Foreword || Preface || Planning Commission
Chapter 1 || 2 || 3 || 4 || 5 || 6 || 7 || 8 || 9 || 10 || 11 || 12 || 13 || 14 || 15 || 16 || 17 || 18 || 19 || 20 || 21 || 22 || 23 || 24 || 25 || 26 ||
27 || 28 || Appendix

Chapter 22:
HEALTH, FAMILY PLANNING AND NUTRITION

Sustained efforts towards promotion of health care services during the last 30 years have resulted in significant improvement in the health status of the country. The mortality rate has declined from 27.4 in 1941—51 to an estimated 14.2 in 1978. The life expectancy at birth has gone up from about 32 years as per 1951 Census to about 52 years during 1976—81. The infant mortality rate has come down from 146 during the fifties to 129 in 1976. The health infrastructure has been strengthened. The country has about 50,000 sub-centres, 5,400 primary health centres including 340 upgraded primary health centres with 30 bedded hospital, 106 medical colleges with admission capacity of 11,000 per annum and about 5 lakh hospital beds. The per capita expenditure on health incurred by the State has fgone up from about Rs. 1.50 in 1955-56 to about Rs. 12 in 1976-77. The doctor population ratio though satisfactory on an average in the country (1977), varies widely from 1 doctor for 8333 in Meghalaya to 1 doctor for 1400 in Delhi. The bed population ratio has also improved but varies widely in urban and rural areas.

22.2 The country was declared free from smallpox in April, 1977. The National Malaria Eradication Programme initiated in 1958 had brought down the incidence of the disease to about 1 lakh cases with no deaths in 1965 although there has been a slippage in the subsequent years. The National Programme for Control of Leprosy, Tuberculosis, Filaria and Blindness have also helped to reduce mortality|morbidity.

22.3 National Programmes have also been initiated for promotion of maternity and child care such as immunization of expectant mothers against Tetanus and children against Tetanus, Whooping Cough, Diphtheria. Tuberculosis, Polio etc., besides prophylaxis against Vitamin 'A' and iron deficiencies. Programmes of improving the nutrition of mothers and children have also been taken up.

22.4 Tn the field of curative services some of the State Hospitals have built m specialised sophisticated service's comn'arable with facilities available in some of the advanced countries for cardiac diseases, cancer and neurological, nephrological disorders.

HEALTH

Review

22.5 The programmes initiated in the earlier plans for control/eradication of major communicable diseases and for providing curative, preventive and promotive health services backed by training of adequate number of medical and para-medical personnel were strengthened further m the Fifth Plan, and in the subsequent annual plans. Provision of minimum health services in the rural areas was integrated with family planning and nutrition for vulnerable groups of population-children, pregnant women and lactating mothers. The programmes were aimed ai:—

1. Increasing the accessibility of health services to rural areas.
2. Correcting regional imbalances.
3. Further development of referral services by removal of deficiencies in District/Sub-divisional hopitals;
4. Intensification of the control/eradication of communicable diseases especially Malaria and Smallpox;
5. Qualitative improvement in the education and training of health personnel; and

6. Development of referral services by providing specialist attention to common diseases in rural areas.

22.6 The Minimum Needs Programme was the main instrument through which health infrastructure in the rural areas was expanded and further strengthened to ensure primary health care to the rural population. The outlays earmarked for this programme were considered almost a prior charge on the Plan budget for medical and public health of the States. The facilities available in selected rural dispensaries were expanded to provide preventive and promotive health care facilities by adding the necessary health components. These functioned as subsidiary health centres. The following table shows Ihe number of sub-centres, primary health centres and upgraded primary health centre's with a 30 bcdded hospital set up by 31st March, 1980 vis-a-vis targets set for 1974—79 Plan:—

Table 22.1 (Nos.)

22.7 The programme of conversion of health workers serving in vertical public health programmes like malaria control. TB control, smallpox etc., into multipurpose health workers through reorientation training was assigned a high priority. This programme initiated in about 183 districts out of 400 districts in the country was completed by 31st March, 1980.

22.8 In accordance with the recommendations ol the Study Group on Medical Education and Support Manpower, (1975) two Centrally Sponsored Schemes viz., (i) Community Health Volunteers and (ii) Re-orientation of Medical Education were initiated in 1977. The community health volunteers programme initiated in October 1977 had the objective of providing a trained community health volunteer selected by the community itself for every village or a population of 1000. Under the scheme of re-orientation of Medical Education, each medical college in the country was to adopt 3 primary health centres in the first phase with the twin objectives of providing a rural bias to medical education and also curative health care and referral facilities to the rural population covered.

22.9 In spite of several significant achievements, the health care system obtaining in the country suffers from some weaknesses and deficiencies. There has been pre-occupation with the promotion of curative and clinical services through city based hospitals which have by and large catered to certain sections of the urban population. The infra-structure of sub-centres, primary health centres and rural hospitals built up in the rural areas touches only a fraction of the rural population. The concept of health in its totality with preventive and promotive health care services in addition to the curative, is still to be made operational. Doctors and para-mcdi:als arc reluctant to serve in the rural areas. They arc generally city oriented and their training is not adequately adapted, to the needs of the rural areas particularly in the field of preventive and promotive

health. There has been over dependence on the States for health care measures and voluntary and local clfort has not been able to take up responsibility in any significant measure. The involvement of the people in solving their health problems has been almost non-existent.

22.10 The incidence of malaria has shown an upward trend since 1965. There have also been reported cases of malaria caused by Plasmodium faliciparum parasite accounting for some deaths. This type of malaria is also spreading from the North Eastern region where it originally occured to other Stales. Resistance of this parasite to specific drugs has been reported. The vector mosquitos have also developed resistance to DDT and BHC in certain areas of Gujarat and Maharashtra. There nas been incidence of Japanese Encephalitis in certain pockets.

22.11 Of an estimated 3.2 million leprosy patients in the country, 20 per cent are infectious and another 20 per cent suffer from various deformities. Curative and rehabilitative services for these are necessary.

22.12 Nearly 2 per cent of the total population in the country is estimated to suffer from radiologically active lesion of which 25 per cent are sputum positive and infectious cases. The control measures adopted under the T.B. control programme do not appear to have made any appreciable dent on the dimensions of the problem and the incidence of TB continues to be high.

22.13 According to the survey conducted by the Indian Council of Medical Research, out of an estimated 9 million blind persons in the country, about 5 million could be cured by proper surgical interference. In addition, 45 million persons were reported to be otherwise visually impaired. It was also observed that the existing backlog of 5 million cataract cases was likely to go up by another millioa new cases every year.

22.14 Maternal and infant mortality rates are still on a higher plateau compared to advanced and some developing countries. The decline in the sex ratio (females per 1000 males) from 946 in 1951 to 930 in 1971 indicates the need for greater attention to maternal and child health care. There are also considerable inter-State and regional disparties in health and medical care standards. The general position of the Scheduled Castes/ Scheduled Tribes and other backward classes is comparatively more unsatisfactory.

Policies and Strategy of Health Care Programme

22.15 An investment on health is investment on man and on improving the quality of his life. It is, therefore, well recognised that health has to be viewed in its totality, as a part of the strategy of human resources development. Horizontal and vertical

linkages have to be established among all the interrelated programmes like protected water supply, environmental sanitation and hygiene, nutrition, education, family planning and maternity and child welfare. Only with such linkages can the benefits of various programmes be optimised. An attack on the problem of diseases cannot bs entirely successful unless it is accompanied by an attack on poverty itseli which is the main cause of it. For this reason the Sixth Plan assigns a high priority to programmes ot promotion uf gainful employment, eradication a poverty, population control and meeting the basic human needs as integral components of the Human Resources Development Programme.

22.16 The country has adopted the policy oi 'Health for all by 2000 AD' enunciated in Alma Ata Declaration in 1977. Alongwith this the long term objective of population stabilisation by reducing Net Reproduction Rate (NRR) to 1 by 1995 is to be achieved. The health care system in the country has to be restructured and re-oriented towards these policy objectives. The strategy to be followed over a period of 20 years upto 2000 AD, based on the recommendation of the Working Group un Health, will be as follows:

1. Emphasis would be shifted from development of city based curative service's and super-specialities to tackling rural health problems. A rural health care system baseu on a combination of preventive, promouve and curative health care services would be built up starting from the village as the base.
2. The infra-structure for rural health care would consist of primary health centres each serving a population of 30,000 and sub-centres each serving a population of 5,000. These norms would be relaxed in hilly and tribal areas. The village or a population of 1000 would form the base unit where there will be a trained health volunteer chosen by the community.
3. Facilities for treatment in basic specialities would be provided at community health centres at the block level for a population of 1 lakh with a 30 bedded hospital attached and a system of referral of cases from the community health centre to the district hospital/medical college hospita's will be introduced.
4. Various programmes under education. v/ater supply and sanitation, control of communicable diseases, family planning, maternal and child health care, nutrition and school health implemented by different departments/agencies would be properly coordinated for optimal results.
5. Adequate medical and para-medical manpower would be trained for meeting the requirements of a programme of this order and all education and training programmes will be given suitable orientation towards rural health care.
6. The people would be involved in tackling theii health problems and community participation in the health programmes would be encouraged. They would be entitled to supervise and manage their own health programmes eventually.

The crucial indicators as at present and those desirable by 2000 AD are shown below:—

Table 22.2

In substance, a reduction of 5.2 points in the death rate and 12.3 points in the birth rate by 2000 AU would be the target for achievement. The rate of infant mortality is also to be reduced by more than 50 per cent and life expectancy raised to 64 years.

22.17 The expanded immunization programme and tile programme of prophylaxis against iron and Vitamin 'A' deficiencies would be strengthened. The targets envisaged for Sixth Plan are indicated in AnneKurc 22.6. All the national public healtM schemes like Malaria control, Leprosy control, TB control etc., would be monitored towards the specific goal of adequate health care for all envisaged for the period 1980—2000 AD.

Rural Health Programme

22.18 The mimiWHB needs programme in the State Sector woald contimie to be the mam. instrument for development of the rural health care delivery system. It will be supplemented by Centrally Sponsored Programme for training of medical and paramedical workers.

22.19 Minimum Needs Programme: Primary health centres at the rate of one for each community development block had been established by the end of Fifth Plan. It was also proposed to have one sub-centre for 10,000 population and upgrade one out of every four selected primary health centres to a 30 bedded rural hospital to serve as a first link in the chain of referral services. Full coverage of the backlog of primary health centres and sub-centres buildings were also contemplated in the Fifth Plan. Although the progress of setting up of primary health centres has been satisfactory, many of them are not having necessary buildings and other facilities. The sub-centre programme has been proceeding very slow. These programmes would, therefore, be accelerated over the successive plan periods to achieve by 2000 AD the objective of establishing one primary health centre for every 30,000 population or 20,000 in tribal and hilly areas and one sub-centre for every 5,000 population. As against the earlier policy of setting up a 30 bedded rural hospital by upgrading one out of 4 primary health centres, a community health centre will be established for a coverage of 1 lakh population with 30 beds and specialised medical care services in gynaecology, paediatrics, surgery and medicine,

22.20 Keeping in view the training capacity of ANMs and other para-medicals and the constraint of financial resources, it is proposed to establish 40,000 additional sub-centres during 1980—85 Plan raising the number of centres to an estimated 90,000 against the total requirement of about 1,22,000 centres i.e.. 74 per cent coverage on the basis of Mid 1984 estimated population. 600 additional primary health centres will be set up in areas where mostly the existing primary health centres cater to a relatively larger population on present norms. Out of these, over 100 primary health centres are expected to be located in tribal and hill areas. In addition, 1000 out of the existing rural dispensaries will be converted into subsidiary health centres to accelerate the promotion of promotive and preventive health care facilities. These will be eventually converted into primary health centres. There will thus be 6000 primary health centres and 2000 subsidiary health centres (1000 existing+1000 new proposed) by 1984-85 against the total requirement of about 18,560 centres. Coverage of backlog construction works of sub-centres, primary health centres buildings and staff quarters, besides construction works of new units to the extent possible within the available resources will be aimed at during the Plan period. 174 primary health centres will be upsraded to Community Health Centres with 30 bedded hospital in addition to completion of construction works of up-eraded primary health centres already taken up. These will be converted into community health centres, emphasising the public health aspects.

22.21 Centrally Sponsored Schemes: The minimum needs programme will be supported bv the Centrally Sponsored Schemes of Community Health Volunteers, Employment and Training of Multi-purpose Workers and Re-orientation of Medical Education which are all continuing schemes.

22.22 The community health volunteers scheme is yet to be evaluated fully, although two quick evaluations have been made. There are about 1.40 lakh community health volunteers in field as on 1st April, 1980. It is proposed to extend the programme further during the 1980—85 Plan to add another estimated 2.20 lakh community health volunteers raising the total number to 3.60 lakhs by 1985, with a view to cover the whole country. The States of Jammu and Kashmir, Kerala, Tamil Nadu and the Union Territories of Arunachal Pradesh and Lakshadweep Islands are implementing alternative schemes of health care at the grass roots level. An in-depth evaluation of the Centrally Sponsored Community Health Volunteers Scheme as well as these alternative schemes will be made to develop, if necessary, a modified scheme to promote health consciousness among the rural people and provide a link between them and the primary health centres.

Training of Multi-purpose workers is expected to be completed by 1983.

22.23 The Re-orientation of Medical Education Scheme was initiated with the twin objective of providing curative health care facilities to the rural people and giving a rural bias to medical education. The 106 medical colleges in the country were provided each with three mobile clinics obtained from the UK Government for the purpose. The scheme provides lor one-time assistance to the medical colleges for meeting a part of the recurring and non- recurring costs, the State Governments meeting the required additional non-recurring and recurring costs. The scheme will be continued in the Plan and each medical College would cover a whole district in due course.

22.24 Schemes to train public health and paramedical workers will be taken up in the Plan since at present there is dearth of trained workers in various fields and the present training courses and curricula are also not standardised in some cases. The requirements of various categories of personnel would be identified and training programmes mounted for the required number. Full advantage would be taken of the 10+2 system and para-medical courses would be introduced in that system to the extent possible.

Control of Communicable Diseases

22.25 Next to rural health, the control of communicable diseases will be given priority.

22.26 Diseases like TB, Gastro-intestinal infections, malaria, filaria, infectious hepatitis, rabbies and hook worm are inter-related to evnironment.

They accounted for 17.2 per cent of morbidity and 20.8 per cent of mortality in 1970. Other preventable diseases like diphtheria, whooping cough, polio and tetanus accounted for 1.0 per cent of morbidity and 0.4 per cent of mortality. Improvement of environmental sanitation and expanded immunization programmes coupled with improved preventive and promotive facilities through the network of hospitals, community health centres and sub-centres would be the main strategy for control/eradication of the communicable diseases,

22.27 The ongoing programmes of control/eradication of communicable diseases like malaria, filaria, leprosy, TB would be further intensified and fully integrated with other health care programmes to ensure effective reach of these services through a net-work of multi-purpose health workers under the supervision of medical officers at the primary health centres. Efforts would also be made for involvement and participation of the community in the programmes. Research and training components of these programmes would be stepped up towards the objective of developing more effective alternate approaches to control of these diseases.

22.28 The details of the programmes are briefly indicated below:—

fi) Malaria: Keeping in view the current status of malaria as discussed earlier, the modified operational plan of control initiated in 1977 will be implemented vigorously. The salient features of the Plan are:—

• Re-organisation of malaria units to conform to geographical boundaries of the district for better supervision bv the Chief Medical Officer of the District entrusted with the responsibility to implement the programme:
• Linking residual insecticidal spray with incidence by continuing spraying in areas with an annual parasite index (API) of 2 or more per 1000 population;
• Full surveillance Including focal spraying i'n areas with an API less than 2:
• Priority attention to P. falciparum infection;
• Assured supply of required quantity of anti-malarial drugs through community health voiunteers, sub-ceatres, primary health centres, panchavat agencies, school teachers etc.
• Multi-media publicity to arouse public awareness and participation; and
• A step up in research effort both in the laboratory and field.

A large allocation of over Rs. 400 crores has been made in the Plan for control of malaria. Research on immunological and therapeutical aspects of Japanese Encephalitis and P. falciparum infection would be intensified.

(ii) Filaria Control: Experimental studies have been initiated in the selected pockets of the country for evolving an effective strategy to control the disease in rural areas. These studies will be further intensified so as to evolve a suitable strategy by 1985 to protect the rural population susceptible to Bancroft! filariasis. Filaria and malaria control measures would be integrated into a composite programme for maximum utilisation of available resources and effective implementation in urban areas.

(iii) Leprosy: The leprosy control programme will be intensified in the Plan towards the objective of its eradication as early as possible. The programme will be directed towards the following objectives:

1. To cover the entire endemic population of the country to the extent of 90 per cent by 1985 and 100 per cent by 1990 with a corresponding step up in disease arrested cases from present level of 20 per cent to 40 per cent. in 1985 and 60 per cent in 1990.
2. To introduce newer drugs, multi-drug therapy and specially supervised treatment of infectious cases and epidemiolog'cal surveillance by a network of early detection measures.
3. To provide medico-surgical facilities to leprosy patients for rehabilitation through reconstructive surgery, physiotherapy, occupational therapy, jobs and tools adoption etc.
4. To improve and extend training facilities in leprosy through training centres. Regional Leprosy Training-cum-Referral Institutes and workshops.
5. Encourage the participation of voluntary agencies through financial support. Public education and mass publicity will be stepped up to remove the social stigma attached to the disease.

(iv) Control of Visual Impairment and Blindness:

Among the major causes responsible for visual impairment and blindne'ss, cataract accounts for 55-58 percent followed by trachoma and other eye infections 20-22 per cent. The balance is due to injuries, malnutrition and other causes. Under the Centrally Sponsored Scheme, Ophthalmic treatment facilities in primary health centres, rural hospitals and District hospitals will be improved. Provision will be made for mobile units and strengthening of ophthalmic departments in selected medical colleges and regional ophthalmic institutes. Comprehensive eye health care facilities throueh the strengthened infrastructure should help reduce blindness in the country from the present 1.4 per cent to about 1 per cent by 1985.

(v) Control of ofhpr diseases: Measures for control and prevention of TB and Cholera, and maintenance

of zero incidence of small-pox would be continued. The Centrally Sponsored Scheme concerning Sexually Transmitted Diseases programme will be integrated with general health care faculties provided through the State Plans with etfect from 1961-82. Goitre is •one of the deficiency diseases which will be tackled in the identified endemic pockets. Attention will be paid to vector borne diseases which are gaining in importance in the areas covered by major irrigation projects.

Hospitals and Dispensaries

22.29 Except in the national capital and selected centres like Chandigarh and Pondicherry, E.S.I. and Central Government Health Service Scheme, hospitals and dispensaries are under the control ot the State Governments/Union Territory Administrations. The facilities in the hospitals of the medical colleges/ district levels have in the past been improved and upgraded systematically to cater to the requirements of curative services, in selected hospitals and institutions, super-speciaiities have also been set up. These facilities are expected to provide curative facilities to the rural population on an increasing scale under the scheme or referral services. Further development of these hospitals would be with reference to felt needs of the region. Measures will be taken for efficient management of the hospitals through consolidation of existing facilities and proper maintenance of equipment and establishment of convalescent homes, poly-clinics and Dharamshalas in the vicinity of hospitals to help reduce pressure on hospital beds would be encouraged.

22.30 Super-specialities will be developed only to the limited extent necessary to meet the regional requirements and to fill in critical gaps.

22.31 The rural dispensaries set up by the State Governments will be gradually oriented towards total health care instead of providing curative facilities only. A good number of them are being converted into subsidiary health centres in the Sixth Plan as already discussed under the minimum needs programme.

Medical Education

22.32 Under-graduate Medical Education: From the 106 medical colleges existing at present in the country, an estimated 11,000 doctors pass out every year. In view of the increasing unemployment of medical graduates and also the imbalance in the ratio of doctors to para-medica;; workers, the policy of the Government is not to increase the number of medical colleges or the intake capacity. The emphasis would be on bringing about qualitative improvement in medical education and training. Despite the high yearly outturn of medical graduates and growing unemployment among them, in several States there are no doctors available to serve in the rural primary health centres/hospitals. This phenomenon can be explained only by the fact that many of the young medical graduates, by their background, training and career ambitions find themselves out of place in a rural set up.

22.33 It will, therefore, be necessary in the years ahead to reonent medical education 10 meet the requirements of rural areas, 'the Centrally Sponsored Scheme of Re-orientation of Medical Education would be continued and the present deficiencies noted in the implementation of the schemes set right, the Medical Council of India has also prescribed service in rural medical institutions for six months as part of the compulsory internship. In addition, reforms in other directions like modification of the curriculum, training of medical under-graduates in cerain fields relevant to the problems of rural health care, community orientation etc., would be necessary. These would be given adequate attention in the Sixth Plan.

22.34 Besides providing incentives to government doctors to serve in rural areas, it would also be necessary to encourage private practitioners to settle in tlie rural areas so that their services could supplement the efforts of Government in the field of rural health. This would also correct the situation where almost every medical graduate, who comes out, looks up to Government to provide him with a job. In fact, it is precisely this situation that has contributed to growing unemployment amongst doctors in some States and not lack of opportunities for service. The nationalised banks have already a scheme for providing financial assistance to professionally qualified people for self-employment including doctors. Elforts v/ould be made to ensure that adequate number of medical graduates are enabled to avail of this assistance. The Government of Andhra Pradesh have initiated a scheme under which some allowance is provided to medical practitioners who settle down in a village where there is no doctor and provide part-time service at the nearest sub-centre. The Tamil Nadu Government have taken up the Mini-health Centre Scheme under which financial assistance is provided to voluntary organisations which provides medical care facilities at the village level through doctors employed on part-time basis. Based on the experience gained from such schemes, suitable steps can be taken to promote the settling of doctors in rural areas.

22.35 Post-Graduate Education: Post-graduate Medical Education would be rationalised to effect a balance between the national requirements of specialities and advanced opportunities for medical graduates.

22.36 The National Academy of Medical Sciences will be strengthened and assisted to fulfil the objective of improving the quality of post-graduate level medical education.

22.37 Improvement of Skills: Continuing education and inservice training facilities will be promoted to help updating the knowledge of service doctors, improve the skills of teaching doctors and familiarise them with modern advances in medical sciences.

22.38 Improvement of facilities: Deficiencies in terms of equipment, "teaching beds", buildings, laboratory staff etc., in the existing medical college hospitals would be assessed and steps taken to overcome these deficiencies under a phased programme within the available resources.

Medical Research

22.39 The current health status of the country discussed earlier calls for vigorous research efforts in several problem areas. Research on Bio-medical and public health problems, particularly communicable diseases call for a high priority. There are also areas such as economic aspects of health administration and management, contraceptive methods and family planning which need attention.

22.40 Task oriented research programmes in the following fields would be initiated towards the above objectives:

1. Promotion of research on epidemiological, microbiological and immunological approaches towards control of communicable dis-seases accounting for major causes of morbidity and mortality.
2. Research in curative practices like rehydra-tion towards the control of diarrhoeal diseases especially among children.
3. Research in the field of nutrition, metabolic problems, food production, processing, preservation and distribution.
4. Research in the field of drugs for various non-communicabJe diseases, Keeping in view the aspects of quality, safety, toxic effects etc.
5. Close and continuous studies in the area of information support, manpower development, appropriate technology, management and community mvolvemem. to ensure the reach of benefits of primary health care programmes to the rural population.

22.41 Besides the Indian Council of Medical Research which would play a pivotal and coordinating role in medical research, otner institutions such as the All India Institute of Medical Sciences, New Delhi; Post-Graduate Institute, Chandigarh; National Institute of Communicable Diseases, Delhi; A.I.I.H. and P.H. Calcutta; JIPMER, Pondicherry under the control of the Health Ministry would also continue to be engaged in relevant research work. Adequate funds for research have been earmarked for the activities of the Indian Council of Medical Research and other institutions under the control of the Health Ministry.

22.42 Cancer research and treatment facilities will continue to be developed through a net-work of early detection centres, cobalt units and development of selected regional research and training centres.

Traditional Systems of Medicine and Homoeopathy

22.43 In recent years some attention has been paid to development and popularisation of traditional systems of medicine like Ayurveda, Siddha, Unani and Homoeopathy. There are certain States where each individual system enjoys prestige and popularity such •ms Ayurveda in Kerala and Siddha in Tamil Nadu.

22.44 Each of these systems has now a Central Council and an attached Researcli Council. Centrally Sponsored Schemes were initiated in the past for providing grants-in-aid to States for promotion of postgraduate education and establishment of pharmacies with Government of India providing 100 per cent financial assistance. These will be continued.

22.45 The State Governments liave also schemes for development of medical education, setting up hospitals and dispensaries under these systems.

22.46 There is need for coordinated efforts for 1'ur-ther research for providing drugs for communicable diseases like Malaria, T.B. etc. as also for such other diseases like cancer, diabetes etc. The traditional system can also contribute to the national effort for finding effective methods of contraception

22.47 It would be necessary to take steps in the following direction's:

1. Prevention of the growth of sub-standard teaching institutions under these systems.
2. Adequate financial support to existing recognised institutions for improving the quality of teaching and research.
3. Introducing modern and scientific methods of investigation and equipping students with adequate knowledge of subjects like physiology, pathology, anatomy etc.
4. Developing curative facilities under these systems through hospitals and dispensaries and involving them in public health activities also.
5. Co-ordinating all research efforts to ensure purposive and fruitful research.

6. Standardising the pharmacopoeia and production o'f quality drugs.

Drug Control and Prevention of Food Adulteration

22.48 Effective measures will be taken for balancing demand and supply of essential and life saving drugs. Vaccine production units will be strengthened to meet the requirements of the country. The pattern of drug production/import and distribution system would be rationalised towards the objective of promoting primary health care and to overcome the short supply of inexpensive anti-infective drugs like Sulphenimides, anti-TB drugs, anti-leprosy drugs like Depsone etc. Measures like cheap packing, marketing by generic-names in preference to brand names and transfer of advantage of exemption from customs/excise duty on drugs to the consumers etc., would be pursued. The infrastructure for testing drugs would be strengthened to ensure that public health is not endangered by spurious/harmful drugs.

22.49 The problems of drug addiction particularly among the student community is causing concern. The problem will be tackled through psychiatry departments of medical colleges in the country and through deaddiction centres in problem p'ockets of urban areas for wliich a new scheme has been included in the Plan.

Prevention of Food Adulteration

22.50 Although the Prevention of Food Adulteration Act has been on the Statute Book from 1954, its enforcement had many shortcomings. There was lack of adequate number of trained inspectors and laboratory facilities for analysis. The administrative machinery was weak. By and large, the municipalities were discharging this responsibility. In recent years, some States have shown greater interest in implementing the Act vigorously by establishing separate Departments for Food and Drug Administration, while others have established a separate Food Wing under the Directorate of Health Services. Under a Centrally Sponsored Scheme, the States were assisted for strengthening their Combined Food and Drug Testing Laboratories and training of Analysts and Food Inspectors. The scheme is now being continued in the States Sector and the State Plans include provision for strengthening of these laboratories, setting up or new laboratories, training and appointment of additional staff, etc. There are four regional laboratories under the Central Government located at Calcutta, Ghazia-bad, Mysore and Pune to serve as referral laboratories.

22.51 Since consumption of adulterated and substandard food is a major health hazard, stringent measures for implementation of the Act will be taken. This will be facilitated by the expanded testing facilities and inspectorate staff provided under the States/Union Territories Plans. The Central Government would continue to lay down the standards for various items of food in consultation with the Central Committee for Food Standards headed by the Director General of Health Services. The Central Laboratories would be adequately strengthened.

Health Education

22.52 Since education has an important role in promoting concepts of health and prevention of diseases health education would be included in the curriculum or school education. It would also be made part of informal systems of education such as workers' education programme, farmers' education programme, etc. Education Bureau in States and at the Centre would effectively coordinate health education promotion activities.

22.53 The school health programme for periodical check up of school going children and attention to their deficiencies and diseases is an important programme which has to be integrated with the programme of nutrition. These programmes have been included in the State Sector to the extent resources permit.

Health Information Systems

22.54 It is necessary that health care facilities are supported by an improved health information system. The machinery in States and at the Centre would be adequately streamlined to ensure a systematic review and evaluation of the on-going programmes.

22.55 The system of collection of statistical data on health at the Central and States levels will be improved so that reliable data base for proper health planning is available. The States are also to strengthen their official machinery tor recording and maintaining vital statistics under the Registration of Births and Deaths Act, 1969.

22.56 Physical targets envisaged under the rural health programme and major schemes of control of communicable diseases are given in Annexures 22.3 and 22.4 respectively.

Outlays

22.57 Resources allocated lor different schemes vis-a-vis the corresponding outlays provided in the Fifth Five Year Plan (1974—79) are indicated in Anne-xure 22.1.

The outlays for the States and Union Territories Plan under the Health Sector are shown in Annexure 22.2, which include provision for the States' share of Centrally Sponsored Schemes also.

FAMILY PLANNING

22.58 According to the estimates of the Expert Committee on Population Projecdons, the population of the country as on 1st March, 1980 stood at 659 million recording a growth of 83 per cent over the 1951 Census figures. The growth rate of population was 1.9 per cent during 1978 alone. This large addition to the population has been the result of a sharp decline in the death rate coupled with a much slower decline in the birth rate. The death rate in the country declined from 27.4 per thousand population in the forties to 14.2 per thousand population in 1978, while the birth rate declined at a much slower rate from 41.2 per thousand population in the sixties to 33.3 per thousand population in 1978. The birth rate is still as high as 40.4 per thousand population in Uttar Pradesh while it is 25.2 per thousand population in Kerala which is the lowest for the States in the country. Uttar Pradesh has also the highest death rate of 20.2 per thousand population while Kerala has a death rate of 7 per thousand population establishing the close inter-relation between fertility and mortality rate. An analysis of the position in respect of other States also by and large supports the nexus between low mortality rate and low birth rates. The other important socio-economic factors influencing fertility rates are higher level of literacy and education, more particularly female education, better status enjoyed by women and greater availability of employment opportunities to them.

Review

22.59 Although the official Family Planning Programme was introduced in the First Five Year plan in 1952, it gathered momentum only in 1966-67 when the programme was made target-oriented and time bound. Since then, the objective of stabilising the growth of population over a reasonable period of time has been accorded a high priority in the Plans. The strategy proved to be successful as judged from the fact that there was a reduction of 8 to 9 points in the birth rate between 1966 to 1978. Unfortunately the Family Planning Programros received a set bade in recent years. Tnc nttU Plan objective of reducing the birth rate from 35 per thousand population at the beginning of the Plan lo 30 per thousand population by 1978-79 could not be achieved. In fact, the level of effective family planning couple protection has come down from 23.9 per cent in 1976-77 to 22.5 per cent in March, 1980. This trend needs to be arrested and reversed especially in the back-ground of an increase in the population in the reproductive age-group.

22.60 The non-attainment of the birth rate targets adopted in the Plans is largely on account of our inability to carry forward the programme throughout the country with the active involvement of the people. Public enthusiasm and community participation in the programme which is necessary for its success has not been generated in adequate measure. This programme is still viewed by the public as a routine governmental activity. Some voluntary organisations have no doubt done creditable work in the field of family planning, but their out-reach is mostly confined to the urban areas. There is need for projecting the programme as a peoples' programme backed by support trom governmental and non-governmental .agencies. Inadequacy in infrastructure available for implementation of the programme has also beon partly responsible for the slow progress of the programme. In some cases, even the infrastructure .available had not been put to effective use or properly maintained. There were shortages of trained manpower under the schemes of appointment of multi-purpose workers and maternal and child health which are so important to the programme. The performance of the family planning staff in motivational work on the basis of well-maintained and updated eligible couple registers, left much to be desired.

22.61 Apart from the constraints on the supply side, the generation of necessary acceptance in favour of the small family norm proved to be a far more elusive problem. Quite a large segment of the population is steeped in poverty, bound by traditional value systems. Certain sections have no doubt adopted the small famuy norm, but their number is small. A large majority of the population has not been adequately motivated and made aware of the benefits of a small family. The communication channels, both formal and informal including the educational system, have by and large not succeeded entirely in imparting the knowledge and information which the community needs.

22.62 The prevalent high rates of mortality in general and very high infant mortality in particular is inhibiting acceptance of family planning and creating a psychological barrier against the programme. The estimates of infant mortality for 1976 available from the Sample Registration Scheme (SRS) of the Registrar General of India shows that this rate is still as high as 139 in rural areas, 80 in urban areas and 129 for the country as a whole. The pre-school death rate among 0—4 age group is also around 51 per thousand population.

Objectives of the Sixth Plan

22.63 The Working Group on Population Policy set up by the Planning Commission has recommended the adoption of the long-term demographic goal of re~ ducing the net reproduction rate (NRR) to one by 1996 for the country as a whole and by 2001 in all the States from the present level of 1.67. The implications of this ,are as follows:—

1. The average size of the family would be reduced from 4.2 children to 2.3 children.
2. The birth rate per thousand population would be reduced from the level of 33 in 1978 to 21.
3. The death rate per thousand population would be reduced from about 14 in 1978 to 9 'and the infant mortality rate would be reduced from 129 to 60 or less.
4. As against 22 p and r cent of the eligible couples protected with family planning at present 60 per cent would be protected.

5. The population of India will be around 900 million by the turn of century and will stabilise at 1200 million by the year 2050 AD.

22.64 Keeping in view the long-term demographic goal of reducing NRR to 1 by 1995 as approved by the National Development Council, the following targe's have been envisaged for the Sixth Plan keeping in view the past performance, present capacity and future potential:—

Table 22.3

22.65 The number of sterilisations which were around 1.74 million in the base year (1979-80) will go up to 5.50 millions in the terminal year of the Plan. The number of IUD insertions will go u'p' from 0.62 million in 1979-80 to 2.50 million in 1985. The percentage of effective couple protection envisaged by 1985 is 36.56 against the present 22.5. This calls for a tremendous motivational effort backed by adequate infrastructural facilities which have to be taken care of in the Plan. It needs mention in this context that a total of 15.5 million sterilisations will be required during the Plan period 1980—85 for maintaining the birth rate at the existing level, assuming present levels of IUD and CC Users. This is because the proportion of women in the reproductive age will be rising. Even if, age-specific fertility rates are held constant, the birth rates will rise unless matched by vigorous family planning promotional efforts.

Strategy and Programme

22.66 It is almost axiomatic that economic development can in the long run bring about a fall in fertility rate. However, developing countries with large populations cannot afford to wait for development to bring about a change in the attitudes of couple to limit the size of families as the process of development itself is stifled by population growth. An important facet of the present demographic situation in the country, is the young age structure of the present population. Nearly 40 per cent of the people are below the age of 14 years, denoting a high dependency ratio which is a heavy burden on the bread winner. It also means a hi.ah potential for rising trends in growth of population in future. Limiting the growth of population is, therefore, one of the main obectives of the Sixth Plan. This has to be achieved through persuation of people to adopt the small family norm voluntarily backed by appropriate programmes of supplies and services for contraception. The Family Planning Trogramme has also to be made a part of the total national effort for providing a better life to the people. The Plan seeks to make a massive attack on the problem of unemployment and poverty through specific programmes directed towards the target groups such as small and marginal farmers, rural artisans, landless labourers, women, scheduled castes and scheduled tribes etc. A National Rural Employment Programme is being initiated to promote gainful employment to landless labourers and marginal farmers families. Under these programmes 'the household will remain the basic unit of poverty eradication. Economic emancipation will enable for children from poor families to attend school to receive adequate nutrition and develop into useful citizens. Special attention will be 'p'aid to the education and employment of women and to liberate them from dependence and insecurity and improve their social status.

Involvement of all Ministries/Departments

22.67 Family Planning Programme must rise above all controversies and should be accepted as a national programme by all Sections of the population. A national consensus on this subject has 'therefore to be developed. ,

22.68 Family Planning cannot be the sole responsibility of any one Department but of Government as a whole. The areas of useful activity in each Ministry/ Department in relation to family planning will have 10 be identified, spelt out in precise terms ,and responsibility for these activities squarely fixed on the Ministries/Departments concerned.

Integrated approach and co-ordination o/ activities

22.69 An integrated approach to the problems of public health and proper coordination of activities of different departments having a bearing on family planning such as maternal and child care are necessary. The Minimum Needs Programme under Health, in particular offers a good infrastructure for promoting the family planning work through proper coordination. At the District level, the Collector could be made responsible for effecting 'the linkages and ensuring co-ordination at the district and lower formations.

Role of Education

22.70 The role of education, specially female education, in reducing fertility is evidenced in our own country by the example of Kerala. Stress has, therefore, to be laid in increasing the enrolment in the high schools and minimising dropouts. At the high school stage a proper syllabus on health and reproductive biology should be introduced. The high school curriculum has to be suitably revised to incorporate this. Considerable work has already been done by NCERT in this regard: this has to be followed up. Education on health and biology of reproduction has to be imparted through all channels of formal and informal education including technical education, professional education, adult education, workers education and farmers education.

Extension Education and Motivation and Involvement of Officials and Voluntary Agencies

22.71 Given its limitations the official extension machinery alone cannot be expected to meet fully the requirements of a programme of mass contact and motivation like family planning. Besides the official extension agencies, all channels of communication available including youth organisations, mahila man-dais, voluntary organisations etc., should be fully exploited. The schemes of community health volunteers and training of opinion leaders offers a good potential for communication. The services of the village "Dai" who is in constant touch with rural women, could also be usefully availed of and training programmes for them could be strengthened. The Pancha-yati Raj Organisations and other local bodies and cooperatives which have a democratic base also offer a useful channel for motivation and for reducing the gap between awareness and acceptance of family planning, as also the gap between acceptance and actual services provided,

The role of the mass media in propagating family planning is crucial. The potential of the mass media such as Radio, TV, Cinema and newspapers will be fully exploited.

Incentives

22.72 The scheme of providing financial assistance to acceptors of sterilisation and IUD by way of compensation for loss of wages will be continued during the Plan period.

Delivery of Services

22.73 The promotion of family planning has to be viewed as an essential component of the total package of health delivery system which includes Health, Family Planning and Maternity and Child Health. The Health and Family Planning infrastructure has to be strengthened towards realisation of these objectives. The Working Group on Health Tor the Sixth Plan 1980—85 has identified the infrastructure that will be required for the purpose by 2000 AD which has been discussed under Health, fn the past, the States have been slow in setting up the sub-centres which are very crucial for the Family Planning Programme, since services like IUD and supplies could be provided to the rural population from these sub-centres. In order to give an impetus to the Family Planning Programme, new sub-centres to be set up in the Sixth Plan would be financed from the budget of Department of Family Planning at the Centre. Keeping in view the importance of rural health infrastructure for the Family Planning, concerted efforts would be made to build up Sub-centres, Primary Health Centres and the Community Health Centres under the Minimum Needs Programme.

Maternity and Child Health Care

22.74 High morbidity and mortality rates among infants and mothers are generally believed to be responsible for the desire for more children. The aim would be to bring down these rates through improvement of health and nutrition status and through various extension programmes of immunisation, prophylaxis, supplementary nutrition and health care services. Diarrhoeal and respiratory diseases being largely responsible for infant morbidity and mortality, ensuring protected water supply to every village and town and also improvement of personal hygiene and environmental sanitation will receive high priority. The school health programme will be strengthened to cover all school going children in due course.

Choice of Methods

22.75 Facilities for all methods of family planning will have to be made available on a wider scale and at all levels. Apart from sterilisation, the non-terminal methods like IUD, CC and Oral Pills have to be popularised, since a large number of young couples will prefer these methods. While the choice of methods would be left to the couples avoiding any form of coerction, it has to be ensured that facilities and supplies under different methods are made available on an adequate scale. There is also "need to remove any misapprehension in the minds of the people about safety in accepting any particular method. Proper follow up of the women accepting different methods like IUD and oral pills is important for timely intervention in case of any complications. Adequate follow up of sterilisation cases also is necessary since any accidental mishap may give a set-back to the programme. Continuous contact of family planning staff with the couples in their area is necessary. An arrangement similar to the Training and Visit System in agricultural extension may be usefully adopted by the family planning staff.

Research Programmes

22.76 No major break-through in contraceptive technology is expected in the immediate future. However, bio-medical research in family planning is important and has to be continued and intensified. In identifying areas of bio-medical research, indigenous methods and practices which have been and are still in vogue have to be examined and evaluated under the research programmes. Socio-economic research relevant to family planning promoting/family planning hampering factors has also to be undertaken. Research in the field of communication and development of the information system for identification of weak spots in the programme has also to be organised.

Staff Motivation

Tim The staff engaged in family planning work has been generally found to be lacking in enthusiasm. Their job is rather a difficult one as they have to bring about almost a revolution in the thinking and outlook of the people. Their motivation needs to be improved by systematising their work and improving their efficiency by proper training, close guidance and supervision. They could be rewarded for good work. They should also be given the status of permanent government servants as their temporary position creates a sense of insecurity. The present wastage of trained manpower, more particularly ANMs, should be avoided.

Legal provisions

22.78 The Medical Termination of Pregnancy (MTP) Act, which is in force now, is in the nature of health measure 'and family planning is not one of its objectives. However, MTP, can be resorted to aS a corrective method for failure of contraceptives. The existence of this Act and the benefits that can be derived are-still not fully known. This needs widest publicity.

22.79 One powerful means of achieving planned parenthood is delayed marriages. Apart from enforcing the law relating to the minimum marriage age for girls and boys, social pressure of the community against early marriages should be built up by appropriate means.

Outlays

22.80 The animal linaucial allocations and expenditure during 1974-80 and outlays by major items for the Sixth Plan are given in Annexure 22.5. The States would continue to get financial assistance from the Government of India on 100 percent basis.

22.81 Besides continuation and strengthening of the existing activities, provision has been made in the Sixth Plan for completion of incomplete buildings and construction of 1100 new buildings for Rural Family Planning Centres, establishment of 51 Rural Family Planning Centres, 40,000 new sub-centres along with 10,000 female health supervisors, 800 urban lamily planning centres, 30 pos^-partum centres at district level and 300 post-partum centres at sub-divisionLil/ taluka level hospitals and procurement of 700 additional vehicles. Certain geographical areas where family planning was lagging behind have been identified for mounting of special health and family planning elforts under the 'Area Projects' which will cover 12 States and 46 districts. New schemes of involvement of voluntary organisations in family planning work and expansion of the capacity of Hindustan Latex Ltd., have also been included in the Plan.

22.82 The expanded programme of immunisation against Polio, Tuberculosis, Typhoid and Measles will be continued and further strengthened. Programmes of immunisation and prophylaxis of mothers and children will also be continued. The training of local birth attendants (Dais) for ensuring safe deliveries will be completed to have one trained 'Dai' for 1000 population. The training programme of ANMs v/ill also be strengthened to meet the requirements of ANMs for the expansion of the sub-centre programme.

22.83 Performance figures and targets in regard to Family Planning and MCH programme are givon in Annexure 22.6.

NUTRITION

22.84 The problem of malnutrition is widely prevalent across the various socio-economic groups, particularly among those below the poverty line, landless agricultural labourers, people in slum and remote tribal areas and those who are affected by constant calamities like drought are more vulnerable to this phenomenon. Children, pregnant women and nursing mothers are seriously affected by malnutrition and the damage they sustain would be irreversible. However, not all children below the poverty line with lower energy intakes and body weights are necessarily mal-nourished. Lack of employment opportunities, illiteracy, safe drinking water, health facilities and unhealthy environments further lower the quality of life and aggravate the morbidity patterns. Inequality of incomes, weak public distribution system, insufficient clothing and housing aggravate these conditions further. Therefore hunger, malnutrition and the associated disorders are closely linked with these aspects.

22.85 In spite of considerable expansion of public health and medical facilities all over the country, int'ant mortality rate continues to be very high and tlie morbidity pattern persists. Infant mortality rate varies widely between rural and urban areas, male and female children and across different areas and socio-economic strata. Nearly 60 per cent of int'ant deaths take place at neo-natal stage. Besides, causes peculiar to infancy, fevers, respiratory and digestive disorders are mainly res-posibilc for high infant mortality. Socio-economic imbalances in the distribution of incomes low purchasing power, mat-distribution of essential food commodities, inadequacy of calories, proteins and other micro nutrients in average diets, limited access to medical and public health facilities, lack of knowledge about the balanced nutrition and hygiene, lack of safe drinking water and sanitation are some of the reasons responsible for high mortality rate and morbidity patterns that are prevailing in the country.

22.86 The estimates of the percentage of population whose calorie-intake is below that of recommended level vary considerably due to the differences in methodology and the adoption of different norms for the levels of intakes. Some of the studies show that the average energy intake is less than that of the re-conn-.ieiided level in about 50 per cent of the population. Others have pointed out that all those who consume less than the suggested norms need not necessarily be mal-nourished. The extent of malnutrition, according to these studies, would be in ths ranae of 15 to 30 per cent. People do not get the minimum amount of cereals and pulses that are necessary to meet their normal requirements. The most seriously affected groups in this regard are preschool children, specially 0-3 age-group, pregnant women and nursing mothers of the lower socio-economic strata and families belonging to landless agricultural labourers, small and marginal farmers particularly living in the drought prone areas.

22.87 Nutritional deficiencies are wide spread due to social, cultural and economic imbalances and inadequate intake of food. Recent studies in India have shown that the chief cause of malnutritior is inadequacy of total calorie intake rather, than inadequacy of proteins. Many groups, particularly, children, pregnant women and nursing mothers have poor stores of Vitamin 'A' and iron. Kwashiorkor and marasmus are the two clinical forms of PEM which lead to both mental and physical growth retardation and impairment of immuno-competance among children. Lack of Vitamin 'A' leads to Xerophthalmia and severe forms of this deficiency may cause permanent blindness. Low level? of Vitamin 'A' among pregnant mothers lead to delivery of babies with poor stores of this Vitamin and low birth weight. Iron deficiency anaemia is an important health problem. Goitre is prevalent in the hill belts of the country. Vitamin 'A' and iron deficiencies are widely seen amongst school children, young girls, pregnant women and nursing mothers. Diarr-noea is a major public health problem among infants and young children. They are susceptible to this due to preparation of supplementary Foods in unclean utensils and contaminated water.

Review

22.88 The problems of malnutrition, morbidity and murialny have been recognised since the Second Plan and a number of schemes have been introduced for combating them. However, during the first three Plans nutrition as such was not singled out for specific plan programmes but formed one 01 the components of the health sector. In the Fourth Plan an Integrated Nutrition Programme with ao outlay of ,Rs. 45.18 crores was introduced. It was observed that production ot 'more food' was needed to solve the problems of malnutrition and to improve the nutritional status of the population. Stress was laid on the development of agriculture along with animal husbandry and fisheries as the base of all effort for the improvement of nutrition. The Applied Nutrition Programme (ANP) was first introduced in 1960 in Orissa and Andhra Pradesh. It was extended theieafter to Tamil Nadu in 1961 and Uttar Pradesh in 1962. During 1973, the programme was extended to all the States. This programme was introduced to spread the concept of balanced diet, production and consumption of protective foods and proper techniques of cooking. The Special Nutrition Programme (SNP) was introduced in 1970-71 as a crash scheme to provide 300 calories with 10-12 grams of protein for the age group 0-6 years for 300 days in a year. It also provides 500 calories with 25 grams of protein for pregnant women and nursing mothers for 300 days. The mid-day meals programme which was initiated in 1962-63 was extenfl ed in subsequent years. It provides supplementary nutrition of 300 calories with 8-12 grams of protein to children in the age group of 6-11 years.

22.89 By the end of the Fourth Plan, the Special Nutrition Programme covered about 3.8 million beneficiaries. The figure rose to 8.2 million children and pregnant women and nursing mothers by the end of March, 1980. Under the mid-day meals programmes, the coverage increased from 4.2 million in 1962-63 to 13.2 million beneficiaries by the end of March, 1980.

22.90 Even though the Special Nutrition Programme has not been evaluated on a representative scale, several studies were conducted in different parts of the country on its cost effectiveness and impact on the beneficiaries. They have pointed out that the target beneficiaries were not selected on the basis of nutritional deficiencies. Besides, the programme lacked continuity and same children were not ensured feeding for the required number of days in a year. It was observed that community involvement was conspicuously absent. The community had a feeling that the beneficiaries were not selected on the basis of the eligibility rules laid down by the scheme. In a majority of cases, the food was shared by non-benefi ciary members of the family. High overhead administrative expenses and pilferage have hampered programme implementation. Besides, the food supplied at the centres did not supplement the deficiencies of the diet particularly among children of the age group 1-3 years. The programme has not served the more important target group i.e. 0-3 years due to difficulty of bringing these children to the feeding centres. It catered primarily td the 3-6 years age group.

22.91 Several studies were conducted to assess the impact of mid-day meals programme as (i) the enrolment of children from the poorer sections and (ii) the nutritional status.

22.92. Only one or two studies with small sample sizes have shown improvement of nutritional status of children in areas where programmes were implemented effectively. But most ot the studies failed to reveal any significant increase in the levels of enrolment commensurate with the investments made on the schemes. They have pointed out that some of the important, reasons for its low impact arc lack of continuity in the supply of food materials to the feeding centres, pilferage in the channels of distribution, non-adherence to the minimum number of feeding days and absence 01 other services like health. The Midday Meal has been often noticed to replace a meal at home and is not generally regarded as supplementary to what is consumed at home. Inadequate cooking and storage facilities at the schools and lack of local community involvement have also contributed to its poor performances.

22.93 The two feeding programmes in the last 10 years have relied heavily on short-term strategies based on narrowly identified target groups. This has resulted in the neglect of initiation of durable long term measures required for solving the problem of malnutrition. Targets have been laid down by the implementing authorities leaving little scope for local variations and experimentations. Adequate infrastructure for coordination, implementation and monitoring has not been developed at the field and district levels. Therefore, the programme lacked effective supervision. [n practice, they have become ineffective exercises in offering food to selected groups as charity.

22.94 Applied Nutrition Programme has also been evaluated. The studies show fh^ the programme h'as not generated the desired awareness for production and consumption of protective fo».>ds. Community kitchens and school gardens could not be taken up or completed due to lack of suitable land, irrigational facilities and low financial investments. The schemes for setting up of poultry units and pisciculture did not make much headway due to inadequate health cover and management failure. Moreover, participation by Panchayati Raj institutions and Mahila Mandals was poor as they were not fully involved. Criteria for selecting the blocks, villages and beneficiaries were not taken into account at the time of selection of blocks.

22.95 The production of balahar, a low cost protein-rich food, was about 1.29 lakli tonnes during 1974— 78 for utilisation in the feeding programmes for children. The production of miltone, a product based on milk and vegetable protein isolate was about 49 lakh litres during 1974—78. Another project for production of a vegetable protein based beverage named 'chaisathi' was developed at Baroda Dairy. By March, 1980 a target of 27251 MT of balahar was reached while the production of miltone was 29.51 lakh litres. The tea enricher plant at Baroda was producing 6,000 litres of 'chaisathi' per day against a target of 5,000 litres.

22.96 Thirty-one mobile extension units were also set up to undertake intensive coverage of rural areas to popularise local low cost indigenous foods, to promote suitable dietary habits, disseminate scientific methods of cooking to spread the message of home science, techniques of preservation of Fruits and vegetables and to propagate Knowledge of nutrition, hygiene and sanitation. They had a very limited impact.

22.97 Nutrition programmes introduced in the past did not succeed as their implementation was not closely linked with other programmes like provision of employment, health, safe drinking water and improvement of environmental sanitation and hygiene. Besides, these programmes which were implemented as ameliorative measures did not produce any lasting impact on the community. Since the programmes to •provide employment, safe drinking water, health services, clothing, housing and public distribution system were not integrated with nutrition schemes, supplementary feeding programmes in isolation did not make any dent to improve the nutrition status of the communities. In the absence of their linkages with developmental activities, these schemes were reduced to mere 'charity' or 'dole' without making, contribution to the improvement of nutritional status.

Objectives

22.98 Nutrition planning would aim at improving the physical capacity of the population, enhancement of the span of working life and increased longevity by enhancing the levels of nutrition, health and quality of environmental sanitation and hygiene. Improvement of functional efficiency of different segments of the population would contribute to the human resource development which would add to the increased productivity of the nation. Besides, the policy-frame would have to be concerned with cor-' rsctine some of the widely prevalent nutritional deficiencies leading to blindness, kwashiarkor and marasmus, goitre and anaemia. The objective of nutrition policy thus would be to reduce mortality and morbidity and to improve functional efficiency and productivity at all levels.

Strategy

22.99 The problem of malnutrition is closely linked with that of poverty, large family size, unemployment, illiteracy, lack of environmental sanitation and hygiene and safe drinking water. Intervention programmes will achieve limited results if this problem is addressed only at individuals in the households like children, mothers and the aged. Therefore, the strategy would have to be framed for the alleviation of hunger and malnutrition in all sections of the society through family centred poverty alleviation measures.

22.100 Nutritional improvement depends mainly upon the awareness, knowledge and income of the family. The nutritional status of the child or other vulnerable members of the family depends more upon the productive capacity of the economically active members of the family, their consciousness of the need of Nutrition and their ability to ensure it. -This consciousness certainly improves with knowledge, education, dissemination of inTormation and access to State or public welfare services. But the essential prerequisite for the improvement of nutritional status of the family is employment and incoms for the persons of working age in the household. Employment is the best and cheapest guarantee to enhance the nutritional status of the families. Subsidiary occupations and income generating projects like small scale production units and the training facilities would he expanded for the generation of additional employment opportunities. The available evidence indicates that children in the age of 0-6 years are highly vulnerable. If children are not adequately nourished before they grow up to enter the active labour force, they may remain physically and mentally so undeveloped that their productivity when in employment will for ever remain below the normal standards and there is a serious danger of long-term biological defects. Besides nutrition, it would be necessary to give psycho-social stimulation to children through story teaching, role play and other forms of non-formal education.

22.101 Education at the formal, p.'imary and middle level for the young and the functional literacy for adults would be given greater attention. Lessons on nutrition, health and population education would have to be introduced through formal and non-formal education. Mass media and other interpersonal instructions would have to be fully utilised for providing non-formal education. The educational content would be focussed on the relationships between nutrition and health, pregnancy, birth rate, immunisation, drinking water, environmental and personal hygiene, eradication of helminths and other intenstinal parasites.

22.102 It has been well recognised that polluted water supply especially for drinking purposes is the cause of diarrhoea, dysentery, gastro enteritis and other intestinal disorders and hepatitis. These infections constitute the single biggest killer of infants and children or even adults in many regions. The provision of safe potable water supply along with the provision of drainage facilities would be accorded high priority in the Plan. Improvement of environmental sanitation could be attempted by involving families and village communities. Families would be encouraged to provide in their houses soak pits and low cost drainage System. It would be possible to expand to other regions low cost community and private latrines, which have been adopted with success in many places. An effort to link them with bio-gas plants will be made. Construction of pit latrines and compost pits would be encouraged in rural areas. Efforts would also have to be made to extend coverage of immunization. One of the major causes of infant mortality is respiratory disease. The reduction of exposure through housing and clothing and immunisation would have to be given greater emphasis.

22.103 Food production and its conservation through improved post-harvest technology including processing and storage and rapid extension of the rationing and lair price shops and its net work to cover the entire country would be given higher priority. Essential consumer goods would be supplied through the consumer cooperatives and stress would be laid on the expansion of decentralised public distribution system. The agricultural policy would be oriented to provide a balance between the production of cereals, legumes, pulse's, oils and other cash crops.

22.104 Tc reduce the cost of nutrition delivery and to maximise the certainty of the delivery system, strong local level community organisations would be developed. Development of these organisations alone with arrangements for coordination of various activities at the village level with provisions for adaptation to meet the local requirements would alone make the programmes successful. Through active involvement of community organisations and effective coordination at various levels, the programme efliciency could be maximised. In this attempt schools, dispensaries and community halls would be used as focal points for integration of various schemes. Youth clubs, mahila iriandals and voluntary organisations would have an important role to play in this endeavour. An integrated strategy with a package of services would liave io be offered to improve the nutritional status of the families. Thus, several schemes would need to be taken up for implementation in a coordinated ""/anner These include : (1) employment and income generation, creation of capital assets for the nation thiough conversion of human labour; (2) family limitation; (3) community organisation and its participation, (4) education with special stress on nutrition and health, (5) equitable food distribution through expansion of public distribution system and production of nutritious foods and ensuring balanced production between the cereals, pulses, vegetables and animal 'products, (6) provision of safe drinking water supply, (7) awareness of public health and personal hygiene, (8) control of communicable diseases and intestinal disorders and (9) provision of housing and clothing for poorer sections would be taken "up for .implementation in a co-ordinated manner.

22.105 Since it will take quite some time before the objectives of full employment, reasonable standards of living, adequate health care etc. are achieved, special attention has to be paid to. those who are malnourished. The direct nutrition intervention 'programmes will still, therefore, be necessary to cater to certain specially vulnerable age, sex groups who are prone to malnutrition and nutritional disorders. The governmental efforts would have to be substantial but selective to benefit children and mothers living in the most backward rural, tribal and disaster-prone areas and urban slums. Ongoing intervention programmes would have to be restructured to make them effective. However, it is important to reduce the costs of nutrition delivery and to improve the certainty of the delivery system. Community organisation and coordination at the village level which can share the success of the nutrition movement would have to be strengthened. The nutrition feeding centres would have to be located either in the schools, dispensaries or community halls, the schools being perhaps the most desirable and various services would have to be provided at that level in an integrated manner under community supervision. The Government machinery at the point of delivery of services to the beneficiaries should be made to work in a coordinated manner through improved managerial systems so as to reduce overhead administrative costs.

22.106 The food for work component of the new National Rural Employment Programme has the largest potential for the long term nutritional improvement ot the people provided the main aim of rural employment and higher incomes for the landless working population is suitably woven with programmes in the priority areas mentioned above. An area-based programme with as half of projects for creation of durable assets for utilisation of human resources during lean months would be used as a main strategy for the improvement of nutritional status.

22.107 Employment programmes under various sectors of development would be expanded to provide larger avenues of employment to the poorer sections of the society. Community organisations particularly mahila mandals, youth clubs and others would be involved in the programme implementation. Universities, research organisations and voluntary agencies would be stimulated to as'sume ;i. larger role In the formulation and implementation of schemes. Control of food adulteration would be given greater attention. Enforcement of labour laws for providing permanent and mobile creches, MCH and medical clinics and canteens in organised sector v/ould be strictly implemented.

Programmes

22.108 Special Nutrition Programmes: The Special Nutrition Programme which provides supplementary nutrition to prp-school children, pregnant women and nursing mothers would be extended to cover 600 ICDS projects from 200 projects at the beginning of the Plan. The scheme would cover about 5 million beneficiaries at the beginning of the Plan. In the ICDS projects, integration of nutrition with health, sanitation, hygiene, water supply, education etc., would be improved.

22.109 SNP outside ICDS projects will also be restructured by providing health and welfare inputs and building it around an activity like socio-enonomic centre, mahila mandals, pre-school etc., and by providing supervision and monitoring. It will be linked with the projects of economic activity, particularly in areas of women's employment so 'as to meet the felt needs of the women from poorer sections. Expansion of SNP outside ICDS will be discouraged. The number of beneficiaries at the beginning of Plan are about 5.73 million outside the Plan and about 1.15 million under Plan.

22.110 Mid-day Meals Programme: This scheme caters to the school children of the age group 6—11 years. About 15.1 million children are covered in the non-Plan and 2.3 million under Plan, i.e. a total of 17.4 million. The existing programme would be reviewed and reorganised to provide health inputs and safe drinking water and to encourage develo'pment of kitchen and horticultural gardens in the schools, before further expansion is undertaken.

22.111 Production wd Processing Schemes: Recent studies have pointed out that local foods should be utilised for imparting nutrition education and reducing transport and administrative costs. The production of foods processed by Government agenices such as balahar, whose per unit cost at the targetted beneficiary level is higher than the cost of locally cooked food will be reviewed.

22.112 Processed and Fortified Foods: The ongoing programme of miltone units would be completed and its further expansion will be reviewed in the light of its evaluation. Its expansion by commercial concerns would also be considered. The emphasis will be placed on the consumption of local foods. Local processing of foods will be encouraged to facilitate employment of women. After completion of the field trials for the fortification of salt with iron, it is proposed to promote its commercial production. Distribution of iodised salt in goitre endemic areas would need to be improved.

22.113 Nutrition Education: An integrated programme for imparting eduaction on health, environmental and personal hygiene, nutrition, child welfare and other subjects would be taken up in collaboration with the Ministries of Social Welafre, Health, Education, Food and Rural Reconstruction, instead ef taking up nutrition education in an isolated manner. An effort will be made to make such feeding centre under SNP and MDM as the nucleus of nutrition education.

Research and Evaluation

22.114 Universities and research organisations would be encouraged to undertake investigations with a common research design so that their findings could be utilised for reformulation or improvement of the schemes. Adequate outlays for in-built evaluation particularly in SNP and MDM would be provided in the Plan for this purpose. Research on production of cereals, pulses and oil seeds, their processing and distribution policy with the object of providing a balanced diet and its availability would be expanded, Research on community education, inter-personal contacts and mass media for dissemination of information on nutritional contents of local foods, their reinforcement or supplementation and modes of preparation would be stepped up. The consumer patterns and consumer acceptability would be studied more intensively. Identification, development and formualtion of recipes for different target groups would be encouraged. Information on the prevention of nutrition leakages by augmentation of drinking water supply, drainage and sewerage disposal is rather scanty. This area needs to be further investigated. Augmentation of funds for assessing socio-economic determinants of malnutrition, specially infra-community variations, family planning and evaluation of ongoing programmes would be further accelerated. Research by specialised institutions and voluntary organisations for developing materials for imparting education through mass-media and inter-personnel communication would be intensified.

Coordination

22.115 Nutrition programmes are being implemented at the Centre and State levels under different agenices. The existing mechanisms for coordiantion would be reviewed and remedial measures initiated for effective functioning at beneficiary level. A Coordiantion Committee at a high level would be set up so as to facilitate inter-Ministeria] interaction in the process of decision making and fixing responsibilities for programme performance.

Outlays

22.116 In Central Sector, the provision is Rs. 14.95 crores vide Anncxurc 22.7. The provision for direct nutrition programmes in the State Sector is Rs. 223 crores vide details in Annexure 22.8.

Annexure 22.1 Sixth Plan Outlays—Health Sector
(Rs. crores)

*This includes Rs.—195.30 crores towards 50% State share for Malaria Control Programme.

Annexure 22.2 Sixth Plan—States/UT-wise Distribution of outlay for Health Sector
(Rs. in Crores)

* Excluding outlay on Centrally Sponsored Schemes borne on the budget of the Health Ministry.

Annexure 22.3 Statement showing Physical Targets and Achievements under Rural Health Programme

Annexure 22.4 Major Schemes under Control of Communicable Diseases Programme

Annexure 22.5 Family Planning—Annual Allocation and Expenditure during 1974—80 and Outlay for the Sixth Plan
A. Annual Allocation and Expenditure during 1974—80
(Rs. crores)

B. Sixth Plan Outlay: Family Planning(Rs. crores)

Annexnre 22.6 Performance of Family Planning Methods and MCH during 1974-75 to
1979-80 and targets for the Sixth Plan (1980—85)
(in million)

*Figures provisional. ©Includes 3 doses as against 2 doses earlier.

Annexure 22.7 Sixth Plan Outlays Nutrition—Central Sector
(Rs. in crores)

Annexure 22.8 Sixth Plan Outlays—Nutrition States/UTs.
(Rs. in lakhs)

Note : The MNP component is Rs. 21874 lakhs.