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Chapter 18:
HEALTH AND FAMILY PLANNING

Health

The broad objectives of the health programmes during 1961—69 have been to control and eradicate communicable diseases, to piovide curative and preventive health services in rural areas through the establishment of a primary health centre in each community development block and to augment the training programmes of medical and paramedical personnel. The programmes were formulated on the basis of the repoit of the Health Survey and Planning Committee of 1961. During the Fourth Plan, efforts will be made to provide an effective base for health services in rural areas by strengthening the primary health centres. These centres render preventive and curative health services, take over the maintenance phase of communicable diseases control programmes for malaria and small-pox and become the focal points for a nation-wide family planning pi ogramme. Sub divisional and district hospitals will be strengthened to serve as ref and rral centres for Primary Health Centres. The campaigns against communicable diseases will be intensified. Medical and nursing education and training of paramedical personnel will be expanded to meet the minimum technical man-power requirements.

18.2. The expenditure during the Third Plan and 1966—69 and the outlays foi the Fourth Plan are indicated in table 1. In table 2, details have been given of the allocations from the Fourth Plan outlay towards different programmes.

Table 1 Outlay on Public Health and Medical Programmes
(Rs. crores)

Table 2 Distribution of Outlays for the Fourth Plan

The annual non-plan expenditure on health programmes at the end of the Third Plan and on the eve of the Fourth Five Years Plan is estimated at Rs. 120 crores and Rs. 190 crorss respectively.

18.3. The programme of eradication of malaria was initiated in April 1958. It made satisfactory progress until 1963-64. After tnis there were set-backs owing to various causes—mainly adminisirative operational and technical. This has resulted in local out breaks in some consolidation and maintenance phase areas. As a result of these outbreaks 19.60 units in the maintenance phase and 51.78 units in the consolidation phase had to be reverted to attack phase. Out of 393.25 units, 209.88 units are in the maintenance phase at the beginning of the Fourth Five Year Plan. In the areas covered by units in the maintenance phase, the programme has been integrated with the regular health services. The remaining 183.37 units are still in the consolidation and attack phases. The National Malaria Eradication Programme which was scheduled to end in 1967-68 is now expected to be completed by 1975. To achieve this objective, steps would be taken to ensure adequate arid timely supply of insecticides and anti-malarials. Besides, laboratory facilities and supervisory staff will be augmented. By the end of the Fourth Plan there will be 30 units in the attack phase and 93.25 units in the consolidation phase.

18.4. The National Small-pox Eradication Programme was launched in 1962-63. It was a three-year programme. At the end of the three years, it was expected that the incidence of small-pox would be reduced to such an extent that it would be possible for the programme to be carried out as a normal feature of the general health services. This expectation was, however, not realised. While re-vaccinations of the easily accessible population were carried out, a large and susceptible population, particularly in the vulnerable age group of0—14 years and also the migratory and labour population, lemained unprotected. During the Fourth Plan it is proposed to strengthen the staff at the block and district levels to ensure primary vaccination of all new born children and to revaccinate vulnerable groups of population at intervals of three years. It is proposed to increase the production capacity of the freeze dried small-pox vaccine in four institutes so that the country may become self-sufficient during the Fourth Plan period.

18.5. As a result of the chemotherapy project in Madras it was discovered that domiciliary treatment for tuberculosis was as effective as institutional treatment. Therefore, the distiict tuberculosis control programme through domiciliary treatment, designed to reduce morbidity and mortality has been taken up as a national programme. By the beginning of the Fourth Plan, 502 clinics have been set up of which 195 are well-equipped. There are 15 training and demonstration centres, one in each State except in Assam, Haryana, Madhya Pradesh and Nagaland. There are three training and research institutes.

18.6. Under the National Leprosy Control Programme, 182 control units and 1136 survey, examination and treatment centres were established before the start ol' the Fourth Plan. Medical officers and para-medical personnel are also being trained at the Central Leprosy Teaching and Research Institute, Chingleput and Medical College, Nagpur. The Fourth Plan programmes for control of leprosy will cover both types of cases—those connected with early detection and treatment with drugs and those involving segregation and institutional treatment of highly infectious cases.

18.7. Rejection of a high percentage of candidates for the defence services on account of trachoma necessitated a country-wide survey of this diseases. The survey indicated wide-spread prevalence of trachoma in eleven States. The national trachoma control programme was accoridingly taken up in the Third Plan. It is proposed to provide eye ointment through the primary health centres in the rural areas where trachoma is endemic.

18.8. The control and ultimate eradication of cholera is dependent upon the provision of safe drinking water and proper disposal of sewage. Increasing financial provisions are being made in the successive Plans under national water supply and sanitation programmes. The outlays for the water supply programme are indicated in the following chapter. Under the health programme an outlay of Rs. 2.34 crores has been made for establishing mobile medical units and strengthening laboratory services in endemic districts for diagnosis, inoculation and control of cholera.

18.9. There were 57 medical colleges at the commencement of the Third Plan. To meet the increasing demand for doctors 30 new medical colleges w and re established during the Third Plan and six more during the following. three years bringing the total to 93 at the commencement of the Fourth Plan. The number of admissions in 1968-69 is about 11,500 as compared with, 10,500 at the end of the Third Plan. During the Fourth Plan, ten new medical colleges are likely to be opened increasing the annual admissions to about 13,000 by 1974. Greater attention will be paid^to improvements in existing colleges. The doctor population ratio has improved from 1 : 6100 in 1961 to 1 : 5150 in 1968 This is expected to improve further to 1 : 4300 by 1974

18.10. The rapid increase in the number of college and their intake capacity has added to the shortage of teachers. Increased emphasis will therefore be laid on post-graduate education. At present four post graduate institutes exist at Delhi, Pondicherry Calcutta and Chandigarh. It is proposed to strengthen them with equipment and staff. Progress r in the training programmes of para-medical personnel continues. About 34,000 nurses have been added in the last eight years, bringing the total stock to 61,000 by 1968-69. Their number by the end of the Fourth Plan is estimated to go up to 88,000.

18.11. The Indian Council of Medical Research is mainly responsible for guiding and financing medical research. In addition to the continuation of research of applied nature in the field of communicable diseases, nutrition, maternity and child health, the Council has initiated research in a wide variety of basic problems and applied investigations clinical medicine. Of late the Council has embarked on a large scale programme of research in the field of family planning and biology of reproduction. For the purpose of carrying out an integrated and simultaneous study of science of crude drugs and classification of the Indian medicinal plants, chemical and pharmacological properties and clinical usefulness, the Council is implementing the composite drug research projects in collaboration with the Centr?! Council of Ayurvedic Research. A pilot programme for evaluating the feasibility of vector control of mosquitoes using the genetic methods is being launched. Although the Council is an autonomous body, the Director-General does not erjoy the same powers as the Director-General of similar institutes like Indian Council of Agricultural Research and Council of Scientific and. Industrial Research. The Central Research Institute, Kasauli, undertakes research studies on cholera, typhoid, rabies, and allied subjects, in addition to produption of vaccines. The All India Institute of Hygiene and Public Health undertakes epidemiological research in communicable diseases in addition to training programmes. The National Institute of Communicable Diseases, Delhi, is concerned with research in Communicable Diseases with particular reference to microbiology, immunology and diseases of animal origin. The Vallabhai Patel Chest Institute. Delhi, undertakes research on allergy diseases also. During the Fourth Five Year Plan an outlay of Rs. 22 crores. has been earmarked for medical research, which includes Rs. 11 crores for the Indian Council of Medical Research, Rs. 2 crores for research under Indigenous Systems of Medicine, Rs. 2 crores for research institutes and Rs. 7 crores for family planning research.

18.12. During the last eight years, 70,100 general beds in Government institutions have been added, bringing the total to 255,700. The target of establishing 54,000 beds during the Third Plan was achieved. The pace of adding new beds slowed down during the subsequent years. During 1969—74 it is intended to add 25,900 beds. Emphasis will be placed on better health care facilities at sub-divisional and district hospitals by provision of specialist's services.

18.13. The: Primary Health Centres form the base of the integrated structure of medical services in the rural areas. By the end of the Third Plan it was intended to establish one Primary Health Centre each in Community Development Blocks. By March 1966, 4631 Centres were set up. During the three subsequent years, 288 primary health centres were established so that at the beginning of the Fourth Five Year Plan 4919 primary health centres are functioning, 261 Community Development Blocks having more than one primary health centre, 4397 having one centre and 340 Blocks having no centre. At the beginning of the Fourth; Plan, about 50% of the primary health centres haw hospital buildings and only 25% residential quarters. Suitable buildings for accommodating primary health centres, sub-centres and staff are not easily available in rural areas. The lack of buildings is one of the main obstacles in posting doctors and nurses in rural areas. In the Fourth Five Year Plan, emphasis will be on the establishment of an effective machinery for the speedy construction of buildings and im^ roving of primary health centres by providing staff, dngs and equipment. It is also proposed during tlie Fourfh Plan to establish 508 primary health centres covering 340 blocks which do not yet have a centre so that there is at least one primary health centre in each block.

18.14. The primary health centres located in the malaria maintenance phase areas will be sirens'.hened with additional staff to take up the vigilance activities in the maintenance phase of the programmes for the eradication of communicable diseases. Such an approach involving as it does the integration of heaLh and medical care, will ensure optimum use of resources and manpower and prevent duplication and wasteful expenditure on the programmes. There is enthusiasm among the public for participation in health schemes. In order to create a sense of partnership with C: overn-ment efforts, voluntary contributions should be encouraged.

18.15. Programmes relating to indigenous systems of medicine which were started in the Third Plan will continue. These pertain to education and r'search compilation of Ayurvedic and Unani pharmacopoeia estabiihment of a central medicinal plant garden at Poona and surveys of medicinal plants.

Family Planning

18.16. Family Planning finds its place in tlie Plan as a programme of the highest priority. Its crucial importance is reflected in the widespread public interest that has been aroused no less than in the magnitude of the effort, organisation and finance which Government is devoting to the programme.

18.17. The estimated population in 1968 (on October 1) was 527 million. The increase in population from 365 million in 1951 to 445 million in 1961 and 527 million in 1968 has been the result of a sharp fall in mortality rate without any significant changs in the fertility rate. The birth rate appears to have remained unchanged around 41 per thousand population during the greater part of the past two decades up to 1965-66. Recent surveys carried out by the Register General and the National Sample Survey Organisation appear to indicate that the birth rate has come down to 39 per thousand population for the country as a whole, the rate being somewhat higher in rural areas. The population growth rate is estimated to be 2.5 per cent per annum. In order to make economic development yield tangible benefits for the ordinary people, it is necessary tliat the birth rate be brought down substantially as early as possible. It is proposed to aim at its reduction from 39 per thousand to 25 per thousand population within the next 10—12 yeais. In order to achieve this, a concrete programme has been drawn up for creating facilities for the married popuation during their reproductives period by bringing about (i) group acceptance of the small sized family, (ii) personal knowledge about family planning methods; and (iii) ready availability of supplies and services.

18.18. A provision of Rs. 27 crores was made in the Third Plan. The expenditure incurred was Rs. 24.86 crores. During this period, family planning bureaux •were organised at the State level and in 199 districts covering all States. At the end of the Third Plan, there were 3676 rural family welfare planning centres, 7081 rural sub-centres and 1381 urban family welfare planning ce itres. These centres provide supplies services and advice on family planning Twentyeight centres were esf ablished for training in which 7641 personnel took regular courses and 34484 short-term courses. Some progress was made in research, conducted in seven demographic centres and seven communication action research centres. Eight centres conduct studies on bio-me'clica aspects of family planning. For technical support, a Central Family Planning Institute was established at Delhi.

18.19. At the end of the Third Pian. the Indian Council of Medical Research approved mass utilisation of tin¹ intra-uterine contraceptive device commonly known as ihe loop. Equal emphasis was placed on the sterilisation, the condom and the intra-uterine contraceptive device (IUCD). The initial response for the loop was encouraging. During the last year of the Plan, 0.8 million IUCD insertions were made. A factory for producing IUCD was established at Kanpur. It has a daily production capacity of 30,009 loops, sufficient to take care of the country's needs. The number of sterilisation operations performed in the Third Plan period was 1.33 million.

18.20. Since April 1966 a separate Department of Family Planning has been constituted at the Centre. It co-ordinates family planning programmes at the Centre and in the States.

18.21. The facilities for IUCD insertions and sterilisations were provided not only free but 'also with some compensation to the individuals for out-of-pocket expenses, conveyance and loss of wages. These are available at static centres and mobile units. A central family planning corps was created to deploy female doctors in areas where there was a shortage. Of the conventional contraceptives, condoms constitute the most important item. A public sector factory at Trivandrum has been set up with an initial capacity for producing 144 million pieces per annum and doubling and quadrupling the production v/hen necessary.

18.22. Family Planning programming cells were located in 22 All India Radio Stations. Thirty audiovisual units were provided under the Directorate of Field Publicity for carrying on intensive campaign in selected districts. The mass education programme through films, exhibitions, wall paintings and hoardings was intensified.

18.23. During 1967-68, the number of voluntary sterilisations exceeded 1.8 million. This is more than double the earlier best performance of 0.8 million during 1966-67 and exceeded the target of 1.5 million for the year During 1968-69, 1.65 milliod sterilisations were performed. The loop programme registered about 0.47 million insertions during 1968-69 as against 0.67 million in 1967-68. The temporary set-back is the result of reported side effects like bl eeding and pain. The machinery for proper pre-insertion education and check-up and post-insertion follow-up has been strengthened.

18.24. On the eve of the Fourth Plan, five Central Institutes and 43 State Family Planning Training Centres are functioning. There are 4326 rural family welfare planning centres, 22826 rural sub-centres and 1797 urban family welfare planning centres in operation. The progress in opening sub-centres has been unsatisfactory. This is due to shortage of auxiliary nurse-mid-wives and want of suitable accommodation for female workers in the rural'areas. At the beginning of the Fourth Plan, 450 Family Planning annexes to Primary Health Centres have been cosntructed (90 completed and 360 in progress) and buildings of 2770 sub-centres have been taken up (1280 completed and 1490 in progress).

Table 3 Review of Progress and Targets

'Outlay

18.25. Family Planning will remain a Centrally sponsored programme for the next ten years and the entire expenditure will be met by the Central Government. It will be ensured that performance does not lag behind with expenditure. The effort will be to achieve enduring results through appropriate education and motivation. General health services will be fully involved in the programme.

18.26. The Draft Plan outlay of Rs. 300 corres has been revised upwards to Rs. 315 crores so that the programmes can be strengthened and speeded up. The organisation of services and supplies by rural and urban centres and the compensation for sterilisation and IUCD will involve an expenditure of Rs. 269 crores. Efficiency in these services can be ensured only with a minimum network of centres and sub-centres all over the country and with more intensive attention to hospitals with a large number of maternity cases and to populous districts. Rs. 46 crores will be spent on training, research, motivation, organisation and evaluation.

18.27. Keeping in view the aim to reduce the birth rate to about 32 per thousand population by 1973-74 from the present 39, it is proposed to step up the target of sterilisation and IUCD insertions and to widen the acceptance of oral and injectible contraceptives. The use of conventional contraceptives will also be stepped up so as to cover 3.24 million persons in 1969-70 and 10 million persons by 1973-74. As a result of these measures, 28 million couples are likely to be protected by 1973-74. The births expected to be prevented will aggregate to 18 million for the Plan period.

18.28. After carrying out studies on pilot projects, the Indian Council of Medical Research is of the opinion that the oral pills could be prescribed by medical practitioners for use after proper medical check up and under their supervision. As a result of this recommendation, the oral pills were introduced in the family planning programme in August 1967 as a pilot project. The results of the pilot projects have been analysed and a depth study is under way. The pill programme will be • expanded both in urban and rural areas in a phased manner depending on experience gained during the expansion of the programme.

18.29. Surgical equipment will be provided in all rural and urban family welfare planning centres (nearly 7000 in number) for vasectomy operations. The efforts of these centres will be supplemented by more than 1000 mobile service units attached to district family planning bureaux. Salpingectomy is becoming popular and it is estimated that 25% of all sterilisations wil) be performed on women. To supplement the effort of hospital authorities in using general beds for salpingectomy, 3300 beds will be provided for this purpose. For intensifying, the family planning programme, some new schemes like post-partum programme, supply of surgical equipments to hospitals, intensive districts and selected area programmes, supply of vehicles at all primary health centres and strengthening of Central and State Health transport organisations have been included for implimentation during the Fourth Plan.

18.30 In addition to the present system of free distribution of conventional contracepvies through family welfare planing centres and voluntary workers (depot holders), a massive programme of distribution of condoms (Nirodh) through 600,000 commercial retail outlets will be developed and sold to consumers at 15 paise for a packet of three condoms. It is estimated that 1200 million pieces will be indigenously manufactured.

18.31. Mass education activities will be strengthened in rural areas and small towns. Traditional and cultural media like song, drama and folk entertainment will be effectively used. Extension education will be strengthened and population education v/ill be introduced. The strategy will be to bridge the gap between knowledge and adoption of family planning by couples in reproductive age-groups.

18.32. Arrangements will be made for training 10,000 medical and 150,000 para-medical personnel. In the research programmes, emphasis will be laid on the bio-medical aspect. New centres for reproductive biology and human reproduction will be established and orien-tation-cww-training courses in these subjects for teachers of medical colleges will be arranged. Demographic and communication studies will be used for efficient implementation of the programme. Its cost under various conditions will be analysed. Fertility surveys combined with KAP studies (knowledge, attitude and practice) will be carried out to evaluate the ultimate and interen-mediate objectives of the programme.

18.33. The programme of family planning is likely to be more effective and acceptable if mater lity "and child health services are integrated with family planning. This has now been done. The scheme of immunisation of infants and pre-school children with DPT, immunisation of expectant mothers against tetanus, prophylaxis a.sainst nutritional anaemia for mothers and children and nutritional programme for control of blindness caused by Vitamin 'A' deficiency among children will bs implemented through family welfare planning centres. Family planning will be effectively integrated with the .general health sei vices of primary health centres and sub-centres.

ANNEXURE I Health : Selected Achievement and Targets
(numbers)

1 In practice.

ANNEXURE II Health Programmes : Level of Achievement at the beginning of Fourth Plan