HEALTH, FAMILY PLANNING AND NUTRITION
Sustained efforts towards promotion of health care services during the last 30 years have resulted in significant improvement in the health status of the country. The Mortality rate has declined from 27.4 in 1941-51 to an estimated 14.2 in 1978. The life expectancy at birth has gone up from about 32 years as per 1951 Census to about 52 years during 1976-81. The infant mortality rate has come down from 146 during the fifties to 129 in 1976. The health infrastructure has been strengthened. The country has about 50,000 sub-centres, 5,400 primary health centres including 340 upgraded primary health centres with 30 bedded hospital, 106 medical colleges with admission capacity of 11,000 per annum and about 5 lakh hospital beds. The per capita expenditure on health incurred by the State has gone up from about Rs. 1.50 in 1955-56 to about Rs. 12 in 1976-77. The doctor population ratio though satisfactory on an average in the country (1977), varies widely from 1 doctor for 8333 in Meghalaya to 1 doctor for 1400 in Delhi. The bed population ratio has also improved but varies widely in urban and rural areas.
22.2 The country was declared free from smallpox in April, 1977. The National Malaria Eradication Programme initiated in 1958 had brought down the incidence of the disease to about 1 lakh cases with no deaths in 1965 although there has been a slippage in the subsequent years. The National Programme for Control of Leprosy, Tuberculosis, Filaria and Blindness have also helped to reduce mortality/morbidity.
22.3 National Programmes have also been initiated for promotion of maternity and child care such as immunization of expectant mothers against Tetanus and children against Tetanus, Whooping Cough, Diphtheria. Tuberculosis, Polio etc., besides prophylaxis against Vitamin 'A' and iron deficiencies. Programmes of improving the nutrition of mothers and children have also been taken up.
22.4 In the field of curative services some of the State Hospital have built up specialised sophisticated services comparable with facilities available in some of the advanced countries for cardiac diseases, cancer and neurological, nephrological disorders.
HEALTH
Review 22.5 The programmes initiated in the earlier plan, for control/eradication of major communicable diseases and for providing curative, preventive and promotive health services backed by training of adequate number of medical and paramedical personnel were strengthened further in the Fifth Plan, and in the subsequent annual plans. Provision of minimum health services in the rural areas was integrated with family planning and nutrition for vulnerable groups of population-children, pregnant women and lactating mothers. The programmes were aimed at :-
(i) Increasing the accessibility of health services to rural areas.
(ii) Correcting regional imbalances.
(iii) Further development of referral services by removal of deficiencies in District/Sub-divisional hopitals;
(iv) Intensification of the control/eradication of communicable diseases especially Malaria and Smallpox;
(v) Qualitative improvement in the education and training of health personnel; and
(vi) Development of referral services by providing specialist attention to common diseases in rural areas.
22.6 The Minimum Needs Programme was the main instrument through which health infrastructure in the rural areas was expanded and further strengthened to ensure primary health care to the rural population. The outlays earmarked for this programme were considered almost a prior charge on the Plan budget for medical and public health of the States. The facilities available in selected rural dis- pensaries were expanded to provide preventive and promotive health care facilities by adding the necessary health components. These functioned as subsidiary health centres. The following table shows the number of sub-centres primary health centres and upgraded primary health centres with a 30 bed-
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ded hospital set up by 31st March, 1980 vis-a-vis targets set for 1974-79 Plan:-
Table 22.1
(Nos.)
At the Target Likely
Programme beginning set for achieve-
of Fifth 1974-79 ment by
Plan Plan (cu- 31-3-1980
1973-74 mulative) (cummula-
tive)
Sub-Centres 33509 43836 50000
Primary Health Centres 5250 5351 5400
Subsidiary Health Centres Nil Nil 1000
Upgraded Primary Health
Centres Nil Nil 340
22.7 The programme of conversion of health workers serving in vertical public health programmes like malaria control, TB control, smallpox etc., into multipurpose health workers through reorientation training was assigned a high priority. This programme initiated in about 183 districts out of 400 districts in the country was completed by 31st March, 1980.
22.8 In accordance with the recommendations of the Study Group on Medical Education and Support Manpower, (1975) two Centrally Sponsored Schemes viz., (i) Community Health Volunteers and (ii) Reorientation of Medical Education were initiated in 1977. The community health volunteers programme initiated in October 1977 had the objective of providing a trained community health volunteer selected by the community itself for every village or a population of 1000. Under the scheme of re-orientation of Medical Education, each medical college in the country was to adopt 3 primary health centres in the first phase with the twin objectives of providing a rural bias to medical education and also curative health care and referral facilities to the rural population covered.
22.9 In spite of several significant achievements, the health care system obtaining in the country suffers from some weaknesses and deficiencies. There has been pre-occupation with the promotion of curative and clinical services through city based hospitals which have by and large catered to certain sections of the urban population. The infra-structure of sub-centres, primary health centres and rural hospitals built up in the rural areas touches only a fraction of the rural population. The concept of health in its totality with preventive and promotive health care services in addition to the curative, is still to be made operational. Doctors and para-medicals are reluctant to serve in the rural areas. They are generally city oriented and their training is not adequately adapted to the needs of the rural areas particularly in the field of preventive and promotive health. There has been over dependence on the States for health care measures and voluntary and local effort has not been able to take up responsibility in any significant measure. The involvement of the people in solving their health problems has been almost non-existent.
22.10 The incidence of malaria has shown an upward trend since 1965. There have also been reported cases of malaria caused by Plasmodium faliciparum parasite accounting for some deaths. This type of malaria is also spreading from the North Eastern region where it originally occured to other States. Resistance of this parasite to specific drugs has been reported. The vector mosquitos have also developed resistance to DDT and BHC in certain areas of Gujarat and Maharashtra. There has been incidence of Japanese Encephalitis in certain pockets.
22.11 Of an estimated 3.2 million leprosy patients in the country, 20 per cent are infectious and another 20 per cent suffer from various deformities. Curative and rehabilitative services for these are necessary.
22.12 Nearly 2 per cent of the total population in the country is estimated to suffer from radiologically active lesion of which 25 per cent are sputum positive and infectious cases. The control measures adopted under the T.B. control programme do not appear to have made any appreciable dent on the dimensions of the problem and the incidence of TB continues to be high.
22.13 According to the survey conducted by the Indian Council of Medical Research, out of an estimated 9 million blind persons in the country, about 5 million could be cured by proper surgical interference. In addition, 45 million persons were reported to be otherwise visually impaired. It was also observed that the existing backlog of 5 million cataract cases was likely to go up by another million new cases every year.
22.14 Maternal and infant mortality rates are still on a higher plateau compared to advanced and some developing countries. The decline in the sex ratio (females per 1000 males) from 946 in 1951 to 930 in 1971 indicates the need for greater attention to maternal and child health care. There are also considerable inter-State and regional disparties in health and medical care standards. The general position of the Scheduled Castes/ Scheduled Tribes and other backward classes is comparatively more unsatisfactory.
Policies and Strategy of Health Care Programme 22.15 An investment on health is investment on man and on improving the quality of his life. It is, therefore, well recognised that health has to be viewed in its totality, as a part of the strategy of human resources development. Horizontal and vertical
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linkages have to be established among all the interrelated programmes like protected water supply, environmental sanitation and hygiene, nutrition, education, family planning and maternity & child welfare. Only with such linkages can the benefits of various programmes be optimised. An attack on the problem of diseases cannot be entirely successful unless it is accompanied by an attack on poverty itself which is the main cause of it. For this reason the Sixth Plan assigns a high priority to programmes of promotion of gainful employment, eradication of poverty, population control and meeting the basic human needs as integral components of the Human Resources Development Programme.
22.16 The country has adopted the policy of 'Health for all by 2000 AD' enunciated in Alma Ata Declaration in 1977. Alongwith this the long term objective of population stabilisation by reducing Net Reproduction Rate (NRR) to 1 by 1995 is to be achieved. The health care system in the country has to be restructured and re-oriented towards these policy objectives. The strategy to be followed over a period of 20 years upto 2000 AD, based on the recommendation of the Working Group on Health, will be as follows :
(i) Emphasis would be shifted from development of city based curative services and super-specialities to tackling rural health problems. A rural health care system based on a combination of preventive, promotive and curative health care services would be built up starting from the village as the base.
(ii) The infrastructure for rural health care would consist of primary health centres each serving a population of 30,000 and sub-centres each serving a population of 5,000. These norms would be relaxed in hilly and tribal areas. The village or a population of 1000 would form the base unit where there will be a trained health volunteer chosen by the community.
(iii) Facilities for treatment in basic specialities would be provided at community health centres at the block level for a population of 1 lakh with a 30 bedded hospital attached and a system of referral of cases from the community health centre to the district hospital/medical college hospitals will be introduced.
(iv) Various programmes under education. water supply and sanitation, control of communicable diseases, family planning, maternal and child health care, nutrition and school health implemented by different departments/agencies would be properly coordinated for optimal results.
(v) Adequate medical and paramedical manpower would be trained for meeting the requirements of a programme of this order and all education and training programmes will be given suitable orientation towards rural health care.
(vi) The people would be involved in tackling their health problems and community participation in the health programmes would be encouraged. They would be entitled to supervise and manage their own health programmes eventually.
The crucial indicators as at present and those desirable by 2000 AD are shown below:-
Table 22.2
Index Present 2000 AD
level Target
Infant Mortality Rate (per 1000 live birth) 129 Below
(1976) 60
Crude Death Rate (per 1000 population) 14.2 9.0
(1978)
Life Expectancy at birth (in years)
Male 52.6 64
(1976-81)
Female 51.6 64
(1976-81)
Crude Birth Rate (per 1000 population) 33.3 21.0
(1978)
Net Reproduction Rate (NRR) 1.51 1.0
(980-81)
In substance, a reduction of 5.2 points in the death rate and 12.3 points in the birth rate by 2000 AD would be the target for achievement. The rate of infant mortality is also to be reduced by more than 50 per cent and life expectancy raised to 64 years.
22.17 The expanded immunization programme and the programme of prophylaxis against iron and Vitamin 'A' deficiencies would be strengthened. The targets envisaged for Sixth Plan are indicated in Annexure 22.6. All the national public, health schemes like Malaria control, Leprosy control, TB control etc., would be monitored towards the specific goal of adequate health care for all envisaged for the period 1980-2000 AD.
Rural Health Programme 22.18 The minimum needs programme in the State Sector would continue to be the main instrument for development of the rural health care delivery system. It will be supplemented by Centrally Sponsored Programme for training of medical and paramedical workers.
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22.19 Minimum Needs Programme: Primary health centres at the rate of one for each community development block had been established by the end of Fifth Plan. It was also proposed to have one sub-centre for 10,000 population and upgrade one out of every four selected primary health centres to a 307 bedded rural hospital to serve as a first link in the chain of referral services. Full coverage of the backlog of primary health centres and sub-centres buildings were also contemplated in the Fifth Plan. Although the progress of setting up of primary health centres has been satisfactory, many of them are not having necessary buildings and other facilities. The sub-centre programme has been proceeding very slow. These programmes would, therefore, be accelerated over the successive plan periods to achieve by 2000 AD the objective of establishing one primary health centre for every 30,000 population or 20,000 in tribal and hilly areas and one sub-centre for every 5,000 population. As against the earlier policy of setting up a 30 bedded rural hospital by upgrading one out of 4 primary health centres, a community health centre will be established for a coverage of 1 lakh population with 30 beds and specialised medi- cal care services in gynaecology, paediatrics, surgery and medicine.
22.20 Keeping in view the training capacity of ANMs and other para-medicals and the constraint of financial resources, it is proposed to establish 40.000 additional sub-centres during 1980-85 Plan raising the number of centres to an estimated 90,000 against the total requirement of about 1,22,000 centres i.e.. 74 per cent coverage on the basis of Mid 1984 estimated population. 600 additional primary health centres will be set up in areas where mostly the existing primary health centres cater to a relatively larger population on present norms. Out of those, over 100 primary health centres are expected to be located in tribal and hill areas. In addition, 1000 out of the existing rural dispensaries will be converted into subsidiary health centres to accelerate the promotion of promotive and preventive health care facilities. These will be eventually converted into primary health centres. There will thus be 6000 primary health centres and 2000 subsidiary health centres (1000 existing+1000 new proposed) by 1984-85 against the total requirement of about 18,560 centres. Coverage of backlog construction works of sub-centres, primary health centres buildings and staff quarters, besides construction works of new units to the extent possible within the available resources will be aimed at during the Plan period. 174 primary health centres will be upgraded to Community Health Centres. with 30 bedded hospital in addition to completion of construction works of upgraded primary health centres already taken up. These will be converted into community health centres, emphasising the public health aspects.
22.21 Centrally Sponsored Schemes: The minimum needs programme will be supported by the Centrally Sponsored Schemes of Community Health Volunteers, Employment and Training of Multi-purpose Workers and Re-orientation of Medical Education which are all continuing schemes.
22.22 The community health volunteers scheme is yet to be evaluated fully, although two quick evaluations have been made. There are about 1.40 lakh community health volunteers in field as on 1st April, 1980. It is proposed to extend the programme further during the 1980-85 Plan to add another estimated 2.26 lakh community health volunteers raising the total number to 3.60 lakhs by 1985, with a view to cover the whole country. The States of Jammu & Kashmir, Kerala, Tamil Nadu and the Union Territories of Arunachal Pradesh and Lakshadweep Islands are implementing alternative schemes of health care at the grass roots level. An in-depth evaluation of the Centrally Sponsored Community Health Volunteers Scheme, as well as these alternative schemes will be made to develop, if necessary, a modified scheme to promote health consciousness among the rural people and provide a link between them and the primary health centres.