16. By the end of the Second Plan, 2800 primary health units will have been established, covering most of the development blocks. The number of hospitals and dispensaries will increase from 8600 in 1951 to 12,600 in 1961 and during the same period the number of beds will increase from 113,000 to 185,600. The working of primary health units during the Second Plan shows that among factors affecting the progress of this programme were (i) shortage of health personnel, (ii) delays in the construction of buildings and residential quarters for staff and (iii) inadequate training facilities for different categories of staff required for service in rural areas. The need has also been felt for strengthening the primary health units and to possibility of integrating as early as may be feasible services such as those for the control of malaria, tuberculosis, etc., with the normal activities of health units. Among other steps to be taken to improve the efficiency of primary health units, are the provision of the minimum staff required, organisation of the necessary training facilities and the integration of the activity of primary health units with other health service available in the area.
17. Difficulties have been experienced in securing a sufficient number of doctors. In order to create the necessary climate and conditions for securing personnel for rural areas,the following measures are suggested :
(i) As is the practice in some States, there should be a single cadre for personnel working in rural as well as urban areas. Service rules may stipulate that each incumbent in the cadre has to put in a certain period of service in rural areas, before he can cross the first efficiency bar or gain the next grade. Period of service in rural areas should be taken into consideration for accelerated promotion, advance increments or selection for post graduate training.
(ii) Residential accommodation and other facilities should be provided for medical personnel serving in rural areas. Due account should be taken of their additional expenditure e.g. on account of the education of children.
(iii) Scholarships should be made avail-able in sufficient number to students undergoing training with the obligation that they will serve in rural areas after graduation for a minimum prescribed period.
(iv) The services of medical practitioners both in urban and rural areas should be utilised on a part time basis in the hospitals and dispensaries and for school health service.
(v) The services of qualified and properly trained graduates in indigenous systems of medicine in primary health units and sub-centres in addition to the medical officer should be utilised.
18. Further, to ensure that the standard of primary health units is maintained and special services are readily made available to them, it is necessary that these units are linked up with referral and district hospitals. Specialised services are at present concentrated in hospitals in the larger cities. To bring these services within easy reach of the population of small towns and villages, it is necessary that the bed strength of district and sub-divisional hospitals is suitably enlarged and X-ray and pathological diagnostic
348 THIRD FIVE YEAR PLAN
services and medical, surgical and obstetrical specialist services are made available. Apart from the increase in hospital beds, out-patient departments should be organised as polyclinics, so that much of the technical equipment may be available and treatment afforded in the outpatient department itself.
19. The overall target for the Third Plan is the establishment of 2000 more hospitals and dispensaries and 54,500 additional beds.
CONTROL OF COMMUNICABLE DISEASES 20. Work on the control of communicable diseases, including malaria, filariasis, tuberculosis, smallpox, venereal diseases, leprosy, cholera and goitre will be undertaken on a larger scale in the Third Plan, special emphasis being placed on the eradication of malaria and smallpox. A total expenditure of Rs. 23 crores was incurred on the control of the communicable diseases in the First Plan and of Rs. 64 crores in the Second Plan. The Third Plan programmes entail a total outlay of about Rs. 70 crores.
21. Malaria eradication.-Anti-malaria measures undertaken during the first two Plans have resulted in marked decline in the annual incidence of the disease from 75 million cases in 1952-53 to about 10 million cases in 1960-61. The child spleen rate diminished from 7.7 per cent in 1956 to 1.4 per cent in 1960. Similarly. the child parasite rate decreased from 1.8 per cent to 0.2 per cent and infant parasite rate from 0.7 per cent to 0.1 per cent. By the end of the Second Plan, 390 malaria eradication units were in position. Surveillance operations have been introduced simultaneously and, as the Third Plan progresses. these units-will be gradually withdrawn and only a few units will be retained, if necessary, particularly in border areas.
22. Filaria control.-Filariasis is prevalent mostly in coastal regions. Surveys conducted during the Second Plan have indicated that about 40 million persons are exposed to the infection in endemic areas. The method adopted for its control consists of mass chemotherapy, anti-mosquito measures and anti-larval measures. Filariasis is predominantly an urban problem and the essential effective long-term measure is the improvement of environmental. sanitation. The number of control units was increased from 11 in 1956 to 48 in 1961. In the Third Plan, anti-filariasis measures will be continued, but priority will be given to drainag schemes in towns affected by this disease.
23. Smallpox.-Smallpox is endemic in India and is a source for the spread of infection to other countries. There has been a decline in morbidity and mortality rates from smallpox due to the vaccination campaigns which have been undertaken, but smallpox cases continue occur during certain seasons in a year and the disease appears in epidemic form once in five or six years.
As smallpox is a preventible disease and as vaccination is a potent weapon for eradicating it, it has been agreed that during the Third Plan an effort should be made to eradicate the disease. Pilot schemes were initiated in all States during 1960-61. The principal items of the programme in the Third Plan would be (1) an increase in the output of vaccine lymph, (2) recruitment and training of vaccinators, and (3) undertaking mass vaccination to cover the entire population before the next outbreak- of the disease. Action has already been initiated to increase the output of vaccine lymph.
24. Tuberculosis.-A sample survey conducted recently under the auspices of the Indian Council of Medical, Research has shown that the total number of cases of pulmonary tuberculosis in the country was roughly 5 million, of which about 1.5 million might be infectious and that while mortality from tuberculosis is showing signs of decline, the incidence rate has remained more or less the same, both in rural and urban areas. During the Second Plan about 120 million persons were tested under the B.C.G. Vaccination Campaign. The number of tuberculosis clinics was increased from 160 in 1956 to 220 in 1961. Ten T.B. Demonstration and Training Centres were established and the number of beds for tuberculosis patients was increased from 22,000 in 1956 to 26,500 in 1961. A National T.B. Training Institute was estab- lished at Bangalore in 1959.
In the Third Plan, the B.C.G. Campaign will be intensified to cover another 100 million persons. The number of clinics will be increased from 220 to 420. In addition, 25 mobile clinics equipped with X-ray for miniature films and the mobile laboratory for collection of specimens and simple examinations will be set up for service in rural areas. Five more Tuberculosis Demonstration and Training Centres will be established. About 3500 more beds for tuber- culasis patients will be added bringing the total number of beds to 30,000 by 1966. Provision has also been made for the setting up of 7 After Care, and Rehabilitation Centres.
25. Veneral diseases.-The common venereal diseases prevalent in the country are syphilis and gonorrhoea and the incidence is fairly high in cities,ports,industrial areas and in some of the sub-Himalayan tracts and is likely to increase with urbanisation and industrialisa- tion. By the end of the Second Plan period 75 district clinics and 8 headquarter clinics were set up. The introduction of effective methods for the rapid diagnosis and treatment of these diseases has made it possible to reduce the reservoir of infection in the population. In the Third plan, 100 district clinics and 6 headquarter clinics will be set up and Procain Aluminium Monostearate (PAM) and antigens will be supplied free of cost.
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26. Leprosy-There are roughly 2 million persons suffering from leprosy in the country of whom about 20 to 25 per cent are in the infectious stage. The incidence of disease varies from 0.5 per cent to 5.0 per cent. Leprosy is brought under control by intensive and extensive mass scale treatment with modem drugs, especially the sulphones. By the end of the Second Plan, 135 Study and Treatment Centres for leprosy had been set up. About 7 million persons had been surveyed and about 90,000 persons were given domiciliary treatment. The Central Leprosy Teaching and Research Institute at Chingleput has been carrying out research into various problems concerning leprosy and training the leprosy workers. The Leprosy Advisor), Committee, set up in 1958, to review the leprosy control schemes has made a number of recommendations for intensifying the leprosy control work in India such as grant of special allowance, free residential accommo- dation, improvement in service conditions and centralised training programmes for workers in this field.
The programme for the control of leprosy during the Third Plan period includes the establishment of 100 more control units and the establishment of survey, education and treatment (SET) centres, besides continuing the existing programmes. A large number of voluntary organisations and social workers in antileprosy work will be associated in this programme. Every hospital and primary health unit in endemic areas would be organised as a nucleus for leprosy control, work.
27. Cholera.-India has been an endemic area for cholera for a very long period. As has been pointed out by a recent expert committee there are five endemic foci in the deltaic regions of the principal rivers in the States of West Bengal,Orissa, Andhra Pradesh and Madras of which West Bengal and Orissa, are the more serious. To prevent frequent recurrence of cholera epidemics, these endemic foci have to be eliminated. This can be achieved only by providing adequate supply of safe water for the population,particularly in the endemic areas and by the adoption of modern methods of sewage disposal.As a practical measure, attention should first be concentrated on towns and cities where the infection spreads much more easily than in the rural areas with their relatively sparse population. By far., the largest and most important endemic focus in India is Greater Calcutta which is situated at the very centre of the main endemic area of West Bengal. The existing system for the supply of filtered river water is an old one and has to be considerably extended. Only two-thirds, of the city area is at present covered by a sewerage system. Improvement and modernisation of the water supply,sewerage and drainage systems of Greater Calcutta calls for careful planning and urgent action. Water supply and sanitary con- ditions in the Calcutta area were, reviewed recently by a team from the World Health Organisation and various steps have been recently initiated.
28. For the complete eradication of cholera, water supply and sanitation have to be improved much more extensively than has yet been possible under the First and Second Plans. In the Third Plan a substantial programme for providing protected water supply is being undertaken. It is suggested that in the States affected by cholera a large part of this programme should be concentrated in the endemic pockets. Specific programmes for these areas should be drawn up speedily and, if necessary, an effort should be made to supplement resources available under the Plan. There is no reason why it should not be possible to reduce the incidence Of cholera significantly during the Third Plan and to eliminate it wholly by the end of the Fourth Plan.
29. Goitre.-Goitre is endemic in the sub-Himalayan region. During the Second Plan period the Government of India, in collaboration with the UNICEF established a factory near Sambhar Lake in Rajasthan, to manufacture iodised/iodated salt for distribution in some endemic districts of the Punjab. This factory is capable of producing iodised salt to meet the requirements of a population of 2.7 million, that is, about a third of the population at risk. To eliminate goitre completely, the production of iodised salt has to be increased and two more plants need to be installed.
30. Provision has been made in the Third Plan for the treatment and control of trachoma. Facilities for the early diagnosis of cancer and for research in this field will be expanded under the Third Plan.
MEDICAL EDUCATION AND RESEARCH 31. Statistics relating to the expansion of training facilities for medical and para- medical personnel during the first two Plans have be-en Net out in table 3. In the Third Plan, training facilities in medical colleges and attached hospital will be expanded further and 18 new medical colleges will be established, bringing the total number to 75, Separate Departments will he established in all medical colleges for the study of social and preventive medicine. The development programme of the All India Institute of Medical Sciences will be completed and in several medical colleges certain departments will be upgraded and facilities for postgraduate training and research will be established.
32. The expansion of training facilities for doctors in the first two Plans has barely kept pace with the growth of population, the population-doctor ratio remaining at 6000 : 1 over the decade 1951-61. This ratio will remain unchanged tinder the programme for the Third Plan, in formulating which the shortage of teachers in the existing medical colleges has had
350 THIRD FIVE YEAR PLAN
to be taken into consideration. Reference has already been made to the shortage of doctors for work in rural areas and to steps necessary for removing this deficiency. A further measure which is recommended is that a new short-term course for the training of "medical assistants" should be instituted at an early date. The trainees should work in primary health units in the rural areas for periods of 3 to 5 years after which they should be given special facilities to obtain the normal medical qualifications and continue in the public service.
33. Postgraduate medical education.-With the rapid expansion of medical colleges and the establishment of new colleges, there will be increased demand for teachers. A larger number of students have to be trained in various subjects to the postgraduate level to take up teaching positions in medical, colleges. The existing facilities available for postgraduate education are adequate for an annual average intake of about 750 students and the out-turn may be of the order of 250. It is estimated that there is already a shortage of about 2000 teachers in the existing medical colleges. For the anticipated expansion of these colleges and the establishment of new medical colleges, about 2500 teachers will be needed so that the total requirement of teachers during the Third Plan will be of the order of 4500. A provision of Rs. 3.5 crores has been made in the Third Plan for the expansion of facilities for postgraduate education. This programme has a very high priority and should be completed in the early years of the Third Plan.
34. Dental education.-There are at present 10 dental colleges with a total annual admission of about 280. During the Third Plan 4 new colleges will be established and some of the existing colleges will be expanded. This will raise the annual admission to 400 per year. Provision has also been made. in the Third Plan. for the opening of dental clinics and for dental research.
35. Medical research.-Research programmes in the Second Plan were drawn up on the basis of the recommendations of the Indian Council of Medical Research. These include research in communicable diseases, particularly tuberculosis, trachoma, leprosy, cholera and virus diseases. The study of nutritional disorders and diseases received special attention. Studies with a view to developing methods for preventing pollution of rivers and streams by industrial wastes were carried out. Research on diseases of viral origin has also been undertaken. Programmes for medical research to be carried out in the Third Plan have been described in the Chapter on Scientific and Technological Research. Priority will be given to the study of problems of environmental sanitation and communicable diseases. Special attention will be. devoted to training of research workers in different fields in sufficient number. Research on indigenous medicine will be intensified.
TRAINING OF ANCILLARY PERSONNEL 36. Although since the beginning of the First Plan, steps have been taken to expand training facilities for nurses and other ancillary personnel, shortages have continued to be acute. The relevant statistics of the progress made and the targets for the Third Plan are set out in Table 3. The problem is proposed to be dealt with in the Third Plan along the following lines :-
(i) Nurses.-To improve the condition of service for nurses and to attract larger numbers of women to this profession it is proposed that in each State, there should be a special Nursing Service and a Nurse Superintendent should advise and assist the Director of Health Services. It is also proposed that competent and experienced Nursing Sisters should be appointed in hospitals.
(ii) Auxiliary nurse midwives.-Auxiliary nurse midwives go through a two-year course of training. The aim is that they should eventually replace midwives in primary health units and elsewhere. Training facilities are being considerably stepped up in the Third Plan.
(iii) Health visitors.-The Plan as at present formulated envisages increase in the number of training institutions for health visitors from 30 to 50, the annual intake rising from 650 to 850. Considering the existing shortage of health visitors and the important role assigned, to them in the rural health services the training facilities need to be augmented to a, much greater extent. It is suggested that the present training programmes in the States should be reviewed at an early date in relation to health visitors as well as other women workers required for implementing the rural health programme
(iv) Dais.-Child births in rural area's are. attended to mostly by dais. They, however,, lack training. The general object is to give to. dais a measure of reorientation and training,to enable them to render better service in the villages. Provision for such training is being made in the Plan..