Agricultural and Allied Activities || Rural Development and Poverty Alleviation || Irrigation, Command Area Development and Flood Control || Environment and Forests || Industry and Minerals || Village and Small Industries and Food Processing Industries || Labour and Labour Welfare || Energy || Transport || Communication, Information and Broadcasting || Education, Culture and Sports || Health and Family Welfare || Urban Development || Housing, Water Supply and Sanitation || Social Welfare || Welfare and Development of Scheduled Castes and Scheduled Tribes || Special Area Development Programmes || Science and Technology || Plan Implementation and Evaluation

HEALTH AND FAMILY WELFARE

12.1.1 Health of the people is not only a desirable goal but is also an essential investment in human resources. The National Health Policy (1983) reiterated India's commitment to attain "Health for All (HFA) by 2000 A.D". Primary health care has been accepted as the main instrument for achieving this goal. Accordingly, a vast network of institutions at primary, secondary and tertiary levels have been established. Control of communicable diseases through national programmes and development of trained health manpower have received special attention.

12.1.2 Many spectacular successes have been achieved in the country in the area of health. Small-pox stands eradicated and plague is no longer a problem. Morbidity and mortality on account of malaria, cholera and various other diseases have declined. The Crude Birth Rate and Infant Mortality Rate (IMR) have declined to 29.9 and 80 (1990 SRS data) as compared to 37 and 129 respectively in 1971. Life expectancy has risen from a mere 32 years in 1947 to 58 years in 1990. However, HFA is a long way off. Disease, disability and deaths on account of several communicable diseases are still unac-ceptably high. Meanwhile, several non-communicable diseases have emerged as new public health problems. Rural health services for delivery of primary health care are still not fully operationalised. Urban health services, particularly for urban slums, require urgent attention due to changing urban morphology.

Programme Thrusts in the Eighth Plan

12.2.1 It is towards human development that health and population control are listed as two of the six priority objectives of this Plan. Health facilities must reach the entire population by the end of the Eighth Plan. The Health for All (HFA) paradigm must take into account not only high risk vulnerable groups, i.e., mothers and children, but must also focus sharply on the underpriviledged segments within the vulnerable groups. Within the HFA strategy "Health for underpriviledged" will be promoted consciously and consistently. This can only be done through emphasising the community based systems reflected in our planning of infrastructure, with about 30,000 population as the basic unit for primary health care.

Minimum Needs Programme (MNP)

Rural Health Programme

12.2.2 Development and strengthening of rural health infrastructure through a three tier system of Sub-centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs) for delivery of health and family welfare services to the rural community was continued during the Seventh Plan. But, lack of buildings, shortage of manpower and inadequate provision of drugs, supplies and equipments constituted major impediments to full operationalisation of these units.

12.2.3 The achievements and the present situation for health infrastructure under the MNP and availability of building and manpower are given in Annexures 12.1, 12.2 and 12.3.

12.2.4 The approach and strategy for rural health during the Eighth Plan would be:-

1. Consolidation and operationalisation, rather than major expansion, of the network of Sub-centres, PHCs and CHCs so that their performance is optimised. This would be achieved through -
   1. strengthening of physical facilities including completion of building of the centres and staff quarters;
   2. provision of essential equipments as per the standard list;
   3. filling up of all vacant posts within a defined time frame and in-service training of staff;
   4. ensuring supply of essential drugs, dress- ' ings and other material. *
2. To monitor the progress of implementation of MNP at the District, State and National levels, a health information management system will be developed and used.
3. The targets regarding setting up of Sub-centre, PHC and CHC on the basis of population norm are indicative only. The States will be given flexibility in establishing these units as per the local needs depending on geographical and population considerations, resources, manpower availability, etc. In opening new centres the needs of tribal population and communities living in difficult and inaccessible areas will be given first priority.
4. The rural hospitals and dispensaries will be suitably modified, equipped and staffed to convert them into Sub-centres, PHC, CHC as the case may be, thereby integrating them into primary health care system.
5. The backlog of Sub-centres, PHCs and CHCs in many States is staggering and the resources required to meet the targets are astronomical and as such unachievable in near future. In view of this the entire policy of establishment of Sub-centre, PHC and CHC with the present norms will be reviewed and new policy options developed to make the primary health care accessible, acceptable and affordable to all. Re-organisation of the Indian Systems of Medicine and Homoeopathy (ISM and H) dispensaries/hospitals in rural areas to create ISM and H health centres is one such option. This would be in line with the Government's accepted policy of promoting ISM and H. Reorientation of existing personnel of these dispensaries/hospitals, provision of additional facilities and/or staff, redefining the roles and responsibilities would be some of the pre-requisites to put the concept of ISM and H Primary Health Centres and Sub-centres in an operational mode.
6. Mechanism will be developed to make the rural health services responsive to the needs of the rural masses and accountable to the community. Panchayati Raj system would become an effective instrument for eliciting community participation in the health programme and providing supervision and support to primary health care infrastructure.
7. Linkages will be developed with the sub-divisional and district hospital to provide referral back-up.

Urban Health Services

12.2.5 More than one quarter of the population in the country now lives in urban areas. In metropolitan and large cities about 40-50% of the urban dwellers are estimated to be living in slum areas where the health status of the people is as bad as, if not worse than, in rural areas. But infrastructure for primary health care in urban areas hardly exists. Serious attempts will be made to develop urban health services as per the recommendations of Krishnan Committee. Organic linkages will be forged with the urban development schemes including Urban Basic Services for a comprehensive development ul' health and welfare services. Local hospitals will be made responsible to run these centres and treat them as their extension counters for provid ing health services to the community. Voluntary organisations and local bodies would be encouraged to develop partnership and ultimately tak ing full responsibility for carrying out these programmes. Health system research to develop a model of urban primary health care services will be undertaken.

Secondary and Tertiary Care Services

12.2.6 Alongwith the emphasis on consolidation of primary health care, the strengtheninr of secondary care services and optimisation of tertiary care services would be the key objectives of the Eighth Plan.

12.2.7 The sub-divisional and district hospitals which are the secondary level medical care institutions, lack adequate manpower and facilities, to be able to discharge their responsibilities satisfactorily. In view of the resource constraints, there is need for raising resources l'> maintain the quality of care and meet risiny expectations of the people. It is time t'nat the concept of free medical care is revk'w.-d ;nc' people are required to pay, even ifparti.-illv tor the services. The system can be so designed tlf:ii the truly indigent population are able to r ,;i free/highly subsidised medical care. lnn<;\:i-tive approaches/practices to this end and a system of medical audit will be developed during the Plan. Maximum cost-effective utilisation of existing services will be another item on the agenda.

12.2.8 In accordance with the new policy of the Government to encourage private initiatives, private hospitals/clinics will be supported subject to maintenance of minimum standard and suitable returns for the tax incentives. Norms for minimal facilities and accredition of private hospitals/clinics would be developed to maintain quality of patient care.

12.2.9 The medical college hospitals and specialised hospitals have to be used exclusively as tertiary care centres and for health manpower development. Important pre-requisites for this would be improvement in the facilities and standards of care available at secondary care level and development of strong referral system.

12.2.10 A conscious decision has to be taken to enforce a balanced development of primary, secondary and tertiary care services in the country with priority for primary health care. Otherwise there is a distinct risk of the paradigm of primary health care as a tool for "Health for All" being overrun by the mechanism of "All for a few". This tendency and trend can be halted only with scientific arguments for which sound epidemiological, health management and health financing data is needed and hence the need for health systems research.

Health Man-power Development and Training

12.2.11 As much as approximately two thirds of the total expenditure on health services is spent on personnel. Yet, health manpower planning, production and management, which constitute key elements for effective implementation of health programme, have not received enough attention.

12.2.12 While the States have been more than anxious to start new medical colleges, their efforts to develop institutions for training of para medical staff have been entirely subopti-mal. This has resulted in a considerable mismatch between the requirement and availability of health personnel of different categories. Ideally, the doctor- nurse ratio should be 1 : 3 but currently there are less than 3,00,000 registerednurses against 4,00,000 registered medical graduates. Similarly, there is a shortage of pharmacists, laboratory technicians, radiographers, dental surgeons, etc., in the country.

12.2.13 The National Health Policy affirmed that the effective delivery of health care services would depend very largely on the nature of education, training and appropriate orientation towards community health of all categories of medical and health personnel. It is, therefore, of crucial importance that the entire basis and approach towards manpower development in terms of national needs and priorities are reviewed and training programmes restructured accordingly. Besides there is an urgent need to asess appropriate health manpower mix to deliver health services at primary, secondary and tertiary level and for the purpose of training and research.

12.2.14 The approach and strategy for health manpower development during the Eighth Plan would be-

1. A National Policy on Education in Health Sciences which when formulated may form the basis of new initatives in manpower development.
2. The existing situation regarding health manpower supply, demand and projection and facilities for training of different categories will be reviewed.
3. Appropriate steps will be taken for bridging the critical gaps in the manpower requirement for primary health care and the higher levels and for training and research needs. Starting vocational courses as part of voca-tionalisation of general education at the + 2 level of the 10+2 system will be supported to expeditiously bridge the gap in the supply of paramedical personnel.
4. The distortions created in the past on account of over-emphasis on training of doctors, often at the cost of other categories of personnel, and also the undue emphasis'on specialisation/super specialisation will*be checked.
5. Continuing education for all categories of staff will be given high priority. For this, district and regional level training institutions will be suitably strengthened. Medical colleges and other institutions including professional bodies like Indian Medical Association (IMA) will continue to play an important role, in coordination with the National Academy of Medical Sciences (NAMS), which has been identified as the nodal agency for this purpose.
6. The existing facilities for training of medical graduates has outstepped the needs. No new medical college or an increase in the admission capacity of the existing colleges will, therefore, be supported during the Eighth Plan. Instead, resources will be used to strengthen the hospitals, laboratories and libraries of the existing medical colleges so that the standards of training are maintained.
7. For ensuring uniform standards of medical and paraprofessional education, need for establishment of universities of medical and health sciences at regional level has been recognised. Necessary support will be provided as and when a policy decision in the matter is taken.
8. Statutory councils will be strengthened and new councils for para-professionals, where they are needed, will be created so that standards of training and education can be laid down and enforced. The proposed Education Commission in Health Sciences will promote and coordinate all educational activities for all categories of health manpower at all levels.
9. Training facilities for epidemiology and health management, the two disciplines which contribute to the maximum extent to efficient functioning of health services including hospitals, will be augmented in medical colleges and created in specialised institutions where training of teachers can be undertaken.
10. Training of doctors ofISM and H will also be reviewed and re-oriented to make it congruent with the needs of national health programmes and primary health care.
11. Efforts for re-orientation of medical education, started during the earlier plans, will be pursued vigorously with emphasis on faculty development through workshops for the teachers to make them conversant with the health needs of the country, national policies and programmes, advances in educational technology, and make them appreciate the need for re-direction and retargetting of medical education, relavent to contemporary and futuristic needs.

Programmes for Control of Communicable

Diseases

12.2.15 A number of national programmes for eradication/control of communicable diseases have been initiated in the country since the early years of planning. Most of the control/eradication programmes for communicable diseases have been in operation since last several plans at huge financial cost. With a few exceptions, however, no national level comprehensive review/evaluation of these programmes have been undertaken. During the Eighth Plan the following strategies will be followed for control of communicable diseases -

1. National level review of the ongoing control/eradication programme to assess the current strategies and their impact on the disease status..
2. Ensuring sufficient supplies and logistic support including mobility for carrying out the programmes.
3. Establishment of epidemiological- cum -surveillance centres at district/regional levels and improvement of health management information system for continuous monitoring of the disease situation and taking appropriate and prompt action .
4. Intersectoral coordination will be strengthened with departments of public health engineering, local bodies like municipalb-ties, Ministries of Information and Broad* casting, Women and Child Welfare, Water  Resources, etc., for control of vector borne and other diseases.
5. The Information, Education and Communication (IEC) activities within each programme would be given special attention for enlisting community participation, which constitutes one of the weakest links, for carrying out the disease control programmes.
6. Strategy of training of staff at horizontal level, both within the primary health care and higher level, is essential.
7. Training in epidemiology is woefully inadequate in the country. Unless this situation is rectified decisions regarding control of communicable diseases and its implementation will be handled by the group of professionals and para-professionals who are not sufficiently equipped to do so with its attendant consequences. Specialised institutions/departments to carry out both pre-service and in-service training in epidemiology for different category of staff will be created and the existing ones strengthened.

Programme-wise strategies are briefly outlined hereunder -

Vector Borne Diseases Malaria Eradication

12.2.16 As a result of introduction of modified plan of operation in 1976 the incidence of malaria has come down from about 6.5 million cases in 1976 to about 1.89 million cases in 1990. The problem of drug resistance of P. falciparum malaria in several States is a cause for concern. Several operational problems and non-availability of matching funds from States to this 50% Centrally Sponsored Scheme (CSS) has resulted in shortfalls in spray operations, decline in blood slide collections and incomplete treatment of cases. Irrigation projects without adequate strategies for management of water resources and floating labour population to cities and major project sites has also contributed to the increased incidence of malaria. Since 30%

of all malaria cases and 60% of the more dangerous P.falciparum infections are in the tribal areas, a major intensification of efforts would be directed towards these areas.

 Kala-azar and Japanese Encephalitis

12.2.17 Kala-azar and Japanese Encephalitis (JE) have emerged as major public health problems in recent years. For control of Kala-azar the twin approach of (i) vector control by insecticide spraying and (ii) case detection and treatment at PHC and referral hospitals was adopted. The reported cases and deaths due to JE in the affected States viz. Andhra Pradesh, West Bengal, U.P. Tamil Nadu and Assam have shown considerable decline during the Seventh Plan with the use of indigenously produced vaccine.

12.2.18 The existing guidelines for Vector-borne disease control include -

1. Residual indoor spraying with appropriate insecticide in areas with population having API 2 and above in any of the last 3 years.
2. Spraying ofBHC in districts reporting 100 or more cases of JE in any one of the years during the past decade.
3. DDT spraying in PHCs reporting 10 or more cases of Kala-azar in any one of the last three years.
4. Continuation of the anti-larval operations;and.
5. Malathion fogging/ULV spraying to be undertaken as a contingency measure in out-break ofJE and Malaria.

These conventional approaches of use of inceti-cides and chemicals would have to be supplemented or replaced, depending upon the local situation, by newer strategies such as biodegradable inceticides, biocides, bioenvironmental improvement and preventive measures like impregnated bed nets. Finally, the surveillance activities would need to be strenghened so as to improve case detection and case management,resulting in a break in the chain of infection/ transmission.

 Leprosy Eradication

12.2.19 The approach under this 100% Centrally Sponsored Scheme has been early case detection and domiciliary treatment and health education. Multi Drugs Therapy (MDT) has been introduced in all 201 endemic districts and 41 low endemic districts (till March 1991) for case treatment. The programme has shown steady progress in achieving its objectives during the Seventh Plan.

12.2.20 Within the Leprosy Eradication Programme the following activities will be pursued

1. Creation of additional physical facilities in all the endemic districts.
2. Extention of MDT to remaining endemic districts and in low endemic districts in phases.
3. Training of the PHC staff in leprosy eradication activities, both in endemic and low endemic districts, with the aim of preparing them to take over the responsibility of leprosy eradication activities following reduction in the prevalance and incidence of the disease.
4. Creation of vocational and rehabilitation facilities for the patients declared cured in those districts which have been under MDT for more than 5 years.

Tuberculosis Control

12.2.21 Early case detection and treatment have formed the strategy for control of Tuberculosis (TB) under a CSS with 50% Central funding. A major achievement of the programme during the Seventh Plan was the successful introduction of short course chemo-therapy in 212 districts, thereby reducing the treatment duration from 18-24 months to 6-8 months. However, the programme has suffered from poor case holding leading to treatment default. Problem of drug resistance is yet another cause for concern.

12.2.22 During the Eighth Plan, the TB Control Programme will be further expanded and strengthened by opening District Tuberculosis Centres (DTCs) in those districts where these do not exist. Short course chemo-therapy will also be introduced, and supply of drugs ensured, in all the remaining districts of the country under the Programme. The DTCs will be strengthened by providing necessary equipments like X-ray machines and maintaining essential supplies like drugs, X-ray films etc.

Blindness Control Programme

12.2.23 This programme which was launched in 1976 as a 100% CSS aims at reducing blindness prevalence from 1.4% in 1980-81 to 0.3% by 2000 AD. Cataract is the cause of more than 80% of blindness. Demographic shift leading to larger old age population has increased the prevalence of cataract in recent decades. So far the main strategy has been to provide access to opthalmic services through eye camps and mobile units. While this has suceeded to some extent, it has fallen short of the requirements. Besides the inherent limitation of the camp approach, the magnitude of the problem demands creation of permanent eye care infrastructure, operational throughout the year and within easy reach of the people.

12.2.24 These initiatives will be combined with an intensification of efforts aimed at ophthalmic manpower developmemt with the ultimate objective of improving the outreach and quality of ophthalmic care at primary, intermediate and tertiary levels.

Guinea Worm Eradication

12.2.25 This programme was launched during 1983-84 with the objective of achieving zero incidence of guinea worm by 1990-91. Although the estimated number of cases has come down from 39,790 in 1983-84 to about 20,000 in 1990-91 the objective of "Zero Guinea worm" still remains unachieved. Total eradication of the disease through better surveillance system and improvement of drinking water supply in the endemic areas will be achieved during the Plan.

AIDS Control Programme

12.2.26 Acquired Immuno Deficiency Syn- ^ drome (AIDS) has emerged as a new public ' health problem in the country. The AIDS Control Programme was launched in 1986 as a Central Sector Scheme. Establishment of surveillance centres, testing of cases for infection, training of personnel and mass health education formed the main activities within the programme. But, the incidence of the disease has shown an increase from 137 seropositives among 41,000 tested up to May 1987 to 7272 seropositives among 13.49 lakhs persons tested by April 1, 1992. Inadequate surveillance system and absence of facilities for examination of blood and blood products and the growing menace of intravenous drug abuse contributed to this upsurge in infection.

12.2.27 For the prevention and the control of AIDS a national programme will be launched during the Eighth Plan. The strategy to be adopted for AIDS control would comprise of -

1. Surveillance of the population with special emphasis on high risk behaviour groups for detection of infection;
2. Strengthening of the blood banks and blood safety measures with priorities on special areas and metropolitan and large cities to start with;
3. Area specific strategy for mounting control of infection and target specific IEC activities based on epidemiological data;
4. Integration of the control programme with the activities of the departments like Social Welfare, Youth and Sports, etc. and other Government and non-government organisations; and
5. Strenghening ofSTD Programme and training of staff.

Diarrhoeal Disease

12.2.28 Diarrhoeal Disease Control Programme which was initiated during the Sixth Plan was strengthened and included as a part of maternal and child health activities in the Seventh Plan. Under the programme, a large number of professionals and para-professionals were trained for the programme implementation and support besides intensifying IEC efforts. Oral rehydra-tion salt for prevention and treatment of dehydration was made available through the existing health infrastructure. Diarrhoeal diseases control would be continued during Eighth Plan as part of the child survival and safe motherhood programme.

Programme for Non-communicable Diseases Control

12.2.29 The increase in life expectancy and the changing life style of the people, have brought in the problem of non-communicable diseases which have added to the already heavy burden of morbidity and mortality due to communicable diseases in the country. Development of models of care and control programmes for non-communicable diseases, therefore, are no longer a luxury but an essentiality.

12.2.30 The strategies for the control of non-communicable diseases have to be based on sound consideration of epidemiology and demography. They must he integrated with the existing health infrastructure to make them cost-effective. Development of appropriate technology and its transfer to the general health services should be an important component of the strategy. Since the life style and high risk behaviour are important variables associated with the rising incidence of most of these diseases, they lend themselves to prevention by health education. Therefore, mobilising community health action through well structured IEC system including mass media will form an important intervention strategy for the control of non-communicable diseases. Development of appropriate learning resource materials for education and training of manpower will be an essential activity. The strategies for the control of specific non-communicable diseases will be as follows -

Cancer Control

12.2.31 Prevalance of cancer in the country is estimated to be 1.5 to 2.0 millions. The Cancer Control Programme, initiated during 1975-76, was converted into a national programme in 1985 with the objective of i) primary prevention of tobacco- related cancer; ii) secondary prevention of cancer of uterine cervix; and iii) extension and strengthening of treatment facilities on a national scale. The last one was the focus of emphasis during the Seventh Plan.

12.2.32 During the Eighth Plan the diagnosfic and treatment facilities for cancer would be further strengthened at the medical colleges and other major hospitals. Primary prevention , particularly for tobacco related cancer and uterine cervix cancer, will form the sheet anchor of the Cancer Control Programme. It will be carried through IEC activities and early case detection approach, mounted on the primary and secondary health care infrastructure and through mass media.

Iodine Deficiency Disorder

12.2.33 The National Goitre Control Programme which was operated during the Seventh Plan as a "Mission" programme, is a purely Central scheme under the Central health sector. According to the present estimates, about 45 million people suffer from goitre and another 6 to 8 millions from other iodine deficiency disorders. Universal iodization of salt and IEC activities are the main strategies of the programme.

12.2.34 Iodine Deficiency Disorder Control Programme would have continued thrust during the Eighth Plan. The basic approach of the programme being universal iodization of salt, proper coordination with major departments concerned with production and distribution of iodised salt nameiy, the. Department of Industry and Railways, will be brought about . Iodized salt will be made available through the public distribution system. To prevent the losses of iodine in the salt due to long-distance transportation under adverse conditions, iodization of salt on small scales in the States far away from the present production centres will be considered and operationalised. Double fortification of the salt With iodine and iron will also be explored to combat the wide- spread problem of anaemia.

Diabetes Control

12.2.35 The National Diabetes Control Programme was launched in 1987 as a Central Sector health programme in the districts of Saiem and South Arcot in Tamil Nadu and Jammu and Kashmir on a pilot basis. The main thrust during the Seventh Plan was to develop an appropriate model for care and control of diabetes meilitus at the district level. The major objectives include (i) prevention of diabetes through identification of high risk subjects and early intervention; and (ii) early diagnosis of disease and institution of management so as ' prevent diabetes associated morbidity and mortality.

12.2.36 The programme has been reviewed and would be further extended to cover additional districts in different states during the Eighth Plan. The experience gained in the pilot districts will be used to develop the programme as an integrated model for diabetes, hypertension and heart disease. The learning resource materials, both print and non-print, developed and validated in the pilot districts, will be used for the training of nurses and primary health care workers.

Accidents

12.2.37 For the treatment and rehabilitation of accident victims, accident and trauma services will be started in major cities and also, on pilot scale along some of the high traffic density national highways.

Mental Health Services

12.2.38 The Seventh Plan document had suggested initiation of a National Mental Health Programme with emphasis on community based approaches. However, due to fund constraints the programme has not made satisfactory progress.

12.2.39 During the Eighth Plan mental health services will be given priority. The strategies for mental health programme will be community based utilising the existing primary health care and district hospital services. A psychiatric centre in each of the districts/divisions will be established. Also, every medical college will be encouraged to start a separate Department of Psychiatry so that the required manpower, both medical and para-medical, can be trained.

Other Non-communicable Diseases Control Programmes

12.2.40 The programme for control of other non-communicable diseases will also be taken up on pilot basis. Resource constraints will not be allowed to come in the way of developing experience and appropriate technology for implementation of the control programme at a later date.

Medical Research

12.2.41 The Indian Council of Medical Research (ICMR) is the premier institution which is responsible for carrying out bio-medical and operational research in India. Imporfant achievements of the ICMR during previous plans include: demonstration of improved vector control using bio-environmental techniques for control of malaria and filaria; establishment of National Cancer Registry; multi drug therapy and short course chemo therapy for leprosy and TB respectively and a national surveillance system for AIDS infection. Various other institutions under the Ministry of Health and Family Welfare and medical colleges have done notable work in the field of medical research.

12.2.42 Research and Development activities by Indian Council of Medical Research and other academic institutions will be pursued during the Eighth Plan through the following strategies -

1. Establishmnet of an integrated Bio-medical Research Complex to strengthen research activities and to optimise the utilisation of the available resources and facilities.
2. Promotion of excellence by rationalising grants to promising scientists in medical colleges and strengthening of extramural centres for research under eminent scientific leadership.
3. Establishment of a network of research units in medical colleges for multi-centric studies.
4. Optimal utilisation of resources through coordination and development of proper linkages with sister agencies, commercial utilisation of research findings, constant review of the status of application of research findings by user agencies, continuing interaction with State authorities to determine area specific research needs, and through providing proper guidance and assistance as well as strengthening of research activities under the State Councils of Medical Research.
5. Development of a Centre for Epidemiologi-cal Intelligence.
6. Augmentation of research activities in specific priority areas viz., integrated Vector Control Programme for Malaria, Filaria and Japanese Encephalitis, integrated control of non-communicable diseases and development of vaccines for communicable diseases as well as fertility regulation.
7. Enhancement of Research and Development on Family Planning and Maternal and Child Health.
8. Collaboration with international agencies for transfer of appropriate technology to the Indian scientists.

 Indian Systems of Medicine and Homoeopathy

12.2.43 Teaching and training programmes in ISM and H were promoted during the Seventh Plan. Clinical research on drugs of various systems, collection, cultivation and propagation of medicinal plants and standardisation of drugs were encouraged. The Central Councils dealing with these systems of medicine have been strengthened to provide support for training and research in their respective area.

12.2.44 The National Health Policy assigned an important role to ISM and H in the delivery of health services. There are about 5.25 lakhs institutionally trained practitioners of ISM and H. These practitioners are close to the community not only in geographical proximity but also in terms of cultural and social ethos and as such they can play significant role in primary health care delivery. The strategy for utilisation of ISM and H for health care delivery during the Eighth Plan would comprise of the following -

1. There are more than 200 colleges of ISM and H. One of the important tasks during the Eighth Plan would be to provide adequate facilities for training in these colleges so that the graduates emerging from these acquire the desired level of knowledge and skill necessary for patient care. Postgraduate training programmes also require strengthening for the purpose of manpower development for teaching and research in ISM and H.
2. To integrate the practitioners of ISM and H in the mainstream of health care delivery system, the graduate curriculum of these systems will be suitably oriented to make them conversant with the national health problems, policies and programmes. Refresher courses will also be organised fot-the inservice practitioners of ISM and H" towards the same objective.
3. There are more than 5000 pharmaceutical units, engaged in the production of drugs of these systems of medicine. Suitable steps will be taken to enforce the provisions of Drugs and Cosmetics Act to maintain the quality of products of ISM and H produced in the country.
4. Research and Development for the production and standardisation of drugs of ISM and H will be supported during the Plan. The existing research institutions will be strengthened for this purpose.
5. The cultivation, conservation and regeneration of medicinal plants will be supported in State/joint sector farms. There is great potential for internal sale and export of these plants, herbs and formulations.
6. Separate departments, directorates and drug control organisations at the Central and State Government level will be established, wherever they are not existing currently.
7. Central Councils for Research in ISM and H would continue to receive support during the Plan so that they can discharge their responsibilities efficiently.

Family Welfare Programme

l2.3.1 High growth rate of the population continues to be one of the major problems facing the country. Although the 1991 Census recorded a marginal decline in the annual growth rate of population from 2.22% in 1971-81 to 2.11% in 1981-91 this would still mean an addition of 18 million people to the country's population annually.

12.3.2 The fast rate of population growth means that the economy has to grow faster to protect the already low level of per capita availability of food, clothing, housing, employment and social services.

12.3.3 The country is committed to social and economic justice to the millions of people living under conditions of poverty and deprivation. Failure to do so within a reasonable time-frame may generate social tensions and unrest. Besides this, the environmental degradation which is associated with unchecked growth of population carries the inherent risk of natural calamities and disasters.

12.3.4 In this context, population control assumes an overriding importance in the Eighth Plan.

 Review of the Performance

12.4.1 The basic premises of the Family Welfare Programme till now have been -

1. Acceptance of the family welfare is voluntary.
2. The Government's role is to create an environment for the people to adopt small family norm. This is done by spreading awareness, information and education by ensuring easy and convenient availability of family planning aids and services and by giving incentives for adopting family planning.
3. The programme, which is a 100% Centrally Sponsored Scheme has integrated family planning and Mother and Child Health (MCH) services and is being implemented through countrywide network of primary health centres and supporting institutions.

12.4.2 In spite of massive efforts in the form of budgetary support and infrastructure development, the performance of family welfare programme has not been commensurate with the inputs. Right from the beginning the achievement of the set goals has been unsatisfactory, resulting in the resetting of targets, as indicated in Table 12.1.

Table 12.1

*CBR: Crude Birth Rate

Seventh Plan Performance

12.4.3 With the long-term objective of achieving the Net Reproduction Rate (NRR) of unity, the Seventh Plan had set the following demographic goals -

* Provisional (SRS Data)

While the Seventh Plan targets of achieving CPR of 42% was achieved, this was not matched by a commensurate decline in the birth rate, possibly because of improper selection of the cases.

12.4.4 The performance in terms of various methods of couple protection were not uniform. While the targets for Intra Uterine Device (IUD) were fully achieved and those for oral contraceptives and conventional contraceptives were exceeded, the targets for sterilisation operations fell short by about a quarter. The targets and performance of the Seventh Plan and the year-wise break up of performance are given in Tables 12.2 and 12.3.

12.4.5 State-wise analysis of performance of the programme reveals that Punjab, Kerala, Maharastra and Tamil Nadu have performed very well in achieving the targets while Assam, LI. P., M.P., Bihar, Rajasthan and some North-Eastern States have performed poorly.

Table 12.2 Target and Performance of the Seventh Plan
(in million)

* Indicates terminal year targets and achievement.

Table 12.3 Yearwise Performance of the Seventh Plan
(Nos. in million)

Note: The figures within brackets indicate percentage achievement.

12.4.6 Under the Maternal and Child Health Programme, which is an integral part of family planning programme, targets for reducing Infant Mortality Rate to 90 per thousand live births and for reducing maternal mortality were fixed for the Seventh Plan. The Universal Immunisation Programme (UIP) launched in 1985 with the objective of providing universal coverage of immunisation to pregnant mothers and infants was a major initiative in this direction. Although ail the districts in the country have been brought under UIP, the targets for immunisation could not be fully met due to problems of cold chain facilities, inadequate trained manpower, logistic problems, etc. Other programmes aimed at women and children viz., control of diarrhoeal diseases among the children, prophylaxis against anaemia and Vitamin A supplementation for prevention of nutritional blindness achieved varying degrees of success. Nevertheless these efforts were able to achieve a suhstatial reduction in 1MR from 97 per thousand live births in 1985 to 80 in 1990.

Constraints

12.4.7 Containment of population growth is not merely a function of couple protection or contraception but is directly correlated with female literacy, age at marriage of the girls, status of women in the community, IMR, quality and outreach of health and family planning services and other socio-economic parameters. Table 12.4 illustrates this.

12.4.8 The Family Welfare Programme has essentially remained a uni-sector programme of the Ministry of Health and Family Welfare. It has yet to be recognised as a major national concern drawing priority attention and concom-mitant strong political, social and administrative commitment for the purpose of making it a significant part of our economic development strategy. A national consensus and strong public opinion in its favour, cutting across political, ethnic, religious and geographical boundaries is as yet lacking.

12.4.9 The family welfare programme has also suffered on account of centralised planning and target setting from the top. Regional variations and diversities have not been generally taken into consideration, with the result that similar set of approaches and policies and targets have been applied in States like UP, MP, Bihar and Rajasthan where the healtn infrastructure is weak and related social inputs are lacking and also for the States like Haryana and Andhra Pradesh where factors other than development of infrastructure contributed to poor performance. Monitoring mechanism under the programme has been reduced to a routine target reporting exercise incapable of identifying roadblocks and applying timely correctives.

12.4.10 Both pro-service and in-service training of programme personnel is poor because of lack of due emphasis at all levels on training programmes for family welfare. Absence of proper training, education and motivation of the programme personnel including supervisory staff has led to an ineffective, insensitive implementation of the programme.

Table 12.4 Selected Indicators

12.4.11 The programme has remained a Government programme, the community's active involvement and participation being marginal. Due to inadequacy of Information, Education and Communication (IEC) activities the knowledge of the community about the contraceptives, their availability, safety, etc. are at a low level. Adoption of the small family norm and use of appropriate measures for birth control are matters of personal choice and decision. The IEC activities have to take this into account. However, till recently, the IEC activities have been directed more to national issues rather than personal issues. Undoubtedly, this incongruity of perception between the people and the providers of services has cost the programe dearly.

12.4.12 Family Planning Programme is being run as a 100% Centrally Sponsored Scheme. The entire outlay is included in the Plan with the result that a major portion (60-70%) of the outlay goes for meeting the expenditure of maintenance nature, leaving very little resources for further expansion, and strengthening of the programme or for any new initiatives. Further, the entire expenditure is borne by the Centre, although the implementing agency is the States Government.

12.4.13 Lot of incentives and awards have been built into the programme. The incentives and awards have not been unequivocally shown to be very effective in the promotion of small family norms. On the other hand , defects such as over-reporting, low quality acceptors and neglect of non-terminal methods of contraception and MCH activities have often been observed to creep into the programme. The element of disincentives is also missing from in programme.

12.4.14 The efforts for the containment of population growth have to be intensified simultaneously on several fronts. This calls for an integrated approach and concerted efforts through both the government and the non- government organisations, besides social and political commitment to make it a national movement.

Strategy for the Eighth Plan

12.5.1 Containing population growth has been accepted by the Government as one of the six most important objectives of the Eighth Plan, with the aim of reducing the birth rate from 29.9 per thousand in 1990 to 26 per thousand by 1997. The IMR will also be brought down from 80 per thousand live births in 1990 to 70 by 1997.

12.5.2 To give a major thrust in this priority area, which constitutes the pivotal point for the success of all developmental efforts, a National Population Policy needs to be enunciated aud adopted by the Parliament. Given the political commitment at all levels, it must generate a cascading effect to become a people's movement. Social determinants such as female literacy, age at marriage, employment opportunities for women, and their status in society are as important as achieving a reduction in infant mortality, improving health and nutrition of pre-school child and providing a comprehensive package of maternal health care services. Such an inter-sectoral interaction, supported by political commitment and a popular mass movement, will constitute the approach to strategic interventions during the plan period. A Committee of the National Development Coun-cil(NDC) on Population has been constituted in February, 1992 to consider these issues and based on its report, a concrete plan of action will be worked out.

12.5.3 Within the above mentioned broad guidelines, which have been enunciated in the Eighth Plan Directional Paper already accepted by the NDC the following strategies will be adopted for achieving the goals of family welfare during the Eighth Plan.

i) Convergence of services provided by various social services sectors, e.g., welfare, human resource development, nutrition, etc. Based on a holistic approach to social development and population control, integrated programmes for raising female literacy, female employment, status of women, nutrition and reduction of infant and maternal mortality will be evolved and implemented. The strategy will be (a) to pool the existing resources available for individual and fragmented schemes on these activities and provide additional resources required; (b) to restructure, redesign and integrate these under a common umbrella; and (c) to evolve proper mechanisms for planning, implementing and monitoring these programmes at various levels.

ii) Decentralised planning and implementation will be another strategy. Although there are likely to be commonalities of approach in the general contours of population policy, it is critical that the programme content relates to area-specific planning at the district, the sub-district and the panchayat level based on critical and indepth disseg-regated analysis of a constellation ofsocio-biological indices and demographic determinants. Area specific strategies would mean flexibility of approach and fund utilisation. Targets, if any, will he determined, fixed and monitoried at the district level and the process will be from below upwards.

iii) As a natural corrolary to decentralised planning and implementation, Panchayati Raj institutions like Gram Panchayat and Zila Parishads, etc., will have to play significant role in planning, implementing and administering the programme. The role of the Centre will be limited to general policy planning and coordination, providing technological inputs where required, safeguarding critical areas and taking innovative leads.

iv) With greater involvement of the people in the population control and family planning programmes through the Panchayati Raj System as envisaged in the Constitution (Seventy-Second Amendment) Bill 1991, the programme will become one of "people's operation with government cooperation". The health planners and administrators must not only become sensitive and responsive to the felt needs of the people but must also adapt to the instrumentality of local self-government.

v) The younger couples, who are reproduc-tively most active will be the focus of attention, with necessarily a greater emphasis on spacing methods, although the terminal methods would continue to remain the important means of birth control. Medical Termination of Pregnancy (MTP) will have to play an important role in the entire scheme of family planning in the Eighth Plan. The coining generation will have to be, therefore, prepared well to accept the small family as a social responsibility. Population education and family life education need to be made a part of general education in which school teachers' role, both as an educator as well as a rolemodel, becomes of paramount importance.

vi) The targetted reduction in the birth rate will he the basis of designing, implementing and monitoring the programme against the current method of couple protection rate. While broad guidelines may he prepared by the Centre, suitable parameters would be designed by the individual States for this purpose. Identification and registration of eligible couples, enforcement of civil registration scheme, registration of mothers and children for child survival and safe motherhood activities arc areas requiring special monitoring.

vii) The outreach and quality of family welfare services will be improved. For this, the health services infrastructure will have to he made fully operational and efficient. This would involve -

1. completion of infrastructural facilities initiated during the earlier plans like buildings for sub-centres, PHCs, CHCs, etc., and installation of necessary equipments;
2. ensuring placement of adequate number of welltrained workers specially at the grass-root level;
3. providing mobility to workers, specially the peripheral ones; and
4. ensuring adequate drugs and other essential supplies at the Sub-centre and PHC by suitably increasing the funds for this purpose.

viii) The entire chain of CHC, PHC and Sub-centres will be equipped to deliver general health and MCH services in an integrated manner with a strong referral suppport and linkage at the District level. For this, facilities for services for mothers and children including reservation of beds for them at different levels will be ensured. Setting up of Regional Maternal and Child Health. Institutes will he part of the strengthening process of MCH infrastructure.

ix) Child survival and safe motherhood initiatives will be vigorously pursued. These initiatives will include (a) strengthening of Universal Immunisation Programme, (b) greater emphasis on Diarrhoea Control Programme and effective implementation of ORT programme, (c) Acute Respiratory Infections Control Programme, (d) Anaemia Management Programme and not just Anaemia prophylaxis, (e) Safe Motherhood Programme with high risk pregnancy approach and (f) intensified effort for training of birth attendants.

x) Any system is as good as the people who operate it. Therefore, major emphasis will be laid on health manpower planning along with a review of the education and training programmes of all categories of health care providers. Training will not only aim at providing requisite knowledge and skill, but also ensure development of such behavioural attributes that will he conducive to a closer interaction with the community. The methodology, the logistics and the content of training programme will be continuously reviewed. Special programmes would be chalked out for imparting pro-service and inservice training in programme management and IEC activities. To meet the training needs, various training institutions will be strengthened or new ones established, by providing adequate funds, staff, equipments and mobility.

xi) The entire package of incentives and awards will be restructured to make it more purposeful. Individual cash incentives have not made any impact and hence will be phased out. The payment of compensation to the acceptors for the wages lost due to hospitalisation, etc., will be left to the discretion of the States, thus providing flexibility in approach to suit the local requirements. Community incentives in the form of priority consideration under IRDP programmes, e.g., opening of schools, provision of drinking water facilities, linkage by roads, etc., will be built^p in the programme. The possibilities @f introducing certain disincentives to the non-adoptors of family planning will also be explored and introduced with due regard to the freedom and the fundamental rights of the people. The performance of the States in this vital sector of human and national concern will be recognised through additional resource allocation as a part of Central Plan assistance to those States which show better performance in terms of pre-determined demographic parameters.

xii) There is an urgent need to secure involvement and commitment of practitioners of all systems of medicine in the Population Control Programme. The practitioners of Indian System of Medicine and Homoeopathy, whose number is estimated to be more than half a million and who are the closest to the community both in terms of place of practice and the socio-cultural milieu of the community will be involved in the programme by -

1. providing well structured educational modules of instructions and training in population dynamics and family planning at the undergraduate level;
2. providing short-term re-orientation courses to the practising doctors;
3. providing incentives and recognition for exhibiting initiative and leadership in population control activities; and
4. promoting a sense of comraderie between these practitioners and the grassroot functionaries of the health and family welfare programme with a view to synergising and potentiating their mutual input. A similar approach is also needed to strengthen and secure deeper involvement of practitioners of modern system of medicine. Organisations such as Indian Medical Association (IMA) will be involved in a greater measure in this national task.

xiii) The role of voluntary organisation in a mass movement such as population control is critical for generation of momentum and accelerating the pace of progress. There is a need to incorporate family planning as a major objective of all voluntary organisations concerned with health and/or education-related activities. Substantially increassed amount of funds will he channelised through these agencies during the Eighth Plan. The establishment of an apex organisation to develop networking between all such voluntary organisations committed to the promotion of national efforts in this important area of human endeavour will be considered.

xiv) As an extrapolation of the concept of voluntary organisations, is the role and place of organised corporate sector which covers approximately 20 million workers and their families. Effective methods will he evolved to get the organised sector involved in the implementation of family welfare programme.

xv) Special efforts will he made to involve the community in the Family Planning Programme. The strategy will he to prepare the community to accept the responsibility, the ownership and the control of the programme fully in the long run. Panchay-ats, youth clubs, village committees, Nehru Yuvak Kendras, women organisations, etc., can play an important role in community motivation, organisation of camps and contraceptive distribution. Grassroot level functionaries, e.g., village dais. Village Health Guides (VHGs), Auxiliary Nurse Midwives (ANMs), Anganwadi workers, village extension workers, primary school teachers. Gram Panchayat staff etc.will play a facilitatory and supportive role to the community organisations for generating the necessary momentum for population control movement by the people. The village level local functionary will he the kingpin of these new initiatives.

xvi) The village/neighbourhood tea shops, pan shops, public distribution system shops, pharmacies, cooperatives, etc., will he utilised for community based contraceptive sale and distribution.

xvii) The social marketing programme, which. was originally launched for Nirodh distribution has demonstrated the significance and importance of involvement of the corporate sector to achieve the family planning objectives. This programme will be extended to the social marketing of oral pills as well as tor market research and educational activities for which the Corporate Sector possesses special skill and sensitivity.

xviii) Information, Education and Communication, which are critical inputs will be further strengthened and expanded. The IEC activities of the health and the family welfare sector will be integrated. Greater use of the mass media will be made to disseminate the message of family planning to the remotest corner of the country. The entire system of pricing the media time vis-a-vis its social responsibility has to be given a fresh look, different from the commercial angle. Area specific IEC material will be developed and produced. At the viewers' level, efforts will be made to pool resources of various social sectors and to provide community TV/ radio sets, besides maintaining them. The backbone of the IEC efforts will, however, remain the inter-per-sonal communication for which the grass-root level female worker will have to be trained and effectively utilised.

xix) A new thrust in the research and development of methods aimed at regulation of fertility in the male, and of vaccines for fertility regulation, both in the male and female, will be given. Fertility regulation practices such as the use of special herbs by the community particularly in the tribal areas, will also be subjected to research. While intensification of bio-medical research is necessary, research in social and behavioural sciences to explore the human dimensions is vital. Health systems research to optimise operational framework, to improve the efficiency and effectiveness of the service provided and to evolve cost-effective interventions in various areas of family planning operation, will be given high priority.

xx) A continuous monitoring, review and evaluation is an essential component for the successful implementation of the programme,. Development and strengthening of health management information system, with district and sub- district data bases of health and demographic parameters and linkages aimed at concurrent evaluation of family planning programme will be developed. This will provide critical inputs at the district and sub- district level and the much needed data for area-specific planning and time-bound implementation.

xxi) The family planning programme has a multi-sectoral dimension. For the purpose of effective intersectoral coordination and to provide the programme appropriate focus and priority, a proper institutional setup with the backing of the highest political and administrative authority is an essential requirement. The recommendations of the Committee on Population, constituted by the NDC, will be implemented.

12.5.4 To sum up, the base and the basis of the population control programme during the Eighth Plan will be decentralised, area-specific micro-planning, within the general directional framework of a national policy aimed at generating a people's movement with the total and committed involvement of community leaders, irrespective of their denominational affiliations and, linking population control with the programmes of female literacy, women's employment, social security, access to health services and mother and child care.

Outlays

12.5.5 The total outlay for the Central Health Sector is Rs. 1800 crores. The outlays for the Central, States and Union Territories Plans under the Health Sector are shown in Annexures 12.4 and 12.5.

12.5.6 The outlays for the Family Welfare Programme are Rs.6500 crores. Details are given in Annexure 12.6.

Annexure 12.1

Progres of Establishment-Minimum Need Programme

*: Excluding Subsidiary Health Centres, Mini Health Centres etc. Source : Working Group Discussions for Annual Plan 1992-93, Planning Commission.

 Annexure12.2
Construction of Buildings for Sub-centres, PHCs and CHCs

Source : Bulletin on Rural Haelth Statistics in India - December 1991 issued by the Directorate General of Health Services , Ministry of Health and Family Welfare , New Delhi.

Annexure 12.3
Health Manpower Working in Rural Areas

Source : Bulletin on Rural Health Statistics in India - December 1991 issued by the Directorate General of  Health Services , Ministry of Health and Family Welfare , New Delhi.
* Includes 67 posts in position in J and K for which corresponding sanctioned posts are not indicated.

Eighth Plan Outlay - Health Sector ( Annexure12.4)
(Rs. Crores) 

Eighth Plan Outlays-Health Sector-Distribution by States/Union Territories. Annexure 12.5   
(Rs. Crores)

Annexure 12.6 Eighth Plan Outlay - Family Welfare Sector
(Rs. Crores)