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Health Policy IssuesandHealth Programmes inUttaranchal

Workshop ProceedingsHealth Policy IssuesandHealth Programmesin UttaranchalMussoorie, 9–10 May 2002Department of Health and Family Welfare,Government of Uttaranchal, DehradunThe POLICY Project,The Futures Group International, New Delhi

ContentsContentsPrefaceList of ParticipantsGlossaryvviixivInaugural Session 1Session 1National Health Programmes and Epidemiological SurveillancePublic Health Issues, Priorities and the Role of the Government 13National Health Programmes: An Overview 20Implementation of National Health Programmes in Uttaranchal 38Use of Epidemiological Surveillance Data for Programme Management 49Designing a Surveillance System 54National Health Programmes in Uttaranchal 58Session 2IEC for Promotion of Health CareIEC Strategies for Health in India 79IEC for Health Programmes in Uttaranchal 87Session 3Private and Public Sector Partnerships in the Health SectorPublic–Private Interaction in Health: Policy Issues 99Cost Recovery Measures in Government Health Institutions 110Arogya Raksha: Health Insurance Scheme for Family WelfareAcceptors in Andhra Pradesh 116Session 4Health Economics: Issues of EquityHealth Financing in India: Some Issues 129Household Health Care Costs in India 140Access to Health Services in Uttaranchal 147

Session 5STI/RTI, AIDS, and TB Control and ManagementQuality of RTI/STI Case Management Services in India:Perspectives and Challenges 159HIV/AIDS: International Perspective 169HIV/AIDS in India and Uttaranchal 176Tuberculosis Control Efforts in India and Uttaranchal 185Session 6Other Health IssuesCare of the Elderly 199Hospital Waste Management 204Streamlining the Drug Procurement & Supply System in Uttaranchal 216Sanitation and Public Health Issues with Reference to Uttaranchal 228Ayurveda and Unani Department and the Convergence of Serviceswith the Health Department in Uttaranchal 234Specific Health Policy and Programme Issues 243iv

I would also like to thank our technical collaborators, The Policy Project, TheFutures Group International, for their support and rich inputs and USAID forproviding resources for the endeavour.I am confident that this volume will serve as a reference document forprogramme mangers and policy-makers and enable the formulation ofneed-based and focused health and population policy for Uttaranchal.(Alok Kumar Jain)vi

List of ParticipantsAlok Kumar JainSecretaryMedical, Health, Family Welfare,Medical EducationGovernment of UttaranchalDehradun 248001Ph. No. 0135-7120550135-733522®Fax No. 0135-712014Dora WarrenDirectorGlobal Aid ProgrammeCentre for Disease ControlAmerican EmbassyNew Delhi 110021Ph. No. 011-4198649E-mail: warrendl@state.govSheena ChhabraTeam LeaderPREM, USAIDNew DelhiPh. No. 011-4198564Fax No. 011-4198612E-mail: schhabra@usaid.govI S PalDirectorate GeneralMedical Health & Family WelfareChander Nagar,Dehradun 248001Ph. No. 0135-7203110135-623723 (residence)Fax No. 0135-628185List of Participants9–10 MAY 2002, MUSSOORIEG NarayanaCountry DirectorThe Policy ProjectThe Futures Group InternationalIFPS Liaison Office50-M Shanti PathGate No. 3, Niti MargChanakyapuri,New Delhi 1100021Ph. No. 011-6886813/6886172Mobile: 9810192840Fax No. 011-6885850Hyderabad officePh. No. 040-3397274Telefax: 040-3394873E-mail: tfgi.narayana@sril.comRameshwar SharmaDirectorBhagwan Mahaveer Cancer Hospital &Research Centre & Visiting ProfessorIndian Institute of Health &Management Research (IIHMR)Jawaharlal Nehru MargSanganer Airport, Jaipur 302011Ph. No. 0141-7001070141-620848/620033 (residence)Fax No. 0141-702021Anil Kumar SharmaJoint DirectorDirectorate of Medical Health &Family WelfareChander Nagar, Dehradun 248001Ph. No. 0135-720311Fax No. 0135-628185vii

List of ParticipantsIndu Kumar PandeyPrincipal Secretary, FinanceGovernment of UttaranchalSecretariatDehradunPh. No. 0135-712018Fax No. 0135-712077Manisha PanwarAdditional Secretary HealthMedical Health, Family Welfare, MedicalEducation & Drinking WaterGovernment of UttaranchalDehradun 248001Ph. No. 0135-712809J C PantFormer Secretary, Govt. of IndiaChairman of the Disaster Management CellShraddha Kunj159/Vasant Vihar,DehradunPh. No. 0135-761819/762453E-mail: pantncdm@sancharnet.inS D GuptaDirectorIndian Institute of Health & ManagementResearch(IIHMR)1, Prabhu Dayal MargSanganer Airport,Jaipur 302011Ph. No. 0141-581431-34Fax No. 0141-582138E-mail: sdgupta@iihmr.orgDiego PalaciosDeputy Representative, UNFPA55 Lodi Estate,New Delhi 110003Ph. No. 011-4646782E-mail: diego.palacios@unfpa.orgK M SathyanarayanaSenior Program SpecialistThe Policy ProjectThe Futures Group InternationalIFPS Liaison Office50-M Shanti PathGate No. 3, Niti MargChanakyapuriNew Delhi 1100021Ph. No. 011-6886813/6886172Fax No. 011-6885850E-mail: tfgi.sathya@sril.comP N RajnaSenior Program OfficerThe Policy ProjectThe Futures Group InternationalIFPS Liaison Office50-M Shanti PathGate No. 3, Niti MargChanakyapuriNew Delhi 1100021Ph. No. 011-6886813/6886172Fax No. 011-6885850E-mail: tfgi.rajna@sril.comAshok Kumar SinghProject OfficerThe Policy ProjectThe Futures Group InternationalSector B, MahanagarH. No. B-928Lucknow 226006Telefax No. 0522-382327R C NautiyalState Leprosy OfficerDirectorate of Medical & HealthChander Nagar, Dehradun 248001Ph. No. 0135-728155Fax No. 0135-728155E-mail: rcnautiyal45@yahoo.co.inviiiD B AcharyaHon. Consultant Armed Forces2/636 HIG FlatJawahar Nagar, Jaipur 302004Ph. No. 0141-225651Telefax 0141-6545531 (residence)E-mail: acharyad_jp1@sancharnet.in

List of ParticipantsA Kameswara RaoDirectorCentre for Population & Dev. StudiesG-3, Shanti ApartmentsAnand Nagar ColonyKhairatabadHyderabad 500004Ph. No. 040-3314736/3323488Fax No. 040-3323488E-mail: cpds@nettlinx.comVivek AdhishReader(MCH & FW)National Institute of Health & FamilyWelfare(NIHFW)New Mehrauli RoadMunirka,New Delhi 110067Ph.No. 011-6165959/6185696011-6182918/6174395 (residence)Fax No. 011-6101623E-mail: vivekadhish@hotmail.comnihfw@mantraonline.comB B L SharmaHead of the Department of Statistics &DemographyProfessor Health EconomicsNational Institute of Health & FamilyWelfare(NIHFW)New Mehrauli Road, MunirkaNew Delhi 110067Ph. No. 011-6107773/6166441/ (O)011-6866323 (residence)Fax No. 011- 6101623E-mail: bblsharma@hotmail.comBulbul SoodProgram Management SpecialistCEDPAIFPS Liaison Office50-M Shanti PathGateNo.3, Niti MargChanakyapuriNew Delhi 110021Ph. No. 011-6880605/6886172Fax No. 011-6885850E-mail: bsood@vsnl.comDinesh C JainJoint Director & Head of the EpidemiologyDivisionNational Institute of Communicable Diseases22- Sham Nath MargDelhi 110054Telefax 011-3928700E-mail: d14zen@vsnl.netDinesh AgarwalManager, Technical Support UnitUNFPA55 Lodi Estate,New Delhi 110003Ph.No. 011-4644671/4628877Fax No. 011-4641679E-mail: dineshagarwal@unfpa.org.inD K MangalDirectorState Institute of Health and Family Welfare,JaipurPh. No. 0141-3802220141-396386 (residence)E-mail: mangaldk@hotmail.comJ S YadavProfessorIndian Institute of Mass CommunicationJNU CampusNew Delhi-110067Ph. No. 011-6184085(O)011-6124887 (residence)Mobile 9810355350Fax No. 011-6166532E-mail: jsyadav_2000@yahoo.comDCS ReddyConsultant WHO, EpidemiologyNational AIDS Control Organization(HIV/AIDS)Nirman Bhawan,New Delhi-110002Ph. No. 011-3018955Mobile 9810607510Fax No. 011-3012450E-mail: dcsreddy2001@yahoo.comix

List of ParticipantsMohmed ShaukatDeputy Director TechnicalNational AIDS Control Organization9 th Floor, Chandralok BuildingJanpath 36,New Delhi 110001Ph. No. 011-3731956Fax No. 011-3731746E-mail: shaukat_naco@yahoo.comA K SinghSr. Principal Executive Officer,Helpage India, LucknowSector 12/ 498, Indira NagarLucknow 226016Ph. No. 0522-357058Fax No. 0522-342962E-mail: helpage@zyberwayavadh.comSuvanand SahuNational Professional Officer-TBOffice of WHORepresentative to IndiaWorld Health organizationRoom No.531-35, A- WingNirman Bhawan, Maulana Azad RoadNew Delhi 110002Ph.No. 011-3018955/3017993Fax No. (91-11)3012450Mobile 9810405754E-mail: s_sahu@vsnl.comsahus@whoindia.orgBarun KanjilalProfessorIndian Institute of Health & ManagementResearch(IIHMR)1, Prabhu Dayal MargSanganer Airport,Jaipur 302011Ph. No. 0141-581431-34Fax No. 0141-582138E-mail: barun@iihmr.orgAlmas AliConsultantE-45, NIHFWResidential ComplexMunirka,New Delhi 110067Ph. No. 011-6160914(O)Renu DhasmanaDirector Health, HIHTHimalayan Institute Hospital TrustJolly Grant,DehradunPh. No. 0135-412611/412022Fax No. 0135-412008E-mail: renudhasmana@rediffmail.comS PurohitJoint DirectorDirectorate GeneralMedical Health & Family WelfareChander Nagar,Dehradun 248001Ph. No. 0135-628185Fax No. 0135-720311Sunil NandrajNational Professional OfficerWorld Health Organisation536 ‘A’ Wing,Nirman Bhawan,New Delhi 110002Ph. No. 011-3018956-57E-mail: nandrajs@whoindia.orgSohanlal SharmaNodal Officer HomeopathyUttaranchalChander Nagar,Dehradun 248001Ph. No. 0135-720311/628185Fax No. 0135-628185Ramesh ChandraProfessorHimalayan InstituteJolly Grant, DehradunPh. No. 0135-412127Fax No. 0135-412008x

List of ParticipantsKailash SinghMOH MussooriePh. No. 9837015433Fax No. 0135-632251S P SinghChief Medical Officer(CMO)NainitalPh. No. 05942-35285/356025Uma PrakashUnit Co-ordinator(HRD)PMU, DehradunSwajal ProjectPh. No. 0135-733433/733381Fax No. 0135-733381E-mail: pmu_uttaranchal@rediffmail.comAmita TiwariHealth & Hygiene SpecialistSwajal ProjectDehradunPh. No. 0135-733455Fax No. 0135-733381E-mail: pmu_uttaranchal@rediffmail.comVaidya Shyam GuptaMedical officer ISMState Ayurvedic Medical CollegeHardwar, UttaranchalPh. No. 0133- 620602D S NathAdditional Secretary Health & DirectorAyurveda, DehradunPh. No. 0135-712097(O)0135-740184 (residence)Fax No. 0135-712097B D NariyalChief Medical Officer(CMO)ChampawatTelefax. 05965-22312B L VermaChief Medical OfficerCMO- BageswarPh. No. 05963-21026H G S ManralChief Medical Officer(CMO)Almora, UttaranchalPh. No. 05962-3301505962-30018 (residence)R C S SayanaChief Medical SuperintendentDoon HospitalDehradunPh. No. 0135-6593550135-654613 (residence)R S BhandariChief Medical Officer(CMO)ChamoliPh. No. 01372-52375/52188Fax No. 01372-52188O S SharmaAdditional Medical Kumau DivisionAdditional office,NainitalPh. No. 05942-36114Fax No. 05942-36114D P BahugunaAdditional Director, Family WelfareDirectorate General OfficeChander NagarDehradun 248001Ph. No. 0135-720311Fax No. 0135-628185G C JoshiD.S.O/Chief Medical Officer(CMO)Udham Singh NagarPh. No. 46081C P AryaDeputy Chief Medical Officer (Dy. CMO)PithoragarhPh. No. 05964-25142xi

List of ParticipantsR K PurohitAdditional Project DirectorUttaranchal Health System DevelopmentProjectChander NagarDehradun 248001Ph. No. 0135-720377/720640Telefax 0135-720377J M SinghSecretaryMamta Samajik Sanstha53-C, Rajpur RoadDehradun, UAPh. No. 0135-653671/655082Fax No. 0135-652111E-mail: jms23@rediffmail.comMamata_s_s@rediffmail.comJ P SharmaExecutive DirectorUttaranchal Voluntary Health Association164/1 Vasant ViharDehradunPh.No. 0135-773006E-mail: uvha@indiatime.comB C PathakChief Medical OfficerDehradunPh. No. 0135-6536410135-654492 (residence)Prema DimriC.M.S. Women HospitalWomen HospitalDehradunPh. No. 0135-659236J P JoshiState T.B. OfficerDirector General of Medical & Health OfficerChander NagarDehradunPh. No. 0135-620706/727137D N DhyaniProject Officer- Reproductive Child HealthDirectorate General OfficeDehradun 248001Ph. No. 0135-659885Vijay DhasmanaChairpersonHimalayan InstituteJolly GrantDehradunPh. No. 0135-412044Fax No. 0135-412008E-mail: dhasmana@sanchand.inJaideep DuttaProvery (Officer in charge) EuropeanCommissionMedical Health, Family Welfare, MedicalEducation & Drinking waterGovernment of UttaranchalDehradun 248001Ph. No. 0135-7203110135-651949/654640 (residence)Fax No. 0135-628185/728155T R JoshiChief Medical Officer(CMO)Tehri GarhwalPh. No. 01376-32093Fax No. 01376-32093S R S RanaState Training officerDirectorate Health ServiceChander Nagar,Dehradun 248001Ph. No. 0135-720311Fax No. 0135-628185H K SrivastavaAdditional Health DirectorPauri GarhwalTelefax 01368-23589A S SaunChief Medical Officer(CMO)UttarkashiPh. No. 01374-22108xii

List of ParticipantsR K ShauD.A.H.O., HardwarDivisional Ayurvedic/ Unani OfficersPh. No. 0133-426026P K MathurMedical SuperintendentHimalayan Institute of Medical SciencesHIHT Jolly Grant,DehradunPh. No. 0135-412016E-mail: pkmathur42@hotmail.comGopi BaunthiyalMedical Officer Women HealthTurner RoadCelement Turn,DehradunPh. No. 0135-640641/640280R K JainChief Medical Officer(CMO)HardwarPh. No. 0133-426023/424296Fax No. 0133-426023xiii

GlossaryGlossaryAbbreviationsAIIMSANMAPIARIAWHAWWBFBMIBoDBSCBVCBRCDHOCDRCHCCMIECMOCMSCEDCOPDCPRCPRCSSMCSWDADAPDDCDGQADHEIODLESAll-India Institute of Medical Sciencesauxiliary nurse midwifeannual parasite incidenceacute respiratory infectionanganwadi helperanganwadi workerbreastfedBody Mass Indexburden of diseaseblood sample collectionbacterial vaginosiscrude birth rateChief District Health Officercrude death ratecommunity health centreCentre for Monitoring Indian EconomyChief Medical OfficerChief Medical Superintendentchronic energy deficiencychronic obstructive pulmonary diseasecontraceptive prevalence ratecouple protection rateChild Survival and Safe Motherhood (Programme)commercial sex workersdaily allowanceDistrict Action Plandrug distribution centreDirectorate-General for Quality AssuranceDistrict Health Education & Information OfficerDistrict Leprosy Eradication Societyxiv

GlossaryDLODMDMH&FWDM&HODOTSDTCDTOESIFHACFLEFPFRUFTDsFWGDPGISGLVGoIHESAHFAHHSHIHIDHMISHOHSRICCICDSICMRICPDIDDIDUIECIFAIMRIOLIPCISMITIUCD/IUDKAPLBWLDCLFADistrict Leprosy OfficerDistrict MagistrateDepartment of Medical, Health, and Family WelfareDistrict Medical and Health Officerdirectly observed treatment short-courseDistrict Tuberculosis CentreDistrict Tuberculosis OfficerEmployees State InsuranceFamily Health Awareness Campaignsfamily life educationfamily planningfirst referral unitFever Treatment Depotfamily welfaregross domestic productgeographic information systemgreen leafy vegetablesGovernment of IndiaHygiene and Environmental Sanitation AwarenessHealth for AllHealthy Home SurveyHealth Inspectorhuman resource institutional developmenthealth management information systemsHealth Officerhealth systems researchInvestigator-cum-CompilerIntegrated Child Development ServicesIndian Council of Medical ResearchInternational Conference on Population and Developmentiodine deficiency disorderintravenous drug usersinformation, education, and communicationiron and folic acidinfant mortality rateintraocular lensinterpersonal communicationIndian systems of medicineinformation technologyintra-uterine contraceptive device/intrauterine deviceknowledge, attitudes, and practicelow birth weightLower Division Clerklogical framework approachxv

GlossaryLHVLILMISMAPMCMCHMDRTBMDTM&EMEPMIMISMLAMMRMMRMMRCMOMOHFWMPOMPWMRSMSMMSSMTPNACONACPNAMPNCAERNCERTNFENFHSNGONHPNIDDCPNIHFHNLEPNMANMEPNMSNNTNPPNSSNTCNTIlady health visitorLeprosy Inspectorlogistics management information systemsMalaria Action Planmiscroscopy centrematernal and child healthmulti-drug resistant tuberculosismulti-drug therapymonitoring and evaluationMalaria Eradication ProgrammeMedical Instructormanagement information systemMember of the Legislative Assemblymaternal mortality ratemeasles, mumps, rubellaMass Media Resource CentreMedical OfficerMinistry of Health and Family Welfaremodified plan of operationsmulti-purpose workerMedical Relief Societymen having sex with menMahila Swasthya Sanghmedical termination of pregnancyNational AIDS Control OrganizationNational AIDS Control ProgrammeNational Anti-Malaria ProgrammeNational Council of Applied Economic ResearchNational Council of Educational Research and Trainingnon-formal eduationNational Family Health Surveynon-governmental organizationNational Health PolicyNational Iodine Deficiency Disorders Control ProgrammeNational Institute of Health and Family WelfareNational Leprosy Eradication ProgrammeNon-Medical AssistantNational Malaria Eradication ProgrammeNon-Medical Supervisorneonatal tetanusNational Population PolicyNational Service SystemNational Tuberculosis Control ProgrammeNational Tuberculosis Institutexvi

GlossaryNTPODOPDOPVORSORTOTPCOPHCPLAPOPoDPPCPPIPRIPTTRCHRFWTCRHSRNTCPRsRTISASACOSADSCsSCSCERTSESSISMISMOSNDSPPSRSSTSTDsSTDCSTISTOTBTBATFATFRNational Tuberculosis Programmeorganizational developmentout-patient dispensariesoral polio vaccineoral rehydration saltsoral rehydration therapyoperation theatrepublic call officeprimary health centreparticipatory learning assessmentProgramme Officerprevention of deformitypostpartum centrePulse Polio ImmunizationPanchayati Raj institutionphysiotherapy technicianreproductive and child healthRegional Family Welfare Training CentreRapid Household SurveyRevised National Tuberculosis Control Programmerupeesreproductive tract infectionStatistical AssistantState AIDS Control Organizationstate allopathic dispensariesScheduled Castesub-centreState Council of Educational Research and Trainingsocio-economic statusSanitary InspectorSenior Medical InstructorSenior Medical Officerschedule for new demandsState Population PolicySample Registration SystemScheduled Tribesexually transmitted diseaseState Tuberculosis Training and Demonstration Centresexually transmitted infectionState Tuberculosis Officertuberculosistraditional birth attendanttarget-free approachtotal fertility ratexvii

GlossaryTHRTRCTRIPsTTTUUDCUIPUPUTVCTVDVHAIVHOVPDsWDIWHOtake-home rationTuberculosis Research CentreTrade-related Intellectual Property Rightstetanus toxoidTuberculosis UnitUpper Division ClerkUniversal Immunization ProgrammeUttar PradeshUnion Territoryvoluntary counselling and testingvenereal diseaseVoluntary Health Association of Indiavoluntary health organizationVaccine-preventable diseaseWomen’s Development InitiativeWorld Health OrganizationIndian TermsAdhyakshaheadAnganwadivillage-level centre under the ICDS ProgrammeCrore 10,000,000Daitraditional midwifeGramvillage-level localPanchayatgovernmentGram Pradhanvillage headmanGram Sabhavillage committeeGram SarpanchChairperson of Gram SabhaKshetraHead of KshetraPramukhPanchayatLakh 100,000Mahila Swasthyavillage-based health groupSanghMandaladministrative unit for a group of villagesPanchayatlocal government body at village levelPradhanheadman/village headmanTehsiladministrative area below central levelVidhan SabhaLegislative AssemblyYatrapilgrimage, journeyZila Parishaddistrict-level local governmentZila Shiksha Samiti District Literacy Committeexviii

Session 1Inaugural SessionInaugural SessionInaugural SessionJ C Pant, former Secretary, Government of India, andChairman, Disaster Management CellHealth issues should be reviewed in a broad perspective. For instance, if wedo rainwater conservation and if this can be done as a people’s movement,then you have all the springs of Uttaranchal revived, which means that cleandrinking water is available to every village. Therefore, this whole concept ofpublic health has to be woven into health policy, though it will haveramifications for the development sector. This can become a people’smovement and I am sure if this question of keeping the rivers clean can betaken up as a movement with the ‘Sants’ and ‘Swamis’ of Hardwar, then I’msure they’ll be willing to join us in this effort because from Gangotri down,the ‘Babas’ are also polluting the Ganga. I’m sure that if we can persuadethem, they’ll stop doing it. It’s the idea of picking up these polythene bagsoccasionally, once in a while. I had a friend visiting India from Australia. InAustralia, they observe one week every year for cleaning up Australia.Everyone just comes out of his/her house and cleans the whole place; that isthe type of effort required.Uttaranchal has several voluntary agencies, although some of them are forthe sake of registration alone. However, the active voluntary agenciesnumber at least 100; I have them in my directory at home. We can call, say, aconference of about 100 non-governmental organizations (NGOs) later thismonth. I had asked Alok Jain to organize one such conference and interactwith them so that you have people’s participation.Gadde Narayana, Country Director, POLICY Project, TheFutures Group InternationalThe Uttaranchal Government, a couple of months back, made a decision tohave a comprehensive and integrated health and population policy for thestate. Other states, like Andhra Pradesh, Rajasthan, Uttar Pradesh, andMadhya Pradesh, also have policies but those policies are only populationpolicies, although they include reproductive health elements. Uttaranchal1

Inaugural Sessionwould be the first state to have an integrated policy combining health, reproductive health,child health, and population stabilization issues.Policy development, in general, involves a series of consultations with stakeholders. Mr Panthas mentioned the need for consultations with NGOs. We had the first round of consultationson reproductive health issues, in Dehradun, exactly one week back. About 60 participants camefrom within Uttaranchal as well as outside the state. National and international experts werepresent and 25 papers were presented on various themes and areas covering fertility andcontraceptive behaviour, coverage of pregnant women for antenatal services, assistance at thetime of delivery, immunization of children, and service delivery systems includingorganizational structure and infrastructure available in Uttaranchal. We also dealt withconvergence with Integrated Child Development Services (ICDS) and involvement of thecommunity, in general, in service delivery systems. Cross-cutting issues like human rights,gender, and empowerment of women were also discussed in the workshop.Several policy issues were identified in the workshop. We do not have the time to go through allthose specific issues, but broadly, what came out of those deliberations was that Uttaranchal isbetter than its parent state in almost all indicators. However, Uttaranchal is not better thansome of its neighbouring states like Himachal Pradesh or some other states like the southernstates or Maharashtra. So there’s a long way to go to improve the health status of the peopleand health indicators in Uttaranchal. What also came out from the discussions in the previousworkshop was the significant inter-district variations within Uttaranchal and that the differencebetween the hill region and the Terai region is significant. For almost all indicators, the hillregion is better off than the Terai region—in terms of literacy as well as in terms of theacceptance of family planning or maternal child health services.This is the second workshop in the consultation process, covering national health programmesas well as health policy issues. We have about 21 papers to be presented in this workshop byvarious experts from both Uttaranchal as well as the national level. The themes to be coveredare national health programmes; epidemiological surveillance systems to make informeddecisions; the role of information, education, and communication (IEC); issues of equity inhealth care; health economics; private–public sector partnerships; reproductive tract infections(RTIs), Acquired Immune Deficiency Syndrome (AIDS), and tuberculosis (TB); andmanagement of health services in general. We are also covering subjects like hospital wastemanagement, care of the elderly, drinking water and sanitation, and convergence of services atthe grass-roots level. Presentations and discussions during this workshop will definitelyimprove our understanding of the health policy issues in Uttaranchal and will also help us toprepare a comprehensive health policy.I must, at this stage, mention that the Uttaranchal government, under the able leadership ofMr Gupta as well as Mr Jain, has made a series of policy decisions related to the healthdepartment. These include the New Drug Policy, the New Transfer Policy, and also privatizationof diagnostic services in hospitals as well as contracting out cleaning, laundry, and diet facilitiesin the major hospitals of Uttaranchal. These are only a few but several other decisions have2

Inaugural Sessionbeen made. This shows that the Uttaranchal government is keenly committed not only todevelop the policies but also to implement the policies as quickly as possible to improve thehealth status of its people.I would like to thank the Uttaranchal government for giving the POLICY Project of The FuturesGroup International an opportunity to collaborate on this important venture. I would also liketo particularly thank Mr Jain, who has provided the inspiration for this, and also all the staff ofthe Directorate who worked very hard to make these workshops successful. I would also like tothank United States Agency for International Development (USAID) for their active support andencouragement.Sheena Chhabra, Team Leader, PREM Division, PHN Office, USAIDI am really delighted to be here today. I had the opportunity of also attending the last workshop,where lots of issues related to population and reproductive and child health were discussed. Iwould like to begin by thanking the Government of Uttaranchal for the invitation to the series ofthe workshops that are being held for the formulation of the policy. I join Dr Narayana in reallycommending the Government of Uttaranchal for taking the initiative for developing acomprehensive policy. Though several states have formulated specific population policies,Uttaranchal will be the first state that will have an integrated health and population policy. TheUttaranchal government also needs to be commended for being the first of the three newlyformedstates to take this visionary step.Health policy formulation really presents a unique opportunity for Uttaranchal. One of thethings that came out in our discussions at the last workshop which Dr Narayana also alluded tois that Uttaranchal is very different from its parent state, UP. This calls for a distinct state policyas until now the thrust of the programme has been driven by the needs of the parent state. AsMr Pant mentioned, there are several indicators, where Uttaranchal compares very well to thenational averages, and to the southern states in some of the cases. Female literacy, for instance,is much higher than what we find in north Indian states of say Madhya Pradesh, Rajasthan, orUP. But in Uttaranchal we have nearly 60% women literacy. This compares very well to thenational averages and to southern states like Tamil Nadu and Karnataka. However, despitemany similarities, the differences are intriguing. In many respects it is neither like the southernstates nor like the northern states. Even though literacy is higher, huge differentials existbetween female and male literacy. There are about 24 percentage points that separate theliteracy levels among men and women. The literacy levels are similar to southern states whilethe gender differentials in literacy mirror the situation in northern states. Overall the sex ratio ismore balanced than the national sex ratio. However, the sex ratio among 0–6 years is 906females per 1000 males, which is lower than the national average of 927 and could be resultingfrom sex selective abortions, differential utilization of health care services for boys and girlsand host of other factors that may be a reflection of a strong son preference at least in someparts of Uttaranchal.The situation in Uttaranchal is complex. Utilization of childhood immunization services andcontraceptive services is moderate but utilization of maternal health services is dismally low.3

Inaugural SessionOnly 18% of the pregnant women receive antenatal check-ups, compared with 44% at thenational level and over 60% in Himachal Pradesh. Though a majority of women have regularaccess to mass media, only one-third have heard of HIV/AIDs. Fewer know how to prevent HIV.Nearly 4 out of 10 women report some type of reproductive health problems, but only 30% ofthese women seek medical advice. Despite higher female literacy rates, only about 50% areengaged in decisions about their own health. Himachal Pradesh, has done exceedingly well, onseveral of these parameters and faces similar challenges related to access because of the hillygeographical terrain. I think it is important to study that model and see if there are anylearnings for Uttaranchal.Clearly though many opportunities exist, many challenges face Uttaranchal. Despite being anew state, it is fortunate to have experienced political and administrative leadership. It has apragmatic and committed administration that cares for its people and this has been illustratedby some of the management decisions that Government of Uttaranchal has taken for improvingaccess to services. The best of policies and plans are not even worth the paper they are writtenon and cannot have the desired impact without the commitment of the state administration toput them into practice. What I am really delighted to see here in Uttaranchal, is that there is astrong political as well as bureaucratic determination on making improvements to the lives ofthe people of Uttaranchal, so that Uttaranchal can indeed become a model Indian state. Thetask at hand is huge. It is important that the government builds effective partnerships with theprivate sector especially the NGOs, private providers, and other community-basedorganizations and networks to meet the needs of its people. I am delighted to note that there isa session that is exclusively devoted on this subject.Before concluding, I would again like to congratulate the Government of Uttaranchal forinitiating the process of development of an integrated health and population policy and makinga commitment that within a short span of three months the policy will be finalized. USAID isdelighted to be a partner in this very important endeavour. We are happy to provide technicalassistance through the POLICY Project that not only has tremendous experience in developingreproductive health policies in other states in India but also has substantial global experience. Ireally look forward to the two days of deliberations and I wish the Government of Uttaranchalthe very best in this endeavour. Thank you.A K Jain, Secretary, Medical, Health and Family Welfare, Governmentof UttaranchalFirst of all, I extend to all of you a very hearty and warm welcome to this two-day workshop onhealth policy issues and health programmes. We already had a two-day workshop onreproductive and child health policy issues in Uttaranchal on the 2nd and 3rd of May.As background, I would like to state that after the elections the new government showed itsseriousness on the whole subject of health and health policy when His Excellency, theGovernor of Uttaranchal, announced on the floor of the house in the first session of theLegislative Assembly that the Government of Uttaranchal will come out with a health policywithin three months. These workshops are all part of the process to generate ideas for our4

Inaugural Sessionhealth policy. I must thank USAID for its full cooperation and support in the task offormulating this health policy because at the initial stage, when we were thinking about howwe would accomplish this gigantic task, we asked for USAID to offer us technical assistanceand they responded whole-heartedly, without batting an eyelid. Immediately, they offeredsupport through the POLICY Project. We thank USAID, Mr Victor Barbiero, Ms SheenaChhabra, and The Futures Group, in particular, for extending their full support andcooperation, which is making these workshops possible.As many of our preceding speakers have mentioned, many of our indicators in Uttaranchal,while they are better than in other states on many fronts, show that we still do not perform sofavourably. As already mentioned, only 41% of our children are fully immunized; 18% of ourmothers receive the full complement of three antenatal check-ups; 21% of births in Uttaranchalwere delivered in a medical facility. Among the births delivered at home, only 17% wereassisted by a health professional. And, as Ms Chhabra just mentioned, 41% of married womenhave reproductive health problems and 69% of them have not sought any advice or treatment.21% of women have an unmet need for family planning. 42% of children three years of age inUttaranchal are underweight, 47% are stunted, and 8% are wasted.Many of these problems, of course, have their roots in the big problem of access. We have a veryscattered population. More than 50% of our population live in villages of less than 200 peopleand over 80% of our population lives in villages of less than 500. So reaching out to suchscattered population itself is a big challenge. To top it all, as we are placed today, we havetremendous insufficiency of both manpower and willingness of many of our public sectorhealth providers to live and work in the remote and inaccessible areas. There is a question ofincentives for these providers to be addressed, and I think these workshops and the healthpolicy will look at it very, very seriously. There are organizational issues also.Of course, there is a question of equity. As has been brought out by the National Family HealthSurvey (NFHS), even today and even in Uttaranchal, where there is a common presumptionthat in the hill areas there are no private health providers, more than two-thirds of our peopleaccess health care services from the private sector and even those below the poverty line (BPL)are going to the private sector—the majority of them. So obviously it brings us to the issue ofequity and also quality and, of course, financial risk protection for the poor. We have sessionson insurance and equity, and I hope these sessions will address the issue. This is also closelylinked to issues of consumer and patient satisfaction because, ultimately, we need a satisfiedpatient when it comes to curative health services.We have to look at our institutions and our institutional arrangements governing the healthsector, and I hope that the workshop will throw up various alternative models. Finally, I thinkthis workshop will bring out the best because we have experts who are nationally acclaimedand experts from institutions that have a lot of respect; it will bring to Uttaranchal the bestpractices that are prevalent in other states and other countries.5

Inaugural SessionMadhukar Gupta, Chief Secretary, Government of UttaranchalI am indeed very happy and honoured to be able to have this opportunity of being here amidstyou today and to have such a presence gathered here to deliberate on and discuss thisexceedingly important issue. As has already been said, the first elected Government ofUttaranchal, immediately upon getting the reins of government, made an announcement in thehouse that a health policy would be formulated within three months. In that context, I’mextremely grateful to USAID and the POLICY Project; they have stepped in an extremely timelymanner to enable us to go through this important exercise.One issue that has been raised is that there are policies for population in various states, butthere are no policies for health. That is a very, very important question: what are the policies onhealth going to say? Is it going to set some quantitative targets? Is it going to set somequalitative targets? What is it going to do? To that extent, I think this whole process ofconsultation, which has been possible last week and today, will determine the objectives andthe strategies for the state. I hope the consultation process will not end here, in this very, veryvital area. When I say future consultations, I would suggest to everybody involved that we havethese consultations with a level of experts who can bring in experience from other states, whocan bring in experience from other countries, who can bring in statistics and data that havebeen researched and analysed. Thereafter, whatever we formulate, I think we will need to take itcloser to the grass-roots level in the form of workshops or consultations with publicrepresentatives or NGO representatives and so on. Then, whatever we do will have aparticipatory aspect about it, and it will not be felt at the end of the day by the beneficiary, bythe ultimate beneficiary, that this is something that has been provided to him from, let us say,the confines of a place like we are gathered in today. As for the policy itself, so much has alreadybeen said by all the people who can really contribute to the process that I find it very difficult tosay anything more or new, except to partly repeat what has been said.On the face of it, there are lots of very interesting indicators insofar as health is concerned—even issues like literacy and the sex ratio and so on. But there is so much hidden in thoseindicators and I think some of the points that were mentioned by Mr Pant, Mr Narayana,Ms Chhabra, and Mr Jain are extremely illuminating and would show that within this wholething is hidden a scenario that one could actually call pretty grim that we need to look at very,very seriously. Some of the issues have already been mentioned—some of the issues that wouldbe relevant to the point of the health policy we might make.Repeatedly, the first and most important issue that comes up relates to access and we have ourproblems. A comparative indication was made vis-ã-vis Himachal Pradesh (HP). Let me justmention that the population of Uttaranchal is almost 25 lakh more than HP and that, of course,would be largely on account of the fact that we have large plains districts in Udham Singh Nagar,Dehradun, and Hardwar. So when you are looking at the hills, that position would be perhapsmore comparable. HP has been in existence as a state for 30 years now so they have been luckyin the sense that they have had time to develop their infrastructure, village connectivity, healthinfrastructure, and all the issues that go into this business of access. Today, of the 16,500 villagesthat we have in Uttaranchal, as many as 8000 are not connected by all-weather roads. Mr Pant6

Inaugural Sessionhad mentioned the issue of the scheme called the Pradhan Mantri Gram Sadak Yojana. Well, weare going about this business of connectivity through that scheme in a very focused manner.But as he very rightly pointed out, in the hilly terrain it is probably not physically possible foreach and every village to be connected. At any rate, in the context of Uttaranchal, it would havevery extreme sensitivities with regard to ecology- and environment-related issues. So howphysical access can be provided is a matter to be seen. In this context, one of the otherannouncements that was made in the address by the government was that within six monthswe would also be preparing a comprehensive connectivity plan—roads that could be from thelevel of national highways to state highways to motor roads to various other types of roads. Inthat process, the point that was mentioned by Mr Pant becomes very important—we need notonly look at that as a matter of all-weather motorable roads, but also where we can have bridlepaths, alternative communication systems like ropeways, and so on. So we take that suggestionon board and we’ll widen it from a master road plan to a communications master plan.Simultaneously, you also mentioned the idea of a growth centre concept, which I think is veryimportant. In the hills, in fact, the chauraha concept (where roads from two to three sides meetand some shops come about and act as a kind of a service centre for some hinterland villages) isa concept that we are adopting for the very wide and large programme of informationtechnology (IT) connectivity that we have submitted to the Government of India. It basicallyconceives of something like 386 centres, which we would be calling communication centres orgrowth centres where these information kiosks, telephone connections, and certain types ofother basic infrastructure activities could become available. We are already fairly advanced inthe process of discussions on this both with the Government of India and with private sector ornon-governmental bodies like ILFS, with whom hand-holding sorts of exercises would be done.In this very context, at another level, there has also been a suggestion that in Uttaranchal weshould revive and reactivate the nyaya panchayat concept, which again fits in with the growthcentre concept, with a cluster of 10 villages and so on. So you see the kinds of things that canbe provided there. That brings me to a thought that I have been expressing for some time, andI wonder whether this workshop could also look at that issue. We have a hierarchy of medicalinstitutions. Right now we are engaged at the highest level of that hierarchy, which is in theform of a medical college, and we are hopeful that the Ministry of Health, Government ofIndia, and the Medical Council of India will be giving us clearance for the college very shortly.They indicated in a recent meeting that they would like the state government to fulfill acouple of other conditions, which the Cabinet has moved very quickly to decide upon. So athighest level we would have that. Then we have, of course, base hospitals, district hospitals,PHCs and CHCs and subcentres, and so on. We did some exercises a couple of years ago andfound that many areas are in a completely uncovered kind of zone, despite theseconventional hierarchies of medical systems. What I have been suggesting is whether we canidentify areas, possibly at the growth centre level or the nyaya panchayat level, that arebeyond certain distances in terms of connectivity and see what kind of a system, in terms oflow-cost infrastructure, we can provide for a dispensary, for a room where a doctor canprovide consultancy, and where a paramedic from the local community can be trained andperhaps also live. We can have doctors coming in from higher levels in the hierarchy on a7

Inaugural Sessionrotational basis for which some sort of incentive could be provided that would make themstay there for 15 days, 20 days, one month at a time—a rotation would provide wider access toresources. Once this is linked with the Community Information Centres (CICs) that we aretalking about, the whole system could become much deeper. So I would suggest that theworkshop may like to deliberate on this. It was just mentioned that USAID and The FuturesGroup have been looking at other possibilities of what can be done here, and I would suggestthat this be one of the possibilities that could be looked into.The other issue that has come up relates to integration with the non-allopathic systems. Now,in fact, in Uttaranchal I think it’s an irony that we might need to talk about it. On the one hand,some 300-odd Ayurvedic dispensaries and hospitals came about here and became more staffedthan the allopathic hospitals on account of organizational difficulties—doctors not beingavailable to go and work in the interior areas and so forth. But on the other hand, we say inUttaranchal that one of our major thrust areas is that of herbs and medicinal plants, whichwould take into account the whole chain (from the pre-cultivation research and technology tolarge, widespread cultivation, to marketing systems and to processing systems). It is in thiscontext that there have been some discussions about setting up an Ayurvedic University toprovide the necessary research. I feel that the area of how this can be integrated and moreactively brought into the system would need to be looked at in considerable detail. In fact, onthe industry side, one of the thrust areas we have indicated is biotechnology linked topharmaceuticals. So bringing these cross-sectoral issues into our deliberations and discussionsis another area for consideration.An extremely important point that was mentioned by Mr Pant is the area of public health andwithin that urban public health, which has been grossly neglected. We are trying to look at howurban infrastructure in that context (sewerage systems, health systems, clean drinking watersupply systems) can be augmented. It will take us some time, but that is also an area where weare trying to see if externally-aided programmes or project proposals or public–privatepartnership frameworks can be developed to strengthen that. Insofar as keeping the riversclean is concerned, in the higher reaches at least, some of the major centres where pollutionoccurs at those heights are clearly related to the yatra routes, where huge numbers of peoplecongregate continuously. I’m happy to mention to you that for the comprehensive yatra route,we asked the Government of India to select it as one of the six circuits that the finance minister’sbudget speech said would be developed on the tourism side. So they have indicated that ouryatra circuit would be one of the circuits to be taken up. In fact, next month it will be fromUttaranchal that the tourism ministry will be launching the Year of Eco-tourism and the Year ofthe Mountains. One of the focus areas that they have taken up is the yatra route. In that context,the whole business of sewage systems, sanitation systems, water supply systems, and so onwould be an extremely important thing.We have recently also constituted our pollution control board, and I’ve in fact requested ourforest and revenue department commissioner be the chairman of it, ex-officio. I’ve suggested tohim that he should immediately convene a meeting and that there are some issues that requireimmediate treatment; for example, polythene and water pollution are two things that we need8

Inaugural Sessionto take up immediately. You will see, hopefully when this yatra season commences, someefforts in the direction of starting a movement for polythene and non-degradable waste removaland so on and so forth. We are taking some initiatives on the tourism department side. So thebroad point is that both the public health and the environmental aspects that you havementioned are extremely important issues to be addressed.Another important point is the issue of convergence. Now, as it has been mentioned, we havetried institutionally to bring about convergence with reference at least to health-care-relatedmatters for children and pregnant women by keeping ICDS and these programmes togetherwith the health department so that some kind of an integral convergence built into the systemswe are developing. Much wider convergence, I think, needs to be brought in at the grass-rootslevel with the whole area of rural development programmes. Now, every year we talk ofimmunization targets, for example. How much have we been able to do? If you could look atimmunization targets within a broader context, you could at least ensure that every family BPLthat has been identified in the last several years has been provided with service or access tosome programmes under the rural development programme. I’m just pointing that out becauseit makes your monitoring process, in other words your accountability process, much simpler.So that is one way of bringing about convergence with the rural development programmes.The other way of bringing in convergence with rural development programmes is with the largenumber of self-help groups (SHGs) have now been set up. We have a target in Uttaranchal.When we became a state we had a 169 SHGs under all the rural development programmes.After one-and-a-half years, we now have 7500 SHGs. By the end of the next two years, we hopeto have 18,000 SHGs. There are similar groups that are being set up under Swajal, which is theparticipatory-approach-based water supply programme. There are similar SHGs that are beingformed under several other programmes. How we can bring these SHGs into the system, howcan we use them in this whole process of health and health-related issues (nutrition, sanitation,cleanliness, and all these sort of issues) are other areas I think one could address.Finally, there is the much broader area of public–private partnership at different levels. One isthe community-based public–private partnership and the other is the institution-based public–private partnership. We have tried to take some initiatives, but it is a difficult area. It’ll take along time to be able to develop systems and possibilities on that front.Finally, let us consider the issue of equity brought out by Mr Jain. Why is it that 22% of BPLfamilies are going to private doctors? On the one hand, I’m told that three-fourths of the doctorsat the health units, even in the rural areas, are private. But at the same time you have PHCs,CHCs, this, that, and the other. Why are they going there? Obviously it has something to do withquality; it has something to do with dependability. Will the doctor be available? Will medicines beavailable? So that is an area where at least the poorest people can have greater access.Another area that we need to look at in that context is insurance. We recently had discussionswith the Life Insurance Corporation (LIC) about some insurance schemes for BPL families thatwere not related to health. They did develop some ideas, which I think Mr Pandey will able to9

Inaugural Sessiontell you more about in the concerned session. They did suggest some sort of a risk-accident,death-risk type of policy in which the premium would also enable some access to education. Sowe told them that the BPL family at that level does not require insurance-related help foreducation—it is already free. Can we build in some element of health there? I would suggestthat you may like to have a more detailed look at that in your afternoon session on that subject.With that and with a repetition that I have very little to say in terms of the intricacies of thesubjects, everybody having mentioned them already, I would like to thank you all once againand wish this workshop, a great amount of success in developing ideas and putting themtogether in such a way that we can successfully put a health policy in place in a timely manner.Thank you very much.I S Pal, Director-General, Health and Family Welfare, Government ofUttaranchalI am here to extend a vote of thanks on behalf of the Department of Medical and HealthServices, Uttaranchal. I am extremely thankful to the Honourable Chief Secretary of Uttaranchalfor sparing his valuable time and for giving us direction and issues to be considered during thisworkshop. I am also extremely thankful to Mr Pant, who has been with us since last week. Iextend my thanks to Ms Chhabra, who has supported this workshop and given several valuablesuggestions. The technical guidance given by Dr Narayana is mainly responsible for the successof the previous workshop, and his guidance for the present workshop will ensure similarsuccess. We thank him for all his support and guidance. I would like to thank the distinguishedexperts from all over the country and the NGOs and the colleagues from my own department.10

Public Health Issues, Priorities, and the Role of the GovernmentSession 1National Health Programmes andEpidemiological SurveillanceChairpersonAlok Kumar JainPublic Health Issues, Priorities and Role of GovernmentS D GuptaNational Health Programmes: An OverviewIndira Murali & Vivek AdhishImplementation of National Health Programmesin UttaranchalI S PalUse of Epidemiological Surveillance Data forProgramme ManagementDinesh JainDesigning a Surveillance SystemDora WarrenDiscussantRameshwar Sharma11

Public Health Issues, Priorities, and the Role of the GovernmentSession 1Public Health Issues, Priorities, andthe Role of the GovernmentS D Gupta, Director, Indian Institute of Health and Management Research, JaipurBackgroundSince the inception of the formal health care system in India, which is based on theconcept of comprehensive health care, major gains have been recorded over thepast five decades in people’s health status. The life expectancy has risen from 36years in 1951 to 62 years in 1995. The crude death rate (CDR), which was as high as27 per 1000 persons, decreased to 8.7 per 1000. Similarly, a significant decline hasbeen recorded for the infant mortality rate (IMR)—down from 145 per 1000 livebirths to 71 per 1000 live births. There has been a spectacular decline in mortalityresulting from major communicable diseases including plague, malaria, choleraand smallpox. Major epidemics have been brought under control and smallpoxhas been eradicated. Poliomyelitis, which is responsible for a high disability rate,is on the verge of being eliminated.Further, health care development has registered high growth for infrastructureand human resources. Vast health care infrastructure and a huge network ofhealth institutions have been created in the public system. Presently, there are21,853 primary health centres (PHCs) and 132,778 health sub-centres havebeen established to provide primary health care and reproductive healthservices. A huge workforce, which includes 360,100 doctors and 620,000 nurses,has been recruited and engaged in health care delivery in both urban anddistant rural areas. In the past 50 years, the accessibility and availability ofhealth care has improved tremendously as a result of enhanced geographicalreach and skilled manpower.However, despite significant and major gains, the health status of the peopleremains dismally poor. Important key features of the current health status are:l high IMRs;l high maternal mortality rates (MMRs);l a large portion of deaths attributable to acute communicable diseases;l common killers such as malaria, tuberculosis, and diarrhoeal disease; andl high prevalence of malnutrition and other nutrition disorders.13

Public Health Issues, Priorities, and the Role of the GovernmentTable 1. India’s Share of the World’s HealthProblemsIndia’s burden of disease (BoD) is unacceptably high (seeTable 1). Two-thirds of India’s BoD is caused by prematureCharacteristicsPercentage (of world)deaths and is highest among children under age five. Thereare regional disparities and wide differences in the BoDPopulation 17among the states. There are also urban and ruralPeople living in poverty (

Public Health Issues, Priorities, and the Role of the GovernmentIndia is witnessing changes in populationstructure, like an increasing ageingpopulation due to increased life expectancy,improved health care, and nutrition. Thepopulation growth rate is unacceptably high.The population has increased from 370million in 1951 to about 1 billion in 2001, thusoutstripping resources and adverselyinfluencing health, especially that of womenand children. Increasing unemploymenthas led to migration to urban areas,thereby creating additional pressure onalready stressed civic amenities and healthcare facilities.Table 2. Top Ten Specific Causes of Death in India, 1998Cause India India/World RatioThousands Percentage PercentageIschaemic heart disease 1,471 15.8 19.9Acute respiratory infection 969 10.4 28.1Diarrhoeal diseases 711 7.6 32.1Cerebrovascular disease 557 6.0 10.9Tuberculosis 421 4.5 28.1Road traffic injury 217 2.3 18.5Measles 190 2.0 21.4HIV/AIDS 179 1.9 7.8Tetanus 165 1.8 40.3COPD 153 1.6 6.8Total deaths 9,337 100.0 17.3Total population 982,223 100.0 16.7The major consequence of India’s health andTable 3. Ten Specific Causes of Disability: Adjusted Life Yearsdemographic transition is an increase in theLost in India, 1998disease burden due to diseases associatedwith ageing, such as cardiovascular diseases, Cause India India/World Ratiohypertension, stroke, metabolic diseases, andDALYs Percentage Percentagecancers. There is also a lack of access to healthAcute lower respiratory infections 24,806 9.2 30.1Diarrhoeal diseases 22,005 8.2 30.1care among the ageing population. PoorIschaemic heart disease 11,697 4.3 22.5social support from the public system andFalls (injuries) 10,898 4.1 40.3changing social norms have left this segment Unipolar major depression 9,679 3.6 16.6of the population in a dismal situation.Tuberculosis 7,577 2.8 26.9Complexity of the Health SystemRoad traffic injuries 7,204 2.7 18.5Measles 6,474 2.4 21.4The health system has grown complex. This Anaemia 6,302 2.3 25.5complexity has arisen from the vastFire-related injuries 5,723 2.1 47.8expansion of the health care network andAll causes 268,953 100.0 19.5inclusion of a wide range of services—superspecialtyvis-à-vis primary health care. A hugeTotal population 982,223 100.0 16.7workforce is engaged in health delivery, both Table 4. Deaths by Broad Causesin the public and private sectors. There areseveral categories of the health workforce thatDevelopingRegionsDevelopedRegionsprovide health care. Lack of both properattitude and motivation have caused a seriousproblem in the functioning of the healthsystem. There is a clear lack of leadership andmanagerial skills at all levels of the system. InCommunicable diseases, maternal,perinatal, and nutritional conditionsNon-communicable diseasesInjuries41.9%47.4%10.7%6.1%86.2%7.6%addition, the health system is poorly managed. The quality of services is far from satisfactory,thus resulting in poor utilization of public services. In addition to the allopathic system, thereare other systems of medicine that exist concurrently—Ayurveda, Unani, Siddha, homeopathy,and traditional healing. The public health system today faces a major challenge.15

Public Health Issues, Priorities, and the Role of the GovernmentRising expectations for better services and the inability of the public system to meet health careneeds have complicated the health system in India. The referral system does not work andprimary health care institutions are bypassed, thus crowding higher-level health facilities. Thereis also the issue of a competing private sector, which poses a serious challenge. Private sectorservices are generally perceived as higher quality services and so despite its higher costs, theprivate sector seriously undermines utilization of the public sector.The public health system operates under severe financial constraints. The Eighth Five-Year Planmade a provision of 11,000 crore rupees for health care. However, a majority of the funds (about90%) are used for salary and related budget items, thus leaving little for other purposes. There isa severe resource crunch and health services are starved for funds.In summary, the health systems work under severe constraints including the following.l Inequity: Lack of access to quality basic health services by the poorllInefficiency: Inferior deployment and supervision of health functionaries and underutilizationand over-crowding of some public health facilitiesRising costs: New medical technologies and ignorant clients; provider-induced demandfor costly test procedures and treatments and continued use of branded instead ofgeneric drugs.InequityThere is appalling inequity in the distribution and use of health care expenditure. Recent workhas provided astonishing data on health expenditure. According to these studies, the poor pay19% of their incomes on health care while the rich pay only 2% of their incomes. Recentstudies report that over 80% of people use the private sector for health care; use of publicservices is marginal. About 55% of in-patients and 80% of out-patients use the private sector. Itis further reported that household expenditures account for a major share of health careexpenses, even for the public sector.The inequity is multi-dimensional. Social inequity is evident from selected health indicatorsfrom the various population groups, namely, those living below the poverty line, women, andmarginalized groups (Scheduled Class/Scheduled Tribe). Not only do these people have poorhealth status (see Table 5), but they also experience low effectiveness of health services (seeTables 6 and 7).Challenges for Indian Policy-Makers and Programme ManagersDespite significant achievements during the past five decades, much still needs to be done.lllA large “unfinished agenda” of communicable diseases and maternal and nutritionaldisorders still exists in the developing world.There is a need to cope with ageing populations and the consequent burden of degenerativediseases and hitherto neglected injuries and accidents.There is a need to be prepared to meet emerging diseases, such as tobacco-related diseasesand HIV/AIDS.16

Public Health Issues, Priorities, and the Role of the GovernmentTable 5. Health Status Indicators: Comparison Between the Poorest and Richest Quintiles ofthe Indian Population, 1992/93Scheduled Scheduled Other OtherCaste Tribes DisadvantagedClassIMR (per 1,000 births) 83.0 84.2 76.0 61.8Under-five mortality rate (U5MR)(per 1,000 births) 119.3 126. 103.1 82.6Total fertility rate (TFR) 3.15 3.06 2.83 2.66Children underweight(% below 2 standard deviations) 53.5 55.9 47.3 41.1Children with anaemia (%) 78.3 79.8 72.0 72.7Children with acute respiratoryinfection in past 2 weeks (%) 19.6 22.4 19.1 18.7Children with diarrhoea in past 2 weeks (%) 19.8 21.1 18.3 50.7Anaemia among women (%) 56.0 64.9 50.7 47.6Table 6. Effectiveness: Health Outcomes by Income Quintiles, Urban IndiaPoorest Second Middle Fourth RichestIMR 121.2 94.2 85.1 67.1 41.9U5MR 143.6 141.6 119.5 90.0 51.5Children underweight (% moderate) 74.3 61.5 56.3 52.5 34.5Children underweight (% severe) 30.9 32.4 21.9 18.9 11.3TFR (4.3) 3.5 3.2 2.9 2.1Table 7. Effectiveness: Health Outcomes by Income Quintiles, Rural IndiaPoorest Second Middle Fourth RichestIMR 108.9 107.2 90.3 64.9 51.3U5MR 155.0 153.8 119.5 85.4 63.9Children underweight (% moderate) 59.5 59.3 55.1 45.0 33.8Children underweight (% severe) 29.0 25.9 21.2 15.3 9.6TFR 4.1 3.6 3.2 2.8 2.2Calcutta Declaration of Public HealthThe Regional World Health Organization Conference in 2000 recognized that public health is thekey to human development and that health systems need to be strengthened and integratedwith other development sectors. Some of the key statements (given below) made in thedeclaration indicate a strong need for public health.l Promote public health as a discipline and as an essential requirement for healthdevelopment in the region. In addition to addressing the challenges posed by ill-health andpromoting positive health, public health should also address issues related to poverty,equity, ethics, quality, social justice, environment and community development andorganization.l Recognize the leadership role of public health in formulating and implementing evidencebasedhealthy public policies; creating supportive environments; enhancing social17

Public Health Issues, Priorities, and the Role of the Governmentllresponsibility by involving communities and increasing the allocations of human andfinancial resources.Strengthen public health by creating career structures at national, state, provincial anddistrict levels and by establishing policies to demand a data-competent background andrelevant expertise for persons responsible for the health of populations.Strengthen and reform public health education, training and research, as supported by thenetworking of institutions and information technology, for improving human resourcesdevelopment.How Do We Address the Problem?l Develop evidence-based policies and strategies. Equally important is effectiveimplementation of strategies at all levels, especially at the district level and below. Thiswould require a continuous and ongoing exchange between researchers and policy-makersfor sharing information and identifying priority areas for policy development.l Health is a development issue, hence promote and develop mechanisms for inter-sectoralcoordination. Develop public health as a holistic model for health care and humandevelopment. There is a greater need for community participation and involvement ofPanchayati Raj institutions (PRIs).l Shift focus to increase access and availability of health to the poor, disadvantaged andvulnerable segments of the population.l Support health sector reforms: policy, organization and management in the health systems,health workforce development and decentralized planning process.l Develop leadership and team-building skills among health managers and health careproviders.l Strengthen management systems and processes: management information systems,planning and implementation, monitoring and evaluation, logistics and supply and qualityassurance.l Evolve health financing mechanisms to support health care systems by increasing the shareof health expenditure in relation to the gross domestic product (GDP). It would also requiredeveloping alternative financing approaches through cost recovery, user charges and otherpayments for health care.l Involve and regulate the private sector and avoid competition. The public system shouldinvest more in primary health care and health promotion and foster partnership with theprivate sector, not only at the secondary and tertiary levels of health care, but also forprimary health care.l Enhance the skills of leaders, managers, and health care providers. Some of the critical areasthat need immediate attention are as follows.n Strengthen public health and make it skill-orientedn Clinical skillsn Epidemiological skillsn Leadership and team-building skillsn Organization and managerial skillsn Social and communication skills.18

Public Health Issues, Priorities, and the Role of the GovernmentRole of the GovernmentThe government has a Constitutional obligation to protect and promote the health and nutritionof the people. Over the past 50 years, the government has focused on the development of healthinfrastructure to accomplish its welfare-oriented goals. Health is a state subject and theConstitution places public health, sanitation and hospitals on the state list.The World Health Report (2000) has identified stewardship as the major role of the government.It has listed three stewardship tasks—(1) formulating health policy and defining vision anddirection; (2) exerting influence through regulations and laws; and (3) collecting and usinghealth intelligence.The key functions the government ought to undertake are as follows.1. Stewardshipl Formulating policies like health policy, population policy, drug policy, and so forth; mainlydefining the vision and directionl Enacting laws and regulations and setting standards of health carel Monitoring indicators of health and development and determinants of health andevaluating performance of health programmes and interventionsl Collecting information for policy development and programme monitoringl Promoting inter-sectoral coordinationl Guiding and overseeing the health system to achieve universal access, equity and qualityof services2. Financing health care; mainly mobilizing resources; evolving financing mechanisms toensure adequacy of funds and their flow and allocating funds appropriately to meetpriority areas3. Administering health workforce policy and development through appropriate recruitment,training and placement4. Providing basic preventive and promotive health care, especially in areas where the privatesector is not willing (e.g., poor and deprived sections of population and other vulnerablegroups)5. Establishing and managing health institutions for primary health care and implementationof health programmes6. Promoting and supporting research in health systems and delivery of health care, anddeveloping mechanisms for use of such research in policy and programme evaluation.19

National Health Programmes: An OverviewSession 1National Health Programmes:An OverviewIndira Murali, Vivek Adhish, National Institute of Health and Family Welfare, New DelhiImprovement of the health status of the population has been one of themajor thrust areas for the social development programmes of India. SinceIndependence, various measures have been initiated by the Government ofIndia (GoI) in terms of improving access to health care by all, especially theunderserved segment of the population, by developing a massive healthinfrastructure at primary, secondary, and tertiary levels. To tackle the majorhealth and population problems in the country, major disease control andfamily welfare programmes have been launched since the first five-yearplan. Over the last five decades, considerable epidemiological changes haveoccurred in this country because of various factors such as technologicaladvancements, changes in morbidity and mortality patterns, demographicchanges such as increased longevity, and changing lifestyles. However theburden of communicable and non-communicable diseases, as well asnutrition problems, continues as a major challenge.At the time of Independence, high morbidity and mortality caused bycommunicable diseases such as malaria, smallpox, leprosy, andtuberculosis (TB) were among the major challenges that adversely affecteddevelopment. Based on the criteria of severity, magnitude, economicimpact on society, vulnerability to various types of interventions, and soforth, these problems were prioritized, and the central government took theinitiative of launching specific disease control programmes. Nutritionrelatedproblems were well recognized and programmes/schemes fortackling deficiencies of vitamin A, iron (anaemia), and iodine were alsolaunched. Even though, constitutionally, the protection of public healthand the provision of health care became the responsibility of the stategovernments, the national disease control programmes continued, more orless, to be run directly by the central government through majorcontributions in planning, technical and financial support, and nationallevelmonitoring and review. A review of the evolution and progress ofthese programmes reveals that care has been taken by the central20

National Health Programmes: An Overviewgovernment in making appropriate interventions commensurate with the changes in theepidemiological, political, and economic climate. Changes in programme strategies havebeen made reflecting research findings and technological advancements. Examples are theintroduction of newer vaccines under the immunization programme and changes intherapeutic regimens for TB and leprosy. In recognition of the importance of lifestylediseases, as well as their relevance in the context of demographic changes happening inIndia, programmes for the control of non-communicable diseases such as diabetes andcancer have recently been initiated. Apart from the central government’s support inmanaging these programmes, support from external funding agencies hasbeen accepted. At times, state governments have been required to contribute theirresources and inputs.Suggestions for the future are presented in this document based on brief reviews of someof these programmes in terms of their achievements and major issues in theirimplementation.The impact of a rapidly increasing population on the quality of life, especially for vulnerablegroups, as well as on the economic status and development of the country as a whole,prompted the government to launch the first-ever national family planning programme.Over the years, this programme has undergone a series of changes in its goals and strategies.The reproductive health approach most recently adopted by the GoI is in consonance withthe Programme of Action of the Cairo International Conference on Population andDevelopment (ICPD).Even though not directly being implemented by the Health and Family Welfare Department, twoimportant programmes–Integrated Child Development Services (ICDS) and the National WaterSupply and Sanitation Programme–are also making sizeable contributions towards improvingthe health of the people in the country.A list of various national health programmes is provided in the box below. Brief descriptions ofmost of these programmes are given in the Annex. A review of the evolution of theseprogrammes shows that some have continued to operate under their original name; some havebeen discontinued due to successful achievement of programme goals; and others, due to policyas well as operational considerations, have been modified/integrated into various otherprogrammes or general health services.No. Programme Goals/Status1. National Anti-malaria Programme Control (Reduce mortality to 50%)2. National Leprosy Eradication Programme Elimination3. National Tuberculosis Control Programme Control (Reduce mortality to 50%)4. National Filaria Control Programme Elimination5. Kala-Azar Control Programme EliminationContd. on next page21

National Health Programmes: An OverviewContd. from previous page6. Japanese Encephalitis7. Dengue/Dengue Haemorrhagic Fever8. Guinea Worm Eradication Programme Eradicated9. Yaws Eradication Programme Eradication10. National Surveillance Programme forCommunicable Diseases11. Vitamin A Prophylaxis Programmefor Control of Blindness Control (Reduce prevalence to 0.5%)12. Iodine Deficiency DisorderControl ProgrammeControl13. National Mental Health Programme Control14. National Cancer Control Programme Control15. National Diabetes Control Programme Control16. Cardiovascular Diseases ControlProgramme17. Reproductive and Child HealthProgramme18. National AIDS Control Programme Control (Achieve zero-level growth inHIV/AIDS)19. Acute Respiratory Infection (ARI)Control ProgrammeControl20. National Smallpox EradicationProgrammeEradicated21. National STD Control Programme Control22. Anaemia Control Programme Control23. Expanded Programme on Immunization Polio Eradication, Neonatal TetanusElimination24. Diarrhoeal Disease ControlProgrammeControl25. Family Welfare ProgrammeOverview of Success Stories and FailuresBased on a review of different aspects of good and bad experiences with implementation ofnational health programmes, some directions for the future can be worked out. The pertinentquestions are as follows:l What are our success stories?l Which are the factors that helped in achieving success?l Where have we failed and why?22Two main successes have been achieved in the eradication of smallpox and guinea worm.Others are the near eradication/elimination of polio, leprosy, yaws, and neonatal tetanus(NNT). Some factors in these achievements have been political and administrativecommitment, an effective surveillance system, people’s awareness of the problems andtheir involvement in implementing the intervention strategies, meticulous micro-planningof activities by the programme personnel and involvement and cooperation from otherrelated sectors.

National Health Programmes: An OverviewEven after reaching a level of near eradication of a health problem such as malaria, theprogramme suffered a set-back that resulted in the disease’s resurgence partly due to technicalreasons, but also as a result of complacency on the part of implementing agencies.TB control is an example of an ongoing programme that has not made a dent in the magnitudeof the problem, even with support from technical advancements. The reason for this could bethe slow pace and lack of efficiency in the programme’s implementation.From this review of successes and failures, certain points emerge that need to be considered forfuture planning and implementation of national health programmes. Some of these arepresented below.Need for Prioritization of ProblemsWhile there are many health problems in the country (malaria, TB, diabetes) that are equallyimportant for all states and Union Territories (UTs), there are many problems that areregionalized (leprosy, filariasis) or localized (Kala-Azar). As per constitutional provisions, thestate government is responsible for identifying and managing these problems with theappropriate allocation and use of resources. At the same time, the role of the central governmentin designing appropriate programmes for problems of national relevance continues, particularlybecause there is wide variation among states in terms of their socioeconomic development andpreparedness and capacity for undertaking huge health programmes. Under thesecircumstances, for effective operation of the national health programmes, some of the followingtips may be helpful.l Criteria for the prioritization of problems need to be defined from epidemiological, socialand economic dimensions.l The extent and nature of the role of the central government need to be specified for eachprogramme and the rationale for these decisions made known to all.l The centre–state relationship in different programmes needs to be specified.Need for Information on the Magnitude of the Problem/DiseaseOne of the major criticisms of many of the national health programmes in India is that they areplanned and implemented without having adequate information on the actual magnitude ofthe problem. Usually some rough estimate is used that may not be made on a sound scientificbasis. Only in a few programmes, such as TB, neonatal tetanus, and blindness, has nationalleveldata been generated. National-level data generation through surveys is highly expensiveand time consuming. We ought to be able to generate reasonably accurate data throughroutine passive surveillance from service institutions, if implemented effectively, despite thelimitation that all cases of any disease are treated by government sources of care from whichthe data is generated.Need for a Strong Surveillance SystemThe network available for disease surveillance is extremely rudimentary, and even the existingsystem does not always provide the required data with any degree of quality. Results are evidentfrom the controversial outbreak of plague and the epidemics of diseases such as malaria,23

National Health Programmes: An Overviewdiarrhoeal diseases, dengue fever, Japanese encephalitis (JE), vaccine-preventable diseases(VPDs) in particular, and measles. A concerted surveillance effort has been one of the majorforces behind the successful eradication/elimination of diseases in the past, such as smallpoxand guinea worm, the likely elimination of leprosy and neonatal tetanus, and the eradication ofpoliomyelitis and yaws. The Government of India has launched a national programme onsurveillance of selected diseases in a few districts.While it is appreciated that sophisticated computerized data for surveillance will be very usefulin programme management, it is too early to consider its implementation in the remote andbackward districts in a uniform manner, and hence, priority will be given to the manualgeneration of surveillance data on a regular basis for important health programmes.Need for Active Participation of the State GovernmentsThe National Health Policy (NHP) 2002 has envisaged a key role for the central government indesigning national health programmes with the active participation of the state governments.The extent of varying levels and patterns of needs/epidemiological characteristics of theproblems should be considered when planning the programmes with the involvement of stateauthorities. Even though financial and technical support comes from the central government,currently actual implementation is through the state system. Any additional inputs requiredshould come from the state government so that a true partnership, as well as a sense ofownership, is generated. The NHP 2002, however, suggests the need for distancing theimplementation of vertical programmes from the state health department to provide operationalflexibility. Merits/demerits, if any, of this suggestion needs to be reviewed/considered by thisexpert group.24Integration of ProgrammesIn the past, the basic philosophy was that independent vertical programmes, with separateinputs and machinery, were necessary for the initial phase of handling major priority problems.However, once the problem had been brought under a reasonable level of control, it wasrecommended that the interventions of the programme be integrated with general healthservices. In India, the same philosophy has been accepted and, under the multi-purpose worker(MPW) scheme, most of the hitherto vertical programmes were integrated, at least at the servicedelivery level. Programmes for malaria, TB, and family planning have been integrated under thisapproach, although in the long run, the effect has not been satisfactory according to manyprogramme managers. Recently, efforts have been initiated to integrate the Leprosy EradicationProgramme. Even when the decision is made for integration, it is important to specify the itemsto be integrated (resources, personnel, management information systems) and the level towhich the programme is to be integrated (primary health centre (PHC), district, state), becauseexperience has shown that integration of different programmes under the MPW scheme has notbeen accepted by all as having made a sufficiently useful impact. It is equally important toensure that the general health services system is prepared to take over the additionalresponsibility (technically and psychologically), for example, an integrated information system,appropriate resource pooling, and a logistics and supply system. Technical preparednessthrough training of all concerned, as well as managerial changes, is necessary.

National Health Programmes: An OverviewIntegrated Management Information SystemOur past experience with the effort for implementing an integrated management informationsystem (MIS) has not been very encouraging. Initially, under the MPW scheme, the integratedmanagement information and evaluation system was launched and, through a series of training/orientation workshops, all or most states were persuaded to adopt it. Later, the MIS wascomputerized and, through the NICNET, it was expected to function. However, it is worthwhile toreview current experience with the MIS, as there appears to be no uniformity of application inmost states.Monitoring and EvaluationQuite closely linked with the MIS is programme monitoring and evaluation. Each programmehas evolved its own system of data generation and reporting to different levels ofadministration. However, currently one of the weak aspects of programmes is the analysis of thedata generated and its meaningful interpretation by programme managers for making rationaldecisions to improve programme implementation. Some programmes have evolvedappropriate monitoring indicators (input and programme performance) and impact indicators(TB, leprosy, and immunization programmes) that are already included in their guidelines.Many programmes have not made such attempts. The purely mechanical transfer of dataupwards from levels below, without its proper utilization, is what is happening in most states.This needs to be corrected soon. Sophisticated computerized data management will becomeeffective only if the programme officers ask for proper analysis of the data generated and basetheir actions on meaningful interpretation of data.Periodical evaluation of national programmes will yield good results, which would be beneficialfor identifying corrective actions based on facts. The Tuberculosis and Leprosy Programmes areregularly reviewed, while the Universal Immunization Programme (UIP) was reviewed at thenational level once in 1989. The Cancer Control Programme is currently being evaluated.Importance of Integrated and Participatory Programme Implementationand PlanningWith the exception of a few programmes, leprosy for example, most national programmeshave been designated as integrated with the general health services at the service deliverylevel. The primary health care staff, the PHC medical officer, and the supporting staff of thePHC are expected to implement the service activities. Because the activities to be performed bythe different staff have not been clearly identified or properly scheduled, there is chaos in theactual functioning of staff at the grass-roots level. Some activities are neglected while othersget overemphasized. One reason for this could be the lack of clear instructions regarding thejob responsibilities of the staff. Another reason is probably the lack of integrated planningwith appropriate coordination of activities under different programmes. Some of theprogrammes are meticulously planned, for example, the UIP in the late 1980s and the currentPulse Polio Programme. In fact, lessons learned for micro-planning from these programmeswere expected to be introduced into the other programmes. So far, however, this does notseem to have happened.25

National Health Programmes: An OverviewEven if the programmes are not fully integrated horizontally at the district level, the concernedprogramme officials have to delineate the job charts for the different staff members under theirprogramme, and share them with officers of other programmes so that these activities can becoordinated. The staff can spell out the activities to be performed under each programme duringa home visit, and give appropriate training and orientation to the concerned staff, as done in theReproductive and Child Health (RCH) Programme for integrated skills training. Similarcoordination is required for clinic activities; maintenance of records and reports; information,education, and communication (IEC); resource planning and so forth.Need for Inter-sectoral CooperationAs already mentioned in the NHP 2002, the overall well-being of the people will depend on thesynergistic functioning of the various socio-economic sectors. This is true for the nationalhealth programmes. One example could be the control programmes against vector-bornediseases, particularly the mosquito. The use of insecticides and environmental control toprevent vector breeding are the anti-vector measures adopted under the programme. In this,the role of developmental projects is well known and project areas have been identifiedcorresponding to risk areas for malaria. Joint planning and consultation with health experts forhealth impact assessment of projects are extremely important for the success of malariacontrol activities.Another important aspect of vector-borne disease control is the use of insecticides. There is thedanger of vectors developing insecticide resistance as well as the apprehension about the effectsof insecticides on health through the contamination of food, water and soil. Different sectors,particularly agriculture, are using insecticides in varying strengths and quantities. Joint andcoordinated use of insecticides, keeping in mind the health effects, need to be considered for thefuture. Tapering off on the use of insecticides is already recommended.Need for More Health ResearchThe NHP 2002 has reiterated the need for focus on health research in general, and in particular,regarding the national health programmes. Research on new therapeutic drugs, vaccines,epidemiological characteristics of diseases, and applied research for developing operationalapplications are important. Vaccines already in the advanced stages of development need tobe tested in the field for efficacy, safety, and operational feasibility. Good examples ofprogrammes to demonstrate the utility of research include leprosy, TB, UIP, and iodinedeficiency disorder (IDD) control. Their strategies have been evolved based on the findings ofsound research studies. However, the need is now to promote operational research forexperimenting and standardizing operational and therapeutic practices in more nationalhealth programmes. Many programmes have support from research and traininginstitutions—the National Training Institute (NTI), the Leprosy Research and Training Centre,the RP Centre, the Filaria Research Centre, the Malaria Research Centre, and the CancerResearch Centre. Their roles need to be redefined and activities expanded to get betterprogramme results.26

National Health Programmes: An OverviewCapacity Building Among StaffIt is also important to ensure a system for capacity development of the programme staff. Thetraining may include modules on epidemiology; management, which deals with programmeplanning, particularly micro-planning; geographical information systems; monitoring andevaluation; MIS; and clinical aspects, such as diagnosis and case management. Even thoughtraining activities are currently being implemented under many programmes, these are verticalin nature and are not sufficiently related to developing skills among the trainees. For primaryhealth care personnel, it is advisable to have integrated training covering all the programmesthat have been integrated at that level, with more focus on practical skills.Community Involvement in ProgrammesBecause services under all the national health programmes are included as part of the deliveryof primary health care, the essential principle of community participation is vital for theirsuccess. For the people to feel a sense of ownership of a programme and its activities, it isimportant that, from the identification stage of the need itself, the people be a party to it. Further,detailed programme planning should be done with the people’s involvement. With theconstitutional provision for strengthening local self-government, the Panchayat and Nagarpalika, with elected representatives of the local population, the involvement of the people inrunning the programme has become easier. A number of scientific techniques, such asparticipatory learning assessment (PLA), that may be applied for achieving communityparticipation have been developed by social scientists and anthropologists. Probably thedifferent “societies” constituted under the programmes (blindness, leprosy, AIDS, RCH) may alsohelp in this direction.With progress in the implementation of programmes for diseases/conditions, such as leprosy,blindness, and polio, there is also the need for better rehabilitation services; more emphasisneeds to be placed on “community-based rehabilitation” with the active participation of thecommunity. Similarly, with more and more cases of people suffering from full-blown AIDS, thereis greater need for home-/community-based care of the affected individuals. Better communityawareness and involvement will also be essential in the future.Effective IEC programmes are extremely crucial for achieving community participation.Focus on Specialized Population GroupsIn India, urbanization is progressing at a fast pace. Due to the inadequacies in expansion ofbasic amenities commensurate with the population growth in urban areas, large numbers ofslums have arisen in many cities. Slum populations are most vulnerable to multiple healthproblems, and because there is no proper arrangement for delivery of primary health care inthese areas, the respective national health programmes also do not get the attention theydeserve. Particularly with programmes like TB and leprosy control, in which case detection andprompt and complete treatment are the main strategies to be followed, the slum and migrantpopulations temporarily settling in these areas are likely to be left out. This may pose ahindrance to the achievement of programme goals. Similarly, the tribal, desert and hilly areas,27

National Health Programmes: An Overviewwhich suffer from inadequate health infrastructure and facilities, also need special attention andappropriate strategies for implementing different national health programmes.Annex: Brief Descriptions of Selected National Health Programmes1. National Anti-Malaria Programme (NAMP)Evolution/Milestonesl 1953: Initially launched as the Malaria Control Programme; achieved great reduction in themagnitude of malaria through appropriate anti-vector interventions and treatment of caseswith anti-malarial drugs.l 1958: Was converted into the Malaria Eradication Programme with a spectacular reduction incases from 75 million to 0.1 million and nil deaths reported in 1965. Thereafter, there was aset-back in the programme and a resurgence of malaria due to technical, financial,administrative and logistic factors.l 1971: An urban malaria scheme was launched realizing the need for special attention tourban areas for tackling the resurgence of malaria, but with little impact.l 1977: The attempt at eradication was dropped and a Modified Plan of Operations (MPO) wasadopted with the aim of effective control of malaria. Insecticide spray was based on theAnnual Parasite Incidence (API) indicator. Continuation of active and passive surveillance;decentralization of laboratory services to PHC level; establishment of Drug DistributionCentres (DDCs) and Fever Treatment Depots (FTDs) under the programme were some of theimportant features of this MPO.l 1977: The Plasmodium Falciparum (PF) Containment Programme was initiated.l 1994: Due to the effect of the MPO, cases of malaria were reduced considerably until 1994when a resurgence of malaria was observed in some parts of the country with epidemics andincreased mortality.l 1995: Based on the recommendations of the expert committee that reviewed the situation, theMalaria Action Programme (MAP) was formulated. Under MAP, high-risk areas based onepidemiological parameters were identified, such as hard-core areas (tribal areas),epidemic-prone areas, project areas, triple-insecticide-resistant areas and urban areas.Accordingly, separate strategies were also evolved.l 1997: The Enhanced Malaria Control Project, with World Bank assistance, was launched,directly benefiting the six-crore-strong tribal population and PF endemic areas in the sevenpeninsular states—Andhra Pradesh, Bihar/Jharkhand, Gujarat, Madhya Pradesh/Chhattisgarh, Maharashtra, Orissa and Rajasthan. In addition, 19 cities reporting highmalaria cases have also been covered under the project in these states and in Tamil Nadu,Karnataka and West Bengal.Components of the project are selective vector control; innovative eco-friendly methods, such asthe introduction of medicated mosquito nets; biolarvicides; epidemic planning and rapidresponse, including inter-sectoral coordination; institutional and human resource development;improved MIS; and IEC.l 2000: Epidemiological situation in India indicated: API 1.97; PF in million 0.9; anddeaths 872.28

National Health Programmes: An OverviewIssues/Commentsl Planning is rather ad hoc instead of using a comprehensive approach to the problem.l Malaria control is truly a problem requiring inter-sectoral and inter-departmentalinvolvement, which has not been achieved.l The desire to eradicate the problem has subsided and, hence, there is less commitment inimplementation.l Only temporary efforts to ward off mosquito bites are adopted.l There is no reliable and true data on the occurrence of the disease due to a lack of concernfor diagnosis, non-reporting, efforts to under-report and so forth.l The treatment pattern adopted by government providers and private practitioners is notuniformly standardized and problems of drug resistance are likely.2. National Leprosy Eradication Programme (NLEP)The National Leprosy Control Programme was launched in 1955. A not very effectivemono therapy with dapsone, along with the high drop-out rates among the patients, resultedin the accumulation of an estimated 4 million cases with a prevalence of 57/10,000population in 1981.In 1983, the programme was redesigned as the National Leprosy Eradication Programme andthe whole country was covered with multi-drug treatment (MDT) in a phased-in manner. It wasgiven a high priority by making it a 100% centrally-sponsored scheme with the goal ofelimination of leprosy (the prevalence rate reduction to less than 1 per 10,000 population) by theyear 2000. Operationally the country was divided into the following areas.l High endemic areas (districts), prevalence > 50/10,000l Moderate endemic areas (districts), prevalence 20–50/10,000l Low endemic areas (districts), prevalence < 20/10,000.Funds were released through 490 District Leprosy Societies set up under the chairmanship of theDistrict Collectors. Leprosy Control Units for every 4–5 lakh people were established in the highendemic areas. Mobile Leprosy Treatment Units were established in the non-endemic districts—two each in moderate endemic districts and one each in low endemic districts. In endemic urbanpockets, Urban Leprosy Centres were attached to general hospitals.The classification of the disease was revised and patients registered on the basis of thepresence of bacilli (pausi or multi) in the skin lesions, skin smears, and the involvement ofnerves. Accordingly, regimens of MDT were prescribed. Single-dose therapy for a single skinlesion was also introduced. Immuno-therapeutic and prophylactic vaccines have not beenrecommended.The Modified Leprosy Elimination Campaign has been introduced in some high endemic statesto increase case detection. The leprosy services are being integrated with general health careservices. Prevalence of leprosy came down from 57/10,000 in 1981 to 5.2/10,000 in 2000.29

National Health Programmes: An Overview3. Revised National Tuberculosis Control Programme (RNTCP)Tuberculosis continues to be a major public health problem. The worst affected population isthe young and economically productive age group. Lifetime risk of developing TB in TB-infectedpeople is about 10% and in HIV-infected people also infected with TB, it is 50%.India accounts for nearly one-third of the global TB burden and about three-fourths of theTB burden of World Health Organization’s (WHO’s) South-East Asia Region. It is estimatedthat in our country, 14 million people are suffering from TB, with 3–3.5 million beinghighly infectious.The National Tuberculosis Control Programme started in 1962 as a centrally-sponsoredprogramme on an equal sharing basis between the central government and the state. TheRevised National Tuberculosis Control Programme (RNTCP), popularly known as DOTS (directlyobserved treatment short-course) was pilot-tested and the programme was formally launchedon 26 March 1997, to be implemented in a phased manner. DOTS is a systematic strategy whichhas five components—(1) political and administrative commitment, (2) good quality diagnosis,(3) good quality drugs, (4) the right treatment given in the right way, and (5) systematicmonitoring and accountability.Diagnosis by microscopy is the primary strategy for case detection. Three samples of sputum(spot-early morning-spot) collected on two consecutive days from the patient are examined. Theyield of three sputum examinations is nearly as good as the results of a culture examination. Thenegative cases are diagnosed by radiological examination in accordance with the diagnosticalgorithm. Nearly 8 out of 10 patients diagnosed since 1993 were cured. The programme hasbeen expanded to more than 450 million in more than 190 districts. The RNTCP has preventedmore than 1.5 million TB infections and saved 125,000 lives. It is proposed to cover the entirecountry by 2005.4. National Filariasis Control Programme (NFCP)Approximately 420 million people in India are living with the risk of filaria infection and about44 million people are actually affected by filariasis.l 1949–55: The Indian Council of Medical Research (ICMR) conducted a pilot study in Orissa.l 1955: the NFCP was launched.l 1978: NFCP bifurcated into two components—research and training under the NationalInstitute of Communicable Diseases (NICD) and operational component under NationalMalaria Eradication Programme (NMEP).Pilot Projectsl Single-dose, mass drug administration initiated in 13 districts in seven states in 1997l Co-administration of DEC and Albendazole as Annual Mass Administration Strategyl DEC medicated salt project, undertaken at Neelaturu (Andhra Pradesh), Parbatpure (UttarPradesh), Lakshadweep, Karaikal (Pondicherry) and the Andamans.30

National Health Programmes: An OverviewProgressl Headquarter Bureaus established exclusively for coordination and supervisionl Survey units (27) established for correct appraisal of the extent and collection ofepidemiological datal Control units (206) established with the objective of evaluating known methods of filariacontrol and evolving suitable strategiesl Filaria clinics (199) established at the rate of one clinic for 50,000 population to reduce thereservoir of infection through anti-parasitic measuresl The total protected population is 41 million.5. Kala-Azar Control ProgrammeKala-Azar is endemic in Bihar, Jharkhand and West Bengal as well as in a few districts of UttarPradesh. A centrally-sponsored Kala-Azar Control Programme has been operative since 1990/91for control of the disease in endemic areas. There has been an 81% decline in annual incidenceand 89% decrease in deaths in 2000 compared with 1992. During 2001, the incidence hasdeclined by about 21% compared to the preceding year.Strategy for Kala-Azar Controll Vector control through indoor residual insecticide sprayingl Early diagnosis and complete treatmentl IEC for awareness and community involvement.Until 2000/01, the programme was operative on a cost-sharing basis between the central andstate governments. The Government of India has decided to provide operational costs,including wages for insecticide spraying, to Kala-Azar endemic states beginning 2001/02.6. Japanese Encephalitis (JE)Japanese Encephalitis, an enzootic viral disease, has been reported in different parts of thecountry, and, so far, 26 states and UTs have recorded JE viral activity.Prevention and Control Strategyl Early diagnosis and prompt case managementl Vector control through anticipatory insecticide spray in animal dwellings and fogging forepidemic containment, as well as anti-larval operations wherever feasiblel IEC for community awareness to promote early case reporting, personal protection, andisolation of amplifier hostl Vaccination of high-risk population groups.There is no separate budget provision available for JE prevention and control. States tackle theseproblems using their resources. Need-based support is diverted for outbreak containment fromresources available under NAMP.31

National Health Programmes: An Overview7. Dengue/Dengue Haemorrhagic Fever (DHF)Dengue/DHF, a viral infection, is widely prevalent in India and all of the four serotypes arefound. Since 1996, NAMP has been monitoring the Dengue/DHF situation in the country.Strategy for Prevention and Control of Dengue/DHFl Surveillance for disease and vectorsl Early diagnosis and prompt case managementl Vector control through community participation and social mobilizationl Capacity building.8. Guinea Worm Eradication ProgrammeSubsequent to the declaration of India as a country free from guinea worm disease by WHOon 15 February 2001, routine guinea worm disease surveillance is being discontinued in allthe states.9. Yaws Eradication Programme (YEP)Yaws has been endemic in India since long. The disease has been reported from 9 states(Andhra Pradesh, Assam, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu,and Uttar Pradesh). The problem is perpetuated in remote, inaccessible, hilly areas, forestsand tribal areas.During 1997, as many as 8,515 cases of Yaws were reported and treated, while during 2001 only 168cases were reported and treated. The YEP was started in 1996/97. The NICD has been identified asthe nodal agency by the Government of India for planning, guidance, coordination, monitoringand evaluation of the YEP. The programme is implemented by the State Health Directorates ofyaws-endemic states utilizing the existing health care delivery system with the coordination andcollaboration of the Department of Tribal Welfare and other related institutions.10. National Surveillance Programme for Communicable Diseases (NSPCD)The Government of India launched a pilot project, the NSPCD, during 1997/98. The mainobjective of this programme is capacity building at the state and district levels for earlyidentification of outbreaks of communicable diseases and the appropriate and timely responseto these outbreaks. The programme is being implemented by the state governments throughtheir existing infrastructure.Under the programme, the surveillance system is strengthened through training of medical andparamedical personnel, dissemination of technical information and guidelines, upgrading oflaboratories and modernization of communication and data processing systems. Theprogramme includes IEC activities to promote community participation in the prevention andcontrol of outbreaks.Presently, the programme is in operation in 80 districts of 28 states/UTs. Multi-disciplinary RapidResponse Teams (RRTS) have been constituted at state and district levels under the programme.32

National Health Programmes: An OverviewThese teams have been provided training in surveillance, prevention and control of outbreaks. Itis proposed to extend the programme to 100 districts of all 35 states/UTs by 2002.11. National Programme for Control of Blindness (NPCB)In 1968, the National Trachoma Control Programme was launched, with priority for high endemicareas where prevalence was at least 50%. It was expanded and the NPCB was launched in 1976 as afully centrally-sponsored programme.A nation-wide survey in 1989 estimated that there were 12 million economically blind people inthe country.Activities under the NPCBl Creating infrastructure for cataract surgeries and support servicesl Providing school eye screening and refraction servicesl Strengthening eye health education through intensified IEC activitiesl Controlling corneal blindness, including the establishment of eye banks.The primary unit responsible for the service delivery at the periphery is the District BlindnessControl Society.Cataract operations have increased from 16 lakh in 1992/93 to 36.3 lakh in 2001/02. During2001/02, 58% of the surgeries were intra-ocular lens (IOL) implantation compared with lessthan 5% in 1994/95. A cataract surgery rate of 400 operations per lakh population is required toclear the backlog.Revised strategies on the basis of studies and surveys in 1998/99 and 1999/2000 includestrengthening services for other causes of blindness, such as corneal blindness, refractive errorsin school-going children, and glaucoma, to shift from the eye-camp approach to a fixed-surgicalapproach and from conventional surgery to IOL implantation.12. National Iodine Deficiency Disorders Control (NIDDCP) ProgrammeOf 282 districts surveyed in 28 states and five UTs, 244 districts are endemic (the prevalence ofIodine deficiency disorders (IDDs) is more than 10%). It is also estimated that more than 71million persons are suffering from goitre and other IDDs. These disorders include abortion,stillbirth, mental retardation, deaf-mutism, squinting, goitre, and neuromotor defects.The National Goitre Control Programme was launched in 1962 and was renamed as the NIDDCPin 1992.Objectives of the NIDDCPl To undertake surveys to assess the magnitude of IDDsl To supply iodized salt in place of common saltl To conduct surveys to assess the impact of control measures every five years33

National Health Programmes: An OverviewllTo monitor the quality of iodized salt and urinary iodine excretionTo conduct health education and publicity.The notifications issued by 26 states and five UTs, covering their entire territory, and partially bytwo states restricting the sale of non-iodized salt in their respective states/UTs are still continuing.Objectives of the Pilot Project(The pilot project against micronutrient malnutrition is merged with the NIDDCP.)l To assess and improve the iron and vitamin A deficiency status of schoolchildren, adolescentgirls and boys, non-pregnant women, and the elderly population who are suffering from ironand vitamin A deficiency by supplementing iron and folic acid (IFA) tablets and vitamin Al To assess zinc deficiency at some level, especially soil and different foodsl To assess the magnitude of dental caries and to prevent and controll To launch an extensive IEC campaign through the mass media for micronutrientmalnutrition in order to improve the dietary habits of the populationl To coordinate with similar ongoing programmes being implemented in the country.13. National Mental Health Programme (NMHP)The programme launched in 1982 envisages a community-based approach to the problems ofmental health, which includel training of the mental health team at the identified nodal institutes within the states;l increased awareness of mental health problems;l provision of services for early detection and treatment of mental illness in the community itselfwith both out-patient dispensaries (OPD) and indoor treatment and follow-up of dischargecases; andl provision of valuable data and experience at the community level in the states and at thecentral level for future planning, improvement in service and research.This programme is being implemented in 25 districts in 20 states.14. National Cancer Control Programme (NCCP)The National Cancer Control Programme was started in 1975/76. Priority was given to equippingthe premier cancer hospitals/institutions. In 1984/85, the strategy was revised and emphasis wasplaced on the primary prevention and early detection of cancer cases. The District CancerControl Programme was started in selected districts in 1990/91.Strategiesl Development of oncology wings in medical colleges/hospitalsl Development of schemes for district projectsl Provision of financial assistance to non-governmental organizations (NGOs)l Cobalt therapy installationl Development of health education materiall Procurement and distribution of pain-relieving medicinesl Assistance for regional research and treatment centres.34

National Health Programmes: An OverviewRegional Cancer CentresNineteen regional centres have been established. The functions of the regional centres are asfollows.l Cancer diagnosis treatment and follow upl Surveys of cancer mortality and morbidityl Training of personnel, both medical and paramedicall Preventive measures with emphasis on screening, health education, and industrial hygienel Research (fundamental and applied).15. National Diabetes Control Programme (NDCP)The National Diabetes Control Programme was launched in 1987.Objectivesl Identification of high-risk subjects at an early stage, and the imparting of appropriate healtheducation with the focus on primary preventionl Early diagnosis of the disease and institution of appropriate management so as to reducemorbidity and mortality—secondary preventionl Prevention, arrest, or slowing of acute metabolic, as well as chronic, cardiovascular-renalcomplications of the diseasel Provision of equal attainments to ensure scholastic as well as physical attainments and jobsatisfaction, thus, ensuring social and emotional adaptation leading to an improved qualityof lifel Identification of subjects with partial or total physical handicaps due to the disease, andensuring of their rehabilitation with emphasis on optimal organ or body function.l The District Diabetes Control Programme was developed in Tamil Nadu, Jammu, andKashmir as pilot projects, which provided a model for integration of diabetes care andcontrol into the primary health care programme. The programme is being monitored at thenational level by the ICMR.16. Cardiovascular Diseases Control Programme (CDCP)The Cardiovascular Diseases Control Programme encompasses a comprehensive nationalstrategy with action at all levels of prevention. There are, in place, a multi-pronged strategy ofIEC, high-risk-individual-focused prevention, public health regulations and cost-effective casemanagement with an inbuilt system of surveillance, monitoring and evaluation. The programmeis being administered by the All-India Institute of Medical Sciences.17. Reproductive and Child Health Programme (RCHP)India was the first country in the world to launch the Family Planning Programme in 1952 withthe objective of stabilizing population by offering the population contraceptive methods. Overthe years, it was realized that this strategy alone was not effective and maternal and child healthcare services, immunization, and medical termination of pregnancy (MTP) were joined withfamily planning to launch the Family Welfare Programme (1978). As diarrhoea and acuterespiratory infections (ARI) continued to be the leading causes of death of under-fives, ORT andARI programmes were added, thus heralding the Child Survival and Safe Motherhood35

National Health Programmes: An OverviewProgramme (1992). It also includes the iron and folic acid prophylaxis and vitamin Aprophylaxis. Experience showed that the top-down approach was a failure in the field and atarget-free approach was launched (1996). With India being a signatory to the ICPD (1994), avision of a holistic approach to maternal health was adopted with the girl child being the focusof attention from birth through adolescence to adulthood. This approach is the Reproductiveand Child Health (RCH) Programme (October 1997).The RCH Programme aims to provide its beneficiaries need-based, client-centred, demanddrivenand high-quality integrated services through decentralized planning. The CommunityNeeds Assessment (CNA) approach is a focal point in the planning of targets by health workersfor their areas. The paradigm shift in this programme has been the involvement of the NGOs, theprivate sector, and the Indian Systems of Medicine (ISM) practitioners for the delivery of servicesand direct financing of states through State Committees on Voluntary Action. Financial incentivesto service providers have been withdrawn. Special strategies have been devised for urban andtribal areas, keeping their unique problems and needs in mind. Attention has been focused onthe reproductive health needs of adolescents.The entire country has been divided into categories A, B, and C in accordance with the crudebirth rate (CBR), total fertility rate (TFR), percentage registered for antenatal care, percentageof hospital delivery and percentage delivery by untrained birth attendants. Districts in eachstate have been categorized similarly on the basis of the CBR and female literacy level. Theessential reproductive health services package is the same in all the districts. Moresophisticated facilities are proposed for relatively advanced districts with the capability to usethem effectively.18. National AIDS Control Programme (NACP)The NACP was launched in 1992 and the National AIDS Control Organization was set up tomanage it throughout the country. Starting with the first case of HIV infection detected in thecountry in a commercial sex worker in Chennai, the disease has spread all over the country, withthe states of Tamil Nadu, Nagaland, Manipur, Maharashtra, Karnataka, and Andhra Pradeshhaving a prevalence of more than one percent among pregnant mothers or five percent in highriskgroups. The programme is implemented in the entire country through State AIDS ControlSocieties and monitored by a computerized MIS. Nation-wide HIV sentinel surveillance isconducted and, on this basis, as of mid-2000, the total number of HIV infections in the countrywas 3.86 million.Because of the association of HIV with sexually transmitted diseases (STDs), an attempt is beingmade to conduct a Family Health Awareness Campaign for the early diagnosis and effectivetreatment of reproductive tract infections (RTIs).36To monitor blood safety, it is mandatory for all blood banks to test blood for HIV, Hepatitis Bvirus), and hepatitis C virus. Voluntary Counselling and Testing Centres have been set up at 208STD clinics all over the country. IEC activities are undertaken using all mass media—observingWorld AIDS Day on 1 December, setting up a telephone helpline, and promoting the school AIDS

National Health Programmes: An Overvieweducation programme. Training of medical and paramedical workers has been accorded highpriority. The STD Control Programme, which has been brought under the purview of the NACP, isbeing implemented by strengthening the setup of STD clinics and by emphasizing thesyndromic management of STDs.It has been decided that prevention of mother-to-child transmission using short courseZidovudine is feasible under the existing framework of the RCH programme and will be carriedout in a phased manner in Tamil Nadu, Maharashtra, Manipur, Nagaland, Karnataka, andAndhra Pradesh.Post-exposure prophylaxis guidelines have been developed and these drugs will be providedfree to doctors and paramedical staff in public sector hospitals. Multi-sectoral collaboration withministries, such as defence and railways, and other sectors, such as the social sector, is anessential component for involving the general population.37

Implementation of National Health Programmes in UttaranchalSession 1Implementation of NationalHealth Programmes in UttaranchalI S Pal, Director-General, Directorate of Medical, Health and Family Welfare, DehradunBackgroundThe National Health Policy (NHP) was last formulated in 1983 and, since then,there have been marked changes in the determinant factors relating to the healthsector. Some of the policy initiatives outlined yielded results while, in severalother areas, outcomes did not met expectations.The draft NHP of 2001 gave a general exposition of the 1983 policy and statedthat the recommended policy changes were required due to the circumstancesthen prevailing in the health sector.The noteworthy initiatives under the 1983 policy were as follows.l A phased, time-bound programme for setting up a well-dispersed network ofcomprehensive primary health care services, linked with extension andhealth education, designed on the basis that elementary health problemscould be resolved by the people themselvesl Intermediation through ‘health volunteers’ having appropriate knowledge,simple skills, and requisite technologiesl A well-worked-out referral system to ensure that the patient load at thehigher levels of the hierarchy was not needlessly burdened by those whocould be treated at the decentralized levell Private investors encouraged to set up an integrated network of evenlyspread specialty and super-specialty services for patients who can pay, sothat the draw on government resources would be limited to those entitledto free use.Government initiatives in the public health sector have recorded somenoteworthy successes over time. Many diseases like smallpox and guinea wormhave been eradicated and polio is on the verge of being eradicated. Otherdiseases, such as leprosy, kala-azar, and filariasis, are to be eliminated in theforeseeable future. While the eradication of these diseases is on the horizon,diseases such as malaria, tuberculosis (TB), and the newly emerging, extremely38

Implementation of National Health Programmes in Uttaranchalvirulent, communicable disease HIV/AIDS, are yet to be countered. The common water-borneinfections and some forms of hepatitis continue to contribute to the high level of morbidity inthe population, even though the mortality rate has declined drastically over the last 20 years(Draft NHP 2001).In this setting, the newly formed state of Uttaranchal has attempted to create appropriatestructures to implement the national health programmes along the guidelines of theGovernment of India (GoI). This paper attempts to provide, for the state level, an overview of thepresent status of national health programmes, issues concerning implementation and plausiblesolutions for the betterment of health care services and the reduction of fertility, morbidity andmortality rates.The national health programmes considered for discussion in this paper include blindnesscontrol, TB, malaria, leprosy, reproductive and child health (RCH), iodine deficiency control,and HIV/AIDS. In the following sections, a summary of the implementation of theseprogrammes will provide an overview of the health status in Uttaranchal.As part of the Society for the Empowered Committee for national programmes of the Medical,Health, and Family Welfare Department, Uttaranchal formed a state-level executive committeefor each of these six programmes–blindness, tuberculosis, leprosy, RCH, malaria, and AIDS. Eachcommittee includes the following members.1. Secretary, Medical, Health, and Family Welfare (MH&FW) Chairman2. Director-General, MH&FW Vice Chairman3. Additional Director, National Programme Member4. Finance Controller, MH&FW Member5. State Programme Officer responsible for the programme Member SecretaryThe composition of the committee remains the same, except that each of the programmeshas a different state programme officer (Member Secretary). The executive committeeformulates plans, monitors and evaluates the performance of the programmes, and isresponsible for financial allocations that are distributed to the respective district-levelsocieties.District-level societies are composed of the District Magistrate (DM), the Chief Medical Officer(CMO), the Programme Officer (PO), representatives from non-governmental organizations(NGOs), and the private sector. The PO is responsible for the day-to-day management of aprogramme.Implementation of National Health ProgrammesBlindness Control ProgrammeThe Blindness Control Society is in place in 10 of Uttaranchal’s 13 districts. The national as wellas the state goal of the blindness control programme is to reduce the prevalence of blindnessfrom around 1% to 0.3%.39

Implementation of National Health Programmes in UttaranchalThe state has inadequate specialized manpower. Three districts do not have any eye surgeons.Against a sanctioned allotment of 33 eye surgeons, only 27 are in position. Of these, 17 havealready completed training in intraocular lens (IOL) implantation, three are undergoing training,and the remaining have been nominated for training. In addition to these, there are 109positions for ophthalmic assistants, with 23 vacancies. Ophthalmic assistants are crucial becausethey serve as the link between the programme and the community. The positions for two staffnurses are also vacant.The District Blindness Control Society (DBCS) conducts eye operations in hospitals and basecamps. In rural areas, eye-screening camps are arranged on fixed dates both in government andnon-governmental set-ups. Area-wise responsibility has been assigned to the district eyesurgeons and agencies to hold eye camps and perform cataract operations. In eye camps,cataract operations are routinely performed and, after proper follow-up, spectacles are providedfree. As part of the national programme, the district also carries out school eye-screening campsfor children aged between 5 and 15 years. These children are examined for refractive error andspectacles are provided free. It is estimated that 6%–7% of children aged between 11 and 15years have refractive error. To circumvent the shortage of staff, teachers are receiving eye-caretraining. In the year 2001/02, the state target of conducting 31,056 operations had anachievement rate of 88.6% with 27,516 conducted, including 17,298 IOL implantations.As part of a World Bank Project, 9 operation theatres, 6 eye wards, 60 eye beds, and 3 dark roomshave been provided to the districts. This, too, is insufficient. The list of equipment andinstruments required has been submitted to GoI and the state is still awaiting the supplies.Shortcomingsl Shortage of manpower at hospitals and other levelsl Lack of equipment and instrumentsl No dark room facilities at the primary health centre (PHC) levell No refresher training given for PHC medical officers, ophthalmic assistants, or staff nursesl No mobile facilitiesl Lack of a transport systeml Poor outreachl Poor community participation.40Solutionsl Adoption of an integrated approachl Addition of contractual appointmentsl Centres equipped by the GoI, as per the list providedl Involvement of NGOs, Panchayati Raj institutions (PRIs), anganwadi workers (AWWs),teachers, traditional birth attendants (TBAs), and Mahila Swasthya Sangh (MSS) forincreasing awareness and outreachl Better monitoring and supervision at the PHC levell Refresher training for existing staff membersl Promotion of information, education and communication (IEC) activities.

Implementation of National Health Programmes in UttaranchalTuberculosis Control ProgrammeThe TB control programme in the state follows the technical and financial guidelines providedby the GoI and the National Tuberculosis Institute. The prevalence of TB in the state is higherthan at the national level. In recently conducted surveys–the RCH Survey and the NationalFamily Health Survey-2 (NFHS-2) by the International Institute for Population Sciences (IIPS)and ORC Macro–the TB prevalence in Uttaranchal was estimated to be 1,225/100,000 populationwhile the prevalence at the national level was 544/100,000 population.TB in the state is uniformly spread across the districts. The high prevalence of TB has been attributedto geographic, social, and economic conditions. Compounding the situation, inadequate diagnosticand treatment facilities have led to irregular and inadequate case finding and treatment.In all, the state has eight district TB centres. The newly formed districts do not have centres andare at present being looked after by their parent districts. In Hardwar district, the programme isbeing managed by the TB hospital. All the centres in the old districts have the properinfrastructure but, in a few places, the equipment, instruments, and vehicles need repairs. Thestaffing situation looks grim; it is crucial to fill the vacancies for district tuberculosis officers(DTOs), medical officers, and laboratory and X-ray technicians.A new programme, the Revised National Tuberculosis Control Programme (RNTCP), is going tobe implemented by the state, initially in two districts. This programme has been sanctioned bythe GoI in the districts of Dehradun and Almora. The programme will operate through thedistrict TB centres to develop TB units and microscopic clinics for better diagnostic facilities andto recruit manpower as required. It will also establish linkages with the PHCs and variousstakeholders in the community. The project will adopt the directly observed treatment shortcourse(DOTS) approach to control TB incidence in the state. Since only two districts are beingcovered, the state, with support from donor agencies, has submitted a proposal to the GoI forthe remaining 11 districts.Shortcomingsl Remote and difficult-to-access areas not coveredl Lack of infrastructure in five districtsl Shortage of manpower at hospitals and other levelsl Lack of a proper transport system.Solutionsl Establishment of TB centres in five districts in order to start the RNTCPl Extension of the RNTCP to the entire state in a phased mannerl Establishment of a State TB Demonstration Centre (STDC) to facilitate training activities andquality assurancel Regional Family Welfare Training Centre (RFWTC) to include TB training until the STDC is establishedl Adoption of integrated approach for DOTS by involving community leaders, teachers and exservicemenl Promotion of IEC activities.41

Implementation of National Health Programmes in UttaranchalLeprosy Elimination ProgrammeUttaranchal’s leprosy rate falls in the category of low endemic state (2.23/10,000population) with the exception of two districts, Hardwar and Udham Singh Nagar. Theprevalence rates in those districts are 5.1 and 3.4, respectively. Leprosy, therefore, is morearea-specific and mostly confined to the plains. The objective of the state is to bring downthe prevalence rate to below 1/10,000 population, to prevent occurrence of deformity byearly detection and treatment, and to create awareness and eliminate misconceptions aboutleprosy in the community.An executive committee has been formed for dealing with leprosy at the state-level. At the districtlevel, umbrella societies are being formed in all 13 districts. Approximately half the positions fordistrict leprosy officers (DLOs), medical officers, non-medical supervisors (NMSs) and nonmedicalassistants (NMAs) are vacant. In the absence of NMSs and NMAs, the programme hashad difficulty in reaching the community; the NMA acts as the point of contact between theprogramme and the community.Nearly half the positions for leprosy workers have been vacant for a long time. To overcomethis problem, the state has initiated the process of integration of this vertical programme withthe general health care service delivery system. About 60% of medical officers andpharmacists at community health centres (CHCs), PHCs, and Additional Primary Care Centres(APCCs) have received a three-day training in leprosy services. The remaining staff membersare to be trained by the end of 2002. Sub-centre-level training will be undertaken andcompleted by 2003.In spite of problems of accessibility and inadequate staff, the multi-drug therapy (MDT) of GoIhas been effective in controlling leprosy. In the second phase of the programme, twoinnovations have been implemented and fairly successful. The Modified Leprosy EliminationCampaign (MLEC) is one of them and the other is Special Application Projects, LeprosyElimination (SAPLE). The MLEC aims at detecting hidden cases while SAPLE reaches out to highprevalence areas and nearly inaccessible and remote areas. In urban areas, the programme isknown as LEC.The state committee, in order to provide expert services in the field of reconstructive surgery,has proposed the upgrading of facilities at Srinagar and Haldwani base hospitals. In this context,a proposal has been developed and submitted for donor support.Shortcomingsl Shortage of manpower at district level and belowl Difficulty in reaching remote areasl Lack of accountability of medical officers and pharmacistsl Programme remains vertical and needs to be integratedl No plan for rehabilitation of patientsl Continued apprehension of people due to poor IEC support.42

Implementation of National Health Programmes in UttaranchalSolutionsl Accountability of PHC medical officers towards the programme to be worked outl Regular detection of leprosy through rapid surveys conducted at regular intervalsl Reorientation training for staff and general health workers to be providedl Indian Systems of Medicine (ISM) practitioners, AWWs, and TBAs to be orientedl Skin camps to be organizedl IEC activities to be promotedl NGOs to be involved in rehabilitation workl Logistics system to be streamlined for easy availability of MDTl Deformity and ulcer care clinics to be strengthened.Malaria Eradication ProgrammeUttaranchal has been implementing the Malaria Eradication Programme (MEP) according to thenational guidelines. It has identified the districts of Hardwar and Udham Singh Nagar as highlyvulnerable. In 2001, these two districts accounted for 79% of the state’s 1,441 total positive cases. Thestaffing at various levels, as observed in other programmes, is inadequate. However, the state hastaken the initiative in providing officiating DMOs in 10 districts where the positions were vacant.The state has witnessed a decreasing trend in malaria in the past few years; the disease is beingclosely monitored, especially in the vulnerable districts. ‘Malaria Month’ is being observed inJune 2002 throughout the state. Despite declining trends, the programme has not been able tosystematically collect blood slides due to the shortage of staff. The multi-purpose worker(MPW) who was collecting blood slides at the sub-centre was assigned to the Panchayatfollowing a state order and there has been no replacement. This has hampered the programmeto a great extent. The government recently decided to return the MPW to the parent department.This will increase the outreach care, but more MPWs are needed.To counter this problem, special malaria camps were organized that were backed with IECsupport. Public meetings were organized to increase public awareness and exhibition boardswere displayed. Capacity-building training was conducted for DMOs, medical officers, MPWsand staff of the Drug Distribution Centre (DDC) and Fever Treatment Depot (FTD).Shortcomingsl Delays due to difficult geography (early diagnosis and prompt treatment [EDPT])l Shortage of manpowerl Lack of field staffl Lack of sufficient budget allocation for insecticides and untimely supply from GoIl Untimely procurement of drugsl No systematic effort for collection of blood slidesl Migration of population from Nepal and Uttar PradeshSolutionsl Building of community awareness through IECl Encouragement of community participation43

Implementation of National Health Programmes in UttaranchallllllllEstablishment of inter-departmental coordination committeeReturn of MPWs to medical and health departmentsTraining of medical and field staffTimely release of funds for drug procurement and supplyCamp approach to be followed until vacant positions are filledAction plan to be adhered to as preparedSurveillance system to be established.Iodine Deficiency Disorder (IDD) Control ProgrammeFollowing baseline surveys conducted between 1980 and 1988, eight hilly districts of present dayUttaranchal (formerly UP) were identified as iodine deficient–Uttarkashi, Chamoli, Pithoragarh,Tehri Garhwal, Pauri Garhwal, Dehradun, Nainital, and Almora. The surveys found that iodinedeficiency ranged from 3.5% in Tehri Garhwal to 40% in each of the three districts of Uttarkashi,Chamoli, and Pithoragarh. The Iodine Deficiency Disorder Control Programme was originatedin 1966 as the Goitre Control Programme.Subsequently, under the provision of the Prevention of Food Adulteration (PFA) Act of theGovernment of UP, storage and sale of non-iodized salt was banned in these eight districts andBijnor district. In 1987, the programme was reviewed by UP and the sale of non-iodized salt wasbanned in all districts of the state.Manpower availability is inadequate in the IDD cell; none of the programme positions havebeen filled. Staff members of other national programmes are managing this programme. Thestate IDD cell has been set up recently and is in the process of streamlining the system byestablishing and equipping laboratory facilities in ML Hospital at Dehradun.Despite these hurdles, the IDD programme has been successful in reducing the iodinedeficiency of the population in Uttaranchal. A 1993 survey in Garhwal found that the prevalencerate of IDD had decreased dramatically and ranged between 7% and 15%. Inter-districtvariations were observed and ranged from less than 1% in Nainital to 46% in Dehradun. Anindependent assessment is being carried out in Dehradun and Almora.Shortcomingsl Shortage of manpowerl Absence of laboratory facilitiesl Lack of technical training for laboratory techniciansl Lack of publicity for the programmel Lack of coordination with the Integrated Child Development Services (ICDS) programmel Quality of salt supplied to be randomly checkedl Quality of remote and less accessible outlets to be checkedSolutionsl Manpower per GoI norms to be filledl Establishment of laboratory facilities to be expedited44

Implementation of National Health Programmes in UttaranchallllllTraining of laboratory technicians to be initiated thereafterIEC support to be provided along with other national programmesICDS linkages to be developed and AWWs to be usedSystematic procedures to be developed and implemented for quality controlMonitoring to be made effective.Reproductive and Child Health ProgrammeThe NFHS-2 in 1989/99 provided a gloomy picture of the status of RCH indicators in the state.The coverage in the maternal aspects of the programme, in particular, has not been veryencouraging. The state has witnessed a higher proportion of high-risk pregnancies due toproblems of accessibility to health services. A large number of births have taken place outsidethe system, the majority being attended by untrained dais (midwives). These have resulted inhigher maternal morbidity and mortality. The child immunization status also does not lookgood. The number of children aged 12–23 months who were fully immunized against the sixchildhood diseases was reportedly low. Moreover, a large proportion of women (above 40%)reported some type of reproductive health problem, including abnormal vaginal discharge,symptoms of urinary tract infection, and pain or bleeding associated with intercourse. Of these,a large majority did not seek any advice or treatment and only a small percentage went to agovernment service provider.The RCH programme was initiated and immediate efforts were made to address theseproblems. Various components of the programme are in different stages of implementation.Strengthening of first referral units (FRUs) has begun and referral linkages are being streamlined.Contractual staff have been appointed, round-the-clock delivery services have been started in afew facilities, and reproductive tract infection (RTI) and sexually transmitted infection (STI)centres have been started with the posting of medical officers (skin and venereal disease).The RCH camps being implemented are supported in five districts as part of the StateInnovations in Family Planning Services Agency (SIFPSA) intervention. In six other districts,the Empowerment Action Group (EAG) states support RCH, while, in the remaining twodistricts, the GoI is supporting the intervention. Besides RCH camps, RCH outreach sessionshave been sanctioned in 11 hilly districts that are difficult to access. This outreachintervention, which aims to provide services to the doorstep of the client, is in operation in asmany as seven districts at present.TBA training has begun with the goal of training one TBA per village. Already, 900 of 3,540 TBAshave received training in 10 districts of Uttaranchal. Apart from this, involvement of the MSS hasstarted for the enhancement of community participation. Prenatal diagnostic awarenessprogrammes have been initiated and IEC support is being provided for all of these activities. Thestate is actively considering the proposal for the Community Midwife Project that will be pilotedin the districts of Chamoli and Udham Singh Nagar. The National Maternity Benefit Scheme hasbeen transferred from the Social Welfare Department to the Medical Department. As part of thescheme, a sum of Rs 500 is paid as nutritional support to a pregnant mother above 19 years ofage who was below the poverty line for her first two live births. Exclusive breastfeeding is being45

Implementation of National Health Programmes in Uttaranchalpromoted by counselling pregnant mothers and their relatives. Linkages with the ICDSprogramme have been forged and AWWs have received a 10-day training on basic RCH.Partnerships with NGOs have been created in rural areas for increasing awareness among thecommunity members and for mobilizing and organizing health camps.All these efforts are under way and, with strong commitment of the stakeholders, it is possible toimprove the RCH status in the state.Shortcomingsl Shortage of manpower especially lady medical officers (LMOs), anaesthetists, staff nurses,and laboratory techniciansl Accessibility in hill areas of the statel Timely provision of logistics, especially in the winter and rainy seasonsl Social and religious taboosl Poor feedback mechanism.Solutionsl Overcome the shortfall of manpower by adopting a multi-sectoral approachl Adopt a camp approach to overcome shortage of LMOs and anaesthetistsl Involve PRIsl Form more MSS groupsl Link trained TBAs with auxiliary nurse midwives (ANMs)l Use NGOs for community mobilizationl Administer IEC support and publicityl Streamline logistics system in general and during difficult seasons, in particularl Provide supportive supervisionl Evolve effective monitoring and feedback mechanisms.AIDS Control ProgrammeThe State AIDS Control Organization (SACO) was established in April 2001, after Uttaranchalwas established as a state. Of the 15 sanctioned positions, only five incumbents are in place.The programme is in its infant stage although it was in operation when Uttaranchal waswithin UP.The state has HIV testing and detection at RTI/STI units. There are two zonal blood testingcentres, 10 district HIV testing centres, two voluntary counselling and testing (VCT) centres, and16 licensed blood banks, of which 10 are government-owned. In addition, there are 9 STI clinicsand one private medical college where testing facilities are available.Under the National AIDS Control Programme (NACP II), a campaign on family health awarenesswas initiated in 1999. It initially covered only six districts but, in 2001, it was scaled up to all 13districts. During this campaign, clients are given information on family health and AIDS,misconceptions are cleared, and clients are screened for RTI/STI and treated.46

Implementation of National Health Programmes in UttaranchalIn spite of these efforts, NFHS-2 found that nearly two-thirds of women in Uttaranchal had notheard of AIDS. Awareness of AIDS was particularly low among women in rural areas and amongilliterate women, women living in households with a low standard of living, and women notregularly exposed to media. Among women who had heard of AIDS, 92% received informationfrom television, 36% from radio, and 31% from newspapers or magazines. Further, women whoknew of AIDS did not know of any way to avoid infection. The state has a long way to go inmaking people aware of AIDS.The state also carries out sentinel surveillance as part of the NACP II. There are six sentinel sitesof which four are STI clinics and two are antenatal clinics (ANCs). The four STI clinics are locatedin the districts of Uttarkashi, Tehri Garhwal, Dehradun, and Almora while the ANC clinics are inNainital and Pithoragarh.Other interventions, such as STI and condom programming, a low-cost community-based careand surveillance system, and those related to high-risk groups are in the planning stages and yetto be implemented.ConclusionSince the state came into existence, it has made efforts to implement the national healthprogrammes in accordance with set guidelines. Executive committees were set up for sixnational programmes as part of the Society for the Empowered Committee for National HealthProgrammes. Programmes such as blindness control, leprosy, malaria, TB, and IDD have had along history of implementation. The implementation mechanisms for these are well defined andwell known, but programmes such as RCH and HIV/AIDS are new ones that have come intobeing only recently. These new programmes are in different stages of implementation, and it willtake some time for them to become established.Nevertheless, a synthesis of common problems and solutions across all programmes isspecifically related to the following:l Accessibilityl Manpowerl Institutions and other laboratory facilitiesl Capacity buildingl Logistics management systeml Bottlenecks in programme implementationl Monitoring and supportive supervisionl IECl Community awareness and involvementl New programmes.After reviewing the problems of each of the health programmes, the state has made tremendousheadway in the past year. Major initiatives to address the shortcomings facing the programmes47

Implementation of National Health Programmes in Uttaranchalhave been made and a few of them are already in place. The initiatives taken pertain tothe following.l Empowered Committee and Executive Committees constitutedl Transfer policy for medical officers readyl Contractual appointments madel Capacity-building activities undertakenl Integration of services within the government set initiatedl Logistics system being streamlinedl Monitoring and supervision being strengthenedl Exploring linkages with other government departments, NGOs, PRIs, MSS groups, teachers,TBAs and ISM practitionersl Area-specific integrated IEC plan being considered.48

Use of Epidemiological Surveillance Data for Programme ManagementSession 1Use of Epidemiological SurveillanceData for Programme ManagementDinesh C Jain, Joint Director and Head, Epidemiology Division,National Institute of Communicable Diseases, New DelhiIntroductionEpidemiology is a basic medical science with the goal of improving the health ofa population, and surveillance is an important tool of epidemiology.Surveillance means keeping a watch over any event with great attention,authority, and often with suspicion. The surveillance can assume any characterand dimension: epidemiological, demographic, or environmental.Epidemiological surveillance refers to the continuous and systematic process ofcollection, analysis, interpretation, and dissemination of descriptive informationfor monitoring health problems. In short, surveillance is data collection foraction; it provides a basis for shaping public health policy.Objectives of Epidemiological SurveillanceThe main objectives of epidemiological surveillance are tolllprovide information about new and changing trends in the health status of apopulation, for example, morbidity, mortality, nutritional status, or otherindicators, and environmental hazards, health practices, and other factorsthat may affect health;provide timely warning of public health disasters so that interventions can bemobilized; andprovide feedback that may be expected to modify the policy and the systemitself and lead to redefinition of objectives.The systematic use of epidemiological surveillance data for the planning,monitoring, and evaluation of health services is a relatively new development.The ultimate goal is to develop a rational process for setting priorities andallocating scarce health care resources. Because of the limited resourcesavailable for health care in all countries, choices have to be made amongalternative strategies for improving health.49

Use of Epidemiological Surveillance Data for Programme ManagementSteps of Epidemiological SurveillanceThe purpose of collecting data must be the production of information; unfortunately, this doesnot always happen, either because the data is inappropriate or because it is stored in a way thatmakes the extraction of information too difficult. Therefore, careful thought must be given to theintroduction of efficient methods for the collection of useful data. The five recommended stepsof epidemiological surveillance are as follows.1 Collection of data2 Compilation of data3 Analysis and interpretation4 Follow-up action5 Feedback.Currently, computerized data collection methods and computerized data analysis, usingspecialized software, are being used quite often.50Prerequisites for Effective Epidemiological Surveillancel In order to develop effective epidemiological surveillance for any programme, theresponsible person must be clear about what information to collect, how often to compileand analyse the data, how often and to whom to report, what format to use, and what actionto take. The data collected should be uniform, regular, and timely.l Case definition A fundamental step in the collection of epidemiological data forsurveillance is defining a case. This requires an assessment of the objectives and logistics ofa surveillance system. Surveillance definitions must balance competing needs for sensitivity,specificity, and feasibility. For diseases, the performance of diagnostic tests may be importantin shaping a case definition. Equally important are the availability of tests, how they areused, and the ability of surveillance personnel to obtain and interpret results. Therefore, thecase definition should be brief and simple.l Analysis, interpretation, and presentation of surveillance data The analysis of surveillance datais generally descriptive and straightforward using standard epidemiological techniques. Inassessing a change detected by surveillance, the first question to ask is, “Is it real?” There are ahost of circumstances that can affect trends, including mundane (but often important)disruptions or changes in staffing, changing community interest in a disease, or changes insurveillance procedures (for example, coding schemes, definition, procedures for datatransmissions and implementation of new forms). The presentation of surveillance data maybe archival to provide a detailed record of health events or geared towards more rapidcommunication of a limited number of key points. Tabular presentation provides acomprehensive resource to those with the time and interest to review the data in detail. Incontrast, presentation using graphs or maps can immediately convey a key point.l Feedback Successful surveillance systems depend on effective collaborative relationshipsand on the usefulness of the information they generate. Providing information back to thosewho contribute to the system is the best incentive to participation. This feedback may be inthe form of reports, seminars, or data that participants can analyse themselves. Documentinghow surveillance data is used to improve services or shape policy emphasizes to participantsthe importance of their cooperation.

Use of Epidemiological Surveillance Data for Programme ManagementCycle of SurveillanceA surveillance system can be described as an information loop, with information coming into acollecting organization and, after processing, being returned to those who need it. The loop iscomplete when the information is applied. The elements of a typical surveillance loop beginwith the occurrence of a health event, its detection via a health care provider, notification of ahealth agency (with successive transfers of information from local to central agencies),analysis and interpretation of aggregate data, dissemination of the results, and actiontaken. Today, microcomputers and daily communications are frequently used to enhancethis process.Approaches to SurveillanceActive Versus Passive SurveillanceThe terms “active” and “passive” surveillance are used to describe two alternative approaches tosurveillance. An active approach means that the organization conducting surveillance initiatesprocedures, such as regular telephone calls or visits to physicians or hospitals to obtain reports.A passive approach to surveillance means that an organization conducting surveillance does notcontact potential reporters but leaves the initiative for reporting to others.Notifiable Disease ReportingHealth agencies have the authority to designate certain diseases as “notifiable,” meaning that,by law, their occurrence must be reported. Traditionally, this approach has mainly been used forinfectious diseases.Laboratory-based SurveillanceUsing diagnostic laboratories as the basis for surveillance can be highly effective for somediseases. One of the advantages of this approach is the ability to identify patients seen by manydifferent physicians, especially when diagnostic testing for a particular condition is centralized.Volunteer ProvidersSpecial surveillance networks are sometimes developed for information needs that exceed thecapabilities of routine approaches, such as notifiable disease reporting. This situation may occurbecause more detailed or timely information is required.RegistriesRegistries are listings of all occurrences of a disease or categories of diseases (e.g., cancer orbirth defects), within a defined geographic area. Registries collect relatively detailedinformation and may identify patients for long-term follow-up or for specific laboratory orepidemiological investigation.SurveysPeriodic or ongoing surveys provide a method for monitoring behaviours associated withdisease, personal attributes that affect disease risk, knowledge/attitude that influence healthbehaviours, use of health services, and self-reported disease occurrence.51

Use of Epidemiological Surveillance Data for Programme ManagementInformation SystemsInformation systems are large databases collected for general, rather than disease-specific,purposes that can also be applied to the surveillance of a specific condition. In some instances,their use for monitoring health may be secondary to other objectives.Sentinel EventsThe occurrence of a rare disease, known to be associated with a specific exposure, can alerthealth officers to situations through which others may have been exposed to potential hazards.Such occurrences have been termed “sentinel events” because they are harbingers of broaderpublic health problems; surveillance for sentinel events can be used to identify situations wherepublic health investigation or intervention is required.Record LinkagesRecords from different sources may be linked to extend their usefulness for surveillance, forexample, linkages of birth with infant death certificates are used to monitor birth-rate-specificneonatal mortality rates.Attributes of Epidemiological SurveillanceSurveillance systems can be judged using a list of attributes. This list can be used to evaluate anexisting system or to conceptualize a proposed system.1. Sensitivity – To what extent does the system identify all of the events in the targetpopulation?2. Timeliness – This attribute refers to the entire cycle of information flow, ranging frominformation collection to dissemination. Is the information loop completed in a specifiedtime frame?3. Representativeness – To what extent do events detected through the surveillance systemrepresent persons with the condition of interest in the target population?4. Predictive Value – To what extent are reported cases really cases?5. Accuracy and Completeness of Descriptive Information – To what extent is the descriptiveinformation on the forms completed? Is the information sufficiently reliable?6. Simplicity – Are the forms easy to complete?7. Flexibility – Can the system change to address new questions?8. Acceptability – Does the effort invested yield useful information?Application of Epidemiological Surveillance Data in ProgrammeManagementPlanning PhaselllThe use of surveillance data provides basic information on the magnitude and extent ofhealth problems.Information on the demographic characteristics of individuals with health problems permitsidentification of groups at the highest risk of disease.Surveillance data also helps in selecting from alternative strategies with the ultimate goal ofprudently allocating scarce health care resources.52

Use of Epidemiological Surveillance Data for Programme ManagementlCollection of information on exposure to risk for specific behaviours provides insight intothe etiology or mode of spread of a disease, and, therefore, can provide guidance onprevention activities before the etiology of a disease is defined.Surveillance data not only provides aggregate data for health planners but also serves to initiateindividual preventive action. Epidemiological surveillance provides the following informationfor planning any disease control programme.l Who contracts the disease?l How many people contract it?l Where do they contract it?l When do they contract it?l Why do they contract it?Implementation Phasel The surveillance data is important for the implementation of a public health programmeand its regular monitoring.l During monitoring, the success of the programme may be assessed by the use ofsurveillance data.Evaluation PhaseEvaluation of the effect of a public health programme on population groups is complex. Healthplanners use continuous surveillance data for observing the effectiveness of any intervention.ProjectionsProgramme managers also need to anticipate future changing demands for health services.Observed trends in disease incidence combined with information about the population at riskcan be used to estimate future trends.53

Designing a Surveillance SystemSession 1Designing a Surveillance SystemDora Warren, Director-India, Center for Disease Control and Prevention, Global Aid ProgrammeIn this paper, an attempt is made to highlight some of the key issues in healthsurveillance. If one wants to be convinced about the need for a healthsurveillance system, then it has to be augmented and some of the key issueson how to put a programme together have to be briefly summarized.We have certain public health realities. There is a heavy burden of disease(BoD) in India; we have seen a lot of those details, both for the country as awhole and for the state. We are moving to a time where there is a heavyburden of communicable diseases but we also have other diseases during atime when there is demographic transition. There are new diseases, HIV beinga key one; there are emerging and re-emerging diseases, malaria being one,plague another. There are limited manpower and financial resourcesavailable in Uttaranchal. The infrastructure limitations in this state will alsohave to be faced. Besides, there are programmatic mandates; sometimes evenwithin a state, and though health is a state subject, there are programmaticmandates and how you fit those into a new strategy is a key issue.There are many definitions of surveillance. Broadly, it is a mechanism thatpublic health agencies of the government use to monitor the health of thecommunities. Its purpose is to provide a factual basis on which agencies canprioritize activities, plan programmes, and take action to promote and protectpeople’s health.The question that arises is why do we need it? It is necessary to detect suddenchanges in disease occurrence and distribution. We found that people’sperception of the government’s ability to deliver health is very fragile andsometimes dependent on how well a government responds to an unusualoutbreak or a critical situation. So we need surveillance because a keycomponent of surveillance is to detect those sudden changes.54

Designing a Surveillance SystemFurther, it is also important to follow patterns and trends of diseases over time to assist inplanning and implementing programmes. It is necessary to monitor and evaluate existingprogrammes and to plan and allocate resources in a reasonable way.Another definition of surveillance that is frequently used is that it is an ongoing, systematiccollection of data as well as analysis, interpretation, and dissemination of health data.To be more specific, first, it is important to review the current situation—what is already knownabout the BoD in the state, and the mandated programme requirements in the state and existinginfrastructure. The next is to set realistic priorities within a realistic time frame. That involvesbringing in groups of individuals and communities to identify priorities. Finally, it is necessaryto develop a plan of action with key programmatic areas, organizational structures andresponsibilities, infrastructure needs, and funding mechanisms.Beginning with the BoD, even if the data is not perfect, it is useful to examine what is currentlyknown about the BoD and then determine the priority areas. Although health is a state subject inIndia, there are national programmes that have surveillance requirements; these will have to beconsidered when developing a policy for surveillance. In addition to infectious diseases, someexamples of other conditions that have national programmes include reproductive health,blindness control, and iodine deficiency control. Lessons from the national communicabledisease surveillance pilot programme should also be considered.Next to be considered is the existing infrastructure. In doing so, the following key elements haveto be addressed as they form an important part of surveillance.l Define the current situation and then set priorities for those diseases and conditions forwhich surveillance has to be done.l What are the mandated ones where you have no option but to execute them?l What are those priority areas that have high disease burden and population risk, which arevulnerable and important for surveillance?l What can you do something about?l What can you link to action?One of the most problematic areas for surveillance is that people try to do too much. During thestate-level meetings of the National Diseases Surveillance World Bank proposal, some auxiliarynurse midwives noted that they were required to report 95 different conditions for varioussurveillance programmes. That is certainly more conditions than one individual should beresponsible for. Therefore, efforts should be made to identify those conditions for whichsurveillance is feasible, where surveillance can be linked to action, and which are a priority forthe state and the nation. Next, it is important to identify the information needed, how frequentlyit should be reported, as well as what should be reported—confirmed or suspected cases.Standard case definitions need to be agreed upon.It is thus clear that a substantial amount of information is being provided to the state and nationalprogrammes. However, much appears to be periodic rather than on a regular time frame.55

Designing a Surveillance SystemOnce priorities for surveillance are developed, a plan of action is needed. There is a system ofreporting from the primary health centre to the district, state, national, and international levels.At all levels, it is critical to specify individual responsibilities. This must include thoseresponsible for data collection, reporting, and analysis as well as feedback action at all levels.This is a key component for a surveillance plan. Finally, the infrastructure needs are critical indeveloping a plan. Several different areas will need to be addressed, including the level ofpersonnel required. Some existing personnel are already collecting data for various nationalprogrammes; can or should their duties be expanded? What additional personnel are neededand where? Next, what are the laboratory requirements for conditions in the surveillanceprogramme and do existing facilities need to be strengthened or new facilities developed. So,where should they be located? Some conditions for which strong laboratories are necessaryinclude tuberculosis and malaria. Another important area to be considered is communications.What sort of communications network will be needed? It is exciting to hear that Uttaranchal isalready planning for a communications network. How can it be used or integrated with thesurveillance programme?Training is another key component of a surveillance programme. Once responsibilities areassigned, then it is important to determine whether the team members have skills to carry outwhat is required. What are the training needs for the personnel? How is it going to be provided?Do the facilities exist and, if not, what will be required to develop the programme? Here it isimportant to consider training needs for all levels of personnel from individuals collectinginformation to those responsible for analysing and acting on the information that is obtained.How are you going to provide quality control? In the United States, there is a saying—“garbage in,garbage out”. You can have a lot of information but if it is not valid or accurate, the plans oractions that are based on that information might be totally useless. So, it is important to ensurethe quality of information that you have.Another important consideration is to determine the available resources for the programme,locally, nationally, or internationally. The National Institute of Communicable Diseases is amajor resource in this country, and there are many other resources in the state as well as thecountry. An important resource to consider is the private sector. For surveillance, this is crucial aswe find that many people don’t go to the public sector; therefore, public–private partnershipsmay be critical for a successful surveillance system. In addition to public–private partnerships,and linking district, state, and national systems with key reference centres, it is important toprovide access to expertise when needed.56Inter-sectoral coordination is important for a successful surveillance programme. It isinteresting to note that committees have already been formed and some of the key programmestalked about include the reproductive and child health programmes as well as education.Tourism has also been discussed. Finally, it is important to look at how the programme will befunded. The level of resources required will depend on the system that is being planned and thelevel of existing resources. This has already been discussed as potential resources for the stateincluding the upcoming proposal by the Government of India to The World Bank for

Designing a Surveillance Systemsurveillance. Priorities in that proposal include communicable and non-communicable diseasesand that it should be state-based, action-oriented, and inter-sectoral and should involve thepublic sector.The proposal is under development and will include state-based project implementation plansas well as national plan of action. A surveillance programme is the priority, nationally andinternationally. There is commitment at all levels for surveillance to be an integral part of thehealth policy for India.57

National Health Programme in UttaranchalSession 1National Health Programmesin UttaranchalAnnex 1Blindness Control Programme in UttaranchalR C NainwalThe newly formed state of Uttaranchal came into existence on 9 November 2000and is composed of 13 districts. As is the case of most states, Uttaranchal has madeattempts to create various health programmes along lines similar to those of theGovernment of India’s (GoI’s) national health programmes. The Blindness ControlProgramme is one such programme that has been implemented in the state.Of the 13 districts in the state, the blindness control society is functioning in the10 pre-existing districts. In the three new districts, the society is in the process offormation. The team composition of the Blindness Control Society inUttaranchal is as follows. The DM is the chairman, while the CMO is the vicechairmanof the society. The Deputy CMO, who is the member secretary, acts as adistrict programme manager and is responsible for the day-to-day managementof the programme. The district ophthalmic surgeon is the technical advisor forthe committee. The other members of the society include representatives ofNGOs, the private sector, and so forth. The state blindness control society isformed under the empowered committee for the National Programme ofMedical, Health and Family Welfare, whose composition includes Secretary/Medical Health (chairman), Director-General/Medical Health (vice-chairman),Additional Director/National Programme, Finance Controller/Medical Health,representative of the Government of India, and State Programme Officer/Blindness Control (all members). This executive committee for the NationalProgramme for Control of Blindness (NPCB) is responsible for planning,monitoring, and evaluating the programme’s work.58The aim of the NPCB is to bring down the rate of blindness from 1.4% to 0.3%.Uttaranchal has fixed its goal on par with the national goal. At present, theblindness prevalence rate in Uttaranchal is below 1%. The DBCS is responsiblefor conducting operations in furnished and well-equipped hospitals and base

National Health Programme in Uttaranchalcamps. Camps are organized with the help of NGOs and private organizations. Eye screeningcamps are arranged on fixed dates at fixed places in rural areas by both government and nongovernmentagencies. In order to conduct eye camps and cataract operations, eye surgeons aswell as agencies are allotted areas. Camps, which provide cataract operation services, arefurnished with well-equipped Operation Theatres (OTs) and provide free spectacles after properfollow-up. Some of the other schemes include school eye screening (SES), in which schoolchildrenaged 5 to 15 years are examined for refractive errors and, if they have problems, areprovided with free spectacles.9 OTs, 9 eye wards, 90 eye beds, and 3 dark rooms were constructed under the auspices of theWorld Bank-aided Cataract Blindness Control Project. The project also provided districts withmoney for furnishings.The government of Uttaranchal plans to focus on the following.l Conducting community needs assessments to assess the districts’ needsl Examining the blind and registering them in Gram Blind Register Updatesl Organizing screening camps to examine refractive errors and providing treatment for allprimary and upper high school childrenl Ensuring that every PHC is provided with a dark rooml Introducing regular guidance and supervision by concerned authorities to improve servicesin rural areas.Table 1. Staff PositionsAt present, there is no government medical collegein Uttaranchal. This is a problem because there is ashortage of trained medical personnel. Of the 33sanctioned posts of eye surgeons, six are vacantand need to be filled. There are no eye surgeons inthe three new districts. Also, no eye surgeons areposted in the Community Health Centre (CHC) –PostEye SurgeonOphthalmic AssistantLower Division ClerkOT TechnicianStaff NursePharmacistSanctioned331094531In Position27864011Vacant623-520Camp Co-Coordinator 1 0 1each CHC should have an eye surgeon and be wellDriver 6 4 2equipped with OTs, eye wards, and so forth – or inClass IV Employee 11 9 2most government combined hospitals. However,17 eye surgeons have undergone intra-ocular lens(IOL) implantation training, three are in the processof taking the training, and the names of the rest of the eye surgeons have been given to the GoI.Five staff nurses have also been trained. Current training needs include a refresher course for allworking ophthalmic assistants, as demanded by the GoI.The DBCS is working to meet other needs as well. Since coordination from various sectors isrequired, the DBCS is trying to provide a forum for activity coordination among thegovernment, private, and voluntary sectors. In addition, every DBCS should have its ownvehicle so that proper transportation to facilities can be provided. Effective Information,Education, and Communication (IEC) activities and community participation and awarenessare also essential.59

National Health Programme in UttaranchalTo improve the rural services, it is essential that every schoolchild be examined annually at thePHC level and be provided with free spectacles. Most of the children with refractive errors arenot regularly provided spectacles under the DBCS. Regarding SES, only a few school-teachershave been trained for examining refractive errors. The refractive error among school children isabout six to seven per cent—there are about 2,060,536 children in the 5 to 15 year age group andthus about 123,632 (about six per cent) of children in that age group have refractive errors. Thecost of spectacles as per the government norms is Rs 75.There is also a need for establishment of a new Management Information System (MIS) andmaintenance of the existing MIS.In 2001/02, the state conducted 27,628 of its target 28,234 cataract operations—a 98%achievement rate.Annex 2Tuberculosis Control Programme in UttaranchalJ P JoshiTuberculosis (TB) is a major communicable disease and India accounts for nearly one-third ofthe global TB burden. It has been found that every year nearly 5 lakh people die of TB. A recentsurvey estimate shows that the TB prevalence in Uttaranchal is about 1225 per 100,000population, while the prevalence rate for India as a whole is 544 per 100,000 population. Thisclearly indicates that the prevalence of TB in the state is muchTable 1. Health Facilities Engaged inTuberculosis Control Activitieshigher than at the national level. This is attributable to variousfactors—socio-economic, geographical, and irregular andDistrict Type of Activityinadequate case findings, diagnosis, and treatment. InUttaranchal, TB is treated under the National TB ControlDehradun Short Course Chemotherapy (SCC)Almora SCCProgramme (NTC) through the state government and underPauriTehriUttarkashiStandard Regimen (SR)SRSRtechnical and financial guidelines from the Government ofIndia and the National TB Institute (NTI).ChamoliNainitalPithoragarhSRSRSRThe state has eight TB centres. In Hardwar district, theprogramme is being run through a TB hospital. Parent districtsUdham Singh Nagar (reported by Nainital), Champawat(reported by Pithoragarh), Bageshwar (reported by Almora),and Rudraprayag (reported by Chamoli) look after the remaining newly formed districts. Aproposal for sanctioning TB centres in the newly formed districts has been sent to the GoI.The state has two TB clinic —one in Dehradun district and one at Rishikesh. There are two TBsanatoria—Bhawali (378 beds) and Gethia 100 beds, both located in Nainital district. Under NTC,there are three TB hospitals—one each in Hardwar, Pithoragarh, and Chamoli, each of which is a40-bed hospital.60Of Uttaranchal’s 13 districts, six have no vehicle facility and in four, the vehicle is off the roads.Only three districts have vehicles on the road. Man miniature radiography (MMR) facilities are

National Health Programme in UttaranchalTable 2. Available Facilities in UttaranchalDistrict MMR Facility X-ray Vehicle Position Microscopic Referral(Condition) Centres (Status) Centres CentresDehradun Not working 6 Off-road 15 17Tehri Garhwal Working 3 Off-road 11 2Uttarkashi Working 2 On-road 4 24Chamoli Not working 4 Off-road 11 12Pauri Garhwal Not working 5 On-road 15 10Nainital Working 12 Off-road 15 5Almora Working 2 No vehicle 13 -Pithoragarh Working 4 On-road 3 4Hardwar Not working 5 No vehicle 5 19Champawat Not available 1 No vehicle 2 -Bageshwar Not available 1 No vehicle 2 -Rudraprayag Not available 1 No vehicle 4 -Udham Singh Nagar Not available 7 No vehicle 10 1Table 3. Staff Positions in Various TB ClinicsName of Sanctioned In Position Vacantthe Post postsDTO 8 3 5MO 12 12 NilLaboratory Technician 16 10 6X-ray Technician 8 3 5BCG Team Leader 8 5 3BCG Technician 48 22 26Treatment Organizer 18 13 5Driver 13 6 7Table 4. Proposed TB Units and Microscopy Centres forDehradun DistrictTB Units (Proposed)TB ClinicRishikeshChakarataMicroscopy Centres (Proposed)DTCPremnagarMussoorieSahaspurVikasnagarRaipurMilitary Hospital ClementownRishikeshDoiwalaThanoJolly GrantIDPL HospitalChakrataKalsiSahiyaTyuniKoti Kanasarfunctional in only five districts. In the remainingdistricts, MMR is either not available or non-functional.Of the eight sanctioned DTO posts, five are vacant. Otherthan the MO posts, all other posts (lab technician, BCGtechnician, X-ray technician, BCG team leader, treatmentorganizer, etc.) need to be filled in.It should be noted that in two districts (Dehradun andAlmora), RNTCP has been sanctioned by the Governmentof India. Action plans for these two districts have beensent to the Central TB Division, the details of which aregiven in Tables 4 and 5.Table 5. Proposed TB Units and Microscopy Centres forAlmora DistrictTB Units (Proposed)TBC AlmoraRanikhetBhikyasainMicroscopy Centres (Proposed)DTC Base HospitalDistrict HospitalLamgdaDhauladeviTakulaBhaisiyachanaRanikhetChaukautiaDwarahatSomeshwarBhikyasainSaltDeghaat61

National Health Programme in UttaranchalWith regard to the remaining 11 districts, there has been a proposal to implement the RNTCPwith WHO and USAID support. The proposal has already been sent to the GoI.Main Constraints Hindering the ProgrammeRemote and inaccessible areas and difficult terrain, as well as inadequate transport andcommunication facilities.Lack of infrastructure: five new districts lack a district TB centre; lack of microscopy facilities alsohampers the TB control activities.Remote and difficult areas not covered by the government infrastructure. It is necessary toestablish new health units in these areas to provide health services to these uncovered areas.Lack of manpower: Uttaranchal lacks key TB staff such as DTOs, lab technicians (LTs),paramedical staff, and so forth. The situation is likely to worsen after the transfer of staff to UP,which is still pending.Future Directions for TB Control in UttaranchalThere is a proposal to establish TB centres in five new districts—Haridwar, Udham Singh Nagar,Champawat, Bageshwar, and Rudraprayag. The schedule for New Demands (SND) has alreadybeen sent to the Government of Uttaranchal for approval.The RNTCP is to be extended to cover the whole state. Regarding this, a project implementationplan (PIP) has already been submitted to the GoI. The proposed dates for starting thisprogramme are as follows.Phase I October 2002 (Dehradun and Almora)Phase II March 2003 (Tehri, Pauri, Haridwar, Nainital, Bageshwar, and Udham Singh Nagar)Phase III October 2003 (Uttarkashi, Rudraprayag, Chamoli, Pithoragarh, and Champawat)Establishment of a STDC is necessary for training and implementation as well as qualityassurance of TB control programmes. As per the submitted plan the Regional Health and FamilyWelfare Training Centre (RHFWTC) will have a separate section devoted to TB training anddemonstration for the time being.There has been a proposal to establish Divisional Culture and Sensitivity Labs at Dehradun(Garhwal Division) and Bhowali (Kumaon Division) that would act as reference labs for the state.Upgrading the labs at these centres has been considered and the district hospital in Dehradun isdrawing up a similar proposal.62One of the most crucial challenges Uttaranchal faces is providing DOTS services in remote anddifficult areas. This is a challenge because of the hilly terrain as well as a lack of medical serviceinfrastructure in these remote hilly areas. The state’s strengths include the availability of anumber of NGOs operating at various levels and of a number of ex-servicemen; their servicescan be utilized as DOTS providers under the RNTCP.

National Health Programme in UttaranchalAnnex 3Leprosy Elimination Programme in UttaranchalR C NautiyalLeprosy is an ancient disease that has been prevalent worldwide for thousands of years.However, it is now endemic to only tropical and sub-tropical regions. About 60% of the leprosypatients in the world are in India; India recorded about 3.84 lakh cases of leprosy in March 2001and the prevalence rate was 3.7 per 10,000 population. The major objective of the NationalLeprosy Elimination Project (NLEP) is to achieve the elimination of leprosy by reducing thepatient load to less than 1 per 10,000 population by the end of 2003/2004.Uttaranchal is categorized as a low endemic state. The prevalence rate in the state is 2.23 per10,000 population. The MDT was introduced in a few districts of the state in 1986 and almost allthe districts were using it by 1995. At present, except for the three new districts (Rudraprayag,Champawat, and Bageshwar), all districts have district leprosy societies. Earlier, the GoI directlyprovided funds for the implementation of the MDT plan; now, the Uttaranchal State LeprosySociety has been formed and registered and will monitor and evaluate the functioning of thedistrict leprosy societies. There are also two District Technical Support Teams (DTSTs)functioning in Uttaranchal – one each in Kumaon and Garhwal divisions – that give technicalassistance to the existing NLEP staff.The primary objective of the Leprosy Elimination Programme in Uttaranchal is to bring downthe leprosy prevalence rate to 1 or less than 1 per 10,000 population. The other objectivesinclude preventing occurrence of deformity by early detection and prompt regular treatment,creating awareness and eliminating misconceptions about leprosy in the community, andchanging the attitude of society towards leprosy patients.The strategies adopted to achieve the aforesaid objectivesare as follows.l Continuing regular detection of leprosy patients by alltypes of population surveysl Promoting reorientation training and involvement ofgeneral health workers, medical officers, and others inthe programmel Conducting survey and treatment work according tospecial strategies (i.e., SAPEL or rapid survey and LEC inurban slums) in remote and inaccessible areasl Providing early, regular, and prompt treatment toreaction cases in order to prevent disabilityl Arranging skin camps in slums and rural areas to screenthe populationl Enhancing IEC activitiesl Involving NGOs in the field of rehabilitation andPrevention of Deformity (POD)l Making MDT easily available.Table 1. Prevalence Rate of Leprosy in UttaranchalDistrict/StatePrevalence Rate per10,000 PopulationPauri 1.12Dehradun 1.40Tehri 1.04Chamoli 0.62Uttarkashi 1.20Rudraprayag 0.35Hardwar 5.10Almora 0.90Nainital 1.50Pithoragarh 1.80Udham Singh Nagar 3.40Champawat 3.34Bageshwar 0.92Uttaranchal 2.2363

National Health Programme in UttaranchalTable 2. Comparative Progress of National LeprosyElimination ProgrammesItem Status on Status on Status on01-04-95 01-04-01 01-04-02Total Cases on Record 3,044 1,973 1,909Prevalence Rate 3.35 1.80 2.23Cure Rate 33.34 55.46 90.00Deformity Rate 9.87 2.69 2.31The leprosy prevalence rate is highest in Hardwar(5.10), followed by Udham Singh Nagar (3.40) andChampawat (3.34). In all other districts, theprevalence is below the state average.Between 1995 and 2002, the leprosy prevalence ratehas declined from 3.35 to 2.23 per 10,000 population.The cure rate has also increased dramatically to 90%.It can be noted that the deformity rate hasdecreased from about 10% to about 2%. However, theannual figures (Table 3) show fluctuations in theprevalence rates.Table 3. Annual Case Detection and Prevalence Rates, UttaranchalYear Estimated Number of new Annual new Cases discharged Balance PrevalencePopulation cases detected case detection during the year active rate perduring the year rate/1000 cases 10,0001998/99 8,125,160 2,041 0.91 1,804 1,513 1.781999/2000 8,249,114 2,278 1.07 1,742 1,828 2.262000/01 8,362,665 1,894 0.226 2,373 1,000 1.802001/02 8,572,837 2,528 0.295 1,950 1,909 2.23Table 4. Staff PositionsPost Sanctioned In Position VacantDLO 10 6 4State Medical Officer (SMO) 1 - 1Superintendent (SUPDT) 1 1 0MO 14 7 7Health Examiner (HE) 10 3 7NMS 60 26 34NMA 281 139 142Physiotherapy Technician (PTT) 8 5 3LT 25 11 14Statistical Assistant 3 1 2Investigator-cum-Compiler 1 - 1Upper Division Clerk 11 6 5Lower Division Clerk 21 16 5Staff Nurse 2 - 2Chief Pharmacist 3 3 0Assistant SUPDT 1 1 -Driver 24 15 9Class IV 37 30 7Sweeper 13 10 3Total 526 280 246Of the total 526 posts sanctioned, 246 arevacant. Of the 10 sanctioned DLO posts,four are vacant. Half of the MO posts arealso lying vacant. Since nearly half of theposts are vacant, the state has initiatedthe process of integration of this verticalprogramme with the general health caredelivery systems.During 2001/02, the target for number ofnew cases detected was 1900. However,2528 new cases have been detected so farand all the new detected cases werebrought under treatment.Integration Statusl A three-day technical training inleprosy services has been given to60% of the MOs at all PHCs/CHCs/APHCs.l 90% of the government health fieldworkers are trained in leprosy services.64

National Health Programme in UttaranchalTable 5. Comparative Statement of National Leprosy Eradication ProgrammeYear New Case Detection New Cases Brought Under Treatment Cases Discharged RFTTarget Achievement % Target Achievement % Target Achievement %1998/99 3,300 2,041 61.84 3,300 1,513 45.8 3,250 1,804 55.51999/2000 1,900 2,278 119.8 1,900 1,828 96.2 2,140 1,742 81.42000/01 1,900 1,761 92.68 1,900 1,658 87.3 2,140 1,445 67.52001/02 1,900 2,528 133.1 1,900 2,528 133.1 2,140 1,950 91.1l 60% of the pharmacists at the PHC/APHC have been trained.l MOs are not actively involved in providing MDT services and are not confident in diagnosingand treating cases.l The pharmacist does not maintain a MDT drug register, though some stock of MDT is kept bythe pharmacist and MO-IC at CHC/PHC/APHC.l The MDT register is maintained by the vertical staff in all districts through drug distributionpoints.l Integration at the sub-centre level will be achieved after integration at the PHC level in theyear 2003.l Integration of vertical staff to be carried out in 2003/2004.l MDT services provided at all PHCs on all working days.Even though the geographical conditions prevailing in the state are not friendly, NLEP isprogressing satisfactorily. On average, about 2000 new cases are deducted annually, of which5%–6% are child cases and 2%–4% are with deformities. The prevalence rate is steadilydeclining with MDT.To discover hidden cases, the 1st Modified Leprosy Elimination Campaign (MLEC) was carriedout in April 1998 and 884 new cases were detected. The 2nd MLEC in 2000 detected 798 cases andthe 3rd MLEC in 2001 detected 493 cases. It is proposed that the 4th MLEC will be carried outbetween September and October 2002.Annex 4Malaria Eradication Programme in UttaranchalAnil SharmaAs in most other states in India, the National Anti-Malaria Programme (NAMP) has beenimplemented in Uttaranchal. In 1999, 2121 positive cases were identified. That number declinedto 2008 in 2000 and to 1441 in 2001. During this same period, there were 390, 424, and 280 PFcases, respectively.Among the districts in Uttaranchal, Udham Singh Nagar had the highest number of positive casesof malaria (695), followed by Hardwar (437), and then Nainital (127). The lowest numbers ofcases were in Tehri (1) and Bageshwar (2).65

National Health Programme in UttaranchalTable 1. Epidemiological Situation in UttaranchalYear Population BSE Total PF Cases PF % SPR ABER API DeathsPositive Cases1999 8,138,775 686,743 2,121 390 18.38 0.31 8.43 0.26 -2000 8,316,754 148,707 2,008 424 21.10 1.35 1.78 0.24 -2001 8,479,562 128,485 1,441 280 19.40 1.12 1.52 0.16 -An examination of the staff positions shows that about 66% of the DMO posts, 90% of theAssistant MO (AMO) posts, 70% of the Medical Instructor (MI)/Senior Medical Instructor (SMI)posts, 42% of the LT posts, and 44% of the Sanitary Inspector (SI)/Health Inspector (HI) postsare vacant.Capacity-building training for DMOs on epidemic preparedness has been conducted inHardwar, Udham Singh Nagar, and Dehradun. Similarily, a malariology course for PHC medicalofficers, an introduction-level course in malaria microscopy for lab technicians, and malariatraining for MPW/DDC/FTD have also been conducted in some districts.Through special malaria camps, 3298 blood slides were prepared, of which 28 PV positive casesgot radical treatment (RT). Also 637 general fever cases were treated at the camps.Handbills, posters, pamphlets, and wall paintings were used for IEC. In all, 129 public meetingsfor public awareness were organized officially in Hardwar, Udham Singh Nagar, Nainital, andDehradun. 178 exhibition boards received from UP were posted in all districts for impartinghealth education and awareness about malaria.Table 2. District-wise Epidemiological Report, NAMP 2000/01District Population Total Number of P.V. Cases P.F. CasesPositive Cases2000 2001 2000 2001 2000 2001Dehradun 1,279,083 64 41 64 41 00 00Pauri 696,851 94 75 94 75 00 00Tehri 604,608 13 01 13 01 00 00Uttarkashi 294,179 06 08 06 08 00 00Chamoli 369,198 49 19 49 16 00 03Rudraprayag 227,461 00 00 00 00 00 00Hardwar 1,444,213 735 437 330 192 405 245US Nagar 1,234,548 805 695 788 663 17 32Nainital 762,912 188 127 186 127 02 00Almora 630,446 33 15 33 15 00 00Bageshwar 249,453 00 02 00 02 00 00Pithoragarh 462,149 21 21 21 21 00 00Champawat 224,461 - - - - - -66

National Health Programme in UttaranchalAchievements, Failures, Constraints, and Solutions ProposedTen districts in the state do not have a full-time DMO. Hence, the department has arranged for anofficiating facility in each of the districts. Fever radical treatment (FRT) is being observed in USNagar and Hardwar since they are highly sensitive districts.Achievementsl There has been a decreasing trend in all the districts of the state. Only three districts have ahigh-risk population.l No deaths have been reported in the state.Failuresl Due to a shortage of field staff, the target number of blood slides collected could not beachieved.l Due to non-availability of supply and funds, spray of malathian/DDT was incomplete.l With regard to IEC, nothing special could be done except for observance of Malaria Month(June 2001).Weaknessesl Non-availability of trained staffl Only 33% of DMOs, 9% of AMOs, 30% of MIs, and 54% of SIs are working.l MPWs deployed to Panchayati Raj Institutions result in low blood sample collection.l Less field staff and difficult geographical situation delays early diagnosis and prompttreatment (EDPT).Threatsl Migrating population, particularly pilgrims, tourists, and labourers to Hardwar, Udham SinghNagar, and Dehradun.l Unhygienic sanitary conditions because of increased industrialization, urbanization, andincrease in populationl Migration of border malaria cases from Nepal and UPl Tradition of water storage in response to water shortagel Poor garbage collection and disposal.Prevention and Controll A system should be established for immediate reporting of and confirmation of an outbreakl Use of insecticides to control mosquito density; use of nets, repellents, and so forthl Elimination of mosquito breeding placesl Prompt treatment with diagnosisl All agencies to be activated and encouraged to respond with EDPTl Community participation and cooperation for eliminating breeding sites, insecticide sprays,reporting cases to health authorities, and so forth.67

National Health Programme in UttaranchalAnnex 5Iodine Deficiency Disorders Control Programme in UttaranchalG S RaiIodine is a micronutrient essential to human beings. Lack of it leads to iodine deficiencydisorder (IDD), which can cause miscarriages, brain disorders, cretinism, and so forth. Iodinedeficiency can be prevented with use of iodized salts. In 1983/84, the GoI adopted a policyaimed at achieving universal iodization of edible salts by 1992. The PFA Act fixed the minimumiodine content of salt as 30 parts per million at the manufacturing level and 15 parts per millionat the consumer level. All states and Union Territories issued notifications banning the sale ofnon-iodized edible salts, as per the Government of India’s order. However, the ban was lifted inSeptember 2000. As per the NFHS-2 estimates, despite the government regulation in effect at thetime of the survey, only 49% of households (57% in Uttaranchal) use cooking salt that is iodizedat the recommended level of 15 or more parts per million.Uttaranchal has been classified as one of the states plagued by iodine deficiency. In 1996, theNational Goitre Control Programme was launched in eight hilly districts (Uttarkashi, Chamoli,Pithoragarh, Tehri Garhwal, Pauri Garhwal, Dehradun, Nainital, and Almora and in Bijnor districtin Uttar Pradesh) that were identified as iodine deficiency districts. The iodine deficiency ratewas about 40% in Uttarkashi, Chamoli, Dehradun, and Pithoragarh; about 30% in Nainital; 21%in Pauri and Almora; and only 3.5% in Tehri Garhwal. Results from the 1983 survey showed 15%iodine deficiency in Uttarkashi and 10% in Dehradun. In accordance with the PFA Act, storageand distribution of non-iodized salt was banned in these districts. In 1987, the programme wasreviewed and sale of non-iodized salt was banned in all the districts.After the formation of a separate state, a state IDD cell was created. The IDD cell has sanctionedposts for a technical officer, enumerator, and typist. An IDD lab has also been established withsanctioned posts for a lab technician and lab assistant. Most of the posts are still vacant and theavailability of manpower is inadequate; the existing lab technician and ward boy working in MLLeprosy Hospital have been given the additional responsibility of working in the IDD lab. Theequipment required for the IDD lab has been acquired from the National Institute of CommunicableDiseases (NICD), Delhi. The IDD lab will start functioning after it is equipped with this equipment.The programme has been successful in reducing iodine deficiency. Service statistics provided bythe IDD Programme for February 2002 estimates that about 93% of people in Uttaranchal usesalt with the recommended level of more than 15 parts per million of iodine. This figure seemsto be much higher than the estimates provided by the NFHS. District-wise figures show that thepercentage varies from about 55% in Dehradun to 100% in Uttarkashi, Bageshwar, andPithoragarh. A survey will be carried out in the 13 districts to assess the iodine deficiency rate inthe population. The Himalayan Institute as per the guidelines of the Ministry of Health andFamily Welfare will re-survey two districts of Almora and Dehradun this year. With regard tohealth education and publicity for creating awareness about IDD, the current budget hasallocated certain funds for publicity materials for all Uttaranchal districts. Despite successes,however, some of the problems that exist include insufficient manpower, no proper laboratoryfacilities or training of technicians, and so forth.68

National Health Programme in UttaranchalAnnex 6Reproductive and Child Health Programme in UttaranchalSudha PurohitD N DhyaniThe prime objective of the RCH programmes of the GoI is the promotion of maternal and childhealth. Its basic goal is for each pregnant woman to receive at least three antenatal check-upsplus two tetanus toxoid injections and a full course of iron and folic acid (IFA) supplementation.In addition, it encourages women to deliver in a health institution or to seek the assistance oftrained health personnel for home deliveries. Child immunization is another importantcomponent of the RCH programmes; the basic objective of the Universal ImmunizationProgramme (UIP) launched in 1985/86 was to extend immunization coverage against sixdiseases (TB, diphtheria, pertussis, tetanus, polio, and measles) to at least 85% of infants by1990. However, as per NFHS-2, only 44% of mothers in Uttaranchal received an antenatal checkupcompared with 65% in India as a whole. Only 18% of mothers received at least threeantenatal check-ups. 54% of mothers received two or more doses of tetanus toxoid injections,while 39% received IFA supplementation. About 80% of the deliveries were home deliveries, ofwhich traditional birth attendants (TBAs) assisted about 59 percent. Health professionalsassisted only 17% of births. About 41% of children aged 12–23 months were fully immunized.About 56% of children received all three doses of DPT and 62% received all three doses of polio;56% of children were immunized against measles as well. Slightly more than 40% of currentlymarried women in Uttaranchal reported a reproductive health problem such as abnormalvaginal discharge, symptoms of urinary tract infections, pain or bleeding associated withintercourse, and so forth. Overall, the results showed that the utilization of health services inUttaranchal during pregnancy, during delivery, and after childbirth is quite low.RCH Activities in the State of UttaranchalRCH CampsFive districts (Tehri, Dehradun, Nainital, Almora, and Bageshwar) are covered by the StateInnovations in Family Planning Services Project Agency (SIFPSA) intervention. The funds arereleased by the state of Uttar Pradesh.Five districts (Hardwar, Chamoli, Pauri, Pithoragarh, Champawat) and two blocks ofRudraprayag district have been taken up by the Empowered Action Group (EAG). An amount ofRs 24 lakh for conducting 120 camps was released in February 2002.Two districts (Uttarkashi and Udham Singh Nagar) are covered by the Government of India andan amount of Rs 3 lakhs has been sanctioned for each of the districts. By February 2002, about32 camps had been arranged.RCH Outreach SessionEleven hilly districts, which are difficult to approach and access, have been selected for RCH outreachsessions. Funds have been provided by the GoI for three districts (Pauri, Uttarkashi, andPithoragarh). An amount of Rs 25.28 lakh for each of the districts was sanctioned and the moneywas released in February 2002. However, physical progress is being awaited.69

National Health Programme in UttaranchalAn outreach session for Chamoli district was conducted when Uttaranchal was part of UP. A totalof 804 sessions were conducted through January 2002. The remaining five districts (Champawat,Bageshwar, Almora, Nainital, Dehradun) and 2 blocks of Rudraprayag are covered by the EAGstates. About Rs 2.6 lakh for each district for the three month-period from January to March wasreleased in February 2002.Dai TrainingFor the first phase, 900 of 3,540 TBAs are undergoing training. This includes TBAs from 10districts (Almora, Bageshwar, Chamoli, Champawat, Pithoragarh, Rudraprayag, Uttarkashi, Pauri,Tehri, and Nainital). The budget of Rs 20.19 lakh was released on 2 February 2002.IEC ActivitiesThe MSS has been involved in community participation in two districts (Nainital and UdhamSingh Nagar). Rs 2.5 lakh has been released for the Prenatal Diagnostic Technique (PNDT) Actawareness programme, which encompasses all 13 districts of Uttaranchal. Health awarenesscamps are being organized to promote RCH awareness among the people.Contractual StaffRecently, 30 LMOs, 79 staff nurses, and 370 additional ANMs were appointed on a contractualbasis to empower the RCH services.24-Hour Delivery SystemIn order to promote institutional deliveries, 24-hour delivery services are being provided in 85health centres in Uttaranchal and certain incentives are proposed for service providers whoconduct deliveries between 8.00 p.m. to 7.00 a.m. Three districts (Hardwar, Dehradun, andUttarkashi) have sent reports of deliveries.A proposal for the release of grant-in-aid for 24-hour delivery services under the RCHprogramme is to be received from the GoI, Ministry of Health that furnishes information on thenumber of expected night deliveries at the PHCs and CHCs. Also, doctors, nurses, and clearingstaff are paid an honorarium at the rate of Rs 200, 100, and 50 per delivery, respectively.RTI/STI and AIDSIn each district hospital one MO has been posted as ‘Medical Officer, Skin and Venereal Diseases(VDs)’ to examine cases of skin and VDs. There has also been a proposal to strengthen the RTI/STI clinics.Integrated Skill TrainingTraining of MOs, supervisory staff, and workers has been completed in some districts.Specialized Skill Training (SST) funds of about Rs 29.97 lakh are available in the state accounts.70In addition to the activities described above, some other activities in the state are as follows.Providing different kinds of drug kits in sub-centres, PHCs, and CHCs to prevent acuterespiratory infection (ARI), diarrhoea in infants, and treatment of RTIs and STIs.

National Health Programme in UttaranchalStrengthening FRUs and referral services.Transferring the National Maternity Benefit Scheme to the Medical Department from the SocialWelfare Department. For nutritional support under this scheme, an amount of Rs 500 is paidto a pregnant mother above 19 years of age who is below the poverty line (BPL) for her firsttwo live births.Promoting exclusive breastfeeding through counselling of pregnant mothers and their relatives.Giving the AWWs of ICDS in rural areas of the state 10 days of basic training to be able to provideminimum health services in the villages. They will now help the local ANMs by identifying highriskmothers, identifying drop-out vaccination cases, and helping treat ARI and diarrhoea byproviding oral rehydration salts (ORS) and other common medicines. They will also assist inproviding nutritious diets to pregnant women and children.Many of the positions in the state are vacant. This isparticularly true in the case of Joint Directors (JDs), LMOs,matrons, staff nurses, and so forth. To further strengthenMCH services, LMO, staff nurse, and ANM staff positionshave been filled through contractual appointments.The state has been performing fairly well in terms of childimmunization. However, utilization of maternal healthservices is low. The rate of unsafe deliveries in the state is aproblem that is attributable to the low prevalence ofinstitutional deliveries and assistance by trained personnel.Table 1. Staff PositionsItem Sanctioned In Position VacantPostJD 12 6 6LMO Class I 24 8 16LMO Class II 147 94 53Matron 8 2 6Assistant Matron 24 9 15Sister 158 117 41Staff Nurse 571 398 173ANM 1,933 1,904 29Some of the difficulties in effectively implementing a RCH programme in the state include shortageof manpower, particularly of LMOs, anaesthetists, staff nurses, and so forth. Lack of properconnectivity and a good transportation network also hamper the programme. Certain hilly areasTable 2. MCH Programme in Uttaranchal, 2000/01 and 2001/02Programme 2000/2001 2001/2002Target Achievement % Target Achievement %DPT 232,505 234,166 100.7 2,412,279 233,767 95.4Polio 232,505 233,849 100.5 2,412,279 229,893 95.5BCG 232,505 235,402 101.2 2,412,279 232,695 96.4Measles 232,505 278,788 94.1 2,412,279 229,511 95.1TT for pregnant women 241,000 221,000 91.7 258,597 221,161 85.5IFA 241,000 184,000 76.3 258,597 174,852 67.6Institutional deliveries 35,000 80,617 29,272 36.3Deliveries by lady home visitor (LHV)/ANM 65,000 153,522 98,003 63.8Deliveries by untrained attendant 39,000 16,856Under 5 years, treated for ARI 33,023 27,294Under 5 years, treated for diarrhoea 33,691 51,31971

National Health Programme in Uttaranchalare distant and difficult to approach and the state has a poor network of roads. This is a problemparticularly during winters and rainy seasons. These factors lead to uncertainty in providingproper health care to pregnant mothers. Religious and social taboos also play a vital role.Suggestions for Improvementl Involvement of AWWs to tag up the health activitiesl Formation of MSS to help in the implementation of health programmesl Involvement of NGOs to organize camps, impart health education, generate healthawareness, and so forthl Involvement of gram sabha personnel in health activitiesl Empowerment of women, particularly through education, health consciousness, socialrecognition, and so forth.Annex 7HIV/AIDS Programme in UttaranchalG S JangpangiKalpana GuptaA clear-cut national health policy was formulated in 1983 and since then improvements in thehealth sector have been rapidly made. As a result of the government initiatives, several diseases,such as smallpox, have been completely eradicated and certain other diseases, such as polio, areon the verge of being eradicated. Uttaranchal is a newly formed state and, like its parent state, itis attempting to implement the national health programmes according to the guidelines set bythe GoI.Like the dreadful plague that swept Europe during the Middle Ages, HIV/AIDS is now taking itstoll and is posing a serious threat in most countries—particularly in the developing world. Indiais home to the largest number of people infected with HIV in Asia. The epidemic is growing evenoutside the high-risk groups. Hence, this issue needs to be addressed and prevention effortsneed to be taken to ensure that HIV/AIDS rates remain low and do not threaten development.The government needs to make efforts to erase the ignorance, misinformation, and fear thatsurrounds the dreaded disease.The state of Uttaranchal came into existence on 9 November 2000 and consists of 13 districts.Under the National AIDS Control Programme (NACP II), the Family Health Awareness Campaignwas launched in 1999. This campaign provides clients with RTI and STI screening in addition toproviding them with information on family health, misconceptions about AIDS, awareness, andso forth. The Uttaranchal State AIDS Control Society was established in April 2001 under theState Empowered Committee for National Programs of Medical Health and Family Welfare. In1996, only six districts were covered, whereas by 2000 all the districts were covered. The primeobjective of NACP II is to keep the HIV prevalence rates below one per cent, reduce blood-bornetransmission of HIV to less than one per cent, increase the awareness level among youth andpeople in reproductive age groups to about 90%, and increase the condom use among the highriskgroups, such as the commercial sex workers (CSWs), to about 90%.72

National Health Programme in UttaranchalThere are two zonal HIV testing centres, 10 district HIVtesting centres, two VCTC, and 15 licensed blood banks inthe state. Of the 15 licensed blood banks, 10 are managedby the government, and remaining five by the privatesector. The state also has 9 STD clinics and one privatemedical college that provide facilities for HIV testing anddetection.In Uttaranchal, sentinel surveillance is conducted everyyear. This includes four STD clinics in Uttarkashi, TehriGarhwal, Dehradun, and Almora and two ANC clinics inPithoragarh and Nainital. A total of 1594 samples weretested, of which four (two male and two female patients)were found to be HIV-positive.Of the total 28,217 blood donors screened for HIV between1997 and 2001, 31 (0.1%) were reported to be HIV-positive.In 2001, a total of seven cases (two female and five malepatients) were detected as HIV-positive.Between 1998 and 2001, a total of 60 cases were found to beHIV-positive and a total of six AIDS cases were reported—one each in 1993, 1996, and 1998 and three in 1995.The total estimated targeted population was smaller inMarch 2002 compared with that of May 2001. About 9% ofTable 4. Total HIV-Positive Cases, 2001Table 1. Units that Exist in the State for HIV Testingand Detection of RTI/STIZonal HIV Testing Centre 2District HIV Testing Centre 10Voluntary Counselling and TestingCentres (VCTCs) 2Licensed Blood Bank 15(Government: 10,Private: 5)STD Clinics 9Medical College (Private) 1Table 2. Reports of Sentinel Surveillance(August to October 2001)Number of sentinel sites (STD Clinics) 4Number of sentinel sites (ANC Clinics) 2Number of samples tested 1594Number of samples found positive 4(Males: 2,Females: 2)Table 3. Blood Samples Screening Report, 1997–2001Year Number of Number HIV PercentageDonors Screened Positive1997 2,327 5 0.211998 4,001 6 0.141999 5,555 8 0.142000 5,858 9 0.152001 10,476 3 0.03Place Type of Programme HIV-Positive CasesMale Female TotalDehradun Sentinel surveillance 1 1 2Narendra NagarTehri Garhwal Sentinel surveillance 1 1 2M.H. Roorkee Blood screening 2 0 2H.I.H.T. Jolly Grant Dehradun Blood screening 1 0 1Total 5 2 7Table 5. Total HIV-Positive and AIDS Cases, 1998–2001HIV-Positive Cases AIDS CasesYear Number Year Number1998 22 1993 11999 22 1995 32000 9 1996 12001 7 1998 173

National Health Programme in UttaranchalTable 6. Family Health Awareness Campaign, Uttaranchal, May 2001 and March 2002May 2001 March 2002Item Male Female Total Male Female TotalTotal estimated targeted population 1,696,411 1,673,650 3,370,061 1,653,878 1,588,641 3,242,519Number (and percentage) of persons whoattended the camp 121,977 185,328 307,305 129,075 238,130 367,205(7.19) (11.07) (9.11) (7.80) (14.98) (11.32)Total number referred to health centres/hospitals 13,162 45,001 58,163 12,763 53,957 66,720Number of RTI/STI cases treated 2,367 23,197 25,564 4,967 35,618 40,585a) with ulcers 420 671 1,091 303 1,203 1,506b) with discharge 835 17,938 18,773 1,578 25,852 27,430c) other (STD) 1,112 4,588 5,700 3,086 8,563 11,649Percentage of persons treated with RTI/STI 17.98 51.54 43.95 38.91 66.01 60.82the targeted population attended the camps in May 2001 compared with 11% in March 2002. Thepercentage of females who attended the camps was much higher than the percentage of malesduring both the reference periods. The total number of cases referred to health centres/hospitals as well as the number of RTI/STI cases treated also increased during the two timeperiods; about 44% were treated for RTI/STI during May 2001 and this increased to about 61% inMarch 2002. During both reference periods, it was found that the females sought treatment moreoften than the males.Present Scenario and Future PlansThe socio-economic and cultural factors in Uttaranchal are slightly different from its parent stateUttar Pradesh. A large number of persons in Uttaranchal are employed in the military andparamilitary forces. Besides, the huge male migration from Uttaranchal for employment createsan environment conducive to the spread of HIV/AIDS. As such, there are no identified red lightareas in Uttaranchal, but specific focus and arrangements are still needed for the migrantpopulation. Also, there is a need to identify indictable drug users in Hardwar and Rishikesh, asthere are a number of sadhus (ascetics) and foreign tourists living in these areas.For prevention of transmission among the high-risk groups, targeted interventions are plannedfor CSW, truck drivers, street children, men having sex with men (MSM), intravenous drug users(IDUs), rag pickers, and migrant populations. Steps will be taken to increase condom use,especially among these high-risk groups. For prevention of transmission among low-riskgroups, IEC (print media, folk media, interpersonal communication, etc.) specific to the area willbe developed.Regarding blood safety, 16 licensed blood banks exist in the state. A model blood bank is to beestablished at Doon Hospital in Dehradun. Four new blood banks are to be established at BaseHospital Srinagar, Base Hospital Haldwani, Combined Hospital Kotdwar, and CombinedHospital Roorkee.74

National Health Programme in UttaranchalFor voluntary counselling and testing, at present there are only two VCTC centres—one at DoonHospital (Dehradun) and the other at Base Hospital (Nainital). A proposal is being sent for 12more VCTCs so that each district has its own VCTC. Voluntary counselling is offered for just Rs 10and is free if the client is referred by a government doctor.There are also plans for AIDS care. Capacity building for low-cost community-based care has tobe built up for better care and support of AIDS cases. Drugs for infections have to be madeavailable at hospitals. All cases of HIV/AIDS should be treated in general hospitals, as in the caseof other ailments. Confidentiality and privacy of the HIV patients is to be maintained.Counselling should form an integral part of management of HIV/AIDS cases. There is also aneed to train family members in taking care of HIV patients.For the strengthening of the programme, surveillance strategy is to be planned, followed by itsmonitoring and evaluation. Sentinel surveillance was conducted between August and October2001 in four STD sites and two ANC sites. This year it will be conducted in these six sites betweenAugust and October 2002. Training of staff at the VCTC, blood banks, and STD clinics is to becarried out.75

Session 2Information, Education, andCommunication forPromotion of Health CareChairpersonManisha PanwarInformation, Education, and CommunicationStrategies for Health in IndiaJ S YadavInformation, Education, and Communication forHealth Programmes in UttaranchalJ S DeepakDiscussantSheena Chhabra

IEC Strategies for Health in IndiaSession 2IEC Strategies for Health in IndiaJ S Yadav, Professor, Indian Institute of Mass Communication, New DelhiHealth and human development form an integral component of overall socioeconomicdevelopment of a nation/society. In India, the government’s concernsince Independence (1947) has been improving the quality of life and the healthof the people. Over the years, both the central and state governments formulatedpolicy frameworks and initiated a number of schemes and programmes todevelop, expand, and strengthen the health and family welfare facilities toprovide better and more equitable health care to all the citizens of the country. Asresult, there has been notable progress, but it has not been equitable in all states,and among different socio-economic groups (Tables 1–3 in the Annexure).Notwithstanding the commitment and efforts to attain the goal of health for all inaccordance with the Alma Ata Declaration of 1978, to which India is a signatory,the fundamental realities continue to be far from reach. As reported in the IndianExpress, ORG-MARG recently conducted a nation-wide survey that revealed thatjust 14% of the respondents were satisfied with the quality of publicly providedhealth services in the country.Like inadequate resources and infrastructure facilities for health, inadequateinformation, education, and communication (IEC) is also a contributory factor tounsatisfactory health, particularly in rural and inaccessible areas. Take the caseof the supply of safe drinking water and provision of sanitation—the mostimportant contributing factors for improving health in any country. As per aWorld Health Organization (WHO) report, 80% of human diseases are due tounhygienic conditions and unsafe drinking water. It is estimated that every yearin India, about 1.5 million children under age five die because of water-relateddiseases. The country loses more than 200 million person-days each year due towater and sanitation diseases. Age-old cultural practices coupled with illiteracyand lack of awareness further complicate and accentuate health problems.In India, about Rs 15,000 crore have been invested in providing safe drinkingwater for villages. However, in a recent nation-wide survey, conducted in 6579

IEC Strategies for Health in Indiadistricts spread across 25 states, concerning the status of water and sanitation in rural India, itwas revealed that many of the hand-pumps and other drinking water facilities provided wereeither not utilized or remained under-utilized because of a lack of IEC.Information is power, and information is also a resource for empowering people. In addition,empowering people to do things is development. In India, the significance of communication inequipping people with new information and skills and mobilizing them for their willingparticipation in various development programmes and activities has been well recognized andemphasized in Five-Year Plans, the blueprint of the country’s development strategies. In theFirst Five-Year Plan, the need for understanding and appreciating various developmentprogrammes and schemes by the people was clearly expressed. In the subsequent plans, theconcern about communication among the people, even in remote villages, was increasinglyvoiced. Consequently, all available methods of communication were developed andstrengthened many times over the years.Based on experience, necessary changes and remedial measures were initiated from time totime. The findings of the 1993 National Family Health Survey (NFHS) were not very encouraging,however. Widespread awareness of the situation was not enough for actual adoption of a smallfamily norm and health practices. At the same time, the 1994 International Conference onPopulation and Development (ICPD) in Cairo echoed the need for a paradigm shift from acontraceptive target approach to population control to a focus on quality of health services inorder to encourage couples to make informed choices with regard to reproductive behaviourand family size.The Government of India accepted the new paradigm shift and, accordingly, launched its newReproductive and Child Health (RCH) programme, which marked a significant shift in governmentpolicy from a past preoccupation of meeting sterilization and contraceptive targets todecentralized participatory planning based on community-need assessment. Not only that, theRCH programme is more broad-based and covers a range of interventions for maternal health,child health, adolescent health, reproductive track infection, and unwanted fertility. Emphasis hasclearly shifted from one of limiting births to one of promoting health. The key mantra has been,“[by] promoting health, births will be limited.” Keeping this in mind, the Government of Indiaformulated a new National Population Policy 2000, a National Health Policy 2001, and a NationalCommunication Strategy for the Reproductive and Child Health Programme 2001.80The paradigm shift for RCH – towards client-centred, demand-driven services – needs strategiccommunication to work as a tool to create demand for quality health and family welfareservices. The communication challenge is one of demand creation and thus would necessitateunderstanding the needs of the target audience and media opportunities, professionalprocedures, and use of marketing approaches. The key tenets of the new communicationstrategy consist of the following.l Interpersonal communication for behaviour change will be the mainstay at the field level,encouraging greater dialogue on RCH issues between individuals within families andcommunities.

IEC Strategies for Health in IndiallllAdvocacy interventions based on normative research, including the use of the media, will beneeded to promote societal change with regard to behaviour norms on RCH issues.The above-mentioned advocacy interventions require decentralization of some IECresponsibilities to state and district levels from the national level, and consequently thearticulation of new roles for each of the three levels.There will be a need for increased engagement with non-governmental organizations(NGOs) and the private sector for social mobilization and IEC for RCH.As roles change, there will be a critical need for capacity building at all levels to undertakethe newly defined tasks and enhance the image of RCH functionaries.In consonance with the thrust of the IEC strategy, the national, state, and district levels areidentified and delineated to make the IEC strategy truly decentralized and participatory. Thefocus is clearly to shift IEC from the media and the distribution of centrally produced mediamaterials, to planning for IEC at the district level with interpersonal communication (IPC) asits mainstay. Accordingly, the need for more financial allocation for district-level IECplanning and execution is emphasized. Further, to make the IPC the mainstay of the IECstrategy work, training of service providers incorporating IEC planning and IPC skills isstrongly recommended.The mainstay of the new communication strategy is on improving IPC of all service providers,particularly at the community/block level, and with auxiliary nurse midwives (ANMs) and otherfrontline health workers who are in direct contact with people and communities, for effectivemobilization and behavioural change. Emphasis of the new approach is to address the issue ofbehavioural change through IPC, not just to create awareness. Mass media and folk forms ofcommunication should play important roles in creating awareness and building favourablepublic opinion. The new communication strategy is likely to be effective, although it is timeconsumingand resource-intensive. Hence, it may not be significantly cost-effective.Decentralized needs assessment, planning, and IPC require new skills and motivation by manyservice providers and administrators/managers of various health and family welfareprogrammes, particularly at the district and block levels. This shift will necessitate reorientationand retraining of health service providers at different levels. However, there are not enoughfacilities and competent trainers to accomplish this task, especially at the district and blocklevels where the need is greatest. Moreover, the new approach will demand the initiative tomake decisions and accept responsibility, which is often alien in the prevailing administrativeset-up and culture. Thus, the IEC strategy needs some rethinking if the challenges of scale are to bemet effectively.It is true that public health initiatives directly contribute to improvements in health indicators;however, there are several other complementary initiatives under the development-sectorumbrella, covering rural development, education, agriculture, food production, safe drinkingwater, sanitation, and so forth, which have a strong bearing on the health of the people. Assuch, a number of the development projects by government and NGOs are occurring indifferent parts of the country, especially for the benefit of the “risk groups” and “below povertyline” families. Many of these projects – Universal Literacy Mission, Self-Help Groups,81

IEC Strategies for Health in IndiaCommunity Based Nutrition Project, and Poverty Alleviation Programme, to mention just afew – are funded by international funding agencies. Community participation, empowermentof women, and improvement of socio-economic conditions for the poor are the main areas offocus for such initiatives. IPC is generally the main approach for mobilization, motivation, andbehavioural change. However, here the greater emphasis is on community andneighbourhood action to facilitate the acceptance of behavioural change on the part ofindividuals. The question of large numbers in the context of Indian society, however, remainslargely unanswered.82One of the ways to improve the efficacy of IPC and meet the challenges associated with vastnumbers of people is to integrate IPC with the media, especially radio. Radio has been used inmany countries, including India, as a development tool, especially for rural and inaccessibleareas. The radio rural forum in the 1950s and the mother/childcare programme supported byUNICEF in the 1980s were fairly successful experiments.Synthesis and Lessons LearnedBased on various initiatives and projects for promoting the health and family welfareprogramme through the years, the following points may be noted.l Communication facilitates both continuity and change; however, since people generallyresist change, behavioural change is not an easy task.l Communication is a highly selective process. Therefore, it is necessary to develop strategiesto harness communications for behavioural change, overcoming resistance to change, andmaking change the more attractive proposition as compared to traditionally held attitudesand practices.l IPC is the most effective method of communication for change; however, it is timeconsumingand not very cost-effective if change is intended to cover a large number ofpeople in a short period of time.l It is imperative to combine IPC with mass communication to harness the communicationresources optimally for behavioural change.l Now with the advances in communication technologies, it is possible to provide foradequate feedback, which was weak in earlier times, to make mass communication a moreinteractive process for effective communication and behavioural change.l Keeping in view the programme and communication needs in relation to a well-identifiedtarget audience, a series of problem-specific radio programmes may be prepared inconsultation with subject specialists.l Language and idioms used are also to be area-specific for easy comprehension andidentification.l Serialized programmes are to be broadcast on a regular basis to maintain the continuity andinterest of target audiences.l Group listing of serialized radio programmes has been found to be more effective in terms ofcommunity/interest group acceptance and action.l Other mass media and folk forms of communication may also be harnessed whenopportunities and resources permit as supplementary and complementary to IPC and radioas the mainstay of communication strategy for behavioural change.

IEC Strategies for Health in IndiaSegmentationTo plan an appropriate and cost-effective strategy for advocacy and IEC inputs in support of thehealth and family planning welfare programme, it is necessary tol segment the target audiences and understand their present perceptions regarding health andfamily welfare services;l clearly specify the planned changes in attitude and behaviour of different target audiences; andl impart new skills.In addition to the target population in a given area or region, specific groups or institutions maybe targeted and given opportunities to play significant roles in promoting health. Some of thegroups that can be identified as key stakeholders in health presently are the following.Service ProvidersRCH and health service providers at first referral units (FRUs), community health centres (CHCs),primary health centres (PHCs)/sub-centres (SCs), block primary health centres (BPHC), anddistrict health centres are the most crucial and important segment for advocacy and IEC inputs.They provide the health services directly to people. They need to be fully informed about thereform in the health sectors, its significance and implications in terms of management, and inrelation to their actual day-to-day work. This would mean their reorientation, motivation, anddedication, but also improvement of their skills and enhancement of their capabilities ineffective management and communication. It has been noticed that the health providers(including doctors) generally are weak in communication skills. Improvement in theircommunication skills will improve management and promote greater satisfaction andparticipation on the part of their clients or people in general. Such a reorientation, motivation, andimprovement in professional skills, together with management and communication skills, wouldrequire well thought out and planned short workshops for service providers at various levels.Panchayati Raj InstitutionsWith the 73rd and 74th Constitutional Amendments, the Panchayati Raj Institutions (PRIs) havebecome important in the democratic decentralization and devolution of power. Theseamendments provide for 33% representation for women in PRIs and make health a key concernand responsibility of PRIs. As such, the village, block, and district panchayats can play importantroles in bringing about health reform under their jurisdictions.Non-Governmental OrganizationsUsually, a number of NGOs are active in providing services in RCH, health, or other related areas.In view of their profiles and the services they provide, NGOs may be the places for appropriateIEC and advocacy efforts to facilitate their work and improve their competence and skills.School-teachersSchool-teachers play an important role in moulding the minds of young students. It will serve agood purpose to associate them actively with the campaign of inculcating desirable health andhygiene practices among young students. Healthy habits of the young will have a ripple effect83

IEC Strategies for Health in Indiathrough their homes and among adults as well. The appropriate IEC and advocacy effortsshould address school-teachers as an important segment.Individuals in the MediaThere is a need to sensitize the media to the importance of various health-related initiatives thatare being taken by the central and state governments and other NGOs in order to co-opt them insupport of health reform. They can play important roles in disseminating information andmaking health reforms more viable and acceptable and behavioural change desirable.Integrated Child Development Services (ICDS) and Mahila Swasthya Sangh (MSS)There is a wide network of ICDS in rural, tribal, and urban slums that caters to the needs of youngchildren and expectant mothers through anganwadis. These can play an important role in RCH andhealth reform. In many areas, MSSs are also actively functioning. IEC and advocacy efforts shouldaddress the information needs of these service providers and focus on skill improvement.Zila Shiksha Samiti (ZSS)Under the adult literacy programme, ZSSs are functioning. These could also be co-opted inhealth and RCH reform programmes through appropriate advocacy and IEC inputs.SummaryTo make optimum use of communication resources, it is necessary to combine the strength ofIPC and mass communication. Based on research and proper segmentation of target audiences,appropriate messages may be designed and communicated, not just disseminated, through bothIPC channels and the mass media, especially radio. The power of mass media to carry messagessimultaneously to a large number of people across an area, using it as a means of distancelearning and using IPC in groups to clarify doubts concerning any of the messages, would helpfacilitate learning and behavioural change. A well-researched approach to combine IPC and themass media will be cost-effective and will facilitate optimum use of IEC resources.ReferencesGovernment of India. 2000. National Population Policy 2000. New Delhi: GoI.Government of India. 2001. Draft National Health Policy 2001. New Delhi: GoI.Government of India. National Communication Strategy for Reproductive and Child HealthProgramme. New Delhi: GoI.ORG-MARG. 2001. Survey “Rs 90,000-cr public disservice every year.” The Indian Express .Water and Sanitation: A Baseline Survey for Rajiv Gandhi National Drinking Water Mission. NewDelhi: Indian Institute of Mass Communication.84Yadav, J S. Streamlining Advocacy Inputs into India’s Health & Family Welfare Programme: fromSituation Analysis towards Operational Management Strategy. New Delhi: European Union.

IEC Strategies for Health in IndiaAnnexTable 1. Through the Years: 1951–2000, AchievementsIndicator 1951 1981 2000Demographic ChangesLife Expectancy 36.7 54 64.6(RGI)Crude Birth Rate 40.8 33.9 26.1(SRS)(1999 SRS)Crude Death Rate 25 12.5 8.7(SRS)(1999 SRS)Infant Mortality Rate 146 110 70(1999 SRS)Epidemiological ShiftsMalaria (cases in millions) 75 2.7 2.2Leprosy (cases per 10,000 population) 38.1 57.3 3.74Smallpox (number of cases) >44,887 Eradicated —Guinea Worm (number of cases) >39,792 EradicatedPolio 29709 265InfrastructureSub-Centre/Primary Health Centre/CommunityHealth Centre 725 57,363 163,181(1999 RHS)Dispensaries and Hospitals (all) 9,209 23,555 43,322(1995/96 CBHI)Beds (private and public) 117,198 569,495 870,161(1995/96 CBHI)Doctors (Allopathic) 61,800 268,700 503,900(1998/99 MCI)Nursing Personnel 18,054 143,887 737,000(1999/INC)85

IEC Strategies for Health in IndiaTable 2. Differentials in Health Status Among StatesSector Population IMR/

IEC for Health Programmes in UttaranchalSession 2IEC for Health Programmesin UttaranchalJ S Deepak, Secretary, Medical & Health, Government of Uttar PradeshIntroductionFormer Soviet leader Leonid Brezhnev, appearing in a nationally televisedaddress, once inadvertently read the same page of his speech twice. And no oneeven seemed to notice, least of all the premier himself! It is indeed sad when aspeaker becomes so involved in reading his speech that he is unaware of what heis saying. But, alas, this is what we almost always do in social sectorcommunication. Messages lack clarity, are confused, and are often contradictory.And those who are to receive them either do not or are not listening.Information, education, and communication (IEC) activities are usually treatedas an end in themselves rather than a means to address an audience’s needs. Amajority of campaigns do not promise any benefit to the client and hence proveineffective. Materials, such as posters and television spots, are often unattractiveor of poor quality, and have to compete with a variety of other commercialadvertisements for the consumer’s attention. Behaviour and attitude change is along-term process influenced by a host of norms, values, and emotions. We knowthat human beings do not change their behaviour readily or simply becauseothers ask them to do so. Positive changes in health-seeking behaviour can,therefore, be brought about only by an effective IEC effort, which involves clearlydefined, accurately targeted, complete, and consistent messages delivered in anentertaining (or at least interesting) manner.Current SituationThe National Family Health Survey of 1998-99 (NFHS-2) shows someinteresting data.Reproductive HealthThe state of Uttaranchal has a population of about 8.5 million, a number whichgrew at a rate of 19.2% during 1991–2001. Almost 78% of the population lives inrural areas. Fertility preferences of women are for large families, and the meanideal number of children for women in Uttaranchal is 2.7. 11% of currently87

IEC for Health Programmes in Uttaranchalmarried women have an unmet need for spacing and, similarly, 11% for limiting. The unmetneed for spacing is 44% among women aged 15–19, which declines with age. Also, the unmetneed for limiting increases with age and is 16% among women aged 30–34. The preference forsons is also an issue among women. For example, for women with two living children,contraceptive use is only 22% if both children are daughters, 41% if there is one daughter andone son, and 58% if both children are sons.While the infant mortality rate in Uttaranchal is 38, this indicator is worse for children frompoorer and less-educated families. However, the infant mortality rate (IMR) is over 60% greateramong children born to mothers age 20 or less as compared with mothers ages 20–29 (an IMR of69 versus 43). Also, infant mortality is more than four times greater among children born lessthan 24 months after a previous birth (110 compared with 23 for children born after a gap ofmore than 24 months).Use of health services during pregnancy, delivery, and after childbirth remains low. Only 21% ofdeliveries are at medical facilities. Antenatal care (ANC) indicators, such as iron and folic acid(IFA) consumption and tetanus toxoid (TT) immunization, are also low. However, what is mostworrisome is that 41% of currently married women report some type of reproductive healthproblems; but almost 70% of these women have not sought any advice. Only 12% have soughtadvice or treatment at government facilities.NutritionThe prevalence of anaemia is particularly high among children and women. More than threequartersof children under three years are anaemic. Children whose mothers are anaemic are inturn more likely to suffer from anaemia. Similarly, more than 40% of children under age 3 aremalnourished, while one-third of women have this problem. Malnutrition of children can partlybe attributed to the fact that only 13% of children aged 6–9 months receive the recommendedcombination of breast milk and solid foods, in spite of the fact that breastfeeding is nearlyuniversal in Uttaranchal. However, due to ignorance, colostrum is not given by almost threefourthsof the women, and the median duration of exclusive breastfeeding is only 2.6 months.Burden of DiseaseAlthough the prevalence of tuberculosis (TB) is low, almost two per cent of the population at anytime is suffering from asthma, two per cent from malaria, and about one per cent from jaundice.At any given time, one-quarter of all children suffer from fever, 17% from acute respiratoryinfection (ARI), and 18% from diarrhoea. The ability of people to understand and treat thesesymptoms is poor. For instance, almost 20% of mothers believe that during a bout of diarrhoea,the child’s fluid intake needs to be reduced.88Empowerment and Service DeliveryDomestic violence is widespread. More than 10% of women have experienced beatings, and, ofthose, one-third feel that their husbands are justified in wielding the stick. Only four per cent ofwomen receive home visits from health workers, and nearly two-thirds of women of Uttaranchalhave not even heard about HIV/AIDS. Among the women who have heard about HIV/AIDS, 37%

IEC for Health Programmes in Uttaranchaldo not know of any way to avoid infection. Interpersonal counselling, the most effective method ofspreading awareness and getting women to seek help, is almost non-existent. Only two per cent ofwomen who know about HIV/AIDS received information about the disease from a health worker.Exposure to Information, Education, and CommunicationExposure to electronic forms of media is fairly widespread in Uttaranchal, where 70% of the ruralpopulation live in villages that have electricity. Overall, 38% of married women listen to theradio at least once a week, 46% watch television at least once a week, and 19% live in villagesthat have a cable connection. At the same time, 40% of women overall are not regularly exposedto radio, television, or other types of media. In addition, because of the high literacy level (61%for females), newspapers and magazines also form an important media source along with wallpaintings and hoardings.Thus, some of the IEC activities that could be exploited include the following.l Addressing the myths, misconceptions, and fears related to family planning that act asbarriers to its adoption and expanding the use of contraceptive methods to meet the unmetneed for spacing for young couples.l Promoting a delay in the birth of the first child and spacing births as an effective method ofreducing infant mortality and child survival.l Improving the levels of IFA consumption to tackle widespread anaemia.l Furthering the acceptance of child immunization as a life-saving measure and TTimmunization of women and adolescents to protect pregnant women and neonates.l Promoting correct breastfeeding practices and excluding breastfeeding and principles ofsupplementary feeding among women, influentials, and providers.l Sensitizing men and starting an advocacy effort among pradhans against domestic violenceand ill-treatment of women.l Increasing knowledge of the causes, symptoms, and treatment of major killers (such as cancer,TB, malaria, leprosy, diarrhoea, respiratory infections) and encouraging people to seek care.l Increasing awareness about HIV/AIDS and the ways to avoid infection.l Promoting quality service sites, training and promoting providers, and encouraging men andwomen to access health services.l Spreading messages related to hygiene, prevention of epidemics, water-borne diseases, andother public health concerns.l Implementing campaigns to reduce alcoholism among the youth.Lessons from IEC ProgrammesIEC activities have played an important role in promoting health and family planningprogrammes in India for many decades. They have also been successful in increasing awarenessand knowledge about family planning methods, the immunization programme, and somepublic health issues. The underlying assumption, however, in the design of IEC strategies andmaterials under the family planning programme has been that women and men do not want toregulate their fertility and therefore need to be motivated to do so. IEC, thus, has been topropagate normative messages about small families, delayed marriage, birth spacing, andsterilization through print materials and electronic media. The primary message has focused on89

IEC for Health Programmes in Uttaranchalthe adverse consequences of rapid population growth, or the “population explosion” approachto family planning, rather than catering to unmet need. In health care programmes as well,sporadic efforts have been made. IEC activities have been carried out to promote TB check-ups,emphasizing that TB is curable and encouraging people to sign up for treatment. Cataractoperation facilities to cure blindness have been promoted, and there have been print mediacampaigns in urban centres to persuade people to have regular cancer detection check-ups atfree clinics. Also, privately funded anti-smoking campaigns are not unknown. HIV/AIDSawareness activities have shot up recently because of the efforts of National AIDS ControlOrganization (NACO) and the State AIDS Control Societies.The budget for IEC activities has also been small—less than three per cent of the family welfarebudget, and lesser for health programmes. The quality of some of the IEC efforts is also dubious. Arecent HIV/AIDS awareness campaign in a major state, extensively relying on panels posted on theback of buses, used an unbelievable colour combination of brown, white, and grey for their panels,together with difficult language and long, boring text. Only an evaluation of the campaign willshow whether it helped to improve HIV/AIDS awareness or merely increased road accidents dueto motorists falling asleep. IEC activities, by and large, suffer from the following deficiencies.l Target audiences are not defined properly or sharply.l Almost no effort has been made to educate newly-weds and adolescents.l Choice of media is often arbitrary, not on the basis of its reach among target groups.l There is no emphasis on pre-testing IEC materials.l There is a lack of systematic monitoring of the implementation of the IEC activities.l Most IEC personnel lack proper knowledge and communication skills.l IEC strategies are designed at the central level, adopting the top-down approach with littleownership at the state, district, or sub-district levels.l Low priority, inadequate budget, and delay in the release of funds for IEC—programmes arepredominantly managed by medical personnel, often IEC positions remain vacant, andfunds are diverted to other activities.However, this is not to say that there have been no successful IEC activities. A good example wouldbe the national Pulse Polio Immunization Campaign, which included a national plan, guidance forstates and districts for the implementation of campaign activities, and material such as leaflets,posters, and spots. The state and districts have been able to use this total package to produceuseful and attractive messages at the local level. This campaign has also extensively used massmedia for disseminating messages; however, the use of non-traditional media such as folk mediahas remained limited. The extent and coverage of IEC activities in different states has also variedwidely as has the competence in managing and planning IEC programmes.90In 1995, the Government of India established IEC bureaus in eight of the country’s mostpopulous states to integrate all IEC, health, and education activities under one roof. In additionto strengthening IEC planning, the bureaus were expected to assume a leadership role in thetraining of health functionaries in IEC skills and in implementing, monitoring, and evaluatingvarious activities and campaigns. Although the establishment of these bureaus has strengthenedthe state governments’ ability to conduct IEC activities and produce attractive and useful

IEC for Health Programmes in Uttaranchalmaterial, certain basic problems remain. The bureaus are not able to provide adequate attentionto the development of comprehensive plans, clear audience segmentation, and implementationof need-based strategies. For instance, research findings show large unmet need for familyplanning; however, there have been few focused communication efforts to help those withunmet need. Also, health activities have been mostly reactive, with an emphasis on print mediarather than on interpersonal communication (IPC) and counselling. Money spentunproductively and unimaginatively on newspaper advertisements in states with low literacylevels, with pictures of VIPs on occasions such as World Health Day, has also contributed towasting limited available resources.In addition to the Pulse Polio campaign, another example of a successful IEC approach is inUttar Pradesh through the State Innovations in Family Planning Services Agency (SIFPSA)-sponsored “Aao Batein Karein” family planning and birth spacing campaign. This campaign,which has been ongoing since 1998, is a research-based, multimedia campaign. Campaignmaterial as well as spots and films have been developed after extensive pre-testing of the theme,effectiveness of the messages for the target audience, and their memorability. The campaign alsoincludes the following.l Extensive elements of training and orientation of field staff in the use of material anddevelopment of their interpersonal counselling skills.l Use of folk media at the local level to carry reproductive and child health (RCH) messages tofar-flung villages in an entertaining way.l Mass media at the state level to reach the intended audience aged 17-25 years.l Elements of monitoring, tracking, and evaluation to be done by external agencies.The campaign was developed using an advertising agency, which interacted closely withexperts, programme managers, and representatives of the intended audience.Successful campaigns, such as for Pulse Polio Immunization and “Aao Batein Karein,” providethe following useful lessons for implementing IEC activities related to health and family welfareprogrammes.l The campaign approach is successful as it ensures proper allocation of resources,coordination, implementation, and proper management.l Audience segmentation, based on research, is a prerequisite for focus; separate messageshave to be designed for married women, adolescents, influentials, service providers, and soforth, and delivered to them in their respective contexts.l Use of a professional advertising agency brings in creative skills and experience in areas suchas message design and media selection from the private sector. This expertise is not widelyavailable with government departments.l Non-traditional approaches such as the use of folk media can contribute greatly in reachingout to remote and resistant groups.l Interpersonal counselling is key to bringing about behaviour change and thus requires lotsof investment in training of personnel and upgrading their skills.l In the clutter of advertisements competing for audience attention, an entertaining approach,or one that contains a “big idea,” is the only way of being heard or seen.91

IEC for Health Programmes in UttaranchalChallenges and Opportunities in UttaranchalUttaranchal has the advantage of having high literacy and a fairly good media reach. The reachof communication channels is also increasing at a rapid pace. The challenge is to utilize this tobring about appropriate change in behaviour necessary for improving the health of thepopulation.On paper, government departments have impressive IEC infrastructures. For instance, theDepartment of Information’s role is information dissemination for all programmes. However,the department in practice works as a public relations adjunct to the Office of the Chief Minister.Its role has been reduced to press and media management, damage control in case of adversepublicity, and the promotion of the image of the government. At the district level, there areDistrict Information and Publicity Officers, who have also become divorced from programmeactivities. The Department of Health is served by District Health Education and InformationOfficers (DHEIO), supported by block-level Health Education and Information Officers, who areassigned key roles in information dissemination for health programmes. In practice, however,the lack of a coherent IEC plan, inadequate budget, vacant positions at the district and blocklevels, and feelings of alienation hamper their work. Being a new state, Uttaranchal has thefurther disadvantage of not having a state-level IEC bureau.The aforementioned gaps in infrastructure are coupled with similar attitudes in the minds ofprogramme managers. Chief Medical Officers, who are responsible for implementing varioushealth programmes, do not generally understand the role and importance of IEC and thedifference it can make in improving programme performance and behaviour change, which hasresulted in the following.l IEC is viewed more as a product and less as a process. Key personnel are only concernedwith the number of posters and pamphlets printed or the number of spots produced ratherthan with their use and effectiveness.l Interventions and activities are designed to suit the needs of the department rather than theclients.l There is no focus or consistency in messages being developed and disseminated at differentlevels.l Promotion and publicity activities take place sporadically, mostly towards the end of thefinancial year when funds are available or to mark important days and visits of VIPs.l There is little research and inadequate emphasis on evaluation of efforts, leading to the samemistakes being made again and again.l The private sector, which has expertise in the field of communication, is not utilized.However, in light of these challenges, communication programmes can be implementedeffectively through the following interventions.92Develop an IEC Strategy for the StateThe IEC strategy should be based on the states’ objectives and developed in coordination withthe programme’s strategy. The two should be mutually supportive and reinforce each other. Theprocess adopted in developing the strategy should involve all stakeholders and draw on

IEC for Health Programmes in Uttaranchalindividual expertise, institutional experience, and research findings. The strategy should ensurethat communication plays the dual role of providing support and reassurance to those who havealready adopted the desired behaviour change and simultaneously creating demand for healthservices and addressing specific fears, obstacles, and barriers to the same. Promotion offacilities, trained providers, and appropriate behaviours would be a crucial aspect of this role.The IEC strategy should specifically focus on the following.l Looking at existing research to determine specific communication needs as well asmethodology of commissioning additional studies to test themes, ideas, and materials.l Segmenting the population according to its needs and in the context of objectives andpriorities of various health programmes.l Identifying barriers and specific methods of overcoming obstacles to move to the desiredbehaviour.l Working out specific messages for each of the above desired changes.l Developing indicators for monitoring and assessment of each intervention and a system offeedback and assessment of impact.l Establishing a system of selection of experts or agencies and production of communicationmaterial.An operational plan should also be prepared to phase out activities over different time periodsand to quickly move from strategy to action.Establish a Multi-sectoral IEC BureauAn IEC bureau should be established at the state level to plan, coordinate, and implement variousactivities under the state IEC strategy. This bureau should have the capacity to plan and executemultimedia campaigns at state and district levels. Ideally, this organization should be responsiblefor all IEC activities related to public health, family planning, nutrition, disease control, education,and welfare to justify adequate outlays for the small state of Uttaranchal. This would also providefor the integration and efficiency in research, media buying, and implementation campaigns andensure consistency of themes, designs, and messages across various sectors.The IEC bureau should also have a Media and Materials Resource Centre (MMRC) to scan andhouse IEC materials produced by the Government of India, state governments, otherinstitutions or NGOs; and those materials being used in different programmes and states,especially the Hindi-speaking ones. The centre should have the capacity to duplicate, produce,and distribute these items to those who need them. This would obviate the need for “reinventingthe wheel,” and lots of good quality material being used elsewhere could become available foruse in Uttaranchal immediately. The MMRC should also perform the functions of a mass-mailingunit to periodically address providers, village pradhans, and so forth, and publish and distributenewsletters.Involve Private Sector Organizations and ProfessionalsGovernments have to recognize that while they deal with some of the most importantprogrammes, which can make a difference to the lives of their citizens, they do not have much93

IEC for Health Programmes in Uttaranchalexpertise in the field of communication. Professional communication skills and creative talentavailable to the sellers of soaps and aerated water are of a much greater calibre. In addition, IECalone does not necessarily produce results. Only communication with the right appeal, message,and focus can make a difference. Thus, it is important that a system is in place to enablegovernments to access the services of advertising, research agencies, and private sectorprofessionals in order to develop quality communication, which can in turn bring aboutappropriate attitudinal and behaviour changes. The additional expenditure that may be requiredfor this approach is not only justified but can make the critical difference. The experience ofSIFPSA in Uttar Pradesh shows that even hiring the best advertising agency produces almost noincremental costs (as it gets its income from media placements); and research, if planned well,can provide great value for the money. Further, it is not possible to implement multimediaactivities on any respectable scale without the support of an advertising agency. Hence, it isnecessary to employ an advertising agency for at least three years in order that it can learn,develop health sector expertise, and work as a key partner in the design and implementation ofIEC activities. Similarly, key technical personnel in the IEC bureau and MMRC should be expertsin their fields.Build Capacity for Interpersonal communicationMass media is an efficient vehicle for reaching large numbers of people. With the increasingreach of TV and radio, popularity of cable networks, and high literacy rates, mass media willcontinue to play an important role in spreading awareness and knowledge, and as a vehicle foradvocacy. However, behaviour change, related to important personal health and family planningissues, influenced as it is by socio-cultural factors, is more easily triggered by personalizedinteraction through peer groups or conversation with providers, where there is an opportunity todiscuss concerns, fears, and experiences. Further, for the approximately 40% of the populationwith no access to mass media, IPC and traditional media are the only sources of information.IPC can be effective if grass-roots workers are equipped with appropriate resources. For this,they require counselling aids and display material, such as flip chart books, pamphlets, andposters with messages consistent with those being disseminated by mass media. Even moreimportant would be their training and skills in counselling.94IPC training should be participatory and preferably conducted in the field. A multi-disciplinaryapproach that teaches workers how to deliver messages related to various programmes that theyare responsible for would be useful. When SIFPSA took up IPC activities in Uttar Pradesh in1998, it was found that most government grass-roots health workers had never used a flip chartbook and had never been taught counselling skills. The experience of SIFPSA in Uttar Pradeshshows that the following elements help improve training quality, management, and usefulness.l Use of private training agencies that can recruit their own resource persons and are given theresponsibility for organizing and conducting workshops in a certain area is essential sincetraining capacity in the government sector is lacking and contracting out reduces themanagement effort required.l Centralized training-of-trainers is essential to ensure quality of trainers and standardizationof the curriculum.

IEC for Health Programmes in UttaranchallllTraining of workers through workshops in the field (such as the BPHCs) ensures logistics andmanageable batch sizes for participatory training.Extensive use of models, role-plays, and audio-visual material such as training films.Assured supply of counselling material to trainees is a must. This is found to be a major gapin government programmes, and the contracted training agencies need to be assigned theresponsibility of transporting material from printers to the workshops.Utilize Folk MediaThe availability of a rich and varied folk tradition in Uttaranchal also provides anopportunity to reach out to rural areas and resistant groups in an entertaining way. Inremote areas, beyond the reach of mass media, folk forms, such as puppetry, magic, ballads,and dance dramas, are perhaps the only attractive media. Such folk forms have been usedfor conducting IEC programmes by SIFPSA, which has extensive experience in organizingmore than 5000 performances in the villages of Uttar Pradesh and Uttaranchal. In spite oflogistic challenges, this activity is found to be one of the most popular IEC interventionssuitable for replication. Large-scale use of folk media requires identifying folk troupes andemploying them to perform in different districts at fixed rates per performance. The nextsteps would be to as follows.l Develop scripts to incorporate programme messages without changing popular story linesand mythological aspects.l Train troupes to effectively deliver messages with appropriate music, lighting, costumes, andstage props.l Follow up to ensure that performances are effective, obtain audience feedback, and assessre-training requirements.l Make a roster of performances for each troupe, tying up local arrangements and prepublicityin neighbouring villages.l Ensure timely payments to troupes.The first three activities can be assigned to expert agencies, whereas the latter two could behandled by NGOs and village pradhans.Adopt a Campaign ApproachIEC expertise in government is limited, and very few skills exist at the district level to design,monitor, and implement IEC activities. While the ultimate objective should be to buildcapacity at these levels to plan and organize district-or block-level IEC activities, based onidentified local needs and gaps, this objective is likely to take time. As an interim measure, IECactivities could be planned centrally with suitable adjustments for regional variations. Acampaign approach would be the most appropriate intervention for this. In addition, tofacilitate better management, this approach ensures the integration of various activities, suchas determining needs assessment, determining communication objectives, focusing on effortsin specific areas, and tracking activities in order to assess their impacts. A campaign approachis also most suited to working in partnership with advertising and research agencies and tohelping coordinate various activities such as mass media, IPC, training, and research within agiven time-frame.95

IEC for Health Programmes in UttaranchalConclusionUttaranchal offers many opportunities for an integrated IEC effort in the health sector to bringabout behavioural change. The availability of services and supplies, the filling of key positions,and the training and motivation of programme managers and service providers are some of theprerequisites for this change. A clear philosophy, focused strategy, and establishment ofappropriate structures and systems, together with partnership with different agencies tomobilize additional inputs and resources, can go a long way in making health communicationprogrammes successful.96

Session 3Private and Public SectorPartnerships in the Health SectorChairpersonRameshwar SharmaPublic–Private Interaction in Health: Policy IssuesRamesh BhatCost Recovery Measures in Government Health InstitutionsD K MangalArogya Raksha-Health Insurance Scheme forFW acceptors in Andhra PradeshA Kameswara RaoDiscussantS D Gupta

Public–Private Interaction in Health: Policy IssuesSession 3Public–Private Interaction inHealth: Policy IssuesRamesh Bhat, Professor, Indian Institute of Management, AhmedabadIntroductionThe role of the private sector in provision and financing assumes considerableimportance in recent times. Recent health financing patterns suggest that the outof-pocketcost on health accounts for about 78% of the total expenditure onhealth (World Bank, 1997). Private health expenditure is estimated to be about4.25% of the gross domestic product (GDP). Insurance coverage mechanisms arenegligible, and most of that expenditure is out-of-pocket (i.e., private financing).Private health care expenditure in India has grown at the rate of 12.5% perannum. For each 1% increase in per capita income, private health careexpenditure has increased by about 1.47% (Bhat, 1996).The share of the private sector in health infrastructure is also quite significant.About 57% of hospitals and 32% of hospital beds are in the private sector. Theshare of private sector investment in health infrastructure (e.g., hospitals,investment in medical equipment and technology, etc.) is also quite significant.Most of the qualified doctors work in the private sector; data suggests that atpresent about 80% of 390,000 qualified allopathic doctors registered withmedical councils in India and 650,000 providers from other branches ofmedicine are working in the private sector. Dependence on the private sector is,therefore, considerable. Utilization studies also show that one-third of inpatientsand three-fourths of out-patients use private health care facilities(Duggal and Amin, 1989; Yesudian, 1990; Visaria and Gumber, 1994).Given the presence of the private sector, various state governments and centresupportedprogramme strategies in the health sector emphasize public–privatecollaborations. The role of private initiatives is considered important in view ofgrowing concerns about shrinking budgetary support from the government tocurative and tertiary health care, increasing burden arising from dual burden(communicable and non-communicable) of diseases, and the growingcomplexities in the areas of technology, patient–provider relationships, anddelivery mechanisms of health care services.99

Public–Private Interaction in Health: Policy IssuesWithin this policy context, the efficiency and effectiveness of the private health care sector issubject to a complex set of market distortions and imperfections, which interact with moralhazard problems of market and information asymmetry. In the absence of appropriate publicpolicy towards the private sector, the growth of this sector may lead to performance that could beless satisfying and have high costs. Review of the private health care sector in India suggests thatgrowing costs of private health care, widening equity and access problems, and increasingconcerns about quality of care are emerging as major issues and set to threaten the basic fabricof the health care system in India. Hence, public policy towards the private sector would becritical in addressing these issues, which should direct the private sector towards achievingpublic goals.The objective of this paper is to describe the public–private interaction and ways that policyinitiatives could channel private initiatives towards private sector goals.Public–Private Interaction: Familiar ChallengesMarket failure emanating from incentives to maximize profits in the private sector is welldocumented. Besides these market problems, which need to be empirically examined,policy-makers should consider the following issues arising out of the growth of the privatesector in India.Growth: Public Goal ChallengeOn the positive side, the significant presence of the private sector eases a considerable amountof burden from the public sector. The public sector alone would find it difficult to cater to thegrowing requirements of health care. The private sector has responded well to demand-sidefactors and has assumed a considerable amount of influence in providing health care in manydeveloping countries. These developments have encouraged the population, who are willingand can afford to pay for health care. The challenge with this kind of growth is how to encouragethe private sector to participate in the public health area and get maximum health gains. With thegrowing influence of private provision, one feels that this sector is increasingly catering todisease patterns that are of public health importance. For example, in maternal and child health,malaria, tuberculosis, and so forth, one finds the growing influence of the private sector. Oneimportant issue that governments of developing countries are trying to address is how toimprove collaboration in these areas.100Issue of Multi-faceted Providers: Diversity ChallengeRecent studies in India show that large numbers of providers in rural areas are not qualified orqualified in traditional systems of medicines and practising allopathic systems of medicine.Rough estimates in India suggest that the population of such providers is about double the sizeof the qualified providers in the allopathic system of medicine. The problem is furtheraggravated by the fact that a large number of pharmacies also dispense medicine. This, however,raises a number of issues. Can we stop them from practising? The sheer numbers and thegeographic spread of such providers suggest that this is perhaps not feasible. What are theoptions? Training, consumer awareness, and strengthening of government facilities? Theseissues need to be debated.

Public–Private Interaction in Health: Policy IssuesIssue of Quality: Delivery ChallengeThere are some studies that show that the quality of private care is a serious problem, particularlyin disease patterns of public importance. For example, tuberculosis, leprosy, and reproductivehealth are specific areas that have been studied to assess quality of care provided by the privatesector. A recent study (Ranson and John, 2001) of a community-based health insurance shows thatquality of hysterectomy care accessed by Self-Employed Women’s Association’s (SEWA’s) membersvaries tremendously, from potentially dangerous to excellent. Seemingly dangerous aspects ofstructure include operating theatres without separate hand-washing facilities or proper lightingand absence of qualified nursing staff. Dangerous aspects of the process include performinghysterectomies on demand; removing both ovaries without consulting or notifying patients; andfailing to send the excised organs for histopathology, even when symptoms and signs aresuggestive of disease. Women pay substantial amounts of money for poor, and potentiallydangerous, quality of care. Another study points out that about 23% of litigation cases in India(through consumer courts) involve women-related problems (medical termination of pregnancy[MTP], sterilization, pregnancy-related, etc.), which tops the list of litigation cases in India. Inaddition, all of these litigation cases are against private hospitals and clinics.Cost: Financing ChallengeCost of care is increasing, and there is considerable variation across facilities in terms ofcharging fees. Most of the fees are out-of-pocket. Insurance mechanisms are quite limited, whichhas a number of implications. One important implication is that the financial burden on lowerincome groups would be significant. A recent study in Gambia (Fabricant, Kamara and Mills,1999) found that low-income households spent 10% of their income on health compared with3.4% by higher income households. The poorest 20% spent about one-quarter of their incomeon health. Policy-makers need to find mechanisms to mitigate some of the effects of theseproblems. What are the options?Provider Behaviour: Self-Regulation ChallengeGenerally, it is expected that the medical profession (and for that matter any other profession)will self-regulate. Most of the countries have developed medical councils, empowering themto regulate curriculum development for medical courses, the opening of medical colleges, andmedical practices. In the private sector, regulating the behaviour of private providers has metwith very little success, and the experience of India suggests that medical councils andassociations have been less successful in regulating the behaviour of private providers. Largenumbers of providers in the private sector are not active members of the associations. Thosewho are, however, are not really bothered about the guidelines of the association. Privateprovider behaviour is left entirely to market mechanisms. Presently, there are no regulatorymechanisms to ensure the safe and appropriate delivery of health care services. Thus, the roleof the state becomes important along these lines. Recent surveys have also shown that themajority of private providers are not aware of major legislation in India.Consumer Knowledge: Awareness Building ChallengeMost developing countries do not recognize the rights of consumers, particularly in the servicessector. Responsibilities of services providers are not clearly defined and recognized, particularly if101

Public–Private Interaction in Health: Policy Issuesthey do not follow standard procedures and cause harm to patients by providing inadequatequality of service. In India, the introduction of the Consumer Protection Act acknowledged therights of consumers. In addition, “paid for medical services” were brought under the Act. Patientscan now take matters to consumer councils (judiciary bodies of about 500 persons established toprovide speedy and cost-effective justice) for their grievances and inadequate quality of services.Do governments pay adequate attention to educate consumers? The consumer movement andadvocacy groups are in their infancies and have a long way to go in order to emerge as forces thatensure healthy practices from the private sector.Regulatory Mechanisms: Implementation ChallengeEffective regulatory mechanisms to regulate various aspects of private health care provision arelacking. There cannot be a single piece of legislation that can tackle all problems. Each stateneeds a set of effective regulatory mechanisms ensuring that systems behave properly.Experiences across Indian states suggest that there is no systematic development of regulatorymechanisms. Implementation of whatever regulations have been promulgated has always beena problem, and implementation and enforcement of rules and regulations (wherever theseregulations have been adopted) is weak because of the following.l With health being a subject for the state in India, response to different legislation has variedfrom state to state.l There has been a considerable amount of resistance from various constituents of the privatehealth care sector (particularly private providers) to accept, in principle, the applicability ofcertain regulation to their profession.l Response of the medical profession to develop rules, norms, and various mechanisms forself-regulation has been poor.l Many pieces of regulation have not changed with the times and, therefore, have lost theirrelevance in the present-day context.l Private sector issues are not high on the public policy agenda; this, however, is changing fast.102There are many developments on the regulation side that strengthen the functioning of the privatehealth care market. Nevertheless, much needs to be done on the regulation side. Thesedevelopments are in the area of providing more powers to consumers and discouraging someinappropriate practices, such as sex determination, organ trading, and privatization of insurance.l Consumer Protection Act 1986 The Supreme Court of India passed a judgment that theConsumer Protection Act is applicable to “paid for medical services.”l Other Recent Legislative Changes Two important pieces of legislation were passed that willdiscourage certain practices.n Human Organ Transplant Act, 1995n Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1996l Privatization of Insurance Under the new economic policy reforms, the government has nowliberalized the insurance sector.Private Participation Initiatives in HealthPrivate participation initiatives in health can be broadly classified into initiatives on the demand side(primarily focusing on financing of health care) and the supply side (provision of health services).

Public–Private Interaction in Health: Policy IssuesUser fees as a policy instrument are advocated to encourage private participation throughprivate financing. Effective implementation of this policy is expected to generate resources andimprove the efficiency of public services. Experiences in implementing the user-fee policy aremixed. A recent study in Gujarat suggests that the total collection of user fees is less than twoper cent of the total hospital sector budget. Experiences in Rajasthan and Madhya Pradeshsuggest that this policy has helped in augmenting the resource base, which has been used toimprove basic services at the facility level. There are a number of management andadministration issues. For example, providing facilities with adequate authority to retain feesat the facility level has been found to be a significant determinant in improving the efficiencyat the facility level.Given the role of the private sector in health, various state governments are exploring theoptions of involving the private sector in meeting growing health care needs in various areas.Public–private partnerships have emerged as among the options to influence the growth of theprivate sector with public goals in mind. For example, policy initiatives, such as developing anincentives system to influence the desired geographical distribution of health facilities and inspecified areas, and involving qualified providers through contract mechanisms in rural areas toimprove the health delivery care system, are some of the options being explored. In general,focus of various public-private collaborations has been on the following.l Developing strategies to utilize untapped resources and the strength of private sector withthe public goal in mindl Enhancing the capacity to meet growing health needsl Reducing the financial burden of government expenditures on specialty and super-specialtycarel Reducing regional and geographical disparity in health care provision and ensuring accessl Reaching remote areas or targeting specific groups of the populationl Improving efficiency through evolving new management structures.These interventions are being explored to improve the effectiveness and efficiency of the healthsector. While exploring these, we need to keep some points in mind. First, not much is knownabout how these markets work in an environment where financing mechanisms are limited andmost payments are out-of-pocket. Recent normative research suggests that given the prevailingprovider payment system (predominantly fee-for-service), the private sector may generateadverse consequences from the view of cost containment, equity, and efficiency. However,empirical research is significantly lacking in this area. Second, the private sector is diverse andvast, per se, consisting of formal–informal sectors, qualified–unqualified providers, practising indifferent systems of medicine, and so forth, which increases the complexity of this sector. Thissuggests the need for serious thinking and deliberations to develop appropriate public policytoward the private sector.Private Financing Initiatives: Unfamiliar OpportunitiesFinancing poses considerable challenges to the growth of the private health care sector. Most ofthe discussion involving private sector financing focuses on demand-side financing. Littleattention, however, is paid to supply-side financing issues and their implications to the overall103

Public–Private Interaction in Health: Policy Issuesdevelopment of the private sector, which is also unfamiliar territory. Public policy in this area isin a nascent stage. Some of the experiences from India are provided below.Financing of Providers’ FacilitiesIt has been observed that large numbers of providers are working in small clinics or small privatehospitals (called nursing homes in India). The average number of beds in these nursing homes is20. Most of these facilities are located in prime areas and are affected by what we call the smallscalesyndrome. Having no access to market-based financing mechanisms, these facilities tend toborrow money from informal markets with interest rates that are phenomenally high. In a recentsurvey by the author, the average rate of interest paid by these facility holders was found to be inthe range of 18%–22%. Looking at the amount of investment required to start a new facility, the costof capital of these enterprises is unreasonably high, reflected in the prices charged from patients.Since the demand for services is quite uncertain and has significant seasonal variation, there isalways a temptation to indulge in various types of malpractice, such as fee splitting, induceddemand, and so forth. All these have implications for the cost of health care.Financing Mechanisms Available to ConsumersOn the demand side, it has been observed that most of the cost is out-of-pocket. In addition,insurance mechanisms are quite limited. In India only eight per cent of financing in the privatesector is through insurance.Joint VenturesJoint ventures are specifically formed to achieve some common goal by providing services thatmeet the requirements of both the entities forming the venture. Introduction of a joint ventureconcept to the health care industry in India is quite new and is in the exploratory stage. Anumber of joint venture projects are under consultation. One such project has already beeninitiated in Delhi.The need for the joint ventures emanates from the urge to create greater opportunities forimproving health care facilities within the framework of the knowledge, expertise, and physicalpresence built up by the two sectors. The nature of the health care industry has changedconsiderably. With the advent of new technologies, the capital intensity has grownphenomenally throughout the period. At the same time, public institutions have found it difficultto find sufficient resources and technical manpower to cope.Joint ventures can assume two different forms, as described below.Contracting out for services (primarily non-clinical): This type of joint venture includes anagreement between two or more (in terms of ownership) separate firms for the exchange ofperformance. There have been a number of collaborations between the private and publicsectors. We have some documentation on contracting experiences and how effective thesemechanisms are in improving the performance of public health care facilities.104Equity joint ventures: This type of joint venture provides for future joint decision making in ajointly owned company. In India, this form of collaboration is proposed on the grounds that the

Public–Private Interaction in Health: Policy Issuesprevious tax incentive system, in which private providers were given fiscal relief for the import ofequipment on the condition that such facilities will provide free care to 25%–40% of patientsbelonging to poor classes. Wherever these initiatives have been implemented, monitoring hasremained an important concern, despite the fact that the government has significant control inthe ownership and decision making of the organization.Public Policy Towards the Private Sector: Unprecedented DilemmasThe role of the government and the Department of Health and Family Welfare is quite critical.Because of the market failures associated with the private sector, the state has to respond insome meaningful manner to reduce the unintended consequences of this growth. What shouldbe public policy towards the private sector? Given the presence and dependence on the privatesector, the objective of this public policy toward the private sector should be that people geteffective health care at a cost that is affordable.What are the policy options that the health departments can pursue? Given the complexities, thedepartments have to pursue a multi-pronged strategy. Strengthening the public sector in a mannerthat is accessible ensures availability of medicines, mobility of providers, maintenance of facilities,and management (4Ms to strengthen public sector) on the one hand, and improvement of theconditions in the private sector on the other. For example, to improve the quality of hospital carein the private sector, the departments have to ascertain that data is collated on a regular basis onthe costs and complications for various providers, and some agency follows-up cases where thetreatments are not as per standard. Similarly, the departments may develop the policy of usingincentives to encourage providers to make efficient and equitable resource allocation decisions, orthe department may also facilitate the contracting out of services with providers who provide ahigh standard of care or who agree to certain conditions. The health departments may developinterventions that provide adequate information to users of private services about costs andbenefits of standard treatments. The departments may also take measures that influence thebehaviour of the provider by making training and continuing education compulsory. The researchbase is inadequate to suggest which approaches are effective, and the health departments have tolearn the best practices and what works effectively.The broad strategies to improve the conditions in the private sector need to consider theconstraints faced by many states in making the private sector work effectively. Some of thestrategies emanate from the following constraints.l Inadequate information basel Poor/ineffective regulatory structure including capacitiesl Lack of consumer awarenessl Absence of advocacy groups and educationl Self-centred medical councils and medical associationsl Weak structure for continuing education.Improve the Information BaseThe first and foremost step in strengthening the public–private collaboration and improving theperformance of the private sector in the provision of health care is to develop an appropriate105

Public–Private Interaction in Health: Policy Issuesinformation base. Governments must assume the responsibility of collecting information. Medicalcouncils, medical associations, and local governments can play important roles in this process. InIndia, various agencies are supposed to collect and update information on private providers.However, this is not being done systematically and regularly, and the roles, responsibilities, andaccountability are not clear. For example, the Medical Council of India (MCI) is supposed toprovide information about the number of doctors registered with it. Information from 1992 is theonly kind available from secondary sources. No data is available concerning the number ofproviders working in the private sector; there are only some estimates. Similarly, localgovernments are supposed to have information about the private hospitals registered with them.These data are also difficult to obtain. Governments need to take quick action to fix theresponsibilities of various agencies, ensuring basic data and information on the private sector.Agencies need to be sensitized about the importance of this information, a situation that becameevident to the local government during the plague epidemic in Surat, India. Information on thenumber of providers in the private sector was needed to design a strategy to handle the epidemic.Similar case studies can help policy-makers highlight the importance of such information.Strengthen the Capacities of Governments to RegulateRegulating private providers will be a new role to many health departments in the states, sincethey lack experience in this area. Studies must be initiated to find out what regulatorymechanisms are available in what places, whether they are sufficient to handle the problems ofmarket failure. International experiences in this area would be useful in discerning what worksand what does not. Experiences in development and implementation of regulations exist; forexample, the Consumer Protection Act, which was implemented with reasonable success butperhaps needs further strengthening. However, at the same time, there are cases inimplementing some regulations, such as the Medical Council of India Act and Nursing HomeAct, which need further strengthening. How to strengthen existing regulations? Which newregulations are required? Do the health departments have the capacity to develop andimplement the new regulations? How to strengthen these capacities?106Develop Capacity of Health Departments to Handle Public–Private CollaborationPublic–private collaboration may assume various forms; for example, collaboration through thedirect provision of the private provider, contracting out of services, informal cooperation,technology, and facility sharing, and so forth. There are a number of legal and managerial issuesinvolved with these collaborations. Handling them are new tasks for the health departments, andthey need to develop capacity in these areas. Governments can provide resources to variousprivate collaborators in the form of land and other assets. The implicit understanding betweenpublic-private partnerships would be to contribute toward equity (for example, by allocating 40%of facilities to the poor) along with know-how. In most cases, the health departments would bebanking on private capital. Since investments will be large (if it is specialty and tertiary care), whoowns the facility and what its revenue-generating model will be are of critical importance.Involvement of private financing in these collaborations needs to be worked out carefully.Investments compete with other opportunities, and departments need to handle private initiativesensuring that they earn reasonable returns, which requires some financial analysis capacity withindepartments. Thus, developing health economics and financing capacities would be critical.

Public–Private Interaction in Health: Policy IssuesEmpowering the Medical Councils and AssociationMedical councils in India were established to ensure standards of medical education byrecognizing the medical qualifications granted by medical institutions in India and maintaininguniform standards of post-graduate medical education and defining a professional code ofconduct. For the latter, the council has prescribed medical ethics and a code of conduct. Statemedical councils have been established to facilitate the role of the MCI.There have been few instances of medical councils intervening and initiating disciplinary actionagainst members of their profession or against whom there is formal complaint of negligence. Atthe same time, consumer courts have been receiving a number of complaints against registeredmembers. In these cases, a copy of the complaint is also forwarded to the councils, but there is noaction. Some of the regulations in the MCI Act have also become outdated. The role of thegovernment is to place the responsibility on medical councils and medical associations.Ensuring Appropriate QualityThe roles of the MCI and state medical councils have been less impressive in India. They havefailed to regulate the medical profession and establish adequate standards to safeguard theinterest of patients, particularly in medical practice. As a first step, the role of regulatingeducation should be separated from the role of regulating practice. The latter would require lotof effort, first in establishing adequate standards, and second in ensuring the implementation ofbasic minimum standards. A separate commission should be established to assume this role.Some initiatives by independent agencies to start the accreditation of hospitals are underconsideration and the departments need to support these initiatives.Technology InvestmentRecently, with the proliferation of medical technologies and diagnostic equipment, investmentsby private providers in urban areas have increased significantly. Rural and remote areas do notattract these investments; however, it has been observed that the growing tendency to acquiremore high-tech., costly technologies by large numbers of providers in urban areas has led toover-capacity of many technologies. MRIs, scanners, and Extracorporeal Shock Wave Lithotripsy(ESWL) technology are examples of such investments. A case study of ESWL in Gujarat by thisauthor found that the amount on investment in ESWL technology by several providers in oneregion led to excess capacity in this area. With the demand divided across all providers, theseinvestments could not recover costs. This resulted in significant increases in costs, andorganizations that had invested this money found it difficult to recover recurring expenses.There are many other instances in which the investment in technology such as ultrasound hasgrown considerably, leading to inappropriate use, such as sex determination at the prenatalstage. States need to evolve appropriate policies regarding investment in medical technologies.The private sector is quite prone to having an over-capacity problem in high-tech medicalequipment and technologies. One may argue that competition can solve this; however, in thehealth sector, excess capacity has many undesirable consequences: high cost, demandinducement, and unethical use of technologies. The health ministry needs to develop appropriatepolicy for the diffusion of medical technologies, keeping in mind the demand conditions and107

Public–Private Interaction in Health: Policy Issuesspatial distribution. One problem observed in India is that most of these investments aregeographically concentrated in fewer places. Appropriate policy may correct this bias.Advocacy, Education, and Consumer ProtectionAdvocacy groups, education, and consumer protection have important roles in the marketeconomy. When illiteracy rates are high, it is important for the state to provide information andeducation to vulnerable populations. Governments should also encourage the formation ofadvocacy groups to be involved in policy-making. Another area is recognizing the rights ofpatients. Many developing countries do not have sufficient legislation to empower consumers.Without acknowledging the rights of consumers and providing pressure from the consumerside, the private sector could be less effective. The health ministry can establish public–privateforums as a mechanism to exchange information between public and private sectors.Promoting ResearchLittle is known about the ways in which the private markets in the health sector function. Thehealth departments should promote initiatives that provide analysis of functioning of privatesector initiatives. The evidence generated from these studies can provide useful insights indeveloping future policies. Development of a policy framework towards private health caresector is a long, drawn-out process, and research can provide useful inputs into the process.Also, there are many interest groups involved that have considerable stakes; the policy reformsin this area will be effective only if these stakeholders are convinced about the utility of theprocesses. Research can be an effective instrument in developing policy reforms. The time isappropriate to initiate efforts in developing a research agenda and a series of research projectsto examine various issues. The focus should be primarily oriented towards developing thepolicy framework for the private health care sector.ReferencesBhat, Ramesh. 1996. “Regulation of the Private Health Sector in India.” International Journal ofHealth Planning and Management 11: 253–274.Bhat, Ramesh. 2000. “Issues in Health: Public–Private Partnerships.” Economic and PoliticalWeekly XXXV (30 December 2000): 4706–4716.Bhat, Ramesh and S Sharma. 1997. “Current Issues in the Implementation of User Fees in PublicFacilities in West Bengal.” DfID Report prepared for Strategic Planning Cell, West Bengal HealthSector Development Programme, Health and Family Welfare Department, Government of WestBengal.Bhatia, M and Anne Mills. 1997. “Contracting Out of Dietary Services by Public Hospitals inBombay.” In Private Health Providers in Developing Countries, edited by Sara Bennett, BarbaraMcPake, and Anne Mills. Zed Books.108Duggal, Ravi and Suchetha Amin. 1989. Cost of Health Care: A Household Survey in an IndianDistrict. Bombay: The Foundation for Research in Community Health.

Public–Private Interaction in Health: Policy IssuesRanson, M K and K R John. 2001. “Ensuring the Quality of Hysterectomy Care in Rural Gujarat:What Can a Community-based Health Insurance Scheme Do?” Health Policy and Planning 16(4).Rao, K Sujatha. 1997. “Financing of Primary Health Care in Andhra Pradesh.” Report prepared forthe World Health Organization.Tulasidhar, V B 1993. “Expenditure Compression and Health Sector Outlays.” Economic andPolitical Weekly (November 6, 1993).Uplekar, Mukund. 1989a. “Implications of Prescribing Patterns in Private Doctors in theTreatment of Pulmonary Tuberculosis in Bombay, India.” Research Paper No. 41. TakemiProgram in International Health, Harvard School of Public Health.Uplekar, Mukund. 1989b. “Private Doctors and Public Health: The Case of Leprosy in Bombay.”Research Paper No. 40. Takemi Program in International Health, Harvard School of Public Health.Visaria, P and A Gumber. 1994. Utilization of and Expenditure on Health Care in India: 1986-87.Gota, Gujarat: Gujarat Institute of Development Research.Vishwanathan, H, and J E Rohde. 1990. Diarrhoea in Rural India: A Nation-wide Study of Mothersand Practitioners. New Delhi: Vision Books.Whyatt, Sylvia and Ramesh Bhat. 1997. “Options for Improving the Relationship between Public,Private and Other Healthcare Providers in West Bengal.” DfID Report prepared for StrategicPlanning Cell, West Bengal Health Sector Development Programme, Health and Family WelfareDepartment, Government of West Bengal.Yesudian, C A K. 1990. Utilization Pattern of Health Services and its Implications for UrbanHealth Policy. Takemi Program in International Health, Harvard School of Public Health (draft).Yesudian, C A K. 1994. “The Nature of Private Sector Health Services in Bombay.” Health Policyand Planning 9(1).109

Cost Recovery Measures in Government Health InstitutionsSession 3Cost Recovery Measures inGovernment Health InstitutionsD K Mangal, Director, State Institute of Health and Family Welfare, JaipurGovernment health institutions provide free primary-secondary- andtertiary-level health care and family welfare services without discriminationto people in all of India's states, as a matter of policy. The central and stategovernments make budgetary provisions for this purpose. However, thebudgetary allocations for the health sector could not be enhanced to keeppace with the ever-increasing demand for health care driven by increasingpopulation, changing population characteristics, changing disease profiles,and increasing unit costs of care associated with modern technology. As aresult of this imbalance and the ever-increasing burden of staff salaries, theavailability of funds for recurring expenses in health institutions–drugs andmedicines, equipment and infrastructure maintenance, and consumables–has decreased. This trend has adversely impacted quality of care and morepeople have tended to seek care from the organized and unorganizedprivate sectors.Several health institutions in different states of the country have tried torespond to both dwindling resources for recurring expenses and the fact thatpeople spend out-of-pocket for seeking health care in the public and privatesectors. Over the last two decades, these institutions have attemptedschemes to generate supplementary resources. The states of AndhraPradesh, Karnataka, Punjab, Haryana, West Bengal, and Rajasthanimplemented such schemes in the 1980s. In the 1990s, more systematicefforts were made under the State Health System Development Project andother donor-assisted projects in the states of Andhra Pradesh, Karnataka,Maharashtra, West Bengal, Assam, Haryana, Madhya Pradesh, Orissa,Rajasthan, Uttar Pradesh, and Kerala. Each state has introduced costrecovery interventions with different structures, purposes, processes, andexperiences (Table 1).This paper presents an analysis (based on secondary data) of cost recoveryexperience as it has been implemented in government health institutions in110

Cost Recovery Measures in Government Health InstitutionsTable 1. States Where Cost Recovery is ImplementedStates Structure Services Charged Excess FundsAndhra Pradesh Quasi-Official Advisory — Funds deposited inCommittees attached togovernment treasuryhealth institutions andHospital DevelopmentSocieties in tertiary hospitalsOrissa District Societies Diagnostic services; private Retained by the healthwardsinstitutionsRajasthan Hospital-based Societies Out-patient department (OPD); Retained by the healthin-patient, registration;institutionsdiagnostic services; privatewardsMadhya Pradesh Roji Kalyan Samiti — Retained by the healthinstitutionsAssam — OPD; in-patient, curative, and Deposited in governmentdiagnostic servicestreasuryHaryana — — Deposited in governmenttreasuryKerala — Diagnostic; surgery; in-patient Retained by the healthinstitutionsMaharashtra — OPD; in-patient registration; Retained by the healthdiagnostic; surgery; meals institutionsUttar Pradesh — OPD; in-patient registration; Partially retained by the healthdiagnostic; surgery; meals institutionsdifferent states, particularly in the state of Rajasthan. The objectives of this paper includediscussing policy issues.Rajasthan ExperienceIn early 1980s, the state experimented with "pay clinics" and "auto-finance schemes," whichwere designed to recover part of health care costs at public health facilities. In pay clinics,specialists offered consultation services at specified times in the hospitals. Patients were chargedconsultation fees, which were divided between the specialists and the state government. Anominal fee was charged for diagnostic tests and X-rays. The fees collected by the governmentwere deposited in the government treasury. Later, each institution was allotted additionalfunding for consumables proportionate to its earnings. However, both these schemes becamedysfunctional because of lack of interest on the part of participating institutions and healthdepartment managers. It is interesting to note that the general public by and large appreciatedthese schemes and offered no opposition.In 1995/96, the Medical & Health Department created Medicare Relief Societies (MRSs) for eachhospital with 100 or more beds. These societies were registered under Section 20 of the SocietiesRegistration Act of 1958 with the following objectives.1. To complement and supplement existing health facilities through additional revenuegeneration and2. To retain and use resources generated in hospitals through decentralized decision making.111

Cost Recovery Measures in Government Health InstitutionsThe MRSs achieve these objectives through the introduction of cost recovery and resourceconservation. The MRSs in Rajasthan were created in 1995 by a Medical & Health Departmentadministrative order. They were permitted to introduce cost-recovery measures and to retainthe revenue generated for improving quality of care. Financial and administrative autonomywas ensured by authorizing the management committee, which was composed of nine to 11official and non-official members, to make decisions without referring matters to the stategovernment. The societies were also authorized to receive donations and loans. The first of theMRS was registered on 28 October 1995 in SMS Medical College Hospital, which is the largesthospital in the state. Now, about 220 societies are functional in the state. The state governmenthas provided seed money worth 39.95 million rupees to facilitate establishment of the societies;transferred control of diagnostic machines; and permitted the societies to fix user charges fordiagnostic tests and services within a broad framework of guidelines, levy charges on otherhospital services and private wards, and receive donations and matching grants.All MRSs in Rajasthan have introduced user charges on diagnostic tests and some haveinitiated levying user charges on therapeutic procedures and surgeries (Table 2). The usercharges for various diagnostic tests are about 40%–50% of the prevalent market rates.Table 2. Charges for Different Services in SMS Hospital, JaipurService SMS Hospital (Rs) Market Price (Rs)OPD registration 2 —In patient registration 10 —X-ray 50 100–150Dental X-ray 20 60–100Blood sugar 15 60Thyroid functions 300 800CT scan 700–1200 2000–2500Angiography 1000 6000–10,000Computerized TomographyTechnology (CTMT) 350 600–800Lipid profile 180 750–1000Source: Medical Relief Society SMS Medical College Hospital, JaipurAbout two-thirds of MRSs have openeddrug outlets named "life line fluid stores"(LLFS) to provide high quality essentialdrugs and surgical items at reasonablecosts – one-third to one-half of the marketcost – thus providing great monetary reliefand convenience to patients. Othermethods of generating funds includecharging for private wards, receivingdonations, using seed money provided bythe state government, contracting out overcycle stand, and so forth. Most of the MRSsin the state have been exceedinglysuccessful in generating additionalresources. Cost recovery ranges from 4%–25% of the hospital budget, with an average of 10%–15%, according to a study conducted in 2000.The MRS in the state has a mandate to provide free services to the poor, widows, freedomfighters, senior citizens, and the disabled and destitute. About 25% of the excess funds generatedby the societies are ear-marked to provide free medicines to patients belonging to belowpoverty line category. The SMS Hospital is providing free emergency services around the clock toall patients, irrespective of socio-economic status.112By way of an example, the SMS Hospital Jaipur, which is the largest and best equipped hospitalin Rajasthan, has generated huge surpluses ever since cost recovery measures have beenintroduced (Table 3).

Cost Recovery Measures in Government Health InstitutionsTable 3. MRS Jaipur: Income and Expenditure During 1995–2001 (in lakh of rupees)Year Income Expenditure SurplusSociety LLFS Total Society LLFS Total1995/96 24.49 — 24.49 — — — 24.491996/97 175.79 6.53 182.32 13.42 1.45 14.87 167.451997/98 328.13 25.43 353.56 186.43 3.09 189.52 164.041998/99 322.89 25.40 348.29 306.71 9.45 316.16 32.131999/00 382.74 17.56 400.30 171.25 7.39 178.64 221.66Grand Total 1,234.04 74.92 1,308.96 677.81 21.38 699.19 609.77The breakdown of sources of the additional funds generated by the MRS Jaipur is given in Table4. It is evident that the major source of revenue is user charges levied on diagnostic tests.Studies conducted in 1997 and 2000 on MRS in Rajasthan report that introduction of costrecovery has not adversely affected the utilization of health care.Additional funds generated are used by the hospitals for purchasing new equipment, repairingand maintaining infrastructure and equipment, contracting out support services such as cleaning,and purchasing consumables. All societies are mandated to use 70% of surplus funds forimproving patient care within the same financial year the funds were generated. The societiesdecide how to use the surplus funds based on the needs and priorities of the institutions.Discussion and Policy RecommendationsThe introduction of user charges in government health institutions in Rajasthan is one of thebetter performing interventions compared with other, similar contemporary experiences inIndia. The factors that differentiate it from these other experiences are as follows.l An autonomous society was created for each health institution.l General guidelines for its functioning were issued.l Societies were empowered with financial and administrative autonomy.l Societies were permitted to retain all the additional funds raised and use them for bettermentof services without referring to the state government.Table 4. Source of Income (in lakh of rupees)Source of Revenue EarnedYear1995/96 1996/97 1997/98 1998/99 1999/00 TotalDiagnostic charges 10.85 92.95 137.65 152.77 267.67 661.89Auditorium — — 1.01 0.79 0.67 2.47Cycle stand — — 5.26 12.20 9.95 27.41Rent of wards and — — 26.71 24.44 17.19 69.34post office — 0.01 0.03 0.04Unclaimed money — 0.84 0.12 0.30 0.02 1.28Interest on FDR/TDR — 13.08 17.85 30.60 29.44 90.97Total 10.85 106.87 188.87 221.11 324.97 852.40113

Cost Recovery Measures in Government Health InstitutionslBroad-based executive committees consisted of official and non-official members, withadequate representation of public representatives.Thus, it is evident that a well-designed and well-implemented cost recovery intervention for thepurpose of generating additional funds in government hospitals has great potential forimproving the quality of health care.On the basis of the discussion above, the following issues must be considered carefully beforedesigning and introducing cost recovery measures.l The objectives of the intervention must be clearly defined and stated. It is a means, not anend, for improving quality of care by generating additional resources in resource-starvedgovernment health institutions. Decentralized participatory decision making by the localhealth managers must be permitted and promoted.l The introduction of cost recovery measures can only generate surplus funds when the costof administration of the intervention is less than the funds generated.l The institutions are authorized to retain the entire funds generated and permitted to usethem based on specific local needs without referring to the state government. If this is notdone or done partially, local hospital staff may not be motivated to generate more funds.l The state government should not reduce the present level of funds to health institutions.Otherwise, it will defeat the very purpose of providing additional funds for recurringexpenditures and maintenance of equipment and infrastructure.l Well-articulated guidelines with simplified procedures for using the funds must be issued.The guiding principles must state exemptions categorically to safeguard the interests of thepoor and disadvantaged.l The management of hospital societies must have adequate representation of publicrepresentatives.l Hospital administrators should be oriented and trained before the intervention isintroduced.l The systems for setting user charges, accounting and auditing procedures, purchaseprocedures, exemptions mechanisms, and the decision-making process should be wellstated. Accountability, transparency in collections, and utilization of user charges forimproving the quality of care are hallmarks of any successful intervention.l The state government must provide continuous monitoring and support for improvement ofthe intervention. This may come in the form of issuing general guidelines and facilitatingfunctioning of the hospital-based societies.l Consultations with different stakeholders, such as the general public, private practitioners,and pharmacists, are of crucial importance in planning cost recovery measures. The abilityand willingness of people to pay for services should be an important consideration.114

Cost Recovery Measures in Government Health InstitutionsReferencesBapna, A S, et al. [n.d.] Medicare Relief Societies in India; An Answer to the Financing Problemfor Basic Healthcare? A Case of SMS Hospital Jaipur, August 2000. Washington, DC: The FuturesGroup International, POLICY Project.ECTA. 2001. Policy Issues Concerning User Charges in Public Health Facilities. ECTA WorkingPaper 2001/46.Indian Institute of Health Management Research (IIHMR). 1999. Health Systems DevelopmentProject Rajasthan, Project Proposal, IIHMR. Jaipur.Lubhaya, Ram. 2000. Health Financing: Cost Recovery Policies in Rajasthan. In FinancingReproductive & Child Health Care in Rajasthan. Washington, D C: POLICY Project.Mangal, D K. 2001. Medical Relief Societies: A Successful Innovation in Rajasthan. Paperpresented in a Joint Meeting organized by MOHFW, GoI, and European Commission, August2001. New Delhi.Sharma, Suneeta, et al. 2001. "Developing Financial Autonomy in Public Hospitals in India;Rajasthan's Model." Health Policy 55: 1–18.115

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra PradeshSession 3Arogya Raksha: Health InsuranceScheme for Family WelfareAcceptors in Andhra PradeshA Kameswara Rao, Director, Centre for Population and Development Studies, HyderabadIntroductionNeed for a State PolicyThe 2001 census in India counted the population of Andhra Pradesh at 75.7million, which is more than double the 1951 number of 31.1 million. In termsof population and area, the state is fifth among the states in the country.Nearly 60% of state income comes from the primary sector, which includesagriculture, animal husbandry, forestry, fishing, and mining. Nearly 80% ofthe population works in agriculture and allied agro-based industries, andapproximately 70% of the total cropped area in the state is under food grains.The state is therefore predominantly agricultural.The birth rate in Andhra Pradesh, which was approximately 31 per 1000 in1981, dropped to 26 per 1000 in 1991, before further falling to 22.5 in 1997.The death rate dropped from 11.1 per 1000 in 1981 to 8.3 in 1997, and theinfant mortality rate, which was approximately 81 per 1000 live births in 1981,dropped to 73 in 1991, before further falling to 64 in 1997.The average age at marriage for girls in Andhra Pradesh is also graduallyimproving, from 16 years in 1971 to 17.6 years in 1991. In Tamil Nadu andKerala, the mean age at marriage for girls is 20.3 and 21.8 years, respectively.The sex ratio (females per 1000 males) is gradually decreasing from 986 in1951 to 972 in 1991 and 978 in 2001, according to the census. As aconsequence of the implementation of the Family Welfare Programme, morethan 52% of couples in the state by the end of March 2001 were protectedagainst pregnancy, although wide variations exist between districts in terms ofcouples practising fertility control methods.Female literacy is low in Andhra Pradesh (33.7% in 1991 and 51.2% in 2001).Nearly 78% of girls drop out of school by the time they reach the 8 th standard,obviously leading to a young age at marriage for girls. In turn, literacy levelsin Tamil Nadu are 56% and in Kerala 87% among girls. In addition, child116

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra Pradeshlabour is high in Andhra Pradesh, ranging from 14%–19% for children aged 5-14 years. Eventhough mortality rates are falling, infant and child mortality is still high, which may reinforce thedecision by couples to have larger families.The dependency ratio (measured as the ratio of population below age 15 and above age 49) isapproximately 75%, which is very high. Socio-cultural factors of Andhra Pradesh reveal thatcouples have a tendency to begin their reproductive activity at an early age and complete theirdesired family size also at an early age. The mean age of acceptance of sterilization is 27.4years in Andhra Pradesh, compared to 30 years for India overall. According to the 1992National Family Health Survey (NFHS) in Andhra Pradesh, the total fertility rate (TFR) ofchildren born per woman is slightly higher (2.6) than the desired TFR (2.1). The survey alsoreported that the percentage of unmet demand for spacing methods is 5.5. Adolescentfertility, lower birth intervals, and the use of terminal methods at younger ages indicate thatsupply constraints, not the demand for family planning services, contribute to the currentlevel of fertility in Andhra Pradesh.The demographics indicate an adverse sex ratio, high dependency ratio, low female literacy, lowage at marriage for females, low level of acceptance of temporary family planning methods, andhigher incidence of adolescent fertility. These are all problems to be tackled at the state level inorder to contain the population growth rate.In Andhra Pradesh, population stabilization policy is formulated basically to reducepopulation growth by improving reproductive and child health (RCH) services. AndhraPradesh was the first state in India to formulate a comprehensive policy to cover health, familywelfare, women and child development, and nutrition. However, the Department of FamilyWelfare (DoFW) cannot alone assume all the responsibility of reducing population growth orbirth rates. The issues concerned are greatly associated with many other socio-economicfactors, such as female age at marriage, female literacy, child labour practices, and so forth. Atmost, the DoFW can help diminish fertility to a desired family size; however, what is needed isa change in desired family size itself to two children per family at the community level. Thus,an integrated approach among various departments is essential, which is envisaged under theState Population Policy (SPP).Objectives of the PolicyA significant increase in female age at marriage, coupled with simple, effective, accessible, andaffordable basic health and family welfare services, as well as a substantial reduction in childand maternal mortality, are essential. Improvement in the perception by couples of theenhanced chances of survival of their children is also necessary to improve the quality of servicetowards realizing state demographic goals.The ultimate objective of the state policy on population and reproductive health is that peoplemust accept the programmes and policies as in their best interest. Institutional support, such asservices and equipment, must consciously and constantly uphold this belief. Synergistic effortsshould be made through strong political commitment, favourable social consciousness, and117

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra PradeshTable 1. Goals for the Health and Family WelfareProgramme in Andhra Pradesh under the SPPgroup effort in better programme performance. Onlyunder such terms can the desired changes inNo Indicator Original Level Goalpopulation size and structure be achieved.1985 1995 20001.2.3.4.5.Crude Birth RateTotal Fertility RateCrude Death RateInfant Mortality RateMaternal Mortality Rate30.63.710.383424.22.68.4653.81927.5452Andhra Pradesh is the first state in India to create apopulation policy of its own. The Chief Minister, in hisforeword to the SPP, stated, “There is a growing bodyof evidence to show that reduction in fertility rates isinextricably linked with the issues of gender equality.Enhancing the position and status of women througheducation, economic independence, and improvedhealth are essential requirements for sustained reduction of the population growth rate”.118The SPP statement clearly states the objectives, strategies, and structures developed at the stateand district levels, as well as the specific operational strategies needed for implementation.Major Objectives of the State Population PolicyThe Family Welfare Programme cuts across various departments, demanding policyinterventions and strategies to bring about changes in the social, cultural, economic, andpolitical environment. Objectives of the DoFW and other related departments that play majorroles in the implementation of the SPP, are as follows.1. Increasing the couple protection rate throughl promotion of the use of spacing methods;l promotion of the use of terminal methods, concentrating on couples with parity two;l increase in the use of male contraceptive methods; andl increase in the accessibility to reproductive health services.2. Reducing the maternal mortality rate throughl increase in coverage of pregnant women with tetanus toxoid (TT), iron and folic acid(IFA) tablets, and other antenatal care (ANC) from the current level of 86% to 100%;l increase in institutional deliveries and deliveries by trained birth attendants from thecurrent level of 28% to 100%;l improvement in the referral system for emergency obstetric care;l increase in accessibility to quality of services like medical termination of pregnancy(MTP) and reproductive tract infections (RTIs); andl screening of mothers for breast and cervical cancer and infertility.3. Reducing infant and child mortality rates throughl eradication of polio cases and deaths by 1998;l reduction of neonatal cases and deaths by 1998;l elimination of death by measles by 1998;l sustained universal coverage of immunization for children;l reduction in the incidence of diarrhoeal deaths by 75% by 2000;l reduction in the incidence of deaths by acute respiratory infection by 75% by 2000; andl reduction in the incidence of low birth-weight babies from the present level of 57% to25% by 2000.

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra PradeshObjectives Related to other Departments1. Increasing the present level of female literacy from 33% to more than 50%2. Increasing the median age at marriage of girls from the current 15.1 years3. Reducing severe and moderate malnutrition among women and children4. Reducing child labour among children less than 14 years5. Developing social, economic, and political empowerment of women.Several strategies were adopted to achieve the desired goals as per the population stabilizationpolicy document. Most important among them are the following.l Wider involvement of people in micro-planning and implementationl Higher priority for quality of care and wider coverage of health services for safe maternityand assured child survivall Informed choice as the axiom of the Family Welfare Programmel Adoption of the latest, acceptor-friendly techniques in the Family Welfare Programme.These strategies are to be exercised by creating district-level population stabilization societies,mandal, and village-level committees. They are responsible for planning and implementationof various interventions for achieving the desired goals of reproductive and child health, and asmall family norm based on the local needs and conditions.Specific Interventions Initiated under the State Population Policyl Nearly 10 to 15 district primary health centres (PHCs) to be converted into women’s healthcentres to provide round-the-clock RCH servicesl Skills training for medical officers in double-puncture laparoscopy and no-scalpelvasectomy; all government doctors to be covered under this programmel Health insurance coverage for acceptors and children of those who have undergonesterilization with one or two childrenl Institution of awards for service providers on World Population Day (July 11)l Constitution of state and district councils for population stabilizationl Increase in the amount of compensation toward the loss of wages for sterilization from Rs200 to Rs 500 per case due to the increase in cost of drugs, materials, and so forthl Regular monthly meetings by the Secretary of Health and Family Welfare to monitor theprogress of activities and actions to be takenl Development of District Action Plans (DAPs), according to the community needs assessmentapproach, for all districts consistent with SPP goals and past performance.Health Insurance Package for Family Welfare AcceptorsFemale literacy is low in Andhra Pradesh. Nearly 78% of girls drop out of school by the time theyreach the 8 th standard, obviously leading to young age at marriage and a higher incidence ofadolescent fertility, coupled with low birth intervals. In turn, this leads to higher infant mortality,which will reinforce a couple’s desire to have a larger family. Even though mortality in general,and infant mortality in particular, is dropping in Andhra Pradesh, infant mortality levels haveremained stable at a level of 65 per 1000 live births. This may be due to the inability of the publicsector health care delivery system to change the perception by couples on improving the survival119

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra Pradeshchances of their children. The government has the responsibility to create confidence that qualitytreatment is immediately available and accessible for a spouse or children in case of emergency.To create the needed confidence regarding “health security” among very poor families, a familywelfare-linked health insurance plan has been formulated under the SPP. This plan provideshealth and hospitalization insurance coverage to a spouse undergoing sterilization and to his orher two children for five years from the date of sterilization. More than 1400 hospitals underboth public and private sector health institutions have been identified that insured families canget treatment nearer to their homes or at the health institution of their choice. This scheme,named “Arogya Raksha,” covers all expenses from hospitalization only, subject to financial limits.Eligibility1. Only couples below the poverty line (i.e., white ration card holders, who are eligible to takethese but do not possess the same) are eligible.2. Only couples with two or fewer living children are eligible.Insurance Coverage: Hospitalization Cases1. Insurance coverage is available for five years for illnesses requiring hospitalization.2. The maximum amount of hospitalization coverage is Rs 4000 per year for all three familymembers (spouse and two children).3. The maximum amount of coverage per hospitalization is Rs 2000; if the bill exceeds this, theexcess amount must be paid by the family.4. There is no maximum limit for the number of times a policy-holder may be hospitalized (i.e.,subject to total expenditure ceiling of Rs 4000 per annum).Personal Accident Insurance Coverage1. Personal accident insurance coverage is available only to the spouse who undergoessterilization surgery.2. The amount payable is Rs 10,000 in case of death due to accident or any serious illness.3. Hospitalization insurance will also be available for treatment in the event of any one or moreof the above occurring.Policy and Premium Payment: Issue of Insurance Certificate1. A single policy will be obtained by the state government, DoFW, once a year to pay thenecessary premium.2. Individual acceptors who undergo sterilization and are eligible under the scheme will beissued a “Certificate of Family Welfare Health Insurance”.3. Certificates will be printed and provided by the insurance company, which will becountersigned and issued by the operating surgeon / medical officer of the hospital or PHC,where the sterilization procedure was conducted.Procedure for Issue of Insurance Certificate1. The insurance company will print and supply numbered, security-printed, insurancecertificates with their facsimile signature to the Commissioner of Family Welfare.120

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra Pradesh2. Individual districts will be supplied a requisite number of certificates. The District Medicaland Health Officers (DM&HOs) will maintain a register for monitoring the furtherdistribution of these of certificates. They will distribute certificates to all Family WelfareProgramme service centres and population policy units and will enter the serial number inthe distribution register. For continuous monitoring, a single register, with separate sections(two or three pages for each service centre), will be maintained.3. At the service centres, certificates will be issued and maintained and in a register, the detailsand number of the certificate would be entered. The certificates will be held in the safecustody of medical officers.4. Auxiliary nurse midwives (ANMs) will be responsible in preparing for the issue of certificates.At the time of the sterilization procedure, they will inform the couples about the healthinsurance scheme and make enquiries about whether they hold rice cards (below thepoverty line), or whether they have only two or fewer surviving children. If the couple iseligible under the health insurance scheme, the ANM will inform them, ensuring that theybring their white ration card (or if they are eligible but do not have a card, an incomecertificate from their mandal revenue officer), and the ANM will issue a certificate regardingthe number of children that the couple has (i.e., two or less).5. After the sterilization surgery is completed, couples eligible under the health insurancescheme would, on producing the two documents above, be issued a health insurancecertificate, but only after entering their particulars in the register. These particulars includetheir names, wife/husband and father/mother names, residential address, and identificationmarks (moles). Thumb impressions of the spouse undergoing sterilization and two childrenincluded on the insurance certificates would be in the register and on the certificate asadditional identity marks, as well as evidence of the issue of the certificate.6. The certificate would then be put in a polythene cover, sealed, and given to the couple, withan explanation of the benefits under the scheme and procedures for obtaining them. Thelist of hospitals in which these benefits can be availed will also be provided.7. The medical officer of each service centre or population policy unit will send a monthly reportto (1) the concerned insurance company branch, (2) the DM&HO, and (3) the Commissioner ofFamily Welfare regarding the number of certificates issued that month. This important reportindicates how the premium payment to the insurance company is adjusted.Availing the Benefits under the Scheme by Certificate HoldersIn the event that any other individual covered with an insurance certificate becomes sick or isinjured and feels that it is serious, he or she should go to any one of the hospitals enrolled inthat scheme, in that district or another district, taking the certificate and white ration card.Admission as In-patient1. After verifying the identity of the person to be admitted, the medical officer at the hospitalwould undertake a preliminary examination of the person to determine whether the personshould be admitted.2. Health insurance scheme beneficiaries can, upon each hospitalization, avail services,including bed charges, diagnostic charges, drugs, surgery charges, and any other medical orhealth items, up to Rs 2000 per hospitalization, and up to a total of Rs 4000 per year for two or121

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra Pradeshthree beneficiaries included on the certificate. There is no limit to the number of times aperson may be hospitalized; however, there is a maximum ceiling of Rs 2000 per event and Rs4000 per year.3. On completion of treatment, the beneficiary can sign and affix his thumb imprint to thereceipt and be discharged if the bill is less than Rs 2000. The hospital will send the bill to theinsurance company to obtain reimbursement. However, if the bill is more than Rs 2000, thebeneficiary would have to pay the amount over Rs 2000. Hospital authorities should clearlyexplain the above policy to the beneficiary at the time of admission.Period of Validity to Avail Benefits under the SchemeThe beneficiary can obtain hospitalization benefits for five years from the date of the issue ofthe certificate, per a maximum of Rs 4000 per year.Hospitals where the Benefits can be ObtainedHospital services under the scheme can be availed in any private hospital that is registeredunder the scheme with the insurance company in the district where the insurance certificate isgiven or any other district in the state. The list will be provided to every certificate holder,together with the certificate.Wrong use of the Insurance CertificateAny certificate holder who seeks to avail services available under the scheme to benefit anotherperson not mentioned on the certificate shall lose his or her certificate, which will be cancelledby the DM&HO.Reimbursement of Bills to the HospitalsInsurance company authorities have assured hospitals that the bills they submit will be paidwithin two weeks. If there is a delay, the DM&HO shall coordinate to ensure that bills arecleared promptly. Any severe delay may be informed to the Commissioner of Family Welfare foraction at the state level.Impact of “Arogya Raksha”Health insurance coverage for the acceptors of terminal methods and their children came about in1999–2000. The Government of Andhra Pradesh has made payments of Rs 150 lakh to theinsurance company towards a lump-sum, single payment to cover two lakh family welfareterminal method acceptors who are below poverty line and have two or less children. Guidelinesfor implementation of the scheme were issued in August 1999 for all family welfare service centres.Certificates for eligible beneficiaries are distributed to all the institutions in the state.122Field studies made in this regard revealed that, although the scheme was operational from 31March 1999, the insurance company did not fully finalize a list of institutions covered by thescheme until the end of December 1999. When contacted, some of the nursing homes wereinformed that they required clarifications regarding services to be provided by them to policyholders.Procedures and other formalities to be fulfilled by the insurance company in enlistingprivate nursing homes under the scheme have not yet percolated down, creating much

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra Pradeshconfusion, ambiguity, and indifference among practitioners and policy-holders. The policyholderswere provided with a list of private institutions they could contact for healthemergencies; however, some private institutions refuse to provide them with services, since theyare not clear as to whether they should spend money for drugs/medicines and make claims laterfrom the company.The benefits and impact of this scheme are to be evaluated by an independent, nongovernmentalorganization. At present, it is recommended that the list of institutions providinghealth services to policy-holders be increased to make them accessible and to enrol only thosewith in-patient and treatment facilities. Regular monitoring of this scheme is desirable if theDM&HOs are to be responsible for collecting and collating data, rather than making theCommissioner of Family Welfare monitor the progress of issuing the certificates by all theservice centres providing certificates.Strengths of the Schemel The scheme creates confidence and strong motivation among couples with two children toaccept terminal methods of family planning.l The scheme ensures coverage of children for five years from the date of acceptance of themethod and the policy.l The scheme will not cause any drain of family income in order to meet hospitalizationexpenses.l The scheme facilitates beneficiaries to select the hospital of their choice among the list ofinstitutions provided.l The scheme increases the accessibility of health services in case of emergencies.l The scheme covers accident risks, such as death and serious injury, for the beneficiary andchildren during the policy period.Limitations of the Schemel Distribution of hospitals in any district is not uniform.l Only those who are sterilized in government hospitals are eligible.l Distribution of policies is not uniform across the districts.l Centralized procedures for the reimbursements of claims create problems for hospitals.l Only 80% of the certificates issued during 1999–2000 are distributed among beneficiaries.l District health administrators and district officers of the insurance company have nosupervisory role.l The beneficiaries of the health policy have no right to demand services from the hospital oftheir choice.l The insurance covers hospitalization expenses only; many morbid conditions of the acceptorand children normally can be treated on an out-patient basis, and hence there is no financialbenefit to policy-holders for sicknesses that do not need hospitalization.l Insurance coverage is limited to Rs 2000 for each sickness, and a policy-holder can use itonly twice a year with a maximum benefit of Rs 4000 per year. Any sickness or morbiditycondition that involves more than the above amount must be paid by the policy-holder.l The policy covers the acceptor and two children, but does not provide family coverage.123

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra PradeshlThe scheme should have been implemented in selected districts as a pilot project beforeextending it across the state.AcknowledgementsThe author is very grateful to Ms Nilam Sawhaney, Commissioner, Family Welfare, AndhraPradesh, and Dr Rangappa, Joint Director in charge of the SPP, for their cooperation and datasupport provided for this study.Table 2. Statement Showing the Distribution of Health Policies and Tie-Up Hospitals byDistricts since Inception in Andhra PradeshNo District Policies Distributed to Policies Issued to Tie up Hospitals Claims byDistricts Acceptors in Private Sector Hospitals Settled1 Srikakulam 16,000 7,000 16 32 Vis’patnam 22,000 9,000 30 323 Vizia’ram 17,000 7,000 26 14 E. Godavari 24,000 10,147 35 15 W. Godavari 24,000 10,956 22 36 Krishna 23,000 9,589 32 17 Guntur 22,000 10,931 30 308 Prakasam 16,000 7,042 15 129 Nellore 16,000 6,223 25 24410 Cudappah 16,000 2,734 20 -11 Kurnool 18,000 7,338 16 1212 Anantpur 21,000 9,421 43 62113 Chitoor 18,000 7,597 18 814 Khammam 14,000 5,193 20 215 Kar’nagar 18,500 7,748 28 3716 Adilabad 14,000 4,748 12 -17 Warangal 17,000 7,625 16 1418 Mab’nagar 15,000 3,824 20 13719 Medak 17,000 6,759 10 19220 Nalgonda 14,500 5,011 20 5721 Niz’bad 15,000 6,070 19 10922 Rangareddy 18,000 7,229 23 10923 Hyderabad 4,000 1,152 20 -Andhra Pradesh 400,000 160,337 516 1,571Note: Among four lakh policy certificates, two lakh were distributed during 1999–2000. In 2000–2001, no policies were issued. Againduring January 2002, another two lakh were distributed. Thus, effectively, the beneficiaries are for the year 1999–2000.124

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra PradeshAppendixAROGYA RAKSHAHEALTH INSURANCE SCHEME FOR THE POORImplementation Guidelines to Family Welfare Service Centre andPrimary Health Centre Medical OfficersI. Objectives of the SchemeThe Health Insurance Scheme aims at strengthening the confidence of poor and illiterate intheir ability to get health care for their children. It also seeks to remove any fears in their mindsabout any risk to survival of their children.II. Scheme Components1. The scheme gives health insurance coverage to such acceptors of sterilization surgery whoare below the poverty line and have only one or two children. The health insurance is for(1) the person who undergoes the sterilization and (2) his/her one or two children only.2. Health insurance coverage extends to “hospitalization or in-patient care services” only,together with all attendant costs such as drugs, diagnostic services, etc. The beneficiary canavail these services in any of the “enlisted” private hospitals in the state. (About 800hospitals were enlisted until April 1999 by the insurance company). A copy of the list ofprivate hospitals enlisted under the scheme in each district will be enclosed with everycertificate issued in that district.3. The value of the health insurance coverage is Rs 2000 (maximum) per each hospitalization;Rs 4000 maximum per year; and for five years from the date of sterilization surgery (i.e., atotal value of Rs 20000 in five years).4. The scheme also has accident insurance benefits to cover death, grievous injuries andincapacitation by accident, of the person sterilized and his/her one or two children.5. The scheme is being implemented through the New India Assurance Company Ltd. in theentire state.III. Eligibility ConditionsThe following are the eligibility conditions under the scheme.1. Only those who have undergone sterilization surgery (i.e., vasectomy, tubectomy, DPL, orNSV) with only one or two children are eligible.2. The acceptor should be below the poverty line (i.e., having an annual income of below Rs 11,000).Proof of being below poverty linea) White ration card (eligible for rice scheme) with a photograph of the acceptor; or with thename of the acceptor; and the fact that the acceptor is the same person whose name is in theration card should be confirmed by the ANM or any other person from the village.b) An income certificate from the Mandal Revenue Officer (MRO) that the person’s income isless than Rs 11000 per annum.3. The acceptor should have adopted sterilization method with one or two living children only.125

Arogya Raksha: Health Insurance Scheme for Family Welfare Acceptors in Andhra PradeshProofa) Certificate of the concerned ANM that the acceptor has only one or two childrenb) Where the ANM’s post is vacant, etc., a certificate from the VAO or the Sarpanch of thatvillage regarding the number of children that person has, is acceptable.4. Persons who have undergone the sterilization surgery in government health institutionsalone will be eligible for the scheme. Persons who undergo the sterilization surgery atprivate hospitals, irrespective of their being below the poverty line or having only twochildren, etc., are not eligible.IV. Procedure for Issue of the “Arogya Raksha” Health InsuranceCertificate1. When is the certificate issued? The Arogya Raksha Health Insurance Certificates shouldpreferably be issued to the eligible beneficiaries ON THE DAY OF THE STERILIZATIONSURGERY ITSELF, together with the compensation amount.2. Preliminary Action All ANMs in the districts should be made fully conversant with theeligibility norms under the scheme. They should, at the time of motivating the acceptors(for sterilization) at his/her village itself, make necessary enquiries regarding their eligibilityfor coverage under the Arogya Raksha Scheme. If they are eligible, the ANMs should see thatthe acceptors bring their white ration cards to the PHC/Family Welfare Service Centre. If theyare below the poverty line (income below Rs 11,000), but don’t have a ration card, theyshould bring an income certificate from the MRO. The ANM herself should prepare acertificate regarding the number of children of the acceptor and be ready with it.3. Acceptors who come on their own, if they have not brought the white ration card/MRO’scertificate, and the certificate of the number of children, should be asked to bring them asearly as possible after the sterilization and take the Arogya Raksha Certificate. As analternative, the ANM may later enquire in the village and bring the white ration card and thecertificate regarding the number of children, to the PHC at a later date; and obtain anddeliver the Arogya Raksha Certificate at the village to the beneficiary.4. Regarding proof of number of children In the absence of ANM’s certificate (due to the post ofANM being vacant), VAO’s certificate or the Gram Sarpanch’s Certificate is acceptable.[Note: (i) Acceptors with MORE THAN TWO CHILDREN ARE NOT ELIGIBLE;(ii) Acceptors with TWINS IN THE SECOND DELIVERY ARE ALSO NOT ELIGIBLE.(iii) Acceptors with only one or two living children, irrespective of number ofchildren born, are eligible]5. Regarding Proof of Income (below the poverty line) Any certificate issued by the MRO for thepurpose of increased compensation (Rs 500) is also sufficient for this purpose.Preparing and Issuing of Arogya Raksha CertificatesEvery six months, Family Welfare Service Centres will be issued a requirement of printed andnumbered Arogya Raksha Certificates. The certificates will have provision for filling in detailsof the beneficiary (i.e., name, address, identification marks, etc.).126

Health Financing in India: Some IssuesSession 4Health Economics: Issues of EquityChairpersonIndu Kumar PandeyHealth Financing in India: Some IssuesB B L SharmaHousehold Health Care CostsBarun KanjilalAccess to Health Services in UttaranchalAlok Kumar JainDiscussantGadde Narayana127

Session 1Session 4Health Financing in India: Some IssuesHealth Financing in India:Some IssuesB B L Sharma, Professor, National Institute of Health and Family Welfare, New DelhiIntroductionA broad attempt has been made here to present and analyse both theNational Health Policy (NHP) of 1983 and the new draft NHP of 2001 to seewhether the new draft policy could face up to the health challenges of the21 st century. Also, the primary question of how the health challenges will befinanced is addressed. This paper focuses on the issues and problemsemanating from understanding health situations that have emerged over theyears, now known as the “double burden of disease”. Perhaps because of thelack of a systematic, bold “economic will” for a clear policy on healthfinancing, India could not meet the “health for all” (HFA) goals for 2000, aspredicted in NHP 1983. NHP 1983 seems to have limited relevance intoday’s world. The new draft NHP 2001 states, “...there have been verymarked challenges in the determinant factors to the health sector and theoutcomes have not been as expected.” Although NHP 2001 mentions this, itdoes not address the critical financing issues on major non-health aspects ofhealth determinants, such as drinking water, basic sanitation, adequatenutrition, clean environment, primary education (especially of the girlchild), and lifestyle-induced health problems.Need and ImportanceIn simple terms, health financing is raising resources (in broad and widereconomic perspectives to pay for health goods, services, and facilities).These resources may be in cash and “in kind”—such as physical labour,technical skills, materials, and so forth. Health finance could meet the dailyoperational requirements as well as the requirements of long-term healthcare sector investments. Now, it has been well-acknowledged by policymakers,planners, and administrators at all levels that financing by itselfmay affect health care prioritization and its production, provision, andutilization of health services. Long-term health financing has a significanteffect on improving overall health status. However, to fulfill the objectives ofhealth security by inducing accessibility, equity, and affordability of services129

Health Financing in India: Some Issuesto the community, health care financing can play a major role of financial support toadministrators at all levels, particularly for districts and lower levels and below for governanceand delivery of services.130Financing of health care, not only in terms of a single framework of “scarcity of resources,” but interms of a broader mandate of “sustainability of financial resources” and “resources efficiency”considerations, is both vital and crucial. However, there is still a need for greater understandingof this area in order to improve financial information for health planning, health administration,and policy making. In the Indian context, district-level health planning and administrationrequire resource transfers at various levels. This is especially true under the process ofdecentralization, which further necessitates the comprehensive and systematic study of healthcare financing. Both health care providers and consumers of health services need to understandissues of health care financing in order to answer the following questions.l How can a balance be created to minimize the divergence of equity, efficiency, and quality?l What should health care financing consist of?l Should health financing be concerned with health care services or health-related sectors?l How much have states been spending for health care and what should be the share of theprivate sector?l How much do central, state, district, and municipal/local government/Panchayati RajInstitutions (PRIs) spend on the promotion of health care?l From what other alternative options and sources could the money for health programmescome?l What type of health programmes and services for health and health facilities could befinanced from different financing options on a priority basis?l Why and how much should consumer health care beneficiaries pay for financing health care?l What can be done to ensure that resources used for financing health care are used moreefficiently?l How far, and in which direction, can health care financing by the government meet theobjective of equity and safeguard the interests of those who are vulnerable?Sources of Health Care FinancingAt the health policy and planning levels currently, there are serious considerations aboutmultiple sources of financing and management of health care services. As proof, in India aseparate working group has been constituted during the eighth Five-Year Plan in the area ofhealth care financing to debate the topic of multiple sources of financing of health care andsuggest viable options, such as user charges and community health insurance, along with asafety net mechanism for poor people.Problems of Health Care Financing in IndiaAlmost all the states in India, particularly in the present financial crisis (including their debtburden) and at macro- and decentralized-levels (i.e., district, block, and village), have specifictechno-economic problems of health financing. These common problems (below) must beaddressed for a common solution.l Lack of funds

Health Financing in India: Some IssueslllllDistribution of resourcesRising health costsInefficiency, waste, and duplication in spendingFlexibility for innovations and experimentsLack of inter-, intra-regional, state, block, and village-level coordinationPolicy on Health Care FinancingThe problems of health care financing are not just about policy statements in general, whether inNHP 1983 or NHP 2001; limitations seem to be related to the policy’s translation into planningefforts and development of planning structures. Of course, these are controlled by otherconsiderations, including rooted power structures and forces of the political economy.One vital aspect of NHP 1983, which was neglected in subsequent plan proposals, was that ittouched directly on issues of financing of health services. NHP 1983 was quite progressive inadvocating private investments in special and super-special health services, in suggestingstatewide health insurance schemes, and in extending Employee State Insurance (ESI), meantfor the organized formal sector, to the unorganized informal sector, especially for agriculturallabourers. Plan proposals have been committed to developing special and super-special healthservices in the public sector; however, they have not come so far as to finance any healthinsurance schemes for the poor in the unorganized economic sectors.Resource Allocations and National Health Policy 1983The pattern of resource allocation in different plans beyond NHP-1983 clearly shows thatpriority did not remain strictly with primary health care. It was secondary and tertiary healthcare (i.e., medical education and other areas away from grass-roots health requirements). Abouthalf of the resources were allocated for medical education, health programmes, and bio-medicaland hospital-oriented curative research areas. About one-third of the resources has been goingto the rural health programme, which has been an NHP 1983 priority. Various state governmentsallocated larger sums to develop bigger hospitals; however, hospitals under social securityschemes, such as ESI, suffered, although NHP 1983 extended their expansion. Further planningproposals have been added to finance major health programmes at tertiary levels, which werenot the financial priority of NHP 1983. Resource allocation planning priorities did not reflect thepriorities indicated by NHP 1983.Policy prescriptions, valid at the time of Independence, that public sector health services besolely responsible at all levels (primary, secondary, and tertiary) for health care of all the citizens,are becoming financially unsustainable. This situation is due to a lack of resources and rampantwaste and inefficiencies; large population size and population growth; the burden of olddiseases and an increase in new diseases; changing demographics; and a host of other factors.Government financing for the health system is hardly able to cope with the health securityrequirements of the people. In addition, it is affecting more vulnerable sectors, such as women,old people, and poor labourers, and marginal farmers from unorganized sectors. A largenumber of people (including those who cannot afford to pay) are being compelled to move toprivate health care providers for health care. This is true for both rural areas and urban slums.131

Health Financing in India: Some IssuesStatistics from various rounds of the National Sample Survey Organization and the NationalCouncil of Applied Economic Research Surveys, and willingness and economic capacity to payfor user-charge studies by the National Institute of Health and Family Welfare (NIHFW), canvouchsafe these situations.Health Financing Policy and Associated Macro- and Micro-economicsOverall, health financing policy of the health sector in general or health care services inparticular has important implications for macro- and micro-health planning andmanagement. Any changes occurring either by way of direct funding through user fees orhealth insurance (private and public) or both could have an effect on fiscal policy andnational allocation of health resources. In health policy for India, financing for health doesnot seem to have been given required and clear-cut weight for its formulation with referenceto the following.l Effect of health care expenditures by different sources and mechanisms on health statusdifferentialsl On micro- and macro-level productivity effecting economic growth differentialsl Financing of preventive health care and economic growth.Draft National Health Policy 2001NHP 2001, under the caption “Current Scenario,” has a separate section on “Financial Resources”.It observes that in-country public health investments over the years have been comparativelylow; and as a percentage of gross domestic product (GDP), have declined from 1.3% in 1990 tonearly 0.9% in 1999. The Indian macro-health economics show that the aggregate expenditure inthe health sector is 5.2% of GDP. Some estimates put it at 6% of GDP. The figures and estimatescompiled from different sources and studies may vary; however, the policy document states thatthe total expenditure, about 20% of aggregate spending, is through the public sector (i.e.,government), the balance being out-of-pocket expenditures (commonly expressed as privatespending through direct user charges, user fees, or financing through private health insurancepolicies to providers of health care).The financial picture further reveals that central budgetary allocations have been more or lessstagnant, whereas in the different states, they have declined from 7% to 5.5%. The current annualper capita health expenditure in India is not more than Rs 160. Adjusting for purchasing power,the situation would be different.The draft NHP 2001, which is circulating for comments, states that, given these statistics(financial statistics), it is no surprise that the reach and quality of public health services havebeen below desirable standards.132Under the constitutional framework of India, the states are mainly responsible for public health.In this framework, the principal contributions to funding public health services are the states’financial resources, with some supplementary financial inputs from central resources to overallpublic health spending, which has been limited to about 15%. The fiscal resources of stategovernments are known to be very inelastic, reflected in the declining percentage of state

Health Financing in India: Some Issuesresources to the total health sector budget. A harder “compressor effect” has also been noticedin state health budgets in the years beyond post-economic reforms.Decentralization Linkage with CentralizationWithin the framework of decentralized health planning, the draft NHP 2001 states that ifdecentralized public health services are to improve significantly, an injection of substantialfinancial resources from the central government budget must be achieved. NHP 2001 cautionsthat it is a necessity if the state public health services–a major component of initiatives in thesocial–sector are not entirely moribund. NHP 2001 has been formulated taking intoconsideration these fundamental realities (economic and fiscal) in regard to the availability offinancial resources.Role of Private SectorWith reference to the financing of health care, a specific and clear rationale has been given that,considering the economic restructuring under way in the country and worldwide, the changingrole of the private sector in providing health care in India is through independent health carepractitioners. Also, the private sector contributes significantly to secondary-level care andtertiary health care. With the increasing role of private health care, the need for statutorylicensing and monitoring of minimum standards of diagnostic centres and medical institutionsbecomes imperative.NHP 2001 would address the issues regarding the establishment of regulatory mechanisms toensure adequate standards for diagnostic centres and medical institutions, conducting ofclinical practices, and delivery of medical services.Impact of Globalization on the Health SectorThe globalization dimension of health financing in India was not a major concern withreference to structural adjustments, balance of payments, and liberalization effects at thetime NHP 1983 became public. However, since liberalization and economic reforms, andparticularly since debates and discussions over the draft NHP 2001 before its adoption,there are apprehensions about the possible adverse impact of globalization on the healthsector. Pharmaceutical drugs and health services have always been available in thecountry at extremely inexpensive prices. However, India has established a reputationworldwide for its innovative “original process of patients”—the manufacture of a widerange of drugs and vaccines within the ambit of its existing patent laws. With the adoptionof Trade-related Aspects of Intellectual Property Rights (TRIPS) and the subsequentalignment of domestic patent laws consistent with the country’s commitment under TRIPS,there is bound to be a significant shift in the scope of parameters regulating themanufacture of new drugs and vaccines. Global experience has shown that theintroduction of TRIPS–consistent patient regime for drugs in a developing country likeIndia–would result in higher cost of drugs and medical services. This has seriousramifications for India’s drug economy, affecting the health economy as well. No doubt,NHP 2001 claims to address the future imperatives of health security in the country in thepost-TRIPS era.133

Health Financing in India: Some Issues2001 Policy PrescriptionsNot only pious statements but financial prescriptions have been indicated in the proposedpolicy as followsFinancial ResourcesIt has been realized that within the framework of implementation, the paucity of public healthinvestment is a stark reality. Given the extremely difficult fiscal position of the stategovernments, the central government plays a compulsory role in augmenting public healthinvestments in coming years.Taking into account the gaps in health care facilities under NHP 2001, it is planned toincrease health care expenditures to 6% of GDP, with 2% contributed as public healthinvestments by 2001.State governments would also need to increase their commitments to the financing of the healthsector. In the first phase, by 2005, they would be expected to increase their commitment to 7% ofthe budget, and in the second phase to increase to 8% of the health budget by 2010. With theincrease of public health investments, the central government’s contribution would rise from 15 to25% by 2010. Providing higher public health investments will also be contingent on the increase in“absorptive capacity” of the public health governance, in order to use the funds gainfully.Yearl Increase health expenditure by the government as a percentage of GDP 2010from 0.9% to 2%l Increase the share of central grants to constitute at least 25% of total 2010health spendingl Increase state-sector health spending from 5.5% to 7% of the budget 2005l Further increase to 8% of the total budget 2010l Establish an integrated system of surveillance under the National Health 2005Accounts and Health StatisticsIt is a step forward that the draft NHP 2001 at least touches on financial/resource statistics andtheir relevance, if only at aggregate levels, whereas NHP 1983 was totally non-committal in termsof its presentation. It discussed such financing mechanisms as health insurance and usercharges; however, no suggested and projected economic figures were provided for meeting HFAgoals by 2000.134Equity DimensionsTo meet the objectives of various types and imbalances under the broad conceptual and“thematic umbrella of equity” across the rural–urban divide, and also between economic sociodemographicclasses, the most cost-effective methods would be to increase the sector outlay forthe primary health sector. NHP 2001 envisages a sizable increase in allocations to 55% of thetotal public health investment in the primary health sector; secondary and tertiary health sectorswould be targeted for 35% and 10%, respectively.

Health Financing in India: Some IssuesNHP 2001 projects that increased aggregate financial outlays for the primary health sector will beutilized not only for strengthening existing facilities but also for opening additional publichealth service outlets both in rural areas and urban slums to correct imbalances.Financing for Quality of ServicesThe draft NHP 2001 states that financing the standards of health is more a function of accuratetargeting of expenditure on the decentralized primary sector than purely a function of theaggregate health expenditure. To support this move, the two sets of figures quoted below are fordeveloped and developing countries.Impact of Globalization on theHealth SectorThe proposed policy also establishes that thegovernment will bring to bear its full influencein all international economic forces to securecommitments to lighten the restrictive featuresof TRIPS in its application on the health sector.In this respect, NHP 1983 had little tocontribute.Table 1. Public Health Spending in Select CountriesCountry Population IMR % Health % Health Exp.with income Exp. in GDP in Total Exp.

Health Financing in India: Some Issuesby the India Institute of Management, Ahmedabad, reports on the National Seminar organizedby the Government of India in May 2000, and the National Seminar on Health InsuranceDevelopment by NIHFW (2000), possibly served as background for the development of policyinitiatives in health insurance for health care financing in India. Mr. Rangachari, Chairman ofthe Insurance Regulatory and Development Authority (IRDA), in his valedictory address raisedmany points at the Health Insurance Seminar at National Institute of Health and FamilyWelfare (NIHFW) in December 2000. Some of these are directly relevant to the financing ofhealth care in India, where about 4.5% of GDP is paid by Indians to private medical sectororganizations for medical care. If this 4.5% of GDP were used to finance the insurancepremium rather than to pay individual nursing homes and doctors for one-time treatment, itwould result in more extensive medical care for the population. Through such insurance,financing mechanisms may lead to support for the provision of health services resulting inhealth security as a fundamental right.User ChargesThe policy of financing health care through user charges was suggested earlier during theseventh Five-Year Plan in documents and also by the Planning Commission’s ExpertWorking Group on Health Care Financing, appointed during the eighth Five-Year Plan. Inthe past few years, as a part of health sector economic reforms, many states have introducedand are gradually instituting user charges in hospital settings. These are being administeredat institutional levels through “Rogi Kalyan Samitis” and similar structures. Even theposition paper prepared by the Prime Minister’s Advisory Council, which consisted ofindustrialists, indicated that the current system of free health care for everyone irrespectiveof their economic situation places a huge burden on government resources. It suggestedthat different segments of the population should contribute to the cost of health careaccording to their ability to pay. Free health care and government financing and expenditureshould be used for the “indigent groups” and for priority public health services, such ascommunicable disease control, immunization, and family welfare. In this context, a studyon user charges in Chamoli District in Uttaranchal, Indore in Madhya Pradesh, Jamnagar inGujarat, Ramanathapuram in Tamil Nadu, Guwahati in Assam, was conducted by NIHFW(2001). The study is based on community-based responses from about 4000 householdsinterviewed on their willingness and economic capacity to pay user charges for health careprovided in government facilities. Except for the community data from theRamanathapuram district in Tamil Nadu, the data from the four other districts–Chamoli(Uttaranchal), Indore (Madhya Pradesh), Jamnagar (Gujarat), and Guwahati (Assam)–themajority of respondents in the NIHFW survey, irrespective of their socio-demographicbackground, were willing to pay user charges for health care. The possible demographicpressures in terms of large families is likely to have resulted in such households being morewilling to contribute finances for use of the government health care services. The majoritywas also of the opinion that government should introduce user charges. At the same time,respondents expected quality, accessibility, and availability of doctors, and the health staff,to be ensured. Moreover, 96% felt that the poor should be exempted from paying usercharges in government-run health facilities.136

Health Financing in India: Some IssuesExternal FundingThe Macro-economic Commission on Health has recommended that the world’s low- andmiddle-income countries, in partnership with high-income countries, scale up the access of theworld’s poor to essential health services. The report further highlights that high-incomecountries should resolve that lack of funds should not be the factor limiting the provision ofhealth services to the world’s poorest people. But the mere addition of funds for health carefinancing may not suffice. Rather, new but basic economic features, such as economicleadership, financial accountability, community partnership, must be interwoven with adequatefinancing to solve the key health problems, which continue to exist. In the case of India,external aid from different sources provides some added financing of health care; however, it isfraught with many problems, including financial sustainability.ReferencesGovernment of India. 1983. Statement of Health Policy 1983. Ministry of Health & Family Welfare,Government of India, New Delhi.Government of India. 2001. Draft Health Policy 2001. Ministry of Health & Family Welfare,Government of India, New Delhi.National Institute of Health and Family Welfare (NIHFW). 2001. Development of Health Insurancein India: Current Status and Future Directions. NIHFW.Sachdeva, Nirupama and B B L Sharma. 2002. Presentation on Draft National Health Policy 2001.New Delhi, NIHFW (Mimeo).Sharma, B B L, T Bir, Sushma Sharma, and G P Devrani. 2001. A Study on Willingness andEconomic Capacity to Pay for Health Care Services. New Delhi, NIHFW.World Health Organization. 2002. Executive Summary of Report of the Commission for MacroEconomics and Health. Geneva: WHO General Assembly.137

Health Financing in India: Some IssuesTable 2. A Comparison between National Health Policy 1983 and draft National Health Policy 2001NHP 1983 DRAFT NHP 2001I. OmissionsWell-developed referral system + -Nutrition + -Child health + -Water supply and sanitation + -Environmental protection + -Health legislation + -Inter-sectoral coordination + -Medical industry + -Integration of other system of medicine + -II. Continuing featuresWith not much differences1. Population stabilization + -2. School Health Programme + -4. Prevention of food adulteration andmaintenance of quality of drugs + -5. Mental health + -6. Role of NGOs/VHOs + -With some changesMedical and health education Reorientation of medical - Establishment ofeducation of all categories Medical Grants Commission- Establishment of moremedical colleges- Emphasis on certainspeciality disciplines- More seats for postgraduationin publichealth and family welfare- Geriatric care to be includedin the curriculum- Skill-oriented, need-basedsyllabiHealth services Restructuring of the health - Extension of services byservices with the primary licensing of medicalhealth care approach within practice by paramedicsthe government systemand practitioners of ISMEquity + ++Health insurance All types at all levels - Only private insurancesystem, that too forsecondary and tertiarysectorsManagement information system Building up of a well- - Besides HMIS,conceived and effectivestrengthening of theHMISsystem by periodicupdating of baselineestimates138

Health Financing in India: Some IssuesSurveillance Epidemiological-cum- - National diseasesanitary stations to besurveillanceestablishednetwork to be fullyoperationalizedMedical research Basic, applied, operations - In tuberculosis, malariaresearch in tuberculosis, and HIV/AIDSblindness and leprosyInformation, Education, Communication Health education: - IPC more emphasisMedia mix - Regular monitoring andevaluationRole of Private SectorMore for curative andespecially in secondaryand tertiary care - At all levels- Potential use under nationalhealth programme- Regulatory machines- Use of telemedicinecommunication monitoringCommunity Involvement Community participation - Community accountabilityIII. Additions1) Involvement of Panchayati Raj Institutions - +2) Urban health - +3) Medical ethics - +4) Regulation of standards in paramedicaleducation - +5) Providing medical facilities to users - +6) National health accounting - +7) Financial resources - - Increased investments- Differential distributionof budget at various levelsof care8) Delivery of national health programmes - - Some programmes toremain vertical, viz HIV/AIDS, TB and malaria- Autonomous state anddistrict bodies forimplementation- Other programmes to beconverged under a singlefield administration139

Household Health Care Costs in IndiaSession 4Household Health CareCosts in IndiaBarun Kanjilal, Professor, Indian Institute of Health and Management Research, JaipurIntroductionLike many other developing countries, Indian state governments are underincreasing pressure to improve the efficiency and financial viability of healthservice delivery systems, particularly in light of renewed commitments toinvest more in reproductive health. The pressure is even more ineconomically disadvantaged states, where a major section of the populationlives under the poverty line and has very limited access to a modern healthcare system. The increasing resource crunch, coupled with the decliningefficiency and effectiveness of public investment, has put the public sectorin a position of comparative disadvantage. The disadvantage of governmenthealth care has induced a structural transformation of the health caremarket resulting in rapid growth of the private sector, especially in thecurative care market.The market transformation has raised several critical issues. What are theimplications of such transformation on consumers of health care, especiallythe poorer section of the society? Does increasing public investment in aless efficient health economy necessarily imply reduced direct economicburden on the beneficiaries? Are they paying too much for even highlysubsidized primary care services? Should we move forward to increasepublic subsidies in all sectors of the health economy? Or, should we explorethe possibility of rationalizing the subsidy system and attempt to mobilizethe resources already being spent by the consumers in a more formal andefficient way?These issues are extremely crucial for policy development. The answers,unfortunately, are not easily available. The most important barrier toresolving these issues is the lack of a database on the consumers’ utilizationand expenditure patterns. Except for very few studies (See section on PolicyIssues) the literature hardly provides any answers to some extremely140

Household Health Care Costs in Indiaimportant questions. How much are households currently spending on health care? What typesof services are being utilized? Do the health care utilization and expenditure patterns of poorhouseholds differ from those of better-off households? What percentage of household out-ofpocketfunds are spent on private providers, either traditional or modern? What proportion ofcosts is allocated to consultations, drugs and medicines, tests, and transportation?Undoubtedly, knowing the answers to these questions is critical for designing policies for thesocial sector. If, for example, households show distinct preference for private services forcurative and tertiary care, the government will probably need to concentrate its attention andresources to provide only very basic services (such as antenatal and child care) at extremelylow prices. If the beneficiaries spend a disproportionately high amount on travel to healthfacilities in rural areas to give birth, the policy should be oriented towards strengthening localreferral hospitals and enabling them to provide emergency and normal reproductive and childhealth (RCH) services. If households have the ability and willingness to pay for services, thegovernment can offer a wider variety of health services and still recover a substantial portionof the costs.This paper attempts to address these questions on the basis of evidence generated by somerecent studies on household health expenditure in India (See next section on HouseholdExpenditure). More particularly, it focuses on some important findings of a recent study onhousehold expenditure on RCH care in one district of Rajasthan (See section on RecentEvidences from Udaipur District, Rajasthan). The policy issues that emerged from this evidenceare briefly presented in the last section with special emphasis on options to deal with the issues(See section on Policy Issues).Household Expenditure on Health in IndiaSeveral studies conducted in the last decade have unequivocally confirmed that Indianhouseholds spend a substantial amount of money on health care (especially curative care). It isalso quite evident that the so called “free” services at the public health care facilities are often amyth, especially when one considers the huge amount of hidden costs associated with theutilization of these services. Studies carried out at both the national and regional level indicatethat the proportion of patients who pay for services is quite high, ranging from 64%–90%(Sundar, 1992; Duggal and Amin, 1989; George, 1997). The proportion of patients who pay wasfound to be about the same in both rural and urban areas.The costs of treatment typically include indirect costs, such as transport, food, rituals, gifts, andtips, and the direct costs, such as fees for consultation, hospitalization, medicines, and tests.Direct costs account for 69%–93% of the total treatment cost (Duggal and Amin, 1989; Sundar,1992 and 1994; George, 1997; Yesudian, 1990; Sujata Rao et al., 1997; Sodani, 1997). Medicineand consultation fees constitute the major share of direct costs.With respect to the severity and duration of illness, results show that treatment costs increasewith severity. For example, Yesudian (1990) reports that, in Bombay, treating a catastrophicillness is 17 times more costly than treating a short-term illness and twice as costly as treating a141

Household Health Care Costs in Indiachronic illness. Similarly, Kulkarni and Chitanand (1994) find that, in Maharashtra, the treatmentcost for a major illness is 12-15 times greater than the cost for a minor illness.Several other studies present interesting findings about the cost of treatment. Studies byKrishnan (1994) find that (1) the cost of treatment is higher in states where the public healthinfrastructure is least developed; (2) poor patients pay more for health care and bear the higherburden of treatment (See section on Policy Issues); (3) hospitalization increases the intensity ofpoverty for poor families; (4) treatment in private hospitals, either as an in-patient or an outpatient,is expensive and out of reach of the poor; and (5) the burden of treatment is the highestfor women, due to the inaccessibility of affordable services.Another study by Gumber and Berman (1997) finds that (1) the in patient treatment tends to bequite expensive and burdensome; (2) for both in patient and out patient care, the burden tendsto be higher in rural areas as most rural patients have to travel to the health care facilitieslocated in urban areas; (3) in cases of no insurance coverage and longer duration of treatment,the financial burden of treatment on households was much higher if the patient was treated in apublic sector institution; (4) there exist inter-state differentials in the burden of treatment whichwere more pronounced for in-patient treatment; and (5) the burden of treatment is inverselyproportional to monthly per capita expenditure.Table 1. Per Capita Annual Health ExpenditureStudy Scope of Study Per Capita HealthExpenditure, Annual(in rupees)National Service System42nd Round, 1992 National 248Duggal and Amin, 1989 Jalgaon 182George, 1997 Madhya Pradesh 299Kulkarni and Chitanand, 1994 Maharashtra 415A few studies attempted to estimate the percapita annual health expenditure (NSSO,1992; Duggal and Amin, 1989 [Jalgaon];George, 1997 [Madhya Pradesh]; and Kulkarniand Chitanand, 1994 [Maharashtra]). Asshown in Table 1, estimates range from Rs182 to Rs 415 per capita.Only the Madhya Pradesh and Jalgaonstudies have directly estimated the share ofhousehold health expenditure of the total income/expenditure. Other studies calculate thisshare indirectly. The proportion ranges between 5% and 15% in the Bombay (Yesudian, 1990)and National Council for Applied Economic Research (NCAER) (Sundar, 1992) surveys,respectively. The National Sample Survey (NSS) 1992 reports that the share of health expenditureof total income is 5.7%. None of these studies have provided estimates of the total annualamount spent on RCH services.142Only two studies (Sujata Rao et al., 1997; Duggal and Amin, 1989), collected information regardingthe source of money that was used by the household to pay out-of-pocket costs. The study bySujata Rao et al. (1997) in Hyderabad reports that about 50% of the families with at least onemember with a health problem financed their health care payments with loans or distress sale oftheir assets. The median amount of loan was Rs 4000–5000, for which monthly interest between3%-5% was paid. According to Duggal and Amin (1989), 1.3% of all episodes of illness were

Household Health Care Costs in IndiaTable 2. Estimate of Annual Household Expenditures on RCH andNon-RCH Services, Udaipur District, Rajasthan (in rupees)Urban/RuralIncome GroupType of Health Costs Total Urban Rural Low Medium HighTotal health expenditure per capita 399.1 551.7 320.5 291.3 418.0 595.6Non-RCH expenditure per capita 303.3 394.9 256.1 225.9 313.3 447.9RCH expenditure per capita 95.8 156.7 64.4 65.4 104.7 147.7RCH expenditure per marriedwoman aged 15–49 years 487.0 754.0 356.4 356.0 557.9 690.3Percentage of total household healthexpenditures spent on RCH services 24.0 28.4 20.1 22.5 25.1 24.8partially financed through loans. During the reference period, for every Rs 1000 of healthexpenditure in the sample, Rs 156 was taken on loan to meet health expenditures.Recent Evidences from Udaipur District, Rajasthan 1This section is based on a recent study of household expenditure on RCH care services in Udaipurdistrict of Rajasthan, conducted by the Indian Institute of Health Management Research (IIHMR) incollaboration with the POLICY Project (The Futures Group). The study involved a survey of 1100households (6859 individuals) in 50 villages/urban wards of the district. Of household heads, 7.9% were from scheduled castes (SC) and 27.5% were members of scheduled tribes (ST), reaffirmingthe tribal base of the district. The proportion of ST population is much higher in rural areas (40.6%)than in urban areas (2.1%). The primary purpose of the survey was to estimate the annualhousehold costs for treatment for RCH care as well as basic health problems excluding RCH care.The components for RCH care considered in the survey were antenatal care, childbirth, postnatalcare, family planning, abortion, and reproductive tract infection.The results from the study are summarized in Table 2. To understand the link between healthcare expenditure and the socio-economic status of households, households were ranked inascending order of reported annual per capita income. This ranking was used to assign eachhousehold into one of three income groups. Households in the lowest two income quartilesmake up the first (low) group, households in the third quartile make up the second (middle)group, and households in the highest quartile make up the third (high) group. As revealed inTable 2, estimated per capita household expenditure on health care is Rs 399.1 per year. Asexpected, urban households spend more on health care than did their rural counterparts (Rs551.7 vs Rs 320.5). Similarly, households in higher income groups spent more than those inlower income groups (Rs 595.6 in high-income group compared to Rs 418 and Rs 291.3 inmiddle and low-income groups, respectively).As Table 2 shows, households in Udaipur spent an average of Rs 95.8 per capita or 28% of totalhousehold health expenditures for RCH services. Out-of-pocket expenditures constituted over1This section heavily draws upon Hotchkiss et al. (2000).143

Household Health Care Costs in India80% of total RCH expenditure (excluding public expenditures on hospitals) in Rajasthan. Urbanhouseholds spent two-and-a-half times more per capita on RCH services than rural households,while high-income households spent more than their middle and low-income counterparts.The RCH expenditure per married woman of reproductive age was approximately five timeshigher than per capita spending on RCH. On average, a currently married woman between 15and 49 years of age reported spending Rs 487 for RCH services, with urban women spendingmore than twice as much as their rural counterparts (Rs 754 and 356 respectively).Policy IssuesSome of the information generated by the Rajasthan study is quite revealing. This sectionpresents some of the findings with their policy implications. 2Substantial Out-of-Pocket Costs for RCH ServicesA commonly held perception among many government health officials is that the public healthcare system provides individuals with access to free health care services. However, the results ofthe Rajasthan study do not support this perception, as most women who use public facilitiesreported spending something to receive services. For example, among women who receivedservices at public facilities, 74% of antenatal care clients, 100% of birth delivery clients, 66% ofpostnatal care clients, and 81% of child health clients reported that they paid either forconsultations, medicines, tests, transportation, or lodging. Moreover, the money that womenreported spending, even when the services are provided by government facilities, are oftensubstantial. For example, on average, women reported spending Rs 729 for birth deliveryassistance in a government facility (Rs 1850 in private hospitals).The large relative size of household out-of-pocket expenditures has a number of importantimplications on policy formulation. First, households may be an important source of funds thatcan be used to further improve the availability and quality of public health care services.Second, that many households are willing to pay for RCH services is a necessary, but not asufficient, condition for increased development of the private sector in this area.Composition of ExpenditureThe major share of household expenses on non-RCH services was absorbed by medicines(52%), followed by consultation (25%), travel (9%), diagnostic tests (9%), and board andlodging (5%). The share of medicine costs is much higher for government services (69%) incomparison with the same for private services (43%) and others (56%). However, the amountspent on medicine by public clients was often quite similar to the amount spent by privateclients. The pattern was more or less the same for expenditures on RCH services also. Forexample, people spent about 63% of their total expenditure for treatment of basic healthproblems on medicines for children below two years of age.One possible explanation for these findings (that people spent a substantial amount onmedicines irrespective of sources of care) is that drugs are often not available at government1442For full details, see Hotchkiss et al. (2000).

Household Health Care Costs in Indiafacilities, and that public clients must rely on the private market in order to purchase drugs. Thefindings also suggest that government officials need to consider the role of pharmaceuticals inhealth policy design. Important issues that merit attention are drug pricing within publicfacilities and the coordination of the role of the public and private sectors in the provision ofpharmaceuticals. The option of running drug outlets by government facilities on a commercialbasis (with adequate subsidy for the poorer patients) should also be explored.Non-Targeting Public Health Care ServicesThe Rajasthan study shows that the overwhelming majority of women from the low-income groupreceived their care from government providers. However, an unexpected finding is the extent towhich women from the highest income per capita quartile used the public sector. For example,65% of antenatal care clients, 79% of postnatal clients, and 72% of child health care clients in thetop income group received care from the public sector. This raises the question of whethergovernment services are properly targeted to those women who are most in need. Previous studiessuggest that the government is not spending enough money on RCH service delivery to be able toprovide services to all women in India. If this is the case, the results presented above suggest thatthe government should consider ways to target services to those who are most in need.Dependence on Private Providers for Curative ServicesThe study reconfirms that, in spite of massive investment by the state government on healthcare and heavy subsidy flowing to primary care, people are still spending a huge sum, eitherdirectly or indirectly, to use the private services. In general, private sources are three timescostlier than government facilities for most of the services. Yet, the beneficiaries showed astrong preference to use private sources for specific problems, such as non-RCH curative care,abortion, and RTI problems. This also contributes to prevailing high per capita cost on healthcare. Given the trend of increasing dependence on private sources especially for curative care, itis important that a comprehensive policy be designed to collaborate with the private providers(formal and informal) with adequate quality- and cost-control mechanisms.Unanticipated Shock to Households’ Economic StatusDue to uncertainties involved in the imposing burden of disease, as well as the burden oftreatment, it is quite conceivable that medical treatment brings forth an unanticipatedeconomic burden on the affected households. The burden is disproportionately high for thepoorer section of the population and often leads to “drain out” of household resources andconsequent impoverishment. This is especially true when the subsidized public services are alsoused by the non-poor; the poorer clients get “crowded out” of the public facilities and seektreatment from expensive private sources.The need for protecting the economically disadvantaged section of the population from suchdevastating shock can hardly be exaggerated. It has now become absolutely essential to exploreand design an appropriate social safety net, either in terms of social insurance or throughcommunity financing schemes.145

Household Health Care Costs in IndiaReferencesDuggal, R and S Amin. 1989. Cost of Health Care: A Household Survey in an Indian District.Bombay: The Foundation for Research in Community Health.George, A (ed.). 1997. Household Health Expenditure in Two States: A Comparative Study ofDistricts in Maharashtra and Madhya Pradesh. Pune: The Foundation for Research inCommunity Health.Gumber, A and P Berman. 1997. “Measurement and Pattern of Morbidity and the Utilization ofHealth Services : Some Emerging Issues from Recent Health Interview Surveys in India.” Journalof Health and Population in Developing Countries. 1(1): 16–43.Hotchkiss, D B Kanjilal, S Sharma, P R Sodani, and G Chakroborty. 2000. “HouseholdExpenditure on Reproductive and Child Health Care Services in Udaipur, Rajasthan.” InFinancing Reproductive and Child Health Care in Rajasthan. New Delhi, India: The FuturesGroup International, POLICY Project; and Indian Institute of Health Management Research.Krishnan, T N 1994. Access to Health and Burden of Treatment in India. Project of the UnitedNations Development Programme.Kulkarni, S and R Chitanand. 1994. Health Seeking Behaviour and Health Expenditure of RuralHouseholds. Bombay: International Institute for Population Sciences.National Sample Survey Organization (NSSO). 1992. Sarvekshana. 42nd Round. Department ofStatistics, Ministry of Planning and Programme Implementation. New Delhi: Government ofIndia.Sodani, P R. 1997. An Econometric Analysis of Health Care in Rajasthan.[Unpublished Ph.D. Thesis] Udaipur: Mohan Lal Sukhadia University.Sujata Rao, K, G N V Ramana, and H V V Murthy. 1997. Financing of Primary Health Care inAndhra Pradesh: A Policy Perspective. Center for Social Services. Hyderabad: AdministrativeStaff College of India (ASCI).Sundar, R. 1992. “Household Survey of Medical Care.” Margin. January–March, 1992.Sundar, R. 1994. “Household Survey of Health Care Utilization and Expenditure.” Margin.July–September.Yesudian, C A K 1990. A Study on Health Services Utilization and Expenditure. Hinduja HarvardProgram for Community Health. “Organizing and Financing Health Care Services for the MiddleIncome Group in Bombay.” 15-16 January, 1990. Bombay: Hinduja National Hospital.146

Session 1Session 4Access to Health Services in UttaranchalAccess to Health Services inUttaranchalAlok Kumar Jain, Secretary, Medical, Health, Family Welfare, Women Empowerment, andChild Development, Government of UttaranchalBackgroundThe state of Uttaranchal was created on 9 November 2000 by combiningformer parts of Uttar Pradesh—the hilly districts of Uttarkashi, Chamoli,Rudraprayag, Tehri Garhwal, Dehradun, Pithoragarh, Pauri Garhwal,Bageshwar, Almora, Champawat, and Nainital with the districts of UdhamSingh Nagar in the Terai region and Hardwar in the foothills. In all, there are13 districts in the state.According to the provisional population totals for India, Uttaranchal has apopulation of 8.5 million, of which 4.3 million are males and 4.2 million arefemales. The sex ratio of the state in 2001 is 964 females per 1000 males,which is higher than the 1991 sex ratio of 936. The population growth rate incomparison to the previous decade has come down from 24% in 1991 to 19%in 2001, while the population density during this period has increased from133 persons per square kilometre in 1991 to 159 persons per square kilometre(Director of Census Operation, Uttaranchal, 2001).The National Family Health Survey (NFHS-2) of 1998–99 survey estimatedthat the majority (78%) of the population of Uttaranchal lives in rural areas.The villages have scanty populations, are scattered, and are in hilly terrainmaking it difficult to provide services (provider and outreach) and for theclients to visit and obtain services from the nearest health facility. The ruralhealth infrastructure in the state comprises 23 community health centres(CHCs), 84 block primary health centres (BPHCs), 138 additional primaryhealth centres (APHCs), 39 rural female hospitals, and 1609 sub-centres ofwhich 84 are main centres. Providing access to basic health services andmaking the services available to the population are important tasks for thestate, in general, and for the Health and Family Welfare Department inparticular.147

Access to Health Services in UttaranchalHence, this paper examines the distribution of villages by population size and the healthinfrastructure in the state with particular reference to accessibility. In addition, the PERFORM(Program Evaluation Review for Organization Resource Management) Survey, carried out in1995, collected information on accessibility to family planning services and the distance to thenearest source. Though the data is related to family planning, it provides the client’s perspectiveand an idea of distances for the client to access the services.Settlement PatternThe distribution of villages by population size in Uttaranchal, according to the 1991 census, hasbeen compiled and presented in Table 1. It revealed that the majority of the villages in the statewere small-sized—more than four-fifths had a population size of less than 500, another 10% hadpopulation sizes ranging between 500 to 999, and the remaining 6% had over 1000 population.District-wise variations were enormous. The percentage of villages with less than 500population varied from a minimum of 25% in Hardwar to a maximum of 95% in Garhwal.Nainital had about 65% of villages with population size less than 500. In the remaining districtsof the state, the population composition of the villages was very small. This finding getsreinforced when analysing the population distribution in rural areas of the state by censusclassification.148Table 1. Percentage Distribution of Villages by Population Size (1991 Census): UttaranchalPopulationDistrict

Access to Health Services in UttaranchalIt can be seen in Table 2 that the mean population size of the state was around 344. Three of the13 districts (Hardwar, Udham Singh Nagar, and Dehradun) had higher population mean sizesthan the state average. Districts such as Garhwal and Pithoragarh had mean population sizes of188 and 244, respectively, with a similar pattern observed in almost all the other hilly districts.With regard to the distribution of population in rural Uttaranchal, the data show that over half ofthe population resided in settlements of less than 200 population, another one third insettlements of 200–499 population, and the remaining 16% in settlements of over 500population. District-wise analysis once again demonstrates the fact that the majority of villagesin hilly districts were more scattered and were of very small population size. This was even moreevident in the case of districts in the Garhwal region.Given this context of settlement pattern, an analysis of accessibility to health and family welfareservices by the population in the state is illustrated in the following section.Accessibility to the Nearest Health FacilityAll currently married women in the state were asked whether they knew any source forobtaining services for each modern family planning method. If they knew more than onesource, they were asked to mention the nearest source and the distance between the residenceand the service delivery point. The results are shown in Table 3.The majority of currently married women who were aware of a source of family planningservices identified the public sector as the major source of access. The dependence on thepublic sector ranged from 78% each for condoms and oral pills to 91% for an intrauterineTable 2. Percentage Distribution of Population by Census Classification of PopulationSize (1991 Census): UttaranchalClassification by Population SizeDistrict

Access to Health Services in UttaranchalTable 3. Accessibility of Service Delivery Points for Modern Family Planning Methods in RuralAreas of UttaranchalPERFORM, Uttaranchal 1995(Regional Estimate-Regular Weights):Oral pill Condom IUCD SterilizationPercentage Percentage Percentage PercentageMentioned public sector as a source 78.0 77.8 90.8 78.9Base: Aware of a sourceDistance to the nearest sourceWithin village 17.6 18.9 11.3 4.31-2 kms 20.8 20.7 15.8 12.93-5 kms 28.3 27.7 25.4 22.6>5 kms 33.3 32.7 47.5 60.2Total 100.0 100.0 100.0 100.0Base: Aware of a sourceSource: PERFORM 1995contraceptive device (IUCD). The awareness of a source for spacing methods was lower incomparison with sterilization.In regard to distance from place of residence to the nearest facility, it was mentioned by currentlymarried women that 18% could access oral pills within the village, 21% between 1 and 2kilometres, 28% between 3 and 5 kilometres, and the remaining one-third expressed that they hadto go beyond 5 kilometres to avail the services. This pattern was true for condoms and IUCDs,although the percentage varied. In case of sterilization, the majority of currently married women(60%) mentioned that they had to go more than 5 kilometres for availing services. In other words,it can be deduced that irrespective of the family planning method, the majority of currentlymarried women have to commute more than 3 kilometres to access services.District-level variations stood out in terms of distance to the nearest source even though thepublic sector was the most prominent source mentioned for all the modern family planningmethods across the districts.It can be observed from Table 4 that among the four districts covered in the PERFORM survey,Nainital and Dehradun districts provided better accessibility to services compared with TehriGarhwal and Almora. Tehri Garhwal had the poorest accessibility followed by Almora. In TehriGarhwal, even for accessing oral pills and condoms, currently married women had to travelmore than 3 kilometres. Other issues that act as impediments to accessibility are the lack ofchoice in mode of transport in such difficult terrain and the time required, even for 3kilometres.150Aside from the survey results, a district-wise analysis of accessibility to a health service facilityhas been compiled for 9 districts of the state. The analysis is presented in Table 5 with thefollowing parameters.

Access to Health Services in UttaranchalTable 4. Accessibility of Service Delivery Points for Modern Family Planning Methods in RuralAreas of UttaranchalPERFORM, NainitalOral pill Condom IUCD SterilizationDistance to the nearest sourceWithin village/town/city 26.7 27.2 14.4 5.41–2 kms 17.3 16.3 17.4 10.83–5 kms 41.5 42.7 38.6 39.6>5 kms 14.5 13.8 29.6 44.2Total 100.0 100.0 100.0 100.0PERFORM, DehradunOral pill Condom IUCD SterilizationDistance to the nearest sourceWithin village/town/city 35.8 37.8 20.2 8.61–2 kms 20.8 21.3 21.4 16.23–5 kms 14.3 12.6 20.3 24.4>5 kms 29.1 28.3 38.1 50.8Total 100.0 100.0 100.0 100.0PERFORM, Tehri GarhwalOral pill Condom IUCD SterilizationDistance to the nearest sourceWithin village/town/city 3.3 3.0 2.3 1.61–2 kms 21.0 22.6 14.3 11.93–5 kms 16.9 15.9 13.4 14.9>5 kms 58.8 58.5 70.0 71.6Total 100.0 100.0 100.0 100.0PERFORM, AlmoraOral pill Condom IUCD SterilizationDistance to the nearest sourceWithin village/town/city 14.5 16.6 10.8 4.21–2 kms 23.0 22.3 13.6 13.73–5 kms 31.2 28.5 24.4 17.9>5 kms 31.3 32.6 51.2 64.2Total 100.0 100.0 100.0 100.0Base: Aware of a sourcellllllllllNumber of BPHCsNumber of BPHCs not connected by a pucca roadAverage distance from a pucca roadNumber of BPHCs above 7000 feetNumber of APHCsNumber of APHCs not connected by a pucca roadAverage distance from a pucca roadNumber of sub-centresNumber of sub-centres not connected by a pucca roadPercentage of villages not connected by a pucca road151

Access to Health Services in UttaranchallllAverage distance from a pucca roadAverage number of villages covered by each sub-centreAverage distance of villages to the sub-centre.Table 5 illustrates that most of the BPHCs in the 9 districts were connected by a pucca road andlocated beside the road. However, in Almora district, seven of 11 BPHCs were located at anaverage distance of two kilometres from a pucca road. Two BPHCs, one in Tehri Garhwal andone in Uttarkashi, were located at an altitude of over 7000 feet. With regard to APHCs, Almorawas less accessible by pucca road and the average distance of the centres from a pucca roadranged between 3 and 8 kilometres. In Champawat, one APHC was not accessible by road; thedistance from the pucca road was as far as 23 kilometres.At the sub-centre level, all the districts had, on average, about 20 centres that were notconnected by a pucca road. The percentage of sub-centres not connected by pucca road variedfrom 10% in Almora district to about 50% in Champawat District, with the average distance froma pucca road varying from 3 to 12 kilometres. Besides this, each sub-centre, on average, coveredabout five to eight villages with the distance from villages to the sub-centre in the range of 2 to42 kilometres. Uttarkashi figured prominently in this category as it had villages that were farthestfrom the sub-centres. Similarly, there is wide variation in the percentage of villages that are notconnected by pucca roads in these eight districts. The findings from the survey on clientperspective, along with that compiled from the state, reinforce the fact that accessibility ofservices (the client reaching the nearest facility or the service provider visiting the villages) is anissue of concern.Until now, the discussion has revolved around physical access to health facilities where theclient had to traverse long distances to reach the nearest health facility or provider. The state, asa matter of fact, does not even have sufficient health infrastructure or human resources to caterto the existing set-up. The issue of resource shortages are presented in the following sections.Problems of Access due to Insufficient Health InfrastructureTable 6 shows that the state has an insufficient number of health facilities as per theGovernment of India (GoI) norms. The state has only 1609 sub-centres compared with therequirement of 2162 sub-centres. Likewise, there are 257 PHCs compared with the required324—a shortfall of 21%, while the shortfall for CHCs was 72%.In addition, many of the sub-centres and PHCs are located in rented buildings with inadequatespace. Table 7 shows that about three-fourths of sub-centres and one-fifth of PHCs are locatedin rented buildings.Problems of Access due to Shortage of ManpowerThere are many vacancies at various levels in the health department. Problems of access due tochallenging mountainous terrain are compounded by the fact that many health providers arenot willing to stay in these hard-to-reach places because of the lack of social infrastructure. Theavailability of staff compared with sanctioned posts is shown in Table 8.152

Access to Health Services in UttaranchalTable 5. Access to Health Service Delivery Point in Rural Areas of UttaranchalDehradun Hardwar Tehri Rudra Almora Udham Singh Champawat UttarkashiGarhwal prayag NagarNumber of BPHCs 4 5 9 3 11 4 3 4Number not connected bypucca road Nil Nil Nil Nil 7 Nil Nil NilAverage distance frompucca road (in kms) NA NA NA NA 2 NA NA NANumber of BPHCsabove 7000 feet Nil Nil 1 Nil Nil Nil Nil 1Number of APHCs 18 19 18 6 19 28 4 8Number not connectedby pucca road 1 Nil Nil 2 6 3 1 NilAverage distance fromroad (in kms) 6 NA NA 7 8 3 23 NilNumber of sub-centres 129 139 128 65 181 147 49 63Number of sub-centres notconnected by pucca road 23 25 37 26 16 22 24 29Average distance frompucca road (in kms) 3 5 5 5 4 2 5 12Average number of villagesserved by one sub-centre 5-8 5 5 10 6 5 20 6-9Average distance of villagesfrom sub-centre (in kms) 2–12 3–8 4–5 5–8 6 2–12 5–20 12–42Percentage of villages notconnected by a pucca road 43.6 Nil 83.9 76.3 68.2 26.0 68.5 58.3Number of sub-centresabove 7000 feet Nil Nil 10 Nil Nil Nil Nil 7Table 6. Status of Health Infrastructure in Uttaranchal, 2001No. Category of Health Requirement as Existing Difference PercentageInstitution per GoI Norms Variation1. Sub-centre/Main Centre 2162 1525 + 84 =1609 (-553) 262. Primary health centres 324 257 (-67) 213. Community health centres 81 23 (-58) 72Table 7. Location of Health Institutions in Uttaranchal, 2001S. No. Category of Health Existing Number in Number in RentedInstitution Government Buildings Buildings1. Sub-centre 1525 391 11342. Primary health centres 257 208 49153

Access to Health Services in UttaranchalTable 8. Staff Positions in Uttaranchal, 2001S. No. Category of Staff Sanctioned Posts In Position Vacant Posts Percentage Variation1. Class-I Medical Officers 295 106 189 642. Class-II Medical Officers (Male) 1187 476 711 603. Class-II Medical Officers (Female) 147 92 55 374. Dental Surgeons 51 23 28 55Manpower shortage is further magnified due to the lack of capacity-building training for medicalpersonnel and the absence of basic medical facilities (e.g., equipment, drugs, etc.) at PHCs andsub-centres.Despite these problems of accessibility and manpower, the state has done reasonably well withfamily planning programming. Although knowledge of contraception is almost universal,contraceptive prevalence in the state is only 41%. Contraceptive prevalence in rural areas (39%)is much lower than in urban areas (57%). Prevalence rates for pills and IUCDs are negligible inboth areas while condom use, at 6%, is the only other popular contraceptive method aftersterilization.The utilization of maternal and child health services is also low in Uttaranchal. The NFHS-2 estimated that mothers of only 18% of the children received at least three antenatalcheck-ups. Only 21% of births in the state were delivered at a medical facility. Amongbirths delivered at home, only 17% were assisted by a health professional. Only one inseven births outside a medical facility was followed by a postpartum check-up within twomonths of delivery. High-risk pregnancies are on the increase and the maternal mortalityrate is high. The universal immunization programme has a target of achieving 100%immunization. However, only 41% of children aged between 12-23 months are fullyvaccinated, 47% have received some of the recommended vaccinations, and 12% have notreceived any of the vaccines.Initiatives TakenThe government of Uttaranchal has undertaken certain initiatives to overcome all theseproblems. The initiatives are described below.(1) Appointment of Medical Officers and Paramedics on a Contractual BasisThe Uttaranchal government will appoint medical and paramedical staff on a contractual basisfor a period of one year, particularly in the hill regions. The government has decided to recruit241 male medical officers, 33 lady medical officers, 18 dentists, 96 helpers, 57 laboratorytechnicians, 28 x-ray technicians, and 370 Auxiliary nurse midwives. So far, the department hasrecruited 154 medical officers on a contractual basis and 116 are in position.154(2) Transfer Policy for Medical OfficersThe Uttaranchal government introduced a radical change in the conventional personnel policyby announcing a transfer policy to address the problem of vacancies in remote and difficult

Access to Health Services in Uttaranchalareas of the state — those who worked in less difficult areas will be transferred to difficultareas. Senior Grade (Class I) Officers will be posted for a maximum of five years in a particulardistrict. Class II officers will be allowed to work in a particular place for a maximum period offive years and up to seven years within the same district. Specialists will be appointed in CHCs,tehsil hospitals, and district hospitals. Those who have completed five years of service indifficult areas will be posted to less difficult areas. Under this new policy, 208 medical officerswere transferred last year.(3) Involvement of Integrated Child Development Services (ICDS) Workers forCombating Access and Bringing about ConvergenceThe government of Uttaranchal has decided to establish effective coordination among differentdevelopment departments, especially the ICDS at village and gram sabha levels. As a first step,all the anganwadi workers (AWWs) were given basic orientation training by the medicaldepartment. The training programme emphasized the need to register all pregnant women, toidentify high-risk pregnancies, and to refer high-risk cases to the nearest referral unit. The AWWsare expected to act as depot holders for iron and folic acid (IFA) tablets, oral rehydration salts(ORS), and contraceptives. They are also responsible for birth registration and provision ofcommunicable disease information.(4) Reproductive and Child Health Outreach ServicesReproductive and Child Health (RCH) outreach services are being provided in 11 districts ofUttaranchal (excluding Hardwar and Udham Singh Nagar) on fixed days of every month. Theoutreach services include antenatal check-ups, vaccination of children aged 0–5 years,management of children suffering from diarrhoea and pneumonia, counselling on birth spacingfor women aged 15–45 years, and organizing an ORS and contraceptive depot at session sitesbeyond the level of sub-centres in difficult out-reach areas.(5) Reproductive and Child Health CampsRCH camps are in operation in all 13 districts of the state on fixed days of every month at theBPHC level. Clients are provided RCH services and counselling for HIV/AIDS. Specifically, theservices include: antenatal checkups, supply of IFA tablets, counselling on safe deliveries,postnatal care, medical termination of pregnancy (MTP) services, counselling on birth spacing,Reproductive tract infection/Sexually transmitted infection management, counselling for HIV/AIDS, child immunization services, management of diarrhoea/acute respiratory infection,family planning, and laboratory tests.(6) Dai TrainingIn order to increase access to safe delivery care, dai (midwife) training has been initiated in 10districts of the state. At this point, 900 traditional birth attendants have undergone the 10-daytraining. More dais will be identified and trained as part of the RCH programme.ConclusionUttaranchal is a newly formed state with about 78% of the population living in rural areas. Thevillages are scantily populated, scattered, and located in hilly terrain. More than four-fifths of the155

Access to Health Services in Uttaranchalpopulation reside in small villages that are hard to reach. Hence, when the client reaches thefacility, it is important that the facility is adequately staffed as per the norms and that the staff istrained to provide quality services both at the facility and for outreach care.In order to increase accessibility and improve performance, the following actions have to betaken.1. Develop geographical mapping of all the inaccessible and remote areas in the state.2. Understand community behaviour and priorities.3. Evolve area-specific strategies.4. Adopt a multi-pronged approach by tapping the potential of other government departmentsand the private sector. The Health Department should take the lead in this effort.5. Develop strong referral linkages between various partners within and outside thegovernment system, community leaders, and ANMs.6. Provide supportive supervision and effective monitoring of performance.156

Session 5STI/RTI, AIDS, and TB Controland ManagementChairpersonJ C PantQuality of RTI/STI Case Management Servicesin India: Perspectives and ChallengesDinesh AgarwalHIV/AIDS: International PerspectiveDCS ReddyHIV/AIDS in India and UttaranchalMohmed ShaukatTB Control Efforts in India and UttaranchalSuvanand SahuDiscussantDora Warren

Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesSession 5Quality of RTI/STI CaseManagement Services in India:Perspectives and ChallengesDinesh Agarwal, Manager, Technical Support Unit, UNFPA, New DelhiIntroductionReproductive tract infections (RTIs), including sexually transmitted infections(STIs), are a major source of morbidity and mortality worldwide, with farreachinghealth, social, and economic consequences. It is estimated that aftermaternal causes, RTIs/STIs are responsible for the greatest number of healthyyears lost among women in developing countries. STIs account for 1.9percent of the burden of disease in disability-adjusted life years for womenglobally, with the highest values occurring in Southeast Asia and Africa (WHO,2000). India has a high incidence of STIs with an estimated annual incidencerate of 5 percent or 40 million new cases a year (National AIDS ControlOrganization, 2000).Ulcerative or non-ulcerative STIs both enhance HIV transmission amongcarriers and increase the risk of acquiring HIV (Hook, 1992; Laga, 1993;Plummer et al., 1991). Sub-groups at greatest risk of incurring STIs are oftenat risk of HIV infection as well. Studies carried out in Pune (Mehendele et al.,1996; Rodrigues et al., 1995) and Chennai (Solomon et al., 1994) demonstratean increase in incidence of HIV infection among STI clinic attendees. Bothstudies observed the risk of HIV infection in STI clinic attendees to be around10 percent per year. The results also suggest that this increase is not confinedto people with high-risk behaviour but is spreading into the population atlarge (i.e., antenatal mothers, voluntary blood donors, and women who claimto be monogamously married). One example of how STI management haslessened the impact of the HIV pandemic comes from Mwanza region inTanzania (Grosskurtu et al., 1995). Independent of their interaction with HIV,STIs are a principal cause of long-term morbidity and secondary infertility,leading to social stigma and economic hardship for those affected, especiallywomen.The Programme of Action, endorsed at the ICPD in Cairo in 1994 (andreaffirmed at Cairo+5), emphasized the urgent need for reproductive health159

Quality of RTI/STI Case Management Services in India: Perspectives and Challengesservices that include case management of STIs, thereby promoting infection-free sex. Thecoincident recognition that STIs enhance HIV transmission, coupled with growing awareness ofthe magnitude of the HIV epidemic, led to a rapid expansion of STI control programmesthroughout the developing world. Within both HIV/AIDS control and conventional familyplanning/MCH programmes, there were rapid and widespread efforts to add STI casemanagement services (WHO, 1999).Present Status of STI Management in IndiaIn India, a vertical national health programme known as the National Venereal Diseases (VD)Control Programme was launched in 1956 to reduce the prevalence of classical VDs in highlyendemic districts of the country. The programme strategy was based on establishing VD clinicsto provide services to those who seek treatment at identified facilities. In medical care settings,treatment services are available through departments of dermatology and venereology inmedical colleges and also in district hospitals. District STI clinics are now established with theNational AIDS Control Organization (NACO) support in most districts in the country. Also, thereis a vast network of private providers belonging to different systems of medicine, includingunqualified practitioners, faith medicine healers, herbalists, and chemists and druggists, whocater to a large proportion of patients suffering from these diseases. As per findings from theNFHS-2, only one-third of women who reported any RTI and sought treatment accessed thepublic health care delivery system (IIPS, 2000).160Family health awareness campaigns (FHAC) have been organized since 1999, as a programmaticresponse to encourage case management of STIs by raising awareness of causation,transmission, and prevention of these diseases and also by offering opportunities for treatmenton scheduled days during the campaign period. Almost all medical officers in the primaryhealth centres (PHCs) have undergone training in syndromic management of STIs using NACOguidelines. Drugs and medicines are also being made available during these camps. However, arecent evaluation of the FHAC (IndiaCLEN, 2000) indicates that among the target population, 73percent in rural areas and 82 percent in urban slums were unaware of the existence of any suchprogramme. Undoubtedly, such campaigns have helped in raising awareness among serviceproviders regarding common STIs, but access and availability of quality treatment services on aregular basis remain major concerns. In UNFPA-supported Integrated Population andDevelopment projects in six states of the country, services for prevention and management ofcommon RTIs are being made available in selected districts within primary health care settings(UNFPA, 2000).Treatment-Seeking BehaviourThere are several treatment-seeking behaviour studies which indicate that patients sufferingfrom STIs access private providers, from both the qualified and unqualified sectors. Whilethere is a culture of silence among women with respect to seeking treatment, men tend toseek services from private sources including chemists. Invariably there is a delay of three tofour months in seeking treatment, as either these conditions are not taken seriously or womenfeel shy or fear stigmatization. Women do know and try common home remedies. Theperceived poor quality of services offered by the public system also acts as a barrier in seeking

Quality of RTI/STI Case Management Services in India: Perspectives and Challengestimely care (Plummer et al., 1991). A study conducted in the slums of Delhi revealed thatwomen generally did not utilize government facilities because of long queues, unsuitabletimings, and improper knowledge of the facility. The most common and easiest way of gettingtreatment was to visit private practitioners, since they were more approachable and not veryexpensive (Garg, 2000).Quality of RTI/STI Case ManagementAppropriate case management for RTIs includes four steps: correct diagnosis, effectivetreatment, treatment compliance and sustainable risk reduction, and effective partnermanagement. There are serious concerns about the quality of services regarding diagnosticapproaches and procedures adopted, regimens offered, partial treatment, and co-treatment(i.e., partner management, condom use, and follow-up advice).The clinical case management approach, based on clinical examination alone without anyaccess to lab services, has traditionally been widely used by the providers. The very lowsensitivity and specificity of this approach has been established (Goyal et al., 2001). Etiologicalcase management based on lab diagnosis has been perceived as largely inappropriate inresource-poor settings. A badly conducted lab test with poor quality control systems is likely tomislead the physician, which is even worse. The lack of affordable diagnostic tests for STIs ledmany providers, including several national programmes, to adopt syndromic diagnosticapproaches, based on algorithms such as those proposed by the WHO. These approaches,which rely on recognition of symptoms and then apply a set of protocols for treatment, allowdiagnosis in one visit, require minimal training, and offer a relatively inexpensive protocolwithout the need for laboratory facilities. However, after 6-8 years of widespread use of theseSTI algorithms, their limitations are increasingly documented. A growing number of studiescomparing their sensitivity and the specificity of algorithms against laboratory diagnosesdocument their poor performance among women in a wide range of settings (Chilongozi andRtal, 1996; Hawks et al., 1999).First, the approach is not designed for asymptomatic cases, and nearly 50 percent of patientssuffering from STIs (especially women), do not manifest any symptoms. The algorithms areparticularly poor in distinguishing between the several conditions that can lead to vaginaldischarge, yet this is the most common symptom of women in community-based surveys. Also,algorithms do not perform well in diagnosing cervical infections as questions for assessingsexual risk are either not asked in culturally sensitive settings by hesitant providers or women donot reveal information about the sexual behaviour of their husbands even if they have specificknowledge of it. In urban slum settings where services are provided through mobile clinics,there is no privacy or confidentiality of examination. As several studies have found, thealgorithms lead to significant over-treatment of women. A recent study in the slums of Delhi(Vishwanathan et al., 2000) concluded that although existing protocols are effective in cases ofmale uretheral discharge and ulcerative STIs, nonspecific diagnosis of vaginal discharge resultsin substantial over-treatment. In addition, there are reports of Neisseria Gonorrhea organismsdeveloping resistance to Norfloxacin, the drug of choice for treatment. Over-treatment withantibiotics may contribute to the phenomenon of emerging drug resistance.161

Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesEffective treatment with antibiotics is the cornerstone of the treatment. Though NACO guidelinesvery clearly spell out drug regimens to be followed, even providers in the public system are notaware of these guidelines. To further complicate the matter, other systems of medicine are alsoindulging in allopathic treatment. As per a recent study from Tamil Nadu, only 19 percent ofhealth care providers (allopathic) actually used these guidelines as observed by the simulatedpatients (APAC-VHS, 1998). Partial treatment by the chemists is also widely reported.Indiscriminate use of antibiotics in sub-optimal dosages is likely to worsen the situation.Counselling is of great importance during the process of case management, with specialreference to risk reduction as these patients are at high risk for repeat infection. Too oftenproviders lack counselling skills and there is lack of privacy. Providers feel hesitant, especially incommunicating with patients of the opposite sex on these issues, and thus very little effort ismade to counsel clients. In a study from Chennai, only 30 percent of STI cases received somecounselling (APAC-VHS, 1998).Partner management is an essential part of STI case management services. It can be eitherachieved through provider referral or health education of the index patient to persuade his orher sexual partner to seek treatment (partner referral). In the Tamil Nadu study, only 8 percentof service provider advised for partner treatment (Kaitharag, 1995).Need for Strengthening RTI/STI Case Management Services in theReproductive and Child Health (RCH) ProgrammeConsiderable progress has been made in placing reproductive health on the national agenda inthe country. The National Population Policy (2000) makes a reference “to include STD/RTI andHIV/AIDS prevention, screening and management in maternal and child health services”(Government of India, 2000). Fully decentralized STI management services should not only bemore accessible to the general population but also less stigmatizing. This will entail developingpartnerships with the private sector as a large number of clients, especially in urban areas,access services from the private sector.Major programmatic decisions are needed pertaining to how to organize services. In general, itis recognized that more convenient arrangements for clients will lead to greater burdens on thefacility. This speaks to the need for feasibility studies on the involvement of the existing healthcare infrastructure.162A comprehensive review of scientific data on the role of STIs in sexual transmission of HIVinfection (Fleming and Wasserleit, 1999) indicated that early STI treatment should be part of ahigh quality, comprehensive HIV prevention strategy. The impact of STI control programmes onHIV is more cost-effective if instituted at the early stages of the HIV epidemic. Evidence alsounderscores the importance of providing continued access to quality STI diagnosis andtreatment, especially to core groups at risk of early infection, and who are likely to infect others.Considering a sero-positivity rate of 0.8 percent for HIV and the major route of transmission(heterosexual sex), improving access to services and STI case management remain highpriorities in the second phase of National AIDS Control Programme (NACP).

Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesRecent years have witnessed a rapid expansion of health care infrastructure in the country. Towhat extent are these services integrated in the ongoing RCH programme at the peripherallevel? The public sector remains a major source for preventive and promotive reproductivehealth care interventions in the country, especially in rural areas. Despite the magnitude of theRTI/STI/HIV problem, family planning service providers are not uniformly aware of itsimplications in their role as service providers. Screening for RTIs among contraceptive acceptorsis an important quality element that needs to be stressed. National guidelines for contraceptivedelivery very clearly articulate the need for such screening and appropriate measures formanagement of such cases. Similarly, many services in the RCH package (i.e., prenatal care,adolescent health services, and services for males) provide opportunities for integration. Manystudies have revealed the frustration of women, because different services are not combinedand coordinated. Programmes are yet to deliver a well-integrated reproductive health servicecatering to the diversified reproductive health care needs of the clients. These services areaccessible to women, genital examination is acceptable, there is a tradition of counselling, anduse of condoms and spermicides is familiar. Standards of access and quality for STI casemanagement warrant review. What standards of effective diagnosis are appropriate andaffordable? Under what disease conditions is a non-specific, widespread approach advisable,versus a more effective approach that targets only specific groups? In the following paragraphs,an attempt has been made to highlight different challenges in strengthening STI casemanagement services.Operationalizing Quality RTI/STI Case Management ServicesProgrammatic ChallengesService ProvisionSince family welfare programmes currently exist, management of STIs should be seen as an addonactivity. The reach and quality of existing services will determine the nature and pace ofintegration. Such integrated services should look for new target groups (i.e., women who aresexually active but are neither pregnant nor potential contraceptive clients). Integration shouldtake place both in outreach and clinic settings in terms of screening, diagnosis, referral, andtreatment of common RTI/STIs. The following matrix depicts service provision at differentlevels in the health care delivery system.According to community-based studies and reports of women seeking assistance from layworkers/MCH&FP clinics, a common presenting complaint is vaginal discharge with/withoutvulval irritation commonly caused by candidiasis, BV, or concurrently with other STIs, such astrichomoniasis, gonorrhoea, and chlamydia. For low-risk women, who will return forreassessment if symptoms persist, non-specialists should be able to provide empiricaltreatment for candidiasis alone. A presumptive diagnosis of BV can be made inexpensively bytesting the pH of vaginal secretion (the procedure involves using pH and a positive amine test(using potassium hydroxide for detection of characteristic amine odour). An accurate clinicaland sexual history using a score-driven approach that ought to be evaluated may be taken toidentify all cases to an appropriate facility. Health supervisors at the PHC level may be trained toperform wet mounts for diagnosing candidiasis and trichomoniasis.163

Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesTable 1. Management of RTIs at Different Levels of the Health Care Delivery System: Some OptionsCommon RTIs Sub-centre health workers-F/M PHC CHCs /hospital out-patientdepartment)Candidiasis + a + +Bacterial Vaginosis (BV) Presumptive diagnosis + +Trichomoniasis - + +Syphilis b - + +GonorrhoeaNot for women; Syndromicalgorithm for men + +Chlamydia c - + +Pelvic InflammatoryDisease (PID) - - +Facilities Standard check list, speculum, Standard diagnostic criteria, Standard diagnostic criteria,litmus paper, potassium microscope, technician microscope, technician trainedhydroxide trained in wet mount & Gram in wet mount, Gram stainstain VDRL/RPRre-techniques VDRL/RPR &TPHA tests & maybelaparoscopy for identifyingPID diagnosisa+ denotes what can be done at the stated level of health care; - means it is not possible.bWhere syphilis is known to be prevalent, every attempt should be made to equip PHC with the VDRL test.cMore than 10 Pus cell/HPF on microscopic examination (should be treated for gonorrhoea and chlamydia).Currently, laboratory techniques for detection of gonorrhoea and chlamydia are complex andexpensive and not cost effective, especially for chlamydia. The need for simple, reliable, lowcosttests to diagnose gonococcal and chlamydial infections among women, particularly amongasymptomatic women, remains a priority.Routine screening of pregnant women should also incorporate examination for candidiasis, BV,and trichomoniasis in symptomatic women. Screening for syphilis should be initiated in aphased manner beginning in areas where prevalence is known to be high. Similarly, specificinterventions need to be designed to reach out to female sex workers and bridge populations.Utilization of health services will also depend on the perceived quality of the services by theclients. Service providers need to be sensitive to the needs of clients and to be nonjudgemental.Decentralized IEC interventions in district settings specifically integrate communicationobjectives related to improved treatment-seeking behaviour and also target differentproviders in the district to emphasize the importance of quality management of STI patientsseeking treatment with them. One generic dimension of quality that is likely to improve isthe nature of provider-client counselling. Promotion of safer sex behaviour, andencouraging the utilization of clean, safe delivery and abortion services should be theobjectives of communication interventions. This calls for addressing all personnelincluding traditional birth attendants (TBAs) involved in obstetric care. Communicationefforts should also be directed to build partnerships with men for responsible sexual164

Quality of RTI/STI Case Management Services in India: Perspectives and Challengesbehaviour and to stress the importance of early treatment from qualified/trained serviceproviders. At the community level, the syndromic approach in men with urethral dischargeand genital ulcers seems to work well in detecting STIs, although its use needs to bevalidated in India. It is also quite possible that men will be more likely to bring in theirpartners for treatment and vice versa, and this may lead to identification of asymptomaticwomen. Public sector facilities providing STI services are predominantly MCH/FP basedand are targeted mainly at women and thus may be unavailable to men. A study inBangladesh (Hawks et al., 1999) has demonstrated the feasibility of establishing STI clinicsfor men, within the existing STI/MCH and family planning system. The activity wouldincorporate not only STIs but provide comprehensive sexual health services for men.Addressing STIs in men will have financial implications in the form of training the existingcadre of male health workers, establishing links with pharmacists and the private sector,and referring patients for medical evaluation and counselling.CostsWorldwide, the cost of adding STI services to the existing list of services offered is a concern tofamily planning programmes. Establishment of any new service involves additional costs,whether provided in combination with other services or not. Costs will vary according to thetreatment regimen offered, services delivered by health workers or physicians, possible casedetection opportunities, diagnostic options, screening services, partner management strategies,IEC, and types of targeted interventions. Additional costs are to be considered in cases wherepregnant women need to be screened for syphilis.PartnershipsIn India, the private sector provides 82 percent of out-patient days of care (National Council ofApplied Economic Research, 2000). Programmes should strive to establish linkages withnetworks of private practitioners for improving the quality of services offered through conductof orientation/training programmes. Focus should be on the use of protocols, counselling, andco-treatment. Similarly, social franchising, which will entail running clinics to achieveobjectives of providing quality care and enhance equity in access, needs to be give a fair trialunder the social marketing programme.Epidemiological ChallengesEvidence from the studies conducted across the country during the last decade deserves seriousattention. There is a continued preponderance of genital ulcer disease (syphilis, chancroid,herpes, and granuloma inguinale) in the country’s STI profile, accounting for close to 75 percentof all STIs. Also, bacterial and treponemal STIs continue to dominate the reported STI profileacross the country as they did during the 1980s. The rise in the incidence of viral STIs, again awidespread phenomenon, is also a matter of concern. Emergence of viral STIs (e.g., HSV1 and 2,HBV, and HPV) are posing new challenges for adopting appropriate screening techniques andtreatment options in low-resource settings. There are reports indicating a high degree ofassociation between HSV-2 and HIV infection with respect to prevalence, stage of HIV infectionand viral shedding of HIV, and HSV-2 among high-risk behaviour groups. The increasing trendin the number of young people reporting to different clinics with STIs is another matter of165

Quality of RTI/STI Case Management Services in India: Perspectives and Challengesconcern. Also there are considerable geographic variations in the distribution patterns ofcommon STIs in the country.A surveillance system for STIs needs to be established for an effective control programme with afocus on case reporting, prevalence assessment, assessment of STI syndromic etiologies,monitoring of anti-microbial resistance, and so forth. Such information would be useful foridentifying population sub-groups with high prevalence and monitoring such trends. Suchinformation would also be useful to establish cut-off prevalence levels for classical STDs forconsideration of presumptive treatments.Technological ChallengesConsidering the poor performance of algorithms, especially for vaginal discharge syndrome, it iscrucial that existing guidelines be re-examined. Low-cost simple diagnostic options (e.g., wetmount, KOH test, pH test, and Gram stain) will considerably improve the sensitivity andspecificity of algorithms. Guidelines should also insist on complete clinical examination toarrive at a diagnosis using algorithms. Rapid diagnostic options should be incorporated in theprogramme as and when such tests are feasible to be conducted in the peripheral settings. Thepossibility of self-sampling by the clients (using tampons, etc.) could be considered.Management ChallengesMonitoring and evaluation are key to the long-term success of any health programme, but theseare particularly critical for assessing the potential value of new approaches, such as integration.Currently, the Community Needs Assessment Approach does not take into account the need toplan services for expected STI patients in the community. Sub-centre action plans and monthlyreporting forms do not have information items on estimated cases based on the currentprevalence levels. Similarly, there is no information on RTI/STI cases either screened or referredby the health worker. Data on monitoring indicators reflecting the quality of services should beincluded in the management information system (MIS). Different sets of reporting formats areintroduced in the FHAC. Similarly, there is an attempt to build surveillance system for STIs bythe State AIDS Control Societies through etiological diagnosis, although such facilities might notbe available at many such reporting units. There is an urgent need to review the existing recordsand reporting formats and eliminating dual recording burdens.Quality of CareQuality elements that need attention include provision of privacy during counselling andexamination of clients, technical competence of service providers (i.e., conducting a speculumexamination, collection of specimens for lab tests, preparation of smear and interpretation ofresults, and counselling skills). Other quality elements that do not get much attention includemechanisms for partner management, follow-up care, referrals, and advice on condom useduring the course of treatment. Counselling for risk reduction will also constitute an importantcomponent of care. Availability of lab equipment in adequate numbers, test kits and reagents,drugs, and medicines should also receive attention. The programme should also focus onestablishing integrated logistics systems involving supplies under RCH and the NACP.166

Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesConclusionsOne of the major recommendations of the ICPD was to “make available universal access to a fullrange of high quality reproductive health services, including family planning and sexual health”through primary health care systems. The situation in many developing countries, includingIndia, has been that neither STIs nor RTIs are systematically managed in the peripheral healthcare settings. In addition, special clinics, such as STI clinics, are not very effective in reachingout to those who need these services. Strengthening STI case management within the gamut ofRCH programmes is a laudable goal. Integration will mean that RCH communicationprogrammes should encourage seeking early treatment; service delivery personnel will have tobe trained in case detection and providing prompt treatment using management protocols; andnecessary equipment and supplies must be ensured.ReferencesAPAC-VHS. 1998. STD: Health Care Facility Survey in Tamil Nadu-A Report.Fleming, D.T. and J.M. Wasserleit. 1999. “From Epidemiological Synergy to Public Health Policyand Practice: The Contribution Other STDs to Sexual Transmission of HIV Infection.” SexualityTransmitted Infections 75: 3-17.Garg, S. 2000. An Epidemiological and Sociological Study of Symptomatic and AsymptomaticReproductive Tract Infections and Sexually Transmitted Infections among Women in an UrbanSlum. Task Force Project under Special Programme of Research, Development and Training.Government of India. 2000. National Population Policy 2000.Goyal, R.S., Raina Neena, and Saulina Arnold. 2001. Management of RTIs: Interplay of SocialEnvironment. Jaipur: IIHMR.Grosskurtu, H., F. Mosha, J. Todd, et al. 1995. “Impact of Improved Treatment of STDs on HIVInfection in Rural Tanzania.” The Lancet 346: 530-36.Hawks, S., L. Morison, S. Foster, K. Gausia, J. Chakraborty, R. Weeling. 1999. “Reproductive TractInfections in Women in Low Income, Low Prevalence Situations: Assessment of SyndromicManagement in Matlab, Bangladesh.” The Lancet 354: 1776-81.Hook, E.W. 1992. “Herpes Simplex Virus Infection as a Risk Factor for HIV Infection inHetrosexuals.” Journal of Infectious Diseases 164: 251-255.IndiaCLEN. 2000. Family Health Awareness Campaign, 2000: Coverage Evaluation.International Institute for Population Studies (IIPS). 2000. NFHS-2. Key Findings. Mumbai.Kaitharag, K., et al. 1995. “STD Services in Madras: Could Their Role in STD Prevention BeStrengthened?” Indian Journal of Public Health 39: 93-99.167

Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesLaga, M. 1993. “Non-ulcerative STDs as Risk Factors for HIV-I Transmission in Women: Resultsfrom a Cohort Study.” AIDS 7: 95-102.Mehendele, S.M., M.E. Shepherd, A.D. Divekar, R.R.Gangakhedkar, S.S. Kamble, P.A. Menon, R.Yadav, A.R. Risbud, R.S. Paranjape, D.A. Gadkari, T.C. Quinn, R.C. Bollinger, and J.J. Rodrigues.1996. “Evidence for High Prevalence of Rapid Transmission of HIV among Individuals AttendingSTD Clinics in Pune, India.” Indian Journal of Medical Research 104: 327-35.National Council of Applied Economic Research. 2000. Who Benefits from Public HealthSpending in India.Plummer, F.A., J.N. Simonson, and D.W. Cameron. 1991. “Co-Factors in Male-Female SexualTransmission of HIV Type I.” Journal of Infectious Diseases 163: 233-39.Rodrigues, J.J., S.M. Mehendale, M.E. Shepherd, A.D. Divekar, R.R. Gangakhedkar, T.C. Quinn,R.S. Paranjape, A.R. Risbud, R.S. Brookmeyer, D.A. Gadkari, M.R. Gokhale, A.M. Rompalo, S.G.Deshpande, M.M. Khalandkar, N. Mawar, and R.C. Bollinger. 1995. “Risk Factors for HIVInfection in People Attending Clinics for STDs in India.” British Medical Journal 311: 283-86.Solomon, S., Anuradha S. Ganapathy, and M. Jagadeeswari. 1994. “Sentinel Surveillance of HIV-1Infection in Tamil Nadu.” International Journal of STDs and AIDS 5: 445-46.UNFPA. 2000. India Mid-Term Review of Fifth Country Programme, 2000.Chilongozi D. and A. Rtal. 1996. “STDs: A Survey of Case Management in Malawi.” InternationalJournal of STD and AIDS 7: 269-275.Vishwanathan, et al. 2000. “Syndromic Management of Vaginal Discharge among Women in aReproductive Health Clinic in India.” Sexually Transmitted Infections 76: 303-306.World Health Organization. 1999. Integrating STI Management in to Family Planning Services:What are the Benefits? Geneva: WHO.World Health Organization. 2000. The World Health Report 2000. Health Systems: ImprovingPerformance.168

HIV/AIDS: International PerspectiveSession 5HIV/AIDS: International PerspectiveD C S Reddy, Consultant WHO, Epidemiology, NACO, New DelhiIntroductionSince HIV/AIDS was first reported in 1981, it has spread rapidly across theglobe, infecting over 60 million people. The enormity of the HIV/AIDSepidemic has had a crumbling effect not only on people’s health and on thehealth systems of affected nations, but also on development as a whole. Thegrowth and magnitude of the epidemic and its consequences vary fromcountry to country and even between provinces within a country. Thesevariations are attributable to the level, appropriateness, and timeliness ofaffected communities’ responses, in addition to the social and behaviouraldeterminants and mode of HIV transmission in that area. An attempt is madehere to summarize the current global HIV/AIDS situation in terms of themagnitude and consequences of the epidemic and to critically examine thefactors / intervention efforts contributing to variations in the epidemic insome relevant settings.The ProblemGlobal ScenarioBy the end of December 2001, 40 million people were estimated to be livingwith HIV/AIDS, of whom 37.2 millions (93%) are in their productive years(15–49 years of age) and 17.6 million (44%) are women. During 2001, anestimated 5 million people contracted HIV and three million people diedfrom AIDS (Table 1).Table 1. Global Summary of HIV/AIDS Epidemic 1 , December 2001People Total Adults Women Children

HIV/AIDS: International PerspectiveMagnitude of HIV Infection in Different RegionsAlthough HIV usually enters and circulates among high-risk population groups, such ascommercial sex workers (CSWs) and intravenous drug users (IDUs), it spreads among thegeneral population as the epidemic advances. It is conventional to use the HIV infection rateamong pregnant women as an indicator of the level of infection in the general population.According to this extrapolated measure, there are severe epidemics in sub-Saharan Africa (8.4%adult HIV/AIDS prevalence rate), the Caribbean (2%), and in South and South-East Asia (0.6%).Sub-Saharan Africa and South and South East Asia account for 85% of the total infections in theworld (Table 2).It is obvious from this data that the epidemic’s growth is not uniform in all regions of the world.It is still in its early stages in many countries; while the HIV/AIDS prevalence in the generalpopulation is more than 10% in 16 countries (all in sub-Saharan Africa), it is less than 1% in 119countries of the world. Such variations are evident even between the provinces within acountry; even when national averages are low, there can be pockets of high prevalence. Forexample, the prevalence of HIV/AIDS is many times higher in northern Thailand than it is in therest of the country. In many countries, the epidemics are concentrated in some high-risk groupswith little transmission in the general population. It is evident from Table 2 that the epidemic’sage and mode of spread alone have not determined the current magnitude of the problem.The highest prevalence rate of HIV among pregnant women has been recorded in Botswana(35%) and its neighbours, such as Zambia, Zimbabwe, and South Africa (20%–30%). In absoluteterms, the largest number of adult infections is documented in South Africa, followed by India.Table 2. Regional HIV/AIDS Statistics and Features, End of 2001Region Epidemic Adults+ Adults+ Adult pre- % of Mainstarted children children valence adult modes ofliving with newly rate (%) women trans-HIV/AIDS infected mission inadultsSub-Saharan Africa Late 1970s-early 1980s 28.1 million 3.4 million 8.4 55 HNorth Africa & Middle East Late 1980s 440,000 80,000 0.2 40 H+IDUSouth & South East Asia Late 1980s 6.1 million 800,000 0.6 35 H+IDUEast Asia & Pacific Late 1980s 1.0 million 270,000 0.1 20 IDU+ H+MSMLatin America Late 70s-early 1980s 1.4 million 130,000 0.5 30 MSM+IDU+HCaribbean Late 70s-early 1980s 420,000 60,000 2.2 50 H+MSMEastern Europe & Central Asia Early 1990s 1 million 250,000 0.5 20 IDUWestern Europe Late 70s-early 1980s 560,000 30,000 0.3 25 MSM+IDUNorth America Late 70s-early 1980s 940,000 45,000 0.6 20 MSM+IDU+HAustralia & New Zealand Late 70s-early 1980s 15,000 500 0.1 10 MSMTotal 40 million 5 million 1.2 48Adults=15–49 years, using 2001 populationH= heterosexual, IDU= Intravenous drug user, MSM= men having sex with menSource: AIDS Epidemic Update 2001.170

HIV/AIDS: International PerspectiveHowever, bare prevalence rates do not reflect the size of the problem in the context of countrieswith large populations, such as China, India, and Indonesia. For example, in India, half amillion infections change the prevalence rate by only 0.1 of a percentage point.The region of Eastern Europe and Central Asia is drawing attention because of its rapidlygrowing epidemic. The total number of HIV infections jumped from a mere 11,000 in 1998 to129,000 in 2001 in Russian Federation counties. Ukraine records the highest adult prevalence at10%. Outbreaks of IDU-related HIV are reported in several countries of this region and threefourthsof HIV infections in this region are now attributed to IDUs. Moderate to severeepidemics (1%–3% prevalence in general population) affect some South American andCaribbean countries as well.Regional ScenarioDespite the relatively late (in the late 1980s) introduction of HIV/AIDS into South and SouthEast Asia, several countries in the region already show evidence of serious epidemics. Thailand,Myanmar, Cambodia, and some parts of India are experiencing generalized epidemics (lessthan 10 HIV/AIDS prevalence in the general population, as indicated by the infection ratesamong pregnant women). In some countries, such as China, Indonesia, Nepal, and Vietnam,the epidemic is growing rapidly among certain high-risk groups. Only a limited spread of HIVhas been observed so far in Bangladesh, Hong Kong, Laos, The Philippines, and South Korea.However, increasing incidence of risk behaviours and sexually transmitted infections (STIs)forewarns impending epidemics in countries such as Bangladesh and Pakistan. It is alsoappropriate to note here that the epidemic has taken a downward trend in Thailand andCambodia with a decline in prevalence from over 3% to about 2%.Consequences of the EpidemicAccording to UNAIDS/WHO estimates, an estimated 23.5 million people have died since thestart of the epidemic. Food Agriculture Organization (FAO) estimates that 7 million farmworkers have died from AIDS since 1985 and 16 million more are expected to die in the next20 years. There has been a steep fall in life expectancy at birth because of AIDS, from 62 yearsto 47 years in Botswana, Malawi, Mozambique, and Swaziland. In South Africa, lifeexpectancy has dropped from 66 to 47 years; in Haiti, from 59 to 53 years. There has been asteep increase – by 60% in the Bahamas and by 70% in Zimbabwe – in under-five mortalityfollowing the advent of AIDS.A study conducted in 15 Ethiopian industries on the impact of AIDS morbidity and mortalitynoted that 53% of all illnesses among industrial workers were AIDS-related. These industriesincurred higher costs because of greater sickness and funeral benefits, insurance claims,sickness absenteeism, and training of new recruits.As a result of AIDS-related morbidity and mortality, the gross domestic product (GDP) falls by0.5-1.2% annually in sub-Saharan Africa. A net fall of 8% is expected by 2010 and of 20% by2020. In Botswana, a quarter of the households are expected to lose their primary earner by2010. A study in Rwanda revealed that families of HIV/AIDS patients spend 20 times more171

HIV/AIDS: International Perspectivemoney on health care. In Thailand and Burkina Faso, agricultural income in rural areas isdwindling. In Burkina Faso, an estimated 20% of the rural population fails to cultivate their landbecause of AIDS-related morbidity and mortality.The adverse impact of AIDS is not restricted to economic-generating sectors alone. Therehas been a – five to six – fold increase in illness among health workers in Malawi andZambia, and similar trends were observed in other professions. In a study in the CentralAfrican Republic, 85% of the 300 deaths documented among school-teachers wereattributable to AIDS.The epidemic impacts uninfected children as well because of the sickness or death of one orboth parents. Because children need to care for their ailing parents and economic constraintsincrease, school drop-out rates, particularly among girls, are mounting in many Africancountries. South Africa and Malawi had to emphasize free primary education by offeringstudents a second chance to enroll in order to overcome this problem. In South Africa alone,12.1 million children have been orphaned by the death of one or both parents.This brief overview makes it clear that HIV/AIDS poses a serious threat with far-reaching socioeconomicimplications in all parts of the world. Although the scope of analysis of this evidencefor the purpose of contributing to policy formulation is enormous, we limit it to a set ofcontext-specific (the focus is on the low prevalence and border-location characteristic ofUttaranchal) questions.1. Are some populations immune to HIV?2. Can prolonged low prevalence indicate that there is no threat of a serious epidemic?3. Does border location add to vulnerability?4. What fuels and drives the epidemic?5. Do preventive efforts produce results?1. No population is naturally protected. There is neither biological nor epidemiologicalevidence to suggest that, once exposed, an individual or a population can escape HIV infection.However, the misconception that HIV is a disease of others and cannot infect “us” is commonamong both individuals and administrators of nations. As illustrated above, the infection is atvery low levels in some nations, such as Pakistan and Bangladesh (0.09 and 0.02%, respectively).In these situations, people tend to convince themselves that HIV is an imported infection.Notwithstanding the question of whether HIV infection is imported or indigenous, it isimportant to consider whether high-risk behaviour exists in the reference population and whatthe magnitude of such behaviour is. This can be assessed by the level of indicator diseases suchas STIs and hepatitis B and C, whose routes of transmission are similar to those of HIV. Forexample, the prevalence of hepatitis C in Pakistan is 89%, the average partner turnover of CSWsin Bangladesh is three per day, and STIs are exhibiting an unprecedented increase in some areasof China. In Jakarta, the percentage of sexually active male school students increased from 7%in 1997 to 25% in 1999. Once the virus gains a foothold in such a population, it will not be longbefore it establishes itself as an explosive epidemic.172

HIV/AIDS: International Perspective2. Prolonged low prevalence situations can turn into explosive epidemics. A feature of theepidemic that has been observed in some countries is its ability to circulate in a population at lowlevels for a prolonged period of time before becoming explosive. A case in point is Indonesia.After a decade of low prevalence rates among IDUs and blood donors, HIV prevalence ratesexploded in 2000 (Figure 1). Low prevalence ratesoften induce complacence in such countries orFigure 1Prevalence of HIV in Blood Donationscommunities by rendering a belief that they arein Indonesia, 1992–2001immune or impervious to HIV. However, evidence0.016shows that the infection spreads in a phased manner0.014from one population sub-group to another after it0.012finds wider circulation in the first. The sequence of0.010spread of HIV in different population sub-groups of0.008Thailand highlights this phenomenon (Figure 2).The cost and effort required for containing theepidemic in its early stages are much smaller andmore effective than in later stages since the targetpopulation size is smaller. However, complacencecauses countries to miss opportunities for costeffectiveinterventions.Percentage HIV Positive0.0060.0040.0020Source: National AIDS Prog ramme, Indonesia3. Border locations and population migration andmobility can increase populations’ vulnerability toFigure 2Onset of HIV Infection in DifferentHIV transmission. Border locations have often beenPopulation Sub–groupssensitive to the spread of HIV owing to increasedType IV pattern: Shift of the epidemic from one group to otherpopulation mobility and migration and refugee influx.Early years of Thai epidemicHowever, this depends on the porosity of, and thus themobility across, the border. Cambodia and Nepal haveattributed epidemics to international migration insearch of work. Among Myanmar refugees in Thailand,HIV prevalence rates were reported to be high. A studyundertaken by FHI in rural Nepal noted that the HIVprevalence increased in correspondence with amigration continuum starting with those who never454035302520151050migrated to those who migrated to other parts of Indiato those who migrated to Bombay. For effectivecontainment of the epidemic, it is essential that the1987 1988 1989 1990 1991 1992 1993migrants have equal access to prevention and care services. Both the countries of origin andcountries of destination need to address the issue of preventing HIV transmission in suchpopulations.PercentageIDUs CSWs M ale STD patients M ale conscripts Pregnant women4. Stigma fuels and drives the epidemic. In many countries and communities individualsaffected by HIV/AIDS are stigmatized because transmission of this infection is predominantlyassociated with promiscuous sex and injecting drug use. This not only breeds social apathy but173

HIV/AIDS: International Perspectivealso culminates in discrimination and denial of care. These, in combination, render the affectedindividuals hide the disease. Any infectious disease epidemic thrives on the hidden orunidentified reservoir. Unless the disease is normalized, this segment of the infected individualswould continue to fuel the epidemic in a given community. The importance of removal ofstigma and normalization of the disease for success of prevention programmes is wellillustrated by the experiences of Switzerland and Australia in the case of IDUs and of Thailandwith CSWs. Notwithstanding their legal statutes, Switzerland and Australia promoted the needleexchange programmes and injecting centres and were effective in containing the spread ofinfection in their countries. Similarly, Thailand successfully implemented 100 per cent condompromotion among sex workers in the country and stands as the first country to reverse thetrend of the epidemic in the region. All the three examples highlight the need to tolerate andaccept some behavioural patterns as normal and initiate interventions with empathy.Figure 3Percentage HIV Positive5. Well-designed and supported prevention efforts can work. Response to preventive actionsis also variable in different countries. Response depends on identifying and targeting thecorrect population sub-groups, quality and coverage of the interventional inputs, andaccessibility and affordability of care. Since HIV requiressocial and behavioural change interventions inHIV Prevalence Among Pregnant Womenin Cambodia, 1997–2000divergent settings, the health sector alone can not meet5the demands. Rather, an adequate response requiresinvolvement of multiple sectors and inflow of additional43resources. Unless there is political commitment at thehighest level, neither an augmented resource flow normulti-sectoral involvement can be achieved effectively.2Cambodia (Figure 3), Thailand, and Uganda present uswith the best examples of political commitment leading10to implementation of quality interventions withadequate coverage. In Cambodia and Thailand, 100%19971998 1999 2000condom promotion in CSW settings enabled thecountries to lower the prevalence from over 3% to 2%.Source: National AIDS Prog ramme, CambodiaIn a recent study comparing the intervention inputs and achievements in four Africancountries, it was noted that although educational interventions were similar in all the countries,Uganda achieved better results and effectively lower HIV prevalence because of the quality of itsinterventions. In Uganda, unlike in the other countries, there was excellent diffusion ofeducational messages through personal communication by peers, which ultimately decreasedthe prevalence of high-risk behaviours and HIV. Such quality educational inputs that result ineffective diffusion of information are possible only with the highest levels of politicalcommitment and multi-sectoral involvement.174The following are, therefore, obvious.1. No community or country is immune to HIV.2. Sustained low-prevalence situations can suddenly turn into explosive epidemics.3. Situations need sustained and continuous monitoring. In low-prevalence situations,

HIV/AIDS: International Perspectivemonitoring of risk behaviours and indicator diseases among high-risk groups pays dividends.4. Denial, stigma, discrimination, and failure to provide equal access to migrants fuel theepidemic.5. Early interventions are more effective and cost-efficient.6. Early interventions facilitate restriction of epidemics to population sub-groups and thusprevent spread to the general population.7. Mere initiation of interventions may not pay dividends; the quality and coverage of theseinterventions decide the beneficial outcomes.High political commitment and multi-sectoral involvement are essential for ensuring theeffectiveness of interventions.175

HIV/AIDS in India and UttaranchalSession 5HIV/AIDS in India and UttaranchalMohmed Shaukat, Deputy Director (Technical), NACO, New DelhiThe first case of AIDS in India was detected in 1986. Since then, HIV infectionshave been reported in all states and union territories. By 31 December 2001,31,336 AIDS cases had been reported. Available data from the beginning ofthe sentinel surveillance to the present indicate a varied picture.Epidemiological analysis of the data and reports in India indicate thefollowing.l The greatest number of HIV infections has been reported in Maharashtraand Tamil Nadu, and among intravenous drug users (IDUs) in the northeasternstate of Manipur.l Trends indicate two distinct characteristics in the spread of HIV infection—from individuals practising risky behaviours to the general populationand from urban to rural areas.Every year from August to October, a survey round is conducted in thedesignated sites. During 2001, the survey was conducted in 320 sites, whichincluded 135 sites in clinics for sexually transmitted diseases (STDs), 170 sitesin antenatal care (ANC) clinics, 13 sites among IDU clinics, and two sites inclinics for men having sex with men (MSM).Forty-nine districts, mostly in high-prevalence states, have shown a highprevalence of HIV among STD and ANC sites during this round.Based on sentinel surveillance data, HIV prevalence in the adult populationcan be broadly classified into the following three groups of states and unionterritories in the country (Figure 1):l Group I includes states such as Maharashtra, Tamil Nadu, Karnataka,Andhra Pradesh, Manipur, and Nagaland, where HIV infection hasexceeded one per cent or more among antenatal women.l Group II includes states such as Gujarat, Goa, and Pondicherry, where HIVinfection has exceeded five per cent among high-risk groups, but theinfection is below one per cent among antenatal women.176

HIV/AIDS in India and UttaranchalFig ure 1Adult HIV Prevalence ( 2001)Jammu & KashmirChandig arhHimachalPradeshPunjabHary anaUttaranchalDelhiArunachal PradeshSikkimRajasthanUttar PradeshBiharAssamNag alandGujaratMadhya PradeshC h ha tis ga rhJharkhandWestBeng alMeg halayaTripuraMizoramManipurDaman & DiuDadra & NagarHaveliMaharashtraAndhraPradeshOrissa> 1% Antenatal wom en> 5% High risk g roup< 5% High risk g roupGoaKarnatakaKeralaTam ilnaduPondicherryAndaman and Nicobar IslandsLakshadweeplGroup III includes the remaining states, where the HIV infection in any of the high-riskgroups is still less than five percent and is less than one percent among antenatal women.Figure 2 shows the sentinel surveillance data from antenatal clinics in seven metropolitan citiesin India. HIV infection has exceeded two per cent in Mumbai; is more than one per cent inHyderabad, Bangalore, Chennai; and is below one per cent in Calcutta, Ahmedabad, and Delhi.This data clearly supports the evidence that HIV infection is percolating from various high-riskgroups to low-risk groups in the population.Data from various sentinel sites in Maharashtra shows that through the years HIV infectionincreased sharply among commercial sex workers (CSWs), rapidly progressing among STD clinic177

HIV/AIDS in India and UttaranchalFigure 2Percentage3.02.52.01.51.00.5Sentinel Surveillance for HIV InfectionHIV prevalence among antenatal wom en inmetropolitan cities–1998attendees, and is now steadily spreading throughout thelow-risk population (Figure 3). The time lag for HIVinfection to spread from high-risk groups to low-riskgroups is between three and five years. The infectionspreads from CSWs to their clients, which act as a bridgepopulation, and then to the clients’ wives.Among IDUs, the infection has spread sharply inManipur, with HIV prevalence at more than 70% (Figure4). It is also spreading in Nagaland.0Figure 3MumbaiHyderabadBangaloreChennaiCalcuttaAhmedabadD elhiHIV prevalence Maharashtra in three sub groupsWindows of opportunities for other states757065605550454035302520151050CSWSTDANCTime lag infectionhigh to low risk(3-5 years)Source: NACO, 1998Figure 49080HIV prevalence among IDU in ManipurTrends of HIV infection among various risk groups inIndia, especially among the states, can be summarized asfollows.l Although HIV prevalence is low in the majority ofstates, the number of HIV infections is high.l There are wide regional variations in HIV prevalence.l There are simultaneous epidemics in certain states,such as the heterosexual epidemic in Maharashtraand Tamil Nadu, and the IDU epidemic in Manipur.Estimation of HIV Infection among theAdult Population, 2001In the Indian context, it is difficult to estimate the exactprevalence of HIV because of the varied culturalcharacteristics, traditions, and values with specialreference to sex-related risk behaviours. The westernAfrican model of making estimates cannot be easilyapplied to the Indian scenario; however, it is possible tohave rough estimates within a range that may be used forplanning of the AIDS Prevention and ControlProgramme. These estimates can also be useful formapping specific vulnerable groups and areas in order toplan targeted interventions in major urban areas andother areas in the states.Percentage706050403020100To estimate the total burden of HIV infection in thecountry, some effort was made previously by the WorldHealth Organization (WHO) and UNAIDS by using thedata generated by the National AIDS ControlOrganization (NACO) and other publications fromvarious research institutes in India. Although the HIVsentinel surveillance data have been primarily used formonitoring trends (i.e., to assess how rapidly HIV178

HIV/AIDS in India and Uttaranchalinfection increases or decreases over time in different groups and areas), it can also provide anestimate of the total burden of HIV infection in the country.The concept of using HIV sentinel data to estimate the burden of HIV infection was demonstratedin the August 1996 WHO document, HIV/AIDS/STD Surveillance Data: Management and Use. Thedocument suggests that sero-surveys of a sentinel population are often the most popular methodsof estimating the burden of HIV infection. A reliable estimate can be determined by using datafrom sero-prevalence studies of different sub-populations at different levels of risk. The HIVprevalence level is then applied to the population that the study group represents. For example, inepidemics in which heterosexual transmission is predominant, the HIV prevalence rate inantenatal women is applied to the sexually active population (15–49 years). For estimating HIVprevalence among various risk groups, an estimation of the size of these groups is necessary. Thecaution here is that risk groups should not overlap.Such estimates are made by applying the following formula.V = Σ (P/T) (R)Here, V is the total estimate, P is the number of HIV-positive population, T is the number ofsamples tested, and R is the estimated size of the population.Given that the extent of reliability of HIV estimates will depend on the accuracy of the estimationof the size of the risk-group population, careful assumptions are required in respect of variousparameters, such as urban–rural mix, male–female ratio, STD prevalence in urban and ruralareas, and so forth. Various assumptions were developed after intensive consultations withnoted epidemiologists and bio-statisticians in the country. The following assumptions coveringdifferent parameters for the estimation of the size of risk-group populations have beenrecommended.1. The 2001 census figures and the projected figures for 2000 will be the basis for state-specificassumptions forl mid-year population (in the age group of 15–49 years),l urban population and rural population, andl male–female ratio.2. STD prevalence rates in both urban and rural populations will be as follows:l STD prevalence in urban areas will be 10% in high prevalence states, 7% in mediumprevalence states, and 5% in low prevalence states. It will be the same for both males andfemales.l There will be five per cent prevalence in rural populations in all states and unionterritories for both males and females.3. For the purpose of HIV estimation in high-risk populations, urban–rural differential will be3:1 in all states. Similarly, for HIV prevalence in the low-risk population, the urban–ruraldifferential will be 8:1 in all states.4. As there are more infected males than females, the following ratio would be applied.l In high prevalence states, for every infected female there are 1.2 males; in moderate179

HIV/AIDS in India and Uttaranchalprevalence states, for every infected female there are 2 males; and in low prevalencestates, for every infected female there will be 3 males.l Similarly, for every male STD patient from high prevalence states, it is assumed that therewould be 0.83 females; for moderate prevalence states, there will be 0.5 females; and forlow prevalence states, there would be 0.33 female patients.5. With respect to the HIV prevalence rates.l The median value of HIV prevalence from state-specific and group-specific sentinel datahas been applied.l For states where the HIV prevalence rate has been reported as “0,” the followingassumptions are made.1. If data were available from a previous round where the prevalence is more than “0,”the rate from the previous round will be adopted.2. If the previous round data also shows “0” prevalence, the arithmetic mean of the lowprevalence states will be applicable in place of the “0” value.6. For estimation of HIV infection among IDUs, the HIV prevalence rate will be applied to theestimated size of the IDU population in the state.7. States will be categorized as high, moderate, or low, based on the following definition.l High Prevalence States States where HIV prevalence in antenatal women is one per cent ormore.l Moderate Prevalence States States where the HIV prevalence in antenatal women is lessthan one per cent and prevalence in STD and other high-risk groups is five per cent ormore.l Low Prevalence States States where the HIV prevalence in antenatal women is less thanone per cent and HIV prevalence among STD and other high-risk groups is less than fiveper cent.The justification for the urban–rural and male–female gradients is as follows.1. It is assumed that HIV spreads from urban to ruralareas, and this differential is maintained even at a highlevel of HIV prevalence.2. It is assumed that a higher percentage of males havehigh-risk behaviours as compared to females in India.In the beginning of the epidemic, males outnumberfemales, but the ratio gets closer to 1 with theprogression of the epidemic in the general population.In all the South Asian countries, males outnumberfemales, and in a high prevalence country like Thailandand Cambodia, this ratio is 1.6:2.3. It is also assumed that the infection shifts from thehigh-risk population to the general population over aperiod of time. Therefore, all the states go through astage of low, then concentrated, and then generalizedepidemic in the absence of effective interventions.Using these assumptions and consistence methodology,estimates of HIV infections have been worked out for1998, 1999, and 2000. A range of 20% is applied to thepoint estimate to provide higher and lower values.Keeping this in mind, the fact that all risk groups are notadequately represented (age groups excluding 15–49years are not included and AIDS cases are not includedin this exercise), the upper side of the range has beentaken as a working estimate for the country, as perdetails given below.1998 3.50 million1999 3.70 million2000 3.86 million2001 3.97 million180

HIV/AIDS in India and UttaranchalFig ure 5Comulative Number of AIDS Cases in IndiaDecember 20013500030000Number of AIDS cases25000200001500010000500001986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001YearsAIDS Case SurveillanceAnother aspect of monitoring the HIV/AIDS epidemic isthe reporting of actual AIDS cases (Figure 5). By December2001, 31,336 AIDS cases had been reported to NACO.These figures are considered only a fraction of the AIDSmorbidity. The low numbers and geographic distributionof AIDS cases shows that these numbers do not reflect thetrue situation in the country, and there is under-reporting.Epidemiological analysis of reported AIDS cases revealsthat1. The disease is affecting mainly people in the sexuallyactive age group. The majority of patients (87.7%) areaged 15–44 years.2. As shown in Figure 6, the predominant mode oftransmission of infection in AIDS patients is throughheterosexual contact (83.2%), followed by IDU (3.8%),blood transfusion and blood product infusion (3.7%),and others (7.3%).3. Males account for 76.1% of AIDS cases and females23.9%. The ratio is 3:1, although this varies by agegroup (Figures 7 and 8).4. The major opportunistic infection in AIDS patients istuberculosis (TB), which indicates the possibility of adual epidemic of TB and HIV in the future (Figure 9).Figure 6Mode of Transmission in AIDS Cases in IndiaDecember 2001Figure 7Number of AIDS casesH eterosexual 84.53IDUs 3.36Blood and blood products 3.27Perinatal 2.14Others 6.7Age and Sex Distribution of AIDS Cases in IndiaDecember 2001140001200010000800060004000MalesFemalesAIDS case surveillance data can also supplement the HIVsurveillance data in monitoring the epidemic andcontribute to the planning of hospital and home/200000–14 years 15–29 years 30–44 years >45 y earsAge group181

HIV/AIDS in India and UttaranchalFigure 8Number of AIDS casesFigure 9Opportunistic Infection among AIDS Cases in IndiaPercentageFigure 10Percentage350003000025000200001500010000605040302010010080604020Age-wise Break up of AIDS Cases in IndiaDecember 2001500000Base: All respondents>45 y ears30-44 years15-29 years0-14 yearsYear(1986-July 2000)n =13304TuberculosisCandidiasisCryptosporidiasisHerpes zosterToxoplasmosisBacterial PneumoniaC ry ptocc oc al M an ing ifisAwareness of HIV/AIDS–All IndiaProportion of respondents aware of HIV/AIDSPC PKa p os iO th e rsUrban Rural Male Femalecommunity-based care for AIDS patients under theprogramme.Surveillance of Sexually TransmittedDiseasesSTD surveillance has only recently begun; thus, there isnot much data available at this point. Various activitiesare underway to generate adequate data to assess themagnitude of STD prevalence as follows.l A protocol on STD surveillance has been developed.l For the preparation of state-specific plans, regionalworkshops with state core groups have beenorganized.l Training on STD surveillance has been completed inthe states.l A regular information system has been establishedto ensure the reporting of STD data through 504 STDclinics. During 2001, 416,910 cases were reported inthese STD clinics.Seven community-based studies have been designedand are presently in progress to ascertain theprevalence of STDs.Behavioural SurveillanceRecognizing the need for behavioural data,behavioural surveillance has figured as an importantactivity in the AIDS II Project. A protocol onbehavioural surveillance was prepared after pretesting,providing adequate inputs from behaviouralscientists and sociologists.An external agency has been assigned to conductbehavioural surveys in both high-risk groups and thegeneral population in all states and union territories.The first round of behavioural surveys in the generalpopulation is complete; the results have provideduseful information on assessment of HIV-related riskbehaviours. The important findings of this survey areshown in Figures 10–17.ConclusionObservations made in different parts of the countryclearly point to the fact that the epidemic is spreading182

HIV/AIDS in India and UttaranchalFigure 11Awareness of Transmission Modes–All Indiab y location9075Figure 12Awareness of Transmission Modes–All India10080Percentage604530Percentage604015200UrbanRural0M aleFemaleBase: All respondentsSexual contactNeedle sharingBlood transfusionVertical transmissionBase: All respondentsSexual contactNeedle sharingBlood transfusionVertical transmissionFigure 13Incorrect Knowledge on Potential of Transmissionby Mosquito Bites and by Sharing Mealswith Infected Persons–All IndiaPercentage35302520151050Urban Rural Male FemaleBase: All respondentsFigure 14PercentageKnowledge of HIV/AIDS Prevention Methods–All India6050403020100Base: All respondentsUrban Rural Male FemaleProportion of respondents aware that having an uninfectedfaithful partner and consistent condom use can prevent HIV/AIDSFigure 151412Sex with Non-regular Partner inLast 12 Months–All IndiaFigure 16Last Time Condom Use with Non-regularSex Partner–All India7060Percentage1086420Base: All respondentsUrban Rural Male FemaleProportion of respondents who reported having sexwith any non-regular partner in last 12 monthsPercentage50403020100Urban Rural Male FemaleProportion of respondents who reported using condom duringlast sexual intercourse with any non-regular sex partnerBase: Respondents who reported having sex w ith any non-reg ular partnerin the last 12 m onths183

HIV/AIDS in India and UttaranchalFigure 17Consistent Condom Use with All Non-regularSex Partners in Last 12 months–All India14not only geographically, but also numerically in differentrisk groups. It further finds its route from these coregroups to the general population.Percentage121086420Urban Rural Male FemaleProportion of respondents who reported consistent condomwith all their non-regular sex partners in last 12 monthsBase: Respondents who reported having sex w ith any non-reg ular partnerin the last 12 m onthsThe epidemic is in a fairly advanced stage inMaharashtra, Tamil Nadu, and Manipur, while it is stillyoung in many northern states. Based on theseepidemiological observations, the programme will focuson preventive strategies in the states with low-levelepidemics, while a dual strategy of prevention andcontrol will be implemented in the remaining states.HIV/AIDS in UttaranchalIn the absence of sufficient data, it is difficult to assess themagnitude of the problem of HIV/AIDS in the state ofUttaranchal. The available data, however, provides some information to help understand thestage of the HIV epidemic in the state.l Using HIV sentinel surveillance, the state conducted survey round 2001 in six designatedsites—four sites among STD patients attending STD clinics and two sites for womenattending ANCs (see table below). The STD clinic data represent the high-risk group, whileANC data represent the general population of the state. Round 2001 data show that HIVprevalence among STD patients is 0.4%, while HIV prevalence among ANC clients is 0.Name of the Site Group Sample HIV Prev. (%)Dehradun STD 250 0.8 %Uttarkashi STD 150 0.0 %Almora STD 250 0.0 %Garhwal STD 86 2.32 %Nainital ANC 401 0.0 %Pithoragarh ANC 403 0.0 %lllOther biological markers of HIV are STD clinic attendees and blood-donor data. As per thereport received from Uttaranchal, VDRL positivity was found to be 5.02%, and sero-reactivityamong blood samples tested for HIV in blood banks was found to be 0.06%. (MPR, 2001).The general population Behavioural Sentinel Surveillance Survey of 2001 (BSS 2001) showsthat the state cluster of Uttar Pradesh and Uttaranchal shows that 50.6% of respondents hadheard of AIDS, 43.7% stated that HIV/AIDS can be prevented by consistent condom use, 19.8percent were aware of common STD symptoms, 4% reported having sex with non-regular sexpartners, and 28.4% reported using condoms during their last sexual activity with nonregularsex partners.Existing data provide us ample evidence to show that the state is at a very early stage of anHIV epidemic, although the potential for transmission exists as evident from the BSS 2001.184

Tuberculosis Control Efforts in India and UttaranchalSession 5Tuberculosis Control Effortsin India and UttaranchalSuvanand Sahu, National Professional Officer for TB, Office of theWHO Representative to India, New DelhiIntroductionTuberculosis (TB) is a serious public health problem in India. The countryaccounts for nearly one-third of the global TB burden. Any change in theglobal TB scenario requires that India improve its situation. Incidence of TBin India has changed little in the past three decades. It is estimated that morethan 40% of the country’s population is infected with the TB bacillus. Everyyear, 2 million people develop TB and 450,000 die from it—approximately1000 deaths a day. TB kills more youth and adults in India than any othersingle infectious disease. Although high maternal mortality has been thefocus of attention in India (and rightly so), TB kills more women than allcauses of maternal mortality combined.TB is a barrier to development, costing India approximately Rs 12,000 crore(US $3 billion) a year. In addition to death and disability, TB causes massivesocial and economic harm. The disease can affect all sectors of the society;however, the poor are particularly vulnerable. On average, a patient with TBloses three months of wages. Further, the social costs of TB are devastating;more than 300,000 children drop out of school because their parents have TB,and more than 100,000 women with TB are rejected by their families. Thiscontinued burden of disease is tragic because TB is nearly 100% curable.TB is an infectious disease caused by the bacterium, MycobacteriumTuberculosis, which is spread through the air by an infected person. Sputumpositivepulmonary TB cases act as the reservoir of infection in thecommunity, spreading infection through coughing. Each untreated patientcan infect 10–15 persons each year, and poorly treated patients develop drugresistantTB, which could be potentially incurable. The best way to stop TB isto diagnose, treat, and cure people who have it. From a public health point ofview, control of TB can be achieved by early diagnosis and effectivetreatment.185

Tuberculosis Control Efforts in India and UttaranchalModern anti-TB treatment can cure virtually all patients. It is, therefore, important thattreatment be undertaken for the prescribed duration, which in every case is a minimum of sixmonths. However, because treatment takes time and patients often feel better after just one ortwo months, and because many TB patients face other problems such as poverty andunemployment, treatment is often interrupted. Therefore, merely providing anti-TBmedication does not ensure that patients get cured. The World Health Organization (WHO)recommends the Directly Observed Treatment Short-course (DOTS) strategy to control TB.The HIV epidemic is likely to worsen the TB situation in India. TB is the most common, serious,opportunistic infection occurring among HIV-positive persons. A person who is HIV-positivehas a 50% lifetime risk of developing TB, whereas a person not infected with HIV but withMycobacterium Tuberculosis has only a 10% lifetime risk of developing TB. TB is the greatestkiller of people who are HIV-positive; however, by using DOTS, it can be cured even among HIVinfectedpersons.Historical BackgroundTB is an ancient disease, referred to in the Vedas and Ayurvedic Samhitas. In India, the first openair sanatorium was founded in 1906 in Tiluania, near Ajmer, and the first TB dispensary wasopened in Bombay in 1917. Because no single drug or combination of drugs were as yet effectiveagainst TB, the main line of treatment was good food, open air, and dry climate. By 1925, chestradiology was available, followed by mass miniature radiography in 1945. In 1946, the BhureCommittee recommended establishing a clinic for each district and providing organizeddomiciliary service. In 1948, work on Bacillus of Calmette and Guerin (BCG) started in India, anda BCG Vaccine Production Centre was established in Guindy, Madras. Anti-TB drugs weredeveloped in the 1950s, with conventional treatment lasting for at least 12–18 months.In 1956, the government established the Tuberculosis Chemotherapy Centre, later known as theTuberculosis Research Centre (TRC), in Madras (Chennai). Work at the centre demonstratedthat the sanatorium treatment method of bed rest, a well-balanced diet, and goodaccommodations were not important, provided that adequate chemotherapy was prescribedand taken. Further, there was no evidence that close family contact with patients treated athome incurred an increased risk of contracting TB. Thus, it was appropriate to treat patients intheir own homes. This finding revolutionized TB treatment globally. Pioneering research inintermittently observed chemotherapy regimens was done later at the TRC, which helped in thedevelopment of the DOTS strategy.The National Tuberculosis Institute (NTI) was established in 1959 to develop through research aTB programme that could be applied in all parts of the country. The institute trained medicaland paramedical workers to efficiently apply proven methods for TB control in their respectiveareas of work.186India has a long and distinguished tradition of TB research. Studies from the TRC in Chennaiand the NTI in Bangalore have provided key knowledge to improve treatment of TB patients allaround the world.

Tuberculosis Control Efforts in India and UttaranchalNational Tuberculosis ProgrammeThe National TB Programme (NTP), established in 1962, created an infrastructure for TB controlthroughout the country. Programme policy consisted of domiciliary treatment; use of astandard, self-administered, 12–18 month drug regimen; free treatment; priority to newlydiagnosed patients; and a decentralized treatment organization. The NTP created an extensiveinfrastructure for TB control, with a network of 446 district TB centres, 330 TB clinics, and morethan 47,600 TB beds.A controlled clinical trial for the efficacy of the BCG vaccine showed that the vaccination didnot offer significant protection against TB of the lung. A committee appointed jointly by theIndian Council of Medical Research (ICMR) and the WHO examined the epidemiologicalaspects of the causation of TB under Indian conditions, and concluded that although BCG maynot protect against TB of lung, which occurs mostly in adults, it could provide substantialprotection against childhood forms of TB, such as tubercular meningitis, miliary TB. Theprotective effect of BCG against these forms of TB was not studied in the Chingleput trial. InIndia, BCG vaccination policy was revised; the vaccination was recommended to be given at anearly age, preferably before the end of the first year after birth by integrating it under theUniversal Immunization Programme (UIP).TB chemotherapy underwent revolutionary changes in the 1970s owing to the availability oftwo highly effective drugs—rifampicin and pyrazinamide. These drugs allowed short coursechemotherapy and made it possible to simplify treatment and reduce its duration. Discoveryof rifampicin in 1967 is considered as one of the greatest achievements in the history of anti-TB drugs.The NTP was reviewed in 1992. The major findings were that the programme suffered frommanagerial weaknesses, inadequate funding, over-reliance on x-rays, non-standard treatmentregimens, low rates of treatment completion, and lack of systematic information on treatmentoutcomes. As a result, the Revised National TB Control Programme (RNTCP) was designed.DOTS and RNTCPSteps were taken since 1993 to implement the RNTCP in selected areas with World Bankassistance. In October 1993, the RNTCP was implemented in a population of 2.35 million infive sites in different states (Delhi, Kerala, West Bengal, Maharashtra, and Gujarat). Success ofthe pilot test led to the implementation of the RNTCP in India in a phased manner. Theprogramme was expanded to a population of 13.85 million in 1995 and 20 million in 1996.Rapid scale-up began in late 1998, when another 100 million population was covered underthe programme. By the beginning of 2002, nearly half of the country was covered (460million). In the past 3.5 years, there has been a more than 25-fold expansion of RNTCPcoverage, making it one of the fastest expanding TB programmes in the world. The nextexpansion plan is to cover 800 million people by 2004, and then the entire country as soon asit is technically and operationally feasible. In the RNTCP, the proportion of TB cases that areconfirmed in the laboratory and the cure rate are both more than double those of theprevious programme.187

Tuberculosis Control Efforts in India and UttaranchalFunding is mainly from the World Bank, with the Department for International Development(DfID) and Danish International Development Assistance (DANIDA) supporting RNTCPimplementation in Andhra Pradesh and Orissa, respectively. WHO, through extra-budgetaryfunds from the Canadian International Development Agency (CIDA) and United States Agencyfor International Development (USAID), is providing technical assistance to the Government ofIndia in implementing and expanding the RNTCP.The RNTCP is an application of the WHO-recommended DOTS strategy in India. Much of theDOTS strategy emanates from pioneering research done in India. The basic principles of theDOTS are as follows.l Political commitment to ensure adequate resources, staff, and other key inputsl Diagnosis, primarily by microscopy of chest in symptomatics presented to health facilitiesl Regular and uninterrupted supply of anti-TB drugsl Direct observation of every dose of treatment in the intensive phase and at least once a weekin the continuation phase of treatmentl Systematic monitoring, supervision, and cohort analysis.The programme aims to reduce the transmission of TB, as well as mortality and morbidity fromthe disease, until TB is no longer a major public health problem. The goal of the RNTCP is to cureat least 85% of new smear-positive cases of TB and to detect at least 70% of such patients after thedesired cure rate has been achieved. Clearly, good outcomes and high case-detection rates areessential. However, it is important that the system is geared up to reliably cure patients beforeattempts are made to expand case detection. Experience shows that with reliable treatment andcure of patients the case-detection rates steadily increase. Cured patients act as the bestmotivators promoting case detection and patient adherence to treatment.The basic curative and preventive strategy is the treatment of TB patients until cured. Thepriority for treatment should be the newly diagnosed, sputum-positive pulmonary TB cases,since those patients are the main sources of infection and are more likely to die unlesseffectively treated. Direct observation of treatment is done through a trained peripheral healthworker or community volunteer who watches as patients swallow the medicines. Directobservation is ensured for every dose in the intensive phase of treatment, and at least one doseper week in the continuation phase. Diagnosis and treatment of TB, including drugs andclinical and bacteriological facilities, are provided free. The outcome of treatment is evaluatedby analysis of the results of quarterly cohorts of all registered cases. Early detection is done inall symptomatic patients reporting to the general health services with coughs lasting threeweeks or more by examination of three sputum smears for Acid Fast Bacillus (AFB). Thediagnosis and treatment of TB are functions of the general health services and hence a part ofprimary health care. Specialized units, such as District Tuberculosis Centres (DTCs), act asreferral centres (particularly for differential diagnosis of smear-negative cases and managementof cases with drug reactions), and also provide training, quality control, and supervision.188The RNTCP at the national level has a team at the Ministry of Health, Directorate of GeneralHealth Services, that manages the programme. The Central TB Division is headed by the

Tuberculosis Control Efforts in India and UttaranchalDeputy Director-General (TB), who is the National Programme Director, assisted bycollaborating central institutes, such as NTI Bangalore, TRC Madras, and Lala Ram Sarup (LRS)Institute of TB and Allied Diseases, Delhi. At the state level, the State TB Officer (STO),supported by other staff, looks after the activities in each state. State TB Training andDemonstration Centres (STDCs) provide programme training, guidance, supervision,coordination, monitoring, and technical assessment. The district level (or municipalcorporation level in large metropolitan areas) performs functions similar to those at the statelevel in this area. The Chief District Health Officer (CDHO), or equivalent, is the principalhealth functionary in the district and is responsible for all medical and public health activities,including the control of TB. The DTC is the nodal point for TB control activities in the districtand also functions as a specialized referral centre. The District Tuberculosis Officer (DTO) at theDTC has the overall responsibility of the programme at the district level and is assisted by aMedical Officer (MO), Statistical Assistant, and other paramedical staff.The sub-district level (also called the TB Unit [TU]) represents a population of about 500,000,stationed at community health centres (CHCs), block PHCs, or other such institutions, andstaffed with special paramedical personnel (Senior TB Laboratory Supervisor [STLS] and SeniorTreatment Supervisor [STS]). Functions at the sub-district level are implementation,monitoring, and supervision of TB control activities in the designated geographical area. Theteam at the TU maintains the TB register and prepares quarterly reports on case detection,sputum conversion, and results of treatment. An MO from the existing health facility where theTU is located is designated as the MO responsible for TB Control (MO-TC). The TU supervisesthe functioning of the Microscopy Centres (MCs), located in health institutions, with a norm ofone MC for about 100,000. Facilities for high-quality sputum microscopy are available at theMC. Intensive modular training, supervision, and cross-checking of the laboratory work ensurethat reliable results are obtained. The MCs also serve as centres for treatment observation(DOTS centre). In addition to the MCs, DOTS centres and DOTS providers are identified basedon the acceptability and accessibility from the patient’s point of view and accountability fromthe health system. In hilly areas, keeping in mind the sparse population and difficult terrain,population norms for TUs/MCs are relaxed. Modular training was used for all staff from MOs tohealth workers.All individuals who have a productive cough of three weeks or longer are identified as chestsymptomatics and referred to the MC for sputum examinations for AFB. Three sputumsamples are collected over two days—two spots and one early morning. Patients with twopositive smear results are diagnosed by the physician as having TB. They are furtherclassified as new or old cases based on their treatment history. Patients with only onepositive smear result are referred to the nearest X-ray facility. Patients who have one smearpositive and a chest X-ray compatible with TB are considered to have TB and are registered assmear-positive. Patients whose three samples are smear-negative are prescribedsymptomatic treatment or broad-spectrum antibiotics for one to two weeks. If symptomspersist, they are re-evaluated by X-ray and clinical examination. Patients who, in the opinionof the physician, have active TB, based on the X-ray findings and persistence of symptoms,are diagnosed as having smear-negative TB.189

Tuberculosis Control Efforts in India and UttaranchalOnce the patient has been diagnosed as having TB, the MO is responsible for indicating thetreatment regimen according to the following categories, depending on the history of previoustreatment and results of investigations.l Category I: New pulmonary sputum-positive, seriously ill sputum-negative pulmonary, andseriously ill extra-pulmonary cases2(RHZE) 3/4(RH) 3(six months)l Category II: Re-treatment cases2(SRHZE) 3/1(RHZE) 3/5(RHE) 3(eight months)l Category III: New non-seriously ill sputum-negative and extra-pulmonary cases2(RHZ) 3/4(RH) 3(six months)The prefix indicates the duration of drug administration in months. The subscript indicates number ofdoses per week. Abbreviations are as follows: R: rifampicin; E: ethambutol; H: isoniazid (INH); S:streptomycin; Z: pyrazinamide. All drugs are administered three times a week.Use of a patient-wise drug box, which contains the entire course of treatment for an individualpatient, is unique to India. It ensures that once a patient is diagnosed, a full course of treatmentis available for him or her. Follow-up sputum smears are done for sputum conversion and cure.One of the strengths of the RNTCP is the recording and reporting system, which ensuresaccountability for every patient who has started treatment. The programme is accountable forthe outcome of every patient treated. The cure rate and other key indicators are monitored atevery level of the health system, and if any area does not meet expectations, supervision isintensified. The RNTCP shifts the responsibility for a cure from the patient to the healthsystem. In areas implementing the RNTCP, the quality of diagnosis has been relatively good,and case-detection rates and sputum conversion rates have been high. In terms of populationcoverage, India’s DOTS programme is now second only to China’s in size globally. In 2001, theRNTCP initiated more than 470,000 patients on treatment, more than any other TB programmein the world. Under the programme, more than 40,000 patients were put on treatment everymonth, saving more than 7000 lives a month. More than one million patients have beguntreatment, saving more than 1.8 lakh lives and preventing more than 2 million infections.India is driving the global progress in TB control. In 1999, India accounted for one-third of theglobal increase in TB patients treated under the DOTS strategy. In 2000 and 2001, it accounted formore than half of the global increase. A key challenge is the need to balance the urgent need forrapid expansion with the equally important need to ensure quality of implementation. Whileundertaking a 25-fold expansion since mid-1998 to cover a population of more than 450 millionin 221 districts of 19 states, India’s quality of services have been maintained, with a cure rate ofmore than 80%, double the rate previously seen. The RNTCP is now the second largest suchprogramme in the world, having placed more than 1 million patients on treatment.190Every month, more than 160,000 patients are examined for TB, more than 4 lakh sputumsmears examined, and more than 40,000 patients placed on TB treatment. This achievementhas required a remarkable commitment from the highest levels of government to the most

Tuberculosis Control Efforts in India and Uttaranchalperipheral health workers, anganwadi workers, and members of the community, includingcured TB patients. 2 lakh health workers have been trained in the RNTCP and more than 7000state-of the-art binocular microscopes distributed. Treatment via many different people asDOTS providers is delivered as close to the patient as possible. Even while undertaking a rapidexpansion, cure rates under the RNTCP have been maintained at more than 80%. Byimplementation and expansion of the RNTCP, more than 180,000 lives have been saved.Experts caution that DOTS must not be implemented too rapidly, however. The experience inthe past four years in India, which matches that of many countries, is that phased expansion iscritical. Trying to expand too quickly can result in a poor programme, which can actuallyworsen the prospects for TB control by increasing drug resistance.The DOTS strategy is in practice in more than 100 countries. DOTS is one of the most costeffectivehealth interventions, with a potential of ensuring huge economic returns. The DOTSstrategy probably represents the most important public health breakthrough of the last fewdecades, in terms of lives saved. It is estimated that for every 100 patients treated under theRNTCP, 18 lives are saved in comparison to the older NTP. Each life saved represents a child,mother, or father who will go on to live a productive, TB-free, life. The operational feasibility ofDOTS in the Indian context has been demonstrated, with eight out of 10 patients treated in theprogramme being cured, as compared with approximately three out of 10 previously.Multi-drug resistant TB (MDRTB) refers to TB caused by strains of bacterium proven in alaboratory to be resistant to the two most active anti-TB drugs—isoniazid and rifampicin.Treatment of MDRTB is extremely expensive, toxic, arduous, and often unsuccessful. DOTS hasbeen proven to prevent the emergence of MDRTB, and also to reverse MDRTB where it hasemerged. MDRTB is a tragedy for individual patients and a symptom of poor programmeperformance.Non-governmental organizations (NGOs) and the private sector play a crucial role in TBcontrol. Private practitioners and private hospitals are often the first places where TB patientsseek treatment. The RNTCP has come out with a policy to involve NGOs and privatepractitioners in IEC and different components of service delivery.UttaranchalUttaranchal was formed on 9 November , 2000, from the state of Uttar Pradesh. The statehas a population of 84.8 lakh, residing in 13 districts organized under two divisions,Kumaon and Garhwal. The capital is located in Dehradun. Also, a major part of the state,especially in the north, comprises hilly and difficult areas in the Himalayan and Shivalikmountain ranges.Two districts, Dehradun and Almora, have been approved for RNTCP implementation.Uttaranchal and the Government of India are committed to expand RNTCP coverage to theentire state, and donor funds are in the process of being identified.191

Tuberculosis Control Efforts in India and UttaranchalBeing a new state, Uttaranchal lacks infrastructure, such as STDCs at the state level and DTCs insome districts, as well as a manpower shortage pending transfer of staff between Uttaranchaland Uttar Pradesh. Difficult and hilly terrain is another constraint faced by the state.State-and district-level programme managers should realize that a poor TB control programmeis worse than no TB control programme at all. Without a TB control programme, infectiouscases eventually die out; however, with a poor TB control programme, infectious cases continuelonger without getting cured, thereby spreading infection to many more people. Theimmediate priority for the state is to start good quality DOTS implementation after a fullpreparation and appraisal of the districts. Initially, all efforts should focus on improving andmaintaining high-sputum conversion and cure rates. Experience from other parts of India hasshown that if service delivery starts poorly, bad habits develop, which subsequently becomedifficult to change; hence, the need to maintain quality right from the beginning.BibliographyBalasubramanian, VN, K Oommen, and R Samuel. 2000. “DOT or Not? Direct Observation ofAnti-tuberculosis Treatment and Patient Outcomes, Kerala State, India.” International Journalof Tuberculosis and Lung Disease 4: 409–413.Cao, JP, LY Zhang, JQ Zhu, and DP Chin. 1998. “Two-year Follow-up of Directly-observedIntermittent Regimens for Smear-positive Pulmonary Tuberculosis in China.” InternationalJournal of Tuberculosis and Lung Disease 2: 360–364.Centers for Disease Control and Prevention. 1993. “Initial Therapy for Tuberculosis in the Era ofMultidrug Resistance: Recommendations of the Advisory Council for the Elimination ofTuberculosis.” [published erratum appears in MMWR Morb Mortal Wkly Rep 1993 July 26;42(27): 536]. Morbidity and Mortality Weekly Report 42: 1–8.Central TB Division, Directorate-General of Health Services. 2000. Operational Guidelines forTuberculosis Control. New Delhi.Central TB Division, Directorate-General of Health Services. 2000. Technical Guidelines forTuberculosis Control. New Delhi.Cohn, DL, BJ Catlin, KL Peterson, FN Judson, and JA Sbarbaro. 1990. “A 62-dose, 6-monthTherapy for Pulmonary and Extrapulmonary Tuberculosis: A Twice-weekly, Directly Observed,and Cost-effective Regimen.” Annals of Internal Medicine 112: 407–415.Comolet, TM, R Rakotomalala, and H Rajaonarioa. 1998. “Factors Determining Compliancewith Tuberculosis Treatment in an Urban Environment, Tamatave, Madagascar.” InternationalJournal of Tuberculosis and Lung Disease 2: 891–897.192

Tuberculosis Control Efforts in India and UttaranchalDye, C, GP Garnett, K Sleeman, and BG Williams. 1998. “Prospects for Worldwide TuberculosisControl under the WHO DOTS Strategy. Directly Observed Short-course Therapy.” Lancet 352:1886–1891.Dye, C, S Scheele, P Dolin et al. 1999. “Global Burden of Tuberculosis: Estimated Incidence,Prevalence, and Mortality by Country.” JAMA 282: 677–686Espinal, MA, SJ Kim, PG Suarez, et al. 2000. “Influence of Initial Drug Resistance on theResponse to Short-course Chemotherapy of Pulmonary Tuberculosis.” Journal of the AmericanMedical Association 283: 2537–2545.Garland, LH 1959. “Studies on the accuracy of diagnostic procedures.” American Journal ofRoentgenology Therapeutic Nuclear Medicine 82: 25–38.Hong Kong Chest Service/British Medical Research Council. 1976. “Adverse reactions to ShortcourseRegimens Containing Streptomycin, Isoniazid, Pyrazinamide, and Rifampicin in HongKong.” Tubercle 57: 81-95.http//:www.tbcindia.org.Iseman, MD, DL Cohn, and JA Sbarbaro. 1993. “Directly Observed Treatment of Tuberculosis.We Can’t Afford Not to Try It.” New England Journal of Medicine 328: 576–578.Khatri, GR 1999. “The Revised National Tuberculosis Control Programme: A Status Report onFirst 100,000 Patients.” Indian Journal of Tuberculosis 46: 157.Khatri, GR and TR Frieden. 2000. “The Status and Prospects of Tuberculosis Control in India.”International Journal of Tuberculosis and Lung Disease 4: 193–200.Ledru, S, B Cauchoix, M Yameogo, et al. 1996. “Impact of Short-course Therapy on TuberculosisDrug Resistance in South-West Burkina Faso.” Tubercle and Lung Disease 77: 429–436.Mitchison, DA and JM Dickinson. 1971. “Laboratory Aspects of Intermittent Drug Therapy.”Postgraduate Medical Journal 47: 737–741.National AIDS Control Organization, Ministry of Health and Family Welfare, Government ofIndia. 2001. Combating HIV/AIDS Epidemic in India: 2000-2001. Delhi: NACO.Ollé-Goig, J E, and J Alvarez. 2001. “Treatment of Tuberculosis in a Rural Area of Haiti: DirectlyObserved and Non-observed Regimens. The Experience of Hôpital Albert Schweitzer.”International Journal of Tuberculosis and Lung Disease 5: 137–141.Ramachandran, R, R Balasubramanian, M Muniyandi, et al. 1999. “Socio-economic Impact ofTB on Patients and Families in India.” International Journal of Tuberculosis and Lung Disease3: 869–77.193

Tuberculosis Control Efforts in India and UttaranchalRegional Office for South-East Asia, WHO. 2000. Joint Tuberculosis Programme Review, India,February 2000. SEA-TB-224. New Delhi: SEARO WHO.Swaminathan, S, R Ramachandran, G Baskaran, et al. 2000. “Risk of Development ofTuberculosis in HIV-infected Patients.” International Journal of Tuberculosis and Lung Disease4: 839–844.Toman, K. 1979. Tuberculosis Case-finding and Chemotherapy. Geneva: World HealthOrganization.Tuberculosis Research Centre, Chennai. 2001. “Low Rate of Emergence of Drug Resistance inSputum Positive Patients Treated with Short-course Chemotherapy.” International Journal ofTuberculosis and Lung Disease 5: 40–45.Tuberculosis Research Centre, Chennai. 2001. “Trends in the Prevalence and Incidence ofTuberculosis in South India.” International Journal of Tuberculosis and Lung Disease 5: 142–157.Volmink, J, P Matchaba, and P Garner. 2000. “Directly Observed Therapy and TreatmentAdherence.” Lancet 355: 1345–1350.Weis, SE, PC Slocum, FX Blais, et al. 1994. “The Effect of Directly Observed Therapy on the Ratesof Drug Resistance and Relapse in Tuberculosis.” New England Journal of Medicine330: 1179–1184.World Bank. 1993. Investing in Health: World Development Report 1993. New York, OxfordUniversity Press.World Health Organization (WHO). 1994. TB—A Global EmergencyTuberculosis Epidemic, 1994. WHO/TB/94.177. WHO Report on theWorld Health Organization (WHO). Framework for Effective Tuberculosis Control. WHO GlobalTuberculosis Programme, 1994. WHO/TB/94.179World Health Organization (WHO). 1995. Stop TB at the Source. WHO Report on theTuberculosis Epidemic, 1995. WHO/TB/95.183World Health Organization (WHO). 1997. Treatment of Tuberculosis: Guidelines for NationalProgrammes. Second Edition. Geneva: WHO. WHO/TB/97.220World Health Organization (WHO). 2000. Anti-tuberculosis Drug Resistance in the World. ReportNo. 2: Prevalence and Trends. The WHO/ IUATLD global project on anti-tuberculosis drugresistance surveillance. Geneva: WHO. WHO/CDS/TB/2000.278.194

Tuberculosis Control Efforts in India and UttaranchalWorld Health Organization (WHO). 2002. WHO Report2002. Global Tuberculosis Control. Geneva: WHO.Case-detection (2001) and treatment successrates (2000) in RNTCP areasZhang, LX, DH Tu, and DA Enarson. 2000. “The Impactof Directly-observed Treatment on the Epidemiology ofTuberculosis in Beijing.” International Journal ofTuberculosis and Lung Disease 4: 904–910.Treatment success1009080706050403020100West BentalMaharashtraBiharJharkhandTamil NaduAll states totalGujaratTreatment success of new smearpositivepatients registered in 2000.Estimated % detection of new smearpositivepatients 2001KeralaHimachal Pr.Madhya Pr.Haryana KarnatakaRajasthanOrissaManipurDelhiAssamUttar Pr.Detection rate195

Session 6Other Health IssuesChairpersonDiego PalaciosCare of the ElderlyA K SinghHospital Waste ManagementD B AcharyaStreamlining Drug Procurement andSupply System in UttaranchalRameshwar SharmaSanitation and Public Health Issues withReference to UttaranchalJayant Keshav NatuAyurveda and Unani Department and the Convergenceof Services with the Health Department in UttaranchalAlok Kumar Jain and D S NathDiscussantRamesh Chandra

Care of the ElderlySession 6Care of the ElderlyA K Singh, Senior Executive Officer, HelpAge IndiaAgeing Scenariol 77 million in 2001: males 37 million, females 40 millionl 177 million in 2025: males 84.96 million, females 92.04 millionl Population over age 80 in 2000: 6,320,000l Population over age 80 in 2025: 33,936,000l 72% residing in rural areas in 2001l 73% of the older persons illiterate in 1991l 40% living below poverty linel 55% of women (60 years or more) are widows.Throughout the world, population groups are ageing rapidly. As family unitsbecome smaller and young adults relocate to find work, increasing numbers ofolder people are left to cope alone. In recent years, the family as an institutionhas undergone a metamorphosis both in terms of structure and function.Industrialization, migration, and urbanization have reduced the extendedfamily to a nuclear family, no longer performing the functions of social securityand socialization of the younger generation. With children migrating to urbanareas for better economic prospects, older people are left alone facingeconomic and social challenges. Most of them want to stay in their homes iftheir quality of life can be maintained. The result is a growing need for homebasedcare services.Home care refers to a range of services provided to people in their own homes, toenable them to continue living as actively and independently as possible. Homecareservices fall broadly into two categories—(1) social care and (2) health care.Social care encompasses both practical and emotional support. It includeshome help (housekeeping), delivering or preparing meals, carrying out errands,escorting (accompanying older individuals on essential visits, for example, tothe doctor), paperwork (filling in forms, writing letters), contact with outsideagencies, some assistance with personal care, and befriending the person.199

Care of the ElderlySocial care is usually provided by family members, friends, neighbours, volunteers, and socialworkers—trained and untrained.Health care includes carrying out health checks, health education (in self care), nursing, therapy,and health-related home improvements. Health care services are usually provided by trainedpeople under the supervision of professional health workers, such as doctors, nurses, socialworkers, and therapists, or by health workers themselves.Home-care services are needed by the small but growing proportion of older people who havedifficulty managing daily living and accessing health care services, and who lack family support.This applies particularly to women, many of whom outlive their husbands. In many societies,older women, particularly widows, have low social status and low income, making themvulnerable to abuse and neglect.Neglect and discrimination that women are exposed to throughout their lives have a majorimpact on their health and well-being as they get older. Women in India suffer from a “tripleburden” that is demographic, because of heavy child-rearing responsibilities accompanying highfertility rates; gastronomic, because of the constraints of poverty, traditional styles, and methodsof cooking and eating; and gerontological, because of additional elders. Women play animportant role as care-givers in families, and it is a life-long activity. Care-giving is stressful, andas women age, they become more susceptible to illnesses that family members and societyhardly recognize.For elderly females, the last two or three decades of life are dominated by two broad categoriesof health disorders greatly impairing the quality of their lives — (1) gynaecological disorders,accumulated during their reproductive years and compounded by post-menopausal morbidityand (2) clinical disorders, commonly associated with ageing, such as diabetes, hypertension,osteoporosis, and cardio-vascular disorders. However, in reality, health support needed bywomen is unfortunately not available to most, even in urban settings.Comprehensive Care of the ElderlyThe joint family system has a strong foundation in the Indian culture. Welfare of the elderly isinherently built in the family system and structure. However, traditional care systems are nowchanging. The increase in longevity and the growing number of elderly, accompanied by thedecline in fertility and continuing reduction in the number of children in families, are adverselyaffecting the care of the elderly. Traditionally, their care has been largely shared by women (i.e.,spouses, daughters, daughters-in-law), who provide physical, emotional, and, frequently,economic support. For widows, for the elderly without children, or for chronically ill elderlyindividuals, care becomes more difficult.Further, due to economic transitions, the entry of women into the labour force, rising inflation,and the necessity of more family members to seek employment, care of the elderly is becomingmore difficult. The number of widows exceeds widowers; discrimination, oppression, poverty,and illness are now becoming their fate in old age.200

Care of the ElderlyThe problem of women in India needs special consideration. Most women have no share inproperty or pensions and, if employed, receive lower wages. Thus, living with kin has becomenecessary for the very old and frail.Harmonious relations between care-givers and recipients, along with mutual respect, love, andaffection, improves quality of care despite economic hurdles and social pressure on thecare-giver. However, demographic trends and the diminishing capacity to provide care arecreating several problems for care-givers. Also, the dynamics of care giving is becoming morecomplex. For example, the ‘money-order economy’ of the Himalayan region is an illustration ofthe suffering of the elderly due to the migration of young folk from the hills to other areas forjobs, who then finance their parents through money orders. The elderly who have always beenpoor in families that continue to be poor constitute the most vulnerable sector of the elderlypopulation. Comprehensive care of the elderly must be physical, emotional, and spiritual. Inaddition, inflation and changes in the social structure need external institutional involvement,strengthening, and restructuring to meet geriatric needs. Presently, the science of gerontology isslightly new to our medical colleges; concerted efforts are needed to meet the challengingrequirements of the elderly in India. More than 50% of the elderly have at least one ailment.Yoga, naturopathy, homeopathy, acupressure, and other traditional systems need to beencouraged.Through proper awareness programmes, the elderly can be usefully engaged in a variety ofdevelopmental activities, which will boost their morale and reduce depression and the feeling ofloneliness. Part-time employment should be encouraged. Religious organizations should takecare of the spiritual aspects and lead them towards a more fulfilling and happy life. This will alsoimprove their inter-generational relationships.Elderly individuals are a highly vulnerable group in society, and their vulnerability increaseswith age. Their vulnerability lies mainly in their lack of employment, financial insecurity, illhealth, and neglect by society. Any social security system for the elderly should address all thesevulnerabilities. Thus, any programme to combat this must be multi-dimensional, providingincome security, health security, long-term care, as well as emotional support. While familiescan provide the basic security for the elderly, the major responsibility for providing their socialsecurity lies with the community and the state.It is important to assess the resources, potential of the primary care physician, and demand andavailability of other social/rehabilitative services with strategies for optimal turnover throughwell-educated health professionals. For achieving this, a classification of both the elderly andservices will be necessary. The elderly are grouped as follows.l With no apparent diseasel With acute diseasel With chronic diseasel With family supportl Singlel Needing terminal care.201

Care of the ElderlyEach group has different problems, both apparent and hidden. A thorough study can only revealthe specific approach to these problems. However, the idea that old age is a time of ailments andphysical infirmities is deeply rooted in Indian culture. The elderly accept physical troubles andlimitations as natural and inevitable.The trends in the size and growth rate of the elderly population in India reveal that gerontologywill become a major social challenge in the future when vast resources are needed to support,care, and treat the elderly. Therefore, it is time to adopt suitable policy measures to minimizethe problems of elderly in the country. The following are some of the measures suggested toimprove the health status of the elderly in India.l Health education for the elderly should be an important aspect of their health care, so thatthey could learn certain “dos and don’ts” related to different diseases and inculcate these intotheir behaviour to prevent the occurrence of diseases or reduce the effects of illnesses.l There is a necessity to train both indigenous and allopathic doctors to handle the specificillnesses associated with ageing.l It is necessary to establish subsidized health care for the elderly with special units inhospitals and with free or highly subsidized medicines. Subsidized health care would alsorepresent an indirect transfer of resources to the family.l Creation of special geriatric wards in major hospitals and the establishment of specialcounters and geriatric out-patient units in existing hospitals will greatly help the elderly.l Social gerontology needs to be a part of the syllabus for medical professionals and paraprofessionals,so that they integrate health education along with the health care provided tothe elderly persons.l A proper coordination between health care and welfare measures needs to be attempted forthat would be most cost-effective as well as more efficient.l Irrespective of their health status, a majority of the elderly, especially those who are poor, areworking full time, mainly to earn a living. Thus, there is a need to introduce communitybased,income-generating schemes for the benefit of the elderly poor.l Among the elderly poor, the lack of food may be a major factor responsible for reduced intakeand consequent poor health. Thus, supplementary nutrition programmes targeting theneedy elderly in poor localities may be considered a priority to help them improve theirhealth status.l Use of appropriate aids, regular medical check-ups, and intake of medicines among theelderly poor is almost absent, in spite of their requirement from a health point-of-view.Therefore, local NGOs working even on other social issues of society may regularly interactwith the elderly of their community and see that the benefits reach them in time.l Community members must be sensitized to the problems of the elderly for greatercommitment to and involvement with the elderly.202

Care of the ElderlyReferencesBhatla, P C. 1999. “Health and Welfare of the Elderly in India–An Assessment.” HelpAge India–Research & Development Journal 6(1): 11–15.Kapoor, R N. 2001. Multigenerational Relationships–Indian Context, Active Ageing in the NewMillennium. Anugraha. pp. 22–31.Karkar, Malini. 1999. “Let Us Care for our Older Women.” HelpAge India–Research & DevelopmentJournal 6(1): 19–21.Singh, Savita. 1999. Feeling Young at Sixty. New Delhi: Ratan Press.Subrahmanya, R K A. 2002. “Social Security for the Elderly.” HelpAge India–Research &Development Journal 8(1): 5–15.203

Hospital Waste ManagementSession 6Hospital Waste ManagementD B Acharya, Senior Health Officer and Controller of Waste Management,Jaipur Municipal Corporation, JaipurIntroduction: Issues and ConcernsThe management of biomedical waste or hospital waste is a globalhumanitarian issue today. The hazards of poor management of biomedicalwaste have aroused concern the world over, especially in light of its far-reachingeffects on human health and the environment.Biomedical waste is generated in the diagnosis, treatment, prevention, andresearch of human and animal disease. Huge quantities of biomedical waste,running into millions of tonnes, are produced by hospitals, clinics, andlaboratories throughout the world. This waste presents health risks to the publicand the environment, and, in particular, to those who generate and come intocontact with it.With the introduction of legislation by the Government of India (GoI) forBiomedical Waste Rules (20 July, 1998), managers of health care facilities suddenlyfound themselves not knowing exactly what to do. The rules provide broadguidelines. However, standard procedures for hospital waste management are yetto evolve. There is a need for specific guidelines for the practice of biomedicalwaste management to be developed and introduced in all health care facilities.Health care waste presents occupational health risks to those who generate,package, store, transport, treat, and dispose of it. Improper biomedical wastemanagement poses serious risks to the environment, patients, medical personnel,and people involved in the provision of support services to health care facilities.Thus, hospitals and medical care establishments as well as the general public areexposed to improperly handled medical waste. Biomedical waste is dangerousand a source of infection for diseases, such as hepatitis and AIDS.Although hospital waste management has become a serious concern throughoutthe world, only a few states and districts in India have given adequate thought to204

Hospital Waste Managementproperly managing the collection and disposal of waste from hospitals. The administration isstill not familiar with proper waste classification, segregation, handling, disposal of the wastegenerated in hospitals, and treatment technologies. In many instances, waste handling is left topoorly educated, low-level workers operating without adequate guidance and supervision. Arecent study demonstrated that hospital waste management throughout the country requiresimprovement in order to reduce health risks from improper handling and disposal ofbiomedical waste. It is a matter of concern that two-thirds of waste-controlling authorities,administrators, and managers of government and non-government health care facilities claimthat they are not aware of either the documents outlining the hospital waste management rulespublished in July 1998 or their directives. About 80%–90% of respondents indicated that theywere not aware of the existing rules.Biomedical waste management is like the ‘Christmas Tree Syndrome’—from one package, theamount of waste continues to grow downwards, and new branches generating more and morewaste arise. Biomedical waste management has assumed great importance the world overbecause of the serious hazards it poses to the environment in general and the public inparticular. Before we understand the basic principles of biomedical waste management, it isimperative to know exactly what constitutes biomedical waste.Perhaps one of the most important issues in biomedical waste management and its regulation is thedefinition of exactly what constitutes infectious waste. Unlike for chemical and radioactive waste, noobjective tests exist to identify or classify infectious waste from the hospital waste stream. Thus,infectious wastes are categorized primarily by subjective evaluation of the health hazard potential.Waste generated from different health facilities will have a different character in the compositionof biomedical waste. Therefore, the waste generated from maternity and obstetric wards willhave large amounts of placentas, abortus, and soiled sanitary napkins, while the wastegenerated from operation theatres (OTs) will consist mainly of swabs, bandages, viscera, tubes,catheters, and so forth. Similarly, the waste generated from pathological centres will have sharps,needles, vials, cotton, body fluids, urine, stool and blood.Infectious and non-infectious waste are generated simultaneously along with other hospitalwaste, and once generated, are difficult to separate because of health and safety concerns.Because of this problem, non-infectious (black bag) waste finds its way into the infectious (redbag) waste, and, unfortunately, this infectious waste may be deposited with the municipal wastethat goes directly to a landfill, polluting the total municipal waste into infectious waste.Improper segregation will lead to all hospital waste being considered as infectious waste,barring waste from kitchens and offices.Although the medical waste stream represents only a small fraction of the total municipal waste,it is most visible and critical in public opinion. In 1996, home health care waste, such as sanitarynapkins, baby diapers, and equipment used in home health care, (syringes, needles, cathetertubes, discarded cytotoxic drugs, etc.), was 16% of the total hospital waste generated. Since then,this figure has grown steadily in India as well as worldwide and needs attention.205

Hospital Waste ManagementA hospital’s infection control programme must include proper hospital waste managementtraining and an action plan as elements of its strategy. With regard to hepatitis B and HIV,biomedical waste is a dangerous source of infection. Compared with other areas of the world,hepatitis B is growing the fastest in India. HIV infection is another major hazard. It is said thatMumbai is the AIDS capital of India, because roughly 5% of the population there is sufferingfrom AIDS or is HIV-positive. In the state of Rajasthan, hepatitis B positivity has been found in4% of the population and is increasing constantly. In fact, infectious diseases remain a leadingcause of death in many parts of the world. Many infectious diseases once thought conquered areincreasing, such as tuberculosis, polio, and jaundice, and continue to be a serious public healththreat. Over the last decade, the health care industry has shifted from a mainly reusable productsupply system (all glass syringes, hospital laundry) to a primarily disposable product supplysystem (disposable syringes and needles, use-and-throw hospital linen). The unscrupulousrecycling of these disposables contributes largely to the spread of infections like hepatitis B andC and HIV.The recent legislation for biomedical waste deals with the following matters.1. Biomedical waste management should aim to prevent occupational, public health, andenvironmental hazards, and should also take into account aesthetic aspects.2. The recovery and recycling of materials must be done with caution, taking into accountsafety, health, and environmental risks.3. Hazardous health care waste should be dealt with as part of an overall hazardous wastemanagement system, with appropriate control procedures.4. It is mandatory that waste contaminated with pathogens of diseases, notifiable underepidemic control regulations, such as cholera, gastroenteritis, and plague, should not leavethe premises unless suitably disinfected.Hospital waste management requires commitment from persons at all levels of the health carefacility. According to the World Health Organization, “The human element is more importantthan the technology. Almost any system of treatment and disposal that is operated by welltrainedand well-motivated staff can provide more protection for staff, patients, and thecommunity than an expensive or sophisticated system that is managed by staff, who do notunderstand the risks and the importance of their contribution.”Management of Hospital WasteIdentification of Various Components of the Waste GeneratedThe 1998 Biomedical Waste (Management and Handling) Rules say that such waste shall besegregated into containers/bags at the point of generation, in accordance with Schedule II of therules, prior to its storage, transportation, treatment, and disposal. All containers bearinghazardous material must be labelled with the ‘biohazard’ or ‘cytotoxic’ symbol as the case maybe, according to Schedule III of the rules. At the same time, the containers should bear the nameof the department/laboratory from which the waste has been generated and the name of theconcerned person so that, in case of a problem or an accident, the nature of the waste can betraced back quickly and correctly and the responsible person can be traced.206

Hospital Waste ManagementIn addition to the above, the containers should also be labelled with the date, name of thedepartment, and the name and signature of the person responsible. This would generate greateraccountability and, in case of a problem or accident, the nature of the waste could be traced backquickly and correctly for proper remediation.Recommended Labelling and Colour CodingLabelling and colour coding have to be in accordance with the notified rules as per Table 1below.A simple and clear notice, describing which waste should go into which container and howfrequently it has to be routinely removed and to where, is to be pasted on the wall or in aconspicuous place near the container. The notice should be in English, Hindi, and thepredominant local language. Preferably, it should have drawings correlating the container in theappropriate colour with the kind of waste it should contain.Table 1. Recommended Labelling and Colour CodingNo. Waste Category Type of Container Colour1 Human anatomical waste (human tissues, Plastic bag Yellow when theorgans, body parts)collected material is toAnimal waste (animal tissues, body parts,be subjected toorgans, carcasses, etc. of experimentalincinerationanimals used in research)Microbiology and biotechnology waste(discarded laboratory cultures, stocks orspecimens of micro-organisms, live/attenuated vaccines, human/animal cellcultures)Solid waste (items contaminated with blood/body fluid such as dressings, plaster casts,cotton)2 Solid waste (disposable items other than Plastic bag / disinfected Red when the waste is towaste sharps, such as tubings, catheters, container be autoclaved/intravenous sets)microwaved/treatedMicrobiology and biotechnology wastechemically(as mentioned above)Solid waste (as above)3 Waste sharps (needles, syringes, scalpels) Plastic bag/ Blue or whiteSolid waste (as above) puncture-proof translucentcontainer4 Discarded medicines and cytotoxic drugs Plastic bag BlackIncineration ash and chemical waste(chemicals used in production ofbiologicals or as disinfectants)Segregated Storage in Separate Containers (at the Point of Generation)Each category of waste (according to Schedule I of the rules) has to be kept segregated in aproper container or bag as the case may be. Such a container/bag must be sturdy enough tocontain, the designed maximum volume and weight of the waste without any damage. It should207

Hospital Waste Managementbe without any puncture/leakage. The container should have a cover, preferably operated byfoot. If plastic liners are to be used, they have to be securely fitted within a container in such amanner that they stay in place during the opening and closing of the lid and can also beremoved without difficulty. The sharps must be mutilated by a needle cutter, which is placed inthe department/ward itself, before putting them in puncture-proof sharps containers. Attemptsshould be made to designate fixed places for each container so that it becomes a part of theregular scenario and practice for the concerned medical and nursing staff.CertificationAfter filling a bag or container two-thirds it is sealed. A tag, indicating the name of thedepartment, the type of waste, its contents/composition, the person responsible, date, shift, time,and so forth, has to be attached. A waterproof marker pen should be used for writing.Common/Intermediate Storage AreaThere needs to be a collection room/intermediate storage area where the waste packets/bagsare collected before they are finally taken. Transportation to the treatment/disposal site isnecessary for large hospitals having a number of departments, laboratories, OTs, and wards.This is all the more important when the waste is to be taken outside the premises. Arrangementfor separate receptacles in the storage area with prominent display of colour codes on the wallnearest to the receptacles has to be made. When waste-carrying carts/containers arrive at thisarea, they have to be systematically put in the relevant receptacle/designated area.Handling and TransportationHandling and transportation activities have three components — (1) collection of different kindsof waste inside the hospital, (2) transportation and intermediate storage of segregated wasteinside the premises, and (3) transportation of the waste to the treatment/disposal facility outsidethe premises (Table 2).A review of Table 2 shows that there is no single technology that can take care of all categories ofbiomedical waste. A judicious package has to be evolved for this purpose. For example, smalland medium hospitals can opt for local (in-house) disinfection, mutilation/shredding, anddedicated autoclaving plus off-site incineration at a common treatment/disposal facilityfollowed by disposal in sanitary and secured landfills.Treatment Technologies for Medical WasteTreatment technologies for medical waste require the following norms.llllllCompliance and performance testingMonitoring and recordingOperator training and qualificationsWaste management planningFacility inspectionsReporting and record keeping.208

Hospital Waste ManagementTable 2. Treatment and Disposal Options According to Categories of Biomedical Waste(Schedule I)Category Waste Category Treatment and DisposalCategory 1 Human anatomical waste (human Incineration @ /Deep burial *tissue, organs, body parts)Category 2 Animal waste (tissue, organs, body Incineration @ /Deep burial *parts, fluid, blood, carcasses ofexperimental animals)Category 3 Microbiology and biotechnology Local autoclavingwaste (laboratory cultures,/microwaving/incineration @stocks/specimen of micro-organisms,live/attenuated vaccines, cell cultures)Category 4 Waste sharps (needles, syringes, Disinfection (chemical treatment @@ /scalpels, blades, broken glass)autoclaving/microwaving) andMutilation/shredding ##Category 5 Discarded medicines and Incineration/destruction and disposalcytotoxic drugsin secured landfillsCategory 6 Solid waste (items such as cotton, Incineration @ /dressings, plaster casts, etc.autoclaving/microwavingcontaminated with blood/body fluid,soiled linen, bedding, etc.)Category 7 Solid waste (disposable items other Disinfection by chemicalthan sharps, such as tubulins,treatment @@ /autoclaving/catheters, intravenous sets, etc.)microwaving and mutilation/shredding ##Category 8 Liquid waste (from washing, Disinfection by chemicalcleaning, housekeeping, disinfecting, treatment @@ and dischargelaboratory, etc.)into sewers/drainsCategory 9 Incineration ash (of any biomedical Disposal in municipal landfillwaste)Category 10 Chemical waste (chemicals used in Chemical treatment @@ andproduction of biologicals, disinfection, discharge into sewer/drains foras insecticides, etc.)liquids and secured landfill for solids@@ Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent.Chemical treatment must ensure disinfection.@ There will be no chemical pre- treatment before incineration. Chlorinated plastics shall not be incinerated.* Deep burial shall be an option available only in towns with a population of less than five lakhs and in rural areas.## Mutilation/shredding must be done in a manner that can prevent its unauthorized use.Environmental considerationsl Issues of concernn Treatment system will emit pollutants.lPotential impacts and risksn Air emissionsn Water effluentn Residue may have hazardous leachate in a landfill.209

Hospital Waste ManagementTreatment Technologies for Liquid WasteTable 3. Advantages and Disadvantages of Medical Waste Treatment and Disposal MethodsMethod Advantages DisadvantagesSanitary sewer l Most suitable for liquid, body fluids l Least suitable for solids and non-(dilution of liquid and other bulk liquids biodegradable wastes (metals orwaste l Sanitary sewer systems are designed plastics)to treat biological waste l Requires safety precautions (andsometimes facility modification) toprotect workers from splashes andaerosolsl Requires approval of local wastewater treatment worksThe standards for effluents generated from the hospital as recommended by the CentralPollution Control Board (CPCB), GoI, are shown in Table 4.Table 4. Effluents Generated from the Hospital Shall Conform to the Following Limits:ParametersPermissible LimitpH 6.5–9.0Suspended solids100 mg/1Oil and grease10 mg/1Biochemical Oxygen Demand30 mg/1Chemical Oxygen Demand250 mg/1Bioassay test90% survival of fish after 96 hours in 100% effluentNote:These limits are applicable to hospitals that are either connected with sewers without a terminal sewagetreatment plant or not connected to public sewers at all.Waste Treatment Process Categoriesl Thermal systemsn Incinerator systemsn Autoclave/hydroclave/autoclave systemsn Microwave systemsn Pyrolysis and plasma pyrolysis systems.l Chemical treatment systemsl Irradiation systemsl Biological process systems.Thermal Treatment Systems (Incinerator Systems)State-of-the-art combustion technology includes the following:l Two-stage controlled air combustion: first chamber temperature 800°C ± 50°C and secondchamber 1200°C ± 50°C with a pollution prevention device called a scrubberl Modulating burners and combustion air blowersl Automatic loading and ash removall Controls, instrumentation, and monitoring.210

Hospital Waste ManagementTable 5. Present Scenario of Incineration System PerformanceNo. Major Performance Difficulties Examples1. Objectionable stack emission l Out of compliance with air pollution control regulationsl Visible emissionsl Odoursl Hydrochloric acid gas deposition and deteriorationl Entrapment of stack emissions into building air intakes2. Poor burnout l Low waste volume reductionl Recognizable waste items in ash residuel High ash residue carbon content (combustibles)3. Excessive repairs and l Frequent breakdowns and component failuresdowntime l High maintenance and repair costsl Low system reliability4. Unacceptable working l High dust conditions and fugitive emissionsenvironment l Excessive waste spillsl Excessive heat surfaces (global warming)5. System inefficiencies l Excessive auxiliary fuel usage (oil or electricity)l Low steam recovery ratesl Excessive operating-labour costsThe Common reasons for incineration failure in installation are as follows.l Incineration equipment manufacturer unqualifiedl Equipment installation contractor unqualifiedl Inadequate instructions and supervision from the manufacturer for system installation bythe general contractorl No clear lines of system performance responsibility between the manufacturer and thegeneral contractor/supplierl Failure to review manufacturer’s shop drawings, catalogues, and materials and constructiondata to assure compliance with contract design documentsl Inadequate quality control during and following construction to assure compliance withdesign (contract) documentsl Payment schedules inadequately related to systems performance milestonesl Final acceptance testing not required for demonstrating system performance in accordancewith contact requirements.There are the following categories of performance problems with incinerators.1. An unacceptable working environment often arises, such as excessive ambient temperatures,uncontrolled waste spillage, and fugitive emissions of fly ash, and sometimes even flames.2. The combustion efficiency according to the CPCB guidelines is achievable only theoreticallyand never practically. All the certificates issued by state pollution control boards or the CPCBare either false or bogus.3. As the fuel is to be arranged from the market, the staff generally sells the fuel, runs only theprimary chamber, and adjusts the fuel sold.211

Hospital Waste Management4. Temperature is detected by a thermocouple with a life of 20–25 days. The thermocoupleburns out because it is in direct contact with the flame. This leads to erroneous readings; theactual chamber temperature may be very low or very high.5. The life of the refractory liner is a maximum of 2–3 years.6. The fuel is purchased through the stores and its erratic supply can result in closure of theincinerator units.7. There has been a difference of more than 200%–300% in the purchase price of incineratorsfor government and private hospitals.8. Most of the hospital waste is scavenged by the ward boy, staff, and rag-pickers. This reducesthe calorific value of waste and requires more fuel.Nearly 80% hospitals depend on incineration for disposal of biomedical waste. 1998 BiomedicalWork Rules for emission standards increase the purchase and operation cost tenfold. Theoptions will includel developing hospital-owned regional disposal facility,l CTF, andl paying high amount for incinerator upgrading or for new technologies.Features of Autoclave Systemsl Direct heatl Temperature/pressurel Steam penetration.Features of Hydroclave Systemsl Indirect heatl Innovation type of steam sterilizationl Double-wall container.The hydroclave is an advanced form of autoclave, according to the CPCB Report, 2000. Inhydroclave steam sterilization, steam is reused and stored in an outer jacket. In fact, themoisture from waste, which averages 40% in Indian waste, is converted into steam by heatingfrom the outside. Hydroclave provides low-temperature steam sterilization with significanttechnological advancement and innovation.l The hydroclave sterilization vessel is a double-walled (jacketed), cylindrical vessel, fittedwith a powerful mixing/fragmenting system on the inside.l Steam heat is applied to the jacket only, while the agitated waste absorbs the heat from thejacket and makes its own steam from its moisture content.l All particles of the fragmented, agitated waste, including sharps and liquids get exposedevenly to the heat.l There is no need for special autoclave bags or pre-treatment of the waste.l Liquids and gases remain locked inside the vessel until sterilization is complete—nothing isvacuumed or pumped out in its infected state.l Jacket steam heat will completely dehydrate the waste, regardless of its original watercontent.212

Hospital Waste ManagementllllllAll the hot condensate from the jacket is recycled back to the boiler, making the hydroclavevery economical to operate.Due to continuous agitation, all particles of the waste achieve a high level of “sterilization”and not just “disinfection.”Hydroclave emissions tested at normal operating temperature (121°C) demonstrated noharmful emissions from the process.There is no worker contact with infectious waste.There is no pre-treatment of infectious waste necessary.There are no special waste bags required.Features of Chemical Treatment Systemsl Chlorine compoundsl Must utilize registered disinfectantl Incorporate shredding.Points to rememberl Put cut gloves and plastic in bleach solution.l Put all other infectious waste, such as pathological waste, bandages, dressings and cotton ina yellow bag.l Always cut needles with the needle-cutter and disinfect with bleach solution.l All sharps to be put into the sharp container.For Recycling of reusable glass syringes and needle steps, the following steps are suggested.l Wear gloves.l Leave the needles attached to the syringes.l Aspire hypochlorite solution or any disinfectant, containing 0.1% available chlorine, intosyringe.l Immerse the syringe and the attached needle in the universal disinfectant solution,horizontally in a flat tray.l Leave them immersed in the disinfectant solution for 20 minutes.l Discharge the disinfectant solution from the syringe and needle.l Rinse the syringe and needle with water, filling and emptying several times.l Examine needles and syringes; if disposable, then discard as sharps waste.l If glass syringe, then sterilize the syringe and needle by autoclaving or disinfecting by boilingfor 20 minutes in water prior to reuse.l Never recap a needle once its cap is removed.213

Hospital Waste ManagementTable 6. Universal Disinfectant: Recommended Dilutions of Chlorine Releasing CompoundsClean conditionDirty conditionAvailable chlorine required (1g/litre) 0.1% 91g/litre) 0.5% (5g/litre)Sodium hypochlorite solution (5% available) 20 ml/litre 100 ml/litreCalcium hypochlorite (70% available chlorine) 1.4 g/litre 7.0 g/litreNaDCC tablets (69% available chlorine) 1.7 g/litre 8.5 g/litreNaDCC tablets (1.5g available chlorine) 1 tablet/litre 4 tablets/litreChloramine (25% available chlorine) 20 g/litre 20 g/litreSanitary and Secured LandfillingSanitary and secured landfilling is necessary under the following circumstances.l Deep burial of human anatomical waste when a facility with proper incineration is notavailable (for towns having less than five lakh population and rural areas) according toSchedule I of the Ministry of Environment and Forests Rules – secured landfilll Animal waste (under similar conditions as mentioned above) – secured landfilll Disposal of autoclaved/hydroclaved/microwaved waste (unrecognizable) – sanitary landfilll Disposal of sharps – secured landfill (This can also be done within a hospital premise asmentioned below).l Disposal of incineration ash – sanitary landfilll Disposal of biomedical waste till such time as proper treatment and disposal facility is inplace– secured landfill.214In case a disposal facility for sharps is not readily available in a town, health careestablishments, especially hospitals having suitable land, can construct a concrete lined pit ofabout 1 metre length, breadth, and depth and cover the same with a heavy concrete slab havinga 1–1.5-metre high steel pipe of about 50 mm in diameter. Disinfected sharps can be put throughthis pipe. When the pit is full, the pipe should be sawed off and the hole sealed with cementconcrete. This site should not be waterlogged or placed near a bore well.Common Treatment/Disposal FacilitiesCommon treatment facilities are necessary because it is not feasible for smaller health careestablishments to set up a complete treatment and disposal system due to lack of space andtrained manpower, minimum scale of operation, and scale of economy. Even large establishmentslocated in congested or densely populated areas cannot have such units due to environmentalconstraints. According to the rules, different kinds of treatment are required for differentcomponents of health care waste and the post-treatment residues have to be safely disposed.Hence, it is desirable that every town/city should have at least one common treatment facility thatmay be used by all the units that cannot have their own facility. It can be set up at the treatment/disposal and landfill site for the municipal garbage, with adequate precaution and control.Training and MotivationThe training programme aims at sensitizing the management and equipping the medical,paramedical, and auxiliary staff with the necessary working knowledge and clear instructions

Hospital Waste Managementabout their respective roles. At the same time, a core group of trainers should be organized forcontinued in-house training of the auxiliary and sanitation staff. For the success of theprogramme, it is essential that training and orientation events be planned for the followingcategories of functionaries and people according to their qualifications, experience, roles, andresponsibilities.l Policy-makersl Civic authoritiesl Hospital administrators, medical superintendents, deans and heads of departmentsl Doctors, surgeons, and specialistsl Auxiliary and nursing staffl Ward boys and cleaning/sanitation staff.The training programme for the various categories needs to be repeated, especially for theauxiliary staff. The interval between two programmes has to be decided by the management,depending upon available staff strength and resources.215

Streamlining the Drug Procurement and Supply System in UttaranchalSession 6Streamlining the Drug Procurementand Supply System in UttaranchalRameshwar Sharma, Visiting Professor, Indian Institute ofHealth and Management Research, JaipurIntroductionThe state of Uttaranchal was created by combining 11 hilly districts of UttarPradesh with Udham Singh Nagar District in the Terai Region and HardwarDistrict in the foothills of Uttar Pradesh. According to the provisional figures,Uttaranchal has a population of 8.5 million which is less than 1% of the country’spopulation. The state has 13 districts, 49 tehsils, 95 blocks, and 16,414 villages.About 78% of the population of the state lives in rural areas. About 36% of thestate’s population is younger than 15 years and only 5% is aged 65 or above.About one-fifth of the households have a lower standard of living while morethan a quarter enjoy a high standard of living. The overall literacy rate is as highas 72%. The state, being a hilly one, is the most sparsely populated state in thecountry with a population density of 159 per square kilometre. (IIPS and ORCMacro, 2002 1 ).The Changing Health SceneThe state is influenced by the changing health scene at the national and globallevels. There has been a major transition in the pattern of diseases and theirdistribution. Infectious diseases, such as diarrhoea, acute respiratory infections,tuberculosis, and malaria, are the leading causes of illness and death. At thesame time, non-communicable conditions, such as cardio-vascular diseases,cancer, diabetes, congenital anomalies, endocrine disorders, and accidents, aretaking root as leading causes of morbidity and mortality. Mental disorders andsubstance abuse are posing additional public health concerns. Thus, the state isnow faced with the double burden of both communicable and noncommunicablediseases. The state is also predisposed to iodine deficiencydiseases and HIV/AIDS.The number of health care providers, including specialists, para-professionalsand registered medical practitioners, has significantly increased along with the216

Streamlining the Drug Procurement and Supply System in Uttaranchalextensive increase in the number of public health institutions in the state. At the same time, therehas also been a proliferation of the private health sector during the last decade. Communityexpectations from the health care system have increased as well and so have their demands forspecial health services. Finally, there has been an increase in the cost of medical care. In spite ofmany national control/eradication programmes, mortality and morbidity remain high.Accessibility of health care and its utilization is still very poor. Only around 23% of thepopulation normally uses the public medical sector (National Family Health Survey [NFHS]-2).Three-quarters of households use private hospitals or clinics for treatment when someone in afamily falls ill.Essential DrugsDrugs have become an essential part of management of both curative and preventive medicalservices. Most of the leading causes of death and disability can be prevented, treated, oralleviated by the use of drugs. Drugs are now an integral part of health care services. Hardly anyhealth care provider can effectively function without the use of drugs. Drugs are essential for thetreatment and control of infectious diseases and for the management of diseases of life-style,such as diabetes and cardio-vascular diseases as well as cancer and kidney failure. Drugsthemselves have a number of side effects and interactions. There has also been an exponentialincrease in the use of drugs by the public at large. The number of drug manufacturing units hasalso significantly increased with a great variance in the cost of drugs. Managing the drug supplyhas thus become a complex issue.Lastly, it has been realized that substantial improvements are possible in the supply and uses ofpharmaceuticals. The potential for improvement in the supply process is tremendous. Only 30%of the current health drug budget results in therapeutic benefits to the patients. There is scopefor improved management to reduce losses. Many countries have adopted a national drugpolicy that provides a sound foundation for managing the drug supply. In India, there is anational drug policy developed by the Ministry of Petroleum and Chemicals that focuses ondrug production, import and export, and price control. The Ministry of Health and FamilyWelfare has been concerned with the availability of drugs to people at large. It is in this contextthat the Ministry has developed a model list of nearly 300 essential drugs.The Increasing Gap in Access to DrugsSince the number of formulations now available in the country is approximately 60,000, andthere has been a plethora of antibiotics, it has been rather difficult for prescribers to updatethemselves regarding composition, side effects, dosage, contra-indications, and so forth. Inmany states in India it has been reported that a sizeable population, particularly in rural areas,has little access to drugs or is struggling to cope with a maze of competitive products, many ofwhich are obscure, over-priced, outdated, ineffective, or dangerous. Two problems exist side byside—no drugs at all in the countryside but hundreds or thousands of drugs competing forcustomers’ attention in the cities. Medical and nursing staff in many areas work without themedicines they need.217

Streamlining the Drug Procurement and Supply System in UttaranchalThe World Health Organization (WHO) has defined the rational use of drugs as“that the patients receive medication appropriate to their clinical needs, in the dosesthat meet their individual requirements for an adequate period of time, and at thelowest cost to them and their community.” 2It is in this context that there is a priority to review the present procurement and supply systemin the state, identify its bottlenecks, and provide possible solutions which, if implemented, willstreamline the public procurement system of drugs.Issues in a Drug Procurement SystemIn most states, the health system has a drug procurement system. However, there are a numberof shortcomings in the system presently adopted. In the absence of a state drug policy, thestructure, systems, and processes are not properly spelt out. The drug needs are worked out onan ad hoc basis depending upon the past consumption of drugs at a particular health unit. Onthe basis of the information supplied by different levels of health units, the district health officercollates the information and projects drug requirements for the district. Accordingly, the statelevel handles central procurement. The identified drugs could be generic as well as branded.They could be a single molecule or formulations. There might be inadequacy in working out thedosages and formats.The second problem is the limitation of budget allocations for procuring drugs. Traditionally,drugs have been provided free in all public health facilities in India. Unfortunately, over theyears, this has not been sustainable, and, as a consequence, the policy of free drug supply isbeing reviewed in many states. In large hospitals, generally 30%-35% of the budget is meant forthe procurement of drugs and other supplies. However, with a decreasing allocation to healthbudgets and a higher proportion being allocated to salaries and maintenance, the availability offunds for drug supplies has been significantly reduced. Similarly, the rising cost of drugs hasreduced the amount of drugs that can be procured through the provided health budget. Underthese circumstances, the number of drugs that are now being made available through the publichealth system has come down significantly. For example, in the state of Rajasthan, the number ofdrugs that are presently supplied at different health institutions has come down to 63 for districthospitals, 76 for medical colleges, and 26 for primary health centres. Even these supplies ofdrugs are not regular or adequate. This is in spite of the fact that the Essential Drugs List hasaround 300 drugs that need to be made available at different levels for the appropriate treatmentof diseases prevalent in a state.218Procurement is defined as a “process of acquiring supplies from private and public suppliers,manufacturers, distributors, or agencies”. The key indicators of a good procurement system arethe assurance of continuous supply, avoidance of duplication and waste, maintenance ofrequirements and quality, and maximum savings in the procurement process.Procurement MethodThere are both centralized and decentralized systems of drug procurement. Generally, drugs arepurchased through open tenders whereby quotations are invited, subject to terms and

Streamlining the Drug Procurement and Supply System in Uttaranchalconditions specified in the tender invitation. In many states, procurement is limited to theEssential Drugs List. The supplies are centrally pooled and in bulk. In states such as Delhi, TamilNadu, and Karnataka, such a procurement system has reduced the cost of drugs significantly. InDelhi state, for example, a saving of approximately 30% was made through the centrally-pooledprocurement of drugs. The method adopted in Delhi consists of a two-envelope system; onecontains the technical bid that ascertains the manufacturers, the products, and their quality, andthe other contains the prices of the various drugs in the bid. 3 The Delhi government has laiddown the criteria for qualifying manufacturers for the supply of drugs. These include a ceiling ofRs 120 million annual turnover of a manufacturing firm, adoption for good manufacturingpractices, non-involvement in tax evasion practices, and so forth. Drugs purchased using a twoenvelope-tendersystem are substantially cheaper than those purchased by government agenciesusing the open-tender system. Procurement of drugs by generic names has now become standard.A supplier of “brand name drugs” may also compete, but its bids should be with generic names.This system has been adopted in some of the states mentioned above; however, implementationhas been difficult because of various internal and external pressures.Procurement AgenciesIn most states, a Store Purchase Committee, constituted by the Medical and Health Department,consists of specialists drawn from medical colleges, the district health system, hospitaladministrators, and financial and legal experts. Such committees set down their own processesand standards for selection of drugs. However, there have been limitations on account of variouspolicy decisions at the state/national level. In some states, preference is still given to small-scaleindustries for the purchase of drugs. Under these circumstances, it is not possible to set downand adopt standards for the quality of supplies. Wherever such committees exist, they have asmall core staff to maintain continuity and facilitate implementation. Sometimes, the staff is notonly inadequate but also under-qualified. The appearance of transparency and fairness isessential to attract the best suppliers at the most competitive prices. However, there have beenlimited efforts to develop standard procedures and promote transparency in the procurementsystem. Sometimes product specifications are inadequate and this leads to problems inselection of drugs and items. The procurement process might be influenced by special interestgroups of suppliers/procurement personnel; orders to increase quantities of certain productsmight be manipulated; supplier qualification decisions might be prejudiced; and the final awardof tenders might be manipulated. The above observations indicate that the procurement processcould be vitiated because of inefficient methods adopted, policy decisions at different levels, orthe influence of interest groups, political leadership, and bureaucratic preferences.Product Quality AssuranceIt has been observed that some of the suppliers decide which drugs are to be made available inview of their cost benefits. Some drugs that are essential for prevalent diseases and arecost-effective are not supplied in adequate quantities at all the centres, while costly drugs aresupplied in excess quantities in selected institutions. Hence, the performance of all suppliersneeds to be monitored and reviewed to determine their continuation as suppliers. Efforts havebeen made to set down procurement system procedures and performance indicators. Theseinclude the percentage of drugs purchased through competitive tenders, from local219

Streamlining the Drug Procurement and Supply System in Uttaranchalmanufacturers, and from the essential drug list; the average time of payment; the percentage ofdrugs sent for quality control testing and those that failed; the restriction of use of genericnames; and so forth. However, in general, such standard indicators are rarely adopted in theprocurement system.220Under legal provisions, there has to be a state drug control system that has an authorized drugcontroller and drug inspectors to collect samples and certified drug testing units to look intothe quality of drugs available in the market as well as those supplied through a procurementsystem. The prevailing system is weak and inadequate. The procedures set down for thecollection of samples of drugs supplied to various institutions for testing has not beenadopted. Very few samples are collected and not all collected samples are sent to laboratoriesfor quality testing. The results of these tests are often delayed and follow-up actions areinvariably absent.Drug Supply SystemThere are a number of approaches for organizing the drug supply in the government healthsystem. These include central medical stores, autonomous supply agencies, and directdelivery systems. Most states have mixed supply arrangements. For example, there are fourmain channels of supply in Maharashtra. (1) The health units purchase selected items fromone of the approved suppliers. (2) A limited number of vital items are purchased for the healthunit by the State Stores Organization. (3) The health units have a small budget for direct localpurchase for emergency items. (4) Drugs under various national disease control programmesare distributed to health facilities by the State Stores Organization. There have been points infavour of decentralization of drug selection, procurement, and distribution. Decentralizationaims to improve the response and efficiency of health services through greater localinvolvement, direct public accountability, increased flexibility, and quicker adoption. However,there are problems with adopting decentralization in drug management including lack ofcapacity, lack of financial resources, increased corruption, increased costs, and decreasingdrug quality.Recommendations for Improving Drug Procurement Systems1. Development of a State Policy The state of Uttaranchal should take the initiative fordeveloping a drug policy at the earliest. State drug policies have been formulated inKarnataka, Delhi, Tamil Nadu, West Bengal, and Andhra Pradesh. A drug policy formulationcommittee, composed of the health minister, senior officials of the state medical directorate,and senior faculty members of the medical colleges, if any, should be constituted.2. Adoption of an Essential Drug List Rajasthan, Delhi, Tamil Nadu and many other stateshave already developed their essential drug lists. The essential drug list for the state shouldbe developed along the lines of states referred to above. The state may also aim to developstandard treatment guidelines for different diseases at the level of primary health centres andhospitals, leading to the development of formularies and an essential drug list. There shouldbe political commitment to adopt an essential drug list for procurement and supply.3. Promotion of the Rational Use of Drugs The ultimate goal of rationalizing drug use is toimprove the quality of health care through effective and safer drug use and to improve the

Streamlining the Drug Procurement and Supply System in Uttaranchalcost-effectiveness of health care through economic and efficient drug use. Strategies toimprove the rational use of drugs can be characterized as educational, managerial, andregulatory. Educational strategies cover training of prescribers through formal andcontinuing education, seminars, and workshops. In addition, they could be supplied withprinted material such as newsletters, treatment guidelines, drug formulations, and so forth.Professional associations could be approached for this purpose. The managerial strategiesinclude selection, procurement, and distribution of drugs; cost information; review of drugutilization patterns; and formation of drug and therapeutic committees in hospitals.Regulatory approaches include drug registration, prescribing restrictions, dispensingrestrictions, and so forth.4. Constitution of a Drug Procurement Agency There should be a state-level procurementcommittee to support and advise the total procurement system at all levels in the publichealth department. Various functions and responsibilities could be further delegated byconstituting different committees to look after specific activities. A list of suggestedcommittees is as follows.l Drug and Therapeutic Committee: consists of experts, users, pharmacists, and clericalsupport for selection of drugs, determination of quantities, and formular managementl Specifications Committee: consists of concerned experts and administrators to set downclear, unambiguous specifications for each productl Tender Committee: consists of administrators, pharmacists, and the finance and auditdepartment for preselection of suppliers and adjudication of tendersl Procurement and Distribution Committee: consists of administrators and pharmacists forpooled procurement and distributionl Finance Committee: consists of senior administrators and the finance and auditdepartment to facilitate payments in timel Quality Assurance Committee: consists of pharmacists, clinical pharmacology/pharmacology and user departments for ensuring quality of products at all steps of theprocurement cycle.5. Procurement Office Staffing and Management There is need for adequate staff that is welltrained, highly motivated, and capable of making the procurement system effective. Oftenpeople are transferred as they become competent and a new cycle of training begins.Salaries of the staff are too low to support an individual with a family, leading to amplescope for corruption and negligence in duties. The procurement office should beindependent and autonomous as in the state of Tamil Nadu. The agency should havepermanent office and secretarial staff to manage and monitor the procurement process.There should also be a procurement manual. A reliable management information system isan essential step. Market intelligence and communication are an integral part ofprocurement management. A reliable payment mechanism and financial support areequally important.6. Development of a Logistics and Supply System Some of the states, such as Assam andRajasthan, have central warehouses along with district-level warehouses promoted undervarious area development projects. Serious consideration needs to be given toappropriateness, design, and utilization of these warehouses. This should be in consonance221

Streamlining the Drug Procurement and Supply System in Uttaranchalwith the drug supply strategy adopted in the state. The state may not require any centralmedical store if the procurement is decentralized.7. Human Resource Development This is an integral part of developing an effectiveprocurement system to promote rational use of drugs. A human resource developmentprogramme has to be developed and implemented in a continuing manner for all categoriesof functionaries involved in the procurement and supply system of the state. At the sametime, there is need for training of prescribers, both pre-service and in-service, throughseminars, workshops, group lectures, and distribution of printed material in the form ofnewsletters, treatment guidelines, drug formularies, and so forth. In many places, costinformation is also made available to prescribers. All this is in addition to the training andorientation of pharmacists, registered medical practitioners, and other drug providers, aswell as the general community.8. Establishing an Effective Drug Supply System The distribution of medicine to the farthestcorners of the state should be entrusted initially, in some districts, to rural drug cooperatives,as it has been done in some countries of WHO’s South-east Region. This would be in additionto restructuring and streamlining the government distribution system, which has proved tobe ineffective in many situations. If the involvement of the private sector improvesdistribution, then perhaps it could also, in due course, be entrusted with procurement anddistribution.9. Research and Development: As seen above, there is great scope for improvement inprocurement and supply systems. There should be a budgetary provision for suchcontinuing feedback and monitoring that would enable the states to make their system moreeffective and efficient and improve accessibility of drugs for people at the grass-roots level.References1 IIPS (International Institute of Population Sciences) and ORC Macro. 2002. National FamilyHealth Survey (NFHS- 2) India, 1998-99. Uttaranchal, Mumbai, IIPS.2 Managing Drug Supply: The Selection, Procurement, Distribution, and Use ofPharmaceuticals 1997. Management Sciences for Health in collaboration with WHO.Bloomfield, Connecticut, USA: Kumarian Press.3 A brief summary of the document is given in the annex.222

Streamlining the Drug Procurement and Supply System in UttaranchalAnnexGovernment of the National Capita Territory of DelhiDirectorate of Health ServicesC P A CellE-Block: Saraswati Bhavan: Connaught Place: New DelhiSl. No. __________Form for pre-qualification for supply of drugs to the Government of NCT of Delhi.PART - IGeneral:1. Name of the tenderer _________________________________________________________2. Full postal address_______________________________________________________________3. Telephone no. __________________________________________________________________Fax no. ________________________________________________________________________4. State whether the tenderer is small-scale, ___________________________________________medium-scale, organised sector (Indianor multinational firm/company)5. Names of persons who are responsible for the conduct of business as explained underSection 34 of the Drugs and Cosmetics Act, 1940.Sl. No. Name Father’s/Husband’s Name Age Residential Address6. Particulars of licences held under the Drugs andCosmetics rules including date of grant of licence:Renewed upto _____________________________(attach photocopy of Drug Licence along with list of items permitted).Notes1. If the licences are under renewal, a certificate from the State Drugs Controller in whosejurisdiction the factory is located, stating that the licences are under renewal and the sameare deemed in force, should be attached with this tender form.2. If the drugs are manufactured under any loan, licence/marketing arrangements with fulldetails should be provided.223

Streamlining the Drug Procurement and Supply System in Uttaranchal7.8.(a) Names of procurement agencies with :which the tenderer is registered(b) Names of procurement agencies to which :drugs have been supplied during the last12 months (copies of supply orders not to beenclosed)(c) Has the tenderer ever been blacklisted by any :procurement agency? If yes, give details.(a) Are any cases pending in the court under the :Drugs and Cosmetics Act? If yes, give details(attach separate sheets) such as names of drugs,nature of complaints.(b) Has the tenderer ever been convicted under the :Drugs and Cosmetics Act? If yes, give details.If not, enclose a copy of a Non-convictionCertificate from the State Drugs Controllerwhere manufacturing unit is located.PART-IITechnical9. Does the tenderer have adequate(a) Space for(i) Storage of raw materials, packing materials :(ii) Manufacturing operations :(iii) Quality control operations :(iv) Other facilities such as water treatment, :heating (emergency electricity generation),waste disposal, etc.(b) Equipment for(i) Material handling :(ii) Manufacture of drugs permitted on the :licences held(iii) Quality control of drugs permitted on the :licences held (or alternatively, the tendererhas arrangements with approved testinglaboratory(ies) for very sophisticated orhighly expensive equipment)(iv) Other facilities like water supply, heating, :air cleaning and air conditioning (whereverrequired), emergency electricity generation,waste disposal, etc.224

Streamlining the Drug Procurement and Supply System in Uttaranchal(c) Specialized testing facilities such as(i) Microbiological (if required for the range :of products quoted)(ii) Biological (if required for the range of :products quoted)10. Number of technical staff with the tenderer(a) For supervision of manufacture of drugs :(b) For quality control of raw materials, :intermediates, and finished products11. Particulars of Heads of Production and Quality ControlName Qualification Whether approved by regulatory agencyFor manufacturingFor quality control12.(a) Has the tenderer carried out stability studies for :the drug formulations for which rates havebeen quoted?(b) How long has the tenderer been manufacturing :and marketing the drug formulations for whichrates have been quoted?Encl: 1) Three-year Manufacturing and Marketing Experience Certificate per proforma enclosed in Annex “A” fromthe State Drug Controller. The certificate should not be more than one year old.2 ) Details of drugs quoted in Price Bid per proforma enclosed in Annex “B”NOTE:Firm will be considered only for those drug formulations mentioned in the certificate.13.(a) Does the tenderer follow good manufacturing :processes (GMPs) as set down in WHOguidelines? Enclose WHO GMP Certificateissued by Drug Controller of State indicating thedate of validity. If date of validity is not given,then it should not have been issued before twoyears ago.(b) Is the tenderer registered with Directorate :General of Quality Assurance (DGQA)? (Enclosea copy of current registration certificate withDGQA, along with list of products registered,valid on the date of opening of tender)NOTE: Tenderer should note that only drug formulations registered with DGQA/listed in WHO GMP Certificatewill be considered.225

Streamlining the Drug Procurement and Supply System in Uttaranchal14. Installed capacity for manufacturing of different dosage forms per annum and actualproduction during the last 12 months.Dosage Form Installed Capacity Actual ProductionTabletsCapsulesSyrup/SolutionsOintment/EmulsionsInjectionsOthersNOTE:1. Any significant variations between capacity and production should be explained.2. The basis on which calculations have been made for installed capacity should be stated and due allowanceshould be given to time loss during changeover of product and maintenance of machinery and equipment.Attach a separate sheet to furnish information.15.(a) Whether any drug(s) manufactured by the :tenderer has/have been recalled during the lastthree years? If yes, give details.(b) What are the results of investigations on the :recalled drug(s)?(c) What action has been taken to prevent :recurrence of recall of drug(s) on that particularaccount? (Attach separate sheet if space isnot sufficient).PART - IIIFinancial Aspects16. Turnover for pharmaceutical items during the last three years (year-wise) 1996/97, 1997/98and 1998/99. Furnish copies of Balance Sheet/Profit and Loss account of the firm for the lastthree years.NOTE: Only those tenderers whose turnover of pharmaceutical items per annum in the last two financial years(1997/98 and 1998/99) is Rs 12 crore or above will be qualified for the opening of the price bid.(Rs in lakh)17. Facilities available from the bank(a) Overdraft facilities :(b) Overdraft facilities against hypothecation :(c) Others :226

Streamlining the Drug Procurement and Supply System in Uttaranchal18. Names and addresses of the bankers of the :firm/company19. Furnish the following information/documents(i) Income Tax PAN :(ii) Central Sales Tax No. :(iii) State Sales Tax No. :(iv) Attested photocopy of the latest Income :Tax Clearance Certificate(v) Attested photocopy of the latest Sales :Tax Clearance Certificate227

Streamlining the Drug Procurement and Supply System in Uttaranchal18. Names and addresses of the bankers of the :firm/company19. Furnish the following information/documents(i) Income Tax PAN :(ii) Central Sales Tax No. :(iii) State Sales Tax No. :(iv) Attested photocopy of the latest Income :Tax Clearance Certificate(v) Attested photocopy of the latest Sales :Tax Clearance Certificate227

Sanitation and Public Health Issues with Reference to UttaranchalSession 6Sanitation and Public Health Issueswith Reference to UttaranchalJayant Keshav Natu, Director, The Swajal Project, DehradunIntroductionThe government of Uttaranchal, with World Bank assistance, is implementingan integrated rural water supply and environmental sanitation project in 848villages in 12 districts of the state. These villages have been selected on thebasis of transparent criteria such as demand, need, technical factors, and soforth. There are four batches consisting of 69, 154, 199, and 394 villages. Thereis also an experimental batch 3x (Panchayati Raj institution [PRI]) thatincludes 32 villages. Short-listed non-governmental organizations (NGOs) actas support organizations to assist village communities in the planning andconstruction of water supply and environmental sanitation schemes. Onlysingle village schemes have been undertaken.The project cycle lasts 33 months, with each batch of villages overlapping theother. The project cycle has three distinct phases—(1) pre-planning, (2)planning, and (3) implementation. In the pre-planning phase, the villages andsupport organizations are selected on the basis of predetermined, transparentcriteria. In the planning phase, community action plans are created thatensure the participation of communities in the project process. Communityupfront and cash contributions are also collected in this phase. All of the mainconstruction activities are executed in the implementation phase.Project Objectivesl To deliver sustainable health and hygiene benefits to the rural populationthrough improvement in water supply and environmental sanitationservices, which will increase rural incomes through time savings andincome opportunities for women, test an alternative to the current supplydrivenservice delivery mechanism, and promote sanitation and generalawarenessl To promote the long-term sustainability of the rural water supply andsanitation sector by providing assistance to state governments foridentifying and implementing an appropriate policy framework andstrategic plan.228

Sanitation and Public Health Issues with Reference to UttaranchalHygiene and Environmental Sanitation Awareness Component in theProjectTo maximize potential benefits of water supply and sanitation projects, technical andbehavioural measures must go hand in hand. The benefits of a safe water supply will be lost ifwater is not collected and handled in ways that protect it from contamination before it is drunk.Latrines may also become a hot bed of diseases if they are not used and cleaned properly.Hygiene and Environmental Sanitation Awareness (HESA) is meant to establish the link betweenimproved facilities and user practices. HESA is derived from the general objective of the project”To provide sustainable health and hygiene benefits through improved water supply andsanitation facilities.”To meet this objective, it is not sufficient to only construct improved water supply andenvironmental sanitation facilities. New facilities have to be used by everyone and in a safe way.This requires an interest on the parts of both communities and project staff in having safe,reliable, and accessible facilities constructed, used, and maintained. HESA aims to beinstrumental in this process by promoting optimum use of water supply and sanitation facilitiesand proper operation and maintenance for their continuous functioning.Water-borne and sanitation-related diseases account for a high proportion of sickness and deathin the project areas. Prevention of such morbidity and mortality depends on intercepting awhole range of transmission routes by which disease organisms pass from one infected personto another. To help people protect themselves and their children, one needs to understand thelinks between human behaviour and disease transmission.Objectives of HESAllThe broad objective of HESA is “to reduce morbidity by generating a demand for safe waterand sanitation”.Its specific objectives are as follows.n Reduction in water-borne diseases, especially diarrhoean Promotion of safe drinking water through proper handling and managementn Promotion of safe disposal of infant excretan Promotion of hand-washing with soap and ash after defecation and before eatingn Improvement in personal hygiene practices such as bathing, nail clipping, and so forthn Improvement in household sanitary latrine coverage and use, thus reducing theoccurrence of open defecation.Strategy for HESAThe project has formulated a Community Empowerment Strategy, which consists of three maincomponents – (1) HESA; (2) Women’s Development Initiative (WDI), and (3) Non-FormalEducation (NFE). In concomitance with the project’s primary objective, it is only natural that themost vital of these three components is HESA; some of the project’s most important methods forreducing disease transmission include the adoption of behaviours and facilities associated withthe safe disposal of human excreta and the use of more water for personal, domestic, and foodhygiene.229

Sanitation and Public Health Issues with Reference to UttaranchalThe particular transmission pattern of each disease and the local circumstances of project areasare determined and taken into account in intervention planning. A situation analysis of eachcommunity provides the data for planning and programming village-level activities. It seeks toidentify the main health problems related to water and sanitation and the opportunities foraction. A knowledge attitude and practice (KAP) study provides project staff with a more intimateunderstanding of people’s knowledge, attitudes, and practices regarding water, sanitation, andhealth. NGOs conduct baseline studies on the socio-economic situation and local water andsanitation conditions of the project communities. Investigative methods such as observationand communication, informal discussions with individuals and groups, focus group discussions,SARAR 1 , and screening are adopted to appraise the current situation in a village. All of thisinformation is used as the basis for HESA programme design and for the later evaluation of theprogramme.230The HESA ProcessIn order to attain HESA objectives, a community-based tool known as the healthy home survey(HHS) has been developed. This is a tool that can be used effectively by the community toregularly monitor the personal, domestic, and environmental health and hygiene of the villageand to promote behavioural change. The methodology for conducting an HHS at the clusterlevel is as follows.Identification of Attributes of a Healthy HomelllInvite one member (preferably a woman) from each house in the cluster.In a non-directive and participative manner, ask them to list the attributes of a healthy home.This might include household hygiene, management of drinking water, safe disposal ofinfant excreta, hand-washing after defecation and before eating, use of a latrine, and cleandrains.Finalize the attribute list.Categorization and Finalization of AttributeslllAsk the groups to categorize the attributes according to three main headings—(1) personal,(2) domestic, and (3) environmental.Introduces cards with pictures of the attributes selected by the other communities in theproject. This serves to familiarize the participants with the previously identified 13 mostimportant attributes. Then ask the participants to discuss each attribute, prioritize them, andthen compare this list with the one they had compiled for the previous HHS.Finalize the attribute list. This list, though determined by the cluster group, should includethe following 13 attributes.n Washing hands with soap or ash after defecationn Washing hands before eatingn Using safe water for drinking and cookingn Disposing of infant excreta safelyn Clipping nails regularlyn Bathing frequentlyn Using latrines for defecation

Sanitation and Public Health Issues with Reference to UttaranchalnnnnnnMaintaining the latrineDisposing cow dung in compost pitIncidence of diarrhoeaCleanliness of drainsCleanliness of lanesPresence of stagnant water pools around water source.Assessing the Status of the Community vis-à-vis Finalized List ofAttributeslllPersonal hygiene: All the women cluster group members may use the secret ballot / pocketchart method to assess their personal hygiene according to the attributes on the list. Totalsare tallied and divided by the number of women present to find out the average for thegroup.Domestic attributes: The group nominates three to four members who are acceptable to thecommunity for the task of entering each house and surveying its domestic sanitationsituation. These members then visit every house in the cluster and decide whether it is“healthy” or “unhealthy” according to the domestic sanitation attributes list.Environmental sanitation: The same three to four nominated members will be asked toobserve their cluster’s overall hygiene situation. They should rate the community as“healthy” or “unhealthy” on the basis of the list of environmental sanitation attributes.Community MappingThe results of the environmental sanitation situation assessment should be recorded visually ona community map. Guidelines for community environmental sanitation mapping are as follows.l Maps are to be prepared cluster-wise and must include the date of mapping.l Maps should include the following locations and notes on their sanitation levels:n Water sourcesn Locations of cow dung and other garbage disposal areasn Locations of soak-pitsn Locations of drainsn Locations of village pondsn Locations of main open defecation areasn Locations of village pathsl A village environmental sanitation map should be compiled on the basis of the completedcluster maps.Sharing and Discussion of HHS FindingsllThe results of the HHS are discussed in cluster women’s groups. The meeting’s minutes andthe date of the survey are recorded.When the HHS is complete in all the clusters, the results are compiled for the village as a whole.The results are discussed in a community-wide meeting and the proceedings are recorded.Fixing of Village HESA Targets as Sub-components of the Community Empowerment Plan231

Sanitation and Public Health Issues with Reference to UttaranchalBased on the findings of the HHS and subsequent discussions, the community must establishtargets for improving village health and hygiene in all categories—personal, domestic, andenvironmental. These HESA targets should be reflected as sub-components of the CommunityEmpowerment Plan.232Finalizing InterventionsThe cluster women’s group, with the facilitation of the Sanitation Office staff, will decide what activitiesshould be initiated to achieve the village HESA targets. Activities will include the following.l Finalizing the frequency, timing, and locations of need-based HESA sessionsl Deciding the types of training needed and curriculal Selecting information, education, and communication material according to therequirements of sessionsl Deciding the number, frequency, and strategy of clean-up campaignsl Deciding the number, types, frequency, and strategy of various quiz and other competitionssuch as healthy baby showsl Deciding the strategy of involving children and youth to act as change agents for HESAl Deciding the frequency of HHSs and community environmental sanitation mapping.Community MonitoringllllHHS and community environmental sanitation mapping are to be carried out at least once ina quarter; the community will decide the frequency.In their discussion of survey results, the community shall compare the current results withthe previous survey’s results.The community may wish to review the attribute list.The community may wish to review the efficacy of the strategy followed thus far.HESA ActivitiesBased on the findings of the HHS, the HESA sessions may pertain to one or more of the followingactivities.l Personal hygienel Domestic hygienel Environmental sanitationl Maternal and child healthl Nutrition and balanced dietl Immunizationl Hygienic use of drinking waterl Water-borne diseasesl Diseases transmitted though the faecal-oral routel Use of kitchen waste water for gardeningl Importance of latrinesl Importance of cleanlinessl Importance of potable waterl Promotion of school sanitation programmesl Diarrhoea management

Sanitation and Public Health Issues with Reference to UttaranchalSome Tools for HESA Activitiesl Focused group discussionsl Street playsl Local art formsl Health campusl HESA quizzes for children.A baseline study for the evaluation of health benefits in Swajal was conducted by the externalagency KGMC (Lucknow) in August–September 2000. A repeat comparison study on healthbenefits was conducted in August–September 2001. Further information on these studies isavailable upon request. 21SARAR is an education/training methodology for working with stakeholders at different levels. The acronym SARAR stands for the fiveattributes and capacities that are considered the minimum essentials for participation to be a dynamic and self-sustaining process —(a) Self-esteem, (b) Associative strength, (c) Resourcefulness, (d) Action planning, and (e) Responsibility(Details at http://www.worldbank.org/poverty/impact/methods/sarar.htm).2Details available withThe DirectorProject Management UnitThe Swajal ProjectUTTARANCHAL RURAL WATER SUPPLY and ENVIRONMENTAL SANITATION PROJECT(Department of Drinking Water, Government of Uttaranchal)Mussoorie Diversion Road, Makkawala,Post Box No. 154, DehradunPh : 0135-733455, 733380Fax: 0135-733381E-mail: pmu_uttaranchal@rediffmail.com233

Ayurveda and Unani Department and the Convergence of Services with the Health Department in UttaranchalSession 6Ayurveda and Unani Department andthe Convergence of Services with theHealth Department in UttaranchalA K Jain, D S NathBackgroundThe Indian System of Medicine (ISM), one of the ancient systems of medicinepractised in India, includes ayurveda, siddha, unani, and homeopathy.Among these, ayurveda is very popular, since it pays special attention to themental, physical, and spiritual health of human beings. Realizing theimportance of ISM in efficacious remedies for maternal and child health, theGovernment of India (GoI), as part its Tenth Five-Year Plan, emphasized theimportant role that ISM can play. Furthermore, the GoI introduced ayurvedicand unani drugs into the national Reproductive and Child Health (RCH)Programme in 1997 (NIHFW, 2001). Seven states, including Uttaranchal, werebeneficiaries of this scheme.After coming into existence, Uttaranchal decided to establish an Ayurveda,Unani, and Homeopathy Directorate on 1 August 2001. Since these threesystems of medicine have had a long presence in the state, an attempt iscurrently underway to use their potential for improving accessibility to healthservices. This paper, therefore, attempts to analyse the areas where theconvergence of services can take place within the allopathic health system.Organizational Structure of Ayurveda and UnaniDepartment in UttaranchalIn Uttaranchal, the Secretary of Health and Family Welfare is also in charge ofmedical education; hence, both Health and Family Welfare and Ayurveda,Unani, and Homeopathy directorates report to the Secretary.As shown in Figure 1, at the directorate level, the Director is supported by oneAdditional Director and three Deputy Directors. The three Deputy Directorsare assigned functions that include planning and establishment, educationand research, and plants and herbs processing. In addition to these staffmembers, there is a drug controller and a drug inspector. At the district level,the Regional District Ayurveda Medical Officer coordinates with the ayurveda234

Ayurveda and Unani Department and the Convergence of Services with the Health Department in UttaranchalFigure 1Organizational Structure of Ayurveda and UnaniDepartment in UttaranchalSecretary, Medical EducationStateDirector, Ayurveda and UnaniAdditional DirectorDeputy Director(Planning &Establishment)Deputy Director(Education & Research)Deputy Director(Plants & HerbsProcessing)DistrictRegional Ayurveda Medical OfficerFieldMedical Officer (Ayurveda)medical officers, working in either hospitals or dispensaries, and manages the implementationof the programme.Health Infrastructure of the Ayurveda and Unani DepartmentThe Ayurveda and Unani Department has 388 institutions providing ayurvedic and unani healthcare services in the state. This includes 386 health facilities and two ayurvedic medical collegeslocated in Hardwar district.As shown in Table 1, there are five 15-bed hospitals in the districts of Hardwar, Tehri Garhwal,Pauri Garhwal, and Uttarkashi, and 311 four-bed hospitals across all the districts in the state.The largest number of these hospitals is in Chamoli District, while the lowest number is inBageshwar District. All provide in-patient and out-patient care services. In addition, there are 70out-patient dispensaries (OPD), ranging from one in US Nagar to 27 in Tehri Garhwal. Only 19 ofthese centres are located in urban areas; the remaining 367 are in rural and remote areas. Thus,the ayurvedic and unani systems of medicine have had a significant presence in rural areas, withTehri Garhwal having the most institutions in rural areas.Most of the above-mentioned health institutions are located in rented buildings. As many as 53institutions are in government buildings, 297 in rented buildings, and 36 in donated buildings(Table 2).Human Resources in the Ayurveda and Unani DepartmentOf eight sanctioned positions at the directorate level, only the position of director has beenfilled. Of nine district-level positions for regional medical officers to supervise dispensaries,only two positions have been filled. Although Uttaranchal has about 602 medical officers, only391 of these positions are sanctioned. * In addition, positions for two lab assistants, 67* At present Uttaranchal has more than the sanctioned number of medical officers and the surplusmedical officers are supposed to be transferred to the parent state Uttar Pradesh.235

Ayurveda and Unani Department and the Convergence of Services with the Health Department in UttaranchalTable 1. Health Infrastructure in the Ayurveda and Unani DepartmentIn-patient FacilityOut-patient facilityDistrict Hospital (15 beds) Hospital (4 beds) OPD TotalNainital — 16 6 22US Nagar — 13 1 14Pithoragarh — 45 — 45Champawat — 11 — 11Almora — 31 5 36Bageshwar — 6 2 8Tehri 1 24 27 51Rudraprayag — 12 7 20Chamoli — 47 2 49Pauri 1 31 5 37Hardwar 2 10 5 17Dehradun — 27 10 37Uttarkashi 1 38 — 39Total 5 311 70 386Note: 1. Two Ayurvedic Medical Colleges at Hardwarl Hrishikul Ayurvedic Degree College has a hospital with 154 bedsl Gurukul Kangri Ayurvedic Degree College has 80 beds2. Nineteen facilities are located in urban and 367 are located in rural areasTable 2. Location of Ayurveda and Unani Health InstitutionsType of BuildingDistrict Govt. Rented Donated TotalNainital 2 18 2 22Udham Singh Nagar 2 11 1 14Pithoragarh 5 39 1 45Champawat — 7 4 11Almora 4 30 2 36Bageshwar — 8 — 8Tehri 20 28 3 51Rudraprayag 2 16 2 20Chamoli 3 45 1 49Pauri 3 31 3 37Hardwar — 12 5 17Dehradun 1 26 10 37Uttarkashi 11 26 2 39Total 53 297 36 386236

Ayurveda and Unani Department and the Convergence of Services with the Health Department in Uttaranchalpharmacists, and 20 staff nurses remain vacant(see Table 3).Norms of Staffing Pattern in DifferentInstitutionsAyurvedic hospitals and dispensaries have wellestablishednorms for staffing. Hospitals with fourin-patient beds are supposed to have one medicalofficer, one pharmacist, one peon, and onesweeper/watchman. Hospitals with 15 beds aresupposed to have one male medical officer, onefemale medical officer, two pharmacists, three staffnurses, two peons, and one sweeper/watchman.Dispensaries consist of one medical officer, onepharmacist, one peon, and one part-time sweeper.Table 3. Human Resources in the Ayurveda andUnani DepartmentCategory Sanctioned In-position VacantDirector 1 1 —Additional Director 1 — 1Deputy Director 3 — 3Drug Controller 1 — 1Drug Inspector 1 — 1Accounts Officer 1 — 1Office Superintendent 1 — 1Senior Assistant 2 2 -Regional Medical Officer 9 2 7Medical Officer 396 607Pharmacist 398 331 67Staff Nurse 36 16 20** 215 transferred from Uttar PradeshType of Services ProvidedAyurvedic dispensaries and hospitals provide a variety of services, including treatment of minorailments; curative services related to skin, abdomen, asthma, and arthritis; and services forheart patients not requiring a nursery. In addition, ayurvedic dispensaries participate in schoolhealth programmes to promote hygienic practices. Ayurvedic medical officers and other staffhave also played a major role in pulse polio campaign and offered publicity to the HIV/AIDSprogramme. Ayurvedic hospitals and dispensaries identify malaria, tuberculosis, and leprosycases, referring patients to appropriate health centres for treatment.Strengths of the DepartmentAyurvedic hospitals and dispensaries have some unique strengths. They are largely located inremote rural areas, where no allopathic services are available. Ayurvedic doctors, unlikeallopathic doctors, remain at their posts. And since they live in remote rural areas, they havebetter rapport with the community. Ayurvedic treatment is less expensive, and a largeproportion of the rural population who cannot afford high-cost health care services dependson ayurvedic doctors. However, these strengths have to be effectively exploited to improvethe health status of the rural population. Thus far, no such attempt has been made inUttaranchal.Issues and ChallengesThere are several issues faced by the Ayurveda and Unani Department:lllThere is no coordination between the Ayurveda and Unani Department and the HealthDepartment. They coordinate only when performing a particular task, such as the PulsePolio Campaign. There are no regular meetings to share experience and information.The Ayurveda and Unani Department operates on a shoe-string budget. For instance, thetotal amount sanctioned for drugs at a 4-bed hospital is less than that sanctioned to asubcentre. Most of the budget goes for salaries.Often ayurveda medical officers feel they do not get the due recognition they deserve from237

Ayurveda and Unani Department and the Convergence of Services with the Health Department in Uttaranchalllllltheir counterparts in the Health Department. These perceptions act as major barriers to thefree exchange of views and inter-departmental cooperation and coordination.There is no well-designed information system for the Ayurveda and Unani Department.Information collected is neither uniform nor complete and, therefore, not useful for makingeffective decisions concerning programme management.The huge infrastructure of the Ayurveda and Unani Department is not put to effective use bythe Health Department to promote primary health care. Both departments operate in thesame area in relative isolation.Ayurvedic dispensaries have no demarcated geographical or population areas they have tocover nor is their role in promoting primary health care clearly defined.The Ayurveda and Unani Department has no efficient logistics system or logisticsmanagement information system.In general, monitoring and supervision is weak, which has been further weakened due to thelack of relevant information on the performance of each dispensary and hospital.Areas of ConvergenceThe Ayurveda and Unani Department can play a major role in promoting RCH services inremote rural areas. Some specific areas where its contribution could be significant include thefollowing:l Ayurvedic medical officers, given their proximity to rural communities, can share theinformation on various available family planning methods and promote informed choiceamong eligible couples of reproductive age.l Ayurvedic dispensaries can act as depots for condoms and oral pills. These supply methodsrequire constant interaction with clients. In a designated geographical area and population,ayurvedic medical officers can supply condoms and oral pills to clients and dispel any mythsassociated with modern family planning methods.l In ayurvedic hospitals that have staff nurses, antenatal care (ANC) services, such as threeantenatal checkups and a supply of iron and folic acid (IFA) tablets, and services for tetanustoxoid (TT) injections can be provided. In dispensaries, IFA distribution and TT injectionscan be given to pregnant women.l Although there is no provision for conducting deliveries in ayurvedic hospitals anddispensaries, medical officers can promote safe-delivery practices by advising pregnantwomen to use the services of a trained service provider at the time of delivery and to observethe “five cleans”.l Ayurvedic dispensaries can play a major and significant role in immunization services tochildren on a designated day in a week.l They can act as a link between clients and referral allopathic hospitals by referring patientsto appropriate service centres.l Since they have rapport with community, they can play a key role in activities related toinformation, education, and communication (IEC) and behavioural change, and createdemand among communities for health care services.l RCH camps offer integrated services on a fixed day each month. Ayurvedic medical officerscan offer their services to clients on that day.238

Ayurveda and Unani Department and the Convergence of Services with the Health Department in UttaranchallIn general, ayurvedic medical officers can promote health education in communities andschools.Institutionalizing ConvergenceFor convergence to function permanently, processes have to be institutionalized:llllllThe first step in this direction is redefining the roles and responsibilities of ayurvedicmedical officers to include some of the activities they can and should perform to promoteand provide RCH services.Since new responsibilities have to be added to their job functions, medical officers requirere-orientation training to understand their roles and functions and to effectively dischargetheir duties.There is a need for regular coordination meetings between personnel of the Ayurveda andUnani Department and the Health Department to share information and experiences, and toreview and monitor performance.Ayurvedic dispensaries are static in nature. They do not have the staff to provide extensionservices or to make household visits. However, they can monitor various health indicatorsand visits of auxiliary nurse midwives (ANMs) to their villages.There is a need to establish a referral system by linking ayurvedic dispensaries withallopathic hospitals and clinics.Management information of the Ayurveda and Unani Department must be strengthened toimprove the performance monitoring of each medical officer and each dispensary,particularly in regard to their contribution to RCH services and other national healthprogrammes.239

Specific Health Policy and Programme IssuesSpecific Health PolicyandProgramme IssuesSummary of ProceedingsSession 1National Health Programmes and EpidemiologicalSurveillanceSession 2Information, Education, and Communication for Promotion ofHealth CareSession 3Private and Public Sector Partnerships in the Health SectorSession 4Health Economics: Issues of EquitySession 5Sexually Transmitted Infections, Reproductive Tract Infections,AIDS, and Tuberculosis Control and ManagementSession 6Other Health Issues241

Specific Health Policy and Programme IssuesSpecific Health Policy andProgramme IssuesSummary of ProceedingsThe following health policy and programme issues, specific to Uttaranchal,are the result of proceedings of the workshop on Health Policy and HealthProgrammes in Uttaranchal held on 9–10 May 2002 in Mussorie. The issuesare based on the papers presented, the remarks of chairpersons anddiscussants, and observations and group reports by the participants.Session 1National Health Programmes and EpidemiologicalSurveillancelllllIn spite of a huge primary health care network in Uttaranchal, as in Indiain general, more than half of the disease burden is caused bycommunicable, maternal, and nutritional disorders—most of which arepreventable or easily managed.Due to significant changes in life-styles and age structures of thepopulation, the disease burden caused by life-style and degenerativediseases is on the increase. There are also emerging diseases such as HIV/AIDS.Public health as a special discipline should be promoted, the role ofpublic health experts should be recognized, and career structures shouldbe created to promote primary health care.There are about 23 national health programmes in the country. Some ofthem are relevant to all states and others are state-or locale-specific.Priorities among programmes should be determined usingepidemiological data.Currently, the health programmes call for inter-sectoral and integratedapproaches, particularly for vector-borne diseases; however, there couldbe improvement in implementation. For instance, measures related tosanitation for the control of vector breeding and the use of insecticides bythe agriculture department are some of the important aspects that need tobe taken into consideration when implementing the malaria controlprogramme.243

Specific Health Policy and Programme IssueslllThe slum population in urban areas is the most vulnerable to multiple health problems.Because there is no primary health delivery system in urban slums, special efforts arerequired to cover the slum population.Epidemiological surveillance data are required for short- and long-term planning andimplementation. Active and passive surveillance, disease reporting, laboratory-basedsurveillance, information provided by volunteers, and registries are some of the methods ofsurveillance. A fully functional surveillance system has to be designed and implemented.Health programmes should involve communities and encourage inter-sectoral approaches.There should also be more allocation of resources to health programmes.Session 2Information, Education, and Communication for Promotion of HealthCarellllllA positive change in health-care-seeking behaviour can be achieved through effectivebehavioural change communication. All over the world, successful health programmes havea strong communication component.A strategic communication package aimed at behavioural changes should includesegmentation of the audience, development of relevant messages, and media planning.Interpersonal communication (IPC) should be the mainstay of the information, education,and communication (IEC) strategy. Workers at the grass-roots level should be trained indecentralized IEC planning and IPC skills. Emphasis should be on behavioural changes andcommunity mobilization rather than on awareness creation.To improve efficacy, the IPC should be integrated with other media, particularly radio.Uttaranchal should have its own IEC strategy developed by involving all stakeholders anddrawing on individual expertise, institutional experience, and research findings.There is a need to establish a multi-sectoral IEC bureau and also a media and materialsresource centre with enough expertise to plan and implement IEC programmes withadequate outlays.Session 3Private and Public Sector Partnerships in the Health SectorllllPublic and private sector collaborations in recent times have concentrated on developingstrategies to utilize untapped resources, enhancing the capacity to meet growing healthneeds, reducing the financial burden of the government for specialty care, reducing regionaland geographical disparity, targeting health services to specific groups, and improvingefficiency with the help of new management structures.The private health sector is very diverse and complex, consisting of formal and informalsectors and qualified and unqualified providers practising different systems of medicine.Given this, there is a need to develop an appropriate public policy towards the private sector.The public policy towards the private sector should improve the information base on theprivate sector, have an effective regulatory structure, and promote continuing education.The lack of consumer awareness, the absence of advocacy groups, and the actions of Selfcentredmedical councils and associations are other challenges that the policy shouldaddress.244

Specific Health Policy and Programme IssueslllThere is a lot of potential for improvement in the quality of health services if the hospitalsintroduce user charges. The health institutions should be authorized to utilize all the fundsgenerated for specific local needs.Well-articulated guidelines with simplified procedures for using the funds are necessary.Hospital administrators should be oriented and trained before this intervention is introduced.Schemes like health insurance coverage for acceptors of terminal methods of contraceptionand their children should be planned carefully, taking into consideration the strengths andlimitations of insurance companies and the ability of the private sector to provide services.The scheme should be pilot-tested in districts before scaling up to the entire state.Session 4Health Economics: Issues of EquitylllllllIn India, public health investments over the years have been comparatively low and as apercentage of the gross domestic product (GDP) have declined from 1.3% in 1990 to 0.9% in1999. Of the aggregate health expenditures in the country, only 20% are through the publicsector.Indians pay about 4.5% of the GDP to the private medical sector for health care. If thisamount were used to finance the insurance premium rather than pay private doctors andinstitutions, it would result in more extensive and better quality health care.Indian households spend substantial amounts of money on health care. The so-called “free”services in the public health care facilities are often a myth. Costs of care go up with theseverity of the illness. Patients from poor families pay a higher proportion of their householdincome on health care than rich families.An appropriate social safety net, either in terms of health insurance or through communityfinancing schemes, should be introduced to protect poor and disadvantaged groups.In Uttaranchal, 78% of the population live in villages. Nearly 80% of villages in Uttaranchalhave a population of less than 500. As a result, access to health services is a major problemin Uttaranchal.Other issues relate to the lack of awareness of available facilities and services offered, thelarge proportion of vacant health care positions, the lack of adequate equipment, and poortransport to facilities.Uttaranchal has taken several steps in the past year to improve access to health services inthe state. These include (1) the appointment of medical officers and paramedics on acontractual basis; (2) a transfer policy for medical officers; (3) involvement of IntegratedChild Development Services (ICDS) workers in health services; (4) reproductive and childhealth (RCH) outreach services and camps; and (5) dai (midwife) training.Session 5Sexually Transmitted Infections, Reproductive Tract Infections, AIDS,and Tuberculosis Control and ManagementlFamily health awareness campaigns to encourage case management of sexually transmittedinfections (STIs) have been organized since 1999. They have helped in improving awarenessamong service providers, but access to quality services on a regular basis is still a majorproblem.245

Specific Health Policy and Programme IssueslllllllAppropriate case management of STIs includes correct diagnosis, effective treatment,treatment compliance and sustainable risk reduction, and effective partner management.Etiological case management based on lab diagnosis has been perceived as largelyinappropriate for resource-poor settings. At the same time, the poor performance ofsyndromic diagnostic methods based on algorithms is a cause for concern.The integration of case management with RCH services should encourage the seeking ofearly treatment. For this purpose, service personnel should be trained in case detection andthe provision of prompt treatment using management protocols.By December 2001, 40 million people worldwide have been estimated to be living with HIV/AIDS. During 2001, an estimated 5 million people contracted HIV and 3 million people diedfrom AIDS. One feature of the epidemic is its ability to circulate in a population at low levelsfor a prolonged period of time before becoming explosive.The sentinel surveillance data from antenatal clinics showed that HIV infection ispercolating from various high-risk groups to low-risk groups in the population. In India, 3.97million people are infected with HIV.Uttaranchal is at the very early stage of an HIV epidemic, but this should not lead tocomplacency as the potential for transmission exists.India accounts for nearly one-third of the global TB burden. Every year, 2 million peopledevelop TB and 450,000 die from the disease. The HIV epidemic is likely to worsen the TBsituation in the country. TB is the most common opportunistic infection occurring amongHIV-positive persons.State- and district-level programme managers should realize that a poor TB controlprogramme is worse than none. The immediate priority for the state is to startimplementation of good quality Directly Observed Treatment Short-course (DOTS) after afull appraisal of district needs.Session 6Other Health Issuesl In recent years, the family as an institution has undergone a metamorphosis in terms ofstructure and function. As family units become smaller and young adults relocate to findwork, an increasing number of older people are left to cope alone. The result is a growingneed for home-based care services. These services should particularly focus on women.l Health education for the elderly, the training of doctors to handle the specific illnessesassociated with ageing, subsidized health care, creation of special geriatric wards, and bettercoordination between welfare and health schemes meant for the elderly are someimmediate measures that need to be considered.l Biomedical waste is generated in the diagnosis, treatment, prevention, and research ofhuman and animal disease. Hospitals, medical care establishments, and the general publicare being exposed to improperly handled medical waste.l Management of hospital waste should include identification of various components of thewaste generated, segregated storage at various places, common and intermediate storageareas, handling and transportation, and treatment technologies for medical waste.l Drug procurement systems, in general, have several limitations. Usually, the drug needs areworked out on an ad hoc basis and the budgetary allocations for drugs are always insufficient.246

Specific Health Policy and Programme IssuesllllFor improving the drug procurement system, the state should have a drug policy, developand adopt an essential drugs list, promote the rational use of drugs, constitute a drugprocurement agency, have trained staff, and develop an effective logistics and supplysystem.The huge infrastructure of the Ayurveda and Unani Department is not put to effective use bythe Health Department to promote primary health care. Each department operates inrelative isolation.Ayurvedic hospitals and clinics can play a major role in promoting modern family planningmethod use, in providing immunization services to children and antenatal care services topregnant women, and in promoting IPC to change behaviour.To institutionalize convergence, the roles and responsibilities of Ayurvedic medical officersshould be redefined and the officers should be reoriented. There should be regularcoordination meetings among all health care providers irrespective of the system ofmedicine practised.247

POLICY is a five-year project funded by the U.S. Agency for International Developmentunder Contract No. HRN-C-00-00006-00, beginning July 1, 2000. It is implemented by TheFutures Group International in collaboration with Research Triangle Institute (RTI) andthe Centre for Development and Population Activities (CEDPA). The views expressed inthis report do not necessarily reflect those of USAIDxix

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