Health Program in India – भारतीय ग्रामीण चिकित्सा परिषद

NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME

The National Vector Borne Disease of programme Control Programme (NVBDCP) is implemented in the State/UT's for prevention and control of vector borne diseases namely Malaria, Filariasis, Kala-azar, Japanese Encephalitis (JE), Dengue and Chikungunya. The Directorate of NVBDCP is the nodal agency for planning, policy making and technical guidance and monitoring and evaluation implementation in respect of prevention and control of these vector borne diseases under the overall umbrella of NRHM. The States are responsible for planning, implementation and supervision of the programme. The vector borne diseases are major public health problems in India. Chikungunya fever which has re-emerged as epidemic outbreaks after more than three decades has added to the problem. The prevention and control of vector borne diseases is complex; as their transmission depends on interaction of numerous ecological, biological, social and economic factors including migration (1).

Out of the six vector borne diseases, malaria, filariasis, Japanese encephalitis, dengue and chikungunya are transmitted by different kind of vector mosquitoes, while kala-azar is transmitted by sand flies. The transmission of vector borne diseases in any area is dependent on frequency of man-vector contact, which is further, influenced by various factors including vector density, biting time, etc. Mosquito density is directly related with water collection, clean or polluted, in which the mosquitoes breed.

Under NVBDCP, the three pronged strategy for prevention and control of VBDs is as follows:

(i) Disease management including early case detection and complete treatment, strengthening of referral services, epidemic preparedness and rapid response. (ii) Integrated vector management (IVM) for transmission risk reduction including indoor residual spraying in selected high-risk areas, use of insecticide treated bed-nets, use of larvicolous fish, anti-larval measures in urban areas, source reduction and minor environmental engineering. (iii) Supportive interventions including behaviour change communication (BCC), public private partnership and inter-sectoral convergence, human resource development through capacity building, operational research including studies on drug resistance and insecticide susceptibility, monitoring and evaluation through periodic reviews/field visits, web based management information system, vaccination against JE and annual mass drug administration against lymphatic filariasis (1)

NATIONAL LEPROSY "ERADICATION" PROGRAMME

The National Leprosy Control Programme (NLCP) has been in operation since 1955, as a centrally aided programme to achieve control of leprosy through early detection of cases and DDS (dapsone) monotherapy on an ambulatory basis. The NLCP moved ahead initially at a slow pace, presumably for want of clear-cut policies or operational objectives for nearly two decades (10). The programme gained momentum during the Fourth Five Year Plan after it was made a centrally-sponsored programme. In 1980 the Government of India declared its resolve to "eradicate" leprosy by the year 2000 and constituted a Working Group to advise accordingly. The Working Group submitted its report in 1982 and recommended a revised strategy based on multi-drug chemotherapy aimed at leprosy "eradication" through reduction in the quantum of infection in the population, reduction in the

sources of infection, and breaking the chain of transmission of disease. In 1983 the control programme was redesignated National Leprosy "Eradication" Programme with the goal of eradicating the disease by the turn of the century. The aim was to reduce case load to 1 or less than 1 per 10,000 population.

To strengthen the process of elimination of leprosy in the country, the first World Bank supported project was introduced in 1993. On completion of this project, the 2nd phase of project with World Bank support was started in 2001-02 which ended in December 2004. Since then, the programme is being continued with Government of India funds with technical support from WHO and International Federation of Anti-Leprosy Association (ILEP) organizations. The programme has been integrated with general health care system in 2002-03, since then leprosy diagnosis and treatment services are available at all PHCs and government hospitals.

The components of the programme are as follows:

(1) Decentralized integrated leprosy services through general health care system; (2) Capacity building of all general health services functionaries; (3) Intensified information, education and communication; (4) Prevention of disability and medical rehabilitation; and (5) Intensified monitoring and supervision.

After introduction of MDT, the recorded case load of leprosy came down from 57.6 cases per 10,000 population in 1981 to less than one at the national level in December 2005, and the country could achieve the goal of leprosy elimination at national level as set by the National Health Policy (2002).

34 states/UTs achieved the status of leprosy elimination. Only 2 states/UTs viz. Chhattis garh and Dadra & Nagar Haveli are yet to achieve elimination. Odisha, who has achieved elimination status earlier, show PR 1 per 1000 population (6).

A total of 209 high endemic districts were identified for special action during 2012-13. 1792 blocks and 150 urban areas were identified for special activities, i.e., house to house survey along with IEC and capacity building of the workers and volunteers (1)

NATIONAL TB ELIMINATION PROGRAMME

National Tuberculosis Programme (NTP) has been in operation since 1962. However, the treatment success rates were unacceptably low and the death and default rates remained high. Spread of multidrug resistant TB was threatening to further worsen the situation.

In 1993, in order to overcome these lacunae, the Government of India decided to give a new thrust to TB control activities by revitalizing the NTP, with the assistance from international agencies. The Revised National TB Control Programme (RNTCP) thus formulated, adopted the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, as the most systematic and cost-effective approach to revitalize the TB control programme in India. Political and administrative commitment, to ensure the provision of organized and comprehensive TB control services was obtained. Adoption of smear microscopy for reliable and early diagnosis was introduced in a decentralized manner in the general health services. DOTS was adopted as a strategy for provision of treatment to increase the treatment completion rates. Supply of drugs was also strengthened to provide assured supply of drugs to meet the requirements of the system (17).

The objectives of the RNTCP are:

1. Achievement of at least 85 per cent cure rate of infectious cases of tuberculosis, through DOTS involving peripheral health functionaries; and 2. Augmentation of case finding activities through quality sputum microscopy to detect at least 70 per cent of estimated cases.

The revised strategy was introduced in the country in a phased manner. The RNTCP has expanded rapidly over the years and since March 2006, it covers the whole country. The RNTCP has now entered into it's second phase in which the programme aims to consolidate the gains made to date, to widen services in terms of activities and access and to sustain the achievements. The new initiatives and the wider collaboration with other sectors aim to provide standardized treatment and diagnostic facilities to all TB patients irrespective of the health care facility from which they seek treatment. The RNTCP also envisages improved access to marginalized groups such as urban slum dwellers and tribal groups etc.

RNTCP is built upon infrastructure already established by the previous national tuberculosis programme, while incorporating the elements of the internationally recommended DOTS.

DOTS strategy adopted by Revised National TB Control Programme initially had the following five main components:

1. Political will and administrative commitment. 2. Diagnosis by quality assured sputum smear microscopy. 3. Adequate supply of quality assured short course chemotherapy drugs. 4. Directly observed treatment. 5. Systematic monitoring and accountability.

In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP. The components are as follows:

• Pursuing quality DOTS - expansion and enhancement. • Addressing TB/HIV and MDR-TB. • Contributing to health system strengthening. • Engaging all care providers. • Empowering patients and communities. • Enabling and promoting research (diagnosis, treatment, vaccine). NATIONAL AIDS CONTROL PROGRAMME

National AIDS Control Programme was launched in India in the year 1987. The Ministry of Health and Family Welfare has set up National AIDS Control Organization (NACO) as a separate wing to implement and closely monitor the various components of the programme. The aim of the programme is to prevent further transmission of HIV, to decrease morbidity and mortality associated with HIV infection and to minimize the socio-economic impact resulting from HIV infection.

The milestones of the programme are summarized as follows (23A):

1986 - First case of HIV detected. - AIDS Task Force set up by the ICMR. - National AIDS Committee established under the Ministry of Health. 1990 - Medium Term Plan launched for four states and the four metros. 1992 - NACP-1 launched to slow down the spread of HIV infection. - National AIDS Control Board constituted. - NACO set-up. 1999 - NACP-II begins, focussing on behaviour change, increased decentralization and NGO involvement. State AIDS Control Societies established. 2002 - National AIDS Control Policy adopted. - National Blood Policy adopted. 2004 - Anti-retroviral treatment initiated. 2006 - National Council on AIDS constituted under chairmanship of the Prime Minister. - National Policy on Paediatric ART formulated. 2007 - NACP-III launched for 5 years (2007-2012). 2014 - NACP-IV launched for 5 years (2012-2017). 2017 - National Strategic Plan for HIV/AIDS and STIs 2017-2024

The national strategy has the following components: establishment of surveillance centres to cover the whole country; identification of high-risk group and their screening; issuing specific guidelines for management of detected cases and their follow-up; formulating guidelines for blood bank, blood product manufacturers, blood donors and dialysis units; information, education, communication activities by involving mass media and research for reduction of personal and social impact of the disease; control of sexually transmitted diseases; and condom programme.

The Government of India initiated programmes of prevention and raising awareness under the Medium Term Plan (1990-92), NACP-I (1992-99), NACP-II (1999-2006) and NACP-III (2007-2012). Based on the lessons learnt and achievements made in Phase I, II and III. India developed the Fourth National Programme Implementation Plan (NACP-IV, 2012-2017). The primary goal of NACP-IV is to halt and reverse the epidemic in India over the next 5 years by integrating programmes for prevention, care, support and treatment.

NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS

The National Programme for Control of Blindness was launched in the year 1976 as a 100 per cent centrally sponsored programme and incorporates the earlier trachoma control programme started in the year 1968. The programme was launched with the goal to reduce the prevalence of blindness from 1.4 to 0.3 per cent. As per 2015-19 survey the prevalence of blindness was 0.36 per cent (11).

Main objectives of the programme in the 12th Five Year Plan period are:

1. To continue three ongoing signature activities, i.e., performance of 66 lacs cataract operations per year; school eye screening and distribution of 9 lacs free spectacles per year to school children suffering from refractive errors; and collection of 50,000 donated eyes per year for keratoplasty (6).

2. To reduce the backlog of avoidable blindness through identification and treatment of curable blind at primary, secondary and tertiary levels, based on assessment of the overall burden of visual impairment in the country;

3. Develop and strengthen the strategy of NPCB for "Eye Health for All" and prevention of visual impairment, through provision of comprehensive universal eye-care services and quality service delivery;

4. Strengthening and upgradation of Regional Institutes of Ophthalmology (RIOs) to become centre of excellence in various sub-specialities of ophthalmology and also other partners like Medical Colleges, District Hospitals, Sub-district Hospitals, Vision Centres, NGO Eye Hospitals;

5. Strengthening the existing infrastructure facilities and developing additional human resources for providing high quality comprehensive eye care in all districts of the country;

6. To enhance community awareness on eye care and lay stress on preventive measures;

7. Increase and expand research for prevention of blindness and visual impairment.

8. To secure participation of voluntary organizations/private practitioners in delivering eye care.

IODINE DEFICIENCY DISORDERS (IDD) PROGRAMME

India commenced a goitre control programme in 1962, based on iodized salt. At the end of three decades, the prevalence of the disease still remained high. As a result, a major national programme - "The IDD Control Programme" was initiated in which nation-wide, rather than area-specific use of iodized salt is being promoted. It was decided as a national policy to fortify all edible salt in a phased manner by end of 8th Plan. The essential components of a national IDD programme are use of iodized salt in place of common salt, monitoring and surveillance, manpower training and mass communication.

The objectives of the programme are (1):

1. Surveys to assess the magnitude of the iodine Deficiency Disorders in districts. 2. Supply of iodized salt in place of common salt. 3. Resurveys to assess iodine deficiency disorders and the impact of iodized salt after every 5 years in districts. 4. Laboratory monitoring of iodized salt and urinary iodine excretion. 5. Health education and publicity.

Significant achievements

Consequent upon liberalization of iodized salt production, Salt Commissioner has issued licenses to 824 salt manufacturers out of which 777 units have commenced production. These units have an annual production capacity of 222 lakh metric tonnes of iodized salt.

The production/supply of iodized salt from April 2015 to August 2015 was 26.44 lakh tonnes and 25.12 lakh tonnes.

Notification banning the sale of non-iodized salt for different human consumption in the entire country is already issued under "Food Safety & Standards Act 2006 and Regulations 2011".

For effective implementation of National iodine Deficiency Disorders Control Programme 34 States/UTs have established iodine Deficiency Disorders Control Cells in their State Health Directorate.

UNIVERSAL IMMUNIZATION PROGRAMME

Experience with smallpox eradication programme showed the world that immunization was the most powerful and cost-effective weapon against vaccine preventable diseases. In 1974, the WHO launched its "Expanded Programme on Immunization" (EPI) against six, most common, preventable childhood diseases, viz. diphtheria, pertussis (whooping cough), tetanus, polio, tuberculosis and measles. From the beginning of the programme UNICEF has been providing significant support to EPI

"Expanded" in the WHO definition meant adding more disease controlling antigens of vaccination schedules, extending coverage to all corners of a country and spreading services to reach the less privileged sectors of the society (39).

The primary health care concept as enunciated in the 1978 Alma-Ata Declaration included immunization as one of the strategies for reaching the goal of "Health For All" by the year 2000. While the WHO's programme is called EPI, the UNICEF in 1985 renamed it as "Universal Child

Immunization" (UCI). There was absolutely no difference between these two. The goal was the same, i.e., to achieve universal immunization by 1990. EPI is regarded as the instrument of UCI (40).

The first vaccine to be introduced in India was BCG in 1962 as part of the National Tuberculosis Programme. Over the years, various new vaccines have been introduced and many milestones achieved. Table 8 gives a chronological listing of some important milestones in India's immunization programme.

The Government of India launched its EPI in 1978 with the objective of reducing the mortality and morbidity resulting from vaccine-preventable diseases of childhood, and to achieve self-sufficiency in the production of vaccines. Universal Immunization Programme was started in India in 1985. It has two vital components: immunization of pregnant women against tetanus, and immunization of children in their first year of life against the six EPI target diseases. The aim was to achieve 100 per cent coverage of pregnant women with 2 doses of tetanus toxoid (or a booster dose), and at least 85 per cent coverage of infants with 3 doses each of DPT, OPV, one dose of BCG and one dose of measles vaccine by 1990. Universal immunization was first taken up in 30 selected districts and catchment areas of 50 Medical Colleges in November 1985. The programme now covers entire country and practice areas of all the 242 Medical colleges, thus creating a base for wider coverage (42). A "Technology Mission on Vaccination and Immunization of Vulnerable Population, specially Children" was set up to cover all aspects of the immunization activity from research and development to actual delivery of services to the target population (43).

The immunization services are being provided through the existing health care delivery system (i.e., MCH centres, primary health centres and subcentres, hospitals, dispensaries and ICD units). There is no separate cadre of staff for EPI. The recommended immunization schedule is on page 136.

Although the target was "universal" immunization by 1990, in practice, no country, even in the industrialized world, has ever achieved 100 per cent immunization in children. 'Universal' immunization is, therefore, best interpreted as implying the ideal that no child should be denied immunization against tuberculosis, diphtheria, whooping cough, tetanus, polio and measles. It is, however, generally agreed that when immunization coverage reaches a figure of 80 per cent or more, then disease transmission patterns are so severely disrupted as to provide a degree of protection even for the remaining children who have not been immunized, because of "herd immunity" (44). It is also important that children are immunized during the first year of life and that levels of immunization are sustained so that each new generation is protected.

Significant achievements have been made in India. At the beginning of the programme in 1985-86, vaccine coverage ranged between 29 per cent for BCG and 41 per cent for DPT. By the end of 2021, coverage levels had gone up significantly to about 85 per cent for tetanus toxoid for pregnant women, about 85 per cent for BCG, 85 per cent for DPT 3 doses, 85 per cent for OPV 3 doses, 85 per cent for HepB3, 85 per cent for Hib, and 81 per cent for MCV₂. Since then, there is a significant decline in the reported incidence of the vaccine preventable diseases as compared to their incidence in 1987, as shown in Table 1.

To strengthen routine immunization, Government of India has planned the State Programme Implementation Plan (PIP) part C. It consists of:

In addition, central government is supporting in supplies of auto-disable syringes, downsizing the BCG vial from 20 doses to 10 doses to ensure that BCG vaccine is available in all immunization session sites, strengthening and maintenance of the cold chain system in the states, and supply of vaccines and vaccine van.

NATIONAL HEALTH MISSION

The Ministry of Health and Family Welfare is implementing various schemes and programmes and national initiatives to provide universal access to quality health care. The approach is to increase access to the decentralized health system by establishing new infrastructure in deficient areas and by upgrading the infrastructure in existing institutions. As part of the plan process, many different programmes have been brought together under the overarching umbrella of National Health Mission (NHM), with National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) as its two sub-Missions. The National Health Mission was approved in May 2013. The main programmatic components include health system strengthening in rural and urban areas; Reproductive - Maternal - New-born - Child and Adolescent Health (RMNCH+A); and control of communicable and non-communicable diseases. An important achievement of NΗΜ has been considerable reduction in out of pocket expenses from 72 per cent to 60 per cent (1).

The Government of India has introduced a series of programmes over the past two decades to address maternal and new-born health. The major milestones so far include (48)

a. 1992 - Child Survival and Safe Motherhood Programme (CSSM) b. 1997 - RCH I с. 2005 - RCH II d. 2005 - National Rural Health Mission e. 2013 - RMNCH+A Strategy f. 2013 - National Health Mission g. 2014 - India New-born Action Plan (INAP) h. 2018 - Ayushman Bharat Programme i. 2018 - Midwifery Initiative j. 2018 - RMNACH+N Strategy

Under NHM, health interventions/ initiatives are regularly designed and implemented to address the healthcare needs of the country. A list of interventions currently being implemented under NHM to reduce IMR and MMR is given below (49):

- Promotion of institutional deliveries through Janani Suraksha Yojana. - Capacity building of health care providers in basic and comprehensive obstetric care. - Operationalization of sub-centres, primary health centres, community health centres and district hospitals for providing 24 x 7 basic and comprehensive obstetric care services. - Name based web enabled tracking of pregnant women to ensure antenatal, intranatal and postnatal care. - Mother and child protection card in collaboration with the Ministry of Women and Child Development to monitor service delivery for mothers and children. - Antenatal, intranatal and postnatal care including iron and folic acid supplementation to pregnant & lactating women for prevention and treatment of anaemia. - Village health and nutrition days in rural areas as an outreach activity, for provision of maternal and child health services. - Health and nutrition education to promote dietary diversification, inclusion of iron and folate rich food as well as food items that promote iron absorption. - Janani Shishu Suraksha Karyakram (JSSK) entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery including caesarean section. The initiative stipulates free drugs, diagnostics, blood and diet, besides free transport from home to institution, between facilities in case of a referral, and drop back home. Similar entitlements have been put in place for all sick infants accessing public health institutions for treatment. - To sharpen the focus on the low performing districts, 184 high priority districts have been prioritized for Reproductive Maternal New-born Child Health + Adolescent (RMNCH+A) interventions for achieving improved maternal and child health outcomes. - Emphasis on facility based new-born care at different levels to reduce child morbidity and mortality: Setting up of facilities for care of sick new-born such as Special New Born Care Units (SNCUs), New-born Stabilization Units (NBSUs) and New-born Care Corners (NBCCs) at different levels is a thrust area under NHΜ. - Capacity building of health care providers: Various trainings are being conducted under NHM to train doctors, nurses and ANMs for essential new-born care, early diagnosis and case management of common ailments of children. These trainings are on Navjaat Shishu Suraksha Karyakram (NSSK), Integrated Management of Neonatal and Childhood Illnesses (IMNCI), Facility Based New-born Care (FBNC), Infant and Young Child Feeding practices (IYCF), etc. - India New-born Action Plan (INAP) has been launched with an aim to reduce neonatal mortality and stillbirths. - Newer interventions to reduce new-born mortality vitamin K injection at birth, antenatal corticosteroids for preterm labour, kangaroo mother care and injection gentamicin to young infants in cases of suspected sepsis. - Home Based New Born Care (HBNC): Home based new-born care through ASHAs has been initiated to improve new born practices at the community level and early detection and referral of sick new born babies. - Intensified Diarrhoea Control Fortnight (IDCF) to be observed in July-August focusing on ORS and Zinc distribution for management of diarrhoea and feeding practices. - Integrated Action Plan for Pneumonia and Diarrhoea (IAPPD) launched in four states with highest infant mortality (Uttar Pradesh, Madhya Pradesh, Bihar and Rajasthan). - Management of malnutrition: Nutritional Rehabilitation Centres (NRCs) have been established for management of severe acute malnutrition in children. - Appropriate infant and young child feeding practices are being promoted in convergence with Ministry of Woman and Child Development. - Some programmes for control of communicable and non-communicable diseases are now under NHM. - Universal Immunization Programme (UIP): Vaccination protects children against many life threatening diseases such as tuberculosis, diphtheria, pertussis, polio, tetanus, hepatitis B, Hib, measles and Japanese encephalitis in endemic districts. Infants are thus immunized against nine vaccine preventable diseases every year. The Government of India supports the vaccine programme by supply of vaccines and syringes, cold chain equipment and provision of operational costs. - Mission Indradhanush has been launched in 528 high focus districts to reach more than 2.5 crore children who are either unvaccinated or partially vaccinated; those that have not been covered during the rounds of routine immunization for various reasons. They will be fully immunized against eight life-threatening but vaccine preventable diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles, haemophilus influenza type B and hepatitis-B. In addition, vaccination against Japanese encephalitis will be provided in selected districts/states of the country. Pregnant women will also be immunized against tetanus. - Mother and Child Tracking System (MCTS): A name based mother and child tracking system has been put in place which is web based to ensure registration and tracking of all pregnant women and new born babies so that provision of regular and complete services to them can be ensured. - Rashtriya Bal Swasthya Karyakram (RBSK) for health screening and early intervention services has been launched to provide comprehensive care to all the children in the age group of 0-18 years in the community. The purpose of these services is to improve the overall quality of life of children through early detection of birth defects, diseases, deficiencies. Development delays including disability. - Under National Iron Plus Initiative (NIPI), through life cycle approach, age and dose specific IFA supplementation programme is being implemented for the prevention of anaemia among the vulnerable age groups like under-5 children, children of 6-10 years of age group, adolescents, pregnant and lactating women and women in reproductive age along with treatment of anaemic children and pregnant mothers at health facilities. - Comprehensive primary health care through Ayushman Bharat Health and Wellness Centres Launched in 2018, Ayushman Bharat works a paradigm shift to move from sectoral and selective approach of health service delivery to a comprehensive range of health care service. - Ayushman Bharat aims to cover preventive, promotive and ambulatory care at primary, secondary and tertiary level by adopting a continuum of care approach. Since the screening, prevention and management of chronic illnesses including non-communicable diseases, tuberculosis, and leprosy have been introduced at these centres, training skill upgradation of the primary health team in all functional Health and Wellness Centres on NCDs and use of information technology application is being done. For details, please refer to page 547.

NATIONAL URBAN HEALTH MISSION

NUHM seeks to improve the health status of the urban population particularly slum dwellers and other vulnerable section by facilitating their access to quality health care.

NUHM would cover all state capitals, district headquarters and about 779 other cities/towns with a population of 50,000 and above (as per census 2011) in a phased manner. Cities and towns below 50,000 population will be covered by NRHM. The NUHM will focus on (39):

1. Urban poor population living in listed and unlisted slums; 2. All other vulnerable population such as homeless, rag-pickers, street children, rickshaw pullers, construction and brick and lime-kiln workers, sex workers and other temporary migrants; 3. Public health thrust on sanitation, clean drinking water, vector control etc.; and 4. Strengthening public health capacity of urban local bodies.

The treatment of seven metropolitan cities, viz., Mumbai, New Delhi, Chennai, Kolkata, Hyderabad, Bengaluru and Ahmedabad will be different. These cities are expected to manage NUHM through their Municipal Corporation directly.

The NUHM will provide flexibility to the states to choose which model suits the needs and capacities of the states to best address the healthcare needs of the urban poor. Models will be decided through community led action. All the services delivered under the urban health delivery system through the urban PHCs and urban CHCs will be universal in nature, whereas the outreach services will be targeted to the target group (slum dwellers and other vulnerable groups). Outreach services will be provided through the Female Health Workers (FHWs), essentially ANMs with an induction training of three to six months, who will be placed at the Urban PHCs. These ANMs will report at the U-PHC and then move to their respective areas for outreach services on designated days. On other days, they will conduct immunization and ANC clinics etc. at the U-PHC itself.

The NUHM would encourage the effective participation of the community in planning and management of health care services. It would promote a community health volunteer - Accredited Social Health Activist (ASHA) or Link Worker (LW) in urban poor settlement (one ASHA for 1000-2500 urban poor population covering about 200 to 500 households); ensure the participation by creation of community based institutions like Mahila Arogya Samiti (MAS) (50-100 households) and Rogi Kalyan Samitis. However, the states will have the flexibility to either engage ASHA or entrust her responsibilities to MAS. In that case, the incentives accruing to ASHA would accrue to MAS (50). The NUHM would provide annual grant of Rs. 5000/- to MAS every year.

Essential services to be rendered by the ASHA may be as follows (50):

(i) Active promoter of good health practices and enjoying community support. (ii) Facilitate awareness on essential RCH services, sexuality, gender equality, age at marriage/pregnancy; motivation on contraception adoption, medical termination of pregnancy, sterilization, spacing methods. Early registration of pregnancies, pregnancy care, clean and safe delivery, nutritional care during pregnancy, identification of danger signs during pregnancy; counselling on immunization, ANC, PNC etc., act as a depot holder for essential provisions like oral re-hydration therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine, oral pills and condoms, etc.; identification of target beneficiaries and support the ANM in conducting regular monthly outreach sessions and tracking service coverage. (iii) Facilitate access to health related services available at the Anganwadi/Primary Urban Health Centres/Urban Local Body (ULBs) and other services being provided by the ULB/State/Central Government. (iv) Formation and promotion of Mahila Arogya Samitis in her community. (v) Arrange escort/accompany pregnant women and children requiring treatment to the nearest Urban Primary Health Centre, secondary/tertiary level health care facility. (vi) Reinforcement of community action for immunization, prevention of water borne and other communicable diseases like TB (DOTS), Malaria, Chikungunya and Japanese Encephalitis. (vii) Carrying out preventive and promotive health activities with AWW/Mahila Arogya Samiti. (viii) Maintenance of necessary information and records about births and deaths, immunization, antenatal services in her assigned locality as also about any unusual health problem or disease outbreak in the slum, and share it with the ANM in charge of the area.

In return for the services rendered, she would receive a performance based incentive. For this purpose a revolving fund would be kept with the ANM at the U-PHC (in the PHC account), which would be replenished from time to time.

REPRODUCTIVE AND CHILD HEALTH PROGRAMME

Reproductive and child health approach has been defined as "people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and wellbeing, and couples are able to have sexual relations, free of fear of pregnancy and of contracting disease" (53).

The concept is in keeping with the evolution of an integrated approach to the programme aimed at improving the health status of young women and young children which has been going on in the country namely family welfare programme, universal immunization programme, oral rehydration therapy, child survival and safe motherhood programme and acute respiratory infection control etc. It is obviously sensible that integrated RCH programme would help in reducing the cost inputs to some extent because overlapping of expenditure would not be necessary and integrated implementation would optimise outcomes at field level.

The RCH phase-l programme incorporated the components relating child survival and safe motherhood and included two additional components, one relating to sexually transmitted disease (STD) and other relating to reproductive tract infection (RTI).

The RCH programme was based on a differential approach. Inputs in all the districts were not kept uniform. While the care components was same for all districts, the weaker districts got more support and sophisticated facilities were proposed for relatively advanced districts. On the basis of crude birth rate and female literacy rate, all the districts were divided into three categories. Category A having 58 districts, category B having 184 districts and category C having 265 districts. All the districts were covered in a phased manner over a period of three years. The programme was formally launched on 15th October 1997.

JANANI SURAKSHA YOJANA -

The National Maternity Benefit scheme has been modified into a new scheme called Janani Suraksha Yojana (JSY). It was launched on 12th April, 2005. The objectives of the scheme are reducing maternal mortality and neonatal mortality through encouraging delivery at health institutions, and focusing at institutional care among women in below poverty line families.

The salient features of Janani Suraksha Yojana are as follows (7):

a. It is a 100 per cent centrally sponsored scheme;

b. Under National Rural Health Mission, it integrates the benefit of cash assistance with institutional care during antenatal, delivery and immediate post-partum care. This benefit will be given to all women, both rural and urban, belonging to below poverty line household. However, with a view to give special focus in 10 low performing states (states having low institutional delivery rate), namely Uttar Pradesh, Uttarakhand, Madhya Pradesh, Jharkhand, Bihar, Rajasthan, Chhattisgarh, Odisha, Assam and Jammu & Kashmir, the benefit will be extended up to the third child if the mother, of her own accord, chooses to undergo sterilization in the health facility where she delivered, immediately after delivery. The other states are called high performing states. The Accredited Social Health Activist (ASHA) would work as a link health worker between the poor pregnant women and public sector health institution in the low performing states. ASHA would be responsible for making available institutional antenatal as well as postnatal care. She would also be responsible for escorting the pregnant women to the health centre.

REPRODUCTIVE MATERNAL, NEWBORN CHILD AND ADOLESCENT HEALTH (RMNCH+A) STRATEGY

In June 2012, the Government of India, Ethiopia, USA and the UNICEF convened the "Global Child Survival Call to Action: A Promise to Keep" summit in Washington, DC to energize the global fight to end preventable child deaths through targeted interventions in effective, life-saving interventions for children. More than 80 countries gathered at the Call to Action to pledge to reduce child mortality to 20 child deaths per 1000 live births in every country by 2035 (57). Eight months after the event, in February 2013, the Government of India held its own historic Summit on the Call to Action for Child Survival, where it launched "A Strategic Approach to Reproductive, Maternal, New-born, Child, and Adolescent Health (RMNCH+A) in India." Since that time, RMNCH+A has become the heart of the Government of India's flagship public health programme, the National Health Mission (64).

With support from USAID and its Maternal Child Health Integrated Programme (MCHIP), as well as from UNICEF, UNFPA, NIPI and other development partners, the Government of India has taken important steps to introduce and support RMNCH+A implementation. This approach is likely to succeed given that India already has a community based programme with presence of 9.15 lakh ASHA workers, as well as the three tiered health system in place. These provide a strong platform for delivery of services. This integrated strategy can potentially promote greater efficiency while reducing duplication of resources and efforts in the ongoing programme.

The RMNCH+A strategy is based on provision of comprehensive care through the five pillars, or thematic areas, of reproductive, maternal, neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care, entitlement, and accountability. The "plus" within the strategy focusses on:

- Including adolescence for the first time as a distinct life stage: - Linking maternal and child health to reproductive health, family planning, adolescent health, HIV, gender, preconception and prenatal diagnostic techniques; - Linking home and community-based services to facility-based care; and - Ensuring linkages, referrals, and counter-referrals between and among health facilities at primary (primary health centre), secondary (community health centre), and tertiary levels (district hospital).

In developing the RMNCH+A strategy, the aim is to reach the maximum number of people in the remotest corners of the country through a continuum of services, constant innovation, and routine monitoring of interventions. In rolling out the new strategy, the emphasis is on high impact interventions in each of the five thematic areas of reproductive, maternal, new-born, child, and adolescent health, and then to focus its efforts, and those of its development partners, on improving the coverage and quality of those interventions in 184 high-priority districts (HPDs) across India. Guidelines and tools were developed and policies were adjusted.

1. High-Priority Districts: The RMNCH+A strategy addresses India's inter-state and inter-district variations. The districts with relatively weak performance against RMNCH+A indicators were identified. Uniform and clearly defined criteria were used to identify 184 high-priority districts across all 29 states. The RMNCH+A approach is a conscious articulation of the GOI's commitment to tailoring programmes to meet the needs of previously underserved groups, including adolescents, urban poor, and tribal populations.

2. Management tools and job aids: The RMNCH+A 5x5 matrix identifies five high-impact interventions across each of the five thematic areas, five cross-cutting and health systems strengthening interventions, and the minimum essential commodities. The 5x5 matrix as shown in Fig. 15, is an important tool for explaining the strategy in simple terms, organizing technical support, and monitoring progress with the states and high-priority districts.

NATIONAL PROGRAMME FOR HEALTHCARE OF THE ELDERLY (NPHCE) (45)

Government of India has launched the "National Programme for Health Care of the Elderly" (NPHCE) to address health related problems of elderly people, in 100 identified districts of 21 states during the 11th Plan period. 8 regional geriatrics centres as referral units have also been developed in different regions of the country under the programme. .

The basic aim of the NPHCE Programme is to provide separate, specialized and comprehensive healthcare to the senior citizens at various level of state healthcare delivery system including outreach services. Preventive and promotive care, management of illness, health manpower development for geriatric services, medical rehabilitation and therapeutic intervention and Information Education & Communication (IEC) are some of the strategies envisaged in the NPHCE. .

It is expected to cover other districts in a phased manner.12 regional geriatric centres in selected medical colleges of the country are expected to be developed under the programme. In addition, 2 National Centre of Ageing (NCA) are being established at AIIMS, New Delhi and Madras Medical College, Chennai, the core functions of which are training of health professionals, research activity and healthcare delivery in the field of geriatrics. .

The details of the geriatric setup and activities undertaken so far under the programme at various healthcare levels are as below (7): .

Department of Geriatric at 20 Super Specialized Institutions: Geriatric Departments are being developed at 8 identified medical institution located in various regions of the country with 30 bedded in-patient facility. Apart from providing referral treatment, research and manpower development, these institutions are involved in developing and updating training materials for various levels of health functionaries, developing IEC material, guidelines, etc. Funds have been provided for manpower, equipment’s, medicines, construction of building, training etc. .

Geriatric unit at district hospitals: The programme is approved for implementation in 2017-2018 in 520 districts, covering 35 states. There is provision for establishing 10 bedded geriatric wards and dedicated OPD services exclusively for geriatric patients. The grant-in-aid has been provided for contractual manpower, equipment’s, medicines, construction of building, training etc. .

Rehabilitation Units at CHCs falling under identified districts: There is provision for dedicated health clinics for the elderly persons twice a week. A rehabilitation unit is being set up at all the CHCs falling under identified districts. The grant-in-aid has been provided for manpower, equipment’s, training. The rehabilitation worker is supposed to provide physiotherapy to the needy elderly persons. .

Activity at PHCs under identified districts: Weekly geriatric clinics are arranged at the identified PHCs by a trained Medical Officer. For diseases needing further investigation and treatment, persons will be referred to the first referral unit i.e. the Community Health Centre or District Hospital as per need. One-time grant is given to PHCs for procurement of equipment. .

Activity at Sub-centre under districts: The ANMs/Male Health Workers posted in sub-centre will make domiciliary visits to the elderly persons in area under their jurisdiction. She/he will arrange suitable callipers and supportive devices from the PHC and provide the same to the elderly disabled persons to make them ambulatory. Also, there will be a provision for treatment of minor ailments and rehabilitation equipment at the identified sub centre’s. .

The tertiary component of the programme has been renamed as "Rashtriya Varishth Jan Swasthya Yojana" (RVJSY). .

NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF CANCER. DIABETES, CARDIOVASCULAR DISEASES AND STROKE (NPCDCS)

India is experiencing a rapid health transition with large and rising burden of chronic non-communicable diseases (NCDs) especially cardiovascular disease, diabetes mellitus, cancer, stroke, and chronic lung diseases. It is estimated that in 2016 NCDs accounted for 60 per cent of deaths. Considering the fact that NCDs are surpassing the burden of communicable diseases in India and the existing health system is mainly focussed on communicable diseases, need for National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke was envisaged. Later on this programme was integrated with National Cancer Control Programme, and National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) came into existence. During the 11th Five Year Plan period, 100 identified districts in 21 states have been covered under the programme. During 12th Five Year Plan, the programme has covered all the districts of the country in a phased manner (7).

A. Diabetes, Cardiovascular Disease and Stroke (DCS) Component under NPCDCS

The programme focuses on the health promotion, capacity building including human resource development, early diagnosis and management of these diseases with integration with the primary health care system.

The major objectives of the programme are as follows (7):

- Prevent and control common NCDs through behaviour and lifestyle changes. - Provide early diagnosis and management of common NCDs. - Build capacity at various levels of health care for prevention, diagnosis and treatment of common NCDs. - Train human resource within the public health set-up viz doctors, paramedics and nursing staff to cope with the increasing burden of NCDs, and - Establish and develop capacity for palliative & rehabilitative care. -

The programme is to be implemented in 20,000 sub-centres and 700 community health centres (CHCs) in 100 districts across 21 States/UTs and the strategies include promoting healthy lifestyle through massive health education and mass media efforts at country level, opportunistic screening of persons above the age of 30 years, establishment of Non-Communicable Disease (NCD) Clinic at Community Health Centre (CHC) and District level, development of trained manpower and strengthening of tertiary level health facilities. For long-term sustainability of the programme, service delivery will be through existing public health infrastructure and systems. The various approaches such as mass media, community education and interpersonal communication will be used for behavioural change focusing on the following messages:

- Increased intake of healthy foods - Increased physical activity - Avoidance of tobacco and alcohol - Stress management. -

National TOBACCO CONTROL PROGRAM

A comprehensive tobacco control legislation titled “The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” was passed by the parliament in April, 2003 and notified in Gazette of India on 25th Feb, 2004. The important provisions of the Act are: .

a. Prohibition of smoking in public places; b. Prohibition of direct and indirect advertisement of cigarette and other products. c. Prohibition of sale of cigarette and other tobacco products to a person below the age of 18 years, d. Prohibition of sale of tobacco products near the educational institutions: e. Mandatory depiction of statutory warnings (including pictorial warnings) on tobacco packs, and f. Mandatory depiction of tar and nicotine contents along with maximum permissible limits on tobacco packs.

The rules related to prohibition of smoking in public places came into force from the 2nd October, 2008. As per rules, it is mandatory to display smoke free signage’s at all public places. Labelling and packaging rules mandating the depiction of speci.

fied health warnings on all tobacco product packs came into force from 31ª May, 2009.

On account of sustained efforts on the part of Ministry of Health and Family Welfare, 34 States/UTs have issued orders for implementation of the Food Safety Regulations banning manufacture, sale and storage of gutka and pan masala containing tobacco or nicotine in the year 2014-15 Besides several states/UTs have banned all forms of smokeless tobacco products such as chewing tobacco, zarda, khaini and other flavoured and processed tobacco irrespective of name and form (45). .

On 24th September 2015, Government of India notified that the rules on "tobacco pack pictorial warnings" would come into effect from 1st April 2016. These rules mandate display of pictorial health warnings on 85 per cent of the principle display area of tobacco product pack on both sides (60 per cent of the picture and 25 per cent of the text) .

National Tobacco Control Programme (3): In order to facilitate the implementation of the Tobacco Control Laws, to bring about greater awareness about the harmful effects of tobacco, and to fulfil the obligations under the WHO-Framework convention on tobacco control, Govt. of India has launched a new National Tobacco Control Programme in the 11th Five Year Plan Pilot phase was launched in 16 districts covering 9 states in 2007-08. It now covers 108 districts in 31 states in the country. The main components of the programme are:

1. Public awareness/mass media campaigns for awareness building and for behavioural change, 2. Establishment of tobacco product testing laboratories, to build regulatory capacity, as required under COTPA, 2003, 3. Mainstreaming the programme components as a part of the health delivery mechanism under the NRHM framework; 4. Mainstream research and training on alternate crops and livelihood, with other nodal ministries; 5. Monitoring and evaluation, including surveillance, e g adult tobacco survey; 6. Dedicated tobacco control cells for effective implementation and monitoring of anti-tobacco initiatives; 7. Training of health and social workers, NGOs school teachers etc. 8. School programme; and 9. Provision of tobacco cessation facilities.

NATIONAL MENTAL HEALTH PROGRAMME

The National Mental Health Programme was launched during 1982 with a view to ensure availability of Mental Health Care Services for all, especially the community at risk and underprivileged section of the population, to encourage application of mental health knowledge in general health care and social development. A National Advisory Group on mental health was constituted under the Chairmanship of the Secretary, Ministry of Health and Family Welfare for the effective implementation of the National Health Programme Eleven institutions have been identified for imparting training in basic knowledge and skills in the field of mental health to the primary health care physicians and para-medical personnel. At present this programme covers 517 districts in 36 states. .

The aims of the NMHP are (a) Prevention and treatment of mental and neurological disorders and their associated disabilities; (b) Use of mental health technology to improve general health services; and (c) Application of mental health principles in total national development to improve quality of life (68) .

The objectives of the programme are:

1. To ensure availability and accessibility of minimum mental health care for all in the foreseeable future. Most vulnerable particularly to the underprivileged sections of population. 2. To encourage application of mental health knowledge in general health care and in the social development. 3. To promote community participation in the mental health services development, and to stimulate efforts towards self-help in the community The programme strategies are: 1. Integration of mental health with primary health care through the NMHP: 2. Provision of tertiary care institutions for treatment of mental disorders, 3 Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority, and State Mental Health Authority.

District Mental Health Programme components are:

(a) Training programmes of all workers in the mental health team at the identified nodal institute in the state. (b) Public education in mental health to increase awareness and to reduce stigma. (c) For early detection and treatment, the OPD and indoor services are provided. (d) Providing valuable data and experience at the level of community to the state and centre for future planning, improvement in service and research

District Mental Health Programme has now incorporated promotive and preventive activities for positive mental health which includes:

- School mental health services: Life skills education in schools, counselling services. - College counselling services: Through trained teachers/councellors - Work place stress management: Formal & Informal sectors, including farmers, women etc. - Suicide prevention services: Counselling centre at district level, sensitization workshops, IEC, help lines etc. -

The National Human Rights Commission also monitors the conditions in the mental hospitals along with the government of India, and the states are acting on the recommendations of the joint studies conducted to ensure quality in delivery of mental care.

Thrust areas (46)

1. District mental health programme in an enlarged and more effective form covering the entire country. 2. Streamlining/modernization of mental hospitals in order to modify their present custodial role. 3 Upgrading department of psychiatry in medical colleges and enhancing the psychiatric content of the medical curriculum at the undergraduate as well as postgraduate level. 4. Strengthening the central and state mental health authorities with a permanent secretariat Appointment of medical officers at state headquarters in order to make the monitoring role more effective. 5. Research and training in the field of community mental health, substance abuse and child adolescent psychiatric clinics.

The Mental Healthcare Act, 2017 (7)

The United Nations convention on the rights of persons with disabilities was ratified by the Government of India thus making it obligatory on the Government to align the policies and laws of the country with the convention There was an increasing realization that persons with mental illness constitute a vulnerable section of society and are subject to discrimination in our society. .

The Mental Healthcare Bill, 2013 was introduced in the Parliament in order to protect and promote the rights of persons with mental illness during the delivery of health care in institutions and in the community and to ensure health care, treatment and rehabilitation of persons with mental illness, is provided in the least restrictive environment possible. Further, to regulate the public and private mental health sectors within rights framework, to achieve the greatest public health good and to promote principles of equity, efficiency and active participation of all stakeholders in decision making. Suicide has been decriminalized under the Act. The bill received assent of the Hon'ble President of India on 07.04.2017 The Ministry has constituted a committee of experts for formulating rules and regulations under the Act. .

INTEGRATED DISEASE SURVEILLANCE PROJECT

Integrated disease surveillance project is a decentralized State based surveillance system in the country. This project is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner in urban and rural areas. It will also provide essential data to monitor progress of ongoing disease control programme and help allocate health resources more efficiently. The project was launched in Nov. 2004 It was a 5 year project up to March 2010. The project was restructured and extended up to March 2012 It continues in the 12th Five Year Plan with domestic budget as integrated Disease Surveillance Programme under National Health Mission for all states. .

A Central Surveillance Unit (CSU) established and integrated in the National Centre for Disease Control, Delhi, State Surveillance Units (SSU) at all State/UT headquarters and District Surveillance Units (DSU) at all districts in the country have been established IT network connecting 776 sites in states/district headquarters and premier institutes has been established with the help of National Information Centre and ISRO (Indian Space Research Organization) for data entry, training, video conferencing and outbreak discussions. .

Under the project weekly disease surveillance data on epidemic prone diseases are being collected from reporting units such as sub-centres, PHCs, CHCs, hospitals including government and private sector hospitals and medical colleges. The data are being collected on 'S' syndromic, "P" probable, and L laboratory formats using standard case definitions Presently more than 90 per cent districts report such weekly data through e-mail/portals. The weekly data are analysed by SSU/DSU for disease trends. Whenever there is rising trend of illness, it is investigated by the Rapid Response Team to diagnose and control the outbreak. It is a multi-speciality team of an epidemiologist, a clinician, a microbiologist and other specialists as per requirement. .

The surveillance is needed to recognize cases or cluster of cases to initiate interventions to prevent transmission of disease or reduce morbidity and mortality; access the public health impact of health events or determine and measure trends; demonstrate the need for public health intervention programmes and resources and allocate resources during public health planning, monitor effectiveness of prevention and control measures, identify high-risk groups or geographical areas to target interventions and guide analytic studies, and develop hypothesis that lead to analytic studies about risk factors for disease causation propagation and progression (69) .

In this project, different types of integration are proposed These include (a) Sharing of surveillance information of disease control programmes; (b) Developing effective partnership with health and non-health sectors in surveillance, (c) Including non-communicable and communicable diseases in the surveillance system, (d) Effective partnership of private sector and NGOs in surveillance activities; and (e) Bringing academic institutions and medical colleges into the primary public health activity of disease surveillance. .

The important information in disease surveillance are who gets the disease, how many get the disease, where did they get the disease, why did they get the disease, and what needs to be done as public health response. .

NATIONAL PROGRAMME FOR PREVENTION AND MANAGEMENT OF TRAUMA AND BURN INJURIES (NPPMTBI)

Trauma Care component (6):

In India, road traffic crashes are one of the major causes of disability, morbidity and mortality. As per the Road Accident Report for 2019, a total number of 4,49,002 accidents took place in the country during the calendar year 2019 leading to 1,51,113 deaths and 4.51.361 injuries. The programme for trauma care started during 9th and 10th Five Year Plans as "Pilot Project for Strengthening Emergency Facilities along the Highways" During the 11th FYP, the programme was approved as "Assistance for Capacity Building for Developing Trauma Care Facilities in Government Hospitals on National Highways" for developing a network of trauma care facilities (TCFs) in the Government Hospitals along the Golden Quadrilateral highway corridor as well as North-South & East-West Corridors wherein 116 TCFs were approved in 17 States on these corridors on 100% Central assistance The scheme was further extended during 12th FYP as "Capacity Building for Developing Trauma Care Facilities in Govt. Hospitals on National Highways" wherein 80 Hospitals/Medical Colleges were approved for financial assistance in addition to other interventions. The scheme is being extended since then.

Objectives of the programme are as follows:

- To establish a network of Trauma Care Facilities on National/State Highways in order to reduce the incidence of preventable deaths and disabilities due to road traffic accidents by observing golden hour principle. - To develop Surveillance, Trauma Registry and Capacity Building Centre for collection, compilation, analysis and dissemination of information for policy formulation and preventive interventions. - To improve the awareness about trauma care among the general masses and vulnerable groups by developing and disseminating IEC material.

B. Burn Injuries component (6):

India has one of the largest burdens of burns with an estimated 7,000,000 burn injuries per year, and an estimated 1.4 lakh deaths and 2.4 lakh disabilities, making burn injuries the second largest group of injuries after road accidents. These figures translate to a mortality rate of over 8.3/100,000 population, disfigurement and permanent disability in 250,000 people annually, and a loss of 5 million disability-adjusted life years (DALYS). .

This high incidence has been attributed to illiteracy poverty, and low safety consciousness in the population. The epidemiology of mortality after burns is unique in India most burn injuries are in young adults and deaths are more common in women than men, contrasting trends observed in other low-and middle-income countries. Burns survivors are also known to be financially distressed, vocationally challenged and socially excluded Death and disability due to burn injury are preventable to a great extent provided timely and appropriate treatment is provided by trained healthcare professionals. .

Keeping in view the magnitude of the problem, a pilot programme on burn care was initiated in the year 2010 by Ministry of Health & Family Welfare in the name of "Pilot Programme for Prevention of Burn Injuries" (PPPBI) this was initiated in three Medical Colleges and six Districts Hospitals. The goal of PPPBI was to ensure prevention of Burn Injuries, provide timely and adequate treatment in case of burn injuries, so as to reduce mortality. Complications and ensuing disabilities and to provide effective rehabilitative interventions if disability has set in. .

The pilot project continued as full-fledged programme for tertiary care level during the 12th Five Year Plan period. The financial assistance towards District Hospital component was undertaken under National Health Mission (NHM). The scheme is being extended since then.

NATIONAL WATER SUPPLY AND SANITATION PROGRAMME

The National Water Supply and Sanitation Programme was initiated in 1954 with the object of providing safe water supply and adequate drainage facilities for the entire urban and rural population of the country. In 1972 a special programme known as the Accelerated Rural Water Supply Programme was started as a supplement to the national water supply and sanitation programme. Inspite of increased financial outlay during the successive Five Year Plans, only a small dent was made on the overall problem During the Fifth Plan, rural water supply was included in the Minimum Needs Programme of the State Plans The Central Government is supporting the efforts of the States in identifying problem villages through assistance under Accelerated Rural Water Supply Programme A "problem village" has been defined as one where no source of safe water is available within a distance of 1.6 km, or where water is available at a depth of more than 15 metres, or where water source has excess salinity, iron, fluorides and other toxic elements, or where water is exposed to the risk of cholera.

The stipulated norm of water supply is 40 litres of safe water per capita per day, and at least one hand pump/spot-source for every 250 persons Information, education and communication is an integral part of rural sanitation programme to adopt proper environmental sanitation practices including disposal of garbage, refuse and waste water, and to convert all existing dry latrines into low cost sanitary latrines The priority is to evolve financially viable sewerage systems in big cities and important pilgrimage and tourist centres and recycling of treated effluents for horticulture, irrigation and other non-domestic purposes (74).

The programme was subsequently renamed as the Rajiv Gandhi National Drinking Water Mission in 1991 In 1999-2000, Sector Reform Project was started to involve the community in planning, implementation and management of drinking water schemes which was in 2002 scaled up as the Swajaldhara Programme.