL CATEGORY STATES
Non-Special Category States
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Andhra Pradesh
Bihar
Goa
Gujarat
Haryana
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
Total:
(Source : PR Division, Planning Commission)
168
______ (Rs. Crores)
Annual Plan
1994-95
1995-96
3.96
5.66
6.80
4.00
6.36
4.11
6.80
2.11
5.64
3.02
4.32
4.09
5.69
5.50
3.94
6.50
2.03
8.29
4.15
3.61
5.72
8.29
5.85
7.00
5.88
6.49
2.31
8.29
2.01
7.93
72.00
84.35
phsfinal.doc
SELECTED INDICATORS FOR MAJOR STATES
States
1993-94
CBR
IMR
OPR
(1993)
(1993)
Mar 94
(Provisional)
(1986-90)
6.
7.
8.
9.
L:ife
Expectancy
Rs. In Crores
Outlay
1.
India
Expenditure
Health
MNP
Health
MNP
2.
3.
4.
5.
113501.03
113501.03
89858.12
33117.32
28.7
74
45.4
57.70
2759.40
3920.00
12014.00
4132.00
2591.71
2460.00
2759.40
3920.00
12014.00
4132.00
2591.71
2460.00
2686.00
5253.00
2370.00
4402.00
2224.00
2432.00
761.83
1649.00
1818.82
1748.17
811.47
987.70
24.3
29.5
32.0
28.0
30.9
26.7
64
81
70
58
66
63
48.2
23.6
24.1
58.2
54.9
56.5
59.10
53.60
54.90
57.70
62.20
62.80
11242.00
2450.00
7640.00
10604.00
3040.00
4600.00
5621.00
7158.00
9833.00
2906.00
11242.00
2450.00
7640.00
10604.00
3040.00
4600.00
5621.00
7158.00
9833.00
2906.00
6990.00
1738.00
6261.00
9379.00
2318.00
2521.00
4900.00
7259.00
7778.00
2749.00
3245.00
461.00
2277.78
4440.79
804.97
717.00
2173.00
2554.89
3492.23
800.00
25.5
17.4
34.9
25.2
27.2
26.3
35.1
19.5
36.2
25.7
67
13
106
50
110
55
82
56
94
58
50.3
51.5
43.1
54.0
39.0
77.4
30.3
54.9
36.5
34.9
61.10
69.50
53.10
62.60
54.40
65.20
55.20
60.50
53.40
60.80
MAJOR STATES
1. Andhra Pradesh
2. Assam
3. Bihar
4. Gujarat
5. Haryana
6. Himachal
Pradesh
7. Karnataka
8. Kerala
9. Madhya Pradesh
10. Maharashtra
11. Orissa
12. Punjab
13. Rajasthan
14. Tamil Nadu
15. Uttar Pradesh
16. West Bengal
Relate to the year 1990.
169
phsfmal.doc
STATE WISE OUTLAY AND EXPENDITURE UNDER FAMILY WELFARE
PROGRAMME
(Rs. IN LAKHS)
STATE
1992-93
Outlay
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Andhra
Pradesh
Arunachal
Pradesh
Assam
Bihar
Goa
Gujarat
Haryana
Himachal
Pradesh
Jammu &
Kashmir
Karnataka
Kerala
Madhya
Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Oijssa
Punjab
Rajasthan
Sikkim
Tamilnadu
Tripura
Uttar Pradesh
West Bengal
1993-94
Expenditure
Outlay
Expenditure
1994-95
1995-96
Outlay
Outlay
5445.33
7316.54
5550.30
9139.67
6412.87
5686.59
147.48
58.09
157.16
67.90
153.17
138.76
2551.73
4800.15
125.19
3386.66
1520.05
993.11
1754.64
6914.11
94.77
4942.94
2322.01
1364.48
2127.81
5188.59
122.84
3740.57
1531.18
1409.82
2299.50
7435.86
100.06
6057.38
2800.81
2188.34
2036.79
6999.29
125.66
4090.20
1729.21
881.67
4169.49
6890.98
133.91
3477.35
1375.84
922.25
1137.92
1222.58
1003.36
1295.31
2788.68
992.62
3094.07
2493.69
5201.07
4158.06
3100.44
6325.25
3333.15
2347.72
6575.01
4515.54
3815.43
8155.46
3624.74
2231.23
5745.48
6482.55
2402.52
5356.93
6491.20
373.48
254.10
152.01
217.48
3196.64
1841.37
3762.22
131.41
4441.96
299.30
12838.90
4895.05
8367.25
478.49
234.41
159.91
229.21
3486.35
3247.65
5002.37
190.37
7221.54
556.94
14526.10
5841.06
6824.49
368.69
257.31
166.88
213.89
2824.57
1915.42
5037.44
173.59
4530.30
316.83
16506.92
5349.45
9510.43
347.96
275.38
167.35
256.58
2465.07
3553.01
5439.35
266.25
4790.10
340.21
19945.65
6317.42
5979.41
351.80
248.97
170.90
217.94
4521.42
2619.43
3716.58
203.08
5125.47
302.66
16228.41
4761.27
6048.42
390.08
265.28
187.99
209.65
2900.31
1785.82
6294.46
236.86
3976.78
326.65
13721.94
6561.74
70.15
72.94
65.10
77.14
70.90
76.41
103.25
20.10
102.45
14.01
115.75
21.80
122.62
18.73
138.25
24.00
155.75
24.72
13.30
619.10
7.35
63.10
13.71
299.68
3.00
61.33
18.52
675.10
8.22
68.00
37.53
816.55
5.67
78.80
21.25
1173.00
9.30
80.00
25.51
1518.07
10.65
88.01
70387.92
29612.08
89682.38
19357.62
78545.78
48546.22
102703.06
28559.22
82783.03
60227.00
82834.89
61165.11*
Union Territories
1. Andaman &
Nicobar
2. Chandigarh
3. Dadar & Nagar
Haveli
4. Daman & Diu
5. Delhi
6. Lakshadweep
7. Pondicherry
Total
Other (Cent. Sect./
Cost Of Supplies)
Arrears Paid to
States
Grand Total
21000.00
10000.00
100000.00
(104100.00)
119040.00
127092.00
(142357.00)
152262.22
14100.00**
143010.03
(153800.00)
158100.00
FIGURES IN BRACKETS ARE REVISED ESTIMATE
** PROVISION MADE FOR ARREARS
170
phsfinal.doc
7.2.10 Family Welfare Programme during Eighth Five Year Plan
It has been stated in the Eighth Five Year Plan document that
the growth rate of population would be about 1.78% per annum during
the Eighth Plan and would come down to 1.65% during 1996 to 2001. It
has also been stated that NRR-1 would now be achievable only in the
period 2011-16 A.D.
The Eighth Five Year Plan has laid down following goals to be
achieved by 1997109.
Indicator
a)
b)
£)
7.2.11
Crude Birth Rate
(Per 1000 population)
Infant Mortality Rate
(Per 1000 live births)
Couple Protection Rate
Goal to be achieved by the
end of the Sth Plan________
26.0
70
56%
To impart new dynamism to the Family Welfare Programme,
•several new initiatives have been introduced and ongoing schemes
revamped. The broad features of these initiatives are as under:
A result oriented Action Plan has been evolved in consultation
with the Government of States/UTs. The Action Plan highlights the
need for reaching a national consensus in support of Family Welfare
Programme and to obtain the participation of all sections of society.
Area Projects which seek to upgrade infrastructure, have been
continued during the Sth Five Year Plan. Two new Projects namely
India Population Project (IPP)-VIII and IX have been initiated during
the Sth Plan. The IPP-VIII project aims at improving health & family
welfare services in the urban slums in the cities of Delhi, Calcutta,
Hyderabad and Bangalore. IPP-IX will operate in the states of
Rajasthan, Assam and Karnataka.
An USAID assisted project named "Innovation in Family
Planning Services" has been taken up in Uttar Pradesh with specific
objectives of reducing TFR from 5.4 to 4 and increasing CPR from 35%
to 50% over the 10 years project period.
Recognising the fact that demographic and health profile of the
country is not uniform, 90 districts which have CBR of over 39 per
thousand (1981 census) have been identified for differential
109
Eighth Five Year Plan, Planning Commission
171
phsfmal.doc
programming. Enhanced allocation of financial resources, amounting
to Rs. 50 lakhs per year per district, have been made for upgradation of
health infrastructure in these districts. This amount is being used for
providing well equipped Operational Theatres, Labour Room, a six
bedded observation ward and residential quarters for para-medical
workers in 5 PHCs of each districts per year.
Realising that Government efforts alone in propagating and
motivating the people for adaptation of small family norm would not
be sufficient, greater stress has been laid on the involvement of NGOs
to supplement and complement the Government efforts. Four new
schemes for increasing the involvement of NGOs have been evolved by
the Department of Family Welfare.
Contraceptives,
namely
Conventional
Contraceptives
(Condoms), IUD, Oral Pills and Sterilisation (male and female) are
provided free of cost. Oral pills and C.Cs are also made available at
subsidised cost under the Social Marketing Scheme. The per capita
expenditure on the contraceptive services (Excluding sterilisation)
during the year 1993-94 was only about Rs. 17/-, which is quite low.
Therefore, in order to enhance the coverage of the programme, the
^expenditure on contraceptive services needs to be increased. This is
also justified in view of the large unmet demand for family planning
services.
A non steroidal weekly contraceptive named Contchroman,
developed through indigenous R&D efforts, has also been taken up for
commercial marketing.
Concerned with the increasing imbalance between the number
of vasectomies and tubectomies, which indicate that presently women
bear the brunt of sterilisation operations, every efforts is being made to
popularise vasectomy. One of the steps taken recently in this direction
is the introduction of the simple technique of vasectomy known as "No
Scalpel Vasectomy". Research and trials are on in new methods like
vaso-occlusion of the male duct and contraceptive vaccines to give a
wider choice of contraceptives to males and to increase male
participation in the Family Welfare programme.
Given the younger age distribution of the population, much
more vigorous steps are called for promoting spacing methods among
the younger age couples. It is estimated that females in the age group
15 to 29 years account for 77% of all births and females in the age
group 30 to 49 years account for only 23% of all births.
An attempt has been made during the Sth Plan to reorient the
Information, Education and Communication activities which seeks to
172
phsfmal.doc
•
carry the Family Welfare Programme to the community, provides full
and integrated support to the community oriented services for mother
and child health, and encourage adoption of small family norm.
Electronic media have been used effectively to communicate all aspects
of family welfare programme. However, there has been a clear
recognition of the limitation of the print/ electronic media owing to
high level of illiteracy and non accessibility to radio and TV sets.
Efforts have therefore also been made to cover those districts and
villages which are not reached by radio and TV through alternative
means like video vans and integrated media like folk dance and folk
troupe'. Specific State level action plans with district level micro plans
incorporating a media-mix joint training of sectoral functionaries and
counselling have been recognised as an area of greater attention. The
need for inter personal communication has been clearly recognised and
at the village level, women's groups named Mahila Swasthya Sanghas
are being organised. Over 49,000 Mahila Swasthya Sanghs have
already been set up in the country.
To improve the quality of services, special emphasis has been
laid on the training of medical and para-medical personnel. Existing
scheme of continuing education provide two weeks training after
.every five years to Medical Officers in the PHCs, Health Assistant
(Male & Female), Health Workers (Male & Female) and key trainers of
the training school. Crash Training Programme of LHVs/ANMs in
IUD insertion and oral pill administration has been taken up to enable
them to independently take charge of the job and provide these
services. Special emphasis is being placed on the training of Dais in
order to ensure clean and safe deliveries. The payment of reporting fee
to the TBAs has been enhanced to Rs.10/ - per case and efforts are on to
provide each of the trained Dai with a kit for conducting safe
deliveries.
In pursuance of the recommendations of the NDC's Committee
on population, a group of Experts was constituted on 19th July1 1993
under the Chairmanship of Dr. M.S. Swaminathan for preparation of a
preliminary draft of the National Population Policy. In addition to the
Chairman, it had 9 members. The Chairman and Secretary of the group
submitted the draft National Population Policy on 24-5-94. The
view/comments of various Ministries/Department of Government of
India and of State Governments/U.T's are being obtained. The report
has been tabled in both houses of the Parliament on 14th June 1994.
Concerned with the successive decline in the sex ratio the
department of Family Welfare had introduced Pre-Natal Diagnostic
Techniques (Regulation and Prevention of Misuse) Bill, in the
Parliament in 1991. The Bill, as reported by the Joint Parliamentary
Committee, has been passed by both the Houses of Parliament in the
173
phsfmai.doc
Monsoon Session, 1994, received the President's approval, the
published as an Act in the Gazette of India. The Bill seeks to permit
pre-natal diagnostic techniques on women only in specified conditions
and in approved institutions. Penalties have been prescribed for
violation of law for the owners of the institutions, doctors and other
staff conducting the test and for the family members of the pregnant
women as well as the pregnant women, unless it is proved that she was
compelled to undergo the test. Rules have been framed, and the Act,
as well as the rules will be brought into force shortly.
For ensuring stronger political commitment, the Constitution
(79th Amendment) Bill 1992 has been introduced in the Rajya Sabha.
The Bill seeks to incorporate promotion of population control and
small family norm in Article 47 dealing with the Directive Principles of
the State Policy and including in the list of Fundamental Duties (Article
51-A), a clause on joining the citizens of India to promote and adopt
the small family norm. The Bill proposes to add an additional schedule
under which a person shall be disqualified prospectively from being
elected or holding office as a Member of either House of Parliament or
on Legislature of a State if he/she has more than two children. The Bill
has been recommended by the Parliamentary Standing Committee on
•Human Resource Development for passage in Parliament.
7.2.12 TARGETS-VIII PLANS
(a)
For the Revised Sth Five Year Plan (1992-97), the following
provisional targets have been worked out:-
Year
Sterilisation
IUD
Insertions
CC Users
(Figure in Millions)
OP Users
Estimated
CPR ($)
1992-93
5.54 (5.28)
6.88 (6.38)
17.79(16.47)
3.36 (4.58)
46.5
1993-94
6.02 (5,18)
7.48 (7.33)
19.34(19.34)
3.65 (5.00)
47.7
1994-95
6.44 (5.33)
8.00 (7.87)
20.67(21.78)
3.90 (5.47)
51.2
1995-96
6.84 (5.06)
8.51 (7.55)
21.98*
4.15 (3.32)
53.4
1996-97
7.25
9.00
23.27*
4.39
55.4
32.09
39.87
N.B. - Figures within brackets are the targets actually fixed
($)- based on provisional proposed targets
*
No targets to be fixed for CC users from 1995-96
174
phsfmal.doc
(b)
Family Planning targets/ELAs and achievements during 199293, 1993-94 and 1994-95 (upto August, 1994) at the national level are
presented below:
F.P. Methods/
Items
1. Sterilisation
Target/ELAs
Achievements
%age Achvts
2. IUD Insertions
Target/ELAs
Achievements
%age Achvts
3. CC Users
Target/ELAs
Achievements
%age Achvts
4. OP Users
Target/ELAs
Achievements
%age Achvts
5. Couple Protection
Rate (%)
1993-94*
11994-95*
1995-96*
5.28
4.29
81.2
5.18
4.50
86.7
5.33
4.51
84.6
1.72$
1.33
65.1#
6.38
4.74
74.2
7.33
6.01
82.0
7.87
6.58
83.7
2.59$
2.68
94.4#
16.47
15.00
91.1
19.35
17.28
89.3
21.78
17.47
80.2
$$
12.85
4.58
3.00
65.5
5.00
4.30
85.9
5.47
4.83
88.3
5.39$
3.76
65.5#
43.5
(31.3.93)
45.4
(31.3.94)
45.8
(31.3.95)
1992-93
$ Proportionate
$$ Targets not fixed under this programme during current year
* Provisional
# Calculated after excluding achievements for target free states
The above table reveals that the achievement levels in case of
sterilisation and CC users remained over 80% during the first three
years of the plan and in case of IUD and OP users, the percentage
achievement was less than 80 during 1992-93 due to short supply of
Oral Pill and Copper "T". However in 1993-94 and. 1994-95, the
achievement level in respect of these two also went up to a level of
32.09 million in 1993-94 as against 27.03 million in 1992-93 and further
to 33.39 million in 1994-95. The Couple Protection rate (CPR) has gone
up from 43.5% in 1992-93 (as on 31.3.93) to 45.4.% in 1993-94 (as on
31.3.94)
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7.2.13 MODALITY/NATURE OF FINANCING OF NATIONAL FAMILY
WELFARE PROGRAMME
The Family Welfare Programme has been and continues to be a
cent percent Centrally sponsored programme right from its inception
in 1952. As the Programme is delivered through health facilities, which
are maintained by the States, there exists an indirect contribution to the
programme by the States. The entire cost of operating the programme
through out the country is met by the Government of India. The policy
principles for guiding the programme as well as the staffing pattern
for organisations established at different levels for implementing the
programmes are laid down by the Centre.
While the State
Governments are charged with the responsibility of administering the
programme the spectrum within which they have to operate the
programme is laid down by the centre. The entire expenditure
incurred by the States is reimbursable by the Central Government in
strict conformity with the approved pattern of schemes.
Expenditure/Outlays during Seventh Five Year Plan (1985-90),
Annual Plans 1990-91 and 1991-92 and first four years of Eighth Plan
.
The year-wise allocation vis-a-vis expenditure as reported by
the States is as follows:
Year
(1)
Outlays
(2)
Expenditure
(3)
1985- 86
1986- 87
1987- 88
1988-89
1989- 90
1990-91
1991- 92
1992- 93
1993- 94
1994- 95
1995- 96
500.00
530.00
585.00
600.00
675.00
675.00
749.00
900.00$
1060.00$
1280.00$
1440.00$
479.68
568.86
584.17
671.84
800.66
849.89
1022.40
1090.40
1312.62
1521.85*
1772.17©
* Provisional
$ Excluding Provision of arrears
@ Anticipated
7.2.14 Monitoring of Family Welfare Services.
In order to conduct research on various socio-economic,
demographic and communication aspects of population and Family
Welfare Programme, 18 Population Research Centres are at present
functioning in various parts of the country. These are located in
universities and institutions of national repute. The Centre are
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provided with 100% grant-in-aid and by the Centre. For quick
evaluation of the family planning programme, the Deptt. of Family
Welfare has constituted regional evaluation teams which carry out
regular verification and validate acceptance of various contraceptives.
Planning Commission has suggested, that the Department may explore
the feasibility whether these evaluation teams can be used to obtain
vital data on failure rates, continuation rates and complication
associated with different family planning methods.
The Office of the Registrar General of India works out the
annual estimates of crude birth rate, crude death rate and infant
mortality rate through their scheme of Sample Registration System.
The system provides an independent check/ evaluation of the impact of
the Family Welfare programme in the country. Besides, the decennial
growth rate as estimated by the office of the Registrar General of India
on the basis of the census also provides indirect evaluation of impact of
the Family Welfare programme.
In 1992-93 the International Institute of Population Sciences has
carried out through the Population Research Centres the National
Family Health Survey. The survey provides information on some of
•the vital indicators of the heath and family welfare programmes.
7.3
OBSERVATIONS, SUGGESTIONS & OVERVIEW:
7.3.1
NDC Committee on Population:
Department of Family Welfare has taken up implementation of
the recommendation of the NDC Committee on population especially
those which could be carried out without major policy and financial
commitments.
In the year 1995-96, the Department of Family Welfare has
exempted 2 states- Kerala and Tamil Nadu from method specific
targets. In addition, one district from each state has also been
exempted from methods specific targets. Data on acceptance of
different method will be collected and reported in the same manner as
the rest of the states.
It is expected that in a couple of years
information of the impact of removal of method specific targets
allocation on acceptance of suitable contraceptive method by eligible
couple will become available. This experiment is in line with the NDC
Committee's recommendation that decentralised planning and area
specific approaches should be adopted for improving performance in
terms of reduction in crude birth rate. The progress under this
programme has to be carefully monitored to assess the impact and also
to see whether any midcourse correction are needed.
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Some of the recommendations of the NDC Committee on
Population which involve large financial and policy implications are
under consideration. The Department should convene the meeting of
the Chief Ministers of the States for wider consultations regarding
some of the recommendations of the Committee such as sharing of
Non plan expenditure for FW, using personal incentives and
disincentives to improve acceptance of small family norms.
7.3.2
Funding:
In view of the critical importance of the programme to the
country's development, the FW programme remains a totally centrally
funded programme. In the last few years, there had also been
substantial increase in external assistance both for infrastructure
creation and provision of commodities. Utilising all these, there had
been planned expansion and improved outreach of the services during
Sth plan period. In spite of the fact that in this Centrally Sponsored
Scheme infrastructural norms for all the States have been similar, there
had been substantial difference in the performance between States. At
one end of the spectrum is Kerala with mortality and fertility rates
similar to developed countries proving that per capita income is not a
-critical determinant of these Family Welfare indices. At the other end
are the four large northern States (UP, Bihar, MP and Rajasthan) with
high IMR and fertility. Recognising the need for special attention and
additional inputs to improve the performance in these States (with
nearly 40% of India's population) the Department of Family Welfare
had taken steps to provide additional funding to improve the quality
and coverage of MCH/FP services in 90 poorly performing districts.
The decentralised planning, implementation and evaluation at district
level is being attempted in these projects. These need be closely
monitored.
In this totally centrally funded programme, the norms for the
construction costs, personnel costs and expenditure on drugs at the
primary health care level were evolved decades ago and have not been
revised taking cost escalation into consideration. As the Centre has to
reimburse the cost incurred by the States in running the programme
according to the 'norms' set by Central Government, there had been
considerable payment of 'arrears' year after year. In view of all the
problems this practice creates, it is contemplated to undertake a
realistic appraisal of the costs involved in running the programme at
the current prices so that appropriate allocations are made every year.
7.3.3
Manpower - Infrastructure Creation:
In order to improve the outreach of the programme it is
imperative that the primary health care services are made available as
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per the norms envisaged in the Eighth Plan. In order to ensure
adequate emphasis on primary health care specific earmarked funding
has been provided in the Plan allocation. Inspite of this the utilisation
of funds under the MNP is suboptimal in some States. This in turn will
adversely affect access to services. Yet another crucial factor is the
quality of services, which need considerable improvement in many
states. Once the National Education Policy in Health Sciences is
endorsed in Parliament, comprehensive sectoral review of the
manpower policy, training and skill development and deployment of
the vast infrastructure in the Family Welfare Programme shall be
undertaken without any further delay so that the existing lacunae are
detected and remedied.
7.3.4
Immunization:
There has been a massive improvement in immunisation
coverage over the last decade, but the target of 100% coverage against
six vaccine preventable diseases before the infant becomes one year old
is yet to be achieved. Yet another problem is the occasional slip up in
the performance of the field workers, thereby affecting the quality of
the services and resulting in occasional morbidity and rare mortality.
•There is a need to improve both timely coverage and quality of
immunisation services.
7.3.5
Pre-Natal Care:
Attempts to improve antenatal and intrapartum care have also
;shown considerable improvement. Coverage of pregnant women for
the tetanus toxoid and iron folic acid is, however still below 80%.
Antenatal or intrapartum care services of acceptable quality are still
not available to majority of rural population and the maternal and
perinatal mortality rates remain unacceptably high. With the initiation
of Safe Motherhood and Child Survival Programme and intensification
of MCH activities it would appear that the target of IMR of 60 by 2000
A.D. is an achievable reality. However, it is essential to achieve the
target in all the states of the country, both in urban and rural areas. It
may be necessary to improve it further because in the next decade, the
adverse consequences of HIV epidemic on maternal and child health
will inevitably start manifesting themselves. Every effort should be
made to optimally utilise the available funds, avoid duplication of
efforts and quality of services should be improved so that their
utilisation increases.
7.3.6
Vasectomy:
Over the last 20 years there had been a steep and continued fall
in number of vasectomies done in the country. Vasectomy is the safer.
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easier than tubectomy and the procedure is well suited to primary
health care services. There is an urgent need to increase acceptance of
vasectomy.
7.3.7
Couple Protection Rate:
The current level of Couple Protection Rate has been estimated
at 45.8 as on March, 1995. Achievement of Eighth Plan target i.e.
increased level of Couple Protection Rate to 56% by 1997 would call for
improvement both in coverage and quality and care.
7.3.8
Improvement in quality of Services:
Huge infrastructure has been created for family welfare services
delivery in the rural areas. The access to, as well as quality of services
being offered need to be improved. Improving the quality will
definitely enhance the acceptability of the various methods of family
planning.
7.3.9
Gadgil Mukherjee Formula:
The States should be convinced about the importance of the
population control programme. A message to the States must be
conveyed in an amplified form that the allocation of funds to the States
under modified Gadgil Formula is not only based on the population
criteria but it is also linked to the decline in birth rate and IMR.
Educating the States about the linkages of Gadgil Formula with the
performance in the social sector can activate the States to show
improved performance under family welfare.
7.3.10 Improving Coverage of Younger Couples:
Family Planning Programme is dominated by the acceptors of
older age group having more than two children. Thus, the impact of
the family planning programmes is not as per the inputs being put in
and hence not as per the expectation. Measures may have to be taken
to increase the acceptance of family planning among, younger couples
having less number of children.
7.3.11 Inter Sectoral correlation:
Keeping in view the correlation between the acceptance of the
family planning methods and the development in related socio
economic sectors, the programme should not be carried out in isolation
and concerted efforts need to be put in not only in health sector but
also in other sectors such as education, social welfare, poverty
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alleviation etc. The programme also needs to be integrated with
Minimum Needs Programme (MNP).
In view of the close linkages between population and
developmental activities inputs from other departments such as Rural
Development, Education, Social Welfare, Women and Child
Development should be sought and utilised in achieving the goals laid
in the National Health Policy.
7.3.12 Improving MNP
There is a wide gap in the physical and financial progress of the
MNP with regard to the health sector. There is a need to assess the
reasons for the under-utilisation of funds in an objective manner and
corrective measures initiated immediately. The funds for MNP should
not be diverted to other programmes and must be utilised only for
creation and strengthening of infrastructure for providing basic health
care facilities.
Department of Family Welfare may critically review the
utilisation of funds allocated for the Minimum needs Programme and
.Social Safety Net and the impact of SSN on the availability and
utilisation of delivery care services.
7.3.13 Research:
Besides, basic research for contraceptive development and
testing, socio-demographic and operations research are required to
support the programme in terms of management and devising newer
interventions.
Newer contraceptive technology development e.g.
vaccines for men and women, testing contraceptives which are known
to be effective in ISM and tribal culture should receive due attention.
Research in social and behavioural aspects of family planning to
understand the perceptions, customs and practices of the people
should be given due attention. Operational research to improve
quality and coverage of eligible couples with appropriate effective
contraceptives through existing health infrastructure should receive
very high priority.
7.3.14 Involvements of NGO's
There is a need for greater involvement of NGOs in the family
welfare programme.
The NGOs working in other sectors e.g.
education, rural development, and nutrition etc. should also be
encouraged to include family welfare as part of their activities. The
current efforts to involve NGOs especially women's organisations
working in rural areas, urban slums and difficult areas in promoting
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small family norm and providing contraceptive care need to be
strengthened and encouraged.
The Ministry of Health & Family Welfare has initiated several
programmes involving several programmes involving NGOs in efforts
to improve Family Welfare Programme. These include:
(i)
(ii)
(iii)
(iv)
(v)
revamping of Mini Family Welfare Centre where couple,
protection rates are below 35%
involvement of ISM & H practitioners
area specific IEC activities through NGOs
establishment of State Standing Committees for Voluntary
Action (SCOVAs) to fund NGO projects promptly
identification of Govt./NGO organisation for training of NGOs
in project formulation, programme management and
monitoring.
There efforts should be strengthened and closely monitored.
7.3.15 Village Health Guide Scheme
The Village Health Guide Scheme (VHG) which was started in
1977 for the purpose of providing primary health care and health
education in villages. The Dept, of Family Welfare took up the funding
of the Scheme since 1981. Currently, more than three lakh Village
Health Guides are available in the country.
The Scheme should be revamped taking into account the lessons
learnt from the past experiences so that VHGs can play an effective role
in improving community participation and effective utilisation of the
Health and Family Welfare services.
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ENVIRONMENTAL HEALTH AND
SANITATION
8.0
ENVIRONMENTAL HEALTH AND SANITATION
8.1
INTRODUCTION
India's population has expanded from 342 millions in 1947 to
846 millions in 1991. It is estimated that India's population will cross
the one billion mark by 2000 AD. The Standing Committee on
Population has projected that the country's population will be 1003.1
million in 2001,1082.2 millions by 2006 and 1250 millions by 2015 AD.
The level of environmental health and sanitation both in urban and
rural areas continues to be poor. The health and environmental
consequences of increasing population density, lack of safe drinking
water and inadequate sanitation are likely to become further
aggravated unless steps are initiated to improve the situation.
The increasing frequency of outbreaks from different parts of
the country, recent outbreak of plague and malaria are clear pointer to
deteriorating environmental health and sanitation facilities and poor
response capability of the Public Health System.
Historically speaking, India has rich traditionally good
.environmental health and sanitation practices as evidenced from the
ruins of Mohanjodaro and Harappa. The Charaka and Sushruta
Samhitas and other ancient texts have glorious examples of holistic
approach in maintenance of human health through proper
environmental and sanitary measures. However, over the period the
environmental and sanitary practices have detoriated adversely
affecting the quality of life.
During British period health services including sanitation and
environmental hygiene were concentrated mostly in the cantonments
and district headquarters. This trend continues till it was realised that
health, sanitation and environmental hygiene of the working
population was closely linked with the productivity of the nation and
its capacity to generate revenue. The Bhore Committee5 for the first
time highlighted the importance of safe water supply and sanitational
measures on a country-wide basis. There after it also received priority
in the national five-year plans.
After Independence, the Ministry of Health, Government of
India constituted the Environmental Hygiene Committee (1948-49) for an
overall assessment of the country-wide problems of Environmental
Hygiene9. A comprehensive plan to provide water supply and
sanitation facilities for 90% of the population within a period of 40
years, was recommended by the committee. In 1953 a National Level
Technical Body (Central Public Health Engineering Organisation) was
established in the Ministry of Health to undertake national water
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supply and sanitation programme, which was initiated as a part of the
health schemes in 1954. A Model Public Health Act was prepared by
the Ministry of Health. The same was drafted by B C Dasgupta and
circulated to all the States for its adoption with modifications in a given
local set up, if necessary. The Model Public Health Act was prepared
to act as a guide for framing the public health acts by the States,
municipal corporations and municipalities and to serve as a reference
book for public health practitioners. The Act had wide ranging
provisions covering the entire gamut of public health activities viz.
water supply, drainage, sanitation facilities, buildings, food sanitation,
control of offensive trade, prevention and control of communicable
diseases including vector borne diseases, control of insects, sanitary
and health regulations during fairs and festivals and special provisions
for lodging houses, health resorts, health camps, parks, play grounds
and green spaces, slaughter houses, markets, etc.
For the first time, a Research-cum-Action (RCA) Project on
Environmental Sanitation was initiated by the Ministry of Health,
Government of India during 1956-61, at Singur (West Bengal),
Ponamallee (Tamil Nadu) and Najafgarh (Delhi).
i
In 1973 the subject of water supply and sanitation was
transferred from the Ministry of Health to the Ministry of Works and
Housing and Local Self Government (presently redesignated as the
Ministry of Urban Affairs and Employment).
The Water (Prevention and Control of Pollution) Act of 1974,
was another milestone in the prevention and control of water pollution
in the country. For implementation of the Act, a Central Pollution
Control Board (CPCB) at the national level and State Pollution Control
Boards (SPCBs) at the State levels were established in 1974. The act was
amended in 1988. The Air (Prevention and Control of Pollution) Act,
1981 was the first step towards prevention and control of air pollution
and environment. CPCB and SPCBs were entrusted with the task of
implementing the Act under the nodal Ministry of Environment and
Forests. The act was amended in 1987.
In 1981 the International Drinking Water Supply and Sanitation
Decade (IDWSSD) (1980-91) was launched in India by the Ministry of
Works and Housing (presently redesignated as the Ministry of Urban
Affairs and Employment).
To improve sanitation further a Centrally Sponsored Rural
Sanitation Programme (CRSP) by the Department of Rural
Development (presently redesignated as MORA&E) and a Centrally
Sponsored Low Cost Sanitation Programme for conversion of dry
latrines into low cost sanitary latrines and rehabilitation of scavengers
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by the end of the Eighth Five-Year Plan (1992-97) by the Ministry of
Urban Development (presently redesignated as MOUA&E) were
launched in 1986 and 1991 respectively.
In spite of all these efforts, recurring outbreaks of water borne
diseases like cholera, dysentery, viral hepatitis etc., vector borne
diseases like malaria, dengue, plague etc. in recent years show the
insufficiency of our efforts in promoting environmental health and
sanitation. The low level of urban, peri-urban and rural sanitation is a
matter of deep concern.
8.2
Constitutional obligations for Environmental Health and Sanitation
Public Health and Sanitation is a State subject as given in the
Seventh Schedule, Article 246, list II-6 of the Indian Constitution. At the
national level, the Department of Health of the Ministry of Health and
Family Welfare, Government of India is the nodal agency for public
health.
The Ministry of Health was responsible for implementing
programmes on intervention measures, viz. water supply and
sanitation both in rural and urban areas till 1973 when it was
transferred to the Ministry of Urban Development (presently
•MOUA&E). In 1985 the subject was further divided and the urban
water supply and sanitation became the responsibility of the Ministry
of Urban Development (presently designated as MOUA&E) and the
Department of Rural Development (presently redesignated as
MORA&E), took up the responsibility of rural water supply and
sanitation.
The 73rd and 74th Constitution Amendment Acts, 1992 provide
a framework for involvement of Panchayati Raj institutions and Nagar
Palikas in all development programmes including Public Health and
Sanitation, in rural and urban areas of the country.
The following is a brief account of various on-going sanitation
programmes and their broad impacts.
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Bombay16A involving 88,562 households (26.1% - urban, rest- rural)
covering 24 States and National Capital Territory of Delhi it was
observed that 68.2% of households had provision of drinking water
from pipe/pump and 69.7% of households had no toilet facility.
In 1954, a Sanitation programme was introduced by the
Government of India. Since then, sanitation has made a slow progress
compared to the Rural Water Supply Programme. A decadal
programme was launched during 1981 which envisaged that 25% of
the rural population would be covered by March 1991. In 1986, a
programme was launched to construct one million sanitary latrines in
the houses of the SC/ST population under the Indira Awas Yojana
(IAY) Housing Scheme; and to provide 2,50,000 additional latrines to
health sub-centres, schools, Panchayat Ghars, Anganwadis, etc. under
the National Rural Employment Programme (NREP) and Rural
Landless Guarantee Employment Programme (RLGEP). During 1987,
the Rural Sanitation Programme was included in the State sector under
MNP. The efforts made under the various programmes indicated
above were highly inadequate. They did not achieve the desired goal
of covering 25% of the rural population by 1991, as envisaged in the
decade programme launched in April 1981. By 31 March 1992, it was
.reported that about 2.73% of the rural population had been provided
with sanitary latrines.
Lack of initiative at all levels, inadequate financial resources,
poor perception of the importance of sanitation, lack of felt need by the
people and lack of people's participation, contributed to poor
achievement under the programme.
UNICEF offers substantial support to the government's efforts
in providing rural sanitation in eight States of India through rural
sanitary marts. Rural Sanitary Marts (RSMs) are outlets for materials
required for construction of latrines and other sanitary facilities. It also
provides designs of various low cost sanitary facilities. They also serve
as service centres.
An assistance of Rs.50,000 for each Mart.
Managerial subsidy is provided up to Rs.18,000 per annum for a period
of two years. One-time assistance up to Rs.12,000 is provided for
publicity, etc. Where UNICEF assistance is not available for setting up
RSMs, the State governments/UT administrations can' set up Rural
Sanitary Marts with assistance from the Central Government through
reputed voluntary organisations/Panchayati Raj Institutions in
difficult areas where proper marketing facilities for sanitary
components do not exist. Such voluntary organisations need to be
carefully selected by assessing their ability to carry out the task11’8.
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8.4.1
Programme Components
The components of the rural programme are as under:
•
Construction of individual, subsidised (80%) sanitary latrines for
households below the poverty line, where demand exists.
•
Setting up of sanitary marts.
•
Construction of village sanitary complexes exclusively for women by
providing complete facilities for hand pump, bathing, sanitation and
washing on a selective basis where adequate land/space within the
premises of the houses does not exist and where village Panchayats are
willing to maintain them.
•
Conversion of dry latrines into low cost sanitary latrines.
•
Total sanitation of villages by constructing drains, soakage pits, solid
and liquid waste disposal plants.
•
Intensive campaign for generating awareness and health education by
.creating felt need for personal, household and environmental
sanitation facilities.
The standing committee on urban and rural development (199495) reviewed the progress of the programme of sanitation and
recommended9:
8.4.2
(i)
Serious thoughts should be provided to the problems of rural
sanitation and available ways & means should be explored
through result oriented action plan for the interest of rural
population.
(ii)
A time bound programme should be chalked out not exceeding
5-10 years and the allocation should be substantially raised to
Rs.100 crore during 94-95 and to Rs.300 crore for 95-95.
Urban Sewerage and Sewage Treatment
Sewage is defined as untreated excrement from human and
other animals while sewerage is the conduit through which sewage
flows. Sewerage and sewage treatment facilities are currently provided
in urban areas under the following programmes:
a.
State Sector Sewerage and Sewage Treatment
b.
Sewage Treatment under National River Action Plan (NRAP)
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The coverage of urban population with sewerage and low cost
sanitation facilities as of 31 December 1991 was 46.63% (101 million).
Of the above coverage, about 60% have full-fledged sewerage facilities
(61 million) and 40% have low cost pour-flush latrines, septic tanks, pit
latrines etc. (40 million).
In India most of the cities and towns do not have any sewerage
system. It is common sight to see sewage flowing on roads and
collecting in some low-lying areas. In villages, the problem is different
because sewage gets absorbed by the soil itself. Surface water resources
are polluted to the extent of 75% and 85% of pollution is created by
sewage alone opine many experts. 20,000 million litres per day of
sewage is generated daily while the total treatment capacity is only
3,000 million litres11"6.
Of the estimated total of 12145.45 million litres of waste water
per day is generated in the Class I cities only 2485.42 mid, 20% gets
primary or secondary treatment before disposal. 41% of the total
population of the 212 Class I cities lives in 12 metropolitan cities which
generate 6462.3 mid of waste water, which is 53% of the total waste
-water. Treatment capacity in the metropolitan cities is 1903.4 mid,
which is 29% of the total waste water generated in these cities. Of the
estimated 1297.52 mid waste water is generated from the Class II
towns. The waste water treatment capacity existing in the Class II
towns is only 26.15 mid which is 2% of the waste water generated in
these towns.
Sewage treatment facilities in urban centres are being provided
with borrowed funds, own resources and the funds made available to
the local bodies by the State governments under the State Plans, under
National River Action Plan of the Ministry of Environment and Forests
and a portion of 'Cess' funds collected under the Water Prevention and
Control of Pollution Act, 1974 as amended in 1988. Sewage treatment
facilities are being provided, as a part of the National River Action Plan
of the Ministry of Environment and Forests, in cities and towns. This
programme needs consolidation and further enhancement with
appropriate inputs from the State governments in close collaboration
with the Ministry of Urban Affairs and Employment, Ministry of
Environment and Forests, Urban Local Bodies/Municipalities and
NGOs.
8.4.3
Urban Solid Waste Management
In India the amount of waste generated by individuals is quite
low - between 300 and 600 g/person/day. On the basis of available
data, it is estimated that the nine major metropolitan centres in India
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are presently producing 8.5 million ton (mt.) of solid waste per annum;
the figure is expected to reach 12 mt. per annum by the turn of this
century110 . Although the collection percentage seems to be relatively
high (92% in Calcutta, 88% in Bangalore, 86% in Bombay, 80% in
Madras and Surat, 67% in Ahmedabad and Lucknow, 64% in Delhi and
as low as 25% in Patna) in the major cities, an uncontrolled amount
piles up, creating a haven for rodents and posing a variety of health
hazards. The municipal solid waste problem is compounded by the
industrial solid waste which are bio degradable, non bio degradable
and hazardous and the same constitutes significant proportion of all
the solid waste generated. Of the industrial wastes 10-20% is
hazardous wastes from chemical industries. Reliable data base about
the disposal practices of hazardous wastes is not available110.
8.5
Hospital Waste Management
Hospital wastes have always been considered as potentially
hazardous in view of the inherent potential for dissemination of
infection. In recent years wider variety of potentially hazardous
ingredient including antibiotics, cytotoxic drugs, corrosive chemicals
and radioactive substances have become a part of the hospital waste110.
It is estimated that in-patient hospital services in India generate
between 1-2 kg of solid waste per person/day. Over 85 per cent of
hospital waste is non-hazardous. There is no standardised system of
segregating hazardous from non-hazardous waste in majority of the
hospitals. Mixing of hazardous with non-hazardous components
results in increased quantity of hazardous wastes that require safe
disposal110.
8.6
Drinking Water Quality Surveillance - Legislation and Standards
Water quality surveillance to ensure that drinking water is safe
is generally the responsibility of the Department of Health at the State
government level. The responsibility for proper operation of the
system to produce safe drinking water is that of the water supply
agency. The local authority is legally responsible to ensure that
drinking water delivered to the consumers is safe. In the case of rural
areas, the responsibility is not legislatively defined but the department
which is entrusted with the subject of rural water supply is technically
responsible for water quality surveillance.
National Water Quality Standards and Codes of Practice have
been issued by the Ministry of Urban Affairs and Employment and the
110 Report of the High Power Committee, Urban Solid Waste Management in India, Planning
Commission, Government of India. 1995.
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Ministry of Rural Areas and Employment as well as the Bureau of
Indian Standards.
8.7
Operation and Maintenance
In urban areas the local authority is responsible for operation
and maintenance of water supply system. In rural areas, operation and
maintenance of simple systems such as hand pump and gravity flow
systems from springs is the responsibility of the beneficiary
community. Since many pipe systems are getting out of operation due
to poor operation and maintenance, in many States the State
PHED/WSDBs have been entrusted with the task of operation and
maintenance as well.
In urban areas, monitoring of water quality at the
plant/operation level is carried out by the operating agency and
samples at different locations of the system are collected and analysed
by the Municipal Health Department or the State Public Health
Laboratory. The facilities available with the local health authority with
regard to monitoring of water quality are so inadequate that
surveillance is poor which is compounded by poorer co-ordination
•between PHED and health departments.
In rural areas, testing of water quality is usually done before
commissioning a source of water supply. Routine regular water quality
monitoring is seldom carried out. During outbreaks of epidemics or in
response to complaints, the health officer and the operating agency
take precautionary and preventive measures such as chlorinating,
warning the public to boil water, and inspection of sanitary protection
measures.
8.8
Industrial Waste Management And Air Pollution Control
8.8.1
Industrial Waste Management
8.8.1.1 Introduction
Environmental pollution is a major problem associated with
rapid industrialisation, urbanisation, and rise in the living standards of
people. Though the problem is multi-dimensional and calls for
integrated efforts by the industry, government policy-makers,
environment managers, and research and development agencies at all
levels and in all sectors, the most important tool in achieving the goal is
the management of industrial wastes.
The National Waste Management Council has been set up by the
Government to render special advice to the government on all matters
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concerned with disposal and utilisation of wastes which may be in the
form of liquid or solid state.
8.8.1.2 Areas of Concern
8.8.1.2.1
Industrial Solid Wastes
Source and Quantum of generation of some major Industrial Solid
Wastes
Coal based thermal power plants produce large amount of
industrial solid waste. A 1,000 MW station using coal of 3.500 kilo
calories per Kg and ash content of 40-45% would need about 500
hectares for disposal of fly ash for about 30 year's operation. In the
country 30 million tonnes of fly ash are generated annually. Although
the blast furnace slag has potential for conversion into granulated slag
which is a used raw material for cement manufacturing it is yet to be
practised in a big way. 35 million tonnes steel and blast furnace slag
are produce annually in the country. Red mud as solid waste is
generated in non-ferrous metal extraction industries like alminium and
copper. The red mud at present is disposed of in tailing ponds for
.settling which more often than not finds its way into the rivers
specially during the monsoon. However, red mud has recently been
successfully tried and a plant has been set up in the country for making
corrugated sheets. Demand for such sheets should be popularised and
their use encouraged. This may replace asbestos which is imported
and also banned in developed countries for its hazardous effects.
2.65 million tonnes of red mud are produced annually; 4.5
million tonnes of phosphogypsum are produced every year.
At present very little attention has been paid to utilisation of
phosphogypsum in making cement, gypsum boards, partition panels,
ceiling tiles, artificial marble, fibre boards, etc. 3 million tonnes of lime
sludge from a variety of industries like paper, sugar, fertilizer etc. are
produced annually. Lime sludge, also known as lime mud, thus
produced is not recovered for reclamation of calcium oxide for use
except in the larger mills. Although few technologies have been
developed to desilicate black liquor before burning, none of the mills
in the country are adopting desilication technology.
8.8.1.2.2
Industrial Liquid Wastes
Discharge of industrial effluents into rivers and streams are
controlled under the provisions of the Water (Prevention and
Control of Pollution) Act, 1974. Pollution prevention through
recovery of reusable material and by-products could contribute
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towards saving of expenditure on raw material. Reuse of waste
water within the industry after necessary treatment helps in
minimising fresh water requirements and reducing waste water
volume for final treatment before discharge. The potential
recoverable materials from industrial waste waters are
summarised as follows:
Recoverable Matter from Industrial Waste Waters
Recoverable Matter
Industry
S.No.
1.
Pulp and paper
Ligno-sulphate, sodium salts
2.
Fertiliser (phosphatic)
Calcium sulphate, fluoride
3.
Petro-chemicals
Acetone, carboxylic acid
4.
Electroplating
Chromium and nickel salts, silver cyanide
5.
Coke oven
Ammonia, ammonium sulphate, napthalene,
phenol, tai, aromatic organics
6.
Dyestuffs
Anthranilic acid, methylaniline, potassium
and sodium hydroxide
7.
Textile
Caustic soda
8.
Distillery
Potassium salts, yeast
9.
Rayon
Zinc, sodium sulphate
Source: Science Reporter, CSIR, April-May 1989
8.8.1.2.3
Industrial Gaseous Wastes
Various waste gases emitted from industrial installations have
potential use but are not being utilised. Examples are: natural gas flare
in oil rigs, carbon dioxide, sulphur dioxide, etc. Indigenous technology
has been developed for recovery of heat from hot gases of cement
kilns. Such technology for other industrial sectors should be
developed and its adoption encouraged.
•
Presently the Oil and Natural Gas Commission (ONGC) is flaring gas
worth Rs.750 crore per annum. This can be conveniently converted into
methanol and used to supplement the requirement of petrol. It has
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been established by the Indian Institute of Petroleum (IIP), Dehradun
that mixing of 5% of methanol with petrol does not require any
modification in the engine of the vehicle. Besides, the use of methanol
in petrol will have proven advantages like (a) the import of petrol and
diesel can be reduced substantially, (b) the highly poisonous CO gas
content in automobile exhaust fumes is reduced up to 75% thereby
reducing air pollution, and (c) the octane number of petrol is
increased.
•
The carbon dioxide emitted from various sources can be used to
produce calcium carbonate (chalk). Sulphur dioxide emitted can be
converted into either sulphur or gypsum. Facilities need to be
provided within the industry which will produce these as raw
materials for other industries and simultaneously reduce air
pollution.
•
Waste heat from hot gaseous emissions can be recovered for optimal
energy utilisation.
8.8.1.2.4
Radioactive Wastes
The majority of such wastes are generated from nuclear power
installations. This waste is highly toxic/hazardous in nature and hence
careful planning is needed for its disposal and treatment to safeguard
public health and environment.
The ministry of Environment and Forests have been making
tremendous efforts in tackling industrial waste management through
National River Action Plan, National Waste Management Council and
Environmental Epidemiological Study.
8.9
Air Pollution Control in India
8.9.1
Air pollution scenario in India
About 50% to 65% of the air pollution in metropolitan cities in
India is contributed by the automobile sector. The major sources of air
pollution in India are as follows :
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Industrial
Transportation
Domestic
Delhi
29%
65%
06%
Calcutta
46%
35%
19%
Bombay
43%
53%
04%
Cities
As compared to several European countries and the USA, the
vehicular population in India is still relatively low. But, even with this
modest population, the vehicular pollution has become a serious
problem in the urban areas. The other reasons of vehicular pollution in
urban areas are: types of engines used, age of vehicular congested
traffic, poor road conditions and outdated automotive technologies.
The principal pollutants emitted by vehicles are: carbon
monoxide (CO), hydrocarbons (HC), oxides of nitrogen (NOx), and
particulate matter (PM). Vehicles using petroleum-based fuels also
emit polynuclear hydrocarbons and aldehydes. Varying amounts of
* SO2 is also emitted depending upon the sulphur content in the fuel. In
addition, the exhaust gases from petrol-driven vehicles contain lead
compounds because of the addition of tetra ethyl lead (TEL) in motor
spirit. Exhaust pipes are a major source (65%-70%) of air pollution from
the automobiles, while about 20% occurs through blowby from the
crankcase and the remaining through evaporative emissions from the
fuel tank breather, carburettor and spillage losses. Heavy duty dieselpowered vehicles emit more of NOx and PM while light duty gasolinepowered vehicles and motorcycles are the major sources of CO and HC
emissions.
8.9.2
Ambient air quality standards
The CPCB has recently revised the ambient air quality
standards. The new standards evolved are based on the effect of air
pollutants on human health, vegetation and property. Besides, criteria
pollutants, like O2, NOx, SPM, CO, and other relevant pollutants in
Indian conditions, like Pb and respirable particulate matter, are also
included in the standard.
8.9.3
Status of ambient air quality in metro cities
The CPCB through a network of 290 stations is monitoring the
ambient air quality in the country. The status of ambient air quality in
the major metropolitan cities is as follows:
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Ambient Air Quality Status in Metropolitan Cities
Pollutant
Delhi
Bombay
Calcutta
Suspended
Particulate
Material (SPM)
SO2_________
NOx__________
Pb(Load)_____
Poly aromatic
hydrocarban
(ng/m3)
(Benzopyrene)
CO (ppm)
200-1400
174-504
453-2091
10-70
30-200
0.8-8.3
36-722
58-268
33-100
1.0-65
150-744
47-163
34-174
0.7-5.6
170-600
Industrial
Area*
360 mg/ cum
Residential
Area*
70 mg/ cum
80
80
1 mg/cum
10
nanogm/cum
15
15
0.5 mg/cum
10
nanogm/cum
5 mgm/cum
Imgm/cum
1.5-9
*Air Quality Standard
Note: all units are in-pg/m3 except wherever mentioned
Source: Central Pollution Control Board.
8.9.4
Status of Air Pollution Control in major air polluting industries
Because of the increasing menace of environmental pollution,
.the Government of India has evolved a 15-point Action Plan with
particular emphasis on industrial pollution control within a time
schedule.
The present air pollution control status in five major categories of air
polluting industries in the country is as follows:
Pollution Control Status in Major Air Polluting Industries
Pollution control status in major air polluting industries is
unsatisfactor. Of the 69 thermal power plants only 28 comply with the
standards. Of the 97 cement factories 81 comply with the standards.
Condition in Iron & Steel plants is worse. Of the seven only 1 complies
with standard. Almost similar is the picture in other major industries.
8.9.5
Constraints in air pollution control in India
Indiscipline in land-use pattern is a serious constraint in India.
Non installation of air pollution control equipment or their poor
functioning
Obsolete and/or inefficient production processes generating a
high percentage of waste co-exist with modern developments in
the country.
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Reluctance to change over to cleaner technologies by the
industries.
Lack of appreciation of the social responsibility by the
industrialists.
Poor air quality monitoring programme.
Fuel efficiency of combustion processes is very poor. Two
wheelers (scooters) in the country are operated on two-stroke
engines, which cause 30% of the fuel being released unburnt.
Scientific traffic management is yet to be given due
consideration in metropolitan cities. Air pollution due to
automobiles could be, to some degree, reduced through efficient
traffic management.
In metropolitan cities, where air pollution levels are already
high, liquid fuel should be replaced by gaseous fuel. This aspect
is yet to receive adequate attention.
8.10 . OBSERVATIONS, SUGGESTIONS & OVERVIEW:
8.10.1
The interactive interdependence of health, environment and
sustainable development was accepted as the fulcrum of action under
Agenda 21 at the Earth Summit at Brazil in 1992. The essence and
essentials of health programmes include control of communicable
diseases and reduction of health risks from environmental pollution
and hazards. The interdigitation of primary environmental care and
primary health care is therefore obvious, as is the substantial synergy
that exists between poverty alleviation and environmental protection.
While a governmental action can provide the much needed initial
trigger, its further amplification depends upon the involvement of
people, both individually and collectively as NGOs, who must assume
the burden of civic responsibility which is the core requirement for a
successful culmination of such endeavours.
8.10.2
A large number of programmes are under operation in the area
of environmental health and sanitation and five ministries are
involved. Major responsibilities are with the Ministry of Rural Areas
and Employment, Ministry of Urban Affairs and Employment and
Ministry of Environment and Forests. The impact of the poor delivery
of the programmes is on quality of life which is primarily determined
by the strength of the public health system and the public health
delivery services are primarily the responsibility of the Ministry of
Health & Family Welfare. Any lapses anywhere primarily affects man
and when man becomes sick the Health Ministry can not escape
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shouldering the responsibility. Therefore, there is an urgent need of
initiating a co-ordinated programme.
8.10.3
Human health being the focus of attention around which all the
public health activities of different ministries are undertaken it will be
appropriate that the Director General of Health Services/Ministry of
Health & Family Welfare becomes the nodal agency for co-ordinating
for improving environmental sanitation activities between the different
ministries.
8.10.4
At this point of time in the Directorate General of Health
Services hardly any component of environmental health and sanitation
exists. The existing institutions with interest and expertise in this area
such as AIIH&PH, Calcutta, NICD, Delhi and NEERI, Nagpur should
be strengthened.
8.10.5
The Model Public Health Act of 1955 revised and circulated in
1987 to all the states and municipal authorities needs to be vigorously
pursued in view of the recent 73rd and 74th constitutional
amendments providing more administrative and financial autonomy
to the municipalities and Panchayats. The Model Public Health Act
.could be further reviewed in consultation with the municipalities and
Panchayats for their adoption so that uniform legislative support to the
public health executive agencies are available.
8.10.6
The resources available with the municipal authorities and
Panchayats in dealing with the public health and sanitation is very
limited. Fortunately the constitutional amendments have indicated
deployment of adequate financial authorities to these municipalties
and local bodies so that they can become administratively and
functionally effective in implementing various programmes connected
with public health and sanitation.
8.10.7
It has been observed that though water supply and sanitation is
better in urban areas compared to the rural areas but wide disparities
exist even within an urban area and the urban slums still continue to
lack basic sanitary facilities. Therefore, while providing the sanitation
facilities due emphasis should be given on the needs of the unserved
and under sub section of the population and the vulnerable groups.
8.10.8
The committee endorses the recommendations of the Report of
the High Power Committee on Urban Solid Waste Management in
India110 with regard to collection and transportation of municipal
wastes, hospital wastes, resources, rcovery and recycling etc. The
committee also endorses the suggestion of the High Power Committee
that it is essential to evolve a National Policy as well as an action plan
for management of solid waste.
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8.10.9
Poverty and environmental degradation is interlinked. Vast
majority of people in the tribal and forest areas are dependant on the
natural resources of the country for their basic needs of food, fuel,
shelter and fodder for their cattles. Population growth or increased
population puts tremendous pressure on the natural resources on the
other hand environmental degradation adversely affects the poor who
are dependant on the resources for their immediate surroundings.
Thus the issues of population growth, sustainable development,
environmental health should be viewed together as intimately inter
linked and, therefore, the entire issue of environmental health could
provide a much needed impetus to family welfare and health
programmes which ae in turn will maintain better environmental
health.
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EPIDEMIC REMEDIAL MEASURES
' ROLE OF STATE AND LOCAL
HEALTH AUTHORITIES
9.0
EPIDEMIC REMEDIAL MEASURES - ROLE OF STATE AND
LOCAL HEALTH AUTHORITIES
9.1
INTRODUCTION:
Health being a State subject, the entire health care delivery
services are primarily through the provincial governments. The
provincial governments have the full authority and responsibility for
the health care services in their states as per the constitutiona
provisions. Historically the Montegau Chelmsford Reforms came m
operation in 1919 when provincial health administration was given
autonomy by the Central Government in matters of public health. The
Government of India Act 1935^ gave further autonomy to the states m
matters of health care. Under the constitutional provisions states have
got absolute authority and responsibility for the health care services
which include responding to the epidemic situation. The state is
required to maintain an efficient epidemiological service which alone
can prevent or minimise epidemics.
This will also help early
recognition & confirmation of the epidemic situation enabling
appropriate control measures thus minimising losses and damage in
terms of human morbidity and mortality.
9.2
State Health Directorates:
Almost all the State Health Directorates have a focal point at
various levels (Joint Director, Deputy Director and Assistant Director
etc.) to respond to any given epidemic situation. It directs and co’ > are directly involved and
ordinates with district health authorities who
All the State Health
responsible for containment of epidemic.
Directorates have a State Bureau of Health Intelligence.
The
organisational structure of the various State Health Directorates
including some of the State Bureaux of Health Intelligence as on June,
1995 is given in the Annexure. In addition to the same the State Health
Directorates obtain useful assistance from the medical colleges
particularly the Department of Preventive and Social Medicine in
undertaking investigation of epidemic as and when necessary. In fact,
epidemics are investigated by the state health authority but as the
laboratory back up support services are not adequately available m
many of the medical colleges, many outbreaks are not properly
investigated for identification of the etiological agent and thus often it
goes un-noticed. Government of India provides the input only when
the outbreaks assume significant level assuming large scale morbidity
and mortality. However, it always responds to the request of the state
health authorities by sending investigating teams from National
Institute of Communicable Diseases, Delhi and sometimes teams are
Ill
The Government of India Act 1935.
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also sent from National Institute of Virology, Pune, National Institute
of Cholera and Enteric Diseases, Calcutta and All India Institute of
Hygiene and Public Health, Calcutta. To control epidemic, drugs,
insecticides etc., if required in such cases, are also provided by the
Government of India but this is purely on ad hoc basis.
As the surveillance machinery for identifying an outbreak early
is weak the state health authorities face major challenges when
epidemic spreads and assumes national importance. Though the
expertise for the containment of epidemic is available but sometimes
the prevention and control is not up to the mark due to delayed
response resulting in large scale mortality and morbidity and this is
mostly due to non-availability of drugs and insecticides and lack of
diagnostic support services, poor mobility, lack of surveillance etc. The
Epidemic Diseases Act 1897 provides appropriate tool to the health
implementing agencies to undertake measures/regulations which are
necessary to prevent the spread of the disease112 . This Epidemic
Diseases Act is applicable to whole of India. The Act also provides the
Central Government to take measures and prescribe regulations which
could be enforced to prevent the spread of the disease. This is with
particular reference to ship or vessel leaving or arriving at any port,
^detention of persons who are intending to sail therein or arrive
thereby as the case may be. The Act has the provision of punishing
anyone disobeying any regulation under this Act under section 188
Indian Penal Code. It also has the provision of protecting the persons
under the Act that no suit or other legal proceedings shall lie against
any person for anything done or in good faith intended to be done
under this Act.
9.3
Municipal Health Authorities:
The Municipal health authorities are responsible for health care
delivery services including epidemic control in their respective
territories. All municipal authorities have bye-laws which provide
some legal instruments in prevention and control of epidemic diseases.
However, none of the municipalities barring a few implement the
municipal bye-laws in right earnestness. Even if the penal provisions
exist under the bye-laws they are not used often and, therefore, non
compliance of municipal provisions with regard to public health and
sanitation is a usual phenomenon. The Government of India drafted a
Model Public Health Act in 1955 and circulated to the states to enable
the local authorities and municipal bodies to appropriately modify
their municipal bye-laws so that municipal bye-laws in India become
uniform and provisions are updated. However, none of the states
acted on the same. The same was revised and re-circulated in 1987.
112
The Epidemic Diseases Act 1897.
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However, nothing much has occurred. The recent 74th amendment of
constitution 1992 gave more authorities to the municipalities with
regard to public health, sanitation and water supply and has provided
important tool to the municipalities in responding to epidemic
situations. Unfortunately, the available health infrastructure in the
urban areas does not have adequate components for effective
surveillance and response capability. For the same, more resources
will have to be made available to the municipalities to establish an
appropriate surveillance and response capability mechanism within
the overall framework of national disease surveillance system. That
will strengthen the public health system significantly.
9.4
District Health authorities:
District is the most important focal point of all health care
activities. All the districts have got a focal point to respond to an
epidemic situation. The district maintains a very important liaison
with the community health centres, primary health centres and sub
centres and on a slightest suspicion of an outbreak normally the district
health authorities are capable to respond to the situation for providing
assistance to the community health centre/primary health centre in
.epidemic investigations. However, as the laboratory support services
to the district health organisation is weak many of the outbreaks are
not appropriately investigated and control measures are taken mostly
on the clinical and epidemiological perception of the nature of illness.
The surveillance mechanism is mostly around monthly reporting and,
therefore, many of the outbreaks are not detected early leading to
higher morbidity and mortality.
Most of the district health
organisations do not have the facilities of computers and, therefore, the
analysis of the data are inadequate resulting in loss of useful
epidemiological information. Many of the district health officers do
not have FAX or direct/STD telephone lines and, therefore, resulting in
delay of appropriate intervention measures.
9.5
Primary Health Centre Infrastructure:
Primary health care infrastructure is the vital point in initiating
control measures. Surveillance mechanism as it exists today is
inadequate to the extent that early detection of outbreak is almost
impossible and, therefore, the medical officer or the para medical staff
in charge of initiating control measures often responds to the situation
very late and it will not be surprising that even the information is
available in the press the medical officer of the PHC does know about
the event.
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9.6
Panchayati Raj System:
Panchayati Raj is a system of rural local self government in Indie,
linking the village to the district having three tier structure at th
village level, intermediate level and district level. Village leve
Panchayat is the Gram Sabha which means a body consisting c
persons registered in the electoral roll relating to a village within tl
area of Panchayat at the village level. A Panchayat at the village leve
will be elected in such a manner as the legislature of a State may by lavr
provide. It may exercise powers and perform such functions at th<=
village level as the legislature of a state may by law provide. The
Panchayat at the intermediate level or district level shall be elected bv
and from amongst the members thereof. The 73rd constitutional
amendment has provided immense powers to the Panchayats fcx
taking care of rural housing, drinking water, health and sanitatic..
including hospitals, primary health centres and dispensaries ai .
family welfare. Until and unless these powers are matched wi i
deployment of financial authorities as well the Panchayati Raj Syste i
will not be able function adequately. Taking in view this important
development the entire health care delivery services including disea-”?
surveillance mechanism should be channelised through the Panchayah
Raj System which can provide also very supportive important tools of
community participation and community awareness which are so vital
in appropriate utilisation of the health care facilities that have been
established and also in successful delivery of the different heaim
programmes.
9.7
OBSERVATIONS, SUGGESTIONS & OVERVIEW:
9.7.1
The local health authorities both in the rural and the urban arr^s
have constitutional power and obligation to undertake all activit s
related to public health and sanitation activities. They have the power
to clamp appropriate legal provisions which may be necessary m
effective functioning of public health and sanitation activities.
Unfortunately, adequate resources and expertise are not available at
the level of local authorities to build up a strong public health system
which can effectively respond to a public health emergency.
9.7.2
Most of the municipalities have very limited capability' of
generating resources to shoulder public health and samtaf m
responsibilities and that is quite evident from the state of avail; de
basic sanitary facilities in both urban and rural areas described m 'he
earlier chapters. Fortunately the recent 73rd and 74th constitutional
amendments have given more responsibilities and authorities to local
areas but until and unless these additional responsibilities are matched
with provision of additional funds and delegation of financial powers
the local authorities will not be able to function as expected of them.
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There is an urgent need that additional funds and financial authorities
are immediately provided to the local areas (Municipalities &
Panchayats) to strengthen their capabilities in building up a strong
public health system.
9.7.3
As on today local authority bye-laws are widely different from
one another and many of the bye-laws are outdated. Penal provisions
are hardly ever implemented. Therefore, non-compliance of local area
bye-laws is common and thus there is an urgent need that all the local
authorities adopt a uniform Model Public Health Law. In this context,
it is stated that the Central Government has already circulated a draft
Model Public Health Act. All the local authorities should examine the
same and adopt it modifying some provisions if necessary, depending
upon the local situation.
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CURRENT STATUS OF HEALTH
MANAGEMENT INFORMATION SYSTEM
AND ITS ROLE
10.0
CURRENT STATUS OF HEALTH MANAGEMENT
INFORMATION SYSTEM & ITS ROLE
10.1
INTRODUCTION
The Central Bureau of Health Intelligence (CBHI) of the
Directorate General of Health Services in consultation with the
National Informatics Centre (NIC) at the Planning Commission and the
NIC unit in the Ministry of Health & F.W., State Health Departments
and apex health institutions have developed a computer based Health
Management Information System (HMIS) which has tried to rectify the
existing deficiencies in the area of health information. This system has
not been perceived to compete with or to replace the information
system of the various health and family welfare programmes. No
attempt is being made in this HMIS for major changes within the
health care delivery system. It is intended to serve as the foundation
and network into other information system serving health sector as a
whole. HMIS which has been designed in 1986-88 was field tested in
1989. The CBHI acts as a nodal agency for the operation of health
information management system. The State equivalent for the CBHI is
the State Bureau of Health Intelligence.
10.2
Evolution of HMIS in India & its current Status
India is one of the signatories to the Alma Ata Declaration 1978.
Under this declaration priority has been laid down on the minimum
essential components of the primary health care which includes at
least, education concerning prevailing health problems, methods of
identifying, preventing and controlling them, promotion of food
supply and proper nutrition, adequate supply of safe water, and basic
sanitation, maternal and child health including family planning,
immunization against major infectious diseases, appropriate treatment
of common diseases and injuries, promotion of mental health and
provision of essential drugs.
The National Health Policy envisages the goal of "Health for
All by 2000 A.D." which is to be achieved through the primary health
care approach. The network of primary health care establishments like
community health centres, primary health centres, sub -centres set up
all over the country with requisite staff following recommendations of
Bhore Committee and with subsequent modification by several other
committees has been further expanded following the National Health
Policy to ensure the effective implementation of the National Health
Programme and for efficient monitoring and evaluation of the
achievements in conformity with the goals laid down. It was decided
that Health Management Information System (HMIS) should be
developed as an information support to HFA strategy.
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Initially HMIS was started in the States of Gujarat, Haryana,
Rajasthan and Maharashtra on a pilot project basis in one district each
of these States. The system was manual and the data which was
generated as a result of implementation of the pilot project proved
very useful. On the basis of the achievement of HMIS which was
known as HMIS Version 1.0, the programme officers of various State
Governments and experts from the related fields were consulted and
the inputs (reporting formats) for each level of institution responsible
for health care delivery, were designed and developed.
During 1988-89 National Informatics Centre set up Satellite
based computer communication Network called NICNET in every
district of the States all over the country. Due to the availability of the
computer facility it was decided that the HMIS
should be
computerised and it should contain the essential minimum core
information parameters which may be useful for providing valuable
information on the health care delivery system provided through
primary health care approach. The modified computerised formats
designed and developed have been brought out in the shape of a
Booklet "Health Management Information System" Version 2.0 and
•were implemented in States/Union Territories at district level.
Emphasis was laid on district level as the computer facility was
available only in the districts. Below the district the system continues
to be operated manually.
Sth five year plan document suggested :
(i)
To monitor the progress of implementation of MNP at
the District, State and National levels a health
information and management system should be
developed and used.
(ii)
Establishment of epidemiological cum surveillance
centres at district/regional levels and improvement of
health management information system for continuous
monitoring of the disease situation and taking
appropriate and prompt action.
To implement the system effectively and to enable the States to
switch over from the manual system to the computerised system WHO
agreed to provide financial assistance in terms of :
•
Printing of reporting formats, registers (Sub Centres) for one year.
Assistance for initial one time training of the State officials and
peripheral staff.
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The funds were released in two or three instalments depending
upon the achievements made by the States concerned. Initially funds
were released to nine States by 1992. The implementation has the
following stages:
1. Training of the trainers (officers) on HMIS strategy. These trainer
officers in turn will be responsible to train the district officers (medical
and others) and peripheral staff involved in the implementation of the
system.;
2. After the training of the State officials is completed and based on any
modifications suggested by them, the reporting formats and registers
are got printed;
3. Integrated units which are responsible for the collection of the various
reporting formats from the different units are to be set up. These
integrated units are responsible for data entry in the computer at the
NIC district headquarters and with the help of NIC officials generate
various reports for use of the programme officers at district. State and
central level.. In States where State Bureau of Health Intelligence are
-there, these are
;
responsible for the above activities and where these
bureaus are not there, equivalent State Statistical Division are
responsible for the above activities.; and
4. The generated reports are to follow a time schedule. The following
time schedule is observed:
•
Receipt of reporting formats from the PHC, CHC, district hospitals,
VOs etc. by 4-5 of the following month.
•
Entry of the information in the reporting formats in the District NIC
computer to be completed by 6-7 of the following month.
•
Generation of the report at district level from 8-10 of the following
month at NIC District Centre.
•
At State level the data is directly captured from the district NIC
centres by the State NIC Unit and the generated reports are made
available by the SBHI/equivalent Statistical Cell at State HQ to the
concerned Programme Officers.
•
At Central level CBHI with the help of NIC Unit at Nirman Bhawan
gets the reports generated through the NICNET facility as the data
is directly captured from the various States.
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•
To facilitate a decision for making use of the various reports
approximately 191 output report formats were designed and
developed in consultation with NIC. In all for various programmes
191 reports could be generated through the computer depending
upon the requirements of the programme officers.
The State of Haryana was provided necessary training in
December, 1992 but due to some operational problems and changes in
priorities in the programme, the system has become operational from
April, 1994 only. The reports are received via NICNET and distributed
to the programme officers at district. State and Centre level.
Besides, Haryana, eleven more States have been sensitized and
training workshops for the trainers have been conducted. These States
namely, Tripura, Sikkim, Gujarat, Andaman & Nicobar Islands, Dadra
& Nagar Haveli, Rajasthan, Karnataka, Pondicherry, Manipur, Punjab
and Maharashtra will start the implementation with effect from April,
1995 except Sikkim. In Sikkim the system has become operational from
April, 1994.
Under the HMIS, information will flow on all the health care
.delivery services provided by the various units like PHC, CHC, district
hospitals, private hospitals, nursing homes, VHO's, Urban Revamping
Centres, MCH Centres etc. on a regular basis at a shceduled time for
effective monitoring and evaluation of the achievements vis-a-vis the
targets laid down.
However, it may be noted that although efforts have been made
to include all the data sources at district level viz. district hospitals,
private hospitals, and nursing homes, VHO's Urban Revamping
Centres, MCH Centres etc. but it is not mandatory on the part of
private hospitals, nursing homes, private practitioners, VHO's etc. to
provide data input to the system and therefore, population coverage is
not 100%. Further in urban areas and mega cities the municipal areas
and hospitals are not covered by it.
To include the urban municipal areas and hospitals it is
necessary to bring them under the coverage of HMIS Ver. 2.0. As a
first step major health institutions and medical colleges in the country
may be connected through NICNET with the responsibility of
collecting urban area data through HMIS Ver. 2.0. This would also
provide them the facility to report any peculiar/abnormal morbidity
pattern of diseases in their respective areas of operation to NICD or
any assigned monitoring agecies in thier zones.
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The HMIS is directly connected through the Satellite based
computer communication Network NICNET at each district centre of
the NIC and has on-line connectivity with them for all the 24 hours.
The output reports generated through the computer not only
provides information but they are required to provide a basis for
effective surveillance, prevention and remedial action particularly
where the achievements are not in conformity with the targets laid
down for a particular programme.
The feed back mechanism
component should work as an effective surveillance for improving the
health care delivery all over the country.
At present under the manual system the retrievability of the
information is remote or very poor. Under the computerised system
data could be retrieved for a period of two years at a stretch without
loss of time.
There is a need for the rapid implementation of the HMIS all
over the country as at present only 40% of the States/UTs stands
covered under the project which is under various phases of
implementation. When the entire country is covered under the project,
.meaningful data for the various health conditions and related aspects
will be available for effective policy planning and for improving health
care delivery system.
The HMIS integrates the health and family welfare programmes
such as, family welfare, maternal and child health, immunization.
National Malaria Eradication Programme, National Tuberculosis
Control Programme, National Leprosy Eradication Programme,
National Programme for Control of Blindness as well as programmes
on Iron and Vitamin A deficiency. It also includes communicable
diseases of national importance and local diseases which are to be
given priority by the individual States.
The system also provides valuable information on the staff
position and the inventory of drugs which in turn helps in the resource
management at various levels.
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10.3
The current status of the HMIS implementation in various States is
given in the tabular form below:
Sr.No.
State
Training
Implemented
i
i
1.
Haryana
Late 1992
Middle of 1993 S/W modified in |
1994 fully implemented and data ,
being
transmitted
regularly ,
every month from mid of 1994
!
2.
Tripura
Early 1993
Not yet operational
3.
Sikkim
Mid 1993
Fully operational from 1994
l
1
i
4.
Gujarat
Nov. 1993
i
Not yet operational
i
5.
Rajasthan
Mid 1994
S/W modified in March 1995 and 1
handed over for implementation '
i
6.
Karnataka
Late 1994
7.
Punjab
April 1995
-do-
8.
Manipur
Late 1994
-do-
9.
Pondicherry
1994
Modified S/W handed over in
March 1995
10.
A & N Islands
1994
Modified S/W sent by post in 1
April, 1995
1
Not yet operational
I
i
i
l
i
11.
10.4
Dadar & Nagar 1994
Haveli
i
Not yet operational
i
Observations:
The format for collection of data through the. computerised
HMIS and through the manual reporting are enclosed as Annexures 12
& 13 for ready perusal. The data have been reviewed for the State of
Haryana for the period from April-December, 1994 in respect of
diseases like Acute Diarrhoeal Disorders, ARI, pneumonia and viral
hepatitis. It has been found that the information obtained through the
manual reporting and information received from the computerised
HMIS vary because some of the manually available data have not been
fed in the computers and hence the computerised data are deficient.
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Default with regard to the receipt of the computerised data in time
from the districts went upto the extent of 40%. In addition to this, it
also does not provide appropriate information with regard to
clustering of cases in any particular geographic area and thus it hardly
gives any tool for an effective early response mechanism to be
mounted. The data received through the computerised HMIS and
manually in respect of the above four diseases from April-December,
1994 are given below. Experts are of the opinion that the data
generated through the HMIS with regard to epidemic prone diseases
are not adequate for an effective surveillance, prevention and remedial
action. These data could best be used for planning purposes.
APRIL TO DECEMBER, 1994
A.D.D.
A.R.I.
Viral Hepatitis
Pneumonia
MANUAL
2,59,505
4,25,467
1,216
4,539
COMPUTER
2,17,512
3,28,785
1,146
Nil
The HMIS was also reviewed recently in the 4th Conference of
.the Central Council of Health & Family Welfare held in New Delhi
from 11-13 October, 1995 and the Council recommended expansion of
HMIS to other states quickly. With the expansion of HMIS to other
states and its establishment on firm footing the epidemic intelligence
component could be appropriately dovetailed within the HMIS and
NICD should take up few districts in some states where HMIS has been
satisfactorily established incorporating the epidemic intelligence
component in the light of the experiences of NICD epidemic prone
disease surveillance project and NATHI Projects of CMC, Vellore on a
pilot basis. If that proves successful that will strengthen further the
HMIS in its response capability. This could form part of operational
research support to the proposed National Disease Surveillance
Programme.
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RECOMMENDATION S
11.
RECOMMENDATIONS
11.1
Short-term
11.1.1 Policy Initiatives
Review of National Health Policy
11.1.1.1
The National Health Policy was formulated and adopted in
1983. During the years since then major changes have occurred
through continuing population growth, rapid urbanisation, industrial
revolution, changing health and demographic scenario, appearance of
new, emerging and re-emerging health problems etc. Two important
constitutional amendments namely 73rd and 74th have been passed
giving more responsibility and authority to municipalities and
panchayats and thus providing appropriate tools to the community to
deal with health, water supply and sanitation etc. more effectively. In
view of the same, the National Health Policy needs a careful and
critical reappraisal.
The committee, therefore, recommends
constitution of a Group of Experts to prepare the draft of the new
National Health Policy by the end of 1996.
Establishment of health impact assessment cell
11.1.1.2
While the link between economic growth and better health is a
strong one, growth in income and a developing economy do not
necessarily ensure improved health status. Many developing countries
are concerned with the possible health impact of economic
restructuring and development policies. The Committee, therefore,
recommends that there is a need to enhance the capacity and capability
of the Ministry of Health & F.W. to undertake health impact
assessment for major development projects, industrial units etc. so that
the project/industrial authorities could be appropriately advised &
guided to incorporate proper intervention measures/changes as the
case may be. All large projects of different ministries should invariably
have health component in the proposal itself and this should be
examined and approved by the Ministry of Health & Family Welfare.
Regular analysis of various public policies and practices of other
ministries viz. agriculture, industry, urban development, rural
development and environment, which have direct link with the health
of the people, must be considered as an essential prerequisite for a
meaningful inter-ministerial co-ordination.
11.1.1.3
Surveillance of critically polluted areas
In view of the population explosion and unplanned
urbanisation and industrialisation, diseases due to ecological and
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environmental imbalances are increasing.
Health impact and
environmental epidemiology related to air, water, and soil pollution
need to be monitored and evaluated particularly in the critically
polluted areas in the country. Ministry of Health and Family Welfare
should initiate actions in this regard urgently, in co-ordination with the
Ministries of Environment, Industry and Urban Development.
Measures such as a properly maintained data-base, mapping of the
vulnerable areas, immediate intervention where possible and
continuing surveillance need to be initiated as a well structured
programme of action.
This is particularly important in view of the large inputs
provided by the Ministry of the Environment and Forests for 100
critically polluted towns and cities. Such surveillance will enable to
understand impact of the interventions made and take appropriate
corrective measures.
11.1.1.4
Search for alternative Strategy/ strengthening of health
services/system research
India is a vast country. Uniform health care strategy for the
‘entire country is not likely to succeed because of a variety of reasons:
geographic, socio cultural, ethnic, economic etc. Therefore, a
continuous search for alternative health care strategies needs to be
undertaken by the health implementing agencies through appropriate
health services research. At present, health system/ services research
receives very inadequate support and poor response from the health
directorates.
Therefore, the Committee recommends allocation of
adequate funds to the Centre, UTs and State Directorate of Health
Services enabling them to undertake or commission Health
Services/System Research and Intervention Studies and to ensure that
such research results are utilised to improve the health care delivery
services.
11.1.1.5
Uniform adoption of Public Health Act by the local health
authorities
Model Public Health Act revised and circulated in 1987 should
be examined by all State health authorities, municipalities and local
health authorities carefully and adopted/enacted to suit local and
national needs. This will give a uniform, updated and modern tool to
tackle many of the old and new, emerging and re-emerging health
problems more efficiently. This is all the more important in view of the
recent 73rd and 74th Constitutional Amendments providing enormous
political, administrative and managerial authorities to local and
municipal bodies so as to enable them to take care of human health and
development.
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11.1.1.6
Establishing National Notification System/National Health
Regulations
The notification system as it exists today varies widely from
state to state and within the state from area to area. The Committee
recommends the constitution of a Task Force drawing experts from
states, NGOs, and public health institutions to examine the existing
notification system and prepare draft National Health Regulations for
adoption by all states. This should be time bound and completed by
1996.
11.1.1.7
Joint Council of Health, Family Welfare and ISM
Homoeopathy
&
Indian Systems of Medicine and Homoeopathy should be
appropriately involved in strengthening further the public health
system of the country. Therefore, the committee recommends that the
existing Joint Council of Health & Family Welfare should be further
broad based to make a Joint Council of Health, Family Welfare and
Jndian Systems of Medicine & Homoeopathy.
11.1.1.8
Establishing an Apex Technical Advisory Body
In order to ensure a mechanism of continuing review and
appraisal, the committee recommends to establish an broad based
Apex Technical Advisory Body and advise the government
accordingly.
11.1.1.9
Constitution of Indian Medical & Health Services
The Committee reinforces in the strongest terms the need to
constitute Indian Medical & Health Services without any further
delay. This has been a long felt need and was recommended as early
as 1961 by Mudaliar Committee. Many of the central health
programme managers have no formal education in public health and
management and have never worked in the states, as a result they do
not have appropriate perception of the problems of the states leading
to poor professional communication and understanding between
central and state government health programme managers. Creation
of Indian Medical & Health Services will facilitate bridging this gap
and improve technical leadership and management both at centre and
state levels.
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entire team together in addition to training of the individuals. This
multiprofessional education approach will provide cohesive
functioning of the team and improve quality and coverage of health
services.
11.1.3.3
The Union Ministry of Health & F.W. is primarily responsible
for public health services but it does not have requisite number of
senior level public health professionals. Many programme managers
at the national level are without any public health orientation or public
health qualifications. The committee, therefore, recommends that
positions requiring public health tasks should be filled by appropriate
qualified public health professionals and until these professionals are
available, these could be operated by general category health
professionals through appropriate training in health services
administration, management and epidemiology.
11.1.4
Opening of Regional Schools of Public Health:
There is a need to open new schools of public health so that
more public health professionals and para-professionals could be
trained. The existing public health schools also be appropriately
^strengthened. The committee recommends that at least four more
regional schools of public health are set up in Central, Northern,
Western and Southern regions. Duly modernised schools could be in
the pattern of All India Institute of Hygiene and Public Health,
Calcutta and School of Tropical Medicine, Calcutta.
11.1.5
Strengthening and upgradation of the Departments of
Preventive and Social Medicine in identified medical colleges
Establishing new schools of public health will require several
years in terms of obtaining resources, construction of buildings etc.
For a vast country like India even establishing few more schools of
public health will not be able to meet the entire needs. Therefore, it is
recommended that some of the existing medical colleges who have
very significant expertise in teaching of preventive and social
medicine/community medicine should be further strengthened in the
form of establishing an advanced centre for teaching of public health or
upgrading the existing departments so that it can take up additional
responsibilities of continuing education in public health subjects for
health professionals and also to undertake responsibilites for
producing more public health professionals to meet the demands of the
country. In this context, it is strongly suggested that a centrally
sponsored programme of upgradation of few identified departments of
preventive and social medicine in the medical colleges could be taken
up during the last financial year of this Plan and during the 9th Plan
period at least 25% of existing departments may be similarly upgraded.
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11.1.9
State Level:
Creation of several positions of Directors at the State level has
led to disintegration of earlier integrated pattern of medical and health
administration. Earlier practice needs to be restored. It is also
recommended that functioning of the Department of Health being
mostly that of technical nature a technical man should be the head of
the Department of Health instead of a bureaucrat.
The committee recommends that on the general principles
suggested for reorganisation and restructuring of the Central Ministry
of Health & Family Welfare and the Directorate General of Health
Services, the State/UT health ministries and directorates should also be
reorganised and restructured.
11.1.10
District level:
Every district should have a strong epidemiological services
input through establishment of an epidemiological unit headed by an
officer of the level of district epidemiologist and supporting staff.
Establishment of this type of unit will also help initiating disease
.surveillance programme including early warning signal mechanism
with appropriate laboratory support.
The committee, therefore,
recommends to establish such units if not already existing under the
National Disease Surveillance Programme.
11.1.11
Establishment of a supervisory mechanism at the Sub-district
level:
In many states district levels officers like district malaria officer,
district family welfare officer and district health officer have been
given responsibility to supervise all health & family welfare
programme in part of the districts in addition to supervising the entire
individual programme for the entire district. This has not given much
dividend, because the officer does not give adequate attention to
activities other than the specific health & family welfare programme
through which his salary is drawn. In addition disease control
strategies/interventions are becoming complex due to variety of
reasons viz. addition of more and more sophisticated technologies,
problems related to resistance to drugs, resistance to insecticide,
ecological changes, management issues covering logistics, cost
effectiveness etc.
Therefore, supervision of the various health
programmes has been suffering and there is an urgent need to institute
appropriate supervisory mechanism at the sub district level.
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11.1.12
Community Health Centres:
Community Health Centre is regarded as the first referral unit.
The National Education Policy in Health Sciences as approved by the
Central Council of Health & Family Welfare in 1993 has recommended
placement of one public health specialist at the community health
centre (CHC) level and if this is implemented the same will contribute
immensely in strengthening the public health system and will offer
suitable correction to present hospital based disease cure emphasis in
health care delivery to make it disease prevention and health
promotion oriented as enshrined in the National Health Policy
statement. The availability of additional manpower in form of one
public health specialist in all the CHCs may not appear immediately
feasible at this stage of available public health specialist manpower.
However, once a beginning is made and National Education Policy in
Health Sciences is implemented in a time bound manner through an
appropriate action programme, this will be possible in foreseeable
future and thus disease control activities channelled through CHC will
have more updated professionally competent support for better
management of disease control programme and transfer of newer
technologies for various disease control activities at the grass root
• level.
At the CHC there are four specialists and one PHC Medical
Officer. Until such time as a Public health expert is available at CHC
level, it is suggested that each of the specialists take up the
responsibility of monitoring the public health programme pertaining to
their speciality in the population covered by CHC e.g. obstetrician will
supervise collection and reporting of data pertaining to Reproductive
Health and Family Planning, Paediatrician for immunization and child
survival, physician for communicable and non-communicable disease
control programme, surgeon for disability limitation rehabilitation and
blindness control programmes. The entire data pertaining to all
programmes in the CHC population may be put together and reported
by the PHC M.O who must be adequately trained in epidemiology and
public health management. Thus with the existing staff improvement
in MIS, disease surveillance and response and accurate reporting of
data pertaining to PHC can be attempted in the CHC. This would also
bring about increased awareness of the clinicians to the*ongoing public
health programmes and result in better integration of clinical curative
and preventive medicine components of the important programmes.
11.1.13
PHC/Sub-Centre level:
The organisational structure of the health services at village
level should be entrusted to the Panchayati Raj institutions which
should decide the nature structure, and priorities of the organisation of
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the health care delivery services at the village level depending upon
the local situation, resource availability etc. This would ensure
participatary management by the community with empowerment for
decentralised area specific microplanning. Within such a framework,
further co-ordination must develop at all levels of local self
governance.
11.1.14
Village level
With the 73rd and 74th Constitutional Amendments providing
enormous political, administrative and managerial powers to take care
of the health and development of the people, it is very important that
the Village Health Guide scheme continues to be supported with
appropriate strengthening through enhancement of honorarium and
drugs so that they become more effective in handling the local health
problems. The committee is of the considered opinion that the Village
Health Guide in the new envisaged role as Panchayat Swastha Rakshak
will provide useful support to the Panchayat system at the village level
in enhancing community awareness and participation.
11.1.15
Prevention of Epidemics:
11.1.15.1
It may not be possible to completely prevent outbreak of
diseases. However, epidemics can be prevented if an appropriate
surveillance mechanism is established. In fact price of freedom from
disease is appropriate surveillance. The Committee agrees with the
recommendations of the Fourth Conference of the Central Council of
Health & Family Welfare (1995) proposing initiation of a National
Disease Surveillance Programme for strengthening of health
surveillance and support services and recommends that this
programme should be initiated as a centrally sponsored scheme within
the existing health infrastructure with appropriate laboratory support
involving already existing expertise in various national institutes,
medical colleges, and district public health laboratories. Additional
support needs to be provided to modernise laboratory support system
through strengthening of conventional techniques and procedures,
induction of rapid diagnostic tests, molecular epidemiology capability
so that the public health system is updated and modernised to respond
to any eventual public health emergency. Initiation 'of a national
disease surveillance programme will improve notification system,
institution of early warning signal mechanism and would enhance
prompt response capability.
11.1.15.2
With the establishment of National Disease Surveillance
Programme, several national institutes at the national, regional and
state level alongwith several medical colleges and important public
health laboratories will be appropriately linked so that the response
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capability becomes faster and expertise available in these institutes
promptly could be harnessed by the executive health authorities at the
district level to respond to an epidemic situation. These institutions
should be appropriately linked and strengthened to maintain an
updated expertise for meeting any future challenges.
India has established a large number of health institutions at the
11.1.15.3
national, regional and state level. Many of these institutions are
suffering due to non-availability of resources and, therefore, even if the
human expertise is available the same is unable to provide requisite
response capability because of non-availability of support services and
resources. Alternatively, in several institutions even if the modern
equipments are available they are not being appropriately utilised
because of the non-availability of human expertise because of poor
allocation of resources, poor quality of continuing medical education,
etc. The Committee, therefore, is of the opinion that during the 9th
Plan a centrally sponsored scheme may be initiated to upgrade these
institutions and laboratories through appropriate allocation of funds so
that these institutions can modernise themselves through capacity
building. This could be appropriately linked with recommendation
under 11.1.7.
11.1.15.4
National Institute of Communicable Diseases prepares
guidelines and procedures for outbreak investigations and epidemic
disease surveillance but the same is either not available through out the
country or not put to practical use under a regularly monitored
programme. At present, such guidelines and procedures are usually
provided on request to various health agencies. To be optimally useful,
these guidelines need to be regularly updated. The entire mechanism
as it exists today is on ad hoc basis. The committee, therefore,
recommends that National Institute of Communicable Diseases should
prepare these guidelines regularly under the supervison of a National
Task Force, update the guidelines at predetermined interval and send
to all health implementing agencies. The guidelines should include
details of the mechanism of detection of outbreak and detection of
early warning signal.
11.1.15.5
The system of civil registration of deaths, Model Registration
Scheme, Sample Registration Scheme subsequently renamed as Survey
of Causes of Death (Rural), certification of causes of death should be
continuously improved by enlarging its scope and coverage so that it
gives more relevant data in the context of the entire country.
The processing of weekly epidemiological statistics being
11.1.15.6
provided by CBHI lacks an appropriate feed back channel to the
various peripheral agencies. The same need to be developed in the
pattern of MMWR (Morbidity Mortality Weekly Report) published by
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CDC and National Institute of Communicable Diseases may take up
the responsibility for the same and initiate action in this regard to
prepare an MMWR type of Bulletin for rapid feed back to all
participating agencies, experts etc. CBHI may continue to act as a
nodal agency for diseases which are being reported on a monthly basis.
The diseases under International Health Regulations and the diseases
under National Health Regulations having epidemic potentiality
should be the responsibility of NICD which has the due expertise in
appreciating the problem and initiating action accordingly.
11.1.15.7
National Institute of Communicable Diseases, Delhi and
Christian Medical College, Vellore have worked on Models of
obtaining information involving peripheral health workers and
physicians in the private sector respectively and if both the models
with necessary modifications if any, can be appropriately dovetailed
within the existing HMIS, the same will provide early warning signals
for detecting an impending epidemic.
The HMIS was also reviewed recently in the 4th Conference of
the Central Council of Health & Family Welfare held in New Delhi
from 11-13 October, 1995 and the Council recommended undertaking
ean urgent expansion of HMIS to other states. It is desirable to develop
health information system at the district level in order to improve all
activities related to Community Health including those in the
Environmental, Community Water Supply and Sanitation sectors
which will directly lead to an improvement in the health and
environmental status of the district's population. Population based
information in respect of socio economic, environmental, cultural,
demographic and epidemiological issues is vital for choosing priority
areas of action and planning public health interventions and evaluating
progress.
With the expansion of HMIS to other states and its
establishment on a firm basis the epidemic intelligence component
could be appropriately dovetailed within the HMIS and a few districts
in some states be taken up where HMIS has been satisfactorily
established incorporating the epidemic intelligence component in the
light of the experiences of NICD epidemic prone disease surveillance
project and NADHI Projects of CMC, Vellore on a pilot basis. If found
successful, it will further strengthen the HMIS in its response
capability. This could form part of operational research support to the
proposed National Disease Surveillance Programme.
11.1.15.8
Epidemic Diseases Act 1897 covers the entire country. This Act
is about 100 years old.
However, not many times regulatory
mechanisms are clamped under this Act because of improper
professional perception of the nature and spread of the epidemic. If
PHSfinal.doc
appropriate provisions under the Act are clamped in time major
epidemics could be averted. Therefore, the committee recommends
that the Epidemic Diseases Act provisions should be made available to
all the health authorities and the provisions under the Act could be
continuously reviewed by a designated group to make it more
comprehensive in the light of the latest scientific information available.
11.1.16
Upgradation of Infectious Diseases Hospitals
Every State has got one or more ID Hospitals. Most of these
hospitals are inadequately staffed with poor maintenance. Many of
them lack the basic diagnostic support services. There is an urgent
need that facilities in these hospitals are appropriately reviewed and
modernised to meet the requirements of infectious diseases
management. These hospitals should also have some provisions
particularly in the major metropolitan cities for management of cases
suffering from dangerous human pathogens.
11.1.17
Water quality monitoring
Inspite of significant progress in the coverage of Urban and
aRural Population with public water supply, reduction in the morbidity
of water borne diseases, has not been commensurate with the
investment made in the water supply sector. One of the key factors
behind this failure is the total lack of water quality monitoring and
surveillance in most of the rural areas and majority of cities and towns.
A recent study by the UNICEF and the All India Institute of Hygiene &
Public Health, Calcutta, has demonstrated the feasibility of a
community based and affordable model of water qualify monitoring
and surveillance. Ministry of Health & Family Welfare should take up
the matter with the Ministry of Rural Affairs and Employment and
Urban Affairs and Employment to initiate a few pilot studies in
different locations in the country to examine the feasibility of the same
and develop National Action Plan, in this regard.
For full benefits of supply of safe and adequate water, domestic
and personal hygiene should be of high order. Therefore, the
committee recommends to launch massive IEC programme on
personal, domestic and food hygiene practices including excreta
disposal.
11.1.18
Urban Solid Waste
The committee endorses the recommendations of the 1995 Bajaj
Committee Report of the High Power Committee on Urban Solid
Waste Management in India, constituted by the Planning Commission
with regard to collection, transportation and safe disposal of municipal
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wastes including industrial and hospital wastes etc. The committee
also endorses the suggestion of the Bajaj Committee, that it is essential
to evolve a National Policy as well as an action plan for management of
solid waste.
‘
if
Pt; I"!
n
11.1.19
I
Inter-sectoral Co-operation:
Large number of health schemes are implemented through the
Ministry of Health & Family Welfare. In addition, there are large
number of schemes having tremendous impact on human health and
quality of life. These schemes are being implemented through several
other ministries. Some of the important ones which have a direct
bearing on the Public Health System are Rajiv Gandhi National
Drinking Water Mission (RGNDWM), Rural Sanitation, Accelerated
Urban Water Supply Programme, Urban Sanitation,. Urban Basic
Services for the Poor, Urban Solid Waste Management, Sewerage and
Sewage Treatment, Prevention of Water and Air Pollution, Nutritional
Programmes like Integrated Child Development Services, Special
Nutritional Programme, Balwadi Nutritional Programme, Midday
Meal Programme etc. All these schemes have been conceptualised to
improve the Public Health System. But as different agencies are
involved and co-ordination between these agencies is not so easily
achieved, the Committee is of the opinion that until and unless a
formal mechanism of co-ordination and co-operation is established
involving all concerned and guidelines indicating detailed
responsibilities in respect of all participating units precisely defined,
even inspite of individual schemes appearing to be technically sound,
the same will not be able to deliver what is expected in terms of
effective improvement in the Public Health System. The Committee
fully believe that such mechanism is very vital in the implementation
of the health schemes and will strengthen Public Health response
capability significantly. The committee, therefore, recommends
establishment of such mechanism on a formal basis with Ministry of
Health & Family Welfare acting as nodal agency.
11.1.20
Nutrition
Interactive interdependence of nutrition, infection and health
have been well recognised. The National Nutrition Policy formulated
in 1993 has defined the Nutrition goals and the key areas of action.
National Action Plan for Nutrition provides the sectoral and
intersectoral interventions to achieve these goals.
Appropriate
indicators and institutional mechanism . for monitoring the
implementation and impact of the ongoing intervention programmes
at local, district, state and national level need be developed, and
internalised so that the efficacy and efficiency of the various strategies
225
PHSfinai.doc
can be assessed on a continuing basis and appropriate midcourse
correction can be taken.
India is in a state of demographic, economic and social transformation.
In this context it is essential that a mechanism of nutritional
surveillance at local, district, state and national levels is built up so that
early recognition and rapid remedial interventions of existing and
emerging nutritional problems becomes possible.
11.1.21
Decentralised and uniform funding pattern:
Salaries for the ANMs in the periphery come from the family
welfare budget and, therefore, they are subservient to the command of
the Family Welfare Department and do not respond adequately for
related work in the Department of Health for which instructions come
from Department of Health. Similar is the situation in respect of male
health workers who receive their salaries from the health budget and,
therefore, they do not adequately respond to the instructions issued
from Family Welfare Department until and unless specific incentives
are provided and in that case he works for Family Welfare only for
incentives at the cost of health related work. Therefore, this
fragmentation of tasks and commands grossly affects the functioning
of the health workers which in turn affects the efficient functioning of
the public health system. Therefore there is an urgent need that both
the departments are under unified command and the budgetary
provisions are made through unified budgeting system. This will also
enable adjustment of funds at the peripheral points depending upon
the situation which will improve better utilisation of funds etc. There
is also a quantitative distortion in the number of filled posts. As the
salary for ANM comes from FW programme which is a 100% centrally
sponsored one, the posts of ANMS have been created according to the
norms. In contrast the salary for MMPW is from the State budget and
often more than 50% of the posts are vacant and not filled up. This
anomaly needs to be corrected immediately to ensure appropriate
involvement of peripheral level functionaries in disease control
programme as well as in FP programmes.
11.1.22
Non-Governmental Organisations (NGOs):
Non-governmental organisations (NGOs) contribute immensely
in the development of public health system and the practices.
However, the service coverage is limited due to financial and other
constraints. If the NGOs and the private practitioners are effectively
involved this will strengthen the public health system and significantly
enhance the response capability of the health care delivery system.
Therefore, the committee recommends that the NGOs should be
226
PHSfinal.doc
1
increasingly involved through an appropriately developed action plan
with suitable funding.
11.1.23
Involvement of ISM & Homoeopathy:
India has over 5 lakh practitioners in indigenous systems of
medicine and homeopathy. Despite the fact that India has a large
number of practitioners in ISM&H, of whom a significant proportion
are institutionally qualified and certified, this potential manpower
resource is yet to be effectively drawn and optimally utilised for
delivery of health care in the country. The committee, therefore,
recommends their involvement in the health care delivery system to
strengthen the public health services and endorses fully the Baja]
Committee Report on Health Manpower, Planning, Production and
Management in 1987 in this regard. The practitioners of Indian System
of Medicine can be gainfully employed in the area of National Health
Programmes like the National Malaria Eradication Programme,
National Leprosy Eradication Programme, Blindness Control
Programme, Family Welfare and universal immunisation and
nutrition. Within the health care system, these practitioners can
strengthen the components of (i) health education, (ii) drug
w distribution for national control programmes, (iii) motivation for
family welfare, and (vi) motivation for immunisation, control of
environment etc.
11.2
Long-term
11.2.1 Broad set up of Ministry:
The recommendations of the Bhore Committee that the Ministry
of Health should be under the charge of a separate Minister is being
followed and is currently in practice. However, the members of the
committee are of the opinion that the several activities linked with the
human health are presently undertaken by Ministry of Welfare,
Ministry of Human Resource Development, Ministry of Urban
Development, Ministry of Environment, Ministry of Rural
Development etc. The work of sanitation and environmental health
was earlier with the Ministry of Health but now it is being undertaken
by several ministries viz. Ministry of Environment and Forests,
Ministry of Rural Areas and Employment, Ministry of Urban Affairs
and Employment and Ministry of Chemicals. It has been further seen
that the inter-sectoral co-ordination which is very vital in successful
implementation of various programmes is not readily available
through a formalised mechanism resulting in poor achievements under
various programmes. Therefore, involving all the activities pertaining
to human health, creation of a new ministry such as Human Welfare
may require serious consideration. Alternatively a National Council of
227
PHSfinai.doc
Human Welfare be constituted under the chairmanship of Prime
Minister of India, and other members being Deputy Chairman,
Planning Commission, Ministers of concerned Ministries, eminent
medical and health professionals and representatives of professional
organisations and NGOs etc.
11.3
Funding
Appropriate budgetary provisions may have to be made in a
phased manner in order to implement the recommendations of the
committee during the 9th Plan and beyond.
228
PHSfmal.doc
ACTION PLAN
ACTION PLAN FOR STRENGTHENING OF PUBLIC HEALTH SYSTEM
Taking into account the existing resources and manpower
constraints, certain areas have been identified to strengthen the public
health system in the country. The same have been given in the Short
term recommendations of the committee. The committee also proposes
some action plans to implement the recommendations.
1.
A Task Force should be constituted to review the National Health
Policy and draft the revised National Health Policy for the
consideration of the government. This could be initiated during the
last year of the Sth Five Year Plan.
(MOH&FW)
2.
Establishment of capacity and capability at the Directorate General of
Health Services to undertake health impact assessment of major
developmental projects to guide the respective ministries accordingly.
This could be taken up during the IXth Plan.
(MOH&FW)
3.
Surveillance activities with regard to human health in and around
.critically polluted areas should be initiated. This could be a part of
overall health surveillance and support services and could be initiated
during the IXth Plan.
(MOH&FW/DGHS)
4.
India is a vast country. Uniform health care strategy will not be yield
satisfactory results for all areas. Search for the alternative strategies
needs to be continued on a long term basis to develop situation specific
strategies for such identified areas. States/UTs should strengthen
health system research through appropriate deployment of resources
specially earmarked for the same during the IXth Plan.
(State/UTs)
5.
All the states, municipalities and local health authorities should be
addressed to modify their existing public health laws in the pattern of
the Model Public Health Act revised in 1987 and circulated including
any modification the local situation may demand. The same should be
followed up meticulously so that during the next few years all over the
country uniform public health practice codes are available.
(NICD/DGHS)
6.
National Health Regulations need to be formulated and distributed to
all states, municipalities and panchayats. A Task Force may be
immediately established to draft the National Health Regulations in
the pattern of International Health Regulations.
(NICD/MOH&FW)
229
PHSfinal.doc
7.
To involve the Indian Systems of Medicine more appropriately within
the health care delivery system the existing Central Council of Health
& Family Welfare should be further broad and a Central Council of
Health, Family Welfare and Indian Systems of Medicine and
Homoeopathy may be formed.
(MOH&FW)
8.
An Apex Technical Advisory Body should be constituted to advise the
Ministry of Health & Family Welfare and the Directorate General of
Health Services in all major technical issues periodically and also to
review the major health programmes.
(MOH&FW/DGHS)
9.
Indian Medical and Health Services should be immediately
constituted. This has been a long pending demand of the medical
professionals and it has been recommended time and again and there
is an urgent need that this is considered immediately by the
government for its implementation.
(MOH&FW)
10.
M Immediate action needs to be taken to set the process of administrative
reorganisation of the Department of Health & Family Welfare and
Directorate General of Health Services in the light of the
recommendations made.
(MOH&FW/DGHS)
11(a) A Health Manpower Division should be established in the DGHS; a
National Institute of Health Manpower Development may be
established to provide appropriate institutional support mechanism to
this important activity. This could be initiated during the IXth Plan.
(MOH&FW/DGHS)
11(b) The Bajaj Committee Report on Health Manpower Planning,
Production and Management should be implemented without any
further delay.
(MOH&FW)
11(c) Positions requiring public health task should be filled by appropriately
trained/qualified public health professionals.
In this connection
Central Health Service needs to be appropriately restructured.
(MOH&FW)
12.
Four Regional Schools of Public Health should be set up in the pattern
of All India Institute of Hygiene and Public Health, Calcutta and
School of Tropical Medicine, Calcutta to train more public health
230
PHSfinal.doc
professionals to meet the growing demands of the health care delivery
services. This could be taken up during the IXth Plan.
(MOH&FW)
13.
The existing departments of Preventive & Social Medicine in identified
medical colleges should be strengthened and upgraded to take up the
additional responsibility of continuing education for health and also to
produce more public health professionals. This could also be taken up
during the IXth Plan.
(MOH&FW/DGHS)
14.
The committee suggest that the state/district national health
programme management focal points are posted for some time in the
Department of PSM in Medical Colleges so that the programme
managers get the benefit of updated academic & technical skills and
the students are benefitted from the practical experience of the
programme managers at the field level. Similarly the teachers of
preventive & social medicine be posted for some time as national
health programme management focal point at district/state level.
(MOH&FW/DGHS)
15.
• A Centre for Disease Control be immediately established in the pattern
of CDC, Atlanta and National Institute of Communicable Diseases
should be substantially strengthened in this direction.
(NICD/MOH&FW)
16.
The urban areas have very good tertiary facilities but primary health
care infrastructure is very poor. The same needs to be established
particularly to reach the under privileged, slums etc. The existing
health outposts/dispensaries should be linked to secondary care
centres and these in turn linked to tertiary care centres situated in the
defined geographic area.
(MOH&FW/DGHS)
17.
Reorganisation of the Directorate of Health Services should be
undertaken in the light of the recommendations made. Process could
be initiated immediately.
(MOH&FW)
18.
A strong epidemiological unit needs to be established at the district
level. The States which have not done so far should establish so under
the National Disease Surveillance Programme. This also could be
taken up during the IXth Plan.
(MOH&FW/ DGHS/ NICD)
231
PHSfinal.doc
Every States/UTs should establish a supervisory^hanisni at the sub
19.
district level. This could be taken up during h(^&FW/state/UTs)
One public health spec«li« should ^ylaVm^Xtive in
20.
XX — health progranunes and other related^services^^
Through the 73rd and 74th Cor^b
have given more administrative
21.
the health care
—:X“
ol sonre funds as one thne
grant to the panchayats.
(panning Commission/ MOH&FW)
Village Health Guide Scheme should be strengthened^and^re^itP ^0
22.
.and also the budgetary allocation f
p
(MOH&FW/Planning Commission)
o be initiated immediately
23(a). National Disease Surveillance Programme
TFisdrctbp^y—
with establishment <---- linkage mechanism involving the me. etc. Microbiology investigative
district public health laboratories
hlished at the district level.
(NICD/MOH&FW,
facilities be also estal-----
23(b). The coverage
valid data in the context of the entire conn y
(Ren
24.
up during the IXth Plan.
25.
(panning Commission/States/U is)
In consultation with
^XinisSy ^Health sho Jd
Xw*"-* °n lhe pilot bMiS XhSw/dc IS)
PHSfi'- ’I. doc
232
26.
Ministry of Urban Affairs and Employment should implement the
recommendations of the Bajaj Committee on Urban Solid Waste
Management.
(MOUA&E)
27.
Health being a multi ministerial responsibility a formal mechanism of
inter-sectoral co-operation and co-ordination needs to be established
involving all the concerned ministries.
(MOH&FW)
28.
Nutrition surveillance shall be in-built part of National Health
Surveillance and Support Services.
(MOH&FW/DGHS)
29.
The female multi-purpose workers are funded through the National
Family Welfare Programme and due to paucity of resources, the state
health authorities have not been able to fill up the positions of male
multi purpose health workers. This should receive high priority
through higher allocation of funds.
(MOH&FW/ State / UTs)
30.
•Involvement of NGOs is very important. They have been providing
very useful services to the people at large. More of their involvement
within the health care delivery system will improve the functioning of
the various programmes. Therefore, every effort should be taken to
involve the NGOs and to meet that higher allocation of funds are
necessary.
(State/UTs)
31.
The country has large number of practitioners of Indian System of
Medicine and Homoeopathy. They should be appropriately involved
within the health care delivery system to make it more effective.
(State/UTs)
233
PHSfinal.doc
STRENGTHENING OF PUBLIC HEALTH SYSTEM THROUGH
THE REMAINING PART OF THE EIGHTH PLAN AND NINTH PLAN
ACTION PLAN
Sr.
No.
Constitution of task force to review
1.
national health policy & draft a revised
national health policy
Preparatory
_____ phase
XXXXXXXXXXX
1st year
2nd year
3rd year
4th year
Sth year
xxxxx
2.
Establishment of Health impact
assessment capability in DGHS
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
3.
Suveillance of critically polluted areas
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
4.
Continuing search for alternative
strategy
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
5.
Uniform adaption of public health laws
xxxxxxxxxxx
xxxxx
XXXXX
XXXXX
xxxxx xxxxx
6.
Task Force on National Health
regulation
XXXXXXXXXXX
7.
Establishment of Joint Council of Health,
Family Welfare & ISM & Homeopathy
xxxxxxxxxxx
234
PHSfinal.doc
xxxxx
8.
Establishment Apex Technical Advisory
Body
9.
Constitution of Indian Medical & Health
Services
xxxxxxxxxxx
10.
Merger of the Department of Health &
Family Welfare Administrative
restructuring of DGHS and MOH&FW
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx xxxxx
xxxxx
Ila. Establishment of Health Manpower
planning capability and establishment of
National Institute of Health Manpower
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
11b. Implementation of Bajaj Committee
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
XXXXXXXXXXX
XXXXX
xxxxx
xxxxx
xxxxx xxxxx
Report on Health Manpower Planning,
Production and Management
11c. Creation of adequate number of public
health positions in the DGHS &
restructuring
12.
Opening four schools of public health
235
PHSfinal.doc
13.
Upgradation of existing Departments of
Preventive and Social Medicine in
identified Medical Colleges
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
14.
Re-organised functioning of the
Department of PSM in Medical Colleges
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
15.
Establishment of centre for disease
control
xxxxxxxxxxx
xxxxx
xxxxx
16.
Primary health care infrastructure in
urban areas
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
17.
Re-organisation of State Health Directors
XXXXXXXXXXX
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
18.
Establishment of District Epidemiology
Cell
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
19.
Establishment of supervisory mechanism
at the district level
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
20.
Availability of Additional Public Health
Speciality of the CHC level
xxxxxxxxxxx
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
Establishing health care delivery
component in Panchayat
XXXXXXXXXXX
xxxxx
xxxxx
xxxxx
xxxxx xxxxx
21.
«
236
PHSfinal.doc
22.
Village Health Guide
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
23a. Initiation of National disease
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
surveillance programme
23b. Enlarging the coverage & scope of model
registration
24.
Strengthening of I D Hospital
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
25.
Water Quality monitoring
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
26.
Urban Solid Waste Management
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
27.
Intersectoral co-operation mechanism
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
28.
Nutrition Suveillance
XXXXXXXXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
29.
Provision of funding of male MPW
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
30.
Involvement of NGO's
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
31.
Involvement of ISM & Homeopathy
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
XXXXXXXXXXX
237
PHSJinal.doc
ACKNOWLEDGEMENT
ACKNOWLEDGMENT
The committee records its deep appreciation to all its members who
have made very significant contributions in preparing this report.
Suggestions/inputs given by the Adviser (Health) and officials of the Health
& Family Welfare Division of the Planning Commission and National
Institute of Communicable Diseases in preparing the report are also gratefully
acknowledged.
Secretarial assistance offered by S/Shri H.L. Kanojia and Beeru Kumar
of National Institute of Communicable Diseases and assistance offered by Mr
Riazullah Khan of Planning Commission are acknowledged with thanks.
238
PHSfinal.doc
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Child Survival and Safe Motherhood Programme - India, Ministry of
Health & Family Welfare, July, 1991.
80
Malaria and its control. Directorate of National Malaria Eradication
Programme.
81
National Institute of Health & Family Welfare, National Malaria
Eradication Programme, National Health Programme Series 4,
reprinted May, 1990.
82
A critical review of the NMEP in India (Hinman Committee),
November,1960.
83
Special Committee of the Preparation for Entry of the NMEP into the
Maintenance phase (Chadha Committee), Ministry of Health,
November,1963.
84
Committee to recommended the staffing pattern of the PHC Complex
(Mukherjee Committee), Ministry of Health, 1966.
85
Special Committee constituted to review with working of the NMEP
and to recommend measures for improvement (Madhok Committee),
Ministry of Health, October,1969.
86
Evaluation in-depth of the NMEP of India, November,1970.
87
Committee to study in-depth all relevant aspects of NMEP (1974),
Ministry of Health & Family Welfare, January, 1974.
88
Consultative Committee of Experts to determine alternative strategies
under NMEP, Ministry of Health & Family Welfare, August,1974.
89
Ray, A.P. (1976) - Resurgence of Malaria after achieving eradication,
Swasthya Hind, Central Health Education Bureau, Vol.20 No.12, page
373.
90
Evaluation Report of the P falciparum Containment Programme under
NMEP of India - January/February, 1989.
244
Programme:
Country
PHSfinal.doc
91
National Leprosy Eradication Programme, NHP Series 6, National
Institute of Health & Family Welfare, 1990.
92
Agenda Notes of the Conference of Central Council of Health & Family
Welfare, October 11-13,1995.
93
National Tuberculosis Institute, Bangalore 1974 Bulletin WHO 51, 437487.
94
Raj Narain, Bulletin WHO, 29,1963, 641-664.
95
Pamra, S.P. 1973, Indian Journal of Tuberculosis, 20.
96
Review of National Tuberculosis Programme in the Country by Govt,
of India, 1992.
97
WHO Technical Report Series No.702, 4th Report of the WHO Expert
Committee on Lymphatic Filariasis, 1984.
98
Annual Review of National Filaria Control Programme 1991, NMEP,
Jndia.
99
Operational Constraints and their Feasible Solutions for efficient
functioning of National Filaria Control Programme (NFCP) Units in
the country - Report of National Workshop - 10-12 December, 1991,
NICD, Delhi.
100
Guinea Worm Eradication Programme in India - Operational Manual,
NICD, 1989.
101
Guinea Worm Eradication Programme in India - Report and
Recommendations, NICD, 1993.
102
National AIDS Control Programme in India - Country Scenario - An
update - September, 1994, NACO, Ministry of Health & F.W., Govt, of
India.
103
The Present Status of National Programme for Control of Blindness,
DGHS, 1993.
104
Proceedings of the Joint Meeting of the Central Council of Health &
Central Family Planning Council, 17-19 April, 1975.
105
National Programme for Control of Blindness - Guidelines for District
Blindness Control Society - Revised - August, 1995, DGHS, Minitry of
Health & F.W.
245
PHSfinal.doc
106
National Programme for Control of Blindness, Schemes for
Participation of Voluntary Organisations (Part I) 1995, DGHS, Ministry
of Health &F.W.
107
Proceedings of the 10th Conference of Central Council of Health &
Central Family Welfare Council, 9-11 July, 1984.
108
Working Group Report on Containment of Non-communicable
Diseases for the Sth Five Year Plan (1990-95).
109
Eighth Five Year Plan, Planning Commission.
110
Report of the High Power Committee, Urban Solid Waste Management
in India, Planning Commission, Government of India, 1995.
Ill
The Government of India Act 1935.
112
The Epidemic Diseases Act 1897.
246
PHSfinal.doc
ANNEXURES
Annex - 1
List of Papers submitted to Committee on Public Health System
1.
Field trial on village level surveillance of epidemic prone disease and
its evaluation - Dr. K K Datta.
2.
Control of Communicable Diseases in India - Dr. Jaiprakash Muliyil.
3.
Health information system [North Arcot District Health Information
System (NADHI)] - Dr. Jaiprakash Muliyil.
4.
Blue Print for a Nation-wide Disease Surveillance Programme - Dr.
Jaiprakash Muliyil.
5.
Renovation of organisational structure of Health Services - Dr. N.S.
Deodhar.
6.
Holistic and Community based approach for intensification of primary
health care and integration with environmental health services - Prof.
KJ. Nath.
7.
Community based water Quality Surveillance in Rural Areas - Prof.
KJ. Nath.
8.
Structural, Functional, Operational and Financial Profile of Indian
Health System (Strengths and Weakness) - Dr. Harcharan Singh.
9.
Proposal for A Feasibility Study to develop a sustainable model of
community based water quality surveillance in three districts of West
Bengal, Assam and Bihar with high endemicity of diarrhoeal diseases
and assessment of the epidemiological impact - Prof. KJ. Nath.
10.
A note on Non Communicable Diseases - Dr. Prema Ramachandran.
11.
A note on Primary Health Care infrastructure in India - Dr. Prema
Ramachandran.
12.
Environmental Health : A national plan of action to support primary
health care delivery system - Prof. KJ. Nath.
13.
Existing HM1S and its capability to provide upto date intelligence for
effective surveillance, prevention and remedial action - Dr. K.K. Datta.
14.
Draft protocols of surveillance of epidemic prone diseases through the
existing HMIS - Dr. K.K. Datta.
phsaiuiex.doc
/
Annex -1A
LIST OF THE MEMBERS OF THE EXPERT COMMITTEE
1.
2.
3.
4.
5.
6.
Prof. J S Bajaj, Member,
Planning Commission.
Chairman
Dr Jai Prakash Muliyil,
Depth of Community Medicine,
Christian Medical College, Vellore.
Member
Dr Harcharan Singh, Ex-Adviser (Health),
Planning Commission.
Member
Dr N S Deodhar, Ex-Officer on Special Duty,
MOH&FW, 134/1 /20, Baner Road,
Aundh, Pune.
Member
Dr K J Nath, Director,
All India Institute of Hygiene &
Public Health, Calcutta.
Member
Dr K K Datta, Director,
NICD, Delhi.
Member-Secretary
List of the officials who assisted the committee
1.
Dr. Prema Ramachandran,
Advisor (Health),
Planning Commission
2.
Dr. Dinesh Paul,
Deputy Advisor (Health),
Planning Commission
3.
Dr. A C Dhariwal,
Joint Director,
N.I.C.D., Delhi.
4.
Dr. S P Rao,
Chief Medical Officer,
N.I.C.D.,Delhi.
ii
phsannex.doc
ANNEX -12
SUMMARY REPORT
STATE:
MONTH AND YEAR :
MORBIDITY AND MORTALITY (CLINICAL DATA)
DURING THE MONTH
DISEASES
OPD
PHC/
CHC
GOVT.
HOSP.
PVT.
HOSP.
IPD
TOTAL
PHC/
CHC
GOVT.
HOSP.
PVT.
HOSP.
INSTT. DEATHS
TOTAL
PHC/C
HC
GOVT.
HOSP.
PVT.
HOSP.
TOTAL
1.
2.
3.
4.
5.
6.
7.
8.
Acute Diarrhoeal Diseases
Diphtheria
Acute Poliomylities
Neo Natal Tetanus
Tetanus (other than 4)
Whooping Cough
Measles
Acute R. I.
(Include
Pneumonia
and
Influenza)
9. Viral Hepatitis
10. Encephalitis
11. Meningitis
12. Rabies
13. Syphilis
14. Gonococcal Infection
15. Any Other Disease of Locimp.
16. All Other Diseases
li
phsannex.doc
ANNEX-13
COMMUNICABLE DISEASES
1.
2.
3.
4.
5.
6.
Name of the State/UT
Month/Year
Total Number of Existing Institutiona in State/UT
Total Number of reporting institutions
for the month in State/UT
Total Number of defaulting institutions
in the month of State/UT.
Reported Cases and Deaths due to Communicable Diseases.
Sr.
No.
Name of the Diseases
1.
Acute Diarrhoeal Diseases (Includeing Gastro Entiritis
and Cholera)
2.
Diptheria
3.
Acute Poliomyelitis
4.
Tetanus - Other than Neonatal
5.
Neonatal Tetanus
6.
Whooping Cough
7.
Measles
8.
Acute Respiratory Infection (Including Influenza and
excluding Pneumonis)
9.
Pneumonis
10.
Enteric Fever
11.
Viral Hepatitis
12.
Japanese Encephalitis
13.
Meningococcal Meningitis
14.
Rabies
15.
Syphillis
16.
Gonococcal infection
17.
Pulmonary Tuberculosis
18.
All other Diseases (Including communicable and Noncommunicable Diseases) treated in Institutions
excluding above mentioned diseases.
19.
Total
Patients
OPD
Treated
IPD
Deaths
(IPD
only)
lii
phsannex.doc
ANNEX-2
Some Important Recommendations taken in various meetings of
The Central Council of Health
SI.
No.
Year
Title of Meeting
Recommendations
1.
January,
1955
Third meeting of the
Central Council of
Health, Trivandrum
1 he Central Council of Health welcomes the
introduction of the National Water Supply and
Sanitation Programme and notes with great
satisfaction the rapid progress that has been
made already. The Council express the hope
that during the Second Five Year Plan this
programme will be expanded very considerably
and urges the State governments to strengthen
their Public Health Engineering Organisations
and take full advantage of the facilities for
training public health engineers and overseers
provided at the All India Institute of Hygiene
and Public Health, Calcutta.
The Council further recommends that the State
Public Health Engineering Organisations should
be placed under the administrative control of
the Ministers of Health.
I he Central Council of Health commends the
revised scheme for the training of such auxiliary
personnel as it will make it easier for the
practitioners of modern medicine to render
health services to the people for adoption with
such suitable modifications as the local
conditions may require. The Council further
recommends that the syllabus for such a course
should as far as possible be uniform throughout
the country.
The Council also recommends to the Union
Ministry of Health to consider the advisability
of establishing an All Indian Institute on the
lines of the Royal Sanitary Institute, London.
2.
January,
1959
Seventh Meeting of
the Central Council
of Health, Shillong
The Council further reiterates its earlier
recommendation that the Public Health
Engineering Departments in the States should
function as integral parts of the State Public
Health Departments.
iii
phsannex.doc
3.
October,
1960
Central Council of
Health to study and
report on the
patterns of statistical
units for Health
Departments.
The Government of India should establish a
National Health Survey Unit in the Directorate
General of Health Services as a part of the
Central Bureau of Statistics. Also this unit
should undertake on co-ordinated basis a
national health survey during the course of the
Third Plan in collaboration with the State
Health Departments.
A Bureau of Statistics should be established in
the office of the Director General of Health
Services under a qualified health statistician of
wide experience with the status and scale of
Assistant Director General of Health Services.
fhe Bureau of statistics of state health
directorate would be on a pattern similiar to
that of Bureau of statistics at the Centre with
the addition of a sub-unit for vital statistics.
Properly staffed statistical units should be
established in large municipalities and municipal
corporations. The State governments should
provide financial assistance to the local bodies
for the purpose.
4.
Nov.,
1963
Eleventh Meeting of
the Central Council
of Health, Madras
The plan provision for water supply and
sanitation should be treated as a committed
expenditure and the states authorised to go
ahead with advance planning.
Steps should be taken to set up regional water
supply and drainage boards in order to deal
with all rural and urban water supplies in the
area.
5.
April,
1963
Special meeting of
the Central Council
of Health, New Delhi
The committee has proposed that regional
organisations should be created and that the
staff provided to them should include two or
three experts in communicable diseases to relay
intelligence reports both to the centre and
within the state concerned.
As part of the suggested steps to be taken
towards expanding and improving infectious
disease hospital facilities, it has been proposed
that every municipality with a population of
50,000 should have a modern isolation hospital.
iv
phsanncx.doc
In respect of such large cities as Bombay,
Calcutta and Kanpur provision of several
isolation hospitals placed in different city zones
is advocated by this committee.
Important recommendations have been made
on the subject of providing public health
laboratories.
The view is welcomed that the duty of
coordinating the programmes and efforts of
several agencies likely to be involved in this
public health engineer Preferably, this officer’s
post should be a component of each district
health organisation.
6.
June,
1966
Thirteenth meeting
of the Central
Council of Health,
Bangalore
The Central Council of Health recommends
that necessary efforts to be made to intensify
measures in the Fourth Plan with adequate
provisions for control programmes for these
diseases. As for the control of cholera, all
gastro-intestinal cases be taken seriously and
investigation of such cases be undertaken
without delay with the help of local
laboratories. State or Central Epidemiological
Units and referral services such as available in
Calcutta Health Education be intensified as a
preventive
measure
alongwith
cholera
inoculations.
Regarding plague all vigilance be kept up
specially in respect of areas of small foci such
as Kolar, Salem, Chitoor and those in Uttar
Pradesh, and concentrated efforts be made to
eradicate these foci
With regard to goitre control, production of
iodised salt be increased so as to meet full
requirement of all endemic areas.
v
phsannex.doc
7.
October,
1967
Fourteenth Meeting
of the Central
Council of Health
Improvement of epidemic reporting in rural
areas. It was recommended that reporting of
outbreak of epidemic through the Panchayats
should be revitalised and that the staff of the
PHCs particularly the BHWs should also be
made responsible for reporting of epidemic
diseases. In the resolution passed at the Eighth
meeting of the Central Council of Health,
amongst other suggestion, the establishment or
strengthening of State Health Statistics Units
was recommended so as to streamline the
health of Health Intelligence in the Directorate
General of Health Services has also initiated
action on collection of information on
cases/deaths due to certain important
communicable disease.
The present system of reporting of epidemics
through the agency of the Panchayats need to
be improved and revitalised
The staff of the PHCs, particularly, the basic
health workers should also be made responsible
for reporting of outbreak of epidemic diseases
in their areas.
Self addressed and pre-paid cards of different
epidemic diseases be printed and supplied to
all workers at the periphery not only those of
health department but also to panchayat,
revenue departments and teachers of the
primary schools.
The medical officer of the PHC should co
ordinated the reporting system at the block
level and pass on the information to the State
Health authorities through the Health Officer of
the District.
vi
phsanncx.doc
With rapid industrialisations, air pollution when
left uncontrolled is likely to present a major
health hazard in urban community life. Air
pollution factors must be evaluated in planning
new developments and in improving the
environments of existing urban areas.
Industrial air pollution problems can usually be
minimised by properly locating the industries
and by establishing suitable air pollution
controls before the problem becomes acute.
Air pollution survey and control work are still
in their infancy in India. Some air pollution
survey work for certain Indian cities has been
initiated by the central Public Health
Engineering Research Institute and much work
is yet to be done.
It will be, therefore,
necessary to encourage air quality monitoring
programmes so as to establish the present
levels of concentrations of various pollutants
so as to assess also future increase in air
pollution with increase in air pollution with
increased industrialisation.
The major
corporations and cities should come forward to
establish air quality monitoring programmes, as
this will lead to better air pollution control and
cleaner air in our cities. The availability of such
data will pave the way for the formulation of
suitable legislation of control of air pollution in
this country.
8.
April, "
1974
Central Council of
Health and Central
Family Planning
Council, New Delhi.
The Joint meeting of the Central Council of
Health and Central Family Planning Council
recommeds that for effective support to
programmes for the control of communicable
diseases, proper and adequate laboratory
services need to be organised in every state.
That the Centre should assist in organising
training programmes for medical officer and
laboratory technicians for a period of three to
six months on request.
vii
phsannex.doc
9.
April,
1975
Central Council of
I leullh and Cenhal
Family Planning
('ouncil, New Delhi
Cholera endemic areas should continue to
receive high piioiily undei the National Watei
Supply and Sanitation Programmes for
expeditious provision of' safe di inking water
supplies and to achieve it, there should be
effective co-ordination between Public I lealth
Engineering Department, LSG Department and
Public Health Departments at State and District
levels.
The cholera endemic States should further
intensify the control efforts in the endemic
areas and expeditiously set-up the cholera
Combat Teams fully utilizing available Central
Assistance of equipment and materials.
The State and Central Governments should
continue to undertake anticipatory preventive
measures before the cholera season including
chlorination of water supplies, prophylactic
inoculation of selected vulnerable population
groups, stockpiling of disinfectant, rehydration
fluids, etc.
10.
April,
1976
Central Council of
Health and Central
Family Planning
Council, New Delhi.
The underground drainage schemes approved
for the towns/cities be expeditiously completed
and more such schemes for towns in filaria
endemic states/Districts be taken up on priority
basis.
11.
January,
1978
Fourth Joint
Conference of
Central Council of
Health and Central
Family Planning
Council, New Delhi.
AU out efforts should be made to enlist
people’s co-operation in the implementation of
the programme. Unless there is full co
operation from the people the huge investment
made by the Govenment will not yield adequate
results
Panchayats, Youth Organisations,
Women’s Organisations, School teachers,
student and medical practioners should also be
involved.
For drinking purposes, water should be free
from disease producing micro-organisms.
Purification pf water is a highly effective health
measures and any pollution in water can create
many diseases, such as typhoid, dysentery,
gastroenteritis, jaundice, etc.
viii
phsannex.ch
There is thus a mounting public health concern
over chemical constituents of water. Further,
there is an utmost need to develop a technology
to maintain safe bacteriological quality and to
remove many of the potential dangerous
chemicals from drinking water. The council,
therefore, resolves that this responsibility can
best be discharged under the aegis and
guidance of the Ministry of Health and Family
Welfare.
The council further resolved that as sewage is
subject to
rapid
decomposition with
accompanying foul odours and contains
organisms causing disease and adequate
sewage system is one of the highest importance
of health of the community, the most effective
agency to deal with subject of sewage is also
Ministry of Health and Family Welfare.
The Council also resolved that the subjects of
noise and environmental pollution should also
be made the responsiblity of the Ministry of
Health and Family Welfare as many health
problems and/or diseases directly emanate from
these factors and the Ministry of Health and
Family Welfare should, therefore, be more
concerned about it.
12.
April,
1979
Sixth Joint
Conference of
Central Council of
Health and Central
Family Welfare
Council, New Delhi.
Recalling Resolution No.9 of the Fifth Joint
Conference of the two Central Councils held on
October, 1978; expressing concern at the
meagre budgetary allocation for the health
sector and calling for measures to imporve the
situation.
The Government of all State/UTs and of the
Centre, earmark adequate funds for this
purpose, taking into account all available
relevant/local/appropriate technology and the
planning Commission also helps’in this task.
Maximum co-ordination be achieved between
this task and health promotional efforts,
preferably by integration of these efforts, under
a single department and, at the central level,
preferably, under the Ministry of Health and
Family Welfare
ix
phsannex.doc
13.
October,
1978
Fifth Joint
Conference of
Central Council of
Health and Central
Family Welfare
Council, New Delhi.
Each State should be encouraged to develop its
own Cancer registry.
The Central Government should take
appropraite steps for ensuring easy availability
of anti-cancer drugs in the country.
The Central Government as well as the State
Governments should provide all possible
assistance in the screening and development of
indigenous anti-cancer drug in the country.
The Central Government should continue with
the assistance for establishment of Cobalt
detection aspects in all the States.
An extensive mass media programme should be
chalked out in the cancer control scheme for
public education
and awareness in the
preventive and early detection aspects of the
disease.
The Central Government should organise a <
training programmes for all categories of the
health professionals involved in cancer control.
Every district hospital and hospitals attached to
the medical colleges should have a properly
equipped cell for early cancer detection.
14.
1981
Central Council of
Health and Central
Family Welfare
Council, New Delhi.
(In paragraph 16, the reference to Municipal
and Local authorities should read as follows:)
Municipal and Local authorities need to be
supported with resources so as to make
effective contribution to preventive and other
public health services.
The scope for
contribution from the community should also
be mentioned.
x
phsaimex.doc
Further, it should be clarified that sanitary-cumepidemiological stations will tackle the
environmental health problems and participate
in the control of epidemics and eradication of
disease. It should be clearly brough out that
while in rural areas, there has been progress in
promotion of integrated, preventive, promotive
and curative services. The services under the
urban areas remain curative and should be
transformed into integrated,
preventive,
promotive and curative services.
The Joint meeting of the Central Council for
Health and Central Family Welfare Council
took not of the reference made by the Hon’ble
Prime Minister, in her inaugural Address to the
large number of practitioners of Indian System
of Medicine and Homeopathy, who provide
curative service to our people, and to her
valuable suggestion that "the knowledge and
talent of the villages Vaids, and Hakims must
be upgraded"
Following up on this
suggestion, the Joint Council would like the
government of India to design a programme of
treatment for the registered practitioners of
Indian Systems of Medicine and Homeopathy
which would enhance their knowledge of their
respective systems, in the promotive,
preventive and curative aspects.
15.
August^
1982
Eighth Joint
Conference of
Central Council of
Health and Central
Family Welfare
Council, New Delhi
The desirability of setting up a Technical
Committee on Epidemiological and Health
Information Services be considered by the
Central Government. This Committee should
include representatives from Central, State
Health
Departments,
I.C.M.R.,
Central
Statistical Organisation, Planning Commission,
Registrar General of India etc. and prepare an
Action Plan for consideration at the next
meeting of the Council.
Suitable legislative measures may be considered
to enforce reporting of common epidemic
diseases; statutory reporting of epidemic
diseases under the municipal/panchayat or
other public health Acts should be made
obligatory on all the medical practitioners and
institutions.
xi
phsannex.doc
Noting that the resolution adopted by the
Fourth and Fifth Joint Conference in January
and October, 1978, respectively and the Sixth
Joint Conference in April, 1979, in regard to
provision of potable drinking water, sewerage
and drainage system and the commitment made
at the National level for ensuring supply of safe
drinking water to the population living in
problem villages as urgently as possible and
that non-availability of safe drinking water
leads to spread of many water-borne diseases in
the community, specially those in the rural
areas.
Reiterates that the responsibility for ensuring
safe drinking water and sanitation to the
population at the National level should rest
with the Ministry of Health and Family Welfare
and in the states the Public Health Engineering
Department concerned with water supply and
sanitation should be also under the charge of
the Ministry for Health.
I
16
July,
1983
17.
•Iuly,
1984
Ninth Joint
Conference of
Central Council of
Health and Central
family Welfare
Council, New Delhi
Noting that Communicable diseases account for
a sizable portion of national morbidity and
mortality and the importance that has been
given to their control in the National
Programmes, the Council recommend that
greater emphasis be given to the teaching of the
National diseases control programmes by
adequately developing the existing departments
of Community Medicines in the medical
colleges.
The Tenth Joint
Conference of
Central Council of
Health and Central
Family Welfare
Council, New Delhi
Disease surveillance should be an integral part
of primary health care so that, an episode is
detected at an early date for initiating prompt
control measures to
interrupt further
transmission. This will involve creating an
epidemiological cell at National, State and
District level with facility for data collection,
processing, analysis, epidemic forecasting and
feed back.
xii
phsannex.doc
The National programme for control of
diarrhoeal diseases should be implemented
vigorously. Emphasis has to be given on the
training of medical officers and paramedicals in
oral rehyderation technology and education of
the community on personal hygiene and use of
oral rehyderation solution, with the objective of
reducing mortality due to diarrhoeal diseases.
Provision of safe drinking water supply
adequate sanitation and sewerage disposal
arrangements are very important features of the
Central Programme.
A National plan of action to control Viral
Hepatitis should be initiated with the help of
the regional Viral Hepatitis Surveillance
centres These centres should be strengthened
for undertaking epidemiological investigation
of outbreaks in the region.
A comprehensive rabies control programme
should be taken up, which will include,
elimination of stray dogs and immunization of
pet licensed dogs.
18.
Sept.,
1986
The Twelfth Joint
Conference of
Central Council of
Health and Central
Family Welfare
Council, New Delhi
Taking into consideration that effective
Management Information System is essential
for planning, reviewing, monitoring and
evaluating the various ongoing. Health
programmes. It is also necessary for assessing
Medical & Health manpower requirement, the
Council resolved.
That Government of India should take early
decision regarding the Integrated Health
Information System, which should be
introduced in all the districts as early as
possible. The state Governments are requested
to extend full support for the implementation of
the system.
That proper orientation and training should be
imparted to. the concerned staff at all levels for
the effective implementation of Health
Information System.
xiii
plisannex.doc
Control of sudden out-break of epidemic in
various parts of the country always causes
problems to the State administration and the
Government of India, as funds earmarked for
other activities are required to be diverted for
epidemic control activities. It is therefore,
recommended that both the Union Government
and the State Government may keep certain
funds specially earmarked for epidemic control
activities, which could be operated upon
whenever any such contingency arises.
19.
February
1988
20.
February
1989
The First Conference
of Central Council of
Health and Family
Welfare, New Delhi
The Second
Conference of
Central Council of
Health and Family
Welfare, New Delhi
1.
State which have not yet set up the
Cancer Control Boards may do this
before the end of the current financial
year.
2.
States which do not have Regional
Centres for Cancer may identify nodal
institutions where there is scope for
developing them into future Regional
Centres in the Eighth Plan.
3.
All recognised Medical Colleges should
have Cobalt units for Cancer.
4.
District Headquarters should have Pap
Smear facilities by the end of this plan.
The health authorities of States, UTs should
strengthen their surveillance and monitoring
systems for the early detection of water-borne
diseases to initiate early control measures;
particularly against cholera and gastro-enteritis.
The health functionaries at grass root level
should be alerted to report any unusual
incidence of diseases at PHC level for initiating
immediate epidemiological investigations.
Medical College hospitals and other major
hospitals should undertake surveillance and
inter-act with State/UTs Health departments.
In case of infective hepatitis no preventive
vaccine is available. However, gama-globulin
to high risk groups such as pregnant women
should be administered.
xiv
phsanncx.doc
ANNEX-3
ORGANISATIONAL CHART
MINISTRY OF HEALTH AND FAMILY WELFARE
DEPARTMENT OF HEALTH
SECRETARY (HEALTH)
—
-
ADDL. SECRETARY (HEALTH)
ADDL. SECRETARY (PB)
NACO
* JS (FA)
DS (IF)
JS (SC)
DIR. (PH)
JS (SB)
JS (KC)
DIR (Hi)
DIR (ME)
NLEP
TB
PCB
NCD
Through DGHS
DIR (PH)
| US (MS)
DIR. (ADMN.)
DS (CHS)
CCA
DIR. (OL)
* Report to the Secretary (H) directly
YV
phannex.doc
ORGANISATIONAL CHART
MINISTRY OF HEALTH AND FAMILY WELFARE
DEPARTMENT OF FAMILY WELFARE
SECRETARY (FAMILY WELFARE)
JS (S)
CHIEF
DIRECTOR (E)
DIRECTOR (M)
DIRECTOR (M)
A.C. (A.P.)
D.S. (A.P.)
—j DIRECTOR (NGO)
JS (A M.) MISSION
DIRECOTR
D.S. (I.E.C.)
DIRECTOR (NGO)
D. C. (P. A.)
* D.D.G. (R.H.S.)
D. C. (T. 0.)
DIRECTOR (MCH)
DIRECTOR (P)
D.C. (MCH)
*
D.D.G. (R.H.S.)
The Officer belongs to Dte.G.H.S
phannex.doc
N E. <
ORGANISATIONAL CHART
MINISTRY OF HEALTH AND FAMILY WELFARE
DEPARTMENT OF INDIAN SYSTEM OF MEDICINE AND HOMEOPATHY
SECRETARY
JOINT SECRETARY
ADV. (A & S)
ADV. (HOMEO)
DS (ISM)
XVII
phannex.doc
ORGANISATIONAL CHART
DIRECTORATE GENERAL OF HEALTH SERVICES
DIRECTOR GENERAL
ADDL. DIRECTOR GENERAL (NB)
DDG (P)
ADDL. DDG
(NCD)
DDC Cell
DDA (M)
DDG (P)
DDG (M)
\DDG (L)
DDG(L)
DDG
(LME)
DDG (RH)
CHIEF
ARCHITECT
DDG (M)
DDA(PH-I) -
NURs.
.ADV.
ADG(TB) -
.ADG
(LEP)
DDA(M) -
ADDL. DDG
(RH)
SR.ARCH. I -
ADDG (M) ■ -
SR. ARCH.II -
DDA(M) ■-
SR.ARCH.III -J
ADG (ME) • -
ADG
DDA
(PH-II)
DDA
(HOSP.)
DDA(D) -J
MONITORING
&.
EVALUATION
(LEP. PROG.)
ADG (HA)
DC (I)
DDA (D)
DDC (I) NDDDC I
A. COMM
(TRG)
OSDCTRGl
DDC (I) NDDDA(M)
_
-J
DDA (D)
DADG (CH)
DDC (I) NDDAC (1 R.G)
DDC (I)
DY.NURs
ADVISER
DDG(MENTAL
HEALTH)
_______ I
CONSULTANT
OPTH
I
DDG (M)
ADDL. DG (PCR)
I
DIRECTOR
(CGHS)
ADDL. D.G.
(STORE)
I
DDG (P)
I_______
DIRECTOR (CHEB)
CMO (RN)
DDA(PH-II)
I
DDG (M)
DDG (P)
DDG (P)
|DD(R)
DD (S.H.E.)
I
I
ADG (STORES)
DDA (STORES)
I_____
I
ADG-II (STORES)
DDA'C (STORES)
.ADV.
(NUT.)
DADG
(EPI)
DD (TRG.)
DDA (CHEB)
DADG STORES
Win
phannex.doc
ANNEX - 7
Si X1SS JY T N. V S. (x_3 _N Jl^.x. 9^
Name of
Date of
Allo. Ayur. Homoe. Unani
city
starting
Apr-1979
Ahmedabad
5*
1
1
Mar-1969
7
Allahabad
1
1
Bangalore
Feb-1976
10
2
1
Bombay
Nov-1963
28
2
4
Calcutta®
Aug-1972
17
1
2
Delhi_____
July-1954
86
13
13
4
14**
Feb-1976
Hyderabad
2
2
2
Jabalpur
Oct-1991
~T~
Jaipur_____ July-1978
5
2
2
Kanpur
July-1972
9
2
2
Lucknow
Mar-1979
6
1
2
2
Mar-1975
14
Madras
2
2
July-1971
6
Meerut
2
2
10**
Nagpur
Oct-1973
2
2
5**
Patna@
Nov-1976
2
2
Pune______ July 1978
7
i
2
Bhubneswar Aug-1988
1#
j Total
233
31
34
8
Including two Sub-Dispensaries. (Figure as on 31.3.1993)
♦*
Including one Sub-Dispensaries. (Figure as on 31.3.1992)
#
Exclusively for A.G.’s Employee only.
a
Figure as on 31.3.1993
Source : Annual Report 1994-95. Min. of Health & Family Welfare
Siddha
Yoga
Total
2
7
9
13
34
21
120
20
3
7
12
9
17
8
13
7
10
1
311
1
1
2
Poly
clinics
2
2
2
2
2
2
CGHS Dental
labs.
Units
1
1
1
1
2
2
17
4
3
31
1
2
1
2
2
T
2
2
1
1
1
1
2
1
18
69
i
No. of
families
7144
28842
47966
96473
96581
305666
68299
9701
21193
38906
20827
55339
14231
31004
20220
32581
No. of
Beneficiaries
33196
163411
200292
376001
410569
1388680
299791
38074
96653
197690
107382
231171
91293
142054
100453
119722
17
894973
3996432
2
2
2
2
2
2
2
2
\
XIX
phannex.doc
Annex - 8
AVERAGE ANNUAL REQUIREMENT OF DIFFERENT VACCINES
A: Capacities
Million Doses
DPT
OPV
BCG
TT
Measles
DT
CRI, Kasauli
23.00
30.00
25.00
PH, Coonoor
16.50
11.00
11.00
12.00
6.00
BCG, Gundi
35.00
HBPCL, Bombay
5.00
37.50
SVI, Patwadnagar
2.00
SH, Pune
114.00
150.00
BE, Hyderabad
24.00
24.00
Radicura Pharma Bibcol
"70.00
40.00
120.00
Total Capacity
182.50
157.50
35.00
229.00
70.00
82.00
B: Requirement
132.24
155.30
50.60
119.00
50.00
35.00
Source:
Annual Report 1994-95, Min. of Health & Family Welfare
XX
phanncx.doc
ANNEX 9
ORGANISATION CHART OF THE PLANNING COMMISSION (GOVT. OF INDIA) AS ON 09.01.1995
CHAIRMAN
AND PRIME MINISTER OF INDIA
P.V. NARASIMHA RAO
DEPUTY CHAIRMAN
PRANAB MUKHERJEE
MEMBER
GA. RAMAKRISHNA
MEMBER
DR. JAVANT PATIL
MEMBER
MISS MIRA SETH
MEMBER
DR(MRS) CHTTRA NAIK
MEMBER SECRETARY
DR A K SENGLTTA
MLNTSTER
OF STATE
MEMBER
DR S Z QASIM
MEMBER
PROF J S BAJAJ
1 EDUCATION (GENERAL OTHER
THAN HIGHER EDUCATION)
2. SOCLA.L WELFARE
3. SC’ST
MEMBER SECRETARY
WORKs
PARLIAMENT
WORK
1 SCIENCE
2. OCEAN
DEVELOPMENT
3 ENVIRONMENT
AND FOREST
1. HEALTH & F.W.
2. NUTRITION
3. YOUTH &
SPORTS
41 ENERGY (INCLUDING
ATOMIC ENERGY &
COAL.
2 TRANSPORT
3. PROJECT APPRAISAL
4. PROGRAMME
EVALUATION
1 AGRICULTURE
2 RURAL
DEVELOPMENT
3 PANCHAYATI RAJ
4 CO-OPERATION
5. IRRIGATION
1 VOL ACTION CELL
2. CULTURE
3 VILLAGE &. SMALL
INDUSTRIES
4. LABOUR
EMPLOYMENT
MANPOWER
5. TOURISM
6. WOMAN &. CHILD
DEVELOPMENT
1 DEVELOPMENT POLICY
2. INTERNATIONAL
ECONOMICS
3 FINANCE RESOUTvCES
4 INDUSTRY & MINERALS
5 PERSPECTIVE PLANNING
6 PLAN COORDINATION
" ADMINISTRATION
MEMBER
DRD SWAMLNADHAN
+
1. EDUCATION (HIGHER &.
TECHNICAL)
2 HOUSING
3 URBAN DEVELOPMENT
4. WATER SUPPLY
ADMSER
(HEALTH)
DY. ADMSER
(HEALTH)
DY CHAIRMAN WORKs
1 ADM. OF THE PLG. COMMISSION
2 MULTI LEVEL PLANNING
3 PLAN COORDINATION
4 STATE PLANS
5 PERSPECTIVE PLANNING
6 HILL AREA &. DESERT DEVELOPMENT
" FINANCIAL RESOURCES
8. NATIONAL INFORMATICS CENTRE
9. INDUSTRY & MINERALS
10 TRIBAL SUB PLAN
11.CIVIL SUPPLIES & PUB. DIS. SYS
12.STAT1STICS & SURVEYS
13.INF. &. BROAD, COMMUNICATIONS
14 TWENTV'POINT PROG MONITORING
15. DATA BANK
16. MINIMUM NEEDS PROG.
C ALL OTHER SUB NOT ALLOCATED TO MINISTER
OF STATE & MEMBERS
18.SPACE
XXI
phsannex.doc
ANNEX 10-A
ANDHRA PRADESH
DIRECTORA I E OF HEALTH ORGANISATIONAL CHART
DIRECTORATE LEVEL :
DIRECTOR OF HEALTH
ADDL. DM&HS
(Admn.I)
(I)
ADDL. DM&HS
(Pig. & Evi)
(2)
ADDL. DM&HS
(C. D)
(3)
ADDL. DM&HS
(Malaria)
(4)
SHTO
ADDL. DM&HS
(Leprosy)
(5)
1.
Addl. Director of Mcdica &
Health Services (Admn.)
I
2.
3.
Dy. DM&HS (Admn.III)
Dy. DM&HS (Stores)
A.P.O.
2.
Addl. Director of Medical &
Health Services (Planning and
Evaluation)
1.
2.
3.
4.
Gazetted Assistant (Planning)
Executive Engineer
Assistant Engineer
Draftsman
3.
Addl. Director of Medical &
Health Services (Communicable
Diseases)
1.
2.
3.
4.
5.
Dy.DM&HS (Epidemics)
Dy.DM&HS (Vital Statistics)
Dy.DM&HS (Health Education)
Dy.DM&HS (School Healtli/Scrviccs and Nutrition)
Dy.DM&HS (RHS)
(6)
6. Dy.DM&HS (I.H.)
7. Dy.DM&HS (STD)
8. Dy.DM&HS (NPCB)
9. Dy.DM&HS (TB & BCG)
4.
Addl. Director of Medical &
Health Services (Malaria)
1. Dy.DM&HS (CML)
2. Dy.DM&HS (Entomology)
3. Zonal Officers - 6
Visakhapalnam, Rajahmundry, Guntur, Cuddapah,
Warangal and Hyderabad.
4. Dy. Director of Medical and Health Services (Filaria)
5.
Addl. Director of Medical &
Health Services (Lcptosy)
1. Special Officer
2. Accounts Officer
6.
Slate Health Transport Authority
1
Dy. S.H T O.
2. A.T.Os... (3)
3. S.E.Os... (21)
XXII
plianncx2
ANNEX 10-B
ARUNACHAL PRADESH
ORGANISATIONAL CHART OF HEALTH AND MEDICAL DEPARTMENT
(Arunachal Pradesh)
A. State Level
(i) Secretariat
SECRETARY (Health & Family Welfare)
Dy. SECRETARY (Health & Family Welfare)
MINISTRIAl STAFF
(ii) DIREC FORA I E
D 11 S
JdLs (Estt.)
DDHS (GA)
DDHS(PH)
Food Inspector
Epidemiologist
I
DDHS (PH)
JDHS (P&D)
JDHS(F.W)
CMO GET
" Supdt. T.B. Hospital
PO (EPCB)
DDHS (NMEP)
|
A.O.
DDHS (T.B.) H E O
Drug Inspector
DDHS (LEP.)
I
I
DDHS(T&S) Admit. Onicer
T O. Officer
xxiii
phannex2
ANNEX 10-C
GOA
ADMINISTRATIVE SET-UP OF DIRECTORATE OF HEALTH SERVICES
HEALTH SECRETARY
DIRECTOR OF HEALTH SERVICES
1.
Medical Store
Deptt.
2.
P&D Section,
D.H.S.
Accounts
Section, D.H.S.
3.
1.
Administration
Section, Dte. General
of Health
Dy. Director (Medical)
Dy. Director
(Public Health)
Director
(Admn.)
Jt. Director
(Accounts)
1.
1.
Urban Health Centres
1.
Hospicio Hospital,
Margao
2.
Primary Health Centre
2.
T.B. Hospital, Margao
3.
Sub-Centres
3.
Leprosy Hospital,
Macazana
Asilo Hospital, Sanquelim
4.
Family Welfare
Programme
5. T.B. Control
Programme
6. Malaria Eradication
Programme
7. Filaria Eradication
Programme
8. Leprosy Eradication
Programme
9. STD Control
Programme
10. AIDS Control
Programme
11. Control of Blindness
12. Japanese Encephalitis
13. NIDI) Control
Programme
14. School of Health
Progra mme
15. Nutrition Cell
16. Epidemiological Cell
17. Health Education
Bureau
18. Environmental and
Pollution Cell
XXIV
4.
5.
6.
7.
Dy. l)iie<u'H(Dental)
Cottage Hospital,
Sanquelim
Cottage Hospital,
Chicalim
Paediatric Ward, Sielim
Maternity Home & Child
Welfare Centre, Shiroda
9. Rural Medical
Dispensaries
10. Public Health Laboratory
8.
11. Institute of Nursing
Education
12. Health Intelligence
Bureau
13. Indian System of
Medicine
14. I.C.D.S.
phannexZ
Dents
Clinics
ANNEX 10-D
GUJARAT
ORGANISATIONAL CHART OF COM MISSION ER
DIRECTORATE OF HEATLH SERVICES (GUJARAT)
COMMISSIONER
1 ADDL DIRECTOR (F W )
_____ I_______
Jt.
t
irector (CSSM)
Jt. Director (D&E)
Dy . Director (CSSM)
Demographer
S.N.S. (H)
Stat.
Dy. Director
ADPH (FW)
(IEC)
- AVO
- EPO
- EDITOR
- SOCIAL SCIENTIST
A.O
CI-2
fficer
Account Officer
C 1-2
Regioinal Dy. Directors Health & Medical Services
(Six- Regions)
C D.HO. }
DFWMO } In 19 Districts
D Immo } Zill Parishads
(Contd
)
XXV
phannex2
GUJARAT
COMMISSIONER (GUJARAT)
2. ADDL. DIRECTOR (HEALTH)
Jt. Din ctor (Malaria)
Dy. Director
(Epidemic)
EN^O
(Moiogist)
Malaria
Officer
A.D.P.H.
(T.B)
A.D P H.
(Epidemics)
Officer 6n Special duty
(Vigl.)
Epidemiologist
I
MO
(C.C.T)
I
MO
(S.T.D.)
(Contd
1
)
xxvi
phannex2
GUJARAT
COMMISSIONER (GUJARAT)
2. ADDL. DIRECTOR (HEALTH)
Jt. director
Jt. Director
Dy. Director
(NLEP)
Dy. Director
(Rural & I lealth)
ZLOs/DLOs
ADPH
ADPH
FNO
A.C. Officer
Account
Officer
(Salary)
r
CPO
(EST)
AO.
(Court Cell)
ADPH
(HEB)
Teih. Officer
(Trg.)
Tech.'Officer
(SH)
Tech J Officer
Account Officer
(Budget)
Ant. Engi. Cum
Transport
Officer
(Media)
Works Manager
(Naroda Workshop)
(Contd
)
xxvii
pliannex2
GUJARAT
COMMISSIONER (GUJARAT)
_______I_______
J
Director
Addl. Director
Addl. Director
(Medical)
AD
Nursing
(Medical)
(Training)
SIHFW
Ahmedabad
(Med. Education)
Dist. & Sub Dist.
Hospitals
Sub. Dist. Hosp.
Dy. Director
(Statistics)
Principal/Officer
I/C Trg. Centre
Rajkot
Bavia
Padara
Aliabada
Sachin
I
Regional Dy. Dirs. (G)
Gandhi Nagar
Ahemdabad
Surat
Vadodra
Rajkot
Bhavnagar
A D (Nur.)
Med. Edu.
r
Dy. Director
(IEC)
Addl. Director
(Statistics)
Addl. Director
(AIDS)
1
Dean and Supdts.
- Medical College
- Teaching College (H)
- Nursing College (I)
- Dental College
T“
Jt. Director
(Bloof Safety)
I ~
Drug. Insp.
CI - 2
(Bloof Safety)
xxviii
plumtiexl
HARYANA
ORGANISATION CHART OF HEALTH DEPARTMENT, HARYANA, CHANDIGARH
DIRECTOR GENERAL OF HEALTH SERVICES
DIRECTOR
Senior Scale
DHS (F.W.)
DHS (Lab.)
DIS (Malaria)
Jt. Director (Admn. >
Statue Drug
CfflrroUer
1. Dy. Director (ESI)
ESI Wing
l.Dy. Director (MCH)
MCH & Immunisation
programme inculuding
cold chain work
2. Dy. Director (Nut.)
Policy Medical Branch
2. Dy. Director (FW)
Family Planning
Programme
3. Dy. Director (M&E)
Assistant Director (V.S.)
Statistical Wing
3. Dy. Director (MM)
i. Mass Media Programme
ii. Mass Media Establishment
iii. Ofst Press______________
4. Assistant Director (Demo i
4. Dy. Director (Nur.)
Assistant Director (Nur.)
i. Establishment of
Nursmg personnel
iL Tranung of Nursing
5. Assistant Director
(Dental)
Dental Establishment
DHS (Health)
ANNEX 10-E
1. Dy. Director (HE)
L H.E.Work
it Food Adulteration/
School Health/
Mental Health
iii. Medical Mannual
2. Dy. Director (T.B.)
T.B. Programme
3. Dy. Director (Optholmology)
Blindness/STD/AIDS/
Disaster Programme.
4. Technical Officer (ME)
Training Programme/MPW
Scheme / Health Education.
1. Dy. Director (Planning)
Planning and
Construction Work.
1. Dy. Director (Malaria)
Malaria Programme
1. Administration Branch
dealing with HQs
Establishment including
Class IV/non medical
Gazetted Offocers
1. Dy. State
Dntgs.
2. Dy. Director (TB)
TB Programme MSD
Branch-Purchase of
Medicine/Stores/Fumiture/
Equipment and correspondence
regarding telephones and
Indent form & stationary._____
3. Transport Officer
Transport Branch Purchase/
Repair of Vehicles.
2. Assistant Director
(Entomology)
Entomology Work
2. E-II Branch, dealing with
establishment of Class I &
II Doctors including
com plaint/d isciplinary
cases of Class I Doctors.
2.
3. Technical Officer
(Malaria)
Technical W ork under
Malaria Programme
4. Establishment Officer
Establishment of
Malria Staff. Biologist
& Other Technical
Staff.
3. E-FV. Branch, dealing with
complaints and
disi plinary/Exjuridication
Journeys of Doctors.
4. Record Branch
3. A-SJ3.C. - II
5. Dnrgs
Bnuches
4. Budget Officer.
E-III, Branch, dealing with
establishment of Pharamsists
Radiographers and Class IV
Field Staff.
5. Administrative Officer (F.W.)
Establishment of AMM (FW')
5. Budget Officer.
BIIl/Budget Branch.
5. Type Branch
6. Account Officer (FW)
Account & Budget of Family
Planning Programme.______
7. Assistant Director (ICDS)
ICDS Progranune
6. Accounts Officer. (General)
Accounts. Audit and Pension
Branch______________________
7. Administrative Officer (General)
L E-l, Branch, dealing with clerical
establishment of Field Staff/
Drivers/ Mechanics.
it PH Branch, dealing with Clerical
Establishment of Field Staff/
Drivers/Mechanics._________
8. Senor Medical Officer (Leprosy).
6. General Administration.
4. A_S^).C. - III
i&n
XXIX
phanne\2
ANNEX 10-F
HIMACHAL PRADESH
HEALTH AND FAMILY WELFARE ORGANISATIONAL CHART
INISTER
HEALTH
SECRETARY (IIEALTII & F.W.)
Addl. SECRE TA RY (HEALTH & F.W.)
Under Secretary
D. IS.
Dy. Secretary
Dy. Director (Admn.)
Jt.Director (F.W.)
ADHS
Principal
HFWTC (VIR) EPI
r~
Director
ADHS
(FW)
ADHS
AD.
(RHS) (Demography)
Aclmnistrativc
Officer
—J
a.dIg.
ADHS
Store
AI5(N)
f
Dy. Director (Dental)
Dy.Director (P H.)
D. J. (IEC) Distt. I’roj.
AD (St.)
DI IS
D. [). Mis.
ADHS (Malaria)
Officer
Statistician
Statistician
M S.
Z.LO.
ZMOS.
(T.B. Santo.)
XXX
plutnnc\2
KEJ&
LA
ORGANISATIONAL CHART OF THE HEALTH & FAMILY WELFARE DIRECTORATE. KERALA
Director of Health Services
(Family Welfare)
Director of Health Services
(Medical & Public Health )
I
ADDL.DHS
(VIG)
I
ADDL.DHS
(F.W.)
I
SR A.O.
T
I
ADDLDHS
(MED)
FO
I
ADDL.DHS
(PLG)
'
I
ADDLDHS
(SH)
□
L
Dy DHS
(MCH)
ADHS
(BN-)
SMEMO
CCO
Audit
Officer
SHTO
AA
PLG.
AA
GEN.
Demographer
I
ADDLDHS
(PH)
1
I
Eh DHS
(TB)
D) DHS
(M&F)
___ L_
ADHS
(HE)
Dj DHS
(TEA)
ADH
(LEP)
.ADHS
(OPTH.)
ADH
(PM&R)
ZMO
.AD
(MS)
State
IUD MO
AD
(NS)
AD
ETO
AD
Filaria
Stat
Officer
TO
GC
SO
GMS
Editor
SO
(FAS’)
I
ELO
Dy DHS
(Dental)
Social
Scientist
RO
(ORT)
ANNEX 10-G
MRO
CS
TA
CS
(LEP)
CHEO
\
AA
FAV
S.V.O.
AO
TO
SHEC
ss
TA
(FOOD)
TA
(LEGAL)
XXXI
phannex2
ANNEX 10-H
MADHYA PRADESH
ORGANISATIONAL CHART OF HEALTH DIRECTORATE
MADHYA PRADESH
DIRECTOR
PUBLIC HEALTH & F.W.
DIRECTOR
MEDICAL SERVICES'
I
DIRECTOR
EPIDEMIC CON.
ADDL. DIRECTOR
IPP - VI
-►
JT. DIRECTOR (F.W.)
♦
A.O. (F.W.)
DY. DIRECTOR (F.W.)
-►
> JT. DIRECTOR (C.S.S.M.)
DY. DIRECTOR
(C.S.S.M.)
JT. DIRECTOR
(IPP - VI)
DY. DIRECTOR (IPP-VI)
JOINT DIRECTOR
(EPIDEMIC)
E.E. (IPP-VI)
*
*
DY. DIRECTOR
* (PLANNING EV.AL. CMOH.)
JT. DIRECTOR
(ESTABLISHMENT)
-►
JT. DIRECTOR
(FINANCE)
>
JT. DIRECTOR
(TRANSPORT)
*
JT. DIRECTOR
(I.E.C.)
DY. DIRECTOR
*
STATISTICS OFFICER
(2>
STATE LEPROSY
OFFICER
>
DISTRICT LEPROSY
OFFICER
DY. DIRECTOR
> COLD CHAIN OFFICER
-►
PROGRAMME OFFICER
(BLINDNESS)
STATISTICAL OFFICER
>
JT. DIRECTOR
(M.AL.ARIA)
JT. DIRECTOR
(DEVELOPMENT)
* (DEMOGRAPHY)
FINANCE OFFICER
PROGRAMME OFFICER
(T.B.)
DISTRICT MSARIA
OFFICER
-►
* STATISTICS OFFICER
>
AO.
PROGRAMME OFFICER
(JEEVAN JYOTI)
t—► PROGRAMME OFFICER
(SCHOOL HEALTH)
FINANCE OFFICER
ASSISTANT ENGINEER
DY. DIRECTOR (NTS)
XXX11
M.L.L.O.
phannex2
MAHARASHTRA
ANNEX 10-1
DIRECTORATE OF HEALTH SERVICES
MAHARASHTRA
DL
F"
I
JT.DHS
TOR
1
T
JT.DHS
JT.DHS
D.d! Plan
Principal
D.D.Goitre
PHI
CAO
Principal
HFWTSs(4)
aiT
AD
TSP
MCI!
CAO
JT.DHS (HEALTH)
I
D.
D.D.
T.B.
D.D.
Nursing C.D.
AD
Nursing
JT.DHS (Leprosy)
D.D.
M.
AD
HI
JT.DHS (Malaria)
I
DD
DD
DD
HIVS
SPHL EPD
I
I
DD
Transport
ST. CAO CCA AD
AD AD
SO
HIVS HE TR
DD
HQ.
AD
HQ.
AD
LEP.
AD
Filaria
Entomologist
(Contd
1CAO
)
xxxiii
phannex2
MAHARASHTRA
MAHARASHTRA
DlREuCIOR
ADDL. DIRECTOR
F.W. MCH.-SN
JT. DBS, F.W
DD, F W.
DD, F.W.
AD, FW.
AD, F W
DD, F.W.
Demorgapher
DD, EPI
AD
(MCH)
DD, F W
AD CAO
(FW)
XXXIV
phannexl
ANNEX 10-.I
MANIPUR
ORGANISATION CHART OF MANIPUR
DIRECTOR OF HEALTH SERVICES
ADDITIONAL DIRECTOR
(Public Health)
Staff Programme Officer
Dy. Director
(Public Health)
N M.E.P.
N.L.E.P.
NPCP
Immunisation
Epidemics
Dy. Director
(Health Education)
I lealth Education
School Health
Goitre Control &
Nutrition
Media Coverage
Joint Director
(Public Health)
Dy. Director
(Statutory Law)
Medical Council
Pharmacy Council
Private Clinic/
Nursing Homes
Registration Act
Prevention of Food
Adultration
Act Drugs Control
Administration
State Aids Officer
Dy. Director (Aids)
Drug-De-Addiction,
Programme,
AIDS.
Blood Bank
Administration
(Contd
)
XXXV
phanncx2
MANIPUR
DIRECTOR OF HEALTH SERVICES
ADDITIONAL DIRECTOR
(Medical Care)
Joint Director
Dy. Director
(Transport & Health Equipment)
S.H.T.O.
(Instruments, Equipment
Maintenance & Repairing)
Accident & Emergency
Disaster Management.
Joint Director (Dental)
Organisation & Management of
Dental Service.
Dy. Director (Hospital)
J.N. Hospital,
Distt. Hospital,
State Medical Board,
Medico-Legal Services,
Medical Records,
Mental Health Prgrammes
Dy Director (Stores)
Materials
Management
U N.I C E F./W.H O.
Assistance
(Contd
XXXVI
)
phannexZ
MANIPUR
DIRECTOR OF HEALTH SERVICES
Additional Director
(Manpower Development/Medical Education)
Joint Director
(Manpower Development/Medical Education)
I
Dy. Director (MO)
Gazetted Establishment,
Parliament and Assembly
Questions.
I
” ~
Dy. Director (Admn.)
Grade Ill (Para Medical)
Establishment
Employees Welfare.
Dy. Director
(Medical Education)
Training of MDBS,
BDS, B Pharma.,
P.G. in Service.
Training of Doctors
&. Para Medicals,
R.II.C. Affairs,
Workshop/Seminar/
Meetings. Library.
(Contd
M.O i/e
I.S.M.
ISM
Nature Care
Homeopathy
)
xxxvii
phannex2
MANIPUR
DIRECTOR OF HEALTH SERVICES
Additional Director
(Planning
Finance)
Joint Director
(Planning & Finance)
Dy. Director (Pig.)
Hospital Planning
Minimum Needs
Programme.
20-Point Programme
Central Council of
Health &F.W.
Graduating/CHCS,
PHC, & PHC.
Administrative Ofllcer
Asstt. Supdt. (Admn.)
Asstt. Supdt. (Accounts)
Personal Administration
Public Relations
Establishment of Grade III
(Non Technical) &
Garde IV Staff etc.
Dy. Director (VS)
Civil Registration,
Vital Statistics,
Health Intelligence,
Annual Administrative
Reports
Governor’s Report,
Quarterly Bulletins.
Nursing Supdt.
1. Dy. Nursing Supdt.
(Hosp. Nursing)
2. Dy. Nursing Supdt.
(Community Nursing,
3. Dy. Nursing Supdt.
(Nursing Educatior'
(Contd
)
xxxviii
phanncx2
ANNEX 10-K
MIZORAM
ORGANISATIONAL CHAR I OE HEALTH & I .W. (Mizoram)
Director of Health Services
JDHS (MS)
DGI S (G)
JDHS (General)
DDHS (FW)
SLO
ADHS (EPI)
S.M.O.
JDHS (Planning)
n
DDHS(M)
DDHS (N)
ADHS
(Nursing)
D.l.
F.A.O.
A.E.
Entomologist
H.E.O.
Asstt. Nursing
Supdt.
DDHS (AIDS)
DDHS (CMS)
Asstt. DHS(AIDS)
DDHS (ADM)
Office Supdt.
xxxix
phiiiiiiexZ
ANNEX 10-L
PUNJAB
ADMINISTRATIVE SET-UP (PUNJAB)
DIRECTOR (Health] & Family Welfare)
I
I
I______
JL Director (F.W.)
Dy. Dir
(T.B.)
1.
W ireless System
I
3.
Pariwar Kalyan
Bhawan
Store Purchase
Matters Regarding
Head 2210 - Med.
Offset
Press
National
T.B. Control
Programme
| Asstt Dir.
i (MCH)
State Cold chain
Officer
I 1. MCH
' 2. EPl
!—
I
ZLO
.National Control
Leprosy Programme
I
Cold Chain
System &
Logistic
Management
(Vaccine)
W orld Bank Project
Activity He will be
assisted by OSD of the
rank of Asstt Dir.
3.
Director (TD)
Dy. Director (BB)
Goiter Control
Programme
Rabies
Blood Bank
Services
VD& AIDS
Control
Programme
2.
Sanitation
Problems of the
Directors
OSD
i G.P.F.
I
1
Asstt Dir. (FW)
Asstt. Dir. (IUD)
Asstt Dir. (HF)
Ad. Officer (FW)
F.W.
Innsport FW(Op.)
Health Education
Bureau (Editor)
Logistic Managements
Financial Matters
Pertaining to Head
2211-FW will be
operationalised
1.
2.
Dy. Dir (FW)
Programme 2
1.
Addl. Director
(World Bank)
Addl. Director
(MCH)
Addl. Director
(F.W.)
I
Addl. Director
(Finance & Accounts)
Addl. Director (F.D.)
Enforcement of Drugs Act
I
Jt Director (FD)
De Addication
1.
2.
He will deals with
financial and Accounts
Mauers including Audit
Paras
De-Addication
Programme
Mental Health
Supersision of
Follow up action
on tour notes
Control of
Blindness
Enforecement of
Food Act.
Prinicipla
FPTRC Kharar
(Jt Director)
I
I
I
I
I
I
Jt Director
(Admn)
Dy. Director
(Medical)
Dy. Director
(Planning)
Jt. Director
(Evaluaiton)
Dy. Dir.
(Malaria)
Dy. Dir.
(AIDS)
Jt Dir.
(Dental)
E.L Branch
C.C. Branch
Weeding of
old records
Record
Branch
Courtcases
P.M.H. Branch
Reimbursment
Meetings
Conferences and
Tours
Medical Branch
I
«.
xl
2.
3.
R.H.S.
Buildings
Planning
Follow up
Plan Schemes
Dy. Director
(Statistical)
Dy. Dir. I
(Nursing) |
phannex2
*
ANNEX 10-M
SIKKIM
ADMINISTRATIVE SET-UP DIRECTORATE OF HEALTH & FAV, (SIKKIM)
DIRECTOR (HEALTH SERVICES)
ADDL. DIRECTOR HEALTH SERVICES
_________ I___________
JOINT DIRECTOR
F.W. CUM STATE
T.B. OFFICER
1.
2.
3.
4.
Adm. OTicer. F.W.
Store Oiiicer, F.W.
cum Motor
Vehicle
Asstt. Director
(Nursing i
Asstt. Engineer
(South ec West)
JT. DIRECTOR
COMMUNICABLE
DISEASES
JOINT DIRECTOR
I.C.D.S. &
NUTRITION &
M.C.H.
1.
I
2.
3.
4.
5.
6.
Dy. Director
(Malaria)
Epidemiologists
cum Programme
Officer, NLEP.
Epidemiologist - II
Sr. Stores Officer
(CSM) (CMS)
Stores Officer
(CMS).
Asstt. Engrn
(North & East)
A.E. (Meeh.)
2.
3.
JOINT SECRETARY
(ADMN.)
Dy. Director
(I.C.D.S.)
Nutrition Officer
Asstt. Nutrition
Officer
JOINT SECRETARY
HEALTH
EDUCATION
1.
2.
SR. FOOD
INSPECTOR
(SOUTH & WEST)
School Health
Officer
Health Education
Officer
SR. FOOD
INSPECTOR
(EAST & NORTH)
SR. A.O.
STAT. OFFICER
CUM LITIGATION
OFFICER
j_________
A.O.
DRUG INSPECTOR
Xli
phannex2
TRIPURA
ANNEX 10-N
ADMINISTRATIVE SET UP UNDER HEALTH & FAMILY WELFARE DEPARTMENT
DIRECTOR OF HEALTH SERVICES
I
______ I
Medical
« linical Side)
|
Suptd. (C.B.)
(Adnin. Side)
Med. Suphl. (ICII)
I/C Medical Suptd.
((.'anccr & Eye)
_____ I_____
I
IK I) (Med.)
IK D (Ortho.)
IK D(Suig.)
IK D(Phych.)
I/C (ENT)
1/C (Skin)
1/C (Dental)
1
(CHiiIcmI Side) (IPD)
Dy. Med. Supdt.
MO l/( (Stoic)
Adnin. (llllccr
Med. Record
Officer, O.S.
R.M.O., Matron,
Ward Master.
(Para clinical side)
M.O. (Anacst)
M.O. (Patho)
M.(). (Blood Bnak)
Programme Officer
('ontrol of Blindness
Dy.Mcd. Suptd.
---- 1
HP.
(( lliilcnl Side)
EyeOPD(M&l)
Cancer OPD(M&E)
Eye ward (MA I )
Cancer Ward (MAE)
Cobalt Unit
I
M.C. (Store)
I
Adnin. Officer
I
O.S.
l/( |>). Suphl.
(Adnin. Side)
D.D.C.
('.S.
Met ron
Wardmaster
I
I
I
I
I
Male OPD and ARV
Female OPD
Dental OPD
( hildren OPD
Pediatric
Gynac. OPD
MCI!
I
(Pam Clinical Units)
Blood Bank
Post Mortem Unit
Jt.DIIS (Adnin.)
I
Jt.DIIS (PH)
.It. DIES (Plan)
I
Dy. D.II.S.
Dy.DIIS (Goitre)
I
AD11 (PH)
Biologist (NMEP)
MO
MPS (FW)
Dy.DIIS
(1 AV. & M.( .11.)
Z.L.M.04^
ADH (PH)
CMI/MI/MPS
(Clinical Side)
MCI I Officer
CCO
(Adnin.)
I
D.D.O.
I
I
RE/HE/ASO
OS.
Modified (.'ontrol Unit
(West)
Leprosy Central Unit
(South)
Leprosy Control Unit
(North)
I
SEI
Urban Leprosy (.'ontrol
(ULC)
I
I
I
Obrih-i li h s A Gymie
Pedlaliid M I P
(.'omimlcablc disease
centre
Gen. Ener.
R.S.
OPI)
I
SEI
UL(
SIH
(Contd
)
xlii
phannex2
TRIPURA
Dy. Drug Controller
Dy. DBS (Store)
VC Kabiraj
Prhichipal RPI~1
E.-.orcement wing
It ecting Officer
(Drugs)
State Homeopath
Testing Wing
I
Vice Principal
(Clinical Side)
M.O. (Homco)
State Drugs
Testing Lab.
~~ I
State Pharmacy
Council
State T.B. Officer
Sr.Chcmist
(Drugs)
I
Clinical Side
Admn. Side
I
D.T.
I
M.O. (West)
I
I
D.D.O.
J
-T
Chief
1 Analyst
S.A.
Nursing
Council
Rado
Lab. Tech.
ADHS (MP)
(Male & Trg.)
o.s.
I
Acctt.
]___
T.O.
(Adnin. Side)
D.D.O.
r~
M.O
Kabiraj
(Ayur.)
BCG Tech.
Control of
Blindness
State Programme
Officer AIDS
Asstt. Dir. (V.S.)
Stat. Officer
State Cancer
Control Officer
(Conical side)
9W Chemist
(Admn. Side)
D.D.O.
chemist
Accounts
~~r
C.H.O.
D.I.O.
A.S.O.
Sample
VC Distt. Hospital
DFWO
D.H.O.
S.D.M.O.
—1
Joi lector
MO.VC
PH/RH
Sub-centre
xliii
phannexl
ANNEX 10-0
ORGANISATIONAL CHART OF THE DIRECTOR^! HEALT H □ER /IcES,
DME SECRETARY
D.H.S. SECRETARY
STATE LEVEL
Jt D.H.S.
(Admn.)
Jt. D.H.S.
(PH & CD)
I
Dir. (CCL)
DDHS
(LEP.)
Supdt
(Past Inst)
I
I
CMO
(CMUHO)
DDHS
(EC, NC & EC)
1
J_ L
DDHS
(MAL)
DDHS
(ICDS)
I
t
I
DDHS
(N)
DDHS
(AA& V)
1
I
DDHS
(Admn.)
SHTO
DDHS
(TMERT)
DDHS
(C&S)
Dir
(SBHI)
Regnl. Dir.
(OPTK)
Zonal
Officer
Supdt
(Vood. Lab.)
I
I
I ADHS I | ADHS I I ADHS I
(MPW)
| (TB) | (MENTAL
| DADHS
(TB)
I
I
I
Principal
(M.C.)
Addl. D.H.S.
(Admn.)
I
—
Director
(S.T.M.)
Director
(1PGME & R)
1 I D,R-
ADHS
|
(T)
|
j
—
-------n
‘
] I ADHS I I ADHS I
(BB) j
I (ADMN) j | (CD)
j
j
j
I
i___
I ADHS I I ADHS I I STATS. I I -ADHS I
[ (MEET) | | (DENT.) | |________ | | (VS) |
| DADHS I I DADHS I
DADHS
(N)
DADHS I
(LEP) |
i
I ADHS I
| (P&E) |
(E&S)J | (A) I
EDITOR
(SH & HE)
Principal
(Coll, of Nursing)
SHEO
ADHS
(P)
ADHS
(P&I)
DDHS
(MIES)
DDHS
(TVS')
n_
I
I
ADHS
(P&D)
ADHS
(TRG.)
1----DADHS
(VS)
Jt DHS
(MIES)
Jt DHS
Dv.DHS
(IPP-IV)
Jt DHS
(SMEIO)
DDHS
(P&D)
Addl. DHS
(AIDS)
Addl. DHS
(IPP-IV)
Addl. DHS
(FW)
I-- ---
1____
I
ADHS
(MCH)
ADHS
(NU)
ADHS
(EPI)
STATS.
PRINC.
(HFVVTC)
DADHS
(MCH)
xliv
phannex2
ANNEX 10-P
ANDAMAN AND NICOBAR ISLANDS
ORGANISATIONAL CHART OF THE HEALTH & F.W. DIRECTORATE
(Andaman & Nicobar Islands)
Director of Health Services
Dy.Dir.
(Health)
Dy.Dir.
(Mai.)
Dy.Dir.
(Medical)
Account Officer
Dy.Dir.
(Lep.)
State
T.B.
Officer
State
F.W.
Officer
Research Officer
CMO
(Stores)
Asstt. Dir. Admn.
ORGANISATIONAL CHART OF SBHI
C.M.O. - 1/C (STATE TB OFFICER)
r
Statistical
Investigator
(Statistics)
r
Computer
High Grade
I
Lower Grade
Peon
xlv
phannex2
UkJC J* ,
ORGANISATIONAL CHART OF DIRECTORATE OF HEATLH SERVICES (DELHI)
DIRECTOR HEALTH SERVICES
Med.Supdt.
Nursing Home
Dy. Director
Health
Services
C.M.O.
Mobile Disp.
Dy.Director
School Health
Services
Med. Supdt
S.G.M. Hosp.
Additional
Director
C.M.O. (Pig.)
(Hosp. Cell)
M.O. Incharge
(Hospital Cell)
Dy. Director
(Pig. & Stat)
I
Research
Officer
Dy. Director
Mobile Health
Scheme
Research Officer
(State Health Intelligence Bureau)
Principal
N.H.M.C.
& Hosp.
Med. Supdt
Dr.N.C. Joshi*
Memorial Hosp.
Med. Supdt
R.T.R.M.
Med.Supdt.
L.B.S. Hosp.
Med.Supdt
B.J.R.M. Hosp.
Jt Director
Admn.
Account
Officer
Admn.
Officer
C.M.O.
(Sale &
Purchase)
Supdt Admn.
Zone
C.M.O.
Stat. Officer
(Pig. Stat)
C.M.O.
North Zone
C.M.O.
East Zone
C.M.O.
West Zone
South Central Zone
Research Officer
Admn. Officer
(34 Dlspy.)
Admn. Officer
(34 Dispy.)
Admn. Officer
(41 Dispy.)
Admn. Officer
(33 Dispy.)
ORGANISATIONAL CHART OF STATE HEALTH INTELLIGENCE BUREAU CUM-RESEARCH AND ANALYSIS CELL
DIRECTOR OF HEALTH SERVICES
Dy.DIRECTOR (Health)
Dy.DIRECTOR (State)
Research Officer
Statistical Assistant
(D
(D
Statistical Investigator
(1)
Typist
(1)
Peon
(D
xlvi
phanncx2
ANNEX 10-R
PONDICHERRY
ORGANISATION CHART OF THE DEPARTMENT OF HEALTH AND F.W. SERVICES,
PONDICHERRY.
DIRECTOR OF HEALTH AND FAMILY WELFARE SERVICES
Officer on
I Special Duty
ZJZ
Dy. Director
(Public Health)
Pondicherry
Dy. Director
(FW & MCI!)
Dy. Director
(ESI)
Dy. Director
(HED)
Medical
Superitendent
Dy. Director
(UIP)
Pondicherry
Cholera
Control
Stu nt I
Ik ith
PH
Pondicherry
ESI
Hospitals
Dy. Director
(UIP)
Karaikal
ESI
Dispensaries
PH
Pondicherry
PH
Pondicherry
PH
Pondicherry
Institute of
Health Sciences
CHCs,
PHCs &
SIICs
i
Family Welfare
Centres
CIIC«
PUCs
Post Partuni
Programmes
Maternity and Child
Health Services
SIICs
ISM
Senior
Public
Analyst
Senior
Accounts
Officer
A
r Director
r (UIP)
dfc^Mahe
Dy. Director
(UIP)
Yanam
T.B. Control
Officer
Food and
Drugs Admn.
AIDS
&
STD
Stores
Supdt.
Drugs
Inspector
(Hqs)
Mental
Health
Scheme
Mobile Eye
Unit
I
Mobile
Dental Unit
Nutrition
Goitre
Control
Programme
I
Asstt. Director
Chief of Government
Pharmacy
T
Uaria
I
Malaria
Leprosy
Nutrition
Hospital
Equipment
Workshop
Manufacturiing
Unit
xlvii
phannex'2
*
Statistical
Ofllcer
*
ANNEX
B DISTRICT LEVEL
D M S.
(11 Nos. Districts)
DFWO
DIO
Supdt.Distt. Hospital (11)
D.Mal.
Homeo Dispensai?
C. Sub-Divisional Level
D. Block Level
CHS.
P.N.C. with or without
Homeo Dispensary
Dispensary (Homeo)
E. Field Level
S.C.
s.c.
T
S.C.
s.c.
MPW (Male)
F. Village Level
Dispensary (Ayur.)
MPW (Female)
Linkage of Institution
with Communities
I
I
Medics
D.H.V.
xlviii
phannex2
I
<»
ANNEX 11-C
WEST BENGAL
DISTRICT LEVEL
i
CMOH
SupUt
(Distt. Hospital)
I
Dy.CMOH
Dy.COMOH
Supdt.
(State Genl/
SD Hospital)
Dy.CMOH (HI)/
Dy.CMOH (IV)
ACOMH
(Sadar SD)
DIHS
ACOMH
(Outlying)
DSI
SO
ACOMH
(PH&FW)
DPHND
ACOMH
(Med&
Admn.)
DDEMO
BMOH
MO (PHC)
r
B|SI
SWO
LAB.Asstt.
Computor
BPI N
S.I.^ M.I
PH
HS (M)
HS (F)
HA M)
HA M)
HGS & TDS
I)
2
ANNEX 11-B
HIMACHAL PRADESH
HEALTH MINISTER
SECRETARY (Health & F.W.)
D.H.S.
C.MO.
J.O.H.
I.P.C.
P.O.
D.T.B.
Officer
U.F.W.C.
M.C.H.
Centre
D.L.O.
D.M.O.
S.M.'O.
MO’s
Hospital
J
Block Medical Officer
MO’
C.H.C.
M.O.P.H.C.
M.O C.D.S.
H.A. (M)
S.C.
S.C.
M.P.W. (M)
S.C.
R.E.W.C.
H.A. (F)
S.C.
S.C.
S.C.
r
F.H.W.
S.C.
M.P.W. (M)
T.B.A.
S.C.
E.H.W.
H.G.
xlix
phannex2
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