HEALTH AND FAMILY WELFARE
12.1 Health of the people is not only desirable goal but is also an essential investment in human resources. The National Health Policy (1983) reiterated India's commitment to attain "Health for All (HFA) by 2000 A.D". Primary health care has been accepted as the main in- strument for achieving this goal. Accordingly, a vast network of institutions at primary, secondary and tertiary levels have been established. Control of communicable diseases through national pro- grammes and development of trained health manpower have received special attention.
12.2. Many spectacular successes have been achieved in the country in the area of health. Small-pox stands eradicated, and plague is no longer a problem. Morbidity and mortality on account of malaria, cholera and various other diseases have declined. The crude birth rate and Infant Mortality Rate (IMR) have declined to 29.9 and 80 (1990 SRS data) as compared to 37 and 129 respectively in 1971. Life expectancy has risen from a mere 32 years in 1947 to 58 years in 1990. However, HFA is a long way off. Disease, disability and deaths on account of several communicable diseases are still unacceptably high. Meanwhile, several non-communicable diseases have emerged as new public health problems. Rural health services for delivery of primary health care are still not fully operationalised. Urban health services, particu- larly for urban slums, require urgent attention due to changing urban morphology.
Programme Thrusts in the Eighth Plan 12.3 It is towards human development that health and population con- trol are listed as two of the six priority objectives of this Plan. Health facilities must reach the entire population by the end of the Eighth Plan. The Health for All (HFA) paradigm must take into account not only high risk vulnerable groups, i.e., mothers and children, but must also focus sharply on the underprivileged segments within the vulnerable groups. Within the HFA strategy "Health for underprivi- ledged" will be promoted consciously and consistently. This can only be done through emphasising the community based systems reflected in our planning of infrastructure, with about 30,000 population as the basic unit for primary health care.
Minimum Needs Programme (MNP)
Rural Health Programme 12.4 Development and strengthening of rural health infrastructure through a three tier system of Sub-centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs) for delivery of health and family welfare services to the rural community was continued during the Seventh Plan. But, lack of buildings, shortage of manpower and inadequate provision of drugs, supplies and equipments constituted major impediments to full operationalisation of these units.
12.5 The achievements and the present situation for health infrastruc- ture under the MNP and availability of building and manpower are given n Annexures 12.1, 12.2 and 12.3.
12.6 The approach and strategy for rural health during the Eighth Plan would be:-
i) Consolidation and operationalisation, rather than major expension, of the network of Sub-centres, PHCs and CHCs sot hat their performance is opti- mised. This would be achieved through -
(a) strengthening of physical facilities including completion of building of the centres and staff quarters;
(b) provision of essential equipments as per the standard list;
(c) filling up of all vacant posts within a defined time frame and in-service training of staff;
(d) ensuring supply of essential drugs, dressings and other material.
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ii) To monitor the progress of implementation of MNP at the district, State and national levels, a health information management system will be de- veloped and used.
iii) The targets regarding setting up of Sub-centre, PHC and CHC on the basis of population norm are indicative only. The States will be given flexibil- ity in establishing these units as per the local needs depending on geographical and population considerations, resources, manpower availability, etc. In opening new centres the needs of tribal population and communities living in difficult and inaccessible areas will be given first priority.
iv) The rural hospitals and dispensaries will be suitably modified, equipped and staffed to covert them into Sub-centres, PHC, CHC, as the case may be thereby integrating them into primary health care system.
v) The backing of Sub-centres, PHCs and CHCs in many States is staggering and the resources required to meet the targets are astronomical and as such unachievable in near future. In view of this the entire policy of establishment of Sub-centre, PHC and CHC with the present norms will be reviewed and new policy options developed to make the primary health care accessible, acceptable and affordable to all. Re-organisation of the Indian Systems of Medicine and Homoeopathy (ISM&H) dispensaries/hospitals in rural areas to create ISM&H health centres is one such option. This would be in line with the Government's accepted policy of promoting ISM&H. Reorientation of existing person- nel of these dispensaries/hospitals, provision of additional facilities and/or staff, redefining the roles and responsibilities would be some of the prerequisites to put the concept of ISM&H Primary Health Centres and Sub-centres in an operational mode.
vi) Mechanism will be developed to make the rural health services responsive to the needs of the rural masses and accountable to the community. Panchayati Raj system would become an effective instrument for eliciting community participation in the health programme and providing supervision and support to primary health care infrastructure.
vii) Linkages will be developed with the sub-divi- sional and district hospital to provide referral back-up.
Urban Health Services 12.7 More than one quarter of the population in the country now lives in urban areas. In metropolitan and large cities about 40-50% of the urban dwellers are estimated to be living in slum areas where the health status of the people is as bad as, if not worse than, in rural areas. But infrastructure for primary health care in urban areas hardly exists. Serious attempts will be made to develop urban health services as per the recommendations of Krishnan Committee. Organic linkages will be forged with the urban development schemes including Urban Basic Services for the Poor for a comprehensive development of health and welfare services. Local hospitals will be made responsible to run these centres and treat them as their extension counters for providing health services to the community. Voluntary organisations and local bodies would be encouraged to develop partnership and ulti- mately taking full responsibility for carrying out these programmes. Health system research to develop a model of urban primary health care services will be undertaken.
Secondary and Tertiary Care Services 12.8 Alongwith the emphasis on consolidation of primary health care, the strengthening of secondary care services and optimisation of tertiary care services would be the key objectives of the Eighth Plan.
12.9 The sub-divisional and district hospitals which are the secondary level medical care institutions, lack adequate manpower and facili- ties, to be able to discharge their responsibilities satisfactorily. In view of the resource constraints, there is need for raising re- sources to maintain the quality of care and meet rising expectations of the people. It is time that the concept of free medical care is reviewed and people are required to pay, even if partially for the services. The system can be so designed that the truly indigent popu- lation are able to get free/highly subsidised medical care. Innovative approaches/practices to this end and a system of medical audit will be developed during the Plan. Maximum cost-effective utilisation of existing services will be another
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item on the agenda.
12.10 In accordance with the new policy of the Government to encour- age private initiatives, private hospitals/clinics will be supported subject to maintenance of minimum standard and suitable returns for the tax incentives. Norms for minimal facilities and accredition or private hospitals/clinics would be developed to maintain quality of patient care.
12.11 The medical college hospitals and specialised hospitals have to be used exclusively as tertiary care centres and for health manpower development. Important prerequisites for this would be improvement in the facilities and standards of care available at secondary care level and development of strong referral system.
12.12 A conscious decision has to be taken to enforce a balanced development of primary, secondary and tertiary care services in the country with priority for primary health care. Otherwise there is a district risk of the paradigm of primary health care as a tool for "Health for All" being overrun by the mechanism of "All for a few". This tendency and trend can be halted only with scientific arguments for which sound epidemiological, health management and health financ- ing data is needed and hence the need for health systems research.
Health Man-power Development and Training 12.13 As much as approximately two thirds of the total expenditure on health services is spent on personnel. Yet, health manpower planning, production and management, which constitute key elements for effective implementation of health programme, have not received enough atten- tion.
12.14 While the States have been more than anxious to start new medi- cal colleges, their efforts to develop institutions for training of para medical staff have been entirely suboptimal. This has resulted in a considerable mismatch between the requirement and availability of health personnel of different categories. Ideally, the doctor-nurse ratio should be 1 : 3 but currently there are less than 3,00,00 regis- tered nurses against 4,00,000 registered medical graduates. Similarly, there is a shortage of pharmacists, laboratory technicians, radiogra- phers, dental surgeons, etc., in the country.
12.15 The National Health Policy affirmed that the effective delivery of health care services would depend very largely on the nature of education, training and appropriate orientation towards community health of all categories of medical and health personnel. It is, therefore, of crucial importance that the entire basis and approach towards manpower development in terms of national needs and priorities are reviewed and training programmes restructured accordingly. Besides there is an urgent need to assess appropriate health manpower mix to deliver health services at primary, secondary and tertiary level and for the purpose of training and research.
12.16 The approach and strategy for health manpower development during the Eighth Plan would be -
i) The draft of a National Policy on Education in Health Sciences which has already been circulated would form the basis of new initia- tives in manpower development
ii) The existing situation regarding health manpower supply, demand and projection and facilities for training of different categories will be reviewed in the light of National Policy on Education in Health Sciences.
iii) Appropriate steps will be taken for bridging the critical gaps in the manpower requirement for primary health care and the higher levels and for training and research needs. Starting vocational courses as part of vocationalisation of general education at the + 2 level of the 10+2 system will be supported to expeditiously bridge the gap in the supply of paramedical personnel.
iv) The distortions created in the past on account of over-emphasis on training of doctors, often at the coast of other categories of personnel, and also the undue emphasis on specialisation/super spe- cialisation/super specialisation will be checked.
v) Continuing education for all categories of staff will be given high priority. For this, district and regional level training institutions will be suitable strengthened. Medical colleges and other institutions including professional bodies like Indian Medical Association (IMA) will continue to play an important role, in
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coordination with the National Academy of Medical Sciences (NAMS), which has been identified as the model agency for this purpose.
vi) The existing facilities for training of medical graduates has outstepped the needs. No new medical college or an increase in the admission capacity of the existing colleges will, therefore, the supported during the Eighth Plan. Instead, resources will be used to strengthen the hospitals, laboratories and libraries of the existing medical colleges so that the standards of training are maintained.
vii) For ensuring uniform standards of medical and paraprofessional education, establishment of universities of medical and health sciences at regional level will be supported with their linkages to the proposed Education Commission in Health Sciences, which would serve as an apex body for the promotion and coordination of education in health sciences for all categories of health professionals and at all levels.
viii) Statutory councils will be strengthened and new councils for para-professionals, where they are needed, will be created so that standards of training and education can be laid down and enforced. The proposed Education Commission in Health Sciences will promote and coordinate all education activities for all categories of health manpower at all levels.
ix) Training facilities for epidemiology and health management, the two disciplines which contribute to the maximum extent to efficient functioning of health services including hospitals, will be augmented in medical colleges and created in specialised institutions where training of teachers can be undertaken.
x) Training of doctors of ISM&H will also be reviewed and re-oriented to make it congruent with the needs of national health programmes and primary health care.
xi) Efforts for re-orientation of medical education, started during the earlier plans, will be pursued vigorously with emphasis on faculty development through workshops for the teachers to make them conversant with the health needs of the country, national policies and programmes and make them appreciate the need for re-direction and retargetting of medical education.
Programmes for Control of Communicable Diseases 12.17 A number of national programmes for eradication/control of communicable diseases have been initiated in the country since the early years of planning. Most of the control/eradication programmes for communicable diseases have been in operation since last several plans at huge financial cost. With a few exceptions, however, no rational level comprehensive review/evaluation of these programmes have been undertaken. During the Eighth Plan the following strategies will be followed for control of communicable diseases -
i) National level review of the ongoing control/eradication programme to assess the current strategies and their impact on the disease status..
ii) Ensuring sufficient supplies and logistic support including mobil- ity for carrying out the programmes.
iii) Establishment of epidemiological- cum - surveillance centres at district/regional levels and improvement of health management informa- tion system for continuous monitoring of the disease situation and taking appropriate and prompt action.
iv) Intersectoral coordination will be strengthened with departments of public health engineering, local bodies like municipalities, Minis- tries of Information and Broadcasting, Women and Child Welfare, Water Resources, etc., for control of vector borne and other diseases.
v) The Information, Education and Communication (IEC) activities within each programme would be given special attention for enlisting community participation, which constitutes one of the weakest links, for carrying out the disease control programmes.
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vi) Strategy of training of staff at horizontal level, both within the primary health care and higher level, is essential.
vii) Training in epidemiology is woefully inadequate in the country. Unless this situation is rectified decisions regarding control of communicable disease and its implementation will be handled by the group of professionals and para-professionals who are not sufficiently equipped to do so with its attendant consequences. Specialised insti- tutions/departments to carry out both pre-service and in-service training in epidemiology for different category of staff will be created and the existing ones strengthened.
Programme wise strategies are briefly outlined hereunder -
Vector Borne Diseases
Malaria Eradication 12.18 As result of introduction of modified plan of operation in 1976 the incidence of malaria has come down from about 6.5 million cases in 1976 to about 1.89 million cases in 1990. The problem of drug resist- ance of P. falciparun malaria in several States is a cause for con- cern. Several operational problems and non-availability of matching funds from States to this 50% Centrally Sponsored Scheme (CSS) has resulted in shortfalls in spray operations, decline in blood slide collections and incomplete treatment of cases. Irrigation projects without adequate strategies for management of water resources and floating labour population to cities and major project sites has also contributed to the increased incidence of malaria.
Kala-azar and Japanese Encephalitis 12.19.1 Kala-azar and Japanese Encephalitis (JE) have emerged as major public health problems in recent years. For control of Kala-azar the twin approach of (i) vector control by insecticide spraying and (ii) case detection and treatment at PHC and referral hospitals was adopt- ed. The reported cases and deaths due to JE in the affected States viz. Andhra Pradesh, West Bengal, U.P. Tamil Nadu and Assam have shown considerable decline during the Seventh Plan with the use of indige- nously produced vaccine.