HEALTH
THE general aim of health programmes during the second five year plan is to expand existing health services, to bring them increasingly within the reach of all the people and to promote a progressive im- provement in the level of national health. The specific objectives are:
(1) establishment of institutional facilities to serve as bases from which services can be rendered to the people both locally and in surrounding territories;
(2) development of technical manpower through appropriate training programmes and employment of persons trained;
(3) as the first step in the improvement of public health, institution of measures to control communicable diseases which may be widely prevalent in a community;
(4) an active campaign for environmental hygiene; and
(5) family planning and other supporting programmes for raising the standard of health of the people.
HOSPITAL SERVICES 2. In providing hospital facilities the aspects to be kept in view are quantity, distribution, integration, and quality. An effective regional system, of hospitals would include four distinct elements, namely the reaching hospital, the district hospital, the tehsil hospital, and the rural medical centre associated with a health unit. Each element in such a system would be linked administratively 'with the others. A coordinated hospital system with its free flow of medical services and patients should help to provide satisfactory medical care both in urban, and rural areas.
3. The creation of more hospital facilities is needed but, in view of the high cost of these services, it is equally important to develop existing hospital services and to make them both efficient and economic. In existing hospitals questions relating to staffing, accommodation, equipment and supplies should receive special attention. Further a long-range programme of action should be promoted by
(1) integration of the working of hospitals,
(2) correlation of their functions with those of clinics; domiciliary care services and public health activities;
(3) accelerated rate of rise of the available beds by reducing 'the turnover interval' and thus shortening wherever possible the average duration of stay of patients;
(4) provision of seperate accommodation for cases of acute communicable diseases, as such cases take up at present a great deal of the bed space in existing general hospitals;
(5) provision of cheaper accommodation with less elaborate medical and nursing care for chronic diseases: and
(6) in view of recent advances in chemotherapy and preventive measures for the control of many diseases, which make services based on clinics and domiciliary care more and more effective, concentration on the expension of such services in prcference to increase of hospital accommodation.
4. It is estimated that in 1951 there were 8,600 medical institutions in the country with about 113,000 beds; in 1955-56 the a number of institutions may be about 10,000 with about 125,000 beds. These figures represent an increase during the first plan of 16 percent in institutions and of 10 per cent in beds. At the end of the second p1an the number of institutions is likely to be about 12,600 and the number of beds about 155,000, providing thus for an increase of about 26 per cent in institutions and of about 24 per cent in hospital beds. The plan provides about Rs. 43 crores for augmenting and improving hospital services, including staff, accommodation, equipment and supplies.
HEALTH UNITS 5. The povision of adequate health protection to the rural population is by far the most urgent need to be
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met in the second five year plan. In view of the programme for ex- tending the national extension service to the entire rural population, the establishment of primary health units in as many development blocks as possible is a necessary step towards providing an integrated preventive and curative medical service in rural areas. The popula- tion of an average development block is too large to be catered for by the proposed health unit staff, but the scheme has the advantage of providing an elementary type of health Organisation throughout the country. In later plans, progressive improvements in the scheme of medical care provided by health units can be undertaken.
6. The ultimate success of the health unit programme depends upon the extent to which essential services are provided. These are:
(1) institutional and domiciliary medical care, with adequate emphasis on its preventive aspects, amongst others, maternal and child health, school health, and control of communicable diseases, (2) environmental sanitation, (3) health education,
(4) improvement of vital and health statistics, and
(5) family planning.
In the early stages, certain services such as those for the control of malaria, filaria, tuberculosis, veneral diseases and leprosy may have to be rendered by special staff but after adequate control has been attained, such services should form part of and be integrated with the normal activities of a health unit. This integration will be greatly facilitated if during the period of the second plan full co-ordination of activities can be established between such specialised services and the health units. The staff employed in each health unit should ultimately be such as to enable the unit to provide the basic services as well as specialised services relating to malaria and other dis- eases. In order that these services may reach the public throughout the area which a health unit serves, the provision of transport has considerable practical importance. It will also facilitate the remov- al of urgent cases to hospitals. It is desirable that a broad uniform pattern for the structure and functions of a health unit should be accepted throughout the country. As far as possible new dispensaries should not be started on the old lines and existing dispensaries should be converted into health units.
7. The difficulty in obtaining doctors and other health personnel in rural areas is due less to lack of trained personnel especially in the case of doctors, as to the present unsatisfactory position in respect of housing conditions, facilities for the education of children and other amenities. An essential step in securing a large flow of health workers into rural areas is to make conditions of service in these areas mote attractive.
8. As against 725 health units set up during the first plan, it is proposed to establish over 3,000 health units in national extension and community projects and other areas. State Governments also pro- pose to convert 1. 31 existing dispensaries into primary health units and to set up a number of secondary health units. The plan provides about Rs. 23 crores for this programme.
MEDICAL EDUCATION 9. The number of medical colleges has increased from 30 in 1950-51 to 34 in 1954-55 and 42 in 1955-56. Annual admissions have increased from about 2,500 in 1950-51 to about 3,500 by 1955. The present training facilities provide for an annual out-turn of about 2,500 doctors during the second plan. There are at present 70,000 qualified doctors in India and about 12,500 doctors will qualify during the second plan. As against this, the number of doctors needed will be about 90,000. It is considered essential that more training facilities should be provided during the second plan so that this gap may be filled.
10. As new medical colleges will take some time to function fully, the expansion of existing colleges should be given the first priority. The plan provides about Rs. 20 crores for the expansion of medical colleges and attached hospitals, establishment of Preventive Medicine and Psychiatric Departments in medical colleges, completion of the All-India Institute of Medical Sciences and schemes for upgrading certain departments of medical colleges for post-graduate training and research. The annual admissions are likely to be increased by about 400 as a result of these expansion schemes. This would, however, cover only a part of the shortfall in the number of available doctors. It would, therefore, be necessary to start some new colleges during the second plan period. An amount of Rs. 6.5 crores has been provided in the plan of the Ministry of Health for establishing new medical colleges.
11. Medical colleges in India are now staffed by teachers who are permitted private practice. This concession is an important reason for low standards of teaching and for the small amount of attention which medical research has received. TO remedy this situation, the Medical Council of India has recommended that every department of a medical college should have a full-time non-practising unit consisting of a professor and other teachers. The strengthening of medical colleges by the inclusion of whole-time units
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is essential for raising standards of undergraduate and post-graduate medical education and for developing research. The additional cost involved in this proposal in respect of each college is expected to be Rs. 2 lakhs per year. The provision necessary for about 35 medical colleges will be about Rs. 3.5 crores in the course of the second plan period.
DENTAL EDUCATION AND DENTAL SERVICES 12. There are only 600 to 700 qualified dental surgeons in the country. Thus, the country has only a fraction of the dental surgeons it needs. The need for a substantial increase of the facilities for training dental personnel is therefore obvious. There are, at present, only six dental colleges in the country and even these are not properly staffed, equipped or housed. The first step should be to bring the existing dental colleges to the required standards of effi- cient functioning and to double the number of admissions. Bombay has two dental colleges and Punjab, Uttar Pradesh, West Bengal and Madras one each. A dental college is to be established at the All-India Institute of Medical Sciences at Delhi. Daring the second plan Andh- ra, Bihar, Madhya Pradesh and PEPSU propose to open new dental col- leges and West Bengal and Punjab have provided for the expansion of existing colleges. The plan provides Rs. 2 crores for dental educa- tion.
13. In order to expand dental services it is suggested that medical men attached to rural dispensaries should be trained for emergency dental treatment. There are about 6,000 to 7,000 dentists who are registered in Part 'B' of the Dentists' Register and they are practising dentistry. They should be given additional courses of training. It is necessary to arrange for the training of adequate numbers of dental hygienists, dental mechanics and dental technicians. They will assist in increasing the efficiency of the limited dental services at present available. During the second plan period dental clinics are to be established in several district headquarter hospitals.
NURSING AND OTHER TRAINING PROGRAMMES 14. Shortages in personnel other than doctors have been more marked and are likely to persist longer than in the case of doctors. At the end of 1954 the numbers registered in different categories in the States were 20,793 nurses, 24,290 midwives, 756 health visitors, 4,468 dais and 946 nurse-dais. As norms to aim at, there should be one hospital bed for 1,000 population, one nurse and one mid-wife for every 5000 population and one health visitor and one sanitary inspec- tor for 20,000 population. For ancillary categories of personnel, figures given in the last column in the statement below are still somewhat distant. They illustrate, however, the character of the present shortages and the need for accelerated and sustained action if even elementary services are to reach the mass of the people in any adequate degree:
1950-51 1955-56 1960-61 No.
needed
Doctors 59,000 70,000 82,500 90,000
Nurses (including
auxiliary nurse- 17,000 22,000 31,000 80,000
midwives).
Midwives 18,000 26,000 32,000 80,000
Health Visitors 600 800 2,500 20,000
Nurse-dais and dais 4,000 6,000 41,000 80,000
Health Assistants and 3,500 4,000 7,000 20,000
sanitary
inspectors.
During the second plan, arrangements are being made for the training of increased numbers of nurses, mid, wives, pharmacists, sanitary inspectors and other technicians at medical colleges and at the larger hospitals which are not in use as teaching hospitals. A provision of about Rs. 6 crores has been made for these training programmes.
15. Nurses.- At present nursing education of different types and at varying standards is being imparted. It is desirable to standardise the training, so that maximum use is made of existing and new facilities for training. The two existing nursing colleges which train candidates for the B.Sc. degree in nursing can continue to provide training for the higher grades of nursing personnel. A great deal of expansion is needed in respect of facilities for the basic nursing course of three years' duration, to which is generally added a course in midwifery for six months or one year. On this depends the development of nursing services. The number of admissions to existing training institutions for nurses should be increased, and every large hospital should be used as a training centre. The basic training course should also be given a bias towards the public health aspect of nursing including family planning.
16. Auxiliary nurse-midwives.- In view of the large development programmes that are being undertaken all over the country, large numbers of auxiliary nurse-midwives are needed. They have a shorter course of training than nurses. Provision for this type of training should be expanded and use should also be made of hospital facilities. It is suggested that institutions at present utilised for training midwives may be upgraded into auxiliary nurse-midwives' training centres and hospitals at headquarters of districts as well as other hospitals in which fifty or more beds are available may be utilised for such training.
17. It is desirable that adequate facilities should be provided to enable nurses belonging to any particular
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class to get successively higher types of training until they become graduates in nursing if they desire to do so. A method by which the maximum use of all available nursing personnel is promoted, is to supplement full-time nurses by the use of part-time workers wherever possible. Nurses often leave the profession after marriage if full- time service is insisted upon. Many married nurses would, however, be willing to take up part-time work provided they do not have to move out of station. If local candidates are selected for training and are later employed in their own areas, without being moved into distant places, many more candidates for nursing would become available.
18. Dais.-- The training of dais should be undertaken in those areas in which they are needed urgently Preference should be given to women from the dai-class. The course should be of six months' duration and training should be given by public health nurses or health visitors who are qualified midwives.
19. Health visitors.- There is at present a marked shortage. of candidates for health visitors' courses. The reason for this lies partly in inadequate facilities for midwifery training which is a prerequisite for the health visitors' course. Another factor is the lack of prospects of promotion for health visitors who do not, have a certificate in general nursing also. Supervisory and teaching posts are so few in number that even health visitors possessing higher qualifications have small prospects of advancement in their own field. It is difficult to get health visitors for work in small towns and rural areas because quarters are not always provided for those who are not attached to hospitals, Yet another handicap for these personnel is disparity in emoluments. Allowances for food, uniform and washing are not admissible to health visitors.
20. There would be many advantages if all categories of nursing personnel (nurses, mid--wives and health visitors) should belong to a single service. At present public health nurses, health visitors and domiciliary mid-wives are not always part of a well-integrated nursing cadre. An integrated cadre assumes to some extent the same basic training for all members of the service. Already, there is a growing body of opinion that the nursing service for hospitals and for public health should be integrated into one service and that all nurses and midwives should also have adequate training in public health and domiciliary practice. In course of time this will certainly obviate the necessity of training- a separate category of health visitors. Though the long-term objective may be to replace health visitors by nurses with public health training and midwives by auxiliary nurse- midwives, in view of the present acute shortage of health visitors, it is not advisable to discontinue training of health visitors. It is therefore essential that the existing facilities for the training of this category of personnel should be strengthened and broadened suitably so as to meet adequately the present needs and to facilitate the transition.
21. Auxiliary personnel.- In considering the training programmes for auxiliary personnel, certain general principles may be started. All training, programmes should be closely related to the problem of employing the persons trained as soon as possible after training. Recruitment for training should be from amongst those who are resident in local areas, as far as possible, and provision for stipends should be made in order to enable deserving students from the lower income groups to avail of opportunities for training. The task of the auxil- iary health worker is to supplement the contribution made by doctors and other highly trained personnel for promoting preventive and cura- tive health activities in their various branches. Them main purpose of training and employing auxiliary workers is to promote a speedy and relatively cheap expansion of health protection to the people. In. most cases, corresponding to each of the main categories of fully trained personnel, there is room for an auxiliary worker. Thus, a sanitary inspector is an auxiliary workers in relation to public health engineer, a radiographer to the radiologist, a laboratory technician to the trained research worker in the laboratory. Similar- ly, to the doctor who is engaged in the ministration of' preventive and remedial medical care, an auxiliary worker who is able to carry out a variety of preventive functions and is able at the same time to administer treatment of an elementary kind, can prove to be of real assistance. In the interests of ensuring health administration and medical care on sound lines, it is essential that auxiliary personnel should work under the supervision of fully trained professional peo- ple. Specific and well-defined functions should be laid down for each type of auxiliary worker. The main principle in the production of such a worker should be. that within the limited field of work pre- scribed for him he should acquire a high degree of competence. It is not the intention that a type of auxilary worker should be developed who is taught a smattering of a number of different types of health functions and becomes proficient in none.