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CHAPTER 43
National Health Programs
Ever since India became free, Government of India has been
putting efforts (since 1947) earnestly to improve (to promote)
the health status of the people by improvement of sanitation,
living conditions, nutritional status and by control/eradication
of diseases, both communicable and noncommunicable,
getting assistance from various international organizations
such as WHO, UNICEF, World Bank, and also from foreign
agencies like SIDA, DANIDA, NORAD and USAID in the form
of various technical and material assistance.
As per the recommendations of Bhore Committee,
Government of India formulated and launched specific
programs called ‘National Health Programs’ right from the
inception of Five Year Plans (from 1951) for controlling/
eradicating health problems.
The National Health Programs (NHPs) are of three kinds:
1. 100 percent centrally sponsored programs, but imple-
mentation is by the State Governments.
2. 50:50 centrally sponsored programs, i.e. the imple-
mentation is by the State Government However 50 percent
of the expenses are incurred by the Central Government
and remaining 50 percent by the State Government.
3. Vertical programs: In this type both the implementation
and incurring expenditure is by the Central Government
only.
It is easier to get international funds for the centrally
sponsored programs.
Further, the central Government does not prelude the
state Government from running their own scheme. For
example, some states have their midday school meal program
in addition to the central one.
Some of the NHPs have ceased, some got merged with
others and some are recently introduced, as follows:
• The National Smallpox Eradication Program (NSEP) was
launched in 1962. Smallpox reached zero incidence on 24
May 1975. India in 1977, was declared to have eradicated
the disease by WHO. Since then NSEP has lapsed.
• The Applied Nutrition Program (ANP) was started in 1963.
It was discontinued, during 6th Five Year Plan (1980-85).
• The National Cholera Control Program (NCCP), the
National STD Control Program and the National Trachoma
Control Program, were merged respectively with those for
diarrheal diseases, AIDS and blindness and renamed as
National Diarrheal Diseases Control Program (NDDCP),
National AIDS control Program (NAIDS CP) and National
Program for the Control of Blindness (NPCB) respectively.
• Some of the NHPs have been renamed as follows:
– National Family Planning Program as National Family
Welfare Program.
– National Goiter Control Program as National Iodine
Deficiency Disorders Control Program.
– National Leprosy Control Program to National Leprosy
Eradication Program and Since 2000 to Modified
Leprosy Elimination Campaign (MLEC).
– Expanded Program of Immunization to Universal
Immunization Program.
– National Malaria Control Program to National Malaria
Eradication Program and then to Modified Plan of
Operation of Malaria Control and now to National
Anti-malaria Program.
– State schemes for the control of Japanese Ence-
phalitis, Dengue fever/Dengue Hemorrhagic fever
have been upgraded into National Control Programs
since 2003–04.
The National Health Program have been grouped into the
following groups:
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Chapter 43 National Health Programs 821

RELATED TO COMMUNICABLE 3. Reproductive and Child Health (RCH) Program

4. All India Hospital Postpartum Program
DISEASES 5. National Water supply and Sanitation Program (1954)
6. Minimum Needs Program (1974)
1. National Anti-malaria Program (NAMP) (1999) 7. 20-Point Program (1975).
2. National Filaria Control Program (1955) The first five (1 to 5) NHPs are together called as ‘National
3. National Kala-azar Control Program (1991) Vector Borne Disease Control Programs’. These come under
4. National Japanese Encephalitis Control Program the national nodal agency of Directorate of National Anti-
(2003–04) malaria Program (NAMP). The first three programs against
5. National Dengue Fever/Dengue Hemorrhagic Fever malaria, filariasis and kala-azar were sponsored equally by
Control Program (2003–04) State and Central Government till 2002-03. The other two
6. National Leprosy Eradication Program (1983) programs related to JE and DF/DHF were sponsored by State
7. National Guinea-worm Eradication Program (1983) Government. However, since 2003-04, Government of India
8. National Polio Eradication Program (1995) launched National Vector Borne Diseases Control Program
9. Universal Immunization Program (1985) (NVBDCP) and has been sponsoring all the National Vector
10. Revised National Tuberculosis Control Program (1993) Borne Disease Control Programs. Emphasis has been paid
11. National Acute Respiratory Infections Control Program more on the development of resources, standardization of
12. National Diarrheal Disease Control Program diagnosis and treatment, improving quality of services and
13. National AIDS Control Program. integration of vector control activities.
The differences between vertical and horizontal health
program of India are shown in Table 43.1.
RELATED TO NONCOMMUNICABLE Table 43.1 Differences between vertical and horizontal health
DISEASES programs of India

Vertical programs Horizontal programs

1. National Program for the Control of Blindness
These are special health These are integrated with general
2. National Cancer Control Program (1975)
programs health services, starting from
3. National Program for Control of Diabetes,
primary health centers
Cardiovascular Diseases and Stroke.
4. National Mental Health Program (1982) These are run by Government These are run by State Health
of India Department
5. National Iodine Deficiency Disorders Control Program
(1962). These do get assistance These do not get assistance from
6. National Program for Control and Treatment of from International Health International organizations
Occupational Diseases. Organizations
7. National Program for the prevention and Control of These are unipurpose programs These are multipurpose programs
Deafness. Expert training is given to Routine training is given to
Medical Officers with special paramedical workers
incentives
RELATED TO NUTRITION These are ‘Target oriented’ ‘Crash’ These are routine program
Programs
1. National Vitamin A Prophylaxis Program (1970) Examples: All National Health Examples: Revised National
2. National Nutritional Anemia Prophylaxis Program Programs except mentioned in Tuberculosis Control Program;
(1970) the right column Anti-malaria Program
3. National Special Nutrition Program (1970)
4. National Balwadi Nutrition Program NATIONAL ANTIMALARIA
5. Mid-Day School Meal Program (1962)
6. Integrated Child Development Services Scheme (1975). PROGRAM

History
OTHER HEALTH PROGRAMS
Control of malaria in the country was first recommended by
Bhore Committee in 1946. It was endorsed by the Planning
1. National Tobacco Control Program
Commission in 1951. Government of India, in April 1953,
2. National Family Welfare Program (1953)

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822 Section 7 Health Administration and Organization
launched National Malaria Control Program (NMCP), when
malaria was the principal health problem. During 1953
malaria accounted for annual morbidity of 75 million cases,
annual mortality of 0.8 million, proportional case rate of 10.8
percent, child spleen rate of 15.7 percent, child parasite rate of
3.9 percent and infant parasite rate of 1.6 percent.
The objective was to reduce the morbidity and mortality
of malaria to such a low level that it should no more be a
public health problem.
The strategy to achieve the objective was to interrupt the
transmission of malaria by controling the vectors (anopheline
mosquitoes) by indoor residual spraying with DDT, twice a year
in endemic areas, where spleen rates were above 10 percent.
The NMCP was operated for 5 years (1953–58). During
1958, the problem of malaria was measured again. The
annual incidence of malaria (which was 75 million during
1953) was reduced sharply to 2 million cases in 1958. Other
malariometric indices also showed marked decline. The
proportional case rate fell from 10.8 to 3.2. Thus malaria
declined by more than 80 percent. It also paid rich dividends
to the country in different fields like agriculture, land projects
and industry. This was due to active functioning of 193 malaria
program units, at rate of 1 unit for a population of 1 million.
NATIONAL MALARIA ERADICATION
PROGRAM
Encouraged by the spectacular results of success of NMCP, it
was decided by Government of India to eradicate the disease
and therefore Government of India launched National Malaria
Eradication Program (NMEP). But it was coupled with the fear
that malaria vectors would develop resistance to insecticides,
public might not cooperate for DDT spraying and malaria
might spread to non-endemic areas. Weighing the pros and
cons of the situation, Government of India decided in favor of
eradication and launched NMEP during 1958.
The objectives were:
• Elimination of reservoir of infection (by case detection
and prompt treatment), and
• Total ending of transmission of malaria, (by control of
vectors)
• Prevention of re-establishment of malaria by 1968-69.
(That means there should not be occurrence of malaria
even in the presence of carrier mosquitoes).
The entire country was brought under NMEP including
non-endemic areas, which were not covered under NMCP.
The NMEP was carried out in the same 4 phases, as originally
conceived for eradication of smallpox, namely preparatory
phase, attack phase, consolidation phase and maintenance
phase.
Preparatory Phase
This consisted of collection of data about the extent of the
problem of malaria and to prepare for attacking the problem.
Since the disease was just then measured during 1958, time
was not wasted and so this phase was not taken up. The
annual incidence was 2.0 million cases and proportional case
rate was 3.2 percent.
Attack Phase
This was taken up directly and it was extended for 3 years
from April 1958 to 61 April. The term ‘Attack’ implied on
the attack of vector anopheline mosquitoes by the principal
activity of spraying insecticides like DDT/BHC in all the
human dwellings, twice a year. By 1959, entire country was
covered. By 1960, Annual Parasite Incidence (API) came to 0.5
case per 1,000 population. Meanwhile a supportive activity
was introduced, called ‘Surveillance scheme (1960)’. This
consisted of detection of cases by passive surveillance and
presumptive treatment, by involving all the doctors working
in hospitals, dispensaries and clinics.
Consolidation Phase
This phase was started when API was reduced to 0.1 per
1000 population, i.e. during 1961. The term ‘consolidation’
implies consolidation of the gains achieved during attack
phase. The principal activity of this phase was stopping
DDT spraying due to complete interruption of transmission
and carrying out only active and passive surveillance and
presumptive and radical treatment. The supportive activities
were epidemiological investigation of cases and remedial
measures for elimination of foci of infection including focal
spraying, in case of focal outbreak, i.e. insecticidal spraying to
be done in about 50 houses around Plasmodium falciparum
infected house.
Active Surveillance
Under this, the surveillance workers (health workers male)
were entrusted with the responsibility of detecting the cases
of malaria actively. Each surveillance worker was allotted
10,000 population, distributed over 5 to 6 villages (or 2000
houses). He used to go to individual houses, once in a
fortnight and ask two questions-anybody is suffering from
fever in the family including guests and visitors on the day of
his visit and also whether anybody had suffered from fever
since his last visit. In either case with positive response, he
takes blood smear and presuming that fever could be due to
malaria, used to give ‘Presumptive treatment’ with 600 mg
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Chapter 43 National Health Programs 823

chloroquine straight for adults and proportionately less for • Injection artesunate, 1 mg/kg IM/IV 2 doses with an
children. If the smear proves to be positive, he used to return interval of 4 to 6 hour on first day followed by once a day
and administer ‘Radical treatment.’ With 600 mg chloroquine for 4 days.
and 15 mg primaquine on first day and only primaquine • Injection artemether, 1.6 mg/kg—in the same way as
15 mg daily from 2nd to 5th day. With this by 1961, API was artesunate.
reduced to 0.1/1000 population and the next phase was taken • Injection artether, 150 mg daily, IM for 3 days for adults
up (Table 43.2). only
• Mefloquine to be used only for P. falciparum cases
Table 43.2 Presumptive and radical treatment of malaria resistant to chloroquine or other antimalarials.
(Under current anti-malaria program) • Sulphadoxine and pyrimethamine is not effective in
P. vivax cases.
Type of Low-risk areas High-risk areas
treatment Note:
(slide positivity rate • Presumptive treatment is given to all the age groups and
is >3) P. falciparum is both the sexes including antenatal and postnatal women.
predominant or drug • Presumptive treatment is also given to fever cases
resistant cases/deaths reporting to drug distribution centers without obtaining
due to P. falciparum blood smears.
Presumptive Chloroquine 600 mg Day 1: Chloroquine 600 • Children are given the drugs in proportionately smaller
treatment single dose for adults mg plus Primaquine doses, starting with half a tablet for infants.
(4 tabs, each of 150 45 mg • Radical treatment is given for all cases proving micro-
mg) Day 2: Chloroquine scopically positive.
600 mg • Radical treatment ensures complete cure and makes non-
Day 3: Chloroquine infectious.
300 mg • Infants are not given radical treatment.
Radical P. vivax: Day-1 P. vivax: Primaquine • Infants and pregnant women are not given primaquine.
treatment Chloroquine 600 mg 15 mg, daily for 5 days • Drugs must be administered cautiously as they are known
single dose + 15 mg P. falciparum: to precipitate hemolytic crisis in glucose 6 phosphate
Primaquine • No further treatment dehydrogenase (G6PD) deficient individuals.
Day 2-5 (4 days) is required, after
Primaquine 15 mg presumptive treatment
daily. • However in chloro- Passive Surveillance
P. falciparum: quine resistant This means cases of malaria to be detected by the doctors in the
Chloroquine 600 mg cases, single dose hospitals, nursing homes, dispensaries and such other static
Primaquine 45 mg of the sulphadoxine agencies by taking blood smear for examination from all those
(1500 mg) and
patients, coming with the complaints of fever, to rule out malaria
pyrimethamine (75
mg) followed by 45
and treat accordingly. This helped in detecting more cases.
mg primaquine on the By 1961, annual incidence came down to hardly 50,000
next day. (They are not cases.
given on the same day Maintenance phase: The word ‘maintenance’ implied
because of hemolytic maintenance of vigilance to detect re-entry of infection in
crisis)
those areas declared ‘free’ of malaria. This phase was started
when no indigenous case of malaria was detected over a period
Severe and Complicated Cases of of 3 years, including two years in the consolidation phase. The
principal activity was a sustained vigilance to detect imported
Malaria cases if any. The supportive activity was to eliminate the
reservoirs. The vigilance activity was handed over to the State
• Hospitalization
Government. Meanwhile ‘Multipurpose Worker Scheme’ was
• Drug of choice is quinine injection, 10 mg per kg body
introduced. The responsibility of the malaria surveillance
weight, IV drip in 5 percent dextrose-saline, to be run over
workers was handed over to multipurpose workers.
4 hours, 8th hourly. Switch over to oral dose as early as
possible and total duration of treatment should be 7 days. The scenario of malaria eradication was as follows:
• Injection artemisinin may be used. Dose = 600 mg/day • API came down to 0.1 per 1000 population,
intramuscularly for 5 days. • Annual incidence was hardly 50,000 cases,

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824 Section 7 Health Administration and Organization
• 25 percent of the population was under attack phase, 25
percent in the consolidation phase and 50 percent under
maintenance phase.
Setbacks (Resurgence of Malaria)
From 1961, focal outbreaks of malaria began to occur and the
annual incidence went on increasing year by year. By 1965,
the cases reported were 1,00,000 (doubled).
By 1971, it was 1.32 million. The steady upward trend
continued and by 1976, it touched an all time high of 6.4
million cases with 59 deaths.
Malaria came back with greater force, i.e., vectors
developed resistance against DDT and parasites started
developing resistance against chloroquine. Hence the term
‘Resurgence’.
Causes
Resurgence of malaria was due to the following failures in the
program.
• Administrative failures: These were due to shortage of
money, manpower and materials.
Shortage of money was because of inadequate sanction
of the budget and diversion of funds in favor of ‘more obvious
needs’ such as family planning program.
Shortage of manpower was due to lack of field workers
and deviation of malaria workers towards family planning
program.
Shortage of materials were interruption in the supply
of DDT from USA due to blockage of Suez canal and the
shortage of other material such as drugs, spray equipment,
vehicles, etc.
• Technical failures: These were due to the development
of resistance by the vectors for insecticides and by the
parasites to the drugs like chloroquine.
• Operational failures: These were inadequate surveillance
activities, inadequate coverage with DDT spraying, non-
cooperation of the public, premature take off to consoli-
dation phase and maintenance phase, etc. resulting in the
relaxation of efforts.
Modified Plan of Operation of
Malaria Control
In response to alarming resurgence of malaria, Government
of India appointed evaluation committees to suggest
appropriate remedies to reverse the trend of malaria. The
committee suggested a change over from eradication, to
effective control. It was on the recommendations of this
committee that the Government of India launched Modified
Plan of Operation (MPO) with effect from April 1, 1977.
Objectives
• To reduce malaria morbidity.
• To prevent deaths due to malaria.
•
•
To consolidate the achievements already made.
To maintain agricultural and industrial production by
undertaking intensive anti-malarial measures in the labor
endemic areas.
The strategy adopted for achieving above objectives was
based on API. Accordingly, the country was classified into
two categories; area having annual parasite incidence of
2 or more and area having API less than 2 per thousand
population. Certain changes were necessitated in the
organization such as integration of the malaria organization
with the state health system and re-inforcement of the
integrated organizations.
• Integration: This consisted of re-alignment and re-
constitution of malaria units, involvement of a chief
medical officer for each district to carry out the work
through medical officers of primary health centers. This
resulted in the replacement of vertical approach by
horizontal approach and the direct involvement of health
infrastructure. The surveillance workers were replaced by
multipurpose workers. The services were integrated with
the routine health care services.
• Reinforcement: This consisted of strengthening the health
infrastructure such as redesignation of malaria unit
officers as District Malaria Officers, establishment of
malaria laboratory in every primary health center manned
by a trained laboratory technician. To improve the passive
surveillance a network of Fever Treatment Centers (FTCs)
and Drug Distribution Centers were established which
are being run by voluntary workers from the community
including school teachers, panchayat workers, dais and
others. While DDC only supplies the anti-malarial drugs,
the FTCs obtain a blood smear from fever cases and then
supplies the anti-malarial drugs. Thus the reinforcement
measures consisted of decentralization of anti-malaria
activities including laboratory services, resulting in the
reduction of the time lag between the collection of the
blood smears and the collection of the laboratory reports.
It also reduced the delay in the radical treatment of
confirmed cases.
Urban Malaria Scheme
Urban Malaria Scheme (UMS) was launched during 1971, when
it was realized that urban malaria was a significant problem
and the vectors breed largely in man-made containers like
over-head tanks, ornamental ponds, water coolers, flower-
vases, building constructions, etc.
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Chapter 43 National Health Programs
The objective was to control malaria by controlling the
vector population through anti-larval measures.
The criteria for selection of the areas were:
• Population more than 50,000;
• Slide positivity rate (SPR) more than 5 ; API > 2 or
• Fever cases more than 30 percent.
Control strategies were:
• Early diagnosis and treatment of malaria cases
• Bioenvironmental management by source reduction
measures such as emptying the water containers
including overhead tanks, ponds, etc. once a week and
observing weekly dry day.
• Controlling the larvae by weekly application of larvicidal
oil, temephos, fenthion. Use of larvivorous fish as a good
alternative method.
This scheme was further strengthened during 1976.
During October 1977, an additional component known
as ‘Plasmodium falciparum containment program’ was
introduced to control falciparum malaria, by providing
special inputs to strengthen the program getting assistance
from Swedish International Development Agency.
Researches are encouraged by Indian Council of Medical
Research (ICMR) to find out effective vaccines against
malaria, effective drugs and better insecticides.
Health education to the public was given to extend their
co-operation in the control of malaria.
Operational Details
1. For areas with API 2 or more, the following principal
activities are carried out:
• Regular insecticidal spraying: Two rounds of DDT
spraying and if the vectors are refractory to DDT, 3
rounds of malathion recommended. If the vectors
are refractory to both DDT and malathion, 2 round of
synthetic pyrethroids are recommended. The dosage
of DDT, malathion and pyrethroids recommended
were 1.0, 2.0 and 0.25 g per square meter surface
area respectively. BHC spraying was discontinued
since 1.4.1997 in view of its adverse environmental
pollution effects.
• Entomological assessment: This is done by the
entomological teams who study the behavior
of the mosquitoes and identify the insecticides,
which can give optimum results in an area. This is
done periodically by the teams (i.e, to assess the
susceptibility of the vector to insecticide).
• Supportive activities are active and passive
surveillance and presumptive and radical treatment.
2. For areas with API less than 2:
In these areas, the principal activities are active and
passive surveillance and presumptive and radical treatment.
The supportive activities are case follow-up, epidemiological
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investigation and focal spraying with DDT (BHC or malathion
if a case of P. falciparum occurs in the area).
Follow-up used to be done by examining blood smears
every month from all positive cases on completion of the
radical treatment, for 12 months. If positive falciparum case
is detected, a mass blood survey used to be carried out for
identification of additional cases if any. The detected cases
were given radical treatment and followed up.
MPO Achievement
1976: There were 6.4 million cases including 0.75 million
falciparum malaria cases in the country with 59 deaths.
1977: Modified plan of operation (MPO) of malaria control
was launched.
1980: API was 11.24.
1986: API became 3.22, annual incidence 2.1 million including
0.55 million cases of F. malaria. The problem was reduced
to over 70 percet in 10 years. Then it remained static for 8
years. But during 1994, country witnessed sudden upsurge
of malaria epidemics in Manipur, Nagaland and Rajasthan
states with four-fold increase in malaria mortality.
During 1994, Government of India decided to change
the nomenclature of the National Program and renamed it
as ‘National Malaria Action Program’ (NMAP). Under this,
7 Northeastern states and states like Andhra Pradesh, Bihar,
Gujarat, Maharashtra, Odisha and Rajasthan were selected in
the country and the anti-malarial activities were intensified
with additional inputs. It was 100 percent centrally sponsored
program.
During September 1997, Government of India launched,
‘Enhanced Malaria Control Project’, (EMCP) with the support
of world bank on September 30, 1997. The total cost of this
project was `891 crores, spread over a period of 5 years. This
benefited 100 selected districts and 19 urban areas.
The primary health centers were selected based on the
following criteria:
• API of more than 2 for the last 3 years
• P. falciparum cases being more than 30 percent of total
malaria cases
• 25 percent or more population of PHC being tribal:
The components under this project included were,
• Early case detection and treatment
• Control of vectors, (use of larvivorous fish)
• Personal protection methods (using insecticide treated
mosquito nets)
• Epidemic planning and rapid response
• Intersectoral coordination.
Synthetic pyrethroids, bednets, rapid diagnostic kits,
arteether injections, blister packs of drugs for radical
treatment, are provided. Funds are provided for IEC activities
and training. Village health guide is entrusted with the
responsibility of distribution of chloroquine tablets to the
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826 Section 7 Health Administration and Organization

patients with fever, thus making the availability of the drugs confirmation of malaria by either microscopy or rapid
within reach of the people. The EMCP was launched for a diagnostic test (RDT).
period of 6 years, i.e. up to March 2003. It was extended for 2
more years up to March 2005. Aims of the Policy
However during 1999, the program was renamed as
National Anti-malaria Program. The components were: • To provide complete cure of the cases (both clinically and
• Malaria action program for rural areas parasitologically).
• Urban malaria scheme for urban areas • To prevent the development of complications and thus to
• Enhanced malaria control project for North-east states. reduce mortality.
• To prevent the development of relapses by administration
Roll Back Malaria of radical treatment.
• To interrupt transmission of malaria by use of
Roll black malaria (RBM) is a global partnership founded in gametocytocidal drugs.
1998 by the WHO, UNDP, UNICEF and World Bank. The aim is To prevent the development of drug resistance.
to halve the world’s malaria burden by the year 2010. Treatment of uncomplicated malaria:
Political commitment is a key priority of RBM. 1. P. Vivax cases should be treated with chloroquine for three
RBM is giving priority to four technical strategies: days and primaquine for fourteen days. Primaquine is
• Prompt access to effective treatment used to prevent relapse but is contraindicated in pregnant
• Promotion of insecticide treated bednets and improved women, infants and individuals with G6PD deficiency
vector control (Table 43.3).
• Prevention and management of malaria in pregnancy and (Note: Patients should be instructed to report back in
• Improving the prevention of and response to malaria case of hematuria or high colored urine, cyanosis or blue
epidemics and malaria in complex emergencies. coloration of lips and in such cases primaquine should be
RBM also seeks to encourage the research in new and stopped. Fourteen days regimen of primaquine should be
better drugs, insecticides and malaria vaccines. given under supervision). Care should be taken in patients
with anemia.
Goals Chloroquine: 25 mg/kg body weight divided over three days,
i.e. 10 mg/kg on day 1 day 2 and 5 mg/kg on day 3.
The goals for the malaria control set for the Tenth Five Year +
Plan are: Primaquine: 0.25 mg/kg body weight daily for fourteen days.
• ABER over 10 percent
• API 1.3 or less 2. P. falciparum uncomplicated cases should be treated with
• 25 percent reduction in malaria morbidity and mortality Artesunate/Artemisinin combination therapy (ACT), i.e.
by 2007 and 50 percent by 2010. artesunate 3 days + sulphadoxine – pyrimethamine on
Day-1, accompanied by a single dose of primaquine on
Day-2 (Table 43.4).
REVISED NATIONAL DRUG POLICY Note:
(2010) FOR TREATMENT • Each sulphadoxine–pyrimethamine tablet contains 500 mg
and 25 mg respectively. Given on Day-1 only.
OF MALARIA
Table 43.3 Age-wise dosage schedule for treatment
Preamble: Malaria is one of the major public health problems of vivax malaria cases
of the country. About 50 percent of the total (1.5 million
Chloroquine tablet Primaquine tablet
confirmed cases annually) cases is due to P. falciparum. The Age (150 mg base) (2.5 mg base)
rise in proportion is due to resistance to chloroquine, which (years)
Day-1 Day-2 Day-3 Day -1 to Day – 14
was used as the first line of treatment for malaria cases. P.
falciparum infections are known to result in complications. <1 ½ ½ ¼ 0
National Drug Policy on Malaria was first formulated 1–4 1 1 ½ 1
in 1982 and has subsequently been reviewed and revised 5–8 2 2 1 2
periodically. The present policy of 2010 has been drafted
9-14 3 3 1½ 4
keeping in view the availability of more effective antimalarial
drugs and drug resistant status in the country. All fever 15 and
4 4 2 6
cases suspected to be malaria should be investigated for above
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Chapter 43 National Health Programs
Table 43.4 Age-wise dosage schedule for treatment of P. falciparum malaria cases
1st Day
Age (yrs) Sulphadoxine +
Artesunate (50 mg)
Pyrimethamine
<1 ½ ¼
1–4 1 1
5–8 2 1½
9–14 3 2
15 and above 4 3
• Dose of sulphadoxine is 25 mg/kg body weight;
pyrimethamine 1.25 mg/kg wt.
• Dose of Artesunate is 4 mg/kg body weight of 3 days.
• Primaquine 0.75 mg/kg wt, given on Day 2 only.
• Primaquine is contraindicated in pregnant women.
• ACT is not to be given during 1st trimester of pregnancy.
However ACT can be given during 2nd and 3rd trimester
of pregnancy.
• Uncomplicated falciparum malaria during first trimester
of pregnancy with Quinine salt, 10 mg three times daily
for seven days. Quinine may induce hypoglycemia.
Therefore it is to be taken only after food and they should
eat regularly. During 2nd and 3rd trimester, ACT to be
given in Table 43.4.
3. Presumptive treatment with chloroquine is no more
recommended. However in cases where parasitological
diagnosis is not possible due to non availability of
either microscope or Rapid Diagnostic Test (RDT),
suspected malaria cases can be treated with full course
of chloroquine, till the results are received. Once the
diagnosis is available, appropriate treatment, as per the
species, is to be administered.
4. Resistance should be suspected if the patient does not
respond within 72 hours clinically and parasitologically.
Such cases not responding to ACT should be treated
with oral quinine with tetracycline/doxycycline. These
instances should be reported to concerned District
Malaria/State Malaria Officer/Regional Officer of HFW
for initiation of therapeutic efficacy studies.
5. Treatment of mixed infections (P. vivax + P. falciparum)
cases: All mixed infections should be treated with full
course of ACT and primaquine 0.25 mg per kg body
weight daily for 14 days.
6. Treatment of severe malaria cases.
Severe malaria case is an emergency. Treatment should
be given immediately. Patient should be treated for associated
complications also.
The guidelines are as follows:
• Artesunate: 2.4 mg/kg body wt IV or IM at the time of
admission. Then at 12 hours and 24 hours and then once
a day.
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2nd Day 3rd Day
Artesunate (50 mg) Primaquine (7.5 mg) Artesunate (50 mg)
½ 0 ½
1 1 1
2 2 2
3 4 3
4 6 4
OR
• Artemether: 3.2 mg/kg body wt IM given on admission
and then 1.6 mg/kg body wt per day.
OR
• Arteether: 150 mg IM daily for 3 days in adults only (not
recommended for children).
OR
• Quinine: Loading dose of 20 mg/kg body wt on admission
by IV infusion or IM in divided doses, followed by
maintenance dose of 10 mg/kg body wt 8 hourly. The
infusion rate should not exceed 5 mg/kg body wt per hour
(loading dose of quinine may not be given if the patient
has already received quinine).
The parenteral treatment in severe malaria cases should
be given for minimum of 24 hours once started. After the
parenteral artemisinin therapy, patients will receive a full
course of oral ACT for 3 days.
Those patients who received parenteral quinine therapy
should receive oral quinine 10 mg/kg body weight three
times a day, including the days when parenteral quinine
was administered, Plus Doxycycline 3 mg/kg body wt once a
day or clindamycin 10 mg/kg body wt 12 hourly, for 7 days.
(Doxycycline is contraindicated in pregnant women and
children under 8 years of age).
OR
ACT as described.
Chemoprophylaxis
This is recommended for only selective group in high P.
falciparum endomic areas. Use of Inseticide Treated Bed
Nets (ITN)/Long Lasting Insecticidal Nets (LLIN) should
be encouraged for pregnant women and other vulnerable
population including military, paramilitary forces and
travelers for longer stay.
• Short term chemoprophylaxis (up to 6 weeks):
Doxycycline: 100 mg once a day for adults and 1.5 mg/
kg wt for children (contraindicated for children below 8
years and not recommended for pregnant women). This
should be started 2 days before travel and continued for
four weeks after leaving the malarious area.
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828 Section 7 Health Administration and Organization
• Long term chemoprophylaxis (more than 6 weeks):
Mefloquine: 250 mg weekly for adults and should be
administered two weeks before, during and four weeks
after exposure. (Mefloquine is contraindicated among
those with history of convulsions, neuropsychiatric
problems and cardiac conditions).
NATIONAL FILARIA CONTROL
PROGRAM
National Filaria Control Program (NFCP) was launched
during 1955 to control lymphatic filariasis in the endemic
states of the country. It is endemic in 20 states and union
territories. Non-endemic states are Jammu and Kashmir,
Himachal Pradesh, Delhi, Sikkim and all North-Eastern states
except Assam.
As per the survey made recently, about 420 million
people are at a risk of infection, 25 million people have filarial
parasites in their blood and about 19 million people are
suffering from the disease.
The control strategy includes:
• Improvement of sanitation with a special emphasis on
underground drainage system of sewage as a ‘source-
reduction’ method of control of vectors
• Anti-larval operations
• Anti-parasitic measures by detection and treatment of
microfilaria carriers,
• Organizing IEC campaigns for community awareness and
participation
• Conducting annual single dose mass drug administration
compaign using Diethyl Carbamazine (DEC) or DEC plus
Albendazole combination.
NFCP is implemented through filarial control units,
filarial clinics and survey units. Primary Health Care System
provides treatment facilities. Thus vertical program has
become horizontal program.
During 1978 June, the program was merged with urban
malaria scheme for maximum utilization of available
resources.
The Regional Filaria Training and Research Centers
situated at Kozhikode (Kerala), Rajahmundry (AP) and
Varanasi (UP), are under the control of Director, National
Institute of Communicable Diseases, Delhi.
At present, there is no viable program for the control of
filariasis.
Elimination of Lymphatic
Filariasis in India
Elimination of lymphatic filariasis (ELF) from India by the year
2015 was set as a goal of National Health Policy 2002. It was
resolved in the National Workshop held on January 5, 2004 in
New Delhi to undertake MDA (Mass Drug Administration) in
all the known 202 endemic districts commencing from June 5,
2004 to achieve the goal. WHO targets global elimination of LF
by 2020.
Objectives
• To reduce eliminate transmission of lymphatic filariasis
by mass drug administration of diethylcarbamazine
•
citrate (DEC).
To reduce and prevent morbidity in affected persons
and
• To strengthen the existing health care services by involving
NGOs, private and public sectors.
Salient Features of ELF Strategy
• Single day mass therapy with DEC at a dose of 6 mg/kg
body weight annually.
• Management of acute and chronic filariasis and self care
methods at door step.
• Information Education and Communication (IEC)
activities are strengthened for inculcating individual/
community based protective and preventive measures for
filarial control.
• Antivector measures to be continued as complimentary
to antiparasite measures and microfilaria carriers are
detected and treated with DEC for 12 days at 6 mg/kg
body wt/day.
Mass Drug Administration
The International Task Force (WHO) has recommended
that in mass treatment, DEC single dose, is given to almost
everyone in the community irrespective of whether they
have microfilaraemia or not, in the area of high endemicity,
except children under 2 years, pregnant women and very sick
patients.
Advantages of single dose mass therapy:
• It avoids the cost of a mass blood examinations program
before treatment.
• It enhances the compliance as all the members of the
community receive treatment.
• It is as effective as 12 day therapy.
• It involves decreased delivery cost.
• It does not require complex management infrastructure.
• It can be integrated into existing primary health care
system.
• Single dose mass treatment has eliminated filariasis in
some countries like Japan, Taiwan, South Korea and
Solomon islands.
Guidelines for implementing mass drug administration:
These encompass a four pronged attack on the disease as
follows:
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Chapter 43 National Health Programs
• A single day mass DEC treatment at 6 mg per kg body
weight once a year.
• Management of acute and chronic episodes (i.e.,
morbidity management) at the doorstep of patients.
• Strengthening Information Education and Communica-
tion (IEC) activities.
• The existing control measures in NFCP towns to be
supplemented by single dose annual treatment with DEC.
Since it is not feasible do to weigh every individual in the
field to calculate the exact amount of drug to be administered,
it is convenient to adjust the dose schedule as per different
age groups as follows.
DEC is now supplied to all MDA districts as 100 mg tablets.
Age-wise dose schedule (Annual single dose MDA) stream-
lined.
Age (in years) Dose of DEC Number of tablets
<2 Nil Nil
2–5 100 mg 1 New strategy to achieve LF elimination:
6–14 200 mg 2
15 and above 300 mg 3 • Lowering the interval of MDA (bi-annual) and increasing
Note: Out of 202 endemic districts, 195 districts under DEC
alone and in the 7 districts (six in Tamil Nadu and one in
Kerala) are under co-administration with DEC + Albendazole
400mg to all eligible population except children below 2 years,
pregnant women and critically ill persons.
This streamlined dose has been approved by National
Task Force.
Drug delivery strategies: These are many as follows:
• House to house administration,
• Booth administration, (booth should not be located
beyond one km from the community),
• Special population groups in places like schools, hospitals,
offices, industries, prisons, etc.
• Community aggregations like market places, bus stands,
railway stations, fairs, etc.
Consumption of DEC tablets by more than 85 percent
population is the most crucial aspect in this program to
achieve success. Therefore the recommended approach
is ‘supervised drug administration by door to door visit
supplemented with drug administration at booths’ preferably
on a single day with three day mopping up operations. Every
village must be provided with drug administrator, preferably
with readily available biscuits to avoid consuming the drug
on an empty stomach and to increase the drug compliance.
Critical areas: The critical areas which require focused
attention in implementation of MDA are:
• Mobilization of adequate trained human resources
• Estimation of the quantity of the drug needed at each level,
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829
Program well in advance and distribute to peripheral
areas.
• Plan and implement IEC activities.
The drug requirement is be estimated as follows:
DEC = 100 mg tabs. Multiply the total population by 2.5.
Albendazole = 400 mg tabs. Multiply the total population
by 1.
Nongovernmental organizations, community Based
organizations, faith based organizations and Panchayats
should also be involved in the elimination of lymphatic
filariasis program. They also play an important role.
Bottle necks of MDA program:
Low compliance: Coverage of 40 to 60 percent is due to fear of
side reaction.
Continued suppression needs adulticidal effect of MDA: To
overcome this alternative dosage schedule are being planned
to enhance acceptability and efficacy.
• Lowering the dose of DEC tablets may help to reduce side
reactions to enhance compliance.
dose of Albendazole 800 mg tackles the more persistent
amicrofilaramia leading to effective transmission block.
NATIONAL KALA-AZAR CONTROL
PROGRAM (NKCP)
Kala-azar is currently endemic in states of Bihar, Jharkhand,
West Bengal and Uttar Pradesh. The trends indicate the
growing menace of this disease. There were 17806 cases with
72 deaths in 1986 due to Kala-azar. It rose to 77,102 cases with
1419 deaths in 1992. However, during 1995, it declined to
22,625 cases and 277 deaths, indicating arrest of progress of
this disease.
The strategy of Kala-azar control includes:
• Control of vectors (sandfly) by undertaking indoor
residual insecticidal spraying operations twice annually.
• Early case detection and complete treatment
• IEC campaigns for community awareness and commu-
nity involvement.
The Directorate of National Anti-Malaria Program has a
Kala-azar control cell, which monitors the implementation of
the control activities in the endemic areas.
This program is making a significant progress. Encouraged
by the results of the program, Government of India is
envisaging the elimination of Kala-azar by the year 2010. To
achieve this goal of elimination, Government of India has
decided to provide 100 percent central support from the year
2003–04.
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830 Section 7 Health Administration and Organization
NATIONAL JAPANESE ENCEPHALITIS
CONTROL PROGRAM (NJECP)
Japanese encephalitis is endemic in states of Andhra Pradesh,
West Bengal, Assam, Tamil Nadu, Karnataka, Bihar, Haryana,
Kerala and Uttar Pradesh. In 1995, there were 2974 cases and
622 deaths due to JE.
The operational strategy for the control JE comprises:
• Early case detection and prompt management
• Control of vectors (Culex vishnui mosquitoes)
• Sentinel surveillance including clinical surveillance of
suspected cases
• Identification of high-risk groups
• Development of a safe and standard indigenous vaccine
• IEC campaign for community participation.
The Directorate of National Anti-malaria Program moni-
tors the control activities.
NATIONAL DENGUE FEVER/DENGUE
HEMORRHAGIC FEVER CONTROL
PROGRAM
During 1996, an epidemic of dengue fever was reported in
Delhi. Since then, epidemics have been reported from other
parts of India.
The technical assistance for investigation, prevention
and control of Dengue/DHF outbreak is provided to the
State Government through Directorate of NAMP and NICD,
Delhi.
NATIONAL LEPROSY CONTROL
PROGRAM
Initially, the program for leprosy control was launched as
National Leprosy Control Program (NLCP) during 1955, as a
centrally aided program. The objectives were:
• To make the infectious case, non-infectious (to arrest
transmission)
• To reduce the magnitude of the problem.
The strategies formulated were:
• To detect cases of leprosy early and to provide treatment
with sulphone monotherapy through trained workers, on
ambulatory basis.
• To give health education to the patient, family and
community at large.
Sulphone chemotherapy was carried out by administering
progressively increasing doses of the drug, initiated with 10
mg daily which was gradually increased to the standard dose
of 100 mg daily over a period of 6 months by appropriate
monthly increments.
Even after two decades, the NLCP could not give the
desired results and the leprosy scene did not change much.
The program lacked momentum due to various reasons,
such as sulphone monotherapy resistance, administrative
shortfalls in manpower, frequent transfers of medical officers,
lack of interest in doctors, delay in release of funds, etc. Thus
NLCP proved to be input oriented rather than output oriented
program.
NATIONAL LEPROSY
ERADICATION PROGRAM
Eventually a breakthrough was achieved in 1981, when WHO
recommended the use of combined chemotherapeutic
regimens (multidrug therapy) for the treatment of leprosy.
Based on the recommendations of the Working Group,
Government of India switched over from NLCP to National
Leprosy Eradication Program (NLEP) during 1983 with a
goal to eradicate leprosy from India by 2000 AD introducing
multidrug therapy as the mainstay of the eradication
process. During 1981, the prevalence rate of leprosy in India
was 57/10,000 population. During 2004, it was reduced to
2.4/10,000 population.
At the outset, the objective of NLEP was to achieve
elimination of leprosy in the country by the year 2000, by
reducing the case load of the disease to 1 or less per 10,000
population with the following strategies.
• Intensification of early case detection by population
survey, school survey, contact survey, etc.
• Multidrug chemotherapy (MDT),
• Health education,
• Rehabilitation services.
Multidrug Treatment
Multidrug chemotherapy used to be initiated only after
confirmation of the disease and classified as multibacillary
(infectious) and paucibacillary (non-infectious) categories.
The treatment used to be given in a phased manner (2 phases)
as follows:
Multibacillary Leprosy
• Intensive phase (lasting for 14 days)
– Rifampicin 600 mg daily (supervised)
– Clofazimine 300 mg daily (supervised)
– Dapsone 100 mg daily (supervised)
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Chapter 43 National Health Programs
• Continuation phase (lasting for 2 or more years).
– Rifampicin 600 mg once a month (supervised) (pulse
dose)
– Clofazimine 50 mg daily and 300 mg (supervised)
once a month.
– Dapsone 100 mg daily (unsupervised).
Where clofazimine is totally unacceptable owing to
discoloration of skin lesions, it used to be replaced by 250 to
375 mg of self administered daily dose of ethionamide and
protionamide.
Duration of treatment used to be for a minimum of
2 years or until 2 consecutive skin smears taken at monthly
interval become negative, whichever is later.
The follow-up was done once in 6 months for 5 years.
Paucibacillary Leprosy
Rifampicin 600 mg once a month (supervised)
Dapsone 100 mg daily (unsupervised)
MDT is very effective with high cure rate and zero relapses.
It prevents deformities and lepra reactions.
Duration of treatment was for one year and follow up was
once in 6 months for 2 years.
Infrastructure
National Leprosy Eradication Program was implemented
through the establishment of following infra-structures:
• Leprosy control units
• Survey education treatment centers
• Urban leprosy centers
• Mobile leprosy treatment units.
Leprosy Control Unit (LCU)
This is established in leprosy endemic areas with the
prevalence rate of 5 or more per 1000 population, each unit
serving a population of 4.5 lakh. Each unit had a staff pattern
of 1 medical officer, 2 non-medical supervisors, and 20 para-
medical workers, (PMW), each PMW covering a population of
15,000 to 20,000 and is expected to examine 8000 persons per
year by house to house survey in his areas of jurisdiction. Each
PMW was specially trained to institute domiciliary treatment.
Thus it was a ‘vertical program’.
Survey Education Treatment Centers
One Survey education treatment (SET) center is established
for a population of 25,000 in those endemic area, where the
prevalence rate of leprosy is less than 5 per 1000 population.
They are attached to the Primary Health Center. Each center
is manned by one para-medical worker (PMW), one non-
medical supervisor for every 4-5 paramedical workers and
the MO of the attached PHC is the administrative, controlling
officer. Only one para-medical worker is attached to a SET
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center. Thus ‘Horizontal Program’ is recommended for low
endemic districts.
Activities under SET:
Survey: The whole population is surveyed by the PMW
to detect cases of leprosy. The school children are also
surveyed. During the survey, the investigator (PMW) looks
for hypopigmented patches for the loss of sensation over the
body, in good day light, with minimum clothes and palpates
peripheral nerves for thickening. Such cases are then referred
to MO for further confirmation.
Education: The PMW gives health education to the patient
that leprosy is curable and he should take treatment correctly
and completely. He educates the family that not all cases are
infectious, it is caused by bacteriae, there is treatment and
that the patient should be shown sympathy and should not be
thrown out of the family.
Treatment: All paucibacillary cases are treated with a
combination of dapsone (DDS) and rifampicin and all multi-
bacillary cases with dapsone, rifampicin and clofazinine. This
is called multidrug therapy (MDT).
Urban Leprosy Centers
Such Urban leprosy centers (ULC) were established in
urban endemic areas, one for every 50,000 population. It is
manned by a nonmedical supervisor, who functions under
the supervision of the medical officer.
Mobile Leprosy Treatment Unit
Such unit provides services to leprosy patients in non-
endemic areas. Each such unit consists of one medical officer,
one nonmedical officer, one nonmedical supervisor, two
paramedical workers and a driver.
All these organizations (infrastructures) work under the
administrative control of the State Program Officer, placed in
the Directorate of Health Services. The State Program Officer
(i.e., State Leprosy Officer) is the chief co-ordinator and the
technical advisor to the concerned State Government.
At the central level, the Leprosy Division of the Directorate
General of Health Services, New Delhi is responsible for
planning, supervision and monitoring of the program. The
division is under the control of a Deputy Director General
who advises the Government on all antileprosy activities.
Progress of National Leprosy
Eradication Program
With the introduction of multidrug therapy (MDT), it opened a
new avenue in the control of leprosy in the country. With MDT
services under the NLEP, a large number of leprosy cases are
being discharged as ‘Disease cured’. For the first time in 1987,
the number of MDT cured cases was 10 percent more than the
number of new cases detected and this percentage of cured
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832 Section 7 Health Administration and Organization
cases gradually increased subsequently. It became 25 percent
in 1988, 38 percent in 1989 and over 90 percent in 1991–92.
The annual case load, which was 4.29 lakh during 1994,
was reduced to 2.2 lakh during 2004. The overall prevalence
rate which was 57.6 per 10,000 population during 1981,
brought down to 2.3 per 10,000 by 2004.
Program Assistance
Nongovernment organizations (NGOs) also have contributed
on functioning of the program. More than 290 NGOs are
working in the field of leprosy throughout the country.
Besides the NGOs, several international agencies
contribute to the leprosy elimination effort in the country.
Among these WHO extends money, man-power and material
assistance to NLEP. It supplies drugs in the form of blister
packs separately for multi-bacillary and paucibacillary
leprosy cases and made available free of cost in all the
primary health conters. World Bank has offered financial
assistance to the program. Support has also come from
Danish International Development Agency (DANIDA) and
International Federation of Leprosy Elimination (IFLE).
Research is carried out mainly in central JALMA Institute
of Leprosy at Agra and the Central Leprosy Teaching and
Training Institute at Chingelput, Chennai, India.
Modified Leprosy Elimination
Campaign (MLEC)
The NLEP was appraised in April 1997 and observed that
even though there was good progress at national level, it was
uneven in some states. So it was decided to launch leprosy
elimination campaign. (Elimination of leprosy means
reducing the prevalence rate to such a low level, that it is no
longer a public health problem, i.e, to less than 1 case/10,000
population). It is presumed that at this low level, transmission
of M. leprae would be reduced and the disease will extinct.
The multidrug treatment regimen for leprosy was modified
under elimination compaign with effect from November
1, 1997, as recommended by WHO Leprosy Elimination
Advisory Group of Expert Committee.
The multi drug treatment (MDT) is given free of cost in
all the Government Hospitals, PHCs and Community Health
Centers. The drugs are available in blister packs. Each blister
pack contains drugs required for one month. The blister packs
are different for Paucibacillary and Multi bacillary leprosy
and for adults and children.
Regimen for Paucibacillary Cases
1. Single skin lesion—single dose
Adults: Rifampicin—600 mg
Ofloxacin—400 mg
Minocycline—100 mg
Children: Half the adult dose
Follow-up: Once in a year for 2 years.
Note: If there is no improvement, treatment to be extended for
6 months, with Dapsone daily and Rifampicin once a month
as below.
2. Single nerve lesion with 2–5 skin lesions.
Adults: Dapsone—100 mg daily self-
administered
Rifampicin—600 mg, once a month,
supervised.
Children: Proportionately less
Duration of treatment: 6 months
Follow up: Once a year for 2 years.
Regimen for Multibacillary Cases
Adults: Dapsone – 100 mg daily. Self administered.
Clofazimine – 50 mg daily or 100 mg on alternate
days. Self administered.
}
Clofazimine – 300 mg monthly (Pulse) dose
Rifampicin – 600 mg (Supervised)
Children: Proportionately less
Duration of treatment: 12 months
Follow up: Once a year for 5 years.
This campaign comprises a package of four activities
namely:
• Teaching and training to all health staff
• Intensified IEC activities
• Case detection by house to house visits to detect new
leprosy case and
• Correct and complete treatment.
The goal was to eliminate leprosy by the year 2005. Several
such rounds of campaigns have been executed. First round
of campaign led to detection of 4.63 lakh cases. Second
campaign was carried out from January to March 2000 with
detection of 2.13 lakh cases. Third campaign was carried out
from October 2001 to February 2002 with detection of 1.65
lakh cases. Fourth campaign was carried out from August
2002 to March 2003 leading to detection of 1.04 lakh cases.
The fourth campaign was different from the first three
campaigns in that the states were divided into three categories.
Category I: Eight states were taken up. In areas with
prevalence rate of more than 5/10,000 population, active
search by house to house visit was taken up and in areas less
than 5/10,000 population, voluntary reporting centers (VRCs)
were organized.
Category II: This included 14 moderate to low endemic
states, where extensive IEC activities were taken up along
with training of health personnel and active search of new
cases.
Category III: This included 13 very low endemic states where
extensive IEC activities and passive detection of leprosy cases
in health centers were carried out.
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Chapter 43 National Health Programs
The fifth campaign was carried out during December
2003 to March 2004 in six high priority areas namely Bihar,
Chhattisgarh, Uttar Pradesh, Maharashtra, Andhra Pradesh
and West Bengal states. The activities carried out in these
states were as follows:
a. For urban areas: Voluntary Reporting Centers were
organized and IEC in slum areas.
b. For rural areas:
• In areas with leprosy prevalence rate of more than
5 per 10,000 population active search for the cases
and
• In areas with prevalence rate of less than 5 per 10,000
population, VRCs and Special Action Project for
Elimination of Leprosy (SAPEL) were established for
early case detection and treatment.
SAPEL constitutes an important initiative aimed at
providing MDT services to those patients living in remote
areas or under difficult conditions as well as those belonging
to underserved population including tribal areas. The main
purpose is to reach the undetected cases and cure them
(reach the unreached).
Leprosy Elimination Monitoring
Leprosy Elimination Monitoring (LEM) consists of assessing
the performance of elimination campaign on various issues
like case detection, quality of services like treatment, IEC
activities, drug supply, management, etc. This is carried out
by National Institute of Health and Family Welfare (NIHFW),
New Delhi, every year in 12 endemic states, for three years
since June 2002.
So far 15 states have reached the goal of elimination of
leprosy, i.e., prevalence rate is reduced to less than 1 per 10,000
population. WHO Technical Advisory Group had suggested
a Pilot testing of Validation of Elimination of Leprosy by Lot
Quality Assurance Sampling Technique.
NATIONAL GUINEA WORM
ERADICATION PROGRAM (NGEP)
During 1984, a total of 40,000 cases of dracunculiasis were
reported from 7 endemic states of Tamil Nadu, Maharashtra,
Gujarat, Andhra Pradesh, Karnataka, Madhya Pradesh and
Rajasthan. Then Government of India launched NGEP during
1984 with assistance from WHO with the following strategies:
• Active surveillance for case detection and treatment
• Vector control (of Cyclops) by chemical (Temephos)
treatment of water
• Provision of safe drinking water on priority in edemic
areas
• Health education of the public.
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Simple epidemiology of guinea worm disease (Dracon-
tiasis), each method of vector control and public co-
operation by health education helped to control the disease
easily so much so the incidence of the disease was brought
down to ‘zero’ by August 1996. Consequently, International
certification team from WHO visited India from 9th to 25th
November 1999 to assess guinea worm situation in the
country. The team presented its report to International
Commission in February 2000 for certification of Dracun-
culiasis Eradication in India, where upon WHO declared
India as a guinea worm free country, on 15th February 2001
and advised the Government to maintain surveillance of the
guinea worm disease till its global eradication. Since then
continued surveillance has failed to detect new case of the
disease. This is a major national achievement of recent times.
UNIVERSAL IMMUNIZATION
PROGRAM
During May 1974, WHO launched a global immunization
program called ‘Expanded Program of Immunization’ (EPI)
to protect all the children of the world against 6 major, vaccine
preventable, killer diseases namely diphtheria, pertussis,
tetanus, tuberculosis, measles and poliomyelitis with 3 doses
of DPT and OPV and 1 dose each of BCG and measles vaccine
during infancy, starting from 3rd month of infancy, extending
up to 16 years of age and also to protect all expectant mothers
of the world with 2 doses of tetanus toxoid to prevent neonatal
tetanus, as a continuous on going program.
During January 1978, Government of India launched the
same EPI program in India, with the same schedule with same
objectives of reducing the morbidity and mortality among
children. Meanwhile Government of India became signatory
to Alma-Atta declaration of achieving the Global Social
target of ‘Health for All by 2000 AD’ in which the goal was to
achieve universal immunization coverage of the children and
expectant mothers.
Since the momentum of the immunization program
was slow, it was observed that Infant Mortality Rate was
not coming down proportionately. Therefore it was felt to
strengthen the existing program by concentrating more on
the infants and expectant mothers (and not children up to 16
years of age). Eventually on 19th November 1985 (Late Prime
Minister Mrs Indira Gandhi’s birthday), Government of India
redesignated the EPI program as ‘Universal Immunization
Program’ (UIP) with the objectives of eliminization of
neonatal tetanus and paralytic poliomyelitis by 2000 AD with
the following strategies:
• 100 percent coverage of expectant mothers with 2 doses of
tetanus toxoid
• At least 85 percent coverage of infants with 3 doses of DPT
and OPV and one dose each of BCG and MV by 2000 AD.
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834 Section 7 Health Administration and Organization
Thus, UIP became a time bound (i.e., 2000 AD) and tar-
get oriented (mothers and infants) program. To achieve these
goals, the immunization schedule was changed and immuni-
zation was recommended from birth-itself. Meanwhile a relia-
ble surveillance system was developed. Immediate reporting of
cases of neonatal tetanus and poliomyelitis was made manda-
tory. This resulted in significant decline in the incidence of vac-
cine preventable diseases and also IMR. The country became
self sufficient in the production of the vaccines. The cold-chain
system for the storage, distribution and transportation of the
vaccines was also developed. During 1992, under the National
CSSM program (vide below), the objectives were elimination of
neonatal tetanus and eradication of poliomyelitis.
NATIONAL POLIOMYELITIS
ERADICATION PROGRAM (NPEP)
Historical Perspective
Government of India (GOI) launched Expanded Programme
of Immunization (EPI) in the year 1978. During 1985, the EPI
was upgraded into Universal Immunization Program (UIP) by
concentrating immunization services to infants and pregnant
mothers. During May 1988, World Health Assembly passed
a resolution to achieve the goal of Global Eradication of
Poliomyelitis by the year 2000, which was the second landmark
in the field of immunization. (First landmark was eradication
of smallpox). Accordingly, Government of India also had to set
the goal of eradication of poliomyelitis by the year 2000 AD.
During 1992, GOI upgraded the Maternal and Child Health
(MCH) services into a national program called “Child Survival
and Safe Motherhood” (CSSM) program and set the goal of
eradication of poliomyelitis under primary immunization
of “Child Survival” component of the CSSM program, by
100% coverage of infants with routine immunization. During
December 1995, GOI introduced a strategy, called “Pulse Polio
Immunization Programme” (PPIP), complimented by Acute
Flaccid Paralysis (AFP) surveillance activity during 1997 and
also Mop up round of Immunization. GOI has committed to
sustain and maintain this massive effort until the wild polio
virus is eliminated from the nature.
Strategies of Polio Eradication
• Routine immunization
• Supplementary immunization
• Acute flaccid paralysis surveillance.
Routine Immunization
This is the immunization of all infants with three doses of OPV in
all the hospitals and primary health centres, as a routine during
6th, 10th and 14th week. Such coverage of routine immunization
among infants must be sustained and maintained at a high
level of 100% because unimmunized children maintain the foci
of infection. High level of immunization coverage will not only
reduce the incidence of poliomyelitis to a very low level but also
will set a stage for eradication of poliomyelitis. Countries which
are polio free, must also continue to maintain a high level of
routine immunization coverage to protect themselves against
importation of polio virus. No nation will be free of poliomyelitis
until all the countries in the world become free, because of jet
travel days. By 1996, 150 countries became polio free.
Supplementary Immunization
This has three components:
1. Pulse polio immunization
2. Subnational immunization
3. Mop-up immunization.
Pulse polio immunization (PPI): This concept was intro-
duced by Government of India during 1995. The term “Pulse”
denotes sudden, simultaneous, mass administration of OPV to
all under five children in the entire country, with cent percent
coverage, with 2 doses of OPV, each of 2 drops, with six weeks
interval, on the indicated days (polio Sundays) during the low-
est transmission season, October to February, irrespective of
the previous polio immunization status. These indicated dates
are called as National Immunization Days (NIDs).
• These doses are only supplementary and not substitutes
to the routine immunization.
• There is no minimal interval between the routine
immunization and Pulse Polio Immunization. (That
means even if the child had received routine OPV on the
previous day of PPI – Sunday, it has to be given PPI dose).
• There are no contraindications for PPI.
This concept of PPI came into vogue because inspite of very
good coverage of routine immunization under UIP (Universal
Immunization Program) a small percentage (of about 10%) of
children are not covered. They can act as reservoir. Since it is
not possible to identify this small percentage of unimmunized
children, it was recommended by GOI that there must be cent
percent coverage of all <5 children, on a particular day, (Polio
Sunday) so that not even a single unimmunized gut should be
available to the polio virus.
To start with during 1995, it was only one day booth activity
and the target age was fixed upto 3 years. In the next year 1996,
the target age was extended to 5 years. GOI has committed to
maintain this Herculean task until the wild virus is eliminated
from the nature and the disease is eradicated.
Mechanism: The polio virus can remain alive outside the
human body for several days to several weeks but cannot
multiply. For the virus to multiply and continue its progeny,
it has to pass through the unimmunized gut within 48 hours
of its excretion. Since there is 100% coverage of under fives
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Chapter 43 National Health Programs 835

on PPI days, and not even a single unimmunized gut is
available, the polio virus cannot multiply and dies on its own
in a natural way. Moreover the immunized child, when drinks
contaminated water containing wild polio virus, it is acted
upon by IgA of the gut, becomes avirulent and is excreted as
vaccine progeny virus. Thus PPI, helps in the replacement
of wild polio virus by vaccine progeny virus and thus in the
eradication of poliomyelitis. However, PPI will be effective
only if there is high level of routine immunization coverage of
more than 85%, preferably 100%.
With the concept of PPI, there was reduction in the
incidence of poliomyelitis but not to satisfactory level. There
were continuous outbreaks of poliomyelitis. Inspite of PPI,
many children were missed on PPI day. So GOI intensified PPI
programme during 1999 from one day booth activity to three
days programme called “Intensified Pulse Polio Immunization
Programme” (IPPIP). It was intensified in order to detect and
immunize the “Missed and Eligible” children, who were not
immunized in the booth, on the first day of the program. To
detect the missed and eligible children, all children who got
OPV on the first day, are marked with gentian violet on the little
finger. So it became an extra effort to reach the unreached.
On the second day “House to House” visit is made by
the health worker and mark “X” for those houses, which
were locked, who were not cooperative or target child is not
having gentian violet mark on the little finger and mark “P” for
those houses, where target children are immunized or target
children are not available.
On third day, visit is made only for those houses marked
“X” and immunize the missed and eligible children, mark
the little finger with gentian violet, wipe off the “X” mark and
convert into “P” mark.
With IPPI programme, there was drastic reduction in the
incidence of poliomyelitis in the country from 1999 to 2001.
The distribution and location of the polio virus in India over
the years is shown in the Figure 43.1.

Fig. 43.1 Location of poliovirus in India, 1998-2001

Source: National Polio Surveillance Project

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836 Section 7 Health Administration and Organization

Subnational immunization: During 2002, there was set
back of poliomyelitis. Large number of polio cases were
reported from North India (Fig. 43.2). there was widespread
and dispersed transmission. So the program was further
intensified from 2 rounds of immunization during December
and January to 4 rounds, from October, November, December
to January, each round with three days activity and called it
as Sub National Immunization (means extra immunization
carried out in sub part of the country). These days are called as
“Sub National Immunization Days (SNID).
The very purpose of intensification of the program is not to
miss any child for OPV and to cover cent percent immunization.
With pulse polio and sub national immunization, there
was remarkable decline in the incidence of poliomyelitis in
the country, by 2005 (Fig. 43.3).
Subsequently during 2006, there was set back of
poliomyelitis, in Bihar and UP inspite of 4 rounds of sub-
national immunization and the number of cases reported
were 784. During 2007, 2008 and 2009, the number of cases
reported were 874, 559 and 732 respectively (Figs 43.4A
and B). Following barriers were identified for increase in the
number of cases, such as technical, administrative, social,
cultural and demographic barriers.
Technical barriers were limitation of the vaccine itself,
associated conditions in the children such as malnutrition,
diarrhoeal diseases, enterovirus infections etc, interfering
with the vaccine.
Administrative barriers include maintenance of cold chain,
failure of vaccine vial monitor (VVM) as a surrogate marker of
the vaccine potency.
Social barriers like gender, caste, purdah system also
limited the acceptance of the vaccine.
Cultural barriers were the various myths and blind beliefs
regarding immunization.

Fig. 43.2 Location of poliovirus in India, 2002–2004

Source: National Polio Surveillance Project
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Chapter 43 National Health Programs 837

Fig. 43.3 Location of poliovirus 2005

Fig. 43.4A Distribution of polio cases in India according to type of polio virus, over the years

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838 Section 7 Health Administration and Organization
Fig. 43.4B Distribution of polio cases in India over the years
and the milestones of history of polio
Demographic barriers are poverty, illiteracy, ignorance,
indifferent attitude towards immunization, migration of the
population etc.
To overcome these barriers, expert group, recommended
six national immunization days and nine subnational
immunization days, specially in Central Bihar and Western
Uttar Pradesh. Since there was nothing wrong with the quality
of the vaccine, following measures were recommended for
Bihar and Uttar Pradesh states.
• To focus on better conversion of “X” marked houses,
• To consistently vaccinate the children,
• To effectively improve the microplans,
• To improve IEC activities and social mobilization,
• To make senior officers accountable for their areas,
• To maintain high level of AFP surveillance,
• To use Salk Vaccine (IPV) in the routine immunization
and
• To use Bi-valent Vaccine (containing type 1 and type 3
viruses, because type 2 was eliminated during 1999) in
pulse polio programme.
With these measures there was remarkable decline in
the incidence of polio in India (Fig. ???). Uttar Pradesh and
Bihar have not reported any case of polio since April 2010 and
September 2010 respectively.
Mop-up immunization: It was felt during 1999 that there
was more than 85% immunization coverage in the country
and not even a single case of polio is expected. If at all a
case of poliomyelitis occurs in an area where immunization
coverage is more than 85%, it is considered as an “Epidemic”
of poliomyelitis and is a “Public Health Emergency”. The
medical officer of that area should immediately notify to
the concerned Dist. Immunization Officer and carry out
containment measures as a Fire Fighting Action on War Foot
Step, within 48 hours of reporting of the case, by immunizing
all under fives living within 5 km radius of the infected house
in the rural area or about 2000-3000 children in the urban area,
irrespective of their immunization status, with two rounds
of OPV with 4 weeks interval. This is called “Mop up round
of immunization” or “Outbreak Response Immunization”
(ORI). Meanwhile active search is also made to detect other
AFP cases if any.
Acute Flaccid Paralysis (AFP) Surveillance
AFP means sudden onset of flaccid paralysis of the limb (of
lower motor neurone type) of four weeks duration, in a child
below 15 years of age, with loss of tone and deep tendon reflexes
and the limb is floppy or flaccid without sensory loss. Such AFP
cases are not only due to poliomyelitis but also due to Guillian
Barre Syndrome, transverse myelitis or traumatic neuritis. (Thus
all AFP cases are not polio, but all polio cases are AFP cases).
Surveillance means case detection. AFP surveillance
means detection, reporting and investigation of all AFP cases
and not just only polio cases. In otherwords AFP surveillance
means surveillance for suspected or possible polio case.
AFP surveillance is an activity introduced during 1997, to
detect the last case (final reservoir) of poliomyelitis, so as to
enable to declare the country as polio free, if zero incidence
is maintained for three consecutive years, from the date of
detection of last case. It is like a manhunt for polio virus. This
is a greatest challenge to health system to detect the last case
of polio. It is being conducted by a network of Surveillance
Medical Officers (SMOs).
Objectives:
• To identify the high risk areas
• To focus immunization in those high risk areas
• To certify the country as polio free.
High risk area is a one where
• A case of poliomyelitis has been reported during the last
one year
• The living conditions are very poor with over crowding
• The sanitation is very poor
• The surveillance activity is very poor and
• The immunization services are very poor.
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Chapter 43 National Health Programs
Types of surveillance:
• Routine surveillance: This means immediate reporting
(notification) of a case of AFP in a child below 15 years
of age, to district immunization officer by a health care
personnel. Dist. Immunization Officer (DIO) will inturn
inform the Surveillance Medical Officer, who will inturn
inform the National Surveillance Center. Suppose AFP
case does not occur, then also the medical officer of
Primary Health Center has to send the report as “Zero
Case”, every week. This is called “Zero reporting”. Thus
routine surveillance is a continuous ongoing activity. Zero
reporting is as important as case reporting. This assures
that surveillance activity is going on.
• Active surveillance: This is done by a designated person
from the department of health, who makes weekly visits
to the department of Pediatrics and Neurology to enquire
about a new AFP case.
Components of AFP Surveillance
• Investigation of AFP case
• Line listing
• Reporting.
• Investigation of an AFP case: This consists of sending two
stool specimens, each of 8-10 gms, collected at least 24
hours apart, within 14 days of onset of paralysis, to WHO
accredited laboratory in a good condition (i.e. in a special
Flow chart 43.1 AFP case classification and follow-up of compatible case
* Recovery from paralysis occurs in cases of Guillian Barre Syndrome, transverse myelitis and traumatic neuritis.
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screw capped bottle, no leakage, no dessication, with
adequate documentation and in reverse cold chain) for
isolation of the polio virus. No preservative or transport
media is used. Special stool specimen carriers have been
provided to Districts for this purpose.
If the case is clinically suspected and the virus is
not isolated for a variety of reasons such as inadequate
specimen, sample dried, cold chain not maintained etc,
such a case is called as “compatible” case. It is neither
confirmed not discarded as poliomyelitis case. Such a
compatible case will be reviewed by an expert committee,
consisting of a Pediatrican, a Virologist and a Neurologist,
who will follow up the case for 60 days and then decide
whether to confirm or discard as polio case, as shown in
the figure (Flow chart 43.1).
• Line listing: This consists of recording the related data of
an AFP case in a prescribed proforma, which provides
information such as name of the case, age, sex, address,
immunization status, date of onset of paralysis, clinical
findings, name of the reporting officer with his contact
number and address.
Line listing helps in:
• Avoiding duplication of the case,
• Follow up of the case,
• Detection of only fresh case,
• Identification of high risk area and
• Implementation of containment measures.
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840 Section 7 Health Administration and Organization
• Reporting: All AFP cases must be reported to the concerned
District Immunization Officer by the quickest possible
means, who inturn will inform the State Surveillance
Officer, who in turn will inform the National Surveillance
Centre.
Ever since the battle against poliomyelitis was begun
since 1970s, today India is free from all the three types of
viruses. Type 2 virus was first to be eliminated during October
1999, then type 3 virus during October 2010. The year 2011
has been very crucial for polio eradication, as we got only one
case of poliomyelitis, the last and the lowest ever recorded,
was on January 13, 2011, when the stool sample showed that
18 months old girl, Ruksar Khatoon, in Howrah, West Bengal
had polio. Thus India appears to have achieved a Herculean
task. Since then the incidence of polio is zero in India. If only
zero incidence is maintained for three consecutive years,
India will be certified as “Polio free” country a greatest public
health achievement. Since February 2013, India is no longer
considered as “endemic to polio”, a status it had harboured
with three other nations – Pakistan, Afghanistan and Nigeria.
If the test for isolation of the virus from the environmental
sewage sampling also becomes negative, India will officially
be deemed to have stopped transmission of indigenous wild
polio virus.
But still, we need to be more vigilant as there is a constant
threat for its spread. Community participation is the need of
the hour. It remains the chief corner stone.
The end game strategy consists of:
• Social mobilization
• Introduction of Salk Vaccine (IPV) in the routine immuni-
zation
• Sensitive surveillance
• Mop up round of immunization
• Hoping to declare polio free India in February, 2014
• To stop OPV administration from 2018.
We must continue our commitment to eradicate poliomy-
elitis and look forward for a day, when no child will be killed
or crippled by polio virus.
REVISED NATIONAL TUBERCULOSIS
CONTROL PROGRAM (RNTCP)
National TB Control Program
National TB Control Progroam (NTCP) was launched by
Government of India during 1962 following the observations
made in two survey reports, one submitted by ICMR, done
during 1955-58, that TB was a major public health problem,
1.5 percent of the population above 5 years was suffering from
radiologically active TB and 0.4 percent of them infectious.
Another survey report submitted was by National
TB Institute (NTC) Bangalore during 1955 to 56 and the
observations were:
• That nearly 50 percent of the cases do not come to health
care facility for treatment
• That domiciliary treatment is as effective as institutional
treatment
• That the expenditure incurred for treating 20-25 TB cases
in the sanitorium, can suffice to serve the population of
about 1500 through establishment of TB clinics.
Objectives of NTCP
• Short-term objectives:
– To detect and treat as many cases of TB as possible
among outpatients
– To vaccinate the newborns with BCG
• Long-term objectives:
– To reduce the problem of TB in the community to
such a low level that it ceases to be a public health
problem, i.e. one infectious case should infect less
than one new person annually and the prevalence of
infection among children below 14 years should be
brought down to les than 1 percent from 30 percent
level then.
Organization and Administration
The organizations established for NTCP has 3 tiers: central,
district and peripheral.
Central Level Organization
In addition to National TB control Division in the Directorate
General of Health Services, two important central insti-
tutions responsible for NTCP are NTI, Bengaluru and TB
Research Center (TRC), Madras (Now Chennai).
NTI, Bengaluru provides training, research and moni-
toring operations to all the personnel involved in TB control
activities. It also issues necessary technical guidance as and
when necessary.
TRC, Madras (Chennai) has contributed by developing
the appropriate strategy for NTCP.
District Level Organization
The functional unit of the NTCP is District TB Control Program
(DTP) and the structural unit is the District Tuberculosis Unit/
Center. It supervises, plans and co-ordinates all the primary
health centers, TB clinics, hospitals and dispensaries in case
detection and treatment activities. It provides training to all
the field staff and serves as a referral center. Over and above
the sanctioned strength of staff members, a BCG team was
also attached to carry out vaccination activities. Thus DTP
used to be the ‘backbone’ of NTP.
The treatment used to be free and offered on domiciliary
basis from all the health institutions. The registered patients
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Chapter 43 National Health Programs
were supposed to come and collect the drugs of their quota
for the month on fixed dates. When the patients were failing
to collect the drugs on the due-date, a letter used to be written
to him/her (first defaulter action) and in the event of no
response for one week, a home visit used to be paid by the
health staff (as a second defaulter line of action).
Peripheral Organization
This comprises chest clinics, primary health centers, general
hospitals and dispensaries. Primary health centers used to
identify symptomatic cases and refer them to nearest chest
clinics for investigation and diagnosis, where upon the clinics
used to refer back the confirmed cases to PHC for treatment
and follow-up.
Patients complaining of fever, cough, chest pain,
hemoptysis were considered as ‘symptomatics’. Those cases
whose sputum is positive for AFB (TB bacilli) were considered
as ‘Open Cases’ and those symptomatics whose sputum
negative and radiologically positive, were considered as
‘Suspected Cases’. Conventional chemotherapy (long course
chemotherapy) was given for all the cases for minimum of 1½
years. There were 5 types of treatment regimens (R1–R5) and
the drugs were given in divided doses:
R1 = INH + Thiacetazone
R2 = Streptomycin + INH
R3 = INH + PAS (Para Amino Salicylic acid)
R4 = INH + Ethambutol
R5 = Streptomycin + INH + Thiacetazone or Ethambutol.
Short course chemotherapy was introduced during 1972.
It was centered around Rifampicin and INH. Those patients
who were able to come to the center twice weekly for 6
months, were given Regimen-A, consisting of Str + INH +
Pyrazinamide for 2 months followed by R and H for 4 months
and those who were unable to do so, were put on Regimen-B,
Consisting of E + H + R + Z for 2 months followed by H + T for
6 months.
Inspite of a nation wide network of facilities, NTCP failed
to yield satisfactory results. Situation of TB remained same. It
remained as a major public health problem only. The goal of
reducing the problem remained a distant dream.
Meanwhile during 1980s, situation started becoming
worse with the emergence of HIV/AIDS.
Revised National TB Control Program (RNTCP): It was
in 1992 that Government of India, WHO and world Bank
together reviewed NTP and remarked the limitations of the
program. Based on those remarks, the program was revised
and launched as ‘Revised National TB Control Program’
(RNTCP) on a pilot project during 1993, with the view to cover
the whole country in a phased manner (Described under
epidemiology of TB). By 1997, it covered the whole country.
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NATIONAL ACUTE RESPIRATORY
INFECTIONS CONTROL PROGRAM
(NARICP)
National ARI control program was taken up as a pilot project
in 25 selected districts in India during the year 1990 and
to expand in a phased manner later. During 1992-93, this
program was included as one of the components of Child-
Survival Safe Motherhood (CSSM) program, which is now
upgraded as Reproductive and Child Health (RCH) program
with the following objectives.
• To reduce the morbidity and mortality due to ARI—
pneumonia among under-fives (which was about 4
million deaths annually then)
• To avoid delay in getting the treatment for those cases of
ARI requiring hospitalization
• To reduce the number of cases needing hospital admission
(i.e. by correct ARI case management at home).
Strategy
• Standard case management by health workers
• Education of mothers to treat cases at home with home
remedies in the early stage
• Education of mothers to recognize fast and difficult
breathing early and to seek referral
• Reduction of inappropriate use of antibiotics in treating
ARI
• Sustain high coverage with immunization specially Mea-
sles, DPT and BCG vaccines
• Surveillance of pneumonia cases and deaths
• Training of health workers to:
– Assess children with cough and cold
– Initiate correct case management
– Give advise to parents for home care
– Refer appropriate cases to higher centers.
The health workers were trained in order to make this
program as an integral part of Primary Health Care. Training
modules are distributed to them after training them.
Administrative Set-up
National level – Deputy commissioner (Nodal
officer) of MCH
State level – State MCH and EPI officers
District level – District Health Officer Assisted
by District MCH Officer
PHC level – Medical Officer
Gross root level – Health worker
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842 Section 7 Health Administration and Organization
NATIONAL DIARRHEAL DISEASES
CONTROL PROGRAM (NDDCP)
This was started during 1978 with the objective of reducing the
morbidity and mortality due to diarrheal diseases. The chief
aim was the promotion of Oral Rehydration Therapy (ORT).
The strategies were:
• Education of the mothers to use home available fluids
with the onset of diarrhea among under five children
• Education of mothers to use ORS and to continue feeding
• Training of health workers, village health guides and
Anganwadi workers in oral Rehydration Therapy
• Distribution of ORS packets and booklets on ‘Home
Treatment of Diarrhea’, published in various regional
languages, to health workers and village health guides
through PHCs
• Every village health guide is supplied with 100 ORS
pockets and every health worker (subcenter) with 200
packets per year
• Establishment of Diarrhea Training and Treatment Units
(DTTUs) in all medical colleges. These units not only treat
cases of diarrhea with ORT but also serve as demonstration
centers (ORT–Corners) for medical students, nurses and
health workers.
The strategies of NDDCP are based on the following
observations:
• Ninety percent of all diarrheal episodes can be managed
at home
• Nine percent will develop ‘some dehydration’, which need
to be managed with ORS packets
• Only 1 percent develop ‘severe dehydration’, needing
hospitalization.
NATIONAL AIDS CONTROL
PROGRAM (NACP)
Realizing the gravity of epidemiological situation of HIV/AIDS
prevailing in the country, Government of India constituted in
1985, a task force to study the problem of HIV and advice on
its control. What is alarming is the problem of HIV/AIDS is not
just confined to the high-risk marginalized population group,
it is also spreading in various directions from urban areas to
rural areas, from promiscuous husbands to faithful wives and
from infected pregnant mothers to innocent offsprings. In
agreement with recommendations of task force, Government
of India launched National AIDS Control program (NACP)
during 1987. Subsequently in 1992, the Ministry of Health and
Family Welfare setup a National AIDS Control Organization
(NACO) as a separate body to implement and monitor the
NACP activities in the country.
The goals of NACP for HIV/AIDS, for the Tenth Five Year
plan are:
• 80 percent coverage of high-risk groups
• 90 percent coverage of schools and colleges by education
• 80 percent awareness among rural population
• Reduction of transmission through blood to less than 1
percent
• Establishment of at least 1 voluntary testing counseling
center for every district
• Reduction of mother to child transmission
• Achieving zero level increase of HIV/AIDS new infections
by the year 2007.
The NACP has moved through three phases:
Phase I (from 1987 to 1999)
Phase II (from 1999 to 2006)
Phase III (from 2006—preparations are going on).
Phase I (From 1992 to 1999)
Surveillance activities were launched in 55 cities in 3 states.
National AIDS Control Organization (NACO) was set-up to
carry out the program activities. Achievements were creation
of awareness, establishment of state level structures for
program implementation and blood safety.
Phase II (From 1999 to 2006)
NACP became 100 percent centrally sponsored scheme.
Aims
1. The focus was shifted from raising awareness to changing
behavior among high-risk groups.
2. Decentralization of service delivery to the states.
3. To protect human rights by encouraging voluntary
counseling and discouraging mandatory testing.
4. To support operational research.
5. To encourage management reforms (such as drugs and
equipment procurement).
Objectives
• To reduce the spread of HIV infection in India and to
reduce morbidity and mortality associated with AIDS.
• To strengthen India’s capacity to respond to HIV/AIDS on
long term basis.
[National AIDS Prevention and Control Policy (NAPCP)
2002 and National Health Policy 2002 have set an aim for
bringing AIDS transmission to zero level (no new HIV/AIDS)
by 2007].
Strategies (Components of NACP): These are shown in Table
43.5.
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Chapter 43 National Health Programs 843

Table 43.5 Components of NACP • Clinical management of HIV/AIDS requires strict
enforcement of biosafety and infection control measures
Prevention Care Surveillance in the hospitals as per the universal safety precautions
a. High-risk population Low cost care Evidence based guidelines.
• Target intervention and support planning ‘School AIDS education program’ is an important activity
• STD treatment • Prevention of • Annual sentinel undertaken in NACP. A training module called ‘Learning
• Condom parent to child surveillance for Life’ has been prepared and distributed in all the states
programming transmission • AIDS case among higher secondary school children.
• Multisectoral • Management detection
collaboration of HIV-TB coin- • Mapping of
• Public private
partnerships
fection
• Treatment of
high-risk
• Behavioral
STI Treatment
b. Low-risk population opportunistic science This is recognized as one of the major strategies, to control
• Holistic IEC and infections HIV because STIs act as co-factor for HIV transmission. HIV is
social mobilization • Piloting ART
transmitted easily in the presence of another STI
• Safe blood • Postexposure
• Voluntary coun- prophylaxis
The objective is to reduce STIs and thereby control HIV
seling and HIV transmission and to prevent morbidity and mortality due to
testing STIs by the following strategies:
• AIDS–vaccine • Development of adequate and effective program manage-
initiative ment
• Sensitizing youths • Promoting IEC activities for the control of STIs
and adolescents • Making arrangements for comprehensive care manage-
• Workplace ment through syndromic approach
interventions • Increasing access to health care by creating new struc-
tures.
Target Intervention
This consists of identifying the high-risk groups (target Condom Programming/Promotion
population) and providing peer counseling, condom pro-
motion, treatment of STIs and enabling environment. This is because nearly 85 percent of HIV-infections occur due
These measures to be delivered largely through NGOs, to unprotected and multi-partner sexual contacts. Correct
Community Based Organizations (CBOs) and the public and consistent use of condoms is the most cost-effective
sector. means of controlling STIs including HIV/AIDS. It not only
prevents STIs and HIV but also prevents unwanted pregnancy
and enhances the pleasure associated with sex.
CARE OF THE PEOPLE LIVING WITH The concerned issues in condom promotion are:
AIDS (PLWA) • Sensitizing the clients and commercial sex-workers to use
condoms
• Availability of low cost and good quality condoms to the
By ensuring: people at the time and place, when they need it.
• Protection of their rights Three major areas in which NACO has significantly made
• Proper care and support in the hospitals and community progress in relation to condom programming are:
• Keeping confidentiality of HIV-status so as not to effect • Quality control of condoms (unlubricated condoms are
education and employment phased out)
• Encouragement and support for the formation of self- • Social marketing of condoms (increasing the accepta-
help groups bility and availability of condoms)
• Encouragement for the participation of NGOs • Involvement of NGOs in the program.
• Sensitization of medical and para-medical people not to
discriminate, stigmatize or deny of services
• Proper counseling of HIV-positive pregnant mothers so Multisectoral Collaboration
as to enable her to take an appropriate decision regarding
continuation of pregnancy and childbirth. There should World bank has been funding this national program since
be no forcible termination of pregnancy on the ground of several years. Bilateral cooperation has been extended with
HIV-status countries like UK and USA.

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844 Section 7 Health Administration and Organization
The Departments which are collaborating are:
• Department of youth and sports (under ministry of
human resource development).
• National Council of Education Research and Training
(NCERT).
• Nehru Yuvak Kendra (NYK)
• Directorate of audio-visual publicity, All India Radio and
Doordarshan under the Ministry of Information and
Broadcasting.
Public Private Partnership
NGOs are continuing to participate in the program for
providing care and support to People Living with AIDS
(PLWA) and their families.
Holistic IEC and Social Mobilization
Since health education is the only measure of prevention of
HIV, it is imperative to continue intensive communication
efforts through IEC activities to raise the awareness, to
maintain healthy practices and to adopt safe-sex. Thus IEC
activities for HIV/AIDS is one of the biggest challenges. At the
national level IEC division in NACO has been setup. At the
state level IEC activities are decentralized.
Family Health Awareness Campaign (FHAC) is an effort
to address the important issues specially to rural mothers
about the reproductive health because Reproductive Tract
Infections (RTIs) including STIs have increased the problem
of HIV/AIDS in the country. Each campaign period is of 15
days.
The objectives of the campaign are:
• To raise the level of knowledge of rural mothers regarding
HIV and its transmission during pregnancy, delivery and
breastfeeding
• To create awareness about the services available for the
treatment of STIs/RTIs
• To facilitate early diagnosis and prompt treatment of
STIs and RTIs, which can significantly reduce the trans-
mission of HIV/AIDS.
Safe Blood
Under the blood safety program, professional blood donation
has been prohibited in the country since 1st January 1998.
Only voluntary blood donation is encouraged. Only licenced
blood banks are permitted to operate in the country. As per
National Blood Safety Policy, testing of every unit of blood
is mandatory for detecting infections like HIV, hepatitis B,
syphilis and malaria. From 1st June 2001, it is mandatory to
test blood for HCV also.
The objectives are:
• To ensure organized blood-banking services;
• To educate and motivate people about voluntary blood
donation and
• To enforce quality control of blood before infusion.
PHASE III (From 2006 to 2011)
The primary goal of NACP III is to halt and reverse the
epidemic of HIV in India over the next five years by integrating
programmes for prevention, care, support and treatment.
This will be achieved through a four pronged strategy:
1. Prevention of new infections:
a. Primary preventive measures: Prevention of new
infections in high risk groups (such as commercial
sex workers, injecting drug users, men having sex
with men) and also among the general population
by seeking to bring them into ambit of health care
services starting with testing at the ICTC (integrated
counseling and testing center). Bridge population (like
clients of sex workers, truck drivers, migrant workers,
etc.) are also covered. The targeted intervention
projects among high risk groups are aimed at effective
behavior change. Intervention for general population
focus on raising their awareness of HIV. Targeted
interventions for high risk group facilitate prevention
and treatment of STDs, as they increase the risk of HIV
infection and link the HIV infected people to care,
support and treatment services.
b. Secondary preventive measures: This consists of pro-
phylactic treatment for HIV infected people to pre-
vent opportunistic infections and when opportunistic
infections occur, it involves their treatment.
2. Providing greater care, support and treatment to the
people living with HIV/AIDS (PLWHA)
The services include management of opportunistic
infections including control of tuberculosis, anti retroviral
therapy, safety measures, positive prevention and impact
mitigation. The total number PLWHA is expected to come
down from 5.2 million to 3.8 million by 2011.
3. Strengthening the infrastructure system, human resources
in prevention, care, support and treatment programmes
at district, state and national level.
4. Strengthening the nationwide Strategic Information Man-
agement System.
Integrated Counseling and
Testing Center (ICTC)
It is a center where a person is counseled and tested for HIV
on his/her own free will or as advised by a medical provider.
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Chapter 43 National Health Programs
It is called integrated because not only HIV counseling and
testing is done for willing persons but also for TB patients
and pregnant mothers for prevention of parent to child
transmission (PPTCT) services, all under one roof. The mission
is to identify people infected with HIV as early as possible and
link them with appropriate services so that they may prevent
future illness or treat current illness in a timely manner.
Before 1997, ICTC was called as Voluntary Counseling
and Testing Center (VCTC). But under National AIDS Control
Program (NACP), PPTCT services and screening of TB patients
are integrated and in 1997, the VCTCs are remodeled as ICTCs.
Functions
• Early detection of HIV by rapid diagnostic tests.
• Providing basic information on modes of transmission
and prevention of HIV/AIDS for promoting behavioral
change and reducing vulnerability, i.e. counseling (pretest
and post test).
• Linking people with other HIV prevention, care and
treatment services so that they may prevent future illness
or treat current illness in a timely manner (post exposure
prophylaxis).
Types of ICTCs
At present there are two models of ICTCs in the country.
• Stand-alone ICTCs: These have full time counseling
and testing personnel. These centers exist in all medical
Fig. 43.5 Model of ICTC
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colleges, Dist. hospitals and 30 bedded Community Health
Centers.
• Facility Integrated ICTCs: This does not have full time
staff.
• It provides HIV counseling and testing as a service along
with other services in the facility. The existing staff like
auxillary nurse midwife (ANM), staff nurse or health
visitor will undertake HIV counseling and testing. These
centers are established in Primary Health Centers under
NRHM and designated TB microscopy centers, where
majority of clients are TB patients and tuberculosis is the
most common opportunistic infection in people with
HIV infection. So it will help to diagnose their status for
accessing early treatment. The model of ICTC is shown in
the diagram (Fig. 43.5). The integration/linkages between
ICTC and other centers are shown in the (Fig. 43.6).
It is not the mandate of the ICTC to test everybody in the
general population. Population who are more vulnerable to
HIV or who practice high risk behavior are in need of ICTC
services such as professional sex workers, men having sex
with men, injecting drug users and those having multiple
sexual partners. Next top priority groups are truck drivers,
prisoners, migrants including refugees and street children,
who constitute bridge population.
Counseling
This is a confidential dialogue between a client and a counseler
aimed at providing information on HIV/AIDS and bringing
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846 Section 7 Health Administration and Organization

Fig. 43.6 Integration of ICTC with other centers

about behavior change in the client and also enabling the • Voluntary and confidential—for voluntary testing and for
client to take decision regarding HIV testing and to understand subclinical/clinical management
the implications of the test results. • For research purposes.
Pretest counseling: This provides an opportunity for Informed consent for HIV testing: The client agrees to
educating about the risks of transmission and also to assess undergo HIV test through giving informed consent based on
how the person may react if HIV test turns positive. It prepares adequate understanding of the advantages, risks, potential
the client for undergoing test and changing his/her behavior. consequences and implications of the test result. This
Post-test counseling: This consists of counseling the permission is entirely the choice of the client and can never
individual after doing the test, irrespective of the result. be implied or presumed.
If the result is negative, the person is supported with
information and counseling to remain HIV negative by
reducing the high risk behavior if any and in case of recent HIV Testing at the ICTC
exposure, he/she is stressed the need to undergo test again
The tests done are called ‘Rapid HIV tests’, because the results
after the window period.
are obtained within 30 minutes. It is done to detect HIV
If the result is positive, the person is informed gently and
antibodies in the serum of the individual, which indicates
allowed to react. It is not a death sentence. It only means
that the individual has HIV infection. If the sample is negative
that the person is educated about taking special care to
in the first rapid test, it is declared as negative. If the test is
prevent progression to AIDS in himself/herself by taking
positive, it could be false positive (that means the test result
ART treatment in the right stage and adhering to it. He/she is
is positive but in reality the person is not infected with HIV).
provided psychosocial support and linked to treatment and
Such a result can result in lot of tension in the individual.
care. The person is also educated not to infect others by the
So it is important to confirm the positive result. Therefore it
following measures:
is recommended that if first test is positive, the same blood
• By not donating blood, blood products or any organ
sample must be tested with two other kits with different
• By consistently using condoms, while having sex
antigens (thus totally three tests) before the individual is
• By not becoming pregnant
declared as positive or HIV infected. If out of three tests,
• By not sharing needles.
two kits show positive result and one negative, the result is
The client is then encouraged to tell spouse.
declared as ‘Indeterminate’ (Flow chart 43.2).
Testing strategies are different for different purposes.
For an indeterminate test result, another blood sample
• Mandatory—for transfusion safety
should be tested again after 14 to 28 days with three different
• Unlinked and anonymous—for epidemiological studies,
kits. If it continues to show indeterminate result, then the
such as monitoring the trend of HIV infection in a
blood sample is subjected to Western Blot test to detect
population
antibodies or Polymerase Chain Reaction (PCR) test to detect
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Chapter 43 National Health Programs
Flow chart 43.2 HIV testing at ICTC
the virus itself if facilities are available or sent to National
Reference laboratory for further testing.
Antibodies are usually produced 6 to 12 weeks after
contracting the infection. So this period when no antibodies
are detected is called ‘Window period’. Therefore the test
result is negative during window period, eventhough the
person is HIV infected. So it is ‘False negative’ result. However
the person remains infectious during window period. So it is
retested after three months.
In case of a newborn to a HIV positive mother, a positive
result upto the age of 18 months could merely mean the
presence of maternal antibodies in the newborn, which
disappears only after 18 months of age. So direct test like PCR
is necessary to detect the presence of virus in the child.
Prevention of Parent to Child Transmission
(PPTCT) Services
This is provided in ICTCs by counseling and testing pregnant
women. It is observed that in the absence of intervention, if
100 HIV positive women give birth to 100 infants, then:
• 5 to 10 infants will be infected during pregnancy
• 10 to 20 infants will be infected during labour and delivery,
• 20 to 30 infants will be infected during breastfeeding
(if breastfed upto 18 months). Thus the total number of
children infected from mother would be about 25 to 40
percent in the absence of intervention.
The ICTC personnel should inform the pregnant mothers
the benefits of testing and after obtaining consent should
test them for HIV and help in reducing parent to child
transmission.
However the mother is made aware of her right to ‘opt
out’ of HIV testing, i.e. she can refuse to be tested. Under such
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847
circumstances, the clinical management should proceed as if
she were HIV positive and suitable clinical protocol followed.
The PPTCT services in ICTC is shown in (Flow chart
43.3).
Integration between ICTCs and TB Services
Tuberculosis being the most common opportunistic infection
among People Living With HIV/AIDS (ALWHA), Government
Policy since February 2008 is to routinely offer voluntary
counseling and testing to all TB patients to know their ‘HIV
status’ so that they take necessary preventive measures when
needed.
HIV infected TB patients should be counseled to get their
sexual partners tested for HIV and TB.
Though TB patients may be referred to ICTC, they have
right to ‘opt out’ of being tested. If the patients opt out,
they must be counseled about how to protect themselves
and others from harm by using safer sex techniques, by not
sharing syringes, etc. Then only they should leave the center.
If the patients do get tested, then regular procedure for pre-
and post-test counseling are to be followed.
AIDS—Vaccine Initiative
Vaccines against HIV are being developed and they are in
various stages of clinical trial but at present none have proven
effective.
Candidate vaccines need to be testing on healthy human
volunteers, through sequential phases. Phase I and II provide
data on the safety of the vaccines in inducing immunity.
Phase III, on efficacy of the vaccine. More than 30 candidate
vaccines have been tried since 1987.
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848 Section 7 Health Administration and Organization

Flow chart 43.3 PPTCT services in ICTC

• AIDSVAX, a gp 120 based vaccine has reached phase III

clinical trial
• CTL (cytotoxic T-lymphocytes) vaccines will not stop an
infection but kills infected cells and can hold down the
viral level in the body
• A recombinant Adeno Associated Virus (TAAV) act as
vector (harmless virus), which infects the cell naturally
and evoke an immune response
• Modified Vaccine Ankara (MVA) also employed as a
Low Cost Care and Support
Funding for home based and community based care, includ-
ing interventions for common opportunistic infections have
been made.
Postexposure prophylaxis: following exposure to HIV,
in case of high-risk, 3 drugs are given ZDV, Lamivudine and
Saquinavir and in case of low-risk, 2 drugs are given ZDV and
Lamivudine for 4 weeks.

•
vector to prepare the vaccine
A recombinant, genetically engineered, subunit HIV
Evidence-based Planning
vaccine is also under process (Subunit vaccine is a one HIV-sentinel surveillance: Sentinel sites/centers are located
which contains a part of the virus). among the risk population areas, so that blood samples
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Chapter 43 National Health Programs
are accessed at regular intervals through an ‘unlinked
anonymous’ procedure. Vulnerable groups of populations are
mapped out and taken care of.
Monitoring and Evaluation
A Computerized Management Information System (CMIS) at
the National and State levels need to be established and staff
should be trained. Baseline, mid-term and final evaluation
and also Performance and Expenditure Annual Review
(PEAR) should be conducted. HIV-Risk Behavior Surveillance
Survey would be more informative for planning.
‘3 BY 5’ INITIATIVE
Globally about 40 million people are living with HIV/AIDS
(PLWA). On December 1, 2003, WHO, UNAIDS and GFATM
(Global Fund Against Tuberculosis and Malaria) announced
a plan to reach ‘3 by 5’ initiative, i.e. providing anti-retroviral
treatment (ART) to 3 million PLWA, in the developing
countries by the end of the year 2005.
This is only an interim target. The ultimate goal being
universal access to ART for any one who needs it.
WHO’s strategic framework for emergency scaling up of
retroviral therapy has five pillars:
• Global leadership, strong partnership and advocacy
• Urgent, sustained country support
• Simplified, standardized tools for delivering anti-
retroviral therapy
• Effective reliable supply of medicines and diagnostics
• Rapidly identifying and reapplying new knowledge and
success.
NATIONAL PROGRAM FOR THE
CONTROL OF BLINDNESS
National Program for the Control of Blindness (NPCB) was
launched in the year 1976 as a 100 percent centrally sponsored
scheme, incorporating National Trachoma Control Program,
started during 1964. The ultimate goal of the program is to
reduce prevalence of blindness in the country from 1.4 to
0.3 percent by providing ‘Comprehensive Eye Care’ through
primary health care, since the cause of blindness being
mainly cataract in India.
The major thrust of this program is on cataract operation.
Objectives
• To reduce the backlog of blindness through identification
of cases and their treatment
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• To develop eye care facilities in every district of the
country
• To strengthen the quality of service delivery
• To develop human resource for providing eye care
facilities
• To secure the participation of voluntary organizations in
the provision of eye care services.
Operational Strategies
• Undertaking blindness surveys
• Performance of cataract operations
• Provision of postoperative care
• Establishment of eye-banks
• Establishment of training and IEC facilities
• Provision of supportive facilities.
Administrative Set-up
NPCB has five tier organizational framework operating at
Central, Regional, State, District and Sub-district level:
• Central level Ophthalmology cell, Ministry of Health
and Family Welfare, New Delhi. This
formulates policies and guidelines for
all activities related to eye care.
• Regional level Regional Institute of Ophthalmology
(Dr Rajendra Prasad Center for
Ophthalmic Sciences, New Delhi)
constitutes the Apex institute. Ten
other such regional institutes of
Ophthalmology operate in the coun-
try. They contribute in the areas of
man-power development, research
and referral care.
• State level State Ophthalmic cell, Directorate of
Health and Family Welfare Services,
Medical Colleges are designated as
training centers. The mobile units
attached to medical colleges undertake
cataract surgery in the field areas.
• District level District Blindness Control Societies
(DBCS) comprising of representatives
from government, non-government
and private sectors participate in
the national program by organizing
eye camps in collaboration with
NGOs and Private Practitioners.
Such societies are formed under the
Chairmanship of District Collector/
Deputy Commissioner. District Ophth-
almic surgeons are posted at District
Hospitals. Mobile services are provided
through district mobile units attached
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850 Section 7 Health Administration and Organization
to District Hospitals. Nearly 575 DBCS
have been functioning in the country.
• Sub district Primary Health Centers are the basic
(Rural) level units. Paramedical Ophthalmic assist-
ants are posted to PHCs. Mobile camp
services are provided by mobile oph-
thalmic units attached to community
health centers.
Procurement and Supplies
The items procured from the center are suture materials,
intraocular lenses (IOL) and the equipments required for IOL
implantation. World bank supplies the major equipment such
as indirect ophthalmoscopes, slit lamps, anterior vitrectomy
units, keratometers, operating microscopes, scan biometer
and 178 YAG Lasers. Medicines and other consumables as
well as spectacles are procured by District Societies out of the
grants provided.
The National Survey carried out on blindness during
2001-02 showed the prevalence of blindness to be 1.1
percent in general population. Cataract continued to be the
leading cause of blindness (62.6%) followed by refractive
error blindness (19.7%), glaucoma (5.8%), posterior segment
pathology (4.7%) and corneal opacity (0.9%). Other causes
were responsible for 6.2 percent of blindness.
The survey has also showed that the prevalence of
blindness is reducing, dependence on eye camps has also
reduced, involvement of MOs of PHCs has increased, the
demand for modern techniques such as IOL implantation
and sutureless surgeries has increased and about 84 percent
of cataract operated persons receive free spectacles from the
health facilities.
Program Components
These are as follows:
• Cataract surgery: The purpose of this component is to
restore the vision of the affected persons, so that they
can return to normal life. A cataract surgery rate of 400
operations per lakh population is required to clear the
backlog. The percentage of IOL implantation has raised
from 20 percent in 1997-98 to 83 percent during 2004-05.
• Eye screening: Under the school eye screening program,
the children are first screened by the trained teachers.
Those children suspected to have refractive errors are
examined by ophthalmic assistants and corrective
spectacles are prescribed. Poor children get the spectacles
free of cost (It is observed in the school survey that nearly 6
to 7 percent of the children have refractive errors affecting
their learning process).
• Eye donation: Under the hospital retrieval program,
donation of eyes are motivated through the relatives to
terminally ill patients, accident victims and other grave
diseases. ‘Eye Donation Fortnight’ is organized from 25th
August to 8th September every year to promote donation
of eyes. Currently about 20,000 donated eyes are collected
every year in India.
• Voluntary organizations: The organizations such as
Rotary International, Lions International and such
others have been active in conducting eye camps and in
providing eye health education, preventive, promotive,
curative and rehabilitative services for the control of
blindness.
• Vitamin A prophylaxis: 5 mega doses of Vit. A in the
form of syrup, administered orally, with an interval of 6
months, for all the pre-school children (0–3 years) are
recommended under the National Vitamin A Prophylaxis
Program to prevent nutritional blindness.
• Training program: This has been an ongoing program,
since 1996-97 to all the ophthalmic surgeons in IOL
implantation. The faculty members of the medical
colleges are trained as trainers. The other training
program includes training of district eye surgeons, nurses,
ophthalmic assistants in their respective fields of services.
• IEC activities: This is a built-in component at all levels
in the NPCB. Prototype IEC material, guidelines, and
training manuals are supplied to all the states in their
regional languages. Adequate funds are provided to district
societies to carry out IEC activities. Special campaigns are
undertaken during ‘Eye Donation Fortnight’ and on ‘World
Sight Day’ on second Thursday of October, every year.
NPCB Achievement
• Rate of cataract surgery is increasing steadily
• IOL implantation has raised from 20 percent during 1997-
98 to 83 percent during 2004-05
• Rate of detection of refractive errors among school
children is increased
• Involvement of medical officers of PHC is increased
• 84 percent of cataract operated cases receive free spectacles.
Revised Strategy
• To make NPCB more comprehensive by strengthening
the services for other causes of blindness like corneal
blindness, glaucoma and refractive errors among school
children
• To shift from eye camp approach to fixed surgical approach
and from conventional surgery to IOL implantation
• To expand the world bank project activities (such as
training programs, supply of materials, equipments, etc.)
to the entire country
• To strengthen the participation of voluntary organizations
in the program and to earmark geographic areas to
NGOs and Government hospitals to avoid duplication of
activities
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Chapter 43 National Health Programs
• To enhance the coverage of eye care services in tribal and
other underserved areas.
Targets for Tenth Five Year Plan
• To increase the rate of cataract surgery to 450 per lakh
population
• To increase the rate of IOL implantation to more than 80
percent among the cataract surgery cases by the year 2007
• To develop 50 pediatric ophthalmology units
• To improve the facilities for early diagnosis and treatment
of glaucoma and diabetic retinopathy
• To develop 25 fully operational eye bank network
• To develop human resources by providing training to
personnel at various levels
• To supply ophthalmic equipments and grants to NGOs.
External Assistance
• World bank assisted cataract blindness control project for
a period of 7 years, from 1995 to 2002. During this period
15 to 35 million cataract surgery was performed against
the target of 11 million. Meanwhile the IOL implantation
rate went up from 3 percent during 1993 to 75 percent in
2002. The project was ‘Highly successful’.
• Danish assistance to NPCB: (i.e. by DANIDA = Danish
International Development Agency).
Danish assisted this program for a period of
5 years, from 1998 to 2003 by providing funds which
were utilized for conducting training program, for the
development of management information system, supply
of equipments, materials for IEC activities, etc.
• WHO assistance: WHO assisted this program by arranging
intra-country fellowships in corneal transplantation,
vitreoretinal surgery, lasers in ophthalmology and
pediatric ophthalmology. WHO also assisted in carrying
out survey on childhood blindness in Delhi, training
programs in district program management, study on
situational analysis of eye care infrastructure and human
resources in India, workshops for medical college faculty
members and development of plan of action for ‘Vision
2020: The Right To Sight’ initiative.
‘Right to Sight’ Initiative
(Vision 2020)
It is a global initiative launched to reduce avoidable (preventable
and curable) blindness by the year 2020. The goal is to reduce
the prevalence of blindness in India to 0.5 percent by the year
2012 and no child in India shall go needlessly blind after 2012.
There must be a vision guardian for every 5000 population by
2020. Government of India has also committed to this initiative.
The main features of the action plan devised for the country are:
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• Identification of target diseases–such as cataract, refrac-
tive errors, childhood blindness, glaucoma and diabetic
retinopathy
• Development of human resources – by increasing the
capacity and skills of ophthalmic personnel
• Development of infrastructure and technology–the
proposed structures for vision 2020 consists of 3 tier
structures of eye care as follows (Fig. 43.7).
First tier (at primary level) comprising 20,000 vision
centers, second tier (at secondary level) comprising 2,000
service centers and third tier comprising 200 training centers
and 20 centers of excellence.
NATIONAL PROGRAM FOR
PREVENTION AND CONTROL OF
DEAFNESS
In India, 6.3% of the population (63 million) are suffering
from significant auditory impairment (loss). This is identified
as the second most common cause of disability (first being
the depression). Of these a large percentage is constituted
by children between the ages of 0-14 years. This amounts to
severe loss of productivity both physical and economical.
Therefore, Government of India, launched this program,
on a pilot phase in 25 identified districts of 10 states and one
union territory of India from July 2006 to June 2008, with a
proposal to cover the entire country by 2012, in view of the
preventable nature of the disability.
Objectives
• To prevent the avoidable hearing loss on account of dis-
ease or injury.
• Early identification, diagnosis and treatment of ear prob-
lems responsible for hearing loss and deafness.
• To medically rehabilitate persons of all age groups
suffering with deafness.
• To strengthen the existing intersectoral linkages for com-
munity of the rehabilitation program, for persons with
deafness.
• To develop institutional capacity for ear care services by
providing support for equipment and material and train-
ing personnel.
The long-term objective is to reduce the total disease bur-
den by 25% of the existing burden by the end of the Eleventh
Five Year Plan.
Strategies
• To strengthen the service delivery including rehabilitation.
• To develop human resource for ear care.
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852 Section 7 Health Administration and Organization

Fig. 43.7 Proposed structure for vision 2020: The Right to Sight

• To promote outreach activities and public awareness

through appropriate and effective IEC strategies with
special emphasis on prevention of deafness.
• To develop institutional capacity of the District Hospitals,
Community Health Centres and Primary Health Centres
selected under the project.
Components of the Program
• Manpower training and development
• Capacity building
• Service provision including rehabilitation
• Awareness generation through IEC activities
• Monitoring and evaluation.
Expected Benefits of the Program
• Direct benefit of various services like prevention, early
identification, treatment, referral, rehabilitation for
hearing impairment and deafness.
• Decrease in the magnitude of hearing impaired persons.
• Decrease in the severity/extent of ear morbidity or hearing
•
impairment.
Improved service network for the persons with ear
morbidity or hearing impairment in the states and
districts covered under the project.
• Awareness creation among the health workers/grass root
level workers through the primary health centre medical
officers and district officers.
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Chapter 43 National Health Programs 853

• Community participation to prevent hearing loss through
Panchayat Raj institutions, mahila mandals, village bodies
etc.
• Creation of collective responsibility framework in the
broad spectrum of the society.
• Leadership building in the primary health centre medical
officers to help create better sensitization in the grass root
level which will ultimately ensure better implementation
of the program.
• Capacity building at the district hospitals to ensure better
care.
• State of the art department of ENT at the medical colleges
under the project.
Functions of the Organizations
• Education of the community about the hazards of tobacco
and persuaded to give up its use and also ‘danger signals’
of cancer
• Education of the community to change their lifestyle
leading to cancer
• Early detection of cancer cervix through exfoliative
cytology and treatment of the detected cases
• Early detection of oral cancers by primary care workers
• Imparting training to medical and paramedical workers
in the control of cancer
• Providing pain relief for terminal cancer cases.

NATIONAL CANCER CONTROL NATIONAL PROGRAM FOR

PROGRAM (NCCP) PREVENTION AND CONTROL OF
Cancer is an emerging public health problem in the country DIABETES, CARDIOVASCULAR
mainly due to change in the life-style of the people. It is DISEASES AND STROKE (NPDCS)
estimated that at any given point of time, nearly 20 lakh cases
of cancer exist in the country and about 7 lakh cases are
added every year. Magnitude of the Problem
Government of India launched NCCP during 1975 by way
During the year 2005, NCD accounted for 53 percent of all
of granting rupees 2.5 lakhs to each of the Regional Cancer
deaths in the age group of 30 to 59 years in India. Of these
Institutes (11 in No.) in the country towards the purchase of
29 percent were due to cardiovascular diseases. It is estimated
cobalt therapy units for the treatment of cancer patients. It
that by 2020, cardiovascular diseases will be the largest cause
was further strengthened during 1984-85 by emphasizing on
of disability and death, as a proportion of all deaths in India.
prevention, early detection of cancer and augmentation of
According to Diabetes Atlas 2006, published by Interna-
treatment facilities in the country.
tional Diabetes Federation, the number of diabetics in India
The following new schemes have been initiated from the
is currently around 40.9 million and is expected to rise to 69.9
year 1990-91:
million by 2025, unless preventive steps are taken.
• Schemes for district project: The scheme envisages
Similarly, 118 million people were estimated to have high
carrying out IEC activities (i.e. cancer education), early
blood pressure during 2000, which is expected to go up to 213
detection and pain relief measures, by providing one time
million by 2025. Not only this, Indians succumb to diabetes,
financial assistance of `15 lakhs to State Governments
high blood pressure and heart attacks five to ten years earlier
for each district project selected. 24 district projects
than their western counterparts, during their most productive
were undertaken between 1992 and 1994. Voluntary
years. This leads to considerable loss of productive years to
organizations recommended by State Governments are
the country, leading to huge economic loss as high as 237
also provided financial assistance for carrying out IEC
billion dollars by the year 2015.
activities.
To contain the increasing burden of Noncommunicable
• Development of oncology wings: The oncology department
Diseases, the Ministry of Health and Family Welfare, Govern-
in the medical colleges are provided financial assistance
ment of India, launched National Program for prevention
up to `1 crore for the purchase of cobalt therapy units,
and control of Diabetes, Cardiovascular diseases and Stroke
brachytherapy unit, linear accelerator and for undertaking
(NPDCS).
mammography.
• Financial assistance to NGOs: Assistance up to ` 5 lakhs to
voluntary organizations is provided on recommendation Objectives
by the State Government for carrying out cancer education
and detection activities, preferably in rural areas and • To prevent and control common NCDs through beahvior
urban slums. Assistance was given to 33 NGOs. and lifestyle chanes.

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854 Section 7 Health Administration and Organization

• To generate awareness on lifestyle changes. Health education program that promotes exercise, weight
• To provide early diagnosis and management of common reduction, screening and early diagnosis are some of the key
NCDs. interventions that need to be promoted at various levels of
• To build capacity at various levels of health care for health facilities. They have been captured in Fig. 43.8.
prevention, diagnosis and treatment of common NCDs.
The following components are envisaged in the program.
• To train human resource within the public health setup,
1. District NPCDCS program (626 districts)
viz doctors, paramedics and nursing staff to cope up with
2. NCD focal centers at medical colleges (54 medical
the increasing burden of NCDs.
colleges)
• To establish and develop capacity for palliative and
3. State/UT NCD Cell (35)
rehabilitative care.
4. National NCD Cell at Center
In the program it is envisaged in providing preventive,
5. IEC/BCC
promotive, curative and supportive services (core and
6. Capacity building and research
integrated services) for Cancer, Diabetes, Cardiovascular
7. Intersectoral convergence
Diseases and Stroke at various government health facilities
8. Monitoring (including MIS) and evaluation.
with provisions for expanding the diseases covered under the
program to chronic lung diseases, geriatric diseases, etc. The
package of services would depend on the level of health facility
and may vary from facility to facility. The range of services
NATIONAL MENTAL HEALTH
will include health promotion, psycho social counseling, PROGRAM (NMHP)
management (out and in patient), day care services,
home based care and palliative care as well as referral for
specialized services as needed. Linkages of District Hospitals
Introduction
to private laboratories and NGOs will help to provide the Psychiatric symptoms like worry, tiredness and sleepless
additional components of continuum of care and support for nights are common among more than half of adults all over
outreach services. The district will be linked to tertiary cancer the world while one in seven experiences some form of
care health facilities for providing comprehensive care. diagnosable neurotic disorder.

Fig. 43.8 Services available under NPCDCS at different levels

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Chapter 43 National Health Programs
Magnitude of the Problem
It is estimated that Disability Adjusted Life Years (DALYs)
loss due to mental disorder is much higher than some of the
communicable diseases like malaria, tuberculosis, diarrhea,
worm infestations, etc. and is expected to represent 15 percent
of the global burden of diseases by 2020 and the common
disorders being depression, general anxiety disorder and
harmful use of alcohol.
WHO has decided to give priority to mental health during
the year 2001, the beginning of 21st century by choosing
World Health Day Theme, ‘Mental Health : Stop Exclusion –
Dare to care’.
In India, studies during the last two decades have shown
that about 2–3 percent of population suffer from seriously
incapacitating mental disorders or epilepsy. Most of them
are in rural areas away from the modern mental health
facilities. About 10 to 15 percent of the population suffer from
other forms of emotional disorders appearing as physical
symptoms. These are often missed because the doctors do not
ask detailed mental health history. This results in subjecting
the patients for unnecessary investigations and treatment.
Keeping in view the heavy burden of mental illness in the
community and the absolute inadequacy of mental health
care infrastructure in the country to deal with it, Government
of India launched National Mental Health Program (NMHP)
in 1982.
Aim
The aim of NMHP is to prevent and treat mental and neuro-
logical disorders by using mental health technology not only to
improve quality of life but also overall national development.
Objectives
• To provide minimum mental health care for all, particu-
larly to the most vulnerable and under privileged sections
of the society.
• To encourage application of mental health knowledge for
promotion of social welfare and in general health care.
• To promote community participation in the mental health
services development and to stimulate efforts towards self
help in the community.
Strategies
• Integration of mental health care services with primary
health care services through NMHP.
• Provision of tertiary care institutions for treatment of
mental disorders.
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• Eradicating stigmatization of mentally ill patients and
protecting their rights through regulatory institutions like
the Central Mental Health Authority and State Mental
Health Authority.
Components of NMHP
• Treatment of mentally ill patients.
• Rehabilitation of disabled mental patients.
• Prevention and promotion of positive mental health.
Organization
• The organizational framework for NMHP is constituted by
tertiary care institutions, mental hospitals and supportive
organizations.
• Tertiary care institutions: These are National Institute
of Mental Health and Neuro Sciences (NIMHANS),
Bengaluru, Central Institute of Psychiatry, Ranchi, and
Institute of Human Behaviour and Allied Sciences, New
Delhi. NIMHANS is the institution of international repute.
It has 650 beds for patients care. It provides training and
research opportunities to aspirants in various areas of
psychiatry and neurosciences.
• Mental hospitals: There are state owned mental hospitals
but have shortage of manpower. Private hospitals are
also functioning. The nature of service is of custodial care
rather than therapeutic care.
• Supportive organizations: These are: (a) Central Mental
Health Authority oversees the implementation of Mental
Health Act, 1987, which protects the mentally sick patients
from stigmatization and discrimination, (b) The National
Human Rights Commission monitors the structure and
functions of the mental health hospitals in states.
DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
Government of India launched DMHP as a 100 percent centrally
sponsored scheme for the first five years at the national level in
1996-97 during nineth five year plan as a pilot project.
Objectives
• To provide sustainable basic mental health services to
the community and to integrate these services with other
health services.
• Early detection and treatment of these patients within the
community itself.
• To provide mental health care at the primary level only.
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856 Section 7 Health Administration and Organization
• To reduce stigma attached towards mental illness through
public awareness.
• To treat and rehabilitate mental patients within the com-
munity after their discharge from the hospital.
Components
• Training programs of all workers in the mental health
team at the identified Nodal Institute in the state.
• Education of the public regarding mental health to
increase the awareness and reduce stigma.
• For early detection and treatment, outpatient services
and inpatient services are provided.
• Providing valuable data and experience at the level of
community to the state and center for future planning,
improvement in service and research.
Services
• The District Mental Health team will provide services to
mentally ill patients and their families as follows:
• Daily OPD services
• Ten bedded inpatient facility
•
•
Referral services
Liaison with Primary Health Center
• Follow-up of treated patients
•
•
Community survey if feasible
Remove stigma of mental illness by creating awareness in
the community.
Thrust areas for 10th Five Year Plan:
• DMHP will be covering the entire country in a phased
manner.
• Modernization of mental hospitals to modify their present
custodian role.
• Upgrading the department of psychiatry in medical
colleges and enhancing the curriculum of psychiatry at
both undergraduate and postgraduate level.
• Strengthening the Central and State Mental Health
authorities with a permanent secretariat to make their
monitoring role more effective.
• Research and training in the field of community mental
health, substance abuse and child/adolescent psychiatric
clinics.
Comments
• Most of the mental health professionals are not aware of
the National Program and so no initiative from them.
• There is shortage of professional manpower.
• Appropriate mental health care can be provided at grass
root level by minimum training of health workers.
• Targets of the program has not been achieved, indicating
the poor commitment of the government, psychiatrists
and community at large.
• The program has given more importance for the curative
aspects ignoring the preventive measures.
• The custodial nature of medical care in the hospital needs
to be changed to a therapeutic approach.
Current Status
There are three Districts which have/are receiving 100 percent
central assistance for DMHP under NMHP. This scheme is for
a period of five years, after which the State has to take over
the scheme. These Districts are – Muktsar, Hoshiyarpur and
Sangrur (Table 43.6).
Table 43.6 Districts receiving cent percent assistance under NMHP
Sl. Nodal Year of
District Remarks
No. institute implementation
Completed
1. Muktsar GMC, Amritsar 2003 5 years on
31.7.2008
2. Hoshiyarpur -’- 2007 -
3. Sangrur -’- 2007 -
NATIONAL IODINE DEFICIENCY
DISORDERS CONTROL PROGRAM
(NIDDCP)
This program was started in 1962 as National Goiter Control
Program.
The sheet anchor of the program is universal iodization of
common salt and its consumption. Even after three decades,
the prevalence of the disease remained high. So it was clear
that the program was a failure one. It was due to the difficulties
such as production of iodized salt did not keep with the
requirement and there were difficulties in the sale of iodized
salt. Meanwhile survey reports revealed that the problem of
goiter was not just restricted to ‘Goiter belt’ of Sub-Himalayan
areas but were reported from the other parts of the country as
well and the manifestations of the iodine deficiency were not
just goiter and cretinism but consisted of a wider spectrum
including still-births, abortions, mental retardation, deaf-
mutism, squint and neuromotor defects. The survey in the
country revealed that the prevalence rate of iodine deficiency
disorders is about 10 percent and estimated that nearly 167
million persons are exposed to the risk of iodine deficiency of
which about 71 million persons are already suffering from the
various manifestations of iodine deficiency disorders.
Considering the magnitude of the problem and its disa-
bling after effects, Government of India upgraded the National
Goiter Control Program into National Iodine Deficiency Dis-
orders Control Program (NIDDCP) during 1992. The essential
component of the program is universal use of iodized salt in
place of common salt.
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Chapter 43 National Health Programs
Aim
To reduce the prevalence of IDD:
• To less than 10 percent among adults, by 2010
• To less than 5 percent among children 10 to 14 years
• To zero percent of cretins among the newborns by the
year 2000.
Objectives
• To assess the magnitude of the IDD problem in the country
• To assess the impact of control measures after every five
years
• To monitor the quality of iodated salt available to consumers
and estimate their urinary iodine excretion pattern
• To conduct IEC campaigns for promoting community
participation in the implementation of the program.
Administrative Set-up
a. Salt Commissioner, Central Office of Government of
India, supervises universal iodization. He issues licences
to salt manufacturers to produce iodized salt liberally
containing 15 ppm of iodine, simultaneously imposes ban
on the manufacture of non-iodized salt. Manufacturers
are given subsidy for buying potassium-iodate.
b. A National Reference Laboratory for monitoring IDD
has been set-up at the Biochemistry Division of National
Institute of Communicable Diseases (NICD), Delhi for
training medical and paramedical personnel.
c. About 100 IDD control cells and IDD monitoring
laboratories have been established in the States to
monitor the quality of iodated salt and urinary iodine
excretion pattern.
d. UNICEF has donated testing kits to District Officers to test
the quality of iodated salt at the consumer level.
e. To encourage the consumption of iodized salt, Direc-
torate of Field Publicity, Doordarshan, All India Radio,
Directorate of Advertisement and Visual Publicity and
Song and Drama Divisions have been asked to conduct
IEC programs vigorously.
NATIONAL PROGRAM FOR
CONTROL AND TREATMENT OF
OCCUPATIONAL DISEASES
Burden of Occupational
Diseases and Injuries
There are 100 million occupational injuries causing 0.1
million deaths in the world according to WHO. It is also
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estimated that in India 17 million occupational non fatal
injuries (17% of the world) and 45,000 fatal injuries (45% of
total deaths due to occupational injuries in the world) occur
each year. Out of 11 million cases of occupational diseases
in the world 1.9 million cases (17%) are contributed by
India and out of 0.7 million deaths in the world 0.12 (17%) is
contributed by India.
This has been launched during IXth Five Year Plan. An
outlay of ` 25 crores was proposed for the program during the
entire plan period.
The scheme was started during 1998-99. Under the
scheme following projects have been undertaken by National
Institute of Occupational Safety and Health. (NIOSH),
Ahmedabad, which has been identified as a nodal agency for
the same.
Following research projects have been proposed to initiate by
the Government
• Prevention, control and treatment of silica tuberculosis
in Agate industry and occupational health problems of
tobacco harvesters and their precaution.
• Evaluation of occupational health problems; Evaluation
and Control.
• Child labor occupational health problems; Evaluation
and Control.
• Capacity building to promote Research, Education and
Training.
• Prevention and control of occupational health hazards
among salt workers in remote desert areas of Gujarat and
Rajasthan.
• Health risk assessment and development of intervention
program in cottage industries with high risk silicosis.
• Hazardous process of Chemicals, Database generation,
Documentation and Information dissemination.
National Institute of Occupational Safety and Health
(NIOSH) has developed a priority list of ten leading work
related illnesses and injuries. Three criteria were used to
develop the list:
a. The frequency of occurrence of the illness or injury
b. Its severity in individual cases
c. Its potential for prevention.
NATIONAL VITAMIN ‘A’
PROPHYLAXIS PROGRAM
This was launched by Government of India during 1970,
and merged as a component of National Program for the
Prevention and Control of Blindness.
Aim
To prevent nutritional blindness among children.
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858 Section 7 Health Administration and Organization

Strategy
Until 1992, the strategy consisted of administration of
2 lakh IU of oral vitamin A concentration to children between
2 and 6 years, at intervals of 6 months.
With the commencement of National Child Survival and
Safe Motherhood Program (CSSM) during 1992, the strategy
was changed to administration of 5 mega doses of Vit. A
concentrate orally to all children between 9 months and 3
years not only to eliminate nutritional blindness but also
other consequences of Vitamin A deficiency. However it can
be extended upto 5 years. Vitamin A prophylaxis schedule is
shown in Table 43.7.
Thus the child is almost immunized against ‘Xero-
phthalmia.’
Note: 2L IU = 1 spoon of 2 ml capacity is supplied alongwith
Vit. A syrup.
In order to improve the coverage of the under five children,
Government of India has linked vitamin A supplementation
to UIP and ICDS activities. To offset the depletion of vitamin
A caused by infections, all children suffering from measles,
diarrhea and PEM are given massive dose of vitamin A.
Pregnant and lactating women should also be covered under
vitamin A supplement to ensure adequate transfer of the
vitamin to every growing fetus and to every suckling infant.
NATIONAL NUTRITIONAL ANEMIA
CONTROL PROGRAM (NNACP)
Described under Nutritional Anemia.
NATIONAL SPECIAL NUTRITION
PROGRAM
This was launched by Government of India during 1970
to improve the nutritional status of children below 6 years
and all pregnant and nursing mother, of urban slums, tribal
areas and backward rural areas, by providing supplementary
food, every day for 300 days in a year, supplying 300 K. Cals
including 10 to 12 g of protein per child per day and 500 K. Cals
including 25 g of protein per mother per day. This program is
merged with ICDS scheme since 1975.
NATIONAL BALWADI NUTRITION
PROGRAM (NBNP)
This was started during 1970, to improve the nutritional
status of the Anganwadi (Balwadi) centers with the daily
supplement of the food, same as above. This is also merged
with ICDS scheme since 1975.
NATIONAL MID-DAY SCHOOL
MEAL PROGRAM
Described under School Health Services.
NATIONAL INTEGRATED CHILD
DEVELOPMENT SERVICES (ICDS)
SCHEME
Described under MCH services.
NATIONAL TOBACCO CONTROL
PROGRAM
National Tobacco Control Program (NTCP) is a national effort
to reduce tobacco related diseases and deaths:
During October 2007, Government of India launched
NTCP in Assam, in a pilot phase with the following objectives.
• To implement tobacco control laws.
• To create awareness on the harmful effects of tobacco use.
• To eliminate exposure to environmental tobacco smoke.

Table 43.7 Vitamin A prophylaxis schedule

Dose no. Age of the child Dose (orally) Remarks

1. At 9th month 1,00,000 IU Along with measles vaccine
2. At 18th month (1½ yr) 2,00,000 IU Along with Booster dose of DPT and OPV
3. At 24th month (2 yr) 2,00,000 IU Nil
4. At 30th month (2½ yr) 2,00,000 IU Nil
5. At 36th month (3 yr) 2,00,000 IU Nil
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Chapter 43 National Health Programs
The main components are:
State Tobacco Control Cell (STCC): This is being set up in
Delhi to facilitate, drive and monitor the proposed District
Tobacco Control Program. The nodal officer at the state will be
responsible for the coordination, monitoring and evaluation
of the program at the district level. He is supported by two
consultants to reduce tobacco use. Thus the Anti tobacco Act
is enforced effectively.
District Tobacco Control Cell (DTCC): The district Tobacco
Control Program comprises the following components:
• Tobacco Cessation Center: This provides counseling
and pharmacotherapy to tobacco users for quitting
the tobacco addiction. It also conducts training and
awareness programs at schools and colleges to promote
quitting and prevent initiation among youths.
• It also brings awareness of the adverse effects of tobacco
consumption on the health by conducting rallies, street
role play, etc.
• Training: The cell conducts training, workshop among
school teachers, health workers, women self help group,
civil society organization, etc. on tobacco epidemic,
tobacco control laws and implementation of the schemes.
• IEC activities: There will be active involvement of the
medias through poster display, article publications,
rallies, street role plays, exhibitions, mela, etc. in
regional languages. IEC materials will be developed and
disseminated in local languages also.
• School programs: This is to create awareness of health
hazards of smoking among school children.
Monitoring of tobacco control laws: This is done by small
teams of trained school teachers, health workers, law
enforcers, women self-help groups, etc. to cover small areas
of each district.
NATIONAL FAMILY WELFARE
PROGRAM (NFWP)
India is the first country in the world to launch a nation-
wide Family Planning Program during the year 1952. The
program was begun with the establishment of few clinics and
distribution of materials on education, training and research.
During the Third Five year Plan (1961-65), family planning
was declared as ‘the very center of planned development.’
The emphasis was shifted from ‘Clinic Approach’ to the more
vigorous ‘Extension Education Approach’, for motivating
the people for acceptance of the ‘Small family norm.’ The
introduction of Lippe’s Loop during 1965, led to the creation
of a separate Department of Family Planning in 1966 in the
Ministry of Health and the program became strong during
1966 to 69, i.e. the infrastructures such as primary health
centers, sub-centers, urban family planning centers were
strengthened.
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During the Fourth Five Year Plan (1969–74), Government
of India gave ‘top priority’ to the program. The program was
integrated with MCH services in the PHCs and sub-centers.
During 1970, the All India Hospital Postpartum Program and
in 1972 the Medical Termination of Pregnancy (MTP) were
introduced.
During Fifth Five Year Plan (1975–80) major changes took
place in the program. During 1976, the country framed its
first ‘National Population Policy’. The ruling party Congress
then introduced forcible sterilization campaign during 1976.
It was a disaster. Many misappropriation took place. In June
1977, Congress Government was defeated and the New Janata
Government ruled out compulsion, and coercion for all times
to come. The Ministry of Family Planning was renamed as
‘Family Welfare’. Since then it is running purely on voluntary
basis.
The pace of the program was accelerated by the involvement
of the local people at the grass root level with the launching of
Rural Health Scheme during 1977. The village health guides,
dais and opinion leaders were involved in the program.
Meanwhile during 1978, Government of India became
signatory to Alma-Atta declaration of Health for All by the
year 2000 AD.
The demographic goals targeted were:
• Net reproduction rate of 1
• Two Child Family Norm
• Birth Rate of 21/1000 MYP
• Death Rate of 09/1000 MYP
• Couple Protection Rate of 60 percent.
To achieve these goals, the Family Welfare Program was
accorded a central place in health development during 6th
and 7th five year plans, by strengthening the existing Maternal
and Child Health-services including Universal Immunization
Program and Oral Rehydration Therapy, thus aiming at the
Welfare of the whole family.
During 1992, MCH services were upgraded into a National
Program called ‘Child Survival and Safe Motherhood (CSSM)
Program to improve the quality of services.
During 1994, following an International Conference on
Population and Development in Cairo, it was recommended
to implement a comprehensive, unified ‘Reproductive and
Child Health (RCH) Program comprising Family Welfare,
CSSM Programs, and also Prevention and Management of
Reproductive Tract infections and the Sexually Transmitted
Infections (RTIs and STIs) including HIV/AIDS. The main
aim was to improve the quality of the services and to satisfy
consumers, covering a wider range of population. Thus
there was a paradigm shift from clinic based, target oriented
approach to target free, client centerd (satisfied), need based,
high quality approach.
Government of India launched RCH Program on April 1st,
1996. (explained further under RCH Program).
In this connection, Government of India evolved a more
detailed and comprehensive National Population Policy
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860 Section 7 Health Administration and Organization
(NPP) during the year 2000, dealing with empowering the
women for improved health, women education, child health,
the unmet needs for Family Welfare services and health care
for the underserved population groups like urban slums,
tribal community, hill area population and displaced and
migrant population, adolescent’s health and education,
increased participation of men in planned parenthood and
collaboration with NGOs.
Evaluation of Family Planning
WHO has defined the following types for evaluation of family
planning services during 1975.
1. Evaluation of need: By Maternal Mortality Rates
2. Evaluation of plans: By assessing the feasibility and
adequacy of program plans
3. Evaluation of performance:
a. Services: Such as distribution of contraceptives, IUD
fittings, tubectomies, vasectomies, education, follow-
up, motivation, etc.
b. Response: Such as number of new acceptors
c. Cost-analysis: Cost-effectiveness
d. Other activities: Such as administration, manpower,
data system, etc.
4. Evaluation of effects: Such as changes in their knowledge,
attitude, behavior, etc.
5. Evaluation of impact: Such as:
• Family size (number of living children)
• Birth interval
• Age of the mother at birth of the first child and last
child
• Birth order
• Number of abortions
• Changes in the birth rate and growth rate.
NATIONAL REPRODUCTIVE
AND CHILD HEALTH PROGRAM
(RCH-PROGRAM)
Historical Background
During 1950s Government of India introduced Maternal
and Child Health (MCH) services as basic health services
in Primary Health Centers because of their increased
vulnerability and morbidity and mortality.
During 1952, National Family Planning Progamme was
launched to control population growth in India. The services
were target oriented resulting in burden on health workers,
which ultimately affected the quality of work.
During 1972, abortion was legalized due to increased
maternal deaths following illegal abortions.
During 1975, emergency was declared in India by the
Government
During 1976, the disastrous forcible sterilization
campaign led to the defeat of congress Government and the
new Janatha Government during 1977, ruled out compulsion
and coercion of Family Planning services and renamed the
program as ‘Family Welfare’ program by providing a package
of services to the mothers and children in an integrated
manner, comprising Maternity services (Antenatal, Intranatal
and Postnatal care), Nutritional services (supplementary
nutrition), Immunization services and Family Planning
services, for the welfare of the entire family.
During 1978 Government of India upgraded the
immunization services and launched WHO recommended
Expanded Program of Immunization (EPI).
During 1978-79, meanwhile Government of India became
signatory to Alma-Ata Declaration of achieving the Global
Social Target ‘Health for all by 2000 AD’.
During 1985, Expanded Program of immunization was
renamed as ‘Universal Immunization Program (UIP)’ by
concentrating the services to infants and expectant mothers.
During 1992, to achieve the social target and to improve
the quality of services to mothers and children, the services
were integrated into a single composite Program called ‘Child
Survival and Safe Motherhood (CSSM)’ Program, a time
bound and target oriented National Program.
The time bound was 2000 AD and the target population
was all mothers and under five children. The objectives of the
CSSM Program were:
• To improve the health of the mothers and children below
5 years
• To reduce MMR, IMR and Child Mortality Rates
• To eliminate neonatal tetanus
• To eradicate poliomyelitis.
The interventions (strategies) were as follows:
Services for safe-motherhood:
a. Essential Obstetric Care comprising
– Registration of all expectant mothers after 12 weeks of
amenorrhea
– Minimum 3 visits to Antenatal Clinic
– Two doses of tetanus toxoid injections
– Distribution of 100 tabs (1 packet) of IFA
– Safe domestic deliveries observing five cleans
– Postpartum services after delivery.
b. Early diagnosis and management of complications
associated with pregnancy by early detection of high-risk
mothers and their referral.
c. Emergency care for those mothers with obstetric
complications such as premature labor, puerperal sepsis,
retained placenta, malpresentations, malpositions,
prolonged labor, rupture uterus, obstructed labor, post-
partum hemorrhage, etc.
Services for child survival:
a. Essential care of the newborn
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Chapter 43 National Health Programs
b. Primary immunization—100 percent coverage
c. Vitamin ‘A’ prophylaxis—(9 month–3 years)—100 percent
coverage
d. Acute Respiratory Infections—correct case management
at home
e. Diarrheal diseases—correct case management at home.
Services for eligible couples:
a. Promotion of contraceptive methods
b. Services for medical termination of pregnancy
During 1994, the services were evaluated and observed that
IMR and MMR were not coming down to the expected level.
Meanwhile it was observed that the incidence of Reproductive
Tract Infections (RTIs) and Sexually Transmitted Infections
(STIs) including HIV/AIDS were increasing among mothers
and adolescent girls all over the world. Eventually when the
International Conference on Population and Development
(ICPD) was held in Cairo (Egypt), (1994), it was resolved to
provide high quality of services to children and mothers,
with a wider coverage of women population from puberty
to menopause (15–44 years), in a client based, non-rigid,
decentrallized, target-free, participatory, demand driven,
approach. Accordingly during September 1996, the CSSM
Program and Family Welfare Program were incorporated into
a single, composite, National Reproductive and Child Health
(RCH) Program to eliminate the overlapping of expenditure, to
reduce the cost of inputs and to optimize the benefit of outputs.
Government of India formally launched RCH Program on 15th
October 1997. Thus RCH Program incorporates a paradigm
shift from a rigid, target based, centralized, coercive system to
a non-rigid, target free, decentralized, participatory, demand
driven, client based approach system aimed at satisfaction of
individual clients with a range of quality services.
In ICPD at Cairo, Fathallah, defined Reproductive Health
as, ‘A state of complete, physical, mental and social well-being
and not merely the absence of disease or infirmity in all matters
relating to reproductive system and its function and processes’.
Fathallah explained reproductive approach based on the
following points:
• People have ability to reproduce and regulate their fertility
• Women are able to go through pregnancy and childbirth
safely
• The outcome of the pregnancy is successful in terms of
wellbeing and survival of mother and infant
• Couples are able to have sexual relation free of fear of
pregnancy and of contracting STIs including HIV/AIDS.
Objectives
• The immediate objective is to promote the health of the
mothers and children to ensure safe motherhood and
child survival
• The intermediate objective is to reduce IMR and MMR
• The ultimate objective is population stabilization, through
responsible reproductive behavior.
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Interventions/Strategies of RCH
Program
• Prevention and management of unwanted pregnancies
• Maternal care (Safe motherhood)
• Child survival
• Prevention and management of reproductive tract
infections and sexually transmitted infections (RTIs/STIs)
• Prevention of HIV/AIDs.
Thus the operational profile of RCH Program can be
discussed under three broad service areas, namely maternal
health, child health and reproductive health.
The framework of RCH program is shown in Fig. 43.9.
Maternal Health (Safe Motherhood)
The service components are obstetric care, infection control
and nutrition promotion.
Obstetric Care
Obstetric care is provided to all pregnant mothers following
their registration after 12 weeks of amenorrhea, starting
from early pregnancy and spans over prenatal, intranatal
and postnatal phases by periodical check-up all along the
course of pregnancy, child-birth and puerperium. High
quality of these services are now made available for high-
risk mothers and also at-risk newborns by upgrading certain
selected PHCs and Community Health Centers into First
Referral Units (FRUs), at the rate of 4 to 6 per district. FRU is
a health institution at Taluka level, where the services of an
obstetrician (to take care of obstetric emergencies) and a
pediatrician (to take care of at-risk newborns) including the
facility for blood transfusion is available. Thus FRUs provide
essential and emergency MCH care at Taluka level.
A trained female health assistant (ANM) is qualified to
conduct health check-ups of normal antenatal and postnatal
cases. A trained traditional birth attendant is qualified to
(*RTI/STI reproductive tract infections/sexually transmitted infections)
Fig. 43.9 Framework of RCH program
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862 Section 7 Health Administration and Organization
provide delivery assistance, to normal, uncomplicated cases.
Pregnant mothers suffering from associated systemic diseases
are referred to appropriate centers for expert management.
To promote institutional deliveries, provision has been
made as additional honorarium to the staff to encourage
round the clock delivery facilities at PHCs.
NGOs are involved in this program to make it peoples’
program. They serve as complimentary agencies for optimiz-
ing, the functioning of RCH program.
Provision has also been made for the involvement of
traditional practitioners of Ayurvedic and Unani medicine in
this program, following an orientation course to update their
knowledge and skills.
Infection Control Measures
• Women are advised to maintain hygiene of the genitals
during menstruation to prevent urinary tract infections.
• They are educated to keep their parts clean by frequent
washings and by using sanitary towels and to avoid using
dirty linen.
• They are advised to prevent STIs by using condoms.
• Every pregnant mother is immunized against tetanus with
two doses of tetanus toxoid.
• The Traditional Birth Attendant (TBA) is trained to
observe five cleans while conducting delivery, to prevent
puerperal sepsis.
Nutrition Promotion
• All mothers are given nutrition education.
• They are explained that pregnancy drains out their
nutrient stores and unless substantial improvement is
made in their daily diet, they would develop malnutrition
which can impair their health and affect adversely the
course of the pregnancy and its outcome.
• They are instructed to consume foods rich in iron content
such as green leafy vegetables and fruits.
• They are also additionally motivated to consume one
large IFA tablet daily, during the last trimester to prevent
anemia and its consequences.
Child Health (Child Survival)
The service components are:
• Essential care of the newborn, including care of the at-risk
newborn by prompt referral service. The neonatal care
consists of care of eyes, nose, throat, skin, umbilical-cord
and rectum.
• Infection control measures:
– Starting from observing five cleans while conducting
delivery
– Early initiation of breast feeding, while avoiding
prelacteal feeds
– By adopting ‘warm-chain’ with the mother
– By minimum handling and handling by barely
minimum number of persons
– By keeping the room clean, dust free and warm
– By giving bath about one week after birth
– By getting primary immunization during infancy
– By educating the mother about Oral Rehydration
Therapy of the child with the onset of diarrhea
– By giving home remedy to treating upper respiratory
infections of the child with ginger syrup and/or
pediatric co-trimoxazole tablets.
• Nutrition promotion:
– By promotion of breast-feeding to the child
– By proper complimentary feeding after 6 months of
exclusive breast-feeding, with fruits and vegetables
– By five mega doses of Vit. A syrup between 9 month to
3 years, with interval of 6 months.
Reproductive Health
• Fertility control: The family planning services include :
– Distribution of conventional contraceptives (con-
doms) and oral pills for newly married couples
– Condoms, and IUDs for spacing after one child
– Sterilization for either of the partners after two
children, including services of laparoscopic surgery
The supportive services provided are:
– Monitory compensation of `200/- for female steriliza-
tion, (per acceptor) and `180/- per acceptor of male
sterilization
– Meeting expenditure incurred by state governments
on sterilization services such as transportation, drugs,
dressings, diet, etc.
– Offering facilities for post-vasectomy semen testing,
which can be availed any time after three months of
vasectomy or after 20 episodes of ejaculation.
– The services are made as ‘Target free’ approach.
• MTP-services (for prevention and management of
unwanted pregnancies). This is provided not only in
District and sub-divisional (Taluka) hospitals, but
also now extended to PHC levels also under MTP-Act,
1971, because nearly 20,000 maternal deaths have been
occurring per annum in our country, only due to illegal
abortions. The aim is to reduce maternal deaths from
unsafe abortions.
– Involvement of adequately equipped and trained
doctors of non-government clinics is also provided.
– Supportive assistance is also provided by training the
doctors in MTP technique, Supply of MTP equipment
to hospitals and health centers and assistance of
trained doctors to PHC, weekly, on fixed days.
• Adolescent counseling: Since adolescence is a stage of
transition physically, mentally and emotionally, ignorance
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Chapter 43 National Health Programs 863

can result in psychological problems among adolescent
boys and girls. RCH program strives for dispelling
misgivings, misconceptions and misapprehensions from
their minds.
The scheme provides for counseling of adolescents on
problems related to sex and sexuality including various
forms of sexual dysfunction, sexual aberrations, sexual
abuse, impotence, etc. Adolescent girls are educated on
menstruation and menstrual hygiene.
They are also educated about the risks associated with
unprotected sex such as transmission of STIs including
Hepatitis B and HIV/AIDS, besides resulting in pregnancy.
They are also advised to consume nutritious diet for
optimum growth and development.
• Prevention and management of RTIs/STIs including
HIV/AIDS.
These infections have a profound effect on the health
of the mothers and children. These infections (RTIs/
STIs) can cause infertility, pelvic inflammatory disease,
ectopic pregnancy, low birth weight, still-births and
childhood mortality. Presently the services for prevention
and management of these infections are available only
in Dist. Hospitals and teaching hospitals. Currently it
is thought to provide such services in CHCs, PHCs and
FRUs, by the dermatologists. This component has been
linked with National AIDS Control Program. The National
AIDS Control Organization (NACO) has been providing
assistance to set-up RTI and STI clinics at district level by Fig. 43.10 ‘Topdown’ approach of family planning program
providing manpower (2 lab technicians) and materials
(drug kits) to test blood and urine of the patients.

Management Strategies of RCH Decentralized Training

Program
Bottom-up Planning
The previous approach in FP Program was ‘Top-down’ i.e.
centralization of services (Fig. 43.10). That means the targets
were fixed at the national level (center). That used to be a
burden on health workers affecting the quality of services,
resulting in inflation of target statistics, specially with
reference to tubectomies, vasectomies and IUD fittings. In
RCH Program, it is ‘Bottom-up planning,’ (and not top-down),
i.e. Decentralization of services (Fig. 43.11). That means the
planning of services is based on assessed needs. At the grass-
root level the needs are assessed by the health workers and
medical officers in consultation with the Mahila Mandals,
Village Panchayats, and Nongovernment Organizations.
The aggregated needs of the villages will make up the PHC
plan. Likewise the aggregation of FRUs, PHC plans will make
up District-plan. Aggregation of District plans will make of
state-plans. Thus ‘Bottom-up’ planning reflects the grass-root
needs.
Training of health functionaries is incorporated in this
program. The training improves the quality of service and
satisfies the clients. The training is skill oriented and not
knowledge oriented by didactic lecture classes. For that
periodically refresher courses and work-shops are conducted
at District Level.
Management Information and
Evaluation System (MIES)
This has been proposed under RCH-Program.
The various indicators included are:
• Proportion of institutional deliveries and deliveries by
trained personnel
• Number of health facilities providing emergency obstetric
care
• Number of poliomyelitis and neonatal tetanus cases
reported
• Number of IEC sessions on ARI and Diarrheal diseases
• Number of ARI cases among underfives, identified and
treated

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864 Section 7 Health Administration and Organization
Fig. 43.11 ‘Bottom-up’ planning of RCH program
• Proportion of acceptors of reversible methods with wife’s
age less than 30 years
• The total number of immunization sessions planned and
held.
IEC and Community Participation
RCH program envisages IEC campaigns (Information, Edu-
cation and Communication). Gender and sexuality issues,
hitherto neglected will be the important components. Com-
munity participation will be elicited through the Panchayats,
Mahila Mandals and other community groups.
To meet this gigantic task of achieving the goals, Govern-
ment of India is enhancing the budget for RCH program. The
World Bank and European Commission have also been sup-
plementing the national fund.
Highlights of this New Approach
• Target free program from April 1, 1996
• Greater emphasis on quality
• Bottom-up approach, Decentralized participatory planning
• Integrated package of services to mothers and children
• Free distribution of condoms
• Comprehensive integrated training programs
• Increased involvement of NGOs
• Area specific IEC campaigns
• Rapid and independent evaluation
• Integrated approach
• Increased male participation
• Gender sensitivity.
REPRODUCTIVE AND CHILD
HEALTH PROGRAM-II (RCH-II)
RCH-II is the continuation of RCH-I, which was for the period
of 1997 to 2002. During the period of 2002 to 2004, planning for
the implementation of RCH-II was going on and RCH-II was
started from 1st April 2005 up to 2009, in order to strengthen/
improve the quality of services and to achieve the Millennium
Development Goals by overcoming the lacunaes of RCH-I.
AIM
The aim is to reduce Infant Mortality Rate (IMR), Maternal
Mortality Rate (MMR), Total Fertility Rate (TFR) and to
increase Couple Protection Rate (CPR) and Immunization
coverage, specially in rural areas.
Goals
• Reduction of decadal rate of population growth between
2001 and 2011 to 1.62 percent.
• Reduction of IMR to <45/1000 livebirths by 2007 and to
<30/1000 livebirths by 2010.
• Reduction of MMR to 1.5/1000 livebirths.
• Reduction of TFR to 2.1 by 2010.
• Increase of CPR from 44.8 percent (RHS 2002–03) to 65
percent by 2010.
• Increase of immunization coverage among children from
48.2 percent (RHS 2002–03) to 100 percent by 2010.
• Improvement in the coverage of full antenatal care from
44.5 to 89 percent by 2010.
• Improvement in the coverage of rural institutional
deliveries from 39.8 percent (Rural Health Survey 2002–
03) to 80 percent by 2010.
Lacunae of RCH-I
They were as follows:
• The outreach services were not available to the vulnerable
and needy population.
• The management of financial resources were inadequate.
• The human resources (manpower) such as doctors,
nurses, health workers, etc. were deficient.
• The management information and evaluation system was
lacking.
• The effective network of First Referral Units was lacking.
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Chapter 43 National Health Programs
• The maintenance of infrastructures was poor, such as
lack of cleanliness, water supply, electricity, instruments,
disposal of hospital waste, etc.
• The range and quality of services in PHCs/CHCs was poor.
• The concentration on neonatal and adolescent health was
lacking.
• The community participation was minimum.
• There were regional variations in the implementation of
RCH-I program.
Andhra Pradesh and Tamil Nadu were doing well.
Whereas in Bihar, Madhya Pradesh, Odisha, Rajasthan, Uttar
Pradesh, Chhattisgarh, Jharkhand and Uttaranchal the health
status is poor. These eight states have been designated as
Empowered Action Group (EAG) states.
Objectives
The main objective of RCH-II is to overcome the lacunae of
RCH-I by the following measures:
• To improve the management performance.
• To develop human resources intensively.
• To expand RCH services to tribal areas also.
• To improve the quality, coverage and effectiveness of
the existing family welfare services and essential RCH
services with a special focus on the above mentioned EAG
states.
• To monitor and evaluate the services.
COMPONENTS OF RCH-II
• Population stabilization
• Maternal health
• Newborn care
• Child health
• Adolescent health
• Control of RTIs/STIs
• Urban health
• Tribal health
• Monitoring and evaluation
• Other priority areas.
Population Stabilization
Strategies
• By incorporating the newer choices of contraceptive
methods such as injectable contraceptives, non-steroidal
hormonal pills (like centchroman) and female condom.
• By increasing the number of trained personnel like
medical officer of PHCs and female health worker of
subcenters.
• By converging the services at grass roots level by having
linkage with ICDS.
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865
• By public private partnership, i.e. by involving private
doctors to provide contraception by paying incentives to
them.
• Social marketing of contraceptives to be strengthened
in rural areas through Rural Health Practitioners and
Community mobilization through satisfied acceptor
couples.
• Involving Panchayati Raj institutions, urban local bodies
and NGOs.
– By training one couple from each village to provide
non-clinical family planning method of services.
– By involving District Urban Development Authorities
(DUDA), co-operative societies and industrial workers
in providing family planning services.
– By identifying NGOs to provide financial, technical
and managerial support.
• By increasing the incentives for family planning acceptors
as follows from:
`300 to `400 for tubectomy
`200 to `400 for vasectomy
`400 to private providers for sterilization
`75 for IUD fitting (only for women of below poverty
line)
`500 as compensation and medical termination of
pregnancy to the women acceptors in case of failure
of permanent method (tubectomy).
Maternal Health
The strategies to improve and strengthen the quality of
maternal services are:
• Essential obstetric care
• Emergency obstetric care.
Essential Obstetric Care
This consists of strengthening the quality of antenatal care by
ensuring the following:
• Three or more checkups including the investigations
• Two doses of tetanus toxoid
• One pack of Iron Folic Acid (IFA) tablets during the last
trimester.
• Counseling on promotion of institutional delivery, danger
signs of obstetric emergency and sensitization on breast-
feeding and family planning methods.
Emergency Obstetric Care
This consists of operationalizing the First Referral Units to be
fully functional round the clock (24 hours).
First referral unit (FRU): It is an upgraded PHC/CHC into a
30 bedded hospital, having a well furnished and equipped
operation theater with a newborn care corner, a labor room,
blood bank and laboratory to provide the services of obstetric
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866 Section 7 Health Administration and Organization

emergencies such as cesarean section, care of the newborn
and sick children and facilities for blood transfusion.
Staff pattern of FRU
• Five specialists namely Obstetrician and Gynecologist,
Pediatrician, Anesthetist, Surgeon and Physician.
• Seven Staff nurses
• One Pharmacist
• Two Laboratory Technicians.
Services of FRU
• Emergency obstetric care such as cesarean section
• Care of the newborn
• Care of the sick children
• Availability of ambulance
• Adequate supply of drugs to the patients.
• Facility for storage of blood
• Family welfare services including vasectomy, laparoscopic
tubectomy and MTP
• Training of Medical Officers (MOs) in anesthetic skills for
emergency obstetric care
• Training of Auxillary Nurse Midwives (ANMs)/Female
health workers to provide obstetric first aid.
All these services should be provided round the clock. All
CHCs and at least 50 percent of PHCs should become FRUs
by 2010.
care and postnatal care through Accredited Social Health
Activist (ASHA).
Eligibility
• Pregnant women belonging to BPL (Below Poverty Line)
families irrespective of caste, creed and community.
• Pregnant women of families having an annual income of
less than `17,000.
• Women aged above 19 years, upto first two livebirths in
High Performing States (HPS).
• Women undergoing sterilization soon after delivery,
irrespective of birth order in Low Performing States (LPS)
namely Uttar Pradesh, Uttaranchal, Madhya Pradesh,
Chhattisgarh, Rajasthan, Bihar, Jharkhand, Odisha, Assam
and Jammu and Kashmir.
• Pregnant women must and should have registered in PHC/
Sub center and has received adequate antenatal care (i.e. 3
visits, 2 doses of tetanus toxoid and 1 pack of IFA tabs).
All women registered under JSY are issued JSY card and
MCH card. Accredited Social Health Activist (ASHA) will work
as a ‘Link Worker’ between the mothers of the community
and the health system in these ten LPS. She is responsible for
making available the institutional care for mothers during
pregnancy, delivery and after birth of the child.

Newer Schemes Benefits

1. Training of MOs in the skills of obstetric management Table 43.8 shows the financial benefit provided under JSY.
including cesarean section.
2. Training of Traditional Birth Attendants (TBAs) for one Table 43.8 Financial benefit provided under JSY
year and designated as Community Skilled Birth Attend-
Category Rural Urban
ant (CSBA).
of states
3. Prasoothi araike: This is to promote antenatal care by giving
`1000 at 6th month of pregnancy to BPL (Below Poverty To To Total To To Total
Line) mothers and another `1000 at 9th month, total `2000. mother ASHA mother ASHA
4. Janani Suraksha Yojana (JSY) Scheme. Low `700 `600 `1300 `600 `200 `800
performing
states
Janani Suraksha Yojana (JSY) High `700 – `700 – – –
performing
This is a modified version of National Maternity Benefit states
scheme for pregnant women of BPL families in both urban
and rural areas. This scheme was launched on 12th April 2005
• `500 if BPL mother delivers at home.
under National Rural Health Mission (NRHM). It is a benefit of
• `700 if she delivers in the hospital and `600/- to urban
cash assistance. It is 100 percent centrally sponsored scheme
mother of LPS.
as a safe motherhood intervention for promoting safe delivery.
• `200 as conveyance allowance for transportation to
The main components of JSY are early registration, micro
referred center.
birth planning, referral transport (home to health institution),
• `1500 for those mothers, who undergo cesarean section
institutional delivery, post delivery visit and reporting, family
in a private hospital, in case the services of Government
planning and counseling.
Doctor is not available.
• `175 for laparoscopic tubectomy.
Objective • Incentive for ASHA should not be less than `200/- per
The main objective is to reduce MMR, NNMR and IMR by institutional delivery for her transport assistance and for
promoting institutional deliveries as well as better antenatal stay during delivery.
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Chapter 43 National Health Programs
• If mother has not taken the help of ASHA, then mother
will get the benefit of both the packages.
• `1500 will be available as advance during emergencies
from Lady Health Assistant.
• All payments to ASHA would be from ANM only, within
seven days of delivery.
• Services are provided round the clock.
All these services/benefits will be available not only in all
the Government hospitals/PHCs/CHCs/FRUs but also in two
identified private hospitals of each district, the list of which
will be notified in the notice board of all the hospitals and
sub centers. List of beneficiaries will be notified in the center.
ANM will conduct the monthly meeting on 3rd of every month
and submits the report to MO by 7th of that month.
Micro Birth Plan Maintained by ASHA
• Identification and registration of expectant mother.
• Filling up of MCH and JSY cards.
• Take necessary step to fix the service center and
transportation.
• Inform dates of ANC visits, TT injection and EDD.
• Collection of BPL/Caste and other necessary certificates
for submission to MO.
• Payment of cash benefit to mother and ASHA.
• Payment of last installment to ASHA.
Janani Shishu Suraksha
Karyakrama (JSSK)
This is an upgraded scheme of Janani Suraksha Yojana (JSY)
Scheme, because this scheme involves/extends services not
only to mother but also to the Newborns during the first 30
days, who are unhealthy/at risk. This program was started
on June 1, 2011 in Mewat District of Haryana State, as an
important step/component of Health For All. The services are
provided free of cost to all mothers and at risk newborns, born
in all Government hospitals, including Primary/Community
Health Centers, both for normal deliveries and cesarean
sections, undergoing for the first time.
The following services are provided to the mother, free of cost:
• Normal delivery or cesarean section.
• Drugs and supplements like Iron and Folic acid tabs,
Vitamin tabs, etc.
• Laboratory investigations of blood, urine and sonography.
• Food supply during their stay in the hospital/health
center.
• Blood transfusion.
• Transportation facility from house to health center and
to referral center if necessary and back to home after 48
hours of stay in the hospital.
• Exemption from all types of fees.
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867
Free services to ‘At-risk’ newborns during the first 30 days
only:
• Treatment and care
• Drugs and supplements like infusion, cotton, dressings,
etc.
• Investigations if necessary.
• Blood transfusion.
• Transportation facility from house to health center and to
referral center if necessary and back to home.
• Exemption from all types of fees.
Newborn Care and Child Health
Figure 43.12 shows the effective health interventions for
the newborn starting from the pregnancy period, through
delivery and the neonatal period.
Objectives
• Increase coverage of skilled care at birth for newborns in
conjunction with maternal care.
• Implement by 2010 a newborn and child health package
of preventive, promotive and curative interventions using
a comprehensive IMNCI approach (Integrated Manage-
ment of Neonatal and Childhood Illness) in the rural
areas through AWWs/LHVs/ASHAs.
• Implement the medium-term strategic plan for the
Universal Immunization Program.
• Strengthen and augment the existing services in areas
where IMNCI is yet to be implemented.
IMNCI + Skilled care at birth + Immunization = ‘IMNCI
plus’.
Strategies
1. IMNCI plus: This approach consists of integration of
immunization services, skilled care at birth and IMNCI
(Fig. 43.13).
2. Strengthening of health infrastructures in PHCs, CHCs
and FRUs for care of infants and children.
3. Ensuring referral of sick neonates and children utilizing
referral funds.
4. Permitting ANMs and AWWs to administer selected
antibiotics like Gentamycin by ANM and co-trimoxazole
by AWW.
5. Uninterrupted availability of drugs and supplies.
6. High quality supervision and monitoring.
7. Ownership of the state and district level program man-
agers.
8. Efficiency of the administrative/financial system.
9. Community based interventions such as:
– Mobilizing the families for JSY.
– Promoting healthy home care practices for new-
born and during illness like diarrhea.
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868 Section 7 Health Administration and Organization

Fig. 43.12 Effective newborn health intervention

– Promoting early recognition of infant and child-

hood illness by educating family.
– Improving referral of sick neonates and children.
10. Promoting infant and young child feeding (IYCF) by
promoting breastfeeding practices and implementing
IMS Act (Infant milk substitutes Act).
11. Vitamin A, iron and folic acid supplementation.
12. Strengthening the quality of UIP to eradicate polio-
myelitis, to eliminate neonatal tetanus and to reduce
mortality due to measles.

Fig. 43.13 Newborn and child health package in RCH II (IMNCI-plus)
Adolescent Health
This is implemented on pilot basis in those districts, where
more than 60 percent girls marry before the age of 18 years,
presuming that the incidence of teenage pregnancy is high in
those districts.
The adolescent health services are provided by coun-
seling once a week in the clinic of SC, PHC and CHC.
Table 43.9 shows services provided for adolescents in the
health center.
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Chapter 43 National Health Programs 869

Table 43.9 Services provided for adolescents in the health center

Level of care Service provider Target group Flow of service delivery activities Services
Subcenter HW(F) Unmarried F During routine • Enroll newly married couples
Married F subcenter • Provision of spacing methods
Unmarried M clinics • Routine ANC care and institutional
Married M delivery
• Referrals for early and safe abortion
• STIs/HIV/AIDs prevention education
• Nutrition counseling including
anemia prevention
Primary Health Health assistant Unmarried male and Once a week, teen • Contraceptives
Center/Community (F)/LHV female clinic will • Management of menstrual disorder
Health Center Medical be organized • RTI/STI preventive education and
officer at PHC for management
2 hours • Counseling and services for
pregnancy termination
• Nutritional counseling
• Counseling for sexual problems

Control of RTIs/STIs • Develop a sufficient number of first referral institutions

capable of tackling emergencies including obstetric
RTIs/STIs are controlled by syndromic approach (discussed emergencies.
elsewhere). • Provide associated supplies, management and infor-
mation.

Urban Health Services

This is improved by providing quality primary health care to
the urban poor by establishing Urban Health Centers (UHC)
at the rate of 1:50,000 population with 1 MO, 3-4 ANMs, 1 lab
assistant, 1 public health nurse/LHV, 1 clerk, 1 chowkidar and
1 peon.
Second tier referral center could be District hospital/
Private nursing home by Public Private Partnership.
Tribal Health (Vulnerable Population)
These are the people who are underserved due to problems
of geographical access and those who suffer social and
economic disadvantages such as SC/ST and the urban poor.
Goal is to improve their health status.
Objective: To bring their health status at par with the rest of
the population.
Strategies
• Assess their unmet needs of RCH services.
• Provide integrated and quality RCH services.
• Improve accessibility, availability and acceptability of
RCH services.
• Promote community participation and intersectoral coor-
dination.
• Promote and encourage the tribal system of medicine.
Table 43.10 shows services provided in tribal areas under
RCH-II.
Table 43.10 Services provided in tribal areas under RCH-II
Tier Services
Community Community based worker/ASHA to work as social
level mobilizer, educator and provider of non-clinical services
and to work as Depot holder for contraceptives.
To act as DOTS provider for the revised National
TB Control Program, to take malaria slides, store and
distribute anti-malaria drugs, create awareness about
sanitation, safe drinking water and participate in the
other health care programs.
Subcenter ANC and PNC services, IFA distribution, delivery by
skilled attendant, referral for institutional delivery,
contraceptive distribution and referral for terminal
methods, immunization, management of childhood
illness, deworming, nutrition and health education for
mothers, treatment of minor aliments including RTI/
STI, services under national program like DOTS, NMCP,
counseling services.
PHC All above + dispense ayurvedic, homeopathic, unani
and tribal system of medicines.
Block PHC/ All above + Terminal method of FP EOC + elective
CHC abortion 1st trimester, MVA, screening and clinical
based services for sickle cell anemia, Thalassemia, G-6
PD deficiency and Lab services.

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870 Section 7 Health Administration and Organization
Monitoring and Evaluation
Management Information and
Evaluation System (MIES)
This is done by the following measures:
• Planning is done at various levels of Sub-center, PHC,
CHC, District and State.
• Monitoring is done by establishing Consumer Need
Assessment Approach (CNAA) cell at District and State
level with an officer incharge.
• Quality assurance/assessment is done by INDIACLEN,
which comprises the faculty members of medical colleges
keeping the quality control of RCH services. It is piloted
on three Empowered Action Group (EAG) states and two
non-EAG states before implementation.
• Evaluation is done through District Surveys, National
Family Health Survey (NFHS-III), focus studies and
census report.
• Validation is by supervision and surveys (Fig. 43.14).
ALL INDIA HOSPITAL POSTPARTUM
PROGRAM
All India Hospital Postpartum Program (AIHPPP) is a
maternity centered, hospital based approach to Family
Welfare Program, by motivating the couples, women being in
the reproductive age group, 15 to 44 yrs, for adopting a small
family norm, through education and motivation, during
antenatal, intranatal and postnatal periods.
The expectant mothers and nursing mothers constitute a
captive audience and most receptive to the advice concerning
herself and her child at this time than at other times. Therefore
that period, specially ‘lying-in’ period (postpartum period)
constitutes the period of highest motivation for family welfare
and is the most opportune time for the efficient spread of
information and service. With this point in view, Government
of India, launched this program during 1969, following the
recommendations of population council of New York in 1966.
Fig. 43.14 Monitoring and evaluation
Objectives
• To improve the health of the mothers and children
• To reduce IMR and MMR.
Rationale
The AIHPPP is based on the rationale that:
• Recently delivered mothers are of proven fertility and are
at risk of becoming pregnant again very soon
• Such mothers constitute very captive audience during
‘lying-in’ period to adapt family planning methods.
The program was extended to the entire country in a
phased manner through hospitals and medical colleges
through Postpartum centers. Later immunization services
were also included.
Condoms and oral pills were distributed for newly
married couples. IUDs were fitted to the mothers after birth of
one child and sterilization used to be done for target couples
(after 2 children). MTP services were also provided.
During 1992, this program was merged with CSSM
program and under RCH program during 1997.
NATIONAL WATER SUPPLY AND
SANITATION PROGRAM
This was launched during 1954 with the main object of
providing safe water supply and adequate drainage facilities
for the entire population of the country.
During 1972, a special program, known as ‘Accelerated
Rural Water Supply Program’ was started as a supplement to
the National Water supply and sanitation program.
During Fifth Plan this special program was included
in the ‘Minimum Needs Program’ of the State Plans. The
Government of India is supporting the efforts of the states
in identifying ‘Problem villages’, through assistance under
accelerated rural water supply program.
A problem village has been defined as a one where:
• No source of safe water is available within a distance of
1.6 km
• Where water is available at a depth of more than 15 meters
• Where water source has excess salinity, iron, fluorides
and other toxic elements
• Where water is exposed to the risk of cholera.
During the year 1981, Government of India launched
‘International Drinking Water Supply and Sanitation Decade
Program’. The targets were:
• 100 percent water supply for both urban and rural
population
• 80 percent sanitation facilities for urban areas
• 25 percent sanitation facilities for rural areas.
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Chapter 43 National Health Programs
During Sixth Five Year Plan (1980–85), 1.92 lakh villages
out of 2.31 lakh problem villages were provided with a safe
water source of drinking water.
The latest assessment indicates that safe water is available
to 80 percent of urban population and 47 percent of rural
population and adequate facilities for waste disposal is available
to 30 percent of urban and 1.0 percent of rural population.
The 20-Point Program of 1986 aims at providing safe
potable water to all villages. A total outlay of `6522.47 crores
was made during the Seventh Plan.
The role of the community volunteers in this program are:
• Inspecting supplies to detect source of contamination
• Devising and implementing methods for protection
• Advising water users on procedures that will diminish the
contamination
• Taking water samples periodically to nearest laboratory
• Reporting the findings to local committee and Ministry of
Health and Water Supply Agencies
• Informing the community of results of these measures
• Health education of the people about the prevention of
pollution of water source by the following measures:
– Preventing the people from defecating into or near the
water supply/source
– Discouraging the people from bathing, washing
clothes or utensils or animals near the water source
– Preventing the underground seepage from nearby
latrines or soakage pits
– Avoiding the people from using dirty containers.
• People are also educated about the following:
– Protecting the water sources
– Diseases transmitted through water
– Need to drink chlorinated water.
MINIMUM NEEDS PROGRAM
Minimum Needs Program (MNP) was launched during
the year 1974, with the objectives of providing certain basic
minimum needs and thereby to improve the living standards
of the people. It was the commitment of the Government for,
‘the social and economic development of the community
particularly the underprivileged and underserved population’.
MNP was revised during 1980. The National Water Supply and
Sanitation program was incorporated into MNP during 1987.
Components of the MNP
• Rural health
• Rural water supply
• Rural electrification
• Elementary education
• Adult education
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• Nutrition
• Environmental improvement of slums
• Houses for landless laborers.
Basic Principles of MNP
• Preference of providing the facilities are to be given to
those areas which are at present underserved, so as to
remove the disparities
• And the services to be provided in a package manner.
Rural Health
Objectives: (to be achieved by the end of 8th Five Year Plan)
• One PHC for 30,000 population in plains and 20,000
population in tribal and hilly areas
• One Sub-center for 5,000 population in plains and 3,000
in tribal and hilly areas
• One Community Health Center (Rural hospital) for a
population of one lakh or one community development
block by the year 2000, by upgrading the existing PHC.
Rural Water Supply
This is carried out in association with point 7 of the twenty-
point program (TPP), which is mainly concerned with
providing clean drinking water specially for members of
Scheduled Castes.
Rural Electrification
Electricity is made available to 60 percent of houses by 1990.
Elementary and Adult Education
The targets laid down were 100 percent enrollment of children
between 6 and 14 years of age 1990 and achievement of 100
percent literacy rate among persons aged 15 to 34 by 1990.
Rural Nutrition
The objectives were:
• To extend nutrition support to 11 million eligible people
• To expand, ‘special nutrition program, ‘to all ICDS
projects’
• To expand, ‘the mid-day meal program’, so as to cover all
persons belonging to SC and ST and backward classes.
Improvement of Urban Slums
All slums of all cities with three lakh population or more will
be provided with water taps, sewers, storm water drains,
community bathing places, paved roads and street lights.
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872 Section 7 Health Administration and Organization
Rural Housing
This is carried out jointly with point 14 of Twenty Point
Program. The services provided are free house sites given
to landless farmers. They are also assisted in construction
of the houses by providing them loan, at the rate of
`2000 per square yard.
Rural Roads
Approach roads are constructed for the villages having a
population of 1500 or more.
Rural Sanitation
Sanitary latrines are provided to those houses lacking them.
TWENTY POINT PROGRAM (20-PP)
This was launched on July 1, 1975. This was initiated by the
Government of India as a special activity, as an ‘agenda’ for
the national action, to promote social justice and economic
growth.
It was revised on August 20, 1986. The objective is to
improve the lot of the poorest of the poor and to provide them
food, shelter, employment and healthy environment, by the
following measures:
• Eradication of poverty
• Raising the productivity
• Reducing in equalities
• Removing social and economic disparities
• Improving the quality of life.
The points are as follows:
1. Alleviate poverty through creating community assets
(tanks, ponds, roads, etc.) and expand rural employ-
ment through promoting rural industries, handicrafts
and handlooms.
2. Promote agriculture through improved seeds, con-
servation of rain moisture and management of water
resources.
3. Improve irrigation by management of catchment areas,
prevention of water logging and co-ordinated use of
surface and ground waters.
4. Increase the production of paddy, edible oil seeds,
pulses, fruits and vegetables.
5. Distribute lands to the landless.
6. Abolish bonded labor.
7. Provide clean drinking water for all, particularly to the
members of Scheduled Castes and Tribes.
8. Expand primary care facilities, control tuberculosis,
leprosy, malaria, goiter and blindness. Ensure 100
percent immunization of infants and pregnant women.
Maintain sanitation in rural areas.
9. Ensure two-child norm through voluntary acceptance.
10. Expand education
11. Provide justice to the members of Scheduled Castes
and Tribes.
12. Ensure the equality of sexes.
13. Provide new opportunities for the youth in the field
of sports, adventure, cultural activities and national
integration.
14. Provide houses for the people. Use low cost materials in
their construction. Loan facilities to be provided.
15. Improve slums.
16. Plant more trees and more forests.
17. Protect environment by judicious selection of sites for
dams, and by the use of the least damaging techniques
for their construction.
18. Show concern for consumers by consumers’ pro-
tection movement.
19. Improve rural electrification.
20. Simplify the administrative procedures and attend to
public grievances.
BIBLIOGRAPHY
1. Aarati Dhar. Editorial, The Hindu, Jan 13, 2012.
2. Anand Krishnan, Vivek Gupta, Ritvik, Baridalyne, Nongkyunrish,
JS Thakur. How to effectively monitor and Evaluate NCD
Programmes in India. IJCM 36, Supplement; Dec 2011 : S 58-59.
3. Arun K Yadav, Atul Kotwal, Hariom Gupta, Aniket Kulkarni and
Ashok K Verma. India Without Poliomyelitis : Time to make it a
Reality. IJCM. Vol 37 (1); Jan 2012 : p 1-4.
4. Babu BV, Acharya AS, Malik G, Jangid PK, Nayak AN,
Satyanarayana K. Lymphatic Filariasis in Khurda Dist. of Drissa,
India: An epidemiological study. Sout East Asian J Trop Med
Public Health 2001;32:240-3.
5. Babu BV, Mishra S. Mass drug Administration under the prog-
tram to Eliminate lymphatic fitariasis in Orissa, India. A mixed
methods study to identify factors associated with compliance and
non compliance. Trans R Soc Trop Med Hyg 2008;102:1207-13.
6. Central TB Division. TB India 2009. RNTCP Status Report, New
Delhi.
7. Directorate General of Health Services. Revised National TB
Control Programme. Technical guidelines for TB Control.
Central TB Division, New Delhi; July 1999.
8. GOI MOHFW. NACO Phase III (2006-11) Strategy and
Implementation Plan. Nov 2006.
9. GOI WHO Collaborative Programme. National Programme for
Prevention and Control of Diabetes, Cardiovascular diseases
and Stroke. A Manual for Medical Officers. 2008-9.
10. GOI. A Guide to Malaria and Its Control. MOHFW; New Delhi:
1999.
11. GOI. A Report on National Guineaworm Eradication Pro-
gramme. Director, NICD; New Delhi : 2000.
12. GOI. DGHS. National Mental Health Programme Document,
1982.
 Free ebooks ==> www.ebook777.com
Chapter 43 National Health Programs
13. GOI. Health Information of India 2000-01. MOHFW, New Delhi,
2003.
14. GOI. MOHFW. Revised National Drug Policy (2010) for Treat-
ment of Malaria. NVBDCP. JIMA. Dec 2010 (108); 12: 844-5.
15. GOI. National CSSM Programme. Programme Interventions.
MCH Division, MOHFW, New Delhi, 1994.
16. GOI. National Mental Health Programme for India. Central
Council of Health and Family Welfare, New Delhi, 1982.
17. GOI. National Programme for the Control of Blindness in India.
MOHFW; New Delhi: 2004.
18. GOI. National Programme Implementation Plan. RCH Phase II,
Program Document. MOHFW. New Delhi 2004.
19. GOI. Plan of Operation for the All India Hospital Postpartum FP
Programme. MOHFW; New Delhi: 1971.
20. GOI. RCH II and Family Planning – Program Implementation
Plan. MOHFW. New Delhi. 2004.
21. GOI. Reproductive and Child Health Programme. Schemes for
Implementation. MOHFW; New Delhi : Oct 1997.
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22. GOI. Tenth Five Year Plan. 2002-07. Planning Commission, New
Delhi.
23. http://phealth.gov.in
24. http://www.developednation.org/india/health.asp
25. http://www.nihfw.org
26. India Canada Collaborative HIV/AIDS Project. Participant’s
Manual level II. March 2006.
27. Kishroe J. National Health Programmes of India. 5th Edn. 2005.
28. NACO ICTC Team Training, Trainee’s Hand Book. Apr 2010.
29. National Polio Surveillance Project. AFP Surveillance in India.
Implementing the Plan of Action. 2004; 2005, 2007.
30. NIHFW – Documentation Services.
31. NRHM Bulletin Vol 7 (1) Nov-Dec 2011.
32. NRHM. State Program Implementation Plan. 2011-12.
33. Nutrition Foundation of India. National Goitre Control
Programme. A Scientific Report (1): 1983.
34. Park K. Park’s Text Book of Preventive and Social Medicine. 18th
Edn. 2005.
35. www.mohfw.nic.in