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LIBRARY
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Compendium
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ECOMMENDATIONS
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VARIOUS COMMITTEES
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IEALTH DEVELOPMENT
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1943-1975
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bureau
of HEALTH
health INTELLIGENCE
intelligence
f.DIRBoRATE
GENERAL OF HEALTH SERVICES
1 f'MInT^ ' C ^t,Nt:KAL OF HEALTH SERVICES
INp OF HEALTH AND FAMILY PLANNING
' -H G°V^ENT of INDIA
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CONTENTS
Page
Item
S.No.
—PyEfACE
vii
-t OVERVIEW ON MAJOR RECOMMENDATIONS
ix
1
.* Health-Survey and Development Committee (Bbore Committee)— 1946
H09
1
’SuinnP-ry of the Report...................................................
•
(a) Tje state of the Public Health in British India
i
3
(b) Causes of the low level of Health in IndiaV ' .
!
4
(c) Inadequate of Health Persor nel
5
• . .(d) Recommendations................................................................
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1. Modern trends in the organisation of a National Health
Services
.
6
.2. The Health Programmes
7
7
8
3. The Long Term Programme
4. The Three Millions Plan
5. The Primary Unit
10
......
10
6. The Secondary Unit
7. Tae District Headquarter Organisation
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8. The Province wise Health Organisation
9. Hospital Provisions
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.
.
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13
17
.
20
12. The Nutrition of the People
27
.
.
.
16. Health Services for School Children
39
.
14. Physical Education
<15. Health Services for Mothers & Children
•
tt — iTV<pace
■ (Vlllj X1WA. "VI UJ
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•
•
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a
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,
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(ix) Filariasis
(x) Guinea Worm Disease
. (xi) Cancer .
.
•'
•
•
•
Xxii) Mental Diseases and Mental Deficiency
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•
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31
'
.
.17. OccupationalHialthincluding IndustrialHealth
(i) Malaria
(>i)TB
(iii) Smallpox
(iv) Cholera
(v) Plague
(vi) Leprosy
(vii) V.D.
.
•
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10
18
i
32
34
36
• 18. Health Services for the more important Diseases
7
.
4 I. Organisation & Administration
13. Health Education
T
.
.
• 10. Dental Services
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•
...
41-
<1
43
46
48
50
52
54
56
56
57
37
58
t
S.No.
Item
Paqb
19. Environment Hygiene
60
(i) Town & Village Planning
(ii) Housing, Rural & Urban • ” '
(iii) Water Supply
61
63
66
....
20. Quarantine
68
21. Vital Statistics
■ .
.
.
(22) Professional Education
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*
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72
74 ’
"(i) Medical Education
(ii) Dent a] Education
(iii) Pharmaceutical Education
(iv) Educa tion of P. H. Personnel
(v) The Trainingof Nurses, Midwivesand Dais
(vi) Medical Research \>
.
\ *
(vii) Alllhdia Medicallnstitute
(viii) Health Organisation Delhi Province
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70
‘23. Drugs & Medicalrequisite
24. ISM V**.
88
.
89
Dcn.'a,: Arsing and Pha,ma.
25‘
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26. Employment of Demobiliied Ptrsonncl
of-the-.Military *
Health Services
27. The Establishment of a C
Committee of Standard for Medical
Institutes & Equipment
29. The Population Problem
•
30. The Alcohol in Relation to Health
31. The Institute of Medical Library Services
32. The Financial Implications of the Programme
!
Summary of Recommendations
94
95
100
102
104
113
2. Internationa] Collaboration
i
94
P,annin8 Committee-(Mudaliar Committee)—
^1961 SUrYCy
1. ConstitutionalProvision
1
93
F
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113-169
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90
P?rS°nI Wh° MVC rCOahcd <he age of .
28’
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77
77
78
79
8T
84
87 ’
I.
3. General
.
4. Medical Care
. .
. ■
113
. 113
11J
•
•
•
115
5. Public Health
(i) Water Supply & Sanitation
(ii) Maternal & Child Health
(iii) School Health
(iv) Nutrition
.
. "
(v) Mental Health
(vi) Housing
(vii) Vita] Statistics
(viii) Health Education
.
ii
i
122
122
124
125
126
127
...128
128
129
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No.
Item
Pagi
(ix) Model Public Health
(x) Physica J Education
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129
129
6..Communicable Diseases
129
(i) Malaria
(ii) Filafia
.
(iii) Tuberculosis .
(iv) Leprosy
(v) Smallpox
(vi) Cholera
(vii) Trachoma
(viii)V. D.
.*
(ix) Plague
(x) Virus Disease
131
131
132
133
134
135
135
135
136
136
@Professional£ducation v.
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138
0} Undergraduate
(ii) Licentiat Course .
(iii) Po<t-graduatcEducation.
(iv) Dental Education
(v) Other Para-medical.
(vi) M-dica| Research .
138
145
145
149
152
152
8. Population Problem
156
9. Drug & Medical Supplies
157
10. Legislation V-
160
11. ISM
163
f
.
‘2. -X l.nin strativc Organisation
164
III. Committee appointed to review Staffing Pattern and Financial
Committee1)"*1" Fafn',y P,annin8 Programme-1966 (Mukharjee
. 173—212
IT
(a) Section I—Introduction .
173
'(b) Section II—Organisation
177
1. Str mg'h'ning of State Headquarter Organisation
179
2. Strengthening of the District F. P. Bureau
183
.
3. Urban F. P. Planning Centre
.
.
.
4: Rural R p. Centre (CD Block)
(c) Section III—Resource Position
.
(d) Section IV—Finance
(e) Section V—Role of Voluntary Agencies
(f) Section VI—Training .
....
.(g) Annexures .... —7------- - —
186
186
189
196
.198
201
(i) State p.imily Planning Bureau (Staff proposed)—Annexure
(ii) Diurict F irally Planning Bureau—Annexure ‘D’
(iii) Rural Family Planning Organisation (in C. D Block)
Annexure‘E’
. - .
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204
206
208
isis
S. No.
Item
Page
'^(iv)' Recommendations made by the’ workshop for training of
Family Planning pen onr el held in New Delhi firm Sthto
12th March, 1966—Aniftrxure‘F’
.
208
i
IV. Committee on Multi-purpose Worker under Health and Family
Planning—1973 (Shri Kartar Singh Committee) . .
,
, 215—258
1. Introduction .
.
2. Existing facilities . ••
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215
221'
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3. Finding of the Committee
",
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4. Jobfunction of the Multipurpose Workers
5. Job functions of the Supervisors
6. Integrationatdifferent levels .
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226
231
235
241 .
.
7. Problemsto be faced
....
8. Mobile Units
.
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245
252
253
.
9. Summary of recommendations
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1. Introduction
.
.
261
2. Health Services for India—a tentative frame work
4. Health Servicesand personnel in the community
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5. From the Communityto the Primary Health Centre
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6. The referral Services Complex
,
•
.
7. The Establishment of the Medical and Health Edvcat.or Com
mission
•
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•
•
•
•
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8. Summaryofrecommendalions
T
263
....
3. Major programme for immediate action
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V. R eport of (he Croup on Medical Fdccaticn and Support Manpower—
( Srivastava Committee report)—1975
261—299
.....
9. Appendices .
27929 r
295
k
!
s
268
269
274
279
(a) Recommendations of various confcrenccs/Committrcj ard
papers/memoranda received from various individuais.asjociationsetc.considered by the Group—Appendix III
295
(b) Training and functions of Health Assistants—Apr* rdixIII
297
VI. Report of the Study Group on Medical Care Services (Shri Jain
Committee)
.
.
.^03—320
Summary ofrecommendations
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3Q3
(1) Orgajii<ation of Medical Facilities
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,
305
(3) Out patient department and emergency services
305
306
(2) Primary Health Centre
(4) Special Hospitals
.
(a.) Tuberculosis .
' (b) Mental--------- T
(c) Maternity
.
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. . ;
...
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307
307
"308 ‘
308
iv
S .No.
Page
Item
309
(d) Paediatric
.
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(e) Cancer
«•••••
(f) Ophthalmic .««•••*
(g) Treatment for Leprosy cases .
(h) Infectious Diseases
•
.
•
•
(i) D-ntalTreatment
.
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•
---------- q C^nval^scint Hornesand Reha.bilitations Centres
309
309
309310
310
310
(5) Integrations of Medical a nd Health Services V
•
310
(T) stiffilng Bittern and requirement of equipments
•
311
. 311
(7) Laboratory and Diagnostic Services
313
(8) Ancillary Services
(9) Sanitation & Security arrangements Public Relaticns rrd
Health Education
«
•
(10) Augmentation of-resources
(11) F. P. Programme in hospitals
>
•
317
•
318
319-
.
ANNEXURES
. 323—338
VTI. Constitution and terms of reference of Committee
I Constitution of Health Survey and DevelCfmrr.t Cttrmittee‘ Pres j communique da ted 18-tC-l 943-Arnrxt re I
a H:alth Survey and Planning Committee— Ccnrtituticn r rd ter mi
of references—Anncxure ....... .......................................
3. Special Committee appointed to review
p? hern and
financial provision under F. P. Programme-For^ constitution
and terms of reference—here refer pages 173—176
4 Committee on Multipurpose Worker under Hca Uh & F.P.—
' Office orders for Composition and terms of reference of the
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327
Committee—
(a) Office order dated 28-10-1972—AnncxureIV(a)
(b) Office order da ted 30-H-1972—Anncxure IV(b)
(c) Offi:iorderdated23-2-1973—AnncxureIV(c)
(d) Offi- order dated 22-5-1973—Anncxure lV(d)
(e) Offizt order dated 27-8-1973—Anncxure IV(e)
(f) Members of the Committee—Anncxure IV(f)
I
329
330'
.
• •
5. Groupon Medical Educationand Support Manpower
(a> Composition—Anncxure V(a) .
.
•
•
1-11-1974—
—Anncxure
Annexure
(b) Office Order No. 321015/1/74PH dt.. 1-11-1974
rr
6. Report of the Study Group on Medical Care Services
.
(a) Constitution and terms of Reference—Anncxure VI .
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318
(12) Central Government Health Scheme
(13) Difficult areas
315
331
331
332332
333
333
333
335
335-
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PREFACE
Health Development is a continuous and dynamic process.
It interacts with the overaU development process of the nauon_
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ment of health services have to be reviewed and altered in tun
with the overall Development plan.
' Since Independence, starting with the First Development
plan based on die Health Survey and Development^
(Bhore Committee) we have already marched a long way to reach
the goal, yet much remains to be achieved.
Subsequent Committees took stock of the progress made and
•suaaested modificadon at some approaches and made certain reco mendations to achieve the goal. Some of die -commendations
of different committees are. very much relevant
Y
Some of the reports of these Committees are out of print or no
readily available to Administrators, Decision Makers and Planners
for consultation and references. In this publication an a“ernp
has been made to reproduce the summary of recommendations
• of various Committees constituted by Govt, of Indm from ti
to time. It is hoped that this publication will be usefu! f°r
Administrators, Planners, Dec.sion Makers, Research Workers
as well as Programme Officers and will serve as a ready reference.
I am thankful to Dr. S. K. Sen Gupta, Deputy Director
General; Dr. Mchendra Singh, Duxctor, Centra! Bureau of
Health Intelligence; and particularly to Dr S. N. Bagchi, DADG
(AR) and Mr. V. P. Bhasin, Statistician, for their assistance in
bringing out the publication.
(Dr. M. D. SAIGAL)
Addl. Director General {PH)
Dated 4th February, 'J985,
INew Delhi
tR
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AN OVER-VIEW OF MAJOR RECOMMENDATIONS
Jn r943>
then British Government governing India
appointed the Health Survey and Development Committee with
Sir Joseph Bhore as Chairman. The Committee popularly known
as Shore Committee, published its report and recommendation in
»1946. Although the Health Development plan of Bhore Com
mittee dealt with a country, then under British occupation which
now comprises three Independent countries—India, Pakistan and
Bangladesh—the recommendation can be taken to be the beginn
ing of modern health planning and development- process of all
these three countries.
*
The recommendation of the Committee are comprehensive
covering almost all facts of health including development of health
manpower and mechanics of funding etc. in the context
of the lan. The main principles underlying the Committee’s
proposal for future health development of the country centred ,
round the foliowin
‘JS &u^’ng principles : —
(a) That no individual should fail to secure adequate
medical care because of inability to pay for it.
(b) The health programme, must, from the very beginning,
lay special emphasis on preventive work with conse
quential development of environmental hygiene.
w
(c) The health services should be placed as close to the
people as possible in order to ensure the maximum
benefit to the communities to be served.
?
(d) It is essential to secure the active co-operation-of the
I
people in the development of health programme, and
active support of the people is to be sought through
establishment of Health Committee in every village.*
T
(e) The Doctor—the leader of the health team should be
a ‘Social Physician’, who should combine remedial and
preventive measures as to confer the maximum benefit
on the community, and the future doctors should be
trained to equip them for all such duties.
*In fact when the Bhore Committee sitting in New Delhi, was formulating
the particular objectives, the All India Institute of Hygiene & Public Health,
Calcutta, under the guidance of Dr. Grant as Director of the Institute was ex
perimenting with a similar model at Singur Health Centre. This expenditure
provided the background and encouraged the Committee to incorporate thia
objective in particular.
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It is striking that the recommendations of the Bhore Committee speaks of ‘Primary Health Care Unit’ with people’s active
co-operation long long before the Alma Ata declaration of 1077
In fact, the recommendation indicated that if the proposals were
earned out truthfully, then perhaps. India could have achieved
Health For All By 1971 AD’. It is also interesting to note that
the Committee touched upon population problem and indicated
containment of population as one of the facets of health develop
ment besides village and town planning as part of environmental
•sanitation and health.
But various constraints prevailed upon after Independence
which caused-the Health’ to occupy a lower priority of national,
problem, and thus Committee's goal remained unachived. HowSCt °Ut- 2 Partern
health development through primary
health care unit which continues till date, the basic obhetive
'
and
framework of all the subsequent Health Development plan In
one word the Bhore Committee’s recommendations provided
inspiration for the development of comprehensive health services
ror India.
r
After nearly 13 years of the publication of Bhore Committee
Reports, the Govt, in 1959 appointed a Health Survey and Plan
ning Committee under the Chairmanship of Dr. A. Lakshmanswaim Mudahar (Mudahar Committee) to assess or evaluate the
h C u 1^“ rc 'cf and public heaith sincc
submission of
the Health Survey and Development Committee’s (Bhore Com
mittee) report, and to review the first and second Five-Ycars-Plan
ca th Projects and to formulate recommendations for the future
plan of health development in the country.
i
Between the period from publication of the report of the
Bhore Committee (1946) and the appointment of the Mudaliar
Committee (1959) many historical events took place in die country.
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\ . ,. Thc country earned Independence (15th August, 1047) and
India was partitioned. At the time of Independence there were
9 Provinces and some 600 Princely States in India. These States
were either merged to adjoining Provinces or constituted the
Centrally Administrative Units, or integrated to for new States,
llus geo-polmcal development provided new situation, not con
ceived of by the Bhore Committee. It has been stated that, as a
result of Partition, ‘British India’ lost about 365,000 square miles
°t land area, and an estimated population of 88 million. On the
PJ-H hand., following the integration of the Princely States,
approximatojy 716,000 square miles of land area and an estimated
■93.2 population had added to the old territory of British India,
which to-day constitutes the Republic of India. Some'other
■events took place following Independence. A few of them
•?
xi
Mow1!—0 heakh develoPment may
briefly pointed out:
lo-nV^^011 °f thC Co£nsctitution °f India (26th January,.
Wd c/s
W Action of Indian '
' (d)f EsCabirishnlcItt of Planning Commission;
' Z o th ^nt
C°Uncl! Of Health^under Article
b'veloo^nr P
‘On:.
r Launching of the Community
the field of Heakh01”110’ § Entry °f InternaUonal Agencies in
With these major back-grounds, the Mudaliar
Committee
CVA
TSUrCS alrdac)y taken in the country and to
suggest further development plan etc.
'
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Year Jhn C°mmittee felt that input given in tst and and Fivehealth^ secto7C Tt0° mCagrc1ln resPccc of
of rhe country in
heaIth sector. It appears that 5.9% (Rs. Mo crorcs) 3nd / 0/
5-9 %
fIcyXXv
Ol,C ay in resPcctive tst and and
f Z I of C ° I c 1 3CT’S
bcl0w dlc -commendation 1
Con^ittZ.
Cl1 l’f
°r ,b-lt of tbe Bhorc |
F
In other words funding m health did not
commensurate
with the need lor health in any plan period.
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The Committee was of the view that the
adrmmstration with which the Health Ministry main area of
was concerned
were (a) provision of adequate medical
carc—prevention and
curative; (b) the training of medical and
para-medical presonnei j
including those for dental care; and (c) resenreh Ail Jk ..l
areas are obviously interlinked and taking the country as a whok!
■IliYn i'rJ kl’d.’s?,0"'"’”'"' •’gS™'” “f "«»" i" “
J™ k,d SiS
The Afudaliar Committee,
following major actions: —
I,’
“1 ^>y
therefore,
recommended the
(a) Formation of Central Health C-idrr in
k- •
posts m the Central and State Ministries of Health will be iT'T
ed; tb) Extension of the functions
-S- tt
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uc'
Commission to education in die fields of th-'^rants
mg. Agriculture and Vatcrinarv Sc’enc^- (’TlnsrimrAeS’’'
;
^”mrn?1 jn
Lx-u^osv,
Eradkadon. SmallooVc“
t0
1 ubercuiosis and fi
Counril of H„lth
X“rs,
fi ■
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Cc"lral
the existing PHCs were far awav’r ^ Commi»^ observed that
Bhore Committee
Committee felt that no ^the/0^
“P by
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existing PHCs should be brought to the norms recommended by
Bhore Committee, and Mobile Health Care Unit to be introduced
. for primary health care. This shift from PHCs to Mobile Units!
was heavily influenced by financial .constraints prevailing at the J
point of time, when Govt.’s policy was aimed at Industrialisation
.as a top priority item. However, several vertical programmes for
.control of Communicable Diseases were initiated following the
■suggestions of the Mudaliar Committee.
The Committee also reviewed the progress made in health
•sector following Bhore- Committee recommendation, and made
number of observations with regard to all aspects of health:
including Health Manpower, Training & Education, Indian
System of Medicine, Research etc. On administration, the Com
mittee felt that the Director General of Health Services should
for all purposes, enjoy the status of an Additional Secretary, and
; Director General’s views and recommendations should be dealt
1 with the highest level without the intervention of the Secretariat.
Regarding International Health matters, the Committee felt that
■there should be a seperate Cell in the DGHS to co-ordinate all
activities of all the international agencies including Bilateral
cultural exchange programme. Head of such Cell should invari
ably be the Secretary to the Delegation to Word Health Assembly
•etc.
During the period the population problem and its organisa
tional matter was reviewed by the Central Family Planning
Council, and in 1965, the Council appointed Special Committee
Mukhcrjt)
headed by the then Secretary of Health (Sri B. Mu
kherji) to
review staffing pattern and financial provision under Family
Planning Programme.
The Committee, while recommending various organisational
and administrative reforms of the existing pattern of Family
Planning Services, and IUD Units and reviewing the potentiali
ties IUCD recommended specially Mobile Sterilisation and Mobile
Education and Publicity Unit for each District Family Planning
Bureau to intensify the activities of the programme, because the
Committee felt that in commensurate with very large base-population and difficult geographical situation, efforts need to be inten
sified in order to achieve any measurable effect on the overall birth
•rate. The family planning infrastructure remained independent
but largely followed the structural pattern of Primary Health
Centre/Sub-Centres and often located within the same set-up at
• peripheral level. As in 1973, there were 399 Sterilisation Units
and 456 IUD Units throughout country under Family Planning
Programme. Family Planning . Programme aiongwith other
health measures brought down the crude birth rate from 41.7
(1951-1961) to 34.5 in 1975.
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^,mrrDUnn?ithc, Penod\vert:caj Pr°gramm« of control of different
h.d
? d7a 1“’
P!aMln° and nutrition, programme .
of each otbT 7 T10^independent ?
of each other and at peripheral level, generally they were work- !
pirimetcr uf PHC SystemimPlies
f°r
same geographical-area, which comprises of 8o-mo thousand
population at PHC level, a large "number of Jfalth workers
TeJvnErn<S S , Tnt VirtiCaJ Pr°gramme area are covering a
1
, oC.identical population at. any point of time. It was.
thought as to whether such health workers could be integrate J
and used for multiple programme with much smaller »eooraphical
may msulX'
for r«pective worker, which
may result in more intensified activities in a newly defined
smaller acuvity zone for each worker.
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A CP,ggl”££ 2L Multipurpose Workers (Kartar Sin«h
Committee)^dwTfelth andFaFmly PlanTTnyPro^fi^-^
FamiPylnpE^n°IcWln5-|
rCCOmmcndation of °the Central
issues
g
’ t0 CXam'nc this and othcr associated
set of woS-TfM^-5 rCCOm,p“datlons "'ere accepted and a new
set of worker (Multi-purpose) drawn from the supervisory level
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the fie d fo all
“ '>HCS W°'li”S
”«««
SrammCS Wcrc,crcated wl’° would work in
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wnrl &
,r
at PHC lcvel have been trained as multi-Duroose
workers and are m position. However the hand lnu,c-PurPosc
workers, drawn f„A verdeal pro"™™, have ve "“X’’*”'
I
£>'
mortality and morbiditv rates of vnrin i
” rCte‘ the
*
*
tidi
°;““e
rale
9'
S,;tn:9TB£"rhS -=”
t™ 30 years in JsrJCen™,)
™
“P
are
'XZS, A’/'Td "’"a'
present the bed population ratio Is o.® per th™s^,d
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There are 16754 dispensaries, of which 11590 are in rural
area and the remaining 5164 in urban area. There are 5739
Primary Health Centres, 59511 Sub-Centres. The 351 upgraded
Primary Health Centres have been or being provided with
Specialists (Medicine, .Surgery, Obstetrics & Gynacology and
Paediatrics) services.
Number of Medical Colleges has risen to-\
106 from 25^ (i94Z24^).^ Steps are being taken for ‘adoption’ by '
the Medical Colleges of 3 primary Health Centres each, thereby
Specialist Services, teaching components etc. will percolate to rural
areas contributing towards improved health care and exposino-j
the .students to actual rural set-up for orientation towards rural/
backgrounds. (Reference Srivastava Committee Report).
With regard to indegenous system of medicine, at present
there are 275 hospitals of Ayurvedic System-19
U^ani System,
having 9783 and 621 beds respectively. There are 18 hospitals
under Nature Cure and Yog System. There are 12827 and 986
dispensaries under Ayurvedic and Unani System respectively.
Siddha System has 426 dispensaries and Nature Cure System has
43 dispensaries.
A chain of research Institutes have been developed in almost
all branches of Medical Science and Post-Graduate Medical Edu-I
P^’o^ ls available in approx. 2/3rd of’the ' Medical Colleges, (
besides in almost all the research or in National Institutes" in
different branches of Medicine and Public Health, in short,
development of Medical Research, Education and quality of
Health Care in India, as achieved has already put India in an
enviable position amongst the developing countries. Some of
the dreadful infectious diseases like Smallpox has been eradicated.
I But the health care, in real term, to die teeming millions in rural
area, comprising 76% of the population is still aluding die plan
ners and decision makers. The accessibility to health care deli
very infrastructure by the community they serve, remain at a low
level, and benefit of health cane delivery infrastructure did not
f percolate to a very large section of population in any PHC. In
1974, Govt, appointed the ‘Group on Medical Education and
support Man Power’ who specially examined the problem.
Alongwith other recommendations, like setting up of Medical &
Health Commission, National Health Services, Involvement of
Medical Colleges in the community health care etc. The com
mittee recommended'a" band of health workersTrom the commu
nity. to be linked to the PHC sethip—Thus taking the services
from PHC to community
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It was also realised that development of health infrastructure,
however, well planned rt maybe—cannot • be effective reasonably
unless other developments of rural area do not march alongwith
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it. Therefore, a Minimum Need Programme for the rural com
munity became an important element since the 5th Five Year Plan.
Elementary Education, Rural Water Supply Scheme, Rural Roads,
Rural Electrification, Housing, Environmental Sanitation etc.
were incorporated alongwith the Rural Health Programme. In
order to increase accessibility to rural health care programme, the
norms for PHC, and Sub-Centres were revised and re-set at one
PHC for every 30,000 population (20000 for tribal and hilly area),
one Sub-Centre for every 5000 population (3000 for tribal and hilly
area) and one Community Health Centre for every one lakh
population with hospital and specialist-services etc. and also
establishing referral services etc. With a view to achieve people’s
participation in health care, a new' type of health volunteers was
introduced following Srivastjava Committee recommendations,
who would be nominated by the community at the rate of one
volunteer per each village or a population of 1000, trained and
sent back to the community he/she belongs, to serve at the locality,
rendering preventive, promotivc and incidental curative services
at a grass-root (village) level. They are termed Health Guides.
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Thus slowly and steadily, the spirit of Bhore Committee of
peoples participation in health care and placing the health services
as close to the people is taking shape, after passing through various
twist and turn of events of time.
New Delhi,
New Delhi,
November, 1983.
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Dr. S. N. BAGCHI
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I—HEALTH SURVEY AND
DEVELOPMENT COMMITTEE—1946
(BHORE COMMITTEE)
A SUMMARY OF THE REPORT
I
Our survey of existing health condiuons in India in volume I
of the report extends to about 220 pages,, while the recommenda
tions for the creation of a better standard of national health-tiirougn
the development of an organised health service on modern lines are
embodied in a second volume of over 500 pages. In
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volumes we have dealt, at some length, with • India s health
problems in order to present an adequate picture of the ex:stI"S
state of affairs and of the proposals for its improvement. In addi
tion to such detailed consideration of matters relating to India s
present and future health administration we feel that it may be ot
advantage to give, in a much smaller compass, the salient features
of our report in rhe present volume. In this summary we have
not strictly-adhered to the chronological order of the chapters in
the first two volumes of our report. It deals with different su jects
such as personal health services, environmental hygiene, professional
education, medical research and so on in separate sections an
indicates briefly,’in each section, the more important matters relat
ing to the subject concerned in respect of both the existing cont 1tions and of our proposals for their improvement.
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(aj THE STATE OF THE PUBLIC HEALTH IN BRITISH
INDIA
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have confined ourselves to the- period ending with 1941 in order
to exclude the adverse effects of abnormal conditions ansing out ot
the War, particularly after Japan’s entry towards the end of that
year The present state of the public health in British India is
low as is evidence by the wide prevalence of chsease and the conse
quent high rates of mortality in the community as a whole and, in
particular, among such vulnerable groups as children and women
in the reproductive age period. The death rate for the general popu
lation in British India was,, in 1937, 22.4 per 1,000 inhabitants and
for infants (children under one year of age) .162 per 1,000 ive
births. In 1941 the corresponding rates were 21 8 and 15b respec
tively. As a contrast the following figures for New Zealand and
Australia arc quoted :—
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General death Infantile jnortalitv rate(1937)
»- a ♦ /1Q1 / t
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l^ew’Zca land
.Australia -
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91
31
9-4
38
2
The high rates of mortality in the community at all ao-e?
periods are reflected in the very low expectation of life in India
We give below the expectations of life for new-born infants it
New Zealand, Australia and British India.
Expectation of lifeatbirth
Males
Females
NewZea)and....................................................... ...........
67-88 (1934)
Au5,ralia•
•
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..63.48
67-14(1932-34)BritishJndia
.
26*91
26'56(192l-30)‘
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2. New Zealand and Australia are two of the: most healthy
countries in the world and the figures quoted above-give an indicaion of what has already been achieved in reducing mortality in thccommumty and in prolonging the life of the individual in those,
countries. India has to go a long way before the health of thepeople is raised to the standards already reached by the other
countries. In all countries in which health administration has
made definite progress the expiation of life for females is higher
than for males. India is an exception the reason being as will be
shown later, the high rate of mortality among women in this
country due to causes associated with pregnancy and childbearing..
3- The rates of mortality among infants and children and
among mothers arc examined below in greater detail.
- n — C?tTS TanionS infants and children under io years of a^e
in British India and in England and Wales are shown below as per
centages of the total deaths at all ages in the two countries. •
_ Deaths at
^-periods shown as percentages of the total deaths at al! ages
T|
Under
one
year
1—5
ye^rs
5-10
yc^rs
Total
under
10 years.
British India (average for 1935-39)
24-3
18.7
5-5
48-5
England and Wales (193?)
6-8
21
11
10.0
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In India, nearly half the total deaths are among children under
io years of age,and-,- of the mortality in this a^e
ige group, one half
takes place within the first year of life. The percentage for
England and Wales in every age group is very much smaller.
Maternal Mortality'
4- About 200,000 women die every year in. British India
rom causes associated . with pregnancy and childbearing and.
probably about four millions suffer from varying -degrees-of dis
ability and discomfort as a’result of the same causes.
The Incidence of Diseases
5. At least 100 million persons suffer from malaria every year .
and the annual mortality for which the disease is responsible,'either
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directly or indirectly, is about 2 millions. About 2.5 million active ;
cases of tuberculosis exist in the country and 500,000 deaths take
place each year from this cause alone. The common infectious'
diseases, namely, cholera, smallpox and plague, are also responsible
for a large amount of morbidity and mortality, the extent.of which
varies from year to year. Among die different countries of the
world for which statistics are available, India ranks high as one of
die largest reservoirs of infection in respect of all the three. These
and the other two are all preventible diseases and their incidence
should have been brought under effective control long ago. In
addition, endemic diseases such as leprosy, filariasis, guinea-worm
and hook-worm diseases are responsible for a considerable amount
of morbidity in the country, although their contribution to morta
lity is relatively small.
(b) CAUSES OF THE LOW LEVEL OF HEALTH IN INDIA
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6. The maintenance of the public health requires the fulfil
ment of certain fundamental conditions., which include the pro
vision of an environment conductive to healthful living, adequate
nutrition, the availability of health protection to all members of the
community, irrespective of their ability to pay for it, and the active
co-operation of the people in the maintenance of their own health.
The large amount of preventible suffering and mortality in the
country is mainly the result of an inadequacy of provision in respect
of these fundamental factors. Environmental sanitation is at a low
level in most parts of the country, malnutrition and under-nutri
tion reduce the vitality and power of resistance of an appreciable
section of the population and the existing health services are al
together inadequate to meet the needs of the people, while lack of
general education and health education add materially to the diffi
culty of overcoming the indifference and apathv with which the
people tolerate the insanitary conditions around them and the large
amount of sickness that prevails.
7. Diet surveys carried out in different parts of the country
have shown, in typical urban and rural groups, that the food con
sumed is insufficient to provide the necessary energy requirements
in the case of some 30 per cent, of the families, that the diet is
almost invariably ill-balanced and that there is, in terms of food
factors, a deficiency of fats, vitamins and proteins of high biolo
gical value. The statistics for food production in India show a
considerable margin of error, but such figures as arc available
suggest that, in regard to cereals which form the staple article of
diet, the deficiency may be of the order of 22 per cent, of the
country's requirements. For other articles such as vegetables,
fruits, milk, meat, fish and eggs, the quantities now produced will
have to be increased several times before adequate amounts will
become available for the proper nutrition of the people.
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8. While tire extent of provision of hospitals and dispensaries
in urban ana rural areas varies considerably among the provinces,
tire rural population has everywhere been less adequately provided
, for than the urban. The inhabitants of the rural areas live more
widely dispersed than those of the urban and the medical aid given
by an institution becomes, to that extent more restricted. In the
United Provinces, for instance, one institution serves in the rural
areas an average population of 105,626 distributed over an average
number of 224 villages.
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9. The quality of service rendered by these institutions leaves
I much to be desired. For instance, the average time given to a
I patient was noted, during our tours, to be 48 seconds'^ one dis
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pensary and about a minute in another. The medical service given
to the people under such conditions-is bound to be of a perfunctory
nature. The medical officers in charge of many dispensaries have,
for long periods, been out of touch with modern medical practice
without an opportunity to work in a well conducted hospital. Other
defects include unsatisfactory
conditions in
in regard
regard to the design of,
tisfactory conditions
and accommodation• in, institutions, considerable overcrowding in
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the wards and ogreat insufficiency of the nursing staff.
10. • The number of beds available in British India for the
Treatment of general and special diseases is about 73,000 or about
. 0.24 bed per thousand population, as against 7.14 in England and
Wales and jo.48 in the United States.
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(c) INADEQUACY OF HEALTH PERSONNEL
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11. Some idea of the magnitude of the task to be accomplish
ed in increasing within the next 25 years, trained personnel of
various type in order to provide a 'reasonably satisfactory health
service to the people may be obtained from the following figures.
We have given existing standard in the United Kingdom'but’have
suggested for India lower ratios as the targets to be aimed at during
the next quarter of a century. The reason is that the available
numbers in the various categories of personnel are so small that
even the attainment of the suggested ratios by 1971 will involve
concerted; intensive and unremitting effort, on an unprecedented
icale, by the authorities concerned.
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Class of
Personnel
Existing
rrtio in the
United
Kingdcm
Number
required
in
1971
Ito 1,000
j 1 to 2.000
185,000
Nerses
7,000
1 to 43,000
1 to 3C0
1 io .'CO
740,000
He. Kh Visitors
750
1 to 400,000 1 to 4,770*
1 to 5.000
74.000
’ per 100
births.
ICO.CCO
1 ph : m. cist
t.' 3 doctors
62,000
io 3 doctors
1 to 2,700
J io -i.000
92.5C0
Midw- ves .
'F
Suggested
rrtipto be
rt.iined in
1971 in British
Indi_ with...
m estimated
pcrulation cf
3“0 millions
47,500 1 to 6,000
• Decors
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Ratio of
Num numbers in
ber column 2 to
avail the pms-nt
able
Dcpulation
now
of British
Tndia
(300 mill ions)
Q. alifiec
Ph. nnecist.
Qeabfied
Dentists.
5,000 I to 60,000
75
1,000
1 to 61St
1 to 4,000,000 1 pharma cis r
i to 300,000
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tBas/d on 1943 figure.
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RECOMMENDATIONS
12. Wc have indicated above certain dark shadows in the
health picture of the country. If it were possible to evaluate, with
any degree of exactness, the loss India surTers annually through
avoidable waste of human material and the lowering of human
efficiency through malnutrition and prcventible morbidity, the
result would be so startling as to arouse the whole country and
create and enlist an awakened public opinion in support of the
war against disease. According to one authority the minimum
estimate of the loss to India every year from malaria alone lies
somewhere between 147 and 187^ crores of rupees. A nation’s
health is perhaps the most potent single factor in determining the
character and extent of its development and progress and any ex
penditure of money and effort on improving the national health is
a gilt-edged investment yielding immediate and steady returns in
increased productive capacity.
13- In drawing up a health plan certain primary conditions
essential for healthful living must in the first place be ensured.
Suitable housing, sanitary surroundings and a safe drinking water
supply are pre-requisites of a healthy life. The provision of
■ adequate health protection to all covering both its curative and
preventive aspects, irrespective of their ability to pay for it, the
improvement of nutritional standards qualitatively and quantitati
vely, the elimination of unemployment, the provision of a living
’ "’age for all workers and improvement in agricultural and industrial
■production and means of communication, particularly in the rural
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areas, arc all facets of a single problem and call for urgent attention.
Nor can man live by bread alone. A vigorous and healthy com
munity life in its many aspects must be suitably catered for. Recrea
tion, mental and physical, plays a large part in building up the
conditions favourable to sound individual and community health
and must receive serious consideration. Further, no lasting
improvement of the public health can be achieved without arousing
the living interest and enlisting the practical co-operation of the
people themselves.
MODERN TRENDS IN THE ORGANISATION OF A
NATIONAL HEALTH SERVICE
14. A study of the tendencies apparent in some of the more
progressive countries of the world in the development of organised
health services for the community has been of great assistance to
us. Broadly speaking;-the modern trend is towards die provision
by the State of as complete a health service as possible and the
inclusion, within its scope, of the largest possible proportion of the
community. The need for ensuring the distribution of medical bene
fits to all, irrespective of-their ability to pay, has also been recogni
sed. The general tendency appears to be towards basing die
national health plan on a system of social insurance. Even in
Soviet Russia, where medical care is free to all, the cost of the
. services is partly met from insurance funds, contributions towards
these funds being made not by individual workers but by the
factories and other institutions in which they work. We have
come to the conclusion that, under the conditions existing in the
country, medical service should be free to all without distinction
and that the contribution from those who can afford to pay should
be through the channel of general and local taxation. It will be
for the Governments of the future to decide ultimately whether
medical service should remain free to all classes of the people or
whether an insurance scheme would be more in accordance with
the economic, social and political requirements of the country at
the time.
15. Taking into consideration th.e need for ensuring adequatehealth service for the vast rural population of die country and the
difficulty experienced in the past in attracting medical practitioners
to the countryside, we have come to the conclusion that the most
•satisfactory method of meeting the situation would be to providea whole-time salaried service, which would enable Governments to: ensure that doctors are made available where their services are; most needed. This conclusion is supported_byt_the evidence of a
number of representatives of medical associations, of private indivi
duals and several medical administrators.
16. We have also come-'to the conclusion that the wholetime ■
salaried doctors employed by the State should be prohibited private •
practice. In our scheme the same doctor will combine in himself.
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at the periphery, curative and preventive health functions and if
seems almost certain that, without the prohibition of private prac
tice, his preventive duties will not receive the attention they require.
As regards medical relief, there was a general agreement among
those whom we interviewed that prohibition of private practice was
essential in order to ensure that the poor man in the rural areas
received equal attention with his richer neighbour. We have there
fore recommended the prohibition of private practice to the fulltime salaried doctors employed by the State and have, at the same
time, suggested scales of pay'which, we believe, will provide
reasonably adequate remuneration for ohe services they render.
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17. The utilisation of the services of suitable medical men7'',
outside the health service on a part-time or even on an honorary I
basis will also be advantageous and even necessary, particularly in .
the earlier stages of our health programme. In the cities* and some
of the larger towns in the country, general practitioners with high
qualifications and specialists arc available for such cmplovment.
THE HEALTH PROGRAMME
18. Wc have drawn up our health plan in two parts, one acomprehensive programme for the somewhat distant future and
the other a short-term scheme covering two five-year periods. Wc
have taken the countryside as the focal point of our main recom
mendations, for the.debt which India owes to the tiller of. the .soil
is immense. When pestilence and famine sweep through the land, it is he who pays the heaviest toll and yet receives only the
scantiest medical assistance. Further, nearly 90 per cent, of the
people in India live in the rural areas and. the basic problem before;
the_country is the provision of adequate health protection to this ■
prcpondcratingly large section of the community. We have there
fore made the villager the chief beneficiarv under our proposals.
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19. We shall first refer briefly to our proposals under the long
term programme and then set out those which are recommended
for each of the two five-year periods, which constitute the short
term programme. In doing so we shall take up first the district •'
health organisation in respect of each programme. The machinery '■
for the organisation and administration of the health services aC ‘
the-Centre and in the Provinces constitutes an integral part of both
the long and short-term proposals and it will be described later.
THE LONG-TERM PROGRAMME
20. The large variations that exist in the density of population
in different parts of the country make it impossible to formulate a
plan which can be applied without modification over all the provin
ces. The desirability of associating the activities of the proposed
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health organisation with those of other Departments of Govern
ment such as Agriculture, Education, Animal Husbandry and
Cooperation has been recognised and it is, therefore, considered
; adxantageous that, as far as possible, die administrative district
should be chosen as the area for the development of the scheme.
; The populations of individual districts vary considerably from over
nve millions to a few hundreds of thousands or even less in .some
cases and therefore,-in-presenting the plan, an arbitrary figure of
three million for a district has been chosen. ’For'the sake of con-~
xenience it will be referred to as the three, million plan. In imple
menting the proposals tne details that are given will have to be
modified in the provinces so as to suit the size and peculation of
their individual districts.
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THE THREE MILLION PLAN
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2i. The district health organisation will have as its smallest
unit of administration the primary unit, which will normally serve
an area with a population of about 10.000 to 20,000. A number
of such primary units (about 15 to 25) will together constitute a
secondary unit and a varying number of the latter (about 3 to 5)
will form the district health unit, the designation by which the
district health organisation will be known/ At each of the head
quarters of the district, secondary and primary units will be estab
lished a Health Centre as a focal point from which the different
types a health activity will radiate into the territory covered bv
each type of unit. The District Health Centre will possess general
and special hospitals with a total bed strength of about 2,500 and
all the consultant and laboratory services required for the diagnosis
-and treatment of disease on up-to-date lines. The administrative
staff of the district health organisation will be located here and
will exercise supervision over the district as a whole. Similarly,
the Secondary Health Centre will be provided with hospital accom
modation of about 650 beds and with equipment and other facilities
on a generous scale, although not up to the standard of the District
Health Centre.' The administrative staff of the secondary unit will
be attached to the Secondary Health Centre and will exercise super
vision and control over the primary units included in it. The
Primary Health Centre will have a 75-bed hospital and health
administration over the area included in the primary
primary unit
unit will
radiate from this Centre.
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22. The district health organisation described above and itsjunctions are shown below in diagrammatic form: —
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LONG TERM PROGRAMME
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Provincial | Minister of Heelih
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Director of Hea Ith Services
District Hea It h Organisation
{Three million plan)
District Health Board
A. .
Officer-in charge of — District He?It}
District Hea It h Services
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District Health Centre
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Auministration Environmental
Hygiene
(Public Health)
Engireer)
(Population 600,000
each)
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Secondary Unit.’(5)
Secondary Health Centre
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Hygiene (Assistant
Public Health
Engineer)
(Population 20,000
each)
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Hospua 1 Service, 2 500-bcds
hospitfl, with out-patient
department
(Medicine, Surgery, Obstet
rics and Gynaecology etc.)
Specie I provision for research
and laboratory service of a
high order L
___
Administration
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/»<
- dcPartrccnt.
(Medicine, Surgery, ObsctricJ.
nnd Gynaecology etc.)
Laboratory service fOr the
secondary unit ?s a whole.
Primary Units (30)
Primary Health Centre
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J~ 7-------------i------Administration Environmental
Hospital Service
Dcmicilirjy Scivrc^
(Each unit divided
Hygiene
7.5-bed Hospital,
with Preventive rrd
wto four circles) (Public Health
with out-patient
Cvretivc.
Inspectors, Health
department.
(He me visit'rg by
Assistants and
(Medicine, Surgery
dcciors, public
fieldstaff)
Obstetrics and
b«lth runes, mid- Z
Gynaecology etc.) wives fcr maternity
^d child welfare
work, school health,
tuberculosis work
etc.)
The medical officers in
'^t ?£
D^artments of Medicine, Surgery etc, in the hospital
the Secondary Health Centre
will, in addition to ttheir
’
'
hospital
duties,
,
-t, .
supervise work in their
respective fields in rk
the hospitals in the primary
primary umts and the
corresponding staff in the hospital at the district headquarters will
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-similarly supervise the work ok the different departments in the
■secondary and primary health centre hospitals. Close and con
tinuous guidance through advice and supervision, which should
-extend even to the remote villages, is fundamental to the success
of the scheme and the administrative staff at the District and
Secondary Health Centres will carry out this task in the different
-..fields of health administration.
THE PRIMARY UNIT
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• 23. Each primary unit will have six medical officers, six public
..health nurses and a 75-bcd hospital with the requisite nursing
staff, and all these should be utilised for organising a combined
curative and preventive health service in the area. Over and above
the hospital nursing staff there are provided six public health nurses,
who should be qualified nurses with training in midwifery and,
. in addition, in rural health work in its preventive and remedial
. aspects. Of these, four may be put on to preventive work in the
homes of the people. Each nurse so engaged should be able to
deal with the health of school children, die welfare of mothers and
children, tuberculosis work and other activities in the houses within
her area of jurisdiction. The remaining two public health nurses
and two medical officers will be available for organising and carry
ing out curative treatment in the homes of the people.
THE SECONDARY UNIT
24. The Staff employed in a secondary unit will be considera
bly larger chan that of a primary unit. The Administrative Officer
at the headquarters of the secondary unit will be responsible for
the supervision and co-ordination of all curative and preventive
health work in the whole area supervised by the secondary unit.
There will be whole-time heads of the different departments of
medicine, surgery, -maternity, tuberculosis and pathology at the
secondary unit hospital and they will perform the dual function of
attending to the duties of their respective sections in rhe hospital
and of inspecting periodically similar work carried on in the
. primary unit hospitals.
25. In addition to these, the^secondary unit provides for two
■ senior public health nurses pnd two senior sanitary inspectors who
. will be responsible for supervising the work of the corresponding
officers in primary units. There is also an Assistant Public Health
Engineer for supervising all activities in connection with environ- mental hygiene throughout the area controlled by the secondary
unit.
THE DISTRICT" HEADQUARTERS ORGANISATION '
26. The provision for medical relief at the district ^.head
quarters is on a much larger scale than at a secondary unit. The
/number of beds in the hospital is 2,500 and the number of medical
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27\ The secondary unit and district headquarters hospitals,
W-if k C1l bcttcr c9u^Pm^nt-aQd.superior type of medical personnel,
wi be the institutions to which the more complicated cases admit
ted in the primary unit hospitals will be removed. The provision
of ambulances and telephone connection between all the three types
of hospitals are essential for ensuring that these institutions are
utilised to the largest possible extent.
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officers and other personnel employed are considerably greater
than in a secondary unit. The provision of 2,500 beds need not
necessarily be made m one large institution. Thes beds include
provision for medical, surgical, obstetrical and gynaecological cases
as well as for patients suffering from infectious diseases, mental
diseases tuberculosis and others. A> number of institutions can be
grouped together convcniendy in the same area in order to proviHc
the required facilities.
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tyP05 hospitals (primary unit, secondary
unit and district headquarters hospitals) social workers arc to be
employed. Their functions include, among odicr things the
visitma of the home of the patient in order to ascertain the causes
U,nc •?r yinS the disability for which he or she has sought the aid of
the hospita and service as a connecting link between die hospital
and the public m the treatment of the. individual patient and the
general health programme of the area concerned. Under our
programme the treatment of disease has been approached not
merely from the standpoint of affording the patient immediate relief
but also from that of attempting to remove the causes which arc
responsible for his condition.
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29. The health organisation briefly described above is expect
ed to produce a reasonably satisfactory service for rural and urban
communities alike. It is based mainly on a system of hospitals of
varying size and of differing technical efficiency. These institu
tions will play the dual role of providing medical relief and of
taking an active part in the preventive campaign. Work in con
nection with maternity and child welfare, tuberculosis, leprosy, etc.,
will be carried into the homes of the people from the hospitals.
i the outdoor organisations in respect of each of them beina closely
re ated to these institutions. The diagnostic facilities that the lar°-e
hospitals will provide will also contribute their share to the preven“™PalSn- The social workers attached to these institutions
t will, help to provide that preventive bias to the treatment of indivi
dual pauents, in the absence of which the medical care bestowed
on them may fail to produce lasting results.
30 By the time the long-term programme is completed the
- ospi al accommodation available,in the country will have risen
from the present figure of about 0.24 bed per r,ooo of the popula-
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tion to 5.67 beds per 1,000. As regards health personnel, the
numbers that will be required under certain categories and those
now available'are shown below : —
Numbers
now
available
Numbers required
for the complete
_ programme
Doctors
[
c
FT
•7
u.
1
3
7
1
7
J
7
««
J
47.5CO
233,630
.
7,500
(including exist .Tgr
health visit cis).
Nurses (including public health nurees)
670,000
Midwives
112,300
5,000
Pharmacists .
77,880
75
Is such a large increase in the numbers of the health personnel
possible? An example of an unparalleled expansion of health
pcisonncl is furnished by Russia. In 1913 there were altogether
19,785 doctors in that country. By 1941 the number had risen to
141,600, an increase of seven times within a period of 28 years. In
India the increase required under these proposals is only about five
j times the existing number of doctors, co be achieved in a longer
' period.
THE SHORT-TERM PROGRAMME
31. Our short-term proposals, which are intended to supple
ment and not supplant the existing health services, do no more
than present a general picture for the guidcnce of the Provinces.
They constitute, in our view, the irreducible minimum if tangible
results are to be produced. The plan includes proposals for the
establishment of personal and impersonal health services. Under
the former head we propose a province-wide organisation for com
bined preventive and curative health work. This will provide,
for each district, (1) a number of primary and secondary units which
are included in the district health unit and (2) special health services
for mothers and children, school-ciflidren and industrial workers
as well as for dealing with the more important diseases prevalent
in India, such as malaria, tuberculosis, venereal diseases, leprosy,
mental diseases, and some others. The three important subjects of
nutrition, physical education and health education have been dealt
with in separate chapters in..yolume II of our report. Our recom
mendations regarding impersonal health services relate to town and
village planning, housing, water supply, drainage and other matters
regarding general sanitation. Specific proposals for the training of
doctors, nurses and other categories of health personnel, for medical
research and certain other important matters have also been made.
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THE PROVINCE-WIDE HEALTH ORGANISATION
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32. While the outlines of the general plan of the district
health organisation will follow those indicated for the lon<x-term
programme the plan-will-be-less elaborate. We suggest that, in
view of the insufficiency of funds and of trained personnel, each
primary unit should cover, during the first ten years, a population
of 40,000, that the primary health centre should have a dispensarv
with two beds for maternity and two for emergency cases instead
ot a hospital and that the secondary health centre should start with
.1 200-bed hospital to be raised^b'y the tenth year, to 500 beds. Wc
also suggest that the establishment of the district health centre
may be postponed till after this period. The staffing and equip
ment of the health centres at die headquarters of the primary and
secondary units will be on a reduced scale. In order expand the
existing meagre hospital facilities in rural areas we also sutrncst that
a 30-bed hospital should be established, at the start to serve four
primary umts, and diat, by the end of tile first ten vears their
number should be doubled so that one such hospital will serve two
primary units.
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d.Mnct healtli orsanuation sugg-sted for the short-term programme and its functions are given below in diagrammatic term :
SHORT TERM PROGRAMME
I
Provincial Minister of Health
Director of Health Services
District Health Organisation
(Three million plan)
i
District Health Board
OUicer in charge of Disirict Health Services___
District Health Council
Secondary Units (1 or 2)
Secondary Heahh Centre
Administrative Xlcdical Officer
-_____________ I _____
1
Administration
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Hospital Service
-00;k-'d or.500-bcd hospital, with its out-patient department
(Medicine, Surgery, Obstetrics and Gynaecology etc.)
Laboratory service for (he secondary unit as a whole.
. Environmental
Hygiene
(Assistant Public Health Engineer)
(Population 40,000 each)
Primary Units (up to 25)
Primary Health Centre
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Administration
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Hospital Service
Domiciliary Service, Curative and
J. One dispensary with two cmcr___
Preventive
gency beds and two materni (Home visiting by doctors, public
ty beds.
|
health nurses, midwives for mater
2. One 30-bed hospital Io serve
nity
and
child
welfare work,
primary units during 1st five
school
health,
tubcrculossis
years and 2 units during
work etc.)
next five years.
viso^ &rt’lCrm ProBfani,mc the establishment of the organisation al
*' contemplated
*’
y unctions exercised by the staff at the Secondary Health Centre will be I he district headquarters is rnot
the administrative anti stipe ron the lines indicated for (he long-term programme.
(Each unit divided into
four circles)
Environmental
Hygiene
(Public Health Inspectors,
Health Assistants and field
staff)
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34- The district health organisation should, from the start, be
established in every district in a province. This organisation
snouid begin with five primary units and one secondarv°unit and
tnese should be gradually increased to 25 primary and two secon
dary units at the end of the first ten years. The following tabular
statement indicates the expansion we suggest for rlie health
organisation in a typical district:—
•■Zxpuiision of hie scheme in a typicul iHstricr
7
7
f
First year
Fifth-ycar
Number of primary units
5
10
25
Number of dispensaries
5
10
25
Number of30-bcd hospital
J
2
J3
Number ofsccondnry units
1
1
2
Number of200-bcd hospitals
1
1
1
Number of500-bed hospitals
Tenth year
1
Starting with about a seventh of the average populate
0,1
a district in fBritish India rhe proposed Ihealth organisation
will, it is expected, serve Ihalf the population of individual districts by the end of the first
N ten years.
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7
The Primary Unit
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35. The primary health centre at the headquarters of the
primary unit will be the focal point from which will radiate the
various health activities contemplated in our programme. For
each unit the staff required during the short-te/m programme
will consist of 2 medical officers, 4 public health nurses for out
door duty, 1 nurse attached to the dispensary. 4 midwives. 4
trained da:s (as an interim measure till a sufficient number ol
midwives becomes available, 2 sanitary inspectors, 2 health assis
tants, 2 clerks, 1 mistry, 15 inferior servants and 1 pharma
cist. This staff, with tlie exception of the public health nurses,
midwives and trained dais, should be stationed at the head
quarters of the primary unit, although their duties will extend
over the whole area covered by the unit. The public health
nurses, midwives and trained dais will be located at different
places so as to make their services • prompdv available, wherever
required.
36. We consider that the health programme in India should
be. developed on a foundation of preventive health work and pro
ceed- in the closest association with the administration of medical
re.ier. A reduction in the demand for curative treatmen’r*can be
•4— SS CBH.I/ND/84
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secured only through successful preventive work. Both the doctors
m the primary unit should therefore perform curative and pre
ventive health duties.
37havc placed maternity and child welfare work in
the forefront of our programme.-- Attention has alreadv been
drawn to the large number of preventib]e~cfeath“s7^vliicl/occurs
annually among children under io years of age and amon-r women
in the reproductive age period as the result of causes Associated
with pregnancy and childbearing. The supreme importance of
dealing immediately with this section of the population is there
fore obvious. Further, a progressive improvement of the public
health depends largely on promoting die hygienic mode of life
among the people by educating them towards this end. This
education should be carried out intensely among women and
children in order to produce lasting results. The women doctor,
the public health nurse and the midwife can carry the message
of health the homes of the people through their numerous contacts
with women and children.
38. In die beginning the country will be faced with the neecs/
sity of providing, in many directions, services manned by imper
fectly trained personnel with the ability to perform only limited
functions. For instance, in order to promote school health work,
selected school masters with limited training in the carrying out
of certain duties will have to be utilised in the place of doctors
and nurses until the latter become available in sufficient numbers.
These teachers will work under the close supervision of the two
doctors in charge of the primary unit in order to ensure that they
carry out dicir duties satisfactorily. "/
39.QN0 permanent improvement of the public health can
Ik achieved unless the active participation of die people in the
local health programme can be secured. We have therefore sug
gested die establishment, in each village, of a Health Committee
consisting of five to seven individuals, depending on the size and
population of the village. The members of the committee, who
will of course be voluntary workers, can, after suitable training,
help to promote specific lines, of heal th-activity. Their local know
ledge and intimate contact with the people should enable the
members of the committee to influence the former to accept and
actively advance the health measures which are designed to pro
mote the public welfare. The committee members should also
be able to promote local effort, widiout payment, towards the
carrying out of many measures which would otherwise prove prohibidve in cost. We consider that the development of local effort
and the promotion of a spirit of self-help in the community are
as important to the success of the health programme as the spe
cific services which thejiealth officials will be able to place at the
disposal of the people. •
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The Secondary Unit
40. From die very start, a secondary unit should be cstablished in each district. The secondary health centre which will
t be established at its headquarters, will help to provide a higher
type of medical service than that' available m primary units as
well as supervison and guidance of the health activities in these
units. When fully developed, a secondary unit may be expected
j to cover an area with an average population of about 600,000.
’ In order to co-ordinate health administration with rhe activities
of other departments of Government, it will be of advantage if
w
the area of a secondary unit can be made to correspond to°that
or a sub-division in
- —.
m the "district
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HOSPITAL PROVISION
41. The anticipated numbers of new institutions in the ill
Governors’ Provinces at the end of the first six years and of the first
ten years respectively are shown below :—
No. of
dispensaries
with four
beds
in each
No. of
30-bed
hospitals
No. of
200-bed
hospitals
No. of
500-bcd
hospitals
End oft he lint six years
2,293
639
216
Nil
End of t he ten year period
3,905
1.990
216
139
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42. In
there will
42.
in addition
additmn there
will be
be separate hospital provision for
11 xreu osis, mental diseases and leprosy. The cxistinir number
or hospital beds m British India is about 73,000 and/with the
proposed new provision, the total accommodation expected at the
end of the first five and first ten_year periods will be as follows:—
At the end of the first five years—Approximately 183,000.
At the end of the first ten years—Approximately 353iooo.
This programme of hospital expansion will raise the exist■ng ratio of bed to population in the manner shown below:—
(
1
Beds per 1,000 population
r
At present
End of five-year programme
0.24
0.55
End of ten-year programme
I
1.03
population and in the United States 10.48 per 1,000.
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DENTAL SERVICE
43. It will not be. possible to develop even the beginnings of
a dental service during the first five years of the programme be
cause of the total inadequacy of existing dental personnel. If
our scheme of dental education should proceed satisfactorily it
would be possible to organise dental service on a modest scale
during the next five years. Our proposals include the establish
ment of dental sections in the 500 and 200 bed hospitals at the
secondary health centres as well as the provision of travelling
dental units for service in the rural areas. If die programme is
completed on the lines envisaged by us there will be, at the end
of the first ten years, 139 hospitals with 500-bed accommodation
and 216 hospitals with 200 beds in each. The number of mobile
dental units will be 710.
i
44. Reference should also be made to certain other matters
which we consider to be of great importance from the point of
view of ensuring the success of the health programme we have
recommended. They are briefly dealt with below.
Housing Accommodation for the Health Staff
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We consider the provision of housing accommodation for the
hcaldi staff essential in the interests of efficiency. Every health
administrator is today faced with the problem of persuading
doctors to settle in tlic villages. The absence in the rural areas
of the amenities generally available in towns, including housing
and water supply, is one of the factors retarding the flow of
doctors from urban to rural areas. The same tendency is noti
ceable, though to a smaller extent, in respect of other types of
health personnel. In the circumstances we consider the provision
of housing is fundamental to die success of our scheme.
a
_Cq-opcration of the Health Services with other Departments
Government
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The national programme of reconstruction should be deve
loped on a broad front and, simultaneously with the inauguration
of the iealth scheme, the reconstruction plans of other Depart
ments of Government should be brought into operation in the
same area.
Village Communications
We must emphasise the. vital importance o£ developing
village communications in order to enable the health organisation
to offer efficient service to the people. Without such development-- ■
our whole plan for the rural areas may either be paralysed or lose
the greater portion of its effectiveness. Further, the economic
welfare of the village population largely depends on the develop-
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mcnt of rural communications and we stress the need for giving
high priority to such development.
Ambulance
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The provision of. ambulances for the transport of patients is
an important factor in the improvement of the efficiency of the
health services. For each 30-bed hospital two motor ambulances
and one animal-drawn ambulance have been provided in our
scheme.
Travelling Dispensaries
. .^.1’ .-
In the sparsely populated parts of individual provinces it will
be advantageous to provide travelling dispensaries to supplement
the health services rendered by the primary health centres.
•?
Utilisation of the Buildings, Equipment and Personnel
available from the Army after the War
made
The needs of a modern Army have brought into existence • i
a number of health services and tl ie personnel, equipment and
buildings connected with these can, in many cases, be utilised in
the development of our health programme, Anti-malaria units,
hygiene squads, hospitals constructed for war purposes, military
camps, large airfields with such amenities ns roads,
]
water-supply
and lighting, motor vehicles of various tv~es, should al be made
available, on easy erms, for the purpose of devclopi
developing the health
programme.
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Delhi Province as a Demonstration Area
Some of us are of the opinion that Delhi Province is parti
cularly suitable for being made a demonstration area by imple
menting here our proposals as well as those.of other Committees
which have put forward schemes for post-war reconstruction.
•w
Objectives for the Third Five-year Term
45. While the proposals outlined above relate to the first ten
years of the health programme, certain broad suggestions are put
forward as the objectives to be kept in view for the third fiveyear term.
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(1) Hospital accommodation to be raised to 2 beds for every
one thousand of the population.
At the end of the first ten years our scheme provides for one
bed per 1,000 population.
(2) Expansion of the scheme so as to cover three-quarters of
the population of individual districts, wherever possible.
(3) The creation of 12-new colleges in addition to the 43
to be established during the first .10 years.
5—88 CBHI/ND/84
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<4) The establishment of aa fourth
.too training cen
fourth set
set of
of .100
tres for nurses.
b
(5) The training of 500 hospital social workers.*
ORGANISATION AND ADMINISTRATION
46. On the administrative side we propose :—
(1)
a j”
Ministry of Health at the Centre;'"
(2) Ministries.of
Health1 in the Provinces; and
---------(3) local area health administrations.
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rhCOns'der ” fundamental that the portfolio of health at
^e Centre and m the Provinces should be in charge of a X
Minister so as to ensure his undivided attention bein/Xen
dte development of the future health programme. Th°e feed for
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dy- bccn stressed- Both in resPe« of leeisfk
J f ^“unistratton it is likely that-some of the measures
ces CA
Wk]1 Offcnd Cxisting SOcial and rcligious practican seA Mln;StCr’ who CIW
confidence of the people and
th
k t
,C0'°Peratl0n> can alone carry such enactments
through the legislature and enforce their working in the countiy.
-t/.
tl'
-i1 giving
b!vin£ ,carerui
carcf}11. considerate
consideration to die question of the
existing
distribution
of
functions between the Centre and
i
V health xunuuuxis
the Provinces and to the large measure of autonomy that the latter
enjoy under the Government of India Act of 1935, we have come
to the conclusion diat certain principles should be taken into con
principles ^Jlmulatlng Plans for futurc development. These
_
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(a) That the wide measure of autonomy that has been
granted to the Provinces should be respected, to the utmost: Posslble extent. Our proposals for the future will
of th^appSion1
C¥flicts wil1
°ut
view the existing machin^r? of^edicS iShefd,stricts- In ^eir
factory, is not iJl-suited to^furnish
7F inadeIcluate and unsahsments. They advocated ev^a disJrihJn
eVCn,y sPread ^provepersonnel, accommodation and eouinment n
^abties accruing from increased
lions, geography and densitv
i
i.the requirements of special instituthe others8coZder thl
S?' the °‘h'r hand
the result may be a congeries o Son,.r
° co“cagu« is accepted,
lions for medical relief fnd Drevenbv^MhhaCCre2OnSJOu,the cxistin£ organisaineirtal purposes underlying
heahh nk
^atvono
the fundabe fulfilled. The schemers intend^ Pt
P 1 forward Jn the report will not
development of remedial and oreventiv^ L wI°m07’ frOni t?ie beginning, the
as to provide an integrated institutional
a Un.lfied bas,s as well
The existing curative and Drevendv?h«ith d dom,Clhary service to the people,
tioning independently of «ch Xr S
on the °ther hand.
“gressive countries the reaiiirem"^5^^^95?11^01017- results- In all proTeatures of a modem
meDtS- iadlcatel above are considered as essential
sider that the suggestion of D^Vish^
rn SOns the majority concssential requirements of the Committee’s ph^*
30 BUtt W°Uld destr0Xt *he
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make for considerable changes in existing health ad
ministration and professional education and we theretore feel that, in carrying out these recommendations,
the closest possible co-operation between the Centre and
he Provinces will be essential.. In order to minimise
riction and to promote mutual consultation between
he Centre and the Provinces in the formulation of
k j Cy itnd ItS lmPlcmcntation, there should be
established a Central Statutory Board of Health conHe'Jlth 0fTtkhC^QntraJ.aLnd Provincial Ministers of
and f^r-’k • iC Ccntre> 7lth lts larger resources in money
d technical personnel, should help the Provinces with
grants-in-aid for the development of their health pro_orammes and with such technical assistance as may be
i, One of the important functions of the Board
ill be that of making recommendations to the Central
overnment regarding the distribution of grants-in-aid.
7
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In our view the co-operation that may be expected
to develop as the result of these proposals, between the
Central and Provmcial Ministers of Health on the one
^he mhtWCin m0'' adminirstrativc and technical staff on
the other should create a firmer foundation for the har
monious development of the health programme over
.the country as a whole than a reversal of the policy of
cccentralisation and a resumption of powers by the
Centre to . regulate and control development in the
Provinces. We recognise that there will be certain cxZrOn? <t,rcymstanc« in which the Central Govern
ment should have power to interfere in Provincial ad
ministration It is, however, to be expected that the
machinery for consultation and cooperation, which has
been suggested above, should help to reduce these oc
casions to the minimum. We believe that a Centre acr
to”hX5 7rapathy and ^agination may well be able
hasten the pace of progress in the provinces by protheir msVP1fnt °f
COmPerition among thenf in
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of health nd
g Pr0S[essivcly higher standards
of health administration m .their respective areas.
hehrhMilliStry °f Hkealth’ Ccntral or Pro'incial, should
be the ultimate authonty.responsible for all the health
-
•
oper-^-g within its jurisdiction and should
*7 d0"’“ln<, 'nfora
ards of health administration for those services which
are withm the immediate control of other department
railways, prisons, labour, etc.)
(c) There should be the closest possible co-operation bet
ween the Ministry of Health and other departments of
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Government in order to promote the pooling of all the
available facilities, curative and preventive, in the in
terests of efficiency and of economy.
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(d) The Ministries of Health, Central and Provincial,
should have the advice and guidance of technical expert
in the planning and maintenance of their health ser
vices. . As has been pomted out in the White Paper
recently issued by the Ministry of Health in England
embodying proposals for a national health service, “the
provision of a health service involves technical issues of
the highest importance and in its administration, both
centrally and locally, there is room for special devices
to secure that the guidance of the expert is available and
does not go unheeded.” We recognise the need for
such technical guidance and have therefore incorporated
in our proposals a recommendation for the creation of
standing councils of experts at the three levels of Cen
tral, Provincial and local area administrations. These
councils will consist of rcsprcscntativcs of the medical,
dental, nursing and other professions.
Functions of the Central and Provincial Governments
48. The main functions which we have recommended for the
Central and Provincial Governments arc broadly those for which
they are responsible at present under the Government of India
T935addition we have suggested that the.Centre should
take a definite lead in planning and promoting the development
of health services, preventive and curative, in the country as a
whole. Provincial activities in the field of health should be assis
ted and co-ordinated by the Centre through a system of grants-inaid of approved schemes in the provinces and of technical assist
ance, where desired. Control of inter-provincial spread of commu
nicable diseases,~the sanitary control of inter-provincial traffic and
the enforcement of standards regarding food and drugs in inter
provincial commerce should also be important functions of the
Central Government. —.
..
In certain exceptional circumstances, the Centre should have
power to take direct action in a province..in the interests of the
country as a whole. Such intervention should, as far as possible,
be after consultation with the proposed Central Board of Health
and, in cases requiring urgent action before such consultation
could take place, the matter should be brought to the notice of
tne Board with the least possible delay.
49. We have recommended the establishment in the provin
ces, of Provincial Health Boards.and of Provincial Health coun
cils with composition and functions similar to those of the Central
Board and Central Council.
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Central and Provincial Health Services
50. The principal technical adviser to the Minister of Health
will be the Director General of Health Services at the Centre and
the Director of Health Services in a Province, who wil! function
in each case as the single administrative officer-for the-curative
and preventive departments of health.; These officers will be as
sisted by a suitable number of Deputy and Assistant Directors
General or Directors as the case may be, who will be in charge
of different functions.
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Recruitment and Control of the Central and Provincial Health
Services
51. The following principles should, we recommend,
guide the authorities concerned with the recruitment and control
of the future Central and Provincial Health Services in India:—
(1) There should be separate and independent Central and
Provincial health services appointed and controlled by
the Central and Provincial Governments respectively,
the venue of recruitment for both being India. Recruit
ment to these services will be restricted to persons living
in India except in the case of a small number of posts in
connection with teaching and research institutions, for
which it may be necessary to obtain suitable persons
from outside the country. Such persons should be re
cruited from abroad on short-term contracts, every effort
being made within the period of the contract to train
a suitable Indian for the post.
•(2) Appointments to posts in the teaching and research ins
titutions should be made purely on merit. One-third
of the general health service posts should also be filled
on merit. In filling up the remaining posts conside
ration may be given to the need for communal repre
sentation, every community being given its share of the
66
per cent in accordance with the proportions laid
down by the Governments concerned. Of the candi
dates from individual communities the best available
should be chosen. After admission into the health ser
vices promQtion to higher posts should be regulated
solely by merit.
(3) To secure opportunities for wider experience there
should be exchanges of officers between the Centre and
the Provinces to be arranged by mutual agreement.
(4) A proportion of the posts in the Provincial Cadres
should have the same salary and status as in the Central
service, so that the exchange suggested above may be
facilitated.
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G) The Central and Provincial Services should be main
tained as purely civil organisations.
(6) All members of these services should have ooportunities
of gaming expenence of both urban and rural health
worK.
(7) There-should be no reservation of posts
under -the---------
Ssr’for thE dvil ta”d’
Health Administration in Local Areas
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of whVch wmCnV1ST ; comPrehcnsi'’e health service, the success
.na rnnS-r
^z1" 7 dfpCnd UP°n the fulfilment of the follown conditions • (a) recruitment of the staff and the conditions
of service should be on s.milar lines throughout the province so as
o permit of the enforcement of fairly uniform standards of perou Tdeffo^ C Wh°IC arCLa and
there Should be “^inuous and effective supervis.on by die higher technical staff over the
work of the health personnel even in remote villages.
nnl k'1'
^Ca.hh Board.—These conditions can be fulfilled
only by a health service maintained by a single authority and not
through a number of separate services controlled by different local
wTrk tl r
1 bamC
,s csscntial ro associatc the public
fin
W T11' at,°n °f llCal,h P°licy and w'th its implementa
tion WC therefore recommend that, so far as health is concerned,
in the place of die existing multiplicity of local health authorities
with them separate staffs there should be a single health authority
over the whole area operating through a unified executive staff.
I his authority may be designated the District Health Board and its
jurisdiction wdl, in due course, extend over the district as a
whole.
z;
54- We consider, however, that the deprivation of the health
tuncnons exerased by local bodies should be limited only to such
as are in our opmion unlikely to be able to maintain the standard
ot sen-ice we have recommended. We therefore suggest that
~~ o
|C'mLniLlpa ltles such'*s‘ Calcutta, Bombay,' Madras
and Karachi, which are governed by their own Acts, as well as
J"" mumcipahnes having a population of at’least 200,000, which
may be considered by the Provincial. Government as beina in
o, POT.O\t0
an independent health service of the req ire tec nica efficiency, may be-excltided from the jurisdiction
------ !he<>ntraI0Bnar5ennfalH-yi1?KS,'y-?f Hea"h Drs- Vishwa
“"d Butt
specific functions Tb/ d -0^ H-afth with a Technical Secretariat discharging
different from (thosP^et forth abole
of the hea^h services are also
them are riven ;
tOr-!\ a^ove-. Tneir views and our observabions -on
reA
- n ln paras- 27-31 of ChaP^ XVII of Volume II of the-
1
1
25
of the District Health Board. All these large municipalities'should develop and maintain health organisations on the lines
suggested by us.
55.. In the earljcstages of the programme only limited-areas
in each district will be brought within the operation of our
scheme. In these areas there will be, as shown above, a unified
health authority with a provincialised health service covering all
categories of personnel. For the areas outside our scheme we
recommended that, in order to secure an improvement, of the
health administration of existing local bodies, certain legal and
administrative measures which -have been taken in the province
of Madras should be applied in other provinces also.
■»
56. We hqve suggested that representation of the people on
Board should be partly secured by direct election bv the people
and partly by election, from their own ranks, by the local bodies
in the areas covered by our scheme. We have also suggested,
that, following the lines laid down in the Madras Public Health
Act, 1939, every municipality included in the area under our
scheme should be required statutorily to contribute to the District
Health Board not less than 30 per cent, of its income from all
sources other than Government grants and that every District
Board or panchayat should similarly contribute not less than 12%
per cent, of its income from such sources. Obviously the actual
amount of the contribution in each case will depend on the pro
portion of the population under the local body concerned, which
is brought within our scheme. Such contributions and any grants
sanctioned by the Provincial Government will constitute the funds
to be administered by the Board.
r
r
57. While the Board will enjoy a large measure of auto
nomy in order to ensure that local opinion in the district is per
mitted to influence health policy, it is essential" that the Provincial
Minister of Health should have the power of ensuring compliance
by the Board with the general policy laid down by him. We
have also recommended that certain legal provisions that exist in
the Province of Madras enabling the Chief Administrative Officer
of the Public Health Department to recommend specific action
by local health authorities in particular directions for the improve
ment of public health and to enforce the carrying out of such re
commendations, subject to the concurrence of the Provincial
Government, should be made applicable to all- the areas under our
scheme.
------- ----------
?
1
Recruitment and Control of the District Health Sendee
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I
58. After giving careful consideration to the question as to
whether the recruitment and control of the district health service
should rest with the Provincial Government or with the District
I
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26
Health Board concerned, we have come to the conclusion that the
balance of advantage is heavily in favour of the provincialisation
of this service. In our view, such provincialisation should extend
over all the posts in the district health organisation bccau.sc. if a
certain number of the more responsible posts are provincialised
and the others are left under the Board, the resulting dual control
—must, we believe, lead to inefficient administration.
•8
1
59. The district health organisation will be in charge of an
officer to be designated the Officer in charge of the District Health
Service. Under our proposals he will be a Provincial Officer
whose services are lent to the Board. He should be responsible
for carrying out the health policy laid down by the Board and
we recommend that he should be its Secretary. This officer will
be removed by the Provincial Government if a recommendation
to that effect is passed by the Board by a two-thirds majority,
taking into consideration its full strength.
I*
District Health Council
±
60. We have, already recommended the creation of a District
Health Council consisting of representatives of different profes
sions (e.g., those of doctors, dentists, pharmacists, nurses etc.)
from the registered members of which the health service will be
recruited. The functions of the Council will correspond to those
of (he Provincial and Central Health Councils. We recommend
that the Officer in charge of the District Health Sendee should
be the Chairman of this Council *
7
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1
Salaries
3
l£
61. We have given considerable thought to the question of
the scales of pay to be proposed for the health staff. Obviously
the country cannot afford rates of remuneration which are out of
all relation to its national income and are higher than those which
economic conditions demand. Further, too generous a provision
on salaries may well wreck or at least greatly handicap the im- •
piementation of any large scale health programme. The ques
tion of salaries, moreover, .is not one which concerns medical and
public health personnel aloncfr* "The necessity for establishing
some measure of parity between the various Provinces in the mat
ter of the salaries of their public health staff has been strongly
impressed on us by a Provincial Minister of Public Health. Ano
ther important consideration, in determining the sales of pay, is
*Mr. P. N. Sa pro holds >Sews which are dinereni from those of <the other
rnembers regarding the constitutional ■ aspects of certain of the proposals out
lined above as wel] as the suggestion for a modification of the existing form
■of local health administration. His views are embodied in two minutes of dis
sent which are appended to Chapter XVII of Volume II of the reports- Our
reply to his remarks regarding local self-government will be found in paras.
58—61 of the same chapter.
27
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1
that of the competitive attraction provided by non-State cmplo-yers. In the circumstances we feel that the subject is of such cpmplexity and importance as to require comprehensive examination
at the hands of an ad hoc all-India Committee which should in
clude medical men. The results of such examination will be of
the utmost value to the Central and Provincial Governments. We
have, therefore, recommended the establishment of such a Com
mittee. For the purpose of estimating the cost of our proposals
we have either adopted existing rates or assumed scales of pay
which appear to us prima facie to be generally not unreasonable.
THE NUTRITION OF THE PEOPLE
62. The national health campaign is concerned not only
with the prevention of disease but also with the development of
a healthy and vigorous population and improved nutrition plays
a vital part in preventing sickness and in promoting positive
health.
63. Under-nutrition and malnutrition exist widely in the
• country. According to the Director, Nutrition Research Labora
tories, Coonoor, an insufficient and ill-balanced diet giving only
about 1750 calorics per day (as against the needed 2400 to 3000
calories) is typical of diets consumed by millions in India. Apart
from inadequate nutrition being responsible for a lowering of the
general standard of health of the individual, continued insuffi
ciency of certain food factors in the diet will produce specific
forms of disease. Such disease arc prevalent, to a varying extent,
in different parts of the country. For instance, bcri beri is not
uncommon among adults and infants in the Northern Circars of
the province of Madras, osteomalacia and rickets are prevalent in
certain parts of Northern India, keratomalacia is a common cause
of blindness in South India and goitre is not infrequent among
the communities living in some parts of the Himalayan and subHimalayan regions.
'1
1
1
1
1
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L
64. The main defects of the average Indian diet arc an in• sufficiency of proteins, mineral salts and vitamins. A general
raising of dietary standards throughout the country is basically
• an economic problem, the solution of which depends on the scien
tific development of agriculture, animal husbandry and fisheries
and the simultaneous development of industrial resources. We
• consider that food planning should have, as its ultimate objective,
“the provision of an optimum diet for all, irrespective of income,
and plans should be laid to reach the objective by forced marches,
stage, by stage, within a specified period of time.
65. As the average Indian diet is inadequate in respect of
’ the quality and quantity of the protein consumed, one of the
28
Protein consumption to the-
required^ever6 P o’/ '
k'"k
oX A chr-,
h'Sc .bl0]og'CaI VaIue arc of
shodd be nrnt
ProPort)on of
protein consumed each day
of food nP h
ChlS
YC ShaI1 deal With thrUrea as a c t eXT"’
milk’
and food yeast,
increasma th
“'^deration in connection with
Xre^Vk -7
7 °f mCat and ^-Production will also be
rcrerrea ro brieny.
Coonoor^X^ Dlrer°k °f iNutrition ^search Laboratories,
th™ h t tUgg7d thc ,ncIus!On of 8 ozs- °f ™lk per day in
^e average Indian diet in order to improve its quality. Expectant
7
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7
1
4
7
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1
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-
muchUmnng mvv I"
C iIdrCn UP “ 14 VCarS of a^e will need
much more. W e have suggested that, taking into consideration
in thXX^™"? f m 7k Products> ■the targer for realisation
exre r F
should be an '"crease in milk production to the
extent of at least no per cent.
It has been brought to our notice that, very recently, thc
production of synthetic milk which, it has been claimed, has the
same nutritive value as natural milk, has been developed on a
laboratory scale in Great Britain. ' In view of the importance of
the milk problem in India wc desire to emphasise the need for
immediate investigation into.thc claims put forward on behalf of
synthetic milk and for promoting its production in India on a
large scale, jf these claims arc justified.
Fish.—India s long coast-line, her numerous rivers, lakes
and tanks afford great opportunities for developing thc fish industry. The total production of fish in India, both fresh water
and marine is estimated at less than two crores of maunds per
annum as against 9/ crores of maunds, thc estimated require
ment of Bengal alone where 90 per cent, of thc people cat fish.
kCcC ,hgur,CS s,10uld llclP t0 g'vc some idea of the extent to which
toe nsn industry will have to be developed in India.
Food yeast.—Yeast is of value as a supplement to poor Indian
diets because of its richness in proteins and vitamins of the 'B'
group. Certain strains of yeast, which can be grown on molasses,
produce palatable products of high nutritive value. We strongly
recommended the immediate investigation of the possibility °of
producing food yeast on a large scale in' India.
Urea —It has been brought to our notice that, while the pro
duction of animal proteins, such as meat and milk, through a
process of feeding natural foods to certain animals is a costly and
uneconomical process, a simple chemical, urea, which can be pro-uc-k. m 2^undarn_quantities_.at a low cost, when fed to ruminants —
is converted largely into proteins of the animal body. The pro
duction of urea may be linked with the process of manufacturing
synthetic nitrogenous fertilisers and it is thus possible to promote
I
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[
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29
the manufacture of both cattle food and plant food at the same
time. We strongly urge that this suggestion should b- carefuhv
investigated without delay.
carefully
66. Our further suggestions for’ improving the nutrition of
the people include the production, in India, of the diffe en vit!
mins m sufficient quantities to meet the requirements of ffi- coun35 the P/0'™ of unities for the storage transport
r?
67. Prevention of food aduIteration.-The subject of food
adu. eratmn was recently investigated in detail by a Comm tt e
7
the Provinces.
1
1
health education
" cludes69‘;norCCn0n|d'ng >° m°dcrn conceptions, health education in-
those activities whichra-e°iT-7 PUrel'a healrl1 mntters’ but also
i
r
[
•»d? Ji X™hSmWT'""T'
,,l'dnd
,“l'h
» MMdSs illy
"f
Ad life of thc^'peoolflnTnl'
dpt'ng its proper place tn
' •*“
e CdrricUlUm or ail normal schools
and teachers’
’•r. fromyj'„ai?f XX m' I1" ‘Bndx ’I
1 hX '™b“» "J”" '™h th'. pers
a'
i rf * “iXT
s JlXe XrtX'?'"?
“”"
“"d
? and
| lead
.
I-
30
71. As regards the general population, health education is
mainly earned out by the provincial public health departments.
In most provinces a special health propaganda organisation exists
in the office of the Director of Public Health. In certain pro
vinces a good deal of hygiene publicity work is also being done
in the rural areas by some other departments of Government. For
instance in the Punjab, the Rural Reconstruction Department and
the Co-operative Department have been actively co-operating in
health educauon of the people. In ho province, however, has health
education come up to the standard reached in the more advanced
countries.
Our Recommendations
1
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7
7
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72. We support the recommendation of the Central Advisory
Boards of Health and of Education that the instruction of school
children in hygiene should begin at the earliest possible sta^e.
Such instruction in the early stages should be entirely practical and
devoted to the formation of health habits and the promotion of
personal hygiene. It is particularly important that the student
should see, in actual operation, the sort of hygienic and sanitary
arrangement^ he is taught and encouraged to demand for himself.
School clubs, societies such as the Indian Red Cross Society and
the St. Jhon Ambulance Association and organisations like the
Boy Scout, Girl Guide, Hindustan Scout and Bratachari move
ments can actively help in the development of the health cduca’tion programme for school children.
Health Education of the General Population
73- The main responsibility for assisting and guiding the
health education of the general population should rest on the
health departments of Governments and the establishment is re
commended of properly constituted Health Publicity Bureaux as
part of the Central and Provincial Health Departments. One of
the functions of the Central Health Publicity Bureau should be
participation in the active promotion of health education among
all sections of the population and the-giving of suitable advice and
help to provincial health departments in organising health pro
paganda in their own territories. Another important duty of this
Bureau should be the publicationjaf an Indian Health Journal.
74. The organisation of health propaganda is a highly spe
cialised task and it should therefore be entrusted to persons '
capable of producing results. The methods of propaganda which
commercial organisations, such as the Indian Tea Association,
have employed with great success- should be studied and adopted,
-as far as practicable, in the development of the health education
-campaign.
75. The establishment of permanent health museums in the
larger towns and cities is also recommended.
-,t-
31
I
PHYSICAL EDUCATION-'
1 1 ?’ TiI1 .the be£inning °f
twentieth century no onelooked upon physical education as an integral and important partof general education. During the last 20 years
changes have taken place in all civilised countries in the concejr
and content of physical edudtion and training.
P
77. Something has been done in India to give physical edu
but°a X^ded15
pIaCC ln thC cducad0'n;d structure,,
but a great dea remains to be accomplished. There is a oreat
dearth of suitable teachers q&fified to impart instruction in°this' ‘
important subject. We require many suitably equipped and staff
cd physical education schools and colleges in the count v At ore
sent there are only five physical education colleges m nd.a
a rough esumate the total number of physical Iraimn " tetchel
trained at these mstitutions during the las 20 years does not 4
ceed 3,ooo_far too small a number for-the nee^s of 14oX
cced
7
,
J
Our Proposals
1
th. J8’ TaC training of physical education instructors—For
he proposed post-war schemes of education thousands of qualified
physical tram,ng teachers will be required. We therefore ™
m^ h 4
C S1
bC °nC °r ?W° Physical training co^s'
m each province. Each institution should grant a rcco-nTd
?omnhiatl°n’ 1 •" add,t,on> Pllysic:11 education should be nude a
compulsory subject m normal schools. A certain number of quali
expenPs?fT ht7in,n§-,nStrUCtOrSSh°uld bc SCnt abroad ^ State
FXsnn hl S7r train’ng- °n rcturn thcv shouhl be emnloS
in responsible udrnmistrative and teaching posts, where them ic ‘
ctal training would be of value.
1
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1
nitv—Inff/hhySiCaI traininS Programme for the commuty- In the beginning it may be advantageous to develop a sin
f uXTfOrh t0 ^t^ needS °f Sch001 and colleg sPtud^
hs
I 4 he ?eneral Public- The scb°01 master, because of
o neral education and of the influence he is nbiu tn
;esC4eSS,VeFSr°Up|S °f pUpils’ is in a P°sition to ^oke a favourable
^nlture t r j
,,
in the matter of physical education and
education n
d therefore be utilised for developing a physical
!
I
sary tXE?
mVh[ thC adult P0pulat,0n- IC b= --■ , b .lsh a suitable organisation in each orovince and tk;°f
EeSrtmJnt
P™nciaI Ed-adon
stau i„duje
»
and the new h, ’ P
d ** danCCS- A
A binding
of the
the old
old
blending of
toe new ln an attempt to evolve a sound scheme of physical
I
* /y1
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32
■culture 1S advisable. In this programme separate provision should
be made for students, the male adult population and [er crj’rls and
'women.
°
HEALTH SERVICES FOR MOTHERS AND CHILDREN
80. We have drawn attention to the hi^h rates ot morbidity
■ and mortality prevailing among mothers and . children in this
country. Measures directed towards a reduction of sickness and
mortality among these sections of the community must have the
.highest priority in our programme of health development.
The Primary Unit—The stafl available for health service for
mothers and children in a primary unit will consist of a women
■ doctor, four public health nurses, four midwives and four trained
dais. The provision for institutional service will consist of a dis
pensary at _thc_.headquarters of the unit and a hospital of 30 beds
serving four such units together. At the dispensary there will be
provision for four beds, of which two will be for maternity cases.
In the 30-bcd hospital six beds will be set apart for maternity
and gynaecological cases and there will be four cots for children.
T
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i
81. At the headquarters of each primary unit and in the
places in which 30-bcd hospitals arc located, the services of
a medical officer- will be available and there will also be provision
for a small number of maternity beds. With these facilities it
should be possible to organise a maternity and child welfare centre
on a reasonably efficient basis. Its range of activity can be ex
panded as and when more trained personnel and funds become
available and communications improve. The functions of the
centre will include the following •*—
(a) to get in touch with as many pregnant women in the
area as possible and to persuade them to visit the clinic
regularly, so that periodical examinations may be cartied out and a record of their medical history kept;
(b) to provide for the skilled assistance of a midwife or
trained dais at the time 0/ delivery and for domiciliary
visits by her for two weeks thereafter;
(c) to keep the mother and infant under observation, if
possible, for a year;
(d) to teach mothercraft in all its branches and to incul
cate sound hygienic habits^ in the mother and child;
(c) to keep children under observation, if possible, till five
years of age;
(f) to organise periodical talks, by suitable persons, for
husbands and fathers.Jn order to secure their co-opera
tion in the development of a healthy and happy home;
and
I
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33
(g) to aim, in general
V1ty in the
concerned.
social actimothers and child.
-Jren are
r “•» ^fXr°mmX™ -tat “nd'tEE^'
Whenever practicable, a <
£l”?o."”d f» <Mdre» of two
five
possible/wi^h SerSh0U,d bc^rovrded as cios^‘to“T °r
to
!
with bathi
1
I
7
■?
fomi
Th? *?™“h 07fe
, .. oflt. The pubhc health nurse should Si? C
oncc a
while the- woman medical officer should tuend
SeSS,On
session.
o
e same
lines of activity should ->« f CVCr^ a'tcrnate
followed in the
,
Peripheral
circle J those d’esr kS T POSS‘bIc> he
n'ty and child1 welfare centre at he h S
thc materprimary unit.
at the headquarters of the
suJr3s o?.chcs'“"dr U"i,-Thc
7
I
s'osp.tal at the head
tout 50 beds reserved
? tbc sccond five-year
7
'C raised'toPrhV,S'0n f°r matcrnity
«hj,'
.
^-h-mSSw^mS
™^oeeTsa.l“™“hSsX
*• telephone and
to extend these facilities to th h1 we have —rccornmended wifi bT
Pnmry
“ 1* n,„„
e™us cas„
»dl Mp
more Sserious
^4- The Provincial
Headquarters—At thc
o7te'h“s“rt;
7
quarters of
-irector
experience in the
with wide
0
^
anisa
^n
of
health
services
for
children.
women and
Social and Economic Factors
s
inad^uaf?0 fW° m°St imP°ttant amorn^ th«
?
P«p»taoa, h0„oe,„ obho
!
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34
produce satisfactory results unless simultaneous measures arc taken
to improve their nutrition. An annual provision has been suggest
ed in the budget of each primary unit in order to enable the woman
medical officer to make suitable additions to the diet of pregnant
women, nursing mothers and growing children.
Overwork.—The strain resulting from overwork affects a
woman’s health-both-during pregnancy and in the postnatal period.
In the chapter relating to industrial health the grant of maternity
benefits apd compulsory abstention from work for a period of six
weeks before and six weeks after confinement are recommended
for all women employed in industry. .We have suggested that
these concessions should, in due course, extend to all women
gainfully employed outside their homes.
Nurseries
i
.7
1
i
86. The provision of nurseries or crcchcs to relieve the mother,
especially the working woman, from her responsibility for the. care
of the child during her hours of work, has been a noticeable
development in all highly industrialised countries. In this connection
we wish to draw attention particularly to what has been accom
plished in the Soviet Union for the development of nurseries as
an integral part of the child welfare organisation (vide Appendix
13, Volume III). The nursery in-Soviet Russia serves a three-fold
purpose, viz., that of relieving the mother, of caring for the child
and of educating the mother and child.
The aim is to make
children healthy in body and mind, to draw out their innate
faculties and to make them self-reliant. •
J
Maternity Homes
7
87. The establishment of private maternity homes, in response
to the growing demand of the public for institutional facilities for
confinement, is a noticeable feature in some of the larger urban
centres. The strictest possible control shouldL.be exercised by local
health authorities over the establishment and maintenance of such
institutions. The provincial Ministry of Health should prescribe
suitable standards in respect of these homes and should see that
they are enforced.
i
HEALTH SERUCES FOR SCHOOL CHILDREN
88. In India, school health services are practically non
existent, and where thev exist, they are in an undeveloped state.
The Functions of a School Health Service
89. The duties to be performed by a school health sendee fall
into two main groups; (i) health measures, preventive and curative,
which include (a) the detection and treatment of defects,'physical
j
35
and mental and (b) the creation and maintenance of a hygienic
environment in and around the school, and (ii) measures for
promoting positive health. The last should include (a) improve
ment of the nutritional state of the.child,. (.b)_physical_culture and
(c). health education by formal instruction and the practice of the
hvmenic mode of life.
!
The duties enumerated in (i) above should be performed by
the health organisation while those indicated in (ii) will devolve
on the teacher. There should, however, be close co-operation
between the health and education staffs.
Some General Suggestions
7
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!
90. (i) In each primary unit the male medical officer should
normally be put in charge of the school health service.
(ii) To begin with, this health service should be restricted to
primary school children, their number being limited to
1,000, which is as much as the medical officer can look after
efficiently.
(iii) At least two teachers from each school should receive
training in certain elementary health duties and should receive an
additional remuneration for attending to such duties.
I
Stages of Development
’ 91. The proposed school health organisation should first be'
developed in an area close to the headquarters of a province, in
association with the Department of Preventive Medicine in the
medical college located there. The second stage would mark the
extension of the school health programme to the districts in two
steps, namely, to the headquarters of the secondary units and
subsequently to the headquarters of individual primary units. Twomore stages arc envisaged, these being extensions, of the scheme
so :as to include (1) the whole area of individual primary units
and (2) the students of secondary and high schools and of colleges.
•»
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92. The school health work to be carried out in a primary
unit should include all the main functions of a school health service
to which we have already referred.
We suggest that a school
clinic should be established at the headquarters of each primary
unit to perform duties in connection with the school health
programme in the same manner in which the maternity and child
welfare centre we have recommended is intended to help in the
promotion of health work among mothers and children. Besides
providing treatment for minor ailments to the pupils in all schools
included in the scheme, the clinic should undertake certainspecialised types of service such as dental care and the treatment
of conditions relating to the eye, ear, nose and throat, which are.
6—-88 CBHI/ND/84
i
36
supplemented by^ cwam amouT’ f SUCh
Such Provision wiI1
out in the school by the two spec.allv L™" d^
cam
-above, under the guidance anf
7 • •
tC2c^crs referred
officer. Follow!
hlT”5”” ,°f ?e “h“l
public health „„„eP XX
h"“S °f ffic child.cn by
t
rectify, as far
for the illhealth of the
as are respons.it
pupil is also an important part of t
preventive school health campaign.
to see^ogedie^th
the school d
organisation for bringhia
h'lJ0 dcVekloPed into !
together
theC- cchiidren/the
the teachers. For this
^ddrcn> the parents ar
arranged at which interestin^and emeetlngs should I
be developed. Educational film
u“tlvc programmes shou
health matters arranged "di
Sh°Wn’ short talks <
and other forms of ‘’entert^n^01’^
talcnt for mus
teachers or pamnts, encomaXdToh "
the
such gatherings a success Th^ nr
iZ
Part towar^s makir
Sc developed wil) bc of advantage to“d“ “«
•?
Co-operation between the Health and Education Authorities
'
_£
development of local self-Lvernf
su^ttt'°ns
for
the
futui
there will be a District Health
jnStltjtI0ns arc carried ou
Board functioning over practical 1 v ^rh
DlStrict: Educatio
districts. In ca?h districta
/
Health and District Education I a
°f the Distric
this body should be XpoSeCStablishcd an
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co-operation between
secured.
ensuring
the
the health and"
5"?"5 that
•
tllC ncccssar
“'th nnd education authorities i
province there should '^bc Teo md^
bcad(?uartcrs °f th
Dheetor ol Pubiie inst^ 2?SStS’TEb'™'- 'h
£
T”
X4
'
as members. The manaov-menf
tJ'rector ot Health Service
approved associations of teachers and° ofprlVatC SCkOoI,s, and 0
represented on this Committee, which wSlTdvise G alS° 6
■on all matters relating to schoo health nd • d
Governmen
the distribution of grants-in-md
admimstration, mcludin,
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■OCCUPATIONAL HEALTH: INCLUDING
INDUSTRIAI
HEALTH
96. The conditions afFectin
broadly speaking, be divided -ig the health of the worker may
which he shares with the 1into two groups, namely, thos<
other members of the genera.'
community among whom he livi
■res and. those-which are associatec
with the occupation he
pursues. In regard to the latter there
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noZ ThTi h l2^5 t0 hfeaithLarisinS °ut of particular occupaflons. The development of anthrax by those handling wool or
S h 1 u ed mTv50^5
3nd ^er^ubstance
’t
whkh
influence on the heali' oTth’e” °rt"
nnfl eflese include the lighting, ventilation and general sanitation
t LT h°P." fM"y’
1
d“S' “d «»“ =2ia“d! “th
r 'mg environment and the provision that exists for rest
pauses meals and personal- cleanliness.
Over and above the
general Provision for health protection which the worker can
share with the other members of the population, he has the ri^ht
adviTeffectsT/1?!! "T 'b0*? bc
t0 ^^eract the
adverse effects of those factors which are associated with hie
funch30011? TbC Provision of Luch sP=cial health measures is the
F
St^Zb=es^r„^_
T
objective
we realise that, in the immediate future, GovcrnmTnte
T
Pl0"'a'""!’ Mnsl»rt
r
The Functions of an Industrial Health Service
well T’ a^bj functions of an industrial health service have been
service have- been
MedidnTc^
fof,lo,wlnS words by the Social and Preventive
Medicine Committee of the Royal College G; p;
rre'cntive
of Physicians, London,
W their- Second Interim Report which deals
--> with industrial
medicines :—
(a)
r
tne latter;
°
(b)
(c)
(d)
(e)
to prevent occupational disease;
to assist in the prevention of injuries at work;
to organise a service for emergency treatment;
to help im restoring the injured and disabled to full
working
o capacity;.
(f) to educate workers in the
preservation of health and
promotion of wellbein^:
kg) to promote research and investigation.
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These may be accepted as t’
the objectives to be aimed at in
basing an industrial health service in India.
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98. The proposed industrial heilth service will not minister
to the general medical needs of the workers. This function will
have to be performed by the health service for the community as
a whole The industrial health organisation is intended to meet
the needs of the worker in respect of that group of factors affect
ing his health which are associated with the occupation he pursues. ’
The two services are complementary to each other and will together
provide him with adequate medical care. The industrial health
organisation should form an integral part of the Provincial Health
Department and should be developed as such.
99. We understand that the creation of a Central Health
Insurance Fund, which will be raised by contributions from
Government, employees and workers and will be utilised
the
benefit of the workers, is under contemplation. If the proposed
Central Fund comes into existence, it should be possible, by grants
from it to promote the development of an even higher level of
general health service for industrial workers than that envisaged
under our shortterm scheme for the community. Further grants
from this fund, if available, could be utilised for establishing an
industrial health organisation on the lines indicated above.
100. While diese proposals for an industrial health service
will obviously take time to materialise, we have put forward certain
recommendations for early consideration and appropriate action by
Governments. These recommendations cover a wide field and it
is only die more important ones among them that are referred to
here. For more detailed information reference should be made
to Chapter X of Volume II of our report.
Maternity Benefit
L
101. The maximum period for maternity benefit for women
workers under the different Provincial Acts is four weekFbeforc
and four weeks after childbirth. Under the International Labour
Convention the period recommended is six weeks in both cases
and we endorse this recommendation. During these periods a
woman worker should be paid her full wages, because it is just
at this time she requires nourishing food and special treatment.
Hours of Work
r
102. From .the health point pf view, we recommend that
e maximum hours of work should be reduced to 45 hours a
week, i.e., 8 hours a day tor five days and 5- hours for another
day in the week and that the Factories and other Acts should be
amended accordingly.
In the case of seasonal factories, which may be obliged to
work under considerable pressure during only a part of the year,
39
this maximum may be increased after taking into account such
relevant factors as the extent of hazard to health which the occaPk
tion involves and the distance that the workers will have to walk
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back to their homes.
’
We recommend an interval for the mid-day meal of not less
than one hour, exclusive of 'working hours.
The period during which a worker may be continuously on
night duty should be limited by statute to a fortnight.
Housing
1U -. (a) In our opinion the housing of the industrial
103
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population
primarily the responsibility of the Governments
population is
is primarily
concerned. The following minimum standards of housing arc,
wc rnneidf-ri
reouired for
for the
the health of the industrial worker and
consider, required
his family.
ft. X 12 ft. x io ft. and a
(i) ~
For• a single man : a room io
verandah 8 ft. x 8 ft. X io ft. For a group of such
quarters there should be provided community
------y kitchens,
.
---latrines and bathing places in accordance with
the Standards to be prescribed by the Provincial Govern
ment
Where common kitchens arc not provided,
provision should be made for choolas on the verandahs
with suitable chimneys for the outlet of smoke. Where
latrines and bathing places for common use are erected,
they should
should be
be at
at aa reasonable distance from the quarters
they
•’ *
- 1 Lby-r a covered way tor
.and,- if possible,
connected
weather
protection during bad weather.
(ii) For a family : for a married couple two rooms
TO ft.x 12 ft. X io ft. with a verandah, kitchen, batnroom anda .auu.v.
latrine, For a family including grown up
the
should be increased by at
children t.—accommodation
------ .
least one extra room of similar size.
(b'J In regard to sanitary conveniences, we suggest that, as far
as possibe, septic tank and soil distribution systems should be
introduced so that the handling of nightsoil may be avoide .
The Nutrition of the Workers
104. Our recommendations for improving the nutrition of
the workers include making it obligatory for industrial «ta
ments employing a minimum number ot workers to ma-^in
canteens providing suitably balanced diets at reasonable cost, tne
encouragement of workers by employers to observe regular meal
hours, the strengthening and stricter enforcement of the lass re
inCT to the sanitary control of the production, distribution and sal
of°food, including measures against adulteration, the active
40
of
s"ti t P
Xi’S "d *'
work among employers and employees.
"
eduCaDVe'
The Zoning and Location of Industry
L
by PrX&iSX3118 RUraI Plannin*
shouW be passed
Minisuv for H 8
; %tting Up in each Province a karatepower7to dea^tKh3^
"" andk Rural Plann>ng with^vide
k.i
(b) Before the establishment of. any new ind^trv
rLi
sss ar
fs
and for adequate environmental amenities.
7
RovaHfo^mi<WiSh '^t"5!.7 t0 rLitCratC thc rccommendation oEthe
ake uds to
°n Lab0Ur
Provincial Governments should
there will notPbe?
UStr'CS
places where
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(d) Where possible, having regard of course to the relevant
sn rl°?,C| fa<itOrSi’ nC.W lndustrics should be dispersed in rural areas
o that the local inhabitants may derive thc fullest benefit F
jndustr.es being brought within their immeSe circle TIw
P sent system of estabhshmg factories near or in bi<r towns whereS ific^nd^
t0
in Crowded tenements and unde
rtihcial and insanitary conditions, is harmful' alike to the town
dwellers and the workers themselves. The health orob rm
F
Employment of Children
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job. (a) The minimum age for
employment in industrial
establishments, docks, etc., should be
rjised
between j15 and ry should be eligible'
’forto 15- and persons
employment asadolescents
------ s on
on the certificate of the certifying
“
surgeon; (b) the minimum ao-e for the employment of ‘ childre.
n on
plantations and public works should
/---- be ij;
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(c) In course of time when the compulsory school leaving,
age is raised and adequtae educational facilities become available,
the employment of children under 15 should be abolished for all
types of industrial establishments and occupations.
*
HEALTH SERVICES FOR THE MORE IMPORTANT
DISEASES
107- Wc shall deal here with the specific measures necessary
for controlling the prevalence-ef the following diseases.
1. Malaria.
2. Tuberculosis.
3. Smallpox.
4. Cholera.
5. Plague.
6. Leprosy.
7. Venereal diseases.
8. Hook-worm disease.
9. Filariasis.
10. Guinea-worm disease.
11. Cancer.
12. Mental diseases and mental deficiency.
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Malaria
io8. Wc have already pointed out that malaria is by far the
most important disease in India from the point of view of
morbidity and mortality and that the economic loss it entails is
immense. A tragic feature of the situation is that much of the
malaria in the country is man-made. In many cases roads, railways
and irrigation projects have a sinister account to their credit, their
embankments having caused conditions of water-loggimr favourable
to the breeding of the malaria carrying types of mosquitoes. The
failure of irrigation engineers to provide for adequate drainage
when water is brought into previously dry areas has been another
fruitful cause of the spread, of the disease, recent examples being
certain areas in Sind, the province of Madras and Mysore.
7
Our Recommendations
109. Antimalaria organisations in the Provinces and at the
Centre.—The Director, Malaria Institute of India, has pointed out
that “an essential preliminary to the successful control of malaria
in India is the formation of an .adequately staffed permanent
malaria organisation in each province, the activities of which
should be linked up with those of the central organisation of the
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Government of India”. We fully endorse this view. Our recom
mendations, therefore, include the establishment of antimalaria
organisations in the provinces as well as the strengthening of the
staff of the Malaria Institute of India in order to enable it°to fulfil,
its important tasks of advising provincial administrations in the
development of antimalaria measures, of co-ordinating such work
in the provinces and of training- the higher types of malaria
personnel tor the country as a whole.
no. The general provincial plan we have recommended is!
the creation.. of an organisation at the headquarters of each province
and the establishment
-f a number of malaria control units, each
------ — of
under a medical officer specially trained in antimalaria work, for
operating
tne affected
artected areas in different parts of the province.
ig in the
The most essential requirements> ;are (a) the provision of trained
staff in ;adequate
'
numbers and (b) the supply of drugs, appliances
and other equipment necessary for' carrying out effectively the
c’ . L. against
campaign
. .................................
the disease. Wc
... deprecate
x
the
___________
idea of spendins
r1
,
large sums off money on the
erection of elaborate buildings in
early stages of our programme.
Drugs of Treatment
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-ill. Quinine and incpacrinc arc the two drugs which an
widely used for the treatment of malaria. There is already ar
indication that an even more effective synthetic product, paludrinc
is likely to come into the field at, an early date. Wc recommcnc
tliat the following three general principles should guide th
production of quinine and other antimalaria drugs:—
i. the prices at which antimalaria drugs arc made availabl
to the people should be sufficiently low to enable th
poorest classes to obtain them in adequate amounts fc~
thc effective treatment of the disease.
2. these drugs, in whatever provinces they may be produi
cd, should be made available, on an equitable basis an
on reasonable terms, for the needs of all parts of th
country and
3- no delay should be allowed to occur in developing the
production.
Wc as a Committee would prefer to leave to the Governmen
the country - the responsibility
JE... Jhe
for deciding wheth
private enterprise should or should not be associated with tl
production of quinine and other antimalaria drugs.*
f ,. Sir Frederick James desires to see that private agencies are siven l
IU|Jest oppor.-unay to take part in quinine production with technical advice a
a price guarantee provided by the State. His views are set out in a note whi
is appended to the section on malaria in volume II of our report.
I------
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112. Quinine and mepacrine.—If the estimate of 100 million
individuals suffering from malaria every year is reasonably correct,
it seems safe to assume that at least 120 to 150 million cases of
the disease will__have_to_.be- treated annually. The Malaria
Commission of the League of Nations has recommended 75 grains
of quinine as the minimum^ quantity required for the treatment
of a case. On these estimates of malaria incidence in India the
amount of the drug necessary for the country as a whole will be
in the neighbourhood of about 1.5 million pounds per year, if
quinine is alone used for treatment. The average annual consump
tion of the drug in the- -pre-war period in India was 210,000
pounds and, of this amount, only about a third was produced in
India. The quantity consumed every year in this country would
provide adequate treatment for about 19.6 million patients. As
the objective to be kept in view for the immediate future, we
recommend that sufficient quinine and mepacrine should be
provided to meet jointly the requirements of at least 50 million
patients. As regards quinine our immediate objective should be
the raising of its production to the pre-war level of consumption
in India from indigenous bark alone. As regards mepacrine,
provision should be made for its production in the country in
sufficient amount to meet the requirements of 30 million patients.
Anti-malarial Insecticides
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113. The cultivation of the pyrethrum plant has been
successfully undertaken n various parts of India including Kashmir,
the
Hill States, mv.
the VilllVkl
United AProvinces,
the Central Provinces,
-- — "Punjab
—--J —
IVMlltVJ. LilV
Madras and Orissa. It has been estimated that,, iin order to make
the country self-sufficient, pyrcthr um cultivation will have to be
extended to about 120,000 acres so "as to produce an annual output
of about 15,000 short tons (2,000 lbs. for a tqn)_ of pyrethrum
flowers. In D. D. T. an even more powerful insecticide has come
into use.
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114. As an insecticide the relationship of D. D. T.
to pyrethrum is somewhat similar to that of mepacrine to quinine
in the treatment of malaria. rThere
"’
is the possibility in both cases
of the synthetic substance replaci
’ cing the use of the other.
The
cultivation of pyrethrum can, in this event, be replaced at short
notice by other crops.
Tuberculosis
115. Annually about 500,000 deaths take place from tuber
culosis in India and about 2.5 million open cases of tuberculosis
exist in the country. These patients are continually disseminating
infection among those with whom they come in contact. There is
reason to believe that the incidence of the disease is higher in
i.
44
“ ™-l «S*™. Owing to
between industrial and
f°r
r°ad transport,
r “ Sprad t0 thc co^’
rural areas and the increased ff
the tendency has been for
^’de. Certain factors such T
and insanitary and overcrowded E33 nuCrltlon and under-nutrition
dieir share toJhe disseStof^eX^
m
I tubercJlt-s^ pSl Sle”?
C°rolIlng the ^ad of
/ cases. As agafnX es iLt
hOn
of infective
/ the country the total numh
°/k2’j miIil10n in^cu*ve patients in
the neighXhood of To^^Thf
“ *
sufficient exoerienn- nF h k
• c numher of doctors with
i» mbereni 2^'^““
'h™ l°r
while those who have hadProbabIy cxcced 7o or 8o,
subject may number about 2 Sh°rt C0UrSC °f four wccks in the-
beak
3-
““
to show7thc magnirndToTthe °h
Position should help
presents in this country and ' bcaIdl Problcm which tuberculosis,
facilities for dealing with it J
inadequacy of the existing
7
Our Recommendations
“I
service thc tuberculosis3™'^^0
.corriPr'bcns*vc and integrated,
domiciliary servic™ °( ‘ Z"1”/0? thoU'd / includc> (0 a
colonics, (5) homes for the *
hospitals, • (4) after-careancillary services.
H mcurablc and.in addition, (6) certain
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organised ^omeTeatoeS’ha^b
Scrvicc—A schcmc foe
.
-------- past few years under rh^ o- 'J
Cw°r*cin8’ ln Dc^i during the
Clinic XtX^^
Ncw DcIb« Tuberculosis
scheme has atiinedonlv T
r
; Associatlon of India. This
-• -. ^L^tain difficult^ iingV^
unsatisfactory housing of rk
’
“o extremely
M
H
h
§
-d (3) ^inad^
°f0^tadr
a‘0°l °f ,h'l.?>“»"™T
*
tinds made available for its
working.
Ua>
difficulty, particuhrlv011^ h°USlnS--s^ms t0 present thc greatestPoorer dastf X ----SpCCt °f tubcrculosis patients^f the
i^impossibi;. ’welcXndX00111
wherc isolation
campaign local anrh v d
3 part of the antituberculosis .
numbergS suitable dweh
shouId --^ct and maintains
of his family can be remold “p
patlCnt and members..
muy can be removed. Patients among the poorer sections -
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: spread
&™»Lh
h'„'a±‘±“ c“c-ti’'
inlo th" homes of 5,”’“'",'
i
will
J ’2 ^rcatment facilities it
. offers will help to cure a r ■-
i
wtll hetl»
™
i
ment in hospital. Those'
------ -—• at the
-ihg ?8 ofThe
the medical and'
the home the patient
Wi l be advised, by the doctor and “the
nurse,
to carry out effectiveisolation, contacts will be persuaded to att
attend
the
^Tjm^e
stepsclinic
wifi for
- and
establishing contact betwee rh
anc, f^cir families by
by
interested in welfare work"
V°luntary organisations.
ep£rx:«,”"±"'r “oid’““d
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122. Tuberculosis hospitals—The provision of sufficient
hospital accommodation
to meet the requirements of the country
is bound to take many years
and therefore in the early stages onj
such patients
are hkcly to benefit should be^^admtted to
hospitals.
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clinics during tlfe^wt term
dcvcIo
Pmcnt °f hospitals and:
develop:
ng rne short-term programme arc given below-.
nstitutional service
The first five-year period :
1
(0 the
establishment
of
of aa
200-bed
1
msp.tal for each unit of to million popula^r
(J The
establishment of
of a large clinic
fi"-'o.-id.
ftn hr
£
culosis n ° ° 1 mc^lca^ and non-medical tuber
culosis personnel, at each of . the places where the
200-bed hospital will be created; and
“
(3) Pe.CSt.ab,ishmcnt of clinics of a smaller type at'
The totadiqUartkrS Ot
d'Strict in Brhish ffdn
The to al number required, after deducting the t
main clinics, will be 183.
0 nc
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Second five-year period .
(0 33 more 200-bed hospitals;
(2) 33 morc main ciinics
,
. ,
-- — —c same
the new Jhopsitals
' ' will be located; and places where
(3) 183 more district clinics.
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The clinics and hospitals can serve only limited areas around
■ the places where they are located. Even so, in these limited areas,
..as domiciliary tuberculosis service should be organised in
.association with each clinic. A certain number of suitable cases
will be sent by’ the clinic to the nearest tuberculosis hospital tor
.more satisfactory treatment than can be provided locally.
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124. After-care of patients.—In a considerable proportion of
cases tuberculosis patients do not completely- - recover their
; previous health and, in order to prevent relapse, it is essential
'that less strenuous working conditions and a more hygienic home
-environment should be provided for them on. their return from
hospital. To meet these requirements after-care, colonies should
'-be established in close association with every tuberculosis hospital.
125. Homes for incurables.—The need here is for the
provision of such care as will make the final phase' of sickness
reasonably comfortable for the patient.
We recommend that,
—-while-Governments should undertake, die building and equipment
• of such institutions, their maintenance can be suitably entrusted
vto philanthropic or religious organisations interested in social
welfare, Governments undertaking to meet a substantial part or
the expenditure through generous grants.
126. Travelling tuberculosis units.—One way of extending
'the activities of the tuberculosis organisation outlined above is by
providing travelling tuberculosis clinics based on the district clinic
and working as far into the rural areas as possible. These units
will have motor vehicles so equipped with all the necessary drugs
and appliances, including provision for x-ray examination of
patients, as to enable them to carry diagnostic and treatment
facilities of a reasonably high order to the areas served by them.
These units should have a fixed itinerary and should make about
3-4 visits per month to each of the 30-bcd hospitals and dispen
saries at the headquarters of individual primary units in the areas
under the scheme. ' Apart from the ’ diagnostic and treatment
•facilities which these units can offer, They should also help the
•tuberculosis campaign by carrying out intensive education
•propoganda in those areas.
Smallpox
127. Smallpox is-one of the three major epidemic diseases
• of India, the other two being cholera and plague. During the
period of 60 years, 1880-1940, the average annual rate of small
pox mortality-pcr hundred thousand of the population has vane
from 10 to 80. Even after making allowance for such variability,
— "there is reason ~to~'beHcve—that-the total incidence of. the disease
has decreased in the country as a whole. For instance if the two
:tcn-year periods, 1902-1,1. and 1932-41, are compared and due
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the rates of moj•rtality from smallpox per 100,000 of the population are seen to be 40 and 25j respectively. Nevertheless, it is a.
matter for serious concern that the average number of deaths per
year from smallpox for the period 1932-41 should have been ashigh as 70,000. The annual epidemiological reports which are
published by the League of 'Nations show that the rate of
incidence of smallpox in India is the highest among all the.
countries for which statistics are given.
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sel
70 I
net
128. Striking evidence of the fact that the vaccinationcampaign in the country has not-so far been carried ouLxffcctiyely:
is that, of the total number of smallpox deaths, at all ages, high
proportions occur among infants under one year of age and among;
children between 1 to 10 years. During the five-year period,
1937-41,-deaths, due .to smallpox among infants under one year,
when, expressed as percentages of the total mortality from this’
caus? at all ages, ranged from 12.1 to 19.7 and, during the
same period, the corresponding percentages for children between
one and ten years varied from 19.2 to 30.5. Ff effective primary
vaccination is being enforced in the country, it is children under
ten who should have the highest measure of protection.
129. One of the serious consequences of smallpox is that;
not infrequently, those who recover from it lose their sight
partially or wholly. Blindness is a very serious handicap in life,
to all persons and is particularly so in the case of children with
the prospect of a much longer period of disability than for those
who lose their sight at a more advanced age.
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Our Recommendations
130. Primary vaccination and revaccination.—Primary
vaccination was compulsory in 1941
only about 81 per cent
of the towns and 62 per cent of the rural circles in. British India.
In the province of Bombay primary vaccination was compulsory
only in 4.9 per cent, of the rural circles while in the NorthWest Frontier Province, the United Provinces, Sind, Assam,
Coorg and Ajmer-Merwara it was not enforcible even in a single,
rural circle. Revaccination has been made compulsory as a
routine measure only in the province of Madras.
131. We consider it’essential that primary vaccination should
be .made compulsory throughout the country without delay. We
also recommend that other Provincial—Governments should, as
early as possible, follow the example of the Government of
Madras in making revaccination compulsory.
132. The training of vaccinators, their recruitment and
conditions of service—There is considerable variation in the
provinces as regards the training given to vaccinators, the methods
48
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■of their recruitment and their conations of service. The duration
of the training varies from 3 to 10 months and the salary paid
r
s from a minimum of Rs. io per month in Bengal
to a maximum of Rs. 50 to a first class vaccinator in Madras. In
the provinces of Bihar and Orissa
__ the
—2 vaccinators employed in
rural areas are given no jsalary at all, the fees they may realise
from the people for vaccinations
carriedI out in their homes being
their sole remuneration. They are normally
” engaged' for
' work
*
•only during the vaccination season, October to March. Such
conditions of service cannot attract and keep the right type of
' worker.
. I33> The lowest figure for the average number of
vaccinations performed in a year by a vaccinator was recorded in
Bihar in I939> namcly i>520> as against an average of 2,951 for
British India as a whole and the highest figure of 7,587 for the
Punjab.
I34areas under our scheme vaccination against
smallpox should be one of the normal functions of the public
health inspectors, public health nurses and midwives employed
in each primary unit and the employment of a special class of
vaccinators is not necessary. Vaccination is only one of the many
forms of specific protection against particular diseases which the
health department should provide for the people, and the
operation itself is so simple that there is no justification for the
employment of a special staff for this purpose. During the first
year of the working of the programmes the total population of
40,000 in a primary unit should be .vaccinated.
For
this individual members of the staff mentioned above will be
required to devote only about 18 to 20 days of work.
J35- fn the areas outside our scheme it is equally essential
at in-intensive vaccination campaign against smallpox should be
organised without delay. An important step in this direction is
an improvement in the training and conditions of service of
vaccinators in many provinces. The number of vaccinators employ'■-^d will have to be increased Adequately and, basing our
recommendations on data available from Madras, we have indicat
ed how other provinces may institute an effective campaign of
primary vaccination and revaccination.
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Cholera"*"
B
i?
----- k---- Cholera is another preventible disease which takes a
heavy toll of life in. the
country and shows a wide
range of variation m its incidence from year to year. Some idea
of this range of variation may be obtained from the cholera
mortality figures for the province of Madras in 1939 and 1943.
In the former the total deaths from the disease numbered about
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—.ooo, the lowest incidence recorded for 6o years. k iq4, it
spread to every d.stric: m the province and the registered momlity
from th.s cause^wag iI7jooo. The incidence -of-cholera varies
bZ BeZlCM dPr°VRCh
A
Which its PrCVaknc£ is
being Bengal, Madras, Bihar .and the Central Provinces and to a
smaller extent, Orissa and the United Provinces.
11re5yired for the control of. the disease fall
broadly into two groups, (a) those which
arc permanent and (2)
those which are of a temporary nature. 1 The
former include the
following:
o —
(1)
r
(2)
r
(3)
the provision of protected water supplies;
^tisfactory disposal of nightsoil so ’as to prevent the
P^ibihty of contamination, by infective material, of
rood and water supphes; and
sale or rood.
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°VCr thC Production> distribution and
In regard to each of these the > ' '
position m India today is far
from satisfactory. Protected water supplies
> are available only in
the larger towns and cities and they serve
serve only small proportions
of the population in individual provinces,
Provision for the
proper collection and disposal of nightsoil is
quite inadequate in
rownsa7nd 3nd “ thc.maiority of urban centres, includin
---’..ig
towns and even certain cities. The sanitary
■ *
‘ many
control exercised
over the production, distribution and sale of 'food leaves
------ J much
to be desired in all parts of the country.
138 Anticholera measures.of a temporary nature are
of
mclude:-C '
an outbreak
the disease taks place. These
3
(1) isolation and treatment of patients;
(2) disinfection of infective material; and
(3) immunisation of the people by mticholera inoculation
bein^hT iJ £'„Vnd tW f’T'
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“>»» “
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”St^
tins measure has been a process of steady mo”T
,
-■ have come to recognise-its value and
k m"’
.
pCOple
» accept inoculation when an outbAk™ L’dS’ X
Our Recommendations
139. Permanent measures.—We have suggested, in
the
chapter$ dealing
with
o
water supply and general sanitation.
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[
basic facilities for sanitary improvement, Provincial Governments
should direct that, in fixing priority consideration shou d be
aiven to the incidence of cholera in individual towns and villages.
Tn this way. the mam centres of cholera prevalence can be_
brought under effective control and the spread of die disease from
such sources of infection, prevented. Simultaneously withjhese
improvements the gradual extension, over the country as a whole
of tire health organisation we have recommended should help o
introduce a large measure of control, over the food of the people
so as to ensure fretdom from contamination There will also b.
a rise in the general level of environmental hygiene The combin
ed effect of all these measures is bound to be a marked reduction
in the incidence of cholera and other bowel diseases.
i
I4o Temporary measures.—The temporary measures we
have indicated above should be carried out by the Prltnary uni
staff as effectively as possible.
The active, assistance of the
members of the Village Health Committees would prove
invaluable in enforcing these -measures.
Pilgrim Centres
J4I Pilgrim centres have, in the past, played an important
part in the spread of cholera. The adoption of special measures
for safeguarJing the health of pilgrim CCn^d.h?7°7habs b^
an established practice in the country. In addition it has bee
r
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f i tn enforce the compulsory inoculation of persons
found useful to en or e
co PmittcJ tQ attcnd such fcstivais.
against cholera before they ar p
nf Health this
At the instance of the Central Advisory Board of Health this
u u.
z-nrried nut bv a certain number of Provincial
measure as cen
j
trc wjth encouraging results.
Governments in selected test
be''an^additional
against the possibility of outbreaks
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of cholera starting in festival centres.
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Plague
■T^ The history of plague in recent times dates from 1896
&
■A
wh
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as
•t tco.ooo. Since then there nas uc ______ mortolitY from
•
u
olaoTie,deu.g
tne average
annual
mon-iuy -1-1
dX ofX-4.
only
>9^=-;^-.
A5"' “
disease of certain rodents
and such
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rodents. In India the animal is the rat while, in other countries,
the reservoirs of plague infection are certain other rodents. Man
becomes infected from such animals through the bite of the fleas
which live and feed on these animals.
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144. Plague appears in two forms, bubonic and pneumonic,
the latter being the more severe of the two. The rate of mortality
in bubonic plague may be high as 60 to 70 per cent among those
. who are attacked, while that^for pneumonic plague is practically
cent per cent.
145. Although the incidence of the disease has become very
much reduced within recent years, the Director of the Haffkine
Institute, Bombay, has pointed out that certain endemic areas
exist in different parts of the country and that they constitute a
constant threat in as much as, under favourable conditions, plague
may spread from these centres to other parts of India. These
centres arc situated in cool and moderately damp areas from the
Himalayas in the north through Central and Eastern India to
the Deccan and the province of Madras.
■
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Our Recommendations
7
j46. The measures against the disease should mainly be
directed against the rat as the primary reservoir of infection from
which the disease spreads to man. The keeping down of the
rat population in inhabited areas, particularly in the endemic
centres of plague, is therefore an important preventive measure..
Rats grow in numbers in human dwellings only when they can
secure food and adequate protection. The elimination of these
conditions is therefore the purpose to be kept in view.
view, The
systematic destruction of rats by various methods is also another
important measure which should be generally adopted.
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147. The steps to be taken for rendering the conditions in
residential areas unfavourable to the growth of the rat population
include (a) the construction of rat proof dwellings and rat proof
grain stores and railway godowns, (b) control over the location
- of certain trades and industries which attract rats and (c) an
improvement of the general sanitary condition of the towns and’
villages, as the throwing of barbage in public places encourages
the breeding of rats by providing them with food. Our
recommendations cover all these steps.
//^ <
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Treatment of Plamie
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148. Till recently, there was no specific
pecihc treatment for plamieplagueand the efforts of the physician were mainly
directed towards *
m; ’
giving relief to the patient and to f
’
the keeping
up of his strength.
A few years ago the Director, Haftkine Institute,3 prepared a
7—88 CBHI/ND/84
7.
COM-sWTYHZMFlC-LL
7A
a?/*'.>£
('> ; ■
8717Q
St. Mirks Fwad,
,?-B 3nqa’ or^ - 560 C-01.
.oxV V-
17^^ F
^5
52
serum which, on held trial, was established to be definitely more
•effective than the ordinary form of treatment.
Sulphapyridin
■and sulphathiazolc have also been found to be useful in the
treatment of plague. Of the two, sulphathiazole is considered
the better drug because its effectiveness is probably a little higher
-and its toxicity less.
Leprosy
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149. The number of persons suffering from leprosy in the
world has been estimated as somewhere about five millions and,
of these, leprosy patients in India are believed to be at least a
million. “There is a belt of high incidence including the whole
of the cast-coast and the south peninsula, including^West Beno-al,
South Bihar, Orissa, Madras, Travancore and Cochin. In lhe
central parts of India the incidence tends to be lower but there
• arc some foci of higher incidence. ~ There is a belt of moderate
incidence in the Himalayan foot hills, running across the north
of India, while in most of the north-west of India there is very
little leprosy.”*
150. In die highly endemic areas its incidence may range
from two or five per cent of the population and, in restricted
areas, it may even be as high as 10 to 15 per cent. In the non’cndcmic regions of North-Western India, on the other hand,
large areas may show no cases at all while the general level of
incidence is stated to be as low as. 0.01 per cent or one per ten
thousand of the population.
151. Cases of leprosy are broadly divided into two groups,
the neural and lepromatous” types. The former constitutes
the “benign” form of leprosy and the odier the more severe and
infectious type. While for the country as a whole the proportion
of lepromatous cases is estimated at about 20 per cent of leprosy
patients, there are areas where the proportion of this severer type
is as low as 4 per cent and others in which it rises even to 50
jer cent. In estimating the importance of leprosy as a public
health problem the rate of incidence and. the relative proportion
of the lepromatous type should both be taken into consideration.
Our Recommendations
■'152. In order to promote antileprosy work on proper lines
we put forward the following*^proposals for the short-term
programme:—
(a) the creation of provincial leprosy organisation;
*Report on Leprosy and its control in India (1941) by the
mittee appointed by the Central Advisory Board of Health.
Special Com
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(b) an increase of the existing provision for institutional
treatment of out-patients and in-patients;
(c) development of group isolation colonies;
(d) substantial financial help to voluntary organisations
engaged in antileprosy work and
(e) the establishment of a Central Leprosy Institute.
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The Provincial Leprosy Organisation
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153. As a preliminary "step towards organising antileprosy
work on sound lines a leprosy organisation should be created at
the headquarters of each province, in which the disease is a
definite public health problem, this organisation being made an
integral part of the provincial health service. At its head will
be the Provincial Leprosy Officer, who will be responsible for
organising antilcprosy work in all its branches.
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An Increase of the Existing Provision for Institutional Treatment
154. The leprosy clinic is an important link in the chain
of measures for the control of the disease and it should perform
the dual role of providing remedial and preventive care to the
people in the same manner that the tuberculosis clinic does in
the campaign against that disease. A start should be made by
providing a properly equipped and staffed leprosy clinic in
association with every secondary health centre hospital. Existing
leprosy clinics require to be staffed and equipped properly in order
to improve the quality of the work that they arc doing.
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155. Existing provision for the isolation of leprosy patient
is limited to about 14,000 beds, while infective cases requiring
isolation may well be about, a quarter of a million, We propose
that, in the first five years of our programme, an additional
14,000 beds should be provided and that, in the next five years,
an equal provision of another 14,000 Ibeds
--------should also be made.
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Development of Group Isolation
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156. An adequate expansion of institutional facilities so as
to provide for the isolation of all the infective patients in the
country can hardly be expected to materialise for a very long time
to come. The possibility of developing group isolation therefore
requires serious investigation. Certain points to remember in this
connection are that the period of isolation will be long, perhaps
years, that provision should be made for medical care although
it may not be of a very high standard, that the scheme, if it is
to be widely adopted, should-be sufficiently cheap to suit
the
economic level of the country and that provision should be made
to promote corporate life in the isolated community and to enable
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the more able-bodied members-of it to
towards the maintenance of the colony.
1
work and contribute
157. Certain experiments for developing isolation colonies
have already been carried out in this country and are being project
ed in the near future. Local conditions vary considerably in
different parts of the country and we consider that group isolation
colonies should be developed in all the more important areas where
leprosy is a health problem. ■ We have suggested an annual
expenditure of Rs. 3 lakhs on the development of such colonies
during the first ten years.
4
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Financial Help to Voluntary Organisations.
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158. Missionary bodies have so far contributed much more
to the development of antileprosy work in India than public
authorities. For instance, it is understood that a little over
10,000 beds out of a total of 14,000 in the country are maintain
ed in missionary institutions. In addition to a wide expansion
of measures against the disease under . the auspices of the
Governments and of local health authorities, it will be necessary
for voluntary effort to continue unabated- in this field and we
have therefore recommended provision to the extent of Rs. 187.5
lakhs during the first ten years to subsidise such effort.
I
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The Central Leprosy Institute
159. We consider it necessary that a Central Leprosy Institute
should be established, its main functions being (1) the training
of leprosy workers, (2) the active promotion of research in the
subject and (3) the development of an information service provid
ing the latest information regarding the treatment of the disease
and antileprosy work in general for the benefit of Governments
and organisations interested in leprosy in India.
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Venereal Diseases
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160. The incidence of venereal diseases in India is unknown.
A survey (the results of which were published in 1933) by Sir
John Megaw, a former Director. General of the Indian Medical
Service, regarding the incidence of syphilis and gonorrhoea in
this country showed that the rate of their total incidence was
somewhere near 37 per 1,000 of the population. This is a
sufficiently high figure to point to the urgent need for fuller
investigation as well as for the starting of a campaign against
them on as extensive a scale as circumstances would permit. Their
importance from the point of view of producing sickness and
incapacitation cannot be over-emphasised. Both syphilis^ and
gonorrhoea are responsible for such blindness. ■ Of the two,
syphilis is the more important.
If not »treated in time and
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adequately, it produces degenerative changes of a varied character
in .the internal organs of the body and, in a certain number of
cases, it also causes the condition known as the general “paralysis
of the insane. The disease is transmissible from parent to offspring
and is responsible for a considerable ’ proportion of the abortions
and premature births that take place. Syphilis accounts also for
a large amount of mental deficiency. Gonorrhoea, in its turn,
contributes to ill-health through joint troubles and various
conditions affecting the genito-urinary organs in both sexes. In
women it may produce sterility.
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Our Recommendations
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161. The measures which are necessary for the control of
these diseases may be divided into two broad groups, namely, (1)
those which provide the best available forms of medical care, pre
ventive and curative, and (2) those which arc designed to dis
courage promiscuity and to control prostitution.
P
162. Our recommendations under (1) include the provision
of free and confidential treatment to all persons seeking such treat
ment, of facilities without payment of fees for personal prophylaxis
and of adequate facilities for the diagnosis of these diseases as well
as the creation and maintenance of a follow-up service and educa
tional work among the people in regard to their spread and control.
163. Measures designed to discourage promiscuity in the
community .and to control prostitution are obviously more difficult.
Io devise and enforce than the medical measures recommended
<ibove. Education in a wide sense of the term, so as to promote
the growth of the individual’s moral sense and of his responsibility
towards himself and the community, and sex education intended
to create a correct appreciation of the problems of sex relationship
and to impart knowledge regarding the spread of venereal diseases
and the dangers that arise from them, must together provide the
conditions essential to secure the success of any attempt to control
indiscriminate sexual intercourse, whether it be in the restricted
field of prostitution or outside it. We have proposed the gradual
provision of sex education to all sections of the community, such
provision starting first with teachers in training schools and col
leges and, through them, extending to school children and college
students. Steps for controlling prostitution are also suggested.
These include the enforcement of severe penalties on those who
keep brothels and on landlords who promote the use of their pre
mises for this purpose. As regards the prostitute, our recommen
dations are intended to provide her with adequate medical treat
ment for venereal diseases as well as to help her, through educative
work, to return to the normal mode of life.
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Hook-Worm Disease
164. The hook-worm produces its .harmful effect on the
human host by the loss of blood it causes through feeding on him*
by irritation of the bowels which it produces and the resulting dis
turbance of the digestive function and by the secreation of a poiso
nous substance, which prevents the clotting of blood and thus
promotes bleeding. The disease is widely prevalent in India. The
labour populations in Assam and certain'parts of South India and’
of the plantations in Coorg are heavily affected as well as the
general population of certain parts of Travancore, Malabar and
South Kanara. Varying intensities of infestation are found in the
provinces of Bengal, Bihar, Orissa, the eastern portion of the Cen
tral Provinces, some parts of the United Provinces and the’Punjab
and on the east coast of Madras. The North-West Frontier Pro
vince, Rajputana, Sind, Kathiawar, Central India States, Hydera
bad, Deccan and Mysore State are practically free.
7
165. Our recommendations regarding the provision of ade
quate arrangements for nightsoil conservancy in rural and urban
areas will, if implemented, constitute an important step towards
the control of hook-worm disease. Soil pollution through human
excreta and the habit of walking barefoot constitute the two main
factors responsible for its spread. What is therefore needed is that
the people should be taught how to render these factors inoperative.
The health education campaign, which we hope will be conducted
in the schools and colleges and among the general population as
an essential part of our programme, should help materially towards
this end. In the meantime mass treatment, by the administration
of the appropriate drugs, should be carried out among the heavily
infested groups of the population. The simultaneous development
of a system ot nightsoil conservancy for such communities, on lines
suited to local conditions, is also necessary.
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Filariasis
166. The disease leads to the permanent swelling of the legs
and certain other parts of the body,-besides causing recurring at
tacks of fever and inflammation of the lymphatic system. It is
responsible for a considerable amount the preventible suffering and
disability, although it does not cause death.
jdy. Bengal is the most heavily affected province in India.
The incidence of filariasis is high in the western districts of this
province and its intensity gradually decreases eastwards and north
wards. The Chittagong Hill Tracts and the northern districts of
Jalpaiguri and Darjeeling are free. In Assam the disease is pre
sent in many districts, although its intensity is lower than in Ben
gal. In Bihar its incidence is relatively high in'the-Gangetic’ plain
and in Orissa in the coastal districts. Tn Madras areas of mode
rate prevalence exist in the districts of Tanjore, Kistna, Godavari..
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and Vizagapatam and in Saidapet near Madras City, while the
coastal tracts of Malabar and South Kanara districts and of the
Indian States of. Travancore and Cochin show areas of high
incidence.
I
168. Extended research has failed to produce a satisfactory
cure for this disease. The only effective measures against it known
at present are those which are concerned with the control of the
carrier species of mosquito. In the affected areas it is therefore
essential that adequate control measures should be undertaken in.
order to secure an effective reduction in the mosquito population.
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Guinea-worm Disease
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169. Guinea-worm disease is widely prevalent in certain dis
tricts of the North-West Frontier Province while its incidence is
relatively low in the Punjab. The Rajputana desert is free but
many of the States in Rajputana and Central India contain heavily
infected areas. In the Central Provinces, Bombay Presidency, the
Nizam’s Dominions and Madras Presidency the disease is prevalent
over wide areas. Well watered tracts, with a fairly heavy rainfall
such as Bengal, are generally free.
170. The prevalence of the disease is dependent on oppor
tunities for the infection of water supplies by persons harbouring
the worm. In the affected areas step wells, tanks and other sources
of water liable to contamination are responsible for keeping up the
infection and the application of lime to such water supplies has
been shown to be effective in sterilising them.
Cancer
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Such evidence as is available seems to suggest that the
relative incidence of cancer in India is probably as high as in wes
tern countries. As regards the causative factors “whether it be the
cervix, the oral cavity, the penis, the skin or the gastro-intestinal
tract, the factor of irritation seems to excel all other possible causes
and brings the problem of this fell disease within the scope of pre
ventive medicine.”
172. Our proposals for the short-term programme are :—
(i) Provision for radium and for deep x-ray treatments
should be made, in addition to existing centres for such
treatments, at all the hospitals associated with the present
medical colleges and with those which will be established during the short-term programme, Thc centres
at which such facilities are now available are shown in
Appendix 20 of Volume III of the repQrt.
58
(2) In addition to the Tata Memorial Cancer Research Hos
pital at Bombay, three more institutions for promoting
advanced research and teaching in the subject are needed
to serve North-Western, Eastern and. Southern India
respectively.
•(3) A considerable extension of diagnostic facilities will be
necessary. The laboratories attached, to the secondary
unit hospitals, the provincial public health laboratory
organisation with its regional branches, which we have
recommended in the chapter on medical research,, and
the special institutes referred to above should all help to
provide this extended service.
Mental Diseases and Mental Deficiency
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173. Conditions of mental ill-health may be divided into
two broad groups, (1) mental disorder, and (2) mental deficiency.
The former may be cither inherited or acquired and very often
it is both. No age is exempt from mental disorder, although the
types may vary at different age periods. A large proportion of
these patients is amenable to modern methods of treatment.
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174. Mental deficiency is ascribed, on the other hand, to a
hereditary or congenital taint or to some accident or illness occur
ring just before or soon after birth. Although the condition is |
generally regarded as incurable, by proper care and supervision the ;
majority of defectives can be made to lead useful but segregated
lives, and they can also be prevented from becoming criminals and,
in the case of girls, social menaces.
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175. In England and Wales there were, at the beginning of
1937, about 129,750 patients under treatment in mental hospital,
2 proportion of 3.2 mental patients per thousand of the popula
tion. In America, the annual admission rate has varied from 5 to
8 per thousand in different years and in different States. In India j
there is no reason to believe that the rate of incidence of mental !
diseases is in any way less than those for England and the United '
States. While certain factors which are operative in those coun
tries may not affect India to the same extent, other factors such as
chronic starvation or under-nutrition, tropical fevers, anaemias and
frequent childbirth in women, who are unfit for motherhood, are
responsible for large numbers of mental breakdown in this country.
In view of these considerations, even if the proportion of mental
patients be taken as 2 per thousand of the population in India,
hospital accommodation should be available for at least 800,000
mental patients as against the existing provision of a little over
10,000 beds for the country as a whole. In India the existing
number of mental hospital beds is in the ratio of one bed to about
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59
40,000 of the population (taking the present population of the
■country as’ 400 millions) while,- in England, the corresponding
ratio is approximately one bed to 300 of the population.
176. As regards the possible numbers-oLpersons .suffering
from varying degrees of mental disorder, who may not require
hospitalisation and yet should'receive treatment, and of-those suf
fering from mental deficiency, it seems almost certain that the
numbers are likely to run into several millions in this country,
if the rate of incidence in England or America can be taken as
even an approximate guide for making estimates for India.
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Our Proposals
177. As against this- background of mental ill-health the
existing provision for the medical care of such patients is altogether
inadequate and unsatisfactory. We therefore make the following
recommendations for the short term programme :—
(a) the creation of mental ‘health organisations as part of
the establishments under the Director General of Health
Services at the Centre and of the Provincial Directors of
Health Services ;
(b) the improvement of the existing-17 mental hospitals in
British India and the establishment of two new institu
tions during the first five years and of five more during
the next five years ;
(c) the provision of -facilities for training in mental health
for medical men in India and abroad and for ancillary
personnel in India; and
(d) the establishment of a Department of Mental Health
in the proposed All-India Medical Institute.
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178. (a) The creation of mental health organisations as
part of the establishments under the Director General of Health
Services at the Centre and of the Provincial Directors of Health
Services.—The creation of mental health organisations as part of
the establishments of the Director General of Health Services at
the Centre and of the Provincial Directors of Health Services is, in
our view, of such great importance that we have placed it first
anw our recommendations. So little information is available
regarding the incidence of mental ill-health in the country and
the developments in this field of health administration, even in
the more progressive countries, arc so recent that we feel we shall
not be justified in attempting to make detailed recommendations
regarding the mental health organisation which the country re
quires. We must leave this task to the health departments with
the guidance of the specialists, whose appointment we have
suggested.
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I79- (b) The improvement of the existing 17 mental hos
pitals and the establishment of two new institutions during the first
five years and of five more during the next five years.—Radical
improvements should be made in the existing mental hospitals in
order to make them conform to modern standards. Provision
should also be made for all the newer methods of diagnosis and
treatment. Apart from such remodelling of existing mental hos
pitals we recommend the creation of 7 new institutions durinothe short-term programme, of which at least two should be estab^
lished as early as possible during the first five-year period.
7
1
7
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7
7
7
s
180. (c) The provision of facilities for training in mental
health work for medical men in India and abroad and for ancillary
personnel in India.—Nowhere in this country are available all thefacilities necessary for the starting of a course for the Diploma in
Psychological Medicine. We recommend that, as early as possible,
courses of training for this Diploma should be developed in Bom
bay and Calcutta in association with the universities concerned.
We also suggest that, as soon as. possible, similar diploma courses
should be developed in the universities, of other provincial capitals.
In the meantime a certain number of carefully selected medical
men, with some experience of work in mental hospitals in India,
should be sent abroad for training. Provision should be made for
sending at least 20 doctors during the first five years and another
20 during the second five years of our programme.
We have also made proposals for developing training facilities
for non-medical mental personnel, including such workers as
occupational therapists, psychiatric social- workers, psychologists,
nursing staff and male and female ward attendants.
181. (d) The establishment of a Department of Mental
Health in the proposed All-India Medical Institute.—This Depart
ment is calculated to promote (1) the development of facilities for
the under-graduate and postgraduate training of doctors in all
branches of psychological medicine and the demonstration to the
provincial authorities of the standards to be aimed at when similar
facilities are created by these authorities in their own territories,
(2) the promotion of research in the field of mental health, and’
(3) participation in the organisation of a mental health programmcfor the area in which die Institute is located.
ENWRONMENTAL HYGIENE
7
182. Under this head we deal with the subjects of (a) town
and village planning, (b) housing, rural* and urban, (c) watersupply, (d) general sanitation, including conservancy and drainage> (e) r^ver and beach pollution, (f) control of insects, rodents
and other vectors of disease,..and (g) control of trades dangerous ~
and offensive to the community.
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......... ...... .
Town and Village Planning
county
cipks of plannin J In L
“J
trial development, the execution of
SCale indus'
activities will in all nrohThTn k i
1C Worts and other’
and aacdenaencs and
n P ,0
>“'™ldps is, dnrtto”“ i21 t ™
f'
?t
ance with SeTrSl
rfCgukt? the =rowth of towns in accordmined effort to eradicate0exT*1
plan,nin°> t0 make a deter-
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W
Urban CCntrCS in
rC»ard to the P™'
in which
I
„„ lgjin ^8*2"d ‘°
Our Recommendations
ning S^^eSiSi’
T°"" and Village Plan"C'' Pr°t™“ “ “'X “
way.
can’the sMea “e i
7
we a “™7'ZC ' ■ ,r°“ "■‘“"V d"""<ls- At
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suog«ting the creation of such a Ministry be '
cause the direct
wi.h Pttwinehtl XS?.±"”^2,execution will rest
an expert in town phnninT’,,!
Sfl°uId bc at the Ccntrc
tion, may be attached to the estnhf
?UlP°Sc °f administraof Health Services under th u
°f thc Dircctor Gcncral
should be thc consultant to Sh M'?1Stry °f Hcalth' This officer
as the Railways and Post;
dcPartme"ts ofA Go-mment such
the provinces for fim ' i '
Telegraphs. All requests from
ffieir^own anreoun; ’a hSnPP°rt
°f
by him from the technicaHoinr0^ S5llcme?,should be Scrutinised
of Town and Village Plannmo- sh° 177’
Centra' Dlrcctorate
L- .
°
■ nninS should also function as an informaL tion bureau
for
town planners throughout the country.
7
Village Planning shoddhas^7tec7
1
and T°wn and
may be called the Director of T
3 7Ti? aS ‘tS adviscr’ who
»«»Me subordinate S“"h"T
improvement trusts buildino• „■ * • j
oca auMonties,.
Private esta'te development con-eT
T induStrlal organisations,,
should submit their schemes for such 7 g?VCrnment departments
ance, if they come X r " -SUCh devcL!°Pment or slum clearI: Provincial Ministry of Hn ■ taln P-^scrlbcd standards, to the
'■ for previous sanction ThTlT
Vi!hge Planning
"mg will be responsible fo
u T?Wn and VilIage
schemes.
P
ror the technical scrutiny of all these
Town and Village Planning Legislation
exists'm ff^pyo^Zs'of 7^?"'
United Provinces
s-
rr"
resPcct of towns
But w h drJS’ Bombay> thc Punjab and the
hut, as far as we are aware, no such provision
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•'exists in respect of rural areas.
We consider that legislation
should be enacted in all the provinces on a fairly uniform basis
and that it should include, within its scope, both urban and rural
areas. We therefore suo'^est that the Central Government should,
in consultation with town planning experts, draw up model
legislation and recommend its adoption by the provinces or, with
their approval, secure the enactment.of an all-India measure. In
cither case, the proposed legislation should include all the require
ments that modern conceptions regarding town and village
planning would suggest for incorporation.
Planning in Urban and Rural Areas .
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187. Large cities.—In some of the larger and more congest• cd cities in India improvement trusts have been engaged, for some
time, in slum clearance and the improvement of housing. The
results have not, however, been satisfactory in a number of cases,
because cleared areas resulting from costly demolition operations
have been allowed to be built over without adequate control. The
existing legal and administrative-procedure should, where
necessary, be so modified as to ensure that such undesirable
developments arc not permitted to continue.
We recommend
that improvement trusts should be established in all the larger
cities of the country for dealing with slum clearance and rehous
ing problems. One of the handicaps from which existing improve
ment trusts suffer is lack of technical assistance. Every trust
should be. required to employ a town planner on its staff as soon
as trained personnel of this class becomes available in sufficient
numbers.
188. Other urban areas.—The urban areas for which the
establishment of improvement trusts is likely to be considered not
feasible will, from the point of view of size and importance, be
such as to make them suitable for inclusion in the district health
organisation we have proposed earlier. The local authority that
should be made responsible for the planning of such urban areas
should be the District Health Board. This authority, should, as
in the case of an improvement trust, be required to maintain on
its establishment a trained town planner.
189. Rural areas.—In the early stages of our programme it
will be difficult to extend planning operations into the rural areas
as a whole. During this period, attention may be confined to the
lay-out of new villages which may be established as the result of
developments in industry, mhyng, agriculture or the setdement
of demobilised personnel. In the case of all new villages,
the
Provincial Director, of Town and Village Planning should be
-consulted beforehand by the department concerned and he should
-design the lay-out.
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Location of Industry
190. The haphazard location of industries in inhabited areas.-.
^UcerSnCOntr°
^g’^tion. Legal provision exists .
1
,4, Provmclal Local Self-government Acts for enabling the
dest'to sOeetydtO
1?Cati°n Within
areas. We
desire to see adequate provision for controlling the location of
*r
Strohn UdCd
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Pr°Posed model legislation for town and.
village planning Our suggestion that the lay-out of any. new
Town anJv-H
p?bmittedit0 the Ministry
Housing-and
a^Jv to dre^fteiP ann,ng
P^*0^ aPPr0Val sEouId also
workers A
f acco^m°d^^n provided for industrial
orkers. A colony for such workers should not be permitted on
duriS’S baS1S?r^ longer period than Chree
and’ cven
during this period, adequate provision should be made for such
amenities as roads, water, drainage, sanitation and lighting.
Training Facilities for Town Planners
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191- We make two recommendations. One is that-a certain.
Am1^ f SCCCtCd individuais should
sent to Europe and
America for tramingtin the subject. The other is that town plan •
nm experts from abroad should, if necessary, be recruited onkaTmaT^-and thaC
^’shoukl bi? set up
at least in a few universities in the country.
Housing, Rural and Urban
192. Housing cundiduus
conditions in India present a- deplorable
picture. The impressions that. wc gained during our tours.
indicate <extremely unsatisfactory conditions of housma i
rh.n n ;■’irf'TC nnrl
_ ___ _____ t
•!»
.
rural and1 11urban
areas and, in particular,
appalling
conditions
of_.
overcrowding in industrial centres.^ The single room tenement is
a common feature of even many of the
more recently constructed
ousing accommodation in industrial areas. Such tenements often
We m„e than toe fatol, and, in any ease, h“e "
°s
m room, kitchen and bed room.
The sanitation of rhrse
ThouS
inldeqUate 3nd °f 3
^imentary na tur.
Thousands of workers have been drawn to these industrial centres
karLnduStnCS Or
dlc expansion of old ones but little
Sd
Th"
Pr°vide Jhe additional accommodation .
Mad 4
; I rauk 1S that condinons
Calcutta, Bombay,
Madras and Kanpur,, to mention only-a few cases are 3
shSe
aH u lnt01erablc- Thousands are without any home or
ice/ id??
1,VC
3 °n PaVementS> Kandahs open
.
> nder trees, in cow sheds or in any temporary shelter.
Recent Housing Developments in Western Countries
hotKin^r Bef'v6™ the two world wars the provision of adequate ■
nft for the people was recogmsed in most Eurooean countries
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.as an urgent and important social problem and Governments
accepted the view that “housing has become a public utility” and
that the right to live in a decent dwelling has taken its place in
the national minima'’—the right to good and abundant water,
to sanitation, to adequate fire and police protection, to the use of
paved and lighted roads, to education, to a certain amount of
medical care, and, in most European countries, to various forms
■of social insurance”. These national housing schemes have certain
■features which include control by the public authority over hous
ing standards and financial aid directed towards promoting the
building of houses of the required quality and in sufficient
numbers, and the maintenance of the scales of rent at reasonable
levels.
Our Recommendations
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194. In India a long-term policy, comprehensive in scope
and modern in outlook, is essential for a satisfactory solution of
the housing problem. The objective to be attained is the creation
of hygienic houses in adequate numbers and of adequate size, in
“sanitated” areas equipped with all the facilities necessary for
community life. In the execution of the housing programme
Governments and public authorities should perform the following
functions:—
the planning, execution and regulation of hous
ing programmes, including participation by local autho
rities and improvement trusts in house construction and
maintenance;
(ii) the grant of financial assistance by long-term loans at
low rates of interests, or grants-in-aid;
(iii) the prescription and enforcement of standards; and
(iv) the promotion of housing research.
(’)
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195. Functions of the Provincial Governments.—Upon
. ' Provincial Governments must rest the primary responsibility for
dealing with housing and town and village planning. The hous
ing of the people is essentially a State responsibility. It may, of
course, be delegated under suitable, conditions and in defined areas,
- to local bodies or public authorities such as improvement trusts.
Elsewhere it will be necessary to utilise every available agency if
a comprehensive programme is to be planned and executed within
a reasonable time. Provincial Governments should consider the
establishment of a statutory body, under the direction and control
of the Ministry of Housing and Town and Village Planning, with
financial resources and power to plan and execute a province-widehouse construction and
town
and village development
programme on a 20—30 years plan, in five yearly stages. The
: .Provincial Ministry of Health is deeply concerned in the proper
65
execution of any housing schemes and should be re«
responsible for
the control and enforcement of minimum standards i
in the design
■and construction, not only of houses but also '
of environmental
amenities, such as water supply, sanitation and
- recreation. The
Two Ministries must work in cl
close co-operation with one another
and the staff of the Ministry of Health
must, at all stages, be in
contact with those whoare responsible for the execution of housing
■schemes and town and villa.ge planning.
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196. Functions of the
l---------ur recommenda-Local Authority—.^
Our
tions for provincial and district health administraf
------ hon, will, if
implemented, establish certain new local authorities in the nlace
of
or existing
existing ones.
ones. We
We visualise the creation of serrate district
organisations to
with health,
organisations
to deal
deal with
health, education, public works nd
foTeXienT ad ’ 'n
fav°urablc conditions
for efficient,
l._
tor
efficient administration.
In carrying U(
out a province wide
housmg and
p
anning
policy
in
urban
and
rural
and Planninp P?licy in urban and rural areasf the work of
enforcement of standards, from the health point of view, will fall
upon the district health organisation and its officers.
On the
other hand, the actual construction and maintemnrZ* of
public" woiksbandrri H
by
by the district agCnCy
agency which
which dcaIs
deals ^
pub He works and winch, in
this connection,
connection, will
will be
be under
under the
the
m this
control of the Ministry of Housing and Town and Vilh4 Plan
-1 ahas
nd Village
Planning^or the authority to which the Ministry
defeated
its'
wnich the Ministry- hnc
197- Housing standards—We have set out certain aenenl
recommendations regarding the minimum standards to b?
enbed for all houses built under public or private auspices pros
details regardmg these standards reference may be made per
to
paragraphs 25 to 33 of chapter XIII of Volume II of 0™
report.
si-inr)1^ • ^P,C Pb'lns- The legal enforcement of housing
housin
standards is only one method of approach towards of
raisins
th?
com? O^COnstructl?n- TyPe plans and estimates coverin'? a
onsiderable range of cost, material and sizes should be prepared
These plans and estimates-should be based on local rates of cnst
as far as possible, and should incorporate locally procurlle
material and they should be made readily available to7the general
Housing for the Lower Income Groups
sb u"; Wc belieVC that an Indi:
>-wide housin
housing programme
India-wide
should give first priority to the
the needs
of
the
lower
needs of the lower iinrn
: me°
of the population. It is not easy
easy to'fix
to'fix an upper limit of •gr°UpS
for oil pr„„„c„. f„ i Soo* I “EJ™" °f '«™C
*50
Rs. i;
•>5O a momhjind
month and in the North Is.
rso to -,0“ Th. r •,
to
bo fixed
fi„d by
by each
each Provincial
Proving c"
"™ld
to be
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200. Urban areas.—In many towns and cities industrial wor
kers Jive interspersed with the general population and the housing
problem must therefore be corrsidered for the community as a
whole and not for industrial workers only, bearing in mind the
income levels we have suggested for defining the working class
population. We believe that future developments in the housing
sphere will be regulated- on proper lines if such developments are
undertaken under public auspices, particularly in the larger urban
centres. We have already said that the responsibility for providing
houses for the people rests on the Governments of the country.
Local authorities and industries should, no doubt, bear their share
of the cost, but the State cannot escape the fundamental responsi
bility.
«
201. Rural areas.—The housing problem in rural areas
presents special difficulty. The Governments concerned, through
such local authorities as may be suitable, should be responsible for
enforcing minimum standards in-any new village construction.
They should also assist, with finance, advice and example, in the
improvement of existing houses in rural areas. Type designs for
new houses and suggestions for the improvement of existing ones
should be made available to the villagers through the Health and
other appropriate Departments. ,As in the case of housing in
urban areas. Governments should be prepared to finance or assist
in financing any approved schemes for new housing or housing
improvement, whether sponsored by the Governments themselves,
by local authorities, by co-operative banks or societies or by private
interest. Governments must, however, exercise control over the
planning and execution of such schemes and, in particular, over the
rents to be charged for new houses, and any increase in the exist
ing rents in the case of housing improvement.
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Water Supply
i
202. According to the 1939 report of the Public Health Com
missioner with the Government of India only 253 towns out of a
total of 1,471 towns of all sizes in British India possessed protected
water supplies. The population served by these was about 12.7
millions or 48.7 per cent, of the aggregate population of all the
towns, but only 4.5 per cent, of the total estimated population of
British India in that year.
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Rural water supplies are drawn mostly from wells, tanks,
rivers and streams and they are almost completely unprotected.
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Our Proposals
f
-------203—A—vigorous policy should be adopted immediately by
Governments for the development of a water supply programme,
which should aim at providing the entire population under their
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charge with safe water for drinkina ind
in a period of about
vears Th. ;
domrestlc purposes withnot be-lef,
aS , ffi
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=
available to complete theproaram
should be made
cal bodies which may be designated C
?
Penod- Techni- and Drainage Board^^JdTSb^m^?0^-1 Water
i.
■
ernments in the planning and fWn, " r
dcr t0 asslst Gov'
«!>»»,
a
“» “dJeof ware, and d™„lge
Pravincbi.—The™’,,0^'^ ““JB"rtls> c'"™l and
carrying out, in the Central Adm' • P ,rform
dual task of
which the Provincial Board will wrfo^ ArCaS’
Same duties
well as of dealing with various m/t - 7 'n
°Wn tcrritory
to more than one province such asYh ° lnterest.and 'mportance
a.n all-India basis L wte^
on
river pollution. In addition^
r
ohlems of drainage and
Cental Coro„„„“t
„ “nl L ? ' “"P
n
n
n
mg co-ordinated effort in the nrn ' * $ ^Cnc^a P°hcy of promot»l »d Wh„i„| £ i V
“d of so’o? bnanaial
• dramage schemes.
furtherance of their water and
n
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formed V.he Cemr^POa“S'
>ns to be pertheir respective'
sources
of water
needs of rK^
to die
and dramage schemes and the pmpiatio
SUPpl'V'
respect of such schemes 6) variLZi k
, f a Pr,or,tV 1'st instandards to be prescribed for rhe n
crnnrters such as the
the training anef registration of P“rlhcatlon °f water and sewage,
tion of special locaT prob^rrs
OP.erntors anc^ the investiga-
r£>,„al “f flSS™ e? and M r*’*" °f
grants to the Government?
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the -recommending of
schemes.
L’0'e-nm^ts concerned for water and drainage
p
—
<3
Water Conservation on an Inter-provincial Basis
n
to °ur°n6otic?bv?he7uD7rintmT'S
WaS f°rciblv broughr
don of £epartmcnt’ the United Provinces^ He^id^tb^/"^
»d fhe'ean™;" bTVb-'^SX'T’
.be Ju^'
suPPlv of several’ lame townTin"}?15 rCperCUSsions °n the water
ed Cawnpore.” H’ a ho
-particu!arlv aAgra
another problem
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d °ut that 1C ^s aaamvated
waste,; Pr°b,em’ nam<^
«le river pollution & t2c-
4
°'~S8 CbHI/ND/84
68
207. The question of conserving, all the available sources of
yater throughout the country and of so allocating the supply,'
from a common source, to meet the reasonable demands of indi
vidual provinces concerned, is of paramount importance from the
standpoint of the health and general welfare of the people and
ve have come to the conclusion that^ this matter calls for special
consideration. Where an urgent decision on such a matter is
required, the Central Government should be empowered to give
a temporary decision which should be binding on the provinces
concerned, until a final settlement is reached through the award of
an Arbitration Board or any other suitable body to which reference
should be made with the least practicable delay. We consider
that rhe same procedure should apply to inter-provincial problems
of river pollution by trade wastes and sewage. Even when an
urgent decision has to be taken by the Central Government we
consider it necessary that such decision should be taken only after
consulting the Central Water and.Drainage Board and the Central
Board of Health in regard to the technical ' and administrative
aspects of the question.*
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208. As regards-the other subjects included under the heading '
“Environmental hygiene” such as general sanitation, river and j
beach pollution, control of insects, rodents and other vectors of j
disease etc., we have set out detailed proposals in the relevant por
tions of chapter XIV of Volume II. These, if implemented, will,
it is anticipated, make for a considerable improvement of the exists
ing unsatisfactory state of affairs.
QUARANTINE
International Quarantine
209. As regards international quarantine two aspects require
•consideration. One is prevention of the export of infection in
jespect of the diseases recognised under the International Sanitary
■Conventions and the other is that of protecting India from the
possible introduction of diseases such as yellow fever, sleeping
sickness and others from which the country is at present free. In
regard to both the measures now enforced in India are considered
reasonably complete and satisfactory.
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210. The ratification of international treaties should be one
among a small group of subjects in respect of which the Centre
should be given-the power to compel a'province to fall in lin«
with the other provinces. The fact that international air line
*Mr. P. N. Sapru does not agree with the above recommendations for dea
ing with these difficult problems. He has dealt with his view in a note whic
is appended to Chapter XIV. of Volume II of our report. The views 'of tl
Test of the Committee on Mr. Sapru’s note will be found in paragraph 22 <
"the same chapter.
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pass through different provinces in the country necessitates action
•on common lines in respect of the health requirements of airports
-and their surrounding areas and it is therefore essential that the
■Central Government should be able to carry out a common policy
throughout India.
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Internal Quarantine
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211. Internal quarantine is concerned with the enforcement
of measures designed to control the spread of infectious diseases
between neighbouring units.^of administration, namely, the pro- '
vmces and Indian States. We make the following recommenda•^lons:—
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212. (i) The Central Government should be responsible for
the enforcement of all measures necessary to prevent the interprovincial spread of infectious disease. In this connection India
may well follow the practice which is in existence in the United
States of America. In that country “the Federal Health Service
has control of sanitation in interstate traffic including supervision
of the sanitary facilities on all interstate vehicles. ^Thc Federal
overnment also assist the States in.the control of communicable
diseases within their own territories, if desired to do so. The
Central Government in this country should be similarly empower
ed to control the mtcr-provincial spread of epidemic diseases.
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(2) The Central Board of Health should draw up, in
consultation with the health advisers at the Centre ’and in the
Provinces, a memorandum of instructions to be followed by the
Central and Provincial health departments in order to promote
the effective control of the spread of infectious diseases. The whole
held of possible co-operation should be examined on a wide basis
and a common programme of action drawn up under the auspices
of the Board.
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214- G) The desirability of creating an inter-provincial fund
for carrying out the measures outlined above should be considered,
the Central and Provincial Governments making their contribu
tions to this fund on some agreed basis. Such a fund will also
constitute an insurance for all Governments against possible disas
ters such as famines, floods and earthquakes.
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215- (4) The measures described above for the enforcement
of internal quarantine can hardly be effective without the active
participation of Indian States. Such participation can be of value
only if those States possess a reasonably good health organisation.
The more important of the States probably satisfy this'condition.
If, in the beginning, even these can be brought into the scheme
by mutual arrangements between British India and the States,
■.he range of activity of the internal quarantine organisation and
its effectiveness will have been greatly increased.
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VITAL STATISTICS
-
he.4) iSeSVfe
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.
0Teif ln char£e of the thana (police station) and the person respon
sible for reporting births, deaths and cases of notifiable diseases
from individual villages is the cho^dar, who i7 perhaps die
lowest grade of public servant and is generally illiterate In the
prosince of Madras the Registrar is the headman of each village. -
■
217. The recorded vital statistics are passed on, through a
Vint- Co Th'0 7
°f PubHc Hea]tb
each promo.. Compilation of the data is carried out at the different
statTLm^HT'T?' MadraSTmS 30
to this general
“reduced the T
™mber of ^rmediary stages has been
of the 1/ f T bcadma" Passing °n his report to the Tahsildar
it dherriv J
T Tl?
and' the IatTcr Scndln?
data f ffi
h' 1
°f ,Pub!,C HcaIth- Compilation of th?
die laTter nffi ° CTPkr°VInCC ^ i T" ccntrali^ i" the office of
and has khaSLbCCn f°Und t0 bc satisfactory
“ °'h“ Pro™"S b’
C^'
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RECOMMENDATIONS
The Areas served by our short-term Programme
I
T
unit 2 Th
CrCati°nkof four registration offices in each primary
“ .i~Thc]p,aci"S
the regtstermg authority as close as possible
o the people >s des.rable in order to improve vital statistics. Wer. ore recommend the establishment of four registration offices
ffie'uffit ^Th3"7
K°f thcSe.beinS at the headquarters of
tK unit. The public health nurses and midwives should be made
Sh°uId be responsib!e for en-
EgS stSfoS"' p'op“ the
"d
2X9- All the members of the public health staff emoloyed
in the pnmarv umt should systematically check the birth and
eaffi registers by house to house enquiry, when they visit villages
on their routine duties. In addition, we anticipate that the village
VC TgCStCd Will-hclp tO bri^ on record evems
which might escape-me—notice—ot -• the chokidar as well as to
toWJS’t mhthC VI agCrS’ 3 sensc of Personal responsibility in regard
to registration.
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The Areas outside our Short-term Programme
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220. We recommend the employment of non-medical per~sonnel with some <elementary
’
type of training, as Registrars in the
areas to which our health
programme
is not
---—th programme is
not extended.
extended. Each
man s range of jurisdiction should be limitedI L.
to such a. number
of villages as would enable him to visit all of them within
period or about 6 days. During three days in the week he should
attend the registration office and the
remaining days should be
devoted to an inspection of the work
of the chotukidars in the
villages within his area.
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Certain Other Proposals
221. (a) House lists in villages
C
and sample
«
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recommend
the
preparation
and
* * ,
- —1 maintenance of house lists for
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individual villages The list should contain information re<rardin<r
the name, date of birth and sex of the head of the fam'ily and
of every normal resident of the house. It should be made oblifktOcn °n ^C, holuselloldcr
give the information required for
c
mg o the house list, should he be-asked by the appropriate
authority to do so.
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In a subcontinent like India the use of the sampling method
is eminent y suitable for the collection of demographic information
o ^ar,ous types and the provision of an accurate house list for
each village will prove invaluable for sample surveys.
222. fb) Tlic provision of adequate incentive to the people
. tor the registration of births and deaths.-An effective method of
stimu ating interest in the people for the registration of vital statis
tics will be by creating conditions requiring, in an increasing
egree, the production of proof of age, community, parentage etc.
It courts, schools etc. could be induced to insist on the production
ot birth and death certificates the public will begin to feel the
necessity for registering births and deaths in their own interest.
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. 223- (a) Compulsory registration of vital statistics.—In the
2reas in which our scheme will be introduced registration of vital
statistics should be made compulsory along with the introduction
o the scheme, wherever such provision does not already exist. In
other areas compulsion should be introduced gradually. The enJ’.Orcement or tne law through the prosecution of offenders is essential if definite improvement is to be secured.
Administrative Organisation
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224. The central organisation.—We recommend the appoint
ment of an officer with the title of Registrar General of Vital and
Population Statistics. He will be attached to the Central Ministry
■°
ealth and will be responsible for the collection, compilation.
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study and publication of vital statistics from ail parts of the counry, for the carrying out of the census at periodical intervals and
for continuous population studies. He will work independently
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bUC m cl°Se C0-°Perad°n with
•
e should publish an annual report on the population of
India incorporating such information-as-is-available Pre<rardin<r
existing conditions and possible tendencies for the future.
°
ral’c "fit mrdlCaJ sectl0n” sh°uld be created in the Registrar Genem) W
pUrp°Se °f Providing statistical help to the Cen
tral Health Department m its day to day administration and in
the carrying out of special investigations.
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225. The provincial organisation.—The provincial statistical
organisation should correspond to that proposed for the Centre and
the functions of the provincial officer'in charge should be similar
to those of the Registrar General. The designation of the provin
cial officer may be the Provincial Registrar of Vital and Population
Statistics. He should be attached to the .Provincial Mimstry of
Health for administrative control and should work independently
ot, but in close cooperation with, the Director of Health Services.
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The provision of “a medical section” in the office of the Pro
vincial Registrar for die same functions as those suggested in con
nection with the Central Health Department is also necessary.
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We have also made suitable recommendations for a distriefi
vital statistics organisation, which will work under the control of
the Provincial Registrar.
226. The employment of statisticians in increasing numbers
will become necessary in the vital statistics, health and other depart
ments of Government. Industry is also likely to employ a grow
ing number of persons trained in modern statistical methods In
the circumstances we recommend the development of facilities for
statistical training of a high order in the universities'and in certain
other centres.
PROFESSIONAL EDUCATION
k ij2l °LUr ma11? °b'cct during the short-term programmeshonid be the provision of adequate numbers of trained staff in
all categories, in order to facilitate the development of our health
programme with the least possible delay. Before indicating briefly
our. proposals for the expansion of existing provision for professiona e ucation in the field of health, we may consider certain:
general questions which are relevant to the subject.
The Target in regard to the Production of Doctors
228. We have placed the target, at the end of the first tenyears of the programme, in regard to the production of doctors
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at an annual output of 4,000 to 4,500 as compared with less than
half -that number of graduates and licentiates combined now being
produced each year. To man the new medical colleges with
suitable teaching personnel we anticipate that-the-A-HTndia-Medi
cal Institute, the establishment of which wre are recommending,
will provide a steady, if limited, stream of teachers of the highest
quality. In addition we have suggested that at least 200 carefully
selected persons should be sent ifor overseas training in order to
equip themselves for filling teaching posts in the country.
The Type of Doctor for the Future
229. Having given serious consideration to the suggestion
that, in the conditions now prevailing in the country,’it might be
desirable to provide both fully trained doctors and a less elaborate
type of medical man, the conclusion which the majority of us
arrived at is that, having regard to the limited resources available
for the training of doctors, it would be to the greater ultimate
benefit of the country if these resources were concentrated on the
production of only one and that the highly trained type of physi
cian whom we have termed the “basic” doctor.*
Admission to Nfcdical_.ColIcges
230. We feel that, as far as possible, the applicants best
qualified to make use of the opportunities provided should be
admitted into the medical colleges. We realise that there are
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•Six of our colleagues (Sir Frederick James, Dr. Vishwa Nath. * Messrs.
Supru and Joshi, Pandit Maitra and Dr. Butt) agreed to the advantage of
having one single type of medical practitioner, but in view* of the overall short
age of doctors, felt that the early realisation df this ideal must be sacrificed to
the immediate needs of the country. In their view the imperative and funda
mental need in India was the large scale production of trained medical personnel
of all kinds and to that end were prepared to use every possible means, includ
ing the adoption of a shorter licentiate course to increase, both rapidly and
substantially, such personnel.
The majority view, while recognising the need for as rapid an expansion
of medical personnel as possible, has taken note of the fact that the “basic’*'
doctor will receive adequate training in the community and preventive aspects
of medicine and that he will, therefore, be much better equipped for fulfil
ling the functions which have been proposed for a medical officer in our pro
gramme than a licentiate with his more limited background of scneral educa
tion and of professional training. Moreover, the “basic” doctor.’supported by
adequate and efficient technicians and other ancillary personnel, is capable of
extending his sphere of public utility to an extent which would be beyond
the capacity of a less efficiently trained, person. It seems.therefore likely that
the anticipated advantage from a larger out-turn of doctors by the continuance
of the licentiate course will be largely counter balanced by the more efficient
and extended service which the ‘basic’ doctor will be able to provide. It is also
considered that the production of two types of doctors is to be deprecated on.
general grounds, because the person with a lower status naturally tends to
develop an inferiority complex and a chronic discontent which cannot but be
mnimical to good work.
A separate note favouring the continuance of licentiate teaching by Drs.
vishwa Nath and A. H. Butt is given in Chapter XVIII of Volume II of the
r.e.port' 0°
pther hand, three other members (Drs. Amesur. Narayanrao and
Wadhwani) consider that admissions to medical schools must be slopped forth
with and that such medical schools as can be up-graded should be converted
into colleges even before improvements to existing colleges are carried out..
Their note will also be found at the same place in Chapter XVIII.
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Snored m
pe.Jps b,
third of the admissio-is
e
Wc !U^ that onebe by pure merit" and th 'e5y-medlCal ,training tnstitution should
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if they
Stipends to .Medical and Nursing Students
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232. In Russia medical education is free and in the UniteH
mg °m, the Goodenough Committee has recommend“d that
ordcr^ °f,the admiss'ons.to_medical schools should he free. In
prevent economic barriers standing in the way of suitable
SZCX§thTdiCal pr°fcSSi0n WC WOuld Hketo see tha:
all those, who are willing to enter the public service after successfully com
t nnnCtln"
COl!rSC’ Sh°uld be Kivcn an annual stipend
of Rs.
instalments
° 'k bCmg rcccovcrcd from them later in easy
ns alments. n v.ew, however, of the large financial outlay that
h.s proposal mvolves we have included, in our estimates, Jrov smn only for 50 per cent, of the entrants.
F
th
V1' nCCd ,'fo,r,nurscs is cvcn greater than that for doctors
here being probably no more than 7,000 registered nurses at
memation 'of
3 Wh°1C- °n thC othcr hand
imple
mentation of our short-term programme will require approxipem1 of RsO°6onUrS=S'
^ggCStCd
Pr°V'sion of a stI‘Rs‘ $° P.cr month f°r pupil nurses, a part of the amount
thus advanced being eventually recovered from them in easy instal-
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Medical Education
Undergraduate Education
233- Considerable thought has been given bv us to the type
■of training necessary for the evolution of the “basic” doctor and
fn 7be
ght J™?
and rcPrcsentative panel of experts
irv** Tkd
medl,cal cducation from different parts of the coun
try.
the main ideas underlying the changes recommended in
the undergraduate curriculum include a reorganisation of the teach
ing both in the pre-clinical and clinical fields a reduction in the
0- i dactlc instruction in certain subjects and an cmohasis
on the inclusion of-principles and methods which-will-enablethestudent to learn for himself, think, observe and draw conclusions;
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lhe establishment, in every medical college, of a Department o£
^Preventive and Social Medicine so as to give the student an insight
into social health problems by contacts with home and community
'- life and the inclusion of a year of “internship” after the qualifying
examination, of which three months will be devoted to work in
a public health unit and the remaining period in a hospital o£
-approved standard. Throughout the whole course, the importance
of research should be stressed and whole-time teachers should
themselves engage in research and encourage any student showing
.an aptitude or learning towards this important aspect of his work
to participate in research.
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234* Our programme of expansion of educational facilities
includes the improvement of existing colleges, the conversion of
suitable medical schools into colleges and the establishment of new
•colleges in different parts of the country.
Postgraduate Education
235- Postgraduate education should be devised to meet two
•different needs. They are, (a) the training of consultants and
specialists and fb) the training of practitioners desirous of practising
a speciality without the definite status of a specialist. Tn the case
of (a) such training will naturally involve several years of work
in special departments and hospitals and lead to a higher quali
fication such as the M.D. or M.S. In the case of (b), the training
in the speciality concerned may range from iz to 18 months under
•suitable guidance. We recommend that courses should be avail
able in (i) Oto-Rhino-Laryngology, (ii) Dermatology, (iii) Radio^°Sy>. diagnostic and therapeutic, (iv) Ophthalmology, (v) Obste
trics and Gynaecology, (vi) Venereology, (vii) Anaesthesia, (viii)
Psychiatry (ix) Pediatrics (x) Tuberculosis, (xi) Malariology, (xii)
$Iood transfusion and resuscitation and (xiii) Orthopaedics.
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236. We have suggested the establishment of a special orgasiisation, the Central Committee for Postgraduate Medical Educa
tion, to be responsible for laying down standards in respect of
postgraduate training in particular subjects and for promoting the
• development of facilities for such education in different parts of
the country on a co-ordinated basis. We have also made sugges
tions for the apportionment of cost of such institutions between '
the Central and Provincial Governments.
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Pefrcsher Courses for General Practitioners
: .
23'7- One of the most serious handicaps in raising the general
I -standard of medical practice in India is the
provirhe absence
absence of
of any
anv provi|*sion for refresher courses. There are several lines along which
ptefresher courses may be arranged.
t
(i) Whole-time refresher courses which may extend from
|
two weeks to two months. It is desirable to encourage
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short-term courses of two to tour weeks, as many medical men imay not find it practicable to be away from
their duties- —
for/ longer periods.
_(ii) Part-time courses which may be—
(a) week-end courses
spread over weeks-or—
(b) whole-day courses y months organised on a
(c) half-dav courses
J systematic basis.
(iii) One educational session
‘
once a week or fortnight conducted throughout the: year.
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(iv) Short-term posts in a recognised hospital
ranging from one month to three months.
LA
for periods:
WC recommend that facilities for refresher courses should be
developed in all hospitals attached to rhe secondary health centres,
district health centres, medical colleges and the headquarters' of
each province.
238. We have also made recommendations regardino- the
dfetetics11
trainin® ^ac*^t’cs *n tuberculosis, mental hygiene and
Special Provision for Licentiates
. 239arc two types of training that may be given, (i)tra‘n‘ng which will enable licentiates to obtain a university degree
and (2) advanced training in the specialities.
C,°^SCS IcadinS t0 degree qualification.—The AllIndia Medical Council has suggested certain changes which some
universities have accepted, foe result of which will be that the
licentiate can within 18 to 24 months obtain the degree of M.B.B.S. .
pecial concessions to those who were serving in foe armed forces
so at they may, after demobilisation, proceed to’ a degree have
also been recommended. We suggest that it should be the endea
vour of every university and every medical college to reserve a
sufficient number of places for licentiates so as io enlarge sub
stantially their opportunities to obtain a medical degree. &'
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241. Advanced training for licentiates.—There are at
present only a few centres where such training can be obtained
au llcc?tiartcs\t^c School of Tropical Medicine, Calcutta, and the- I
All-lndia Institute of Hygiene and Public Health be in a- two insti
tutions which afford opportunities for them to acquire foeir diplo
mas It is also understood that the Government of Madras have
introduced special courses in Ophthalmology. Obstetrics and Gynaeco °gy> Tuberculosis and Clinical Laboratory Sciences for licentiates- Such diplomas should be made more freely available tothem by other authorities in different parts of the country.
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Dental Education
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242. We suggest that provision should be made for the training ot three types of dental personnel^-the dental surgeon, (2)—
the dental hygienist and (3) 'the dentefmecharfic:
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between medical and dental
l------ 1 colleges, while the training of the ■
other two cclasses
l j-T 1 undertaken entirely by the dental colleges.
In viewr of the difficulty in obtaining well trained dental teachers
during
o <our short-term programme, the number of dental colleaes
that we propose should be opened in the country is limited. We
recommend
--nd ithat dental colleges should be established at Calcutta,.
Bombay, Madras, Lucknow and Patna and that
at Lahore should be expanded. Each
Each dental
dental collca
collegeC for
for po^
p
guradU2tC Stu^cnts shou,d bc associated with a medical
college
medical college so
that the teachers of the latter can assume responsibility for the
instruction of dental students in those
those subjects
subjects which
which'form
form parr
ot tbc normal studies of the undergraduate in medicine.
Postgraduate Dental Education
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• n2i3‘ Appointments as “house surgeons” should bc instituted
in all dental hospitals run in conjunction with the medical colleges
so that dental training on a salaried basis may be available for
graduates. In view of the present shortage of teachers, graduates
in dentistry should be encouraged to proceed to a higher decree
and Pr°vlsl0n for this should bc made in all universities by‘’the
establishment of the degree of Master of Dental Surgery. As a
temporary measure dental graduates should be encouraged to proceed overseas to obtain higher qualifications as well as pursue.training in special subjects.
244. Dentistry as a science can make little progress in thr
eountry until it is upheld by suitable legislation directed to compul
sory registration and prohibition of practice by unregistered persons.
. nstead of each province having its own Dental Act, it is suacrested
t at comprehensive all-India dental legislation should be enacted.*'
Pharmaceutical Education
245. We consider it necessary to provide educational facilitiesor three classes of personnel, (1) licentiate pharmacists, (2) gra-.
uate pharmacists and (3) pharmaceutical technologists. The first
c ass is intended to provide for the large number engaged in dis
pensing work in chemists’ shops, dispensaries and hospitals. The
course for the graduate pharmacist will be designed to train the
number who will be engaged in manufacturing concerns,
7
iS- h4W>Veru 0L,he vLew th3Jt such Illation is premarXL ' ‘T P3S d- ,tJsh°uld not be mad= applicable to those areas
distance
cf 3 re«lstered dent,st are not available within a reasonable.
lure
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Dental Legislation
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■analytical laboratories and educational
i •
third type of course is for
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dlCai lnsututions. The
■tore of pharmaceuticals and dr, deSInng t0 take UP the manufacthem there shonlX
an ,d drugs on a commercial scale. For
macy, an additional Xs^oToneV^
?rad?ate.course
course .in
Phar1 the graduate
in pharyear in chemical technology,
■design, equipment, etc.
■pent
•with.
COmPoun<krs should be dispensed
Education of Public Health Personnel
-Medical Men
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■curriculum of the undergraduate medical student.
The postara-
Heakh
wirLTeT,
Pr07dCdi thIr°Ugh thc DiP'°ma in Pu"blic
rk. rn
’c
.bc'icve, largely be incorporated in the future in
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c course of training for the undergraduate. Postgraduate train
ing m preventive and social medicine will then have, as its obiec■es'^f LPrOT,On
faC1 ities,for advan«d training in such branchind Of ) t JCC as ma.,a™logy> maternity and child welfare,
utdostrial hygiene, public health administration, epidemiology
public health laboratory, practice and statistics. Such specialised
traming may be of two types. The first will be of a limited
wort
>kd W'
aS ’tS pUrP°5C thc ccluipment of health
orkrs with a reasonable measure of proficiency in the subject
•concerned, the course of instruction ranging ordinarily from a
months to one year The second will be for those.who desire to
■attain the status of specialists in preventive health work. For.
"mem the period of training will be from 3 to 5 years, the candi
dates being attached to the Preventive and Social Medicine Departmem of a medical college and being associated more and more
wi the teaching, research and administrative activities of that
•department, including participation in the field training given to
•students.
°
Public Health Engineers and others
, 247- Our proposals for postwar health development require
a large number of qualified public, health engineers for the tackling
ot the problems of environmental hygiene. A beginning in trait?
ing can be made at the All-India Institute of Hygiene and Public
’ a cutta, in collaboration with the Bengal Engineering
' C°ll«ge and the Calcutta University. At a later stage, it is propose t at this subject should occupy a definite place in the course
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fco"£s“»
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ic4 the qualification of all engineers! We have X 7“ 3 part f
engineers.
or| for the training of public
health inspectors and dh^T^'
lr. I laboratory workers.
S and public health.
F?
Tne Training of Nurses, Midwives and Dais
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| deplorable living conditions accomnnm>J
I lack of recreational and cultural facilities
pro™»„ («r Se„„al sup=™„u
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consequent overwork,.
as Ov"crow^ln& and
.ab”"“ »f_
C“J‘?J;eprol>lbl>'
I sbout
h
7
about So,ooo nurses Wirhnnr
f?
tsclt rec]u|re
e I number it is impossible to proceed with'^lvel'pmTnt of hospiS
h1
J—l
4111HUS31UIC co proccc
c |t ^public
n^0^health
cr institutional
facilities
nurs?nas;±X
organj'satl°'’ of die
1 T' the homes of the people. In Chaptc?!^ vl prCVintive work itt
ii.
:- ■£
we have su<raested that bv to-'t h 1 f Vo,umc 1 of our report
’ * available in the country shoddk’raisedto^o
step towards the achievement of this nk r4 ,00°- An essential
the existing unsatisfactory conditions of Va W a d rCm°VaI
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« have ma<fc propools Ls„cd M
“*
«> of r
>s
SO’ there wguIJ
puonc nealtn services.
Even
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-each taking 50 pupils, should be started two years before the health
- organisation begins to be established, that anonher set of 100 centres
should be created during the first two years of the scheme and
-that a third group of the same number of centres should be esta. blished- before the third year of the second quinquennium.
251. (a) We have suggested that there should be two grades
in the nursing profession with corresponding types of training, a
junior grade and a senior grade. The entrance qualification for
the former should be, we have suggested, a completed course for
the middle school standard and for the latter a completed course
for the matriculation.
252. We have also recommended the establishment of nurs■ ing colleges in order to provide a five-year degree course in nursing
as well as advanced courses in hospital nursing administration,.in
the teaching of nurses and the training of public health supervisors.
Male Nurses
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253. Owing to the existing social conditions and customs in
• certain parts of India, male nurses will have to play an important
part in the health programme. Male nurses and male staff nurses
should be trained and employed in large numbers in the male
wards and male outpatient departments of public hospitals, thus
relcasiilg women workers for other work.
Public Health Nurses
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254. We have also made specific proposals in regard to the
training of public health nurses. They are fully qualified nurses I
with training in midwifery also. In addition their educational
programme should stress, throughout, the preventive point of
view. The curriculum should integrate class room instruction in
the science and art of nursing and in social studies with well-plan- I
ned experience in hospitals, community health services and in the
home.
Midwives
7
255. The number of midwives actually available for mid
wifery duties in the country is probably 5,000. In order to provide
bne midwife for every 100 births,, approximately 20 times that
number or 100,000 midwives will be required for British India.
256. Existing training schools for midwives require consi
derable improvement. The most serious drawbacks are (1) lack
of properly trained and well equipped supervisory staff, (2) lack
of facilities for antenatal and .postnatal work, (3) lack of domi
ciliary practice and (4) lack of opportunities for witnessing compli
cated cases of labour. We have laid down certain fundamental
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. .
------- an institution is rcr €Ogniscd as a [training
centre for midwives and have also made
| detailed recommendations for their* fra/rnng coursS
Dais
22t‘ kThC COnI?,?ued cmPIoyment of these women will, for
rhe
P
^;n
ln7tatle- XVhilcL^°g“^g
attempts to tram
r
the A and make her reasonably satisfactory in the practice of
have ui
m many
many cases
cases tailed,
failed, the
the discre
discrepancy between the
: midwifery uavc
• existing number of midwives and that requiredI to meet the needs
■ "f..the ““try is so great that, as
as an
interim mca;
an interim
measure, the possi. bihty of elaborating a system of training whereby th.ie most effective
: use might be secured out of .this
type of
—s. type
of person.
personnel cannot be
ignored. We have. TT
described
i.
x In sornc detail the experience that
one of us (General Hance) has had in developing a midwifery
service fk
through
1 -West Frontier
&
k trained
1_- dais
/ in tt^L C XT
^Ordl
Province,
aS n dC SChT; achlcved
L
a
rca
«™ble
measure
of
-J a reasonable measure of success.
success. We
i fr°m anOdlCr membcr of
°f our
Committee (Dr.
our Committee
(Dr.
; Butt)
that
attempts
b
attempts to improve the normal practice of midwifery
; t^e PublkI0Wh bUlt
'P
,n,n§’ haVC
bC£n CC
lUally successful
suecessful i.in
training
have been
equally
-; the Public. We have, im the circumstances, advocated the trainin"
as an interim
untilan adequate number of mid'’wives'wdl
lntCnm measure
Until
wives
will
become
avadable
and
have made certain suggestions
.
- ----------------- -U.uuuun. dlJU HdV(
: tor their training for urban and
rural
--------- 1 practice.
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Medical Research
Existing Medical Research Activities
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258. Organised medical research at the present time depends
mamly on two organisations (1) the Central and Provincial Gov
ernment Lnboratones and the Medical Research Department and
(2) the Indian Research Fund Association. The more important
institutes and laboratories existing in the country for the promotion
Ot medical research are shown below
---(1) The Central Research Institute, Kasauli, (2) The Haffkine
Institute Bombay, (3) The King Institute, Guindy, Madras,
(4) Ihe Pasteur Institute of South India, Coonoor, (5) The
Pasteur and Medical Research Institute, Shillong, (6) The
School of Tropical Medicine, Calcutta, (7) The All-India Insti
tute of Hygiene and Public Health, Calcutta, (8) The Malaria
Institute of India, Delhi, and (9) The Nutrition Research
i-aborarories, Coonoor.
. -59these, .tile Central Research Institute, the All-India
Public naim
Health ana
and rne
the Malaria Institute
| Institute
V-.'"”?- “of*■ Hygiene “and
““ ^uum.
- ot India are maintained by the Central Government, the Nutrition
f
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f and the other institutions, with the exception of the Pasteur Instij tute of South India, by the Provincial Governments concerned
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The last is die property of the Pasteur Institute Association a bodv
registered under the Societies Registration Act of i860,’and its
management is vested in a Central Committee of which "die Sur
geon General with the Government of Madras is the Chairman
and the Director of the Institute is the Secretary. For information
regarding the development of these research laboratories and
and the
work that has been accomplished by them, reference should be
made to Chapter XIV of Volume I of our reoort.
The Medical Research Department
260. The medical research department was established by
the Government of India for. the provision of a
permanent cadre
of specially selected and trained officers for the furthercnce of
research. With the creation of Central and Provincial
-------- 1 Government laboratories die officers of diis department were appointed
as Directors and Assistant Directors of the various Government
laboratories. More recently, however, the extended activities of
the provincial laboratories have necessitated_.the employment of
workers for special duties and they have been appointed, as required
widiout drawing upon the medical research department. Officers
the latter department have been placed on foreign service, from
time to time, widi odier organisations such as the Indian Research
bund Association and the Pasteur Institute Association.
The Indian Research Fund Associadon
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261. The Indian Research Fund' Association is a registered
association in close touch widi the Government of India, from
which its funds have been mainly derived. The chief objects of
the Association arc (i) to initiate, aid, develop and co-ordinate
medical scientific research in India, to promote special enquiries
and to assist institutions for the study of diseases, their preventive,
causation and remedy; (2) to publish papers or periodicals in
ifurtnerence of the objects of the Association and (3) to propogate
knowledge regarding the causation, made rf spread and prevention
of diseases. The entire control and management of the affairs
of the Association arc vested in a Governing Body, its President
. being the, Hon’ble Member in charge of Health in the Governor
General’s Executive Council and its Secretary the Public Health
Commissioner with, the Government of India. The Governing
Body appoints a Scientific Advisory Board to advise on technical
matters and on allocation of funds, the Chairman of which is the
.Director General, Indian Medical Service, and the Secretary the
Public Health Commissioner. The Association approves an annual
programme of research, sanctions grants-in-aid of research and,
in certain cases, may constitute special enquiries. An annual confe
rence of medical research workers’is~hdrmally held, at which the—
work of the past year is reviewed and proposal for the coming
year are put forward.
....
83
.
RECOMMENDATIONS
262.. We recommend the constitution of a statutory organisa
tion consisting of : —
(0 a Scientific Board, which .will be the executive machi
nery of the organisation and
(2)
’t
an Administrative Body which would form the link
between the Board and the Government of India and
exercise general supervision over the working of the
organisation.
•
The Scientific Board
*?
263. The composition of the Board should include medical
research workers of standing and experience, representatives of
universities and medical colleges, representatives of the principal
scientific bodies in India, prominent workers in the field of public
health and clinical medicine, non-medical representatives of allied
and fundamental sciences and persons with experience of health
administration. The work of the Board should be aided by the
formation of an adequate number of expert.advisory bodies for
special subjects.
1
Administrative Body
264. The Administrative Body should have the
type of membership:—
7 .
following
(a) the Minister of Health in the-Central Government; (h)
representatives of the Government Departments of Agriculture,
Industry, Labour and Finance; (c) one representative of rhe Coun
cil of State and (d) two representatives of the Legislative Assembly.
The Director General of Health Services with die Government of
India should be in attendance at all meetings of this body.
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The Board would make recommendations regarding the'
allocation of funds for the furtherance of research to rhe Admi
nistrative Body in which would be vested the power of giving
: sanction to such allocations.
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265. The main functions of the central medical research
organisation proposed above should be (1) the formulation of
-■ policy in regard to the future development of medical research in.
: India, (2) stimulation of research activities in the provinces, unirtr■ siries and medical colleges and (3) co-ordination of such research,
activities throughout the country.
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266. Our recommendations deal also with future develop
ments in respect of Government research institutes and tcachincr
t institutions. In addition we have suggested the provision of imr proved laboratory services in the different provinces through the
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creation of regional laboratories, to be linked locally with other
XTn’Sa^nS In c0nncction
the health programme and for
technical direction, with the central laboratory at the headquarters
o the province. We have also made suggestions regardmo- the
nuXXn^I Of 'rcscarch.m sPfciaJ subiects ^ch as malaria0 and
nutrition Investigation into the social and environmental factors
Son'refaSJX11
X°
SU^cstcd- F°r informa-
r
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The Recruitment and Training of Medical Research Workers
fo -rX7'f The numbcr of suitable medical research workers and
bCfoXanvretra,niI?S
are ,!na,deC5uatc at Prcscnt in India and,
can be uXd 7inS'Onk °f mCd‘Ca
°n 2 rcasonable scale
can be undertaken, the primary requirement will be a orcat info^recmiX nUmJCr1of Pr0Pcr,y traincd workers. Responsibility
for recruiting medical research workers and for the creation oE
training centres for them must be the primary function of the
XK
" specific
mCCdiCal
rcf-incdthis behalf
ab°- also.
-d
v aveeXTd"
made153110
certain
recommendations
The Manufacture of Biololgical Products
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=68. One of the activities of Government laboratories is the
manufacture, of biological products such as vaccines and sera
marnly for the use of Public Health Departments. While recocrnising.that the preparation of these products by commercial firms
in India is an industry which is now well established and has been
making rapid progress, the majority of us consider that the larzc
^ale production of basic prophylactics such as cholera, plague,
TAB vaccines, vaccine lymph and anti-rabic vaccine is of para
mount importance to the public health authorities in India in
PXtCXTg c
against cPidemics and that their production
isnouid therefore remain a Government responsibility.*
2
. All-India Medical Institute
5
269. Our recommendations in the section dealing with pro
fessional education arc intended to promote the production of
health personnel under the different categories, in as large numbers
and as rapidly as possible. Side by side with these developments
however, we consider it of the first importance that at least a few
kiS kX10™’ WhX Wl11 conccntrate on quality, should also be estaOhshed in suitable centres in different parts of the country. In
the first place we recommend the establishment of one such trainXnufacXe8 of such prcJduc^Sd^be a rJ^nsibUity"0^
Under suffic,ently st.rict Government inspection to ensure public
been appended Io OjapUr'xK'of Voluni0?! of
haS
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^““*"14°
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cl» incSSon’^ilS
®a“ttSn ”„( " T3 ’“/
W <» providePpM„a:
•n £
t> i an advanced character in an atmosoher^ which
W.1I Jo® the true tciendfe
,
"fertd
r? ■
‘^tihnhe
“X “ti,=
apostles ot the progressive spirit in whatever field they may be
called upon to serve, whether it be teaching, research TeJeS
health work or administration. Though the al^i of such
n institute may not be numerous, we feel confident that the
»"■
». ors^tS
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mpoosiblc fw^'ilhhment'
7
should be
The Range of the Institute’s Activity
aim a2t7nroXCinvSgCr
11 tHc
thc Institu^ should
th? Sin no o?Snn 7
Ttra,n,ng ‘n 311 itS branchcs and also
linL 1 g °f£nurses- The Institute must therefore have as an
Lnri^k Part
2t’ a mec’lca* c°Ilegc with its teachino- hospitals
and aboratones as well as a college to provide the hHies ^pe
of nursmg education. Later on provision should be made for the
f training of all the higher types of health workers.
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f The Selection of Students
[ .. 27I- The students to be admitted to the medical and nnre.’nn
colleges attached to the Institute should be selected very carefully’
Imerit being the sole- criterion for admission. As the ne-ds of he
1
PndiTshould beh° F LI
?rVed’ appIicants frcm a’> P^ts of
| noia should be eligible for admission.
K
|Organisation and Control
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,The organisation and control of the Institut- shnnlH
Institute
should
C admlnistrativc fieId and (2) rhe technical
and scientifil
'■<nvi^The ad^’ni^tarti''c Held.—An institution of the typ- we
JScge should have freedom to develop its own activir;/d
p»a».ly >„d without th. delaying a£
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strict governmental control may entail. We therefore propose
that its administration should be vested, from the time of its inau
guration, in a Governing Body of suitable composition.
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The. technical_and scientific field.—Although it may appear
somewhat novel in diis country, we. suggest that the technical
work of the Institute should be developed and directed not by an
outside body, however eminent its members may be, which- will
impose its ideas on die Director and Professors of die Institute
but the latter diemsclves acting as a medical faculty. In making
this recommendation we are not putting forward a procedure
without precedent. We understand that, in the Johns Hopkins
Medical School, a similar arrangement has worked successfully tor
many years and that it has contributed materially to the attainment,
by that institution, of the pre-eminent position itTiolds in.the world
of medical education. We also understand that this system gene
rally prevails in the United States.
Recruitment of the Staff
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273. Our recommendations in connection with the recruit
ment of the health services, which have been set out earlier, apply
generally to the recruitment of the staff of the Institute also. As
regards procedure, however, a departure seems desirable from our
suggestion that recruitment to the different health services should
be made through the various Public Service Commissions. We
feel that die adoption of the procedure, which has been practised
in the Johns Hopkins University and which we understand is
generally followed in other universities in the United States, may
widi advantage be tried here. In the Johns Hopkins Medical
School recommendations for the appointment of professors are
made by the medical faculty of that institution, which consists of
its own professors. While the authority for making the appoint
ment is vested in the university, it is understood that the recom
mendation of die medical faculty is invariably accepted. We
desire to see this principle adopted for the recruitment of the staff
of the Institute, the Governing Body being the appointing autho
rity and the Medical Faculty, the recommending body.
f
Finance
274. We consider that the Central Government should fulfil
adequately the responsibility of financing- the-Institute on a suffi
ciently generous scale to promote its development into, and main
tenance as, an all-India training centre on the lines indicated by
us. An appeal should, however, be made to the public for contri
butions. The Institute is of such paramount importance for the
full development of the proposed national health progdammc that
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its financial stability should be’ensured by the Government of India
•endowing it with an amount sufficient to secure, through the ac
cruing interest, at least half the estimated annual expenditure of
the institution in its fully developed form and by a statutory provi
sion for any balance that private benefactions may fail to provide.*
Health Organisation for Delhi Province
r
.
Thc Central Government should attempt to demonstrate
in Delhi Province the effects of implementing not only our proposals
but also those put forward by other committees, which have made
recommendations for postwar development in different fields of
community life. The purpose in view is to demonstrate, to the
country as a whole what can be achieved, through co-ordinated
effort, to improve the health and. general prosperity of the com
munity.
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Our Proposals
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276. While our proposals for the health organisation in Delhi
Province follow the main outlines of the general plan suggested
for the counter as a whole, there arc modifications in certain dircc■ lions. These are designed to secure a higher level of efficiency
in the proposed health service, in view of Delhi being a demon
stration centre for the country as a whole. For instance, a rural
primary unit in this province will have only a population of 20,000
!
as against double that number which has been suggested for the
rest of the country. The proposed provision for medical relief
will be higher in Delhi Province than that suggested by us in
other provinces. The dispensary at the headquarters of the pri
mary unit will have five emergency beds as against two elsewhere,
/ while the 30-bed hospital will serve in Delhi a population of
I 60,000 as against 160,000 in the rest of the country. In view of
I the limited number of women doctors available in India, our
I proposals for the appointment of a woman doctor to each primary
I unit may not be possible of being carried out in the country as
a whole in the early stages of the programme. It should, how| ever, be possible for Delhi Province to secure women doctors for
I the relatively smaller number of such units which will be deve£ loped here. In proportion to the population Delhi will, have
| double- the number of midwives and trained dais in each primary
f unit as compared with the rest of the country. Thus health work
among women and children should be capable of development
f here: on a more effective basis in the other provinces.
I
*Nfr. P. N. Sapru and Dr. Hameed do not agree with the rest of the
Committee on a few points. Their-note is appended to Chapter XX of volume
JI of the report.
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DRUGS AND MEDICAL; REQUISITES
Supplies
In lmPortancc only to the provision of trained
health personnel
must come the supply of the therapeutic sub
stances and medical appliances without which doctors and public
health workers generally
i
may be reduced to a stage of virtual
impotency in the practical
1 exercise of their profession. We have
had evidence 1to show how grave has been the lack in this country
rlpKtVsom dalS‘ k-T ;vhCn thcy 3rc
the
,
—- cost ia
respect or some is so high as t_
. ’ " ’ or at least gravely
to
prohibit
restrict
their use. Quinine may be cited
'"’^d as an example. We are told
that, m the year 1935-36, the actual
cost of producing quinine in
whiF/tk
hOmc Sr0Wn bark was about Rs- 6/8/J mU ?°VCrnDrnent selIinS Price of this article was • a. pound,
,
.
------ was Rs. 18 and
RS’ 22-a pound.
P°Und- This
te was
was largely
This market
market ra
rate
decided by an international
<
J organisation, Kina bureau, which
controlled about 95 per cent, ofworld’s
----- □ supply of quinine. Nor
can be indigenous profiteer be absolved from the charge of criminal exploitation. We feel that such
a state of affairs should not
be permitted to continue and that it calls for immediate attention
2nd remedy.
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ent J?; 7' rC.COmmcnd thata sma" committee, mainly but not
the Sst^nfl1" COmP°sition> sbould bc appointed ^examine
and nth?
rccl?rcmcnts of
country in respect of drugs
po
t matters which it should investigate:—
'
•
(a) What are the drugs and other medical requisites essential
tor general use in the country?
(b) What practical steps should be taken to ensure their
manufacture in the country in sufficient quantities and
their sale at a price which will make them available to
all who need them?
(c) What are the circumstances
which would justify the
conclusion that the manufacture
___ of
Ji any of these in the
country is inadvisable?
(d) What should be the respective fields of Government and
ut private enterprise in the manufacture of these requirements?
(e) What aid and assistance should be given to private a^en.cies in such cases and-under what condition?
/A
V7 What machinery should be established to develop research
—re:gar mg drugs and other medical requisites and their
production in India and to ensure the continuity and
co-ordiation of such research?
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(g) What
machinery
tt
mdcuincry should
snould be
be set up to ensure a steady flow
ot trained technical personnel?
j
279. We believe that it should be possible adequately to pro
vide for these essentiaLneeds-through a combination oZ pX
en erpnse suitably assisted, where necessary, and production by the
State where this is found to be in the public interest. The fina
responsibility should rest with the Government for seeing that the
teauSLnXdS °f thc ,C0,untry in rcsPect of aH important medical
covering Z
f1S rcsPonsibility should be interpreted as ’
met satfs^r J
cnsurin£ ^t these requirements are
met satisfactorily in regard to quantity, quality and price.
Control
■
tral
DrUgS Act
I94°’ which was Passcd by the Cen
tral Legislature, now provides for the regulation of rhe import
ot druas th' lna™facturc> distribution and sale in British In^ia
Acr will h
U2derStancd that certain statutory rules under the
of TnHin \br§ht •nt° f°rCC at an canly datc by the Government
■t Should h K PTsl0ns of this A« and the rules made under
ngidy
“un,ry
indigenous systems of medicine
,
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1 28c’ lWc arc unfortunately not in a position to assess the real
value of these systems of medical treatment as practised today as
nnsn|ayc
Unabe,’ Wltb fbe time and opportunities at our disLr f’ tOiCOnduct such an investigation into this problem as would
] stify clear-cut recommendations. We do, however, say quite
definitely that there are certain aspects of health protection which,
th Our ,°PI[1,on’.can be secured wholly or at any rate largely only
through the scientific system of medicine.. Thus public health
2 f,r Prcvcnnvc medictne, which must play an essential part in the
t . future ot medical organisation, is not within the purview of the
I ~,d,S.cn,0Lls systems of medical treatment as they obtain at present.
|
he indigenous systems of medical treatment do not also at present
C2 with such vital aspects of medicine as obstetrics, gvoaecolocry,
\anced surgery and some of the specialities. Furthen no system ■
treatment, which is static in conception and practice
nd does not keep pace with the discoveries and researches of
workers
the world over, can hope to give the best availr -scientific
“'■‘■“q\»u
IKers me
[ a c ministration to those who seek its aid.
I
207 xVe ,ieel fbat we need no justification in confining our
f wf>?kSa-S t0
country-wide extension of a system of medicine
f
C,’ ln our Vlew> must be regarded neither as Eastern nor WesI in?tnUlaS a C°rpus °f scientific knowledge and practice belongs cent -k be wdo e wor!ci and t0 which every countrv has made its
f
L^nrribution.
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286. We consider this position unsatisfactory. We are re
commending that, for the future, there should be only one basic
medical qualification for entry into the profession throughout
India and that the portal of entry should be a university degree.
The production of the licentiate type of doctor will cease after
some time if these recommendations of ours are accepted. In .the
circumstances we recommend that the Medical Council of India
should be empowered to maintain an All-India Register when the
training of licentiates ceases throughout the country.*
287. The need for restricting the right to prescribe drugs in
the British Pharmacopoea and to practise scientific medicine by
unqualified and unregistered personnel was emphasised in our
discussions. In this connection we considered the desirability of
enacting legislation providing (1) that no medical practitioner
should be entitled to affix the designation
doctor before his
name unless he is a registered medical practitioner in modern
scientific medicine, (2) that no person should be entitled to P1'0-'
cribc drugs in the. British Pharmacopoea, especially injections and
poisonous preparations, unless he is
i: a registered practitioner, and
{3) that those who practise Unanii or Ayurvedic svstems of mediHakims” or uVaids ’ as the case
cine should style themselves as “E
may be.
288. We consider that the public is entitled1 to know the
they call for advice and
exact credentials, of persons on whom
1
treatment and to protection against fraudulent imposition. We
suggest that legislation-should be made so as to provide that no
person shall be entitled to use the style or appellation of doctor
other than those who (a) hold the Doctor’s degree of a Faculty
of a University recognised by the State or (b) are practitioners
qualified to practise modern scientific medicine.
289. Rule 65(9) of the Drugs Rules, 1945, under the Drugs
Act, 1940, provides that a number of poisons, which are included
in Schedule H of. these Rules, shall not be sold in retail except
on and in accordance with a prescription of a registered medical
practitioner. But Schedule H does not contain all the poisons
enumerated in Schedule E of the same rules. We consider that,
if ‘ Schedule E can also be included within the operation of
Rule 65 (9), our colleague’s recommendation would be met ade
quately and that any further restrictive legislation is of doubtful
advisability and. practicability.
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290. The terms “Hakim” and “Vaid” are honourable titles
of considerable antiquity ’ and it is by no means clear to us why
persons entitled to use these honourable appellations should desire
*Drs. Vishwa Nath and Butt are not in agreement with this recommenda
tion and their note Will be found appended to Chapter >C<1V of Volume II of
the report. They suggest the maintenance of the existing position in respect
of all these Councils.
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to assume any other. We do not feel c_
competent to make any
recommendations
regarding
• j.
o the
— organisation
—and regulation of
indigenous systems of medicine. We therefore confine ourselvesto the
-e recommendation that Provincial Governments, if they desire
to Jrecognise these systems, might with profit follow the example
of the
Government
r
"men: of of
Bombay and enact legislation by which
all p'-------■’ *
^”°nS Pr^ctlsln». any
healing art are compelled.
to secure registration~.in a schedule
--------- or schedules appropriate to the
system in vogue and their qualifications in such^svslem*
The Dental Profession
apt. The profession of dentistry is, as yet, totally unorganised
in India and no legal provision exists for its regulation. We re
commend that legislation should be undertaken in order to create
Central and Provincial Dental Councils. The latter sould be
charged with the duty-of recognising training institutions and of
crcatmg and maintaining Dental Registers as well as with the
disciplinary regulation of the profession, subject to appeal. The
Central Dental Council should be concerned with the direction
and co-ordination of the activities of the Provincial Councils, the
definition and maintenance of minimum educational standards,
which implies the right of inspection and recognition of training
institutions, the maintenance of an All-India Dental Register, the
disposal of appeals against disciplinary decisions by the Provincial
Councils subject, as may be necessary, to the directions of the
Federal Court and the regulation of reciprocity within and without
India.
Regulation of the Nursing Profession, including those of Midwives
and Health Visitors
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292. At present the regulation of the nursing profession,
which includes those of midwives and health visitors, is vested in
Provincial Nursing Councils which maintain registers of persons
who have completed approved courses of training in institutions
recognised by them for the purpose and have passed the prescribed
•examinations. Persons so registered arc entitled to practise the
profession in their own province.. Arrangements for reciprocity
with other provinces exist to a degree which varies with the Nursing Council concerned.
293. We recommend the creation of an All-India NursinoCouncil to co-ordinate the activities of the Provincial Councils, to
lay^ down-minimum-educational standards and to safeguard theirmaintenance. Questions of reciprocity within and outside India
should be the concern of this Central Nursing Council: We re
commend the maintenance of an All-India Register by this Coun
cil, with separate schedules for the entry of approved qualifications
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health programme -for the country which .we contemplate. - We
therefore consider it essential that the services of all such person:nel should be utilised, except in cases of proved unsuitability.*
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THE ESTABLISHMENT OF A COMMITTEE OF STAN
DARDS FOR MEDICAL INSTITUTIONS AND EQUIPMENT
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298. In view of the heavy constructional programme which
■will have to be formulated to supply the new accommodation re
quired under our proposals, to carry out the structural alterations
necessary in respect of existing buildings and to provide the vast
number of fittings of all kinds required by laboratories, health
■centres, hospitals etc., it seems desirable that some system of stan
dardization should be evolved which will introduce order into
what may otherwise well tend to become chaos. With the achieve
ment of order there will be obtained the further advantage of
reduced cost that automatically accompanies effective standardiza
tion. We urge the setting up of a Committee of standards for
.Medical Institutions and Equipment and suggest that it should
be closely linked with the appropriate section in the Central Mini■stry of Health. Its composition should include: —
(1) . architects with experience of designing and construction
. of medical institutions under tropical conditions;
(2) engineers with similar experience;
(3) medical practitioners, not merely as doctors, but as having
an interest in, and experience of, design, construction and
administration of medical institutions;
(4) laboratory scientists with an interest in the elaboration
of laboratory fittings on a transferable unit system and
(5) members of the nursing profession with a special
knowledge of the problems of internal hospital design. !
299. We recommend that the Committee should, among other |
things, give serious consideration to the feasibility of adapting some
■of the many existing*buildings of a temporary nature, which have
been set up for war purposes by the military and civil departments
of the Central and Provincial Governments, to purposes in connec
tion with our health development programme.
RE-EMPLOYMENT OF PERSONS WHO HAVE REACHED
THE AGE OF SUPERANNUATION
I
300. Among the major difficulties which have to be overcome----in the successful implementation of. our recommendations probably *E>rs. Vishwa Nath and Butt, Sir Frederick James and Lieut.-General J. BHance desire to lay further emphasis on the remobilisation, for civil purpos
of demobilised medical and ancillary personnel and their separate note will
found at the end of Chapter XXV of Volume II of the report.
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Gora„mmt
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son^TCVt d’ h“biM ph’'Sica[ a"d ■"^■“■2.^-
Ft
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should be superannnilKd “""^S «(
WKh the requirements of the situation, at a°ny rare
drroughout the short-term period and probably i„ the earlie! years
mitted m rnnt’ 1
St
°£ suPerannuation should be per-
not stand in1 ±c wly o7nS pXrionsT
they should be made to retire before they are
in the health services,
re-employed.
f ,ThLcse,I^coram&nc,ations of ours should
apply to all members
or the health services.
T1
3
THE POPULATION PROBLEM
Ph«tin?tt?f£Xd£ K'idTs-,teh h“ 'tl
^»s~
7
ignore the implications of the population problem.
^growth of
Migration
o
3
, . 3°3- Owing to the restrictions which
other countries have placed on the entrv nF YnJ
7
GoVerr» ol01
7
Mortality
•
^lc Past two decades there has been a steadv nil
tn the mortality rate of the country A
f n • t 'V/a
Oeeur if the large scale pmgXZ' ^im±’“m”
“
the community advocated bv for
S
heaJfo or
committees are effectively put into operatioJ HThe05^ P annlr‘o
to believe that there wili be a XZ ofat iJ tW
every year m British India, which will b mThs rate jt.)"5
down to foe level of what has already b^n acc^mplLd ij^
number of other countries. In the decennium betwee^’iqh r - J
whll
avSra^. ycarly additiori-to the population of India a“s a
oe was 5 millions. An annual-saving of 3 mi]lions in Britjsh
I
96
**
-E
’India as the result of improved health conditions will raise India’s
rate of growth to 8 millions a year, without taking into considera
tion any fall in mortality that may be brought about in the Indian
States through similar health measures. Under such conditibns the
very large increase of 83 millions, which took place in the 20-year
period between 1921 and 1941, is likely to be reached within
half that time. A purposeful control of mortality, without a
corresponding fall in the fertility rate of the community, can thus
have rar-reaching consequences.
Fertility
J.
1
305. All available information seems to suggest that the fall in
the fertility rate in India during the past 60 years has been negli
gible compared with the fall in mortality. In this connection
certain estimates of the rates of fertiliy and mortaliy for the country
are quoted from an interesting study of India’s population problem
by Kingsley Davis, under the title of “Demographic Fact and
Policy in India,” published in the Milbank Memorial Quarterly
(July 1944).
Year
Fertility
rate
3
1
I
Estimated
Death
rate
<
1 881—1891
49
41
j
1891—1901
46
44
1901—1911
49
43
1911-1921
48
47
1921—1931
46
36
t
t
r
e
d
1931—1941
45
31
?
4-
i
306. It seems fairly clear that, at least in the immediate future,
there is little reason to believe that there would be a marked fall
in the fertility rate of the country.
_£
Our Recommendations
307. In the absence of certain natural checks such as famine
and disease whose operation will, speaking generally, become more
and more limited as our various programmes of social security and
improvement in living conditions develop, the growth of popula
tion in India will become an increasingly serious problem. Growth
of population may be prevented from becoming a menace to the
standard of life of the community (a) by migration, (b) by
increasing the production of natural resources and (c) by a reduc
tion in the rate of additions to the population. We have already
pointed out that the prospects of emigration helping to lessen the
P
ci
€(
in
lo
in
m;
of
an
cdi
bet
wh
me
an
ten
J
Li
I
r
97
pressure of population on the means of subsistence in
the country
appear to be remote.
- Increased Production
r
308. The advance of science, careful planning and concen
trated effort on the part of the community to develop the country’s
resources may make possible the support of a largely increased
population on even a better standard of living than that which
xists at present. Such measures, however, can constitute only a
porary expedient, because a limit to'economic productivity will
be reached, sooner or later, and uncontrolled growth of population
rountry5
0UtStnp thc Productivc opacity of the
F?
i
r*
rT
Reduction in the rate of Addirions to Population
rate oTLS^ 'T’''
a-ainSt a rcduction in ^e
he tie thT °f P0Pu,at,°" being brought about by permitting
the death rate in thc community to rise. We have therefore to turn
to three other means for decreasing the rate of growth, namely
in theT'Y ° thfCra(§C Of ™rnagc for g'fls- (2) an improvement
n the standard of life and (3) intentional limitation of families.
7
I
TT
!
310. Raising of the age of marriage for girls.—Carefully
collected
:ted statistics from several ccountries
— support the
’ view
•
.
that
the
fertility of women is at its highest during ’the age'period
1 *5 to 19.
1 ne raising
micinnr /~>h
°
_
The
of the age of. _____ _- e \
' marrln£e for girls by a few years from
thc
the present jminimum of 14 would probably effect a reduction in
thc birth rate.
There are also strong physiological reasons for
raising
the
minimum
even T«
v ----.-r age tor the marriage of girls to 16, 17 or
danon
rkra‘n’ ,0WCVer’ frOnl makin" 3 sPecific recommen
dation, partly because we are not unanimous on the point and
par ly because the question is so intimately bound up with social
consk?
tradltl0n’ ^at the Governments concerned should
onsider the state of public opinion before taking any decision.
311. Improvement in the standard of livina—An imnrove
mentm the standard of living generally tends to promote a
Znl
J3* by£helPinS to create an incentive in
ndiv duals to limit the size of their families in the interests of
am ammg .or themselves and their children q reasonable’ level
and
hanK °f Cnab mg the ,3tter’ ^^h proper education
and through the opportunities for earning their living which such
b«
? “p th' sa"d"d ”f “*">
“d
whde
T
h
mUSt h°WeVer be 3 sIow Process and,
vbile this development goes on, it seems likely that the active
an an^
proposed health services will result in
an appreciate reduction of the death rate and thus produce a
mporary acceleration of the rate of growth of population.
9S
I
r
E
ii
£
i
i
li
I
312. Intentional limiiaiion of families.—If we believe that
limitation of families is advisable, we should first ask ourselves 'the
question whether it is possible that this could be secured through
self-control. Our answer must be, we fear, not to any material
extent. While a limited number of individuals may be under-sexed
or may, by nature, be so constituted that they can sublimate most of
their sexual urge into intellectual, artistic or other creative channels,
the large majority of mankind, although able to convert a part of
their sexual impulse into activities useful to the community, may
still have to find satisfaction in the sexual act itself. In the circum
stances we seem to be left with birth control through positive
means as the only method which is likely to be effective.
The Extent to which the State should help to promote the Birth
Control Movement
■
313. All of us are agreed chat, when childbearing is likely to
result in injury to mother or infant,_tlierc is every justification for
the practice of contraception. In such cases it should be the
responsibility of Governments to provide instruction regarding
contraception in maternity and child-welfare centres, dispensaries,
hospitals and any other public institutions which administer medical
aid to women. We also consider that the supply of contraceptive
requisite should be made, free of cost, by the State to necessitous
women when the practice is advocated for reasons of health. There
is also unanimity among us in respect of State action in two other
directions, namely, ft) control over the manufacture and sale of
contraceptives as in rhe case of food and drugs and (2) assistance
from public funds towards research for the production of a safe
and effective contraceptive.
•314. Some of us arc of the opinion that, on economic grounds
also, contraception is justified in the interests of the individual and
of the community and that the State should provide facilities for
imparting knowledge regarding birth control when drs'rcd for
such reasons. The others, while they fully appreciate the impor
tance of relating population to the economic resources of the
country, feel that the active promotion by the State of contraceptive
practices for economic reasons will be. justified, in view of objections
to it on religious grounds in certain quarters, only if there is
substantial support from public opinion.
The Extent to which the proposed Measures are likely to Restrict
the Growth of Population
315. For various reasons, which include the inadequacy of
medical women and of health visitors to impart birth-control’
knowledge to the women of the country, the enormous cost of
making a safe and effective contraceptive available to the people,
[
'
f
■
[
99
nicies look on birth conrrnl Fn
> «p,d
w^lc^ certain comma-
r •
.heXbferf0,"
IS unlikely i„ the imire fu^„
n
"" h'!i™P'Opfc
*«
there is little immediate Prospect of’raisina ^h ^^^ /° “ that
for gIrls by legal enforcement On the oth?r haYF 0,f maImafe
been pointed out, the immediate prospect is rhtand’,as,has aI^dy
non of the proposed health services and of S’
H
I,ntroduc-
I to advance the welfare of thr rnmm •
mcasurcs designed
population mav show an acceleration°f gr°Wth °f
While recognising fully the
Wlth d* Pa^lation, we feel that the only practical steps thnr
rCasc
PnPu1) a relentless pursuit of the measures thaLre "k
for the reconstruction of national life in r i now bc,ng proposed
of living and (a) the spreading of rhe t
? ra‘Se thc stanclard
7
the country will permit.
1
7
peculiar circumstances of
Genetics and Population Policy
■
316. The application of knowledge rcnardinyr k
r r
,
development of a healthy and vigorous" tS of
7
e
nnunals and plants has been mack- by mm wi?h im’T MPCC'CS °f
■n respect of many forms of life L
> rcmnrkablc success
disease and defect is at orcsenr vr °
?
I
?
.'lcredirary transmission of
pledge, it
effective population policy directed rn °
atc and «ccute an
Jca,d7a"d wcll-endowed community ^hemf Crat'°n,of a
desirable that, as a part of the study of rh h [.Ore cons£der it
>n luma, the part which heredity and e—at:°? Pr°blem
transmission of valuable humm'traits mJ
j’cnt
"' p,ayin the
e?jv,rodefects
.f n?s
investigated.
*
a s nd
should
---- 1 be.Study of the Population Problem
r
be thc subject of cont'inuo^study Aoartio^0? pr°b.Jcm shouU
of population growth, such matter'ProQablc trend
J ^o^li'y rates and surveys of morbid^ arnof^Tfcrt:!ity and
0 the community are of int-rest and ’,^
> thc yar!0^ sections
« ™» Ot sound :,Jrai„isMti“ tL'Xw”"
'ir P»"'
emuranmenr In relation „ „0pt,|atio 0P,-bJ™s » hmlny and
consideration. Wc desire to see such smJ ' sh°Uid a,sO-«ceive
ducted on as broad a basis of collabnnr'
S Oroan,sea' and conthat the Registrar General rnd Pttmaa"
3nd SWst
respective stafis of trained statistics- the Mgi
W‘tb thcir
Central and Provincial, and Department^ Feo
.DePartments,
i 10-88 CBHI/nd/84
Economics, Sociology,
100
Statistics and Genetics in the Universities,
should participate in such studies.
i
L
r.
Ff
J
j.
■
wherever they exist,
alcohol in relation to health
318. Drinking has, as pointed out by Professor Sigerist in his
book “Civilisation and Disease”, two main causes. “One is social
and economic. Misery, poor living conditions, lack of education
and of recreational facilities drive a man into drinking, in Russia
in 1913, the annual consumption of vodka amounted to 8.1 litres
or more than 2 gallons per person, and the average worker spent
over a quarter of his wages on liquor. When conditions of tho
working population changed after the Revolution the per capita
consumption of liquor dropped steadily. It was 4.5 litres in 1931,
3.7 in 1935
Another cause of harmful drinking is to be
sought in folk customs and group habits. Since alcohol removes
inhibitions and makes people talk more freely, it became the
custom to drink alcoholic liquors whenever people gathered for
social intercourse. This alcoholisme mondian, as the .French call
it, affects the most highly educated classes. It is not so spectacular,
but has nevertheless very deleterious results.” A campaign for
reducing alcoholism in the community must therefore take into
account both these factors. A rise in the standard of living
accompanied by the provision of educational and recreational
facilities on as wide a scale as possible seems to be essential to ensure
the success of the campaign. The harmful effects of convivial
drinking can be brought home to the people and their co-operation
secured for its effective control only tnrough education.
Education regarding the Fundamental Facts in relation to Alcohol
I
i
5
T
F
&>
319. In the United States, all but two States (Arizona and
Wyoming) have laws requiring that all schools supported partly
or wholly from public funds should include, in their curricula for
children, courses of instruction dealing with the effects of alcohol
and other narcotics on the human system. We desire to see such
provision made in this country also. Proper text-books on the
subject should be prepared by some central agency and they should
be translated into all the languages of individual provinces by the
respective Provincial Governments. In doing so it should be
possible to include material, diagrammatic and narrative, which will
give a local colour to the different subjects that are discussed.
^Certain Other Suggestions for Combating Alcoholism and for
Restricting Alcohol Consumption to the Minimum
520. We recommend the strict control of existing liquor
-shops and the severe restriction or even prohibition of opening new
shops, particularly in the areas occupied by the poorer sections of
the community, including industrial workers. There should be a
I
-"
[
101
[ reduction in the lour'
sa^e °f alcohol. The alcoholic content
E of the beveray- so]-*’
such places for public consumption should
| Be withm certa’n limits to be prescribed by the Provincial Governipmenc. T^ie aim should be to make the places, where alcoholic
: beverages are permitted to be sold, decent establishments where a
high standard of cleanliness is maintained and suitable alternative
refi^hments are provided, so that a man can take his family and
order food along with drinks. The experience in the West is
that, under such conditions, the excessive consumption of alcohol
is generally checked. There should also be provision for the supply
of non-alcoholic beverages. Milk bars, tea and coffee shops, if
run on cheap lines, can help to divert the craving for intoxicating
drinks into less harmful channels. The desire for alcohol at the
close of the day is perhaps partly-stimulated by the lack of oppor
tunities for other forms of useful activity, including recreation and
social intercourse.
321. Provincial Government obtain today a substantial part
or their revenues from alcohol. “Little economic meric can be
c aimed for a system of taxation which raises any considerable part
of the public revenue from the sale of alcohol, unless, as a part of
the plan of government, this tax money is used to reduce the /ZC?
extent of facilities for the. sale of alcoholic beverages; to promote 77/'
observance of restrictive laws; to meet the cost of prevention, c;ireV<s_
and treatment of alcoholism among the considerable number qhi ' xOP Q *-o
7 ir
a:
persons whose health will be injured and whose earning capaciK < 09
§
t
‘
;
a?
will be reduced by the use of alcohol”. Ic
Ic seems
seems important
important to
to 11$^ j -J
O
u. u
that^a substantial part
derived anuuiu
should ne
be ucvoccqr
devote^''_ ■
-v of the money so uuntu
£
by Governments in this
(’ \ country to measures designed to prevent^4. k,
the spread of alcoholism and to rehabilitate those wdiose health and
Co
forking capacity have been injured by the excessive use of alcohol.
I
31
A
ttj
Treatment and Rehabilitation of Alcoholics
322. The treatment of acute and chronic alcoholism is
essentially a medical problem and adequate provision should be
made for it as a part of the general health programme. The rehabili
tation or the chronic alcoholic is, however, a much wider problem.
, ere, apart from any medical measures that may be adopted,
toerc is the question of re-educating him to a saner outlook on life
|!?rerc IS L^e question of re-educating him to a saner outlook on
| ife and his responsibility towards those who are dependent on
him The rescuing of the growing children in the home of
such - an individual from the degrading effects of brutish
behaviour resulting from drunkenness is' an equally important
fatter. The establishment of houses of detention for those alco
holics who require.segregation and treatment, medical and social,
JfShould receive senous consideration. Legal sanction for such
Retention
will,’
I
doubt, be required and the question of acquiring
I
C- -
7^/
CW.nNif ( ’-1? V.TH "LL
•r.iSi r.OCf; J*. Mirl.S r.t2dx
Co\^\\ ' 30-d’-
07170
in’nr.3 -
n 7’ C'
( T.
|pH' IO0
11263
102
L
r
the necessary powers should also be consic
T ,•
k
consiG?"
of activity voluntary effort can render valuable^
of the inchvdual back to normality can be help
by properly directed efforts in which social workers and relisiuJ
leaders should take an active part.
323- Tae consumption of alcohol, during working hou-^j by !
persons engaged in certain occupations is dangerous to^themselves
and to others. For instance, pilots in charge of aeroplanes and
motor-drivers should be forbidden alcohol during working hours.
It should be an oflence punishable under the law for such persons
to be found m a drunken state when engaged in their respective
occupations. We have given these only as typical instances and
there are many others in which the use of alcohol should be equally
forbidden in the interests of the community. There is abundant
evidence to show that the efficiency and output of the industrial
worker arc lowered by a alcohol and that the accident rate is raised.
The enforcement of total abstinence during working hours appears
therefore to be of advantage from the point of industry and of
workers alike.
THE INSTITUTION OF A MEDICAL LIBRARY SERVICE
RLi
n
i
LB
Li
324. One of die prime needs of an intellectual community is
an effective library sendee and this is more especially the case where
a highly technical subject such as medicine is concerned. India
is at a great distance from other centres of scientific thought and
she must inevitably draw her knowledge of advances and discoveries
from books and journals published in odicr countries. She must
be largely self-contained and the need for a full and wcll-sclcctcd
Central Library is even greater than diat of Europe and America,
where facilities for the dissemination of knowledge are more highly
developed.
07
325. India has not the funds to enable her at present to
institute a library comparable with the more important libraries
of the world, such as Washington with its 420,000 volumes,.
Leningrad with 600,000, Paris with' 500,000 or even with that of
the Royal Society of Medicine in London with 160,000 volumes.
It seems to us, however, to be not unreasonable that we should
recommend the establishment in India of a Central-Library,
providing, in the first instance, For the housing of 60,000 to
100,000 volumes.
326. In order to put the proposed library service on a sure
foundation, an exploratory survey of the facilities existing in the
United Kingdom, the United States and elsewhere should be under-
i
r
f
r
r
■
103
r
; -- taken by one or two officers (of whom at Ic^ one should be an
;
Indian) deputed for thei purpose.
F«
=
»■»
ff
nr
327. There should be, in London, a correspondent to •he
library who will watch, its interests in the West and net: ai the
concerned
channel both of information and of supply is mat-ers co:
with the library service.
328. The Central Library , we envisage is one chieflv devoted
to research and should be established in association with the AI1Jndia Medical Institute. When similar medical institutes are esta
blished elsewhere they will have to be provided with tlieir own
libraries. A case can be made out for an entirely separate library
in the directorate of the future civil health service. We prdcr,
however, to leave that question, together with the proposals tor
the establishment of regional libraries, to the consideration of the
Governments concerned after the survey, which we have saggeste
has been completed, when fuller and more exact information wi
be available.
3
LEGISLATION
329.
heads :—
(I)
(2)
3
Our proposals for legislation fall mainly under four
those which arc.intended to assist in the formulation and
execution of a national health policy based on the brges
possible agreement between the Central and Pronncia
Governments and to promote the coordination of central
and provincial health activities;
those which are designed to improve health administration
in the provinces, particularly die standard of such admim-
(ration in local areas;
those which are required for conferring special powers on
(3)
health authorities to enable them to carry out their dunes
more effectively than they are able to do at present an
those which are intended to give statutory sanction _to
(4)
certain proposals of ours, e.g. the establishment of.the_A1 India Medical Institute, the Central Committee for Post
graduate Medical Education and Central and Pronncia
Water and Drainage Boards.
Consolidated Public Health Acts, Central and Provincial
-0 In addition we recommend the enactment of consolidated
public health Acts by theCentral and Province legislatures^ Such
Acts can serve at least three purposes, namely, (1) tc> brin
. h
existing legal provisions relating to health, which are scattered
over va’rioul enactments, (2) to modify those sections of the law
104
I
L
sXSnreqU^zChar-,n the interTS of PromotinS efficient admininecXrvT
7 '"^P0^ ffie new pwvisions which will be
necessary fOr me development of thr health programme
r -we have
STt1 AC
Pr0visions ^atTng to heakh
i are
roujxj in about 40 different Acts while, in the 1
'
provinces also,' a
var.ing number of legal enactments contain such provisions.
take snm' rUCh ]eSisIation at
that the CeXrGove^3”^ J"
Centre and in the Provinces may
m^nt,mc ic « recommended
in n
/
r Go'ernmen£ should undertake to brina toother
■ Centml^nd^ProTnrial311
t0
bo£h
the FINANCIAL implications of the programme
L
otncr malting and inadequate schemes which
bring liulc rcturnCforOthgenCral
s£;,l]dards •',nd which would
‘ • ,■ rc£urn tor tno expenditure mvo ved
We dcridrH
our gmdmg principle should be that the short-term oh
\
comI.j k_v
r?
U
demonstrated Thp
P P *
no satisfactory results could be
a se back ft J consc^nces of such failure might even be
in‘Ie''i“pm“' <*
5
J
i
1
incurred
- health depoVmX ^^
f
°f
""'r m"fcJ “d P“W»
eseStWxb
order Xs„„ai„ „h“^
it may not be out of place to examine the corresponding expenditure----rtam other countries, where the provision & ZX
th protection to the people exists on a much larger scale than
I
r
r
5
105 .
i
in India. In Great Britain, the per capita ^P^tmre• on medical
country on its health
Rs =;i-6-o. The expenditure incurred by a c
,
and India
services must necessarily depend on its
:
two
countries
compares, in this respect, very unfavourably with th
J of national income for these
mentioned above. Certain estimates
which we may reasonably
reasonably att-ch
attach
three countries from sources to ’---value are quoted below
LC1L/*T
r*
Country
—------
Source of information
Income per
capita
Rs.
A.
P.
British India
62
«3
3
Great Britain
1,049
6
5
United States
1,371
7
3
Ff
•’
r*
Journal of the
Royal
Statistical
Society, Vol. 103, 1940, pafiC 517.
3
3
F*
7
Monthly
Labour
1941, page 114.
Review, Vcl.53r
n The per capita income of the United States ts about
22 timi that o^f India and that of Great Brttam about. t/^n
Even after making due allowance for the much
t
incomes in those countries, India sio
e\D..njiturc On k‘*',bk
Rs. >S-o per head of the population, if her e^nc t urt; on health
as die
sen-tees were to bear he same
measures
amount spent in Grea Bn
■ 9^e3b5asjs of a simil.ir compabore to her own national
expenditure on
health should be Rs. 2-5-0’»
From our survey of mot
imSSs i^hose countries
°re°d^3t?Sfied with the provsion for the health protection^ot^ *ir
people and that «pendKure on
th^‘^eumexuung smi«s !J “"dfr0““vdo. , mod„„ bol* orgxnisjtion,
s
its execution, a demonstrable improvement or the public .Rtalth.
106
Tiie Estimates -of Cost
our ^mately'cost^p^^^^ar form, foe
E
7'ld fiVC
ffiain items of
years and the
short-term proj^
of
^PPraxiatate estilno,es of cos,e
?
b amme-
^rvey aai DeVelopmem CoZ'uttee fa
HeM
----------------- ---------
FirS,five^-fSecondfive
__ .
First ten years
years
» ions associated with the
Rs.
80.88,00,000
(henSn7"eS andOf ,n Hea)'hPro-a<
Vincek
3 ' pr°f,e“'onal education
• Exp-nditureonotheritems
'
22,45,00,000’
50,42,00,000
4. Centre
Rs.
118,64,00,000
.19,86,00,000 42,31,00,000
50,20,00,000 100,62,00,000
_____ 11 >3 2,00,000
5- British]ndiaaSil whoJe
Rs.
199,52,00,000
■ Ii
:
20,54,00,000
EXPENDITU?^
’’^■udinj thhea'%- SCrvieRECURRING
«
116,10,00,000 1250,02,00.000
3 66,12,00,000
h= M ntstertes of Health a?
XCen,reand i"n’e pro'
H:
2. EEn^d'0™1 cdu«<‘on .
5.
I.?.:.nd''“reo"o-hcrile,n
mss
Liavcw Twscrvc
-----
32,00,00,000
<54,00,000'
67.24,00,000
67,24,00,000
7,83,00,000 I h'os ooooo /^'^10-0’000
I 22,91,00,000
160,47,00,000 ,
/
312,66,00,000
9,63,00,000
473,13,00,000
/ 18,76,00,000
28,39,00,000
170,10,00,000 /
25,076,00,000 '331,42,00,000
M.SMO.OOO
501,52,00,000
100,30,00,000
f
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6. British India ta whole
^yment towards
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of mn
non-recurrmg cxp;Ddilure
Tolalrccurring expenditure
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195,86,00,000
39j7oo^000^
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315 millions
Annual per capita expenditure
Rs. A. p.
1 4 0
405,96,00,000
601,82,00,000
.^1,19,00,000
60,18,00,000
337.5 millions 326.25
million
Rs. A. P.
Rs. A. p.
, ^2 7 0
1 14 0
336. After matin.
our country as compared3with'Sose G^t r" nationaI income of
Sta es, the rate
Bn?,n and
United
States,
_ of expenditure: S m2
Tndia.
ndta. should be about Rs. 3-2-0 per h^d^ ?ubhc serv,ces in
7 er m reach the levej of similar expend3 °‘-tbc P0Pulati°n in
59.34-35Land-about Rs. 2.5.o -0
‘ P "dl>n Great Britain in
- proposals involve c rcacn that of the United State's in
*93 8. Om
execution. ™ anticipated expendit^pf
tfn years
their
the population.therefore claim that th/’
pCr head of
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development we have put forward cannot be considered extravagant
from the financial point of view. When it is remembered that,
in Great Britain and the United States, a further rise in public
expenditure on health services has been considered essential in the
interests of the people, we hold that there is still greater justification
for considering that the demands which our scheme will make on
the public purse are in no way unreasonable.
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I he Financing of the Health Programme
337- We realise, at the same time, that even the proposed fcr
capita annual expediture of about Rs. 1-4-0 during the first five
years of the programme will require that Provincial Governments
should make provision,- for spending on health measures, amounts
many times in excess of what they are budgeting now. The latest
available figures for the combined expenditure on provincial medical
and public health departments relate to 1944-45 2nd they are given
.below.
Combined expediture on medical realief and public health activities in the provincesduring 1944—45
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Province
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expenditure
jper capita
tn annas
Expenditure on medical relief and
public h:alth expressed as a
percentage of total provincia I
expenditure
Madras
6.2
4.7
Bombay
. 10.9
4.5
Bengal
7.1
5.7
U.P.
3.9
4.9
Punjab
6.1
5.1
Bihar
3.2
7.3
C.P. and Berar
2.8
3.1
Assam
5.4
6.2
N.W.F.P.
7.7
5.0
Orissa
3.4
5.9
Sind
8.2
2.5
338- While a small number o£
of items of existing expenditure
in rhe. provinces on health administration will fall within the cost
•of the scheme, the -vast majority of them will not and, broadly
speaking, the expenditure involved in the execution of our proposals
will be in addition what the Governments, Central and Provincial,
.are now inccurring on their medical and public health departments,
which as shown above is generally on a meagre scale.
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339- A reference to the last column of’ the above table will
show that the expenditure incurred by Provincial Governments on
health measures, curative and preventive, constitute but a very
small rraction of their total annual expenditure, the percentage
ranging from 2.5 to 7.3. On the other hand, the corresponding'
percentage in Great Britain during 1934-35 was 20.4 and in the
United States 13.8 during 1938. It is abvious that Governments
in India have, in the past, devoted an unduly small proportion of
their incomes to health administration and there is therefore every
justification for demanding that the ratio of expenditure under
this head must be raised considerably. Governments should be
prepared to increase the money spent on health to at least 15 per
cenL of the total expenditure. If this is done a considerable advance
will have been made in providing the required funds for the
proposed health programme. At least in one province (Madras)
the local legislature has laid down (Section 127 of the Public
Health Act?) that every municipality “shall earmark not less than
30 per cent, of its income from all sources other than Government
grants, for expenditure on the advancement of public health in
its local area, including expenditure on medical relief and every
district board or panchayat rhall similarly earmark not less than
12 per cent, of its income from such sources’1. We recommend
that it should be a statutory obligation on Governments to spend
a minimum of 15 per cent, of their revenues on health activities.
340. We consider it highly desirable that a searching enquiry
should be instituted into building costs and the data on which
Public Works Departments base tlieir estimates. Instances have
been brought to our notice in which private agencies have been
able to carry out new building work at less than 50 per cent, of
the estimates prepared by the Public Works Departments. We
do not venture to base any criticism on such information, but
there is undobutedly a widespread and persistent belief that the
Public Works Departments are unduly expensive agencies for the
construction of Public buildings. This calls for careful investi
gation, as considerations having far-reaching consequences for
development in many spheres are involved. In this connection wewdsh to draw attention to the report of a Mission which was sent
to the United States of America by the Ministry of Works in the
Unicd Kingdom in 1944. The object of the Mission, which was
an expert body, was to study American practice with a view to
securing in GrearBritain in the postwar period (a) increased speed
and output, (b) reduced building costs, (c) improved standard of
equipment and finish and (d) improved conditions for operatives.
341. An enquiry into building methods and costs, with special
reference to the Central and Provincial Public Works Departments
in India would now be helpful, particularly if, with the enquiry7,.
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one or two of the representatives of His Majesty’s Government’sMission to the United States were associated as well as some non
technical persons.
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342. We desire to stress the organic unity of the component
parts of the programme we have put forward. Large scale provision
for the training of health personnel forms as essential part of the
scheme, because the organisation of a trained army of fighters is
the first requisite for the successful prosecution of the campaign
against disease. Side by side with such training of personnel, we
have provided for the establishment of a health organisation which
will bring remedial and preventive services within the reach of the
people, particularly of that vast section of the community which
lies scattered over the rural areas and which has, in the past, been
largely neglected from the point of view of health protection on
modern lines. We have drawn attention to these aspects of the
health programme because we feel that it is highly desirable that
the olan should be accepted and executed in its entirety. We
would strongly deprecate any attempt, on the plea of lack of funds,
to isolate specific parts of the scheme and to give effect to them
without taking into consideration the inter-relationships of the
component parts of the programme. Our conception of the process
of development of the national health services is that it will be
a co-operative effort in which the Centre, acting with imagination
and sympathy, will assist and guide a co-ordinated advance in the
Provinces. We therefore look forward to a pooling of resources
and of personnel, as far as circumstances permit, in die joint task,
that lies before the Governments.
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mftlOUS COMMITTEES
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{HEALTH DEVELOPMENT
1943-1975
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l^NTRAL -BUREAU OF HEALTH INTELLIGENCE
IfbjflECTQfATE GENERAL OF. HEALTH SERVICES
Ministry of health and family planning
5 GOVERNMENT OF INDIA
•‘NlftMAN BHA VAN
NEW DELHI-. (C 311
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COMMUNITY HEALTH CELL
Society for Community Health Awarness, Research & Action
(SOCHARA) Bangalore
Library and information Centre
AUTHOR .
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CALL NO.
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TITLE .
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Borrower’s Name
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Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
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H—HEALTH SURVEY AND
PLANNING COMMITTEE-1961
(MUDALIAR COMMITTEE)
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HEALTH SURVEY AND PLANNING
COMMITTEE-1961
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SUMMARY OF RECOMMENDATIONS
CONSTITUTIONAL PROVISIONS
1Al1,dj:0USh under the provisions of the Constitution of India
a State subject, and although more effective
central action and a larger measure of Centre-State and inter-State
co-ordination is necessary, any amendment of the constitutional
provisions, to secure this, does not appear to be called for.
On the other hand, in keeping with the democratic traditions
J 1- being
built up in this country, the objective can be better achieved
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by the growth of healthy conventions, greater goodwill and better
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education; by a system of grants-in-aid by the Central Government
m support of public health programmes of a national character
like those of water supply and sanitation, eradication/control of
communicable diseases, family planning and schemes of training of
health personnel, by the setting Up of an All-India Health Service,
by the creation of regional organisations of the Central Healih
Directorate, by the Central Council_of Health being made a_more
effective organ for policy making and implementation in the' matter
of national health programmes, by the promotion of zonal Councils
on the lines of the Southern Regional Health Ministers’ Council’
and by the utilization of the University Grants Commission, or a
comparable agency that may be set up for the purpose of advance
ment of medical education and research.
INTERNATIONAL COLLABORATION
The assistance and support received from international bilateral
and other agencies has been most valuable and it is to be hoped
: that it will continue to be forthcoming to supplement the national
| -effort towards the attainment of a higher standard of health.
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GENERAL
II. Having given due credit for the implementation by States
of many health measures, it must be confessed that the general
picture presented bv health statistics of different States does not
enable us to take too optimistic a vie. of the present state of health
and of the future health protection of the citizens.
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a. Unless tt. conscience oi: .he <
as a v.r-uJe is simu
lated to demand and accept .-tter stand^-cs c: health, unless the
principles -if sound hygiene aie inculcated into tho masses through
health education and other efforts, and ides? Government feel
strengthened in taking positive measures rc promote health, it will
be difficult for health authorities alone to insure that the measures
contemplated are actually implemented. Tuere are at present wide
variations as between States, not only in providing necessary tacilines for health care but in the measure ct control exercised by
authorities in preventing the spread of enidernic diseases. This
aspect should be attended to carefully.
3. While appreciating the efforts made by Governments to
give relief and provide satisfactory methods of rehabilitation to
displaced persons, the absence of a measure of willingness on the
part of the displaced persons themselves has created difficulties not
only for the displaced persons but also the nopulations of the States
concerned and those of adjacent areas.
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4- The increase in the number of hospitals, dispensaries, and
beds has not created the impression that might have otherwise been
made because of large increase in the popubtion.
5. The arrangements for medical care for the people have to be
examined carefully. Overcrowding in hoxntals, inadequate s^iff,
non-availability of essential drugs and miedkmes, mixing of serious
with minor cases, lack of co-ordination of baspital services and the
dose proximity of the out-patient department with the hospital
proper, are some of the organisational defects which have to be
remedied at an early date.
6. There is a maladjustment in the distribution of trained
personnel who congregate in urban areas owing to lack of amenities
and gainful employment in rural areas. Moreover highly trained
doctors of the medical profession arc being utilised to carry out
routine duties which can as well be done bv lesser qualihed peoole.
The need is to conserve such highly trained personnel to jobs that
they ought to be doing and to make greater use of auxiliary health
personnel.
7. The attemptYo start mass campaigns against certain diseases
like tuberculosis, smallpox, cholera, leprosy and fiiariasis is com
mendable, but the method of dealing wtith these diseases individually
will not be conducive to the organisation of unified efforts needed
fer the promotion of total health care. The health personnel
engaged in such mass campaigns must be trained to tackle all
ems in
health problems
i any area. While the overall supervision for
particular diseases may require special attention through specialists,
in rural areas it is neither possible nor desirable to have separate
agencies to deal with separate diseases.
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8. The intensive'steps taken at the time of the out-break of
epidemics
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s or at the time of sudden catastrophes have led to waste
of. effort and finance. Instead of sporadic efforts at the time of
|®': . epidemics, large amounts can be conserved and more lasting results
. achieved if permanent measures for eradication of diseases are
undertaken.
®;
9; While it is noted with satisfaction that the position
® regarding plague is now more satisfactory than before and that
•there has been no epidemic of plague for several years, there are
certain factors which do not tend to give us the confidence that
recrudescence of plague may not occur.
I0- I*1 attempting to provide school hygiene it should be ensur
ed that apart from providing minimum standards of sanitation in
s^h°ols and colleges, conditions are made available to inculcate in
children proper health habits from the earliest stage.
MEDICAL CARE
J. It does not appear feasible for the State to provide free
medical service on the scale visualised by the Bhore Committee in
the near future. It should be considered fairly satisfactory if the
ratio of one bed per i,ooo population, is achieved during the fourth
or hfth Plan periods.
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2. The question of nnancing of medical care, needs a careful
study. The introduction of i system of graded chatges for ah
| hospital services except in the case orffie genmhelv'indigent
! patients, is called for. The possibility of the levy of a health otss
I IS also worth explonn£.
3- Steps need also
be taken for the extension of medical
|. - are
the Promocon jafjiealth. insurance .schemes. The
| initial steps taken in this direction in the form of the Emplov ees
, State Insurance and Contriutory Health Service Schemes, should be
j. fol owed up bv extending their scope bv giving coverage to other
;; sectors of the population a the case of the former and by bringing
y all Government servants within the purview of the latter as eariv
I. as possible.
‘
4. The Government should also <encourage the development
of medical care facilities rn co-operative lines., on an experimental
| measure, through suitable subsidies.
y The district hospital
should
,
___ occupy the key position
| regard
to
medical
care
ar:c
should
be
.
.
Y;--------and strengthened
| With
___ expanded
__should be
specialist facilities, resides,- there
mobile £ams of
| specialists to cover all areas of the district
and
——
to provide ne^essarv
supervisorv and consultam Silkies at the periphery. On the other
;; hand,
nano- the
r^.. taluk
finr hospital? should fc>£ developed to take over the
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11—88 CBHI/NDty
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0. ihe primary health centre programme as it has developed
o -rs no resemblance to that visualised £7
Bfaore Committee, k
sat that while the idea of th- primary health centre is an excellent
eie, it will not serve any us - <-■ purpes; jf centres are established
v mom adequate facilities, resources and personnel.
7b,The /
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f<ogramme needs to be radically revised and it is suggested that
of primary health centies on the existing
prt.eni should be aiscontmued and any primary health centres th« W
. ? opened hereafter should be on the tsattern suggested to serve
a pop-eiauon of upto 40,000 and should have full complement of fft.
staff recommended by that Committee. Further the primary health W
centres alr^dym existence should be ungraded by Stages to reach »
tne full-fledged pattern of the Bhore Committee.
■(
It will be preferable to pronde medical coverage to the
rest ot ...
the. rural Al
population through
moode ulculu
health units
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mobile B
vans
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nsnng^
them from
disuyt^
and uuua
taluk 1JV.
headquarters than wH
,
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------ . —
trough poorly equipped and: staged primary health centres. Those ;
requiring hospitalisation or intensive medical care can be brought
in ambulances to the taluk or district hospitals, for necessary treat- I
ment When facilities in regard to personnel, finance and other I Bi
requirements are sufficiently enlarged, the Shore Committee formula 1
or the Primary Health Centres can adopted.
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8. The primary Health Centre should provide residential
accommodation to all the personnel of the Centre and should have
a bed strength of io including two beds for emergency cases.
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9. There should be suitable
conveyance including
. ^conveyance
including an
an ambu
ambu-
lance and a jeep
j— at every
------ Centre.
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Wherever possible the Centre ; M&J
should be at a place where other activities such as education,
agriculture, animal husbandry, etc. are concentrated.
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10. It is suggested that before this new programme of Primary
Health Centres is implemented on a 1large scale,
' each
’ State
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should
establish some model centres so that necessary
necessary adjustments
adjustments can be
carried out in the light of experience at a later stage. The model
centres will be supported by hospital services at taluk and district?;
telephonic, ambulance and mobile service facilities.?
Tacumes of the police vrireless communication now available in
the greater part of the country should be fully utilized.
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11. Apart from improving the conditions of service of the?
inedica! and auxiliary personnel serving in primary health centres, i^fc. ■
is imperative that training should be given to prepare the largo
bulk of students, going through the medical colleges, for public
health duties in rural areas and for improving the equipment and
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.-staffing of the primary health centres so as to allow a better standard
.of work to be undertaken.
12. The Primary Health Centre medical officers should not be •
.allowed private_practicex but should be given non-practising plus
^public health allowances together with residential accommodation.
There should be onejimified.cadre of Assistant^Suregons in the
State to man rural health centres as also hospitals at higher levels.
All medical officers in that cadre should be given rural assignments
by rotation and posting to a primary health centre should normally
be after one or two years of service in a hospital under the super
vision of a senior medical officer. Service in rural areas should be
.ah essential condition for confirmation in Government service and
-for crossing the efficiency bar. Preference for post-graduate training
should be given to those who have served in rural areas.
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13. Taluk hospitals should have a minimum bed strength of
50 and should have three Medical Officers dealing with medicine,
surgery, obstetrics and gynaecology. Such a hospital should serve
as a referral centre for routine type of gases from two or three
Primary Health Centres in that area. Of the three medical officers
one should preferably be a woman medical officer for maternity
and child health and family planning work. Good clinical side
room facilities should be available. One of the three medical
officers should have had training in laboratory work.
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14. Each District Headquarters Hospital should be expanded
to 300 to 500 beds, of which 75 may be set apart for maternity
and-5O'f6f'~p’aediatrics. Specialist services in medicine, surgery,
obstetrics and gynaecology, eye, ear, nose and throat, paediatrics,
■tuberculosis, dentistry and veneral diseases should be provided.
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15. The specialist in medicine, surgery and obstetrics and
•gynaecology should have the status of a Civil Surgeon.
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16. There should be an isolation unit of 50 beds attached to
■the District Hospitah The Tuberciilosis, Clinic and Public Health
‘ laboratories at the district headquarters should work in close asso
ciation with the distixt hospital. There should also be a chronic
and convalescent hospital, in order to relieve the congestion in the
hospital and the consequences strain on the staff.
17. A number okdistrict hospitals should be linked with the
teaching hospital on 2 regional basis in order‘to 'gar 'expert "advice
and assistance in the matter of investigation, diagnosis and
treatment.
18: Every district and teaching institution should have a blood
bank service. The headquarters of each State should develop a
■special department far blood transfusion service.
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T9- I planning hospital facilities ths basis c*
of
bed for
even-- i.wc ^jpulation. should ba taken fcr each
Hospitals
_ at the taluk level will provide 6oo to Soo ieds aad rx primary
health centos will provide io beds each. In. addintc. the beds
avada&.e tn pnvate or voluntary hospitals should also k taken into
consideration. The important thing is to ensure tk- from the
smahcst .to tire biggest hospital they function as an inter-;~ whole.
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20. The planning and organisation of‘the Out-paten- Depart
ment deserves special care. It should be oukde the carpound of
tae in-patient department with a separate entrance. T-e‘Casualty
Department for emergency cases, and the Orthopaedic Department
for accident cases should be attached to the Out-patient Department
Certain other departments, such as Eye and E.N.T. could also
k ij c SIrUntft
the out-patient department buddiarr. There
shojid be full facihties in the out-patient department for X-Ray
and laboratory services, immunization and anti-rabic treatment
Special cluucs like diabetic clinic, border-line mental mnic, chest
clinic, could also be located in the out-patient departm-rr
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2i. There is a great need for special hospitals for rerTfrep.
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21(a). Apart from the provision made in distric and taluk
hospitals and primary health centres for maternity beds, wherever
possible independent maternity hospitals should 'be breuzht into
existence so as t0 lncrea5c within the shortest
.b]c
faaliues for materm ty cases. Maternity wards or mater tv hospi
tal should be available in all large towns and cities acd shoidd
be so spread over that facilities are afforded for women k different
locaiine to get admission easily. It is desirable to encccrao-e the
habit of pregnant women attending the ante-natal Him- As far
as possible only booked cases should be ultimately anrr^d into
maternity hospitals. Domiciliary visits should be paid rv trained
health visitors or midwives. Maternity hospitals should alo have
laciiities for post-natal care.
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The larger maternity hospitals should serve as traincentres
for nurses, midwives, nurse-midwives, medical students md other
para-tnedteal personnel who serve in the field of maternal and child
care. A planned method of development of maternity hames and
maternity hospitals which attached ante-natal clinics and facihties
for the system of promoting booked cases, is reenmm-nfed
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22. Each taluk hospital should have io to 15 beds for isolation
of T.B. cases. Similarly, at the district level where tot- h no
separate T.B. hospital, 30 to 40 beds should be reserved for T B
cases.
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23. Each district hospital should have a Psychiatric Ginic and
five to ten beds may be earmarked for psychiatric cases.
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.24. Mental hospitals should be developed <on a regional basis.
the. optimum bed strength being about 750.
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25. Each teaching hospital should have a separate cancer
clinic and each State should have a full-fledged hospital eauipped
with modern facilities for the surgery and radio-therapv of cancer.
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It is also necessary to have leprosy hospitals for treatment
m of cases26.requiring
isolation, surgery and rehabilitation.
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27. In regard to blindness those concerned with preventive
and social medicine should be properly instructed about the aetiology
and incidence of eye diseases and the measures necessary for preven
ting them. Special surveys and provision of adequate number of
beds are necessary. .At the under-graduate level the students should
be adequately trained in Ophthalmology. This will encouraao
them to take up Ophthalmology as a career.
28. Mass campaign against diseases like trachoma, and other
diseases causing blindness like smallpox, etc., should be conducted.
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with 300 to 350 beds, besides the provision made in the district
hospitals.
30. Centres for the rehabilitation of the adult blind should be
established.
31. Eighty to ninety per cent of deafness is preventable. This
requires education of mothers and children on the simple causes of
deafness.
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3Incidence of deafness is likely to increase with the rapid
industrialisation of the country and with the frequent exposure of
the human ear to loud noises. Steps should be taken to remedy
the situation.
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33. Training of ear surgeons is necessary.
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34. Mechanical hearing aids should be manufactured in India.
35* The deaf schools in the country should be supervised and
uniform standards of teaching prescribed by a National Committee.
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36. Every State should have an orthopaedic hospital with
wings for accident cases. Hospitals for handicapped children with
physiotherapy, occupational therapy and other facilities should be
organised in each State.
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S/* -^hv existing institution for training workers in Physio
therapy at Bombay should be fully developed so as to enable it to
ta^e on limb fitting activities which' are* at present being done
entirely by the Army Limb-Fitting Centre at Poona.
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u c-.. -'ic it i.A3v not -:-e ;
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c devdopmc t of Dental?
. y' to have full time Deputy
c
s Di-ectorates for Dentistry.
j, /S suggc>tc-...i f.-iat .rrmcipa?? of uentd Colleges m the States*
V:.jvi€ ^uoii exif p cr the seraor -mo ft JJcata! Swgec. in the State
sj-'Opie a:..I as Co..suitanc <0 Health Directorates to draw programmes
for deiital sendees.
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.39Strict level a full-equipped and staffed dental
c. jz.'c
..a form part of' the headquarters hospital. Besides die
I
ourget;!! there should be a dental hygienist and a dental
£. echanic.
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40. In each district there should in addition be a dental mobile
v«a, which should visit the taluks and other centres on a carefully
drawn schedule. Cases referred from primary health centres for
dental examination of school children can be examined in this
manner.
i
41. It is suggested that some orientation in dental care may
be given to the auxiliary health worker in each primary health
centre, so that he may assist the dental hygienist
42. The Armed Forces Medical Services can cooperate with
th^L Pyilian. counterparts in order to improve the health of the
country and to train medical auxiliary' personnel of which there is
an extreme shortage in the civil side. A short period of service in
the Armed Forces may usefully be rendered by every civilian
medical officer. Interchange of specialists for periods, between the
Armed Forces and Civilian institutes is also highly desirable.
Medical Care in Railways:
43. In an organised service like the railways it should be
feasible to subject all employees to periodical physical examination.
J
nccessary to provide checks against patients suffering
from infectious diseases> freely using the railway trains and
platforms.
45. Stringent control is required in the matter of cleaning of
railway carriages, the inspection of food and the manner of its
vending or platforms and refreshment rooms.
46. The public health staff of railways required to be trained
at all levels. There appears to be no reason why the Railway
Health Sendee should continue to remain in a water-tight compart
ment. A common cadre with the Central Health Service is
suggested. While retaining the administrative structure of theRailway Health service in general., it is time that railways drew
upon the pool of the general Health Services for their medical
personnel.
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47. It should be possible to make suitable arrangements for
advice and assistance from specialists in Government hospitals in
bigger cities being made available to the railway hospitals as and
when required and vice versa.
Factories:
48. Special provision should be made available for hospital,,
domiciliary and clinical care of workers. There should be separate
hospitals for the insured patients except when specialist treatment
is required.
49. There should be no discrimination whatsoever in the
.existing Government institutions between the Government servant*
the insured patient or the civilian patient.
I'. Plantations:
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P
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_ ________
50. By and large the health care facilities provided in plantations are poor and inadequate. Emphasis has largely been placed
on providing expensive medical care facilities without adequate
regard to the need of preventive health services.. In a majority of
plantations, sanitary facilities for health education, immunization
programmes, etc. have not been carried out on the required scale.
51. The provisions of the existing law in regard to health in
plantations should be enforced by the State health departments.
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Tribal and Backward Areas:
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52. The major public health problems are .those of water
supply and sanitation, malaria, tuberculosis, V.D., leprosy and
nutritional disorders. The problem is made difficult because of
the sparseness of the population, lack of communications and
primitive voodooistic outlook of the majority of the tribes to disease.
Oyer-zealousness in providing scientific medicine should not lose
sight of the attitudes of the tribes and the village doctor should
be treated as an ally by the health worker rather than a rival. The
so-called'civilising influences should be extended to the tribal people
with judgement and discrimination so as not to do violence to
certain cultural patterns peculiar to the tribes.
\
1
5^. One of the most urgent needs of tribal areas is expansion
of training facilities so that health assistants, health visitors, sanitary
inspectors and other technicians are trained out of local tribal candi
dates. The standards of basic education applicable to the rest of
the country should not be insisted upon tor some time to come in
such cases. The training centre at Passighat in NEFA should serve
as a model and similar centres should be set up in ail tribal areas
to meet the needs of the tribal population.
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5'4. Xo rate:
y- ciocic-".- in TribJ «
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tribsi student sr..-yjb
even w^k at school
for
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tra
■ riing
as c’-xtorc and shetb be
be g-’.-en training ir State Medical
Coib.... ,— eges”
on condition k3at th; wili serve the tnh- areas after qualifying.
. ->• £---dc; th:st duty m the tribal .-.reas
ror limited periods
.6
S-Syy
f“ =’™k"
S-r\jt_s b5
and State Health Services.
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Private Medkal Practitioners :
4
jo. Closer liaison should be established between thprivate
practitioners and the hospital authorities.
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Fraclitioners can operate with Government in
“h“' h«l*.
Hanans »nd
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K -th
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to erScTTLS£TC ;k" cc^P"at,on of private practitioners and
o e^bi u.m to play a ntal role m the matter of medical care
•°mX -tT- tn£V roUSt b£ ^Ven refr“her cours«
time to
i.m
^boratorv services at nominal cos: and other facilities
shou.d oe made available to them in the public institutions.
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5< Gov"rnmen; hospitals and dispensaries should profitably
.he services of private practitioners 02 part-time or honorary
of --d>^?rb»?nCt,r-°nrs s?oa’id,a!so be cr’lised in State schemes
of mecical c_._ hke the Employees State Insurance Scheme..
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PUBLIC HEALTH
wi
■no
tt’ater Supply and Sanitation
mat-rial-^rf13105
nOt COm-D,’cte,y quipped with men and
mat...ah to carry out water supply and sanitation programmes
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th; ™al
of the
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San,tatlOn Profamme i? la^ing and there is a
*1 A k ' °A 2^cn_cics entT.u$ted with this programme, with the
.suit that progress has been halting and results achieved doubtful.
A reorientation of the existing policy and procedures is necessary,
sbn- ’7 ,FHMed?ed State Public Health Engineering Organisations
Xf
XTomg-mlntconsultation
° CTnCC X
' Publicdenartments
h£abh e^in“
...... camed
with 1such
regardg
..•■scb
. -arc
t
nti
-'•■cor,
hel
■sew
fk5'■effl,
agendlT’ CSt™at=S- CtC- wherc the Nation is through recognised
' ' wit
. 3: 'rd= magnitude of the urban and rural water simply and
^m.ascn .-ra^x-ae will involve a large outlay the lowfst esH-- c. v.m.n is ot me order of Rs. 1,500 crores.' The aim should
t s pi
f area
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be to accomplish this entire woTk within about 25 years if any
■ angib e improvements are to be expected. A muchmeeded’change
m outlook in the management of water supply projects is called
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Conference for the formation of Water and Sewage Boards tofe^
t n™Le5_O,fJnUa,Clpailties and otb" local authorities in an area
.is commanded.
I4?)' A.nother direction in which reorientation is necessary is
^station for conserving water sources and for regulatir-the
exploitation of ground water.
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riv.rJlk11 IS suSSCfted that the possibility of tapping perennial
should h V‘niS ’“T^antjties of unutilised water into the sea
r i6 “ ' °J °
S re eXoir
w Se
Cntry int0
thc SC3 withoi’t a^mg
Such U'3ter may be collected
storage tanks.^ carried
CamM through Cconduits
°nduitS t0 many vi,la"es
6. In areas where there
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ther Poss,:faaty of providing water in coastal areas may
I he> by disahnatjon
of sea water.
I ■With t A SCIheme focr provision of water supply to every village
lc
B ro X? PhatIOn °f
before the end of The Fourth Plank
W not too ambitious to put through.
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. 9- It is of the utmost importance that drainage and sewerage
"Schemes should run paiiller
to water supply, schemes in urban
areas.
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Titles for w3^ °f the ?ODX advanced by- Government to local authoTitles for water supply senemes should be treated, as grants A
hX oMoJ0"that the Schemes undertaken ^th the
sewerage schemed
effluents' XX'"
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arc int^ated
linage and
T” be research in the ?reatme«
” "X “ “ b™s “ hi«h • ””” “
area will h^110^
As??saJ
human excreta most suited to each
area ydl nave to be evened. It is -suggested that in every dare
oXw^^aTi 'V°'l!d
Kt Up-t0 s:udy various methods of disposal
°l S"A‘1 ' an,J human excreta in rural areas.
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■ ‘;;!lKc 15 •' - gEy or s4 opinion that suitable
;nd .°; :wc raecaiEscal devices should be-
5; - - -sal ux :xxxgnc-soH
?,V!g* souid>
n; ^htruc inrj practice.of coIIection and I
be br-
I
m-.y; Xi’ > J that not °?iv hca!th t-™on but ako punitive
“ ?r"e0' 'h' “ »f »P“
tfe™*ZnirSatISf^fy SoIutiOn of thc
^trinc programme will
XrT11 “ appeaI to the Ccivic ^“ness of the comJl£dXian °n moUvatwn of
in<iividual villager. The
x -OrganlSatl ,a m ““
should take the
re^xlij to fabricate approbate rural latrines and to supervisepe^-odical the servicing of such latrines.
16. Competitions at the Block and Zila Parishad levels may
S
T i tOkT Of
of editable effort
o°
mdlndt^s and commuruna for the improvement
of rcral hygiene, may be awarded. Efforts in this direction should
bi thre vrous agcnclcs Iike the Community
DevJopment Blocks, Local Bodies, State Departments of Health
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„ -c I7'„Thc SOUr“s of air Poison are many and the effects" of
sum pollution on human health are multifarious. It is suggested
that the programme for control of air pollution in the bigger cities
of India should be given due attention bv research, establishment
or a monitoring machinery and legislation.
■ an
Maternal and Child Health
18. Greatest attention should rationallv be given to the care of
the nealth of the children. There is no agency
_ 7 to ensure that a
systematic fodow-up of ante-natal, midwifery, post-natal, infant
and child welfare services takes place. This work must be
organised properly.
19. Every effort should be made to develop and expand thenetwork of maternity health centres so that within a period of
ten years one midwife is in position for 5.000 to 6,000 population
m nrd areas, supported by a public health nurse and an auxiliary
neaim worker for twice that number.
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20. The Departments of Social and Preventive Medicine *
shoutd give due importance to maternity and child health. Undergraduates should have more experience and practical training in.an^e-natal and post-natal care and in midwifery.
Enough maternity beds must be provided in teaching;
hospitals to^aliow each under-graduate to do the normal qt^pta o£20 cases. 1 raining in mid-wifery should also be domiciliary.
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22. Mid-wifery, paediatrics and health education should
I officers CpubKn 1th 0nCntatio°and rcfrcsh" courses for medic J
g officers, pubhc health nurses and auxiliary health workers.
1 onJ o3' - J110 °UtpUt
publ’C heaIth nurses> Iady health visitors
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uxi tary nurse-midwives should be increased considerably.
1 be
and thiI.d health services in hospitals should
> be co-ordinated properly with those of the M.C.H. Centres The
l aw^^
and -duce lem to
I centres cb Se -7']^ The
rendered by maternity
I anaS f h d
udc lmmunizahon and nutrition education
I healffi^rJs011'?^
C^d
MaternitV and child
I family nlann ’
J
talks’ d(;monst«tions, film shows,
• family planning education, home visits and health education in
I faison
Centrcs sh°uld establish ciosc
■ cEen
agCnCleS
®aIvadis for the care of pre-school
9
25. Creches should be set
up in commercial and industrial
9 establishments.
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26. For children play grounds should be provided.
I the
number of trained mid-wives,
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illa&c dai should be trained for use in certain areas.
icenr 28\ThM cady HeaJth Visitor and hfid-wife posted to health
I a“d Nutrition
CdUCati°n’ Personal hygiene
1
29. Hwlth centres anc referral and district hospitals should
I , T iPaK °f a” lntcSratcd ’hole with telephone connections and
ambulance services in order to attend to abnormal deliveries, surgiS ca* cases and blood transfusions.
II , 3°' The primary heath centres and maternity and child
I health centres in rural areas should take a greater part in the
°f “s®® of children and in the notification
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°f rb'rrths and deaths- They should also attend to
j the distribution of food supplements like skimmed milk.
School Health'
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Thc Advisory Boaras to be set up at the headquarters and
SH
„ ls.ln States on vaich *6 Departments of Education,
I
1b’ Rousing, Agriculture and Social Welfare, a represented,
| shomd play an important pare in developing policies .nd program| mes connected with the heath, services for school children.
J of -I2’ i^ch Dii:ec;ofate ® Health Services should have a Bareau
* ®.? ■°1 HeaIth Semces »
initiate School Health Service
c: iCs-*nimcS, to co-Oidinate ■ne activities of the Government, the
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organisation? ,r. i tc establish close ;
~
ttlc -c-ducaucn Departments i~ the States,
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33. General hygiene and sank, on
.^J premises and
smroundings should De improved. Even- school must have
a source or wholesome water supply, sanitev facilities and regular -J.
I <i}0:
proper cleaning up of the class rooms and the school campus. ■ f
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, . 34- Officers of the Primary Health Centres should consider it f
stained. SCe
q^tely g^c
s:aniEar-------------------y facilities in schools
are ?dc
adequately
i
35. The production of birth and vaccination certificate should W F
jX
36. Teachers should see to it that lists of students are prepared I 5bo::
tor re-vaccination after three years and such lists are made available '|^ren
Wjne medical officers of the Primary’ Health Centres for necessary M
,
k made compulsory for admission to scbcols.
p
d
_p7- ^nc school staff should activelv assist in inoculation of <
at the
___
pr-rJs at
the t-im®
time of any epidemic.
. 1BKura011
3-- The school feeding programmes being carried out in
certim States should be watched carefullv and steps taken in the
—i,-. of experience to improve and extend them.
actio
38(a). Kitchen gardens should be cultivated in a large majo
of village schools for supplementing the menu For school
rzeafs.
hospi
for a
ting
, 39’ The Primary Health Centre staff mav not be able to cater . togic;
tr the medical coverage of the school population except in 20 to •
ry vulages. Therefore, for
tor the
the remaining
remaining portion
portion of
of the
the Block
Block •<
serrices of private
te medical practitioners i.in the nearest .^n ■
tc-wzs may be made use <of“ cither through a system of per capita ?f
,
.
•
fee or by payment of an honorarium.
These private
practitioners enlar.
ciay ao periodical examinations and inoculation, while minor such
ailments may be attended to by the Primarv Health Centre staff
arm. the more detailed investigations may be done by the district
D25p*tals. the mobile specialists and the ambulance sendees, being cians
recommended elsewhere..
cstabl
Nutrition
jo. In spite of the priority given to agriculture in the two
Frty A ear Plans, major emphasis was laid on the increase of food and t
c~z«auction only, and adequate attention was not paid to increasing Siinat
tze output of protective foods, for the vulnerable groups of the
pccu_2tion.
A sound nutrition policy involves collaborative effort on the
ot the Ministries of Food and Agriculture, Community Deve'
^enta
i€<cment, Education and Health.
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127
0 improving thp hrerH of cmlr
fare otheAvays o
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more fodder,
and fish Produc^n
■ told be pa?d .X'dX^X”™ ”bt
■ of processed and synthetic fSods
3nd Production
H
I shouldVoLed Tdnt£CtiOn
u Health
'nst in the St3t
State
Health De
Di P^ents
■t strengthened
’
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—ing
-‘g ones should be considerably
exis
*-« >« “>Pl»yrf
an<i
■^ould5be^nppUeTtonthetnllne^^abl|,■ er1^1
B Rural Health Centres, \L C H
sS ‘T^
■ ^tion should be taken in X^ ’15’
»
t^0Ugl1
“
46. Clinical Research Units should be established in t
v
I ,®j13Se -for * ■>' ■— pwS sk:
I
S^HXSiSri?s,a5-'h?
W of Hygiene and Puhii/
n i
3nd i e
I
India Institute
for
i anrl r49' Consic,er‘lbIe precaution should be taken whil| and transporting foodgraras to - that such goods are notstoring
conig
■w. minated wi th other poisonous sue stances like foilidol.
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Mental Health
stx
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xj_ca xor LHC setting up q£
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t x.
rreventivc tncntal health y.r-. .... ;cr t-?: expansion and ir;
merit of curative scrvic-•••. fee the instuudon of training r<iuties -f
and for research and survey programmes.
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Housing
t
51. Early steps should be taken to see that as far as possible,
housing accommodation is made available to all employees of State
and Centra! Governments, ail industiial workers employed in large f
factories and all those who are associated with public utility
concerns.
52. Any new industrial area should be sufficiently large and f .
well planned to meet the requirements of industrial labour for
.
housing and other amenities.*
53. The creation of large towns will no doubt, involve corp J
53struction of multi-storied buildings but safe-guards regarding perfla-fg
tion of air, easy transport facilities, ancillary necessaries like schools, |
hospitals, play-grounds and parks should all be provided.
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54. The removal of slums and provision of alternative accommodation to slum dwellers is another important point to remember,
55. Co-operative housing schemes should be encouraged.
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56. The proposal of the Life Insurance Corporation to sub-, K
g;
sidise housing schemes should go a long way to solve the housing gv
problem.
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57. The type of houses in urban and rural areas should bei g
considered carefully from the point of view of public health and g
sanitation.
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58. The policies for Town and Country Planning laid down |
bv the Central Government should be taken full advantage of by
the States. There should be a proper town and country planning
before housing schemes are sanctioned. All schemes of housing
should be regulated by special Boards on which the Health Engineering and Administrative authorities should be represented along I ■'
with experienced non-offickds.
Vital Statistics
t
59. Health Statistic should not be confined to disease alone g.
but must include, in future, information on the socio-economic and ■. >
cultural pattern of the community.
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60. More and more longitudinal studies should be made
concurrent|| ■
future for purposes of problem measurement and
evaluation.
61. State Bureaux of Health Intelligence should be establishedf -
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129
62. There must be co-ordination between the Vital and Health
Statistical units in States and the Registrar-General and intemational agencies.
2
63. Centres should be established for the training of officers
and other persons engaged in Health Statistics work.
j
j
64. A Central Health Statistics Act should be enacted to
bring about uniformity in the collection and reporting of health
statistics throughout the country.
g
Health Education
I
k.
65. In view of the great importance of the subject, all States
should establish Health Education Bureaux which must work in
-co-operation with the Central Health Education Bureau to promote
health education of the people and make them health-conscious.
|
Model Public Health Act
{
|
66. In the interest of public health all oyer the country, the
time is come when every State should have a Public Health Act
of its own. Such an Act should include all the subjects mentioned
in the Model Public Health Act framed by the Ministry of Health.
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Physical Education
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67. Physical education has yet to receive its due emphasis in
this country. The general public should be made aware of the
contribution that physical education and sports can make to the.
balanced development of personality. There is need for a more
wide-spread realisation on the part of all concerned that physical
education including games and sports is an essential part of educa
tion and that no educational system can be called complete if
physical education is not allowed to play its full role.
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COMMUNICABLE DISEASES
General :
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1. Control of communicable diseases cannot be dealt with
exclusively as a State subject. It should be simultaneously a Central
responsibility. It will be too late and not very effective for the
Centre to intervene only in the event of an inter-State spread of
infection.
2. There should be an organisational set-up representing the
Central Government and the States in each zone to deal with
communicable diseases on the lines of the Regional Organisations
-set up for the Malaria Eradication Programme. Two or three
I
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’
t
concerned v/i?'- Goinnii-jlcabie Di<ea<es should be aswith dus.organis^ion. "] i--> will -end to promote greater
ce^shoration and more prompt action wherever necessary.
3. Some compensator (either under the Workmen's Com penso’s.?."?. \ct or under any f 'hcr lepislatioi' to be passed) should r
given to the health personnel,, mcdica! and non-medical, who are
cso-osed to unusual risks through contact with patients suffering
from communicable diseases. .
x. The development of a national outlook through .the proc es
ses of cooperation and discussion is preferable to the enforcement
of acdon for the control of Communicable Diseases by statutory
sanctions.
i
5. Necessary measures to enforce the legal obligations in
, regard to the notification of Communicable Diseases should be
/ promoted.
6. The network of Police Wireless Stations may be used for
the transmission of intelligence about communicable diseases from
rural areas to the nearest District Health Organisation.
Infectious Diseases Hospital:
* There is prime need to improve the conditions of Infec
tious Diseases Hospitals so as to make* them fit for the treatment
of the sick. A modern isolation hospital with facilities for treat
ment of Smallpox, Cholera, Diphtheria, Plague and other epidemic
diseases should be established by every municipality’ with a popu
lation of 50,000. In municipalities of smaller size, isolation wards
should be attached to general hospitals for the purpose. In bigger
cities Like Bombay, Calcutta, Madras, Delhi and Kanpur, there
should be as many as three to six separate isolation h^p^als distri
buted in the different parts of the Corporation areas.
S- Apart from Infectious Diseases Hospitals, everv General
Hospital (including maternity hospitals') should have a small isola
tion block for the purpose of observation and treatment of cases
suspected of communicable diseases.
Public Health Laboratories :
I
l
c. Public Health Laboratories equipped to undertake labora•torv and field investigations must be considered as the essential
pre-reCTfsites in any Communicable Diseases Programme. There
should be a chain of such Laboratories in each State. Besides other
facSides, they should have a mobile unit for field investigations.
There should be a Blood Bank in such laboratories. These labora
tories should cater also to the needs of private medical practitioners
for the examination of clinical material in connection with die
diagnosis of infectious diseases.
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‘i Epidemiological Units:
131
.
io. Each State should have a fully equipped mobile epidemioI S
”? trt?
^£“b“
oiate tor nelri onH
:____ -j_. .•
a eX"“'“d
themVhoSd3^^011 ? thC SmaU ePidemiol°gi«l units in States,
tneiv should be a nucleus organisation at the Centre the services
of which can be called upon by any State in an emeroenev The
^pe'"5
“‘t A™'d F‘>ras
Servioes £° 1j,?
taken in this regard.
-
*
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ST7L-1
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,
ic
Malaria :
> of thek
11 ,S
Malaria Eradication Programme
L n A Sovernnx-nt of India will achieve the targets in the couS
■ of the Fourth P an period if not in the Third, Attention mavT
KS is
rwTof0^
WiDg PrOblcmS Which afC likelv t0 croP up as a
i result of the mass campaign of this size :
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ij
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(a) The question of the possible developifients of resistant
in the mosqmto to the insecticides and the need for the
completion of the programme before this becomes manitest on a wide scale.
I
■j
s
(c) Careful consideration of jhe routine use of insecticide to
msect-borne diseases of man and animals and also against
agricultural pests, in present circumstances.
I
Filariasis :
•J
<»
*—
i -
f ■
■’■
'J™ « be esKblitd ih IoiHUe J,0Sp;H,s
I in areas where the
diseaseis endemic.
-----------
I • - l6' There Sh°uld
I
I
1
seP^re section for filariasis in the
epidemiological bureaux
to re created in each State. This section
•! should work in close c.
ttHjperatton
with the Public Health Engi•r| neering Section of the StaM
I
W;
I
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i
1
(b) The possibilities of insects other than malaria vectors
becoming reastant to the insecticide in use, e.g. the rat
. flea and sand-flies which transmit plague and'kala-azar
respectively, and
-
I
-P
12—58 CBJn/ND/84
1
4
if132
an
the S.cxU.
Health <•:- cu-: ..: on the r.-,.•■>>■.■ v; ef fi]ai-;as;3 shrva;j
■ P-r. ci r;le .cLvuy of th< . ^aia Education Bureau in
! £
v J ^\Ye.kre'^aY1<im'training unit ^cu3d be established in
eacu . tate where filariasis is a major prcblem.
i-
*9- Control of fi’anasts is not amenable to a crash eradication
;W br
pro^nme as m the case of malaria. The effort will have
to bew ^<8______
contmned for an appreciable time with
vij. adequate financial support ft
befcrc any tangible results can be obtained..
Il vi
btaifieA -
po. While anti-larval measures may be expected to stem the
tide e mporanly, only adequate drainage facilities can provide the
long-term solution of the problem.
Ws
Yo<
I Mac
Tuberculosis :
jj ||-
21. TJe emphasis on anti-tuberculosis work must continue
to be jin the public health aspects including protection of the
vuln^mie population, early detection of cases, control of the spread
of infection and attempts at converting an infective case into a
Domimective one within the shortest possible time.
i I
1'
22. Emphasis is also required on earlv detection of the disease
in persons who come into contact with children as well as contacts
or active cases.
i
'rkWtilc.113253 BCG vaccination should continue durina the
Tiurc Plan, active steps should be taken to integrate BCG vaccina
tion programme and other tuberculosis schemes.
Tn
pnonty should be given to the establishment of
1 .B. climes so that fully equipped and starred clinics come into
existence in each district with the least possible delay.
25. Since modern chemo-therapy has proved to be verv effec
tive ar.d is likely to be the basis of any mass anti-tuberculosis pro
gramme, it is essential to ensure that adequate stocks of such dm 0-5
are made available at a reasonable cost.
JILlri
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11
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26. The provision of a mobile van equipped with X-ray is
essential at each of the T.B. clinics. The mobile vans should visit
■ Bthe ta:uk hospitals and primary health centres at stated inervals.
■r
tiDr
he subnet clinic would become the base from which the BCG.
vaccination teams operate.
’
idi
IpSPatC
mn 2/* ?3e
UP
demonstration and training centres in
l.b. one for each State, must be considered as a sine qua non for ■ K
the envelopment of an efficient anti-tuberculosis service.
W
If
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2>. Owing to limited hospital beds and extremely poor
-housing conditions in the country, facilities for isolation of advanced
L -of
I •"'
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I
133
.or infective cases should be provided c\r»
1
I js contemplated at present and at a mutn mUch
I 50,000 beds should be available in the coum^
than
’“I
7
| isolation.
Purposes of
^a^el^^^XesVd^tV
f°r h°SPilalSw -sation
ii be for a bed strength of noHess th^XtST^
315010
vided^mS^11
Pr°-
w Services of each State idus^fSchSg^of^tT*6 °f
W- both preventive and curative. The State TBo^'
adequate training and experience and the er£ T
35 one unitary service in
-muniS>i?d?s^rkSddahP° °^KrS W°rkinS for “ntrol of comtreated as
H al?b r jttractlve, rcmuneration and
™”»“£iXp°
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1
voluntary organisations
Leprosy
he
eo^i*'
a
8
p^X«P
mT'S'
■r-
ip
i . of
I
I
I =”-£.«,relieving “edical
■ ;
3.6. For some time to come, steps will have to be taken to
provide facilities foi
of the leprosy problem m the ^.r £re
P
J
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AaAaA
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.
LAA ;
.
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Tr- The altemyfor made for -f
.■;* prevention of infectb. -
Arn hy segff£aT<> 6em
uOt y ueccd -ty apprenah^
infaS
------ ; parents ha .
i-
K:
3i
30 fecent observes indicate rS.
e possioie jsc of che«~proru jixis m contracts ?.s well as tkc
-k- ‘
'-V B.C. (i vgr-rxieitlOa
tv
P^nve data are yet avaihble reg?
th- adeauacv o£ tb ■ ;£vmethoas. llus 1S a matter for research.
‘
w
Smallpox
40. On the termination of the Smallpox Eradication Pr,c. W
gramme planned by Government, there should be a follow-up bv #£•
a sustamed programme of re-vacdnatioE and primary vaccination O
or new born babies.
•
A*} improvement in the method of repcrtina of vital H
sen sties and adequate supervision of the vaccination work is called - ®
far.
I
Ebe present tendency towards rnirldpltcatior .=f agencies for J 1
the conduct of immunisation and other preventr programmes, 1 B
is wasteful and should be avoided.
1c fe
42. Normal health agencies should take up
up the
work now
now| K
the work
Deng done by independent units for tuberculosis, leprosv etc., byr
;
making a larger use of para-medical personnel under 'a'qualified '
medical officer s supervision.
43. In addition to official health services, the services of 1 fc
private practitioners should be utilised on an increasing!v lar^ “ W
-scale.
bJ
44. In order to develop immunisation programmes properly, ' K;
States should carry out pilot studies in selected areas. '
1
45. Up to now, no concerted and properly controlled vaccina- I E
&on drive has been organised. Haphazard measures can never.3
acmeve eradication of this disease. The experience gained recently
m the pilot projects should be fully utilised when the Smallpox ; foT
Eradication Programme is launched.
i-
r pE
II
46. In spite of our knowledge of the efficacy of vaccine lymph
as a prophylactic against smallpox and the continuing vaccination .
effort over a century, expected results have not been achieved in -fo.;.
India, although limited local experience and experience in other .; T‘
countries show that an organised effort does yield results. There' .fc;
fc.
fare, steps
be-------taken—to—
deal
more effectively
effectively makin
making
± should---— with it more
g Jigfe
nfo preliminary arrangements such as recruitment and training
ot personnel,
eauipment, manufacture of adequate
adeouate
.
- procurement of equipment,
quantities of lymph etc. before the actual
actual mass
mass vaccination
vaccination propro ’ffo-/
gramme starts. The progarmme must be carried1 out within 2s -g .
■
•
11
' fc11
■
H
-
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f
K
Kg short period of years taking careI3^
to see that new-borns are vacdnated within- six months after■ birth,
Thereafter surveillance
eJ | services should be established tc
to take care of children who have
R nOt
primary Vaccination.
sf
st
tW' .
Th* ~gcnc
- y
- of••thc eradication
------------ 1 programme is strondv
eW' emphasised • The
programme should be pushed through oiT a
flfc? coordinated basis under the direction
- —-----n or a central authority’.
w;
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Cholera
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^c°mmcndations made by the Expert Committee
tion of Choi
G?VCrninCnt °f India in I958’ to review th=
it amfuHv endo11^ pCOmniend ways “d means to deal
it, are fully endorsed. Extensive measures are needed in West
Bengal area for the control of the disease because that area is the
most important focus of infection in the country.
Trachoma
5°. Taking into account the results of the country-wide
S1?J:OfndUkted dun?&rthc last five years and the efforts already
t m- f°r lhc COrltr °f th‘S discase’ k is considered that instead
extend tKg ^P1?^ Piece-meal, a comprehensive approach tn
reX-l ^e-Ct 1
CSPCcially in ^ose States where
r choma is known to be a serious public health problem, should
oc made.
px(
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:
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Venereal Diseases
ah Ji- Compulsory notification of Venereal Diseases cannot be
an effective
effecuve step so hr
far as India iis concerned. Indirect methods
o^T0 d0?6 ^Tk3’ eFOr thiS’ prOpCr monthly returns mav
be obtained
obtamed from all the State on the different types of venereal
diseases teeated m all institutions. Serological surveys in select
groups of population, random sampling h highly endemic ™
serological testing of all pregnant woXn assume ofTe X
T
sources of getting sadh information.
torai
sens
sh’h
g
D.p
of c
el i
shnu1d2k?Ji meas?es to.^scourage prostitution and promiscuitv
should be taken up by social welfare agenaes and health educstioi
sections of the heakh services.
v .J3', The .NadoQal Venereal Diseases Control Pror:-,-^should be instituted with the long-term objective of reducing thincidence of these diseases to a negligible proportion and ev>- .
tually eradicating them. Sustained efforts would therefore have
to be made for at kast the next 20 or 25 years. Greater use will
have to be made oE epidemiological methods.
tk
4
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'4- it is extre:hr,.,.,......
,
Uj Vr KStlaS and treaty at chm7
ao<i «nxind
F mines on
£«?
fOntaCts broagbt
11
svs^mati
t fi
™~rX'FsliJp^ I' p
#' o
j.
B
for testing of
©i- 11
IP
sfranon Centres, health eXation fin
F Trammg and Demon- I >s
’? F cj
at° vT’ es£aWisfrnent of a Centra?77
to voluntary
-uuj, i^ooratory J I lr
Bombay, Calcutta . j t A
for VJ). treatment, incomoX^/
at
sea-ports
n
Programmes of medicafofficere
“J13’ “ the
ife Vi
adequate remuneration to P7oX w°7
HcaIth Centres and
steps that should be tScen IoSD§ 7 ^J’0' Programmes,
Ws
programme.
n t0 achleve the objectives of a V.D.
ft
and co/nsSrSvJlX7nsTouW,V°IMUDicabl;
^iits. Raising the social level
heaJth
be another necessary measure Th
PoP^ation concerned will
vested „ State V.D.“»»°l »f v,«, sbo„U be
Plague
the countr^^H^^XfJrn^^ t£
B. P1
I
Resurvey
B?F
If o:
I ta
I
f
‘W-
Ip.
“ CCrtain
ft
of
gradually developing resistance to DDT ^T^0" °f pITC’ arC
changes in the rat population R R
'i
ls. ev|dence of
shif^'0 t0 pIagUC “Jetton, is replachS ^SI^-whlch is highly
shift in rat population may create Pfa , § m No?'eSlcuS- This
genng off the epidemic ir^nm fa'ourable conditions for tigDepa^tmentsofStateTshodJ ffe
Public
of outbreaks of plague. In’tf- n^’
3
t0
Possibility
elimination measures should
L° en^fr dangerous areas rat
The epidemioE unS pronoTd 7^7
en 7
on a3 p...... .
Proposed
forrathe
ib“Id
over d.er
”:?>
^State
SSyHealth
Sh
--—as at an
Virus Diseases
59- In view <of' the
' practical difficulties in instituting --tme measures against influen2a;
!g quaran----- [ not be adopted iin
C2
ft ca
I-i b‘
B - ol
ft-
17- sa
5U
I
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ft A:
p ? th
■ -fe - sb
ft: tlC
fe
B
IS
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'137-
S
S
Fac^ti“ may
crcated at different centres for the
g production of tnfluenza vaccines at short notice on the ifoes of the
g techniques developed by the Pasteur Institute, Coonoor In foe
i
5 foTSSSCalTlnC Shf°f be mai e available for the Protectiorl
H ot the special groups of foe population such as the medical
such
S personnel, transport workers, etc.
1
6o. Entero-virus infections should be studied in more detail.
H in th1' ThCre iS a Wide PrevaIence of polimyelitis in the country
| m the younger age groups. Steps should be taken in time to
I SCvardCVe hPmknt °f
lnfcction in
later age groups
E Salk vaccine has been used extensively in many countries X
I encouraging results, although there is evidence to show that the
I A
rKiS “ comParatively
a short duration.
I noXac^TUn atlOn Progranime with Salk Vaccine is therefore
I vaccfo of /ho W
apPCar that Sabin’s oral vaccin= is the
S in th/
f h
m organismg mass immunisation programmes
» m this country against Poliomyelitis.
F S
I
|
nof 62' h is.necessary t° take steps for the production of oral
polio vaccine in centres where facilities are available.
I
I
I
I
|
soeriaHr^6 “ k°
^^t for infections hepatitis, but
m hreaterde^-l51° mvestlSate outbreaks of this disease
or toread bv
”
f ,ls P?ssibIe to prevent its occurrence
Seen
g’obuJin. Steps should therefore be
taken to produce gamma globulin in the country.
I
|
cal imtrfXi6'5/110^
f°r a thorough epidemiological investigauon of epidemic encephalitis in children.
S
5
f
'
carriecFon5^5 vn
orthr°’Pod-bome virus diseases now being
Saul fo“
Rcsearcb Centpe, Poona) shouId
of rhX “ 7 7 hiP m the elucldation of the etiology of many
of these infections, foe precise nature of which is yet Unknown.
sanita^nnUnlCSS therci “ 0Vera11 fmpto'ement in environmental
sanitation, no matenal impact vvtill be made on the prevalence of
mai
’n
CQmmunity- A serious attempt should be
made to tram as many scientists as possible to undertake work fo
t and'wh^k0'
PJr°b,em at 25 ma"y centr« - PO^ble
shn-il?
Cnj SUCh
personnel become available attempts
£»° AS' ” °m °p dia8"“,ic
cons at suitable regional centres.
9
11
'»iA
is ne2/^7led^ roDCCrnin?
purification of water supplies
should t'A ■kdy
“ter(>-vlrus infections. Special facilities
Should therefore be created to develop measures of water purifica-
.. :
'S-X*. /•.., M.
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P
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I
138
professional education
Undergraduate
1. Aether colleges are run by the State Government or by
prh’ate agencies the responsibility for recognition of college- res‘1
wth the L’niversitii
■es concerned and no medical college should be
started unless the conditions laid down by Universities have been
fully sadshed.
t'
I
j&r?
"s "f^y to
C01 °f s““ppi
is necess
that full infoSJi^in ±
*'’-J
the authorin’ concerned
efSIOn
Government or
recognition/ - ' d W°re the univerati« are approached for
2 nCW medical college is si•tarted by a State Govem- ■ft;
ment or othcr
it
t to a standard plan laid
Jn”^Thc UniverSity should
appoint a Commis- I
wh-rK
r "f Ot
teachers and experts to decide I
whether aL the conditions are satisfied
or not.
4. State Government should r.
‘^
not
start new <colleges without .'sfr
ion and of the Ministry ft’-
t
I
“hare ■ d“'”f”
at the end of the Fourth Plan
period.
There should be one medical colleae
college for at least 5 million
populatwn, which would 1
’• 0
2St
mean, taking into consideration the
-- 90 medical
£3*^“
w
---- -
JFI
;■
bt—
kZV A1VCUVX
'ft-.;
ursing, pharmacentres and other para-medical training institutions. " *
In order to give as much personal attention
to individual
students as possible, the number of admissions to
medical
colleges
should not ordinarily exceed 100.
* _
KIfe
sr
Ir
suo,ect m pnysical and mental fitness.
r
33
sradU^^T21 9°vt-'nment sh°uld give grants for under
graduate ^d post-graduate medical education, on the analogy of
1 Ui
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W
HiN
I
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i
1
K
& '1
pa .
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tn
A
139
i
SUCH
the grants being made by the U:G.C. for post-graduate terhnological education.
8. In deciding the location of medical colleges and while plan
ning and constructing them the following considerations mav be
Kept in view :
.
I«I
ac
won
U »
r
(a) closer contact with Arts and Science Colleges ;
C2—
S»:.
(b) the site chosen should be sufficient for future expansion
for construction of quarters etc. ;
(c) it is not necessary to construct a medical college within i
city limits—in fact it may be desirable to build it in
rural surroundings provided facilities like electricitv,
water and roads are available ;
£
■(d)
the campus for a medical college and hospital should be
between 6o to ioo acres ;
for easy communication between department and depart
ment and between departments and tLe hospital, it will
b^t nccessan’ to have three to four storied buildings with
(0 clinical tncatres and demonstration zooms should be
made available in the hospital or in the out-patient poly
clinics ; and
.
r '
l
<g) the buildings for medical colleges mav either be permsnent using standard materials or thev mav be pre
fabricated structures which will cost much less, accord
ing to the discretion of State Governments;
I- ?
A
.a j
ti
I
l!
I■h
n
aivn
Che
c
S 1
c
provision should be made for libraries in the college
buildings on the ground floor;
0
hostel accommodation should be provided to at least
75% of the students ; and
seic
(j)
a high powered Committee with full authority to vet
all plans should be set up to prepare a master pbn.
!
pai
9. English should continue to be the medium of instruction
in medical colleges.
' I
io. Graduates in mathematics and physical sciences and
natural sciences should be encouraged to get admission to medical
colleges, provided they possess First or Second Class Degrees and
their pre-professional record is of th: minimum standard prescribed
for admission to medical colleges and provided also that in the
pre-ciinical course they take up study of the subjects which may
not have been cover J in the pre-university course.
>:v
?
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(h)
I.)
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ec i
con*
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I
140
ji. Graduates may be selected in addition to those who have
passed pre-professional examination, hirst and Second class graadmitted to the first year of the medical course, if
me) ^ve me basic pre-prbfessionai requirements for admission.
At ...east 10 percent of the total admissions should be reserved for
such graduates.
o-
1
II
t
(
t
S
12. A separate entrance examination for candidates seeking
admission to medical colleges is not recommended. The best course
wouiu be to select candidates on the basis of the result of the preUDiversity or equivalent examination.
1-
/
L
i
13. Where interviews are considered desirable for selecting
candidates, not more than 10 per cent of the total marks of the
myersity examination in the subjects concerned should be assign
ed for the interview and the following factors should be taken into
considerations at the interview, among others,
0 Extra-curricular activities,
fn) Membership of N.C.C., Boy-Scouts, and Girl Guides,
(Hi) Sports, and
(iv) Personality'.
The assessment for sports should be on the basis of the candi
date having reached university, inter-university or national
14. The Selection Committee for admission of candidates to
medical colleges should consist of Principals of medical colleges
along with a senior educationist of standing nominated by the •ViceChancellor of the University concerned. There should be a
common Selection Committee for all the medical colleges in a
State.
E
■Jg
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11
fp
11|pa
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31
f
; i31
j f-
Ith
■ fvi.
" tr
5 sir
; |10*
t?sei
fc-
15. Merit should be the only consideration in the selection
of students.
16. In regard to reservation of seats for scheduled castes,
scheduled tribes and backward communities, it is felt that in selec
ting from these groups only the best among the candidates are
selected for medical colleges.
17. A minimum of 5 per cent of the total number of seats
should be reserved for special cases like sons and daughters of
parents migrating from one State to another, either for official
duties or in connection with trade and business. This reservation
will not include cases of students coming from outside India and
nominated by the Government of India.
in
B gr:
■i
; gra
■t
■Ife.
^3^
bog
18. Twenty per cent of the seats may be reserved for women
in certain States where there is a dearth of women students. The
I
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Bi?
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141
fere'served quota of
SzoV
7’U 1£
admitted on meritg/ the event of more than
than
20/0 of girl candidates qualifying on merit
there would, of
W3 | of
seats for them.
!h“ld be «>ly fcr a
Komhlnd period of S,
W should9'be 17 XTTnTs^O
to a radical college
J grated course7 ff 6
and 18 D| Orfca^ pining the inL
&
[ regular medical course oft yeX
Cand,dates iouung the
fIsIf
B I monks' ald'th^mS^bi^
shouId ex-nd to 18
g-1
8 [Physiology including-Biont °Istudy “d examination will be
I
-
E and Anatomy including
r^aI1IC Chemistry, Bio-chemistry
I practical appl4XnJ^ss should be laid on the
| the candidates clinical years.
SubjCCtS.that W111 foIlow during
II Il EtoenK
a half ye2' Se"^
fT”8 sh,M,d “Md » “d
' sSfcfa KoXrf™ .'ngod'rfd “ S“bi“B
I
| and Introduction to Medicine.
Lted“»eXblS
° Psycho 0S7 ‘1Ild Sociology
““'-S
bo on an into,
SUbi”S
f al» taking a pan Md re^Mi^ S'roaL^
iB
J ^eloK'e'ro ^TelSkS
| wsual aids nlKreeer possible.
»d
C'dcmonser3t,ons With audio-
■4a
■
bf » ,!« it w
O logical conferences should VhelJ ° 7’ 1 Besides dimcopathoK medicine and surgery and such
Week 1)0111 011
< «niot student. „/tZ g* and yd, ^“"aU^
"'“dCd br
fc dte^d^d?. ”c£S
Sh”J'd
b« Si-
B. gcatiuaK stage and the l«x1seh^p s^ge"“n''d for the 1“'-
® coropiicated Ifm^lXati? sZb"**
o„,yP by*
f devoted td^the srodlrf
J
and applW
“ '"'“““S’
V»"!”bould be completely.'
“d
of preventive and social mediand facilities for the training ofL
® teachers in this subject should’ b.
he developed.
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-9. The teaching c:
jxrihpr.jieiice should in Riture
be mtricted to the broader
:?f rrrisprudence including
professional behaviour, hue so h ng as a generate cadre of medical
jurists is not established in ' 'ich Stare and yruperly trained medical
jurists are not made available, the Kacmng c£ medical jurisprudence
should be continued or; ide present bsm.
G
c
51
f n
3
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d
r<
1
30. Examinations in all subjects, other than Medicine, Surgery,
•Obstetrics and Gynaecology toged./r
together with ssplied
-applied aspects of prevenp
•.
tive medicine and pathology should be ccmpleted by the end ot ■.
the 4th year of the study.
s*
331.
1- ’ The teaching of paediatrics and mental diseases should
form part of the under-graduate training. At least a period of
h
...
.1
three months should be devoted to the medxal and1 surgical
aspects |
-of paediatrics and a question or two on [paediatrics should torm >
part of the medicine and surgery papers.
Bi. a
32. So far as ophthalmology’ and ccorhinolaryngology are ■R
•concerned, a separate examination paper may continue to be pres- |
cribed where this practice has been in vogue.
33. Examinations by'themselves will not serve the purpose of | fe
^producing a well-qualified basic doctor. Greater importance
|g
•should therefore be given to the training methods adopted to make y g
the medical students more and more self-reliant. The interest
which a student takes in 2 subject depends upon the particular | g|
fc n
Professor.
34 While the day-to-dav evaluation of the student s w’ork -|
commendable idea, in actual |
£o
r
■of an examination, will be possible, realistic or fair m co ege
where a large number of students are admitted and where
J
•contacts between students and head of the department is no hketyjto be as intimate as it ought to be. This method of evaluauong Bo
Jd
-can be adopted only to this extent, viz. that
ong w
||
standard attained by the student in his University examination, v . >tl
may be given a certificate by the college concerned giving "’W'sl
general attainment during the college career.
35. In regard to orientation in rural health, the system of|BF'a
having certain days of the week when students are taken
taken to
to village^
s d ag
.1
along with the teachers will be of some benefit. Jisitsto
in urban areas should also be included. The Professor of Pre
also clinical tcachcr^^^^
-five and Social Medicine and his associates as ano
should take a prominent part in such study tours.
hc®
fte D
36. Teachers in medical colleges have generally too many
dents to teach and too little assistance Teaching facilities are unsa
factorv. Well-qualified and experienced Nisons are not aw
’
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.
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I
if
i
few
O1
143
HB
^VaiIaA C kTr
kause
unattracttve terms of «rvice
K Cons’^rable difficulty is felt m getting qualified teachers for preB Object SmX ^ySted tJat.traincd funnel in these
f n0.n-medlc:d m?n
utilized as
< institutions, so that the-
B auxiliaries in teachina
medical men
i
| devo^
fW'' research.
B
tt
Jn Edition
to Jthe .rC
regular
professional
l1
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r
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3
w°rk,should also be
be undertaken
undertaken by
by other
other members
members of’ the staff
— of
,A
|||pg 3S donc when lectures and demonstration classy
f are not held.
3^* Attention should be given to the number of
38.
nf 1»- l
employed
m
„ in relation
re|ation „
adm
T mediI<^1 <tJkg
^ges
to the number of scents
adnutted the qualificanons of these teachers at different levels and
r caching experience. The time has come when some uniform
nomenclature should be giv^n to the differ
Kv-'
ir'
simple drfSTK? ‘1’'
“d,CTS-
(1) Professor, including Associate or Additional Professor ;
(ii) Reader or Assistant Professor ; and
ij
£
(m) Lecturer and Registrar.
CatCg°ry WiU BC ^“onstrators
Tutor^" d°Wn “
and
39. There should be some full-time paid units in al] ^^hcs
of study in medical colleges articularly in the pre-clii^al, labo
ratory sciences and cenzin of the clinical subjects.
■
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40. Full-time units should be available in medicine, surgery,
obstetrics and gynaecokgy. All these full-time units nould devote
their time, entirely to teaching ailCf should not cq^ge either in
active or consulting p«cuce. In view of diffievtics in meeting
the entire requirements of teaching and medical-chef by full-time
staff, part-time teaching units are necessarr Fully qualified
persons should be appanted to work as hon^ry medical officers
and assistant medical o&ers for teaching
for care of patients
The honorarium paid iem should be °nimensurate with their
responsibilities and thev should be give foe same designation as
Professors. Readers or lecturers proved they have the reouireri
qualifications and expeience.
41. There should be a c^ of full-time teachers in the
categories of Professors, Beader^ti Assistant Professou, liablto •
transfer to ocher teaching;
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144
42. Lecturers should have an occssionL ^penence of work
ing in non-teaching hospitals as weii as in -he districts. Such
peopie may be selected later for the pos-rs of ILci’cssoxs
Readers.
42- No tutor, demonstrator or registrar should be attached to
t-
.2 teacning hospital for more than five year^
44. Teachers of clinical subjects should have a minimum
basic qualification of M.D., M.S. or an equivalent qualification.
Teachers of non-clinical and prc-dinica! subjects should have a
minimum qualification of M.SC; or -Ph.D. Along with these
qualifications they should have the requisite number of years of
teaching experience^
't
11 5
I
JB
45. The duties of Registrars should be specified where they
function as Lecturers besides collecting records. They should then
be equated to the grade of lecturers. Where they work only as
Tutors and Demonstrators, they should be equated to such posts.
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46. Lecturers should all have post-graduate qualifications in
the particular subjects or specialities (A post-graduate diploma or
degree in the clinical subjects or a NLSc. or PhD. or equivalent
in non-clinical subjects).
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47. Taking the basis number of admissions to the medical
college to be 100, the teacher-student ratio inclusive of tutors and’
demonstrators in each department should be r : 5.
I s.
48. Considerable improvements of out-patient department of
teaching hospitals are necessary if the student is to have the full
beu*{h of the ^<u4«ty of cases available in such departments.
■ 4,- in
- ®
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I
.
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49- The following minimum scales of pay are suggested for
teaching staff :
B stij
Professor.
..............................................
1300-2,500
Associate l-ofessors .
1-250-2,000
Readers (As^t. professors)
.Rs. 1,000-1,500
Lecturers & R^istrars
.
.000
Tutors & Denu,strators .
.
.
. Ks.
350-600
. Egto
ft of
fe
•
I ins
50. Class I Sb]es of pay for those recruited to the Medical
and Public Health Lsts should be the same as the I.A.S. scales of
pay, where it is a rum.ng scale depending on the length of service
and not on the positionheld by an indvidual. The scale of pay
of Class II posts should L
same as fir other Class II posts in
Central Government
S-r-
'S sta:
-;g
XPU]
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51. Internship has been fovid to be unsatisfactory and it
should be replaced by one yeaf •< \mpul<ory housemanship, with
provisional registration as a part of v training course prior to final
registration in the medical register.
months of his house_manship period should be spent in
health work and one of
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I ?he
■
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-
•'-ri
—Sapi
145
iI
these three months should necessarily be spent in a Primarv Health
Centre as an Assistant to the Medical Officer in charge' of thffi^M’rT SlC!\iOUSemev should WOrk under
rcoervffion of
the Medical Officer-m-charge and should undertake complete
'1 " ^ponsib*7 f°r aU types of work pertaining to the Primarv Health
h Centre.
—They should be provided with free accommodation and
a subsistence allowance of not less than Rs. 150/- per month. In
general all housemen should be provided with free furnished
accommodatton within the hospital or as near the hospital as
Rs^icn/tOgethcr Wlth a subs’stence allowance of not less than
-Ks. 150/- per mensem.
1?
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Licentiate Course
tk 2' 11 WiiUrbe ULnfortunatc if « the present stage the proposal
men^C r^?val of a .short-tc5m medical course is accepted by Govern
ment. The licentiates and students trained in short-term courses
arc n°t at all likely to settle down in rural areas as is popularly
believed. Moreover, rural areas cannot be treated on a differential
basis from urban areas. On the other hand, the training of several
of paramedical personnel suggested elsewb^e, would
"s “p
gap “
Post-graduate Education
1 in ST
1 hh’ndng “prions, in district and taluk hospitals andp'2in
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54- The
of canaida
candidates for post-graduate train
mg in pre-climcal subjects should be
stipends.
‘
remc(licd by grant of
— —
J-
55- It is felt that every medical college is not immediately
immediately fit
fit
to be a post-graduate centre for training in the several branches
ot medicine The recognition given at‘’present’ to s^e “of^ese
institutions should depend upon their satisfying the conditions in
regard to equipment and personneL
56. It is felt that the upgraded departments which were
started as a temporary measure and which have already served their
purpose,
- tr 1 jshould
. be? merged with post-graduate centres wherever
established and no more upgraded departments should be created.
■J'
57- There should be at least one well-developed post-graduate
centre of training in each State where all the
the specialities
specialities will
will
gradually develop.
li
58; The maintenance of such post-graduate centres should be
the entire responsibility of the Central Government for at least the
• <
I imii
i in
II I, III
IM
I.■? !
.I
146
t-F
nf ten yean if uniformity of standards is to be maintained.
Al
is drawn in this connection to the position of higher
tec .ologma! institutions in die field of engineering set up by the
Government of India.
1
I
58-A- It is suggested that the Ministry of Health may follow
the praetke of the Ministries of Education and Scientific Research
& Cultural Affairs, by giving through the U.G.C. lumpsum grants,
to post-graduate medical education centres.
I■..
ft
1'
59. During the Third Plan a beginning should be made to
ri-velop ar least six such Regional Post-graduate Centres with the
assistance of the Government of India, besides the All India Insti
tute of Medial Sciences, Nw Delhi. Tk- post-graduate centre
at Calcutta should be taken over by the Government of India as
a Regional Centre and strengthened for all disciplines.
ines. The
remaining five Regional Centres should be located at Bombay,
Madras, Hyderabad, Lucknow and Chandigarh.
60. The regional post-graduate centres referred to above should
serve the surrounding State till such time as post-graduate centres
are established in each State.
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61. Admission to the post-graduate centres should be on a
regional basis.
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62. Under-graduate teaching may also be imparted at the
proposed post-graduate training centres till such time as it is pos
sible to have separate under-graduate colleges at these places, the
number of under-graduates to be trained being limited to 50 in
-- a-
sj i
i
| Fp
ts
63. The methods of selection of candidates for post-graduate
study need eereful examination. The numbers to be trained in a
particular speciality must be strictly limited if proper training is
64. A National Council for Post-graduate Education should
take chargiFe otr the
1 functions of inspection, recognition and approval
of mstitunom giving post-graduate instruction. The manner in
which post-graduate institutions have developed round outstanding
individuals in many countries, is far more conducive to effective
^IXUVUVV
growth of centres of post-graduate education than a recognition
___
given and continued on the strength of an assessment of£ f-k,.
the facili
4__ :k ■
ties available at the start. It is, therefore, necessary to lay down
that recognition once given should not automaticallv continue.
The teaching personnel should be of a high grade 'and should
command the confidence of the medical profession. It would be
essential to see that the candidates admitted to post-graduate studies
come up to the standards required.
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65. It would be a mistake to consider post-graduate medical
education without considering also the necessity to provide post
graduate instruction in allied fields, such as, nursing, social medi
cine, anatomy, physiology, pharmacology, bacteriology, patholo^v,
bio-chemistry and dentistry. The training given in post-graduate
centres should be of a comprehensive nature including not onlv
the basic medical sciences but some of the fundamental physical
and biological sciences.
£.
L
66. It is suggested that 80% of the seats in these post-graduate
centres should be filled by candidates from the States in the region
and 20% should be made available to candidates from other parts
of India, until such time as each State has got its own post-graduate
Centre. Even then there should be available some seats for
graduates from other regions.
i
67. In selecting the subjects for post-graduate training at anv
centre, emphasis should be on the qualifications of the teaching
staff available there, besides equipment and other facilities.
<
I. 68. Candidates for post-graduate training should have as a
1■
qualification either a Master of Surgery or a Doctor of Medi
I' basic
cine or some basic post-graduate qualification before specialising ki
1
1
I
11
[
any subject. In selecting candidates for post-graduate studies,
preference should be given to those who have obtained prizes and
medals in university examinations, those who have passed the
f M.B.B.S. examination in the minimum period of time, those who
| 1 have shown special aptitude
a
1e iin any branch of medicine and those
others found suitable on their academic records.
i
1
69. There should be a Selection Committee for each postt graduate centre consisting of the Vice-Chancellor of the university
i where the Centre is situated, 3 to 5 Principals of medical colleges
of the region and the Director or Deputy Director of Medical Edu
Edu-
cation of the State concerned.
v70. A large number of stipends should be available to candi
dates taking up post-graduate studies in these regional centres.
. should
__________________
71. Opportunities
be given to post-graduate students
research workers to participate‘in teaching, so that they get
practice in the method of teaching, such teaching being recognised
for appointments to higher teaching posts.
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72. For the posts of professors additional and associate profes
sors in the post-graduate training centre the scales of pay should
be higher than those obtaining for similar posts in under-graduate
institutions.
73- Gran'ng of,pc^-graduate diplomas is recommended, so
that such diploma hokk will be available 'g?- service in differ-nt
positions o her than those for teaching, p
who are
13—88 CBHI/ND/84
- '-../J.- .
i
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148
5
I
> '’ obtain the requisite standard tor a p^t-^raduate degree at a
oc-na: centre, but who have otherv*doe attained a . reasonable
■ .odard of proficiency may be given Certificates on the analogy
certificate of Graded Special .'ts in the Armed Forces Medical
: ;:.-vices and utilised in district <md taiuk headquarters hospitals
■••• oere specialists are badly needed,
74; J1 will be advantageous to have liaison between Indian
universities and some of the foreign universities so that teams of
experts from other countries may be exchanged, seminars held
and various- problems concerning medical education discussed to
mutual advantage, bor this purpose State and Central Govern
ments should provide adequate financial assistance.
75. Refresher courses for service doctors and private practitioners should be provided in greater degree. The courses shdtild
not merely consist of theoretical lectures but should be accompanied
by practical demonstrations and seminars.
I
•s
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E
’
76. The training of the general practitioner should be the
special responsibility of the profession, of post-graduate teachers and
of specialists ; and every training institution in the Faculty of
Medicine should therefore, make a special effort to see that refre
sher courses are given as frequently as possible and in a practical
manner to the general practitioners.
t'
■
77. Suitable units should be developed in districts and tehsils
for giving opportunities for training of practitioners and for ■
research in community organisation.
78. A Committee on Public Health Practice should be set up
under the Indian Council of Medical Research and an Institute for
Research in Public Health Practice should also be established in
due course.
79. It is considered essential that a large number of techni
cians should be trained for multi-purpose duties in the field of
medicine. All district headquarters hospitals and the larger
hospitals with 200 beds can train such multi-purpose technicians.
80. Lay administrators for hospitals are not satisfactory.
Hospital administrators should be specially trained so that
"
they
can work in close co-operation with medical personnel without
unduly trenching on their professional duties or responsibilities.
J
S'■- ■
£•
81. The health and welfare of the student population in
medical colleges and other training institutions should be paid
greater attention. For this purpose, apart from proper hostel
accommodation, facilities should be provided for periodical checkuc. tree treatment and accommodation jn the hospitals, for keeping
of all records of illness of each student and for running of canteens
ki
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sxch"s' -
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ds I 1 PnWic Health Training:
•f
W
g
£te*^dS °f
m
of^E;
-
M IB|<arry out public health and saitation'mea’XeT^
t0
t° ,
n- 'X
Ik. “medzeal
77 officers
Sinontt
pSc
the field^f public heJ th
eStabHshcd°f
tikr alS°,Var,ous othcr
Id U: “Agones of public health perwCel lib
Pubhc health engineers,
rd ® sanitarians, public health
O legists and field workers TheF!h u
? • workcrs> maiario>e ® «.* under-graduate and pM-gradnate StuL'^
id
Df J
i
“Ae «*- ’J
e- |
woffi” P?Il!1 hrakh
al 1t| 5-8 years’ experience in public
Is
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I Assistant Director. admU,1Stranve dub« can be carried on bv an
p I beinlSoF^o^.^001 °f PuWic Health ^d
»r J
n I
| Health^beffiginsfitS ffiTun’3 SC°Pfor a Degree in Public
L-
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| health worker of the Facoltr of mEJ’0’10’ ’a
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yt 3-5
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rf
tfnhwd public
la tne’Siud”“d hyg!“te ’“'i fc bleated
in the minds of pupils
practical S£.
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Dental Education
88. The out-tum of existing dental
colleges should be
i i doubled.
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89, There should.be a rnininiuni of one dental college m each
State.
90. facilities should be provided for die training of dentists
registered in Part B of the Dental Kegister.
v-s■ . — I
B
’
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*. or
91. There should be increased facilities for
xvi post-graduate
yt^L-^idciuaic traintrain- #
Si
ing of dentists, so tthat
’
* requisite
x * ’ number
* * of' teachers for dental
the
colleges may become
ne available.
g92. The training of dental hygienists and mechanics should
Wbe undertaken at all dental colleges. Dental hygienists may be used
_ „
.
_
'®rtin
for elementary dental services in rural arras' until fully
' ” qualified W coi
dentists become available.
Nursing :
8
93. There should be three grades of jnurses, viz. the basic
nurse with 4 years of training, the auxiliary nurse midwife with
2 years of training and the nurse with a degree qualification.
Il-jnu
s^c
94. Candidates admitted to the general nursing course should
have the minimum qualification of matriculation or equivalent ;
and the candidates for the Degree course should h5ve passed the
higher secondary or pre-university examinanou.
95. In view of the need for securing a larger number of
recruits for the nursing profession the age of admission can be relax
ed to 16 in suitable cases as a transitional measure particularly in
States where there are difficulties in recruiting candidates at the
age of 17.
I
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g qu;
£ Clh
I
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96. The medium of instruction should preferably be English
K ciej
for the general nursing course, while the Degree course should be
taught only in English.
i311
97. Nurse pupils should not be over-burdened with the routine ic' cor
dudes in hospitals, but more attention should be given to training
and practical experience. They should not be subjected to too
fl nu]
many spells of night duty in hospitals.
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98. A larger number of hospitals in the country can be utilised j
for Nursing Schools. District headquarters hospitals with a bed j
B P°s
strength of 75 to 100 should also be utilised for this purpose.
J
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99. The minimum number of admissions to the course should ?
B’ • be in.
|> wo:
100. Student nurses should be provided free furnished 1 | ■ rch.
accommodation in hostels, free board, free supply of uniforms I
laundry arrangements, free books, free medical services, medical &]
Bf.
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I | check-up twice a year and suitable recreational facilities, r The
I stipend during training should be a minimum of Rs. 35/- increasI .ing by Rs. 10/- every year.
•.>
101. The recommendations of the Committee set up by the
Central Council of Health (Shetty Committee) in regard to scales
| of pay and ratio of nurses to hospital beds etc. are endorsed.
I
|
102. There should be a Nursing Advisory Committee in each
I school for advising on admissions and welfare of the trainees.
l
103. Each nursing school should have its own-separate budget.
i .
104. The training of auxiliary nurse-midwives should be conp tinned and extended, because it will be necessary for a long time to
I come to have a second line of trained personnel to meet the needs of
I; the country.
I05- The number of auxiliary nurse-midwives to be trained
should be phased in such a way that there will be one auxiliary
| nurse-midwife for 5,000 population by the end of 15 years.
I
*’
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106. The training of midwives should also be continued and
j they should replace the dais who are now being utilised at certain
? places.
:
107. The time is come when fresh thinking on the type of
training at present given to health visitors should be done. There
should, instead, be a Public Health Nurse with a basic nursing
qualification and one year's further training particularly in domiciliary care and other public health aspects of community work.
108. The continuance of the training of dais in certain States
as a temporary measure is recommended, till such time as a sufficient number of midwives are trained to replace them.
I
109. Any person trained in one category of nursing should get
an opportunity of being trained in the next higher grade, under
conditions to be specified by the Indian Nursing Council.
no. There should also be higher training for the general sick
nurse, public health nurse, pediatric nurse, knental nurse, theatre
I sister, sister tutor and nursing administrator.
f
in. Promotion oi Degree course nurses or basic nurses to
posts of higher responsMity should be considered only after a
minimum of 3 to 5 years of practical experience after qualification,
has been put in.
■I-
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112. Male nurses should be trained only for certain types of
work e.g. mental hosphsls, army hospitals, V.D. clinics and
rehabilitation centres,
.
/
community health cell
47/1. (Fiist Hcoo St. Macks Rvad.
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Banualore • 560 001.
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151?
uj. In geoerrd, sufheiendy attract:-.-; ttrms should
J-' C-5M
caMe
S
a th- nursing'prop-r
&■ a ratner than the cjencal profess.
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€
Other Para-medical Personnel
¥
- TM.'I?Crr,15 2X1 urSent nced for ‘i^erent types of
C
- ; public health auxiiianes to hsio doctors and’*r '
public health, -t
in various fields. A separate c.ass of persons, cailer?
..■.■•niJiary Health Workers’ should be trained mainly in'
.
the field Wi f,
ot bealth to assist public health officers." Such .uTlu.
auxiliary lie;:!th 5?.
personnel may also be used at Primary Health Centres.
W-
115. Para-medical personnel recruited at present for individual
* _B C G” kP5°M malaria and hlariasis should H
SI™ ^e5..r^ary trailli?g
other iscascs o^er to make W
them multi-purpose personnel Ind to attach them to the urbanMr 1
n;
rural centres. Otherwise there is likely to be an immense loss or
of ' |
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man-power.
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116. Hospital architects should be specially trained. There I t
should be a cell for hospital architects in each Public Health 1 S;di
hngmeenng Department
..?j K. di
-
117. Medical and public health technicians, pharmacists, sani- | J’
tary inspectors, etc., discharged from the Armed Forces every year - B ce
should be employed in State Health Services either bv relaxing
an
W”C*5 necessary the standards normally required or by giving them
re
an additional short course of training to make up for anv dificien-
■ tre
Medical Research
I”
u8. If the medical profession of this country’ is to occupy the
place it should in the international world, contributions in the'field
of medical research arc as important as contributions in other fields.
h; co
India cannot for all times be a debtor country in this respect. ;A
Research should form a prominent part in the nations' activities
in the iicld of medicine, greater importance should be given to it ■-; f int
.:
of
and necessary facilities made available.
iF
1
119* Manufacture of sera and vaccine in the existing research
institutes in India may have to continue for some time, but it should |
not be a permanent feature. The main function of these institutes f4 c^
must be research. The manufacturing side may be separate wings q
of the institutes manned suitably by trained staff but under the 3W coi
overall supervision of the Director.
I of
tdel
*
'
Apart
from
operational aspects of research, the institutes
wit
should be the main
source
foroftwo
t, r activity, viz.,
-- ...j types
research
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(2) fundamental research and research m regaru ter certain aspects. | SUC
120.l
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of diseases which may be referred to the institutes and (b) Eeld
research to make available to the State concerned valuable data on
certain epidemiological conditions or on certain rare disuses which
may spring up from time to time or on problems which arise in the
very process of giving effect to remedial measures suited for
certain diseases.
The research sections of such institutes should have
responsibility only in regard to quality testing, standardisation and
further research.
122. It is hoped that ultimately the production side unll be
taken over by the private or public sector, subject to quality testing
being done byy an independent organisation responsible to the Stet?
123. Research centres must keep in close touch with the inter
national organisations and it should be their e’ndeavour not merely
to cc-operate with schemes of research as may be undertaken b'v
international centres but also to serve the very necessary purpose of
msseminating the latest information in regard to causation of
diseases, methods of treatment and measures for the eradication of
diseases.
in
^3
124. The Indian Council of Medical Research should be a
CCto collect information from international centres
and make it available to the profession through the research centres
reterred to above.
IiI
125. For this purpose the trained personnel at
at the various
research centres will have to be strengthened.
Edueational institutions cannot divert themselves of the
responsibility for research and the best teaching is imparted in those
colleges where there is an academic atmosphere of research. Evcrv
encouragement should, therefore, be given to research in medical
colleges m the country.
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127. Any teacher in a 1medical colleoe who is £cnuincfv
C-,J it possible
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interested in research can always« find
to devote
: a portion
ot his time for this purpose.
1^. The assistance of various disciplines, both in the faculty
of medicine and in allied faculties, is essential for research and the
cooperation of the Departments of Bacteriology, Pathology BioHca1^ Radidogy, etc. shotdd be obtained by
considerably reducing the routine work that is being done in tfe<?
departments and by augmenting the staff.
with
should be set up in everv medical college
Sth oth^0 T03 ’ BaCtol?i°glca! and Biochemical section besides
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^iere should be an animal house in each medical coliei
which should not merely be a shed for arHaJ but should approxi- S ' ;
mate to conditions where hospital treatzxnt can be given vj,
wc- Rimals. The animal house may suitaMv be situated in the top. »
noc; O;. the college building, with separate provision for an (opera(
Mor: theatre and postoperative ward for sumals.
t;
t
zf
Every post-graduate medical centre must have research
facLities and there should be a separate isrard of io to 15 beds
available for the purpose with special nurses for looking after the
pauents and for periodical observations and maintenance of relevant
records.
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132. Research on indigenous drugs which is now being done
in some of the medical institutions should be extended.
I
k J
*n -he casc
me^cal coEege research units the
budget of the various research centres L
in the country should be
separate and specific sums for research must be earmarked.
. , .J34- In institutions where a large amount of research work
is being done there should be an attached statistical section.
135. Wherever possible there should be close co-ordinatiun
between the university departments of science and the deoartments
ot medicine in the matter of research.
136. While teachers in medical colleges are <expected to
interest themselves in research, it is necessary to give them the help
of trained research workers or persons with aptitude for research, so
that a good deal of routine experimentation and maintenance of
records can be done by them.
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137. The proposal of the Indian Council of Medical Research
to award a number of fellowships to help colleges to extend their
research activities is commended.
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138. While the responsibility for medical research has been
mainly that of the I.C.M.R. so far, it is suggested that Government at the Centre and State levels should realise their responsibility
to a ,arge extent and should contribute financially and otherwise to
foster research. The responsibility for stimulating research work
i%the country will, however, largely rest with the I.C.M.R.
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J39- The reconstitution of the I.C.M.R. is also called for in
the light of past experience.
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140. In each State a Committee should be constituted to ' W ii
consider research programmes and recommend adequate grants for « .
the same. A permanent allotment should be made for this purpose
to different institutions teaching or otherwise, which are expected
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155
to carry on research. The expenditure on equipment, drugs, or
® appliances should be met by Government.
.141- The time is come when in the larger interests of the -*
H--' country there should be established an all-India cadre of research
Mg- workers, with persons chosen from amongst trained research
Bl workers or workers with an aptitude for research who should devote
|Bj their whole time to research problems. It is noted that a proposal
B for an all-India cadre of research workers has recently been
B approved by the I.C.MJL
ag?'
142. Whatever may be the method for eradication or control
B of diseases, it is necessary to have from the start an evaluation unit
B- which will at the commencement draw up the manner in which
Jr results of these operations can be recorded and interpreted. OthcrX-. wise at the end of a long period of research work no definite conB elusions can be arrived at regarding the success or otherwise at the
B scheme. This Evaluation Organisation should have an all-India
B pattern.
B'
-143. The working of these evaluation teams and the expense
B therefore should be part and parcel of the particular programme
B f°r which the Evaluation unit is appointed, although advice and
B guidance in regard to methods to be adopted by the teams may be
B forthcoming from the I.C.M.R.
W
144. Such evaluation teams will be useful not only in the field
B:. of medicine but also in the case of many other projects.
145. So far as industries are concerned two types of research
work are urgently needed, viz., one for the industry itself in order
to improve methods of production and the other and more imB: portant being connected with the health, welfare and safety of
| industrial workers.
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146. In all big industries there must be one or more units for
carrying on research in regard to industrial health and the expendimre for research must come largely from the industry itself.
Technical advice and assistance for such research should be fortbcoming from the Council of Scientific and Industrial Research and
the Indian Council of Medical Research. The industrial research
units should work in dose co-operation with the Employees’ State
Insurance Corporation.
147. The health and welfare of the people and of the emplo-^,
•yees of various departments are at present being looked after by /
different Ministries of Government, namely, Railways, Labour,
Health, Industry, etc. It is recommended that the resources of all
‘these Ministries should be pooled together and coordinated at a
high level to ensure the best utilisation of funds for schemes relatt0 industrial health and research.
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156
W- ■
POPULATION MOSLEM
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1. Voluntary and social organisanocs
'
' ‘
nave a large part to i
p-ay in impressing on the pubhe the aecsstv of familv pfannmo- 1.
and urgency or tne problem by propaganda, education and mass i I
contacts. Financial aid should be given by the Government
an A
____ Tit in
in an
1--equate measure to such organisations for this purpose. AB B
c
posable steps should, therefore,”be taken fir the
the iincreasing assodation and participatioa by voluntary and sodd organisations, parti- WJ }
cularly in regard to measures of mass <confarr
... A, ,and education of the I
r
public in familv planning. The creation of: autonomous
a
family 1 !>;< planning boards is not, however, considered to be
. j in the best interest; |
of the movement
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2. The dimensions and the urgency of the
problem are
are such
such ?
the problem
o
that the appomtment of a State Minister in the
fo. Health
ILealdi Ministry
Ministry 1® 3
who coild gne all his time and attention to this work, would be- -1
justinecL
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3- Much more intensive demographic, sociological and anthror
f
'
--------- O--------------- ---------------- -----pological study is necessary
—
necessary for
for decidinodeciding tK*
the methods of rfamily
«|
planning best suited to each area.
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4. The National Council on f
Population which has already
\
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b«n set up under the Chairmanship r\^
of^ HomTMinTterTr- ‘
‘ ’
■
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■
■••■“-” ■
“
Etan^rapiuc Advisory Committee. It is felt that this Demoora- "1
I
phic Adnsotr Committee should continue to function under the- =
Fh
Ministry of Health.
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5- The educative part of the familv planning programme B o*
should
id be adjusted to the availability of senices. Indigenous | . n
action of contraceptive
amtracepuve should have b^
been
p d‘
production
cu taker
ulkc- in hand
simultancoisly
the launching of the• family
planning pro—“ I< s^
ramiiy planning
gramme on a national scale. Therefore, a ]_prionrv
* ’ * no less high than I--:
that of any other major project should ’now ’be given to the“project W w
of setting up of plants for the production of contraceptive appliances;. I ar
in tne country. Priority should also be given in the meantime for
I't
foreign exchange for the import of certain contraceptives.
wX-'' -
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6. The AE India Radio should be increasingly utilised for
propaganda on larnilv planning. In addition, educative material in
at regional languages through films, posters, pamphlets, charts,,
graphs, plavs, shows and other means should be utilised for familyplanning educational purposes.
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Family Pianmng activity should be included within the- ■...®'
I
scope of primary nealth centres, community development blocks,
—tra“ .
elfare Board and other similar organisations,
lhe workers m me community development and Panchavat Raj
organisations saomd oe onented m family planning and utilised’
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L to bring home to the people in rural areas the necessity for control
| of population.
BF5-'
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C.
r of political
‘
\parties should also be enlisted for
8. The _l
help
B propaganda purposes.
I
9. With the existing social patterns and cultural background'
B of the teachers and taught in the large majority of schools and
E< colleges, the inclusion of sex education, may not be desirable.
Bj Education on the biological lines of life may, however, be imparted
|, in colleges.
.
1
|
10. The demand for sterilisation operations is gaining momen| turn and it is noted that some States have undertaken large-scale'
I sterilisation according to certain established procedures. This is
L. one of the many sided attacks on the family planning problem.
The after-effects of sterilisation should, however, be studied:
h carefully.
11. Laboratory and field research in regard to oral contra-F- ceptives should be intensified.
■
DRUGS AND MEDICAL SUPPLIES
S1. There is a case for going into the cost^structurejjf manuK- facturcd drugs and bringing the cost down. This can be done
S under the provision of the Industries (Development and RegulaK tions) Act.
2. It is recognised that while in recent years the final stages
of manufacture of drugs have developed fairly fast and a large
number of sizeable factories have come up, the extent of depenK dcnce on imported raw-materials and intermediaries has only been
K slightly reduced. The indigenous pharmaceutical industry has
therefore to contend with competent know-how, big capital, world
wide sales, unfair competition from mushroom units, and a long
and tortuous licensing procedure under the Industries (Develop
ment and Regulations) Act.
f;
3. The industry as a whole has not promoted any significant
research activity, either on a^ collective or on an individual basis.
This situation needs to be remedied.
4. The universal complaint with regard to excise restrictions
on the use of alcohol appears to call for finding ways and means
of the regulations not coming in the way of legitimate manufacture.
5. There should be close co-ordination between the Drugs
Control Organisation and the Development Wing of the Ministry
of Commerce and Industry and the policy in respect of setting up
of pharmaceutical industries should be based on the need of the
B
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r-irntr ii-n .- ~ >■:, indiistria] naiicv G--t*=-d._
r3pf I: 3
tLi.-efore that'the
mti
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mould oe cone av..ay witl- a m the hcensii’ for dn.;.-.
i-._-._Lacture shc-uL oe the function of the 5hr;istr-H*a'•
5ac'h*,J bs a? appropriate ormnisatic- m the V.'
rsmm m charge or an officer of standing, canable of dealm.•' v.-th
^^otmterpart in the Ministry of Commerce and indusirv's
xn£i2est secretariat level.
Pi!arrnaccuti^ industry is to prosper and if
rhe
natIO? 15 t0 be safeguar<1ed’-no quartoDe
gtj-~ to „ny manufacturer merely on the ground of his bdag
a
ss-iih-scaie manuracturer.
z. The Drugs Control Organisation by and large mar be said
■ extremely inadequate in comparison with the growffi? nee^
1^- reconimenaed that in States where any substantial drj mlS
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analytical laborator;- should
WK1’
finmcial support from manufacturers.
Kts^..n Mings should be attached to selected laboratories. Strict
m^sures should be taken to enforce the conditions of ilcenting.
8 In the training of drug control inspectors it would be usetu_ m have at least one or two inspectors adequately trained in
■
so that the number of acquittals now resulting from
tcunmcal flaws may be avoided.
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wJLAn ^P'Y1 Cornmittce consisting of the top men in various
se
-F^-^ties should be set up to examine the question cf reduring'
- xcst of medicinal items permitted to be stocked and sold in 1
J-y-ountry and to work out a list of the essential drugs and | sc
tormmauons. Normally the import, manufacture, distributi^ and
or drugs and formulations should be confined to the list rrerared I
7
t:'-PJCrt Committee- The list will of course, have 'to be rev^-e. :nd revised periodically. In the meantime, Central and
Governments should give a lead by restricting the use. n-tparanon and supply to State hospitals of those drugs and fomtn i "t
lauans included in the National Formulary. The use of oroorietary preparations in Government institutions should be
1-fe
I
i.
io. The responsibility for the manufacture and sale of sera
anc vaccines should be that of Government. Such sale should be
on < nopront-no-loss basis.
‘I* The nJ.a^u^acture of drugs coming under the indigenous
*'7*--Zis
_ S of
°7j medicine
nie^'c,ne should t:
be controlled to ensure standard’
.u-v and satisfactory conditions of manufacture. For this our<PS—
poss- arags used m indigenous medicine should be broach: aider
me yrotrsions of the Drugs Act.
"
. -_
h.Cgarding Patent Lav.', as applied to the nharmaccutioal
mcusny, it is recommended that a patent should be for the nrocess
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and not for the product, the specifications of the process clearly des
cribed to leave no room for doubt or for blocking the efforts of
others in revising the process. The pcriod_cpYCied_by the patent
should be reduced to between 5 and 10 years, extensions not being
granted as a matter of course. Thefe~ should be automatic rev<>
cation of patents in the event of manufacture not being under
taken within four yean of the grant of such patent. There should
be compulsory provisions for .the grant of manufacturing licenses
under the patent within the period of one year after the date of
such an application.
13. The efforts made so far for the manufacture of instru
ments, hospital appliances, laboratory equipment, etc., have been«
sporadic and unorganised. There arc no standards, Ifttle technical
know-how and imported raw materials arc not readily available.
The country should become self-sufficient as early as possible in the
manufacture of these instruments and equipment. A panel should be set up to study the position with regard to the estimated require
ments of such instruments and appliances, particularly optical and
electronic, and to work out detailed specifications. After the re
commendations of the panel are received one of the corporations
in the public sector mav be entrusted with the manufacture; or a
new factory in the public sector may be established; or private
sector may be allowed to undertake the manufacture. The Tech
nical Organisation in the Ministry of Defence for laying down
standards for inspection and testing of instruments and appliances,
should be taken advantage of and made to include civilian needs
within their scope and functions.
14. Based on the existing Defence Services institutions,
similar organisations should gradually be built up in collaboration
with the Ministries of Defence and Commerce and Industry.
-
.
15. In order to encourage private entrepreneurs in this field
a strong technical advisory organisaSonlKdul'd be set up in the
Mimstry of Commerce and Industrv to provide
provide guidance
guidance and
help.
16. Medical stores depots should be modernised, expanded
and made to work as public corporations for the manufacture
and supply of drugs to meet the needs not only of civil depart
ments, but also of the Defence sendees. The Civil and Defence
Medical Stores Organisations should be merged'." ’ Thev’ should
cover the needs of railways too. For a more effective and expedi
tious programme of procurement and distribution, the number of
depots will have to be increased progressively, so as to provide a
closer regional coverage, the vrdmate target being one medical
stores depot for each State.
*
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It would be in the interetts of :;xi.-ch in genera;, and
■k the mdustrv m pzrncular. if v.ei'.s and -ears could be found
tc^ inducing the pharmaceutical industry to pool their resources
':S °biect of promoting research on niedicina: plants. One
ci mt practical ways ot giving effect to .th-/ -u--‘stibn will h~ o
insist on tv setting apart bv the industry c< a certai- ptopor; on
o: their pronts for research. This may be in the fcrm^of a cess,
.as is Being done in the case of cotton and textile industries.
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.P^ drug research programme outlined by the Council
Ox Scientihc and Industrial Rcscarcn is endorsed.
h
d
r »kI9AT??™ h ? 12rPe
for the «^si°n of the actinries
* °* i T.1MPO under
Ministry of Scientific Research and Cul
tural Affairs, m regard to cultivation of medicinal plants.
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LEGISLATION
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t. While it is realised that a great deal has been done to
coordinate the standards of training in the different medical colle
ges under the provisions of the Indian Medical Council Act., a
number of difficulties have been felt in this matter by the Univer
sities and the medical colleges. It would not be in the interest of
meaical education to divest Universities of their responsibilities or
to make them feel that they are merely to carry out the recommen- ‘
dauons of the Indian Medical Council.
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n
g
C
, . , ?' The Universities should no doubt accept the standards
laid oown by the Indian Medical Council and also their advice in
to1™‘1’or. matt*r5 relating to professional education, while
they should be free to implement details at their discretion.
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3- The main responsibility for recognition of medical quali
fications should no doubt be that of the Indian Medical Council
supject to the provisions of the Act and also subject to the final’
approval of the Government of India which acts in this case like
the Pnvy Council of Great Britain.
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4- There is no necessity for the Indian Medical Council to
seek the approval of the Medical Councils of other countries in
regard to recognition of degrees awarded Ln India. This requires
serious consideration.
5. Recognition of degrees should be with reference to a University and not with reference to L
” ’* ' colleges. Th** su^individual
..UL• V,bv the C01
gestion that individual colleges should
be recognised
>unci _ not one which is consistent with the position of ’the Univvernor will it improve
standard. A
A certain
certain amount
ti
.X . the------------amount of
of time
snould oe
allowed
for
improvenvnf
nnri
;
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k„.
.
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.
IC .Z? v. f°r
and it is here that the Council’s
adwee would be most valuable. However, some temporary'
j
; measures may have to be taken to brins
" ' colleges
bring the new m;edical
ot
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161
|| coming rapidly into existence to the required standard. In such
H cases as a temporary expedient, individual colleges may be insH pccted and reported upon for purposes of recognition.
6. While the Universities should get all the advice of the
B Indian Medical Council they should also see that such advice is
|| implemented with the co-operation of the State Government or
H other management.
7. The agency which carries out inspection of medical cob
H leges should be much more broadbased and should inspire confiH dence. Such an inspecting body should consist of an educationist,
U a representative of the University concerned and three experts
g nominated by the Council, who should be serving or have served
S as professors of medical colleges for not less than 10 years. There
ft should be two or three permanent inspectors of the Council, cue
ft of whom will be a member of this inspecting body. A represenft tative of the State Government in the case of Government colleges
ft and a representative of the management in the case1 of other instift tutlons may be co-opted as an observer.
ft
8. The Indian Medical Council as at present constituted may
\ not be in a position to review the recommendations of the post
graduate Committee. In order, therefore, to safeguard and pro: mote the interests of Post-graduate Medical Education, it is sugb gested that the Post-graduate Committee of the Indian Medical
Council should be reconstituted and designated as the Post-graduate
Medical Council with 20 members, 10 of whom will be elected by
the Indian Medical Council, five elected on a zonal basis bv the
Universities and five nominated by the Central Government. All
the 20 members should possess the prescribed qualification viz.
10-years of post-graduate teaching experience. The recommen
dations of the Post-graduate Council should be forwarded ditectiv
to the Government of India, the Indian Medical Council being
simultaneously apprised cf those recommendations.
9. The qualifications granted by the Dental, Nursing and
other Council in the form of University degrees should be regu
lated on the same lines as is now being done in the case of the
Indian Medical Council.
10. With regard to the Diploma and other qualifications in
Nursing, Dentistry, Pharmacy, etc. standards must be laid down
with the approval of the Government of India.
I
11. It is not desiraEe to allow disparities between the provi
sions of the different Acts to continue and it is suggested that the
Dental, Nursing and Pharmacy Acts should be amended so as to
bring them in fine with ue Indian Medical Council Act
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12. Although certain standards o: training have been laid
down for pharmacists by the Pharrmu"' Council, it is felt that as
a transitional measure it mav be necessary to have somewhat lower
qualifications prescribed. This matter mt be considered by the
Pharmacy Council in consutation with Government of India in
the interests of uniformity. The State Niedical Council should be
the agency to see that the general code cf ethics is observed by
medical practitioners, a reference being made to the Indian Medical
Council before the removal ot a name from the State Register.
Unqualified persons now in practice shohd be placed in a separate
section of the medical register. Persons possessing qualifications
included in the Medical Council Schedule shall alone be placed
in the main section of the State Regisnr. and have the right 50
elect a representative to the Medical Cccmtil.
I
F
13. It is imperative that steps should be taken to ensure that
registration is made an essential pre-recuisite before anyone sets
up practice. After initial registration subsequent registration
should be open only to those who possess recognised qualifications
in one or another system of medidne through recognised institu
tions. The practice of medical profession by persons other than
those mentioned above should be made a penal offence.
I
14. Legislative action is called for in regard to radiological
clinics, use of isotopes and other practices involving radiation
hazards.
15. In the interests of public health all over the country, the
time is come when every State should have a Public Health Act
of its own on the basis of the Mode! Public Health Act framed
by the Ministry of Health.
16. In regard to the Drugs Act, an adequate and honest
enforcement machinery should be orovidec. The inspecting and
prosecuting agency should be independent of local authorities and
should be directly under the State Governments. Facilities for
analysis should be provided at Public Health Laboratories on a
larger scale than at present. The punitive provisions of the Drugs
Act should be made more stringent.
<
17. Legislative sanction for autopsy examination of dead
bodies to enable donation of eyes f?r comeal grafting, etc. is not
likely to have any effect. Methods of persuation and education are
likely to lead to better results.
i8. The Indian Lunacv Act i> outdated and completely out
of context in the present dav outlook on mental diseases. No
I
further time should be lost in amending the Act to bring it in
line ^dth the present day requirements.
4
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163
INDIGENOUS SYSTEMS OF MEDICINE
i iVi draining in Ayurveda and other indigenous systeru
should be in the Shudha in place of the integrated system.
•u
Tfie Central Government should establish in collaboration
with State Governments a Central Institute of Medicine for find
ing authentic and original manuscript and books in Ayurveda
scattered in different parts of the country and for publishing them
tor the benefit of students and teachers.
in all Medical Colleges.
system of medicine should be established
4. The student of Ayurveda should havee a good knowledge
of Sanskrit: similarlv. the student of--------Siddhaa system should re
well-versed in ~
"
lanul and the student of the Unani of Medicine H
Arabic.
5* They should have the minimum basic qualification cf
school leaving certificate or matriculation.
6. The preparation of syllabus and courses of study should be
left to experts in Ayurveda, Siddha and Unani. /• The period of study should be about 3 to 4 years, so that
wiU be able to concentrate their attention solely on
Ayurveda, Siddha or Unani.
8. The need for giving a Degree qualification in modem
medicme ts recognised provided the students are trained upto the
standard. The students who qualify in Ayurveda should be <dven
opportunities to be trained in the modern system of medicine^after
completing the Ayurveoa course and after they pass the prescribed
I
their services can be utilised in the health s«vice
q t
-H-t, however, ennde them to a^XmXnt^
of post-graduate centres ip Avurveda.
X btl7 °neJf? iach r^10n’ is deslrabIe and such a
’
should be guided by the experience gained at Jamnag,development
;ar. To en
ourage graduates in me modern medicine to m;u
join
graduate centres, the estzolishment of Chairs of Indian such post----- 1 Medicine
. Iready recommended will prove helpful.
c.nt1;' TRcsCtarch “ indigenous systems should be done in the
Central Institute of Meoiane and in modern medical collet
14—88 CBHI/ND/84
college.-,.
i
<■
■
-^4
r
rci a respect of .nedicind . ■ .ts, drugs and disease. •a-Zl
b- - inu jrtant function of the
post-graduate and research
centres.
12. I ost-graduate training snowc also re available to tetn
med-cal men trained in modern meUzdre who have had an in
tensive training in Ayurveda a .er thexr M.B.B3. and to Shudha
Ayurvedic men who have taken a degree in modern medieme.
13. The growth of a body of trsned personnel on the fees
indicated above is essential in the interests of Ayurveda and mooern.
medicine and the integration of two systems of medicine will ev^ptualiv come about as a result of the labours of such sciemmc
workers.
14. The Central and State Governments should provide sum
cient financial support to trainees in indigenous systems of medicine,
15. Selection for post-graduate education in indigenous sys
tems of medicine should be on men: and candidates so sejected
should be given stipends.
16. The establishment of a separate council of Aymrveda cm
the lines of the Medical Council of India is advocated, to se: the
required standards of training and to ensure uniformity* through
out the countrv. Similar councils for Siddha and Unani will also
be of advantage and there should be a co-ordinating committee
for the three systems.
17. The newly constituted Council of Ayurvedic Resi
should work in close collaboration 'with the l.C.M.R.
18. The task of developing appropriate standards for■ medBcsl
preparations in Ayurveda throughout metcounrrv would
1J appear to
be verv necessary although it may present formidable difficuhies.
In this, task a Central Institute of Indian Medicine, the Post-gra
duate Regional Institutes, the Research Wings attached to Madera
Medical Colleges should all collaborate. State pharmacies sbcold
be established and should become the source of all drugs unfeed
in Avurvedic hospitals and in dispensaries, maintained by Go^emmem and local bodies.
ADMINISTRATIVE ORGANISATION
i
i. The abolition of the post of Public Health Commisxuner
ar c the merger of the organisation with the Directorate-General
o' Health Services, while good in itself, has indirectly resufec in
the weakening of the epicemiologicaL statistical and other asp rets
of rublic health activity’, due to inzdequancy of staff and the
drvin^ up of the sources from which the Directorate recrurred
e:<oerienced health administrators. On the other hand, due to
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I.Secr
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1 will
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163
INDIGENOUS SYSTEMS OF MEDICINE
1. Training in Ayurveda and other indigenous systems
should be in the Shudha in place of the integrated system.
2. The Central Government should estabUsh in collaboration
with State Governments a Central Institute of Medicine for find
ing authentic and original manuscript and books in Avurveda
scattered in different parts of the country and for publishing them
for the benefit of students and teachers.
!
3. Chairs of Indian system of medicine should be established
in all Medical Colleges.
4. The student of Ayurveda should have a good knowledge
of Sanskrit: similarly the student of Siddha system should be
well-yersed in Tamil and the student of the Unani of Medicine in
Arabic.
• i
I
5. They should have the minimum basic qualification of
school leaving certificate or matriculation.
6. The preparation of syllabus and courses of study should be
left to experts in Ayurveda, Siddha and Unani.
•i
IB'
Il •
1
7. The period of study should be about 3 to 4 years, so that
students will be able to concentrate their attention solelv on
Ayurveda, Siddha or Unani.
.8. The need for giving a Degree qualification in modern
medicine is recognised provided the students are trained uoto the
standard. The students who qualify in Ayurveda should be given
opportunities to be trained in the modern system of medicine after
completing the Ayurveda course and after they pass the prescribed
examination.
The duration of training for the modern system,
should be 3 to 4 years in such cases.
9- For the majority of those qualifying in Ayurveda, subse
quent training in modern medicine should be for a period of 2
to 3 years and should cover preventive medicine, obstetrics and
gynaecology and principles of surgery, so that after such training
their services can be utilised in the health services. Such training
will not, however, entitle them to a Degree in modern medidne.
10. The development of post-graduate centres in Avurveda,
eventually one for each region, is desirable and such a development
should be guided by the experience gained at Jamnagar. To en
courage graduates in the modern medicine to join such post
graduate centres, the establishment of Chairs of Indian Medidne
already recommended will prove helpful.
11. Research in indigenous systems should be done in the
Central Institute or Medicine and in modern medical colieo-es
i
1
14—S3 CBHJ. ?1D/S4
°
I
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164
Res^earch in respect of medicin? i ;
dregs and diseases
be an important function of the vai ous post-graduate and research
centres.
| Pl
-
12. Post-graduate training should also re available to both
meuical men trained in modern medicine wr-o have had an in
tensive training in Ayurveda after their M.EjB.S. and to Shudha
Ayurvedic men who have taken a degree in modern medicine.
| -sh
I|
Ilthse''
13. The. growth of a body of trained personnel on the lines
indcated above is essential in the interests of Ayurveda and modem
medicine and the integration of two systems of medicine will cveotually come about as a result of the labours of such sdendne
workers.
I ID?
i
I tar
14. The Central and State Governments should provide sum
dent nnancial support to trainees in indigenous svstems of medicine.
II ■°s^r <
I
15. Selection for post-graduate education in indigenous svs
tems of medicine should be on merit and candidates so selected
should be given stipends.
I Bu
Tf
kg
pr<
loj
16. The establishment of a separate council of Ayurveda on
the lines of the Medical Council of India is advocated, to set the
required standards of training and to ensure uniformity- through
out the country. Similar councils for Siddha and Unani will also
be of advantage and there should be a co-ordmating committee
for the three systems.
sn<
mt
17. The newly constituted Council of Awrvedic Research
should work in close collaboration'with the l.C.M.R.
Ed
of
iS. The task of developing appropriate standards for medical
preparations in Ayurveda throughout the country- would appear to
be yerr necessary although it may present formidable difficulties.
In this task a Central Institute of Indian Medicine, the Post-Gra
duate Regional Institutes, the Research Wings attached to Modern
Medical Colleges should all collaborate. State oharmacies should
be established and should become the source of all drugs utilized
in Ayurvedic hospitals and in dispensaries, maintained by Govern
ment and local bodies.
or<!
CXI
in
inc
the
Dii
ADMINISTRATIVE ORGANISATION
des
in
I. The abolition of the post of Public Health Commissioner
and the merger of the organisation with the Directorate-General
oi Health Services, while good in itself, has indirectly resulted in
the weakening of the epidemiological, statistical and other aspects
or public health activity, due to inadequancv of staff and the
drying up of the sources from which the Directorate recruited
experienced health administrators. On the other hand, due to
wil .
par
the
I
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w
w increased activities in the health field as a result of the Five 'iear
flans the need of leadership and co-ordination at the Central level
®has become more pronounced.
®
2. It is felt that the Director-General of Health Sendees
.®-should for all purposes, enjoy the status of an Additional Secreto the Government.
15
j
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2. While in matters of administration and financial nature
■ the normal channel of communication should be through the
Secretary to the Ministry of Health, in purely technical matters
the Director-General’s views and recommendations should be dealt
with at the highest level without the intervention of the Secre
tariat.
4. Technical advice given by the Heads of Health Sendees
should be directly available to the Minister for Health at the Centre
or in the States, subject of course, to comments on financial and
administrative angles by the Secretary of the Ministry/Department.
5. A well-staffed and well-equipped Health... Intelligence
Bureau in the Directorate-General of Health Services is called for.
I ■ This bureau’s task will be to keep itself up-to-date in health intelligence,, serve as a model for State and be capable or organising
programmes for the training of health statisticians and epidemio
logists.
I
■i
Jj
6. If the Central Government is to play the role which it
should in the matter of fostering and developing all aspects of
medical education, it is essential that a separate divisionl on Medical
Directorate-General
Education should be formed in the
of Health Services. This will be more imperative if the regional
organisations which are being recommended elsewhere come into
existence.
7. Similar divisions for Medical Education should be set up
in the States, with a Deputy Director of Health Services being in
independent charge, as Director of Medical Education.
-
1
8. A division of Planning should also be a distinct unit of
the Directorate-General of Health Services under a Senior Deputy
Director-General.
I
I
I
9. Yet another aspect of administrative organisation which
deserves serious consideration is that of a permanent machinery
in the Directorate for evaluation which would become a normal
feature of all major health plans. This machinery for evaluation
will be independent of the administrative agency concerned with
particular schemes.
10. Strong Health Education Bureaux should be set up in
the Central and State Health Directorates. There should be close
II
1i
166
i
liaison between the - ,,.t and the Central Health Education Bu- <
reaux so.as to evolve common methods of approach in matters I
connected with the health education of the public. Audio-vis^ 1
u 5 50,Wc^°Pted “ Westera countries should I
.tuaied and suitably m'odihed to meet the requirements of India. |
it. The State Government should also, as in the Central I
Government, establish^separate public health engineering divisions f
Ch3F
u 11,6 Dlrectoratc of Hedth Services. The 1
Hr^h En^neer in
^te should have the status f
of an Additional Director of Health Services.
I
12. There should be a separate’ section dealing with inter- ®
national heakh matters in the Directorate-General of Health Ser- ft
vices. It is essential that a distinct and well-defined cell should f
come into
to
a . existence
.
• ^-.^-^^.Sternational
and biTateral a<tenYlth P°Bct dexiSoas on administrauve and financial matters of all United Nations agencies X ...
A
k’k to bpcf the Indian delegation to the World Health
eThC Head 0f 11115 CeT1 “ *e Directorate Sd
inv^ly be the Secretary to the Delegation to the World Health
£d^UrTg’iJI?™F^Srand Public Hcaldl Engineering pro- It™se th?ElSri m'
SCt UP at
Ccntral ^Statel^els. f
■I
advise the Health Ministers on programmes and policies Thr
tenure of members of such advisory committees should be 3 rears
with provision for gradual replacement of sitting members by fresh
of better coordination and more effective
in
^ge number of schemes i
L
in
which
s'
«=9itive
but in which
finaiicij..and foncttonaLstahe, an administrative tier at a
a
regional
Or.f°Ur States.should be brought into exigence
on the analogy of such organisations in the Ministry of Scientific
Retearch and Cultural Affairs. Such regional' offices should be
r-nr21' J"
“X af a
°f
°f 3 D’D-G- and ^nld
|
’
,
I
i
1
I
.1
s^ve as a two-way channel for intelligence purposes and also as
niS^f°r ^heme5 Of Prof“sional education.
, commu- A regional committee, consisting of the
Directors of Health Services of th.
the States, Secretaries to Governmeats of States, some jnon-ofiidal
----- members and representatives of
1
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167
jjli profesicmal organizations ix. Medical, Nursing,, Dental and Pharj£j nacist bodies concerned, may be set up which may meet twice a
Jcar or °ftener t0 discuss matters of common interest.
15. The technical set-up in States should be headed by the
jXrector of Health Services assisted by a suitable number of Deputy
d|| Directors including one for Public Health, one for Medical Relief,
^ePut7 Director for Professional Education, a Drugs Controller,
pan Officer-in-charge of Maternity and Child Health, School Health
Land Family Planning, a Deputy or Assistant Director of Nursing
! Services and a Deputy Director or Assistant Director for Planning.
‘ There should in addition be a Public Health Engineer with the
-status of an Additional Director of Health Services.
1I
16. The Public Health Engineering Organisation in every
State should be attached to the Health Departments and not to the
Public Works Departments.
17. The Public Health Engineers of Municipalities and local
bodies should be members of the Public Health Engineering Ser
vice under the over-all control of the Public Health Engineer of
die State.
■j.'
18. Statistical and epidemiological units should be developed
as part of the public health section of each State Directorate.
19. There should be State Healt^Advispiy_£oaxdsjcpnsisting
of
Ministers
dealing with Health, Housing, Education^ Industry,
|
Labour
and
Local
Self-Government, The Chairman of some of
0 fhe~Zila Parishads and
a few members of Legislatures should also
on
body, along with the President of the State Branch of
w the Indian Medical Association. The State Health Advisory Board
W diould survey the health programmes initiated in. the State" so that
U these programmes are fully co-ordinated and implemented and
should advise Government in regard to measures necessary for imM provement of health conditions of all sections of the population.
|
20. For placing emphasis on preventive aspects of medical
%
at the peripheral level it is necessary to bring into existence in
|iKrtach State regional organisations between the headquarters and
»the districts. These regional organisations should be in charge of
SJ'a Deputy or Assistant Director of Health Services with two or
HI three District Health and Medical Officers, Superintendents for
W M.C.H., Family Planning and Communicable Diseases and Assis
tant Public Health Engineers. All hospitals with 300 beds and
more should be under the direct control of the Regional Director,
rf all other rural institutions being left to the District Medical and
Health Officer.
I
J
21. The designation of the officer-in-charge of health at the
-'•I district level should be District Medical and Health Officer. He
\
.1
M
^-Xl
w
168
will be responsible for medical care, pifsiiii health and environmen- r
tai sanction and will co-ordinate the w?rk of all hospitals with. a ;,
bed strength of less than 300.
.&
■ft
22. In order to co-ordinate the acmties of the District Medb iv ■
csl and Health Officer and the Regional Director, there should be a.&
C ordination Committee under the Charmanship of the Regional,|b;
Director, the Superintendents of Hospital and the District Medical, H?
and Health Officer being members.
.|3
23. The Medical Officers, Health Visitors, Auxiliary Nurse O
Midwives and Sanitary Inspectors attached to Primary Health Cen--fetres should belong to the State cadre and should be under the Dk®
rector of Health Services through the Drscrict Medical and Health O
Officer in regard to technical and disciplinary control. The re*»f
maining staff, other than class IV, should be from a district cadre: W.
Disciplinary action against this staff should only be taken in consaltation .with the medical officer-in-charge of primary health cen-j®
ties with a right of appeal to the Zila Parishad.
J
I
hi
I
24. The problem of integration-of medical and public health ft
services should not be postponed, because of certain initial diflfc K
culffes/Tn a long-term programme, periodical shifting of personnd from medical to public health and vice versa will'be desirable
if the problems of medical relief and public health are to be dealt;
with properly.
f
B.
25. An All-India Health Cadre-sbouid be brought into exis-Oi
T’Kic
ttfiII rMon rk/ActT »r» C'X^mictrl^c
tence. This service will man posts in Central Ministries other than
Defence and provide a quota for State posts, to which officers may®
mayl Bbe seconded, thus enabling qualified and experienced persons being®|
being! ;
made available in various fields of work in different regions cfflEofl
r
■
...
the country. “
The
structure of..................
the All-India
Health Services shouldftt
be on the lines of the I.A.S. The.
The.Central
Central Health..
Health..S
Ser
ervice
vice nojy|
under the consideration of the Health Ministry should be enlar^fe
to provide_a_deputatipn^quotaJ so that the requirements of States^;
may be met from time to time. The posts of medical officerFjg.
under the Employees State Insurance Schemes in the various Stat^^p
should be made a part of the All-India cadre. The time has coni^gp
when consideration should be given to the pooling of medical
cers for all Central institutions through the Health Ministry.
I
Ifl
i
26. A separate cadre of medical jurists should be establishci^gto whom all important and complicated cases will be referred^f:
These medical jurists should be specially trained.
27. The question of seconding officers of the Armed Forc^^gj
Medical Services of the Civil Department, which proved a
success before Independence, should be revived. Similarly it 'VIU f
■Of:
•
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t 1 ’
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I 1i
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4
169
ie^
ei
>ea
*naL
ical
be desirable that people recruited for the Civil Medical Service
should have experience of work in the Defence Forces.
28. There should be a permanent organisation for morbidity
survey in the countrv. This organisation should function in co
operation with special surveys for other communicable diseases and
with epidemiological units.
fl
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irse
enDi’
Itt
rere.
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ay
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I^MPENDIUM
jdF '
Recommendations
ftARIOUS COMMITTEES
low
.
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IWEALTH DEVELOPMENT
I
1943-19751 fl . 'd
1943-1975
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I - CENTRAL BUREAU OF HEALTH NTELUGENCE
|.|blfiECTOFATE GENERAL OF, HEALTH SERVICES
■«’
i ^MINISTRY OF HEALTH AND FAMILY PLANNING
I • GOVERNMENT OF INDIA
| "-NIRMAN BHAVAN
I NEW DELHI-IIOGH
4
1
'*.'1
COMMUNITY HEALTH CELL
Society for Community Health Awarness, Research & Action
(SOCHARA) Bangalore
Library and information Centre
CALL NO. M)^ " 10O
^35'
ACCN.NO
CB hi.
TITLE .
V’s-3aa‘
........ ....... ....................
Borrowed
On
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Borrower’s Name
\ /<^ap, . » ^ /
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Mr • Arjisjr' Gopal n
PPP-1/97 L10t)l
E-L8<
•locj^
j^of
ja^nt
anage
/s'
Baflner^ialt^
B a ngaio r
Phone ^6.
ad
Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
Returned
On
11—UM-JUL Illi III II
1.11 III Illi III
II
1
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COMMUNITY HEALTH CELL
Library and Information Centre
No. 367, Srinivasa Nilaya, Jakkasandra,
I Main, I Block, Koramangala, Bangalore - 560 034
this book must be returned by "
the date last stamped_
At-IM
t
__1__________
API
v - ¥
nr FING PATTERN AND FINANCIAL
PROVISION UNDER FAMILY
PLANNING-1966
(MUDALIAR COMMITEE)
xj i t
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171
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SECTION I
i:
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1 •
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SPECIAL COMMITTEE APPOINTED TO REVIEW
STAFFING PATTERN AND FINANCIAL
PROVISION UNDER FAMILY PLANNING
PROGRAM ME-1966
1£
i ■■i
-i
INTRODUCTION
In the first meeting of the Central Family Planning
1.1
*
z'- it* was reCouncil held at Madras on the 31st December,
1965,
solved that a Committee be formed of the following officers: —
I.
2.
3-
J
. ' r.
s
.’
•k
A L-
■
I
I'
•Aw
I
1
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gj^Iw
Secretary, Ministry of Health & Family Planning, Gov
ernment of India.
Secretary, Department of Health, West Bengal-Caicurta.
Secretary, Department of Health, - Maharashtra.
4- Secretary, Department of Health, Mysore.
Commissioner, Family Planning as Member -Secretary.
5“to review what additions and changes are necessary as a result
of the greatly altered situation due to the I.U.C.D. having come
in the forefront of the programme, in the staffing pattern, finan
cial provisions etc.” The need for such a review had become quite
apparent. The 1963 .rCQr^anBed_scheme, while it did ngndv
emphasize the need to make the programme to the masses had
been approved before the I.U.C.D. programme was adopted ^or
large scale implementation. It provided principally for the tree
flow of supplies and community’ education and was based mainly
on the use of condoms and on male sterilization. In fact however,
because a vast network of distribution centres needed for product
ing a real impact on the problem through the use of condoms was
not organised and because on account of foreign exchange dimculties condoms have been in short supply, so much so chav th<.
scheme for their central purchasing and distribution through the
Medical Stores Depots introduced in May, 1965 could not be im
plemented even tS today, the main reliance came to be placed
on sterilization. Although spectacular results have been achieved
in sterilization in a few States where a great deal of enthushxsm
for this programme was generated, there can be little doubt that
by relying only on this method, the Family Planning Programme
could never be mace a mass movement which in some .wa\ s under
lay the'philosophy of the 1963 reorganised scheme. It is Prin
cipally because of the I.U.C.D. method becoming availaoie that a
173
■y'
-,. 777r„__.
174
“fe”
r
Hon. These advantages have now t
.a^tages over_ sterilizabecome well known and well acceD*ed°
.“^shed and have
opened up of. developing the Panvf
P055*11’*? thus
national scale by uXll]
>’
Prog™ on a
I-U-C:Do _.SterhLationg anH ,>
?e P1^31 methods, namely,
cubar emphasis’ on the first ; T^r^011^ bUt Placin£ P^necessary of the true dimensions rh^k C asesmcnt has become
I
■fez
1
i
and is capable now
ProgrJmm^
to acquire
gramme has to acquire, very larsl dime1^0111 <J“estion’
Pr°that constitute the tentative all
naocs- Even die figures
That have to be rSched » 3
m^ods.
order that the ^rate mlvT^^k3
°f 10
“
4t per thousand to 25, will shot
every likelihood tha/’the acJSTta^ blg
‘1
I
thc_present
k Thcrc IS
•'S
bigger than these target figures
°Ut t0 b.e even
facts such as, that ofr
t “^“te, if account is taken of
not yet know what would S £ rate T
Wc do
of I.U.C.D. over a period of
k I “P*^011 and Kovals
be more than what iHs at presS hh'Ch “
to
to only a few months- thS £
^E^nce is limited
PU.C.D. programme wodd ge^hm * °f
1
il
on the
programme progresses and fa'
needs to be knXfor an edit.
S8Cr
morC dlfficult as this
momentan:.
much that
as much of the current Planning
not-yet known
1
I
II
*'unrh,
principal ways'in'whic^ thl com’111""’
granunc principally affects the
family planninfprogramme:-
n
-
,foUowing are the
°j
fl
w1
I-U.C.D. pro
Stratc^ of
i
B-
the birth St^e of reducing
the stipulated peri^
P??^011 ^thin
should be fixedin tele
The ^gets
affect the birth rate And ° I re\U b dlat W1U directly
tf= plan for pri™»
‘^'0.■'><»«
supphes etc. which will achieve 2’ ta^V ^P1^
address in the first meetincy r l t^Scts-- ^4 her
Planning Council at Mad
°J ?C Central Family
«er
a“±“i A'
Hal*
must have targets for diff
rcacbe^ when we
g S tOr dlfferent aspects of the pro
il
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175
1
grammy for each State, for each district, for each city
and for each block. While planning targets, it was
necessary to plan and organise all the steps necessary
to reach the targets. Targets should be reviewed at
least once in two months and if there are any short
falls reasons for the lag should be ascertained and rec
tified without delay. This requires that considerable
emphasis be now placed on planning, organisation,
administrafion, supervision and evaluation on the basis
of assessment of results through a good and sound
. system of reporting. This process has to be organised
at all levels of implementation, from the State Head
quarters down to the block. In order that this require
ment should be fulfilled, organisational- strengthening
becomes a necessity.
I•I r
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?
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(ii) There is need for considerable strengthening of the
educational and publicity effort. While the effect at
creating public awareness of the concept of family
limitation has to be continued' and even intensified
much greater effort has to be made to spread the know
ledge concerning birth control methods.
1
3
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*> now much greater need for providing the
(iii) There is
supplies and services almost simultaneously with the
motivation. The need for this has already been re
cognised in the instructions given some- time ago that
orientation camps should be, as far as possible, ac
companied bv service camps. This requires that, on
the one hand, all difficulties that may come in the way
of motivanaQ of eligible couples for accepting the family
planning methods of their choice be removed and, on
the other, that much larger resources of manpower of
the requisilr kind be drafted in the service of the pro
gramme and all difficulties that there may be in their
working wzh maximum enthusiasm and efficiency be
removed. Fortunately, with the I.U.C.D. method it is
possible to cbvelop easily and effectively the facilities for
rendering -tris advise of service in all medical institutions,
Government or private, medical; colleges, M.C.H.
Centres, po.x-partum clinic, well-baby
”
clinic
* : etc. It is
important rial all such resources should be fully utilised.
(iv) In order to ziake the programme a truely mass move
ment as it das to become, it has to be supported by
voluntary aemcies and local leadership to a much larger
extent than las hitherto been necessary; and their assis
tance can be taken in a variety of ways as well be mentiomi later.
fl
..
<’r"
176.
1.3 Arising from the above requirement, the
•dealt with the following main fields : —
Committee
■ I
Q Organisation.
(ii) Finance.
(iii) Resources of manpower.
(iv) Role of voluntary agencies.
(v) Training of personnel.
I
' I xor
|fea
■1
'The sections that follow are arranged under these topics.
i-4 The Committee had three meetings of two days each
one in Calcutta and two in Delhi. The conclusions reached by
the Committee are based not only on the experience of the mem
bers constituting the Committee and the discussions amongst them
selves but equally on consultations with an participation in the
meetings of representatives from other States too, who were specially
invited to the meetings. Suggestions had also been invited from all
the state Governments and such of the suggestions as came within
the scope of the -work of the Committee were considered by the
Committee and most of them were also discussed with the repre
sentatives of the State Governments who attended the meetings.
The Chairman of the Committee and the Commissioner. Family
Planning, had had the advantage of visiting the States of Mysore,
Madras, Andhra Pradesh, Maharashtra, Uttar Pradesh, Madhya
Pradesh and Gujarat where they had studied in detail
the programme being implemented by these State Gov
ernments and discussed its problems in detail with the
officials and non-officials like Honorary District Education
Leaders, Members of the State Family Planning Board,
etc. The Committee also referred to the Evaluation Report of the
World Bank (Bell Mission Report), the U.N. Evaluation Report
and the Report of the Family Planning Programme and Evaluation
Committee and found that many of the conclusions reached by the
Committee also find corroboration in these other reports.
I*5 The Committee wish to place on record their sincere
thanks to all the invitees who responded to the Committee’s invitaand extended considerable assistance to them in their studies. The
Committee also wish to record their appreciation of the valuable
spade work of collecting material, preparing statements and mak
ing available previous references which was done by Dr. H. Baner
jee and which greatly facilitated the task of the Committee.
7
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1
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^>lo
me.
<nit
gui
•ijeve;
I^dec
||tive
I that
WiQD
Wmg
I call|<the
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Ifolk
■: abse
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rwhi.
Ifiind.
Irela.
Ibea
pnen
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177
SECTION II
■Ml
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I#
ORGANISATION
.2,1 .^s has been mentioned in the previous cem’nn
«l
■"/*= IUCD p„gramme n,i„PT “ass pX™
Mi table and a|„ enptases the impotmee „d
Mi
ll
-tl
I ffedaeee fo, the efficient and speed, i^lentenitinS of ™ p“8
. j gramme. This
Xs of
n°‘ X d"t
organisationP at
fl different levels ii
TISItn SIZC and co™petencc, but also that
A| it is well rnm
i“T^ejd rC
;"d welI-manned and the method and tethj. j niques of work■ are improved, procedures are streamlined and
JI everything needed is done to'
. .J create leadership at all levels so that
11 decision making takes pla,
ice in a decentralised manner and mitiaW SCt£
as many points as possible. ■
1 r o ,■
aCqU,TCS added ^Pomnce. Bv andS^ © °f
By “d large, these
rc9uircjficnts
at present
are nottaking
fulfilled
JI detailed
integrated
State Plans
6care oHJl tEmn'
.X X™ n’J
I
liSsigsgs
| ?»,.f buiiding"pX^XrVXj^id
, financial provisions, fixation of r
ffi,
— ~ie scrutiny
’
i of correctives, of the
cases etc., is either largely
ffie .deveinp^ent S
1 of the reports and the tarrel, application
±1 SoX^'^UTthXd-ffi ■" rer
J
up into district Plans
<1
and
I
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I
1
iigss^sass?
be
of'diX
f”"’”’
■'
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“d'S.S
o”"
“
»»<f dsc'JmsMcesXheS
Of detailed p anning at the district level will assume qnntT
dimension. A great deal remains to be done in the Ed ofT^
uig. _ A very pointed reference has been made bv the wtrld S
hajssion m their report la the gap that exists and has^o k fiE
i
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I
178
up in the field of training. More has been said on this subject '1
in a later part of the report. That the instrumental capacity has i I'
to be sufficiently strengthened and enlarged and at all levels of ]
implementation of the prc. ranime has been finding of all the 1
Evalm »on teams. They only corroborate the experience of the |
members of the Committee and of other officers in the States |
wnere any serious effort at implementing a sizeable programme has I | J
been made.
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2.2 The Committee are convinced that for some of the
reasons mentioned in the earlier section, it would be wise for ug
to plan for a much bigger effort than even the l^id down, targets |
would seem to require. The very promising results in terms of | l(
members achieved in some parts of the country within the first 1 H
few months of taking up the IUCD programme are not sufficient I
indication that the Organisational strength provided for under the •
^963 reorganised programme is capable of‘achieving the very big :
targets that have to be achieved to bring down the birth rate to
the desired extent in the short period of 10 years. In a programme
<1
of this nature seeking to bring about change in traditional beliefs I ■-1
of mostly illiterate people, by appeal to reason, the success achieved I in the initial stages, when only small groups and generally the I
Is
caser ones are tackled, is not enough guarantee that the programme I ’if
can be given the necessary momentum in die coming years with- I
out substantially strengthening the implementing agencies. It |
would be pertinent to quote here from the report of the World I F5
Jra
Bank Mission as follows :—
J
hIr
ts
ft
“The numbers relating to various methods are impressive I
but the base population is so large that massive numbers -I
of effective users are required if there is to be any measurable. I
effect on the overall birth rate”.
* 11
h
“
1 ti
i
It would be natural to expect that many among those who readily
b
accept a family planning method would not use L
it persistently ■
and effectively. In the coming years more difficult areas and j d
more resistant groups will have to be tackled and more effort J
would be needed. Further, we will soon have to become more j
selecrive than is the case at present in approaching couples for j
motivating them to adopt the kind of family planning method I
which will produce the maximum results in terms of reducing • j [Ma
births in the shortest period of time. This again will make the
task harder and the increase in the number of users of the diffe- 1
rent methods slower. There is already indication coming from d
.fca
some parts of the country that the rate of increase in IUCD insef*ts
tions of the early months tending, to slow down.
11 A.
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51
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2.3 Our educational and publicity effort needs to be considerably strengthened, as has already been mentioned in the previous Section. We have to use the various forms of mass media "-ROh<
feb
Bia
t:
11
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179
I
more extensively and effectively and in a much more sustained
manner than hitherto, supplemented by the use of special media
J which is most suitable for different areas and regionsand ™
JI of people Lse could be made with advantage of normafcom
n mercial channels of distribution of contraceptives for purposes of
| educational and propaganda work as these agencies wdl be mte: rested in doing their own promotional work as a part of salesmanship. The use of local leadership on the largest^cale possible
1 ancI going down upto the village level is essential for the Success
f sidered^T^r'seSon't
VOllmtary
beCn COn’
I
Strengthening the State Headquarters Organisation.
vjew^e^^^S- XZZX
givhh"”^pns S:.1’1'1963 ors““d sd““ “5
■g
1
W
1
|
1
staff for F^Jv9#
schcmc did not provide for any
fmm
P^n^g for the State Secretariat. All proposals
om the State Health Directorate have to be processed b^ the
wkhX^l^Tr SanCd?nS given °r ordePrs issucd- 'EvJn
and ths Sd b^a
0J.PowcrsJt° thc Health Directorate,
siderable
t0 d°' there wiI1 sti11 be
be attend'd m °f, wo^ for thc Secretariat, and this work has to
be attended to with efficiency and speed if the operation of rhe
tO **ih”Pcrcd- AI1 correspondence with the
I StSrs** I“'e ” d™c *s«= nJ*
1 thePSt«e w’vrh J
*? th(: tempo of work in those of
the State uhch have been implementing the programme in a
i bigger wav than others, the work of the Secretariat h?c1 a
become so h«w that it is no longer pcJible to deal wS it “5
Department
some
of ^e
State
Heahh
1
I
J
tional staff
I1
Centrally sponsored
being found by the
90n!mitTce recommmend that the^ddiHealth Departments of
as
other
“.for «*
“ similar staff.
The Committee recommend that
there should be a separate ceil in the ou
in the State Secretariat for dealing
T
With thc Fami]v Planning
This cell
| should be headed by an V
<, Secretary/Assistant
-r
5o’ programme.
under
Secretary with
I a small supporting staH so that all proposals relating to the familv
| planning programme can
be processed quickly and put up to the
? 15—88 CBHI/ND 84
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180
appropriate authorities for expeditious decision/ The Commits
recommend that this cell should have the following staft^
Proposed stafffor Health Department (Secretariat')
Under Sec etary/Asstt. Secretary
U. D. Assistant
Steac-typist
Orderly Peon
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^ith this staff, a beginning
can be nude but it may become
necessary before long to further strengthen it if from L_r.J
experience
it is found that on the programme gaining more momentum*
th^
increase volume of 1work that will have to be handled in the
in the
State Health Departments (Secretariat) would need
-J more staff.
2.7^Thc Committee also recommend that c
agency should be TOKd J jC o~™
a str“3
the Health Directorate oAach State
Govern „ dad exclusive!,
inis agency should have t^ hill
r
Branches of the Directorate whose support is’hecessarv forvarithe I
implementation
ofkthe
family
pl programme. This agency
shoulH
h------planning
should
uld be headed by
bv an <officer of adequate status. In the Spinion
ofi thet Committee,z the
~ status of this officer should not be below
that -°
of a3 jTi?.
’ 1'2 1LCC^sr r°fs Health Services, otherwise he will not
be able to discharge hi;
wc
’ ’ • with
’ ’ dse
'
night
^e,
r UbCi exceptions
““P00115 to
t0 this
11115 rule when an individual Deputy Director
ox Health Services, because of his special suitability and experience
or, for other similar
kZ---- i rcasons’. may be preferred to a Joint Director,
but these can Ibe only exceptions. If the status of the officer is not
adequate
it would
powers n(™
” t T v P0STe t0 delc?ate t0 him adequate J
cessary to facilitate the operation of the programme As !
■1
I i
Sth dde Jrinn d fUnCUOn
“ a decen^alised manner
wiith deleganon of powers to the implementing agency all down J
cisedlt
djClil°n.ma.klng
Place and initiative exer- I
iSector of hLS 5
though in a State the 1
fvTll 4, Health Scrvices/Director of Public Health will be in I
the State
° T Pr.0Sramme> the officer actually in charge of 1
Sffiffie CUrCaU shou]d bave,th= authority to correspond directly I.-. .1
S^ic«
Kaiai\yc Planning- The Director of Heatlh I p
^'burdeid^rb0116116t0
mateS and should not I
-II
'1
Slav
TkinT? r°Utlne TT
Otherwise thei-e is bound
II •
and reTnoS-n^T5
°ther officOT wU1 not take initiative
?/■
^responsibihty The. Director should help the Joint Director ft
£ DireetnrT6 T C.00P,eJation and MP °f the other officers of r;
ft ■
S-Wa T
°
him
and only to the »
. ..nt that is necessary.ior purposes of discharging these functions,
. -5
• —- ----- _
-----
-
...
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.------- --------
-
-lali
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a
?1 ■‘that the Director shc-uld keep himself informed of what is happen<• J - ing in die family planning programme.
ta
2.8 The Committee would wish to emphasise that the Suite
“ Planning
'
Bureau as the State Headquarters Orgamsadon
.Family
Organisano
..-responsible for the implementation of the programme has to, be
c
-.regarded more as an administrative agency, than one providing
the clinical services and should be structured and staSed accord
ingly. Administration in this context would involve the prxess
nf" planning, operation, supervision and evaluation. It will not
have the rcsponsibilitv of actually providing the services such as
sterilization, IUCD insertions etc. It may continue to be allied
the State Family Planning Bureau, but the concept of providing
IB.' the clinical services and of information and advice often associated
forefront
with a bureau should not be allowed to come to the foreiront
but instead that of an administrative headquarters. The State
Family Planning Bureau should have two major Divisions, namely.
Administrative and operational. The set-up which the Committee
recommended is shown in Annexure ‘C’.
I
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2.9 The Administrative Division should be headed by an
Administrative Officer not below the rank of a senior Deputy
Collector of the Provincial Civil Service. This Divisions should
attend to all administrative work including budget and snculd
have a small unit which will deal with grants to voluntary organi
sations. In a later Section dealing with voluntary agencies, we
are recommending a certain scheme of delegation of powers, to
saction grants to voluntary agencies which will give considerably
more work to the State Governments than at present. An L pp^f
Division Assistant should be sanctioned for this cell. I ne
Administrative Section should have a Stores section under a Stores
Officer which will be concerned with supply, of all types of con
traceptives, training materials, charts, nospital equipments, for
IUCD, 'teriEzation etc. It will organise a proper system of distri
bution, adenting etc. which will ensure that supplies are always
available and in adequate quantities at all points of consumption.
This work is vcrv important will grow in size and complexity
and will have to be attended to with efficiency and promptness^ if
the progress of the programme is not to be affected when it begins
to gain momentum.
......
;
2.10 The Operational Division should be headed bv an
Assistant Director of Health Services and will be divided into
two sections—one to deal with education and information and
the other to look after planning, field operation, evaluation and
training.
The education and information section will be
headed"bv a Health Education Officer who will be responsible
for the educational and publicity campaign in the State. V- e are
change m the designation of this Officer from the
F
"1
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182
existing designation ‘Health Educator’, because we consider .V ®'necessary that this officer should functiai not merely as a Health
ifWi
fcecator and m that capacity supervise the work ol the
|
tu
^.-n ion Educators (we have suggested a change in the desioMuon of this officer also as well as ammfication ff his functions^ | m<
msnoned ^tha^
PrC^mme- We have a heady iiCc
^fboned that considerable intensificmon of the educational 1
B
St
X
ensure that for the Family Planning Prolamine intensive mJ
I
l(
[?0]
»f “kf-md problems that would have to be attotded to in S
P^of dus programme, such as of training doctors in IUCD
g=nmg the services of pnvate doctors, arranging the camps and
^^°grammcs of
mobile teams (described, fully hter)
armnging supplies organising the follow-up work etc., the Com-
anOther docr “ bc appointed in
in
«v'■
me ^tate. Family Planning Bureau exclusively for the IUCD pro
3nd 3 sma11 ceI1 be created for this with an U.D.
™e^teCSCnpi
I
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W
■ pr5
■Tn<
j|d
Bco.
Ftio
Ip1
the mstricts.
The officers of this Division will have £ keX “
IF
rd
1^
1 IS dlr°Ugh thlS Dlvision that there should be th?
S
^nd of constant contact between the State Organisation and the
ith<
tatJ-'of?hganiSatl0n that V needed f°r
succcssful implemenUdm of the programme. It is very likely that as the programme
IP3
Imi
^n.^ momentum and its magnitude and complexities and the ariswua
CmS
more /“Uy realised this Division will need to
be tvier strengthened from what we have suggested in Annex«nr
W!, havc.alr=ady said that training will need special
Ihe
sSXf wIvl1S air-u iy a?ig
11131 h3S to be filled- The
Svatisnml work that will be done in this Division will relate to
S^StlCS'rkeeded
pUrp0SeS °f
Pro?ress from
s^1?b %
morc,Iong term studies based on statistics tipi
State’s Statistical Bureau which by so
|lx
DCC“Sa7 s,uPP°rt t0 the WOrk of the State Familv
IT^g Bur“u- Sumlarly,^ State Health Education Bureau
f'w
-J —Ip in family panning education. These two bureaux
s
A
I fr
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71
ifc.d
tl
■
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J will need to be suitably strengthened. Each State should work
: '|
lts Proposals for such strengthening and the Committee recom• mend tnat the cost that will be incurred may be met bv the
Central Government as a part ot the family planning programme
Strengthening of the District Family Planning Bureau
I
The Committee examined in very great detail the
j requirements of staff ar rhe District level with reference to
■ the nature and load of work that will have to be performed at
i this level. The district continues to remain the most important
I unit of administration.
The District has also to be the unit
| for the preparation of detailed operational plans and much
| of the responsibility for the implementation of the Familv
- TIanning Programme will also have to be discharged at the
j iyistnct level. The bulk of the w’ork will be administrative and
j organisational, involving planning, supervision, evaluation,
• f application of correctives etc. Problems relating to these will
| predominate and not clinical problems. The .Committee recom| mend that the District Family Planning Bureau should he organis| -ed and manned in the manner shown in Annexure D. The existing
4 Pa^ern.^as ak° °een incicated in the annexure for purposes of
.comparison. It will be ?een that the District Family Planning
| Bureau will have three Dwisions Administration Division, EducaJ tion and Information Drraon and Field Operation and Evaluation
Division. The administndon Division will be in charge of an
I Administrative Officer
the rank of Sub-Deputy Collector,
I Tehsildar of the State Cffii Service, and should look after general
administration, stores and accounts. We have suggested the
t-strengthening of the Accounts Section, to consist of one Accoun| Tant, one Assistant Accountant and Cashier because the work of
| account keeping will consderabiy increase as a result of some of
11 ^ls rccommendations made by us later in the report in regard to
| payment of incentives, grants to voluntary agencies etc. In a fast
| moving, diverse and finardally well supported programme of the
.1 nature of the Family Planning Programme, proper budgeting,
•5| accountkeeping and control over expenditure should be given
l|| ^portance. The Education and Information Division should be
| headed by the Health Edaxaticn and Information Officer and the
Tield Operation and Evaluation Division by a Statistical Investi^e-3-d of Eie Bureau would be the District Familv
| Planning Officer who sbmld be a Class I Medical Officer. The
| yvork of the Education and Information Division will extend over
J both the field of educanr-i
. on as well as general publicity
for the programme Fk-C opertdons and Evaluation Division
| will look after the field operation ■- -:?e pr^mmmc
its current
^valuation. The mode
working of the District . ureau shodE'
ne the same as of the Sta> Bureau^ The District Family Planning
F-
•r
"'"w
i
134
SresP°nsi^ ?or
State He^Ss.10
attached^ mn?
?amUy
Bureau should be
pSS Ink The “:2atl°r
3 rnobile education and
CnTnT
Th
P of tht mortfc sterilization unit is also
District FamiT
D‘
W°uld aIs°
attached to the
District Family Planning Bureau mobile units for IUCD according
labhsCof°PUh?0H °f jach district’ PrOTi:Eng one unit for 5 to 7 f
ati ofPr°rt ?n’
°n the
sudc centtJ
IUCD
i
programme and should:
°^ers at the
B-
and de"^ f popm
kuon of the district The Committee wish to emphasise that ■ ' i
admittedly6cZn? W,t?
.rnanFKm^r resources-aSd this will 1
be7oTew>k
t0 reTain
for quite some time-will |
Would be
fro™
XaS S the P
'"’J'’??11
of circumstances the
acS IUCD Pnmary.Health Centres, so far as rendering of
mfe roundS?’
IS/?ncerned’
extend-to only a few
miles rougd tjie centre and there are bonnd to remain big pockets
g1 e^ery district which cannot be served by the Primary Health
1 ? C °f ? sul>ccntrcs
only be educational and
momational; there will be no agency at the sulxentre for actuallyrendering the clinical services and even its role of guiding the'
person motivated to go and get service from the Primary Health
Centre, will be achieved only to a ven- limited extent. For quite
to come it will be difficult for most States to fully man
P-H‘ °S' and sub-centres. It should be possible for the
I.U.C.D. compaign to forgo ahead of the P.H.C. programme and
not depend over much on the latter. The World Bank Mission
have also recommended this. It is for these reasons that the Committee strongly recommend the use of mobile I.U.C.D. units to
1 e-1n]a.r'tIiU?1 cxtent possible, which, of course, will depend on
availability of staff, vehicles, equipments etc. Admittedly, the units
can be organised only gradually; but that emphasis on 'the organi
sation of such units to the largest extent possible and as quickly as
possible should continue to be placed, is what the Committee would
strongly recommend.
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2.15 The Committee have considered the question of attach
ing the mobile units to the Primary Health Centre as an alter
native to their being attached to the District Bureau and are of
the view that attachment to.the latter would give considerable
operational advantages as well as ensure that the units would be
put to more fruitful use in a planned manner. It is the Com-,
mittee s suggestion that for each mobile unit a detailed pro. ‘.
giamme, i<jr one or two months at a time, should be prepared bv
the District Bureau, sufficiently in advance and circulated to all the- w;' ■
workers concerned at the Sub-centres, ro village leaders and;
voiuntary organisations, who may be brought into the programme^.
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\t all the
.odonal
:k would have been done in adv: ce
c : the arrival k t unit at any centre. When the unit : :s
amat a centre n; avoidance'with programme all the prtr raticr. would have :xr.. made and it will be able to accomplish :he
maximum amount ct >rorx during its short stay if one or
o
days at each centre. Arter completing the work in one cer-..e,
the unit will move to the nev'c centre according to schedule, tnus
completing the whole programme within the stipulated period.
The staff will then remain at the Headquarters for some time
and other staff should take over the duties of the mobile unit.
In this manner it wall not be necessary for the same staff , to
do long periods of hard touring in the villages nor will they
be doing exclusively I.U.C.D. work for long periods, wnich
work can be boring and will, therefore, fail to attract in suffi
cient number of doctors. The staff of the Primary Health Centres
should also be interchanged in a similar manner with the
staff of the mobile units. This will give to all the staff work
ing on the programme in the whole district an evenly dis
tributed load of u^ork of ail kinds in the medical, public health
and family planning programme. To achieve this purpose also
it is necessary that the mobile units be attached to the District
Headquarters/
2.16 The Committee will further recommend that there
should be some administrative arrangements at the district level
wherebv proper coordination would be established between the
District Civil Surgeon, who controls the hospital staff, the District
Health Officer and the District Family Planning Officer. If neces
sary, the senior most among them could be put in overall charge
the’
the enc.re health and Family planning programme in the
District, but only for purposes of effecting necessary coordination
that has been referred to/ Definite directives should be issued bv
the State Governments that all concerned officers should give full
and effective support to the family planning programme.. It will
also be an advantage to have at the District levelI an implerr-entation Committee which may be presided over by
I the District Collector and should have all important District Officers as its members,
uarticularly those who can lend support in one wayr or another
ro the Family planning programme. This
..— Committee
------------- will review
trie progress’of the programme from time to time, bring about coordihation in the functioning of the different departments, so far
as the family planning programme needs it and see Ithat the supx the entire District administration to the extent necessary
is i:.-;en to this programme. This proposal has already been made
by' the Ministry to the State Government.
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2.i; In view of the key role which would be pia-ed in
: implementation of tlic programme by the District Familv
186
a.
s'
*e post should carry a spechf nav
3
“ J °fficer and
may be appropriately fixePd with ref^Tali
am0'Jnt
m similar posts in the State S;mn 1 1 to allowances payable
attached to the mobile unite 1
officcrs w'ho would be
the period they wi?lI be oTmobt d
SOme aIlowance
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r
that an allowance of Rs icn n n c*
.^omm^ttee suggest
he appropriate. This should bf
Assistant Surgeon will
that they may . be entitled n
10 thc T-A’
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Government/ If the
under the fwmal rules of the State
static duty suggested eXt“g
' n5°bi!e and thc
is not feasible in ;
attached to the mobile units may be retoirXj“y T*’ 1116 °fficerS 1
a specified period of say one1 may
year be retained d
j?°Sition for
m a some static position.
7 at a time and may then be put
of population andgtill others in teriX/IX’
ln terms
country in which an intensive nrng °f b°th) Dlstncts in the
managed
by one
properly
this
pfoblei
oneDistrict Pam’l ni ^ramroe ^nnot
' Tobedeal
Pwith
into two parts and a&Bureau mav h
dividGd
suggestion was that one gr twXhl,
another
Sub-divisional level with less staff thari?115
^-Startcd at thc
As the Committee could nor act ik 0r2
• ^lstr’ct Bureau. "■
Native opinion on this problem the^ udQrmati°n and represencommendation of thei/own but dY ar\unable t0
any recretc proposals are submitted hv d
if conon this problem they would merge ^d G?ver"ments bearing
Government
7
mCnt considc™on by the Central
1/
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Urban Family Welfare Planning Centres
»p should
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h^^on'shodd be made forap^ointment of a sweeper either wtaletim
sary m any case. The Committe.ae or part-tune as may be necesorganisational set-up for the •c also considered the existing
static and mobile sterilization
units attached to the Urban Family
Welhm
’e Planning Centres
as adequate.
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Rural Familly Planning Centre (C.D. Block)
2.20 With the revised r ■
which now provides for one
suixcntre for everv 10,000 pattern
of
Staffinff P^em
tor the Block in adequate
adequate. While agreeing with the principle
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gj -that health service should be provided in an integrated manner
| .and the workers should be multi-c-urpose for the basic health
If field, incArling Family Planning, as ifar as possible, the
Committee is definitely of the opinion that- some change is needrif ed in the durie- of: 1the
’ Basic
" ‘ Heoith
T ’ ’ Worker
’
rf
and Health Assistant,
» so far as the famdy
tardy planning wcrx: is concerned. The duties and
. J responsibilities assigned to the Basic Health Worker will leave him
ti'iT-rtlrr -intr
_ ________ _______ 1
,
/• « »
| hardly
any time for doing
any substantial Twork in
the
field. of
| family planning and if he is required to do this latter work also,
f it
— can
—-1 only be at the expense of the other health programme
programme.’
| The Committee is, therefore, of the view that the Basic Health
[ Workers should be a multipurpose worker for the general health
services, but for family planning he can onlv provide some information to the people. The Health Assistant (Family Planning)
who should have, some experience of communitv health work,
can do adequate justice to the Familv Planning work, if he is not
required to superwise the work of the Basic Health Worker. There
should be one health assistant for every 20.000 population, irres
pective of whether the area is in the malaria maintenance phase
or not. In difficult terrain the limit of population mav be reduced
to 15,000 or even 10,000.
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2.2i There should be one Health Visitor for each unit of
. 40.000 population to supervise the work of the 4 Auxiliary Nurse
midwives. Since in the staffing pattern there is already provision
for one Health Visitor for the Primary Health Centre, this recom
mendation of the Committee will involve the appointment of only
one additional Health Wsitor. In the malaria maintenance area
there should be one male supervisor to supervise the work of the
4 Basic Health Workers. There is one male supervisor at this
level in areas which have not entered the malaria maintenance
phase. The recommendation of the Com miner, therefore, invol
ves the retention of this person even after the area enters into the
maintenance phase. The recommended set up is shown in Annexure E.
2.22. These recommendations are the same as the conclu
sions that were reached in the Special Workshop organised bv the
; on “Training of Family Plan
ning Personnel”.
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2.23 The Committee recommend that wherever District
authorities con.'ider that it would be useful to have part-trine
workers may be appointed on payment of an honorarium 't
for motivating and bringing cases far vasectomv and LU.C.D. in
sertions, such workers may be appointed on payment of an ho-.*>
ranum of Rs. 50 p.m.. or altet^iuveh the honorarium mav oe
!.... p ■
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ks. 30 p m. and if more than 50 cases of vasectomv/IUCD
a-.bright by the worker in a month he or she mav be paid Re. 1
each additional case above 50. This latter mode of payment wH]
act an incentive for putting in additional effort and enthusiasm
SfdlV^Thev ihn\workers.win na^y have to be selected
tally. They will have to be persons having influence in the
locality and enjoying a good reputation. The appointment should
be made by the District authorities, making it clear to the per
sons appointed that their continuance in their position will depend
entirely on their performance.
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2.24 The Committee are of the vipr that one Honorary
District Education Leader cannot cover the whole district suffi'ciently intensively as
- is
’ needed
’25for the programme of Family Plan- -|
nmg and since die Educational workf which noi^ffkhl'l^fe j
can best do, is of great importance to this programme, the. Com- J
mittee recommend that Honorary Education Leaders should be 1
appointed one for each Block. Such block level leaders
leader. . should
chnnM |
be given an all inclusive honorarium of Rs. 600 per annum to.
meet their incidential expenses inclusive of the expenses on their J
tounng. They should be appointed for six months at a time and
their retention should be dependent entirely on their performance.
I he appointments should be made by the District authorities.
It would be best of these appointments are made by the District I
elector on the recommendation of the District Family Planning• 2’2?
conclU(hng this subject of organisation needed at
various levels, the Committee would strongly recommend that
CXlbl lty sh°.u*d be allowed in the matter of qualifications
0 d^etept categories of personnel. The rigid application of the'
qualifications laid down by the Central Government is <creatingconsiderable difficulties for the State Governments in recruiting
e necessary number of persons in the different categories. Apart
irom this, it has also been the experience of the State Governments
that even persons possessing the stipulated qualifications have not
necessan y turned out to be suitable. For example, young per- J
sons fresh from college with M.A. degree in Sociology have pro- 4
ved ineffective as District Extention Educators. It would be best J
it the State Governments are allowed to frame their own recruit- ' i
ment rules for the various categories of personnel taking into . 1
account the availability of candidates and die kind of qualities and
experience required in the different posts.
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RESC : XE POSITION
3.1 We have already drawn attention to the fact that 2Ithough the I.U.C.D. method orondes very great administra
and clinical advantages which makes a mass programme possi
the need also arises for the emolovment of doctors and pi
medical personnel in much larger numbers. There is not oXy
shortage of doctors for the family planning programme, but also
general reluctance on the part or doctors to work on this pro
gramme and, were particularly so, if they are stationed in he'
rural areas, or have to be on mobile duty. The reasons for de
reluctance are several. Naturally, the doctors do not wish to ger
cut off from their wide field of clinical work by being put exclu
sively on family planning work. Added to this, often by being
appointed in tfie family planning programme doctors suffer in
their emoluments. Sometimes they lose house rent allowance
and other allowances. In the rural areas if residential accom
modation is not provided by Government, houses are difficult tn
get. Some of the State Governments are imposing conditions m
all doctors entering Government service or in some cases even
when a student is admitted to a medical collage, that they wGl
serve in the rural areas for a certain number of years after joining
service or obtaining their degree. The Committee is strongly of
the view that along with the imposition of such obligations. 2
serious effort should also be made by the State Governments zj
improve the conditions of sendee of doctors serving in the -uril
areas so as to compensate them tor the hardships of disadvanmgesNo doctor employed in the family planning programme shomd
suffer any loss of emoluments. If any allowances are being grn
to other doctors holding other similar posts, ndt irr the femrv
planning programme, the doctors working in the family planning
programme should be compensated by being given a su-tahje
family planning allowance. The Committee have already reemsmendeu earlier that a special allowance should be given to doerrs
on duty with mobile units. Rs. 150 p.m. could be regarded as a
r
amount for this a’i?>wance. A condition could be itxened that at least 150 v’... ;.'’-ies or 300 UJCD, of equivatet
combin-iden of these, shetad be done per month. This
be test of performance to justify that with the al Iowan-” ' oe
wc-rx is af jnded to with -accessary enthusiasm and e^tnest.
.
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■ In addition t~ protecting the emoluments and ccn .
□r the hardihi?> of mobile dun- as recommence: r
ComXztee also BiT.-ng-. * recommend that doctors
•' :
special incentive, on tm. hm^s c£ their per:•
.VX'../. 1
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ensure that they will put
their best efe in ’ ‘
in the famiiv* Xplan_____ 1
follfw?—?amm“
Commite‘’s recommendations
—j are as
4^
“ steriliza-
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Aeir^ffff no 'Tl
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ase of doctors who are withdrawn from their normal
they^should' ^n0dMt0 fbC ^P10^ ln the camps while
lUCn
th
Pald f°r .vasectomy> tubectomy and
of 2s°/
ratC ?sabove, a deduction
■th 5 ° ia°m t?eir tOta ^Ucs should be mad- because
bC Perf°r^n&
normal duty for the
penod that they would be attending to work in the
AgaBSfr. -
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1t
vdlll Llw
(U) famfl?11? PriVatC med,’Cal Practitioners who work in
planning centres should be paid a fixed allowSX ■ kPCr mi°nth f°r WOrking 2 houn a day,
Aree days in the week or for three hours a dev tssj
^.s ’n^ week. This is also the present pmctke-
mentor181 lty
d
a,lowcd tQ
mcnts to suit the local situation.
ft
State Govern-’
Over and above this
tel™0ZmCC thCSe Part'timC mediCaI °fficerf should
T*JT
some monetary incentive on the basis of perwo^akn t° thati thcy undertakc some promotional
rk also to get larger number of cases. The present
>ys>em ot pay„„t of
aIlrama.
d“,"“
cntliusiasm
p“2
yiml L, h Committee recommend that these partShwame »
pa'd' “
“ ■h=
IO P" vasectomy over and above io
cases done in a month and Rs. 2 per IUCD insertion
wer and above 50 insertions done in a month. There
may be combination of vasectomy and IUCD insertions
due pUrp0SeS °f “kulating the amount of payment
due on vasectomy being considered equivalent' to 5
i.U.C.D. insertions.
?
employment of Private Practitioners in the Sterilization and IUCD
Programme
_3'3-’rhe cmP>oymcnt of more and more nrivate doctors in
“ ?±P”"
parfafarly £
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'Sectirc use of them, should
en considerable importance. The hitherto prevalent
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attitude among the majority 1of private doctors that the
iamily planning programme is; a Government programme
end not a part of their own professional responsibthrv
responsibility
must be changed. This change has to be brought about
by introducing family planning as a part of the regular medical
education, (which has already been done) by training private
doctors in IUCD work, and by providing them the needed faci
lities and incentives for doing the work To quote from the report
oi the World Bank Mission : “with the use of the IUCD a new
role for the private physicians in the national programme becomes
evident. To encourage the participation of these doctors is to in
crease immediately the effectiveness of any programme. For inser
tion costs to the Government are likely to be lower in the form of
a subvention to private doctors than in any other part of the pro
gramme.”
3.4 These private doctors should be selected carefully. They
should be persons of integrity and good reputation. According
to the existing pattern private doctors are already being utilised
in sterilisation camps and IUCD camps, though not to be same
extent in every State Private doctors are also allowed to under
take insertions of IUCD in their own clinics. The pattern of
assistance, however, is not attractive enough to get a large num
ber of private doctors coming forward to work in the programme.
The Committee consider that private doctors should also be
allowed to do vasectomv operations in their own clinics / nursing
homes. These clinics - nursing homes should be carefully selected
and only after inspection to ensure that they are suitable for
IUCD and sterilization operations. These doctors should be
required to submit reports to the State Health authorities, giving
all particulars of the patients. After the selection of doctors is care
fully made, they can be largely trusted, but some random checks
should be done with the information furnished in the reports m
prevent malpractice. If the conduct of any doctor comes under
suspicion, his name mav be removed fro mthe list of approved
doctors.
3.5 As regards payments, from the information gathered by
the Committee they art convinced that the present rates of pay
ment are not adequate incentive for involving private Medical
practitioners in the programme in any large way. .The Committee
private
suggest that the following payments be made to privatedecro’s.—
(i)
•7
For the sterilization programme Rs. io per case
done in their own clLtir or nursing home and Rs. in
per case sub^er? to- a maximum-of Rs. 150 on any sin—
iA
gle day for doing vas rtc
ganised by the State
.
•i :U.t.i’-.;>-^-'oxi cam os or^
(ii) For IUCD insertions Rs. 5 per case if insertion is done
in the doctor's own c’rr.c C'rsing home; R.s. 2 ner
case if the doctor pertorms K. CD insertions in a cez-tre run by the State Government within the same
town; and Rs. 3 per case subket to a minimum of
Rs. 25 per day if done in camps, organised by .the
State Government. The minimum has been suggested
because the number of cases available in a camp depend
on its organisers and not on the doctor and not many
private doctors would be willing to devote a whole day
.at the cost of their private practice, without being as
sured of a minimum payment of Rs. 25.
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3.6 The Committee also, recommend that in the case of
women from the upper strata of societv who may prefer to go
to their own family doctor for IUCD insertion and wall pay for
this service, the doctor may be allowed to charge his fees but
Government should supply him loops free of charge and the
doctor will be required to' submit certain returns and statistics to
the State Health authorities.
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Compensation for the indindual
r.
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3.7 The Committee consider that for achieving the maxi
mum results it would not be enough onlv to give to the medical
personnel the incentive recommended above. Their efforts would
be most fruitful when at the same time the individuals who have
to undergo the sterilisation operation or the women who have to
have the IUCD inserted, are compensated for the difficulties, loss
of wages or any other such disadvantages which they have to
sufier. The Committee is aware of the view against giving any
fmancial incentives to persons who undergo sterilization operation
or to women who have IUCD insertions, as this is capable of
being abused and can lead to malpractices and also because the
main reliance in the family planning programme has to remain
on the educational and promotional activities. After carefully
considering this objection, the Committee remain con
vinced that some payment should be made to the individual and
this would be fully justified. These payments arc to be regarded
more correctly as necessary for removing the difficulties and dis
advantages and not as a financial inducement The principle
nas already been accepted in the case of vasectomy where pay*
ment.caji be hnade to wage earners for loss of wages. There
should therefore, be no objection to extend this principle to apply
also to IUCD persons in the rural areas are becoming desirous
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193
•of haying a higher standard of living. They are also bcccmizg
conscious of the need for limiting the size of their families, if
e gains that are made by increasing agnculture production are
to be preserved. So the situation is getting gradually more and
more favourable for extending the Family Planning Programmr
on a mass scale. People are getting ready to adopt family phnmng methods, and though the extension education method 'should
continue to be applied as the principal means of motivation, it
is necessary and important to remove any difficulties that rruy
come in the way of persons motivated io actually adopt the
family planning methods of their choice. Women of the pocrer
classes coming to camps for IUCD insertion lose at least a day’s
wage; often their husbands or other men-folk accompany them
and they too lose a day s wage. Very often children if rbrv
are very young and cannot therefore be left alone at home are
also brought to the camp and some expense is incurred on their
feeling. It is already the experience in several parts of the comtry where the IUCD Programme has been rapidly catching np
that women-folk in the rural areas generally prefer to
to
distant clinics or camps for IUCD insertion for reasons of pri
vacy and this involves expenditure to them on the travel " In
most cases they have to go to the clinic for check-up once or
even twice after the insertion. Already the information seems
to be spreading in the areas where IUCD has been rapidly sprea
ding that a number of visits have to be made to the clime whkh
involve expenditure on travelling. It is, therefore, necessary
that some payment is made to meet the expences of such :ourneys, if the programme is not to suffer a set-back after some
time. The representatives from the West BcngaF Government,
including the member of the Committee stated that alreadv in
some areas of that State it was beginning to appear as if me
programme was slackening because of this reason. For the suc
cess of the IUCD programme a systematic follow-up of the mses
is of utmost importarte. If this is not done and cases where
there is trouble are neglected it would give a serious set-bark to
the programme eventually. Even in cases of minor complicarkxis
following IUCD inscruons it always helps to meet the person
and remove her fears. For the requirements of this kind of
follow-up to it is necessary to encourage, rather than allow a
situation to develop where it will discourage, women from com
ing forward for the IUCD insertions and for subsequent rherk- •
up when necessary.
3.8 Taking all tiese factors into consideration the Commirteg
is strongly of the view that for IUCD insertions a woman shor’d
be paid Rs. 5 towards k?ss of wages, cost of food, transport
and other incidental expenses. They have given due considera
tion to the ait-ernath'r course of Government providing the transI?'- ’
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bi “ Vh-n^nro^
nM
ad®iaistrativek
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nected voth the follow-up ’ jou^evl '^-rdintr^
s&s iS (Xr'A5 L’
a®l«
ssx
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•ia be „
2^ “ d5
>
of°toS "P.“£S- - There
£
'*“ IUCD i»eS»
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insertion by the voluntary
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agency. State Government or local bodv r '
such payment is accepted. The CommittedSo rthe principle of
- 3 recommendatian
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Out of the i
„f Rs. 7 „d
. iamount
Kndci) isB adeauat*
many charges. an adequate amount cannot txe paid to the cover <0
wosnaa
to meet J*her expenses and remove her difficulties.
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3-9 The Committee considered c - carefulk the danger of Mak
-- . * j
----- 5 on atot the view that the danger can
-------- 3 convictio*!
r
,
-----Ganger
that will defimtely threaten the success of‘ the programme if this
payment is
not made.
This latter danger
maX not become apparent in the
early stages of the p—-,
programme,
but
is bound to arise in a sufficiently senous form befo;
—ore long to effect the progress of the programme. There is $0 far
belief that an;T *large
s‘°n
practice, or b^ parties to it, of
j-ow »ger
»ot be
III
5
loop removed they wil] have
to incur some expenditure and
what may be left of this
pa^
’
ment
of Rs. 5 may, therefore, be
hau diy worthwhile. Also,'it'i
’ 15 unt^clv t^lat many women will
submit themselves ^qxmtedly
i
to tne examination and insertion
of IUCD to make his small'
taken or all the trouble —
u..J„ amount of money, when account is
and expense involved in going to a centro, spending the whole dav there, i
Tal-irJ
~n7
meurnng expenditure on food.
travelling etc
; •
et^Talung
all aspects of the matter into considemhon the Committee
— are convinced that whatever risk there mav
Pay®cnt is verv much
ulturu-L^jT 5c found 1
the profframmr. if malpractice to
the beginning to guard
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y
3
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195
not so real and great and also because too rigorous a check will
affect privacy of the women and hamper the progress ci the pro
gramme.
3.10 As regards payment for vasectomy, the charges paid
at present are all right except that the payment on accoimr of loss
of wages may in all cases be Rs. 12. At present no payment has
been provided on account of loss of wages for salpingectomy.
The Committee recommend for this a payment of Rs. 25 which
will provide for loss of wages, for care after the operation and
other incidental expenses. Persons undergoing vasectomy opera
tion get six days special casual leave. Persons undergoing salpin
gectomy operation should be given special casual leave for 14 days
when such an operation is not performed during the period of
maternity leave. Women undergoing IUCD insert;ces should
also be given one day’s special casual leave.
3.11 The Committee was informed that in the States indus
trial employees were not entitled to any casual leave for sterilisation
operation. It is recommended that the Ministry of Labour and
Employment should be approached to make it obkgatory for
industrial establishments to grant special casual leave oe the same
lines as given to the Central Government employees for sterili
sation.
3.13 For providing incentives and promoting a wjnit or com
petition. the Committee recommend :—
(i) that a special fund be placed at the disposal cr the State
Governments out of which rewards can be gwen to the
members of the staff for any outstanding work and to
villages and groups of villages which show outstanding
achievement.
(ii) that the auxiliary nurse-midwives, nurses, etc- who work
beyond their normal hours of duty’ in camps be allowed
an amount equal to their normal daily allowinces from
the family planning budget, to compensate them for
hard work that has to be done in camps.
16—83 CBHI/ND/84
i
b.
1
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s
•'W'^
196
SECTION IV
FINANCE
and
,eX,amining
financial pattern
Pa«em of budget provisions the Committee make the follow-
W for thTdnfi tlOnS W?
fiU UP
up ror the deficiency that exist :__
i7
PreSCnt gaPs or make
(i) Cost of drugs, dressings etc. payable to State Governments, local bodies or voluntary agencies.—At present
there is no provision for this payment in the financial
pattern. The Committee recommended that for salpin
gectomy Rs. io per case should be paid for drugs and
ressmgs. For vasectomy Rs. 7 should be payable which
will include Rs 2 for food. For IUCD Rs. 3 per case
should be payable for drugs and dressing. This will be
indusive of the expenditure on treatment of cases, which
initially on examination are not found fit for IUCD
insertion, and on follow-up. Care will be taken to ensure
that payments on these accounts are not made twice
over, once through hospital contingencies and a^ain
separately per case. The Committee Ire convinced that
these payments arc necessary if the reasonable expenses
incurred by the State Governments etc. are to be reim
bursed to them and the treatment of cases initially not
fit tor insertion and the follow-up are not to be
neglected.
(n) Travelling Allowance and Daily Allowance.—For block
level workers there should be a fixed monthly travelling
allowance. The amount can be fixed in each case by
the State Governments taking into account the amount
ot touring that officers of the various categories will
have to undertake and the scales of fixed T.A. given to
officers of similar category in the State.
&
At the District and State level, a sum equal to 20 °/ of
the Division on account of pav and allowances
ot the officers and stafi sanctioned for those levels should
nAPrO^lcd 111-dlc budSet t0 covcr their T.A. and
1TA. The provision will be inclusive of the expenses on
the mobile teams.
I
I
I
ft;
It
I
I
I
II
I
Ilr.
I
I
II
1
I
(m) Provident Fund.—The share of the employers’ contri
bution should be met by the Central Government in res
pect of staff of the State Governments, local bodies and
voluntary agencies.
ft
(iv) Hiring of accommodation.—The State Governments,
local bodies and voluntary agencies should be given
1;
I
ft
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!
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i.i i m
i
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I
197
authority to hire accommodation, both for office and
residential purposes, where there is no provision for
construction of buildings or pending the construction
of buildings. The scale of accommodation should be
such as may be certified by the State Government to be
suitable and the rent to be fixed at an amount which
the State P.W.D. will certify as being reasonable. This
recommendation should apply to all cases, to Family
Planning Centres, clinics, training centres, contraceptiyes distribution depots.
(v) Maintenance of vehicles.—Budget provision should be
made for the maintenance of vehicles at the following
rates :—
(a) Foi petrol, oil, lubricants and minor repairs etc.
Rs. 6,000 per annum per vehicle. This figure has
been reached on the basis of actual expenditure
that has been incurred by some of the State Gov
ernments. This amount will be treated more or
less as ceiling; the actual expenditure incurred
will be recoverable from the Central Government.
(b) For major repairs, replacement of tubes, tyres etc.,
it is recommended that a fund may be created for
this purpose, to which the central government
should contribute io per cent of the actual expen
diture on item (a). This additional amount will
be drawn together with what will be admissible
under (a) and the State Governments would be
expected to meet the charges on major repairs,
replacements of tubes, tyres etc. when they arise.
(vi) Publicity and educational material.—The Committee
recommend that in the field of publicity and mass
education, the respective roles of the Central and
State Governments should be well defined. While the
Central Government could best utilise the all India
media, such as the A.I.R., cinema films, newspapers of
all-India standing, the State Governments should use the
media of local importance, such as, local newspapers,
exhibitions, drama and other traditional media best used
in the different regions. It was considered that since
a total allocation of Rs. 25 lakhs annually would be
avail able for the publicity programmes, a sum of Rs. 1
to 1J/2 lakhs should be made available for pubheip; to
each State Government. If anv special publicity pro
gramme like & production oi a film were taken up
-i."
I
i
198
”'™wi'1 h"' “
(vii) General contingencies.-^ per cent of the bud
vision on pay and allowances should be provFded^ as
general contingencies.
1
s
SECTION V
ROLE OF VOLUNTARY AGENCIES,
Prog«mme has toi™ '
f’
must be induced to
p^ay an increasing role in its implcmenauon. A much more
^Xn^n^ °f V01r^,ag^ should be tak^n Xn
Sirh n
hlthert0*1 Jt would “ctooe all kinds of agencies
nidi are willing to make a contribution in the programme and
Ki whose «se a view can justifiably be taken tifat ^111 be
smcere m doing their work and can be trusted. Voluntary agencies
should include those of trade and industry, of labom localSl
^2/°^ n?ht down t0 d* Vlllage Panchayat level, various"
kmas of associations, women’s organisations, organisations of all
whkh
I*
I
I
B
^d^numr'AV0''’3^*'111 WOUld E P^i&e to bnng I
I
<S5-’„
,I dj l y-dlcd Assoaaaon, etc
Only by havin'-- a
B
B
in -brge numbers of them in the programme.
to Ji^vTfnr0 ”nHitiOnS Shouldbc fui^Ilod by a voluntary agency
to e-a ify for participation in the programme, apart from their
un vT^Vt^ cart /d0^rhc work
-S
L^-omble t ( } 7 7 hca,e a defincd ob’ective which
PU-^oX S the fam^ 1
t0 Pr°mOte for
sPhc^id havdn I ?y PIann,ng programme, and (2) the agency
fcS to k Tr • CVel/atUS’ P^^g the entrustment of public
-n an J
necessary' that all voluntary agencies should
tak;
£ eT'? V' ?r°Sn“ae' S™' »«>>■ like
to : ■°»
- up the educational and promotional art of' the work
others may™IllyIie
^tribution of contraceptives and
still
others
Som- mav Sh m
mg t0 rl“ *. ccntre with all ife functions.
Skkl may wish to take up an activity only on some special occaSt
Pamily P1™g Edition on thPe ±i“n
or pmticipate in an educational drive?
P^tog Weck- In admitting voluntary a^en- cies _-= should be taken not to have overlapping jurisdiction?.
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199
S
.
5.3 Since it is the Committee’s recommendation that lar^e
numbers of voluntary agencies should be brought into the or^gramme, it is necessarj- that the authority to sanction granc-maid to them should be decentralised. Under the existing sv^tem
ewn with much smaller numbers of voluntary agencies workhm
m the programme, there has been many cases of delav in san^
Zoning grants-in-aid. This has a particularly dampening effect on
voluntary agencies which do not have abundant resources of thetr
own There has also been persistant demand from State Govern
ments that they and their authorities should have much greater
say in giving grants to voluntary agencies. Hitherto not having
T f?Ven
au*orit>’ ® unction the grants State Government
and then- officers have shown a certain measure of indifference
m keepmg in touch, helping and reporting on the voluntary
agencies that have been receiving grants-in aid from the Centre,
the Committee will venture to submit that it will help to create
greater enthusiasm and feeling of participation in State Govern
ments and thus help in bringing in much greater contribution of
voluntary agenaes in the programme if State Governments and
their officers are entrusted with the function" of selectin'- and
sanctioning grants to the voluntary agencies.
..
5’4. Thc Committee recommend that grants mav be sanclioned, both1 new grants and continuation grants, as follows.—
(i) Office"15 UPt° 5'00° by
(H)
District Family PIanning
Amounts exceeding Rs. 5,000 but not exceeding
Rs. 20,000 by the State Family Planning Officers:
(iii) Applications for amounts exceeding Rs. 20,000 should
be considered by a Grants Committee, consisting of the
Administrative Medical Officer of the State, the State
Family Planning Officer and the Regional Assis
tant Director General of Health Services. The recom
mendation of the Grants Committee should be sub
mitted to the State Governments. The State Govern
ments should have the authority to sanction grants-inaid upto and asiount of Rs. i lakh. Applications for
higher amounts should be forwarded to- the Commis
sioner, Family Planning, with the recommendation of
the State Government. Commissioner, Family Planning
should have Riii powers to sanction such grants.
Tr 5-5
The grants-in-aid
by the various
'
d should be sanctioned bv
authorities in accordance with the rules to be framed for this
rpurpose.
.
...
Tais
...................
will obvias the
’ necessity of consulting the Finance
Department in every case. These
I he sc rules should ninter alia bv lay down
ceilings tor the various sxms of expenditure, but the sanctioning
I
200
rent item Jpfo
t'“',i°8s “*“■ *' *'&*
fi-
t
S-er„^
II
garding
d apply
assessment of the work of
-”“XaSc£^t"t"E.}'tk
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I
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ft
I
3K«k
-------> achieved.
J
b' "‘T'J » tab
<» dte Sl^ve^^”':,0
!
Of expenditure incurred on account^pra^01150^^'1 statcmcnt
tary agencies. For this purpose
Volundown. .
•
purpose a proforma can be laid
esMsS^?--.
statement of
I upon in the
"ch cases the
C accou1nts audited by their own
auditors. The CommL^
depending
District Family Planning R„rJ 5’
work. These audito^n i u \°
appointed for each
this kind of audit
of grants-in-aid in the area
“ no delay in subSg^jXd^^0111115’ r*
get timely release of
? d.jd ^:cment of accounts to
to help encourage and mudTrh
objective should be
out of them tha? m Xj
t0
I
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I
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I
11
I
it
for
araXg K ^d
arc,
<° “"^= rerpon.
P2™"S Welfe Centres
lation, or to the extent rbs/tL rn’ 0110 ^?r every 5°,000 of popuCeaernment Sool?”
».
-he tote
finandal assistance iro„
c^nlr" ^l^“, “d, sh"ld 8«
pedyUnned,
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is pro-
quarters organisation which may be of th
Sh°U 3 be a head~
al
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201
5*11,
brough: to tne nonce of the Committee that
m several States the programme was not advancing under the
mP 0-yecs
Insurance Corporation as the Corporation have
not been able to set up Family Phmiing clinics under the scheme.
1 he Committee recommend that in such areas where the Em
ployees State Insurance Corporation has not set up family planning
clinics, industries and associations of industries who wish to take
up Family Planning work on the pattern of voluntary agencies,
should be encouraged to do so and should be given financial assis
tance as to a voluntary agency. This does not affect the Commiree s general recommendation that voluntary’ agencies of trade and
industry and labour should be encouraged to participate in the
programme to the maximum extent possible and should be riven
grants for this purpose.
&
5.12 As regards the pattern of financial assistance to volun
tary agencies for the I.U.GD. programme, the voluntary agencies
can be classified in two categories^ (i) those that receive separate
recurrnng and non-recurring grant for running Family Welfare
Tk nnJ,n£ Centres, and (if) those that do not receive such assistance.
The Committee recommend that voluntary agencies in the first
category should get Rs. 2 for each case of insertion and those in
the second category should get Rs. 5 per insertion. This will be
inclusive of the changes for drugs and dressings referred to in
paragraph 4.1. In additxja to this they should also get the charges
payable to the State Governments for the Dai or neighbour bring
ing the case, and for food, transport and incidental expenses payable
to the women receiving the insertion and the incentives recom
mended earlier for the doctor.
J
J
SECTION VI
TRAINING
i
6.1 In the Section cn Organisation” mention was made of
the added importance whxh training ot the personnel require for
developing that Family Planning Programme into a mass pro
gramme has acquired, and the big gap^that already exists in this
he:^. The Committee’s arention was drawn to the report of the
V/orkshop recently organised by ti
Centra! ~
Family Planning
Institute on the ‘’Training of Famfi v Planning Personnel”, The
Committee are in agreement with the vVork shop ’ s re co mme ndations. These recommends dons will take
_Lc care of the principal
C->
n
tmosr
* ? I
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il
202
requirements of the situation which could be summarised as
follows :—
sh
tri
ar
th
ur
(a) demarcate the respective spheres of work of the Central
and State training centres;
(b) take care of the much larger numbers of personnel of
various categories that will have to be trained now;
?u
(c) make the initial courses shorter and more job-oriented
job-oriented
and provide later for refresher courses, and lay down
revised and more precisely defined job description of
the various categories of personnel where necessary. Let
the requirements of the I.U.C.D. programme get due
emphasis in all training and orientation courses:
(d) provide training to the higher level personnel working
in supervisory positions in administration, planning
supervision, evaluation and in accounts and budgetting;
(e) provide for the orientation in family plannings
through symposia, seminars etc. for leaders of public
opinion and also for higher officers of the administration
who will have to play a supporting role in the imple- n
mentation of the programme;
(f) provide more extensively and systematically for educa
tion and training in Family Planning in all medical and
public health centres of all kinds and even in other
educational courses whenever possible; and
(§) provide for large scale training of private medical practitioners in I.U.C.D. method.
6.2 The Committee wish to emphasise that the scheme sc
formulated should be put into affect as soon as possible in order
that the big gap that exists at present in the field of training is
quickly filled up. The recommendations of the Workshop "are
appended to this report for facility of reference (Annexure F).
^•3 The State Governments should now quickly draw up
a detailed programme of training in accordance with the pattern
Wkj^ °Ut by
Workshop and implement it according to
schedule. It will be important to ensure that the plan for the deveopment of the training facilities of any State is synchronised with
that of the recruitment of the personnel of various categories that
a situation is not created in which the capacity of the training
centres set up is not fully utilised or is short of requirements.
l:I jnac
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203
j
6.4 The Committee recommend that the State Go\ernments
pould be allowed some flexibility in developing their scheme of
iaining centres and training courses organisation big deviations
jre made from the pattern formulated by the “workshop” and
lie total expenditure does not exceed the ceiling of expenditure
finder the Centre’s scheme the flexibility may be allowed in matters
tuch as the place where the various kinds of training will be given,
the staffing pattern of training centres, duration of courses etc.
6.5 The Committee also wish to emphasise the need for
federating the training a paramedical personnel, nurses, auxiliary
lurse-mid-wives, etc. required for the Family Planning Pro
gramme. The Committee were informed that in several areas of
he country it was difficult to get girls with the prescribed educaional qualifications for taking the A.N.M. training. The Comnittce recommend that where such was the case, suitable women
rom the local area should be recruited and oiven a short course of
raining to work as additional female workers. Later on these
ivomen could be given further training to make them fulfledged
LN.M. The programme of training of dais should also be taken
ip quickly.
J
6.6 A training reserve should be created for all cadres equal
rto 8 per cent of the cadre strength to ensure that the personnel
[would be released by the State Governments for undergoing the
training. This is essential to do otherwise either training capacity
twill be wasted or the field work will suffer.
I
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ANNEXURB C
State Family Planning nttreau (Staff Propoaed)
Joint DiancToa/DBruTV Dmieron
I
I
Existing Staff
Administration & Stores
Division
1. Dy. D.’reclor, F. P. &
M.C.
1
2. State Family Planning
Officer.
I
1
5. Steno-typist
I
6. Superintendent/Health
Clerk.
I
8. Lower Div. Clerks
Driver
.
.
3. Office Superintendent
4. Statistician 1 Statisticr 1
Asitt.
7. Assistant/Upper Division
Clerk.
1. Administrative
Officer
(FP) (Senior Deputy
Collector from F.C.S.
Cadre)
2. Store Officer
3. Health Educator
Operation Division
1
1. Asstt. Director of Health
Services (FP)
. 1
3
I
.
Education Information
Planning, Field Orcration,
Evaluation & Training
1
■■
4. Stenographer
1
5. Inspection
Stores.
2
Officers of
6. Upper Division Assis 3
tants (One for Stores).
I. H’Mth Education
Officer.
' I
2. Upper Div. Clerk .
3. Assistant Editor
I. Medical Officer Iiichnrac
(IUCD Programme.)
I
1
2. Statistician
1
1
3. Statiitic? 1 Assistant.
1
d
1
3
1
7. Senior Accountant
1
3
.
4. Artist-c«m-Photographcr
I
I
I
8. Accountants (one for
Stores.)
MM
2
3t Steno-typist
I
4. Upper Division Clerks
2
■
iiiiNi
•i
£
10. Cleaner •
H. Peon
•*
I
I
9. Lower Division Clerks •
3
10. Typists
3
II. Packers
2
12. Peons .
3
13. Drivers
2
14. Cleaners
2
15. Night Guard
I
-...
K>
O
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i
Annexure d
Existing pattern
I'
f
1. Distt. r...::,
;
Family Planning
Medical Officer.
1
2. Asstt. Surgeon
(Fomaic),
I1
Grade I
3. Asstt. Surgeon Grade I
(Male).
4. Distt.Extension Educators
(1 Male & 1 Female)
5. Statistical Asstt.
1
Froposed^revision
2
.
.
Education & Information
Division
I
I. Health
EJ
Education &
Information dfflcc
1
1. Statistical Investigator .
i
2. Upper Division Clerk .
I
2. Dhtt. Extension Educn- 2
for (IMale & IjFeniale)
2. Fnmlly
Planning Field
& Evaluation
Workers
(1 Malc&l Female)
2
1
I
3. Accountant
•
I
4. Asstt. Accountant
I
5. Cnshlcf
I
1
8. Clerk-cnw-typist
,
I
7. Lower Division clerkcum-Typisf.
2
9. Operation Theatre Attcndant.
1
8. Steno>typist
I
•
.
1
11. Driver-cam-Mechanic
1
9. Peons •
,
*
*
s
1
4. Projectionist
,
I
.
I
5. Ddver>t7/m-Mechnnlc
7. Upper Division Cierk-cx<mStorefceeper
.
3. Artist-cw/n-Photographer
.
2
6. Cleaner
1
Field Operation & Evaluation
Division
1. Administrative Officer
(Sub-Deputy Collector/Tchsildnr).
1
I
S33^*^**^*^^
District Family Planning Officer (Class
I-Officer)
6. Upper Division Clerk
(Stores).
10. Projectionist
V
|
Administrative Division
6. Operation Theatre Nurse .
i
District Famity Planning Bufean
I
£
1
i
MB
Mt-'
i'.;
82. Cleaner .
8 3. Family Planning FieldWorkers (i Male & j
Female).
1
2
STERILIZATION UNIT (MOBILE)
MOBILE IUCD UNIT
(One per District Bureau)
(One for 5 to 7’5 Lakhs population)
1. Assistant Surgeon Grade-]
I
2. Operation Theatre Nurse I
I
3. Opera don Thea tie Attendant
/1. Hi Iv.r-cn/H Mfcluiiilc
5. Cleaner ....
1
I
I
I
1. Asst I. Surgeon Grude-I (Preferably
Lady Doctor).
a
1
2. Auxiliary Nurse Midwife
1
3. Ailcndnnts(l Mn|< & | Fnnnk) .
2
4. Drlvcr-cviwpMcchanlo .
1
5. Cleaner
,
1
£
■
W-s
*
208
annexure e
'H
Rural Family Planning Organisation (La C. D. Block)
(See Paragraphs 2.20 an~ 2.22)
Existing Pattern
Proposed revision
Main Centres at the P.H.C-
Asstt. Surgeon Gr. (Women)
1
Main Centre at the P.H.Q.
♦Asst:. Surgeon Gr. I.
1
Extension Educator (F.P.) .
1
Compoicr
.
Extension Educator, F. P.
Computer
.
.
.
St ore-keeper-cam-Clerk-ctz/nAccountant
1
ANJ^L
1
.
♦ *Sub-centres (1 fori 0,000
population)
A.N.M.
Voluntary Worker to act as
female attendant .
Male F.P. Field Worker (FP
Health Asstt.)
to sub-centres
entering Malaria
Maintenance
Phase otherwise
two per Block.
1
1
9
1
Storekttper-cK/n-ck rk•i■cumzxccocntant
#
1
A.N.M.
1
Sub-centres (1
popuiatisd)
for 10,000
1
A.N.M.
1
Voluntary Worker
female attendant
1
♦♦♦Male FJ». Field Worker
.
(F.P. Health Assistant for two
sub-crnrres)
1
to
.
act as
♦♦♦♦Lady Health Visitor .
for 40,000
population
1
j
1
♦This Officer should be a lady and all attempts should be made to appomt
ladies. If lady medical officers are not available then male medical officers may be
appointed.
**3 of the sub-centres are according to original scheme of P,H Cs The addittonalsub-centres above 3 wdl be financed by Family pbnnins Pro^aZe
***In difficult terrain the population to be covered bv the Familv m
Health Assistant may be reduced to 15,000 or even 10,000.
****Provision for One Lady Health Visitor already exists in th.
pattern of P.HC., one additional Lady Health Visitor will therefore me^S
requirements of most of the P.H.Cs.
1
¥
h
I*
5t
annexure F
fono^gZndX^-^^5 °f Family
P^D“-C
^onne! came to the
1. Orientation
ai
powerful favourable public
• / Family Planning Institute should c—........ g this purpose
i_°Ie P^sibilitiw
sympoas/sem.nars for MPs, MLAs, and other5Xleaders'of
pubiTc of arrangrrg
.
opinion.
a
fl
■i
It
209
ss.'assisa sa £»
i.
On^tation for sub-divisional and block level
should be
arranged. These should be co-ordinated bv the regional officers
_cntral Family Planning Field Units may be involved in it. A.D.Gs. and rhe
I Strengthening of other courses
feSfUKva 5S
SSr.BWKi-SiWS, gy-g as?
otay be Standardized by All India Intotu^or HyX a^’miic
2.2 Other institutions giving similar public health courses mav
SalisSbyX^lMr^u:?^
Jdto^ ts^of S^eat,^imr^^tat!<x!2I!Attetnp«Iemade
pursue to^inauer f^rthe/0'1'’
CeoIral Fami)y Planning Institute sbeaid
tions'in
acquire the necessary con^cd^
able to
programme. THe Central Fanuly Planning Institum
dte
°f
explore ^ui^
* - ^t ^e
in
2.6 Family Planning instruction
so- th^g
that Fanuly pt^ng^rSe^
offered by universities so
tai make-up of the young people
take this r:‘L *.he
’ ” ■
UP with
Board.
3. Training of Technical PersooDd
3.1 General Consideration
Si?:=j=s?asas=SH
js^safSEssis
J Way
n
e ILCD --rogramme.
It is of paramount hnpSSS
3.2 Allocation of ResponsSfitie! and Mechanism of Training
Traini°g °f state ttaicmg centres should be trained at the Central
■^Principle?
°
r^euu. The following may be the gmemg
I
3.2.1.1 The duration should be 70 working days.
|
3.2.1.3 Three such courses should be offered during the year.
jin a^str^o^ ^Odld
35 a tem o£ ?n *« instructors. Insn-ton
4aace 7^-4^ J5
.f U
aspect—planning, supervision and raid-.
g
evaluation, and health education should form an intSd
prt or aiaaing wiin the active ^rtcipaiicn of NIHAE and CHEB
of 3?.ber °f aiJoess-,rafce« in «ch b^h or course should
I
I
■?x
-
210
3-2.15 The content of the course should be reviewed in the light of
curresit discussions.
l?.the^?0Te
trainin8 these nmers should famiiiaries themstaTO With the method ana content or tram-rg of DEPOs and DEFs at /h
ciaer Central Training Institutions.
~
ana
at ^e
Ksisna
trained at the AU India.
3-22L1 The duration should be 45 workiiir days.
3-22L2 Four courses should be offered dcring a year.
32123 A maximum of 30 candidates shonld be admitted to each course.
« ^wpSS. ShOUld include adm“'sh*^. planning, budgeting, financTrainin?1 °£,the DFPOs shou!d ^“dc orc
~... • If
one week in New Delhi
Central Family Planning Institute.-. .The
NIHAE , and other senior admi- s?
—
»BEsmeors in Delhi can assist in femphasising
—
’
the different
aspects of adminis- 11
tzzbcft.
&e ^Tof^se^nC^dSon^
I
**“ ’H’*'”' may ** modified “
3-“3 District extension educators should he trained at the Central Health
faHiaUoc Bureau, New
f016 “FamiIy Piinning Training and Research I:J' * Delhi,
w__’;■ __
Cesftre. Bombay, iand
..so.... and
u Family Planning I
the_ ~Institute
of Rural Health
mav be the
th. guxi^g
-------? ^uuing^ | .
GaDdmgram. The following may
princTpte.
duration |l
- 2-3 re- li
sa se&s&Ts m r-£se j“X,e^?S3T I
,
Candidates for training in the CHEB will be from Assam. Bihar^
PUtb- ^sthan/ut^Sad^k aorw^gal and i
P-3^ Kerala, Madras, M«Ore and Pon^chez^' GandhlEram- from
the
|
HeaTth Educat,ok Lurea^
>» done by
— —programme will be
and they will provide necessary assistance. 1?
I'
Ct^lmn
the 60"da«-^±^?"’ W11' ”<« and
joS kSatmns
the tr2,niaE °f d'Stt'
f
the common
based on their
if
f°r
d??ict "’^ion educators training pro-
I-'
3-2.4 The Central institutions will start their training programme as pcf
Kxednie below: —
EdUCatiOn ^-“-February and September 1
►
211
P,aBniD8’
3.2.-U .Ml India Institute of Hygiene & Public Health, Calcutta—Februarv
4ay, August and November (District Family Plannng Officers!.
ar
Central Family Planning Institute—Februarv. July and Octo»er (Trainers of training centres).
*
J
duration of training for each category ofi other workers aM die
enue of training should be as under : —
Block Mecicas Cfficer (MO. PAC)
Lady Assistant Surgeon
Block extension educator
Health Assistant
Lady Health Visitor
Comptor
Auxiliary Nurse midwife
Health Inspector •
.
Basie Health worker
Storekeeper-c^m-Clerk
One Week
’(excluding
IUCD and
sterilisation)
SFPTC
15 days
One month
One month
7 days
7 cays
7 days
4 days
3 days
3 days
SFPTC
Do.
Do.
SFETC/Dini.
District
Dist./PHC
Distt.jPHC
Distt./PHC
PHC
Training at the district and PHC levels is contingent upon facilities being
anie <e.g. 3a tninmcr
avaiable
training r*^li
cell in
in •>a district Family
a fcHow Vp
1110 :r3ining programme the various training mstiU^Dmg.may OrgiaiSe refresher COUIS» for personnel who have taken the imtial
3.3. Special Groups
practitio°cn
medicine who have facilities for insertSI :o^SDIXf?\n^ thVr Special 30011 oncnution training. Wherever possible
the iocal IMA and the Government agencies may provide the necessary trainings
„•
"Comi7,ssioner. Family Planning and the Central Family
mng
Institute
may take
steps to hem
like Railw^vc rv»f*»nr^ t .i... - __
Labour.
Voluntary
Organisations,
ex. agencies
i^nintthri
m^ucn of the Family Plannme Programm! with”"^
3.4. Refresher seminars
3.4.1 Orientation seminars for senior general and health
at the national and State levels sacuid be orZnised bv th. C^i ^ ^
Planning Institute. These may be held in
® torv
seminar catering to the needs of a smd group of States
country, each
3.4.2 The Central Family Plamrsng Institute should c
.0J8?nise ^hort seminars
;er speaal groups with a view to dtiussing administratio^^Pla^n^
’ , udaer.ns. and programme, planning and imDlemeatation
may
CB™TShIte- These
5
i
I
he!d in differeat
a
212
fte country. Teachers and research workers in these fields should be invited
these seminars. It was suggested that this seminar may follow the
israi.- planning workers’ conference that may be held annually in which the
efioers menuoned above will also participate.
3-4.4 In annual conference on family planning to be attended by workers
al levels may be organised by the Commissioner, Family Planning'.
I
4. A^iiniili ■tii e considerations
jI
4J There should be a training division in the family planning Commisarmers Office, adequate in size and capacity to undertake the responsibilities
mvxMved-
The Commissioner, Family Planning may assume the responsibility
Icr nupiementing and coordinating training from the operational point of view
armoioce the courses to the States, ensure that the trainees are deputed in
me « per capacity of the various institutions and evaluate the effectiveness
cr me training programme. Subsequent enquiries in regard to training mav co
Gsrc: to the institution concerned.
6
43
I
Commissioner, Family Planning may also provide staff and renecessary for each training centre to take up the new responsibility.
44 Certifi^tes may be awarded to the trainees on successful completion
g
cotyte by the training centre concerned, under the signature of the
teccr of the Institute and the Head of the Faculty. These certificates should
be recognised by the Govt, of India.
45 A report of each training course offered by the Central institution,
kxtck- be prepared within a month after' the end of- the course and circulated
u.e:aer training institutions. A form for uniform reporting will give all the
uE^ciation necessary for the purpose in view, should be designed by the CenFamily Planning Institute.
4x Faculries of each of the training centres may meet at least once a
par a: the different training institutions. This will give a scope for visiting
tn-^rr w discuss the training programmes with the staff the host institute and
z*ar held training areas so as to review and modify the training prorrEzm and bring uniformity and standardisation in the total curriculum.
22
T1* -srouP
ft11. strongly that training cells should be established
district and should include one health educator and one public health
I ms would be in addition to a training centre for every 10 million
“ost states, the field units are doing good work. Iu
In some Siates
States
SOi^L°Ot
uscful they could be made more useful.
u°’}s “ould be continued, and wherever necessary they should be
^ZEmened. If any State needs one more unit, this should be provided These
S?? 3ZSld ** “?? USCfu
trainin? of family planning workers at the
^osre the state training organisation is not yet strong enough to
- td®? ofJuch training. These few units can also be very useti- J-J’vmg orientation training to various lay groups. They could also take
i maSS c®mmum^tion and evaluation of specific programmes,
difV? ,CILd * ha-nd ln
service programme. What
U? ♦
Play should be determined by the State authorities
StJS® UJ Jai°mS Programme of State- The units should work
J?1® State D-H-S. and be administratively controlled by
<h= S^e- Authorities although they will continue to be treated as Central units
purposes. In this manner it would be ensured that these field
rmzi work m unison with the State policies^
If
I|
I
.t0. exaniine the extent to which existing rural health
C?TS-ra J .frain1?? centres administered by the development departbe utilised in training family planning personnel.
Ifl-
I
11
i
II
I
fl
Jhi
M
!
Cor-{riittc.E
-H7L/
s
I®f 4
I'wlVi.
I Sw’
f' V
■ •
rr-;
KpMPENDaUM
cfr
L
r'-V’-'--'
■
' ■ :''
.
RECOMMENDATIONS
jiOF';c
■
WAHiOUS COMMITTEES
i
‘ONEALTH DEVELOPMENT
I" 1943-1975
i?-'
;
I
I
;
■
<
p' - •
■
■i
!|^N1?AL -BUREAU Or HEALTH INTELLIGENCE
[^WECTOFATE GENERAL of, health services
“MINISTRY OF HEALTH AND FAMILY PLANNING
? GOVERNMENT OF INDIA
"NlftHAN BHAVAN
NEW DbLHI.-HO 011
. ».J
'■■
•
......- M.
POlZ T^)
u i ’i 0 I
-
I
cELL
CALL NO. tO..}?.'0*0
AUTHOR . ....S.P5 V-A
rx
JI ”Q'
nTLE .
Borrowed
__Qn
fV'2) 5^
............ ACCN.NO
Borrower's Name
Returned
On _
Ob
Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
I
-
i
IV—REPORT OF THE COMMITTEE
ON MULTIPURPOSE WORKERS
UNDER HEALTH & FAMILY
PLANNING PROGRAMME—1974
(KARTAR SINGH COMMITTEE)
I
.213
I
t
i
IK
1
.
- . ......
i
|
I
f
F
OF THE COMMITTEE on multi“ PLANSPROgKmmTIW4&
■,1,
INTRODUCnCN
“un^J
Emme^11^
KvorkSs of TheT 1S htdeOr n° coordination between the ffi
En^ofT^
f-ctionanS
separate and independent functionaril
„ llx
Primary Health Centre forms the
> working
at the pnmaty health atntre, had stp„lalv 5Fhacs orseparate
spheres
of
activities,
one
tionkhasS b°r famiIyP
lannln
g and
F„
ullulg
ana 'the
lthe other
other for
for health
health. "
This sitnaHaTioST^h3t
by Gov™'nt of India
letter No. 23-10/69-Ply,
dated
5-7-7
x
and
23'IO_ I/— 6t_9--1ply>c dated
5-7-71
and now in most places the
£WO 1
f
•« *
b'“<h"s”'a
Igramme in the area covered
each
i ‘pnS
®
eo-eSd
'r PHC
™c,b!^7j
liX^theTat^'pHC
h”^by“
tO hut in
■he PHC h^XC'7„“.™°"i”g “
limited No. of patients admitted in'“the” PHC.
fee District and State headquarter levels too there i
Ifor
ZS
£Or family
lamilv planni'ni;p^k
Diannincr nnkb'/- hSth ScJmtiv
__ 1 ...
• ”Sth
t
lent m\’2 In,West B^gal, toe PHC complex developed in a differ
111 Ind^one^1 Tho ^h
SraduaUy Ranged to the
fetoTT”0’
I
j
{
I
II
s^t“££L"s,
I
fferarion^ors-aff^it
0 h”
ha5 resulted in proiiLnoz
°F Siaii’ Jt “s a!so P^ed some results. For examole
|59/O x me country JS now m Malaria maintenance phase whi£ a
1
II
215
J
■I
l!
216
few years ago malaria claimed millions ci lives in this country
B
Ti „
W
' been XX
is tme the process
-aJXSallSl
base not
eradicated, k
nevertheless,
^as bX en I
things nf rh-
conimmic^ble diseases would bel
' c-
Sample Registratioa| j
- - -I*
the efforts of the stag I. -
g
A^litodly there has been success; although of varyin®
a
-111 X
is, hoover, disquieteni^
to note jf
agrowang danand for increase of staff under each pr^ramme.
----•
j
4
0
—»» ■
The justification offered for this demand is f
'
'°
the need to reduce populanon/area covered by each worker.
’ -
monJ111' dcman^ heh1? iogical, a question is however, raised in
coordinSX Whetfacr the same objective cannot be achieved by j K
coordmatmg these programmes
and r
pooling
the personnel - ™ !
J
------ & —f^uvrxxuj. Could Iz
no. such an integration reduc.
;.L
C
pupulauon/arra
reduce ifhc population/area of each worker I
V't1 > o 11
---- — . _
tims making his coverage Osmaller
and consequently
i__ _
r more
enectivo ? K
J
Allowing recommendation
made
------j at the I?
first meeting of the Executive Committee of the
Central
Family fc
Planning Council held on 20th September, 1972.
■
I
S?S
bT,tak'n for the integration of medical public l|
Dcalth and family planning services at Ithe peripheral level 'Ii
raoaZ“.S^”“
“P “
“j
and I
IUVing rnulti'PurPosc^hi-purpose workers in II
® 2'd!±?',£"
supervisory levels; KSnttd ”"** ” *
(ll) JS'fiel?
Jij-
LL
(in) training requirements for such workers; and
(iv) utilization of mobile service units set up under family I
p arming for integrated medical, public health and family |
ptanmng services operating from tehsil level”.
*’
foUoXXlnberSllI? °f the CommittK recommended
was
r
asjl
iSSSS*
• c“"“
3. Health Secretary, Uitar Pradesh.
< Health Secretary, Tanjil Nadu.
3. Health Secretary, Maharashtra.
6. Deputy Commission (Pg Department of Family Planning .
I
•I
K
1 ;i
Member
Secretary
K .
ii
f1
W
MW
■t
ai
M
tel
I
■■ ?,
t
1
s
217
t
iS
It rurther recommended, that the Committee may visit some
1
3 States to study the actual wording at the district and peripheral level
and should submit its report within 4 months.
$
The terms of reference of the Committee were to study and
make recommendations on :
(i) The
for integrated sendees at the peripheral
U;
1 he structure ror
and supendson levels.
(ii) The feasibility of having multi-purpose/bi-purpose
workers in the field.
.
(iii) The training requirements for such workers.
(iv) ^he utilisation of mobile sendee units set up under family
planning programme for integrated medical, public
health and family planning sendees operating from
tehsil/taluq level.”
n
The Committee was asked to visit some
some States
States to
to study
study the
the
actual working at the district and peripheral levels, and to furnish
its
its report by the end of February, 1973.
1.6 Two further modifications of this order were issued.
The first was dated 30th of November, 1972 in which the member
ship was increased by the addition of Chief (Health) Planning
Commmission, Director. NIHAE, Director, Health Services,
Haryana, and Director, Health Services, Gujarat. The DirectorGeneral of Health Sendees was made Vice-Chairman of the Com
mittee. The second modification was dated 23rd February, 1973
in which Deputy Commissioner (T & R) was made the MemberSecretary of the Committee in place of Deputy Commissioner (P).
The date of submission of the report was first extended to 30th
April, 197j then to r^th August, 1973 and subsequently to 15th
September, 1973
Government of India order dated the 22nd
May, 1973 and of 25th August, 1973.
1.7 The Planning Commission is also seized of the problem
and in the Report of the Steering Group on Health,' Family
Planning and Nutrition plans for Fifth Five Year Plan, the follow
ing observations were made :—
I
5
I
T-37 Integration of Health, Family Planning & Nutrition.
i rogrammes under Health, Family Planning and Nutrition have
been in operation for a le^g time. These programmes are mostly
vertically conceived and are being implemented at the field level
by thstaff deployed implement these programmes individually,
with little co-ordination or integration of the sendees. The Steer
ing Group feeis that the proper mregration of Health. Family
Planning and Nutrition ^grammes is highly desirable as it would
be more economical and ezeenve. It may be appreciated that the
i-
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!
w
218
lor,'
£>ra*S tf’^ferefe
arrnnj out integrated funmons and
? ^gnaKd faith ami.
“t ',"trU!red "«> the
K
11
l-pt’
tio
ftp
Heal th auxiliaries may'consist of thra (^riW°U.d
&at
orker at the lowest level. Health Visitor
Tk i’^’ BaS’C HeaJti
mediarv level and H—Irk a
^Health Inspector at inter
Ae higher M
« ^perrisor,
i&s
«’* to amvbtg at an eSecdw pattern of i?
U
that>
from operational and training an<dc
^gr,at,on of
services
Igei
Perts oe appointed immediate^
’ ° ^king Groups of ex0) defining functional role of the^fST
of :
1|dj
health programmes, conditions of servdcJ\,jUX,llary !n ,n«grated
for promotion, etc. and fii'l defin’
strucure' avenues
grammes, construction"of
°f lining pro.
skills required to achieve the obiectri^idS Of knowIedge “d
l^ir
toons, etc., and give the
’ ^-'^Alng training instituJr •
IP
This should be done exoeditSTs a^'S^' "
shaPe'
In regard to nutrition schemes th. an.adrjnce action m 1973-74.
rnent of Community Develonment^M’1*^ ^ajned
DepartDepartment of Social Welfare V ’ MlnisST of Agriculture and
Welfare, should not k
Ed,ication ^ Social. ■ i«
-Family Planmng and Nutrition
f“tegration of Health,
fol
programmes tailored to local needs shn3!/^ ckarts and training
sonnel of Departments o HeaSi Fatil
for the
Commum-n- Development and
7
SoC,al Welf^
I
31
grammes. Nutrition feedin "nma?
ln nutrition
|i)<
with other Health and Welfare pro^m'
^c’0 t0 intcSrated
Package which will include ap^re filmTJ t0
3 comP™te
care, immunisation and improremem? fCCd?1S’ miIumum health
I’-'
Integration of personnel from nutrition CDVlrDnmental sanitation,
viewed from this angle.
°n Pro^m™ will have to be
If
ft
t
lifl
h:
It
I
Iw
Station
HwkLjSfy pZn^an^M imP°rtance t0 the intesuggests that funds should “ nS-J^^0^™311111105 and
Snmg
paT d^
^ ^X^an £
health -workers; and (ii) oSerwork^” “ H multJPurP03£ basic
tion feeding and nutrition edS^ Cngagcd in nutri'
take up the integration work
pr°gramn<:s ^d who would
(i> intcSrahon of
building OoTS^iw
grabon of personnel.
g
r
IH
F.
J of
ide
Jpi
lor
1 sn
ftp1
j1V;
S'Jxn
equipments, and (hi)
I
219
1.40 Since the Health. Family Planning and Nutrition pn>
Jtammes are proposed to be delivered through health auxiliaries and
- her workers based at primart health centres and su^centrc. the
nnldmgs will serve a common purpose. Under the existing patseparate family p anning unit buildings have
;t all the primary health centres and approximately ^0% of the
^-centres m each block. Under an integrated arrangement, it
s not necessary to have separate buildings or separate fading for
k.Ir 1S> therefore suggested that the buildings for theinteated services should be funded from a single source and separate
' lays for buddings under various programmes are net to becalld tor Funds to be provided under health and faimlv planning
ector
^or for buddings of primary health centres and sub-centresIhotdd
rdinanly be pooied. together
and used for making
defi
icncies in the cxi.ning
c*’“'~ 5lbuilding
._:i j- component and. for the expansion
f the services. The tentative outlay for buildings in
it ic
is understood,
Rs. j.too
60
crores
k* it
J D___ cror"es“(Rs7
zt*
z® ^dS^nZS
I
aum health programmes and Rs. 40 crores
Hanning programmes).
under
me
famdv
J
1.41 Drugs and Equipment.—The drugs and equipment
omponent will be common to all the three services and hence
hould not be earmarked separately to all the three sen-ces for the
mansion programme or taking up special programmes under any
f the heads. It should be a charge to Central funds to ensure
roper implementation of the integrated programmes.
On the
nes suggested for buddings, the merging of funds under drugs
nd equipment for all the three services should be earned out add
o distinction made at the time of procurement and supplies.
1.8 Programme of the Committee
1. The Committee held it is first meeting at Delhi on 15th
larch, 1975.
I
It was decided to co-opt Dr. P. Dinesh, Commissioner. Rural
ieaith, as a Member of the Committee.
At this meeting, it was unanimously agreed that the concept
t the mum-purpose workers at the periphery was both feasible and
esirable. It was left for further discussion whether such multiurpose workers could be introduced throughout the coantrv or
nw in those areas where malaria was in maintenance -base'and
nu.lpox was under control. Some members felt that' :f multiurpose workers were put into operation in areas where -naferia.
as in attach or consolidation phase, it would be difficult to control
I
It was decided that the Committee would obtain more infortation by paying visits to some of the States, talking to the
-. ...
’
J
220
nite coniSrJtXof
C°ming t0 defi'
2- The Committee paid three field visits :
A.
B.
C.
Pradesh
Harvana and
22nd April, 1973.
on 20th to
To Mysore and Tamil Nadu on 21st to
24th June, 1973.
To Bihar, West Bengal and Orissa on
19th to 22nd July,,
I97J-
J
On each visit, the members visited
nndasub^entreme-k
eT„!m ?.VlS1Kd ~a Primary aunui
health centre
centre >7
- —
each btate and interriewed various field workers >
milV
TT_ l.f
a
•
“
TT 1
W-'
—, -------------, Basic Health |
etc The supervisory staff like LHV, Sanitary I
Inspector, Vaccinatioj
>n nspector, Health Inspector were also inter- *
^ewed. While on visit to Mysore & Tamil Nadu, the Committee
^50 met the field workers and Senior Health administrators of
Kerala. Opinions were
r
....
1
• a11A1, m
—— ———
before the Committee,
Sh
Comrmttee. The doctors working in the primary
health c—‘
_____ ;
’
,,TL3 so Sucstl0ned about their views on having
multi-purpose workers
th-’----PHC _
” •n
was made to assess the attitude
off
PHC doctors
vis-a-vts their role as leaders of the health team
in the entire area
of the VlllpCTr* f“-
D»™s,o« were held With the State Heja auXridXd I
their views
were also
the' “n=l>' °f' tnulti-purpose
"
LT'
’Ssought
°US5' about
abo"' th
”dJ±£.?
bkS •
h™ » t* otereoXX
workers ar
-'
I
I
\Jk. MJ3-
I
—------ --- —
cussing the subject with some c
’ State ”Health
” ■ * ■Ministers.
off *the
|
. 1.9 During the •/
vc^
‘ir first visit, 1itl. Was dccided that the Comnurtee should confine itself
1
to the question of multipurpose workers
for the rural areas only,
nn 7.
This was done for the following
reasons :—
I
I
I
(i) The main area of
1 ' operation for the multi-purpose workers
I
j
,
.
•
- —
in ihe^uraHertors
sectors11*
*AXLXAUI"L
ro"rammes was
’ ‘plamlinS
wP
programmes
was
I
I'
I
(u) There was a fair degree of uniformity
u
of the staffing
(IU)
o^er1.Lal,d’
muI"Pk authorities in the ,i
sfcr
^TpaI““’ '"“sc i“p‘iais"'<im'dieai 1Jf
plau^g'p’;™^”
■
I•
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li
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221
For these reasons workers engaged in health and fami’v
planning programmes in urban areas have been excluded for the
purpese of this Committee’s report
3. The last meeting of the Committee was held on 2-th &
28th August, 1973
Delhi where the draft report was discussed
and finalised.
r.io Acknowledgement:
i
ine Committee wishes to acknowledge its gratitude to the
Sta^ Health Authorities of Punjab, Haryana, Himachal Pradesh,
Mysore, Tamil Nadu, Bihar, West Bengal and Orissa, for the
courtesy extended to its members during their visits to the respectiveStates. The Committee wishes to express its sincere thanks for ail
these States did to make the field visits really fruitfuL
The Committee is also grateful to the officers of the Ministry
of Health & Family Planning and the DGHS for their valuable
help.^ The Committee wishes to express its sincere thanks to its
Member-Secretary, Dr. D. N. Gupta, who prepared the draft of this
report- Thanks arc also due to Dr. B. N. Halder, Assistant Commissicaer (FP), for assisting the Committee.
1
EXISTING FACILITIES
i. Staff
3-i Nomenclature
Li general, there exists a certain degree of uniformity in the*
staffing pattern at the primary health centre level in different States.
Minor modifications, however, are in evidence in some Stans & the
gaps between the sanctioned staff and the staff positioned in differ,
ent Stares widely vary. Whereas some States have recruited almost
the emrre sanctioned staff, there are others in which there are wide
disparmes. This is narticularly so in the case of categories like*
ANMs and LHVs. ‘
L
1
r
5
Awarding to the figures available, there are 5197 PHCs func
tioning it present in the country catering to the rural popdaricn off
435-S million (I97I C-nsus). In general, a PHCf caters to a
population of 80,000 to 1.50,000 or even more. However, in cer
tain ,parts like the tribal, hilly, and desert areas, a PHC covers a
much smaller population. The area covered by a PHC also varies.
Usually, ffiere are six to right sub-centres in a PHC, each sub-centre
222
S'™ h'°PH,?l’“la“” «f ■« 10 I '
PHC»s»^)' as J5 thousand.
The staff sanctioned
t Doctors
2
Block Extension EducaIor
3. Fami]yPlannin8He2l(hAssista’nIs ’
'
’
4. Vaccianators .
”«««««*»<*•
7- ANMs .
’ 2
8- Lady Health Visitors
.
9- Sanitary Inspector
’
’
• 10
■
• 2
*i’th different dcsiaI nrrv/i**.-__
> oeruor
'°i’ ’“>»»«« and
l
JMeren,” ,”“^2
Ji.sK.ncal ras„m and Ac p“S„
V'
ab°"t '’“«■>« of
staff recruited.
P
i°n of promotional avenues to the
is
a""8 SHff Positi'>” as supplied bv the
* 'cn in Annexure V.
different States
2-2. Job responsibilities
Wines of different WrionlX^A6/ ^H11315 °l
given ln Annexure VI.
’
’°b resP°nsi-
A few rc
ptesentative sampl
sample are
representative
2-3- Educational qualifications
git functionaries in
Generally-the old entrants were non m
fiavebee "
training
• incr
Matriculates whoS .
■»S T variaUe
<?Ualifications °f diffcrWithin
State,
WCrC recruit'
SU,bsctiuc« recruits
2-4- Pay scales
different States
W^C var^atlons in the pav scale
=*
Yr^adu s pay scale is R}
* •
I7O.22_ y|nlnMthe
of ANMs, Tamil
1J
w
I--t
i
I
1
rf
r
&S?
i
i
I
i
I
223
-2-5- Training facilities
well organised m es^lhhed
country. These centres are beinp-%n
sPrea^ aU over the
a^ce- The training facilities unde- Heqlrh^ 100 % Central assistable in the State run Sanitary
i
4
“s”“d
25.1 Under Family Planning Programme
T
•
-___
(a) fCentral Institutes
(Five)
fOI
l'
New Delhi,
of India). This Insrihit
Wanning, Government
the trainers. An AXTaleT^ Progr“
pared by the Insritufc^d 5
k°f activities is P«preof Family Planning.
PProved by the Department
2. Central Hatidi Education Bureau, NeW Delhi
*= control .* DireTOr.Cram| Of Hwltl:
UT
family pfan””g7mSX".i”SFr£‘ES fOr b°,i “h ”<<
the Department of Famly Planning rr
’c
aid from
Programme, the training programmes a^e for^ t 301,17 Plannin?
runs a Diploma Course m Health EdJXn
Ien' Ic 3150
verSIty of Delhi. It plates an ArS c 'TT*5^ by fhe Uniwhich is approved by the Director O ' ?3
°f lts activ’t’es
Education, Public Health and Nutri^
“ HeaIth
4'
of India).
■
'
‘
It conducts courses for the train'-’tr
PIamung like District Er-nsinn Frin^g
rf
Ba.
y Planning, Government
■
n
ners m family
™2
224
5. Gandhigram Institute of Rural Health & Family Planning
(run by a voluntary agency and aided by the Department
of Family Planning).
This Institute runs training courses for trainers like District
^Extension Educators and has conducted long courses for Block Ex
tension Educators. This Institute also gives a Diploma in Health
Ed ucabon.
(£)
Regional Family Planning Training Centres.
■ I at
Id
I
:h
i u
I
i
i;
£
These centres provide orientation and ^hort-term training to
PHC doctors. Block. Extension Educators, ANMs, FPHAs and to
other personnel engaged in family planning programmes. 46 such
centres have been sanctioned and 44 are in existence in different
parts of the country. Each has a stac of 26, consisting of 1 Princi
pal, 1 Medical Lecturer-cum-Demonstrator, 1 Health Education In
structor, 1 Social Science Instructor, 1 Statistician, 1 P.H. Nurse
Instructor, and 4 Health Education Extension OfScers plus a Pro
jectionist, a Draughtsman and some office staff.
(c)
0
I
2
1
f
16 Family Planning Field Units.
These are peripatetic training teams which provide on-the-job
orientation training in family planning to ANMs, Family Planning
Health Assistants, school teachers and others engaged in family
planning programmes. Each has the following staff :
Family Ptinning Officer
1
Assn. Surgeon
I
Health Educator, Gazetted
•
I
1
Junior Health Educator
1
Social Workers
1
Projecrionrst................................................................
Mechanic
'I
*
1
1
Driver
Urper Division Clerk
1
5I
Lower Division Clerk
1
1
Peon
Sweeper (Part-time)
A
......
1
2.5.2 Under Health
1. Sanitary Inspector Training Centres.—There are about 40
Sanitarv Inspector Training centres run mostly by State Govern
ments and a few bv private agencies. The duration of the course
used to varv from 5 months to 1 year, but has since been fixed at
one vear by the Government of India.
I
[
I
fl
5
■
L
I
v.
I
g•
6
I
I
JI
I
Iia
i
*
225
3
J
Rural Training Centres.—One at Najafgarh and the other
gat Singur under Government of India and sixteen others under
| dinerent States.
3*
mentioned above, advantage is also taken of disrrrr
| hospitals and medical college hospitals for providing short-term train
ing to health workers like Vaccinators, Malaria workers, etc.
1
■
2.5 3 ANMs and LHVs receive pre-service training in recog
nized ANM and LHV schools. There arc 320 ANM Shook and
23 LHV schools in different parts of the country.
(a) Majority of ANM schools (223) are run by State Govern
ments and of these 60 are Centrally aided by Department
of Family Planning.
The remaining 97 are run by
voluntary agencies and 62 of these are aided by the De
partment of Family Planning. Though rhe admission
capacity’of all these schools is 8169 per yean vet for
want of adequate hostel facilities the number admitted
each year is lower, viz., about 6500. The course is of
two years duradoa and the minimum educational quali
fications for entry is VII class pass. Of late, a large num
ber of girls who have passed Matriculation have been
coming up for admission.
(b) Lady Health Visitors’ Course is of 2^ years duration
and Matriculation is the minimum educational qualifica
tion for admission. The annual in-take of all the schools
is 1043, but the number admitted each year is about Soo
only.
(c) Public Health Nursing : Facilities
Facilities for
this course are
for this
available at Nursing Colleges and at some of the NursmoSchools.
2.6 Mobile Units
i
I
■1
i
I
I•;
I
$
!
j
Mobile Sterilisation Urits
have beenininposition
position since
sinceAugust.
August,
---------------1964. In 1966 the Mukherjee Committee recommended
_2_2 the
„ inin
troduction of
IUD
------ U units 1to provide a greater coverage for this programme. ‘The Committee, after
after weighing
.k. ___
the pros and
attachingxIUD
units either
eitherDx P.H.C.
P.H.C. or toto District
JD units
District Bureau,
Bureau,vwas in
kvom of the latter alternative. It also recommended that th,te staff
of Primary Health Centre ^ill be interchangeable with the stai of
The Government accepted the reco^nSdo^
the mobile units.
of this Committee. and sectioned establishment
of one mobile
----- ----- wZ
sterilisation unit and one mcoile IUD unit
for
a
population
of 5 to
-------- .• a populatzon ot
7.5 lakhs in each district. 5—”1 order to ~-p*
•make the visits of these iinirg
more profitable for rural areas, it was decided in SSeptember.
’
1967
that each of the units wil] carry general medicine
__ for
—: emerge nev
medical relief.
226
Since the performance under IUD
h
* to
£?J' "“s —
bfc
“ achieve target s- Wtdl “d th^
would provide all die
I
I
M 17’ ” w“ d«ikl-
?U’l,I!l6’ktl“'“ ad<il'ti'>" » AeniSr
‘ggr ih°“M “
i
I
i'“ F*™?y. wr
° t.- dC- ?
therefore.
snch mobile service units as were n\r kt
5-e se^ce facilities
Tr?5.month was on
“ Oct°her 1971 that
°P^ use and
4% roSSiXSgd »^SS
f
fl
F1'
r 399h s'^-
I
I
Ld^Xi"5 °f M'di“' Officer I
r
^foe.BSaff,«MyAssi,Mt“d«a^ Each IUD mit
2
'
h
S
k
r
a
o
FINDINGS of THE COSBnTTEE
3.1 Background
.
hcalth
present staff of
the health and family planning „ CS Cannot adequately deal
^volved
The popuUnS
P°Pda^^tely covered and freauenrfv --^A Worker ls too large
- _ - f nas a population of to to re th
u^ted. For example, an
“ to Ptpvide maternity- services a Io™
:n which shc « ^pectchild health care and also do fJLX j^l113331 311 d post-natal
h°Plkanjn 11137 be concentrat™in a
pension work.
h^q-rters or scattered m-er
3
rades radius or even more. The
J ger
of to to i,
P«taon is c^h
£“hf=
our ffic. ffie prople a„
I
G
I a
I 3J
I P
I
p
lI; •CC
I,e
Iw
IIPtr;1
1ST]
commmity lcaj
'F
i pr1
F
I 38C1~
li
1?
I
i
UJLU ii [■iiiii
mi mi
I
I
I
Wth vorkX?
^P^^.and family planning
ad to^ehe^^
Sco^S
fews md^Aer adX7dk'l*aX'ib£ “a”*”"1 ‘l’“'
Um al„
in^ed if Act
Imcntary treatment for minor ailments.
I
From time to time, stumes have been undertaken to ascertain
if bv increasmg the number of health family planning ToTeS
AN.M ln one block and io,oco in the otf^r.
F F
P
.
Limited experiments on similar lines for male workers have
■ also been tried in aMaharashtra.
[having a basic health worker for all hlltb
[recently this experiment has been introduced^inJ-
hlso by
in^J
°£
Ad "S,X ISSttl
lof each of Ac 52 sectors io Ac district. This inteoratctl d ■°ri
| covers ,% of Ae rrrral and ecban oCCTArrioo “f SScf ■'
pS^°fh * orulti.
I the Committee, similar fear< -arte csn-rs^H b
^SKS of
| Health authorities To-dtte ZLfS
°f
State
I conducted bv NIHAE fa W^q/“Pental study
jec.) A Kiioi bloch of Roh« As^SS^'Sl^ '’f
hvorkers engaged under
stuSpoz™ S
I programme have been grouped togeth^given a sh^
I training of one week and put riro the field as r 1 ■ ‘
* 'nentation
worxers.
This project has been in ^Deration formuld-purpose
j— ‘
7 iust
over a year.
Tne performance of workers -^various health
& famil
.
---planningprogrammes prior to the intrrduction i '
ot
multi
-purpose
’
scheme vis-a-vis their performame as mum-purpose‘ work^rsworkers
’i
.
------is
givea
[18—88 CBHI/ND/84
r
I
I
I
*
I
;■
ir
228
-I'
in Annexurc VIiI. It shows that there is a definite improvement ,
m the makna progmmme (both active surveillance and passive
surveillance) by way of increased number of slides collected and the
number of positive cases detected; increased number of both primary
vaccinations and revaccinations and in the family planning pr(^ '
gramme. The results so far obtained are extremely encouraging. ’
3-3 The Maharashtra Government has also instituted a pro
ject similar to the NIHAE Project at Mrraj Medical Centre. In
this project they intend giving intensive training of about io weeks
to the future multi-purpose workers. ‘Their supervisors will go
through the same programme plus two weeks more for supervisory
dupes. It is proposed that the ANMs should also undergo a short
training to acquaint themselves with the activities of the multipurpose workers. The sponsoring instimte of this project is the
Miraj Medical Centre.
’
i
|
1
1
I
1
1
J
3.4 Findings
fl
3.4.1 Feasibility
fl
In the light of experience obtained in the various studies and
consequent upon the discussions with the State Health authorities
and District Medical Officers of Health; the views expressed by the
peripheral workers themselves and the reactions of the communityt
the members of the Committee felt convinced that the concept of
having multi-purpose workers was both desirable and feasible. The
field workers were quite enthusiastic about this concept and they felt
that it would enhance their acceptance and effectiveness. The Committee felt that the results of the Kiloi project have been sufficiently
encouraging to dispel any apprehensions in this matter.
3.4.2 Number of workers involved
fl
fl
fl
fl
I
I
1
1
I
«
fl
The number of male workers engaged in malaria, smallpox ■
and trachoma and family planning programmes is sufficiently large I
and after integration each male worker will have 6 to 7 thousand 1
population to cater to. The position regarding the ANMs is, how- ■
ever, not satisfactory. Their number is onlv about half that ’of the fl
male workers. It was ascertained from some of the male workers fl
engaged in malaria, smallpox and familv planning programmes, .fl
that it would not be possible for them to undertake maternity’ work fl
nor would they be acceptable to the community in this role On fl
the other hand some of the ANMs felt confident that they could do fl
malaria and smallpox work in addition to their own.
S
3.4.3 Phasing
fl
On the question of phasing of the programme, some mem- fl
hers of the Committee felt that multi-purpose workers should be fl
*
i
229
introduced only in those areas where malaria was in the rn^intenance phase and smallpox has been controlled. Others were of the
opinion that the programme could be introduced all over, irrrsocctive of the stage of control of these diseases. After mature consi
deration. the Committee feels that since the number of workers to
be trained is so very large, a practical way out would be as
follows :—
To begin with, the training of the workers as multi-purpose
functionaries could be started in those areas where smallpox is con
trolled and malaria is in the maintenance phase. Since such areas
constitute 59'z3 of the country, the number of workers to be trained,
though still large, would be more manageable. After a few years
when these workers have been trained and, other areas have been
brought into maintenance phase, the programme could be extended
to cover the entire country.
It was felt that to start with, workers of onlv four
programmes i.e., malaria, smallpox, trachoma and ' family
planning including M.C.H. be included in the multipuipose concept. Since filaria, cholera and leprosy are of
regional or zonal importance and since the number of
workers engaged under these programmes is comparativelv email,
these programmes may continue to run as vertical programmes for
the time being and the workers in these programmes could condnue
as um-purpose workers. Trachoma is also zonal in distribution,
but since ±e number of workers involved in this programme is
small and their job is very specific, it was decided that these workers
may be included from the start. It was also felt that the same
applied zo B.C.G. workers. This, however, should only be a tem
porary phase and eventually, the Committee felt that ail the workers
should be brought under this programme.
I
3-4-4 Supervisors
Time and again it was brought home to the Committee that
lack of proper supervision was an important factor in the unsatisfactory functioning of the peripheral workers. The Committee,
therefore, is strongly of the opinion that equal attention needs to be
paid both to the muli-purpose workers and their supervisors.
I
It was felt that in an ideal situation, there should be one female
worker (ANXf) for a population of 3000 to 3500 or in an area
of not more than 5 kilometres radius from her place of work. A
male worker could also eriectively cater to the same population.
Taking into consideration the number of available workers both
male and female, it was fdt that a male worker according to the
existing number would have to cover a population of 6 to 7 thous
and. although this coverage will not -be totally effective. An
230-
ANM on the other hand will have to wort fOr a
.
*>°ut to to 15 thousand. Till SUeh
J
population of
on be increased, it was considered! tha^X^ X
°f ANM*
may be divided into two zones an
P0?11131101110r an ANftf
j
3
-itta
a radios
3 “ 4 1>»«of Cha ceaaabaU iT TV W‘‘,gh''
should be fully rcsponifleTS MCH
“TT ““ sk
VC.-O -Mein ,1,0 ‘Slight' zone he,“ T>'
«on request.
&
C semce would be available only
I
I
I
3-4-5 New designations
™ £xs.of
the multi-purpose workers
new nomenclature
new job responThe consensus
new
j
j
j
j
|
(u21^“md ’’E?
s"p'™s»rs "e
'
nd Hcallh Supervisor (female)
j
there will have to be a senaraM
1 uPcrvislon> it was felt that
nave to be a separate male and a separate female super-
|
I
°™' !
4=..X..o"T
Hillh Supervisor
respectively.
be increased.
It is felt char for □
’
should
°f °ne
junior
a PHC for 50,000 4^
two doctors, on. of LPm tho“d 1,“!. ™. W°"ld
(a)
(b) commuUm^enhTal±OUworktt. 3
of I
^°’
I
I
I
-5 I
I
eff^veness I
. 3-5^2J acceptabiliX XTc"^
sue, enhanced
(^eandle^sXuM^XX^^P^ I
worker I
memcmes for minor ailments costing up to
X? f
S™ple I
per sub-centre. These medirin« .k fa
’ ?000/’ Per annum S
intervals. The workers must be taughwhen"m rSJcls3' b
d I
tneir competence to the PHC doctor '
” *
beyond ■
3-6 The Committee was convinced 4,,.. ■< •
.
succeed it should not only be confineH n^ k
lntccrano11 “ to
hM Che eoueepr mnst al >
«K
fl
fl
|
1
?
a
J
9
• 131
and also to the State headquarters. For the multipurpose and inte^.ated outlook to develop fully in the district and at lower levels
,at “e^Strlct
be under the overall charge
of the Chier Medical Omcer who will be fully responsible for the
■
nJedlcaI’ h“lth- family planning and nutrition programme
in that district. He will be assisted bv Deputy Chief Medical Offieers, who will assist him in the execution of all programme listed
abose. These Deputy Chiefs mav also be entrusted'WTthX work
of coordination of specific programmes but they should be given
peripheral responsibility m respect of field implementation of all the
programmes on an area basis.
It Will be necessary to give the Chief Medical Officer technical
and adnumstrahve assistance. Such assistance is available from the
ex sung staff. The Aomimstranve Officer and the District Mass
In ormation and Education Officer and the District Extension Edu
cators could be attached directly to the C.M.O. so that the Admini
strative Officer provides him assistance in administration
^t^bshment and orgamsanon at the headquarters and the DMETO
and DEE become Public Relations Officers for all programmes
z-rt
hc?dc.uarters Icvcl the total authority for medi
cal, health family planning and nutrition, would rest with the
hvTdffi H t/n
S™5' Ke would be assisted
±>y Addi./Joint/Dcputy Directors.
JOB FUNCTIONS OF THE MULTI-PURPOSE WORKERS
fl
~
I
I
i
g
4
a
Health Workers (Female)
4.1 According to the information made available to the
Committee there are 40^25 ANMs employed in the countrv.
1 dey include all those who are working in sub-centres, PHCs. urban
centres, and in district and other hospitals. In general z ANMs
are stationed at each PHC, one provides nursing care to the in
patients of PHC and the other looks after the area in the mmediate neighbourhood of the PHC. Thus the number of ANMs
working in the subcentrts only would be about 20 to 25 thousand.
As mentioned earlier, there is a far greater shortage of ANMs
than of.their male counter-parts. The Committee felt that a concerteu ettort should be made to increase the number of ANMs even
tor the minimum needs programme of health and family planning
bmee the existing training programme for an ANM is of two veers
curation, it will take a fairly long time to make up the shortage.
.-s partial solution of this problem could be to post all ANMs“to
su^-centres and take them out of all other places/ For the nursinocare ot the in-patients of PHCs and in district and other hosoitalZ
", e C0ldd with advantage be taken by trained nurse-midwivfc
J he latter, the Committee was informed, are available and wX
!
*
232
r
reb-ve ANM^fn^h nursin“ care of
in-patieas and would a>u>
^dA W for me
„rt for whjch they m
i
s
Is
I:
I
4-1.1 Job responsibilities recommended
i'
to a
I0L°% ante-na,ai and post-na^
W a population of 3 to 4 thousand and about so0/ c coverage
infra-nattd care. For the add.tional populatioVi^thecoverage for
^ne her services should be available on J^uest only : “twilight”’
The following will be her job responsibilities :
u-
(i) Ante-natal care;
1. Registration of pregnant women from three
months
pregnancy onwards.
2. Lo^mg after pregnant women throughout the
period of pregnancy.
3. Urine examination of
pregnant women wherever
possible.
f
4. Distribution of iron and folic acid tablets to ante—
natal and nursing mothers.
J
5- Referral of cases of abnormal pregnancy.
It
6. Immunisation of expectant mothers u-ith Tetenus
V
VZzLQAlXle
h
(b) Intra-natal care
1‘
r
She.wi11 condu« about 5o% of deliZ
hc/.,ntcnslvc
and whenever called in
the twilight area.
2" Ihed^" deIiveri« conducted by dais whenever
hnn
niJ
3. Referral of cases of difficult labour.
(Hi) Post-natal and infant care
e^chSS Pay
Po^liverv visits for
inrofrh^ casejnd render advice regarding feeding of the new born.
15
i|
2‘ vareS
vaccination and BCG
vaccination to all the new bom infants.
(iv) Family Planning:
I. Maintenance of a copy of eligible couple registers.
2‘ wo'm-n^
meS5age °f familX Panning to the
contrac
area ant^ distribute conventional
contraceptives amongst them.
I
Ir “n
I?111!i
I
2
I 3
1I '
I
■ fej
Bl
F
I
s
I
233
|
3- Follow-up of IUD and sterilisation cases.
(v) Nutrition :
1. She will give advice on nutrition to pregnant
women, nursing mothers and infants, in arms (o-i.
year age), but she will not be responsible for storage,
preparation and distribution of food.
2. As stated above, distribution of iron and folic acid
tablets to pregnant and nursing mothers. If requir
ed, she will distribute Vitamin ‘A’ to children of o
to i year age.
(vi) Training :
She will help in the training programmes of Dais.
(vii) Health education :
She will take part in health education programme during
home visits and also when mothers come to the
centre.
(viii) Health Care :
1. She will render health care for minor ailments and
provide first aid in case of emergencies.
2. She will refer cases bevond her comoetence to the
P.H.C. or to the nearest dispensary.
A
«
4.2 Health Worker (Male)
1. According to the figures available, the following are the
number of difierent categories of workers which can be made male
multi-purpose workers :—
1. Basic health workers
.
2. Malaria surveillance workers .
3. Vaccianators
4. Family Planning Health Assns
5. Health education assistants (Trachoma)
22,000
21,190
- 20,314
12,500
374
.
Total
76,378
As mentioned earlier, workers engaged in cholera and leprosy
control and for BCG vaccination may be allowed to continue as uni
J
purpose workers for some time. Their number is as follows :
752
1 461
1448
1- BCG technicians
2. Cholera workers
3. Para-medical Assistants (Leprot>y)
Total
4,661
I
f
234
\
The Alealth Worker
,^4s'”-sSadh:
that too for a comparativdv Th
_— counter-part has had
ex^mg workers in health and |
e converted into multi. |
°nC fie]d
-ri
2Ctivity and I
The diurauoa of the I
be imparted are discussed
----- 1 in I
wa
I
h "I tk= ptOOTmrres
HC r?LWOrk in co,laborTt£n wiih °hi 7 7 ^OUSaild
at Pr««t j
Haith Worker (female) Both of 1
counIcrpart, i.e. _
village.
“« - a
^The
»
I
fetX-f T “
the. effeedveness
Pooce'*of theD<SXhtre'‘that mai”^:
''
i™siK 'o
planning programmes do noM^ “ hcaJth Md
m mme in contact wkh
adc4uate topportunities
This is because the maioriX j C, membcrs of the rural1 communiy.
or have to go out to work 7»°wort
m in the field |
working
able to the male workers durin/ JeiX'
sre not availof change of working homTof th^ XT'
~ question
-i—
The
°^HSScd' A suggestion was made that tX Worhcrs was therefore
afferent working hours startin al
Work«s should' have Jv
hte evening. Du^Xl™ V
COntinU,
'ntinuing 1
, -of..-.Jr,
it was brought out I
admiXstr7ti;
------- c problems li
S'voA between the male
----It was. therefore
I
batt?? thC .SUal
■wherever they can find them.
I!
hours’ I
rn at?ntl0I1r0nJy to the home visits ’
members of the rural community
4-2.2 Job responsibilities recommended :
'2/
Health Programme
1- y ill help in the
control
of
For
this h7
diseases includ- I
ing malaria.
house-hold once c
h
uceks and contact all rases f
of fever. di~
He will
?'Tf ««dy
ouirak „( I
mfectious
P». etc.
”Ch “ d«’fc". typhoid, pobo, S„J. |
evSt
rTIar Vis* *> ^ch I
o-eyeae t„
"
H' will also re»aS“t,
after every three” " "" 1<Mts
’
"hoopi^ rasib.
'5
r
E
0I
I'-'1
bI •
I
w
ip
■ 4k ■;
I
235
3. He will assist the supervisor in the school immunisation
programme.
✓ii) Family Planning
I
I■■
He will be responsible for the preparation, u^datintj and
maintenance of eligible couple registers. He wilf also
supply a copy of these to the Health Workers (Female)
■2- He will distribute Nirodh to the population in his ar’ea.
3‘
Aprad thc ?rSS5e of famiIv Pining amoncst
males of his area and follow-up the acceptors.
!(iii) Health Education
1. He will help in the health education programme during
programme during
2.
“d
3‘ 2ucate
Icaders
with their help
“ health,
h“"h-family
h“al
(iv) Nutrition
He Wi%iMtbC r™00 Programmc of thc p^chool
agnd ref2 b^
°£ “"tion
and refer them m Balvadis or PHC for necessary nutrition
JhFT °r trcimcnt- Hc
however^ot be res-
±
ot
“d
“d
(v) Health Care
1. He will provide medical aid for minor ailments and render first aid.
2. He will refer c^es beyond his competence to the PHC
or to the nearest dispensary.
JOB FUNCTIONS OF SUPERVISORS
Health. Supervisor (female)
r tjxz5*11 The suPCI7is3Qn 3f ANMs,
LHVs'
A^Ms> i most places, is done bv
LHVs. _ This
'" * ‘
1-HVs.
This functionarv
functions- 3 a Matriculate
who has had 2 54 vea-s
1
- o’
------- *^“■‘$5 to ‘-,1U vum:
course content of her Xrricuiurn, this training is coizmunitv oriented
or.»,
1" J
'T * g “
Ae N»i„
il™bJ” f^“'“
nuing the LHV course. .W of the State Nursing Councils have
236
have
■*>' LHV Mininoration come lor nonS
commilmcF health
y=a-3 course and out them
midwiyes wnc have undergone 3 /
™ Wert Be„S P" ^7“““'^
c
I
have, however? continued h LW Vt’ ' Ab?Onty of the other States
Council’s objection
H
msPIte of the ^ing-
admission mpcity^f nLT^oZrh LHV ''Ch°OlS
aided and 15 £ State-IL
5chools
I
I
I
8
i
an annual
are Centrally
?{ the ^“‘“'e had
id opportunities to talk to
addibo’nal
r
Wh° had ^civcd
I
'dson of ANMs.
day LHV was not
x
k
I
I
If
j -».**>wuxvu lu me rac
^number required and hence ha^
guidance to the ANMs in materni ’
Sixr ’ort to“= ^4 4
s= m
>fe«£SlXOnmeMlShlri S“f
on
when not ar snpemroSof XnMc
h“l'h
o the eorlronmcn, in
™h“ “
I'-
i
th- r^-^n’v^n.era^ concensus in the Committee was that for
tS X2 l'he "™t »f
WorkerZS) I
health. She shouM h r
ls Priniarily trained in community
of her training and should °lat^rnity Practice as a major component
to render
ad^
to practice in this field in order
community oriented than hospital biased
morc
W«
b
emplS’.r^MS'ir”^ “t^ "d ,?* hulih „
r
■ta UH- »Mv
health kLs
PHX,
„
“ g°
Ar^S5
JK* “
heLad(?uarters
h
h
I
well as disrict public
PHc'^ZT^0^ 2 LHVs4
h™ dmer a dSc Mf SSd
■ of ANMs and LHVs available, it is;
obvioos that if all ANMs
> are to be put in subcentres and all LHVs-
I
I
j
i
•X
I
237
ti“"?»">*»“««■»
S“
of not more than 4 AiWfs
therefore obvious
Th
suPcrvlses
I
'vork
d f°r haV,n« more LHVs “
5-2- Job responsibilities recommended :
J' hVcS
skiUs in Health Worker (female)
°£
her
2’ SmcmUPCJT ^d^dc
H-W- (fcmale) in givK
3nd F:uluIy Planning services to the public in
3- She will observe and supervise the work of H.W.
(female) trained dais.
deiiveria0
deliveries.
COnd“Ct °nC
4- shiCp7kinsdp tbca improvc Kchaical
56.
s
human ldahon-
XT
7< s?h W1!1 Visitkat :<ast once a week’ on fixed days each
5
'n hC7 ,unsdiction- During these visits^he
will conduct ante-natal and well-baby clinics
Durins-
J
8. She will arrange n» give group talks to expectant mothers
9-
*c * “j
io.
wo“" “ a“oi <*
confcScnces once a ^nth with the
H.W. (female) ana tramed dais work; ig within her area.
12. She will give an eraluation
®•
•I
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' 238
’3men "
“ “ b'
if
14-
I5-
t
f°' d»“idi>7 c»nli£
With the help of
X^g.P"°“"f
I
“f””' ““
y
1
5-3 Health Supervisor (Male)
5-3-J In-most of the State
worked in a
’
promoted to die higher grade
Was
eastern States like ®
anote
of ,
worker—the health
wcrc 1/
bracketed with
i?SJfCtOn’ cte-> as
i
as their salara hJ concemeTC'h
are comparable to ‘Bare F<7t Doctoi^f Chi^ ST’L
programme was however given ,.n
'-mna. This training i
°t health atshUM i, theXe gradnX
n“n,te I
GeneSrf hSasK
I
of worken who, after sutable SiX ^”“^r“d ““S'™ I
■asKj for the male health workers.
P6”0™ supervisory |
(i) Health Inspectors/Sanitarylnspeaors
(>i) Malaria Surveillance Inspectors
(•«) Vaccinator/Supervisors
3200
5207
4649
Total
41856
Of these, the number
available for the rural areas will be
2rx>ut half, i.e., 22000.
As the number of 1male health workers available would be
little
over 76,000
and if thZ
available
would bebca
supervised
by one’ s^e^r
,°!*vurKcrs
4
WOrkers
the total
required would besupervisor,
about 19 oo^
oriv number
nUTher of male
male,suPervisors j
a surplus of about 3,000 of male su^viso^ wX"$
* 1
supervisory workers.
The number of male health
wnerrit
the number of female s«
rvi Th>UI y worKcrs thbeing
_r - over three times- j
supervisory
workers,
to concentrate on increasing
the nuX
”’ there
of feis an urgent need
workers
during irOiXeTrS
the Fifth Five Yeo di
• ,eiVa,e “
supervisory
w«tm^^danng
’'"““'t 1
this problem of
/
,n P^od’
—■ possibility of giving
tiered
the
giving* thefd
X7 task^o?c “ Colnmittee consi- 1
nmlti-Durnose
. K ot
",t’'p“rpo“ ™ri“ >» ■>* "■p=™»n.
0
i
k
B
S
fi
[■
I
239
l £nr^°n TK5
reIuCt2nt
^cked confi| dence. The Committee also feels that the work of the female
I supervwrs°SC WOrkerS CLrlnot:
effectively supervised by the male
J
According to the existing number of supervisors, there will be
I one male supervisor over three to four male health workers as con| trasted to one female supervisor for six female workers for the time
I bemg.
;
5-4 In addition to the categories mentioned above in some
; States there are supervisors in still higher grades. These are senior
sanitary inspectors, semor malaria and health inspectors and senior
vaccination inspectors. The Committee considered this problem
and suggests that since this is not an all-India pattern, and the num
ber involved is not very large, the only solution is to abolish such
posts for future. During the interim period, one senior inspector
of
or health, malaria or smallpox can be posted at the PHC.
5.5 The position of the Block Extension Educator is peculiar.
He is generally a graduate in social sciences who Bas had a short
orientation training in family planning work but has no knowledge
of medical or health programmes. In some States, BEEs are matri
culates His scale of pay is the highest of all the workers engaged
in health and family planning programmes. At present, he is incharge of extension education for the entire block and he stavs at
the PHC headquarters.
hereas his higher academic qualification
is an asset, the lack of trainin; and knowledge of health and medi
cal programmes is his handicap.
The Committee was therefore faced with the problem of
fitting this functionary in the proposed set up. It considered plac
ing him m the category of male Health Supervisor along with
Sanitary’ Inspectors/Health Inspectors but the KILOI experiment
was discouraging. According to the report, he proved to be re
calcitrant to an integrated approach. He was apprehensive that if
converted into the role of a health supervisor his area of influence
would be reduced resulting in loss of prestige. Moreover, if he is
to be made a male health supervisor his training would be longer
and more intensive as compared to the health inspector/sanitiv
inspector, etc.
The Committee therefore felt that as an interim measure, the
BEE should be posted at the PHC and should serve as an assistant
to the Medical Officers. He would render the medical officers
assistance in arranging meetings and camps and all public relaticns
work.. He would also help the PHC doctors in office work and
record keeping. It is suggested that his designation be changed
to “Block Health Assistant”'.
t>
i
a
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■f
ft
I1
240
He would, however, not be in a position to exercise anr Ki,supervision over- -----health1 supervisors.
’
,
It was felt that in all probability such a change mav be n-lu '
m future. Their promotion to the post of "District
could be considered where they would work 2
to the C.M.Os for extension work.
^ant5
gr
rnm
1%
to
^-single-purpose sarin,,
community health workers is of crucial importaL.P t£
is discussed in a subsequent chapter.
^aspect
J
vison’odi^ ReSp°nsibilities ^commended for Heahh Super-
i. To supervise the work of male health workers and
10
provide adequate guidance to 1them by making ------frequent
visits to each worker in his jurisdiction.
If
To arrange small group meetings with the hrin of
community leaders for spreading the message of family
I
I
7
3- To check vaccination of all school-going childrem
.. |
4- To check and supervise the malaria maintenance work
workS. Sman'p0X vaccinati°n work of the male health
I
|
5- To supervise the records maintained by the maJworkers.
I
6. To
keep a close
watch
demies'lie
choice,
sma?p*'
7. To treat all cases whose blood smears are positive mr
malaria.
8. To supervise spraying of insecticides.
9- To supervise the work of male health workers re^dir^
environmental sanitation, disinfection of wells, 4IO.
I-
To periodically check the registers and records mair-ained by male health workers by actual physical verihcmiom
it To be responsible to the primary health centre doctms
for delivery of health, family panning and
services to the community.
S
nutrmon
h’
J
'12.
To mamtain adequate supplies of
contraceptives for distribution.
Nirodh and other
I
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241
INTEGRATION’ AT DIFFERENT LEVELS
PsLscm“ ““p”™"
mediciKS „d
«d
medicine there are indivndn-l
niCn 111 Prevent3VC
programmes like malaria, small mTcSF01'5'5 ’ f°r’ diffcrcnt
Below the PHC level th^e are a^ Jff
tubCT,cwos1^ «c.
individual and separate progratSes
s^^
leprosy, cholera, family
maIana’ ^all-pox,
""AW.
worte
sectoral level, wEt mtegratira ofESe ^P^’150/5 at
complex problem^1
“'l a f”"' »“<>■> »1 Ibe
’
as firacSSd
pillar of curative medicine. Any worker eS Zi ■ 1 a^0Und a
family planning activities must be able to provTdf'oiAtiv^th
for simple ailments if he/she is m k- P1071^ curative measures
the community. The same is anotfe
acceptable to
doctor will prove effective for motivating0 Sople^fm far??
ly that
Only
family plan
treat them for their
6-4 Present scene
6.4.1. PHC level.
ShJ“ p’l*”'”””^ 0“i 'X
deeA^^
vcnient to coniine
j •
i
’ dlereiorc, finds it con-
“.^±^7s As
situation.
’
-tnis is obviously a serious
in mi, SAf‘tX* SJX?' 1 ’”X
voioomcy
„d' rAXi'xxs
“ Viomdi d„Mn „ b
i nm i i mi i mi iimi
242
or Homoeopathic practitioners,
these dispensaries and the PHC.
J
There is no inter-link between
■ I
II
3- The distance between a PHC and the next larger hospital
where greater expcrtrse is available, varies from 5 to roo miles In
general there are no graded hospitals in-between the medical
college hospitals where specialists and wide array of investigative
are available and the PHC where neither is available.
There are however, some well equipped District Hospitals where
adequate facilities for investigations and treatment are available.'7
I1
I '
ii
;
jl 1
(
1? c
Ih
4- The administrative hierarchy, too, is both diffuse and
“Hfrang- For the preventive services the PHC doctor is responsi
ble to the district health officer and for the curative medicine he
has to make referrals to the district hospital. In some States
famfly planning and health services are combined in one function
ary ix. the district medical officer of health and family planninnwhile-m others, two separate functionaries exist.
&
ftIl (<
1
will
The^oct°rs °f PHC during their visits to sub-centres
wfl not only render health care to the population but will also
check the work of the health workers and their supervisors.
hr.M?'4'1;2
tS:tais,PcPsafi«
S shonl/^ bC
die jurisdiction of a primaryPHG and ^h dispensary
»
I
1'
I
I
£ctor should go out in field visits and extend integrated health.
ofkand T1^™011 SCrV1Ces t0 tbe Population. Thus
I
-y« I
S
■
Wherever there is one lady doctor at the PHC
, she should
render specialist services for imaternity
’ and- child
health to the
entire PHC population.
I
64.2. Taluq/Tehsil level
Wherever tehsfl/taluq hospitals are in existence snecialist
suTb
m7stlgatlve facilities are, in general, poor. Wherever,
are
f° ‘T
WOrking
these hospitals
are responsible for the health care of only rhe in-patients of the
orSJ“ar^ 7
nOt reSPOnsible for the public health activities
VJl.
1
LLIxX w ciTCH.
a
1
1II
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iI-
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243
6.4.3. District level :
ft
At the district level, there is a Civil Surgeon who is usually
1 incharge of die district hospital. In many distnet hospitals
1 there arc junior specialists in surgery, medicine and obsL and gynoc.
fi X-ray and laboratory facilities are available to a limited degree.
1 in addition to the Civil Surgeon, there are two, three or more
g district medical officers of health. In some States, district medi1 cal officers have combined responsibilities for health and family
planning while in others the two are separate. In most of the
States, the Chief Medical Officer has an overall charge of bodi the
civil hospital and the public health services of the district. In
general the promotional avenues tend to gravitate towards the Civil
Surgeon and not from the Civil Surgeon to medical officers of the
health and family planning.
6.4.4- State Headquarters :
In manv States there is only one man at the top, the Director
of Health Services, for all the health and family planning pro
grammes including education and training. He is assisted bv a
number of Deputy Directors and Assistant Directors. In other
States, medical education is taken away from the purview of the
Director of Health Services and a separate Directorate has been
set up to look after medical education. Usually an officer of the
rank of an Assistant Director posted at the State headquarters looks
after the nursing and MCH sendees. There is hardly a State in
which training of the para-medical staff is entrusted to a single
officer in the Directorate.
6.4.5. Medical Colleges :
In the vast sea of health and family planning sendees of the
States, Medical Colleges and the attached hospitals are islands in
themselves. Their responsibility starts and ends with under
graduate and post-graduate medical education and rendering of
medical care to those who seek help either as out-patients or are
admitted into the wards. Their specialist services and the sophis
ticated investigative techraques are hardly ever extended to tne
community at large. Whatever liaison exists between tire staff of
the medical colleges and the doctors working in the district
hospitals or in PHCs, is on personal basis.
Although each medial college is supposed to have, and many
do have, a rural and urban held practice area, it is more of a show
piece and hardly ever caters to the health needs of the community
within this area.
19—88 CBHI/ND/84
E
«-
244
I
^•5- Comments :
i-
With such a diverse, diffuse and
2Z times conflicting array
or medical facilities available in the
there is a cons'tanT^“TnegLTaX^nad'
SUrPrisinS that
is a constant cry of neglect and
for the
sections of
Jla.d^uac1,es particularly
— under-privile^d
under-pnvileged
the vast
majority. E^n sections
though
whlch constitute
majority.
though *
population
ratio?as Even
compSo
3
doct°tsas <
inescapable fact
fact that
that ao o
l
d^°Pcd societies, it is
inescapable
resources . •
reorganisation ofren^s^
of the
Alving the health problems of the co^X.^ S° *
ifl i
mcdicaI college
hospital on one^hle^dffhe^rS
with taluq and district hospitafs in b^w^a^ b
'^.es „„
j
Other’
bdc
I
I
hygiene m medical coUeges and £
dePartments of
replacements (Departments of Previnrecent prestigeous
to be evaluated. Whereas som
S°aal Mcdicine) have
Jike general medicine surgery obs^oohth I
“ °f medicinc
be there, it is questionable ff ^visions’ hJ^^0 0^’- CtC' havc 't0
«„<, (mily
wemisan'm
d,e rMl’P”sal°£
“■bole
^rtsions bo± on account of historical devd^^7’ TjC cxisting
cd ideas from the west need tn h
•
Pmcnts and of borrowover-hauled.
t0 be reviewd and the entire system
6-6. Recommendations:
-n
^mcdioJ colleges in the
sc
tl
j
a medical college with its attached3^ d?St?[ts- Ir ls suggested that 1
the entire health, family planninDbc.made responsible for 1
say three districts. Of course th^ M nutrition programmes of |
-ork in C|OK c<>„rf““on”^ “^Colleges Jil, km „ 1
LSt
Otncers of the concerned Diet ; «- cLStrict ^ca^th & Medical <
lines will have to be laid down Each
pr°per guidc' I -gr
to 150 bedded hospital with special^
? Sh°uld have a 100 I •va
obst, ophthalmology and well dp /
m me^c^ne, surgery, A
U»d„ tbfd2“a
S" • 75 bedded taIoq,ttM
£”? ”d
pW
W(
Tl
mi
ins
I
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1
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245
I bboT-trv EV™'
P-rovisions “d limited X-ray and
I with “- to to ST PC
Sk in this chain wou!d be
PHC
I orifsation
\
SyStem C3n be !nbuilt in sucb “
t k ? by paCentS can be referred fro™ a PHC to the
MeJJcSleST? T t0
medical C°1,eSe hosPitaL The
HeT 5
“S3111* m consultation with the District
^and T “TT
P^-nes for the docSJ
TTTd Para'Ined!cal,staff within their jurisdiction. This will
make training more relevant to the day-to-day needs of th-
co.dd h
°f In^a’ 1'e’’
Calcutta, Madras and Delhi
could be converted into such specialist institutions. The Committee
b'
—“d
c^’X X^”fld“±Xt £ch“Tbe thean
-
PROBLEMS TO BE FACED
fTZICeS’ 3 ™mbcr of problems are to be faced. Broadly toeakT
these van be grouped under Administration and Training.
7-i. Administrative Problems
St-!tAT bcen br-7ght 0Ut * an cariier chaPter that in different
States Jiere is a wide variation in the educational qualification':
Arning background and par scales of workers who could be
uped together to form multi-purpose workers. In "eneral thhave the lowen pay Jalekand eAxaXl bB^'oni
I
To put all these workers into one category of male health
: worKers, is therefore going to raise some administrative problems
The Committee recommends that for the future entrants, a mini
mum qualificatiion of matncuhaon m science subjects should be
insisted upon. 1 ne existing mncnonaries after suitable training
fl
I
246
mav be grouped together in one pay scale with marginal adjust
ments of their existing scales and protection of the individuals
present pay.
I|!
7.1.1. Promotional avenues
p
For a successful implementation of any programme it is essen
tial that the workers involved should have suitable avenues of
promotion. The Committee, therefore, recommends that twothirds of the posts in the higher cadre of die health supervisors be ;
reserved for those who successfully complete at least three years of •
service as health workers. This period mav be extended to five
years for those who are not matriculates. The Committee recom-.
mends that the new entrants in the health supervisors’ cadre should
have passed Inter Science or Higher Secondary with science
subjects.
i
A suggestion made by West Bengal Government was to have
two or three grades for all types of para-medical staff and a fixed
percentage of promotions from a lower to a higher grade. The
Committee, however, feels that it would be more advantageous
to have only two categories with two grades, one for the junior
and the other for the senior health workers.
h
1
I
;
i
7.1.2. Another problem faced by the Committee was whe
ther to have the same pay-scale for the male and the female workers.
This is relevant as an ANM has a two vears pre-senice training
whereas the malaria or small-pox worker of today has onlv 1 to 3
months in-service training. Moreover, AXMs are in short supply
as compared to the male workers. Conversely it was also felt that
for a proper teamwork, no discrepancies between the two workers
should exist.
Taking iinto consideration all this, it is recommended that
there should be a uniform grade for both male and female health
workers. It is also recommended that fixation of the grade for the
time being should be left to an individual State which as far as
possible should be the highest that exists in that State for theseworkers, All the grades, however, should be made uniform in
due course.
All
A-1— __1
1
1
t 1
f
«
•
•
!
•
i
The Committee also considered the question of the
It
was felt that such functionaries may continue wherever tfiey exist
and perform the prescribed duties. For future, however, there
was no need to have any Class IV employees at the Sub-Centre or
sectoral level, except for sweepers.
^>lass I\^ employees like attendants, disinfectors, etc.
S'
7.1.4. The
lhe question of trained dais is, however, different.
In some States, trained dais are regular employees getting fixed
amount of Rs. 50 to 100 per month. They help ANNfs in their
J
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247
day-to-day work and also undertake home deliveries. The Govern
ment of India had recently appointed a Committee to go into the
question of training of indigenous dais. The report has been sub
mitted and this Committee has brought out that suitable incentives
have to oe offered to the indigenous dais to undergo training. It
has also highlighted that in the next 5 to 10 years training of indi
genous dais shall have to be stepped up to fill the gap of ANMs
shortage. Amongst other suggestions, this Committee has recom
mended that in order to attract indigenous dais for the training
programmes, posts of ANMs attendants may be created on the exist
ing pattern of Haryana giving them a suitable salary of say Rs. 100
a month or so. An alternative suggested is to give them fees on pro
rata basis on the number of cases delivered each month. This Com
mittee endorses the view that creation of posts of suitably trained
indigenous dais would be appropriate till such time as the ANM
shortage is made good.
7.2. Problems in Training
In recent times, greater and greater emphasis is being placed
on training for better job performance. Although the accent on
training for improved job functions is of recent origin derived
mainlv from the experience in American industry, the concept is
as old as antiquity. The older method of a son following the trade
of his father or of a young apprentice attached to a master crafts
man are examples of the same. All tht*
are „ number
the wme.
same, rhere
there a._
of problems in the sphere of training in the field of health. These
problems may be considered
”
I as general and specific.
7.2.1. General
By and large, training of the 1workers engaged in health
j:__i staff,
. rr^ |s unJerta]-eI1
programmes, doctors, nurses or para-medical
in specified training institutes. These institutes impart training in
an atmosphere which is usually devoid of the knowledge of the
actual needs of the workers. It is commonly patterned on similar
training/comses run in other places mostly in USA and UK. Not
only the main features of these courses are borrowed, but in several
instances even the terminology used is the same. Since many of
the trainers have had their own training in training institutes
abroad, the terms and phrases used by them are foreign and many
a time unintelligible to the trainees. During the last few years
many terms have been introduced in this field which are not in
common usage in this country and poorly understood by -all others
except those who use them. This has resulted in training for
training s sake, devoid of any relevance to the actual needs and the
job requirements of the trainees. The trainers hardly move out
or then- training centres, are not in touch with the field workers
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iTlhU^job^
I
°f thC Pr°blanS faCCd by die
tra^nees are sent t0
training institutes less on their I?
own initiative and more on administrative orders. Promotion is
not linked with training. Historically the pattern of our education
and training m this country is based on tn; English model. An
individual expects to add some letters of alphabet to his name i
following formalized training, be it a cerdncate, a diploma or a I
degree course. Since no such addition is' possible after the present
aj training courses, and since promotion or even increments in. !
pay are not linked with a satisfactory training, there is reluctance
i
on the part of trainees to come for training. Moreover, the stipend1
paid to the trainees is low and since he has to run two establishJ
ments during this pnod, he is reluctant to add to his already heavy
I
hnancial load. All this results in under-utilisation of tlie training
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neS’i. l . ,agaU1’ frc<lucnt transfers from one job to another
I
add to the backlog of training load. The administrator on the
II ’
other hand feels concerned when he finds that the expenditure
I[ <
n training does not yield commensurate results. This vicious
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Wol
U”'rcla.tc5110 job, Performance, under-utilisation of
I 1
Uy lnade^u^te gaining facilities, high expenditure and poor
j c
deliver’vZTrb Z b1e,broken- Tbose, who are responsible for the
I r
nmXZ f
SCrV1CCS’ must bavc a say in the training
I c
P
mes and the trainers must be intimately aware of' the
I'
requirements of the trainees.
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f.
h
a
L“ k
a* mucb as possible. This not only lengthens
On his renbu
releVant t0 ths Prevailing situation.
what h 1
. r°m th. C°UrSe tbe trainee finds a gre« deal of
that Hs bX ZV0 reJeVancc.t0 bis j°b requirements. It is felt
Xog
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"™ns “““ shor‘ “d
7.2.2. Specific
7.2.2.1. Doctors
• ZZT *C P^^’bed
years under-graduate course an
undergraduate underg<
goes one year of pre-registration internship
programme. 7In service orientation training in family planning,
of one week toJ one month duration, is given in different States.
Short training courses of
— a few days are also given to doctors
engaged in /
’ ‘ programmes like malaria, small-pox, B.C.G.
special
etc.,allbut
are nCIther standardhed nor are available
thesuch programmes aTe
in all the States.
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|
I leadef of
I training is imXci tTffr
3 doctor is said t0
a
“d/ara’medical staff’ “
I
I wonder therefore thar □
j
expected of a leader. Little
I his team only h nam 7at the JPHC is a leader of
I « viUages rathe,. thM lxt of physi"^ ^“““,7 "'"l
I
I reared 1„
“T”? » fc wnd.tom
II able
even isina private
practicewithThe
I
large hospital
all av^l
Wp of SogphiZS
thM k ™
which he would he
i™11 ^e/ce^s programme
or
most comfort-
hcE* bs7"S “'1I7
education in this count™ ;« knL-i i cccnniques- Since medical
I model, he is more suitable for the rnn?051 en?re V on
Western
countries than in his own.
dltl0DS that pteVail in Wcstem
changed, the (Smnri^rrcomX^6T °f mcdical education is
of 6 to 8 weeks may be given to each
familiar with the role that he would h
leader of his team. Thi would
a<tai„iSMi„ „d finanoa,
pre-service or in-service.
B.Se. „„„mg
anJ
”C d°ctor t0 make him
tO Pcrform as
jT”* "
]amr
“h fipat”1^”"
qSBo^ rf
imparted in wnrnl med' i ’ ,PractIcal training is
maternity tEny’ ^5“
SUrgic^ ^‘fg and
Community trainina- k n S
5ssentlal component,
followed ^In aene?al ?reSCnbed but not always strictly
deficient in staF™^ ?
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,
has been submitted and is under the consideration of ~ | •
the Department of Family Planning. This Com- I' ■
mittee is of the view that for future entrants, |
matriculation should be the minimum educational |
qualification and the training should be modihcd giving |
emphasis on midwifery, public health and nursing in j |
that order. It is also our view that the duration of the |
course could be reduced to iS months. This can be
conveniently done by reducing the period spent by the
trainees in the medical and surgical wards.
I
The Committee is also of the view that an ANM during her
training should stay at a PHC for a period of at least
three months. From the Primary Health Centre she can
be taken to a Sub-Centre
by her tutor to learn the con
-,
ditions at first hand. Such’ an exposure would prepare i
her better for the job that she would be required to
perform after her training.
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The urgent need of having more AN Ms particularly in States
like UP and Bihar where their number is extrem'ely
small has been emphasised in an earlier chapter.
i
(b) L.H.V. :—The controversy involving L.H.V. and nurse
midwife with community health training has been •
referred to. The Committee is of the view that there
has to be a female supervisor for the female Health
Workers and that such a supervisor should receive
training with a greater community bias rather than
hospital-oriented training. The Committee is also of I
the view that after some years it may be possible to have
common courses for all the nurses but for the next 10 to
15 years, it will be profitable to have separate categories
of hospitals biased nurses and community oriented nurses.
The Committee also feels that the present-day L.H.V. is not
a very effective worker. She does not provide technical
guidance to A.N.Ms. nor is she a competent supervisor.
The Committee is of the view that her training needs
modification. It is recommended that the duration }
of the L.H.V, course could be reduced from 2j4 years
to 2 years and emphasis placed on equipping her to be
come a suitable supervisor and technical expert in the
field of maternity and child health for the female Health
Workers.
7.2.2.3. Para-Medical.—Apart from a course for Sanitary
Inspectors, there are no regular training courses for the p^ra';
medical workers engaged in the field of Health. In the Family j
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rf Planning, however, 1 to ; months courses for extensions educators
H and family planning health assistants are run in regional family
J planning training centres. The Sanitary Inspector's course used
S to vary from 5 to 10 months. This has now been made uniform
S and its duration is 12 months. There are at present 40 Sanitary
S Inspector schools in different States.
It was painful to observe that whereas the duration of the
2 eourse for Sanitary Inspectors is one year, their job is mostly
» confined to supervision of disinfection of wells, looking after
S sanitation and almost nothing else. One seriously wonders if it
S is essential to have one year’s training for performing the task
S which Sanitary Inspector does at present.
7.3. Recommendations
Since the number of persons who would require training to
equip them for :uties of multi-purpose health workers and their
supervisors is very large, the Committee attaches a lot of importance
To the training programmes.
7.3.1. It strongly feds that all training facilities should be
pooled together and trailing imparted in an integrated manner.
It was not possible for the Committee to go into the details of the
curricula, content and the duration of the training. The committee
feels that it requires a demiled study and some experimentation.
Borrowing from the experience of Kiloi experiment, it is suggested
that the male health worker may be given one to two weeks initial
orientation training, preferably at the PHC followed by 6 to 8
weeks training at selected training centres. Such a training will
be for all the national health programmes and in family planning
and nutrition.
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7-3-2- There are at present 16 field units in different parts
of the country. The Derurtment of Family Planning has recently
taken a decision to disband the field units as it was felt that there
was no longer any need for their continuance in view of the
establishment of the regional training centres. The Committee is
of the view that since there is going to be a tremendous training
load and existing training facilities are meagre, it will be worth
while to reconsider this decision. The field units are mobile and
functioning and can be udlised for providing to the community
health workers on the ico initial orientation training.
7-3.3. For the new entrants, it is recommended that a one-year
pre-service training mav be insisted upon. The Health Supervi
sors mav be given one to two weeks orientation training at PHC
followed by a similar training imparted to the health workers
plus two weeks training m supervisory duties. The new entrants
>•
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.tS of XlXT*=iaing' A; s“is”«
ad;
&0„ KiS’iKi rf
aw m
LC°I
i»S oiHid SSSTlTntha'»’OTP ““«•
of
-iOS
fc--
’ -T %
f?'
iW
.•.■?■■•
*
-
.
jls
:ea
aavities,
M°BILE UNITS
8.:
..
§_.
i
bringing out training manuals,
’ n'* •> Tr^ning I^on be
u,
Plani}ing- This Division
Health and
o
-
-
^ggest training
« of the
“d
:e.
pr
twi
r
units and 456 IUD
uuicrcnr otates. Tbe staff
51
in position in
----- units has steadily
ee years. At the same time the number
I an
||
rhe
I m
gr
m
be
seeo.^---------------------------------------- '
2S ^.T
°„«f d st0Scontinue
"^nZ
” a“d'
oo&e-s^
r e~
0 necd
these units “o5,;!:\Z:,■“
goieral was shared by them.
I P1
Asstt Surgeon. Though the
ach unit has a L^y
admitted by all, some State Health5a’Te0^311'? °f the Units was
time that more lady dXrs wl
fclt ^at till such
necessary to continue the mobile IUD unl^ ' * PHCs 11 ma>' be
of India have
tor With effect &<„ ISI A°ui'™“ “S °“P' on',for n«b
I1I B<wtl
I
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[' n
n
f<
rc
onits in the intensive district? wn.
Tke Pattern °f mobile
vehicles and staH. which w ll
COntinuc- T^
the disbanding of these unite are
P .conseclucnt upon
of two States^ extension of ’
1
^^’here. In case
beyond rst August, I973 has been^ee^to
°f
K
in ea!h 'moblle service unit
[v
marilv as It’D unit If th- iari J 3 a^7 doctor and used priquate training and exPeriete i^■In
2 Unit ha^
vices could also be mfde availabl? frformin? nibectomies, her sera'ailable for ass'stmg the PHCs having-
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h
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IAdequate facilities to undertake such c-perations. , Tne continuance
[f
|)f these
these units, the Committee recommends, should be linked with
£omoletion of fixed targets with proem fohow-up action.
I
SUMMARY OF RECOM51ENDATIONS
9.1. Mylti-purpose workers for the delivery of health, family
fanning and nutrition services to the rural communities are both
easible and desirable. (3.4«i)
9.2. A new designation is proposed for the multi-purpose wor
ker—Health Worker (male/female).
(
I
The newly designated female Health Workers will be the
present ANMs and the newlv designated male Health Workers
will be the present day Basic Health XV orkers, Malaria Surveillance
Workers, Vaccinators, Health Education Assistants (Irachoma}
and the Family Planning Health Assistants. (3.4-5)
9.3. The programme of having multi-purpose workers should
’
be introduced," in the first phase,
in areas where malaria is in
maintenance phase and smallpox has been controlled. The programme can be extended to ‘ other areas as malaria passes; into
---- will
maintenance phase or where small-pox is controlled. This
)C the second phase.
The workers engaged in cholera control, filaria and leprosy
)rogramme may continue as such for the time being. Similarly,
}CG vaccinators mav also continue as such. However, all these
workers will be made multi-purpose workers in the third phase of
the programme. (3.4.3)
9.4. There should be a ream of two health workers, one male
and one female, at the sub-centre level. (3.4.5)
I
9.5. After training in ail programmes each health worker,
male and female, should be ^iven a first-aid kit and also some
medicines for minor ailments costing up to Rs. 2,000 per annum
for each sub-centre. These medicines should be replenished at
regular intervals. (3.5)
9.6. The field visits of tire male health workers should not be
limited to the homes of the villagers but they should also go to
the places of work of the villagers. (4.2.1)
!
0.7. In order to reduce the-existina shortage of the female
«
.XT-.,
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. _27r____ 1
T->L_rr'
j health
workers,
ANMs
whose
job •is confined
to the PHC
heada: the district hospitals and at other
| quarters, and others posted at
f places should be withdrawnl and posted at sub-centres. The posts.
| vacated by the ANMs should be filled by nurse-midwives. (4.1)
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254
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pks
9-8. Jurisdiction for each health workers :
p
ad-auaPfarH-ri311 U?imate obie«ive it - recommended that when
■^equate facihties of men, material and monev are mad- avaiUk!
™ "”1’ °f ™C’ ^uld he
I 2
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■ It ■ hX i1:.
Ii2
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spending on topography and means of communications.
■«- fSe hS IS"
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9.8.b Taking into consideration T
the existing number of male
-^d female health workers, it is recommended that:
L *
look afeP; nA T1* heaith WOrker wou;d havc f°r the present to
took after a population of 6 to 7 thousani (42)
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not more than c K M
%
c 3 , ~ thousand °r an area of
■Will be resnnn ^kr
1" radlus froin her place of stay, where she
Timning sen-kes andVoST^t
Hea,th and FamU7
„
I5
’
^Hl be available for narH 1
tW1
where her services
□e available for partial coverage on request only. (3.4.4)
- ices8^f3t^"nl:theL lnterun Per.iod- “ is suggested that the
II
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SCXt10fareas.
arSlne1ndaiHbe
U5cd -Pearly
i the
---------- 7 in
uioni areas. In order to make
make the
the -trained
...............
dais -reliable assistants of the female Health Workers, th.
ey may be given a suitable
remuneration. (7.1.4)
Sa® d,,, have a„ aCOtt sh“.
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9-to. Jurisdiction for each health supervisor:
Population havin<A6 rentreT3^ °^ec?Te
<4 males and 4 females) would h
a PHC for 50.000
“p-i- "ilaS «jsxy
- ?Ah:vXs„"K" £■“ -s
^^-XaZKaS
workers
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255
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I supervisor, it is recommended that for the time being one male
I health supervisor may supervise the work of 3-4 male health workers
| and the female health supervisor (LHV) may supervise the work
I of 4 female health workers. (5.3.2)
J
9.10.C. The present day lady health visitors now designated
I as female Health Supervisors should be withdrawn from all posts
I other than those of ANM supervisors. For example, lady health
I visitors at PHC headquarters, or at urban centres or in ' district
I headquarters, etc., should be withdrawn and posted for field work
I of the sector allotted. Nurse-Midwives may be posted in their
I place in urban centres and the District for static duties. (5.3.2.)
p.io.d. Nurse-midwives with community health trainino- Or
qualified public health nurses should be recruited to take up3 the
I deficiency in the number of female Health Supervisors. (5.3.2.)
I
9.11. Two-thirds of the posts of the Health Supervisors
| both male andjemale should be reserved for promotion from the
health workers’ cadres. The remaining one-third should be filled
by direct recruitment. (7.1.1).
9.12. Training :
It is recommended that a small group consisting of health
administrators, trainers and technical experts be constituted to
go into the details of the training that is to be imparted to the
future multipurpose workers and their supervisors. Such a <roup
would also devise manuals, and prescribe curricula for the trammer
of the present day uni-purpose workers in order to make them
multipurpose workers. The course content and the duration of
training for those who are to be recruited in future as multipurpose
workers will also be indicated by this group along with the places
where such a training can be imparted.
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g.i2_a The same group should examine the existing curricula
of the .YXMs and LHVs and suggest ways and means to main- the
training of these functionaries more practical and job-oriented
(7-3-4)
9.12.0. Pending the recommendations of the proposed group
the Committee recommends:
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9-i2.b.i. The existing, uni-purpose peripheral male workers
may be given 1-2 weeks orientation training followed by 6 to 8
weeks intensive training. (7.3.1.)
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9. i—b.2 The supervisory workers should receive 1 to weeks
orientation training followed by 6-3 weeks common trainma with
|
health worke-s Plus 2 weeks of supervisory turning;
256
^.iz.b.j. The duration of ANM and LHV training can. be
^conveniently reduced by six months in each case, (y.z.z.a)
h
9.12. C. The minimum educational qualifications for the new
entrants as Health Workers (females) should be preferably matri
culation or equivalent with science and biology and for the male'
Health Workers, Matriculation with Science and Biology. For
the Health Supervisors (male and female) Higher Secondary with
Science should be the minimum qualification.
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9.12. d. Training for all the workers engaged in the field of
health, family planning and nutrition should be integrated. (7.3.1)
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9.12.0 A training division should be established at the centre.
(7-3-5)
9.13. The job responsibilities of the proposed Health Workers
and their supervisors (male and female) are given in Chapters
IV and V.
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9.14. The pay scales of the health workers and their super
visors should, as far as possible, be made uniform in all States
(7.1a.)
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9.15. The doctor-in-charge of a PHC should have the overall
charge of all the supervisors and health workers in his area. He
will be assisted by the Block Health Assistant for his headouarters’
work. (5.5)
1
ip
9.16. The doctors of PHC during their visits to sub-centres
W! 11 not only render health care to the population but will also
check the work of the health workers and their supervisors. (6.4.1.1)
9*I7’
dispensaries in the jurisdiction of a primary
health centre should be linked with the PHC and each dispensary
doctors should render referral services to the cases referred by the
health workers. (6.4.1.2)1
9.18. The doctors at the PHC should divide the population
on a geographical basis for their field visits.
While one doctor
attends to the out-patients and in-patients at the PHC, the other
doctors should go out on field visits and extend integrated health,
family planning and nutrition services to the populatipn. Thus each
doctor will be at the PHC for three days and will be away on field
visits for the other three days of the week.
£
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Wherever there is one lady doctor at the PHC, she should
render specialist services for maternity and child health to the
entire PHC population. (6.4.1.3)
ar
so
bi
or
fe:
9.19. In order to bring about an effective integration of
■workers engaged in vertical programmes of health and family
planning, the concept should be extended to the district and the
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| State level. The division of work amongst the
district medical
| officers should be on a geographical basis rather than on a proI gramme basis. (3.6)
I r -i9'2?’ T‘!e concePt °‘ medical colleges integrating all health
I fonvard VeT) nUtntiOn’ 21:6
programines, has been put
?
.,9-21- Ic « suggested that there is no valid need for mobile
sterilisation units. For IUD work there may be a justification for
maintenance of some units but their continuation should be made
subject to hilhlment of specified targets. (8.3)
NOTE BY Dr. D. N. GUPTA, MEMBER-SECRETARY OF
i
THE COMMITTEE
At present there are a little over too medical colleges in the
, country Of these, there are four coUeges each in the four major
towns-Delhi, Calcutta, Bombay and Madras. Six other towns,
re Jk- yde5abad’ Ahmedabad, Poona, Nagpur. Bangalore and
Ludhiana have two medical colleges each. The rest about 71 medi
cal colleges are located in different States either at State headquarters or in large district towns.
Apart from under-graduate medical education which is im
parted in each medical college, more than half ajso impart post
graduate medical education. In many, the attached hospitals
impart training to the nurses. A few also undertake training for
para-medical staff like laboratory technicians. X-ray terhnirians
Some also participate in the training of some categories of health
start. As such, medical colleges are important training centres for
doctors, nurses and para-medical workers.
°
Though the medical colleges provide a large nucleons for the
training of health workers, it is common knowledge that their
role in the health delivery system of the country is meagre. The
trainers hardly know the job requirements for which they impart
training and those who have to utilize the services have very little
say in the training programmes. The producer and the consumer
therefore work almost in isolation of each other.
The medical profession in India today is caste ridden. There
are generalists and specialists, preventive and curative health-wallas,
administrators and non-administrators and teachers and non
teachers. In the latter there is again a distinction between clinical
and non-clinical teachers. Each group has its own vested interests
and there are group rivalries. There are several reasons for this,
some histoneal, come due to influence of rapidly advancing science’
but mostly on account of a lack of an over-view by a central body
or authonty. This has resulted in a situation where both the profession and the public are dissatisfied.
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It is felt that if the medical colleges could be made respon- I
sible tor the health delivery services of a section of population this B
trend can be reversed. The recommendation in the report of only 1
coordinating the existing patterns is considered a mere patch work 0
and the situation will not change materiallv. It is felt that direct £
and unequivocal responsibility for training and health care must B
be given to a single authority. The country be divided on popula- it
tion basis or the existing districts could be taken as units, three r
or four being entrusted to each medical college for training and. if
comprehensive health care including familv planning and *nutri- W
tion programmes. In such a set-up there will be graded facilities J
for health care, investigative facilities, and specialist services. . The h
health staff working in all the institutions in the area from sub
centre to the medical college hospital will be the staff of |f;
the medical college. There will be no division between preventive |and curative medicine and teachers and non-teachers. Facilities of 1
all the centres, PHC, Taluk, District or the medical college would I
be utilised for training. The staff would not be static but could I
be moved from one to the other centre. Those who dispense cura- I
tive medicine, be it in paediatrics, opthalmology, maternity or I
general medicine would also look after its preventive side.
««. I
Such a re-organisation would also result in a better referral
system whereby patients can be referred from one level to the
other and their records can be complete and traceable whenever
needed. A greater cohesion in the staff whether of the PHC or
of the district would also result, since all will belong to one department. The training imparted would become meaningful since it
would be related to the actual requirements. The much desired
shift in the outlook of health staff of all categories from the hospitai bias to the community would be brought about as all would
be required to work in the community for their training. The
young medicos will develop greater self-confidence as they would
get a feeling of belonging to a team though working at different
levels. A great deal of team spirit is also likely to develop between
the doctors, nurses and para-medical staff as they would have
common training places.
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It is thus visualized that a medical college (if preferred it
may be redesignated Health Institute) wall become a miniature
directorate where the only division is of various branches of medicine. The Civil Surgeon, District Medical Officers of Health,
Family Planning Officers, etc., would merge in the larger unit
each member engaged both in health delivery and training.
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It is suggested that this concept may be tried on experimental I '
basis in some medical colleges of some States. Alternatively, a i
Commission may be set up to examine this concept in depth.
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IfALTH development;
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1943-1975
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Rb|flECTOPATE GENERAL OF, HEALTH SERVICES
l/rtlNIS'TRY OF HEALTH AND FAMILY PLANNING
1 GOVERNMENT OF INDIA
rNIRMAN BHAVAN
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COMMUNITY HEALTH CELL
Society for Cotnntun^-Heatth ,.warness, Research 4 AcMon
(SOCHARA) Bangalore
Library and information Centre
CALL NO.^.R.Z..I30....N^n no
P-i \j a sqr fv'vvy-
author .
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Col
^ar-^apurx Roa<l,
Bang^alorex- 560/ 34.
Phone Nd. 55 0 724
Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
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COMMUNITY HEALTH CELL
Library and Information Centre
No. 367, Srinivasa Nilaya, Jakkasandra,
I Main, I Block, Koramangala, Bangalore - 560 034.
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V—REPORT OF THE GROUP ON
• MEDICAL EDUCATION AND
SUPPORT MANPOWER-1975
(SHRIVASTAVA COMMITTEE)
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20-38 CBHI/ND/84
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REPORT OF THE GROUP ON MEDICAL
I EDUCATION AND SUPPORT MANPOWER-1975
(SHRIVASTAVA COMMITTEE)
INTRODUCTION
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The Government of India, in the Ministrv of Health
■ and Family Planning, have invited attention to seme of the
J pressing problems and needs of medical education and support
> manpower and especially to:
rr
.j
the essentially urban orientation of medical education in
J
India, which relics heavily on curative mediods and
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sophisticated diagnostic aids, with little emphasis on the
1
preventive and promotional aspects of commumtv health,
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the failure of the programmes of training in the fields of
nutrition, family welfare planning, and maternal and
child health to subserve the total needs of the communitv
because of their development in isolation from medical
education.
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the deprivation of the rural communities of doctors, in
spite of the increase of their total stock in rbr society,
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—
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the need to re-orient undergraduate medical education
to the needs of the country, with emphasis on community rather than on hospital care, and
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— the importance of integrating teaching of various aspects
I
of family planning with medical cducationI
and have expressed the view that the structure at medical
I education has to be modified to meet the changing requirements
I and to provide adequately for future needs, particularly of the
?1- rural community. Government have also stressed the need to
I improve the delivery of health services by better trained and more
qualified personnel working under the supervision of fully-equip| ped medical doctors.
c
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1.02 In the light of these limitations of medical educational
ll* health services,, we have been requested—
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(a) to devise a suitable curriculum for training a cadre of
Health Assistants conversant with basic medical aid,
preventive and nutritional services, family welfare, and
maternity and child welfare activities so that they can
serve as a link between the qualified medv-a] practi
tioners and the multipurpose workers, thus forming an
261
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elective team to debv**’_
r ■nutritional services to thTp^^’ famiIy W'Ifar: a:^
5
II
Co) to suggest steps for
• •
cational processes as" to<T^.tne,CXIStlIig medical eduproblems particularly relevantn
e?phasi.S on
■keeping ip
*-h2
tiu' u0, natI0nai requiremeins
Committees ol
I
“iT by earii^
cal Education Co^mSee^
cation conference S and ^
I t
Ir
¥,edical Ed“‘
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for in.pfa^
jecdves'‘3MtoES IkeSj* ""
t
it
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the approach, Broj^Ind' OTpSf^?11'5 arosc tiding
•T<
fore, sought an interview with th w
R'Port and we, therePlaarnngt and in thXhTof
M!n!S^.of Health and Family
ocaded that our pmp^s for ^h
him’ “
cation and the orXnisation of
rtf°nnS in mcdical edum tne context
foe organisation^
ih°uld be made
context of
of the
health services
'co^try^V^could. indicate
ca tentative, framework, it
.
« *«»ld onphaSe"",'fcwT"'0^
" ^J„01 j^ro^ramrn^ for jinunecfiate
action and highlight the nr^n,k create the essential
J struc.
education,
the subject wh>ch follow
have to be
►ns which were approved
P
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‘of hX'S pZ”sp£,5;
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on the subjeos
doc"l”e”t> sraibblc I
gestions received from various as-J L
memoranda and sug- |',av
would like to convey our crratefu?^ T
l?dlviduals*- We ISt]
Director, National Health ServiS ££• Dr A^T^' S‘ SanjiV’’
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H«„ai a„d dJ. d f J: »•*>
«t Heald, Services,
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fo
Pos-graduate Medical Educadm ‘andTirch W
k°f I
gave us tneir valuable advic- and na^t
> PondlcherrD who
|
meeizgs We would also
of 0Ur I
Hon o- the unstinting- hard wort rm?* I °n Tecor^ our apprecia- rr
Dr. Sharad Kumar lut fo“ by
Mcmber Sc^«a^
I
to rmish our work inshOn ' ri
W
^le . I
Dr. s. K. Sen Gupta, Director
P r C aA,SIt?Ilce’ tendered by '
AD.G. (HA) inPo^S£ti2td’^d
C Ghoshat
ass^ceprov^ by the DirectorarX^^S.^f
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*T^ delails are given in Appendix R
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HEALTH SERVICES FOR INDIA :
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framework
A TENTATIVE
for the first
Its recommendations as well as rhn^ n/ X
de
tees in this field Tn
f «.k
odier imPortant committhe imprX results
sub.sta,n^1 investments made and
medical manpower thr h Itk ParUcu^y
production of
far fromTXS
StatUS °f the ^ian people is still
remain is so grea^and thVaddH™8?'^ °f the tasks
sha11
purpose anneafroLr
resources available for the
ourPhealthPneeds o S° !™Ited that onc aImost despairs of meeting
Broad models wp
°Ur asPirations on tite basis of ±e
come wTenle
t0
• A rimc has> before,
work of efficient and^fl^n^T1^ kf Pr0Vldlnff a nation wide net
de-novo wiffi a
* .KrVICeS needs t0 be reviewed
ment more suitable Fn °
jP ,a ternative strategy of developlities.
°r 0Ur cond'tlons- limitations and potentiaGeneral Principles
TflIS-Stratf^’ “ our opinion, will have to satisfy cer• ‘ c crltena such as (i) development of an integrated servicces andgfamTv0D17’
CUrativc aSPectS of hea’th ni
tain
hility to ah cities
t"1''"531
and eClual accessi- «
available in th
’
un ,satlon °f Para professional resources
s^ctured
C°?man:t;- and thcit supplementation by a well
,(4) Promotlon °f 4enious
j . s ,we" ,as fnH use of the latest scientific developments
S'o4
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(i)fA universal and egalitarian programme ot efficient
and effective health services cannot be developed
agamst the background of a socio economic structure
m which the largest masses of people still live below the
poverty line. So long as such stark poverty Persists, the
creative energies of the people will not be fullv released;
the state will newer have adequate resources 'to finance
even minimum national programmes of education or
health: and benens of even the meagre investments made
in these services will fail to reach the masses of the people,
inere is, thererore. no alternative to makina a direct
sustained and vigorous attack on the problem of mass
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poverty and
ana for
tor creation of
ot a more egalitarian society.
A nation-wide programme of health services should be
developed side by side as it will support this major
national endeavour and be supported bv it in turn, i
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2. ^Development essentially means the development of men
and not of things. It also implies an emphasis on the
development of human rather than of material resources.
For this purpose, the most significant tools, are education,
and- health. It will be difficult to define the inter-se
priority between them. But there is no doubt that,
taken together, they form the most powerful instruments
for the development of man and human resources. Both
education and health should therefore, receive the highest
priority and adequate allocation of resources, both at
the Centre and in the States and these in their turn,
should be supplemented by local resources. What is
even more important, the available resources should be
used most economically and supplemented by well plan
ned human effort to obtain the best results possible.;
3. We have adopted tacitly, and rather uncritically the
model of health services from the industrially advanced
and consumption oriented societies of the West. This
has its own inherent fallacies : health gets wrongly
defined in terms of consumption of specific goods and
services; the basic values in life which essentially deter
mine its quality get distorted: over professionalisation
increases costs and reduces the autonomy of the indivi
dual; and ultimately there is an adverse effect even on
the health and happiness of the people. These weeknesses of the system are now being increasingly realized
in the West and attempts are afoot to remedy them.
Even if the system were faultless, the huge cost of the
model and its emphasis on over professionalization is
obviously unsuited to the socio-economic conditions of a
developing country like ours. It is, therefore, a tragedy
that we continue to persist with this model even when
those we borrowed it from have begun to have serious .
misgivings about its utility and ultimate viability. It is,
therefore, desirable that we take a conscious and deli
berate decision to abandon this model and strive to create
instead a viable and economic alternative suited to our
own conditions, needs and aspirations. The new model | •
will have to piace a greater emphasis on human effort |
for which we have a large potential rather than on mone- |
tary inputs (for which we have severe constraints). * |
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4- Health is essentially an indindual responsibility in the
sense that, if the individual cannot be trained to take
proper care of his health, no community or State pro
gramme of health services can keep him healthy. The
issue is, therefore, basically one of education.' Every
individual must be given the relevant information about
tos body and its functioning, must be taught the essen
tial health skills (including the care of himself and of
other persons in illness and preventive aspects of health,
and must be enabled to develop values of self control
and discipline without which no person can remain
healthy. It is also desirable to educate an individual in
developing proper attitudes to health and disease, to
accept old age gracefully as a natural process, to over
come abnormal sensitivity to physical pain and to learn
to accept death cheerfully as an essential ingredient of
lire itselL It is a pity that these basic values which
our tradition has been inculcating among our people for
generations are being eroded, rather than strengthened
in the processes of modem formal education.
5- (_The community responsibilities in health are even more
important. It is the duty of the community to provide
a proper environment for helping each individual to be
healthy. This will include, amongst others, the supply
of safe drinking water; adequate measures for disposal
of human excreta: avoidance of air pollution; and con
trol of communicable diseases. In our own tradition,
these social aspects of health are the weakest and they,
therefore, need strengthening and the highest emphasis/1
6. The State has an over all and supreme responsibility for
providing a comprehensive and nationwide net work of
health services. This includes; and the direct attack on
mass poverty; provision of adequate nutrition; development of integrated services in education and health;
and the organization of para professional and profes
sional services to cover the promotive, preventive and
curative aspects, with emphasis on maternal and child
health services which are of the highest emphasis in> this
country. Unfortunately, several of these programmes
have received inadequate attention, all of them have deve
loped mostly in isolation from one another and there
has. been, an undue empnasis on the curative aspects
which are probably the least important. It is high time
that all these programmes are developed as a package
deal and in their proper perspective.
266
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7. The over-emphasis on provision of health services
through professional staff under state control has been
counter productive. On the one hand, it is devaluing
and destroying the old tradition of part time semiprofessional workers which the community used to train
and throw up and which, with certain modifications,
will have to continue to provide the foundation for the
development of a national programme of health services
in our country. On the other hand, the new profes
sional services provided under state control are inade
quate in quantity (because of the paucity of resources)
and unsatisfactory in quality (because of defective train
ing organisational weaknesses and failure of rapport
between the people and their so called servants). What
we need therefore, is the creation of large bands of part
time semi professional workers from among the com
munity' itself who w.ould be close to the people, live
with them, and in addition to prombtive and preventive
health sendees including those related to family plan
ning, will also provide basic medical services needed in
day-to-day common illnesses which account for about
eighty per cent of all illnesses. It is to supplement
them, and not for supplanting them, that we have to
create a professional, highly competent dedicated, readily
accessible, and almost ubiquitous referral sendee to deal
with the minority of complicated cases that need specia
lized treatment.
8. In the existing system, the entire programme of health
services has been built up with the metropolitan and
capital cities as centres and it tries to spread itself out in
the rural areas through intermediate institutions ‘such as
Regional, District or Rural Hospitals and Primary’ Health
Centres and its sub centres. Very naturally, the quan
tum and quality of the services in this model are at
their best in the Centre, gradually diminish in intensity
as one moves away from it, and admittedly fail at what
is commonlv described as the periphery. Unfortunately,
the ‘periphery’ comprises about 80 per cent of the people
of India who should really be the focus of all the wet
fare and developmental effort of the State. It is, there
fore, urgent that this process is reversed and the pro
gramme of national health services is built with the
community itself as the central focus. This implies
the creation of the needed health services within the
community bv utilizinp all local resources available, and
then to supplement them through 2 referral service
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267
which will gradually rise to the metropolitan or capital
cities for dealing with, more and more complicated
cases.
9- Throughout the last two hundred years, conflicts have
arisen, in almost every important aspects of our life
between our traditional patterns and the corresponding
systems of the West to which we have been introduced.
In many of these aspects the conflicts are being resolved
through the evolution of a new national pattern suited
to our own genius and conditions. In medicine and
health services unfortunately, these conflicts are yet
largely unresolved and the old and new continue to exist
side by side, often in functional disharmony. A sustain
ed effort is, therefore, needed to resolve these conflicts
and to evolve a national system of medicine and health
services, in keeping with our life systems, need and
aspirations.
I
io. Education and health have continued to grow in isola
tion from each other to the detriment of both. It must
now be emphasised that no programme of education
(which means a sound mind in a sound body) can
succeed unless it is blended with that of health educa
tion. Similarly, no programme of health services (which
is essentially one of individual responsibilitv) can succeed
without education which alone can give each individual
tlie needed information, skills and value orientations.
We must, therefore develop these programme together,
not only in the formal education system, but also through
non-formal methods which cover the out-of-school child
ren and youth, the adult population, and especially the
workers.
II. Nutrition is one of the most important components of
health. There is overwhelming evidence of hunger and
malnutrition among the large masses of people living
below the poverty line, and especially among the vulne
rable groups of voung children and pregnant and lacta
ting mothers. The problem will, therefore, have to be
tackled on several fronts. We must produce more food
and ensure its proper storage. A large scale public
distribution system must be developed and employment
at reasonable levels should be available to every person
so that he will be able to procure at least the minimum
food needed for himself and his familv. Programmes
of supplementary feeding for vulnerable groups like
pregnant and lactating mothers or voung and school
going children or for the control of preventable diseases
I
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hke nutritional blindness or anaemias and ^oitre should
be developed A progtanune of immunizatfonS X
.^eloped side by side to break the S circ e
SSn t
“^tion reducing £
resistance to infection and infection, in its turn accent
tant isStfeC
o£ m^tridon. Equally’hnpor-
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K
I
Sg and dietary
> UCahabits
yVf-prOgranlmc
of
the Cookof the people of scientific lines.
I2’ S^rvJiannmg lS
bask
in development just
Xntro T*
isSUC “ population
trot A massive and urgent programme of family
plannmg, based on the application of existing contracer^
the
Ogy’ mUSt 1>C dcvcloPccl °n a warfooting and
the birth rate must be brought down to replacement
grnng problems which the country will have tb face
it its population nses, as anticipated, to a billion mark
eve! by the turn of the century; adoption of measures
to spread the small family norm through education,
reduction in mfant mortality, increasing the cost of
bringing up c. .Jren, etc., spread of education amon<r
women and improvement of their status, development
ot programmes of non-formal education (in which family
planning is an essential ingredient) for youna persons
m the age group 15-25 training of large numbers of
tamily planning workers from the community itself and
particularly from among the educated housewives; and
making family planning an integral and important part
or the comprehensive health sendees of the country’.
.1. 2r°3 YC recommen^ that Government should undertake theot evolving a national consensus
consensus on
on the
the broad
broad strategy
strategy to
to be
be
scooted for the development of: a comprehensive
’
•
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nation-wide' net
"work of health sendees in the country during the vyears ahead;
general principles stated above and the broad frame-work
which they indicate for the development of these services may be
taien as a basis for consideration in this effort. z
MAJOR PROGRAMMES FOR IMMEDIATE ACTION
3.01 If a viable model of national health sendees is to becreated on the basis of these broad principles, immediate action
will have to be initiated on the following four programmes,
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1. Organisation of the basic health sendees (including nutrition, health education and family planning) within the*
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community itself and training the personnel needed for
the purposes;
2.
Orgamsation of an economic and efficient programmes
of health services to bridge the community with the first
level referral Centre, inz.y the PHC (including the
strengthening of the PHC itself);
3- The creation of a National Referral Services Complex
by the development of proper linkages between the PHC
and higher level referral and service centres; and
4- To creat the necessary administrative and financial
machinery for the reorganisation of the entire program
me of medical and health education from the point of
view of the objectives and needs of the proposed pro
gramme of national health services.
We shall discuss these four programmes seriatim in the sections that follow.
HEALTH SERVICES AND PERSONNEL IN THE
COMMUNITY
£°ri^
4.01 The first assistance that any community needs in the
health services should be provided within the community
4.02 For some of these services, it is necessary to provide
paid and trained professionals in public services. Some other
services may be provided by fully trained professionals who are self
employed. It is, however, erroneous to assume that these sendees
should be provided only by these two categories of professional staff.
At the community level, what is needed most is not professional
expertise so much as nearness to the community, its confidence,
emotional rapport with the people, willingness to assist, low cost,
and capacity to spare the needed time. It is, therefore, necessary
that some of these services should be provided by the members of
the family itself and also by part time trained oara professional
persons who operate on a self employment basis. Even in societies,
which are affluent enough to provide all health services through
fully trained professional persons, either in public service or in self
employment, it is now become increasingly evident that the
quality of life and of the health services will infprove through the
introduction of suitably trained part time para professional persons
working on a self emplovment basis. For developing countries
whose resources are extremely limited this method of providing
health services is not oniv desirable but also inscapable.
4.03 It may be recalled that, in the past, almost all health
services and used to be provided by part tune para professional
?
5
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P'r““
« »h«
o„ a self e^io,.
-inent basis,
MS?
”' °‘ “«?'■>» ’I®™ <>1 »=ic„e
trained in a__
_
4 n Or dte village dais who still perform
the bulk of deiii.l_
advantages of the svstem, instances of this practice. While the
low cost, are obvious r , such as its closeness to the communitv or
i«
its main weakness lies in the fact that the
“die mSZ andi^ences^^! to modern
m°dern devdoD:ncn
*
develouments
~ scienccs
50 onTr'^Mi;
that h often leads to qmiery.
L a oris™
^P10^
. - - '’ery competent,
-------7 trained persons
P^int^^B^ “ D° d0ubt
-- — doubt vciy conpctent from a technical
and social advant- " 1 of theSOmC
tb; system
“notional,
1
traditional
and^^^
*hat we will nor
tradiliona^-'Tstetn and it
univcrsalist
it. What
werSfiJvS
•thJc to
?ood
featutes oTboih
*e is necessary
----- : systems. If
tn k k 1
the individuals and train tliem"
, according
aHable by rhe latest develop-^XVVklw*
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K
siiiis
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SU'
an
It
ne
sk
P*
sa
ca
1
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dcncc X TcnT1?’ ?
B C10SC t0
thcir “nfisimple and day to^v
Froviding
immediate,
community • d) ;r mil
and rthcir scrvices needed bv the
structure ^f
J
fouD<utI0n on which a soperhc advantaaennX ^1 d
, Professional re&rral services ban
of medical ^nd h 1 ’
11 wou’d have created a pattern
than die^D^
Which WOuld
q^htativeh- better
resourS E tTf” ^d
r6lmin wthi" thc ^c-ial
at are likely to be available in the near future.
iXXV
IX ‘«3t4
-pprovision^ f
famly ltScIf
Participation in the
mntiv
f suclJ ^ces or in attending upon sick persons. This
WOdd -v ? t0 be
further through the
to ™
Sh°Uld pr°Vlde 3 COre of health cd^tion
to eery student and also require him, as a part of work experience
□ nt?
to nurse sick persons in his own family or outside
and also it participate m the development of services of a promotive
vidual
cfaaiart~. This wall enable a large number of indi
viduals to drover meir own interests and antitudes. Manv of
b±COla£ para Professi°nals bv acquiring the speciah?d SklkLn=CeT^ and °Perate on a P^ time self emplov^ment
basis or become full mne professionals within or outside the nublic
pei
Or
is
2.5
wh
An
An
eve
in
but
for
inc
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BIUU-J-
271
4.05 It would also not be proper to regulate the number of
inch workers Such a step would lead to the creation of a scaititv
md monopoly sttuanon with well known adverse consequent
It should, on the other hand, be open to any individual with the
necessary aptitude, background and talent to acquire the necessarv
skills and to prov.de the services. In fact, the more such trained
people in a community the better for all concerned
I
4.06 In every community, we should
should have
have trained
trained local,
>emi professional, part time workers of at least the followin'
----- o
categories :—
5
I.
An adequate number of dais to provide matemiry
services (some of them could also be trained to
the whole range of MCH services including family
planning).
A large number of family planning workers from anting
adults, young men, housewives and public function.
3- Persons who will be able to dispense a set of specific
remedies selected from all systems of medicine for ordknary, common ailments.
4- Persons who have been trained in the skills needed in
programmes for the control of oommunicable diyases
and whose services can be harnessed readily in case of
emergencies.
5- Persons who can help to develop promotional and preven
tive health activities (especially those relating to improved
nutrition, environmental sanitation, control of common
diseases, yoga, physical exercise and so on).
2.
4.07 These skills could be imparted to selected rouna
poisons from the commumty who may have the necessary apt3mdes°
One unprtant group which may be considered in this context
is that of the primary school teachers who now number about
2.5 million and are present even in the remotest rural areas and
who have considerable acceptability and status in the community
Another important group would be that of educated housewives’
An increasmg pool of educated women is now becomino- availAle
even in rural areas (the census of 1971 records 1.5 millfan uuaen
m rural areas who are enumerated as housewives or non-wodeers.
but who are educated up to matriculation and beyond) and these
form a large and useful pool for the training of such work^
including those for family planning. These workers, it mar U
pointed out, need not necrssmly be multipurpose.
4.08 We would like to emphasize the point that perfadfa-d
retraimng °f these personnel is extremely important as wed as to
provide them with necessary guidance and counselling fa their
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day to day work. The referral services should also be made availa
ble to them. In fact they should be looked upon as important
links between the communit}’ and the trained professionals and the
organized referral services.
4.09 This emphasis on the creation of a large band of semiprofessional and part time health workers in the community itself
is proposed merely as a second level supplementary personnel to
fully trained professionals and not as a substitute for them. Where
doctors or other personnel trained in indigenous or modern system
of medicine are available, their services should be fully utilised,
not only to provide health care to the people in the way best suited
to each case, but also to train (or retain) and assist other workers,
honorary or part time, of a semi professional character. We
visualize that these two cadres would work closely together in an
integrated fashion, the para professional personnel in the commu
nitv reheving the trained professionals of the innumerable small
things over which their time would otherwise be wasted and the
trained professionals taking over the more complicated cases direct
and also providing referral and guidance services to the para profes
sional people.
4.10 It would not be desirable to try to convert these para
professional workers into a cadre, to give them remuneration from
State funds or to supervise them. This will alienate them from the
people and convert them into petty bureaucrats with all their
faults. The general policy should be to leave them free to work
with all their faults. The general policy should be to leave them
free to work with the community on the basis of the trust and
confidence they oan generate. The investment of the State in the
organisation of this group of para professionals within the commu
nity’ should be limited to the provision for training and retraining,
free of cost, on as large a scale as possible and to the provision of
Guidance and counselling through health workers, the proposed
health assistants and doctors. Where necessary, the State should
make supplies of materials (such as specified remedies) available
at reasonable prices and on an assured basis. The overall financial
investment on all these items would be comparatively small ; and
but the returns therefrom would be far greater.
r
to
cm
SPC
alsi
pre
ah
the
xor
ah
cu
ha
th
ac
st
st
be
C3
th
4.11 These proposals might perhaps cause an adverse reaction
in certain quarters on the ground that they would create, and let
loose on the community, a large number of quacks who, in the
lon^ run, may do more harm than good. But a close examinatioti
wilFshow that this will not be the. case. The role assigned to
these para professional functionaries m the fields of promotiye or
preventive aspects of health and family planning are basically
educational and are capable of doing immense good without any
untoward implications. Some apprehensions may anse with regard
ffl
ill
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”
?^.”XL“Tfsr S'" “d
selection criteria for workers,
the duration and content of their
training and retraining,
counseling, including
& U1L1UUJUS
—
the provision of guidance
periodical evaluation,
~
Snn repaf tlon1Iof1marteriia]s for these personnel in simple
terms and in all the Indian languages, and
P
~
°f’“^tons where their training, etc
will be conducted, including the training for the Jiners”
and
S "d
accepted m principle by Government. ’
started 711
J™US
0"'b?
programme is
Scheme cannot ^mediately be
x-s
*
tegunug Md a fairly rapid genendizahon i„ iL
possible.
T
out by
’jr as
•
2. After early consultations with the State
tbr-
should l» foafed qulddy „d a,
end of the current Tear.
rnc
3* 'The necessary financial provisions for th.
be made in f
’
J
a centrally sponsored scheme of the
-- —j Fifth Five Year
Plan.
“
S“= Mgi'S”? “
4- The work of the scheme should begin in selected
areas
m each State/Union Territory in 1976-77 and
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274
5. The scheme should be expanded to cover a fairly large
part of the country’ by the end of the Fifth Plan and the
entire country’ by the end of the Sixth Plan.
L
4.14 These bands of community level health workers once
created, will form the links between the people at large and the b
multipurpose workers functioning at thq sub centres and the doctors
t
at the PHC level. This wrill make a much better utilization of
their time and energy possible. Their training should, therefore, ! I
be adequate- to ensure that, while they can freely offer
services within a well defined sphere of simple urgent and
!
day to day needs of the commuiritv, they would be able
to decide when a case needs referral or consultancy from
trained professional staff and take action accordingly without hesi
tation or delay.
FROM THE COMMUNITY TO THE PRIMARY HEALTH
CENTRE
5.01 Beyond the community (and the local professional or
para professional health workers within it) Ties the next stage in
the organisation of health services. In this area, we have, at
present, various categories of health workers and their supervisors
at the sub Centres and the PHC itself which also has its comple
ment of doctors and other facilities. In our opinion, the provision
of these services between die community’ and the PHC needs
reorganisation and the Primary Health Centre itself requires
strengthening.
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5.02 The Bhore Committee visualised the development of the
Primary Health Centres in two stages. As a short terms measure,
it was proposed that each PHC set up in the rural areas should
cater to a population of 40.000 with a secondary health centre to
serve as supervisory, coordinating and referral institution. For
each PHC, two mcdioal officers, four public health nurses, one
nurse, four midwives, four trained dais, two sanitary inspectors, two
health assistants, one pharmacist and fifteen other Class IV
employees were recommended. In the long term, the Committee
visualised a PHC to serve a population of only 20,000. The
function of the PHC were to include medical relief to both in
patients and outpatients, maternal and child health services inclu
ding family planning, control of communicable diseases, school
health, environmental sanitation and health education. But un
fortunately it has nor been possible on financial grounds, to imple
ment even the shon term proposals of the Bhore Committee to
this dav. At present, the Primary Health Centre serves a total
population of about 8c,000 to 120,000 and has a num smaller
stafi than that visualised by the Bhore Committee for a population
coverage of 40,000 only. It also has a number of sub centres.
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275
I rougWv at the rate of one for every to,000 population.
Under
1 Sth wo t1’ and.“Pe,clally hl the absence 8f community level
| health workers on the desired scale and of the right qualiw it is
I no wonder that the out reach of our Primary Health Centres in
I rural areas is very inadequate.
I
5-03 It will not be financially practicable to inrr^c- the
I number of Primary Health Centres except marginally.
I
°f devel°P”e£ in ±e imiedhte
I future should be on the following three programmes :
I
(1) To reorganise the service of Health Workers and to
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increase their number as resources become available and
ultimately to provide one male and one female health
worker for every 5,000 population;
(2) To create a new cadre of health assistants bv providing
suitable training to the existing health supervisors and
to increase their number so that there is ultimately one
health assistant (male/female) for every two health
workers (male/female); and
(3) To strengthen the Primary Health Centres.
I Reorganisation of the Services of Health Workers and the Creation
of the New Cadre of Health Assistant
I tinnan«4w?Ukng ^5laSt ^“7 four years,, the cadres of funo
tionanes which provide various health services to the commnnitv
^CvT? I? !ed/Cry fear bcC:1USe cach heal6h Programme was
run virtually independendy of the others and with little coordination, both among the field workers and amongst those at the
r d0CtorS at
EVC,1
P« HeaS
Centte had separate spheres of activity, one being devoted to the
family planning programme and other to the provision of <mneral
wdl asTeffi 1S D0W
th3t in
interest of econfmvZ
well as of efficiency, it is necessary to creaoe a single multinun^^
PromotIve’ Preventive and active
control of communicable
heakVte^^0
SesJ ^d5 re?d-
Sre
1 S° r mC Udt- Wldun the responsibilities of this
nj VLmlCUln °f .curat3TC
an emphasis on maternal
^e
7 ?r
PlanninS The Prn^Xf
CbyS^ r lng5 C0m7IttCC ?this ^rd have been accSJd by
m the States We fully support them subject to the observations
made in the following paragraphs.
Health Workers
At pres,ent- ^7
a maIe health worker" for everv
6?ogo-a,ooo population and one female health workers for eveZ
6,000-7,000
To.ooo population. The praised target for the Fifth Fiv^ v//
21-88 CBHI/ND/84
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t.
ian is to provide one male and one female worker each for a
. filiation of 8,000. While we welcome this, we recommend that
by the end of the Sixth Plan, we should strive to provide one male
and one female worker each for every 4,000 population.
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5.06 Wc also recommend that every health worker should bo
trained and equipped to give simple special remedies (including
proven indigenious remedies as well) for day to day illness. Apart
from the fact that this will provide an essential and needed curative
service to the people, it will also increase the acceptability, utility
and efficiency of the health workers themselves
f
Health Assistants
i
5-oy At present, there are several cadres of unifunctionary
supervisors. The Kartar Singh Committee has done a signal service
bV
the integration of all of them into a single cadre of
health supervisors. While wc endorse these proposals, we are of
the view that they are inadequate to meet the situation and recom
mend the following changes :—
I
1. All this supervisory personnel should be designated as
‘Health Assistant’ r
1 ’J ’’ ’ the
*’ ’ roler of assisting
to highlight
the work of the doctors at the level of forming a
link between the PHC and the health workers.
[
2.
I
The present position is that we have one male supervisor
for every 20,000 population (or onejor every three male
health workers) and one female supervisor for every
60,000 population (or one for every six female health
workers). In the Fifth Five Year Plan, there is a proposal
to increase the number of female supervisors. The
Kartar Singh Committee has recommended one super
visor for every four health workers. We recommend
that we should strive to provide one male and one female
health assistant for two male and two female health
workers respectively.
3. The Health assistants should be located invariably at the
sub centres and not at the PHC.
4. The Health assistants, like the health workers, should
also be trained and equipped to give specified remedies
for simple day to day illnesses but at a higher level, of
competence. The curative services for which they should
be trained, the medical kit which they should carry, all
this needs to be carefully worked out, should be immediately undertaken by the Director General of Health
Services.
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5. While the health assistants do have a supervisory role,
they should also function as health worker in. their
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277
area’ carrying out the same dudes and responsi
bilities. but at a higher level of technical competence.
They will be specially responsible for the promotive and
preventive health measures ano all the national health
programmes. The female health assistant should take
particular care of xhildren and expectant and lactatin^
mothers.
5.08 Our proposals regarding health assistants may fall
in two phases. The first phie is qualitative in the sense that it
is not proposed to increase the total number of persons at the
supervisory level, but to replace the existing varieties of unifunctionaries by a broad based single cadre of multipurpose, middle
level workers, comprising the sub-doctorate and sub-professional
groups. From the point of view, persons in the existing categories
of health supervisors, after suitable screening, should be given
intensive training for varying periods so as to fit them for the job
expected of them as health assistants. In the second phase, we
propose that the number of health assistants should be increased
as suggested above in para 5.07(2).
5.09 We regard the cadre of health assistants as incentive
and promotional cadre for health workers. We, therefore, recom
mend that the recruitment to the category of health assistants
should ordinarily be restricted to health workers who are duly
qualified to shoulder the higher responsibilities involcd. Where,
however, such qualified health workers are not available for promo
tion, an alternative channel of lateral recruitment from the open
market should be provided.
5.10 Details relating to eligibility qualifications for promotion
or selection into the category of health assistants, the period and
kind of training that will have to be provided to health workers
for the purpose, the institutional arrangements needed for such
training and its curriculum content, etc. are important and will
have to be worked out by each State on the basis of general
guidelines provided by the Centre*. In course of time, as the health
assistants replace the existing^ health supervisors, the latter category
would eventually be phased out.
5.11 Both the health workers and the health assistants will
have to function as important links in the referral services. Thev
will deal freely with cases within their sphere of competence; but
their training would have to emphasize that they should refer the
cases beyond their competence to the appropriate agency without
delay or hesitation.
have
in Appeodx ITT. a broad outline of the functions of the
.HeaKfe Assistant as vol as the venue and curriculum of training.
*
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5.12 Wliile attempts to Induce doctors to settle down in
rural areas should continue and the services of all available doctors
in rural areas should be fully utilised, there is no doubt that
thv category of health assistants will still be needed for years to
come to supplement the available pool of medical man power in
rural areas, it is also necessary to cmphaHze that the health assis
tant is not a functional substitute for a doctor. But he will be
providing useful health services in the sub centres and thus will
increase effectively the out-reach of the Primary Health Centres
themselves.
“
The Primary Health Centre
5.13 The creation of local para professional workers in the
community itself to provide simple specified medicines for common
u j° •
1^ncss
the introduction of a curative function in
the duties of the health workers and health assistants in providinosome medical relief to the community will lead to a change in
the functions and responsibilities of the doctors at the Primary
Health Centre. They need no longer spend a greater part of their
uS
Prcscnt’ *n providing simple medical relief and wduld
“us °c a^ e to devote more attention to the referred cases and
to the development of provision and preventive programmes of
community medicine and health. In spite of this, however, we
do feel that the Primary Health Centre itself needs to be
o cued in manpower resources. In view of the fact that
women and children form the bulk of the population, we recom
mend that the immediate programme should be to add one more
doctor, especially to look after maternal and child health services
and one nurse. This will not only create an important readily
accessible professional skill in the PHC area, but would also ensure
greater coverage and more effective use of the existing beds at the
PHC. Similarly, the existing allotment of Rs. 12,000 earmarked
tor the purchase of drugs at each PHC is inadequate and needs
to oe increased. The additional funds needed for this programme
should be found on a priority basis.
&
S-M The National Service^Act, in its application to the
medical proxession, need not be used to strengthen the medical
manpower available at the Primary Health Centre. It is also not
desirable to post the young inexperienced doctors at the Primary
-wealth Centres and more so because the present system of medical
education does not produce a doctor properly oriented to commit
mtA needs. It should, however, be possible to use the newly
recruited young doctors to strengthen the medical manpower at
me medical college, regional district or taluk/tehsil hospitals and
tc^ utilise the sendees of some senior doctors who would thus beeueved to work at the PHC level. We further recommend that
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a ru^e t0 t^le eSect that every doctor in
Lt
h SCrV1C£ ^^IspenS, between the firth and fifteenth
at a PwrS
? P^r10^ °f nct less than two consecutive years
at a PHC should also be explored.
THE REFERRAL SERVICES COMPLEX
t^e 0P’r|lon drat the para-professional groups
c^u^hes’thc hcaith w°rkers’the hea>^
dnf’
ri "t,
PHC doctors cannot satisfactorily perform the
du^es and functions expected of them unless they are properly
n n^atel mt0 A weU-organised referral system which would
provide them with adequate support and guidance. From this
accessihl V'e7’ 11
n£cessV>; to develop an efficient and readily
i°f
£r°m the PHC to hiSher “d more
d
T
neighbouring taluka/tehsil, district,
h^nital
medlCa co leSe hospitals. At present, most of these
hospitals function m almost total isolation from one another and
without satisfactory links with the local community and a wide
gulf separates them from the Primary Health Centres. We
s&ongly feel that th« situation has to be immediately remedied.
We therefore recommend that the Primary Health Centres, as
hosnitalthbTMUka/3'CJS,1’IDiStriCt’ rCgional and medical
hospitals should each develop living and direct links with the
community around them and also have functional links with one
another within, a total referral service complex. This linkage can
Dro<re>mmSeCUkel
P™?"1? organized internship
programme which will be discussed in the following section.
Once established, it will create a viable and economic referral
services complex which will have several advantages. It will
provide a programme of total health care : promotive, preventive
curative and rehabilitative. It will also form a nidus for trainins
in community medicine. The services of the outpatient depart
ments of the semi-urban and urban hospitals would become
available to individuals and their families in rural areas.
A medical college hospital whose health care has its out-reach in
the community through such a complex can become an effective
taimng ground for training personnel oriented to community
health and for the more efficient delivery of health services to the
community. Taken as a whole, the programme will not only
provide the most efficient health care services possible to the
community but will also provide feedback from the community
to the system of health care ifrelf and lead to great improvements
therein over tune.
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the establishment of the medical and health
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EDUCATION COMMISSION
/.oi It is common knowledge that the existing system or
medical education docs not prepare the right type of personnel
et
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E-<fed for a national programme of health services. If thesy-em of comprehensive health care visualized in the preceding
sa-avas is to be developed properly and worked efficiently it it
enviously necessary to restructure the entire programme of medical-
Basic Issues in Medical Education.
7.02 Among the basic issues in medical education, probably
ffie most important is the training of the general medical practitoner who occupies a central place among the different functionanes needed for the health services. His work is not merely
with treatment of sickness and prevention of disease but also
with those social and cultural problems that contribute to thetaonc ot health. His commitment is to man and to the human
must cilange his outlook from an excessive concern
with disease to a irole of full social responsibility. The manner
is which physicians
. ; are educated and the nature of the educational
outcome are therefore of paramount importance,
7-°3 It is widely recognized that the present system of
undergraduate medical education is far from satisfactory^. Despite
tne recommendations made by numerous Committees and Confe
rences, improvements in the quality and relevance of medical educa
tion have been tardy. Although the setting up of Departments
Qt Preventive and Social Medicine in the medical colleges over
15 years ago was a step in the right direction, this by itself has
not met with significant success as it lacked scholarly foundations
ano the field practice areas were not adequatelv prepared.
The stranglehold of the inherited system of medical education,
tne exclusive orientation towards the teaching hospital (five years
an^ three months out of five years and six months of the total
period of medical education being spent within the setting of the
trrdnng hospital), the irrelevance of the training to the health
needs of the community, the increasing trend towards specialisa
tion and acquisition of postgraduate decrees, the lack of incentives
an. adequate recognition for work w thin rural communities and
thv. attractions of tne export market for medical manpower are
some of the factors which can be identified as Being responsible-,
for the present day aloofness of medicine from the basic health
net Oh of our people. Tne relation ot medical education to the
social framework of the commumtv h largely brought out towards
th. end or the students period ot rormal training and medical
education continues to postpone, rcther- than, prepare, a doctor
for the practice or medicine m the community. A vacuum:
separates the health centre and the doctor from the village and
the people^and the cr/Jcs. neafin n-ec" of people remain laro-ely
Uiz -;_l. rhe~ greatest challenge to medical education in our*
coc^iry, therefore, is to des.’gn z . . .2': that is deeply rooted in
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| th© scientific method and yet is profoundly influenced by the local
| health problems and by the social, cultural and economic settings
I in which they arise. We need to develop methods and tools of
instruction which have relevance to the resources and cultural
patterns of each area. We need to train physicians in whom an
interest is generated to#work in the community and who have
th© qualities for functioning in the community in an effective
manner. In addition to medical skills, they should be trained
in managerial skills and be able to improvise and innovate.
Objectives of Undergraduate Medical Education
7.04 If these far-reaching reforms are to be carried out
several basic issues will have to bo discussed in depth and appro
priate decisions taken thereon. The first relates to the objectives
of under-graduate medical education. Whether it is the training
of a physician or an auxiliary, the principles of educational science
should find increasing application in the educational process. Goals
of education must be clearly defined at the outset Appropriate
instructional methods must be selected and the curriculum con
structed and duration determined to enable these goals to be
accomplished. The outcome should be evaluated'by the use of
appropriate criteria to see if the desired change in the functional
behaviour of the student had in fact taken place.
7.05 There is a definite need to define the skills that a doctor
should hav© and the qualities that he should possess. The ‘Basic
Doctor’ was defined in the report of the Medical Education
Conference held in New Delhi in 1970. The objectives of under
graduate medical education that are appropriate for developing
countries have been set out in the WHO Inter-Regional Confe
rence on Medical Education and in numerous other Confemces
dealing with medical education. The language, sequence, mode
of presentation, and relative emphasis vary from statement to
statement but they all have a fairly common core. We do not
propose to attempt a full and detailed statement on this subject.
We are, however, convinced that whatever the form in which the
objectives of undergraduate medical education may come to be ulti
mately formulated, one thing is certain : the over-riding objective
of the under-graduate medical courses should be to give a positive
community orientation to the*entire programme. It is from this
point of view that the several recommendations made on the
subject by earlier committees and conferences will have to be judg
ed and the several experiments now going on in the field will have
to be evaluated.
Pre-medical Education
7.06 The curriculum of undergraduate medical education will
depend, not only on the objectives of the undergraduate medicaf
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kvTnTn’ bUt aiS0 °n P™dicaJ edua»on which determines thel of preparation at which students will enter the under-gradu-e
I
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a ^OcT/n
educati°n “ S
at a balanced education in humanistic and scientific studies h
o^LgTatehCOntlnUCd
Phenom“on of living
education ’itsetf ob’ectIves cannot be divorced from those of medical
eaucation itself. The two vears <ofr continuous study
- of- pre-medical
science after ten years of school as
as envisaged
envisaged in
the
in the new pattern of
school education snould result in a better and mt '
closely integrated
--- more
Fe-meic^ education. The basis of medicine
he?
e
--—
-J
in biology and
it should be taught as a C
dynamic, multilateral and comparative
science ranging from the molecuhr W
- --1 to that of individual
human bei•m
’___ * ■
commumues
and populations. Physics and Mathe^Hatics are closely allied to one auvma ano ineir runction is to
facilitate
10 °°e1anothcr and their function is to
2^
P
•2nd accurate
hab't of
of thinking.
thinking. Chemistry
Chemistry is
an
accurate habit
is an
experimental science and students----- ’
•
“
---- -H must be encouraged to make
The^eLTsner- problems rather than observe sct
set ^monstrations,
demonstrations.
nr, i j' *■Pec.!a!lzatl0n
at
secondary
school
level
in vogue
vogue until
until
---i at secondary school level in
now led to serious
inroads
available fm libe
liberal
Xation^n
Ch°US ln
-rOads jinto
nu° the
ihc time avaiiable
^
education in humanities
humanities and
and behavioural
behavioural sciences.
sciences. Medicine
Medicine is
is
prarnsed
not
in
a
world
bounded
by
science
alone
but
m.one
in
which, ccono^’Xll
d'd-by
A“ bu,'“ i"
Tb C t <\C0n°mic>.c^tural scoial influences play an important role
The study humanities should provide the student with an intefli-
s I
!
!
pa5t and °f the Srcat idcas that bave
should fliuXaniCIV, ,Satl0'LJhJe contcntof Preniedical education
should thus be deeply embedded in the framework of natural
Circes, humanities and social sciences. We are also of the view
that pre-medical education should be provided by the Universities
in consultation with the authority to coordinate and determine
standards in medical and health education. It should not be
provided in medical colleges.
Curriculum, of Undegraduate Medical Education
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t0 dlscuss the curriculum of unders;. actuate medical education m detail because considerable useful
material on the subject is already available. We would, however
mvite attention to some important considerations in this recTaid’
ror instance, major challenge before medical education for quite
a few years will be, as stated earlier, to give a community orientaron to undergraduate medical education and to equip the entire
system of medical education in adequately for the puroose. Thteaching of community medicine has therefore, to become a joint
r??Ur 01 ther^oic facil!r)’
merely a responsibilhy of
Deprtment ot Preventive anc Social Medicine. The DiAartP{cventIVf an^ Social. Medicine itself will have to be '
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.aoened m concept anu extendeo in operational aspects. Jr wul
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areas in which active health service programmes are in operation
and which will be fully utilized in the implementation of the
educational programme of community medicine. There should be
an emphasis on the teaching of nutrition, maternal and child
health, immunology and infectious diseases, and reproductive bio
logy and famHv planning. The curriculum should also reflect the
application of some of the principles of educational science, namely
encouraging the students to learn by themselves, introduction of a
system of continuous assessment of student learning, objective
methods of assessment, small group teaching, integrated interdisci
plinary teaching, and accent on the experimental method. The
development of such a new programme will involve, not only a
radical revision of the existing curricula, but also appropriate
preparation of teachers, the production ‘of effective teacning and
learning materials, the adoption of suitable methods of
teaching and evaluation, the creation of the necessary physical
facilities in all medical colleges and consequent reform of the
hospitals attached to them. This is a programme ‘that will
obviously need sustained implementation over the next few years
! on the basis of a clearly formulated policy supported by adequate
authority, funds and continuous evaluation.
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Duration of Under-graduate Medical Course
7.08 Certain issues have now become irrelevant to the discus
sion of the problem of duration. For instance, it need no longer
be linked un with the problem of producing an adequate number
of doctors for rural areas. There are ammense socio-economic
issues involved in getting doctors to settle in rural areas. While
these should be squarely faced and sustained efforts made to over
come them, it idle to hope that a mere reduction in the course
would achieve the result. Similarly, there is hardly any sense in
suggesting the reintroduction of the diploma or licentiate course
for meeting the needs of rural areas. With the type of reorganisa
tion of the health services that we have proposed earlier, what we
need, even for rural areas, is a better trained doctor rather than a
less trained onc^ All things considered, we strongly feel that there
is no justification to make any change in the present policy of
producing an adequately trained general practitioner, both for rural
and urban areas. Nor should financial considerations be allowed
to outweigh academic needs and standards in medical education
should not be diluted to save funds. It may prove to be a costly
and unwise economy in the long run.
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7.09 But even on good academic considerations. We, do feel
that it is possible and desirable to reduce the existing duration of
the course bv six months-to one year yet ensure an improvement in
standards. Several suggestions 10 this end were put before us. Wc
do not propose to discuss them in detail and it would serve the
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limiico purpose we have in view to highlight a few major points
^ose in our discussions of the □robelm. For instance, wz
Sisould emphasize, not the duration oi the course but the producof the right type of doctor which b the crucial issue. We do
nost produce the right type of the doctor even with this long
bdrauon and a mere shortening (or lengthening) of the course whli
by itself, produce the basic doctor. *There is also the danger
^'.22Z snort-sighted administrators may implement this recommendaLon on financial grounds and without implementing the others with
hich it is indissolubly linked so that the bad situation which exists
a-_ present will only become worse confounded. Above all, this is
a recommendation which can be imDlemented in isolation (it
is plated intimately to the restructuring of pre-medical education,
cmnitipn of the goals of under-graduate education, revision of
c, .rricula, provision of adequate facilities in medical colleges, etc.)
and an adequate organization to watch carefully over its
implementation.
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k ternship
7.10 The internship plays a very important part in the conso
ndation of skills and the knowledge gained by the medical students.
k was with this intention that it was introduced as a regular
iczture of the under-graduate medical course. All committees
bare endorsed the need to continue internship training. The
K^edical Education Committee went even further and recom
mended that as long a period as of six months (out of a total
internship period of one year) should be spent in community health
centres. The actual experience of the programme of internship isr
however, bitter; and it is agreed by all concerned that the internsmp training as it is now being practised is a waste of the most
crincal period of the young graduates life, everyone is dissatisfied
wim it The teachers tend to feel that the interns who have already
passed out of the medical education system are a burden upon them
and they devote more of their time to the undergraduates and to
postgraduate and research students, if any, working under them.
The position of interns in the teaching hospitals which abound with
house-surgeons and post-graduate students is also very tenous. The
interns themselves feel that the period of internship has some-how
t? pc got over before they either go to practice or joint the teaching
hospital as a house surgeon for further specialization. The situation
ii unmtenable and needs early remedial action.
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7.11 We serious!v debated he advisability of doine away with
t. ? internship period but came :o the conclusion that, even after
modified curriculum involving community teaching is brought
'.j full force, the period of imernship which enable an undtrg/c^mte to acquire experience and to mature from a Hedging to
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a fully-grown medico is absolutely necessary. What is needed, there
fore, are steps to ensure that this period is fruitfully utilized. ■
7.12 We recommend that the training of the internee should
not be earned out in the teaching hospitals of the medical collegesbut in the district Sub-divisional and taluka/tehsil hospitals whmh
should be used as the out-reaches of the medical colleges for entering into the community. At the end of the formal under-graduate
course (in fact even before it ends), groups of undergraduate
students should be earmarked for being trained at selected taluka/
tehsil/sub-divisional and district hospitals where proper facilities
are known to exist. Such hospitals should also take on selected com
munities within their catchment areas whose care would be the res
ponsibility of the interns under the supervision of that particular hos
pital. The doctor incharge of such hospital, the interns attached tothat hospital along with staff of the Department of Community
Medicine of the Medical college, should practise community medi
cine in such selected communities. In addition, the interns should be
given practical training in curative and hospital practise under the
guidance of the taluka/sub-divisional/district hospital doctors. For
this purpose, the facilities available at such hospitals should be
strengthened where necessary. Wc would also caution that thislinkage should not involve all the departments of the medical
college at once. It should first be tried at in the Department of
Community Medicine. Once these links are established in respect
of the Department of Community Medicine, they can later be
strengthened and also developed in respect of other specialized,
departments and faculties.
7.13 It is our view, therefore, that the internship period'
should be fully spent in the distnct/sub-divisional/taluka hospitals
with occasional forays into the community through the primary
health centres. We also think thst internship training should focus
on the doctor as a member and leader of the health team, the
importance of continuous care, handling of emergencies, the care
of combined preventive and curative services to the individuals the
family and the community, MCH and Family Planning Care, the
identification of entry points for family planning community
involvement and the role of the physician as a health educator.
7.14 The utilisation of the district sub-divisional and taluka/'
tehsil hospitals for internship training and development of their
linkages with the medical college will not only improve the qua
lity of health care and referral provided at These places but
will also act as a pace-setter for decentralisation of medical
education and development of (fisrrict hospitals in the foreseeable
future as centres for imparting of medical education, thus enabling
i a movement away from the urbanized concept of medical educa
tion. The existing medical colleges can then be used more profi
tably for postgraduate specialisation and development of courses
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of training in respect of various categories of para-medical and
technical personnel needed in the health field. fiTthe Sterns^o
by us1^bovVsre wodd also like tc attadi
gr atest importance to the desrabiHty of associating general
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ends will be better served if either one or the other is retained
out not both.
7.16 In the system of medical education prevalent today,
any doctor who goes out of the system of the medical college
Ms httie opportunity to come back' to update his knowledge and
skills; and no facilities exist outside the system of medical educa
tion to achieve this objective. It is, therefore, essential to make
adequate provision for the continuing education of doctors in the
medical pool of the country. In the modern world where a virtual
exp osion of knowledge is taking place in most sciences and the
existing stocks of knowledge are being doubled every’ seven years
or so, a programme of continuing education assumes immense
significance.
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7.17 By continuing education, we mean the training of a
physician, not with a new tc gaining additional degrees or diplch
mas, but with a view to assisting him to maintain and extend
his professional competence throughout his life. The basic problem
of continuing education for physicians cannot be solved without
fundamental changes in the pattern of undergraduate medical
education. The implementation of these changes will necessarily
take time. But in the meanwhile, the pressing problem is one
of arranging continuing education for those who have already
been trained in a system that was not conducive to the develop
ment of proper attitudes for continued life-long learning. Conti
nuing education for physicians must concern itself with those
issue that are of deep significance to the health of the community
2nd also with educational activities for mixed teams of health
workers. Inter-professional education is of critical importance for
the members of the health team to learn together how to solve
problems. It is. therefore, necessary to develop an organisational
pattern for the continuing edveatjon of phvsicians, whether they
be serving in Government or in private, as point activicv between
toe medical college, the professional associations and the health
sendee.
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. National System of Medicine
7.18 A reference has already been made to the need to evolve
national system of medicine for the country by the development
f an appropriate integrated relationship between modern
nd indigenous systems of medicine. We recognize the .significance
•f the issues involved for the development of a comprehensive
Jan of health services suited to our needs and aspirations although,
or want of time, it has not been possible for us to go into details.
Vfedical Manpower
7.19 Problems of medical manpower needs have not received
idequate attention. The number of admissions to medical cob
.eges and the number of medical colleges themselves should be
3ascd on a sound policy of Health Manpower Devdopment which,
in its turn, should be related to the health needs and national
resources. Urgent steps need to be taken to generate such a policy
along scientific lines on a national basis. For the present, we are
of the view that there is no immediate need for increasing the
number of- medical colleges admissions. On the country, attempts
should be made to reduce the admissions to the existing medical
colleges so that the teacher: students ratio, and quality of edu
cation may improve. Similar exercise have also to be undertaken
for all otner categories of medical manpower. Needfess to say,
such exercises in forecasting manpower needs and adjusting the
system of medical education to them are continuous rather than
one-shot affairs.
Content, Structure and Process of Educational Change
7.20 There are three ingredients of every educational change:
—
content or a determination of the type of change we
need;
—
structure or the creation of a machinery which is charged
with the responsibility of bringing about the needed
change; and
—
process or the initiation of the actual process of
the educational change needed and nursing it to grow
till our main objective of bringing about the needed
change is realized.
-- What is happening at present in education is that everyone
is busy about the content of change or about deter
mining the type of changes we need. We have no
deal th of ideas on the subject and if all the recommen
dations made by educational committees and commis
sions were put one after another, instead of going
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round and round in circles as they often do, we may have
a ladder stretching from-the earth to the moon. zOn the
other hand, little attention is^ivcn.lo die more important
question of creating appropriate structures for educational
change although everyone knows that, without the exis
tence of the structures, no planned educational change
can be brought about. What is worse, hardly any atten
tion is paid to the most important question of initiating
the needed change processes and of carefully nursing
them to grow.
7.21 The story' of developments in medical education is not
any different from that of developments in general education as
a whole. We have been able to identify the basic issues in the
reform of medical education such as:
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determination of the objectives of undergraduate medi
cation education and especially the overwhelming need
to give a community orientation to it;
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revision of curricula, production of learning and teach
ing materials, adoption of suitable teaching methods,
examination reform, improvement of facilities in medi
cal colleges, preparation of teacners and such other issues
for tl;e attainment of the-e cblectives:
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reform of hospitals attached to iiiedic^i colleges and their
integration into a scheme of■1 national referral services
complex;
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determination of the right duration of the undergraduate |
course;
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re-organisation of the pre-medical course in 10 4- 2 4- 3
pattern and of the programse of internship;
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the future of the first year of junior residency;
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provision of continuing education;
post-graduate education and research;
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studies of medical manpower n:,ds;
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and so on. We recognize that these
. "ns have been become |
extremely urgent and complex and demand aady and satisfactory' I
solutions. All our ettenben in the last few years has. however, |.
been devoted mainly to denning the
c-f change and we |
have any number of excellent recommendations from all sorts of |
ad hoc bodies. It is time we realize that a mc-*e discussion of the -|content of change, however continuous and learned a.nnot bring
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the cducaucnal change we need may even confuse the issues,
1 he xact is that there is no structure to bring about die needed
•changes and. in the absence of die structure, the question of
initiating the change process does not even arise. In 2 situation of
this type, we see little purpose in producing one mere learned
report and in making yet anomer series of pious and well mean
ing recommendations on the content of the reform of medical
education. We may do it as well as or as ill as any other group
of seven persons and the exercise will meet the same fate as that
of earlier attempts on the subject. It is, therefore, of the utmost
iniportant that a suitable structure or an organisational framework
should be established which is charged with the task of imple
menting the needed reforms and of initiating and nurs
ing the change process. We are thus convinced of the need
for me establishment of a UGC-type body for medical education
and reaffirm the recommendation made on the subject by the Edu
cation Commission (1964-66). In the absence of some such machinery with the authority and resources to implement the desirable
reforms, we are afraid that the quality and relevance of medical
education may continue to remain as a no man’s land between
the Centre and the State; and without such a structure, there is
no possibility of initiating a change process to ensure that medical
education advances to keep pace, not merely vyith advances in
medical knowledge and technology, but also with the needs and
priorities of national health.
7,22 Several other equally weighty considerations can be
advanced in support of this proposal. VZe have already shown
that the organisation of a national programme of comprehensive
health sery;<es cannot be attempted unless the entire pattern of
medical education is overhauled and that this, in its turn, cannot
be attempted, in the absence of an organisation, with adequate
authority and funds, to decide the complex issues involved and to
implement the decisions through a vigorous and sustained pro
gramme of action. The coordination and maintenance of standards in higher education (including general, agricultural engi
neering and medical educabon) is a constitutional responsibility
of the Government of India. Institutional and financial arrange
ments to give effort to this responsibility have been made under
the UGC (for general education), ICAR, (for agricultural educa
tion) and the AICTE (for engineering education). The important
field of medical education hs»-unfortunately no such arrangements;
and the neglect of this constitutional responsibility of the Centre
all these years is absolutely indefensible. The case for the crea*
tion of a structure for the reform in medical education is further
strengthened by the failure
all earlier attempts to reform medi
cal education through repot after report, and rertxnmendation,
oi commltteeSj conierences, working groups, seminars and the
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Let us not forget that die reform of medical education is
no a oneshot affair. It needs continuous reaction between tlx
out cut of the system and its management, between the Centre and
the States, and between Universities and institutions of medical
education. No such reaction is possibly unless there is a. suitable
structure charged with the responsibility of reforming medical edu
cation in all its aspects.
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The Medical and Health Education Commission
7.23 We, therefore, recommend that immediate steps should
be taken to setup, by an Act of Parliament, a Medical and Health
Education Commission for coordination and maintenance of
standards in health medical education. It should be broacily
patterned after the UGC with a whole-time Chairman who should,
and a leading personality in the field of health
be a non-official
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services and education. The total membership should be between
9 and 15, one-third representing the Central and State Governments and the universities, one-third representing the various
national councils and one-third consisting of leading persons in
the field of health and medical education and services. Its role
should be promotive and supportive and it should be responsible
for planning and implementing the reforms needed in health
1—Id. and
—d
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_ It
necessary ---------------administrative
medical________
education.
L should
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d._ ---------machinery and steps shouff also be taken to place substantial re
sources at its disposal in the Fifth Five Year Plan so that it can
' start vigorously and become effective.
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7.24 We have deliberately used the term “Medical and Health
Education Commission”. Ixt us not forget that, in the totality
01 health services, the doctor is the most important but not the
sole functionary. Equally important are a variety of para-medical
personnel who constitute important links of Che health service. The
nurse, the pharmacist, the technicians in the field of laboratory
se-vices such as X-ray, pathglogv or microbiology form the essentird back-up of medical care. The dentists provide a specialised
st 'Hee is can important and related field. Any programme of
training that aims at improving the quality of medical care or
rermicturing of the system of medical education towards comm mity care, must recognise the need of assessment of the educat ' -ial needs of all these other categories of medical and paradical personnel. What we need, therefore, is an organisation,
only for the reform of the undergraduate or even the whole
E
medical education, but an organisation which will be responC
c
for the reform of the entire field ot health and medical c z-.i\ in all its. aspects.
,25 It is for this reason ti'p.t we are propagate that Mec:rd
Health Education Commission shall have on it the rerre.' nins of all the relevant ..adoral councils and that it will also
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work in close collaboration with all of them. The oldest, largest
and the most important of these is the Medical Council of India.
The others include the Dental Council of India the Pharmacy
Council of India and the Nursing Council of India. We would
like the prestige, authority, and the good-will of all these Coun
cils to be fully utilized for purposes of bringing about an early
and effective reform of medical and health education. As every
one is aware, the organisation of all these Councils leaves a good
deal to be desired, especially because they w’ere originally set up
only to exercise an indirect regulatory function while we are now
proposing to vest them with promotive and supportive func
tions as well. We, therefore, recommend that the Government
of India should open • negotiations with all those Councils and
amend their Acts, especially with the purpose* of making them
operationally more viable and efficient to discharge the regula
tory, promotive and supportive functions for the improvement of
medical and health education. We would also appeal to all these
Councils to cooperate with the Government in this programme.
In particular, each Council should be required to set up an edu
cation panel on prescribed lines and the Medical and Health Edu
cation Commission should be under a statutory ‘'obligation to
implement its programmes of reform and also to operate its finan
cial powers in consultation with the panel of the concerned Coun
cil. This will make full use of all the prestige, authority, good
will and expertise of all the existing Councils and strengthen the
hands of the proposed Medical and Health Education Commis
sion in functioning as an apex coordinating organisation and in
implementing a radical programme of reform in medical and
health education.
7.26 We would like to make it clear that the regulatory
functions which arc now being exercised by the Councils will
continue to vest in them unchanged. In addition, they will also
take on the responsibilities of advising the Medical and Health
Education Commission on pnxnotive and’ supportive measures in
their respective fields.
n.T] It is our considered opinion that the most important
step now needed is to establish the Medical and Health Education
Commission. It will be the responsibility of this Commission to
then start the process of change and to nurse it to grow. The
sooner this basic reform is implemented, more the better it will
be for the future of health and medical education and all that
will follow therefrom.
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SUMMARY OF RECOMMENDATIONS
S.oi For convenience of reference, our main recommenda
tions are briefly summarised in the paragraphs that follows.
22—88 CBHI/ND/84
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A nation-wide network of effiSdex
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elective health ; .v;ces .
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-rfre Programme cf r—-zj.
rads^o hneW £ n£t
°f £f“ asd ^ecn« heakh ^ces
B-eds to be reviewed de nws wim 2 view to evolvina ~
alternative strategy of development mor- suitab]£ for ou, c^ad.
ns^ limitations and potentialities. W; recommended mat Gov«nm=nt should undertake the task of evolving a national Z
jrsus on the sub)(xt. The general principles staid in paSSa^
cl mavT? vfOT the drloPment of Network of Li
ces may be taken as a basis for consideration in this effect.
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Para-professional or Semi-professional Health Workers in
the
community itself
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8.03 IWe recommended that steps should be taken to create
bands of para-professional of semi-proressional health of the workers
om the community itself to provide simple promotive, prevenuve
^.curau ve h^lth services whidh are needed by the* commu.. They will include dais, farnnv planning workers, persons
^no could provide a simple curative service, imd persons Lined
m promonona1 and preventive health activities, including the
^..ol of commumcable diseases. They need not be multipurpose.
3-3F y “;gPc™ns,ln the community, elementary school teachers,
and particularly educated and willing housewives would be the
poo, from whidh these workers could be drawn. There is no
n-ed to regulate their numbers nor to form them into a cadre
-nd pay them a remuneration from public funds. It would be
curable to leave them to work on a self-employment and partume bans. The responsibilities of Government in their regard
vnl. be to make careful selection, to provide training and re-aming, and guidance and counselling (including " periodical
evaluation), and supply material- needed at reasonable pricesj The
director General of Health Services should be requested to work
oc^all the details of the programme during the current year and
, d oegm, as a centrally-sponsored scheme, in 1976-77. A
rainy large part of the country should be covered by the scheme
-efcre the end of the Fifth Plan and the entire country should
covered by the end of the Sixth Plan.
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scmi-professmnal or professional health workers within) and the
we should develop two cadres health workers and health
assistants.
(1) At present, there is a male health worker for ever}' sixseven thousand population and one female health worker
for ever}’ ten thoussnd per dation. 1 ne proposed target
for the Fifth Five Ye?r Plan is to have a male and
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£ fenale worker each for a population
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.of eight thousand. Wejecomniend that, by the end of the skth
ue-should strive to prov-de
provide one male and o"c
xemale worker each for every
--coo population.
population.
■-try 5.000
also recommend that every health worker
----- r should be
trained and equipped to give„ k
simple specified remedies
(including proven indigenous remedies
”-S as well) for dayto-day illness.
(2) Between the health workers and the PHC, there should
be a new cadre of health assistants. We should strive
to provide one male and one female health assistant for
nvo male and two female health workers respectively,
rhe existing multipurpose supervisors should be incor
porated into this cadre after suitable training and it
should, in future, be treated as an incentive and
promotional cadre for health workers. The health
assistants should be invariably located at the sub-centres
and not at the PHC. Like the health workers, they
should also be trained and equipped to give specific
remedies for simple day-to-day illnesses While they
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l as
health workers in their own areas and carry out the
same dupes and responsibilities, but at a higher level
of technical competence.
(3) The PHC itself should be strengthened by the addition
of one more doctor, especially to look after maternal
and child health senaces and one nurse. The existing
allotment of Rs. 12.000 earmarked for the purchase of
drugs at each PHC is inadequate and should be increased,
me possibility of utilising the services of senior doctors
at, the medical college, regional, district or taluka hospi
tals tor bnet periods of work (sav two years at a rime)
at the PHC level should also be explored.
The Referral Services Complex
8.05 We recommended that the Primary Health Centres as
well as the taiuka/tehsil, district, regional ^nd medical colleae
hospitals should each develop living and direct links with thcommumty around them as well as with one another within a
total referral services complex. This linkage can best be secured
through a properly organised internship programme. The way
in which the internship programme is organised at present is
wasteful. V/e recommend that, for purposes of training tie
the ini.
interns
the district, sub-divisional and taiuka/tehsil hospitals shouldI be
used as the out-reaches of the medical colleges for entering into
the community and the programme itself organised on the'broad
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anes indicated in paragraphs 7.10-13.
attach great importance
0 the desirability of associating general practitioners of good stand
ing and experience in the training of under-graduate.;. The desi
rability of continuing both the internship and the first year of the
junior residency as organised at present also needs examination.
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Establishment of Medical and Healdi Education Commission
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8.06 There are several important issues in medical and health
education which need discussions in depth and decisions and what
is even more important, immediate, vigorous and. sustained imple
mentation. These include: the determination of the objectives
of under-graduate medical education and giving a positive
community orientation to the entire programme; the re-organisation of pre-medical education in the 10 -r24-3 pattern; provi
sion of the under-graduate curriculum including the preparation
of teachers, production of teaching and learning, materials, adop
tion of suitable methods of teaching and evaluation, the creation,
of necessary physical facilities in all medical colleges and conse
quent reform of the hospitals attached to them; determining the
duration of the course and reducing it, if possible, by six months
to one year, even while improving the standards; reorganisation
of the internship programme and of postgraduate teaching and
research, continuing education; and studies of medical and health
manpower needs; evaluation of a national system of medicine;
and so on. No useful purpose would be solved by continuing
an endless debate on the content of these reforms. What is needed
most is the creation of a suitable structure, with adequate admi
nistrative machinery and funds at its disposal, and to charge it
with the responsibility of determining and implementing a radical
programme of reform in medical and health education in the years
ahead. From this point of view, we recommended that the Gov- ,
ernment of India should, under an Act of Parliament, immediately
set up a Medical and Health Education Commission for coordinahon and maintenance of standards in medical and health education.
t
8.07 The Medical and Health Education Commission should
re broadly patterned after die UGC with a whole-time Chairman
" ho should be a non-offidal and a leading personality in the field
c health services and education. The total membership should
r : between 9 and 15, one third representing the various National
Councils and one-third consisting of leading persons in the held
i.'Calth and medical ecucadon and sendees. Its role should be1.:■□motive and support?v.-?
:.t should be responsible for plann.ng and implementing the reforms needed in health and medi
cal education. It should b? provided with the necessary ad mini su-ative machinery and step’ r-bou’d be taken to place substantial
roo^cces at its disposal in *. te Firth Five-1 ear Plan.
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8.o8 ihe Medical and Health Education Commission should
Adncuon as an apex coordinating agency and in close and effective
collaboration with the National Councils. For this purpose, the
Government of India should open negotiations with all the Coun
cils and amend their Acts, especially with the purpose of making
tnem operationally viable and efficient to discharge the regulatory,
promotive and supportive functions. We also appeal to all these
Councils to cooperate with the Government in tins programme.
In particular, each Council should be required to set up an edu
cation panel on prescribed lines and the Medical and Health Edu
cation Commission should be under a statutory obligation to imple- "
ment its programme of reform in health and medical education
and also to operate its financial powers in consultation with the
panel of the concerned Council. This will make full use of the
prestige, authority, good will and expertise of all the National
Councils and strengthen the hands of the Medical and Health
.Education Commission in implementing a radical programme in
Health and Medical Education.
APPENDICES
APPENDIX II
Recommendations of various Conferences Committees and Papers. Memoranda,
<*c.* received from various ladivid^t^Associarions, etc^ considered by the
(a) Recommendations of various Conferences/Committees.
1. Relevant recommendations from die Shore Committee Report—1946.
2,
Recommcndauon5 made at the Conference on Medical Education—
3.
Recommendations made at the Conference on Medical Education—
Recommendations made at the 1st Conference of Deans and Principals
or Medical Colleges m India—1960.
5.
Relevant recommendations from the Mudaliar Committee Report—
■6.
Recommendations made at die 2nd Conference of Deans and Prin
cipals of Medical Colleges in India—1962.
8.
Recommendations made by the Chadha Committee for the streng
thening of health services in the Malaria Maintenance Phase—1963.
Recgmmeudations of Mukherjee Committee Report on Strengthening
or Health Services—1966.
9.
R/C3?1?ei^'ons “ade at the 3rd Conference of Deans and Principals
of Medical Colleges on Under-enduate Medical Education—1967.'
10. Recommendations madeby the Mudaliar Committee on maintenance
“’2° Standard of Preparaiocv training in the Pre-medical course—
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11. Recommendations made by the Medical Education Committee in its
kepon ot 1969 whtcn were modiaed cr enlarged at the Medical Edu
cation Comerence heid in 197Q jusd finally accepted bv the Govern
ment o*. Inaia m Ms Resolutkm or 8-.0-1970—1970. 12. Recommendations made by the Kartar Singh Committee on Multi*
purpose Health Workers—1973-
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fc. References, memoranda, papers, etc., Kceiired from various i.-sssociaiions,
individuals, etc:
1. Anand, D.
Note on the p oposed plan,
Professor of Preventive and social Medi
for training of para-medicajcine, Jawaharlal Institute of Post-gradsaie
wcrkeis.
Medical Education and Research, Pon
dicherry.
2. Association, Indian Medical Pampbsa*
No. 37 of 8-4-74.
3. Association,Trained Nurses oflndia
Suggestions reg*rding changesin medical Education.
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. Memorandum opposing the new
cadre of Health Association.
4. Banerjee, D.
An article on Social and Culturat
Foundations of the Health.
Jawaharlal Nehru University, New Ddhi
Senices System of India.
i
5. Bisht, D.B.
Note on
approach tp thetraining of medical students,
Principal, Jawaharlal Institute of Post
suited to Indian conditions^
graduate Medical Education and Re
search, Pondicherry.
^tions on changes
-cal Education.
6. Chaudhry, S- M.
Su
Maulana Azad Medical College, New
Delhi.
7. George, G. M.
Trichur.
iir
Opposition to Health Assistt
Cadre. Suggestions on
re
duction in MBBS course and
opening of new medical colleges.
Report on the activities of
8. Ghoshal, B. C.
Chittaranjan Mobile HospitalA.D.G. (HA).
prepared at the end of the
Directorate General of Health Services,
4th Plan.
New Del hi. (formerly DAD) (CH)
*
9. Health & Family Planning Ministry of . Views of the Group on thesuggestions for National Ser
vices for a specified period
as a precondition for the
grant of a degree.
10. Kasliwal, R.M.
Jaipur.
Suggestions regarding training
of Health Assistant
A note for rationalisation of
11. Kumar, Sharad
undergraduate medical cur
Deputy Director General (Medical),
riculum in the Indian Medical
Directorate General of Health Sendees.
Colleges.
12. Mathur, P. D.
Jaipur.
Suggestions for improvement
teaching in medical colleges.
13. Murthy, T. S.
Warangal
Support for Health Assistant
cadre and proposal to reint;-.cornice BSc. (PH) school
at V.'atang?! if Central as_
sisiance is forth coming.
14- Naik, J. P.
Member of the Group.
Parer:, “elaiin? to a seminar on
♦r.e
of training
vj.
and .'-^alth Personae;
•15. NIHaE
Rr
pf the Task Force oa
rera'ion ? -■esreb for nr*
?ry of Health.
S-ervices (I?’’- ).
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15. Nd-..-, Stxshila
KL-siurba Health Sodatey, Seagram.
Suggistions regarding change
in the pattern of undergra
duate and post-graduate medi
cal education.
1
17. Pradhan, P.N.
Nagpur.
N^ed for curriculum in Rural
Medical
at undergraduate
and postgraduate levels far
a degree or diploma course
18 Puri, V.V<
Ex-S^.cretary.Msdical Council of .India
Suggestions regarding changes in
medical education.
19. Ramalingaswami, V V.
A note on some features of
Director, All India Institute of Medical
; nd; -graduate medical edu
.Sciences, New DJai.
cation.
20. Sanjivi, K. S.
Madras.
Paper on training of Medical
and Health Assistants and
changes in the contents of
curriculum for medical gra
duates.
APPENDIX III
Training of Health Assistant
Venue of training.—Since the Health Assistant will be working primarily in
the rural setting* a large part of his training should take place in that en*
vironment. Appropriate experience is necessary in rural hospitals, in
demonstration and training health centres and in small rural dispensaries.
Thus the Health Assistants by working under close supervision in these
institutions will be prepared bar work that may be less supervised. Dur
ing his training the Health Assistant should spend more tune in practical
field work rather than in the dass room.
The Health Assistant should be trained in Government institutions.
Hut-line of the curriculum.—Curriculum for Health Assistants as well as cur
ricula for existing. Health Supcryisora to qualify for Health Assistant after
an orientation course as weti for regular training of new entrants have
been framed after a detailed study of the course contents of training for
the current categories of health workers and also proposed course contents
for basic health workers. Health Assistants and other such categories of
workers available in the fieid.
FUNCTIONS OF THE HEALTH ASSISTANT
1.
Curative:
(a) first-aid in medical and str.^ical emergencies;
(b) diagnosis and outpatient treatment of common diseases, major surgery
in sub-centres;
(c) referral to the primary heaith centre of emergencies and cases requiring
hospitalisation ;
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X Public Health Functioas :
7.. • (a) -to carry-out ail functions required of the public health services and
family planning and mata^ry child welfare services;
(b) immediate initiation of epsdemic control measures;
(c) Initiation and supervision of vaccination and preventive measures for
communicable diseases;
(d) school health and related activities, including nutrition , and dietetics^
dental and health educatiaa:’
'
(e) registration of births and deaths ;
(f) environmental sanitation, housing and latrines, disposal of sewage and
refuse, safe water supply.
;
(g) regular visits to all-the vDigea in his area for the above functions.
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The Health Assistant is required to aci as the first-line-of-attack
first-Iine-of-attack against
diseases arising from environmental saniiawm oeiccs.
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3.
Supervisory Fuucijons i
1. The Health Assistant will exercise supervision over the area covered
by the multipurpose health workers both nwe and female.
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2. The Health Assistants will check the work of the Health Workers both
male and female.
T
r
In the course of tour, the Health Assistant will ensure the regularity of
visits, authenticity of records, rigid implemeEiation of instructions, issued from
time to time and maintenance of adequate standards of work by the sub
ordinate staff.
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ORIENTATION TRA’NING COURSE FOR EXISTING HEALTH
SUPERVISOR TO QUALIFY FOR HEALTH ASSISTANT
#
Total duration of training ............................................. 6 months.
Institutional
.
...................................................... 4 months.
Field experiences at P.H.C.
.................................... 2 months.
Total number of working hours in 4 months*
.
. 5x20x4=400 Hrsz
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Knowledge and skills required
1. Supervision, guidance and control.
2. S ore-keeping, accounting and book-keeping.
3. Treatment of emergencies.
4. Medical tre?tment for various common ailments at ,
P.H.C.
5. Hialth administration.
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Subjects to be covered :
*
1. Amtomy and Physiology....................................... 25 hours.
2. Microbiology, Parasitology and Entomology
. - . 30 hours.
3. Pharmacology and Pathology
.... 50 hours.
4. Public Hukh Administration including store-keeping
accounting and book-keeing
.
.
.
.90 hours.
5. Treatment of emergencies and diagnosis and treatment
of common diseases
.
.
. 80 hours.
6. Hospital and casualty posting .
. 100 hours.
. 25 hours.
7. Environmental sanitation .
8. Examination, etc.
. 20 hours.
C(
*Five hours a <'day and twenty days in amoath, ten days being allowed for
Sundays, holidays and monthly tests.
REGULAR TRAINING COURSE FOR HEALTH ASSISTANTS FOR
NEW ENTRANTS
Minimum qualifications for admission .
Toia! period of training .
.
.
.
Period of institutional traiining .
Period for field posting (internsbsp)
No. ot’working hours in one dy
No. of working hours in one month .
No. of working hours in one semester 6 months .
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. *Higher Secondary
pass examination or
its equivalent with
medical group of
subjects
and
mathematics.
. 2 y^ars.
. lyar.
. 6 months
. 5 hours
. 5x20= 100 hours
. I-00 x 5 = 5CO hours.
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io ss sic sciences,
island end semester (SOW hours)
Lab-procedures ana near;;! arg-ms^.^n r--cJ«i.
3rd Semester (SOOhourt) for trammg in crst-aid =na treatment
of minor ailments.
Deiailsof subjectsand topics wtht.me diitribmicn (didactic and practice Is
, .
.
. 20 hours.
I. Introudction
...•••
2. IPsic sciences and lab. P'^cedu^s Anatomy, Pbynology, 100 hour .
Microbiology, Parasitology anu Entamoiosy, Pathology
and Pharmacology.
hours
3. Health Services Admiristraticn .
.
4. Controlof communicablediseasesand epiodemilogyrrd SO hours.
’ national programmes.
105 hours.
socia i1 3VIVL4WO
sciences and research methodology
5. Statistics, SOUICI
- ------— - (data
•
* colUction.compilation/.abulationand .presentation).
. 75 hours.
6. Environment a 1£ sanitation .
•
•
•
. 100 hours.
7. M.C.H........................................... •
. 20 hours.
8. Growth and development ....................................
. 50 hours.
9. Nutrition and nutritional programmes .
. 20 hours.
10. School Health ..•••••
. 20 hours.
II. Industrial Health
. 75 hours.
12. Health education.
•
•
•
♦
*
. 100 hours.
13. Family Planning and Population education «
.
40 hours.
>4. Nursing techniques and arts.
•
•
. 50 hours.
15. Laboratory techniques
•
•
•
•
. 50 hours.
16. Immunization and injection techniques .
•
•
. 50 hours.
17. Examinations
. 332 hours.
18. First-aid andtreatment of miner ailments
mmw
1383 hours.
♦ With the adoption of 10-r2+3 system of education the minimum
educatima; qualification will become 104-2 i.e., after 12 years at the school.
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fepMPENDIUM
lot '
| RECO M M 5 N D AT! O NS
tor,
.
Wahious committees
Ion .
.
|Sealth development '
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1943-1975
S^by
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•fcfNTRAL.BUREAU OF HEALTH ^NTELUGENCE
^DIRECTORATE GENERAL OF, HEALTH SERVICES
(IWNIShTRY OF HEALTH AND FAMILY PLANNING
GOVERNMENT OF INDIA
“NlftMAN BHAVAN
NEW DELHI-HOOH
I
a
t T THS
b / ‘1. 1 0
COMMUNITY HEALTH CELL
Society for Community Health Awarness, Research & Action
(SOCHARA) Bangalore
Library and information Centre
CALL NO. .£1.P.2 I 00
AUTHOR .
ACCN.NO
io
CBH\.
TITLE
OF
Borrowed
On
Returned
U)
<3 Vom' (c—
Mt. ZV.
1%
LdScTV
\^A n i
1^4
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lAi? r^ .'
S^-QGC
Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
f
s
VI—REPORT OF THE STUDY GROUP
ON MEDICAL CARE SERVICE
(AJIT PRASAD JAIN COMMITTEE)
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REPORT OF THE STUDY GROUP ON MEDICAL
CARE SERVtCES
(AJIT PRASAD JAIN COMMITTEE)
SUMMARY OF RECOMMENDATIONS
ORGANISATION OF MEDICAL FACILITIES
1. In order to develop institutional facilities the following
pattern is recommended to be attained by 1971 ;—
Teaching Hospitals .
500 (to be increased according to the numher of students).
District Hospitals
200
Tehsil/Taluq Hospitals
Primary Health Centres
(may be rais'd upto 300 beds dependingon population).
50 (may be raised dependingc»n pcpLiation).
.
6 (may be increased to 100 depending
on needs).
of 125 uibincEs
districts which
2* The bed strength ux
wmcn have
nave at least one
200 beaded hospital may be raised to^joo depending
j on the
r popula
tion served. In the remaining 210 districts hospitals, having less
than 200 beds, the strength should be raised to a.minimum of 200
beds. Ordinarily the distribution of these beds should be as
under :—
Medical
Surgical
60
.
40
Gynaecology and Obstetics including Maternity
....
Paediatrics
Orthopaedics
5
....
Eye .
10
E.N.T
10
Skin
5
E5n?rgency
Isolation
35
15
....„,
.
.
.f
5
10
Psychiatry
5
200
3. Since the district bospttal is to serve as a referral centre it
snoula provide specialist services in Medicine, Surgery, Obstetrics
Gynaecology, Eye, E.N.T.. Paediatrics, Dentistery, Psychiatry, VI)’
The T.B. Clinic at the district headquarters, where it exists should
work m_ close liaison with the district hospital and the medical
omcer of the clinic should work as T.B. soecialist to the district
hospital.
303
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4. Each of the 947 tehsils/ialuqs. which do not have hospi
tals at present, should be provided with one hospital each with a
minimum bed strength of 50. In other tehsils or taluqs, where
the bed strength is less than 50, it should be raised to a minimum
of 50. The distribution of beds should generally be; Medical =
20, Surgical =15. Maternity and Gynaecology = 10 and Isola
tion =5 beds. The tehsil/taluq hospital should be provided with
three medical officers, one each for the three basic specialities i.e.
Medicine, Surgery and Gynaecology and Obstetrics. The doctor
in-charge of Gynaecology’ and Obstetrics should preferably be a
woman. She can also take charge of Maternity and Child Health
work and Family Planning.
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5. At Primary Health Centres, of the six beds recommended.
'4 should be for maternity cases and the bed strength could be raised
to ten depending on the needs.
.
6. The present number of beds viz. 3,18.000 should be rais
ed to 4,20.000 in 1^71 and to 6,30,200 beds in 1976, bringing the
bed-population ratio from 0.61 per thousand of population as at
present to 0.75 in 1971 and one bed per thousand of population by
1976.
7. A regular system of giving liberal grants-in-aid to volun
tary and charitable organisations to open new teaching institutions
and other institutions for giving medical care and sendee should be
instituted on nor restrictive basis.
8. In order to make full utilisation of the beds available in
hospitals/Primary Health Centres, the following measures arc
suggested :—
(a) When a patient no longer needs the specialised medical
care of a regional or a district hospital he should be sent
back to the tehsil/taluq hospital or the Primary Health
Centre nearest to his residence for general treatment.
(b) Convalescent homes may be set up where chronic and
incurable patients may stay on nominal payment and in
case of indigent persons free of charge.
(c) Medical Inns may be set up in the vicinity of bigger hospi
tals, preferably by private bodies, where patients and
their relatives from mofussil areas may stay on payment
during the period of diagnosis; and
(d) Specialist, laboratory and diagnostic senices as recommended by the Group, may be provided soon. at smaller
hospitals and Primary Health Centres^ m order to help
create a climate of confidence and facilitate the working
of referral system.
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o. In order to provide specialist services to the peoole living
.an rural areas all teaching hospitals should be treated as regionS
hospitals, each serving a specified area or hinterland covering, if
necessary, two to three districts. District hosnitals, in areas which
remain,unattached to the teaching hosnital, should be developed as
full-fiedged referral centres.
10. Cases from district hospitals should be referred to teach
ing hospitals, while cases from Tehsil/taluq hospitals and Primary
Health Centres should be referred to District Hospitals. Primary
Health Centres should refer cases to their nearest referral hospital.
The referring doctor, however, may in serious cases exercised his dis
cretion and refer the cases to the teaching/special hospital direct
Cases unless needing hospitalisation or specialised treatment should
be referred back to the originating hospitals or Primary Health Cen
tres with proper diagnosis and instructions for further treatment.
11. In difficult areas and in areas where distances are long
and means of communication difficult such as hffiv districts and
difficult areas like Bastar, certain tehsil/taluq hospitals should be
developed as full-fledged referral centres.
12. Mobile teams of specialists from district and teaching
hospitals should visit tehsil/taluq hospitals and Primary Health
entres at regular intervals to advise the doctors on cases being treated there or for the transfer of cases needing specialist care
to referral hospitals.
°
PRIMARY HEALTH CENTRES
13. The coverage of So,000 population by a Primary Health
Centre is too heavy. In practice the Primary Health Centre does
n?t2erve mrOre tha? 30 t0 40
people'living within a radius
ot two to four miles of the main centre and sub-centres.
It is
therefore, suggested that bv the year 1976 at least one of the sub
centre jn the Block should be raised to the status of Primarv Health
Centre.
7 .
14. Medical Officers of the Primary Health Centres should be
0nC?t4d ln Py? ,'C h“kh and
facilities for the type of staff
needea should be augmented.
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n . 15’
doctt’r for the Family Planning work at the
Primary Health Centre should always be in addition to the lady
medical officer on health side.
J
16. In appropriate cases, wherever the need exists, the num
ber or beds in the Pnmarv Health Centre mav be increased from 6
to
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17. Full use of specialists visiting Primary Health Centre at
regular intervals should be made and the Primary Health Centre
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306
doctor should keep such cases needing specialist treatment in readi
of to
make
ness. Ambulance service should also be fully made use cf
---------the referral sendee successful.
18. The laborator}’ technician with a microscope provided at
the Primary Health Centre under National Malaria Eradication Pro
gramme should be utilised to undertake simple tests like stool, urine,
blood etc. of patients attending the Primary Health Centre.
19. The allopathic dispensaries functioning within the juris
diction of the Primary Health Centre should be continued as
hitherto and be treated as sub-centres to the main Priman- Health
Centre. In Blocks which , do not have a Primary Health Centre,
one of the existing allopathic dispensaries should be upgraded^ to
the status of the Primary Health Centre and other dispensaries
would function as sub-centres.
20. As an incentive to doctors to work in rural areas the pro
vision of residential accommodation, grant of rural allowance and
posting by rotation in rural and urban centres should be made a
must Efforts should also be made to improve working conditions
at the Primary’ Health Centres to form a unified cadre of doctors
in the State Government sendees and to provide regular training
facilities to the doctors of the Primary Health Centres preferably
at the district hospital.
OUT-PATIENT DEPARTMENT AND EMERGENCY
SERVICES
21. The Out-patient Department should be planned to pro
vide services for one per cent of the population of the area to be
catered for. It should be located at suitable distance from the in
door wards, and be connected by a corridor to laborator}’, X-ray
and other diagnostic rooms. In smaller hospitals and others where
sufficient accommodation is not available, the O.P.D. may be located
on the ground floor and indoor wards on upper floors.
22. The Out-patient Department should be sufficiently large
so as to avoid congestion. There should be a reception-cum-informarion counter situated at a prominent and easily accessible place
in the Central Registration Hall.
23. In order to help illiterate people coming from rural areas,
the Out-patient Department cards issued to patients should be in
different colours and if possible the symbols of speciality like Eye,
Ear, Nose, X-rav may be printed prominently to identify concerned
clinical Department.
24. There should be arrangements, in the vicinity or tne hospi
tal, for stay of patients and their attendants seeking admission to
hosoitals for diagnostic purposes, either free or at nominal charges.
s
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307
Such facilities can be easily provided by charity minded individuals
or organisations. Provision of a cafetaria for patients and their
attendants should also be made.
n
25. While planning out-patient Department provision for the
treatment of at least 10% of the total number of patients expected
to attend the out-patient Department should be made for emergency
cases.
26. An emergency ward should be added to every hospital
where a patient needing emergency service should be admitted at
once and kept for 24 hours, before being transferred to a regular
concerned ward.
I
27. Ambulance service to bring patients needing emergent
service should be prorided at the Out-patient Department.
!
28. There should be separate doctors and other staff for the
Emergency Department and they should work round the clock.
Services of other specialists should be available at call. The ser
vices of a pathologist and radiologist should immediately be avail
able to the Emergency Ward. In teaching hospitals there should
be a separate set-up of these services.
29. The budget for drugs, medicines, instruments, equip
ment and dressings for the Emergency Department should be kept
separate and be at least double of the needs of other corresponding
Departments. Buffer stocks of drugs should be kept with the
Medical Superintendent to meet the needs of the Emergency Depart
ment.
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SPECIAL HOSPITALS
30. To remove disparity in the distribution of special hospi
tals, preference should be given to the backward States in the
matter of establishment of new special hospitals and provision of
additional beds in existing institutions.
t
31. Treatment in special hospitals should be restricted to re
ferred cases and cases which need specialised attention of the highest
order.
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Tuberculosis
J
32. There should be do district without having at least one
T.B. Clinic with a minimum of 100 beds and those having less than
100 beds should be raised to 100 beds by 197^*
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33. Domiciliary treatment of T.B. should be intensified. Ad
mission of patients in T.B. hospitals should be confined
to (1) medical emergencies, (2) surgery cases, (3) sputum positive
cases, and (4) cases not responding to domiciliary treatment.
23—88 CBHI/ND/84
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J
ihould run m
and T.B. Ge
: of the
gs to the f '
red and
»
ry Health ce
: patients dn
baby iho>.l“terB.Gc“^tl" 1,“pi'?1 th'
va^e
the hospita
pate prov
ospitais.
in
Mental Hospitals
-ed to3!7’- iBZoon76 Te
Tr
/ri 5Lt
Strcngth f?r mcntal cascs should
raishospitals should have a psychiatric
nave a psychiatric clinic with a minimum of 5 beds
Regional
disJkts XS of0thd SCt UP f°r 3
°f * to 10 contiguous
the^t f
f
CXKting mental hospitals should be raised to
£oo beds °f ?n3 h°Sp,t:i S by increasin? thch strength to 300rl?nt hi Zk
7 TCntal Cases should
^ated h psycLtric
hSpkals °re
t0 tCaching h0SPitals or to
“ental
;es should
a psych
ct hospital
beds.
B j
to io contig
bould be r; '
strength tc i
ted in psych
or to die ~i
expanded to
d teaching i
adeauate
Colleges shou]d bc expanded to train
ilT <r
of doctors ln mcntal scicnces and teachina hospi
tals be utilised for training para-medical personnel.
°
P
39Alental Health Legislation.
AQt Sh°_______
uld
rePlaced by a Stable
Maternity Hospitals
-o bXn
b£<? recommcnded by the Group, namely
H°S?ltais’ 35 m District Hospitals, to in Telisil
Aead3a £ ?n*yPn
HcaIth need
Ccntrebosp^tion.
have
madc
£
SUCT
? Ty
"T
would
b- admitted m hospitals and ordinary deliveries should be done in
the homes of the patients by qualified niidmves.
•
<h.
ced by a
and equipment for applving advance practice m
and0 fo sisola^ ^c^om deaS caS £
nu°^*™
SpeT nurs,nS care to treat cases of toxaemia, tetamissina
JTh°S1S/tC-’ whl“
now V£I7 much Icking or
- missing, snouid be made up.
7
0
: Group,
tals, io in T
ze been n
talisation. ;
ould be doi
vance pra___
n clean cas<
f toxaemi
nuch lacl
r
!
hould run in dose
and T.B. Centre;
; of the Tehsil /
gs to the patients
red and agenev
7 Health Centres
: patients domicithe hospital the
pate provision of
ospitals.
es should be raisFe a psychiatric
ct hospital should
3eds.
Regional
to ro contiguous
hould be raised to
•trength to 300—.
ted in psychiatric
or to the mental
expanded to train
d teaching hospiced by a suitable
: Group, namely
tals, 10 in Tehsil
^0 been made on
talisation, would
ould be done in
^ance practice in
a clean cases in
f toxaemia, teta^uch lacking or
J
30$
4-* Training facilities for Midwives, Auxiliary ?
Mid
wives and for Dais should be made at the District Hose
The
Dais should also be paid similar stipend during the cours, • ? train
ing as to Auxiliary Nurse Midwives.
Paediatric Hospitals
43. There should be one Paediatric hospital in each State
-attached to one of the medical colleges. This hospital should have,
in addition to general section, a number of specialised sections such
-as Paediatrics Haemotoiogy, Endocrinology, Neurology, Surgical
Paediatrics, Orthopaedic Paediatric and Dental Services.
Cancer Hospitals
44. The existing four Cancer Hospitals at Bombay, Madras,
Calcutta and Delhi should be upgraded to regional centres and ope
rational areas attached to each of them. In addition, two more
regional centres be opened one in Madhya Pradesh attached to
Bhopal Medical College and another at Varanasi, or at some place
in the State of Bihar.
Ophthalmic Hospitals
45. Training of specialists in Ophthalmology and provision of
more beds to reach the norms of advanced countries namely, one
eye specialist and one ophthalmic bed needed for 10,000 and 5,000
population respecivcly is an ideal, which should be achieved. The
work done by voluntary agencies in certain States in the field of
eye relief is appreciated and suitable action be initiated in other
places also.
46. Mobile ophthalmic units, manned by the specialists of
the district hospital, should hold periodic eye clinics and camns at
Primary Hospital Centres. Periodic check up of eye diseases
should be included as an important item in the School Health
Programme.
Treatment for Leprosy Cases
47. Excellent work done for the control of leprosy by volun
tary agencies and International Organisations is appreciated and
they need further encouragement and financial help.
48. Special emphasis should be laid on the detection of leprosy
in the School Health Programme for this age group.
49. Leprosy programme should be integrated with the Pri
mary Health Centre and sufficient stocks of sulphones .should be
maintained at the Primary Health Centres who should obtain the
services of a specialist at S.E.T. Centre wherever required.
WW-U1 J
310
dsplofablelute
Infectious Diseases Hospitals
sh.oujdserioiy notice of the
State Governments should
,In^caiQUS Dlscas« Hospitals.
Infectious DiseaS HoX^X^
™mung
Hospitals should have Son be^
Distri«
except smallpox be ^ted
B
peases
an hSe^oTlS HoS^ 5
°[
provide temporary shelter 10^060“^^ patiSiT" Sh0U1.d
Cental Treatment
Should be included in the School HedthlX.
Convalescent Homes and Rehabilitation Centres
of
-4
INTEGRATION OF MEDICAL AND HEALTH SERVICES
c
suggested that curative and preventive service
SSSS’K?^^ “d
•’■SkSMS
sibU f' TherC should be °ne single officer in the District resnon-
Ths PreMf ^st of Family
. The Chief Kfedical Officer
and all other med’ 1
.-SuPcnat£:ncIent of the District Hospital
char^ Tjf n d T mEtItan,0Ils,i3 ^e District will be under his
-on triniZ in n ^rLShodd be PVSE ^ee months’ orients-
Offi g
Krm-)-
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311
57. Medical Officer-in-charge of the Primary Health Centre
should be put . in full administrative control of the entire health
staff and be designated as die drawing and disbursing authority with
powers io grant leave to his staff.
STAFFING PATTERN AND REQUIREMENTS OF
EQUIPMENT
58. The standards for hospital appliances, equipment and in
struments evolved by the Indian Standards Institute should be strict
ly followed and no departure from these standards should
be permitted.
59. Staffing pattern for a Hospital with 50, ioo, 200 and 300
beds have been recommended.
60. Private practice should be permitted to all Government
doctors except in the case of doctors working on the health side,
doctors working on laboratory and diagnostic services, doctors serv
ing in teaching hospitals, Civil Surgeons of the Districts and Medi
cal Superintendent of Hospitals and doctors working on research
projects. Adequate non-practising allowance should be paid to the
incumbents of these posts.
61. State Governments in the case of medical men working
in Directorates of Health and Medical Services and Central Govern
ment in case of medical men working in the Directorate General of
Health Services should take their own decision in regard to payment
of non-practising allowance depending on their resources and service
conditions.
62. Doctors working in difficult and remote areas should be
granted a special allowance during the period of their postin 2 at
such places.
63. System of honorarics should be continued in places where
whole-time Government doctors and specialists are either not avail
able or Government cannot afford to engage them for want of funds.
* The services of eminent persons who are known to be devoted to
their profession and are prepared to work as honorarics, should be
utilised. The honorarics should be subjected to same discipline as
whole-time doctors. Their terms for recruitment and conditions of
working like hours of duty etc. should be clearly laid down.
LABORATORY AND DIAGNOSTIC SERVICES
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64. Laboratory services in India vary from State to State and
within the States at all levels. Efforts to strengthen the services at
district and peripheral levels should be made. Any potential savings
by way of space, equipment, personnel and funds need to be over
looked.
b
■d""
)
a-;
0 7^
/ilO
X/
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should^include Clinkal'^Bi^e
S££ UP ?” la“°ratory services-
dons, Haenutolo^v including BkwH*
roa?ae examinaMicrobiology including Stofl CSF PI^' ^pathology, Clinical
Surgical Palology, Aiop^ including C
sections should be'under the
*n# ^^§7- Each of these
ed officer with a comolement
a0II:PctEn!; and well trainlit}- for techffical s“Xffi?h °^echnlcaJJ^ but the responsibiof the College.
should r«t with me parent department
logy including Blood Bank CHffial
mclude HaemotoC.S.F. Se^
^■rangements for cnrK
K resources do not permit^
of Pathology and Microbiolnov111^
t^C ^cPartmcnt
tai. Laboratories at. the ofsffict leveZhX^
hospi- .
technicians, 2 laboratorv attend /
should have 4 laboratory
«affi At the Xd/t^q kvj^ra
h"
“a Dis™
ii”X“7e wS »EgsK^4pu,"i
“Mm4b^.
»>■
’ labt™-y “ 1"?' k“PMs
sboaldl
training in pathology should h
OU
as the maximum.
P
*
ad<l‘tion to general '
L’
sh6"l‘1Ibe feed
} trained &-'^ician per month
accessible
Sh°Uld be S° SIted 33 t0 be readily
accident and^cy^^^
300 to^oo MA?^th“PitaIS Jh°ruld
plant of 35—50 Xf A.'and'rh f
plants or mXestr DraffiX
four X>ay PUnts one of
■
^'A‘’ 3nd
a Portable
Plant besides
infra red. In large and bnsv\ Y
tOr U^okt and
miniature X-ray set.
hospitals there may be an additional
72. In district hospitals with
200 or more beds there should ■
be one 200 M.A. Unit, one t
too MA. and one 35—50 M.A. portable unit and one for dental
k3'?’/ • id? naVmS IamPs for uI-avjolet and infra red. TJ.
rhe tehsil/tamq hospitals should have one
L-ray plant of 50 M.A.
and .amps tor ultraviolet and infra red.
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73. Radiotherapy should oe confined to a few selected bcspt
tals and teaching hospitals.
74. Radioisotopes should be limited to teaching hospital- only.
ANCILIARY SERVICES
75. Supply of linen in a hospital should be the responsibility
of an officer of the status of Matron or Assistant Matron who should
be in-charge of the service. Central linen room is recommended.
76. Clothing supplied to patients should be simple, economical, durable, clean and suited :o the climatic requirements of the
place.
77. Mechanical laundry for linen in hospitals where the quan
tity of linen is not less than 45,000 pieces per week is considered
economical, quick and involving the minimum wear and tear and
pilferage. For this purpose smaller hospitals may be grouped.
Hospitals in the same city may combine to have central mechanical
washing. Small domcstia washing machines may be used in Dis
trict and Taluq hospitals.
78. Hospitals with more than 200 beds should have a whole
time dietician. In others one of the sisters should be trained in
basic knowledge of diets and put incharge of‘dietary and food ser
vices. Trolleys insulated with saw dust and stainless steel thermo
jars with a tap should be used for carrying food. Kitchen should
be preferably on the ground floor and be neat, clean and spacious.
Stainless utensils and gas or smokeless chullah should be used.
79. Central Sterilisation Supply Department should be orga
nised in all hospitals with bed strength 200 or more.
District
Hospitals should supply sterilised materials including dressings to
hospitals and dispensaries attached to them.
Blankets must be
thoroughly sterilised. The C. S. S. D. should be on the ground
floor near the operation theatre and connected with telephone.
80. Non-store holding purchases organisation should be set
up in all States to coordinate the demands of medical stores and
drugs from various hospitals. Rate contracts should be settled with
suppliers /manufacturers and supplies received from them directly,
in larger packings and sent to the District Hospitals from where the
drugs and equipment be supplied to Tehsil/Taluq Hospitals and
Primary Health Centres in tha district. Medicines should be stock
ed for a period of six months. Quality control organisation should
ensure quality of drugs received from suppliers and supplied to
hospitals.
81. Hospital pharmacies should be established in all teaching
hospitals and tablets, injections, fluids and other common mixturesand ointments should be manufactured there.
I
=
IM, IL U.IJL1J.JXMJL .II.MI11.J Jill ...
!
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consiskglf0 S^'S^uld^X5110^f6 it
cases of misuse and exc^ssiv^ nc
examine
j
:i“ “J’the National
“^“^STstaH
poeia
or generalic
‘
rT
y-- Pharmacoshould
7‘^ r
name
2nd USe
— of
ot hrand^
branded and patent medicines
should b?7
be discouraged.
, 84. In addid
’ Library havi.
and Periodicals,
periodicals, as well
piCtOr,a]
journals
-d health education XnS.
should
be a fairly good librarv and dn t
. - -e
Hospitals mere
of the
- district should fornm
C ors worKlce hi other hospiMedical and professional in
i
meryhers and borrow books
availabIe in all
hospitals and even in PrmarTHealth°C
lating medical and profesXnal iourml0^^ A
of circu--ign
counts
shouTd'
£
Xbl^ed
cd in foreirof important
□nt material
:_iI may
,
aonsned. If possible extracts
be got cyclostyled and circulated. ..
or
of the State to repS^ma^hrneTand?
511015; dCpCnding on dlc siz=
repair machines
set up. Technictlns attach-c to
T'.™* should be
«Hy visit hospitals to check un rr^T works^ should periodispot or bring them to workshop
periodically a certificate to th- Health°Ty
and plants in the hospital me in wn
,rtpair thern on the
audlor‘Dts should send
aI! machines
studies records sboul^bFkXtln fr0VKVno P°«-gruduate medical
and -areserved in bound volumes o- ,— *
with indexing
"d b-^hcrc fc,t
SSict^S
marked by the doctors.
Record should be mainta’3
3 ?lmP^e method
ofrecord keeping.
_
-----fication of Diseases. In’maoh^ho133?? °i! Intcnlationa*i'cffi
be"^
Medical Record Officer ^ing hospitals there3
should
Technicnn5
^d other
complementary clerical staffMw£
Techfli
“
one Mediicers in the hospi-
«P™d „
Me^
37- All hospitals with — oanis. ' D^Sd
S-T
h"' = "»od
donate blood.Blood B^nkc jri re;lds -nd reiatiyes of patients to
“ ln Aching Hospitals should supply
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i
blood to hospitals attached to them. These hospitals should have
refrigeration facilities and dust-free accommodation for ^storage and
equioment for blood transfusion. Blood Banks should oe equipped
with a utility' van which should serve as a multipurpose vehicle for
transoorting donors, blood donation teams and social workers, and
when free for propaganda purposes and for blood collection. . A
■small committee of experts to lay down standards for the collection
and storage of blood and for techniques of grouping and matching
should be appointed.
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88. Designs of mortuaries for different sizes of hospitals have
been suggested. Cold storage arrangements should be available in
’ district and teaching hospitals. Cold room chambers should keep
a temperature of 4°C. Provision of ice in case of electricity or com
pressor failure should be made.
The floor should be
stain-proof and easilv washable. Proper record for incoming and
outgoing dead bodies should be maintained and whenever required
the services of photographic and X-ray units should be available.
Ground floor is the best location for a Morgue. It shouia have a
suitable exit leading to a loading area concealed from the view of
patients, and the public. On an average there is one death per
hospital bed per vear and facilities for the custody of bodies and
post-mortems should be provided accordingly.
89. All out effort to inform the relatives, friends or persons
who may be visiting the patient during his illness, about the death
of the patient should be made before declaring a dead body as un
claimed. Unclaimed bodies may be sent to teaching hospitals for
teaching and research purposes. Post-mortem need be done on
legal and police cases or for pathological purposes for teaching and
research. Delay in handing over the dead body on this account
should be minimised to the maximum extent possible.
SANITATION AND SECURITY ARRANGEMENTS PUBLIC
RELATIONS AND HEALTH EDUCATION
90. Full fleged House-keeping Cell with a qualified Sanitary
Inspector, Havaldars, Sweepers, Scavengers and Gardeners has been
suggested.
91.. Three to four per cent of capital cost should be provided
for the maintenance and repairs of hospital buildings. Restrictions
imposed on account of emergency or other matters in the allotment
of funds for repairs should not apply to hospitals.
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92. Hospitals should have arrangements to maintain a daily
supply of 50 gallons of water per bed.
Drinking water in the
form of water coolers should be provided in verandahs and out
patient department at suitable location. Private donations should
be solicited for providing water coolers.
I-
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hosoS °whIatrinC Seat2°r every six
shouid « DrOTdcd in
Hi.
piped Water SUPP1y “ avaiiabie- 'all tk surto th. 7
Sh°UM 06 converted lnto water-borne latrines attached
borne non-flushing latnnes shouid be provided with a septic tank.
with fXi
J°Od SCn'er?’ attendailts etl who come in contact
ith food should be screened and their health records maintained
will
Re^lar Physical verification of stores in all departments
wdl reduce pilferages. Architects should pav adequate attention
f consideration of security in the designing^ hospitals.
i
worked
J°Od and “ur*0115 behaviour on the part of hospital *
Zian^d-S0CtorS and
?CCPtivCness
Pad“B and dteir
sSinf W1U “nstItutc good Public relations. This cannot be
stnctly enforced but are to be realised.
In
hospitals, a Public Relations Officer should be
appointed to look into the complaints and difficulties, bring them
to the notice of the concerned officer and secure redress.
shnnl^L
^afualty.and Emergency Departments the doctor
should be particularly polite and sympathetic and should spare no
-borts to console the relatives and attendants of the patient A.
brochure containing the “Dos” and “Don’ts" i.e. acts which he is
not expected to do, should be available for the benefit of the inwticnts.
P9" Appointment of Hospital Advisory Committees in teach
ing and district hospitals is suggested. These Committees should
take lively interest in the affairs of the hospital and the staff and
suggest measures to add to the comforts of patients, build better
relations ana secure hospital support
r
^2
of w*
voluntary institutions, charitably disposed persons and sociaTworkers.
i
education Hospitals form
“ceI,Ient nu<Jcus for imparting health
In teaching hospitals there should be a qualified Health
wdth
soc>al science
----- -- training. He Miuuiu
th ,medical
medical°or
or social
should uc
be
assisted by medico-social
Thee
icdico-social workers trained in health education. Th
set-up should include a projectionist
’
to operate the audio-visual
equipment and amst-cum-photographer for
f„. preparing education
__ ____ * T
mas
District hospitals should be provided with medico-social
workers
The Medical Officer-in-charge of the Primarv Health
Centre should be responsible for health education in the Block and
he should utilise tne Block extension Educator in planning educa
tion matenai for the Primary Health Centre.
•!
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tor. The equipment for health education work for hospitals.
o£ various sizes have been suggested.
!
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102. Adequate display of health education material, be ?ks.
pamphlets and arrangements for display of short films may be made
in the Out-patient Departments in hospitals.
AUGMENTATION OF RESOURCES
103. In order to augment financial resources the following
measures are suggested :—
(i) Levy
.. of a charge of io paise per attendance in the cut
patient departments of hospitals and dispensaries.
(ii) A minimum charge;e of 25 paise per day of hospital stav.
(iii) .Payment of diet-charges byj lpatients
have
----- who
• • —mw
. »e a montnl y
income of Rs. 200/-or above.
(iv) Setting
- up. of pay
x , clinics ijin all major hospitals in towns
with a population of five lakhs.
(v) Provision of paying beds in district and teaching hosoitals, where these do not exist
(vi) Extension of Central Government Health Scheme and
Employees State Insurance Scheme.
(vii) Starting of Health Insurance Scheme in selected areas or
among selected groups of population. <
(viii) Contribution from the L.I.C., and
(xi) Health Cess.
104. The revenues, raised by measures suggested above.
should not go to the public exchequer but made available tcTthe
hospital concerned either directly or through an equivalent increase
in its budget Donations for putting up of hospital
hospital buildings.
building.
enco^aoed0^ ^C<^S *n C^eni anc^ ^or runn*n& hospitals should be
rT°5,
Government Health Scheme and Emplovees
State Insurance Scheme should be extended to uncovered population
and areas
Health Insurance Scheme may be tried on pilot basis
m selected areas, both among the urban and rural populations.
State Governments should also initiate health insurance schemes
tor their employees by some banks and other organisations should
be discouraged and these orgamsations should also start their own
Heal tn insurance schemes.
•.u Ito6; iThanft Insurance Corporation should also join hands
wim health agencies in their endeavour and be asked to set apart
a prescribed proportion of its profits to finance the Health Insurantbeneme.
IO7- - The levy of Health Cess as imposed in the State oT
Mysore may be considered by other States also as a source for rais
ing revenues.
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318
FAMILY PLANNING PROGRAMME IN HOSPITALS
JpS. All medical men, general practitioners, specialists pae
diatricians and others should be made to take interest in Family
Planning work, and they be made aware of the urgency of the
population problems, modern methods and latest research in Family
Planning.
.
‘
7
109. Family Planning Committees should be set up
up in all
hospitals to plan and review the progress made in regard to Family
Planning.
.
'
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ii°. Family Planning services should be provided in all hospik 1
Family PlanninS Welfare Centres and no post should
be left unfilled. In teaching hospitals the Family Planning Welfare
entres should work as a part of the Department of Gynaecology
and Obstetrics. These centres should also organise “Well-baby”
Clinics. Occasion, 'hen women come for fitness for loop inser
tions or some other tamily planning advice, should be utilised for
detection of abnormal]’ties/disease and wherever possible proper
advice given for treatment.
in. All hospitals should have facilities for sterilisation.
112. Doctors and para-medical staff who take active .interest
in Family Planning, a remark to this effect may be made in his
character rolls. For outstanding work in Family Planning the
staff may be allowed double increments in pay.
II3- As for educational programmes, the Family Planning
Welfare Centre should be situated at advantage point, all doctors
wherever possible, should advise patients for Family Planning as
part of patient s care; nurses during the patient’s stay in hospitals, ‘
can educate and motivate them for Family Planning. At the time
when patient is discharged from hospital, eligible patients may be
clearly told the type of Family Planning advice needed and the
place to be visited by them.
114. Orientation courses in Family Planning for doctors and
nurses should be organised in teaching hospitals. Staff of Re
gional Family Planning Centres may also be involved. Family
Planning should be made a subject of study in medical colleges as
part of undergraduate curriculum.
CENTRAL GOVERNMENT HEALTH SCHEME
II5priority should be given to the construction pro
gramme or dispensaries. The action on proposals (?) to have a
separatae Hospital for Central Government Health Scheme benencianes in Delhi and (ii) to set up one poly clinic for every five
aispemaries to provide laboratory, diagnostic and specialist services
should be expedited.
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. 116’ Much or 41- time spent by the patients in the dispen
saries will be reanr’d it the Pharmacist’s counter is enlarge to
ac^cmmoaate both toe compounders dispensing special and ~ erdinary medicines and separate timings be fixed for old and new cL<es
and ti.ese timings are strictly enforced excepting for emergezev
cases.
117- Direct consuLtanon with the specialists by benefin'-r?,-^
drawing Rs. 1,200/- or more per month is not justified on medi
cal grounds and as such this distinction should be removed.
118. A Central Pharmacy be established in the medical ^mre
tor the manufacture of certain drugs.
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119. The CGHS formulary of medicines is quite exhaustive.
ine practice of giving medicines outside the formulary and in ex
cessive quantity should be voluntarily discontinued and doctors
should be considered as the best judge to prescribe the medicine
120. A committee of experts should be set up to go into this
question ana suggest measures for removing the disparity in enenditure in various dispensaries.
7
I2i The use of proprietory names should be progressrav
eliminated and the drugs should bear generic names. Stricter inxrnai checks should be enforced to eliminate pilferage. To prevent
impersonation separate indentity cards for every beneficiary ontaming his/her photograph should be issued.
7
, . I22\ Tbe rates of contributions has remained the same smee
the inception of the scheme in 1954 inspite of sharp rise iiTexpenditore. Contributions made bv the beneficiaries to the CGH3
should be raised in the same proportion as the rise in total emolu
ments to the benchaanes since the rates of contributions were last
fixed.
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I23' Since the C.G.H.S., dispensaries are providing comnrehensive health care, they should be redesignated as “Health Cezra
for Central Government Employees”.
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DIFFICULT AREAS
124. The referral functions entrusted to District Hosnimls
generaUy, should, m case of Difficult Areas, be made in respoiisbility of the Sub-Divisional hospitals (tehsil, taluq or another suitable
aamimstratiye subdivision.) These hospitals may have more than
50 oeds and in addition to surgical, medical, gynaecological and
obstetrics specialities should have other specialities such as oprSai.
mciogy, dermatology, E.N.T. venereal diseases and dentistTv/
T25. The number of Primary Health Centres should be ~crd
to two m a Block. The frequency of visits of health workers
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should be raised gradually to one in a week. There should be a
provision of io beds and in addition an isolated hut
126. Within areas of Primary Health Centres suitable sub
centre to be known as key villages’ should be selected in such a
manner that one or another of the key villages lie- within half a
day’s march from the fartherest village. Doctors from the P.H.C.
should visit the village, examine patients and dispense medicine,
once in a week, on days extensively publicised.
127. First aid kits should be kept in village and school
teacher or a Surpanch or one of the Panchs should be given short
training course to provide first aid services to villages.
128. Doctors working an difficult areas should bc**givcn
higher rural allowance than obtaining in other rural areas. .
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Position: 1758 (3 views)