Schemes and plans for major community health problems in India:
Health care in India is the responsibility of constituent states and territories of India.
The constitution charges every state with “raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”. The National Health Policy was endorsed by the parliament of India in 1983 and updated in 2002.
The art of Health care in India can be traced back nearly 3500 years. From the early days of Indian history the Ayurvedic tradition of medicine has been practiced. Public health system in India suffers from many problems which includes insufficient funding, shortage of facilities leading to overcrowding severe shortage of trained health personnel. There is also lack of accountability in the public health delivery mechanisms. Following are some major schemes and plans for tackling community health problems in India.
Kala‐azar is a serious public health problem endemic in Bihar and West‐Bengal. Kala‐azar control was being provided by the Government of India out of the National Malaria Eradication Programme (NMEP), until 1990‐91. The Centre provides insecticide, anti‐Kala‐azar drugs and technical guidance to the affected states.
During the Ninth Plan, the focus was on ensuring effective implementation of the programme so as to prevent outbreaks and eventually to control infection. DDT continued to be the mainstay for insecticide spray as the vector (phlebotomus argentites) is still susceptible to DDT.
National Anti‐Malaria Programme was implemented in 1958, which reduced the annual incidence of malaria to one lakh in 1965. Deaths due to malaria were completely eliminated. But resurgence of malaria necessitated review of vigorous anti‐malaria activities. The Modified Plan of, Operation (MPO) was implemented from April, 1977, which reduce the incidence of malaria to 1.66 million in 1987 from 6.47 million in 1976.
In view of the high incidence of malaria and resource, constraints in seven north‐eastern states, 100 per cent Central Government assistance was provided with effect from December, 1994. For effective control of malaria, the Enhanced Malaria Control Project was launched in September 1997, with World Bank assistance, under which 100 hard core and tribal predominant districts of Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Rajasthan and Orissa and 19 problematic towns of various states have been included.
It was launched in 1955 and it took up several activities including: (a) delimitation of the problem in hitherto unsurveyed areas and (b) control in urban areas through recurrent anti‐larval measures and anti parasite measures. At present about 49.87 million urban populations is protected by anti‐larval measures through 206 control units, 199 filaria clinics and 27 filaria survey units
Japanese Encephalitis (JE) has been reported in the country since mid‐fifties and caused by virus and spread by mosquitoes has a mortality ratio of 30 to 45 per cent. Due to development of irrigation projects and changing pattern of water resource management there has been a progressive increase in the number of states reporting cases of J.E. in India. The National Malaria Eradication Programme (NMEP) has been implementing, the recommendations of the Expert Committee on J.E. control. Under the Ninth Plan, Information, Education and Communication (IEC) activities to ensure community awareness and co‐operation, for prevention and control of vector borne diseases will be intensified.
Tuberculosis is a major health problem in India. Studies carried out by the Indian Council of
Medical Research (ICMR) in the fifties and sixties showed that:
· Unlike the situation in developed countries, BCG did not protect against adult TB and BCG given at/soon after birth provided some protection against TB in infancy and early childhood.
· Domiciliary treatment with anti TB drugs was safe and effective.
It was initiated in 1962 as a CSS, which aimed at earl) case detection in symptomatic patients reporting to the health system through sputum microscopy and X‐ray and effective domiciliary treatment with standard chemotherapy The short course chemotherapy introduced in selectee districts in 1983, has shortened the duration of treatment to nine months.
The Revised National Tuberculosis Programme (RNTCP) was launched in the country on March 1, 1997, and is proposed to be implemented in a phased manner in 102 districts of the country, covering a population of 271 million, with the assistance of World Bank.
Under; the Ninth Plan, the NTCP (National TB Control Programme will be strengthened in 203 Short Course Chemotherapy (SCC) districts as a transitional step to adopt the RNTCF Under the Ninth‐Plan, standard regime will be strengthened in the remaining non SCC districts and Central Institutions, State TB cells, and state TB Training Institutions throughout the country will be strengthened.
Dengue fever is a viral disease which is transmitted through the bites of female Aedes mosquitoes. There are four serotypes of Dengue virus which are prevalent in India since 1950. Dengue viral infection may remain a symptom attic/manifest itself either as undifferentiated febrile illness (Viral syndrome), Dengue fever (DF) or Denguhaemorrhaphic fever (DHF).
An outbreak of Dengue was reported in Delhi in 1996, when 10,252 cases and 42 deaths reported, and was also reported from U.P, Punjal Haryana, Tamil Nadu, and Karnataka. Formulation of a National Dengue Control Programme is under consideration of the Central Government.
During the Ninth‐Plan efforts was made to:
· Establish an organized system of surveillance and monitoring.
· Strengthen facilities for early diagnosis and prompt treatment.
· Intensify IEC efforts to ensure that all households implement pre‐domestic measures to reduce breeding of Aedes.
The National Leprosy Eradication Programme (NLEP) was launched in 1983 as hundred percent centrally sponsored schemes with the availability of Multi Drug Therapy (MDT). It became possible to cure leprosy cases within a short period (6‐24 months) of treatment. The NLEP programme was initially taken up in endemic districts and was extended to all over the country from 1994 with World Bank assistance. The first round of Modified Leprosy Elimination Campaign (MLEC) is to be implemented in all the states and UTs to create mass awareness.
It is estimated that there are 12.5 million economically blind persons in India. Of these over 80 per cent of blindness is due to cataract. The National Blindness Control Programme started in 1976 as 100 per cent centrally sponsored programme with the objective of providing comprehensive eye care services at primary, secondary and tertiary health care level and achieving substantial reduction in the prevalence of eye disease in general and blindness in particular.
The activities under the programme are yet to show an impact in reducing the prevalence of blindness to the goal level of 0.3 per cent by the year 2000 A.D. A major thrust was given under the Eight Plan to strengthen the programme in Jammu and Kashmir and Karnataka. Funds from domestic budget as well as EAP were provided for this. At the tertiary level of opthalmic care there are eleven regional institutes of ophthalmology including the apex institute, Dr. Rajendra Prasad Centre for Ophthalmic Sciences in the All India Institute of Medical Sciences, New Delhi.
The programme priorities during the Ninth‐Plan is to improve the quality of cataract surgery, clear the backlog of cataract cases, improve quality of case by skill upgradation of eye case personnel, improve service delivery through NGO and Public Sector collaboration and increase coverage of eye care delivery among underprivileged population. The targets set up under Ninth‐Plan are 17.5 million cataract operations and 100,000 corneal implants in between the period 1997‐2002.
Control of Sexually Transmitted Disease (STDs) was introduced as a national control programme by the Government of India during the Fourth Five Year Plan (1967). Since STD was one of the major determinants for transmission of HIV infection, the programme has been merged with National AIDS Control Programme (NACO). There is involvement of private practitioners in STD control through Indian Medical Association (IMA).
Realizing the gravity of the epidemiological nature of HIV infection, the Government of India launched a National AIDS Control Programme in 1987. In 1992, National AIDS Control Organization was established and a 5 year strategic plan was implemented with a US $ 84 million soft loan from the World Bank and another US $ 1.5 million in the form of technical assistance from the World Health Organization. Under the Chairmanship of Minister of Health and Family Welfare, National AIDS Committee has been constituted. The apex Government of India body for HIV surveillance is the National AIDS Control Organization (NACO). The majority of HIV surveillance data collected by the NACO is done through annual unlinked anonymous testing of parental clinic (or antenatal clinics) and sexually transmitted infection clinic attendees. Annual reports of HIV surveillance are freely available on NACO’s website. The government of India has also raised concerns about the role of intravenous drug use and prostitution in spreading AIDS, especially in north‐east India and certain urban pockets.
· National AIDS Control Programme in Five‐Yearly Plan:
I. More effective implementation of the Programme to ensure safety of blood/blood products.
II. Increasing the number of HIV testing network.
III. Augmenting STD, HIV/AIDS case facilities.
IV. Improving hospital infection control and waste management to reduce accidental infection.
V. Improving HIV/AIDS awareness, counseling and care.
VI. Strengthening Sentinel Surveillance. Components of NACP (Phase II)
VII. Reducing HIV transmission among poor and marginalized section of community at the highest risk of infection by targeted intervention, STD control and condom promotion;
VIII. Reducing the spread of HIV among the general population by reducing blood based transmission and promotion of IEC, voluntary testing and counseling;
IX. Developing capacity for community based low cost care for people living with AIDS;
X. Strengthening implementation capacity at the National, States and Municipal corporations levels through the establishment of appropriate organizational arrangements and increasing timely access to reliable information and
XI. Forging inter‐sectoral linkages between public, private and voluntary sectors.
Iodine Deficiency Disorders (IDD) has been recognized as a public health problem in India since mid‐twenties. IDD is not only a problem in sub‐Himalayan region but also in reverie and coastal areas. It is estimated that 61 million populations are suffering from endemic goitre and about 8.8 million people have mental/motor handicap due to iodine deficiency.
The National Goitre Control Programme was initiated in 1962 as a 100 per cent centrally funded, centre sector programme with the objective of conducting goitre survey, and supplying good quality iodized salt to areas having high IDD, health education and resurvey after five years. In 1985, the government decided to iodise the entire edible salt in the country by 1992 in a phased manner. To date the production of iodated salt is 42 lakh MT per annum. The NGCP was renamed and redesigned as National Iodine Deficiency Disorders Control Programme (NIDDCP) to emphasize the importance of all the IDDs.
During the Ninth‐Plan the major objective of the NIDDCP programme is,
· Production of adequate quantity of iodised salt of appropriate quality.
· Appropriate packaging at the site of production to prevent deterioration of quality of salt during transport and storage.
· Facilities for testing the quality of salt not only at production level but also at the retail outlets and household level so that consumers get and use good quality salt.
· IEC to ensure that people consume only good quality iodised salt.
· Survey of IDD and setting up of district level IDD monitoring laboratories for estimation of iodine content of salt and urinary iodine excretion.
National Surveillance Programme for Communicable Diseases which has potential of causing large outbreaks such as acute diarrheal diseases, viral hepatitis, dengue/DHF, Japanese encephalitis, leptospirosis and plague. The objective of the programme is capacity building at the district level for strengthening the disease surveillance system and appropriate response to outbreaks.
The National Mental Health Programme was started in 1982. The programme did not make much headway either in the Seventh or Eight Plan. The Mental Health Act (1987), which came into existence from April 1993, requires that each State/UT set up its own state level Mental Health Authority as a statutory obligation. Majority of the State/ UTs have complied with this and have formed a Mental Health Authority.
The Cancer Control Programme was initiated in 1975‐ 76 as 100 per cent centrally funded centre sector project. It was renamed as National Cancer Control Programme in 1985. The objectives of the programme are
I. Primary prevention of tobacco related cancers.
II. Secondary prevention of cancer cervix.
III. Extension and strengthening of treatment facilities on a national scale.
Iv. Intensification of IEC activities so that people seek care at the onset of symptoms.
v. Provisions of diagnostic facilities in primary and secondary case level so that cancers are detected at early stages when curative therapy can be administered.
vi. Filling up of the existing gaps in radiotherapy units in a phased manner so that all diagnosed cases do receive therapy without any delay as near to their residence as is feasible.
vii. IEC to reduce tobacco consumption and avoid life styles which could lead to increasing risk of cancers.
The National Diabetes Control Programme has included a pilot programme in Seventh Five Year Plan.
It was initiated in Tamilnadu and in one district in J and K.
In 1983‐84, India became the first country to launch an eradication programme against the disease, which had been causing great human suffering where safe drinking water is not available. The programme was implemented through existing primary health care infrastructure along with Ministry of Rural Development and the State public health engineering departments.
It can be cured and prevented by a single injection of long acting (benzathine benzyl) penicillin. Yaws is amenable to eradication. The pilot project to eradicate the disease in Koraput district was started in 1996‐97. The programme has been extended to districts in Madhya Pradesh, Andhra Pradesh, Maharastra and Gujarat in 1997‐98 and 1998‐99. The programme is proposed to be extended to all affected districts during the Ninth Plan for which Rs. 4 crore have been earmarked.
In a 2005 World Bank study, World Bank reported that “a detailed survey of the medical knowledge of medical practitioners for treating five common conditions in Delhi found that the average doctor in a community health care center has around a 50‐50 chance of recommending a harmful treatment”. Random visits by government inspector showed that 40% of public sector medical workers were not found at the workplace.
Medical Services are primarily provided by Central and State government, apart from Charitable, voluntary and private institution.