Report of the Working Group on National Rural Health Mission (NRHM) for the Twelfth Five Year Plan

(2012-2017)

WG1: Progressand Performanceof NationalRural HealthMission (NRHM)and suggestions

WG-1
No. 2(6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 Dated 9th May 2011

OFFICE MEMORANDUM

Subject: Constitution of working group on Progress and Performance of National Rural Health Mission (NRHM) and suggestions for the Twelfth Five Year Plan (2012-2017)
With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on Progress and Performance of National Rural Health Mission (NRHM) and suggestions for the Plan under the Chairmanship of Shri K. Chandramouli, Secretary, Department of Health & Family Welfare, Government of India. The composition and the terms of reference of the Working group would be as follows: 1 2 3 4 4 5 6 7 8 9 Shri K. Chandramouli, Secretary, Department of Health & Family Chairperson Welfare, Government of India Mission Director (MD) NRHM, Department of Health & Family Welfare, Government of India Secretary, Department of AYUSH, Ministry of Health & Family Welfare, Government of India Ms Anita Das, Former Secretary, AYUSH , GOI Dr. N.K. Sethi, Former Sr. Adviser (Health), Planning Commission ,GOI Joint Secretary (RCH) Ministry of Health & Family Welfare., GOI Joint Secretary (PH) Ministry of Health & Family Welfare, GOI Representative, Ministry of Women and Child Development, GOI Principal Secretary (H&FW), Uttar Pradesh Principal Secretary (H&FW), Bihar Member Member Member Member Member Member Member Member Member

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Principal Secretary (H&FW), Rajasthan Dr. Manohar Agnani, Mission Director, NRHM, Madhya Pradesh Mission Director, National Rural Health Mission (NRHM), Tamil Nadu Mission Director, NRHM, Assam Director, ,National Institute of Health and Family Welfare(NIHFW) New Delhi

Member Member Member Member Member

Director,International Institute for Population Sciences (IIPS), Member Mumbai Executive Director, Population Foundation of India), (PFI) New Delhi Member Dr. H. Sudarshan, Karuna Trust, Bangalore Dr. Sunil Kaul, Action Northeast Trust, (ANT) Bongaigaon, Assam President, Federation of Obstetric and Gynecological Societies of India, (FOGSI) Mumbai Ms. Renu Khanna, Society for Health Alternatives, (SAHAJ) Vadodara, Gujarat Dr. M. Prakasamma, Director, Academy of Nursing Studies, Hyderabad Dr. N.K.Arora, Director, International Clinical Epidemiology Network (INCLEN), New Delhi Member Member Member Member Member Member

Dr. Shalini Bharat, Professor, School of Health System Studies, Tata Member Institute of Social Sciences, Mumbai Dr. Nerges Mistry, Foundation for Research in Community Health, Pune Dr. P.Nirmala Nair, Ekjut, Jharkhand Ms. Madhavi Kukreja, Uttar Pradesh Dr. Pankaj Shah, Self-Employed Women's Association (SEWA) Rural Gujarat Dr. Shakeel, Patna, Bihar Member Member Member Member Member

Dr. Dhruv Mankad, Lead Consultant, Project Evaluation Team at Sir Member Dorabjee Tata Trust,Nasik Dr. Joe Verghese, Senior Programme Coordinator, Christian Medical Member Association of India, New Delhi Dr. Mohan Rao, Professor, Centre of Social Medicine and Community Health, JNU, New Delhi 2 Member

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Sh. S.M.Mahajan, Adviser (Health), Planning Commission JS (Policy), MOHFW

Member Member Secretary

Terms of Reference
1. Critical review of progress and performance of NRHM against its goals, objectives and expected outcomes; documentation of its strategies and assessment of its strengths and weaknesses; commenting on regional and socio-economic imbalances in its health coverage. Review the trends in public sector expenditure in health over the last 5 years of NRHM and the absorptive capacity of the States and Districts. Review the healthcare infrastructure, human resources and provision of health services, specifically to women, children and the rural population of the country. Review the programme management capabilities consequent to setting up of the State, District, Block and Facility level Programme Management Units and involvement of professionals under NRHM. Review the community processes and community ownership of public health services and the change in the system since 2005 due to flexible funding. Review the strategies for Reproductive and Child Health and Nutrition undertaken under NRHM and the progress so far. Review the involvement of private sector and the existing Public Private Partnerships under NRHM for their effectiveness, strengths and weaknesses. Review status of integration of all vertical programmes under one umbrella and strengthening of State Health Systems to deliver the health services. Review the performance of the disease control programmes under the umbrella of NRHM and the way forward. Review availability of and access to drugs, including promotion of generic drugs and indigenous diagnostic facilities and suggest reforms to make distribution more equitable. Review the strategy of Population Stabilization and suggest effective measures to meet the 12th Five Year Plan targets. Explore the possibility of an overarching National Health Mission that subsumes NRHM and the NUHM. Deliberate and give recommendations on any other matter relevant to the topic. 3

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The Chairman may constitute various Specialist Groups/ Sub-groups/ task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitorable goals, while making recommendations. Efforts must be made to co-opt members from weaker sections especially Scheduled Castes, Scheduled Tribes and minorities working at the field level. The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the nonofficial Working group members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. The Working group would submit its draft report by 31st July, 2011and final report by 31st August, 2011.

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(Shashi Kiran Baijal) Director (Health)

Copy to: 1. 2. 3. 4. 5. 6. 7. 8. 10. 11. 12. Chairman, all Members, Member Secretary of the Working Group PS to Deputy Chairman, Planning Commission PS to Minister of State (Planning) PS to all Members, Planning Commission PS to Member Secretary, Planning Commission All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission Director (PC), Planning Commission Administration (General I) and (General II), Planning Commission Accounts I Branch, Planning Commission Information Officer, Planning Commission Library, Planning Commission

(Shashi Kiran Baijal) Director (Health)

Contents
List of abbreviations .............................................................................................................. 6 Background and Terms of Reference: ..................................................................................... 1. Review of NRHM: Goals and Objectives TOR I ......................................................... 7 2. Trends in public sector expenditure in health and the absorptive capacity of the States and Districts TOR II ................................................................................................... 12 3. Infrastructure Development and Provision of Services under NRHM TOR III......... 19 4. Increasing Human Resources for Health TOR III ...................................................... 26 5. Programme Management TOR IV ............................................................................. 32 6. Strengthening of Community Processes under NRHM TOR V................................. 36 7. Progress in RCH Services TOR VI ............................................................................ 43 8. Engaging the Private Sector TOR VII ........................................................................... 48 9. Integration of Vertical Programmes and Performance of Disease Control Programme TOR VIII and TOR IX .................................................................................................. 52 10. Access to Drugs and technologies TOR X ................................................................. 55 11. Population Stabilization - TOR XI ................................................................................ 57 12. National Urban Health Mission TOR XII ................................................................... 59 13. A. Gender Concerns in the Health Sector - TOR XIII ................................................. 62 13. B. Accountability Framework - TOR XIII .................................................................. 63 Key Recommendations and Budget Proposals for the Twelfth Five Year Plan .................. 65 Annexure 1 - List of Publications of relevance to working group on NRHM................... 102 Annexure 2 Constitution of the Working Group .................................................................. Annexure 3 Minutes of the First Meeting of the Working Group .................................. 105 Annexure 4 Minutes of the Second Meeting of the Working Group.............................. 113

List of abbreviations
ANM ANMTC ASHA AYUSH BMI BRMS CRM DDO DLHS EAG IMR JSSK MIS MCTS MIS MMR NFHS NHA NRHM NSSO NUHM OOP PCPNDT PPP PRI RCH RKS RSBY SBA SIHFW SRS TFR TOR U5 MR VHSNC Auxiliary Nurse Midwife ANM training Centre Accredited Social Health Activist Ayurveda Yoga Unani Siddha and Homeopathy Body Mass Index Bachelor of Rural Medicine and Surgery Common Review Mission Drawing and Disbursement Officer District Level Household Survey Empowered Action Group Infant Mortality Rate Janani Shishu Suraksha Karyakram Management Information System Mother and Child Tracking System Management Information System Maternal Mortality Ratio National Family Health Survey National Health Accounts National Rural Health Mission National Sample Survey Organisation National Urban Health Mission Out Of Pocket Pre Conception, Prenatal Diagnostic Test Public Private Partnership Panchayati Raj Institution Reproductive and Child Health Rogi Kalyan Samiti Rashtriya Swasthya Bima Yojana Skilled Birth Attendant State Institute of Health and Family Welfare Sample Registration System Total Fertility Rate Terms of Reference Under 5 Mortality Rate Village Health, Sanitation and Nutrition Committee

1. Review of NRHM: Goals and Objectives TOR I

1.1. The National Rural Health Mission (NRHM) of the Eleventh Plan was conceptualized in response to what were perceived as systemic flaws in the health system namely, the lack of a holistic approach, absence of linkages with collateral health determinants, gross shortage of infrastructure and human resources, lack of community ownership and accountability, non-integration of vertical disease control programs, inadequate responsiveness to community needs and lack of financial resources (background paper issued by Planning commission to Twelfth five year plan process for health sector). 1.2. Measurable Objectives of the Eleventh Five Year Plan: The Eleventh Five Year Plan had set time bound measurable goals and some process objectives. The Measurable Outcomes specified were: Reducing MMR to 1 per 1000 live births (100 per 100,000 live births). Reducing IMR to 30 per 1000 live births. Reducing TFR to 2.1 Providing clean drinking water for all by 2009. Reducing malnutrition among children of age group 0 to 3 to half of its present level. Reducing anaemia among women and girls by 50%. Raising the sex ratio for age group 0 to 6 to 935 by 2011-12 and 950 by 2016-17.

1.3. Outcomes in Maternal Mortality: 1.3.1. MMR has reduced from 254/100000 live births in 2004-06 to 212/100000 live births in 2007-09 (SRS), a reduction of 42 points over a three year period or 14 points per year. At this rate of improvement MMR of 156/ 100000 live births could be achieved by year 2012, which would be short of the target of 100/ 100000 live births set by the eleventh plan. 1.3.2. In the four southern states, Kerala and Tamil Nadu have already achieved the goal of a MMR of 100/100000 live births but, within the group, Karnataka lags significantly behind with a MMR of 178/100000 live births and at current rate of decline would only reach about 130/100000 live births in the year 2012. In the non EAG large states the MMR is 149/100000 live births. Though potentially these states should also achieve the goal by 2012, some caution is needed- as all these states except perhaps Maharashtra have faced a slow down. At the current rate of decline of only 8 points per year, the group average would reach near the MMR target of 100 /100000 live births by 2012. 1.3.3. In the sub-group of EAG states including Assam, there has been a sharp fall and at this rate of 22 points decline per year for the group the 2012 figure should be around 220/100000 live births. Many of these states have shown acceleration in 7

improvements in the latest three year period notably Assam, Madhya Pradesh and Rajasthan. Assam where MMR declined at only 3 per 100,000 in the previous three years now recorded a decline of 30 points per year- but still at a MMR of 390/100000 live births, Assam remains Indias most maternal death prone state. The caution is that it is difficult to sustain this rate at the lower levels of the curve. 1.3.4. Another important feature is the comparisons between MMR as maternal mortality ratio and the maternal mortality rate. West Bengal and Gujarat for example have the same ratio- 148 and 145, but the Gujarat maternal mortality rate at 12.8 is 30% higher than the west Bengal rate at 9.2. At the other end Assam has a MMR of 390 versus Uttar Pradesh 359, Rajasthan- 318 or Bihar- 261- but the maternal mortality rates of the Assam is 27.5 against 40.0, 35.9 and 30.1 for the latter. Clearly the life time risk is much higher in the latter states due to the much higher fertility rates for these states which points out to the tremendous reduction in total number of maternal deaths, lower fertility rates by themselves bring about.

1.4. Outcomes in Infant and Under 5 mortality (U5 MR): 1.4.1. The national infant mortality rate has declined from 57 /1000 live births in year 2006 to 50 /1000 live births in the year 2009. Of this the decline in rural areas was more (from 62 /1000 live births to 55/1000 live births). In urban areas, the decline in IMR was from 39/1000 live births to 34/1000 live births. The rate of decline across the sexes, in both urban and rural areas was the same. At the all India level, by 2012 at the current rate of decline, we would have reached an IMR of 44/1000 live births, well short of the goal. 1.4.2. The decline in under 5 mortality was similar. The current levels have reached a total of 64/1000 live births with a rural of 71/1000 live births and urban of 41/1000 live births - a larger difference than for IMR. Gender differentials are also higher- much more in rural areas. Female U5 MR 76/1000 live births in rural areas compared to 66/1000 live births in males- a difference of 10 points. In urban areas also there is a difference of 5 points. 1.4.3. Comparing between IMR and under 5 mortality rates, one notes that the greatest contribution of the 1 to 4 deaths is amongst the rural girl child- the difference between rural female IMR and rural female under 5 mortality rate being 20 as compared to only 12 in rural males and only 11 in urban females and 7 in urban females. Gender acting through neglect of the girl child more than through nutrition, has a disproportionately higher role to play in 1 to 4 mortality.

1.4.4. Ten states and union territories have reached the NRHM goals of IMR of 30. At the current rate of decline a total of 15 states would have crossed the goal-post by 2012. 8

1.4.5. Of the remaining states, the poorest performing nine states account for 68% of total infant deaths in the country. These nine states however have all shown higher rate of improvements as compared to the national average except for Meghalaya which unfortunately has seen an increase in IMR.

1.5. Progress on Population Stabilization: 1.5.1. The national TFR is 2.6 in the year 2008. By 2012 it could reach 2.4 and this would be short of the target of 2.1 which the eleventh five year plan had set. 1.5.2. Nineteen states and five union territories have reached population stabilization goals of a TFR below 2.1(2008) and/or a crude birth rate below 21 per 1000 population (2009). Three states are on way to achieving it- Haryana, Gujarat, Assam. 1.5.3. Six large states have a TFR above 3.0, which is matter of concern, but even these six states have shown steady improvements. Four of these states had a 0. 4 point TFR decline in these five years and the other two declined by 0.3 points, as compared to an all India decline in TFR of 0.3. TFRs are not available for small States and UTs. 1.5.4. The Census 2011 report states that the report marks a milestone in the demographic history of the country, as it is perhaps for the first time, there is a significant fall in growth rate of population in the EAG states after years of stagnation. The rate of fall of the five most populous states of these 8 states was even faster. That it fell, when IMR was also falling in these states, shows the potential for early achievement of population stabilization even in states where the challenges are the most. Census 2011 shows growth rate for the nation as a whole as 17.4; and this is a significant decline from the previous decade.

1.6. Progress on Clean drinking water for all: 1.6.1. The coverage statistics on habitations according to National Rural drinking water programme data for July 2011 show that out of 1,661,058 habitations about 1,180,684 habitations have 100 percent drinking water coverage, 43,963 habitations have 0 to 25 % drinking water coverage, 97,119 habitations have 25- 50% drinking water coverage, 153,256 habitations have 50- 75% drinking water coverage, 116,320 habitations have 50- 75 % drinking water coverage and 69,716 habitations have no drinking water coverage. The mid- term review of the eleventh plan highlights that slip- backs continue to happen on an ongoing basis. 1.7. Progress on Reducing malnutrition among children of age group 0 to 3 to half its present level and reducing anemia by 50%

1.7.1. The most recent figures available on these are from NFHS- III which formed a base line for the plan. No further figures have since been generated. 1.7.2. The proportion of children under weight below the age of three is 40.4% (NFHS III). The proportion of severely underweight is 15.8% (NFHS III). 52% of underweight children were among Underweight mothers (BMI <18.5). Malnutrition is highest in Madhya Pradesh, where 60% of the children were underweight and 27% severely underweight; followed by Bihar & Jharkhand (56%), Meghalaya (48%) and Orissa (40%). Stunting was at 44.9% with severe stunting at 22%. The state of Uttar Pradesh has shown the highest proportion of children stunted (56.8%), followed by Bihar (55.6), Chhattisgarh (55.9%) and Gujarat (51.7%). The proportion of children under wasting is 22.9% (NFHS III), and severe wasting is 7.9% (NFHS III). Malnutrition is consistently much higher in SC and ST families.

1.8. Raising the sex ratio for age group 0 to 6 to 935 by 2011-12 and 950 by 2016-17. 1.8.1. The child sex ratio in India has dropped to 914 females against 1,000 males - the lowest since Independence. According to 2011 Census, the child sex ratio has declined from 927 females against 1,000 males in 2001 to 914 in 2011. 1.8.2. Disaggregating by states, an increasing trend in the child sex ratio (0-6 years) has been seen in Punjab, Haryana, Himachal Pradesh, Gujarat, Tamil Nadu, Mizoram and Andaman and Nicobar Islands. Some of these states had faced major declines in the past and the reversal of the trend in the northern three states and in Gujarat is a welcome development. 1.8.3. In all remaining 27 states and Union Territories, the child sex ratio shows decline from census 2001 to census 2011. The major decline in child sex ratio is recorded in state of Jammu and Kashmir by 82 points from 941 in 2001 to 859 in 2011. 1.8.4. Much of the decline is due to declining sex ratio at birth, and the most common reason for this is sex selective abortion, which despite the PCPNDT, has not been adequately curbed. Another significant contributor to the declining sex ratio is the differential mortality with much lower child survival rates in the girl child of the 0 to 5 age group.

1.9. Other than the above measurable goals, the Eleventh Five Year Plan also specified a number of important process or health sector development goals on disease control and a number of process/public health infrastructure goals. These are: Increase in public health expenditure

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Increase in healthcare infrastructure, human resources and provision of health services, specifically to women, children and the rural population of the country Improvements in programme management capabilities Strengthening community processes and community ownership of public health services: and changes in flexible funding. Improved delivery of Reproductive and Child Health and Nutrition services. Involvement of private sector and strengthening Public Private Partnerships. Improved performance of the disease control programmes and their integration with the rest of the health sector. Improved access to drugs and diagnostics. Achievement of Population Stabilization with gender balance.

We shall consider these in subsequent sections.

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2. Trends in public sector expenditure in health and the absorptive capacity of the States and Districts TOR II
2.1. Over the last six years, the central government has made a total of Rs. 52,832 crores release under NRHM for the explicit purpose of financing their state plans to strengthen public health services with a focus on primary health care. (Source: Public Accounts Committee 32 Report, 2010-11). The total expenditure by the central government in the period 2005-06 to 2009-10 was Rs 73,606 crores of which the total NRHM component was Rs 38, 420 crores , that is 52.2%. 2.2. The central government budgetary expenditure for health increased by 21.45 per cent per year (compounded annually) in the post NRHM phase (2005-06 to 2009-10) as compared to 10.85 per cent per year in the pre-NRHM period (2001-02 to 2004-05). The increase was from 9650 crores in 2005-06 to 20,996 crores in 2009-10 and this includes the NRHM. In 2009-10 the NRHM release was Rs. 11,225 crores and this comes to 53.46 % of the central government health budget. 2.3. The state governments combined budgetary expenditure increased by 19.87% (compounded annually) from 22,031 crores in 2005-06 to 45,493 crores in 2009-10 2.4. The utilisation rate of the funds in the first years was slow, but subsequently it picked up and compensated for the low initial releases. The utilisation rate of RCH Flexi pool increased from 27.77 per cent in 2005-06 to 104.32 per cent in2010-11, whereas NRHM flexi pool utilisation increased gradually from 4.24 per cent in 2005-06 to 141.74 per cent in2010-11. Overall during the six years (2005-06 to 2010-11) the utilisaion rate of NRHM Flexi Pool was 97.87 per cent and RCH Flexi Pool was 92.63 per cent (Source: NRHM MIS State Wide Progress as on 31.03.2011) 2.5. The trend is not confined to the Society route of funds only. A similar encouraging trend is also seen in the utilization of treasury route of funds for health. The RBI budget figures show that utilization of capital expenditure for all states, increased from 63.36 per cent in 2003-04 to 89.31 per cent in 2008-09 (expenditure as percentage of budget allocated) while the revenue expenditure of state health budget for all states remained steady at 90.87 per cent in 2003-04 to 95.11 per cent in 200809. 2.6. We note that as the expenditure cycle of procurement and civil works (constructions/renovations) is around 2-3 years, especially in the EAG and NorthEastern states, the low level of expenditure upto 2008 needs to be understood in that context. Booking of expenditures, implying absorption of funds would be increased in the subsequent years as funds related to civil works and procurement undertaken after 2007-08 start getting booked by the close of 2009-10.

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2.7. Another major reason for the initial problems in absorption of funds and subsequent decrease in this is due to better understanding of the programmes and procedures and due to increased institutional capacities - functional Societies and RKS, training and orientation of staff, addition of management and accounting technical staff. The increased deployment of skilled human resources also led to improvement in fund absorption in the later years. 2.8. Another reason for improved absorption, is that in funds flow through the society mode, the power of authorizing and actually undertaking the expenditure moved down to health facility and village level, whereas under the treasury route the Drawing & Disbursing Officers (DDO) are limited only to the block level, and does not go below that. The society mode of operations is not aimed at replacing the treasury system, but targets those specific areas of decision making and expenditure which is immediate and localized in nature. Addressing such needs through the treasury system might not be very efficient with respect to the timeliness and appropriateness of the response. However in the first two years, since procedures and mechanisms had not been established absorption of funds remained low. 2.9. The NRHM funds have been released to states through the state health soceities as four components- RCH flexi-pool, Mission flexi-pool, Immunization (including Pulse Polio) and the National Disease Control Programmes. Under RCH flexi-pool the total amount released to states in these six years was Rs 14,488 crores and under Mission flexi-pool the total amounts released was Rs 16,265 crores. For Immunisation and Pulse Polio, a sum of Rs 2728 crores has been released. In these six years, for disease control, the amount released was Rs. 4667 crores. In addition through the treasury route, Rs 14,250 crores was released for infrastructure maintenance. (Table :) 2.10. Most of NRHM funds released (31%) went to finance the health system strengthening taken up under Mission flexi-pool. This is followed by funding the maternal and child health interventions under RCH-II ( 28%), immunization and disease control programmes (14%) and on Sub Health Centre expenses (27% under the head infrastructure maintenance which flows through the treasury route and not under society route) ( The Per Capita expenditure on National Rural Health Mission was Rs. 80.44 in 2005-06, which increased to Rs. 129.77 in 2007-08 and then to Rs. 163.62 in 2009-10 (Source: Public Accounts Committee 32 Report, 2010-11) 2.11. The proportion of releases between primary, secondary and tertiary for the health sector is one area of concern. If all of NRHM is considered as primary and secondarythis accounts for approximately 70% of the health budget. The rest has gone to medical research, medical and nursing education and to tertiary care hospitals. The NHA 2004-05 data shows that at the state level, 38% of health expenditure is spend on primary health care, 18.67 % on secondary health care ,21.84 % on tertiary health

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care and rest on direction and administration and other services. This has not been changed substantially by 2008-09 as per the NHSRC budget tracking report.1 2.12. Rate of expansion of financing did not keep pace with expectations. The annual expenditure in 2010-11 was to reach 55,000 crores. The NRHM Framework for Implementation estimated an expenditure of Rs 175,000 crores over seven years. But in fact we have reached only Rs 50,000 crores or less than one thirds of this projected amount. Even including the 2011- 12 expenditures we would achieve about 75,000 crores only. 2.13. This period of the NRHM has also seen a considerable increase in state health sector expenditure also. Most of this is in the non plan aspects. States were committed to increasing their expenditures by 10% annually and most states have adhered to it. Increase in states own health budget has gone up by more than 10 % in most of the states (including EAG states) post NRHM period.2 2.14. They were expected to pay 15% of the cost of the NRHM state budgets and most states have made some contribution in this regard. In 2007-08 only 4 States/UTs made the desired contribution of 15 percent of State PIP from their own budget .By the year 2008-09, 25 out of 35 states had contributed 68.75 % of the total state share requirements. And in 2009-10 34 out of 35 states had contributed 79.28 % share of funds due towards state contribution. (Source: Public Accounts Committee 32 Report,2010-11) 2.15. Most states spend around 4 to 5 % of the state budgetary outlay on health and less than 1% of the GSDP on health- which is insufficient to meet the NRHM goals. . The total public expenditure on health in the country as a percent of GDP stands at around 1.1 percent in 2009-10. The state share of public expenditure on health was 0.67 percent of GSDP in 2005-06 and this increased gradually to 0.70 percent of GSDP in 2009-10, whereas the central share increased from 0.29 percent of GDP to 0.39 percent during the same period. However, if we take into consideration the health related inputs which includes the expenditure on water supply, sanitation, nutrition and estimated expenditure on national insurance programme (RSBY) this is around 1.96 percent of the GDP. (Source: Mid Term Review of the Eleventh Five Year Plan) 2.16. There has also been some concern that the money provided to states under NRHM substituted instead of supplementing state health expenditures. Though there are sectoral instances of this in some states, especially as regards contractual appointment
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In Bihar the share of state expenditure on primary health care services in 2008-09 was 55%, secondary health care 14% and tertiary health care 26%, in Jharkhand it was 52%, 12% and 20 % ,in Tamil Nadu it was 38%, 39% and 8%.

2 As per the budget tracking study done by NHSRC in 2007-08, the increase in states own share of health budget over the previous year for Bihar was 10%, Chhattisgarh 36%, Himachal Pradesh 13%, Karnataka 40%, Maharashtra 25%, Rajasthan 16% ,West Bengal 16% and Tamil Nadu 5%

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and maintenance funds, on the whole, there is no such trend and if anything it has spurred states to spend more. The state expenditures increased by about 20% per year and in parallel to the central government increase. However much of this increase could be non plan and consequent on increase in salaries and does not necessarily reflect greater investment in health. 2.17. Though absorption is much less a problem it is likely to recur as fund flows increase. One important reason is that one has to estimate and provide for considerable funds to remain in the pipeline and not expect utilization too prematurely. 2.18. Yet another major constraint to absorption at the current higher level of fund flows- is that funds flow within the districts was on a per facility normative basis and not responsive to utilization patterns leading to scarcity in some facilities and stagnant funds in others. JSY has brought over a crore pregnant women into public health facilities but the delivery load is unevenly distributed across facilities. The fund flows however are evenly spread across all the facilities. Since funds to the districts are provided through the State Health Society, the State Governments need to plan their allocations according to the felt needs and the District Health Action Plans. 2.19. The expansion of management structures and institutions, has not kept pace with requirements and this begins to slow down the pace of the programme. The third and fourth CRMs both pointed out that states that invest in a state level infrastructure development management unit absorb infrastructure funds better; states that have a good procurement and logistics system spend far more on drugs and get much more value for the money spent. Even programmes like ASHA, training of skilled workers, quality improvements in public facilities etc utilize their full funds only if corresponding management structures at the state level are created. 2.20. Non inclusiveness in expanding capacity to spend the amounts and implement the activities is also a major constraint to expanding expenditure. Weak development of partnerships with non governmental agencies and private sector, even for purposes of strengthening public service delivery through auxiliary services and management contracts and a trend to try to get all work done with only the staff and set ups that are already existing. 2.21. Though there has been a major expansion of human resources efforts in this direction need to be continued and rationalization of deployment and reforms in recruitment process must be taken up with greater vigour. 2.22. The Twelfth Five Year Plans needs to address these constraints creatively especially the central problem of efficiency in resource allocation to districts and within districts. Having said that it needs to provide a much larger resource envelope to all states for them to be able to achieve their goals. The current public spending is roughly 1% of the GDP and the urgency of it rising to 2-3% of the GDP should not be minimized.

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India ranks very low in terms of financial protection as more than 70% of the financing is through OOP payments by individual households at the time of utilization of health services. As per the NHA (2004-05), Of the total health expenditure, the share of private sector was the highest with 78.05%, public sector at 19.67% and the external flows contributed 2.28%.Out-of pocket spending accounts for over 95% of total private health spending and 71.13 % percent of total health spending in India, which is one of the highest, even amongst low-income countries. The high OOP expenditure on health care forms a barrier to accessing care and can cause households to incur catastrophic expenditures, which in turn can push them into indebtedness and poverty. According to a recent article published in lancet, health expenditures account for more than half of Indian households falling into poverty, with about 39 million Indian people (306 million in rural areas and 84 million in urban areas)being pushed into poverty every year due to health costs. The NSSO morbidity and health care utilization surveys show that between 199596 and 2004, the absolute expenditures per outpatient visit and inpatient visit in rural and urban areas increased, particularly affecting the ability of the poorest individuals to access services. The average expenditure for inpatient care in public facilities increased from Rs .2080 in 1995-96 to Rs .3238 in rural areas and from Rs .2195 to Rs.3877 in urban areas. In the private sector the average expenditure increased from Rs .4300 to Rs. 7408 in rural areas to Rs. 11553 in urban areas. Expenditures on drugs represent 70 to 80% of these out of pocket payments and this has been rising at twice as fast as the general price increase. The rise in the private sector was much higher than in the public sector. 2.23. One of the functions of the public sector is to provide protection against the rising costs of care. However, out of pocket expenditures even in the public sector are high, and for hospitalization they can be as high as Rs. 3288 per episode in rural areas and Rs. 3877 in urban areas. Paradoxically, the out of pocket expenditure in the public sector is much higher in the high focus states and in the northern states of Haryana and Punjab and Himachal. The average total medical expenditure for inpatient care in public hospitals for rural areas is Rs. 4998 in Bihar, Rs .3096 in Orissa, Rs. 5464 in Rajasthan, Rs. 7648 in Uttar Pradesh, Rs. 6035 in Himachal Pradesh and Rs. 11, 665 in Haryana. But in these states the bottom 20 % of the population incurred very high out-of-pocket expenditure with Rs. 3443 in Bihar, Rs. 3096 in Orissa, Rs. 3453 in Rajasthan in public hospitals. Compared to these states in Tamil Nadu, the bottom 20% spend Rs. 152 as OOP in government hospitals. The 60th round of NSSO survey showed that in both in rural and urban areas the financial burden of the medical treatment as an inpatient is very heavy. It is also seen that the number of untreated ailments are on the increase gradually due to financial reasons. In 1986-87 the financial reason was reported by 15% and 10% in rural and urban areas respectively. The same has increased to 28% in rural and 20% in urban areas in 2004. In rural India, about 47% of the hospitalization cases were financed by loans, sale of assets etc. In urban India, about 31% of the hospitalization cases were financed by loans, sale of assets etc.

16

2.24. Social protection through insurance programmes has been launched in a number of states. In Andhra Pradesh and Tamil Nadu and Karnataka, such publicly financed insurance is for the BPL and covers tertiary care. Sustainability of these schemes needs to be examined. In most other states, the RSBY is the main insurance mechanism made available to the poor. Though intended for social protection, the actual degree of social protection it offered is not quite known especially for RSBY, where the information on the cases handled and category of persons who benefitted is not in the public domain. It is understood that in many states the RSBY has a poor claims ratio despite widespread moral hazards of overcharging, except in Kerala where the claims ratio is over 130%. It also has the propensity to convert primary and secondary care- into tertiary care and outpatient care into in-patient care. Mechanisms of gate-keeping or monitoring are weak and critical data needed for its evaluation is difficult to access. While recognizing the great hope and potential that lies behind this scheme, prudence calls for evaluation before this is scaled up even further- much less projected as the general solution. Publicly financed insurance programmes, when much better structured, monitored and regulated could play an important supplementary function, rather than become the main vehicle of health care financing. 2.25. The Twelfth Plan recommendations therefore need to address the following aspectsa. increase in total public expenditure as % of GDP, b. principles of allocation to state, c. principles of resource allocation to districts, d. the problem of making resource allocation responsive to local needs as expressed by communities and as assessed by public health studies, e. the mechanisms for improved absorption of funds, f. the monitoring and achievement of substantial reductions in out of pocket expenditure in both public and private sector, e. g. the fulfillment of the social protection obligations of the public health sector. These are all suggested in the last section on proposals for the 12th Five Year Plan. Table- 1 NRHM Releases by Components from 2005-06 to 2010-11:Rs. in Crores Year NRHM RCH Flexi NDCP Pulse Flexi Pool Pool Polio 2005-06 962 1050 564 313 2006-07 2054 1426 648 452 2007-08 3133 1843 795 422 2008-09 2597 3070 812 618 2009-10 3366 3478 888 593 2010-11 4154 3622 961 370 16265 14488 4667 2768 Source: NRHM MIS State Wide Progress as on 31.03.2011 Infrastructure Maintenance 1546 1195 2317 2527 2900 3765 14250 Total NRHM 4434 5774 8509 9625 11225 12871 52438

17

Table 2- Central and State Government Health Budget: Rs. in Crores Central Government Percent increase over previous year State Government Percent increase over previous year 2.8% 6.7% 7.6% 12.3% 15.2% 13.9% 18.8% 32.4% 10.6%

2001-02 5937 2002-03 6504 9.5% 2003-04 7249 11.5% 2004-05 8087 11.6% 2005-06 9650 19.3% 2006-07 10948 13.4% 2007-08 14410 31.6% 2008-09 17661 22.6% 2009-10 20996 18.9% 2010-11 25055 19.3% Source: Government of India Budget Documents State Finances: A Study of Budgets of 2009-10 (RBI)

16627 17094 18235 19617 22031 25375 28908 34353 45493 50297

Note: The budget figures for central government for the year 2010-11 corresponds to budget estimates and that for state government for 2009-10 are revised estimates and 2010-11 are budget estimates.

18

3. Infrastructure Development and Provision of Services under NRHM TOR III

3.1. One of the stated purposes of the NRHM was to close health infrastructure gaps. The Eleventh Five year plan document identified a requirement of 158792 subcenters with a short fall of 13.36% , 26022 PHCs with a short fall of 18.46% and a requirement of 6491 CHCs with a short fall of 40.87%- the last of these being identified as the most critical short fall. The NRHM envisaged all these gaps as being closed and the necessary manpower as required to make these fully functional as per IPHS guidelines as being put in place. The emphasis was on making the existing 145,000 sub-centers, the 22669 PHCs fully functional rather than creating new facilities at this level. At the CHC level it envisaged 6500 facilities becoming functional. In the penultimate year of the Eleventh Five year plan (2010) we find that there are 147,046 sub-centers functioning and 22834 PHCs and 4745 CHCs which have been established. One of the aims of the NRHM was that every government facility should have its own, adequate building. Of the sanctioned facilities 38% of sub-centers are not in a government building, and 13% of PHCs and 3% of CHCs are not in their own building. There are a number of health facilities in which construction is ongoing. 34% of the new work would be getting completed in high-focus states by 31st December 2011 with another 51% in progress, while 49 % of new construction would be completed in non-high focus states with 39% of new construction work is under progress in non-high focus states. NRHM supported renovations of Public Health Facilities have made good progress with 72% work getting completed in high-focus states, while 49 % of sanctioned work has been completed in non-high focus states. Under NRHM, it is proposed that all Community Health Centres would be upgraded to level of a 30 bed hospital with functional Operation Theatre and all basic specialties. Construction of 70 new buildings for Community Health Centre was sanctioned in high focus Non-NE States and 96 new CHC buildings were sanctioned in NE States till 31st December 2010 and 157 CHCs in other states- a total of 323. Of these 142 are completed, the pace of construction being slowest in the NE. The Fourth CRM concluded that where states had a dedicated institutional arrangement for infrastructure development, the performance was better. But in many states largely due to the lack of such management capacity, progress has been slow. The other major issue is in prioritization. The Eleventh Plan had stated that population based norms would be modified by flexible norms comprising habitation based needs, community based needs and disease pattern based needs. This policy should be continued more effectively in the next plan. Facilities which have higher volume of cases and which are more utilized because of central location or better quality service providers need to be prioritized for better infrastructure. Similarly 19

3.2.

3.3.

mapping areas of lack of access and using such gap identification to locate new facilities must also be done. Though facility surveys were done to identify gaps- the prioritizing of facilities based on infrastructure, human resources, skills, equipments and supplies would be closed in a synergized fashion was not done adequately. 3.4. There is also a question of the impracticality of achieving the same level of package delivery and the same range of services in all facilities of a certain type. The provision of healthcare should move closer to people to enable easy and timely access to quality care. Ideally one must be able to access the health services in their village itself. For which, we require a long term goal of setting-up of one sub-centre in each village. A simpler clinic, adequate for holding an outpatient clinic for antenatal care would have helped achieve the goal of universal access easier. In states like Kerala and Tamil Nadu, Punjab etc, the sub-center has officially or by convention been withdrawn from the task of providing delivery services and even much of the outreach services have migrated to the PHC and CHC and the female MPW plays a much more active role in school health, adolescent health and other newer priorities. The major learning from this pattern should be to base prioritization of facilities and outreach centers for development on access mapping. Access to a functional health team is seen as preferable to a lone provider in an isolated clinic- be it a subcenter of a PHC. A smaller number of facilities well located with better assured referral transport system would then in a large number of districts be adequate to achieve the goal of universal access. In some highly dispersed districts however we may need a much higher number of facilities then the current population norms. The increase in population within a village should be met with more staff in existing PHC. Infrastructure development must be prioritised accordingly by taking into consideration both population served and standards of access. The number of primary and secondary care beds required in the district should be based on population and epidemiological norms with the option for the district plan to distribute these beds between the various facilities- PHCs, CHCs and SDH and DH. Thus for a 10 lakh population we could start with a minimum of 500 beds and increase beds in facilities depending on bed occupancy rates. Maximum size of a district hospital could also be fixed. We however would have a base line of 30 beds in a CHC and 200 for a district hospital in a population of 10 lakhs. WHO norms are 1500 beds for 10 lakhs- but given both private sector presence and also limited public sector capacity- a 500 bed per 10 lakhs starting point as a baseline for all districts is being proposed. The 4 to 6 beds in the PHC are largely day care beds and for institutional delivery and stabilization care and are not counted either for reaching norms of bed creation or later in bed occupancy calculations. The other finding we have from various studies is that a) the district hospitals are now managing a huge part of the case load and b) they provide the major part of all specialist care for obstetrics and infectious disease and c) they are the only place 20

3.5.

3.6.

3.7.

where we can expect specialist care for chronic disease of at least secondary level to be established within a district in the plan period. The district hospital is also the site of nurse training, ANM training, SBA training, IMNCI training and so on. However the investment in district hospitals in this eleventh plan period has been very limited and grossly insufficient to meet even the increased load due to JSY.. The Twelfth Plan would therefore need to plan for much larger district hospitals with at least 200 beds ( for a ten lakh population) with an additional 100 beds for every further 10 lakhs population and the ability to support and complete set of district level services as envisaged in the IPHS. 3.8. The approach paper to the 12th Plan mentions that the aim should be to locate a Sub Centre in every Panchayat. The current establishment of Sub Centre is on a population norm of 5000 for the plains and of 3000 for the hilly/tribal/desert areas. Aligning it with the Gram Panchayats may result in the reduction of the number of Sub Centres in some States, as the average population covered by a Gram Panchayat is much more than 5000 in these States. Hence, there would be provision for at least one health Sub Centre in every Panchayat. An additional ANM may be added for upto 10% of Sub Centres which have high delivery loads. In hilly/tribal/desert areas the existing norm may be further relaxed to ensure that the people do not have to travel long distances or for long durations to reach the health Sub Centres. With these caveats and conditions in place, the Twelfth five year plan could aim to achieve universal access to a health care facility- with adequate infrastructure in this five year period. Funds release to states would be conditional on their showing that they have put in place a management capacity to not only absorb the funds but also ensure quality construction. Type Health Facility of Number New Construction
Sanctioned Completed

3.9.

States

Renovation
Sanctioned Completed

High-focus DH Non-NE States CHC (EAG ) PHC SC NE States DH CHC PHC SC

312 2053 11602 71738 77 242 1421 7255 216 2240 10650 68076

24 271 367 9737 6 101 318 2943 25 262 844 2467

18 23 168 5105 3 01 108 1194 12 211 401 1204

326 1262 2065 5463 56 201 706 1985 110 1014 4148 4640

119 500 1505 3365 53 151 483 1765 42 712 2832 3455

Non-high DH Focus States & CHC UT PHC SC

21

3.10 3.10.1.

The Provision of Services: Range of Services: The promise of NRHM was to move towards comprehensive health care services- which meant not only RCH services but also infectious diseases and emergency services and for chronic diseases. We know that institutional delivery services increased in all states, and that emergency obstetric care and the management of obstetric complications and the provision of other dimensions of RCH expanded, but at a slower rate. This had spin off effects in reviving these facilities leading to general increases in outpatient and in-patient care at the PHC and CHC level- but systematic increase in care for infectious diseases and chronic diseases was not adequately prioritized. Mainstreaming of AYUSH: One of the core strategies of NRHM was to promote co-location of AYUSH services with other mainstream health facilities, so that people have a better access to AYUSH, a choice between systems and so that the human resource and infrastructure can be shared and synergized for better reaching NRHM goals. Under this scheme 11575 AYUSH doctors and 4616 paramedical staff have been appointed- over 60% of these doctors being in high focus states. In a total of 18222 health care facilities AYUSH services have been collocated- and this includes 416 district hospitals, 2942 CHCs and 1246 other sub-district hospitals, 9559 PHCs and 4059 equivalent primary care facilities. Apart from the above services there is an almost equal or more number of AYUSH standalone facilities at the Primary and Secondary Level AYUSH Hospitals (3360) and Dispensaries (21769) as well as 7 National Institutes which offer tertiary level care. These health facilities deliver the services of their own system. However, collection of information about their services through collocation - either through HMIS, or in surveys is currently not being done. Building on AYUSH systems: Measures to utilize and build upon our AYUSH strengths are: inclusion of information on AYUSH and Local Health Traditions services and their utilization in surveys and HMIS, continuing education programmes for AYUSH providers on AYUSH services, training to AYUSH providers for provision of essential services of public health importance-a form of multi-skilling or mid-level provider creation, and resource centers at state level, linked to research institutions in AYUSH so as to develop better knowledge management in this area, leading to better resource inputs for programme implementation and better research questions for knowledge generation. Meanwhile both the co-located facilities and the stand-alone facilities should continue to be strengthened. The representative of the Department of AYUSH during discussions in the Working Group, and subsequently followed up through a written communication, pointed out that with the present system of release of funds under NRHM, the objective of mainstreaming of AYUSH as set out in the National Policy on ISM&H, 2002 and as 22

3.10.2.

3.10.3.

3.10.4.

included as part of NRHM mandate, was not having the desired impact at the State level, since health is a State subject and States are free to set their own priorities from the funds received by them. The Deptt of AYUSH further pointed out that in the light of this position, the States when faced with shortage of resources to the extent sought by them, quite often tend to restrict the outlay in the AYUSH sector. The Department of AYUSH therefore suggested that since mainstreaming of AYUSH is the core strategy of NRHM, Rs. 10160 Cr may be earmarked out of NRHM funds at the disposal of Department of AYUSH. If the Planning Commission finds it difficult to earmark and place the funds of Department of Health and Family Welfare under the Department of AYUSH, then mainstreaming of AYUSH may be separated from NRHM Flexipool and an amount of 10,160 Cr may be placed with the Department of AYUSH for effective implementation and monitoring during Twelfth Plan. 3.10.5. However, under NRHM, annual Resource Envelope is indicated to the State and they are given flexibility to prepare their own annual Programme Implementation Plan. Earmarking of funds is not done for any activity except funds for annual maintenance grants, Rogi Kalyan Samiti grants and untied funds for healthcare facilities. This is to ensure that funds actually flow to the facilities where they are needed and they are not retained at the State level. These non-negotiable items of NRHM are not earmarked for any particular activity and are done in order to promote the objective of Decentralisation. Earmarking of funds under NRHM for AYUSH activities, as suggested by Department of AYUSH is not possible since it runs against the basic tenet of NRHM. States decide what activities are to be taken up during the financial year. As proposed by Department of AYUSH as an alternative, the Steering Group may take a view to allocate the funds separately to Department of AYUSH. In that case it would become necessary to rework the strategy for mainstreaming of AYUSH under NRHM mandate. Quality of Services- Overview: The provision of quality services requires in addition to infrastructure and human resources, proper equipment, drugs and supplies, an efficient organization of work and a high level of motivation and a consciousness about quality. It is also important to observe how affordable the services were in the public sector. And finally there is the issue of how women friendly and child friendly the hospital is, with affirmative action to ensure that there are no social barriers or processes of exclusion that are keeping out the poor and marginalized. While the States should be allowed flexibility, quality assurance should be standardized across all the States. Quality of care- the availability of medicines: In this period expenditure on drugs and supplies increased and availability of drugs also increased but high out of pocket expenditure continues. Only Tamil Nadu and to some extent Kerala have 23

3.10.6.

3.10.7.

3.10.8.

curbed out of pocket expenditure on drugs in the public hospital significantly. Part of this is due to the procurement and logistics systems in place- organized by the TNMSC. Kerala now has a similar model in place. Maharashtra, Karnataka, Andhra Pradesh, Punjab, Delhi and West Bengal have similar systems of drug procurement in place, and this is welcome for it leads to better quality and costs of drugs purchased. But it still does not lead to reduced OOPs on drugs in the public hospital and uninterrupted supplies of drugs in the facilities- because the entire procurement system is not automatically responsive to the actual consumption of drugs. Tamil Nadus system is logistics driven- with facilities indenting from district warehouses in response to their needs such that at all times they have a buffer stock and district warehouses maintaining a three month stock of every drug on the essential drug list, with orders placed as and when a district warehouse stock falls below the threshold level. The Eleventh Plan period has been a period of increasing advocacy for a TNMSC like system- not only of procurement but also of drug logistics. The Twelfth Plan must aim to ensure that this is now implemented in all states. 3.10.9. Quality of care- Diagnostics: User fees need to be rationalized in both inpatient care and diagnostics. Exemption for the BPL, senior citizens, pregnant women and newborn should be provided both in registration fee and at the diagnostic laboratory. The range of diagnostics available need to be significantly expanded.

3.10.10. The Twelfth five year plan must move towards reduction of out of pocket expenditure on account of drugs and diagnostics and make available a wide range of supplies in these areas. 3.10.11. Quality Improvement Approaches: In the eleventh five year plan period a number of measures was tried to improve quality of care. This was based on an understanding that even with available inputs, at the level of the hospital there were many management steps that could improve quality of care. Patient satisfaction often related to the dignity with which they were treated and to basic amenities in the hospitals which the untied funds were to be used for. The most widespread approach to quality in this plan period was the creation of quality assurance committees which would use a check list to monitor for quality gaps. With few exceptions, this approach did not sustain or gain the necessary importance it needed nor have measurable impacts. They were indistinguishable from routine monitoring. The major reason for this was lack of adequate professional set up of quality assurance cells at State and district level. For sustainability of quality in the service provision it is essential that States should have their own quality assurance mechanism. The quality assurance cells at State and district level needs to be strengthened in 12th Five Year plan The other was a number of hospitals taken up for NABH in a number of states- Kerala, Gujarat, Madhya Pradesh- to name a few. However except for two or three hospitals across the country, most never got accredited and the high degree of inputs needed to get NABH and to sustain such an accreditation was prohibitive. Another approach which was piloted by NHSRC 24

approach built on the ISO system adding 24 state government- NHSRC specified mandatory processes which were to be audited. Currently over a 100 facilities are certified and another 500 are in the pipeline. 3.10.12. Quality Certification: The Twelfth Plan should encourage quality certification of public hospitals. One type of certification involves certification of quality of care in terms of the input standards infrastructure, human resources, drugs and equipment and the outputs in terms of package of services available. This is certification for the achievement of IPHS. Another form of certification relates to the organization of work and processes central to providing ethical, efficient and effective quality care, and such certification is relatively independent of the level of inputs. It only certifies that there is a quality management system in place which ensures the best quality of outputs for the level of inputs currently available. Quality certification should not remain limited to standards of infrastructure but it should have thrust on comprehensive in-house quality assurance for both infrastructural and service delivery. A good quality service delivery should be first certified by district and State quality assurance cells/committees before any third party certification. 3.10.13. Women-friendly hospitals: There has been a greater awareness of the need to make hospitals more women friendly and baby friendly, and CRMs show modest improvements in this dimension. Where they are put in place, ASHA help desks provide valuable services to the patient in guiding them through the hospital. These initiatives needs to be further strengthened. There is a role for non-governmental partnerships with activists groups and ASHAs and their support structure to provide such a facilitator service in all public hospitals. 3.10.14. Assured services- building a district road map: The Twelfth Plan thus envisages that every district would announce as part of its five year strategic district plan, the package of services each facility would guarantee such that taken together the district health system would ensure universal access to a good quality of comprehensive RCH services, emergency care and trauma related services, infectious diseases management and chronic disease management. Such a district plan would become the instrument to be used for programme audit by the government and for social audit and community monitoring purposes. 3.10.15. Assured services- balance between preventive, primary and secondary care: In each of the four health service areas- RCH, emergency services, infectious disease and chronic disease the emphasis and major expenditure of the plan should be on primary prevention and then on primary health care and secondary prevention. This would be the most cost effective approach in a situation where the district health system has to pay for the primary, secondary and tertiary care costs. For example in emergency care , prevention of road traffic accidents or burns is the priority- but were it to happen, quick transport to facilities where trauma care is well-publicized and known to be available, through an emergency response system is essential. 25

4. Increasing Human Resources for Health TOR III

4.1

The eleventh five year plan period has seen positive changes in four major dimensions of human resources for health. These include a. Increasing availability of skilled professional through the expansion of professional and technical education. Recruitment and deployment of additional human resource as contractual staff financed by NRHM Skill development of existing staff. Measures for attracting and retention of staff in rural and remote areas.

b.

c. d.

Increasing Medical and Nursing Education: 4.2 In the last six years of NRHM, 82 medical colleges have been added, and 9751 seats have been increased. Of 595 ANM schools, 1227 GNM schools, 1026 B.Sc nursing courses, 405 post basic B.Sc nursing courses, and 327 M.Sc nursing courses have also been added. . The ANMTCs and Nursing Schools in most states had shut down and the faculty dispersed. Reviving these schools took a few years and the first batches of ANMs and nurses needed to close critical gaps are graduating only in the later years of the programme. Further in the poor performing districts, the lack of such schools is much higher and the ability to start them up with human resources available within such regions is very weak. This lack of skilled trainers and teachers was also a problem for the roll out of training programme in the poor performing districts. The design should have revived and built up the training institutions and sites in the first year, with a substantial reform and strengthening of apex institutions of training like SIHFWs to lead this effort. This remains a weak link even at the final year of the NRHM. There have also been substantial increase in paramedical education in this periodbut the gaps here are some of the largest especially in disciplines like Optometrists, Physiotherapists, Dental Hygienists and Multi Purpose Workers (Male)

4.3

Increased Recruitment and Deployment in public service delivery 4.4 One of the major contributions of the NRHM has been the addition of 148361contractual skilled service providers (as on 31/3/2011) to the public health services in the space of these six years. Of these 60268 are ANMs, 33667 are 26

staff nurses, 21740 are paramedics, 11575 are AYUSH doctors, 4616 AYUSH paramedics, 9432 are medical officers, and 7063 are specialists. 4.5 This does not include the substantial increases in workforce that has resulted by filling up of regular vacancies under state government financing. Some of these like in the male worker post were directly under insistence from the NRHM, while the rest was responsive to the increased attention given to revitalization of primary health care. These measures have led to a substantial decline in the number of Sub Centres without ANMs and in PHCs without doctors. In addition to the increase in service providers, NRHM also takes credit for the induction of a number of non clinical personnel-, 583 district programme managers, 565 district data managers, 575 district accounts managers, 3771 block managers, 4143 block accountants and 5458 PHC accountants. Over 500 management and public health consultants have been inducted at state management roles. This staff has played an important role in improving the quality of programme management. The Indian Public Health standards have also contributed by giving State planners a direction in how many staff they need to recruit. One caution is the need for rationalization of recruitment even when based on IPHS norms. Firstly there is a tendency to go in for normative recruitment based on a mechanical understanding of the IPHS. Thus many facilities would have more staff then their case loads merit and other facilities would have less. Over reliance on contractual appointments as the main mode of increasing service providers and managerial staff has limitations. There is a high turn-over and reluctance to invest in training them. In some states, contractual staff, instead of being additional and supplementary became substitutes for regular staff. There is significant difference in pay between the contractual and the regular employees. The salaries of contractual employees should be higher than regular staff. Skill development of Existing staff. One of the major activities under NRHM was training of different categories of service providers and programme managers. Such training aimed to increase the skill sets of existing service providers so that they are more effective in saving lives, and provide a better quality of services. The major training packages were as follows: 4.9.1 ANMs and staff nurses 4.9.1.1 SBA (21 days) 42530 trained- for providing skilled birth assistance in every PHC and potentially in every sub-center as well. 27

4.6

4.7

4.8

4.9

4.9.1.2 IMNCI (8 days)- 47843 trained ( UNICEF data base)- This training is meant not only for ANMs and nurses, but also for every Anganwadi worker and ASHA. Including all these categories of staff 329546 have been trained. 4.9.1.3 IUCD (5 days)- 27522 trained 4.9.2 Medical OfficersShort term training programmes for life saving anesthetic skills (18 weeks) and an Emergency Obstetric Care training (16 weeks) has been initiated to overcome the shortage of skilled manpower at district and sub-district level. Over 100 medical colleges and 180 district training sites have been developed with about 280 Master Trainers available for the LSAS training. About 13000 MBBS Doctors have been trained in Life Saving Anesthetic Skills gynecological Societies (FOGSI). About 168 Master Trainers at medical college and 231 district hospital practical trainers are available for the EmOC training. About 830 MBBS doctors have been trained in EmOC including C-Section. However, we have not been able to achieve the targets of the training since could not depute enough number of doctors for the training due to shortage of workforce at the health facilities in the State. In addition there are short training programmes on Basic emergency obstetric care (3892) and on medical termination of pregnancy (15 days- 9037 trained), female sterilization, (12 days- 9723 trained) and male sterilization ( 5 days- 2286 trained)and F-IMNCI- (4017 trained), Newborn care( 2days), blood storage unit training(3), RTI/STIs(2 days), Immunization (2 days) These trainings are meant to ensure every 24*7 facility provides these services. One day training programmes on malaria, tuberculosis, leprosy, blindness control, and IDSP programmes about 500 to 1200 trained in each of these programmes There are also programmes to train trainers for SBA and IMNCI training.

4.9.2.1

4.9.2.2

4.9.2.3

4.9.2.4

4.9.3

In addition to the above, over one lakh have been given orientation programmes on NRHM, 1785 programme officers have undergone three month public health management training( professional development course) and 2861 contractual programme managers have 28

undergone 5 to 10 days of training for NRHM programme management. All these data are from the training data base maintained by NIHFW. 4.10 This is a great amount of inputs which need to be duly noted. However this pace of training is far from adequate. There is a need for every skill based service provider to undergo full refresher training at least once in three years. Even for SBA training and IMNCI training only about one thirds of the training requirements have been addressed. Quality of training and post training follow up was a major problem. Selection of trainees is another concern as those providing the greatest volume of services are generally taken up for training last, and those unlikely to start up with services are generally taken up early. The other major problem as well as reason for the poor progress in training was the lack of professionally managed training institutions and training teams. The Twelfth five year plan should give priority to developing institutional capacity in training. The Outcome/impact of all training programs needs to be monitored to bring about improvement in training modes and quality.

4.11

Strategies of attraction and retention of skilled professionals in rural areas 4.12 One of the central issues of human resource planning is the challenge of getting skilled professionals to join in public health systems and agree to stay and work in rural and remote areas. Since most doctors come from urban middle class backgrounds, the economic loss and professional and social isolation of rural service, deters them from public service. NRHM has begun to change this scenario with multiple strategies for attracting and retaining the skilled providers in the rural and remote areas. Initial results have been very encouraging. The various measures tried are listed below: Incentives- Financial and Non financial. Difficult area incentive - Introduced in most states for doctors, nurses and midwives working in remote areas. There is a wide diversity between states in categorizing difficult areas. Incentives are given as a difficulty allowance or as performance based incentives linked to institutional delivery, C-sections, sterilizations, cataract surgery etc. Non financial incentives include preference for post-graduation and promotion. Chhattisgarh has rural service cadre that packages a large number of financial and non financial incentives. States like West Bengal and Chhattisgarh have introduced group housing for health workers living in remote areas. Workforce management - Tamil Nadu, Karnataka, Nagaland have shown that a major impact on worker morale by providing rotational posting in difficult areas. Simplification of recruitment process in Haryana, Maharashtra, and West Bengal has yielded positive results in filling up vacancies.

4.13

4.14

29

4.15

Educational Strategies: Measures to preferentially admit only those students who are likely to serve in under-serviced areas and moulding education to retain this commitment are also most successful. In West Bengal, locality based selection of ANMs by a process involving the community/Panchayats and posting them back to the Panchayats helped find and train 10,000 more ANMs within 4 years. The Swalamban Yojana (self-reliance plan), in Madhya Pradesh provides scholarship against a bond for candidates from remote areas. Chhattisgarh provides a career path for Mitanins (ASHAs) to train for becoming ANMs and nurses in their villages and over 400 Mitanins have opted for this. Chhattisgarh and Assam have introduced 3 year diploma courses with the objective of filling in vacant positions in the remote, far flung and rural areas with skilled providers for primary care services. Government of India has proposed a three and a half year Bachelor of Rural Medicine and Surgery (BRMS) course, to be taught in medical schools affiliated to different universities in the country. This cadre would be posted in rural areas to provide primary level health care as Community Health Practitioners. Training AYUSH graduates to work as medical officers in primary health centers has been used extensively in states like Chhattisgarh, Maharashtra, Orissa, Gujarat. Regulatory: Compulsory rural bonds for those obtaining medical education from government colleges have been used in Kerala, Tamil Nadu Meghalaya and Nagaland to fill vacancies in rural areas. A number of other states have made rural service mandatory criteria for admission into post graduate programmes. Strategies for retention were not rolled out in most states- and best practices in some states were not picked up by others for replication. There is a need to provide for a scheme to resolve the problem of retention based on experiences gained. The Approach Paper to the Eleventh five year plan, raised this but the Twelfth Plan should provide for concrete schemes to address this issue. The Twelfth Plan should allow a maximum of 30 % of the most difficult facilities within high focus states and 15 % in non- high focus States to qualify for a difficulty allowance. Besides this, states may add on non financial incentives, like preferential consideration for post graduation, for workshops and training programmes and for study trips abroad, preferential admission for their children in boarding schools etc. The financial incentives should be substantial to have an impact. The selection of the facilities should be based on objective criteria, by which every single facility is scored and there is complete transparency in its decision. The Twelfth Plan would also invest in measures implemented specifically to provide support and a positive practice environment for those working in difficult rural and remote areas. The problems of professional isolation should be addressed by special continuing education programmes and telemedicine or even short three week internship opportunities, and by special conferences and 30

4.16

4.17

4.18

4.19

workshops that interest them and builds their skills in public health. Their social isolation should be addressed by more opportunities to interact both with peers and with the community they serve. Special support groups that reach out to them, and keep them in contact and provide assistance to them could be mooted. Very short duration postings with frequent rotation in areas of special difficulty areas and other innovative measures would be useful supplements. 4.20 A pool of dedicated trainers at State and district level for supervision, monitoring and hand holding of trainees being trained should be developed. Performance monitoring and organising CME/ refresher courses for updating knowledge and skills of the health personnel should be done. A nursing division at State level with proper staffing and with distinct responsibilities for both ANM and GNM should be developed. Simultaneously, developing mid-wifery cadre, developing public health midwives and creating management/supervisory cadres of midwives will be focused in the twelfth plan.

4.21

31

5. Programme Management TOR IV

5.1 The NRHM envisaged improvements and reform in programme management as one of the keys to improved health care. The efforts it made in this regard could is listed below. Creation of new institutions of governance:

5.2

5.2.1 At the national level it was the mission steering group, the empowered financial committee. Set up for policy making as well as implementation will be strengthened at Central as well as State level for better planning, implementation and monitoring.
5.2.2 At the state level it was the state health mission and the state health society. 5.2.3 At the district level it was the district health mission and the district health society. The Panchayati raj institutions would provide leadership to the district health society with participation of the block panchayats. 5.2.4 At the facility level it was the governing body of the hospital development society that would provide leadership with leadership of the block panchayat and participation of gram panchayats at the appropriate levels. 5.2.5 At the village level, the village level health and sanitation committees at the revenue level with leadership from the gram panchayats. 5.3 Strengthening/creation of appropriate institutions of management

5.3.1 At the state level- it was 1.strengthening the directorates of health services, 2. Creation of state programme management units under the state health societies, 3. Creation of institutions or divisions for infrastructure development, 4. The creation of institutions or divisions for procurement and logistics, 5. The strengthening of state instituted of health and family welfare for training functions, 6. The creation of State health systems resource centers for technical assistance and innovation or the utilization of equivalent bodies often paid for by development partners and 7. The creation of institutions for managing the community processes. 5.3.2 At the district level it was the creation of a district programme management unit. 5.4 Addition of a large number of management professionals- at district and state level- Programme managers at state and district level; Accounts managers/ accountants and data managers/data entry operators at state, district, block and in some states even at the facility level.

32

5.5

Addition of a large number of public health professionals as consultants at the national and state levels. These are either placed in the national level in ministry divisions or in state programme management units or in NHSRC and SHSRCs or in the NIHFW/ SIHFWs. Encouragement of qualification in public health or public health management has been an important development during these five years. Other than the one year diploma in public health management run in five institutions, over a 100 public health education courses have come up during this period and a further few courses are available in distance learning format also. A public health cadre has been mooted but not implemented. Creation of Health Management Information Systems where a national web-portal playing a nodal function. Institutionalizing monitoring and evaluation mechanisms systematically. Thus the NRHM has in place the annual common review missions and the joint review missions, the concurrent evaluation process led by the IIPS, and the number of studies and evaluations done by the international advisory panel, and various national institutions. The SRS, the NFHS and DLHS and now the annual health surveys also provide important health data. Creation of improved financial management systems with clarity on flow of accounts and accounting process, and with e-banking and computerized accounting at every level. All these above initiatives have made important contributions in the direction of reform. However, improvement in design and execution is desirable. The immediate lesson is of course to persist, because even to establish these changes took years and one could easily undermine them, by failing to recognize their existence and gains. One of the most important areas where persistence and quality is needed is in the state level institutions of management and governance. Governance institutions need to function as good governance and need to have the necessary separation from management functions. The governing boards of the state and District Health Societies and Rogi Kalyan Samitis must perform different functions from the executive committees. The programme management units must function as secretariats of the executive committees. The synergy of the directorates of health with the new institutions of governance and management should be thought through. At one level this is posed as a problem of NRHM becoming a parallel structure and the need for merging it with the health department. Such a perception relegates every institution or organization created in this period to being seen as an ad hoc arrangement that 33

5.6

5.7

5.8

5.9

5.10

5.11

5.12

should pass away with directorates (or state programme management units) eventually taking over. The creation of a public health cadre is seen as the critical step needed for directorates to be able to be strengthened and to take over these functions as institutional permanent arrangement. But at another level, the pressures on the ground and the practice are to multiply and strengthen institutions outside the directorates- even whilst calling all of these as ad hoc arrangements. There are many reasons for this contradiction, other than the limitations of existing directorates. Firstly as health management becomes increasingly inter-disciplinary, the conventional structures of government administration do not allow space for their inclusion and bodies outside it become necessary to recruit such skills. Secondly merely adding on technical consultants into existing structures without mechanisms for their workforce issues and capacity development and leadership roles, also dumbs them down into extra hands rather than extra minds and fails to sustain them. Areas like logistics, or community mobilization, or quality improvement or human resource development or financing have all become disciplines in their own right and merely conceiving of these areas as commonsense based decision making that doctors or general administrators could perform without specialized learning, fails to recognize the needs of knowledge management in the modern health care scenario. For these reasons, the recommendation for multiple institutional arrangements at the state level is unavoidable. There is much experience to be gained from best practices in each domain on how to form and run such institutions. It is within this context that the strengthening and leadership role of directorates of health and the synergy of NRHM structures with directorates has to be resolved. 5.13 The creation of a public health cadre must remain a priority. The creation of public health management skills in leadership roles is necessary at all levels. The technical divisions at national level needs strengthening and supports for adequate supervision and guidance to the States. There should be a mix of technical and managerial skills and national level for achieving this. It is also important to define the direction of development of the health management information systems. The approach should be towards permitting multiple systems which meet well defined and regulated data standards and standards of inter-operability, with each user level or institution able to access the information most useful at that level- rather than one single system to which all data entry and interpretation in the nation must conform. If such an architecture is created the Twelfth five year plan period would see a massive expansion in the integrated use of health informatics for human resource planning and management, GIS applications, mobile transmissions, hospital information systems, disease surveillance systems and nutrition and social determinants monitoring, death reporting, case based follow up systems including what is referred to as pregnancy and child tracking. The current HMIS and tracking systems captures RCH service delivery indicators and needs more inter-operability with existing systems. If the 34

5.14

district plan is to take on management of infectious disease, emergencies and chronic disease in addition to RCH, given the varied development of these programmes across and within districts, there would be an urgent need for decentralized information systems- which the center by creating appropriate policy and standards must provide stewardship for- instead of trying to run all of it, all by itself. Of course the center would have its own information needs for decision making and these would be supplied through electronic bridges by all the other state and even district systems. 5.15 The Concurrent Evaluation of the NRHM and the DLHS-III were two main sources of information pertaining to outcome evaluation on the mid-term performance of the Eleventh Five Year plan. For 284 districts covering the main high focus states of the north and Assam from the north east, the Annual Health Survey done in 2009 will serve as a detailed source of information on outcomes and as a baseline for district planning in these states. The DLHS-IV starting up in November 2011 and completing by March would provide an end of the plan outcome report for the Eleventh Plan and a baseline for the Twelfth Plan, but it would be covering only the districts not covered in the Annual Health Survey. There is a need to further strengthen quality of data collection by using health paraprofessionals in data collection. District Health Plans - challenges of integration, convergence and decentralization: 540 districts prepared plans in the last year- an increase from 310 in the first year of the NRHM. The plans have helped integration of all department activitiesdisease control, RCH and AYUSH as part of an integrated health systems development, but have not yet addressed inter-sectoral convergence. Plans and societies as vehicles of decentralized governance remain a challenge due to varying levels of Panchayat involvement and due to problems of matching resource allocations to locally developed plans. The initial enthusiasm has declined as the exercise is time consuming and is not linked to resource allocation, and often not even for review of progress. The challenge before us to built a resource allocation policy that can interface with the participatory nature of planning being responsive to both public health needs as measured and felt needs as expressed by communities. There is need for adequate techno managerial structure at State and district level. The present focus is more on administrative aspect and technical support is weak. This needs priority strengthening in 12th Five Year plan.

5.16

35

6. Strengthening of Community Processes under NRHM TOR V

6.1. The NRHM launched a number of initiatives to promote space for community processes and increased public participation. The main programmes that would be considered in this section are : i. The ASHA and her support structures ii. The Village Health and Sanitation Committee iii. Rogi Kalyan Samitis: at the level of the PHC, CHC and District Hospital iv. The use of untied funds at all levels v. The community monitoring programme vi. The district and state health societies. 6.2. The ASHA was designed to facilitate access to health services, mobilize communities to realize health rights and access entitlements and provide community level care for a number of health priorities where such intervention could save lives and improve health. This includes counseling on improved health practices and prevention of illness and complications, and appropriate curative care or referrals in pregnant women, newborn, young children as also for malaria, tuberculosis and other conditions that are location specific. This mix of roles was deliberately proposed and seen as critical to both sustain the programme and to bring around much needed health outcomes. The NRHM also envisaged a support and training structure for the ASHA to enable these roles. 6.3. The ASHA programme is the most visible face of the NRHM, and is likely the worlds largest community health volunteer programme, with approximately one ASHA for every 1000 population in rural India. There are presently a total of 849331 ASHAs selected across the country3, of which 492784 ASHAs are in the high focus states, 53619 in the NE states, 298286 in the Non High focus states and 4642 in the union Territories. The proposed total is 8,80,739, of which 93.73% have been selected overall with over 97% of selections completed for the high focus states. Although it was only intended to cover high focus states and tribal areas in the non high focus states, in 2008 the remaining states4 opted for the programme. 6.4. The ASHA programme differs from past efforts in distinctive and substantial ways. Its key features are enumerated below: i. Comprised solely of women, ii. Selected by the community
3 4

ASHA update, January 2011 (Data as of December 2010) Except Himachal Pradesh, Pondicherry, Goa, and Damn and Diu, and the non tribal areas of Tamil Nadu

36

iii. Remunerated on a performance based reimbursement, iv. Support systems extending from sub block to national levels. v. Periodic review meetings and on the job training and support vi. A well crafted modular training strategy with a strong element of health rights; consists of seven training modules for initiation. These modules include key skills for provision of appropriate community level care. There is a commitment to sustain training at least 20 days per year-. vii. Equipped with a drug kit which includes essential minor equipment. 6.5. Most ASHAs have completed the first four rounds of training and in states that had initiated this, the fifth round of training as well. (94% in the NE states and 85% in the other high focus states). 96% of all ASHA have been provided with a drug kit in the high focus states, with the exception of Bihar, where the drug kit distribution has just been initiated. 97% of ASHA in the NE have received drug kits, and in the non high focus states, 79% of ASHA have received drug kits. Procurement and distribution is underway in Gujarat, Kerala, and Tamil Nadu. Most ASHA earn between Rs. 500 to Rs.1000 per month from this task. Most states have provided identification badges, bicycles for increased mobility, passes for travel, staying arrangements at health facility, rest rooms for ASHAs and help desks for patients referred by ASHAs, and recognition by way of annual ASHA awards. The programme has expended Rs 1098 crores-over five years- which is only one fifth of the expenditure that was envisaged for the programme. 6.6. The ASHA programme is a well studied component of NRHM. The studies have ranged widely in scope, methods and outcome measures. One overriding finding is that the programme is the single most important instrument for community outreach and has significant potential for saving lives. A recent large scale evaluation of the programme in a sample of 16 districts across eight states5, offers important evidence on the functionality and effectiveness of the ASHA. The finding that about 74% of women with a child up to 6 months and about 71% of women with a child under two who had an episode of illness in the past month, reported receiving services from ASHA indicates that nearly 30% of the populaiton is still not reached. The second significant finding is that ASHAs were very active and effective in promoting institutional delivery and immunization and to some extent access to sterilisation, because the support system was geared to promoting exclusively these aspects. The ASHAs were therefore less functional and effective in tasks related to community level counselling, care provision and in mobilisational work and the lessor effectiveness is correlated to the inadequate emphasis on skills in the training
Which way forward?: An Evaluation of the ASHA programme in eight states, National Health Systems Resource Center, 2010
5

37

curriculum and lack of support systems for ongoing mentoring,support and supervision. Thus at this stage though we are getting outcomes related to improved institutional delivery and increased attendance at immunisation, the role of the ASHA in child survival has only been strengthened recently with issue of guidelines on Home Based New born Care and introduction of 6th and 7th Module training. These deficiencies have since been corrected and the last year of the plan has brought considerable focus on skills and home based newborn care as envisaged so clearly in the eleventh five year plan. This plan would need to persist for at least three years before an acceleration in child survival can be seen. 6.7. The studies indicate that an important corrective needed is greater clarity on the ASHAs functions to mid and senior level programme managers- so that they see how health outcomes relate to ASHAs work. Other findings relate to the need for a full time dedicated set of trainers, the need for special efforts to reach the marginalized and immediate attention to timely payments and drug kit replenishment. 6.8. In the eight high focus states and Assam, the focus should be to provide the ASHA with the skills and support to strengthen her ability to provide home based new born care and care for the child. This should be the pattern for the high focus districts in other States as well at least for the period of the Twelfth plan. In the non high focus States, where programmes for non communicable diseases, mental health, palliative care, disability, etc, are beginning to be piloted or scaled up the ASHA should be trained in counseling for behaviour change, basic screening such as for diabetes, hypertension, and selected cancers, referral and home based drug distribution. 6.9. As the programme enters the next plan period, we need to evolve a strategy of sustainability of the programme. Firstly this implies planning for as much as a 5% turnover and fresh recruitment every year. Secondly it needs to recognize the different aspirations with which women have volunteered and provide for some of these aspirations. Some states such as Orissa and Chhattisgarh have made provision for reservation of seats and enabling ASHA to complete the required educational level for entry into ANM training schools. Others have given preference to her recruitment as anganwadi workers. The gaps left by such turnover can be easily replaced and the training already invested in her is not lost. Still others who have more interest in the mobilization and leadership role have become elected Panchayat members or active in non-governmental organizations 6.10. But while increasing her avenues for progression for those who have such an aspiration, the voluntary nature of the ASHA programme needs to be preserved. Allocating multiple roles is likely to reduce her motivation and the spirit of the programme. Her work should be such that it is done without impinging on her main livelihood and adequate monetary compensation for the time she spends on these tasks- through performance based payments. 38

6.11. Managing this 5% to 15% turn over, retraining ASHAs and facilitators and creating new interventions for implementations by ASHAs need some established training and development centers at the state level. Training cum demonstration and experimentation site for community processes should be encouraged and developed in each State. These would also pilot new models, evolve guidelines, field test material and nurture and support a resource team. 6.12. The Village Health Sanitation and Nutrition Committees (VHSNC) were intended to function as a village level organization comprising of key stakeholders including members of PRI, ASHA, AWW and ANM, and include representations from women (including from Self Help Groups) and marginalized communities. The VHSNC was expected to develop village health plans, specific to the local needs, support the ASHA and generally serve as a mechanism to promote community action for health, particularly for social determinants of health. There is a need to bring in NGO participation in a major way so as to expand the systemic capacity to train and support VHSNCs to play a role in addressing social determinants of health in a meaningful way. 6.13. The Approach Paper to the 12th Plan suggests that the Anganwadi Centre and the Sub Centre both could be brought under the oversight of Panchayat level Health Nutrition & Sanitation Committee. However, the Health Sanitation & Nutrition Committees under NRHM are set up at the level of village and not the Gram Panchayat. While the number of Gram Panchayats is approximately 2.45 lakhs in the country, the number of Village Health Sanitation & Nutrition Committees (VHSNC) is approximately 5 lakhs at the moment. Hence, the appropriate course would be to ask the States to issue necessary notifications to put the health Sub Centre, Anganwadi Centre and also the Village Health, Sanitation & Nutrition Committees under the oversight of the Gram Panchayat. 6.14. The NRHM also created a platform at the village level, the Village Health and Nutrition Day (VHND) where the ANM was expected to provide services for antenatal care, immunization, postpartum care, etc, and the ASHA was expected to mobilize mothers and children, with the Anganwadi center being the venue, with a view of fostering convergence between the ICDS and the health systems. Two related components of the NRHM were expected to strengthen and enable the Community Processes component. The first was to provide financial assistance to NGOs to undertake functions related to training, mentoring and implementation support to various elements of the CP, and the second was a pilot effort for community monitoring. 6.15. A total of 483496 VHSNCs have been formed in the country [1], covering about 76% of the villages. Of these, 9% (42640) are in the NE states, 56 %( 269213) are in the non NE High Focus states, and the remainder in the non high focus states. States 39

such as Bihar, Uttar Pradesh, Haryana, Himachal Pradesh, Kerala and Tamil Nadu have formed the VHSNC within the Gram Panchayat while in the remaining it is at the level of the revenue village. There was a provision of Rs 10,000 untied funds for each VHSC. Under this scheme a total of Rs 1464 crores have been disbursed over four years for expenditure by the VHSC at the village level. Of this 11% went to the north east VHSCs and 50% has gone to the VHSCs of other high focus states. 6.16. There is less information available on VHSNCs as compared to other community programmes. VHSNC functionality in six of the eight states, as seen in the ASHA evaluation study showed that functional VHSNCs defined minimally as at least holding some meetings in the year was about 83% (mode- across the states- range 58% to 97%). This is based on information collected independently from the ASHA and ANMs and Anganwadi workers of the village. The VHSNCs appear to be active in support to VHND and promotion of immunization in about 63%, in health awareness campaigns in 56%, in promotion of institutional delivery in 53% (excluding Kerala where this was not necessary), and in clearing stagnant pools of water in 45%. On Village Health Planning, there appear to be wide variations, but overall, about 60% of VHSNCs had made such an effort. About 20 to 40% of ASHAs felt supported by the VHSNC, but it was precisely in these villages that the mobilization role of ASHA played out best. VHSNC members helped ANMs in hosting village level meetings and in disseminating key health related information. Although, in terms of percentages the achievements are modest, the absolute numbers of people mobilized by the VHSC and sensitized to health issues are likely to be high. 6.17. The Village Health Sanitation and Nutrition Committees remain the key mechanism to address action on social determinants including age at marriage, literacy, water and sanitation, nutrition, substance abuse. This aspect was always part of the design, but there was no management capacity to handle this. There is a need to bring in NGO participation to expand the systemic capacity to train and support VHSNCs to play a role in addressing social determinants of health in a meaningful way. This VHSNC programme with an adequate support structure is also needed to support the ASHA and for the ASHA to play her mobilisational and health education roles. 6.18. Rogi Kalyan Samitis- or hospital development societies: 678 district hospitals, 4875 CHCs, and 27596 other facilities have a registered RKS in place. A total of Rs 4373 crores have been released to these facilities, of which Rs 898 crores was in the form of RKS corpus funds and the rest in the form of untied grants, grants for annual maintenance, and grants for up-gradation of CHCs. Though there are exceptions, in most states, meetings of RKS are held regularly. However its functionality and effectiveness need to be assessed more carefully. 6.19. There are multiple expectations of the Rogi Kalyan Samiti. The Rogi Kalyan Samitis should be strengthened by having better rules in place for public participation and transparency and by orientation to ensure quality of care and 40

improved access to care. The NRHM provided space for inclusion of representatives of the public in the hospital development committees (Rogi Kalyan Samitis). It also provided similar space for public participation in the district and state health societies and in various committees like the implementation of PCPNDT Act, quality assurance committees etc. The impact of the RKS on enhancing community participation is highly variable across the states, and findings from successive reviews suggest that in general RKS need strengthening and better oversight. The Twelfth five year plan period must build on the hesitant beginnings with clearer policies of norms for membership in these structures and mechanisms for ensuring their functioning. 6.20. The other expectation of RKS and DHS is as a vehicle for inter-sectoral coordination, a function it played well where a senior officer or the district Panchayat played the leadership role effectively. This could become a problem if the senior officer could not find the time. Correction of this problem requires much better monitoring and review of RKS and DHS functioning in the state health society. 6.21. Yet another expectation of the RKS was as a vehicle for untied grants and for user fees, providing local facility managers to utilize the funds for local facility level improvements. After initial delays and hesitations, this function has picked up very well across the states. The problem now is that all facilities, irrespective of level of functioning get equal finances and the money gets locked up in facilities with low levels of functioning and is inadequate for improvements in the facilities handling larger case loads. This problem is sought to be addressed through differentially financing different facilities. The other problem is that RKS becomes the manager of only the user fee and untied grant, or like in Punjab, only the manager of the untied grant- with all other aspects of facility management and access to care and quality of care being placed outside its purview. This was not the purpose of the programme, and the aim should be to see how the RKS is re-vitalized to meet all its expectations and not get reduced to some narrow and limited role. For this too, specific RKS training programmes should be undertaken to provide the additional capacity needed. 6.22. The community monitoring programme is intended to collect information about community health needs and how they are met (according to locally developed yardsticks and key indicators) and provide feedback through Jan Sunwais or public hearings to improve accountability and responsiveness of the public health facilities. Nine states implemented a pilot phase of this programme in 1620 villages of 324 PHCs spread across 108 blocks and 36 districts. These nine states were Assam, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan and Tamil Nadu. The design and implementation was through an Advisory Group on Community Action composed of renowned civil society representatives. One NGO, the PFI plays the secretariat function for this group. It 41

was implemented for a period of about eighteen months covering a total of 1620 villages, 324 PHCs and 108 blocks in 36 districts and facilitated by NGOs. The programme was shown to have resulted in increased utilization of services and greater accountability in the facilities. This programme has recently been scaled up across the entire state in Maharashtra, Karnataka and is planned to be expanded in phases in Bihar and Madhya Pradesh. 6.23. Given the importance of NGO participation to retain the mobilisational character and spirit of community processes in NRHM and given the fact that such community works also has its own set of skills and experience requirements; there is a need for the Twelfth plan to address the needs of sustained NGO participation and growth. NGO participation can be effective in training and support to ASHA, VHSC, RKS and community monitoring programmes. It is also valuable for district planning, environmental and occupational health, in PCPNDT implementation, in promotion of rational drug use, and in health communication, and in advocacy for health promoting and safeguarding policies for example tobacco control. It is also needed for innovation and action research in this area. There should therefore be joint mechanisms developed with states to build leadership capacities in this sector in the states. Such leadership capacity would then be able to build requisite programme implementation capacities in district and sub-district NGOs. There should be national standards set for transparency, financing and appraisal of NGO performance and with conformity to these standards grant in aid committees can be formed in the states. The role of the center is in accrediting this grant in- aid committees as conforming to the standards. Such state level grants in aid committee going along with capacity building in this sector, would speed up and improve the quality of NGO participation rapidly. The huge task of NGO participation requires such policy initiatives. The NRHM Framework for Implementation provided for spending upto 5% of its funds on NGO participation. This is necessary for quality outcomes in this sector and above all to address many social determinants of health care.

42

7. Progress in RCH Services TOR VI

7.1 The Eleventh Five year Plan envisaged universal access to quality antenatal care, post natal care & universal access to safe delivery services. It is represented by access to skilled birth attendants in an institution or a trained person at home. It also envisages universal immunization, access to emergency obstetric care through a network of (First Referral Units) FRUs, a functional referral transport system, access to safe and quality abortion services, facility based services for sick neonate and child, care for Reproductive Tract Infections (RTIs), child nutrition and adolescent health. The provision of these services is discussed below broadly categorized into outreach services and facility based services. Outreach services refer to services provided by ANMs in the sub-centers usually through outreach sessions held in Anganwadi centers in the villages. These include immunization services, antenatal care, post natal care and access to temporary methods of contraception. Facility based services includes institutional delivery, emergency obstetric care both basic and comprehensive, safe abortion services, sterilization services, management of Reproductive Tract Infections / Sexually Transmitted Infections (RTI/STIs) and adolescent health clinics. Outreach services also refer to all the services offered at the anganwadi center for the young child. Three Antenatal care checkups, a sensitive indicator of access to outreach care in pregnancy has improved in rural areas from 36.7% in 2005 to 63.3% in 2009. Quality of care is now part of the monitoring framework. The efforts need to be expedited in the 12th plan period for universal antenatal care checkups. Full immunization in rural areas has improved from 47.4% to 58.5%, an increase of 11.1%, over four years. Measles immunisation in rural areas improved from 61.8% to 72.4% over the same period. In contrast, urban full immunisation stayed unchanged at about 67.5. Urban measles immunisation coverage in this period declined from 79.4% from 78.3%. Thus, rural-urban aggregation underplays the improvement in rural areas. According to the coverage evaluation survey 2009, institutional delivery rose from 53.3% in 2005 to 72.9 % in 2009. The 11 States which had the weakest performance at the baseline, i.e. States with less than national average of 53% institutional delivery showed substantial increase. Institutional Delivery in rural areas improved from 39.7% in 2005 to 68% in 2009 resulting in a jump of 28.3 %( all India increase 19.6%). In urban areas, where access to facilities is much easier and where Janani Suraksha Yojana is also available, the increase was from 78.5% to 85.6%- a mere 7.1% increase. Though Janani Suraksha Yojana is a major contributor to improvements in institutional delivery, other dimensions of NRHM listed below also contributed significantly to the increase in institutional 43

7.2

7.3

7.4

7.5

delivery in rural areas. This trend is also confirmed by District Level Health Survey (DLHS) which shows an all India increase in institutional delivery from 40.5% in 2002-03 to 47% in 2007-08. 7.6 Part of this improvement could be attributed to the strengthening of sub-centers under NRHM. Of the total of 145,920 sub-centres, 95% are functional with at least one ANM. In 2005, one fourth of sub-centers did not have a single ANM or were non functional for similar reasons. Further, 35% of current sub-centres (50,728 in number) have a second ANM. In 2005, no sub-center had a second ANM. It is worth noting that under NRHM, a total of 53,552 ANMs have been appointed, most of them as second ANM at the sub-centre, but also to close critical gaps in PHCs and sometimes as a first ANM in the sub-centers. Other than the provision of second ANM, NRHM has contributed to strengthening of the sub-centres through the provision of Rs 20,000 as untied funds and Annual Maintenance Grants. Another factor that contributed to the improvement in antenatal care, immunization and access to skilled birth attendants is the renewed emphasis given to a fixed monthly Village Health and Nutrition Day (VHND) held in every village. Over 58.7 lakh VHNDs were held in 2009-10 and 69.25 lakh during 2010-11. This works out to about 4.8 lakh VHNDs per month as against 6.38 lakh villages. Another major factor that led to improved outreach services is the introduction of Accredited Social Health Activists (ASHAs). ASHAs were uniformly active in promotion of the VHND and attendance for immunization. They were less effective in improving health practices or in providing appropriate home based care for common illnesses. There are Mobile Medical Units (MMUs) in place in 461 districts of which 66% are in high focus States. In 2005, very few districts had mobile medical unit. This has helped at least immunization and antenatal care to reach to a higher population. Improvements in Referral Transport for pregnant women and the newborn: about 22 States have some sort of emergency response system or referral transport system in place. In 2005, two States had a very preliminary model of emergency response system or referral transport system. Janani Suraksha Yojana (JSY) benefits are availed by over one crore women each year who avail of cash benefit under this scheme. It has also put pressure on the system to improve the provision of obstetric services.

7.7

7.8

7.9

7.10

7.11

44

7.12

However significant the improvements, these are still well short of Eleventh Plan targets. Reasons for a lesser performance could be attributed to a number of factors. One major factor, as the above discussion shows is the stagnation in urban areas in immunization, ante-natal care and even in institutional delivery. Another major constraint was that States that could have benefitted from the second ANM have been slow in deploying second ANMs. Most of them spent the first years in filling the first vacancy, and then in expanding ANM education. Only now these States are approaching deployment. There are also problems of the clarity in working conditions between first ANM and the second contractual ANM. Poor work allocation between the two compounds the problems. The number of sub-centers, their distribution and the number of outreach sessions, requires expansion and better micro-planning with logistics support. In the critical States of Bihar, Uttar Pradesh and Jharkhand which are lowest performers in immunization, the last Ice Lined Refrigerator (ILR) point of the cold chain stops at the block level which in these States is over 2.0 lakh of population. In other States, the last storage point in the cold chain (referred to as the ILR point) reaches up to the sector. The confusing way in which the block PHC is referred as PHC obscures huge differential in cold chain management which needs to be addressed. Provision of comprehensive emergency obstetric care: At the onset of the NRHM, there were 1,052 First Referral Units (240 District Hospitals+ 410 Sub District Hospitals+402 Community Health Centres). As of March 2011, this had increased to 2,891 FRUs (574 DH + 826 SDH+1491 CHCs). In High focus States; the increase was of 786 FRUs from 97 FRUs to 883 FRUs. It is 52.5% of the nationwide increase of 2,654 FRUs in these five years. In North East States, the increase was 114%from 56 FRUs to 120 FRUs. In non high focus large States; the increase was 130% from 798 FRUs to 1842 FRUs, which represents 54% of the nationwide increase in FRUs. In one FRU is present for every 5 lakh population equal to the WHO norm and this is excluding the urban private tertiary care facilities which provide these services. despite the dramatic 648% increase in FRUs in high focus States under NRHM, the gaps between targets and achievements still are higher in the high focus States. In the non high focus large States, there is 1.35 FRU per 5 lakh population, and in the NE States as well as in other small States, there is 1.1 FRU per 5 lakh population, in the high focus large States, the number of FRUs is still 0.58 per 5 lakh population- half of the minimum required. NRHM and Eleventh five year plan made a commitment to move towards an FRU in every CHC which means almost one FRU per 1.2 lakhs population. By that standard we are at only one fourth of the distance to the target. Thus much more needs to be done to increase the number of FRUs so that they cater to a higher proportion of the population.

7.13

7.14

7.15

45

7.16

Primary health care facilities are providing Basic emergency obstetric care services on a 24x7 basis. In the year 2005, there were 2,243 facilities functioning as 24x7 facilities (this consisted of 1,263 PHCs and 980 CHCs). Now, there are 18,348 sub-district facilities (9107 PHCs, 3,338 other primary health care facilities, 4531 CHCs and 1,372 other sub-district facilities) functioning on a 24x7 basis. This represents a 718% increase over the base line.

7.17

Of the total increase in 24x7 sub-district facilities, 59% is from non high focus large States and 37% is from high focus States( other than NE). 2.7% is from the NE States and 0.75% in the small States and UTs. In terms of regional achievements, there is 774% increase in high focus large States, 755% increase in other large States, an 88% increase in NE States and 446% in small States and UTs. The major problem with the 24x7 facility concept was that it either became defined or measured by the presence of three nurses or by the availability of services round the clock. While both definitions are applicable, the central definition is the availability of a package of services which includes basic emergency obstetric care, facility based care for sick newborns and children, safe abortion services for less than 12 week fetus, RTI/STI management, VCTC etc. However, these have become the most important sites of institutional deliverydefined in this context to mean access to a skilled birth attendant.

7.18

7.19

Many 24x7 facilities fail to become functional because there are higher level public facilities almost as easy to access providing a better range and quality and assurance of services. The development of roads, the desirability of health teams as compared to single doctor PHCs or single nurse sub-centers, the changes in health seeking behavior have all made a number of facilities redundant. A large number of partnerships with private sector hospitals have been encouraged to expand the capacity to cater to the increasing load of institutional delivery. As of last year end, a total of 6,043 private sector institutions had been accredited for JSY of which 5,133 are from the non high focus States. In the North east States, there were only 38 private hospitals and in other high focus States, only 836 hospitals could be accredited. It is largely a reflection of low availability of willing private sector hospitals where they are needed most. In addition, a modest number of private sector hospitals in 8 States have become partners to provide free obstetric service to poor women, their charges being reimbursed by the government ( similar to the Chiranjeevi model of Gujarat).

7.20

Monitoring and supervision, though improved from earlier periods, still remains weak. Supervision which ensures that clinical protocols are followed along with building up of skills is exception rather than rule. Community monitoring helped 46

in bringing pressure to bear on erring employees at the peripheral facility- but even in this was limited in outreach to what the centrally sponsored initiative could achieve. It did not get picked up and replicated by States in a major way. It was unable to address even issues like district plan implementation, fidelity of data systems, organization of support services, and use of untied funds. Its overall contribution to improved facility functioning remained limited.

7.21

Though under JSY, the major increase in institutional deliveries has been managed by the public sector, when it comes to complications a significant number get shifted to the private sector. In the public sector, the district hospital does most of the management. There is no cost protection or support for the second referral, especially when it is to the private sector. Due to limited amenities and problems of transport, women tend to leave soon after delivery when the risk of complications is still very high. Out of pocket expenditures even in the public hospital are high.

7.22

7.23

To address these issues, Government has recently announced the Janani Shishu Suraksha Karyakram (JSSK) which promises free treatment with no out of pocket expenditures for both the pregnant woman and the newborn- upto one month. This would include provision of diet and other amenities during her hospital stay and free transport to the hospital and drop back home..

7.24

In 12th Five Plan improving quality of care for services being rendered will be a major thrust. All health facilities should have a citizen charter and protocols on technical services being rendered.

47

8. Engaging the Private Sector TOR VII

8.1. National Rural Health Mission aimed at bringing architectural corrections in the health sector. It also adopted strategies to supplement the public healthcare system by partnering with the private (for-profit and non-profit) sector to provide quality healthcare accessible to poor and marginalized sections. Within the ambit of Public Private Partnership (PPP), NRHM tried to consolidate already existing frameworks for engaging the private sector (under RCH-I/II, RNTCP, NPCB, etc.). However it provided flexibility to the States regarding the actual design and financing of PPPs. Various States had embarked upon various models and frameworks for engaging the private sector. It included contracting for specific services, outsourcing clinical and non-clinical services and outright purchase of care/services from the private parties. However, the proportion of funds spent on PPP was not substantial as most of the funds were actually getting used to strengthen the public system through improving physical infrastructure, hiring human resources, etc. By 2008-09 the all-India level spending on Innovations & PPP were Rs. 61.10 crores under Mission Flexipool and Rs.118.31 crores under both RCH-II and Mission Flexible pools combined (both being less than 2% of the respective flexible pools). The PPPs adopted by various States under NRHM varied greatly. They covered the entire spectrum of contracts and types of services. The broad types of PPPs implemented under NRHM are listed in the table below. The categorization is ad hoc and there is considerable overlap between categories. This is more of an exercise of mapping some of the major types of PPPs that have taken place in last 5 years. The approach Paper to the 12th Plan says that the 12th Plan will explore the possibilities of introducing a government funded Health Insurance Plan, which will focus on both preventive and curative aspects. The working group is of the view that it would be prudent to continue strengthening the public health infrastructure, keeping quality in mind and recommends that preventive health care and also primary health care should be delivered through public health infrastructure and should be kept outside the ambit of health insurance and health insurance for secondary and tertiary care should be introduced with caution.

8.2.

8.3.

8.4.

48

Chiranjeevi for obstetric care Cataract surgery Sterilization services from Purchase of Janani care/service Vouchers for child healthAgra/ Haridwar AND Insurance schemes PHCs:(Arunachal /Karnataka) Contracting Boat clinics In or out MMUs (outsource) HMRI Fixed-day specialist clinics Clinical services

ANM Microscopy Training centers for (West RNTCP Bengal)

Janani Express

Types of PPP Contracts

Diagnostics (LabsBihar) Imaging systems in TN Clinical support services

Cleaning (Sulabh) Diet Laundry Nonclinical services

1.Community monitoring 2.PRI EMRI/108 training 3. ASHA support Referral transport Community level

Types of Services

8.5.

As can be seen from the table, there are some examples of all these types of PPPs adopted by the States under NRHM. There are also multiple ways of categorizing and discussing these. Various evaluations and case studies have been documented by various agencies highlighting the operations and challenges faced in the PPPs. As has been pointed out by the review of EMRI, which is a major PPP, adopted across more than 11 States in India, the financing and monitoring of the PPP had been a major shortcoming in an otherwise very popular and innovative scheme. It has been found that most of the PPPs are actually managed at the district level (day-to-day management, monitoring and to some extent payments), whereas the contracts had been designed and signed at the State level, causing a gap in understanding the deliverables and parameters of the PPP. Hence district and State level capacity building of health officials, managers and administrators is required in terms of contracts management.

a.

49

b.

A general trend observed is that the private sector had been engaged in those areas where public system found it difficult to provide assured services on a regular basis (PHCs in difficult areas, ambulance service, diagnostic/radiological services in block and PHC levels, etc.). However, engaging the private sector does not absolve the public system of managing the services contracted out. The service might become unregulated and give rise to fissures with the private partner (as happened with diagnostic services in Bihar). This calls for greater capacity of the public system in supervising and managing the services contracted out which was lacking in the first place and which is why it was contracted out. This gives rise to a peculiar dichotomy which also needs to be addressed. In the Twelfth Plan, Public Private Partnerships would play an important supplementary function to the development and strengthening of the public health function. When constructing such partnerships, care would be taken to ensure the following key principles of engagement. One principle is that PPPs would supplement and not substitute existing public health systems. They would bring in fresh investment. That there would be a government or independent cell or team put in place to ensure that the terms of the MOU especially as regards, cost and quality terms are adhered to and there is no double charging, and to assess the public health benefits as envisaged are obtained. This includes assuring that the governments responsibilities in the MoU are also adhered to despite changes in leadership and payments are made promptly. Priority for not for profit providers of essential services should be built in for example, to recruit mission hospitals providing emergency obstetric care services where even the district hospital is not doing so to ensure cashless services and access to the poor. There would be also preference given to private sector units who are willing to get totally contracted in- thus becoming a public sector equivalent with private management. There would be also an effort in the district plan to indicate which set of essential services currently not available in the district public health system can be immediate purchased in from the private sector that is operational in the district- even if it is from commercial providers. Much higher levels of district programme management capacity would be required than currently available to be able to do such purchasing efficiently. The potential and need for PPPs in the Twelfth Plan period evidence seems to be based on the

c.

d.

e. f.

High potential and value in referral transport and emergency response systems, High potential and value in outsourcing of major support functions of the public hospitals. Low but important potential for outsourcing PHCs- as something which would add value in niche situations without it being posed as a general solution. Niche 50

g.

solutions largely refer to a dedicated NGO or even a dedicated specialist wanting to take up such work in a PHC or block as part of a personal and organizational commitment. The system must flex to find place for such individuals and organizations- but these would be interesting exceptions only. h. Very high potential in NGO involved in community processes would be mandatory and bring in additional technical capacity and would be another major area of expansion of PPPs. Modest potential in purchasing care- where the element of care is well defined and easy to package, and where supplementary capacity is needed for the delivery of essential services- eg- cataract surgery, emergency obstetric care, trauma care, etc. Often such private options are either physically unavailable where public sector does not offer this service, or unwilling to be purchased at reasonable rates as they operate in a favorable market and would like to limit their clientele to those who can pay. But the contention is that there are enough providers, especially not for profit hospitals, mines hospitals, other public sector undertaking hospitals etc- who would be available for such purchasing of services and these opportunities would be maximized during this plan period.

i.

51

9. Integration of Vertical Programmes and Performance of Disease Control Programme TOR VIII and TOR IX
9.1. Five major National Disease Control Programmes (DCPs) are included under the NRHM umbrella. They include - Revised National Tuberculosis Control Programme (RNTCP), the National Vector Borne Disease Control Programme (NVBDCP), The National Leprosy Elimination Programme (NLEP), the Integrated Disease Surveillance Programme (IDSP) and the National Programme for Control of Blindness (NPCB). The following are the stated goals of the DCPs for the 11th Plan: i. Malaria Mortality Reduction Rate - 50% up to 2010, additional 10% by 2012. ii. Kala-Azar Mortality Reduction Rate - 100% by 2010, sustaining elimination until 2012. iii. Filaria/Microfilaria Reduction Rate - 70% by 2010, 80% by 2012, elimination by 2015. iv. Dengue Mortality Reduction Rate - 50% by 2010 and sustaining at that level until 2012. v. Cataract operations- increasing to 46 lakhs until 2012. vi. Leprosy Prevalence Rate reduce from 1.8/10,000 in 2005 to < 1/10,000 thereafter. vii. RNTCP: Maintain 85% cure rate, also sustain planned case detection rate.

9.2. Integrated Disease Surveillance Programme (IDSP): This programme now extends to all states and 618 districts. It has provision for gathering disease surveillance reports from every facility, analyzing it and organizing an investigation followed by necessary action whenever a disease outbreak is picked up. 9.3. RNTCP: This programme reached a nationwide coverage in 2006, the second year of NRHM. The case detection rate which was 66% in the first quarter of 2005 has over the last five years increased to 71% (3rd quarter, 2010). Sputum conversion rates are over 90% and treatment success rate is 87%. Following integration with NRHM, systems response has improved with better laboratory support, more equipment, and an improved human resource situation. At the community level ASHAs are trained for DOTS provision. The ASHA evaluation study showed that about 80% of those ASHAs, who reported a TB case in their village, were DOTS providers, thus decentralizing DOTS providers to the habitation level. Building on this experience ASHAs are further to be trained in identifying the suspected cases 52

and also in sputum collection. However, with decentralization of DOTs, it is imperative to include infection control measures at all levels for safety of community and health personnel. 9.4. National Vector Borne Disease Control Programme: 9.6.1. Malaria: Malaria cases reported declined from 17.85 lakhs to 14.95 lakhs in 2010with an adequate annual blood examination rate of 10 crores. The blood smear examination of the suspected cases has remained steady at 10 Cr. in 2006 and 2010. Highest numbers of cases were reported from Orissa, Chhattisgarh, Jharkhand, West Bengal and Maharashtra. Confirmed deaths reported into the system declined from 1707 in the second year of NRHM to 767 in 2010- but actual number of deaths would have been higher. The introduction of long lasting bednets in a massive way, a major increase in residual spraying, the training and empowering of ASHAs to diagnose the disease through Rapid Diagnostic Test Kits and provide Artemisinin Combination Therapy for treatment of Pf cases in endemic areas are all major initiatives which are expected to make further dents into this major problem. 9.6.2. Filariasis: Micro filarial rate declined from 1.24 in 2005 to 0.65 in 2009. The rate continues to range above 1.00 in Jharkhand, Bihar, Dadar and Nagar Haveli. Out of 20 states reporting the disease, 10 States have achieved a rate of less than 0.5 and a national goal of zero is achieved in Goa, Puducherry and Daman & Diu (0.07). As part of the control strategy in 250 endemic districts of 20 states 85.55 % eligible population are covered under Mass Drug Administration in 2010. This MDA campaign owes much of its success to community level sensitization, mobilization and drug dispensation by VHSCs and ASHAs. 9.6.3. Kala Azar: The disease is currently endemic in 48 districts, mainly in Bihar, but also a few in Jharkhand, Uttar Pradesh and West Bengal. The number of cases have declined from 32, 803 cases at the start of NRHM in 2005 with 157 deaths out of which 90% of deaths reported from Bihar to 28,610 cases reported in 2010 with 98 deaths out of which 90% deaths reported from Bihar. The NRHM has provided funds for prolonged hospital stay, for supervisory support, for community mobilization and for training and involving ASHAs in this process. 9.6.4. Other vector borne diseases : Japanese Encephalitis Dengue and Chikungunya reports an increase in incidence, but deaths due to these diseases are low and declining- about 667 for Japanese encephalitis, 110 for dengue and none for Chikungunya. Japanese Encephalitis Vaccination Campaign, launched in the second year of NRHM extends to 11 most sensitive districts and 86 endemic districts. In many states the ASHA and VHSC were used for reduction of vector density, and health workers for spraying and source reduction monitoring. Both rapid urbanization and climatic changes are contributors to the rise of these diseases. 53

9.5.

Leprosy: Leprosy Prevalence rate has declined from 8.37 per 10000 population in 2001 to 0.77 per 10,000 population in 2010. There are still about 70,000 new cases detected, of which about 47% are the more infective multi-bacillary form and 9% are in children. But even this level of disease is decreasing.

9.6. Non- Communicable diseases: There are a number of new initiatives launchedfor cardiovascular disease, stroke and diabetes, for cancers, for mental illness, for deafness, for flourosis, for tobacco control, for iodine deficiency disorders, for oral health and for occupational disease. There are also 243 highway based trauma centers which are established. Most of these except for blindness control are at an early stage of planning and implementation. Their integration into the district health plan needs to be planned. These programs may not be brought under the umbrella of NRHM as the non-communicable diseases require separate focus and attention. Bringing these under the umbrella of NRHM, at this point of time, may dilute the attention towards these programmes. 9.7. One concern of NRHM has been the horizontal integration of vertical programmes. The main vehicle of integration has been by bringing their flow of funds and their monitoring and reporting into the purview of the state and district health societies. They are also part of the district plan. This has been a major step forward. There has been a greater sharing of equipment and technical staff and infrastructure across the programmes and with the NRHM structure. The information systems and the vertical supervisory structures are yet to be completely integrated.. This level of integration is operationally convenient and a greater operational integration may be gradual. 9.8. Flexibility needs to be built into the Disease Control Programme framework to align with State requirements and priorities. The reporting and performance evaluation system for the officers of various DCPs should have a clearly defined role for the Mission Director NRHM of the State to facilitate better integration and coordination. The policy and guidelines in different areas like HR, Infrastructure etc. of various DCPs should be synchronized.

54

10. Access to Drugs and technologies TOR X

10.1. As there is a separate working group on this area, this working group report does not dwell at length on this area. There are broadly four aspects of concern to NRHM which are identified below as Access to adequate quantity of essential drugs and technologies through the public health service. Control of cost of drugs and technologies. This will lead to lower out of pocket expenditure in the private and public sector, and lower costs of care in the public system. Rational use of drugs and diagnostics and health technologies. Generation of new drugs and technologies that would improve health status. In access to essential drugs and technologies the major components are An efficient, transparent system of drug procurement and logistics benchmarked to the TNMSC An improved system of equipment purchase, installation and maintenance. Expansion of public health facilities and reduction of social barriers and costs barriers to its access.

10.2.

10.3.

10.4. 10.5. 10.6. 10.7.

10.8. 10.9.

10.10. In Control of costs of drugs and technology availability the main components are: 10.11. Adequate manufacture of drugs where necessary invoking compulsory licensing. Indigenous manufacturing capacities in health technologies. Development of more cost effective drug and technology solutions. 10.12. Drug price control mechanisms. 10.13. Bulk purchase by the public system- both for its own use and for distribution through fair price shops. 10.14. Rational drugs and technology use. 10.15. In Rational drugs and technology use the required interventions are 10.16. Creation of essential drug lists, drug formularies and standard treatment protocols. 10.17. Active promotion and monitoring to ensure adherence to rational drugs use in the public sector and investment in consumer and provider awareness to curb irrational prescription and consumption.

55

10.18. Legislation and administrative action to withdraw irrational drugs and hazardous drugs from the market and to curb sharp practices that misuse and over use technologies for unethical monetary gains. 10.19. For generation of new drugs and technologies the main areas of intervention would be mapping the gaps and opportunities- identifying the areas where innovation is needed to either reduce costs, or increase access, or address neglected problems. It also includes creating a favorable climate for generation and absorption of innovation, including the creation of a national technology assessment institution, comparable to National Institute of Clinical Excellence. This would help assess each new drug and technology in a fair, transparent and professionally competent manner, keeping costs and social dimensions included, before they are included in the national health programmes or approved for use. It also includes a policy for building synergy between different sources of innovation and knowledge generation.

56

11. Population Stabilization - TOR XI

11.1 The outcomes as regards the goal of population stabilization have been discussed in an earlier section. The main strategies for population stabilization has been to increase availability of a menu of contraceptives from which people could choose, to promote the small family norm, to push back the age of marriage, delay the first child and increase the spacing between children. It is certain that population stabilization should be a an area of focus during the 12th Five Year Plan, All ministries e.g. Agriculture, Rural development, Railways, Road transport, Environment, Infrastructure sector, Women and Child development, Law and order (home) etc. get affected by ever growing population. Thus, population stabilization should not be the concern of Health Ministry alone. 11.2. In most States, the percentage of marriages below 18 and the first child below 19 has reduced appreciably largely related to advances in girl childs school education. Contraception promotion and use for delaying the first child is still minimal. The pattern, even in most States where there is a decline in fertility rates is therefore a first child soon after marriage, followed within two to three years by a second child and then option of sterilization- usually female sterilization. To address this pattern, there has been renewed emphasis given to spacing and the promotion of male sterilization with the introduction of a new IUD with better training and non scalpel vasectomy as the main area in which significant advances were made. However, we are still well short of the limited objective of at least 10% of sterilizations being male sterilization and there is much more work to be done in this front. The Behaviour Change Communication (BCC) inputs have to be intensified for the promotion of spacing and male sterilization and pushing back the age of marriage. 11.3 There are however eight States where crude birth rates are above 21 and TFR above 2.5. Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Jharkhand, Chhattisgarh Assam and Meghalaya. The situation amongst those accepting and accessing contraception services is the same as in the other States but there is still a large part of the population which is either not accessing or not accepting contraception for limiting family size. There needs to be a differential strategy for two contexts. 11.4. In the context of the high fertility States- the aim is for a massive increase in supply side provisioning for contraceptive services by both recruiting many private providers and by an intensive training programme on non laparoscopic based forms of sterilization. With the huge increases in emergency obstetric care loads in the public hospital consequent to JSY, gynecologist services are difficult to withdraw from the district hospital without immediately causing loss of lives. Sterilization camps based on laparoscopic sterilization need gynecologists and surgeons and become more difficult to perform. The common belief that JSY influences health behaviors in favor of larger families has no evidence. Studies indicate that JSY merely covers out of 57

pocket costs of institutional delivery thus enabling access to institutional services. Familys reasons for opting for institutional delivery or home relates to other factors like their perception of quality of care, the availability of transport etc. Similarly, the decision on family size too has little to do with the availability of this meager amount at the time of delivery and there is no evidence to the contrary. 11.5. Behaviour change communication (BCC) for promoting the small family norm is needed. What needs to be focused on is BCC for improved access to contraceptionthe how, rather than the why. Spacing methods including a greater use of IUD and oral contraceptive pills should be actively promoted, though sterilization services still remain the main strategy. Efforts will also be made to introduce injectable contraceptives. 11.6 In the context of all States the focus of population stabilization efforts is on a shift from sterilization methods to a variety of other methods and pushing back the age of the mother at the time of the first child and increasing the spacing between children. Contraception should become part of the routine package of services available at the block hospital, and the focus of public health efforts should be on counseling. 11.7 Availability of contraception of temporary methods both condoms and oral pills is best done through social marketing, supplemented by easy availability in public facilities. The ASHA as the main vehicle of social marketing is an approach that is being rolled out in a major way in the sale of sanitary pads and in contraceptives. 11.8 In addition to all the above strategies we should seriously consider the introduction of a mid-level service provider for conventional tubectomy, mini-lap and vasectomy services- a task shifting- that needs to be considered- only for the States where unmet needs are over 30% and simultaneously TFR is over 3.0. Task shifting too is an option. We note that in Maharashtra, AYUSH providers are legally permitted and they do provide this service and this could be one option. In these same States we should also consider a center- State jointly managed project for accrediting private providers for the provision of these services. This could extend to hiring specialized not for profit agencies that are active in this area. 11.9 For States that have already achieved a replacement TFR of 2.1 or less, the Planning Commission may ask all central ministries to set up a Population Stabilization Incentive Fund which will be used to additional allocation to these States/UTs. This fund will also be utilized to incentivize those States with high TFR which are taking positive steps towards controlling population growth. This additional allocation would be a kind of untied fund available with the State governments, with the rider that with this money, works can be taken up in the same sector. This will incentivize the states which have checked their population growth or are taking effective steps to continue to maintain this. This will also encourage other states with high rate of population growth to take necessary steps urgently. 58

12. National Urban Health Mission TOR XII

Meeting the public health challenges and the health needs of the urban poor

12.1.

Conservative estimates show that 38 crore people are living in urban areas at present, which is projected to increase to 54 crore by 2050. This unprecedented urbanization brings with it influx of migrants, rapid growth of populations, expansion of the city boundaries and a concomitant rise in slum populations and urban poverty. As per NSSO estimates, urban poverty has risen from 15% in 1970s to 25% in 2004-05 (NSSO 61st round). The Planning Commission has estimated that 8 crore of the urban population is poor. However, the approximation of slums populations vary and city wise mapping accurate figures are needed for proper planning. The distribution of the urban poor is 41 % in the EAG states, 18% in Maharashtra, 9% in Tamil Nadu, 8% each in Karnataka and Andhra Pradesh with the rest of India contributing to 16% of the urban poor populations. Therefore, for planning and resource allocation prioritization should be done based on the number of urban poor.

12.2.

As per Census 2001, 4.26 crore people lived in slums spread over 640 towns/ cities (population more than 50,000). There are more than 2 million births annually among the urban poor [Based on CBR 19.1 for urban population and 100 million urban poor] and the health indicators in this group are poor. 56% deliveries among the urban poor take place at home. Under 5 Mortality at 72.7 among urban poor is significantly higher than the urban average of 51.9. In addition, several health indicators among the urban poor are significantly worse than their rural counterparts. 60% urban poor children do not receive complete immunization compared to 58% in rural areas. 47.1 % urban poor children <3 are under-weight as compared to 45%of the children in rural areas and 59% of the woman (15-49 age group) are anemic as compared to 57% in rural India. The invisibility of the urban poor has contributed to their systemic exclusion from the public health care system. Lack of economic resources inhibiting/ restricting their access to private facilities, Illegal status, poor environmental condition, overcrowding and environmental pollution has further contributed to their poor health status.

12.3.

Further, no systematic investments and efforts have been made to improve health care in urban areas. There has been a history of underinvestment with a project based approach instead of comprehensive strategy. The Public Health Network in urban areas is inadequate and functions sub optimally with a lack of manpower, equipments, drugs; a multiplicity of service providers, weak referral system and a focus on RCH and in-adequate attention to public health. Recognizing the 59

seriousness of the problem, urban health will be taken up as a thrust area for the 12th Five Year Plan. The National Urban Health Mission (NUHM) will be launched as a separate mission for urban areas with focus on slums and other urban poor. The NUMH core strategies include Decentralized Planning with the flexibility to develop city specific models, strengthening the urban health system and capacity building, communitization and development of partnerships with CBOs, NGOs, charitable organizations and other stakeholders, development of IT and e- governance systems for effective programme monitoring, evaluation and implementation, and focus on intersectoral convergence with other programmes like the JNNURM, RAY, etc.

12.4.

The NUHM will ensure health services for all urban dwellers targeted on: urban poor population, living in listed, unlisted slums and other parts of the cities, identified by the urban local bodies; All other vulnerable population such as homeless, rag-pickers, street children, rickshaw pullers, and other temporary migrants; Public health thrust on determinants of health like sanitation and clean drinking water; and Correcting structural (infrastructure and human resource) imbalance of public health system in urban areas with a thrust on Urban Local Bodies (ULBs).

12.5.

The NUHM is designed in a way that accords primacy to public sector for the provision of public health. It will be launched in 779 cities/towns (772 cities/towns + 7 metros), having a population of 50,000 or more including all district headquarters. Towns having less than 50,000 population will be covered under healthcare infrastructure/ system created under NRHM. Seven mega cities (Mumbai, New Delhi, Kolkata, Chennai, Bengaluru, Hyderabad, Ahmedabad) will be treated differently their municipal corporations will implement NUHM. In other cities, District Health Societies will be responsible for NUHM. Flexibility will be given to states to hand over management of NUHM to cities/towns where sufficient capacity exists with ULBs. In the 12th Plan period NUHM and NRHM will be separate programmes which may be merged in the 13th Plan period or later. The budget allocation for NUHM in the 12th Plan period is envisaged to be approximately Rs 30,000 Crores.

12.6.

At the Primary Care level, one Urban Primary Health Centre (U-PHC) will be established for every 50-60 thousand population. These U-PHCs will provide services to the entire urban population in their catchment's areas. At the community level, outreach services will be provided to the urban poor in slums and other vulnerable population. An Urban Social Health Activist (USHA) will be posted for every 200-500 households and a Mahila Arogya Samiti (MAS) will be established

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for every 50-100 households. The MAS will be provided an annual united grant of Rs 5000 per year.

12.7.

Creation of Sub Centers has not been proposed. Outreach services will be provided through Female Health Workers (FHWs)/ANMs headquartered at the U-PHCs, utilizing community halls, AWC, etc., as fixed points for these services. Communitization through Mahila Arogya Samiti (MAS), Rogi Kalyan Samiti (RKS) and Urban Social Health Activist (USHA) has been envisaged. Secondary and Tertiary level care and referral services will be provided through public or empanelled private providers. A National Program Management Unit (NPMU) has been envisaged for effective implementation and continued monitoring of the NUHM. The proposed framework provides for active need-based engagement with the private and the non-government sectors.

12.8.

NUHM also envisages an effective monitoring and evaluation framework - regular monitoring at District/ City and at State level by the respective PMUs, Societies and Mission and feedback. A web based M&E framework effectively integrated and leveraging MIS of other National programmes like IDSP is also proposed along with baseline and end line evaluations, and community monitoring through Rogi Kalyan Samiti/ Mahila Arogya Samiti.

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13. A. Gender Concerns in the Health Sector - TOR XIII

The report of the working group on NRHM has addressed gender concerns related to this sector and many places in the report. In this section we do a round- up of all these concerns as gathered from the different sections and some more issues that need to be addressed. 13.1 The single greatest concern is the declining sex ratio in the 0 to 6 age group. The Twelfth Plan should give priority to an effective implementation of the laws in place to curb illegal sex determination and sex selective abortion. It would combine this with action taken to raise awareness against son preference attitudes. It would also address the problem of the neglect of the girl child leading to higher child mortality on girls by orienting the ASHA, the VHSC and other community processes for greater efforts to promote appropriate care seeking for the girl child.

13.2

The programmes that address the needs of adolescent girls have been sub-critical. The Twelfth plan would make a major effort to improve the range and effectiveness of programmes addressing adolescent girls. This would include adolescent health clinics and would include correcting malnutrition and anemia in adolescent girls through a well focused effort reaching out to both in-school and out of school girls.

13.3

Population stabilization programmes should aim to empower women to make their own choices on when they would have a child and also on how many children they would have. This means much more effective counseling and much easier access to contraception. It would also mean a rise in the proportion of male sterilizations and the use of methods that involve greater and more informed male participation. Delaying the age of marriage and pushing back the age of the mother at the time of the first child birth are also very basic requirements for womens health and womens rights. Adequate spacing between children is also essential to safeguard health of women and access to counseling and contraceptives for enabling this is a womens right.

13.4

There shall be universal access to safe and quality abortion services. The same criterion of universal access as stated for emergency obstetric care applies.

13.5

Making hospitals women friendly, in terms of amenities, ensuring privacy, maintaining dignity would be a mandatory part of every quality assurance system that is put in place.

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13.6

The Twelfth plan should lead every district to provide universal access to quality reproductive and child health care. This would include the availability of assured referral transport and a site for basic services within 30 minutes to an hour of every habitation and an emergency obstetric care center within one hour of any basic obstetric facility. Every village health sanitation committee would have at least one thirds, preferably 50% representation of women. Not only are all ASHAs to be women, their immediate supervisors are also to be all women. ASHAs would have grievance redressal cell that is functional. When they go to a facility, there must be a place where they can stay and rest.

13.7

13.8

13.9

All women employees must be assured of the following as part of their terms of employment: maternity entitlements, privacy, freedom from harassment, a functional grievance redressal mechanisms and ASH committee and equal opportunities for career advancement. There would be a greater emphasis on rolling out programmes related to the prevention and a health system response to gender based violence. A few carefully chosen indicators should be deployed to trace gender disaggregated patterns where it is relevant- e.g. on full immunization rates, on OPD or IPD attendance, on mortality etc. The same or even better quality of information and action is made possible by the correct choice of a few select indicators. It would be important to start using existing gender disaggregated data for action, even without waiting for more- e.g. in differential mortality rates.

13.10

13.11

13. B. Accountability Framework - TOR XIII

13.12 The NRHM aims at providing effective, affordable and equitable health care to the rural population, especially the vulnerable sections including women and children. It creates certain entitlements and service guarantees. The Mission has a robust social accountability mechanism and seeks to actively involve people in the public health system not only as consumers but also as key stakeholders involved in planning, decision making, and monitoring to ensure community ownership. Further, in the 12th Plan Period, a system of constructive accountability is envisaged with the aim of bringing about improvements in the public health system rather than holding people accountable in order to reprimand them or take other punitive measures. An accountability framework needs to be built with clearly identified responsibilities for all stakeholders at all levels. Involvement of communities should

13.13

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be strengthened to ensure that the accountability framework is implemented effectively. 13.14 The principles of good governance and transparency are to be emphasized and practices such as display of expenditures on the district and State websites as well as at the facility level on a monthly basis could be mandated to ensure transparency in the 12th Plan. The accountability framework should include managerial as well as financial accountability. Physical progress on monitorable targets should be evaluated periodically.Territorial responsibilities of Medical Officers and Programme Managers should be fixed and their performance monitored and appraised. The Logical Framework Approach could be used to identify and quantify inputs, outputs, outcomes and means of verification. The financial management process and financial monitoring at both State and district level will need further strengthening. It must be ensured that funds are utilized as per the mandate and not diverted or substituted. Capacity building to demand and facilitate accountability would be encouraged. In the 12th Five Year Plan, NRHM should realize a positive connotation of accountability with the aim of bringing about concrete improvements in public health care services.

13.15

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Key Recommendations and Budget Proposals for the Twelfth Five Year Plan
I. Setting Objectives for the Twelfth Five Year Plan

1. The Twelfth Plan will build on the successes of the NRHM in treating healthcare as a system of preventive and curative medicine. Thus, universal health would include all aspects of a clearly defined set of healthcare entitlements including preventive, primary and secondary health services. In setting targets for achievement in the Twelfth five year plan period, we must re-examine the methodology used to arrive at the Eleventh five year plan- targets, especially for the states. State specific targets will be set for reduction of IMR, MMR, TFR and disease prevalence. In case of IMR, target for each State will be to reduce IMR by 40% and MMR by 55% over the 5 year period of 12th Plan. Similarly for TFR and disease control programs, state specific targets will be set in the MoU to be signed with the states 2. At the national level, we could repeat the following targets: Reduction of MMR to < 100 per 100000 live births. Reducing IMR to < 27 per 1000 live births. Reduction in NMR to < 18 per 1000 live births Reducing TFR to 2.1 Providing clean drinking water for all by 2017 Reducing wasting among children of age group 0 to 3 to half its present level Reducing anaemia among women and girls by 30% with a 50% reduction in moderate and severe anaemia in pregnant women. h. Raising the sex ratio for age group 0 to 6 to 950 by 2016-17. 3. In terms of service delivery goals, we could aim for the following: a. Over 80% institutional delivery in high focus states and over 95% in non high focus states and 100% safe delivery in all states. b. Over 80% Immunisation in all states with over 95% immunisation in non high focus states. c. Over 90% antenatal and post natal care in all states with 100% in non high focus states. d. Met emergency obstetric care rate of over 50% to be provided in a cashless manner. (15% of all pregnancies are the expected complications in pregnancy rate and the number of complications managed is the met emergency obstetric care rate. When institutional delivery is being demand driven this may be a better indicator of what is happening to maternal mortality.) e. Universal access to safe abortion services f. Meeting the unmet need for contraception with equal emphasis on spacing and limiting methods a. b. c. d. e. f. g.

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g. An average public sector OPD attendance in each district of 2 per year per capita for the district. At least 70% of this load should be managed in the PHCs and CHCs. h. A bed occupancy rate in each district of over 70% for in-patients. i. An assured referral transport system between facilities and an emergency response system in every district. j. Access to emergency life saving services and trauma care in every district. k. Free distribution of medicines as per the Essential Drug List and basic diagnostics should be provided free of cost in public sector hospitals.

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II.

Resource Allocation and the District Health Plan

1. Achieving the above health outcomes and service delivery outcomes would require an estimated health expenditure that would be 2.5% of the GDP or approximately 3 lakh crores over the plan period. 2. Current pattern for determination of Resource Envelope of States under NRHM will be continued. States should allocate higher resources to the high focus districts to bridge the gap between the high focus and the non high focus districts. 3. The district NRHM grant would have five components- One part of the sum allotted would go to finance the community processes costs- ASHA programme, the VHSC, the BCC activities, and action on social determinants. Another part of the sum allotted to districts would go to every health facility as institutional support costs (equivalent to the current untied funds, RKS fund and maintenance fund and up-gradation funds as of now plus costs of supervision and quality assurance and training costs to be spent within and by the district) and a third part would be a district level untied fund to be used to pay for institutional operational costs of hospitalisations and outpatient case load at the block PHC or CHC, SDH and DH. This could be made available per institution as reimbursement for in patients seen over and above a minimum specified case load. The operational costs includes referral transport costs where admissible, includes costs of drugs and supplies (provided in kind to facility, but with costs booked against the facility in the TNMSC approach); costs of local support staff and services- diet, security, cleanliness, sanitation and laundry; and where admissible provider incentives. The fourth component is the demand side cash transfers (JSY and sterilisation compensation). The fifth component is the skilled HR costs and this is made against a district HR plan that would be able to link additional HR to additional work outputs expected. The district HR plan would also bring clarity on what part the state government is paying for, and what it is committed to taking over the payment for in the future. The HR plan would ensure that HR is deployed keeping both case load and equity considerations in mind and that there is commensurate increase in service delivery outputs for additional human resource deployment. The institutional costs- support and operational could be used for purchase of some services from private sector, which is not available in public sector, but available in the private and judged as essential and complementary. 4. In return for this district grant, the district would have to ensure that within the first three years, the minimum standards of universal access to quality RCH services would be achieved and there would also be progress on achieving standards of access to three more packages of care as defined in their district plan towards- a. emergency medical and trauma care and b. care for infectious disease and c. for chronic diseases over the plan period. An MOU between the State and District Health Society and the District Health Society would be useful to give clarity on what is expected as the 67

outcomes and to make explicit and public the road-map on which the district is expected to proceed towards universal health care. The strategic five year district plan must be the road map for providing assured universal preventive, promotive, curative and rehabilitative care needed for a population within the district itself- with only very few disease conditions requiring highly specialised care needing to go outside the districts. Areas within the districts and districts which are more marginalised or have greater problems of access would receive a greater investment of human and financial resources. 5. Assured services- building a district road map: The Twelfth Plan thus envisages that every district would announce as part of its five year strategic district plan, the package of services each facility would guarantee such that taken together the district health system would ensure universal access to a good quality of comprehensive RCH services, emergency care and trauma related services, infectious diseases management and chronic disease management. Such a district plan would become the instrument to be used for programme audit by the government and for social audit and community monitoring purposes. 6. While the States should be allowed flexibility, quality assurance should be standardized across all the States. 7. To achieve minimum standards of universal access to quality RCH services, every sub-centre, PHC and CHC is not expected to develop equally. A number of health facilities within the district will be prioritised for development such that between them they could ensure that there is access on a 24 * 7 hour basis to a skilled birth attendant, to basic and comprehensive emergency obstetric care and corresponding levels of safe abortion services, institutional care for sick newborn and sick child, and for RTI/STI management and contraceptive services. This system should be interconnected by referral transport, such that once the user enters the public health system at any point, the facility network acts as a single unit to provide the appropriate level of care, wherever it is available. This first point of entry or contact should be within 30 minutes - preferably by local transport but at least by an assured referral transport system. For remote and underserved areas such timely access is not possible, provisions must be made for birth waiting rooms where a one week or two week stay anticipating onset of labour is possible. Services to pregnant women and sick neonates should be made available free of cost in public sector facilities. There should be no withdrawal of existing services in other facilities. Sub-centres and PHCs not prioritised for delivery services or emergency obstetric care will still have to perform outreach functions and out-patient clinic management. 8. The quality of RCH services provided would be based on minimum standards laid down and would emphasise the processes that need to be in place and the use of clinical protocols of care. This should qualify the facility for a higher rate of payment of institutional operational costs. Periodic evaluation of quality parameters will be

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undertaken at all levels. Rational Prescription of drugs, use of generic medicines, standardised clinical protocols which are subject to medical audits are to be mandated. 9. The district plan would also specify the development of care for emergency medical services and trauma care. This will be funded by a national programme, which would expand to all districts in the Twelfth five year plan. Similarly the district plan would also specify the facility development required to implement the national disease control programmes as well as the respond to district specific infectious diseases, based on epidemiological data. Finally the district plan would also specify the facility development plan in order to provide care to chronic diseases. In setting priorities for facility development and for action on social determinants and preventive action for each of these three areas of care- community participation play a major role in deciding the content of the package and in the choice of the technology. The choices cannot however be driven by community alone, for the system must have the capacity to respond, and public health considerations will need to be taken into account. Therefore the community representatives, the district health management, and public health experts, would have to enter into a dialogue to finalise the priorities of packages and facilities. Districts which have already achieved universal access to RCH care could rapidly advance to make the same assured services available in these three areas as well. 10. In financing district level care for emergency services, infectious diseases and chronic diseases the same approach as suggested for RCH, could be applied, i.e., show the community process costs which includes preventive action and action on social determinants, the institutional support costs, the institutional operational costs, the demand side cash transfers required and the skilled HR costs separately and then resource allocation is made to the facility based on the volume and package of services provided. For top management, the advantage of this approach is that it will help correlate financial expenditure (inputs) with outcomes in terms of service delivery improvements. For the grassroots, it would enable the system to respond to community expectations generated by participatory planning. This could also be shaped to help close the gap between vertical programmes and the convergent district plan as well as to close the gaps between programme implementation (eg RCH plans) and facility development (NRHM plan). 11. Development of emergency response systems and development of referral transport systems two distinct but overlapping objectives is also an important part of the district plan. The former is more resource intensive and addresses trauma care best, then emergency health care needs and currently plays a limited role in referral transport for pregnancy. Voucher based partnerships with local small scale public transport service providers like the Janani express of Orissa are quite effective in referral transport for pregnancy, but do not constitute an emergency response system. The department would develop guidelines for developing an appropriate system of emergency medical transport for all the districts.

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12. Since it is unlikely that all these areas of care can be developed upon, even in a selected number of facilities in most districts, the only facility where we should aim to provide assured services in all four of these areas is the district hospital. The Twelfth Five year plan should specially emphasise that all 640 district hospitals would provide a minimum level of assured care in all these four areas- RCH, infectious disease care, emergency medical and trauma care and chronic disease care. The district hospital must provide advanced level of secondary care. Where the district hospital role is being played by a medical college hospital or where the district hospital has been handed over to support a medical college, it should continue to attract the financial support from NRHM that a district hospital would have got. Since the district hospital also serves as human resources development centre in a number of areas, there is even greater urgency to get in place a district hospital which can be the standard of excellence in the use of standard clinical protocols of care, and in quality management systems which provide certified level of quality of care. In the past, the district hospital has been relatively neglected in financing, and as a result the increasing case load is addressed with decreasing quality of care. There is a need to de-pressurise the district hospitals from primary care work, but even if we decentralise and distribute primary care, as a consequence of doing so, secondary care needs would rise high enough to merit such a major investment in the district hospital. 13. When planning for the district hospital- in infrastructure, staffing and organisation of work, it would be the endeavour to also develop the district hospital as a district knowledge centre for training on a broad array of health workers including nurses, mid-level health workers, paramedicals, and other public health and health management professionals. In many larger districts, these would also be developed as hospitals attached to medical and nursing colleges. 14. There is a need to differentially plan for the health sub-centre and also for its human resources. In upto 10% Sub-Centres where deliveries are taking place, an additional ANM may be provided taking the number of ANMs posted in such centres to two. Thus, in such sub-centres there would be two ANMs and a male paramedical worker who would be supported by ASHAs as the community mobiliser. The ASHAs would provide for all preventive and promotive care which would include not only provide antenatal and postnatal care for approximately 125 pregnant women and immunisation and health care for 500 children below 5, conduct RDK test for individuals with fever, but also screen every person over 30 for hypertension and diabetes annually, and ensuring that those with hypertension and diabetes are referred and maintain control etc. They would also promote tobacco control, prevent and support disability. In all other sub centres there would be one ANM and one male paramedical worker. The ANMs would also provide school health in the primary or middle school in their area and adolescent counselling and services to every eligible couple. 15. Careful resource allocation to the districts and facilities along these lines should lead to substantial reductions of out-of pocket expenditures for all elements of care as 70

provided by public health facilities and this improvement in the social protection function of the public health facility would be measured and reported upon. The JSSK is a welcome first step in this regard- eliminating OOPs in care for pregnant women and newborn- but it should gradually extend to more and more dimensions of health care delivery. Without such a commitment, it would be difficult to eliminate OOPs for only select categories of care. The government would consider a situation in which most categories of drugs on the essential drugs list and most diagnostics when used in consonance with standard treatment guidelines would be available for free. 16. All of the above steps require a higher degree of institutional capacity for planning than has been available hitherto. Such institutional capacity needed for effective district health planning would include skills in epidemiology, health care financing, quality assurance systems and human resource development, systems of generation and use of real-time information validated by both external surveys and community feedbacks and an institutional memory of past plans, outcomes and constraints and systems of resource allocation which are responsive to the planning effort and performance audit based on the district plan. One of the challenges of the 12th five year plan would be in building up such district level capacity. Focus on development of faculty and capacity in public health, planning and management at all levels, an improved functioning of state level resource centres and other technical support units, the development and expansion of courses in public health which are multidisciplinary, open to physicians and non physicians, problem-solving oriented, attuned to the needs of district health systems and made available both as a full time option and on distance education formats, are all essential supplementary strategies needed to develop this capacity. 17. Untied funds and RKS grants will be merged and named as Untied Funds which will be utilized as per the decisions of RKS.

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III.

Infrastructure Development

1. Infrastructure development would be parallel with the facility development priorities as discussed above. Further expansion in sanction of new facilities other than sub-centres should be undertaken only when mapping of access demonstrates the need for new facilities to improve accessibility. In public hospitals we need to add more beds and staff in existing facilities than add more secondary care hospitals- provided a minimum base line of at least one 30 bed hospital per block is met. A norm of minimum 500 beds per 10 lakh population in an average district (additional 100 beds for every additional 10 lakh population in the district) could be followed such that 200 beds are at the level of District Hospitals and the remaining are distributed judiciously at the CHC level. 2. Presently, we are following the norm of one sub-centre per 5000 population in general and one sub-centre in 3000 population in hilly areas. The provision of healthcare should move closer to people to enable easy and timely access to quality care. The approach paper to the 12th plan mentions that the aim should be to locate a Sub Centre in every Panchayat, If the sub Centre norms are aligned with the Gram Panchayat it may result in the reduction of the number of Sub Centres in some States, as the average population covered by a Gram Panchayat is much more than 5000 in these States. Hence, there would be provision for at least one health Sub Centre in every Panchayat and if the population of the Panchayat so requires, there may be more than one Sub Centre also. In hilly/tribal/desert areas the existing norm may be further relaxed to ensure that the people do not have to travel long distances or for long durations to reach the health Sub Centres. 3. Ideally one must be able to access the health services in their village itself. For which, we require a long a long term goal of setting-up of one sub-centre in each village. However, since there are constraints of skilled manpower this may not be possible to achieve in the Twelfth Five Year Plan, the number of sub-centres would be increased as per the current norm to meet the needs of increased population as per the Census 2011 figures. A dispensation will be made whereby the villages in hilly and hard to reach/ inaccessible areas will get health subcentres at a further relaxed norm. 4. For PHCs (that serve 30,000 population), the increase in population within a village should be met with more staff in existing PHC. Infrastructure development must be prioritised accordingly by taking into consideration both population served and standards of access. Those large blocks with population above two lakhs, where only one or two PHCs are functional, must be given the priority for facility development- combining both construction of new PHCs where needed and revitalising existing PHCs which have become moribund.

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5. NRHM and Eleventh five year plan made a commitment to move towards an FRU in every CHC. The gap in the High Focus States is larger than in other States and this should be bridged in the Twelfth Plan. Optimum functioning of the existing FRUs needs to be ensured to provide referral services for maternal and child health. Similarly, the District Hospitals need to be strengthened to provide advanced secondary level of care. 6. Every state is to develop a team to manage infrastructure development and they must be trained and certified by an appropriate agency to understand the needs of hospital design, as well as the intricacies or tendering, contracting and quality control. This team shall then be deployed to plan, contract out and supervise the construction of the health facilities and ensure that is achieved with quality. Third Party monitoring of infrastructure projects should be undertaken to ensure quality of work. A sub-centre which by its location in relation to PHCs and CHCs is unlikely to become a site for midwifery services would be built without the labour room but for the most part, the design of the buildings is the same as currently recommended. It is only the priority of construction that would change to meet the needs of achieving assured universal access at the earliest. The state plans should indicate a clear road map to complete the infrastructural gaps for health care delivery by the end of the 12th five year plan period- and this should include a rational prioritisation plan- so that the most urgent gaps are filled first.

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IV.

Human Resources for Health

1. In the generation of human resources- the effort would be to give preference to candidates from districts which are HR-constrained for admission into training schools for ANMs, nurses, para-medics and medical doctors set up in these districts/ divisions. If the seats remain vacant, candidates from other districts/states may be considered subject to signing a bond with adequate security amount for serving in the district for 5 to 10 years. The second major effort would be to open publicly funded institutions within states which have a major short-fall of educational institutions. A third effort would be for faculty development and accreditation and support to the faculty of both public and private institutions. 2. Present recruitment process calls for major reforms to speed up recruitment process to fill up the vacant posts. State Governments would be encouraged to carry out reforms in this area. States where graduates from government accredited private nursing and medical education institutes are not eligible for government employment may consider doing away with these conditions to improve availability of health human resources. 3. Implementation of human resource policies which ensure transparency and fair play, regarding place of posting, transfers, promotions, would need to be clearly articulated and effectively implemented by the States. The creation of minimum posts needed (as defined by IPHS) in the state non plan budget and the gradual movement away from contractual appointment to regular recruitment should be the major direction. Each health Sub Centre will have one ANM and one multi purpose worker (Male). Additional ANM will also be considered for upto 10% of Sub Centre having high delivery load. 4. Clear roles of ANMs, ASHAs and AWWs would be articulated and a more effective supervisory role of ANMs on ASHAs is envisaged. Similarly, role of Male Multipurpose worker would also be clarified. 5. A package of financial and non financial incentives should be considered to attract and retain skilled workers in difficult, most difficult and inaccessible areas. A ceiling of 30% of total number of facilities in high focus states and 15% of total number of facilities in other States would be there for provision of such incentives. The facilities located in such areas will be identified by the State Government in consultation with Government of India. Efforts would be made to improve the working conditions and remunerations of all frontline workers- both contractual and regular- and build positive practice environments which will reduce their sense of isolation.(approach paper quote) 6. A nursing division at State level with proper staffing and with distinct responsibilities for both ANM and GNM should be developed. Simultaneously, developing mid-

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wifery cadre, developing public health midwives and creating management/supervisory cadres of midwives will be focused in the twelfth plan. 7. The network of training institutions- for skill based in-service training and for training of multi-purpose workers would have to be revitalised. The capacity of these training institutions should be adequate for them to be accountable for all those in service provision in their allotted districts to have the necessary skills. Non governmental institutions could also be encouraged to participate. A scheme for faculty development and quality assurance in all the training institutions and training programmes would be put in place. The outcome/impact of all training programs will be monitored. Use of Information Communication Technology should be encouraged at all levels. A pool of dedicated trainers at State and district level for supervision, monitoring and hand holding of trainees should be developed. Performance monitoring and organising CME/ refresher courses for updating knowledge and skills of the health personnel should be done. 8. District hospitals should also function as training centres. Medical colleges should be linked to the district public health system for technical assistance and program monitoring support. 9. In the high focus districts of the high focus states, the training requirements are very high, but internal capacity to accelerate current rate of achievement is very limited. We need training in every aspect of RCH delivery- conventional tubectomy and minilap, non scalpel vasectomy, IUD insertion, RTI/STI management, safe abortion services, sick newborn care, management of nutrition rehabilitation centres- other than the core of skilled birth attendance training and training in emergency obstetric care. Not only do we have to catch up with these basic skills, there is also the need to train and deploy supervisors who can ensure that clinical skills taught are practiced and who can provide on the job training. Further, there is a mind-set in training and in work culture that would have to be contended with, if a change has to be brought around in the quality of care. For these reasons, as a supplement to the training institutions and their faculty, a number of suitable agencies should be hired from all over India, train and support additional training faculty who shall work in the training institutions of the poor performing states to improve the quality and number of skilled workers. The training faculty should also act as motivators and change agents in the way such services are provided. Such an infusion of fresh blood and skills into the training hierarchy will cost resources and will need active cooperation of many public health institutions and civil society organisations but potentially it can help. After a two to three year period when this additional faculty go back, the local training teams would have become functional. Those who do opt to stay could be retained. 10. There would also be major initiatives in multi-skilling, in skill upgradation in-services and pre-service programmes leading to the creation of many mid-level cadres. ASHAs could be given preference in admissions in ANM schools and ANMs could be given extra preference in admission to GNM/Nursing Schools. Adequate weightage may be 75

given to knowledge, skills and training already received by these ASHAs/ANMs over the years to reduce duration of course for them. Paramedicals in laboratory work, pharmacy, radiology, and even dressers and supervisors, could get multi-skilled to play the role of a multi-skilled paramedical who provides a comprehensive support to clinical services at the PHC level. Similarly, ANMs could be upgraded into staff nurses in places where ANMs are working, but staff nurses are not available. 11. Efforts of State Governments to start three year course of Rural Health Practitioners would be encouraged. All these measures for creation of mid- level cadre or multiskilled cadres would be a priority in the Twelfth Plan. 12. There is a need to re-introduce specialist public health nurses, and merge the now almost defunct LHV programme into this. A special national level faculty development programme for ANM and nursing schools and well equipped skill labs in all district training centres to refresh skills and on the job training support are all essential for improving the quality of nursing and midwifery services. 13. In the mid-level provider training programmes discussed above there are four important things to be considered: 1. The trainee must be from the areas where their services are required. The best proof that they would go to work in these areas, is that they are already working in these areas with commitments to stay on there. 2. The training prepares them and certifies them for service in the public system and not to enter into the general provider market, that too in the over-crowded provider situation of urban areas. 3, the training content is carefully oriented to the needs of the situation they would occupy, preferably in the state language- as this would help retention. 4. The training institution should be as near their residence and final work place and enable considerable practical postings in this area. If new cadres are created without attention to these important considerations, it could create numerous problems of its own. 14. One area of human resource development that would be addressed by building it into all training programmes is gender sensitivity in all service providers and in all facilities. The need for starting up of help desks and public grievance mechanisms and indeed the understanding of health rights must be part of the consciousness of every service provider- more so in the public health system which caters to the poorest and most marginalized sections of society. 15. One concern is that almost half the doctors and nurses in the public health system and almost all the skilled professionals added on in the eleventh five year plan period are on contractual basis. This has advantages in the short term and needs to be retained and their workforce issues and performance managed more professionally. But there are disadvantages related to both in house skill upgradation and retention of such staff especially after skill upgradation, and in the long run to both quality of care and system performance. Contractual appoint is therefore not to be seen as a substitute to developing sustainable health care capacities and the state level for which states 76

would need to invest in expansion of sanctioned posts in the facility level- in line with the IPHS recommendations. The approach paper indicates a desirable threshold of 2.5 health workers per 1000 population counting only midwives, nurses and doctors. There is also a desirable ratio of three nurses and midwives to one doctor. Even with full implementation of the IPHS recommendations and counting in the qualified private sector, most districts would have their skilled worker strength well below this norm and this understanding should inform states when planning for their human resources for health. 16. The Twelfth Plan should thus begin with states adopting a plan for human resources for health which commits to reaching the IPHS in human resource deployment and builds a road map to achieving this. The plan would also establish a human resource health management system for improved recruitment, retention and performance, rationalise pay allowance and incentive structures, and create career tracks for competence based professional advancement.( approach paper quote) 17. The ongoing programme of mainstreaming AYUSH would be continued. Both colocated facilities and the stand alone AYUSH facilities should continue to be strengthened. A clear road-map for mainstreaming of AYUSH should be developed and role of AYUSH doctors need to be defined and a policy on the same needs to be articulated for guidance. 18. The main direction of mainstreaming is to give service users a choice of both systems and make AYUSH services easier to access. Efforts would be directed towards better integration of AYUSH with Primary Health Care system for meeting public health goals. 19. Inclusion of information on AYUSH services and their utilisation in surveys should be introduced. Similarly, information on utilisation of AYUSH services in the facilities where AYUSH has been collocated under NRHM should be incorporated in the HMIS. 20. In the proposed budget for the Twelfth Five Year Plan, requirement of Rs. 2332 Cr has been projected for AYUSH doctors. Provision has also been made for engaging AYUSH paramedics and training of AYUSH manpower, which is a part of the overall Human Resource and Training budget and has not been quantified separately for AYUSH. 21. The representative of Deptt of AYUSH during discussions in the Working Group, and subsequently followed up through a written communication, pointed out that with the present system of release of funds under NRHM, the objective of mainstreaming of AYUSH as set out in the National Policy ISM&H, 2002, and as included as part of NRHM mandate, was not having the desired impact at the State level, since health is a State subject and States are free to set their own priorities from the funds received by them. The Deptt of AYUSH further pointed out that in the light of this position, the states when faced with shortage of resources to the extent sought by them, quite often 77

tend to restrict the outlay in the AYUSH sector. The Department of AYSUH, therefore, has proposed allocation of Rs. 10160 crore for earmarking out of NRHM fund for the man power requirement and training for AYUSH personnel for mainstreaming of AYUSH. 22. Earmarking of funds under NRHM for AYUSH activities, as suggested by Department of AYUSH is not possible since it runs against the basic tenet of NRHM. States decide what activities are to be taken up during the financial year. As proposed by Department of AYUSH as an alternative, the Steering Group may take a view to allocate the funds separately to Department of AYUSH. In that case it would become necessary to rework the strategy for mainstreaming of AYUSH under NRHM mandate. The projected requirement for NRHM will reduce by Rs. 5000 Cr (approx), which can then be allocated to Department of AYUSH for promotion of Indian Systems of Medicine in the country. 23. Family Medicine should be treated as a specialist discipline. This would help in better provision of primary health care at CHC level. 24. Availability of paramedics like Optometrists, physiotherapists, dental hygienists and Multi Purpose Workers will be improved by focussing on increasing and strengthening of paramedical and MPHW Schools.

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V.

Procurement and Logistics

1. Procurement and logistics should be built up similar to the TNMSC, where the emphasis is on ensuring uninterrupted drug supply at the facility level with the district warehouse as the hub, where the supply is responsive to the pattern of needs and forecasting of the needs is no longer necessary except for some items like vaccines which have limited availability in the open market. The procurement system allows huge cost savings and ensures very good quality and safety in drug purchase. This is a good example of the balance between centralisation and decentralization, with rate contracting done at the state level to gain economies of scale and ensure quality and safety of drugs done centrally where such and the district being the unit for which orders are placed and to which supplies are sent, where such supply is responsive to actual consumption patterns. Minor equipment (thermometer, hemoglobinometers, weighing machine, BP apparatus, colorimeters, Hb pipettes, wall mounted tapes, etc.) should also be a part of the essential drugs and supplies list and should be purchased, stocked and procured on similar lines to drugs. 2. A central procurement authority is being set up at the national level. This would ensure that all central procurement adheres to the highest standards of quality and transparency and that states are supported in terms of capacity building and regulation with regard to procurement for the public health sector. 3. Efficient procurement and logistics system needs to be supplemented by an essential drugs and supplies list, a state drug formulary that is based on this list, and standard treatment protocols all printed in adequate quantities and supplied to each facility with a fixed periodicity of not less than once a year. This has to be accompanied by advocacy and promotion of the concept of rational drug use and prescription audits to monitor improvements. Additional technical capacity has to be recruited or this process of advocacy and audit outsourced. Otherwise given all the other deadlines and commitments, and the existing mindsets, this task would get marginalized.

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VI.

Programme Management

1. To avoid duplication, and enable a holistic approach to health, convergence among all the existing National Health Programmes, including Urban Mission, HIV- AIDS control and of the State Directorates with existing NRHM set up would be focused on. 2. Set up for policy making as well as implementation will be strengthened at Central as well as State level for better planning, implementation and monitoring. 3. The State programme management unit and the district programme management units function as the implementing structures and secretariat of the state and district health societies. Better integration of State and District Health Program Management Units with State Health Department at various levels will be focussed on. An expert committee has been set up to look into the issue. The state and district programme management unit should not only have the contractual staff- but both regular programme officers and contractual management or public health consultants or contractual staff working together. 4. The NRHM has in place the annual common review missions and the joint review missions, the concurrent evaluation process led by the IIPS, and the number of studies and evaluations done by the international advisory panel, and various national institutions. The SRS, the NFHS and DLHS and now the annual health surveys also provide important health data. These would be encouraged and strengthened. 5. Mandate of NIHFW and SIHFW should be expanded to include health promotion. SIHFW could play a role in skill development, and provide technical assistance like an SHSRC and also provide leadership to community process like an ASHA or community process resource centre. A process of capacity development and apprenticeship in knowledge management for each of these structures using the best of national and international public health and management experience would also be necessary, since states may have insufficient internal capacity to grow and guide these three institutions. 6. Territorial responsibilities of Medical Officers and Programme Managers should be fixed and their performance monitored and appraised. An accountability framework needs to be built with clearly identified responsibilities for all officers at all levels. Involvement of communities should be strengthened to ensure that the accountability framework is implemented effectively. The principles of good governance are to be emphasized and practices such as display of expenditures on the district and state websites on a monthly basis could be mandated to ensure transparency in the 12th Plan. 7. Logical Framework Approach could be used to identify and quantify inputs, outputs, outcomes and means of verification. 80

8. The financial management process and financial monitoring in both state and district level will need further strengthening especially if the proposed form of district financing is undertaken.. 9. The health information management systems must support regular analysis of data and providing the same at decentralised level to help in decision making at State, district and sub-district levels. Information systems would need at a minimum to integrate service delivery information and death reporting (which is the current HMIS), with hospital information systems, disease surveillance systems, human resource management systems, finance management systems, drug inventory management systems, and information for private sector regulatory systems, e.g., PCPNDT implementation. Further there must be linkages to GIS application and to mobile transmissions. States differ in a major way in their health and management priorities and their readiness in terms of technical and human capacity to absorb technology. The health information architecture opted for should conform to common data standards with high standards of interoperability in an information grid, so that each user can draw down the information they need. The Centre would have a national web-portal- which could communicate with the state and district level systems and other national health information systems, from which it would take the information needed for its working. 10. There is an existing HMIS data system in place, and the problems of its data quality have been studied and noted. While not insurmountable, managing these problems requires patient understanding of the details clear implementation strategy. One urgent corrective measure could be a system of independent assessment of data quality by accredited agencies identified by the States, which samples and verifies recorded and reported data from each district and provides a feedback on data quality. Another is the dissemination of the analysis of key data elements like maternal mortality reports by district to community monitoring groups, Panchayat leaderships, VHSCs etc, with assistance from them to correct gaps in information. These inputs for identifying and correcting data quality gaps should be on a continuing basis. The most important step for making data quality better and more usable is to use the data on a regular basis for monitoring the implementation of various programmes and planning for activities at all levels. 11. The DLHS and AHS should be further strengthened with the use of more qualified researchers and quicker analysis and provision of results. It would also gather data on height & weight measurement, blood test for anaemia and sugar, blood pressure measurement and testing of iodine in the salt used by households would also be collected. It could be adapted to include certain state specific components. It could be built upon to add some more relevant elements related to service delivery for communicable and non communicable disease and for information on costs of care. These could be included especially both in the household and facility survey component. The direction of change would be to integrate the various undertaken by the Ministry of Health and Family Welfare over different periods, into one integrated 81

National Health Survey with a periodicity of three years. Meanwhile programme evaluation of specific strategies would be continued using appropriate methodologies to assess the contribution of each programme to the overall goals. 12. The National Urban Health Mission (NUHM) would be launched and kept as a separate entity in the 12th Plan to provide the necessary focus. The two missions could be merged in the 13th Plan. The NUHM should have the same National Mission Steering group and the same state health society and in most cases the same district health society as well- but with addition of concerned stakeholders for the urban component. 13. Medical colleges should be involved for improving the health status of the population. A defined area for jurisdiction should be defined for each of the colleges.

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VII.

Private Sector Regulation and Public Private Partnerships:

1. The private sector is a major contributor to curative health care services and would play an important supplementary role to the development and strengthening of public health services. PPPs could bring in additional professional skills or additional investment. However all PPPs must have a minimum standards of quality and cost of care monitoring and good contract management. Adherence to terms of contract and prompt payments for services should be strictly monitored. Priority for not for profit providers of essential services should be built in- for example charitable hospitals providing emergency obstetric care services where even the district hospitals are not doing so- so as to ensure cashless services and access to the poor. Preference would be given to private sector units who are willing to get totally contracted in- thus becoming a public sector equivalent with private management. PPPs made for the explicit purpose of strengthening public provision of services like outsourcing ancillary and auxiliary functions of the hospital if well managed can add efficiency and quality to public health services. District plans must indicate which services cannot be currently provided in the public sector but are available in the local private sector. Partnership with professional bodies such as FOGSI, IMA, IAP etc could be explored. 2. Containment of cost of care and promotion of ethical care requires urgent measures for regulation of the private sector in health care delivery. The implementation of the clinical establishments act or equivalent state acts in all the states is one of the priorities of the Twelfth five year plan period. PPPs would do better in an environment where the overall regulation of private sector is robust. 3. One major concern is in the introduction of new drugs and technologies in terms of containing health care costs, in terms of provision of quality care and in terms of avoiding iatrogenic health hazards. This will also need to be addressed. 4. The approach Paper to the 12th Plan says that the 12th Plan will explore the possibilities of introducing a government funded Health Insurance Plan, which will focus on both preventive and curative aspects. The working group is of the view that it would be prudent to continue strengthening the public health infrastructure, keeping quality in mind and recommends that preventive health care and also primary health care should be delivered through public health infrastructure and should be kept outside the ambit of health insurance and health Insurance for secondary and tertiary care should be introduced with caution.

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VIII. Community Processes and action on social determinants of health 1. For the ASHA programme to impact on maternal and child survival the ASHA must be taught the skills for counselling pregnant women and families with children on nutrition and improved health care practices as well as community level care for the newborn and sick child. Just ensuring increased attendance at immunization and promotion of institutional delivery exclusive of other strategies, cannot make a dent on child survival, nor be able to reach out to the most marginalized. Modules 6 and 7 for the ASHA programme for home based new born care must be scaled up rapidly and effectively. The current emphasis on community mobilisation must be strengthened. ASHAs can also be used in prevention, behaviour change and screening of noncommunicable diseases. All this in turn would mean strengthening the support structures and creating high quality training teams at state and district levels. Additionally, training cum demonstration sites at the State level would be developed. 2. Sustaining the ASHA programme in the next phase of NRHM requires planning for an annual turnover and fresh recruitment of the ASHA from between 5% to 10%. Increasing the avenues for career progression of those ASHA who have such an aspiration, will enable expanding the human resource pool at the local level by giving them preference in education in local training institutions. Senior and mid level managers would be appraised of the role and contribution of ASHAs, which is of utmost importance in implementation of the programme. 3. The voluntary nature of the ASHA programme needs to be preserved. Her work should be such that it is done without impinging on her main livelihood and adequate monetary compensation for the time she spends on these tasks- through performance based payments. 4. Managing the turn over, retraining ASHAs and facilitators and enabling the implementation of newer interventions by ASHAs requires established training and development centers at the state level. 5. The Village Health, Sanitation and Nutrition Committee (VHSNC) remains the key mechanism to address the action on social determinants including age at marriage, literacy, water and sanitation, nutrition, substance abuse etc. This aspect was always part of the design, but there was no management capacity to handle this. There is a need to train and support VHSNCs to play a role in addressing social determinants of health in a meaningful way. This VHSNC programme with an adequate support structure is also needed to support the ASHA to play her mobilisational and health education roles. The VHSNC would need recurrent rounds of training- and just one round would not suffice. It would also require linkages with block level and district level committees. Incentives in the form of awards can be introduced to VHSNCs for specific achievements. 6. The approach paper for the 12th Plan suggests that the Anganwadi Centre and the Sub Centre both could be brought under the oversight of Panchayat level Health Nutrition 84

& Sanitation Committee. However, the Health Sanitation & Nutrition Committees under NRHM are set up at the level of village and not the Gram Panchayat. While the number of Gram Panchayats is approximately 2.45 lakhs in the country, the number of Village Health Sanitation & Nutrition Committees (VHSNC) is approximately 5 lakhs at the moment. Hence, the appropriate course would be to put the health Sub Centre, Anganwadi Centre and also the Village Health, Sanitation & Nutrition Committees under the oversight of the Gram Panchayat. 7. In the Eleventh Plan NRHM flagged the issue of action on social determinants. In the Twelfth Plan, the VHSNCs supported by civil society organisations could take the lead in action on social determinants of health, especially on equity of access. Block level health committees would provide coordination to this VHSNC action and these committees would report to the district health societies. An important aspect of this approach is that the VHSNCs action gets focussed on identifying and acting on inequities within panchayats and between panchayats. The village health plan should express health priorities as perceived by people, it should identify and address inequities in access, and it should address social determinants. On determinants like roads and township planning, it should ensure convergence with rural development and urban development plans so that health concerns are adequately addressed in their plans. 8. NGO participation would be enhanced. The provision that upto 5% of the resources of NRHM can be spent through NGO assisted interventions should be retained. The support from these NGOs should be broad based in the twelfth five year plan. A substantial proportion would be for capacity building and support for community processes (the VHSC, the ASHA programme, public participation in RKS, public participation in district planning and in community monitoring). The element of community monitoring could be further expanded in areas such as improving data quality in HMIS and MCTS, measuring availability of drugs, monitoring support to JSSK, support to users in RSBY and other cashless PPP arrangements. NGOs must be supported to mobilise additional technical capacity from a national canvas, where intra-district management capacity and training capacity is overwhelmed by requirements in high focus districts. A National Resource Centre and Regional Resource Centres would be set up to coordinate and support country wide NGO assisted interventions, provide support, develop capacity and monitor performance of NGOs. While the engagement with NGOs will be operationalised in a decentralised way, the Centre may offer direct grants to a few NGOs for very innovative projects. 9. NGOs must also be used for supplementing capacities in some key areas where they have interest and a high priority, but where medical professionals are unable to give continued attention to it. Examples include the monitoring of PCPNDT implementation, assessing environmental health impact, monitoring of food and drug adulteration (consumer education and assistance to inspection roles), promotion of rational drug use- amongst the population and amongst professionals.

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10. The Rogi Kalyan Samitis should be strengthened by having better rules in place for public participation and transparency and by orientation to ensure quality of care and improved access to care. It should act as effective grievance redressal mechanism at the facility level. The engagement of PRIs should be very active in RKS. The exact position that the PRI leadership has in the RKS will vary from state to state depending on the context, but there should be an institutionalised process of capacity building so as to ensure their increasing role in the RKS. Regularity in their functioning would be ensured by improved supervision and support. In fact, RKS should take leadership role in the management of the facility to give it a patient friendly orientation. 11. Community monitoring which emerged as a viable strategy in the Eleventh plan needs to be built upon in Twelfth plan and scaled up. VHSNCs and service user groups should have the capacity to undertake monitoring. This is one area where NGOs can play an important role in capacity building and support as for the line department staff, building capacity at the local level to monitor itself would understandably a low priority activity. However this must be closely linked to village health planning and facilitation of service delivery- and efforts must be made to bring community and service provider closer together and develop mutual trust and support. 12. The platform of Village Health and Nutrition Day would be more effectively utilised to provide MCH services. Increased participation of the PRI members and community is envisaged. Utilisation of this platform for other services like measurement of anaemia, etc, will also be explored. 13. Effective district level grievance redressal systems for the public to address their grievances and have it redressed with timely feedback on action taken- would be an important step forward. The grievances not addressed by RKS and VHSNC may be escalated to district level grievance redressal system. These systems and mechanisms would need adequate publicity and public participation to be effective across a wide form of contexts.

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IX.

RCH Services

1. Approach to achieving assured delivery of RCH services has already been discussed in detail. The JSY programme would continue with necessary fine tuning based on implementation experience. Timely payments to beneficiaries under the scheme should be ensured and states should put in place effective monitoring mechanisms for the same. The Janani Shishu Suraksha Karyakaram (JSSK) should be strengthened and universalised in the 12th Plan which would guarantee free services with no out of pocket expenditures for all pregnant women coming for delivery in public institutions and sick newborn This would include referral transport and drop back home. Complications in the ante-natal and post natal period should also be covered. Maternal death reviews should be ensured by the States and the information should be analyzed for taking appropriate corrective actions to reduce maternal mortality. The emphasis on promoting institutional delivery would continue, but in areas where home deliveries cannot be avoided due to difficult terrain or cultural reasons, facility of ANM assisted home deliveries would also be developed. By popularising minimum standards of care and certification of its achievement and measurement of the gaps, by a better HR policy, the quality of care issues associated with institutional delivery as presently recognised would be addressed. Accreditation of private facilities for provision of RCH services could be encouraged and the accreditation should be carried out by a national authority to ensure quality. A framework for the same which is being developed by the Planning Commission could be used. 2. For achieving accelerated reduction in mortality, both pregnant women and newborn shall be provided a comprehensive and integrated continuum of care package. The package shall provide care during the crucial peri-natal period (after 28 weeks) for preparing he prospective mother, ensuring safe delivery (both facilities and home deliveries), reducing still birth, strengthening facility level care and post-natal home visits for all mothers and newborns till 6 weeks after delivery. To ensure quality and assist functionaries, it proposes using separate checklists for ANC, birth planning, delivery, immediate post delivery period, discharge criteria and post natal home visits. 3. The high focus district approach is another major feature of the NRHM. The exact number of districts and criteria for being on the list should be reassessed with an RCH focus. The existing list of high focus districts was based on many considerations LWE affected, high SC /ST population, poor socio economic indicators and poor RCH performance indicators- and though mostly these districts overlapped, there were some LWE and SC districts included in the list which have good RCH performance while some other districts with poor RCH performance have been left out. The annual health survey results could be the new basis for identification of high focus districts.

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4. In a high focus district, there would be enhanced thrust on capacity building as indicated earlier and on technical assistance and monitoring. There would also be urgency and more investment available for facility development. Death reporting would also be closely monitored with community support in these districts and underreporting investigated and acted upon. Birth Waiting Homes in the health institutions in remote and tribal areas with poor road connectivity should be constructed, where such an intervention is needed. 5. Availability of safe and quality abortion services would be included as part of the standards for provision of RCH services. 6. Given the major load in referral medical college hospitals and large district hospitals on account of JSY, there would be an effort to strengthen the district hospitals and increase the number of beds for providing quality antenatal, intra-natal, postnatal and child care to cope with increasing case loads of pregnant women, newborns and children, and with a focus on post partum family planning services. Separate Maternal and Child Wings may also be constructed wherever they are required to cater to the higher case load. 7. Other priorities would include a scheme for the prevention and control of moderate and severe anaemia among children, adolescents and pregnant and lactating mothers. Universal screening of pregnant women for anaemia may help in detection and reduction of moderate anaemia among women. The data should be recorded in the moher and child protection card. Weighing of preschool children by Aanganwari centres should be undertaken for screening them for undernutrition. There would also be a new focus on prevention and control of endemic diseases in children; notably sickle cell anaemia, thalassemia, haemophilia, rheumatic heart disease, congenital heart diseases and congenital syphilis. Emerging issue of childhood obesity also need to be attended to. 8. There would be improvement in the quality of ante-natal care with better detection and treatment of hypertension and anaemia. This would require technical improvements like supply of better BP apparatus, better weighing machines, measuring tapes and improved methods of anaemia measurement made available at every VHND site. It would also require better monitoring and supervision. Moderate and severe anaemia would be actively detected and treated and the reduction of moderate and severe anaemia in pregnant women would be an important measured objective. There would be a major focus on scaling up of HIV Testing & Counselling during Ante-Natal Care - up to 24X7 PHC level in convergence with NACP-4 as well as free treatment for children with HIV infection. Testing for syphilis should also be expanded based on epidemiological grounds. Prevention & control of Malaria in Pregnant Women in identified endemic areas would also be a priority. 9. The elements of prevention, community outreach and extension education would be emphasized in the training of ASHAs, Anganwadi Workers, ANMs and block 88

extension educators. They would be sensitised to the special needs of disadvantaged sections. Panchayat functionaries, members of village health and sanitation committees and Rogi Kalian Samitis would be oriented to the importance of preventive and promotive health. Active cooperation and synergy between the ASHAs, Anganwadi workers and ANMs would be actively promoted to facilitate changes in health care practices and improvements in utilisation of health services. This synergised action on health promotion by front line workers would be promoted by innovative use of folk and electronic media, mobile telephony and multi-media tools- which would create an enabling environment for changes that lead to healthy living. 10. Other major features of the Twelfth five year plan would be making the school health programmes universal, strengthening a national framework on adolescent health, currently the weak pillar of RCH and expansion and strengthening of cold chain system through identification of more cold chain points near the community. 11. There would be a major thrust on improving access to facility based newborn care. Provision of services for sick newborn through establishment of SNCUs in every district of the country would be a target. Establishing newborn care corners at every delivery point and some level of stabilisation care at all 24*7 PHCs which provide basic emergency obstetric care would be a priority. Such facility based newborn care would be complemented by a nationwide effort in improving home based post-natal and newborn care through the ASHA programme. 12. One major area of intervention would be the development of Joint field operational plans in convergence with ICDS for result oriented management of malnutrition. This would include the establishment of NRCs for management of severe acute malnutrition and their subsequent follow up in the community. Such follow up would be IT enabled for better monitoring. Interoperability between the IT enabled monitoring systems of the ICDS and the health department would play an important role in bringing the two departments together the link between nutrition surveillance and disease surveillance/prevention and response to illnesses- for the elimination of malnutrition. Breastfeeding support in the first year of life, complementary feeding and prompt management of illness would be key interventions to prevent malnutrition. Food supplementation programmes would be needed for elimination of malnutrition, and whether in schools, or in below 5 age group, it should be implemented in a manner where it leads to measurable reductions on malnutrition. All sections which are nutritionally stressed or when they are nutritionally stressed should have access to such supplementation programmes- but such access is most important for adolescent girls and pregnant women as malnutrition in these sections. 13. Addressing the challenge of skewed sex ratio would be through tighter implementation of the PCPNDT Act and through active support to reaching the girl child for care in illness. For implementation of PCPNDT act, better monitoring and sensitization of the medical community, greater role for civil society action in both 89

addressing son preference and in monitoring sex determination practices are key steps that are envisaged. For addressing neglect of the girl child in illness care, observing sex ratios in hospital admissions for illness in children, and proactive support to girl children through the ASHA and Anganwadi system should be undertaken. 14. The Tenth Plan had clearly articulated that 20% of the current population growth is due to unmet need for contraception. A further 20% is due to high wanted fertility due to high under 5 mortality. Thus reduction in IMR will contribute to lower wanted fertility. Therefore, in the Twelfth Plan meeting the unmet needs of contraception and reduction in the under 5 mortality will be prioritised. 15. For addressing population stabilization we need to take a differential approach between the seven high fertility states- and the rest. Whereas in the rest, the focus is on promotion of spacing measures, without reducing the levels of achievement required for sterilization, in the high fertility states, we need to think out of the box. Intensification of skill development strategy of government providers and thrust in recruiting and deploying private providers will be focused upon for both spacing and limiting methods. Post partum contraception would also be promoted. In all states there would be a planned effort to promote spacing methods, especially the IUD for spacing, and better family planning counseling, and focus on motivation for male sterilizations. Efforts will be made to introduce injectable contraceptives. Social marketing of contraceptives through ASHAs will be actively promoted and ASHAs will be paid incentives/commission for their efforts. 16. Efforts for addressing infertility by providing assisted reproductive technology at identified public facilities such as medical colleges would be introduced.

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X.

National Urban Health Mission

1. The health care needs of the urban poor and vulnerable populations have long been neglected, with the result that health indicators in some urban areas have been found to be poorer than their rural counterparts. Recognizing the seriousness of the problem, urban health will be taken up as a thrust area for the 12th Five Year Plan. National Urban Health Mission (NUHM) will be launched as a separate mission for urban areas with focus on slums and other urban poor. This will be done by investing in health professionals, appropriate technology, creating new & upgradation of existing infrastructure and strengthening the extant health care service delivery system. 2. NUHM would ensure adequate resources for addressing the health problems in urban areas; need based city specific urban health care system to meet the diverse health needs of the urban population with focus on urban poor and other vulnerable sections; institutional mechanism and management systems to meet the health-related challenges of a rapidly growing urban population; partnership with community for a more proactive involvement in planning, implementation, and monitoring of health activities; and partnerships with NGOs, charitable hospitals, and other stakeholders. NUHM would cover all cities/Towns with a population of more than 50000. Thus, 779 cities/towns (including 7 Mega cities) Towns with a population below 50000 will be covered under NRHM. Principally NUHM will cover the entire urban areas irrespective of dwelling status (including general population/listed slum/unlisted slum). But outreach services will be targeted for slum/slum like areas and other vulnerable populations including street vendors, railway and bus station coolies, homeless people, and street children, construction site workers, who may be in slums or on sites. Intersectoral coordination mechanism and convergence will be planned between the Jawaharlal Nehru National Urban Renewal Mission (JNNURM), Rajiv Awas Yojana (RAY) and the NUHM.

3.

4. An effective monitoring and evaluation framework - regular monitoring at District/ City and at State level by the respective PMUs, Societies and Mission and feedback. A web based M&E framework effectively integrated and leveraging MIS of other National programmes like IDSP will be set-up and community monitoring will be done through Rogi Kalyan Samiti/ Mahila Arogya Samiti. 5. In the 12th Plan period NUHM and NRHM will be separate programmes which may be merged in the 13th Plan period or later. The budget allocation for NUHM in the 12th Plan period is envisaged to be approximately Rs 30,000 Crores.

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XI. 1.

Other areas:

Disease control programmes: There is a separate working group on disease control programmes. In order to align State requirements and priorities, flexibility needs to be built into the Disease Control Programme framework. The reporting and performance evaluation system for the officers of various DCPs should have a clearly defined role for the Mission Director NRHM of the State to facilitate better integration and coordination. The policy and guidelines in different areas like HR, Infrastructure etc. of various DCPs should be synchronized. There is a separate working group on non communicable diseases which will provide its recommendations. On drugs and technologies a separate group would make its recommendations. This working group has flagged the following areas of concerns: better access to essential medicines and technologies through the public health system, promotion of rational use of drugs and diagnostics, cost controls and its relevance in both public and private sector and the need for a technology assessment institution on the lines of NICENational Institute of Clinical Excellence, UK. Research and development is also a priority. There is a need for policies and investment that identify gaps and opportunities for innovation and build a favorable environment for innovation in the area of pharmaceuticals, medical devices and non drug technologies, health information and communication technologies and health systems and programmes. There is a need for systems that would encourage and absorb innovations and evaluate and scale up successful innovations. An Operation Research Group will be set up under the aegis of NRHM drawing experts from public health institutions, medical colleges, Ministry of Health and Family Welfare and other Centres of Excellence. Experts in the group will be drawn from the field of Epidemiology, Bio-Statistics, Reproductive and Child Health and other relevant public health disciplines. The group will facilitate building up a repository of comprehensive data and commission its analysis to academic and research institutes. An exercise of mapping such organizations with specific expertise would be undertaken. Funds will be earmarked for supporting the Operation Research Group and for carrying out studies, reviews, evaluations etc. The group will be housed in NHSRC. The Planning Commission may ask all central ministries to set up the Population Stabilization Incentive Fund which would be utilized to incentivize those States/UTs that have already achieved a replacement TFR of 2.1 or less. This fund will also be utilized to incentivize States with high TFR which are taking positive steps towards controlling population growth. This additional allocation would be a kind of untied fund available with the State governments, with the rider that with this money, works can be taken up in the same sector. This will incentivize the states which have 92

2.

3.

4.

5.

6.

checked their population growth or are taking effective steps to continue to maintain this. This will also encourage other states with high rate of population growth to take necessary steps urgently.

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ProposedBudgetforthe12thFiveYearPlan
Sr.No 1 1.1 1.2 1.3

Activity
InfrastructureDevelopment NewConstruction Renovation DistrictHospitals

Amount(RsinCr)
31668 1288 16000 2100 70747 7075 2589 1700 5266 1936 260 447 6244 10996 10000 2862 15965 13628 756 3712 1012 1530 5165 100 1600 2450 20331 4790 200

ChildHealth(ConstructionofNBCC,SNCU,NBSU 1.4 andNRCs) 2 HumanResources 2.1 2.2 2.3 2.4 3 3.1 3.2 3.3 Salaries(bothforTreasuryrouteandcontractual engagement) Incentivesforhardareas TrainingProgrammes Strengtheningoftraininginstitutions FacilityMaintenanceandoverheads UntiedGrantstofacilities AnnualMaintenanceGrants Qualityassurance

3.4 InfectionManagementandEnvironmentProtection 3.5 4 4.1 4.2 4.3 4.4 4.5 MaintenancetoUrbanFamilyWelfareCentres/ HealthPostsandFamilyWelfareBureaus MaternalandChildHealth MaternalHealthPackage JSY ChildHealthPackage Immunisation Referraltransportation

4.6 AdolescentSexualandReproductiveHealth 4.7 MenstrualhygienePromotion 4.8 4.9 5 5.1 5.2 5.3 6 7 7.1 7.2 7.3 SchoolHealthProgramme PNDTImplementation FamilyPlanning FamilyPlanningIncentives Contraceptives(otherthansterilisation) IncentivetoStatesforPopulationstabilisation OutreachservicesthroughMMU CommunityProcesses ASHA VHSNC CommunityMonitoring

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Sr.No 8 9 10 10.1 10.2 11 11.1 11.2 11.3 11.4 11.5 12 13

Activity
NGO IEC/BCC ProcurementandLogistics Drugsandsupplies EstablishingcorporationsandWarehouses(TNMSC type) MonitoringandEvaluation ConcurrentMonitoringandEvaluation ManagementInformationSystems(MIS) ThirdPartyEvaluation PeroiodicEvaluationsurveysDLHS/AHS/NHS/CES Researchstudyandreports NHSRC,SHSRC,DistrictPlanning TrainingInstitutions

Amount(RsinCr)
8631 4450 5511 600 2120 750 1500 550 2245 850 182 501 142 14386 2877 17276 30000 334987

NationalInstituteofHealthandFamilyWelfare 13.1 (NIHFW),NewDelhi 13.2 13.3 14 14.1 14.2 15 16 InternatinnalInstituteofPopulationSciences, Mumbai PopulationResearchCentres Managementcost ManpowerandoperationalCost ITinitiatives(MCTS,HMIS,others) DiseaseControlProgrammes UrbanHealthMission GRANDTOTAL

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Basis for budgeting provisions

Major assumptions: Projections based on Census 2011 population(121 Crores) Rural population assumed as 70% , i.e. 84.71 Crores Rate of construction works as per CPWD schedule Existing norms for Programme Management, M&E, IEC/ BCC and PPP/ NGOs Norms for untied fund, AMG and RKS enhanced by 50% Incentive fund for population stabilization for States who have achieved TFR targets. One Regular MPW at each Sub-Center, contractual 2nd ANM to be provided only in up to 10% sub-centers conducting deliveries. 1. Health Infrastructure: 1.1 New constructions: Gaps in the health infrastructure are analyzed as per Census 2011 population. The population norms for setting up health facilities have remained unchanged. The norms for construction cost are enhanced by 100% as CPWD rates have gone up by 73% since 2005. One sub-centre is proposed to be set-up at each gram Panchayat. Thus, there is a total requirement of 2,45,655 sub-centres. Since there are only 56,896 sub-centres in government buildings currently, 1,55,478 new sub-centres need to be constructed. As this is difficult to achieve in 5 years period, it is proposed that 20000 new sub-centres could be constructed per year on an average at the rate of Rs. 18 lakh per sub-centre. Funds required for construction of sub-centres is Rs. 18000 Cr. At the current norms of population for PHCs and CHCs, there is a requirement of 11,337 new PHCs and 2933 new CHCs. Cost of new PHC and new CHC construction is estimated to be Rs. 65 lakh and Rs. 210 lakh respectively. Funds required for construction of PHCs and CHCs is Rs. 7369 Cr and Rs. 6159 Cr respectively. 1320 birth waiting homes are proposed to be constructed in remote and inaccessible blocks in 264 high focus districts to encourage institutional delivery in remote areas at an approximate rate of Rs. 10 lakh per birth waiting home. Funds required for construction of birth waiting homes is Rs. 140 Cr. 1.2 Renovations: 1/6th of all the existing facilities in the government buildings are proposed to be renovated in the plan period. Funds required are Rs. 1288 Cr. 1.3 Strengthening of District Hospitals: Rs 16000 Crores for Strengthening of District Hospitals in 640 districts @ Rs 25 Cr per district is proposed inclusive of Rs. 5035 Cr for maternity wings in DH.

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2. Human Resources in Health: 2.1 Salaries of Permanent and the contractual staff HR requirements determined as per Indian Public Health Standards 2010. Every Sub Centre (SC) is to have one ANM and one Male Multi Purpose Worker (MPW) supported by Central Government. The present norm of providing one LHV for 6 SCs is maintained. The salaries of ANM/ LHV will continue to be borne by the GoI through the Treasury Route. Salary of MPWs will also flow through the same route. The training capacities of the States have been considered while calculating the number of MPWs that can be employed. Training capacities are set to be doubled every year. Thus, by the end of the 12th Five Year Plan, 2.09 lakh MPWs are proposed to be employed. It is assumed that 20% of the posts will be vacant at any given point of time. Appointment of contractual personnel will be supported to bridge this gap. 2.2 Incentives Incentives for hard to reach areas is calculated at the rate of 10% of total salaries. 2.3 Training: Training under RCH, Training of ASHAs & PRI members, Training of AYUSH doctors, Training for M&E and Training under Immunization are supported here. A 10% increase in the budget of training per year is calculated. Training of ASHA is included in the ASHA package. 2.4 Grants for Training institutions: Grants to ANM training centers (ANMTC), LHV training centers (LHVTC), MPW training centers (MPWTC) and Health and Family welfare Training Centers (HFWTC) will be supported with a 40% increase in grants over the current level for the first 2 years followed by 10% increase in every year from the third year of plan. Additionally Rs. 50 lakhs per year to SIHFW, Rs. 5 lakh per year to HFWTC, LHVTC, ANMTC and MPWTC, and Rs. 2.5 Cr for setting up training institutes for cold chain mechanics as maintenance grants is proposed. 3. Facility Maintenance: 3.1 Untied grants to the facilities: The norms of annual Rogi Kalyan Samitis and annual Untied grants have been revised as follows: Rogi Kalyan Samiti Grants (Rs) Untied Funds (Rs) Old norms New Norms Old Norms New Norms Sub-Centers 10000 15000 PHCs 100000 150000 25000 37500 CHCs 100000 150000 50000 75000 District 500000 750000 Hospitals

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3.2 Annual Maintenance Grants: The norms for Annual Maintenance Grants has been revised as follows: Facility SC PHC CHC Old norms 10000 50000 100000 New Norms 15000 75000 150000

3.3 Quality Assurance: Accreditation and external certification: Cost of accreditation is approximately Rs. 10 lakh per district hospital as per NHSRC norms. So total cost for 604 hospitals will be Rs 60.4 crores ISO Certification for PHCs/ CHCs A lump sum amount of Rs. 200 Crores for assistance to States for certification of designated centres. 3.4 IMEP: Biomedical waste Management in higher facilities is based on unit costs of Tamil Nadu. Funds required for the same is Rs. 375 Cr. Construction of sharp pits and burial pits is based on WHO standards and estimated for Rs. 72 Cr. 3.5 Maintenance of Urban Family welfare Centers/ Health Posts/ Family welfare Bureaus: Annual increase of 10% in budget over current norms is assumed while calculating grants for State and District Family Welfare Bureaus, Urban Family Welfare Centers and urban Family welfare Posts. Total fund requirement for maintenance of these institutions is Rs. 6244 Cr.

4. RCH Programme: 4.1 Maternal Health Package Sr. No 1. 2. 3. 4. 6. Component Free Drugs and Consumables with supplementation Free Diet Free Blood Free Diagnostics Iron Sucrose Intervention Total Rs. In Crore 5152 3450 431 1917 46.22 10996

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4.2 Janani Suraksha Yojana: The demand has been projected on the response received to JSY in the Eleventh Five Year Plan. Expenditure in 2010-11 on JSY was Rs. 1609 Cr. Based on these, Rs. 10000 Cr. is proposed for meeting the demand of JSY in the Twelfth Five Year Plan. 4.3 Child Health Package: Rs. 2862 Cr for control of specific diseases in children. 4.4 Immunisation: S. No 1. 2. 3. 4. 5. 6. 7. 8 9 Component Procurement of Routine vaccines Procurement of new vaccines (Pentavalent, MMR, IPV, Rota, Pneumococcal) Procurement of AD syringes Expansion of Cold Chain points Modernization of Alternate Vaccine Delivery expenditure on mobile network Establishment of regional mobile workshops Mobility to district cold chain mechanics & PHCs Procurement of OPV Operational Cost Total 4.5 Referral Transport and Emergency Services: A. First Referral (From Home to Health institution) through Emergency Response Services with one vehicle per 1 lakh population (norm as per existing services in Gujarat, Karnataka, Uttarakhand etc) One ambulance would be placed per one lakh population. Replacements to be provided by the State/UT governments. Out of the total requirement (7350) of ambulances, it is proposed to provide 10 % Advanced Life Support (ALS) ambulances and 90% Basic Life Support (BLS) ambulances. Thus, calculated at a unit cost of Rs. 15 lakh for Advanced Life Support and Rs. 13 lakh for Basic Life Support and provision of 40% of operational cost on an average; total funds required for Emergency Response services is Rs. 5038 Cr. B. Second Referral (From Health Facility to Higher Health Facility) through referral vehicles/ ambulances at selected PHCs. 15000 PHCs, and all CHCs, SDHs, Taluk Hospitals and District Hospitals will be provided with operational cost. and Rs. In Crore 750 6500 403 35 1184 18 65 3870 3140 15965

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C. Drop back (From Health Facility to Home) in case of institutional deliveries at public health facilities and for sick neonates. Total requirement of funds is Rs. 1875 Cr. 6. Mobile Medical Units: At least one Mobile Medical Unit is proposed to be supported per district. For the districts with large population one MMU per 10 lakh population will be admissible. For tribal/ desert/ hilly areas more than this may be considered on a case to case basis. No. of Districts with MM Units in 2009-10 is 343, which will be replaced. MMUs provided in 2010-11 and 2011-12 not to be replaced. Overall nearly 1500 MMUs might be required. Operational cost is estimated for all 1500 districts. The norms of providing new mobile medical units and its operational cost are revised. The proposed amount is based on a revised norm of Rs. 10 lakh for providing a mobile van with staff and Rs. 25 lakh for providing a Mobile Unit with diagnostic facilities. Similarly, norm for operational cost is revised to RS. 25 lakh per unit except in States of the NE region, Jammu and Kashmir and Himachal Pradesh where an operational cost of Rs. 30 lakh per Unit is estimated keeping in view the difficult terrain. 7. Community Processes: 7.1 ASHA: The current norm of one ASHA per 1000 rural population will continue. However for hilly and tribal areas, norms will be relaxed to have one ASHA per 600 population. Activities of ASHAs will be expanded to enable them to earn incentives of Rs. 2500 per month on an average. The ASHA package excluding the incentives is maintained at the current Rs. 10000 and includes all cost like training, drugs, etc., borne by the States per ASHA. 7.2 Village Health, Sanitation and Nutrition Committee; Revised norm of Rs. 15000 per VHSNC per year is applied to be set-up at each revenue village. 7.3 Community Monitoring: Up-scaling of the community monitoring initiative piloted in 9 States to the entire country to ensure greater community participation and social accountability @ Rs. 20 lakh per district per year. 8. NGO: Requirements are calculated as per the norm of 5 % of total budget. It is budgeted in the budget plan for 3%. The remaining 2% is suggested to be accommodated from budget of existing activities. 9. IEC/BCC: Present norm of Rs. 10 per capita is maintained. One third of which is to be utilized at National, State and District levels each.

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10. Procurement and logistics: 10.1 Drugs and supplies: 15% annual increase in allocation is proposed. Thus, total requirement for the 5 years is Rs. 5511 Cr. 10.2 Drug Warehouses and Cooperations: Rs 500 Cores for constructing new drug warehouses and renovating the existing ones A lump sum amount of Rs. 100 Crores is proposed to provide support to the States to set up corporations to streamline procurement of drugs and equipments at the State level. 11. Monitoring and Evaluation: 11.1 Concurrent Monitoring and Evaluation: It is proposed to allocate funds for Monitoring and evaluation up to Rs. 5 per capita; 25% to be used at the national level, 25% at the State level and rest at district level and below. 11.5 Research Studies and Preparation of State and District Annual Health Reports: Existing norm of Rs. 5 per capita for research is maintained. Additionally, Rs. 50000 per District per year and Rs. 2 lakh per State per year is proposed to be provided for preparation of State and District Annual Health Reports. 12. NHSRC, SHSRC, Decentralized Planning: Rs. 17 Cr is the estimated budget for NHSRC per annum. Rs. 1 Cr per year per State is proposed for SHSRC. Rs. 10 lakh per State and Rs. 20 lakh per District per year is proposed for effective decentralized planning. 14. Management Cost: Management cost for Human Resources and Operational Cost is calculated at 5% of the total outlay for NRHM excluding the Vector Borne Diseases. 1% of the total outlay of NRHM is proposed to be used for development of IT initiatives like HMIS, MCTS, etc.

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Annexure 1 - List of Publications of relevance to working group on NRHM

(NB- this is not a comprehensive list- this is only to initiate sharing of resources for the working group on NRHM)

Ministry of Health Family Welfares documents

1- Rural Health Statistics 2010( under printing) ,2009 (available at www.mohfw.nic.in ) 2- First Common Review Mission Report 2007, Second 2008, Report 2009, Fourth 2010( available at NRHM website: www.mohfw.nic.in/NRHM.htm) 3- Update on ASHA program, June 2010, January 2010: (available at NHSRC website: www.nhsrcindia.org) 4- Concurrent Assessment of JANANI SURAKSHA YOJANA (JSY) SCHEME IN SELECTED, STATES OF INDIA, 2008, (available at NRHM website: http://mohfw.nic.in/NRHM.htm) 5- Five years of NRHM, Meeting the needs of the people in partnership with the states 2005-2010. ( available at NRHM website: www.mohfw.nic.in/NRHM.htm) 6- Annual Report 2010-2011( available at MOHFW website- www.mohfw.nic.in) 7- Concurrent Evaluation of National Rural Health Mission 2009(available at NRHM website) 8- Family Welfare Statistics 2009, 9- State wise Progress as on 31.12.2010, http://mohfw.nic.in/NRHM.htm 10- Mid-term Appraisal of Eleventh Five Years Plan, Planning Commission of India( Planning commission website)

National Sample Surveys:

1- Sample Registration Survey Reports- released annually. Latest July 2011. has details on IMR, U5 MR, MMR , birth rate, death rates and still birth rates and institutional delivery rates. 2- India Report, DLHS-3(2007-2008) - International Institute of Population Sciences: Available at IIPS website. 3- State reports,DLHS3(2007-2008)- ibid. available at IIPS website 4- Compendium India, State & UTs of DLHS-3 (2007-2008) ibid. available at IIPS website 102

5- India Report NFHS-3(2005-06)6- State Reports, NFHS-3(2005-2006) 7- Coverage Evaluation Survey, 2005, UNICEF 8- Coverage Evaluation Survey, 2009, UNICEF

NHSRCs Studies and Evaluations(All documents available at NHSRC website- http://nhsrcindia.org/ )

1- An Evaluation of the ASHA programme in eight states, ASHA: which way forward? National Health Systems Resource Centre, 2010 2- Programme evaluation of the JSY, National Health Systems Resource Centre ,2010 3- Status and Role of AYUSH and Local Health Traditions, under National Rural Health Mission, National Health Systems Resource Centre, 2010 4- EMRI an evaluation, National Health Systems Resource Centre, April 2009, 5- HMRI evaluation, National Health Systems Resource Centre, December 2010 6- HR studies Nursing in five states, medical officers and specialists in six states, retention case studies from over 5 states, National Health Systems Resource Centre, September 2009 7- Common Review Mission Reports- 2007. 2008, 2009, 2010

Other Publications on NRHM

1 Bajpai Nirupam , Sachs D. Jeffrey and Dholakia H. Ravindra , Improving access, service delivery and efficiency of the public health system in rural India Mid-term evaluation of the National Rural Health Mission, CGSD Working Paper No. 37 October 2009 2 Primary evaluation of service delivery under the National Rural Health Mission (NRHM): Findings from a study in Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan http://www.accountabilityindia.in/article/document-library/769-primaryevaluation-service-delivery-under-national-rural-health-mission

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3 Mukherjee Srabanti , A Study on Effectiveness of NRHM in Terms of Reach and Social Marketing Initiatives in Rural India, European Journal of Scientific Research ISSN 1450-216X Vol.42 No.4 (2010), pp.587-603 http://www.eurojournals.com/ejsr.htm 4 Arun Kumar Sharma; National Rural Health Mission: Time to Take Stock, Indian J Community Med. 2009 July; 34(3): 175182. doi: 10.4103/0970-0218.55268 5 Singh MK, & Al, Factors Influencing Utilization of ASHA Services under NRHM in Relation to Maternal Health in Rural Lucknow, Indian J Community Med. 2010 Jul;35(3):414-9 6 Mani MK., The National Rural Health Mission (NRHM) in review; Natl Med J India. 2008 May-Jun; 21(3):1489. 7 Kapil U, Choudhury P. National Rural Health Mission (NRHM): will it make a difference, Indian Pediatr. 2005 Aug; 42(8):783-6.

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Annexure 2 Minutes of the First Meeting of the Working Group

Secretary Health & Family Welfare chaired the 1st Meeting of the Working Group on Progress and Performance of NRHM and Suggestions for the 12th Five Year Plan on 10th June, 2011 in Room No. 155-A, 1st Floor, Nirman Bhawan, New Delhi. The list of members of the Working Group and other officers who attended the meeting is annexed. At the outset Sh. Amit Mohan Prasad JS (Policy), MoHFW welcomed the members of the Working Group and other officers present in the meeting. presentation on progress of NRHM and challenges. Secretary HFW in his remarks highlighted the progress of NRHM and the benefits that have accrued due to integration of various programmes. He also informed the members that the Planning Commission has formed 4 Working Groups for the 12th Five Year Plan (FYP) on Primary Health Care, Tertiary Care, Communicable and Non-Communicable diseases, Drugs and a Sub Group on Human Resources. Thereafter, Secretary H&FW invited members of the Working Group to put forth their views. The members made following observations/ suggestions. The main points discussed by the Working Group are as follows: Mrs Poonam Muttreja, ED- Director PFI shared the following suggestions: Clarification regarding High Level Expert Group (HLEG) Committee on Universal Health Coverage may be provided what it means in terms of infrastructure and tie ups with private sector. More information and assessment studies on NRHM are needed to make useful suggestions for the 12th Plan. HMIS Quality and data reliability needs to be stressed upon. Additional investment is required with a systems approach to improve HMIS. While the ASHA programme has been successful, more investments in training (health skills, managements and counselling) and supervision is required. In addition, the ASHAs supervision and management needs to be looked at (the 2nd ANM may be given some managerial skills in this regard). The Catch programme underway in Sikkim is an example of a successful screening programme for Non-communicable Diseases where the PHC doctor screens individuals in the field setting. This programme needs to be evaluated to determine if it can be scaled up in other parts of the country. Thereafter, he made a

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Repositioning of Family Planning for Maternal and Child Health is important. Differential incentives for HR in difficult areas should be given. For effective Community Monitoring a robust redressal mechanism needs to be institutionalised.

Dr Nerges Mistry, Director FRCH, FMR mentioned that: Convergence of NCDs with TB and HIV/AIDS for better disease management and control should be looked at. There is a perpetual shortage of essential drugs at health facilities replenishment of drugs should be prioritised. ASHA - Shortage and replenishment of ASHA drug kits remains an issue. Better methodology for evaluation of JSY & RSBY should be looked at. Lack of fund flow at sub district level leads to reduced motivation among PRIs and communities. Quality of care provided at public health facilities is an issue. Career growth and accreditation and training of ASHAs needs to be defined. In terms of institutional deliveries the link between 24x7 PHCs and higher referral centre needs strengthening. A holistic approach to Infrastructure Development should include provision of power, water and ensure road connectivity for all public health facilities. Dr. NK Arora, INCLEN informed the group that: A comparative analysis of public and private sector health facilities in 16 districts has reported that the public sector has better infrastructure, trained HR and supplies. However, it lags behind the private sector in terms of efficiency and utilisation of resources. This needs to be rectified. The Currently available HMIS needs more investment. Real time analysis of HMIS data should be done.

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Malnutrition is a major cause of childhood morbidity and mortality. More emphasis at the national level is required on the issue of child nutrition.

Anemia among children, adolescents, adult men and women is a major public health issues in India. A systematic review of Anemia and Iron Deficiency is required and provision of Vitamin B12 (an important cause of pernicious anemia) should be a part of the anemia control strategy.

The JSSY scheme launched on 1st June is a step in the right direction towards controlling MMR and IMR. However, due importance needs to be given to Still Births, Ante Natal Care and Care in the first 6 weeks of life. The role of AWW, ASHA and ANM needs to be defined clearly to make the initiative a success.

To deal with the problem of shortage of skilled doctors a 2 year postgraduate course in Family Medicine is being developed by the MCI - training in Child health, maternal health, Adult and Geriatric medicine and essential surgical skills will be imparted. These trained post graduate doctors could be utilised to fill vacant positions in CHCs and PHCs.

Partnerships with Private sector to help people set up private practice in remote areas with a shortage of doctors may be looked at.

Mrs Anita Das said that: Better evaluation and assessment studies for NRHM are required. Malnutrition in children is a significant public health problem and it needs greater attention. A subgroup to examine strategies for combating malnutrition in the 12th plan is suggested. AYUSH doctors role of AYUSH doctors in primary health care needs to be clarified. A policy thrust on AYUSH is required. The role of AYUSH in preventive medicine may be explored. Rational deployment of the 7 lakh AYUSH trained manpower should be done to provide better traditional health care.

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ICMR can undertake studies to validate the remedies offered under the traditional systems of medicine, and to put the tested drugs into the Essential Drug List.

Dr. Mohan Rao, JNU was of the opinion that: In terms of the numbers provided in the presentation proportions (with denominators) would be more useful in assessing the current situation and providing informed inputs. Quality and Cost of Care is an issue. Rational use of technology in health care, especially in private sector. Regulation of care needs attention especially in the private sector.

Dr. M. Prakasamma, ANSWERS, Hyderabad mentioned that: More clarity on processes and proportions in the presentation would have been useful for the group members. Details on indicators for ANC, Facilities used viz Abortion, contraception, Utilization of IFA tablets, Anaemia control; etc could be furnished to the group. States should have functional Maternal Death Review system Clarity regarding 2nd ANM, and the role description of 1st ANM and 2nd ANM is required Public Health Nursing cadre needs to be revitalised.

Dr. Prema Ramachandran, Director NFI, New Delhi emphasised that: HMIS is important but the quality and reliability needs to be prioritised. Local capacities should be developed to improve HMIS. Quality of care and optimal use of resources at each level should be stressed on. Interventions like the mother and child card are a step in the right direction and need to be multiplied.

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Curative part of PHCs should be strengthened.

Dr. P.K.Shah, President Elect, Director General, FOGSI, Mumbai: Dr. Shah appreciated the significant reduction in IMR in Odisha (30 points). He suggested that the strategies that helped the State to bring down the IMR could be replicated across the country. He further stated that: The JSY scheme has lead to dramatic increase in institutional deliveries. However, this has not been accompanied by decreasing MMR. Increasing case load of normal deliveries at tertiary centre has burdened the staff and indirectly diverted attention from complicated cases. Rationalisation of case load needs to be done at facilities so that normal deliveries are handled at the primary level and tertiary facilities can focus on handling complicated deliveries. Teams of Gynaecologist, Anaesthetist, Neonatologist and the requisite infrastructure must be made available at the PHC level in order to rein in MMR and IMR. Better living conditions and monetary and other incentives for doctors in rural areas. Compulsory posting of post graduate medical students for 6 months in rural areas to provide the necessary care. Drugs like injectable iron sucrose, Magnesium sulphate and Misprostol must be widely available at all maternal health facilities to reduce maternal mortality. Joint effort from MoHFW, WCD, and HRD Ministry is required to control the current MMR in the country. Mrs. Nirmala Nair, EKJUT, Jharkhand said that: Impact of community mobilisation on womens health should be evaluated. ASHAs role in community mobilisation needs greater attention. In addition, ASHAs need to be sensitized to attend to the marginalised communities. Robust progressive surveillance system is required and the HMIS data needs to be analysed.

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Prof. Deoki Nandan, Director, NIHFW suggested that: A Cadre of public health specialists should be set up to address the shortage of trained public health staff. Redefine responsibilities of public health professionals with proper deployment according to their skills. Pre- service and In- service training of health professionals is required. Linkage between training centres at National, State and District level. A training cadre may be established. There should be an interface between teaching institutions and public health services. Investment in supportive supervision for ASHAs with one facilitator for 20 ASHAs. ASHAs should identify local influencers in cluster communities who can facilitate BCC and IEC for which they can be incentivised. Capacity building of district level staff for data management and analysis is required to improve data quality and use of the data for programmatic corrections. HMIS needs to be linked with PRIs, VHSCs for social audits. Shri S.K. Mahajan, Advisor Planning Commission said that: Terms for recruitment and retention of doctors in rural areas need to be made more attractive. Other factors in addition to population should be taken into account when formulating norms like consumer based appraisal. 24x7 facilities should provide other services in addition to deliveries.

Shri Anil Kumar, Secretary, AYUSH observed that the traditional system of Indian Medicine is underutilized. He suggested that: Integrative system of medicine should be instituted so that patients should have the right to choose the form of therapy. Salaries of AYUSH and Allopathic doctors should be equalised. Allopathic doctors should be oriented in AYUSH. 110

Shri John Ekka, MD NRHM Assam opined that: Training of AYUSH doctors in BEMOC to increase their skill level can be done. There is a need of annual surveys so make remedial actions in the programme if required in real time SBA, F-IMNCI training should be included in the medical curriculum. Non communicable disease prevention and control should be included under NRHM. Support should be given to tertiary care centres medical colleges by NRHM. An outreach programme for data collection on NCDs in the community should be instituted to find out the public health burden of NCDs in the population. Dr. T Sundaraman, ED NHSRC suggested that: Wealth of studies on NRHM are available on national portal, NHSRC, IAP etc, which could be utilized by the members. EMRI has had a huge transformative response in the last 6 years. There has been different strategies and response between states: the Non High Focus states have performed better in terms of infrastructure development but the High Focus States have shown a greater change in health indicators. Shri P K Pradhan, MD NRHM & Special Secretary Health & Family Welfare, summarised the discussion and put forth the following suggestions: Best practices of States should be compiled so that evidence based strategies can be adopted under NRHM. Focus on facility based care to make it more effective. Performance benchmarks to be linked to incentives in the 12th plan. Maternal and Child Tracking System is being implemented, it is required to use this data for better implementation. Fund flow at the sub district level needs to be streamlined. Better coordination between ICDS and MoH&FW is needed.

111

A national protocol for injectable iron sucrose and injectable contraceptives need to be developed which can then be rolled out in all states. A protocol is being developed by FOGSI which can be evaluated and submitted to the GoI for consideration.

Strengthening of District hospitals to provide advanced secondary care. SNCU at all DH should be in place. Strategies for the 12th FYP would include: Nutrition issues, Adolescent health, School health, Joint Health card, rolling out of MCTS. Help Desk and redressal mechanisms for ASHA. Timely referral should be prioritized. Public Health cadre needs to be developed for the 12th Plan with focus on compensation of HR and reducing attrition.

Shri Chandramouli, Secretary Health and Family Welfare summarised the discussion and added that: Positioning of one MPW Male at every sub centre with clearly defined role may be supported by NRHM in the 12th FYP. A draft strategy paper for the 12th FYP would be prepared by the NHSRC before the next meeting of the Working Group and shared with the members. Training and Career progression for ASHA, ANM, and Nurses needs to be emphasised. District wise assessment is required to analyse the differential achievement between districts (facility wise monitoring, data validation). Capacity building at State and District level for data analysis, validation and monitoring is required. Differential planning and provision of funds should be done for facilities according to case load. In the end, the Secretary thanked the members of the working group for their support and contributions and informed that the next meeting of the Working Group would take place after the meeting of the Steering Group. 112

Annexure 3 Minutes of the Second Meeting of the Working Group

Shri.K.Chandramouli,SecretaryHealth&FamilyWelfarechairedthe2ndMeeting oftheWorkingGrouponProgressandPerformanceofNRHMandSuggestionsforthe12th FiveYearPlanon28thJuly,2011inRoomNo.155A,1stFloor,NirmanBhawan,NewDelhi. ThelistofmembersoftheWorkingGroupandotherofficerswhoattendedthemeetingis annexed. AttheoutsetSh.AmitMohanPrasadJS(Policy),MoHFWwelcomedthemembers of the Working Group and other officers present in the meeting. Thereafter, Dr. Sajjan Yadav,DirectorNRHMmadeapresentationonissuesidentifiedthroughthediscussionsin the previous meeting and the correspondences received from the Members, State Governments,ExpertsandcivilSocietygroups.Healsooutlinedtheproposalsforthe12th FiveYearPlan. ItwasobservedduringthepresentationthatsomeStatesparticularlytheNEStates find it difficult to commit the existing 15% of State share. This was discussed and it was decided that a call on the matter would be taken by the Planning Commission. Ms. Renu Khanna, SAHAJ, pointed out that nothing much had happened in Community Monitoring afterthefirstpilotphase.Shesuggestedthatitshouldbemadeapartofthe12thFYP.Dr. Shakeel,PatnasuggestedthatVHSCsshouldbesetupatvillagelevelandnotatPanchayat levelasisdoneinstateslikeBihartoensureinclusionofthesociallyexcludedgroups.Itwas clarifiedthatasperNRHMframework,VHSCistobesetupineachrevenuevillages.Smt. Girija Vaidyanathan, Principal Secretary,Health & Family Welfare, Tamil Nadu suggested that in the nationwide surveys like DLHS and AHS, States should be allowed to include certainStatespecificcomponents. Smt.GirijaVaidyanathan,suggestedthatinsteadofrestrictingupgradationtoonly District Hospitals, States should be allowed to choose one major hospital in the district, which could include medical colleges for upgradation in the 12th Plan .At this, Sh. P.K. Pradhan,SS&MDNRHM,wasoftheopinionthatwhileDistricthospitalswhichhavebeen upgraded into Medical Colleges could be covered, It will be difficult to allow States to choose other major hospitals for upgradation. Dr. M. Prakasamma, Director, Academy of Nursing Studies stressed on the need to specify and highlight the exact areas of inter sectoralconvergencetoaddresssocialdeterminantsofhealth. 113

Ms.RenuKhanna,broughttothenoticeofthegatheringthatoneroundofcapacity building through training is not sufficient to ensure proper functioning of the VHSNC and this requires greater investment. Further, she pointed out that the linkages between the VHSNC and health committees at the block level and above are nonexistent and this requiredimmediateattention. Dr. M. Prakasamma suggested that VHSNCs could be given monetary incentives/rewards to ensure 100% immunization and 100% institutional deliveries to improve their participation in these programmes. Dr. Shakeel stressed on the need for renewedemphasisonspacingmethodsinFamilyPlanningandpointedoutthatthelackof trainedpersonnelfor methodssuchasCu.Tinsertionsis amajorreasonfor themethods notbeingcurrentlyutilized. Dr.DhruvMankad,LeadConsultant,ProjectEvaluationTeamatSirDorabjeeTata Trust, pointed out the need for special efforts for infrastructure development to reach SC/STandunreachedpopulations. Dr.Shakeelpointedoutthatwhilepopulationnormsforinfrastructuremayremain unchanged,itisessentialthatthesamearefollowedandthatthereshouldnotbeonePHC for2lakhpopulationasisthecaseinsomeStateslikeBihar. Ms.RenuKhannareflectedthatwhileweshouldfocusonstrengtheningofDistrict Hospitals its important that focus on PHCs is retained in the process. Dr. Dhruv Mankad pointedoutthatwhiledevelopinginfrastructureitshouldberememberedthatroadaccess tothefacilityisensured.Constructioncostscanincludethecostofdevelopmentofroadsto reach the facility if required using the currently prominent township planning approaches andconvergencewithPWDdepartmentshouldbeanimportantfocusarea. Dr. Nerges Mistry, Director FRCH, emphasized the need for outreach/ extension services and also maintaining quality and standards of services at the health facilities. Linkagesbetweenfacilitiesforreferralsshouldbestrengthened. Dr. M. Prakasamma gave some important pointers towards improving the nursing andANMcadreinthecountry.ShepointedoutthatacourseonCommunityMidwifeshould be introduced in the country and that other countries have greatly benefitted from this initiative.ThiswouldentailexpandingthecourseoftheANMby6months.Shealsopointed out that it is not required that every nurse should be a midwife and thus specialized trainingscouldbeimpartedtoonlythosenursespostedatthelabourrooms.Shefocused 114

ontheneedforrevivalofPublicHealthNursingCadre.Shealsoidentifiedthatwhilenursing schoolsarebeingestablishedthereisagreatdeficiencyoffacultyfortheseinstitutionsand thusaNationallevelTrainingInstitutefortrainingofFacultyfornursingistheneedofthe hour.MostofallshepointedtotheneedforsettingupskilllabsatDistricthospitalLevel whichwouldfacilitatecomprehensivetrainingatthedistrictlevelwiththehelpofpatients aswellasmannequins. Shri. P.K. Pradhan, SS & MD, NRHM observed that there is a need to speed up recruitment processes and to address this some States have modified their recruitment processestoincludecampusrecruitmentsandwalkininterviews.Dr.Shakeel pointedto the need to invest further in skilled HR production and suggested that more Nurses/ ANMTCsandMedicalcollegesshouldbeopenedbythegovernment.Addressingthepoint raisedaboutRuralMedicalPractitionersShri.K.Chandramouli,SecretaryHFW,clarifiedthat discussionswithMCIwereonregardingtheirrecognition. Dr.MohanRao,Professor,CenterofSocialMedicineandCommunityHealth,JNU, New Delhi emphasized that a subgroup on regulation of private sector, technologies and healthcarecostswastheneedofthehour. Dr. Nerges Mistry observed that performance based payments should be encouraged.Dr.ShaliniBharatmentionedthatitwastimethattheexistingyardsticksare reevaluated and the present criteria for infrastructure development should be expanded beyondpopulationnorms. Shri Amarjeet Sinha, Prinicpal Secretary (H&FW) Bihar, mentioned that outreach servicesthrough MMUsatvillagelevelwereessential andanexperiment inthisregardin Bihar was very well received. He said that if adequate amenities are provided to doctors, theyareencouragedtojoingovernmentservice.Herecognizedtheneedofoneskilllabat every district. Most importantly he pointed to the need for central support to State governments in setting up Medical Colleges. Innovations in HR recruitments at the State levelshouldbeencouragedinthenextplanperiod. Addressingqueriesonprocurement,Shri.K.Chandramouli,informedthegroupthat a Central Procurement Authority is being set up at the National Level. Dr. Sudarshan, Karuna Trust observed that management structures under NRHM required to be strengthened including at the National level. Smt. Anuradha Gupta, JS (RCH), MoHFW agreedwithDr.SudarshanandfurtherpointedoutthatRCHmanagementstructuresatthe 115

StateandDistrictlevelsalsoneededstrengthening.Smt.GirijaVaidyanathansharedthatin her State where they have initiated tie ups with doctors from medical colleges for strengthening of directorate since the doctors were unwilling to work full time at the directoratefortechnicalinputs.Shri.AmarjeetSinhaalsodescribedsimilararrangementsin Biharandagreedthatsucharrangementscouldbeencouraged. Smt. Girija Vaidyanathan suggested that while there is need for strengthening of RKSandmakingthestructuremoretransparentandcommunityoriented,Statesshouldbe giventhelibertytodecidewhetherthePRImembershouldbemadeachairpersonofthe RKS.Shri.AmitMohanPrasad,remarkedthatRKSmeetingsarenottakingplaceanditsrole as a grievance redressal forum is currently lacking and thus there is a great need for PRI involvement. Ms.RenuKhannaemphasizedtheneedforformationofteamsofANMs,ASHAsand MPWsatthegroundlevel,withgreaterconvergencebetweenthethree.Shesuggestedthat MPWscanplayanimportantroleinNACPandRCHconvergenceandcanactasarolemodel forthemalecommunityinareasofARSHandpreventionofSTDs. Dr.ShaliniBharatpointedoutthatfocusonsexualhealthandhealthpromotionis missing.ShealsosuggestedthattheroleofASHAsshouldbeexpandedtoincludegeriatric care. Ms.PoonamMutrejasuggestedthatASHAsshouldbegivenfixedremuneration.Dr. Sudarshan,suggestedconversionofASHAsintofulltimeemployeesinsteadofkeepingher as a volunteer. However many other members of the working group did not support this suggestionsayingthatgovernanceandaccountabilityissuesrelatedtootherregularhuman resources would also arise in the ASHA programme seriously affecting her current functionality. Shri. P. K. Pradhan informed the group about the ministrys inclination to substantiallyincreasetheincentivestoASHAs. Dr.PremaRamachandran,DirectorNFI,pointedoutthatthereisaneedtoredefine thegoalstoensurethattheyaremorespecificandachievablesuchasredefiningthegoalof reducing anemia to reducing moderate and severe anemia. She also suggested that a stronglinkbetweendetectionofundernutritionandinvolvementofconcernedaanganwadi centre needs to be developed. Shri. K. Chandramouli supporting the above suggestion, stated that there was a need for clear articulation of the areas and strategies for

116

convergence. Dr. Prema Ramachandran, suggested that Annual Health Survey could be conductedbystafffromthehealthdepartmentinsteadofschoolchildren. Dr. N.K. Arora, International Clinical Epidemiology Network (INCLEN), New Delhi raised the issue of role clarity between ASHA, AWW and ANM and stated that ASHAs should not be given curative tasks and her work should be restricted to community mobilization. He also suggested that RKS should accept public grievances. Ms. Anuradha Gupta, seconding his observations said that RKS could be empowered for handling grievanceredressal. Shri. Amit Mohan Prasad, suggested that every village should have one health centre.OthermembersandSecretaryHFWalsoagreedandaskedthistobemadepartof the recommendation. Ms. Renu Khanna specified that while fixing a goal of 80 % institutional deliveries it is important to remember that the focus should be on safe deliveriesthanoninstitutionaldeliveries.Dr.ShaliniBharatalsosupportedhersuggestion thatsafedeliveriesrequiregreaterfocus.Dr.ShakeelsuggestedthattheroleofTBAinsafe deliveries should be recognized. Shri. Manohar Agnani, MD (NRHM), Madhya Pradesh, pointed out that while safe deliveries should be on focus, the emphasis on institutional deliveries should not be reduced as it puts a tremendous pressure on the Government system and the hospitals to perform, strengthening the system in the bargain. Ms. AnuradhaGupta,alsomentionedthatJananiShishuSurakshaKaryakram,launchedbythe GOI,alsoputspressureonthesystemtoperformbetter.Sheclearlystatedthatthescheme looksatreducingthecausesofMMRintotalityanddoesnotpromoteastandalonestrategy of institutional delivery. Also State governments have been encouraged to identify areas where home deliveries are prevalent and plan for ANM assisted home deliveries in these areas. Dr. N. K. Arora, International Clinical Epidemiology Network (INCLEN), New Delhi pointedoutthatinthewakeofJSSK,introductionofacourseoncommunitymidwiferyisof great importance. He also shared that a checklist has been devised on identification of motherswhorequire48hoursstayinthehospital.Ifthechecklistisfilledbythedoctorat thetimeofdischargeofthemother,thenmotherswhorequire48hoursstaycouldbeeasily identified and maternal deaths could be avoided. He thus suggested that the same be introduced in the system. Shri K Chandramouli requested him to submit the details and othersuggestionsforfurtherfollowup. 117

Smt. Girija Vaidyanathan, requested that with regards to EMRI, Central Government assistance should not be completely stopped and GoI should continue to provideminimumsupport. Dr.N.K.Arorasuggestedthataddressingchildhoodobesityshouldalsobeapriority. Atthis,Dr.PremaRamachandransuggestedthatHemoglobinestimation,weightcheckup andheightcheckupsshouldbemandatoryforeverypatiententeringthehospitaltoaddress theissueofmalnutrition. Dr. Renu Khanna shared that health care providers are getting cautious about conducting MTPs and have started refusing MTPs to women in the second trimester with thefearofprosecutionunderthePC&PNDTact.Thismaybedetrimentaltoprovisionof safeabortionservicesforwomenandthuscautionisneededintheimplementationofthe act. She also pointed out that special focus is required to address female under five mortalityandShri.P.K.Pradhanagreedtoincludethesameintheproposal. Dr.ShakeelbroughtoutthepointthatEmergencycontraceptivepillsarebeingused by patients as regular contraceptives which is harmful to the health of women. Dr. P.K. Shah, President, Federation of Obstetric and Gynecological Societies of India, (FOGSI) Mumbai supported this and suggested that while over the counter availability of EC pills shouldnotberestricted,IEConthesamedefinitelyneedstobestrengthened.Ms.Poonam Muttreja suggested that injectible contraceptives should be introduced. It was informed thatmanyMPshavealsomaderequestinthisregard.Itwasalsosuggestedinthemeeting that GOI should write to the States that post partum acceptance of IUCD should be encouraged. Shri. P. K. Pradhan pointed out that currently, integrating NRHM in the health system and improving governance are the major challenges faced by NRHM. Dr. Dhruv Mankad, put in a caution that it should be taken care that insurance programmes should notreplaceprimaryhealthcaresystemsinthecountry.SecretaryHFWagreedwiththisand mentionedthatstrongpublicsectorinhealthcareisrequiredinthecountry. Dr. Pankaj Shah, SelfEmployed Women's Association (SEWA) Rural Gujarat suggestedthatSickleCellDiseaseControlshouldbegivenpriority.Hespecificallyurgedthat duplication of record keeping at the facility level should be avoided and there is a great need for streamlining the reporting system. Shri. P. K. Pradhan suggested that Dr. H. Sudarshan should submit a proposal for strengthening capacity building of NGOs for 118

community monitoring. Ms. Poonam Muttreja suggested that a National and State level resourcecentresforcapacitybuildingofNGOsaretheneedofthehour.Dr.ShaliniBharat pointedoutthatqualityofcareneedstoincludegendersensitivityasanintegralpartand helpdesksshouldbeavailableatallpublichealthfacilities.Dr.N.K.Arorapointedoutthat patientsafetyandqualityofcarerequiregreaterfocus. TherewasagreatconcernamongmembersforclarifyingtheroleofAYUSHdoctors

under NRHM. There was a general understanding that a greater focus is required on mainstreamingofAYUSHandthatStatesneedtobegiventhedetailedunderstandingofthe responsibilities of AYUSH doctors under NRHM. Shri. K. Chandramouli instructed the representative from the AYUSH department to submit a document specifying the role of AYUSHdoctorsunderNRHM.Ms.RenuKhannapointedoutthatAYUSHmedicinesneedto beapartofthetreatmentguidelinesunderpublichealthsystem. Dr. N.K Sethi, former Sr. Adviser (Health), Planning Commission GoI, gave two important suggestions namely that essential drugs should be made completely free at all public health facilities and that all investigations and diagnostic services should be made freeforallpatientsatpublichealthfacilities. Shri.ManoharAgnanisuggestedthatStateshareunderNRHMshouldbeincreased to25%ifStateGovernmentsspendingonhealthistobeincreased.Attheend,Shri.P.K Pradhanthankedallthemembersfortheiractiveparticipationandinvolvementandstated that amendments would be made in the draft paper based on the discussions and suggestions received. The meeting ended with vote of thanks by Shri Amit Mohan Prasad,JS(Policy)

119

REPORTOFTHE WORKINGGROUPON TERTIARYCARE INSTITUTIONSFOR 12THFIVEYEAR PLAN(20122017)

WG2:Tertiary CareInstitutions

WG-2
No. 2 (6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 Dated 9th May 2011

OFFICE MEMORANDUM

Subject: Constitution of working group on Tertiary Care institutions for the Formulation of the Twelfth Five Year Plan (2012-2017)
With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on Tertiary Care institutions and other major tertiary care institutions under the Chairmanship of Prof J S Bajaj, Former Member, Planning Commission, Government of India The composition and the terms of reference of the Working group would be as follows: 1. 2. 3. 4. 5. Prof. J S Bajaj, Former Member, Planning Commission, Chairperson Government of India Dr. R. K. Srivastava, DGHS (Directorate General of Health Member Services) Director AIIMS, New Delhi Member Director PGIMER (Post Graduate Institute of Medical Member Education and Research), Chandigarh Director JIPMER (Jawaharlal Institute of Postgraduate Member Medical Education & Research) Puducherry Director Sree Chitra Tirunal Institute for Medical Sciences Member & Technology, Thiruvanthapuram, Kerala Director Tata Memorial Hospital, Mumbai Director, Institute of Liver & Biliary Sciences, New Delhi Member Member

6. 7. 8.

9. 10.

11. 12. 13. 14. 15. 16.

Medical Superintendent, Vardhman Mahavir Medical Member College & Safdarjung Hospital, New Delhi Director, North Eastern Indira Gandhi Regional Institute of Member Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya Director, School of Tropical Medicine, Kolkata, West Member Bengal President, National Board of Examination, New Delhi Member Director, Institute of Human Behaviour and Allied Member Sciences, Dilshad Garden, New Delhi Vice Chancellor, The Tamil Nadu Dr. M.G.R. Medical Member University, Chennai, Tamil Nadu Prof. S. K. Sama, Gastroenterologist, Sir Ganga Ram Member Hospital, New Delhi Dr. Arun K. Agarwal, Dean, Maulana Azad Medical College, New Delhi Member

17. 18.

Prof. Sunil Maheshwari, Personnel and Industrial Relations Member Area and Strategic Management IIM, Ahmedabad Prof. Ranjit Roy Choudhury, National Institute of Immunology, New Delhi Dr. Mansoor Hassan, Cardiologist, Lucknow, Uttar Pradesh Principal Secretary, H&FW, Government of Karnataka Principal Secretary, H&FW, Government of Gujarat Principal Secretary, H&FW, Government of Punjab Prof. Jayati Ghosh, University, New Delhi Economist, Jawaharlal Member

19.

Member

20. 21. 22. 23.

Member Member Member

Nehru Member

24.

Dr. Anand Zachariah, Professor, Department of Medicine, Member CMC (Christian Medical College) Vellore Prof Snehlata Deshmukh, Pediatric Surgeon, Former Vice Member Chancellor, Mumbai University

25.

26.

Dr. Prema Ramachandran, Director, Nutrition Foundation Member of India Joint Secretary Development) (Ministry of Human Resource Member

27.

28. 29.

Mr. Ambrish Kumar, Adviser (Health) Planning Commission

Member

Joint Secretary, PMSSY, (Pradhan Mantri Swasthya Member Suraksha Yojana) Secretary

Terms of References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. To review the progress of PMSSY I & II. To suggest a completion plan for ongoing projects under PMSSY. To advise about midterm corrections in PMSSY and finance mechanism along with possible advice about resource mobilization. To identify new locations for PMSSY, to be taken up for 12th Five Year Plan. To assess regional imbalances in the availability of tertiary healthcare services and suggest appropriate measures to correct these imbalances. To assess the infrastructure and human resource requirements for establishing/ augmenting tertiary healthcare facilities, especially for the critical specialties. To suggest appropriate cost effective models for efficient functioning of tertiary health-care institutions. To suggest measures for optimal use of available human resources in the tertiary health sector. To recommend measures for wider use of telemedicine and IT technology in providing tertiary healthcare facilities. To study appropriate PPP model in tertiary healthcare sector and integrating the private sector facilities with Government Sector to provide cost effective services to the public. To assess the gaps in governmental efforts for faculty development through various schemes of medical education & suggest remedial measures.

11.

12.

The Chairman may constitute various Specialist Groups / Sub-groups/task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitorable goals, while making recommendations. Efforts must be made to co-opt members from weaker section especially SCs, Scheduled Tribes and minorities working at the field level. The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the non-official Working group members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India The Working group would submit its draft report by 31st July, 2011and final report by 31st August, 2011.

13.

14.

15.

16.

(Shashi Kiran Baijal) Director (Health)

Copy to: 1. 2. 3. 4. 5. 6. 7. 8. 10. 11. 12. Chairman, all Members, Member Secretary of the Working Group PS to Deputy Chairman, Planning Commission PS to Minister of State (Planning) PS to all Members, Planning Commission PS to Member Secretary, Planning Commission All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission Director (PC), Planning Commission Administration (General I) and (General II), Planning Commission Accounts I Branch, Planning Commission Information Officer, Planning Commission Library, Planning Commission

(Shashi Kiran Baijal) Director (Health)

Contents

1. 2. 3. 4. 5. 6. 7. 8. 9.

Executive Summary Chapter 1: Introduction Chapter 2: Human Resources for Tertiary Health Care Chapter 3: Expanding Capacity and Enhancing Quality Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) Chapter 4: Strengthening of District Hospitals and Linkages with Medical Colleges Chapter 5: Strengthening Partnership between different Service Providers (PPP option) Chapter 6: Information and Communication Technology in Health Care Chapter 7: Futuristic Vision for Education & Research in Tertiary Care Summary Record of the discussions of first Meeting

6-12 13-20 21-27 28-41 42-44 45-51 52-59 60-70 71-79

Executive Summary India has systematically improved health conditions. Life expectancy has doubled from 32 years in 1947 to 66.8 years at present; Infant Mortality Rate (IMR) has fallen to 50 per thousand live births. However levels of malnutrition and rates of infant and maternal deaths still remain high. Nearly one million Indians die every year due to inadequate healthcare facilities and 700 million people have no access to specialist care and 80% of specialists are working in urban areas. India faces a huge need gap in terms of availability of number of hospital beds per 1000 population. With a world average of 3.96 hospital beds per 1000 population India stands just a little over 0.7 hospital beds per 1000 population. The budgetary support for expansion of public health facility has been inadequate from governments. In most states salaries and wages account for as much as 70 per cent of the total health budget, leaving hardly any resources for expansion of services. Further it is estimated that public funding accounts for only 22% of the expenses on healthcare in India. Most of remaining 78% of private expenditure is out-of-pocket expense. The share of the richest 20 per cent of the population in total public sector subsidies is nearly 31 per cent, almost three times the share of the poorest 20 per cent of the population. The existing scenario suggests that public healthcare service should ensure three Es- Expand Equity - Excellence. Access to adequate health care would need expansion of tertiary care facilities. Tertiary care should be equitably distributed to different segments of population. The setting up of new facilities will have to address imbalances at three levels- Regional, specialties, and ratio of medical doctors to nurses and other healthcare professionals. The Working Group members were unanimous in their opinion that the expansion in the next five year plan must be systematic whose contours must be based on infusing quality in the future medical education and care. Effective delivery of health care services would depend largely on the nature of education, training and appropriate orientation of all categories of medical and health personnel. Equally urgent therefore is the need to assess appropriate manpower mix in terms of the required numbers and assigned functions of human resources for health in tertiary health care. Chapter 2 of the report examines the need to strengthen the manpower availability and skills. PMSSY was first launched in March 2006 with the primary objective of correcting the imbalances in availability of affordable/reliable tertiary level healthcare in the country in general and to augment facilities for quality medical education in the under-served States. The scheme is reviewed and suggestions
6

are made in Chapter 3 of the report. Six AIIMS like institutions (ALIs) in the underserved and un-served regions of the country were planned to be setup. The group recommends creation of 4 (four) new AIIMS Like Institutions (ALIs) during the 12th Plan period. The pattern of governance and management of ALIs was approved by the Union Cabinet in August 2010. It was decided that each of these institutions would be registered under a society. These societies will be functional till the ALIs are brought under an Act of Parliament. It is noteworthy that a High Powered Committee was set up recently to review the Governance and HR practices at the AIIMS. The experience of the review indicates that the existing Institutions would also need similar review to optimize their functioning. PMSSY also envisaged up-gradation of several existing medical institutions in different states in the country. Initially the estimated outlay for up-gradation was revised to 150 crores per institution (from initial estimate of Rs. 120 crore), with Rs. 125 crore as the share of Central Government. During the 11th Five Year Plan a Scheme for Up-gradation & Strengthening of State Government Medical Colleges for starting new postgraduate disciplines and increasing postgraduate seats by central funding has been launched. This report proposes grants to be released to selected State Government medical colleges / institutions directly as per their actual requirement under a funding patter of 75% by Central Government and 25% by State Government. For creating a larger pool of doctors and other health workers that can be used at PHC and CHC and providing super specialty health care to the population in that region, 25 Medical institutions have already been approved under PMSSY. It is suggested that additional 30 medical colleges, established at least 20 years back and requiring immediate financial assistance for strengthening and upgrading its facilities, be identified for support through PMSSY. Recently, mid-term appraisal of the 11th Five Year Plan indicates a major effort for the redevelopment of hospitals / institutions. Redevelopment of the AIIMS is to be expedited. Similar development support is recommended for Lady Hardinge Medical College & Smt. S.K. Hospital; Kalawati Saran Children (KSC) Hospital, New Delhi; RIMS, Imphal; Lokapriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur; Safdarjung Hospital & College, New Delhi; Postgraduate Institute of Medical Education and Research, Chandigarh; and Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry. For optimizing the functions of presently established as well as upgraded institutions it is suggested that every medical college should undertake periodic
7

review through external peer level Institutes like IIMs for continuous strengthening of these parameters. It is equally imperative to strengthen Human Resource Management Policies. Medical profession demands much higher commitment, knowledge, skills, complexity and competence than any other stream. To attract, retain and nurture talent, HR practices need to be strengthened. It is recommended that a group of senior professionals / administrators from the Post-graduate Medical Institutions, IIMs and IITs may be constituted to undertake an in-depth review and make appropriate recommendations. In view of the time over-runs and cost over-runs in the implementation of PMSSY, and the need to develop sound governance and management systems, the Working Group suggests that Ministry of Health & Family Welfare may consider creating an Apex Team that may facilitate these projects. Medical colleges and other tertiary care centers should be connected through tele-networking to cater the demand of distance education in health education, training, faculty development, tele-consultation etc. The members of the working group further recommended that the Ministry of Health and Family Welfare must open channels of interaction with Ministries of Defence, Railways and Labor (ESI), which are also running medical colleges and health care institutions. Ministry of Health and Family Welfare can explore the possibility of developing tertiary care centers at these institutions by providing financial and technical assistance on sharing basis and even transform health care institutions of these Ministries into medical colleges. The working group recommends that the existing infrastructure at the District level needs to be strengthened to ensure access, quality of healthcare to all, and in strengthening the referral system. With the standardization of processes with the application of technology, many specialist conditions may be effectively managed at the district level. Chapter 4 of the report discusses the issues relating to district hospitals. Medical College could be linked to 1-3 districts for tertiary referral services, on hub-spoke model. The upgraded medical colleges under PMSSY, in the first instance, must be made responsible for tertiary care services in the district hospitals. The District Hospitals linked to upgraded medical college should be provided necessary financial and technological support through a centrally sponsored scheme in the 12th Five Year Plan.

The medical college could use the district health system for training of undergraduate and postgraduate medical students and residents. Part of undergraduate and postgraduate training should be provided in the learning setting outside the medical college in the district health system. It is recommended that all medical colleges should be encouraged to develop their own corpus to attain financial flexibility over a period of time. The colleges could decide the fee and charges for different facilities for patients in paying beds. Government can contribute matching grant to help them develop their own corpus. Public-Private Partnership (PPP) is seen as one of the instruments to improve or reform the health status of the population. PPP related recommendations are made in Chapter 5 of this report. The success of PPP is anchored on three principles. First, a relative sense of equality between the partners; second, there is mutual commitment to agreed objectives; and third, there is mutual benefit for the stakeholders involved in the partnership. PPP can be used beneficially to increase the efficiency in service delivery, operations and management owing to better capacity utilization; to make services equitable, accessible and of good quality; to ensure availability of additional resources (technical, infrastructure and financial) to meet the growing needs in the sector; and to ensure access to advanced but fast changing technology. However to take the advantage of PPP, Government will have to develop certain competencies, create structure and enabling environment to plan and execute PPP effectively during the 12th Five-year plan. Initially bottom-up approach of costing should be undertaken to set the standards. Once the standards are in place, monitoring should be based on topdown approach, using relative value units (RVU), hospital days, or some other metric to assign total costs for a healthcare system to individual services. Government will have to create mechanisms for smooth system for payments. To ensure positive bahaviour of actors in PPP, appropriate HR and communication system would be developed. A detailed study for this may be given to institute like IIM for this purpose. Chapter 6 highlights that Information and Communication Technology (ICT) in health can be effectively deployed in four areas viz. Education, Research, Referral, and Management of Data. National Knowledge Network (NKN) connects 1500 knowledge institutions in India.
9

It is common experience that work places in the health systems are not adequately governed especially in remote areas. The management of medical colleges and district hospitals can be strengthened significantly with the application of Hospital Management System. Working Group recommends setting up a National Mission on ICT in Health with a clear mandate to conceive design, and deliver ICT based health education and health care and converge all existing programmes under this mission. Budgetary allocation of about Rs. 600 crores may be made in the 12th Plan for ICT in Health. Hospital Management System should be installed in all the institutions of tertiary care and district hospitals. A separate IT cell should be created in the Ministry of Health & Family Welfare at the Centre. This centre will develop appropriate formats for appraisal of performance and collect real time data for reports and forward those reports to appropriate authorities for review and necessary action. Lastly in Chapter 7 report discusses futuristic vision and additional strategies. These deserve serious consideration. The advances in biomedical sciences suggest creation of Institutes and Centres, each with a specific research agenda, focusing on specific constellation of diseases or body systems. The following list includes the institutes that may be of relevance to national needs, and may be established during the 12th Five Year Plan: National National National National National National National National National National National National Cancer Institute Institute of Infectious Diseases Institute of Arthritis and Musculoskeletal Diseases Institute of Child Health Institute of Diabetes Institute of Mental Health and Behavioural Sciences Centre of Life Sciences Centre of Biomedical Imaging and Bioengineering Centre for Hospital and Healthcare Administration Centre for Nursing Education and Research Centre for Information Technology (IT) and Telemedicine Centre for Complementary Medicine

The working Group recommends the up-gradation of following centers in 12th Five-Year Plan. National Centre of Excellence for Cancer Treatment and Research National Centre of Excellence for Ophthalmic Sciences
10

National National National National

Centre Centre Centre Centre

for Mental Health and Behavioural Sciences of Excellence in Neurosciences: of Excellence in Cardiology and Cardiac Surgery of Excellence in Liver and Biliary Sciences

The essential and critical prerequisite for optimal functioning of existing and proposed National Institutes and Centres of Excellence for tertiary care, is a strong foundation of primary care and a well organized and coordinated system of secondary health care. With increasing investments in health both by the public sector as well as by the private sector, a continuing appraisal and articulation of health policy is necessary. A Centre of Health Policy Research with core faculty of experts in public health, health planning, health economics, health management and social sciences, amongst others, may provide the necessary forum for ensuring equity and accountability in health care. Setting up Universities of Health Sciences: To ensure appropriate manpower mix of different categories of health professionals involved in delivery of healthcare, the working group conceptualized the University of Health Sciences aimed at creating a physical and academic environment where all faculties of health sciences could interact and provide a model for education and training of healthcare teams, through multi-professional and interprofessional education. To achieve this it was recommended that one such university should be set up in each state, and in the initial stage one in each region. The universities will affiliate all Medical Colleges, Dental Colleges, Paraprofessional Colleges, besides possibly considering grant of affiliation to Colleges, imparting graduation level of education in health sciences in the State. Study and research programmes through multi-disciplinary Study Centers need to be established in the following areas and networking between the universities and identified institutions established. Study Study Study Study Study Centres Centres Centres Centres Centres of Population and Environmental Sciences for Health Systems and Health Services management for Education Technology for Planning and Development of Human Resources for Health for Continuing Education in Health Sciences

Central support must be provided to Health/Medical Universities during the 12th Five Year Plan, with efforts to establish similar universities in other states. In addition to the role, relevance, and functions of Health/Medical Universities as envisaged earlier, they may also subserve a most significant bridging function between the proposed National Commission for Higher Education and Research
11

and the proposed National Council for Human Resources in Health, thereby strengthening medical education and research in the country. ******

12

Chapter 1: Introduction Introduction: There is a continuing concern over the performance of the healthcare delivery system in India. With inadequate budgetary support both at the Central and State levels, most state governments are finding it increasingly difficult to expand their public health facilities to cater to the healthcare needs of their growing populations (Table 1.1). However, the growth of private sector has been impressive in the last two decades. Table 1.1
Year Centers expenditure (Rs. in Crore) % of Union Budget % of GDP States Expenditure (Rs. in Crore) States share in total Total as a % of GDP

2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

8086 9649 10948 14410 17661 21680 25154

1.6 1.9 1.9 2.0 2.0 2.1 2.3

0.26 0.27 0.26 0.29 0.32 0.35 0.36

18771 22031 25375 28908 38579 43848 -

69.9 69.5 69.9 66.7 68.6 66.9 -

0.85 0.88 0.90 0.88 1.02 1.06

In terms of resource allocation, the areas that have suffered most are secondary and tertiary care. This is because expansion of tertiary health care facilities needs considerable resources to adequately respond to the needs of state of art diagnostic procedures and treatment modalities. Most state government budgets show that a major component of budgetary allocations goes to meet the recurrent costs to maintain existing levels of public health care delivery system. In most states salaries and wages account for as much as 70 per cent of the total health budget, leaving hardly any resources for expansion of services.
13

Further it is estimated that public funding accounts for only 22% of the expenses on healthcare in India. Most of remaining 78% of private expenditure is out-of-pocket expense. The total public expenditure on health has been around 1% of GDP. This is leading high health cost burden on people, especially in lower economic stratum. It is estimated that 11.88 million households are falling below poverty line every year because of health related expenses due to spiraling cost of healthcare (India Health report 2008). It is often argued that Public Health system supports the health care needs of poor population who cannot afford private healthcare facilities. However, the pattern of healthcare beneficiaries indicates a very different scenario. At the allIndia level, the share of the richest 20 per cent of the population in total public sector subsidies is nearly 31 per cent, almost three times the share of the poorest 20 per cent of the population. In rural areas the share of the top 20 per cent in public subsidies was nearly four times that of the poorest 20 per cent. Tertiary care services are expectedly more expensive than primary care or secondary care services and viability of their establishment and maintenance is a big issue. With the result such services in public sector are few given the percentage of public expenditure on health out of GDP. Thus availability of tertiary care services is skewed towards private domain vis--vis public sector and the costs again drive the private sector to get concentrated in urban setup. There are also geographical inequities. Tertiary care health services in India are concentrated in big cities and there is gross inequity between rural and urban setup. People in rural areas requiring such services have to invariably travel to the big capital cities and more often than not to the major metropolitan cities to get the required treatment. Lack of tertiary care infrastructure in the rural area is to a large extent because of the trained manpower in the field shying away
14

from settling in such areas apparently because of lack of other civic and social amenities in the rural setup and also due to apparent inadequate reimbursement of their technical skills as compared to their counterparts in cities or for that matter away from the home country, thus giving rise to regional and geographical imbalances in availability of services. The current market model of private tertiary care is based on patients ability to pay and focuses on diseases, specializations and treatments that enhance profitability. Lack of expansion of public hospitals in proportion to population growth and health needs, has facilitated the growth and development of private and corporate hospital sector in India (Share of hospital beds in private hospitals 78.3% and public hospitals 21.7%, India Health report 2010). The growth of private tertiary care hospitals has been concentrated in the Southern states and urban metropolises. The corporate sector has invested in the multispecialty hospitals that focus on income earning procedures, interventions and checkups. In the public sector, government has developed tertiary hospitals in medical colleges to the extent possible. more than half are in the private sector. India has substantial achievements to its credit. Longevity has doubled from 32 years in 1947 to 66.8 years at present; Infant Mortality Rate (IMR) has fallen to 50 per thousand live births (CBHI data); smallpox and Guinea worm disease have been completely eradicated and leprosy and polio are nearing elimination. Indian doctors are comparable to the best in the world. They are technically proficient, and capable of performing sophisticated procedures and that too at a fraction of the cost available in the West. However these achievements should not mask India's failures. Levels of malnutrition and rates of infant and maternal deaths stagnated during the
15

However, of the 330 medical colleges

1990s. Although India accounts for 16.5% of the global population, the country contributes to a fifth of the world's share of diseases: a third of the diarrhoeal diseases, TB, respiratory and other infections and parasitic infestations, and perinatal conditions; a quarter of maternal conditions and a fifth of nutritional deficiencies, diabetes & CVDs (NCMH sources). Apart from the unfinished agenda of communicable diseases, there is emergence of life style diseases in a big way. In addition, there is increase in microbial resistance and emergence of new pathogens. Injuries and road traffic accidents are also posing a tremendous challenge. Accidental trauma is one of the leading causes of mortality and morbidity in India. 80,000 persons die every year & 1.2 million are seriously injured. By the year 2020, Road traffic accidents in India would be a major killer accounting to 5,46,000 deaths and 1,53,14,000 disability adjusted life years lost (Projection WHO- 2002). India faces a huge need gap in terms of availability of number of hospital beds per 1000 population. With a world average of 3.96 hospital beds per 1000 population India stands just a little over 0.7 hospital beds per 1000 population (ehealthonline.org source). Nearly one million Indians die every year due to inadequate healthcare facilities and 700 million people have no access to specialist care and 80% of specialists are working in urban areas (TOI). The decline in public investment in health and the absence of any form of social insurance have heightened insecurities. The unpredictability of illness requiring substantial amounts of money at short notice is impoverishing an estimated 3.3% of India's population every year. The poorest 10% of the population rely on sales of their assets or on long-term economic prospects. Defining Tertiary Care: Tertiary care is specialized consultative health care,
16

borrowings, entailing inter-generational

consequences on the family's ability to access basic facilities and affecting their

usually provided for inpatients following referral from primary or secondary health professionals, in an institution that has personnel and facilities for advanced laboratory and imaging investigations as well as for highly skilled clinical management. In this paper we argue that some of the tertiary care provisions can be made at the level of District Hospitals by strengthening them. Health being a state subject, Central Government can announce a scheme that could encourage states to strengthen the District Hospitals. Expand-Equity-Excellence Three Es of Tertiary Care: The first

requirement for any population is to have access to adequate health care. Tertiary care should be accessible to people who need it. In an integrated national health system patients receive care at the primary and secondary level for most conditions, and are referred for tertiary care when appropriate. However, such a system needs strong and effective primary and secondary system of health. In India the problems of PHCs and CHCs are well known. It is unlikely to change quickly in near future. Even super-specialty institutions like AIIMS are facing high burden of patients who could have been treated at secondary level. It is matter of concern that patients have to travel from farflung areas for tertiary care at institutions such as AIIMS. Hence, the current functioning of three-tier system needs to be reviewed. Further the cost of setting up the tertiary care hospitals is increasing fast. Also worth mentioning is the fact that there is a continuing improvement in general awareness, literacy rates and patient preferences in healthcare decisions because of which it has become imperative for healthcare institutions in India to guarantee quality healthcare to all. There is a revolution in technology & information management systems. With rise in income levels and
17

increasing adoption of health insurance, the demand for tertiary care is expected to grow. Hence, it is essential to expand the healthcare facilities across the country so that everyone could have access to healthcare services. The health care infrastructure needs to support all those who need health services. Currently such services are not equitably distributed. As stated earlier, several tertiary care services can be delivered at the level of the district. To provide quality care to all, referral system needs to be strengthened and well coordinated with secondary level institutions, primarily the district hospitals. Super-specialty institutions of national recognition and regional importance, can support this system. They are centers of excellence. Access and equity would not serve the purpose unless system ensures quality of care. One of the prime reasons of high burden of clinical services on nationally recognized institutions has been their repute for high quality care. Such high burden also seems to be impacting the balance of activities of the highly skilled professional staff in these institutions with a significant decrease in time devoted to biomedical research. To overcome this challenge, it is suggested that a system of accreditation could be developed. Health services accredited by nationally recognized institutions and similar institutions of high repute would strengthen quality of care, referral system and balance of activities at centers of excellence in the country. Emerging Scenario: The tertiary healthcare infrastructure in the country has expanded significantly in the post-economic liberalization period, mainly through private sector. The corporate hospitals came into existence after the government allowed private participation and investment in hospitals. The entry of corporate sector into the Indian healthcare industry has improved high-tech infrastructure and raised the quality of services. Simultaneously it has also
18

attracted many high performing doctors from public health system to private sector owing to high remuneration, state of art technology and general working environment. Healthcare services seem to be moving away from the reach of the poor. Other issues and challenges in public health system include ethical issues, political interference in administration, low awareness of diseases, skewed infrastructure facilities, low penetration of health insurance, increasing competition. Currently the Indian healthcare industry is growing at an annual rate of 13%. Indian middle class is driving the demand for quality healthcare services higher. The consequent expansion of private hospitals and increased public spending on health could lift the growth rate further. Other factors that could drive the overall growth include ageing population, growing urbanisation, improving physical infrastructure, higher awareness, skilled professionals, low-cost treatments, health insurance, bank funding, telemedicine, business process outsourcing and health tourism. Major private hospitals are planning to come up with health cities in several metros by offering facilities such as hotels, residential facilities, recreational facilities etc. By 2025, the population of India will reach ~1.4 billion, 45% of which will be urban adults (>15 years). To cater to this demographic change, the healthcare sector has to improve its contribution to GDP to 8-10%. By then, the ten leading corporate hospitals will capture as much as 30% of the market (Cygnus Business Consulting Report 2009). Already the rate of technology changes is high. The speed of technological advances would be increasingly higher in years to come.

19

Given the role of the private sector in health, various state governments are exploring the options of involving the private sector in meeting growing health care needs. Public-Private Partnerships have emerged as one of the options to direct the growth of private sector towards public goals. Developing incentives system to influence the desired geographic distribution of health facilities, and in specified areas, involving qualified providers through contract mechanisms in rural areas to improve the health delivery care system are some of the options being explored. Public health system has also been strengthened in the 11th Five-Year plan through Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) and other centrally sponsored/supported schemes, with a view to correcting the imbalances in availability of affordable/reliable tertiary level healthcare as well as to augment the capacity of production of specialists / super-specialists in adequate numbers and of requisite quality and competence to provide such services. These issues are inter-linked and are reviewed in Chapters 2 & 3.

20

Chapter 2: Human Resources for Tertiary Health Care The success for achieving the national health objectives will depend upon the effective delivery of health care services, which in turn, would depend largely on the nature of education, training and appropriate orientation of all categories of medical and health personnel. Equally urgent therefore is the need to assess appropriate manpower mix in terms of the required numbers and assigned functions of human resources for health in tertiary health care. Projected Need for specialists An Assessment: For a proper assessment of needs, one requires reliable morbidity data, as also information on available numbers of outgoing graduates and specialists of various types working in the community across the country. Data of this nature is limited and one may have to rely on sub-optimal information. For proper future projection, the Government may consider commissioning an external agency for providing reliable information. A group constituted by MCI studied these issues in depth and relied on data available from MCI and NBE regarding number of outgoing graduates and the data on morbidity provided by Ms. Shyama Nagarajan of the World Bank. The principles on which the numbers of postgraduate seats in various specialties were worked out included consideration of: (i) The need for overcoming the approximately 30% present deficiency of teachers in medical colleges; (ii) The numbers required, fulfilling the increasing needs of all medical colleges over the next 20 years including new colleges; and (iii) The numbers required, providing for specialists required outside of medical colleges. The suggested numbers of doctors with postgraduate qualifications are shown in the following tables (Table 2.1, Table 2.2, & Table 2.3).
21

Table 2.1 *Projected need for Specialists and Teachers Need assessment Clinical Specialties
2010 Total # of Specialists 842,598 2021 2031 2,319,237 Per Year 2030 Total Specialist 185,539 371,078 208,731 115,962 185,539 115,962 92,769 92,769 46,385 92,769 Need of seats 8079 16157 9089 5049 8079 5049 4039 4039 2020 4039 16000 3600 860 96 15000 80 100 1,380,214 Per Year 2020 Need Total of Norms Total MCI DNBE Actual Need Gap Specialist seats Gen Surgery 8% 60590 1800 200 2000 2020 20 110,417 4039 General Medicine 16% 121180 1900 250 2150 4039 1889 220,834 8079 Gynecology 9% 68164 1500 350 1850 2272 422 124,219 4544 Orthopedics 5% 37869 1000 250 1250 1262 12 69,011 2525 Pediatrics 8% 60590 1200 300 1500 2020 520 110,417 4039 ENT 5% 37869 700 100 800 1262 462 69,011 2525 Ophthalmology 4% 30295 900 280 1180 1010 -170 55,209 2020 Chest Medicine 4% 30295 300 50 350 1010 660 55,209 2020 Psychiatry 2% 15148 450 50 500 505 5 27,604 1010 Dermatology 4% 30295 450 50 500 1010 510 55,209 2020 Anesthesia DNA 1600 350 1950 4000 2050 8000 Radiology DNA 700 200 900 2000 1100 1800 Radiotherapy DNA 200 15 215 400 185 430 Transfusion Medicine DNA 24 0 24 50 26 48 Family Medicine DNA 182 5000 5000 10000 Nuclear med DNA 1 10 20 20 40 Others DNA 15 30 30 60 Based on OPD Patients Data, MOH website, MCI website, NBE website/WHO disease burden Approximately Double by 2020, Four times by 2030 (medical colleges - 2020- 400, 2030 - 500) Per Year Seats 2010

* Source : Medical Council of India : Under-graduate and Post-graduate Working Group (2010-2011)
22

Table 2.2 Need Analysis Super-specialty

2010 Total # of Specialists 842,598 Per Year Seats 2010 Norms Neurosurgery CTVS Cardiology Urology Neurology Gastroenterology GIS Plastic Surgery Endo Nephrology Hematology Pediatric surgery Oncology Geriatrics Immunology Surgical Oncology Clin. Pharm. Neonatology Cardiac anesthesia 4% 6% 4% 5% 4% 1% 1% 1% 3% 1% 3% 1% Total MCI DNBE DNA 152 17 30295 136 24 45443 202 58 30295 134 8 37869 123 23 30295 73 16 7574 20 11 7574 137 11 7574 38 6 22721 66 27 7574 11 0 DNA 104 8 22721 36 15 7574 0 DNA 10 2 DNA 33 10 DNA 13 DNA 13 8 DNA 8 DNA - Data Not available Actual 169 160 260 142 146 89 31 148 44 93 11 112 51 0 12 43 13 21 8 2021 1,380,214 Per Year 2020 Need Total of Specialists seats 300 55,209 300 82,813 400 55,209 300 69,011 250 55,209 200 13,802 100 13,802 250 13,802 100 41,406 200 13,802 50 200 41,406 100 13,802 25 80 25 50 25 2031 2,319,237 Per Year 2030 Total Specialists 92,769 139,154 92,769 115,962 92,769 23,192 23,192 23,192 69,577 23,192 69,577 23,192 Need of seats 600 600 800 600 500 400 300 500 200 400 100 400 200 50 160 50 100 50

23

Table 2.3 Need Analysis Basic Sciences and other Specialties

2010 2020 Approx Number of Seats Need of Available Pass per Year Need teachers Gap Pathology 1000 700 6000 1500 8000 Anatomy 450 150 3600 1500 4800 Biochemistry 360 150 3600 1500 4800 Microbiology 500 300 4200 3500 5600 Forensic 200 70 2400 1200 3200 Physiology 440 150 3600 1500 4800 Pharmacology 450 300 3600 600 4800 Community Medicine 500 400 6000 4500 8000 BASIC specialty data projected on need for teachers 2030

Need 10000 6000 6000 7200 4000 6000 6000 10000

24

Explanatory notes to needs data: 1. Calculation required for various specialists is based on projections drawn from the following data: a. Ministry of Health b. Medical Council of India c. National Board of Examinations d. OPD patient data. This, however, does not include those specialties that are non-OPD based such as Pathology, Anesthesia, Radiology etc. The calculation for these latter specialties is based on perceived needs taking into consideration the health care needs of community outside the teaching institutes also. 2. The basic principle followed took cognizance of the following: a. The available number taken for calculation includes those qualifying from institutes recognized by MCI and the National Board. b. The projected number also makes allowance for 30% deficiency that exists now. c. The numbers proposed for immediate increase reflects doubling of seats in some specialties that are critically short and a marginal increase in others. 3. The proposal visualizes doubling of seats by 2020 and a further doubling by 2030. 4. Basic specialties like Anatomy have enough seats per year but many seats are vacant and hence shortage of teachers persists. There is, therefore, a need for more incentives- like differential pay scales, special pay or accelerated promotions for teachers in these subjects. In some areas such

25

as Anatomy/ Physiology/ Pharmacology, one may also have a cadre of non-medical teachers. clinical departments. 5. For Basic sciences and Para clinical sciences, need assessment has been made based on number of teachers required in medical college. Numbers have been doubled to take care of other health care facilities and dental/ nursing colleges. 6. The problem of shortage is not only due to lack of seats but also due to the lack of popularity of courses amongst potential candidates. Hence private institutions are hesitant to start courses in basic specialties. Special incentives may need to be given to these institutions for this purpose. 7. The projected increase in number of specialists is notional. Passing rates are up to 70% in MCI courses and 50% in National Board courses. Hence the number of doctors available will be about 70-80% of the projected numbers every year. (Approximately 20% are lost due to failures in examinations, migrations etc.) With the suggested increase in numbers of outgoing postgraduates, the concern for faculty development becomes much more critical. The quality of output will be far from desirable unless measures in this direction are immediately initiated. Imbalances: Disequilibrium results from a discrepancy between the numbers, categories, functions, distribution and quality of health To attract medical graduates to subjects like Anatomy they may also be given the opportunity to work as part time in

26

professionals and allied health workers, and the national needs for their services to achieve its defined health objectives and also its ability to employ, maintain and support them. The setting up of new facilities will have to address imbalances at three levels: a) Regional: It will remain an important task for the Government to choose locations for setting up new medical colleges/institutes/centers at places that have relatively inadequate facilities. b) Specialties: As discussed in above tables, centers and institutions will aim to overcome the imbalances in specialties. c) Ratio of medical doctors to nurses and other healthcare professionals will have to be maintained. Historically capacity enhancing issues for nursing and other healthcare professional have been ignored. In the ultimate analysis, functioning of tertiary health care delivery team must be optimized.

27

Chapter 3: Expanding Capacity and Enhancing Quality Pradhan Mantri Swasthya Suraksha Yojana The tertiary care is generally associated with the health care provided at specialty and super specialty levels. These institutions also act as training centers for doctors and other allied health workers. These institutions are often equipped with the most modern technical equipments the knowledge of whose working provides the trainee with the advanced and updated hands on experience with latest technologies. During last few years, there has been sudden upsurge in the occurrence of diseases both communicable and noncommunicable. The central government was implementing various health programs across the country besides providing financial assistance to the States. However, the need for a more systematic and inclusive health program was felt which primarily catered to the need for more tertiary care centers in the country. It was in this backdrop that PMSSY was first launched in March 2006 with the primary objective of correcting the imbalances in availability of affordable/reliable tertiary level healthcare in the country in general and to augment facilities for quality medical education in the underserved States. Scheme set up six AIIMS like institutions (ALIs) in the underserved and un-served regions of the country. Cabinet Committee on Economic Affairs (CCEA) approved the scheme in March 2006 for Rs 332 crores per institution. The cost, however, escalated to Rs 820 crores per institution in March 2010. The places selected for setting up of six AIIMS Like Institutions (ALIs) are Patna (Bihar), Raipur (Chattisgarh), Bhopal (MP), Jodhpur (Rajasthan), Bhubneshwar (Orissa) and Rishikesh (Uttrakhand). The criteria for selection of these places were various socio-economic indicators like human development index, literacy rate, population below poverty line and per

28

capita income and health indicators like population to bed ratio, prevalence rate of serious communicable diseases, infant mortality rate etc. Each one of these six ALIs would have a 960 beds hospital with 300 beds dedicated to super specialty care in 42 disciplines. Initially the institution would have an intake of 100 students for MBBS course. Apart from this, facilities for imparting PG and doctoral courses are also proposed at these centers. These ALIs would also have a nursing college as a Centre of Excellence to run B.Sc. (Nursing) with 100 seats and M.Sc. (Nursing) with 25 seats. However, initial years of implementation of PMSSY faced certain problems that largely owed them to lack of experience, absence of credible inputs etc. Apart from this, there were other factors like delayed preparation of Detailed Project Report (DPR) and non-fulfillment of normative requirements. These factors collectively resulted in delay in tendering process that escalated the cost of the project with the passage of time. Nevertheless the proper governance structure for smooth and effective implementation scheme was established within the Ministry. A separate Division was constituted exclusively dedicated to the PMSSY scheme. The construction work at these six sites commenced during 2007-2008 and work of housing complexes, at Jodhpur and Raipur has already been completed. However, the construction work of Medical College and Hospital Complex has only been completed to the extent of 23-36% and 10-21%, respectively at various sites. It is expected that all civil works (housing; The medical college; and hospital) will be completed by September 2012. construction at other four sites would also be completed by May 2012.

29

The passing years have not only witnessed steady growth of PMSSY but there has also been a substantial experiential learning for the Central Government. The Ministry of Health and Family Welfare is now capable enough to take up such other projects as deemed necessary by the Planning Commission. Indeed, two additional ALIs have already been sanctioned for states of Uttar Pradesh and West Bengal. Current status of Six ALIs is as per Table 3.1. Table 3.1 Current Status of Six AIIMS Like Institutions
Institution Housing Complex
% Complete Contractual date of completion

Medical College
% Complete Contractual date of completion

Hospital Complex
% Complete Contractual date of completion

Bhopal Bhubaneshwar Jodhpur Patna Raipur Rishikesh

71.50 18.00 100.00 75.20 100.00 87.00

Dec 2011 Mar 2012 Completed Dec 2011 Completed Dec 2011

34.18 31.61 36.00 41.32 23.46 32.25

Nov 2011 Aug 2011 Dec 2011 Nov 2011 Aug 2011 Dec 2011

9.78 14.85 18.00 19.17 16.15 21.06

Sep 2012 Sep 2012 Sep 2012 Sep 2012 Sep 2012 Sep 2012

Financial allocations and utilization under PMSSY during 11th Plan is shown in Table 3.2.
Table 3.2 Expenditure Statement of PMSSY Project (Total budget: Rs. 3955 Crore)
Year 2007-08 2008-09 2009-10 2010-11 2011-12 Total Utilization (Rs. Crore) 87.49 484.01 474.48 652.01 1616.57 (expected) 3314.56 % of total allotted budget 2.21 12.23 12.00 16.49 40.87 83.80

30

Pattern of governance and management of ALIs was approved by the Union Cabinet in August, 2010. It was decided that each of these institutions will be registered under a society and will have two tier organizations and management infrastructure. The governing council under the chairmanship of Health Minister will be the apex body to decide on policy matters. There will be a board of governors with Secretary (Health) as the chairperson and persons with knowledge in the field of science and medicine will be nominated by the governing council. It was considered that creating legal entities in the form of societies for these institutions will facilitate greater autonomy and faster execution of projects and will expedite the release of government funds. These societies will be functional till the ALIs are brought under an Act of Parliament. It is noteworthy that a High Powered Committee was set up recently to review the Governance and HR practices at the AIIMS. The experience of the review indicates that the existing Institutions would also need similar review to optimize their functioning. It may be appropriate to consider the report of AIIMS Review Committee while formulating governance and management policies with respect of ALIs. B. PMSSY also envisaged up-gradation of several existing medical institutions in different states in the country. The following 13 existing medical institutions were identified in the first phase for such upgradation : 1. 2. 3. 4. Government Medical College, Jammu (J&K) Government Medical College, Srinagar (J&K) Kolkata Medical College, Kolkata (W.B.) Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (UP)

31

5. 6. 7. 8. 9. 10. 11. 12. 13.

Institute of Medical Sciences, BHU, Varanasi (UP) Nizam Institute of Medical Sciences, Hyderabad (AP) Sri Venkateshwara Institute of Medical Sciences, Tirupati (AP) (50% cost of upgradation will be borne by the TTD Trust) Government Medical College, Salem (TN) Rajendra Institute of Medical Sciences (RIMS), Ranchi (Jharkhand) BJ Medical College, Ahmedabad (Gujarat) Bangalore Medical College, Bangalore (Karnataka) Grant Medical College & Sir JJ Group of Hospitals, Mumbai (Maharashtra) Medical College, Thiruvananthapuram (Kerala)

Initially the estimated outlay for upgradation was 120 crores per institution, of which 100 crore was to be borne by the Central Government and the remaining by respective State Government. In view of the cost escalation, the outlay now has been revised to 150 crores per institution, with Rs. 125 crore as the share of Central Government. The current status of the upgradation of medical institutions under PMSSY is shown in Table 3.3. Table 3.3 Up-gradation of Medical Institutions under PMSSY (Current Status)
Name of the Institution
Tiruvananthapuram Medical College, Kerala Salem Medical College, Tamil Nadu Bangalore Medical College, Karnataka SGPGI of Medical Sciences, Lucknow, UP NIMS, Hyderabad, Andhra Pradesh Kolkata Medical College, West Bengal OPD Block

% Complete
100.00 100.00 100.00 100.00 100.00 100.00

Likely date of completion

Completed Completed Completed Completed Completed Completed

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Academic Block Super Specialty Block Jammu Medical College, Jammu and Kashmir Srinagar Medical College, Jammu and Kashmir Institute of Medical Sciences, BHU Varanasi, UP Ranchi Institute of Medical Sciences, Ranchi, Jharkhand BJ Medical College, Ahmedabad, Gujarat SVIMS, Tirupati, Andhra Pradesh Grants Medical College, Mumbai, Maharashtra

85.00 Work Started in April 2011 99.00 47.00 73.00 65.00 88.00 85.00 79.00

Aug 2011 April 2013 Aug 2011 Apr 2012 Nov 2011 Dec 2011 Oct 2011 Oct 2011 Oct 2011

In addition, the following institutions have also been included for upgradation under PMSSY : Phase II 1. 2. 3. 4. 5. 6. Government Medical College, Amritsar (Punjab) Government Medical College, Tanda (Himachal Pradesh) Government Medical College, Madurai (Tamil Nadu) Government Medical College, Nagpur (Maharashtra) Jawaharlal Nehru Medical College of Aligarh Muslim University, Aligarh (UP) Pandit BD Sharma Postgraduate Institute of Medical Sciences, Rohtak (Haryana) Phase III 1. 2. 3. 4. 5. 6. Government Medical College, Jhansi (UP) Government Medical College, Rewa (MP) Government Medical College, Gorakhpur (UP) Government Medical College, Dharbanga, Bihar Government Medical College, Kozhikode (Kerala) Vijaynagar Institute of Medical Sciences, Bellary (Karnataka)

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Expanding Capacity: It is a fact that there is an acute shortage of medical doctors besides imbalanced growth of medical colleges in the country. The shortage of medical teachers, PG specialists and super-specialists is particularly acute in pre and paraclinical disciplines, which entail adverse impact on the quality of education and patient care. To increase capacity, a Centrally Sponsored Scheme Up-gradation & Strengthening of State Government Medical Colleges for starting new postgraduate disciplines and increasing postgraduate seats by central funding has been launched during the 11th Five Year Plan. The objective of the scheme is to meet the shortage of faculty in pre and para clinical disciplines which is bottleneck for starting new medical colleges and to ensure that specialists with requisite clinical disciplines are available in required numbers. The scheme aims to provide central funding to assist State Governments to upgrade the existing infrastructure in Government Medical Colleges to start postgraduate courses and increase seats in existing postgraduate courses over a period of time. The medical colleges will be chosen for assistance under the scheme on the basis of following criteria: i) The State Government medical college / institution must be permitted / recognized by Central Government for running MBBS and or PG degree / higher specialty courses. ii) iii) The State Government Post Graduate medical institutions without MBBS must be recognized by Central Government. Needy States where PG courses are very few in comparison to other States will be given preference for starting / increasing particular specialty. iv) More PG courses will be started in the Government Medical colleges in northern part of India to reduce the imbalance in geographical and specialist distribution.

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Grants are proposed to be released to selected State Government medical colleges / institutions directly as per their actual requirement under a funding patter of 75% by Central Government and 25% by State Government. During 2009-2011, the Central Government provided financial assistance of Rs. 241 crores to 46 State Government owned medical colleges for strengthening and up-gradation to start new post-graduate Departments, which has resulted in the creation of an additional 2384 seats for postgraduate courses. With projected enhanced capacity of post-graduate education at all levels, and to maintain optimal ratio between specialists / super-specialists and general medical practitioners, it will be imperative to increase the admission capacity for undergraduate medical education. This can be done by increasing the number of seats in existing medical colleges as well as by establishing new medical colleges, especially in underserved districts / states. Recently, mid-term appraisal of the 11th Five Year Plan* indicates a major effort for the redevelopment of hospitals / institutions. different stages of completion. The process of redevelopment of hospitals / institutions under the central sector is at Redevelopment of the All-India Institute of Medical Sciences is being taken up in a comprehensive manner. Lady Hardinge Medical College & Smt. S.K. Hospital and Kalawati Saran Children (KSC) Hospital, New Delhi: Comprehensive Redevelopment Projects comprise of 3-4 phases. Phase I during the Plan, involves increasing existing bed strength of Smt. S.K. Hospital from 877 to 1,397 (an additional 520

* Mid-term appraisal of the 11th Five Year Plan, Health, P. 158

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beds) and increasing bed strength of KSC Hospital from 370 to 420 (an additional bed strength of 50). Regional Institute of Medical Sciences (RIMS), Imphal, Manipur: Upgradation involves repair / renovation of hospital building, construction of academic complex, new OPD building, nursing and dental wings, and hostel accommodation. Lokapriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam: Upgradation involves construction for the main hospital building, residential quarters, hostels, mortuary, incinerator building, sewerage treatment plant, renovation of the existing building, procurement of equipments and machinery, and additional human resources. Safdarjung Hospital & College, New Delhi: The redevelopment plan includes upgradation of specialties and super-specialty departments and increasing the bed strength from 1,531 to 3,000. Postgraduate Institute of Medical Education and Research, Chandigarh: Upgradation involves modernization of Nehru Hospital, modernization of the research block, advanced cardiac centre, advanced trauma centre, advanced eye centre, advanced mother centre, Institute of Paramedical Sciences, renovation of hostels for doctors and nurses, and augmentation of equipment. Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry : Comprehensive Redevelopment project comprises of the construction of a teaching block, a 400-bedded women and children

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hospital, upgradation of existing departments, construction of a new hostel complex, and procurement of equipment. Governance and Management of Health/Medical Institutions: For

optimizing the functions of presently established as well as upgraded institutions, and ensure similar outcomes of the institution to be established during the 12th Five Year Plan, the major concern is regarding the governance and management of these institutions while ensuring their professional autonomy. Key factors that adversely affect the functioning of the public health system relate to structure, governance mechanisms, administrative capabilities and weak Human Resource Management policies. In addition to the expansion of capacity, it would remain essential to strengthen the management and governance of the existing medical colleges/hospitals. It is suggested that every medical college should undertake periodic review through external peer level Institutes like IIMs for continuous strengthening of these parameters. It is equally imperative to strengthen Human Resource Management Policies. Medical profession demands much higher commitment, knowledge, skills, complexity and competence than any other stream. To attract, retain and nurture talent, remuneration should be so fixed as to provide compensation to medical fraternity commensurate to their years of study and experience. Research Grants should allow the faculty / researcher(s) additional salary support. It is recommended that a group of senior professionals / administrators from the Post-graduate Medical Institutions, IIMs and IITs may be constituted to undertake an in-depth review and make appropriate recommendations.

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Recommendations/Suggestions: The working group is of the firm opinion that the expansion of tertiary care institutions is an essential requirement in the country. The group has however sounded a note of caution on compromising the quality for sake of increasing the numbers. The members were unanimous in their opinion that the expansion in the next five year plan must be systematic whose contours must be based on infusing quality in the future medical education. The growing demand for super specialty care has drastically increased load of patients at existing centers which is making it difficult for health service providers and is causing hardships to the patients. The Working Group commends the intensive and concerted efforts during the 11th Five Year Plan, especially since 2009, through PMSSY as well as centrally sponsored and centrally supported initiatives. The following suggestions/recommendations are given for inclusion in the 12th five year plan (2012-17). 1) The group recommends creation of 4 (four) new AIIMS Like Institutions (ALIs) during the 12th Plan period in addition to 8 (eight) already established under PMSSY (phase I & II), on the pattern followed earlier. The selection of regions for developing these facilities would be the geographical location, physical infrastructure, ease of connectivity with medical colleges, as well as health indicators and local disease burden. 2) The possible modes for developing 4 new AIIMS like institutions can be as follows a. Option 1 - These institutions can be set up as stand - alone facilities.

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b. Option 2 These institutions can be developed in the existing centers of medical education and health care. In view of the time over-runs and cost over-runs in the implementation of PMSSY, and the need to develop sound governance and management systems, the Working Group suggests that Ministry of Health & Family Welfare may consider creating an Apex Team that may facilitate these projects. 3) The government medical colleges should be strengthened for the dual purpose of creating a larger pool of doctors and other health workers that can be used at PHC and CHC and providing super specialty health care to the population in that region. As 25 Medical institutions have already been approved under PMSSY, it is suggested that additional 30 medical colleges, established at least 20 years back and requiring immediate financial assistance for strengthening and upgrading its facilities, be identified for support through PMSSY. 4) Other medical colleges can also be considered under centrally sponsored scheme for the purpose of upgradation & strengthening of State Government Medical Colleges for starting new postgraduate disciplines and increasing postgraduate seats by central funding. The scheme should include 80 medical colleges during 12th Five Year Plan. Thus with 55 medical colleges supported under PMSSY Phase II & III and 80 medical colleges strengthened through centrally supported scheme, nearly 90% of all Government Medical Institutions would upgraded during 12th Five Year Plan. 5) The major effort launched during the 11th Five Year Plan for redevelopment of hospitals / institutions under the central sector is
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commendable.

However, all projects planned / launched need to be

completed without undue delay. In addition, during the 12th Five Year Plan, other hospitals / institutions may be identified for redevelopment. These may include CIP Ranchi, LRS Inst. Of TB & Respiratory diseases, New Delhi, NTI, Bangalore, and ND TB Centre, New Delhi. 6) Medical colleges and other tertiary care centers should be connected through tele-networking. The National Knowledge Network is being actively implemented throughout the country. Still these efforts need to be reinforced with more such steps. Even private institutions can also be made a part of this network on payment basis. The proposed tele-network would cater to the demand of distance education in health education, training, faculty development, tele-consultation etc. centers of health care. 7) The members of the working group further recommended that the Ministry of Health and Family Welfare must open channels of interaction with Ministries of Defence, Railways and Labor (ESI), which are also running medical colleges and health care institutions. Ministry of Health and Family Welfare can explore the possibility of developing tertiary care centers at these institutions by providing financial and technical assistance on sharing basis and even transform health care institutions of these Ministries into medical colleges. 8) Medical profession demands much higher commitment, knowledge, skills, complexity and competence than any other stream. To attract, retain and nurture talent, remuneration should be so fixed as to provide compensation to medical fraternity commensurate to their years of study and experience. Research Grants should allow the The flow of knowledge and consultancy would be from tertiary to lower

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faculty / researcher(s) additional salary support. It is recommended that a group of senior professionals / administrators from the Postgraduate Medical Institutions, IIMs and IITs may be constituted to undertake an indepth review and make appropriate recommendations.

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Chapter 4: Strengthening of District Hospitals and Linkages with Medical Colleges As discussed in Chapter 1, Expand-Equity-Excellence - Three Es of Tertiary Care would be essential to improve the quality of health care delivery system in the country. The mandate of the Working Group is to focus on tertiary health care during the 12th Five Year Plan. Nevertheless, it needs to be reiterated that the essential prerequisite for building tertiary health care is a strong foundation of primary health care and a well organized secondary health care. A blend and balance between different levels of health care is critical for a holistic approach to health delivery system. The existing infrastructure at the District level needs to be strengthened to ensure access, quality of healthcare to all, and in strengthening the referral system. With the standardization of processes with the application of technology, many specialist conditions may be effectively managed at the district level. Further, good tertiary care requires accurate decisions regarding referral from the district hospital, proper communication, information transfer, and transportation between district hospital and medical college. Medical Colleges can support district hospitals through telephone and telemedicine and also provide training of district and subdistrict staff thereby improving the quality of secondary care. Patients who complete tertiary care need to be referred back to secondary level for chronic disease and step down care. Conditions that require rehabilitation and palliative care are better managed at the primary and secondary level with referral support. Therefore it is important to think of tertiary care as a continuum with secondary care and the rest of the health system.

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District Hospitals During the Eleventh Plan, upgradation of district hospitals was envisaged as a key intermediate strategy, till the vision of healthcare through PHCs and CHCs is fully realized. The scheme has two components strengthening of maternal health and child health wing / hospital and other wings in district hospitals (this component has since been subsumed under NRHM) and upgradation of district hospitals into teaching hospitals in underserved areas. The latter component has since been bifurcated into two: (i) upgradation of state medical colleges for meeting the shortage of specialists; and (ii) upgradtaion of district hospitals into teaching hospital in underserved areas through PPP. Strengthening of Linkages between Medical Colleges and District Hospitals: Medical College be linked to one district/ or 2-3 districts for tertiary referral services. The number of district hospitals to be linked with a Medical College should be based on population, geographical area and availability of hospital based health services in the particular district. The upgraded medical colleges under PMSSY, in the first instance, must be made responsible for tertiary care services in the district and provide referral support through telephone, telemedicine and through training of district level specialists. The District Hospitals linked to upgraded medical college should be provided necessary financial and technological support through a centrally sponsored scheme in the 12th Five Year Plan. This would enable requisite upgradation in terms of specialized manpower,

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equipment and treatment facilities for ailments such as cardiovascular diseases, diabetes This care and its complications, substantially Financial neurothe for psychiatric illnesses and cancer, along with provision of quality rehabilitation the load on facilities. tertiary would help outlay community to avail facilities at district level, thereby also reducing institutions. upgradation of 100 district hospitals needs to be provided during the 12th Five Year Plan. The ongoing and continued support shall be the responsibility of the respective State departments. The upgradation of the district hospitals in the 12th Five Year Plan should be based on: (i) epidemiological assessment of diseases burden in the area. Care of common diseases prevalent in the region which require specialist services that can be provided at the District Hospital level; (ii) technologies and treatments that are cost-effective need to be provided at the District Hospital level and personnel for the same, if not available, can be trained at the medical college. The medical college should use the district health system for training of undergraduate and postgraduate medical students and residents. Part of undergraduate and postgraduate training should be provided in the learning setting outside the medical college in the district health system. It is recommended that all medical colleges should be encouraged to develop their own corpus to attain financial flexibility over a period of time. The colleges could decide the fee and charges for different facilities for patients in paying beds. Government can contribute matching grant to help them develop their own corpus.

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Chapter 5: Strengthening Partnership between different Service Providers (PPP option) As discussed earlier, private sector plays a dominant role in Healthcare Sector in India. However, tertiary care is not an easy business for private sector and they constantly look towards Government for support. With potential 25-30% EBITDA margins in steady state, along with 25-30% ROCE, tertiary care is a highly attractive business, if executed well. However, operators need deep pockets and patience to succeed owing to long gestation periods. Land and building account for nearly one third of the total cost of setting up a hospital bed. Given the shortage of skilled professionals, hiring and retaining personnel is a challenge. Public-Private Partnership (PPP) is seen as one of the instruments to improve or reform the health status of the population. In addition to resolving the problem of decreasing budget support, such partnerships are also able to overcome the inadequacies on the part of the public sector to provide public service on their own in an efficient and effective manner owing to lack of financial or other resources, and management issues. The success of PPP is anchored on three principles. First, a relative sense of equality between the partners; second, there is mutual commitment to agreed objectives; and third, there is mutual benefit for the stakeholders involved in the partnership. Approaches to Partnerships: PPPs are modeled on different partnership mechanisms. Among the types and models of partnership the most common are contracting (contracting-out and contracting-in); franchising; social marketing; joint ventures; subsidies and tax incentives; vouchers or service

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purchase coupons; autonomous institutions; build, operate, and transfer (BOT); philanthropic contributions; health co-operatives; grants-in-aid; capacity-building; leasing; and social health insurance. Advantages and Disadvantages of PPPs in healthcare: Governments worldwide have increasingly turned to the private sector to provide healthcare services that were once delivered by the public sector. The prime advantages in this are: Increased efficiency in service delivery, operations and management owing to better capacity utilization. Making services equitable, accessible and of good quality Availability of additional resources (technical, infrastructure and financial) to meet the growing needs in the sector; and Access to advanced but fast changing technology There are some advantages and disadvantages linked to partnerships with different private sub-sectors. Informal sector has the advantage of accessibility, client orientation and lower cost. It carries a limitation of quality of care, mainstreaming and adequately educated. Not-for-profit organizations are characterized by high quality of care, targeting to poor, lower cost and community orientation. However there is an inherent limitation of small coverage, lack of resources, difficult scaling up and ad hoc intervention. For-profit organizations are characterized by high quality, high reach, innovation and efficiency. However, they are generally clustered in cities and are expensive. Hence the choice with any sub-sector would be driven by the purpose of partnership. Partnerships appear to be most justified where traditional ways of working independently have a limited impact on a problem; the specific desired goals can be agreed by potential collaborators; there is relevant complementary expertise in both sectors; the

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long-term interests of each sector are fulfilled and the contributions of expertise and resources are reasonably balanced. Competency Requirements of the Government in Implementing Partnerships: Capacity constraints that the government may have in implementing PPPs have to be overcome through appropriate capacity strengthening exercises. Some competencies that the government needs to develop in order to overcome the constraints include: 1) Capacity to design and prepare reforms a. Development of a clear framework b. Ability to seek consensus for the policy/programme c. Ownership and political commitment d. Bringing in involvement of civil society organizations 2) Capacity to implement new delivery structure a. Adequate number of personnel b. Good administrative, management and planning skills and competencies c. Motivation of personnel available for the programme. d. Proper financial and information systems e. Ability to coordinate and communicate with partners f. Ability to overcome bureaucratic and rigid systems 3) Capacity to contract services a. Ability to make judgments on contracting arrangements to be made b. Skills for contract design and negotiation c. Skills of monitoring

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4) Capacity to regulate and enable a. Appropriate government legislation b. Legal expertise c. Adequate information systems d. Credibility and trust of government Enabling Conditions for Partnership: Partnerships are no substitute for good governance and that partnership requires governmental leadership. Factors that contribute significantly to providing an enabling environment for partnerships are the financing, payment mechanisms, management structure, behavior of the partners as well as the regulatory norms. Financing: Financing plays one of the most important roles in the performance of the health system since it determines how the money is made available, which partner makes the finances available, who controls it and how it is used optimally. Costing Approaches: For financial purposes of schemes, costing will have to be worked out. Accurate estimation of the costs of specific healthcare services and the cost of care for individual patients is critical to the efficient administration of healthcare systems, to prevent inappropriate payment incentives, and to the conduct of health services research. Approaches to estimating costs could be top-down and bottom-up. a) Top Down Approach: It uses relative value units (RVU), hospitals days, or some other metric to assign total costs for a healthcare system to individual services. b) Bottom Up Approach (such as activity-based costing): It assesses the amount of each resource that is used to produce an individual healthcare

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service and assigns costs accordingly to generate aggregate costs for a healthcare system. Bottom up approach is more detailed and accurate of the two. However, it is more complex and therefore more difficult and costly to implement. In the context of PPP, top down approach is likely to be more efficient. Payment or Incentives: Making finances available for a partnership programme is the first step towards reform, but the next and equally important step is to determine which organizations and individuals have to be roped in as partners in the reform process. It is also important to decide how much they have to be paid and for what. Management Structure: Undoubtedly, adequate financing and proper

incentive strategies are important to make the public-private partnerships work. However, in order to ensure that the funds are being allocated effectively and efficiently and targets being achieved, it is imperative to have a sound management structure in place. The roles of all the partners have to be clearly outlined. In this respect, governments can resort to signing of a contract between the partners. Regulatory Mechanism : Before a public-private programme takes off, there has to be a regulatory mechanism in place to see that the health care targets are being achieved, the target population is benefiting out of the partnership and that the concerned partners are functioning honestly and efficiently. The regulatory mechanism should be able to settle issues like disagreement on price, terms and condition of the contract at that particular time, and any shortfall in honoring the contract from both the parties.

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Institutional Mechanisms: Effective guidelines and institutions should be in place in order to regulate various stakeholders in the partnership. Institutions for managing PPP should be established at a cross-sectoral level in order to share experiences from different sectors and adapt it for the health sector. Suggestions: 1) Immediate requirement would be to enhance capacity to manage PPP, as discussed earlier in this chapter, in the areas of designing and preparing reforms, implementing new delivery structure, contracting services, regulating and enabling PPP. 2) Creating Enabling Conditions for Partnership 3) Initially bottom-up approach of costing should be undertaken to set the standards. Once the standards are in place, monitoring should be based on top-down approach, using relative value units (RVU), hospital days, or some other metric to assign total costs for a healthcare system to individual services. 4) Government will have to create mechanisms for smooth system for payments. 5) For ensuring that funds are being allocated effectively and efficiently and targets being achieved, it is imperative to have a sound management structure in place. The roles of all the partners have to be clearly outlined. In this respect, governments can resort to signing of a contract between the partners.

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6) Before a public-private programme takes off, there has to be a regulatory mechanism in place to see that the health care targets are being achieved, the target population is benefiting out of the partnership and that the concerned partners are functioning honestly and efficiently. 7) To ensure positive bahaviour of actors in PPP, appropriate HR and communication system would be developed. A detailed study for this may be given to institute like IIM for this purpose. 8) Lessons drawn from PPP successful models such as Chiranjeevi for obstetrical care of BPL women in Gujrat need to be carefully analyzed and if applicable, adapted/adopted. 9) Institutions for managing PPP should be established at a cross-sectoral level in order to share experiences from different sectors and adapt it for the health sector.

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Chapter 6: Information and Communication Technology in Health Care The country already has the advantage of a strong IT fibre backbone and indigenous satellite communication technology with trained human resources. With enhanced efforts, telemedicine could help bring specialized healthcare to the remotest corners of the country. Telemedicine is likely to provide the advantages of tele-diagnosis, especially in the areas of cardiology, pathology, dermatology, and radiology besides effectively operationalizing Continuing Medical Education (CME) programmes. Although e-Health (Telemedicine) was included in the 11th Five Year Plan, no significant progress has been made till date*. In addition to strengthening National Medical Library and networking of Institutional Libraries, the Working Group sharply focused on the use of Information and Communication Technology (ICT) in health care and medical education and took stock of utilization of existing facilities for wider use of telemedicine, tele-education and IT in enhancing the quality and reach of tertiary health care and in promoting continuing professional development of human resource in health. Telemedicine: Telemedicine can be defined as the use of electronic communication technology to exchange patient information and provision of health care services at remote locations. World Health Organization defines telemedicine as the delivery of health care services, where distance is critical factor by all health care professionals using information and communication technology for the exchange of valid information for diagnose, treatment and prevention of disease and injury, research and evaluation and for continuing education of health care providers, all in the interest of advancing the health of individuals and their communities. * Mid-term appraisal of the 11th Five Year Plan, Health, P. 161
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Global Telemedicine has gone far beyond providing health care services alone. It is now being extensively used also for education, research and management of data. It is, however, paradoxical that despite Indias strength in information technology, the use of telemedicine is still at a fairly nascent stage especially in the public health sector. Although, initially introduced by the private sector, sporadic projects have been subsequently developed both through Government and private initiatives. Ministry of Health and Family Welfare, apart from setting up a Task Force on Telemedicine, has also designed tele-ophthalmology under the Blindness Control Programme and ONCONET under the National Cancer Control Board. Both these projects are yet to be commissioned on nationwide scale. The Clinical Establishment Act of 2010 mandates a nation-wide network for registration of clinical establishments. Similarly, the Some Transplantation of Human Organs Amendment Bill, 2011 seeks to create a nation-wide network of all organ retrieval and transplant centres. work has also been done on Electronic Health Records. The Central Government Health Scheme has successfully networked all its dispensaries across 24 cities. AIIMS is also implementing a tele-education project in partnership with Ministry of External Affairs for five African countries. Despite its strengths and potential, telemedicine has not become an extensively used tool for the dissemination of information and knowledge in the health care and medical education sector. There are both technical as well as logistical issues that are responsible for this. Foremost among these issues is the problem of last mile connectivity. Further in the Government sector, non-availability of dedicated human resource that could be deployed for achieving the telemedicine objectives has been a major bottleneck. Most

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secondary and tertiary health care institutions of the Government are so over-crowded and over burdened that the Doctors are unable to spare time to attend to the telemedicine calls. Erratic power supply, especially in our rural areas, is another obstacle in the expansion of telemedicine. In many parts of the country, power supply is not available to charge the UPSs attached to computer system. Therefore, in an effort to popularize telemedicine, the first and foremost challenge is to address these three core issues, if any tangible success is to be achieved. Further, there is also need for converging all Government initiatives on telemedicine and IT initiatives in health under one umbrella. Currently, Ministry of Health and Family Welfare, Department of IT, Department of Space, and Knowledge Commission amongst others are all working in this field but without any cohesion and coordination. Synergies are yet to be developed. Despite these constraints, telemedicine and information technology have the potential of exponentially upscaling capacities for delivering quality health care to remote places and also multiplying human resources in health. Use of Information and Communication Technology (ICT) in health can be broadly in four areas viz. Education, Research, Referral, and Management of Data. National Knowledge Network (NKN) connects 1500 knowledge institutions in India. NKN was launched in march, 2010 and is expected to complete all connections by March, 2012. As a network, NKN will continue for 10 years. NKN supports 1 Gbps (Giga Bits Per Second) connection today. NKN encompasses all engineering, science, medicine and agriculture institutions that are engaged in education and research. Using the principle of coherent synergy, NKN expects to provide an ambience in which researchers learn from each other and work on problems that are transdisciplinary in nature.

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Health and Education:

When ICT is applied to medical education, it is

possible to make high quality education available pan India seamlessly. NKN does just that. In fact, unified effort by practicing medical doctors, clinical and para-clinical researchers, medical research institutions, academies such as National Academy of Medical Sciences and a host of other such institutions from engineering and sciences (especially biosciences) can significantly enhance the effectiveness and reach of medical education. Hospital Management System: It is common experience that work places in the health systems are not adequately governed especially in remote areas. The management of medical colleges and district hospitals can be strengthened significantly with the application of Hospital Management System. It is surprising that even the apex institutions like AIIMS have not been able to take full advantage of ICT. Pilot Project Experiences and implications: Under the National Knowledge Network, a pilot project has been sanctioned at AIIMS to create virtual teaching module to deliver quality medical education to various network institutions. The collaborating colleges in this project are AIIMS, Delhi; PGIMER, Chandigarh; PGIMER, Calcutta; NEGRIHMS, Shillong; JIPMER, Pondicherry; Bhopal; UCMS, Delhi; LHMC, Delhi; and CNBC, Delhi. The Pilot project is expected to achieve the following: 1) The utility of NKN connectivity in Medical Teaching. 2) The acceptability of virtual teaching in medical education. 3) The equivalence of virtual teaching with at least a significant proportion of traditional medical teaching.

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In addition, this project will also establish a template for creation and utilization of virtual teaching modules. Eventually the virtual teaching programme can be used for: 1) Mentoring of the 6 (and eventually 12) AIIMS like institutions. 2) Developing a virtual curriculum in all medical colleges. 3) Virtual teaching in post graduate courses. Under the pilot project, the cost for equipment has been kept at Rs. 10 lakhs per institution. Given the facts that there are 335 MCI recognized medical colleges, of which 154 are in public (Government) sector, setting up virtual classrooms in all of them would cost approximately Rs. 15 crores. Private medical colleges / institutions, if they wish to avail of the facilities, shall bear the necessary cost. This of course is only the cost of equipment. Operational costs will be known only after the pilot project becomes operational. Medical fraternity could create lessons and make them available electronically for all on a 24 x 7 basis. Concepts that are hard to explain can be shown through video or animated graphics. Surgical practices can be shown live or recorded and shared electronically. Leading medical institutions can be encouraged to build video walls for electronic interaction with peers and peer groups. Lectures can be shared; an organized mission oriented program needs to be launched to create an asset of educational material for the whole country. Once in place, a process would be established that updates the material so generated, on an ongoing basis. To expose young students to these emerging opportunities, first level course in Imaging Technology, including IR imaging may be designed to show the potential to replace the existing imaging methods.

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Health Research: ICT can potentially transform the medical scene in India, by bringing about a sea-change in medical research. From traditional clinical research to the modern synthetic biology-based research, the opportunity is immense. Work on problems such as Cancer prevention, screening, diagnosis, and therapy can benefit from inter disciplinary cooperation. Medical fraternity has availed such benefits when MRI and Nuclear Imaging was integrated into medicine a few decades ago. Health and the Referral Chain: India has many top quality tertiary hospitals spread across the country. Due to under developed secondary and primary care systems and over-applied referral system, all these fine institutions are bursting at their seams, having to care for the number of patients several times more than they are designed for. Perhaps, India could redesign the referral chain by developing ICT in abundant measure. What ICT can do is to annihilate distance and time. In the case of patient care and emergencies, these are very useful to provide secondary to primary, tertiary to secondary, and tertiary to primary support as needed as if all the medical specialists concerned are in the same room with the patients. Perhaps, institution such as AIIMS can start right away experimenting with this idea using the National Knowledge Network. Health and Management of Data: Electronic Medical Records (EMR), is a fundamental pre-requisite in using ICT seamlessly in healthcare. While EMR is available in several forms, size, shape, and format, Indian medical community with a specific mandate should standardize EMR, create and establish ICT platforms for using EMR based systems, for universal benefits. Such an action plan will mesh well with NKN, NFON, and UID the three major initiatives in ICT deployment. Of course, medical applications will require the finest possible display as well as rendering technologies.

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The use of IT as outlined above seems to be most promising and costeffective. Nevertheless, a word of caution may be in order. A recent editorial in the Lancet (Issue 9791, p. 542, 13 August, 2011) described the fate of a similar project planned in the UK in 2002 that aimed at creating a fully integrated centralized electronic care records system to improve services and patient care. The budget for the undertaking was a substantial 11.4 billion. 9 years on, the Department of Health has spent 6.4 billion on the project so far, failed to meet its initial deadline, and has had to abandon the central goal of the project because it is unable to deliver a universal system. Recommendations: 1. Set up a National Mission on ICT in Health with a clear mandate to conceive design, and deliver ICT based health education and health care and converge all existing programmes under this mission. 2. Budgetary allocation of ~ Rs. 600 crores may be made in the 12th Plan for ICT in Health. 3. Encourage trans disciplinary research in medicine by associating with scientists, engineers, and technologists. 4. Introduce a didactic cum practical course at MBBS and MD (all specialties) highlighting the prospects of using ICT in Medicine. 5. Define the use of EMR in an integrated manner to seamlessly bring together primary, secondary, and tertiary healthcare.

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6. Once the pilot projects are successful, design the health referral chain with ICT integrated. Redefine the medical protocols as necessary and create sufficient hardware and software to automate the process. Emphasize on use of local languages and dialects, as it relates to common man. 7. Hospital Management System should be installed in all the institutions of tertiary care and district hospitals. 8. A separate IT cell should be created in the Ministry of Health & Family Welfare at the Centre. This centre will develop appropriate formats for appraisal of performance and collect real time data for reports and forward those reports to appropriate authorities for review and necessary action. 9. Reform and transform health education across the country using ICT and NKN to maximally utilize the services of content experts in medicine, science, engineering and technology for undergraduate and post graduate education.

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Chapter 7: Futuristic Vision for Education & Research in Tertiary Care Capacity building includes physical infrastructure, state-of-art technology, management information system, and more importantly, optimal number and quality of human resources for specialist services. Most of these issues have been reviewed in Chapters 2-6. Long-term planning requires futuristic vision and additional strategies. These deserve serious consideration. Bhore Committee (1943-46) recommended a blue print of health service delivery as well as of Human Resource Development for Health. All-India Institute of Medical Sciences (AIIMS) was proposed as a model for setting patterns of under-graduate and post-graduate medical education in the country as well as for the development of specialties for clinical care and for advanced education and training. Replicating AIIMS like institutions as a part of PMSSY is a most welcome initiative. However, it would adopt the same pattern that was considered by Bhore Committee nearly 75 years ago. Subsequent advances in biomedical sciences may necessitate consideration of additional models of biomedical research and post-graduate training and education in highly specialized areas. One of the models is National Institutes of Health in the US. Presently it On the

comprises of 27 Institutes and Centres, each with a specific research agenda, focusing on specific constellation of diseases or body systems. suggestion of Chairman of Working Group on Tertiary Health Care, the proposal was unanimously endorsed by the Working Group and is being included in the Final Report. The following list includes the institutes that

60

may be of relevance to national needs, and may be established during the 12th Five Year Plan: 1. National Cancer Institute: There is a major increase in the prevalence of malignant diseases, with significant morbidity and high mortality. National Cancer Control Programme, launched more than 25 years back, is intensifying efforts at screening, early diagnosis, and management through a network of centres located in district hospitals and medical colleges. Apical centres located in Delhi, Mumbai, Chennai, and Kolkata are providing highly skilled professional services to a large number of patients. However, the need of a National Cancer Institute primarily focused on basic and clinical biomedical research, and providing advanced professional skills development through education and training, with the aim of cancer prevention, early diagnosis, and innovative treatment interventions, is acutely felt. 2. National Institute of Infectious Diseases: A concerted effort needs to be mounted to undertake high quality collaborative research that strives to investigate epidemiologic pattern(s) and pathogenesis of infectious diseases prevalent in India. The Institute will intensify efforts to effectively deal with emerging and reemerging infectious diseases, mechanism(s) of drug resistance in diseases such as Cholera and Malaria, immune mechanisms underlying pathogenesis, and nutrition-immunity interactions. Such studies shall facilitate development of treatment protocols for common infectious diseases. 3. National Institute of Arthritis and Musculoskeletal Diseases: There is a felt-need of a centre that supports research into the causes, treatment, and prevention of arthritis and musculoskeletal disorders.

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There is a lack of skilled clinical researchers and laboratory investigators who can initiate high quality research into the causes and consequences of such diseases, and develop protocols for new modalities of treatment for acute as well as chronic long-term management of subjects with these disorders. 4. National Institute of Child Health: Integrated and collaborative basic and applied research on fertility regulation, medial disorders associated with pregnancy, neonatal screening, postnatal growth and development, as well as medial rehabilitation, strives to ensure that every child is born healthy and wanted, and enjoys normal growth and development, free from disease and disability. 5. National Institute of Diabetes: Diabetes Mellitus, especially Type 2 Diabetes (T2D) is now taking mini-epidemic proportions, carrying not The only immense disease burden but also entailing high social and economic costs due to its chronic macro- and microvascular complications. basic and applied research, and would establish an proposed institute will provide opportunities for supporting and conducting environment conducive to the training of leadership for national programme in diabetes (including associated non-communicable disease), endocrinology, and metabolic disease. 6. National Institute of Mental Health and Behavioural Sciences: There is an imperative need to enhance the understanding of the sociobiological basis of mental illnesses, develop intervention strategies for their prevention, and undertake clinical research to improve the quality of management. There has been a palpable lack of epidemiological research focusing on mental health concerns of people who live in rural

62

areas, especially in the border areas.

In addition to diverse pattern of

mental illnesses, drug abuse including alcoholism are affecting large segments of population in these areas, requiring urgent action to develop new and better interventions that take into consideration the diverse needs and circumstances of such rural population. National Centres of Excellence: The following list includes the Centres that may be of relevance to national needs, and may be established during the 12th Five Year Plan: 1. National Centre of Life Sciences: Basic biomedical research that is not targeted to specific diseases provides the key to futuristic scientific breakthroughs in biomedical sciences. Studies on genes (genomics), proteins (proteomics), and cells (cellular and molecular biology) provide the fundamental base and bases of our understanding of essential life process(es), and lay the foundation for future scientific discoveries for diagnosis, prevention and management of diseases. generation of biomedical scientists. 2. National Centre of Biomedical Imaging and Bioengineering: There is an acutely felt need of a national centre that improves health through enhanced quality and outcome of biomedical research by promoting fundamental discoveries, diagnosis and development of innovative technologies, and translation and assessment of technological capabilities in biomedical imaging and bioengineering enabled by relevant areas of bioinformatics, information technology, and computer sciences. Such research training programmes nurture national talent to produce the future

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3. National Centre for Hospital and Healthcare Administration: Under the PMSSY, establishment of AIMMS-like Institutions, up-gradation of existing medical colleges with focus on development of specialties and super-specialties, and establishment of new medical colleges, is being undertaken on an unprecedented scale. The number of medical colleges in the country is projected as close to 500 by the end of the 12th Five Year Plan. While each AIIMS-like institution will have provision of 900+ inpatient beds, hospitals associated with upgraded medical colleges will also have increased bed strength so as to facilitate expansion of postgraduate training and education. Most of our hospitals in public sector are not managed by trained medical administrators. One possible reason for this may be the lack of trained hospital administrators in the country. Currently postgraduate course in hospital administration (MD/MHA) recognized by Medical Council of India (MCI) is being offered at 7 institutions with combined annual intake capacity of about 20 students only. In this background of scarcity of trained hospital administrators and the need of the same for the efficient functioning of hospitals, it is recommended that a centre be established which can give skill upgradation training to those who are engaged or will be engaged in management of hospitals and healthcare institutions. The training will include modules such as : (i) management of Human Resource; (ii) management of Finance; (iii) management of Equipments and assessment of Medical Technology; (iv) management of roles and responsibilities administrative of various clinical cadre staff, of healthcare professionals staff, nursing like and staff, engineering

paramedical staff.

To reinforce these efforts, similar Centres for

Management in Health Care may also be established in one or more IIMs.

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One

or

more

centres

of

excellence

in

Hospital

and

Healthcare

Administration will function as Human Resource Development (HRD) Centre for AIIMS, 12 (8+4) AIIMS like institutions as well as for the healthcare workforce of the country. The centres will provide training facilities & capacity-building as per national health requirements. 4. National Centre for Nursing Education and Research: Major

emphasis has been placed in the recent years on reorientation of medical education with emphasis on skill development. To make the health care team optimally efficient, a similar reorientation is required to develop competency-based nursing education with emphasis on communication skills and professionalism in nursing practice. Patterns of nursing education, appropriately validated, can serve as models to be adapted / adopted by the nursing institutions in the country. 5. National Centre for Information Technology (IT) and

Telemedicine: There is an urgent need to incorporate the power of modern computational systems into the biomedical programmes so as to enlarge the scope and reach of telemedicine both for enhancing the quality of health care as also for enlarging the reach of continuing professional development. With the availability of National Knowledge Network (NKN), tertiary care institutions as well as National Academy of Medical Sciences must be connected with a large number of professional institutions. The advancing knowledge and new skills can thus be widely disseminated. 6. National Centre for Complementary Medicine: There is a felt but unmet need of continuing research and development in various systems of complementary medicine so as to disseminate authentic information

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and evidence-based practices of such system of medicines i.e. AYUSH through a rigorous scientific research and validation. Upgradation of Existing Centres into National Centres of Excellence: The following list includes the centres that are of relevance to national needs, and may be upgraded during the 12th Five Year Plan: 1. National Centre of Excellence for Cancer Treatment and Research :The Tata Memorial Centre , Mumbai is already fulfilling its role as national comprehensive centre for the prevention, treatment, education and research in cancer. It is recognized as one of the leading cancer centres not only in India but also in the South East Asia Region. Presently supported by Department of Atomic Energy, Tata Memorial Centre can reinforce its role as a leader in innovative research not only in advanced areas of genomics, proteomics, metabolomics and stem cell, but also in development of new drugs and drug delivery systems including research in herbal medicines. 2. National Centre of Excellence for Ophthalmic Sciences: Dr. R.P. Centre for Ophthalmic Sciences at the All-India Institute of Medical Sciences, New Delhi and Advance Eye Centre at Post-graduate Institute of Medical Education and Research, Chandigarh, are playing a pioneering role in providing quality ophthalmic care in several sub-specialties of ophthalmology eg. vitreoretinal surgery. With requisite additional financial support, the centres may be designated as National Centres of Excellence for Ophthalmic Science 3. National Centre for Mental Health and Behavioural Sciences: Till such time that a National Institute for Mental Health and Behavioural

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Sciences is established, the existing Institute of Human Behaviour and Allied Sciences may be upgraded into a National Centre of Excellence, subsequently developing into the National Institute of Mental Health and Behavioural Sciences. Likewise NIMHANS, Bangalore may also be upgraded into a National Centre of Excellence. 4. National Centre of Excellence in Neurosciences: The Neurosciences Centre at the All-India Institute of Medical Sciences, New Delhi is recognized for providing high quality medical and surgical tertiary care for neurological disorders. It also provides education and training in superspecialties in neurosciences. With additional financial support, it may be designated as National Centre of Excellence in Neurosciences. 5. National Centre of Excellence in Cardiology and Cardiac Surgery: The Cardiac Centre at the All-India Institute of Medical Sciences, New Delhi has played a pioneering role in providing high quality tertiary care for a large number of cardiac patients. As a part of All-India Institute of Medical Sciences, it has also been providing facilities for education and research in the super-specialty of cardiology, pediatric cardiology, cardiac surgery etc. With additional financial support, it may be designated as National Centre of Excellence in Cardiology and Cardiac Surgery. 6. National Centre of Excellence in Liver and Biliary Sciences: Presently, the Institute of Liver and Biliary Sciences in New Delhi is developing into a national resource facility for prevention, treatment, education and research in liver and biliary sciences. Its recognition as a Centre of Excellence would accelerate the pace of its growth and development.

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The essential and critical prerequisite for optimal functioning of existing and proposed National Institutes and Centres of Excellence for tertiary care, is a strong foundation of primary care and a well organized and coordinated system of secondary health care. With increasing investments in health both by the public sector as well as by the private sector, a continuing appraisal and articulation of health policy is necessary. A Centre of Health Policy Research with core faculty of experts in public health, health planning, health economics, health management and social sciences, amongst others, may provide the necessary forum for ensuring equity and accountability in health care. Setting up Universities of Health Sciences: The Bajaj Committee in 1987 recommended ways to ensure appropriate manpower mix of different categories of health professionals involved in delivery of healthcare. The committee conceptualized the University of Health Sciences aimed at creating a physical and academic environment where all faculties of health sciences could interact and provide a model for education and training of healthcare teams, through multi-professional and inter-professional education. To achieve this it was recommended that one such university should be set up in each state, and in the initial stage one in each region. The universities will affiliate all Medical Colleges, Dental Colleges, Paraprofessional Colleges, besides possibly considering grant of affiliation to Colleges, imparting graduation level of education in the State. The university will help in continuous upgradation of curriculum, monitoring of educational process, and methods of assessment and evaluation to enhance the quality of education. Several universities have already been established in different states. However, these universities are almost entirely devoted to granting affiliation of professional and para-professional

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institutions, recognizing courses of instruction and training programmes besides organizing, monitoring, and supervising various examinations including entrance examinations to such courses. As recommended in the

report of Bajaj Committee* : It is entirely likely that several new faculties will grow in the Universities of Health Sciences : faculties such as those of health management, health economics, social and behavioural sciences and nutrition are needed even today. Likewise, the universities must ensure that graduating professionals are imbued with a spirit of service and a healthy respect for the patients dignity, rights, religious faith and beliefs. Members of the faculty and other professional staff must serve as role models. To provide an intellectually stimulating and academically rewarding

environment, social issues of contemporary relevance need to be identified in relation to the growth and development of these Universities as originally envisaged. Study and research programmes through multi-disciplinary Study Centers need to be established in the following areas and networking between the universities and identified institutions established.

1. Study Centres of Population and Environmental Sciences: To focus on epidemiology, demography, sociological and behavioural aspects related to population and environment. 2. Study Centres for Health Systems and Health Services management: To focus on research and analysis to determine the cost-benefits and cost effectiveness of various health and family welfare programmes. 3. Study Centres for Education Technology: To focus on enhancing computer literacy among medical practitioners, informatics, telematics, tele-medicines, and distance learning.

*Report of Expert Committee on Health Manpower, Planning, Production and Management, Ministry of Health & Family Welfare, Government of India, New Delhi, 1987, p. 34-35

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4. Study Centres for Planning and Development of Human Resources for Health: To focus on research and analysis of manpower requirements in different specialization and categories. 5. Study Centres for Continuing Education in Health Sciences: To focus on continuous monitoring, review and upgradation of competence, knowledge and skills of health professionals.

Central support must be provided to Health/Medical Universities during the 12th Five Year Plan, with efforts to establish similar universities in other states. In addition to the role, relevance, and functions of Health/Medical Universities as envisaged earlier, they may also subserve a most significant bridging function between the proposed National Commission for Higher Education and Research and the proposed National Council for Human Resources in Health, thereby strengthening medical education and research in the country.

*****

70

No. 2(6)/2010- H&FW Planning Commission (Health Division)

Subject: Summary Record of the discussions of Working Group on Tertiary Care

institutions (WG 2) for the Formulation of the 12th Five Year Plan (20122017) : Reg. 1. The 1st meeting of Working Group on Tertiary Care institutions for the Formulation of the 12th Five Year Plan (2012-2017) was held on 13th July, 2011 under the Chairmanship of Prof. J S Bajaj, Former Member, Planning Commission, in Room No 122 Yojana Bhawan, New Delhi.

List of participants is annexed.

2. On behalf of the Planning Commission and Member (Health), Shri Ambrish Kumar, Adviser (Health) extended a warm welcome to the Chairman and Members of the Working Group and requested for a round of self-introduction. After the introduction, Prof. J S Bajaj requested Dr. Syeda Hameed, Member (Health), Planning Commission to share her vision with the members of the Working Group. 3. Member (Health), welcomed the Chairman and all the members and informed that they have been selected carefully so as to have the best resource for the formulation of the 12thFive Year Plan. Planning Commission is already in the process of finalizing the Approach Paper to the 12th Five Year Plan. For this the consultations took place across the country wherein 90-100 Civil Society Organizations participated and voices of people are being heard.Five regional consultations have been heldand the views of the State Governments solicited.We are also consulting Industry Associations and PRIs. 4. Member (Health) further informed that Honble Prime Minister has given directions that the Planning Commission should focus on performance and progress against the targets, achievement of monitorable goals, issues relating to cost and time overrun and road map to address challenges in the health sector. She further stated that the Working Group on tertiary care should look into the aspect that how preventive and public health

71

awareness be an integral part of the tertiary care system. Investment in preventive health care will give much higher return than investment in tertiary care. We need to address issues relating to clean drinking water, sanitation and other social determinants as they are going to affect the tertiary care. Member (Health) mentioned that all the programmes and schemes should have monitorable targets and all efforts should be made to achieve these goals. At present we do not have good quality monitorable indicators for many of the programme and this is a major deficiency in designing and implementation of major schemes in the tertiary care sector. 5. Prof. Bajaj, the Chairperson of the Working Group referred to the Terms of Reference (ToR). He mentioned that planning, development, and management of Human Resources in Health is the most crucial issue. The present scenario of concentrating more only on a few categories of specialists without ensuring a balanced growth of all specialties is unlikely to improve efficiency of tertiary health care. With regard to another ToR relating to enhancement of quality of tertiary care he explained that enhancing quality of tertiary care means improvement in delivery, accessibility, accountability along with the technical feasibility. It also means how needs of tertiary care may be minimized by concentrating on preventive and promotive aspects at

primary and secondary care levels.

6.

Prof. Bajaj requested all the Members to indicate, in the context of ToR, their choice of preference as their area of interest in which they would like to contribute. He informed that sub-groups would be constituted consisting of 5-7 members who can focus on the issue(s) as per Terms of Reference of the Working Group in order to give suggestions and recommendations to achieve the goals, targets, vision and mission.

7.

The Chairperson noted the preferences of Members of the Working Group for the area in which they would like to contribute as per ToR. In view of multiple preferences by several members, the Chairman was requested to constitute Sub-groups/Task Force.

72

The Chairperson mentioned that ToR 1-4 relates to PMSSY and requested Shri Debashish Panda, Joint Secretary, DoHFW to present the objectives, content, progress and performance of PMSSY.

8.

Shri Debashish Panda, Joint Secretary, Department of Health gave a detailed presentation of the current status of the PMSSY. He mentioned that the programme was launched in March, 2006 with the objective of correcting regional imbalance in the availability of affordable/reliable tertiary healthcare services and also to augment facilities for quality medical education in the country. He further mentioned that the PMSSY was conceptualized by the Ministry without adequate experience. In the first few years, there were bottlenecks and Department of Health did not have any mechanism to handle the project of such magnitude and complexity. He stated that most of the cost estimates were not based on ground realities. The cost estimates were highly under estimated. There were no DPRs, estimation of bed strength was wrong; requirement of specialists, super specialists was not accounted, and tendering process took lot of time.

9.

He further mentioned that by learning through experience most of the bottlenecks have been removed. DPR has been finalized and standardized. Based on the reliable figures for bed strength, faculty and specialists. Department has been able to arrive at much more realistic cost. The present average cost of an AIIMS like Institute is Rs. 900 crores.

10.

A Project Monitoring Cell has been established in the Department which is monitoring the schemes much more rigorously and efficiently. HLL and HLCC have been engaged as project Consultants.It was observed that in the beginning there was cartel among tendering parties and the bids were on higher side and during the rebid process cost scaled down to Rs. 600.00 Cr. Good contractors like L&T, BL Kashyapetc have been hired. Revised schedule for completion of the projection is in place. A provision has been introduced in MoU under which Department can penalize the contractor for not

73

adhering to schedule of completion of the project. There is a clause to incentivize the contractor for completing the project before the schedule.

11.

While informing about the physical progress of the AIIMS like institutions, Joint Secretary informed that the work on all the six sites is in full swing and it is expected that by Sept. 2012 hospital buildings would be ready in all the institutions. He further informed that Directors of the institutes have been selected and 3 institutes, namely, AIIMS, New Delhi, PGIMER, Chandigarh and JIPMER, Puducherry have been selected for mentoring new Institutes. Other faculty and staff for the Institutes would be selected once the Directors join. The Directors of the new Institutes have been selected.Preclinical and Para clinical faculty would be selected by the Director of the institute.

12.

Prof. Bajaj asked about the status of 2 AIIMS like institutions in Uttar Pradesh and West Bengal. JS, M/o H&FW informed that for the two institutions the land has not been made available by the State Govt. Once the land is available the project can be started easily as DPR is ready and cost estimates would be relooked for slight variations and within 12 months the work on the institutes can be started and the period of completion of these projects would be 24-36 months. It is expected that land for these two Institutes may be made available by the State Government shortly.

13.

Prof. Bajaj further enquired about the Governance of the AIIMS like institutions whether the governance would be on lines of AIIMS, PGIMER, JIPMER or Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. Governance

should blend the strengths and avoid the constraints, in the context of past experience. In response, it was stated that more autonomy in finances, research and academic would be provided to the new institutions. A High Powered Committee was constituted by the M/o H&FW to look into the structural changes required in the governance and administration of proposed AIIMS like institutions. The Committee has recommended inclusive approach in decision making. It was stated that the High Powered Committee has recommended collegium system i.e. rotational headship. Prof. Bajaj desired that the

74

recommendations of the Committee may be shared with the Working Group members, assuring that the confidentiality would be maintained.

14.

Joint Secretary, Department of Health then gave the status of the up gradation of the Medical Colleges and Hospitals under PMSSY. He stated that MBBS Seats have been raised from 150 to 250 and the intake at PG level has been doubled. To meet the requirement of infrastructure for these seats, 13 Medical Colleges are being upgraded. In the 1st phase of PMSSY. Out of these 13 Medical Colleges, upgradation works in 6 Medical Colleges have been completed.

15.

Dr. MayilVahanan Natarajan, Vice Chancellor, Dr. MGR University, Chennai stated that though Medical Council of India (MCI) has increased the seats at graduate and post graduate level but there are practical problems. There is no infrastructure available to make the increase effective. JS, M/o H&FW clarified that the college can rationalize their requirement with the help of MCI. Prof. Bajaj asked whether MCI has tried for 2nd shift mechanism in Medical Colleges so that the shortage of human resources in heath sector can be contained. Dr. Shiv Sarin, Former Chairperson, Board of Governors, MCI said that the Working Group was constituted in MCI to look into the issue. The report of the Working Group is yet to be finalized. Prof. Bajaj said with the functioning of Medical Colleges in two shiftst, the cost and time constraints can be partially overcome. Dr. Natarajan, Vice Chancellor, Dr. MGR University, Chennai said that for the 2nd shift for Medical College, there is a problem of OPD. Prof. Bajaj said the OPD can be run in the evening which would be beneficial for the public also.

16.

17.

Joint Secretary, Department of Health presented the detailed plan and current status of 2nd Phase of PMSSY. He said that the 2nd Phase of PMSSY aims at increasing the training capacity from the current nearly 30,000 to 70,000 students per year. He said the new Medical Colleges are to be established in underserved areas. As per an earlier

75

committee recommendation one Medical College is required for the population of 50 lakh and accordingly Medical Colleges would be established in 10 States.

18.

Regarding optimal utilization of all human resources and health, Prof. Bajaj stated that there are large number of AYUSH practitioners who are available and can be deployed. It is the need of the time that AYUSH practitioners be integrated with the mainstream health care delivery system during the 12th Plan. He further stated that the required doctor nurse ratio is1:3. Hence, a major effort is required not only to expand nursing education but also to create opportunities for specialized courses in nursing to cater to the needs of tertiary health care.

19.

Dr. Nimesh G Desai, Director, IHBAS stated that Joseph Bhore Committee (19431946) had recommended three broader areas to be looked into namely biomedicine, mental health, hygiene and public health. He said that Biomedicine is looked through AIIMS. Though for Mental Health, NIMHANS, Bangalore has been working now but still not much focus has been given to hygiene and public health and even mental health. JS, M/o H&FW clarified that the ministry thought of four regional institutes in addition to strengthening Medical Colleges for mental health and public health. He said the Ministry is seized of the matter that the disease burden is changing and delivery mechanism needs to be upscaled.

20.

Prof. Snehalata Deshmukh, Paediatric Surgeon, Former Vice Chancellor, Mumbai University requested that the Working Group should also look into child health as it has been neglected for long. Prof. Bajaj emphasized that efficient delivery of health care requires consideration of epidemiological, demographic and public health needs. Ultimately it requires amalgamation of schemes and channelization of resources to build a system of comprehensive health care inclusive of tertiary care.

21.

Dr. AnandZachriah, CMC, Vellore said that the AIIMS like institutions have been envisaged with the perception that there would be impact on health of people of the area. Has there been any thought on the point that how the institution will improve the health care of the area. Prof. Bajaj clarified that there are models available which can be
76

chosen to give the good results. He said that 8th Plan had laid emphasis on regional Universities of Health Sciences. At present there are nearly 17 Universities of Health Sciences as well as Medical Universities in different states. There is a need to review their impact both on medical education and on community health including environment and occupational health. 22. Dr. R.A. Badwe, Director Tata Memorial Hospital, Mumbairequested that for the telemedicine and wider use of IT technology in tertiary care National Knowledge Network may be used. He also requested that Dr. Chidambaram may be inducted and be made member for IT group. He also said that it is important to retain the merit to cover whole spectrum of the society. Prof. Bajaj responded by stating that he has already co-opted Prof. S.V. Raghavan, Scientific Secretary in the office of the Principal Scientific Advisor as a member of the Working Group. Prof. Raghavan could not

participate in todays meeting because of his prior commitments. 23. Prof. Sunil Maheshwari, IIM Ahmedabad said that IT group may also include Management Information System and may try for Institutional level collaboration like AIIMS with IIT, mentoring of institutions by other institution .

24.

Dr. Mansoor Hassan, Lucknow suggested that a sub group may look into the compassion, ethics, morality and empathy aspects of the health care providers. He said that there is enormous increase in complaints/ litigations against doctors. Health friendly environment needs to be maintained and needs to be taught.

25.

Dr. AnandZachriah, CMC, Vellore said that appropriate tertiary care definition is important. The present tertiary care means to deal with large hospitals. District hospitals are neglected for tertiary care. It is also important to strengthen district hospitals. There is an urgent need to define role of tertiary care at District Hospital. Also, it is important to give priority to research in tertiary care.

The meeting ended with a Vote of Thanks to the Chair.

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First Meeting of Working Group on Tertiary Care Institutions for the Twelfth Five Year Plan (2012 2017) under the Chairpersonship Dr. J S Bajaj, Former Member, Planning Commission held on 13.07.2011. Chairperson Dr. J S Bajaj, Former Member, Planning Commission Planning Commission 1. 2. 3. 4. 5. 6. 7. 8. 9. Dr. (Ms.) Syeda Hameed, Member (Health) Shri. Ambrish Kumar, Adviser (Health) Shri. S. M Mahajan, Adviser (Health) Dr. RakeshSarwar, Adviser (Health) Mrs. ShashiKiranBaijal, Director (Health) Mrs. Arundhati Singh, Director (Health) Ms. SurayyaShahab, Research Officer (Health) Mrs. JyotiKhattar, Economic Officer (Health) Dr. Amandeep Singh, Young Professional (Health)

Others 1. Shri. Rajesh Kishore, Principal Secretary (Medical Education), Health & Family Welfare Deptt. Govt. of Gujarat 2. Shri. Debashish Panda, Joint Secretary, Deptt. of Health & FW, New Delhi 3. Dr. R K Srivastava, DGHS, Deptt. of Health & FW, New Delhi 4. Dr. T. S Sidhu, Medical Superintendent, Dr. R M L Hospital, New Delhi 5. Dr. N. K Mohanty, Addl. DG & Medical Suprintendent, Safdarjung Hospital &VardhmanMahavir Medical College, New Delhi 6. Dr. A K Agarwal, Dean, Maulana Azad Medical College, New Delhi 7. Dr. Amod Gupta, Dean, PGI (For Director PGI), Chandigarh 8. Dr. S. Jalal, Vice President, National Board of Examination, New Delhi 9. Dr. D P Pande, Executive Director Health Planning (Railways), Ministry of Railway, New Delhi 10. Dr. S K Sarin, Director, Institute of Liver & Biliary Sciences, New Delhi 11. Dr. R. C Deka, Director, AIIMS, New Delhi 12. Dr. Nimesh G Desai, Director, Institute of Human Behaviour and Allied Sciences, New Delhi 13. Prof. M E Yeolekar, Director, NIEGRAMS, Meghalaya 14. Dr. K S V K SubbaRao, Director, JIPMER, Puducherry 15. Dr. K Radhakrishnan, Director, SCTIMST, Kerala 16. Dr. Bipin Batra, Executive Director, National Board of Examination 17. Dr. Anand Zachariah, Medicine I, CMC, Vellore 18. Prof. Sunil Maheshwari, Professor, IIM, Ahmedabad

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19. Dr. MansoorHasan, Lucknow 20. Dr. R.A Badwe, Director, Tata Memorial Hospital, Mumbai 21. Dr. Snehalata Deshmukh, Former Vice Chancellor, University of Mumbai 22. Dr. Mayil V Natarajan, Vice Chancellor, The Tamil Nadu Dr. MGR Medical University, Chennai 23. Dr. Ranjit Roy Chaudhary, Apollo Hospital, New Delhi

79

Report of the Working Group on Disease Burden for the 12th Five Year Plan

WG3(1): Communicable Diseases

WG-3
No. 2(6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 Dated 9th May 2011

OFFICE MEMORANDUM Subject: Constitution of working group on Disease Burden (Communicable and non-communicable diseases) for the formulation of the Twelfth Five Year Plan (2012-2017)
With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on Disease Burden with sub groups on Communicable Diseases and Non-communicable Diseases for the formulation of the Twelfth Five Year Plan (2012-2017) under the Chairmanship of Dr. R. K. Srivastava, DGHS, Ministry of Health and Family welfare, Government of India. The composition and the terms of reference of the Working group would be as follows:

Subgroup I: Communicable Diseases

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Dr. R. K. Srivastava, DGHS, MoHFW Dr. Yogesh Jain, Jan Swasthya Sahyoj Dr. Shiv Lal, Adviser, DGHS, MoHFW Joint Secretary (Pubic Health), MoHFW Dr. Lalit Kant, Scientist G and Head (Epidemiology and Communicable Diseases Division), ICMR, New Delhi Director, Patel Chest Institute, Delhi Director, All India Institute of Hygiene and Public Health (AIIH & PH), Kolkata Director, National Vector Borne Disease Control Programme (NVBDCP), New Delhi Director, National Institute of Epidemiology, Chennai Director, Voluntary Health Association of India, New Delhi Dr. J.C. Suri, Head Dept. of Pulmonary Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital Hospital (VMCC & SJ ), New Delhi Dr. C.S. Pandav, Dept. of Community Medicine, AIIMS, New Delhi Prof. Jay Prakash Muliyil, Head of Dept. of Community Medicine, Christian Medical College, Vellore Dr. John C Oommen, Krushi Hospital, Cuttack, Orissa Dr. Biswaroop Chatterjee, Microbiologolist, West Bengal Dr. S Sridhar, BASIX (Bhartiya Samruddhi Investments and Consulting Services), Gujarat Chairperson Co- Chairperson Member Member Member Member Member Member Member Member Member

12. 13. 14. 15. 16.

Member Member Member Member Member

17. Dr. M. Bhattacharya, Head Community Health Administration, NIHFW (National Institute of Health & Family Welfare), New Delhi 18. Dr. Shreelakha Roy, Voluntary Health Association of Tripura 19. Principal Secretary (H&FW), Government of Chhattisgarh 20. Principal Secretary (H&FW), Government of Orissa 21. Mr. S M Mahajan, Adviser (Health) Planning Commission 22. Director, National Centre for Disease Control (NCDC), New Delhi

Member

Member Member Member Member Member Secretary

Terms of Reference
I. To document the burden and trend of communicable diseases including emerging and re-emerging infectious diseases in India II. To review the achievement of ongoing major communicable disease control programmes their target and suggests corrective measures to improve their implementation in the 12th Plan. III. To suggest introduction of new programmes/ continuation of existing programmes for control of communicable diseases and modifications required, if any, in the 12th Five Year Plan on the basis of 1& 2 above along with detailed budget for each programme. IV. To review the current system of monitoring and evaluation of the existing communicable disease control programmes and suggest measures to make the system more effective V. To suggest mechanisms of partnership with mother NGOs/private

sector/community/local self government in implementation and monitoring of the health programmes proposed in the 12th Plan. VI. To review the current status of HMIS in terms of its quality and utilization and propose to develop it into an effective system during the 12th Plan for providing reliable and updated data base for communicable diseases. VII. To review the functioning Integrated Disease Surveillance Programme in terms of its effectiveness in strengthening surveillance for picking up early warning signals of outbreaks and institution of appropriate control measures in a timely manner, identify gaps and suggest measures to strengthen the surveillance system for prevention and control of communicable diseases during the 12th Plan. VIII. To review the status of implementation of International Health Regulations 2005 in the country with special reference to public health response to various types of public health emergencies of international concern and suggest measures to comply with requirements under IHR.

IX.

To deliberate and give recommendations on any other matter relevant to prevention and control of communicable diseases.

Subgroup 2: Non-Communicable Diseases

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Dr. R. K. Srivastava, DGHS, MoHFW Dr. H.C. Goyal, Adviser, DGHS, MoHFW Sh. B. K. Prasad , Joint Secretary MoHFW New Delhi Dr. Bela Shah, Scientist G and Head (NCD Division), ICMR, New Delhi Dr. Rajender A Badwe, Director, Tata Memorial Hospital, Mumbai Prof. Ashok Seth, Chairman, Max Heart Hospital, Saket, New Delhi Dr. B.K. Rao, Chairman, Sir Ganga Ram Hospital, New Delhi Dr. Sanjay Aggarwal, HOD, Dept. of Nephrology, AIIMS Dr. Sanjay Wadhwa, Addl. Professor, PMR, AIIMS Dr. G. N. Rao, L. V. Prasad Eye Institute, Hyderabad Mr. Tulsiraj, Arvind Eye Care, Tamil Nadu Ms. Shobha John, Leading Anti Tobacco Activist Dr. R. Krishna Kumar, NIMHANS, Bangalore Dr. Suresh Kumar, Director, Institute of Palliative Medicine, Calicut
Dr. Raman Kataria, Pediatric Surgeon, Jan Swasthya Sahyog, Chhattisgarh

Chairperson Member Member Member Member Member Member Member Member Member Member Member Member Member Member Member Member Member Member Member
Member Secretary

Dr. Krishna Kumar, Amrita Institute of Medical Sciences, Kochi Dr. Sara Bhattacharji, MD Professor CMC, Vellore Principal Secretary (H&FW), Jammu and Kashmir Principal Secretary (H&FW), Goa Mr. Ambrish Kumar, Adviser (Health) Planning Commission
Dr. D. Bachani, DDG (NCD), Dte. General of Health Services, MoHFW

Joint Member Secretary for Subgroup I & II Dr. Jagdish Kaur, Chief Medical Officer, Ministry of Health & Family Welfare

Terms of Reference
I. II. III. To document burden and trend of non-communicable diseases in India. To review status of ongoing Central Sector/Centrally Sponsored Disease Control Programme for non-communicable diseases. To suggest introduction of new programmes/ continuation of existing programmes for control of non-communicable diseases and modifications required, if any, in the 12th Five Year Plan on the basis of 1& 2 above along with detailed budget for each programme. This shall include initiating a Programme for any non-communicable disease of public health importance not yet covered under any Programme. To assess the need for developing a National Institute for Health Promotion and Control of Chronic Diseases to play leadership role in prevention and control of NCDs and suggest its broad set up and fund requirement.

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VIII.

IX.

To study and work out comparative effectiveness of interventions at different levels of health care such as health promotion, prevention, community based services, screening/ early diagnosis, treatment and rehabilitative care taking into account short term and long term needs for prevention and management of non-communicable diseases. Based on the assessment made as at 5 above, suggest proportionate expenditure on preventive, promotive, curative and rehabilitative health care for non-communicable diseases for maximizing impact of these interventions and optimizing resources available. To develop a scheme for building up a platform for Emergency Medical System (EMS) by modifying and up-scaling the on-going trauma care programme. To review ongoing schemes for Emergency Medical Relief, and intensify ATLS training programmes and expand mobile hospital and CBRN Centre for disaster management. To deliberate and give recommendations on any other matter relevant to prevention and control of non-communicable diseases. The Chairman may constitute various Specialists Group / Working Groups / Sub-groups/task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitorable goals, while making recommendations. Efforts must be made to co-opt members from weaker section especially SCs, Scheduled Tribes and minorities working at the field level. The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the Working group Members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. The Working group would submit its draft report by 31st July, 2011 and final report by 31st August, 2011. (Shashi Kiran Baijal) Director (Health)

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Copy to: 1. 2. 3. 4. 5. 6. 7. 8. 10. 11. 12. Chairman, all Members, Member Secretary of the Working Group PS to Deputy Chairman, Planning Commission PS to Minister of State (Planning) PS to all Members, Planning Commission PS to Member Secretary, Planning Commission All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission Director (PC), Planning Commission Administration (General I) and (General II), Planning Commission Accounts I Branch, Planning Commission Information Officer, Planning Commission Library, Planning Commission (Shashi Kiran Baijal) Director (Health)

Working Group on Communicable Diseases For th 12 Five Year Plan

Report (30-07-2011)

Table of Contents
Sl. No.
1.

Contents
Office Memorandum on Constitution of Working Group on Disease Burden (Communicable & Non-Communicable Diseases) for the formulation of 12th FY Plan

Page No.
1-2

2. 3. 4. 5. 6.

Sub-Groups on Communicable Diseases Vision Communicable Disease Burden Executive Summary Proposals for 12th Five Year Plan A. B. C. D. National Vector Borne Disease Control Programme (NVBDCP) Revised National Tuberculosis Control Programme (RNTCP) National Leprosy Eradication

3-5 6-7 8 - 16 17 - 26 27 - 241 27 - 126 127 - 142 143 - 185 186 - 233 234 - 239 240 - 242

Programme (NLEP) National Center for Disease Control (NCDC) 7. 8. Brief of the proposals of 12th Five Year Plan Summary of the total budget proposed for Communicable Diseases in the 12th Plan

Composition of the Sub-Groups on Communicable Diseases

Sr. No.
1. Malaria

Theme

Sub-Group
1. Dr. Shiv Lal, Former Spl. DG (PH) & Director, NCDC & Adviser, NCD 2. Dr. R. S. Shukla, JS (PH), MoH&FW 3. Dr. Rashmi Arora, Sr. DDG, ICMR 4. Dr. P. L. Joshi, Former Director, NVBDCP 5. Mrs. Anu Garg, Principal Secretary, Govt. of Orissa 6. Dr. G. S. Sonal, Additional Director, NVBDCP 7. Dr. R. S. Sharma, Joint Director, NVBDCP 8. Dr. K. S. Gill, Joint Director, NVBDCP 9. Dr. L. A. Singh, RD, Imphal 10. Dr. G. C. Sahu, RO, RD Office, Ahmedabad 11. Dr. Ravi Kumar, CMO, R.D. Office, Bengaluru 12. Dr.NeeruSingh, Dir., RMRCT,Jabalpur 13. Director, NIMR, New Delhi 14. Dr. A. C. Dhariwal, Director, NVBDCP 1. Dr. Shiv Lal, Former Spl. DG (PH) & Director, NCDC & Adviser, NCD 2. Dr. R. S. Shukla, JS (PH), MoH&FW 3. Dr. Rashmi Arora, Sr. DDG, ICMR 4. Dr. P. L. Joshi, Former Director, NVBDCP 5. Dr. D. K. Srivastava, Prof. & HOD, PSM, BRD Medical College, Gorakhpur 6. Dr. K. K. Khound, Prog. Officer (JE), Assam 7. Dr. A. K. Dhaon, Joint Director, AES Nodal Center, UP 8. Dr. M. M. Gore, Scientist F, NIV Field Station, BRD Medical College campus, Gorakhpur 9. Dr. Sanjay Wadhwa, Addl. Prof., AIIMS, New Delhi 10. Dr. A. C. Dhariwal, Director, NVBDCP 1. Prof. C. S. Pandav, Deptt. Of Community Medicine, AIIMS 2. Dr. Yogesh Jain, Jan Swasthya Sahyog, Bilaspur 3. Dr.Madhulekha Bhattacharya, Head Community & Health Admin., NIH&FW, New Delhi 4. Dr. Suman Lata Wattal, Asstt. Director (Filaria), NCDC 5. Dr. Jambu Lingam, Director, VCRC, Pudhucherry 6. Dr. Ram Singh, Officer-in-charge, NCDC Branch, Patna 7. Dr. Thomas Mathew, Prof. PSM, Trivandrum Medical College, Kerela 8. Dr. Omkar Nath Chattopadhya, Additional Co-ordinator Member Member Member Member Member Member Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Member

2.

AES/JE

3.

Other Vector Borne Diseases (Filariasis, Kalaazar, Dengue & Chikungunya etc)

4.

Revised National TB Control Programme (RNTCP)

5.

National Eradication (NLEP)

Leprosy Programme

6.

Disease Surveillance & Response

Director, NVBDCP 9. Dr. P. K. Srivastava, Joint Director, NVBDCP 10. Dr. S. N. Sharma, Joint Director, NVBDCP 11. Dr. Kalpana Barua, Joint Director, NVBDCP 12. Dr. Ravi Kumar, CMO, R.D. Office, Bengaluru 13. Dr. N. K. Yadav, State M.H.O., New Delhi 14. Dr. Pradeep Das, Director, RMRI, Patna 15. Director, NIV, Pune 16. Dr. A. C. Dhariwal, Director, NVBDCP 1. Dr. J. C. Suri, HOD, Pulmonary Medicine, Vardhman Medical College, New Delhi 2. Dr. K. S. Sachdeva, CMO (SAG), TB 3. Director, Voluntary Health Association of India, New Delhi 4. Dr. G. R. Khatri, Former DDG (TB) 5. Dr. L. S. Chauhan, Director, NCDC 6. Dr. P. Kumar, Director, NTI, Bengaluru 7. Dr. D. Behera, Director, LRS Instt., New Delhi 8. Dr. Ranjana Ramachandaran, Microbiologist, SEARO, WHO, New Delhi 9. Dr. Ashok Kumar, DDG (TB) 1. Director AIIH&PH, Kolkata 2. Dr. Anoop Puri, ADG (Lep.) 3. Dr. Kiran Katoch, Director, JALMA, Agra 4. Dr. M. A. Arif, ILEP Coordinator, India 5. Prof. Atul Shah (Plastic Surgeon), Director, Novartis CLC Associate, Mumbai 6. Dr. Ranganath Rao, Lepra India 7. Dr. K. M. Kamble, Joint Director (Orthopedics), RLTRI, Raipur 8. Dr. C. M. Agarwal, DDG (L) 1. Prof. Jay Prakash Muliyil, Head of Deptt. Of Communitiy Medicine, CMC, Vellore 2. Dr. R. S. Shukla, JS (PH), MoH&FW 3. Dr. Jagvir Singh, Additional Director & NPO (IDSP) 4. Dr. Anil Kumar, HOD (Epid), NCDC 5. Dr. Pradeep Khasnobis, CMO (IDSP), NCDC 6. Dr. S. K. Jain, Joint Director, NCDC 7. Dr. Vishwajit Ringe, Sr. Technical Director (Health), NIC, Nirman Bhawan, New Delhi 8. Dr. V. S. Dhruvey, State Surveillance Officer, IDSP, Gujarat 9. Dr. R. P. Vashisht, State Surveillance Officer, IDSP, Delhi 10. Consultant (IT), IDSP, NCDC, Delhi 11. Dr. L. S. Chauhan, Director, NCDC

Member Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Member Member Member Convener

7.

Strengthening of NCDC & its branches

1. Director, NIE, Chennai 2. Dr. Shashi Khare, Additional Director (Micro), NCDC 3. Dr. D. Chattopadhya, Additional Director (Micro), NCDC 4. Dr. Anil Kumar, HOD (Epid), NCDC 5. Dr. R. S. Gupta, Additional Director & Incharge NCDC Branch, Alwar 6. Dr. Arvind Rai, HOD(Biotech), NCDC 7. Dr. L. S. Chauhan, Director, NCDC 1. Dr. Rashmi Arora, Sr. DDG, ICMR 2. Dr. R. L. Ichhpujani, Additional Director (Micro), NCDC 4 3. Dr. Veena Mittal, Additional Director (Micro), NCDC 4. Dr. U. V. S. Rana, Joint Director, NCDC 5. Dr. Mala Chhabra, Joint Director (Micro), NCDC 6. Dr. A. B. Negi, Joint Commissioner, Deptt. Of Animal husbandary, New Delhi 7. Dr. Arvind Nath, Scientist C, ICMR HQ, New Delhi 8. Dr. Bambal, Asstt. Commissioner, Live Stock Health, Min. of Agriculture 9. Dr. L. S. Chauhan, Director, NCDC 1. Dr. Biswaroop Chatterjee, Microbiologist, West Bengal 2. Dr. Shashi Khare, Additional Director (Micro), NCDC 3. Dr. Sunil Gupta, Additional Director (Micro), NCDC 4. Dr. Renu Datta, HOD (Microbiology), LHMC, New Delhi 5. Dr. C. Wattal, Sr. Microbiologist, Sir Ganga Ram Hospital, New Delhi 6. Dr. Anita Kotwani, Pharmacologist, Patel Chest Instt., Delhi 7. Dr. Arvind Rai, HOD (Biotech), NCDC 8. Dr. R. L. Ichhpujani, Additional Director (Micro), NCDC 1. Dr. John C. Oommen, Krushi Hospital, Cuttak, Orissa 2. Dr. S. K. Sarin, Director, Inst. of Liver & Biliary Sciences, New Delhi 3. Dr. Sunil Gupta, Additional Director (Micro), NCDC 4. Dr. Charu Prakash, Additional Director (Micro), NCDC 5. Dr.P. Kar (Gastroenterology), G. B. Pant Hospital, New Delhi 6. Dr. Haldar, A.C. (Immun.), MoH&FW 7. Dr. Shashi Khare, Additional Director (Micro), NCDC

Co-ordinator Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Member Convener Co-ordinator Member Member Member Member Member Convener

8.

Zoonotic infection/diseases

9.

Containment of AntiMicrobial Resistance

10.

Viral Hepatitis (Surveillance, Prevention & Control)

Communicable Diseases - Proposal for 12th Five-Year Plan

Vision
Although non-communicable diseases like cancers, diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases, etc are on the rise due to change in life style, communicable diseases, like tuberculosis, malaria, kala-azar, dengue fever, chikungunya and other vector borne diseases, and water-borne diseases like cholera, diarrhoeal diseases, leptospirosis etc, continue to be a major public health problem in India. In fact, diarrhoeal diseases, respiratory infections, tuberculosis and malaria cause about onequarter of all deaths in the country (Report on causes of death in India, 2001-2003). Well defined strategies have been identified to control communicable diseases. These inter alia include (i) risk reduction, (ii) adequate health care infrastructure, (iii) availability of adequately trained health manpower, (iv) an efficient disease surveillance and response system for early detection and treatment of cases and for early detection and control of outbreaks of epidemic prone disease and (v) risk communication. Based on these strategies, national disease control programmes are making efforts to control communicable diseases. Early identification and adequate treatment of cases is the key strategy for control of tuberculosis under Revised National Tuberculosis Control Programme (RNTCP). The same strategy along with risk reduction by using anti-vector measures has been adopted by the National Vector Borne Disease Control Programme (NVBDCP) to control malaria, kala-azar and other vector borne diseases. Important killers during the childhood period namely acute diarrhoeal diseases, acute respiratory infections, especially pneumonia, and vaccine preventable diseases such as measles, diphtheria, pertussis etc are taken care of under the Reproductive and Child Health Programme (RCH). While availability and use of Oral Rehydration Therapy (ORT) is important to reduce mortality due to acute diarrhoeal diseases, administration of vaccines under Universal Immunization Programme (UIP) has greatly reduced the mortality due to vaccine preventable diseases. An effective disease surveillance and response system helps in early detection and control of outbreaks of epidemic-prone diseases. Epidemics are public health emergencies which disrupt routine health services and are a major drain on resources. Besides direct costs in epidemic control measures and treatment of patients, the indirect costs due to negative impact on domestic and international tourism and trade can be significant. For example, plague which was not reported from any part of India for almost a quarter of century, caused a major outbreak in Beed district in Maharashtra and Surat in Gujarat in 1994 and resulted in an estimated loss of almost US$ 1.7 billion. Based on the lessons learnt during implementation of these national disease control programmes in 11th Five-Year Plan, considerable strengthening has been proposed during 12th Five-Year Plan. Universal access to quality DOTS services is proposed under RNTCP to improve the case detection and cure rate. This could be ensured by extending DOTS services to patients
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diagnosed and treated in private sector. This will help in reducing the prevalence of disease to such an extent that elimination could be possible by year 2050. All efforts would be made in 12th Five Year Plan to empower grass-root workers in diagnosing and treating malaria cases even in remote and accessible areas by scaling-up the availability of bivalent Rapid Diagnostic Kits (RDK) and Artemisinin-based combination therapy (ACT). These efforts coupled with integrated vector control strategies including distribution of Long Lasting Insecticide Treated Nets (LLIN) in endemic areas will greatly reduce the malaria morbidity and mortality and a proposal for elimination of malaria in the 13th Five Year Plan may become a reality. Zoonotic diseases, which account for a substantial burden of morbidity and mortality due to endemic as well as emerging diseases, are a major concern. While 61% (868/1415) of all identified infectious organisms are zoonotic, about 75% (132/175) of pathogens associated with emerging diseases are zoonotic. A strong coordination is needed between human health and animal health sectors to control the zoonotic diseases like avian influenza, plague, rabies, leptospirosis etc. This will be addressed by posting a veterinary consultant under the Disease Surveillance and Response Programme in all states/UTs. We expect that gains in control of communicable diseases in the 12th Five Year Plan will be substantial. While poliomyelitis and yaws will be eradicated, filaria, kala-azar and leprosy will be eliminated as public health problems. There would be substantial reduction in morbidity and mortality due to malaria, tuberculosis, dengue fever, Japanese encephalitis, rabies, leptospirosis etc. National Centre for Disease Control (NCDC) will be strengthened considerably and will have presence in all States/UTs to help them in control of diseases and in implementation of International Health Regulations (2005). Integrated Disease Surveillance Project will be further strengthened and continue as Disease Surveillance and Response Programme under the NCDC to generate early warning signals to detect and respond to outbreaks of epidemic prone diseases in early rising phase. A network of 500 district public health labs will be established and linked to about 200 medical colleges/referral labs under Disease Surveillance and Response Programme.

Burden of Communicable Diseases

The communicable diseases like Tuberculosis, Leprosy, Vector borne diseases (Malaria, Kala-Azar, Dengue, Chikungunya, Filaria, Japanese Encephalitis, etc.), Water-borne diseases (Cholera, Diarrhoeal Diseases, Viral Hepatitis A & E, Typhoid Fever etc.), Zoonotic diseases (Rabies, Plague, Leptospirosis, Anthrax, Brucellosis, etc), and Vaccine preventable diseases (Measles, Diphtheria, Tetanus, Pertussis, Poliomyelitis, Viral Hepatitis B etc) are endemic in many parts of the world and continue to be a major public health problem. The non-communicable diseases like cancers, diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases etc are on the rise due to urbanization and changes in life style. In addition, there is always a threat of new emerging and re-emerging infectious diseases like Nipah virus, Ebola virus, Avian Influenza, SARS, novel H1N1 Influenza, Hanta virus etc. Thus, due to industrialization and the persisting inequality in health status between and within States/UTs (due to varying economic, social and political causes), the developing countries like India currently face a Triple burden of diseases, which are as follows: 1. Unfinished agenda of Communicable Diseases, 2. Emerging Non-Communicable Diseases related to lifestyles and 3. Emerging Infectious Diseases

Impact of Infectious Diseases

Infectious diseases caused by pathogens such as bacteria, viruses, fungi and parasites are major causes of morbidity and mortality all over the world. Epidemics due to these diseases disrupt routine health services and cause public health emergencies. The lost productivity, the missed educational opportunities and the high health care costs caused by infectious diseases thus directly impact growth of society. Also, the indirect costs due to negative impact on domestic and international tourism and trade can be significant. Children are particularly vulnerable to infectious diseases. Pneumonia, diarrhea and malaria are leading causes of death among children under five years of age. Impact of emerging, re-emerging and novel infections: o 37 new pathogens with epidemic potential identified globally during last 3 decades o Besides huge morbidity and mortality the emerging & re-emerging infectious disease outbreaks have huge economic impact on national economy. The plague outbreak of 1994 in Surat caused an economic loss to the tune of $ 1.7 billion. Some recent outbreaks are of Influenza A H1N1, H5N1 and Crimean Congo Hemorrhagic Fever (CCHF). o Emerging and re-emerging infections increase awareness of our global vulnerability, highlight the borderless impact of diseases and underscore the need for strong health care systems.

Strategies to control communicable diseases

Many Expert Committees, dating back to the Bhore Committee in 1946, reviewed the existing health infrastructure/situation in the country and made recommendations needed to control diseases including communicable, non-communicable and emerging diseases. More recently, the Expert Committee on Public Health System (1996) and the National Commission on Macroeconomics and Health (2005) examined these issues. National Five Year Plans, National Health Policy (1983, 2002) and many international initiatives such as Health for All by 2000, Calcutta Declaration on Public Health in South-East Asia (1999), U.N. Millennium Development Goals (2000), Global Commission on Macroeconomics and Health (2001), Revised International Health Regulations (2005), Asia Pacific Strategy for Emerging Diseases (2005, 2010) have also provided strong policy directives for the development of health care delivery system to control/prevent diseases. As a result of these efforts, health infrastructure was strengthened and several national disease programmes were initiated to eradicate, eliminate or control communicable diseases. Well defined strategies have been identified to control communicable diseases. Based on these strategies, the national disease control programmes are making efforts to control communicable diseases. The strategies include (i) risk reduction, (ii) adequate health care infrastructure, (iii) availability of adequately trained health manpower, (iv) an efficient disease surveillance and response system for early detection and treatment of cases and for early detection and control of outbreaks of epidemic prone disease, and (v) risk communication.

Recent advances against infectious diseases include

Efforts to achieve the sixth Millennium Development Goal (MDG), which focuses on stopping and reversing the spread of infectious diseases by 2015. Regional accomplishments, such as: o A 92 % reduction in deaths resulting from measles in Africa and a 93 % reduction in the Eastern Mediterranean between 2000 and 2008. o In Southeast Asia, an increase in successfully treated tuberculosis cases from 33 percent to 88 percent between 1995 and 2007. o The near eradication of polio and guinea worm diseases, and lower prevalence of several other tropical diseases over the past few decades. o A renewed interest in the research and development of new diagnostics, vaccines and drug treatments.

Global Burden of Infectious Diseases

CHOLERA

Worldwide, there are an estimated 35 million cholera cases and 100,000 120,000 deaths due to cholera every year. For 2008 alone, a total of 190,130 cases were notified from 56 countries, including 5143 deaths. V. cholerae O1 causes the majority of outbreaks, while O139 first identified in Bangladesh in 1992 is confined to South-East Asia. Recently, new variant strains have been detected in several parts of Asia and Africa. Observations suggest that these strains cause more severe cholera with higher case fatality rates.

CHIKUNGUNYA

Chikungunya occurs in Africa, Asia and the Indian subcontinent. Human infections in Africa have been at relatively low levels for a number of years. Starting in February 2005, a major outbreak of Chikungunya occurred in islands of the Indian Ocean. In 2007, transmission was reported for the first time in Europe, in a localized outbreak in north-eastern Italy. A large outbreak of Chikungunya in India occurred in 2006 and 2007.

DENGUE

Dengue has been identified as one of the 17 neglected tropical diseases by WHO and current estimates show that there may be 50 million Dengue infections worldwide every year. About 2.5 billion people (as in 2009) two fifths of the world's population are now at risk from Dengue. The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific.

DIARRHOEAL DISEASE

Diarrhoeal disease is the second leading cause of death in children under five years old. It is both preventable and treatable. Diarrhoeal disease kills 1.5 million children every year. Globally, there are about two billion cases of diarrhoeal disease every year.

JAPANESE ENCEPHALITIS

Japanese Encephalitis is reported under umbrella of Acute Encephalitis Syndrome cases. Around the world, the incidence has gone up from 44,000 in 2004 to 58,000 in 2009; with deaths ranging from 14,000 -16,000 in the last five years.

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KALA-AZAR

It is estimated that 350 million people in 88 countries are at the risk of developing the disease. About 500,000 people suffer from it. In the South East Asia Region, about 200 million people are estimated to be at risk from the disease. In India, Bangladesh and Nepal alone, the estimated number of cases is about 100,000.

LYMPHATIC FILARIASIS

Over 120 million people are currently infected, with about 40 million disfigured and incapacitated by the disease. Currently, more than 1.3 billion people in 81 countries are at risk. Approximately 65% of those infected live in the WHO South-East Asia Region, 30% in the African Region, and the remainder in other tropical areas. One third of the people infected live in India, one third in Africa and the rest in South Asia, the Western Pacific and parts of Central and South America. India accounts for 32% of the total cases.

LEPROSY

More than 244,000 new cases of Leprosy were reported in 2009; most of them belonged to Asia and Africa. The global registered prevalence of leprosy at the end of 2008 was 213,036 cases. The number of new cases detected globally has fallen gradually in the last five years. Leprosy has been eliminated from 119 countries out of 122 countries where the disease was considered as a public health problem in 1985.

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MALARIA In 2008, there were 247 million cases of malaria and nearly one million deaths mostly among children living in Africa. Malaria is prevalent in 108 countries of tropical and sub-tropical world, as a perennial problem. Every year, malaria is reported to cause more than 250-660 million infections and more than a million deaths. The World Malaria Report estimates a total of 225 million cases and 781,000 deaths due to malaria in 2009. SEAR contributes to 11-12% of the total global burden. India contributes to 70% of total malaria cases in SEAR, and has a total of about 1.5 million cases of malaria. Of these, 50% are due to P. falciparum. The reported annual incidence is 1.3 cases per 1000 population. MEASLES During 2000-2008, global mortality attributed to measles declined by 78%, from an estimated 733,000 deaths in 2000 to 164,000 in 2008. In 2008, there were 164,000 measles deaths globally nearly 450 deaths every day or 18 deaths every hour. More than 95% of measles deaths occur in low-income countries with weak health infrastructures. Measles vaccination resulted in a 78% drop in measles deaths between 2000 and 2008 worldwide. Worldwide, the number of reported measles cases declined 67%, from 852,937 in 2000 to 278,358 in 2008. PNEUMONIA Pneumonia is the leading cause of death in children worldwide. Every year, it kills an estimated 1.6 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. RABIES Rabies occurs in more than 150 countries and territories. Worldwide, more than 55,000 people die of rabies every year. Rabies is present on all continents with the exception of Antartica, but more than 95% of human deaths occur in Asia and Africa. 40% of people who are bitten by suspect rabid animals are children under 15 years of age. Every year, more than 15 million people worldwide receive a post-exposure preventive regimen to avert the disease this is estimated to prevent 327,000 rabies deaths annually. TUBERCULOSIS Overall, one-third of the world's population is currently infected with the TB bacillus. WHO estimates that the largest number of new TB cases in 2008 occurred in the South-East Asia Region, which accounted for 35% of incident cases globally. According to the Global tuberculosis control 2010, WHO report, o In total, approximately 1.7 million people died of TB in 2009. An estimated 1.3 million deaths (range 1.2 - 1.5 million) occurred among HIV-negative cases of TB. This includes 0.38 million deaths (range 0.3 - 0.5 million) among women.
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There were an estimated 0.4 million deaths (range,: 0.32 million0.45 million) among incident TB cases that were HIV-positive. The estimated number of TB deaths among both HIV-negative and HIV-positive people equates 26 deaths per 100,000 population. The TB death rate has fallen by 35% since 1990. o There were 9.4 million new TB cases (including 3.3 million women) in 2009, including 1.1 million cases among people with HIV. o The estimated global incidence rate fell to 137 cases per 100,000 population in 2009, after peaking in 2004 at 142 cases per 100,000. The rate is still falling but too slowly. VIRAL HEPATITIS Viral Hepatitis A o An estimated 1.4 million cases of Viral Hepatitis A occur annually. Viral Hepatitis B o About 2 billion people worldwide have been infected with HBV and about 350 million live with the chronic infection. o An estimated 600,000 persons die each year due to the acute or chronic consequences of hepatitis B. o HBV is 50 to 100 times more infectious than HIV. HIV INFECTION Worldwide, an estimated 33 million people are living with HIV. Since the beginning of the HIV epidemic in 1981, 25 million people have died of AIDS globally. Every day, there are 7,400 new HIV infections, 96% of which are in the low-and middle-income countries. Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for 67% of all people living with HIV and for 75% of AIDS deaths in 2007. Recently, there is evidence that HIV is decreasing in some of the heavily affected countries such as Kenya, Rwanda, Uganda and Zimbabwe, resulting in a stabilization of the global epidemic. South-East Asia Region o SEAR is the second-most affected region in the world, with an estimated 3.6 million people living with HIV (PLHIV); of these, 37% are women. o Five countries India, Thailand, Myanmar, Indonesia and Nepal account for majority of the Regional burden. o HIV incidence is the highest among sex workers and their clients, men who have sex with men and injecting drug users. o The overall adult HIV prevalence in SEAR (0.35% in 2007) has changed little in the past five years but there are important country-wise variations. In India, Myanmar, Thailand, Nepal and Sri Lanka, HIV epidemics have declined or stabilized.

13

Infec ctious Diseas Bur D se rden in Indi ia

MALAR RIA Malaria in In M ndia account for about 1.5 million cases with 5 ts 50% due to P falciparum P. annually und public he a der ealth system reporting w m where nearly 100 millio fever case y on es are a examined annually. Due to unde d erreporting a treatmen seeking b and nt behavior from m private secto this appea to be an under estim of the t p or, ars n mate true burden of Malaria i in the t country. There is no p precise estim of Mala burden i the countr mate aria in ry. The T annual reported inc cidence of 1.3 cases pe 1000 pop er pulation at country level indicates tha eliminatio is achieva at on able; however, a few states are per rsistently wit th more than 2 cases per 10 populatio which po challenge to the coun m 000 on, ose ntry. About 80% of malaria burden is i Northeast A in tern states, Chhattisgarh Jharkhand, h, Madhya Pra M adesh, Orissa Andhra P a, Pradesh, Ma aharashtra, G Gujarat, Raj jasthan, We est Bengal and Karnataka. H B K However, ot ther states ar also vulne re erable and h have local an nd focal outbrea f aks.

CULOSIS TUBERC One-fifth of the global i O incidence of TB is cont f tributed by India, which amounts t to ab bout two mi illion new T cases each year. T.B. Annual risk of TB infecti (ARTI) h reduced from 1.5% (during 2002 A o ion has 2-03) to 1.1% % (d during 2007-10). Estimated pr E revalence of TB as per WHO 2 2010 report is 266 ca ases per lak kh population. er ulation are dy yeing becaus of TB in I se India each ye as per th ear he 23 persons pe lakh popu WHO report 2010. W CHIKUN NGUNYA Chikungunya reemerged in country during 20 C a d y 006 with ab bout 1.39 m million case es occurring in 1 States/UT 16 Ts. n tates reporte 48,176 cli ed inically susp pected cases of Chikungu unya. In 2010, 18 st

DENGUE E Dengue is end D demic in 31 States/UTs. In 2006, the country wit n tnessed an o outbreak of DF/DHF wi 12,317 c ith cases and 18 84 deaths reporte from 18 States/ UTs ( ed S (270 districts). In 2010, a to of 28,29 cases and 110 death were repo n otal 92 d hs orted from 2 States/UT 27 Ts (4 districts) which is hi 403 ) ighest in the country in l two deca last ades.

ESE JAPANE ENCEPHALITIS In India Jap n panese Ence ephalitis (JE is repor E) rted under the umbrel of Acute lla Encephalitis S E Syndrome (A AES). During 2010, 5149 cases and 677 dea due to A D aths AES/JE were reported fro 15 states e om s. The T case fatality rate has been reduce from 25% in 2005 to 12% in 2010 ed % 0. KALA-A AZAR About 129 million popula A ation is at ris of Kala-az in endem districts. sk zar mic Kala-azar is endemic in total of 52 districts of States of Bihar, Jhar K n 2 o f rkhand, We est Bengal and U B UP. The T annual in ncidence of disease has come down from 77,099 cases in 19 to 28,94 9 992 41 ca in 2010 and deaths have declin from 141 to 105 du ases 0; s ned 19 uring this per riod. Tripartite Me T emorandum o Understan of nding has be signed be een etween India Banglades a, sh an Nepal in 2005 for elim nd mination of Kala-azar by 2015. y LYMPHA ATIC FILARIASIS In India, Lym n mphatic Filar riasis is end demic in 15 states and 5 UTs with approximatel a ly 600 million populations a risk. p at There are 8 lakh lymph T hoedema an 4 lakh hydrocele ca nd h ases line listed in thes se st tates/UTs. Lymphatic Filariasis has been targe L F s eted for elim mination by 2015. The microfilaria y e pr revalence ha been redu as uced from 1.2 24% in 2004 to 0.34% in 2010. 4 n LEPROS SY During 2009D -10, 133,717 new cases o Leprosy have been rep 7 of h ported in Ind dia. Of O these, 411 cases hav been dete 17 ve ected with Gr-II disabilit and 13,331 new case G ty; es ar children. re

LEPTOSPIROSIS The outbreaks of Leptospirosis, an emerging zoonotic disease, are increasingly been reported from many States/UTs such as A& N Islands, Kerala, Gujarat, Tamil Nadu, Karnataka, Maharashtra and Orissa. In addition, sporadic cases have also been reported from Goa, Andhra Pradesh and Assam. RABIES The number of human deaths is 20,000 every year of the total of 55,000 global deaths. Estimated number of animal bites : 17.5 million /year HIV INFECTION 2.5 million persons have HIV infection (7.6% of the global burden of 33 million cases). INFLUENZA Influenza A H1N1 Pandemic in India (data upto 3 July 2011): First positive case confirmed on 16 May 2009. Till 3rd July, a total of 207,671 samples sent for laboratory testing for Influenza A H1N1; of which 46,575 (23%) samples tested positive. No. of deaths of lab confirmed Influenza A H1N1 cases 2762.

H5N1 outbreaks in Poultry in India: First outbreak in Jan/Feb 2006. Last outbreak occurred in February 2011 in Tripura. No human case in India so far (15 countries reported human cases).

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Executive Summary
Introduction
Communicable diseases continue to be a major public health problem in India. Many communicable diseases like tuberculosis, leprosy, vector borne diseases (malaria, kala-azar, dengue fever, chikungunya, filaria, Japanese encephalitis), water-borne diseases (cholera, diarrhoeal diseases, viral hepatitis A & E, typhoid fever etc), zoonotic diseases (rabies, plague, leptospirosis, anthrax, brucellosis, salmonellosis etc), and vaccine preventable diseases (measles, diphtheria, tetanus, pertussis, poliomyelitis, viral hepatitis B etc) are endemic in the country. In addition to these endemic diseases, there is always a threat of new emerging and re-emerging infectious diseases like nipah virus, avian influenza, SARS, novel H1N1 influenza, hanta virus etc. Local or widespread outbreaks of these diseases result in high morbidity, mortality and adverse socio-economic impact. Community surveys have revealed that about one-quarter of all deaths in the country are due to diarrhoeal diseases, respiratory infections, tuberculosis and malaria. Many Expert Committees, dating back to the Bhore Committee in 1946, reviewed the existing health infrastructure/situation in the country and made recommendations needed to control diseases including communicable, non-communicable and emerging diseases. More recently, the Expert Committee on Public Health System (1996) and the National Commission on Macroeconomics and Health (2005) examined these issues. National Five Year Plans, National Health Policy (1983, 2002) and many international initiatives such as Health for All by 2000, Calcutta Declaration on Public Health in South-East Asia (1999), U.N. Millennium Development Goals (2000), Global Commission on Macroeconomics and Health (2001), revised International Health Regulations (2005), Asia Pacific Strategy for Emerging Diseases (2005, 2010) have also provided strong policy directives for the development of health care delivery system to control/prevent diseases. As a result of these efforts, health infrastructure was strengthened and several national disease programmes were initiated to eradicate, eliminate or control communicable diseases. Malaria, which used to cause 75 million cases in early 1950s, has been reduced to about 1.5 million cases every year. Revised National Tuberculosis Control Programme, launched in 1996, presently covers the entire country, detects over 70% of new sputum cases with treatment success rate of 87%. TB mortality has decreased from over 5 lac deaths every year at the beginning of the programme to about 2.8 lac deaths presently despite growth in population. Leprosy has been eliminated as a public health problem from many states. Life expectancy has increased from 36.5 in 1951 to more than 64.2. While crude death rate declined from 25.1 in 1951 to 7.3 in 2009, the Infant Mortality Rate (IMR) declined from 146 per 1000 live births in 1951 to 50 per 1000 live births in 2009. However, because of the existing environmental, socioeconomic and demographic situation, the population continues to be vulnerable to infectious diseases, especially the rapidly evolving micro-organisms. Therefore, the control of communicable diseases continued to remain the focus in all FiveYear Plans. To further control communicable diseases, the 12th Five Year Plan needs to address several public health challenges, such as ensuring primary health care to all including urban slum population, strengthening of health care infrastructure as per Indian Public Health Standards, increasing public health workforce, strengthening disease surveillance and response system, strengthening and networking of public health laboratories, optimizing use of modern information technology for disease control, formulation and enforcement of appropriate Public Health Laws, enhancement of public private partnership in disease prevention and
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control, increasing public health allocation and spending and decentralizing and communitizing planning and response. It is important to develop an adequate number of public health professionals in the country with appropriate competencies and skills to make proper use of large health infrastructure developed with focus on core public health functions and competencies. Public health should address the demographic and epidemiologic transition needs. Time has come to increase allocation for public health to deliver the services efficiently. Keeping in view the above, sub-group on communicable diseases is recommending the strengthening of existing programmes and proposing several initiatives with enhanced financial requirement in the 12th Plan.

A. National Vector Borne Disease Control Programme (NVBDCP)

The National Vector Borne Disease Control Programme (NVBDCP) is an umbrella programme for prevention and control of six vector borne diseases namely Malaria, Dengue, Chikungunya, Japanese Encephalitis (JE) Lymphatic Filariasis and Kala-azar. The strategy employed to prevent/control these diseases include disease management including early case detection and prompt treatment, strengthening of referral services; integrated vector management including indoor residual spraying, use of insecticide treated bed nets/ Long Lasting Insecticidal Nets (LLIN), larvivorous fish and supportive interventions like human resource development, behaviour change communication, public private partnership, monitoring and evaluation, and operational research. Presently, about 1.5 million cases of malaria and less than 1000 deaths are reported every year. About 80% of malaria burden is in Northeastern (NE) states, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Andhra Pradesh, Maharashtra, Gujarat, Rajasthan, West Bengal and Karnataka. However, other states are also vulnerable and have local and focal outbreaks. In the 12th Plan, the focus would be on empowering grass-root workers in diagnosing and treating malaria cases even in remote and accessible areas by scaling-up the availability of bivalent Rapid Diagnostic Kits (RDK) and Artemisinin-based combination therapy (ACT). Nevertheless, thrust would also be given to prevention/control of malaria (and other VBD also) in urban areas under the Urban Malaria Scheme which is presently implemented in only 131 towns/cities. These efforts coupled with integrated vector control strategies including distribution of Long Lasting Insecticide Treated Nets (LLIN) in endemic areas will greatly reduce the malaria morbidity and mortality and a proposal for elimination of malaria in the 13th Five Year Plan may become a reality. To tackle increasing dengue and chikungunya cases in urban, peri-urban and rural areas because of expanding urbanization, deficient water and solid waste management, the emphasis is on avoidance of mosquito breeding conditions in homes, workplaces and minimizing the man-mosquito contact. 27 states reported 28,292 cases of dengue and 110 deaths and 18 states reported 48,176 clinically suspected cases of chikungunya in 2010. Improved surveillance, case management and community participation, inter-sectoral collaboration, enactment and enforcement of civic by laws and building bye laws are emphasized for both these vector borne diseases. Japanese encephalitis is a major problem in Uttar Pradesh, Assam, Andhra Pradesh, Goa, Karnataka, Kerala, Manipur, Tamilnadu, Maharashtra, Bihar and West Bengal. The disease is presently reported as Acute Encephalitis Syndrome (AES). During 2010, 5149 AES cases and 677 deaths were reported in 15 states. In addition to various JE control measures like strengthening of surveillance, availability of case management facilities, vector control and other supportive interventions, vaccination of 1 to 15 year old children with a single dose of live attenuated SA-14-14-2 vaccine was initiated in 2006 under the Universal Immunization Programme. 111 districts have been covered till 2010.
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Lymphatic Filariasis (LF) has been targeted for elimination by 2015. The strategy of annual Mass Drug Administration (MDA) with annual single recommended dose of DEC + Albendazole tablets is being implemented in the country since 2004. In addition, scaling up of home based foot care and hydrocele operation have been initiated for disability alleviation. The coverage of population during MDA is more than 80% and about 150 districts have achieved the target of less than 1% microfilaria prevalence. Kala-azar is endemic in 52 districts of Bihar, Jharkhand, West Bengal and UP. The Kala-azar Control Programme was launched in 1990-91. The annual incidence of disease has come down from 77,099 cases in 1992 to 28,941 cases in 2010 and deaths have declined from 1419 to 105 during this period. Important recent initiatives taken include case detection through rapid diagnostic kits and improved treatment compliance by using oral drug Miltefosine. In addition, compensation to the patients for loss of wages and incentive to ASHAs/volunteers for case detection and ensuring complete treatment have also been provided. The existing activities for prevention and control of malaria and other vector borne diseases would continue in 12th Plan. There would also be emphasis on identified thrust areas. The initiatives and additional inputs, presently being supported by externally aided projects will also be continued and expanded through domestic budget support. This would result in moving towards pre-elimination stage of malaria, and control of dengue, chikungunya and Japanese Encephalitis. In addition, the elimination of Kala-azar and Lymphatic Filariasis by 2015 is being envisaged. An amount of Rs. 10693 crore is proposed for NVBDCP in 12th Plan.

B. Revised National Tuberculosis Control Programme (RNTCP)

Since its inception, the Revised National TB Control Programme (RNTCP) has evaluated over 44 million persons for TB and initiated treatment for over 12.8 million TB patients and has saved more than 2.3 million lives. The Annual Risk of TB Infection (ARTI) has reduced from 1.5% to 1.1% and prevalence has also reduced from 316 per lakh population in 2007 to 266 per lakh population in 2010. These achievements need to be further consolidated in 12th Plan. The objectives for 12th Plan include (i) early detection and treatment of at least 90% of estimated TB cases in the community (all types) including TB associated with HIV, (ii) successful treatment of at least 90% of new TB patients, and at least 85% of previously-treated TB patients, (iii) reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%, (iv) initial screening of all re-treatment smear-positive cases till 2015 and all smear positive TB cases by year 2017 for drug-resistant TB and provision of treatment services for MDR-TB patients, (v) offer of HIV counselling and testing for all TB patients and linking HIV-infected TB patients to HIV care and support and (vi) extension of RNTCP services to patients diagnosed and treated in the private sector. To achieve the objective of universal access to TB care and complete coverage of MDR services, key strategies and innovative approaches proposed under RNTCP include (i) intensified case finding activities in high risk groups like smokers, diabetics, malnourished, HIV, urban slums & difficult to reach areas etc, (ii) development of a dedicated sputum collection and transport system across the country to all health facilities (including PHCs without DMCs), (iii) improved surveillance by case-based electronic notification systems & data quality assurance, (iv) evidence-based re-alignment of TB Unit (presently at 1 per 5 lakh population) to Block level, (v) promoting rational use of anti-TB drugs to reduce drug resistance levels, (vi) establishing referral linkages between Primary Health Centres with secondary and tertiary hospitals for diagnosis of extra-pulmonary TB cases and paediatric TB cases, (vii) conducting prescription audits in private and public sectors, (viii) regular drug resistance surveillance, (ix) use of telecommunication in demand generation, service delivery & patients tracking, (x) designing & implementing innovative Advocacy, Communication and
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Social Mobilization (ACSM) tools, Non Government Organization- Public-Private Mix (NGOPPM) approaches and evaluating their impact, (xi) establishing a network of 73 Culture and Drug susceptibility testing (C&DST) laboratories, (xii) priority deployment of newer rapid diagnostics in HIV care settings, (xiv) nationwide provision of TB preventive therapy among HIV-infected individuals after pilot, (xv) notification of cases diagnosed and treated in the private sector through interface agency, (xvi) expansion of performance-based incentive strategies, (xvii) promoting need based operational research, and (xviii) conducting impact evaluation studies. An amount of Rs. 5825 crore is proposed for RNTCP under 12th Plan.

C. National Leprosy Eradication Programme (NLEP)

The objective during the 12th plan period is to provide quality leprosy services to all sections of population and achieve the target of less than 1 case per 10,000 population (Elimination) in all the districts of the country and reduce the burden of disability due to leprosy. The NLEP programme strategy under 11th Plan included (i) provision of high quality leprosy services for all persons affected by leprosy, through general health care system including referral services for complications and chronic care, (ii) involvement of ASHA under NRHM for leprosy work, (iii) enhanced Disability Prevention and Medical Rehabilitation (DPMR) services for deformity in leprosy affected persons, (iv) enhanced advocacy to reduce stigma and to stop discrimination against leprosy affected persons and their families, (v) capacity building among health personnel in integrated setting both for rural and urban areas and (vi) strengthening of monitoring and supervision. There is significant impact on disease burden in 11th Plan. (i) Six states/UTs achieved Leprosy Elimination status, (ii) Annual New Case Detection Rate (ANCDR) decreased from 14.27/100,000 in 2005-06 to 10.48/100,000 in 2010-11, (iii) Prevalence Rate decreased from 1.34/10,000 in 2005-06 to 0.69/10,000 in 2010-11, (iv) Treatment Completion rate improved from 90.34 in 2006-07 to 92.26 in 2009-10, (v) Reconstructive Surgery (RCS) was conducted in 11825 persons affected by leprosy in 4 years to reduce disability, (vi) No. of high endemic districts (ANCDR >10/100,000 population) reduced from 275 in 2005-06 to 209 where special activities are now proposed in the 12th Plan period. Key lessons learnt from the implementation of programme in 11th Plan include (i) slow achievement in reduction of cases, (ii) detection of new cases from various pockets, mostly from 209 districts in 16 States, (iii) poor quality of services through integrated service delivery, (iv) inadequate referral services at the District Hospital level, (v) role of ASHA at village level for early case detection and for completion of treatment is very encouraging, (vi) poor performance of RCS in Govt. Institutions though their number has gone up from 20 to 44, (vii) keeping the clause of BPL families for receipt of incentives for undergoing RCS operation is counter productive as BPL Cards are not easily available, (viii) delay in release of funds from State NRHM to districts resulting in non execution of planned activities. The proposed strategy for 12th Plan includes (i) focus attention to 209 already identified districts and other districts to be identified20 future, (ii) backlog for RCS to be cleared, (iii) in promotion of self care, (iv) capacity building especially in Prevention of disability (POD), (v) to improve referrals at district level, and (vi) improved monitoring & supervision. Policy changes to be made in implementation during the 12th Plan are (i) Reassess the burden of leprosy in the country by shifting from prevalence as the main indicator to Annual New Case Detection Rate (ANCDR) and burden of disability in new cases of leprosy (ii) Improving the quality of services to all patients with easy accessibility without discrimination, (iii) Provide integrated leprosy services with primary health care system for
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sustainability, (iv) Adequate Referral System for complicated cases, (v) Prevention and management of impairments and disabilities, (vi) Improving community awareness and involvement, (vii) Support of National Rural Health Mission, (viii) cure and rehabilitation, (ix) re-define the indicators for monitoring and evaluation. It is expected that in 12th Plan Prevalence Rate (PR) will reduce to <1/10,000 population and ANCDR will reduce to <10/100,000 population in all districts. Cure rate for Multi-Bacillary (MB) leprosy would be >95% and cure rate for Pauci-Bacillary (PB) leprosy would be >97%. Thus, the thrust under 12th Plan would be on achieving elimination of leprosy in all the districts of the country and reduction in Gr. II disability through prevention of disability (POD) and reconstructive surgery. An amount of Rs. 787.00 crore is proposed for NLEP under the 12th Plan.

D1. National Centre for Disease Control Ongoing Activities

(a) Upgradation of National Centre for Disease Control (NCDC) National Centre for Disease Control (formerly National Institute of Communicable Diseases) is an apex public health institute for control of communicable diseases. With headquarters in Delhi, it has 8 out-station branches located in different states. CCEA approved the upgradation of NCDC (headquarters only) in December 2010 for Rs. 382.41 crore. The upgradation includes construction of new buildings, provision of new technical posts and establishment of several technical centres and new diagnostic and lab services. The accepted outcomes from proposed upgradation, amongst others would include (i) enhanced scope of referral diagnostic support services for disease outbreak investigators and networking of public health laboratories, (ii) enhanced data management capacity under Disease Surveillance and Response Programme, (iii) enhanced capacity for development of trained manpower in public health, (iv) trained, dedicated central rapid response teams available for disease outbreak control, (v) enhanced quality operational research for better disease control and (vi) preparedness against probable threats of bioterrorism. An amount of Rs. 350 crore is proposed for the 12th Plan for upgradation of NCDC. An additional amount of Rs. 6.10 crore is proposed for 24X7 Outbreak Monitoring Cell and an amount of Rs. 14.0 crore is proposed for operational research in the 12th Plan. (b) Continuation of Integrated Disease Surveillance Project (IDSP) as Disease Surveillance and Response Programme IDSP was launched with World Bank assistance in November 2004. The project has been extended for two years up to March 2012 but the World Bank is funding Central Surveillance Unit (CSU) at NCDC & 9 identified states and the rest 26 states/UTs are being funded from domestic budget. Further World Bank assistance will not be available after March 2012 and the programme will need to be implemented with GOI domestic budget. It may be mentioned that IDSP has already been merged with NCDC administratively & financially in June 2006. Under the project, surveillance units have been established at all state and district headquarters and training of state/district surveillance teams has been completed for 34 States/UTs and partially completed for Uttar Pradesh. Presently, 85% districts in the country report weekly surveillance data through e-mail and more than 67% districts report through portal. The weekly data gives information on the disease trends and seasonality of diseases. Whenever there is rising trend of illnesses in any area, it is investigated by the Rapid Response Team to diagnose and control the outbreak. Accordingly, on an average, 20 outbreaks are reported every week by the states to CSU. A total of 553 outbreaks were reported and responded to by states in 2008, 799 outbreaks in 2009 and 990 outbreaks in 2010. In 2011, 538 outbreaks have been reported till 29th May. Earlier, only a few outbreaks
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were reported in the country by the States/UTs. This is an important public health achievement. Since disease surveillance and response is a core public health activity which has to be undertaken on a continuous basis, all activities being undertaken presently under IDSP are proposed to continue in the 12th Plan as Disease Surveillance and Response Programme under NCDC as a Central Sector Scheme. Central Surveillance Unit will be merged into Centre for Integrated Disease Surveillance under NCDC. All support to states/districts health societies including additional contractual staff given under IDSP will continue in the 12th Plan. The funds will be released to the state health societies for implementation of disease surveillance and response programme within their health system. A network of 500 district public health labs will be established and linked to about 200 medical colleges/referral labs to improve the quality of data and outbreak investigations. An outlay of Rs. 851.81 Crore is proposed for Disease Surveillance and Response Programme for 5 years in 12th Plan. (c) Implementation of IHR (2005) The International Health Regulations (IHR) are an international legal instrument that is binding on 194 countries across the globe including India. The purpose and scope of IHR (2005) is to prevent, protect against, control and provide a public health response to the international spread of disease in ways commensurate with and restricted to public health risks which avoid unnecessary interference with international traffic and trade. IHR (2005) came into force in 2007. Under the International Health Regulations (2005), it is mandatory for the country to develop, strengthen and maintain core capacities for disease surveillance and response and at points of entry to detect, assess, report, notify and control all events irrespective of origin and source which may constitute a public health emergency of international concern. As the country has committed to implement IHR (2005) and has nominated the Director, NCDC, Delhi as the National Focal Point for IHR (2005), NCDC needs strengthening under 12th Plan to fulfill the obligations under IHR (2005). An amount of Rs. 12.53 Crore is proposed for strengthening of National Focal Point (NCDC) and strengthening of core capacities at points of entry. Core capacities for surveillance and response will be strengthened under the Disease Surveillance and Response Programme. (d) Prevention and control of Rabies Rabies is a major public health problem in India. An estimated 20,000 deaths occur annually which is about one-third of total global mortality. While an estimated 17.5 million animal bites occur annually, only 3 million receive Post Exposure Prophylaxis (PEP) Treatment. Dogs inflict more than 95% of bites. Rabies is invariably fatal; however, it can always be prevented by timely and appropriate post exposure prophylaxis. As a New Initiative under 11th Plan, a pilot project on Prevention and Control of Rabies is being carried out in five cities viz Ahmedabad, Bangalore, Delhi, Pune and Madurai with the main objective to prevent human deaths due to rabies. Based on the success of the pilot project in 11th Plan, National Rabies Control Programme is proposed in 12th plan which will focus on (i) strengthening of PEP to prevent human deaths in all states/UTs, (ii) vaccination of stray dogs at 30 selected sites initially, (iii) operationalization of cost effective and efficacious intradermal route for vaccination, (iv) extension of rabies treatment facilities to peri-urban/rural areas, (v) active involvement of NGOs and community, and (vi) strengthening of inter-sectoral coordination. An amount of Rs. 384.59 crore is proposed in 12th Plan to carry out these activities.
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(e) Prevention and Control of Leptospirosis The outbreaks of leptospirosis, an emerging zoonotic disease, are increasingly been reported from many states/UTs such as A& N Islands, Kerala, Gujarat, Tamil Nadu and Karnataka. In addition, cases have also been reported from Goa, Andhra Pradesh and Assam. A pilot project on Control of Leptospirosis was approved as a New Initiative in the 11th Plan in 5 endemic states with the objective to reduce the morbidity and mortality in pilot project areas. The proposal is to expand and implement the strategy developed during 11th Plan in all the endemic states during the 12th Plan period. The strategy evolved and guidelines formulated will be shared and distributed to all endemic states. The suspected cases of leptospirosis will get timely and appropriate treatment and awareness in community will help in reducing mortality and morbidity due to leptospirosis. An amount of Rs. 3.69 crore is proposed in 12th Plan to carry out this activity. (f) Surveillance of Yaws and Guinea Worm Guinea Worm Disease has already been eradicated from the country. However, its continuous monitoring is required till the disease is eradicated globally. Its budget shall be reflected in the regular budget of NCDC. Yaws has been declared eliminated from the country since 2006. However, for eradication of the disease, activities like sero-surveillance, active search, awareness generation in the community and independent appraisals etc. will be carried out and the results will be placed before WHO Commission for declaring eradication of Yaws from the country. It is an ongoing activity of NCDC and budget shall be reflected in the regular budget of the NCDC.

D2. National Centre for Disease Control New Activities

(a) Up-gradation of existing branches and establishment of 27 new branches of NCDC Currently, there are eight branches of National Centre for Disease Control located at Alwar (Rajasthan), Varanasi (UP), Patna (Bihar), Rajahmundry (Andhra Pradesh), Jagadalpur (Chhattisgarh), Bangalore (Karnataka), Coonoor (Tamil Nadu) and Kozhikode (Kerala). These branches provide some support to the states in control of communicable diseases. However, over the years need has been felt to strengthen these branches so that they function as complete units for decentralized presence of NCDC. There is also a need to strengthen laboratory capacity and entomology facility in these branches for early diagnosis of epidemic prone diseases and to undertake entomological surveillance for vector borne diseases. Need has also been felt that NCDC has branches in all states/UTs rather than in only 8 states. Keeping above in view, NCDC is proposing up-gradation of 8 existing branches and 23 establishment of 27 new branches. The location of the new branches shall be finalized in consultation with the states. The norms of construction, equipment, manpower and other logistics shall be as applicable to the existing branches (upgraded) and shall conform to the administrative and financial norms. The State government officials shall be regularly and actively involved in all the activities of the branches. NCDC branches will help in carrying out the disease surveillance effectively, meet the needs of the IHR (2005), enhance the efficiency of disease control activities and additionally help in better implementation of the new proposed programmes such as National Rabies Control Programme, National Anti-Microbial Resistance Containment Programme and Prevention and Control of Viral Hepatitis etc. An amount of Rs. 288.50 crore is proposed for upgradation of existing branches and Rs. 854.80 crore for establishment of 27 new branches of NCDC. (Total Rs. 1143.30 crore).
23

(b) National Programme for Containment of Antimicrobial Resistance (AMR) Development of Antimicrobial Resistance in pathogens of public health importance is a major public health problem which can lead to serious health, social, economic and disease transmission problems, if not tackled timely. There is no organized Antimicrobial Resistance Containment Programme in the country despite increasing antibiotic resistance developing in pathogens causing diseases of public health importance. A national Task Force was constituted by MoH&FW in August 2010, under the chairpersonship of DGHS, to frame national policy for containment of AMR in the country. Based on the strategy spelt out by the Task Force, the National Programme for Containment of Antimicrobial Resistance (AMR) is proposed in 12th Plan with an outlay of Rs. 112.25 crore. The activities would inter alia include (i) surveillance of antimicrobial resistance, (ii) surveillance of antimicrobial use, (iii) development and implementation of National Infection Control Guidelines and Standard Treatment Guidelines, (iv) operational research on antimicrobial usage, environmental surveillance and AST methodology and (v) creating awareness among the health care workers and community about rational use of antibiotics. (c) Prevention & Control of Viral Hepatitis There are at least five viruses which can cause viral hepatitis. These viruses are hepatitis virus A, B, C, D and E. HAV and HEV are transmitted by faeco-oral route through contamination of water and food. HAV affects most of the people during childhood when the disease is mild. Outbreaks of viral hepatitis are usually caused by hepatitis E virus. Important mechanisms of transmission of HBV are mother to infant in perinatal period, parenteral (through infected needles and syringes, blood transfusion) and sexual routes. HCV is usually transmitted by parenteral route; the risk of transmission by household contact and sexual activity appears to be very low. HDV which needs the presence of HBV for its multiplication is transmitted like HBV. Hepatitis B, C and D can lead to persistent infection (chronic carriers). The sequelae of persistent infection include chronic active hepatitis, liver cirrhosis and liver carcinoma. Around 3 to 5% of our population is estimated to be chronic carrier of hepatitis B. Currently, there is no program for viral hepatitis in the country. The proposed programme in 12th Plan with an outlay of Rs. 120 crore will include (i) setting up of 25 labs having facilities for all markers of hepatitis viruses, (ii) preparation and circulation of guidelines for prevention, anti-viral and interferon therapy, repeat testing & quantitative analysis, (iii) provision of vaccine for high risk groups, and (iv) assessment of role of interferon and antiviral therapy for management of hepatitis B & C in selected patients through medical colleges in a project mode. NCDC will coordinate all the activities and there will be central supply of kits and reagents for each lab.

24

(d) Establishment of inter-sectoral coordination and control of selected Priority Zoonotic Diseases Zoonotic diseases account for a substantial burden of morbidity and mortality due to endemic as well as emerging diseases. While 61% (868/1415) of all identified infectious organisms are zoonotic, about 75% (132/175) of pathogens associated with emerging diseases are zoonotic. A strong coordination is needed between human health, animal health and other sectors at all levels to control the zoonotic diseases like avian influenza, plague, rabies, leptospirosis etc. Existing Committees and Groups (for example, Standing Committee on Zoonoses, Joint Monitoring Group) at central level and existing disease surveillance committees at state level will be responsible for inter-sectoral coordination. A zoonosis coordination cell will be established at NCDC, Delhi to monitor the activities. One additional contractual position for a veterinary (consultant) is proposed under the Disease Surveillance and Response Programme at state level to improve intersectoral coordination and to support the State Surveillance Officer in tackling the zoonotic diseases. At the district and the block levels, District Surveillance Officer would coordinate the activities between veterinary, municipal corporation/committees and other local bodies and voluntary agencies involved in the subject. Activities would also include lab strengthening for identified target diseases, manpower development and IEC. An amount of Rs. 51.08 crore is proposed in the 12th Plan for these activities. Total Budget for NCDC including Disease Surveillance and Response is proposed as Rs. 3049.35 Crore.

E. Communicable Disease Division at Central Directorate General of Health Services

DirectorGeneralofHealthServices*

SplDGHS(PH)*

AddlDG(CD)**

Director(NCDC)*

DDG(PH)*

Director(NVBDCP)*

DDG(TB)*

DDG(Leprosy)*

State Branchesof NCDC**

Director(CRI)* Director(BCGI)* Director(AIIHPH)* Director(RHTC)* ADG(PH)* ADG(PH)*

*Existing ** Proposed

CentralDirectors(PH)in placeofRDs**
25

Under the overall supervision of DGHS, supported by Special DGHS (PH), the division will be headed by Addl. DG (CD) who would be assisted by Director, NCDC and Project Director, IDSP; Director, NVBDCP; DDG (TB) and DDG (Leprosy), DDG (PH), Directors , CRI, Kasauli; BCG Vaccine Institute, Guindy; All India Institute of Hygiene and Public Health, Kolkata and RHTC, Najafgarh. DDG (PH) would be supported by ADG (PH). Each state will have one Central Director (PH) who will have a National Programme implementation ccell, M&E Cell and health intelligence cell. This will be the new face of RD office, wherever they exist and a new office in States where RD office do not exist. This will take care of State Level programme implementation, monitoring and evaluation and health intelligence (surveillance). The division will be assisted by a Technical Advisory Committee (TAC) consisting of various health experts. One Additional post of Addl. DG, 16 additional posts of Central Directors (PH) (presently 19 posts of Regional Directors are available) & 27 officer-in-charges of NCDC state branches in addition to existing 8 NCDC branches would be required along with supporting staff to strengthen the prevention and control of communicable diseases. The RHTC is proposed to be placed back with Dte. GHS as the functioning of the organization is technical in nature.

Summary of the total budget proposed for Communicable Diseases in the 12th Plan ( Rs. In crore)
Sr.No. 1. 2. 3. 4. Total Programme 2012-13 2013-14 2014-15 NVBDCP 2329.13 1969.51 1992.82 RNTCP 936.12 949.93 1173.27 NCDC 718.34 1025.09 408.84 NLEP 167.03 152.13 166.05 4150.62 4096.66 3740.98 2015-16 2107.28 1316.27 433.82 151.65 4009.02 2016-17 2294.45 1449.68 463.26 150.14 4357.53 Total 10693.18 5825.28 3049.35 787.00 20354.81

26

Proposals for th 12 Five Year Plan

National Vector Borne Disease Control Programme (NVBDCP)

INDEX
1. Background Note on National Vector Borne Disease Control Programme (NVBDCP) 2. Status of NVBDCP during 11th Plan a. Malaria b. Dengue and Chikungunya c. Japanese Encephalitis d. Lymphatic Filariasis e. Kala-azar Part II Proposed 12th Five Year Plan 3. Introduction & Vision of vector borne diseases 4. Proposed activities for prevention & control of VBDs during 12th Five Year Plan a. b. c. d. e. Malaria Dengue and Chikungunya Japanese Encephalitis Lymphatic Filariasis Kala-azar

5. Cross cutting Vector Borne Diseases Issues 6. Restructuring Directorate of NVBDCP

7. Total proposed budget

(i)

NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME (NVBDCP)

1. Background
The National Vector Borne Disease Control Programme (NVBDCP) is an umbrella programme for prevention and control of vector borne diseases (VBD), viz., Malaria, Lymphatic Filariasis, Kala-azar, Dengue, Chikungunya and Japanese Encephalitis (JE). These diseases pose major public health problems and hamper socio-economic development. Generally the rural, tribal and urban slum areas are inhabited mostly by low socio economic groups which are more prone to VBDs and are considered as high risk groups. 1.1 National Vector Borne Disease Control Programme (NVBDCP) About 75 million malaria cases and 0.8 million deaths were estimated annually during pre-Independence era. Malaria morbidity and mortality had affected agriculture, industrial development and national economy. Repeated attacks of malaria were responsible for deterioration in mental and physical capabilities resulting into enormous loss of productive man days. Global experience in malaria control and availability of the cost-effective intervention measures for malaria control with use of insecticides in fifties indicated that with their effective and efficient use, malaria could be controlled or even eradicated within a short period. Considering this concept, a centrally sponsored National Malaria Control Programme (NMCP) was launched in 1953 for malaria control in high endemic areas which was modified in 1958 to a countywide National Malaria Eradication Programme (NMEP) in view of spectacular success of NMCP. The success achieved in preventing deaths due to malaria and also reducing annual malaria incidence to an all time low of 0.1 million cases by 1965 could not be sustained for various technical, administrative and financial constraints. Resurgence of malaria became noticeable in 1976 with 6.47 million cases that necessitated launching of the Modified Plan of Operation (MPO) in 1977 with the immediate objectives to prevent deaths and to reduce morbidity due to malaria. Modified Plan of Operation successfully brought down annual incidence of malaria from 6.47 million (0.85 million P. falciparum) in 1976 to 2.18 million cases (0.65 million P. falciparum) by 1984. The developmental activities like rapid unplanned urbanization, construction, river valley projects, mega-industry, irrigation projects, etc. with deficient water management and inadequate mosquito control provisions again led to increased malaria incidence. Migration of population from endemic to other areas on account of such developmental projects also increased malaria transmission. The country-wide resurgence of malaria was again experienced in 1994 which led to high level review by the Prime Minister on 5th December,1994. In pursuance with the review of programme, an Expert Committee was constituted which submitted its report on 27th January, 1995. Based on the recommendations of the Expert Committee, a Malaria Action Programme (MAP) 1995 was drawn up and sent to the states and UTs for prioritizing the high risk areas and implementation of strategy accordingly. As a result, the cases were reduced to around 2.5 to 3 million annually. To tackle malaria problem in high risk areas other than North-Eastern (NE) states, an Enhanced Malaria Control Project (EMCP) with the assistance of World Bank was implemented during 1997-2005 with additional inputs of human resource, effective insecticidal spraying, Information, Education & Communication (IEC)/ Behavioural 27 Change Communication (BCC) activities, and capacity building. The malaria

incidence reduced in the project areas significantly. The strategies were focused on control of malaria, hence, the programme was changed from NMEP to National Anti Malaria Programme (NAMP) during the year 1998. To sustain the impact of this project, 93 high-endemic districts in 8 states have been identified for additional inputs through World Bank assisted Project in 2008 for a period of five years which is being implemented from March 2009. In North Eastern states, malaria control activities were intensified with additional inputs provided under Global Fund supported Intensified Malaria Control Projects from July 2005 to June 2010. These initiatives have been extended by another Global Fund supported project for a period of five years to cover all the districts of seven North-Eastern States. The prevention and control of other vector borne diseases namely Lymphatic Filariasis, Kala- azar was also being dealt by the Directorate of NAMP in addition to need based support for Japanese Encephalitis and Dengue. In view of synergies in prevention & control of vector borne diseases including Japanese Encephalitis and Dengue, the programme was renamed as National Vector Borne Disease Control Programme in 2003 with the integration of three ongoing centrally sponsored schemes viz., NAMP, NFCP and Kala-Azar Control Programme and converging prevention and control of JE and Dengue. In 2006, Chikungunya re-emerged in country and was also brought under purview of this Directorate.

1.2.

The Urban Malaria Scheme (UMS)

The implementation of control measures under erstwhile NMEP showed reducing malaria incidence in rural areas in the country till 1965, but at the same time increasing trend of malaria was observed in some towns/cities as a result of which, Madhok Committee (1969) reviewed the problem and found that 10 urban areas in Andhra Pradesh and Tamil Nadu contributed 11.2% of the total malaria cases in the two states during 1963. The Committee felt that if effective antilarval measures were not undertaken in urban areas, the proliferation of malaria cases from urban to rural areas might spread in a bigger way in many states and recommended adequate central assistance for tackling the programme. Accordingly the Urban Malaria Scheme was approved in 1971 as a 100% centrally sponsored scheme which from 1979-80 was changed to on 50:50 sharing basis between centre and state governments. The UMS scheme was scaled up in a phased manner by including 23 towns in 1971-72, 5 in 1972-73, 87 in 1977-78, 38 in 1978-79, 12 in 1979-80 and 17 in 1980-81 making a total of 182 towns. Since states have the responsibility of providing human resources and infrastructure, the scheme could be implemented only in 131 towns for which GoI is supplying anti-larvals. The drugs are made available through states. At present, Urban Malaria Scheme is protecting about 116 million population from malaria and other mosquito borne diseases in 131 towns.

1.3

The National Filaria Control Programme (NFCP)

The programme was launched in 1955 to delimit the problem and implement the treatment of microfilaria carriers and disease cases with Diethylcarbamazine tablets along with anti-larval measures in urban areas. Filaria is endemic in 20 States/UTs except Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Tripura, Sikkim, Jammu & Kashmir, Himachal Pradesh, Haryana, Punjab, Chandigarh, Rajasthan, Uttarakhand and Delhi. NFCP activities are implemented through 206 control Units, 199 Filaria Clinics and 27 Filaria Survey Units located in urban areas of endemic states. The programme has undergone various paradigm shifts and has revised the strategy. Currently the disease has been targeted for elimination which is
28

defined as Elimination is achieved when Lymphatic Filariasis(LF) ceases to be a public health problem, when the number of microfilaria carriers is less than 1% and the children born after initiation of elimination activities are free from circulating antigenaemia (presence of adult filaria worm in human body). The strategy of elimination is interruption of transmission by annual Mass Drug Administration (MDA) with anti filarial drugs to entire population at risk of LF. It is being implemented in 250 LF endemic districts since 2004. The anti-larval operations in 206 towns covered under NFCP is continued and the budget of NFCP merged with UMS for this support.

1.4.

Kala-azar

Kaka-azar was highly endemic in India during pre-DDT era and had affected economic growth of country due to high morbidity and mortality rates. Cyclic epidemics used to occur with an inter-epidemic period of about 10 years or more. With the launching of extensive insecticidal spraying under National Malaria Control Programme/National Malaria Eradication Programme since 1953 and 1958 respectively, the disease declined to negligible proportion due to collateral benefit of insecticidal pressure on the vector, Phlebotomus argentipes, with consequent interruption of transmission. However, there was resurgence in the 1960s and by seventies the disease established itself in endemic form in Bihar and then in West Bengal. In the absence of any organized control activity, the disease slowly spread to several areas in these states. Considering the seriousness of the problem, centrally sponsored Kala-azar Control Programme was launched in 1990-91. The disease has also been targeted for elimination by 2015 as per tripartite agreement between India, Nepal and Bangladesh. Various initiatives have been taken towards elimination of the disease.

1.5.

Dengue, Chikungunya and JE

For prevention and control of these viral diseases, there were no separate programmes but need based assistance and technical supports were being provided by the Directorate of NVBDCP. However, during 11th Plan period, separate budgeting was planned and various initiatives were taken to control outbreaks and contain the disease by strengthening surveillance, diagnosis, case management and awareness etc.

1.6.

Entomological surveillance

The three important components of disease transmission are causative organism (parasite or pathogen), human being as host and the vector as transmitting agent. Not all the mosquitoes transmit the disease, hence the knowledge about capacity to transmit disease and their predominance in terms of time and space are very crucial to facilitate the decision about their control strategies. Entomological surveillance covers all these aspects and for such entomological surveillance, 72 zonal malaria offices were established in the country with support of entomologists, insect collectors and support staff. The expenditure on this infrastructure is met by the States from state resources. In addition, 16 Regional Offices for Health & FW, GoI were also equipped with entomologists for carrying out entomological activities in addition to other public health activities. Gradually, due to non adherence of due importance to the entomological work, the progress on entomological surveillance has suffered, though some states like Tamil Nadu, Andhra Pradesh, Gujarat and Maharashtra etc. have attached more importance on zonal teams and strengthened them with entomologists and infrastructure. Presently out of 72 zones, only 50% are functional. To generate latest information about various entomological parameters in the country for revising prevention and control activities against 29 vectors at national, state and local level, the

entomological zones need to be strengthened with additional human resources and infrastructure with basic minimum facilities like mobility support for field visits etc.

1.7 Objectives under NVBDC

During XI Plan, the following objectives were enlisted: To prevent mortality due to Vector Borne Diseases namely Malaria, Kalaazar, Dengue/DHF and Japanese Encephalitis To reduce morbidity due to Malaria, Dengue/DHF, Chikungunya and Japanese Encephalitis Elimination of Kala-azar and Lymphatic Filariasis. Towards reducing the burden of vector borne diseases and paving the way for healthy and socio-economically developed nation, the Government of India (GoI) in its National Health Policy (2002) has envisaged the goal to reduce mortality on account of malaria, dengue and Japanese encephalitis by 50% by 2010, elimination of Kalaazar by 2010 and elimination of lymphatic filariasis by 2015. Reducing morbidity and mortality on account of malaria is also Millennium Development Goal. The programme has also been subsumed under National Rural Health Mission (NRHM) to improve the availability of services and access to health care to people, especially for those residing in rural areas, the poor, women and children.

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2. Status of National Vector Borne Disease Control Programme during XI Plan

2.1 Malaria
2.1.1 Objectives To reduce malaria morbidity & mortality by 50% by 2012 (Base line 2006).

2.1.2. Targets and indicators Targets ABER over 10%. API 1.3 or less. 25 per cent reduction in morbidity and mortality due to malaria by 2010 and 50 per cent by 2012.

Indicators Percentage of blood smears examined from population under surveillance during the year. Number of laboratory confirmed malaria cases per 1000 population (API). Number of malaria deaths per 100,000 population. 2.1.3 Strategy to achieve the objectives of XI Plan Period was as follows: The basic approach for vector borne disease control involves a strategy directed against the parasite and vector, and to enlist involvement of community in practising various preventive measures. Based on this concept following major strategies were adopted under the National Vector Borne Disease Control Programme during the XI Plan Period. Disease Management Early case detection and complete treatment Strengthening of referral services Epidemic preparedness and rapid response Integrated Vector Management (For Transmission Risk Reduction) Indoor Residual Spraying in selected high risk areas Use of Insecticide treated bed nets and upscaling of long lasting insecticidal nets in last two years of XI plan Use of larvivorous fish Anti larval measures in urban areas including biolarvicides Minor environmental engineering Supportive Interventions Behaviour Change Communication (BCC) and IEC activities Public private partnership & inter-sectoral convergence Human resource development and capacity building Operational research including studies on drug resistance and insecticide susceptibility
31

Monitoring and Evaluation The Government of India provides antimalaria drugs, insecticides and larvicides under the National Vector Borne Disease Control Programme. The programme is implemented and monitored by the state health authorities. The operational cost including the wages for contractual labour for spraying are borne by the state governments except in North-Eastern states and UTs. Certain commodities are to be met out of state resources. Recently the procurement of drugs and larvicides have been decentralized for which Govt. of India provides cash assistance. DDT procurement & supply still remains with GoI. In addition, the commodities to be supplied under externally assisted projects are also procured and supplied by GoI to the identified states/districts. Cash grant is also provided by GoI to the states/UTs for various preparatory activities and towards the salary of contractual human resources.

2.1.4 Initiatives and achievements Human Resource: To intensify the programme activities, the efforts were made to bridge the gaps especially to strengthen surveillance diagnosis and treatment. Additional human resources of various categories were provided to high malaria endemic states on contractual basis. These categories were state and district level consultants, Malaria Technical Supervisors (MTS), Kala-azar Technical Supervisors (KTS), Lab. Technicians (LTs) and male Multipurpose Workers (MPWs). The externally aided projects also supported such endeavors and therefore in the states supported under World Bank and Global Fund Projects, the above mentioned categories except male MPWs were provided. The male MPWs were provided out of Govt. of India funds to high malaria endemic states. To handle the project activities and its monitoring. National Consultants with support staff were also provided at central level. The expertise of these consultants was also utilized for activities supported under domestic funding as an ad-hoc arrangement. However, the real need of programme in the whole country needs to be addressed from domestic funding. ASHAs were involved for diagnosis and treatment for which they have been trained. So far about 3.5 lakhs ASHAs have been trained and involved in malaria diagnosis and treatment, especially in Pf predominant areas. Such newly engaged personnel were given orientation on programme activities and specific to their job for which they were engaged. Their capacity building was taken up in addition to regular training programmes for various categories of staff in the States. Surveillance & Diagnosis: The surveillance for malaria is carried out through active agencies where health workers approach patients and through passive agencies where patients approach health facilities. Active surveillance has been affected due to shortage of male health workers (states responsibility), however, in high malaria risk areas contractual male multipurpose health workers were provided during 11th plan period by GOI. Many public health facilities (PHCs, Block PHCs & CHCs) in rural areas through inputs under NRHM in last few years have undergone major changes to provide certain minimum health facilities, thereby attracting the community comparatively more. The passive surveillance therefore has also increased due to a large number of people approaching to these peripheral health institutions where doctors and LTs are present. The involvement of ASHAs in surveillance, diagnosis and treatment of Pf
32

malaria cases in high risk areas was found a feasible solution to overcome the shortage of male MPWs. Initially for the involvement of ASHAs, 61 districts were identified during XI plan but later based on the field experience ASHAs involvement was expanded to 257 districts after recommendation of Empowered Programme Committee (EPC) of NRHM and approval by Mission Steering Group (MSG) in 2010. With these initiatives, the number of persons screened for malaria through blood slide (microscopy) and through RDT has been around 95 million, thereby maintaining the annual blood examination rate around 9.2% against the target of 10%. The RDT was scaled up in last two years of 11th plan and about 14 million out of 95 million fever cases are screened per year through RDT. Presently the RDTs used in the programme is for detection of only Pf cases which if not detected and treated timely, may become fatal. To strengthen the surveillance further, additional sentinel sites at district hospitals/medical colleges are being established in districts covered under externally assisted projects. Malaria clinics, dispensaries and hospitals are also involved in passive surveillance in urban areas the reports of which are collected and compiled in the respective districts. In addition, certain private hospitals, medical colleges and malaria clinics at Regional Offices for Health & FW, GoI also screen the suspected fever cases visiting these institutions and provide the treatment after diagnosis. These records are also collected by the States and incorporated in their report. Efforts have been made to intensify it by training lab. technicians of these institutions.

Treatment: The conventional treatment protocol of vivax and falciparum malaria has been revised. During 11th plan, revised treatment protocol with 14 days radical treatment of vivax malaria and treatment with artemisinin based combination therapy (ACT) against falciparum malaria has been implemented. The use of ACT was upscaled due to emergence of chloroquine resistance in P.falciparum cases. The drug resistance is being monitored regularly by 13 existing teams located at different Regional offices for Health &FW (GoI). However, since these teams were formed out of project staff and were merged in 1995 in pursuance to the order of Supreme Court with the condition that these posts will not be created after the retirement of project staff, hence these posts can not be filled up. The support of National Institute of Malaria Research Centre (NIMR) of ICMR was obtained to generate more data. Vector Control: Under integrated vector control initiative, Indoor Residual Spraying (IRS) is implemented selectively in high risk areas taking sub-centres as a unit. Over the years, targeted population for IRS has been reduced in view of paradigm shift to alternative vector control measures like use of insecticide treated nets/long lasting insecticidal nets. During 2006, 65.11 million population was covered with IRS; population covered during 11th plan period ranged between 50-70 million population. Initiatives have been taken to strengthen the supervision of IRS by deputing central officers to the field during the spray season. During initial years of 11th plan, Insecticide Treated Nets (ITNs) were promoted but in the later phase of XI plan period, use of long lasting insecticidal nets (LLINs) have been upscaled. Till date, 4.51 million bed nets and 4.81 million LLINs have been supplied. In 2011 additional 6.58 million LLIN would be supplied.
33

Legislative Measures: The strict implementation of civic bye-laws and building bye-laws by the enforcement agencies were taken up to prevent the development of mosquitogenic potential in urban areas. States have been emphasized to initiate the implementation of such acts wherever available and other states to start the process of formulation and enactment of such bye-laws. World Bank Supported Enhanced Malaria Control Project was implemented in 1045 PHCs in 100 districts of 8 states (Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh Maharashtra, Rajasthan and Orissa) predominantly inhabited by tribal population and were provided 100 per cent support towards operational expenses from 1997 to 2005. The World Bank Mission 2005 had rated programme of EMCP as satisfactory although much more improvements were still desirable especially in States like Orissa & Jharkhand. In the EMCP areas, reported cases have shown a decline from 1.19 million in 1997 to 0.65 million in 2004 (45% decline); deaths due to malaria have declined from 539 to 226 (58%). The Pf cases reduced from 0.72 million to 0.41 million (43%). Out of 100 Districts, 48 have shown Annual Parasite Incidence (API) of 2 or less. The World Bank is again assisting the programme through the National Vector Borne Disease Control Project (20082013) for malaria control activities to cover a population of about 185 million in 93 districts of 8 states i.e. Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Orissa and Karnataka. Under the project following additional inputs are being provided to states: Human Resources including State level M&E, Finance, Training, IEC/PPP, Logistic & Procurement consultants; at district level one VBD consultant for each project district; at sub-district level Malaria Technical Supervisor (MTS) and Laboratory technicians for Sentinel site hospitals. Logistic support including RDT, ACT, Artether injections, LLIN and mobility support for monitoring and supervision. In addition, support for training, BCC and Vulnerable Community Plan (VCP) to ensure service delivery has also been extended through different agencies.

Global Fund supported Intensified Malaria Control Project (IMCP) in 10 states (7 NE States & selected high risk areas of Orissa, Jharkhand and West Bengal) has been implemented since 1st July 2005 with the objective to increase access to rapid diagnosis and treatment in remote and inaccessible areas, reduce malaria transmission risk by use of insecticide treated bed nets (ITNs) and enhance community awareness about malaria control and promote community, NGO and private sector participation. The goal set in the project has been achieved in the project areas. To intensify anti-malarial activities in the high endemic districts, Global Fund (GF) supported another project for 5 years has been approved for 86 districts of N.E states except Sikkim. Under Global Fund supported project, following inputs are being provided: a. Human resource including State level Project Coordinator, M&E, Finance and IEC consultants; District VBD consultants, Malaria Technical Supervisors (MTS) and Laboratory technicians.
34

b. Logistic support including commodities like RDT, ACT, Artether injections, Insecticide treated nets with insecticide for treatment, LLINs and support for monitoring and evaluation. Monitoring has been strengthened with the support of additional human resource made available under external assistance. a. The involvement of ASHAs necessitated data recording from village level on RDT and blood slide collection. The monitoring formats were accordingly revised. b. During XI plan period, external evaluation of programme was done in World Bank and GF supported projects during 2008 and 2010. c. Monitoring of disease trend through sentinel sites has been strengthened which is being intensified in many states. d. Monitoring of implementation of project and programme activities has been further strengthened by introducing Lot Quality Assurance Sampling Survey methodology for selected activities like use of LLINs etc. e. Monitoring of financial management in World Bank project has been strengthened through agencies for fiduciary review. Similarly, monitoring of logistics has been undertaken by another agency, especially for supply chain management. Operational Research: To monitor the drug resistance, pharmaco-vigilance, quality assurance and insecticide resistance the operational research studies were initiated in 2008 with the help of NIMR under the funding by World Bank. More than 15 sites have been selected throughout the country for these studies in association with NIMR. Involvement of NGO/Private Sector/Community/Local Self Government: In addition to involvement of local NGOs in bednet distribution, social mobilization, CARITAS a consortium of NGOs has been involved in implementation of the programme activities under GF supported IMCP-II in NE States. Quality Assurance for Laboratory Diagnosis: Microscopy and newer rapid diagnostic are being used across the country for diagnosis of malaria. Guidelines for Quality Assurance on Microscopy and RDT were prepared during the XIth Five Year Plan which are being followed. Behaviour Change Communication (BCC): Community based approach and strategies were developed to facilitate changes in behaviour and life style of people related to prevention and control of malaria. NGOs in high-risk areas were also involved to enhance the BCC activities. Every year, June is observed as Anti-Malaria Month during which the IEC and BCC activities are intensified.

2.1.5. Current situation of Malaria in the country The malaria situation in India has steadily improved during the past decade with the number of reported cases being around 1.5 million with about thousand deaths annually at present. The countrywide malaria situation from 2001-2010 is given in Table 1.
35

Table 1, Countrywide Epidemiological Situation (2001 2010)

Deaths due to malaria 1005 973 1006 949 963 1707 1311 1055 1144 767

Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010* *Provisional

Total Malaria Cases (million) 2.09 1.84 1.87 1.92 1.82 1.79 1.51 1.53 1.56 1.50

P.falciparum cases (million) 1.01 0.90 0.86 0.89 0.81 0.84 0.74 0.77 0.84 0.78

Pf % 48.20 48.74 45.85 46.47 44.32 47.08 49.11 50.81 53.72 52.12

API 2.12 1.82 1.82 1.84 1.68 1.66 1.39 1.36 1.36 1.30

API: Annual Parasite Incidence (cases per thousand population per year), Pf: Plasmodium falciparum

Comparative status (2010 Vs 2006) of distribution of districts based on API

Jammu and Kashmir

Jammu and Kashmir

Himachal Pradesh Punjab Uttaranchal Haryana Sikkim Rajasthan Uttar Pradesh Bihar Madhya Pradesh Gujarat Jharkhand West Bengal Chhattisgarh Dadra&Nagarhaveli Maharashtra Orissa Assam Nagaland Meghalaya Manipur Tripura Mizoram Arunachal Pradesh

Himachal Pradesh Punjab Uttaranchal Haryana Sikkim Rajasthan Uttar Pradesh Bihar Madhya Pradesh Gujarat Jharkhand West Bengal Chhattisgarh Orissa A ssam Nagaland Meghalaya Manipur Tripura Mizoram Arunachal Pradesh

API - 2006
0-1 >1-2 >2-5 >5-10 >10
Andaman Nicobar Iland

Daman & Diu Dadra&Nagarhaveli Maharashtra

API - 2010
0-1 >1-2 >2-5 >5-10 >10
A ndaman Nicobar Iland

Andhra Pradesh Goa Karnataka

Andhra Pradesh Goa Karnataka

Lakshadweep Ilands Pondicherry Tamilnadu Kerala

Lakshadweep Ilands Pondicherry Tamilnadu Kerala

Fig. 1, API-wise distribution of districts in 2006

Fig. 2, API-wise distribution of districts in 2010

The API wise distribution of districts in 2006 and 2010 given in Table 2, shows that the number of districts with API >10 has decreased from 52 in 2006 to 46 in 2010 and the number of districts with API <1 has increased from 374 in 2006 to 444 in 2010.

36

Table 2, API wise distribution of Districts in 2006 and 2010 2006

Number of Districts with API SN 1 2 3 4 5 6 7 8 9 11 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Name of the State Andhra Pradesh Arunachal Pradesh Assam Bihar Chhattisgarh Goa Gujarat Haryana Himachal Pradesh Jharkhand J&K Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Punjab Rajasthan Sikkim Tamilnadu Tripura Uttaranchal Uttar Pradesh West Bengal A & N Islands Chandigarh D & N Haveli Daman & Diu Delhi Lakshdweep Puducherry All India >10 0 9 5 0 5 0 0 1 0 6 0 1 0 0 0 0 2 0 0 14 0 2 0 0 2 0 1 2 1 0 1 0 0 0 0 52 5 10 0 1 3 0 3 1 0 2 0 5 0 2 0 1 1 1 1 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27 2- 5 1- 2 1 2 1 1 8 3 0 0 3 1 0 1 7 9 3 4 0 0 7 1 0 0 4 5 0 0 12 15 2 2 1 4 2 0 4 0 5 2 3 3 0 0 7 10 0 1 2 1 1 1 0 0 4 3 2 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 80 71 <1 20 0 4 38 4 0 10 10 10 3 8 19 14 20 31 5 0 0 5 4 20 13 3 39 0 13 62 13 0 1 0 2 1 1 4 377 >10 0 6 4 0 3 0 0 0 0 6 0 2 0 0 0 0 3 5 0 12 0 1 0 0 2 0 0 1 0 0 1 0 0 0 0 46 5- 10 0 4 1 0 6 0 0 0 0 9 0 0 0 2 2 0 2 0 2 5 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 34

2010
Number of Districts with API 2- 5 1 4 3 0 1 0 2 1 0 4 0 3 0 6 0 2 1 1 3 3 0 2 0 1 1 0 2 0 0 0 0 0 0 0 0 41 1- 2 2 0 2 0 3 2 11 1 0 1 0 6 0 16 5 0 0 3 4 5 0 2 0 1 1 0 2 2 0 0 0 1 0 0 0 70 <1 20 1 17 38 3 0 14 19 10 4 12 22 14 24 29 10 1 0 3 5 20 28 4 40 0 13 66 16 3 1 0 1 1 1 4 444

37

Table 3, Epidemiological Indicators for Malaria in India (2001-10)

Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010* Blood Smear Examined 90,389,019 91,617,725 99,136,143 97,111,526 104,143,806 106,725,851 94,928,090 97,316,158 103396076 106040223 Positive cases 2,085,484 1,841,229 1,869,403 1,915,363 1,816,569 1,785,129 1,508,927 1,526,210 1,563,574 1,495,817 Pf Cases 1,005,236 897,446 857,101 890,152 805,077 840,360 741,076 775,523 839,877 779,549 ABER 9.18 9.04 9.65 9.33 9.62 9.95 8.73 8.69 8.99 9.21 API 2.12 1.82 1.82 1.84 1.68 1.66 1.39 1.36 1.36 1.30 SPR 2.31 2.01 1.89 1.97 1.74 1.67 1.59 1.57 1.51 1.41 SFR 1.11 0.98 0.86 0.92 0.77 0.79 0.78 0.80 0.81 0.74 Deaths 1005 973 1006 949 963 1707 1311 1055 1144 767

*Provisional ABER: Annual Blood Smear Examination Rate (percentage of blood smears examined in a year of total population) SPR: Slide positivity Rate (includes confirmed by RDT) SFR: Slide falciparum Rate (includes confirmed by RDT)

Fig. 3, Trend of Malaria cases, Pf cases and Deaths due to malaria from 2000 to 2010.

TrendofM alariainIndia(20002010*)
2 .5 17 0 7 16 0 0 2 1 31 1 11 4 4 1 05 5 1 .5 932 1 00 5 973 1 00 6 949 963 767 1 6 00 10 0 0 8 00 18 0 0

14 0 0 12 0 0

0 .5

4 00 2 00

0 20 0 0 2001 2 00 2 20 0 3 2004 2 00 5 20 0 6 2007 2 0 08 20 0 9 2 0 1 0*

Total Malar iaCases (in m illio n)

PfCases (in millio n

Deaths

*P rovisional

The data in Table 3 shows that Annual Parasite Incidence rate has consistently decreased from 2.12 per thousand in 2001 to 1.30 per thousand in 2010 but confirmed deaths due to malaria have been fluctuating during this period between 1707 and 767. The Table 3 shows the information on indicators by which malaria prevention/ control activity in India are monitored and evaluated. Slide Positivity Rate (SPR) and
38

Slide Falciparum Rate (SFR) have reduced over the years from 2001 to 2010. It is also observed that ABER has ranged between 9.95% and 8.73% during that period. Fig 3 shows that the cases have consistently declined from 2.08 million to 1.50 million during 2001 to 2010. Similarly Pf cases have declined from 1.0 to 0.78 million cases during the same period. Less than 2000 deaths were reported during all the years within this period with a peak in 2006 when an epidemic was reported in NE States. The country SPR has declined from 2.31 to 1.41 and SFR has declined from 1.11 in 2001 to 0.74 in 2010. This indicates declining trend of malaria in the country However, the actual burden may be more because a large number of cases may be reporting to private health providers who do not report the cases to the programme. The Government of India recently has started rapid scale up of newer malaria control interventions, namely Rapid Diagnostic Test (RDT), Artimisinin based Combination Therapy (ACT) and Long Lasting Insecticidal Net (LLIN). The scaling up of these interventions is one of the biggest opportunities to have a significant impact on malaria mortality and morbidity. The programme is being implemented through out the country by the states and union territories under the technical guidance of the Directorate of National Vector Borne Disease Control Programme (NVBDCP). Over the past decades the problem of malaria has been effectively controlled in many parts of the country. At present, 80% of burden of disease in the country is confined to the most remote and inaccessible areas spread across the North Eastern States, Orissa, Jharkhand, Chhattisgarh and some districts of West Bengal, Rajasthan, Gujarat, Madhya Pradesh, Maharashtra, and Andhra Pradesh. The most potent malaria vectors are prevalent in these areas warranting intensive inputs. The Govt. of India is providing 100% central assistance to the North Eastern States for malaria control activities including provision of bed nets and spray wages. The Enhanced Malaria Control Project (EMCP) with World Bank assistance was implemented during 1997 2005 in 100 districts of eight high malaria incidence states. The World Bank is assisting the programme again through the National Vector Borne Disease Control Project (2008 2013) for malaria control activities to cover a population of about 185 million in 93 districts of 8 states i.e. Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Orissa and Karnataka. The Intensified Malaria Control Project (IMCP) - I funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) was in operation during 200510 in 106 districts covering the entire 7 North Eastern states, and some districts of Orissa, West Bengal and Jharkhand. The IMCP II (2010 2015) funded by GFATM Round 9 has been initiated to provide intensive coverage with malaria control interventions in 7 North Eastern states. There are many constraints for malaria control but there are ample opportunities too. Prevention with vector control interventions aims to reduce transmission and thus decrease the incidence and prevalence of infection and disease. Early and effective case management of malaria shortens disease duration and prevents complications and deaths from malaria. In addition, interruption of transmission will also result.

39

2.1.6 Urban Malaria Scheme (UMS) 2.1.6.1 Objectives To control urban malaria

2.1.6.2 Targets and Indicators Under UMS, anti-larval operations are aimed at elimination of breeding of vectors which are monitored, therefore the target was elimination of breeding at its source and indicator was measurement of density of aquatic stages of vector mosquitoes and epidemiological impact.

2.1.6.3 Strategies The following components for vector control strategy under Urban Malaria Scheme have been implemented: Recurrent application of larvicides for polluted and non polluted water Use of larvivorous fish, Gambusia affinis and Poecilia reticulata in ornamental tanks, ponds and other seasonal and permanent water bodies Filling up of unused wells and water pools, disilting and deweeding of the margins of the drains and water channels Use of legislative measures and prosecution of defaulters for creating mosquitogenic conditions in domestic places by implementation of civic byelaws. Indoor space Spray with 2% Pyrethrum extract diluted to 0.1% in and around 50 houses of positive cases Use of fogging of insecticide in case of very high densities of Aedes aegypti and An.stephensi. 2.1.6.4 Current Disease Burden in urban areas The Urban Malaria Scheme (UMS) was launched in 1971 with the objective to control malaria by reducing the vector population in the urban areas through recurrent anti-larval measures, and detection and complete treatment of malaria cases through the existing health services. Population migration to urban and peri-urban areas is increasing leading to unplanned urbanization, large scale urban conglomerations prone to vector borne diseases and mega construction activities with vertical growth of cities and led to increase in urban malaria from 7.79% (1996) to 13.8 % (2010). The following Tables indicate the malaria situation in urban towns under Urban Malaria Scheme: Table 4, Year wise malaria situation in Towns under UMS Year 2004 2005 2006 2007 2008 2009 2010 Population 95814228 102423064 105782505 112448027 113334073 114699850 115999944 Total cases 150917 135249 129531 102829 113810 166065 207165 P.f. cases 19659 14905 17278 18038 18963 31134 32656 Deaths 62 96 145 125 102 213 149

40

Fig. 4, Trend of Malaria incidence and deaths

250000 Positive Cases 200000 150000 100000 50000 0 Total Cases Pf cases Deaths 250 200 Deaths 150 100 50 0

2004 150917 19659 62

2005 135249 14905 96

2006 129531 17278 145

2007 102829 18038 125

2008 113810 18963 102

2009 166065 31134 213

2010 206498 32665 149

The epidemiological situation for the year 2010 revealed that the urban towns contribute 13.8% of total cases, 4.19% of P. falciparum cases and 19.42 % deaths of the country. Country level Country total Total cases in urban towns (131) Population Total (in cases million) 1210.0 1495817 116.0 (9.59 %) 207165 (13.85 %) Pf. Cases 779549 32656 (4.19 %) Deaths 767 149 (19.42 %)

Certain cities contribute large proportion of Malaria in the state like Chennai in Tamil Nadu and cities like Mumbai had shown an increase. The comparative picture of these town vs the state is indicated below. State level Tamil Nadu Chennai Corp. Maharastra Mumbai Corp. Population (in million) 67.20 4.81 (7.15%) 111.65 13.6 (12.18%) Total cases 15271 9789 (64.10 %) 138506 76755 (55.41%) Pf. Cases 506 64 (12.6% ) 32383 13363 (41.26%) Deaths 2 0 (0.00%) 190 145 (76.31%)

In urban areas, large number of people avail Medicare services from the private sector. The reporting system from the private sector is practically nil. Therefore actual malaria disease burden may be much more than the reported cases. The hospitals in the cities/towns also provide referral services to malaria cases including the severe and complicated forms of malaria from the catchments areas of the cities/ towns. Therefore there is a need to strengthen the referral facilities and capacity of the hospitals for management of malaria cases.
41

2.1.6.5 Constraints Increasing urbanization: The proportion of urban population has increased in the last few decades which is mainly by migration of population from rural to urban areas for earning and also attraction for availing both medical care and education opportunities etc. Unplanned Urbanization: Haphazard and unplanned growth of towns has resulted in creation of urban slum with poor housing and sanitary conditions promoting vector mosquito breeding potential for malaria, filaria and dengue fever/ Dengue haemorrhagic fever. Supply of drinking water: Deficient/restricted water supply has led to water storage practices in artificial containers which have generated breeding potential of An.stephensi vectors of urban malaria and Aedes aegypti, the vector of DF/DHF Development project with Health Impact Assessment (HIA): Development project activities without health impact assessment have resulted in malaria outbreaks in short terms and endemic malaria with foci of P.falciparum resistance strains in long term. The outbreaks of malaria and increase in malaria cases in Mumbai are examples of this kind. Inadequate health infrastructure: With rapid growth of population in urban towns, existing staff strength has not increased correspondingly and is therefore inadequate for service delivery. 2.1.6.6 UMS Budget The allocation in approved Budget estimates during 11th Plan period is as under: Table 5, Budget under UMS Year 2007-08 2008-09 2009-10 2010-11 2011-12 Total B.E. 399.50 472.25 442.00 478.00 520.00
Rs. in crores

Allocation under UMS 20.90 20.09 20.90 0.20 -

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2.2 Dengue and Chikungunya

2.2.1 Objectives To prevent mortality due to dengue/DHF. To reduce morbidity due to dengue and chikungunya.

2.2.2 Target To reduce morbidity due to dengue & mortality due to DHF/DSS To reduce morbidity due to chikungunya.

2.2.3 Indicators Case Fatality Rate (CFR) associated with dengue/DHF. Frequency of outbreaks

2.2.4 Strategies for Dengue and Chikungunya control Dengue and chikungunya are two different viral diseases transmitted by same vector Aedes mosquito. Therefore, the strategies are also same for prevention and control of both the diseases, which were three-pronged as under: Early Case reporting and management Establishment of sentinel surveillance sites with laboratory support Case management Strengthening of referral services Epidemic preparedness and rapid response Integrated vector management for transmission risk reduction Entomological surveillance including larval surveys Anti-larval measures Source reduction Chemical larvicide / biocide Larvivorous fish Environmental management Anti- adult measures Indoor space spraying with pyrethrum extract (2%) Fogging during outbreaks Personal protection measures Protective clothing Insecticide treated bed nets and repellents Supporting Interventions Behaviour Change Communication Inter-sectoral convergence Human resource development through capacity building Operational research Supervision and monitoring
43

2.2.5 Initiatives Prepared a long term action plan for prevention and control of chikungunya and dengue in the country and disseminated to the states in January 2007 for adoption. The main components of the long term action plan are as under: Early case detection and reporting Sentinel Surveillance Hospitals (SSHs) were identified in endemic states for carrying out proactive surveillance during the inter-epidemic period and to augment diagnostic facilities in endemic states. For this purpose in 2007 to begin with, 110 Sentinel Surveillance Hospitals have been identified in consultation with the State Governments. Subsequently the numbers had been increased to 137 in 2008, to 171 in 2009, to 182 in 2010 and to 311 in 2011. Each SSH has necessary equipment (ELISA reader & washer) for conducting serological tests. Wherever, equipment was not available with any SSH, the State Programme Officer had been requested to make the facility available by utilizing NRHM funds in consultation with the Dte of NVBDCP. Total 13 Apex Referral Laboratories (ARLs) have been identified across the country with advanced diagnostic facility in 2007 for capacity building and backup support to the Sentinel Surveillance Hospitals and one more added in 2011 totaling to 14. A sum of Rs 25.0 Lakhs (Rupees Twenty five lakhs only) as one time grant had been provided to ARLs to strengthen the participating institutions wherever necessary. Recurring grant of Rs 1.0 lakh per year to meet the contingency expenditure has also been provided. To make the Sentinel Surveillance Hospitals functional ,Rs 0.50 lakh provided every year to each to meet the contingency expenditure. National Institute of Virology (NIV), Pune has been entrusted for supply of dengue and chikungunya IgM MAC ELISA test kits to all SSHs and ARLs as per technical requirements of the states under the guidance of Dte of NVBDCP. The cost of these kits is being reimbursed by Govt of India. Kit production capacity of NIV, Pune was also up-scaled. Newer diagnostic tool, ELISA based dengue NS1 test, introduced in the programme in 2010. For early capture of any outbreak through health workers and grassroots level functionaries such as ASHA, Anganwadi worker and Fever Treatment Depots guidelines on fever alert surveillance have been prepared and circulated to the states in Feb 2007 Epidemic preparedness and rapid response Endemic states were advised to prepare a contingency plan dealing with emergency hospitalization for most effective use of hospital and treatment facilities in case dengue or chikungunya outbreak occurs, based on the previous years epidemiological data.

44

 As soon as a suspected case is reported, the district vector borne disease control Officer/ District Chief Medical Officer or Municipal Health Officer is being intimated by telephone, fax or e-mail so that he/she can immediately initiate remedial measures in the affected area(s) in order to effectively interrupt the transmission before infection spreads further. Case management National guidelines for clinical management of Dengue Fever, Dengue Haemorrhagic Fever, and Dengue Shock Syndrome have been sent to the States in March 2007 for circulation in all hospitals. States were suggested to ensure availability of minimum diagnostic materials and therapeutics in the hospitals for outpatient department as well as for indoor patients management. Integrated Vector Management for transmission risk reduction As Aedes aegypti mosquito, the vector of Dengue/Chikungunya, breeds in man made containers in and around houses, community based vector control has been envisaged. A targeted source reduction programme has been undertaken that emphasizes removing larval habitats that are most productive (tyre dumps, scraps, water storage tanks, cisterns, air coolers, solid waste, coconut shells, etc) and treating those that cannot be removed with Temephos. Periodic household spray with Pyrethrum 2% extract (0.2% ready to spray solution with kerosene oil) where the case was detected. In addition, Ultra Low Volume (ULV) spraying of the entire ward/village, may be carried out in case of clustering of cases involving a large area. Behaviour Change Communication As most transmission occurs at home, therefore, ultimate success of the programme depends on community participation and co-operation. For awareness of the community, Government of India advocates inter-sectoral convergence and communication for behavioural impact for involvement of the non-health sector stakeholders and the community for implementing appropriate prevention and control interventions. A comprehensive communication plan with media mix has been developed and activities are being initiated for dissemination of message through television, radio and print media and inter-personal forum with intensification during the transmission season. Month of July has been declared as anti-dengue month all over the country. Messages on chikungunya have also been added up in the campaign. Capacity Building Training of national trainers on Dengue/ Chikungunya treatment is carried out every year in All India Institute of Medical Sciences, New Delhi, who in turn impart trainings at state level. For capacity building of state/district level health functionaries, trainings were imparted on rapid response at NCDC, Delhi. One laboratory team (one Microbiologist and one Technician) from the Sentinel Surveillance Hospitals has been trained in the Apex Referral Laboratories on 45 diagnosis.

Inter-sectoral collaboration For Inter-ministerial convergence for prevention and control of dengue and chikungunya involving the Ministries of Urban Development, Rural Development, Panchayati Raj efforts have been made and circulars have been sent to the concerned departments in the States requesting to take necessary measures to control the spread of vector borne diseases including chikungunya. The Village Health and Sanitation Committees (VHSC) under NRHM have been requested to carrying out weekly cleanliness drive in the respective villages by making use of the flexi-pool. Logistic support In addition to the supply of logistics, Govt. of India had released emergency package to the affected states to the tune of Rs. 2.21 Crores in 2006-07 and subsequently Rs. 1.78 Crores in 2007-08 to sustain the activities for prevention and control of chikungunya outbreak. Monitoring and evaluation Periodic reviews are carried out to determine the progress of work and actual inputs received by the programme. Situations in the States are being monitored regularly through reports and feedbacks are provided as and when required. Field visits are made for situational analyses of the programme implementation in the states and for technical guidance. Achievements States are implementing strategies of long term action plan for prevention and control of Dengue and Chikungunya since 2007. Established 311 Sentinel Surveillance Hospitals with laboratory support for augmentation of diagnostic facility for dengue in endemic States and linked with 14 Apex Referral Laboratories with advanced diagnostic facilities for back up support. To ensure the quality of diagnostics, IgM test kits to these institutes have been supplied by National Institute of Virology, Pune since 2007. Following national guidelines, clinical management of dengue cases has been improved and dengue case fatality rate reduced by 69.2% in 2010 as compared to 2006. Better and improved case detection. Dengue cases increased by 129.7% in 2010 (28292) as compared to 2006 (12317) but chikungunya cases decreased from 13,90,322 in 2006 to 48,176 in 2010. Early diagnosis through ELISA based dengue NS1 test which can detect a case from 1st day onwards of onset of the disease in addition to IgM MAC ELISA which can detect a case after 5th day of onset of the disease.

46

Monitoring through the daily reports received during transmission period and weekly in low/no transmission period from State Health Authorities and reviewing the preparedness of the State Governments for prevention and control of dengue and chikungunya. Committee of Secretaries under the Chairmanship of Cabinet Secretary reviewed the Dengue & Chikungunya situation and programme strategies on 24th August, 9th September, 12th November in 2010 and 26th May 2011. Effective IEC campaign to make programme interventions at grassroot level and initiate community empowerment and mobilization. Trainings of various health functionaries are being conducted by states/districts by involving regional offices.

2.2.6 Disease burden and trend 2.2.6.1 Dengue Dengue Fever is an outbreak prone viral disease and is the fastest-growing arborvirus infection with a rapidly evolving epidemiology. It is listed among the 40 emerging diseases of global importance. Dengue has been identified as one of the 17 neglected tropical disease by WHO (First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases. 2010). In India, in recent years the Fig. 5, occurrence of dengue fever was reported during 1956 from Vellore district in Tamil Nadu. Since than, out of 35 States/Union Territories in the country, 31 have dengue cases during last two decades from 1991 to 2010. Recurring outbreaks of DF/DHF have been reported from Andhra Pradesh, Delhi, Goa, Haryana, Gujarat, Karnataka, Kerala, Maharashtra, Rajasthan, Uttar Pradesh, Puducherry, Punjab, Tamil Nadu and West Bengal. In 2006, the country witnessed an outbreak of DF/DHF with 12,317 cases and 184 deaths reported from 18 States/ UTs (270 districts). In 2010, 28292 cases and 110 deaths were reported from 27 States/UTs (403 districts) which is highest in the country in last two decades. A state wise situation from 2006 to 2010 is given at Table-6. Fig. 6 The case fatality rate (deaths per 100 cases) due to dengue which was 1.5 % in 2006 has declined to 0.4% in 2010 after the National guidelines on clinical management of DF/DHF/DSS were developed and circulated in 2007 All the four virus
47

serotypes DENV 1-4 have been isolated in India. Aedes aegypti is the most efficient vector of dengue in India. Ae. albopictus is also involved as secondary vector in some parts of the country. The risk of dengue has shown an increase in the recent years due to rapid urbanization, life style changes and improper water storage practices in urban, peri-urban and rural areas, leading to proliferation of mosquito breeding sites. Due to the manmade environmental and lifestyle changes DF/DHF has now spread to rural areas as well. Dengue is an ecological disease and the transmission is related to rainfall and temperature. Every year during the period of July-Nov there is an upsurge in the cases of Dengue/DHF. However, in the peninsular states and western parts of the country the disease has become perennial. Based on the dengue transmission potential at macro and micro levels, WHO has categorized the countries in SEARO. Till 2009, India was in Category B, grouped with Bangladesh and Maldives where cyclical epidemics are becoming more frequent, multiple virus serotypes circulating and expanding geographically within countries. However, in view of increasing endemicity, WHO in 2010 grouped India in Category A countries with Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste where dengue is a major public health problem, leading cause of hospitalization and death among children, hyperendemicity in urban centres, spreading to rural areas and multiple virus serotypes circulating (Comprehensive Guidelines for Prevention and Control of DHF Draft 2010 (in press), WHO SEARO).

2.2.6.2 Chikungunya In India a major epidemic of chikungunya fever was reported during the last millennium viz.; in1963 (Kolkata), 1965 (Puducherry and Chennai in Tamil Nadu, Rajahmundry, Vishakapatnam and Kakinada in Andhra Pradesh; Sagar in Madhya Pradesh; and Nagpur in Maharashtra) and in 1973 (Barsi in Maharashtra). Thereafter, sporadic cases also continued to be recorded especially in Maharasthra state during 1983 and 2000. After quiescence of three decades in 2006, chikungunya outbreak occurred again in India. Though Andhra Pradesh and Karnataka had reported clinically suspected chikungunya cases in November and December 2005, chikungunya infection was serologically confirmed in January, 2006. Reports of large scale outbreaks of fever caused by chikungunya virus infection in several parts of southern India have confirmed the re-emergence of this virus after a quiescence of three decades. A total of 13,90,322 clinically suspected cases have been reported by 16 states/UTs (190 districts) in 2006. All the peninsular states were affected. Maximum cases were reported by Karnataka, followed by Maharastra. In 2007 again, 14 states reported 59,535 clinically suspected cases. Kerala reported highest number of cases followed by West Bengal. In 2008, 95,091 cases were reported, of which 49 % cases were reported by Karnataka alone, followed by Kerala (26%) and West Bengal (19%). In 2009, 73,288 cases were reported; again maximum cases were reported by Karnataka followed by Kerala. In 2010, 0.48 million clinically suspected cases were reported from 18 States/UTs (135 districts). A state wise situation is given at Table-6. Chikungunya cases start appearing in post monsoon period that is May onwards with a in July, August and September as during this period vector density is very high and decline thereafter. Aedes aegypti plays the major role in transmitting the disease in all the states except Kerala, where Ae. albopictus plays the major role. In northern part of the country the most favoured breeding habitats of Ae. aegypti are desert coolers, over head tanks, water storage vessels, animal water troughs, flower pots and discarded junks like discarded tyres, disposable food containers etc. In southern India, over head
48

tanks, water stora vessels, coconut she , age ells, refrigera tray, flo ator ower pots an nd discar rded junk m materials ar most fav re voured. Ae. albopictus breeding is s detect in latex collecting cu of rubber plantation fruit shel leaf axil ted ups ns, lls, ls, tree h holes etc. T areas re The eporting chikungunya, m mostly over rlapping wit th Dengu affected a ue areas, are as under:

Dengue affe D ected areas

Chiku ungunya aff fected areas

ystem including status of MIS, d s disease surv veillance, it quality & ts 2.2.7 M & E sy utilization Functioni of all ide ing entified Senti Surveill inel lance Hospit tals Data on n number of ca and deat not received timely f ases ths from all the S States. Private se ectors not rep porting the n number of ca and deat ases ths Proper mo onitoring & analysis of d at distri data ict/state level lacking Nil or poo entomolog or gical monito oring at the municipality/district/state level m e State/distr level rap response teams for timely action on report of cases rict pid f Endemic states are r regularly m monitored thr rough repor received daily durin rts ng nd n m transmission period an weekly in remaining period from the states Monitorin situations in the peri ng s iphery throu visiting the field by officers an ugh y nd staff from the Directo m orate of NVB BDCP, Regio Offices. onal 2.2.8 Constraint ts Administ trative

Dengue is not a No otifiable Disease in all th States. he Preven ntion and con ntrol of Den ngue and Ch hikungunya i not a priority for urba is an local bodies and pa anchayats No dru is availab to treat or any vacc ug ble cine availabl to preven dengue an le nt nd chikun ngunya infect tion. Geogra aphical sprea of both dengue and chikungunya has shown a increase i ad an in the rec cent years d to various factors in urban, pe due eri-urban and rural area d as, leading to prolifera g ation of mosquito breedi sites whi are: ing ich Demog graphic and societal chan nges: De emographic and societal changes le eading to unp planned and uncontrolle d ed ur rbanization and concurre populatio growth h put seve constrain a ent on has ere nts on civic amenities, particularly wate supply a solid wa n er and aste disposa al, thereby increa asing the bre eeding potent of the ve tial ector species s.

Technica al

Solid waste management: There have been significant increases in the use of consumerism and introduction of non-biodegradable plastics, paper cups, used tyres, etc. compounded by nonexistent or insufficient waste collection and management which facilitate increased vector breeding. Booming automobile industry leading to large-scale storage, import, export and dumping of used tires infested with Ae. aegypti larvae resulting passive spread of the disease to new areas (movement of incubating eggs). Increased population movement (work, travel, tourism or pilgrimage) has resulted in a constant exchange of viruses (dengue serotypes and CHK virus) Significant increase in plantations: Increased demand of rubber and being a profit making cash crop banana, pineapple, coconut, arecanut etc are increasing and simultaneously favourite breeding habitats of Ae albopictus also increasing in plantations. Operational

Operationalizing all identified Sentinel Surveillance Hospitals with equipment, tests kits and trained manpower Timely sending the linelists to the district VBD officer and/or municipality health officer for implementation of effective vector control measures to interrupt the transmission before spreading further Quite a large number of patients receive treatment through private sector which goes unreported or under-reported. A good vector surveillance and control is the mainstay for reducing incidence of dengue and chikungunya. Sustaining social mobilization for Behaviour Change Communication and community involvement in source reduction activities. Absence of civic byelaws or building byelaws to prevent mosquitogenic conditions in all municipal and corporation areas. Though a few urban areas have adopted legislation for the prevention of nuisance mosquitoes, however, lack in implementation at the ground level.

Financial

Non-receipt of adequate funds on time by the districts due to non-release by states due to administrative delays. Non availability of funds in municipality/ local bodies for source reduction activities adversely affecting the programme. Inadequate budget for dengue and chikungunya control programme. Only 3.3% of the total NVBDCP budget dedicated for dengue and chikungunya. However, during XI plan due to financial constraints only 40% was made available for programme activities.

50

2.2.9 Mid Course Correction The intensity of dengue transmission has shown substantial increase over the years, therefore a need has arisen to revisit the current strategies of Long Term Action Plan and develop a programmatic and comprehensive Mid Term Plan. The conceptual framework of Mid Term Plan which has been approved by Committee of Secretaries in a meeting held under the Chairmanship of Cabinet Secretary on 26th May 2011 is a comprehensive and integrated approach that places equal weight, including fiscal and human resources, on all elements of the programme for prevention and control of dengue and chikungunya in the country.

2.2.10 Outlays & Expenditure Until Xth plan no specific funds were provided for dengue control and the assistance was provided out of National Anti Malaria Programme provision on as and when required basis. After the re-emergence of chikungunya in 2006, it was included under the umbrella of NVBDCP as the 6th VBD in May 2007, following which in XIth plan for both dengue and chikungunya dedicated funds have been approved for the first time. Since then Govt. of India provides cash assistance (Grant-in-Aid) to the endemic states for strengthening surveillance, epidemic preparedness, monitoring & evaluation, capacity building and IEC. Cost of the IgM test kits are released to NIV, Pune. Insecticides are provided under urban malaria scheme. The allocation in approved budget estimates during 11th Plan period is as under:

Table-6, STATE-WISE DENGUE CASES (C ) AND DEATHS (D) IN THE COUNTRY Sl No State 1 2 3 4 5 6 7 8 9 Andhra Pd. Assam Bihar Chhattisgarh Goa Gujarat Haryana Himachal Pd. J & K 2006 C 197 0 4 0 1 545 838 0 24 0 109 981 16 0 736 0 0 D 17 0 0 0 0 5 4 0 1 0 7 4 0 0 25 0 0 C 587 0 0 0 36 570 365 0 0 0 230 603 51 0 614 51 0 2007 D 2 0 0 0 0 2 11 0 0 0 0 11 2 0 21 1 0
51

2008 C 313 0 1 0 43 1065 1137 0 0 0 339 733 3 0 743 0 0 D 2 0 0 0 0 2 9 0 0 0 3 3 0 0 22 0 0 C

2009 D 11 0 0 7 5 2 1 0 0 0 8 6 5 0 20 0 0 C 1190 0 1 26 277 2461 125 0 2 0 1764 1425 1467 0 2255 0 25

2010 D 3 2 0 0 0 1 20 0 0 0 7 17 1 0 5 0 0 776 237 510 4 242 2568 866 3 0 27 2285 2597 175 1 1489 7 0

10 Jharkhand 11 Karnataka 12 Kerala 13 Madhya Pd. 14 Meghalaya 15 Maharashtra 16 Manipur 17 Nagaland

18 Orissa 19 Punjab 20 Rajasthan 21 Sikkim 22 Tamil Nadu Uttar 23 Pradesh 24 Uttrakhand 25 West Bengal 26 A&N Island 27 Chandigarh 28 Delhi 29 D&N Haveli 30 Puducherry TOTAL

1 1166 1805 0 477 639 0 1230 0 182 3366 0 0

0 6 26 0 2 14 0 8 0 0 38 0 0

4 28 540 0 707 132 0 95 0 99 548 0 274 5534

0 0 10 0 2 2 0 4 0 0 1 0 0 69

0 4349 682 0 530 51 20 1038 0 167 1312 0 35 12561

0 21 4 0 3 2 0 7 0 0 2 0 0 80

0 245 1389 0 1072 168 0 399 0 25 1153 0 66 15535

0 1 18 0 7 2 0 0 0 0 3 0 0 96

29 4012 1823 0 2051 960 178 805 25 221 6259 46 96 28292

5 15 9 0 8 8 0 1 0 0 8 0 0 110

12317 157

Table 7, Budget allocation for Dengue & chikungunya control

Rs. in crores

Year 2007-08 2008-09 2009-10 2010-11 2011-12

Total B.E. for NVBDCP 399.50 472.25 442.00 478.00 520.00

Allocation for Dengue & Chikungunya 11.30* 27.00 26.00 23.00 17.44

*includes Rs 1.78 Crores emergency package released to chikungunya effected states

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2.3

Japanese Encephalitis (JE)

After approving an Umbrella Programme under National Vector Borne Disease Control Programme for control of Vector Borne Diseases including Malaria, Kala-azar, Filariasis, Japanese Encephalitis and Dengue/Dengue Hemorrhagic Fever (DF/DHF) since December 200. Directorate of National Vector Borne Disease Control Programme is the nodal agency responsible for the control programme of these diseases including JE. 2.3.1 Objectives during XI five year plan To reduce morbidity and Case Fatality Rate To reduce frequency of outbreaks 2.3.2 Targets for XI Plan, indicators and mean of verification Reduction in mortality by 50% by the year 2010 (as per National Health Policy Goal - 2002) 50% Reduction in morbidity Reduction in frequency of outbreaks Facilitation of institutional strengthening for diagnostic facilities in all 133 JE endemic districts. Vaccination in JE endemic districts 2.3.3 Strategies during Xl five year plan for prevention and control of JE include 2.3.3.1 Early diagnosis and prompt treatment of JE cases Proper case management: Strengthening of referral services: Referral support must be available at district level. Management of Sequelae: Sequelae management by drugs, orthopedic and rehabilitation procedures in all District/Medical College Hospitals/specialist Hospitals in JE endemic areas. Epidemic preparedness and rapid response: A rapid response team should be constituted in all JE endemic districts to monitor the JE situation and outbreak in vulnerable areas.

2.3.3.2 Integrated vector control method Vector Control is limited in JE due to outdoor resting habits of the vector. Vector control by fogging with technical Malathion/Pyrethrum for immediate killing of infected mosquitoes is recommended during an outbreak. 2.3.3.3 Capacity building Capacity building & manpower development through training for Clinicians/Nurses in JE case management in all JE endemic districts and for Laboratory Technicians and Laboratory In charge/microbiologist in diagnosis of JE cases by MAC ELISA method in all sentinel laboratories in a phased manner. 2.3.3.4 Behaviour Change Communication For promoting early case reporting and early referral of patients, increasing awareness of clinical signs, personal protection including segregation/improved habitation of pigs away from human population/mosquito proofing of pigsties etc.
53

2.3.3.5 Supervision and monitoring Supervision and monitoring through periodic reviews/reports and field visits for proper monitoring for Japanese Encephalitis. 2.3.3.6 Vaccination JE vaccination programme has been made an integral component of Universal Immunization Programme (UIP) of MOH & FW, Govt. of India in a phased manner using single dose live attenuated SA-14-142 vaccine. Children between 1 and 15 years of age are presently covered. Till 25.5.2011, 111 districts have been covered under vaccination campaign.

Table 8, JE Vaccination Coverage 2006 - 2010

Sl.No. 1 2 3 4 5 Year 2006 2007 2008 2009 2010 2.3.4 Number of District 11 28 22 29 21 Targeted Children 10531554 21008249 20040262 27170604 16996546 Total Vaccination 9308698 18431087 16881941 18097182 14648130 % Coverage 88.39 87.73 84.24 66.61 86.18

Current Status and Achievements

Japanese Encephalitis (JE) is caused by a virus and is transmitted through mosquitoes. The main reservoirs of the JE virus are pigs and water birds and in its natural cycle, virus is maintained in these animals. Man is an accidental host and does not play role in JE transmission. Children below 15 years are mostly affected. JE is an outbreak prone viral infection having cyclic trend with seasonal phenomenon. Outbreaks of JE usually coincide with the monsoon and post monsoon period when the density of mosquitoes increase. The Case Fatality Rate (CFR) ranges from 20% to 52%. Fig. 7, New states that reported cases during 2010

* Currently the disease is being reported from the states of Andhra Pradesh, Assam, Bihar, Goa, Haryana, Karnataka, Kerala, Maharashtra, Manipur, Nagaland Tamil Nadu, Uttrakhand, Uttar Pradesh and West Bengal
54

From the grap below it is clear tha the strateg ph at gies to contr JE death in endem rol hs mic eas re since 1978 h have been u useful in red ducing the in ncidence wit th are which ar affected s av vailable preventive and control measu c ures, howev being an outbreak pr ver, n rone disease it is not possible to bring a dramatic change in disease tren and cycle There ha e any c nd es. as be remarkab reduction in the incid een ble n dence of JE p positive case in the end es demic distric cts bu the inciden of non-J AES case has marg ut nce JE es ginally increa ased due to circulation o of no on-JE viruses s. Fig. 8

Fig. F 9

CFR,20 005,25 CFR,2007,24.21 CFR,2006 6,23.08

CaseFa atalityRate(CFR)ofJEsince20 005

200 05 7.82 CFR,2008,1C CFR,2009,17. .27 CF FR,2010,13.1 15 CFR,2011,11.68

The T input pro ovided durin Xl year pl has led to significant decrease in the mortalit ng lan o t n ty of JE cases in recent pas because o better case manageme in the en st of ent ndemic state es nd ing nel FR as to d ng an functioni of sentin sites. CF which wa reported t be around 25% durin 2005 has now been broug down to approximate 12% duri 2010. w ght ely ing

The incidence of JE in the country during the last five years (during Xl five year plan) as per the reports received from the states/UTs is given below:

Table 9, Year wise cases and deaths, 2005-2010 Year Cases Deaths 2005 6720 1684 2006 2871 663 2007 4110 995 2008 3839 684 2009 4482 774 2010 5149 677 During 2009, altogether 4482 cases and 774 deaths due to AES/JE were reported from 12 states in the country. During 2010, 5149 AES/JE cases and 677 deaths have been reported from 15 states in the country. During 2011, till 19.5.2011, 522 AES/JE cases and 61 deaths have been reported from Andhra Pradesh, Goa, Karnataka and Uttar Pradesh. During 2010 cases were also reported from 7 new districts from the states of Arunachal Pradesh, Meghalaya and Uttarakhand Table 10, Trend of Acute Encephalitis Syndrome/Japanese Encephalitis since 2005 AES/JE Cases and Deaths In The Country Since 2005 Sl. N o 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Affected States/ UTs Andhra Pradesh Assam Bihar Goa Haryana Karnataka Kerala Maharashtra Manipur Nagaland Punjab Tamil Nadu Uttarakhand Uttar Pradesh West Bengal Total 2005 C 34 145 192 6 46 120 1 51 1 0 0 51 0 D 0 52 64 0 39 12 0 0 0 0 0 11 0 2006 C 11 392 21 0 12 80 3 14 0 0 0 18 0 D 0 119 3 0 6 3 3 0 0 0 0 1 0 2007 C 22 424 336 70 85 15 2 2 65 7 0 42 0 D 0 133 164 0 46 3 0 0 0 1 0 1 0 2008 C 6 319 203 39 13 3 2 24 4 0 0 144 12 D 0 99 45 0 3 0 0 0 0 0 0 0 0 2009 C 14 462 325 66 13 245 3 1 6 9 0 265 0 D 0 92 95 3 10 8 0 0 0 2 0 8 0 C 139 469 50 80 1 143 19 34 118 11 2 466 7 2010 D 0 117 7 0 1 01 5 17 15 6 0 7 0 494 0 677

6061 1500 2320 528 3024 645 3012 537 3073 556 3540 12 6 0 0 16 2 58 0 0 0 70 6720 1684 2871 663 4110 995 3839 684 4482 774 5149

56

2.3.5 Monitoring & Evaluation system including status of MIS, disease surveillance, its quality and utilization Monitoring was done through periodic reviews and monthly/weekly/daily reports and field visits etc. Web based MIS has been developed for proper monitoring of Japanese Encephalitis. Strengthening of JE surveillance as per the national guidelines that have been issued by NVBDCP. Surveillance of AES has been adopted during lX plan period. Overall evaluation of impact of vaccination by an independent agency. 2.3.6 Constraints during Xl plan During recent past the incidence of Japanese Encephalitis (JE) was reduced remarkably throughout the country but the number of AES cases have increased because of circulation of non-JE viruses (entero viruses) in the rural endemic district. Poor coverage of routine immunisation in endemic districts. Lack of rehabilitation due to unavailability of sufficient rehabilitation centres in the endemic districts. Lack of priority to Japanese Encephalitis among states, as a result of which new states reported cases of AES/JE. There are gaps in surveillance case management and BCC/IEC measures. Inspite of providing ample resources to the endemic states, poor surveillance still persists. Lack of coordination between surveillance and laboratory personnel. Research and development in vector borne diseases particularly on Japanese Encephalitis has been lacking. There are major gaps in the present knowledge and available technology. Concerted efforts are required to be made for an effective Research and Development programme. Some of the critical areas related to JE prevention and control requiring operational research include: Improved vector control interventions Development of early warning signals for prediction of JE outbreaks Vector Bionomics Study on vaccine efficacy Mosquito control in pigsties 2.3.7 Initiative and mid course correction GOI has established Vector Borne Disease Surveillance Unit (VBDSU) which is headed by Professor & Head of Department (SPM), BRD Medical College, Gorakhpur. This unit coordinates with the state on technical issues related to eco-epidemiology, prevention and control. In addition to this, major initiative has been taken by GOI by establishing 50 bedded JE endemic ward in BRD Medical College for better case management. Close monitoring of AES/JE cases by the DGHS & Addl. DGHS in the endemic states. Capacity building and manpower development through training of clinicians & nurses for better case management of JE in endemic districts
57

and for laboratory technicians and laboratory in- charge for diagnosis of JE cases. Better diagnostic and laboratory facilities have been established by making most of the sentinel sites functional. Field unit of NIV Pune has been established for detection and isolation of non-JE viruses. JE Sub-office of ROH&FW has been set up for closely monitoring disease trends and coordinating with the UP state for effective control measures. 2.3.8 Outlays during Xl five year Plan During Xl five year plan an amount of Rs. 1268.5 Lakhs was allocated for prevention and control of AES/JE in the country. In addition to above allocation Rs. 8.64 crores was made out of NRHM additionality for strengthening case management at BRD Medical College, Gorakhpur, Uttar Pradesh and for intensifying surveillance across 16 identified sentinel sites in the state. With above allocation following programme components were strengthened. 1. 2. 3. 4. 5. Diagnosis and case management Disease and vector surveillance Vector control BCC/IEC Capacity building Budget in 11th five year plan Details of State-wise funds allocation under NVBDCP for prevention and control of JE during 2007-08 to 2011-12 are given in Table 11. Table 11, Budget allocat ion for JE Control Year Total B.E. 2007-08 399.50 2008-09 472.25 2009-10 442.00 2010-11 478.00 2011-12 520.00 Rs. in crores Allocation for JE 1.00 4.37 2.50 2.50 3.00

2.3.9

58

2.4 Lymphathic Filariasis

2.4.1 Objectives Elimination of lymphatic filariasis in the country by the year 2015 by: Progressively reducing and ultimately interrupting the transmission of lymphatic filariasis (LF). Preventing and reducing disability amongst affected persons through disability alleviation and morbidity management.

2.4.2 Targets The targets during 11th Plan document were as under o To cover all the eligible population living in LF endemic districts during Mass Drug Administration (MDA). o To line list the lymphoedema and hydrocele cases and augment home based morbidity management for lymphoedema and hydrocele operations for the hydrocele cases. 2.4.3 Strategies The strategies for elimination of lymphatic filariasis adopted were as under: Annual Mass Drug Administration (MDA) of single dose of DEC (Diethylcarbamazine citrate) for 5 years or more to the eligible population (except pregnant women, children below 2 years of age and seriously ill persons) to interrupt transmission of the disease. Co-administration of DEC+Albendazole was upscaled since 2007 after approval of National Task Force on Lymphatic Filariasis. Home based management of lymphoedema cases and up-scaling of hydrocele operations in identified CHCs/ Distt hospitals /medical colleges. Capacity building for home-based management of cases with lymphodema. 2.4.4 Initiatives Various initiatives were taken to achieve the target of covering the entire population in LF endemic districts during MDA which was launched in the year 2004 at national level. The major initiatives taken are as below: Dissemination of technical guidelines for Elimination of Lymphatic Filariasis (ELF). Conducting various sensitization workshops at national, regional, state, district and PHC levels. Capacity building for district & PHC level medical officers as well as for para medical staff. Massive IEC & social mobilization for improving the drug coverage during MDA. Involvement of Medical Colleges/ Research Institutions for conducting independent assessment to provide a feedback on actual drug compliance for its improvement. Release of cash grant to the States for all the preparatory activities and incentives to drug distributors including ASHAs. The strip packing of DEC was introduced in the programme. The acceptance and compliance of drug has been improved with strip packing of DEC. Coadministration of DEC with Albendazole was also introduced for MDA.
59

2.4.5 Status and achievement Lymphatic Filariasis (LF) is a seriously debilitating and incapacitating disease. During the early phase of Infection, the infected person remains apparently healthy but serves as a source of infection for transmission. This stage may continue for 5-7 years and can be treated with microfilaricidal drug (DEC) and or DEC+Albendazole, when detected. The transmission of filariasis is through mosquitoes namely Culex quinquefasciatus. Subsequently, the infected person may develop swellings of limbs and genitals which keep on increasing and making the person incapacitated and suffering from social stigma. The person also suffers from frequent attacks of lymphangitis, high fever, swelling and pain. There is no cure for this stage and person is forced to live with huge swellings exposed to secondary infections. Control of lymphatic filariasis is immensely important because of personal trauma to the affected persons and associated with social stigma, even though it is not fatal. International Task Force for Disease Eradication identified lymphatic filariasis as one of the six infectious diseases to be eradicable or potentially eradicable. The World Health Assembly in 1997 adopted resolution, WHA 50.29, for Elimination of Lymphatic Filariasis (ELF) as a global public health problem by 2020. National Health Policy (2002) of the country envisaged the goal of Elimination of Lymphatic Filariasis by the year 2015 in India. In pursuit to achieve the goal set by NHP (2002), the GoI launched nationwide annual Mass Drug Administration (MDA) with Diethylcarbamazine citrate (DEC) tablets in single recommended dosage for the population living at the risk of filariasis. The districts were selected as implementation unit based on historical evidence of filaria endemicity, presence of lymphoedema and hydrocele cases and also the presence of microfilaria Fig. 10, Filaria endemic areas carriers. The microfilaria rate reported from the States revealed an overall average of 1.24% at national level based on data of the endemic states, which was taken as baseline. The objective of Annual Mass Drug Administration was to bring down microfilaria rate in the community to less than 1% because the Elimination of Lymphatic Filariasis is defined by WHO as Lymphatic Filariasis ceases to be a public health problem, when the number of microfilaria carriers is less than 1% and the children born after initiation of elimination activities are free from circulating antigenaemia (presence of adult filaria worm in human body). There are about 250 Lymphatic Filariasis endemic districts with approximately 600 million population at risk of LF in the country. The Mass Drug Administration was launched in 2004 covering 202 districts with coverage rage of 73% and was upscaled to all the 250 LF endemic districts in 2007. The coverage percentage reported in subsequent years was 76% in 2005, 81% in 2006, 83% in 2007, 86% in 2008, 86.7% in 2009 and about 87% in 2010. The strategy of MDA with DEC alone was changed to the co-administration of DEC + Albendazole since 2007. The co-administration was also upscaled and in 2007 two states (20 districts of Tamil Nadu & 11 districts of Kerela were 60

covere ed); in 2008, 4 States (20 district of Tamil Nadu & 11 districts o ts of Kerala 8 district of Karnat a, ts taka and 16 districts o Andhra P 6 of Pradesh) wer re covere whereas since 2009, it is being implemente in all the LF endem ed , ed e mic States of the coun s ntry.The state wise data is given in T e i Table 12. Micro ofilaria surv vey: The m microfilaria su urvey in all the implem mentation uni its (distri icts) is being done throu night blo survey b g ugh ood before MDA The surve A. ey is don in 4 sentin and 4 ran ne nel ndom sites a per the gui as idelines. Th analysis o he of overa reports r all reveals that during 2004 (baseline the micr t e), rofilaria rat te was 1.24% which has been brought do 1 h own to 0.65% in 2009 a 0.34% i % and in 2010 respectively The data o 2009 and 2010 revea y. of d aled that out of 250 filaria endem districts, 152 district are with M rate less than 1%. T state wis mic , ts Mf The se data is shown at Table 13. s T
Fig. 11, MDA Coverage vs Microfilaria R . M Rate

Social Mobilizat l tion: Intensi social m ive mobilization towards LF eliminatio F on was carried out b various s c by states/ UTs involving p political/ opi inion leader rs, decisi ion makers, local leaders and c , community. The inte ensified IE EC campa aigns have improved a actual drug compliance which is revealed b e by reduct tion in gap between drug distribution cov p verage and actual dru ug compl liance throug independ assessment reports. gh dent Monit toring and Evaluation For monit n: toring and e evaluation of actual dru o ug compl liance, the m medical colle faculties Research Institutions and Regional ege s/ office for Health & FW ha been inv es h ave volved. Dire ectorate of N NVBDCP ha as provid funds fo this every year. The independent surveys ha been don ded or y t ave ne using pretested qu uestionnaire formats afte MDA in m er many district ts. Morb bidity Mana agement: Line listing of Lymphoedema and Hy f ydrocele case es were initiated since 2004 by door to doo survey in the LF ende or emic district ts. ases dated every y and till 2010, 8 lakh lymphodem and 4 lak year h ma kh The ca are upd hydro ocele cases have been lin listed from LF endemi districts. A per repor ne m ic As rts receiv from sta ved ates, 72464 hydrocele c cases have b been operat ted. The state wise e data a is given n in

Table 14. e 246C i

61

Though the programme has been able to enhance drug delivery to more than 500 million people, the actual drug consumption has been the major issue. The supervised drug administration for better compliance is challenged by large population to be covered @ 250 persons per day per worker. Moreover, urban population is usually not convinced. Involvement of local leaders and volunteers for MDA as well as for quality IEC/BCC activities in local languages for interpersonal communication. Conducting microfilaria survey in night time is very important and adherence of time of survey from 8 p.m. to 12 mid night is very crucial. Availability of experts on lymphatic filariasis to match the programme requirement for training and monitoring etc.

2.4.7 Mid course correction DEC tablets were procured and supplied in strip packing to improve the acceptance of drug by the community. Global strategy of co-administration of DEC with Albendazole was introduced in the programme as per the recommendation of National Task Force under the chairmanship of DGHS. ASHAs were involved as volunteers during mass drug administration which has improved the confidence among people to accept the drug. Intensification of lymphoedema management and hydrocelectomy has increased the visibility of the programme at local level.

2.4.8 Financial Assistance The allocation in approved Budget estimates during 11th Plan period is as under: Table 15, Budget Allocation for ELF Year 2007-08 2008-09 2009-10 2010-11 2011-12 Total B.E. 399.50 472.25 442.00 478.00 520.00 (Rs. in crores) Allocation for ELF 30.00 41.32 27.35 28.21 42.90

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Table 12, Population Coverage (%) during Mass Drug Administration (MDA) Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 States/UTs Andhra Pradesh Assam Bihar Chhattisgarh Goa Gujarat Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal A&N Islands D & N Haveli Daman & Diu Lakshadweep Puducherry Total ND: MDA Not Done YD: Yet to Do 2004 84.78 25.42 81.64 84.17 97.92 45.47 42.25 85.22 86.1 73.74 78.68 90.11 95.18 66.4 39.58 85.85 91.13 94.96 64.53 94.76 72.41 2005 81.05 42.94 77.82 82.8 95.33 98.23 74.16 89.31 90.15 79.29 86.48 90.6 ND 71.03 51.24 88.31 98.26 73.23 88.23 96.63 75.99 2006 89.66 67.33 79.77 ND 97.17 69.6 72.75 90.2 ND 88.01 87.8 87.4 ND 75.97 ND 93.17 94.93 87.17 80.00 ND 81.61 2007 89.13 78.32 77.23 89.53 97.83 92.11 79.03 89.67 92.19 88.48 88.39 88.47 77.22 79.87 76.63 98.73 94.16 93.27 86.83 96.3 82.75 2008 91.96 81.34 ND 91.3 97.46 93.25 84.64 90.53 93.67 90.14 89.71 85.43 87.61 81.67 77.79 94.1 96.67 91.85 86.32 97.01 86.03 2009 91.85 ND 77.91 91.53 96.32 97.63 85.99 89.30 77.81 87.59 89.51 89.81 94.13 ND 86.93 91.40 95.84 91.56 89.00 96.02 86.71 90.74 86.11 90.63 YD 81.50 YD 77.12 96.20 92.04 YD 96.72 86.96 2010 92.50 76.08 YD 92.99 94.63 98.33 YD 91.46 81.91

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Table 13, Microfilaria rate (%) in the states

Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 States/UTs Andhra Pradesh Assam Bihar Chhattisgarh Goa Gujarat Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal A&N Islands D & N Haveli Daman & Diu Lakshadweep Puducherry National Average ND: Mf survey not undertaken NR: Not reported 2004 1.36 ND 1.50 ND 0.11 0.22 ND 1.87 0.68 0.83 1.13 2.60 0.04 1.77 4.74 1.40 1.96 0.47 1.19 0.42 1.24 2005 0.74 0.04 2.15 1.96 0.04 0.84 0.84 0.84 0.50 0.40 1.45 2.37 0.38 1.01 4.10 0.09 2.01 0.14 0.09 0.50 1.02 2006 0.69 0.19 1.38 ND 0.02 0.84 1.40 0.69 0.67 0.38 1.13 1.11 0.39 0.83 2.72 0.15 2.91 0.27 0.07 0.15 0.98 2007 0.24 1.46 0.68 0.61 0.08 0.42 1.34 1.15 0.65 0.70 0.83 0.99 0.29 0.32 2.83 0.34 3.47 0.09 0.02 0.06 0.64 2008 0.38 0.88 NR 0.45 0.01 0.83 1.10 1.07 0.29 0.36 0.35 0.74 0.15 0.41 0.89 0.19 1.82 0.13 0.27 0.03 0.53 2009 0.45 0.81 1.07 0.54 0.00 0.92 1.11 0.93 0.39 0.40 0.46 0.69 0.12 ND 0.48 0.46 1.23 0.07 0.00 0.00 0.65 2010 0.35 0.01 NR 0.35 0.01 0.46 NR 0.89 0.17 0.19 0.53 0.42 0.07 0.29 0.44 0.10 0.95 0.06 0.00 0.00 0.34

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Table 14, Updated Line Listing of Lymphoedema and Hydrocele Cases ( Figures in subsequent years includes previous years data) ( Hydrocele cases are reduced due to operations) Sl. No. State L 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Andhra Prd. Assam Bihar Chhattisgarh Goa Gujarat Jharkhand Karnataka Kerala Madhya Prd. Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal A&N Islands Daman & Diu D & N Haveli Lakshadweep Puducherry Total 138931 878 212536 5554 193 2051 79776 15306 2941 61885 67607 25313 104849 55429 0 117 120 172 1539 786037 2007 H 541 7556 40 508 34189 2555 1495 46516 34109 16181 40140 32406 0 58 13 21 184 L 776 5814 191 2529 86949 16782 10840 3399 53468 61784 34431 77980 45862 75 176 107 283 1539 2008 H 968 7283 100 2049 36392 2520 410 7448 38118 30633 8060 37739 32190 25 70 0 87 184 L 776 4731 182 3569 89330 17041 10101 3399 53878 61784 39510 77849 52325 159 149 77 254 1539 2009 H 909 7995 41 2137 37152 2746 671 2766 39088 30633 21220 35600 31207 85 44 0 87 184 L 1079 4731 153 3848 89330 16135 14746 3399 53992 61784 39510 91912 52325 140 142 77 254 1539 2010 H 7949 1472 7100 64 1960 36458 3391 1518 2766 38812 30633 20792 43094 31090 91 57 0 87 184

6334 138931

6696 154061

6864 158119

164543 212536 164543 214907 173334 214907 173334

10840 Not listed

387389 754452 375515 785621 392763 808122 400852

L- Lymphoedema H - Hydrocele

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2.5 KALA-AZAR
2.5.1 Objective
Elimination of Kala-azar by 2015

2.5.2 Target and Indicators

The target is to bring down kala-azar incidence to less than one case per 10,000 population at sub-district level (block level).

The Indicators are

Reduction in the annual incidence and mortality due to kala-azar Full treatment compliance rate in the confirmed cases. Good quality coverage of Indoor Residual Spray (IRS) with DDT for vector control

2.5.3 Strategy
Interruption of transmission through vector control by undertaking two rounds of DDT spraying annually in villages reporting kala-azar incidence. In addition, promotion of environmental and personal protection measures. Case detection and treatment through the existing primary health care system supplemented with periodic annual active searches (Kala-azar Fortnight) for case detection followed by free treatment of all Kala-azar cases. Treatment compliance to be ensured by a patient coding system, whereby all patients being treated in government institutions or non-government sector, can be tracked to village level. Health education for social mobilization through all probable approaches including NGOs, voluntary and private agencies to ensure community awareness of the disease prevention, treatment and availability of free diagnostic and treatment facilities. Social mobilization is an integral part of the programme. Capacity building at all echelons of programme implementation. All the personnel involved in programme implementation, various stakeholders, partners and community, the ultimate beneficiaries, are provided with appropriate support for awareness, skills and specific roles to be performed to achieve the expected outcome. Both institutional and individual capacity building is part of the strategy. Monitoring, Supervision and Evaluation within all programme implementation levels as well as through Kala-azar coordinators to be posted at district, state and national levels.

2.5.4

Initiatives and Achievements

Incentives: Several Incentives have been introduced to improve upon the case reporting and treatment of the confirmed cases. A confirmed case of kala-azar is being paid Rs. 50/- per day towards loss of wages during the period of treatment. There is a provision of free diet for the patient and one attendant. ASHA is being actively involved at the grassroot level for detection of suspected cases of kala-azar and for ensuring complete treatment. There is a provision for Rs. 50/- to refer a suspected case of kala-azar to the nearest PHC and Rs. 150/- for ensuring treatment after its confirmation. Case Search and Effective Treatment : Currently, a lot of effort is going into active search of cases through campaigns i.e. camp approach instead of house to 66 house visits. Simpler diagnostic procedure and availability of oral drug are likely

to substantially improve case detection output, as more and more cases will get diagnosed, and come forward for simpler treatment. Programme Management : The kala-azar elimination programme management is being strengthened with placement of consultants, VBD Consultants and KTS at the national and state levels, for more intensive monitoring of the programme activities. BCC and Environmental Plans: Two independent agencies have been hired for Behavioural Change Communication for community involvement and Environmental Management Planing to address the issues related with safe handling of insecticides to promote community involvement in the programme activities.

2.5.5 Kala Azar situation in the Country Kala-azar incidence is being recorded in 31 districts of Bihar, 11 districts of West Bengal, 4 each in UP and Jharkhand An estimated 130 million population is living at risk of kala-azar. The annual incidence of disease in three states reveals an increase initially (1990-92) followed by decline (1993-95). There has been an overall decline of 75% in kala-azar cases in 2005 as compared to 1990, the year of commencement of kala-azar control programme. The state of Bihar contributes 70-80% of the total disease burden in the country. In the endemic state, the disease affects the poor and marginalized people.
Fig.12,ACHIEVEMENTSTRENDSOFKALAAZARININDIA Cases
78000 77102 68000 61670 57742 58000

Deaths
3300

Cases Deaths
45459 44533 39173

2800

2300

48000

1800 33598 28939 1300

38000

1419
28000 27049 25652 22625

32803 24479 18214

24212 800

838
18000

606

710 384 277

17429

687

14753 13627 12886 12239 12140

8000

255 226 297

150 213 168 210 155 157 187 203 151 93

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

300

105
-200

-2000
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year
2000

2.5.6 M & E system including status of MIS, Disease surveillance, its quality & utilization Data on number of cases & deaths delayed and underreported. State/districts requested to provide age & gender-wise information up to subcentre level. Proper monitoring & analysis of data at sub-centre/PHC/district level lacking. Poor monitoring & reporting of spray completion reports. Information on number of PKDL cases inadequate. All endemic districts have reliable data on incidence of kala-azar. Kala-azar endemic states are regularly monitored through monitoring visits by officers and staff from the Directorate of NVBDCP, R.D. office, Patna.
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2.5.7 Constraints
2.5.7.1 Administrative

Kala-azar is the notifiable disease in Bihar. In other three affected states, similar step needs to be taken up. 2.5.7.2 Technical Active case search schedules not properly followed. Indiscriminate use of medicines and incomplete treatment by the private sector service providers. Drug unresponsiveness, particularly to first line drug Sodium Stibo Gluconate (SSG) has increased in some areas. Treatment protocols are not followed properly. Treatment cards recommended for use under the programme often not used. Detection of PKDL and its treatment are not at the optimum level. No networking with dermatologists. Coverage and quality of IRS unsatisfactory. Complete treatment compliance is a problem as presently used drugs, injectables /parenteral infusion with long duration regimen. 2.5.7.3 Operational Political commitment exists but insufficient monitoring of control interventions and resource utilization; variable absorption capacity of states in relation to utilization of funds/commodities. Limited socisal mobilization. Behaviour Change Communication needs scaling up to increase the visibility and acceptability of Kala-azar Elimination programme. 2.5.7.4 Financial Non-receipt of funds by the Districts/PHCs due to non-release by states due to administrative delays. Non-submission of SOE & UCs by the states hampering release of funds by the GOI

2.5.8 Mid course Correction

Active case search operations are being organized on a half yearly basis through the Kala-azar Fortnight in every endemic district. Field visits to the sprayed areas by teams from the Directorate NVBDCP/Coordinators, NCDC, RMRI/ICMR to ensure adequate supervision, monitoring of IRS in the endemic villages. To improve diagnosis of kala-azar at the peripheral level, rapid dipsticks coated with rK39 are being introduced into the programme. rK39, a rapid dip stick test, has been thoroughly investigated in India and elsewhere and is known to be highly sensitive and specific. Miltefosine, a safe and effective oral drug is being introduced, as the first line of treatment in the programme on a pilot basis in 10 districts of Bihar, Jharkhand and West Bengal. 0.86 million 50 mg capsules of miltefosine are being procured for supply to these districts. This drug has been registered for use in India. Necessary guidelines have been circulated for its use to the states.

2.5.9 Outlays & Expenditure

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Until 1989-90, no specific funds were provided for Kala-azar control and the assistance was provided out of National Anti Malaria Programme provision for insecticide. Planning Commission concurred enhanced Govt. of India assistance for Kala-azar control since 2001-02, so that Govt. of India could provide operational cost including spray wages to enable States to implement programme strategy effectively.

Since December 2003, Govt. of India provides 100% assistance in cash and kind to four endemic states namely, Bihar, Jharkhand, Uttar Pradesh and West Bengal under Kala-azar Control Programme for insecticides and anti-Kala-azar medicines as well as resource based IEC, capacity building and case search activities and operational wages for spray workers. Govt. also meets freight charge for DDT transportation up to consignee level. Details of assistance provided since 2006-07 by the Govt. of India and expenditure incurred by the four affected states are as under:

Table 15, Budget allocation for Kala-azar elimination programme (In Rs. crores) Year 2007-08 2008-09 2009-10 2010-11 2011-12 Total B.E. 399.50 472.25 442.00 478.00 520.00 Allocation for Kaka-azar Elimination 20.86 29.51 18.17 14.75

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PART II PROPOSED 12th FIVE-YEAR PLAN

3. INTRODUCTION
The existing activities for prevention and control of malaria and other vector borne diseases, as in 11th Plan would be continued in 12th plan period. In addition, there would be added emphasis on identified thrust areas. The initiatives and additional inputs presently being supported by externally aided projects will be continued and expanded through domestic budget support. This would result in moving towards pre-elimination stage of malaria, and control of Dengue, Chikungunya and JE. In addition, the elimination of Kala-azar and Lymphatic Filariasis by 2015 is being envisaged.

3.1

Vision for Vector Borne Disease Control

Vision A well informed and self sustained, healthy India, free from vector borne diseases with equitable access to quality health care Mission Integrated and accelerated action towards reducing mortality on account of Malaria, Dengue and Japanese Encephalitis; reduction in morbidity due to Malaria, Dengue, Chikungunya and Japanese Encephalitis and elimination of Kala-azar & Lymphatic filariasis. Priority for 12th plan period In pursuit of achieving the above mentioned vision and mission, the programme priorities during 12th plan period would be: 1. Elimination of two diseases namely Kala-azar and Lymphatic filariasis by 2015. 2. Control and contain the outbreaks of Dengue, Chikungunya and Japanese Encephalitis. 3. Paving the way for pre-elimination phase of malaria. Directorate of NVBDCP deals with six vector borne diseases namely, Malaria, Lymphatic Filariasis, Kala-Azar, Dengue/Chikungunya and Japanese Encephalitis. Out of these six diseases Kala-azar and Lymphatic Filariasis are targeted for elimination by 2015. Malaria, Dengue/Chikungunya and Japanese Encephalitis are outbreak prone diseases. The control and containment of these diseases require intense efforts and resources. For initiation of pre-elimination strategies for malaria huge resources are also required in terms of technical manpower and quality material. There by matching financial resources are essential. During 11th Plan period various initiatives for prevention and control of malaria and other vector borne diseases like Kala-azar, Dengue, Chikungunya, Japanese Encephalitis and Elimination of Lymphatic Filariasis have been initiated which has shown the impact, however, various constraints were experienced and during 12th Plan those issues need to be addressed. The Sub-group of experts have found the plan document technically sound for implementation and operationalisation with a view to achieve the desired goal. The gaps identified have been addressed in the 12th Plan by proposing new initiatives and shift to certain strategy which will result in implementation and ultimately achieving the desired goal of physical and financial performance. It has been learnt that without strengthening the state component the objective and targets of the programme cannot be achieved. In view of it, the provisions to fill up all gaps at the centre and states have been considered and budget provisions have been made.
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4. PROPOSED ACTIVITIES FOR PREVENTION AND CONTROL ACTIVITIES FOR VECTOR BORNE DISEASES DURING 12th FIVE-YEAR PLAN
4.1 MALARIA 4.1.1 Key lessons learnt from 11th Five Year Plan
Human Resource development The program has made available a pool of trained technical and administrative personnel to function at national, state, district and sub-district levels for better programme management in collaboration with PHFI, NCDC, NIHFW and NIMR. Additional human resources were provided under programme through domestic budget (MPWs) and through external assistance (state/district consultants and at subdistrict level MTS/KTS and LTs). Their recruitment, deployment and timely payment towards their salary, mobility and honorarium has been the issue. Initiatives have been taken for building partnerships with public sector, private sector, NGOs and civil society. Sustainable building of managerial capacity is another important challenge. Capacity building is required at the national, regional, state, district and sub-district levels. In addition, the rapid decentralization of malaria control has led to a greater need for skills (especially program management) at all levels. There is a dearth of technical experts (e.g. M&E specialists, entomologists, lab technicians and other health staff). Thus, there is a strong need to enhance the managerial and technical skills of all health personnel, especially in areas where there is a high demand. Surveillance Strengthening of surveillance has been achieved at village level by involvement of ASHAs. Under NRHM, ASHAs have been deployed in villages. Dte. of NVBDCP has involved these ASHAs in identifing high endemic districts with provision of performance-based incentives for detection and treatment of cases at village level. The services rendered by ASHAs have been found to be very useful in timely diagnosis and treatment and improving the surveillance. M&E information systems have been revised. The reporting formats have been updated to include newer interventions such as RDT, ACT and LLINs. Additional staff for M&E have been provided to track the essential indicators which are measured through regular surveys and strengthened the routine health information systems. These were put in place in project areas and the lesson has been learnt, that effective monitoring can be achieved through systematic intensified efforts. The revised M&E has been now extended to entire country. Sentinel sites have been identified in each of the World Bank (WB) and Global Fund (GF) project districts for monitoring of management of severe malaria cases and mortality due to malaria. The data received from the sentinel sites have helped the states and the project districts to identify the problem both in geographical and functional areas and has helped them to take corrective actions at the local level. Diverse eco-epidemiological paradigms are a challenge. A major challenge for malaria control programme in India is to ensure access to high-quality & affordable drugs according to updated national drug policies through all types of providers. Involvement of private providers in the treatment of malaria cases as per country specific drug policies is also a major challenge. A significant part of the malaria burden is borne by isolated ethnic groups or new settlers who reside close to the forest and mobile/migrant forest workers (e.g. for
71

logging, mining, plantation work and field cultivation). It is a challenge to provide interventions to such populations in these areas because they are hard to reach and traditional vector control interventions (LLINs / ITNs, IRS) are not always effective in these settings. In some states, the minimum target of surveillance is not achieved even if in some, it is higher than the target. To achieve the minimum target is an issue to be addressed. Moreover the data on surveillance is captured under public health facilities hence excludes persons examined under private facilities; private facilities like private practitioners, RMPs, private hospitals and corporate hospitals in urban areas.

Diagnostics During the 11th Plan, in addition to parasitological diagnosis through microscopy, Rapid Diagnostic Tests (RDT) has been introduced for diagnosis of Pf cases. Under the programme, approximately 100 million tests are done annually by microscopy and RDTs. Approximately 1214 million RDTs are being procured annually for use by community level health volunteers (ASHAs) and health workers (MPWs) in difficult to reach areas where microscopy facilities are not reachable. This has helped in improving the surveillance and early diagnosis thus facilitating timely treatment at the village level through ASHAs / Volunteers. The system for quality control of microscopy under programme is in place by crosschecking of all smears tested positive and 5% of negative slides. Standard Operating Procedures (SOP) have been developed for quality control of microscopy. Similarly, the guidelines have also been developed for the quality control and quality assurance of RDTs. Provision of diagnostic services through rapid diagnostic tests or microscopy and prepackaged ACT to the entire population through public and private healthcare systems, including in remote /inaccessible rural villages is another important challenge. Functional microscopy services at PHC level as per the recommended norms of 30000 /20000 population in plain / hilly & difficult areas respectively, have not been established till now by majority of States. Further, the RDTs used currently are monovalent (Pf specific), thus the delay in diagnosis of Pv cases and their subsequent treatment is delayed due to time lag of microscopy examination. The bivalent RDTs (for both Pf and Pv) will address this problem.

Treatment A paradigm shift has occurred in the treatment of Pf cases in high burden districts. Initially, ACT was provided to falciparum cases reported in chloroquine resistant PHCs and surrounding cluster of PHCs. Later ACT was rolled out for treatment of all Pf cases in the high burden districts. As per the National Malaria Drug Policy (2010), all uncomplicated falciparum cases in the country are being treated with ACT. Therapeutic efficacy studies are conducted on a regular basis in 15 sentinel sites across the country by Dte. of NVBDCP in collaboration with National Institute of Malaria Research (NIMR) for updating the Naional Drug policy. Programme has also initiated the Pharmaco-vigilance studies to monitor the adverse effects of antimalarial drugs. It has shown that very few side effects are reported with the ACT. Irrational use of Artemisinine based compounds, especially by the unqualified private providers, is a major challenge. Monitoring, preventing, and containing anti-malarial drug resistance is a big challenge, especially in areas adjoining to international borders. The strengthening of monitoring systems for drug resistance is therefore essential in collaboration with research institutes like ICMR.

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Interventions for vector control In addition to Indoor Residual Spray (IRS), other vector control measures like longlasting insecticidal nets (LLINs), larviciding and environmental management are being upscaled appropriately. Non health sector networks are also being involved in distribution of LLINs enabling improved access in remote areas. Private organizations or consortia are also being contracted out for conducting IRS by the states where quality of spray is an issue as spraying is a skilled job. To address the environmental issues related to safe use of insecticides, larvicides and non-degradable diagnostic equipment, an `Environment Management Plan has been developed for ensuring proper transportation and storage, safe handling and usage of insecticides to minimize adverse impact on environment. Poor community acceptance and low coverage of IRS are reported from the field. Low coverage of IRS is often due to non/inadequate funds with the states for procurement of decentralized insecticides as well as operational cost to meet the spray wages. Further, supply and usage of ITN /LLINs is restricted to a few high endemic districts. Scaling up of LLINs for achieving universal coverage is a major challenge. Increased levels of resistance to insecticides in vector mosquitoes is an important technical challenge. Entomological surveillance is affected due to poor manpower status both at States and Zones including Regional Offices of Health and Family Welfare. Out of 35 State entomologists, only 7 are in position. Similarly, against 72 Zonal Entomologist posts, 35 are in position. At the ROHFW (GoI), all the 16 sanctioned posts of Assistant Director (Entomologist) are lying vacant, Even at Dte. NVBDCP HQ out of 9 posts, 5 are vacant. Because of this gap the latest data on various entomological parameters are lacking which is very crucial for facilitating the decision about appropriate vector control measures. Further, due to lack of mobility support, large vacancies of insect collectors, shortage of entomological kits and insufficient support for capacity building, the existing entomological units could not be optimally utilized, which resulted in to lack of data generation Logistics management In the initial years of the 11th plan period, anti malarial drugs & other drugs for vector borne diseases, insecticides, larvicides, rapid diagnostic kits for malaria and Kala Azar, Long lasting Insecticide treated nets (LLINs) were being procured by GOI. Subsequently, Govt of India has decentralized the procurement of certain commodities to be procured by states out of cash assistance. Delay in release of budget from state health societies for the purpose has resulted in untimely availability of required items. A supply chain monitoring agency has been hired under WB supported project which need to be sustained. Malaria in Urban areas The large number of developmental activities, especially construction activities, have resulted in aggregation of labour leading to mushrooming of slums. Most of local bodies are found lacking in financial resources to carry out malaria control measures and State Governments also could not supplement the resources to bear the extra burden to contain the emerging malaria problem. No corresponding additional infrastructure and budgetary provision have been made resulting in additional pressure on the existing staff though spatial spread of urban areas has occurred, which has resulted into poor disease surveillance and inadequate vector control measures. This necessitates intensification of vector control measures through the existing scheme and larger involvement of other sectors responsible for creating mosquitogenic conditions.
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4.1.2 The 12th Plan - objectives, strategies, and activities. Objective: To bring down annual incidence of malaria cases to less than 1 per 1000 population at national level by 2017 and its monitoring at district level.

Targets: ABER > 10 % API < 1 per 1000 Population

Indicators All fever cases suspected for malaria are to be screened (70% through quality microscopy and 30% by Rapid Diagnostic Test). All P. falciparum cases will be treated with full course of ACT and all P.vivax cases will be treated with chloroquine for 3 days and primaquinine for 14 days. All health Institutions with indoor facilities will be equipped with microscopy facility and RDT for emergency use and injectable artemisinin derivatives. All district and Sub-district hospitals will be strengthened as per IPHS with facilities for management of severe malaria cases in malaria endemic areas.

Strategy The strategy adopted during XI Plan period was for malaria control. Considering the feasibility of malaria elimination defined as no indigenous transmission, it is proposed to change the focus of strategies based on endemicity level. This will facilitate in achieving long term goal of elimination. This necessitates the stratification of states based on incidence so as to decide and execute area specific intervention. This would lead to reduction of incidence in high endemic areas and sustain it in low endemic areas which will pave the way to enter the country into Pre- Elimination stage. To reach Pre- Elimination stage, entire country would require adequate inputs in terms of technical, logistic and financial support. Accordingly the states have been stratified as under: o Category 1: States with less than 1 API including all the districts in the state with less than 1 API o Category 2: States with less than 1 API with few districts reporting more than 1 API o Category 3: States with more than 1 API with either all the districts with more than 1 API or few districts with less than 1 API and many with more than 1 API The broad strategies to be adopted are as under: Epidemiological Surveillance and Disease Management o Early case detection by further strengthening the existing surveillance system and involving private providers o Strengthening of referral services o Epidemic preparedness and rapid response o Involvement of private providers Integrated Vector Management o Effective entomological surveillance
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o o o o o o o

Source Reduction using minor engineering methods Biological control using larvivorous fish and bio-larvicides Larvicides (Chemical) Indoor Residual Spray in selected high risk areas Insecticide Treated Nets (ITN)/ Long Lasting Insecticidal Nets (LLIN) Implementation of legislative measures Operational research

Supportive Interventions o Behaviour Change Communication o Public Private Partnership & Inter-sectoral convergence o Human Resource Development through capacity building o Operational research including studies on drug resistance and insecticide susceptibility o Logistic Management Information System (LMIS) o Monitoring and evaluation through periodic reviews/field visits and web based Management Information System Activities Activities proposed for different strategies and strata of states are as follows: Epidemiological Surveillance and Disease Management 1. Early case detection by further strengthening the existing surveillance system
and involving private providers

Strengthening of active, passive and sentinel surveillance by providing additional MPWs, LTs and involving more ASHAs, GPs, RMPs and Medical practitioners of other health partners Strengthening diagnosis by providing additional microscopes and up-scaling use of RDTs. Diagnostic and treatment facilities will be strengthened by increasing the number of microscopy centers and capacity building of technicians, up-scaling of RDTs and providing microscopes and by establishing malaria clinics @ 1 clinic per 20,000 population in urban slums. Ensuring continued availability of diagnostics and anti-malarial drugs at all levels of treatment Adopting evidence-based newer technologies for improving diagnosis and treatment services like introduction of bivalent RDT, fixed dose ACT etc.
2. Strengthening of referral services

For rapid transportation of severe malaria cases to the nearest health facility, transport facility under NRHM will be used. In case such facility is not available in certain areas, programme will support transportation. Strengthening of referral centers by equipping them with requisite diagnostics, antimalarials for management of severe malaria cases. Optimal utilization of the available life saving support systems under NRHM.
3. Epidemic preparedness and rapid response

Use of Early Warning System for detection of epidemics in coordination with IDSP. Strengthening of Rapid Response Team (RRT) in each district, with financial support from NVBDCP during outbreak situation. For tackling outbreak, adequate antimalarials, diagnostics, insecticides etc. will be 75 provided by earmarking 20% buffer stock

Integrated Vector Management 1. Effective entomological surveillance Entomological surveillance would be carried out by the Zonal Entomologists in the country. The entomological teams will survey for entomological parameters viz., vector density (adult and larval), seasonal prevalence, susceptibility status to insecticides in vector mosquitoes, feeding behaviour, quality of IRS spray, residual effectiveness of insecticides through conducting Cone Bioassays test. These parameters would provide data on impact of the ongoing vector control interventions in the Zones to suggest for mid course corrections. These teams will also assess the effectiveness of ITNs and LLINs. 2. Source Reduction using minor engineering methods Control of larval breeding would be done to limit the transmission of the VBDs. Clearing the margins of the water bodies, de-weeding to ensure proper flow of water, filling of small temporary water collections will be done to limit the breeding. However, for large excavations and water bodies, the technical guidance for prevention of mosquito breeding would be provided to the concerned agencies who are responsible to create mosquitogenic conditions. 3. Biological control using larvivorous fish The larval control using larvivorous fish is feasible in certain ecotypes and settings. This method would be propagated in these areas as supportive intervention to control the breeding. The source for supply of larviorous fish, its applications and monitoring would be put in place. 4. Larvicides Presently Temephos - the chemical larvicide and bio-larvicides are used in programme. Their judicious use would be monitored. 5. Indoor Residual Spray in selected high risk areas Depending on the API, different areas would be covered with appropriate insecticide. About 80 million population are covered with IRS annually. To ensure quality spray, supervision would be strengthened along with safety precautions. 6. Insecticide Treated Nets(ITN)/ Long Lasting Insecticidal Nets (LLIN) LLINs have been introduced in the program as personal protection tool and to interrupt transmission. The upscaling of LLINs is on priority and about 29 million LLINs are expected to be procured and distributed in next five years. 7. Implementation of legislative measures The civic by-laws for prevention and control of mosquitogenic conditions are existing in few states/ towns. The state governments would be emphasized to extend these bylaws in other towns/cities and implement effectively. Supportive Interventions 1. Behaviour Change Communication o Establishing IEC/BCC Cell at Dte. NVBDCP with regular communication expert supported with media assistants. o Development of strategy specific prototype materials and Healthy Public Policy through an hired agency. o IEC/BCC activities through print and electronic media at national, state and 76 regional level

o Strengthening of IEC/BCC activities at grass root level through inter-personal communication, folk media etc. for social mobilization towards acceptability of services provided under programme. o Special campaigns during spray, distribution of LLINs and anti- malaria month o Strengthening of service delivery through vulnerable community plan for marginalized sectors.
2. Public Private Partnership (PPP) & Inter-sectoral convergence

o Improving outreach services through partnership with Non-Governmental Organizations (NGOs), Faith Based Organizations (FBOs), Community Based Organizations (CBOs) and Local self-government (Panchayat). o Implementation of 6 existing PPP schemes of NVBDCP by earmarking separate budget. o Flagging the issue of Inter-sectoral convergence through Planning Commission to various Ministries/agencies like Agriculture, Urban Development, Education, Information and Broadcasting, Tribal and Social Welfare, Railway, Surface Transport, Civil Aviation, Port Health Authorities and Textiles etc to ensure support and incorporation of Health Impact Assessment component in the projects under respective ministries. o State level annual inter-sectoral meeting and districts level quarterly meeting for sensitization.
3. Human Resource Development through capacity building

o Providing additional HR like National, regional, state, zonal and district consultants, Malaria Technical supervisors/Kala azar technical supervisors at sub district level, LTs and MPWs at PHC and subcentre level respectively to bridge the gap so that implementation of programme activities are carried out efficiently. o Emphasizing states for creation / filling up of required positions at various levels o Continuation of performance based incentives to the programme personnel including ASHAs /village level volunteers o Capacity building of trainers by involving medical colleges and apex institutions like NIHFW for further providing job-specific training to newly recruited personnels and reorientation of the existing programme personnel.
4. Operational research including studies on drug resistance and insecticide susceptibility

o To monitor the drug resistance, pharmaco-vigilance, quality assurance and insecticide resistance, the operational research studies would be undertaken with the help of NIMR. o Studies on vector bionomics and changes in respect of their biting and resting behaviour. o Research also would be conducted for the development of new tools and methods for vector control.
5. Logistic Management Information System (LMIS)

o Procurement Division would be strengthened by recruiting regular procurement specialist (Joint Director level officer) supported with consultants. o Supply chain monitoring would be done through hired agency, to ensure the availability of programme commodities upto PHC level.
77 6. Monitoring and evaluation through periodic reviews/field visits and web based Management Information System

o The existing NMMIS would be made fully functional by replacing all old computers and providing internet facility at district level. o Communication support would be provided i.e. computer/laptop /palmtop and communication systems like data-card, internet, mobile, telephone etc. would be provided to MIS staff as per their role . o Integration of reporting of core indicators with the NRHM HMIS. o Establishing Sentinel Surveillance Sites (SSS) at the districts and prominent hospitals to monitor the trends of disease morbidity and mortality. o Periodic review at all levels and programme evaluation at periodic intervals o Positioning of consultants at national, State and district level, VBD Technical supervisors at block level and data manager at district lvevel o Use of Lot Quality Assurance Sampling (LQAS) methodology at sub-district level for monitoring the implementation of programme and project activities Strategy for different categories of the states to be intensified o Category 1: States with less than1 API including all the districts in the state with less than 1 API Keeping a vigil in these states is very crucial as low endemic areas are more prone to malaria outbreaks. Therefore, passive and sentinel surveillance will be strengthened. Epidemiological Surveillance and Disease Management: Focus on passive & sentinel surveillance Involvement of Govt. Health system (State and central), Medical Colleges (Public and private), Railways, defense, paramilitary forces, ESIC, AYUSH, Mission Hospitals and private providers enlisting, training, logistic support, reporting laboratories enlisting of private laboratories, training, logistic support, reporting. Screening of migrants in project areas. Referral system (if necessary). Epidemic Preparedness and Response. Integrated Vector Management (IVM) Source reduction, biological control, insecticidal focal/space spray during outbreaks/epidemics and complex emergencies, effective entomological surveillance in sentinel and random sites at quarterly intervals by the designated teams. Supportive interventions including IEC and BCC activities with the involvement of village health and sanitation committees (meetings on monthly basis) and involvement of other sectors for social mobilization towards prevention and control of malaria o Category 2: States with less than 1 API with few districts reporting more than 1 API Though the average API of these states are less than 1, few districts are having more than 1 API. More intensified surveillance and interventions would be required in these states. Therefore, active, passive & sentinel surveillance will be strengthened. Epidemiological Surveillance and Disease Management 78

Strengthening of referral services total support from NVBDCP for strengthening of district and sub-district hospitals under NRHM (high power committee under chairmanship of Dr. Shrinath Reddy) Epidemic preparedness and rapid response Integrated Vector Management (IVM) IVM will be implemented involving entomological surveillance at sentinel and random sites at quarterly interval, appropriate use of insecticides for supervised IRS with full support from NVBDCP, use of LLIN (if supported and feasible), intensified anti larval operation in urban and peri-urban areas within these states/districts along with supportive intervention components like use of fish, source reduction, minor engineering etc. and use of focal spray in case of any increase in cases or outbreak. Supportive interventions including IEC and BCC activities using village health and sanitation committee meetings (monthly basis) and inter-sectoral collaboration meetings in district and blocks with API more than 1 and involvement of other sectors for social mobilization towards prevention and control with coordinated efforts by district programme managers. o Category 3: States with more than 1 API with either all the districts with more than 1 API or few districts with less than 1 API and some with more than 1 API. This category needs maximum attention for all the activities with a view to reduce disease burden. Therefore, active, passive and sentinel and surveillance will be strengthened institutions with all possible inputs for microscopy, RDT and quick collection of reporting of data. Epidemiological Surveillance and Disease Management Early Case Detection and complete treatment. Active Passive and Sentinel surveillance. Management of severe malaria cases (strengthening of district and sub-district hospitals). Referral mechanism (NVBDCP funding for referral including transportation). Integrated Vector Management (IVM) IVM will be implemented involving o entomological surveillance at sentinel and random sites at monthly interval, o appropriate use of insecticides for supervised IRS with full support (including spray wages) from NVBDCP, o use of LLIN o treatment of community owned bednets, o intensified anti larval operation in urban and peri-urban areas within the states/districts o Upscaling use of larvivorous fish, outsourcing of fish use through NGOs would be explored with PPP model, o Source reduction, minor engineering etc. would be achieved through involvement of panchayat raj at village level. Supportive interventions including IEC and BCC activities using village health and sanitation committee meetings (monthly basis) and inter-sectoral collaboration meetings in district and blocks with API more than 1 and involvement of other sectors for social mobilization towards prevention and control with coordinated efforts of district programme managers. Monitoring and
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supervision for the activities as well as monitoring towards timely performance of the activities. 4.1.3. Modalities to improve efficiency and quality of services at primary, secondary and tertiary levels

Primary level ASHAs under NRHM, Aganwadi Workers of ICDS and Community Volunteers of NGOs would be trained for diagnosis (using RDT) and treatment services. The diagnostic capability of PHC in endemic areas would be improved by ensuring positioning of trained laboratory technicians with functional microscopes in all PHCs. All the CHCs would be equipped to provide in patient facility for management of Pf malaria cases. Laboratory surveillance from private sector would be enhanced by coordination with private practitioner and private laboratories. Logistic and supply chain management will be strengthened to ensure continuous supply and avoid expiry of drugs and diagnostics.

Secondary level Training of Medical Officers, Lab. Technicians and Community Volunteers of public and private sectors would be taken up to strengthen the quality of services at secondary level. District level hospitals would be equipped with case management facilities including laboratory services to manage the severe and complicated malaria cases. The investigation of each death due to malaria would be taken up, so that, corrective action for appropriate management would be in built in the system itself and it would serve as a public health tool also to measure the effectiveness of the programme. Sentinel sites will be established at the District and sub-district level hospitals especially in high-disease burden areas to monitor the trend of malaria morbidity and mortality.

Tertiary level The Medical College hospitals and other referral hospitals will manage all referral cases. The state health authorities will coordinate with Medical Colleges for malaria control activities. Medical Colleges will undertake operational research on use of effectiveness of rapid diagnostic kits, efficacy of combi pack and therapeutic efficacy studies etc. Medical colleges will also be involved in capacity building by creating district level resource pool for training.

Plan for improving reporting Upsurge in VBDs in recent years has led to general feeling that the VBDs surveillance activities need to be increased to keep eye on increase in number of cases so that preventive actions can be taken up immediately to contain the outbreaks /epidemics of these VBDs. The 12th plan proposes measures to overcome the bottlenecks to improve the reporting system. At the same time NVBDCP is planning to engage human resources at various levels to increase and improve the surveillance. The details of the proposals for the same are given below:
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States shall create 66120 and fill up 88483 positions (inclusive of existing vacancy against sanctioned) of MPWs as per the norms at the sub center level with 100% financial assistance from Government of India through NRHM. Create 10682 post and fill up 15244 positions (inclusive of existing vacancy against sanctioned) of one microscopist at PHC level covering 30 to 40 thousand population. Positioning 5924 VBD Technical supervisor (@ one VBD Technical Supervisor at block level) for effective supervision and monitoring. State shall be encouraged to fill up all posts of DMOs on priority basis 620 District VBD consultants (excluding high altitude districts) will be provided from GoI. Enlisting the support of IMA and ushering in public private partnership models in the programme to improve diagnosis and treatment. Up-scaling of use of RDT (including bivalent RDTs) Provision of 15,000 microscopes. Quality control of malaria microscopy by strengthening of Regional Offices (GOI), state /zonal laboratories. Quality control of RDT by identified institutions. Advocacy with private and other sectors. PPP schemes for case detection and treatment.

Monitoring and Evaluation is important at National, State, district and local levels to track and guide the programme implementation and its impact. Robust and reliable data are critical for monitoring progress toward achieving the goals and disease specific targets. The country programme is having detailed Monitoring and Evaluation Plan which has been revised from time to time to include the monitoring of newer interventions. During the XI plan period the monitoring and evaluation activity was strengthened with the funding from World Bank. During this period, monitoring and evaluation system of country malaria programme was reviewed twice (in 2008 and 2010) using the Monitoring and Evaluation System Strengthening Tool (MESST) developed by the Global Fund. The reporting system of NVBDCP is being integrated with NRHM-HMIS portal. In NRHM-HMIS portal data entry is being done at district level for both data compilation (reporting) and recording in a consolidated form. Monthly Epidemiological Surveillance: Based on the monthly report received through M4 format in HMIS, epidemiological analysis would be strengthened at district, state and national levels to identify the trends of malaria cases and deaths to identify the areas for intervention. Sentinel surveillance & Death Monitoring: Data generated at the sentinel surveillance sites established at the two/three SS Hospitals in a district would be compiled at the DMO office. M4: Fortnightly Report of Cases - Provider wise: this provider wise M4 format is being compiled similar to the M4 (Health facility wise), based on the M1 reports from all reporting units. This would provide a fair estimate of the cases being diagnosed and treated by each category of health provider.

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4.1.4 Urban Malaria Scheme (UMS) Apart from malaria, other vector borne diseases like dengue, chikungunya, JE, filariasis and kala-azar are also increasingly becoming frequent in urban areas. Integrated control strategies are needed by meeting the requirement of additional staff and matching budgetary provision. It is proposed to enhance the capacity of exiting 133 urban cities inclusive of 2 new towns to manage all VBDs prevalent in the urban areas. The vector control measures will focus to deal with all VBDs and special emphasis would be given for implementation of health impact assessment (HIA) component in all major developmental projects through enforcing appropriate legislature measures. The key lessons learnt during XI plan period and current challenges with respect to urban areas have already been outlined in the overall malaria component. Based on it the objectives, strategies and activities have been proposed under XII Plan for UMS. Objectives 1. Prevention of malaria mortality and reduction of morbidity in identified urban areas. 2. Effective management and control of other VBDs Targets 1. To improve vector surveillance and elimination of breeding at the source 2. To bring down cases of malaria and other VBDs in urban areas Strategy (i) (ii) (iii) (iv)
Activities

Detection and management of malaria cases and other VBDs Integrated Vector Management Capacity building and BCC Intersectional coordination

(i) Diagnosis and case management: Diagnostic and treatment facilities will be strengthened by establishing malaria clinics @ 1 clinic per 20000 population with special focus to urban slums. Involvement of other sectors /private providers for diagnosis, treatment and reporting Sentinel sites will be equipped with necessary diagnostic kits for diagnosis of VBDs (ii) Integrated Vector Management Larval control through source reduction, chemical larviciding and use of larvivorous fish and minor engineering. Space spray during the outbreaks /epidemics. LLINs for targeted vulnerable population of identified wards/burroughs under Municipal Corporations of mega cities. (iii) Capacity building and BCC Training of personals involved in anti-malaria activities in urban areas including engineers and town planners Focused BCC Advocacy workshops for NGOs/ CBOs/ FBOs/ stakeholders for their involvement in VBD control activities Social mobilization through inter-sectoral collaboration.
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(iv) Inter-sectoral coordination 4.1.5 Adoption of Model civic bye-laws for prevention and control of vector breeding Health Impact Assessment (HIA) of Developmental projects

Entomological Surveillance

To monitor the programme activity at zonal level (5 to 7 districts), the zonal offices were established with the responsibility of monitoring of entomological and entomological data and operational aspects pertaining to districts under their jurisdiction. The zonal officer since 1977 (after Modified Plan of Operation) had a special component of zonal entomological team to monitor the vector densities, susceptibility status of vector to the insecticides/larvicides, vector incrimination, bionomics, etc. and to correlate the entomological data with entomological parameters. The technical guidelines and monitoring formats for entomological parameters were made available from time to time to the states. However, the entomological surveillance by these zones have been affected as the priority to entomological work was not accorded in many of the states and many posts falling vacant have not been filled up. With a view to generate latest information, it is proposed to strengthen and intensify entomological surveillance in the country by providing additional technical human resource like entomologists, insect collectors and mobility support for field visits, especially during night times as the entomological surveillance are carried out whole night. The cost towards different components have been integrated into proposed budget for malaria and also under cross cutting issues separately.

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4.1.6 Proposed Budget The estimated budget for prevention and control of malaria including Urban malaria and strengthening entomological surveillance and issues is shown in Table 16.

Table 16, Proposed Budget for Malaria including Urban malaria & entomological surveillance (Rs. In Crore) Sl No Components I 1 2 3 4 A II 1 2 3 4 5 6 7 8 B Diagnostic & Treatment Rapid Diagnostic Tests Microscopy ACT Other antimalarials Sub Total (Dignostic & Treatment) Vector Control (100% Support) Insecticides LLIN Operational cost Biological and Environmental Management through VHSC Larvivorous Fish support Commodities and Products (UMS) Commodities and Products (Entomological Zone) Operational Cost (Entomological Zone) Sub Total (Vector Control) Grand Total (A+B) 250.00 295.24 51.00 84.00 12.00 85.65 1.28 10.81 789.97 944.60 250.00 97.53 51.00 84.00 12.00 84.24 10.81 589.57 682.81 250.00 51.00 84.00 12.00 82.08 0.51 10.81 490.40 628.14 10.81 649.67 790.34 250.00 154.63 51.00 84.00 12.00 87.23 250.00 295.24 51.00 84.00 12.00 86.11 0.51 10.81 789.67 930.34 1,250.00 842.64 255.00 420.00 60.00 425.31 2.30 54.05 3,309.29 3,976.24 59.33 76.22 7.36 11.72 154.63 7.36 11.72 93.24 7.36 11.72 137.74 7.36 14.65 140.67 7.36 14.65 140.67 74.16 118.66 118.66 118.66 489.48 76.22 36.80 64.45 666.95 2012-13 2013-14 2014-15 2015-16 2016-17 Total

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4.2. Dengue & Chikungunya (proposed plan during 12th Five Year Plan)
4.2.1 Key Lessons Learnt during 11th Five year Plan Case Surveillance The surveillance for dengue and chikungunya should be proactive. Most states conduct reactive surveillance with health authorities waiting until medical community recognizes transmission. Passive surveillance is not sensitive enough for early detection of outbreaks, since all clinical cases are not correctly diagnosed, especially during the interepidemic period when physicians may not suspect dengue, and thus mild cases may not enter the health care system at all. Indeed, in most cases epidemics are near peak transmission before they are recognized and confirmed as due to dengue. By then, it is generally too late to implement effective preventive measures that could have an effective impact on transmission and thus on the course of the epidemic. Functioning of Sentinel Surveillance Hospitals Though the numbers of Sentinel Surveillance Hospitals (SSHs) was increased every year to augment diagnostic facilities in endemic States, their functioning had been a great concern. Apex Referral Laboratories are not conducting regular Serosurveillance, hence clinicians do not get any information on prevailing/circulating dengue virus serotype in a given time and place. Severity of dengue depends on type of virus serotype (s) prevalent in an area. Reporting A few states submit their data daily but some states submit their report very late. Besides, private sector is not submitting the data on cases and deaths which were treated by them as dengue is not a notifiable disease in some states. Hence, real disease burden could not be estimated. Fever alert surveillance For reporting of increase in fever cases in a village, the guidelines were developed and sent to the states in 2007. However, early capture of an incipient outbreak through health workers and grassroots level functionaries (ASHAs, Anganwadi workers and MPWs etc) is not effective in the states. Rapid response A trained rapid response team with all supportive logistics including mobility support in each endemic district has been envisaged. However, with the transfer or superannuation or multiple job responsibilities of any team member, the team becomes incomplete. Besides, the mobility support is often not made available for timely movement of the team. The reports of the Sentinel Surveillance Hospital are also received late. Due to these, many impending outbreaks could not be interrupted in incipient stage. Dengue and Chikungunya outbreaks evolve quickly and need immediate action to prevent further spread.

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Case management Though case fatality rate has declined, most of, deaths due to dengue (if not all) are potentially avoidable. One of the primary problems in management of dengue is misinterpretation and resultant confusion because of the term haemorrhagic fever Hence a reorientation training as per National guidelines for clinical management of Dengue cases on assessment of the haemodynamic state, prompt but judicious fluid replacement in dengue management is necessary for all the treating physicians at tertiary, secondary and primary level hospitals including in private sector. Vector surveillance and Management In absence of any drug or vaccine against dengue and chikungunya infection, vector control is the main stay to prevent transmission. Due to vector bionomics, adult vector control is not easy. Larval control needs constant and concurrent monitoring of the vector breeding. Effective mosquito control primarily based on source reduction is virtually nonexistent in most of the Dengue and Chikungunya endemic states/towns. Besides, emphasis has been placed on ultra-low volume (ULV) insecticide space sprays for control of adult mosquitos though it is relatively not very effective approach for controlling Ae. Aegypti which are very active during day time. Lacking or poor infrastructure The reality of limited financial and human resources has resulted in a "crisis mentality" with emphasis on implementing emergency control methods in response to outbreaks rather than on regular programme to prevent transmission. In fact, most of states have no staff or resources to implement the strategies for dengue/chikungunya prevention and control during inter-epidemic period. The vertical dengue/chikungunya programme based on vector control by field workers visiting every household in a specific area to eliminate breeding is practically getting setback due to increasing urbanization, budgetary constraints, lack of personnel, increasing numbers of closed households and householders rejection for the emptying and cleaning of domestic water-storage containers. Monitoring and evaluation Due to improper monitoring and evaluation programme implementation is hampered at State and district level as early warning signals are not captured on time. Entomological component is totally absent in most of the States/Municipalities and very weak or poor in other states/towns. Out of 72 Entomological Zones, posts of Entomologists are vacant in 34. Similarly, out of 35 state Entomologist only 10 are in position. Wherever present they do not have the facilities like mobility support or other logistics to carry out entomological surveillance especially in early morning, late evening and during night hours. Enactment of Legislation At the national level, all countries are signatories to the International Health Regulations which have a specific provision for the control of Ae. aegypti and other disease vectors around international seaports/airports. Dengue needs to be added in the list of diseases that require mandatory notification by each state. It was envisaged in the beginning of 11th Five Year Plan to develop civic byelaws by each state to prevent mosquitogenic conditions in households/premises. Building byelaws for health impact assessment in all development projects and building construction activities having inbuilt provisions of mosquito breeding free premises covering all aspects of environmental sanitation in order
86

to effectively prevent breeding of Dengue and Chikungunya vector. However, most of the States could not develop their byelaws. Though a few municipalities in the country, namely Mumbai Municipal Corporation, New Mumbai Municipal Corporation, Municipal Corporation of Delhi, Chandigarh, Goa and Chennai etc. have adopted legislation for the prevention of nuisance mosquitoes, they lack its implementation at the ground level. Legislative support is essential for the success of not only dengue control but also for all those diseases which are caused by mosquitoes like malaria, Chikungunya, filaria etc. 4.2.2 Objectives To reduce the Dengue case facility rate to below 1% To reduce the incidence of Dengue and Chikungunya To strengthen the nationwide surveillance mechanism for Dengue and Chikungunya

Targets Dengue case facility rate to below 1% Functional Sentinel Surveillance Hospital in all endemic districts/towns/ cities Functional Rapid Response Team in all endemic districts/towns/cities

Indicators Dengue case fatality rate Dengue and Chikungunya incidence No. of functional Sentinel Surveillance Hospital No. of functional Rapid Response Team

2.2.3 Initiatives To reduce the burden of Dengue and Chikungunya, a new approach to fully integrate disease and vector surveillance, vector control, clinical case management and capacity building of health personnel is needed. This is especially important as GOI has also health sector reform efforts for the forthcoming 12th Five year plan and the fact that most local health services, now responsible both politically and administratively for prevention programs, are not sufficiently equipped to take on these programmes. In view of the above a need has arisen to revisit the ongoing strategies of Long Term Action Plan and develop a programmatic and comprehensive Mid Term Plan for prevention and control of Dengue and Chikungunya. The Committee of Secretaries under the Chairmanship of Cabinet Secretary on 26.05.11 approved the Mid Term Plan for prevention and control of Dengue and Chikungunya in the country. The thrust Areas of Mid Term Plan are: Focused monitoring and improved reporting by strengthening the Dengue control programme. Strengthening diagnostic facilities by establishing at least 1 Sentinel Surveillance Hospital in each endemic district/town Improved and effective case management to bring down dengue case fatality rate. Strengthening of infra-structure in local bodies for source reduction activities. Effective intersectoral collaboration of various health and non health sectors. Capacity building of medical and para medicals on Mid Term Plan strategies. Sensitization of the community on source reduction activities through media mix IEC/BCC strategies as per Media Plan.
87

Availability of trained entomological teams and rapid response teams in states and districts Timely and effective utilization of funds.

4.2.4 Strategies Surveillance - Disease Surveillance and Entomological Surveillance Case management - Laboratory diagnosis and Clinical management Vector management - Environmental management for Source Reduction, Chemical control, Personal protection and Legislation Outbreak response - Epidemic preparedness and Media management Capacity building- Training, strengthening human resource and Operational research Behaviour Change Communication - Social mobilization and information Education and Communication (IEC) Inter-sectoral coordination - Health, Urban Development, Rural Development, Panchayati Raj, Surface Transport and Education sector Monitoring and Supervision - Analysis of reports, review, field visits and feedback

4.2.5 Mechanism of Involvement of NGOs/PPP/community/local self government Non-Governmental Organizations (NGOs), Community Based Organisations (CBOs), Faith Based Organisations (FBOs) can play an important role in source reduction activities. Social mobilization campaign for community awareness on source reduction activities will be carried out through inter-personnel communication, focused group discussion, advocacy workshops, inter-sectoral meetings, with monitoring and evaluation at all levels. 4.2.6 Modalities to improve efficiency and quality of services at primary, secondary and territory levels Intensive supervision, capacity building during process of programme implementation through involvement of Inter Sectoral partners like Ministries of Urban Development, Rural Development, Panchayati Raj, research institutions involved in VBD, medical colleges and schools will be initiated at state, district and PHC level. Besides, local leaders and NGOs will be involved. 2.2.7 Monitoring and Evaluation Monitoring & Evaluation covers monitoring of all the activities for effective implementation of Mid Term Plan Strategies approved by Committee of Secretaries across the country, like functioning of all the identified Sentinel surveillance Hospitals, equipped with diagnostic kits and manpower, Functional entomological team in each district, Urban bodies & state level. All Hospitals having trained clinicians on National guidelines for case management, trained rapid response team (RRT) at district and municipality with mobility support & logistics, sustaining source reduction activities in each block/town/city and timely analyzing and interpreting all the reports and feedback. The expected outcomes at the end of 12th plan are: Effective implementation of Mid Term Plan with focused monitoring at national, regional, state and district level, Case detection at early stages will improve case management leading to reduction in case fatality in Dengue and morbidity management in Chikungunya,
88

Improved reporting, especially in outbreak situation, Regular source reduction activities in all local bodies, Awareness amongst community towards prevention and control of Dengue and Chikungunya Enactment of bye-laws in all urban areas to prevent mosquitogenic conditions

2.2.8 Sustainability In order to achieve the proposed objectives of 12th Plan by implementing the approved strategies, adequate funds/resources need to be provided to endemic states/UTs to sustain the activities effectively. Hence it is proposed to make a policy for separate budget head for Dengue and Chikungunya like Malaria, Kala-azar, and Externally Assisted Components. The release of funds from district to PHC & VHSC needs to be ensured under NRHM mechanism of financial release. During outbreak, the funds from NRHM can be supported proactively as has been done in past during Chikungunya outbreak in 2006. The capacity of state programme officer needs to be developed on financial aspects to process the funds released from NRHM quickly and implement programme activity in a time bound manner. 2.2.9 Overlapping/Duplication within or across Health Programmes; convergence issues The Dengue and Chikungunya control programme is already integrated within umbrella of NVBDCP. The strategies mainly focus on inter-sectoral convergence with other National Health Programmes, non-health sector departments, civil society organizations (Non-Governmental Organizations/Faith Based Organizations/ Community Based Organizations/ Panchayati Raj Institutions/Self-Help Groups), corporate sector, medical academia, professional bodies etc. Following the instructions of CoS, Ministries of Urban Developoment, Rural Development and Panchayati Raj have already issued instructions to their counterparts in the states for implementation of guidelines to prevent mosquitogenic conditions and community sensitization. 2.2.10 Estimated budget (Activity and year wise) The budget proposed has been worked out separately for various activities included in Mid Term Plan which is as under: Surveillance Establishing Sentinel Surveillance Hospitals with laboratory facility in each endemic district/town/cities. Currently 311 Sentinel Surveillance Hospitals and 14 Apex Referral Laboratories have been identified. Strengthening of Sentinel laboratories under NVBDCP for diagnosis of dengue and Chikungunya would be done to establish a network of laboratories with high level of intra & inter laboratory comparability of results for correctly identifying the true positives and true negatives through trainings in premier laboratories like NIV, Pune; NCDC, Delhi. ELISA facility in Sentinel Centres would be ensured. Recurring grant of Rs 50,000 paid to Sentinel Surveillance Hospitals per year to meet the contingency expenditure has been proposed to be increased to Rs 1.0 lakh per year to meet the operational cost as per NVBDCP guidelines. Similarly for Apex Referal Laboratories, Rs 1.0 lakh is increased to Rs 2.0 lakhs to strengthen the training facilities, 89 quality control of sentinel labs through cross-checking of tests and Serotyping of virus.

Funds will be provided to states for making ELISA readers or washers available in the Sentinel Surveillance Hospitals wherever necessary. Costs of test kits NIV would manufacture dengue and Chikungunya kits to be supplied to all the sentinel labs in the country. NIV would be provided financial assistance to produce and supply test kits IgM (dengue & Chikungunya) and NS1 (dengue). Case management Strengthening District Hospitals for dengue case management & Rehabilitation of post CHK sequel: Medical rehabilitation including physiotherapy would be strengthened in the district hospitals by providing Rs.1 lakh to each district hospital. It is proposed to improve the capacity of doctors working in sentinel hospitals, community health centers, primary health centers in clinical management of dengue and Chikungunya. Trainings of the trainers (clinicians) would be conducted in premier institutes like AIIMS, New Delhi involving national/ international faculties (Clinical experts from dengue endemic countries in SEA/WP regions). Further in each state about 20 training batches of 30 medical officers each (2 days duration) would be taken up. Appropriate clinical guidelines would be developed at the National level for management of dengue in view of the recent guidelines of WHO and would be circulated to states for replication and supply to the training institutes. Vector control and environmental management Source reduction activities to eliminate the vector breeding are the only effective tool for preventing Dengue and Chikungunya transmission. Community volunteers will be engaged to sensitize the households for reducing the productive breeding sources by making house to house visit. Dengue transmission is related to monsoon which facilitate vector proliferation. Hence it is very essential to carry out this activities at least for 5 months (depending on local transmission and period). Due to the fund constraint the states and urban bodies are unable to carry out this most important activity. For cities having population above 40 lakhs, 200 volunteers; cities with 10 to 40 lakh population, 100 lakh volunteers and cities with less than 10 lakhs population 50 volunteers have been proposed and funds are provisioned, for which urban area/towns have been categorized at 3 levels. Similarly for rural areas also, funds to the tune of Rs.5 lakh will be provided to carry out source reduction activities in the blocks/panchayats. Funds are provisioned for hand operated Fogging machines, which would be procured, if required. Outbreak response and Epidemic preparedness would be strengthened in all endemic and non-endemic districts. To strengthen the epidemic containment, Rapid Response Teams would be activated at state and district level. Operational cost would be provided to all the units.
90

Capacity building Strengthening human resource No additional infrastructure in terms of manpower has been provided after the integration of dengue and Chikungunya under the NVBDCP. Since both Dengue and Chikungunya are viral diseases and transmitted by the same vector mosquito and are being looked after by one division, it is proposed to strengthen the division of Dengue and Chikungunya by providing two Consultants for Monitoring & Evaluation, two Consultants for vector control, one Data Manager, two Office Assistants and one Office attendant to monitor the implementation of the strategies of Mid Term Action Plan for Prevention and Control of Dengue and Chikungunya by states and other stakeholders, coordinate with the States; provide technical guidance by reviewing the data and by field visits. Besides, monitoring the functioning of SSH & ARLs and supply of test kits also needs to be strengthened. It is proposed to budget for their salary, travel, office equipment etc. Strengthening human resource at National HQ for Dengue & Chikungunya division has already been approved by CoS on 26-05-2011. Training At the state and peripheral level, Medical Officer, Prog Manager, Entomologist, MPW, ASHA/USHA trainings would be taken up. Capacity building of microbiologists and technicians would be taken up through training. In each state 9 batches of 25 participants each (5 days duration) would be taken up. Capacity building of entomologist/assistant entomologist, insect collector etc would be taken up. In each state, training of total 9 batches of 25 each (5 days duration) would be conducted. Printing of guidelines/manuals/ formats would be taken up. Operational research It is desirable to prioritize its research areas and develop new strategy by undertaking operational research with a view to improving its effectiveness and efficiency of the existing tools for giving greater scientific credibility to Dengue and Chikungunya control in India. At national level and state level, a number of research projects are planned. Monitoring, Evaluation and Supervision - Analysis of reports, review, field visit and feedback Online (electronic) reporting will be introduced for improving weekly reporting from 300 districts in 23 endemic States/UTs in the first phase. The remaining 321 districts in 12 States/UTs will also be included in online reporting so that any area in the country will be alerted for any reported or indigenous case. It is proposed to develop a dedicated software for GIS Mapping for the entire country and to develop risk maps at appropriate levels and conduct periodic re-mapping (to be linked to periodic surveillance) To facilitate online reporting, data card and telephone call charges (mobile) would be provided. Contingencies for stationary, computer consumables, report writing, local meetings, statistical analysis, unforeseen expenses would be provided at different levels. Mid term evaluation of Mid Term Plan strategies in 2013 and 2015 would be taken up to assess the improvement in control programme and to make any correction if required by involving experts. M& E cost would be provided to Regional Office for Health and FWs which are 19 in number and are functioning as eyes and ears of the central health ministry.
91

M&E cost would be provided to states and districts for reviews, feedback, mobility support for field visit etc.

Behaviour Change Communication - Social mobilization and information Education and Communication (IEC) An extensive advocacy cum action campaign would be taken up in all endemic urban and rural areas. A team called Aedes breeding survey and control team would be constituted in the urban wards / village panchayats. The team would comprise of ASHA, Anganwadi worker, village panchayat members, VHSC members, social workers, NGOs etc. In each urban ward / village panchayat about 12000 households would be surveyed for identifying Aedes breeding sites in and around houses. This activity would be guided by the entomologists. Trained health workers will take ASHA / Anganwadi worker and some members of the team to every house. A format would be used to collect and tabulate the potential and actual breeding sites of aedes. The output from this survey would be used in the advocacy session arranged on the same day in the ward / village telling the people about the actual situation among their households. Live larvae collected from their own households would be shown to the people. Ways of dealing with the breeding sites would be told to the people. Actual demonstration would also be done. A repeat survey would be conducted after about one or two months in the same ward /village / panchayat to find out any change. Reports received from a number of sites would be monitored to see any significant improvement in terms of reduced number of breeding sites. At the national level, designing/developing prototype IEC material & tool kit, video spots etc would be taken up. Sensitization workshops are planned at different levels.

Inter-sectoral coordination Health, Urban Development, Rural Development, Panchayati Raj, Surface Transport and Education sectors would be involved. Task force meetings are planned at National level, State & district levels.

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Table 17, Estimated Budget for Dengue and Chikungunya (activity and year wise)

Rs. In Crores
Sl No Component Activity Operational Cost to Sentinel Surv Labs Operational Cost to Apex Ref Labs ELISA facility to Sentinel Surv Labs Cost of Test kits IgM NS1 strengthening Dist Hospitals for dengue case management & Rehabilitation of post Chikungunya sequele For Source reduction volunteers @ Rs100 perdayx20daysx5months 200 volunteers per towns /cities <40.0 lakh pop 100 volunteers per Towns /cities >40.0 to 10 lakh pop 50 volunteers per Towns /cities >10.0 to 1 lakh pop Districts for rural areas PHC/Block level Fogging machine Rapid Response State District Unit Cost 0.01 0.03 0.05 2012-13 2013-14 2014-15 3.11 0.42 5.00 3.50 2.50 4.00 0.42 5.00 3.50 3.00 4.50 0.42 5.00 4.00 3.00 Total 2015-16 2016-17 Cost 6.00 0.42 5.00 4.50 3.50 6.50 0.42 5.00 5.50 4.50 24.11 2.10 25.00 21.00 16.50

Strengthening Disease Surveillance

Case management

0.02

2.00

2.00

3.00

3.00

3.00

13.00

Vector Control and Environment al Management

0.20 0.10

1.00 9.50

1.00 9.50 16.50 50.00 7.50 0.70 5.00

1.00 9.50 16.50 50.00 7.50 0.70 5.00

1.00 9.50 16.50 51.50 7.50 0.70 5.15

1.00 9.50 16.50 52.50 7.50 0.70 5.25

5.00 47.50 82.50 247.0 0 37.50 0.00 3.50 24.70

0.05 16.50 0.10 0.0075 0.02 0.01 43.00 7.5 0.7 4.30

4 5 5.1

Epidemic containment Capacity building Human Resource National HQ

5.2 Training

5.3

Operational Research Monitoring & Evaluation

Salary Travel Office equipment Medical Officer, Program Manager, Entomologist, MPW, ASHA etc Printing of guidelines /manuals/ formats National level State level

0.40 0.07 0.20 5.00 0.04 1.40 2.00 2.00

0.44 0.07 0.01 5.00 1.40 2.00 2.00

0.48 0.07 0.01 5.00 1.40 2.00 2.00

0.53 0.07 0.10 5.00 1.40 2.00 2.00

0.59 0.07 0.01 5.00 1.40 2.00 2.00

2.44 0.35 0.33 25.00 7.00 10.00 10.00

6.1

Reporting cost

GIS Mapping - cost of software & accessories, maintenance ( National) software development for e-reporting & training Cost of data card for state & district level

0.25 1.00 0.001

93

0.05 0.10 0.00

0.05 0.10 0.00

0.10 0.10 0.00

0.05 0.10 0.00

0.50 1.40 0.68

0.68

Monthly renta of data card @Rs 750/-+ Annual Maintenance incl data entry @Rs1000/Contd/-Sl No Component M&E costs including reviews, feedback mobility support for field visit Mid course evaluation IEC/BCC for Community awareness Advocacy campaign Media Campaign Designing / developing prototype IEC material & tool kit, etc Inter sectoral convergence Grand Total Activity

0.001

0.68

0.70

0.72

0.75

0.75

3.60

Unit Cost

2012-13 2013-14 2014-15

2015-16 2016-17

Total Cost

M& E cost to ROHFWs M&E cost to states M&E cost to districts National & State level 0.05 0.005

1.00 1.75 2.15 0.00

1.00 1.75 2.50 1.00

1.00 1.75 2.50 0.00

1.00 1.75 2.58 0.00

1.00 1.75 2.63 1.00

5.00 8.75 12.35 2.00

6.2

6.3

At Panchayat/Ward level by districts State National (A/V, print)

0.05 0.1

21.50 3.50 5.00

25.00 3.50 5.25

25.00 3.50 5.25

25.75 3.50 5.50

26.25 3.50 5.50

123.50 17.50 26.50

National

0.50

1.00

0.30

0.30

0.30

2.40

Task force meeting at National level State & district level

0.03 0.01

0.03 0.35 148.48

0.03 0.35 161.27

0.03 0.35 161.63

0.03 0.35 167.08

0.03 0.35 172.15

0.15 1.75 810.61

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Table 18, Abstract of Budget proposed for prevention & control of Dengue & Chikungunya

(Rs. in crores) Sl No 1 2 3 Component 2012-13 14.33 2.00 77.50 5.00 2013-14 15.92 2.00 84.50 5.70 2014-15 2015-16 2016-17 Total 16.92 3.00 84.50 5.70 19.42 3.00 86.00 5.85 21.92 3.00 88.71 13.00

Disease Surveillance Case management Vector Control & environmental management 4 Epidemic containment 5 Capacity Building 5.1 Human resource strengthening at national level 5.2 Training 5.3 Operational Research 6 Monitoring & evaluation 7 IEC/BCC for social mobilization 8 Inter-sectoral convergence Total

87.00 419.50 5.95 28.20

0.67 6.40 4.00 7.50 30.50 0.38 148.48

0.52 6.40 4.00 7.10 34.75 0.38 161.27

0.56 6.40 4.00 6.12 34.05 0.38 161.63

0.70 6.40 4.00 6.28 35.05 0.38 167.08

0.67 3.12 6.40 32.00 4.00 20.00 7.28 34.28 35.55 169.90 0.38 1.90 172.15 810.61

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4.3 Japanese encephalitis (Proposed Plan during 12th Five Year Period)
4.3.1 Key lessons learnt from 11th five year Plan Despite setting up of 51 sentinel sites hospital based surveillance centres, the actual disease burden has not been fully assessed. Though some of the states like Assam, Karnataka, Tamil Nadu, Goa and Uttar Pradesh have made efforts to make sentinel sites functional but additional inputs are required to be provided to reach close to actual disease burden. The case management facilities are poor in many states due to lack of infrastructural facilities and modern equipment. Though 111 districts have already been covered under JE vaccination, 1014% JE sero positivity is still being reported due to poor coverage of new cohorts under Routine Immunisation. Persistence of AES case in the state of Uttar Pradesh due to lack of developmental activities in Gorakhpur and Basti districts. Though NIV Field Station has been setup at BRD Medical College, Gorakhpur since July 2008 however, not more than 2-4% of entero virus has been detected in the states. Entomological surveillance is poor due to dismantling of entomological zones in the states.

4.3.2 Objectives during 12th five year plan Prevention of outbreak Reduction in number of JE cases and mortality by 50% till 2017

Target for 12th five year Plan, Indicators, Mean of verification Improved disease and vector surveillance by increasing sentinel sites from 51 to 75 during Xll five year plan. Enhanced case management at district and sub district hospitals through improved facilities like setting up of ICU in high endemic districts. Rehabilitation of the disabled patients by setting up Rehabilitation Centres at state/district levels. Effective and timely vector control through improved vector surveillance by providing the requisite equipment and operational cost. Intensified IEC & BCC activities at field level for quick referrals to the sub district/district hospitals. Enhanced capacity building at state/district /block level for improved surveillance & case management. Inter sectoral convergence for exploring the possibility of mosquito proofing of pig sites in priority areas.

Indicators Incentivization of ASHAs for helping in early referrals Training of Clinicians/Nurses in management of JE cases in CHCs and District Hospitals in endemic areas. Availability of necessary infrastructure for management of JE cases in CHC and District Hospitals in endemic areas and upgradation of ICU facilities and rehabilitation centers at district levels. Increasing number of JE diagnostic facilities across the country. Analysis of entomological and epidemiological data for epidemic outbreak prediction and timely remedial measures
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Focus on early referrals and source reduction/personal protection through IEC/BCC activities. Assess the impact of vaccination and guide the future strategies. Developing nationwide surveillance networking with data management.

Means of verification CFR over the next 5 years. Number of outbreaks being reported Increased number of sentinel sites. Overall evaluation of impact of vaccination by an independent agency. Improved case management facilities in district hospitals. Review of training reports, pre, & post training assessments Review of reporting through MIS/surveillance data for prediction of epidemic outbreaks. Data management of JE cases on regular basis. 4.3.3 Strategies during 12th five year Plan Early Diagnosis and Prompt treatment of JE cases : Early Diagnosis and Prompt treatment of JE case through existing health care infrastructure/ hospitals etc. helps in reducing case fatality rate and would increase the credibility of improved health system in the country. It includes: Proper case management at district/sub district level: Prompt and effective case management would need more improved inputs and care from health care providers (medical and paramedical) and sufficient availability of drugs and equipment in treatment centres. Infrastructure of clinical Management with Standard Operating Procedure/guidelines for management of cases will be available at District/sub district level. Strengthening of referral services: Referral support will be made available by the state at District/sub district level to transport the seriously sick patients to the referral hospitals. Facility for diagnosis in all endemic districts: Surveillance and sentinel laboratories for diagnosis of JE cases will be strengthened at peripheral level (in JE endemic districts) in a phased manner. Management of Sequelae: Sequelae management will be done by drugs, orthopedic and rehabilitation procedures in all District/Medical College Hospitals/specialist Hospitals in JE endemic areas. The rehabilitation centre will be setup at state/district level. Epidemic preparedness and rapid response: A rapid response team will be constituted in all JE endemic districts to monitor the JE situation and outbreak in their areas. Strengthening of JE surveillance While implementing the surveillance plan during 11th Five Year Plan which focused on the reporting of all suspected JE cases under AES, it has been realized that in the absence of adequate infrastructure for detection and isolation of viruses other than JE, this aspect of detection and isolation should rest with NCDC and other regional apex laboratories so that NVBDCP focuses on reporting system of suspected JE cases and strengthens the sentinel laboratories for confirmation of JE cases. R and D aspects as mentioned above would be taken up by NCDC.
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Surveillance will be strengthened to detect all suspected JE and Laboratory confirmed JE cases. Private Practitioners will also be involved to report JE cases as per guidelines. For effective disease surveillance, the data collection will be uniform and regular through standard proformae. For this national guidelines will be provided to states. Following components of the surveillance need to be strengthened: (a) Serological surveillance: For effective serological surveillance, following activities will be carried out: Strengthening of laboratory for serodiagnosis by providing JE kits/ELISA Reader. Collection of samples and analysis in serology laboratory. Training of Technicians/Microbiologist for MAC ELISA for diagnosis of suspected cases Establishment of 25 additional sentinel site laboratories in high endemic areas. (b) Entomological Surveillance In the states where entomological zones are intact or under urban malaria schemes, identification and mapping of breeding sites of JE vectors will be done during transmission and non transmission season with the manpower available in NFCP units/UMS. Regular monitoring of vector density will be done at fixed as well as randomly selected sites. Screening/isolation of JE virus will be done from suspected JE vector mosquitoes and possible reservoirs. Entomological investigation will be carried out through trained manpower available in the district/state. Integrated vector control method The main tool in vector control is fogging using technical malathion/pyrethrum for immediate killing of mosquitoes during an outbreak and anti-larval operations wherever feasible. Promoting personal protection method by using insecticides treated bed nets and curtains, wearing full sleeve clothes during evening hours etc. Biological control with approved biolarvicides in limited breeding areas. Capacity building Capacity building & manpower development through training of Clinicians/Nurses on JE case management in all JE endemic districts and for Laboratory Technicians and Laboratory In-charge/microbiologist on diagnosis of JE cases by MAC ELISA method in all sentinel laboratories in a phased manner. Integrated training on vector borne diseases including JE will also be conducted. Behaviour change communication (BCC) Involvement of Sarpanch and Gram Pradhans in rural endemic areas. Increasing awareness of clinical signs and symptoms amongst rural community thereby encouraging early referral of patients. Enhancing activities regarding safe drinking water practices. Insentivization of ASHA workers in the endemic village on early referral of suspected AES/JE case.
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Involvement of local prominent people for mass mobilization. Personal protection including segregation of pigs away from human population/mosquito proofing of pigsties etc. Early reporting of cases. Dissemination of knowledge on environmental sanitation and proper hygiene. Activities for prevention of JE will be included as integral part of BCC on vector borne diseases control.

Vaccination Vaccination in high risk areas and high risk population wherever feasible. Live attenuated JE vaccine has been imported during the year 2006 (X plan) and Govt. of India launched a JE vaccination programme for children between 1 and 15 years of age in 11 districts of 4 states (Uttar Pradesh, Karnataka, West Bengal and Assam) in 2006. In 2007, 2008, 2009 & 2010 28, 22, 29 and 21 new districts have been added under campaign mode as well as Routine Immunisation against JE. On the basis of availability of vaccine, plan for the other districts is being developed by UIP along with the budget. Supervision and monitoring Supervision and Monitoring would be done through periodic reviews/reports, field visits and Web based MIS for proper monitoring for Japanese Encephalitis. Monitoring plan would be prepared by the state in order to ensure that activities envisaged by the states are implemented at the field level. Directorate of NVBDCP routinely monitors monthly incidence of JE and during epidemics, daily monitoring is carried out. Weekly monitoring will also be done during transmission season. Surveillance data will be collected from the states and will be analyzed to detect early warning signals (EWS) for JE outbreak. Sero-surveillance centers and vector surveillance centers existing in the state will provide the information regularly to the Directorate of NVBDCP through State Health authorities. The team of state, centre and ROH&FW will carry out supervising activities.

4.3.4 Policy initiatives during 12th Plan Provisions of ICU facilities at district level for better case management. Incentivization of ASHA for disseminating information on causation and prevention of AES/JE as well as for encouraging community for early referral of sick patients. Setting up of rehabilitation centres at state/district level for the patients affected from JE. Provision of vector control equipment like fogging machines. Increased coverage of routine immunisation in campaign districts throughout the country. Regular communications with State Programme Officer for improved actions towards prevention and control of Japanese Encephalitis. For strengthening the case management facility at BRD Medical College, Gorakhpur, Government of India released an amount of Rs.5.88 crores during 2009-10 for further strengthening the JE epidemic ward which was already constructed by the State Government and the funds provided by Government of India helped in providing additional manpower and the
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important equipment for making the JE epidemic ward functional. The state Govt. will be requested to sustain this case management facility. Continuation of JE sub-office of Regional Office for Health & Family Welfare (ROH&FW) which is manned by Public Health Specialist (II) has been established in Gorakhpur in April, 2007 to coordinate with the state/districts regarding prevention & control measures. Continuation of Vector Borne Disease Surveillance Unit (VBDSU) with Professor of Preventive and Social Medicine as its head at BRD Medical College, Gorakhpur for carrying out sero-epidemiological and entomological studies in the field, and for maintaining a close coordination with the district authorities for taking timely preventive measures. Continuation of NIV field Unit at Gorakhpur that was established on 11/7/08 with a senior level officer from NIV, Pune as its in-charge for detection and isolation of non JE viruses because Gorakhpur is located in between the centre of 7 endemic districts which has been highly affected from AES/JE cases from recent past.

4.3.5 Research and Development Research & development in vector borne diseases particularly on Japanese Encephalitis has been rather inadequate so far. There are major gaps in the present knowledge and available technology. Concerted efforts are required to be made for an effective Research and Development programme. Some of the critical areas related to JE control requiring operational research include: 1. Operational Research on various JE control interventions and their implementation such as use of neem coated urea in the rice field, use of insecticides treated Bed Nets/curtains. 2. Use of impregnated bednets at pig sites. 3. Vaccine coverage assessment. 4. Detection and isolation of non-JE viruses. 5. Coordination with referral apex laboratories for identifying other etiological agents. 6. Differential diagnosis of other AES agents. 7. Epidemic Preparedness and Response by developing early warning signals for prediction of JE outbreaks. 8. JE Vector bionomics for planning of intervention methods.- Bionomics of JE vectors including seasonal prevalence and estimation of vector density in indoor sites such as human dwelling/cattle sheds/mixed dwelling and outdoor situations such as bushes, plantations, standing crops, sugarcane fields in standard prescribed formats to be studied. 9. Study on the efficacy of JE vaccines in the vaccinated areas and overall evaluation of impact of vaccination by an independent agency. It is desirable that above mentioned activities would be continued on a regular basis and specific funds be earmarked for sponsored research coordinated by the programme directly for addressing key issues related to operational research. Nodal officer of NVBDCP will coordinate these activities. 4.3.6 M & E system including status of MIS, disease surveillance, its quality and utilization

Monitoring would be done through periodic reviews and monthly/weekly/daily reports and field visits etc. Web based MIS is to be developed for proper monitoring for Japanese Encephalitis.
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Strengthening of JE surveillance as per the national guidelines to be issued by NVBDCP. Surveillance of AES needs to be adopted. Overall evaluation of impact of vaccination by an independent agency.

4.3.7 Sustainability If the funds proposed during Xll five year plan are made available, all out efforts will be made to sustain and maintain progress of the programme implementation.

4.3.8 Overlapping/Duplication Overlapping/duplication will be avoided by taking all the necessary measures and with close coordination of the states. Estimated Budget

4.3.9

Funding Pattern for Japanese Encephalitis Control National Vector Borne Disease Control Programme will have following pattern of funding: Grant in Aid to be provided to the states for covering components under JE Control Programme. Cost sharing between Centre and States. One time non-recurring central assistance in terms of ELISA Reader, Ventilator, Fogging machines and other equipment etc. Drugs and Malathion technical (insecticides) to be provided by the centre during outbreak. Fund for diagnostic kits, training and IEC to be provided by the centre on regular basis. JE vaccination programme has been made an integral component of Universal Immunization Programme in a phased manner using single dose live attenuated SA-14-14-2 JE vaccine. Rehabilitation units funded by Central Government for the first 5 years may be established in Government Medical College / district and other hospitals. Incentivization of ASHAs for early referrals of suspected JE cases and for sensitizing community regarding Japanese Encephalitis. Establishment of ICU units in the endemic districts for better case management with central funds.

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Table 19, Proposed Budget of JE for Xll five year Plan ( Rs. in crores) Japanese Encephalitis 2012-13 2013-14 2014-15 2015-16 2016-17 Total Diagnostics and Case 3.40 3.74 4.11 4.53 5.00 20.78 Management IEC/BCC Activity 2.55 2.81 3.09 3.39 3.73 15.57 Capacity Building 1.70 1.87 2.06 2.26 2.49 10.38 Fogging Machine 4.60 0.65 0.70 0.75 0.80 7.50 0.90 1.00 1.10 1.21 1.33 5.54 Vector Technical Malathion Control Operational costs for 0.51 0.56 0.61 0.67 0.74 3.09 malathion fogging Operational Research 3.00 1.50 1.50 1.50 1.50 9.00 Monitoring & Supervision Rehabilitation Setup for selected endemic districts ICU Establishment in endemic districts ASHA Insentivization for sensitizing community Other Charges for Training /Workshop Meeting & payment to NIV towards JE kits at Head Quarter Total 1.70 20.00 40.86 0.10 0.45 79.77 1.87 0.15 0.50 0.10 0.45 15.20 2.06 0.20 1.00 0.10 0.45 16.98 2.26 0.15 1.00 0.10 0.45 18.27 2.49 0.15 1.00 0.10 0.45 19.78 10.38 20.65 44.36 0.50 2.25 150.00

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4.4

4.4.1 Key Lessons Learnt during 11th Plan

ELIMINATION OF LYMPHATHIC FILARIASIS

The strategy of Annual Mass Drug Administration with single dose of DEC was revised to co-administration of single dose of DEC with Albendazole based on the recommendation of ICMR study. Massive efforts through social mobilization were made to improve the coverage of population during Mass Drug Administration which has resulted into overall coverage of more than 85%. However, there are variation in actual compliance and reported coverage though the actual compliance has also improved in comparison to that in 2004 & 2005. It has been observed that the reason for low drug compliance is mainly because the community living at the risk of Lymphatic filariasis is apparently healthy without any signs & symptoms. Secondly, one worker allotted to cover 250 persons has to devote a lot of time to convince people and therefore is not able to complete the target in one day. Thirdly, the honorarium of Rs. 50/- per day for drug distribution which is less and needs to be increased. About 8 lakhs Lymphoedema patients and about 4 lakhs hydrocele cases have been line-listed. In addition, there may be some more cases as people do not reveal these manifestations at early stages because of social stigma. The affected people need continuous persuasion for lymphoedema management at home and for surgical operations of hydrocele. Involvement of medical professionals from all sectors including private medical practitioners, elected representatives and civil society organizations in the programme need to be strengthened. The media sensitization at local level is of utmost importance which needs to be geared up through advocacy workshops and repeated meetings. A software on Filaria Management Information System was developed by VCRC (ICMR), Puducherry but there is a need to test it for data entry of few states and do necessary amendments, if required. Simultaneously, the HMIS of MOH&FW has also incorporated the minimum data required on Lymphatic filariasis. The major constraint is data entry into the system to make it functional and sustain its functionality. Timely availability of DEC and Albendazole tablets has always been the issue for the programme implementation. Since 2010-11, these drugs have been decentralized. It means the states will have to procure these drugs as per the assessed technical requirement for which cash grant will be made available by GoI. DEC will have to be procured by all the LF endemic States/UTs whereas Albendazole will have to be procured by few states whose requirement cannot be met out of WHO free supply which is limited to only 300 million tablets against the requirement of 600 million tablets.

4.4.2 Objectives, Targets and Indicators During 12th plan period, the objective of Elimination of Lymphatic filariasis will be as below: To progressively reduce and ultimately interrupt the transmission of lymphatic filariasis. To augment the disability alleviation programme to reduce the sufferings of affected persons through appropriate home based morbidity management and hydrocelectomy.
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Targets, Indicators and expected outcomes

Targets to achieve the above objectives, the targets will be:

To cover all eligible population living in all (presently 250) Lymphatic filariasis endemic districts during MDA. To line list the cases of lymphoedema in all the districts and augment home based morbidity management and hydrocele operations in identified district hospitals/CHCs. The indicators will be % of target population that actually consumed Drug. Microfilaria rate in sentinel and random sites of the districts. Number of LF endemic districts with microfilaria rate less than 1%. Number of Hydrocele operations conducted out of total enlisted. % of Lymphoedema cases practising Home based management. The expected outcome of the above indicator would be Drug compliance of more than 80% among eligible population . All LF endemic districts achieving MF rate less than 1%. MDA will be stopped in 250 LF endemic districts and process of elimination certification will be initiated. More than 80% of line-listed hydrocele cases will be operated in 12th FYP. More than 80% of line-listed Lymphodema cases will adopt home based management of maintaining simple limb hygiene. 4.4.3 Means of Verification The verification of the performance will be done through assessment of drug compliance, microfilaria survey, monitoring of side reaction due to DEC, if any. Coverage and Compliance: will be verified by independent assessment by involving medical colleges and research institutions through questionnaire. In rural areas, three clusters each having 30 households (about 150 inhabitants) and one cluster of 30 households in urban area in each district will be surveyed. Thus, a total of 120 households having about 600 inmates would be covered through interrogation including physical verification of tablets using a pre-designed and pre- tested Proforma. Microfilaria Survey: The minimum number of slides to be collected need to be ensured and selection of sentinel and spot-check sites will be done under the guidance of medical college faculty and District in-charge for prevention and control of vector borne diseases. The time of night blood survey i.e between 8.30 pm and 11.30 pm will be cross-checked by concurrent and consecutive visits. In the consecutive visits the community will be interrogated about the time of survey. All the microfilaria positive blood smears and 10% of the negative blood smears will be cross-checked by Regional offices and State Head quarter. Side Reactions due to DEC: DEC is known to cause mild side reactions such as headache, nausea, vomiting, dizziness etc. however these symptoms are self limiting and usually subside within few hours. The side reactions are usually seen in those people who harbour microfilariae. In case, these symptoms persist, they require medical attention or hospitalization which is very rare. However, such serious adverse experiences of DEC, if any, will be monitored and immediately attended by Mobile teams (Rapid Response Teams). Validation for MDA stoppage: As the target for elimination of Lymphatic filariasis 104 is by the year 2015, the assessment of districts will be done as per WHO guidelines for MDA stoppage. These assessments will include additional round of microfilaria survey in atleast 10 additional sites in each LF endemic districts. In case of

confirmation of microfilaria prevalence less than 1%, the prevalence of new infection in children born after initiation of MDA (6 years age) will be assessed through Immunochromatographic test (ICT). MDA will be stopped in qualifying districts. 4.4.4 Strategy The strategy for elimination of lymphatic filariasis will continue as below: Annual Mass Drug Administration (MDA) of single dose of DEC (Diethylcarbamazine citrate) and Albendazole for atleast 5-7 years (usual life span of adult worm) to the eligible population (except pregnant women, children below 2 years of age and seriously ill persons) to interrupt transmission of the disease. Home based management of lymphoedema cases and up-scaling of hydrocele operations in identified CHCs/ Distt. hospitals /medical colleges. Capacity building for home-based management of cases with Lymphodema. Strategy for MDA stoppage as per WHO guidelines will be undertaken.

4.4.5 Initiatives proposed Improvement in drug compliance during MDA by States is the issue for which intensive social mobilization has been emphasized. Morbidity management services (foot hygiene for lymphodema and operations for hydrocele cases) need to be intensified. Monitoring & Evaluation (assessment by involving medical colleges and research institutions) have been emphasised. Verification of microfilaria survey prevalence and antigaenamia test for MDA stoppage. Post MDA surveillance through microfilaria survey in the districts where MDA will be stopped have been included. Certification for elimination will be initiated as per WHO guidelines.

4.4.6 Priority Social Mobilization for improved drug compliance and morbidity management. Supporting mass drug administration and management of adverse reactions. Involvement of faculties from medical colleges, research institutions and Regional Directors (GoI) for monitoring and independent assessment Morbidity surveys and morbidity management for all patients individually and also at community level. Motivating people suffering from Hydrocele to go for surgical intervention.

4.4.7 Mechanism of Involvement of NGOs/PPP/community/local self government The BCC campaign will be implemented through four-pronged activities: advocacy workshops, inter-sectoral meetings, programme communication and monitoring and evaluation at all levels (national/state/district/urban areas/blocks/sub-centres/villages) with the objectives of: Enhancing awareness on lymphatic filariasis and its elimination aspects, Promoting attitudinal and value changes among target audiences leading to 105 informed decisions, modified behaviour, desirable practices regarding drug consumption and home based morbidity management,

Building support for the programme across inter-sectoral partner organizations, influential sectors of society and health care service providers (public/private) and eliciting commitment for action, Stimulating increased and sustained demand for quality prevention and care services, Ensuring availability of services

Non-Governmental Organizations (NGOs), Community Based Organisations (CBOs), Faith Based Organisations (FBOs) can play an important role in LF elimination. Therefore, these will be involved in the programme by building their capacity on various aspects of ELF programme eg. local monitoring of distribution of drug, mopping up operations for improvement in coverage and compliance. This would be achieved through their participation in intensive social mobilization and BCC campaign. 4.4.8 Modalities to improve efficiency and quality of services at primary, secondary and territory levels Intensive supervision, capacity building during process of programme implementation through involvement of research institutions and medical colleges will be initiated at state, district and PHC level. Besides, local leaders and NGOs will be involved. 4.4.9 Monitoring and Evaluation Monitoring & Evaluation of ELF programme covers process monitoring viz., assessment of timely implementation of activities as per calendar, assessment of coverage of drug distribution during MDA and compliance of drug (actual drug consumption) for enhancing the drug compliance, impact assessment through night blood survey for prevalence of microfilaria among community followed by assessment of prevalence of new infection in children and assessment of activities for Behaviour Change Communication. Formats for Data Capture: Planning and implementation of any disease control programme depend on information support. Information is derived from data and hence the quality of information depends on how the data are collected and the nature of the instrument employed in the collection procedure. Therefore, formats for data capturing have been circulated to the filaria endemic states/UTs so as to collect the data in a uniform pattern. The HMIS programme for Lymphtic Filariasis is integrated under NVBDCP and ultimately in MOH&FW HMIS. With the operationalization of HMIS, the reports on ELF activities will be received at the Directorate without much lapse of time. Compliance: The issues of coverage of distribution and consumption are ideally recorded as primary data at the time of drug administration, in which case, sampling design is not required. Since consolidation of compliance data based on drug providers records may not be authentic, a sample survey is carried out subsequently by involving medical college faculties/research institutions/ Regional Directors offices (GoI) to assess and validate the data. These surveys also include components relating to compliance, adverse reactions if any, and efficacy of IEC tools employed. Questionnaire surveys are carried out within a limited period of time from the date of MDA considering the memory of individual respondents, which will influence the quality of data. The sampling units are individuals who are interviewed from selected households in the identified villages in rural areas and similar households from selected wards in towns and municipal areas.
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Impact evaluation: This evaluation is based on the parasitological surveys in human population before and after the intervention covering certain proportion of population

in selected villages / wards. Distribution of filariasis is known to be clustered and therefore selection of villages for impact assessment is done by taking representative samples from different clusters (such as low, medium and high) within a given district. Eight sites (fixed and random) are selected for each district and a minimum of 4000 persons (500 per site) are examined for microfilaria. The detailed guidelines have been provided to states/UTs. 4.4.10 Validation The districts reporting microfilaria less than 1% in sentinel and Random sites will be subjected to validation by conducting Microfilaria survey in additional 10 sites and after ensuring microfilaria rate <1%, the prevalence of current infection in children of 6 years ago will be assessed through ICT as per WHO guidelines. MDA will be stopped in those districts where observance of prevalence of current infection (i.e. the for circulating antigenemia) is evidenced. The districts where MDA will be stopped will be kept under post MDA surveillance for 5 years. During post MDA surveillance only microfilaria survey and antigenemia survey will be conducted as per WHO guidelines. Based on trend and success achieved in reducing microfilaria rate, it is expected that by 2014-15, 250 Lymphatic Filariasis endemic districts will be subjected for MDA stoppage and verification for elimination. The WHO revised guidelines 2010 will be circulated to all states/districts, research institutions, medical colleges, Regional offices (GoI) etc., involved in assessment and implementation. 4.4.11 Sustainability In order to achieve the National Health Policy goal of ELF by the year 2015, adequate funds/resources need to be provided to endemic states/UTs to sustain the ELF programme. As a policy, the budget head for ELF is to be marked separately like Malaria, Kala-azar and Externally Assisted Component. The availability of allocated funds at state, district and PHC level need to be ensured as often the release of funds are dependent on availability of total balance funds under NVBDCP programme which, however, are earmarked for different activities like decentralized commodities, salary of contractual MPWs, ASHAs incentives for malaria etc. 4.4.12 Overlapping/Duplication within or across Health Programmes; convergence issues The programme is already integrated under umbrella of NVBDCP. The strategy of ELF includes partnership with other National Health Programmes, non-health sector departments, civil society organizations (Non-Governmental Organizations/Faith Based Organizations/ Community Based Organizations/ Panchayati Raj Institutions/Self-Help Groups), corporate sector, medical academia, professional bodies. Since, its strategy and monitoring and evaluation are different, there may not be any chance of overlapping or duplication in the field of either implementation or data capture.

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4.4.13 Estimated budget (Activity and year wise) The budget proposed has been worked out separately for various activities related to annual mass drug administration, its assessment, validation, post MDA surveillance and for disability alleviation including lymphoedema management and hydrocele operations. The details are indicated below with the year-wise and activity-wise budget break up is shown in Table 20. Preparatory activities for mass drug administration includes various sensitization meetings, trainings of various categories, intensive IEC/BCC activities, monitoring and evaluation including mobility support for field supervision and movement of rapid response team. The budget for various sensitization meetings at national, state and district level has been provisioned @ Rs.3.95 crores per year amounting to total requirement of Rs.19.75 crore for 12th FYP. IEC/BCC activities are the most crucial in improving the acceptance of the drug during MDA as most of the people apparently look healthy even if they are infected. The fund of Rs.10 lakh per district per year has been provisioned with 10% of it to be allocated for the state level activities. This amounts to be Rs.27.50 crore per annum (Rs.137.50 crores for 12th FYP). This is about 19% of total ELF budget proposed during the plan period. Capacity Building Specific orientation and training are required for medical, paramedicals, Lab.Technician for microfilaria survey and drug distributors at various levels. Accordingly the funds have been provisioned at state, district and PHC levels. The required funds per annum will be Rs. 27 crore and total for 12th FYP will be Rs. 135 crore. Lymphoedema management The persons showing manifestations of different grades are required to maintain hygiene for which they need to be demonstrated the simple foot hygiene method. Rs. 150/- per patient per year has been provisioned which will include one morbidity management kit comprising of one mug or small buket, one soap, small towel and anti-bacterial or anti-fungal cream. Budget has been provisioned @ Rs.11.80 crores per year amounting to total requirement of Rs.59 crore for 12th FYP. Hydrocele operations The listed hydrocele cases are to be motivated for surgical operation for which Rs. 1250/ per person (incentive of Rs.500 to surgeon, Rs.100 to staff nurse, Rs.50 to ward-boy, Rs.50 to attendant, Rs.400 for medicines etc. and Rs.150 towards transport charges to patient) have been provisioned. In 5 year plan period, all hydrocele have been targeted @ 20% operation per year. Budget has been provisioned @ Rs.9.80 crores per year amounting to total requirement of Rs.49 crore for 12th FYP. Impact of MDA on Microfilaria prevalence - To analyse the impact of annual Mass Drug Administration towards interruption of transmission, the prevalence of microfilaria in sampled population as per guidelines is assessed through night blood survey in 8 sites of every MDA covered district as an inbuilt mechanism of monitoring the performance. This activity is most crucial and is being done since 2004 and will be continued till the MDA is stopped. The funds earmarked for this activity is Rs.6.5 crore for 12th FYP. Honorarium rates The drug distributors including ASHAs involved during Mass Drug Administration are to cover 250 persons or 50 houses during MDA on single day with mopping up for 2 subsequent days. The rate of honorarium per day is Rs.100 per person. This works out to be Rs.48 crore in first year, Rs. 27 crore in second year, Rs.16 crore in third crore, Rs.14 crore in fourth year and Rs.13 crore in fifth year (Total Rs.118 Crore). The MDA is expected to be stopped in phased manner on yearly basis, therefore the funds provisioned for honorarium has also been reduced. In addition to these volunteers, the honorarium for supervisory staff (1 per 10 drug distributors) has also been provisioned at the
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rate of Rs. 4.82 crore per annum which works out to be Rs. 24.10 crore for plan period. Contingency to meet the contingent expenditure at different level, it is proposed to provide Rs.2 lakhs per district for 250 LF endemic districts which amounts to be Rs. 5 crore per annum (total Rs.25 crores for 12th FYP). Mobility the fund for mobility support is being provided at the rate of Rs.80,000 per district to facilitate the movement of local officials, transportation of drugs, movement of rapid response team in case of emergent situation and monitoring and supervision of the programme during the Mass Drug Administration. 10% of the total amount allocated in this Head is earmarked for state headquarter to facilitate their movement to the districts for supervision during MDA. Budget has been provisioned @ Rs.2.20 crores per year amounting to total requirement of Rs.11 crore for 12th FYP. Independent assessment through experts from ICMR, ROHFW, Medical Colleges on coverage and compliance - To carry out these activities by Research institutions/ medical colleges/ Regional offices, funds have been provisioned @ Rs. 15000/- per district (TA for 2 persons @ Rs. 2000 each; Honorarium for 2 persons @ Rs. 1000/- per person per day for 4 days); contingency Rs. 1000/- and POL Rs. 2000/-). Budget has been provisioned @ Rs.9 crores per year amounting to total requirement of Rs.45 crore from 12th FYP. Rs. 45000 per districts is kept for outside experts from Research Institute and Rs.3 lakhs for undertaking training, sensitization of PHC Medical Officers of districts and compilation of report etc. Verification and validation for stoppage of MDA in LF endemic districts by conducting mf survey/ICT survey through experts from ICMR, ROHFW, Medical Colleges and University o This activity is very crucial to verify and validate the data on prevalence of microfilaria. The additional mf survey through night blood survey in 10 sites of identified districts will be done and Rs. 70000/- per district has been provisioned to meet the travel cost of 3-4 local technicians/ assistants/health workers, their honorarium, cost of 5000 slides, pricking needles, cotton spirit etc. and honorarium for examination of 5000 slides. Budget has been provisioned in a phased manner amounting to total requirement of Rs.1.93 crore for XII FYP. o Further, districts are to be screened through ICT for presence of circulating antigenemia in children (presence of adult worm as evidence of current infection) to initiate MDA stoppage. For this activity, funds have been provisioned @ Rs. 1.5 Lakhs per district in a phased manner which amounts to a total of Rs. 4.57 crore for XII FYP. o The cost of ICT Cards have also been considered to be procured through WHO for the above mentioned activity which works out to be Rs.11.49 crore.

The total budget worked out for the verification and validation for stoppage of MDA is Rs.17.99 crore for 12th FYP. Verification of LF endemicity in non-endemic districts - As during 12th Plan period, the WHO will be requested for initiating process of certification of elimination, the districts reported to be non-endemic for Lymphatic Filariasis (other than 250 districts covered under MDA) will have to be surveyed for infection of Lymphatic Filariasis through microfilaria and antigenemia survey by involving ICMR, NCDC, ROH&FW and states. Such activity has been strongly recommended by experts of sub-group and accordingly budget has been provisioned.
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o Out of 640 districts, 250 districts are known LF endemic which are covered under MDA; 65 districts have already been surveyed and found to be very low endemic/ non-endemic. Remaining 325 districts will be surveyed first for presence of Lymphoedema & Hydrocele cases in the villages by involving ASHAs or health workers. Rs.100 has been provisioned per worker as incentive to enlist the persons having Lymphoedema or hydrocele manifestation in their village and send it to PHC. The fund provisioned for this activity is Rs.4.5 crore. This activity is to be completed within 3 years. o Though these districts are reportedly non-endemic but the presence of Lymphoedema & Hydrocele cases will necessitate the survey for prevalence of microfilaria through night blood survey for which Rs.195 crores has been provisioned. This activity is expected to be completed within 3-4 years. o The presence of infection in children is the indicator of current infection for which the test through ICT cards is to be done for which provision of Rs.9.8 crore at the rate of Rs.1.96 crore per year has been kept. Post MDA Surveillance - The districts covered under MDA will be subjected to the process validation and verification and MDA will be stopped in the districts fulfilling the criteria for MDA stoppage as per WHO guidelines. Such districts are to be kept under Post-MDA surveillance as per WHO guidelines through night blood survey for microfilaria and for presence of adult worm in children through ICT to ensure that no new cases occur so that process of certification of elimination is initiated. Funds of Rs.6.75 crore have also been provisioned for the activity. DEC & Albendazole - DEC and Albendazole requirement is expected be reduced in subsequent years as the districts march towards MDA stoppage. Albendazole is supplied partially by WHO. Based on present trend of Mf rate, it is expected that after 2 years, the requirement of Albendazole can be managed out of WHO supply. The funds have been provisioned accordingly. The total fund of Rs. 76.40 crore for DEC and Albendazole has been reflected during 12th FYP.

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Table 20, Estimated Budget for ELF (activity and yearwise) Rs. In Crores
Sr. Activity 2012-13 2013-14 2014-15 2015-16 2016-17 Total No. 1. Meeting National, State and 3.95 3.95 3.95 3.95 3.95 19.75 District level 2. BCC/Advocacy/IEC at centre, 27.50 27.50 27.50 27.50 27.50 137.50 state, district/PHC, sub centre 3. Training District Officers, PHC MOs, Paramedical staff, drug distributors 4. Lymphoedema Management 5. Hydrocelectomy 6. Monitoring by Microfilaria Survey 7. Honorarium for Drug Distribution a) Honorarium to volunteers b)Honorarium to supervisory staff 8. Contingency expenses for social mobilization & advocacy 9. Mobility Support (POL) 10. Monitoring & Evaluation (Assessment) 11. Verification and validation for stoppage of MDA in LF endemic districts a) Additional MF Survey b) ICT Survey c) ICT Cost 27.00 27.00 27.00 27.00 27.00 135.00

11.80 9.80 1.30

11.80 9.80 1.30

11.80 9.80 1.30

11.80 9.80 1.30

11.80 9.80 1.30

59.00 49.00 6.50

48.00 4.82 5.00

27.00 4.82 5.00

16.00 4.82 5.00

14.00 4.82 5.00

13.00 4.82 5.00

118.00 24.10 25.00

2.20 9.00

2.20 9.00

2.20 9.00

2.20 9.00

2.20 9.00

11.00 45.00

0.55 1.17 2.65

0.70 1.48 3.36

0.40 0.90 1.87

0.12 0.27 1.61

0.16 0.75 2.00

1.93 4.57 11.49

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Sr. Activity No. 12. Verification of LF endemicity in non-endemic districts a) LY & Hy Survey in 350 distt b) Mf Survey in Non- endemic distt c) ICT survey in 200 distt 13. Post-MDA surveillance 14. DEC Albendazole Total

2012-13

2013-14

2014-15

2015-16

2016-17

Total

1.50 60.00 1.96 0.55 15.00 21.40 255.15

1.50 65.00 1.96 1.20 12.50 14.00 231.07

1.50 70.00 1.96 1.60 7.00 0.00 203.60 1.96 1.70 3.30 0.00 125.33 1.96 1.70 3.20 0.00 125.14

4.50 195.00 9.80 6.75 41.00 35.40 940.29

Table 21, Abstract of Budget proposed for Elimination of Lymphatic Filariasis (Rs. in crores)
Component Drug Training BCC Operation cost Honorarium for Drug Distribution Verification & validation for MDA stoppage Survey of LF endemicity and verification in non endemic district Total 2012-13 36.40 27.00 27.50 39.10 52.82 8.87 63.46 255.15 2013-14 26.50 27.00 27.50 39.10 31.82 10.69 68.46 231.07 2014-15 7.00 27.00 27.50 39.10 20.82 8.72 73.46 203.60 2015-16 3.30 27.00 27.50 39.10 18.82 7.65 1.96 125.33 2016-17 3.20 27.00 27.50 39.10 17.82 8.56 1.96 125.14 Total 76.40 135.00 137.50 195.50 142.10 44.49 209.30 940.29

112

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4.5

4.5.1 Key Lessons learnt during the 11th Five Year Plan

KALA-AZAR ELIMINATION PROGRAMME

Inadequate ownership and commitment by the states. Poor programme implementation at grassroot level. Ongoing efforts are not sustained and the kala-azar incidence is showing increasing trend. Poor quality and coverage of indoor insecticidal spray for vector control. Due to prolonged injection based treatment, some of the cases do not complete the full treatment. Absence of tracking mechanism to follow up defaulter patients. There remained some untraced or untreated cases which act as parasitic reservoir. Presence of Post Kala-azar Dermal Leishmaniasis (PKDL) cases which also act as active source of Kala-azar transmission. Inadequate monitoring & supervision. 4.5.2 Objectives To Achieve Elimination of Kala-azar from the country by 2015 Target To reduce the annual incidence of Kala-azar to less than one per 10,000 population at the block level by 2015. Indicators No. of Kala-azar cases per 10,000 population at block level Kala Azar case fatality rate Treatment compliance rate 4.5.3 Strategy Parasite elimination and disease management o Early case detection and complete treatment. o strengthening of referral. Integrated vector control o Indoor Residual Spraying (IRS), o environmental management by maintenance of sanitation and hygiene, Supportive interventions o Behaviour Change Communication for social mobilization, o Inter-sectoral convergence, o Capacity building by training and Monitoring and Evaluation. Initiatives The following initiatives would be undertaken : Surveillance and Case Management Strengthen case search for hot spots : Case search on quarterly basis shall be undertaken in all the sub-centres covering the hot spots. Upscaling of RDT & Oral drug for early detection and complete treatment : To improve treatment compliance, a new oral drug Miltefosine would be expanded to all the kala-azar 113 endemic districts as the first line of treatment.

Mechanism for Directly Observed Treatment : The treatment with Miltefosine would be taken up on the DOTS pattern as a supervised treatment with patient coding system being followed for each patient registered at the treatment centre. ASHA would be trained and fully involved to ensure complete treatment compliance. The provision for the incentive to ASHA has been increased from Rs. 100/- to Rs. 200/(Rs. 50/- to refer a suspected case to the nearest PHC and Rs. 150/- for ensuring the complete treatment) Patient coding scheme will facilitate the tracking of all patients of kala-azar down to the village and individual household level with greatly improved default retrieval. The use of Treatment Cards and Master Kala-azar Patient Register will be ensured for proper line listing of all cases and for proper follow up visits. To allow a rapid and easy diagnosis of Kala-azar, rK39 rapid diagnostic test kits for use at the grassroot level. The use of Miltefosine and rapid diagnostic test kits are expected to greatly improve case detection particularly the passive case detection. However, initiatives will be taken to improve active case detection by increasing the frequency of door to door visit by observing the Kala-azar fortnight every quarter i.e four times in a year and also through camp approach. Volunteers would be drawn from organizations like Nehru Yuva Kendra, NCC etc. to intensify the case searches including the PKDL cases. These volunteers would be provided necessary orientation. Monitoring of diagnosis and treatment will be accelerated by frequent visits by programme personnel as well as by proposed coordinators. Training & IEC/BCC. Monitoring & Supervision. Vector Management Indoor residual spraying (IRS) for interruption of transmission will be taken up in all the 52 endemic districts of the country to ensure good quality spray and coverage above 80 %. Monitoring of the process and impact of indoor residual spraying would be improved through independent studies on the effect of spraying on vector populations and susceptibility studies. Environment sanitation will be given considerable importance in a BCC campaign to eliminate the breeding sites of the vector species. Initiatives are underway for the provision of alternative housing sites to the poor and marginalized population in the Kala-azar villages, who are the most common victims of disease, under the Indira Vikas Yojna. Necessary modules will also be developed for capacity building at various levels to strengthen skills for programme implementation. 4.5.4 Mechanisms of involvement of NGO/Private sector/ community/local self government in implementation and monitoring programme Networking with NGOs and Private Sector will be taken up more thoroughly during the plan period. Reporting formats will be communicated to all the major private practitioners and NGOs who are treating Kala-azar cases. Linkages will also be established with all the NGOs and Faith Based Organisations. The media plans and media kits will be developed for vigorous BCC campaigns to involve community in treatment and vector control. 4.5.5 Priority areas for basic, clinical, applied and operational research The following areas are priority areas for applied and operational research.
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Pharmaco-vigilance on the use of Miltefosine as the first line of treatment. The operational use of RDK for kala-azar and its quality assurance. The use of alternative methods of rapid diagnosis. The operational research on the treatment of PKDL. The development of guidelines on the treatment of PKDL. Intensive studies on vector bionomics and the impact of insecticide spraying and susceptibility of Kala-azar vectors. 4.5.6 Modalities to improve efficiency & quality of services Effective strategy implementation Strengthened passive surveillance Intensification of Active case detection in hot spots. Declaring Kala-azar a notifiable disease Standard treatment protocol compliance and follow up through treatment cards and DOTs Effective DDT spray under close supervision Effective IEC campaign for community mobilization Efficient manpower development through trainings Networking with other health care service providers in public/private sector Linkages with other national health programmes like NLEP/NACP/RNTCP etc. for case search & IEC. In addition to the above, the coordinator will be engaged at the rate of one coordinator per district for all the 52 Kala-azar endemic districts on contractual basis. This provision has been made for mobility support of these district coordinators for supervision and monitoring of the programme. 4.5.7 M & E system including status of MIS, Disease surveillance, its quality & utilization Data on number of cases & deaths to be received timely. State/districts asked to provide age & gender wise information up to sub-centre wise. For line listing of kala-azar cases, new coding scheme is being introduced to avoid duplication and overlapping. Proper monitoring & analysis of data at sub-centre/PHC/district level envisaged. Ensure regular monitoring & reporting of spray completion reports. 4.5.8 Programme Sustainability depends upon Priority to the Kala-azar problem at all levels of programme implementation. Strengthening of infrastructure. Required funds in place in time. Availability of drugs, insecticides, equipment, vehicles, etc. Ensure timely and effective spray coverage. Regular monitoring and evaluation. 2.5.9 Overlapping/duplication within or across health programme; convergence issues Presence of different institutes for same cause i.e. ICMR, NCDC, Medical College, RD office. There is no coordination among these on their functioning on kala-azar implementation. Functioning of state heath directorate and state health society (NHRM). Functioning of MPHW, ANM, ASHA & Anganwadi Worker, NGOs. 115 Functioning of private & public practitioners.

4.5.10 Proposed Estimated Budgetary Outlay for Vector Borne Disease Control Programme (Kala-azar) for 12th Five Year Plan The activity-wise and year-wise break up of proposed funds for elimination of kala-azar is indicated in Table 22. Table 22, Estimated Budgetary Outlay for Kala-azar for 12th Five Year Plan (Rs. in crores) Component IRS DDT Amphotericin-B Miltefosine RDK for KA Case search / Camp Approach Spray pumps & accessories Operational cost towards wages POL/Mobility/ supervision Capacity Building IEC /BCC/ Advocacy Evaluation Total 2012-13 64.50 0.25 15.30 1.97 5.20 4.90 29.70 3.90 4.65 13.50 0.50 144.37 2013-14 64.50 0.25 20 1.97 5.20 4.90 29.70 3.90 4.65 13.50 0.50 149.07 2014-15 64.50 0.12 20 1.97 5.20 0.70 29.70 3.90 4.65 13.50 0.50 144.74 2015-16 64.50 0.12 10 1.0 5.20 0.70 29.70 3.90 4.65 13.50 0.50 133.77 2016-17 64.50 0.06 5 1.0 5.20 0.70 29.70 3.90 4.65 13.50 0.50 128.71 Total Amount 322.50 0.80 70.30 7.91 26.00 11.90 148.5 19.50 23.25 67.5 2.50 700.66

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5. Cross cutting Issues (inclusive of special focus and additional inputs during 12th Plan
In view of lessons learnt during 11th Five Year Plan and challenges encountered, it has been felt that special focus has to be given to some of the vital components and additional inputs for supporting engagement of key technical manpower need to be provided for effective implementation, supervision, improving monitoring and evaluation and reporting. Further, it has also been observed that due to inadequate /non- availability of funds for procurement of decentralized insecticides and operational cost for IRS, the coverage of IRS which is a key vector contril measure, has not been achieved at the desired level. This necessitates that during 12th Plan period, this component should be fully supported by the Central Government. The component wise details are as follows: 5.1 Human resource ASHAs

ASHAs are important for implementation of national programmes at field level. This is especially true for NVBDCP where in the field surveillance is an important component of Early detection and complete treatment (EDCT). Presently ASHAs are involved in the diagnosis and treatment of malaria cases and bringing the Kala Azar cases to the health facilities. ASHAs perform rapid diagnostics test, prepare slides and give treatment to malaria positive cases. ASHAs are given incentive for each of these activities like Rs. 5 per RDT and slide preparation, Rs. 20 per complete treatment for Pf cases and Rs. 50 for radical treatment of Pv malaria. Presently, NVBDCP is giving such incentive to ASHAs in 257 identified high risk districts which mainly comprise of the World Bank and Global Fund supported project areas. The programme proposes in the 12th plan to extend the incentive to all ASHA in all the districts for catering services for all the six VBDs depending upon their endemicity in the area served by the ASHAs. More than 6 lakh existing ASHAs will be involved throughout the country. The programme has earmarked Rs. 250 per ASHA per month with an overall ceiling of Rs. 3000 annually for this. It is expected that this incentive will greatly help in increased surveillance of all the six VBDs under the programme for taking timely corrective actions.

MPW (M)

As against the requirement of 145894 MPWs (as per NRHM data 2009 RHS) are 79774 and in place are 57439. Thus there is a vacancy of 26208 MPWs. But considering the total requirement as per the population norms, there is an actual shortfall of 88483 MPWs. Recently, the union government has proposed to revitalize MPW training centers in the states, so as to make available adequate number of MPWs for the field work. NRHM may initiate steps to recruit and train such numbers in the 12th plan period. MPWs are essential for NVBDCP as they are the health workers (besides ASHA) who are responsible for field surveillance and constitute an integral part of EDCT. Success of the programme depends heavily on them. Effective field workforce will greatly help the programme in achieving the desired outcomes. NVBDCP has recruited 9956 MPWs contractual in the XIth Plan period in the high endemic states supported by World Bank and Global Fund and proposes to continue with these contractual MPWs till regular appointees join the programme or the existing contractual workers are absorbed in the health services of the respective states.
117

Laboratory Technicians

There are presently 12904 LTs in place as against the sanctioned strength of 17219 leaving a vacancy of 5591 (NRHM data 2009, RHS). However NRHM has calculated the LT requirement as 27901, based on the provision for one LT each for PHC/CHC taking into account the shortfall in existing PHCs/CHCs. Therefore, the actual shortfall is of 15244 LTs (@ one LT for a population of 40,000). Out of this shortfall, nearly 20% has been filled by contractual LTs recruited under RNTCP, NACP III etc.; thus having a present vacancy of nearly 12,195 LTs. As microscopy is still gold standard for malaria diagnosis and crucial for EDCT, the programme proposes to recruit these 12,000 LTs with a provision for binocular microscope for quality diagnosis and treatment.

VBD Technical Supervisors (Like MTS/KTS)

NVBDCP has started an innovation for effective monitoring and evaluation of the malaria and Kala-azar in the form of Malaria and KA technical supervisors in the high endemic areas in the project states. This has paid rich dividends as these TSs have proved very effective for supervision and M&E of programme implementation, and management of logistics and drug supply as well as tracking of cases at block /field level. Encouraged by the outcomes, NVBDCP plans to expand this and proposes to recruit one Vector Borne diseases Technical Supervisor in all the blocks of the country (one for each block) for looking after the VB disease(s) in their area.

District VBD Consultants

Like the MTS/KTS in the high endemic blocks, NVBDCP has recruited District VBD Consultants in the high endemic districts of the WB/GF project states. This has improved M&E and the programme implementation aspects. Therefore, NVBDCP has planned to expand the DVBDC network to all the 640 districts in the country (one for each district). They will be assisting the District Programme Officers who, at times, are over burdened with various other duties and are not able to devote adequate time to VBDs. They will be provided with support for mobility and operational expenses. In addition, it is planned that each district will have one Data Entry Operator to facilitate the recording and reporting under the programme.

State Level Consultants

In order to strengthen M&E activities and supervision of implementation aspect of the programme at the state level, additional support is required in the form of contractual consultants for various functional areas and they will be qualified experts in their field. They will be provided mobility and operational support. Like the District VBDC, they will assist the state programme officers at the state level. Each state will have one M&E consultant (Medical graduates with Public Health qualification), one VBD consultant (preferably entomologist) and one Finance and logistics consultant. The project states already have such consultants working and the plan is to further extend them at each State. In addition to this, one Data entry operator shall also be provided at each state HQ to facilitate the recording and reporting under the programme.

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Strengthening of ROHFW

At present, there are 19 Regional offices (RDs office) in the country, many of which are facing acute shortage of skilled manpower. RD offices perform the function of monitoring the programme and act as liaison between the Directorate and State Programme Offices besides training and other activities. NVBDCP is of the opinion that RD offices need strengthening and accordingly, it is proposed to have one entomologist and one epidemiologist (with medical background) at each of these regional offices with mobility and operational support.

Strengthening of Zonal Entomology Units

During the 12th five Plan, the NVBDCP proposes to revive and reactivate the 72 zonal entomological units currently spread all over the country with an adequate budget provision. It is proposed that support for filling up 37 vacant posts of entomologist and 65 vacant posts of insect collectors will be provided by the Central Government Assistance will also be provided for mobility, equipments etc., so that adequate data on various entomological aspects are generated on a regular basis. Provision of training of newly recruited entomologists will be made. It is projected that Rs. 93.3 crore will be required for this component during 12th Five Year Plan.

5.2 Capacity building Capacity building is an ongoing activity undertaken by NVBDCP regularly to build the technical and managerial capacity to improve overall programme implementation. For cascading on training Medical Colleges will be involved through NIHFW for preparing of training resource pool up to district level. This resource pool will be shared with NRHM, so that during imparting of integrated training, appropriate faculties for VBD can be drawn from this resource pool. During 12th Plan large numbers of technical manpower are to be engaged, therefore, adequate budget provision for training and reorientation of these manpower has been kept. The categories of manpower to be trained are Community volunteers (ASHAs, AWW, FBOs, NGO, CBOs), MPWs (Male and Female), Lab technician, MO (PHC), Physicinas, Dist. VBD Consultants, VBD technical supervisors, etc. Special training programmes i.e. malariology and entomology trainings will also be conducted for State Programme Officers and District Programme Officers. 5.3 BCC and Social Mobilization IEC/ BCC is one of the core activities of the programme. The support for these activities has been provided through Domestic Budget Support (DBS) as well as from EAC. For effective development of IEC and BCC tools and implementation activities agencies have been hired under WB supported project which mainly focus in the project areas. Under GF supported project, the IEC/BCC activities are being carried out with the partner Civil Society/ NGOs. Under the WB project there is no cash provision to the States which hampers execution of IEC activities at grassroot level. Under DBS, a meager amount is provisioned for IEC/BCC. Under the WB project, a greater chunk of IEC budget is allocated to the agencies for execution of task. There is no IEC/BCC support unit at the Directorate for taking up these important tasks. Under the 12th Plan, the programme proposes to establish an
119

IEC/BCC division with communication experts and support media staff. This has been reflected under restructuring of NVBDCP. Adequate funds have been provisioned for the states to carry out approved and on-going IEC/BCC activities under the programme.

5.4 Public Private Partnerships (PPP) For promoting partnerships with private sectors, NGOs, FBOs, CBOs and local self Governments, the NVBDCP has developed six schemes on PPP during the 11th Plan period. These schemes have been reviewed, revised and already hosted at the website of NVBDCP. However, a separate budget has not been provisioned in 11th Plan period due to cut in budget of NVBDCP at the time for final allocation. Therefore, the states have not been able to get the fund for implementation of these schemes. During 12th Plan period, a separate budget is proposed for its implementation to facilitate building partnerships. Establishing IEC/BCC Cell at Dte. NVBDCP with regular communication expert supported with media assistants. Development of strategy specific prototype materials and Healthy Public Policy through hiring an agency. IEC/BCC activities through print and electronic media at national, state and regional levels. Strengthening of IEC/BCC activities at grass root level through inter-personal communication, folk media etc. for social mobilization towards acceptability of services provided under programme. Special campaigns during spray, distribution of LLINs and anti- malaria month. Strengthening of service delivery through vulnerable community plan for marginalized sectors

Public Private Partnership (PPP) & Inter-sectoral convergence Improving outreach services through partnership with Non-Governmental Organizations (NGOs), Faith Based Organizations (FBOs), Community Based Organizations (CBOs) and Local self-government (Panchayat). Implementation of existing 6 PPP Schemes of NVBDCP by earmarking separate budget. Flagging the issue of Inter-sectoral convergence through Planning Commission to various Ministries/agencies like Agriculture, Urban Development, Education, Information and broadcasting, Tribal and Social welfare, Railway, Surface transport, civil aviation, Port Health Authorities and Textiles etc to ensure support and incorporation of Health Impact Assessment component in the projects under respective ministries. State level Annual Inter-sectoral meeting and districts level quarterly meeting for sensitization.

5.5 Monitoring &Evaluation Monitoring and Evaluation for Prevention and control of VBDs A robust programme management and monitoring system will be implemented to monitor progress towards targets and objectives and provide continuous feedback to strengthen and improve delivery mechanisms at all level. To strengthen the monitoring and evaluation function for prevention and control of vector borne diseases, the
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NVBDCP will continue and adopt the following strategic activities under the programme: Existing NAMMIS will be made fully functional by replacing all old computers, providing internet facility and positioning of data managers at District level. Further, a comprehensive web-based reporting system will be developed inclusive of all VBDs by up-grading NAMMIS to NAMMIS Plus. Monitoring of drug and insecticide resistance by involving NIMR, ICMR, ROHFW and Medical Colleges. Establishing Sentinel Surveillance Sites (SSS) at the districts and prominent hospitals to monitor the trends of disease morbidity and mortality. Periodic review and programme /project evaluation at various levels with appropriate periodic intervals and taking necessary corrective actions based on the review. Supervisory field visits by officers from NVBDCP, ROH&FW, State level officers and consultants hired under the programme /projects to supervise the implementation of programme /project activities at the field level. Improving the reporting system with the use of computer/laptop /palmtop and communication systems like data-card, internet, mobile, telephone etc. Making available monitoring consultants at national, State and district levels, VBD Technical supervisors at block level and data entry staff at various levesl for ensuring timely recording and reporting system and improving the monitoring and supervision at various levels. Training of the staff for correct use of recording and reporting formats. Use of Lot Quality Assurance Sampling (LQAS) methodology at sub-district level for monitoring the implementation of programme and project activities. Periodic evaluation of the programme and project activities as defined, by hiring external agencies for doing external evaluation. Internal evaluation will be done by periodic review meetings held at State and national level. Hiring of independent agency for monitoring the logistic and supply chain management. Hiring of independent agency at national level for monitoring and supervision activities. 5.6 Logistics and supply Large numbers of commodities i.e anti malarial drugs & other drugs for vector borne diseases, insecticides, larvicides, rapid diagnostic kits for Malaria and Kala Azar, long lasting Insecticide treated nets (LLINs) are being procured through agencies engaged EPW of MOHFW. However, there is no regular procurement specialist in the Directorate. At present procurement consultants hired under EAC are assisting. In view of intense and timely procurement and its supply up to the grassroot level user facilities for managing seasonal diseases is a challenge. Some of the diagnostics and drugs are having short expiry and their monitoring becomes extremely important through a mechanism of supply chain monitoring. At present a supply chain monitoring agency has been hired under WB supported project. This component has to be sustained through domestic budget. The quality control of all commodities during pre and post supply are to be ensured to ascertain good quality of commodities. During 12th FYP, the existing norms of commodity support will continue. The centralized and decentralized items are mentioned below:
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Centralized procurement under NVBDCP: ACT Combi Pack (Tab. Artesunate + Tab. Sulphadoxine Pyremethamine) (for different age group), Injections Arteether 150 mg, Rapid Diagnostic Test Kits for Malaria and KalaAzar, Synthetic Pyrethroid (wdp) for project areas, Long Lasting Insecticidal Bednets (LLIN), DDT for Malaria and Capsule Miltefosine. Decentralized Procurement: GoI is providing cash assistance in the form of Grant-in-aid for procurement of Tabs. Chloroquine, Primaquine, Qunine, DEC, Albendazole, Inj.Quinine, NS-1 Antigen kit for Dengue, larvicide (Temephos). Decentralized items: The items like malathion 25%, Synthetic Pyrethroid (wdp), larvicide other than temephos, lab reagents, etc. are decentralized items to be procured by the State funds.

Due to lack of procurement capacity, many states could not take up the procurement process for the items under decentralized procurement and cash assistance has not been utilized. During XII plan the states will be urged to enhance their procurement capacity. Under the 12th Five Year Plan, the NVBDCP proposes to continue the existing procurement policies. The inputs currently supported from the externally aided projects (WB and GF), will be supported from the domestic budget after the end of the projects for sustaining the gains and achievements beyond the project periods.

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Table24,ProposedBudgetforCrossCuttingIssuesRsinCrore Sl No Components 2012-13 2013-14 2014-15 2015-16 2016-17 1 2 3 4 5 A 6 a b c d B 7 a b c C

Human Resource (including M&E) Human Resource (Malaria) Human Resource (UMS) Human Resource (Entomological Zone) ASHAs LTs Sub Total Infrastructure and Equipment Regional Directors State / District UMS Entomological Zone Sub Total Training Malaria UMS Entomological Zone Sub Total Operational Research IEC Consultancy PPP/NGO

Total

116.01 16.56 6.39 219.33 109.76 468.05

131.47 17.98 6.39 219.33 164.64 539.81 17.18 4.85 22.03 87.39 0.46 0.40 88.25 20.00 20.00 20.00 20.00 730.08

182.07 19.53 6.39 219.33 219.51 646.84 17.78 4.85 22.63 87.39 0.46 0.40 88.25 20.00 20.00 20.00 20.00 837.72

200.08 21.25 6.39 219.33 241.46 688.52 10.88 4.85 15.73 87.39 0.46 0.40 88.25 20.00 20.00 20.00 20.00 872.49

219.89 23.13 6.39

849.53 98.45 31.95

219.33 1,096.67 265.61 1,000.98 734.36 3,077.58 10.88 4.85 15.73 87.39 0.46 0.40 88.25 20.00 20.00 20.00 436.96 2.25 2.00 441.21 100.00 100.00 100.00

1.14 89.10 17.26 13.01 120.50 87.39 0.41 0.40 88.20 20.00 20.00 20.00 20.00 756.75

1.14 89.10 73.98 32.39 196.60

Grand Total(A+B+C)

20.00 100.00 918.33 4,115.38

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6. Restructuring Directorate of NVBDCP

The Directorate is the nodal agency for making policy, programme evaluation and technical advice on the vector borne diseases. Accordingly, it requires adequate manpower for effective functioning. The structure of Directorate of NVBDCP was conceived with the focus on malaria only. However, over the years, five more VBDs have been added without adequate support in terms of human resource. Out of these six diseases, four diseases are outbreak prone and warrant intensive regular monitoring and immediate technical support to the states for containment of outbreaks. Remaining two diseases are targeted for elimination which requires intense monitoring and evaluation. Over the years, the budget for the NVBDCP has been enhanced and large number of commodities and services are to be provided. Due to the increased programme activities and large volume of financial and procurement matters, the legal issues are also to be dealt. The volume of work towards monitoring and evaluation at Directorate NVBDCP has increased to a great extent which requires officials to visit the states, to examine, analyze the data and provide feedback to the states. In view of these circumstances, a sustainable system strengthening on technical and other related matters (finance, procurement, legal etc.) has to be built up within the Directorate of NVBDCP which necessitates the restructuring of NVBDCP with additional human resource. The existing strength of NVBDCP includes 6 public health specialists including Director, 2 medical professionals of GDO cadre including Additional Director, 11 nonmedical scientists including 10 entomologists 1 toxicologist, one administrative and accounts officer. Besides, there are 3 posts of statistical officers for assessment, on deputation from statistical services. The restructuring of Directorate would require additional Human Resource as detailed below. The existing posts of Director and Additional Director would continue. A total of 13 Public Health Specialists excluding the post of Director will be required of which 5 post are already sanctioned resulting into a gap of 8 posts which need to be bridged. A total of 2 Medical officers (GDO Cadre) excluding Additional Director would be required, of which one post is already sanctioned. One more post is required. A total of 19 entomologists would be required, of which 11 post are already sanctioned. Eight more post are required. At present there is only one post of Accounts officer (Group B) is sanctioned, it is proposed that a Joint Director level post for finance and budget along with 2 accounts officer (one already sanctioned) need to be deployed. Two more posts are required. At present there is no logistic specialist officer and it is proposed that a Joint Director level post for logistic specialist along with 1 officer need to be deployed. At present there is no IEC / BCC cell. It is proposed that an IEC / BCC cell is created with one Joint Director level communication specialist supported with 2 media officers. At present only one Administrative officer (Group B) is sanctioned. It is proposed that a Joint Director level Administrative officer supported with Administrative officer is deployed. One more post is required. All divisions need to be supported with appropriate number of consultants with specialization in their field. At present 27 consultant posts are sanctioned and 9 more consultants are required.

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Accordingly the details has been worked out and indicated in table 23: Table 23, Statement showing Human Resource at the Directorate of National Vector Borne DiseaseControlProgramme DiseaseControlPorgramme Sl No Component Consultants StatisticalDesignated Public MO /Technical Entomologist Officer Officer Health (GDO) Officer 1 1 1 1 1 1 2 2 2 2 11 2 1 2 2 1 19 2 8 1 8 11 0 3 3 0 3 1 2 2 3 8 2 6 1 1 0 2 4 5 3 3 3 3 1 4 4 2 4 36 27 9

1 Director 2 AdditionalDirector 3 Malaria a Research&TrainingManagement b GFATMProject c WorldBankProject d UrbanMalaria e CentralCordinatingOrganization f IntegratedVectorControl(IVM) g EntomologicalDivision SubTotal(Malaria) 4 MonitoringandEvaluation 5 Filaria 6 JE 7 Dengue&Chikungunya 8 KalaAzar 9 PlanningandCoordination 10BCC/PPP/IEC 11ProcurementandLogistic 12Administration&HR 13FinanceandBudgetDivision 14TotalRequirement SanctionedPost GAP

2 1 1 1 5 3 1 1 1 1 1 14 6

1 3

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7. Proposed NVBDCP Budget for 12th Plan (Rs. in Crore)

Components Malaria Dengue Chikungunya Japanese Encephalitis Lymphatic Filariasis Kala-azar Cross cutting Total 2012-13 944.60 148.48 79.77 255.15 144.37 756.75 2,329.13 2013-14 682.81 161.27 15.2 231.07 149.07 730.08 1,969.51 2014-15 628.14 161.63 16.98 203.6 144.74 837.72 1,992.82 2015-16 790.34 167.08 18.27 125.33 133.77 872.49 2,107.28 2016-17 930.34 172.15 19.78 125.14 128.71 918.33 2,294.45 Total 3,976.24 810.61 150.00 940.29 700.66 4,115.38 10,693.18

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Revised National Tuberculosis Control Programme (RNTCP)

INDEX
1. Tuberculosis disease burden & Trend in India 2. Brief on RNTCP 3. Achievements of ongoing RNTCP 4. Major challenges 5. RNTCP Proposal for 12th Five Year Plan 6. Summary of the New/Innovative approaches of RNTCP in 12th Plan 7. RNTCP Budget requirements for 12th Plan 8. Annexure I - Goals and achievements of 11th Plan 9. Annexure II Goals and targets of 12th Plan

(ii)

1.

Tuberculosis Disease Burden & Trend in India

1.1 Incident NSP (New Smear Positive) TB Cases (Target 70% of estimated NSP cases to be detected)
Incidence rate (all NSP cases per lakh population) 75 75 75 75 75 75 75 75 75 75 75 Estimated no of NSP cases ** 552791 601659 650527 699395 748264 797132 846000 846000 861000 873000 882750 Total no of NSP cases notified under RNTCP 93,359 183,970 243,529 358,490 465,616 507,089 554,914 592,262 616,027 624,617 630,165 % of estimated NSP cases detected 17% 31% 37% 51% 62% 64% 66% 70% 72% 72% 72%

Year 2000 * 2001* 2002* 2003* 2004* 2005* 2006 * 2007 2008 2009 2010

* DOTS expansion was done in phased manner with complete coverage by March 2006. Thus the total number of NSP cases notified under RNTCP till 2006 are lesser. ** Estimated by WHO based on ARTI (Annual Risk of TB Infection) survey in India, conducted by NTI / CTD in different zones of country.

1.2
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Trends of NSP case detection rate and success rate in the country
85% 87% 86% 86% 72% 69% 55% 59% 56% 66% 66% 70% 72% 86% 86% 87% 87% 87% 72% 72%

84%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Annualised New S+ve CDR Success rate

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1.3
Year 2000 * 2001* 2002* 2003* 2004* 2005* 2006 * 2007 2008 2009 2010

Incident New TB (NSP + New Smear Neg + Extra Pulmonary) cases

Incidence rate (all NEW TB cases per lakh population) ** 168 168 168 168 168 168 168 168 168 168 168 Estimated no of NEW TB cases 1238251 1347716 1457181 1566645 1676110 1785575 1895040 1895040 1928640 1955520 1977360 Total no of NEW TB cases notified under RNTCP 195,077 382,488 511,615 759,329 991,454 1,070,551 1,140,017 1,197,670 1,226,472 1,241,756 1,227,667

* DOTS expansion was done in phased manner with complete coverage by March 2006. Thus the total number of cases notified under RNTCP till 2006 are lesser. ** Estimated by WHO based on ARTI and assumption of equal proportion of smear positive and smear negative cases amongst new cases while extrapulmonary cases occurring at the rate of 20% of new smear positive cases.

1.4

Prevalent All TB cases (NSP+NSN+NEP + All re-treatment cases)

Prevalence rate (all TB) cases per lakh population) ** 434 418 401 384 367 350 333 316 300 283 266 Estimated no of all TB cases in population 3,201,394 3,349,234 3,475,115 3,579,039 3,661,004 3,721,011 3,759,060 3,568,992 3,438,834 3,290,628 3,129,055 Total no of TB cases notified under RNTCP 240,835 468,360 619,259 906,638 1,188,545 1,294,550 1,400,340 1,474,605 1,517,363 1,533,309 1,522,147

Year 2000 * 2001* 2002* 2003* 2004* 2005* 2006 * 2007 2008 2009 2010

* DOTS expansion was done in phased manner with complete coverage by March 2006. Thus the total number of cases notified under RNTCP till 2006 are lesser. ** Estimated by WHO based on series of prevalence Surveys, ARTI, notification data & expert opinion. Trend used based on 1990 estimation and last three years estimation for projecting the annual estimation of prevalence rate
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2. Brief on RNTCP in 11th Five Year Plan (2007-12)

National TB Programme (NTP) was being run from 1962 till 1992 for the control of Tuberculosis in the country which was jointly reviewed by Govt. of India and WHO in 1992 after which WHO recommended DOTS strategy which was piloted from 1993 till 1997 for its feasibility and effectiveness. In 1998, DOTS strategy was accepted and Revised National Tuberculosis control Programme (RNTCP) was launched in 1998 and expanded through out the country achieving complete geographical coverage by year 2006. The Revised National TB Control Programme (RNTCP) widely known as DOTS, which is WHO recommended strategy, is being implemented as a 100% Centrally Sponsored Scheme in the entire country. Under the programme, diagnosis and treatment facilities including a supply of anti TB drugs are provided free of cost to all TB patients. For quality diagnosis, designated microscopy centres have been established for every one lakh population in the general areas and for every 50,000 population in the tribal, hilly and difficult areas. Sputum microscopy, instead of X-ray avoids over diagnosis and identifies infectious cases. More than 13,000 microscopy centres have been established in the country. Drugs are provided to the TB patients in patient wise boxes to ensure that all drugs for full course of treatment are earmarked on the day one, a patient is registered for treatment under the programme. More than 4,00,000 Treatment centres (DOT centres) have been established near to residence of patients to the extent possible. All government hospitals, Community Health Centres (CHC), Primary Health Centres (PHCs), Sub-centres are DOT Centres, in addition, NGOs, Private Practitioners (PPs) involved under the RNTCP, Community Volunteers, Anganwadi workers, Women Self Groups etc. also function as Community DOT Providers/DOT Centres. Drugs are provided under direct observation and the patients are monitored so that they complete their treatment. The programme has launched DOTS Plus for the management of multi-drug resistance tuberculosis (MDR-TB) since 2007. Till date these services are available in 18 States. The programme is presently in the process of scaling up DOTS Plus services and aims to make these services available in all States by end 2010 while achieving complete geographical coverage by 2012. TB-HIV collaborative activities are being implemented in collaboration with NACP to provide TB treatment and care and support for TB-HIV patients. To further extend reach of programme and involve non-programme providers and community, the programme has already revised its guidelines for involvement of Non Government Organizations and private practitioners with enhanced outlays. The programme has also enhanced provisions for contractual staff to prevent staff turnover. To further enhance the capacity of the programme staff in effective implementation of the programme and increase their capacity the programme continuously reviews the training needs of programme personnel and undertakes regular capacity building programmes. The programme is also actively advocating with Drug Controller General of India to consider enforcing appropriate legislation to stop misuse of anti-TB drugs in private sector. A consensus statement to promote rational use of anti-TB drugs is being widely disseminated in association of professional associations like Indian Medical Association, Indian Pediatrics Association, Association of Family Physicians and Indian Public Health Association. Programme management is notable for decentralized financial control, management, and supervision to State and District health systems, supported by a small number of supervisory staffs. RNTCP diagnostic and treatment services are wholly integrated within the general health system and medical colleges. Now RNTCP is an integral part of the
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National Rural Health Mission (NRHM). The Central level serves only for organizing and distributing financing for TB control activities within the NRHM, centralized drug procurement and distribution to States, development of comprehensive normative guidance, capacity building, and monitoring and evaluation of States and Districts programme management units. Experience has shown that DOTS strategy can be well implemented for TB control in an integrated manner by the general health system under the umbrella of NRHM if additional support is given by RNTCP

3. Achievements of Ongoing RNTCP

(1) Since inception, RNTCP has evaluated over 44 million persons for TB and initiated treatment for over 12.8 million TB patients. (2) Prevention of mortality has been biggest achievement of RNTCP saving more than 2.3 million lives. (3) Having achieved national coverage, with special emphasis to areas classified as Tribal and/or Backward, RNTCP is well on track to achieve the Millennium Development Goal (MDG) of halting and beginning to reverse the spread of the disease. (4) The RNTCP and National AIDS Control Programme have significantly expanded joint TB/HIV services, which are currently available in 18 states with the aim to cover all states by 2012. (5) A national lab scale-up plan with secured funding to establish a network of culture and DST laboratories is in place. By 2010, MDR-TB services were available in 132 districts in 12 states and the programme had diagnosed and provided treatment to almost 4217 MDR-TB patients till quarter ending March 2011, with a vision for nationwide coverage by 2012. (6) Medical college involvement has been largely successful. Efforts to engage the private sector have revolved around outreach, directly via public-private mix (PPM) schemes and through intermediary groups such as the Indian Medical Association (professional organization) and Catholic Bishop Conference of India (CBCI, a faith based organization). (7) A major initiative to expand the role of civil society and affected communities in TB care and control is currently underway for 2010 2014, supported by a grant from the Global Fund directly to civil society partners. (8) Repeat ARTI surveys suggests the Annual Risk of TB Infection in the country has reduced from the national average of 1.5% to 1.1% since 2002-03 to 2007-10 showing a decline of 3.5% annually. With successful implementation of RNTCP the decline in ARTI is indicative of reduction in incidence of TB in India. If we apply this ARTI for incidence estimation, it suggests that the incidence of New Smear Positive TB cases has reduced from 75 per lakh population to 55 per lakh population. While the incidence of all types of TB cases is then estimated to be around 121 per lakh population. (9) While the indirect estimate of prevalence of the disease by WHO suggest that around 30 lakh TB cases are prevalent in India currently, the trend in estimated prevalence of TB suggest >50% reduction from its 1990 level of 583 per lakh population to around 250 per lakh population.
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(10)

Key achievements during 11th Five Year Plan Indicator 11th FYP Planned * Achieved * 23.72 27.5 5.04 2.34 5 85% 6.4 2.46 4.2 87%

No of TB suspects examined (millions) Total number of patients to be put on treatment (millions) New Smear Positive patients to be put on treatment (millions) No of MDR TB patients to be put on treatment (000) Success Rate in New Smear Positive patients in RNTCP (%) Estimated Annual Prevalence per lakh population Annual Risk of TB Infection (%) * First 4 out of 5 Years (11) Economic impact of RNTCP

Reduced from 299 to 250 Reduced from 1.5% to 1.1%

A study on the economic impact of scaling up of RNTCP in India in 2009 shows that on an average each TB case incurs an economic burden of around US$ 12,235 and a health burden of around 4.1 DALYs. Similarly, a death from TB in India incurs an average burden of around US$ 67,305 and around 21.3 DALYs. A total of 6.3 million patients have been treated under the RNTCP from 1997-2006. This has led to a total health benefit of 29.2 million DALYs gained including a total of 1.3 million deaths averted. In 2006, the health burden of TB in India would have risen to around 14.4 million DALYs or have been 1.8 times higher in the absence of the programme. The RNTCP has also led to a gain of US$ 88.1 billion in economic wellbeing over the scale-up period. In 2006, the gain in economic wellbeing is estimated at US$ 19.7 billion per annum equivalent on a population basis to US$ 17.1 per capita. In terms of TB patients, each case treated under DOTS in India results in an average gain to patients of 4.6 DALYs and US$ 13,935 in economic wellbeing.

4. Achievements of Ongoing RNTCP

Reaching the un-reached is one of the important challenge as it necessitates innovative strategies for ensuring universal access to TB diagnostic and treatment facilities. Advocacy and communication strategies need to be inclusive of such efforts towards social mobilization for achieving universal access. (1) DMCs are operational in less than third of the PHCs and developing sputum collection & transport mechanism has been neglected, thus forcing referral of TB suspects from such PHCs to nearest DMCs, which is a barrier in universal access. (2) Diagnostic facilities for extra-pulmonary TB cases has not been well established and are under utilized due to lack of prioritization of EP-TB as well as inadequate coordination between primary, secondary & tertiary hospitals. (3) Further, reducing treatment default of patients put on treatment under Programme is another challenge in order to prevent drug Resistant TB.
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(4) Misuse of anti-TB drugs and interrupted treatment, largely in the private sector lead to development of drug resistance (MDR/XDR) and then can be spread in the community unless it is correctly diagnosed and treated. This misuse of anti-TB drugs continues to be largely in the private sector but also is observed in medical colleges which are not fully following DOTS strategy. Over the counter (OTC) sale of first line and second line anti-TB drugs exists in the country despite these drugs being schedule H drugs. (5) Linking HIV-infected TB patients to HIV care and support and implementing measures to prevent TB in HIV care settings need further strengthening. (6) PPM efforts though beneficial, remain a very small proportion, relative to the large numbers of private sector providers; hence the impact of these efforts has so far been relatively limited. (7) Though Management information system of RNTCP is prompt and well organized, still it caters the data of TB patients in terms of numbers of patients and case based information is not transcribed or reported above the sub-district level. Thus no epidemiological information is lost and conclusions cannot be drawn at district, state or national level as case information is lost to disaggregated data. (8) One of the most serious challenges to TB control is urban TB control. Urban areas still experience intense levels of TB transmission, where urban primary health care systems tend to be weaker and private health care predominates. (9) Despite the progress in implementation of DOTS strategy, TB incidence and mortality are still high, and an estimated 280,000 people died of TB in 2009.

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5. RNTCP Proposal for 12th Five Year Plan (2012-17)

5.1 Vision
The vision of the Government of India is a TB-free India - through achieving Universal Access by provision of quality diagnosis and treatment for all TB patients in the community.

5.2 Goal
The goal of TB Control Programme is to decrease the morbidity and mortality by early diagnosis and early treatment to all TB cases thereby cutting the chain of transmission.

5.3 Objectives
(1) Early detection and treatment of at least 90% of estimated all type of TB cases in the community, including TB associated with HIV. (2) Successful treatment of at least 90% of new TB patients, and at least 85% of previously-treated TB patients. (3) Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%. (4) Initial screening of all re-treatment smear-positive till 2015 and all Smear positive TB patients by year 2017 for drug-resistant TB and provision of treatment services for MDR-TB patients. (5) Offer of HIV Counselling and testing for all TB patients and linking HIVinfected TB patients to HIV care and support. (6) Extend RNTCP services to patients diagnosed and treated in the private sector.

5.4 Targets
1. Detection & treatment of about 87 lakh Tuberculosis patients during 12th FYP. 2. Detection & treatment of at least 2 lakh MDR-TB patients during 12th FYP. 3. Reduction in delay in diagnosis and treatment of all types of TB cases. 4. Increase in access to services to marginalized and hard to reach populations and high risk and vulnerable groups.

5.5 Key strategies & approaches under RNTCP for 12th Five Year Plan
In addition to the continuation of existing activities (as per 11th five year plan) following strategies are proposed for achieving the objectives of RNTCP including universal access: (1) Evidence-based shift of operational units from Tuberculosis Units to Health Blocks: Pilot testing of re-organization of programme operational units from present Tuberculosis Units to Health Blocks. This will further strengthen and align with the General Health System and National Rural Health Mission (NRHM). (2) Development of a dedicated Sputum collection and transport system across the country, all Health facilities (PHCs without DMCs) in order to increase access.
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(3) Intensified case finding activities in high risk groups like smokers, diabetics, Malnourished, HIV, urban slums & difficult to reach areas etc. (4) Developing evidence-based diagnostic algorithms for Extra-Pulmonary TB cases in consultation with Professional Associations like IMA, IAP, FOGSI, IOP etc (5) Establishing referral linkages between Primary Health Centres and with secondary and tertiary hospitals for diagnosis of Extra-pulmonary TB cases and paediatric TB cases. (6) Creating support mechanisms for establishing linkages with district level hospitals for management of seriously ill and drug resistant TB cases by strengthening the district hospitals. (7) Promoting rational use of anti-TB drugs to reduce drug resistance levels Prevention of emergence of Drug resistant TB by ensuring quality diagnosis, DOTS & default prevention as well as promoting rational use of first & second line anti-TB drugs. Coordination with overall implementation of National Policy on antimicrobial which includes mandatory double (copy) prescription by any medical practitioner while prescribing the antibiotic. Professional bodies like Indian Medical association (IMA) & Civil Society will play a major role in promoting this rational drug use. Over The Counter (OTC) sale without proper prescription will thus be curtailed to a large extent which will reduce the occurrences of drug resistant TB. Conducting prescription audits in private and public sectors including medical colleges Regular Drug Resistance surveillance is inbuilt and will be further strengthened with complete coverage of the country. Two IRLs (Ahmedabad & Hyderabad) has been identified for developing capacity to conduct second-line Drug susceptibility testing which will aid the surveillance for XDR-TB. (8) Case-based electronic notification systems for data quality improvement: Development of TB register in EPI-CENTRE and auto-generation quarterly reporting by 2012. Case-based web-based electronic notification by 2015 of all patients for individual case monitoring in real time. Extending this electronic notification system to all patients diagnosed and treated in the private sector. (9) Re-evaluation of the existing diagnostic algorithm for Pulmonary TB cases to reduce provider delay and addressing the reasons for drop-out of suspects at health facilities for subsequent steps of diagnosis & treatment in cases of TB as well as non-TB amongst such TB suspects (10) Development & capacity Building of national TB Institutes like NTI, New Delhi TB Center, LRS Institute of TB & Chest diseases under RNTCP (11) Enhancing access to services for tribal, vulnerable and at risk populations by fostering partnerships and promoting innovations like mobile diagnostic & treatment facilities, using technology etc. (12) Focused Advocacy & communication efforts to reduce stigma and generate demand for quality services through social mobilization aiming to develop support mechanisms for empowerment of TB affected community. Sensitization and participation of Panchayati Raj Institutions (PRIs), private practitioners and Self Help Groups (SHGs) will be the activities that will reduce the gap between services and the need in the urban slums. (13) Introduction and scale-up of new diagnostics.

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(14)

(15)

(16)

(17)

(18)

Evaluation and demonstration of cartridge-based automated nucleic-acid amplification systems (CB-NAAT) and manual nucleic acid amplification systems (NAAT) in rural and urban settings. Phased deployment of automated CB-NAAT for achieving universal DST for all re-treatment TB cases and as initial TB diagnostic in PLHIV. National scale-up for diagnosis and treatment of MDR and XDR TB: 43 Culture and Drug susceptibility testing (C&DST) laboratories to be established by 2013. Another 30 C&DST laboratories to be established in government and other sectors through public Private partnerships by 2015. Complete geographical coverage of MDR-TB treatment services up to district level by 2013. Establishment of 120 DOTS Plus sites (1/10 million population indoor facility for MDR-TB) for initial management of MDR-TB treatment by 2013 while also involving secondary and tertiary level hospitals in patient management. Decentralization of second-line drug susceptibility testing to identified State reference laboratories, for routine application in diagnosed MDR TB cases. Procurement of anti-TB drugs for the management of patients with MDR TB and also additional second-line anti-TB drug resistance (e.g. XDR TB). Developing evidence-based treatment guidelines for TB cases resistant to drugs other than Rifampicin. Early diagnosis and improved management of HIV-infected TB patients: Priority deployment of newer rapid diagnostics in HIV care settings. Nationwide provision of TB preventive therapy among HIV-infected individuals after pilot. Scale-up of Public-private partnerships: Review of RNTCP guidelines to accommodate practices in the private health sector and Medical colleges if they are as per internationally approved standards of TB care (ISTC). Notification of cases diagnosed and treated in the private sector through interface agency. Pilot testing approaches to improve flexibility of patient treatment options involving social marketing of ATT drugs under programme supervision. Involvement of Private corporate sectors for Tuberculosis control in areas with persistently poor performance for lack of proper health infrastructure. Contracting-out of services like the necessary laboratory accreditation, contract management and quality-control systems. Review of NGO PP schemes according to the unit cost of activity and the quantum delivered. Expansion of performance-based incentive strategies: To improve the quality and effectiveness of services through performance-based incentive linked to case finding and holding for various community / rural health workers. Promoting need based Research: Support to basic research - New diagnostics, drugs, and vaccines for TB are in the development pipeline, and hold the possibility of greatly facilitating TB control efforts by the STOP TB Secretariat. However the programme will support to evaluate these improved tools or strategies, collect evidence for scale-up, and if indicated deploy them
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quickly so that TB control advances may quickly save lives and benefit the country. Operational research - Programme will continue to focus on the operational research for improvement in quality and proficiency of services. The priority areas for research will be listed and regularly updated on annual basis. Capacity building for Operational research will be facilitated in addition to funding & guidance for researchers. Diagnostic & treatment delays both on part of patients and providers will be an area of research in addition to the TB risk perceptions, health seeking behaviour, KAP of patients and providers and reasons of opting of RNTCP. (19) Urban TB Control: Despite the successes of the programme, TB burden and transmission remains highest in the urban areas, which have the largest and most dense concentrations of vulnerable populations including the slum populations, migrant laborers etc. Improved TB control will be a key outcome in national efforts to strengthen urban health care infrastructure. Stopping TB transmission in cities will require early diagnosis, which necessitates largescale engagement of private providers and deployment of improved diagnostics across all points of care. (20) Impact evaluation - Improvement in surveillance, both by strengthening routine surveillance as well as planning large inventory studies. National, regional and state disease prevalence surveys. Impact evaluation studies for measuring TB incidence, prevalence and mortality (21) Re-alignment & development of existing human resources: Analysis of human resource requirements for activities to achieve universal access, and deployment of required human resources in an phased manner Strengthening existing supervision and monitoring systems, improving and sustaining the quality of service delivery. Developing capacity of States and district in Managing Information For Action (MIFA)

6. Summary of the New / Innovative approaches of RNTCP in 12th Five Year Plan
Key Sr Programme No Area Case detection 11th Five Year Plan Objective 70% of estimated New Smear Positive TB cases 12th Five Year Plan Objective Universal (90%) access to care for all types of estimated TB cases 90% amongst New & 85% amongst retreatment TB cases registered under RNTCP Key strategies Community empowerment for early self reporting for diagnosis and treatment Mobilizing community based organizations Intensifying appropriate involvement of formal and informal private health care providers New / Innovative approaches Evidence-based realignment of TB Unit (presently at 1 per 5 lakh pop) to Block level Use of telecommunication in demand generation, service delivery & patients tracking Designing & implementing innovative ACSM tools, NGO-PPM approaches and evaluating their impact Intensified case finding activities in high risk groups like smokers, diabetics,

Treatment success

85% of all New Smear positive TB cases

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Further Prevention of reducing the drug resistant default in TB TB patients on treatment

Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%

Ensuring quality diagnosis, DOTS & default prevention Strengthening the cross border referral & feedback system between districts / states with a focus on migratory population in urban areas

TB-HIV

Management of Drug resistant TB

Offer of HIV Counselling and testing Strengthen for all TB collaboration patients and and crosslinking HIVreferral in 14 infected TB states patients to HIV care and support; Initial screening of all retreatment smearIntroduce positive till diagnostic 2015 and all and Smear treatment positive TB services for patients by MDR-TB in year 2017 phased for drugmanner resistant TB and provision of treatment services for

Early diagnosis and improved management of HIV-infected TB patients Strengthening of TB-HIV intensified package implementation 43 Culture and Drug susceptibility testing (C&DST) laboratories to be established by 2013 Another 30 C&DST laboratories to be established in government and other sectors through public Private partnerships by
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malnourished, HIV, urban slums & difficult to reach areas etc Use of newer rapid diagnostic tools Conducting prescription audits in private and public sectors including medical colleges Exploring legislative options for regulating & promoting rational use of Anti-TB drugs and diagnostics Case-based electronic notification systems for data quality improvement Notification of cases diagnosed and treated in the private sector Developing diagnostic algorithms for Extrapulmonary TB in consultation with professional bodies Establishing referral linkages between primary, secondary and tertiary hospitals Priority deployment of newer rapid diagnostics in HIV care settings Nationwide provision of TB preventive therapy among HIV-infected individuals after pilot Exploring the possibility of alternative regimens in HIV positive TB patients Decentralization of secondline drug susceptibility testing to identified State reference laboratories, for routine application in diagnosed MDR TB cases Procurement of anti-TB drugs for the management of patients with MDR TB and also additional second-line anti-TB drug resistance (e.g. XDR TB) Developing evidence-based treatment guidelines for TB cases resistant to drugs other than Rifampicin

MDR-TB patients

2015 Establishment of 120 DOTS Plus sites (1 per 10 million population indoor facility for MDR-TB)

Establishing drug resistance surveillance in the country Involving secondary and tertiary level hospitals in management of Drug resistant TB Developing guidelines for addressing TB care in special settings like, prisons, mines, alcoholics, beggars, homeless, migrant labourers etc Developing gender sensitive approaches to facilitate access and utilization of TB control services by both men and women Inter-sectoral coordination for increasing access and quality of TB care Initiating TB surveillance in health care workers Promoting implementation of Airborne Infection control guidelines Increased human resources commensurate to realignment of TUs to block level Performance appraisal system for contractual staff Development & capacity Building of national TB Institutes like NTI, N.D.T.B. center, LRS under RNTCP Operational research o Improvement in quality and proficiency of services. o Diagnostic & treatment delays both on part of patients and providers o TB risk perceptions, health seeking behaviour, KAP of patients and providers and reasons of opting of RNTCP. Improvement in surveillance, both by strengthening routine surveillance as well as planning large inventory studies.

Addressing at risk and vulnerable population

Developing and implementation of Tribal Action Plan Linking TB patients with existing social welfare schemes Strengthening the contact tracing policy implementation

HRD & capacity building

Capacity building of state & district programme managers

Continuation of existing contractual manpower Need based continued training

Research & independent Evaluation

National level surveys to study the impact of the programme

Third party evaluation

 Epidemiological studies for incidence, prevalence and mortality measurement. Coordinating with NRHM division for development of long-term policy on sustainable human resources in states for RNTCP Coordinating with NRHM division for clearly defining the roles and responsibilities of directorate of health services and mission directorates in the state; while empowering the STOs & DTOs in financial and programmatic management and reporting within the framework of NRHM Individual patient monitoring facilitated by electronic updating of patient treatment card Developing monitoring indicators in view of changes and updates to cover all areas Bar coding usage for tracking of patient wise boxes Regular measurements of the quality of the programme through indicators like delays in diagnosis and treatment

Health system strengthening

10

Monitoring and Evaluation of the Programme

Identifying poor performing units with intensified monitoring

Continue to do the monitoring of performance of all states at national level Regular central & state level internal evaluations of programmes in the districts

7. Budget Requirement for 12th Five Year Plan

As per the approval of CCEA (Cabinet Committee on Economic Affairs) the current phase of As per the approval of CCEA (Cabinet Committee on Economic Affairs) the current phase of RNTCP is up to September 2011 with closing by March 2012. The total budgeted amount for the period 2012-17 is 582,528 lakh INR, of which there is committed funding from the Global Fund and UNITAID to the tune of 117,087 lakh INR. The Global Fund support is available till March 2015 under RCC mechanism (Rolling Continuous Channel) and till September 2015 under Round 9 of Global Fund. Of the estimated funding gap of 465,440 lakh INR, extension of RNTCP-II project by World Bank for the period April 2012 to March 2014 is envisaged to provide 82,800 lakh INR. The remaining amount of 382,640 lakh INR will be contributed by Government of India.

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Funding Requirements of the National Strategic Plan of RNTCP 2012-17 (Lakh INR) Budget Head 2012-13 2013-14 2014-15 2015-16 2016-17 Total Key assumptions Number of TB patients 1,630,988 1,651,855 1,796,348 1,818,194 1,839,861 8,737,245 Number of MDR-TB 30,000 40,000 50,000 60,000 205,500 1.2 patients put on treatment 25,500 2 Budget Heads (All figures in lakhs INR) 2.1 Civil Works, Office 1,946 1,457 1,753 1,694 1,739 8,589 2.2 Vehicle hiring and 7,441 4,950 6,299 6,385 6,552 31,628 2.3 Human Resource 16,899 17,891 24,871 26,143 27,363 113,168 2.4 Training 1,612 1,632 3,303 3,342 3,381 13,270 2.5 Laboratory Services 12,367 10,992 10,496 14,288 17,236 65,379 2.6 Drugs (First Line) 12,179 12,388 13,459 13,688 13,924 65,638 2.7 Drugs (Second Line) 23,460 27,600 33,120 41,400 49,680 175,260 2.8 Printing 1,359 1,377 1,672 1,693 1,713 7,814 2.9 Outreach(PPM/ACSM) 10,639 10,798 14,177 15,308 15,571 66,493 2.1 Office operations 3,292 3,334 4,726 4,784 4,841 20,977 2.11 Consultancy and 1,654 1,770 2,607 2,016 2,038 10,085 2.12 Technical Assistance 765 803 843 886 930 4,228 Total (2.1 to 2.12) 93,612 94,993 117,327 131,627 144,968 582,528 3 Confirmed sources of funding (Lakhs INR) Global Fund Rolling 16,761 18,569 20,800 56,130 3.1 Continuation Channel 3.2 Global Fund Round 9** 18,396 18,494 17,771 54,661 3.3 UNITAID 3,657 2,640 6,297 Total Committed 38,814 39,702 38,571 117,087 4 Estimated Funding 54,797 55,291 78,756 131,627 144,968 465,440 5 Funding Source to fill 5.1 Proposed World Bank 41,400 41,400 82,800 5.2 Contribution of 13,397 13,891 131,627 144,968 382,640 78,756 Total (5.1+5.2) 54,797 55,291 78,756 131,627 144,968 465,440 *Excluding funds to CBCI and IMA projects **Excluding additional financing provided directly to civil society partners for advocacy, communication, and social mobilization. Estimated grant-in-kind value of laboratory commodities Opinions and inputs from State Programme Officers and RNTCP Consultants from states, in house thematic groups at CTD, and eleven thematic sub-groups for National Strategic Planning were deliberated in RNTCP sub-group of working group of communicable diseases (CD) under chairmanship of DGHS. These groups at various levels critically examined and analyzed the situation of TB Control, its challenges in order to meet the challenges it strongly recommended new initiatives as detailed above. These new initiatives warrant the substantial enhancement of fund requirement as detailed above. This is the dire minimum funds required for RNTCP which should be considered in totality. Sr 1 1.1

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Annexure I

8. Goals and achievements of 11th Five Year Plan (2007-12)

Indicator Source 2007 2008 2009 2010 2011 Achieved * 7.5

Planned Achieved Planned Achieved Planned Achieved Planned Achieved Planned Number of patients to be examined (millions) Total number of patients to be put on treatment (millions) New Smear Positive patients to be put on treatment (millions) Success rate in New smear positive patients in RNTCP (%) National Programme Reporting System National Programme Reporting System National Programme Reporting System National Programme Reporting System

5.93

6.5

5.93

6.8

5.93

7.2

5.93

7.5

5.93

1.26

1.47

1.26

1.51

1.26

1.53

1.26

1.52

1.26

1.26

0.57

0.59

0.58

0.61

0.59

0.62

0.60

0.93

0.61

0.93

85%

87%

85%

87%

85%

87%

85%

87%

85%

87%

* expected achievement - data will be available by March 2012

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Annexure II

9.

Goals and targets of 12th Five Year Pan (2012-17)

Indicator Source National Programme Reporting System National Programme Reporting System National Programme Reporting System National Programme Reporting System National Programme Reporting System 2012-13 2013-14 2014-15 2015-16 2016-17

Number of patients to be examined (millions) Total number of patients to be put on treatment (millions) MDR-TB patients to be put on treatment (000) Success rate in New TB patients in RNTCP (%) Success rate in Re-treatment TB patients in RNTCP (%)

7.8

8.2

8.4

8.7

1.63

1.65

1.79

1.81

1.84

25.5

30

40

50

60

87%

87.5%

88%

89%

90%

77%

79%

81%

83%

85%

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National Leprosy Eradication Programme (NLEP)

INDEX
A. 11th FIVE YEAR PLAN AND ACHIEVEMENTS 1. Background 2. Objective 3. Targets and Indicators 4. Strategy 5. Programme Components 6. Impact of Programme Activities during 11th Plan 7. Constraints 8. Additional Support to in NLEP B. PROPOSED 12th FIVE YEAR PLAN 1. Key Lessons learnt from 11th Plan 2. Objectives 3. Policy Changes in implementation 4. Targets and Indicators 5. Justification 6. Strategy 7. Result based strategy and Activities 8. Additional/New activities during the 12th Plan 9. Budget and source of funds 10. Additional Support to NLEP 11. Expected Outcome 12. Component wise proposed budget for 5 Years of 12th Plan

(iii)

NATIONAL LEPROSY ERADICATION PROGRAMME

I 11th FIVE YEAR PLAN AND ACHIEVEMENTS 1. Background
Govt. of India started National Leprosy Control Programme in 1955 based on Dapsone domiciliary treatment through vertical units implementing survey, education and treatment activities. It was only in 1970s that a definite cure was identified in the form of Multi Drug Therapy. The MDT came into wide use from 1982, following the recommendation by the WHO Study Group, Geneva in October 1981. Govt. of India established a high power committee under chairmanship of Dr. M.S. Swaminathan in 1981 for dealing with the problem of leprosy. Based on its recommendations the National Leprosy Eradication Programme (NLEP) was launched in 1983 with the objective to arrest the disease activity in all the known cases of leprosy. However coverage remained limited due to a range of organizational issues, fear of the disease and the associated stigma. At this stage in view of substantial progress achieved with MDT, in 1991 the World Health Assembly resolved to eliminate leprosy at a global level by the year 2000. In order to strengthen the process of elimination in the country, the first World Bank supported project was introduced in 1993. Subsequently the 2nd National Leprosy Elimination Project with World Bank support was started from 2001-02 which ended in December 2004. Thereafter, Govt. of India decided to continue the programme activities at the same level of intensity during the period January 2005 till March 2007 with Govt. funds alone. The programme has remained a 100% centrally sponsored scheme through the past five year plan. During the last two decades (1983-2005) the National Leprosy Eradication Programme has made tremendous progress. The disease has come down to a level of elimination i.e. less than one case per 10,000 population at the national level by December 2005. This level is very important from public health point of view. However still the disease is prevalent with moderate endemicity in about 20% of the districts. The disease also has a long incubation period and therefore need a longer period of surveillance. Since the programme aims for eradication i.e. zero endemicity of leprosy, as the ultimate goal, sustained control measures need to continue even during the 11th plan period i.e. April 2007 till March 2012.

2. Objective
Further reduce the leprosy burden in the country. Provision of high quality leprosy services for all persons affected by leprosy, through General Health Care System including referral services for complications and chronic care. Enhanced Disability Prevention and Medical Rehabilitation (DPMR) services for deformity in leprosy affected persons. Enhanced advocacy in order to reduce stigma and stop discrimination against leprosy affected persons and their families.
143

Capacity building among Health Service personal in integrated setting both for Rural and Urban areas. Strengthen the monitoring and supervision component of the surveillance system.

3. TargetsandIndicators
3.1.PhysicalTargetsandachievements Table1 Indicators Prevalence Rate (PR) < 1/10,000 in States/ UTs Prevalence Rate (PR) < 1/10,000 in Districts Annual New Case Detection Rate(ANCDR) Cure rate for MB Cure rate for PB No. of Gr. II disabled cases Outcome expected by March 2012 100% 100% < 10/100,000 >95% >97% 25% reduction (Base 2006-07) Achievement till March 2011 91.4% 82.8% 10.48 89.87% 94.55% **

** Due to increased efforts for case detection and treatment, Gr. II disability in new cases have not shown reduction. 3.2.FinancialTargetsandutilization Table2 S.No. 1. Allocation 2. Expenditure (upto 2010-11) 11th Plan 219.29 143.19 2007-08 40.00 25.01 2008-09 45.45 45.72 2009-10 44.50 35.11 2010-11 45.32 37.35 2011-12 44.02

4. Strategy
Provision of high quality leprosy services for all persons affected by leprosy, through General Health Care System including referral services for complications and chronic care. Involvement of ASHA under NRHM for Leprosy work. Enhanced Disability Prevention and Medical Rehabilitation (DPMR) services for deformity in leprosy affected persons. Enhanced advocacy in order to reduce stigma and stop discrimination against leprosy affected persons and their families. Capacity building among Health Service personnel in integrated setting both for Rural and Urban areas. Strengthen the monitoring and supervision component of the surveillance system.
144

5. Programme Components
5.1.Infrastructure The erstwhile state & district leprosy societies were merged with the state & district health societies. The state & district leprosy units worked under the Health societies as component of the NRHM. 5.1.1. In the 27 States viz. Andhra Pradesh, Assam, Arunachal Pradesh, Bihar, Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Jharkhand, Jammu & Kashmir (separate SLS for Jammu division also), Karnataka, Kerala, Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, Punjab, Rajasthan, Sikkim, Tamilnadu, Tripura, Uttar Pradesh, Uttaranchal and West Bengal, for strengthening the State Leprosy Unit, following categories of staff were provided to the State Leprosy Unit on contract basis:Budget and Finance cum Admin. Officer 1 Admin. Assistant 1 Data Entry Operator 1 Driver 1 5.1.2. In 8 smaller State/ UTs viz. Goa, Delhi, Chandigarh UT, A& N Island, Lakshadweep, D&N Haveli, Puducherry and Daman & Diu. following categories of staff were provided to the HQ State Leprosy Unit on contract basis:Admin. Assistant 1 Data Entry Operator 1 Driver 1 The State Leprosy Unit also got the support from the Financial Management Unit as well as the state Data Management Units of NRHM. 5.1.3. The District Leprosy Officer either full or part-time and a fully functional District Nucleus was the basic structure of the DLS. One driver on contract basis was provided to the districts where regular driver is not available. 5.1.4. A Surveillance Medical Officer (SMO) was posted in the 27 major states and in Delhi, Chandigarh and Dadra & Nagar Haveli. 5.1.5. During the 11th Plan period one NMS per district was provided to the state(s)/UTs of Punjab, Haryana, Delhi, Chandigarh UT and Dadra & Nagar Haveli as they did not have any regular staff to even form the district nucleus.
145

5.1.6. The Central Leprosy Division was supported with only the Training Consultant out of the programme budget. In addition one National Consultant was provided with WHO support and another Consultant in DPMR was provided with ILEP support WHO also provided support with information & education officer- I BFO-I and Logistics Consultant-I. 5.1.7. The Central Leprosy Teaching and Research Institute (CLTRI), Chengalpattu and 3 Regional Leprosy Teaching and Research Institute (RLTRI) at Raipur, Aska and Gouripur continued to provide support to the programme during the 11th plan period. 5.2. Integrated Leprosy Services and Special initiatives 5.2.1. Integrated Leprosy Services through all the Primary Health Care facilities continue to be provided in the Rural areas. 5.2.2. All the urban areas were covered under the urban leprosy control programme integrating services from all the partners available in the area, including the private practitioners. 5.2.3. Involvement of the Multi-purpose Health functionaries, ASHA in villages and selected NGOs in urban areas engaged for case follow up during treatment. 5.2.4. Emphasis was laid on providing best quality leprosy services through the GHC system. This means easy availability of services on all working days to all patients, correct diagnosis and adequate counseling to patient and family members, provide MDT to patient whenever approached, regular monitoring of the patient during treatment. Treatment completion by all patients was the desired outcome of the programme.

5.2.5. The system of referral of difficult cases to the District hospital for diagnosis and management, was strengthened with capacity building of persons involved at PHC as well as District Hospital level.

5.2.6. The laboratory facilities at the District Hospitals for smear examination to diagnose difficult cases was further strengthened. 5.2.7. Data specific for Female, Schedule Tribe and Schedule Caste patients were also maintained.

5.3.

Services through ASHA The scheme to involve ASHA under NRHM was extended to all the States/UTs to bring out cases from the villages for diagnosis at PHC and after diagnosis, to follow up the patients for completion of their Treatment. The ASHA were entitled to receive incentive as below146

(i) On confirmation of cases brought by them Rs. 100/(ii) On completion of full course of treatment within specified timePB Leprosy case Rs. 200/MB Leprosy case 400/5.4. Drugs, Material and Supplies 5.4.1. Supply of MDT to the leprosy patients was maintained free of cost through WHO during 11th Plan period. 5.4.2. Material and supplies including supportive drugs were procured at district level for use under the programme. 5.5. Vehicle Hiring and POL / Maintenance Mobility for man and material is important to run the programme smoothly. Each district should have one running vehicle for mobility of district nucleus team and DLO. As many districts did not even have a vehicle, provision of hiring vehicle was made during the 11th plan period. For the 36 state societies, provision was kept for 2 vehicles to each state/UT during the 11th five year plan period. 5.6. Information, Education and Communication For sustaining the anti-leprosy campaign, it was important to integrate leprosy IEC with the IEC of other Health Programmes. This will address the problem of not having technical expertise on communication at various levels of leprosy offices. IEC planning and implementation was therefore under the NRHM IEC cell at Central Level and the State/District NRHM Units at Peripheral level. 5.7. Training and Capacity building 5.7.1. During the 11th plan period a large number of training programmes were organized for different categories of staff under GHC system to cover different aspects of the programme need. Main groups of trainee were :Medical Officer New and Refresher. Health Supervisor/Health Worker New and Refresher. ASHA and Anganwadi Workers. District Leprosy Officers and State Leprosy Officers - New. Laboratory Technicians. Surgeons in RCS. Physiotherapist. PRI members, women group, private practitioners Advocacy.
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5.7.2.

Learning Material A manual for training of Medical Officers was published.

5.8.

Disability Prevention and Medical Rehabilitation (DPMR) 5.8.1. During the 11th five year plan, more emphasis on the Disability Prevention and RCS services for the leprosy patients was given as compared to the previous plan period. 5.8.2. Prevention of Disability During the 10th plan period the programme emphasis was on case detection and treatment so that elimination of leprosy can be achieved quickly. During 11th Plan emphasis was shifted to providing quality services through prevention of disability and care of the disabled. Health Workers were trained to suspect cases of leprosy reaction, relapse, insensitive hands and feet and refer to PHC for diagnosis. They also empower patients with self care procedure for prevention of deformity. PHC Medical Officers were trained to diagnose cases of reaction and treat them. Severe reaction cases were referred to the District Hospital, if they did not respond well within 2 weeks of starting treatment. Service and care for impairment such as ulcers, cracks and wounds, septic hand or feet etc. were available from all the Health Institutions routinely. Complicated ulcer cases were referred to District Hospital. Microcellular Rubber (MCR) footwear were supplied to all patients with insensitive feet by the District nucleus staff at the concerned Health institution. An appropriate system of need assessment, procurement and supply was drawn up by the State/ UTs, under guidance from the Central Leprosy Division 5.8.3. Medical Rehabilitation Services for the Deformed All patients with grade II disability diagnosed at the PHC were referred to the District Hospital/ District nucleus for further assessment and care. Cases suitable for RCS were referred by District Hospital to the tertiary level care hospital for further care. No. of Institutions conducting RCS operations were increased from 51 at the beginning of the 11th Plan to 85 (Govt. Instt. -44 and NGO-41).
148

Aids and appliances for Medical Rehabilitation were supplied to the patients. During the XIth plan, following new initiatives were taken to facilitate RCS in leprosy:

Incentive to Patient As an incentive and to offset the financial difficulties faced by leprosy affected persons who belong to Below Poverty Line (BPL) families, undergoing reconstructive surgery at the identified institutions Government Hospital or NGO institutions), will be paid an amount of Rs. 5000/- (Rupees five thousand only) per major RCS. Incentive to Institutions It was felt necessary that Government Sector Medical Colleges/ Physical Medicine and Rehabilitation (PMR) centres also need to be facilitated to enable them to carry out RCS. An incentive of Rs. 5000/per major RCS was paid to the Govt. Institutions for conducting RCS, to facilitate procurement of materials for the surgery.

5.9.

Urban Leprosy Control Supportive Medicine Additional fund was provided for supportive medicines for the urban area institutions. MDT delivery services and follow up of under treatment patient. Separate fund was provided for this component. Local NGO/Volunteers can be engaged for follow up of under treatment patients to cut down treatment defaulters. Monitoring, supervision and coordination by the nodal agency which includes periodic meeting and mobility. Separate fund was provided for this component as well.

5.10.

NGO Services 5.10.1. SET Scheme The Modified SET Scheme was revised with effect from 1st April 2004. The scheme covers NGOs/ NGO Hospitals working for the benefit of the leprosy affected persons. The Govt. of India decentralized the SET scheme sanctioning power to the state Govt. with effect from the year 2006-07. The scheme was continued during the 11th plan. A total of 39 NGO are now engaged under the scheme.
149

5.10.2. The International Federation of Anti-Leprosy Associations (ILEP) also supports nearly 130 NGOs/ Hospitals on their own as per State Govt.s need. 5.11. Operational Research

Research was conducted through the National Institute of Medical Statistics (ICMR), New Delhi, in Bareilly district to finalize a sampling design to carry out National Sample Survey to assess the burden of leprosy in the country. Another Operational Research was conducted through the National JALMA Institute for leprosy and other Mycobacterial diseases, Agra to assess the total disability burden in one district each of UP and Haryana. 5.12. Supervision, Monitoring and Review 5.12.1. Supervision and Travel cost The programme mainly provided services through the General Health Service infrastructure with supervisory support from the District nucleus staff. Supervisory visits were made by the State level officers as well. While regular State Govt. staffs were drawing their TA/DA from the source of their salary, contract staff like surveillance Medical Officer, BFO and drivers were paid from the programme budget. In addition, NMS posted to the special category of states were also paid TA/DA from programme budget. Similarly travel by the consultants from the Central Leprosy Division to various states, was also made regularly. 5.12.2. Programme Monitoring A Mid Term Evaluation of the NLEP by an Independent Agency was carried out during the year 2010-211. 5.12.3. Review Regular Review at National, Regional, State and District level were carried out as per plan at annual, quarterly or monthly basis.

6. Impact of Programme Activities during 11th Plan

1. 2. 3. 4. 5. Six States/UTs achieved Leprosy Elimination Status. ANCDR decreased from 14.27/100,000 in 2005-06 to 10.48/100,000 in 2010-11. Prevalence Rate decreased from 1.34/10,000 in 2005-06 to 0.69/10,000 in 2010-11. Treatment Completion rate improved from 90.34 in 2006-07 to 92.26 in 2009-10. RCS conducted in 11825 persons Affected by Leprosy during 2007-08 to 2010-11 (4 years), to help in reduction of disability. 6. High endemic districts (ANCDR >10/100,000 population) reduced from 275 districts in 2005-06 to 209 districts where special activities proposed during the 12th Plan period.
150

7.

Constraints
With reduction in case load, priority given by States/UTs to the programme gets reduced. Removing suitable Officers from key posts, keeping posts vacant are great hindrance to the programme. Non-availability of a competent District Nucleus Team consisting of a well trained District Leprosy officer, Medical Officer, Non-Medical Supervisor and Para Medical Worker to supervise the services provided in the Primary Health Centres, in most of the districts is a big problem. Referral services at the District Hospital level is not adequate, which need to be organised. Fund utilization at district level is hampered because there is procedural delay in release of funds from State NRHM to districts.

8.

Additional Support to in NLEP

8.1 World Health Organization (WHO) Supply of MDT free of cost for treatment of all leprosy patients in the county with funds from Novartis. Manpower & Equipment maintenance support and review meetings etc. with funds from Sasakawa Memorial Health Foundation and The Nippon Foundation, Japan

8.2

International Federation of Anti-leprosy Association (ILEP) The ten members organization working as Partners in NLEP in India under the banner of International Federation of Anti-Leprosy Associations (ILEP) was providing support to NLEP as a partner. Details of areas for their work were finalized and a MoU was signed between the GoI and the ILEP on 24th October 2007. As per the MoU, ILEP support was on the following six Thematic areas: Monitoring and Supervision Capacity Building Support to DPMR (Referral system) Operational Research Support to local NGO Socio economic rehabilitation and community participation.

151

PART II PROPOSED 12th FIVE YEAR PLAN Vision

A Leprosy free India is the ultimate visionary goal. Interim aim during the 12th plan period is to provide quality leprosy services to all Section of population and achieve the target of less than 1 case per 10,000 population (Elimination) in all the districts of the country, also reducing the burden of disability due to leprosy.

1.

Key Lessons learnt from 11th Plan

Slow achievement in reduction of cases. Detection of New cases from various pockets, mostly from 209 districts in 16 States. Poor quality of services through integrated service delivery. Inadequate referral services at the District Hospital level. Role of ASHA at village level for early case detection and for completion of treatment is very encouraging. Poor performance of RCS in Govt. Institutions though number has gone up from 20 to 44. Keeping the clause of BPL families for receipt of incentives for undergoing RCS operation is counter productive as BPL Cards are not easily available. Delay in release of funds from State NRHM to districts resulting in non execution of planned activities.

2. NLEP Objectives under 12th Plan

To make the NLEP Plan more compliant to the NRHM Guidelines Paradigm changes made in the 12th Plan relates to changing the hitherto activity based plan to a result based plan. The objectives of the plan is therefore changed with aim to achieve following results i. ii. iii. iv. v. vi. vii. Improved early case detection Improved case management Stigma reduced Development of leprosy expertise sustained Research supported evidence based programme practices Monitoring supervision and evaluation system improved Increased participation of persons affected by leprosy in society
152

viii.

Programme management ensured

3. Policy Changes in implementation

To make NLEP planning, compliant with NRHM guidelines, the 12th plan proposal has been made a result based plan Reassess the burden of leprosy in the country by shifting from prevalence as the main indicator to Annual New Case Detection Rate and burden of disability in new cases of leprosy. Improving the quality of services to all patients with easy accessibility without discrimination. Provide integrated leprosy services with primary health care system for sustainability. Adequate Referral System for complicated cases. Prevention and management of impairments and disabilities. Improving community awareness and involvement. Support of National Rural Health Mission. Care of the cured patients and their rehabilitation. Re-define the indicators for monitoring and evaluation.

4. Targets and Indicators

PR < 1/10,000 in all districts ANCDR <10/100,000 in all districts Cure rate MB Cure rate PB 100% 100% >95% >97%

No. and rate of new cases with Gr. II disabilities cases/10,00,000 population-35% reduction (Base 2011-12) other additional indicators to assess the quality of services provided e.g. proportion of cases correctly diagnosed, Defaulter rates, Cases with disability after initial treatment, number of relapses, Proportion of new MB, Child, Female and Disability cases are to be used.

5. Justification
153

The strategy of NLEP adopted during the 11th Plan period was discussed in the specialist sub group constituted on National Leprosy Eradication Programme to formulate the 12th Five Year Plan. The strategy was found to be good, however, there are certain gaps in implementation of the strategy due to various administrative and operational issues. Because of this, implementation of activities under the programme is not as desired resulting in low expenditure. Also the country has at present 209 districts where the detection of new cases of Leprosy is high. If these issues are taken care of, implementation will be more effective resulting in quality services in the programme & improvement in expenditure and the programme will be able to achieve the outcome proposed during the 12th Plan. For implementing the newer activities viz. Special focused activity in 209 high endemic districts & in addl. high endemic districts ( if identified), Strengthening of DPMR services including RCS, Consultants/Staff in CLD (from WHO/ILEP funding to GoI funding), Upgradation of CLTRI & RLTRI, Referral services at District level hiring of Physiotherapists, Support at high endemic Block PHC with one Para Medical Worker each Increased emphasis on Monitoring, Review and Evaluation, the hike in budget during the 12th Plan is essential and justified in interest of the programme.

6. Strategy

209 districts identified to give attention. Additional districts, if identified during the plan period, will also be given special attention. Clear backlog for RCS. Promotion of Self Care. Capacity building especially in POD. Improve referrals at district level. Improve Monitoring & Supervision.

7. Result based Strategy and Activities

7.1 Improved early case detection
7.1.1

Integrated Leprosy Services through all the Primary Health Care facilities will continue to be provided in the rural areas. However for Providing Technical support to the Primary Health Care System to strengthen the quality of services being provided, a team of dedicated workers including Medical Officer and other Para-medical worker/supervisors are placed at district level, known as District Nucleus. All the urban areas will be covered under the urban leprosy control programme integrating services from all the partners available in the area, including the private practitioners. As started during the 11th plan, involvement of the Multi-purpose Health functionaries, ASHA in villages and selected NGOs in urban areas are to 154

7.1.2

7.1.3

be continued for case follow up during treatment to ensure regular MDT collection and consumption, so that all the cases put under treatment gets cured in shortest possible time.
7.1.4

Emphasis will be laid on providing best quality leprosy services through the GHC system. This means easy availability of services on all working days to all patients, correct diagnosis and adequate counseling to patient and family members, provide MDT to patients whenever approached, regular monitoring of the patient during treatment. Treatment completion by all patients will be the desired outcome of the programme. Regular monitoring and surveillance at National, State, District and Block level will be continued to locate weak areas, so that plan for corrective action can be taken on time. The surveillance medical officer at state level and district nucleus team at district level will enforce routine monitoring and supervision. Special activities for case detection to be adopted in difficult and inaccessible areas. Innovative strategy for early case detection - While it is accepted that new cases are occurring regularly and the people are still hesitant to come forward to get themselves diagnosed and treated due to the stigma associated with the disease since long. Detection of the new cases at the early stage is the only solution to cut down the transmission potential in the community and also to provide relief to the leprosy affected persons by preventing disability. However Active search for case detection is not recommended routinely as their procedure puts large number of non leprosy cases as leprosy which again is not desirable on humanitarian ground. It is therefore suggested that the states will draw up innovative plans so that the leprosy affected persons seek services from the Primary Health Care institutions. In this regard states may consider the following: (i) Improved access to services (ii) Involvement of women including affected persons in case detection (iii) Skin camps are useful for detecting leprosy patients while providing services for other skin conditions. (iv) Contact survey to identify the source in the neighbourhood of each child or M.B. cases. (v) Maintain regular awareness attempt through the ANM, AWW, ASHA and other Health Workers visiting the villages, to suspect and motivate leprosy affected persons to report to the Medical Officer. (vi) Involve Representatives of organizations of people affected by leprosy in spreading awareness to motivate people for early 155 reporting to health centres.

7.1.5

7.1.6 7.1.7

7.1.8

Services through ASHA- A scheme to involve ASHA under NRHM was started during 11th plan to bring out cases from their villages for diagnosis at PHC and after diagnosis to follow up the patients for treatment completion. The ASHA will be entitled to receive incentive as below(i) On confirmation of cases brought by them Rs. 100/(ii) On completion of full course of treatment within specified timePB Leprosy case Rs. 200/MB Leprosy case 400/Before involving the ASHA for leprosy work they were given special sensitization to enable them to take the role for providing quality services to the leprosy affected persons in their home. It is proposed that the scheme will be further extended in the State/UTs during the 12th plan also.
Table 3

Item 1 2 Performance based incentive ASHA Sensitization of ASHA Total

7.1.9

Yearly costs Average Rs.400 to 20,000 6,500 26,500

(Rs. In Thousands) Cost for 5 years 100,000 32,500 132,500

Additional/New activities during the 12th Plan - It is proposed to cover the identified priority districts under special programme activities during the 12th plan period. As the thrust during the 12th plan is to achieve elimination in all the districts of the country, 209 districts have been identified as priority districts as on March 2011, based on ANCDR more than 10/100,000 population. These 209 districts will be continued to be treated as priority district during the entire plan period, irrespective of change in status expected in any of the years. Further, on the basis of ANCDR, Disability rate, child case rate and training status of medical and paramedical personnel these 209 districts will be categorized. Special activities will vary according to the category of the district. Similar categorization will also be done in all the districts of the country for suitable necessary action.

Cost:
Table 4
156

(Rupees in Thousands)

Sl. Item 2012-13 2013-14 2014-15 No 1 Special activities* 150000 150000 In High endemic districts - Active search - Capacity building of staff - Awareness drive - Enhanced monitoring and supervision 1 person per block - Validation of MB and child cases * These activities will be carried out twice in five years. 7.2 Case Management
7.2.1

2015-16 -

2016-17 -

Total 300000

The system of referral of difficult cases to the District hospital for diagnosis and management, which has already been started, will be further strengthened with capacity building of persons involved at PHC as well as District Hospital level. While management of reaction and neuritis to prevent disability will be taken up at the PHC level, all difficult to manage cases will be referred to District Hospital/Leprosy Institutions. Strengthening of the leprosy service delivery components at the District Hospitals will be emphasized. The laboratory facilities at the District Hospitals for smear examination to diagnose difficult cases will be further strengthened. Quality control of smears and biopsies can be carried out in central / regional leprosy training institutes and NGO institutions Data for Female, Schedule Tribe and Schedule Caste patients are to be maintained at all levels. Prevention of Disability - People affected by leprosy often suffer from deformity of hands, feet or eyes due to involvement of nerves and resultant muscular weakness and paralysis. Such patients may come with deformity at the time of diagnosis of the disease. Although the disease is fully curable on treatment with MDT, however, impairment already developed is not curable. Further secondary impairment may occur in the hands, feet and eyes due to 157 reaction/ nerve involvement even during treatment. However such deformity

7.2.2

7.2.3

7.2.4

can be prevented more easily than primary impairments by following certain procedures. Although the number of visible deformity in leprosy affected persons has reduced substantially yet quite a backlog exist for specialized care to remove their deformity. Such efforts will help in regaining the status of the leprosy affected in public mind thereby reducing the stigma to the disease. During the 10th plan period the programme emphasis was on case detection and treatment so that elimination of leprosy can be achieved quickly. During the XIth plan emphasis had been shifted to providing quality services through prevention of disability and care of the disabled. All suspected cases of leprosy reaction, relapse, insensitive hands and feet are referred to PHC for diagnosis. They also empower patients in self-care with material like self-care kit, splints, grip aids etc. for prevention of deformity. All PHC Medical Officers diagnose cases of reaction and treat them. Severe reaction cases were referred to the District Hospital, if not responded well within 2 weeks of starting treatment. Service and care for impairment such as ulcers, cracks and wounds, septic hand or feet etc. are available from all the Health Institutions routinely. Complicated ulcer cases were referred to District Hospital. Referral centers will be developed depending on the need at all district hospitals and Medical colleges. The referral centers will be supported by dermatologists of district hospital and physiotherapists will function in the centers. Posting of one Physiotherapist for each District Hospital has been proposed on contract basis during the 12th Plan period.

Microcellular Rubber (MCR) footwear are supplied to the patients with insensitive feet by the District nucleus staff at the concerned Health institution. The States have prepared the list of LAPs with insensitive feet which will help MCR requirement planning during the 12th Plan at the rate of 2 pairs per person.

PHCs will provide follow up treatment to all patients referred back by the secondary and tertiary level units for reaction, complication or post surgery care. Operational guidelines for primary, secondary and Tertiary level institutions are available in all Centres.
7.2.5
158 Medical Rehabilitation Services for the persons with disability -

All patients with grade II disability diagnosed at the PHC are referred to the District Hospital/ District nucleus for further assessment and care. Cases suitable for RCS are referred by District Hospital to the tertiary level care hospital. Aids and appliances for Medical Rehabilitation are supplied to the patients.

Disability care services will be organized as routine activity and by organizing camps particularly in areas not easily accessible and in Tribal areas. These camps will be used to screen patients for RCS also. During the 11th plan new initiatives were undertaken to facilitate reconstructive surgery by involving NGO institutions as well as medical colleges as below: Incentive to patient As an incentive and to offset the financial difficulties faced by leprosy affected persons who generally belong to Below Poverty Line (BPL) families, undergoing reconstructive surgery at the identified institutions (Government Hospital or NGO Institutions), it was decided to pay an amount of Rs. 5000/- (Rupees five thousand only) per major RCS. The reimbursement of Rs. 5000/- is sought to be provided for Incentive @ Rs.100/per person x 2 x 20 days = Rs. 4000/Transportation for 2 persons (4-5 times) Total = Rs. 1000/= Rs. 5000/-

Although the scheme to provide incentive to the patients undergoing RCS was very useful in motivating the poor patients, many states reported inability to make the payment, because BPL cards are not available in many States/UTs. It is therefore proposed that the clause BPL may be substituted with the word poor patients, for which each State have their own criteria and certification system. Incentive to Institutions In addition to the 41 NGO leprosy Institutions who are conducting reconstructive Surgery (RCS), 44 Centres in Govt. Medical Colleges & Hospitals have been identified for RCS. While the surgeons are conducting RCS free of cost, these institutions have to 159 incur additional expenditure for hospitalization and treatment of patients. As these

are additional activities, some fund is required to procure necessary drugs, dressing materials, Plaster of Paris (POP), splints and other ancillary items required for reconstructive surgery of such patients. The incentive scheme was approved to provide support to these newly involved Government Medical Colleges / PMR centres @ Rs. 5000/- per major operation conducted, for procurement of supply & material and other ancillary expenditure. Remuneration for surgeon or physiotherapist was not to be incurred out of this fund. NGO institutions were not provided the incentive under this scheme as they were already equipped to provide surgery to LAP with disability. During the 12th Plan, it is proposed to provide Rs. 5000/- per major operation as incentive to all NGO Institutions who are willing to undertake RCS in leprosy patients as in the case of Govt. Hospitals/Med. Colleges.
Table 5

Sl.No Item 1 MCR Foot wear

(Rupees in Thousands) Name & Rate Cost for 1 year Total cost for 5 years 100,000 pairs per 30,000 150,000 year @ Rs.300/ per pair. 15360 15,000 76,800 75,000

2 3

4 5

Rs.24,000/district/per year 640X 24,000 Welfare Allowance for Rs.5000 per RCS patient patientx3000 RCS per year (Refer by DLS) RCS Rs.5000/- per RCS X 3000 RCS/per year Equipment for RLTRI and CLTRI Total Urban Leprosy Control

Aids & Appliances

15,000 200 75,560

75,000 1000 377,800

7.2.6

Urban leprosy control is one of the important component for improving case identification and case management. This aspect needs due attention in the plan.

7.2.6.1

Additional fund for urban areas

These states will be provided additional fund to implement urban control plan under following Heads Supportive Medicine This will be in addition to the provision available under the component for the District Society. That means additional fund will be provided for supportive medicines for the urban area institutions. All institutions should have adequate stock of drugs and materials irrespective of 160 their organization.

MDT delivery services and follow up of under treatment patient. Separate fund will be provided for this component. Local NGO/Volunteers can be engaged for follow up of under treatment patients to cut down treatment defaulters. The State/UT can develop their own mechanism to hire volunteers on need basis. Monitoring, supervision and coordination by the nodal agency which includes periodic meeting and mobility. Separate fund will be provided for this component as well. General fund under District Society Training of Medical Officers working in all Govt. and Non-Govt. institutions providing leprosy services. This is covered under training component of the annual action plan. IEC activities This is part of the overall IEC plan for the district and funded accordingly.

7.2.6.2

Number of urban areas identified for support

Table 6

Sl. No. 1 2 3 4

Type of urban area Township Medium Cities I Medium Cities II Mega Cities Total

Number # 354 55 5 8 422

Located in State/ UT * 28 19 5 7 28

#. The exact number of urban areas will be available from 2011 census. The activities and budgets are increased to accommodate increased number of urban areas. * No additional urban area identified in Arunachal Pradesh, Goa, Sikkim, UT Chandigarh, Dadra & Nagar Haveli, Daman & Diu and Lakshadweep as programme at present is covering all areas of these States/ UTs.

161

7.2.6.3

Cost
UnitandAnnualCostActivityandCategorywise Table 7

Sl. No.

Item

Category of urban area Township Medium City I Medium City II Mega City Township 354 Medium City I 55 Medium City II 5 Mega City 8 Towns & Cities422

1 18 36 72 80 6372 1980 360 640 9352

(Rupees in Thousands) Activities * Total 2 3 46 50 114 104 200 240 16284 5720 1000 1920 24924 100 200 240 17700 5500 1000 1920 26120 240 472 560 40356 13200 2360 4480 60396

A.

Unit cost per year

B.

Total cost per year

Total of B

* - 1. Supportive Medicine includes Prednisolone, Dressing material and Medicines. 2. MDT delivery services and follow up of under treatment patient. 3. Monitoring, supervision and coordination which includes periodic meetings and mobility. As the category of urban areas are based on population, fund allocation proposed under each of the activities are also estimated on a pro-rata basis. Cost for the period 2012-13 to 2016-17 (5 years) Total of B x 5 i.e. Rs. 60396000 x 5 = 301980000/i.e. 30.198 Crore

162

7.2.7

Supply of MDT to the leprosy patients is to be maintained free of cost during the 12th plan through WHO. MDT Cost
Table 8

Sl.No 1 2 3 4 5

Year 2012-13 2013-14 2014-15 2015-16 2016-17 Total

(Rs. In Thousands) Cost of MDT 70,000 70,000 70,000 70,000 70,000 350,000

7.2.8 Material and supplies including supportive drugs are to be procured at district level

under the sub head supportive drugs, laboratory reagents & equipments and printing of forms. Material and supplies
Table 9

Sl.No Item 1 2 3 Supportive Drugs Laboratory reagents and equipment Printing forms etc Total

Districts 640 640 640 640

(Rs. In Thousands) Cost/per Cost for 1 Cost for 5 district/year year years 50 32,000 160,000 10 6400 32,000 20 80 12,800 51,200 64,000 256,000

While most of the medicine required for treatment of leprosy patient should be available in the PHC/Hospitals out of their regular source under NRHM, leprosy patients require some specific drugs for treatment of reactions and disability which are required to be procured separately by the State/District and supply to the primary, secondary & tertiary level institutions.
7.2.9

NGO Services

7.2.9.1 SET Scheme The Modified SET Scheme was revised with effect from 1st April 2004. The scheme now covers about 40 NGOs/ NGO Hospitals working for the benefit of the leprosy affected persons. The Govt. of India has decentralized the SET scheme sanctioning power to the state Govt. with effect from the year 2006-07. The scheme need to be continued during the 12th plan also.

163

7.2.9.2 As is the practice now, proposals from NGOs for working in a specific area for NLEP will be submitted to the concerned District Leprosy Officer, who will recommend the suitable proposals to the State Leprosy Officer. The State Leprosy Society will examine the proposal and give approval. Once approved the NGO will receive fund from the State Leprosy Society. The State Leprosy Society will monitor the activities and continue to support the NGO in the subsequent years based on their satisfactory performance. Govt. of India will provide required funds to the SLS for this purpose based on the State Annual Action Plan. 7.2.9.3 Programme need of NGO support Under the SET Scheme, the NGOs are presently involved for disability prevention and ulcer care, IEC, referral of suspected cases, referral for RCS, Research and Rehabilitation. As the number of cases have gone down dramatically the NGO support can now be extended to ensure follow up of the under treatment cases particularly in urban locations and in difficult to access areas. Such follow up has become necessary because nearly 10% of the patient diagnosed do not take the treatment regularly and often had to be deleted otherwise. For a quality leprosy service one has to ensure that each and every patient complete the treatment in the fixed time. The NGOs can support the Hospitals/ PHCs in this important activity. 7.2.9.4 The International Federation of Anti-Leprosy Associations (ILEP) & other organizations also support NGOs on their own and will continue to support such organizations as per State Govt.s need. 7.2.9.5 Cost
Table 10

No. of NGO 50

Rate per NGO project per year 800

(Rupees in Thousands) Cost per year Cost for 5 years 40,000 200,000

7.3

Stigma reduction Rationale for proposed IEC strategy The IEC strategy during the 12th plan period is proposed to be changed in its approach and contents, to focus on communication for Behavioral changes in the general public. Changes are required because Stigma against the disease and discrimination against the leprosy affected persons have been still perceived to be very high. The IEC activities towards 164

7.3.1

awareness development have helped a lot, but still many more have to be done. Certain level of awareness has developed in the communities due to the persistent efforts in communication during last decade. However continuous efforts are needed to cover the uncovered areas. Coverage will have to move from high risk centric to general community at large. With reducing number of leprosy cases in the community, awareness about curability of the disease, lessening number of deformity due to leprosy, stigma associated with the disease has become slightly less. The effective way to deal with this difficult challenge of stigma removal is to embark on intensive interpersonal communication (IPC) with the target groups. For sustaining the anti-leprosy campaign, it is important to integrate leprosy IEC with the IEC of other Health Programmes. This will address the problem of not having technical expertise on communication at various levels of leprosy offices. IEC planning and implementation will therefore be under the NRHM IEC cell at Central Level and the State/District NRHM Units at Peripheral level.
7.3.2

Objectives of the Communication Plan To develop effective communication vis--vis the target audiences and take on the task of effectively delivering the same. To compliment and support the detection and treatment services being provided through the General Health Care System, making it more acceptable to the population. To strive to remove stigma surrounding leprosy and prevent discrimination against leprosy affected persons. To specifically cover clients, Health providers, influencers and the masses.

7.3.3

IEC Plan for the years 2012-17 A. Central Level The Central Leprosy Division will draw up annual plan and implement same with the NRHM IEC unit. Mass media activities at National level will be through Doordarshan channels and AIR. National level press will be used for central level communication. Information Design Complete curability and non contagious nature of the disease.
165

Availability of good quality treatment (with MDT) free of cost from all Govt. Health Centres. Rectification of deformities is possible through surgery. Leprosy affected person on treatment can live a normal life alongwith the family. B. State and Peripheral Level IEC under NLEP will be decentralized to the States/ UTs who will make their own plan and implement same. Central Leprosy Division will provide broad guidelines with allotted budget to the States/ UTs, who will have the flexibility to allocate cost to districts as per local Priority areas and Target groups to be attended to through Mass Media To a limited extent through local centers of TV, Radio and press in local languages. Outdoor Media - Hoardings, Bus panels, Wall paintings, posters, Rallies including Banners. Rural Media - IPC group meetings, School IEC, Folk media, Exhibitions and Health Melas. Advocacy Meetings with Zila Parishad, Mahila Mandals, NGOs etc.

For IEC/BCC special efforts will be made for Involvement of people affected by leprosy in improving awareness, case detection and stigma reduction Interpersonal Communication (IPC) through the Health staff involving communities, Panchayat leaders and NGO through advocacy workshops will remain the focused approach.

Priority Areas States with low literacy rates in general and female literacy rates in particular. Tribal population majority areas in State/ UTs Endemicity of districts (ANCDR >10/100,000). Urban areas with problem of migratory population.

166

Target groups Women from the areas where literacy rate is low. School children Population groups residing in remote inaccessible areas and tribal population. Migratory population. People living in urban slums. An IEC campaign towards achieving Leprosy free India was started from the 30th January 2008 which continued through the year 2008-09. Main theme of the campaign was based on the concept that The efforts for further reducing leprosy burden in the communities have to be prioritized so that visible deformity in newly detected cases is reduced to the minimum. Early reporting and complete treatment of leprosy cases prevent disability. Quality of services provided to leprosy affected persons be at optimum level to reduce suffering and prevent consequences in all cases put on treatment. Leprosy affected persons will not be stigmatized and discriminated and would lead a socially and economically productive life.

Similar Campaign approach for 15 days of intensive IEC to be organized every year from 30th January which is being observed as Anti Leprosy Day in the country. IEC Cost
Table 11

Medium Mass Media (TV, Radio, Press) Out Door Media Rural; Media Advocacy Meetings Total

( Rs. In Thousands) Year Agency Total 2012-13 2013-14 2014-15 2015-16 2016-17 State GoI(CLD) 20,000 20,000 20,000 20,000 20,000 25,000 75,000 100,000

20300 28,000 4000 72300

20300 28,000 4000 72300

20300 28,000 4000 72300

20300 28,000 4000 72300

167

20300 28,000 4000 72300

101500 140,000 20,000 286500

75,000

101500 140000 20,000 361500

7.4

Development of leprosy expertise

During the 11th plan period a large number of training programmes were organized for different categories of staff under GHC system to cover different aspects of the programme need. 7.4.1 Learning Material In view of the integration of the leprosy services through the General Health Care staff, the learning materials for training large number of GHC staff were modified, shortened to 3 days duration, printed and supplied to all State/ UTs with ILEP support first in the year 1999. Subsequently again these learning materials were revised, updated and reprinted through ILEP support in the year 2005-06 for District nucleus and other Medical Officers and Health Supervisor/ workers. For POD training also learning material were prepared and used. A training manual for Medical Officers was prepared in 2009-10 and supplied to all States/UTs. A training guide for ASHA was also prepared and supplied.
7.4.2 Training needs during 12 plan period
th

Training has to remain a continuous process during the 12th plan period as well. Although the country has achieved elimination of leprosy as a public health problem, yet there are quite a few districts and Block areas that have high endemicity of leprosy. Further, due to huge turnover of Medical Officers in the major states the staff in the Primary Health Centres keep changing every year. In a number of states, Medical Officers on contractual basis works in the PHC, where the turn over is very high. The new entrants are needed to be trained regularly, so that the services to be provided to the people from the GHC system do not suffer. Training of 2 days duration will therefore be carried out every year. This training can be jointly done with the integrated training programme under the National Rural Health Mission. Similar 2 days training in leprosy will be required for Medical Officers working in the urban areas both under Govt. and other Non-Governmental institutions regularly. In addition to the above mentioned new entrants, remaining Medical Officers under GHC will also require 2 days training. This re-orientation is required firstly to keep the diagnostic and management skill upto date, in view of low number of cases in the community. This should help in improving the quality of services provided by the PHCs. Secondly they should also be able to refer the difficult to diagnose cases to the referral centers i.e. District Hospitals at the earliest. The Disability Prevention and Medical Rehabilitation (DPMR) component will be major focus in all these trainings for the Medical Officers. Training for Health Supervisors (M & F) and Health Workers (M & F) for 2 days duration will carried out regularly every year. Smear examination to detect the Mycobacterium Leprae is one of important requirement for diagnosis of otherwise difficult to diagnose cases. Skin biopsy
168

examination would be required for a few cases. Biopsy facilities will be made available in central/regional training institutes and institute of pathology and NGO institution. Pathologists will be identified for biopsy investigations and they will function as faculty for training the lab technicians. Now that the district hospitals are being upgraded as referral centre for such cases for diagnosis and management, the laboratory technicians working in these hospitals need to be given specialized re-orientation training under the programme. Atleast 2 lab technicians from each district hospital laboratory are proposed to be trained. These trainings for 2 days duration each will be continued every year on need basis. A large number of ASHA are being appointed under NRHM in the states. These village level workers will be provided training on leprosy during their induction training. In addition to sensitize them further one day capacity building at the PHC level will be carried out for all ASHA. Funds under Services through ASHA will be utilized for sensitization of ASHA and hence not included separately in the training budget. It is to engage Physiotherapist at the District Hospital in a bid to strengthen the Referral Service delivery. These Physiotherapists will be provided 2 days training in identified Institutions. Training in programme Management, Supervision & Monitoring is proposed to be given for 3 days to the District Nucleus staff viz. DLO & MO, during the 12th Plan period.
7.4.3 Training Load

Rough estimates of human resources to be trained during the 12th plan period has been worked out as below. However, the Districts/States will work out actual requirements in their plans for implementations: Table-12 Sl. No. 1 2 3 4 5 Type of training Year-wise training load 2012-13 2013-14 2014-15 2015-16 2016-17 Total Medical Officer Training for 2 days. Physiotherapist Training for 2 days Training for Lab technician for 2 days Training for Health Supervisor/Worker for 2 days Training for District Nucleus Team for 3 days 4500 330 750 3000 300
169

4500 310 750 3000 300

4500

4500

2000

20000 640 1500

3000 300

3000 300

2000 80

14000 1280

Cost Unit cost for conducting different courses for 30 persons have been worked out as below:
7.4.4

Table-13 Norms for calculation M.O. H.S./H.W./P.T./ L/T. (2days) 2400 4500 24000 12000 7500 50400 M.O.

TA/DA for Trainers (21000 / 600 per day) TA for Trainees (30300/150) DA for trainees (303/4 days) Working Lunch & Tea @ Rs. 200x30x2/3 days Misc. Expenditure Rs. 250 per participants Total

(2day) 4000 9000 42000 12000 7500 74500

(3 days) 6000 13500 63000 18000 7500 108000

Year-wise and Category-wise training cost

Table 14

Sl. No. 1 2 3

Category and type of Yearlycost training 2012-13 2013-14 Medical Officer Training for 2 days. Physiotherapist Training for 2 days Training for Lab technician for 2 days Training for Health Supervisor/Worker for 2 days ManagementTraining for District Nucleas Team for 3 days Total 11175 554 1260 11175 554 1260

2014-15 11175 -

(Rupees in Thousands) TotalCost 2015-16 2016-17 11175 4992 49692 1108 2520

5040

5040

5040

5040

3377

23537

1080 19109

1080 19109
170

1080 17295

1080 17295

324 8693

4644 81501

7.4.5

Revival of training in Leprosy In addition to the short course training given to the different categories of staff, it is felt necessary that longer duration courses for developing expertise in leprosy diagnosis and case management is necessary. Such trainings were held in preintegration days at the govt. leprosy institutions viz. the central leprosy research and training institute, Chengalpattu, Tamilnadu and the three Regional Leprosy Research and training institutes at Raipur, ASKA and Gouripur. Such longer duration courses are required for State Leprosy Officers/ District Leprosy Officers, Medical Officers, Non-Medical Supervisors, Non-Medical Assistant/PMW and Physiotherapist. These institutes need to be revived for such longer job oriented courses for which curriculum and plan need to be worked out. In addition to the Govt. leprosy institutions, other institutions that can be linked up are the National Institute for Health and Family Welfare, Delhi, Schieffeline Institute of Health Research and Leprosy Center, Karigiri, Tamilnadu and Training Center of The Leprosy Mission, Naini, Uttar Pradesh.

7.4.6

Updating of leprosy curriculum in under graduate medical course It is observed that the teaching in leprosy in the undergraduate medical curriculum is not in accordance with the National Leprosy Eradication Programme. This makes it difficult for the fresh MBBS graduates to fully grasp the need of the programme to deliver as per public health requirement. Linkages are to be developed with the medical council of India and medical universities for updating the course curriculum as per programme requirement. Till such time it is necessary to impart NLEP oriented training in Leprosy to fresh MBBS graduates. Training of other graduates Similar changes in curriculum need to be developed in relation of Para medical and nursing courses in consultation with their respective councils.

7.4.7

7.5

Operational Research Priority Topics : It is proposed to carry out Operational research during the 12th Five Year Plan on the following topics Missing cases Training Need assessment Self-care kit in POD Management of cases with reactions under the program Focused approach for IEC Drug resistance surveillance

7.5.1

These studies will be carried out through ICMR or other organizations viz. CLTRI, RLTRIs, SIHR&LC Karigiri, The Leprosy Mission, National Institute of Epidemiology Chennai, JALMA institute, Agra, Blue Peter Public Health & Research Center, LEPRA, Hyderabad and Stanley Brown Lab, TLM Delhi as identified by the Central Leprosy Division.
171

7.5.2 Cost
Table 15

(Rupees in Thousands) Sl. No. 1. 2. 3. 4. 5. 6. Topicforstudy Missing cases Training need assessment Self-care kit in POD Mgmt. of cases with reactions Developed focus approach for IEC Support drug resistance surveillance Total 7.6 2012-13 1000 1000 2000 1000 2000 500 7500 Year of study & cost 2013-14 2014-15 2015-16 1000 1000 1000 500 3500 500 500 500 500 2016-17 Total 2000 2000 2000 2000 2000 2000 12000

Supervision, Monitoring and Review Supervision and Travel cost The programme will mainly provide services through the General Health Service infrastructure with supervisory support from the District nucleus staff. Supervisory visits will be made by the Central/State level officers & experts drawn from other organization as well. While regular State Govt. staff & experts will be drawing their TA/DA from the source of their salary, but contract staff like surveillance Medical Officer, BFO and drivers will have to be paid from the programme budget. In addition, NMS posted to the special category of states will also have to be paid TA/DA from programme budget. Similarly travel will have to be made by the consultants from the Central Leprosy Division to various states.
TravelCostfordifferentlevelofficials Table 16

7.6.1

(Rupees in Thousands) Sl. No 1. Categories Central Leprosy Division Annual Rate (In Rupees) 300000 (a) States with > 50 districts 150000: 2 (b) States with > 25-49 districts 100000 : 8 (c) States with > 10-24 districts 80000 : 12 (d) States with > 5 - 9 districts 60000 : 5 (e) State/UT with up to 5 districts 40000 : 9 640 districts X 25000 Yearly Cost 300 300 800 960 240 360 16000 18960 Total 1500

2. 3

States/ UTs Districts Total

13300 80000 94800

172

7.6.2

Programme Monitoring (i) Appraisal While programme will be monitored at different level through analysis of routine reports and through field visits by the supervisory officers, it is proposed that there should be a component of Programme appraisal by a committee of experts identified by the programme, twice during the plan period. Such appraisal may be conducted during the 2nd and the 4th year of the plan Cost
Table 17

(Rupees in Thousands) Sl. No. 1. Activity Programme Appraisal Year and Cost 2013-14 2015-16 5000 5000 Totalcost 10,000

The appraisal of the programme will be carried out after drawing out specific Terms of Reference (TOR) (ii) Annual Assessment Performance under the programme will be annually assessed by an Independent expert group. Cost
Table 18

(Rupees in Thousands) Sl. No. 1. Activity Programme Assessment by Independent expert group Yearly Cost 2000 Totalcost 10,000

7.6.3

Review Meetings Programme review meetings are to be held periodically at Central, State and District level. At central level, Annual review meeting for the State Leprosy Officers will be continued to be held every year with funds from WHO country budget subject to the agreement with WHO. Regional review meetings for SLOs will be supported by ILEP (3 meetings per year) subject to the agreement with ILEP
173

 A review meeting of all institutions involved in DPMR services will be held every year from programme budget Similar review meeting for NGOs working under the NLEP were also held earlier annually with WHO biennium funds. As this has been discontinued, NGO review meeting is proposed to be held for review of performance of NGOs under modified SET scheme twice during the plan period. At state level quarterly review meetings for the District level officers are to be held every year with programme funds. For this activity budget is to be earmarked under the plan. NGOs working in the states are also to be invited these meetings for review of their activities. At district level, monthly review meetings are held under the chairmanship of the District Chief Medical and Health Officer in which leprosy is also discussed. Separate fund for this purpose is not needed from the programme budget.

Cost
Table 19

(Rupees in Thousands) Sl. No. 1. Activity Review of institutes involved in DPMR NGO review meeting State level review meeting District level review meeting Periodicity Unit Cost (In Rs.) 1000 Yearly Cost 1000 Total

Annual

5000

Biennial

1000 20000 to 50000 (Avg.25000) No cost

2000

3.

Quarterly

5272

26360

4. Total

Monthly

6272

33360

174

7.6.4

Office operation and Maintenance

Following provisions are being made under different heads of office operation and maintenance. 7.6.4.1 Office Expenditures
Table 20

Item Rent, Telephone, Electricity, P&T charges, Miscellaneous District

No. of units

(Rupees in Thousands) Rate per Total for 1 Total for 5 year year years

640 State Leprosy Cell 36* 676

35 / distt. 75 / state

22400 2700 25100

112000 13500 125500

Subtotal Office Equipment Maintenance cost State Leprosy Cell 36* 50 / state 1800 9000 Subtotal 36 1800 9000 Total 26900 134500 *Jammu Division & Kashmir Division of J&K are treated as separate state units.

7.6.4.2 Consumables
Table 21

Item Stationary Items District State Leprosy Cell Central Leprosy Div. Total

No. of units 640 36* 1 648

(Rupees in Thousands) Rate per year Total for 1 Total for 5 year years 30 / distt. 50 / state 75 19200 1800 75 21075 96000 9000 375 105375

*Jammu Division & Kashmir Division of J&K are treated as separate state units.
7.6.5

Vehicle Hiring and POL / Maintenance Mobility for man and material is important to run the programme smoothly. Each district should have one running vehicle for mobility of district nucleus team and DLO. The vehicles provided to the districts under NLEP are now very old and many districts do not even have a vehicle. Provision of hiring vehicle was made
175

during the 11th plan period. It would be useful for the programme to keep provision for hiring of one vehicle per district where no vehicle is available. For the 36 state societies (Jammu Division & Kashmir Division of J&K are treated as separate units) provision has been kept for 2 vehicles each for the 12th five year plan period also. Cost
Table 22

Sl. No. 1 2 3

Office

No.of Units 640 36 1 677

No of Vehicles 640 72 1 713

District leprosy unit State Leprosy Office Central; Leprosy Division Total

(Rs. In Thousands) Rate per Total Total for year per for one 5 years vehicles year 150 9600 480,000 200 14400 72000 150 150 750 110550 552750

7.7

Increased participation of persons Affected by Leprosy in NLEP The stigma associated with leprosy, which has prevailed in virtually every culture and has resulted in discrimination, stereotypes, labeling and ultimately the exclusion of individuals affected by leprosy from equal participation in society. Adoption by the UN General Assembly on 21st December 2010 of the resolution on principles and guidelines for the elimination of discrimination against persons affected by leprosy and their family members was a milestone. The WHO (2011) has brought out guidelines for strengthening participation of persons affected by leprosy in leprosy services. Accordingly it is felt necessary to keep this aspect while formulating the 12th five year plan.
7.7.1

Primary issues in the WHO guidelines are stigma and discrimination, equity, social justice and human rights and gender equality. It is suggested that it is necessary to a. Work with persons affected by leprosy to identify and change negative attitude, belief and practice b. Provide opportunities to share experiences, develop new attitudes and acquire new skills c. Work with individuals and organisations representing persons affected by leprosy, to educate people who have experience leprosy, programme staff and the community about human rights. d. Develop / support group especially for woman e. Promote participation of women in delivery of services
176

7.7.2

Under NLEP, it is proposed to encourage increased participation of persons affected by leprosy in planning as well as in programme implementation. At the central level, the Chairman of the National Forum for People Affected by Leprosy is a member of the Technical Resource Group on NLEP. Towards this end, the States / UTs will be requested to include one member from the local organization of persons affected by leprosy in each of the following committees: i) Village Health and Sanitation committee ii) PHC Health Monitoring and Planning committee iii) iv) v) Block Health Monitoring and Planning committee District Health Monitoring and Planning committee State Health Monitoring and Planning committee

7.8

Programme Management The erstwhile state & district leprosy societies have been merged with the state & district health societies. The state & district leprosy units will work under Health societies. However, a separate NLEP account will be maintained under NRHM. 7.8.1. Central Leprosy Division The Central Leprosy Division need to be provided with consultants for different vital functions like, Disability care, Training/IEC, Finance, public health, Programme Monitoring, Research & Evaluation, Data entry operator, Programme assistant and Driver.
Table 23

Sl. No. 1. 2 3 4 5 6 7 8 9 10

Post

No

Public Health Consultant Training/IEC Consultant DPMR Consultant Programme Monitoring Research & Evaluation Finance Logistics & Supply Date Entry Operator Prog. Assistant Driver Total

1 1 1 1 1 1 1 5 2 1 15

(Rs. In Thousand) Consolidated Salary Cost for 1 Total per month in Rupees year cost for 5 years 50,000 600 3000 50,000 600 3000 50,000 600 3000 50,000 600 3000 45,000 540 2700 40,000 480 2400 40,000 480 2400 12,000 720 3600 15,000 360 1800 11,000 132 660 5112 25560

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7.8.2. State Leprosy Societies 7.8.2.1 In the 27 States viz. Andhra Pradesh, Assam, Arunachal Pradesh, Bihar, Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Jharkhand, Jammu & Kashmir (separate SLS for Jammu division also), Karnataka, Kerala, Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, Punjab, Rajasthan, Sikkim, Tamilnadu, Tripura, Uttar Pradesh, Uttaranchal and West Bengal, for strengthening the State Leprosy Unit, as during the 11th Plan Period, following categories of staff will be required to be provided to the State Leprosy Unit on contract basis for smooth functioning :Budget and Finance cum Admin. Officer 1 Admin. Assistant 1 Data Entry Operator 1 Driver 1 7.8.2.2 In 8 smaller State/ UTs viz. Goa, Delhi, Chandigarh UT, A& N Island, Lakshadweep, D&N Haveli, Puducherry and Daman & Diu. following categories of staff will be required to be provided to the HQ State Leprosy Unit on contract basis for smooth functioning:Admin. Assistant 1 Data Entry Operator 1 Driver 1 7.8.2.3 These staff will be in addition to the regular staff being provided to the State & District Leprosy Unit by the State/ UT from Non-Plan budget. The State Leprosy Unit will also tie up with the state NRHM and get the benefit from the Financial Management Unit as well as the state Data Management Units. The State Leprosy Officers are likely to be holding more than one post. In such a situation, another officer is needed to be in position in the State HQ Cell to assist the State Leprosy Officer. During the 11th Plan a Surveillance Medical Officer (SMO) was posted in the 27 major states and in Delhi, Chandigarh and Dadra & Nagar Haveli. The SMO may be a Medical graduate (MBBS) with about 5 years experience in working in any public Health Programme. The post of SMO is proposed to be continued during the 12th plan period in the 30 States and UTs.

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Manpower Cost
Table 24 (Rs. In Thousand)

Sl.No

Post

No

1 2 3 4 5

Surveillance Officer

Medical 30

Consolidated Cost salary per year month/per person (in Rupees)* 40,000 30,000 16,000 12,000 11,000 -

for

1 Cost 5 years

14,400 10,080 6,912 5,184 4,752 41328

72,000 50,400 34,560 25,920 23,760 206640

Budget & Finance officer 28 cum Administrative officer Admin Assistant Data Entry Operator Driver Total 36 36 36 136

*The salaries are indicative and need to be firmed up considering respective state salaries and NRHM scales. 7.8.3 District Leprosy Society 7.8.3.1 The District Leprosy Offices will function during the 12h Plan period, with the existing staff. The District Leprosy Officer either full or part-time, and a fully functional District Nucleus will be the basic structure of the DLS. In addition to the regular staff being provided to the District Leprosy Cell following staff on contract basis will be required. Although 209 districts have been identified as high endemic districts there may be some other districts where special activities may be required to be conducted. It is proposed to place one Medical Officer in each of about 300 high endemic districts to strengthen district leprosy programme. Physiotherapists are essential for POD care and for pre and post RCS care, who are not available under the programme now. It is proposed to keep provision for 300 Physiotherapists on Contractual basis in the District Hospitals of high endemic districts, so that the referral system can be put in right perspective. During the 11th plan period, provision of 1 contractual driver per district where regular driver was not available was kept for use (A total of 300 drivers were provided). Provision for about 300 contractual drivers have been kept for the 12th plan period. However the allotment per state will be based on actual requirement
179

indicated in the annual action plan. The states are requested to utilize services of surplus drivers available in health departments / other departments in districts which could be utilized for running vehicles under NLEP.
Table 25 (Rs. In Thousands)

Sl.No Post

No

1 2 3

Medical officer Physiotherapist* Driver Total

300 300 300

Consolidated Salary per month in Rupees 40,000 25,000 11,000

Cost for 1 Cost year years

144000 90,000 39,600 273600

720,000 450000 1,98,000 1368,000

7.8.3.2 During the 11th Plan period a few skeleton leprosy staff was provided to the states of Punjab, Haryana, Delhi, Chandigarh UT and Dadra & Nagar Haveli as they did not have any regular staff to even form the district nucleus. Provision of one NMS per district need to be made for these States/ UTs during the 12th Plan period. One NMS is also proposed to be provided to Lakshadweep on contract basis, during 12th Plan, as the UT has no regular NMS.
Table 26 (Rs. In Thousands)

Sl.No

State /UT

1 2 3 4 5 6

Punjab Haryana Delhi Chandigarh UT Dadra & Nagar Haveli Lakshadweep Total

No. of Consolidated NMS Salary per month in Rupees 20 20,000 21 20,000 10 20,000 2 20,000 1 20,000 1 20,000 55

Cost for 1 Cost 5 year years 4800 5040 2400 480 240 240 13200 24000 25200 12000 2400 1200 1200 66000

7.8.3.3 For better programme management, it is essential that the District Nucleus component is filled up with DLO, MO, NMS/PMW and Physiotherapist / Physio-technician as per requirement with mobility support. 7.8.3.4 The District Nucleus unit members should be well trained and remain functional.

7.8.4

Block PHC
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7.8.4.1 Leprosy was a vertical programme run by specially trained staff under the District Leprosy Officers till 2002-03. The teams had adequate staff strength with mobility support. The integration of leprosy services with the General Health Care system was started from the year 2002-2003 and was completed by March 2005. At that time only 25% of the erstwhile vertical staff (NMS, PMW, Physiotechnician, Health educator etc.) were retained with NLEP and rest of the staff was surrendered to the GHC to work as Multi-Purpose Workers and Supervisors. During this process senior persons were retained under NLEP as they had greater expertise. During the last 6 years, a number of persons have retired on superannuation and in most of the states, these posts remained unfilled. This resulted in shortage of manpower like Para Medical Worker (PMW) at block PHC level. 7.8.4.2 To run the NLEP at block level, the medical officers are still dependent on the vertical components, which are gradually receding. The GHC staff has to perform various other programme works and therefore to provide one person only for leprosy work is getting difficult. In high endemic districts and block having ANCDR > 10/100,000 population, due care could not be provided to the persons affected by leprosy.

7.8.4.3 The SLOs are voicing their concern as programme activities as designed for NLEP are not being fully carried out at block PHC level, resulting in not attaining the level of quality services as desired. It is therefore felt necessary that during the 12th five year plan, the state should be advised to post one PMW in the block PHC in each high endemic block. 7.8.4.4 In the 300 high endemic districts identified for special action during the 12th five year plan, there are approx.3000 blocks with ANCDR>10/100,000 population. Provision of about 3000 PMWs on contracts basis, need to be made under the plan.
Table 27

(Rs. In Thousands) Sl. Post No Consolidated Salary Cost for 1 Cost 5 No per month in Rupees year years 1 Para Medical Worker 3000 16,000 576,000 288,00,00

7.8.5

Central Govt. Institutions

7.8.5.1 Central Leprosy Teaching and Research Institute (CLTRI), Chengalpattu and 3 Regional Leprosy Teaching and Research Institute (RLTRI) at Raipur, Aska and Gouripur are to continue to provide support to the programme during the 12th
181

plan period. These Central Govt. Institutions will not involve any cost to the programme, for these regular activities. However it is proposed to upgrade the Central Leprosy Teaching and Research Institution (CLTRI), Chengalpattu and the Regional Leprosy Teaching and Research Institution (RLTRI), Raipur to the level of comprehensive Rehabilitation Institutes. For the above purpose, following categories of staff are proposed to be provided on contractual basis (i) Junior Resident - 2 (1 for each Institution) (ii) Orthotist / Prosthetist - 2 (do) (iii) OT Technician - 2 (do) (iv) Data Entry Operator - 2 (do) In addition provision for few necessary equipment has been kept.
7.8.5.2 Cost Table 28

Sl. No 1. 2 3 4

Item

No

Junior Resident Orthotist/Prosthetist OT Technician Data Entry Operator Total

2 2 2 2 8

(Rs. In Thousands) Consolidated Cost for 1 Cost for 5 years Salary per month year in Rupees 35,000 840 4200 20,000 480 2400 15,000 12,000 360 288 1968 1800 1440 9840

Additional/New activities during the 12th Plan

It is proposed to cover the identified priority districts under special programme activities during the 12th plan period. As the thrust during the 12th plan is to achieve elimination in all the districts of the country, 209 districts have now been identified as priority district as on March 2011 based on ANCDR more than 10/100,000 population. These 209 districts will be continued to be treated as priority district during the entire plan period, irrespective of change in status expected in any of the years. Further, on the basis of ANCDR, Disability rate, child case rate and training status of medical and paramedical personnel these 209 districts will be categorized. Special activities will vary according to the category of the district. Similar categorization will also be done in all the districts of the country for suitable necessary action.

182

Cost Table-29 (Rupees in Thousands) 2015-16 2016-17 Total Rs. 20.90 Cr.

Sl. No 1

Item

2012-13

2013-14 -

2014-15 104500

Special activities 104500 In High endemic districts

Budget and source of funds

Proposed requirement of fund under 12th plan budget has been worked out to Rs 787.00 crore. Entire cost is to be borne out of Govt. of India budget except for free supply of MDT drugs till 2017 by WHO. Year-wise and Source-wise budget proposed are as below:Table 30

(Rupees in Crores) Source GOI EAC Total

2012-13 160.03 7.00 167.03

Year-wise Budget 2013-14 2014-15 2015-16 145.13 159.05 144.65 7.00 7.00 7.00 152.13 166.05 151.65

2016-17 143.14 7.00 150.14

Total Budget 752.00 35.00 787.00

Component and item-wise proposed budget is given at Annexure I/A.

Additional Support to NLEP

9.1 World Health Organization (WHO) MDT WHO has already intimated that the support of providing MDT & BCPs for treatment of all leprosy patients in the country will continue with funds from donor NOVARTIS. Special Package for NLEP The support being provided by WHO with funds provided by the Sasakawa Memorial Health Foundation and The Nippon Foundation, Japan is to continue till December 2011. WHO support under this Head during 12th Plan is not known.

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9.2 International Federation of Anti-leprosy Association (ILEP) The ten members organization working as Partners in NLEP in India under the banner of International Federation of Anti-Leprosy Associations (ILEP) is providing support to NLEP as a partner till March 2012 as per MoU signed between the GoI and the ILEP on 24th October 2007. The ILEP support during the 12th Five Year Plan and its scope is not known.

10

Expected Outcome
The Main indicators to be used under the programme to measure the progress and outcome expected are as below Indicators PR < 1/10,000 all districts ANCDR <10/100,000 all districts) Cure rate MB Cure rate PB Outcome expected by March 2017 100% 100% >95% >97%

No. and rate of new cases with Gr. II disabilities cases/10,00,000 population-35% reduction (Base 2011-12) Other additional indicators to assess the quality of services provided e.g. proportion of cases correctly diagnosed, Defaulter rates, Cases with disability after initial treatment, number of relapses, Proportion of new MB, Child, Female and Disability cases are to be used.

184

Annexure I/A Component and Item-wise Cost for 5 Years of 12th Plan (April 2012 to March 2017) (Rs in Crores) . S. No. 1 Component Early Case Detection Component-wise cost 43.25

2 3

Case Management Stigma Reduction Development of Leprosy Expertise

148.57 36.15

8.15

Operational Research

1.20

Supervision Monitoring & Review Programme Management Total

94.07

455.60 787.00

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National Center for Disease Control (NCDC)

INDEX
A. NCDC:ONGOING ACTIVITIES
1. NCDC UP- GRADATION 2. Pilot Project on Prevention and Control of Leptospirosis in 11th Plan 3. Pilot Project on Prevention & Control of Rabies in 11th Plan 4. Disease Surveillance and Response Programme 5. Surveillance of YAWS & Guinea worm 6. Implementation of IHR (2005)

B. New Activities during 12th Plan

7. Up-gradation of existing regional branches and establishment of 27 new branches of NCDC 8. National Programme Resistance (AMR) for Containment of Antimicrobial

9. Prevention & Control of Viral Hepatitis 10. Establishment of inter-sectoral coordination and control of selected Priority Zoonotic Diseases

(iv)

ONGOING ACTIVITIES

1. NCDC UP-GRADATION
National Centre for Disease Control (NCDC), formerly known as National Institute of Communicable Diseases (NICD), is an apex public health institution which was established to function as a national centre of excellence for control of communicable diseases and in the areas of training and research using multi-disciplinary integrated approach. The institute provides expertise to the States and Union Territories (UTs) on rapid health assessment and laboratory based diagnostic services. Surveillance of communicable diseases and outbreak investigation also form an indispensable part of its activities. In view of the changing disease scenario and emerging public health challenges, there is a need to broaden the scope of NCDC. This institute provides technical expertise in the field of disease control activities and acts as a center of excellence for man-power development, providing technical guidelines and advice to various health agencies including national authorities. It undertakes surveillance of major communicable diseases, keeps vigil over emerging health problems and recommends appropriate measures to the Government to tackle the situation. NCDC played a major role in successful eradication of Smallpox and Guinea worm disease from India, has been the nodal agency in containment of SARS, Avian Influenza & Pandemic Influenza and is also working towards Yaws Eradication. NCDC, with its composite expertise for disease investigation, prevention/control and management activities, is unique among all public health institutes in the country. The Institute has eight out-station branches located in different states at Alwar (Rajasthan), Bangalore (Karnataka), Coonoor (Tamilnadu), Jagdalpur (Chattisgarh), Kozhikode (Kerala), Patna (Bihar), Rajamundry (Andhra Pradesh) and Varanasi (Uttar Pradesh). The Institute is proposed to be upgraded as a Centre for Disease Control and renamed as the National Institute for Disease Control (NCDC). The up gradation of this premier institute in the country tasked to address the matters relating to infectious diseases is the need of the hour particularly when it is called upon to address newer infections and is also to keep pace with developments in disease control happening around the globe. Laboratories shall be strengthened through procurement of modern equipment to make the diagnostic services modernized, including induction of rapid diagnostic support services. The proposed up-gradation envisages creation of newer centers, newer divisions and up scaling of the existing ones to cope-up with the ever increasing horizon and magnitude of emerging and reemerging and new diseases. The expected outcomes from proposed upgradation, amongst others would include: Enhanced scope of referral diagnostic support services for disease outbreak investigations and networking of public health laboratories. Enhanced data management capacity under Integrated Disease Surveillance Enhanced capacity for development of trained manpower in public health.
186

Trained, dedicated Central Rapid Response Teams (RRTs) available 24X7 for disease outbreak control. Enhanced quality operational research for better disease control. Preparedness against probable threats of bioterrorism. EFC recommended the project at a total cost estimates of Rs.382.41 crores. The cabinet committee on economic affairs (CCEA) approved the proposal in December, 2010. National Building construction corporation (NBCC) has been engaged as an agency for construction of civil and services works. Agreement between NCDC and NBCC is under finalization and expected to be executed shortly. Specifications for equipment to be procured and installed have been finalized. Out of 245 additional posts proposed, 103 technical posts have since been sanctioned by the government. The matter is being followed for sanction of the remaining additional posts proposed. In addition, efforts are being made at various levels to obtain approvals from local authorities on the site plan and master plan before tender is floated by the construction agency.

1.1 Status of upgradation of NCDC

HSCC (India) Limited, NOIDA engaged as Consultant for preparation of Detailed Project Report (DPR). DPR-I and DPR-II submitted by HSCC. The Expenditure Finance Committee under the Chairpersonship of Secretary (Expenditure), Department of Expenditure, Ministry of Finance recommended the proposal for proposed upgradation of NICD to NCDC in its meeting held on 3rd August, 2010. Cabinet Committee on Economic Affairs (CCEA) approved the proposal in December, 2010 at a total cost estimate of Rs.382.41 crore. National Buildings Construction Corporation (NBCC), New Delhi has been engaged as agency for construction of civil and services works. Agreement to be executed between NBCC and NCDC is under finalization. The matter is being pursued regularly at various levels for obtaining required approvals of the various local authorities (clearances from Delhi Development Authority and Delhi Fire Services Department on master plan and site plan received. Application for seeking clearance from Heritage Conservation Committee (HCC) submitted). After clearance from HCC, approval from Delhi Urban Arts Commission (DUAC) shall be obtained. After receipt of approval of DUAC, Construction Agency will float the tender for engaging contractor. All existing buildings except heritage structures would be demolished for undertaking construction of new buildings.

187

1.2 Budget
11thPlanOutlayapprovedforNCDCupgradation:Rs.450.00Crore CCEAapprovedupgradationofNCDCinDecember2010forRs.382.41Crore Expenditureduring11thplanason15.6.11:Rs.2.59Crore

Finally approved up-gradation of NCDC seeks to accomplish its mission by working with state health authorities throughout the country to achieve the following: Providing Leadership and advocacy for public health activities, Detecting and investigating health problems, Developing human resource in public health through post graduate doctoral and inservice programmes, Conducting applied research to enhance prevention, Developing and advocating healthy public policies and prevention strategies, Promoting healthy behaviors, Developing network of public health institutions, Capacity Building for public health and laboratory services Working as National Reference Center (somewhat similar to CDC, USA) for diagnosis, prevention and control of diseases of major public health importance.

To accomplish the above tasks new technical centers have been approved by CCEA in 11th Five Year Plan which are:

1.3 New Technical Centres

1.3.1 Central Administrative Complex 1.3.2 Central Facilities
Central Library/ Archival & e-Library Central Auditorium/Conference Complex Guest House & Hostel Complex Central Recreation Unit & Central Cafeteria Central Maintenance Wing & Other Supportive Services

1.3.3 Epidemiology & Disease Control Complex

24x7 Disease Control Cell Centre for Integrated Disease Surveillance Centre for Infectious Diseases o Vector-borne & Other Arboviral /Exotic Diseases o Air-borne Respiratory Diseases o Blood-borne Diseases & STIs o Water/ food-borne Diseases
188

1.3.4 Centre for Vaccine Preventable Diseases

Polio/ Measles/MMR /Meningitis vaccination strategies Rabies vaccination strategies Viral Hepatitis vaccination policy Newer vaccines: vigilance & policies

1.3.5 Centre for International Health & Bioterrorism Prevention

International Health, Health Intelligence & Communication International Health Regulations (IHRs) Ethical & IPR Considerations Vigilance on Bioterrorism and Prevention Initiatives

1.3.6 Centre for Disaster Epidemiology & Emergency Response

Post-disaster control of diseases Disaster Epidemiology & Management

1.3.7 Centre for Medical Informatics & Bio-statistics

EDUSAT Earth Station & Information Technology Cell Central Computer Facility Bioinformatics & MIS Biostatistics & Data Analysis

1.3.8 Centre for Manpower Development

Planning & coordination of National/ International/ WHO Trainings Organizing Workshops, Seminars, Meetings and Conferences

1.4 Referral Diagnostics & Laboratory Services Complex

1.4.1 Central Laboratory Facilities
24x7 Central Sample Collection & LIMS-based e-reporting Central BSL-3 facility Central Electron Microscopy Unit Central Instrumentation Facility Central Animal House

1.4.2 Centre for Viral Diseases & Vaccines

Polio/ Enteroviruses Reference Laboratory Measles/ Respiratory Viruses Reference Laboratory National Nodal Laboratory for Endemic/Pandemic-prone Viruses (SARS, Corona, Nipah, InfluenzaA H5N1, H1N1 & other emerging viruses) Congenital Viruses (Rubella, CMV, HSV) Laboratory Viral Hepatitis Laboratory
189

1.4.3 Centre for HIV/AIDS & Related Diseases

National AIDS Reference Centre HIV Serology & Quality Control AIDS: Cellular Immunology Laboratory HIV: Molecular Diagnostic Laboratory VCTC: HIV/AIDS Counselling Centre

1.4.4 Centre for Arboviral & Zoonotic Diseases

Arboviral/Exotic Viral Infections Plague Reference Laboratory Kala-azar & Toxoplasma Laboratory Leptospira Reference Laboratory Typhus/Rickettsial & Newer Zoonotic Infections Rabies Reference Laboratory

1.4.5 Centre for Bacterial Diseases & Drug Resistance

Cholera/Typhoid & other Enteric Bacterial Infections Pulmonary & Extra-pulmonary Tuberculosis Laboratory Meningitis and other Respiratory Bacterial Infections Anaerobic Bacteriology Bacterial STIs, Chlamydia/ Mycoplasma Reference Laboratory Bacterial Drug Resistance Unit

1.4.6 Centre for Biotechnology & Molecular Diagnostics

Molecular Diagnostics & DNA Fingerprinting of Disease Pathogens Gene Cloning & DNA Synthesis Laboratory Molecular Virology/Bacteriology Reference Laboratory Real-time PCR for Quantification & Prognostic Follow-up Drug Resistance Gene Monitoring Laboratory

1.4.7 Centre for Parasitic & Fungal Diseases

Human Parasitic Diseases o Malarial/ Helminthic Infections o Intestinal Parasites & Amoebiasis Human Fungal Diseases o Deep mycosis o Superficial mycosis

190

1.4.8 Centre for Clinical Biochemistry & Toxicology

Clinical Biochemistry/Hematology Environmental Toxicology IDD Reference Laboratory Protein Chemistry & Antigen Assay Laboratory

1.4.9 Centre for Pathology & Immunohistology

Clinical & Diagnostic Pathology Immunohistology

1.4.10 Centre for Medical Entomology & Vector Management Complex

Medical Entomology & Disease Ecology o Vectors of Malaria, Dengue, JE, Filaria, Kala-azar, Ectoparasites o Transmission dynamics & Vector Ecology o Archival Museum

1.4.11 Integrated Vector Management

Chemical Control of Disease Vectors Alternate methods of Vector Control Environmental management methods for Disease Control

1.5 Reporting system (24X7) for capturing & disseminating disease related information on real time basis for early warning signals
1.5.1 Objective
To provide data for better informed action regarding influenza and other diseases prevention and control efforts, including vaccination campaigns. These include data on:

o o

epidemiology and seasonality data of influenza & other diseases ; groups at higher risk for severe outcomes, including hospitalization and deaths;

1.5.2 Activities
Round the clock working of outbreak monitoring cell and data collection & analysis of outbreaks in different parts of the country There will be one epidemiologist and 6 technical staff, one data manager to make the cell operational, 24X 7. NCDC will provide rest of the facilities.

191

Budget Influenza /24x7: Rs.6.10 crore .

PROPOSOSAL FOR 12th FIVE YEAR PLAN IN RESPECT OF INFLUENZA SURVEILLANCE (FIGURES IN CRORES OF RUPEES) Sr.No 1 Major Head "2210" Professional Services Grant Total 2012-13 1.22 1.22 2013-14 1.22 1.22 2014-15 1.22 1.22 2015-16 1.22 1.22 2016-17 1.22 1.22 GRAND TOTAL 6.10 6.10

1.6 Masters of Public Health (Field Epidemiology) [MPH-FE] course

NCDC is involved in public health service delivery (e.g., emergency response, outbreak investigation) and in multiple, long-term and short-term training activities in various disciplines. Two years Master in Public Health Field Epidemiology (MPH FE) of NCDC started in 2006. The course is affiliated with Guru Gobind Singh Indraprastha University, Delhi. The Goal of the course is to strengthen Public Health services by developing a cadre of professional Field Epidemiologists for the benefit of the society. MPH students have extensive supervised field visits. The students not only have to learn from the experience of NCDC faculty but also learn from faculty from other institutes through out the country. For this, NCDC needs temporary additional input to ensure the quality of the didactic learning activities and field investigations, to coordinate with various State Governments/ Institutes. During field investigation students require laptops/ software and other IT equipment. Budget for this activity will improve the quality of the course. The budget requirement to be reflected in the regular budget of NCDC.

Budget required for NCDC Upgradation will be as under:

(Rs. In Crores)

Major Head 1. Supportive Infrastructural development 2.Machine & Equipment non-recurring Total

2012-13 200.00 4.00 204.00

2013-14 103.00 38.10 141.10

2014-15 0.00 4.90 4.90

2015-16 0.00 0.00 0.00

2016-17 0.00 0.00 0.00

Total 303.00 47.00 350.00

* Note In accordance with EFC, budget for additional regular post to be provisioned in regular budget of
NCDC (Plan) after March 2012.

192

1.7 Operational Research Activities

1.7.1 Introduction
Disease burden estimates which are based on good epidemiological research provide the crucial evidence for public policy. Disease burden data can enable focused targeting and help decide what needs to be done and where, for whom and when. Diseases that are more common among working age adults or the poor, as is the case with HIV/AIDS, tuberculosis (TB), etc, have major impact.

1.7.2 Justification
Limited data is available on burden of diseases in India. According to the report published by National Commission on Macroeconomics and Health on Burden of Disease in India exhaustive review of the available literature brought forth two factors of critical importance to public policy: (a) for almost all diseases/conditions identified, and more particularly the National Health Programmes in which government investment was substantial, namely, malaria and other vector-borne diseases, TB, leprosy, reproductive health and childhood conditions, there is a paucity of high-quality epidemiological information and validated data for arriving at any baseline estimations on prevalence or incidence.. In view of the scarcity of disease burden data especially for communicable diseases, NCDC proposes to conduct longitudinal epidemiological studies to estimate the burden of important communicable diseases in India.

1.7.3 Budget
The budget requirement for disease burden estimation is about Rs. 14 crore using infrastructure under disease surveillance programme.

193

2. Pilot Project on Prevention and Control of Leptospirosis in 11th Plan

2.1 Magnitude of the problem
Due to rapid ecological changes in the region during the past decade many zoonoses have emerged and resulted into epidemics causing significant morbidity and mortality in human beings in different parts of the country. Leptospirosis is one of the disease which predominantly occurs in coastal region. The Andaman Islands have been known to be an endemic focus of leptospirosis since the 1920s. The outbreaks of leptospirosis are increasingly being reported from other states such as Kerala, Gujarat, Tamil Nadu and Karnataka. In addition, cases have also been reported from Goa, Andhra Pradesh, Orissa and Assam.

2.2 Activities in the 11th Plan

A pilot project on Control of Leptospirosis was approved as a New Initiative in the 11th Five Year Plan in March, 2008 and was carried out in 5 endemic states. The project was carried out in 4 districts of Gujarat (Surat, Navsari, Valsad and Tapi), 2 districts of Kerala (Kottayam and Allepey), 2 districts of Tamil Nadu (Villupuram and Thiruchirapalli,) 4 districts of Maharashtra (Ratnagiri, Thane, Sindhudurg, Raigad ) and 2 districts of Karnataka (Mangalore & Shimoga). The objective of the pilot project was to reduce the morbidity and mortality due to Leptospirosis in pilot project areas.

2.3 Budget
A total of Rs. 2.36 Crores allocated, of which Rs. 2.31 Crores spent.

2.4 Pilot Project Strategies

Reduction of morbidity Strengthening laboratory diagnostic capacity Strengthening of patient management facilities Developing trained manpower Creating awareness regarding timely detection and appropriate treatment of patients

2.5 Outcome of the Pilot Project

Clinically suspected Leptospirosis patients in leptospira-endemic project areas during rainy season were given presumptive treatment of leptospirosis at PHCs. All suspected leptospirosis cases whether positive or negative with rapid immunodiagnostic test having features of organ dysfunction were immediately shifted to higher centre. With the implementation of the

194

components of pilot project strategy there has been reduction in morbidity and mortality due to leptospirosis in pilot project areas. The strategy for prevention and control of leptospirosis has been found to be feasible and implemenable and shall be provided to the States for further implementation.

2.6 Gaps in the 11th Plan

The Pilot project was carried out only in five endemic states of the country. The remaining endemic states were not covered. The intersectoral coordination was inadequate during the implementation of Pilot project in the 11th five year plan.

195

2.7 Proposal for Leptospirosis control in the 12th Plan

The proposal is to expand and implement the strategy for prevention and control of Leptospirosis developed during 11th Plan in all the endemic states during the 12th Plan period. The strategy evolved and guidelines formulated will be shared and distributed to all endemic states.

2.7.1 Does the strategy need change/paradigm shift?

The strategy of the pilot project was critically reviewed in different meetings chaired by DGHS and in the meetings of Standing Committee on Zoonoses. The strategy was found to be effective and implementable and can be provided to the States for further implementation. Thus there is no change required or proposed in the strategy.

2.7.2 Ownership
The roles and responsibilities of various components at centre, state and intersectoral level shall be clearly defined in consultation with the states.

2.7.3 Capacity building

Training of professionals regarding prevention, diagnosis, management and control of Leptospirosis will be undertaken. This will help in early case detection and proper management of the patients.

2.7.4 Inter-sectoral co-ordination

Sensitization of other sectors viz. veterinary and agriculture will be undertaken to establish intersectoral coordination for prevention and control of Leptospirosis.

2.7.5 Strengthening of patient management facilities

Funds will be provided for strengthening the existing patient management facilities.

2.7.6 Information, Education and Communication

IEC will enhance awareness in the general public regarding prevention and control of Leptospirosis. The awareness will result in early reporting of cases to treatment facilities.

2.7.7 Monitoring of the activities

The activities would be periodically monitored and evaluated by undertaking visits to the endemic areas. On day to day basis monitoring will be done by the designated officers of the state governments.

196

2.7.8 Outcome
The suspected cases of leptospirosis will get timely and appropriate treatment and awareness in community will help in reducing mortality and morbidity due to leptospirosis in endemic states.

2.7.9 Budget
The estimated total cost is Rs. 3.69 Crores Budget: Prevention and control of Leptospirosis, 12th Five year Plan (Rs. In Lacs) st nd rd th Capacity Building: Training courses 1 yr 2 yr 3 yr 4 yr 5th yr Total Training of professionals on management and control of Leptospirosis (2 courses/yr X 20 participantsX Rs 200/participant) Laboratory diagnostic techniques (1 course/yr X 10 participantsX Rs 200/participant + lab reagents) Strengthening Patient management Facilities (10 lacs X 6 State) Intersectoral coordination: Expert group meetings (1 meeting/yr X 20 participantsX Rs 200/participant) Professional services Consultant @Rs 50000/pm & DEO @ Rs 15000/pm x12 mths Printing of Strategy TA/DA for field visits Total 0.08 0.08 0.08 0.08 l 0.08 0.40

0.50

0.50

0.50

0.50

0.50

2.50

60.00

60.00

60.00

60.00

60.00

300.00

0.08

0.08

0.08

0.08

0.08

0.40

7.80

7.80

7.80

7.80

7.80

39.00

2.00 5.00 75.46

5.00 73.46

5.00 73.46

5.00 73.46

5.00 73.46

2.00 25.00 369.30

197

3. Pilot Project on Prevention & Control of Rabies in 11th Plan

3.1 Magnitude of the problem
Rabies is a major public health problem in India. An estimated 20000 deaths occur annually which is about 1/3rd of total global mortality. Estimates suggest that 17.4 million animal bites occur annually (APCRI, Multicentric study to Assess Disease Burden 2004). Dogs inflict more than 95% of bites. Only about 3.0 million receive Post Exposure treatment as per available vaccine utilization data. Rabies is cent percent fatal however it is nearly cent percent preventable by timely and appropriate post exposure prophylaxis (PEP).

3.2 Activities under 11th Plan

As a New Initiative a Pilot project on Prevention and Control of Rabies is being carried out in five cities viz Ahemdabad, Bangalore, Delhi, Pune & Madurai with the total budget of Rs 3.69 crores. The main objective of the project is to prevent human deaths due to rabies. The project focuses on Improving the management of animal bite cases o Training of health professionals o Operationalisation of ID route in selected centres o Ensuring availability of rabies vaccines and Immunoglobulins (RIGs) Enhancing awareness in general community regarding timely and appropriate Post exposure treatment Strengthening diagnostic capabilities Establishing interface with animal husbandry department Strengthening surveillance

3.3 Budget
Budget allocated Rs. 3.69 Crores; expenditure Rs. 2.53 Crores

3.4 Outcome of the pilot project

Improvement in management of animal bite cases: 43 core trainers trained at NCDC, Delhi have in-turn trained approximately 2065 doctors and paramedical staff in appropriate animal bite management in the pilot project areas improvements are: o Uniform and appropriate animal bite management as per the guidelines. o Wound washing facilities in all the centres.
198

o Implementation of ID route -wider coverage in the available quantity of vaccines and economical PEP: 54 centres in the pilot project cities have implemented ID route of inoculation of cell culture vaccines. o Increased and appropriate immunoglobulins. use (local Infiltration in the wound) of

o Establishment of new ARCs in Ahemdabad, Bengaluru and Pune. Enhanced awareness in general community regarding timely and appropriate treatment. Diagnostic capabilities strengthened in each pilot project city. Interface with other sectors is being developed for coordination of health and veterinary component to develop national consensus strategy. Surveillance has been strengthened.

3.5 Gaps in 11th plan

Rabies continues to be a major public health problem in India accounting for about 1/3rd of global mortality No organized control activities in the country, though a Pilot project in 5 cities to prevent human deaths due to Rabies was started. No tangible control of rabies in reservoir (stray dog) Availability of PEP limited to urban and peri-urban areas Inadequate community involvement

199

3.6 Proposal for National Rabies Control Programme in 12th Plan

Based on the successful implementation of the Pilot Project of Rabies Control in 5 cities during 11th Plan, it is proposed to expand and implement the strategy as a National Programme for control of Rabies during the 12th Plan. This will also include initiating vaccination of stray dogs at 30 selected sites in first phase along with Community involvement in Rabies Control and strengthening inter-sectoral co-ordination

3.6.1 State Ownership

The roles and responsibilities of various components at Centre State Civic Body level and intersectoral coordination level shall be clearly defined in consultation with States

3.6.2 Justification of proposal

Rabies is of immense public health importance because The disease is endemic throughout the country. Rabies is 100% fatal yet 100% preventable with timely and appropriate post exposure treatment. The number of human deaths: 20000 every year of the total 55000 global deaths. Estimated number of Dog bites : 17.4 million /year. Besides human deaths, rabid dog bites cause heavy financial loss to live stock owners from deaths in cattle, camel, horses, sheep goat etc. 95% of human rabies deaths due to rabid dog bites.

Rabies therefore poses a heavy burden both in terms of loss of humans /animal life as well as financial loss.

3.6.3 Objectives
Reduction of human mortality due to rabies and cutting down transmission

3.6.4 Strategies
The programme focus on: Based on the success of 11th Plan pilot project a National Rabies Control Programme is proposed. Strengthening of PEP to prevent human deaths in all States/UTs. Vaccination of stray dogs at 30 selected sites initially. Operationalization of cost effective and efficacious intradermal route for PEP. Extension of rabies treatment facilities to peri-urban/rural areas. Active involvement of NGOs and community. Strengthening intersectoral coordination.

3.6.5 Outcome Indicators

200 Establishment of new Anti-rabies Centers (ARCs).

Increased number of ARCs giving immunoglobulins. Number of ARCs using intradermal inoculation of vaccines. Number of ARCs with wound washing facilities. Increased laboratory based diagnosis of rabies. Increased registration and licensing and immunization of pet dogs. Vaccination of 70% of dog population in identified areas.

3.6.6 Monitoring and Evaluation

The programme will be regularly monitored by nodal agencies and periodically reviewed by Standing Committee of Zoonosis, Joint Monitoring Group and Inter -Ministerial Group

3.6.7 Budget
The estimated total budget is Rs.384.59. Budget: National Programme for Rabies Control: Proposal 12th Five year Plan (Rs. in crores)
Capacity Building: Training courses Supplementary provision of Immunoglobulins Mass Vaccination of stray dogs in 30 centers Laboratory strengthening 5 Regional labs @ 10 lakhs per lab IEC Intersectoral coordination: monitoring Contractual Manpower Printing & district wide dissemination of Strategy Total 1st yr 0.5 50.00 4.20 0.50 20.00 1.0 1.026 0.04 77.266 2nd yr 0.5 50.00 4.20 0.05 20.00 1.0 1.026 0.04 76.816 3rd yr 0.5 50.00 4.20 0.05 20.00 1.0 1.026 0.04 76.816 4th yr 0.5 50.00 4.20 0.05 20.00 1.0 1.026 0.04 76.816 5th yr 0.5 50.00 4.20 0.05 20.00 1.0 1.026 0.04 76.816 Total 2.50 250.00 21.00 0.70 100.00 5.0 5.13 0.20 384.59

201

4. Integrated Disease Surveillance Project in 11th Plan

4.1 Background
Integrated Disease Surveillance Project (IDSP) was launched with World Bank assistance in November 2004 to detect and respond to early warning signals of disease outbreaks and to initiate an effective response in a timely manner. The project has been extended for two years up to March 2012 but the World Bank is funding Central Surveillance Unit (CSU) at NCDC & 9 identified states and the rest 26 states/UTs are being funded from domestic budget. Further World Bank assistance will not be available after March 2012 and the programme will need to be given all the funding from GOI domestic budget. It may be mentioned that IDSP has already been merged with NCDC (National Centre for Disease Control) administratively & financially in June 2006.

4.2 Objectives
To strengthen the disease surveillance in the country by establishing a decentralized state based surveillance system for epidemic prone diseases to detect the early warning signals to detect and respond to outbreaks at the earliest at all levels.

4.3 Project Components

i. Integration and decentralization of surveillance activities through establishment of surveillance units at district (DSU), state (SSU) and central level (CSU). Human Resource Development Training of State Surveillance Officers (SSOs), District Surveillance Officers (DSOs), Rapid Response Teams (RRTs) and other medical and paramedical staff. Use of Information Communication Technology for collection, collation, compilation, analysis and dissemination of data. Strengthening of public health laboratories.

ii.

iii.

iv.

4.4 Achievements
i. Surveillance units have been established at all State and District Headquarters (SSUs, DSUs). Central Surveillance Unit (CSU) is established and integrated in the National Centre for Disease Control. Training of State/District Surveillance Teams (Training of Trainers) has been completed for 34 States/UTs and partially completed for Uttar Pradesh. 202

ii.

iii.

IT network has been established to connect all States/District HQ and premier institutes in the country for data entry, training, video conferencing and discussion related to outbreaks. So far, IT equipment have been established at 776 out of 800 sites. A portal under IDSP has been established for data entry and analysis to report outbreaks, and to download reports, training modules and other material related to disease surveillance (www.idsp.nic.in). As on July 2011, 85% districts in the country report weekly surveillance data through email and more than 67 % districts report through portal. The weekly data gives information on the disease trends and seasonality of diseases. Whenever there is rising trend of illnesses in any area, it is investigated by the Rapid Response Team to diagnose and control the outbreak. Data analysis and actions are being undertaken by respective State/District Surveillance Units. On an average, 20 outbreaks are reported every week by the States to CSU. A total of 553 outbreaks were reported and responded to by states in 2008, 799 outbreaks in 2009 and 990 outbreaks in 2010. In 2011, 538 outbreaks have been reported in 2011 till 29 May. Earlier only a few outbreaks were reported in the country by the States/UTs. This is an important public health achievement. Majority of the reported outbreaks were of acute diarrhoeal diseases, food poisoning, measles, etc. Media scanning and verification cell was established under IDSP in July 2008. It detects and shares media alerts with the concerned states/districts for verification and response. A total of 1441 media alerts were reported from July 2008 to May 2011. Majority of alerts in 2010 were related to diarrhoeal and vector borne diseases. A 24X7 call center was established in February 2008 to receive disease alerts across the country on a Toll Free telephone number (1075). The information received is provided to the States/Districts surveillance Units through e-mail and telephone for investigation and response. The call centre was extensively used during 2009 H1N1 influenza pandemic and dengue outbreak in Delhi in 2010. About 2.33 lakh calls have been received from beginning till May 2011, out of which about 35000 calls were related to Influenza A H1N1. 50 identified district laboratories are being strengthened in the country for diagnosis of epidemic prone diseases. These laboratories are also being supported by provisions of a contractual microbiologist to mange the lab and an annual grant of Rs 2 lakh per annum per lab for reagents and consumables. Till July 2011,18 States i.e. 26 labs have completed the process of procurement. In 9 World Bank funded States, a referral laboratory network is being established by utilizing the existing 65 functional labs in the medical colleges and various other major centers in the States and linking them with adjoining districts for providing diagnostic services for epidemic prone diseases during outbreaks. Based on the experience gained, the plan will be implemented in the remaining 26 States/UTs. 12 Labs have been strengthened and made functional under IDSP for Avian/H1N1 influenza surveillance.
203

iv.

v.

vi.

vii.

viii.

ix.

x.

xi.

xii.

Recruitment of contractual manpower under IDSP has been totally decentralized in May 2010 so that the State Health Societies recruit them at the earliest. A total of 291 Epidemiologists, 50 Microbiologists and 23 Entomologists are working in States/Districts till now. States have been requested to expedite filling up the remaining contractual positions.

4.5 Reporting of disease surveillance data and outbreaks under IDSP

Morbidity data on selected diseases reported by the states to CBHI during 2006-10 are shown in Table1. Table 1, Morbidity data for selected diseases, 2006-10 (CBHI) 2006 2007 2008 2009 2010 (Prov) ADD 1,02,13,917 1,09,93,639 1,14,08,666 1,19,84,490 1,01,12,845 Viral Hepatitis 1,52,623 1,10,055 92,291 1,24,085 85,164 Enteric Fever 7,89,004 8,20,360 9,34,469 10,99,331 10,34,642 ARI 2,61,52,957 2,61,71,496 2,74,51,421 2,82,40,346 2,47,20,144 Pneumonia 6,81,560 7,46,714 7,32,759 8,01,391 7,32,132 ADD=Acute Diarrhoeal Diseases; ARI= Acute Respiratory Infections. Data from all health facilities including sub-centres which are not manned by a doctor. CBHI collects data on cases and deaths from the entire country. Under IDSP, only 85% districts are presently reporting weekly surveillance data on epidemic prone diseases. These districts report only morbidity data in P Form (based on probable diagnosis by a doctor). No data are collected on mortality in this form. P form will be revised in next plan to collect data on the no. of deaths also. Data reported on selected diseases through IDSP are given in Table 2. Table 2, Morbidity data for selected diseases, 2009-11 (IDSP) 2009 2010 2011 (upto 5 June 2011) ADD including 45,51,508 1,02,83,238 41,62,883 bacillary dysentery Viral Hepatitis 70304 132226 76799 Enteric Fever 614760 979743 399635 ARI 1,19,90,219 2,68,45,978 1,10,08,328 Pneumonia 409388 505343 205730 Note: Data reported by 85% of districts through e-mail/portal (Based on probable diagnosis by a doctor) in 2010 and 2011. There is continuous improvement in reporting. It may be mentioned that about 10 million cases of ADD are reported every year. However, the community based studies indicate that more than 300 million episodes of acute diarrhoea occur every year in India in children below 5 years of age. Thus reported data grossly underestimates the actual problem.
204

States detect, investigate, control and report outbreaks of epidemic prone diseases under IDSP. Outbreaks reported by states in 2008, 2009, and 2010 are shown in Table 3. Table 3, Disease-wise outbreaks reported by states under IDSP, 2008-10 Sl. No. Disease/Illness No. of outbreaks 2008 2009 2010 1 Acute Diarrhoeal Disease 228 332 411 2 Food Poisoning 50 120 184 3 Measles 40 44 94 4 Malaria 43 34 37 5 Chikungunya 25 61 25 6 Viral Fever/PUO 33 39 41 7 Chicken Pox 12 45 47 8 Dengue 42 20 40 9 Cholera 20 34 34 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Total Viral Hepatitis Enteric Fever Acute Encephalitis Syndrome Leptospirosis Anthrax Acute Respiratory Illness Meningitis Mumps Scrub Typhus Dysentery Kalazar Diphtheria Rubella Others 28 6 6 6 2 4 2 0 3 0 1 1 0 1 553 30 10 5 3 6 3 3 2 1 1 0 1 1 4 799 24 10 11 6 3 3 1 3 1 3 3 1 2 6 990

Total 971 354 178 114 111 113 104 102 88 82 26 22 15 11 10 6 5 5 4 4 3 3 11 2342

Note: 538 outbreaks reported in 2011 upto 29 May. It was envisaged that under IDSP weekly disease surveillance data on epidemic prone diseases would be collected from all health facilities providing primary, secondary and tertiary health care. Although 85% of districts are reporting currently, such data are collected from primary health care units and indoor wards of secondary and tertiary care facilities. Efforts are now being made to collect OPD data also form major hospitals. Further, there is also a need to improve the quality of data and outbreak investigations by involving public health laboratories which continue to be the weakest link under the project.

205 4.6 Budget for IDSP under 11th Plan and Utilization

Outlay under 11th Five Year Plan for IDSP Rs. 300.45 Crore Rs. 126 Crore given to DAHD for animal component of Avian Influenza in 2007 Expenditure/amount released to the states till 31 March 2011 Rs. 146.64 Crore

Table 4, BE and Expenditure under IDSP during 11th Plan Period (Rs. in crore) Year BE Expenditure/release Comments 2007-08 80.0 41.36 2008-09 72.0 21.75 2009-10 48.5 39.95 2010-11 35.0 43.58 An additional amount of Rs. 5.40 crore given to NE states diverted from Rural Family Welfare Services Head (total Rs. 48.98 crore) 2011-12 63.0 Total 298.5 146.64

4.7 Gaps / Constraints faced during 11th Plan

Low Priority to public health/disease surveillance by states Dedicated State/district surveillance officers not in position Key human resources (Epidemiologists, Entomologists, Microbiologists) not/less available in most districts Currently weekly disease surveillance data are collected from primary health care units and indoor wards of secondary and tertiary care facilities. OPD data are usually not collected from major hospitals. Absent/poor public health laboratories in most states/districts Inadequate intersectoral co-ordination

4.8 Disease Surveillance 206 Response Programme: & Proposal for 12th Plan

4.8.1 Background
Although non-communicable diseases like cancers, diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases etc are on the rise due to change in life style, communicable diseases like tuberculosis, malaria, kala-azar, dengue fever, chikungunya and other vector borne diseases, and water-borne diseases like cholera, diarrhoeal diseases, leptospirosis etc continue to be major public health problems in India. While many of communicable diseases are endemic, some frequently attain epidemic proportion. The outbreaks/epidemics are public health emergencies which disrupt routine health services and are major drain on resources. Besides direct costs in epidemic control measures and treatment of patients, the indirect costs due to negative impact on domestic and international tourism and trade can be significant. For example, plague which was not reported from any part of the country for almost a quarter of century, caused a major outbreak in Beed district of Maharashtra and Surat district of Gujarat in 1994 and resulted in an estimated loss of almost USD 1.7 billion. In addition, avoidable human misery resulting from diseases and death can not be quantified in economic terms. Because of the existing environmental, socioeconomic and demographic situation, many areas in the country are affected by epidemics/outbreaks. Under IDSP, a total of 553 outbreaks were reported and responded to by states in 2008, 799 outbreaks in 2009 and 990 outbreaks in 2010. In 2011, 538 outbreaks have been reported in 2011 till 29 May. Earlier only a few outbreaks were reported in the country by the States/UTs. This is an important public health achievement. It is impossible to always prevent outbreaks, but we can always mitigate their impact by anticipating them and by being prepared. Disease surveillance and response system, availability of laboratories, trained professionals, fast communication, and strong coordinating mechanism between different sectors, especially between animal and human health sectors, are critical for prevention/control of outbreaks and minimizing their impact.

4.8.2 Justification of Proposal

Disease surveillance and response is a core public health activity which has to be undertaken on a continuous basis. Although state and district surveillance units have been strengthened under IDSP to detect and respond to outbreaks at the earliest states reported 990 outbreaks in 2010 - they are at varying stages of implementation. The states/districts still need continuous central support till they have adequate disease surveillance and response mechanism. Under the International Health Regulations (2005) which came into force in 2007, it is mandatory for the country to develop, strengthen and maintain core capacities for surveillance and response to detect, assess, report, notify and control all events irrespective 207 of origin and source which may constitute a public health emergency of international

concern. Thus, disease surveillance and response capacities are also critical in implementation of IHR. Public Health Preparedness and Response for Emergencies/Epidemics essentially requires three core capacities. These are: Establishment/strengthening of a laboratory based IT-enabled disease surveillance system to collect baseline data on epidemic-prone diseases, monitor disease trends and to detect epidemics in early rising phase, Development of epidemiological, clinical, entomological and laboratory capacities to investigate the epidemics to characterize the cases in terms of time, person and place and to understand the transmission dynamics, Development of response capacities to prevent/control the epidemics to reduce the morbidity and mortality to the minimum.

The Pragramme aims to strengthen these core capacities at all district/state levels. Therefore, all activities being undertaken presently under IDSP are proposed to continue as Disease Surveillance and Response Programme under NCDC in the next Five-Year Plan as a Central Sector Scheme. Central Surveillance Unit will be merged into Centre for Integrated Disease Surveillance under NCDC. All support to states/districts health societies including additional contractual staff given under IDSP will continue in the next Plan. The funds will be released to the state health societies for implementation of disease surveillance and response programme within their health system.

4.8.3 Proposed Strategy

The strategy for Disease Surveillance and Response Programme was deliberated in the subgroup. It was unanimously felt that it is a sound strategy and does not require any change. However, some administrative and operational gaps have been identified in the implementation of the Integrated Disease Surveillance Project which resulted in less than expected outcome, both physical as well as financial. By addressing these issues, the implementation of the strategy would be very effective resulting in improved implementation of the project. For addressing the identified gaps, the activities proposed require more financial inputs, hence the budget proposed for it in the 12th Plan is Rs. 851.81 Crore.

4.8.4 Objectives
To strengthen/maintain a decentralized State-based disease surveillance and response system for epidemic prone diseases by Weekly collection of disease surveillance data to monitor disease trends Detecting early warning signals of impending disease outbreaks and taking timely 208 control measures

4.8.5 Proposed activities during 12th Five-Year Plan

Collection, collation, compilation, analysis and dissemination of data o Complete reporting of weekly disease surveillance data through portal o Data entry /data analysis facility up to block level in a phased manner o Detection, investigation and control of outbreaks in early rising phase Use of Information Communication Technology o ICT equipment would be provided to the newly created districts which have not been provided ICT equipment so far o 15% of ICT equipment may need replacement every year o ICT connectivity with all states / districts surveillance units & premiere institutes o Portal strengthening/maintenance o Call center (24X7 toll free) maintenance o GIS integration with portal o Media scanning and verification to detect and verify media alerts to detect early warning signals/outbreaks Human Resources o Essential contractual manpower provided in the 11th Five Year Plan will continue in the 12th Plan to support the states in implementation of disease surveillance and response programme. o One additional contractual position for a veterinary (consultant) is proposed to improve intersectoral coordination and to support the State Surveillance Officer in tackling the zoonotic diseases like avian influenza, plague, leptospirosis etc which are important epidemic prone diseases Capacity Development o Induction training of new epidemiologists, microbiologists, entomologists and veterinarians o Refresher training of State Surveillance Officers, District Surveillance Officers, Rapid Response Team members and contractual staff o Paramedical staff on principles of disease surveillance. Strengthening of public health laboratories o Monitoring / support to district public health laboratories established under IDSP & through NRHM. o All districts will have a public health laboratory or will have access to a public health laboratory for which equipment will be provided by NRHM and consumables will be provided under the Disease Surveillance and Response Programme under the 12th Plan. o About 190 Medical colleges labs/referral labs will be linked to about 500 district public health laboratories. Presently 65 labs in 9 states have been linked with districts. o A Lab Expert Group will be constituted to provide technical support and to monitor public health laboratories in the country.

In addition to above mentioned activities, special focus will be on surveillance of influenza and sentinel surveillance for vaccine preventable diseases
209

Surveillance for influenza through 16 labs. Presently 12 labs are functional. 4 more labs will be identified in areas not covered by the existing labs and strengthened under IDSP.

Sentinel surveillance system for vaccine preventable diseases (case based surveillance) at 30 identified sentinel sites.

Infrastructure created under the Polio Eradication Programme will be used by the Disease Surveillance and Response Programme after the eradication of poliomyelitis in the country.

4.8.6 Monitoring and Evaluation

(1) (2) (3) (4) (5) (6) Regular monitoring of the programme by (i) field visits by MOHFW/NCDC officers/consultants, (ii) meeting of all State Surveillance Officers twice in a year Every State will undertake in-depth review of programme in at least one district in a month NCDC will undertake in-depth review of the programme in at least one state in a quarter Annual review of Programme by the Common Review Mission of NRHM Third Party monitoring of this as well as other national programmes under NRHM Two Independent appraisals of the programme in 12th Plan period (Mid-term and at the end)

4.8.7 Outcome indicators

(i) (ii) All State/District Surveillance Units staff will get trained Almost all districts will report disease surveillance data on epidemic prone diseases every week. (iii) All DSUs and SSUs will have the capacity to compile, analyse and interpret data to detect outbreaks (iv) Clinical samples will be collected and sent to the laboratories in at least 70% of outbreaks (v) All DSUs and SSUs will have the capacity to investigate and respond to outbreaks.

4.8.8 Proposed changes in 12th Five Year Plan

(1) (2) (3) (4) (5) (6) (7) The Programme will be totally funded through domestic budget. Roles and responsibilities of state/district surveillance officers will be further defined so that they own the programme. OPD data will be collected from major hospitals including medical colleges hospitals All data to be reported and managed through portal only (currently, they use e-mail as well as portal for this purpose). P form will be revised to collect data on morbidity as well as mortality. The call centre will be popularized among the community, especially among local leaders, to get early information about potential outbreaks. Absence of public health laboratories continues to be the weakest link. About 500 district public health labs will be strengthened and also linked to about 210 190 medical colleges/referral labs under the 12th Five year Plan. This will help in improving the quality of data and outbreak investigations. Case based surveillance is proposed to be started in 30 sentinel centres for vaccine preventable childhood illnesses.

(8)

(9)

Recruitment of a Veterinary (consultant) at each state surveillance unit to strengthen coordination between animal and human health sectors to control zoonotic diseases.

4.8.9 Budget
Proposed outlay required, year-wise, in the 12th Five Year Plan period (2012-2017) is annexed. NCDC would release funds to the state health societies with approval of Ministry/IFD for implementation of disease surveillance activities within their health system. It is mentioned that no budget for IEC is proposed as all activities related to IEC are undertaken by NRHM. However, required IEC material will be prepared and distributed to states. Similarly, no budget for civil work and furniture and fixtures has been kept considering the same would be provided by NRHM wherever needed.
DISEASE SURVEILLANCE AND RESPONSE PROGRAMME - PROPOSOSAL FOR 12th FIVE YEAR PLAN (2012-17) ( Rs in Lakhs) Major Head "2210" CENTRAL SURVEILLANCE UNIT (NCDC) 270111 - Travel Expenses 270120 - Other Admn. Expenses 270121 - Material & Supply (AI) 270126 - Advertisement & Publicity 270128 - Professional Services (Training & Remunerations) 270131 - Grants-in-aid - General (AI Lab - Staff remuneration & operating expenses) 270150 - Other Charges (Review meetings, Consultancy Services, Meeting of all SSOs & other meetings) 270328 - Professional Services (IT - Portal, Call centre, AMC, NIC Services) GRANT TO STATE HEALTH SOCIETIES 270431 -Grants-in-aid General (States/UTs) 2012-13 77.0 140.0 300.0 87.5 435.0 141.6 45.5 2013-14 80.9 147.0 373.0 91.9 456.8 161.1 47.8 2014-15 84.9 154.4 408.0 96.5 479.6 181.7 50.2 2015-16 89.1 162.1 445.0 101.3 503.6 203.6 52.7 2016-17 93.6 170.2 484.0 106.4 528.7 226.6 55.3 Grand Total 425.5 773.6 2010.0 483.5 2403.6 914.5 251.4

570.3

598.8

628.7

660.1

693.1

3151.0

11396.6

13071.6

14857.8

16735.2

18706.8

74768.0

Grand Total 13193.4 15028.7 16941.6 18952.6 21064.7 85181.1 Note: (1). A total of 10 % of the plan outlay will be earmarked for NE States. (2) The budget for remuneration of contractual staff at State/District level is estimated by considering 85% of the total staff in position at given time. (3) Development of District Public Health Labs (including civil work and equipment) will be done under NRHM. Remuneration for Microbiologist and consumables will be provided under Disease Surveillance and Response Programme.

5. Surveillance of YAWS & Guinea Worm 211

Guinea Worm Disease has already been eradicated from the country. However its continuous monitoring is required till the disease is eradicated globally. Its budget shall be reflected in the regular budget of NCDC YAWS has been declared eliminated from the country since 2006. However for eradication of the disease, activities like sero surveillance, active search, awareness generation in the community and Independent appraisals etc. will be carried out and the results will be place before the WHO Commission for declaring eradication of YAWS from the country. It is an ongoing activity of NCDC and budget shall be reflected in the regular budget of the NCDC.

213

6. Implementation of IHR (2005)

6.1 Background
The International Health Regulations (IHR) are an international legal instrument that is binding on 194 countries across the globe including India. The purpose and scope of IHR (2005) is to prevent, protect against, control and provide a public health response to the international spread of disease in ways commensurate with and restricted to public health risks which avoid unnecessary interference with international traffic and trade. IHR (2005) were adopted by the World Health Assembly in 2005 and came into force in 2007. The key country obligations under IHR include: 1. 2. 3. Designate National Focal Point (NFP), update his/her details and communicate to WHO every year. Assess ability of existing national structures and resources to meet minimum requirements under IHR (2005) Develop, strengthen and maintain core capacities for surveillance and response to detect, assess, notify, report and control Public Health Emergencies of International Concern (PHEICs). Strengthen core capacities for points of entry (Airports, ports, ground crossings) for responding to the events. Assess all urgent events irrespective of origin and source within 48 hours and notify WHO within 24 hours of assessment of events that may constitute PHEIC (Public Health Emergencies of International Concern). Designate Airports, Ports and Ground Crossings which have the core capacities. Revise Legislation, Health Documents/Forms/Certificates and charges in accordance with IHR (2005)

4. 5.

6. 7.

6.2 Justification
Under the International Health Regulations (2005) it is mandatory for the country to develop, strengthen and maintain core capacities for Disease Surveillance and Response and at Points of Entry to detect, assess, report, notify and control all events irrespective of origin and source which may constitute a public health emergency of international concern. As the country has committed to implement IHR (2005) and has nominated the Director, NCDC, Delhi as the National Focal Point for IHR (2005), NCDC needs strengthening under 12th Five Year Plan to fulfill the obligations under IHR (2005).

6.3 Proposed Activities during 12th Five Year Plan

To implement IHR, the following activities are proposed during 12th Five Year Plan 1. 2. Strengthening of National Focal Point to implement the IHR (2005) Strengthening of core capacities for surveillance and response
214

3. 4. 5. 6.

Strengthening of capacities at Airports, Ports and other points of entry (ground crossings). Strengthening of communication with all International Airport and Port Health Organizations and Point of Entry to improve reporting and response Identification, sensitization of and coordination with IHR focal points of all states/ points of entry and all stakeholders Communication with WHO

6.3.1 Strengthening of core capacities for surveillance and response

Presently, core capacities for surveillance and response to detect, assess, notify, report and control Public Health Emergencies of International Concern are being developed under Integrated Disease Surveillance Project (IDSP). The Project is upto March 2012. All activities being undertaken IDSP are proposed to continue and further strengthened under 12th Five Year Plan as a separate proposal.

6.3.2 Strengthening of capacities at Airports, Ports and other points of entry (ground crossings)
IHR (2005) require specific core capacities at international entry airports/ports and other Points of Entry for undertaking health measures at all times and during the time of PHEIC. Health measures at all times include (i) surveillance of international passengers and crew for yellow fever disease, (ii) quarantine, (iii) medical care to ill travelers and facility for transportation, (iv) vaccination for yellow fever disease, (v) measures for conveyances and cargo-inspection and disinsection, (vi) vector control and surveillance, and (vii) food safety. Measures during PHEICs include (i) surveillance and response measures during PHEIC - screening (exit/entry) for early detection, laboratory diagnosis, pharmaceutical & non-pharmaceutical intervention, clinical management and risk communication; (ii) measures for the conveyances (aircrafts/ships/others) - inspection, disinsection and decontamination, (iii) measures for the baggage, cargo for possible sources of PHEIC and its transmission, and (iv) provisions for transit travelers. Each APHO/PHO would be strengthened by 2 contractual positions - one epidemiologist and one entomologist. 2 contractual epidemiologists and 2 DEOs are proposed for NFP.

6.3.3 Budgetary requirement

Activity (Rs. In Crore) 0.30

1 Training (Sensitization/Orientation/ reorientation of the existing manpower and new persons joining 2 3 4
in place of transferred out/ retired) and periodic meetings NFP, SSO, APHO/PHO/Ground staff, Stakeholders and Core group) Additional Human Resources One Epidemiologist* & 1 Entomologist** each @19 PoEs; 2 Epidemiologist *& 2 DEO*** at NFP (*@ Rs. 50000/- PM; **@ Rs. 35000/- PM; ***@Rs. 10000/- PM) Logistic support @ PoEs IT and other equipment (@1 lakh); AMC; Broadband connection and reporting @ 10000/- Per month Operational cost for NFP Contingency/Stationary/Miscellaneous Total

10.82

1.35 0.06 12.53

215

Budget for IHR - 2005 for 5 years

Sl. No. No. of units Budget per yr. (Rs) For 5 yrs. (Rs.)

Activity Training (Sensitization/Orientation/ reorientation of the existing manpower and new persons joining in place of transferred out/ retired )

Sub activity

NCDC faculty SSO APHO/PHO/Ground staff

2 batches (15/batch) 10 19

30000 250000 475000

90000 1250000 950000

Periodic meetings

Stake holders Core group Subtotal POE Epidemiologist* (@50000 pm with 3% increment /yr) POE Entomologist * (@35000 pm) NFP: Epidemiologist* (@50000 pm with 3% increment /yr) NFP: DEO** (@10000 pm) Subtotal

40 20

112000 30000 897000

560000 150000 3000000 60420000 39900000 6720000 1200000 108240000 1900000

Additional Human Resource

19 19 2 2

11400000 7980000 1272000 240000 20892000

IT

IT and other equipments (@1 lakh) AMC; Broadband Connection and reporting @ 10200 per month FOR 19 POEs Subtotal

19 (19 ports/Airpo rts/Ground crossing )

1900000

2325600 4225600

11628000 13528000

Operational cost for NFP Subtotal Total

Contingency/Stationary/Miscellaneous 120000 26134600 600000 125368000

* to co-ordinate with states/ APHO/PHO/ Ministries ** to assist the NFP, Epidemiologist

216

NCDC: New Activities during th 12 Plan

7. Up-gradation of existing regional branches and establishment of 27 new branches of NCDC

7.1 Current Status
NCDC has been established to function as a National Centre for excellence for control of communicable diseases. The head quarter is located at Delhi and currently there are eight branches of National Centre for Disease Control located in Alwar (Rajasthan), Varanasi (UP), Patna (Bihar), Rajahmundry (Andra Pradesh), Jagadalpur (Chattisgarh), Bangalore (Karnataka), Coonoor (Tamil Nadu) and Kozhikode (Kerala). These branches at present are carrying out disease specific activities only (Such as Malaria, Filaria, Kala Azar, Plague Surveillance etc.)

7.2 Justification
Over the years need has been felt to further expand the mandate of these branches so as to function as complete units for decentralized presence of NCDC. Hence these branches are proposed to be upgraded to function as mini-NCDCs in the area of their location to cover all issues of public health importance. To deal with emerging infectious diseases, there is need to strengthen laboratory capacity and entomology facilities in the branches to provide rapid diagnosis and formulate prevention and control measures rapidly. Large numbers of diseases have re-emerged in the last three decades and no new expertise has been added at NCDC Branches. Strengthening of the branches would support the HQ in rapid diagnosis and reporting of diseases to meet the requirements of IHR. Capacity building to respond to increasing problem of emerging and re-emerging diseases. To assist State Rapid Response Teams in disease outbreak investigation in control of epidemics. Develop technical manpower in the field of public health

7.3 Gaps observed during 11th Plan

It was experienced that NCDC branches could not have effective interaction with the states where these were not physically located. The location of the branch in a state develops close working relations with the concerned states and the same is very helpful for fulfilling the mandate of the NCDC

217

7.4 Need for Additional NCDC branches

For closer interaction with the states in the field of Communicable Disease Control it is proposed to augment the decentralized presence of NCDC by way of opening a new branch in each of the remaining 27 states/UTs.

7.5 Activities to be undertaken

The strengthened branches of NCDC shall be carrying out the function of disease surveillance capacity building in public health, carrying out operational research and closely interface with the State/UT health authorities for efficient implementation of Disease Control activities.

7.6 Ownership of the States

The location of the new branches and local priorities shall be finalized in Consultation with the states. The norms of construction, equipment, manpower and other logistics shall be as applicable to the existing branches and shall conform to the Govt. administration and financial norms.

7.7 Monitoring & Evaluation

The branches shall be under the administrative control of the NCDC head quarter, which shall be responsible for monitoring & evaluating the functioning of the branches. The State Government officials shall be regularly and actively involved in all the activities of the branches.

7.8 Major decentralised presence of NCDC

It is a major step in the focus of the NCDC. The presence of a branch of NCDC in each state shall help in effectively carrying out the disease surveillance, meet the needs of the IHR-2005, enhance the efficiency of disease control activities and additionally help in better implementation of the new proposed programmes such as National Rabies Control Programme, National Anti Microbial Resistance Containment programme and prevention and control of Viral Hepatitis etc

7.9 Budget:
7.9.1 Up-gradation of 8 existing regional branches of NCDC
S. No. 1. 2. 3. 4. 5. 6. Activity Salary Professional Services Motor Vehicle Material, Supply, other charges Rent Rates and Taxes Up-gradation of regional branches- new constructions, equipments etc @ Rs 30.00 crore/branch Total
218

For existing 8 branches (Rs. In Crore) 29.50 3.50 4.00 8.00 3.50 240.00 288.50

7.9.2 For the proposed 27 new branches

S. No. Revenue For proposed 27 new branches (Rs. In Crore) 1.40 4.20 2.80 7.00 28.00 25.20 11.20 705.00 854.80

I. II. III. IV. V. VI. VII. VIII.

Office expenditure T. E. Material supplies Other charges Prof. Services Motor Vehicle Mach. & Equipment New construction including @30 crore X 20= 600 land @15 crore X 7= 105 Total

Total (A+B) = 1143.30 Crore

219

8. National Programme for Containment of Antimicrobial Resistance (AMR)

8.1 Magnitude of the problem
The published reports in the country reveal an increasing trend of drug resistance in common diseases of public health importance i.e Cholera: showing high level of resistance to commonly used antimicrobials eg Furozolidone (60-80%), Co-trimoxazole (60-80%) and Nalidixic Acid (80-90%), Enteric fever: Chloramphenicol, Ampicillin, Co-trimoxazole (30-50%), Fluoroquinolones (up to 30%), Meningococcal infections: Co-trimoxazole, Ciprofloxacin and Tetracycline (50-100%), Gonococcal infections: Penicillin (50-80%), Ciprofloxacin (20-80%),

8.2 Gaps in the 11th Plan

Development of AMR in pathogens of public health importance is a major global and national public health problem which can lead to serious health, social, economic and disease transmission problems if not tackled timely. We may finally end up in Post-antibiotic era with very few treatment options available. There was no organized Antimicrobial Resistance Containment Programme in the 11th Plan in the country despite increasing antibiotic resistance developing in pathogens causing diseases of public health importance as mentioned above. However, a National Task Force was constituted by MoH&FW during August 2010 under the chairpersonship of DGHS to frame national policy for containment of AMR.

8.3 Does the strategy need change or paradigm shift?

There is an urgent need to change the strategy for containment of AMR in the country. The strategy has been well spelt out in the recommendations of the Task Force, which includes strengthening of regulatory component, discouraging the over-the-counter sale of antibiotics, limiting access to newer antimicrobials, promoting rational use of antibiotics, strengthening hospital infection control practices, setting up a network of quality controlled laboratories for AMR surveillance, ascertaining the pattern of use of antimicrobials in the community and hospitals, reducing extra-human use of antibiotics and communicating with doctors and community at large regarding proper use of antibiotics.

8.4 Ownership of States

States would be actively involved for ownership of the programme by involving not only the doctors in the public sector but also doctors in private sector and by educating the community.

220

8.5 Proposed Activities

8.5.1 Meetings of Task Force
A national Task Force has already been constituted by MOHFW for framing strategy for AMR containment, the meetings of the Task Force would be held at regular intervals for monitoring various activities for containment of AMR.

8.5.2 Working group meetings

For implementing the various recommendations of the task force, different technical working groups would be formed eg for AMR surveillance, antimicrobial usage studies, hospital infection control etc. the working groups would be meeting on regular basis for framing relevant guidelines and to monitor the implementation of the same

8.5.3 Establishment of Quality Assured Laboratory Network for AMR surveillance

In order to generate quality data about burden of AMR in communicable diseases of public health importance in the country, a network of around 100 microbiology laboratories preferably located in the medical colleges representing different zones of the country would be established. The laboratories would be asked to carry out identification as well as antimicrobial sensitivity testing of identified bacterial pathogens using a standardized methodology and reagents., the data generated would be analyzed by the respective laboratories using established tools and the results would be communicated to NCDC for collation. The network laboratories would be strengthened in terms of manpower (Laboratory Technician, Data Manager), office and laboratory equipment, laboratory reagents and money for contingent expenses. The network would be backed up by strong External Quality Assessment System.

8.5.4 Surveillance of antibiotic usage & operational research

A network of institutions (Around 100) would be strengthened to carry out surveillance for antimicrobial usage in the country both in hospital settings as well as the community. The surveillance would be done initially during the first year of the project and second time at the end of the project to see the change in trends. The institutions would be representative of the different geographical settings in the country. Before establishing the complete network, a pilot study would be done in a few sites and based on the results of pilot study, the detailed action plan for the scale up would be developed. The identified institutions would be provided with funds for manpower recruitment and travel expenses.

8.5.5 Strengthening of Hospital Infection Control Practices

Infection control practices play a pivotal role in preventing development of AMR in hospital settings. Though, such policies are available and being implemented in a large number of hospitals in the country, the same needs to be strengthened, In this regard, national hospital infection control guidelines would be developed and disseminated to the hospitals for implementation. The funds would be utilized for developing prototype Hospital Infection Control Guidelines. Each hospital should establish a hospital infection

221

control committee for implementation and monitoring of hospital infection control guidelines. The budget needed for this has to be arranged by the respective hospitals.

8.5.6 Training/ Manpower development

A large number of training workshops would be conducted by NCDC in partnership with some other identified institutions for different levels of health care workers addressing all the above issues. The trainings would be done for the laboratory professionals in identification of pathogens as well as AST methodology and AMR data analysis. NCDC along with some identified National Institutions would be conducting trainings for the core trainers drawn from different states. Subsequently, these core trainers would be facilitating state/ district level trainings. The funds would be provided for the purpose.

8.5.7 IEC for dissemination of information about rational use of antibiotics

Self medication of antibiotics by community at large is a major issue that needs to be addressed through various IEC activities to generate awareness in the community about the problem of AMR and the role of community in preventing the same. Prototype IEC module would be developed centrally. The same would be provided to the State Health Authorities for printing in local languages and further dissemination.

8.5.8 Strengthening of diagnostic tools to prevent misuse of antibiotics

It has been observed that one of the major factors for irrational use of antibiotics is due to non availability of correct and timely diagnosis of an infectious disease, therefore stress would be given to strengthening of laboratory diagnostic capacity of laboratories in the country at different levels of health care facilities. An interface would be developed with the laboratory strengthening component of IDSP.

8.5.9 Co-ordination with DCG(I) for regulatory issues

Since, widespread availability of antibiotics over the counter in our country is one of the major causes for misuse of antibiotics leading to development of AMR, the regulatory issues in this regard need to be strengthened by DCG(I). A coordination mechanism would be developed with the office of DCG(I) for this purpose.

8.5.10 Interface with Department of Animal Husbandry to minimize extra-human use of antibiotics
Since extra human use of antibiotics meant for human use specially in animals is one of the important reasons of development of AMR, the issue needs to be addressed by Deptt of Animal husbandry. An interface would be developed with them for this purpose.

8.6 Expected Outcomes

Containment of antimicrobial resistance Increased awareness among medical practitioners regarding judicious use of antibiotics.

222

Implementation of infection control policy including use of antibiotics across the country

8.7 Budget
National Programme for Containment of AMR for 12th Plan
Activity National Task Force / Steering committee / Working group meetings Surveillance of Antimicrobial Resistance in Humans 1st Year 0.2 2nd Year 0.2 3rd Year 4th Year 5th Year 0.2 Total 1.0

Rs. (in Crores) 0.2 0.2

10.50

8.5

8.5

8.5

8.5

44.50

Surveillance of Antimicrobial use in humans Development and implementation of National Infection Control Guidelines, Standard Treatment Guidelines Training and capacity building of professionals in relevant sectors Operational Research on antimicrobial usage, environmental surveillance and AST methodology Create awareness and educate the HCW and general population about rational use of antibiotics through IEC activities

11.95

0.2

0.2

0.2

10.45

23.0

0.05

0.05

0.05

0.05

0.05

0.25

3.5

3.5

2.0

2.0

2.0

13.0

2.5

2.5

2.5

2.5

2.5

12.5

4.0

3.5

3.5

3.5

3.5

18.0

Grand Total

112.25

223

9. Prevention & Control of Viral Hepatitis

Hepatitis is defined the defused inflammation of the liver caused by a variety of etiologic agents. Some viruses that primarily target liver are collectively named as hepatitis viruses. There are, at least, five different hepatitis viruses (HAV to HEV) that primarily target the liver in humans, whereas the role of the newer hepatotropic viruses i.e HGV, TTV and SEN viruses has not been established. Although basic symptoms produced are similar, these viruses differ greatly in their structure, mode of replication and transmission, thus requiring altogether different control strategies.

9.1 Global Burden

An estimated 1.4 million cases of hepatitis A occur annually. HBV is the major cause of chronic liver disease and hepatocellular carcinoma. About 2 billion people worldwide have been infected with the virus and about 350 million live with chronic infections. An estimated 600 000 persons die each year due to the acute or chronic consequences of hepatitis B. About 25% of adults who become chronically infected during childhood later die from liver cancer or cirrhosis (scarring of the liver) caused by the chronic infection. The hepatitis B virus is 50 to 100 times more infectious than HIV. About 10%-15% of Chronic Liver Disease and Hepatocellular carcinoma (HCC) are associated with HCV infection in India. HDV infection is infrequent in India and is present about 5%-10% of patients with HBVrelated liver disease. HEV is considered benign but during epidemics is associated with severe liver disease affecting mainly the pregnant women (12- 20%). Fulminant form of hepatitis develops, with overall patient population mortality rates ranging between 0.5% - 4.0%. Fulminant hepatitis occurs more frequently in pregnancy and regularly induces a mortality rate of 20% among pregnant women in the 3rd trimester

9.2 Burden of Disease in India

Viral hepatitis is a major public health problem in India and these can be water-borne or blood borne infections. Water borne: Among the water borne viral hepatitis HAV and HEV are hyper endemic in India. 224 Some seroprevalence studies reveal that 90%-100% of the population acquires anti-HAV

antibodies and becomes immune by adolescence .However, recent studies including findings of the recent outbreaks occurring in India have shown shift in age and cases are being reported among adults.HAV related liver disease is uncommon in India and occurs mainly in children. Many epidemics of HEV have been reported from India. HEV is also the major cause of sporadic adult acute viral hepatitis and Acute Liver Failure. Pregnant women and patients with chronic liver disease (CLD) constitute the high risk groups to contract HEV infection, and HEVinduced mortality among them is substantial, which underlines the need for preventive measures for such groups. Children with HAV and HEV coinfection are prone to develop acute liver failure. Blood borne: India has intermediate HBV endemicity, with a carrier rate of 2%-4%. HBV is the major cause of chronic liver disease and hepato cellular carcinoma. Chronic HBV infection in India is acquired in childhood, presumably before 5 years of age, through horizontal transmission. Vertical transmission of HBV in India is considered to be infrequent. Inclusion of HBV vaccination in the Expanded Programme of Immunization will reduce the HBV carrier frequency and disease burden. HBV is the major cause of CLD and HCC. HBV genotypes A and D are prevalent in India. HCV infection in India has a population prevalence of around 1%, and occurs predominantly through transfusion and the use of unsterile syringes and needles. HCV genotypes 3 and 2 are prevalent in 60%-80% of the population as reported in different studies carried out in India .Genotype1 has also been reported from southern and northeastern parts of India. About 10%15% of CLD and HCC are associated with HCV infection in India. HCV infection is also a major cause of post-transfusion hepatitis. HDV infection is infrequent in India and is present in about 5%-10% of patients with HBVrelated liver disease. HCC appears to be less common in India than would be expected from the prevalence rates of HBV and HCV. The high disease burden of viral hepatitis and related CLD in India, needs attention and as the information is still not available from different parts of country we needs to initiate certain actions to know actual incidence of disease so that control and prevention measures can be initiated.

9.3 Current Status of Viral Hepatitis facilities at NCDC

NCDC has viral hepatitis laboratory having facilities for diagnosing all types of hepatitis and supports all outbreaks in the country however, the surveillance system in India through lab network which was established 15 years back with the support of WHO could not be sustained in the country. Though there is an existing laboratory support for markers of viral hepatitis in some laboratories still many parts of country lack the diagnostic support and there are no quality checks on testing of the laboratories.
225

Recently in view of large outbreaks not only due to Hepatitis A& E but also due to Hepatitis B & C requires a lab based surveillance system to be established in the country. In view of this, it is proposed to set up laboratory based surveillance in a phased manner in the 12th five year plan.

9.4 Objectives
a) To establish laboratory based network for surveillance of viral hepatitis in different geographical locations of India. b) To find out the incidence of different types of viral hepatitis in different parts of the country. Measure and monitor trends in the burden of a disease including detection of epidemics/ outbreaks and changes in related factors; c) To assist State and local health agencies, and governments in their efforts to decrease the incidence of new infections of water borne hepatitis A and E and blood borne hepatitis B and hepatitis C viruses . d) To decrease risks for chronic liver diseases including cirrhosis and liver cancers in persons with chronic hepatitis B and hepatitis C infections.

9.5 Proposed Activities

Currently there is no program for viral hepatitis in the country and large number of outbreaks is being reported and exact burden of the disease in the country is not known and it is a major step forward under the newer initiatives in the 12th five year plan. The surveillance plan would be initiated in a phased manner involving 10 laboratories of the Medical colleges under the IDSP project initially. Five labs will be rolled out every year in the 2nd, 3rd, 4th year so as to have laboratory set up in 25 states. All the kits for testing different types of viral hepatitis including hepatitis B markers would be provided by NCDC. Regular workshops and trainings will also be imparted by NCDC. There will be provision for primary and secondary guidelines formulations based on data collected and analyzed. Following activities shall be carried out. Setting up of 25 laboratories for initial diagnosis for all viral markers for hepatitis A,B,C,D,E Collection of data and samples transport to laboratories. For Quantitative analysis (viral load) and genotyping of viral hepatitis B and C, specialized laboratories will be set up so as to have at least one such laboratory in each Zone. NCDC will coordinate all the activities and there will be central supply of kits and reagents for each laboratory. Secondary prevention guidelines including anti-viral and interferon therapy, repeat testing & quantitative analysis etc. will be formulated and circulated to all stakeholders for implementation. Assessment of role of interferon and antiviral therapy for management of hepatitis B & C in selected patients through five medical colleges in a project mode.
226

Primary prevention guidelines and provision of vaccine for high risk groups.

9.5.1 Responsibilities of the designated laboratories

Identifying a nodal person for carrying out surveillance activity Collection of samples and sending to the designated laboratory Testing and analysis of samples Reporting results to the sentinel site on weekly basis Reporting results to NCDC on monthly basis

9.5.2 Responsibilities of the centre (NCDC)

Coordinating with the sentinel sites. Kits evaluation for finalization of diagnostic kits and there provisions to participating laboratories. Funds management Training of the personnel Analyzing the results received from the designated lab. Development of primary and secondary prevention guidelines.

9.53 Responsibilities of the State/centre

Implementation of primary and secondary guidelines.

9.6 Justification
Viral hepatitis is of major public health concern. Indian population is at high risk for both blood borne and water borne infections. To detect changes in health practices and the effects of these changes on disease the system is essential To prioritize the allocation of health resources for control of diseases. Describe the clinical course of disease; and Provide a basis for epidemiologic research To setup diagnostic capability across the country.

9.7 Expected Outcomes

Burden & Baseline data of different type viral hepatitis for the country. Early warning signal for any outbreak. Suggestions for strategies for prevention and control Develop and evaluate the effect of therapeutic and preventive measures including vaccination for hepatitis B vaccine. Determining natural history and risk factors
227

9.8 Monitoring & Evaluation

Standardization of indicators to assess proportion of cases reported with risk factors Determining the frequency with which individual data elements are reported with nonmissing data Time between date of diagnostic testing and date reported to health department Proportion of at risk contacts immunized Monitor disease transmission patterns and to identify high risk groups that need to be targeted by vaccination programs Surveillance through a network of labs would help in monitoring the effects of education, counseling, other prevention programs, and newly developed therapies on the burden of the disease

9.9 Budget estimates for 5 years under 12th plan

Setting up of 25 labs for initial diagnosis including Collection of data and samples transport to labs Primary prevention guidelines and provision of Vaccine for high risk groups Secondary prevention guidelines including anti-viral and interferon therapy, repeat testing & quantitative analysis etc: Testing Treatment Total Budget Rs 1000.00 lakh Rs 1000.00 lakh

Rs 2000.00 lakh Rs 8000.00 lakh Rs 120.00 crores

PROPOSOSAL FOR 12th FIVE YEAR PLAN 2012-17 SURVEILLANCE OF HEPATITIS - NCDC( PLAN ) DELHI (Rs. In Crores) Major Head GRAND Sr.No "2210" 2012-13 2013-14 2014-15 2015-16 2016-17 TOTAL 1 Travel Expenses 0.01 0.01 0.01 0.01 0.01 0.05 2 Office Expenses 0.01 0.01 0.01 0.01 0.01 0.05 Rent, Rates & 1.00 3 Taxes 1.00 1.00 1.00 1.00 5.00 4 Material & Supply 5.00 10.00 10.00 20.00 20.00 65.00 5 Other Charges 1.00 1.00 1.00 1.00 1.00 5.00 6 Motor Vehicles 0.01 0.01 0.01 0.01 0.01 0.05 Machinery & 8.00 7 Equipments 8.00 8.00 10.00 10.00 44.00 Advertisement & 0.10 8 Publicity 0.15 0.15 0.20 0.25 0.85 Grand Total 15.13 20.18 20.18 32.23 32.28 120.00

228

10. Establishment of inter-sectoral coordination

and control of selected Priority Zoonotic Diseases
10.1 Problem statement
Globally more than 850 pathogens are recognized as zoonoses, some of them being of major economic importance. Zoonotic disease prevalent in India can be divided into three categories: endemic (Rabies, Anthrax, Brucellosis, Toxoplasmosis, Cysticercosis, and Echinococcosis); reemerging (JE, Plague, Leptospirosis, Scrub Typhus, and KFD) and emerging (Avian Influenza, Nipah, Trypanosomiasis, Swine flu, CCHF).

10.2 Gaps in the 11th Plan

In the 11th plan there was inadequate inter sectoral co ordination and low priority for control of Zoonotic diseases in an integrated fashion. The coordinated control activities with the community involvement is required to address the problem of zoonoses.

10.3 Is a policy change required in the 12th Plan?

For control of Zoonotic diseases there is requirement of mutisectoral integrated response which is practically non existent in the country. This is the major policy change proposed in the 12th plan proposal. There is a need for collaboration among medical, veterinary and other related departments for effectively preventing the Zoonotic diseases. Strengthening surveillance and response capacity, development of early warning systems, and formulating appropriate policies to control these diseases is of utmost importance. The intersectoral coordination established for responding to Avian Influenza pandemic is an encouraging example.

10.4 State ownership/Community Involvement

States/UTs shall be actively involved in the formulation, implementation and evaluation of the activities for control of zoonoses. The roles and responsibilities at each level shall be clearly defined with the emphasis on monitor able parameters. Community as well as NGOs shall be involved in the control activities. In 12th Five year plan the expert group opined that the focus should be on 1. 2. 3. 4. 5. Establishment of Inter-sectoral Coordination Mechanism Focus on prevention and control priority zoonoses. Rabies, Brucellosis, Leptospirosis, Anthrax and Plague are chosen for co-ordination to begin with. Laboratory capacity development for diagnosis of Zoonotic diseases Manpower development IEC

10.5 Establishment of Intersectoral Coordination Mechanism 229

To establish the intersectoral coordination the following mechanism should be strengthened/ developed at the Centre, State and District level utilizing and strengthening the existing system and facilities rather than creating new ones.

10.5.1 Centre
10.5.1.1 Zoonosis Coordination Cell at NCDC, Delhi The Zoonosis coordination cell at NCDC, Delhi under the Directions of Director NCDC shall monitor the prevention and control activities regarding Zoonosis and submit the progress to Inter Ministerial Group, Joint Monitoring Group and Standing Committee on Zoonosis for guidance and also provide feed back to the States. 10.5.1.2 Inter-Ministerial Group With the representatives from Ministries of Health & Family Welfare, Agriculture, Food and Civil Supplies, Environment & Forests and Commerce. Members from other Ministries may be co-opted based on the needs. This group should meet at least twice in a year to review the progress submitted by Director NCDC and monitor the activities of prevention and control of Zoonoses in the country. 10.5.1.3 Joint Monitoring Group The scope of the existing Joint Monitoring Group on Avian influenza should be expanded to undertake the monitoring of other Zoonotic diseases of public health importance. This group should meet atleast biannually to coordinate the activities of prevention and control of zoonoses in the country, based on the progress reported by Director NCDC. 10.5.1.4 Standing Committee on Zoonoses Which is in existence since 2006 under the chairpersonship of DGHS should meet biannually to advice on various facets of the work on zoonoses in India, ensuring intersectoral coordination between medical, veterinary and other allied institutes, strengthening of laboratories in health and veterinary sectors and formulation of projects on priority problems. Zoonoses Division at NCDC, Delhi should coordinate the activities of the Standing Committee on Zoonoses.

10.5.2 State
Existing State Surveillance Committees under IDSP should form a subgroup to undertake the activities on Zoonoses. State Surveillance Officer (SSO), under IDSP should coordinate the activities of Sub Committee. This committee shall monitor the progress of the Districts in the State and provide feed back to NCDC regularly. The Veterinary officer appointed under IDSP should assist the SSO in carrying out the activities and establishing the intersectoral coordination. Provision of appointment of 35 veterinary officers, one for each State/UT, has been made under IDSP in 12th Five year plan.

10.5.3 District

230

For effective coordination between the medical and veterinary professionals at the district and the block levels, District Surveillance Officer (DSO), under IDSP should coordinate the activities between veterinary, municipal corporation/committees and other local bodies and voluntary agencies involved in the subject.

10.6 Focus on prevention and control priority zoonoses viz Rabies, Brucellosis, Leptospirosis and Plague
Priority Zoonotic diseases identified after deliberations are as follows:

10.6.1 Rabies
Rabies is a major public health problem through out the country. A National Rabies Control Progamme is being proposed in the 12th plan, building on the success of the pilot project implemented in the11th plan.

10.6.2 Brucellosis
Brucellosis is a major problem in livestock in India. The Dept of Livestock Health, Ministry of Agriculture has identified this disease to be undertaken in 12th Five year plan. The magnitude of problem in humans is not known however it is one of the important occupational disease and forms differential diagnosis of Pyrexia of unknown origin with effective treatment. If no interventions are undertaken the magnitude of the problem may not be known in human beings.

10.6.3 Leptospirosis
Leptospirosis is a major public health problem in the western and southern belts involving six States of the country. Leptospirosis control was undertaken in 11th Five year Plan in 2008. The strategy developed was effective in reducing the burden of the disease. . To further consolidate the strategy the disease has been identified for 12th Five year plan to be extended to all the endemic states in the country.

10.6.4 Plague
Plague is important disease with international implications. Maintenance of continuous surveillance is key in early detection and prevention of human plague. The manpower meant for surveillance of plague is depleting in the country. If the effective surveillance the disease is not undertaken, more outbreaks may occur. Thus the disease is included in the 12th Five Year Plan.

10.6.5 Anthrax
Anthrax is primarily a disease of herbivorous animals that occasionally affects humans. . In the past few years Anthrax cases have been reported in humans from Andhra Pradesh, Orissa, Karnataka, Tamil Nadu and West Bengal. Antibiotics are effective if the disease is recognized early and treated fully. If left untreated, mortality is high.
231

There is need to strengthen diagnostic capability in endemic areas and create awareness in the general community regarding non-consumption of meat of dead animals and proper disposal of carcass. In 12th Plan provision of laboratory facilities in the endemic states along with IEC and improved inters sectoral co ordination will be under taken.

10.7 Strengthening of laboratory services for Zoonosis

Laboratories identified under IDSP should be further strengthened enabling them to undertake diagnosis of Zoonotic diseases.

10.8 Manpower development

NCDC should identify and train the core trainers. These core trainers shall in turn train the professionals in their respective States/districts. The names of the core trainers should be made available at NCDC website.

10.9 Information, Education and Communication (IEC)

10 per cent budget earmarked for undertaking IEC activities for prevention and control of Zoonotic Diseases. Prototype material should be developed at NCDC and provided to State governments with the provision of funds for translation in local languages for wider dissemination.

10.10 Proposed Budget

Budget proposed for Intersectoral coordination and priority zoonotic diseases under 12th five year plan is Rs in crores st nd rd 1 yr 2 yr 3 yr 4th yr 5th yr Total Intersectoral coordination meetings Priority Disease specific budget Plague, Brucellosis, Anthrax Laboratory Strengthening Manpower Development IEC Total 0.50 0.50 0.50 0.50 0.50 02.50

3.566

1.566

1.566

1.566

1.566

9.83

0.50 0.25 07.00 11.816

0.50 0.25 07.00 9.816

0.50 0.25 07.00 9.816

0,50 0.25 07.00 9.816

0.50 0.25 07.00 9.816

02.50 01.25 35.00 51.08

232

TOTAL PROJECTED OUTLAY FOR 12th FIVE YEAR PLAN FOR NCDC
(RUPEES IN CRORE)

Head NCDC UPGRADATION STRGN. OF EXISTING BRANCHES ESTT. OF 27 NEW BRANCHES INTEGRATED DISEASE SURVIELLANCE 24x7 REPORTING SYSTEM & INFLUENZA SURVEILLANCE IHR 2005 STRENGTHENING INTERSECTORAL COORDINATION FOR PREVENTION & CONTROL of ZOONOTIC DISEASES HUMAN RABIES LEPTOSPIROSIS VIRAL HEPATITIS ANTI MICRO. RESISTANCE OPERATIONAL RESEARCH GRAND TOTAL

2012-13 2013-14 2014-15 2015-16 2016-17 TOTAL 204.00 141.10 4.90 0.00 0.00 350.00 40.00 200.00 16.50 16.00 16.00 288.50

200.00

400.00

85.80

84.00

85.00

854.80

131.94

150.28

169.42

189.53

210.64

851.81

1.22

1.22

1.22

1.22

1.22

6.10

2.53 11.81

2.50 9.81

2.50 9.82

2.50 9.82

2.50 9.82

12.53 51.08

77.26 0.75 15.13 32.70

76.82 0.73 20.18 18.45

76.82 0.73 20.18 16.95

76.83 0.74 32.23 16.95

76.86 0.74 32.28 27.20

384.59 3.69 120.00 112.25

1.00

4.00

4.00

4.00

1.00

14.00

718.34

1025.09

408.84

433.82

463.26

3049.35

233

7. Brief of the proposals of 12th Five Year Plan

Programme Malaria Disease Burden 1.5million cases reported every year (50% of them are falciparum malaria) Reported annual incidence at national level-1.3 cases /1000 population Expert Committee estimated 4.9 million cases and 30,000 deaths due to malaria in 2009. North Eastern states, Orissa, Chattisgarh, Jharkhand, Madhya Pradesh, Andhra Pradesh, Maharashtra, Gujarat, West Bengal and Karnataka contributes 80% of malaria burden.
About 30,000 cases in 52 districts of 4 states Cases<1/10,000 population in 320 blocks Cases >1/10,000 population in 194 blocks

Risk Factors Unplanned urbanization with inadequate infrastructure. Rapid Industrialization Ecological changes Insecticide and drug resistance. Population migration Poor coverage in Routine Immunization for JE Poor Vector control measures Livestock kept close to human dwellings and sleeping habits of people

Achievements during 11th Plan ABER 9.2% API 1.3 Reduction in Morbidity by 16.2% (base 2006) Reduction in Mortality by 55.1% (base 2006) 3.5 lakh ASHAs trained for diagnosis and management Upscaling of RDT Upscaling ACT 4.81 million LLIN supplied; 6.58 million being supplied

(Rs. Icrores) Plan of Action during 12th Plan Budget 3976.24 To reduce API to <1 Quality microscopy at all health facilities to screen 70% of the cases, remaining 30% by RDT Introduction and up-scaling bivalent RDT (both for Pf & Pv) - 160 million RDTs Up scaling of ACT to treat all Pf cases (about 13 million doses) Improved reporting including from private sector Strengthening Treatment Facilities for severe malaria Up-scaling & replenishment of LLINs (about 36 million) 100% support for Indoor Residual Spray (IRS) and larvicides Additional technical and managerial Human Resource to strengthen state and district VBD units
Elimination by 2015 Strengthening of case search for hot spots using RDT Drug delivery on Directly Observed Treatment (DOT) pattern Quality Indoor Residual Spray (IRS) with > 80 % coverage in 52 districts Training & IEC/BCC Intensive M&E Maintaining dengue CFR below 1% Sustaining effort for containment of Dengue & Chikungunya outbreaks Strengthening of diagnosis and case management 400 diagnostic centres Thrust on entomological monitoring, source reduction Strengthening HR Development, Inter-sectoral convergence & Monitoring 700.66

Kala-azar

Dengue

Endemic in 31 States 28292 cases and 110 deaths in 2010

Chikungunya

Reemerged in 2006, 1.39 million cases Endemic in 19 states

320/514 endemic blocks reported <1 case per 10,000 population in 2010 Reduction of kala-azar deaths in 2010 - 44% (base 2006) Additional staff for improved monitoring Focus on complete treatment Upscaling of RDT, miltefosin Intensified IEC/BCC 311 sentinel surveillance hospitals & 14 apex labs established CFR due to DHF reduced to 0.4% in 2010

810.61

234

Programme JE

Disease Burden 5149 AES cases and 677 deaths in 2010 565 JE cases and 110 deaths reported by 11 states in 2010

Risk Factors

Achievements during 11th Plan JE vaccination in 111 districts through campaign JE vaccine integrated in UIP 51 sentinel sites strengthened Improvement in case management NIV Field Station, RD Field Unit at Gorakhpur MC

Plan of Action during 12th Plan Prevention of outbreak Reduction in JE mortality by 50% Thrust on case management at district and below >80% JE coverage under RI Medical rehabilitation of disabled cases Strengthening of disease and vector surveillance Enhancing capacity building & Intensified BCC/IEC Elimination by 2015 To cover entire population in 250 endemic districts during MDA Awareness intensification for improvement in Drug Compliance Intensification of Lymphoedema management with specific training Up scaling Hydrocele Operations Use of MC and research institutes for M&E Post MDA surveillance in districts where MDA is stopped Honorarium for MDA to ASHAs & Supervisors Independent assessment & Elimination verification

Budget (Rs. In crores) 150.0

Filaria

Endemic in 250 districts of 20 states 600 million population at risk 40 million infected, 1/3 of global cases Microfilaria rate more than 1% in 100 districts 8 lakh lymphodema and 4 lakh hydrocele cases line listed

All 250 endemic districts covered during MDA MDA coverage 85%. 8 Lakhs Lymphodema & 4 Lakhs Hydrocele cases line listed 72,464 hydrocele operated Mf rate reduced from 1.24% in 2004 to 0.34% in 2010

940.29

NVBDCP including crosscutting budget (Rs. 4115.38 Cr)

10693.18

235

Programme RNTCP

Disease Burden 2 million new cases every yr (1/5 of global TB burden) Estimated prevalence of TB is 266 cases /lakh population 23 person/lakh population dies annually Annual Risk of TB infection-1.1%

Risk Factors HIV Diabetes Smoking Malnourishment Overcrowding Congregate settings Increasing age, male Low standard of living

Achievements during 11th Plan Case detection 70% Cure rate of 86-87% achieved in each year >27million TB suspect cases examined, >6 million cases treated in 4 years DOTS plus for the management of MDR-TB started; 4200 cases treated in 4 years 19 C&DST labs established for diagnosis of MDR-TB cases

Plan of Action during 12th Plan Case detection target > 90% Cure rate of >90% of new TB cases, >85% of previously treated cases Universal access to quality DOTS Extend RNTCP services to cases diagnosed & treated in private sector Complete geographical coverage of MDR-TB treatment services by 2013 Total 73 Culture and Drug susceptibility testing (C&DST) laboratories to be setup for the diagnosis of MDR-TB patients Treatment for all MDR-TB patients diagnosed HIV testing and counseling to all TB cases 100 % districts to achieve PR < 1/10,000 population To achieve ANCDR <10/10,000 population in all districts Focus attention to 209 districts to achieve elimination To achieve >95 % cure rate of MB patients To achieve > 97% cure rate of PB patients To reduce grade-II disability by 35% base year 2011-12 Enchanced IEC activities to reduce stigma

Budget (Rs. In crores) 5825.28

NLEP

Half of global burden contributed by India 126,800 new cases reported in India during 2010-11 Prevalence Rate0.69/10,000 population in 2010-11 at national level 125,756 Grade-II disability cases as on 31st March 2011.

Close contact with cases (Reducing contact with known leprosy patients is of dubious value)

Prevalence Rate (PR) <1/10,000 population (Elimination of Leprosy) achieved in 82.8% districts Annual New Case Detection Rate (ANCDR)<10.48/10,000 population No. of high endemic districts reduced from 275 in 2005-06 to 209 89.87% cure rate of MB leprosy achieved 97% cure rate of PB Leprosy achieved. Grade-II Disability reduced by 25% ( base year,2006-07)

787.00

236

Programme Disease Surveillance and Response Programme

Disease Burden Communicable diseases are major public health problem. ADD, respiratory infections, TB, malaria cause 24% of all deaths.

Risk Factors Poor hygiene and sanitation Uncontrolled population growth and high density Rapid urbanization Population migration International travel Breakdown of public health measures Climate change Rapid deforestation Contact with animals Poverty and social inequality 25 million stray dogs Inadequate control/IEC

Achievements during 11th Plan Surveillance units established at all States and Districts. RRT trained in 34 states Data centre equipment installed at 776 sites 85% districts report weekly data About 20 outbreaks reported every week

Plan of Action during 12th Plan IDSP is proposed to be implemented as Disease Surveillance & Response Programme All contractual positions to continue All districts to report through portal All districts will have/have access to public health lab 500 labs 190 referral labs will be linked to districts labs Collection of OPD data from major hospitals Case based surveillance from 30 sentinel centres for Vaccine Preventable Diseases

Budget (Rs. In crores) 851.81

National Programme Rabies Control

for

17.5 million animal bites annually 20000 death annually

Pilot project at 5 sites Strategy for preventing human death operationalised

Prevention and control of leptospirosis

Predominantly in costal areas Outbreaks in Kerala, Gujarat, Tamil Nadu, Orissa, Karnataka, Maharashtra, A&N etc Major public health problems >75% emerging diseases are zoonotic

Presence of infected rodents Alakline soil Agriculture practices High rains

Pilot project in 5 states Strategy developed to burden of disease

reduce

Intersectoral coordination and control of priority zoonotic diseases

Vast reservoir of animals Close interface between animals and human

Pilot project on rabies and leptospirosis JMG for AI/swine flu established Integrated avian influenza pandemic plan developed

Programme to be introduced in the entire country both in rural & urban areas Strengthening of Post-exposure prophylaxis Using ID route for vaccination Vaccination of stray dogs at 30 sites initially Strengthening intersectoral coordination Strategy developed in 11th Plan will be extended to all endemic states Development of trained manpower Focus on case management facilities Intersectoral coordination Improvement in lab capacity Augmentation of surveillance Establishment of Intersectoral coordination mechanism One Con (vet) at SSU under IDSP Focus on priority diseases, brucellosis, anthrax, plague Development of lab capacity Strong IEC

384.59

3.69

51.08

237

Programme
Prevention and control of viral hepatitis

Disease Burden
Major public health problem HAV very common in children Almost all outbreaks of viral hepatitis are due to HEV 2-4% HBV carrier rate (35 million carriers) HBV common cause of Chronic liver disease and cancer HCV prevalence 1% Increasing trend of drug resistance

Risk Factors
Unsafe water, food and poor hygiene and sanitation are risk factors for HAV, HEV Unsafe blood transfusion, exposure to body fluids, contaminated injections, unsafe sex are risk factors for HBV, HCV, HDV

Achievements during 11th Plan

No organized viral hepatitis surveillance in the country

Plan of Action during 12th Plan

Setting up of 25 labs for diagnosis of hepatitis A, B, C, D, E Setting up 5 regional labs for genotyping of Viral hepatitis Central supply of kits and reagents Development and dissemination of Primary / secondary prevention guidelines Provision of hepatitis B Vaccine for high risk groups Guidelines for anti-viral and interferon therapy to be formulated and disseminated Strengthening of regulatory component Discouraging the over-the-counter sale of antibiotics Limiting access to newer antimicrobials Promoting rational use of antibiotics Strengthening hospital infection control practices Setting up a network of quality controlled laboratories for AMR surveillance Antimicrobial use surveillance Reducing extra-human use of antibiotics Sensitizing doctors and community at large regarding proper use of antibiotics All the proposed activities in the approved EFC will be completed Ongoing activities and proposed newer initiatives shall be implemented

Budget (Rs. In crores)

120.0

National programme for AMR containment

NCDC upgradation

NA

NA

Irrational use of antibiotics Over the counter availability of antibiotics Rampant use of antibiotics to feed livestock Inappropriate prescription Lack of proper infection control practices Inadequate surveillance

National Task Force constituted in August 2010 to frame national policy

112.25

Approval of the EFC for upgraded NCDC The cabinet committee on economic affairs (CCEA) approved the proposal in December 2010. NBCC engaged as an agency for construction of civil and services works Out of 245 additional posts proposed, 103 technical posts have been sanctioned by the government Expenditure during 11th Plan as on 15.6 11is Rs. 258.57 Lac

350.00

238

Programme Strengthening of NCDC Branches Establishment of 27 new NCDC branches 24x7 reporting system and influenza surveillance

Disease Burden NA NA NA

Risk Factors NA NA NA

Achievements during 11th Plan During EFC of NCDC upgradation, Planning Commission and PMO observed the need of strengthening NCDC Branches Outbreak Monitoring Cell (OMC) already functioning

Plan of Action during 12th Plan Strengthening of 8 existing branches so that they function as mini NCDC Opening of NCDC branches in the remaining 27 States/UTS also Round the clock working of OMC and data collection & analysis of outbreaks in different parts of the country There will be one epidemiologist and 6 technical staff one data manager to make the cell operational 24X 7. NCDC will provide rest of the facilities. Strengthening of NFP to implement the IHR (2005) Strengthening of capacities at points of entry Strengthening of communication with all APHOs/PHOs and Point of Entry to improve reporting and response Identification, sensitization of and coordination with IHR focal points of all states/ points of entry and all stakeholders Communication with WHO In view of the scarcity of disease burden data especially for communicable diseases, NCDC proposes to conduct longitudinal epidemiological studies to estimate the burden of important communicable diseases in India

Budget (Rs. In crores) 288.50 854.80 6.10

Implementation of IHR (2005)

NA

NA

NCDC designated as National Focal Point (NFP) under IHR (2005)

12.53

Operational Research

NA

NA

14.00

NCDC Total

3049.35

239

8. Summary of the total budget proposed for Communicable Diseases in the 12th Plan (Rs. In crore)
Sr.N o. 1. 2. 3. 4. Total Programme NVBDCP RNTCP NCDC NLEP 2012-13 2013-14 2014-15 2015-16 2016-17 Total 2329.13 1969.51 1992.82 2107.28 2294.45 936.12 949.93 1173.27 1316.27 1449.68 718.34 1025.09 408.84 433.82 463.26 167.03 152.13 166.05 151.65 150.14 4150.62 4096.66 3740.98 4009.02 4357.53 10693.18 5825.28 3049.35 787.00 20354.81

Report of the Working Group on Disease Burden for 12th Five Year Plan

WG3(2):Non Communicable Diseases

WG-3
No. 2(6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 Dated 9th May 2011

OFFICE MEMORANDUM Subject: Constitution of working group on Disease Burden (Communicable and non-communicable diseases) for the formulation of the Twelfth Five Year Plan (2012-2017)
With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on Disease Burden with sub groups on Communicable Diseases and Non-communicable Diseases for the formulation of the Twelfth Five Year Plan (2012-2017) under the Chairmanship of Dr. R. K. Srivastava, DGHS, Ministry of Health and Family welfare, Government of India. The composition and the terms of reference of the Working group would be as follows:

Subgroup I: Communicable Diseases

1. 2. 3. 4. 5. Dr. R. K. Srivastava, DGHS, MoHFW Dr. Yogesh Jain, Jan Swasthya Sahyoj Dr. Shiv Lal, Adviser, DGHS, MoHFW Joint Secretary (Pubic Health), MoHFW Dr. Lalit Kant, Scientist G and Head (Epidemiology and Communicable Diseases Division), ICMR, New Delhi Director, Patel Chest Institute, Delhi Director, All India Institute of Hygiene and Public Health (AIIH & PH), Kolkata Chairperson Co- Chairperson Member Member Member

6. 7.

Member Member

8.

Director, National Vector Borne Disease Control Programme (NVBDCP), New Delhi Director, National Institute of Epidemiology, Chennai

Member

9.

Member Member Member

10. Director, Voluntary Health Association of India, New Delhi 11. Dr. J.C. Suri, Head Dept. of Pulmonary Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital Hospital (VMCC & SJ ), New Delhi 12. Dr. C.S. Pandav, Dept. of Community Medicine, AIIMS, New Delhi 13. Prof. Jay Prakash Muliyil, Head of Dept. of Community Medicine, Christian Medical College, Vellore 14. Dr. John C Oommen, Krushi Hospital, Cuttack, Orissa 15. Dr. Biswaroop Chatterjee, Microbiologolist, West Bengal 16. Dr. S Sridhar, BASIX (Bhartiya Samruddhi Investments and Consulting Services), Gujarat 17. Dr. M. Bhattacharya, Head Community Health Administration, NIHFW (National Institute of Health & Family Welfare), New Delhi 18. Dr. Shreelakha Roy, Voluntary Health Association of Tripura 19. Principal Secretary (H&FW), Government of Chhattisgarh 20. Principal Secretary (H&FW), Government of Orissa 21. Mr. S M Mahajan, Adviser (Health) Planning Commission 22. Director, National Centre for Disease Control (NCDC), New Delhi

Member

Member

Member Member Member

Member

Member Member Member Member Member Secretary

Terms of Reference
I. To document the burden and trend of communicable diseases including emerging and re-emerging infectious diseases in India
2

II.

To review the achievement of ongoing major communicable disease control programmes their target and suggests corrective measures to improve their implementation in the 12th Plan.

III.

To suggest introduction of new programmes/ continuation

of

existing

programmes for control of communicable diseases and modifications required, if any, in the 12th Five Year Plan on the basis of 1& 2 above along with detailed budget for each programme. IV. To review the current system of monitoring and evaluation of the existing communicable disease control programmes and suggest measures to make the system more effective V. To suggest mechanisms of partnership with mother NGOs/private

sector/community/local self government in implementation and monitoring of the health programmes proposed in the 12th Plan. VI. To review the current status of HMIS in terms of its quality and utilization and propose to develop it into an effective system during the 12th Plan for providing reliable and updated data base for communicable diseases. VII. To review the functioning Integrated Disease Surveillance Programme in terms of its effectiveness in strengthening surveillance for picking up early warning signals of outbreaks and institution of appropriate control measures in a timely manner, identify gaps and suggest measures to strengthen the surveillance system for prevention and control of communicable diseases during the 12th Plan. VIII. To review the status of implementation of International Health Regulations 2005 in the country with special reference to public health response to various types of public health emergencies of international concern and suggest measures to comply with requirements under IHR. IX. To deliberate and give recommendations on any other matter relevant to prevention and control of communicable diseases.

Subgroup 2: Non-Communicable Diseases

1. 2. 3. 4. Dr. R. K. Srivastava, DGHS, MoHFW Dr. H.C. Goyal, Adviser, DGHS, MoHFW Sh. B. K. Prasad , Joint Secretary MoHFW New Delhi Dr. Bela Shah, Scientist G and Head (NCD Division), ICMR, New Delhi Dr. Rajender A Badwe, Director, Tata Memorial Hospital, Mumbai Prof. Ashok Seth, Chairman, Max Heart Hospital, Saket, New Delhi Dr. B.K. Rao, Chairman, Sir Ganga Ram Hospital, New Delhi Dr. Sanjay Aggarwal, HOD, Dept. of Nephrology, AIIMS Dr. Sanjay Wadhwa, Addl. Professor, PMR, AIIMS Chairperson Member Member Member

5. 6.

Member Member

7. 8. 9.

Member Member Member Member Member Member Member Member

10. Dr. G. N. Rao, L. V. Prasad Eye Institute, Hyderabad 11. Mr. Tulsiraj, Arvind Eye Care, Tamil Nadu 12. Ms. Shobha John, Leading Anti Tobacco Activist 13. Dr. R. Krishna Kumar, NIMHANS, Bangalore 14. Dr. Suresh Kumar, Director, Institute of Palliative Medicine, Calicut 15. Dr. Raman Kataria, Pediatric Surgeon, Jan Swasthya Sahyog, Chhattisgarh 16. Dr. Krishna Kumar, Amrita Institute of Medical Sciences, Kochi 17. Dr. Sara Bhattacharji, MD Professor CMC, Vellore 18. Principal Secretary (H&FW), Jammu and Kashmir 19. Principal Secretary (H&FW), Goa 20. Mr. Ambrish Kumar, Adviser (Health) Planning Commission
23062649

Member Member Member Member Member Member

21. Dr. D. Bachani, DDG (NCD), Dte. General of Health Services, MoHFW (O) Member Secretary

Joint Member Secretary for Subgroup I & II Dr. Jagdish Kaur, Chief Medical Officer, Ministry of Health & Family Welfare (O)23063120 Terms of Reference
I. II. To document burden and trend of non-communicable diseases in India. To review status of ongoing Central Sector/Centrally Sponsored Disease Control Programme for non-communicable diseases. III. To suggest introduction of new programmes/ continuation of existing

programmes for control of non-communicable diseases and modifications required, if any, in the 12th Five Year Plan on the basis of 1& 2 above along with detailed budget for each programme. This shall include initiating a Programme for any non-communicable disease of public health importance not yet covered under any Programme. IV. To assess the need for developing a National Institute for Health Promotion and Control of Chronic Diseases to play leadership role in prevention and control of NCDs and suggest its broad set up and fund requirement. V. To study and work out comparative effectiveness of interventions at different levels of health care such as health promotion, prevention, community based services, screening/ early diagnosis, treatment and rehabilitative care taking into account short term and long term needs for prevention and management of noncommunicable diseases. VI. Based on the assessment made as at 5 above, suggest proportionate expenditure on preventive, promotive, curative and rehabilitative health care for non-communicable diseases for maximizing impact of these interventions and optimizing resources available. VII. To develop a scheme for building up a platform for Emergency Medical System (EMS) by modifying and up-scaling the on-going trauma care programme.

VIII.

To review ongoing schemes for Emergency Medical Relief, and intensify ATLS training programmes and expand mobile hospital and CBRN Centre for disaster management.

IX.

To deliberate and give recommendations on any other matter relevant to prevention and control of non-communicable diseases.

1.

The Chairman may constitute various Specialists Group / Working Groups / Subgroups/task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitorable goals, while making recommendations. Efforts must be made to co-opt members from weaker section especially SCs, Scheduled Tribes and minorities working at the field level. The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the Working group Members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. The Working group would submit its draft report by 31st July, 2011 and final report by 31st August, 2011. (Shashi Kiran Baijal) Director (Health)

2.

3.

4.

5.

Copy to: 1. 2. 3. 4. 5. 6. 7. 8. 10. 11. 12. Chairman, all Members, Member Secretary of the Working Group PS to Deputy Chairman, Planning Commission PS to Minister of State (Planning) PS to all Members, Planning Commission PS to Member Secretary, Planning Commission All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission Director (PC), Planning Commission Administration (General I) and (General II), Planning Commission Accounts I Branch, Planning Commission Information Officer, Planning Commission Library, Planning Commission (Shashi Kiran Baijal) Director (Health)
6

Preve P ention & C n Contro of ol No on-Co ommunica able D Diseas (N ses NCDs) )
Proposal for the P r 12th Five Year Plan 2 e r n

Worki G W ing Group on D Disease Burden: e Non-C N Communica able D Diseases (NC CDs)

Direct torate Gener of Health Serv ral h vices Minis stry of Healt & F f th Family Welf y fare
7

CONTENTS
Page

EXECUTIVE SUMMARY MAIN REPORT

Section 1: DISEASE BURDEN DUE TO NON-COMMUNICABLE DISEASES Section 2: RISK FACTORS & DETERMINANTS OF NONCOMMUNICABLE DISEASES Section 3:PROGRESS OF ONGOING NATIONAL PROGRAMMES FOR NCDs Section 4: PLAN OF ACTION TO PREVENT AND CONTROL NCD DURING 12THPLAN

3
10 50 67 89
94 101 105 108 117 140 149 152 153 166 168 175 187 216 219 226 232 237 240 254 255 259 264 267 276 279 289 309 321 323 330

Programmes for Prevention and Control of Life Style Chronic Diseases:

1. 2. 3. 4. 5. 6. 7. 8. Cancer Diabetes, Cardiovascular Diseases (CVD) & Stroke Chronic Obstructive Pulmonary Diseases Chronic Kidney Diseases National Organ Transplant Program National Mental Health Program National Iodine Deficiency Disorders Control Program National Program for Prevention & Control of Fluorosis 9. Oral Health

Programmes for Disability Prevention and Rehabilitation:

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Trauma Care facilities on National Highways Prevention & Management of Burn Injuries Disaster Preparedness and Response in Health Sector Emergency Medical Services Prevention and Management of Musculo-skeletal Disorders Upgradation of Department of Physical Medicine & Rehabilitation National Blindness Control Program National Deafness Control Program National Program for Health Care of the Elderly Prevention & Control of Neurological Disorders (Epilepsy, Autism, Dementia) Prevention & Management of Congenital Diseases 21. Prevention & Management of Genetic Blood Disorders (Sickle Cell Anaemia, Thalassemia, Haemophilia)

Health Promotion and Prevention of NCDs and risk factors

22. National Tobacco Control Programme 23. Prevention and Control of Nutritional Disorders & Obesity 24. National Institute for Health Promotion and Control of Chronic Diseases 25. National Program on Patients Safety 26. Establishment of Air Port Health Office/Port Health Office Section 5: BUDGET REQUIRED TO PREVENT& CONTROL NCDs FOR 12TH PLAN Annex. 1: Monitoring and Evaluation of NCDs Annex. 2: Broad Organizational Structure at National, State & District levels Annex. 3: References Annex. 4: Composition of Working Group on Disease Burden (NCD) & sub-groups

EXECUTIVE SUMMARY
1. Burden of NCDs Non-communicable Diseases(NCDs) account for nearly half of all deaths in India. Among the NCDs, Cardiovascular Diseases (CVD) account for 52% of mortality (52%) followed by Chronic Obstructive Pulmonary Disease (COPD), Cancer, Diabetes and Injuries. Projection estimates have shown that unless interventions are made, burden due to NCDs will increase substantially. NCDs account for 43% of the DALYs. The potentially productive years of life lost (PPYLL) due to CVDs in the age group of 35-64 was 9.2 million in 2000 and is expected to rise to 17.9 million in 2030.Since the majority of deaths are premature there is a substantial loss of lives during the productive years as compared to other countries. Heart diseases, stroke and diabetes are projected to increase cumulatively, and India stands to lose 237 billion dollars during the decade 2005-2015. Considering the high cost of medicines and longer duration of treatment NCDs constitute a greater financial burden to low income groups. Studies carried out in India have shown that the cost of treating NCDs such as diabetes has doubled from 1998 to 2005 particularly among urban households. Road traffic injuries are increasing precipitously, and are estimated to account for as much as 25% of all health care expenditures in developing nations. Injuries and diseases of the musculoskeletal system account for more than 20% of patient visits to primary care. More than 20% of the population has at least one chronic disease and more than 10% have more than one. Chronic diseases are widespread in people who are younger than 45 years and in poorer populations. Whereas socioeconomic development tends to be associated with healthy behaviours, rapidly improving socioeconomic status in India is associated with a reduction of physical activity and increased rates of obesity and diabetes. The emerging pattern in India is therefore characterized by an initial uptake of harmful health behaviours in the early phase of socioeconomic development. Such behaviours include increased consumption of energy-dense foods and reduced physical activity and increased exposure to risk factors. Health-damaging behaviours such as smoking, drinking, consuming unhealthy diets (rich in salt, sugar and fats, and low in vegetables and fruits) are also found to be common among the low socioeconomic group. However, personal behaviours are not only a matter of personal choice, but may be driven by factors such as higher levels of urbanization, technological change, market integration and foreign direct investment.

Government Response to NCDs Government of India had supported the States in prevention and control of NCDs through several vertical programmes. National Health Pogrammes for Cancer and Blindness were started as early as 1975 and 1976 respectively, followed by programme on Mental Health in 1982. However, in the 11th Plan, there was considerable upsurge to prevent and control of NCDs. During 11th Plan, an allocation of nearly Rs. 10 thousand crore was made for NCDs. New programmes were started on a low scale in limited number of districts. Convergence with public sector health system was a feature of these programmes. Some of the programmes were within the framework of National Rural Health Mission. New programmes focused on CVDs, Diabetes, Stroke, Tobacco control, deafness, trauma, burns, Fluorosis and geriatric problems. These programmes have given insights of problems and experiences in implementation that would be useful in upscaling and expanding programmes across the country. Broadly, across programmes, following experiences were observed and lessons learnt in implementation of programmes, which need to be addressed during the 12th Plan: 1. Health promotion and prevention need to be given more attention to reduce the incidence of NCDs and their risk factors. 2. The States need to be given flexibility in implementation of the programmes based on their public sector health system, prevalence and distribution of NCDs and socio-cultural context. The flexibility would, however, will be within brad policy framework. 3. Convergence and integration would be critical in implementation of large number of interventions which would require unified management structure at various levels. 4. Integration of cross cutting components like health promotion, prevention, screening of population, training, referral services, emergency medical services, public awareness programme management, monitoring & evaluation etc. would save on costs and make implementation more effective. 2. Plan of Action to prevent and control NCDs during 12th Plan 3.1Justification: There is adequate evidence that NCDs are major contributors to high morbidity and mortality in the country. Risk factors including tobacco and alcohol use, lack of physical activity, unhealthy diet, obesity, stress and environmental factors contribute to high disease burden of NCDs which are modifiable factors and can be controlled to reduce incidence of NCDs and better outcomes for those having NCDs. Most of the NCDs like Cancer, Diabetes, Cardiovascular Diseases (CVD), Mental Disorders and problems relating to ageing are not only chronic in nature but also may have long pre-disease period where effective life style changes can turn around health status of individuals. Costs borne by the affected individuals and families may be catastrophic as treatment is long term and expensive. The economic, physical and social implications of NCDs

10

are significant justifying investment both for prevention and management of NCDs and well established risk factors. The efforts made by Government of India and the States have not been able to check rising burden of NCDs. Investments during the 11th Plan and earlier plans have been more on provision of medical services which have not been adequate in the public sector. Private sector has grown particularly in urban settings but is beyond the reach of the poor and middle sections of the society. The present proposal is a comprehensive scheme that will be first major attempt to focus on health promotion and prevention of NCDs and their risk factors and comprehensive management of NCDs at various levels across the country. While Government of Indias role will be policy formulation, population based multi-setoral interventions, technical and financial support, the onus of implementation will be with the States. Lessons learnt during the 11th Plan will be addressed and the programmes for various NCDs and their risk factors will be integrated and converged with public sector health system. As many programmes are either new or expanded after piloting in small number of districts and as NCDs are prevalent in riral as well as urban areas, it would be critical to have a separate implementation structure at various levels particularly during the 12th Plan though as an integral part of Public Sector Health System. 3.2Strategies: A comprehensive approach would be required for both prevention and management of NCDs in the country. It is proposed to continue ongoing efforts and introduce additional programmes to cover important NCDs of public health importance through following key strategies: Health Promotion for healthy life styles that preclude NCDs and their risk factors Specific prevention strategies which reduce exposure to risk factors Early Diagnosis through periodic/opportunistic screening of population and better diagnostic facilities Infrastructure Development and facilities required for management of NCDs Human Resources and their capacity building for prevention and treatment of NCDs Establish emergency medical services with rapid referral systems to reduce disability and mortality due to NCDs Treatment and care of persons with NCDs including rehabilitation and palliative care Health Legislation and population based interventions through multi-sectoral approach for prevention of NCDs Building evidence for action through surveillance, monitoring and research. 3.3Scope Most of the NCDs are prevalent across the country though there may be regional variations. The Plan of Action therefore would cover all States and UTs of the country in a phased manner during the 12th FY Plan. To ensure convergence and integration with public health services, a decentralized approach is proposed with District as the management unit for programs. Major
11

NCDs that are proposed to be covered during the 12th Plan are summarized in three broad categories: (a) Programmes for Life Style Chronic Diseases& Risk factors 1. Cancer 2. Diabetes, Cardiovascular Diseases (CVD) & Stroke 3. Chronic Obstructive Pulmonary Diseases 4. Chronic Kidney Diseases 5. Organ and Tissue Transplant 6. Mental Disorders 7. Iodine Deficiency Disorders 8. Fluorosis 9. Oro-dental disorders (b) Programmes for Disability Prevention and Rehabilitation 10. Trauma (including Road Traffic Accidents) 11. Burn Injuries 12. Disaster Response 13. Emergency Medical Services 14. Musculo-skeletal (Bone and Joint) Disorders 15. Physical Medcine & Rehabilitation 16. Blindness 17. Deafness 18. Health Care of the Elderly (Geriatric Disorders) 19. Neurological Disorders (Epilepsy, Autism) 20. Congenital Diseases 21. Hereditary Blood Disorders (Sickle Cell Anaemia, Thalassemia, Haemophilia) (c) Health Promotion and Prevention of NCDs 22. Tobacco Control 23. Prevention and Management of Nutritional Disorders & Obesity 24. National Institute for Health Promotion and Control of Chronic Diseases 25. Patient safety programme 26. Establishment of APHO/PHO 3.4Implementation To ensure long term sustainability of interventions, the programmes would be built within existing public sector health system and wherever feasible introduce public private partnership models.Following will be major components of NCD programmes: 1. Primary Health Care: Health promotion, screening , basic medical care, home based care & referral system (integration with NRHM) 2. Strengthening District Hospitals for diagnosis and management of NCDs including rehabilitation and palliative care: NCD Clinic, Intensive Care Unit, District Cancer Centre, Dialysis Facility, Geriatric Centre, Physiotherapy Centre, Mental Health Unit, Trauma & Burn Unit, strengthening of facilities for Orthopaedic, Oro-dental, Eye and ENT Departments, Tobacco Cessation Centre, Obesity Guidance Clinic.
12

3.

4. 5.

Tertiary Care for advanced management of complicated cases including radiotherapy for cancer, cardiac emergency including cardiac surgery, neurosurgery, organ transplantation etc. Emergency medical care and rapid referral system including Highway Trauma Centres and 108 EMS services Health Promotion & Prevention: Legislation, Population based interventions, Behaviour Change Communication using mass media, mid-media and interpersonal counselling and public awareness programmes in different settings (Schools, Colleges, Work Places and Industry). Facilities developed at various levels and key functions are summarized below:
Facility Sub-centres PHCs CHCs/Subdistrict Hospitals District Hospital Development of Facilities Screening facility Screening facility Vision Centre NCD Clinic Rehabilitation Unit NCD Clinic, Intensive Care Unit, District Cancer Centre, Dialysis Facility, Geriatric Centre, Physiotherapy Centre, Mental Health Unit, Trauma & Burn Unit, Tobacco Cessation Centre Obesity Guidance Clinic. Strengthening of Orthopaedic, Oro-dental, Ophthalmology and ENT Tertiary Cancer Centre Cardiac Care Centre Organ Transplant Facility Nephrology, Endocrinology Neurology Department Geriatric Department Psychiatry Department Glaucoma,Vetrioretinal Surgery Burn/Trauma Department Key Functions for NCDs Health Promotion, Screening, Referral Health Promotion, Screening, Followup, Referral Early Diagnosis, Home-based care, Managing common uncomplicated NCDs, Referral Early Diagnosis and Management of all NCDs except cancers requiring adiotherapy, complicated cases of renal diseases, cardiac cases requiring surgery, retinal diseases, NCDs requiring laser treatment, organ transplantations

Medical Colleges/ Tertiary level Institute

Comprehensive cancer treatment, cardiac care including cardiac surgery, neurosurgery, organ transplantation, tertiary level care for ENT, Ophthalmology, Geriatrics etc.

2.5 Coverage: It is proposed to expand various schemes for NCDs to all 640 districts in a phased manner during the 12th Plan. To ensure convergence, common districts will be selected for all three major programmes. The schemes would be flexible to meet local requirements as there would be
13

variation in prevalence and availability of existing health infrastructure. Districts will be selected for each year of the Plan based on selected parameters including disease burden and availability of HR and facilities but in consultation with the States. Program-wise coverage targets are given below:
S.No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Program Component Cancer Blindness Mental health IDD (Iodated Salt) Tobacco Highway Trauma Centres Deafness Fluorosis Oral Health Diabetes, CVD, Stroke Health Care of Elderly Burn Injuries Upgradation of PMR Disaster Response Organ & Tissue Transplant Health Promotion Patient Safety Program Airport/Port Health Office Neurological Disorders Thalassemia, Sickle Cell Disease and Hemophilia Coverage by March 2012 100 Districts All Districts 123 Districts 71% popn. 42 Districts 243 Centres 203 Districts 100 Districts 25 Districts 100 Districts 100 Districts 6 Districts 28 Med.Col. New New New New New New New Target by March 2017 All Districts All Districts All Districts 100% Population All Districts Cover major highways & accident prone roads All Districts All 230 Endemic Districts All Districts All Districts All Districts All Districts All Govt. medical colleges Cover 22 vulnerable States 11 OPDO & Biomaterial centres National Institute for Health Promotion & CCD All Districts All Intl. Airports, Ports and Land Borders covered All districts Pilot in selected endemic districts

Estimated Budget It is envisaged that for comprehensive and sustainable programmes to prevent, control and manage important non-communicable diseases and key risk factors across the country, a large investment would be required during the 12th Plan. Rs. 58072 crore would be required over the period 2012-17. Cancer, Diabetes, Cardiovascular Diseases, Chronic Lund Diseases and Chronic Kidney Disease account for most of the mortality due to NCDs and would require substantial budget. Trauma, Disasters, Emergency Medical Services, Diseases of Bones &Joints, Mental Health and Health Care of the Elderly are disabling diseases and requiring investment for not only treatment but also rehabilitation. NCDs have affected both urban and rural population though there may be some differences in prevalence. It is also important to invest on preventive programmes and health promotion to check occurrence of new cases and reduce at risk population. The proposal therefore seeks budget for activities across that will not only result in prevention of NCDs but also develop
14

facilities with capacity to manage NCDs. The programmes will reduce morbidity, disability and mortality due to NCDs and add on productive years for the population. The investment will be cost-effective in long run. Nearly one-third of the budget would be required for primary health care in the rural areas. Secondary and tertiary level care is important to manage these chronic and fatal diseases and injuries and large share of the budget would be required to upgrade and strengthen District Hospitals, Medical Colleges and other Tertiary level institutions. Many of the NCDs occur due to exposure to risk factors like tobacco, obesity, unhealthy diet, lack of physical activity and stress. Adequate provision has been made for public awareness and behaviour change communication, an important step to prevent NCDs. 3.7 Expected Outcomes The programmes and interventions would establish a comprehensive sustainable system for reducing rapid rise of NCDs, disability as well as deaths due to NCDs. Broadly,following outcomes are expected at the end of the 12th Plan: Early detection and timely treatment leading to increase in cure rate and survival Reduction in exposure to risk factors, life style changes leading to reduction in NCDs Improved mental health and better quality of life Reduction in prevalence of physical disabilities including blindness and deafness Providing user friendly health services to the elderly population of the country Reduction in deaths and disability due to trauma, burns and disasters Reduction in out-of-pocket expenditure on management of NCDs and thereby preventing catastrophic implication on affected individual and families

15

SECTION 1 DISEASE BURDEN DUE TO NON-COMMUNICABLE DISEASES Chronic non-communicable diseases (NCDs) have replaced communicable diseases as the most common causes of morbidity and premature mortality worldwide. About 80% of the burden occurs in low / middle-income countries, and 25% is in individuals younger than 60 years.The global economic impact of NCDs is enormous: by 2015, just two diseases (cardiovascular diseases and diabetes) are expected to reduce global GDP by 5%.Approximately half of the total economic burden is reported to account for by CVD including stroke, ischemic heart disease and peripheral vascular disease, which together cause more deaths than HIV/AIDs, malaria and tuberculosis combined2. In recognition of the increasing burden and importance of chronic diseases, in 2005 the World Health Organization (WHO) issued a plan for NCD prevention and control which offers the health community a new global goal: to reduce death rates from all chronic diseases by 2% per year over and above existing trends during the next 10 years3.This goal had been presented as a formal action plan to the 61st World Health Assembly in 20084. Central to any plan to reduce the impact of NCDs is definition of the specific diseases to be targeted. The WHO plan for NCDs focuses on diabetes, cardiovascular disease (CVD) including hypertension, cancer and pulmonary disease. 1.1 Burden of Non-communicable diseases As of 2004, NCDs contributed half of the (50%) of the total mortality and are the major causes of death6. Among the NCDs, cardiovascular diseases are number one cause of mortality (52%). NCDs account for more than two fifth (43%) of the DALYs and among this group cardiovascular diseases, diabetes, cancers together account for 40% of the NCD related DALYs in India. Regional studies have reported that even in rural India the leading cause of death (32%) is NCDs followed by injuries and external cause of deaths (12%)7. Projection estimates from the WHO have shown that by the year 2030, CVDs will emerge as the main cause of death (36%) in India. Since the majority of deaths are premature there is a substantial loss of lives during the productive years as compared to other countries. Graph:Pattern of overall DALYs (age standardized) and NCD related DALYs in India, 20046

16

The salient features of the Causes of Death Survey (2001-03) conducted by the Registrar General of India were 8:
1. The overall non-communicable diseases are the leading causes of death in the country,

2.

3.

4.

5.

constituting 42% of all deaths. Injuries and ill-defined causes constitute 10% of deaths each. However, majority of ill-defined causes are at older ages (70 or higher years) and most of illdefined deaths are likely to be from non-communicable diseases. In the case of non-communicable diseases, it is the Other States which have a higher proportion (50%) vis--vis the EAG states and Assam (33%). The mortality due to injuries is also more in proportion in Other States. Urban areas have a lower number of deaths from communicable, maternal, perinatal and nutritional conditions but a higher proportion from non-communicable diseases (56%). Their proportion is less in rural areas (40%). Injuries constitute about the same proportion in both rural and urban areas. Overall, the leading cause of death is cardiovascular disease (19%), followed by respiratory diseases (namely chronic obstructive pulmonary disease or COPD, asthma, other respiratory diseases; 9%), diarrhoeal diseases (8%), perinatal conditions (6.3%), respiratory infections such as acute pneumonia (6.2%), tuberculosis (6%), malignant and other neoplasms (5.7%), senility (5.1% which is concentrated at ages 70 and higher), unintentional injuries: other (4.9%), and symptoms, signs and ill-defined conditions (4.8%). Notable differences by gender are seen in the case of diarrhoeal diseases with 10% of women deaths against 7% of men deaths, tuberculosis with 5% of women deaths vis--vis 7% men deaths, and cardiovascular diseases with 17% women deaths versus 20% men deaths. Fig: Distribution of major causes of deaths in India, 2001-2003 8

17

Summary of Major NCD Burden Contributors in India 8

1. Diabetes: Prevalence, increasing in both urban and rural areas, is in the range of 515 percent among urban populations, 46 percent in semi-urban populations, and 25 percent in rural populations. Diabetes is particularly increasing among the marginalized and the poor. 2. Hypertension: Present in 25 percent of the urban and 10 percent of the rural population. The number of people with hypertension will rise from 118.2 million in 2000 to 213.5 million by 2025. 3. COPD: Prevalence among men is in a range of 29 percent in north India and 14 percent in south India. Among men, tobacco smoke is the major cause of COPD, while smoke from indoor combustion of solid fuels is the major cause for women. 4. Cancer: Over 70 percent of cases are diagnosed during the advanced stages of the disease, resulting in poor survival and high case mortality rates. Tobacco use is the major cause of cancer for both lung and oral cavity diseases. 5. Smoking: Prevalence is similar to other South Asian countries (men 33 percent, women 4 percent) while smoking prevalence among youth is higher (boys 17 percent, girls 9 percent). Smoking accounts for 1 in 5 deaths among men and 1 in 20 deaths among women, accounting for an estimated 930,000 deaths in 2010. 6. Alcohol: A study on CVD risk factors in industrial populations found higher alcohol consumption conferred a higher risk for CVD.11 The reasons for the lack of protective effect found in other populations could include (i) unfavorable enzymatic metabolism of alcohol in Indians that is known to impact CVD, (ii) harmful drinkingv patterns with irregular heavy or binge drinking that is associated with CVD, and (iii) consumption mostly among the disadvantaged and poor who carry a higher risk of CVD than others. 7. Injuries: Road traffic injuries and deaths are on the increase along with the rapid economic growth. Annually, they result in more than 100,000 deaths, 2 million hospitalizations, and 7.7 million minor injuries. Nonfatal road traffic injuries are highest among pedestrians, motorized two-wheeled vehicle users, and cyclists. This is a major problem among young populations, with three-quarters occurring among 1545 year olds, predominantly among men. If the present pace of increase continues, in 2010 150,000 deaths and 2.8 million hospitalizations are likely and, in 2015, these numbers will rise to 185,000 and 3.6 million. 8. Diet: Exact data on consumption of oils/fats at the individual and household level are missing. However, national aggregate statistics show high consumption of unhealthy oils. The share of raw oil, refined oil, and vanaspati oil (hydrogenated oil) in the total edible oil market is estimated at 35 percent, 55 percent, and 10 percent, respectively. Trans fats are added to vanaspati oil, which is widely used in the commercial food industry to lengthen shelf life.

1.2 Impact of NCDs With losses due to premature deaths due to heart disease, stroke and diabetes are projected to increase cumulatively, and India stands to lose 237 billion dollars during the decade 2005-20153. India also loses a substantial number of lives during the productive years of its citizens. The potentially productive years of life lost (PPYLL) due to CVDs in the age group of 35-64 was 9.2 million in 2000 and is expected to rise to 17.9 million in 20309. This estimate is more than the combined estimated loss in China, Russia, USA, Portugal, and South Africa (16.2 million). Further, WHO estimates that a 2% annual reduction in national-level chronic disease death rates in India would result in an economic gain of 15 billion dollars for the country over the next 10 years 3. Modelling studies have shown that the per-capita income in India would increase by 87% if the CVD mortality rate per annum declines by one percent whereas a three percent annual decline would increase per-capita income by 218% by the year 2030. Similarly, road traffic injuries are estimated to result in economic loss of $11,458 million (INR 550,000 million) or nearly 3% of GDP every year10.
18

Consider ring the high cost of m medicines an longer du nd uration of tr reatment NC CDs constit tute a greater fi financial burd to low i den income grou Studies carried out in India hav shown tha the ups. ve at cost of tr reating NCD such as di Ds iabetes has d doubled from 1998 to 20 particula among u m 005 arly urban 11 househol lds . Low income grou spent a higher prop i ups portion of th income on diabetes care heir s (urbanpo 34% and rural poor 2 oor 27%). In add dition, the hig ghest increasein percent tage of house ehold income d devoted to diabetes care was also found to be the lowe economic group (34 of d e ein est c 4% income i 1998 vs. 24.5% in 20 in 2 005). The CREATE reg gistry study on acute cor ronary synd drome highlight that the poor are less likely to g evidenceted p s get -based presc criptions afte acute coro er onary 12 syndrome due to hig cost of the drugs . Sm gh e maller propo ortions of po patients t oor than rich pat tients received key treatme such as thrombolyti (52.3% v 60.6%), lipid-loweri drugs (36.0% ents ics vs. ing vs. 61.2% Angioten %), nsin-Conver rting Enzym (ACE) inh me hibitors or a angiotensin r receptor blockers (ARBs) (54.1% vs. 63.2%) perc cutaneous co oronary inte ervention (2.0 vs. 15.3% and coro %), onary artery by ypass graft surgery (0.7% vs. 7.5%) Poor also had greater 30-day mo s % ). r ortality (8.2% vs. % 5.5%). Acute ev vents of card diovascular d diseases are a associated w major he with ealth expens owing to high ses o cost of d drugs, therap peutic proced dures, other hospital exp penses and w wage losses. A study ca arried out in so outh India among CVD patients w an acute event show that ca a D with e wed atastrophic h health spending as a result of treating an acute even of cardiov g o n nt vascular disease was experienced by three fourths ( (72.9 %) of the house f eholds particularly the lowest soc cioeconomic group. Dis stress financing was low am g mong the ric chest (36%) as compared to the poo orest (51%). Income loss was s highest a among poor households The impo s. overishment due to the care of NCDs has not been estimated The Worl Health Su d. ld urvey has shown that, in India, impo n overishment in general i the t is highest a among house eholds in middle expend diture deciles (fifth and s s sixth), which could be d to h due 13 treatment cost of NC t CDs . In In ndia, the trea atment costs for an indiv vidual with diabetes are 15 e 25% of t their househ hold earning One in f gs. four Indian f families in w which a fam membe has mily er heart dise ease or strok has catast ke trophic expe enditure, pus shing 10% of these fami ilies into pov verty. Where fa amilies have no access to affordable care, they fo o orego care o risk financ ruin; the poor or cial 14 end up su uffering the worst . w Fig: Cos of hospita st alization due to diabetes rises with addition of each comp e s f plication15
Rupees R 20000 15000 10000 5000 0
16565 9888

12781 7668

99 1329

19

1.3 Burden due to Key NCDs a. CANCER Cancer is a major public health concern in India and has become one of the ten leading causes of death in the country. It is estimated that there are about 28 lakh cases of cancer at any particular point of time with 10 lakh new cases occurring every year. About 5 lakh deaths occur annually in the country due to cancer. As per WHO Report 2005, the estimated Cancer Deaths in India is projected to increase to 7 lakh by 2015. The burden of cancer is expected to further increase due to increase in life expectancy, demographic transitions and the effects of tobacco and other risk factors. 40 % of cancer cases are due to Tobacco use. The leading sites of cancer are the oral cavity, lungs, oesophagus and stomach among men and cervix, breast and oral cavity amongst women. Recent estimates based on National Cancer Registry Program (ICMR) 16 The leading site of cancers is varied in different parts of the country. Among males the leading site of cancer is Ca Lung in the PBCrore of Delhi, Mumbai, Bhopal, Kolkata, Bangalore, Chennai, Thiruvanathapuram. Ca Mouth is the leading site among males in PBCR of Ahmedabad. In North East, the leading site among males is Ca Oesopahgus in Assam, Ca Stomach in Mizoram & Sikkim, Ca Lung in Manipur. The leading site of cancer among females is Ca Breast in PBCrore of Delhi, Mumbai, Bhopal, Kolkata, Bangalore, Chennai, Thiruvanathapuram& Ahmedabad. In North East the leading site among females is Ca Breast in Assam, Ca Lung in Mizoram & Manipur and Ca Stomach in Sikkim16. Cancers account for 14% of the overall NCD mortality and 7% of the NCD related DALYs in India6. The pooled estimates for data of all six population based registries (Delhi, Mumbai, Chennai, Barshi, Bangalore and Bhopal) were 25.19 per lakh for men and 23.52 per lakh for women in 2004. The prevalence of cancer in India is estimated to be around 2.5 million, with over 800,000 new cases and 550,000 deaths occurring each year due to this disease in the country17. In India, cancers account for about of 3.3% of the disease burden and about 9% of all deaths. These estimates would change as many of the common risk factors for cancers, such as tobacco and alcohol consumption continue to become more prevalent in India. It is estimated that the number of people living with cancers will rise by nearly one- quarter between 2001 and 2016. Nearly 10 lakh new cases of cancers will be diagnosed in 2015 compared to about 807,000 in 2004, and nearly 670,000 people are expected to die10. Since the commencement of the ICMRs National Cancer Registry Program (NCRP) in 1982, which covers only 7 percent of the Indian population, a brief report on time trends in incidence rates was presented in the consolidated report for 199096. The first systematic report on trends in incidence rates over 2 decades shows a steady and consistent increase in the age-adjusted incidence rates of certain cancers across all major urban registries. Among men, cancers of the prostate, colon, rectum and liver have shown statistically significant increase in incidence.
20

Cancer o the prosta is the lea of ate ading site of cancer amo men in most wester countries as is f ong rn cancer of the colon. f Disea Burden due to Cancers in Indi ase ia
9.99 8.07

10 9 8 7 6 5 4 3 2 1 0

No. .ofCases(Lakh) h

2005 5 2015 5
0.9 1.13 90 1.40 1.131 3 0.350.43 0.220.50

Bre east Can ncer

Cancer rof LungCancer Cancerof AllCancers Cervi ix Stomach

Among w women, cancers of the b breast, corpu uteri and lung have s us shown a rise While the first e. e two of these cancer could be accounted for because of cohorts with later age at marr rs riage, decreasin multi-par and so o the increa in lung c ng rity on, ase cancer could be attributed to an inc d crease in the us of tobacc by wome Lung cancer in wom may al be increa se co en. men lso asing becau of use environm mental expos sure to smok (passive sm ke moking). Th other sit of cancer that have sh hree tes r hown an increa in incid ase dence rates i women a ovary, th in are hyroid and gallbladder. The increa in ase gallbladd cancer is seen in reg der s gistries that h have recorde a compar ed ratively lowe incidence than er e Delhi, w which showed an increas d sing trend on during t earlier y nly the years, with a decline in more recent ye ears. There have been ris h sing incidenc rates for c ce cancers of th brain as w as in tum he well mours of the ly ymphoid and haemopoet system, e d tic especially no on-Hodgkin lymphoma in both men and n women. The decline in the incid dence of can ncer cervix i seen acros all registr includin the is ss ries ng shi. e f ized screenin or ng rural registry at Bars This decline is observed in the absence of any organi early dete ection progr rammes in th registry ar he reas. The fac ctors contrib buting to an i increase in b breast cancer co ould possibl be respon ly nsible for th decline in the incidence of canc of the ce he n cer ervix. Another possible rea ason for the decline cou be an in e uld ncrease in th number o child-birt at he of ths institutions (as oppo osed to hom deliveries) leading to improved maternal an maternity care me o nd y including genital hy g ygiene. This could be a result of th family w he welfare drive initiated by the e y governm ment about 4 decades a ago and wh hich is cont tinuing. Bet tter genital hygiene, ba arrier contracep ptive use and superior n d nourishment could all ha contribut to the reducing incid ave ted dence of cancer of the cervi r ix

21

TABLE: Estimated new cancers at all anatomical sites (ICD-10: C00C96) 18

The common sites for cancer in India are oral cavity, lungs, esophagus and stomach in men and cervix, breast and oral cavity among women. Over 70% of the cases report for diagnostic and treatment services in advanced stages of the disease, resulting in poor survival and high mortality rates. Tobacco use is the major cause of cancer in India particularly for cancers of lung, oral cavity, esophagus, larynx, pancreas and bladder. Parts of India have the world's highest incidence of cancersof the gall bladder (Delhi), oral, and lower pharynx (Mizoram) 19. b. DIABETES Diabetes mellitus (Madhumeha) has been discussed even in Ayurveda (the ancient system of medicine in India) from ancient times as a urinary disorder characterized by sweetness of urine. Projection estimates show that the number of people with diabetes in India is 40.9 million and is expected to rise to 69.9 million by 202520. In the ICMR study on Assessment of Burden of NCDs in India21, the prevalence rates of diabetes varied from 103 per thousand to 124 per thousand in these studies. The overall prevalence rate of diabetes in urban and rural areas combined was estimated as 62.47 per thousand. The pooled estimates of prevalence rates for diabetes mellitus for urban and rural areas were found to be 118.02 per thousand and 38.67 per thousand respectively. It was estimated that there are 37.77 million diabetics in India in 2004; 21.4 million in urban areas and 16.36 million in rural areas. Diabetes accounts for 1.09 lakh deaths in a year. Diabetes mellitus is responsible for 11.57 lakh years of life lost due to the disease, and for 22.63 lakh DALYs during 2004. The estimated number ofDALYs attributable to diabetes was 20.72 lakh in the year 2000. The estimates of number of DALYs in the present study were 22.63 lakh. The first documented study on diabetes was a hospital based study from Kolkata in 1938 showing a prevalence of glycosuria as 1.3 percent. Population based surveys done in the early 1970s in different Indian cities and nearby rural areas reported prevalence of diabetes ranging from 1.2% to 2.5%. The first multicentric study in India was done by the Indian Council of Medical Research (ICMR) between 1972 and 1975, screening more than 34,000 individuals from six representative areas of India for capillary blood glucose level of above 170 mg/dl. This study reported a prevalence of 3.0 % in urban areas and 1.3% in rural areas. From these reports, it is evident that till the 1970s, the prevalence of diabetes was less than 3.0% even in urban areas. The rise in prevalence of type 2 diabetes was reported in 1980s, which accelerated after 1990s, showing rapid rises in the southern parts of the country22.
22

Fig: Changes in Diabetes and Impaired Glucose Tolerance prevalence in urban southern India23

Several studies showed declining ages of diabetes reporting to around 30 years, and a concomitant rise in urban and rural populations22. According to NFHS-3, self reported prevalence of diabetes in the age group of 35-49 was 2.1% among women and 2.7% among men suggesting substantial gaps in the awareness 24. In an ICMR-WHO six site study across four regions of the country on comprehensive NCD risk factors using WHO STEPS approach, the lowest prevalence of self-reported diabetes diagnosed by a physician was recorded in rural (3.1%) followed by peri-urban/slum (3.2%) and the highest in urban areas (7.3%, odds ratio (OR) for urban areas: 2.48, 95% confidence interval (CI): 2.21 2.79, p < 0.001). Urban residents with abdominal obesity and sedentary activity had the highest prevalence of self-reported diabetes (11.3%) while rural residents without abdominal obesity performing vigorous activity had the lowest prevalence (0.7%) 25. Increase in the prevalence of diabetes has also been reported among the marginalized and the poor. Urban locations have been observing a reversal of socio economic trends with the burden of disease increasing among the poor26. Diabetes substantially increases the propensity to macrovascular and microvascular complications, such as cardiovascular disease, cerebrovascular disease, retinopathy, nephropathy, neuropathy and foot problems, all of which account for considerable mortality and morbidity27. Assuming 40 million people with diabetes in India, the prevalence of various complications would be: Retinopathy (7 million); Nephropathy (0.8 million); Neuropathy (10.4 million); Coronary heart disease (8.5 million); and Peripheral vascular disease (2.5 million). In addition, a third of the heart attack patients in India have concurrent diabetes12.Fatality rate after myocardial infarction is greater in diabetic patients, and overall prognosis after coronary heart disease is worse. Hence, it has been proposed that diabetes should be considered as a coronary heart disease risk equivalent i.e. diabetic individuals without previous myocardial infarction have as high a risk of future heart attack or death as compared to non-diabetic subjects with previous myocardial infarction. Diabetes also increases the risk of stroke particularly ischemic type of stroke. Hence early detection and management of diabetes is important. Diabetic retinopathy was estimated to be 17.6% in a populations based study in Chennai in 2005, the prevalence of
23

neuropathy in urban population was 26.1% and the prevalence of coronary artery disease was 21.4% among diabetic subjects compared to 9.1% in subjects with normal glucose tolerance, whereas the prevalence of overt nephropathy was found to be 2.2% and that of microalbuminuria was 26.9%22. A review of published literature has highlighted several barriers in addressing the growing burden of diabetes28. Only 12% of the general population is aware of the risk factors of diabetes. Even among those with established diabetes only 40.6% were aware that it could result in organ damage. Even in tertiary care centers, poor glucose control was observed in half of the patients highlighting poor management of individuals with diabetes. Managing multiple risk factors in subjects with diabetes and other established CVD complications is particularly challenging and also adds to heavy financial burden to both the households and the health system. As per International Diabetic federation there were 5.1 crore in 2010 expected to increase to 8 crores by 2030. It is estimated that the overall prevalence of diabetes is 62.47 per 1000 population of India. c. HYPERTENSION Elevated level of blood pressure is a major risk factor for cardiovascular diseases. Hypertension is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India29. The meta analysis of eight studies carried out in urban areas gives a pooled prevalence rate of 164.18 per thousand and in rural areas was 157.44 per thousand. About 16% of ischaemic heart disease in the country is attributable of hypertension. 21% of peripheral vascular diseases and 24% of AMI cases could be attributed of elevated hypertension. The population attributable risk due to hypertension was found to be 29% for stroke21. Pooling of epidemiological studies shows that hypertension is present in 25% urban and 10% rural subjects in India. At an underestimate, there are 31.5 million hypertensives in rural and 34 million in urban populations. A total of 70% of these would be Stage I hypertension (systolic BP 140159 and/or diastolic BP 9099 mmHg). Recent reports show that borderline hypertension (systolic BP 130139 and/or diastolic BP 8589mmHg) and Stage I hypertension carry a significant cardiovascular risk and there is a need to reduce this blood pressure29. Indian urban population studies in the mid-1950s used older WHO guidelines for diagnosis (BP 160 and/or 95mmHg) and reported hypertension prevalence of 1.24.0%. Subsequent studies report steadily increasing prevalence from 5% in 1960s to 1215% in 1990s. Hypertension prevalence is lower in the rural Indian population, although there has been a steady increase over time here as well. Recent studies using revised criteria (BP 140 and/or 90mmHg) have shown a high prevalence of hypertension among urban adults: men 30%, women 33% in Jaipur (1995), men 44%, women 45% in Mumbai (1999), men 31%, women 36% in Thiruvananthapuram (2000), 14% in Chennai (2001), and men 36%, women 37% in Jaipur (2002). Among the rural populations, hypertension prevalence is men 24%, women 17% in Rajasthan (1994)29. Hypertension diagnosed by multiple examinations has been reported in 27% men and 28%
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women executives in Mumbai (2000) and 4.5% rural subjects in Haryana (1999).Over the years, from 1942 to 1997, there has been a significant increase in the mean levels of systolic blood pressure in the Indian population particularly among urban men aged 4049 years (from 120.4 mmHg to 130 mmHg)30. According to the estimates of the Indian Council for Medical Research, 24% of acute myocardial infarction, 29% for stroke and 21% of peripheral vascular diseases in the country are attributed to hypertension. Detection and management, though relatively easier, less than half (31-37%) the hypertensive subjects get to identify their hypertensive status. Less than half of the hypertensive subjects undertake any kind of medication and only half of them achieve good control31. There is a strong correlation between changing lifestyle factors and increase in hypertension in India. The nature of genetic contribution and gene environment interaction in accelerating the hypertension epidemic in India needs exploration. d. CARDIOVASCULAR DISEASES& STROKE Cardiovascular Diseases (CVD) denotes a mix of conditions that includes acute myocardial infarction, angina pectoris, congestive heart failure, inflammatory heart disease and cerebrovascular diseases (stroke). As of 2004, of the NCDs, cardiovascular diseases account for one fifth (22%) of the NCD burden in terms of DALYs in India6. Starting from a level of about 380 lakh cases in the year 2005, there may be as many as 641 lakh cases of cardiovascular disease (CVD) in 2015. The rates of prevalence of CVD in rural populations will be lower than in urban populations, but will continue to increase, reaching roughly 13.5% of the rural population in the age group of 60-69 years by 2015. The prevalence rates among younger adults and women (in the age group of 40 years and above) are also likely to increase. A crude estimate of mortality on account of CVD, which could throw some light on prevalence, also shows wide inter-state disparities; with Rajasthan and MP having higher mortality levels of 275 and 229 per 100,000 than Kerala and Karnataka, which were 187 and 175, respectively. Of course this also reflects the level of treatment and management facilities available10. The number of cases of ischemic heart disease (IHD) is estimated to be about 22.37 million in India in the year 2004. These consist of 11.67 million cases in urban areas and 10.67 million cases in rural areas. The total number of DALYs attributable to IHD is estimated to be 16 million. The pooled estimates of prevalence rates for urban and rural areas were found to be 6.4% and 2.5% respectively. In urban areas, the pooled estimate of prevalence rate was 6.1% for men and 6.7% for women. In rural areas the pooled estimate for prevalence rate was 2.1% for men and 2.7% for women. The prevalence rate of stroke is 1.54 per thousand. The figures for YLL per hundred thousand are 496.3, and DALY per hundred thousand is 597.6. The total number of stroke cases in India in year 2004 is expected to be 9.3 lakh. The total number of DALYs attributable to stroke are estimated to be 6.37 million for the year 2004 in India21.

25

Fig: Burden of Cardiovascular diseases in India

AllCases CoronaryHeartDisease Stroke RheumaticHeartDisease CongenitalHeartDisease 0 17 12 7 7 1.62 1.62

380 359

641 615

2015 2005

No. ofCVDCases(Lakh)

100 200 300 400 500 600 700

Table: The prevalence rates of stroke from various major epidemiological studies in India32

During the last decade, the age-adjusted prevalence rate of stroke was between 250-350/100,000. Recent studies showed that the age-adjusted annual incidence rate was 105/100,000 in the urban community of Kolkata and 262/100,000 in a rural community of Bengal. The ratio of cerebral infarct to hemorrhage was 2.21. Hypertension was the most important risk factor. Stroke represented 1.2% of total deaths in India32.
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In addition, CVDs in the Indian population are characterized by three facets: early occurrence (Indians acquire the disease at least ten years earlier than their western counterparts), higher case fatality (a comparatively higher proportion die after a heart attack as compared to the western population) and the occurrence of disease at lower risk factor threshold particularly overweight and obesity12, 33. The prevalence of coronary heart disease is reported to be between 6.5- 13.2% urban India and 1.6 7.4% in rural India. Similarly stroke prevalence is between 136 842/ 100,000 population in urban areas and 143-165/ 100, 000 population in rural areas34. Several well designed studies indicate a reversal of socio economic gradient for cardiovascular disease (which is a major contributor to NCDs) and its risk factors35. The poorer sections of the society, the less educated and the rural population have high prevalence of smoking and in certain settings such as worksites, high prevalence of diabetes and high blood pressure are seen among less educated groups. While self reported surveys such as NFHS-3 suggest that it is the rich who have high prevalence of risk factors, well designed studies show the risk for heart attack is higher (more than twice) among the uneducated, under-educated and the poor. The differences observed between NFHS-3 and comprehensive surveys are largely due to low risk factor awareness and control among the less educated and poor24. As per NCMH, it is estimated that there were 2.9 crores CVD cases which are expected to increase to 6.4 crores by 2015. According to a WHO report (2002), cardiovascular diseases (CVDs) will be the largest cause of death and disability in India by 2020. It is estimated that the overall prevalence of hypertension, Ischemic Heart Diseases (IHD) and Stroke is 159.46, 37.00 and 1.54 respectively per 1000 population of India. e. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) COPD is a leading cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. COPD prevalence, morbidity, and mortality vary across countries and across different groups within countries. The burden of COPD is projected to increase in the coming decades due to continued exposure to COPD risk factors and the changing age structure of the worlds population. In 2010, almost 24 million adults over the age of 40 in India had COPD. It is expected this number to increase 34% to approximately 32 million by 2020. Prevalence rates varying from about 2 to 22 per cent in men and from 1.2 to 19 per cent in women have been shown in different reports. Chronic Respiratory Diseases (CRD) mainly includes asthma and chronic obstructive pulmonary diseases (COPD, dama). As of 2004, chronic obstructive pulmonary diseases (COPD) accounted for 5.2% of the total NCD burden and 12.2% of the NCD related mortality6. The estimated burden of asthma was 3 million DALYs (2.4% of the total NCD burden) and account for 1.1% of the NCD related deaths. A higher prevalence of asthma was observed among women
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as compared to men (2.6% vs. 2.2%) and in urban areas than rural areas (2.6% vs. 2.2%) with a higher risk of having asthma among the poor than the rich36.Projection of NCMH shows that asthma is expected to rise from 28.3 million in 2006 to 35.9 million by the year 2016. COPD is primarily a disease of the adult while asthma is seen largely among younger age group individuals.The prevalence of COPD among men in India ranges between 2.12% to 9.4% in north India and 1.4% to 4.08% in South India37. A large multi-site study carried out by the ICMR has reported a higher prevalence of COPD among men (5.0%) than women (3.2%) aged above thirty five years38. A higher prevalence was observed in low income groups as compared to the well-off (5.4% vs. 3.3%) and in rural areas as compared to urban regions (4.4% vs. 3.7%). According to the estimates of National Commission on Macroeconomics and Health (NCMH), the number of COPD cases in the country is to rise from 17.0 million in the year 2006 to 22.2 million by 201610. More recently, in Phase I of the ICMR study titled Indian Study on the Asthma, Respiratory symptoms and Chronic Bronchitis (INSEARCH)39at Delhi, Bangalore, Kanpur and Chandigarh, the population based prevalence of ever asthma in subjects aged more than 15 years was 2.4 percent, and other respiratory related symptoms was 4.3-10.5 percent. Chronic bronchitis was diagnosed in 4.1 percent population, with a male to female ratio of 1.56 to 1. Some variations were seen in the population due to socioeconomic grouping and place of residence, but major differences were related to exposure to tobacco smoke and solid fuels combustion Tobacco smoke is the most important cause for COPD and is the major cause of COPD among men. The smoke from combustion of solid fuels such as dried dung, wood and crop residue used for cooking and heating, is an important cause of indoor pollution which is responsible for a large number of COPD cases in the rural areas and women in particular. Air pollution due to exhausts from vehicles and industrial units; dusts, fumes and smoke from burning of crop residues in the field act as airborne allergens and irritants (for example, tobacco smoke) causing allergic responses triggering asthma and cause other chronic respiratory disease as well40. The spectrum of clinical manifestations of COPD is wide. There are great variations in the reported morbidity, which could partly be due to differences in the definition of a case. The data on mortality also underestimate COPD as a cause of death because the disease is more likely to be cited as a contributory rather than an underlying cause of death, or may not be cited at all. Depending on the severity of the disease, the 5-year mortality rate for patients with COPD varies from 40% to 70%. The three major causes of death have been identified as COPD itself, lung cancer and cardiovascular disease. Majority of the studies were confined to limited areas and do not represent the general population of that State or region. Table below presents the variation in prevalence rates reported by different researchers in India during (1975-2006). The prevalence of COPD is confined to adults 30 years of age and above. According to the studies mentioned in the Table given below, the prevalence rates of COPD in males varied from 2.12% to 9.4% in studies conducted in north India and from 1.4% to 4.08% in south India. The respective ranges for females were 1.33%4.9% in north India and 2.55%
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2.7% in south India. The median values of these prevalence rates are 5% for males and 2.7% for females. Thus, COPD is more common among males than females. The male to female ratio varied from 1.32:1 to 2.6:1 with median ratio of 1.6:1.

A strong association exists between tobacco smoking and the occurrence of COPD. The reported smoker: nonsmoker prevalence ratio varied from 1.6 to 10.2. Thus, smoking has been identified as a high-risk factor for COPD. Surveys in India have revealed that 29.4% of males and 2.5% of females are current smokers. However, in those 30 years of age and above, the prevalence of smoking in India is 40.9% for males and 3.9% for females. The difference in the prevalence of COPD among males and females could be due to the differences in their levels and type of smoking. In these studies, indoor air pollution due to traditional domestic fuels was considered an important factor affecting the lung function of females in rural areas in prevalence studies of COPD. The occurrence of severe bronchitis among non-smokers was mainly due to their exposure to tobacco smoke either at home or at the workplace. The prevalence of COPD was much higher in heavy smokers than among those who smoked a lesser number of cigarettes. The odds ratio was 2.4 for the total population4.7 for that seen among non-smokers. Similar observations were also made in large-scale studies conducted in the USA and Canada. There is very limited data on the economic impact of the disease burden of COPD at a nation wide level. However, one large-scale study was conducted in 2001 in the geographical area of
29

Hyderabad under the aegis of an IES project to study the health effects analysis of COPD including its economic burden. The unit values of hospital admission for COPD were US$ 122.23 towards medical costs and US$ 14.30 for opportunity loss; outpatient visits cost the patients US$ 8.26 for medicines and another US$ 1.43 because of opportunity losses. These costs (reported for the year 2001) were used to arrive at the current cost of COPD. It was noted that, on an average, a person with COPD spent Rs 11,952 per year in 1992 and the same treatment cost Rs 23,300 in 1999. This increment in the cost of treatment was calculated on a pro rata basis for the period 19962016. In the present exercise, the same rate of change was applied for all other costs. In this study the number of cases with chronic and severe COPD was estimated by using the projected population figures for the period 19962016. The expected changes in the mortality figures in India were considered in this exercise. Only the population of those 30 years of age and above was considered, and a constant percentage (26.82%) for the urban population was operated till 2016. Estimated number of patients with chronic and acute COPD and their distribution by sex and residence are shown in table below. Health providers/planners need to get ready to face a caseload of COPD of about 222.16 lakh in 2016a majority of this would be from rural areas where the poverty levels are high.Estimated caseload according to the severity of COPD is also given below. In addition, there would be patients with acute COPD who need hospitalization and expert care.

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f. CHRONIC KIDNEY DISEASE Although chronic kidney disease (CKD) is not currently identified as one of those targets, there is compelling evidence that CKD is not only common, harmful and treatable but also a major contributing factor to the incidence and outcomes of at least three of these diseases targeted by WHO (diabetes, hypertension and CVD). CKD strongly predisposes to hypertension and CVD; diabetes, hypertension and CVD are all major causes of CKD; and major risk factors for diabetes, hypertension and CVD (such as obesity and smoking) also cause or exacerbate CKD. In addition, among people with diabetes, hypertension, or CVD, the subset who also have CKD are at highest risk of adverse outcomes and high health care costs. Thus, CKD, diabetes and cardiovascular disease are closely associated conditions that often coexist; share common risk factors and treatments; and would benefit from a coordinated global approach to prevention and control. The incidence of end-stage kidney disease in India is estimated to be 150 to 175 per million population per year (or between 150,000 and 175,000 cases), and is attributable to diabetes in 30 40% of patients41.The studies show that the prevalence of moderate chronic kidney disease (CKD)-stage-3 onwards in India in adults is around 0.8%. The leading causes of CKD in India are diabetes (30%) and hypertension (20%)i. Given projected increases in the prevalence of major risk factors for CKD (diabetes, hypertension and CVD), the prevalence of CKD in developing countries is expected to dramatically increase over the next two decades. g. MENTAL DISORDERS It is estimated that 6-7 % of the population suffers from mental disorders. As per metanalysis of studies on mental disorders by Reddy & Chandrashekhar (1998), the prevalence of mental disorders is 58 per 1000 in all ages.The World Bank report (1993) revealed that the Disability Adjusted Life Year (DALY) loss due to neuro-psychiatric disorder is much higher than diarrhoea, malaria, worm infestations and tuberculosis if taken individually. Together these disorders account for 12% of the global burden of disease (GBD) and an analysis of trends indicates this will increase to 15% by 202042. One in four families is likely to have at least one member with a behavioral or mental disorder42. These families not only provide physical and emotional support, but also bear the negative impact of stigma and discrimination. Most of them
31

(>90%) remain un-treated. Poor awareness about symptoms of mental illness, myths & stigma related to it, lack of knowledge on the treatment availability & potential benefits of seeking treatment are important causes for the high treatment gap. Mental health affects about 6.5% of the Indian population and is expected to increase due to stress on account of frequent disruptions in incomes, unemployment, lack of social support systems, etc. The National Commission on Macroeconomics and Health, 2005 estimated the burden due to mental ill health, as shown below10

Predominantly the age group of 25 44 years, except those specific to paediatric and geriatric age groups, are most vulnerable to mental health challenges. The productive state of individual in this period of the life cycle leads to severe degrees of unproductivity and its spiraling effects on quality of life with associated stigma. Certain mental illnesses will manifest more in women, like unipolar depression is higher among women in 15- 44 yrs, while schizophrenia and other mood disorders are more among men. Alcohol dependency and its hazardous use, drug abuse is exceptional to men. Increasing trends of its common usage among women in both urban and rural areas has been a recent phenomenon (1%-5 %). The World Health Survey 2003 covered urban and rural population above 18 years of age in 6 States of India. A summary of its findings on pyschosis and depression is provided below43. The rates of treatment were lower in rural compared with urban areas (61.7% v. 47.5%), and higher in the higher income quartiles.

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The gross disparity between the number of mentally ill persons and the available treatment facilities and trained professionals is reflected in the large treatment gap in the community. The challenges of mental health care in India have been identified as follows44; 1. Large unmet need for mental healthcare in the community 2. Poor understanding of psychological distress as requiring medical intervention in the general population 3. Limited acceptance of modern medical care for mental disorders among the general population 4. Limitations in the availability of mental health services (professionals and facilities) in the public health services 5. Poor utilization of available services by the ill population and their families 6. Problems in recovery and reintegration of persons with mental illnesses 7. Lack of institutionalized mechanisms for organization of mental healthcare h. IODINE DEFICIENCY DISORDERS Iodine is essential micronutrient with an average daily requirement of 100-150 micrograms for normal human growth and development. On the basis of surveys conducted by the Directorate General of Health Services, ICMR, Health Institutions and the State Health Directorates, it has been found that out of 324 districts surveyed in all the 28 states and 7 UTs, 263 districts are endemic i.e. where the prevalence of Iodine Deficiency Disorders (lDD) is more than 10%. It is also estimated that more than 71 million persons are suffering from Iodine Deficiency Disorders. Thus, no States/UT in the country is free from IDD. Iodine is required for the entire population daily. i. FLUOROSIS Fluoride endemicity has been reported in about 230 districts of 19 States of the country. The affected population with fluororsis is about 66 million in the country. Based on excess level of fluoride content in No of districts, the States have been classified as mild, moderate and severe endemic States of Fluorosis. It affects all ages. States like Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Meghalaya, Orissa, Punjab, Rajasthan, Uttar Pradesh, Uttarakhand, Tamil Nadu, West Bengal are affected from fluorosis. Fluorosis brings about changes in skeletal system and teeth which becomes irreversible in due course of time. Therefore, the focus of management of fluorosis is on prevention, health promotion, deformity correction and rehabilitation.

33

j. ORO-DENTAL DISEASES According to the World Health Report-2003, oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world. The greatest burden of oral diseases is on disadvantaged and socially marginalized populations. Poor oral health may have a profound effect on general health. Oral diseases have been linked to bacterial endocarditis due to transient bacteremia from oral focus. Also, inflammatory mediators in periodontal disease are not only involved in local tissue destruction but have the potential to modulate the course of cardiovascular, chronic obstructive lung and autoimmune diseases, diabetes mellitus and preterm birth. In addition, major impact on peoples daily lives in terms of pain and suffering, impairment of function and quality of life due to missing, discolored or damaged teeth must be considered. The economic impact of oral disease is also significant. Traditional treatment of oral disease is costly. In developing countries, resources are primarily allocated to emergency oral care and pain relief; if treatment were available, the costs of dental caries in children alone would exceed the total health care budget for children. Furthermore, oral diseases restrict activities at school and work, causing millions of school and work hours to be lost each year throughout the world. Oral disease burden in India is very high due to several reasons. Many oral health surveys have been done from time to time from different regions: the comprehensive data on oral health was cited in the report by National Commission on Macro-economics and Health 10 and Oral Health in India: Report of multi-centric oral health survey (Shah et al, 2007). According to these reports, prevalence of various oral diseases in the population is as follows:
S.No. 1 2 3 4 5 6 7 8 9 10 11 Disease Dental Caries Periodontal diseases Malocclusion Cleft lip and palate Oral cancer Oral submucous fibrosis (pre-malignant
and crippling condition of mouth)

Prevalence 40-45% >90% (Advanced disease in 40%) 30% of children 1.7 per 1000 live births 12.6 per lakh population 4 per 1000 adults in rural India

Dental Fluorosis Endemic in 230 districts of 19 States Edentulousness (tooth loss) 19-32% of elderly population >65 years Oral lesions due to HIV/AIDS 72% of HIV/AIDS patients Birth defects involving oro-facial 0.82 to 3.36 per 1000 live births complex Others: Traumatic injuries Mucosal lesions associated with radiation and chemotherapy Morbidity and deformity following oral cancer surgery. 34

Given the burden of oral diseases in our country and their impact, oral diseases need to be paid attention along with prevention and control of other non-communicable diseases under NRHM. Promotion of healthy lifestyles with respect to oral health needs to be considered. World Health Assembly in 2005 included Oral Health with other non-communicable diseases (NCDs) for health promotion & disease prevention strategies. Congenital Anomalies: Congenital anomalies (CA) which includes craniofacial anomalies (CFA) are major cause of infant mortality and morbidity, affecting 2-3% of all newborn babies. (Source: Global registry and database on craniofacial anomalies-WHO). The treatment of congenital craniofacial defects has been prioritized by the WHO. According to WHO: Their impact on speech, hearing, appearance and cognition has a prolonged and adverse influence on health and social integration. The costs incurred from CFA in terms of morbidity, health care, emotional disturbance, and social and employment exclusion are considerable for affected individuals, their families and society. (Source - Global strategies to reduce the healthcare burden of craniofacial anomalies: Report of WHO meetings on International Collaborative Research on Craniofacial Anomalies; November 2000 Cleft lip and palate is one of the most common congenital deformities of the new born. Statistics suggest an increasing incidence of cleft lip and palate patients. The incidence of cleft lip and palate is reported to be highest in Afghans (4.9 per 1000 live births) and lowest in Negroid (004 per 1000 live births) population. In Caucasians it is reported close to 1.0 per 1000 live births. The approximate incidence of cleft lip and palate is around 1.4/1000 live births in India and for isolated cleft palate it is 0.3/1000 live births. According to rough estimates about 182 cleft children are born every day and about 40,000 cleft children are born every year in India. Since the treatment of the disease is long drawn and spans across more than 20 years of the patients life, the cumulative burden of disease is huge, possibly unimaginable. Global burden of disease More than 94 percent of the births with serious birth defects and 95 percent of the deaths of these children occur in low and middle income countries.

35

39 52/1000 live births 52 60/1000 live births k. NEUROLOGICAL DISORDERS 61 70 /1000 live births EPILEPSY live births 70 90/ 1000 The prevalence of epilepsy in India is about 1% of population56. Prevalence rate of epilepsy is higher in rural population (1.9 %) as compared to urban population (0.6 %).Out of the total global disease burden of 7 million DALYs, 0.5% is contributed by epilepsy alone57. There exists a very severe form of epilepsy (Status Epilepticus-SE), which is a life-threatening condition in which the brain is in a state of persistent seizure. It is defined as one continuous unremitting seizure lasting longer than 5 minutes or the occurrence of 2 or more seizures without gaining consciousness between them58. In a study conducted in Delhi out of 451 patients 30 (6.65%) were found to develop SE59, and in another 243 patients it was 84 (38%)60. In the USA out of 16 veteran medical centers and 6 affiliated hospitals 570 cases out of 1705 (33.4%) were found to be of SE61. Mortality in epilepsy: In a study conducted by Banerjee (2010) in Kolkata 309 incidence and 66 prevalence cases were studied. The total deaths in the study were 20. The annual mortality rate estimated in the study was about 7.63/100,000. The Standardized mortality ratio (SMR) was found to be 2.58/100,000. Mortality rate due to SE was reported to be 29% 62. Sudden death due to the disease varied widely (2-18%) in another study63. It is estimated that nearly 2-3 lakh patients may die due to epilepsy is they remain untreated. Stigma associated with the disease:
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Stigma is referred to as a severe social disapproval of personal characteristics or beliefs that are against cultural norms. Persons with epilepsy face stigma in many communities. In a study conducted by Radhakrishnan K (2000) a total of 1,175 persons were studied. Among these 31% thought epilepsy as a hereditary disorder, 27% as a form of insanity, 40% were denied employment due to their condition and 11% of the parents did not allow their child to play with epileptic children and 55% of the women concealed their epilepsy during marriage negotiations64. Out of those who concealed,18% were legally divorced and 20% were separated from their spouses because of the disease. Cost of epilepsy (Economic burden): The treatment of epilepsy includes both direct and indirect costs. Direct cost includes the cost of the hospitalization, treatment, medicines, homecare and ancillary services. The indirect cost includes loss of time and productivity, the income lost by the family members and the foregone leisure time. The cost attributed to pain, suffering and social stigma comes under intangible costs. The direct and the indirect cost of treatment represent 27.1 and 72.9% of the total cost treatment65. Krishna et al 2001 conducted a study on 184 patients and found that the annual cost per capita was $ 27.51. 79.2% of the patients in the study had been given monotherapy and the first choice of the AED was phenytoin (93%). Radhakrishnan in 1993-95 studied 972 outpatients and found the annual cost per capita at about $47.73. 76.4% patients had been given the monotherapy. The first choice of the AED was Carbamazepine in 44.2%, Valproic acid and phenytoin in 20-20% cases. 1% cases were treated with newer AEDs. 285 outpatients were studied by Thomas in 1998 and found $53.75 annual cost. 75.5% of the patients were kept on monotherapy. CBZ was the first choice of treatment in 48% and phenytoin in 33% cases. 10% of the patients were tried with newer AEDs.It can hence be said that indirect costs would increase if the patient does not undergo effective treatment, and a small effort in improving the direct costs would bring down the total costs, including the indirect one. Reason for unemployment: A study conducted on 118 patients in Kerala shows that various reasons have been given by the patients for their unemployment. The reasons are summarized in the table given below:

Reason Seizure related falls Fatigue/drowsiness due to AEDs

Number (%) 34 (29.1) 46 (22.8)

37

Fear of seizures in workplace Low education because of epilepsy Frequent seizures Denied job because of epilepsy Lack of motivation to do job

44 (21.8) 41 (20.3) 36 (17.8) 32 (15.8) 32 (15.8)

l. AUTISM SPECTRUM DISORDERS (ASD) Autism spectrum disorders (ASD) are a group of neuro- developmental disorders characterized by impaired communication and social interaction, restricted interests and repetitive behaviors, with onset before 3 years of age. Examples of ASD include Autism and Asperger syndrome. Although the degree of severity and impairment in ASD is highly variable, ASD have a substantial impact on the affected children and their families. For decades after Kanner's original paper on autism was published in 1943, it was generally considered to be a rare condition with a prevalence of around 2-4 per 10,000 children. The first epidemiologic study of autism was done in England in 1966 and found the autism rate to be 4-5 per 10,000 children in the general population. Other community studies published before 1985 reported prevalence rates from 4-6 per 10,000. Studies published between 1985 and 1995 reported higher prevalence rates than studies published prior to 1985, with a mean of 11.8 per 10,000 children. A recent scientific review of studies on the prevalence suggested a conservative estimate for autism of 1 out of every 1000 children, with as many as 1 in 500 persons affected with some form of this disorder. 1,2Most estimates that include people with similar disorders are two to three times greater. 3 Emerging in childhood, it affects about 1 or 2 people in every thousand and is three to four times more common in boys than girls.4 Prevalence of autistic spectrum disorder in children aged 5-14 yrs in the UK in north east London has been reported as 19 per 10,000 children. 5 The prevalence of autism is on the rise as reported from all over the world. Whether this is because of increased awareness, increased detection rate or because of actual rise in prevalence is debatable. An analysis was carried out using a national data source to comparethe prevalence of autism with that of other disabilities amongsuccessive birth cohorts of US school-aged children 6 to 17 years
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of age between1992 and 2001.A disability category classificationof autism, Intellectual disability (mental retardation), speech and language impairment,traumatic brain injury, or other health impairment, as documentedby state departments of education and reported to the Officeof Special Education Programs, US Department of Education was used. For theautism classification, there were birth cohort differences,with prevalence increasing among successive (younger) cohorts.The increases were greatest for annual cohorts born from 1987to 1992. For cohorts born after 1992, the prevalence increasedwith each successive year but the increases did not appear tobe as great. No concomitant decreases in categories of Intellectual disability (mentalretardation) or speech/language impairment were seen. These data do not support the hypothesis of diagnostic shifting. 6 Current estimates of global prevalence of ASD range between 50 to 60 per 10,000 school--aged children, making ASD a serious public health concern. 7 In India, Epidemiologic studies are not available. However, few case series from tertiary care centers are available. These children need multidisciplinary management. Autism has been identified as one of the four major disabilities by National Trust under ministry of social welfare. In fact, National Trust for Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disability Act, 1999 has provisions of legal guardianship of the four categories. The Ministry of Finance has also included income tax exemption for parents/ guardians of children with autism according to Section 80DD and Section 80U of the Income Tax Act 1961. m. DEMENTIA Dementia is a syndrome usually chronic, characterized by a progressive, collective deterioration of intellect including memory, learning, orientation, language, comprehension and judgment due to disease of the brain. It mainly affects older people; about 2% of cases start before the age of 65 years. After this, the prevalence doubles with the increase of every five year. Dementia is one of the major causes of disability in late life. The major sub-types of Dementia include, Alzheimers Disease (50-75% cases), Vascular Dementia (20-30% cases), Dementia with Lewy Bodies (DLB) (<5%), and the uncommon sub-types of Dementia include Fronto-temporal Dementia (FTD) (5-10% cases), Creuzfeld Jakob and Hutingtons disease etc. Once considered a rare disorder, Alzheimers Disease-AD is now seen emerging as a major public health and social problem that is seriously affecting millions of older people and their families. The global figures are estimated at 36 million people living with Alzheimers and related disorders as per Alzheimers Disease International-ADI world report 2010. By 2040, over 82 million elderly people are expected to have AD if the current numbers hold and no preventive treatments become available. In India the population with Alzheimers and related disorders is estimated to be around 3.7 million (2.1 million women and 1.5 million women) which are based on recent scientific studies validated by ADI. The cost of caring, has been conservatively estimated at present ( as per
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Dementia India Report 2010 brought out by Alzheimers and Related Disroders Society of India, a NGO dedicated for the cause) Rs.159 billion, which is likely to go up to Rs.327 billion at the current cost estimates without any escalation by 2030. The indirect costs of caring are often not quantified in India due to more home based care through traditional family systems compared to western countries. Institutional care is seldom available across the country and wherever it is available could only cater to the fractions of the actually affected population. The diagnostic and simple screening techniques to detect early onset of Dementia is far from lacking due to inadequate knowledge and basic awareness about the disease. The challenges as assessed in India are broadly Growing epidemic Weakening Family care Lack of awareness Addressing the needs of caregivers Lack of treatment facilities and improvement of treatment gap for dementia High cost of care Scarcity of Human Resources for Mental health services Need for more research on dementia in India Develop alternate facilities for dementia care Advocacy: Enabling Govt. participation through focused strategies n. CONGENITAL DISEASES Congenital and hereditary genetic diseases are becoming a significant health burden in India, and hence there is a need for adequate and effective genetic testing and counselling services. In Indias urban areas, congenital malformations and genetic disorders are the third most common cause of mortality in newborns. Factors contributing to this high prevalence include consanguineous marriages, high birth rate, improved diagnostic facilities, and a lack of expertise in genetic counselling. Due to the high birth rate in India a very large number of infants with genetic disorders are born every year almost half a million with malformations and 21,000 with Down syndrome. A recent study carried out in three centers (Mumbai, Delhi and Baroda) on 94,610 newborns by using a uniform proforma showed a malformation frequency of 2.03%, the commonest malformations are neural tube defects and musculo-skeletal disorders. The frequency of Down syndrome among 94,610 births was 0.87 per 1000, or 1 per 1150. Screening of 112,269 newborns for aminoacid disorders showed four disorders to be the commonest--tyrosinemia, maple syrup urine disease and phenylketonuria. Screening of cases of mental retardation for aminoacid disorders revealed four to be the commonest--hyperglycinemia, homocystinuria, alkaptonuria, and maple syrup urine disease. Disorders, which deserve to be screened in the newborn period, are hypothyroidism and G-6-PD deficiency, while screening for aminoacid and other metabolic disorders could presently be restricted to symptomatic infants.

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Congenital Heart Disease (CH D) refers to a problem with the hearts structure and function due to abnormalheart development before birth. Congenital malformations are the most common of all birth defects. CHD affects about 8-10 per 1000 live births and is a leading cause of infant mortality. The burden of CHD in India is enormousdue to very high birth rate. This emphasizes the importance of this group of heart diseases. It is known that 180,000 children are born with CHD each year in India. Approximately 10% of present infant mortality in India may be accounted for the CHD alone. o. HEREITARY BLOOD DISORDERS There are approximately 10,000-12,000 new thalassemia syndrome and 7,000-10,000 new sickle cell anaemia patients added every year in India. Moreover, approximately 1, 20,000 patients of Hemophilia are there in our country out of which 14,000 are registered. As the patients are mainly managed in bigger hospitals, this data from hospital and treating centres is likely to be an underestimate. As the services are being extended in the rural areas, more and more patients are likely to be identified. Moreover, many patients of severe genetic disorders like hemophilia, B thalassemia and sickle cell anaemia will survive to adulthood with availability of proper management and their number in society is likely to increase. As thesehereditary blood diseases are lifelong conditions and have many dimensions, management of these are best achieved with close co-operation with voluntary organizations/NGOs representing the interests of these patients in the society. p. TRAUMA Expansion in road network, motorization and urbanization in the country has been accompanied by a rise in road accidents leading to road traffic injuries (RTIs) and fatalities as major public health concern. Today road traffic injuries are one of the leading causes of deaths, disabilities and hospitalization with severe socioeconomic costs across the world. Road traffic injuries kill nearly 1.3 million women, men and children around the world every year and are responsible for hundreds of thousands of injuries and disability. World Health Organization estimates predict that road traffic injury will increase from being the ninth leading cause of death globally in 2004, to be the fifth leading cause of death by 2030. In 2004, road traffic injury was the tenth leading cause of death in the WHO South-East Region and was responsible for 2% of all causes of mortality. As per the data of Ministry of Road Transport & Highways during the year 2009 there were around 4.9 lakh road accidents which killed 1,25,660 people and injured more than 5 lakh persons in India. These numbers translate into one road accident every minute and one road accident death every four minutes for India. Road traffic injuries and fatalities impose a huge economic burden on developing economies in particular.

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Road traffic accidents since 1970 are summarized below in the Table.
Total No. of Road Accidents (in numbers) 114100 153200 282600 391449 406726 Total No. of Persons Killed (in numbers) 14500 24000 54100 78911 85998 Total number of Registered Motor Vehicles (in thousands) 1401 4521 19152 48857 67033 No. of Accidents per ten thousand Vehicles 814.42 338.86 147.56 80.12 60.68 No. of Persons Killed per ten thousand Vehicles 103.5 53.09 28.25 16.15 12.83

Year

1970 1980 1990 2000 2003

In India more than half of the road accident victims are in the age group (25-65 years), the key wage earning and child raising age group. The loss of the main bread earner and head of household due to death or disability can be catastrophic, leading to lower living standards and poverty, in addition to the human cost of bereavement. As per the data of National Crime Record Bureau 8,96,18,000 vehicles are registered in the year 2008 in comparison to 7,27,18,000 vehicles in the year 2007. As per the report of National Crime Record Bureau (2009) 4, 21,628 traffic accidents were reported during the year 2009, which killed 1, 26,896 people and injured 4, 68,849 Road traffic injuries and fatalities impose a huge economic burden on developing economies in particular.Injuries account for 11% of deaths and 13% of DALYs in India in 20046. The precise number of people hospitalized and injured is not available for intentional injuries such as attempted suicides and homicides. According to NCMH, road traffic injuries (20%), suicide (27%), violence-related deaths (11%), burns (9%), poisoning (6%) and drowning (6%) were the major causes of injury deaths10. Road Traffic deaths and Injuries (RTIs) are on the increase along with the rapid economic growth. An incidence study on RTI carried out in the city of Hyderabad has shown that the incidence (per 100 persons/year) of non-fatal RTI was highest in pedestrians (6.4), motorized two-wheeled vehicle users (6.3), and cyclists (5.1)40. RTIs in particular are a problem of the young with three-quarters occurring among 15 45 year olds, predominantly among men45. RTIs every year result in death of more than 100,000 persons, 2 million hospitalizations and 7.7 million minor injuries. During 2007, road RTIs and suicides resulted in 114,590 and 122,637 deaths, respectively46. If the present scenario continues, India will witness deaths of 150,000 persons and hospitalization among 2.8 million people by 2010, increasing further to 185,000 deaths and 3.6 million hospitalizations by 2015 due to RTI alone45. Similarly the rate of suicides in the country is also on the rise. According to National Crime Records Bureau, the number of suicides in the country during the decade (19972007) has recorded an increase of 28.0% (from 95,829 in 1997 to 122,637 in 2007)47. Other groups of injuries such as occupational injuries contributed to 2% of total deaths,

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1.8% of total life-years lost due to disabilities and 2% of DALYs (11). It is also estimated that 19 fatal and 1930 non-fatal accidents (1:101) occur annually per 100,000 workers. q. BURNS Burn Injuries is a potential public health problem yet under-recognized in our country. It is the second largest group of injuries after road accidents. Burn injuries data is not available at national level as no such study has been conducted. However, based on extrapolation of patients reported at three burns units (Safdarjung, Dr. RML.& LNJP Hospital) of Delhi, it is estimated that annual burn incidence is approximately around 7 million in the country, out of which 10% (7 lakhs) need hospital admission. Approximately, 1.40 lakh die annually and 2.5 lakh get deformed due to burn injuries. The deformity is also not 100% correctable by surgery. However, 90% of all burn injuries are preventable. The burn scenario is grave in India not only due to the high incidence but is also compounded by absence of organized burn care at primary and secondary health care level. Hence, the Program for Prevention of Burn Injuries has been started on pilot basis with scope for expansion at national level in 12th Five Year Plan based on the outcome of concurrent evaluation. r. DISASTERS National Disaster Management Act (2005)48 defines disaster as a catastrophe, mishap, calamity or grave occurrence in any area, arising from natural or manmade causes, or by accident or negligence which results in substantial loss of life or human suffering or damage to, and destruction of, property, or damage to, or degradation of, environment, and is of such a nature or magnitude as to be beyond the coping capacity of the community of the affected area. A string of major disasters over the last decade in India had witnessed profound health consequences in terms of death, disease and injuries. The Bhuj earthquake in Gujarat in January, 2001 accounted for 13805 deaths, the Tsunami (2004) another 10749deaths and the recent Pandemic Influenza, 2761 deaths (as on 20.6.2011).This apart, each year disasters account for loss of thousands of crores in terms of social and community assets. Disasters: Global Scenario Disasters that affect all parts of the globe causing harm to human and animal health, damage to property and environment, are most often natural but can also be man-made. Globally, natural disasters are increasing in frequency, severity and complexity. There is evidence based linkage3 to climate change causing extreme weather events like heavy rains, floods, flash floods, drought, cyclones, windstorms, heat and cold wave etc and further health impact in terms of increasing morbidityand mortality.

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Fig: Global Trends o Disasters (1900-2005) of )

[ Source: s source - EM-D (www.em DAT mdat.be)]

Disasters: Indian Sc cenario s ly nerable to na atural disaste on accou of its uni ers unt ique geo-clim matic India has traditionall been vuln condition Some of the major d ns. f disasters tha struck the country inc at clude Latur (1993) and Bhuj (2001) earthquakes, Orissa cycl lone (1999) and Indian Ocean tsun nami (2004) flash floods in ), North Bi ihar (2008) and Leh, J J&K (2010). The vulne erability pro ofile shows that 68% o the of cultivable land area is vulnerab to droug a ble ght, 58.6% of the land dmass vulne erable to sei ismic activity o moderate to very hig intensity and 40 mil of e gh llion hectare (12% lan area) pron to es nd ne 49 floods.Of the 7516 km long coas line, close to 5700 km is prone to c f m st cyclones and tsunamis . d India has a high bu s urden of com mmunicable diseases, such as Tuberculosis, M Malaria, Japa anese Encphali itis, Chikung gunya, Deng gue, Mening gococcal Me eningitis and they often result in m d n major outbreaks causing high morbidity and mortality. Disease of internat y es tional conce such as S ern SARS (2003), A Avian Influenza ( 2003 and Pan 3) ndemic Influ uenza (2009 spread g 9) globally and also d affected I India. Of pa articular inter are the h rest human-anim interface of zoonotic diseases. 75 of mal 5% all emerging disease in the p es past decade that affecte human p ed population w were zoonot in tic 50 nature . Among m man-made di isasters, met thyl isocyana gas trage ate edy(1983) in Bhopal, Ma n adya Pradesh is a h grim rem minder of wh industria accidents involving hazardoussu hat al ubstances ca cause. In an ndias quest for energy th hrough nucl lear options means tha our nuc s at clearfacilitie need to have es preparedn ness to resp pond to even of the m nts magnitude wi itnessed at C Chernobyl, R Russia (198 or 86) Fukushim Japan (2011). Terr ma, rorism, that too in the context of using chem mical, biolog gical, radiologi and nucl agents, i yet anothe area of con ical lear is er ncern.

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Heightened vulnerabilities to disaster risks can be related to expanding population, urbanisation and industrialisation, development within high-risk zones, environmental degradation and climate change. In the context of human vulnerability to disasters, the economically and socially weaker segments of the population are the ones that are most seriously affected. Within the vulnerable groups, elderly persons, women, children-especially women rendered destitute, children, orphaned on account of disasters and differently abled persons are exposed to higher risks49. Impact of disasters Disasters whether natural or manmade, causes both human and econimoc losses. Globally, the estimated loss was of US $ 10 billion in 1950. In sharp contrast, this was about US$ 180 billion for the year 2005. Fig: Trends of Economic losses due to Disasters

[Source : Geo-natural catastrophes 2006: Analysis, assessments, positions, Munich Re]

India, though affected by major disasters, the impact has not been quantified in economic terms, but agreeably there have been substantial human and financial loss. Estimates available at one of the most-used international database -EM-DAT (www.emdat.be) is as under: India - Natural Disasters from 1980 2010 No of events: No of people killed: Average killed per year: No of people affected: Average affected per year: Economic Damage (US$ X 1,000): Economic Damage per year (US$ X 1,000):
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431 143,039 4,614 1,521,726,127 49,087,940 48,063,830 1,550,446

Public Health Impact of Disasters Public health impact of disasters are manifested primary in the form of; deaths, injuries and population displacement exposing the displaced people to a number of public health implications including disease outbreak, psycho-social & mental health, maternal & child health and adolescent health issues, gender and extreme-age public health issues etc. s. MUSCULO-SKELETAL DISEASES In the lastfew decades, the Government of India has been successful in controlling most of the communicable diseases and achieved an increased life-span through its various programs. On the other hand, during the last two decades changes in life style and dietary habits hasledto a rise in the incidence of non-communicable diseases like obesity, cardiovascular diseases, diabetes, hypertension, various cancers, stress and other psycho somatic disorders. The burden of MSD is global and looking at the gravity of the situation and due to its increasing prevalence associated with large personal and societal costs MSD is recognized as a significant public health problem. Musculoskeletal Disorders (MSD) are one of the major causes of morbidity, having a substantialinfluence on healthandquality of life, imposing an enormousburden of cost on the healthcare system. The existingresearch verifies that musculoskeletal conditions compriseover 150 diseases and syndromes usuallyassociated with pain. These can broadly be categorized as joint diseases, spinal disorders and conditions resulting from trauma. Globally the burden of MSD contributes substantial disease burden and therefore to emphasis on the gravity of the situation WHO has declared 2000-2010 as the Boneand Joint decade. Musculoskeletal conditions are highly prevalent and their impact is pervasive. These significantly affect the psychosocial status of affected people as well as their families and careers. Musculoskeletal conditions cause more functional limitations in the adult population in most welfare states than any other group of disorders. Health related quality of life in people with MSD has affected the working of people in the general population. The worst quality of life patterns were found for osteoarthritis (OA) of the hip or knee, osteoporosis, rheumatoid arthritis (RA), and fibromyalgia. Health related quality of life scores were lowest among those with multiple musculoskeletal diseases. Compared with other chronic diseases, patients with musculoskeletal disorders usually report the lowest health related quality of life. All MSDs involve pain and reduced physical functioning. The impact of MSD in the general population has been associated with disability and assessed by measures of health related quality of life surveys from the industrialized world has revealed a high prevalence of MSD and its negative effect as compared with other
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common chronic conditions . The disaggregation by developing and developed regions, however, shows that while musculoskeletal conditions account for around 3.4 % of the total burden of disease in the developed world, they account for 1.7 % in the developing world. They significantly affect the psychosocial status of affected people as well as their families and careers. Musculoskeletal conditions cause more functional limitations in the adult population in most welfare states than any other group of disorders. Across the world, musculo-skeletal conditions affect hundreds of millions of people, at a huge cost to society (estimated at $215 billion per year in the USA alone).

Magnitude of MSDs: MSDs are the most common cause of severe long term pain and physical disability affecting hundreds of millions of people around the world and a major cause of years lived with disability in all continents and economies. In the Ontario Health Survey, for example, musculoskeletal conditions accounted for 40% of all chronic conditions, 54% of all longterm disability, and 24% of all restricted activity days51. In surveys carried out in Canada, the USA, and in Western Europe, the prevalence of physical disabilities caused by a musculoskeletal condition repeatedly has been estimated at 45% of the adult population52. They are the most common cause of severe long-term pain and physical disability as they affect hundreds of millions of people around the world. The global prevalence of MSDs ranges from 14% to as high as 42%. Musculoskeletal impairments rank number one in chronic impairments in the United States and 1 out of every 4 people in developed and less developed countries reports chronic musculoskeletal pain. As per WHO estimates 2001 musculoskeletal conditions account for approximately 1.7 and 2.4 % of the burden of disease experienced by males and females, respectively, or across both genders, approximately 2 % of the global burden of disease. WHO estimates that 40% of people over the age of 70 years suffer from OA knee, 80% of the patients with OA have some degree of limitation of movement and 25% cant perform their major daily activity of living. Amongst the set of musculoskeletal conditions, OA accounts for the largest burden, approximately 52 % of the total in developing regions and 61 % in developed regions. COPCORD India with its vast experience of collecting community data on MSD and pain in both urban and rural regions describes the status and challenges of community rheumatology in India. Soft tissue MSD pains were found to be the dominant rheumatic ailment by almost all COPCORD surveys and not surprisingly the most frequent sites reported were those of knees and lower back; the prevalence was >5% with higher values reported from the rural survey. Bhigwan study reported mild, moderate and severe grades of disability in 74%, 15% and 6% of the MSDS subjects respectively; the main difficult activities in these rural subjects were walking, occupation, and hygiene care (squatting for ablution).

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In a recently completed multi-centric study by the ICMR (2007-11) has shown a prevalence of MSDs in 7.08% in Delhi, 11.52% in Dibrugarh and 9.53% in Jodhpur. These figures are indeed alarmingly high compared to any of the Non Communicable Diseases (NCD) in India. The prevalence of MSD was higher in urban area at Delhi and Dibrugarh as compared to Jodhpur where the prevalence was found to be higher in rural area. Across all the three study centres the prevalence of MSD was lowest in the age group 18-30 years and the rate gradually was found to increase from 40 years and above. According to the HAQ score 47.56% of the MSD patients in Delhi had moderate severity of disease. In Dibrugarh 63.75% of MSD patients had mild severity of disease and 44.68% in Jodhpur with mild severity of disease. About 9.31% of the patients in Delhi, 8.31% of patients in Dibrugarh and 4.32% of patients in Jodhpur reported absence from work due to MSDs. At least some functional limitation was observed in 84.10% patients in Delhi, 86.20% patients in Dibrugarh and 66.44% in Jodhpur.

Major contributors of MSD: Low back pain is a major health and socioeconomic problem in western countries. A large study from the Netherlands reported an incidence of 28.0 episodes per 1 000 persons per year and for low back pain with sciatica an incidence of 11.6 per 1000 persons per year. Low back pain affects men more than women and is most frequent in the working population, with the highest incidence seen in those aged 2564 years53. New episodes are twice as common in people with a history of low back pain. Lifetime prevalence is 5884% and the point prevalence (proportion of population studied that are suffering back pain at a particular point of time) is 433%. Back pain has a marked effect on the patient Fragility fractures have doubled in the last decade as 40% of all women over 50 years will suffer an osteoporotic fracture with the number of hip fractures rising from about 1.7 million in 1990 to 6.3 million by 2050 unless aggressive preventive programs are started. Osteoporotic hip fracture account for a large proportion of the morbidity, mortality and the cost of the disease. Back pain is extremely common in both industrial and developing countries, with up to 50 % of workers suffering an episode each year. Back pain causes 0.8 million disability adjusted life years (DALYs) each year and is a major cause of absence from work and of correspondingly high economic losses. Low back pain has reached epidemic proportions, being reported by about 80% of the people at some time in their life. Low back pain is also the most frequent cause of limitation of activity in the young and middle aged, one of commonest reasons for medical consultation, and the most frequent occupational injury. Back pain is the second leading cause of sick leave. The number of individuals over the age of 50 is expected to double between 1990 and 2020. 1. Osteoarthritis (OA) accounts for half of all chronic conditions in persons aged over 65 with about 25 % of people over the age of 60 have significant pain and disability from osteoarthritis. OA accounts for half of all chronic conditions in persons aged over 65.
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Measured in terms of disability adjusted life years (DALYs), musculoskeletal disease condition osteoarthritis is the 4th most frequent predicted cause of health problems worldwide in women and the 8th in men; OA is more common in women than men but the prevalence increases dramatically with age. 45% of women over the age of 65 have symptoms while radiological evidence is found in 70% of those over 65 years. OA of the knee is a major cause of mobility impairment, particularly among females. OA was estimated to be the 10th leading cause of non-fatal burden in the world in 1990, accounting for 2.8% of total YLD, around the same percentage as schizophrenia and congenital anomalies The prevalence of OA increases indefinitely with age, because the condition is not reversible. Men are affected more often than women among those aged <45 years, whereas women are affected more frequently among those aged >55 years. Worldwide estimates are that 9.6% of men and 18.0% of women aged 60 years have symptomatic osteoarthritis and on society because of its frequency and economic consequences. A community-based cross-sectional study was carried out by in an urban resettlement colony in South Delhi to study the prevalence of knee osteoarthritis in women aged 40 years and treatment seeking behavior of women suffering from osteoarthritis found 47.3% of women (123/260) to be suffering from knee osteoarthritis. It was the sixth leading cause of years of living with disability at the global level, accounting for 3% of the total global years of living with disability. Its impact can be described by health state descriptions developed as part of the global burden of disease 2000 project disability. 2. Rheumatoid Arthritis (RA): The prevalence of) prevalence in most industrialized countries varies between 0.3% and 1%; in developing countries it lies at the lower end of this range. The Pune Bhigwan COPCORD study, reported a point prevalence of 0.55%, which was unexpectedly high for a rural population. The Delhi study reported a much higher prevalence of 0.75 urban population study from west Bengal had reported a crude prevalence of 0.3%. The prevalence of RA was found to be 5.5% in large government hospital based patient population evaluated over six year in south India. 3. Rheumatic Muscular Skeletal Disorders : In yet a recently conducted study in an urban slum population of Mumbai revealed that there is a substantial burden of Rheumatic Muscular Skeletal Disorders (RMSD) as 18% of the subjects were suffering from RMSD and it had a moderate effect on daily living in most of the subjects.. The prevalence of RMSD was 0.9% in 15-24 years and 11% among 25-34 years as compared to 41.1% in 45-54 years. Also the prevalence in the age group above 55 years was in the range of 29-33 % which is more than that in the younger age group below age 35. Rheumatoid arthritis is a more disabling disease with two-thirds of patients having mild-to-moderate disability and less than 10% having severe.

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4. Osteoporosis :Although reliable epidemiological data are lacking, hospital data suggest that hip fractures are common in India. and occurs ten to fifteen years earlier than the western /developed nations .As reported by Mithal etal based on 2001 census, approximately 163 million Indians are above the age of 50; this number is expected to increase to 230 million by 2015. Even conservative estimates suggest that of these, 20% of women and about 10-15 % of men would be osteoporotic. The total affected population would, therefore, be around 25 million. If the lower bone density is shown to confer a greater risk of fracture, as is expected, the figure can increase to 50 million54. The studies on magnitude and burden of musculoskeletal conditions at global level indicate that an estimated 1.7 million hip fractures occurred world wide in 1990, the figure is expected to exceed to 6 million by 205055. According to the World Health Organization worldwide, the lifetime risk for women to have an osteoporotic fracture is 3040% , Occurrence of osteoporosis is 10 years earlier in Indian people than in the West. It currently affects approximately one in three women and one in five men over age 50. Because of related morbidity, disability, diminished quality of life, and mortality, osteoporosis and fractures associated with it are major public health concern Several studies from India have revealed that overall, Indians have poor bone health, and osteoporosis is common in India. Peak bone mass achieved during puberty is a strong predictor of development of osteoporosis in later years. High prevalence of vitamin D deficiency in India is a major contributor to low bone mass. 5. Road traffic injuries are increasing precipitously, and are estimated to account for as much as 25% of all health care expenditures in developing nations. Injuries and diseases of the musculoskeletal system account for more than 20% of patient visits to primary care. In developing countries, poverty with its attendant malnutrition, infectious diseases, ignorance and inadequate medical facilities are all associated with the occurrence of MSD. 6. Overuse injuries, also known as cumulative trauma disorders, occur when a tissue is injured due to repetitive sub maximal loading resulting from repetitive demand over the course of time. Year round growing number of young people participating in sports at an early age the incidence of overuseinjuries has risen in the near past. The ignorance about the existence of the nature of these is the main cause of negligence and management of these injuries In chronic or recurrent cases, continued loading produces degenerative changes leading to weakness, loss of flexibility, and chronic pain Thus, in overuse injuries the problem is often not acute tissue inflammation, but chronic degeneration Constraints: Despite their enormous impact worldwide MSDs does not receive the attention due to perception that MSDs are less serious because unlike CVD, AIDS and cancer, they are largely chronic, nonfatal and tend to be seen as a consequence of ageing.
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With the rise of elderly population the burden would increase for the health care system and society. At present there is no medical focus on MSDs as a group. Most afflictions of the MSD are still being looked after by a variety of specialists ranging from Internist to Orthopaedician to Rheumatologist. The persons suffering from MSD are commonly cared for by Physiatrists and Geriatric Specialists. There is little defined attention specifically to MSDs. Policies and systems changes are needed to monitor the burden of MSDs and identify factors that influence the development or progression of MSDs or preventions of disabilities related to MSDs as well as to heighten the awareness and improve access regarding the importance of early diagnosis and appropriate management of MSDs. It is appropriate to put in place a system of care and services for the population affected with MSD. Services for MSD must be provided at all levels of health care delivery system where it is almost negligible for prevention, screening and diagnosis, early management, chronic care including residual rehabilitation and follow-up with availability of appropriate manpower, drugs investigation and equipments pertaining to MSDs. As musculoskeletal system account for more than 20% of patient visits to the health care delivery system efforts for strengthening means for prevention of many MSDs related functional limitations and disabilities at this level needs to be focused.

t. DISABILITIES As we enter into the 2nd decade of the 21st century, the demographic and epidemiological transitions are continuing to progress thereby altering grossly the morbidity and disability prevalence. Unlike other public health programmes for designing of policy and implementation of the programme for People with Disability, the situation analysis needs to be undertaken in terms of not only number of disabled but also underlying health conditions, co-morbidities, access to general health care, secondary conditions and medical rehabilitation services. In the Health Care Delivery System of India, medical care and rehabilitation services for People with Disabilities are less than optimum or simply do not seem to exist. There is a pressing need to develop capacity of varieties of trained health professionals and training institutions in this area with the objective of accessing services for the People with Disability. Information on point prevalence is made available by Census and NSSO (National Sample Survey Organization). The reported prevalence of the disability as per Census is 2.13% of the total population and 1.9% of the total population as per NSSO, which seems to be a fraction of the population having disabilities as world disability report published on 9th June, 2011, states that the proportion of population with disability is rising and stands at 1 billion or 15% of the global population.
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Systematic epidemiological, health system research studies need to be instituted for analyzing (collating) the needs of disabled in terms of health care and specific rehabilitation. The gross variance of this magnitude is obviously because of inclusion criteria to be identified on disabled. General Assembly of United Nations has stressed in its regulation 63/150, 64/131, 65/156, the importance of improving disability statistics for better comparison of data at national and global levels in the purpose of policy designing, planning and evaluation from disability perspective. Therefore, it is necessary to initiate systematic epidemiological status health system, research studies and create mechanism for sharing and updating of the data between the different programmes divisions of the different Ministries. The convention on the rights of the Persons with Disability in articles 20, 25 and 26 requires member states to develop means for continuing training for professionals and staff so to improve access to mobility devices, health care and rehabilitation services. Trends in health condition associated with the disability: A) Communicable diseases- Communicable diseases with intensive public health interventions, universal immunization programme, the incidence of cluster of childhood diseases and especially paralytic polio-myelitis has come almost to the point of elimination. Poliomyelitis - There are more than 2 3 million persons afflicted with the polio-myelitis in the past who have disability and require rehabilitation services and access to health care facilities. Leprosy India is one of the countries which has not reached the bench mark of incidence of less than 1 per 10000 population. Here, too the backlog cases of hand and foot deformities require rehabilitation services and efforts have been made to integrate the programme. Filariasis, Tuberculosis, HIV, encephalitis, etc. have been contributing significantly to the morbidity and the disability. B) Non-communicable diseases- At this point, the Non-communicable diseases have a profound effect on disability with a pronounced increase which has projected its contribution into the burden of disability in the coming 20 years. Contrary to the popular assumption most chronic diseases are equally prevalent in rural population and in lower socio-economic strata. Rising incidences of diabetes, cardio-respiratory diseases contributed significantly to the morbidity and disability (66.5% of all years lived disability).

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C)

Accidents and Injuries - Road traffic accidents and injuries due to violence and disasters are also significantly contributing to morbidity and disability. In India 1.6 lakh people die every year on the road and 2 to 3 million people are injured of which many end up with lifelong disability.

u. BLINDNESS Of the total estimated 37 million blind persons (VA<3/60) in the world, 7 million are in India. Due to the large population base and increased life expectancy, the number of blind particularly due to senile disorders like Cataract, Glaucoma, and Diabetic Retinopathy etc. is expected to increase. Prevalence of Blindness has been gradually decreasing since inception of NPCB in 1976 as indicated below:
Year 1976 2002 2007 2020* *Target Prevalence of Blindness (%) 1.49% 1.10% 1.00% 0.30% Source NPCB-WHO Survey Rapid Assessment (GOI) Rapid Assessment (GOI)

As per information available from various studies, there are estimated 12 million bilaterally blind persons in India with VA<6/60 in the better eye, of which nearly 7 million are with Visual Acuity < 3/60. Main causes of blindness in this population are as follows:

Cataract Refractive Error Corneal Blindness Glaucoma Surgical Complication Posterior Capsular Opacification Posterior Segment Disorder Others

62.6% 19.70% 0.90% 5.80% 1.20% 0.90% 4.70% 4.19%

v. DEAFNESS Based on 2004 estimates 6, 275.7 million people have moderate to severe hearing loss. This represents approximately 4.2 percent of the worlds population. Out of these, two-thirds live in developing countries. In addition, 360.8 million people have mild hearing loss. The total global YLD (Years lived with disability) for hearing loss is estimated to be 24.9 million or 4.8% of the
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total YLD due to all causes. This makes hearing loss the second leading cause of YLD after depression and gives it a larger non-fatal burden than alcohol use disorders, osteoarthritis and schizophrenia. Hearing loss ranks seventh among persons aged >15 years, contributing to a total of just over 26 million years of healthy life lost, which is 5.5 per cent Dalys (Disability adjusted life years) from all causes. As per WHO estimates, 2004, 6% of the Indian populationsuffers with moderate to severe hearing impairment, also termed as Disabling Hearing impairment. As per the NSSO (National Sample Survey Organisation estimates, 2002), 3,061,700 persons in India are afflicted with the hearing disability. This is 16.56% of the total number of 18.49 million disabled persons in the country. As per a World Bank report, persons living with disabilities in India, including hearing impairment, have a much higher unemployment rate and child not attending school or dropping out. This compromises to severe loss of social and economic productivity of the country. Hearing Impairment is mainly caused due to Congenital causes (mainly Rubella), Acute Suppurative Otitis Media, Chronic Suppurative Otitis Media, Secretory Otitis Media, Trauma and Noise induced hearing loss. Majority of these causes are preventable. Others can be treated through early identification and intervention. However there is shortage of trained manpower such as ENT specialist, Audiologists and Audiometric Assistants. The ENT department of Medical Colleges and District Hospitals are also not fully equipped for early identification, management and rehabilitation of Hearing Impaired. At primary health care level, where the large number of cases of ear ailments such as ear discharges, wax, injuries etc. is reported, the medical officers are not trained to identify these common ear ailments and manage them appropriately. w. GERIATRIC DISORDERS The population of elderly persons is rapidly increasing world over and same is true for our country. As per Census 2001 total population above 60 years of age was 76.6 million which forms 7.5% of the total population in 2001. The elderly population was around 20 million in 1951 and since then it has increased fourfold. At the present pace of growth, it is likely to rise more rapidly in the coming years due to further increase in life expectancy and decline in fertility rate. According to estimated projection by Registrar General of India (RGI), the population of elderly above 60 years of age will increase from 7.5 to 12% of the total population by 2026. As per the multicentric study the burden of various diseases in elderly is as under:

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Health Problems in elderly Poor Vision Bowel complaints Hypertension Anemia Difficulty in Hearing Arthritis Diabetes Depression Urinary / Constipation Weight Loss Asthma Fall / Fracture COPD TB IHD

Rural 47.3 31.4 31.8 19.8 21.6 37.4 9.8 25.5 19.6 23 7.8 9.3 5.9 3.7 7.0

Urban 43.3 31.8 44.7 13.8 19.4 34.7 16.9 21.6 12.0 16.2 5.4 8.2 3.6 2.5 8.3

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SECTION 2 RISK FACTORS AND DETERMINANTS OF NONCOMMUNICABLE DISEASES An unprecedented opportunity exists to improve health in some of the world's poorest and most vulnerable communities by tackling the root causes of disease and health inequalities. The most powerful of these causes are the social conditions in which people live and work, referred to as the social determinants of health (SDH), as opposed to biological or genetic causes. Even in the most affluent countries, people who are less well off have substantially shorter life expectancies and more illnesses than the rich. These differences in health are an important social injustice. Poor social and economic circumstances affect health throughout life eg., poor education, stress, early life events, social exclusion, work, unemployment, poor housing, transportation, food, addiction etc. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Nor are the effects confined to the poor: the social gradient in health runs right across society, within each strata also. Both material and psychosocial causes contribute to these differences and their effects extend to most diseases and causes of death. These disadvantages tend to concentrate among the same people, and their effects on health accumulate during life. The longer people live in stressful economic and social circumstances, the greater the physiological wear and tear they suffer, and the less likely they are to enjoy a healthy old age. The Millennium Development Goals (MDGs) recognize the interdependence of health and social conditions and present an opportunity to promote health policies that tackle the social roots of unfair and avoidable human suffering.

More than 20% of the population have at least one chronic disease and more than 10% have more than one. Chronic diseases are widespread in people who are younger than 45 years and in poorer populations. Whereas socioeconomic development tends to be associated with healthy behaviours, rapidly improving socioeconomic status in India is associated with a reduction of
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physical activity and increased rates of obesity and diabetes. The emerging pattern in India is therefore characterised by an initial uptake of harmful health behaviours in the early phase of socioeconomic development. Such behaviours include increased consumption of energy-dense foods and reduced physical activity, increased exposure to risk factors for road traffic injury such as driving above the speed limit, after intake of alcohol, or without appropriate safety precautions like wearing seat belts or motorcycle helmets. After the early phase of socioeconomic development, increased health literacy and public awareness of chronic diseases will lead to richer people adopting healthier lifestyles more quickly than less educated and poorer population groups. Health-damaging behaviours such as smoking, drinking, consuming unhealthy diets (rich in salt, sugar and fats, and low in vegetables and fruits) are also found to be common among the low socioeconomic group. However, personal behaviours are not only a matter of personal choice, but may be driven by factors such as higher levels of urbanization, technological change, market integration and foreign direct investment. Table: Socioeconomic patterning of Non-communicable Diseases Risk Factors in a Rural population67
Parameter Mens socioeconomic status Low (n-147) 36.8 23.1 33.7 65.2 81.0 5.0 6.6 23.6 17.6 1.8 36.6 36.0 Middle (n-358) 28.1 25.1 26.9 72.4 75.6 9.9 12.1 23.4 17.1 3.3 29.3 19.2 High (n-850) 14.7 23.1 20.1 72.9 63.1 25.4 28.2 38.5 20.8 8.0 15.5 16.2 Womens socioeconomic status Low (n-106) 1.2 7.6 11.2 66.0 86.6 13.3 9.9 32.2 17.8 3.9 29.8 330 Middle (n-143) 1.1 6.6 8.1 73.5 78.5 19.2 11.6 32.3 20.5 5.1 24.2 29.5 High (n-359) 0.3 2.0 2.5 76.5 69.9 35.0 23.8 35.7 25.3 5.2 12.9 20.3

Smoke tobacco Chew tobacco Alcohol use Low physical activity Low intake of fruits and vegetables BMI > 25 High waist circumference Total: HDL cholesterol 4.5 Hypertension Diabetes Underweight Short stature

Source: Kinra S etal, BMJ 2010;341:c4974

A survey undertaken at 7 sites in Tamil Nadu on NCD risk factors according to the level of urbanicity (low, medium and high) revealed an increase in the gradient of prevalence of major NCD risk factors from low to high urbanicity indicating to the influence of urbanization of ill health68.

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The differential in the development indicators are reflective of the social inequities existing in the population. These factors fuel unrest in some parts of the country and occasionally translate into armed conflicts in affected pockets. In addition, terrorism poses a major challenge to the security of the nation. The unrest and conflicts have the potential to add to the burden of injuries and mental ill health. Investing in basic infrastructure to boost the growth of the economy and facilitating equitable economic prosperity of all sections of the society is a potential solution for containing these challenges. Most evidence on the social determinants is limited to epidemiological and descriptive studies which have demonstrated association and causation. What is lacking are studies demonstrating effectiveness of interventions in reducing these determinants and their health outcomes.
120 100 80 60 40 20 0 Dailysmoking LowPhysical Lowfruit&Veg activity intake HighBMI HighBP Low Medium High

NCD RISK FACTORS Risk is defined as a probability of an adverse health outcome, whereas risk factor refers to an attribute or characteristic or exposure of an individual whose presence or absence raises the probability of an adverse outcome3. The World Health Report 2002 identifies top 20 leading risk factors in terms of the burden of disease according to the mortality status in the population7. Ezatti et al 69estimated that in 2000, 47 per cent of premature deaths and 39 per cent of total disease burden resulted from the combined effects of the risk factors studied. Risk factors are present for a long period of time during the natural history of NCD. It is now well established that a cluster of major risk factors (tobacco, alcohol, inappropriate diet, physical inactivity, obesity, hypertension, diabetes and dyslipidaemias) govern the occurrence of NCD much before these are firmly established as diseases. ICMR coordinated the implementation of the comprehensive NCD risk factor surveys in 7 States of India (Andhra Pradesh, Kerala, Tamil Nadu, Madhya Pradesh, Maharashtra, Mizoram and Uttaranchal) in 2007-2008 under the World Bank supported Integrated Disease Surveillance Project (IDSP) in urban and rural men and women aged 15-64 years. The risk factors surveyed
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included tobacco, alcohol, diet, physical inactivity, blood pressure, weight, height and body mass index. The summary of this population based survey is given below: NCD Risk Factor Profile in 7 States of India covered under IDSP (2007-08) (53)

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a. Tobacco Tobacco is the foremost preventable cause of death and disease globally as well as in India. Globally approx. 6 million people die each year as result of diseases resulting from tobacco consumption and if urgent actions are not taken, the death toll could rise to more than eight million by 2030. It is estimated that more than 80% of these deaths occur in the developing countries. Tobacco has also been identified as the risk factor for 6 of the 8 leading causes of death. As per the tobacco control report (2004) nearly 8-9 lakh people die every year in India due to diseases related to tobacco use. However, as per newer studies nearly one million death annually can be attributed to smoking alone in this decade and majority of these deaths will occur in the most productive age group i.e. 30-69 years. There is scientific evidence available to prove the health hazards to Second hand Smoke (SHS) or Environmental Tobacco Smoke (ETS). This is the smoke resulting from smoking by someone else and inhaled by the non smoker. SHS is known to contain more than 4000 chemicals, many of these are cancer causing substances (carcinogens). Inhalation of SHS results in cancer and heart diseases in adults, and Sudden Infant Death Syndrome (SIDS), acute respiratory diseases, exacerbation of asthma, middle ear diseases in children. For the tobacco industry to survive it must hook new customers to replace those who die or quit. It must catch them young. Hence, India is a very fertile ground for the tobacco Industry as youth constitutes about 30 % of its population and they are therefore aggressively targeted by the tobacco Industry. There are studies to indicate that every day more than 5500 new youth in India get addicted to tobacco. Since tobacco Industry needs new replacement users its focus is on youth and they spend billions of dollars worldwide each year spreading its marketing net as widely as possible to attract and lure young customers. Nearly 30% of cancers in males in India and more than 80% of all the oral cancer are related to tobacco use. The majority of the cardio vascular diseases and lung disorders are directly attributable to tobacco consumption. Other diseases which are associated with tobacco consumption are stroke, cataract, peripheral vascular diseases etc. Moreover tobacco use leads to impotence. Studies have indicated that incidence of impotence is 85% higher among smokers. Tobacco use by pregnant women leads to low birth weight babies, still births and birth defects. The costs related to tobacco use are significant, as per the Health Cost Study conducted by ICMR/AIIMS in 1998-99 the cost of treatment of just three diseases caused by tobacco use i.e. cancers, lung diseases and cardiovascular diseases far exceeds the economic benefits from tobacco. It was estimated that the economic impact / health cost of these three diseases was Rs. 30,833 crores (extrapolated to rates of 2002-03), which far exceeded the tax revenue collection (approx. Rs. 27,000 crores) for the same year. The adverse socio-economic & health impact of

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tobacco production or consumption outweighs any perceived benefit that the tobacco industry contributes to GDP of the country. The economic impact of early death, disability and lost productivity contributes to the burden of poverty, retarding national development and further widening health inequities. Therefore, tobacco control is not only a public health priority, but also a key development issue. There is no safe way to use tobacco whether inhaled, sniffed, sucked, or chewed; whether some of the harmful ingredients are reduced; or whether it is mixed with other ingredients. Keeping in view the high mortality on morbidity and its economic implications the Government of India introduced the Health Cess (2005-06) on tobacco products. Although huge substantial amount are generated by this cess but the same has not been routed for tobacco control purpose. Tobacco: A risk factor for Non-communicable disease (NCDs) Tobacco use is also a leading risk factor for NCDs and accounts for more than two-third of all new cases of NCDs. Tobacco use alone accounts for one in six of all deaths resulting from NCDs. Every day more than 1 billion people chew or smoke tobacco because of their addiction to nicotine, and about 15000 die from tobacco related disease; tobacco use accounts for half the health inequalities, as assessed by education, in male mortality. The burden of NCDs is increasing in low-income and middle-income countries like India, contributing to poverty and is becoming a major barrier to development and achievement of MDGs. NCDs disproportionately affects individuals who are poor thus increasing inequalities. There are studies in India which indicate that 25% of the families, who have a member suffering from cardiovascular disease are driven into poverty. The implementation of the various components under FCTC has been identified as the most cost effective and evidence based strategy for reducing the burden of NCD,s and creating a tobaccofree world by 2040 bringing the prevalence to less that 5%. It is estimated that the implementation of all the components of FCTC would avert 5.5 million death over 10 years in 23 low income ad middle income countries where the burden of NCDs is high. Status of Tobacco use in India In India tobacco is consumed in many forms, both smoking and smokeless, e.g. bidi, gutka, khaini, paan masala, hukka, cigarettes, cigars, chillum, chutta, gul, mawa, misri etc. India is also the second largest consumer and second largest producer of tobacco in the world, second only to China. As per the Global Adult Tobacco Survey (GATS-India ) 2009-10 the prevalence of tobacco use among adults (15 years and above) is 35%. The prevalence of overall tobacco use among males is 48 percent and that among females is 20 percent. Nearly two in five (38%) adults in rural areas and one in four (25%) adults in urban areas use tobacco in some form. In absolute figures, the estimated number of tobacco users in India is 274.9 million, with 163.7 million users

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of only smokeless tobacco, 68.9 million only smokers, and 42.3 million users of both smoking and smokeless tobacco. Further as per the Global Youth Tobacco Survey (GYTS), 2006, 14.1% children in the age group of 13-15 years are consuming tobacco in some form and that the age of initiation into tobacco use has declined. It is, therefore, evident that the consumption of tobacco products in the country is increasing in all age groups and is a matter of grave concern. Tobacco is widely used in several forms in India. Most common form is beedi followed by cigarettes. Bidis, along with smokeless tobacco account for 81% of the Indian tobacco market70. According to NFHS-3 carried out during 2005-06, prevalence of tobacco use (all forms) was 57% in men and 10.8% in women24. One third of men (33.4%) and 1.4% of women were cigarette/ bidi smokers. The number of adult current daily smokers is reported to be higher in the rural areas (31.3%) as compared to urban areas (21.5%)13. In addition, daily consumption of all forms of tobacco use was higher among the lower income quintile (41.8%) compared to higher income quintile (15.5%) and elderly population (43.9% among 65+ age group) compared to younger age group (14.7% among 18-24 age group). Tobacco use among children and adolescent group is another concern. Tobacco use (all forms) is reported to be higher in low education group35. Fourteen percent of students in the age group of 13-15 years were reported to be using some form of tobacco. High prevalence of tobacco use among school students has been reported in the north eastern states like Nagaland (63%), Manipur (46.7%) and Sikkim (46.1%)71. Tobacco use is a major cause for premature mortality. A large national case control study carried out in India has shown that among the 30-69 years age group, smoking was associated with a two fold difference in the risk for death between smokers and non-smokers decreasing their survival by eight years among women and six years among men72. Over half of the smoking related deaths occur among illiterate adults. Further, smoking accounts for 1 in 5 deaths among men and 1 in 20 deaths among women. By 2010, smoking is estimated to cause about 930,000 adult deaths in India; of these, about 70% will be between the ages of 30 and 69 years. Because of population growth, the absolute number of deaths in this age group is rising by about 3% per year. Apart for cardiovascular diseases (CVDs), tobacco is reported to cause nearly half of the cancers among men and one fifth of cancers among women10. In addition, tobacco smoking is responsible for over 82% of Chronic Obstructive Pulmonary Diseases (COPD) burden in India particularly among men. Revenue collected from tobacco products annually in India is 1.62 billion USD (largely coming from taxation of cigarettes) whilst annual direct health cost of three tobacco related diseases (cancer, coronary artery diseases and chronic obstructive lung diseases) is 6.32 billion USD73.

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b. Diet and Nutrition Diet is a significant modifiable risk factor for NCDs. An unhealthy diet high in saturated fats, salt and refined carbohydrates increases the risk of NCDs, particularly CVDs and diabetes. During the course of economic development, populations undergo nutrition transition characterized by an increase in the consumption of fats and simple sugars and a decrease in fruit and vegetable intake. Nutrition transition that is currently underway in Asian countries such as India is characterized by moving away from the traditional diets that are high in carbohydrates and low in fat, to a modern diet which has higher contribution of energy from fats and lower contribution of energy from complex carbohydrates74. An analysis carried out by Deaton et al has shown that there has been a sustained decline in percapita calorie consumption during the last twenty five years75. The proportionate decline was larger among better-off sections of the population. The decline of per-capita consumption largely applies to proteins, carbohydrates and many other essential nutrients with the sole exception of fat consumption which has increased steadily in both urban and rural areas. Even though the calorie consumption is declining, the nutritional status of the population appears to have improved as evident from the population anthropometric data. During 1975 to 2005, the proportion of adults with body mass index below 18.5 fell from 56% to 33% among men and 52% to 36% among women. Similarly, between 1975-79 and 2004-05, there have been reductions of around fifty percent in the prevalence of severe under nutrition, among children as well Table: Time trends in per capita intake of nutrients in rural and urban India 76
Years Energy (Kcal/person/day) Rural Urban 2266 2221 2153 2149 2047 2107 2089 2071 2156 2020 Carbohydrates* (gm/person/day) Rural Urban 450 433 407 397 375 390 377 366 369 341 Protein (gml/person/day) Rural Urban 62 62 60.2 59.1 57 56 57 57.2 58.5 57 Fats (gm/person/day) Rural Urban 24 27 31.4 36.1 35.5 36 37 42 49.6 47.5

1972-73 1983-84 1993-94 1999-00 2004-05

*Estimated = Total energy (sum of energy from protein and fat)/ 4. An upward trend has been observed in the height and weight of urban middle and upper class children77. Despite this improvement in BMI, for both adults and children, anthropometric indicators of nutritional status in India are among the worst in the world. Close to half of all Indian children are underweight, about half suffer from anemia and India is among the most undernourished countries in the world. According to UNICEF, only Bangladesh and Nepal have higher proportions of underweight children than India. However, for comparable levels of under-nutrition, adverse outcomes may be different among different populations. Therefore, a
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uniform definition of under-nutrition may overestimate the burden of childhood under-nutrition in South Asia78. Analysis of the NFHS-3 data show that the twin burden of under-nutrition and over-nutrition in India is observed more frequently in high income inequality states (based on GINI coefficient) such as Tamil Nadu, Maharashtra, Arunachal Pradesh, Kerala etc24. The inequalities in the society increases the risk for NCDs as the risk starts from infancy, accumulates from early childhood and is influenced by risk factors acting at all the stages of the life span79. Several studies have demonstrated the inverse relationship of low birth weight and under nutrition during early childhood to diabetes and cardiovascular diseases. As mentioned earlier, this increased risk of CVD and diabetes stems both from biological mechanisms and social determinants. Further poverty and low levels of education are major determinants of NCD. Poverty and lack of access to basic health amenities make a large section of the society vulnerable to NCDs that further has a trans-generational impact on the population. Within the dietary profile, macronutrients such as fats/oils play an important role in the development of NCDs. For example, among fats, trans-fats and saturated fatty acids add to higher risk for coronary heart diseases. Although the exact data on consumption of these different types of oils/fats at the individual and household level is missing, national aggregates on consumption statistics show a high consumption of unhealthy oils in India. For example, the consumption of edible oil has risen from 9.7 million tons in 2000-01 to 14.3 million tons during 2007-08. The share of raw oil, refined oil and vanaspati oil (hydrogenated oils) in the total edible oil market is estimated at 35%, 55% and 10% respectively. Trans-fats, present in the popular vanaspati is widely used in the commercial food industry including sweets due to higher shelf life of products. Fats/oils high in saturated fats such as butter/ghee, lard, coconut oil, palm oil etc accelerate the process of atherosclerosis. Dietary use of coconut oil is confined to southern states such as Kerala and Tamil Nadu, whereas, Palm oil is widely used and India is the second largest market for Palm oil in the world. The edible oil import statistics for the year 2007-08 shows that Palm oil accounts for 85% of the edible oil imports80. The poor and the food industry use more Palm oil, due to its cost advantage over healthy oils such as sunflower oil, soya oil, groundnut oil, mustard oil, safflower oil and rice bran oil which are high in poly unsaturated and monounsaturated fatty acids. Re-heating and re-cooking vegetable oil is often practiced at both households and commercial food vendor level. These practices alter the healthy profile of fatty acids in the vegetable oils, increases the content of trans-fats and release free-radicals that increases the risk of both coronary heart diseases and cancers. Household use of cooking oils has been reported by the ICMR-WHO survey that was carried out in six sites in India covering 44491 subjects during 2003-05. It is reported that a large proportion
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of those surveyed used vegetable oils (83%) for cooking meals. The use of hydrogenated oils (such as vanaspati) was higher in urban areas (4.8%) compared to rural areas (1.7%) and is higher among the slum group (4.1%). Butter/ghee is used as the major cooking oil/fat by 0.6 0.7% of the participants. However these figures do not match with the national consumption statistics due to weakness in the methodology of assessing consumption. Among dietary components, fruits and vegetable are protective against several NCDs but their intake is grossly inadequate among Indians81. Adequate consumption of fruits and vegetables (5 or more servings per one typical day) is reported to be higher in urban areas than rural population (27% vs. 21%)13. Insufficient intake of fruits (less than five servings a day) was higher in low income groups as compared to the high income groups (lowest quartile: 84.5%; highest quartile: 78.3%). The sharp rise in price of fruits and vegetables as compared to oils and fats has resulted in a negative impact on the consumption pattern among poor. The poor tend to reduce the consumption of vegetables and fruits that are healthy while the consumption of cheaper saturated oils tends to remain the same82. Nearly 10-15 per cent of the grains and 25 per cent of the fruit and vegetables in India perish each year due to lack of warehouse infrastructure in the rural areas83. Agricultural polices and better rural storage and transportation is critical to ensuring adequate supply and affordability of such healthy foods to the masses. A study in the areas of Delhi, Mumbai and Trivandrum, most diets consumed were of traditional regional food items and could be categorized as the Delhi, the fruit and dairy dietary pattern which was positively associated with abdominal adiposity and hypertension, Trivandrum, the pulses and rice pattern was inversely related to diabetes] and the snacks and sweets pattern was positively associated with abdominal adiposity and in Mumbai, the fruit and vegetable pattern was inversely associated with hypertension and the snack and meat pattern appeared to be positively associated with abdominal adiposity84. The food items consumed did not appear largely unhealthy by Western standards, yet the cardio-metabolic risks were comparable to those seen in US and Europe. c. Physical Activity Physical activity is a key determinant of energy expenditure, and thus is fundamental to energy balance and weight control. A physically active life reduces the risk of coronary heart disease, type 2 diabetes, stroke, colon cancer and breast cancer85. Thirty minutes of moderate-intensity physical activity 5 days per week is the minimum recommended to level of physical activity. However, rapid changes in urbanization and associated mechanization and sedentary jobs increase the level of physical inactivity in the population. Due to methodological difficulties, reliable estimates of physical activity of individuals in relation to various domains of life at community level have been scanty. The World Health Survey which used standardized questionnaires reported that, overall in India, 29% of the
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population were having inadequate physical activity (in all domains of life) particularly in the older age groups13. A quarter of men (24%) and one-third of women (34%) of women report inadequate physical activity (defined as 1-149 minutes of activity in the seven days preceding the survey). The proportion of respondents with inadequate physical activity is 39% in urban and 27% in rural areas. High income group in general were found to be physically inactive (28.6% vs. 24.7%) as compared to low income group. The NCD risk factor study carried out by the Indian Council for Medical Research has shown that work related sedentariness is high in urban (64.1%) and peri-urban areas (44.8%) as compared to rural areas (39.0%). The figures for leisure time physical inactivity were urban: 84.3%; peri-urban/slum: 87.9%; and rural: 86.0%86. d. Obesity and Overweight Physical inactivity and inappropriate nutrition are directly reflected in the growing burden of overweight in the Indian population predominantly in the urban areas. Almost 30-65% of adult urban Indians are reported to be either overweight (BMI>=25) or obese (BMI>=30) or have central obesity87. Studies among urban school children have also reported a rising trend in overweight and obesity (72, 73). Large national studies such as NFHS-3 reported higher prevalence of overweight (BMI>=25) among the well-off (23.6% in men & 30.5% in women) as compared to the poor (1.4% in men & 1.8% in women)24. The prevalence of obesity (BMI>=30) was 1.3% of the population. NFHS-3 also highlights the co-existence of both malnutrition and obesity in the population. The World Health Survey also supports these findings which reported that a quarter of the men (24%) and women (29%) were below the standard body mass index weight of 18.5 kg/m2 13. As described earlier, both underweight and overweight attribute a higher risk for NCDs in the life course.
Double burden of Obesity and malnutrition in the Indian population (%)

120.0 100.0 80.0 60.0 40.0 20.0 0.0 Urban Men 26.5 15.9 57.6

Obesity (BMI>=25) 5.6 23.5 56.0 51.5 25.0 Urban Women 38.4 Rural Men 40.6 Rural Women 51.9 7.4

Source: Results of the National Family Health Survey-3

Projection studies show that prevalence of overweight is expected to rise from 12.9% (134.8 million) in 2005 to 27.8% (290.7 million) by the year 2030. Similarly obesity figures will rise from 4.0% (42.2 million) in 2005 to 5.0% (52.1 million) by the year 203088. Though generalized
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obesity based on high BMI measurement appear to be moderately low, the proportion of people with central obesity (higher waist circumference or pot belly) is high both in urban and rural population. Several small but well designed community studies report the prevalence of central obesity as high as 72% in urban men and 40% in urban women as against a lower rural prevalence of 55% in men and 36% in women89. Central obesity is an important risk factor for diabetes and appears to better predict the risk of diabetes among Asian Indians90. India is in epidemiological, nutrition, socio-economic and lifestyle transition, all contributing to problem of obesity. Obesity has reached epidemic proportions in India in the 21st century, with morbid obesity affecting 5% of the country's population. India is following a trend of other developing countries that are steadily becoming more obese. Unhealthy, processed food has become much more accessible following India's continued integration in global food markets. Indians are genetically susceptible to weight accumulation especially around the waist. While studying 22 different SNPs (single nucleotide polymorphisms) near to MC4R gene, scientists have identified a SNP (single nucleotide polymorphism) named rs12970134 to be mostly associated with waist circumference91. India has controlled the problem of severe under-nutrition to a substantial extent, but is now facing a rising epidemic of obesity. This epidemic is assuming serious proportions in cities and is affecting young adults and children92.Recent trends in Indian population indicate a rise in obesity both in children as well as adults. Almost 38-65% of adult urban Indians in Delhi fulfill the criteria for either overweight/obesity or abdominal obesity93. India shows that children aged 4 and 8 years who were born small and later showed accelerated growth had a propensity to abdominal obesity. The prevalence of Obesity and over weight is increasing rapidly worldwide. In 1995, there were an estimated 200 million obese adults worldwide but as of 2000, the number of obese adults has increased to over 300 million. In developing countries it is estimated that over 115 million people suffer from obesity-related problems. (WHO-2000) Currently more than 1 billion adults are overweight and at least 300 million of them are clinically obese, according to reports by the World Health Organization. Obesity is a complex condition, one with serious social and psychological dimensions, that affects virtually all age and socioeconomic groups. It imposes an economic burden on both developed and developing countries. In the analyses carried out for World Health Report 2002, approximately 58% of diabetes and 21% of heart disorders and 8-42% of certain cancers globally were attributable to excess weight.

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State and Gender-wise % of overweight/obese persons as per National Family Health Survey (2007) are given below:
S. No. States 1. Punjab 2. Kerala 3. Goa 4. Tamil Nadu 5. Andhra Pradesh 6. Sikkim 7. Mizoram 8. Himachal Pradesh 9. Maharashtra 10. Gujarat 11. Haryana 12. Karnataka 13. Manipur 14. Uttarakhand 15. Arunachal Pradesh 16. Uttar Pradesh 17. Jammu and Kashmir 18. Bihar 19. Nagaland 20. Rajasthan 21. Meghalaya 22. Orissa 23. Assam 24. Chattisgarh 25. West Bengal 26. Madhya Pradesh 27. Jharkhand 28. Tripura All States Males (%) 30.3 24.3 20.8 19.8 17.6 17.3 16.9 16.0 15.9 15.4 14.4 14.0 13.4 11.4 10.6 9.9 8.7 8.5 8.4 8.4 8.2 6.9 6.7 6.5 6.1 5.4 5.3 5.2 12.1 Females (%) 37.5 34.0 27.0 24.4 22.7 21.0 20.3 19.5 18.1 17.7 17.6 17.3 17.1 14.8 12.5 12.0 11.1 10.5 10.2 9.0 8.9 8.6 7.8 7.6 7.1 6.7 5.9 5.3 16.0

The incidence of obesity in India is about 9% and is mainly concentrated in urban areas. While a third of Indian population still falls below the poverty line, there has been a steady growth of the relatively affluent urban middle class now estimated to number over 200 million. Assuming that the upper middle class in India number around 100 million (half the number of middle class) it
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may be said that there are roughly 50 million over weight subjects belonging to the upper middle class in the country today according to a report by WHO (2003). The Nutrition Foundation of India (NFI), a food-policy NGO, estimates that about 45% of women and 29% of men in urban areas are overweight. The obesity rates across the country are rapidly escalating. 55% of women in India between the age group of 20 and 69 years old are overweight, which is also home to half of all undernourished people in the world. Overweight among middle-class adults in India is already a major problem. The prevalence of abdominal obesity is 29 per cent among middle-class men and 46 per cent among women94. Consequences of obesity on various NCDs Obesity is defined as having a body mass index of more than 30 kg/m2, is a condition in which excessive body fat accumulates to a degree that adversely affects health. (WHO, 2000) Obesity has been linked with the development of many Non-Communicable Diseases and this section reviews the effects of obesity in the genesis of these NCDs. It is estimated that the direct medical cost associated with obesity in the United States is US $100 billion per year95. Obesity is positively associated to many chronic disorders such as hypertension, dyslipidemia, type 2 diabetes mellitus, coronary heart disease, pregnancy, bone metabolism and certain cancers96,97. Obesity Hypertension and Cardiovascular Diseases Adipose tissue has a central role in lipid and glucose metabolism and produces a large number of hormones and cytokines, e.g. tumour necrosis factor-alpha, interleukin-6, adiponectin, leptin, and plasminogen activator inhibitor-198. Obesity and lack of physical exercise through its effects on adipose tissue dysfunction leads to low plasma HDL-c (high density lipoprotein cholesterol) and elevated TG, all independent vascular risk factors, lead to the genesis of hypertension and CVDs. Dysfunctional adipocytes of obese subjects produce AGT and angiotensin II. Angiotensin II may impair intracellular insulin signaling similarly to TNF-a and FFAs leading to reduced glucose uptake and diminished adipocyte differentiation 99. These are closely associated with abdominal obesity and can often be controlled by dietary changes and weight reduction. Obesity and Diabetes Mellitus, Dyslipidemia and metabolic syndrome Obesity is commonly associated with Dyslipidaemia, metabolic syndrome (MetS) and type 2 diabetes mellitus (T2DM). The predominant features of dyslipidaemia in these disorders include increased flux of free fatty acids (FFA), raised triglyceride (TG) and low high density lipoprotein cholesterol (HDL-C) levels. Insulin resistance (IR) appears to play an important role in the
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pathogenesis of dyslipidaemia in obesity, Metabolic Syndrome and Type 2 Diabetes mellitus100. Hypolipidaemic drug combinations (including statins with cholesterol ester protein inhibitors, niacin, fibrates or fish oil, as well as fibrate-ezetimibe combination) on the residual vascular risk in patients with obesity, MetS or T2DM. Obesity and Pregnancy Overweight and obesity during pregnancy raises the risk of gestational diabetes and complications during delivery. Lifestyle factors like physical activity may ameliorate many of these risks through its beneficial effects on the glucose homeostasis101. Obesity and Bone Metabolism Obesity is associated with low-grade chronic inflammation as the expression of a proinflammatory cytokine, tumor necrosis factor- (TNF-), is elevated in the adipose tissue of obese mice which provided the first evidence of a link between obesity and inflammation102. As obesity is associated with chronic inflammation, excessive fat accumulation is detrimental to bone mass. The increased circulating and tissue pro-inflammatory cytokines in obesity may promote osteoclastic activity and bone resorption through modifying the receptor activator of NF-B (RANK)/ RANK ligand/osteoprotegerin pathway103. Further, high-fat intake may interfere with intestinal calcium absorption and therefore decrease calcium availability for bone formation. The decreased bone mass with obesity may be due to increased marrow adipogenesis at the expense of osteoblastogenesis, and/or increased osteoclastogenesis because of up-regulated production of pro-inflammatory cytokines Obesity and Cancer Obesity has been linked to cancer which has been shown by some recent studies. Cells of White Adipose Tissue (WAT) secrete soluble molecules (adipokines) that could stimulate tumor growth Interleukin-6 is strongly linked to inflammation-associated colorectal cancers, such as those associated with inflammatory bowel disease (IBD). Further, the endocrine/paracrine signaling by WAT could provide a mechanism by which obesity-related metabolic disorders drive cancer. Data from these studies suggest that the recruitment of WAT-derived cells by tumors may at least partially account for advanced cancer progression in obese individuals104. There is evidence that obesity may be linked to breast cancer. This is because a ready supply of adipose tissue-derived angiogenic adipokines, notably VEGF(Vascular endothelial growth Factor), leptin, and the production of inflammatory cytokines by infiltrating macrophages that occurs in adipose tissues with obesity, promotes the paracrine stimulation of vascular endothelial growth needed for adipogenesis that is favorable for breast tumorigenesis105.

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e. Alcohol Alcohol consumption has both health and social consequences via intoxication and alcohol dependence. Overall there is a causal relationship between alcohol consumption and more than 60 types of diseases and injury. Alcohol is a risk factor for oesophageal cancer, liver cancer, cirrhosis of the liver, homicide, stroke, psychiatric illness and motor vehicle accidents worldwide106. According to South-East Asia Regional Information System on Alcohol and Health, 25% of road accidents in India are alcohol-related, and 20% of accident-related head injury victims seen in emergency rooms of hospitals have consumed alcohol prior to the accident107. In addition, alcohol-related problems account for 17.6% of the case load of psychiatric emergencies. Further, the prevalence of alcohol use disorders among people who committed suicide in the city of Chennai was as high as 34%. The per capita consumption of alcohol per year in India is estimated to be of two litres per adult. Community based studies have reported that alcohol use ranges between 25% and 40% in north India and 33% and 50% in south India, with a higher prevalence among the less educated and the poor. The proportion of frequent heavy drinkers, who consume five or more standard drinks in four or more days per week is estimated to be 1.3%13. Punjab, Andhra Pradesh, Goa and northeastern states have the highest consumption figures108. The prevalence of alcohol is reported to be lowest in Gujarat (7%) and the highest is in the north-eastern state of Arunachal Pradesh (75%). Low prevalence in Gujarat is likely to be due to underreporting due to the prevailing ban on alcohol in the state. For example a study carried out in the villages around Navsari town in Gujarat has shown that 60% of the healthy men were using alcohol109. The prevalence of alcohol use among women has been less than five percent in India. About 80% of alcohol consumption is in the form of hard liquor with high concentrations of alcohol. Furthermore, country liquor accounts for 60% of alcohol consumption with the poor being the predominant consumers. It is estimated that the Indian Government spends nearly 5 billion USD (INR 224 billion) every year to manage the consequences of alcohol use, which is more than its total excise earning 4.8 billion USD (INR 216 billion). Clearly Indian society is losing more than it is gaining due to alcohol110. Although moderate consumption of alcohol appears to be protective for heart attacks in western populations it appears to be either neutral or conferring higher risk among South Asians111. The results from a large sentinel surveillance study on CVD risk factors in the Industrial population also shows higher risk associated with alcohol consumption and CVDs112. This is possibly related to the binge drinking practices in India. f. Unsafe Health Care Unsafe health care is becoming a serious global public health issue. As many as one in 10 patients is harmed while receiving hospital care in developed countries (WHO). In USA (2000)

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estimated 44,000 98,000 medical error deaths occur annually (more than deaths from highway accidents, breast cancer, or AIDS). Health Care Associated Infections (HCAI) complicate between 5 and 10% of admissions in acute care hospitals in industrialised countries. The risk of HCAI is upto 20 times higher in developing countries. At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals and at least 50% of HCAI could be preventedthrough the promotion of best practices in hand hygiene and infection control(WHO). Ventilator-associated pneumonia (VAP) occurs up to 17 times more frequently in developing than in developed countries, with an excess mortality rate as high as 27%. Every year unsafe injections result in 1.3 million deaths worldwide mainly due to Hepatitis B, Hepatitis C and HIV. In India, nearly two-thirds of injections are administered in unsafe manner (62.9%). Waste disposal was found to be unsatisfactory at the health facilities (53%) at the terminal level for plastic syringes and disposable needles and was found to be least at immunisation clinics (49%)66. Burden of unsafe Surgical care: Globally, about 234 million major surgical operations are conducted a year. (one operation for every 25 persons).7 million patients annually may have post-operative complications and 1 million patients would die every year during or after an operation. Half of all harmful events affecting patients are related to surgical care. Half of these events are preventable if standards of care are adhered to and safety tools, such as checklists, are used.Surgical site infections are the most frequent in developing countries with rates of up to 25% of all surgical procedures. In developing countries, at least 50% of medical equipment is unusable or only partly usableresulting in substandard diagnosis & treatment (WHO). Approximately 20% of hospital waste is biomedical waste, which is hazardous /infectious in nature. Because of its composition, there are significant risks associated with Biomedical Waste (BMW). Infections are the most common health hazard associated with poor waste management.5 to 10% of HIV is transmitted through unsafe blood.Many States in the country are lagging behind in implementation of the Safe waste management practices and lack systems for development.

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SECTION-3 REVIEW OF ONGOING NATIONAL PROGRAMMES FOR PREVENTION & CONTROL OF NON- COMMUNICABLE DISEASES Government of India had supported the States in prevention and control of NCDs through several vertical programmes. National Health Pogrammes being implemented during the 11th Plan, their current status and allocation during the 11th Plan are summarized below:
S.No 1 2 3 4 5 Year of Launch 1975 1976 1982 1986 2007 National Health Program National Cancer Control Program National Blindness Control Program National Mental Health Program National Iodine Deficiency Disorders Control Program National Tobacco Control Program Trauma Care Facility on National Highways National Deafness Control Program National Program for Prevention and Control of Fluorosis Pilot Project on Oral Health National Program for Prevention & Control of Cancer, Diabetes, CVD, Stroke National Program for Health Care of the Elderly Pilot Program for Prevention of Burn injuries Upgradation of Department of PMR in Medical Colleges Disaster Management/Mobile Hospitals/ CBRN Organ and Tissue Transplant Current Status Integrated with NPCDCS in 2010-11 Ongoing in all districts Revised Program (2003) being implemented in 123 districts, 60 courses in med.Col.& 11 Centres of Excellence Availability of iodated salt 100%. At present,71% population using iodated salt. Being implemented in 42 districts in 21 states; 9 states have cells, 5 testing & one research lab; media campaign 140 Trauma Care Centres set up along golden quadrilateral highways & NE and SW highways in 11th Plan Initiated in 25 districts. Expanded to cover 203 districts by March 2012 Initiated to cover 100 districts The Program could not take off Initiated to cover 100 districts by March 2012 Initiated to cover 100 districts by March 2012 Piloted in Assam, Haryana, H.P. in 1 med. Col. & 2 Distt. Hosp. each In 28 medical colleges (15 covered during 2010-11; rest in 2011-12) Technical specifications and operational details finalized Model network for organ procurement & distribution in progress . Biomaterial centre for tissue being established Allocation 11th Plan (Rs. Crore) 2400.00 1550.00 1000.00 155.40 471.92

6 7 8 9 10 11 12 13 14 15

9th Plan 2006-07 2007-08 2007-08 2010-11 2010-11 2010-11 2010-11 2010-11 2010-11

732.95 100.00 68.00 25.00 1660.50 1000.00 5.09 __ __ __

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Progress and achievements during 4 years of the 11th Plan for each program is given below: 1. National Cancer Control Program (1975) National Cancer Control Programme (NCCP) is a centrally sponsored scheme which was initiated in the year 1975, with priorities given for equipping the premier cancer hospital/institutions. Later the programme was modified in the year 1984-85 with emphasis on primary prevention and early detection of cancer. The District Cancer Control Programme was introduced during 1990-91 and later modified in 2000-01. NCCP was evaluated in 2004 and the programme was further revised w.e.f 1st January 2005. So far, NCCP has supported 85 Oncology Wings in medical colleges including 27 Tertiary Cancer Centers across the country. As per Atomic Energy Regulatory Board there are 250 institutions having radiotherapy facilities with 450 Radiotherapy machines (50% Pvt. + 50% Govt.). To financial support the poor and the needy cancer patients a Health Ministers cancer fund have been started. The NCCP is being evaluated. The Palliative care services in the Tertiary facilities of the country were evaluated and it was found that more than 60 percentage of cancer patients registering at Regional Cancer Centers are in need of palliative care. But less than 50 % of Regional Cancer Centers have any palliative care facilities. Most of the states have very few services in public or private sector. The state of Kerala is an exception. All the districts in Kerala have palliative care services developed through collaboration between the government machinery and local NGOs. This project is supported by National Rural Health Mission. Keeping in view the preventable common risk factors of Cancer and other Non Communicable Diseases (NCDs), the Ministry has formulated a National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) after integrating the NCCP with National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS). The programme will have two components, one is cancer and the other is Diabetes, Cardiovascular Disease and Stroke (DCS). The outlay for Cancer is Rs. 731.52 crores from the total outlay of Rs. 1230.90 crores for NPCDCS during 2010-11 & 2011-12. There is 80:20 sharing basis by Centre & State Govt. respectively. The major components of the programme is to strengthen 100 districts in 21 States for cancer care services, strengthen 65 centres as Tertiary Cancer Centres throughout the country, establish NCD cells for monitoring the programme implementation at the selected States/Districts and promote IEC for creating awareness generation among the community about cancer and its available services. Funds have been released to 30 districts taken up during 2010-11 and will be released to 70 districts taken up during 2011-12.

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2. National Blindness Control Program (1976) National Programme for Control of Blindness (NPCB) was launched in the year 1976 as a 100% centrally sponsored programme with the goal to reducing the prevalence of blindness. India was the first country to launch the National Programme for Control of Blindness in 1976 with the goal of reducing the prevalence of blindness. In order to bring out an improvement in the quality of services, substantial efforts have been made through following initiatives: Banning outdoor surgical camps; Emphasis on IOL implantation in cataract surgery at institutional level and greater coverage for women and underprivileged sections of the society etc. High quality instruments and equipment provided for all eye care units under NPCB. Achievements during 11th Plan
SNo. 1 2 3 4 5 7 8 Component Cataract operations (lakh) School Eye Screening (Spects to School Children) (lakh) Collection of Donated Eyes (thousand) Regional Institutes of Ophthalmology (new) Medical Colleges supported PHC/Vision Centres Eye Surgeons trained Target 300 15 265 3 150 3000 2000 Achievement (2007-11) 231.20 21 170 2 150 2725 1500

Program Constraints: There are constraints to further reduce prevalence of blindness. Some of the key constraints are described below: 1. Unequal distribution of Eye Surgeons There are an estimated 12,000 Eye Surgeons in India for more than 1 billion population with an average of ratio of 1 surgeon for about 1,00,000 population. However, there is wide disparity between urban and rural areas. Eye surgeon- population ratio varies from 1:20,000 in urban area to 1 in 2,50,000 in rural areas. This disparity has led to significant differences in services offered/sought by the public. 2. Insufficient number of paramedical eye care personnel. While desired eye surgeons- paramedic ratio should be 1:3 to 1:4 but there are less number of qualified paramedics as compared to eye surgeons. The surgeon therefore have to sometime perform job like refraction, pre-operative care and undertaking diagnostic tests, which can generally be carried out by paramedical personnel.
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3. Sub Optimal Coverage by Govt. Institutions Government facilities, NGO and private sector are usually located in urban/ semi-urban areas. Geo-physically remote and socio-economically backward population remains underserved. NGO sector has been contributing affectively to reduce backlog of cataract from the country including NE Region. 4. Inadequate service provision for Eye Diseases other than cataract Cataract intervention has been given the highest priority attention under the National Programme for Control of Blindness and the problem of Corneal Blindness, Glaucoma and Diabetic Retinopathy have not been adequately addressed. Similarly Pediatric Ophthalmology and low vision have also received a lower priority. 5. Lack of Public Awareness Rural, illiterate and under privileged population are not fully aware about various interventions that are available to restore vision of the blind. Integration with primary health care is also limited and therefore rural health workers are not motivating potential beneficiaries. RAAB (Rapid Assessment of Avoidable Blindness: (2006-07) The National Program for Control of Blindness (NPCB) has consistently based its projections and program implementation on evidence collected by reputed eye care institutions through population based surveys over the past three decades. For the first time in the country, a Rapid Assessment of Avoidable Blindness was undertaken. This methodology improves upon the methodology used in Rapid Assessment and allows causes of blindness to be established. This is achieved by coupling an eye examination by an ophthalmologist to the methodology used in rapid assessments. Therefore, data can be comparable to both the rapid assessment as well as the detailed surveys conducted earlier. It was observed that overall, the prevalence of low vision, economic blindness and social blindness had decreased in the districts covered compared to the earlier surveys. Lowest prevalence of all blindness (social + economic) was seen in Solan (Himachal Pradesh), Bhatinda (Punjab) and Palakkad (Kerala). Pooling data of all districts together the prevalence of blindness as defined by the National Program for Control of Blindness has shown a reduction of 6% in overall prevalence of blindness above the age of 50 years. This reduction is significant as there is an increasing life expectancy in India which translates into more and more people living beyond 50 years of age. Since a significant proportion of blindness in India is age related, any reduction above the age of 50 years is a direct gain from the strategies adopted by the National Program in the country. The prevalence of blindness was observed to be 1.34 times higher in females compared to males. It is difficult to state whether this is due to a true rate of higher incidence among females or
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because of lack of access to services. Though a larger number of surgeries were reported of women, this would be expected as 55% of the respondents were female. The prevalence of blindness increased with age, with those above 70 years having a 16 times higher risk of being blind compared to those aged 50-54 years. Cataract surgical coverage showed a significant increase compared to the previous surveys with 82.3% having at least one eye operated among those who had a vision < 3/60 and were blind from cataract. This is much higher than the previous surveys. In RAAB, analysis was also presented for cataract surgical coverage using the NPCB definition of blindness. For the first time this is being used in the country as it was felt that this would act as a baseline for future surveys as more and more people would get operated before they reach a stage of vision < 3/60. The survey showed that the gains in Southern States (Andhra Pradesh, Kerala and Tamilnadu) and in high performing States like Gujarat continued to improve over the years. Performance in the States of Orissa (Ganjam district) and West Bengal (Malda district) needs to be augmented so that the gains of the technological revolution in eye care can be effectively harnessed across the country. There is a distinct increase in IOL surgeries in the past five years when results are compared to the earlier surveys. This is a welcome sign as more and more ophthalmologists are now adept at IOL implants than previously. Most of the survey districts have achieved more than 80% IOL rate in the past five years. However, though the total number of surgeries was higher among women, the IOL rate was 5% higher among men. This gender disparity needs to be addressed through innovative approaches. A large proportion of individuals were not using spectacles after surgery and there were many who in-spite of an IOL implant needed correction as they showed significant improvement with a pinhole. Cataract remains the single largest cause of blindness, low vision and one eye blindness in India if the data of the 16 districts are pooled together. The trend is observed across all districts also. Results indicate that the country should continue to prioritize cataract surgical services and their augmentation. The support to other blinding conditions should not be at the cost of cataract as any slackening may prove catastrophic in the long run. Lack of awareness and affordability still continue to be barriers to the uptake of cataract surgery in many parts of the country and efforts need to be made to surmount these barriers so that no person needlessly remains blind because of lack of knowledge or the lack of access due to financial constraints.

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Extrapolating the results to the population of all ages across the country, it is evident that there has been a perceptible reduction in the prevalence of blindness in the country in-spite of increased life expectancy. The country seems headed in the right direction and attention to problem regions on a priority basis will provide a further impetus to blindness control efforts in India. Prevalence of Blindness in general population is 1.0%. 3. National Mental Health Program (1982) The Government of India launched the National Mental Health Programme (NMHP) in 1982, with the following objectives: To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population; To encourage the application of mental health knowledge in general healthcare and in social development; and To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community. The NMHP was restrategized to include the following schemes in 2003 : District Mental Health Programme (DMHP) Modernization of State Run Mental Hospitals Upgradation of Psychiatric Wings of Medical Colleges/General Hospitals IEC The Manpower Development Schemes- Centres Of Excellence And Setting Up/ Strengthening PG Training Departments of Mental Health Specialities were implemented during the 11th five year plan, thus placing additional emphasis on strengthening the mental health manpower in the country. The schemes under the programme are described briefly below: District Mental Health Programme (DMHP): DMHP is the core component of NMHP and provides basic mental health services at the community level. Presently the DMHP is being run in 123 districts across the country. Based upon evaluation conducted by an independent agency in 2008 and feedback received from a series of consultations it was to revise and consolidate DMHP on new pattern of assistance with added components of Life skills education in schools, College counselling services, Work place stress management and suicide prevention services. These components are in addition to the existing components of clinical services, training of general health care providers and IEC activities. 123 District were approved for funding support, out of which 16 district are dysfunctional due to pending utilisation of funds and rest are carrying out basic mental health activities as per provision of under the scheme.

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Modernization of State Run Mental Hospitals Most of the state run mental hospitals in the country were established long time back and were in dilapidated state, lacking even basic amenities for the patients. A sum of upto Rs. 3crores per hospital, on the basis of benchmark of requirement and level of preparedness was made available under this scheme. The grant would cover activities such as construction/repair of existing buildings, purchase of equipment, provision of infrastructure such as water- tanks and toilet facilities, purchase of cots and equipments. It did not cover expenses in the nature of salaries and recurring expenses towards running the mental hospitals and cost towards drugs and consumables. During the 11th plan, 23 State run Mental Hospitals were funded for modernization of mental hospitals. Upgradation of Psychiatric Wings of Medical Colleges/General Hospitals - Every medical college should ideally have a Department of Psychiatry with minimum of three faculty members and inpatient facilities of about 30 beds as per the norms laid down by the Medical Council of India etc. Out of the existing medical colleges in the country, approximately one third do not have adequate psychiatric services. One time grant of up to Rs. 50 Lakhs was made available for upgradation of psychiatry wings of medical colleges/general hospitals.71 Psychiatric Wings of Medical Colleges/General Hospitals were funded for up gradation during 11th Plan IEC activities dedicated funds were made available for IEC activities under NMHP for awareness generation regarding treatability of mental health disorders and removal of stigma related to mental illness. Manpower Development Scheme In order to improve the training infrastructure in mental health, Government of India has approved the Manpower Development Components of NMHP for 11th Five Year Plan. It has two schemes delineated below. Centres of Excellence (Scheme A) - Under Manpower Development Component at least 11 Centres of Excellence in mental health were to be established in the 11th plan period by upgrading existing mental health institutions/medical colleges. A grant of upto Rs.30 crore is available for each centre. The support includes capital work (academic block, library, hostel, lab, supportive departments, lecture theatres etc.), equipments and furnishing, support for faculty induction and retention for the plan period. The proposal of the State Governments for these centers must include definite plan with timelines for initiating/ increasing PG courses in Psychiatry, Clinical Psychology, PSW and Psychiatric Nursing. 10 centres have been funded under this scheme. Current status: - 10 centres have been selected and grant has been released for establishment, 1 centre is in pipeline of submitting state commitment.

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(Scheme B)- Setting Up/ Strengthening PG Training Departments of Mental Health Specialities: To provide an impetus for development of Manpower in Mental Health other training centres (Government Medical Colleges/ Government General Hospitals/ State run Mental Health Institutes) would also be supported for starting PG courses in Mental Health or increasing the intake capacity for PG training in Mental Health. The support would involve physical work for establishing/improving department in specialities of mental health (Psychiatry, Clinical Psychology, Psychiatric Social Work, and Psychiatric Nursing), equipments, tools and basic infrastructure, support for engaging required/deficient faculty etc. Till date 23 courses have been supported under this scheme. Target: Strengthening/setting up of 120 PG departments of Psychiatry, Clinical Psychology, Psychiatric Social Work and Psychiatric Nursing during the 11th five year plan. Current status: Psychiatry 7 (established) +1 (in pipeline) = 8 Clinical Psychology 5 (established) + 5 (in pipeline) = 10 Psychiatric Social Work 3 (established) + 5 (in pipeline) = 8 Psychiatric Nursing 5 (established) + 6 (in pipeline) = 11 Gap Analysis No. of departments yet to established w.r.t. the target along with estimated cost: Psychiatry (30-8) = 22 departments Clinical Psychology (30-10) 20 departments Psychiatric Social Work (30-8) 22 departments Psychiatric Nursing (30-11) 19 departments 4. National Iodine Deficiency Disorders Control Program (1986) The Government of India is implementing a 100 per cent Centrally assisted National Iodine Deficiency Disorders Control Programme (NIDDCP) with the following objectives:1. 2. 3. 4. 5. Surveys to assess the magnitude of the Iodine Deficiency Disorders. Supply of iodated salt in place of common salt. Resurvey after every 5 years to assess the extent of Iodine Deficiency Disorders and the Impact of iodated salt. Laboratory monitoring of iodated salt and urinary Iodine excretion. Health education and Publicity.

On the recommendations of Central Council of Health in 1984, the Government took a policy decision to iodated the entire edible salt in the country by 1992. The programme started in April, 1986 in a phased manner. The Central Government is implementing ban notification on the sale
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of non-iodated salt for direct human consumption under Prevention of Food Adulteration Act, 1954 with effect from 17th May, 2006. The annual production and supply of iodated salt in our country is 55 lakh metric tones per annum during 2009-10. The National Iodine Deficiency Disorders Control Programme (NIDDCP) was evaluated by the National Institute of Health & F.W., New Delhi during 2007-08. The Directorate General of Health Services, State Health Directorate, Health Institutions, Indian Council of Medical Research have conducted district level IDD Survey in the various parts of the country and reported significant reduction in the Prevalence of IDD. The visible goiter is drastically reduced in the entire country. The consumption of iodated salt at the community level was evaluated by the National Family Health Survey, 2005-06 and indicated the consumption of adequately iodated salt at the community level was about 51% while salt having nil and inadequate iodine was about 49%. Further, the Coverage Evaluation Survey, 2009, UNICEF revealed adequately iodated salt consumption in the country was about 71% and the salt having nil and inadequate iodine was about 29%. It may be pointed out that in both the studies the consumption of adequately iodated salt is the rural population is far below in comparison to urban population. We have to focus more on rural population where the National Rural Health Mission (NRHM) has been playing a very important role and NIDDCP is under part D component of National Disease Control Programmes of NRHM. Thus, the activities carried out during 11th Plan have shown significant improvement in implementation of the NIDDCP, a 100% Centrally Assisted Programme, in the country. 5. National Tobacco Control program (2007) In 2003 Parliament enacted Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act (COTPA) in 2003, to reduce consumption of tobacco products in society, protect the youth and children from tobacco use and protect the health of non smokers from the harmful effects of second hand smoke etc. The specific provisions under this Act include: a) b) c) d) e) f) Ban on smoking in public places. Ban on direct/indirect advertisement of tobacco products. Ban on sale of tobacco products to children below 18 year. Ban on sale of tobacco products within 100 yards of the educational institutions. Specified health warnings including pictorial warnings on tobacco products. Testing of tobacco products for tar and nicotine.

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In order to facilitate the effective implementation of the Tobacco Control Laws and to bring about greater awareness about the harmful effects of tobacco and to fulfill the obligation(s) under the WHO-FCTC, the Ministry of Health and Family Welfare, Government of India implemeted the National Tobacco Control Programme (NTCP) in 2007- 08. Currently the programme is under implementation in 21 out of 35 States/Union territories in the country covering 42 districts. In the first phae of the Prgramme state a well a distrit cell were etablished however in the 2nd phase vovering 12 states only district tobacco control cells were established. The main components of the NTCP with an outlay of Rs. 182 crores, during the 11FYP are given below: a. National level i. Public awareness/mass media campaigns for awareness building and behavioral change. ii. Establishment of tobacco product testing laboratories, to build regulatory capacity, as required under COTPA, 2003. iii. Mainstreaming the program components as a part of the health delivery mechanism under the National Rural Health Mission framework. iv. Mainstream Research & Training on alternate crops and livelihoods in collaboration with other nodal Ministries. v. Monitoring and Evaluation including surveillance e.g. Global Adult Tobacco Survey (GATS) India. b. State level Dedicated tobacco control cells for effective implementation and monitoring of anti tobacco initiatives. c. District level i. Training of health and social workers, NGOs, school teachers etc. ii. Local IEC activities. iii. Setting up tobacco cessation facilities. iv. School Programme. v. Monitoring tobacco control laws. WHO Framework Convention on Tobacco Control (WHO- FCTC) The Government of India ratified the treaty WHO-Framework Convention on Tobacco Control (FCTC) in February, 2004. FCTC enlists key strategies for reduction in demand and reduction in supply of tobacco. Some of the demand reduction strategies include price and tax measures & non price measures (statutory warnings, comprehensive ban on advertisement, promotion and sponsorship, tobacco product regulation etc). The supply reduction strategies include combating

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illicit trade, providing alternative livelihood to tobacco farmers and workers & regulating sale to / by minors. Mid Term review of NTCP by Planning Commission The Planning Commission in the Mid-Term Appraisal of the National Tobacco Control Programme Tobacco Control Programme has remarked that even though all the provisions of the Act, have been implemented including ban on smoking in public places, health warnings on unit packs of cigarettes and other tobacco products including pictorial warnings, except regulation of nicotine and tar contents in tobacco products, however the district level programme, is yet to be implemented in most of the districts. Compliance with provisions of the Act is still a major challenge as the personnel in different parts of the State and District Administration lack sensitisation to the significance of this programme. The cessation services to encourage quitting tobacco are inadequate. An independent monitoring of implementation of COTPA in 21 States, where National Tobacco Control Programme is under implementation has revealed that only about half of the states (52%) have mechanism for monitoring provisions under the law and reporting. Although 15 states have established challaning mechanism for enforcement of smoke-free rules, out of which only 11 states collected fines for violations of ban on smoking in public places. Further, only 3 states collected significant amount of fines for such violations. Similarly steering committee for implementation of section-5 (ban on Tobacco advertisements, promotion and sponsorship) has been constituted in 21 states but only 3 states collected fines for the violation of this provision. Similarly enforcement of ban on sale of tobacco products to minors and ban on sale of tobacco products within 100 yards also remains largely ineffective in many states. Setting up of tobacco cessation facilities at district level is also a big challenge. Less than half of the states under the programme have established tobacco cessation facilities at district level. 6. National Deafness Control Program (2006-07) The programme has been expanded to 176 districts of 16 States and 3 U.T. in a phased manner. By the end of this 11th F.Y.P. (i.e by March 2012), the programme would be expanded to cover a total of 203 districts. Progress made by the programme in different components of the programme is summarized below: (a) Training: Trainings for all levels of manpower have been planned in the programme. The trainings have been planned to take place in a cascade manner for the following groups of personnel: Sensitization training for ENT doctors and Audiologists at the District level Skill based training for ENT doctors and Audiologists at the District level Obstetricians and Paediatricians at the Secondary and Primary levels. Primary level doctors posted at the CHCs and PHCs
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MPWs, PHNs, AWWS Anganwadi workers, ASHA Parents of disabled children

Training material in the form of training manuals and training lectures have been developed and field tested. Training of medical officers, PHN, AWW, MPW, ASHA and school teachers (level 4 to 7 staff) was undertaken by RCI in 2007-08 in all the 25 districts in Pilot phase of the programme. In the expansion phase, the responsibility of training was transferred to the states, for which funds were provided to the state health societies. In the expansion phase, the states of Uttarakhand, Karnataka and Gujarat initiated the training upto level 4 (i.e. Medical Officers). Beyond level 4 only the state of Assam, Uttarakhand and Andhra Pradesh are being organizing trainings in the districts. Tamil Nadu has conducted first level of trainings. (b) Screening camps Screening camps are carried out at district through support of NGOs as per the guidelines. Regular screening camps have been conducted by the states of Tamil Nadu, Karnataka, Chandigarh, Sikkim and Andhra Pradesh. Very few screening camps have been organized by the other states. (c) Procurement of Equipment To strengthen the ear & hearing care services at the community level, the district hospitals, CHC and PHC are being strengthened through provision of suitable equipment under the programme. States namely Sikkim, Uttarakhand, Karnataka, Tamilnadu , Assam, Gujarat and Chandigarh have procured the equipments specified within the Programme. However, there is delay in procurement by other states due to problems in procedural formalities at state level and cost considerations. Process of procurement has been completed in 40 districts of 9 states and is under process in the remaining 136 districts of other states. (d) Recruitment of manpower Two additional personnel i.e. Audiometric Assistant (AA) and Instructor for Speech & Hearing Impaired (IHS) are being placed at the district hospital on contract basis to carry out audiological and ear related work under the programme. However, only 40 AAs and 4 IHS have been recruited so far. Recruitment is low due to non availability of local candidates and low honorarium. (e) Hearing Aids Under the programme, fitting of free hearing aids on identified children up to the age of 15 years with free service for a period of one year is being undertaken at the level of the district hospital.
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2459 hearing aids were distributed in the 22 pilot districts of the programme. The state of Uttar Pradesh and Manipur could not distribute the Hearing aids due to poor implementation of the programme in these states. (f) Awareness campaign: IEC materials in form of posters / pamphlets have been distributed to the states for further dissemination. Mass Media campaigns have been carried out in different regional languages. 6.2 lakh posters have been distributed in the various states. 6 video films and 3 audio spots have been developed addressing the various themes related to ear & hearing.

National Institute of Health & Family Welfare, New Delhi conducted the Impact assessment of the IEC campaign done for NPPCD in 4 states (Tamilnadu, Gujarat, Assam and Uttarakhand) where in it was observed that awareness generation was not satisfactory due to low impact of TV and radio media. Significant factors in this are the short duration of awareness campaign and low frequency of telecasting of the spots on the TV and Radio. (g) Monitoring & Supervision Mechanism of Monitoring and Supervision of the programme activities at various levels has been developed. However, the quarterly progress reports are not been submitted by the states on regular basis due to lack of dedicated manpower under the programme. 7. Trauma Care Facility on National Highways Road Safety Initiatives by the Government of India The Department of Road Transport is also contemplating to set up national and State level Road Safety and Traffic Management Boards by enacting the National Road Safety and Traffic Management Act. These Road Safety Boards are to be set up for the establishment of National and State level Road Safety and Traffic Management Boards for the purpose of orderly development, regulation, promotion and optimization of modern and effective road safety and traffic management systems and practices including improved safety standards in road design, construction, operation and maintenance, and production and maintenance of mechanically propelled vehicles and matters connected therewith or incidental thereto. The safety of road users is primarily the responsibility of the concerned State Government. However, the Ministry of Road Transport & Highways has taken several steps to improve road safety for road users which are as under: Refresher Training for heavy vehicle drivers Model Driving Training Schools National Highway Accident Relief Service Scheme (NHARSS) Road Safety Equipments Publicity Measures and Awareness Campaign on Road Safety
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Initiatives taken by NHAI on Safety. NHAI Ambulances are stationed at 50 Km of completed national highway stretch through operation and maintenance contract. The Ambulances provided are stocked with essential medicines, requisite equipments and paramedical staff to help the victims in case of the accident. The ambulances are having the telephone and helpline numbers of the nearby hospitals in the 50 km. length. The helpline numbers are also displayed all along the completed corridor. Prevention and control of road traffic injuries requires an integrated and coordinated approach between all concerned ministries and departments. The new understanding of road traffic injuries reveal that if systematic programmes can be put in place, it is possible to prevent road crashes. A road safety management authority is crucial to guide, coordinate, integrate, monitor and evaluate several activities, without which road safety cannot improve. Since Road Traffic Injuries happen due to several causes, the solution are also several. Different types of interventions need to be implemented in an integrated manner to obtain maximum results It is an accepted strategy of Trauma Care that if basic life support, first aid and replacement of fluids can be arranged within first hour of the injury (the golden hour), lives of many of the accident victims can be saved. The critical factor for this strategy is to provide initial stabilization to the injured within the golden hour. The time between injury and initial stabilization is the most critical period for the patients survival. Thus disability and death following road accidents are preventable to some extent. Strategic activities to achieve this objective include: Initial stabilization by trained manpower available within a defined period of time, Rapid transportation and Medical facilities to treat such cases. Review status of ongoing programme The Government will strive to achieve its target that all persons involved in road accidents benefit from speedy and effective trauma care and health management. The essential functions of such a service would include the provision of rescue operation and administration of first aid at the site of an accident, the transport of the victim from accident site to an appropriate nearby hospital. Strategies to improve emergency medical services along national highways is as under: i. To improve communication system available with police and other emergency services as a means to reduce response times and to assist in planning and implementation of Traffic Aid Post Scheme.
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ii. To train police, fire and other emergency service personnel such as those on ambulances and paramedics in basic first aid for road crash victims. iii. To develop local and regional trauma plans based on study of post-accident assistance and consequences for road traffic accident casualties. The Ministry of Health & FW started a pilot project (1999) during the Ninth five year plan to augment and upgrade the accidents and emergency services in selected State Govt. hospital that are located in most accident prone areas of national highways. The scheme envisaged providing financial assistance (Rs.150.00lakhs) for upgrading emergency services of selected Government hospitals. In the light of the feedback received and the general consensus that emerged during consultations with various stakeholders, it is proposed to design and develop a network of Trauma Care Centres that would in the first phase cover the entire Golden Quadrilateral connecting DelhiKolkata-Chennai-Mumbai-Delhi and North-South-East-West Corridors. This project would be a major stepping stone in moving towards the desired objective of bringing down preventable deaths in road accidents to around 10%.Subsequently and after evaluation of the project, National Highways [other than GQ & NS-EW corridor] with substantial number of accidents &: Connecting two capital cities Connecting major cities other than capital cities Connecting ports to major cities Connecting industrial townships with capital cities could also be covered by the proposed network/system of trauma care. The present Scheme covers entire Golden Quadrilateral and North-South and East-West corridors. Subsequently, after evaluation of the project, other National Highways with substantial traffic density would be taken up. During 11th Plan, So far 113 Government Hospitals (out of 140 identified hospitals) have been provided financial assistance amontiang to Rs.281.34 Crores for different approved component for trauma care facilities in 15 states which are at various stages of progress. Out of 113, in 16 Government hospitals trauma center are partial operational for Trauma Care facilities. One advance life support ambulance is provided by Ministry of Surface Transport at each of the trauma care centers, while NHAI is providing one basic life support ambulance at every 50 kms of the highways. Recently, Ministry of Road Transport & Highways one Advance Life support Ambulance to be deployed in 70 identified hospitals in various states. Year wise budget allocation viz-a-viz the expenditure incurred on the scheme during 11th Plan is as under:

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Year 2007-08 2008-09 2009-10 2010-11 2011-12

Funds allocated (Rs. crores) 42.00 120.00 55.00 79.00 100.00

Funds released (Rs. crores) 37.00 110.34 55.00 79.00 --

8. National Program for Prevention and Control of Fluorosis (2007-08) National Programme for Prevention and Control of Fluorosis was approved in the year 2007-08 for 100 districts with an amount of Rs.680 crores with the following objectives: To collect, assess and use the baseline survey data of fluorosis of Deptt. of Drinking Water Supply for starting the project. Comprehensive management of fluorosis in the selected areas. Capacity building for prevention, diagnosis and management of fluorosis cases. The following strategies are adopted for implementing the programme:: Training:- Impart training to health personnel for prevention, health promotion, early diagnosis and prompt intervention, deformity correction and rehabilitation. Capacity Building:- Capacity building of district and medical college hospital for reconstructive surgery and rehabilitation. Laboratory Support Development:- Establishment of diagnostic facilities in the District hospitals I.E.C. :- Health Education for prevention and control of Fluorosis cases

9. National Program for Prevention & Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (2010-11) A pilot programme, the National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS) was initiated on life style diseases like Diabetes, Cardiovascular Diseases and Stroke in 2008 under new initiatives. The objectives of the pilot project were to model the impact of providing preventive, promotive and treatment services at peripheral centres to reduce therisk of developing these chronic diseases and appropriate management. It was started in 10 states with one district each namely, Assam (Kamrup), Punjab (Jalandhar), Rajasthan (Bhilwara), Madhya Pradesh (Jabalpur), Karnataka (Shimoga), Tamilnadu (Kancheepruam), Kerala (Thiruvananthapuram), Andhra Pradesh (Nellore), Madhya Pradesh (Jabalpur), Sikkim (East Sikkim).

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Keeping in view that Cancer, Diabetes, Cardiovascular Diseasesand Stroke have commonpreventable risk factors, a National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) has been formulated a after integrating the National Cancer Control Programme with the pilot programme of NPDCS. The programme will have two components, one is cancer and the other is Diabetes, Cardiovascular Disease and Stroke (DCS). The outlay for DCS is Rs. 499.38 crores from the total outlay of Rs. 1230.90 crores for NPCDCS during 2010-11 & 2011-12. There is 80:20 sharing basis by Centre & State Govt. respectively. The major components of the programme is to strengthen 100 districts in 21 States for early diagnosis & prompt treatment of cancer, diabetes, hypertension and acute cardiovascular diseases, establish NCD clinics at CHCs & District Hospitals for screening, diagnosis and management of these disease. Opportunistic Screening for diabetes and high blood pressure will be provided to all persons above 30 years including pregnant women of all age groups at the point of primary contact with any health care facility. Support is given for promotion of healthy life style through IEC among the community about DCS, its risk factors and its available services. Funds have been released to 30 districts taken up during 2010-11 and will be released to 70 districts taken up during 2011-12. 10. National Program for Health Care of the Elderly (2010-11) The existing health care facilities for older people in our country in terms of infrastructure, skilled manpower are almost none existing. Dedicated and separate health infrastructure is available only in a few medical colleges/institution. Some institutions are running geriatric clinics for the elderly. Taking into consideration the rising population of elderly and keeping in view the recommendations made by National Policy on Older Persons as well as provisions made under the Maintenance & Welfare of Parents & Senior Citizens Act 2007, a new initiative was been taken to start a national programme National Programme for Health Care of Elderly (NPHCE) during 2010-11 & 2011-12 for an amount of Rs. 288 out of which 20% is State Govt. share. Major components of the programme are to establish geriatric department in 8 regional medical institutions of the country and strengthening health care facilities for elderly at various levels of 100 identified districts of the country. Funds have been released to 30 districts during 2010-11 and will be released to 70 districts during 2011-12. 11. Pilot Program for Prevention of Burn injuries The Pilot Programme for Prevention of Burn Injuries (PPPBI) was launched as new initiative during the XIth Plan in the year 2010-11 on pilot basis in 3 states viz. Assam, Haryana and Himachal Pradesh covering one Medical College and 2 district hospitals each as below. The three states were selected as they represent diverse nature of the country.

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Himachal Pradesh- Tanda Medical College, Hamirpur District & Mandi District Haryana- Rohtak Medical College, Panipat district & Gurgaon district Assam- Gauhati Medical College, Nagoan district & Dhubri district Objectives To reduce incidence, mortality, morbidity and disability due to Burn Injuries. To improve the awareness among the general masses and vulnerable groups especially the women, children, industrial and hazardous occupational workers. To establish adequate infrastructural facility and network for BCC, burn management and rehabilitation. To carry out Formative Research for assessing behavioral, social and other determinants of Burn Injuries in our country for effective need based program planning for Burn Injuries, monitoring and subsequent evaluation. ComponentsPreventive Programme:This component is being implemented through Central Health Education Bureau and Awareness Programme in School for generating awareness. Treatment Programme: This component includes capacity building of healthcare manpower and quality burn injury management at all the levels of Health-care delivery system. Rehabilitation Programme:Rehabilitation services to be provided at district and state level to restore functional capacity of the burn patients. The total outlay for two years of the 11th Five Year Plan (i.e. 2010-11 & 2011-12) is Rs. 29.70 crore. Allocation for 2010-11 was 19.38 crore out of which Rs.5.25 crore were sanctioned. Allocation for 2011-12 is 10.32 crore. Progress: 1. Establishment of burn unitsDuring 2010-11, GOI have released Rs. 5.06 crore (30% of sanctioned budget) to the medical college/district hospitals of the identified 3 states towards construction & procurement. In Medical College, Rohtak and District Hospital, Panipat, construction plan has been finalized and construction work taken up. However in Rohtak, the Trauma Centre building where burn unit was to be located temporarily is not yet ready and will take some more time. In District Hospital, Gurgaon, the agreed space on 2nd floor terrace could not be used. Hence, inspection visit needs to be conducted for alternative site in the hospital campus. Medical College, Tanda, District Hospital, Mandi and District Hospital, Hamirpur the Construction work has been taken up on the identified land/space. Pending construction, space has also been earmarked for burns unit & beds have been provided to the patients.
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In Medical College, Guwahati, renovation of existing medical ward as burns unit is complete. Construction work has been taken up in District Hospital, Nagaon. However, as the District Hospital, Dhubri has been declared as a Medical College by the State govt. approval of state authorities is still awaited. As establishment of new burns unit will take time, the states have been requested to start providing burn services at the earliest by identifying space for temporary locating the unit and earmarking 2-4 beds for burn cases. Rs. 0.65 cr. was transferred to CHEB in 2010-11 for carrying out the planned activities under education and prevention component. CHEB has prepared IEC material for 5 audio spots, 2 video spots and for charts, leaflets & posters in consultation with expert committee. The material has been produced by DAVP and ready for dissemination. The 6 days training programme schedule for Surgeons/Medical Officers to be trained under the programme have been prepared. 2 Surgeons/Medical Officers each from the Medical Colleges / District Hospitals would be trained during July - August 2011 in Delhi. Burn Injury Management protocol which will be distributed as part of the training programme is being prepared by experts. Concurrent evaluation of the pilot program would be carried out during 2011-12. 12. Upgradation of Department of PMR in Medical Colleges Health Sector has been consistently initiating several projects / programmes on pilot basis to assess the most appropriate training and services delivery system to be evolved for integration into the health care delivery system. The following is the brief of such initiatives1) A Project with the objective of integrating Community Based Rehabilitation as a component of primary health care through the strengthening of the referral system at the district and sub-district level was undertaken during the 8th Five Year Plan to be translated into a National Programme of Rehabilitation as an activity of AIIPMR. During the 10th Five Year Plan period, the scheme Upgradation of facilities in the department of PMR in Medical College amounting to Rs.5.2 Crores was approved in 2004. The scheme aims at creating an independent Dept. of PMR within the existing Medical College set-up and augmenting / strengthening the Dept. through acquisition of essential equipment and manpower for comprehensive rehabilitative services. During the year 2006-07 following medical colleges were taken up for the creating and strengthening of the PMR Dept. JIPMER, Pondicherry Govt Medical College and Hospital, Chandigarh Lady Harding Medical College & Associated Hospitals, New Delhi UCMS, Delhi 2) The scheme for strengthening of Physical Medicine and Rehabilitation department in 30 medical colleges is envisaged with an aim to build up infra-structure and rehabilitation
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team. In all, 21 medical colleges have been identified for establishing / up-gradation of P.M.R. department. The scheme involves signing of memorandum of understanding with State Governments for providing adequate space and logistic support in medical colleges and designation of Nodal Officer and grant for financial assistance for procurement of equipment and engagement of manpower on contractual basis as shown in the table below:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Silchar Med. College, (Assam) GB Pant hosp. Agartala NEIGRIHMS, Shillong S.N. Medical College, Agra LLRM Med College, Meerut B.R.D. Medical College, Gorakhpur M.K.C.G. Med College, Behrampur (Orissa) B.J. Med. College, Ahmedabad Surat Municipality Medical College R.N.T. Med. College, Jodhapur (Rajasthan) S.N. Med. College, Jodhapur, (Rajasthan) JIPMER, Puducherry Gandhi Med. College, Bhopal GM Med. College, Chandigarh Lady Hardinge Medical College, New Delhi VCSG Govt. Medical Sciences & Research Institute, Garhwal (UK) Guru Nanak Dev Hospital Govt. Medical College, Amritsar Goa Medical College & Hospital UCMS & GTB Hosp, Delhi1 S.V. Medical College, Tirupati RML Hosp, New Delhi

A team constituted by the DGHS visited the medical colleges identified by the State Govt. to inspect the availability of the adequate space and other requirements, only upon receipt of the inspection report, funds were released to the State Govt. As envisaged in the 10th Five Year Plan the district and community health care based rehabilitation centers could not be started as it took considerable efforts and time for building up the department in medical colleges since it involved sensitization and seeking favorable response from the State Government authorities and medical colleges and lack of proper commitment for selection of faculty, procurement of the equipments and preparation of sites for installation, etc. The following constraints were experienced for setting up the Dept. of PMR in the various Medical colleges: Non-availability of Specialists in PMR which necessitated mid course correction. Non-availability of other categories of paramedical personnel viz. speech therapist, psychologist, prosthotist, orthotist etc.
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Inadequate communication and co-ordination with the Central Implementation Cell, the State and Medical College authorities. Non receipt of periodic feedback from the medical colleges regarding the status of upgradation and commencement of services. Despite the above constraints, the challenge for building up capacity for providing quality in rehabilitation services will have to be carried forward vigorously in the years to come as anticipated as it may take number of years or considerable time to harness such services which are different from other types of health services in the Health Care System. 13. Patient Safety Programme There have been some initiatives for safety of patients seeking health care services in the Public Sector as given below: Patient Safety committees have been formed in three central government institutions in Delhi namely Dr Ram Manohar Lohia Hospital, Safdarjung Hospital and Lady Harding Medical College & associated Hospitals. The committee is headed by Medical Superintendent / Additional Medical Superintendent. Beside Hospital experts, the members of committee also include representative of a Non Govt. Organization, One Journalist and one patient or his or her attendant. These hospitals conduct meetings of their patient safety committees to review the various patient safety issues, adverse events reported, actions taken and maintain records of all the meetings of their patient safety committees. Globally accepted interventions like Hand Hygiene, surgical safety etc. have been introduced. Trainings in Patient Safety including Hand hygiene, infection control and Bio-medical waste management are being conducted in these hospitals. Two Training Modules for Doctors have been developed through IGNOU. Self learning modules in the area of Health Care Waste Management for doctors, nurses and paramedical and Group D employees have been developed. Following Patient safety Performa introduced Check list for safety of surgical patients in the ward and OT (Modified version of WHO Surgical Safety check list) Patient Safety Evaluation Performa : Feedback from patient /attendant at discharge Adverse Event Reporting Patient Safety Monitoring Proforma Do not use list from Joint commission introduced to avoid prescription reading mistakes A National Consultation Workshop on Patient Safety has been held from 10th May to 12th May 2010 at SGPGI Lucknow and guidelines developed for implementation of the identified Patient Safety Priorities. Adverse Event Reporting cells created
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Process correction studies undertaken in casualty /trauma centre and based on the studies improvements done. Global Call for Action on Hand Hygiene is being observed as a World Hand Hygiene Day on 5th May since last year. Patient Safety and Infection Control have been included in the Indian Public Health standards for CHC, Sub-district and District Hospitals. A National Policy for containment of Antimicrobial Resistance developed by NCDC National Initiative for Patient Safety (NIPS)was launched byDepartment of Hospital Administration, AIIMS in September 2009 and under this the department has been holding four workshops on patient safety in a year for multidisciplinary teams from medical colleges and tertiary care hospitals. Sofar more than 60 medical colleges and tertiary care hospitals in public as well as private sector have been trained in these workshops. Till now more than 400 healthcare professionals from these institutes including doctors (surgeon, physician, anaesthetist and microbiologist), administrators and nurses have participated in these workshops.

Lessons Learnt: Broadly, across programmes, following experiences were observed and lessons learnt in implementation of programmes, which need to be addressed during the 12th Plan: 1. Health promotion and prevention which would reduce the incidence of NCDs, need to be given more attention. 2. The States need to be given flexibility in implementation of the programmes based on their public sector health system, prevalence and distribution of NCDs and socio-cultural context. The flexibility would, however, will be within brad policy framework. 3. Convergence and integration would be critical in implementation of large number of interventions which would require unified management structure at various levels. 4. Integration of cross cutting components like health promotion, prevention, screening of population, training, referral services, monitoring & evaluation, IEC etc. would save on costs and make implementation more effective.

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SECTION 4 PLAN OF ACTION TO PREVENT AND CONTROL NON-COMMUNICABLE DISEASES DURING THE 12TH FIVE YEAR PLAN Strategic Approach to Prevent & Control NCDs in 12th FYP There is adequate evidence that NCDs are major contributors to high morbidity and mortality in the country. Risk factors including tobacco and alcohol use, lack of physical activity, unhealthy diet, obesity, stress and environmental factors contribute to high disease burden of NCDs which are modifiable factors and can be controlled to reduce incidence of NCDs and better outcomes for those having NCDs. Most of the NCDs like Cancer, Diabetes, Cardiovascular Diseases (CVD), Mental Disorders and problems relating to ageing are not only chronic in nature but also may have long pre-disease period where effective life style changes can turn around health status of individuals. Costs borne by the affected individuals and families may be catastrophic as treatment is long term and expensive. The economic, physical and social implications of NCDs are significant justifying investment both for prevention and management of NCDs and well established risk factors. The efforts made by Government of India and the States have not been able to check rising burden of NCDs. Investments during the 11th Plan and earlier plans have been more on provision of medical services which have not been adequate in the public sector. Private sector has grown particularly in urban settings but is beyond the reach of the poor and middle sections of the society. The present proposal is a comprehensive scheme that will be first major attempt to focus on health promotion and prevention of NCDs and their risk factors and comprehensive management of NCDs at various levels across the country. While Government of Indias role will be policy formulation, population based multi-setoral interventions, technical and financial support, the onus of implementation will be with the States. Lessons learnt during the 11th Plan will be addressed and the programmes for various NCDs and their risk factors will be integrated and converged with public sector health system. As many programmes are either new or expanded after piloting in small number of districts and as NCDs are prevalent in riral as well as urban areas, it would be critical to have a separate implementation structure at various levels particularly during the 12th Plan though as an integral part of Public Sector Health System. Strategies: A comprehensive approach would be required for both prevention and management of NCDs in the country. It is proposed to continue ongoing efforts and introduce additional programmes to cover important NCDs of public health importance through following key strategies: Health Promotion for healthy life styles that preclude NCDs and their risk factors Specific prevention strategies which reduce exposure to risk factors Early Diagnosis through periodic/opportunistic screening of population and better diagnostic
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facilities Infrastructure Development and facilities required for management of NCDs Human Resources and their capacity building for prevention and treatment of NCDs Establish emergency medical services with rapid referral systems to reduce disability and mortality due to NCDs Treatment and care of persons with NCDs including rehabilitation and palliative care Health Legislation and population based interventions through multi-sectoral approach for prevention of NCDs Building evidence for action through surveillance, monitoring and research

Scope of programmes on NCDs Most of the NCDs are prevalent across the country though there may be regional variations. The Plan of Action therefore would cover all States and UTs of the country in a phased manner during the 12th FY Plan. To ensure convergence and integration with public health services, a decentralized approach is proposed with District as the management unit for programs. Major NCDs that are proposed to be covered during the 12th Plan are summarized in three broad categories: (a) Programmes for Life Style Chronic Diseases& Risk factors 1. Cancer 2. Diabetes, Cardiovascular Diseases (CVD) & Stroke 3. Chronic Obstructive Pulmonary Diseases 4. Chronic Kidney Diseases 5. Organ and Tissue Transplant 6. Mental Disorders 7. Iodine Deficiency Disorders 8. Fluorosis 9. Oro-dental disorders 10. Neurological Disorders (Epilepsy, Autism) 11. Congenital Diseases 12. Hereditary Blood Disorders (Sickle Cell Anaemia, Thalassemia, Haemophilia) (b) Programmes for Disability Prevention and Rehabilitation 13. Trauma (including Road Traffic Accidents) 14. Burn Injuries 15. Disaster Response 16. Emergency Medical Services 17. Musculo-skeletal (Bone and Joint) Disorders 18. Physical Medcine & Rehabilitation 19. Blindness 20. Deafness 21. Health Care of the Elderly (Geriatric Disorders)

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(c) Health Promotion and Prevention of NCDs 22. Tobacco Control 23. Prevention and Management of Nutritional Disorders & Obesity 24. National Institute for Health Promotion and Control of Chronic Diseases 25. Patient safety programme 26. Establishment of APHO/PHO Programms Components: To ensure long term sustainability of interventions, the programmes would be built within existing public health sector and wherever feasible introduce public private partnership models. To ensure universal coverage including rural population and underprivileged urban poor, the schemes will beimplemented through Public Sector Health System. Following will be major components of NCD programmes: 1. Primary Health Care: Health promotion, screening , basic medical care, home based care & referral system 2. Strengthening District Hospitals for diagnosis and management of NCDs including rehabilitation and palliative care: NCD Clinic, Intensive Care Unit, District Cancer Centre, Dialysis Facility, Geriatric Centre, Physiotherapy Centre, Mental Health Unit, Trauma & Burn Unit, strengthening of facilities for Orthopaedic, Oro-dental, Eye and ENT Departments, Tobacco Cessation Centre, Obesity Guidance Clinic. 3. Tertiary Care for advanced treatment of complicated cases, radiotherapy for cancer, cardiac emergency including cardiac surgery, neurosurgery, organ transplantation etc. 4. Emergency medical care and rapid referral system including Highway Trauma Centres and 108 EMS services 5. Health Promotion & Prevention: Legislation, Population based interventions, Behaviour Change Communication using mass media, mid-media and interpersonal counselling and public awareness programmes in different settings (Schools, Colleges, Work Places and Industry).

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Facilities and functions at various levels are summarized below:

Facility Sub-centres PHCs Development of Facilities Screening facility Screening facility Vision Centre NCD Clinic Rehabilitation Unit NCD Clinic, Intensive Care Unit, District Cancer Centre, Dialysis Facility, Geriatric Centre, Physiotherapy Centre, Mental Health Unit, Trauma & Burn Unit, Tobacco Cessation Centre Obesity Guidance Clinic. Strengthening of Orthopaedic, Orodental, Ophthalmology and ENT Tertiary Cancer Centre Cardiac Care Centre Organ Transplant Facility Nephrology, Endocrinology Neurology Department Geriatric Department Psychiatry Department Glaucoma,Vetrioretinal Surgery Burn/Trauma Department Key Functions for NCDs Health Promotion, Screening, Referral Health Promotion, Screening, Follow-up, Referral Early Diagnosis, Home-based care, Managing common uncomplicated NCDs, Referral Early Diagnosis and Management of all NCDs except cancers requiring adiotherapy, complicated cases of renal diseases, cardiac cases requiring surgery, retinal diseases, NCDs requiring laser treatment, organ transplantations

CHCs/Subdistrict Hospitals District Hospital

Medical Colleges/ Tertiary level Institute

Comprehensive cancer treatment, cardiac care including cardiac surgery, neurosurgery, organ transplantation, tertiary level care for ENT, Ophthalmology, Geriatrics etc.

Coverage: It is proposed to expand various schemes for NCDs to all 640 districts in a phased manner during the 12th Plan. To ensure convergence, common districts will be selected for all three major programmes. The schemes would be flexible to meet local requirements as there would be variation in prevalence and availability of existing health infrastructure. Districts will be selected for each year of the Plan based on selected parameters including disease burden and availability of HR and facilities but in consultation with the States. Program-wise coverage targets are given below:

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S.No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Program Component Cancer Blindness Mental health IDD (Iodated Salt) Tobacco Highway Trauma Centres Deafness Fluorosis Oral Health Diabetes, CVD, Stroke Health Care of Elderly Burn Injuries Upgradation of PMR Disaster Response Organ & Tissue Transplant Health Promotion Patient Safety Program Airport/Port Health Office Epilepsy Thalassemia, Sickle Cell Disease and Hemophilia

Coverage by March 2012 100 Districts All Districts 123 Districts 71% popn. 42 Districts 243 Centres 203 Districts 100 Districts 25 Districts 100 Districts 100 Districts 6 Districts 28 Med.Col. New New New New New New New

Target by March 2017 All Districts All Districts All Districts 100% Population All Districts Cover major highways & accident prone roads All Districts All 230 Endemic Districts All Districts All Districts All Districts All Districts All Govt. medical colleges Cover 22 vulnerable States 11 OPDO & Biomaterial centres National Institute for Health Promotion & CCD All Districts All Intl. Airports, Ports and Land Borders covered All districts Pilot in selected endemic districts

Expected Outcomes: The programmes and interventions would establish a comprehensive sustainable system for reducing rapid rise of NCDs, disability as well as deaths due to NCDs. Broadly, following outcomes are expected at the end of the 12th Plan: Early detection and timely treatment leading to increase in cure rate and survival Reduction in exposure to risk factors, life style changes leading to reduction in NCDs Improved mental health and better quality of life Reduction in prevalence of physical disabilities including blindness and deafness Providing user friendly health services to the elderly population of the country Reduction in deaths and disability due to trauma, burns and disasters Reduction in out-of-pocket expenditure on management of NCDs and thereby preventing catastrophic implication on affected individual and families Details of each programme are given below:

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A. PROGRAMMES FOR PREVENTION & CONTROL OF CHRONIC DISEASES: 1. Cancer Cancer pattern is varied in different parts of the country with increasing urbanization, sedentary habits & life style behavior it is becoming a major life style problem. At this juncture the country is equipped with only 450 radiotherapy machines in 250 institutes, where as the requirement is 1160 (1 per million population). The experts felt that Cancer should be a notifiable disease for the whole country like the State of West Bengal. It is essential that at all levels of the health facilities there is availability and accessibility of facilities for prevention, early detection, diagnosis, treatment and follow up of common cancers. The common cancers namely Oral, breast & cervix cancers can be easily prevented and detected early with simple measures and appropriated training of health professionals. Awareness generation on early warning signals, risk factors will help reduce at lest 1/3rd of the common cancers. Regular Oral Clinical/ Self/ Examination for prevention of Oral Cancers, regular Physical examination of the breasts for Breast Cancers and r will help in reducing the morbidity on common cancers. At this juncture emphasis on availability of HPV vaccine at district level may not be required as simple advice on personal hygiene and early symptoms of Cervix Cancer and training of Health worker in VIA techniques will help in prevention & early detection of cervix cancers. Heath promotion & life style changes will help in reducing NCDs including cancers. Palliative care is an important and essential part of cancer care therapy, at least 10% of the budget need to be earmarked for these services at level of cancer care services. For availability of health professionals at the districts it may be made mandatory that there be 1 year posting at district hospitals after completion of the courses in Oncology in Medical/Surgical/Radiotherapy/Medical Physicst after which the degrees would be provided. For radiotherapy, Linear Accelerator requires higher maintenance compared to Cobalt machine and the down time of Cobalt machines is much lower than a Linear accelerator, so Cobalt machine is preferred. It is essential that at the tertiary level for Radiotherapy there should be at least the three: a Cobalt, a High Density Radiotherapy & a Treatment Planning System. In addition to these three any other radiotherapy equipment may be sought according to the requirements. Where feasible Linear Accelerator may be sought. The District cancer services will be expanded to all 640 Districts. 100 Tertiary Cancer Centres will be strengthened in Govt. Medical Colleges & NGO Institutions Hospitals for comprehensive cancer care services across the country, 20 State Cancer Institutes will be established for all specialized cancer services, Training of specialists & Research during the 12th plan period. Support will be provided for 3 National Cancer Institutes including Chittaranjan National Cancer Institute (CNCI). The National Cancer Registry will be expanded to all Tertiary Cancer centres
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and cancer institutions. At all levels of health facilities provision is being kept for palliative care services including provision specific beds, training and development of required manpower for these services. a. Cancer Services at District Hospitals: At present the programme is being implemented in 100 districts across 21 States. The programme will be expanded to all the 640 districts in the country. Under this scheme, District Cancer Centre will be established at the selected districts to provide common diagnostic services, basic surgery, chemotherapy and palliative care. District Surgeon, Physicians, Gynaecologist will be trained in management most of the common cancers including palliative care. In addition to the existing manpower support is provided for contractual staff. District hospital is being strengthened for prevention, early detection and management of common cancers especially oral cancer, breast caner & cervix cancer. Nurse/Health worker will be trained in awareness generation on early warning signals of cancers, Oral self examination, Physical examination of breasts and VIA techniques for cervix cancer. Nurses will be given special training in Stoma care. For diagnosis of Cervix Cancer, white light source will be used as recommended by TMH. It is hand held device that works on regular 220V AC electricity with a bakelite casing for halogen bulbs for shadow free illumination of the cervix. For palliative care there will be dedicated 4 beds at the district hospital. Doctors, Nurses & Health worker will be trained in basic palliative care. One of the doctors in the District hospital need to have a 2 weeks training in palliative care. Along with the local NGOs home care programme will be organized to empower the patient and their families. Necessary medicines including Oral morphine should be made available in the District by amendment of State regulations. Support will be provided for Chemotherapy drugs required for cancer patients in addition to support for a Day care Chemotherapy facility for patients on chemotherapy regimens. Laboratory investigations which are not available at the districts can be outsourced. A home base team consisting of nurse and counsellor (from DCS) would be trained in chronic, debilitating and progressive cancer patients. Support would be given for White Light Source (bakelite casing with halogen bulbs) Manpower:1 Medical Oncologist, 1Cytopathologist, 1 Cytopathology technician, 2 Nurses for Day care Day care Chemotherapy facilities ( 4 beds) Chemotherapy drugs patients @ Rs. 1 lakh per patient for 100 patients/ year/ district Outsourcing of Laboratory investigation including Mammography Miscellaneous activities including TA/DA, home based palliative care
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b.

Tertiary Cancer Centres (TCC) Scheme: Support will be given for 100 Govt. Medical Colleges/ NGO Institutions/erstwhile RCCs or institutes supported under Oncology wing scheme to be strengthened as Tertiary Cancer Centres across the country to provide comprehensive cancer care services. The institute/ hospital should have at least 100 general beds or should be 50 bedded exclusively cancer hospital with three years of experience in cancer treatment. There could be exemptions made for hilly/ difficult areas/ NE states and in States where there are no cancer treatment facilities. The TCC should be well within 300 km of identified districts under NPCDCS. The institute should have well equipped and functional departments of Medicine, Surgery, Gynecology & Obstetrics, ENT, Anesthesia, Pathology and Radiology.These departments can be part of the institute or part of hospital attached with a Government Medical College in near vicinity in the same city which has entered into a formal understanding with TCC. These institutes will be supported with a capital grant for construction, equipments related to cancer care services including palliative care & pathology services. Support will also be given for Human Resource development, drugs, consumables etc as a recurring amount.These institutes will have a Palliative Care unit with at least 4 in- patient beds and 2 beds in Day care for palliative care. There will be dedicated staffs in the palliative care unit: 2 Doctors, 6 nurses, a part time Pharmacist & a part time Physiotherapist. There will be OPD services for palliative care, 3 days per week and home care facilities. At least 10% of the total budget for TCC will be for Palliative care services including availability of opioids drugs e.g oral morphine. These centres will also ensure availability of opioids drugs including oral morphine in the district centres. The TCC will give an undertaking to ensure generation of cancer care health professionals by the 3rd year (2014-15) of the 12th five Year Plan. They shall initiate/increase courses in MD/MS/Mch/DM (Surgical oncology, Medical Oncology, Radiotherapist, Palliative Care, Diploma courses in Palliative Medicine, Pathologist, Medical Physicists etc.). They shall initiate/increase courses in Oncology Nursing and Diploma courses in Palliative Nursing. They should function as institutes to generate cyto-technicians, cyto-pathologists and other paramedicals for cancer care services. These centres will be referral centres for the District Hospitals and provide comprehensive cancer care services. These institutes will also be training and research centres for cancer care. The TCCs will coordinate with other institutions, NGOs, medical colleges and the general health care delivery infrastructure in conduction of cancer related activities including peripheral outreach services in their respective geographical areas/ region.

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c.

State Cancer Institutes (SCI): Support will be given to 20 centres in the country to function as Centres of Excellence. These centres will be state-of-the-art treatment centre for different cancers including site specific specialties, minimal access surgery, multidisciplinary groups and Oncology Nursing care for better delivery of treatment, better outcome results and optimum use of resources. The institute/ hospital should have at least 150 general beds or should be 100 bedded exclusively cancer hospital with three years of experience in cancer treatment. The institute should have well equipped and functional departments of Medical Oncology, Radiation Oncology, Surgical Oncology and supportive departments of Medicine, Surgery, Gynecology & Obstetrics, ENT, Anesthesia, Pathology and Radiology.The erstwhile Government RCCs/TCCs may be upgraded to State Cancer Institutes. Like the TCCs these institutes will also have a dedicated Palliative Unit with 10 beds, 4 day care beds, dedicated staff (3 doctors, 10 Nurses, I full time Pharmacist and Part time Physiotherapist) for palliative care services. The SCI will ensure availability of opioids drugs including oral morphine. These centres will also ensure availability of opioids drugs including oral morphine in the district centres. There will be OPD services for palliative care, 3 days per week and home care facilities. At least 10% of the total budget for SCI will be for Palliative care services. These institutes will be supported with a capital grant for construction, equipments related to cancer care services including palliative care & pathology services. Support will also be given for Human Resource development, drugs, consumables etc as a recurring amount.The SCI will give an undertaking to ensure generation of cancer care health professionals by the 3rd year (2014-15) of the 12th five Year Plan. They shall initiate/increase courses in MD/MS/Mch/DM (Surgical oncology, Medical Oncology, Radiotherapist, Palliative Care, Diploma courses in Palliative Medicine, Pathologist, Medical Physicists etc.). They shall initiate/increase courses in Oncology Nursing and Diploma courses in Palliative Nursing. They should function as institutes to generate cyto-technicians, cyto-pathologists and other paramedicals for cancer care services. These centres will be referral centres for the TCC/District Hospitals and provide specialized cancer care services. These institutes will also be training and research centres for cancer care. The SCIs will coordinate with other institutions, NGOs, medical colleges and the general health care delivery infrastructure in conduction of cancer related activities including peripheral outreach services in their respective geographical areas/ region.

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d.

National Cancer Institute (NCI): Support will be given for 3 National Cancer Institute in the country one in the North, one in the South & one in the east of India. These will be apex centres for providing training, research and in generating quality manpower related to cancer care services. NCI will be state of art research & referral which will have comprehensive cancer care facilities. The institute will have department in Medical Oncology, Surgical Oncology, Radiation Oncology, Rehabilitation & Palliative care centre. NCI will also have focus in Urooncology, Gastrointestinal Oncology, Gynaecological Oncology, Community Oncology, Nuclear Medicine, Cell & Tumor Biology, Cancer Immunology, Radiation research etc. Wherever necessary the Medical Social Worker will facilitate the treatment of cancer patients. There will be Bone Marrow transplant facilities for Leukemia, Lymphoma patients supported with blood transfusion. There will be supportive departments in Anaesthesia, Pathology, Microbiology, Biochemistry, Blood Bank etc. There will be enough scope for recreation/ spritual for all kinds of cancer patients from children to adults. To start with the NCI will have 300 beds with day care facilities and will be expanded to accommodate 500 beds. The institutes will also have a dedicated Palliative Unit Department for training & research in palliative Care. There will be dedicated staff (5 doctors, 30 Nurses, 2 full time Pharmacist, 2 Physiotherapist, 4 Social workers and other supportive and administrative staff) for palliative care services. The NCI will ensure availability of opioids drugs including oral morphine. At least 10% of the total budget for NCI will be for Palliative care services. There will be Administrative block, Research block, Academic block, OPD and other service blocks. There will also be facility for a 200 rooms budget hotel, a hyper market, basement parking, a pedestrian plaza. The institute will work in close association with the Tertiary Cancer Centres in the country. The administration of NCI will be headed by Director who will be assisted by a Joint Director. There will be Medical Superintendent of the Hospital Block assisted with an Assistant Medical Superintendent. There will be a Administrative Officer, Accounts Officer along with other support staffs. Each clinical department will have a Professor assisted by Associate Professor and Assistant Professor. There will be Senior & Junior Residence too. There will be Chief Medical Officer, Medical Officer, Research Associates, Scientist, Veterinary Surgeon and Technical staffs at NCI. The Nursing Services will be headed by the Nursing Superintendent (NS) and assisted, Deputy Nursing Supdt (DNS) and Asst. Nursing Supdt (ANS). The ward duties will be carried out by the nursing sisters and the staff nurses.

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The Nursing Council of India norms of staffing will be adhered while calculating manpower requirement for different nursing units. Establishment of NCI will have comprehensive cancer care facilities in Surgical, Medical, Radiation and Community Oncology and Palliative care. The institute will have facilities for Research & Development, Training and Capacity Building. There will be research fellows in areas of Epidemiology, Biostatistics, Cell Biology, Molecular Biology, Genetics, Pathogenesis, Cancer Screening etc. The institute will also have course on Oncology Nursing. The institute will be good source of quality manpower in cancer research. There will be 1-2 research fellowship per year in the different areas related to cancer research totaling to 8-10 per year. In view of the status of the institute as an apex centre for referral and research, the most sophisticated, state of the art instruments will be procured for both the research and clinical divisions. These institutes will be supported with a capital grant for construction, equipments related to cancer care services including palliative care & pathology services. Support will also be given for Human Resource development, drugs, consumables etc as a recurring amount. National Cancer Institutes will give an undertaking to ensure generation of cancer care health professionals by the 3rd year (2014-15) of the 12th five Year Plan. They shall initiate/increase courses in MD/MS/Mch/DM (Surgical oncology, Medical Oncology, Radiotherapist, Palliative Care, Diploma courses in Palliative Medicine, Pathologist, Medical Physicists etc.). They shall initiate/increase courses in Oncology Nursing and Diploma courses in Palliative Nursing. They should function as institutes to generate cytotechnicians, cyto-pathologists and other paramedicals for cancer care services. These centres will be referral centres for research and treatment and provide specialized cancer care services. Chittaranjan National Cancer Institute (CNCI) is an autonomous organisation jointly funded by Government of India and the Government of West Bengal. Support will be given for the existing institute to be up gradated and for a 2nd campus hospital to accommodate the increasing patient load. This will be the NCI for the east of India. There will be one established in the North & South of India. e. Human Resource Development: Training will be provided at Tertiary Cancer Centers/ State Cancer Institute for the health professionals for cancer care services. (District Surgeons/Physicians/Gynecologists, District Radiotherapist, Medical Physicist and Cytopathologist/Cyto-technician).
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f.

Monitoring & Supervision: Monitoring and supervision of the programme will be carried out at different levels through NCD cell through reports from the state, regular visits to the field and periodic review meetings. State and District NCD cell will be established at the selected States/ Districts for monitoring programme implementation. National Cancer Registry Programme &Research: At present Population based cancer registry is present only in 23 institutes mostly in the urban area. The programme will be expanded to all TCCs and Cancer Treatment Institutes in the country for having a data base for cancer cases in the country including rural areas. Support would be provided for research activities related to cancer including surveillance. IEC activities: Awareness generation about cancer will be done in the community through Inter Personal Communication, education, mass media etc.

g.

h.

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2. Diabetes, CVD & Stroke At present the programme is being implemented in 100 districts across 21 States. The working group recommended that each of the health facility should be strengthened for prevention, early detection and management of Diabetes, Cardiovascular Disease and Stroke (DCS). The staff in these facilities will be trained to handle these diseases. Each of these facilities will have a generic drug list for management of these diseases. A standard regimen would be followed to handle each stage of these diseases. The programme will be expanded to all the 640 districts in the country. a. District Hospital up-gradation: District hospital is being strengthened /upgraded for management of Diabetes, Cardiovascular Disease and Stroke (DCS). Health professionals will be trained in awareness generation on early symptoms, screening of and home based care of these diseases. All districts will have NCD clinic on a daily basis for screening, counseling and awareness generation about DCS. Each district hospital will have a 4 to 10 bedded multi Purpose Medical Intensive Care & Stroke Unit (ICSU). There will be 2 beds dedicated for stroke patients. These beds will also be utilized for patients of COPD and elderly with NCD problems. In addition to the existing staff support is given for contractual manpower. The District Physician will be trained in management of DCS. The Specialist proposed on contractual can be either a full time or visiting specialist according to the availability. Under the NPHE, there are 2 Consultants on contractual; their services also could be utilized for NCD services. One of the consultants may be MBBS trained in PMR whose services can be utilized for rehabilitative services of NCD patients. The nurses will be trained in management of DCS and Special training will be given for Nurse in the ICSU. Health workers will be trained in awareness generation on early symptoms of these diseases, screening of diabetes & hypertension and home based care. The districts will be supported with certain essential drug list including TPA for Stroke patients. All districts will have support for a CT scan through PPP mode. Under this scheme support will be given for: NCD Clinic for screening, diagnosis and management of DCS. Opportunistic Screening for diabetes and high blood pressure to all persons above 30 years including pregnant women of all age groups. Developing/Strengthening and equipping Multipurpose Intensive Care & Stroke Unit (ICSU). Strengthening/Outsourcing of Laboratory investigations which are not available at the districts
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Availability of life saving drugs @ Rs. 50000/month Transport of Referred/Serious patients IEC activities Home based care for bed ridden cases. Contractual Manpower (Specialist-1, Nurses-3, Physiotherapist-1, Counselors-1, DEO-1 & Care Coordinators-1) Training of health professionals. Miscellaneous cost for communication, TA/DA, POL, contingency etc.

b. District NCD programme: The health facilities below the districts will be supported for prevention, early detection and management of DCS. Community Health Centres (CHCs): NCD clinic will be set up at CHCs for diagnosis and management of Cardiovascular Diseases (CVD), Diabetes & Stroke. Opportunistic Screening will be done for diabetes and high blood pressure to all persons above 30 years including pregnant women of all age groups. Strengthening/Outsourcing of Laboratory investigations which are not available at the districts. Each CHC will be supported with contractual staff (1 Doctor, 2 Nurses, 1 Counselor and 1 DEO) and will be trained for management of DCS. Home based care will be for bed ridden cases. The services of the Rehabilitation worker under NPHCE will be utilized for rehabilitating the DCS & COPD patients. Support is also being provided for transport of referral cases, IEC activities, consumables etc. Essential drugs required for DCS will be made available at each of theses CHCs. Primary Health Centres (PHCs): Opportunistic Screening will be done for diabetes and high blood pressure to all persons above 30 years including pregnant women of all age groups. Each PHC will be provided with Glucometer for screening of Diabetic patients. Doctors, Nurses & health workers will be trained for management of DCS. Support is provided for strengthening/outsourcing of laboratory investigations not available at these PHCs. Home based care will be for bed ridden cases. Support is also being provided for transport of referral cases, IEC activities, consumables etc. Essential drugs required for DCS will be made available at each of theses PHCs. Sub Centres (SCs): Opportunistic Screening will be done for diabetes and high blood pressure to all persons above 30 years including pregnant women of all age groups. Each SC will be provided with Glucometer for screening of Diabetic patients. Health workers will be trained for management and prompt referral of DCS. Home based care will be for bed ridden cases. Support is also being provided for transport of referral cases, IEC activities, consumables etc. Essential drugs required for DCS will be made available at each of theses SCs.

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c. District Dialysis Facility: Support will be given for Dialysis Facility at districts through PPP mode. d. Strengthening of Medical Colleges: It is proposed to strengthen Government Medical colleges all over the country to provide specialized tertiary care facilities in NCDs and also to work as resource centre for training and Research. Each medical college will be assessed for existing infrastructure, human resources and facilities to identify gaps for support under the programme. Each medical college will be supported for essential equipments and facilities required for investigations and management of NCDs. Capacity will be built to provide high quality services for Cardiology, Nephrology and Neurology. The state/UT shall develop a clear cut referral protocol for cases needing further referral from the district hospital level to tertiary care level. Each medical college will be linked with districts in its catchment area for providing following services: i. High Quality Tertiary Care: Medical Colleges shall provide quality services for key NCDs including diabetes, heart diseases, stroke and complications including due to these diseases through OPD services, acute and chronic care and other specialized interventions including surgery etc. Training: Medical colleges shall serve as resource centres for undertaking training of State/District level officials on various aspects of the NCDs. Detailed training strategy, containing training module for all health functionaries at all levels shall be developed and shared with the states for implementation through state training centers/ nodal training centers and selected medical colleges. Research: shall participate in the Operational research on various aspects of programme implementation and management and also in academic research on the underlying patho-physiology of diabetes, heart disease and stroke and the effectiveness of prevention interventions which will enhance the evidence base for the development of effective program and services. Research on sleep disorders and its linkages with the NCDs would also be encouraged Medical colleges shall submit research proposals through State level committee. Monitoring & Evaluation: Selected medical colleges will be involved in monitoring, Disease Registry and evaluation studies to assess effectiveness of the programme.

ii.

iii.

iv.

For budgetary purpose, an average capital grant of Rs. 3 crore and recurring grant of Rs. 1 crore per year for human resources, training, consumables and maintenance is proposed for support to Medical Colleges.
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e. Monitoring & Supervision: Monitoring and supervision of the programme will be carried out at different levels through NCD cell through reports from the state, regular visits to the field and periodic review meetings. National, State and District NCD cell will be established for monitoring programme implementation. f. Human Resource Development: Training will be provided for the health professionals in the various health facilities for management of Diabetes, Cardiovascular Disease and Stroke (DCS). Home carers should also be given training for care of the bedridden patients. The staff of 108 ambulance established in various parts of the country should also be trained in Stroke management. Medical colleges would be encouraged to conduct courses on Community Diabetology & Cardiology for generation of trained manpower. g. Surveillance & Research: Support will be given for surveillance & research on NCDs. Emphasis should be given on research on programme outcomes. h. IEC activities: Awareness generation about Diabetes, Cardiovascular Disease and Stroke (DCS) & Health promotion will be done in the community through Inter Personal Communication, education, mass media etc.

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3. Chronic Obstructive Pulmonary Disease (COPD) COPD is of great public health importance, because it is largely preventable if identified in the early stages and treated properly. In the initial stages, no abnormal signs are seen. If not detected and attended to with proper medication, deterioration slowly sets in as it progresses into the moderate form with breathlessness and/or wheezing on moderate exertion. The disease is gradually progressive with each episode of exacerbation leading to further respiratory disability and, ultimately, death10. A strong association exists between tobacco smoking and the occurrence of COPD. In 80% of the cases tobacco smoking is responsible for COPD37.Tobacco use being a major preventable cause of premature death and disease. Bringing in behavioral change and life style changes will reduce the mortality and morbidity of NCDs including COPD. The clinical course of COPD is characterized by a variable number of acute exacerbations which may be rather frequent. Each exacerbation may also result in structural alterations contributing to the irreversibility of airway obstruction causing an increase in respiratory and systemic morbidity, increased rate of lung function decline, systemic effects and premature mortality. Though no disease modifying drug is available as yet, early and comprehensive management with antibiotics, anti-inflammatory drugs and other supportive drugs may help in reducing morbidity and mortality of an acute exacerbation,. Therefore, emphasis is placed on primary and secondary prevention especially by reducing smoking and other noxious exposures37. Capacity building of peripheral health workers/providers for detection of mild cases of COPD and initiation of basic treatment with inexpensive drugs would go a long way in early detection and prevent disease progression to moderate and severe forms. Despite the lack of reversibility of the disease, patients often report symptomatic improvement with medication10. The key aims of COPD treatment are to improve quality of life, increase the capacity for exercise and ultimately, reduce morbidity and mortality for COPD patients. The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a collaborative project of the World Health Organisation and the National Heart, Lung and Blood Institute (USA), has developed the GOLD Guidelines which aim to: Relieve symptoms; Prevent disease progression; Improve exercise tolerance and health status; Prevent and treat complications; Prevent and treat exacerbations; and Reduce mortality.

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Proposed Programme Objectives of COPD control program: a. To prevent and control COPD through behaviour and life style changes. b. To provide early diagnosis and management of COPD. c. To build capacity at various levels of health care for prevention, diagnosis and treatment of COPD. d. To train human resource within the public health setup viz doctors, paramedics and nursing staff to manage COPD and e. To establish and develop capacity for rehabilitative care. Components of COPD control program Community Awareness through IEC about smoking, biomass fuel exposure and its association with COPD for early detection and initiation of treatment. Capacity building of PHC for early diagnosis of mild to moderate of COPD. Appropriate referrals of severe cases to District Hospitals/ Medical Colleges. Support for: Pulse oximeter (portable) 1 and funds for consumables (batteries etc.). Training of Health Worker for prevention, early diagnosis & management and prompt referral of COPD cases. Treatment of mild to moderate of COPD cases. Training in Pulmonary Rehabilitation (breathing exercise, Yoga etc.) Referral services. IEC on cessation of smoking and use of biomass fuel exposure Capacity building of CHC for early diagnosis of mild to moderate of COPD. Appropriate referrals of severe cases to District Hospitals/ Medical Colleges. Support for: Financial assistance for Spirometry-1 Pulse oximeter Hospital model-1 Pulse oximeter (portable) - 1 Nebulizer 1 Non-invasive ventilator- 1 Miscellaneous amount for drugs, consumables (batteries etc.). Training of Health Worker for prevention, early diagnosis & management and prompt referral of COPD cases. Treatment of mild to moderate of COPD cases. Training in Pulmonary Rehabilitation (breathing exercise, Yoga etc.) Training of ECG technician in Spirometry Referral services.
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IEC on cessation of smoking and use of biomass fuel exposure Capacity building & strengthening of District Hospital: Financial assistance for Spirometry-1 Pulse oximeter Hospital model-1 Pulse oximeter (portable) - 1 Nebulizer 1 Non-invasive ventilator- 1 Invasive Ventilator - 1 Miscellaneous amount for drugs including vaccination for Pneumoccocal & Influenza, consumables (batteries etc.). Training of Doctors, Nurses & Health Worker for early diagnosis of COPD Treatment of COPD. Laboratory Investigations/ Outsourcing Pulmonary Rehabilitation (breathing exercise, Yoga etc.) IEC on cessation of smoking and use of biomass fuel exposure. Human Resource Development: Training of the various health professionals for management of COPD at the different health facilities. (District/ CHC/PHC/SC).

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4. Chronic Kidney Disease (CKD) Central to any plan to reduce the impact of NCDs is definition of the specific diseases to be targeted. The WHO plan for NCDs focuses on diabetes, cardiovascular disease (CVD) including hypertension, cancer and pulmonary disease. Although chronic kidney disease (CKD) is not currently identified as one of those targets, there is compelling evidence that CKD is not only common, harmful and treatable but also a major contributing factor to the incidence and outcomes of at least three of these diseases targeted by WHO (diabetes, hypertension and CVD). CKD strongly predisposes to hypertension and CVD; diabetes, hypertension and CVD are all major causes of CKD; and major risk factors for diabetes, hypertension and CVD (such as obesity and smoking) also cause or exacerbate CKD. In addition, among people with diabetes, hypertension, or CVD, the subset who also have CKD are at highest risk of adverse outcomes and high health care costs. Thus, CKD, diabetes and cardiovascular disease are closely associated conditions that often coexist; share common risk factors and treatments; and would benefit from a coordinated global approach to prevention and control. Justification: Prevention and management of CKS should be included as an integral part of programmes to prevent and control NCDs due to following reasons: i. CKD is common in India CKD is classified into stages 1-5, with stages 1 and 2 requiring the presence of kidney damage such as proteinuria as well as reduced GFR113.Many authors now refer to moderate, or clinically significant, CKD as stage 3 (GFR <30-59 ml/min) and 4 (GFR 15-29 ml/min) with <60 ml/min chosen as a cutoff because it represents loss of about 50% of normal renal function, although there is now ample evidence of increased risk in earlier stages114.The role of proteinuria as well as GFR measurements in assessing CKD is particularly important since people with Stage 1-2 CKD and proteinuria have worse outcomes than people with stage 3 and no proteinuria, and development of both ESRD and CVD are predicted much more accurately by proteinuria measurements than by GFR.The leading causes of CKD in India are diabetes (30%) and hypertension (20%)114. Given projected increases in the prevalence of major risk factors for CKD (diabetes, hypertension and CVD), the prevalence of CKD in developing countries is expected to dramatically increase over the next two decades. ii. CKD is harmful and expensive to manage It is now well established that only a small minority of people with CKD will develop ESRD, due to the competing risk of accelerated atherosclerosis. A much greater problem is now welldocumented 8-10 fold increase in CVD mortality in CKD populations, thus strongly linking CKD to cardiovascular disease (CVD), the second and largest target in the WHO Plan13, 115.

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Further, the most obvious societal effect of CKD is the enormous financial cost and loss of productivity associated with ESRD. It is also well known that CKD is associated with extremely high morbidity and mortality even in its earlier stages116. Mortality for ESRD patients is 10 to 100 times greater than in age-matched controls with normal kidney function. This situation is even worse in India as ESRD constitutes a death sentence since RRT is often unavailable or unaffordable. Nearly 1 million people die with ESRD each year in developing nations117. At the individual level, CKD affects all facets of health; physical (increased burden of CVD morbidity & mortality) and social (low quality of life, decreased productivity and job losses, family pressures and mental disorders)118. iii. CKD is treatable In the last decades, ample evidence from clinical trials and meta-analyses have shown the efficacy of several management options for CKD to reduce risk of progression to ESRD and to lower CVD risk119. These treatments are based on the control of its established modifiable risk factors. Control of proteinuria with inhibitors of the renin-angiotensin system is highly effective for slowing the progression of diabetic and non-diabetic CKD. iv. CKD disproportionately affects the poor In addition to the well-documented relationships linking poverty with hypertension, diabetes and CVD, low socioeconomic status is also associated with CKD. Sadly, CKD already disproportionately affects the poor and the socially disadvantaged a situation that is expected to worsen over the coming decades. v. Awareness of CKD is low As with many NCDs, awareness of CKD is also low, generally <20%, even at more advanced stages. Awareness rates among those with CKD stages 3 or 4 is higher if co-morbid diagnoses of diabetes and hypertension were present, but even then they are quite low (20% and 12%, respectively). Awareness of CKD in developing nations including India is markedly lower, which probably serves as a barrier to accessing appropriate care even where available. vi. CKD dramatically increases the risk of adverse outcomes among people with other NCDs The majority of patients with CKD have diabetes, hypertension, and/or CVD120.Just as costs are highest among people with CKD superimposed on other chronic diseases, the presence of CKD (reduced eGFR or proteinuria) identifies the subset of people with diabetes, hypertension, or CVD who are at the highest risk of adverse outcomes but are least likely to receive appropriate treatment. Therefore, where resources are limited in countries like India, the presence of CKD could be used to identify people with diabetes, hypertension and/or CVD in which intervention might be most beneficial and economically attractive.

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Thus, CKD meets accepted criteria for a major public health problem121,based on the tremendous burden of death and disability that it causes, its inequitable distribution among the poor, and the existence of effective and affordable treatments that are not available to a large proportion of those affected. It is closely linked to other major NCDs recognized by WHO such as diabetes, hypertension and CVD but which independently increases the likelihood of adverse outcomes and high health care costs, suggesting that it can be used to identify the highest risk subset of patients, who may benefit most from treatment. Further, optimal management of these other NCDs may require modification when CKD is also present. The rationale for including CKD in the strategy for NCDs 1. Measuring GFR and albuminuria in populations at risk for NCDs would meaningfully enhance risk prediction 2. Measuring GFR and albuminuria in populations at risk for NCDs is practical and inexpensive 3. Targeted population-based screening for CKD using dipstick urinalysis and GFR testing appears to be cost effective 4. Identification of CKD would change management of NCDs and improve outcomes 5. Health systems of developed countries have already learned a great deal about how to identify and treat CKD 6. Health systems of developing countries are already scaling up efforts to identify and treat CKD 7. Existing efforts to raise awareness about CKD will also raise awareness of the NCD epidemic Action plan for the Future It is ironic that many government programs that reimburse the enormous cost of Renal Replacement Therapy often provide little or no incentive to conduct inexpensive early detection and prevention programs that have the potential to reduce those costs in the future. There is strong evidence supporting the detection and treatment of CKD as a key component of the NCD strategy. The major benefits will occur in individuals at high risk and in developing countries like India. Simple and inexpensive measurements of GFR and proteinuria can be used for casefinding, especially in high-risk populations including people over 55 and those with diabetes, hypertension, cardiovascular disease and a family history of kidney disease. Inexpensive, costeffective interventions are available to treat individuals found to have CKD, to target reductions in proteinuria, and to control traditional CVD risk factors. Such interventions will reduce the risk of both ESRD and CVD. The general steps necessary to accomplish these goals are outlined in the WHO 2008-2013 Action Plan for the Prevention and Control of Non-communicable Diseases. Initiatives to optimize early detection and prevention of CKD should be included in such plans if their impact

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is to be fully realized. Doing so will reduce the burden of ESRD and early mortality in CKD patients and thereby improve health to the maximum extent possible. Objectives & Strategies Based on experience of existing programme and WHO guidelines, the programme will focus on following four areas: 1. Assessing the magnitude of CKD in India 2. Increasing awareness about CKD 3. Screening for CKD in high risk population and its management 4. Increasing dialysis facilities for patients of ESRD The objectives of the programme are: 1. To establish the database of CKD in India 2. To promote screening for CKD in high risk population 3. To assess the impact of management on CKD progression, morbidity and mortality 4. To compare the effect of generic drugs with branded on retardation of CKD progression 5. To establish the database of dialysis facilities in India 6. To train required manpower for dialysis facilities in India 7. To establish newer standalone dialysis facilities in India 8. To standardize the dialysis care in India 9. To monitor and audit CKD care and dialysis facilities in India Following strategies would be adopted:1. Assessing the magnitude of CKD in India 2. Enhancing the CKD awareness in community 3. Increasing the CKD screening through change in attitude and approach 4. Building up human resource - Training of required manpower for screening of CKD in high risk and dialysis program 5. Assessing the impact of CKD on other NCDs Activities National and regional workshops on issue of CKD and its prevention along with dialysis would be carried out with purpose of advocacy in community. Steps would be taken to make provision for diagnostic tests at affordable and subsidized cost to CKD patients in the public sector health care delivery system. Financial assistance for drugs including erythropoietin has also been kept separately. Rastriya Aroygya Nidhi (RAN) would be modified to make provision for dialysis in private centres and financial assistance on regular basis. A CKD registry would be initiated. Collaboration with National Board of Examinations & IGNOU would be done for various training programs. Training would be required in the field of dialysis.
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Main activities under the programme are given below: 1. Developing IEC material and organize information campaign for CKD and dialysis 2. Screening for CKD in high risk groups like diabetes, hypertension, patients with family history of kidney disease, persons above 65 years and patients presenting with complaints related to kidney diseases 3. Development of system to make available diagnostic tests and drugs free to persons with BPL category and at affordable cost to others 4. Establishing dialysis facilities in each district hospital 5. Strengthening of existing dialysisfacilities in Government sector 6. Establishing CKD registry with an aim to assess need, morbidity and mortality in CKD and impact of CKD on other NCDs 7. Developing network with organ transplant centre (level I - III) for increasing the organs transplant 8. Networking of the dialysis centers throughout country 9. Improving the standard of dialysis and auditing its delivery system to patients 10. Training dialysis physician and dialysis technician through a structured programme. 11. To undertake activities related to policy/programme correction as & when required. Components 1. Scheme for promotion of awareness for CKD 2. Financial assistance to institutions for diagnostic tests to be made available to patients with CKD and patients on dialysis 3. Financial assistance for drugs to CKD patients of various stages 4. Build up networking of hospitals at Level I-III and different dialysis unit to state and national office 5. Develop a manpower training program for dialysis physician and dialysis technician 6. CKD and dialysis surveillance system through CKD and dialysis registry Training Plan Training of personnel (Human Resource Development) is an important aspect for the success of the program. There are mainly two aspects (i) increasing the opportunities for training programs for different categories and (ii) training the existing personnel for skill in the area of dialysis.Training would be required in the field of Dialysis for the following: 1. Dialysis physician 2. Dialysis Nurse/ Technician IEC Activities Awareness is required for prevention of CKDs. Despite the 1.23 billion-population size and high incidence of ESRD, India is yet to make any major headway in the government run dialysis
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program and CKD prevention program in the country. It is necessary to improve awareness about the CKD and its prevention so that requirement of dialysis can be decreased along with decreased morbidity and mortality of patients with CKD. 1. National and district level IEC would be done through TV/Radio/Print media. Website would also be created for mass scale information about factors causing CKD, its clinical features, its impact on other NCDs and its effect on morbidity and mortality of patients. This should be part of other common NCD program. The main thrust of IEC would be to change the attitude of public about various NCDs along with CKD. Details would be worked out separately. 2. Some state level units would be asked to carry out State level IEC. Dissemination of information about CKD prevention and success of dialysis would also be done. 3. Various workshops would be held all over India. An estimate amount of Rs. 5 Lakhs for each workshop is required. Rs. 50 Lakhs needs to be allocated for this purpose for first year. Promotion of Care for CKD and Dialysis Mass Media Campaign for creating awareness of CKD and approach to its prevention Engage the support of various nephrology associations, medical associations etc for making this awareness Organize discussions on TV & Radio channels Lobby with NCERT and CBSE for a small reference to CKD in the curriculum Lobby with MCI for reasonable reference to CKD in undergraduate curriculum Success stories for patients who are maintained on dialysis for years Expected Outcome 1. Awareness in public about prevention of CKD and its prevention 2. Early detection and management of CKD accessible and affordable to the public. 3. New Dialysis units established and older ones strengthened (At least some centers in each metro) 4. Rate of dialysis acceptance at least 100 pmp at the end of 12th five year plan 5. Quality of dialysis good and uniform throughout country 6. Networking of the dialysis centers 7. Training of personnel in dialysis 8. Affordable drugs for management of CKD and dialysis India with its vast population and increasing percentage of end stage organ disease (ESOD) due to high prevalence of NCDs has to adopt two-pronged strategy for management of ESOD, especially end stage kidney disease. On one hand, it should build up capacity for reduction of
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ESOD, on the other end; it should build up a system for management of ESOD. While former will need lifestyle modification, behavioral changes, improved information campaign etc. through various NCD prevention and control programs being implemented separately; later will need capacity building for renal dialysis, organ retrieval and transplantation. Deceased Organ Retrieval as well as living donors promotion is going to be main area for improving supply. More transplant centre, dialysis centre, transplant surgeons and nurse will build up the capacity of improved services. Free or subsidized diagnostic services & immunosuppressive drug supply will ensure better outcome of transplant services. India is also taking steps towards managing its population burden of diseases contributing to endstage organ failure. Despite limited budgetary support for public health, several comprehensive prevention initiatives have been implemented. Examples include the National Rural Health Mission and the National Program for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke, which is going to include CKD also. Additional initiatives include an integrated disease surveillance program, introduction of universal HBV vaccination, a tobacco law and program initiative and a national alcohol policy. Inter-sectoral health promotion efforts will also contribute to decreasing the burden of these diseases. Activity-wise physical targets for key indicators on coverage, output and outcomes
Availability of Dialysis services Free services to poor & needy Prevention of Kidney disease Early detection of kidney disease Human Resource 100 Districts or 1/6th of population 35% of population Integrated with the NPCDCS Program Integrated with the NPCDCS Program Training of Dialysis Physicians course through IGNOU; annual production 50 trainees per year Increase in the seats of DNB & DM Nephrology

Output Availability of Dialysis facilities Outcome Maintenance of patients on dialysis till transplant is done National Program for Prevention and Control of Cancer, CVD, Diabetes & Stroke is establishing vertical structure for implementation and monitoring of the NCDs. There would be National, State and District cells for administrative functions while there would be NCD clinics at District Hospitals & Community Health Centres (CHCs) for clinical functions including early detection and treatment. It would be difficult to create parallel structure for all NCDs separately and it is proposed that interventions for kidney patients would be done through these mechanisms at all levels. The allocation of budget proposed for NPCDCS appears to be sufficient and it would cater for Kidney investigations, drugs and other common interventions.
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It is recommended that Kidney should be included besides cancer, Diabetes, CVD & Stroke in the name of the program NPCDCS. Prototype of Dialysis (stand alone) centre Advisory group meetings were held to develop prototype for standalone dialysis centers. The aim is to provide long term high quality hemodialysis facility for general public (& Govt. beneficiaries) at reasonable affordable cost. A Price per Treatment (PPT) package would cover the supply of dialysis equipment and dialysis disposables for a specific clinic project. In this business model, Government does not make an outright purchase of capital equipment for a dialysis clinic and instead, Government enters into a contractual agreement to lease its capital equipment requirements to private hemodialysis provider company or patient brings his own dialysis disposables. During the contractual period, Government purchases its dialysis consumable requirements exclusively from private partner . There has to be a fixed term of payment to private partner, say every month or say 30 day. The concept is to set up a chain of dialysis centers that would have a non nephrologist dialysis trained physician present at the centre round the clock. In the US there are a large number of stand-alone dialysis centers. In India, this concept would initially be piloted in the CGHS at Delhi. Cover of a nephrologist would be provided through government run hospitals like RML Hospital, AIIMS, MAMC etc. A tie up could be made with identified agency for provision of services including equipments, manpower and consumables etc. while the responsibility of Govt. would be to provide space. This would be done in 100 districts. The patients from Below Poverty Line (30%) would be treated. There would be one standalone dialysis centre operationalised in 100 districts with private public partnership. In due course of time dialysis is envisaged up to all Distts. States would be encouraged to have dialysis facilities through decentralized National Rural Health Mission planning. The average cost of dialysis in Delhi is as follows:
Item Average cost of Dialysis Per dialysis cost for Haemo dialyser ( 600 for 4 time use) Haemodialysis fluid used in each dialysis Saline drip used in each dialysis Inj. Heparin in each dialysis Total cost of Each dialysis Cost of investigations and medicines Total cost per dialysis including investigations & medicines Cost 1000 150 200 100 50 1500 600 2100

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Till the time dialysis facilities are developed, chronic kidney patients who are below poverty line would be paid for dialysis on per case basis. Reputed large Hospital in the region would be taken on retainership basis and paid per case basis. For this purpose if 1000 dialysis per month are to be supported the expenses would be about Rs. 2100 each dialysis session x 1000 sessions per month x 12 = Rs. 2.5 Crores per year. This model would be shifted to private public partnership wherein 1000 dialysis per month per centre would be assured. Govt. would provide the land/building and everything else would be vendors responsibility. Total budget required for 12th five year plan (2012-17) would be Rs. 1350 Crores

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5. National Organ Transplant Program India with its vast population and increasing percentage of End Stage Organ Disease (ESOD) due to high prevalence of NCDs has to adopt two-pronged strategy for management of ESOD, especially End Stage Renal Disease (ESRD). On one hand, it should build up capacity for reduction of ESOD, on the other end, it should build up a system for management of ESOD. While former will need lifestyle modification, behavioral changes, improved information campaign and pharmacological interventions etc. through various NCD prevention and control programs being implemented separately; (It is important to be aware that there is no prevention and control program for CKD as it is still not considered a NCD disease) later will need capacity building for dialysis and organ retrieval and transplantation. Deceased Organ Retrieval is going to be main area for improving supply, although living organ transplant particularly for kidney and to some extent for liver needs to be continued. More dialysis centres and its staff, transplant centre with transplant surgeons and nurses will build up the capacity of improved services. Free or subsidized diagnostic services & immuno-suppressive drug supply for the poor and needy will ensure better compliance and outcome of transplant services. Strategies for implementation 1. Based on experiences of existing program and/or WHO guidelines, there would be three main areas of the proposed National Organ Transplant Program (NOTP): 2. Increasing the availability of organs from cadaver donors 3. Capacity building for retrieval of organs and transplantation 4. Post-transplant services to transplant recipients and living donors Strategies: Enhancing the facilities for organ transplantation throughout India Establishing network for equitable distribution of retrieved deceased organs. Increasing the organ availability through change in attitude and facilitating the retrieval of deceased organs. Building up human resource - Training of required manpower i.e. transplant surgeon, nephrologist, dialysis physician, transplant coordinators & others. Acceptable incentives & facilities to the transplant donors and recipient on follow up. Objectives: To organize a system of organ procurement & distribution for deserving cases for transplantation. To promote deceased organ donation. To train required manpower. To establish new transplant facilities & strengthen existing units. To protect vulnerable poor from organ trafficking.

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To monitor organ transplant services and bring about policy and programme corrections/ changes whenever needed.

Activity-wise physical targets for key indicators on coverage, output and outcomes There would be apex national autonomous organization National Organ Procurement & Distribution Organisation (NOPDO) at the centre. There would be ten regional autonomous organizations State Organ Procurement & Distribution Organisation (SOPDO) governed and assisted by NOPDO. Each SOPDO will have a zonal units (as required depending on population and load) which will be responsible for specific activity in the zone. Each zonal unit would look after few hospitals in their respective jurisdiction for organ retrieval/transplantation. Operation of each SOPDO will remain confined to one states or UT in current five year plan. They will look after dialysis, organ retrieval & transplantation within the zone. One new transplant centre would be established and one would be strengthened in Govt./Pvt. NGO sector based on Govt. recommendation. An organ transplant registry would be initiated. Collaboration with National Board of Examinations & IGNOU would be done for various training programs. Training would be required in the field of transplantation & Dialysis. Co-ordination is required from other ministries e.g. surface transport, Govt. and private airlines, IT Ministry, Govt. reimbursement schemes, insurance etc. A co-ordination committee could be formed to look into the actions and co-operation required from various ministries and departments. National and regional workshops on issue of organ transplantation would be carried out with purpose of advocacy at all levels for various stakeholders. Certificate of recognition to the donors will be given by the transplant centre on behalf of the appropriate authority. Steps would be taken to make provision for diagnostic tests at affordable and subsidized cost to the transplant recipients and donors patients in the public sector health care delivery system. Free annual health check to living donor & free treatment of all donor related complications would be promoted. Rashtriya Arogya Nidhi (RAN) would be modified to make provision for transplantation in private centres and financial assistance on year to year basis. Financial assistance for immunosuppressant drugs has also been kept separately which would benefit about 5000 patients every year @ Rs. 1 Lakh/yr. Medical Insurance for the donors may be funded by the recipient. Activities: 1. Developing IEC material and organize information campaign for organ donation (deceased donation) & also on preventing organ trafficking.

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2. Development of organ procurement & distribution system through State located empowered

3.

4. 5. 6. 7. 8.

9.

10. 11. 12.

functionally independent State Organ Procurement & Distribution Organization (SOPDO), which are autonomous in functioning. Development of organ retrieval teams in each SOPDO, which should be empowered legally, logistically financially for organ retrieval, safe storage, transport and report availability to SOPDO. Establishing 10new facilities for Kidney & 2 new for liver Transplantation in Govt./Pvt. sector. Strengthening of 10 existing kidney & 2 existing liver transplantation facilities in Govt./Pvt. sector. Developing network with trauma care centre (level I - III) for increasing the organs procurement. Networking of the transplant centers for organ sharing. Training retrieval team members, transplant surgeon, dialysis physician, nurse, grief counselor, coordinator and dialysis technician through a structured programme. Leading centres e.g. Sir Ganga Ram Hospital, I P Apollo and Medanta Medicity etc. to be involved in training program. Establishment of the umbrella National Organ Procurement & Distribution Organisation (NOPDO) within Dte.G.H.S. Initially for co-coordinating with SOPDOs. Later it would be autonomous organization. To undertake activities related to policy/programme correction as & when required. To start scheme for promoting/facilitating deceased donation & protecting donors/transplant surgeons. To organize an organ transplantation surveillance system through registry.

Geographic criteria of cadaver organ allocation The organ donation criteria follow a system in which priorities are decided as follows: 1 Emergency 2 Hospital 3 City 4 Region 5 Area 6 General turn Co-ordination mechanism National Coordination - Central Administration Regional Coordination Local coordination Hospital coordination
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Professionals (a) Kidney transplant (b) Heart transplant (c) Lung transplant (d) Liver transplant (e) Pancreas (f) Cornea (g) Other organs / tissues such as small bowel Transplant coordinators Other stakeholders (a) Social Agents (b) Mass media print & tele (c) Patient Associations (d) Religious institutions (e) Judges/Lawyers (f) Other institutions (g) Corporate houses / Industry (CSR- corporate social responsibility) General Population Components of NOTP 1. Build up structure (prototype) of NOPDO/ SOPDO/organ retrieval team / renal transplant unit/- Network with ICU of level I & II trauma centre, & transplant centre/ stand-alone renal dialysis unit. 2. Develop a manpower training program for NOTP, consisting of training of a dialysis physician, transplant surgeon (kidney/ Liver/ Heart etc.), Anesthetist, Intensivist, transplant histopathologist, transplant nurse, transplant co-coordinator (both donor & recipient), organ retrieval team, staff of NOPDO & SOPDO. 3. Financial assistance to institutions for infrastructure including machinery & equipment for development of transplant facilities would be provided through SOPDOs. 4. Financial assistance to patients for maintenance therapy of immunosuppressive drugs. 5. Scheme for promotion of organ donation/ protecting donors health/ protecting transplant surgeon/protecting vulnerable poor. 6. Protecting the rightful interests of the personnel (Health care workers) lawfully involved in the Transplant activities (as per THOA) 7. Organ transplant surveillance system through registry. Component Details National Organ Procurement & Distribution Organisation (NOPDO)
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Function: National Organ Procurement & Distribution Organisation (NOPDO) would function as apex centre for the all India activities in organ procurement and transplantation. It would be governed by Governing Body at Centre. It would lay down policy guidelines and protocols for various functions. The data from SOPDO would be compiled and published. The allocation of organs would be confined to areas/ States under respective SOPDO. Manpower: A chief Executive Officer (CEO) would head the NOPDO along with Biomaterial centre (Tissue bank). CEO would be assisted by 2 SAG level officers separately for NOPDO & Tissue Bank. There would be 6 contractual consultants (salary up to Rs 80,000 which is equivalent to junior specialist entry level salary as per 6th pay commission) (1-IEC, 1-co-ordinator & procurement, 1demand listing & distribution, 1-data management & statistics, 1 research, publication & media management, 1-finance). These consultants will have respective departments with their support staff. Staff details
1 2 3 4 5 6 7 8 9 10 Director/In-charge (full time) Deputy Director General (Technical) Joint Director (Technical) Consultant (Coordination & Procurement) Consultant (Finance) Consultant (IEC/Media) Consultant (Data management & Statistics) Consultant (Research/Publication) Consultant (Logistic Management) Data Entry Operator cum Assistants 1 1 1 1 1 1 1 1 1 10 HAG Scale SAG Scale NFSG Scale Dy. Secretary Scale -do-do-do-do-doAs per prevailing rates

Each consultant would be responsible for respective area and would be In charge of that unit. Activities: NOPDO would undertake all activities to prepare and launch various components of the programme. It would also engage consultants by outsourcing. It would have cell for kidney, liver & heart organs, dealing with policies, quality control etc. It would comprise of bio statisticians, finance & accounts, IT, media, legal consultants and Data Entry Operators. Tissue bank will be under NOPDO. NOPDO would be apex level body for the policy and guidelines, inter regional coordination, training, budget allocation, data compilation and analysis etc. There would be six divisions namely Co-ordination & Procurement, Finance, IEC/Media, Data management & Statistics, Research/Publication, demand listing & distribution. NOPDO would have advisory role related to Transplant of Human Organ Act and would not assume the regulatory role. Training would be organised in systematic manner which is explained later.
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Intensive awareness campaign w e would be car rried out to p promote dec ceased organ donation so that n o at the tim of sudde death or in brain st me en r tem dead pa atients the o organ donati is agree by ion ed relatives. Details abo IEC have been descri . out e ibed later. Organization Struct ture of NOP PDO Function ning of NOPD will be w followin organizat DO with ng tional structu ure:

SOPDO package posed progra amme will o operate throu SOPDO which wil be structu like MOP ugh O, ll ure PDO, The prop but havin a territor limitatio as predef ng rial on fined for ea SOPDO. The SOPD package will ach DO e consist of SOPDO, tr ransplant cen & retrie centre. ntre eval

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Each SOPDO will have a capacity to expand, as the programme will grow in size, & more and more transplant being done within SOPDO area. It is considered feasible to support a package of SOPDO, zonal centre & transplant/retrieval centre, one each in 10 states/UTs as identified in program. SOPDO will list monitor and distribute organs, zonal centre will coordinate retrieval team, retrieval centre & transport & transplant centre will perform transplantation. There would be autonomous organizations State Organ Procurement & Distribution Organisation (SOPDO) governed and assisted by NOPDO. Each SOPDO will have onezonal centerwhich will be responsible for specific activity in the zone. In States of bigger size, even 2-3 zonal centers will be established in next five year plan. Each zone will be bound by border of states/cities. Each zonal center would look after 1-2 hospitals in their respective jurisdiction for organ retrieval/transplantation during current plan. In next plan, number of centers for transplant & retrieval will be increased.

NOPDO
SOPDO SOPDO Z Z SOPDO SOPDO Z Z SOPDO SOPDO Z Z SOPDO SOPDO Z Z SOPDO SOPDO Z Z

= Zonal unit (one for several various hospitals)

There will beinitially 10 SOPDO (list next page) having their own territorial coverage. Each SOPDO would have its notional territorial boundary. Targets of organ procurement would be fixed population wise maximum reaching to 1 organ procurement per million populations (PPM) during current five year plan up to 2012. These targets would be flexible from region to region. Each regional centre will be autonomous, independent, fully centrally funded unit having organogram similar to NOPDO & similar staff structure. Locations The SOPDO would be located in the cities mentioned below at 10 places initially. Its coverage will be confined to Metro cities & big cities during 12th five year plan because of availability of other essential supportive services. These cities will cut across different states & UT. Operation of each SOPDO will remain confined to a state or UT in 1st phase.
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Organisational structure of SOPDO would be as follows:

1 2 3 4 5 6 7 8 Director/In-charge (full time) Joint Director (Technical) Consultant (Coordination & Procurement) Consultant (IEC/Media) Consultant (Data management & Statistics) Consultant (Research/Publication) Consultant (Logistic Management) Data Entry Operator cum Assistants4 1 1 1 1 1 1 1 10 SAG Scale NFSG Scale Dy. Secretary Scale -do-do-do-doAs per prevailing rates

Area requirement for SOPDO = 1500 sq ft. (10 rooms) There will be State governing council where Secretary (Health) will be chairman & there shall be one special invitee from NOPDO. The Governing body would be similar to NOPDO. SOPDO locations in 12th five year plan
State Jurisdiction area GNCT Delhi Maharashtra Tamil Nadu West Bengal Andhra Pradesh Gujarat Punjab, Haryana & UT Chandigarh Kerala Uttar Pradesh Karnataka SOPDO location city Delhi Mumbai Chennai Kolkata Hyderabad Ahmedabad Chandigarh Thiruvanthapuram Lucknow Bangalore

There are about 200 Kidney, 30 liver and 14 heart transplant centres in India. In case of transplant centre/retrieval centre being located in private hospital, state Govt. will be permitted to do so, but through private public partnership (PPP) mode and MOU would be signed between institutions, State Govt. & Central govt. The identification, monitoring & supervision of such private hospitals will be done by Dte.G.H.S. (centre), Director Health Services (State Govt.) and Director of private institute. Any deficiency will be reported to State health system through SOPDO. SOPDO financial aspects 2 regular officers @ Rs. 10 Lakhs per year x 2 = Rs. 20 Lakhs 5 Consultants/Manager @ Rs. 6 Lakhs per year x 5 = Rs. 30 Lakhs 6 Prog. Asstt. @ Rs. 1.8 Lakh per year x 6 = Rs. 9 lakhs Electricity/Water/POL/communications/staionary/travel/misc = Rs. 20 Lakh per yr.
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Rent Rs. 1 Lakh per month x 12 = Rs. 12 Lakhs Total Recurring cost = 20+30+9+20+12 = 91 lakh per year Zonal centre Zonal Centres would be below the level of SOPDO functioning at the identified transplant centre in the area served by SOPDO. Minimum one zonal centre would be required for coordination of retrieval, transport and transport of organs. They will network for organ procurement with retrieval, procurement and transplantation centers according to the priority indicated by SOPDO. Thus each SOPDO would have one zonal centre to begin within the current plan. Financial package for zonal centres: Cost of one zonal center is given below. Building Suggested structure with 6 rooms (Call Centre, Grief counseling room, data management room, transplant co-ordinator/ manager room, pantry, waiting area, toilet, meeting area/seminar room) Approx. area requirement = 1100 sq. feet. Layout Map design drawing enclosed. It shall be taken on rest and the cost is reflected in recurring expenditure. The institutions would modify suitable as per available space and requirements. Cost estimates
S.No. 1 2 3 4 5 6 7 8 9 10 11 12 Item Civil Work Electrical Furniture Split ACs (8 no.) Plasma Screen PA System Computers Server UPS projector, refrigerator, fax, photocopier etc Advanced life support ambulance Software/Hardware for customized video conferencing etc Total Cost (Rs. lakh) 15 5 5 5 5 5 5 3 2 2 50 10 112

Total non-recurring cost per centre (one time) = Rs. 112 Lakhs Manpower requirement: Two types of mechanism could be followed:1. Regular appointment (requires creation of post) 2. Ad hoc appointment (requires availability of vacant positions) Financial requirements of Regular/Adhoc appointment in the 1st phase are as follows:

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SNo 1 2 3 4 5 6 7

Post Director (Medical) Manager/ co-ord. Medical Officer Med. Social Worker Stenographer Data Entry Operator Driver Total

Prerevised Pay Scale 12,000-375-16,500 10,000-325-15200 8,000-275- 13,500 5,500-175-9,000 4,000-100-6,000 4,000-100-6,000 3,050- 80- 4,590

No 1 1 2 5 1 2 1 13

Monthly Pay-Rs. 65000 50,000 40,000 25,000 20,000 20,000 8,500

Total monthly pay 65000 50,000 80,000 1,25,000 20,000 40,000 20,000 4,00,000

Recurring expenditure for Manpower @ Rs. 4 Lakhs/ month (Rs. 48 lakhs per year) Electricity/Water/POL/communications/stationery/travel/misc = Rs. 10 Lakh per yr. Rent Rs. 50,000 per month x 12 = Rs. 6 Lakhs per year Recurring cost = 48+10+ 6 = 64 Lakhs per year Total expenditure = Rs. 176 Lakhs for first year & subsequently Rs. 64 Lakhs per year Technical SOPDO package Working of network To facilitate organ transplantation in safest way in shortest possible time: 1. Maintaining the waiting list of patients requiring/ needing transplants 2. Facilitating Multi organ retrieval from a Brain stem death donor. Co-ordination from procurement of organs from a donor till the transplantation into a recipient 3. Dissemination of information to all concerned hospitals, organizations and individuals 4. Creating awareness, promotion of organ donation and transplantation activities. 5. Matching of recipients with donor & organ allocation as per the designed policy. 6. Post-transplant patients & donor family (in case of live donors) follow-up of graft rejection, survival rates etc. 7. Monitoring of transplantation activities in the region and maintaining datafor assessment bank

8. To operate various schemes for organ donation, donor health check-up & safeguarding vulnerable population. 9. To assist in data management for organ transplant surveillance & organ registry. 10.Distribution of organs within region. Establishing and strengthening transplantation centres The establishment of a new transplant centres would be considered in big cities preferably in Govt. sector based on Govt. recommendation. The centers would be identified later based on the State Govt. recommendation. One new renal transplant centre would be established while
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transplant

another one would be strengthened/ upgraded in each SOPDO. (No strengthening or upgrading is proposed since liver centers are few and are comparatively new ones.) It is estimated that expenditure for strengthening/ up gradation would be about 50% of the cost required for infrastructure and equipment for a new transplant centre. However it would be based on facility survey for gap identification. The likely expenditure is as follows:New Renal & Liver Transplantation unit - Expenditure for new facility except land at each centre has been estimated as follows:Table showing the likely expenditure on transplantation units (amount in Rs. crores)
S.No. 1 2 3 4 Item Infrastructure Equipment Manpower Recurring cost Renal per unit cost 15.0 10.0 1.50 0.25 No. of units 10 + 2 10 + 2 10+2 10+2 Total cost 150 + 15 = 165 100 + 10 =110 18 3 296 Liver per unit cost 20.0 15.0 3.0 0.5 No. of units 2+2 2+2 2+2 2+2 Total cost 40+20 = 80 30+15 = 45 12 2 149

Total expenditure on transplant units = 296 + 149 = Rs. 445 crores Strengthening of existing one transplant centre will be 50% cost of the new centre. Thus in each SOPDO, one renal transplant unit would be established and one would be strengthened. Liver transplant units would be one each (new + strengthening) in north and south region. In case of private institutions, private public partnership would be done and MOU would be signed between institution, State Govt. and Central Govt. for establishing the facilities and monitoring of the same. Expenditure at each SOPDO (in Crores)
Item SOPDO Zonal Centre Total Non recurring 0 1.12 1.12 Recurring (per year) 0.91 0.64 1.55 Recurring ( 5 years) 4.55 3.2 7.75

Total expenditure SOPDO State package for 10 SOPDO7.75 x 10 = Rs. 77.5 crores Organ procurement and transplant registry This registry will be on line with similar registry maintained in other countries so that entries of registry bear global comparability besides having National & Regional relevance. It will have entries for all types of organ procurement, matching, distribution, transplantation, &complication
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on globally acceptable format. It will also maintain entries of transplant centers, transplant surgeon, dialysis physician & dialysis centre & other contributory system within national healthcare, which are directly relevant to NOTP. The National Registry will be electronically connected to its regional registries, each of which will operate independently except for National data feeding & fund sharing. Data required for Global observatory on donation and transplantation Organizational System Official body or specific organization responsible for overseeing and coordination donation and transplantation activities about organs, tissues and cells. Activities, report and funding of this organization. National Technical Committees / Advisory Boards or Ethical Committees dedicated to donation and transplantation activities. Surveillance system and reporting of adverse events in the process of transplantation, reactions and untoward consequences in organ transplant recipients. Surveillance system of donation complications in live organ donors. Registries for collection and analysis of data on donation and transplantation activities. National / provincial standards or written instructions or guidance for transplants from deceased or living donors. National training programs to harmonize practices for staff involved in organ procurement and transplantation. Legislative System Specific legislation for donation and transplantation activities. Role of the National Health Authorities in the regulation and oversight of the donation and transplantation activities, included authorization and licence for transplantation. Legal requirements for quality, efficacy and safety of the donation and transplantation procedures. Legal requirement for consent to donation from deceased and living donors. Legal requirements and restrictions for living donation. Penalties in the event of commerce with donated organs, cells and tissues. Explicit prohibition of organ trafficking in the legal framework. Distribution and allocation criteria for organs, tissues and cells. Confidentiality and traceability specified by law. Import and export of organs, cells and tissues controlled by law. Activity data Number of transplantation centres. Organ donation activity.
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Organ transplantation activity (kidney, liver, heart, lung, pancreas, small bowel, multivisceral). Donation and transplantation activity on tissues and cells.

Deceased organ donation registers by general public in their lifetime Indian Organ Donor Register would become a Register of consent, enabling individuals to record their legal decision to becoming an organ or tissue donor after death. The Register will be operational as a consent register as soon as possible. The Donor Register will ensure that consent (or objection) to donating organs and/or tissue for transplantation can be verified 24 hours a day, seven days a week by authorised medical personnel, anywhere in India. In the event of death, information about decision will be accessed from the Donor Register, and provided to family. National Transplantation Register: National data would be compilation of the State Govt. registers about the transplantation done in their respective jurisdictions. In due course of time this would be periodically updated online through software on day to day basis. DONOR INFORMATION: Basic data, BD tests, image tests, laboratory, serologies, time at CCU, medical history, clinical situation, drugs, ORGAN EVALUATION: Recovered/no (causes); implanted/no (causes) WAITING LIST Recipient characteristics: age, weight, blood group, diagnosis WL movements: Urgency, active, excluded, transplant, death OFFERS: Center, criteria, acceptance, causes no acceptance FOLLOW-UP REGISTRIES Transplantation results Analyze factors related with graft and patient survival Collaboration framework for tx teams Participation in International Registries These are required for different organs kidney, liver, heart etc. An amount of Rs. 100 crores is being kept for this purpose. This amount would be used for infrastructure, manpower, computers and software development, technical services etc. including the recurring costs in running the program. National level inter-sectoral stakeholders meetings Various stakeholders would be invited for national level inter-sectoral meetings. The stakeholders would include following:1. Surface transport 2. Railways 3. Licensing authorities
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4. 5. 6. 7. 8.

Professional associations National Board of Examination Transplant Centers Professional councils e.g. MCI etc. others

National training programs (Training of Trainers) for Transplant Surgeon (3 diff. categories)/ Transplant Coordinator/ Dialysis Physician/ Dialysis Nurse/ Technician/ Organ retrieval team/ Staff of NOPDO/ROPDO/ Rs. 10 lakh each training x 10 = Rs. 1 Crores ( non recurring) Immunosuppressant & erythropoietin supply mechanisms The cost of continuous treatment with immunosuppressive drugs is unaffordable. Steps would be taken for increasing availability of immunosuppressant drugs and erythropoietin free of cost/affordable cost (as the case may be) to transplant recipients. These steps may include reduction of excise duty, custom duty, sales tax etc. for reducing the cost. Efforts would be made to provide drugs at cheaper rates to patients through co-operatives similar to Rajasthan model or through National Rural Health Mission. Common drugs used: 1. Cyclosporine 2. Tacrolimus 3. MMF 4. Prednisolone 5. Azathioprine 6. Erythropoeitin 7. ATG 8. Simulect 9. Antifungal & antibiotics 10. Recombinant Factor VII (Novoseven) etc. 11. Immunoglobulins 12. Gancyclovir and Valagancyclovir 13. Bortozumab Common immunosuppressive protocol for organ transplant is Cyclosporine/ Tacrolimus and MMF/Azathioprine with Prednisolone. The trademarks and companies are as follows: Cyclosporine - Sandimmune (Novartis) Panimmune (Panacea biotech) Tacrolimus- Pangraf (Panacea), Vingraf (Emcure), Prograf (Astellas)
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MMF- Cellcept (Roche), Mycept (Panacea) Prednisolone common drug Azathioprin Azoran, Imuran

Individual drug costs Cyclosporine (av. 100 mg BD)- monthly cost- approx 5000-6000/ month Tacrolimus (av 2-3 mg BD) approx cost Rs 4000/ month MMF (av 1 gm BD), approx cost Rs 6000/ month Prednisolone 10 mg/day , approx cost Rs 100/month Azathioprine- 100 mg/day , approx cost Rs 500/ mont Regimen costs Standard CyA +MMF +Prednisolone = Rs 10- 12,000/ month Tacrolimus +MMF + Prednisolone = Rs 10-12,000/month CyA/Tacro + Azathioprine + Prednisolone = Rs Rs 5000-6000/month First year expense with drugs is Rs 1.5 to 2 lakh (live unrelated donors) with related donors; the cost is Rs 50,000 less. In subsequent years, the cost is approx Rs 1 lakh per year. Duration of immunosuppressive therapy In renal transplant drugs are used as long as graft is functioning- life long till graft lasts (average 8-10 years) List of brand names and manufacturers are annexed. For the promotion of generic immunosuppressant & erythropoietin, private public partnership (PPP) would be evolved. Discussions have been held with three major suppliers of these drugs. They informed that they are supplying drugs to Govt. institutions at about 72% of MRP rates since 28 % expenses (of MRP) are incurred for distribution and retail. Suggestions received included adoption of patients by companies and provision of drugs at cheaper rates to the deserving patients who cannot afford the treatment. Such patients could be certified by Govt. institutions or doctors. Discussion with companies revealed that it is not possible to reduce the price of common immunosuppressant drugs and erythropoietin in general. Custom duty could be reduced in case of bulk imports and finished products and companies would pass on the benefit to the consumer. They have also suggested reducing the VAT, excise duty and sales tax and similarly the benefit would be passed on. Companies would provide the details about what is possible from their side. The modalities would be worked out in due course of time based on the details from the companies concerned. We may keep provision for financial assistance to 5000 needy and poor patients (out of expected 30,000 transplant cases) every year for immunosuppressant therapy. An amount of about
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Rs.10,000 is spent on average by a patient every month on immunosuppressant therapy. Rs. 1.2 lakh per patient per year would be required. For 5000 patients for 2 years period of five year plan the requirement would be @Rs. 1.2 Lakh x 2 year x 5000 = Rs. 120 Crore. It is envisaged that other patients would manage the expenses through insurance or their own sources besides various Govt. schemes. Rashtriya Arogya Nidhi (RAN) would be modified to make provision for transplantation in private centres. Patients on regular dialysis or on continuous medication with immunosuppressant should be provided yearly financial assistance rather than one year as existing at present. At present the grant for kidney transplant for supporting 3 months of dialysis + Donor workup + Expenditure for renal transplant procedure + one year immunosuppression cost. is given. The efforts would be made to enhance the grant as well as provide financial assistance on regular basis for follow up medication etc. Training Plan Training of personnel (Human Resource Development) is most important aspect for the success of the program. There are mainly two aspects (i) increasing the opportunities for basic training programs for different categories and (ii) training the existing personnel for skill in the area of transplantation in various categories. Training would be required in the field of transplantation & Dialysis for the following: Year-wise break up of no. of trainees and cost of various training programs
S. No. Training OPDO/SOPDO directors Transplant Surgeons Tr. Co-ord. Transplant physicians Nurse Pathologist/Immunologist Anesthesiologists, intensivist, radiologist etc. Total Trainees No. 15 40 400 200 500 50 50 Total Cost (Rs. crore) 2.0 3.0 5.0 10.0 10.0 2.5 2.5 35.0

Promotion & care of organ donation Awareness is required for prevention of NCDs, legal provisions of THOA & organ donation. Despite the one billion-population size and a high accident rate, India is yet to make any major headway in the harvesting of human organs. It is generally perceived that social and cultural factors inhibit people from donating their organs or those of their loved ones who have tragically predeceased them. Religious considerations and the Hindu belief in re-birth minus the missing organs are also contributing factors that come in the way of a robust organ donation programme

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in the country. To dispel these misconceptions, it is necessary to improve awareness about the donation of human organs and thereafter to motivate people to donate organs. Mass Media Campaign for creating awareness about organ donation so that the general public is made aware that human organs can be donated to save lives. This campaign would be sustained from time to time. Engage celebrities to promote organ donation. This would encourage people to be inspired to emulate such celebrities Engage the support of religious sects/leaders. Sects like the Radha Swamis of Beas (Punjab) are supporting organ donation actively. Ask TV & Radio channels to organize discussions free of cost and to show TV serial regarding the success of organ donation and transplantation. Lobby with NCERT and CBSE for a small reference to organ donation in the curriculum Awareness about Legal Provisions people should be aware of the law on donation of organs and the penalties for illegal transactions FAQs : e.g. who can donate, location of authorized transplant centers etc. Financial aspects for promoting organ donation i. Rashtriya Arogya Nidhi (RAN) would be modified to make provision for transplantation in private centres. Patients on regular dialysis or on continuous medication with immunosuppressant should be provided yearly financial assistance rather than one year as existing at present. At present the grant for kidney transplant is 1.8 lakhs and Rs. 10,000 for first year only is given. The efforts would be made to enhance the grant as well as provide financial assistance on regular basis for follow up medication etc.. ii. Incentives to Live Donors and the next of kin of deceased donors. iii. Medical Insurance for the donors may be funded by the recipient iv. Enhance insurance cover to 10-12 lakhs for a common man. IEC/Media Campaign 1. NOPDO/National level IEC would be done through TV/Radio/Print media. Website would also be created for mass scale information about rights, benefit, legal protection of donors besides functioning of NOPDO. An amount of Rs. 5 Crores every year would be required for National level IEC. For two years the requirement would be Rs. 10 Crores. The main thrust of IEC would be to change the attitude of public about deceased organ donation. Details would be worked out separately. 2. Ten SOPDO units would be asked to carry out State level IEC. Dissemination of positive information about organ donation, organ retrieval & transplantation, various legal requirements before donation or retrieval, & penalty & punishment for agents involved in forced/illegal retrieval & transplantation would also be done. An amount of Rs. 10 crore per SOPDO would be required. 10 SOPDOs would require Rs. 100 Crore for two years. For this purpose media plan would be made by professional agencies e.g.
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NICEF etc. SOPDO will hire the agency for this purpose and approve the same at their level. Focus campaign would be carried out in respective States through organized media. 3. Ten Advocacy workshops would be held all over India. An estimate amount of Rs. 5 lakhs for each workshop is required. Rs. 50 lakhs needs to be allocated for this purpose. Item wise details Cost of making 5 TV spots in 10 regional languages = apprx. Rs. 50 lakhs Cost of TV broadcasting 5 spots/week at 10 locations= apprx. Rs. 10 crores Development of 5 radio messages at 10 locations = apprx. Rs. 1 lakhs Cost of Radio broadcasting 5 spots/week at 10 locations=apprx. Rs. 1 crores 24 advertisements in newspapers in 15 languages in a year= apprx. 10 Crores Personal contact program Specific programs Organ pledging Brain stem death declaration Organ retrieval/organ transplantation/organ trafficking/Incentive schemes Total amount required for IEC is Rs. 110 Crores Establishment of a Biomaterial Center for advance tissue banking India is having good number of such bone banks/tissue banks which are operating in different states for 5 to 10 years. Even in Delhi there are bone banks in All India Institute of Medical Sciences and Sir Ganga Ram Hospital. There are similar bone banks in Chennai, Mumbai and Andhra Pradesh. There are large number of Eye Banks which are developed both under private and government sector in different cities under National Programme for Control of Blindness. Therefore, this is the right time for India to go for establishment of a National Biomaterial Center. Moreover, tissues are included in THOA also. This center will take care of following tissue allografts i. Bone and bone products e.g. deep frozen bone allograft, freeze dried bone allograft, dowel allograft, AAA Bone, Duramater, facialata, fresh frozen human amniotic membrane, high temperature treated board cadaveric joints like knees, hips and shoulders, cadaveric cranium bone graft, loose bone fragment, different types of bovine allograft, used in orthodontics ii. skin graft iii. Cornea iv. Heart valves v. vessels This is a highly technical body, which is to be headed by a Medical Specialist preferably having degree of orthopedics and experience in the field of bone banking, sterilization, storage and distribution. The structure of this organization is as follows:
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There would be four divisions of the ITBBMC as follows:1. Bone bank 2. Cornea bank 3. Heart valve Bank 4. Skin Bank The administrative structure would be common while the technical processing and supply mechanism would be separate. Staffing of a Biomaterial Center There will be one HAG, one SAG level medical officer along with 30 other officials including scientists / technicians. There would be four sub divisions in scientific wing which would work for respective banks namely Bone, Heart Valves, Cornea, Skin banks. Overall administrative structure would be common while the laboratories setup would be different for each of the different units of tissues. Budget The budgetary requirements have been estimated for the three year remaining period of year 2009-12 in the 11th five year plan. Further details would be firmed up after the approval is received and money is allocated for this purpose. (a) Construction cost for two stories (floors) building with 1500 sq. meter area. The estimated cost would be Rs. 250 Crore (b) Cost of salary of staff: Initially key staff would be taken while most of the staff would be required in the third year when the bank would be fully functional. Class IV staff would be either contractual or outsourced. The year-wise details are given in the table below.

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Table showing manpower requirement and expenditure

S.No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Post Executive Director (HAG) Advisor (SAG level) Director (Admn,) Senior Manager Technical Officers Store Manager Sr. Accounts Officer Coordinators Lab Technician PRO Store Keeper Clerks/D.E.O. Attendants Driver Class IV Total Revised Pay Scale (Rs.) 67000- 79000 Pay band 4 (Rs 3920067000) Grade pay 10000 Pay band 4 (Rs 3920067000) Grade pay 8700 Pay Band 3 (15600-39100) Grade pay 7600 Pay Band 3 (15600-39100) Grade pay 7600 Pay Band 3 (15600-39100) Grade pay 6600 Pay Band 3 (15600-39100) Grade pay 6600 Pay Band 3 (15600-39100) Grade pay 5400 Pay band 2 (8700 34800) Grade Pay 5400 Pay band 2 (8700 34800) Grade Pay 5400 Pay band 2 (8700 34800) Grade Pay 5400 Pay band 2 (8700 34800) Grade Pay 4200 Pay band 2 (8700 34800) Grade Pay 4200 Pay band 2 (8700 34800) Grade Pay 4200 Outsourced/hired No. 1 1 1 1 4 2 1 4 4 1 2 3 6 1 2 34 Monthly Pay (Rs.) 130000 120000 90000 60000 60000 55000 55000 50000 25000 25000 25000 20000 20000 20000 10000 Total monthly Pay (Rs.) 130000 120000 90,000 60000 240000 55000 55000 200000 100000 25000 50000 60000 60000 60000 20000 13,20,000

Yearly salary = Rs. 13.2 lakh x 12 months = Rs. 1.58 crores per year For three years = Rs. 1.58 Crores x 2 years = Rs. 3.16 Crores (c) Consumables: Consumables like chemicals, reagents, gloves, storage envelopes, labels, gases, soaps and detergents etc. would be required as per need. The estimated cost of consumables is about Rs. 1 Crores for 2 years.
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(d) Contingency: There could be unforeseen expenditure which has not been envisaged this time. Therefore an amount of Rs. 1 Crores is being kept for contingency. (e) Overhead (Electricity / Water): Electricity would be required for lighting, refrigeration, airconditioning etc. An amount of Rs. 0.5 Crores is proposed for overheads for 2 years. (f) Research: This is research intensive field. New types and shapes of grafts could be used. Newer modalities can be tried in tissue grafting. An amount of Rs. 5 crores is being kept for research studies. (g) Training: An amount of Rs. 1 crore can be kept for training of various health personnel in India and abroad. (h) Irradiation/Storage/Transport of Tissue: An amount of Rs. 0.5 crore may be kept for this purpose for next two years. Irradiation would be done by outside agency for which payment would be made on per specimen basis including transportation cost. (i) Quality control: An amount of Rs. 0.5 crore may kept for quality control including development of guidelines, manuals and inspections etc. Component-wise expenditure (Biomaterial Centre)
Component Construction Staff Equipments Consumables Contingency Overheads Research Training Irradiation Quality control Total Total (Rs. crore) 250 25 100 25 25 25 20 10 10 10 500

An amount of Rs. 500 Crores would be required in 12th five year plan. Bio-vigilance, tracking safety & quality assurance of Tissue Transplantation It involves the process of donation, verification, procurement, processing, preservation, storage, distribution, and application of Tissues and Cells Register of authorised centres Minimum standards of quality and safety Qualification and training Inspections and sanctions Imports / Exports
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Supervision of human tissue and cell procurement Accreditation, designation, authorization or licensing of Tissue and cell preparation process Inspections and control measures Traceability Import/ Export Register and reporting obligations Notification Donor Selection and evaluation Principles governing tissue and cell donation Consent Data protection and confidentiality Selection, evaluation and procurement Provisions on the quality and safety Quality Management Responsible Person Personnel Tissue and cell reception Tissue and cell processing Tissue and cell storage conditions Labelling, documentation and packaging Distribution Relations with 3rd parties

Exchange of information, reports and penalties Coding of information Reports Penalties Consultation of Committees Technical requirements and their adaptation to scientific and technical progress Consultation of one or more scientific committees Final provisions Transposition Annex on information to be provided on the donation cells and /or tissues

There are several actions required for bio vigilance, tracking, safety and quality assusrance regarding tissue which becomes obligatory after THOA amendment bill is passed as well as international commitments. An amount of Rs. 50 crores is being kept for this purpose. This amount would be required for various activities including infrastructure, manpower, networking software and hardware etc. including the running expenses.
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SWAP living donor organ program 1. SWAP or paired donation (exchange of donor organs between two recipient families) is alternative to solve the scarcity of cadaveric donors. 2. Decrease the number of patients in the waiting list for renal and liver transplants. SWAP would be permissible after the THOA amendment bill 2009 is passed by Parliament. Any two or more pairs with their own legally permissible donors (related or emotionally related donors with approval of authorisation committee) can cross exchange their pairs for organ donation. If this is not possible between 2 pairs then it could be between many more such pairs. In this regard, paired donation registries have to be maintained.

An amount of Rs. 10 crore is being kept for this purpose Expected Outcomes 1. Public awareness about prevention of NCDs, legal provisions of THOA & organ donation 2. Early detection and management of NCDs accessible and affordable to the public. 3. New organ Transplantation units established and older ones strengthened. 4. THOA Act and Rules changed for facilitation organ donation, registration of organ retrieval centres, clear cut procedures and policies for various processes regarding organ transplantation 5. Networking of the centers for organ sharing established 6. Training of personnel in transplantation and Dialysis done 7. Dialysis facilities established at 10 centers in the metros and major cities. 8. Rules & Regulations for tissues and cells made 9. Recognition and incentives to the donors operationalised 10. Affordable Immuno-suppressive therapies. 11. Establishment of the NOTP Head Quarter and Governing body 12. Rate of organ transplantation increased from 0.4 pmp to 2 pmp in 5 year time.

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6. NATIONAL MENTAL HEALTH PROGRAM Vision To provide basic and comprehensive mental health care at all levels. Mission 1. Integration of Mental Health services with general health 2. Improving availability of mental health manpower 3. Promotion of community participation in service delivery 4. De-stigmatization of mental disorders though awareness generation 5. Strengthening of preventive psychology Introduction to 12th plan The 12th FYP will envisage strengtheningof 11th Mental Health plan with expansion and few modificationsin existing components. On Contrary to the 11th plan, current plan will focus on functional and service delivery aspects of NMHP then infrastructural aspects. The plan has been build up from the experiences gained through past plan periods. It has both carry over components with modifications and newly introduced components. The model of plan is inclusive and integrative of community health approach. New Proposed Components Public Private Partnership programme. Long term community treatment / Rehabilitation Services. Integration of NMHP Components with NRHM and NPPCD. Mental Health Services Strengthening of Under graduate courses in medical colleges Strengthening of Post graduate courses in medical colleges Help-Line and Public Information Services Mental Health Emergency Services Integration of other Neuro-sciences facilities to COEs

Carry over components of 11th FYP I. DMHP (Community out-reach programme)-The component is focus point of community mental health care has shown direct impact on service delivery.DMHP envisages to provide basic mental health care services at the community level. Since its inception during 9th plan, only 123 districts have been covered under the scheme. Steps were taken to consolidate the existing DMHPs and improving availability of mental health manpower during the 11th five year plan. As per direction of EFC, no new district was taken up under the e DMHP scheme during the 11th plan. There has been large demand from many of the states for DMHP scheme. It is proposed to expand DMHP to all the districts during the 12th FYP in a phased
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manner to cover the entire country. This would ensure uniform coverage and access to basic mental health services. Every year 123 new districts may be taken up for under DMHP. This will serve to cut down the existing loads on Tertiary care centres and will help in early recognition and treatment hence better outcome of Mental illnesses.The DMHP services are further strengthened by introducing new components, revised salaries and provision of appointing MO on contract under DMHP. Flexibility to programme will be provided by creating provision of programmeflexi-pool to carry out need based additional activities. The district hospitals will be supported to provide 10 bed inpatient facility.2 MOs and 4 Nurses will be provided to DMHP team for the purpose. The District health authorities will facilitate incorporation of mental health services to general health services at district level to help dissemination of services at grass root level. There are two main components of DMHP : 1. Service provision i.e. identification, diagnosis and treatment of mental disorders. There is provision of mental health clinic (outdoor services) and inpatient services at the district level. The district mental health clinic would provide referral support to the primary health care teams and the inpatients services would be available for patients needing acute care within the district including emergency psychiatry services. 10 beds will be made available for the same in the district level. 2. Out-Reach Component DMHP will undertake following outreach activities: a. Satellite clinics: 4 satellite clinics per month at CHCs/ PHCs by DMHP team for service delivery, supervision and support to Primary health care level. This will help in sensitisation and training of primary health care workers. b. Targeted Interventions: Life skills education & counselling in schools, College counselling services, Work place stress management, suicide prevention services will be provided at District and Sub-district level.States may propose state specific targeted interventions according to regional needs in their PIPs. 4 visits to provide Need based Targeted interventions services to CHC/PHCs e.g. suicide prevention clinics, school and college mental health services, stress management etc. c. Sensitization training of health personnel: The District mental health team will carry training activities in imparting mental health skills to health care personnel at the district level. The trained primary health care team will in turn conduct the sensitization of community leaders and members of PRIs. This will not only build the capacity of health staff in early identification and appropriate referrals of mental health disorders but will also help in de-stigmatisation of mental illnesses. Sensitization classes will be conducted by team of trainers for 2 days at CHC level by using training material standardised at central level. 1 sensitization programme will be conducted every month for 5 years until all health staff below district level gets sensitised.
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d. Awareness camps: It will be carried out in the communityfor purpose of dissemination of awareness regarding mental illnesses and related stigmathrough involvement of local PRIs, faith healers, teachers, leaders etc. Sensitization classes will be conducted by team of trainers for 2 days at CHC level by using training material standardised at central level. 1 sensitization programme will be conducted every month for 5 years until all health staff below district level gets sensitised. e. Community participation: The DMHP team will build coalitions in the district for provision and improvement of mental health services. Linkages will be developed with Self-help groups, family and caregiver groups, NGOs working in the field of mental health. The sensitization of enforcement officials for Mental Health Act regarding legal provisions will also be undertaken to ensure effective implementation. The roles and responsibility of DMHP team will also be to undertake following tasks at district and Sub district level:1. Provision of essential drugs: The availability of basic essential drugs will be ensured at the primary health centers and the stock will be checked periodically by the DMHP team during their visits for outreach activities. 2. Simple recording system: Records for registration of cases seen in the PHC and CHC (new and follow up) will be sent to DMHP at regular intervals. This will be collated at the state mental health cell and forwarded to Central Mental Health Division/CBHI. 3. Monthly reporting, monitoring and feedback The DMHP team will hold regular meetings with PHC/CHC staff to review the progress of mental health care delivery, logistics, supplies, follow up and field level activities. Regular feedback will also be provided to the primary health care doctors and staff. The meeting will also should provide opportunity to sort out logistic difficulties and issues of coordination with different stakeholders. Composition of DMHP Team is given below: Psychiatrist 1 Medical: Medical officer 2 Paramedical: Nurses 4 Psychiatric Social Worker 1 Clinical Psychologist 1 Programme Manager 1 Programme Assistant 1 Record keeper 1 DMHP Component of NMHP suffered major set-backs in previous plan periods to implement the community mental health services, in view of this additional component of Manpower
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development scheme was introduced in 11th FYP under Scheme A and B to fill up the existing gap and strengthen the community mental health services which envisage starting PG courses in mental health. However, in addition to production of man power there should be effective manpower retention policy to prevent migration of mental health professionals to western countries which has happened in past few decades. It is noted that without good retention policy achievements of programme will be futile. Manpower development scheme itself has suffered man power retention problem of experts in public sector because of following reasons Lack of new posts in state and central medical colleges/institutes/hospitals In appropriation salaries package to mental health professionals under NMHP Lack of growth opportunities in long term In order to ensure operationalisation of mental health services at district and sub district level, additional provision under PPP model i.e availing services of local private psychiatrist/ CP/ PSW/ DPN (private medical colleges/practitioner) on payment of honorarium basis (on number of cases/ fixed days OPD basis) will also be made. Annual 10% increment in remuneration of DMHP staff will also be factored in with additional provision of freedom to do private practice after duty hours to incentivise the staff and facilitating continuous and sustained availability of mental health services. New salary structure under programme
SNo. 1 2 3 4 5 6 7 8 Designation Psychiatrist Trained Medical Officer Clinical psychologist Trained Psychologist Psychiatric social worker Trained social worker Psychiatric Nurse Trained Nurse Programme Manager Programme Assistant Record Keeper State Programme Coordinator Existing Salary p.m. 50,000 30,000 30,000 18,000 30,000 18,000 25000 15,000 25,000 8,000 10,000 Proposed Salary p.m. 70,000 55,000 45,000 25,000 45,000 25,000 45,000 25,000 30,000 25,000 13,000 50,000

Salaries are subject to 10% yearly increment to all grades as per existing policy. There is provision of additional 10% increments to best performing professionals as reward and Additional Support to poor performing DMHP through flexi-pool.

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Targets Operationalising 123 districts / year. II. STRENGTHINING CMHA/SMHA There will increase funding to strengthen functional aspects of state cell and central cell. SMHA will help monitor mental health services and issues pertaining to implementation of Mental health Act and Human Rights. There is provision of appointing additional staff for secretarial and monitoring purpose. The bigger states ( more than 20 districts) will be provided with greater financial support. III. MAN-POWER DEVELOPMENT SCHEME The NMHP will continue support of funding to departments to start / expand PG courses of mental health hence, Scheme B is carried over whereas Scheme A of Man Power Development is dropped. The targets will be to expand / establish 30 PG courses in each PG departments in mental health. The financial support will be provided based on 11th plan guidelines. Trainings and Research Activities- The training will be provided to DMHP team in clinical and managerial skills to help them learn and understand common mental disorders, plans, policies and implementation of the same. Their training wills also focus on technomanagerial, supervisory and leadership skills. Trainings will be carried out every year and will include Refresher trainings of existing staff for capacity building and Standard training to new members of the team. Trainings will be standardised and will be delivered by identified centres meant for providing training and manpower development. TITs of the identified centres will be organized centrally before taking up further modular trainings. Sensitisation programme of community health workers under DMHP may be outsourced to NGOs working in mental health. The trainings will build the capacity of DMHP staff and they will also be able to train the primary health care staff in an effective manner. The support for undertaking epidemiological mental health researches to gather evidence based data from different region of the country, this will help understand regional needs and framing future plan for various parts of the country. I.E & C The component will be strengthened through increase in funding at Central and District Level. The districts may develop their state specific IEC material, nodal institutes will provide support to develop and disseminate information by forming state level IEC committee. The central level dedicated website will be introduced under DGHS to provide on hands information on mental health resources, activities, plans, policy and programmes. Extensive mass media activities will be supported at district and sub-district level. The support for TV / RADIO programmes on mental health in vernacular languages through local channels.

IV.

V.

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VI.

Monitoring & Evaluation Monitoring and Evaluation is the most important component for success of any programme. Till now the mechanism for Monitoring and Evaluation of NMHP was not properly defined. The 12th plan will envisage strict monitoring system through creation of MHIMS (mental health information monitoring system). This will be an online data monitoring system and will also facilitate bilateral communication between participating units. MHIMS is expected to bring significant improvement in the programme implementation as possibility of mid course correction based on the feedback will improve. A State level coordinator will be appointed for monitoring DMHPs and to facilitate coordination and management between different DMHPs units. He/She will ensure monthly evaluation of reports from the districts, M&E and will be helpful in solving technical problems at various levels. They will in turn coordinate with State Mental Health Authorities and state nodal officers. Periodic review of the functioning and requirements of DMHP units will be undertaken in collaboration with SMHAs. An independent evaluation of schemes under NMHP will be undertaken at the end of 12th five year plan. New Components of NMHP 12th FYP I. PPP MODEL In view of existing shortage of manpower in public sector and increase community participation PPP model will be encouraged at different levels in 12th plan. There is sufficient data to prove efficacy of PPP model. The model will be helpful in service delivery, advocacy and trainings. Guidelines will be framed to establish the model. LEVELS District level State level Country level II. AREAS OF PARTICIPATION Advocacy, local IEC, Rehab. Services and service delivery mechanism, Sensitization of Community health workers, 108 emergency services Research, IEC, Dedicated Help line

Rehabilitation Services/Long term community treatment services The Rehabilitation of treated mentally ill will be supported under the plan. Patients with Chronic debilitating Mental illness constitute about 20% of treated psychotic cases they are generally non-responders or minimal responders to treatment. They constitute sub category of wandering mentally ill persons. They require enormous support and constant supervision to carry out self care and daily activities. It poses significant burden of disease on families and carers, leading to burn-out of families / carers. This sub-group requires separate attention to maintain the continuum of care for such people. Currently there is gap between treatment and long term rehabilitation/ care services which
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consequent to homelessness and wandering mentally ill. There is virtually non existence of half way / dedicated rehabilitation homes in the country. The schemes may be set up under PPP model for supporting and establishment of day care services and rehabilitative services. SMHA will be given responsibility to monitor such facilities with service provision from DMHPs and Mental health Service component. The destitute mentally ill patients requiring long term psychiatric care will be kept under direct supervision of psychiatric social worker and psychiatric nurse. CP and psychiatrist in facilities would provide part-time services. Guidelines will be prepared to create partnership with private sector. III. Integration of NMHP components with NRHMDMHP till date is restricted to 123 Districts across the country and has limitations in terms of manpower and financial constraints. The best way of reaching out to community for providing basic mental health services is to integrate different components of NMHP with NRHM. Integration mechanism is proposed as given under :
NRHM School Health MCH/RCH Adolescent friendly clinics National Programme for Health Care of the Elderly NPPCCD IEC NMHP School mental health services (life skills training) Post partum disorders Premenstrual disorders for females& life skills trainings, stress management, suicide prevention Geriatric mental health Counsellor at the CHC level may undertake mental health counselling IEC of NRHM

IV.

Mental Health Services The new component of mental health services are included to improve service delivery by providing flexibility of choice of service delivery components according to the needs of area, these services will be delivered through medical colleges departments preferably those who have already been supported earlier under upgradetion of medical college wings component of NMHP. Two types of service delivery packages are as under:Basic Mental Health Services package- Medical colleges without mental health services will be supported to appoint mental health professionals and deliver basic mental health services on DMHP pattern.
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Advanced Basic Mental Health Services package Medical colleges with PG departments will be supported in delivery of services to reach out tribal areas, Specific population groups, Jail screenings, disaster management program and insurgency ridden areas. The component will help providing extensive exposure of community mental health to under trainee PG students. The services will be provided under supervision of faculty members. Mental Health services may be tailored and proposed through state PIPs according to reach and needs of district.The financial support of 10 Crore / year will be kept under the component and proposals will be invited from government medical colleges under the component. Flexibility to the components will be provided by creating provision of programmeflexi-pool to carry out additional activities under NMHP. V. Mental Health Help Line A country wide 24 hours dedicated help line for public to provide information on mental health resources , emergency situation and crisis management , information pertaining to destitute mentally ill patients , registration of complaints on Human Rights Violation of mentally ill and assistance on medico-legal issues. The helpline would provide enormous support in emergency situations and reduce treatment gap and generate awareness. This will also help in creating country wide data base. The helpline service will be provided in partnership with Private sector and remuneration will be done on number of case managed. 108 Emergency Ambulance Services Services of 108 Ambulance will be partnered to pick and drop acute agitated violent patients from homes / roads to nearest mental health facility for treatment. The staff of ambulance will be sensitised to restrain and control such patients with help of family(where available) or police/medical officer/staff (where not available). Ambulance staff will be sensitised to the issues related to involuntary treatment/ restrain. The terms and condition will be same as applicable to TOR signed by states. The funds for running these services will be provided through programme officer of DMHP. Up-gradation of Centre of Excellences(COEs) The COEs upgraded in 11thFYP will be further supported to provide basic Neurology and Neuro- surgical facilities, the service delivery will be through hiring human resource on contract. This will include extending infra structure and providing assistance for purchase of technical and non technical instruments. This will be help building specilaised tertiary care services and would provide referral linkages to district hospitals.

VI.

VII.

Out Come Indicators (Evaluation after End of Every Financial Year)

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Central level Programme outcome Indicators:1. Number of States with mental health policy initiative. 2. Percentage of financial contribution provided by state government on mental health. 3. Percentage of Districts taken over by State governments after completion of 5 year funding. 4. Number increase as result of Manpower Development scheme in Psychiatry 5. Number increase as result of Manpower Development scheme in Clinical Psychology 6. Number increase as result of Manpower Development scheme in Psychiatric Social Worker 7. Number increase as result of Man Power Development scheme in Diploma Psychiatric Nursing 8. Percentage utilisation of NMHP funds / year State level programme indicators :1. Number of fully functional DMHP. 2. Number of cases/year seen in OPD of Mental health Institutions 3. Bed Occupancy Rate of Mental health Institution/Hospital/Medical 4. Bed Occupancy Rate of Dept of psychiatry in medical colleges 5. Number of DMHP reviews/ years by SNOs 6. Expenditure done under various heads of DMHP/year 7. Monthly cases attended on Dedicated mental health Help line 8. Number of trainings done under DMHP/Year 9. Percentage utilisation of DMHP funds / year District Level Programme outcome Indicators 1. Number of Disability Certification granted / month 2. Number of Targeted Intervention activities done per district / month 3. Number of IEC activities at District Level /month 4. Number of OPD Cases registered in district hospital/month 5. Bed occupancy rates/month in district hospital 6. Number of referrals made to tertiary care centres/month 7. Number of cases brought to District hospital through 108 Emergency Ambulances 8. Percentage utilisation of DMHP funds / year 9. Number of Post vacant under DMHP

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7. National Iodine Deficiency Disorders Control Program Under the 12th Five Year Plan new initiatives stated in 2011-12 have been included to ensure that 100% population consumes adequately iodated salt at the household level which is very low at present in comparison to neighboring countries as per WHO/UNICEF report. Program Goal The following goals of National Iodine Deficiency Disorders Control Programme (NIDDCP) taking into account the MDG for the 12th Plan are proposed: To bring down prevalence of IDD below 5% in the entire country by 2017 AD. To ensure 100% consumption of adequately iodated salt (15 PPM) at the household level. Activities &components of NIDDCP 1. IDD Surveys : It is proposed to continue the existing IDD survey amount of financial assistance to the states and UTs Rs 1.00 lakh per district during the 12th Plan in view of the increase in the cost of Petrol/Diesel and other activities. Hence, it is estimated that an amount of Rs 643 lakh will be required during the entire Five Year Plan period for one time IDD survey/resurvey of 643 district of the country. 2. Establishment of IDD Control Cells For the effective implementation of NIDDCP, it essential for the State Governments to ensure that the IDD Control Cell is fully established with one Technical Officer(IDD), one Statistical Assistant and one LDC-cum-Data Entry Operator to implement and monitor various components of NIDDCP such as Surveys/Resurveys, monitoring the quality of iodated salt and health education. The estimated funds requirement for IDD control cell @ Rs.12 lakh per State/UT will be 12x35=Rs.360 lakh per annum. For five years, Rs. 16 crore will be required. 3. Establishment of IDD Monitoring labs Establishment of IDD Monitoring labs with one Laboratory Technician and one Lab Asstt. @ Rs 7 lakh per lab for existing 35 States/UTs. The estimated funds required is Rs.245 lakhs per annum. For 12th Plan period the estimated amount will be Rs. 245 x 5 = Rs.1225 lakh. 4. Training Programme So far DTe.GHS has been conducting training programme in the management of NIDDCP for the State level Programme Officers/Technical Officer as well as in the management of IDD monitoring Labs for the Lab Technicians at the State level through WHO funds. In the 12th Plan it is proposed to include the training component under NIDDCP for district level functionaries as the salt being tested by ASHA at the household level. An amount of Rs.1 lakh for district level training of medical and paramedicals is proposed. Amount required will be Rs. 6.43 crore.
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5. Production and Distribution of Iodated Salt The Annual production of iodated salt has almost reached the target of 55 lakh MT during 200910. It is proposed to strengthen the labs during the 11thPlan period and continue the sanctioned posts of technical and other staff under the programme. A provision of Rs 15 crores @ Rs.3.0 crore per annum has been proposed in the 12thPlan for quality control of iodated salt production level under Salt Commissioner. 6. Health Education and Publicity Health Education activities under NIDDCP have been intensified in association with the Song and Drama Division, Directorate of Field Publicity, DAVP, Railwasy reservation ticket and the All India Radio to promote the consumption of iodated salt in the remote and backward areas, besides, telecast of IDD spots through Doordarshan, Prasar Bharati. It is proposed that during the 12th Five year Plan period besides the above organizations IEC activities will also be carried out through the Private TV Channels. An amount of Rs.20,000 lakh for five year Plan @ Rs.4000 lakh per annum at the Central level is proposed. 7. Qualitative iodated salt testing at the community level for creating awareness A Salt testing kit(STK) to show the presence of iodine in iodated salt has been development as an effective tool for creating awareness and monitoring of iodine content of salt among the community. In order to insure 100% consumption of iodated salt at the community, it is proposed to distribute about 12 salt testing kits to each ASHA/ AWW/Health worker at the community level. The number of ASHA in the country is about 8.4 lakh. The cost of one Salt Testing Kit is about Rs.12/-. The approximate cost for the procurement of STK @ Rs.1200 lakh per annum will be Rs.60,00 lakh for the 12th Plan period. 8. Incentive to ASHA for Community Level Awareness of Iodated Salt: For creating awareness and sustainable demand of adequately iodated salt at the household in the community and its regular monthly monitoring, an amount of Rs.25 per month to each ASHA for testing of 50 salt samples per month is proposed. An amount of Rs.300 per ASHA per annum is required. Rs. 126 crore will be required for this purpose during the 12th Plan. 9. Strengthening of Central IDD Control Cell 1. For the effective implementation of NIDDCP and regular monitoring of the programme in States/UTs, it is essential to review the post of Technical Asstt. (IDD), Investigator (IDD), Field Assistant IDD etc. The post of consultant (IDD), Programme Assistant(IDD), Data Prosessing Assistant on consolidated salary of Rs.50,000/- P. M., Rs.25,000/ P. M., Rs.20,000/- P. M. respectively are to be continued during 12th Plan. 2. To upgrade the post of Adviser (Nutrition), National Programme Officer of NIDDCP to
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SAG Grade and that of RO(IDD) to Group A with Grade pay Rs.5400. 3. To create one post of DADG, Group A (Micronutrient Malnutrition) with the Grade Pay of Rs.6600/- for monitoring quality control of iodated salt, implementation, IEC and surveys etc. of NIDDCP. 10. Health Education and Publicity by the State/UTs Health Directorate An amount of Rs.1,00,000/- per district is proposed for Health Education and Publicity including celebration of Global IDD Prevention Day on 21st October every year. Thus amount required will be Rs.1,00,000 x 643 x 5 = Rs.3215 lakh. Evaluation of the Performance The National Iodine Deficiency Disorders Control Programme (NIDDCP) was evaluated by the National Institute of Health & F.W., New Delhi during 2007-08. The Directorate General of Health Services, State Health Directorate, Health Institutions, Indian Council of Medical Research have conducted district level IDD Survey in the various parts of the country and reported significant reduction in the Prevalence of IDD. The visible goiter is drastically reduced in the entire country. The consumption of iodated salt at the community level was evaluated by the National Family Health Survey, 2005-06 and indicated the consumption of adequately iodated salt at the community level was about 51% while salt having nil and inadequate iodine was about 49%. Further, the Coverage Evaluation Survey, 2009, UNICEF revealed adequately iodated salt consumption in the country was about 71% and the salt having nil and inadequate iodine was about 29%. It may be pointed out that in both the studies the consumption of adequately iodated salt is the rural population is far below in comparison to urban population. We have to focus more on rural population where the National Rural Health Mission (NRHM) has been playing a very important role and NIDDCP is under part D component of National Disease Control Programmes of NRHM. Thus, the activities carried out during 11th Plan have shown significant improvement in implementation of the NIDDCP, a 100% Centrally Assisted Programme, in the country. The proposed activities of 12th plan will further improve the nutritional iodine status of the people and prevent physical and mental retardation. This will be improving human resource development and productivity of the country. Expected Outcomes The expected outcomes of NIDDCP at the end of the 12th Five year plan are as follows: 1. Prevalence of iodine deficiency disorders in all districts is expected below 5%. 2. The Visible goiter in the country will disappear. 3. No cretin due to nutritional iodine deficiency will be borne in the country. 4. Nutritional iodine status will improve significantly to prevent physical retardation in children.
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8. National Program for Prevention and Control of Fluorosis The activities of the 11th Plan 100 districts are to be continued during the 12th Plan. The Programme will be expanded in remaining endemic districts of the country. Goal: To prevent and control Fluorosis cases in the country Activities of the 12th Plan A. Central Coordination Cell The Central Coordination Cell consists of one Consultant on consolidated pay of Rs.50,00060,000 per month and one Data Entry Operator @11,000 13,000 per month. The total expenditure for Central Coordination Cell including the travel, contingencies, etc. for a year will be about Rs.17 lakhs. District level activities: 1. Assessment of prevalence of fluorosis in endemic districts. For this, there is one Consultant at a consolidated salary of Rs.40,000-50,000 per month for the plan period. For three field staff investigator who will be appointed for the survey period of six months the amount required will be Rs.1.98 lakhs. The travel and contingencies expenditure are Rs.3.02 lakhs. Thus, for assessment of fluorosis cases in a district, an amount of Rs.11 lakhs will be required. 2. Medical Management of Fluorosis including treatment, surgery and rehabilitation for which estimated budget is Rs. 25 lakh 3. Laboratory Diagnostic facilities for Management of cases: The recurring expenditure for contractual appointment of one Lab Technician @ Rs.10,000 per month or payment of honorarium to lab technician who will do this work. The reagents cost about Rs.3.8 lakh. Thus the recurring cost of the expenditure of laboratory at districts level will be Rs.5.0 lakh. Non-recurring expenditure of laboratory which is an amount of Rs.10 lakh consist of the equipment given below is required.
Ion-meter Table Top (specific for fluoride estimation in biological fluid) Table Top Centrifuge without refrigeration Digital pH Meter Metaler Balance Mixer Incubator Pipettes/Micropipettes

4. Training of medical and paramedical personnel at district level @ Rs. 3.00 lakh 5. Health Education & Publicity at District level: Rs.2.00 lakh 6. Coordination meeting every year @Rs 2.0 lakh for each district Expected Outcome Managed and rehabilitated the fluorosis case in programme district. Capacities of laboratory testing build-up in programme districts. Health Sector manpower in Govt. set up trained in programme districts. Improved information base of public in programme districts.
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9. Oral Health Given the burden of oral diseases in our country and their impact, oral diseases need to be paid attention along with prevention and control of other non-communicable diseases under NRHM. Promotion of healthy lifestyles with respect to oral health needs to be considered. World Health Assembly in 2005 included Oral Health with other non-communicable diseases (NCDs) for health promotion & disease prevention strategies. Core strategies: 1. Promote access to improved oral healthcare 2. At PHC level, either specially trained dental hygienist or staff nurse may deliver simple preventive, interceptive and curative oral health services (like pain relief, ART, early diagnosis of oral cancer and HIV/AIDS related oral lesions and their referral) in addition to giving oral health education. 3. Strengthening existing CHCs and formulation of Indian Public Health Standards, defining personnel, equipment and management standards for oral health care provision. Supplementary strategies: 1. Promotion of public private partnerships for achieving public health goals. 2. Reorienting dental education to support rural health issue. Promote access to improved oral healthcare One of the major criticisms of oral disease preventive measures has been the isolated and compartmentalized approach adopted, essentially separating the mouth from the rest of the body. This uncoordinated approach at best leads to duplication of efforts. The WHO Global Strategy for prevention and control of non-communicable diseases and thecommon risk factor approach is a new strategy for managing prevention and control of oral diseases. The common risk factor approach recognizes that chronic non-communicable diseases such as obesity, heart disease, stroke, cancer, diabetes and oral diseases share a set of common risk factors. This approach provides a rationale for partnership working in oral and general health education through ASHA. Training of ASHA workers with respect to oral health is necessary to equip her with the necessary knowledge and skills to achieve this objective. The content, personnel involved in training and the methodology- all these issues need to be considered. Oral disease prevention methods, identification of common oral conditions, emergency care and referral can be included in induction, periodic and on-the-job training of ASHA workers. The training cascade i.e. Block Training Team (BTT), District Training Team (DTT) and State Training Team (STT) should also consist of dental personnel such as dentists posted in CHCs, district hospitals, students and staff in dental colleges and private practitioners. Training material may consist of training manual, audio-visual aids, models etc.
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The job responsibilities and compensation of ASHA workers with respect to oral health should be defined. ASHA should perform the dual responsibility of referring dental patients from village community to the CHC, as well as undertake IEC activities. Cash incentives can be provided to ASHA for referral of cases. IEC activities should be monitored through a duty roster mentioning the number of times the activity has been performed in a given time-period. IEC material can be prepared in the form of flip charts, posters and booklets in a separate workshop with resource personnel under NRHM. Strengthening existing CHCs for oral health care provision The Community Health Centres (CHCs) which constitute the secondary level of health care were designed to provide referral as well as specialist health care to the rural population. In order to combat the oral disease burden, particularly in rural areas, oral healthcare service provision is necessary at CHC level. Various national and international studies have shown that service provision at community level is a feasible strategy to overcome financial, social and other barriers to access care (references shall be provided). In order to ensure quality of services, the Indian Public Health Standards have been set up for CHCs so as to provide a yardstick to measure the services being provided there. Presently, dental care has not been included under the Assured Services to be provided in CHC under IPHS. A mention has been made of optional dental clinic in the outpatient department. There is a need for setting of IPHS standards for compulsory oral health care provision at CHC. A detailed plan for budgetary requirements, manpower, type of services to be provided at CHCs, space, infrastructure, furniture, equipments, instruments, recurring expenditures on consumable hospital supplies and dental materials needs to be formulated. Oral health care at Primary Health Centre (PHC) The Primary Health Centres (PHCs) were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. PHC is the first contact point between village community and the Medical Officer. The PHCs are established and maintained by the State Governments under the Minimum Needs Programme (MNP)/ Basic Minimum Services Programme (BMS). They are established on the basis of national norm of one PHC for every 30,000 rural population in the plains, and one PHC for every 20,000 population in hilly, tribal and backward areas for more effective coverage. There are 22,370 PHCs functioning as on March 2007 in the country, achieving an average coverage of 33,191 population per PHC. At present, a PHC is manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4 6 beds for patients. The functions of the primary health center include the 8 "essential" elements of primary health care including medical care, Maternal and Child Health (MCH) including family planning, safe water supply and basic sanitation, prevention and control of locally
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endemic diseases, collection and reporting of vital statistics, health education, National Health Programmes, referral services, training of village health workers and basic laboratory services. In addition to other health problems, the oral disease burden of this population needs to be considered. With an average prevalence of dental caries of 50% in all the age groups, approximately 15,000 people in a catchment area of a PHC would require restorations/extractions. About 45% of adults (60% of the population) i.e. 8100 persons would require oral prophylaxis. As many as 7% of the population i.e. up to 2100 people may suffer from oral premalignant and malignant lesions. Oral health care with emphasis on preventive and promotive aspects needs to be provided at PHC level. This would include oral health education, tobacco cessation counseling, oral prophylaxis, and pain relief, early identification of oral precancer/ cancer and other common oral diseases and referral. Also, a minimally invasive procedure using hand instruments Atraumatic Restorative Technique (ART) may be carried out to restore carious teeth. These services can be provided by an extended-duty dental hygienist. Till the time enough number of extended-duty hygienist can be produced, these services can be provided by trained nurses. Also, adoption of suitable number of PHCs (minimum 3) by each dental institution for carrying out oral health education and screening should be made mandatory. Existing PHCs need to be upgraded with respect to equipments and materials for carrying out the above procedures. The cost involved in making oral health care provision at PHC would include that of extended training of dental hygienists and nurses (to include health education, tobacco cessation counseling, basic pharmacology, ART), salaries of dental hygienists or nurses (as per the State rules), one-time expenditure on PHC extension/ up gradation for oral health care provision and dental equipments and recurring expenditure on consumables and maintenance. The monitoring and evaluation would include process indicators such as percentage of PHCs with dental hygienist/ trained nurse and dental equipments. Outcome indicators such as number of times IEC activity and oral prophylaxis performed in a given time-period and number of referred dental patients/ dental hygienistneed to be evaluated. This would require maintenance of records and its monthly submission to District HQ. Annual survey of oral health knowledge, attitude, practices and oral hygiene status of the catchment area would be useful impact indicators. Oral health care at Community Health Centre (CHC) The Community Health Centres (CHCs) constitute the secondary level of health care and are designed to provide referral as well as specialist health care to the rural population. CHCs are being established and maintained by the State Government under MNP/BMS programme. Each CHC covers a population of 80,000 - 1.20 lakh population (one in each community development block).
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As on March 2007, there are 4045 CHCs functioning in the country. It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. One anesthetist and one Medical Health Administrator are also employed on contractual basis. Recently, an Opthalmic surgeon has been added at CHC level. It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. Indian Public Health Standard (IPHS) have been set up to provide a yardstick to measure the services provided at CHC. As per the IPHS standards, all Assured Services as envisaged in the CHC should be available, which include routine and emergency care in Surgery, Medicine, Obstetrics and Gynaecology and Paediatrics in addition to all the National Health programmes. Unfortunately, dental care has not been included under the Assured Services to be provided at CHC. However, if the oral disease burden of the population served at CHC is considered, it is tremendous. With an average prevalence of dental caries of 50% and average DMFT of 1 in children (34% of population), 40,800 restorations would be required. With an average prevalence of dental caries of 50% and average DMFT of 3 in adults (60% of population), 2,16,000 restorations would be required.28,800 children would require preventive therapy in the form of fluoride varnish and pit and fissure sealing, if provided to children up to 9 years of age (24%). About 45% of adults (60% of the population) i.e. 32,400 persons would require oral prophylaxis. 30% of geriatric population (8% of the population) i.e. 2880 persons would require prosthetic care. As many as 7% of the population i.e. up to 8400 people may suffer from oral premalignant and malignant lesions. Therefore, there is a need to provide routine and emergency care in dental surgery at CHC level. This would include oral health education and School Health Education Programme as an outreach activity, identification of oral pre cancer/cancer and other common oral diseases, oral prophylaxis, dental extractions, biopsy of oral lesions, restorations and application of topical fluorides. 1 dental surgeon along with 1 chair-side assistant is a necessary requirement to provide the above mentioned services. Also, public-private partnership should be considered for providing removable prosthesis. The cost involved would include one-time expenditure on CHC extension and dental equipment, salaries of dentists and recurring expenditure on consumables and maintenance. The monitoring and evaluation would include process indicators such as percentage of CHCs with dentists, chair-side assistants and dental equipments. Evaluation of outcome indicators such as number of out-patients attended, dental procedures and outreach activity performed in a given time-period would require maintenance of records and monthly submission to District
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HQ.Annual surveys of oral health knowledge, attitude, practices and oral health status of the catchment area of the CHC would be useful impact indicators. IEC, Education and Training The ASHA worker covers about 1000 population and works in close coordination with ANM, AWW and other health workers. Since her primary role is to inform community, counseling on health issues, mobilization and facilitation in terms of health care delivery and distribution of essential drugs, she would be of extremely help in generation of oral health awareness, facilitation for oral health care services utilization and emergency pain relief. Therefore, the roles expected from ASHA as a part of her ongoing health promotion activities can be Instructions on oral hygiene Simple methods of prevention of oral problems Dietary counseling Counseling on tobacco Early identification and referral Infant dental care instructions Oral care for pregnant mothers Instructions during school programme on dental caries prevention Analgesics for toothache She can be empowered with the required competencies during the induction and on-job trainings. Village Health and Sanitation Committee members must be sensitized on oral health using a reference manual and short discussion so that they can declare oral health as a theme periodically during village health days etc. Oral health instructions may also be converged with HIV/AIDS, School health, adolescent health, RCH, Geriatric health and other NCD IEC activities. She must be provided with check list containing probable opportunities and starting points for discussion on oral health.ASHA must be given following items: o Reference chart o Laminated leaflets on basic details of common dental problems o Flip chart for educating the community o Larger charts for display at appropriate locations o Training manual with following contents Explaining oral cavity Common oral diseases & linkage with general health Methods to provide basic oral health care & pain relief Methods to provide oral health care at home Tips on tobacco counseling Information on tooth friendly diet and role of carbohydrates Information on Infant dental care, geriatric dental care

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Training o ASHA worker has to undergo 23 days induction training during first year and then she is updated with new skills and knowledge every year during on job trainings. o The induction training is undertaken at District Institute of Health and Family Welfare or similar training institutes by a Block Training team (BTT) comprised of ANM, AWW, Health Educators, Members of SHG and NGOs etc. The members of block training team may be empowered on oral health related training by the District Training Team (DTT). o Both BTT and DTT should be provided with a reference manual on oral health and can co-opt oral health professionals for such trainings. o The DTT is trained as Master trainers at state level by the State Training Team at higher centers like State Institute for Health and Family Welfare (SIHFW). The Dental teaching institutions in the state can help the SIHFW in forming the training guidelines, development and contents of IEC materials, reference manuals, training manuals etc. for further training of DTT and BTT. Monitoring o Monitoring can be effectively done by panchayati raj institutions at grass root level. o Oral health indirect indicators (attendance at dental health care facility in the locality, number of referrals) may be used for monitoring and evaluation. Additional Suggestions: o Incentives for best performing ASHA/ICDS/SHG/ CBO etc. to be decided by PRI, preferably on the lines of Nirmal Gram Puraskar out of the untied funds o Individuals adopting good health seeking behaviour also can be rewarded o In order to give incentives to patients to report to dental health care facilities, modalities for free distribution of tooth paste & brush through PPP will be devised. o A pilot can be undertaken for training through teleconferences in states equipped List of Equipments
District Hospital S.No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Item Electrically Operated Fully Programmable Dental Chair Autoclave Storage Cabinet Dental X-ray Unit with Day-light Manual Developer Panoramic with Cephalomatric X-ray unit Electro Cautery Unit Digital Pulp Tester Digital Apex Locator Surgical Micromotor 164

Dental lab for making dentures and orthodontics appliances S.No. Item 1. Model Trimmer With Carborandum Disc 2. Dental Lathe ( 2 speed) 3. Hanging Motor 4. Lab Micromotor 5. Vibrator 6. Dewaxing Bath 7. Acrylizer 8. Hydraulic Press Sub-District Hospital/ CHC S.No. Item 1, Electrically Operated Fully Programmable Dental Chair 2. Autoclave 3. Storage Cabinet 4. Dental X-ray Unit with Day-light Manual Developer 5. Electro Cautery Unit 6. Surgical Micromotor PHC (If Dental surgeon is appointed at PHC as per recommendation) S.No. Item 1. Electrically Operated Fully Programmable Dental Chair 2. Autoclave 3. Storage Cabinet 4. Dental X-ray Unit with Day-light Manual Developer 5. Electro Cautery Unit

Establishment of Comprehensive Cleft Care Centers PURPOSE Cleft lip and palate is a congenital defect which can be seen, felt and heard. Cleft lip and palate are among the most common birth defects. Approximately one newborn in around 700 has cleft lip, cleft palate, or both. In India the disease burden of clefts of the maxillofacial region is approximately 190 cleft children born each day and 45,000 each year. Nevertheless, many families have never heard of cleft lip or palate until their child is born. It can be a scary and confusing time. Among some races and people it is still considered a curse of God. It involves facial appearance, the teeth and occlusion, and speech and hearing. The planning and management for future treatment begins shortly after birth. Health is defined in the WHO constitution of 1948 as: A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity. When treatment is well planned and coordinated over time, the result is very promising and satisfying.
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The Clinic would provide the best possible course of treatment, with a confident, healthy child as the ultimate goal. The team approach is the logical answer to the problems of the cleft child and his parents. Indeed, it is the only one. Total rehabilitation of the child with cleft is so complex that many different aspects must be brought into unison by as many different specialists. Rehabilitation is progressive, not static; each age period has a unique set of problems and full participation from all members is required at all times to tackle the situations correctly. The primary purposes of the Clinic are: provide periodic interdisciplinary evaluations determine and prioritize treatment needs coordinate and follow up on treatment Counseling of parents and family members. facilitate treatment in their local community The team could provide a comprehensive diagnostic and treatment services for children up to age 21 who have: A cleft lip and/or palate A sub-mucous cleft palate Speech concerns (for example, hyper-nasal speech) Cranio- Facial abnormalities or abnormal head shape Micrognathic or Macrognathic jaw Dental concerns related to the above conditions The Cranio maxillofacial surgical clinic would comprise of several different members. The team members all have different parts to play in the care of babies, children, young people, and their families. Services to adults would also be offered. Interdisciplinary Cranio maxillofacial surgical clinic comprises of: Oral & Maxillofacial Surgeon Plastic/Pediatric Surgeon Orthodontist Pediatrician Otolaryngologist (Ear, Nose, Throat) Prosthodontist Pedodontist Neurosurgeons Ophthalmologists Audiologist (Assesses hearing function) Speech-Language Pathologist Radiologist Geneticist Pediatric Nurse Anthropologists Psychologist Social Worker

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COMPREHENSIVEPROTOCOLFORCLEFTLIPPALATEMANAGEMENT
AGE BIRTH ORTHODONTICS Records FeedingPlate Appliancesif Indicated GENERALDENTAL CARE ORALSURGERY &PLASTICSURGERY E.N.T&AUDIOLOGY 3MONTHS1YEAR 1YEAR Records RegularCheckup LipandPalate Repair Behavioural Audiometry Tympanometry AcousticReflex Test ENTCheckup Audio Monitoring Localisation Audiometry Tympanometry ABR Audio Mointoring Grommets PlayAudiometry Tympanometry ABR Audio Mointoring SPEECHTHERAPY CaseHistory PreverbLSkills Pre Speech/Languag eCounselling

AdviceonDental Evaluation care CounselParents Preventive Measures DietCounseling

3YEARS 5YEARS

Records

DecisiononRe Pharyngoplasty, LipRevisionand PalatalFistula Closure

Language Assessment Articulation Assessment Resonance Assessment

7YEARS

Records XRays Interceptive Orthodonticsif Indicated

 89YEARS Records Decision regarding AlveolarBone Grafting(ABG) PreABGOrtho PostABGOrtho PostABG Records Followup DefinitiveOrtho Treatmentfor NonSurgical cases Periodontal Assessment Extractionsif indicated AlveolarBone Grafting PlayAudiometry Tympanometry AcousticReflex Test Audio Mointoring FollowUp

10YEARS 1214YEARS

RegularCheckup

Followup

16YEARS

1820YEARS

21YRS

Records Decision regarding Orthognathic Surgery Presurgical Ortho PostSurgical Ortho FinalCheck FullRecords

FixedorRemovable DentureWork

Decision RegardingLip, ScarorNose Revision Orthognathic Surgery DentalImplants

FinalCheck FullRecords

ESTABLISHMENT OF CLEFT CARE CENTRES IN INDIA In spite of the vast resources of human capital in the field of medical sciences, there remains a gap in the management of these disorders. As we now know, management of craniomaxillofacial disorders requires an interdisciplinary team approach between medical, dental, nursing and paramedical and paradental fields. Thus there is an urgent need to set up Dental health care infrastructure / Cranio- maxillofacial centres which would specialize in the management of cranio- maxillofacial disorders in various Medical Colleges in every part of India. It is herewith proposed, that the Government consider: 1. A National Research and Development (R&D) Centre in Delhi to be established at The All India Institute of Medial Sciences, New Delhi, under the leadership of Dr. O. P. Kharbanda (Head of Department, Department of Orthodontics and Dentofacial Orthopedics) 2. A National Coordinating Centre to be established at Lady Hardinge Medical College (Sucheta Kriplani Hospital), New Delhi under the leadership of Dr. Pravesh Mehra (Head of Department, Department of Dentistry and Maxillofacial Surgery) 3. Ten Service Centres spread across 5 geographical regions of the country namely North, South, West, East and North East. 4. A Pilot Project External Evaluation Committee proposed to evaluate the functioning and outcome of the proposed centres over a period of five years National Research and Development (R&D) Centre (AIIMS, New Delhi) This facility will be required in Delhi to oversee the Research and Development aspect of the cleft care programme. This centre will also function as a base for exchange of education and research programmes with other centres in the country and abroad. The prime objectives of the R&D Department will be: Identify the right interventional strategy for the right age from the day the child is born. Design protocol specific to / suitable for the Indian demographics and Health Care Facilities Collect, Collate data with respect to the genetic or anti-partum causes of cleft lip and palate, carry out statistical analysis and identify suitable intervention that can be replicated in the Indian setup To monitor and evaluate the performance of the coordinating centre and the ten service centres being established. Identify current national and international trends in cleft diagnosis and treatment and disseminate relevant knowledge to the service centres.

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Coordinate with partner institutions*and eventually assist the Directorate, Health Services, Ministry of Health and Family Welfare in auditing the project.

Partner Institutions ICMR Dept. of Biotechnology Directorate General Health Services, Ministry of Health, Govt. of India National Coordinating Centre (Lady Hardinge Medical College, New Delhi) Objectives Be model institution for dissemination of cleft awareness and comprehensive cleft care. Be the coordinating centre for the 10 service centres across India. Identify interventional strategies to reduce the overall morbidity and mortality related to craniofacial clefts in India. Minimize the secondary complications of cleft lip and palate. Generate data for the R&D department. Identify pre-surgical, surgical and post surgical interventions and assist the R&D unit in devising the Indian Protocol. Service Centres Objectives Be centres of comprehensive cleft care for masses. Identify interventional strategies to reduce the overall morbidity and mortality related to craniofacial clefts in India. Minimize the secondary complications of cleft lip and palate. Generate data for the R&D department. Identify pre-surgical, surgical and post surgical interventions and assist the R&D unit in devising the Indian Protocol. S. No. Region 1. 2. 3. 4. 5. North South East West States & Cities Identified Jammu and Kashmir (Srinagar); Uttar Pradesh (Lucknow) Andhra Pradesh (Hyderabad); Kerala (Thiruvananthapuram) West Bengal (Calcutta); Bihar (Patna) Gujarat (Ahmedabad); Maharashtra (Nagpur)

North- East Meghalaya (Shillong); Manipur (Imphal)

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These States are chosen on t basis of high incide e the f ence of Cra anio- maxillo ofacial disor rders. There is very littl support fr le rom the Stat Governm te ments to patie ents/ familie suffering from es such d disorders. Al would be State Gover ll rnment based Medical C d Colleges / Ho ospitals, and thus d would provide af d ffordable, ac ccessible, acceptable, qu uality based equity cran maxillof niofacial disord health ca in the most effective a efficient manner. der are and t Pilot P Project External Evalu uation Comm mittee An ex xternal evalu uation comm mittee is prop posed to eval luate the fun nctioning an outcome o the nd of proposed centres over a perio of five ye od ears. The co ommittee wi convene t ill thrice during this g time, f first after 2 years of proj commen y ject ncement and then twice a intervals o 1.5 years. d at of Propo osed Commit Member ttee rs: 1. D S. P. Agg Dr. garwal (Direc ctor, Green P Park Dental Institute and Research C d Centre) 2. D Mahesh Verma (Princ Dr. V cipal, Maula Azad Ins ana stitute of Den Sciences, Delhi) ntal 3. L Gen. Dr. Paramjit Sin Retd. (Di Lt. P ngh irector Princ cipal, Rayat b bahara Dent College, tal Mohali) M 4. D S. P. Baja (Plastic Su Dr. aj urgeon, Jaipu Golden H ur Hospital, Delh hi) 5. D V. K. Tiw (Profess Plastic S Dr. wari sor, Surgery, Safd darjung Hosp pital. New D Delhi) 6. D Rajender Sharma (Pro Dr. ofessor, Dep of Rehab ptt. bilitation, Saf fdarjung Hospital, New Delhi) D

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PROGRAMMES FOR DISABILITY PREVETION AND REHABILITATION 10. Trauma Care Facility on National Highways Based on analysis of the 11th Plan, the strategies proposed for the 12th plan are as follows: The construction activity is taken 2-3 years time causing delay in release of funds for equipments which takes round about a year for procurement. The funds are released in the phase manner which delays the entire project. In order to augment the pace of implementation of scheme it is proposed that the funds for construction & equipment may be released in first phase. The procurement of equipment may be initiated on completion of the civil structure upto terrace. The funds for the other component like manpower, communication, Legal assistance may be released in second phase on receipt of audited UC & SOE for construction and equipment. Prioritizing the identification of hospitals for developing trauma care facilities based on the deprived States, backward States, far flung areas, hilly & tribal area. The list of the deprived States & Districts is identified under NRHM. To identify the 160 Government Hospitals on the national highways (other than GQ, NE, SW corridors) are as - connecting capital to Airport/Seaport, connecting two major cities other than capital connecting Capital to major industrial township cities in 12th Five year Plan. Capacity building at State-level by identifying State Trauma Resource Centre in each State. The L-1 Centres would be hub for the training of doctors, nurses etc. besides the State Trauma Resource Centre will also be involved to impart training. Integrating pre-hospital care with the scheme of Emergency Medical Services initiated by EMR Division. Establishing communication linkage with the mobile units, highways locations and the designated trauma centres. To assist the States to develop and manage an appropriate trauma referral system. To develop, implement and maintain statewise and National Injury Surveillance System. To develop Trauma Registry in JPN Apex Trauma Centre and PGIMER RML Trauma Centre and gradually expand it to other institutions.

The priority for identifying district Deprived States & District (list from NRHM). Far flung area Hilly & Tribal Area

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Activity wise physical targets for key indicators on coverage:-Broadly, the annual targets would be as under: Year 2012-13 Activity Convey in-principle approval for 160 institutions and sign MOUs with State Govts. Survey & identification of 46 new institutions Sensitization of personnel of 113trauma centers sanctioned in 11th Plans in injury surveillance. Release of funds for 46 Trauma Centre for construction and equipment and spill over cases of 11th plan. Inspection of 62 new institutions for implementation Sanction & release funds for 62 institutions. Compile and publish data on injury surveillance. Inspection of 52 new institutions for monitoring implementation Sanction & release of funds for 52 institutions Compile and publish data on injury surveillance Mid Term appraisal. Annual inspection of 160 institutions Compile and publish data on injury surveillance Appraisal of project Handing over all liabilities to State Govts. Finalisation of project for 160 new institutions to be implemented in the 12th FY Plan. Publish report on project implementation and injury surveillance.

2013-14

2014-15

2015-16 2016-17

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11. Prevention & Management of Burn Injuries The program needs to continued and expanded in the 12th Plan becauseTotal number of burn injury cases annually in India is approximately 70 lacs (7 million) and the cases are on increase In India approx. 1.4 lacs people die of burn every year More than 7 lacs burn injury cases require admission every year 70% of all burn injuries occur in most productive age group (15-35yrs). 4 out of 5 burnt cases are women & children. 80% of cases admitted are a result of accidents at home (kitchen related mishaps). Amongst all traumas, burn cases have highest duration of hospital bed occupancy. Cost of hospitalised burn injury case management is extremely high which may cost enormous financial burden to the country. The rehabilitation of the individual may be a challenging and daunting task. In view of the above, the program is proposed to be expanded in the 12th Plan period at national level in a phased manner covering the District Hospitals and Govt. Medical Colleges (approx.150) spread across all the states. However, to avoid duplication of services, districts where medical college is already functioning, the district hospital will not be taken up for establishing burns unit. Further, the high focus districts (i.e districts with poor health infrastructure) and the states showing willingness for implementing the program, having enough load of burn cases and scope for establishing burn unit in terms of availability of land/space would be included for implementation on priority. The remaining states/districts would be taken up for implementation in subsequent years. Hence, approximately 150 Government Medical Colleges and 492 district hospital would be taken up for implementation in phased wise manner as follows12th Plan Year Additional Medical Colleges 20 35 40 35 17 Additional District Hospitals 50 100 120 130 86 Cumulative no. of Medical Colleges 3 23 58 98 133 150 Cumulative no. of District Hospitals 6 56 156 276 406 492

By March 2011 2012-13 2013-14 2014-15 2015-16 2016-17

During 12 plan

th

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Before inclusion of the Medical Colleges/ district hospitals, a central team consisting of an expert, architect and representative from MoH&FW/Dte.GHS so formulate would conduct an inspection visit for examining facilities available and gap analysis. Strategies for implementationThe programme will be implemented at National level with following objectives2. To reduce the incidence, mortality, morbidity and disability due to Burn Injuries. 3. To improve the awareness among the general masses and vulnerable groups especially the women, children, industrial and hazardous occupational workers. 4. To establish adequate infrastructural facility and network for BCC, burn management and rehabilitation. 5. To monitor and supervise the programme at various levels of implementation and carry out Operational Research for assessing risk factors for burn injuries and its management for effective need based planning. The programme will be continued with the following components1. Preventive Programme:This component is being implemented through Central Health Education Bureau (CHEB) and Awareness Programme in School for generating awareness. 2. Treatment Programme: This component will include capacity building of healthcare manpower and quality burn injury management at all the levels of Health-care delivery system. 3. Rehabilitation Programme:Rehabilitation services to be provided at district and state level to restore functional capacity of the burn patients to optimum. 4. Monitoring and supervision: Development of mechanism for monitoring and supervision of programme activities at central, state and district level for better implementation of the programme. 1. Preventive Programme (IEC):More thrust will be given on IEC component of the programme. It is proposed to keep IEC budget for the states for carrying activities at various level. CHEB would be the nodal agency for IEC activities. The Central Health Education Bureau (CHEB) will carry out detail planning of IEC, provide leadership and develop core messages, mass media and advocacy events. The Central Health Education Bureau will maintain coordination with State Health Education Bureau (SHEB)/IEC Bureau. IEC would be implemented at state level through support of SHEB/IEC Bureaus.

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Following activities have been proposed under this programme Situational Analysis is proposed to be carried out in all the states in the first year of the Plan period. This Situational analysis is proposed to be the basis for selecting specific messages, selecting communication networks and planning a relevant IEC strategy. Impact assessment (4 events) of the IEC initiatives taken under the NPPBI is proposed to be conducted at the end of each plan year. Terminal evaluation of the IEC initiatives taken under the NPPBI during the entire plan period 2012-17 is proposed to be carried out in the fifth year of plan period. This evaluation will be a part of total programme evaluation. Electronic media: Doordarshan, AIR, Cable TV, Internet, Mobile phone SMS. CCTVs at the railway stations, hospitals, schools and other public places are the available Medias, which could be used for educating the masses starting from urban to rural areas. Scroll bar messages on the prevention of burns could also be given through DD, Cable TV etc. Print Media: Newspapers advertisements, magazines, posters, charts, folders will be used for disseminating information on burns. Melas, Rallies and Quiz, Folk Media etc. Orientation training programme for medical and education professionals and mass awareness programme for general public and school children, Public meeting / lecture for general public. Awareness campaign for school children. Outdoor publicity in form of Hoardings, Wall Paintings, Neon Signs, Kiosks, Bus Panels, etc Following manpower would be required for CHEB to be engaged on contractual basis to carry out above activities Consultant-one @Rs,50000/-per month. Programme Assistant One @Rs.25000/-PM Data Entry operator 1 @ Rs.15000/-PM Support staff/MTS- 1@ Rs.8000. P.M

Cost proposed for the educational and preventive component for 12th Plan would be for Rs 209.60 crore. 2. Treatment Programme: For quality management and rehabilitation of burn injuries at various levels of Health-care delivery system, certain additional requirement of physical infrastructure (construction/renovation of burn units), trained manpower, equipments & materials would be provided to the medical colleges and district hospitals.
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Additional space will be located in Medical colleges and District Hospitals for establishment of burns unit where such facilities do not exist and all such places will be provided with equipment required for burns management and rehabilitation. It shall be the responsibility of the states to provide for adequate land / build up structure which can be suitably modified for creating the burns unit at medical college and district hospitals levels. Financial support will be provided by MOH & FW for construction of burns unit. To implement the programme, it is imperative that additional medical, nursing and paramedical manpower would be required. Financial support for recruitment of manpower on contractual basis for the period specified will be provided by MOH & FW. Each district will be provided with an advanced life support (ALS) system ambulance if not already available. This will create a burn support system for the village, primary health center, CHC and district level. This will also be utilized to transport serious burn patients from the place of injury to the district or the designated burns unit. These ambulances will be provided with multi disciplinary workers who will be running the ambulance and helping in dressing the serious burns patients to the district or at designated burns unit. Construction- Rs. 1.00 crore for construction of burn unit at one district hospital and Rs.1.95 crore for medical college have been proposed.The cost involved for 12th Plan would be Rs 772.65 crore. Equipments- Rs.0.48 crore for procurement of equipments at one district hospital and Rs.0.98 crore for medical college have been proposed.The cost involved for 12th Plan would be Rs 371.58 crore. Recruitment of manpower-Rs.0.62 crore for recruitment of contractual manpower at one district hospital and Rs.1.79 crore for medical college have been proposed.The cost involved for 12th Plan would be Rs. 1712.62 crore. Training: To improve the quality of burn management, a network of trained manpower from Medical colleges and District Hospitals will be created. The training plan isdetailed as follows: Training in first aid to burn cases for Ambulance drivers, Multipurpose Workers, Nursing staff, Dressers, OT Technicians, and other Paramedical staff at the Medical Colleges & Districts. Training in first aid to burn cases for Ambulance drivers, Multipurpose Workers, Nursing staff, Dressers, OT Technicians, and other Paramedical staff at the District Hospitals.

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Medical College Level: Training of the workers in Medical College Hospitals will be done by the Surgeons who are already trained in Burn care or who receive training under the programme. District Level Training: Training of the district level workers will be done at district hospitals by the Surgeons and Medical officers trained in burn care under the programme. The National Level Training: Two Surgeons / Medical Officers from each district shall be trained by the Burns & Plastic surgeons at burns units of Dr. R.M.L. Hospital, L.N.J.P. Hospital or Safdarjung Hospital or any Medical College/ Selected Training hospitals in the country having such facilities.

The training will be conducted by each Training centres closest to the district hospitals. If required, on-the-job training of the medical college workers will also be done at existing burn centres. Orientation training for the primary level workers will also be done at district centre by the trained Surgeon / Medical Officers. The expenditure for training of Surgeonsinclusive of TA/DAagainst this component would cover the cost of training material / module / literature / sample stock of consumables / demonstration material etc. and would be provided to each trainee (Surgeon / Medical Officer from District) in a Kit. Rs. 50,000 for training of surgeons/medical officers/paramedical staff per district has been proposed.The cost involved for 12th Plan would be Rs 3.21 crore Gained from the experience of the pilot programme, in many district hospitals and Medical Colleges, burn services could be started immediately, albeit at a slightly lower level, by altering/ renovating existing space, and that a full fledged burn unit as envisaged in the plan would take much longer time to establish. Therefore, under construction component funds may be kept either for renovation/alternation of existing structure, or for new construction as the case may be. Further, to start burn services immediately and expeditiously in the infrastructure already available in Medical Colleges / District Hospitals provision may be kept for simultaneous release of funds for construction work, procurement of equipments and recruitment of manpower. 3. Rehabilitation Programme: To restore the burn patients back into the society to their normal functional capacity as what existed prior to the burn injury. This rehabilitation services is to be provided at district and state levels. The budget is included in the Burns Injury management program as stated above.

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It is proposed that for proper program implementation there should be a provision of payment of incentive in the form of monthly allowance / honorarium to surgeons managing burn cases at district hospitals. Burn management is an unpleasant task and the district surgeon needs to be incentivized for their work in providing this service. The incentive may be either an increment in pay scale or a fixed incentive of Rs 1000/- per month, which can be disbursed to all district surgeons receiving burn management training or it could be linked to submission of a Medico-legal case record from the district, which would also help in case monitoring and surveillance.An incentive of Rs.1000/- per month for three surgeons/medical officers for each district for management of burn cases is proposed. The cost involved for 12th Plan for this component would be Rs 2.27 crore. 4. Monitoring and supervision- For strengthening monitoring & supervision of the programme at various levels and also facilitating implementation of the program following structure would be required1. Central Burn Cell at Dte GHS, New Delhi (already existing) with following staff - Program Manager/ Nodal officer/DDG - National Consultant-2 - Program Assistant-2 - DEO-2 - Peon/Helper-1 State Burn Cell with following staff - State Program Manager (probably from state health directorate) - Consultant-1 - DEO-1 District level Cell- District Program Manager (probably a technical expert) Cost involved- Nil Program Implementation Committee- Following Committees would be required at various levels under the programa) Central level- National Monitoring & Advisory Committee (already existing)- The Committee will consist of an expert group from well established burns units and other eminent authorities in the field of burns injury management. This group will interact through frequent meetings at the centre and will be advising the Program officials for monitoring, supportive measures and other issues essential for smooth functioning of the program. b) State level- State Implementation Committee will act as advisory body for monitoring, supporting and dealing with core issues for smooth functioning of the program at state

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level. The Director/ Jt. Director of Health Services, Director/ Jt. Director of Medical Education, Executive Engineer/Architect from state PWD, State IEC Officer and the State Programme Manager could be the members of the Committee. c) District level- District Co-ordination Committee would function for addressing issues at district level. The Committee would comprise of CMO, Medical Superintendent of district hospital/Principal of medical college and District Program Manager. Monitoring & Evaluation A National Burn Registry would be formulated through a common process of administrative channel of sub centre / PHC to CHC to District Hospital / CMO to State Cell to Central Cell, Dte.GHS and State Health Education Bureau to Central Health Education Bureau based on the availability of data through a regular feedback mechanism of reporting. Mid-term Evaluation of the programme for assessing progress of various activities is proposed to be carried out in third year (2014-15) of the 12th five year plan. Evaluation would cover approximately 25% of the implementing medical colleges/district hospitals. Cost involved for this activity would be Rs. 3.00 crore Expected outcome Establishment of fully fledged Burns Care Services in the Medical Colleges and district hospitals Availability of trained manpower at the Medical Colleges and district hospitals Increased awareness regarding prevention of Burns Injuries, safety measures and availability of services through IEC. Establish out-reach burn care services through mobile burn care delivery system (ALS ambulances) Reduce the incidence of burn injuries and the consequences thereby reducing the burden on Govt. exchequer and improving the quality of life of the community.

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12. Disaster Preparedness and Response in Health Sector Preamble: National Disaster Management Act (2005)48 defines disaster as a catastrophe, mishap, calamity or grave occurrence in any area, arising from natural or manmade causes, or by accident or negligence which results in substantial loss of life or human suffering or damage to, and destruction of, property, or damage to, or degradation of, environment, and is of such a nature or magnitude as to be beyond the coping capacity of the community of the affected area. A disaster is a function of the risk process. It results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk. Risk assessment and management would require a collaborative approach from all concerned stakeholders at all levels. This also underscoredthe need to adopt a multi dimensional endeavour involving diverse scientific, engineering, financial and social processes; the need to adopt multi disciplinary and multi sectoral approach and incorporation of risk reduction in the developmental plans and strategies. Disaster management occupies an important place in this countrys policy framework as it is the poor and the under-privileged who are worst affected on account of calamities/disasters. Disasters retard socio-economic development, further impoverish the impoverished and lead to diversion of scarce resources from development to rehabilitation and reconstruction. The steps taken by the Government of India have been translated into a National Disaster Framework culminating into the Disaster Management Act, 2005, encompassing institutional mechanisms, disaster prevention strategy, early warning system, disaster mitigation, preparedness and response and human resource development. The common strategy is to flow through the planning process of relevant stakeholders including health sector. Thus this action plan follows the dictum of DM Act and Disaster Management Policy49 of a paradigm shift from a relief centric approach to that of prevention, preparedness, mitigation, response, recovery, rehabilitation and reconstruction. The foregoing paragraphs summarize the legal, institutional and operational framework for disaster management in India with focus on health sector. Legal and Policy Framework Constitution:Under the constitution, disasters and health are State subjects. National Disaster Management Act, 2005 The National Disaster Management Act was enacted in 2005. It provides for legal, institutional and operational arrangements including capacity development at central, state,

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district & local levels forprevention, preparedness, mitigation, response, recovery, rehabilitation and reconstructionfollowing natural and manmade disasters. Transaction of Business Rules: In exercise of the powers conferred by clause 3 of article 77 of the constitution, Transaction of Business Rules have been framed which provides for the Standing Committee of the Cabinet on Management of Natural Calamities to oversee all aspects relating to management of natural calamities including assessment, programme development, implementation, and monitoring134. The National Crisis Management Committee (NCMC) under Cabinet Secretariat and headed by Cabinet Secretary is the Apex Committee in Government of India that deals with major crisis which have serious or national ramifications. It will be supported by the Crisis Management Groups of the Central Ministries. As per the Crisis Management Plan of the GOI, Ministry of Health and Family Welfare is the nodal ministry for biological disasters. Relevant Acts supporting Disaster Management A number of legislations, other than those stated above, support management of disasters. At the global level, International Health Regulations [IHR] (2005) adopted by the World Health Assembly on 23 May 2005 came into force on 15June 2007. The purpose and scope of IHR (2005) is to prevent, protect against, control and provide a public health response to the international spread of disease and to avoid unnecessary interference with international traffic and trade135. At the national level, some of the important Acts like the Water (Prevention and Control of Pollution) Act, 1974, the Air (Prevention and Control of Pollution) Act, 1983 and the Environment (Protection) Act 1986 and Rules (1986) provide for protection of Water, Air and environment respectively. The Environment Protection Act, 1986 also provides for the Biomedical Waste (management and Handling) Rules 1998 with a view to controlling the indiscriminate disposal of hospital/biomedical wastes. At the State and District level, the Epidemic Diseases Act (Act 111 of 1897) provides for prevention and spread of dangerous epidemic diseases. Relevant portions of the Indian Penal Code (IPC) [1860] may be invoked as and when the need arises. Disaster Management Policy Disaster Management Policy for the country was unveiled in 2009 by National Disaster Management Authority. The policy advocates a paradigm shift in Disaster Management from relief centric approach to a proactive regime emphasis on preparedness, prevention and

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mitigation. It also calls for a holistic approach and recommends incorporation of disaster management into the sustainable development planning by all concerned departments. Institutional Framework The institutional mechanism at Central, State and District level for Disaster Management in general and specific to health are: At Central Level National Disaster Management Authority (NDMA): The National Disaster Management Authority was established in year 2005, under the provision of National Disaster Management Act 2005. Prime Minister is the ex-officio chairperson. Powers are vested with the authority to perform certain functions that include laying down of national policy and guidance for disaster management, approval of the national plan and plans of various ministries, capacity development, coordination with various agencies to ensure implementation of national policy and guidelines. It also has a lead role to initiate the institutional measures for prevention, mitigation and preparedness with a view to generate a holistic, integrated and preventive approach to disaster management. Institutions established under the DM Act by NDMA The Disaster Management Act also provides for the line ministries in the Central Government to develop plan and implement the same to support capacity development for prevention, preparedness, mitigation, response, recovery, rehabilitation and reconstruction. A National Disaster Response Force (NDRF) has been constituted with specialized capacities to respond to natural, manmade and Chemical, Biological, Radiological and Nuclear (CBRN) disasters. Under the Act, National Institute of Disaster Management (NIDM) provides for human resource development, academic and research support. Ministry of Health and Family Welfare (MoH&FW): This is the nodal ministry for biological disasters. It also has the supporting role to provide medical / health care to mitigate health impact of other types of disasters. State Level State Disaster Management Authority (SDMA): The SDMA, being set up under the provision of DM Act, provides for the same powers as envisaged for the NDMA, to carry out similar functions at the State level. State Health Department: This is the nodal department for managing health sector prevention, preparedness, mitigation, response, recovery, rehabilitation and reconstruction for disasters.

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District Level District Disaster Management Authority provides for the convergence of all sectors at district level to develop and execute the operational plan for prevention, preparedness, mitigation and response. Operational Framework Public Health Delivery System in India Under the Indian constitution, clear responsibilities have been delineated between the Central and State Governments keeping in mind federal structure of the country. Health being a State subject, the State Governments (through state, district and block level public health institutions and state owned medical colleges) are primarily responsible to meet the public health needs (both preventive and primary, secondary and tertiary curative care) of the population and manage the public health delivery system on day-to-day basis and also meet the emergency public health needs of the population. The Union Ministry of Health and Family Welfare support the state in terms of advocacy, laying down guidelines, standard operating procedures, capacity building and provide logistic support on selective basis. The specialized central government hospitals and institutions provide tertiary care facilities in the selected cities and also in the selected specialities. These institutions in the process of its functioning also act as reservoir for large pool of medical manpower which facilitates emergency mobilization during crisis situation. Besides the health system response to mass casualty events, the MoHFW also supports the State Governments in addressing issues relating to pandemics, epidemics / outbreak of diseases in terms of capacity development, rapid emergency public health needs assessment, surveillance and response, outbreak investigation, laboratory support, health system response, logistics (drugs, equipment and vaccines) and risk communication. Besides MOHFW, also carries out research activities relevant from the public health point of view through the Indian Council of Research (ICMR). . Besides MoHFW, the major Central organizations having Health units like those in Indian Railways, Employees State Insurance Corporation and Ministry of Defence are factored in for health sector response if the need arises. Ministry of Defence in particular acts as first responders based on State Governments request. In addition to the public sector involvement, the private sector also plays a significant responsibility in the public health delivery system in India. Approximately, 70 percent of health services are provided by private sector on payment basis. Private hospitals are better organized and equipped since they are permitted to generate their own resources.

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The financing norms for disaster relief are governed by funds stipulated by the Ministry of Finance, namely Calamity Relief Fund (CRF) and National Calamity contingency Fund (NCCF). The norms for CRF/NCCF has been clearly laid down and includes the items like (i) outreach services through relief camps, (ii) prevention of epidemics (iii) replacement of damaged drugs ad equipments and (iv) immediate restoration of primary health care facilities. Strengthening of health delivery system to meet the routine and emergencies public health needs As per the National Disaster Management Act, the state and the district authorities are responsible to operationalize the disaster management plan at the community level. Ministry of Health & FW being the nodal ministry for biological disasters and support ministry for other disasters has initiated a series of steps to strengthen the overall health delivery system at primary, secondary and tertiary level which would contribute to the surge capacity of the state and district health delivery system to meet the public health needs of the vulnerable population especially during any emergency situations. Salient features of the programmes and projects that got initiated in the 11th Plan relating to strengthening public health delivery system that facilitate emergency public health emergency management are: 1. National Rural Health Mission (NRHM). The NRHM is a flagship programme in mission mode to provide support to states for strengthening system of health care in rural areas through provision of physical infrastructure, human resources, equipment, emergency transport, drugs, diagnostics etc. The upgradation involves new construction/renovation of sub-centres, primary health centres, community health centres and district hospitals. An important component which contributes to disaster preparedness, apart from the human resource and infrastructure strengthening, is emergency transport system which has been made operational in 12 states with assistance of 2919 ambulances. In addition, 1674 ambulances have been provided to the states for working at PHCs, CHCs, Sub-districts and District hospitals. Also 1031 mobile medical units are operational in various states under NRHM. 2. AIIMS like institutions for tertiary level health care and programme for strengthening of medical colleges: Under the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) (Phase-I) six AIIMS like institutions are being set up in the states of Bihar (Patna), Chhattisgarh (Raipur), Madhya Pradesh(Bhopal), Orissa (Bhubaneswar), Rajasthan (Jodhpur) and Uttrakhand (Rishikesh) at an estimated cost of approximately Rs. 820 crore per institution. The construction is in full swing and these institutions are likely to become functional by December, 2012. In addition, under this scheme, 13 existing

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medical colleges are also being strengthened. This would provide much needed tertiary care support during disasters. Phase II of this programme is under consideration. 3. National Highway Trauma Care project- The programme thrives to have trauma centres and pre-hospital care along the golden quadrilateral and north, south, east, west corridors. These highways pass through some of the most vulnerable disaster prone districts. So far 113 select government hospitals have been provided financial assistance for establishing trauma centres to the tune of Rs.281 crores in the 11th Plan. For the 12th Plan an amount of Rs. 1476 crores have been projected. The ambulances required under this project and to be stationed on the highways and trauma centres are being supported by Ministry of Road Transport/National Highway Authority of India. 4. Burns Management Programme: A pilot programme for prevention of burn injuries has been started in the 11th Five Year Plan with an allocation of 29.70 crores. Under this pilot project, one medical college and two district hospitals each in the states of Haryana, Assam and Himachal Pradesh have been taken up for creating infrastructure and human resource for burn management. The programme would be scaled up under the 12th Five Year Plan. 5. Blood Transfusion Services: National AIDS Control Organization (NACO), currently supports a network of 1127 blood banks, 155 component separation units, 795 district level blood banks and 28 model blood banks. It has supported modernization of all major blood banks at state/ district levels. In addition it is proposed to establish blood storage Centres in 3222 CHCs (presently 685 blood storage centres are functional). 6. Integrated Disease Surveillance Project (IDSP): The IDSP was launched in November 2004 with the objective of strengthening Disease surveillance system for epidemic prone diseases to detect and respond to outbreaks. The major components are (i) integrating and decentralization of surveillance activities (ii) strengthening of public health laboratories (iii) human resource development for use of information technology for data management. The network covers the entire country with 776 data centres, 24X7 call centres and a media scanning cell. Gaps: Though there are overall improvement in the health delivery structure, still there are wide inter- state / intra state variation. The primary and community health care infrastructures are not construed to support mass casualty events. There is wide differential among the states in the range and quality of services provided by the district level hospitals. Medical college hospitals or other tertiary care institutions run by the state health department or municipalities

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are overwhelmed even with the routine load and their surge capacity is limited. Apart from infrastructure shortcomings, the human resource manning these institutions, at all levels, are not sensitized to act as first responders, triage, manage cases and do appropriate referral. There is also need to mitigate the impact of disasters on health infrastructure (hospitals) through structural and non structural modalities. A major gap is the preparedness and response for chemical, biological, radiological and nuclear disasters. For communicable disease outbreaks, surveillance and response capacity need to be strengthened further. Scope and Limitations: The action plan addresses specific activities particularly those which provide for specialized capacities targeted to fill the gaps in health sector preparedness and response to disasters. It does not address overall health sector capacity development which is being undertaken under various projects and programmes as detailed in para 4.1.2. Goal: The goal of 12th plan document for health sector preparedness and response to disasters is to reduce mortality and morbidity by increasing communities resilience to disasters. Objectives Overall Objective: The overall objective is to strengthen capacities of the health sector to prevent, remain prepared to respond and to mitigate the adverse outcome of disasters. Specific Objectives To build capacities in human resource at all levels to respond to health aspects of disasters by 2015. To institutionalize uninterrupted continuing medical care to victims of disasters where hospital buildings have been affected by 2015. To ensure disaster resilience, structural and non structural , in Central Government hospitals by 2020. To strengthen health sector communication in 15 vulnerable states through strategic health operation centres by 2017. To develop specialized capacities for handling CBRN disasters for the country from centres identified in vulnerable States/ Districts by 2018. To develop health sector specific IEC materials for creating awareness among public by 2013. To provide rapid health assessment and response through quick response medical teams in disaster settings by 2013.

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Activities 1.Human Resource Development Capacity building activities proposed in this plan includes training of grass root level functionaries as medical first responders; the health workers and pre hospital service providers in basic life support; doctors at district level and above hospitals (in vulnerable districts) in cardiac and trauma life support; hospital administrators in hospital preparedness and public health personnel on public health emergency management. The basic and advance life support courses have already been rolled out on pilot basis and would be expanded across the country through identified regional hospitals. The training of trainers has been affected for hospital preparedness. The course for health managers on public health emergencies would be advanced through the support from World Health Organization. 2.Mobile Hospital Mobile hospital is a pre-fabricated, self-contained, container based 100 bedded hospital which can be deployed by road, rail or air during a disaster which has affected the health facility. The container based hospital includes medical, surgical, diagnostic, operation theatres, intensive care, imaging services and other supportive services that include kitchen and sanitary services. This can be deployed in minimum time possible and would provide medical care to the victims of the disasters who could not be otherwise attended to by the health facility which has been affected by the disaster. 3. Safe Hospital Initiative The safe hospital initiative would address the structural and non structural component. The structural component would endorse issuing guidance to the States for constructing hospitals/ health facilities in the vulnerable zones using laid down building bye-laws / codes. For existing hospital buildings, standards as advised by NDMA would be followed for retrofitting. During the plan period the Central Government hospitals would be assessed for retrofitting. Non structural components would include guidance to health facilities for proper anchorage of equipments, ensuring their functionality and training of staff. 4. Strategic Health Operation Centre (SHOC) There is a felt need in establishing a command and control centre in health sector to address the post-disaster public health needs during acute emergency phase, relief and recovery phase through improved, coordinated communication network amongst the different levels of public health administration and institutions involved with the health sector disaster management. It would be necessary to meet the communication needs with fail proof information technology with adequate redundancy. This technology need to be robust, both terrestrial and satellite

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based that has connectivity to all the district headquarters of vulnerable States with high speed data transfer, voice and video conference facility. SHOC would also fulfil the need to collect and manage data that would create evidence for future planning. 5. Risk Communication The risk communication activity would focus on communicating the risk to the population atrisk. Generic IEC materials on simple public health measures would be communicated through print and visual media. Prototype IEC materials that are disaster specific would be developed and kept ready, to be rolled out at appropriate time. 6.Management of CBRN Disasters For managing chemical, biological, radiological and nuclear disasters, six centres of excellence would be established on regional basis that would address tertiary care, teaching, training and research requirements. Requisite human resources would be identified, recruited and trained to handle CBRN exposure/ injuries. These centres would also have the capacity to provide outreach services for districts/ cities other than those identified as vulnerable districts / cities. In addition prioritized districts / cities with nuclear power plants or those vulnerable to terrorist attacks would have basic facilities for detection, protection, decontamination, decorporation, treatment/ stabilization and referral. Other activities would include securing stockpile of drugs and equipments for all identified facilities and creating awareness among medical practitioners and general public on prevention and protection aspects of chemical, biological, radiological/ nuclear exposure. 7. Rapid Health Assessment and Response Training would be provided to health administrators on Rapid Health Assessment. It would be ensured that trained Rapid Response Teams are available to respond quickly during disasters.

Implementation Plan The implementation would span through the 12th plan period and beyond. Human resource development for managing health consequences of disasters would be top priority and taken up immediately. The capital investment in terms of infrastructure creation / strengthening would be spread across the plan period. Gantt chart for the proposed activities is given below:

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Financial Year Quarter Activities Human Resource Dev. ATLS Establishment of Centres conduct of trainings ACLS Establishment of Centres Launching of trainings BLS Establishment of Centres Launching of trainings First Responders Trainings for ASHAs and Health Workers Development of training module Launching of trainings HOPE Launching of trainings PHEMAP Launching of trainings Mobile Hospital Procurement of mobile hospital Recruitment of staff Safe Hosp. Initiatives Non structural mitigation guidances Retrofitting 2013-14 1 2 3 2014-15 1 2 3

2015-16 1 2 3 2016-17 1 2 3 2017-18 1 2 3

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Financial Year Quarter Strategic Health Operation Centres (SHOC) Establishment of SHOC in Centre Establishment of SHOC at identified vulnerable States CBRN Centres of Excellence Establishment of Centre of excellence Human resource development recruitment Human resource training Strengthening identified hospitals CBRN facility expansion in these identified facilities Human resource training Secure stockpile of drugs and equipments Strengthen and fast track research for drug development Awareness generation amongst professional and general public Community based psychological care 2013-14 1 2 3 4

2014-15 1 2 3 4 2015-16 1 2 3 4 2016-17 1 2 3 4 2017-18 1 2 3 4

Monitoring EMR Division of Directorate General of Health Services would implement the programme on disaster preparedness and response in health sector. The programme would be monitored through a set of input / process / output indicators.

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S.No

Activity Developing Human Resource Component

Input and Process Indicators 1. No. of training labs identified. 2. TOT planned

Mobile Hospitals

1. Specification finalized 2. Procurement procedure undertaken

Output / outcome Indicators 1. No. of training labs made functional 2. No. of TOTs conducted 3. No. of Trainers trained 4. No. of trainings done in each category 5. Capacity built of different categories of s each specific training. 1. No of mobile hospitals procured in the last 2. No. of patients attended-category/Speciality 3. No. of operative procedures done specialty 4. No. of Nosocomial Infections confirmed 5. Intra-operative mortality observed

Safe Hospital Initiative Non-structural 1. No. of hospitals identified for non-structural measures. 2. Guidelines prepared and circulated. 1. No. of hospitals identified to undergo retrofitting. 2. Guidelines circulated to all health care facilities in vulnerable zones 1. Vulnerable states identified for establishing SHOC. 2. SOP finalized for SHOC 1. No. of prototype IEC material developed. 1. No. of hospitals implementing non structura 2. No. of hospitals following the mandated gu 3. No. of staff aware of these plans

Retrofitting

1. No. of units retrofitted and functional

Communications SHOC 1. No. of SHOC centres identified against th %. 2. % of SHOCs following SOP. 1. Prototypes rolled out during disaster throug 2. Utilization of IEC budget Assessment of BCC 1. 2. 3. 4. 5. 6. No. of units completed per year as per time No. of staff of different categories recruited No. of trainings done Number of mock drills conducted %utilization of budget. Capacity to handle CBRN enhanced.

Print/Visual media 5 CBRN

Centre of Excellence (COE)

1. Number of Centres planned 2. Minimum standards established for COE. 3. Budget sanctioned

Strengthening existing hosp. for 1. No. of districts identified based CBRN in 50 on vlnerability profile. Districts/Vulnerable 2. Minimum standards laid down cities Rapid Health Assessment (RHA) and Emergency Response 1. Funds allocated 2. Collaboration with NRHM to train Health Workers/ASHAs as med. first responders.

1. % vulnerable districts covered with CBRN 2. Number of mock drills conducted. 3. Specialized capacity attained to manage C in vulnerable districts. 1. 2. 3. 4. RHA SOP prepared QMRTs identified and trained upto district % of Districts covered with trained QMRTs % of trained QMRTs utilized in a disaster e

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 13. Emergency Medical Services

The world war field planning for carrying war casualties, coupled with progress in automotive industry provided an opportunity to the resource rich countries to develop and refine organized emergency medical care for the civilians. Emergency Medical Services (EMS) got evolved to reflect change from a simple transportation system ferrying the patient to a point of care to one where patients were provided with emergency medical care with life saving support systems during transportation. The key feature is timely response in attending to the patient. It further got integrated with the point of care ensuring that the standards of emergency care received during transportation are continued uninterrupted at the point of care.The two components of EMS, facilitated by timely communication, form a chain to provide emergency care delivery, the outcome of which is likely to be sub-optimal, with increased mortality and morbidity unless they are well conceptualised and organised to suit the countrys needs and resources. Global Scenario The emergency medical services evolved over time in the last century showed resource rich countries developing capacities to attend to an emergency case in a given setting (domestic, work place, road side, incident site, hospital etc) and transport him/her along with continuum of emergency care to a defined point of care facility within defined time, moving away from the traditional golden hour concept (reaching with in the first hour) to the platinum 10 minutes concept.Countries like USA, UK and Israel have over 30 years of experience in system development for EMS, yet there are constraints. Further efforts in these countries were to integrate the pre hospital services with emergency departments of hospitals and to develop capacities among medical and paramedical professionals to manage emergencies. Now, the Emergency Medicine has emerged as a separate and distinct discipline. A large number of models available globally undermine the fact no size fits all. Many countries follow the Anglo American Model where trained Emergency Medical Technicians perform standardized life saving skills during transportation by road or air (air or heli ambulances)[eg USA]. The Franco German model followed in Germany, France and Scandinavian countries follow a more hands on approach with emergency physicians providing advanced pre hospital care. The levels of care also ranges from providing non invasive basic life support to advance mobile coronary care, neonatal care or specialized hazardous material life support. The operational mechanism also varies from 100% Government owned and operated (NHS, UK) to varying elements of public private partnerships. This include those operated by hospitals; voluntary organizations like Red Cross and St Jon ambulance (Ireland, Germany, Austria) and those stand alone systems operated by private organizations.

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WHO estimated that without proper emergency services at first referral level, up to 10% of the population will die from injury and 5% of pregnancies will result in maternal death. Indian Scenario Current Status In India Emergency Medical Services is relatively a new concept. The most dominant model is that initiated by the then IT corporate, Satyam Computers who established a Emergency Medical Research Institute [EMRI], brought in information technology for communication and vehicle tracking etc and trained human Resource. The implementation through pilot project in Andhra Pradesh, saw its expansion, with Government of India adopting the model for National Rural Health Mission. Presently, under the PPP mode, EMRI has its operation in 11 states with 2858 ambulances [Andhra Pradesh (752), Gujarat (476), Karnataka (517), Tamil Nadu(428), Goa(22), Madhya Pradesh(94), Assam(282), Meghalaya(30) and Uttarakhand (114), Himachal Pradesh (107), Chhattisgarh(36)].Rajasthan has 164 supported by service providers other than EMRI. In their area of work, EMRI provides pre hospital emergency care (basic life support) from incident site to an appropriate hospital. Being a component of NRHM, the services were initially planned for rural population (one ambulance for 100,000 population) with emphasis on obstetric emergencies. However, in many States were EMRI is operational, the services are provided in major towns and cities that too,to provide only transportation with the paramedic capable of doing first aid procedures. Few more service providers namely ZIQITSA (Bihar, Kerala, Rajasthan), AAA Foundation (Ambulance Access for All) in Mumbai and Emergency and Accident Relief Centre, Tamilnadu operates on PPP mode. In the formative stages the Central Government provided 100% capital expenditure and 95% of the operational expenses. From the year 2009-10 onwards, the State would be bearing 40% of the cost during first year, scaling to 60% and 80% for 2nd and 3rdyear and subsequently to be owned up by the concerned State Government. SWOT analysis Strengths o Political will to provide services o A model has been established under PPP mode o More number of States are getting covered. Weakness o Lack of Integration with hospital services o No standards for pre hospital or Emergency Department (ED) care o The hospitals do not have emergency physicians. The present concept of casualty is based on specialty care provided by specialists from basic and advanced specialties attending the victim at ED on call basis.

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o Lack of qualified Emergency Medical Technicians capable of performing invasive life saving measures. Human Resource not competent to provide basic / advance life support. o The present ambulance deployment could serve only a small percentage of population. o Lack of fiscal management for a sustainable system. Opportunities o Improve quality of emergency health care services in India o To establish a techno legal regime to regulate EMS o Provide equitable pre hospital services to poor and marginalized population o Use alternate financing options such as insurance. Threats o Lack of trust, failure to strengthen government institutions and integration of prehospital and hospital services coupled with demand generation would establish private players with sole profit motive. o Spending on emergency health care by way of out of pocket expenses would further drain the savings of poor and marginalized population.

Strategic Approach Evolve EMS policy : techno legal, regulations, rules, standards and guidelines Provide emergency medical care at site of event/ incidence through outreach pre hospital care services and integrate it with appropriate emergency medicine departments of hospitals. Expand on the existing ambulance services under NRHM. Explore Public Private partnership in programme delivery. Innovative financing options for sustainability. Scope and limitations: The response time of 15-30 minutes is based on the data generated by EMS in the State of Gujarat. The large inter-state and intra state differentials in health delivery system, even more so pronounced between urban/ rural areas, would limit standardized application of EMS across India. The sub district and district hospitals has to the backbone of EMS. The Emergency Departments of these hospitals has to get a complete face lift with competent emergency physicians, nurses and technicians manning them. The geographic spread of some districts, road conditions and difficult terrains would necessitate the introduction of cost intensive alternates like heli ambulances to meet the laid down standards.

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Objectives Overall Objective: To establish Emergency Medical Services in India with response time ranging from 10 to 30 minutes. Specific Objectives: By the end of the XII plan period: Evolve EMS Policy: techno legal, regulations, rules, standards, guidelines and financing norms . Set up Institutional mechanism for EMS at National/ State/ Districts and strengthen administrative units of the departments. Establish capacities for creating large number of Emergency Medical Technicians / Ambulance Officers envisaged in the programme. Plan and implement EMS pilot project in 10 districts including 2 difficult terrain districts. Strengthen the emergency departments of identified hospitals pilot project areas. Evaluate pilot, and prepare a vision document for implementing Emergency Medical Services across India. Policy formulation Legal Framework The Supreme Court in a series of connected matters has made rulings on emergency care. The Law Commission in its 201 report on Medical treatment after accidents and during emergency medical condition and women in labour have recommended a law to compel hospitals and medical practitioners to attend on victims of accidents those in emergency medical condition and women under labour. Law Commission also circulated model law for the States to adopt. The State of Gujarat enacted the Gujarat Emergency Medical Services Act in April 2007 which provides for emergency medical services in that State and for that purpose established Gujarat Emergency Medical Services Authority and the city and district emergency medical councils in the State. A national consultation collaborating with Ministry of Law would provide policy guidance for Central/ State law, rules and regulations governing provision of emergency medical services in India. Institutional Framework Government is responsible for providing effective emergency services. This could be accomplished through proposed institutions as detailed below, existing institutions at primary, secondary and tertiary level along with other partners-private and non-governmental. The

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coordinated institutional framework need to ensure policy, continuing standards, clinical guidelines, standard operating procedures, records, quality and audit. National Emergency Medical Services Authority For the purpose of providing emergency medical services in the country, a National Emergency Medical Services Authority would be established with a senior technical officer, ex officio or otherwise, as Chairperson, as decided by the Government with appropriate members. The function of the authority would be to oversee all aspects relating to provision of Emergency Medical Services in India. State /City/District Emergency Medical Councils For providing emergency medical services in every state, city and districts, State / City/ District Emergency Medical councils would be set up. The functions of the councils would be to ensure provision of emergency medical services in their respective States/ cities/ districts. At the city and district level the councils will focus on the operational aspects of the scheme ensuring that all the components are functional optimally. Strengthening Central and State Health Directorates Central Level For managing the programme, an EMS division would be established in DGHS with an officer equivalent to the rank of Addl DG heading it. A post of Joint Secretary would be created in the ministry to administer all programmes connected thereto or incidental therewith. The existing Emergency Medical Relief (EMR) Division and Highway Trauma Programme would be merged into EMS division, elevating the post of Director, EMR to a Joint Secretary equivalent post (SAG level) , supported by two Directors one for EMR and other for EMS. State Level Each state will have a Director, Emergency Medical Services to supervise and control emergency medical services. In addition he / she would also meet the requirement of prevention, preparedness, mitigation, response, recovery and rehabilitation from health consequences of disasters, for which as of now, there is no earmarked personnel or organization with in the health department. District / City level Each District/ City would have an Emergency Medical Services Officer implementing and monitoring the emergency medical services in the district / city.

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Programme Components A. Pre-Hospital Services Pre hospital services would include all services provided from incident site till handing over the patient to the emergency department of the hospital. The services would be established after assessing the appropriateness of modality of transport from the incident site to the point of care, the basic indicator being the response time. The modalities of transport are: Ambulance Services (a) Life Support Ambulances: India has now manufacturing units having capacity to fabricate good ambulances but there is no uniform standards. The EMS would follow uniform standards across the country. The patient cabin area ambulance must be adequate to accommodate patient (62 length) and roof height must not hinder advanced life support measures. The head end should be free to seat the doctor / EMT to perform head end manuvours. Besides that it should have enough space to accommodate one ambulance officer. Standard specifications for a life support ambulance are provided at Annexure I. the standard operating procedure both for patient interventions would be clearly laid down. There would be one ambulance for 50,000 population. For response time of 15 -30 minutes, one ambulance could be considered to cover an area of 5-10 km. radius. The terrain, accident vulnerability of the area for RTAs and disasters would be considered before fixing the number of ambulances required for a particular area. (b) Heli / fixed wing aircraft ambulances For difficult terrains, where patients cannot be transported through road with in the prescribed response time, heli ambulances would be put into services. Heli Ambulances/ fixed wing aircraft ambulances are cost intensive and have their own limitations. For example the operating cost of heli ambulance is about INR 5.00 crores per year. As the Ministry of Health would not be in a position to operate or maintain heli/ air ambulances, these services would be outsourced.As a test case, two districts with difficult terrains would be included in the pilot project. (c) Two Wheeler ambulances Two-wheeler ambulance service would target busy metros where four wheeler ambulances find difficult to reach due to blocked traffic. The EMTs on two wheelers would reach the spot faster and attend to immediate emergency requirements till such time the four wheel ambulance reaches the incident site. These ambulances would be equipped with communication gadgets, first aid kits, splints, cervical collars, life saving kits, resuscitation kit and portable suction machine.

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Ambulance Stations: Ambulance Stations would be parking, resting and communication hub for the ambulance officers. These stations would be at easy to access locations (petrol pumps / fire stations/ Government office complexes/ hospitals). Each ambulance station would have two rooms of 15x15 dimensions with attached bathroom. Each Station will have one ambulances to provide uninterrupted services on 24x7 basis. An ambulance station would cover an area of 5/10 Sq Km radius. Inter-Hospital Transfer Hospitals may continue to receive emergencies other than those brought in by EMS (till such time the services are well established and accepted by the population). The life support ambulances would be made available to identified hospitals for inter hospital transfer. B. Emergency Department (ED) The archaic term Casualty should be replaced with Emergency Department. The speciality of Emergency Medicine is distinct and comprises of more than caring for war casualties as the name was originally intended to be. The most commonly available system for emergency patient care worldwide is the hospitalbased ED, a place which intends to facilitate medical and surgical care to all people who seek immediate attention for acute health problems. Therefore, the department needs to be conducive to prompt and efficient patient care. It is important to realise that this does not end with establishing four walls and facilities but involves planning, organising, staffing, training and quality control. Even though District Hospitals have functional Emergency Rooms, many such areas do not provide standard emergency care due to lack of planning, trained staff and equipments. Therefore, it is of utmost importance that emergency services in the District Hospitals be upgraded, for better outcome. a. Emergency Services: The emergency department would provide well-organized medical, paediatric, (including neonatal) surgical, obstetric, trauma care and anaesthetic services. b. Physical facilities: Physical facilities should include reception, triage area, treatment area, operating theatres, labour and delivery room, high dependency area, blood bank, laboratory, diagnostic imaging, sterilization, water, electricity, safe waste disposal and communications. The district hospitals would be upgraded to the required level and equipped adequately. The physical facility requirement for an emergency is at Annex.II.

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c. Equipment and instrument: The District hospital would be equipped with surgical instruments for minor surgery, major surgery, obstetrics and gynaecology surgery, orthopaedic surgery, anaesthetic equipment, resuscitation equipment and monitoring equipment. Recommendations for minimum equipment requirement for a District Emergency Department are Annexure-III. d. Supplies system:There would be uninterrupted supply of essential drugs, blood and intravenous fluids and other consumables e. Personnel: Clinical personnel with appropriate qualification and training in emergency medicine, general surgery, orthopaedics and traumatology, obstetrics and gynaecology; anaesthesia and resuscitation should be available along with adequate number of nurses and support staff. Evaluation of training needs and coordinated plan for continuing medical education, especially for enhancing skills, should be an ongoing programme. The duties and responsibilities of the staff should be well defined. The practice of emergency care is team work and all personnel need to work together to achieve expected standards of emergency care. f. Quality Assurance: A quality assurance system to improve the quality and equity of patient care needs to be in place. Standard treatment protocols and standard operating procedures are essential in the ED to ensure safe patient care especially for inexperienced physicians or nurses. Protocol Manuals are available and an indigenously developed one is most suitable and practical. Moreover it is prudent to implement treatment protocols in concurrence with the various departments of the hospital. The department should have standard operating procedures and treatment protocols for most of the emergencies that present to the department and it is recommended that all clinical personnel of the ED follow the same such that standardised and uniform clinical management is ensured. Proper digital record management and clinical audit also assures quality service in hospital systems. C. Triage Triage is the process of getting the right patient to the right place at the right time with the right care provider. In disaster settings where there are multiple emergencies, effort would be to provide the most effective care for the greatest number of patients. In non disaster settings, the efforts of emergency department would be to provide the best care for each individual patient. The guiding principles would be to identify patients requiring immediate care, determine the appropriate area for treatment and facilitate patient flow through the emergency and avoid unnecessary congestion. A 3 stage uniform coding would be followed for patients requiring immediate care, those requiring monitoring for worsening of conditions and those
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who could be managed in out- patient departments. Every emergency department nurse would be trained in triage. Guidelines on triage are at Annexure-IV. D. Human Resource Development The crucial gap in human resource is the Emergency Medical Technicians [EMT] without which any ambulance, however advanced it may be, would only serve the purpose of transporting the patient. As of now, the paramedics in ambulances providing services under NRHM have no legal sanctity to provide for advance life support medical interventions and only perform first aid. To raise a breed of EMTs, technically competent to handle emergencies and to imbibe a culture of EMS is the biggest challenge for the EMS programme. The EMTs should be placed at a pedestal equivalent to nurses. For the time being nurses desirous of working as EMT would be provided one year in-service training in emergency medicine followed by six months internship. Nurses by way of their training are better placed to handle human emergencies. A curriculum developed by the sub group for EMT is at Annexure-V. Apart from EMTs, the human resource at the emergency departments needs to be reoriented for the new job. Details of patients staffing Emergency Department and their training requirements are at Annexure VI. 3. Communication System Communication system would be the nerve centre of the EMS. It would be realized through satellite based, terrestrial band-width based and truncated radio system. It provides for receiving call, dispatch of the ambulance, communication to and fro from ambulance and hospital, tele/video conferencing, ambulance tracking and data management. (a) Command and Control Hub System Architecture Ambulance Call Centre (ACC) It is intended to use Geographical Information System (GIS) and Global Positioning System (GPS) technologies to track the Ambulance Vehicles and graphically display its position on the map at the Ambulance Control Centre (ACC). The proposed system must have an open architecture and be based on Web Browser technology, capable of scaling up. It would have CLI (calling line identity) enabled and CTI (Computer Telephony interface) enabled with features like least call routing, automatic call distribution, trunk guard, emergency calling; direct inward / outward system access; single digit operator calling; blank call recall; live call monitor etc. The configurations should provide for enabling telemedicine operations within the network and identified centre. The control room would house servers, switches, backup power system, dispatch etc and work stations for the call taker, call dispatcher and supervisor. Workstations would be required for all

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call takers / dispatchers, supervisor, data entry, and administrator positions The Mobile Data Terminal (MDT) Ambulance The MDT will be located in driver cabin in the ambulance and the laptop / mobile computing devise / I pad will reside in patients cabin; there would be two data channels, GPS Receiver and digital camera. There would be back up digital Trunking Radio System. Suitable bandwidth would ensure teleconferencing from the ambulance. The windows/browser based software interface would allow the attending officer to record the name and other details. The system would be able to send visuals of the patient (extend of trauma) and the procedures being done with in the cabin through a camera to the central control room and the specialist station and get real time feed back to the ambulance. The medical equipments defibrillator + monitor combo, ECG machine, Transport ventilator, Pulse oxymeter, and glucometer etc) would be tele-medicine compliant and be able to interface through the mobile computing device/laptop / I pad / data card. Data Terminal-Hospital The data terminal within the hospital would reside in the communication control room. It would provide three way communication with ambulance / the ambulance station, the central control centre and higher referral centre. Ambulance Tracking system The Ambulance Tracking System (ATS) would consist of three Sub-systems viz., (i) Ambulance Call Centre / Control Room (ACC) Sub-System, (ii) Vehicle Sub-system and (iii) Communication Sub-System. The specifications are such that it can be scaled up for the future to address the need of a fleet of 15000 ambulances operating through multiple control rooms. Communication Sub-System The data communication channels would be based on the 3G/ EDGE/ /GPRS/ GSM or CDMA technologies. This could be taken from any service provider who should ensure dedicated connectivity.The Block Diagram of the Ambulance Communication System is at Annexure VII. Toll Free Number The telecommunication department would provide with a nation-wide applicable 3 digit call number which would replace the existing multitude of 3 digit/ four digit numbers. Implementation Plan The XII plan period would focus on developing the techno legal regime and implementation of EMS in 10 districts and their evaluation. Towards the end of the plan period the Instituional frame work of National authority and the State councils would take shape. Expansion of EMS to district/ cities would be taken up in subsequent plans.
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Annexure-I
Specifications for Ambulance PART - A

Item No.

Description Ambulance 3350 mm WB, fitted with TD 2650 FTI, Turbocharged, Intercooled DI Diesel Engine Bharat Stage IV TECHNICAL PARAMETERS FOR AMBULANCE: Type of Body: Monocoque Minimum Engine Capacity: 2596 CC Emission Norms: BS-IV Engine Output: 70 HP @ 3200 rpm Torque : 195 Nm @ 1800-2000 rpm Turning Radius: 6.5 Mtrs. Brakes : Four piston disc brakes with wear indicator DIMENSIONS: Wheel Base: 3350 MM Overall Length : 5235 MM Overall Width: 1975 MM Overall Height: 2550 MM Front Overhang: 720 MM Rear Overhand: 1165 MM Min. Ground Clearance: 190 MM - Fuel Tank Capacity: 70 Ltr.

Quantity

1.00

01 Units

PART B Equipments to be installed in the Ambulance

S.No. 1. 2. 3 4. 5. 6. 7. 8. 9. 10. 11 12 13 14. 15. 16. 17. 18. 19 Particulars Scoop Stretcher Foldable spine board Folding Stretcher Deluxe extremity vacuum splint Kit Model: D-S1749, Set Contents: (a) 2 Splints(leg, arm and wrist/ankle) (b) 1 Double action pump (c) 1 Adapter (d) Carrying case Combi collar: Adjustable Cervical Collar model Aluminium AAA type O2 Cylinder, O2 Regulator (Imported Pin and Index flow regulator) BP Instruments (Wall Mounted Aneroid) Stethoscope Defibrillator + Monitor [12 lead ECG, NIBP, O2 saturation with standard accessories Transport Ventilator Infusion pump Nebulizer Resuscitation bag (ambu bag. airways & mask of different size including paediatric, Endo Tracheal tubes of different sizes) Electrically operated suction pump First Aid Box (dressing materials/antiseptic lotion/analgesic etc.) Linen/Blanket Laryngeal mask airways of all sizes Burns Shield Qty. 01 No. 01 No. 01 No 01 No. 01 No.. 01 No. 01 No. 01 No. 01 No.. 01 No. 01 No. 01 No.. 01 No. 01 No. 01 No. 01 No. 01 No. 01 No. 01 N.o

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PART - C

S.No. 1. 2.

Particulars Patient Cabin: Interior top and side wall panelling done in GFRP (Glass Fiber Reinforced Polymer). Fibre thickness 6mm, Patient Cabin: Water proof plywood with Vinyl flooring AIR CONDITIONING (Patient Cabin only) Micro bus blower, 508, Heavy duty condenser 1No. Heavy duty drier 1No. Heavy duty electrical fan for condenser 1No. Key Switch 1No. with complete wiring and insulation. Engine Room: 135AH Alternator, Patient and Driver Cabin: Complete wiring, Sleeves with channel routed. SCB (Short Circuit Breaker) Switch for 220V ac line & 12V. Fuses with fuse box for all 12v lights. Patient Cabin: 800VA, High Frequency Inverter, Pure Sine Wave output, with 90AH sealed mobile lead acid maintenance free battery. Patient Cabin: Fibre cup-boards to fix ventilator / monitor / defibrillator / and suction with concealed 220v plug points (5 Nos) and O2 outlets with alarm panel (1No.) Patient Cabin: 12v fan for Doctor and Patient Patient Cabin: Medicine rack, 3 drawers with containers for keeping bandage, gauzes and other sterile items. Patient Cabin: Medicine rack, 4 drawers with containers for keeping medicine, ampoules, vial etc. Patient Cabin: S.S.Wash Basin, electrically foot switch operated with 25 litre water tank capacity Patient Cabin: Anti skit and shock absorbing mat for keeping medical equipments like ventilator, monitor, defibrillator, infusion and syringe pump. Patient Cabin: Retractable Doctor seat with safety belt Patient Cabin: Multifunction stretcher/ trolley GAS SOURCE: Complete gas pipelining with tubing embedded in panel having superior STAINLESS STEEL outlet points for oxygen (1No.O2 outlet for oral mask and 1 No. O2 outlet for ventilator) with Rail Mounting Systems (RMS) for loading and unloading the 2 Nos. of D type bulk cylinders. (cylinders are not included) Low O2 Alarm, O2 failure alarm, O2 Cylinder pressure Manometer and 0.2 micron dust filter Patient Cabin: Overhead Fibre Cupboard with glass door in RHS of the ambulance to store medical equipments accessories. Patient Cabin: CFL Tube Light (220V, 36W) Patient Cabin: patient examination light(12v, 55w) Patient Cabin: IV Bottle hook with bottle holder Patient Cabin: Dust Bin Holder: Disposable Polythene bag for syringe & Needle Waste. Disposable polythene bag for other bio waste. Fire Extinguisher(Non refillable) Red and Blue high illuminating LED side blinking lights Patient Cabin: Patient attender seat (3 seater) with safety belt and cup-board

Qty. 01 No. 01 No..

3.

01 No.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

01 No. 01 No. 01 No.. 01 No. 02 Nos. 01 No.. 01 No. 01 No. 01 No. 01 No. 01 No..

15.

01 No.

16. 17. 18. 19.

01 No. 04 Nos. 01 No. 02 Nos.

20.

21. 22.

01No. 01No. 01 No. 10Nos. 01 No..

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23. 24. 25. 26. 27. 28. 29. 30.

01 No. 01 No. 01 No. 01 No. 01 No. 01 No. 01 No.. 01 No.

Complete painting work Sticker work (Classic I model) UV radiation resistant sun control film Designer bigger foot rest for easy access into the patient cabin. Blue and Red Siren Lights, 100W Siren amplifier, Public Address System, 100w Siren Speaker Handheld Spot Light Cool / Warm Boxes Patient Cabin: Two way communication EPABX, with table top phone VEHICLE TRACKING SYSTEM: Model: Cansys RVTS 30 GPS satellite data is streamed continuously to our server using GPRS giving a real time, on-line trace of vehicle movement. VTS 30 uses SMS in case of GPRS link failure. Cansys RVTS 30 can be used by operators having Intra city / urban area operations. (Server charges will be charged separately) or any superior model combatable with the Control room Ambulance Tracking System Driver Cabin: Unitex mat upholstery work Driver Cabin: 12V Oscillating fan and 12V/18w Tube light

31.

01 No.

32. 33.

01 No. 01 No.

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Annexure-II
Setting up Emergency Medicine Department at District Hospital THE INFRA-STRUCTURE OF THE ED 1. Location: The ED should be strategically located so that there is adequate visibility and easy approachability for patients. It should have direct and easy access to service areas such as the radiology department including CT facility, laboratories, blood bank, intensive care units, operation theatres, hospital lifts and pharmacy. The following are the minimum requirements: 2. A reception area and registration counter situated close to the entrance of the ED. 3. Triage area: Patients coming to an ED have a wide range of illnesses with varying degrees of severity and it is important to examine a critically ill patient before a patient who is comparatively more stable. Triage is important in a busy ED because it helps to categorise patients according to their severity of illness so that an unstable patient can be examined before a more stable one regardless of what time the two patients arrived in the department. 4. Resuscitation Areawhere patients who have had a cardiac arrest, patients in shock or poly-trauma patients can be resuscitated. This room should be of an adequate size so that at least two patients can be simultaneously resuscitated. It should have the required resuscitation drugs and equipment, a defibrillator with external pacer, cardiac monitor and pulse oximeter. 5. Main Patient care area where all patients can be examined and treated. This should have a number of cubicles or beds isolated by curtains for privacy. There should be oxygen, suction and monitoring facilities for each bed because most patients coming to an ED will require oxygen and monitoring. 6. Central nursing station - where all the patients can be easily monitored by the medical and nursing staff. There should be cabinets where commonly used medications, syringes, needles, intravenous cannulae and sets are kept. 7. Trauma care area where trauma patients can be examined and treated. Facilities for application of splints and Plaster of Paris casts should also be available. 8. Sterile procedure room where minor surgery and sterile procedures under conscious sedation can be performed. 9. Observation Area which has beds or trolleys, where patients can be observed for up to twenty four hours in the ED. This room should have adequate monitoring facilities. Patient toilets should be attached. 10. Operating Theatres-Should have an operating theatre to perform minor and major procedures.

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11. Labour and delivery wardand Neonatal management facility: The District hospital should have facilities or normal delivery and complications arising due to pregnancy and to safeguard the health of new born. 12. Isolation area where patients with infectious diseases can be managed. 13. High dependency area: About 10 beds should be high dependency beds to manage all critical patients. 14. Pharmacy attached to the department. 15. Doctors Duty Room with lockers and wash rooms. 16. Security station located at the entrance to ensure safety of the department. The security staff can help to restrict the entry of unnecessary visitors in to the ED and can also handle untoward incidents. 17. Store rooms for the department 18. Support Services _ Continuous oxygen supply _ Blood bank and laboratory _ Diagnostic imaging Autoclave and other means of sterilization _ Safe waste disposal _ Water, electricity and communications.

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Annexure-III
Equipments / consumables required for an Emergency Department at District Level Equipments and instruments o Surgical Instruments are needed to cover all common surgical, orthopaedic and obstetrical procedures. Several sets of duplicate instruments may be needed to allow continuous provision of services during sterilization. o Anaesthesia :A dedicated set of anaesthetic apparatus is required whichprovides a source of oxygen, inhalation anaesthesia and the ability to ventilate the lungs, Paediatric anaesthesia system. o Resuscitation equipment : Oxygen, Oxygen concentrator, Resuscitation kit (Adult and paediatric resuscitators), Suction machine, Transport ventilator, Laryngoscope Macintosh blades 1-3(4), Laryngeal masks (multiple sets). o ICU / Monitoring equipment :Defibrillator with pacer, ventilator, multichannel monitor, ECG machine, blood pressure and pulse oximeter, Infusion pumps. o Imaging equipments: CT scan, X-ray unit, Portable Ultrasonogram o Laboratory equipments: Automated Analyser, BGA, Cell counter, Na/K Analysis o Miscellaneous : Trolly beds, Wheel Chairs, bedside cabinets, drug trolleys, Dressing trolleys All equipment and instruments require continuing maintenance, technical support, consumables and spare parts.

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Annexure-IV
Triage Guidelines, suitable for India Introduction Triage is derived from the French 'Trier', meaning "to sort. It is a brief clinical assessment that determines the sequence in which patients should be seen in the field or in the Emergency Department. Conventional queuing service is based on a first-come-first-served basis. However, in clinical practice that would be unsuitable since an unstable patient, waiting for his turn in the queue is bound to deteriorate significantly if there is delay in medical attention. The philosophy of triage is to ensure that the sickest is seen first and is based on quick evaluation of the patient. The patient's overall appearance, history of illness and/or injury, vital signs and mental status are crucial markers in triage decision. Triage in the Emergency Department Triage includes focused physical examination appropriate to the organ system, referred to in the chief complaint. For example, patients who have complained of earache must have an examination of the ear. Patients with a sore throat must have their throat examined. Triage should be routine daily operation and all patients presenting to an Emergency Department should be triaged on arrival by a specifically trained and experienced registered nurse. Triage findings must be recorded on the patient's medical record, which then becomes a permanent part of the hospital's medical record system. Triage for India Although many systems exist, a simple 3-tier system is recommended. It is in practice in India since 1997 and has been found to be efficient and practical. Using this system, the patient's vital signs, chief complaint, and other key indicators are evaluated by the triage nurse, and the patients are classified into an appropriate III - tier Priority category. Category I (obvious life-threatening emergency): The physician must examine the patient with zero delay. Case examples include cardiac arrest, continuous seizures, acute severe chest pain, haematemesis, sudden loss of consciousness, major trauma with hypotension, etc. Category II (Potential for life-threatening emergency): The possibility of an occult or pending emergency condition. Although some of these patients initially may appear to have not-so-serious chief complaints, about 25% of these patients have high-risk conditions. The patient needs full evaluation and treatment by a physician within 10 minutes of arrival, since there could be potential instability to the vital observations. Case examples include dyspnoea, high fever, acute abdominal pain, acute confusion, severe pain, serious extremity injuries, large lacerations, etc.

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Category III (non-life-threatening emergency): These patients' presentation need emergency care but provide no reason to consider the possibility of threat to life or limb. These patients need to be seen by an EM physician on a first-come first served basis in the Consultation Room. Case examples include chronic, minor, or self-limiting disorders, medication refill, skin disorders, mild adult upper respiratory tract symptoms, mild sore throat, blood pressure check, etc. Guidelines for Triage Some of the observations which indicate high risk emergency are: General appearance - Patient looks unwell, patient's skin looks poorly perfused, patient shows signs of dehydration Vital signs - Grossly abnormal Mental status - Evidence of abnormality Acute inability to walk Respiratory rates must be carefully counted. High respiratory rates are one of the most sensitive indicators of severely ill or injured patients. Patients with severe pain should be categorised as Priority I and should immediately be seen in the ED by a physician. The person performing triage should not judge whether the person might be exaggerating his or her pain. Each patient's temperature must be taken and repeated if it does not match the clinical condition, for example, as in the case of a patient who feels warm but has a normal temperature. Patients assigned to a waiting room should have vital signs retaken every 2 hours, on the most urgent categories of triage. Failure to do so may result in patients who progress to critical illness while sitting in the ED waiting room.

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Annexure-V Curriculum for Diploma for Emergency Medical Technician (EMT) Description of the course Diploma for Emergency Medical Technician is for Two years for 10+2 candidates with science subjects with biology One year for BSc Nursing This will be followed by six months com pulsar internship in both categories Selection criteria: 1. B. Sc Nursing will be given preference 2. B.Sc(Physics,Chemistry & Biology) 3. Selection of the candidates for admission to the course will be made on merit, on all India basis in government hospitals 4. No of seats: 30 in each batch at each center. 5. Reservation for SC/ST/OBC categories shall apply as per government rules Age for Admission: The age should be minimum 17 yrs at the time of applying for admission. Medium of Teaching: English Staffing Full time teaching Faculty in the ratio of 1:6 Minimum faculty: Five faculty by name should be available for the course. Chief Co-ordinator: Emergency physician /Anesthesiologist/ Gen Surgeon/Gen Physician Coordinators : Orthopedics surgeon, Emergency physician/ Physician/ cardiologist etc Roles of All Faculty should be defined clearly. Instruction manual for faculty must be made. Course objectives: At the end of the course the student will be able to Describe the concepts and principals of Emergency Medical Care Perform basic and advanced life/limb saving skill in pre-hospital & hospital setting Apply clinical knowledge and practical skills to real life scenarios. Conduct research in pre-hospital and in hospital emergency care Maintain emergency case registry and use it for improvement in prevention and care of emergency patients Assist and plan development of Emergency department /Units Assist, Teach and supervise work of EMT students. Maintain and operate all types of ambulances equipment and vehicle including driving. Budget: There should be budgetary provision for Audiovisual aids, stationary, Library, secretarial help, contingency expenses etc Physical facility 1. Lecture Hall Adequate size

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2. Library- permission to use institute library having current text books, internet, trauma journal, Emergency medicine journals etc. 3. Teaching Aids: Desk top/Laptop Computer with printer, LCD projector Video recorder with accessories Internet facility Photocopier facility Simulation equipments Manikins o Airway/intubation trainer o Bag mask ventilation o Basic Life Support o Advance life support o Intravenous assess o Any other as per requirement Moulage material 4. Office facility: Desktop computer with printer, Secretarial assistance, Stationary, Telephone, Fax Clinical Facility Medical College/teaching institute should have the following: 500 beds hospital Emergency department/trauma ED Ambulances: Distribution of course: For two years Theory & Clinical practice Internship Examination (including preparation) Leaves Public Holidays

40/60 %, 32weeks/52 Weeks 6 months 4 weeks as per rules

Condition for Admission to Examination I. Theory and practical attendance: As per rules. II. Internship attendance: As per rules III. Log book to be made as per guidelines Examination 1. To be conducted by both internal and external examiners. 2. Semester System with 20% of total grade as per grading system in internal assessment 3. Assessment should be as grading and report, not marks with written detail report on all the objectives of examination . The objective of the examination is to assess following:

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1. Knowledge :Assess the knowledge of basic concepts, theory, and principles of Emergency medical care 2. Comprehension; Candidate should be able to recall the knowledge and discuss as per patient requirement 3. Application : The candidate should be able to apply this knowledge to specific situations 4. Analysis: Candidate should be able to divide a problem into its component parts 5. Synthesis: Candidate should have the ability to combine theory and practical skills to solve complex situations 6. Evaluation : Candidate should be able to judge whether an action finally taken is good or bad for the ultimate outcome of the victim. 7. Last but not the least, Does the candidate have positive attitude for care of emergency patient . Number of days/hours It is commonly assumed that these are 180 working days in a year including the days earmarked for admissions and examination. It is presumed that these will be minimum of 360 days for theory & practical teaching in 2 years & with 6 working hours a day, the total member of working hours in a year will be (360 x 6 = 2160 hours) based on this a 2yrs course. The 2year course shall have 4 modules as under S.No. Module Days x hours Total hours -----------------------------------------------------------------------1. Module 1 90 x 6 540 2. Module 2 90 x 6 540 3. Module 3 90 x 6 540 4. Module 4 90x 6 540 -----------------------------------------------------------------------Total = 2160 -----------------------------------------------------------------------EXAMINATION SCHEME (2year Course) Paper Name of PaperHours Theory PracticalTotal Marks Marks Marks ---------------------------------------------------------------------------------------------Paper I Module I 3 hrs. 40 60 100 ---------------------------------------------------------------------------------------------Paper II Module II 3 hrs. 40 60 100 ---------------------------------------------------------------------------------------------Paper III Module III 3 hrs. 40 60 100 ----------------------------------------------------------------------------------------------Paper IV Module IV 3 hrs 40 60 100 Total Marks 160 240 400 -----------------------------------------------------------------------------------------------

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QUALIFYING MARKS 60% in theory with 80% in practical for each module. Failed student may be allowed to appear in that module for maximum of 2 attempts .Unsuccessful candidates shall have to reappear in all modules . AWARD OF CERTIFICATE Emergency Medical technician The certificate shall be awarded by the admitting institution after the candidate has qualified in all the modules successfully and after completion of the compulsory internship. CURRICULUM Course Internship 24months 6 months Basic Sciences 540 hrs 40:60(216:324 hrs) Medical Emergencies 540 hrs 40:60(216:324 hrs) Surgical emergencies 540 hrs 40:60(216:324 hrs) Emergency Setup, Ethics 540 hrs 40:60(216:324 hrs) MODULE I Topics Clinical Anatomy and applied Physiology: Respiratory system Cardiovascular system Neurological System Gastrointestinal system Endocrine system Musculoskeletal system Genitourinary system Reproductive system Sensory organs Electrolyte physiology Biochemistry in relation to lab investigations Pharmacology Pharmacokinetics Anaesthetic agents Analgesic/ Anti inflammatory agents Antibiotics, Antiseptics

Module 1: Instruction Hours Theory/Practical Ratio Module II Instruction Hours Theory/Practical Ratio Module III Instruction Hours Theory/Practical Ratio Module IV Instruction Hours Theory/Practical Ratio

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Drug reaction and toxicity Drugs used in emergency Principles of drug administration and care of drugs Microbiology: Immunity Infection ( Bacterial, Viral, Fungal) Communicable disease Principle of asepsis, sterilization and disinfection Diagnostic tests in microbiology Standard safety measures and biomedical waste management Clinical Pathology including hematology Blood transfusion and blood products Basic Life Support: Scene safety Checking for breathing, pulse Chest compression Giving breaths: Mouth to mouth, Mouth to mask and Bag and mask AED application and usage Special situations: Hypothermia, Drowning, Electrocution Practical and Tutorials: Osteology X-Ray, ECG and ABG Basics Monitoring Drugs Techniques of culture collection Laboratory investigations Sterilisation methods Infection control: Hand washing, cross contamination Basic Life Support MODULE II Topics Pre-hospital resuscitation Emergency preparedness Setting and management of emergency department system Triaging Interfacility transportation Ambulance transport and services Planning of ambulance service Planning men and material for ambulance An ideal ambulance Air transport Diaster management HAZMAT management Medico-legal and ethical issues in emergency

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Legislations and regulatrions related to emergency care Consumer protection act Negligence and malpractice Medico legal aspects Records and reports Role of EMT in legal issues Organ retrieval Research and statistics MODULE III

Topics: Medical Emergencies Respiratory: COPD, Asthma, Respiratory failure, Misc 1. Control of Airway 2. Suctioning Techniques 3. Oxygen Therapy 4. Nebulisation 5. Setting of ventilator Cardiovascular: Acute Coronary Event, Chest pain, Shock of different etiology, Tachycardia, Bradycardia, Cardiac arrest 1. Scenario based teaching 2. Defibrillation 3. Intravenous canulation 4. Cardiac Drugs 5. Overview of temporary pacing 6. Cardioversion Fluid electrolyte and acid-base imbalance Gastrointestinal: GI bleed, Abdominal pain, Vomiting, Diarrhoes Urinary:Acute retention, CRF CNS: Stroke, Encephalopathy, Seizures, Coma Poisoning, Snake bite Behavioral emergencies: Suicide Homicide Substance abuse: Alcohol and drugs Panic attack Sexual assault Acute depression Post traumatic stress disorder (PTSD) Fever, Sepsis Myopathies, Diabetic Ketoacidosis, Hypoglycemia Obstetric and gynaecological emergencies Pediatric emergenciesd

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MODULE IV Topics: Surgical Emergencies Abdominal Trauma: Blunt, Penetrating Chest Injuries Head and spine Injuries Musculoskeletal injuries Hemorrhagic Shock management Acute abdomen: Perforation, Torsion, Peritonitis, Renal colic, pancreatitis, cholecystitis ENT trauma, foreign body removal, Retropharyngeal abscess, epiglottitis, stridor, Sudden hearing loss Eye trauma: Foreign body, perforating injury, sudden visual loss, acute glaucoma attack Burns Procedures Assisted: Chest tube insertion Lumbar puncture Arterial Blood gases sample collection Tracheostomy Central venous canulation Procedures Performed: Airway management: Opening and securing of airway Needle thoracocentesis Needle cricothyrodotomy Cardiac monitoring Defibrillation Heimlichs maneuver Peripheral intravenous cannulation Gastric Lavage Splint application Care of traction

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Annexure-VI
STAFFINGOFTHEEMERGENCYDEPARTMENT(DistrictHospital) Chief Emergency Medical Officer (CEMO). The Chief coordinating multidisciplinary services under critical and stressful circumstances is complex and requires the services of a senior consultant with sufficient years of clinical / administrative experience. Some of the responsibilities of the CMO are: To coordinate and integrate the medical, nursing and paramedical divisions of the department. To be the bridge between the ED and the hospital management. To lay down policies and procedures for patient care and to ensure its implementation. To supervise and coordinate the various duties, shifts and responsibilities of the medical staff To obtain necessary materials and equipment for the department Emergency Medical Officers (EMO): It is recommended that the superseded term Casualty Medical Officer be re-designated as Emergency Medical Officer. The main responsibility of the medical officer is to ensure that all patients coming to the department are stabilised and adequately treated with minimum amount of waiting time. It is recommended that these EMOs be provided with a minimum of 3 months of training in managing common medical emergencies in the Emergency Department of a Medical College, with full financial support from the Govt. The number of medical officers appointed will depend on the patient load and design of the department. Emergency Physicians/ General physicians; Paediatricians, General surgeons, Orthopaedic surgeons, obstetricians, Anaesthetists: From the district hospital or visiting specialist arranged through firm contractual agreements. Nursing Matron: The Nursing matron is responsible for coordinating the various nursing activities. She prepares the duty roster and ensures that the appropriate nursing staff be posted to the various facilities of the department. Nurses: The number of nurses depends on the case load of the department. They should have ongoing training in emergency procedures, investigations and patient stabilisation. Further, they should ensure the replacement of all appropriate drugs in the resuscitation cart as well as miscellaneous disposables. Nurses should ensure the working condition of monitors and other electronic equipment and notify malfunction. They shall take care of Triage.

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Emergency Medical Technicians: Emergency Medical Technicians (EMT) are trained members of the Team who work on Ambulances as well as in the EDs; they respond to emergency calls, perform certain on-site medical procedures and transport patients to hospital in accordance with established protocols and guidelines. They are trained in the knowledge and skills to assist medical and nursing personnel in the Emergency Department. Operating room personnel, Laboratory and imaging technicians Ancillarystaff:Someoftheresponsibilitiesofthesestaffare: To transfer patients from the ambulance into the department and to Radiology andtothewards,whentheyareadmitted To carry blood samples to the laboratories, collect blood from the blood bank; collect blood investigation reports from the laboratory and X ray, CT and MRI filmsreportsfromtheradiologydepartment. Tobringtheoldrecordsofpatientsfromthemedicalrecordsdepartment. Tomaintaintheoverallcleanlinessofthedepartment.

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Telemedicine Consultant Server

Incomingcalls

Minimum2mbpsLeasedLinefor 3G/GPRS/EDGEconnectivity

VOIP Recorder

SERVERS Communi cation, Database, ATS

IPPBX

Phone Database & GIS Servers

GigaBitLAN

Printer

Voice

CallTaker / DispatcherOperator

10 Positions
220

Administrator

DataEntry

Supervisor

GPRS Wireless Communication

GPRS/LeasedLine

Ambulances

Hospitals

BLOCK DIAGRAM OF ACC SYSTEM

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14. Prevention and Management of Musculo- Skeletal Disorders (MSD)

Justification: Musculoskeletal complaints are the common reason for consulting a doctor and account for about 10% to 20% of primary care visits. They are the leading cause for long-term absence from work (> 2 weeks) in many countries. They are also among the leading causes of longterm disability. Their direct and indirect cost is considerable and their management utilizes a significant part of the gross national product of many countries. As a public health measure, it is important to detect and manage early and prevent the musculoskeletal diseases by disseminating information & IEC to adopt and encourage bone health though appropriate exercises at all ages, promote calcium intake and ensure adequate exposure to sun light.. These three are the crucial elements in determining peak bone mass. There is thus an urgent need for greater public awareness in this regard. For the middle aged and elderly, early detection and treatment of osteoporosis and management of rheumatic diseases at an early stage with available agents can significantly reduce the risk of fractures, deformities and associated morbidity and mortality. This in totality justifies the need for developing a program on a district model for Musculo- skeletal disorders in the country. Objectives: 1. To build capacity at all levels of health care delivery system focusing on district and subdistrict level hospitals for providing services for prevention, screening and diagnosis, early management, chronic care including residual rehabilitation and follow-up with availability of appropriate manpower, drugs investigation and equipments pertaining to MSDs. 2. Creating awareness in the community on the importance of MSD as a public health problem Components: 1. Setting up of district and sub-district level MSDs care unit in all the districts by the end of 12th five year plan in a phased manner (a) District MSDs care unitat district level hospital through the provision of appropriate manpower for MSD like 1 Physiatrists / Physician / Orthopedic Surgeon from the existing strength and 1 Physiotherapist / Rehabilitation therapist /Occupational Therapist, 1 BMD Technician, 1 Data entry operator, 3 field rehabilitation workers on contractual basis; and specialized diagnostic facilities and treatment facility such as BMD for early diagnosis of Osteoporosis and specialized Laboratory facilities for early diagnosis of RA. MSD ( RA, LBA etc) (b) Sub District MSDs care unit at CHC by assigning one existing doctor and on contractual basis 2 Community Multi Rehabilitation Workers, 1 X-Ray Technician, 1 Dark Room Asst. and 1 nurse at CHC and siagnostic facility such as X Ray to be placed at CHCs for screening of MSDs (osteoarthritis, RA, LBA and osteoporosis).
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2. Creation of awareness of MSD and its impact by use of IEC activities at district and sub-district MSD care unit regarding ADL modifications and health educations related with MSD so that patients can be educated regarding their ergonomics and life style modifications and thereby prevention of MSDs could be possible at this level which could further limit the burden of disabilities related to MSDs. 3. Provision of specific drugs at district and sub-district level pertaining to MSDs like commonly use NSAIDs, bisphosphonates, DMARDs. Special provision for providing Calcium and Vitamin D to infants and women of both child bearing age and post menopause for both prophylactic and therapeutic purpose. 4. Training: a) At State Level: Training for sensitization and programme concept on MSD of Physiatrists / Physician / Orthopedic Surgeon of district hospitals for 1 day In the Medical College with an established Dept of PMR b) At District Level: Training of 1 - 2 Medical Officer of each CHC and for 5 days at district level hospital in MSD care unit for MSDs assessment, prevention, early diagnosis and intervention. 5. Management information system for monitoring and evaluation through a structured data base mechanism for gathering information on availability of manpower, logistics, performance and other relevant information pertaining to the programme. Strategies: The proposed strategy is to establish district and sub-district MSD care unit by respective states and to integrate it with the existing health care system at PHC and CHC level. (a) Infrastructure: Directorate of Health Services of the States will be responsibile to provide services for MSD at district and sub district levels utilizing existing health healthcare delivery system by establishing district and sub-district level MSDs care units. Initially services will be provided at District level and CHC level and the state Government will identify the districts and CHC to be included in a phased manner. (b) Human Resources: District MSD care unit Specialist (from existing pool): Physiatrist/ Orthopaedician/Medical specialist to be trained in the PMR /orthopaedics/rheumatology departments of Medical Colleges. Physiotherapist/Occupational Therapist/ Rehabilitation Therapist: (1 on contract) BMD Technician (1 on contract) Field Rehabilitation Workers (3 on contract) Data entry operator (1 on contract) Sub- district MSD care unit (At CHC) Medical officer (from existing pool) trained at district MSD care unit X ray Technician (1 on contract) Dark Room Assistant (1 on contract) Community Multi-purpose Rehabilitation Workers (2 on contract)
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Nurse (1 on contract) (c) Investigation facilities Proposed strategy is to assess and provide the basic investigations facilities pertaining to MSDs at district and sub-district in first phase of the 12th five year plan. District MSD care unit Specialized diagnostic facilities and treatment facility such as (c) BMD for early diagnosis of Osteoporosis (d) Specialized Laboratory facilities for early diagnosis of MSD Sub- district MSD care unit (At CHC& PHC) X- Ray Facility Basic Hematological investigation facility for MSD (d) Drugs Proposed strategy is to assess and provide the specific drugs at district and sub-district level for prevention and treatment of MSDs like commonly used NSAIDs, bisphosphonates, calcium, Vitamin D, DMARDs etc. Training At State Level training will be provided for sensitization for MSD to Physiatrists / Physicians / Orthopedic Surgeon of district hospitals for 1 day In the Medical College having an established Department of PMR At District Level training of Medical Officers of CHC for MSDs assessment, prevention, early diagnosis and intervention. Monitoring and Evaluation Development of a management information system for monitoring and evaluation through a structured data base mechanism for gathering information on availability of manpower recruited, position of trained manpower, logistics in terms of availability of BMD and X Ray machines, laboratory facilities and availability of consumables performance, performance indicator including epidemiological information and other relevant information pertaining to the programme. This would facilitate to understand the burden of repetitive stress injuries/MSDs at all levels (school, college, professionals and community) All sub- district MSD care units will transmit the statistical data of MSD to the respective district MSD care unit where it will be compiled and send to the Directorate of Health services of the state. Expected Outcome The programme at the end of the 12th FYP would facilitate the following: Establishment of MSD Units at District and Sub district level which would in turn would be accessible to the community at large. Creation of awareness in the community on prevention and remedial measures for MSD Mechanism for nutritional supplements for prevention of MSD especially osteoporosis Reduction of MSD and thereby prevention of residual disability Creation of a pool of trained manpower and infrastructure for combating MSD

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15. Upgradation of Department Of Physical Medicine & Rehabilitation In Medical

Colleges Expansion of scheme During the 12th Five Year Plan, it is proposed to expand the scheme of establishment / upgradation of PMR department in 150 medical colleges (including the 21 medical colleges taken up during the 11th Plan) with the main objectives of setting up of full-fledged department of PMR in medical colleges. Based on the response, necessity of services and willingness of the states/ medical colleges for implementing the program the medical colleges will be selected on priority. The phase-wise inclusion of medical colleges would be as shown below in the table:
Medical Colleges New Cumulative 2012-13 10 40 2013-14 30 70 2014-15 35 105 2015-16 25 130 2016-17 20 150 Total 120 150*

150* medical colleges include 30 medical colleges that are targeted to be covered in 11th Plan and 120 new medical colleges proposed to be covered in the 12th Plan.It is proposed to provide resources to 150 medical colleges under the Central / State Governments or Municipal Corporation in the forthcoming Five Year Plan including further support to the recently supported PMR department in 21 medical colleges. II.Establishment / up-gradation of four centers of excellence (model Rehabilitation Institution in various regions of the country / AIIPMR like institutions) with emphasis for 1. Neuro rehabilitation (strokes) 2. Cardio-vascular rehabilitation 3. Spinal Cord Injury Rehabilitation 4. Cerebral Palsy and other Neurological Disorders in Child 5. Amputee rehabilitation These institutions will impart training disability prevention, detection and early intervention for undergraduate and post-graduate medical students and other health professionals. General Objectives1) To build capacity in the Medical Colleges for providing comprehensive rehabilitation services and to train adequate manpower required at all levels of Health Care Delivery System. 2) To build State of Art rehabilitation centers for providing quality services to conduct research and development, initiate epidemiological and HSR studies and to evolve evidence based practices.
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Sub Objectives 1. To set up an independent Department of Physical Medicine and Rehabilitation in Central / State Governments or Municipal Corporation totaling around 150 colleges. 2. To train medical and rehabilitation professionals in the districts in adequate numbers for providing secondary and tertiary level rehabilitation services. 3. Training programme on Disability Prevention, Detection and Early Intervention at Undergraduate & Postgraduate level for all Medical Officers in the participating District. 4. To train the District level Specialists and Health Professionals in disability assessment computation, prevention and Rehabilitation through CBR. 5. Provision of Rehabilitation Services in the setting of rehabilitation services in a comprehensive manner so that all clinical departments are involved and thereby to evolve a strategy of continuation of care even in the domiciliary and community set up. 6. To upgrade and develop apex PMR departments in four regions of the country for acting as a Model teaching and training centers with comprehensive service delivery system include inpatient services, Rehabilitation Surgery and community based rehabilitation services. Targets 1. Setting up of independent Physical Medicine and Rehabilitation Department in 150 medical College/Training Institutions during the end of the 12th Five Year Plan. 2. Training of 1000 Medical doctors and allied health professionals in disability assessment and early identification. 3. Develop Linkages and registration of Medical Rehabilitation to impairments and functional limitation arriving out of acute and chronic conditions undertaking treatment at Medical Colleges. 4. Development of 4 Centers of the excellence (AIIPMR like Institution) in various regions of the country. Strategy 1. It is proposed that the Govt. Medical colleges are selected in consultation with the respective states. 2. Ministry of Health & Family Welfare, Govt. of India will identify the location of the Centers of Excellence after carefully studying the availability of the trained manpower in the region for upgrading the Institutions to the level of international standards. 3. Training of Medical College students at UG level in Medical Rehabilitation by PMR faculty of the medical college. 4. Provision of Medical Rehabilitation Services to PWD viz. Medical, P.T., O.T., S.T., fitment of aids and appliance, mobility aids, counseling and follow-up. 5. Training of Medical Officers in disability assessment and computation for issue of disability certificates.

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Implementation strategya) Directorate of Medical Education of respective states along with the college authorities will identify the medical college in the district for establishing Rehabilitation Services. b) An inspecting team consisting of experts from the MoH&FW, Govt. of India will visit the concerned medical colleges and assess the existing facilities including space within the college premises for establishing the Department of PMR. The medical college will have to provide their space and infrastructure for the Department. Subsequent capacity building of the Medical College in terms of equipment and manpower keeping in conformity of MCI norms and PMR guidelines will be evaluated by the inspecting team. c) A Memorandum of Understanding between the competent authority of the State Govt. and Govt. of India will be signed for initiating the scheme. d) Once funds are released to the medical college as per the inspection team recommendation, components wise funds will be utilized by the authorities maintaining all codal formalities as per norms including procurement, manpower, recruitment, etc. as laid down under the guidelines. e) All expenditure to be accounted for and submitted to the MoH&FW through the statement of expenditure component- wise and Utilization Certificate in GFR 19A form duly audited. f) Procurement of items will be made as per recommendation of the inspecting team. g) Recruitment of manpower on contractual basis will be done as per guidelines adopting state recruitment procedure and for all non-technical posts, if recommended, would be outsourced. h) Service department will be started first and will be converted into a full-fledged teaching unit after adequately trained manpower are put in place. This will be carried out in phased manner. i) Annual review meeting of state level Nodal Officers will be held to take stock for the implementation along with feedback from the Nodal Officers for improvisation and improvement of the strategy. j) Having experienced the shortage of medical personnel training in the rehabilitation as stated earlier to be one of the main constraints, it is proposed to include training component into the scheme so that the faculty from the medical colleges designated as Nodal Officer for their PMR department will undergo orientation, in equipping them with the knowledge and skills of programme management on PMR. This will be only be required in the event of a qualified PMR Faculty being not available. k) Medical colleges already inducted in 11th Plan would be taken during the 12th Plan only when adequate manpower i.e. qualified PMR expert / orthopedic surgeon / pediatrician / general surgeon / medical specialist with six months training in designated PMR institute are appointed as independent in-charge of the department in the event of the non availability of a regular qualified PMR Faculty.

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Phase of implementation: A full-fledged teaching unit or a non teaching department of PMR, will be developed in a phased manner. Given below are the requirements for a well developed department but starting of a departing or its development can be planned according to the sources available and requirement of the facilities in the area. Phase-I: For establishing the Dept. with the appointment of a designated HOD for the Dept. of PMR. Phase-II: After Dept has been established independently & all posts or PH I filled up. Phase-III: After functioning independently and all posts of PH II filled up. Staff & Facilities(to be Inducted Phase-wise)Staff Asst. Professor Sr. Resident Jr. Resident Physiotherapist Occupational Therapist Speech Therapist/Audiologist Orthotist/Prosthetist Clinical Psychologist Staff Nurses Medical Social Worker DEO cum Record Assistant Orthoptic/Prosthetic Multi-tasking Worker Indoor Facilities (Beds) Phase I 1 1 1 1 1 1 1 1 2 1 1 2 1 6 Phase II 1 10 Phase III 14

Component-wise budget requirements1. Recruitment of manpower-:

A. Central Level Proposed No. of Annual monthly pay Posts Expenditure (Consolidated) 60000 2 1440000 30000 15000 130000 1 2 6 360000 360000 2160000

Sl. No 1 2 3

Name of Post Consultant Programme Assistant Data Entry Operator Total

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B. Medical College Level (For recruitment of manpower on contract basis in PMR department)
Proposed monthly pay (Consolidated) 55000 45000 38000 20000 20000 20000 20000 20000 20000 20000 15000 12000 9000 354000 No. of Posts 1 1 2 1 1 1 1 2 2 1 1 2 2 18 Annual Expenditure 660000 540000 912000 240000 240000 240000 240000 480000 480000 240000 180000 288000 216000 4956000

Sl. No

Name of Post

1 2 3 4 5 6 7 8 9 10 11 12 13

Assistant Professor Sr. Resident Jr. Resident Physiotherapist Occupational Therapist Speech Therapist / Audiologist Clinical Psychologist Orthotist & Prosthetist Staff Nurse Medico Social Worker DEO cum Record Assistant Orthotic/Prosthetic Technician Multi-Tasking Staff Total

2. Procurement of equipments-Rs.0.55 crore for procurement of equipments for each medical college have been proposed.Equipments would be supplied in phased manner as given below1st year of inclusion: Rehabilitation equipment for diagnosis & treatment, Workshop equipments. 2nd year of inclusion:Audio-logical & Psychological Tools, Teaching material including A-V aids. List of equipments is given below: Medical1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 3. 4. OT equipment (as per requirement) Dia. Ultrasound Port. X-ray Cystocopy Set EMG & Evoked Potential Urodynamics Gait analyzer Ventilators Cardio pulmonary monitors Balance master Short wave diathermy Wax heating Chamber Hydroculator Ultrasonic therapy 223

Physiotherapy-

 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Neuromuscular stimulator TENS lumber and cervical traction Infrared Crutches, walker Parallel bars and other ambulatory Various exercise therapy Dumbbells, pulleys, weights, suspension, systems quadriceps table. Shoulder wheel Ramp & Stairs Exercise mats Hand grip strength kit Cerebral Palsy Finger climbers Vertical & horizontal sanding Medicinal ball Assessment (ndt) kit Standing co-ordination Activity board Co-ordination activities kit for hand functions Prevocational evaluation cortical function evaluation/treatment Transfer boards Tit-table Computers for measurement Biofeedback

Occupational Therapy-

Vocational Centre1. Carpentry 2. Book binding 3. Typing and short hand 4. Computer repairing 5. Candle making 6. Knitting machine 7. Sewing machine 8. Painting 9. Watch-repairing Teaching Aids and books1. 2. 3. 4. Computer with printer LCD projector Laptop compute Library with 100 Books/Periodicals & television

3. Office expenses and maintenance- Equipments viz. desktop computer with printer, fax machine, photocopier, fax, modem, internet connection etc. have been proposed for central cell and medical colleges required for carrying out day to day office activities. This would be one time budget. However, consumables required would be recurring budget. Total cost involved would be Rs 4.40 crore.
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4. Material & supplies- Rs. 2.00 lakhs have been proposed for material & supplies for each medical college each year. This would be recurring expenditure. Total cost proposed for this component is Rs. 10.00 crore. Apex Institutions (Centre of Excellence) for Medical RehabilitationIt is proposed to Establish National Centres for Medical Rehabilitation in field of Medical Rehabilitation in 4 different parts of the country either by up-gradation of the existing Institution or by starting new centres in response to scaled up needs of disabled population. The centre will have highly trained manpower in the respective field and state of art technology for providing rehabilitation intervention to various categories of disabled as the specific needs of various categories of disabled are different. It is necessary to have focuses approach to viz. stroke and neuro rehabilitation, cardio vascular rehabilitation, amputee rehabilitation, spinal cord injuries autism and spectrum disorder etc. Each centre is proposed to have separate unit for above category of disabled and treatment guidelines on the basis of evidence, conduct research, interact with various engineering Institution periodically for designing, manufacturing of aids and appliances, assistive devices and independence devices for physically disabled.

Highly trained manpower in rehabilitation in specific areas is the need of the hour considering the fact that there is huge demand in the private sector for experienced rehab personnel. India being a premier medical tourism destination, even for western countries, the creation of centre of excellence to match international standard will also have to be taken along with proposed up-gradation of PMR department in medical colleges. Approximately budget requirement for each institution would be Rs. 50 crores excluding land cost. Budget for 4 such institution would be Rs.200 crores.

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16. National Blindness Control Program India is committed to reduce the burden of avoidable blindness. The proposal is to modify pattern of assistance to effectively reduce prevalence of blindness and develop infrastructure and Eye Care services delivery system during 12th Five Year Plan. Focus Areas: Cataract: Cataract is the leading cause of blindness contribution around 62.6% of the total cases in 50+ populations. In spite of all out efforts, there is a backlog of cataract in the country due to various reasons including inadequate eye care infrastructure, ophthalmic manpower. It has, therefore, been proposed to continue assistance for control of assistance with the involvement of NGO sector and private practitioners Refractive Error: Refractive Errors comprises a major part of avoidable blindness, which can be reduced by providing proper attention towards this problem. It has, therefore, been proposed to provide assistance for control of Refractive Error. Low Vision: keeping view large number of low vision cases, it has been proposed to assistance for control of Low Vision. Corneal Blindness and other emerging diseases like Glaucoma, Diabetic Retinopathy, and causes of Childhood Blindness like Congenital Cataract, Squint, Amblyopia etc. needs immediate attention to eliminate avoidable blindness from the country. Among the emerging causes of blindness, diabetic retinopathy and glaucoma need special mention. 6% of Indias population is expected to be diabetic. 20% of diabetics have diabetic retinopathy and this number is likely to grow in future. Prevalence of blindness due to glaucoma is estimated to be 4% in persons aged 50 years and above. Addressing Constraints under NPCB: To meet the requirement of additional eye surgeons, it is proposed to continue the 250 eye surgeons sanctioned in the 11th plan and upscale the number of surgeons to 650 in all District hospitals on contractual basis To meet the deficiency of ophthalmic assistants, it is proposed to appoint 425 additional ophthalmic assistants in District Hospitals and PHCs/Vision Centres. To make NPCB more comprehensive, assistance for eye diseases other than cataract was initiated during the 11th Plan. It is proposed to continue the same initiative during the 12th plan. For more public awareness about eye care and utilization of eye care services, IEC activities will be intensified through print, audio-visual media as well as mid-media and interpersonal counseling. New Initiatives & expansion of existing services during the 12th Plan 1. Multi-Purpose mobile ophthalmic units to be introduced at all the districts level to reach the remote areas not covered by existing facilities and to be involved in all the following activities a. Screening Eye Camp
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b. c. d. e. f. g.

School Eye Screening Transporting Patients for treatment On the spot refraction and provision of glasses Diagnosis of diseases like diabetic retinopathy, glaucoma etc. Display of IEC NPCB messages on its outer panels Monitoring of NPCB activities by DPMs

2. Construction of dedicated Eye units in District Hospitals in North-Eastern States, Bihar, Jharkhand, J&K, Himachal Pradesh, Uttarakhand and few other States where dedicated Operation Theaters are not available as per demand. 3. Appointment of the following personnel (Contractual):
1. 2 3. 4 5. 6. Ophthalmic Surgeons Ophthalmic Assistants Ophthalmic Assistants Eye Donation Counselors Data Entry Operatorss Driver cum Assistant In all District Hospitals. In PHCs/Vision Centers, where they are not available. In Eye Banks under Government Sector and NGO Sector For all the districts One for each district

4. Grant-in--aid to NGOs for management of other Eye diseases under New Initiatives as follows:Diabetic Retinopathy (a & b) a). flouroscein Angiography only b).Angiography plus complete laser treatment Keratoplasty and vitreo-retinal surgery Other major Eye Diseases ( ROP,Squint etc.) Amount in ` Upto ` 1000/- per person Upto ` 3000/- per person Upto ` 5000/- per person Upto ` 1500/- per person

5. Involvement of Private Practitioners under NPCB . 6. Maintenance of Ophthalmic Equipments supplied to Regional Institutes of Ophthalmology, Medical Colleges, District/Sub-District Hospitals, Vision Centres. Component wise comparative statement of 11th Plan and 12th Plan showing proposed increase in the existing norms and new initiatives during 12th Plan is given below: Training of Human Resources (Eye Surgeons, PMOAs, ANMs and Asha Workers) For a population of more than one billion in the country there are an estimated 20,000 eye surgeons. It is estimated that the ratio of eye surgeons in urban area is 1:20,000 and 1:2.5,0000 in rural areas,. In order to strengthen the NPCB during the 12th Plan, it has been planned to train 2500 eye surgeons in the under mentioned field of Ophthalmology to provide specialized service to Indian population in the field of eye care.
1. ECCE/IOL Implantation 2. Small Incision Cataract Surgey 227

 3. 4. 5. 6. 7. 8. 9. 10. 11.

Phaco-emulsification Low Vision Services Glaucoma Diagnosis and Management Pediatric Ophthalmology Indirect Ophthalmology & Laser Techniques Medical Retina and Vitreoretinal Surgery Eye Banking and Corneal Transplantation Oculoplasty Strabismus Diagnosis Management both Medical and Surgical

Similarly training programme have been developed for the PMOAs, ANMs and ASHA at the State level to keep them abreast with the new developments in their respective fields to benefit the public at large. IEC Since NPCB is a successfully run centrally sponsored programme, people from all walks of life should become aware of its various activities like free cataract surgery with Intra Ocular Lens (IOL), free spectacles for school children and old persons, diagnosis and treatment of corneal opacities, diabetic retinopathy, glaucoma, squint etc, It is highly desirable that the information about NPCB activities reaches every nook and corner of the country Operational Capabilities Various programme activities are implemented at central, state and district level. Organizations responsible for programme implementation at various levels are indicated below:Central Level At the central level, the National Programme management Cell in DGHS/ MoHFW would be the responsible organization. State Level The scheme is proposed to be implemented through the State Government. A State Programme Cell is already in place for which five posts including that of a Joint Director (NPCB) have been created. A State Health Society at the State level and District Health Societies at district level have been established in the States/UTs. State Health Society
Secretary (Health) Director of Health Services Representative of Finance Department One reputed expert in Ophthalmology One representative of NGO Nominee/Representative of MOHFW Joint Director (NPCB) Chairman Vice chairman Member Member Member Member Member Secretary

The function of State Health Society would be to monitor and supervise implementation of
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NPCB in the State, release and monitor flow of funds, expenditure and functioning of District Health Society, implement training and IEC activities in the State and recommend grant-inaid to NGO for non recurring grants. The mechanism would also enable the government of India to release funds for District Health Societies through the State Health Societies. This would also release pressure on the Central Government to focus more on programme monitoring and quality issues. District Level The responsible unit of implementation of the programme at the district level is the District Health Societies. It is the District Health Society which is responsible for coordinating different agencies and monitoring implementation of the programme by pooling in all the resources available. There is a proposal to create additional posts in the Government sector during the 12th plan, like one Ophthalmologist, one Ophthalmic Assistant, one Data entry operator in the Dist. Hospital, one driver cum assistant for multi-purpose district mobile unit, one Ophthalmic Assistant in PHC/Vision Centres, Eye Donation Counselors in Eye Donation Centres on contractual basis. Strategic Initiatives for improved implementation: Development of Mobile Ophthalmic Units in NE States, Hilly States & difficult Terrains for diagnosis and medical management of eye diseases. Involvement of Private Practitioners in Sub District, Blocks and Village Level. Maintenance of Ophthalmic Equipments supplied to Regional Institutes of Ophthalmology, Medical Colleges, District/Sub-District Hospitals, PHC/Vision Centres. All diabetics should be referred for regular fundus examination from all Medicine departments across the country and necessary IEC material to be developed for implementing the same. Delink all Central government hospitals& Medical colleges of Delhi from Delhi State Health society and be funded @ Rs 80 lac directly from center. In order to procure uniform and high quality cost effective equipment a Rate Contract to be established in the Central cell in NPCB for all major equipment to be specified. A technical committee to be set up at central level for specifications. Eye banks should be established in all existing RIOs. Strengthening of existing RIOs on priority and link the medical colleges for training and development. Expected Outcomes: It is proposed to perform 350 lakh Cataract operations during the period 2012-17 of which minimum of 90% operation will be by Intra Ocular Lens implantation. About 60 lakh school children with refractive error and presbyopic middle aged poor persons will be provided free spectacles. Presbyopic glasses to be provided as a new initiative to all BPL persons requiring corrective glasses for sharp near vision.
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Network of eye care infrastructure and commodity assistance in the form of equipments, consumables and drugs will be established to increase capacity of the state in providing comprehensive eye care services to the community. Increase in eye donations by strengthening eye banks and eye donation centres. Training of adequate number of eye care personnel. Reduction in disability years and increasing productivity
Physical Targets Cataract Surgery Spectacles to School Children Collection of Donated Eyes Spectacles for near work to old persons (Once in every five years) 11th Plan 300 lakh 15 lakh 2,65,000 Nil 12th Plan 350 lakh 50 lakh 3,00,000 10 lakh

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Year-wise Physical Targets during the 12th Plan (2012-2017)

2012-13 Strengthening of Facilities Regional Institutes of Ophthalmology Medical Colleges (Pediatric Ophth. /Low Vision, other sub specialties District Hospital for IOL surgery SICS/ Phaco Emulsification Sub- district Hospital for IOL surgery Primary Health Center (Vision Center) (Govt.+NGO) Eye Banks Eye Donation Center Non recurring GIA to NGO for setting up/expanding eye care units in Urban Non recurring GIA to NGO for setting up/expanding eye care units in Semi urban/Rural Development of Dedicated Eye Units. District Mobile Ophthalmic Units Services Cataract Surgery & other diseases Intervention (in Lakh) Spects to school children (in lakh) Collection thousand) Training Training of Eye Surgeons Nurses in Ophthalmic techniques Refresher Training of Ophthalmic Assistants / Ophth. Nurses. Management training of State and District Programme Managers Medical Officers PHC, CHC, DH ASHA & AWW (ICDS) 500 250 600 200 1000 1000 500 250 600 200 1000 1000 500 250 600 200 1000 1000 500 250 600 200 1000 1000 500 250 600 200 1000 1000 2500 1,250 3,000 1000 5000 5000 of Donated Eyes (in 65 3 50 65 3 50 70 3 50 75 3 50 75 3 265 350 15 265 4 30 130 20 600 4 20 2 4 30 130 20 600 4 20 2 4 30 130 20 600 4 20 2 4 30 130 20 600 4 20 2 4 26 111 20 600 4 20 2 20 2 6 130 2 6 130 2 6 130 2 6 130 2 6 111 30 631 20 146 631 100 3000 20 100 2013-14 2014-15 2015-16 2016-17 TOTAL

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17. National Deafness Control Program In the 12 F.Y.P. it is proposed to implement the programme in entire country in a phased manner, however high focus districts would be included on priority basis, with the proposed strategy as under: A. Prevention through behavior change communication (BCC) B. Capacity building (Human Resource and equipments) at different level of Health care delivery system for early identification, management and rehabilitation. C. Monitoring and evaluation

A. Prevention through behaviour change communication (BCC) The common causes of Hearing Impairment are mainly due to Congenital (mainly Rubella), Acute Suppurative Otitis Media, Chronic Suppurative Otitis Media, Secretory Otitis Media, Trauma and Noise induced hearing loss. Majority of these causes are preventable through raising awareness among the Health Care Providers and the community. For such awareness generation, various categories of mass media, community education and interpersonal communication approaches are proposed to be used. Interpersonal communication would be carried out through health care providers and grass root functionaries i.e. ASHA, AWW, SHG/ Youth Club, panchayat members etc. for which education material would be developed to facilitate IEC/BCC activities. B.Capacity building (Human Resource and equipments) at different level of Health care delivery system for early identification, management and rehabilitation The capacity building for early identification and management of hearing impaired personnel, and rehabilitation of profoundly impaired will include B.1 Training: Seven types of training are proposed as under for various catagories of health professional/ personnel at different levels of health care facilities during 12th plan. Training /sensitization of Anganwadi workers and their supervisors, teachers, ASHA and parents of disabled children will be undertaken through the budget proposed under BCC/NRHM Sensitization training for ENT doctors and Audiologists at the District level Skill based training for ENT doctors and Audiologists at the District level Obstetricians and Paediatricians at the Secondary and Primary levels. Primary level doctors posted at the CHCs and PHCs MPWs, PHNs, AWWS Anganwadi workers, ASHA Parents of disabled children

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B.2 Manpower support It is proposed to strengthen the ear care services at district and CHC level by providing manpower support such as one Audiologist, one Audiometric Assistant and one Instructor for hearing impaired at each district. Audiologist: A technical person with 4 years graduation in Audiology & Speech language pathology. The job responsibility of the Audiologist will be as under: Provision of audiological services Organizing of screening camps Assist in training programmes Monitoring and Evaluation of the Programme Maintenance of Database Audiometric Assistant: A technical person with 1 year diploma in Audiology /Audiometric Assistant, if Audiologists cannot be employed/ available under the programme. The audiometric assistant will provide support to CHC by visiting on fixed day in screening of HI persons. The job responsibility of the Audiologist will be as under: Assist in providing audiological services Assist in conduct of screening camps Assist in training programmes Monitoring and Evaluation of the Programme Maintenance of Database Teacher for the Young Hearing Impaired: It is proposed that a teacher may be inducted on contractual basis, to look after the therapy and training of the young hearing impaired children at the district level. The job responsibility of the Audiologist will be to provide training, therapy and early education for the young hearing impaired children. B.3 Equipments To strengthen the early detection and management of hearing impaired, health care facilities will be provided the financial support to procure the equipments. The details are as under: PHC: For screening of ear morbidity and detection of Hearing loss, the equipment required would be:1) Head Light, 2) Ear Specula, 3) Ear Syringe, 4) Otoscope, 5) Jobson Horne Probe, 6) Tuning fork, 7) Noise Maker CHC: For screening of ear morbidity and detection of Hearing loss, the equipment required would be: Head Light, 2) Ear Specula, 3) Ear Syringe, 4) Otoscope, 5) Jobson Horne Probe, 6) Tuning fork, 7) Noise Maker, 8)Screening Audiometer District hospital: The District hospital is an important center for the management of ear problems and deafness cases, which are referred from the health care facilities at various levels. The equipment provided at the district hospital level is as follows: a. Microscope
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b. c. d. e. f. g.

2 sets of Microdrills with 2 hand pieces and burrheads 2 sets of Micro ear surgery instruments Pure Tone Audiometer Impedance Audiometer OAE machine Sound treated room

Medical College: It is envisaged that Medical college has to play greater role under the in order to improve the quality of services a greater involvement of medical colleges is essential. It is envisaged that the each state should identify one medical college as a mentoring and referral centre for 3-5 districts (based upon geographical factors and faculty strength of the medical college). The role of the medical college should include: Availability of advanced audiological facilities must be ensured at the level of the medical college. Wherever such facilities are lacking, they will need to be facilitated under the programme. A list of equipments will be charted out from which each medical college may choose as per their requirement. B. 4 Rehabilitation and Hearing Aid provision: All patients who are identified as having an ear problem that either requires surgery, hearing aid fitting or rehabilitative therapy will be referred to the ENT doctor and Audiologist at the district level. Those who need surgery will be given the appropriate treatment at the district hospital. Complicated cases that cannot be adequately handled at the District hospital will be further referred to the Medical College for expert treatment. Patients who suffer with Sensorineural hearing loss that is not amenable to medical or surgical correction and which requires hearing aid, will be fitted with the same at the district level. This will include children who are suffering with Bilateral sensorineural hearing loss. The hearing aids will be issued as per the criteria developed for implementation of the program. It is proposed that collaboration with the Ministry of Social Justice & Empowerment will be established for this purpose. The requirement for Speech therapy and Hearing therapy will be met with by the Audiologist and Instructor for hearing Impaired at the District level. Provision has been kept to involve ASHA/ Other link workers in identification of Hearing Impaired. Accordingly incentive will be paid for assisting in fitting of HA and there maintenance. B.5 Ear Screening Camps Screening camps will be organized by the team of District ENT specialist and Audiologist at least one each month. Screening camps will be organized at the PHC/CHC and District level for screening the general population in respect of ear problems, hearing impairment and deafness.
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Detection and treatment of common ear problems. Spreading awareness regarding ear problems, early detection of deafness, available treatment and health care facilities for referral of such cases. Education of community, especially the parents of young children regarding importance of right feeding practices, various common ear problems, early detection of deafness in young children and available treatment for hearing impairment/deafness. Education of Panchayat members, members of Mahila Mandals and Youth leaders. B.6 Referral services: Effective linkages would be developed from peripheral level to district level with the help of functionaries and personnel from grass root level (AWW, ASHA and sensitized parents and PRIs), subcentre level (Male and female MPWs), PHC level Medical officers, Public health nurses, School teachers and School health doctors, private practitioners and District level officers. C. Monitoring and Supervision One of the lacunae of the programme during its implementation in the 11th 5 year plan, has been the lack of a suitable mechanism for implementation and monitoring of the programme at all levels. In order to overcome this shortcoming, there is a strong need for creation of suitably empowered Programme implementation Committees with monitoring cells at the various levels within the health care delivery system. The following actions are proposed: C.1 Strengthening Monitoring & Supervision - Monitoring of the programme components may be strengthened at all the level by creating Monitoring Cell at Central level, State level and District level.
i. Monitoring Cell at Central level 1. National Consultants 2 (Rs 60000/- per mth) 2. Programme Assistants 2 (Rs 30000/- per mth) 3. Data Entry Operator 1 (Rs 12000/- per mth) Monitoring Cell at State level 1. Consultant 1 (Rs 50000/- per mth) 2. Programme Assistant: 1 (Rs. 25000/- per month) 3. Data Entry Operator 1 (Rs 12000/- per mth) Monitoring Cell at District level 1. Consultant 1 (Rs 40000/- per mth) 2. Data Entry Operator 1 (Rs 12000/- per mth)

ii.

iii.

C.2 Advisory Committee: The advisory committee will be constituted at central , state and District level to advise, review and monitor the Program Implementation. The committee will consist of subject experts programme officers, Administrators etc.

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D. Public Private Partnership Public Private Partnership model will be adopted for early identification and management of Hearing impaired children at the district level involving private ENT specialist wherever ENT specialists are not present in the district hospital. E. Coordination with NRHM For effective implementation and monitoring of programme Timely release of funds Involvement of training centers for training of health care personnels under the programme. Involvement of ASHA and other voluntary health care workers Involvement of IEC officer for creating awareness under the programme. F. Research & Evaluation Operation Research will be conducted with respect to different aspects of programme and its components to assess its suitability in different areas. The recommendations of these will be integrated in the programme strategies for further implementation of the programme. The programme will also be evaluated at the end of 3rd and 5th year about its achievements.

G.

Key Indicators for Activities wise physical targets on coverage, output/outcomes

G.1 Manpower training: Number of different health care personnel available in the district Number of different health care personnel trained under the programme. G.2 Capacity building: Number of District Hospitals, CHCs and PHCs provided with the equipment under the programme and there usage verified by the Central observers. G.3 Rehabilitation: Number of Hearing Impaired identified for the provision of Hearing Aid Number of persons rehabilitated with hearing aids and therapy under the programme No of Hearing Impaired children rehabilitated by Hearing & Speech therapists. G.4 Service Delivery: a. Decrease in the prevalence of hearing loss in the districts. (Assessed on the basis of the Family based proformas maintained by the MPWs at the Sub centre level and the School based proformas filled by the school teachers). b. Number of screening camps organized in a district. c. Persons identified & treated with hearing loss and ear diseases at the Screening camps d. Number of ear cases referred for diagnosis and treatment to the PHCs, CHCs and District Hospitals. e. Number of patients who received treatment at the District Hospital and the State Medical Colleges.
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18. National Program for Health Care of The Elderly Health facilities will be strengthened at all levels to handle the increasing problems of the elderly. The manpower and the facilities under the NPCDCS will also be utilized to improve the health of the elderly. Health care facilities at District: At present the programme is being implemented in 100 districts covering 21 states. Keeping in view the recommendations made in National policy on older Persons and Maintenance and Welfare of Parents and Senior Citizens Act 2007, the programme will be extended to all the districts covering all the states /UTs. 540 more districts will be covered under the programme. Geriatric services in District Hospital: District hospital is being strengthened /upgraded for management of the elderly. Health professionals will be trained in problems in the elderly and home based care of the bedridden cases. All districts will have 10 bedded Geriatric Ward and a Geriatric OPD on a daily basis for care of the elderly. Under the NPCDCS, each district hospital will have a 4 to 10 bedded multi Purpose Medical Intensive Care & Stroke Unit (ICSU). Geriatric patients requiring Intensive care will also be managed in the ICSU. In addition to the existing staff support is given for contractual manpower. There will be 2 Consultants taken under contract, one of them will MD Physician and the other M.B.B.S trained in PMR for rehabilitation services. There will be 6 Nurses, 1 Physiotherapist, 2 Hospital Attendants and 2 Sanitary Attendants taken on contract who will be trained in geriatric services and their services also could be utilized for NCD services. The districts will be supported with certain essential drug list for NCD under NPCDCS & COPD which will be utilized for the health care of the elderly. Local NGOs/ community leaders will be roped in geriatric services. Under this scheme support will be given for: 10 bedded Geriatric Ward and a Geriatric OPD Drugs and consumables, Machinery, Rehabilitative appliances Transport of Referred/Serious patients IEC activities Home based care for bed ridden cases. Contractual Manpower (Consultant Medicines- 2, Nurses-6, Physiotherapist-1, Hospital Attendants- 2and Sanitary Attendants-2) Training of health professionals. Miscellaneous cost for communication, TA/DA, POL, contingency etc. District Programme for Health Care of the Elderly: Under this scheme, Geriatric Clinics will be set up in selected CHCs and PHCs. Aids and appliances required by elderly will be made available from the recurring grant. As per the NSSO survey around 8 % of the elderly are bed ridden. It is proposed to provide support for home-based care for rehabilitative
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services at the door step of such elderly patients. In case of emergency, ambulance and referral services will be provided to the elderly persons Community Health Centres (CHCs): Geriatric clinic will be set up twice a week at CHCs. A Rehabilitation Worker will be taken up on contract for Physiotherapy and medical rehabilitation services for the elderly. CHC will also be supported with certain appliances and aids for the elderly. Domiciliary visits for bed-ridden elderly and counselling to family members for care such patientsby the rehabilitation worker. The services of the staff under the NPCDCS will also be taken to facilitate the geriatric services at the CHCs. Support is also being provided for transport of referral cases, IEC activities, consumables etc. Essential drugs required for NCDs under the NPCDCS will also be utilized for the geriatric patients. Primary Health Centres (PHCs):PHC Medical Officer will be in-charge for coordination, implementation & promoting health care of the elderly. A weekly geriatric clinic will be arranged at PHC level by trained Medical Officer. Support will be given with certain appliances and aids for the elderly. Home based care will be for bed ridden cases. Support is also being provided for transport of referral cases, IEC activities, consumables etc. Sub Centres (SCs): The ANM / Male Health Workers posted will be trained for Health Care of the Elderly. Annual check-up of all the elderly at village level need to be organized by PHC/CHC. Support will be given with certain appliances and aids for the elderly. Home based care will be for bed ridden cases. Support is also being provided for transport of referral cases, IEC activities, consumables etc. Developing Geriatric Department in Medical college of each States/UTs: It is proposed to develop 12 additional Regional Geriatric Centres in selected Medical Colleges of the country in addition to 8 Regional Geriatric Centres being developed during the 11th Plan. The regions and Medical College proposed are: Chandigarh- PGIMER, Chandigarh Uttar Pradesh- KGIMS, Luvknow Jharkhand- Ranchi Medical College, Ranchi West Bengal- Kolkatta Medical College, Kolkata Andhra Pradesh- Nizam Institute of Medical Sciences, Hyderabad Karnataka- Bangalore Medical College, Bangluru Gujarat- B.J.Medical College, Ahmadabad Maharashtra- Government Medical College, Nagpur Orissa- S.C.B.Medical College, Cuttack Tripura- Agartala Medical College, Agartala Madhya Pradesh- Gandhi Medical College, Bhopal Bihar- Patna Medical College, Patna These centres will provided tertiary level of care for referred cases, undertake training programmes and research in the field of Geriatrics. Each of these Medical college will
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have department of Geriatrics with 30 beds and OPD facilities including academic and research wing. These institutes will ensure initiation of 2 PG seats for MD in Geriatric Medicine. Support will be provided for Construction/renovation/extension of the existing building and furniture of department of Geriatrics. Support will be provided for Machinery and Equipment and Video Conferencing Unit. Financial assistance will be given for the Drugs and consumables, Research Activities, Human Resources (Contractual) and training to faculty members and doctors from district hospitals. All Government Medical Colleges will be encouraged to statrt ageriatric unit. 4. National Institute of Aging (NIA): The proposal for National Institute of Aging could not be considered during 11th Plan. It is proposed to support development of National Institute of Aging in New Delhi and Chennai attached to AIIMS and Madras Medical College respectively. 5. Human Resource Development: MD in geriatric medicine is already a MCI approved course. Medical colleges to be covered under the scheme of Regional Geriatric Centre will have provision for 2 PG seats in Geriatric Medicine. Apart from this, a 6 month certificate course in geriatric medicine will be developed for training of in service candidates in these colleges. Every medical college will train 6 candidates at a time and there will be 2 session each year. 6. Research Research areas will be identified on priority which will include clinical, programmatic and operational research. A special research project on alziemers disease will also be initiated as a multi-centric study. Grants made available to Regional Geriatric Centres will be used for this purpose. Expected Outcomes 20 institutions with capacity to produce 40 postgraduates in MD in Geriatric Medicine per year Additional 6400 beds in District Hospitals and 1000 beds in Medical Colleges for the Elderly Geriatric Clinics in the OPD and Physiotherapy units in 640 District Hospitals and more than 2000 Geriatric clinics in CHCs/PHCs Free aids and appliances to elderly population Improvement in life expectancy and better quality of life of the elderly population

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19. Prevention and Control of Neurological Disorders 19.1 Epilepsy There is need to initiate interventions for managing epilepsy which will improve health outcomes and alleviate untoward social issues related to it. The issues described below justify initiation of programme to prevent and manage Epilepsy in India. Treatment gap despite availability of medicines in India: Treatment gap is broadly classified into primary and secondary. 78% of persons with epilepsy are affected by this gap122. In a highly literate population of Kerala a treatment gap of 38% has been found123. Hackett RJ in 1997 found a treatment gap of 50% in Calicut district of Kerala. In Kuthar valley of south Kashmir a treatment gap of 75% was found124. 65% treatment gap was found in the Baruipur block of west Bengal125. A very high treatment gap of 90% was found in West Bengal districts126. More treatment gap in epilepsy results in status epilepticus, death, stigma, loss of quality of life and social alienation. Various reasons have been given for the discontinuation of treatment leading to the treatment gap. 90% of the patients discontinue due to the cost factor, 21% due to unemployment, 20% due to frustration, 21% due to lack of medicines and 10% due to marital disharmony127. Treatment gap has been found to be higher in the rural areas and in the low income countries128. The main problems faced by the health care professionals are lack of diagnostic facilities (51.9%), treatment compliance (28.2%), non-availability of new AEDs (17.3%), lack of educational services (17.3%), and training (40.4%), and non-availability of epilepsy surgery by 17.3%129. Affordable treatment is available : Phenytoin, Carbamazepine, Phenobarbital and Valproic acid has been the choice of first line of treatment in most of the cases. 80% of the patients remain free from seizures on first drug, and additional 13% on a combination of two drugs. In other words 93 % of epilepsy cases are controlled with 1-2 medicines130. 90% of the seizure free patients took only the moderate dose of the drugs131. If the patient has been properly treated it would result in a seizure free life. The patient would not have personal or social stigma and the unnecessary cost of the treatment would be curtailed132. Phenobarbital has been the first choice of treatment in 96% of the developing countries, Phenytoin in 68.2%, CBZ in 42.6% and Valproic acid in 22.5%133. Objectives: 1. To reduce the treatment gap of epilepsy in the country. 2. To promote public awareness about epilepsy: alleviation of myths and misconceptions, provision of treatment and prevention. 3. To build capacity at all levels of human resource on prevention and management of epilepsy.
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Strategies: 1. Training: Health workers in the community can be effectively trained to identify cases and persuade them to seek treatment. Physicians at PHCs, CHCs and DistrictHospitals will be trained for public health aspects, prevention, differential diagnosis and diagnosis of epilepsy, particularly of generalized tonic clonic convulsions. Doctors will receive training by the GEMIND (Guidelines for epilepsy management in India- IES) and ETP (Epilepsy teaching program) on various aspects of management of epilepsy and reduction of treatment gap of epilepsy. The district medical officer will be considered as the core person to be trained in all aspects stated (public health aspects, prevention, differential diagnosis and diagnosis of epilepsy, particularly of generalized tonic clonic convulsions, febrile convulsions etc.) who in turn will provide training to the PHC doctors on essential components. Thus the emphasis will be to "train the trainers -TOT" (M. Gourie-Devi, 2003). Personnel involved in monitoring and data collection will also be trained in the use of various scales for monitoring change. 2. Awareness generation: Intensive health awareness campaign will be carried out to promote public awareness about epilepsy, its prevention, benefits of treatment, myths and misconceptions etc. Communication needs assessment will be carried out to understand gaps in knowledge and attitude towards epilepsy and treatment practices. IEC will be through multi-media including print and electronic media.Street plays and the railway network and public transportation will be deployed. The role of the chapters of the Indian epilepsy association (IEA) will be harnessed. 3. Provision of Medicines Free supply of Antiepileptic drugs (AEDs) will be provided to ensure the management of epileptic patients. First line of drugs will be made available at selected PHCs, CHCs and all District Hospitals. If required, second line of drugs can be prescribed at Medical Colleges and Tertiary Care hospitals. 4. Strengthening Medical Colleges/District Hospitals : Government Medical colleges/District Hospitalswill be strengthened with Portable EEG machine and a Technician. Each Medical college will cater 4-5 districts. Role of the medical colleges will be in diagnosis, management and training for epilepsy. A neurologist and a technician from the medical college will visit to the district hospitals periodically for EEG and management of complicated cases. Continued follow-up of patients on treatment and referral system from primary level to secondary/tertiary level hospitals will be developed under the programme. Approximate cost of Firstline medicines for epilepsy and their costs are given below, which will be made available at all levels of care.
First Line Drug for management of Epilepsy 1. Phenobarbital at 120mg/day @ Rs. 8/day 241

 2. 3. 4. 5. 6.

Carbamazepine at 1000 mg/day @ Rs. 11/day Valproic Acid at 1000 mg/day @ Rs. 12/day Phenytoin at 300 mg/day @ Rs. 11/day Intranasal Midazolam at 0.5 mg/day @ Rs 250/spray bottle Intranasal Midazolam at 0.5 mg/month @ Rs 250/spray bottle

Government Medical colleges/District Hospitalswill be strengthened with Portable EEG machine and a Technician. Each Medical college will cater 4-5 districts. Role of the medical colleges will be in diagnosis, management and training for epilepsy. A neurologist and a technician from the medical college will visit to the district hospitals periodically for EEG and management of complicated cases. Continued follow-up of patients on treatment and referral system from primary level to secondary/tertiary level hospitals will be developed under the programme. Second line medicines for treatment of epilepsy and their current prices are given below:
Drug dosage Lamotrigine 200mg/day Leviteractam 3000mg/day Topiramate 100mg/day Clobazam 30mg/day Lacosamide 600mg/day Gabapentin 2400mg/day Current price (Rs.) 32/59/20/21/47/83/-

Below is the proposed flow chart for patient follow up : Bottom up approach

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* Symptoms check list & Video identification-mobile Male/Female HW

Peripheral Health volunteer (Anganwady/Asha )

Probable Case identification

Subcenter

Case Definition
Video of sz types & Train Presumptive Type of EpilepsyMO -PHC

Sub-centre

AED

No Improvement/doubt in diagnosis

Training of all personnel

3-6 Months
Red flags- prog deficits, altred sensorium, headaches, etc early referral to CHC/Medical college

Refer PWE

CHC

Confirm Dist Hospital

CT Scan& other invstigations

No improvement /doubt diagnosis

Medical College Hospital Tertiary care hospital

MD Med MD Ped DM Neurology

(*CasedefinitionAnandK,2005Epilepsia,Seizuresinbothadultsandchildren) Top Down:

Institutions in the country region-wise Medical College (Each Medical College could adopt one three districts (based on the distribution of colleges) Government Colleges to be given more responsibility. District as a Unit Complete coverage to be ensured (through Health / ASHA Workers). IEC activity / models for awareness to be culturally specific need to be emphasized.

Monitoring Indicators: National programme on epilepsy will be monitored and evaluated on the following indicators: 1. Physicians and the doctors at the PHCs, CHCs and District Hospital trained for management of epilepsy. 2. Number & % of patients diagnosed and those provided anti-epileptic drugs (by gender) 3. Number of patients who were investigated by EEG

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19.2 Management of Developmental Delays including Autism: Introduction Developmental delay is one of the most common conditions encountered by pediatricians in clinical practice. Early identification and diagnosis have implications for treatment, genetic counseling and estimation of the risk of recurrence, management of possible associated conditions, prognostication and prevention, both at the individual and community level.134 In developing (Low and Middle Income (LAMI) ) countries,134 as childhood mortality has decreased, developmental difficulties, including disabilities, disorders, or delays in cognitive, language, social-emotional, behavioral, or neuromotor development that begin during early childhood are increasingly recognized as important Research in Western countries has shown contributors to morbidity across the life span.135-139 Burden of the Problem The World Health Organization (WHO) estimates that about 10% of the worlds population has some form of disability134. In India, 3.8% of the population has some form of disability. Reported prevalence of various forms of developmental disabilities varies from 2.5% to 9.5 % in our country.More common survey under NSSO 2002 in India showed a prevalence rate of 1.77% disabilities among all age groups 130 among children of the lowest socioeconomic class families when compared with the next-to-lowest class families. 138In a Nationwide house to house survey of 3560 children 06 years of age at Delhi, disability was identified in 6.8% of those assessed. 140As reported by Sachdeva et al in a Cross sectional descriptive study conducted in field practice areas of Aligarh on 468 children aged 03 years, as many as 7.1% of the children screened positive for global developmental delay. Maximum delay was observed in the 0-12 month age group (7.0%). In community based study from Kerala on 12520 children upto 5 years, there were a total of 311 children with developmental delay, deviation, deformity or disability giving a prevalence of 2.5% (95% CI, 2.22 2.77).141 The prevalence of developmental disabilities up to 2 years was 2.31 (95% CI, 1.91 2.71) and from 2 5 years 2.62% (95% CI, 2.25 2.99).142 Speech and language problems were observed to be the most common disabilities (29.8%). Hospital based study conducted on 200 apparently healthy children below 2 years of age attending immunization and well baby clinic in Bhopal reported prevalence of developmental delay in 9.5 % of apparently healthy children as early as three months of age by TDSC.143 Retrospective analysis of case records of 100 consecutive children attending Early Intervention Clinic in Chandigarh reported 88% of the assessed children to be mentally retarded, 50% had cerebral palsy, 25% had epilepsy and 26% had other co-morbid physical disorders. 144 Learning disorders, ADHD, behavioral problems (mainly temper tantrums and
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disobedience) and autism were seen in 24%, 12%, 10% and 4% children respectively. In majority of the children, age of acquiring speech functions was delayed even though structure and function of speech mechanism was relatively preserved Environmental causes: De-novo mutations and advanced parental age as a risk factor for ASD also suggest a role for environment. The existence of inborn genetic vulnerabilities in metabolic pathways may lower the threshold at which the influence of environmental factors may be felt, leading to an impact of environment that differs across the population based on genetic substrate. A number of environmental agents like heavy metals have been shown to demonstrate neurotoxic effects either in human or laboratory animal studies. Exposure to environmental agents with neurotoxic effects can result in a spectrum of adverse outcomes from severe mental retardation and disability to more subtle changes in function depending on the timing and dose of the chemical agent. There role is biologically plausible because they are known to disrupt enzyme functions, alter cellular signaling processes generate oxidative stress leading to apoptosis. Heavy metal poisoning is likely to be a major public health problem among Indian children especially those presenting with autistic spectrum disorders. The economic and other costs associated with neurobehavioral disabilities are tremendous. Therefore, there is an urgent need to identify potentially treatable and preventable environmental causes of at least some of these neurodevelopment disabilities. Justification for programme Research in Western countries has shown that children and their caregivers benefit from developmental monitoring during health visits in a number of ways: (1) If the child is developing typically, clinicians can provide reassurance, support parenting competence, and provide anticipatory guidance; (2) If the child is at developmental risk or has an established or emerging delay or difficulty, this can be detected early and addressed; and (3) In both situations, caregivers can be supported and informed about how to enhance their childs development. 140-145 The proposed programme will address following issues relating to ASD 1. Late referral of majority of children with developmental disabilities: Mean age of the children attending the Early Intervention clinic has been reported to be 4 years, 11which indicates that majority of the children are either referred late or that parents try out all other options before bringing over the child to EIP. 2. Need for a uniform screening tool in the country:The prevalence of developmental delay reported by various authors in different studies varies over a wide range. This could be a result of a lack of uniformity in the instruments employed to assess developmental performance.
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It has been reported that pediatricians more often referred children, who were more than 3 years of age or children with more severe disabilities, for special services. It may be possible that pediatricians rarely use developmental or behavioral screening tests, preferring to rely more on developmental surveillance in the context of normal health care provision. For screening at community level, there is a need for a standard uniform development screening tool. 3. No National guidelines for incorporating developmental screening into existing health care: In high-income countries, an important strategy for the early detection and management of developmental difficulties has been the integration of developmental monitoring of children (i.e., standardized screening and surveillance) into health care.140145 .To date, however, methods designed specifically for developmental monitoring of young children by health care providers in developing countries are lacking.135-139, 146-148. 4. Focus on identification of the domain of developmental delay targeting at specific intervention not yet practiced in India: Its vital to look at any dissociation between the domains of development (Speech and Language, Motor, Fine Motor, Personal and Social, Global). Identifying the patterns of developmental delays in children can aid in the diagnoses of neurodevelopment disorders and help anticipate the overall outcome of a childs disability. 5. Evidence in the form of muticentric studies representative of the entire country still lacking in India: The major focus of work in India has been the identification of generic disabilities through the administration of short screening tools by community based grass roots workers, such as community health workers (CHWs) and anganwadi workers (AWWs), or other grass roots workers depending on the cultural context. However all the studies have been reported from an individual institution/state and no study is yet available in India which is a representative sample of the entire country. Hence, thisproject would be the first multicentric study with representation from all parts of the nation. 6. Need for convergence at the community level, awareness raising and the involvement of local government: A large population in the South East region is rural based. It has been observed from the country reports at UNESCAP/JICA meetings on disability in 2003, that there is significantly higher prevalence of disability in general (3 5 times more) among the rural population in the region as compared to the urban. 140 Traditional western models of urban, informed health seeking behavior have not been commonly observed in the countries, due perhaps to many exclusionary factors associated with the stigma related to developmental delay and lack of awareness among professionals, policy makers, families and civil society. For spreading awareness, networking with ongoing national programs (Integrated Child Development Scheme, Family planning, etc.) is very important. Anganwari workers, multipurpose health
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137

workers, Auxiliary Nurse Midwives and Non Government Organizations working in the community need to be educated. 7. Emphasis on parent participation in both the detection of early symptoms and during intervention: Only 9% families were aware of the early signs of developmental delay, provision of disability certification and various welfare facilities provided by the central and state governments. Parents of the children with development delay are a rich resource in the community and are the childs best and first teacher. Their concerns regarding delays/deviations in development have usually proved to be right. It is therefore logical and cost effective to involve them at every step of the planning and implementation process and treat them as co therapists. 8. Human resource development for developmental screening and intervention in India In last 20 years, in India there has been a recognition that the quality and relevance of services for persons with disabilities is heavily dependent on a regular supply of well trained service providers and that investments in the development of human resources is the best strategy for the sustainability of rehabilitation services in the long run. This project also aims at training the grass root health workers along with the medical professionals at the secondary and tertiary levels of health care. Developmental delays including autism disrupt the entire family unit. The diagnosis for underlying etiology is very challenging as etiology is multifactorial. Early diagnosis and team management are necessary but the specialists involved in diagnosis and management like developmental pediatrician, child neurologist, child psychologist, geneticist, occupational therapist, physiotherapist, speech and language pathologist, radiologist, social welfare personnel and requisite resources are usually not available under one roof especially at peripheral level. Searching for diagnosis and management drains the resources of families. There is, therefore a burning need to develop centres of expertise which can liaison with peripheral health care centers to provide easily available right intervention. Programme objectives: 1. Screening of children from 0-6 years of age for developmental disabilities including autism. 2. Training of community based health workforce (AWW, ASHA, ANM, male health worker) for developmental delays and disabilities using culturally acceptable simple tools. 3. Strengthening of pediatric department of Medical College Programme Strategies: 1. Building skills and knowledge about early warning signs called red flags of autism, training on use of diagnostic scale DSM IV TRfor autism amongst pediatrician by child neurologists. The red flags include not developing: Babbling by 12 months
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Gesturing (e.g., pointing, waving bye-bye) by 12 mo Single words by 16 months Two-word spontaneous (not just echolalic) phrases by 24 months Loss of any language or social skills at any age. Community based health workers will be trained to identify the developmental delays. 2. Screening of children below 6 yrs of age: Children from 0-6yrs of age for developmental disabilities including autism with the help of community based workers. The settings of immunization clinic, anganwadis, and antenatal clinics may be used for the purpose. After preliminary screening suspected children for developmental delays will be referred to nearest tertiary health care facility or medical college. Number of screening tests has been constructed for use in LAMI countries to identify disabilities in children. There is reported no single ideal screening instrument. These instruments may need to be adapted to be culturally appropriate. 3. Child Development Resource Centre Child Development Resource Centres will be set up in Govt. medical colleges in a phased manner as multi-disciplinary centre to provide support and rehabilitative services to children and families affected by developmental delay disorders.Each medical college will be provided support for hiring following contractual manpower: Clinical child psychologist Occupational therapist Audiologist Speech therapist. Counselor Data Manager Support will also be provided for infrastructure renovation and essential tools and equipments.The programme will be linked with existing programmes on child health and NCDs.

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19.3 Dementia Challenges to manage growing problem of Dementia can be addressed through a nation-wide programme with following objectives and strategies: Objectives: 1. Nation-wide promotion of awareness, knowledge and understanding of the disease 2. Enable a human rights perspective for the people affected with the disease 3. Recognizing and strengthening the key roles of families and care givers 4. Enabling early detection, prioritize access to health and social care to the affected patients and their family members 5. Ensuring holistic treatment after diagnosis to the affected 6. Promote prevention of the disease, through ensuring research and improvements in public health Strategies for achieving the above objective 1) Provide public information about the symptoms, non-pharmacological treatment methods and the course of the disease 2) Reduce stigma by promoting understanding and awareness 3) Provide training and tools to healthcare professionals (including social workers), para medical personnel and family caregivers in managing people with Dementia-PWD 4) To encourage early assessment, diagnosis, appropriate care, and access to optimal nonpharmacological treatment through humanitarian means of love and affection. 5) Provide a legislative framework to regulate and protect the rights of those people with dementia who lack the capacity to manage their everyday lives through exclusive Dementia India Report brought out by Alzheimers Related Disorders Society of India, a National organization, dedicated to the cause since 1992, with an outreach in 15 locations all over India including all Metro cities and few mega cities. 6) Prioritize research into Alzheimers disease and other form of dementia through developing exclusive regional centres dedicated for the disease in Major cities of India. These regional centres shall provide access to primary and secondary health care services, responsive to the needs of people with dementia. These centres shall promote access to a range of options for long-term care that prioritize maintenance of independence, home and community based care and support for family care givers. These regional centres shall ensure all care environments, including (acute) hospitals and long term care institutions, safe places for people with the disease by standardizing the care parameters Engage in training people and disseminate up to date knowledge from time to time. These centres shall also ensure a standard of living adequate for health and well being, including food, clothing, housing and medical care for people with the disease from its vicinity. Activities: Specific activities thus designed essentially include the following: 1. IEC: Dementia Awareness campaign throughout the country through talks, interactive sessions, radio/TV programmes, wall writings etc.The knowledge base about the disease is extremely low especially in Medium, small towns, rural areas. Even large cities, the knowledge is very limited about the disease. This leads to low detection ratio of affected elderly who are often
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consigned to the status of senility, which is commonly attributed to old age. Such kind of fixed ideas, myths, and fallacies surrounding memory loss or insignificant behaviours needs to be dispelled in an interactive mode and needs to be emphasized, that all elderly are vulnerable to such situations, irrespective of their family backgrounds, status and lifestyles. More so, there is also complete ignorance of such disorder, hence Radio/TV programmes, Wall writings on screening/treatment service availability in the near vicinity by Panchayats, Urban Local Bodies shall ensure increased knowledge leading to access of available facilities and more correct and early diagnosis shall be possible memory problems. There are around 620 Districts all over India, it is proposed to have around 2 events each month in each district amounting to around 25 events (talks, interactive sessions, radio/TV Programmes, wall writings etc during the whole year. Thus during each year, there shall be 15500 sensitization exercises done covering an intended elderly population of each district. Large awareness programmes at Regional level need to be organized on an annual basis. Since detection of Dementia, a number of evidence based researches have been conducted world over. The large awareness programmes shall actually be conferences at Regional Level which shall show case such recent developments taken up globally in the form of presentations, papers and poster sessions. After an expert group analysis, a plenary session shall be scheduled at the end of each sessions as well as end of the conference. The participants are expected to be Doctors from all over the country, para medical staff, care givers, NGOs working in the field etc and visiting lecturers from prominent research Institution on the subject of Dementia. Each year four regional conferences shall be held to keep abreast the stakeholders informed on the innovations, development and invention of medicines etc. The deliberations at the end of each conference shall be published as compendium in different volumes to act as future repository for people seeking up to date information. 2. Training: Bi-annual Training of doctors on the nuances of Dementia and its treatment trends The care givers, family members of patients have always had horrible stories to share, when it comes to managing patients with Dementia by even educated doctors. The doctors who are little aware of Dementia, often complicate the treatment procedures of a person with Dementia, by the time they realize the course of treatment should have been different, enough damage is done. To essentially improve upon the knowledge base on handling, managing and treating people with Dementia, it has been proposed to have a training programme exclusively for doctors on a bi-annual basis. This training shall be held at all districts levels, with the help of expert organizations (ARDSI-National Office) in the field. The total number of trainings envisaged has been estimated as 1240 trainings in 620 districts. Bi-annual training of nurses/para-medical staff on the nuances of Dementia and its efficient handling needs The patient majorly remains under the care of nurses, para-medical staff. There is a great need to suitably train these care providing nurses and other staff on sensitive, correct and appropriate handling of People with Dementia. The various stages of Dementia requires
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different type of care, which shall be methodically put in to a training module and shall be taken up at each district level on a biannual basis, thus during each year 1240 trainings shall remain concluded. 3. Setting up of memory clinics at each District Hospitals Memory loss among elderly is commonly ignored and does not get diagnosed at right times leading to aggravated conditions by the time it is detected. This is mainly because of lack of knowledge and also lack of facilities. There are many methods to diagnose, however, the common evaluation is done through a small questionnaire which looks into the cognitive memory in terms of long and short time happenings, occupational, recollection, time periods etc. This lucid questionnaire is famously known as Mini Mental State Examination-MMSE, which gives a fair picture on severity of the memory impairment. However, the examination where this test is conducted needs to be established in each geriatric ward of all Distric Civil Hospitals of India. This will allow the benefit of early detection of memory disorders and for planning the right type of prognosis. A total of 620 such memory clinics shall be established and the persons manning the clinics shall be adequately trained by experts from Alzheimers Related Disorders Society of India. 4. Setting up of four Regional centres of Excellence to look exclusively into Dementia related ailments In India, there are only two Govt. institutions imparting Geriatric courses for medical students. For Dementia, there is not even a single institution offering any specific courses. Dementia management, as has been empirically evidenced, requires personalized care, which essentially differs from person to person. There are lots of efforts made using nonpharmacological interventions, which needs to be consolidated and condensed for education, moreover, lots of evidence based regional researches are required to assess prevalence, incidences, control, prevention etc. In addition the severity of the disease across different age groups of 60-65, 65-70, 70-80, 80-85 and so on needs to be methodically assessed to bring about a demographic profile and effect of the disease. Many short term, long term training programs on dementia management needs to be evolved to benefit various categories of care givers. To realize all the above needs, a Regional centre of Excellence in Dementia care and management in four major cities has been envisaged. The detailed intervention, possible outcome and financial implications are given below:

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SNo Typeof Activity 1 Dementia Awareness campsin eachDistricts (throughtalks, interactive sessions,radio programmes, wallwritings etc) Large awareness programmes atRegional levelonan annualbasis

Objectives

ProposedDeliverables/ outcome Talks interactivesessions, radioprogrammeswith doctorsandinteractive telephonicconsultation, wallwritings Publicannouncement trolleys Alltheaboveresulting morepeopleavailing diagnosisandtreatment facilitiesatdistrictslevels Seminarswithplenary sessions Participationofexperts Discussionofuptodate topics Knowledgesharing

Requirements/inputs

Tospreadknowledgeabout Dementiaanditsvarious subgroups Tourgepeoplewith memoryproblemsforearly clinicaldiagnosis Todisseminateinformation onfacilitiesavailableona permanentbasis.

Resourcepersons Radiotimeslot Provisionforwallwritings Annoucementtrolleysin panchayatsandurban localbodies. 620districtsX25 programmesperdistrict (includingmanpower)

Tospreadknowledgeabout Dementiaandworldwide developments Toupdateandcrossshare informationthrough variouscasestudies Involvenonclinical stakeholderstocontribute totheneedofdementia patients Tospreadknowledgeabout Dementiaanditsvarious subgroups Totraindoctorstoidentify possiblepatientswith memoryproblemsand referthemforadvanced diagnosis Totraindoctorson sucessfulrunningof memoryclinics. Tospreadknowledgeabout Dementiaanditsvarious subgroups Totrainnursesinefficient handlingofpossible patientswithmemory problems Totrainnursesonenabling successfulassistancein runningofmemoryclinics.

Resourcepersonsfrom variousexpertstreams fromalloverIndiaand overseas Venue eventcostsfortwodays

Biannual Trainingof doctors onthe nuancesof Dementiaand itstreatment trends

Seminarswithplenary sessions Onthejobexposure Abilitytohandle problemsfacedbyelderly withmemory deficiencies.

Exclusivegeriatricwards whichareinclusiveof treatmentfacilitiesfor variousformsof Dementia. Resourcepersonsateach civilhospitallevels Diagnosticfacilities (memoryclinicetc) Ensuringparticipationof doctorsfromeachCHCs atBlocklevels. Exclusivegeriatricwards whichareinclusiveof treatmentfacilitiesfor variousformsof Dementia. Resourcepersonsat eachcivilhospitallevels Diagnosticfacilities (memoryclinicetc) Ensuringparticipationof nursesandcaregivers fromeachCHCsatBlock levels.

Biannual trainingof nurses/para medicalstaff on thenuances ofDementia andits efficient handling needs

Seminarswithplenary sessions Onthejobexposure Abilitytohandle problemsfacedbyelderly withmemory deficiencies.

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5 Settingupof memory clinicsatEach district Civil/general hospitals Settingupof fourRegional centresof Excellenceto look exclusively intoDementia related ailments Toscreenforpossible patients withmemoryrelated problems Toenableearly identificationofpatients Tohavebestdiagnosis facilities Tohavebestbehavioural andsocialresearchfacilities TohavebestNeuroscience unit. Tohavebestpsychiatric facilities Tohaveexclusivecare givingfacilitieswitha50 beddedcapacity Todisseminateknowledge gainedintreatingunique patientsinforumsand seminars.

Functionalmemoryclinics areabletoscreenpatients withmemoryproblems efficientlyandareableto referforfurtherdiagnosis Aseparateplace designatedformemory clinicwithintheGeriatric wards. Fullfunctionalmemory clinicwithtwotrained professionalmanagingit Besttalentswith neuroscience,psychiatry andresearchbackground Acampussprawlingin around5000Sqmtswith fourfloors. Agroupoftalentedpara medicalsupportstaff Agroupoftalented administrativestaff Meetinghalls Agroupoftalented visitingdoctorsofvarious specializationstolookat variouscommon problemsthepatients sufferfromlike cardiology,diabetes, Pulmonary,stomach ailmentsetc.

Thecentresofexcellence areabletotreatacuteand chroniccasesofDementia andallitssubgroups.

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20. Prevention and Management of Congenital Diseases Objectives 1. Facilities for management of congenital level in selected institutions. 2. Human Resource & capacity building for pre-natal diagnosis and management. 3. Information, Education & Communication (IEC) for prevention of congenital disorders 4. Developing a state level registry for congenital disorders. Strategies for implementation: 1. Strengthening of Medical Colleges/institutions for diagnosis and management of Congenital Disorders Based on prevalence of congenital disorders, capacity of existing institutions and scope for strengthening, 20 medical colleges/instituions will be strengthened by additional human resources, infrastructure, equipment and other items required for management of congenital disorders. 2. Development of Laboratory Services for pre-natal diagnosis of congenital disorders Facilities for pre-natal diagnosis of congenital disorders will be made available in all Govermnment medical colleges. 3. Training of Human Resources for prevention, diagnosis and management of congenital disorders 20 primier medical institutions strengthened for managemenet of congenital disorders will also be involved in training of human resoiurces at various levels for prevention, diagnosis and management of congenital disorders. 4. IEC: Knowledge and awareness about predisposing factors that attribute to congenital disorders would be enehanced through IEC activities through mass media and interpersonal communication. Parental pre-marital and pre-natal counseling would be implemented through existing maternity services 5. Registry, Monitoring and Supervision:Registry of congenital disorders will be initiated that will give actual data on type of congenital disorders, their risk factors and distribution across the country. This will help to monitor congenital disorders averted, cases managed and their survival

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21. Prevention & Management of Genetic Blood Disorders Objectives 5. Management of individual cases. 6. Carrier detection in the community & Pre-natal diagnosis. 7. Human Resource & capacity building. 8. Information, Education & Communication (IEC) of patients, family, community and the influential political and religious members of the community. 9. Developing a state level registry for these disorders. Policies and Strategies for implementation: 1. Strengthening of Medical Colleges/hospitals for diagnosis and management of Hereditary Blood Disorders To provide comprehensive care service including diagnosis and management of Hereditary Blood Disorders, 120 Medical Colleges/hospitals will be strengthened to cover entire country. These Centres will be strengthened in a phased manner.30 new centres each year of the 12th FYP will be selected for the purpose. Unit of following professional will be required to provide such services. Haematologist/ Biochemist/Pathologist Physician/Paediatrician/ Blood bank medical officer Physiotherapist Social worker Day-care nurse Dentist Orthopaedic Surgeon General Surgeon Psychiatrist/genetic counselor.

A research Officer of Medical background and a laboratory technician will be recruited for the support of the unit The help of other specialities (Dentists, orthopaedic and general surgeons, gynaecologists and endocrinologists will be required more often than other specialities) may be sought as and when required. Core members of comprehensive care facility may meet once a week/fortnight to discuss or sort out difficult cases. If a patient needs admission after Daycare management, he /she may be admitted. The severe haemophilia patients require approximately 20,000 units of factor concentrates for on demand therapy per patient per year. As there are presently 14,000 recorded/registered patients with severe haemophilia, provision for this amount of concentrate shall be made at district hospitals/tertiary centres. Each Medical college/District Hospital will be supported with Rs. 20 lakh as one time grant and Rs.1 crore / year as recurring budget for Human Resource, drugs, reagents and other consumables.
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2. Development of Molecular Genetic Lab. for confirmatory diagnosis Molecular genetics laboratory shall be developed at 20 medical colleges which shall act as final referral centre for designated districts. These Molecular genetics laboratories will be developed in phased manner with 5 new each year of the 12th FYP. In the first year of the plan, institutes which already have some infrastructure like AIIMS, CMC Vellore, KEM Mumbai, PGI, Chandigarh and at Calcutta will be strengthened. These Institutes will also train gynaecologists/sonologists to do the prenatal diagnostic procedures for prenatal diagnosis for hereditary disorders. .The department of Haematology, AIIMS, New Delhi may coordinate the Quality Control for the diagnosis of Haemoglobinopathies and Haemophilia. National Inatitute of Immunohaematology (NIIH), Mumbai may coordinate the Quality Control for molecular testing. Each Molecular Genetic Lab will be supported with Rs. 25 lakh as one time grant and Rs.20 lakh /year as recurring budget for Human Resource, drugs, reagents and other consumables. 3. Training: There is need to have training centres for comprehensive care of hereditary disorders throughout the country. The centres like All India Institute of Medical Sciences, New Delhi, PGIMER, Chandigarh and National Institute of Immunohaematology (NIIH), Mumbai could serve as nodal training centres since these centres are already carrying out such comprehensive care. Counsellors may be trained in the psychiatric department of different medical colleges (tertiary care centres). A fully fledged DM (Clinical Genetics) programme may be developed at one of the tertiary care centres. An amount of Rs.25lakh each year will be required for this scheme. 4. IEC: Targeted IEC would be required that includes Interpersonal communication, advocacy through group leaders and religious leaders, proper signages in hospital and health care facilities etc. 5. Registry, Monitoring and Supervision: Registry of hereditary blood disorders will be initiated that will give actual data. Eventually the state should develop its own data base of patients so that regular budgeting can be done for all the activities needed to manage and contain such disorders. Govt. of India would provide technical guidelines/protocols for management of various disorders. NCD division at centre will be responsible for this. A Technical resource group will be constituted for the purpose. State and District NCD cells would take care of day to day management with the help of focal persons for these disorders. 6. Formation of an Advisory Committee for management and Control: To provide technical advice for all NCDs, A common Advisory Committee would be formed that would include at least three members of each specialised field. The committee shall direct, supervise and advice the management and community control of these diseases. The
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committee may be constituted at National, State and District level. Each of the committee, there may be Members from voluntary organizations/NGOs. Director Medical Education and Director Health Services in case of State level committee, Dean of Medical Colleges in tertiary level and Medical Superintendent in district level committees. Doctors: haematologist/ physician/ paediatrician/ biochemist/ pathologist/ public health specialist. Representative from state blood transfusion centre at each level or blood bank medical officers, as the case may be. Other officials (finance, tribal welfare, social welfare, etc.) who may be of help for smooth functioning of the programme. Community leaders. Equipment required at Medical colleges/hospitals for diagnosis of hereditary blood disorders
S.No. 1 2 3 4 5 6 7 8 9 10 Equipment Biorad: High Performance Liquid Chromatography (HPLC Instrument) Cell Counter Thermal Cycler Laminar Flow Gel Documentation System Centrifuge Gel Electrophoresis System Platelet Aggregometer Automated Coagulometer Incubator Estimated Cost (Rs. lakh) 12.00 5.00 5.00 2.50 6.00 3.00 1.00 6.00 12.00 2.00

Investigations at Medical colleges/hospitals for diagnosis of hereditary blood disorders

S.No. 1 2 3 4 5 6 Investigation Complete blood Cell Count HPLC for hemoglobinopathies Prothrombin and Activated Partial thromboplastin time Coagulation Factor Assay Platelet Aggregation Polymerase chain reaction (PCR) for mutation screening and carrier detection Cost (Rs.) 35.00 300.00 50.00 200.00 500.00 2000.00

List of 20 medical collegeswhere molecular genetics laboratory shall be developed & which shall act as final referral centres for designated districts, is given below:

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Andhra Medical College, Visakhapatnam Govt. Medical College, Chandigarh Pt. J.N.M. Medical College, Raipur All India Institute of Medical Sciences, New Delhi Maulana Azad Medical College, New Delhi University College of Medical Sciences, Delhi Pd. BD Sharma Postgraduate Institute of Medical Sciences, Rohtak Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow Seth GS Medical College, KEM, Mumbai BJ Medical College, Pune Armed Force Medical College, Pune Institute of Medical Sciences, BHU, Varanasi KGs Medical College, Lucknow Medical College, Calicut Seth GS Medical College, Mumbai SCB Medical College, Cuttack Medical College, Calcutta Post Graduate Institute of Medical Sciences, Chandigarh Center for Cellular and Molecular Biology, Hyderabad Regional Medical Research Centre for Tribals (ICMR), Jabalpur

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(B) HEALTH PROMOTION AND PREVENTION OF NCD& RISK FACTORS 22. National Tobacco Control Program Vision: To create a tobacco free Nation Mission: To reduce demand and supply of tobacco products to protect and the masses. To reduce the prevalence of tobacco use To implement the COTPA across the country. In order to carry forward the momentum generated by the NTCP during the 11FYP and baseline data generated through the GATS-India Survey, indicating high level of prevalence of tobacco use, it is imperative to upscale the programme in the 12th FYP. The proposed plan is being developed keeping in mind the learnings of the 11th FYP, the global best practices and the International obligations under WHO-FCTC. The goal of the National Tobacco Control Programme is to reduce the prevalence of the tobacco use by 5% at the end of the 12th FYP and the broad objectives are as under To build up capacity of the States / Districts to effectively implement the Anti tobacco initiatives; To train the health and social workers; To undertake appropriate IEC/BCC and mass awareness campaigns, including in schools, workplaces, etc.; To set up a regulatory mechanism to monitor/ implement the Anti Tobacco Laws; To establish tobacco product testing laboratories; Treatment of tobacco dependence To conduct Adult Tobacco Survey for surveillance, etc. It will facilitate the effective implementation of the Tobacco Control Laws and to bring about greater awareness about the harmful effects of tobacco and to fulfill the obligation(s) under the WHO-FCTC. a. National level 1. Public awareness/mass media campaigns for awareness building and behavioral change. 2. Establishment of tobacco product testing laboratories. 3. Advocacy, inter-sectoral linkages and National Tobacco Regulatory Authority (NTRA). 4. Research. 5. Monitoring and evaluation including GATS. 6. Expansion of cessation facilities 7. Tobacco Quitline and helpline b. State level Dedicated tobacco control cells for effective implementation and monitoring of anti tobacco initiatives in the state. c. District level 1. Training of health and social workers, NGOs, school teachers, enforcement officers etc. 2. IEC activities.
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3. Setting up & expansion of tobacco cessation facilities. 4. School Programme. 5. Monitoring tobacco control laws. d. CHC level 1. To integrate tobacco control strategies at CHC/PHC level under the NCD package of programmes. 2. Since tobacco is a risk factor for a number of disease viz. NCD, TB, IEC awareness and other similar activities under those programme will have a component of tobacco. Hence efforts will be directed for convergence of the programme at grass-root level with NRHM, other NCD programme Strategies & Manpower requirement National Level Public awareness/mass media campaigns for awareness building and behavioral change: The main objective of this programme is to create awareness about the harm effects of tobacco usage, second hand smoke and various provisions under the Act using a variety of media. This can be only developed through sustained round the clock IEC/BCC campaign targeting youth, women and vulnerable population through development of appropriate communication strategy, organizing awareness and sensitization camps using a mix of the media and other traditional methods so as to promote health seeking behavior. Establishment of tobacco product testing laboratories: Section 7(v) of the Indian Tobacco Control Act mandates compulsory depiction of nicotine and tar on tobacco product packages, which is in sync with the Articles - 9 & 10 of the WHO-FCTC. Four regional referral labs and one Apex lab for research is proposed to be established. The strategy adopted is to build the capacity of the existing labs rather than creating stand alone labs for tobacco testing. The global best practices and the and strategies developed by the WHO-FCTC guidelines and the recommendation of the specialist tobreg/toblabnet will be looked into while developing the protocol and framing the rules. Advocacy, intersectoral linkages and NTRA :Tobacco control is beyond a health issue as there are number of Ministries of the government who can directly or indirectly be involved is the demand and supply reduction strategy viz. Ministry of Finance taxation, Ministry of Agriculture crops, Ministry of Rural Development vocational training/ livelihood promotion, Department of Education, Ministry of Labour vocations training & administering Bidi workers welfare funds etc. it is felt that there is a need to do advocacy with them and bring them on board so that their policies are aligned to the cause of public health. It is felt that for effective monitoring of various provisions of COTPA, a dedicated set up under the Government of India having quasi-judicial powers is required. Further, since the tobacco products are proposed to be regulated for nicotine and tar content, there is a strong felt need to establish an independent mechanism, i.e. National Tobacco Regulatory Authority
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(NTRA). The proposed NTRA will be the nodal agency for monitoring and coordination with States on proper implementation of the Anti Tobacco Laws. It will also serve as the agency for following up on violation of the provisions, and will closely liaise with State Governments / Legal machinery for appropriate administrative / legal action. The NTRA would include representatives from Ministries like Commerce, Labour, Revenue, Agriculture, Expenditure, I&B, HRD, Law, Consumer Affairs and Small Scale Industries, etc. in their exofficio capacity. Research: Research on critical and cross cutting issues like alternative livelihoods to people engaged in the tobacco sector, alternative cropping system, occupational health hazards of bidi rolling, smokeless tobacco , health cost study, and other new and emerging needs to build evidence can be taken up during the 12th FYP. Monitoring and evaluation including GATS: As a part of surveillance of tobacco use GATS will be undertaken up on a timely basis to evaluate the programme. Further, in order to monitor the programme a monitoring format will be developed and data from CHC/ district level and state level will be compiled. A separate monitoring for mat for the TCC shall also be developed. Expansion of cessation facilities: As per the GATS46.6% of tobacco users who visited healthcare provider were interested in quitting smoking, and 45.2% were interested in quitting smokeless tobacco use. In addition, 38.4% of smokers and 35.4% of smokeless tobacco users made an attempt to quit tobacco use in the past 12 months. Very small percentage of tobacco users was able to access counseling services to quit tobacco use. Further, only 46.3% of smokers were advised by the health care provider to quit smoking and only 26.7%of smokeless tobacco users were advised to quit smokeless tobacco use by the health care provider. In order to address the huge demand and supply mismatch on the availability of cessation services, it is envisaged that under the 12 FYP new cessation facilities will be established in 400 medical/dental and academic institutions, PHC, CHC. Quit-line/ Helpline: In order to address to huge miss match between demand and supply of cessation services, it is proposed to establish quit-line /help line that will provide online services to those who want to quit. The latest state of Art system will be outsourced for the same. It will be established keeping in view the global best practices and the learnings from countries who have successfully established such system. Programme Management & Implementation Strategy Community Health Centre; under the 12 FYP at CHC level the infrastructure for NCD and NRHM will be used to create awareness about the harmful effects of tobacco usage. The screenings camps under NCD strategy will also be used to create about the tobacco. The counselors under NCD will also be used for cessation

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District Tobacco Control Cell: The District Tobacco Control Cell (DTCC) established at District level will be the focal point of all the activities carried out at district and sub-district level. The DTCC will be manned by Social Worker, Psychologist/ counselor, Consultant and DEO/ Progm Asst. the total budget for each Cell each year is Rs. 38.44 Lakhs. Each year 150 new DTCC will be established under the programme. At the end of the FYP about 600 DTCC will be established covering almost all the district of the country. Key components at District Level: Training of health and social workers, NGOs, school teachers, enforcement officers etc. Local IEC activities. Setting up & expansion of tobacco cessation facilities. School Programme. Monitoring tobacco control laws.
Key Deliverables activity wise Each year the programme will be covered in 150 new districts by the end of the programme 600 district of the country will be covered. 600 state tobacco cell cum cessation centres to be established covering all districts of the country. 2400 trained manpower will be available for tobacco control intervention at district level. More than 60% of the government schools will be covered through the school programme. More than 80% of the districts will have monitoring mechanisms.

Manpower at District Level Social worker Psychologist/ counselor Consultant Programme Asst / DEO State Tobacco Control Cell: The State Tobacco Control Cell (STCC) will be established in the 26 of the remaining states where the STCC have not been established under the 11th FYP. STCC will monitor and review all the activities under NTCP carried out in the state. Each STCC will have a nodal officer , identified by the Government, and it will be further be supported by State programme Manager, Consultant, DEO/ Progm Asst and a legal officer. The total budget for each STCC per year will be Rs. 36.40 Lakhs. Key components at State Level: IEC and Advocacy Training of key stakeholders including enforcement officers, schools teachers etc.
Key Deliverables activity wise All the states 35 states/UTs will be covered by NTCP and state level Tobacco control cells cum cessation centres will be established. States will develop state specific plans for implementation of the NTCP. Legal officer will be available at each state to look into the legal issues at state level. Diverse stakeholders will be sensitized and involved in tobacco control efforts at state level. State specific IEC strategy and convergence with other NCD programme will be developed. 262

Manpower at State Level State Programme Manager Programme Assistant/ DEO Legal officer National Tobacco Control Cell: The NTCP envisages setting up of a National Tobacco Control Cell (NTCC) at the level of Ministry of health & family Welfare for overall planning, strategizing, coordination, implementation and monitoring of the NTCP. NTCC will also be responsible for National level mass media, conducting research, GATS, setting up labs for tobacco product testing, fighting up the legal cases and carrying Advocacy with other stakeholder Ministry to align their policy for tobacco control. The focal point for the NTCC will be a senior officer, Joint secretary/ Addl DG from the Health Ministry and will be supported by contractual consultant for Policy, State Coordination, Legal Advisor, IEC & advocacy and support Staff in form of data manager. The annual budget for this will be Rs. 98 crore
Key Deliverables activity wise Labs will be started for tobacco product testing. IEC /Mass media campaigns will be carried out at regular period to sensitize the youth, masses and vulnerable population, evaluation will be done at the end of all the campaigns. 2nd ATS will be carried out for evaluation of the NTCP. New evidences shall be created through research on Health cost, alternative livelihood and alternative cropping. NTRA to provide a framework and strengthen the enforcement of the tobacco control will be established. 400 cessation centres in different medical /dental colleges, CHC, PHC will be established.

Manpower at National Level IEC & Advocacy Coordinator Training Coordinator Consultant Policy Consultant State Coordination Legal Consultant Data Manager/Junior Consultant

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23. Prevention and Control of Nutitional Disorders and Obesity The important nutritional disorders of public health significance are Protein Energy Malnutrition/under Nutrition, Nutritional Anaemia, Iodine Deficiency Disorders, Vitamin A Deficiency, overweight/obesity and Diet Related Chronic Non-Communicable Disorders. Goal: To prevent and control nutritional disorders both under-nutrition and overweight in the country. Objectives: To enhance public awareness about causes and consequences of nutritional disorders and obesity on health To set up facilities for assessment and counseling for prevention and management of nutritional disorders and obesity To set up physical activity promotion avenues with adequate infrastructure to demonstrate the same To initiate population based interventions for prevention of nutritional disorders and obesity Programme Strategies Strengthening of National Nutrition Cell Setting of District Nutrition Cell Advocacy and IEC activities through mass media, mid-media and interpersonal counseling Assessment, counseling and follow-up of overweight and obese students as integral part of School Health Programme Promotion of physical activities and healthy diet at schools, colleges, work places and other institutions/organizations Set up Obesity Guidance Clinic linked with NCD clinic in District Hospitals Coordination with other Ministries like Food Processing, HRD, Sports & Youth, AYUSH etc. for population based interventions Facilities for investigation and management of secondary causes of Obesity Activities: 1. Strengthening of Nutrition and IDD Cell of the Directorate In order to plan, implement, monitor and coordinate National Programme for Prevention and Control of Nutritional Disorders, five Consultants viz. Consultant (Nutrition), Consultant (Over-weight & Obesity), Consultant(Micronutrients), Consultant(Junk Food and Neutraciticals) and Consultant(Health Education) with consolidated salary in between Rs.60,000-80,000 per month; Five Programme Investigators at consolidated salary Rs.40,000-50,000 per month and five Programme Assistant at consolidated salary of Rs.30,000-40,000 are proposed.
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2. Setting up District Nutrition Cells In order to implement the activities of National Programme for Prevention and Control of Nutritional Disorders at the community level in letter and spirit one District Nutrition Consultant in 640 districts of the country is proposed at consolidated salary of Rs.40,000 per month. In addition, funds are provisioned for operationakl costs including travel within the district for monitoring and coordination. 3. Supply of Equipments The Body Mass Index(BMI) will be measured by taking weight in Kg/Height in metre2 . The machine for weight and height measurement is needed for measurement for Body Mass Index(BMI). There are about 12 lakh anganwari centres, 10 lakh primary schools and 8.5 lakh ASHAs totalling to 30.5 lakhs in the country. The programme will fund procurement of about 2 lakh sets for distribution within the health sector up to sub-centre level. Other sectors will procure these funds from their own sources (ICDS and Education Sector) 4. Community Based Interventions Advocacy on the importance of nutrition through healthy food options. Enhancement of nutrition knowledge of caregivers, children and teachers etc in the community through various intervention like lectures, group discussions, healthy food stall, display of healthy lifestyle on bulletin boards, talks by health experts, celebration of health week etc. Public should be made aware about serving size, quality of food and nutrition labeling. Coordination with other ministries like- agriculture, food processing, FSSAI, WCD etc to collaborate and plan effective population based strategies for the prevention and control of obesity in India. 5. Information, Education & Communication Generating awareness and education of the masses including parents, children, teachers and community on counseling for healthy lifestyle and healthy eating practices. Mass awareness through print and electronic media about causes, prevention and management of obesity Restrictions on advertisements related to unhealthy food Public awareness through mid-media and community based approaches like role plays, street shows etc. Development of website on healthy life style 6. School Health Programme Convergence with School Health Programme particularly on laying emphasis on importance of physical activity in schools through regular physical activity classes, regular PT/exercises, competitive sports. Physical activity/NCC/NSS and outdoor sports to be considered as an essential part of the curriculum
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Advocacy for restriction of unhealthy food in school canteens and neighborhood and availability of healthy food options Organize regular health check-up including height, weight, BMI, hemoglobin, blood pressure, blood glucose and triglycerides

7. Nutritonal Services in the Health Sector Obesity guidance clinics set up in District Hospitals and Medical Colleges run by qualified Nutritionist. Nutritional counseling as an integral component of NCD Clinics at CHC level also. Hospital based counseling sessions should be complemented by family based counseling particularly for children at risk Simple BMI calculators made available in all district hospitals, medical colleges, health centres, schools and work places. Organize training of health service providers in nutrition and related issues. Expected Outcome: Obesity Guidance Clinic in all District Hospital (640) and Medical Colleges (150) Facilities for assessment of obesity and overweight persons in health care facilities, schools, workplaces etc. to encourage regular assessments Reduction in persons with obesity and obesity related problems Enhanced public awareness about causes, prevention and management of obesity

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24. National Institute For Health Promotion & Control of Chronic Diseases Background The Central Health Education Bureau (CHEB) is a subordinate organisation of Directorate General of Health Services (Dte. GHS), Ministry of Health and Family Welfare (MOH&FW) established in the year 1956. The objective of the organisation was to plan and formulate programmes for the promotion of health education through training of health professionals, school teachers and facilitate behavioural research in the field of health education. Over the period of time there has been epidemiological and demographic transition due to increase in life expectancy leading to ever increasing geriatric population. These coupled with life style changes have led to increase in incidence, prevalence and mortality due to noncommunicable diseases notable cardiovascular diseases, diabetes, renal diseases, cancers and other degenerative diseases. Most of these diseases can be altered by health lifestyles for which continuous multisectoral approach is required for promoting health and changing behaviours. Health Promotion focuses primarily on the social, physical, economical and political factors that affect health and include such activities as the promotion of physical activity, healthy living, good nutrition, healthy environment and control of tobacco and alcohol consumption etc. The goal of Health Promotion is to improve the quality of life of individuals and communities. This goal can be achieved by mitigating the impact of risk factors associated with the broad determinants of health as they lead to illness and premature death. According to WHO, the most cost effective and economically productive intervention for non -communicable diseases are health promoting interventions, which could be in the form of one of the following: Promotion: Health Education Healthy Diet Physical activity Avoidance of Tobacco Consumption Avoidance of Alcohol Consumption Genital Hygiene for Cervical Cancer Self examination method for Breast Cancer Prevention: Early detection of disease Diagnosis of pre-Cancerous condition Diagnosis of pre-Diabetic status Diagnosis of pre-Hypertension Diagnosis of abnormal blood lipid Diagnosis of grade-I, grade-II fatty liver changes Diagnosis of over-weight / border line obesity
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Care:

Diagnosis of pre- COPD status Diagnosis of pre-dementia status Diagnosis of pre-stroke status Diagnosis of early osteoporosis Strengthening of centers for treatment facility including emergency care facility. Palliative care in terminal stage of the disease. Medical rehabilitation care.

Justification: Considering the gravity of the situation, GOI has initiated various National Programmes on NCDs which are proposed to be further expanded during the 12th Plan. The main focus of the programmes is to bring behavioural change in the life style of the community by various health promotional measures. Redevelopment of CHEB would strengthen programme implementation by providing evidence based technical support. The institute would also provide need based technical assistance to other communicable and non communicable disease programmes. National Institute of Health Promotion & CCD shall be the main coordinating and facilitating agency for all the Health Promotion related activities of the Government of India. The guidelines related to Health Promotion would be formulated and disseminated to all concerned Ministries and States/UTs. Although, Health Promotion is a multifaceted activity and requires inter-sectoral collaboration, the key roles of NIHP & CCD would be: Plan, formulate and coordinate Health Promotional activities with main focus on prevention and control of chronic diseases; Job-oriented Training of required health / non health professionals Analyse available information required for health promotional activities, identify gaps and conduct/facilitate socio-behavioural research relating to Chronic Diseases. Multi-sectoral approach in Health Promotion with other sectors including Ministries of Environment, Agriculture, Women and Child Development, Human Resource Development, Rural Development, Transport, Defence, Home Affairs, Empowerment & Social Justice, and Urban development etc. In view of the above background it is proposed to develop CHEB as NationalInstitute of Health Promotion and Control of Chronic Diseases to fulfill its redefined roles and responsibilities as a premier institute of the country for Health Promotion. Vision of National Institute of Health Promotion & CCD Promoting Health by changing life style for the people in India

Mission of NationalInstitute of Health Promotion & CCD

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To function as an apex institute to promote the health of population through integration of health promotion into the sectoral policies and development plans, advocacy, capacity building and research. Aim &Objectives To be the centre of excellence in India, for promoting health by changing lifestyle of the people through developing personal skills, strengthening community action, reorienting health services and creating supportive environment, backed by healthy public policies. Specific Objectives: 1. To review and analyze existing sectoral policies to develop healthy public policies, carry out advocacy with allied sectors in order to incorporate requisite health components in respective policies & plan for health promotion strategies that: Involve community in planning, policy-making, delivery and evaluation of health promotion strategies. Strengthen community action Build upon health promotion policies impacting on daily life patterns and local traditions of the communities Utilization of evidence in making decisions related to policy, advocacy and programme interventions 2. To create networks & foster alliances with stakeholders /partners and liaise with stakeholders in States/UTs/Local Bodies/ civil societies in: Formulating and implementing health promotion policies and plans of action Implementation of existing health promotion-related legislations and regulations, Generating finance from alternative sources. Support, foster and sustain local, regional and global partnerships, alliances and networks in harnessing new technical knowhow in order to expand multi-sectoral collaboration to promote health. 3. To conduct, facilitate and build the capacity for conducting research in areas of: Health Behavior. Measures needed to tackle the identified determinants of health. Impact of sectoral policies on health and its determinants Efficacy and Effectiveness of health promotion interventions Cost-effectiveness and sustainability of programme interventions. 4. To build a competent health promotion work force comprising specialists, practitioners and functionaries at different levels and in different sectors aiming at : Developing knowledge and skills for advocacy and mediation with peoples representatives; policy makers, managers, implementers in Govt. , Non Govt. ,private sectors & civil society
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Assessing the impact of sectoral policies on health and its determinants Accessing and using available information and evidence while planning and implementing and evaluating interventions. Use of Conventional & IT enabled on line trainings in collaboration with globally available internationally recognized courses in health promotion. 5. To develop communication strategies based on the life patterns, culture and languages of communities using lifecycle approach to enable : individuals, families and communities to perceive the threat of environment and risk factors to health Change in behavior to adopt healthy and avoid risky practices. Sustenance of healthy life style practices Documentation of best available practices in communication strategies and their appropriate utilization at local level. Identification through national and inter-national literature review of the best available health promotion intervention strategies and their applications. To empower specific vulnerable and high-risk groups by formulating setting-specific strategies to enable them to promote their health: Through ideal setting and infrastructure to support the promotion of health of a large audience by influencing "physical, mental, economic and social well-being"; By formulating workplace wellness programs.

6.

Structure of National Institute of Health Promotion & CCD Keeping in view the objectives of the National Institute of Health Promotion , the following divisions/departments have been proposed and the details of the objectives and activities of the divisions are annexed. 1. 2. 3. 4. 5. 6. Policies, Planning Strategy Development and Co-ordination Division Health Promotion Research Division Human Resource Development Division Health Communication Division Division for Healthy settings Administrative & Finance Division

Details of each Division are given hereunder:

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1.Policies, Planning Strategy Development and Co-ordination Division

Objectives To plan and develop evidence based health promotion strategies among different population groups and settings by involving multiple sectors in the country. To advocate/advise policy makers on policy measures to prepare, strengthen and re-orient health systems (structures and processes to integrate health promotion technologies and activities) to practice health promotion in the country. To advocate policy makers in nonhealth sectors to appreciate the impact of their policies on the health of the people and to develop and implement re-distributive and welfare policies to address determinants of health. To Advocate/advise the policy makers to create enabling environments in different settings (Schools, work places, industries, hospitals etc.) to promote healthy behaviours/life styles (physical activity, healthy diet, no tobacco, or excessive consumption of alcohol and responsible sexual behaviour etc.) among the people To develop necessary linkages, convergences and networks for collaborative work and to develop/ create new institutions, technologies, methodologies and tools/ or improving/upgrading existing institutions to build strong health promotion infrastructure and its institutionalization in the country. To Formulate nutrition policy for healthy India. Activities
1. Identifying Policy needs to take care of the changing disease profile of India especially emerging Non-communicable Diseases 2. Review of existing policies (both health &non-health) which have a bearing on health e.g. National Health Policy, National Population Policy, National Policy for Older persons National Nutrition Policy, National AIDS Prevention and Control Policy, National Blood Policy etc. and suggest modifications needed. e..g. The National Nutrition Policy of WCD ministry mentions the problem of over-nutrition but does not mention any intervention programme for this. National Health Policy 2002, talks about increase in expenditure on health, equity, IEC and school health but does not talk about Lifestyle diseases which contribute a significantly to morbidity and mortality. 3. To prepare, strengthen and re-orient the existing health systemsfor health promotion work in terms of Governance (to improve access to health), Financing, equity, Capacity building in coordination with HR development division and Service delivery. 4. Identify priority areas for action for the next five years in respect of Health promotion in the existing Policies and programmes especially for noncommunicable diseases. 5. Formulating new Policies based on the data generated by the Health Promotion Research Division in the identified priority areas. 6. Designing Policy strategies and guidelines 7. State consultations, meetings/advocacy workshops :Development of New Policies as well as review of existing policies will require State consultations, meeting/advocacy workshops with different stakeholders (administrators, professionals, experts, public representatives, politicians, NGOs and interest groups); Arrive at an Inference/Consensus and then recommendation to the Govt. 8. Planning for development of Health promotion InfrastructureImprovement/up gradation of old/ existing buildings for Health Promotion ; establishment of new institutions e.g. Area Specific/population-based/settingsbased/problem specific Health Promotion units at different levels i.e. State, districts and local. Policies for Use of new Technology like ICT (Information and Communication Technology) to equitably improve health literacy, by building the ICT capacity of health professionals and communities and maximize the use of available ICT tools 9. Networking, Partnerships and Inter-sectoral Coordination:To develop necessary linkages, networks and Partnerships in the priority areas for action with both National and International organizations 10. Coordination with the sectors within and outside the health system to facilitate inter-sectoral action in the areas like food security, nutrition, urban planning, integrated rural development, public transport, recreation and entertainment spaces, food adulteration etc 11.Consultancy and Advisory Services in respect of Health promotion

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2. Health Promotion Research Division

Objectives
1. To plan, design and conduct research studies on the determinants of health as well as health related behaviour, attitudes, beliefs & knowledge among members of the community with regard to desirable health practices in order to feed and support the policy makers / planners and programme implementers across the various sectors for developing, integrating and strengthening health promotion. 2. To coordinate, develop & strengthen the capacity at the central & state levels as well as South East Asia region to gather evidence through research on health promotion in order to support policy, advocacy and programmes of interventions pertaining to health promotion. 3. To plan, design and conduct research studies on various health promotional initiatives focussed on different settings for health promotion (schools, workplaces, hospitals ,specific vulnerable &high risk groups etc.) with a view to ensure their maximum utilization . 4. To conduct evaluation studies on various healths promotion initiatives taken in the country as well as on trainings initiatives to provide feedback to the programme implementers in respect of cost effectiveness, sustainability, effectiveness and efficacy of health promotion interventions. 5. To collect, review and analyse the information on health promotion research in order to document and disseminate to all stakeholders including practitioners, funders, policymakers, researchers and the general public and allied. 6. To plan, facilitate and conduct evidence based research studies to explore the efficacy and mechanism of local, regional and global partnership, alliances and networks with a view to develop, strengthen and expand multi-sectoral collaboration in harnessing new technical know-how to promote health. 7. To collaborate with universities, research and training institutions to promote research studies on various issues pertaining to health and health promotion in order to function as a knowledge hub of health promotion research.

Activities
Policy Research Policy research will include studies which provide evidence for policy-makers to develop and implement public policy for improving the health of the population. Population Health Research To explore patterns of health related behavior, attitudes, beliefs & knowledge of the community and Assessment of Health Promotion Needs Programme Development & Evaluation Generate data for for evaluating ongoing health programmes and developing health promotion interventions in collaboration with practitioners, policymakers & local communities in the identified areas as listed under the ingredients. Health Services Research Studies examining health services provision, with a particular focus on equity of access. Research networking Collaboration and coordination with other institutes for Research. Training Need Assessment in relation to Health Promotionin different focus areas for various stakeholders Documentation and dissemination of information related to health promotional research to all stakeholders. Diet and Nutrition Research food and diet survey in the country specially all States/UTs covering districts, regional diversities, recipes, nutritional disorders per se, survey, operational research, newer techniques and modifications, etc. Implementing nutrition related components of various National Programmes for chronic diseases. To conduct Diet and Nutrition Survey to find out relationships between different types of determinants including social determinants and nutritional disorders Research/ other data generation on nutrition

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3. Human Resource Development Division

Objectives Prepare and standardize training curriculum for the training of various categories of personnel from health and allied fields and peoples representatives Sensitize the govt .officials especially those involved in decision making policies at national and state level to the need of coordinating the efforts of various ministries for health promotion. provide training in health promotion through long and short term training programmes for both technocrats and bureaucrats to equip them with knowledge on various health promoting aspects requiring policy level decision To develop health promotion field laboratory for the trainees To utilize the same laboratory for field work of various divisions of NCHP To provide need based health promoting services to the selected field area throughout the year Activities 1. Identify Human Resource needed for Health promotion and develop training programmes accordingly e.g. Experts in Policy areas, Social Scientist Strategies development, Research, Biostatisticians etc. 2. Curriculum development for Training for various stakeholders in the focus areas as mentioned under Ingredients. 3. Conduct In service training programs for medical and paramedical professionals, teachers and other stakeholders 4. Conduct Need based Orientation and Sensitization courses for different stakeholders including Schools, Panchayati Raj Institutions and Community members. 5. Off campus training programs 6. Collaboration with other institutions, organizations and Health Promotion Foundations, both national and international for training purpose. 7. Conducting seminars; symposiums conferences etc 8. Use of Exhibition Ground as Field Practice area for Health promotion training.

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4. Health Communication Division

Objectives To assess the health communication needs of different strata of target audiences through operational research in collaboration with ICMR and other Research and Academic centres of excellence. To design and disseminate different tools of health communication for empowering people to have better control of their health and determinants of health To develop and promote the communication linkages with the policy makers, planners, managers and users of Health Promotion initiatives in the country To suggest tenable/feasible media plan at national level for facilitating health Communication on different health issues as per need To share the information on health communication needs with all the Stake-holders. To suggest need-based, settings based, issue based, population based Communication interventions for operationalization. To function as resource centre for health communication related data base, viz. Health communication research findings, evidences of health promotion actions, IEC/BCC instruments developed and used by different Stakeholders. To network with national and international players in this field.To map the NGOs and Private players in this field and create a vibrant network of these agencies. To develop and maintain vibrant and interactive Website on Health Promotion To bring out a monthly newsletter and other publication for wider dissemination amongst the Stake holders To create awareness about Healthy and Junk Foods, Diet Related Chronic Disorders, prevention of nutritional disorders To understand the current stressful situations and evolve steps methods, strategies for corrective healthy eating habits for overall improvement in the health and mental well beings of the community at large. Activities Designing evidence based health communication Strategies for different health programmes. Designing & production of Print & Audio Visual materials. Pre testing of the prototype Health Education Tools and Techniques Communicate key messages for Healthy living through media. Documentation and Resource centre for NCDs Networking and Coordination with all stakeholders. Monitor and follow up the communication initiatives Create & Maintain vibrant Website on Health Promotion To design and organize Health communication campaigns and allied events on focus areas mentioned above. Use of exhibition ground for Health promotion Undertake Need based IEC and BCC Projects.

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5.
Objectives

Division For Healthy Settings & Environment

Activities 1. To identify health promotion needs in respect of different health settings 2. To develop health promotion strategies for different settings e.g Name of setting Health promotion Possible Strategies needs Interpersonal communication Adolescent Health Schools/ Organizing Declamations, seminar, workshops, Healthy behaviour colleges/ Involvement of youth groups e.g. Nehru Yuva Life Skill education Universities Kendra, Campaigns, Provision of special Educating specially schools and educators for specially challenged challenged children children Hospitals Health Patient Safety and Hand Hygiene Promotion, Safe Waste centres Infection Control Disposal, Safe Surgeries, Green buildings, Healthy and Safe Landscaping , Solar Energy, Horticulture, Hospital environment Water Harvesting, Disabled friendly, Disaster preparedness Workplaces Healthy environment Executive Health programmes, fitness and yoga and healthy centres, De-Stress workshops. Provision of individuals crche and feeding areas Airports Healthy and Safe Smokers lounge, mock fire drills, Disaster environment; Food preparedness, Disabled friendly features, Hygiene and safety regular Food surveillance Hotels Healthy and Safe Smokers lounge, Fire fighting measures. safe Restaurants environment exit plan, wellness centres, Spa, fitness centre, swimming pool Food Safety Awareness & actions for safety of food Tribal and Hilly Hygiene, women and Mid-media, Folk Media, interpersonal Settings child health, nutrition communication in local dialects etc Market place Healthy environment Clean toilets, General Sanitaion, Disabled Friendly, Safe products, Fire prevention, Zoning, Safe food, Display information on food products, Waste disposal, Safe water Fairs and Mela Crowd Management, Sanitation Chlorination of water etc. Healthy environment Rain water Harvesting, Use of Solar energy, Rural settings / Village Gobar Gas plants, Smoke-free chulhas, Healthy habits, Sanitary toilets, Nutrition, Health Checkups etc. 3. Advocacy for creation of enabling environment for promoting Healthy Lifestyles in different settings. 4. To provide mechanisms for communities to identify key areas to be addressed and organize themselves and through partnerships address health and environment issues (Participatory Learning for Action). 5. To facilitate different settings for networking and information sharing 6. To provide technical support and assist in pilot projects

To help formulate healthy public

policies aimed at creating supportive environments for different settings eg. School colleges, workplaces, health facilities villages cities etc.

To help build appropriate

infrastructure and partnership mechanisms for implementation of health promotion programmes/policies for different settings.

To provide orientation and training

to various stakeholders to ensure their broadest possible commitment and participation.

To develop community-based
health and nutrition education and promotion activities/interventions that is tailor-made for different settings.

To strengthen, revise and develop

school curriculum as per the health promotional needs of children.

To formulate interventions aimed

at improving the access to essential health and nutrition care

To identify the social determinants

of physical and environmental problems under different settings, and initiate dialogue with policymakers with the aim to have them addressed.

To help forge strong linkages

among political leaders and different ministries as well as local administrations.

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25. National Programme on Patients Safety Objectives: 1. To achieve a successful, healthy outcome of patient care 2. To make the health care safe and error-free 3. To implement the globally accepted interventions to ensure the following Safety in Clinical Procedures Hand Hygiene, Surgical Safety, Injection and Blood Safety, Safe management of Bio-medical Waste (BMW) and Medication Safety These measures are also directed towards hospital infection control. 4. To achieve comfort and peace of mind for patients and providers. Tools already available for implementation Globally accepted guidelines for Hand Hygiene, infection control, surgical safety from WHO. Patient Safety and Infection control training module (developed through IGNOU) Report of National Consultation Workshop on Patient Safety including guidelines. Waste Management rules, guidelines and self learning modules Strategies It has been envisaged to implement various patient safety activities at the three levels: At central level At medical college level District hospital level Creation ofCentral Patient Safety Cell: A central patient safety cell shall be created to act as repository of information and data collected through voluntary and non punitive reporting mechanisms throughout the hospitals in the country. The cell will be equipped with one consultant, one data entry operator and necessary infrastructure and equipments. This cell will also provide technical inputs to the stakeholders with the help of experts on various issues related to all the aspects of patient safety. Later on such cells can be created at regional or state levels once the necessary expertise is developed in this subject at these levels. Development, printing and dissemination of Policies and guidelines will also be undertaken by the central cell. The cell will also undertake monitoring and evaluation. Patient safety committee - Each hospital willing to participate in this program must show its commitment by forming a Patient safety committee which will among other things oversee the functioning of Hospital Infection control committee. The hospitals must designate a trained nurse as Infection control nurse exclusively for infection control work. The committee will also do the gap analysis in their respective institutes with the help of a checklist developed for the same or through some standardized proforma. The aspects covered must
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relate to, among other things, infrastructure and policies and procedures being followed. Hospitals will be required to organize regular meetings of the patient safety committee to review various patient safety issues, adverse events reported, actions taken and maintain records of all the meetings of their patient safety committees Research: Under the programme the globally accepted interventions for ensuring Patient Safety shall be implemented, however, it is appropriate to know the magnitude of the problem to know the baseline existing situation in the country so that the progress of the programme can be assessed periodically. Research activities will be undertaken for this. Patient Safety surveys will also be undertaken at the level of each medical college and district hospital to identify the gaps and take appropriate corrective measures. Research shall also be undertaken to develop appropriate models for implementing various strategies. Awareness generation - it is necessary to create requisite awareness regarding the problem so as to draw the attention of all the stakeholders as well as community in general. Different methods can be adopted to achieve the same. Awareness generation shall be undertaken at all three levels; National, medical college and District Hospital. a. IEC - Information can be disseminated by all possible means e.g. through posters,booklets, promotional CD etc. Media, both electronic as well as print, may be used to create impact among the general public. professional bodies like IMA, Nursing associations etc. can also be utilized for spreading the message among healthcare professionals. Approriate IEC tools shall be developed at both National and State level to improve awareness. b. Advocacy workshops for all stakeholders shall be organized or academic forums like conferences etc. shall be tapped to promote patient safety. In this endeavor the services of professional medical associations and similar bodies will help in creating awareness and training programmes. A strong messages gone from them will have ripple effect. Moreover, the participation of these bodies will result in "buy in" of the concept of patient safety among healthcare professionals. c. Patient safety day shall be celebrated to highlight its importance in the country every year. Training Master trainers will be identified at National Level and if necessary capacity building of Nodal officers of the programme and Master trainers shall be organized. Mater trainers will impart Training of Trainers through workshops to train the identified trainers/ programme officers from States/Medical colleges regarding the concepts of patient safety to implement the steps in their institutions for providing safe patient care. These trained professionals shall act as Patient Safety Champions/Ambassadors for further training at the level of medical colleges/district Hospital level so as to percolate the practices at all levels of care including District Hospitals, Sub-district Hospitals and Community Health Centers. Regional Patient safety centers - Some of the medical colleges and hospitals can be encouraged to assume the role of Regional centers and they can adopt hospitals in their region for propagating the patient safety culture.
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Upgradation of existing infrastructure - Financial support shall be provided to the medical colleges and district hospitals for upgradation of the existing infrastructure including procurement of equipments to facilitate safe practices e.g. provision of hand washing facility, needle destroyers, procurement of color coded bags for BMW management etc. Activities of the Programme To implement the above strategies, the activities of programme at the three levels will be as given under Central level 1. Development, Printing and dissemination of Policies and guidelines 2. Organization of Training of trainers workshops 3. Organization of Advocacy Workshops/conferences 4. Development, Printing and dissemination of IEC tools 5. IEC activities at National level 6. Grants for Patient Safety Research projects 7. Monitoring and Evaluation Medical Colleges All 149 medical colleges will be covered during the 12th Plan. District Hospitals: All 640 district hospitals will be covered during the 12th Plan Grant-in-aid under this head shall be spent on the following activities: 1. Support for provision of Hand washing Facilities 2. Purchase of Hand Rub 3. Creation of Adverse reporting Cell 4. Purchase of BMW management equipments: autoclave, microwave, shredder, trolleys 5. Waste Bins & Bags and Puncture proof containers 6. Support for Sterilization facilities 7. Hub cutter and Needle destroyer 8. Provision of Oxymeter 9. Printing of check lists, performa 10. Support for Infection surveillance and infection control activities 11. Development of SOPs 12. Purchase of PPE 13. Purchase of mercury free equipments, Mercury Spill Management Kit etc. 14. Maintenance of Equipments

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26. Establishment of additional Airport Health Organizations (APHOs), Port Health Organizations (PHOs) and Land Border Quarantine Centres Background It is a well known fact that some communicable diseases spread from one country to another through international traffic and trade routes. Many of such diseases are very fatal and also have potential to spread very rapidly. The history is full of such instances where diseases prevalent in a country has spread to other countries causing severe damage to the mankind . Recent outbreak of swine flu pandemic is still poised to be threat to the world security. In order to prevent cross country spread of such infectious diseases, traffic restriction are being applied to the travelers and cargo since the time immemorial. However, these restrictions were not based on scientific evidences till WHO introduced international Sanitary Regulations in 1951. These sanitary regulations were renamed as International Health Regulations (IHR) in 1969 and since then are being applied by all the member countries throughout the world for the purpose of protecting their countries from invasion of dangerous infectious diseases from abroad. Since diseases enter through airports/ ports/land borders being are the main entry point of international traffic, IHR(2005) has prescribed Setting up of health units at these entry points in the time frame of 2012 which is mandatory for the member countries.. Regulatory provision In compliance to IHR every country make its own regulations on the principles set down in the IHRs. In our country there are 2 set of rules known as Indian Aircraft (Public Health) Rules, 1954, and Indian Port Health Rules, 1955 to be applied at international Airports and ports respectively. The aircraft rules are also applied to the land borders. Already there are 21 such health units functioning in our country since 1950s at various airports, ports and land border of the country for implementation of statutory regulations. Aims & Objectives The basic main aim of these health units is to implement provisions contained in International health regulations (IHR) as well as Indian Aircraft (Public Health) Rules and Indian Port Health Rules which are analogous to these IHRs in order to prevent and control international spread of public health emergencies of international concern with minimum interference to the traffic and trade. Existing infrastructure There are 21 such health units already functioning at various airport, ports and land borders of the country established under the regulatory provision. These are known as Airport Health Organization (APHO) at airports, Port Health Organization (PHO) at ports and Border Quarantine Centres at the land border The detail of these organizations are as below: APHOs: There are 7 APHOs functioning at various international airports of the country atDelhi, Kolkata, Chennai, Mumbai, Tiruchirapalli, Bengaluru, Hyderabad. Three more
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APHOs are ready to be operational and awaiting allotment of space by the Ministry of Civil Aviation. These are Lucknow, Ahmedabad, and Trivandrum. Ministry of Civil Aviation has been requested to provide space for these organizations. Out of these 10 airports 5 (Bengaluru, Hyderabad, Lucknow, Ahmedabad, and Trivandrum) are under plan scheme. PHOs: There are total 10 such organizations functioning atMumbai, JNPT NavaSheva, Kolkata, Kandla, Chennai, Cochin, Mandapam Camp, Tuticorin, Marmagoa and Visakhapatnam.Out of these 10 units 2 are working under plan scheme i.e Tuticorin and Navsheva Land quarantine border: Attari border Quarantine Centre at Amritsar is the only land border functioning at Attari border on the India Pakistan border. Functions: Following are the major functions of Port/Airport Health Organizations 1. Isolation and Quarantine work: The health screening of international passengers . 2. Disinfection, disinsection and deratting of aircrafts and ships. 3. Supervision of sanitation, drinking water supply, anti-mosquito and anti-rodent work . 4. Dead body clearance. 5. Administration of yellow fever vaccine and issue of yellow fever vaccination certificate at identified yellow-fever vaccination centres. 6. Isolation and the quarantine arrangements . 7. To attend medical emergencies. 8. VVIP food inspection. 9. Inspection of food stuff, catering establishments inside the premises of airport and ports under the Prevention of Food Adulteration Act. 10. Sampling of imported food items and forwarding the lab analysis report, as and when requested by custom authorities. 11. Licensing of eating establishments within the local limits of airports as per the provisions of PFA Act, 1955. The Organizations use to keep constant vigil on all the factors leading to outbreak of diseases of international concern and take all preventive measures to safeguard countrys health. The effective roles played by APHOs and PHOs in preventing the spread of SARS and swine flu in India is well known. Need for strengthening the existing organizations At present, there are 10 APHOs and 10 PHOs and one border quarantine centre are in place. Most of these unit were established way back in 1950s and since then are functioning with almost same sanctioned manpower even though the workload has increased manifold during all these years due to increase in the international traffic. There is urgent need to strengthen the organizations in terms of technical manpower. Need for continuation of existing units Out of the 21 units 7 are working under plan scheme and being statutory in nature , continuation of the organization is essential till these schemes are converted in to non plan scheme.

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Need for creation of additional APHO/PHOs At present, there are 25 airports, 12 ports and 7 international land boarders catering to international traffic where as the health units are functioning only at 10 airports, 10 ports and one Land border. If the remaining 23 entry points to international traffic are not equipped with proper health infrastructure, the whole purpose of existing units will be diluted. Further, like custom and immigration, these are statutory organizations and every airport/port/Land border needs to be established under provision of Indian Aircraft (Public Health) Rules and Indian Port Health Rules. The list of these places is given below: List of new International Airports, Ports &Land borders Airport Port 1. Amritsar 1. New Mangalore port 2. Calicut 2. Paradeep (Orissa) 3. Cochin 4. Coimbatore 5. Varanasi 6. Goa 7. Jaipur 8. Nagpur 9. Pune 10. Srinagar 11. Gaya 12. Port Blair 13. Guwahati 14. Bagdogra 15. Patna Proposal for consideration of 12th Plan Continuation of existing plan scheme There are 2 plan schemes already running to operationalise 7 ( 6 +1) such units. As explained above, these are performing statutory nature of functions and hence needs to be continued. Detail of these units is mentioned under the heading of Existing Infrastructure. Total expenses required for these two schemes during the 12th plan will be to the tune of Rs. 12 crores approx. Strengthening of existing plan and non plan units As mentioned in the proposal, there are 21 units of APHOs/PHOs functioning at various international airports/ports and land border of the country. These units were created way back in 1950s and since then these are working with the same manpower, although, the workload has increased tremendously due to increase in the international traffic. In view of this, there is an urgent need to strengthen the technical manpower in terms of medical officers, health inspectors and nurses of these organizations. As per the guidelines, the
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Land Border 1. Raxaul ( Bihar) 2. Jogbani ( Bihar) 3. Akhaura (Tripura) 4. Petrpole( West Bengal) 5. Dawki (Meghalaya) 6. Moreh ( Manipur)

additional manpower strength has been calculated. There is a need of 39 medical officers, 38 health inspectors and 16 nurses additionally required for which an amount of Rs 20.5 crores approximately will be needed during the entire Five Year Plan. Details of the proposal are given below. Introduction The APHOs/PHOs are the statutory health units of ministry of health and FW functioning at various international ports and airports of the country under provision of Indian Aircrafts (Public Health) Rules 1954 and the Indian Ports Health Rules, 1955. The objective of these units is to protect the country from invasion of dangerous infectious diseases like swine flu from abroad. At present, there are 10 APHOs and 10 PHOs and one border quarantine centre are in place. Most of these unit were established way back in 1950s and since then are functioning with almost same sanctioned manpower even though the workload has increased manifold during all these years due to increase in the international traffic. Details of these airports and their location are given below: Out of these 21 units, 7 units are functioning under Plan scheme which was approved in 2004. Airport Health Organizations (APHOs): There are 10 APHOs functioningat various international airports of the country at Delhi, Kolkata, Chennai, Mumbai, Tiruchirapalli, Bengaluru, Hyderabad. Lucknow, Ahmedabad, and Trivandrum. Port Health Organisations (PHOs) :There are total 10 PHOs functioning at Mumbai, JNPT NavaSheva, Kolkata, Kandla, Chennai, Cochin, Mandapam Camp, Tuticorin, Marmagoa and Visakhapatnam. Land quarantine border: Attari border Quarantine Centre at Amritsar The load of international traffic has tremendously increased during the last few decades. However, the staff strength has not increased since their inception. Consequently, the units are not able to discharge the statutory functions smoothly due to paucity of technical staff. But otherwise are fully equipped in terms of infrastructure to undertake these responsibilities. Under such circumstances when there is emergence of a dangerous diseases like swine flu, Avian influenza, SARS etc. it is felt necessary to strengthen these units in terms of technical manpower. In this connection, the guidelines have been framed by Directorate General of Health Services for the minimum requirement of manpower in the existing circumstances of repeated outbreak of dangerous diseases of international concern. Minimum technical staff required as per laid down criteria for each unit :
To be filled To be filled in Minimum during 12th plan during 13th plan Requirement 4 3 Medical Officer 7 1 3 Nursing staff 4 4 4 Health inspector 8 10 9 Total 19 Post 282

Additional Manpower and financial implication Accordingly, the details of existing strength of various types of manpower and the required strength have been calculated and are reflected in the following table: Medical Officer
S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. TOTAL Name of Organisation APHO,Chennai APHO,Tiruchirapalli PHO,Chennai PHO,Kandla PHO,JNPT,Sheva PHO,Cochin PHO,Vishakhapatnam PHO,MandpamCamp PHO,Marmagoa ABQ,Amritsar PHO,Tuticorin APHO,Bangalore APHO,Hyderabad APHO,Lucknow APHO,Ahmedabad APHO,Trivendrum Existing Strength 2 2 2 2 3 2 2 1 1 2 1 1 1 1 1 1 25 Proposed Strength in 12th plan 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 64 Additional requirement 2 2 2 2 1 2 2 3 3 2 3 3 3 3 3 3 39 Expenditure per head p.m. 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 52,844 Expenditure on additional strength p.m. 1,05,688 1,05,688 1,05,688 1,05,688 52,844 1,05,688 1,05,688 1,58,532 1,58,532 1,05,688 1,58,532 1,58,532 1,58,532 1,58,532 1,58,532 1,58,532 20,60,916 Expenditure per annum on the excess strength 12,68,256 12,68,256 12,68,256 12,68,256 6,34,128 12,68,256 12,68,256 19,02,384 19,02,384 12,68,256 19,02,384 19,02,384 19,02,384 19,02,384 19,02,384 19,02,384 2,47,30,992

Health Inspector
S. No. Name of organisation Existing Strength 1 0 2 2 2 2 2 1 1 1 2 2 2 2 2 2 26 Proposed Strength 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 64 Additional requirement 3 4 2 2 2 2 2 3 3 3 2 2 2 2 2 2 38 Expenditure per head p.m. 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 26,851 Expenditure on addl.manpower p.m. 80,553 1,07,404 53,702 53,702 53,702 53,702 53,702 80,553 80,553 80,553 53,702 53,702 53,702 53,702 53,702 53,702 1020338 Expenditure per annum on addl. strength 9,66,636 1,288,848 6,44,424 6,44,424 6,44,424 6,44,424 6,44,424 9,66,636 9,66,636 9,66,636 6,44,424 6,44,424 6,44,424 6,44,424 6,44,424 6,44,424 1,22,44,056

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. TOTAL

APHO,Tiruchirapalli PHO,Chennai PHO,Mumbai PHO,Kolkata PHO,Kandla PHO,JNPT,Sheva PHO,Cochin PHO,Vishakhapatnam PHO,MandpamCamp PHO,Marmagoa PHO,Tuticorin APHO,Bangalore APHO,Hyderabad APHO,Lucknow APHO,Ahmedabad APHO,Trivendrum

Staff Nurse
283


S. No. Name of organisation Existing Strength 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Proposed Strength 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 16

Additional requirement 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 16 Expenditure per head p.m. 26,851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 Expenditure on additional manpower p.m. 26,851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 26851 4,56,467 Expenditure per annum on the additional strength 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 3,22,212 54,77,604

1. APHO,Tiruchirapalli 2. PHO,Mumbai 3. PHO,Kolkata 4. PHO,Kandla 5. PHO,JNPT,Sheva 6. PHO,Cochin 7. PHO,Vishakhapatnam 8. PHO,MandpamCamp 9. PHO,Marmagoa 10. PHO,Tuticorin 11. APHO,Bangalore 12. APHO,Hyderabad 13. APHO,Lucknow 14. APHO,Ahmedabad 15. APHO,Trivendrum 16. APHO,Chennai 17. ABQ,Amritsar TOTAL

As far as the overhead expenses and recurring and non-recurring costs on these organizations is concerned with respect to infrastructure and equipments,existing organizations are fully equipped and there will not be any additional overhead expenditure. Setting up of 23 new units under 12th plan Background It is a well known fact that some communicable diseases spread from one country to another through international traffic and trade routes. Many of such diseases are very fatal and also have potential to spread very rapidly. The history is full of such instances where diseases prevalent in a country have spread to other countries causing severe damage to the mankind. Recent outbreak of swine flu pandemic is still poised to be threat to the world security. In order to prevent cross country spread of infectious diseases, traffic restriction are being applied to the travelers and cargo since the time immemorial. However, these restrictions were not based on scientific evidences till WHO introduced international Sanitary Regulations in 1951. These sanitary regulations were renamed as International Health Regulations (IHR) in 1969 and since then are being applied by all the member countries throughout the world for the purpose of protecting their counties from invasion of dangerous infectious diseases from abroad. Since diseases enter through airports/ ports/land borders which are the main entry point of international traffic, IHR(2005) has prescribed Setting up of health units at these entry points in the time frame of 2012 which is mandatory for the member countries. At present, there are 25 airports, 12 ports and 7 international land boarders catering to international traffic where as the health units are functioning only at 10 airports, 10 ports and
284

one Land border. If the remaining 23 entry points to international traffic are not equipped with proper health infrastructure, the whole purpose of existing units will be diluted. Further, like custom and immigration, these are statutory organizations and every airport/port/Land border needs to be established under provision of Indian Aircraft (Public Health) Rules and Indian Port Health Rules. Reasons and justifications With the globalization of trade and traffic, there has been manifold increase in the international traffic and with this the probability of international spread of diseases from one country to other has also increased. The spread of such diseases can be prevented by applying appropriate health measures to the traffic and cargo in a scientific manner at the entry point of international traffic which are Airports, Ports and land borders. Along with increase in the volume of traffic, there has been emergence and re-emergence of a number of deadly diseases of international concern like SARS, Swine Flu, Avian Influenza, Ebola Virus disease etc. These diseases spread very rapidly and can assume the pandemic form in a short span of time unless necessary preventive and control measures are undertaken in time. If any of these diseases are introduced in the country, the extent of human loss as well as economic damage will be unimaginable. Hence, the establishment of health organizations has indirect benefit on the countrys economy by preventing large scale morbidity and mortality. Infrastructure requirement for Organizational setup There are already 18 units functioning in the country many of which were established way back in 1950. Basic requirement for setting up these organizations are mainly manpower and space. Requirement of space space for discharging health screening responsibility; space for administrative office,; space for isolation and quarantine facilities including Yellow Fever vaccination.

For this purpose, a minimum space of 600 sq. feet of space is required both in arrival and departure hall of the point of entries and 1500 sq meter of constructed space for isolation and quarantine facilities within the airport premises at each airport. The organizations are being set up under statutory requirement and hence, it is the responsibility of the respective administrative agencies at airport/port/land borders for providing rent free space. Manpower requirement Doctors, health inspectors and supportive staff required for each unit are given below:

285

Manpower Requirement Per unit on regular basis

Type of Manpower 1. Medical Officer 2. Nursing staff 3. Lab Technician 4. Health inspector 5. LDC/UDC 6. Food inspector Total Number Required 7 4 2 8 3 1 25 To be filled in Phase-I 4 2 1 4 2 1 14 To be filled in Phase-II 3 2 1 4 1 0 11

Staff per unit to be outsourced

Name of the posts Health Assistant Ward Assistant Field Worker Peon Data Entry Operator Safaiwala Driver Total Number required 8 8 8 1 1 1 3 30 To be filled in Phase-I 4 4 4 1 1 1 2 17 To be filled in Phase-II 4 4 4 1 13

Requirement of regular manpower and financial implication per year

Type of Manpower Total requirement To be filled in Phase-I 23x 4 =92 23x 2=346 23x 1=23 23x 4=92 23x 2=46 23x1=23 322 To be filled in Phase-II 23x 3 =69 23x 2 =46 23x 1 =23 23x 4 =92 23x1=21 Nil 253 Financial implication per annum Phase-I 58339776 14821752 7410876 29643504 8427384 7410876 126054168 Approx. 12.60 crore Financial implication per annum Phase-II 43754832 14821752 7410876 29643504 4213692 Nil 99844658 Approx. 9.98 crore

1. Medical Officers 2.Nursing staff 3. Lab Technician 4.Health inspectors 5. LDC/UDC 6. Food Inspector Total

23x7= 161 23x4=92 23x2=46 23x8= 184 23x3=69 23x1=23 575

286

Total requirement of out sourced staff and financial implication per year

Number Type of manpower Health Assistant Rs 12000/- pm Ward Assistant Rs 10000/-pm Field Worker Rs 10000/- pm Peon Rs 8000/- pm Data Entry operator Rs 10000/- pm Safaiwala Rs 8000/- pm Driver Rs 12000/- pm Total required 23x8=184 23x8=184 23x8=184 23x1=23 23x1=23 23x1=23 23x3=69 690

To be filled in Phase-I 23x4=92 23x4=92 23x4=92 23x1=23 23x1=23 23x1=23 23x2=46 391

To be filled in Phase-II 23x4=92 23x4=92 23x4=92 23x1=23 299

Financial Implication per year Phase-I 132.48 lacs 110.4 lacs 110.4 lacs 22.08 lacs 27.60 lacs 22.08 lacs 66.24 lacs 491.28 lacs (Rs. 4.91 crore)

Financial Implication per year Phase-II 132.48 lacs 110.4 lacs 110.4 lacs 33.12 lacs 386.4 lacs (Rs.3.86 crore)

Staffing norms The functioning of these organizations are of statutory nature and therefore require round the clock deployment of the staff because of round the clock movement of flights/ships. Apart from statutory functions related to passenger screening which are performed round the clock, there are many routine functions to be performed during daytime. Important day time routine works are; Vaccination, Supervision of sanitation and food hygiene, Dead body clearance, Licensing of catering units within the premises of airport/port and vector control activities etc. For round the clock arrangement, at least four sets of manpower of all categories are required. Further, strength of the categories of manpower in each shift depends on the passenger load. Based on the past experience, bare minimum strength of manpower is being proposed uniformly for all the units to maintain round the clock functions. The posts will be of floating nature and would be distributed according to work load. A meeting of experts under the Chairmanship of DGHS formulated minimum core requirements in terms of space and manpower at each airport, port and land borders. The space and manpower suggested by this committee will be the basis for deciding the total requirement for this purpose. Deployment of manpower will be done in two phases and as mentioned above, the post will be of floating nature so that adjustment of staff can be made depending upon the passenger load at a particular place. some post carrying higher responsibilities will be of permanent nature and rest of the posts will be out sourced. Details of these posts are at annexure- III.

287

Timelines All the units will be established during 12th plan period. However, manpower deployment will be in 2 phases. The 1st phase of manpower deployment will be completed during 12th plan period whereas 2nd phase will be implemented in 13th plan period. Non recurring expenses: Purchase of necessary material and equipment for establishing a fully operational unit. Minimum office automation with furniture, computers, printers, fax, etc will be required. Besides the above, necessary equipment will also be required for vector control measures like sprayers, equipment for checking breeding of mosquitoes, etc. A lumpsum amountRs. 1 crore for each unit is proposed for each unit. Following articles will be procured for Each unit: Furniture & Electrical Fixtures including fans, ACs, De-freezer Computer, FAX, Photocopier, Conferencing & communication System Equipped Ambulance Insecticides Spray Machines, Beds, Ventilators, ECG Machines.
Designation Average basic pay +NPA 26250 13500 13500 13500 13500 7100 7100 7100 7100 7000 DA 51% HRA 30% TA AA Monthly emoluments for each post 52844 26851 26851 26851 26851 15267 15267 15267 15267 13576 Yearly emoluments for each post 634128 322212 322212 322212 322212 183204 183204 183204 183204 162912 Total No. of posts Total Yearly emoluments

Medical Officer (15600-39100)+ 5400 Staff Nurse (9300- 34800)+ 4200 Lab Technician(930034800)+ 4200 Health Inspector(930034800)+ 4200 Food Inspector (930034800)+ 4200 Health Assistant(520020200)+ 1900 Ward Assistant (520020200)+ 1900 LDC +DEO+Accountant (5200- 20200)+ 1900 Driver(5200- 20200)+ 1900 Field Worker (520020200) + 1800 TOTAL

13387 6885 6885 6885 6885 3621 3621 3621 3621 3570

7875 4050 4050 4050 4050 2130 2130 2130 2130 2100

4832 2416 2416 2416 2416 2416 2416 2416 2416 906

500 -

17x3=51 17x2=34 17x1=17 17x4=68 Nil 17x4=68 17x4=68 17x1=17 17x2=34 17x4=68 425

32340528 10955208 5477604 21910416 Nil 12457872 12457872 3114468 6228936 11078016 116020920

288

SEC CTION 5 BUDGE REQUIR ET RED FOR P PREVENTI ION & CON NTROL OF F TH NON-COMM N MUNICABL DISEAS FOR TH 12 FIV YEAR P LE SES HE VE PLAN Disease-w Budget: wise It is envi isaged that for compreh hensive and sustainable programme to prevent control an es t, nd manage i important no on-communi icable diseas and key r factors a ses risk across the co ountry, a larg ge investme would be required du ent e uring the 12th Plan. Rs. 58072 crore would be required ove 2 e er the perio 2012-17. Cancer, Dia od abetes, Cardiovascular D Diseases, Ch hronic Lund Diseases an nd Chronic Kidney Dise ease accoun for most o the morta nt of ality due to N NCDs and would requir w re substanti budget. T ial Trauma, Disa asters, diseas of bones & joints, mental disorde and healt ses ers th care of th elderly ar disabling diseases and requiring investment f not only treatment bu he re d i for ut th also reha abilitation. Disease-wise Budget req D e quired durin the 12 P ng Plan is depic cted in graph hs below:
Rs. cror re
20000 15000 10000 5000 0

15855 8480 8447 7 5392 42 223 3908 3147 3050 3 2121 180 1648 02

Percentag ge
Cancer

6 8 8

4 3

31

Diabetes s,CVD,Stroke, ,CKD,COPD Trauma,Burn,Disasterresponse&EMS MentalH Health MusculoskeletalDisea ases,PMR

17 11 16

Blindness&Deafness HealthCa areofElderly Oral,Neu urological,Genetic,Congen nital TobaccoControl&Hea althPromotio onetc. Nutrition nalDisorders& &ObesityCon ntrol OrganTr ransplant

289

Compon nent-wise Bu udget: NCDs ha affected both urban and rural pop ave a pulation though there m be some differences i may in prevalenc It is also important t invest on preventive programmes and health promotion t ce. o to p s to check oc ccurrence of new cases and reduce at risk popu f ulation. The proposal th herefore seek ks budget fo activities across that will not onl result in p or ly prevention o NCDs but also develo of t op facilities with capaci to manag NCDs. The programm will red ity ge mes duce morbid dity, disabilit ty tality due to NCDs and add on prod ductive year for the po rs opulation. Th investmen he nt and mort will be co ost-effective in long run e n. Nearly one-fourth of the budget would be re f equired for p primary heal care in th rural area lth he as. Secondar and tertia level care is importa to mange these chron and fatal diseases an ry ary e ant e nic l nd injuries a large sh and hare of the b budget would be require to upgrad and streng d ed de gthen District Hospitals Medical Colleges and other Tertia level inst s, C ary titutions. Many of the NCDs o f occur due to exposure to risk factors like tobacco obesity, unhealthy die o, u et, lack of physical activ and stre Adequat provision has been m p vity ess. te made for pub awarenes blic ss and beha aviour chang communic ge cation, an im mportant step to prevent NCDs. Com p t mponent-wis se budget is shown in ta and grap below: s able ph
Compon nent PrimaryHealthCare DistrictH Hospitals MedicalColleges& TertiaryCareInstitute es Training HealthP Promotion&I IEC Program mManagemen nt M&E Others Total Rs. crore 10875 5 19905 5 7 20397 1354 4 2449 9 1101 1 1190 0 801 1 58072 2 %
2.3% 1.9% 2.0% 1.4% 4.2% 18.7%

18.7 34.3

35.1%

35.1 2.3 4.2 1.9 2.0 1.4 100.0

3% 34.3

PrimaryHealthCare DistrictHospitals D MedicalCollege M es&TertiaryCare Training T HealthPromotion&IEC H ProgramManag gement M&E M Others O

Program mme-wise Bu udget: Budg for each p get programme is given in d details below w:

290

Prevention and Control of Cancer Rs. in Crore Component National Cancer Institute (Minimum 400 beds) Capital Grant (one-time) for construction/ equipment Recurring Grant (HR, Drugs, Consumables, maintenance, training etc.) @125 cr./year Total for National Cancer Institutes CNCI, Kolkata (including 2nd campus) State Cancer Institutes (Minimum 150 beds) Capital Grant (one-time) for construction/ equipment Recurring Grant (HR, Drugs, Consumables, maintenance, training etc.) @25 cr./year Total for State Cancer Institutes Tertiary Cancer Centres (Minimum 50 beds) Capital Grant (one-time) for construction and equipment (e Recurring Grant (HR, Drugs, Consumables, maintenance, training etc.) @ 2 cr./year Total for TCCs District Cancer Centres (Minimum 10 beds) Capital Grant (one-time) for equipment/ renovation Recurring Grant (HR, Drugs, Consumables, maintenance, training etc.) @1.5 cr./year Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for DCCs Cancer Registry, Monitoring and Research Training of specialists (Central Activity) IEC Activities Total for Cancer Control during 2012-17 50.00 25.00 50.00 5 5 5 1.50 1.50 1.50 1.50 1.50 200 300 400 500 640 300.00 450.00 600.00 750.00 960.00 3380.00 250.00 125.00 250.00 15855.00 0.50 640 320.00 15.00 2.00 100 100 1500.00 1000.00 2500.00 150.00 25.00 20 20 3000.00 2500.00 5500.00 1000.00 800.00 125.00 2 2 1600.00 1250.00 2850.00 1000.00 Unit Cost No. Total

291

Prevention and Control of Diabetes, CVD & Stroke

Rs. in Crore Component District Hospital Upgradation (NCD Clinic, Cardiac Care Unit etc.) Capital Grant (one-time) for equipment (1.5 cr) 1.1 and renovation (0.5 cr) Recurring Grant (HR, Drugs, Consumables, 1.2 maintenance, training etc.) @0.5 cr./year Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for District Hospital upgradation 2 District NCD programme: NCD Clinic at SDH/CHC, Screening for NCDs, Glucometers, Kits, Medicines, Referral etc. Capital Grant (one-time) for equipment and renovation @Rs. 20 lakh/district Recurring Grant (HR for NCD Clinic at CHCs, Kits, Drugs, screening, referral etc.) @ 1 cr./year Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for District NCD programme 3 Strengthening of Medical Colleges Non-recurring grant for Cardiology, 3.1 Endocrinology and Neurology Departments Recurring Grants for HR, Training, 3.2 Consumables 4 State NCD Cell @ 25 lakh/year 5 District NCD Cell @ 20 lakh/year Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for District NCD Cells 6 IEC Activities 7 Surveillance, Monitoring and Research 8 Training 9 National NCD cell Total for NCD Control during 2012-17 292 1 Unit Cost No. Total

2.00

640

1280.00

0.50 0.50 0.50 0.50 0.50

200 300 400 500 640

100.00 150.00 200.00 250.00 320.00 2300.00

0.20

400

80.00

1.00 1.00 1.00 1.00 1.00

200 300 400 500 640

200.00 300.00 400.00 500.00 640.00 2120.00 447.00 745.00 35.00 40.00 60.00 80.00 100.00 128.00 443.00 100.00 40.00 50.00 12.50 6292.50

3.00 1.00 0.25 0.20 0.20 0.20 0.20 0.20 20.00 8.00 10.00 2.50

149 149 28 200 300 400 500 640 5 5 5 5

Prevention & Control of Chronic Obstructive Pulmonary Diseases Unit Cost (Rs. lakh) Total (Rs. crore)

Component 1 Support to selected Primary Health Centres Finger Pulse Oximeter (1) 2 2.1 2.2 Support to Community Health Centres/SDH Capital: Spirometer (1.0), Pulse Oximeter (0.50), Finger Pulse Oximeter-2 (0.10), Non-invasive Ventilator (3.0), Nebulizer-Heavy duty hospital model (0.20) Recurring expenditure for drugs, consumbales, maintenance etc. Year 1-400 new centres Year 2: 400 existing and 400 new centres Year 3: 800 existing and 400 new centres Year 4: 1200 existing and 400 new centres Year 5: 1600 existing and 400 new centres Sub-total for CHCs/SDH 3 Support to District Hospitals Capital: Spirometer (1.0), Pulse Oximeter (0.50), Finger Pulse Oximeter-2 (0.10), Invasive Ventilator (10.0) Non-invasive Ventilator (3.0), Nebulizer-Heavy duty hospital model-2 (0.40) Recurring Grant (Drugs, Consumables, vaccination, maintenance, training etc.) Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for District Hospitals 4 5 6 IEC Activities Surveillance, Monitoring and Research Training Total for COPD during 2012-17

No.

0.05

10000

5.00

4.80

2000

96.00

1.00 1.00 1.00 1.00 1.00

400 800 1200 1600 2000

4.00 8.00 12.00 16.00 20.00 156.00

3.1

15.00

640

96.00

3.2

25.00 25.00 25.00 25.00 25.00 1000.00 100.00 300.00

200 300 400 500 640 5 5 5

50.00 75.00 100.00 125.00 160.00 606.00 50.00 5.00 15.00 837.00

293

Management of Chronic Kidney Disease Component Average cost of Dialysis Cost for Haemo dialyser per dialysis (Cost of haemodialyser is Rs 600; used 4 times) Haemo dialysis fluid used in each dialysis Saline drip used in each dialysis Inj. Heparin used in each dialysis Investigations & Medicine Total cost per dialysis Component 1 1.1 2 3 4 5 Annual cost of 1000 dialysis per month per centre Cost of Dialysis @1000 dialysis per month *100 Centres for 5 years Training @ Rs. 2 crore per year IEC & health education @ Rs. 2 crore per year M&E and Research @ Rs. 2 crores per year Cost of investigative methods specially urine testing strips for 100 districts Total Programme Cost National Organ Transplant Programme Rs. crore Total 25.00 78.00 500.00 445.00 200.00 150.00 50.00 10.00 35.00 155.00 1648.00 Cost (Rs.) 1000 150 200 100 50 600 2100 Cost (Rs. crore) 2.50 1250.00 10.00 10.00 10.00 70.00 1350.00

A B C D E F

S.No. Component 1 National Organ Procurement & Distribution Org. 2 State Organ Procurement & Distribution Org. Bio-material Centres (National Centre (300 cr.) and 10 3 State Centres @ 20 Cr.) Establishment /strengthening of Transplant 4 Centres/Units 5 Immuno-supressant Drugs 6 Registry, Monitoring and Research 7 Bio vigilance, safety & QA in Tissues 8 SWAP living organ donor program 9 Training 10 IEC Activities, Meetings, Workshops Total Budget

No. 1 10 11 30

294

National Mental Health Programme

Recurring Budget for District Mental Health Programme (DMHP) per year

S.No. 1 2 3 4 5 6 7 8 9 10 11

Component Personnel & Operational Costs (Clinical Services) Drugs Rehabilitation Services (NGOs) Work Place Management Suicide Prevention programme Training & Sensitization IEC M&E Staff travel Ambulance Services (108) Flexi-pool TOTAL

Rs.Lakh 92.80 40.00 14.90 4.00 4.00 2.00 2.00 2.00 2.00 4.00 10.00 177.70 Rs.crore

BudgeEstimatesforDMHPfor5years Nonrecurring(10beddedward,OPDClinicand ChildMentalHealthClinicinDH&ClinicinSDH) Recurring Year1123existingand100newdistricts Year2:223existingand100newdistricts Year3:323existingand100newdistricts Year4:423existingand100newdistricts Year5:523existingand119newdistricts TotalforDMHP

92.00 177.70 177.70 177.70 177.70 177.70

642 223 323 423 523 642

590.64

396.27 573.97 751.67 929.37 1140.83 4382.76

Total Budget for National Mental Health Programme Rs. crore

S.No. 1 2 3 4 5 6 7 8 Component NMHP (Schemes A, B) NMHP (support to NGO/CBOs) DMHP covering all [642]districts Support to SMHA Support to MHRC and state panels Implementation, technical support M&E, MIS and Research IEC activities (at Central level) Total Budget 575.00 100.00 4382.00 50.00 155.00 30.00 50.00 50.00 5392.00

295

National Iodine Deficiency Disorders Control Programme Rs. crore Component 1 2 3 4 5 6 7 8 9 10 State IDD Control Cell @12 lakh p.a. Surveys/Resurveys by States @1 lakh per district IDD Monitoring Labs @ 7 lakh p.a. IDD cell DGHS @ Rs. 50 lakh p.a. Salaries to Staff to Salt Commissioner's Organizations IEC Activities by States/Uts @ 1 lakh/district IEC Activities with other agencies Training @ 1 lakh per district Salt Testing Kits each @ Rs.12 *10000000 Incentives to ASHA/AWW/HW @Rs. 300 p.a. GRAND TOTAL Unit Cost (Rs. lakh) 12.00 1.00 7.00 50.00 300.00 1.00 4000.00 1.00 1200.00 No. 35 643 35 5 5 643 5 643 5 8.4 lakh Total 21.00 6.43 12.25 2.50 15.00 32.15 200.00 6.43 60.00 126.00 481.76

National Program for Prevention & Control of Fluorosis Rs. crore Component 1 2 Central Coordination Cell @17 lakh p.a. District Level Programme Cost of 26 new districts Running Cost of existing districts @40 lakh Total in 1st year Cost of 26 new districts in year 2 Running Cost of existing districts @40 lakh Total in 2nd year Cost of 26 new districts in year 3 Running Cost of existing districts @40 lakh Total in 3rd year Cost of 26 new districts in year 4 Running Cost of existing districts @40 lakh Total in 4th year Cost of 26 new districts in year 5 Running Cost of existing districts @40 lakh Impact Evaluation of the Programme Total in 5th year Total for 5 years Unit Cost (Rs. lakh) 17.00 58.00 40.00 58.00 40.00 58.00 40.00 58.00 40.00 58.00 40.00 No. 5 26 100 26 126 26 152 26 178 26 204 Total 0.85 15.08 40.00 55.08 15.08 50.40 65.48 15.08 60.80 75.88 15.08 71.20 86.28 15.08 81.60 75.00 97.43 381.00

2.1

.2

2.3

2.4

2.5

296

Oral Health Component 1 1.1 1.2 Strengthening of Dental Clinics in Distt. Hospitals NR grant: renovation, dental chair, equipment (7 lakh) Recurring grant pa for HR (8 lakh), consumables (5 lakh) Year 1-100 new districts Year 2: 100 existing and 100 new districts Year 3: 200 existing and 100 new districts Year 4: 300 existing and 150 new districts Year 5: 450 existing and 190 new districts Sub-total Distt Dental Clinics Setting up Dental Clinics in SDH/CHC NR grant: renovation, dental chair, equipment (3.5 lakh) Recurring grant: HR (4 lakh), consumables (2 lakh) Year 1-400 new centres Year 2: 400 existing and 400 new centres Year 3: 800 existing and 400 new centres Year 4: 1200 existing and 400 new centres Year 5: 1600 existing and 400 new centres Sub-total Dental Clinics in SDH/CHC Annual check-up of School Children IEC Activities Training Total Budget 7.00 13.00 13.00 13.00 13.00 13.00 640 100 200 300 450 640 44.80 13.00 26.00 39.00 58.50 83.20 264.50 70.00 24.00 48.00 72.00 96.00 120.00 430.00 48.00 20.00 5.00 767.50 Unit Cost (Rs. lakh) No. Budget (Rs.crore)

3.50 6.00 6.00 6.00 6.00 6.00 1.50 400.00 100.00

2000 400 800 1200 1600 2000 640 5 5

3 4 5

297

Comprehensive Cleft Palate Units Rs. Crore Component 1 1.1 1.2 Strengthening of Medical Colleges/ hospitals for diagnosis and management of Genetic Blood Disorders NR Grant for Equipment Recurring grant for HR, drugs, reagents and other consumables 2012-13 2013-14 2014-15 2015-16 Total Recurring Cost 2 2.1 2.2 Development of Molecular Genetic Lab. for confirmatory diagnosis NR Grant for Equipment Recurring grant for HR, drugs, reagents and other consumables 2012-13 2013-14 2014-15 2015-16 3 4 5 Total Recurring Cost Training IEC Registry, Monitoring & supervision Total 0.25 0.25 0.25 0.25 0.25 0.50 0.50 5 5 5 5 5 5 5 6.25 5.00 3.75 2.50 17.50 1.25 2.50 2.50 448.75 0.25 20 5.00 1.00 1.00 1.00 1.00 30 30 30 30 150.00 120.00 90.00 60.00 420.00 0.20 120 24.00 Unit Cost (Rs. lakh) No. Budget

298

Trauma Care Facilities on National Highways Component Budget(Rs.crore)

1 New Trauma Centre on National Highways LI LII LIII LII LIII

3 4 5 6 Consultants Mid-term Appriasal Surveillance & Registry State Resource Trauma Centre Neurorehabilitation Centres (5) Rehabilitation Centre at Trauma centre IEC TOTAL 382.32 668.12 589.05 700.00 500.00 2.78 2.00 150.00 280.00

Trauma Centres on Accident Prone Roads

350.00

8 9

150.00 100.94 3875.21

299

Prevention and Management of Burn Injury Rs. in Crore Component Burn Unit in Medical Colleges Construction Equipment & Furniture Human Resources for Medical Colleges Year 1-3 existing and 20 new Medical Colleges Year 2: 20 existing and 35 new Medical Colleges Year 2: 55 existing and 40 new Medical Colleges Year 2: 95 existing and 35 new Medical Colleges Year 2: 130 existing and 17 new Medical Colleges Total for Human Resources in Medical Colleges Total for Medical Colleges Burn Unit in District Hospitals Construction Equipment Human Resources for District Hospitals Year 1-6 existing 50 new District Hospitals Year 2: 56 existing and 100 new District Hospitals Year 3: 156 existing and 120 new District Hospitals Year 4: 276 existing and 130 new District Hospitals Year 5: 406 existing and 86 new District Hospitals Total for Human Resources in District Hospitals Total for District Hospitals Rehabilitation Training IEC Activities Monitoring & Evaluation State Cell Central Cell Total Budget Unit Cost 1.950 0.925 1.79 1.79 1.79 1.79 1.79 No. 147 147 23 55 95 130 147 Total 286.65 135.98 41.17 98.45 170.05 232.70 263.13 805.50 1228.13 486.00 139.73 34.72 96.72 171.12 251.72 305.04 859.32 1485.05 2.27 3.21 209.60 3.00 0.55 1.85 2933.65

1 1.1 1.2 1.3

2 2.1 2.2 2.3

1.000 0.288 0.62 0.62 0.62 0.62 0.62

486 486 56 156 276 406 492

4 5 6 7 8 9

300

Health Sector Preparedness and Response to Disasters Rs. crore Component 1 1.1 2 2.1 2.2 3 3.1 4 5 6 7 Mobile Hospitals (one in each region to cover 22 vulnerable States) Human Resources for Mobile Hospitals Safe Hospital Initiative Non-structural Retrofitting CBRN Medical Management Centres with capacity to manage Disasters Human Resources for CBRN Medical Mgm Centres Strengthening existing hospital for CBRN in 50 Districts/ Vulnerable cities Strategic Health Operation Centre (SHOC) Human Resource Component : Training IEC Activities Total Budget 10.00 70.00 6.20 2.00 3.00 6 6 3 50 15 1.00 60.00 420.00 18.60 100.00 45.00 20.00 40.00 881.10 Unit cost 40.00 3.30 No. of units 4 5 Budget 160.00 16.50

301

Prevention & Management of Musculo-skeletal Disorders Component Building renovation Major diagnostic equipment Major treatment equipment Support tools Office equipment Manpower Lab. Consumables Training Office admn expenses Monitoring /evaluation IEC Equipment maintainence Total Central 0.00 0.00 0.00 0.03 0.02 0.73 0.00 0.00 0.01 0.13 1.00 0.00 1.91 State 0.18 0.00 0.00 0.26 0.26 10.16 0.00 1.30 0.39 0.25 8.75 0.55 22.09 District 64.00 340.00 102.00 17.00 3.40 287.38 48.30 11.25 1.67 3.34 7.00 1.94 887.28 Subdistrict 104.80 1362.00 113.50 22.70 0.00 1036.06 121.40 0.00 5.56 0.00 11.14 0.00 2777.16 Total (Rs. crore) 168.98 1702.00 215.50 39.99 3.68 1334.33 169.70 12.55 7.63 3.71 27.89 2.49 3688.44

Upgradation of Department of PMR in Medical Colleges Budget Required (Rs. crore) 201213 10 40 201314 30 70 201415 35 105 201516 25 130 201617 20 150 Total

Targets/Components

Unit Cost (Rs. lakh)

Target (New)>> Target (Cumulative)>> 1 1.1 1.2 1.3 1.4

Upgradation of PMR in Medical Colleges Equipment Human Resources Material & Supplies Office Expenses & Maintenance Sub-total Med. Col. 55.00 49.56 2.00 2.50 5.50 19.82 0.80 1.00 27.12 5000 0.24 40.00 0.24 67.36 16.50 34.69 1.40 1.75 54.34 40.00 0.24 94.58 19.25 52.04 2.10 2.63 76.01 40.00 0.24 116.25 13.75 64.43 2.60 3.25 84.03 40.00 0.24 124.27 11.00 74.34 3.00 3.75 92.09 40.00 0.24 132.33 66.00 245.32 9.90 12.38 333.60 200.00 1.20 534.80

2 3 4

Apex PMR Institutes Central cell Total

302

National Blindness Control Programme Unit Cost (Rs. lakh) 150.00 80.00 40.00 20.00 1.00 25.00 1.00 50.00 100.00 30.00 60.00 Budget (Rs. crore) 30.00 116.80 252.40 20.00 30.00 5.00 1.00 8.00 30.00 30.00 36.00 1620.00 60.00 50.00 100.00 10.00 60.00 90.00 43.20 7.20 20.00 3.00 10.00 25 10 5 5 630 5 17.50 3.50 5.00 2.00 96.40 200.00 2957.00

Component Non-recurring Cost 1 2 3 4 5 6 7 8 10 11 11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Regional Institute of Ophthalmology Medical College District Hospital Upgradation Sub-district Hospitals (New) Vision Centres Eye Banks (New) Eye Donation Centres (New) Non-rec. GIA to NGO Hospitals (New) Construction of dedicated eye ward Multi-purpose District Mobile Ophth. Unit @ Rs. 30 lakh Teleophthalmology Unit @ Rs. 60 lakh Recurring Costs GIA to NGOs for Cataract Surgery @1500 GIA for other eye diseases @3000 Vitreoretinal surgery & corneal transplantation @5000 Free Spectacles to school children @Rs. 200 Free Spectacles for near work to old persons @ Rs. 100 Collection of Donated Eyes @2000 per pair Ophthalmic Surgeon @50000 pm for 2-5 years Ophthalmic Assistant @12000 pm for 2-5 years Eye Donation Counsellors @12000 pm for 2-5 years Training of Eye Surgeons @80000/trainee Training of Nurses/Oph.Asst. & other staff Maintenance of Oph. Equipment upto 20 lakh Management of State Health Society (large) Management of State Health Society (small) Central Programme cell MIS, Moniotring, Evaluation, Surveillance Support to Distt.Blindness Control Society @25500 pm IEC Activities TOTAL

No.

20 146 631 100 3000 20 100 16 30 100 60 108 lakh 2.0 lakh 1 lakh 50 lakh 10 lakh 3.00 lakh

6.00 1.44 1.44 0.70 0.10 20.00 14.00 7.00 100.00 40.00 3.06 4000.00

600 1200 200 400 3000

303

National Programme for Prevention & Control of Deafness Rs. crore Components/Year IEC Training Manpower Equipments Hearing Aid Screening Camps Monitoring PPP Research & Evaluation Total 2012-13 21.06 17.80 11.00 69.61 23.02 8.00 14.63 2.00 168.21 2013-14 23.06 6.50 25.60 26.70 30.69 10.00 37.03 2.00 1.50 165.17 2014-15 25.06 6.50 29.20 26.70 38.38 12.00 45.47 2.00 2.00 190.4 2015-16 27.06 8.85 41.36 32.81 48.80 14.00 53.95 2.00 2.00 236.09 2016-17 29.84 46.31 48.80 13.53 59.37 2.00 2.50 208.08 Total 126.08 39.65 153.47 155.82 189.69 57.53 210.45 10.00 8.00 950.69

304

National Programme for Health Care of the Elderly Rs. crore Component 1 1.1 1.2 District Hospital (Geriatric Clinic & Ward) Capital Grant (one-time) for equipment (0.5 cr) and renovation & furnishing (0.5 cr) Recurring Grant (HR, Drugs, Consumables, maintenance, training etc.) @ 50 lakh./year Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for District Hospitals District Geriatric Programme: Capital Grant for setting up Geriatric Clinic at SDH/ CHC/PHC, equipment etc. @Rs. 20 lakh/district Recurring Grant (HR for Geriatric Clinic at CHCs, aids, medicines, homebased care, referral @ 50 lakh Year 1-100 existing and 100 new districts Year 2: 200 existing and 100 new districts Year 3: 300 existing and 100 new districts Year 4: 400 existing and 100 new districts Year 5: 500 existing and 140 new districts Total for District NCD programme Regional Geriatric centres in Medical Colleges Capital Grant (one-time) for construction, furnishing, equipment, video-conferencing for 12 new Regional Geriatric Centres Recurring Grant (HR, Medicines, Training, Research @ 2 cr./year Year 1-8 existing and 4 new centres Year 2: 12 existing and 4 new centres Year 3: 16 existing and 4 new centres Year 4: 20 centres Year 5: 20 centres Total for Regional Geriatric Centres Medical & Health Care for Old Age Homes National Institute of Ageing (2) IEC Activities Monitoring & Evaluation Total for NCD Control during 2012-17 Unit Cost 1.00 No. Total

400

400.00

0.50 0.50 0.50 0.50 0.50

200 300 400 500 640

100.00 150.00 200.00 250.00 320.00 1420.00 80.00

2 2.1 2.2

0.20

400

0.50 0.50 0.50 0.50 0.50

200 300 400 500 640

100.00 150.00 200.00 250.00 320.00 1020.00

4.00

12

48.00

2.00 2.00 2.00 2.00 2.00 0.045 150.00 5.00 1.00

12 16 20 20 20 500 2 5 5

4 5 6 7

24.00 32.00 40.00 40.00 40.00 224.00 112.50 300.00 25.00 5.00 3106.50

305

Prevention & Control of Nutritional Disorders & Obesity

Component 1 2 3 4 4.1 4.2 Nutrition Cell in Dte.GHS @ Rs. 100 lakh p.a. District Nutrition Cell @Rs.9.8 lakh p.a. Equipment for Body Mass Index at Sub-centres, PHCs, CHCs and Urban Health Units Obesity Guidance Clinic in District Hospital and Medical Colleges Capital Grant (one-time) for equipment and furnishing 0.50 lakh) Recurring Grant (Nutritionist @ 20,000 P.M. and School Obesity Prevention Initiative, Investigation & management of secondary obesity and local IEC) Year 1-100 existing and 100 new clinics Year 2: 200 existing and 100 new clinics Year 3: 300 existing and 100 new clinics Year 4: 400 existing and 100 new clinics Year 5: 500 existing and 140 new clinics Total for Obesity Guidance Clinics IEC Activities Training of doctors, nurses, ANMs, teachers etc. M&E and Nutritional Surveillance, Research Total during 2012-17 National Institute for Health Promotion & Control of Chronic Diseases Rs. crore Budget Allocation Civil Works Equipment, Furniture Fixtures Salaries, Office Exp., Consultancy Resource and Documentation division Advocacy, Publication Health Promotion Research Human Resource Development Health Communication Healthy Settings & Environment Policies, Planning & Co-ordination Total Budget 2012-13 24.00 2.30 3.00 0.50 1.00 2.50 1.50 2.50 1.00 2.00 40.30 306 2013-14 22.00 3.50 3.00 0.50 1.00 2.50 1.50 2.50 1.00 2.00 39.50 2014-15 0.00 0.00 3.00 0.50 1.00 2.50 1.50 2.50 1.00 2.00 14.00 2015-16 0.00 0.00 3.00 0.50 1.00 2.50 1.50 2.50 1.00 2.00 14.00 2016-17 0.00 0.00 3.00 0.50 1.00 2.50 1.50 2.50 1.00 2.00 14.00 Total 46.00 5.80 15.00 2.50 5.00 12.50 7.50 12.50 5.00 10.00 121.80 Unit Cost Rs. lakh) 100.00 9.80 0.02 No. 5 640 200000 Budget (Rs. crore) 5.00 313.60 40.00

0.50 20.00 20.00 20.00 20.00 20.00 1500.00 1000.00 500.00

790

3.95

100 250 400 600 790 5 5 5

5 6 7

20.00 50.00 80.00 120.00 158.00 431.95 75.00 50.00 25.00 940.55

Patients Safety Programme Unit Cost (Rs. lakh) 2.00 10.00 2.00 2.00 Budget (Rs. crore) 2.98 14.90 14.90 14.90 47.68 6.40 32.00 32.00 32.00 102.40 0.07 0.50 3.50 3.00 1.25 8.32 158.40

Component 1 1.1 1.2 1.3 1.4 2 2.1 2.2 2.3 2.4 3 3.1 3.2 3.3 3.4 3.5 Grant to Medical Colleges Patient Safety Survey Infrastructure upgradation Training @ Rs. 2 lakh/year IEC @ Rs. 2 lakh /year Sub-total Medical Colleges Grant to District Hospitals Patient Safety Survey Infrastructure upgradation Training IEC Sub-total District Hospitals Central Activities Office equipment & furnishings Human Resources & Office Expenses Training of Trainers IEC Activites M&E, Supervision and Research Sub-total Central Cell Total Budget

No.

149 149 149 149

1.00 5.00 1.00 1.00

640 640 640 640

10.00 70.00 60.00 25.00

5 5 5 5

Establishment of APHO/PHO & Land Border Quarantine Centres Rs. crore Component 1 1.1 Development of new APHO/PHO 1.00 9.04 23 23 23.00 207.86 12.00 20.50 263.36 Unit Cost No. Total

Non-recurring grant for furniture, fixtures, equipment, ambulance etc. of new units Recurring Costs: Salaries & Operational Costs 1.2 of new units 2 3 Continuation of Existing plan scheme Recurring Costs Salaries & Operational Costs of 7 existing units Total Budget

307

National Tobacco Control Programme

Rs. crore COMPONENT 1 2 3 3.1 3.2 4 5 6 IEC Laboratory Support HR & Management National & State District level Training M&E, Research Others TOTAL National level 310.00 150.00 2.75 0.00 0.00 30.00 0.00 492.75 State Cells 9.51 0.00 40.68 0.00 9.51 9.51 0.00 69.20 District Cells 185.05 0.00 0.00 381.73 132.18 105.74 211.49 1,016.19 Total 504.55 150.00 43.43 381.73 141.68 145.25 211.49 1,578.14

308

Annexure 1 Monitoring and Evaluation of NCDs Monitoring of programmes for prevention and control of non-communicable diseases and their determinants will provide the foundation for advocacy, policy development, program planning, monitoring and evaluation. Monitoring is not limited to tracking data on the magnitude of and trends in non communicable diseases, it also includes evaluating the effectiveness and impact of interventions and assessing progress made. An evaluation of the implementation of the plan and outcomes will be carried out at the mid of the plan and at the end of the plan period. The mid-term assessment will offer an opportunity to learn from the experience, taking corrective measures where actions have not been effective and reorienting parts of the plan in response to unforeseen challenges and issues. Under the group of NCDs, each programme will have specific programme monitoring indicators. The overall broad indicators for monitoring and evaluation on prevention and control of non communicable diseases are mentioned below: 1. Established unit for the prevention and control of non communicable 2. Diseases (with dedicated staffing and budget at National, State and District level 3. Effective surveillance mechanisms built within National health information system 4. Establishing and strengthening effective mechanisms of intersectoral action for improving health care for people with non-communicable diseases 5. Strengthening of health care facilities at all levels for diagnosis, investigation and management of NCDs 6. Training of health care providers in comprehensive management of NCDs 7. Developing complete smoke-free legislation covering all types of places and institutions 8. Bans on tobacco advertising, promotion and sponsorship. 9. Developing national food-based dietary guidelines. 10. Developing national recommendations on physical activity for health. 11. Providing smoking cessation support (including counseling and/or behavioural therapies) into primary health care 12. Early detection and screening programmes for NCDs 13. Access to affordable essential medicines for NCDs, including those needed for pain relief and palliative care (like oral morphine). 14. Provision of diagnosis and investigation facilities at PHCs, CHCs and District Hospitals for NCDs. 15. Prevalence of tobacco use among adults aged 2564 years. 16. Prevalence of low consumption of fruit and vegetables among adults aged 2564 years. 17. Prevalence of low levels of physical activity among adults aged 2564 years. 18. Prevalence of overweight/obesity among adults aged 2564 years. 19. Prevalence of raised blood pressure among adults aged 2564 years. 20. Prevalence of raised fasting blood glucose concentration among adults aged 2564 years. Circulated for discussion at Moscow meeting, April 2011 The agenda was also recently discussed in Meeting of Health Ministers in Moscow in April 2011. The table below summarizes discussions among the WHO and other partners to date on proposed NCD targets and their indicators and main data sources. These targets focus on mortality, morbidity, key risk factors, health service delivery, and NCD related policy. For each indicator a target has been suggested for 2025. The targets were proposed based on
309

scientific review of the current situation and trends, combined with a careful assessment of feasibility. Using the same set of indicators, targets by the end of 12th FY plan are proposed (March 2017). Proposed NCD Targets and Indicators
S.No. 1 Indicator Premature mortality from cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases from age 30 to 70 Prevalence of diabetes mellitus among persons aged 25+ Prevalence of raised blood pressure among persons aged 25+ Prevalence of current daily tobacco smoking among persons aged 15+ Prevalence of obesity Prevalence of physical inactivity Prevalence of raised total cholesterol among 25+ persons Primary care management of cardiovascular risks Coverage of cervical cancer screening Comprehensive tobacco control measures that protect the entire population, including high tobacco product tax, large pictorial health warning labels, comprehensive smoke-free legislation and ban on all forms of tobacco advertising, promotion and sponsorship. Regulations and controls on the reduction of salt and replacement of trans fatty acids with PUFA in manufactured food. Comprehensive alcohol controls including taxation and pricing policies decreasing affordability of alcohol; comprehensive and legally binding restrictions on alcohol advertising and marketing of alcoholic beverages; comprehensive restrictions on access to alcoholic beverages. Target 2025 (Rec. by WHO) 15% relative decline Target 2017 5% Source Death registration system, with medical certification of causes of death or surveys with verbal autopsy Survey (with biomarkers) Survey (with biomarkers) Survey

2 3 4

5 6 7 8 9 10

10% relative reduction 20% absolute reduction 25% relative reduction and below 20% prevalence . No increase compared to 2010 levels 10% relative reduction 20% relative reduction 50% reduction in coverage gap 50% reduction in coverage gap 100% of countries have implemented all four of these components

3% 8%

20% and prevalence below 15% No Survey increase 2% 5% 20% 20% All districts covered Survey

Survey (with biomarkers) Survey (with biomarkers) Survey Policy review

11

100% of countries have implemented these components 100% of countries with comprehensive alcohol control policies implemented

Control measures initiated Control measures initiated in all States

Policy review

12

Policy review

Expected Outcomes
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It is expected that NCD programmes will have significant impact on morbidity and mortality due to NCDs. Some key expected outcomes at the end of the 12th Plan are indicated below:
Programme Area Health Promotion and Control of Life style Chronic Diseases Programme Component Cancer Diabetes CVD & Stroke COPD & CKD Tobacco Use Mental disorders Oral Health Fluorosis (Endemic) Disability Prevention and Rehabilitation IDD Blindness Deafness Highway Trauma Burn Injuries Expected Outcome Early detection leading to increase in cure rate Early detection and management, reduction in complications Reduction in incidence and mortality Reduction in mortality Reduction in tobacco use in adults & youth Improved mental health; improved management of severe mental diseases Reduction in oral and dental disorders Reduction in prevalence and no. of endemic districts Universal coverage with iodated salt Reduction in prevalence of blindness Reduction in prevalence of deafness Reduction in deaths and disability due to trauma Reduction in deaths and disability due to burns

311

Key Monitoring Indicators and Targets (wherever applicable) for each Programme:

Cancer Status by March 2012 0 0 27 100 Target by March 2017 2 20 100 640

S.No. Monitoring Indicators A30 1 2 3 4 5 6 7 8 National Cancer Institutes established No. of State Cancer Institutes established No. of Tertiary Cancer Centres supported and functioning No. of District Cancer Centres set up No. of patients seeking chemotherapy from District Hospitals No. of specialists trained in cancer management No. of District Teams trained in cancer management No. of institutes networking on Cancer Registry

500 640 27 122

Prevention and Control of Diabetes, CVD & Stroke Status by March 2012 100 800 0 21 100 100 800 100 20000 1 Target by March 2017 640 2500 149 35 640 640 2500 640 100000 5

S.No. Monitoring Indicators 1 2 3 4 5 6 7 8 9 10 No. of District Hospitals upgraded (NCD Clinic, ICU) No. of NCD Clinic at SDH/CHC/PHCs No. of Medical Colleges strengthened for management of NCDs No. of State NCD Cells established No. of District NCD Cells established and functioning No. & % of additional staff recruited in District Hospitals No. of Medical Officers of SDH/CHCs/PHCs trained No. of Nurses & technicians of District Hospitals trained No. of sub-centres with trained ANM/MHW Annual Risk Factor Surveillance conducted

312

Chronic Obstructive Pulmonary Disease & Chronic Kidney Disease Status by March 2012 0 0.05 0 Limited Target by March 2017 10000 2000 640 640

S.No. Monitoring Indicators 1 2 3 4 No. of Primary Health Centres with Finger Pulse Oximeters No. of Community Health Centres/SDH with Spirometer and Pulse Oximeter No. of District Hospitals with Spirometer, Pulse Oximeter, Ventilators, Nebulizer etc. No. of District Hospitals with facility for Dialysis

Organ Transplant Status by March 2012 0 0 9 Limited Target by March 2017 1 10 11 30

S.No. Monitoring Indicators 1 2 3 4 5 National Organ Procurement & Distribution Org. set up No. of State Organ Procurement & Distribution Org. set up No. of Bio-material Centres set up No. of Transplant Centres strengthened/established No. of Specialists trained in Organ/Tissue Transplant

Mental Health Status by March 2012 123 0 9 Target by March 2017 640 10 11

S.No. Monitoring Indicators 1 2 3 4 No. of counseling center and ward set up in district hospitals No. of Additional Staff recruited out of no. sanctioned No. of staff trained in Mental Health No. of students undergoing MD in Psychitry per year

313

Iodine Deficiency Disorders Status by March 2012 Target by March 2017 643 35 643 1 crore

S.No. Monitoring Indicators 1 2 3 4 No. of districts where Surveys/Resurveys conducted No. of IDD Monitoring Laboratories established No. of DistrictTeams trained No. of salt testing kits distributed

Fluorosis Status by March 2012 100 100 Target by March 2017 230 230

S.No. Monitoring Indicators 1 2 3 Initiate programme in endemic districts incl. surveys Facility for management of Fluorosis in District Hospitals No. of patients with fluorosis treated

Oral Health Status by March 2012 0 0 0 0 0 Target by March 2017 640 2000 2640 10 1

S.No. Monitoring Indicators 1 2 3 4 5 No. of Dental Clinics in District Hospitals strengthened No. of Dental Clinics in SDH/CHC set up No. of personnel given training in Oral Health No. of Cleft Palate Care Units set up Centre for Congenital Birth Defects and Craniofacial Deformities establsihed

314

Epilepsy Status by March 2012 Limited Limited Limited Limited 0 Target by March 2017 640 149 790 790 640

S.No. Monitoring Indicators 1 2 3 4 5 No. of District Hospitals supported for treatment of epilepsy No. of Medical Colleges supported for 2nd line treatment No. of EEG Machine & other equipment supplied No. of EEG Technicians appointed No. of District Team of Trainers trained

Hereditary Blood Disorders Status by March 2012 0 0 Target by March 2017 120 20

S.No. Monitoring Indicators No. of Medical Colleges/ hospitals strengthened for diagnosis and management of Genetic Blood Disorders Molecular Genetic Lab. Established for confirmatory diagnosis of Genetic Blood Disorders No. of personnel trained in diagnosis and management of Sickle cell anemia, Hemophilia and Thalassemia

1 2 3

Trauma Care Status by March 2012 Target by March 2017 20+50+90 0 1 (Apex) 4 (Regional)

S.No. Monitoring Indicators 1 2 3 4 No. of New Trauma Centre (L-I, L-II, L-III) set up No. of Neuro-rehab Centres established Trauma Registry set up and maintained No. of road traffic accidents provided treatment

315

Prevention & Management of Burns Status by March 2012 Limited Limited Target by March 2017 147 492

S.No. Monitoring Indicators 1 2 3 No. of Medical Colleges with Burn Units No. of Burn Units set up in District Hospitals No. of Burn Cases provided treatment as in-patients

Health Sector Response to Disasters Status by March 2012 Target by March 2017 6

S.No. Monitoring Indicators 1 2 3 4 5 6 7 8 9 10 No. of CBRN Medical Management Centres established No. of training labs made functional No of mobile hospitals procured No. of units retrofitted and functional No. of Strategic Health Operation Centre (SHOC) set up No. of Trainers trained No. of staff of different categories recruited No. of personnel trained in each category No. of vulnerable districts covered with CBRN facility No. of districts covered with trained QMRTs

4 6 15

50 6

Musculo-skeletal Disorders S.No. Monitoring Indicators 1 2 3 4 5 No. of MSD Units set up in District Hospitals No. of MSD Units set up in CHCs No. of MSD Cases provided treatment as in-patients No. of MSD Cases provided rehabilitation services No. of personnel trained in each category 316 Status by March 2012 Limited 0 Target by March 2017 640 4520

Physical Medicine & Rehabilitation Status by March 2012 30 0 Target by March 2017 150 4

S.No. Monitoring Indicators 1 2 3 4 Upgradation of PMR in Medical Colleges Apex PMR Institutes No. of staff appointed No. of cases treated in PMR Department

Blindness Control Status by March 2012 Target by March 2017 20 146 631 3000 20 30 100 60 3.50 crore 50 lakh 10 lakh 3.00 lakh 600 3000

S.No. Monitoring Indicators 1 2 3 4 5 6 7 8 10 11 12 13 14 16 No. of Regional Institute of Ophthalmology strengthened No. of Eye Deptt. of Medical College strengthened No. of Eye Deptt. of District Hospitals upgraded No. of new Vision Centres set up No. of new Eye Banks supported No. of dedicated eye ward and OT constructed No. of Multi-purpose District Mobile Ophth. Unit set up No. of Teleophthalmology Units set up No. (&% of IOL) catarct surgeries performed No. of school children with refractive errors given glasses No. of old persons given free Spectacles for near work No. of donated eyes collected and utilized No. of additional eye surgeons and other staff recruited No. of Nurses and Ophthalmic Assistants trained

317

Deafness Control Status by March 2012 Target by March 2017

S.No. Monitoring Indicators 1 2 3 4 5 6 7 8 No.of health care personnel trained under the programme. No. of District Hospitals provided equipment No. of CHCs/PHCs provided equipment No. of Hearing Impaired persons identified No. of persons rehabilitated with hearing aids and therapy No. of Hearing Impaired children rehabilitated by Hearing & Speech therapists. No. of screening camps organized No. of persons identified with hearing impairment, referred and treated following screening camps

640

Health Care of the Elderly Status by March 2012 100 Target by March 2017 640 2000 8 0 0 20 2 1400

S.No. Monitoring Indicators 1 2 3 4 5 6 7 No. of District Hospital with Geriatric Clinic & Ward No. of Geriatric Clinic set up at SDH/CHC/PHC No. of Regional Geriatric centres in Medical Colleges National Institute of Ageing established No. of Old Age Homes supported for Health Care No. of persons treated in Geriatric Clinics (in- & out-patients) No. of bed-ridden elderly provided home based care

318

Tobacco Control Status by March 2012 Target by March 2017 35 640

S.No. Monitoring Indicators 1 2 3 4 5 No. of State Tobacco Control cells established No. of District Tobacco Control cells established No. of tobacco product testing laboratories set up No. of tobacco cessation centres set up Global Adult Tobacco Survey conducted

Obesity Status by March 2012 Target by March 2017

S.No. Monitoring Indicators 1 2 3 4 No. of Obesity Guidance Clinic set up in District Hospitals No. of Nutritionists appointed in District Hospitals No. of nurses and teachers trained No. of persons attended Obesity Guidance Clinics

National Institute for Health Promotion & Control of Chronic Diseases Status by March 2012 Target by March 2017

S.No. Monitoring Indicators 1 2 3 4 5 6 Civil Works for NIHP-CCD completed & institute functioning No. of additional staff recruited and continuing No. of publications and documents published by NIHP No. of Health Promotion Reasearch studies completed No. of training programmes organized No. of personnel trainined by each category 319

Patient Safety Status by March 2012 Target by March 2017 149 640

S.No. Monitoring Indicators 1 2 3 No. of Medical Colleges complied with Patient Safety norms No. of District Hospitals complied with Patient Safety norms No. of staff received training on Patient Safety guidelines

Development of APHO/PHO/Land Border Quarentine Centres S.No. Monitoring Indicators 1 2 3 4 5 No. of Air Port Health Organizations developed No. of Port Health Organizations developed No. of Land Border Quarantine Centres developed No. of persons recruited against additional posts No. of staff trainined Status by March 2012 10 10 1 Target by March 2017 25 12 7

320

Ann nexure 2: OR RGANIZATION STRUCTURE C

321

322

ANNEXURE 3 REFERENCES 1. Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, Mohan V, Prabhakaran D, Ravindran RD, Reddy KS. Chronic diseases and injuries in India. Lancet 2011; 377: 41328. 2. Anderson, G.F. & Chu, E. Expanding priorities--confronting chronic disease in

countries with low income. N Engl J Med356, 209-211 (2007).

3. World Health Organization. Preventing chronic diseases: a vital investment. Geneva: 2005 4. World Health Organization. 2008-2013 action plan for the global strategy for the

prevention and control of noncommunicable diseases : prevent and control cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. (2008).
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REPORTOFTHE WORKINGGROUPON DRUGS&FOOD REGULATIONFOR THE12THFIVEYEAR PLAN

WG4:DRUGS &FOOD REGULATION

WG-4
No. 2(6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 Dated 9th May 2011

OFFICE MEMORANDUM

Subject: Constitution of working group on Drugs and Food Regulation for the Formulation of the Twelfth Five Year Plan (20122017)

With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on Drugs and Food Regulation under the Chairmanship of Shri K. Chandramouli, Secretary, Ministry of Health & Family Welfare. The composition and the terms of reference of the Working group would be as follows:

1. 2. 3. 4.

Shri K.Chandramouli, Secretary(HFW), MoHFW Secretary, Dept. of Health Research, Govt. of India Secretary, Dept. of Bio-technology, Govt. of India Secretary, Department Government of India of Pharmaceuticals,

Chairperson Member Member Member

5.

Director General of Health Services, Government of India Additional Secretary Drugs & Food MoHFW Sh. V.K.Tiwari, Adviser (Nutrition), MoHFW Principal Secretary (H&FW), Himachal Pradesh Principal Secretary (H&FW), Maharashtra Medical Superintendent , AIIMS, New Delhi Medical Superintendent, Safdarjung Hospital, New Delhi

Member

6. 7. 8. 9. 10. 11.

Member Member Member Member Member Member

12.

Medical Superintendent, Dr. Ram Manohar Lohia Hospital, New Delhi Prof. M.C. Gupta Dean Pharmacology, B D Sharma PG Institute of Medical Sciences, Rohtak Director, National Institute of Pharmaceutical Education and Research (NIPER), Chandigarh Dr. G. Bhubaneswar, Dean, Sri Chitra Institute Tirunal Institute of medical Sciences, Trivandrum State Drug Controller, Gujarat State Drug Controller, Karnataka Representative of Government of India Department of Agriculture,

Member

13.

Member

14.

Member

15.

Member

16. 17. 18.

Member Member Member

19.

Representative of Department Government of India

of

Commerce,

Member

20.

Representative of Department of Food Processing, Government of India CEO, Food Safety & Standards Authority of India (FSSAI) ADG (Prevention of Food Adulteration), FSSAI Drug Controller General of India CEO, Tamil Nadu Medical Services Corporation (TNMSC) Ms. Sunita Narain, Director, Centre for Science and Environment, New Delhi Dr. Narendra Gupta, Prayas, Rajasthan. Dr. Usha Gupta, Dept. of Pharmacology, Maulana Azad Medical College, New Delhi Ms. Leena Menghaney, Mdecins Sans Frontires, New Delhi Dr. Mira Shiva, Director, Initiative for Health Equity & Society New Delhi Dr. Jacob Puliyel, Head of Paediatrics, St. Stephens Hospital, New Delhi

Member

21.

Member

22. 23. 24.

Member Member Member

25.

Member

26. 27.

Member Member

28.

Member

29.

Member

30.

Member

31.

Mr. S Srinivasan, Low Cost Standard Therapeutics (LOCOST), Vadodara Gujarat Dr. Gopal Dabade, Dharwad, Karnataka Dr. Anant Phadke, Society for Assistance to Children in Difficult Situation (SATHI), Pune Mr. Ambrish Kumar, Adviser (Health) Planning Commission Joint Secretary (Drugs), MoHFW

Member

32. 33.

Member Member

34.

Member

35.

Member Secretary

TermsofReferences
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. To review the drug & food regulatory mechanism in the country to ensure providing quality, safe drugs and wholesome food in the country. To review the incidences of anti-biotic/anti-microbial resistance and suggest measures for rational prescription of drugs especially anti-biotics. To review and suggest measures for promotion of generic drugs. To review the progress of Pharmaco Vigilance programmes and suggest measures to strengthen the same. To review the existing manpower in CDSCO/FSSAI and suggest measures for further strengthening. To review the Drug & Food testing labs under the Central Government and suggest measures for their strengthening. To review the existing manpower in of food & drug regulations in States and suggest measures for further strengthening including financial assistance. To review the Drug & Food testing labs in States and suggest measures for their strengthening including financial assistance. To suggest modifications in policies, priorities under the drug & food regulatory framework during the 12th Five Year Plan. To indicate the financial outlay required for the implementation of the initiatives stated above during the 12th Plan. To deliberate and give recommendations on any other matter relating to the topic. The Chairman may constitute various Specialist Groups/ Sub-groups/ task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitorable goals, while making recommendations. Efforts must be made to co-opt members from weaker sections especially Scheduled Castes, Scheduled Tribes and minorities working at the field level.

13. 14.

15.

16.

The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the nonofficial Working group members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. The Working group would submit its draft report by 31st July, 2011and final report by 31st August, 2011. (Shashi Kiran Baijal) Director (Health)

Copy to: 1. Chairman, all Members, Member Secretary of the Working Group 2. PS to Deputy Chairman, Planning Commission 3. PS to Minister of State (Planning) 4. PS to all Members, Planning Commission 5. PS to Member Secretary, Planning Commission 6. All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission 7. Director (PC), Planning Commission 8. Administration (General I) and (General II), Planning Commission 10. Accounts I Branch, Planning Commission 11. Information Officer, Planning Commission 12. Library, Planning Commission (Shashi Kiran Baijal) Director (Health)

REPORT OF THEWORKINGGROUP ON DRUGS&FOODREGULATIONS

FORFORMULATIONOF12THFIVEYEARPLAN
MINISTRYOFHEALTH&FAMILYWELFARE DEPARTMENTOFHEALTH&FAMILYWELFARE

CHAPTER1

DRUGSREGULATION

(I) STRENGTHENING OF DRUG REGULATORY MECHANISMS AT THE CENTRE AND IN THE STATES

Strengthening of Drugs Regulatory Mechanism at the Centre and in the States

Summary Strengthening of Drugs Regulatory Mechanisms is one of the major public health interventions. This ensures that safe, efficacious and quality drugs are made available to the people. Keeping in view the recommendations of the Mashelkar Committee, it is important that the infrastructure, both physical and human resource, both at the Centre as well as in the States is substantially augmented. A more transparent and effective monitoring of Clinical Trials is required. Regulation and control of all medical devices needs to be tightened. The proposed financial outlay for these activities is Rs. 6256 cr, for the Centre and the States which includes manpower augmentation, creation and upgradation of labs, setting up of new offices of drugs regulatory control, strengthening Pharmacovigillance and creating awareness among people (care givers and receivers) regarding safe drugs both at the Centre and in the States. For providing financial and human resource support to the States, a Centrally Sponsored Scheme is proposed.

Background Drug Regulatory System in India. One of the main interventions of the Central Government to achieve its Public Health objectives is to ensure that drugs available to the public are safe, efficacious and conforms to prescribed quality standards. Regulatory control over the quality, safety and efficacy of drugs in the country is exercised through a central legislation called the Drugs and Cosmetics Act, 1940 and the Rules made thereunder. Licensing of manufacturing and sales premises is looked after by the State Governments while imports, permissions for marketing of New Drugs in the country, and for conduct of Clinical Trials, are mainly the responsibilities of the Central Government. Indian Pharmaceutical Industry is one of the most vibrant sectors of Indian Industry. It has been growing at the rate of 11-12%. It is the 3rd largest in the world by volume and 13th in value. The total size of the Indian Pharmaceutical Industry is about Rs 100, 000 crore out of which exports account for Rs 42 000 Crore and the rest is the size of the domestic market. It is 8% of global production and 2% of world pharma market. The sub-group is of the opinion that problems in the drug regulatory system in the country are mainly in the following areas: Inadequate manpower at the State and Central level Inadequate or weak drug control infrastructure at the State and Central level Inadequate testing facilities

Non-uniformity of enforcement of law and regulation Lack of training to regulatory officials Lack of data base Inadequate IT services These problems have got further accentuated with the increasing growth of the Pharma Industry in the country. RECOMMENDATIONS

A. Strengthening of CDSCO : 1. The Central Government should create additional posts for uniform and effective implementation of Drugs and Cosmetics Act and Rules thereunder : The additional posts are required : i. To comply with recommendations of Dr.Mashelkar Committee report ( one Drugs Inspector for 50 manufacturing units and one Drugs Inspector for 200 Sale premises) ii. To regulate all medical devices (at present only 14 notified medical devices are regulated under the said Act) iii. iv. v. vi. To regulate Clinical Trials effectively (Clinical Trial Site inspections etc) To implement effective pharmacovigillance program To implement the Antibiotic policy. To effectively regulate export and import of drugs/cosmetics/medical devices. Additional manpower CDSCO would require 1045 additional posts, to regulate the pharmaceutical market in the country. For this, Rs 45 crore is required per annum. The details of additional posts required for CDSCO and its financial requirements is at Table 1 For 5 years, Rs 51 X 5 = Rs 255 Crore is required for additional man power(Salary Component only) for CDSCO and Rs 375 Cr is required for existing manpower of CDSCO, Indian Pharmacopoeia Commission and the National Institute of Biologicals (Salary, TA, Chemicals/Reagents etc) Total manpower and other establishment Costs for CDSCO, IPC, NIB is Rs 255 cr + 375 Cr = Rs 630 Cr Additional manpower is also required for the following: S.No 1 Manpower For Newly Created Laboratories Cost 200 personnel at Cost of Rs 9 Cr per annum. For 5 years: 9X5= Rs 45 Cr Total For 8 labs Rs 45X8= Rs 360 Cr

For up gradation of existing laboratories

100 personnel at the Cost of Rs 4.5 Cr per annum. For 5 years: Rs 4.5X5=22.5 Cr

For 6 labs Rs 22.5X6= Rs135 Cr For 20labs Rs5.5X20= Rs110 Cr

For Mini Labs

25 personnel at the cost of Rs1.1 Cr per annum For 5 years: Rs 1.1X5= Rs 5.5 Cr

For Mobile labs

10 personnel at the cost of Rs 0.45 Cr per annum For 5 years:

For 50 vans Rs 2.25X50= Rs 112.5 Cr

Rs 0.45X5= Rs 2.25 Cr Say Rs 113 cr 5 For Pharma Research Laboratory 100 personnel at the Cost of Rs 4.5 Cr per annum. For 5 years: Rs 4.5X5=22.5 Cr 6 For National Training Academy For 50 personnel at the cost of Rs 2.25 Cr per annum For 5 years: Rs 2.25X5= Rs11.25 Cr 7 For E-governance For 50 personnel at the cost of Rs 2.25 Cr per annum Rs 11.25 Cr For 5 years: Rs 2.25X5= Rs11.25 Cr
8

For one lab Rs 22.5 Cr

For one Academy Rs 11.25 Cr.

Cosmetics Lab

Diagnostic kits lab

For 100 personnel at the cost of Rs 4.5 Cr per annum For 5 years Rs 4.5 cr X 5= Rs 22.5 Cr For 50 personnel at the cost of Rs 2.25 Cr per annum For 5 years: Rs 2.25X5= Rs11.25 Cr ( Say Rs 11 Cr) For 50 personnel at the cost of Rs 2.25 Cr per annum For 5 years: Rs 2.25X5= Rs11.25 Cr ( Say Rs 11 Cr) 4300 personnel

For 5 labs Rs 22.5 cr X 5 = 112.5 Cr Say Rs 113 Cr

For 3 labs Rs 11 Cr X 3= Rs 33 Cr

10

Medical devices lab

For 5 labs Rs 11 Cr X 5 = Rs 55 Cr

Total

Rs 964 Cr

2. The Central Government should construct new CDSCO offices at Ahmadabad, Jammu, Bangalore, Indore, Goa, Guwahati and New Delhi (independent building). 10

The approximate financial outlay for these offices would be Rs 35 Crore (Rs 5 crore each X 7 offices) (Table-2) 3. For upgradation of existing CDSCO offices, Rs 60 Cr is required. (Rs 3 crore each office X 20 offices (Table-3) 4. For creation of Mini labs at Ports(both at Sea and Air ports where drugs are imported /exported) Rs 96 Crore ( Rs 8 crore each lab X 12 ports) (Table-4) 5. The Central Government should create new Central Drugs Testing Laboratories to strengthen testing capacity. It is proposed that having regard to expanding Pharma Industry in the country the Central Govt should set up 8 new laboratories at the cost of Rs 40 Crore each amounting to total Rs 320 Crore (Table-5) 6. The Central Government should upgrade existing CDSCOs 6 labs at the cost of Rs 15 Cr each. The financial outlay is Rs 15 Cr X 6 = Rs 90 Crore 7. The maintenance and running cost of the each lab (@ Rs. 2 Cr) for five years period would be Rs 10 crore each. For 6 existing labs Rs 10 Cr X 6 = Rs 60 Crore For 8 new labs (for two years) Rs 4 Cr X 8 = Rs 32 Cr Total Rs 60 cr + 32 Cr = Rs 92 cr 8. There is a need to establish CDSCO Training Academy for updating knowledge and skills of the regulatory officials. The approximate cost for creating of CDSCO Training Academy would be Rs 50 Crore. (Table-7) 9. Effective management of the issues on spurious drugs lies with the Drug Regulatory Agencies at the Centre and in the States. The menace of spurious drugs would be checked by providing mobile drug testing laboratories. The cost of each mobile drugs testing lab would be Rs 5 Cr and there is a need of 20 such laboratories all over India. The cost is Rs 5 Cr X 20 = Rs 100 Crore (Table-8). 10. Although many Central Drugs Laboratories have adequate facilities for testing of drugs (quality) as per the prescribed standards, these laboratories are not well equipped to test foreign (contaminated) substance in drugs. Hence there should be a State of the Art Pharma Research Laboratory to carry out sophisticated analysis of drugs to detect such substances. For the setting up of such Laboratory, the financial outlay would be Rs 50 Crore (Table-9). 11. Globalization has fundamentally changed the environment for regulating drug products and created unique regulatory challenges for CDSCO for the following reasons: i. More foreign manufacturing facilities supplying bulk Drugs, Medical Devices, Blood Products, Diagnostics, Anti Cancer drugs to India. ii. iii. iv. Increasing volume of imported Medicinal Products Greater complexity in supply chain Imports coming from countries with less developed regulatory system 11

v.

Export of Medical Products from outside India with the label Made in India

It is therefore important that the CDSCO should have India Country Offices, at least one each in 5 countries. Initially, such offices could be set up in China and South Africa to inspect foreign manufacturing facilities and address other regulatory issues. The offices in the other three countries could be set up o a need analysis basis.The financial outlay for each office would be Rs 35 Crore and total is Rs 175 Crore (Rs 35 X 5 locations). (Table-10)

12. There is a need for increased transparency in CDSCO and a need a to increase and maintain credibility with the public. This can be achieved by having proper EGovernance system in place. With this, all offices of Zonal/Sub-Zonal/Port offices/Laboratories of CDSCO and offices of State Drugs Controllers will be interlinked for fast communication and effective monitoring of quality of Drugs. It includes IT enabled services, National Registry, Video Conferencing facilities, archiving of all files etc. This will cost around Rs - 250 Crore13. A Pharmacovigillance Program of India (PVPI) has been launched on 14th July 2010 to capture Adverse Drug Reaction (ADR) data in Indian population in a systematic way. The main objective of the Program is to monitor ADR in Indian population. The data would be captured through the Medical Colleges in the country which would be provided necessary administrative and logistic support. It is envisaged that through this Program, India will be able to generate independent, evidence based ADR data which would help in taking regulatory decisions on safety aspects of drugs marketed in India. To implement effective Pharmacovigillance program in India, the financial outlay would be Rs 50 Crore per year. For 5 years, it would be Rs 250 Crore. 14. There is a felt need to educate and sensitise both the medical care providers and recipients on promotion of generic drugs, antibiotic resistance, spurious drugs. It is therefore proposed to earmark funds for IEC activities for the Plan period at Rs. 150 crore 15. Various APIs are imported into India for manufacturing drug formulations. Recently, the CDSCO has carried out overseas inspections of the manufacturing units in China to verify the GMP compliance. The results have been encouraging. It is proposed to increase such overseas inspections in the Plan period. It is therefore proposed to earmark Rs. 25 crore for this activity. 16. With increased globalisation of the regulatory mechanism apart from the changing profile of the pharma industry, it is important to impart continuous training to the drug regulators. It is, therefore proposed to have an earmarked fund of Rs. 50 cr for this activity and Rs 20 Cr for travel expenses. Total would be Rs 20 cr for the Plan Period 12

17. The Central Government should create new Central Drugs Testing Laboratories for testing of Cosmetics. It is proposed that having regard to expanding Cosmetics Industry in the country the Central Govt should set up 5 new laboratories at the cost of Rs 40 Crore each amounting to total Rs 200 Crore (Table-11) 18. The Central Government should create new Central Drugs Testing Laboratories for testing of Diagnostics kits/reagents and Blood samples. It is proposed that having regard to expanding Diagnostics Industry and blood banks in the country the Central Govt should set up 3 new laboratories at the cost of Rs 20Crore each amounting to total Rs 60 Crore (Table-12)

B. Strengthening of State Drugs Regulatory Systems: Drugs and Cosmetics Act is a Central Act implemented by both Centre and States. Major responsibilities of States are to grant/renew the drugs manufacturing licenses and sale licenses. They are also involved in enforcement of various provisions of Drugs and Cosmetics Act and Rules including drawing of samples for analysis, prosecutions etc. At present, States have grossly inadequate infrastructure and manpower. There is a crying need to strengthen State Drugs Control organisations. Considering the sensitivity of the Pharma Sector and lack of resources available with State Governments, it is important to have a Centrally Sponsored Scheme to strengthen their infrastructure, both physical and human resources. The Scheme would be funded by the Centre and the States in a ratio of 60:40. However, it has to be ensured, by way of a MoU that States bring in their share upfront and also sanction required number of Posts, in order to be eligible to receive funds from the Central Government. The following components along with cost estimates would be covered in the Scheme :-

Item

Cost for each (Cr)

Total number 26 5 yrs

Total cost(Cr)

Upgradation of State labs Manpower (Regulators) cost (2500 personnel @ Rs 40000/Person/month) Maintenance and Running cost of State labs

15 120/annum

390 600

6/annum/lab

26 for 5 yrs

780

Construction/expansion/up gradation of State Drugs Control offices

10

35

350

13

Creation of more State labs

30

20

600

Manpower for labs (2000 personnel@Rs 40000/person/month) * Proposed share of expenditure between the States and the Centre in the ratio of 60:40

96/annum

5 yrs

480

Total

3,200 crore

For strengthening of State Drugs Regulatory and Control mechanisms, Rs 3200 Crore will be required. The States would bear 40% of the cost ie Rs 1280 Crore and the Central Governments share @ 60% would be Rs 1920 Crore.

Strengthening of Medical Devices Regulations: Import, manufacturing, sale and distribution of Medical devices is regulated under the Drugs and Cosmetics Act 1940 and Rules 1945. At present, only those Medical Devices that are notified by Central Government are regulated under the said Act as drugs. These medical devices include Disposable Hypodermic Syringes, Disposable Hypodermic Needles, Disposable Perfusion Set, In vitro Diagnostic Devices for HIV, HbsAg and HCV, Cardiac Stents, Drug Eluting Stents, Catheters, Intra Ocular Lenses, I.V. Cannulas, Bone Cements, Heart Valves, Scalp Vein Set, Orthopaedic Implants and Internal Prosthetic Replacements which have been notified by the Govt. of India from time to time. At present, there are many concerns/ gaps in the existing regulations applicable for Medical Devices, as these are considered as Drugs and all provisions of Drugs are applicable to Medical Devices also. The Working Group had requested comments from various experts and stakeholders. Most of them have suggested : Independent authority for regulation of Medical Devices Inter-departmental expert committee Ample funds for international travel for participation in technical committees Testing laboratories Training Academy Dedicated regulatory personnel

14

In view of the above, the Govt of India has already initiated steps to amend the Drugs and Cosmetics Act to have separate provisions for Medical Devices. The salient features of the proposed bill would be to provide a separate definition of Medical Devices, their risk based classification for regulatory control, Clinical Trials on Medical Devices, Conformity Assessment Procedures, Penal provisions, etc. The proposed amendments are under active consideration of the Ministry of Health and Family Welfare for putting forth a Drugs and Cosmetics (Amendment) Bill in the Parliament. The CDSCO has to be strengthened in terms of manpower and other infrastructure to take up additional responsibilities in the growing area of medical devices. C. Recommendations for Medical Devices: a. Dedicated Regulatory personnel for Medical Devices (300 personnel) . As proposed in the Drugs and Cosmetics (Amendment) Bill, all categories of Medical Devices would be regulated. b. Experts in the field of Medical devices (10 experts). The regulation of Medical Devices requires multi disciplinary experts like Bio technologist, Bio materialist, Electronic Engineer etc. c. Set up of National Medical Devices Testing Laboratories (Category wise 5 labs) Rs 40 Cr each. ( Rs 40 cr X 5 labs = 200 Crore) (Justification is same as CDTL lab) d. Funds for international travel. (Rs 5 Crore )

D. Recommendations for Clinical Trials:

Clinical trials are regulated by Central Drugs Standard Control Organisation (CDSCO), Directorate General Health Services, Ministry of Health & Family Welfare. Clinical trials are required to be carried out in accordance with requirements and guidelines specified in Rule 122DA, 122DAA, 122DB, 122E and Schedule Y of Drugs & Cosmetic Rules. The Working Group discussed various issues on regulation of clinical trials including its monitoring. The Group took note of various steps already taken to streamline the regulation of clinical trials in the country. Constitution of 12 New Drug Advisory Committees for evaluation of proposals of clinical trials and approval of new drugs & mandatory registration of clinical trials in ICMR clinical trial registry www.ctri.in were appreciated by the Group.

The Group after discussion recommended the following:

15

Issues of consent, ethical review, monitoring of adverse events etc. need to be specifically reviewed and regulations strengthened wherever required. Accountability and liability of multiple stakeholders particularly, ethics committees, principal investigators and sponsors, CROs need to be clearly mentioned. To streamline reporting of adverse events their analysis , issues of payment of medical expenses and compensation in study/trial related injury or death, awareness & training of stakeholders, advocacy to participants rights, categorization of injuries etc. . To consider regulations for demonstration projects, and observation studies, non-interventional studies etc. CDSCO should take immediate steps to finalise current draft on regulation of clinical trialsandCROs.ReviewandamendscheduleYtostrengthenclinicaltrialregulationsand examinewhetherICMRguidelinesforresearchcouldbemergedintoScheduleY.

The infrastructure & manpower at CDSCO needs to be increased manifold

to cope with

challenging tasks of reviewing the increasingly mounds of data that are submitted for clinical trials and drug approvals. CDSCO should provide all the relevant and necessary information on the web site to make the decision making transparent.

TOTAL FINANCIAL OUTLAY FOR 12TH FIVE YEAR PLAN FOR DRUGS SECTOR:

S.no A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Item For CDSCO Manpower New offices Up gradation of existing offices Mini labs at Port offices New CDTL labs Up gradation of existing labs Running/Maintenance of labs National Training Academy Mobile labs Pharma Research lab CDSCO Overseas Country offices E-governance/Archiving Pharmacovigillance IEC Overseas Inspections Man power for S.no 4, 5,6,8,9,10,12, 17,18 and Medical devices lab. (4300 personnel) 16

Cost ( Crore) Rs 630 Rs 35 Rs 60 Rs 160 Rs 320 Rs 90 Rs 92 Rs 50 Rs 250 Rs 50 Rs 175 Rs250 Rs 250 Rs150 Rs 25 Rs 964

17 18 19 20 21

B 1 C 1 2 1 1 1

Training to Regulators Travel Expenditure Cosmetics labs Diagnostic labs/Blood testing labs Spurious drug survey and Samples cost for testing of Drugs, Cosmetics, Medical Devices etc For Strengthening of State Drug Regulatory System Central Govt Share(60%) for Strengthening States Drugs Regulatory Systems Medical Devices National Labs Funds for International Travel IPC Manpower/other expenses NIB Manpower/other expenses
CDL Kasauli

Rs 50 Rs 20 Rs 200 Rs 60 Rs 20

Rs 1920

Rs 200 Rs 25 Rs 100 Rs 100 RS 10 Rs 6256 cr Rs 6256 crore

Manpower, Infrastructure, Training etc Total

Total financial outlay for Strengthening of Drugs Regulatory System during the Plan period.

Table-1

17

S. No. 1 2 3 4 5 6 7 8 9 10 11 12 13

Name of the Post JDC(I) DDC(I) ADC(I) DI Medical Device Officer (New Cadre) ADI Senior Account Officer Account Officer Director (Admn and Vig.) Dy. Director (Admn) Dy. Director (Budget and Accounts) Section Officer Specialists I. Clinical Pharmacologist 10 II. Biochemist 02 III. Immunologist 02 IV. Biotechnologist 02 V. Biostatistician 02 VI. Bio Medical Technologist 05 VII. Bio Materialist 01 VIII. Electronic Engineer 01 IX. Chemical Engineer 01 X. Plastic Engineer 01 XI. Cosmetologist 02 XII. Veterinarian 02 XIII. Molecular Biologist 01 XIV. IT Specialist 02 XV. Toxicologist 02 XVI. Oncologist 01 XVII. Heamatologist 01 XVIII. Endocrinologist 01 XIX. Urologist 01 XX. Gastroenterologist 01 XXI. Dermatologist

No. of Posts 015 032 055 431 300 269 002 009 001 009 001 003 064

Pay band + Grade Pay (Rs.) PB-4+8700 PB-3+7600 PB-3+6600 PB-2+4800 PB-2+4800 PB-4200 PB-3+7600 PB-3+6600 PB-4+8700 PB-3+6600 PB-3+6600 PB-2+4800 PB-3+6600

Monthly expenditure 12,79,725 18,00,480 26,95,275 1,46,90,635 1,02,25,500 69,79,205 1,12,530 4.41,045 83,315 4,41,045 49,005 1,02,255 31,36,320

18

XXII. XXIII. XXIV. XXV. XXVI. XVII. XVIII. XXIX. XXX.

01 Pulmonologist 01 Neurologist 01 Psychiatrist 01 Ophthalmologist 01 Cardiologist 01 Gynecologist 01 Anesthetist 01 Orthopedist 01 Data Processing Manager (Including Zonal/Sub-Zonal Officers) 14 1,96,020 4,22,34,355

14 Legal Officers 04 PB-3+6600 Total 1195 Annual Expenditure 4,22,34,355 X 12 =Rs. 50,68,12,260, Say Rs 51 Crore

Table-2 Creation of New CDSCO offices:

S.No 1

Item Civil Construction

Furniture and IT Services/Library

Cost Rs 1500/Sft 20,000 sft 1500X20000=3,00,00,000 Rs 2 Cr Total (for each office)

Total Cost Rs 3 Cr

Rs 2 Cr Rs 5 Cr*

Note: * Excluding land cost. Total cost for creation of all new 7 CDSCO Offices would be Rs 5 Cr X 7 =Rs 35 Cr

Table- 3 Up gradation of existing CDSCO offices:

S.No 1

Item Civil Construction

Cost Rs 1500/Sft 19

Total Cost Rs 1.5 Cr

Furniture and IT Services/Library

10,000 sft 1500X10000=1,50,00,000 Rs 1.5 Cr Total (for each office)

Rs 1.5 Cr Rs 3 Cr*

Note: * Excluding land cost. Total cost for up gradation of 20 CDSCO Offices would be Rs 3 Cr X 20 =Rs 60 Cr

Table- 4 Creation of Mini Labs at Port offices of CDSCO

S.No 1

Item Civil Construction

2 3 4

Equipment/Instruments Furniture and IT Services/Library Reagents/chemicals

Cost Rs 1500/Sft 4,000 sft 1500X4000=60,00,000 Rs 5 cr Rs 1.5 Cr Total (for each office)

Total Cost Rs 0.6 Cr

Rs 5 Cr Rs 1.5 Cr Rs 0.9 Cr Rs 8 Cr*

Note: * Excluding land cost. Total cost for creation of all new 20 Mini labs at Port office of CDSCO would be Rs 8 Cr X 20 =Rs 160 Cr

Table-5 Creation of New Central Drugs Testing Laboratories: Expected Testing Capacity: 10,000 Drug samples per annum per lab S.No Item Cost Civil Construction 1 Rs 1500/Sft 40,000 sft 1500X40000=6,00,00,000 Equipments/Instruments 2. Rs 22 Cr Reagents/Chemicals 3 Rs 1 Cr per annum For 5 years 4 5 Furniture and laboratory Rs 6 Cr furniture/IT Services/Library Miscellaneous Rs 1 Cr Total (for each Laboratory

Total Cost Rs 6 Cr

Rs 22 Cr Rs 5 Cr

Rs 6 Cr Rs 1 Cr Rs 40 Cr*

Note: * Excluding land cost. Total cost for creation of all new 8 CDTL laboratories would be Rs 40 Cr X 8 =Rs 320 Cr

20

Table- 6 Up gradation of existing CDSCO Labs Expected Testing Capacity: 5,000 Drug samples per annum per lab S.No Item Cost Civil Construction Rs 1500/Sft 1 20,000 sft 1500X20000=3,00,00,000 Equipments/Instruments Rs 1.20 Cr 2. Reagents/Chemicals Rs 0.5 Cr per annum 3 For 5 years 4 5 Furniture and laboratory Rs 3 Cr furniture/IT Services/Library Miscellaneous Rs 0.5 Cr Total (for each Laboratory

Total Cost Rs 3 Cr

Rs 6 Cr Rs 2.5 Cr

Rs 3 Cr Rs 0.5 Cr Rs 15 Cr*

Note: * Excluding land cost. Total cost for up gradation of 6 CDSCO laboratories would be Rs 15 Cr X 6 =Rs 90 Cr

Table-7 Creation of CDSCO Training Academy Expected to train 50000 Regulatory Personnel (State & Centre) every year

S.No 1

2. 3

Item Civil Construction (Auditorium, Rooms, Canteen, Resident Director house, Case study rooms, etc) Equipments/Projector/Airconditioning/Generator etc Maintenance/Running cost/ Electricity

Cost Rs 1500/Sft 40,000 sft 1500X40000=6,00,00,000 Rs 15 Cr Rs 2 Cr per annum For 5 years

Total Cost Rs 6 Cr

Rs 15 Cr Rs 10 Cr

4 5

Furniture and Auditorium Rs 15 Cr furniture/IT Services/Library Boundary Wall/Lawn/ Miscll. Rs 4 cr Total

Rs 15 Cr Rs 4 Cr Rs 50 Cr*

Note: * Excluding land and Manpower cost.

Table-8 Mobile testing Laboratories. 21

S.No 1 2. 3

Item Mobile Van Equipments/Instruments Reagents/Chemicals/Fuel

Cost Rs 1 Cr Rs 3 Cr Rs 0.2 Cr per annum For 5 years Total (for each Mobile Van)

Total Cost Rs 1 Cr Rs 3 Cr Rs 1 Cr

Rs 5 Cr*

Note: * Excluding Manpower cost. Total cost for 50 mobile testing labs Rs 5 Cr X 50 =Rs 250 Cr

Table-9 Pharmaceutical Research Laboratories

S.No 1

Item Civil Construction

2. 3

Equipments/Instruments Reagents/Chemicals

Cost Rs 1500/Sft 30,000 sft 1500X30000=4,50,00,000 Rs 30 Cr Rs 1 Cr per annum For 5 years

Total Cost Rs 4.5 Cr

Rs 30 Cr Rs 5 Cr

4 5

Furniture and laboratory Rs 5 Cr furniture/IT Services/Library Air-conditioning, Lawn, Boundary Rs 5.5 cr wall, Generator etc Total

Rs 5 Cr Rs 5.5 Cr Rs 50 Cr*

Note: * Excluding land cost and Man power Table-10 CDSCO Country Offices in 5 Countries (to start with in China and South Africa) S.No 1 Item Rented Accommodation Cost Around 2000 Sft Rent Rs 0.6 Cr per annum For 5 Years Rs 6 Cr Rs 2 Cr per annum For 5 years Rs 3 Cr per annum For 5 years (Electricity, Rs 0.2 Cr per annum For 5 years 22 Total Cost Rs 3 Cr

2. 3

Furniture/ IT Services/ Library Manpower Minimum of 6-8 officials Travel Cost

Rs 6Cr Rs 10 Cr

Rs 15 cr

Miscellaneous Telephone bill, etc)

Rs 1 Cr

Total (for each country)

Rs 35 Cr

Note: For 5 country offices Rs 35 X 5 = Rs 175 Cr. Table-11

Creation of New Central Cosmetics Testing Laboratories: Expected Testing Capacity: 10,000 Cosmetics samples per annum per lab S.No Item Cost Civil Construction 1 Rs 1500/Sft 40,000 sft 1500X40000=6,00,00,000 Equipments/Instruments 2. Rs 22 Cr Reagents/Chemicals 3 Rs 1 Cr per annum For 5 years 4 5 Furniture and laboratory Rs 6 Cr furniture/IT Services/Library Miscellaneous Rs 1 Cr Total (for each Laboratory

Total Cost Rs 6 Cr

Rs 22 Cr Rs 5 Cr

Rs 6 Cr Rs 1 Cr Rs 40 Cr*

Note: * Excluding land cost. Total cost for creation of all new 5 laboratories would be Rs 40 Cr X 5 =Rs 200 Cr

Table -12
Creation of New Central Diagnostic kits/Blood Samples Testing Laboratories: Expected Testing Capacity: 5000 Diagnostic Kits/Blood samples per annum per lab S.No Item Cost Total Cost Civil Construction 1 Rs 1500/Sft Rs 3 Cr 20,000 sft 1500X20000=3,00,00,000 Equipments/Instruments 2. Rs 11 Cr Rs 11 Cr Reagents/Chemicals 3 Rs 0.5 Cr per annum Rs 2.5Cr For 5 years 4 5 Furniture and laboratory Rs 3 Cr furniture/IT Services/Library Miscellaneous Rs 0.5Cr Total (for each Laboratory Rs 3 Cr Rs 0.5Cr Rs 20 Cr*

Note: * Excluding land cost. 23

Total cost for creation of all new 3 laboratories would be Rs 20 Cr X 3=Rs 60 Cr

24

 (II) PROVISION OF FREE MEDICINES FOR ALL IN PUBLIC HEALTH FACILITIES UNDER NRHM/NUHM

25

ProvisionofFreeMedicinesforAllinPublicHealthFacilitiesunder NRHM/NUHM

Summary Duringthe12thFiveYearPlan,aprovisionwillbemadeforfreemedicinesforallinPublicHealthFacilities undertheNationalRuralHealthMission(NRHM)forfacilitiesuptotheDistrictHospitalinthosedistrictswhich are/wouldnotbecoveredundertheNationalUrbanHealthMission(NUHM)andintheDistrictHospitalsand other tertiary care centres under the NUHM. As part of the provisions all State Governments will be encouragedtosetupmedicalsuppliescorporationsonthelinesofTamilNaduMedicalSuppliesCorporation (TNMSC)tosupplyfree,qualitygenericmedicinesessentialmedicinestobothindoorandoutdoorpatients whoseekcareinPublicHealthFacilities(about52%ofthetotalnumberofpatients,includingtheerstwhile 20%ofunreached,verypoorpeople).ThetotalcostonthisaccountduringtheplanperiodwouldbeRs28675 croresforrunningcostsandanadditionalRs1293croresasonetimecapitalcosts.TheCentrescontribution at85%wouldbeRs25667croresfortheentirePlanperiod.Throughthisprovisionitshallbeensuredthat 52% patients begin to seek medical care from public health institutions and out of pocket expenditure in healthcareisreducedsignificantlybytheendof12thFiveYearPlan.Thisprovisionwouldnotonlymeetthe social objective of providing care to the poor and the vulnerable but would also bring in efficiency gains by bulk procurement of drugs. Allocation for this provision under the National Rural Health Mission (NRHM)/ National Urban Health Mission (NUHM) would be over and above the normal allocation for the 12th Plan Period.

Background
Health care costs are the second most frequent reason for rural indebtedness. A major component of health care costs is medicines.1 Studies show that in India the cost of medicines is anything between 50 to 80 percentofthetotalcostoftreatment.Currently,manyofthepatientsseekingcareinPublicHealthFacilitieshave tobuymedicinesfromretailshopsandthesemedicinesareverycostlyforavarietyofreasons.However,inTamil Nadu, since 1995 all patients visiting Public Health Facilities (which in Tamil Nadu, constitute 40% of the total number of patientsper as NSSO 60th round figures) get all medicines free. This has been possible because of setting up of an autonomous corporation in the Public Sector, the Tamil Nadu Medical Services Corporation (TNMSC), which procures in bulk directly from manufacturers, quality generic medicines through a transparent bidding process. TNMSC then supplies these to the Public Health Facilities (PHFs) through a demand sensitive passbook system instead of the traditional supply driven inflexible system of distribution. It supplies about 260 drugstoPublicHealthFacilitiesasperitsEssentialDrugListand192specialtydrugsforsecondaryandtertiarycare asperneed.TheTNMSCprocurementpricesofqualitygenericmedicinesareverylow;formanymedicinestheyare onetenthandsometimesevenonefiftiethoftheretailprices(seealsotableinAnnexure).Henceevenatabudget ofRs.29percapita,(BudgetofRs.210croreforapopulationof7.2crore)plusmedicinessuppliedbytheCentral Government (about Rs 20 per capita), Tamil Nadu is able to provide free medicines to all indoor and outdoor patientsinallPHFs(fromallPHCstoallsecondaryandtertiarycarehospitalsundertheStateGovernment).The GovernmentofKeralahasadaptedtheTNMSCmodel.ThegovernmentsofBiharandRajasthanareintheprocessof doingso.

RECOMMENDATIONS
Adaptation of TNMSC model of Free Medicines for All in Public Health Facilities (PHF)During the 12th FYP, significant advance towards the goal of Free Medicines for All in Public Health Facilities (PHF) under the NRHM/NUHMwouldbemade.Forthispurpose,allStateGovernmentswouldbeencouragedtoadoptandadapt

1 See: Sakthivel, Selvaraj and Anup K Karan (2009): Deepening Health Insecurity in India: Evidence from
National Sample Surveys since 1980s, Economic & Political Weekly, October 3, XLIV: 40.

26

(taking into account specific features, if any, of different states), the Tamil Nadu model to reach the goal of free medicinesforallinthePHFs. Out of 100 patients needing care, currently only 80 use public or private facilities; 20 are unreached. Amongstthosewhoaccesshealthcare,currentlyutilizationofpublichealthservicesisonanaveragearound2025 %.BasedontheTamilNaduexperience,itishopedthatitwillincreaseto40%whenfreemedicinesandqualitycare willbeprovidedinthePHFs.Infrastructurestrengtheningfordeliveryoftheschemeisbeingseparatelyprovidedfor under the NRHM which will also carry out IEC activities for creating awareness about this Scheme. Secondly, the erstwhile20%unreachedverypoorpeoplewouldalsonowaccessservicesinPHFs.Itisthereforeestimatedthatby theendofthe12thPlan,indifferentstates,onanaverage,52%ofallpatientswouldreceivecarefromthePHFs. The budgetary outlay required for quality generic medicines for these patients has been estimated in the table belowbyextrapolatingfromtheexperienceofTamilNadu.Ideallyofcoursetheseestimatesneedtobecalculated from the disease burden. This will help the target population (including the hitherto unreached) access free medicines.

BudgetaryOutlayforMedicinesforAllSchemeforPublicHealthFacilities
1. SubjectHead TNs budget for medicines at 40 % accessofPHFs AmountinRs 210 crores Remarks Rs 210 crores2 for TN population of 7.2 crores as per 2011 census provisional figures. (In TN, out of patients seeking treatment, 40% go to PHFs, that is 40 % utilization) Extrapolated to patients seeking treatment from 121 crores population of India:Rs210croresx(121/7.2) This translates to 62.5 % increase in patientsattendingPHFs*:1.625xRs3530 crores.Seefootnote. AtRs5735croresx5 (85% of Rs 28675 crores)/5 = Rs 24374 crores/5=Rs4875croresperyear.

2.

All India requirement at TNMSC 3530 crores procurementprices All India requirement inclusive of 5735 crores additionalrequirementfortheverypoor 20 % patients who are currently totally deprived Total AllIndia Requirement for 5 year 28675 crores PlanPeriodformedicinesforPHFs a) At 85 % central contribution of Rs.24374 runningcosts(NRHMformula) crores b)CapitalCosts IT enabled Supply Chain system @Rs 5 31.55 crores lakhsperdistrictforallIndia Warehouses and related infrastructure 1262 crores like cold storage, storage racks @ Rs 2 croresperdistrictfor631districts c)TotalCapitalCostsallIndia 1293 crores

3.

4. 5. 6. 7. 8

631districts@Rs5lakhs At 1012000 sq. feet per warehouse; and 631districts@Rs2crores.

9. 10.

d) Centers Contribution at 85% of (a) Rs.25667 plus100%of(c) crores

Rs24374 croresplusRs1293crores

*Outofper100patients,currentlyonly80seektreatment;20areoutofthereachofbothprivateandpublichealthservices.Outofthese
80patients,32(40%)gotothePHFs;rest48gotoprivatepractitioners.DuetotheFreeMedicinesforAllscheme,itisassumedthatall overIndia,likeinTN,now40%ofpatientswilltaketreatmentatPHFs.Secondly,nowthe20patientswhowerehithertounserved,will also take treatment from PHFs. Thus out of 100 patients, now 52 instead 32 patients will take treatment at PHFs. Thus under this

Source:TNMSC,July2011.ThisdoesnotincludeCentrescontributionforNationalProgrammeetc.

27

assumptionthatallthese20hithertounservedpatientswillalsotaketreatmentinPHFs,numberofpatientsreachingPHFswillincreaseby 62.5%(52/32x100).SeeAnnexure2formoredetails.

TheaboveestimateistobeseeninthelightofthecurrentGovernmentexpensesonmedicines.Roughfigures from the budget estimates of 201011 show that Government (Centre and States put together) had spent about Rs. 6,000 crores with the Central Government alone spending around Rs. 2,500 crores. Hence the additionalannualexpenseisonlyRs4875croresduringtheplanperiodfortheCentreforthisSchemefor85% th contribution for the recurring costs. It is expected that during the 12 FYP, the health care expense would increasequitesubstantiallyfromcurrent1.1%ofGDPto2.5%ofGDP.HenceItwouldbepossibletogetthe aboveestimatedfundsforthisprovisionunderNRHM/NUHM. SummaryofCosts Thetotalcostduringthe5yearPlanPeriodtotheCenterforFreemedicinesforallinPHFswouldbe At85%contributionfromtheCentreforrecurringcosts:Rs24374crore(Rs4875croresperyear)plusRs 1293croresfor100%ofthecapitalcostswillbeequaltoaTotalofRs25667croresforthe5yearPlanPeriod. Note:
Inflationhasbeenignoredbecausetheestimatedoutlayhassomecushion;fullamountwillnotbeutilized from the first year. Secondly bulk medicine prices have not increased during last 5 years and in fact in TNMSC procurement,theyhavedecreasedinmanycases. OnlyTNMSCpriceshavebeenconsideredforestimation. FinancialoutlayrequiredforAYUSHhavenotbeentakenintoaccountinthesecalculations. Itisexpectedthatin5years,ifnotearlier,thesystemwouldbeselfsustainingbycharging(asisbeingdonein Tamil Nadu) the Government health facilities a percentage of (~ 5 to 10%) on the drugs procured by the State level procurementagency.

ImportantFeaturesandessentialConditionsfortheScheme
ItmaybenotedthatinTNMSC,bulkprocurementisdirectlyfromScheduleMcertifiedmanufacturers,of qualitygenericmedicinesthroughatransparentbiddingprocess.Alistofselectedmedicinesincludingmainly theessentialmedicinesisusedforprocurement.However,thisisnottheonlyreasonforthesuccessofthe TNMSC model. Autonomy for the professionally run Public Sector procurement agency working in a transparentmannerandademandsensitivepassbookbasedsupplysysteminsteadofthetraditionalsupply driven inflexible supply system are the two other essential elements of the success of the TNMSC model. Hencewhileadoptingthesysteminotherstatesfollowingstepswouldbeconsideredessential 1) Bulkprocurementofgenericmedicinesdirectlyfromthemanufacturerswillbedonefromalistofmainly essentialmedicinesandsomeothers,drawnuptakingintoaccountstatewisevariationsinmorbidity.For thispurposetheNLEM2011wouldbeusedaguide..Theprocurementofdrugsneedtobemadeunder InternationalNonproprietaryNames(INN)only Only TNMSC prices have been taken for estimation, though a similar system is in operation in Kerala since 200708 because the TN system has been in place for the last 15 years and has been studied, evaluated in detail. Initially, some small States may not be able to bargain for prices as low asTNMSC prices.However there is enough cushion in the budget as all the budgeted amount will not be utilized fullyfromthefirstyearinallStates. While working within the framework given by the State Government, the procurement agency would function as an autonomous and transparent set up. Requirement of technical support to States for settingupsuchprocurementsystemsandmechanismswillbemetoutoffundsunderNRHM/NUHM Ademandsensitivepassbookbasedsupplysystem,onlinesupplychainmonitoring,strictqualitycontrol, blacklistingofdefaultingsuppliers,completetransparencyandsystemsofpublicaccountabilitywouldbe ensured. Institutionalized prescription audits and standard treatment guidelines will be put in place to ensurerationaluseofmedicines.

2)

3)

4)

28

Annexure1
Table:AComparisonofChittorgarh,TNMSCProcurementPricesandRetailMarketMRPs GenericNameofDrug (1) Unit (2) ChittorgarhTender Rate(Rs.) (3) MRPPrintedon pack/strip(Rs.) (4) TNMSCPrices 201011(Rs)*

(5) AlbendazoleTabIP400mg AlprazolamTabIP0.5mg Arteether2mlInj AmylodipineTab5mg Cetrizine10mg Ceftazidime1000mg AtorvastatinTab20mg DiclofenacTabIP50mg DiazepamTabIP5mg Amikacin500mg 10tablets 10tablets 1injection 10tablets 10tablets 1injection 10tablets 10tablets 10tablets 1injection 11.00 1.40 9.39 2.50 1.20 52.00 18.10 2.20 1.90 6.95 250.00 14.00 99.00 22.00 35.00 370.00 170.00 25.00 29.40 70.00 4.62 0.45 9.71for80mgpervial 0.42for10tabsof2.5mg 0.50 8.77for250mginjection 2.30for10tabsof10mg 0.63 0.47 6.78

Source:PricesinColumns(3)and(4)fromthenCollectorSamitSharmaspresentation,July2009,andwebsitescited, op.cit.SourceforTNMSCprices:http://www.tnmsc.com/tnmsc/new/html/pdf/drug.pdfand http://www.tnmsc.com/tnmsc/new/html/pdf/spldrug.pdf *Forsimilarstrengthsandpacksizesunlessindicatedotherwise.Accessed,April29,2011.

29

 Annexure2 ADetailedExplanationofHowtheAllIndiaEstimateofRs5735croreswasarrivedat UnderKeyAssumptionthatoutof100patientsneedingtt,20patients(20%)whoareverypoorand deprivedarenotreachedatall.Andoftherest80patients(80%),32(40%)seektreatment(tt hereafter)ingovernment/PublicHealthFacilities(PHFs);and48(60%)seekttintheprivatesector. Thecalculationsremainsameifwehadassumed20%ofthepopulation(sayofTNorIndia)was unserved. 1.TotalpopulationofTN=7.2cr.Andletthefractionofpatientsneedingtttototalpopulationbey. ThereforeTotalNoofPatientsneedingttinTN=7.2ycrores. 2.Outof7.2ycrores,20%arenotreachedinTN.Thatis20%of7.2ycroresarenotreached(or0.2x 7.2ycrores).Thereforethosewhoareabletoaccessttis80%of7.2ycrores(or0.8x7.2ycrores). 3.UtilisationofthePHFsinTNis40%.Thatis40%of(0.8x7.2ycrores)=32%of7.2ycr=0.32x 7.2ycr=2.304ycr. 4.TotalOutlayofTN=Rs210cr 5.Thereforeperpatientcostis=Rs210cr/2.304ycr=Rs.91.145/y. 6.TotalpopulationofIndia=121cr. 7.Andthereforeassumingsameyfactor,thereare121ycrorepatientsinIndia 9.OutofthisNoofpatientsseekingttfromPHFs=32%of121ycr=38.72ycrpatients(asin3 above). 10.Costoffreesupplyforabove=38.72ycrx(Rs91.145/y)=Rs3530crapprox.(A) 11.20%ofpatientsinIndia=20%of121ycr=24.2ycrpatients. 12.Costoffreesupplyofmedicinesfor(11)above=24.2ycroresx(Rs91.145/y)=Rs2205.70 crores.(B) 13.Totalof(A)+(B)=Rs3529.13cr+Rs2205.70cr=Rs.5734.83crsayRs5735cr.Thisamountwill reachthroughPFIs,(32+20)%x121ycror52%x121ycrpatients.

30

 (III) ESSENTIAL DRUGS LIST (EDLS), DRUG RESISTANCE, IRRATIONAL DRUGS AND PRESCRIPTION,PRICINGANDIP

31

Essential Drugs List (EDL), drug resistance, irrational drugs and prescription, pricing and IP
Summary India has the largest number of people who do not have access to all essential drugs that

they need an estimated 680 million. Expenditure on medicines is also a leading cause of rural indebtedness. India therefore, in the coming decade, would be faced with not only the task of increasing access (availability and affordability) to essential medicines in its public and private health system, but would also be faced with the difficult challenge of safeguarding domestic production of medicines and regulating prescription and dispensation of medicines in the private sector to address public health challenges such as drug resistance. This chapter captures the background of discussions on irrational drugs and prescriptions, drug resistance particularly anti-biotics, access and promotion of generic drugs and pharmacovigilance and provides detailed policy recommendations for the 12th five year plan. RECOMMENDATIONS: National List of Essential Medicines (NLEM): - Having a national list of essential drugs (NLEM) makes it easier both to quantify needs and to procure and manage drugs more efficiently. An essential drugs list provides a firm foundation on which to introduce standard treatment guidelines which play a crucial role in rational prescription and use of medicines. 1. NLEM implementation should be strengthened with the introduction of Standard Treatment Guidelines. Implementation of Standard Treatment Guidelines in the private sector is a priority to address drug resistance, promote rational prescription and rational use of drugs. 2. While the NLEM should guide the choice of medicines for treatment guidelines, it must be reviewed at least once in two years , with inputs from not only experts, but also from health groups and communities of people living with cancer, HIV, mental health, hepatitis, etc. 3. The drugs in the list should be finalized keeping in mind treatment guidelines, their safety and therapeutic efficacy and requirement even if price of the drugs are too expensive. Inclusion of a drug in the NLEM makes it easier for the Government to use measures such as -price control, compulsory licensing to reduce prices. IRRATIONAL DRUGS AND FIXED DOSE COMBINATIONS (FDCs): Irrational FDCs, nonessential vitamins/tonics, cough syrups feature in the top selling pharmaceuticals in terms of value and volume but they harm public health and patients by increasing adverse effects, imposing higher financial burden on patients and facilitating - emergence of drug resistance (in the case of FDCs of antibiotics). Therefore, stricter criteria for registration and - regulatory review of medicines by CDCSO should be a priority. - This helps weed- out substandard, toxic, irrational medicines from the market. It is therefore necessary that:1. CDSCO implements a much stricter registration regime for FDCs. Products should be selected and approved only when the combination has a proven advantage in therapeutic effect, safety, adherence or in decreasing the emergence of drug resistance in malaria, tuberculosis and HIV/AIDS. 2. Except FDCs included in the WHOs essential Drug List, all FDCs registered in India are reviewed in terms of their therapeutic effect and legally sustainable action taken for phased out weedingof all irrational FDCs, DTAB should set up a suitable mechanism for the purpose.

IRRATIONAL PRESCRIPTION AND A CORRESPONDING RISE IN DRUG RESISTANCE: - With hardly any new antibiotics, anti-TB, anti-malarial being developed, the control of drug resistance to currently available medicines has become crucial. It is therefore necessary that:1. There is a well evidenced and compelling need for public and patient education in the appropriate use of drugs particularly antibiotics/antimicrobials, with potential benefits to the individual patient and public health. 32

2. Treatment guidelines of the HIV, TB, malaria programme should be formulated for the public and the private sector. These prescription guidelines can then be made applicable not only in government ART and DOTs centres but also to private health facilities and providers. 3. Use of generic names or the international nonproprietary name (INN) should be encouraged at all stages of procurement, distribution, prescribtion and use as it contributes to a sound system of procurement and distribution, drug information and rational use at every level of the health care system. 4. Pharmaceutical marketing and aggressive promotion also contributes to irrational use. There is a need for a mandatory code for identifying and penalizing unethical promotion on the part of Pharma companies. 5. The Ministry of Health and Family Welfare will set up a Committee to review and suggest measures for the effective implementation of the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 (DMRA). 6. The Health Ministry in collaboration with MCI should incorporate into the medical, pharmacy and nursing syllabus rational use antibiotic policies, and promotion of generic medicines. 7. A comprehensive law is required to mandate prescription audits, a measure necessary to curb drug resistance. 8. The DCGI and FSSAI will jointly examine the neutraceuticals having multivitamins, minerals etc for prophylactic and therapeutic purpose AFFORDABILITY (PRICE CONTROL, TRADE MARGINS & IP): Besides linking the National List of Essential Medicines to the Drug Price Control Order, a number of policy and legal measures by the Health Ministry can address the issue of making medicines available and affordable in India. It is necessary that :1. All drug pricing related matters should be under one Ministry and not be divided between MOHFW and MOCF. Particularly the Health Ministry should be the nodal Ministry for NPPA. 2. Review of the DPCO to determine which loopholes are used by companies to escape price control. 3. Prescriptions must be made in INN name which could play a crucial role in removing incentives for doctors to prescribe the most expensive brands of generic drugs. 4. Linking the drug regulatory authority (CDCSO) to IP delays generic competition. Patent matters must continue to be firmly delinked from the drug licensing process for clinical research, manufacture and marketing approval. 5. Ministry of Health shall identify and issue compulsory licenses for patented expensive drugs required for public health programmes and take steps to make them affordable. 6. There is a need to ensure that foreign direct investment in existing Indian drug companies is shifted from the automatic route to the FIPB route so that the Government could get a chance to scrutinize such proposals from the public health perspective. PHARMACOVIGILANCE OF ADVERSE DRUG REACTIONS: The Health Ministry has started a pharmacovigilance programme to allow physicians and patients in India to report toxicities and adverse drug reactions tol assist drug regulators in limiting the use or even phasing out approved drugs with high toxicities. There is therefore a need to :1 2 3 4 5 Ensure that the process of reporting adverse reactions is simple and accessible. To encourage patients and consumer protection groups - to report drug reactions as it has been observed that consumers do a better job in reporting drug reaction than doctors. Develop and maintain a national (computerised) pharmacovigilance database consisting of all suspected adverse drug reactions to medicines observed in India. Mandate that the report of any suspected adverse drug reaction should be filed with the national pharmacovigilance database and not with the manufacturer. Sensitise the overworked physicians to the why and how of pharmacovigilance. -

CDSCO: The implementation and effective enforcement of all the recommendations listed above is dependent on a strong drug regulatory mechanism. Conflict of interest declaration (especially with respect to the medicine/medical device industry, clinical trials) be made mandatory for all individuals, official and non-official, involved in policy making and those who are part of committees related to policies and laws. 33

 CHAPTER2

FOODREGULATION

34

Report of the Sub- Group on Food Regulation

1. The first meeting of the Working Group on Food and Drugs Regulation, constituted by the Planning Commission was held on 13.06.2011 and it was decided to form two separate sub-groups on Food and Drugs. The items of the TOR of the Working Group relevant for the Sub-Group on Food are: To review the food regulatory mechanism in the country to ensure providing quality, safe and wholesome food in the country. To review the existing manpower in FSSAI and suggest measures for further strengthening. To review the food testing laboratories under the Central Government and suggest measures for further strengthening. To review the existing manpower in respect of food regulation in States and suggest measures for further strengthening including financial assistance. To review the food testing laboratories in States and suggest measures for further strengthening including financial assistance. To suggest modifications in policies and priorities under the food regulatory framework during the Twelfth Five Year Plan. To indicate the financial outlay required for the implementation of the initiatives stated above during the Twelfth Five Year Plan. To give recommendations on any other matter relating to the topic.

2. The Sub-group on Food, chaired by CEO, FSSAI comprised Ms. Sunita Narain, Director, Centre for Science and Environment, Dr Mira Shiva, Director, Initiative for Health Equity & Society, All India Drug Action Network, Dr. Arun K. Panda, Joint Secretary, MoHFW, Shri Sanjay Prasad, Director, MoHFW and Dr. Dhir Singh, ADG (PFA), FSSAI. The Sub-Group held 3 meetings on 22-06-11, 28-0611and 21-07-11.

Background 3. The Sub-Group noted that the Food Safety and Standards Act, 2006 came into force from 5.08.2011 and replaced multiple food laws, standard setting bodies and enforcement agencies with one integrated food law. The FSS Rules and Regulations also came into force with effect from 5.8.11. The Acts and Orders that were repealed when the FSS Act came into force are the Prevention of Food Adulteration Act, 1954, the Fruit Products Order, 1955, the Meat Food Products Order, 1973, the Vegetable Oil Products (Control) Order, 1947, the Edible Oils Packaging (Regulation) Order, 1998, the Solvent Extracted Oil, De oiled Meal and Edible Flour (Control) Order, 1967, the Milk and Milk Products Order, 1992. The objective of the FSS Act is to consolidate the laws relating to food and establish the
35

Food Safety and Standards Authority of India for laying down science based standards for articles of food and regulating manufacture, storage, distribution, sale and import of food articles to ensure availability of safe and wholesome food for human consumption. 4. The challenges that the Act seeks to address include movement from multilevel and multi-department control to a single line of command, with FSSAI being a single reference point for all matters related to food safety throughout the entire food chain, a unified licensing system, encourage self-compliance, provision of graded penalties based on severity of offence together with a mechanism of speedy disposal of cases, focus on food safety, and harmonization between domestic and international food policy issues without compromising on public health and national interest. 5. The Sub-Group further observed that several activities have already been initiated towards implementation of the Act. This includes setting up the Food Authority in September, 2008, the establishment of the Scientific Committee and Panels in May, 2009 and the Central Advisory Committee in October, 2009, integration of staff from different concerned ministries and departments, notification of all sections of the Act, taking over the imported food clearance process at major seaports and airports, organising training programmes, and holding national and regional consultations/ conferences.

Recommendations of the Sub-Group 6. The Sub-group noted that the FSSAI is in the process of setting up its structure to implement its vast mandate. Now in the wake of the FSS Act coming into force, the process needs to be accelerated supported by adequate funds and faster decisions. 7. On the issue of transparency the Sub-group was informed that the FSS Act contains provisions [sections 16 (4) (a) to (d) and section 18 (2) (d)] with regard to the transparency and disclosure/ confidentiality of information which guides the functioning of the FSSAI. Accordingly the Food Safety and Standards Authority of India (Procedure of Scientific Committee and Scientific Panels) Regulations, 2010, stipulates that the minutes of the meetings of the Scientific Committee, Scientific Panels and Working Groups are posted on the FSSAIs website after their adoption. The Regulations also state that the members of the Committee, Panels and Working groups and external experts shall undertake to act independently of any external influence and have to make a Declaration of Commitment and an Annual Declaration of Interest, and for each meeting a Specific Declaration of Interest. The Regulations also provide for uploading of the agenda and minutes of meetings of Scientific Panels and Committee on FSSAIs website. In this context the provisions of Clause 16(6) of the Act were noted by the Sub-Committee: The Food Authority shall not disclose or cause to be disclosed to third parties confidential information that it receives for which confidential treatment has been requested and has been acceded, except for information which must be made public if circumstances so require, in order to protect public health.

36

8. The Act lays down a transparent procedure to be followed for standard setting and the Food Authority has laid down a detailed procedure that will be followed for drawing up/revision of standards. FSSAI is also developing an online transparent licensing system that would integrate in phases the licensing and registration process throughout the country as a part of e-governance initiative. The Sub-group recommended that being in the nascent stage the FSSAI may continue to focus on evolving appropriate organisational culture and practices to ensure transparency in its functioning and decision making. Further the interest of public health and safety should guide the processes of new product approvals and standard setting, including review of current standards. In the context of laboratories to be established/ upgraded in the States, the sub-group observed that the labs could be fully functional only when adequate manpower is provided. Therefore, the Sub-group recommended 100% central funding for these laboratories. 9. The Sub-group recommended that bio-safety should be an integral part of any risk assessment being undertaken by FSSAI. 10. The Sub-group further recommended that a proper surveillance system needs to set up which should be directed to build public information on current and new threats. Food surveys may be carried out regularly and results be made public. An annual report on state of food safety may also be published, and food safety policies that are preventive and promote healthy food may be developed. 11. The Sub-Group was of the view that sufficient focus on food safety issues is lacking in the curriculum of MBBS and an appropriate module on food safety and bio-safety needs to be introduced at the earliest. 12. The Sub-group further recommended that since the actual working of FSSAI will commence in the 12th Plan Period, a mid-term appraisal may be carried out in the 3rd year of the Plan for any course correction that may be required. 13. With regard to housing for the employees of the FSSAI the Sub-Group recommended that FSSAI should take houses on lease for the entitled employees rather than constructing houses as it would be difficult for a small organisation to maintain assets at so many places in the country. 14. The Sub-Group emphasised that with a view to put necessary infrastructure along with manpower at State level which has been a short coming in some of the earlier schemes, it is recommended that minimum required manpower that is essential to make statutory FSS structure including laboratories should be fully funded for the 12th Plan period with the understanding that the expenditure would be borne by the States in next plan. Approximately Rs 2620 crore has been assessed for next five years in this regard. All releases of funds to State Governments should be linked to tight guarantees regarding fulfilling of the States obligations through an MOU. It was also recommended that the scheme should explore innovative ideas for successful implementation of the projects envisaged under the Scheme. 15. The Sub-Group agreed that for effective implementation of the Act and achieving the goals envisaged, it is imperative that sufficient resources are made available to the Food Authority, both at the Central and State levels. The Sub-group recommends a total outlay of Rs.6548 crore (including Rs. 2246 crore for manpower related grant to States) for FSSAI for the 12th Plan period. This includes manpower
37

for FSSAI headquarters and Regional Offices, adequate laboratory infrastructure at Central and State levels, putting in place a strong food safety surveillance system along with establishment of E-governance system, establishment of a state of the art risk assessment and food safety research centre, adequate training of personnel and stakeholders and generation of awareness about food safety issues among consumers and other stakeholders. The details are given below. 16. The Sub-Group examined in detail the various components of the Proposed Scheme and recommended the following (further details can be seen in the scheme document appended to this report) : A. CREATING SYSTEMS AND INFRASTRUCTURE FOR SCIENCE BASED STANDARDS (i) National Food Science and Risk Assessment Centre(NFSRAC) - Total Outlay Rs.155 crore It is proposed to set up a dedicated institution under the direct control of FSSAI for regulatory research and risk assessment, as well as to oversee surveillance in the lines of international institutions like the Centre for Disease Control (CDC) and Centre for Food Safety and Applied Nutrition in USA and other countries. The institute is also envisaged to carry out a food safety risk analysis training programmes. Total fund requirement of Rs.155 crore has been projected for manpower, purchase of advanced equipment, training of staff, surveillance, research and development and recurring and miscellaneous expenses. Implementation Schedule: The Centre will become functional within one year of sanction of the project. Deliverables: The Centre will be the repository of all food standards and will carry out all risk assessment related work and analyse food surveillance data received from labs and other surveillance organisations.

(ii)

Upgradation of Central Food Laboratories (CFL) (NABL /GM testing)Total Outlay Rs.40 crore It is proposed to upgrade and develop the existing Central Food Laboratories at Kolkata and Mumbai (being set up) as control laboratories for development of testing methods, standardise practices, exercise technical supervision over nearly 100 referral and basic testing laboratories each. The estimated cost is Rs.10crore for CFL,Kolkata and Rs.30 crore for CFL,Mumbai (a new lab already sanctioned).

(iii)

Nationwide Food Safety Surveillance network and data collection on regular basis-Total OutlayRs.50crore. It is proposed to carry out periodic surveys for surveillance purposes with built in mechanism for emergency warning and linked with rapid action machinery.
38

This will publish annual state of food safety reports. The cost of sampling and testing and implementation through outsourcing has been assessed at Rs.50 crore for the 12th Plan period. Implementation Schedule: Implementation will be through an agency which will be engaged within 6 months of the sanction of the project. Deliverables: Generation of data regarding food hazards, possible outbreaks of food borne diseases etc which will help establish public health priorities for prevention, intervention and control. (iv) Strengthening Of Food Safety And Standards Authority Of India (Manpower/Administrative and Establishment Expenses at FSSAI Headquarters and Regional/Field Offices (Existing/Proposed)-Total Outlay Rs. 525 crore) Existing sanctioned establishment The total expenditure towards administrative expenses of FSSAI during the 12th Plan period is estimated at Rs.175crore (approximately Rs.35cr per year.). This includes rent, electricity, publicity, procurements, office expenses etc. Expansion of scientific wing, imported food testing/screening, additional regional offices, Codex wing etc. As regards establishment expenses, apart from the expenditure on the existing establishment (@Rs.10cr per year), FSSAI requires additional posts for its new Regional offices at 7 locations (210 posts), for smooth operation of the imported food clearance process (372 posts), upgradation or strengthening of laboratories (42 posts), international coordination and functioning of the National Codex Contact Point (33 posts), strengthening of the existing sub-regional offices (35 posts) and emergency response centre and media/ public relation cell (13 posts). FSSAI had proposed 531 posts in its original proposal for manpower against which sanction was received only for 355 posts, which includes 31 posts for a new scientific division. Thus in effect, FSSAI has been sanctioned only 324 posts which is even less than the 328 posts transferred to FSSAI from various ministries and departments. There is thus a gap of 176 posts between proposed and sanctioned posts. These posts are essential for the smooth functioning of FSSAI. Thus, additional requirement of manpower is of 881 posts. The financial implication of the establishment is assessed at Rs.350crore for the Plan period. Implementation Schedule:

39

Once approved, the proposal will be processed within 2-3 months for sanction and FSSAI will fill up the posts within 6 months of receipt of the sanction order. Deliverables: Establishment of a well organised structure in FSSAI having personnel / manpower with appropriate set of skills and experience to achieve the mandated role of FSSAI. Office accommodation (construction of new office building, including NFSTI) Presently, FSSAI headquarters is functioning from the 3rd & 4th Floors of FDA Bhavan which is also the office of the CDSCO. As the organisation is expanding and with the increased manpower component, a new office building is required. It is proposed to have a multi-storey modern complex which will also house the proposed National Food Safety Training Institute. The estimated expenditure is Rs.300crore. Implementation Schedule: The design and plan have already been prepared for the site adjacent to the FDA Bhavan from where the FSSAI is presently functioning. The construction work will be awarded within 6 months from the date of approval of the proposal and the building will be ready within approximately 2 years from the date of award of the work. The land is already with the Ministry of Health and Family Welfare. Deliverables: Independent premises for FSSAI Headquarters along with establishment of the National Food Safety Training Institute would be completed within the 12th Five Year Plan. Housing (to be taken on lease) Since FSSAI employees will not be eligible for general pool accommodation and also as the Department of Expenditure has agreed to provide leased accommodation only to CP and CEO, it will be difficult to attract experienced and qualified personnel unless residential accommodation is provided by the organisation. It is, therefore, proposed to that provision would be made for leasing at least 200flats in the NCR region and at least 10 flats each (total 100) at the location of Regional offices. The total estimated expenditure is Rs.60crore. Implementation Schedule: FSSAI will start leasing accommodation immediately after the proposal sanctioned. However, progress of leasing will be staggered over the next 2 years in keeping with the progress of sanction and filling up of posts.
40

Deliverables: The housing satisfaction level that is expected to be reached during the 12th Plan is around 25%. B. FOOD SAFETY MANAGEMENT SYSTEM Under the FSS Act, all food testing has to be done in accredited laboratories and prosecutions based on testing in non-accredited laboratories will fail in the courts on this ground alone. Presently almost all the public sector food laboratories are not accredited. FSSAI commissioned a gap analysis study for up-gradation of 50 food laboratories under the Central and State Governments. The study has indicated that there is an urgent need to upgrade the infrastructure, strengthen staffing and training inputs and put in place more reliable laboratory management and operational procedure. The Sub-group observed that a network of efficient laboratories is the backbone of any credible food safety initiative. Most existing PFA laboratories lack facilities for testing of microbiological parameters, heavy metals and residues. Further, adequate number of food testing laboratories is essential for effective enforcement with greater rate of conviction of violators, citizen empowerment and voluntary testing by food establishments to comply with the law. The hierarchy of laboratories proposed is: Cluster Food Testing Laboratories (1 in 5districts) doing basic tests, Zonal Food Laboratories (1 in 10districts) performing all tests including residues and heavy metals, 10 Referral Laboratories and two control labs under FSSAI. In addition, mobile laboratory facilities are also required in the country to cater to festivals, natural calamities and inaccessible areas. Some of the members of the Sub-Group expressed concern that the State governments may not provide adequate manpower for running the laboratories, as a result of which the equipment provided by the Central Government would lie unutilised and the laboratories may not become functional. Therefore, it was agreed that there should be 100% funding of the laboratories by the centre for the States strictly on the basis of State Guarantees through an MOU. (i) Cluster laboratories of accredited standards for every 4-5 districts (one time cost for setting up of 125 laboratories for 625 districts and recurring expenditure for Plan period (@ 6.5 crore per lab) Food testing facilities need to be available closer to the place of collection of samples for successful implementation of the FSS Act. Access to food testing facilities is also essential for the empowerment of citizens who may keep an eye on the quality of food available in the area as also provided in the law. It is, therefore, proposed that there should be at least one primary food testing laboratory for a cluster of 5 districts on the average in the country which will be able to perform the basic physical, chemical and microbiological tests. Cost of establishment and operation of each such laboratory is assessed at Rs.6.5 crore. As 125 such laboratories are proposed to be established, total fund implication during the Twelfth Plan is Rs.812 crore.
41

(ii)

Up-gradation of existing 62 Public Food Labs to accredited standards for comprehensive testing facilities as Zonal Labs- one laboratory for every 10 districts (@ Rs 5 crore / lab) From the Gap Analysis Study conducted by FSSAI, it was brought out that there is an urgent need to upgrade infrastructure of the existing laboratories in the States. Equipment proposed to be procured are HPLC, GC-MS, LC-MS, AES and microbiology unit. It is proposed to allocate Rs.5crore for up-gradation of each laboratory. To ensure successful operation of the scheme procurement of equipment with operation and maintenance clause for 5 years will be explored.

(iii)

Up-gradation of existing 10 Public Labs to accredited Referral Laboratories (@ Rs 10 crore per lab) It is proposed that 10 of the existing 72 public laboratories may be upgraded to referral laboratories with fund allotment to the respective States @ Rs.10 crore for each laboratory. These laboratories will receive referral or appellate samples from Designated Officers and also have other specialised testing facilities. In this case also, to ensure successful operation of the scheme procurement of equipment with operation and maintenance clause for 5 years will be explored.

(iv)

35 Mobile Food Labs for remote area, large public congregations, disease outbreaks etc (@ Rs. 7.5 crore per lab per State) It is proposed to allot Rs.7.5 crore to each State for setting up mobile food laboratories during the Five year Period. These will carry out screening and analysis of samples to provide rapid results, provide additional sampling and testing capacity and also reduce time period between sample collection, analysis and reporting. The mobile laboratories will work in close coordination with the local laboratories and samples requiring more extensive testing would be sent to the fixed-site local laboratory. Such mobile laboratories will be highly useful during festivals and large public gatherings, remote areas, natural calamities and other emergencies.

(v)

Networking of all food testing labs working under FSS Act The laboratories under administrative control of FSSAI and States shall in normal functioning and under special circumstances while conducting surveillance shall be undertaking testing/analysis of food samples/food
42

additives etc. which after analysis may prove to be unsafe /hazardous to health. Networking of all the laboratories would be essential for sharing of information about hazardous food material detected while testing for emergency response/alerts whenever necessary. The networking shall also ensure collation of sampling/analysis data for risk management. As per estimates, it is proposed to have an outlay of Rs 9 crore for networking and maintenance of data bank/software. C. ENFORCEMENT (i) Setting up of enforcement structure in States/UTs (Manpower) It is proposed to provide financial assistance towards cost of manpower to State Governments for establishing new district level food safety offices being created for the first time under the Act. The total estimated cost of manpower is Rs 2246 crore in the 12th Plan period. FSSAI will sign MoUs with States/ UTs to specify their responsibilities for availing the assistance. Implementation Schedule: Subject to the signing of MoU, funds will be released to the State Governments. Deliverables: Timely issuance of license and registration of FBOs, more sampling and inspections, enhanced conviction rates through proper handling of samples, proper maintenance of records and timely submission of reports for taking further decision, increased awareness amongst stakeholders and better coordination in emergency situations.

(ii)

One time assistance for infrastructure/operational equipment/facilities for strengthening District Level Food Safety Office for 626 districts Availability of critical infrastructure and operational equipment/facilities at field level is essential for smooth functioning and timely action for enforcement of provisions under FSS Act and discharge of duties/responsibilities by the cutting edge level functionaries. It is proposed to provide onetime financial assistance to the State Governments/UTs to meet the cost of infrastructure/operational equipment/ facilities for setting up of new district level food safety offices being created under FSS Act. The total financial implication would be Rs.374 crore. FSSAI will sign MoUs with States/ UTs to specify their responsibilities for availing the assistance. Implementation Schedule:

43

Subject to the signing of MoU, this fund will be released to the State Governments. Deliverables: Timely issuance of license and registration of FBOs, more sampling and inspections, enhanced conviction rates through proper handling of samples, proper maintenance of records and timely submission of reports for taking further decision, increased awareness amongst stakeholders and better coordination in emergency situations.

D. TRANSPARENCY AND OVERSIGHT (i) National Food Safety Helpline It is proposed to establish a National Food Safety Helpline for direct communication with all stakeholders in an interactive manner, centred at FSSAI Headquarters. It will be linked to the emergency response centres in the States. Expected expenditure is about Rs.1 crore per year in the 12th Plan Period. Implementation Schedule: A small cell has already been established for the operation of the National Helpline. The Helpline will be fully functional within a period of 6 months from date of approval. Deliverables: Establishment of direct and interactive communication channels with all stakeholders in food safety matters. (ii) Emergency Response and Rapid Alert Centre (@ Rs 1 crore per States/UTs) It is proposed to have in place an emergency response system in each Food Safety Commissioners office at an average cost of Rs.1 crore each for responding to food alerts/ threats to public health etc. These response centres are proposed to be finally linked with all district headquarters, panchayats and other local bodies for collection/ dissemination of information through networking under e-governance plan. Total expenditure for 35 States/UTs would be Rs.35crore. Implementation Schedule: The State Governments will be establishing the emergency response centres and it is expected they will be operational within 1 year from the date of approval.
44

Deliverables: Establishment of direct and interactive communication channels with all stakeholders in food safety matters. (iii) Whistle Blower Scheme A draft reward scheme for information on unsafe/adulterated food has been prepared for encouraging general public and employees to furnish information regarding unsafe food and malpractices within or outside the system. Funds are proposed to be allocated to the States/UTs during the 12th Plan on the basis of their population. Actual disbursement will, however, depend upon the response to the scheme. Implementation Schedule: The scheme is expected to be approved within 6 months and fund utilization after that would depend on the response of the State Governments. Deliverables: Better surveillance of food safety issues due to availability of information regarding adulterated/ unsafe food from all stakeholders.

(iv)

E-Governance Inter-connecting all licensing & registration offices and laboratories and introduction of GPS based sample collection system, online licensing It is proposed to establish a computerised system to integrate all the food safety systems from district level upwards for an integrated online licensing and registration system, maintenance of a database on food safety issues and provision of GPS based sample collection system for transparency. It will enable a transparent licensing and registration system and aid in food safety surveillance and rapid response to any emergency. Funds are proposed to be given to the offices of the Designated Officers and the State Food Safety Commissioners for hardware and manpower. Total fund requirement is envisaged at Rs.175crore during the 12th Plan period. Implementation Schedule: Implementation will be through a competent agency who will carry out the work on all India basis. The agency will be engaged within 6 months of receipt of sanction and the work will be completed within 2-3 years thereafter. Deliverables: All District headquarters and laboratories will come under E-Governance and get connected to the National grid to enable all information to be available on one system.

45

E. CAPACITY BUILDING (i) National Food Safety Training Institute (NFSTI) (apex institute to do human resource planning for whole country and prepare trainers) Training at NFSTI As a part of the strategy to build a motivated and technically uptodate cadre of food safety personnel in the country, the Regulations have made it compulsory for every officer to undergo refresher courses besides intensive entry level course. This will require a large number of trainers throughout the country. At present, there is no training institute in the country which imparts training on food safety issues. It is proposed to establish a National Food Safety Training Institute at the FSSAI Headquarter which will provide regular training programmes for trainers of food safety personnel and also other stakeholders. Courses would include induction training, upgradation of knowledge, refresher courses and training on specialised subjects. An outlay of Rs.15 crore is proposed during the Twelfth Five Year Plan for conducting training programmes, including payment of honorarium etc. to resource persons. The cost of construction of the centre is included in the projections for the building for FSSAI Headquarter. Implementation Schedule: The Institute will start functioning within 6 months of approval. Deliverables: Establishment of the first of its kind nodal centre for training on food safety related issues in the country. (iii) Trainings by States/UTs Implementation of FSS Act would largely depend on the training of the officials/officers who shall be engaged in regulation and enforcement of FSS Act at State level. State Governments will therefore be required to hold training programmes for food safety personnel at the State and District levels. It is proposed to provide token assistance to the States for conducting such trainings for ensuring capacity building of personnel engaged in enforcement/implementation of the Act for which it is proposed that a provision of Rs.30 crore may be made for the Twelfth Five Year Plan Period. Disbursal would be on the basis of training plans developed by the States/ UTs. Implementation Schedule: Disbursal would be on the basis of training plans developed by the States/ UTs. Deliverables:
46

(ii)

Capacity building of personnel /stakeholders on implementation/ food safety related issues at State/district levels. F. AWARENESS GENERATION/ IEC The success on the food safety front substantially depends on awareness of all the stakeholders about the food safety issues and rights and obligations under the law. Also, it is imperative that food safety messages percolate down to all levels for which a strong communication campaign is required. Some preliminary work in this direction has already been done through advertisements and TV programmes. At the same time, training, and capacity building of food safety personnel is essential for enforcement of the Rules and Regulations and proper training infrastructure and institutions need to be in place. (i) Awareness Activities and Educational Programmes by FSSAI For generating awareness amongst consumers and all other stakeholders, FSSAI proposes a vigorous awareness campaign through media- print & electronic- and non-media distribution of IEC material - approaches, dedicated programmes like Doordarshans Kalyani programme, distribution of food testing kits, special events at National and State levels, printing of handbooks on food safety, implementation of a specific Action Plan on food safety, audio- visual shows in villages, schools, municipal areas etc. and general advertisements in public places, journals, national dailies etc. It is proposed that for awareness activities through media Rs.350 crore may be allotted and for non-media Rs.319 crore may be allotted during the Twelfth Plan.

Implementation Schedule: The work will be executed by engaging a reputed agency for managing media related activities.. The work related to selecting the agency will start shortly so that actual work can begin within 6 months of approval. Deliverables: Increased awareness of food safety related issues at all levels. (ii) Grant to States for IEC Activities (@ Rs 2 crore per State per year) It is proposed that Rs. 2 crore per State/ UT per year may be provided to the State/ UT for awareness generation campaigns on food safety at the State/ UT level on issues specific to that region in local dialects for deeper penetration of the food safety messages and provisions of the FSS Rules and Regulations right down to the village level. Implementation Schedule: Release of grants to the States/UTs will be on the basis of the response received from them to the scheme.

47

Deliverables: Better trained food safety personnel at State and District levels and increased awareness about food safety issues right down to the village level.

17.

Details of Proposed Financial Outlay Fund required in 12th Plan Period (Rs. in crore) FSSAI States CREATING SYSTEMS AND INFRASTRUCTURE FOR SCIENCE BASED STANDARDS 155.00 National Food Science and Risk Assessment Centre Component/ Scheme Manpower Rs. 12.25 crore Equipment Rs. 25 crore R&D Rs.20 crore Workshops/Seminar/Training Rs.15 crore Infrastructure and recurring expenses Rs. 82.75 crore Up-gradation of Central Food Laboratories (CFL) (NABL /GM testing)- Control Laboratories CFL, Mumbai (Rs. 30.00 Cr. new set-up) CFL, Kolkata (Rs. 10.00 Cr. up-gradation)
48

A (i)

(ii)

40.00

(iii)

Nation-wide Food Safety Surveillance network and data collection on regular basis Strengthening of Food Safety and Standards Authority of India Existing sanctioned establishment Expansion of scientific wing, imported food testing/screening, additional regional offices, Codex wing etc. Office accommodation (construction of new office building, including NFSTI) Housing (to be taken on lease) FOOD SAFETY MANAGEMENT SYSTEM Cluster laboratories of accredited standards for every 4-5 districts (one time cost for setting up of 125 laboratories for 625 districts and recurring expenditure for Plan period (@ 6.5 crore per lab) Up-gradation of existing 62 Public Food Labs to accredited standards for comprehensive testing facilities as Zonal Labsone laboratory for every 10 districts (@ Rs 5 crore / lab) Up-gradation of existing 10 Public Labs to accredited Referral Laboratories (@ Rs 10 crore per lab) 35 Mobile Food Labs for remote area, large public congregations, disease outbreaks etc (@ Rs. 7.5 crore per lab per State) Networking of all food testing labs working under FSS Act

50.00

(iv)

175.00 350.00 300.00 60.00

B (i)

812.00

(ii)

310.00

(iii)

100.00

(iv)

263.00

(v)

9.00

C (i) (ii)

ENFORCEMENT Setting up of enforcement structure in States/UTs (Manpower) One time assistance for infrastructure/operational equipment/facilities for establishing new District Level Food Safety Office for 626 districts 2246.00 374.00

D (i) (ii) (iii)

TRANSPARENCY AND OVERSIGHT Whistle Blower Scheme National Food Safety Helpline Emergency Response and Rapid Alert Centre (State level control room) (@ Rs 1 crore per States/UTs) 25.00 5.00 35.00

49

(iv)

E-Governance Inter-connecting all licensing & registration offices and laboratories, introduction of GPS based sample collection system, online licensing CAPACITY BUILDING National Food Safety Training Institute (NFSTI) (apex institute to do human resource planning for whole country and prepare trainers) Training at NFSTI Trainings by States/UTs AWARENESS GENERATION/ IEC Awareness Activities and Educational Programmes by FSSAI Media Rs. 350 Crore Non-media (production of Rs 319 Crore educational material, targeted activities for women, youth, children, food manufacturers, processors, handlers, exhibitions etc) Grant to States for IEC Activities (State specific Schemes with emphasis on local language) (@ Rs 2 crore per State per year) Total Grand Total (FSSAI + States) 1853 6548 669.00 7.00

175.00

E (i)

(ii) (iii) F. (i)

8.00 30.00

(ii)

350.00

4695

Summary of Financial Outlay

Fund required in 12th Plan Period (Rs. in crore) FSSAI States CREATING SYSTEMS AND INFRASTRUCTURE FOR SCIENCE BASED STANDARDS 1130.00 Component/ Scheme FOOD SAFETY MANAGEMENT SYSTEM

50

9.00 C ENFORCEMENT

1485.00

2620.00 D TRANSPARENCY AND OVERSIGHT 30.00 E CAPACITY BUILDING 15.00 F. AWARENESS GENERATION/ IEC 669.00 Sub-total Grand Total (FSSAI + States) 1853.00 350.00 4695.00 30.00 210.00

6548.00

51

REPORTOFTHE WORKINGGROUPON HEALTHRESEARCH FORTHE12THFIVE YEARPLAN

WG5: HEALTH RESEARCH

WG-5
No. 2(6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 Dated 9th May 2011

OFFICE MEMORANDUM

Subject: Constitution of working group on Health Research for the formulation of the Twelfth Five Year Plan (2012-2017)
With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on Health Research under the Chairmanship of Dr. V.M. Katoch, Secretary, Department of Health Research, Ministry of Health & Family Welfare. The composition and the terms of reference of the Working group would be as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Dr. V.M. Katoch, Secretary, Department of Health Research & Chairperson Director General, ICMR

Prof M S Valiathan, Director of the Sree Chitra Tirunal Institute of Medical Sciences (SCTIMS) , Thiruvananthapuram Joint Secretary (ME), MoHFW, Government of India JS (Public Health), MoHFW, Government of India Representative, Department of AYUSH, Government of India Representative, Department of AIDS Control, Government of India Representative, Department of Biotechnology, Government of India Representative, Department of Science and Technology, Government of India Representative, Department of Information Technology, Government of India

Co Chairperson Member Member Member Member Member Member Member Member

10. Representative, Defence Research and Development Organisation, Government of India

11. Representative Department of Agricultural Research and Education (DARE) & Director General, Indian Council of Agricultural Research (ICAR) , Government of India 12. Nominee of Secretary, Department of Scientific & Industrial Research (DSIR) & Director General, Council of Scientific and Industrial Research (CSIR) 13. Nominee of Chairman, Atomic Energy, Government of India 14. Representative, Department of Environment & Forests Government of India 15. Dr. Satish Chandra, Director, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore 16. Dr. Syed E. Hasnain, Former Vice Chancellor, University of Hyderabad 17. Dr. K. Ramnarayan, Vice Chancellor, Manipal University, Manipal 18. Dr. G.K. Rath, Prof. & Head, Institute Rotary Cancer Hospital (IRCH), AIIMS, New Delhi 19. Dr. U.C. Sharma, Vice Chancellor, S.S. University of Health Sciences, Guwahati, Assam 20. Prof. K.K. Talwar, Director, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 21. Dr. Ab. Hameed Zargar, Director, Sher-I-Kashmir Institute of Medical Sciences, Srinagar 22. Sarojini NB, Sama, Resource Group for Women and Health, New Delhi 23. Dr. George Thomas, Chief Orthopaedic Surgeon, St. Isabels Hospital, Chennai and Editor, Indian Journal of Medical Ethics 24. Prof Padmanabhan, Former Director, Institute of Science 25. Dr. Indira Nath, Pediatrician, Fellow, Indian Academy of Science, Formerly at AIIMS 26. Principal Secretary (H&FW), Government of Uttaranchal 27. Principal Secretary (H&FW), Government of Kerala 28. Principal Secretary (H&FW), Government of Sikkim 29. Mr. S. M. Mahajan, Adviser (Health), Planning Commission 30. JS (DHR), Department of Health Research

Member

Member

Member Member Member Member Member Member Member Member Member Member

Member

Member Member

Member Member Member Member Member Secretary

Terms of References
1. To identify major issues, areas for policy research in health sector for 12th Five Year Plan 2. To identify technology and operational gaps in health especially in the context of wide range of capabilities and infrastructural base in the country and build up coordination of basic, applied and clinical research in the Medical and Public health education. 3. To select technologies and approaches which are to be encouraged for development, programmes. 4. To identify and build up health research human resources and develop an interface between new technology developers (researchers in the Medical Institutions; State or Centre), health systems operators (Centre/State health services) and the beneficiaries (community). 5. To look into the research governance issues including ethical issues in medical and health research. 6. To explore the possibility of public-private partnership in medical, bio-medical and health research related areas. 7. The Chairman may constitute various specialists groups / Sub-groups/task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. 8. Working Group will keep in focus the Approach paper to the 12th Five Year Plan as well as the identified goals, while making recommendations. 9. Efforts must be made to co-opt members from weaker sections especially SCs, Scheduled Tribes and minorities working at the field level. 10. The expenditure towards TA/DA in connection with the meetings of the Working group with respect to the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the nonofficial working group members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. 11. The Working group would submit its draft report by 31st July 2011and final report by 31st August 2011. implementation and evaluation in the public health

(Shashi Kiran Baijal) Director (Health)

Copy to: 1. 2. 3. 4. 5. 6. 7. 8. 10. 11. 12. Chairman, all Members, Member Secretary of the Working Group PS to Deputy Chairman, Planning Commission PS to Minister of State (Planning) PS to all Members, Planning Commission PS to Member Secretary, Planning Commission All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission Director (PC), Planning Commission Administration (General I) and (General II), Planning Commission Accounts I Branch, Planning Commission Information Officer, Planning Commission Library, Planning Commission

(Shashi Kiran Baijal) Director (Health)

REPORT OF

THE WORKING GROUP ON HEALTH RESEARCH FOR XII PLAN

SEPTEMBER-2011

DEPARTMENT OF HEALTH RESEARCH MINISTRY OF HEALTH & FAMILY WELFARE

CONTENTS

ReportoftheworkinggrouponHealthResearch.1 fortheXIIPlan Newscenario...3

TheXIIPlanApproachforS&T....4

AssessmentofCurrentsituation....7 CreatingaPromotiveEnvironmentforHealthResearch...11 BroadFrameworkofactivitiesofDHR..13

i) EstablishmentofaNationalNetworkforViralDiagnostic /InfectiousDiseaseLaboratories..14 ii) Establishmentofotherspecializedresearchunitsincludinglabs..15 iii) HumanResourcesDevelopmentforHealthResearch....15 iv) Intersectoralcoordination&nationaland/internationalcollaboration..16 v) Establishmentofregulatoryframeworkforresearchgovernance18 vi) StrengtheningandexpansionofprogrammesofICMR...19 vii) UseofInformationTechnology...21 viii) Strengthensynergyandcoordination.22

PriorityareasThe10Pointagenda..23 Budget..25 AnnexureI.AchievementsofDHR/ICMRduringtheXIPlan.26 AnnexureII.ConstitutionoftheWorkingGrouponHealthResearch


Report of Working Group on Health Research for XII Five Year Plan

REPORTOF THEWORKINGGROUPONHEALTHRESEARCH FORTHEXIIPLAN

Health research is the key to a well functioning and effective health sector in the country. Major scientific breakthroughs hold the promise for more effective prevention, management and treatmentforanarrayofcriticalhealthproblems. Theresearchtobeundertakenshouldbe oncountry specifichealthproblemsessentialfor theformulationofsound policiesandplansfor fieldaction. Butnewinterventionsanddevelopmentofnewhealthproducts(drugs,diagnosticsandvaccines) arepossibleonlywhenthereiswelldefinedfunding,infrastructureandpriorityforhealthresearch. Medicalresearchinthecountryneedstobefocusedonnewtherapeuticdrugs/vaccinesfortropical diseases,normallyneglectedbymultinationalpharmaceuticalcompaniesonaccountoftheirlimited profitability potential. In addition, India is also witnessing the dual disease burden with the non communicablediseaseslikecardiovasculardiseases,diabetes,cancersetc.threateningtoovertake infections.Thethrustandfocusofourmedicalresearchthereforeneedstobeonboththeinfections as also the newly emerging NCDs using cuttingedge science and technology based on genetics, molecularbiology,genomicsetc.Itwould bereasonabletoinferthatwiththecurrentlowbudget allocationtohealthresearch,itisdifficulttomakeanydramaticbreakthroughwithinthecountry, bywayofnewmoleculesandvaccinesandotherhealthproducts. TheNationalHealthPolicy2002definedthegoalforHealthResearchasfollows: Over the years, health research activity in the country has been very limited. In the Government sector, such research has been confined to the research institutions under the Indian Council of MedicalResearch,andotherinstitutionsfundedbytheCentral/StateGovernments.Researchinthe private sector has assumed some significance only in the last decade. In our country, where the aggregateannualhealthexpenditureisoftheorderofRs.80,000crores,theexpenditurein199899 onresearch,bothpublicandprivatesectors,wasonlyoftheorderofRs.1150crores.Itwouldbe reasonable to infer that with suchlow research expenditure,itisvirtuallyimpossibleto make any dramaticbreakthroughwithinthecountry,bywayofnewmoleculesandvaccines;also,withouta minimal backup of applied and operational research, it would be difficult to assess whether the health expenditure in the country is being incurred through optimal applications and appropriate public health strategies. Medical Research in the country needs to be focused on therapeutic drugs/vaccinesfortropicaldiseases,whicharenormallyneglectedbyinternationalpharmaceutical companiesonaccountoftheirlimitedprofitabilitypotential.Thethrustwillneedtobeinthenewly emergingfrontierareasofresearchbasedongenetics,genomebaseddrugsandtherapies,vaccine developmentandmolecularbiologyetc. Sinceitsestablishment,theICMRhasbeenmakingconcertedeffortstoaddressthehealthneedsof thenation.Givenitslimitedresourceshuman,financialandinfrastructuraltheCouncilhas 1


Report of Working Group on Health Research for XII Five Year Plan

dischargeditsnationalobligationsthroughitsnetworkof31nationalinstitutesincluding6regional medicalresearchcentres,over100fieldstationsandastrongandvibrantextramuralresearchin medicalcollegesandotherinstitutes.Therapidlygrowingeconomywithanaverageannualgrowth rateofalmost9.0%hasthrownupnewchallengesinthehealthsector:apopulationthatisdivided into an increasing number of middle and upper middle class and the marginalized segment of society. The health challenges continue to be huge, and complex. We have at the same time serious problems of malnutrition, both undernutrition among children and growing problem of obesityinschoolgoingandadolescents,continuedinfectiousdiseaseburdenamongthepoorto rising cardiovascular disease and diabetes disease load among the rich. What is more, developmentrapidindustrializationofIndia,useofpesticidesandfertilizersforimprovingcrop yields are rapidly degrading the environment, causing air and water pollution resulting in several healthproblemsfromchemicalsinbreastmilktoincreasingcancersindifferentcommunities. Duetoimprovedhealthcare,thereisagrowingandgreyingmiddleclassaddingtooldercitizens which is demanding specialized geriatric care. To address these unique double burden, the nationalresearchagendaneedstobeconstantlyupdatedtocopewiththesenewchallenges.Finally, theglobaltradeandnewintellectualpropertyrightsregimeshaveaddedanotherdimensionofthe rise in costof medicinesandthe limitedpossibility ofproducingaffordable generics in the future. Weneedtocreateourownproductsandprocesses,ifwehavetoensureaffordablehealthcarefor our population; even to address the infections like TB, malaria, HIV/AIDS etc. that largely come underthepublichealthsystem. Clearly, Medical Research in the country needs to be focused on creating our own therapeutic drugs/vaccines and other interventions especially for tropical diseases for which there have been fewinventionsinthelastdecades.However,thedevelopmentofnewhealthproducts(diagnostics, drugs and vaccines) is a long and complex process and we need to have systems in place to encourage innovation andappropriateethical andregulatory frameworkfor preclinicalwork and clinicaltrialsforbringingourhealthproductstomarket. Thethrustandfocusthereforeneedstobetocreatenewdirectedknowledgegeneratedinfrontier areas of research based on genetics, molecular biology, etc. and conventional means to develop affordablegenomebaseddrugsandvaccines,whichisthestrengthoftheresurgentIndia.Overthe years,theCouncilhasbeendoingitsbestinalltheseareas,despitelimitedresources.


Report of Working Group on Health Research for XII Five Year Plan

NewScenario
During the last 10 years, the overall situation has somewhat changed with more resources being providedforbiomedicalresearchtoandthroughtheICMR,andtootherscienceagencies.Butunlike biomedicalresearch,healthresearchismuchmoreencompassingcoveringawiderhorizonforthe creation of new knowledge and tools for application in human populations. To address this challenging task and to give a greaterthrustand focus to HealthResearch, a newDepartmentof Health Research (DHR) under the Ministry of Health & Family Welfare was created on the 17th September,2007.TheDepartmentwasformallylaunchedon5thOctober,2007. ThemandateofDHRisasfollows: 1. Promotion and coordination of basic, applied and clinical research including clinical trials and operational research in areas related to medical, health, biomedical and medical profession and education through development of infrastructure, manpower and skills in cuttingedgeareasandmanagementofrelatedinformationthereto. 2. Promote and provide guidance on research governance issues, including ethical issues in medicalandhealthresearch. 3. Intersectoral coordination and promotion of publicprivate partnership in medical, bio medicalandhealthresearchrelatedareas. 4. Advanced training in research areas concerning medicine and health including grant of fellowshipsforsuchtraininginIndiaandabroad. 5. International cooperation in medical and health research including work related to internationalconferencesinrelatedareasinIndiaandabroad. 6. Technicalsupportfordealingwithepidemicsandnaturalcalamities. 7. Investigation of outbreaks due to new and exotic agents and development of tools for prevention. 8. Mattersrelatingtoscientificsocietiesandassociations,charitableandreligiousendowments inmedicineandhealthresearchareas. 9. Coordination between organizations and institutes under the Central and State Governments in areas related to the subjects entrusted to the Department and for the promotionofspecialstudiesinmedicineandhealth. 10. AdministeringandmonitoringofIndianCouncilofMedicalResearch. With the creation of Department of Health Research, a paradigm shift in pursuing the national healthresearchagendaisexpected.Sinceindependence,Indiahasspentmostofitsresourcesand energyonthe development anddeployment ofnew knowledge aboutvarious diseases (especially infectious diseases which account for most deaths) in a concerted attempt to control, treat or eradicatethem.Whiletoolsusedweremostlyglobal,thestrategiesdevelopedwerelocal.Thenew disease control/treatmentregimens and methodsof theirusage inpublic healthweretheoriginal conceptsfromIndia,especiallyfordiseasesliketuberculosisandleprosy.Thesestrategieshavebeen widelyacclaimedandrecognizedandhavefoundtheirwayintointernationalprogrammesoperated throughagenciesliketheWHO.Indiahasthusspentconsiderableeffortsinsuccessfullyputting 3


Report of Working Group on Health Research for XII Five Year Plan

various ideas into action. As a result, we have achieved great successes in the area of infectious diseaseslikeeliminationofguineawormdisease,eradicationofsmallpox,eliminationofleprosyand polio as public health problems. During the recent times, the country showed remarkable and globallyacclaimedsuccessesincontrollingthespeedofspreadofH1N1epidemic.Inaddition,there have been emerging and reemerging infections like H1N1, exotic viral infections that have been continuouslychallengingthehealthsystem.Astheinfectiousdiseaseshavenorespectforborders, we may well have prevented a disaster of spread of these epidemics in the Indian subcontinent. Whilewecountthesesuccesseswithlegitimatepride,therehavebeenfailuresinsomesectors.We have also not been able to successfully address issues like the huge maternal and child mortality and have been way behind in the achievement of MDGs 4 and 5. We have also not been very successful in providing access to even minimal health care to our large tribal and marginalized communities. All these remind us of the need for constant vigilance and a nationwide targeted, concertedandcommittedtimeboundactionplan.Sucheffortsneedtobeonamissionmodewith defineddeliverableskeepinginmindavailablehumanresources,infrastructure,anduniquesocio economicaswellasgeographicalrealitieswhilesettingachievableandrealistictargetsfortheXII Plan.

TheXIIPlanapproachpaperforS&Tlaysemphasison
(a) An in depth review of our existing institutions, structures and mechanisms so that the muchneededresources,financialandhuman,aredeployedinanoptimalfashion.There isnoalternativebuttofocusoninnovationstodevelopanddeployaffordabletoolsfor themanagementofvariousdiseasesguidedbyequityasthecorevalue. Building of alliances and partnership as another key element for a vibrant innovation ecosystemfortranslatingresearchoutputstomeasurablesocialandnationaloutcomes.

(b)

This is especially important as in the postTRIPS era, there is little chance of using products and processesdevelopedoutsideforuseinIndiainviewofprotectionofintellectualpropertyrights. Discovery and development of indigenous health products is imperative to achieve equity with accesstoourlargepopulations.Indiahasoftenbeenfoundwantingonconvertingideasandleads intoproductsandprocessesforvariousreasons.Buildingofalliancesandpartnershipforavibrant innovationecosystemfortranslatingresearchoutputstomeasurablesocialandnationaloutcomes therefore has been emphasised as one of the key elements in the approach paper of the XII Five Yearplan. Consideringthathealthis amajordriverofeconomicdevelopmentandsocialcontentmentin any country, India has unique challenges due to its large population and demographic transition. We havethelargestyoungpopulationandasignificantspurtofthepeoplewhoarelivinglongerand needspecializedgeriatrichealthcare.Toaddresstheseexistingandnewchallenges,Departmentof HealthResearch hasbeenassigned 10business ofwhich 9 are newandtheir evolution isvital for developing the health research agenda of the country for achieving the targets in a time bound manner. 4


Report of Working Group on Health Research for XII Five Year Plan

The only ongoing activity of Department of Health Research pertains to administering and monitoringIndianCouncilofMedicalResearch(ICMR)whichisinits100thyearofexistence.Today, theICMRstandsoutasaformidableandstrongstructurehaving31nationalandregionalinstitutes and more than 100 field stations under its fold. More significantly, the Council has been able successfullyaccessthestrongmedicalcollegesystemacrossthecountryandsupport/collaborate with other national research institutions. It is, therefore, imperative that ICMR be further strengthenedbycontinuousmodernizationofitsowninstitutionsaswellasbyopeningofnew centres focussed on the new emerging communicable and noncommunicable diseases, cutting edgebasicscienceliketransplantimmunology,genomics,proteomicsetc.,strengtheninfrastructure foranimalexperiments,clinicalpharmacology,criticalhealthpolicyissues,healthsystemsresearch, sociobehaviouralscienceresearchetc.ThehumanresourcewithintheICMRisverysmallinterms of the numbers with many institutes/centres functioning with subcritical scientific pool. It is absolutely essential to enhance the number of researchers and supportive workforce in the ICMR. There is no gain saying the fact that ICMR will continue to be the fulcrum of the new DepartmentofHealthResearch,dedicatedtotakingthemodernhealthtechnologytothepeople. The DHR has already embarked upon path of improving research governance by developing appropriate policies; establishing authorities to implement the policies; initiating the process of creationofsuitableinfrastructureinamedicalcollegesandotherinstitutions;developingaspecial scheme to strengthen human resources in medical colleges and state structures; initiating the establishment of an extensive infrastructure encompassing all regions of the country to carry out research on various infectious diseases aimed at containing all future outbreaks or epidemics. Lastly,DHRhasalsoplannedamajorinitiativeinrespectofestablishingavibrantandeffectiveinter sectoralcoordinationamongstscienceagenciesinthecountryhavingthestrengthandmissionof developingnewproductsandprocessesorhaveoverlappingareasofactivity.Theseincludeagencies of Government of India involved in basic science and/or innovation on one hand (DST/DBT/CSIR/DSIR/DRDO etc.), or with a major emphasis on epidemiology and public health (ICMR/DHR/ICAR/DARE), agencies like DIT, DAE having a strong technology platform, Rural Development & Water Supply, Alternate Energy Sources, Women & Child Development, Environment and Forests, having complimentary areas of activity. Towards this end DHR plans to establishduringtheXIIPlanwelldefinedmechanismstocreatesynergies,structuresfortechnology generation and its introduction, and implementation of the knowledge locally or internationally whichsuitsourneeds. Before undertaking an assessment of the current situation it is necessary to recap the vision and tasksidentifiedforthenewdepartment,afterwideconsultationswiththestakeholders,atthetime of its creation in 2007. These have been further fine tuned during the process of preparation of Results Framework Document (RFD). Most of these, as pointed out at the beginning were completelynewareasofactivity. TheDepartmenthasavisionTobringmodernhealthtechnologytothepeoplethroughinnovations relatedtodiagnostic,treatmentmethodsandvaccinesforprevention;totranslatetheminto 5


Report of Working Group on Health Research for XII Five Year Plan

productsandprocessesand,insynergywithconcernedorganizations,introducetheseinnovations intopublichealthsystems.

OBJECTIVES
1. To provide research leadership for resolving existing and emerging health challenges by promotion,coordination&developmentofbasic,applied,clinicalandoperationalresearch. 2. To address matters related to major health problems pertaining to epidemics, natural calamitiesandotheremergingcausesofmorbidityandmortality. 3. Toimproveresearchgovernance. 4. To accelerate translational programmes specially by facilitating joint projects with other stakeholderslikeDSIR,DARE,DRDO.,DBT,DAE. 5. To promote publicprivate partnership for translating research leads into development of affordable diagnostic technologies and pharma products including vaccines to achieve broaderobjectivesofprovidingbetterhealthcareforthepeople. 6. Toaccelerateinternationalcooperationinmedicalandhealthresearch.


Report of Working Group on Health Research for XII Five Year Plan

AssessmentofCurrentsituation
The Department has analyzed the current situation so as to prepare a strategy for future. The importantpointsemergingfromthisanalysisaredescribedbelow a) StrengthsCurrentlyhealthresearchinthecountryisprimarilybeingsupportedby31ICMR institutions and nearly 100 Field Stations/Units funded by ICMR. In addition, other science agencies like DBT, DST, DRDO, Department of Information Technology, DARE, DSIR/CSIR, DepartmentofEnvironmentandForests,DepartmentofAtomicEnergy,MinistryofWomenand Child Development, etc. are funding certain sectors of health research mostly through extramuralfundingandtosomeextentthroughtheirspecializedinstitutions. b) ChallengesNotwithstandingmanystrengthsenumeratedabove,thehealthresearch inIndia faces several challenges/hurdles which include emerging and newly emerging infectious diseases; increasing burden of chronic noncommunicable diseases; decline in mortality and fertilityrates;ageingpopulation;lackofadequateinfrastructureandhumanresources;poor funding and priority setting in comparison with developed nations; inadequate regulatory structure for such governance; health inequities between rich and the poor, including marginalizedcommunity/sectionsetc.Lackofcoordinationandtranslationmechanisminterms of testing institutions and illdefined regulatory pathways, is another pressing challenge. Collectively, all of these have retarded the pace of progress in health research field as also translationandimplementation. The XI Five Year Plan of the ICMR had identified certain challenges based on the report of National Commission on Macro Economics and Health. The challenges identified included demographic changes, disease burden due to communicable diseases (HIV, TB, Malaria and emerging and reemerging infections); noncommunicable diseases (cardiovascular diseases, diabetes,cancer,mentalhealth,chronicandpulmonarydiseases,asthma,accidentsandinjuries, oralhealth,suicidesandstrokeandneurologicaldisorders;urbanhealth;nutritionalproblems; reproductive&childhealth;qualityofdrugsanddevices;narrowresearchbase;limitedhuman resourceandneglectoftranslationalresearch.TheXIPlanhadalsomentionedofashiftfrom medicaltohealthresearchandtheneedforstrengtheningthegovernancestructureformedical research. Creation of a dedicated Department of Health Research is a step in that direction. Significantly, even at the beginning of XI Plan, the challenges were mostly the same. Yet, despitetheearlierdisadvantages,therehasbeensignificantprogressduringthelast5years. (AnnexureI).TheICMRlaunchedseveralresearchinitiativesforcontainingthetransmissionof HIV,treatmentofthedrugresistantTBandmalariaaswellasotheremergingandreemerging infections. New programmes have also been launched to carry out research on various non communicable diseases in a much more focused and accelerated way than before. Nevertheless,severalnewchallengeshaveemergedduringthisperiodthatinclude: i)increaseinthedrugresistanceamongvariousinfectiousagentsduetomisuseofdrugsaswell aslaxityinthesafetyprecautionsinthehospitals; 7


Report of Working Group on Health Research for XII Five Year Plan

ii)geneticdisorders,thatarebecomingmoreevidentduetoavailabilityofnewdiagnostictools butarelargelypreventableduetoimprovementinthetechnology; iii)increaseininjuriesduetoaccidents/traumaduetohighurbanization; iv)significantneonatalmortalitydespiteincreaseinthehospitaldeliveries; v)deathsduetochildhoodpneumonia,diarrhoea; vi)morbidityandmortalityduetopyrexiaofunknownorigin; vii)lackofadequateprogressongenderrelatedissuesinhealthcare; viii)inadequatedeliveryofadequatehealthcaretomarginalizedsectionsincludingtribes; ix)increaseinthediseasesduetounsafewater(communicableaswellasnoncommunicable); x) slow progress in the developing of the areas like disease burden studies specially vaccine preventablediseases;and xi)healthsystemsresearch,healtheconomicsandsociobehaviouralaspects. xii) subcritical qualified/trained human resource despite reasonably high inputs into various aspectsofthehealthresearchbynearlytendepartmentsofGovt.ofIndia.Someofthemajor challengesareelaboratedbelow: Epidemiological and demographic transition: India continues to grow both in terms of young populationaswellasincreasingproportionofelderlypopulation.Thehealthservicesthusneed to be geared to face the burden of all the chronic diseases faced by this growing elderly population. Thus, the research efforts need to be geared towards identifying the health problemsinthecontextofchangingsocialnormsandthecareofelderlypopulation. Emerging and reemerging infectious diseases: Due to the vastness of our country, the assessmentofprevailingdiseasesisverychallenging.Further,newdiseasesareemergingand oldandextinctdiseasesarereemerging.PandemicH1N1,firsttimereportsofhumancasesof CrimeanCongohemorrhagicfeverandamajorproportionofencephalitislikediseasewiththe causative agent as yet unidentified underscore the enormity of challenge of new and emerging diseases. The distribution and epidemiological significance of several drug resistant organisms also remains inadequately understood. Further, the cause of death due to fevers (acuteaswellaschronic)alsoremainsundeterminedinasignificantproportionofthesecases. Newervaccinesarebeingdevelopedandamajordecisionwouldneedtobemadeastowhether theyshould beintroducedintotheimmunization programme. Suchdecisions requireresearch onthecosteffectivenessofvaccinesversusthecurrentmethodsofsanitation,mosquitocontrol, cleanwateretc.Thereis asyet no concerted effort to studythese aspects specially incaseof available/ likely to be available vaccines against rota virus, influenza, papilloma virus etc. Researchisneededonpolicyissuesashowsuchinterventionscouldbeintroducedvisavistheir acceptabilitybypeople,costbenefitanalysisetc. 8


Report of Working Group on Health Research for XII Five Year Plan

Reproductive and child health: During the XI Five year plan, there has been gradual improvementinthepercentageofunder5mortalityrates,maternalmortalityratesaswell as birthrate.However,theprogresshasnotbeenastargetedandintenseoperationalresearchis requiredtoacceleratethepaceforachievingthedesiredresults.Lowbirthbabiesareamajor publichealthissuewhichneedsocialaswellashealthinterventions. Nutritional problems: The problems of under nutrition and increasing childhood obesity continue to be worrying. Micronutrient deficiencies, toxicity due to arsenic and fluoride, pesticidesandotherharmfulmaterials(additives)otherimportantproblemswhichneedtobe addressed. UrbanHealth:Urbanhealthhasemergedasamajorhealthissueintherecenttimes,especially migration from rural and tribal areas is on the rise. Accidents and injuries now constitute a majorcauseofconcernasover2.0lakhpeopledieinIndiaduetoaccidents.Thistripleburden ofcommunicable,noncommunicableandinjuriesneedtobeconsideredforbothresearchand healthcare.Mostruralfolkareforcedtocometocitiesfortreatmentwheretheyfinddifficultto getadmission/stay.ItispredictedbytheMckinseyGlobalInstitutethatinthenext20years, India will have 68 cities with more than one million population. Currently, we have 42 such cities. Thus by 2030 India would have twice as many cities as the whole of Europe. Urban population would increase from 340 to 590 million which means that 10% of the Indias populationwillresideincities.Weneedtostartplanningforurbanhealthnow.Ifurbanhealth care system is improved, the rural population would also benefit by the improved health infrastructure and manpower. But this requires multi level and multisectoral planning. Fresh thinking on research approaches for policy making would be required rather than the current verticaldecisionmaking.Atransdisciplinaryapproachesinvolvingnotmerelymedicalpersonnel but also engineers, economists, social scientists and the civil society would be needed. The experience of developed countries like Japan and Korea where overcrowding has broken up extendedfamiliesputtingpressureonthenuclearfamilywithresultantisbutapointertothe impendingmentalhealthchallengesinourcountry.Risingsuicidesamongstchildrenandlackof careforagedhavebecomeworrisome. Noncommunicablediseases:Withincreasinglifespan,thenumberofageingpopulationison therisewithresultantriseinnoncommunicablediseaseslikecardiovascularandneurological problemsarebecomingmoreandmorepronounced.TherecentstudyconductedbyICMRhas shown the prevalence of diabetes ranging from 2.5% in Jharkhand to 10% in Chandigarh and other urban areas of the country. While the percentage of population having cancers has remained static, the profiles are changing and burden due to absolute numbers is showing a markedincrease. Trauma: The number of injury cases mainly due to road side accidents has been rapidly increasinginIndia.Thenatureofservicestocopewithsuchemergenciesisgrosslyinadequate. Intenseresearcheffortsarerequiredtounderstandtheprofileoftheseinjuriesfortheir 9


Report of Working Group on Health Research for XII Five Year Plan

appropriate management strategies which include preventive, curative and rehabilitation services. Drugs and devices: Adequate availability of drugs as well as devices at affordable prices has been the cause of concern. Despite the stated goals of tackling this problem, the progress remainstobeslowandtheimpactisnotvisible. Increasing health inequities: During the XI Plan, health care facilities in urban areas have undergone major changes. While the number of specialized/super speciality hospitals in the privatesectorhasseenarapidincreasewhichhavealsobeenreflectedbymedicaltourism,this hasalsoledtoagreaterdivideinthecapabilityofallIndiansgettingappropriatemedicalcarein a cost effective way. The gap between rich and poor specially marginalized communities/sections has shown an increase resulting in heavy economic burden on populationspushingthemdowntheeconomicladder. Inadequate infrastructure and human resources: At macro level, the facilities for different disease investigations and patient management continue to be grossly inadequate despite attemptsofthegovernmenttoopenAIIMSlikeinstitutionsandgrantingpermissiontoopena largenumberofmedicalcolleges,thenumberofhealthpersonnelremainsfarbelowthenorms and is also not equitably distributed. These personnel are either not adequately trained in research methodology or have poor motivation due to various reasons in most parts of the country.Thoughalotofinitiativeshavebeentakentoimprovethesituation,itwilltakequite sometimetoreachdesirablestandards.

10


Report of Working Group on Health Research for XII Five Year Plan

CreatingaPromotiveEnvironmentforHealthResearch
SeveralchangesinthenationalandinternationalhealthresearchenvironmentduringXIPlanperiod canbeusedasstrongpositiveinputstodrivethenewhealthresearch. 1. ThePrimeMinisterofIndiahasdeclaredinnovationasthemainpathwayfordevelopment of the country. The Honble Prime Minister has also expressed the commitment of the governmenttodoublethespendingonResearchandDevelopmentsector. 2. TheDBThascreatedatranslationalhealthresearchinstituteandsimilarinfrastructure. 3. TheICMRhascreatedadedicatedstructurefortranslationalresearch. 4. There is a felt need and initiative for the indigenous production of medical devices and healthequipmentsforaffordablehealthcare. 5. Indiacontinuestobeagloballyacceptedleaderintheproductionofhighqualitylowpriced pharmaceuticalsandvaccines. 6. Indian industry is investing more in R&D aimed to create new IPR and is partnering with Indianinstitutionstoproducegloballycompetitiveproducts. 7. Alargenumberofleadspotentiallyusefulfordevelopmentofdiagnostics,therapeuticsand vaccinesareavailablefromthepubliclyfundedIndianinstitutions. 8. Ten science and other departments of the Govt. of India are contributing towards the development of better/improved diagnostics/therapeutics and vaccines and also contributingtoimplementationresearch. 9. Translational research, implementation research, health systems research, policy research, healtheconomicsandothervitalareasimportantforharnessingthefruitofadvancesinthe knowledgehavemadetheirpresencefeltintheIndianscenario. 10. Nongovernmental agencies like the Public Health Foundation of India are partnering with thegovernmentalinstitutionstostrengthenpublichealthresearchinIndia. 11. Theregulatorymechanismsarerapidlyimprovingandbecomingmoreuserfriendlywhich is conducive to the growth of thinking and innovative environment in the academic institutionsaswellastheindustry. 12. Amassivenationaleffortisunderwayforthedevelopmentofhumanresourcesatalllevels school,college,universityandnewschemestoretainandattracttherightkindofqualified scientistsandphysiciansfromoverseas. 13. There is positive resonance to the initiatives to enlarge the health research base of the country by increasing funding to medical colleges and institutions in the periphery, strengtheningtheinfrastructurebaseinthemedicalcollegesandintersectoralcoordination bycreatingsynergyamongstscienceanduserdepartments. 11


Report of Working Group on Health Research for XII Five Year Plan

DuringtheXIIPlanperiod,thestrategyofDepartmentofHealthResearchwouldbe: Nationwide strengthening of infrastructure and developing human resource to ensure availability of geographically equitable resources and environment for enablinghealthresearch. Strengtheninghumanresourcesandcreatingenablingenvironmentforthepursuitof healthresearch. Establishment of surveillance and diagnostic facilities for service and research on infectiousdiseases. Intersectoralcoordinationforensuringoptimizationofresources.

Tosumup
TheDHRaimsatbringingmodernhealthtechnologytocommunityby: Encouraginginnovationsrelatedtodiagnostics,vaccinesandtreatmentmethods. Translatingtheinnovationsintoproducts/processesbyfacilitatingevaluation/testingin synergy with other Departments like MOH&FW and other science departments and introducing these innovations into the public health system through health systems researchasthemainpathwaytoachievethegoals. Strengthening the ICMR so that it serves as fulcrum of this Department in generating scientificknowledgefortranslationandimplementationthroughDHRmechanismsand inpartnershipswithotherscienceandhealthdepartments.

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Report of Working Group on Health Research for XII Five Year Plan

BroadFrameworkofactivitiesofDHR
In the current scenario, the ICMR focuses on active research programmes for generation of new knowledgewhereasDHRconcentrateson Governance Development of infrastructure and manpower in medical colleges, state health systems, universitiesetc; Promoting the translation and implementation research through Central & State Govt Institutionsthroughoptimumuseofknowledgemanagement&NKNandbypartneringwith professionalbodies,NGOs/privatesectorandotherstakeholders Strengthenandaugmentinternationalcollaborationsinhealthand

Creationofmechanismsformanagementofepidemics/pandemicsetc. The abovementioned strategy proposed for the XII Plan was discussed by the experts of the WorkingGrouponHealthResearchsetupforthispurpose.(AnnexureII)Theindividualproposals andtheobservationsoftheWorkingGroupinrespectofeacharediscussedbelow:

Specialsupporttomedicalcolleges:
India has currently nearly 300 medical colleges, about 150 in the government sector. Various medicalinstitutionshaveservedwellandcontinuetocontributeintermsofspecializedhealthcare, educationandtosomeextentresearch.Whileresearchshouldhavebeenanintegralactivity,ithas nothappenedinthatwayandtheresearchactivityhasbeenmostlyconfinedtoabout2025medical collegeswhogarnermostoffundingforbiomedicalandhealthresearch.Thishascreatedaheavy responsibilityandworkloadonthesenationalinstitutionswhichisaffectingthegrowthofquality health care, health education and health research in the country. The DHR has plans for establishing multidisciplinary research units (around 250 units) at least in all the government medicalcolleges.Theseunitswillprovidethemoderntechnologyinfrastructurewhichwillimprove thequalityofthespecializedcare,trainingofdoctorsandotherhealthcareprofessionalsandthen researchaspertheneedsofthepopulation. Experts of Working Group on XII Plan have emphasized that the DHR should focus on schemes aimed at modernizing the infrastructure for research in medical colleges and consider working withMCIandNAMStofindwaystoimprovetheenvironment/facilitiesforresearchinmedical colleges.Strengtheningshouldbeforresearchlaboratoriesaswellasauxiliarysupportsystems like bioinformatics/biostatistics/nationwideelibrary network etc. A FISTlikeprogrammeofthe Department of Science & Technology can be used as a model by the DHR to augment and complementfacilitiesandinfrastructureprovidedtomedicalcolleges. 13


Report of Working Group on Health Research for XII Five Year Plan

This special programme for medical colleges which is not so far in mainstream of healthcare and academicsystem,isexpectedtobringaqualitativechangeintheworkingofthesecollegesespecially those in the public sector. The outcome of the support system in these medical colleges will be reflected by quality medical education which would lead to more patients being provided with advanced medical care across the country, larger number of researchers generating good quality researchprojectsintheareasofnationalpriorityandthuscontributingtoastrongknowledgebase ofthecountry.

Establishmentofmodelruralhealthresearchunits:
There is awidegap betweenthe available specialized healthcaretechnology andthetechnology beingdevelopedvisavis theirutilization in the Statehealth systems.This isparticularly true for ruralhealthsettings.Itisgenerallyfeltthattechnologyapplicationneedsspecializedinfrastructure andcanbedoneonlyinurbansettings.Inordertodevelopmodelsfortransferofsuchtechnology totheendcareusers,theDepartmenthasplannedtoestablishmodelruralhealthresearchunitsin all the States (about 50); more than one in larger states) where technology transfer and the researchtargetinghealthinterventionswillbedoneinpartnershipwiththeStates. Duringtheconsultations,expertshavesuggestedthatpublicprivatepartnership(PPP)modelmay bepursuedbyDHRforlaboratorystrengtheningatthevillage/districtlevelsthroughasystemof empanelment. This special programme for rural areas will lead to continuous transfer of technology for handling infectiousandnoninfectiousdiseasesbythestatehealthservicesresultinginreductioninmorbidity and mortality. This will also be measurable by active joint projects by Unit , local medical colleges andstatehealthservicesaddressinglocalproblems.Thesechangeswillbecontinuouslymonitoredto ensuresustenance. i) EstablishmentofaNationalNetworkforViralDiagnostic/InfectiousDiseaseLaboratories India continues to have outbreaks/ epidemics due to various infectious pathogens. Currently national apex institutes like NCDC, New Delhi and NIV, Pune are mandated to undertake the investigations that results in heavy burden affecting their real referral role. The resultant delay in diagnosis/detection and adequate/incomplete data about these outbreakssignificantlyimpacttheresponsetimeforinterventions.Significantly,avoidable delays in both short and long terms strategies for prevention, treatment through vaccine production/introduction and upgradation of infrastructure etc. The Department is planningtoestablishabout250laboratoriesofthreegradesoninfectiouspathogenswhich will work under the overall guidance of apex institutions like NIV, NCDC through appropriatelinkagesandnetworking. As suggested by Experts a separate dedicated centre for Influenza research is being proposedintheschemesofDHRforpromptinvestigationofepidemics/outbreaks. 14


Report of Working Group on Health Research for XII Five Year Plan

Impact of this major empowerment will be visible by prompt and accurate diagnosis and management of various infections; identification of causative agents for the outbreaks/ epidemicsandsmoothdataflowfromacrossthesitesofepidemicsbyefficientknowledge management using NKN for policy interventions like quick deployment of resources and measureslikeintroductionofpreventivestrategieslikenewvaccinesetc. ii) Establishmentofotherspecializedresearchunitsincludinglabs Asaemergingdevelopingcountry,Indiahasplansandambitionstobeintheforefrontin the creation of new knowledge/technology and making the technology available to our population through appropriate interventions. For this purpose, modern clinical / public health oriented setups are needed to work on cutting edge science like stem cells, molecular medicine, nano medicine etc., and specialized centres/Institutes for mental health, oral health, health systems, health economics, policy related to research on implementation, molecular & transplant immunology etc. The Department plans to establish/developsuchcentresforservice,educationandresearch. During the consultations, experts also emphasized that the DHR should have a well developedDivision/Centre(s)onFood&Nutritiontostudythepotentialharmfuleffects ofadditivespresentinfoodaswellasothersafetyissues(imported/local).Healtheffects of pesticides and other environmental factors may be given special attention. The DHR shouldhelpinthedevelopmentof46apexlaboratoriesandempanelmentofspecialized labs/ set ups in the country for testing of pharmaceutical/biological products which is vital for the growth of pharmaceutical/biotech industry: Establishment of a Special division/ centre on research on Disaster management and Bioterrorism should be explored. The DHR should have a dedicated cells/ divisions/ units for studying critical aspects related to National Programmes; responses required to deal with health issues gainingimportanceinmediaetc.;Thereshouldbeacell/centrewithintheDHRtoadvise onvariousaspectsofnewlydeveloped/introducedvaccinesoranyotherintervention. As suggested by experts, all of these specialized laboratories, cells/ divisions have been proposedintheXIIPlan. Impact of these initiatives will be reflected by increase in number of research studies in cuttingedgeareas,developmentofmoreaffordablereagents/technologies/toolsforpublic healthuseandalso global leadership indiagnosticsandpharmaceuticalproducts.Thiswill also result in affordable advanced health care thus saving costs on public health expenditure. iii) HumanResourcesDevelopmentforHealthResearch A major constraint in the current scenario is the lack of adequate and properly trained humanresourcesforthehealthresearch.Asaresult,theoutputdoesnotmatchtheinput 15


Report of Working Group on Health Research for XII Five Year Plan

wemakeastheinvestmentisconcentratedin fewplacesonly. TheDepartmentplansto strengthen human resource base of the country by organizing focused training programs within and outside India, for midcareer professionals in medical colleges and other academic establishments. Over 3000 personnel are proposed to be covered in various programmesmentionedbelow.Improvingthecareerpathforyoungresearchers,expanding thenumberofspecializedresearchersandthenprovidinggoodinitialsupportintheformof startupgrantsareplannedasapartofthisprogramme.Activitiesproposedinthisregard are: (a) Fellowshipsfortraining:Researchersinidentifiedadvancedfields (b) ScholarshipsatPGlevel:Supportforproducinghumanresourcesinnewerareas (c)Youngresearcherprogram:Toencourageyoungstudentsforresearch (d) Special training programs: In specified areas, this also includes support to selected institutionsfortraining (e) Midcareerresearchfellowships:Facultydevelopmentformedicalcolleges During the consultations, experts emphasized on the need for a strong career development & advancement schemes for research students, medical faculty and other researchers, creation of a dedicated Research Cadre, innovative fellowship systems trainings (that address issues as not losing seniority in the Govt system), schemes for womenscientists(wholeaveresearchondomesticandothergrounds)torejoinresearch career with other career incentives and establishment of Research Chairs/ special researchpositionsinmedicalcollegesinpartnershipwithState/CentralGovt.Buildingofa strongandvibrantpartnershipwithacademicbodies,HealthUniversitiesaswellasother universitieswerealsoemphasized. AllthesehavebeenincludedintheproposedactivitiesofXIIPlan. All these activities will create a strong human resource development mechanism for providingmentorshipandcreatingconduciveenvironmentforneedsofdifferentcategories of aspiring researchers. Outcome will be measurable by the numbers of persons trained; projectsgeneratedbythemanddevelopmentand/orintroductionofnewtechnologiesinto thehealthcaresystematalllevels. Intersectoralcoordination&nationaland/internationalcollaboration While several science departments are significantly contributing to innovation related to different aspects of biomedical research, it is felt that translation process and further implementation research is not as strong as is needed. In order to strengthen research effort in which the partnership of different government agencies, NGOs and Industry is required, the Department has planned to provide support in the form of grantinaid to selectedprojects;createawards,dedicatedfundingfortranslationofinnovationsandtheir implementationandsupporttoprofessionalassociationsetc.fordevelopingguidelinesand 16

iv)


Report of Working Group on Health Research for XII Five Year Plan

prioritysetting.Thustherewillbespecialfocusonencouraginginnovation,theirtranslation andimplementationbycollaborationandcooperationwithotheragenciesbylayingspecial stress on implementation research so that there is a better utilization of available knowledge.IntheXIIPlanitisproposedtofocusonsuchareasandfundprojectswhere synergyisexpectedtobringbetterresults. ItisproposedthatanInterdepartmentalmissionofbiomedicalandhealthresearchmaybe launchedaroundmedical/healthprioritiessuchas: i) Tuberculosis.

ii) Viralinfectionswithpotentialforoutbreaks. iii) Zoonoticdiseases. iv) MaternalandChildhealthincludinggenderissuesinhealth. v) NutritionandFoodsafety. vi) Diseases preventable through measures like vaccines, environmental interventions, publichealtheducationetc. vii) Diabetes,cardiovascular,mentalandchronicneurologicaldisorders. viii) Affordablehealthcaretechnologies(diagnostics,therapeutics,devicesetc.). ix) Innovationinhealthcaredelivery. x) Ruralhealthcare. Whileendorsingtheaboveareasexpertsemphasizedthatprioritybegiventoemerging infections; mental health and ageingrelated diseases such as dementia, Parkinsons Disease, etc.; Urban health; especially the emerging triple disease burden due to communicable and noncommunicable diseases and trauma; mechanisms to provide information / guidance on healthy life style; Gender issues in the provision of health services,settingupofdistrictresearchstations,etc. AllofthesesuggestionshavebeenincorporatedinXIIPlan Asdiscussedabove,itisofparamountimportancetocreatesynergyamongvariousscience agencies/ departments those mainly involved in basic science and or innovation on one hand (e.g., DST, DBT, CSIR/DSIR, DRDO etc.) to those with major application on epidemiology, public health (e.g., ICMR). Thus, the effort should be on i) establishing mechanisms to evaluate technologies for improving health care at individual & public health level; ii) fostering academiaIndustry link: creating processes and cell to link developers with industry for translation of leads into products/processes; and iii) establishment of a rapid clearing house mechanism for evaluation of health research technologies including the commercial applications In addition agencies/ departmental havingwithcomplementaryactivitieswithDHRsuchas,DIT,ICAR/DARE,SocialJustice, 17


Report of Working Group on Health Research for XII Five Year Plan

EnvironmentandForests,WomenandChildren;Waterresources;otheruserdepartments ofMOH&FWetcareproposedtobeengagedintheprocess.Strengtheningofinternational collaborationsofscientificandstrategicmutualinterestwillbeapriority. During the consultations it was emphasized that DHR should focus on development of mechanisms (regulatory/promotional) to accelerate the indigenous production of instruments/medicaldevicesthatarevitalforaffordablehealthcare;DHRshouldfocus onschemesaimedatmakinghealthcareaffordableforthepoor/marginalizedgroups/ communities; The DHR should set up Technology Assessment Board/ Department consistingofeconomists,socialscientists,publichealthprofessionalsandotherspecialists (similar to the Offices of Technology Assessment in some countries) whereby new technologies can be scientifically assessed for promotion and also before introduction / procurement. Schemes to promote development of indigenous products by the Indian pharmaindustryshouldbeestablishedonthelinesofDST/CSIRmodel.WithoverUS$85 billionofpharmaproductsgoingtobeoffpatentduringthecoming5years,thedomestic industrywouldhaveagoodopportunityforgrowth.Butthereisalsoneedtosetupstrict regulatory mechanisms systems and mechanisms for quality control of drugs and other health products. To address this need, the DHR should set up apex drug testing laboratoriesandrelatedregulatoryinfrastructureineverystateinsynergy/coordination withDCGIandotherappropriatemechanisms.Theexpertgroupalsosuggestedsettingof aMedicalTechnologyDevelopmentBoardtopromotedevelopmentofindigenousmedical technologies. AllofthesesuggestionshavebeenincludedinXIIPlan. These new initiatives will help in the creation of an efficient, promotive and regulatory structure involving different agencies in the Govt as well as outside to develop integrated solutions for the promotion of health. Outcome of these initiatives will be reflected in the generation of joint interdepartmental/ interagency projects on health problems ( some already identified above); more affordable technologies for public health use; lesser dependenceandexpenditureofimports/technologiesforadvancedhealthcareandstronger indigenoushealthcaregloballycompetitiveindustry. Establishmentofregulatoryframeworkforresearchgovernance ResearchgovernanceisoneofthemajortasksallocatedtotheDepartment.Duringthelast two years, the Department has already developed a National Health Research Policy, KnowledgeManagementPolicyandalsopreparedadraftBillonEthicalIssuespertainingto BiomedicalResearch.DepartmentisalsoperusingAssistedReproductiveTechnologyBillas wellasaBillonAlternateSystemofMedicine.DuringtheXIIPlan,allthesepoliciesareto be implemented. Department proposes to establish an authority (ies), systems and extractingevidencegenerationthroughmodelprojectsforimprovingtheresearch 18

v)


Report of Working Group on Health Research for XII Five Year Plan

governance in health in India. Further mechanisms are being built to create systems/ administrativestructuresforrecognitionofhealthresearchinstitutionsandforidentification &promotionofaffordabletechnologiesforimproveddiagnosis,treatmentandprevention ofvariousrelevantdiseases. Tosummarize,DHRplanstoimprovegovernanceby a) Putting in place appropriate Guidelines, Acts, through appropriate regulatory authorities and structures to evaluate and recommend technologies, programmes, studiesetc.forintroductionintothepublichealthsystem b) Enactment of an Ethics Bill and the establishment of the National Bioethics Authority. c) Creation of National Health Research Forum for implementing National Health ResearchPolicy. d) Establishmentofmechanismsformapping,accreditation/recognitionetc.ofhealth researchinstitutions. e) Research for establishment of mechanisms for knowledge management for better service,educationandresearch. Development of robust ethical systems to promote ethical animal and human research programmesanditsimplementationwasconsideredasatopprioritybyExperts.Existing regulatoryandrelatedloopholesemergingfromthecurrentexperienceshouldbeplugged andusedtodevelopregulatoryframework. Outcomeoftheestablishmentofabovesystemsandregulationwillbereflectedinimproved ethical standards in biomedical research; proper allocation and utilization of resources for healthresearch;betterenvironmentforproductdevelopmentfordomesticandinternational purposesandoptimumusageofinfrastructureaswellashumanresourcesforhealthcare, medical/biomedicaleducation,trainingandresearch. StrengtheningandexpansionofprogrammesofICMR The Indian Council of Medical Research (ICMR) continues to provide critical support to variousnationalprogrammesbygeneratingnewknowledgeaboutthediseases,developing and evaluating tools for diagnosis and treatment and provide help in the framing of its policiesforguidingresearchandprovidingfeedbacktothegovernments: i) DuringtheXIPlantheICMRhascreatedadedicatedsystemoftranslationalresearchin whichtheleadsobtainedbyitsscientistsaswellasotherresearchersinthecountryare beingexploredfortheirapplicationinthehealthcaresystem.

vi)

ii) The ICMR continues to synergize/ harmonize its agenda with national health programmes.Overtheyears,ICMRhasestablishedalargenumberofInstitutions(31 19


Report of Working Group on Health Research for XII Five Year Plan

of which two the National Institute for Research in Environmental Health (NIREH), BhopalandNationalcentreforDiseaseInformatics(NCDI),Bangalorewereestablished duringcurrentplan),fieldcentresandhascreatednetworksofInstitutes/centres/units on diseases ranging from vector borne diseases, viral infections, tuberculosis, leprosy, kalaazar to nutrition, cancer, genetics, blood disorders and reproduction as well as traditionalmedicineandherbalremedies. iii) Establishment of a Tribal Health Research Forum for promotion of health of marginalized communities and creation of a Vector Science Forum are recent landmarks.AmajorinitiativeonHealthSystemsResearchandinitiationofprogrammes onnewerareaslikenanomedicinewereotherimportantdevelopments. iv) While the Council has maintained its focus on diseases of poverty, several other initiatives have been launched such as special drive to develop projects in medical colleges in the periphery, strengthening the fellowship programmes, further strengthening international partnerships , increasing attention on maternal and child health,mentalhealthandthroughDHRmechanismisworkingtowardsbettersynergy with other science departments and user departments in MOHFW to ensure faster transfer of technology to end users. All the above programmes need to be further strengthenedandconsolidatedduringXIIFiveYearPlan. v) During XII Plan, it is proposed to further expand and strengthen its extramural research programme with focus on medical and other institutions, programmes on mentalhealth,socialandbehaviouralresearch,healthsystemresearch,climatechange andhealth,genderissues,complementaryaspectsoftraditionalandmodernmedicine, trauma and other noncommunicable diseases while continuing its emphasis on infectiousdiseases. vi) Strengthening of the human resource base (number of scientific, technical and managerial/ administrative) of ICMR is further proposed to be strengthened by restructuringandcreationofnewpositions.Newpositionsareproposedtobecreated for long term programmes that are currently run as extramural yet will always be important. New schemes for development of dedicated Research Cadre in medical collegeswillbeinitiatedbytheDHR/ICMR. vii) Opening of new centres on Primate research, other animal models (National Animal Resources),PolicyResearch,Zoonoticdiseases,Drugresistance,NCDs,HealthSystems Research, Health Economics, Clinical pharmacology, Genetics, Transplantation Immunology,Clinicalresearch,oralhealth,socialandbehaviouralresearchetcisbeing targetedasfuturepriorities. viii) Encourage schemes to develop health research in a holistic approach (integration of differentsystems/guidelinesforbetterserviceandtoprovidesupporttoinvestigateon reportedlyusefultreatmentmethodsnotcoveredbyanyothermedicalsystem)willbe explored. 20


Report of Working Group on Health Research for XII Five Year Plan

While all the above aspects for areas need to be strengthened to fulfil the aspirations and needs of different stakeholders, ICMR proposes to give special emphasis to the followingareas: 1. Extramural research programmes: Though the ICMR is proposing to expand and strengthen its own institutions, this will only partially meet the needs of the Country. Further empowerment of medical college system across the country is expected to provide greater capacity for not only research but service and good educationasallthreeareinterlinked.Keepingthisinview,ithasbeendecidedthat theICMRInstitutions/Centreswillfocusonlyonselectedareas and strengthenthe research in the country by expanding the extramural research programme with a special emphasis on public health aspect and implementation research through medicalandotherinstitutionsintheperiphery.Further,theICMRplanstocontinue itsfocusoncommunicablediseases,vectorbornediseases,mentalhealth,socialand behavioural research, health systems research, gender issues, climate change and health, complementary aspects of traditional/ alternative systems and modern medicine, oral health, trauma and other non communicable diseases. The extramural research programme of the ICMR which has expanded several fold duringrecentyearswillbefurtherexpandedintheXIIPlan. 2. SpecializedCentres:DuringtheXIPlan,ICMRhadproposedtoopenseveralcentres mainlyonnoncommunicablediseases.Duetovariousconstraints,onlytheNational Centre on Disease Informatics, Bangalore and National Institute for Research in EnvironmentalHealth,Bhopalcouldbeestablished.DuringtheXIIFiveYearPlan,it isproposedtoestablishthecentresforwhichactionhasalreadybeeninitiated.In addition, it has been planned to open centres on policy research, drug resistance, healthsystemsresearch,healtheconomics,clinicalpharmacology,clinicalresearch, social and behavioural research, transplant immunology and other cutting edge/ relevantareas.Wherever,permanentinstitutionstakelongtimetoestablish,asan interim measure it proposed to set up centres of advanced research/Centres of excellenceinextramuralmode. 3. Application of egovernance/ management in health research: Department of HealthResearchhasalreadydecidedtogoforegovernancebycreatingITenabled systemsforpublic,projectreviewprocessandanalysis.TheITcomponentisbeing proposed in the DHR budget for efficient emanagement for not only governance but also as a research tool for operational research to implement knowledge managementpolicydevelopedbythedepartmentduringtheXIPlanutilizingNKN. All model projects, appropriate administrative systems are proposed to be establishedduringtheXIIPlan. vii) Use of Information Technology: During the consultations, experts have made several generalrecommendationswhichcutacrossspecificareas/aspectsmentionedabove: 21


Report of Working Group on Health Research for XII Five Year Plan

viii) The DHR should have ITenabled systems for dealing with public and a paperless projectmanagementsystem. DHR/ ICMR shouldhave an userfriendlyelectronic system for theapplicants to know therealtimestatusoftheirproposals. AITcomponentshouldbeincludedintheDHRbudgetforemanagement. AsystemofresearchauditshouldbeestablishedbytheDHR.

Strengthen synergy and coordination: Experts emphasized that appropriate mechanisms maybe considered to strengthenthe synergy/coordinationbetweenthe DHR,DCGIand FSAI which have common objectives and mandate towards ensuring safe food to Indian people. ExpansionandstrengtheningoftheICMRwillbereflectedbytheoverallimprovementin quality and quantity of health research by medical colleges, universities, other academic institutionsaswellasICMRnetwork.Outputoftheseresearchwillalsobemeasurableby theresearchleadstranslatingintoproducts/processesandinterventionsintroducedinto theprogrammesandpractices.ThesewillalsobeintheformofICMRinputsintopolicy change for disease prevention and management at patient and public health level. Number of publications and patents; persons trained through capacity building; contributions to disaster management as well as new leads/ knowledge generated will alsobemeasurableoutcome.

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Report of Working Group on Health Research for XII Five Year Plan

PriorityareasThe10Pointagenda:
Whilealltheareaslistedaboveareimportantandstronglyrecommendedbytheirchampions,after discussionsondraftpaperdepartmenthasproposedthefollowingareastobeoftoppriorityagenda fortheDHRfortheXIIPlan: 1. Strengtheningofresearchinfrastructure:Establishmentofmultidisciplinaryresearchunits in medical colleges, model rural health research units in the states; creating a network of laboratories for infectious diseases; noncommunicable diseases and specialized areas is consideredasoneofmainpriorities. 2. Strengthening of human resource and creating enabling environment for research in medicalcolleges,universitiesandhealthresearchinstitutionsandtoconsiderpathwaysfor developingagoodenvironmenttopromotehealthresearch. 3. Efficient research governance and regulatory frame work on core areas pertaining to ethics,clinicaltrialsonnewdrugs/devices;ensuringwelldefinedmechanismsforapprovals andpassageaswellasimplementationofbills/policiesdevelopedisconsideredasamong highpriorities. 4. Development of centres on policy related areas such as vaccine preventable and other chronic diseases, health economics and health systems research, social and behavioural sciencesareproposedtobemajorthrustareasforXIIPlan. 5. Translational and implementation research is proposed to be given special emphasis. Besides specific programmes in governmental and academic institutions promotion of publicprivatepartnershipwillbegivenspecialattentionfortranslatingresearchleadsinto developmentofaffordablediagnostictechnologiesandpharmaproductsincludingvaccines toachievebroaderobjectivesofprovidingbetteraffordablehealthcareforthepeople. 6. Establishment of efficient mechanisms for the selection, promotion, development, assessmentandevaluationofaffordabletechnologiesandtheirjudiciousapplicationhas beenidentifiedaspriority.ForthispurposestructureslikeTechnologyDevelopmentBoard/ TechnologyAssessmentBoardsetchavebeenenvisaged. 7. Creation of efficient mechanisms for intersectoral coordination and national/ international collaboration is among the high focus action areas in XII Plan. This would include development of mutually acceptable systems/mechanisms for collaborative action amongdepartments,institutionsandotherstakeholdersinthecountryandothercountries. 8. Strengthening of ICMR institutions, establishment of new specialized centres within and outsidetheICMRandexpansionofexistingextramuralprogrammesoftheCouncil. 23


Report of Working Group on Health Research for XII Five Year Plan

9. Optimum use of Information Technology using the National Knowledge Network as backbone for health research aimed at service, education and research and research management. 10. Research priorities will be guided and focused on problems of tribal and other marginalized communities and addressing gaps in the knowledge in diseases affecting thesepopulations.

24


Report of Working Group on Health Research for XII Five Year Plan

BUDGET
During the XI Plan, Rs.4496.08 crores outlay was approved for the ICMR. The DHR was created duringthemiddleoftheXIPlanandnoseparatebudgetwassanctionedforthisDepartment. FortheXIIPlan,anoutlayofRs.15,000croresisproposed.Mainbudgetaryitemsare:

DHRotherthanICMR:(Rs6500crores)
Infrastructuredevelopment(Rs.3000crores;250multidisciplinaryunitsinmedicalcolleges; 50MRHRUunits;specializedcentres/units) Human Resource Development (Rs 1000 crores; 1000 midcareer and 2500 young investigators;2/3frommedicalcolleges) Laboratory network for research on viral and other infectious diseases (Rs 900 crores; 6 regionalBSLIII;50cat.Istatelevellabsand200Cat.IIdistrictlevellabsinmedicalcolleges) GrantinAidschemeforprojectsrequiringintersectoralcoordination,translationspecially in PPP mode and IT enabled governance as well as implementation research ( Rs 1500 crores) Governanceanddepartmentalexpenses(Rs100crores)

ICMR:(Rs8500.00crores)
Fundingofextramuralprojects(Rs2500croresincludingtheongoingprojects); Funding of intramural programmes through ICMR Institutes/ Centres ( Rs 2500 crores includingtheongoingstudies) New Institutes/ Centres/ upgradation of existing ones (Rs 3150 Crores Non communicablediseasesCardiovascular,neurological,mental,ageing;Primatesandother animal models; Health Systems Research, Health Economics, Policy Research on Drug resistance,VaccinePreventableDiseases,ClinicalPharmacology,MolecularandTransplant Immunologyetc.) Outbreak/DisasterResponseFundRs50crores Newpositions(Rs300crores)MostlyscientificforcreatingessentialstructureinDHR,its outreachunits/labs;ICMRInstitutes/CentresindeficientareasaswellasnewInstituteand HospitalatBhopal.

25


Report of Working Group on Health Research for XII Five Year Plan

ANNEXUREII

AchievementsofDHR/ICMRduringtheXIFiveyearPlan
DepartmentofHealthResearch(DHR)wascreatedin2007andstartedfunctioningonaregularbasis around end of 2008 when new Secretary who is also the DirectorGeneral of Indian Council of Medical Research (ICMR) joined. DHR has been assigned ten business of which nine are new and administeringandmonitoringtheICMRwastheonlyongoingactivity. During the XI Plan period the Department of Health Research took a number of initiatives to implement the nine new business besides the strengthening of ICMR. Four schemes have been prepared after wide consultations which will serve as Phase I of new department. These schemes pertain to infrastructure development for research in medical colleges and rural areas in state services; human resource development; network of laboratories and mechanisms to deal with outbreaks/ epidemics/ pandemics and other disasters and grantin aid to projects which require intersectoral coordination to develop affordable technology/ knowledge to address public health issues. All the schemes have been approved in principle by the Planning Commission and other proceduresarebeingcompletedtolaunchwithinXIPlan.Further,inordertoimprovetheresearch governance, various policies like Health Research Policy, Knowledge Management Policy, policy to map and recognize healthinstitutions as wellBills forAssisted Reproductive Technologies;revised Bill on Ethics The Biomedical and Health Research involving human participation Regulation Bill, 2011havebeendeveloped. In the meantime, the DHR through its century old organization ICMR has made many important scientificcontributionstofacethechallengesofnationalcriseslikeH1N1pandemic,previouslynot reportedinfections such as CrimeanCongo fever and also contributedtonew knowledgetowards developmentoftechnologiesthathave/willhavepotentialapplicationinournationalprogrammes oncommunicableaswellasnoncommunicablediseases. TwonewinstitutestheNationalInstituteforResearchinEnvironmentalHealth(NIREH),Bhopaland National Centre for Disease Informatics and Research (NCDIR), Bangalore were established during theXIPlanperiod.

Somesignificantachievementsarelistedbelow.
FourflagshipprogrammesoftheDepartmentofHealthResearchviz.,TribalHealthResearch Forum, Vector Science Forum, Special support to medical colleges and Translational ResearchhavebeeninitiatedthroughICMRmechanismduringthisplan. During200711,15CentresforAdvancedResearchwereestablishedinadditiontofunding 283multicentreTaskforcestudiesand623adhocresearchprojects. About1200projectsareongoingintheareasofepidemiologyandcommunicablediseases, reproductive, maternal & child health and Nutrition, noncommunicable diseases , basic medicalsciences,healthsystemsandsociobehavioralaspects. 26


Report of Working Group on Health Research for XII Five Year Plan

TribalHealthResearchForumhasbeenestablishedtosynergizeandintensifytheresearch efforts of seven ICMR Institutes engaged in the area of tribal health research and work towardstranslatingtheidentifiedleadstopublichealthbenefit. VectorScienceForum,createdtopromotefocused coordinatedresearchon vectorborne diseases meets regularly to review progress, identifies new areas that need focused and whichcouldbeintroducedintoournationalprogramme. Special support to medical colleges on a mission mode has been initiated as part of the DHR/ICMRsoutreachprogramme;thisprogrammehasidentifiedseveralmedicalcolleges, especiallythoselocatedinNorth,NortheastpartsofIndiawheretheoutreachwasminimal, for intensive training of the faculty on research methodology, study design etc and has startedprovidingseedgrants. Translational Research that envisages harvesting the innovations/leads identified into products/processes/methodologieswithaportfolioofover100potential leadsforawide spectrum of disease conditions and for varied applications such as diagnostics, methods thathaveapplicationindiseasecontrolprogrammes,hasabout50leadsinadvancedstage of validation and refinement for converting them to products, processes and methods for publicgood. TheflagshipjournaloftheCouncil,TheIndianJournalofMedicalResearchcontinuedtobe thetopmedicaljournalinIndiawithhighestimpactfactor.TheJournalisnowavailablefull textfreetoaccesssinceinception(1913)andhastotallywebbasededitorialmanagement. During the period, about 50 patents (both in India and abroad) were filed and several technologiesareinadvancedstageofcommercialization.

CreationofNewInfrastructure
SomemajorinstitutionssetupincludetheSchoolofPublicHealthatNIE,ChennaiinJuly2008. NewfieldstationsofRMRCPortBlairatCarNicobar,Narcowry;NIVPuneatGorakhpur,UP, Alappuzha, Kerala were established. The NIMR shifted to its own campus at Dwarka, New Delhi and is fully functional. The Institute has also been identified as Centre of Excellence (COE))inmalariaresearchbytheNIH,USA. AllICMRinstituteshavefurtherstrengthenedtheirlinkageswithStateGovernmentsinlocal healthrelatedissuesfortechnicalandoperationalsupport Model Rural Health Research Unit at Ghatampur was strengthened so as to develop it as a modelofpartnershipwithstatesfortransferoftechnologytoendusers. The National Clinical Trials Registry in India, an online system for registration of all clinical trials(www.ctri.nic.in)inIndiawasestablished ANetworkofViral/InfectiousDiseasediagnosticlaboratoriessetupinthecountrytobuild capacity for handling outbreaks of all emergingreemerging and common viral diseases all acrossthecountryandtocarryoutresearch.Threedifferentlevelsoflaboratoriesarebeing 27


Report of Working Group on Health Research for XII Five Year Plan

set up. Sixteen new ( 14 BSL II and two BSL III) laboratories have been established within ICMRandalsootherinstitutionssofarduringXIPlantodealwiththesepathogens;oneBSLIV plus a few other category of such laboratories are scheduled to be commissioned soon. EventuallythisprogrammewillmergeandsynergizewithDHR. A network of laboratories for diagnosis and characterization of H1N1 influenza virus was established with NIV, Pune as coordinating Institutions during the crisis of the 20092010 pandemic.NIVhasearlierbeenidentifiedasaWHOreferralcenterandreferencecenterwith eightotherregionalcenters. Malaria Parasite bank (Plasmodium falciparum, P .vivax and P.malariae) with over 1075 isolates serves as a national resource/facility for Plasmodium isolates in the country. Other repositories on mycobacteria, HIV and leishmania also continued to function during this period. NationalTumorTissueRepository(NTTR)atTataMemorialCenter,Mumbaiwithabout15000 normalandtumourtissuesfromvariousanatomicsitesforresearch.

HumanResourcesDevelopment
Atotalof45medicaldoctorsjoinedtheMDPh.D.ProgrammeofICMRduringXIPlanwhereas 250haveavailedoftheschemethatoffersfinancialassistanceforMD/MS/MCH/DMthesis. Over 500 Senior/Junior Research fellowships and more than 3500 Short Term Studentship programmestoundergraduatemedicalstudentsweresanctionedduringthePlanperiod. A new Centenary Postdoctoral Fellowship scheme was launched, 33 fellowships have been awardedsofar. InternationalFellowshipschemelaunchedtoprovidedsupporttoJunior(12)andseniorlevel (6)biomedicalresearchers. Newlycreatedfellowships(6)underGermanScienceCentreforInfectiousDiseases(IGSCIDI)

TechnologyDevelopmentandTranslationResearch
A real time RTPCR useful for early diagnosis was developed for detection of dengue viral RNA. AkitforJEdevelopedandsuppliedfornationalprogramme. DNAchips developed for studying themolecular mechanism(s) ofsurvivalofTB and Lepra bacilliinhostandseveralusefulcandidatesfortranslationidentified. New rapid molecular methods for detection of rifampicin, isoniazid and ethambutol resistanceinTBdeveloped. Developed a new DNA fingerprinting method useful for diagnosis of TB and other mycobacterialinfections. 28


Report of Working Group on Health Research for XII Five Year Plan

Luciferasereporterphageassaydevelopedusingrecombinantmycobacteriophagesforboth rapiddiagnosisanddrugsusceptibilitytesting. Studyofgenomicdiversityofleprosybacillusandexpressionofitsgenesinhumanhosthas led to identification of genetic markers with potential to elicit diversity among M. leprae strains. Developedanimmunechromatographicdipstickkitfortherapiddiagnosisofcholerawith sensitivityandspecificityof92%and73%respectively. Monoclonal antibody based indigenousdiagnostic assay developed fordiagnosingpatients withChlamydiatrachomatisinfection. RapidIgMELISAandLatexAgglutinationTestsforLeptospirosisdeveloped. Technology developed for the production of mosquito larvicide, Bacillus thuringiensis var. israelensiswastransferredtoindustry. MultiplexPCRfordetectionof An.annularis species complex and theirvectorial attributes developed. Bivalent rapid diagnostic malaria kits tested, approved and successfully inducted into the Nationalprogramme. Realtime PCR assay developed to diagnose and simultaneously estimate parasite load in clinical samples of Visceral Leishmaniasis (VL) and Post Kalaazar Dermal Leishmaniasis (PKDL). DevelopedaELISAkitforidentificationofParagonimiasis(lungfluke)aftercharacterization ofParagonimusspeciesinNEIndia. Noninvasiveprenataldiagnostictechniquedevelopedforhemoglobinopathyshowntobe suitabledetectioninthe10to15weekpregnancy. Simple and inexpensive screening test for Fragile X syndrome, a common cause of mental retardationinmales,developed. Established an inexpensive, fast and accurate flow cytometric technique for evaluation of osmoticfragilityinhemolyticanemias. Technology for estimation of Vitamin A in blood samples using Dried Blood Spot (DBS) developed. Technologiesofdoublefortifiedsalt(DFS)andfortificationofwheatattawithironandother essentialnutrientstransferredtotheindustry.

ClinicalTrialsforNationalHealthProgrammes
ThecurrentdosingscheduleleadstoadequateplasmalevelsofnevirapineinHIVinfected childrenreceivingantiretroviraltherapywithfixeddosecombinations. 29


Report of Working Group on Health Research for XII Five Year Plan

A bivalent whole cell killed oral cholera vaccine ( developed by International Vaccine Institute)inaPhaseIIIrandomizedcontroltrialinKolkatashowedprotectiveefficacyof67% inallagegroupsattheendoftwoyearsand65%attheendofthreeyearspostvaccination. Developed and proved the concept of common regimen for treatment of leprosy, now adoptedasUniformMultidrugTherapyRegimen(UMDT)byWHO.

CoadministrationofalbendazolewithDECisoperationallyfeasible,safeforcommunityuse andhasanedgeoverDECalonefortheLymphaticFilariasis(LF)eliminationprogrammeand hasbeenacceptedandimplementedbytheNationalProgramme. Established that the combination therapy of DEC and albendazole for filariasis resulted in enhancedefficacyagainstgeohelminths. Demonstrated better efficacy of reduced osmolarity ORS in young children and adults in dehydratingdiarroheacomparedtothatofstandardORS. PhaseIII Clinical Trial with an intravasical injectable male contraceptive RISUG did not indicateanysideeffectsaftertwoyearsofintervention. Longterm retrospective follow up study (after 910 years) of RISUG injected subjects showed no serious adverse clinical symptoms suggesting its safety and efficacy as a long termmalecontraceptive. Phase3clinicaltrialwithsubdermalcontraceptivesinglerodimplantImplanonindicated itsefficacyandacceptabilitytowomenasacontraceptive. Lowdosemagnesiumsulphatewasasgoodasstandarddoseformanagementofeclampsia. A combination of metformin and life style modification could help women with Polycystic Ovarian Syndrome (PCOS), improve ovulation, pregnancy outcome, selfesteem and endocrineparameters. DECfortifiedsalthasbeendemonstratedtobeapotentialsupplementarystrategytoMDA ofannualsingledoseDEC.

Epidemiological/Operationalresearch
KeyresultsontheHomebasedmanagementofyounginfantsare:IntheShishuRakshakarm therewas21%declineinearlyneonatalmortalityratecomparedtocontrolarm.Declinein IMR (29%), young infant mortality rate (25%) postneonatal mortality rate (42%) was observedinShishuRakshakarmcomparedtocontrolarm.IntheAnganWadiWorkerarm also13%declineinIMRwasobservedcomparedtocontrolpopulationbutitwasstatistically notsignificant.TheimpactonNMR,postneonatalmortalityrateandyounginfantmortality rateintheAWWarmwaslessremarkableand/orstatisticallyinsignificant. Developed a Mental Health Needs Scale of the mental health needs of the people living with HIVAIDS (PLHAs) which is now being used by National AIDS Control Organization (NACO). 30


Report of Working Group on Health Research for XII Five Year Plan

MathematicalmodelsforHIV/AIDSepidemicdevelopedtostudythetransmissiondynamics ofHIV/AIDSinthepopulation. Epidemiological studies at Ghatampur (UP) have showed a steep decline in prevalence of diseaseindicatingtheendemicitytobeduetobacklogofcasesandthatM.lepraepersists inenvironment. Use of Remote Sensing (RS) and Geographical Information system (GIS) established for assessingthedensityofmalariavectors. AfilariasistransmissionriskmapforIndiawascreatedusingaGISbasedgeoenvironmental riskmodel. Control of Aedes spp. successfully demonstrated using temephos and environmental managementinaperiurbanareathroughinvolvementofcommunityvolunteers. Allowingofparamedicstoprovideemergencycontraceptivepill/serviceswouldenhanceits accessibilitymanifold. The Pune low birth weight (LBW) study birth to adulthood showed that all LBW children showedpoorspeedondifferentialaptitudetestwithlowerIQs. The National Level Expert Group recommended a maximum residue level of one part per billion(ppb)foranindividualpesticideforcarbonatedwaterbasedontheICMRdata. RevisionofnutrientrequirementsandrecommendeddietaryallowancesforIndianscarried out. Based on the findings on ICMRICAR data, on analysis of aflatoxin levels government recommended PAU201 rice variety samples collected from Punjab to be safe for human consumptionandshowedthatblackspotsarenotindicativeoffungus. Dataonthesafetyofconsumptionoflaukijuicerecommendedthatlaukishouldbetasted beforeextractingjuicethatitisnotbitterandguidelinesforcliniciansformulated. An intervention model to manage the effects of fluorosis was prepared through the combination of Safe drinking water and supplementation mainly with calcium, vitamin C, iron and vitamin D3. led to complete reversal of bone deformities caused due to fluorosis bothinmildandmoderatecasesandpartialreversalinseverecases. JaivigyanMissionModeProjectonRheumaticFeverandRheumaticHeartDiseasesrevealed the prevalence of beta haemolytic streptococci (BHS) in 26.5% and 8.8% respectively, whereas,thatofGroupAstreptococcuswas11.1%and2.5%inthroatsamplesrespectively inChandigarhandVellore.Asignificantdevelopmentoftheprojecthasbeenupscalingof this project to Punjab Rheumatic and Congenital heart disease Programme by Chandigarh nodalcentre.TheprogrammehasalsobeeninitiatedinfourdistrictsofHimachalPradesh. Databaseonnationalprevalencedataondiabetesfordifferenttimeperiods. PublishedCancerAtlasthathelpedmappatternsofcancer. 31


Report of Working Group on Health Research for XII Five Year Plan

Developedamagnifyingdevice(Magnivisualizer)forcancerscreeninginthefield. NationalCancerRegistryProgramme(NCRP)providedinformationaboutpatternsofcancer patientcareandsurvivalthroughCancerRegistries.

GeneticpolymorphismestablishedinrelationtohypertensioninNorthEast.

Guidelines:
NationalGuidelinesdevelopedforthePrevention,ManagementandcontrolofReproductive TractInfectionsincludingSexuallyTransmittedInfections(RTIs/STIs). GuidelinesforManagementofDiabetes Guidelinesformanagementofthreetypeofcancers(oral,buccalandstomach)developed.

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REPORTOFTHE WORKINGGROUPON AIDSCONTROLFOR THE12THFIVEYEAR PLAN

WG6:AIDS CONTROL

WG-6 No.2 (6)2010 Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001 23rd May, 2011

OFFICE MEMORANDUM

Subject:

Constitution of working group on AIDS Control for the formulation of the Twelfth Five Year Plan (2012-2017)

With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on AIDS Control under the Chairmanship of Shri Sayan Chatterjee, Secretary, Department of AIDS Control, Ministry of Health & Family Welfare. The composition and the terms of reference of the Working group would be as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Shri Sayan Chatterjee, Secretary, Department of AIDS Control Shri J.V.R. Prasada Rao, Former Secretary, MoHFW Ms. Aradhana Johri, Additional Secretary (NACO) Adviser (Health), Planning Commission Dr. Bimal Charles, Project Director, AIDS Prevention and Control (APAC), Chennai Dr. Smarajit Jana, Chief Advisor, Durbar Mahila Samanwaya Committee (DMSC), Kolkata Ms. Kaushalya, Representative of PLHA network, Positive Women's Network, Chennai Dr. R. Paranjape, Director, National AIDS Research Institute (NARI), Pune Dr. K.Sudhakar, Senior HIV/AIDS Advisor, CDC, New Delhi Dr. Rajshekhar, Tambram Institute, Chennai Chairperson CoChairperson Member Secretary Member Member Member Member Member Member Member

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

Dr. S. Sundararaman, Director of the AIDS Research Foundation of India, Chennai Dr. DCS Reddy, Former Prof. BHU, New Delhi, currently Consultant WHO India, New Delhi. Dr. Geeta Bamzai, Department of Communication Research, Indian Institute of Mass Communication, New Delhi Radharani Mitra, Creative Director, BBC World Services Trust, New Delhi Shri Ashok Rao Kavi, LGBT rights activist, Mumbai Mr. Anand Grover, Director of the Lawyers Collective HIV/AIDS in India Mumbai (M) 9820184788 Ms. Donna Fernandes, Vimochna, Bangalore, Karnataka Sh. S.P.Goyal, Project Director, SACS, Uttar Pradesh. Ms. Hajarimayum Jubita Devi, Executive Director, Ereima Gender Empowerment and Resource Centre (EGERC), Manipur Ms. Anjali Gopalan, Naz Foundation, New Delhi Ms. Akhila Sivadas, Centre for Advocacy and Research, New Delhi Dr Kurien Thomas, CMC Vellore

Member Member Member Member Member Member Member Member Member Member Member Member

Mr. Vijay Kumar, Special Secretary, Department of Health & Family Member Welfare, Government of Tamil Nadu Principal Secretary, H&FW, Mizoram Principal Secretary, H&FW, Nagaland Member Member

24. 24.

Terms of Reference:
1. To review the status of on-going National AIDS Control Programme with reference to objectives, strategies, plan initiatives, targets and outlays during 11th Five Year Plan and achievements, problems detected, midcourse correction, utilization of funds. To deliberate on ways and means to ensure equal access to healthcare services, nutrition, safe water, sanitation, and education, ensuring continuum of care and support for persons living with HIV/AIDS. To deliberate on ways and means to address issues of skill development and employment for persons living with HIV/AIDS.

2.

3.

4.

To lay special emphasis on protection of especially vulnerable groups (sex workers, transgenders, injecting drug users, men having sex with men, etc) and re-strategize for regions with high and/or growing incidence of HIV/AIDS (North East Region, Goa, Punjab, Tamil Nadu, etc) To suggest improved support structures, including healthcare services, education, recreation facilities, etc for children living with HIV/AIDS as also those orphaned due to HIV/AIDS. To deliberate on ways and means to legally and culturally (through IEC) counter professional and social discrimination. To give suggestions regarding proposed objectives, strategies, initiatives and targets for 12th Plan including sustainability, overlapping and convergence with other health programmes with special emphasis on awareness generation through creative use of IEC and prevention of HIV transmission. To identify the funding requirements during 12th Plan. To suggest improved mechanisms of involvement of Civil Society Organisations, private sector, PRIs/ULBs in design, implementation and monitoring of programmes. To review the current pattern of design, monitoring and evaluation of programmes and suggest improvements during 12th Plan. To review the current status of surveillance, its quality and propose improvements. To review implementation structures at national, state and district levels and suggest improvements. To deliberate and give recommendations on any other matter relevant to the topic. The Chairman may constitute various Specialist Groups/ Sub-groups/ task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitorable goals, while making recommendations. Efforts must be made to co-opt members from weaker sections especially Scheduled Castes, Scheduled Tribes and minorities working at the field level.

5.

6.

7.

8. 9.

10.

11.

12.

13.

14.

15.

16.

17.

The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the non-official Working group members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. The Working group would submit its draft report by 31st July, 2011and final report by 31st August, 2011.

18.

(Ambrish Kumar) Adviser (Health) Copy to: 1. Chairman, all Members, Member Secretary of the Working Group 2. PS to Deputy Chairman, Planning Commission 3. PS to Minister of State (Planning) 4. PS to all Members, Planning Commission 5. PS to Member Secretary, Planning Commission 6. All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission 7. Director (PC), Planning Commission 8. Administration (General I) and (General II), Planning Commission 10. Accounts I Branch, Planning Commission 11. Information Officer, Planning Commission 12. Library, Planning Commission

(Ambrish Kumar) Adviser (Health)

Rep port of The Planning Commission Wor n rking G Group on AIDS Control for n l e lation of 12th Fi Year Plan f ive r the formul

National AIDS C N Control Program mme Pha IV ase (2012-2017)

Abbreviation AIDS ANC ANM ARSH ART ARV ASHA BCC BCSU BSU CCC CD 4 CHC CLHIV COE CSMP CST DAPCU DCG(I) DHR DIC DLN EID EQAS FOGSI FRU FSW GIPA HBV HIV HIV/TB Acquired Immuno Deficiency Syndrome Antenatal Clinic Auxiliary Nurse Midwife Adolescent Reproductive and Sexual Health Anti-Retroviral Therapy Anti Retro Viral Accredited Social Health Activist Behaviour Change Communication Blood Component Separation Unit Blood Storage Unit Community Care Centre Cluster of Differentiation 4 Community Health Centre Children Living with HIV Centre of Excellence Condom Social Marketing Programme Care Support & Treatment District AIDS Prevention & Control Unit Drugs Control General (India) Department of Health Research Drop in Centre District Level Network Early Infant Diagnosis External Quality Assessment Scheme Federation of Obstetric & Gynecological Societies of India First Referral Unit Female Sex Worker Greater Involvement of People Living with AIDS Hepatitis B Virus Human Immunodeficiency Virus Human Immunodeficiency Virus/Tuberculosis

HRD HRG IAP ICF ICTC IDU IEC IMA IT LAC LFU MARA MARP MCI MDG MOH MSM NABL NACO NACP NERO NGO NRHM NRL NYKS OI OST PHC PLHIV PPP PPTCT PRI

Human Resources Development High Risk Group Indian Academy of Paediatrics Intensified Case Finding Integrated Counseling and Testing Centre Injecting Drug User Information Education Communication Indian Medical Association Information Technology Link ART Centre Lost Followup Cases Most At Risk Adolescent Most At Risk Population Medical Council of India Millennium Development Goals Ministry of Home Affairs Men having Sex with Men National Accreditation Board for Testing and Calibration Laboratories National AIDS Control Organisation National AIDS Control Programme North Eastern Regional Office Non-Governmental Organisation National Rural Health Mission National Reference Laboratory Nehru Yuva Kendra Sangathan Opportunistic Infection Opioid Substitution Therapy Primary Health Centre People Living with HIV/AIDS Public Private Partnership Prevention of Parent to Child Transmission Panchayati Raj Institution

PwP RCH RNTCP RRC RRE SACEP SACS SHG SIMS SJE SRL STD STI STRC TB TI TSU VBD VHC WCD

Prevention with Positives Reproductive Child Health Revised National Tuberculosis Control Programme Red Ribbon Club Red Ribbon Express State AIDS Clinical Expert Panel State AIDS Control Society Self Help Group Strategic Information Management System Social Justice & Empowerment State Referral Laboratory Sexually Transmitted Disease Sexually Transmitted Infection State Training & Resource Centre Tuberculosis Targeted Intervention Technical Support Unit Voluntary Blood Donation Village Health Committees Women & Child Development

Introduction In 1992, the Government launched the first National AIDS Control Programme (NACP I) and in 1998 NACP II was initiated. Based on the learning from NACP I and II, the government designed and implemented NACP III (2007-2012) with an objective to halt and reverse the HIV epidemic in India by the end of the project. There is a steady decline in overall prevalence and nearly 50% decrease in new infections over last ten years. India is committed to achieving Millennium Development Goals (MDG) in reducing HIV mortality. The country is clearly progressing towards achieving this goal through focused effort by a large number of partners bought together through National AIDS Control Program. NACP is an excellent example of community involvement and ownership in developing appropriate strategies and in reaching out to high risk and vulnerable populations. The program has been greatly benefited by the critical role played by civil society and PLHA networks in community mobilization, increasing access to services, addressing stigma and discrimination issues. NACP IV will build on the motivation of these stakeholders particularly at the community level (NGOs, social activists, service providers, consumers and policy makers) to actively engage with complex issues of HIV. It will focus on reduction of stigma and discrimination at health care setting, work places and educational institutions. Funding from Development Partners has played significant role in supporting the NACP programme interventions in the past. During NACP III external resources were substantial. In fact Domestic Budgetary Support to the Department of AIDS Control was less than 5% of the Departments budget. However, in light of the global economic recession external funding for HIV will shrink dramatically. Therefore, the next phase of the programme will primarily depend upon domestic resources. Therefore, one of the critical challenges is to move towards more effective and efficient approaches through convergence and integration of programme components such as basic HIV services, comprehensive care, support and treatment with National Rural Health Mission (NRHM) and general health systems to the extent possible.

2.

NACP III Implementation and Achievements

Based on the learning from NACP II, the government designed and implemented NACP III with an objective to halt and reverse the HIV epidemic in India by the end of the project period. Analysis of targets done at the time of mid-term review and subsequent joint implementation review mission suggest that most of the targets have been achieved or will be achieved by end of the program by 2012. Results of the epidemiological models and program data (surveillance ANC, HRG population, and ICTC) shows that the target of halting the epidemic has been achieved and reversal process has been initiated at the national level during this time frame. 2.1 NACP III Targets and Achievements

The targets and key achievements of NACP III can be summarised as follows: High Risk Group (HRG) Coverage: There has been substantial scale up in the coverage of FSW (78%), MSM (69%) and IDU (76%) through Targeted Interventions (TIs). This has been achieved through 1577 TIs for high-risk groups (HRGs). Link Worker Scheme was established to reach out to rural HRGs and their partners and vulnerable groups. 5350 IDUs were provided OST through 57 centres including NGOs and public health settings. Coverage of Bridge Populations: The programme targeted about 20 lakh long distance truckers through 82 interventions. The programme has reached 36 lakh high-risk migrants through 230 destination TIs. Counseling and Testing: Counseling and Testing have been rapidly scaled up during NACP III. Of the total target of 22 million, nearly 74% has been achieved through 5246 ICTCs and 3012 facility integrated ICTCs and ICTC units managed through PublicPrivate Partnership (PPP) model. In addition, 0.8 million HIV-TB cross referrals have been made and about 42,000 HIV-TB co-infections detected. STI Control: The coverage of STD services has been scaled up through collaboration with National Rural Health Mission (NRHM). Most of the STD treatment is mediated through district hospitals, PHC, and CHC under NRHM. Currently it is estimated that 50% of this target has been covered by the program through NRHM and STD clinics. Regular screening of HRG for STI has been initiated. At present 30% of registered HRG has been treated through 3523 TI-STI clinics. The coverage of STI services has been scaled up through 1033 designated STI clinics, 4036 Preferred Private Providers for HRGs and CHC/PHC under NRHM. Provision of Safe Blood: 80% of estimated 10 million units of safe blood availability required for the country has been achieved under NACP III through a network of blood banks of about 2609 facilities including public, voluntary/trust, private hospitals and private stand alone blood banks. Of this 80% is through voluntary blood donation. Majority of the districts in the country now have well established blood banks. Blood component separation units have also been established in tertiary care hospitals. Work has began for setting up of four Metro Blood Banks as Centres of Excellence in Transfusion Medicine with capacity to process more than 100,000 units of blood each annually in New Delhi, Mumbai, Kolkata and Chennai, and a Plasma Fractionation Centre with a processing capacity of more than 1,50,000 litres of plasma, which can fulfill the countrys demand. Condom Promotion: There has been significant up-scaling of condom distribution and sales through a substantial scale up in condom social marketing channels, non-traditional outlets and demand generation campaigns. Condom promotion has achieved 70% of the target of 3.5 billion through 1.2 million retail outlets and 8 social marketing organizations. IEC: NACO has been conducting regular thematic Mass Media campaigns on TV and Radio to cover issues of condom promotion, ICTC/PPTCT, STI treatment and services, stigma and discrimination, vulnerability of youth to HIV, ART, HIV-TB and blood safety. The Red Ribbon Express (RRE) program covered 8 million population and 81,000 grassroots functionaries were trained on HIV/ AIDS issues in the villages to further take down the messages. In addition, through mainstreaming with NYKS and other youth
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organizations, out-of-school youth have been reached. As part of mainstreaming efforts a large number of self-help groups, ASHA, ANM, Anganwadi Workers and PRI members have been trained/ sensitized on HIV/ AIDS. Red Ribbon Express (RRE): The Red Ribbon Express is a special exhibition train, on HIV/ AIDS and other health issues. This initiative has been recognized as the worlds largest mass mobilization drive on HIV and AIDS. Apart from three exhibition coaches on HIV and AIDS, a new exhibition coach on NRHM providing information on common diseases has been added. The Red Ribbon Express phase II completed one-year journey on 1st December 2010 after traversing 27,000 kms covering 152 stations in 22 states. It disseminated messages on HIV prevention, treatment, care and support. Outreach programmes and activities were also held in the villages through IEC exhibition vans and folk troupes. During RRE-II, around 80 lakh people were reached through the train and outreach activities; 81,000 district resource persons were trained, 36,000 people got themselves tested for HIV and 28,000 people received general health check-up services. Impact assessment of RRE indicates that the comprehensive knowledge of routes of HIV transmission, methods of prevention, condom use, STI prevention and treatment and other services such as ICTC, PPTCT and ART was significantly higher among respondents exposed to the RRE project as compared to those not exposed. Mainstreaming: About 6.5 lakh front line workers and personnel from various Government Departments, Civil Society Organisations and corporate sector were trained during 2010-11. Over 1,300 companies have adopted work place policies on HIV/AIDS Care, Support and Treatment: Currently about 426,000 PLHA are on 1st line ART. Care, support and treatment services are being provided through 313 ART centers, 641Link ART Centres (LACs) and 259 Community Care Centres (CCC). It has exceeded the original NACP III Target. The program has also started providing 2nd line ART in a phased manner and more than 2400 persons have been given 2nd line ART. Early infant diagnosis (EID) has been rolled out through 766 ICTCs &181 ART centres. The program has reached 6.63 million pregnant mothers and provided treatment to 11962 infected mother-baby pairs at the time of delivery. Strategic Information Management: Strategic Information Management System (SIMS) has been established and nation-wide rollout is under way with about 15000 reporting units across the country. This will enable the programme to collect, analyze and use the program data for planning and implementation. Data triangulation and risk profiling of districts is currently underway. Capacity Building: Capacities of service delivery units in the public sector and civil society partners have been enhanced: The capacities of SACS, District AIDS Prevention and Control Units (DAPCUs) have been strengthened. Technical Support Units (TSUs) were established at National and State level to assist in the program monitoring and technical areas. To assist the all the North-Eastern states, a dedicated North-East regional Office has been established. State Training Resource Centers (STRC) were set up to help the state level implementation units and functionaries. Laboratory services: External Quality Assurance System (EQAS) system was established in all national (13) and state (120) reference HIV testing laboratories. Assessments and follow-up plans for strengthening the laboratories have also been
11

undertaken. This paves the way for accreditation of these laboratories from National Accreditation Board for Laboratories (NABL). A number of national reference laboratories have also applied for accreditation. The next phase of NACP will build on these achievements and the lessons learned will ensure that these gains are consolidated and sustained. 3 National AIDS Control Program Phase IV

3.1 Assessment of Current Epidemic Scenario & Challenges The burden and trends of HIV in different states of the country is assessed by national level HIV Sentinel Surveillance System. It monitors the prevalence of HIV among Antenatal women representing general population, High Risk Groups (HRG) comprising of Female Sex Workers (FSW), Men having Sex with Men (MSM), Transgenders and Injecting Drug Users (IDU) and vulnerable population such as migrants, truckers and STD patients. Higher levels of positivity were seen mainly in High Risk Groups and bridge populations. The recent HIV estimates highlight an overall reduction in adult HIV prevalence and HIV incidence (new infections) in India. The estimated number of new annual HIV infections has declined by more than 50% over the past decade. It is estimated that India had approximately 1.2 lakh new HIV infections in 2009, as against 2.7 lakh in 2000. This is one of the most important evidence on the impact of the various interventions under National AIDS Control Programme and scaled-up prevention strategies. This has been due to rapid scale up of interventions resulting in hitherto untouched areas being brought into the ambit of the programme and a strong evidenced-based approach including mapping of high risk populations. While this trend is evident in most states, some low prevalence states have shown a increase in the number of new infections over the past two years, that underscores the need for the programme to focus more on these states with low prevalence, but high vulnerability. Of the 1.2 lakh estimated new infections in 2009, the six high prevalence states account for only 39% of the cases, while the states of Orissa, Bihar, West Bengal, Uttar Pradesh, Rajasthan, Madhya Pradesh and Gujarat account for 41% of new infections. The adult HIV prevalence at national level has continued its steady decline from estimated level of 0.41% in 2000 through 0.36% in 2006 to 0.31% in 2009. All the high prevalence states show a clear declining trend in adult HIV prevalence. HIV has declined notably in Tamil Nadu to reach 0.33% in 2009. However, the low prevalence states of Assam, Chandigarh, Orissa, Kerala, Jharkhand, Uttarakhand, Jammu & Kashmir, Arunachal Pradesh and Meghalaya show rising trends in adult HIV prevalence in the last four years.

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EstimatedAdultHIVPrevalenceandNumberofPLHA
2.61 2.58 2.54 2.49 2.44 2.4

0.5 0.4

NumberofPLHAinMillions

0.39

0.37

0.36

0.34 0.32 0.31

0.3 0.2

1.5 1

0.5 0
2004 2005

0.1 0
TotalNumberofPLHA
2006 2007

AdultHIVPrevalence

2008

2009

Fig 1: Estimated Adult HIV Prevalence and Number of PLHA, India, 2004-09 This round of estimates has confirmed the clear decline of HIV prevalence among Female Sex Workers at national levels and in most states. However, the evidence shows that Injecting Drug Users and Men who have Sex with Men are more and more vulnerable to HIV with increasing trends in many states. The patterns of prevalence of positivity in different risk groups are given in Figure 2.
WomenattendingAntenatalClinics LongDistanceTruckers SingleMaleMigrants PatientsattendingSTIclinics FemaleSexWorkers MenhavingsexwithMen InjectingDrugUsers

0.48% 1.62% 2.35% 2.46% 4.94% 7.30% 9.19%

0%

2%

4%

6%

8%

10%

Figure 2: Pattern of Prevalence in different Risk Groups 3.2. Key Priorities for NACP-IV NACP III and previous phases have ensured that programme interventions are focused on HRG and vulnerable sections of population. The targeted intervention approach has demonstrated excellent results and shaped up as a successful strategy. India is committed to achieving Millennium Development Goals (MDGs). Keeping this in view, the primary goal of NACPIV is to accelerate the process of reversal and further strengthen the epidemic response in India through a cautious and well-defined integration process over the next 5 years. The Guiding principles for NACP IV will continue to be:

Continued emphasis on Three Ones (i.e. One Agreed Action Framework, One National HIV/AIDS Coordinating Authority and One Agreed National M&E System) Equity Gender Respect for the rights of the PLHA
13

AdultHIVPrevalencein%

2.5

Civil society representation and participation Improved public private partnerships. Evidence based and result oriented programme implementation.

In addition, NACP IV will reinforce the focus on five cross-cutting themes namely: Quality Innovation Integration Leveraging Partnerships Stigma and Discrimination

Prioritization of states and districts Recent trends indicate that many of the states with emerging epidemics and higher vulnerabilities are those with relatively poor health infrastructure and having weak implementation capacities, governance and ownership of the program. The next phase of NACP will specifically focus on these areas and will reach out to the high risk, vulnerable and hard-to-reach groups by ensuring effective delivery of HIV services. The changing patterns of HIV epidemic also warrant a relook at the grouping of states, beyond just high prevalence and low prevalence states. HIV prevalence is no more a true marker of epidemic due to ART scale up that tends to sustain prevalence and masks the impact of prevention on reduction of new infections. Though prevalence is low in many states, the HIV trends are rising and number of new infections in some states is large. So, considering only the prevalence may mask the attention to be given to the states with rising trends and vulnerabilities. Hence, it is important to take into consideration the stage of the epidemic and trends and quantum of new infections for identifying focus states under NACP-IV. The categorization of districts in the country during NACP-III into A, B, C and D has helped not only in understanding the prevalence and risk across the country but also in allocating resources effectively. The districts will be re-categorized based on the epidemic profile and vulnerability and programmatic efforts will be intensified in those areas accordingly. Emerging Epidemics The epidemic patterns and dynamics of HIV transmission are changing over time. NACPIII could successfully contain the epidemics among FSW that were characterized adequately. However, newer forms of sex work that make FSW less accessible, are an important area of concern during NACP-IV. Epidemics due to MSM, Transgenders & IDU are being identified in greater number of pockets across the country with higher levels of HIV and hence, continue to demand highest priority in the coming years. Migration is increasingly identified as an important factor driving the epidemic in several north Indian districts. Dynamics of HIV transmission in migration-driven settings and the
14

unique challenges they pose to ensure reach of prevention services to the target population will be an important focus area under NACP-IV. Finally, in the mature epidemic states, long-standing prevention interventions could bring out successful declines among FSW and their clients. However, spousal transmission in the general population has emerged as an important source of new infections in these states, warranting a special focus and approach to address the same during NACP-IV. Thus, emerging epidemics due to MSM, IDU, migration, newer forms of sex work and spousal transmission shall be given priority during NACP-IV, besides sustaining the reach of existing interventions. In view of the above, it is imperative that the AIDS control programme should be sustained and vigilance maintained in order to prevent resurgence of the epidemic in the country. Key Priorities NACP IV seeks to consolidate the gains of NACP III and learn from the lessons of the previous phases of programme implementation. It aspires to further strengthen and decentralise the programme management capacities to state and district levels in particular. NACP IV focus will remain a prevention oriented plan with adequate coverage of the HIV care in the context of the concentrated epidemic situation in India. NACP IV will to the extent possible integrate with other national programmes and align with overall Twelfth Five Year Plan goals of inclusive growth and development. The key priorities under NACP IV are: Preventing new infections by sustaining the reach of current interventions and effectively addressing emerging epidemics Prevention of Parent to child transmission Focusing on IEC strategies for behavior change in HRG, awareness among general population and demand generation for HIV services Providing comprehensive care, support and treatment to eligible PLHA Reducing stigma and discrimination through Greater involvement of PLHA (GIPA) Ensuring effective use of strategic information at all levels of programme Building capacities of NGO and civil society partners especially in states of emerging epidemics Integrating HIV services with health systems in a phased manner Mainstreaming of HIV/AIDS activities with all key central/state level Ministries/departments will be given a high priority and resources of the respective departments will be leveraged. Social protection and insurance mechanisms will be leveraged.

Package of services will be customized to suit the requirements of different states and districts. NACP IV proposal of package of services shifts from the concept of uniform district based services to package further differentiated on the basis of maturity of epidemic, need of integration, comprehensiveness of package of services and difficulty factor of the region.

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Response Integrated Level District/Subdistrict CHC PHC/ Community Mature

Maturity of Epidemic

Basic Services D
High Range and Intensity of Service Low

Emerging

Responses Maturity vs. Emerging 3.3 The Preparatory Process An elaborate and extensive process to develop the Strategy and Implementation Plan for NACP IV has been initiated early this year. It is envisaged that the next phase will continue to be inclusive and focused on high-risk and vulnerable, marginalised and hard-to-reach populations. NACP has explored various approaches to reach out to these groups over the years and achieved significant outcomes. NACP IV will continue to provide focused prevention services to the high-risk groups and vulnerable populations along with care, support and treatment services to all eligible populations. The 12th Five Year Plan scheduled is to begin on 1st April 2012 and the next phase of the NACP formulation is also in synchronisation with the 12th Five Year Plan timeline. Hence, the process has been initiated with a sense of urgency and expediency to ensure that the NACP IV preparation process also feeds into the national 12th plan planning processes. The key steps in NACP IV preparation process: Collating inputs from 15+ Working Groups with sub-groups (about 20 -25 representatives from central and state levels, people living with HIV/AIDS, civil society, subject experts, development partners and other stakeholders in each group) Consultations with civil society Consultations at the state level with SACS and partners Regional consultations with PLHAs, public-sector, private sector and other key stakeholders E-consultations / discussions on specific topics to enrich the project development process and strategic approaches. Commission of Studies / Assessments
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Collaboration with Development Partners Preparation of draft Strategic Plan Reviews, clearances and approvals Launch of NACP IV

The NACP IV planning has adopted the inclusive, participatory and widely consultative approach similar to that of NACP III and is further strengthening on the globally acclaimed and successful planning efforts of NACP III. The list of working groups and the participant affiliations for each working group are given below:

List of working groups Sl. No. Working Group 1 Program Implementation and Organizational Restructuring 2 Finance Management Innovative Financing 3 Procurement 4 Laboratory Services 5 Sexually Transmitted Infections (STI)/ Reproductive Tract Infections(RTI) 6 Condom Programming 7 Communication Advocacy & Community Mobilisation 8 Greater Involvement of People Living with HIV/AIDS (GIPA), Stigma, discrimination and ethical issues 9 Mainstreaming & Partnerships 10 Blood safety 11 Integrated Counseling and Testing Centers (ICTC)/ Prevention of Parent to Child Transmission (PPTCT) 12 Care, Support and Treatment 13 Strategic Information Management (SIMS) Surveillance Research and knowledge management Monitoring and Evaluation 14 Gender, Youth and Adolescence 15 Targeted Interventions (TI) a Female Sex Workers (FSW) b Men having Sex with Men (MSM) c Injecting Drug Users (IDU) d Capacity Building e Migrant f Link Worker g Transgender h Truckers
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Developme nt Partners

Sl. Name of the Group No.

List of working Groups Representation Network Experts NRHM Civil Society

NACO

Other Govt. 1 1 1 1 1 1 1 1 3 1 1 1 2 1 1 1 2 10 1 1 2 2 4 2 8 4

SACS

2 3 4 5 6 7

8 9 10 11 12 13 14 15

Program Implementation and Organizational Restructuring Finance Management Procurement Lab Services STI/RTI Condom Programming Communication Advocacy & Community Mobilisation GIPA stigma and ethical issues Mainstreaming & Partnership Blood safety ICTC/PPTCT CST SIMS Gender Youth and Adolescence Targeted Interventions Total Grand Total

4 2 2

7 4 8 7 6 18

6 2 1 2 2 3

8 6 1 7 6 6

11 3 3 3 3 0

3 3 3 4 9 8 11 74 130

3 1

2 1 6 9 11 24 2 20 131

3 4 1 6 12 13 6

6 5 4 4 4 7 3

4 3

1 1 1 8 15

6 8 11 3 29 94

26 22 95 94 623

1 16

8 188 48 623

Each of the above-mentioned working groups met twice during May-August, 2011 and in each round of working group meetings, 623 members participated in this elaborate exercise. They discussed the current status and achievements under NACP III, identified gaps, emerging priorities, potential strategic options and national, state district level operational aspects. All working members have provided excellent inputs and covered geographical, thematic, operational and policy level issues thoroughly and contributed to the future programmatic directions, priorities, capacity building needs and monitoring and evaluation requirements. The working groups have also addressed policy level and implementation options. After two rounds of deliberations most of the working groups are in the process of finalizing the reports. However, the preliminary reports and consultations have provided invaluable insights and the groups have identified a wide range of suggestions and
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Total 29 42 17 15 25 22 31 24 28 14 35 48 73 32

recommendations. After receiving the final reports from the Working Group Conveners, these inputs will be taken into consideration and fine-tuned while developing the overall strategy and implementation plan for NACP IV. Based on the preliminary reports a list of the recommendations suggested by the WG has been incorporated under each strategy.

4 NACP IV - Goal, Objectives and Strategies 4.1 Proposed Goal and Objectives of NACP IV Having initiated the process of reversal in several high prevalent areas with continued emphasis on prevention, the next phase of NACP will focus on accelerating the reversal process and ensure integration of the programme response. Though the national level epidemic is showing reversal, it is evident from the data triangulation and recent surveillance data that many districts in India, which were previously of low prevalence, are showing increasing levels of infection and also there are geographical regions with emerging epidemic. It would be critical to provide a greater focus on prevention services in these areas and reduce new infections. Based on this analysis, the goal and objectives of the NACP IV may be stated as follows: Proposed Goal: Accelerate Reversal Integrate Response

Proposed Objectives: Objective 1: Reduce new infections by 60% (2007 Baseline of NACP III) Objective 2: Comprehensive care, support and treatment to all persons living with HIV/AIDS To achieve the goal and objectives the following key strategies have been identified. 4.2 Key Strategies

Strategy 1: Strategy 2: Strategy 3

Strategy 4: Strategy 5:

Intensifying and consolidating prevention services with a focus on HRG and vulnerable population. Increasing access and promoting comprehensive care, support and treatment Expanding IEC services for (a) general population and (b) high risk groups with a focus on behavior change and demand generation. Building capacities at national, state and district levels Strengthening and use of Strategic Information Management Systems
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A synopt view of th NACP IV strategies a cross-cu tic he V and utting themes s.

escriptions of the propos strategies with working group re o sed ecommendations/ Brief de activitie are given below: es ategy 1: In ntensifying and Consol lidating Pre evention ser rvices with a focus on n 4.3 Stra HR and vuln RG nerable popu ulations tion will con ntinue to be the core st e trategy of N NACP IV as more than 99% of the e Prevent people are HIV ne egative. NAC IV will continue to implement Targeted In CP o nterventions s mong high-r groups such as FSW MSM, TG risk s W, G/Hijra and IDU and wi reach out ill t (TIs) am to the bridge popula b ation (vulner rable migran and truck nts kers). Efforts will be made to ensure s e access t quality H services in particula STI/RTI c to HIV s ar care, quality condoms, ICTC, ART y T and also facilitate enabling environment. o e lso explore the possib bilities of streamlining the coord s dination and d NACP IV will al ement of blood transfu fusion servic (a) by identifying appropriat structural ces g te l manage changes at national, state and d s district levels and (b) by establishing a dedicated program to s g d o manage this compo e onent. The p program will continue to link preven l o ntion with care, support c t and trea atment.

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NACP IV will also reach out to the general population through mass media, women groups and youth clubs to create awareness and increase access to HIV services.

Key Activities 4.3.1 Prevention: Targeted Interventions Flexibility in the TI to accommodate and address location specific issues and concerns of the target population Involvement of the community Establish and institutionalize linkages and referrals Gender sensitive programming Strengthen positive prevention Simplify and strengthen of M&E indicators and system Free supply of condoms should continue along with social marketing Support operations research to understand the trends in condom use and related issues Roles and responsibilities of all participating agencies in Targeted interventions should be clearly defined Strengthen strategies for enabling environment Harm reduction would continue with focus on Injecting Drug Users and their partners Strengthen evidence building and consolidate the truckers interventions with increased participation of all stakeholders The programme will mainstream with other Ministries and departments in respect of the following: For Opoid Substitution Therapy (OST), through public health care settings Linkages for legal services, livelihood and poverty alleviation Mainstreaming of HIV prevention activities with existing community, social and health resources/infrastructure For strengthening responses to intervene among HRGs, migrants and truckers Ministries of Labour, Transport, Railways, Heavy Industries, Corporate Affairs, Panchayati Raj, Women &CD, Social Justice & Empowerment. Convergence with health department/NRHM to ensure gradual integration 4.3.2 Migrants NACP IV provides an opportunity to further strengthen strategies by enhancing the evidence and designing interventions tailored to the dynamics of migrant populations including the typologies that influences their vulnerability. Scaling up responses by adopting local strategies, collaborating with corporate sector, expanding workplace interventions in unorganized sectors.
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Strengthen and scale up responses among female migrants and female spouses of returned and active migrants (at source areas). Strengthen strategies to improve access to services. Strengthen capacities of SACS, industry bodies, corporate, civil society for integrated response.

4.3.3 Sexually Transmitted Diseases Provision of standardized STI/RTI management to general population through all government health facilities (Medical colleges, district hospitals, sub-divisional hospitals, PHC, CHC etc) The provision of comprehensive sexual and re-productive health services through the functional linkages with respective units. Continue with Syndromic Case Management (SCM) with minimal Lab support wherever facilities are available. Provision of STI drugs, training and supportive monitoring for NRHM Syphilis screening of pregnant women to be scaled up across all ICTC/PPTCT and FICTC located in the facilities supported by NRHM. (NRHM should budget to procure the requisite numbers of syphilis screening test kits.) Involvement of Urban Health facilities (Urban health facilities, health posts, corporation hospitals and to cater to populations living in urban and peri-urban slums). Mobile medical units under NRHM will be linked with difficult to reach population and linkages to be established between MMU and link workers, ASHA and AWW. ICTC & STI services should be integrated with mobile van under NRHM. Programme should explore the possibility of task shifting i.e., getting nurses and AYUSH doctors to prescribing the drugs for SCM. An Operations Research should be conducted to establish the feasibility, usefulness & safety. Counsellors, all laboratory technicians in the ICTC/PPTCT programme also to be trained for syphilis testing. Syphilis screening along with HIV screening through single window at all HIV testing facilities in the country should be offered to HRG, STI clinic attendees and ANC attendees. Improved IEC and BCC tools for demand generation from vulnerable population for accessing STI service and compliance to required genital examination. Existing infrastructure of the organized sectors (Public & Private) will be utilized for providing standardized STI/RTI services to their dependant population. STI management amongst HRGs will remain NACO priority. The essential STI/RTI service package to HRG would be supported by NACO, comprising of o o o o Provision of free STI/RTI treatment. Regular Medical Check-up Biannual syphilis screening and HIV testing Presumptive treatment to FSW and MSM/TG
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o Free supply of condoms for core population o Partner management. o Counselling services along with the PE led BCC and health education The program will ensure minimum essential standards (Infrastructure) for the TI-STI service delivery in Static clinics are: o Confidentiality and Audio visual privacy o Areas for examination, counselling and consultation. o Equipment necessary for examination like, speculum, proctoscope, flexi-lamp, examination table etc o Waste management system The programme will pilot service delivery for HRG through qualified ANM/ nurses to counter the non availability of qualified providers especially for north eastern states. All identified TI STI service providers at the Hot Spot to be trained in STI/RTI management guidelines as per NACO prescribed curriculum for ensuring provision of effective management to all the HRG and their clients. TI NGO will coordinate and link with the CMOH/DHO/CS, Rogi Kalyan Samiti/district health samiti of the district to obtain some basic general ailments medicine for HRGs, so as to facilitate comprehensive health care for the HRG. Provide continued support towards strengthening the Regional STI centers to conduct of antimicrobial sensitivity studies, periodic etiologic surveillance, and community based prevalence studies, operations research. Strengthen linkages between selected TI projects participating in surveillance and State and Regional STI centres for laboratory screening of STI/RTI Strengthen 45 state reference centres and 7 regional centres Strengthen capacity of participating state and regional laboratories so that they can progressively move towards NABL accreditation.

4.3.4 Blood Safety (Blood Transfusion Service): Although Blood Safety is currently an integral component of NACP, it has been recommended by the Working Group to change the nomenclature from Blood Safety to Blood Transfusion Service, in view of the expanded scope with inclusion of other elements of Blood Transfusion Services. Further, in view of the changing role of this component, till the time, it is recognized as a separate programme under Department of AIDS Control, it will continue to be reflected under NACP - IV. During NACP-IV, the aim of this activity is to achieve 90% of the annual requirement of blood exclusively through voluntary non-remunerated donation. Educating the society for recruitment and retention of low-risk blood donors. Training of voluntary organizations in donor recruitment and retention. Integrate messages on blood donation in the school curricula
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One dedicated donor motivator cum counselor to be provided up to district level blood bank. Augment partnerships with government departments and nongovernmental organizations such as national Red Cross, voluntary blood donor organizations, national service organizations. For targeting rural areas, co-ordinate with NYKS to promote VBD. Blood banks and blood storage centres at district and sub district levels will be established during NACP IV where such facilities are non-existent. Computerization up to district level blood bank will be required for implementation of networking with one data entry operator in each blood bank and a nodal officer at the state level. The mechanism of transportation of blood and blood products to be strengthened. There is a need to introduce a phase wise automation in large volume blood banks. To institute EQAS programme for blood bank serology. Proficiency testing (EQAS) will be initiated to improve quality. Implementation of quality management systems in all blood banks which includes o Support accreditation of blood; and develop quality policy, procedures and reporting formats to ensure uniformity in documentation and traceability.

Appropriate use of blood and blood products Hospital transfusion committees would be set up in all medical colleges and district hospitals so that regular performance audit are preformed and feed back given to health providers on use of blood and blood products. Haemo-vigilance to be piloted in select centres and then scaled up in a phased manner.

Convergence with NRHM/other departments and Ministries Access to safe blood at the FRU level will ensure improvement in health indicators in general and maternal health in particular. Linkage of VBD program with Anemia Control Program through Department of Health/ WCD for Prevention of Anemia to ensure that significant number of voluntary donors who are deferred due to anemia will be able to donate blood. A joint coordination committee at State Level of SACS, NRHM and other health officials to be constituted for supervision and monitoring of various facilities under the programme. Develop a cost sharing mechanism with state on provision of safe blood

4.3.5 Integrated Counselling and Testing Services To continue, expand and accelerate coverage of counselling and testing services to at risk population.

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Strengthen the existing stand alone ICTCs supported by NACO: All existing stand alone ICTC will be continued and strengthened during NACP IV with focus on vulnerable states, so as to ensure services atleast up to CHC level. Integrate testing and counselling with the general health services of NRHM (facility integrated ICTC) and expand the coverage of testing and counselling services among the rural population and to integrate ICTC services in the general health system through all the 24x7 PHCs Expanding testing and counselling in the private health sector through public private partnership (PPP) program: To increase the coverage of pregnant women and key populations accessing private sector. Different schemes for private sectors will be developed and strengthened to ensure maximum participation Initiate community based HIV screening: Community based screening by front line health workers such as Auxiliary Nurse Midwives will be initiated after pilot testing in high burden districts (with low rates of institutional delivery) for augmenting PPTCT coverage Integrate HIV screening at TB clinics: HIV screening will be integrated as part of routine care at all the RNTCP Designated Microscopy Centers through training and multi tasking role of the existing personnel under RNTCP. Routine offering of provided initiated HIV counseling and testing for all TB clients, will be scaled up across the country Screening of PLHIVs with early signs and symptoms of TB during home visits by ANMs and referring them to RNTCP for TB screening and treatment. Decentralize and strengthen existing services, use of mobile clinics to reach hard to access populations and mobilization through ASHAs and link workers to increase the uptake. Integration with NRHM for expanding coverage of ICTC services through sharing of resources and multi-tasking. Link workers and mobile ICTCs will be utilized to increase the uptake among underserved sexually active and vulnerable populations. Linkages between ICTCs and prevention interventions (TI) will be strengthened through capacity building, facilitation of cross visits, monitoring of referrals, and increasing the visibility of ICTCs and their personnel. Strengthen the communication and counselling skills of counsellors and health care providers to sensitively respond to the counselling and testing needs of vulnerable and marginalized groups and to provide client friendly services Sensitization of field health functionaries like Anganwadi workers/ ASHA Worker/ PHC/CHC staff in basics of HIV / referral and linkages. Improve quality of HIV counseling and testing services in all ICTCs HIV Testing quality control procedures will be strengthened by the laboratory network so that high quality laboratory standards are maintained for all ICTCs. Strengthen supply chain management to ensure uninterrupted services at all ICTCs

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To strengthen the follow up particularly of PLHIVs including HRGs to be strengthened through Anganwadi workers/ ASHA Worker/ Link Worker/ Outreach Worker Advocacy for creating an enabling environment and reducing stigma and discrimination both at the health facility and the community level will be undertaken to further increase testing uptake particularly among HRG populations. Media campaigns will be augmented by strengthening linkages and referrals between ICTCs, STI clinics and the ongoing prevention intervention programs targeted at migrant workers, truckers etc. Communication tools that are targeted to improve risk perception, health seeking behavior, and knowledge about services among clients To link all HIV positive individuals with care, support and treatment services available under NACP

4.3.6 Prevention of Parent to Child Transmission (PPTCT) Expand PPTCT services to all pregnant women who are covered through RCH services in close collaboration with NRHM. Sensitization of all field health functionaries like Anganwadi workers/ ASHA Worker/ PHC/CHC staff for better co-ordination and delivery of PPTCT services. Community based screening of pregnant women through front line health workers will be expanded in all A & B and emerging districts of the country. Leveraging existing public private sector partnership to scale up PPTCT services in the private sector Couple counselling for positive prevention Sensitize and train private providers in collaboration with professional organizations (FOGSI, IAP, IMA and others) Link all of HIV positive pregnant women who are identified by the program to care, support and treatment services Ensure linkage to EID services to all babies born to HIV positive pregnant women under the PPTCT programme. Wide use of communication tools that are targeted to improve risk perception, health seeking behavior and knowledge about PPTCT services.

4.3.7 Condom Promotion Consistent condom use will be one of the most critical aspects of NACOs prevention strategy for HIV / AIDS control In NACP IV, NACO will continue its sentinel role of ensuring availability, accessibility, and affordability of condoms to the marginalised, hard to reach, commercially ignored populations through ramping up its Condom Social Marketing Programme (CSMP) across the country. To achieve this, it will be essential to promote
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condom usage amongst general population with a focus on awareness building, demand generation, leading to behavioural change, while intensifying quality prevention services for HRG and vulnerable population by ensuring availability of condoms (free and subsidized condoms) Based on these, the objectives for Condom Promotion for NACP IV are 1. Grow the Condom Usage in India to 3.1 billion by 2017 2. Increase condom availability to 600+ districts in 2.4 million outlets A. Key Strategies 1. Segmented and differentiated marketing approach to states for effective condom social marketing programme especially in underserved areas 2. Process redesign for inventory management and supply of condoms to ensure nil stock outs. 3. Integrating/harmonizing / converging Ministry and NACO social marketing programs for cohesive distribution strategy , increased operational efficiencies, close monitoring and optimisation of subsidy and greater sustainability. 4. Converge with NRHM for social marketing of condoms through ASHAs. 5. Product and Brand Re-engineering of Deluxe Nirodh to make the brand more contemporary and relevant to current consumers and enable achievement of condom promotion objectives. 6. Development of a long term communication strategy and implementation plan with approved periodic tactical implementation with timelines, ownership and monitoring to ensure timely execution of communication elements. 4.3.8 Reaching out to HRG and Vulnerable population in rural areas Reach out to HRGs and vulnerable men and women in rural areas with information, knowledge, skills on STI/HIV prevention and risk reduction. Increasing the availability and use of condoms among HRGs and other vulnerable men and women. Establishing referral and follow-up linkages for various services including treatment for STIs, testing and treatment for TB, ICTC/PPTCT services, HIV care and support services including ART. Creating an enabling environment for PLHA and their families, reducing stigma and discrimination against them through interactions with existing community structures/ groups, e.g. Village Health Committees (VHC), Self Help Groups (SHG) and Panchayati Raj Institutes (PRI). To develop and sustain intervention models to address the rural intervention keeping in mind the diversity in the epidemic

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Increase uptake of both HIV prevention and care related services in the rural areas specially in selected districts Reduction in stigma and discrimination against HRGs and PLHIV and improvement in the quality of their lives in the rural areas Address issues related to gender inequity and its influence on increase in risk and vulnerability in the rural context

Positive Prevention Improving knowledge, attitudes and behavior of PLHIV regarding positive strategies through PLHIV Networks Improving linkages of ICTC with CST services Provision of 1st and 2nd line ART to all Eligible PLHIV Encourage social marketing of condoms through PLHIV networks Improving the quality of counseling services to encourage partner counseling and partner notification Promoting voluntary testing for HIV for sexual partners of PLHIV Strengthening BCC and condom promotion in IDU interventions Enhance program efforts to reduce stigma and discrimination for PLHIV Initiate studies on discordant couples to understand effectiveness of Positive Prevention strategies and provide mid course correction. All identified PLHIV will receive information of Positive Prevention strategies of the program at the time of post test counseling All identified PLHIV will be referred to Service Centers including ART, TB screening, STD clinic. Train PLHA so that they can participate effectively on PwP activities

4.3.9 Laboratory Services Positioning laboratory services as a distinct component of the program at the national and state levels Constitute Laboratory services division at NACO headed by medical microbiologist, supported by appropriately qualified program officers, as well as technical officers and other support staff. Constitute State level division headed by a designated nodal officer and appoint Quality Manager for laboratory services in all SACS Appoint Technical Officers at NRLs, SRLs and molecular testing facilities.. Ensuring continuation and sustainability of existing structure and activities of the laboratory services division Mentoring of the laboratory staff through the laboratory network - The strategy to achieve this objective would involve ensuring mentoring and monitoring through a
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three tiered pyramidal system focused on bringing about total quality management. The laboratory personnel would be supervised by qualified laboratory experts for improvement of their capacity. Enhance Diagnostic Services with focus on quality in laboratories at all levels Review of HIV testing strategy from time to time. National EQAS program for all participating labs at district and above for HIV related diagnostic services Enhance supportive supervision for laboratories at sub-district levels. Innovative strategies for enhancing implementation of laboratory services would include: o Creation of e-resource for addressing needs of laboratories o Evaluation of appropriate newer technologies including point of care diagnostics o Initiation of incidence testing for augmenting HIV sentinel surveillance o Sustaining and expand the scope of NRL Consortium on Quality o Strengthen laboratories to support STI sero-surveillance in selected medical colleges. Establish structure for technical supervision at every level located at the NRLs, SRLs, CD4 and molecular testing laboratories and catering to all HIV testing facilities Will ensure adherence to national/state norms to achieve improvement in HIV-related laboratory safety. Provide technical resources to enable combined training programs for laboratory personnel in the existing health systems outside of NACO for HIV testing. Advocate with MCI, DHR, DCG(I), state counterparts and other national programs on impact of adherence to quality standards.

Improvement in laboratory safety in HIV testing premises Preventive action e.g. HBV vaccination of laboratory personnel. Incident reporting and corrective actions. Institution of occupational safety measures.

4.4 Strategy 2: Comprehensive Care, Support and Treatment NACP IV will implement comprehensive HIV care services for all those who are in need of such services and facilitate additional support systems for women and children. With wide network of treatment facilities and collaborative support from PLHIV and civil society groups, it is envisaged that greater adherence would be possible thereby avoiding/delaying resistance to ARVs. Additional Centers of Excellence (CoEs) and ART

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centers will be established to provide high-quality treatment and follow-up services, positive prevention and better linkages with health care providers in the periphery. It is proposed that the comprehensive care, support and treatment of HIV/AIDS will inter alia include: (i) free anti-retroviral treatment (ART) including second line as per National Guidelines (ii) management of opportunistic infections and (iii) facilitating social protection for PLHIV through linkages with concerned Departments/Ministries. The program will also explore avenues to increase public-private partnerships. The program will enhance activities to reduce stigma and discrimination at all levels particularly at health care settings. NACP IV will evolve a comprehensive care and support model whereby existing support structure i.e. CCCs, DIC and PLHIV networks will brought under one stop shop to provide HIV Care and Support services including adherence counseling, Psycho-social support, nutritional counseling, positive prevention etc. presently being undertaken through CCC/DIC under NACP-III. These mechanisms will be evaluated, reviewed and strengthened accordingly. Link up with key Ministries like WCD, HRD, SJE, Transport and other for extending benefit of existing social protection schemes on health, nutrition, education and other special schemes. 4.4.1 Anti-Retroviral Treatment Increase access to Anti Retroviral Treatment to all eligible PLHIV including women and children, free of stigma and discrimination. Scale up ART centers, COEs and LACs as projected in the target Every district of the country will have either an ART centre or an LAC, as per laid down criteria Increase demand generation IEC to ensure greater enrolment of PLHIV Strengthen regular follow up of all registered PLHIV to start ART as soon as eligibility criteria are satisfied. Improve linkages with ICTC, RNTCP, STI and TI Services Improve quality of CST delivery and ART adherence. Scale up of specific lab services (CD 4 and viral load) to meet the diagnostic requirements of ART. Strengthen Pre-ART follow up to identify all eligible people for treatment. Strengthen Information System to track, follow and retrieve PLHIV lost to follow up through initiatives like Smart Card etc. Initiate chemoprophylaxis for common OI in PLHA 2nd Line ART Scale up facilities to handle increase load of second line requirement Faster screening of PLHIV through SACEP Scale up quality diagnostic services to pick up drug resistance
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4.4.2 Treatment of Children Infected with HIV Scale up of Pediatric ART services to districts with high load of CLHIV Regular follow up of children living with HIV including 6 monthly CD4 testing. Nutritional counseling/support to be integral component of care and support through linkage to respective Ministries. Counseling on pediatric HIV and ART to children and their caregivers to be strengthened through training of counselors, nurses and doctors (general and pediatricians). Strengthening support services with linkages with PLHIV network

4.4.3 HIV/TB Co-infection Expansion of ICF activities to cover PLHIV also at LAC, CCC etc. along with high risk groups catered to by NACO TI projects Introduction of intensive case finding in LAC, CCC and TI Strengthening infection control practices in all HIV care setting Strengthening HIV/TB reporting through SIMS

4.5 Strategy 3: Expanding IEC services for (a) general population and (b) high risk groups with a focus on behavior change and demand generation The programmatic thrust will be on the General Population, specially the Youth and Women; identified populations at risk, including the Most-at Risk Populations and Bridge Populations; demand generation for uptake of services; and strengthening the enabling environment. Communication Channels to reach the targeted Population including promotion of demand generation Under NACP IV, multimedia approach using strategic mediums of communications would be used which will involve thematic mass media, mid media, outdoor, and folk performance specially for media gray areas in rural areas. Different approach will be developed to reach to different target population including Youth, Women, Most-at Risk Populations and Bridge Populations and for Targeted Intervention including services like STI, ICTC/PPTCT, ART, HIV-TB, promoting voluntary blood donation, condom promotion. 4.5.1 Stigma and Discrimination The communication strategies to be considered would include: Promotion of better understanding among people of influence of HIV/ AIDS and its stigmatizing and discriminatory effects, ensuring that advocacy efforts under NACP IV pay special attention to this.

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Designing campaigns using multiple channels i.e. mass media, mid-media, outdoor and inter-personal communication to address stigma and discrimination. Equipping persons living with or affected by HIV/ AIDS with communication skills and involving them as positive speakers at various forums. Training PLHIV to develop strategies and tools to address stigma and discrimination, including self-stigmatization. Documenting, publishing and disseminating successful innovative stigma reduction interventions. Promotion of the crisis response mechanism that may be formally constituted under NACP IV, both at NACO and SACS. Ensuring that all campaigns and training curricula are vetted from a stigma lens.

4.5.2 Advocacy Advocacy in NACP IV will be built on the achievements of NACP-III for reaching out to the elected leaders at the national, state, district and panchayat level. With the adoption of National Policy on HIV/ AIDS and the World of Work, linkages with employers and industry associations need to be expanded for effective implementation of the policy. A major gap is the unorganized sector. This will be prioritized in NACP IV. Advocacy packages will be developed for different target audience including why it is important for them to address HIV/ AIDS issue and how they can do it. 4.5.3 Convergence with NRHM HIV/AIDS messages can be suitably incorporated in the larger campaigns launched by NRHM. NRHM messages for care and tests during pregnancy may include messages on PPTCT services. RNTCP messages may include messages on HIV-TB co-infection. Condom messages by both NACO and NRHM should project triple benefits and STI messages need to be disseminated by both in a coordinated manner. Adolescent health campaigns under NRHM can include messages on youth vulnerabilities to HIV/ AIDS, delayed sexual debut and condom use. Linkages will be established with the ARSH programme of NRHM for clinical services to those adolescents and youth who need it. 4.5.4 Youth & Adolescents Programme Priorities & Programme Targets 1. Extending coverage of government and government aided schools along with selected private schools through AEP. 2. Extending coverage of government and government aided graduate and higher level colleges through RRCs. 3. Mainstreaming with various government and other outreach programmes to reach out-of-school youth with focus on Most at Risk Adolescents (MARA).

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4.5.5 Gender and HIV prevention Strategy: Mainstream gender concerns relevant to HIV in national programmes Demand generation for women and girls access to services

4.5.6 Stigma & Discrimination under NACP - IV Programme Priorities While NACP-IV will further build up and strengthen the initiatives taken up during NACP-III, the efforts will focus on the following: Creating an overarching enabling environment which reinforces positive attitudes and practices at the societal level Addressing Self- stigma among PLHIV and MARPs Stigma in family settings Stigma at health care settings Stigma at workplace Stigma at educational institutions Protecting and promoting the rights of PLHIV, marginalised and vulnerable populations by reviewing and developing polices and legal instruments.

The interventions to address stigma and discrimination will have greater focus on women in view of the evidence that women are more likely to be stigmatised and discriminated if they are HIV positive or belong to marginalised communities.

4.5.7 GIPA & NACP - IV Greater involvement of People Living with HIV/ AIDS will be ensured by building their capacity, setting up grievance redressal mechanism at different levels. IEC material on different important issues will be provided as well as appropriate guidance will be provided for network strengthening. 4.6 Strategy 4: Strengthening institutional capacities The objective of NACP IV will be to consolidate the trend of reversal of the epidemic seen at the national level to all the key districts in India. The programme management structures established at state and district levels under NACP will be strengthened further to achieve the NACP IV objectives. Programme planning and management responsibilities will be strengthened at state and district levels to ensure high quality, timely and effective implementation of field level activities and desired programmatic outcomes.

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The planning processes and systems will be further strengthened to ensure that the annual action plans are based on evidence, local priorities and in alignment with NACP IV objectives. Sustaining the epidemic response through increased collaboration and convergence, where feasible, with other departments will be given a high priority during NACP IV. This will involve phased integration of the HIV services with the routine public sector health delivery systems, streamlining the supply chain mechanisms and quality control mechanisms and building capacities of governmental and non-governmental institutions and networks. Some key activities include:

The institutional strengthening of NACO, SACS, DAPCU and facilities Strengthening the support structures such as TSU, STRCs and NERO for North East Strengthening human resources, process of planning and coordination, organizational relationships and linkages, programme component linkage and use of technology to strengthen the quality Linking up with institutions in the public and private sector for quality assurance Strengthening the process of outsourcing and contracting out mechanisms and processes and ability to handle the contract management Strengthening mechanisms and capacities for imparting induction and refresher training to all technical components

4.7 Strategy 5: Strategic Information Management Systems (SIMS) Indias success in tackling its HIV/AIDS epidemic partly lies in how India has developed and used its evidence base to make critical policy and programmatic decisions. Over the past 15 years, the number of data sources has expanded and the geographic unit of data generation, analysis, and use for planning has shifted from the national to the state, district and now sub-district level. This has enabled India to focus on the right geographies, populations and fine tune its response over time. Given the proliferation of data sources and the emerging capacity within India to analyze and use data, it is imperative to identify these opportunities to strengthen the national programmes use of data for better programme decision-making at the district, state and national levels. Under NACP-IV, it is envisaged to have an overarching Knowledge Management strategy that encompasses the entire gamut of strategic information activities starting with data generation to dissemination and effective use. The strategy will ensure high quality of data generation systems such as Surveillance, Programme Monitoring and Research; strengthening systematic analysis, synthesis, development and dissemination of Knowledge products in various forms; and emphasize on Knowledge Translation as an important element of policy making and programme management at all levels.

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The element of Knowledge Translation will be given the highest priority to ensure making the link between Knowledge and action at all levels of the programme. The programme will focus strongly on building capacities of epidemiologists, monitoring officers, statisticians as well as programme managers at national, state and district levels in appropriate methods and tools of analysis and modeling. Institutional linkages will be fostered and strengthened to support programme for its analytical needs. The surveillance systems will be further strengthened with focus on tracking the emerging epidemics, incidence analysis, identifying pockets of infection and estimating the burden of infection. Efforts will be made to establish behavioural tracking at district level among the key risk groups. Triangulation approaches will be refined and adopted to make the best use of epidemiological information from programme sources such as PPTCT, TI and ART. Private sector will be actively involved in surveillance activities to ensure adequate data representation. Other special areas such as mortality related to HIV, HIV among children, developing India specific data for key modeling parameters and establishing mechanism for cohort tracking of key population groups will be focused. HIV case reporting mechanisms will developed and integrated into the existing systems. To ensure robust reporting and monitoring, Strategic Information Management System (SIMS), a web-based integrated monitoring and evaluation system has been developed and rolled out. The roll-out of SIMS is ongoing and will be firmly established at all levels including over 12,000 reporting units, to support evidence based planning, program monitoring and measuring of programmatic impacts. Simple analytical tools will be developed that can be used by programme managers to assist them in day-to-day requirements of decision making. The relevant, measurable and verifiable indicators will be identified and used appropriately. Research priorities will also be customized to the emerging needs of the program. Emphasis will be given to undertaking HIV/AIDS research required to answer the key questions and grey areas in the programme. Strategies and systems for concurrent evaluation of various interventions will be built into the programme, so that timely assessments can be undertaken in a robust and easy manner. NACP IV will also document, manage and disseminate evidence for effective utilization of programmatic and research data. A knowledge hub will be developed for NACP, as a one-point source of information on HIV/AIDS for a wide array of stakeholders and that can also serve as a place holder for various tools for knowledge sharing. Specific activities will be undertaken for promoting data use at national, state and district levels. Scientific writing within the programme on important topics will be promoted and their publication in peer-reviewed journals and conferences will be facilitated.

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5 Cross-cutting Themes The objectives of NACP IV will be accomplished not only by effectively implementing the above-mentioned strategies but also ensuring the cross-cutting issues are given adequate attention. They include: (a) (b) (c) (d) (e) Ensuring Quality, Promoting Innovation, Leveraging Partnerships, Phasing Integration and Reducing Stigma and Discrimination

5.1 Ensuring Quality Each intervention in NACP needs to be viewed in terms of a set of interrelated interventions leading to better outcomes and therefore need to be addressed in an integrated manner and coordinated effectively. The quality framework based on analysis of chain of activities from condom promotion, BCC, STI, ICTC and TI, and various other activities critical in programme process will be strengthened. Similarly care and support component will be examined in terms of a set of inter-related activities and circumstances leading to better effectiveness of interventions. Towards this end the programme will focus on developing robust systems to ensure better quality of services. Five pillars of service quality: (a) human resources, (b) process of planning and coordination, (c) organizational relationships, (d) programme component linkages, and (e) technology (use of IT to track services) will be strengthened. 5.2 Innovation Given the maturity and complexity of NACP, the fourth phase provides the right opportunity to develop innovative approaches to achieve the goals of the programme. NACP IV will emphasize the spirit of innovation within all key programme strategies. Continuing the previous efforts innovative approaches will be used for integration of services, quality assurance at all service delivery points, coverage saturation, treatment adherence, data quality and use. IT based solutions for developing strategies for monitoring, information sharing and integration 5.3 Leveraging Partnerships In order to achieve the goal of the NACP IV, the programme envisages promoting and leveraging of partnerships. NACP design offers a number of interventions, which need widespread coordination and collaboration between various public and private sector entities. Partnership will be made with communities, civil society, positive networks, Government health system, other related Ministries/Departments of the Government, public sector units and the private sector both in the health and non-health sector. Leveraging on strengths of each other can significantly contribute to the achievement of targets. Specifically, the following areas will be focused through leveraging on: (a) existing programmes (b) social protection schemes and related mechanisms.

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5.4 Integration The programme has adopted the strategy of using various interventions with focus on integration of services and work towards sustainability of NACP activities. The interventions in areas of TI, basic services and care, support and treatment have the potential of getting integrated with the general health system in a phased manner without compromising on quality and coverage. It is proposed to enhance integration of OST interventions with MOH and harm reduction and social protection strategies with Ministry of Social Justice and Empowerment, STI care of general population, counseling and testing services and CST services with the general health care services as part of NACP IV. However, it requires a phased approach and NACP IV will examine various options of integration of programme interventions. NACP IV will also ensure that integration of programmes will maintain the pace and quality of interventions and do not increase the financial burden of communities. 5.5 Reducing Stigma and Discrimination NACP-IV will further build up and strengthen the stigma and discrimination initiatives taken up during NACP-III and increase the efforts on the following: (a) creating an overarching enabling environment which reinforces positive attitudes and practices at the societal level, (b) addressing self-stigma among PLHIV and most at risk populations, family settings at health care settings, at workplaces, and at educational institutions, (c) facilitate support to PLHIV, marginalised and vulnerable populations by periodically reviewing /developing polices and legal frame work and (d) encourage Greater Involvement of PLHIV (GIPA). Address stigma and discrimination issues particularly in health care settings Levels 1 Individual Level Activities Training to increase knowledge and awareness on stigma and discrimination 2 Institutional Level 3 Policy Level Training of health care providers in all public health facilities on universal precaution Provision of post infection prophylaxis in all public health setting attending HIV patients. Development of mandatory institutional policy for management of HIV related illness in tune with national policy in both public and private health institutions Strengthening legal frame work for support of PLHIV who are discriminated in health care setting

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6. Proposed Targets for NACP IV

The targets for NACP IV are being derived from working group recommendations, analysis of program data and NACP III achievement of targets and projections. The detailed activity-wise targets are given in Annex-1. 7. Budget Estimate

The budget estimates have been worked out based on the targets projected for NACP IV and by using existing costing norms. The total budget for the programme works out to be Rs 12,824 crores.

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Annexure 1 Proposed Targets for NACP IV

S.No. Programme Components Prevention
A 1 2 3 4 5 6 B 1 Targeted Interventions among High Risk Groups FSW MSM IDU Number of TIs Prevention in Bridge Population Truckers High Risk Migrants Integrated Counselling and Testing Number of vulnerable population accessing ICTC services No. of pregnant mothers tested under PPTCT Number of PPTCT/ICTC centers established No. of HIV +ive mother and child pair receiving Prophylaxis Sexually Transmitted Infections No. adults with STI symptoms accessing syndromic management No. of STI episodes in HRG treated through TIs Blood Safety No. of Blood Component Separation Units (BCSUs) No. of Blood Banks No. of Blood Storage Units (BSU) No. of units of safe blood available for transfusion Percentage of Voluntary blood donation Condom Promotion No. of condoms distributed (Free + Social + Commercial) Comprehensive Care, Support and Treatment PLHIV requiring ART PLHIV requiring First Line ART Children requiring First Line ART PLHIV on second Line ART 340000 300000 40,000 Nil 426,000 394609 31,391 2,400 800,000 690000 50,000 60,000 162 1,177 3,222 10,000,000 90% 3,500,000,000 155 Work in Progress 1,127 685 8,010,000 78% 2,694,000,000 1,500 2,537 12,000,000 90% 3,114,000,000 8,68,000 4,12,000 1,77,000 2,100 20,00,000 42,00,000 709,000 379,000 155,000 1,741 1,480,000 3,670,000 1,000,000 445,000 180,000 1,800 1,600,000 5,600,000

Targets NACP Achieved 2010- Targets for III 11 NACP IV

22,000,000 7,200,000 5,000 37,290

15,800,000

28,000,000 14,000,000 14619 34400

2 3 4 C 1

6800000
8,258 12,590

150,00,000 20,00,000

1,00,20,000 298,000

170,00,000 10,00,000

2 D 1 2 3 4 5 E 1 F 1 2 3 4

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Minutes of the Working Group Meeting on AIDS Control The first meeting of the Working Group on AIDS Control was held on 5-9-2011 at NACO and was presided over by Secretary & DG, NACO with Shri J.V.R. Prasada Rao, former Secretary (Health) as co-chair. The meeting was attended by the designated members and special invitees from NACO and civil society. The list of attendees is given in Annexure I. Secretary & DG, NACO welcomed all members and summarized the planning process that had already been undertaken by NACO involving elaborate consultation with all stakeholders. The inputs from the thematic Working Group discussions, regional consultations and e-consultations have fed into the Strategy Paper for NACP-IV, a draft of which had been shared with all members to serve as a basis for discussions. The process of consultation has involved 623 individuals in 25 thematic working groups representing positive networks, communities, civil society, technical experts, SACS representatives and officials from other central government departments. In addition, regional consultations with civil society representatives and other stakeholders were also held, as were e-consultations. Sh. Ambrish Kumar, Advisor (Health) Planning Commission appreciated the strategy paper. He also mentioned that Planning Commission has laid down a strict timeline for submission by end of September. Secretary & DG invited Dr Sudhakar, Senior HIV/AIDS Advisor, to present an overview of the Strategy Paper for NACP IV. After the completion of the presentation, Shri J.V.R. Prasada Rao, former Secretary, MOHFW, appreciated that the strategy paper seems to have covered all the broad areas. He made observations on the following aspects:1. In the context of shrinking resources for HIV internationally, and the expected decline of external support for Indias HIV programme, he underscored the need to be strategic in identifying what the programme should do and what activities could be optimally assigned to others. He made specific mention of areas of education, labour and the Anganwadi workers, where the responsibilities of Ministries of HRD, MOLE and WCD, with reference to NACO IV need to be clearly delineated. 2. Shri Rao spoke about the constant challenge NACP has faced in varying levels of governance in state structures. There was an urgent need to improve their functioning. He suggested the option of having PD as a tenure post from the State Government, to ensure stability. He also mentioned the need to ensure robust coordination between the DAPCU and DM in the districts. 3. He mentioned that SIMU seemed to be missing and needs to be highlighted given its central role in NACP. 4. He suggested that the CST budget seems to be less and needs to be reviewed. 5. He also highlighted the need for a legal framework to tackle stigma and discrimination and made specific mention of the need to identify resources for sensitization of the police, so that an enabling environment could be created.

Dr. Jana, Chief Advisor, DMSC Kolkata, was of the opinion that the strategic plan was a replication of NACP-III. He felt that innovation was a cross cutting issue and should, perhaps not appear as an objective. Instead community mobilization needed to appear as an objective, as this was important for creating an enabling environment. He also stressed issue of sustainability and implementation of mechanisms for determining cost effectiveness and cost benefits of activities, for instance of M&E and capacity building activities. He questioned why Lab Services needed to 40

be part of NACP given that a large number of areas were being identified for integration with the larger health system. He reiterated the need to create an enabling environment given the unique nature of HIV.

Dr. Vijay Kumar, Ex-PD of TN SACS expressed the concern that state ownership is lacking in the programme and state contribution, as in the case of NRHM, should be implemented in NACP IV to address this issue. He also emphasized the need to mainstream at the state level and gave examples from Tamil Nadu. He spoke of the potential of integrating with Departments like Rural Development and PRIs. He also stressed the need to have a stringent process of NGO accreditation in NACP-IV. Dr. Bimal Charles, PD APAC, also felt the need for increasing state ownership by having a share of state contribution in the programme budget. He also spoke of the need of political commitment at the state level. He advised caution on integration because of stigma at service centers. Shri. MenukholJohn, Principal Secretary (Health) of Nagaland emphasized the need for flexible norms to meet state specific requirements. He appreciated the facility of mobile ICTCs for areas such as the North East and wondered if they could be used to deliver more services. He highlighted the need for pay parity at the field level between various centrally sponsored health schemes to ensure retention of staff. He mentioned the need for instructions being issued from the Centre to facilitate convergence between different departments at the state level. Shri Naresh Chandra Yadav, representative UP Positive Network, urged for effective steps for early detection, emphasized the need for social protection schemes and there dissemination at grassroots level. Ms. Anjali Gopalan, Social Activist, Naz Foundation, struck a note of caution on identifying the programme objectives too closely with the experience of Southern states and spoke of the need to focus on the North. She also felt the need to be careful with integration as stigma and discrimination may lead to a drop in HRGs accessing services. Instead, she felt the need to focus on integration of Care and Prevention services within the programme. Mr. Anand Grover, Director, Laywers Collective, was concerned on the high mortality rates which need greater analysis. He emphasized the need for the programme to build on community mobilization. In his opinion, NACP has always had an implicit rights based approach, which he felt should now be stated explicitly, where legal redress would be available in case of denial of services. He emphasized the need for testing on consent basis. On this issue of convergence with NRHM, he advocated adoption of a deliberate strategy that built on mutual strengths, rather than a generic approach. Mr. Shiv Kumar, CEO, SWASTHI, Bangalore, felt that it would be necessary to ensure that all issues are resolved at the level of sub-strategies. He voiced the need for an organisational framework to be mentioned in the document. He was also of the view that innovation and quality were cross cutting themes and should not be put in separate boxes. He wondered if the increasing concerns around migrants were the indicators of an emerging rural epidemic. He emphasized the need for social protection schemes for MARPS. He also wondered whether states specific plans were being considered. 41

Ms. Akhila Shivdas, Consultant, Centre for Advocacy and Research, felt that the experiential insight of the community was needed and mentioned that the regional civil society consultations had made a frontal appraisal of what worked and what did not in NACP III. She felt that the Strategy Paper contained everything but perhaps required better articulation. Ms. Radharani Mitra, Creative Director, BBC World Services Trust, drew attention to mass of BCC material created during NACPIII which should be used in the next phase also. She mentioned the potential of exploiting new technologies like internet and mobile telephony. The IEC plan should be 360o and not limited to mass media. She also spoke of the scope for using the increasing rural context of television for spreading the HIV message. She also mentioned the need to strengthen monitoring and evaluation of IEC activities Ms. Darshana Vyas, PATH Finder, Pune, felt that the successes of NACP III need to be articulated well. She felt the need to involve panchayats when moving to the village level. She also emphasized the need for state buy-in and of the need to create state-level resource centres. Dr. Paranjape, Director, NARI, emphasized the need for quality and strengthening monitoring systems. He felt the Lab Services division was essential and that NACP III has been a trendsetter in this regard. He mentioned the need for separate strategy for out-of-school children. He also emphasized the need for continued research on new regimens, new drugs and drug resistance. He felt that the projected budget was only marginally higher than NACP III and may not be adequate in view of inflation. Dr DCS Reddy, Consultant, WHO, highlighted the divergence of epidemic and the differentiation across states: While some states were showing a decline (and these were mainly high prevalence), others were showing an increase or stabilization. He was also of the opinion that the figures projected for ART seem to be on the lower side and advised a review of the model. He was cautious on integration and cited the example of Malaria. Ms. Anandi Yuvraj, Representative of Positive Network, emphasized the need for targets for food security, socio-economic support, and issues concerning children living with HIV. She also felt that the time have come for evaluation of IEC programmes beyond process indicators to determine, for example if they had succeeded in removing stigma. She also highlighted the need for better regulation for the private sector. She felt that the integration response was too medicalized. She argued for greater involvement of communities. Ms Kaushalya, Representative of Positive Network, felt that the budget for CST needed to be increased. She highlighted the needs of women, widows, and children and for social and rehabilitation measures. She also spoke of the need to improve drug adherence and scale up early diagnoses. She emphasized the need to avoid drug stock-outs and felt that community involvement was necessary for this. She agreed that sates need to make a contribution to ensure ownership. She also argued for provision of more services through mobile ICTCs. Mr. Ashok Rao Kavi, LGBT Right Activist, Mumbai, also felt that the ART budget needed to be increased. He lauded NACO for taking the initiative to identify TGs as a separate subset but felt that the strategy needed greater attention. He spoke of the need for partner notification and treatment. 42

Mr Raju, Coordinator, Indian Harm Reduction Network, also mentioned the need for strengthening community systems and increasing ownership. He advocated the need for improving pay of frontline workers. Dr Sundararaman, Director, AIDS Research Foundation of India, emphasized the need for a governance superstructure to make sure that integration actually works. He also felt the need for effective mechanisms to ensure greater accountability of SACS for service delivery. He drew attention to the need for examining sustainability of prevention activities, perhaps through a convergence of epidemiological intelligence and community intelligence. In his opinion, an emphasis on IDUs would be required and the North would be the battleground in NACP IV. He also mentioned that the budget of no- NACO actors should also be clearly specified and could be segmented into (i) critical NACO activities; (ii) cost sharing for activities with other Ministries; and, (iii) cost outsourcing for activities by other Ministries . He also spoke of the need of revisiting the goals statement to ensure that there was no undue emphasis on accelerating reversal in high prevalence states at the expense of controlling the emerging epidemic in other states. While speaking of the fatigue element, Dr Gita Bamzai, Prof. & Head, Department of Communication Research, Indian Institute of Mass Communication, mentioned the need for NACP IV to say something new. She said that analysis of gaps of NACP III should serve as learning. She emphasized the need for advocacy with NRHM and felt that integration should be approached with caution as quality would remain a major issue. She suggested that the mechanism of VHSCs and ASHA and Anganwadi workers should be used. Ms Aradhana Johri, AS, NACO while responding to the main points clarified that innovation had been identified as a separate objective as this was a priority in the framework of World Bank funding. She agreed that it was a cross cutting issue. She also endorsed the view voiced by several members of the need for state flexibility as no one size fits for all. She mentioned that the recategorization of districts would help in tailoring responses to local needs and in targeting vulnerabilities. She felt that one of the challenges for NACP IV would be to place HIV on top of the agenda in hitherto low prevalence states which are less well governed states and where the epidemic is showing an increase. On the issue of integration, she drew attention to the fact that HIV issues had low priority for NRHM, and of the need for dealing with stigma issues while integrating. She also emphasized that community involvement had been a strength of NACP III. However, community empowerment is visible in southern states but is seriously lacking in northern States which are an emerging concern in NACP IV. With regard to the private sector, she shared the experiences of NACP III and stated that attention would focus on private sector involvement for PPTCT, for capacity building of the private sector for tackling irrational ART regimens, and involving private sector for surveillance activities. She also drew attention to the Prime Ministers statement during the Convention of Zila Parishad Chairpersons and Mayors on HIV wherein he had emphasized that the response to HIV must be multi-sectoral and other Ministries and Departments must ensure that marginalized populations infected and affected by HIV/AIDS are also extended benefits of their schemes. She requested Advisor, Planning Commission to ensure that social protection for High risk Groups and HIV positive persons is adequately reflected in budgets of related Ministries. She also added that in order to capture state specific inputs, state representatives were included as members of all working groups and five regional civil society / multi-stakeholder consultations were also held in all regions of the country.

43

Secy. & DG thanked all members for their time and the fruitful discussions on the draft, the inputs from which would be incorporated in the final document for the Planning Commission. Some members requested a clarification if the amended draft would be shared again before finalization. He explained that the tight time schedule may not make that possible.

44

Annexure I Meeting on Working Group on AIDS Control Programme by Planning Commission List of Participants Sl.No. 1 2 3 4 5 Name ShriSayanChatterjee ShriJ.V.R.PrasadaRao Ms.AradhanaJohri ShriAmbrishKumar Dr.BimalCharles Designation Secretary&DG FormerSecretary(MoHFW) AS Advisor(Health) ProjectDirector Address NACO NACO PlanningCommission APAC,VoluntaryHealthServices, Adayar,T.T.T.IPost,Chennai 600113 DurbarMahilaSamanwaya Committee(DMSC),12/5 NilmoniMitraStreet,Kolkatta 700006 NationalAIDSResearchInstitute (NARI),73,GBlock,MIDC Bhosari,Pune411026 AIDSResearchFoundationof India,20/2BagirathyAmmal Street,TNagar,Chennai600017 WHO,537,AWing,Nirman Bhawan,MaulanaAzadRoad, NewDelhi110011 DepartmentofCommunication Research,IndianInstituteof MassCommunication,JNUNew Campus,ArunaAsifAliRoad, NewDelhi110067 BBCWorldServiceTrust,E21 HauzKhasMarket,NewDelhi 110016 Mumbai LawyersCollectiveHIV/AIDSin India,7/10,BatawalaBuilding, HornimanCircle,Mumbai 400023 NazFoundation,A86,Eastof KailashNewDelhi110065 CentreforAdvocacy&Research, NewDelhi

Dr.SmarajitJana

ChiefAdvisor

7 8

Ms.Kaushalya Dr.R.Paranjape

RepofPLHANetwork Director

9 10

Dr.Sudhakar Dr.S.Sundararaman

SeniorHIV/AIDSAdvisor Director

11

Dr.DCSReddy

Consultant

12

Dr.GitaBamezai

Prof.&Head CommunicationResearch

13

RadharaniMitra

CreativeDirector

14 15

ShriAshokRaoKavi Mr.AnandGrover

LGBTRightActivist Director

16 17

Ms.AnjaliGopalan Ms.AkhilaSivadas

45

Sl.No. 18 19 20 21 22

Name Dr.KurienThomas Mr.VijayKumar Shri.MenukholJohn ShivKumar Dr.DarshanaVyas

Designation SpecialSecretary PrincipalSecretary CEO

Address CMCVellore DeptofHealth&FamilyWelfare, Govt.ofTamilNadu H&FW,Nagaland SWASTHI,Bangalore PATHFinder,CASPBhavan3rd Floor,132/2,SurveyNo.132/2, PlotNo3,PashanBanerLind Road,Pune411021 UPPositiveNetwork NACO NACO NACO NACO NACO NACO NACO NACO NACO NACO

23 24 25 26 27 28 29 30 31 32 33

Mr.NareshChandraYadav Dr.Venkatesh Mr.KanwaldeepSingh Mr.Rajagopal Dr.S.Khaparde Dr.Mohd.Shaukat Dr.SandhyaKabra Dr.NeerajDhingra Dr.R.S.Gupta Mr.Krishnakumar Mr.Manilal

DDG(M&E) Director(Finance) Director(Admin) DDG(STI) ADG(CST) ADG(LS) ADG(TI) DDG NPO(Fin) PO

46

ReportoftheWorking GrouponAYUSHforthe 12thFiveYearPlan (201217)

WG7: AYUSH

WG-7 No. 2(6)2010-H&FW Government of India Planning Commission Yojana Bhavan, Sansad Marg New Delhi 110001
Dated 24th June 2011

OFFICE MEMORANDUM

Subject: Constitution of working group on AYUSH for the Twelfth Five Year Plan (2012-2017)
With a view to formulate the Twelfth Five Year Plan (2012-2017) for the Health Sector, it has been decided to constitute a Working Group on AYUSH under the Chairmanship of Shri Anil Kumar, Secretary, Department of AYUSH, Government of India. The composition and the terms of reference of the Working group would be as follows: 1. 2. 3. Shri Anil Kumar, Secretary, Department of AYUSH, Government of India Dr. R.H. Singh, Prof. Emeritus, Banaras Hindu University, Varanasi Dr. Bhushan Patwardhan, Director, Institute of Ayurveda and Integrative Medicine, Foundation for Revitalization of Local Health Tradition (FRLHT), Bangalore & Vice-Chancellor, Symbiosis International University, Pune Shri Ranjit Roy Chaudhary, Ex- DDG, Indian Council of Medical Research (ICMR), New Delhi Chairperson Member Member

4. 5.

Member Member

Dr. G.P. Dubey, Retd. Dean, Faculty of Ayurveda, Banaras Hindu University, Varanasi Homoeopathy 6. .Dr.V.K.Gupta, Former Principal, Nehru Homoeopathic Medical College, New Delhi.
1

Member

7. 8.

Dr.Eswara Das, Former Director, National Institute of Homoeopathy, New Delhi. Dr Issac Mathai, Soukya International Holistic Health Center, Bangalore.

Member Member

Unani 9. 10. Hakim Khaleefatullah, Vice-President, CCIM, Chennai, Member

Dr. Mohammad Khalid Siddiqui, Retired Director General, CCRUM, Member Faridabad-

Ayurveda 11. Shri Ashok D.B.Vaidya, Research Director, Kasturba Health Society, ICMR Advanced Centre of Reverse PharmacologyMumbai Dr. C.Katiyar,Head, Health Care Research, Dabur R & D Center, , Sahibabad , Gaziabiad Dr. M.S.Baghel, Director, IPGT&RA, Jamnagar, Institute for Post Graduate Teaching & Research in Ayurveda, Gujarat Ayurved University, Jamnagar-.Gujarat Member

12. 13.

Member Member

Siddha 14. 15.

Dr.T.Thirunarayanan, Director, Centre for Traditional Medicine and Research, Chennai Dr. G. Sivaraman, Director, Arogya Health CareChennai

Member Member

Sowa-Rigpa 16. Prof. Geshe Ngawang Samten (Vice Chancellor), Central Institute of Higher Tibetan Studies (Deemed University), Sarnath, Varanasi Dr. P. Gurmet ,Research Officer Incharge Sowa Rigpa Research Centre, Leh-194101 Member

17.

Member

Director Generals/Directors of National Institutes 18. 20. 22. 19. Dr. Ramesh Babu Devalla, Director General, Central Council for Research in Ayurveda & Siddha, New Delhi 21. Dr. Alok Kumar, Director General Incharge, Central Council for Research in Homoeopathy, New Delhi 23. Prof. Shakir Jamil, Director General, Central Council for Research in Unani Medicine, New Delhi
2

Member Member Member

Dr. B.T.C.Murthy, Director, Central Council for Research in Yoga & Naturopathy, Janakpuri,New Delhi Dr. I. Basavaraddi, Director, Morarji Desai National Institute of Yoga, New Delhi Dr.V.V.Prasad, Director, Rashtriya Ayurved Vidyapeeth, New Delhi Smt. S.K.Baijal, Director (Health), Planning Commission Dr. Rakesh Sarwal, Joint Secretary , Department of AYUSH, New Delhi Dr. D.D.Sharma, Joint Secretary, Department of AYUSH, New Delhi

Member Member Member Member Member Member Secretary

Terms of Reference
1. To review the coverage for mainstreaming of AYUSH under NRHM and its areas of strengths in the delivery of health care. To review infrastructure of existing AYUSH hospitals & Dispensaries in Govt. Sector / Public Sector. To review availability of trained paramedical staff like AYUSH nurses, Pharmacists, Panchkarma masseurs etc. To review fast depletion of medicinal plan resources in forest and wild areas: address issue of non-availability of good quality of raw materials To review lacks of support price of support for Medicinal Plants through appropriate policy To review the restructuring and strengthening the Research Councils and National Research Institute To review infrastructure and training institutes for Nursing Pharmacists & other paramedics in AYUSH To review measures for the generation of awareness within the country and outside the country.

2.

3.

4.

5.

6.

7.

8.

9.

To review the progress achieved in the 11th Plan in the areas of infrastructure, production of high quality drugs, co-locate facilities under NRHM, quality of education and research & development To project financial physical requirements for implementation of these programmes during the 12th Five Year Plan. To deliberate and give recommendations on any other matter relevant to the topic. Deliberate and give recommendations on any other matter relevant to the topic. The Chairman may constitute various Specialist Groups/ Sub-groups/ task forces etc. as considered necessary and co-opt other members to the Working Group for specific inputs. Working Group will keep in focus the Approach paper to the 12th Five Year Plan and monitor able goals, while making recommendations. Efforts must be made to co-opt members from weaker sections especially Scheduled Castes, Scheduled Tribes and minorities working at the field level. The expenditure towards TA/DA in connection with the meetings of the Working group in respect of the official members will be borne by their respective Ministry / Department. The expenditure towards TA/DA of the non-official Working group members would be met by the Planning Commission as admissible to the class 1 officers of the Government of India. The Working group would submit its draft report by 31st July, 2011and final report by 31st August, 2011. (Ambrish Kumar) Adviser (Health) Copy to: 1. Chairman, all Members, Member Secretary of the Working Group 2. PS to Deputy Chairman, Planning Commission 3. PS to Minister of State (Planning) 4. PS to all Members, Planning Commission 5. PS to Member Secretary, Planning Commission 6. All Principal Advisers / Sr. Advisers / Advisers / HODs, Planning Commission 7. Director (PC), Planning Commission 8. Administration (General I) and (General II), Planning Commission 10. Accounts I Branch, Planning Commission 11. Information Officer, Planning Commission 12. Library, Planning Commission (Ambrish Kumar) Adviser (Health)
4

10.

11. 12. 13.

14.

15.

16.

17.

Report of Working Group on AYUSH for th 12 Five-Year Plan (2012-17)

Department of AYUSH Ministry of Health & Family Welfare Government of India

August 2011

Report of the Working Group on AYUSH for 12th Five-Year Plan Preamble
The strategic role of AYUSH to meet health needs as part of medical pluralism was visualized at the beginning of 11th Plan and has been found to be equally relevant while formulating the 12th Plan on AYUSH. Accordingly, it is emphasized in the discussion note received from the Planning Commission to evolve interventions and innovations that could help realization of AYUSH potential with integrative approaches in health care. As better health is not only about curative care but also about better prevention, the need of effective contribution from AYUSH systems, which are by and large preventive and promotive health systems, is thought of with strategic interventions and programmatic utilization of AYUSH among communities at national and global levels. With the perpetual growth of demand of improvement in various aspects of AYUSH, Government response in allocating financial outlay for AYUSH has grown phenomenally over the plan periods. In the 11th Five year Plan (2007-12) it is to the tune of Rs. 3988 crore, which is the highest ever since the Dept. of AYUSH came in to being in 1995. Through various Centrally Sponsored and Central Sector Schemes implemented during the last three Plans, a lot of financial support has been provided to AYUSH sector for strengthening of education & industrial infrastructure, capacity building of institutions & workforce, quality control & strengthening of regulatory mechanism and awareness building. These schemes appear to have succeeded in bridging the gaps to certain extent and need to be continued in 12th Plan to build up marked quality difference, outreach and outcomes in strengthening the mutually inclusive growth of various AYUSH facets for health benefits of the people. Adequate implementation of the schemes, predominantly on account of huge size and needs of the AYUSH sector and limitations of funding provisions, has to be ensured to achieve value outcomes with effective strategies and monitoring mechanisms. In the emerging scenario of lifestyle and psychosomatic diseases aiming at more and more people to adopt AYUSH way of living and health care, it is highly desirable for the Government to devise the initiatives for 12th Plan in such a way as are structured with focused objectives & implementation plans for specific outcomes and are supported with effective mechanisms for appraisal, screening, monitoring and evaluation of projects with regard to their likely impact in the AYUSH sector on the basis of specified indicators and clearly articulated transparent criteria. While doing so the pertinent point to note is that image & utility of AYUSH sector is significantly influenced by private and voluntary sector initiatives particularly in the wake of the fact that about 75% of the AYUSH institutes belong to private players and the industry & other non-governmental institutions has a bigger role in AYUSH growth & development. Moreover, peoples out of pocket spending on health also amounts to more than 70% of the total health expenditure. It would, therefore, be befitting to allocate significant proportion of Plan outlay for supporting activities, creativities and innovations in private sector, preferably through PPP mode. In view of the current needs of AYUSH sector and catapult it in to a vibrant area for government investments, it is considered that the hallmark of supporting AYSUH activities in 12th Plan should be based on Health System approach, which aims at developing effective regulation & governance, financing, human resources, service delivery, health technology and health information. AYUSH health systems being important component of the health system are equally responsible to meet the societal health needs, their functions need to be mapped, 6

strengths assessed and weaknesses addressed for improved implementation and monitoring & evaluation of goals.

II.

Working Group and Terms of Reference

The details of the Working Group on AYUSH set up by the Planning Commission and its Terms of Reference are annexed.

III.

Strategic direction for the 12th Plan

India has a strong foundation and a rich heritage of AYUSH systems which are widely recognised for their holistic approach to health and capability for meeting emerging health challenges. Medical pluralism in the country provides people options to avail treatments of their choice and help bridging the gaps in health care. Approach Paper of Planning Commission for the 12th Plan envisages that better health is not only about curative care but also about better prevention from diseases. Preventive health care and health promotion are the fortes with which AYUSH systems were visualised to operate at the start of 11th Plan and still hold equal relevance while the 12th Plan (2012-2017) is being formulated. Strategic interventions and programs, therefore, need to be planned keeping in mind the health sector trends and accordingly equipping the AYUSH sector to achieve tangible health outcomes. The mandate of AYUSH Department encompasses seven key areas of activity and intervention, namely AYUSH services, Medicinal Plants, Research & Development, Human Resource Development, International Collaboration, IEC and Drug administration. The prime functions of the Department are aimed at improving health delivery mechanism in terms of quality & outreach, enforcement of educational standards, quality assurance & effective regulation of drugs, fostering collaborative & interdisciplinary AYUSH research of contemporary relevance, awareness building both within and outside the country, mainstreaming of AYUSH in health delivery system and development of properly trained and professionally competent AYUSH workforce. Department of AYUSH intends to ensure that more and more people adopt AYUSH way of healthy living, disease prevention and cure of diseases and AYUSH systems are positioned with optimal quality & standards of education, research and health care services. Thrust is proposed to be given on the following areas in the 12th Plan-

i) ii) iii) iv) v)

Availability of AYUSH services in 100% of districts through NABH accredited hospitals; Improving quality of education & training and developing Centres of Excellence in government and private sectors; Promoting quality research to validate the efficacy and safety of remedies; Ensuring availability and conservation of medicinal plants; Accelerating Pharmacopeial work; AYUSH

vi) vii) viii)

Ensuring availability of quality drugs; Positioning AYUSH national institutes as leaders in SAARC region; Propagation of AYUSH for global acceptance as systems of medicine

It is, therefore, carefully attempted to specify the scale for the implementation of proposed schemes compatible with the expected results and targeted deliverables and mobilize resources accordingly towards niche areas that demand proportionately adequate chunk of allocation, detailed resource projection is provided in Annexure-I

IV.

Justification for enhancing allocation under Ongoing Schemes

The ongoing schemes of 11th Plan comprise of eleven Central Sector Schemes with allocation of Rs. 2053 crore and three Centrally Sponsored Schemes with allocation of Rs. 1935 crore. The total allocation amounted to Rs. 3988 crore. The 38th Report of the Public Accounts Committee 2006-07) has seriously pointed out that the share of AYUSH in the total health plan at the central level has been only 2% in-spite of the policy pronouncement of raising AYUSH share to 10% with designated growth of 5% in every Five-Year Plan. Inadequate allocation for AYUSH has been considered by PAC the main reason for not achieving the envisaged objectives. Accordingly, the 12th Plan allocation for Central and Centrally Sponsored Schemes is proposed to be enhanced almost by 7 times and 17 times respectively, including the transfer of Rs. 10000 crore from NRHM Flexipool for implementation of state AYUSH PIPs. All this has led to total projected allocation of Rs.47535.55 crore (about 12 time-hike from 11th Plan allocation) to pave for effective implementation of projects in strategic thrust areas identified above and to step up the process of mainstreaming of AYUSH. Necessary updating and revision of the norms, without making any structural change or change in the funding pattern of the schemes, will be done to ensure that the objectives of the schemes are adequately met, project proposals in targeted thrust areas are properly funded and the outcomes happen to be of long term value for the AYUSH sector.

(A)
(1)

Central Sector Schemes

System strengthening: The ongoing six schemes namely, Strengthening of Department of AYUSH, Statutory Institutions, Hospitals & Dispensaries, Strengthening of Pharmacopoeial Laboratories, IEC and AYUSH & Public Health function under the head of System Strengthening. In the 12th Plan (2012-17) a provision of Rs. 1409 crore has been proposed against the 11th Plan outlay of Rs. 282.75 crore. Sub-scheme wise details and justification are as underStrengthening of Department of AYUSH This scheme in the 11th Plan has allocation of Rs. 47 Crore for engagement & maintenance of Secretariat Social Services in the Department of AYUSH to run the administration and for supporting Pharmacopeia Committees of Ayurveda, Siddha and Unani and strengthening of Pharmacopeia Commission of Indian Medicine.

a)

The major achievements during the 11th Plan are Three national institutes and a Pharmacopoeia Commission of Indian Medicine have been/are being set up. Publication of pharmacopeial standards and Standard Operating Procedures (SOPs) of 152 Ayurvedic formulations. Publication of pharmacopeial monographs of 101 single plant drugs and 21 minerals. Publication of macro & microscopic and TLC atlases of 172 drugs. Development of eight community herbal monographs in the format given by European Medicines Evaluation Agency (EMEA) for submission to EU.

Midterm appraisal of the scheme implementation pointed out the need to adequately strengthen the administrative framework and construction of a separate building for the Deptt. of AYUSH and to accelerate the work of laying down pharmacopieal standards of Ayurveda, Siddha and Unani drugs through Pharrmacopeia Commission. The proposals for 12th Plan with needed allocation under this scheme aim at Strengthening Secretariat Social Services in the Department of AYUSH by engaging need-based more technical & administrative staff and filling up the vacant posts to facilitate smooth disposal of administrative & technical work and hiring/construction of new building for the Department in consideration of its enhanced mandate, responsibilities and sphere of interface and administration (Rs. 100 Cr.). Augmenting pharmacopeia work to develop 1000 monographs and strengthening Pharmacopeia Commission & associated laboratories to accelerate the work of standardization & quality parameters of ASU drugs as per global requirements & acceptability, to take up development of monographs of such medicinal plants as are widely used in folklore/tribal medicine but not documented in ASU literature and to work on the lines of other Pharmacopoiea Commissions of the world (Rs. 50 crore). Providing support to build up the initiative of safety monitoring of Ayurveda, Siddha and Unani drugs under the pharmacovigilance system, which was introduced in the country during the 11th Plan period, by designating one National Pharmacovigilance Resource Centre, 8 regional centres and 30 peripheral centres to develop the culture of reporting adverse drug reactions of ASU drugs (Rs. 15 crore). Setting up National AYUSH Library & Archives under the Department of AYUSH for collecting, showcasing and dissemination of AYUSH literary resources & materials and publication of AYUSH newsletter, journals etc. - Rs. 50 cr.

The increased allocation of Rs. 215 crore proposed for 12th Plan amounts to 4.57 times hike over the 11th Plan allocation.

b)

Statutory Institutions The sub-scheme Statutory Institutions in the 11th Plan comprise of three components under which provision of Rs. 2.95 Crore is made for granting financial support to the Regulatory Bodies- Central Council of Indian Medicine (CCIM), Central Council of Homeopathy (CCH) and Pharmacy Council of Indian Medicine & Homeopathy. The salient achievements during 11th Plan are Revision of course curricula. Publication of Central Register of Homeopathy Organisation of twelve workshops on quality education issues and revision of course curricula including the one for principles of postgraduate colleges.

It is proposed to continue the first two components of the scheme in the 12th Plan with almost 33% enhancement of the allocation amounting to Rs. 4.00 crore only and to delete the third component of setting up Central Pharmacy Council for Indian Medicine & Homeopathy, which could not materialize in the 11th Plan. The projected allocation is required to match the need of strengthening infrastructural facilities and developmental activities in the Regulatory Bodies, whose sphere of regulating education and practice of Ayurveda, Siddha, Unani and Homeopathy and updating of central registers of practitioners has increased significantly after the opening of new colleges and increased turnover of practitioners. c) Hospitals & Dispensaries Under this scheme four components are provided in the 11th Plan- (i) All India Institute of Ayurveda (AIIA), New Delhi (Rs. 150 Crore), (ii) CGHS expansion of AYUSH dispensaries (Rs. 6.30 Crore), (iii) Advanced Ayurvedic Centre for Mental Health in NIMHANS, Bangalore (nil allocation) and (iv) CGHS Ayurveda Hospital, New Delhi (Rs. 6.50 Crore). 11th Plan allocation for them amounts to Rs. 162.80 crore excluding that of the third component as it ceased to be supported from 10th Plan onwards. In the 11th Plan establishment of AIIA has been taken up vigorously, construction of its buildings started since 2009-10, services of Director, personal staff and Clinical Consultants have been engaged, OPD facility started and several posts got created. It was noted that the AYUSH dispensaries opened in CGHS could not be made functional due to shortage of Medical Officers & Paramedical staff and non-creation of posts as well. Mid-term appraisal found the AIIA project on track and recommended necessary action for creation of posts on priority basis for AYUSH dispensaries in CGHS as done for NRHM. Allocation sought for this scheme in the 12th Plan amounts to Rs. 450 crore, which would be used for AIIA to complete the remaining capital works and make the institute functional in academic and clinical departments (Rs. 300 Crore). Taking up expansion and strengthening of AYUSH under CGHS by creating dedicated administrative set up with provision of Additional Director, CGHS 10

(AYUSH), opening new dispensaries/hospitals in various CGHS-covered locations and up-gradation of existing CGHS Ayurveda Hospital, New Delhi (Rs. 150 cr.). The third component of the scheme- Advanced Ayurvedic Centre for Mental Health in NIMHANS being part of CCRAS will be supported in 12th Plan through the relevant scheme and the same will be scratched from the instant scheme.

d)

Strengthening of Pharmacopoieal Laboratories This scheme is meant for supporting Pharmacopoeial Laboratory of Indian Medicine (PLIM)-Ghaziabad, Homeopathic Pharmacopoeia Laboratory (HPL) Ghaziabad and Public Sector Drug Manufacturing UndertakingIndian Medicines Pharmaceutical Corporation Limited (IMPCL), Mohan (Uttrakhand). The 11th Plan allocation for the scheme is to the tune of Rs. 25 crore and it is intended to continue all the three components in 12th Plan with enhanced allocation of Rs 105 crore (4.2 times hike) to augment standards development, quality control and production of ASU&H drugs with standard quality. 11th Plan achievements of significance until March 2011 include Development of identity and quality standards of 256 ASU & 92 homeopathic drugs, quality testing of 1342 ASU and 3709 homeopathic samples and conduct of 31 workshops/training programs by the Pharmacopoeia Laboratories. Implementation of detailed capacity enhancement project of IMPCL worth Rs. 33.86 crore.

Midterm appraisal of the scheme in 11th Plan realised the need to accelerate the work of laying down pharmacopoieal standards & quality control and recommended for IMPCL additional share capital to facilitate modernization and introduction of new technology to enhance quality production of drugs and turnover in business. Accordingly, allocation of Rs. 105 crore is sought in the 12th Plan under the scheme with provision of Rs. 50 crore for PLIM, Rs 5.00 crore for HPL and Rs. 50 crore for IMPCL to facilitate achievement of higher targets set for standardization & quality testing of drugs and enhance the production capacity of IMPCL to meet with entrepreneurship approach the increased supply requirements of the states for Ayurveda and Unani medicines under NRHM.

e)

Information. Education and Communication (IEC) The scheme on IEC provides for awareness building and public education about the AYUSH systems and their potential strength areas. It avails allocation of Rs. 25 crore only in the 11th Plan, with which Department of AYUSH has been able to organise/support/participate in Arogya fairs and health exhibitions and launch multimedia campaigns for popularisation of AYUSH. The achievements include 30 National and State level Arogya melas and 23 multi-media campaigns on individual and collective strength areas of AYUSH. 11

Development and nationwide dissemination of publicity materials in different languages.

During the mid-term appraisal of the scheme implementation in 11th Plan, it was decided to increase the funding pattern for state Arogyas and expand the schemedomain by collaborating with States in carrying out IEC activities including setting up of IEC cells and supporting preparation & translation of publicity materials/documentaries/short films in different languages. Concept of developing AYUSH cities, where quality AYUSH facilities exist, as AYUSH destinations by providing financial support to strengthen the available infrastructure was also emphasized. In view of the need for developing IEC cells and awareness-building initiatives in collaboration with the states and to introduce AYUSH elements in school curricula & health program, for preparation of customised AYUSH information materials for mass distribution and for organising annual interactive meets with scientists and medical fraternity for propagation of AYUSH, it is proposed to have an allocation of Rs. 300 crore in the 12th Plan. The projected allocation amounts 12 times more from the corresponding 11th plan allocation to meet the costs of the anticipated volume of IEC work with diverse range of advocacy activities. Engaging a professional agency on specific terms of reference and targets for strategizing, planning and coordination of IEC activities and development of advocacy materials is also intended under this scheme.

f)

AYUSH and Public Health This scheme is aimed at supporting innovative proposals of government and non-government organisations to promote AYUSH interventions in public health care and encourage AYUSH practitioners in taking up public health programs on project-basis at district, taluka or block level. 11th Plan provided allocation of Rs. 20 crore for such projects. 28 projects have been supported through scheme till March 2011 and 10 projects are targeted in 2011-2011. In order to support more such projects in the 12th Plan with focused deliverables and for exploring and implementing strategic AYUSH interventions of public health importance through the relevant public health programs/public health organisations, a scaled up allocation of Rs 335 crore is proposed for the 12th Plan. The targeted outreach, number of proposals and pilot projects with AYUSH interventions will be determined accordingly to have specific health coverage & outcomes among the communities like for food supplementation for malnutrition management, anaemia control, RCH services, AYUSH-based public health education etc. It is intended under this scheme to bring about two specific interventionsAYUSH Gram and AYUSH Telemedicine in the 12th Plan for expanding the access to AYUSH health care and facilitate people for adopting AYUSH-based lifestyle for healthy living and disease-prevention. The funding for these purposes is in-built in the proposed allocation of Rs. Rs 335 crore and concept details are given in subsequent pages under the head New Components/Schemes.

(2)

Educational Institutions: Twelve sub-schemes fall under the head Educational Institutions and these are meant to support the eleven institutions working under the 12

administrative control of Department of AYUSH and for development of AYUSH Centres of Excellence in non-governmental/private sector in the area of AYUSH education, research, drug development, folk medicine etc. Amount of Rs. 100 cr. was allocated for these schemes in the 11th Plan. Sub-scheme-wise present allocation and achievements in the 11th Plan period are reported as underi) IPGTRA, Jamnagar (Rs. 10 crore): 179 postgraduates and 68 Ph.Ds of Ayurveda passed out, organised 21 health check-up camps for school children, 42 medical camps, 8 workshops, 36 CME/Re-orientation Training programs and 25 pharmacovigilance trainings, under consideration to be designated as WHO Collaborating Centre for Traditional Medicine. NIA, Jaipur (Rs. 49.18 crore): Total turnover of 318 graduates, 332 postgraduates, 33 Ph.Ds and 110 diploma holders, Ayurvedic treatment provided to 1638330 patients in the OPD and 165977 patients hospitalised, organised 115 mobile camps, Panchakarma facilities expanded, RAV, New Delhi (Rs. 5 crore): Training of 717 Ayurveda students under GuruShishya Parampara, 7 workshops, 10 publications and nationwide implementation & monitoring of CME/Re-orientation Training Programs. NIS, Chennai (Rs 20 crore): 168 scholars admitted for post-graduation in Siddha, 13.54 outdoor patients and 1.36 lakh indoor patients given Siddha treatment. NIH, Kolkata (Rs. 45 crore): 258 graduates & 81 postgraduates of Homeopathy passed out, three PG departments added, 20 CME/ROTPs conducted, 9.76 lakh outdoor patients and 5297 indoor patients treated with homeopathy, hospitals bed capacity increased, 33 posts created NIUM, Bangalore (Rs. 25 crore): 106 scholars admitted for post-graduation in Unani Medicine, Unani treatment of 1.81 lakh outdoor patients and 39547 indoor patients, 10 CME/Re-orientation Training programs. MDNIY, New Delhi (Rs. 20 crore): 413 students admitted for diploma course in Yoga Science, Diploma Course for medicos started, conducted certificate course for 9 batches, 42 Foundation courses, 230 camps, 5 orientation training programs, started school health program in 385 districts and under consideration for the designation of WHO Collaborating Centre in Traditional Medicine. NIN, Pune (Rs. 13.5 crore): 5963 Naturopathy programs, 956 treatment cum awareness programs, 16 Re-orientation training programs, 9240 Yoga training programs and 5 food fairs conducted, 1.97 lakh patients attended institutes OPD for naturopathic treatment. NEIAH, Shillong (Rs. 81 crore): Cabinet approval taken, Consultant for project implementation appointed, Director and essential staff appointed, OPD services and construction work started.

ii)

iii)

iv)

v)

vi)

vii)

viii)

ix)

13

x)

NEIFM, Passighat (Rs. 41 crore): Cabinet approval taken, Project Management Consultant appointed and Rules-Regulations & Bye-laws are being finalised, construction of buildings about to start. Centres of Excellence (Rs. 100 crore): 30 projects for upgrading infrastructure & functioning of private AYUSH centres supported.

xi)

These schemes except Vishwayatan Yogashram, New Delhi will be continued in the 12th Plan and it is intended to add up the following activities with projected allocation for each up-gradation of National Institutes with modernised capital works, scientific equipment & machinery and IT gadgets for strengthening of hospitals to and laboratories and appointment of more technical and non-technical staff required for increased work loadIPGTRA, Jamnagar (Rs. 92 crore), NIA, Jaipur (Rs. 128 crore), NIS, Chennai (Rs. 116 crore), NIH, Kolkata (Rs. 110 crore), NIUM, Bangalore(Rs. 92 crore), NIN, Pune (Rs. 50 crore), NEIAH, Shillong (Rs. 100 crore), NEIFM, Passighat (Rs. 80 crore) and up-gradation of Rashtriya Ayurved Vidyapeeth as National Training Institute (like NIHFW) to oversee and implement all AYUSH-related trainings, CME and capacity building programs (Rs. 218 crore).

Strengthening Yoga hospital & laboratory of Morarji Desai National Institute of Yoga, and setting up under its aegis 400 District Yoga Wellness Centres and continuation of existing 200 District Yoga Centres (Rs. 178.05 crore).

Development of non-governmental Centres of Excellence in the states by providing support to enable well-equipped facilities for scientific learning, clinical research, drug development, instrumentation and technology development (Rs. 3262.50 crore). Development of referral hospitals in National Institutes, details given under the head New Components/Schemes (Rs. 820 crore)

The total plan outlay of Rs. 5246.55 crore for the above activities is sought accordingly, which is 12.78 times higher than the 11th plan provision of Rs. 410.68 crore.

(3)

Research & Development including Medicinal Plants Under this head ten sub-schemes mainly pertaining to AYUSH research & studies and medicinal plants are provided with total outlay of Rs. 719.57 crore in the 11th Plan. Central AYUSH Research Councils and National Medicinal Plants Board (NMPB) are funded through this scheme. Individual sub-scheme wise allocation and achievements in 11th Plan are as under -

14

a) Central Council for Research in Ayurveda & Siddha: 23 clinical research projects, safety studies on 5 drugs, 154 villages covered under Tribal Health Care Research Program, 253 surveys of medicinal plants, standardization of 193 single drugs & 139 formulations, 32 publications, 17 Ayurveda drugs developed under the feasibility study of introducing Ayurveda in RCH program and screening of 7.62 lakh patients done for safety monitoring of Ayurveda & Siddha drugs under the pharmacovigilance system. b) Central Council for Research in Unani Medicine: Developed 13 Unani drugs, validation studies on Unani drugs for chronic & common ailments, SOPs and pharmacopieal standards of 263 compound formulations & 150 single drugs developed, chemistry studies on 8 medicinal plants, safety evaluation of 8 drugs, 20 surveys on medicinal plants, 21 farmers meets on cultivation & marketing of medicinal plants, published 4 monographs & reprinting of 28 rare books, translation of eight books, 12 seminars/workshops and 168 research papers published. c) Central Council for Research in Yoga & Naturopathy: 44 research projects (6 literary and 38 others) undertaken, 136 institutions supported for promotion of Yoga & Naturopathy, organised 4 seminars/workshops, grant-in-aid provided to 66 seminars/workshops, 14 newsletters published, 15 events conducted under national campaign on Yoga and construction of two Central Research Institutes of Yoga started. d) Central Council for Research in Homeopathy: 15 research studies conducted; 55 research articles & 25 drug-proving studies published; drug-proving studies completed on 14 homeopathic drugs; clinical verification of 34 drugs completed; 6 Fundamental Research studies completed; brought out 24 books, 27 handouts, homeopathy research journals & newsletters; 29 health melas/exhibitions; 19 seminars/workshops; 10 CME programs and massive nation-wide campaign on Homeopathy for mother and child care. e) Central Council for Research in Siddha: The Central Council for Research in Siddha has been created in 2010-11 with bifurcation of CCRAS and annual budget allocation of Rs. 6 crore provided for 2011-12; the achievements of the Council include completion of 3 clinical studies and 3 observational studies on clinical safety of selected Siddha mineral/metallic medicines; completion of 26 pharmacological and 39 pharmacognostic studies; and publication of 10 scientific documents. f) Central Councils Combined Building Complex: Renovation and modernization of the building has been done.

g) Extramural Research Projects through Research institutions etc: 65 projects completed and 96 other projects have been supported. h) Patent Cell for ISM&H intellectual property rights: Transcription of 61359 ASU formulations and 1195 Yoga postures done in patent compatible format, access agreement signed with 5 international patent offices. i) Survey on Usage & Acceptability of ISM&H systems: National Sample Survey Organisation (NSSO) has been finalised to take up the survey on AYUSH-based health seeking behaviour of people and extent of usage among communities. 15

j)

National Medicinal Plants Board (Rs. 360.07 crore): Support was provided to 39 projects about medicinal plants cultivation, 86 projects on Storage Godowns & JFMCs, for conservation of medicinal plants on 26158 hectares of land, 67 R&D projects, 85 capacity building & IEC activities and for setting up 3123 school/home herbal gardens.

During the mid-term appraisal it was felt necessary to increase the outlay of Research Councils because of revision of salaries, filling up of vacant posts, creation of new posts and also to undertake research activities in the thrust areas, where more funds would be required. Research Councils have also been entrusted with several new initiatives for scientific development of AYUSH on the basis of recommendations of various Committees and forums. For medicinal plants sector, it was emphasized to provide greater focus to set up Medicinal Plants Conservation Areas (MPCAs), support Joint Forest Management Committees (JFMCs)/Panchayats for value addition, warehousing and marketing and to encourage ex-situ conservation of prioritized species of medicinal plants. Extension of support for management, R&D, training/capacity building and promotional activities in the area of medicinal plants was also recommended. Considering the limitations of the intramural and extramural research programs and the need of supporting innovative proposals and opening up networked research activities, it is felt necessary to broaden the scale and ambit of government-supported research. Horizontal as well as vertical strengthening of the research initiatives is required both within and outside the Research Councils for keeping possibilities open to support innovative scientific endeavours and structures in the interest of AYUSH development. The research areas left out of the priority list of existing programs have to be taken up to inculcate trans-disciplinary and collaborative R&D and build up institutional and human resource capacities. Catering to the training needs of postgraduates, young researchers and scientific writers is an important area to develop dedicated human resource that can act as change-makers in the emerging AYUSH sphere. AYUSH research is accordingly proposed to be given a paradigm shift in the 12th Plan with addition of following specific interventions & indicative financial implication -

i) Establishment of five regional Hi-tech quality testing laboratories under Research

Councils, concept note in this regard is given in subsequent pages under New Components/Schemes - Rs. 500 cr. (this projection is included @ Rs. 100 cr per laboratory in the individual councils allocation).

ii) Setting up of Central Council for Research in Sowa-Rigpa, concept note of this
proposal is provided under New Components/Schemes - Rs. 50 cr.

iii) Mandate-based strengthening of infrastructure and scientific staff of Research

Councils units to develop as accredited Centres of Excellence one each for Clinical Research, Fundamental Research, Pharmaceutical & Drug Research, Literary Research- Rs. 900 cr.

iv) Networked program for development of robust standards and safety & efficacy data
of selected AYUSH remedies/ therapies of global importance, new dosage

16

forms/drug delivery mechanisms and AYUSH-based diagnostic/prognostic tools and disease-markers - Rs 250 cr.

v) Fellowship Program for AYUSH postgraduate & Ph. D scholars and non-AYUSH
scientists with needful strengthening of identified institutes, 100 fellowships per year on prioritised AYUSH research topics will be provided, concept of this initiative is provided under New Components/Schemes - Rs. 50 cr.

Besides, it is also proposed to undertake validation studies of 50-100 classical formulations each listed in AS&H pharmacopeias and formularies, development of postgraduate AYUSH research registry, strengthening of Research Councils infrastructural facilities and their on-going research activities. These interventions will be appropriately accommodated by making necessary modifications in the intramural and extramural research programs. The allocation for AYUSH-targeted surveys & studies has been scaled up significantly to facilitate conduct of gap-analysis studies of AYUSH facilities and for generating objective data required for policy decisions, planning and health management information. In order to strengthen the on-going research activities and materialize the above-mentioned scientific initiatives & structures of innovative nature, it is proposed to provide an outlay of Rs. 2649.50 cr in the 12th Plan under the subhead Research Councils. The Central Sector Scheme for Medicinal Plants administered through National Medicinal Plant Board (NMPB) is proposed to be expanded with an aim to widen the cultivation & conservation base, improve the export and reduce the import of medicinal plants and build up organisational capacity at central & state levels. With this the National Medicinal Plants Board and the State Medicinal Plants Boards being the nodal points need to be strengthened and focused interventions & required resources as under are intended in the 12th Plan to imbibe capacities and facilities for quality production, processing and management of medicinal plants & herbal raw materials Reforestation/conservation of medicinal plants covering 60000 hectares-Rs. 700 cr. Support for development of 100 herbal gardens- Rs. 50 cr. Research & Development Studies- Rs. 200 cr. Development of agro-techniques- Rs. 2 cr. Setting up Medicinal Plants Conservation Areas (MPCAs)- Rs. 40 cr. Capacity building & IEC activities related to medicinal plants including promotion of GACPs, Good Storage Practices etc.- Rs. 150 cr. Setting up National & State Repositories of medicinal plants- Rs. 30 cr. Support for primary processing of medicinal plants by JFMCs- Rs. 200 cr.

17

Strengthening of State Medicinal Plants Boards- Rs. 50 cr. Four new initiatives have been included under the central scheme for (i) Development of National Institute of Medicinal Plants - Rs.100 cr. (ii) Development of National & State Herbal Gardens- Rs 125 cr. (iii) Operationalizing Quality Certification Scheme for Herbal Products & Fiscal Incentives thereto- Rs. 50 cr. and (iv) Development of newer candidate species for global markets.

Thus, an allocation of Rs. 1797.00 crore would be required to implement the above interventions under the sub-head Medicinal Plants. The proposed interventions shall be operationalized through State Medicinal Plants Boards, State Forest Departments, Horticulture Commissions, Quality Council of India, and Research & Development Institutes for Medicinal Plants, SPVs of Industries and Facilitation Centres for training & capacity building.

Total allocation projected under the head Research & Development including Medicinal Plants thus amounts to Rs. 4446.50 cr.

(4)

Human Resource Development Visits/Up-gradation of skills etc.)

(Training

Programs/Fellowships/Exposure

National Institutes, Model Colleges, Central Research Institutes , Universities, Central/State Resource Training Centres, State AYUSH Directorates /Boards, Open Universities, Distant Education Centres etc are supported through this scheme to undertake HRD activities like CME, Re-orientation training etc. of AYUSH personnel. The allocation in 11th Plan for this scheme was Rs. 30 crore including Rs 5 crore specifically for HRD activities other than CME and Re-orientation Training. 11th Plan achievements under the scheme up to 2010-11 include 406 re-orientation training programs for AYUSH teachers and 10 for paramedics 311 CME programs 38 other HRD activities In the mid-term appraisal the scheme has been found to be useful to the AYUSH personnel to update their professional knowledge & skills and learn scientific inputs & current trends. It was recommended to strengthen the scheme to promote mainstreaming of AYUSH and add new teaching program of 50-100 hours on Ayurveda for allopathic doctors with financial support @ Rs. 5 lakh for one batch of 20 participants. Considering the mid-term appraisal of the scheme and to address the diverse training needs of the AYUSH personnel, it is proposed to increase the scheme allocation in 12th Plan to Rs. 165 crore and merge the two components of the existing scheme. With this much allocation it is intended to-

18

broaden the training base of AYUSH in the country for encouraging AYUSH personnel to undergo need based professional training and skill development, which may also include training programs for AYUSH researchers/scientists, drugs regulatory staff, drug manufacturers regarding SOPs/GMP/GLP etc and for scientific writing . do need-based restructuring of the training programs & modules and bring in new elements of training as per the contemporary needs of AYUSH practitioners, teachers and paramedics, and to conduct Mainstreaming of AYUSH-related trainings of health/AYUSH workforce, ASHAs, Anganwadi workers etc with customised modules for specific training outcomes.

(5)

Cataloguing, Digitization of Manuscripts and AYUSH IT Network The activities undertaken through this scheme are of national importance to protect AYUSH knowledge imbibed in rare manuscripts and engage in relevant literary research and publication. In 11th Plan period, major achievements of scheme implementation include Acquisition/digitization and publication of 23 manuscripts Publication/translation of 14 books and manuscripts. It is sought to enhance the schemes outlay of Rs 40 crore in 11th Plan to Rs.125 crore and continue with both the components in 12th Plan as under the first component for development of AYUSH related IT tools/applications and networks to enhance the visibility of AYUSH systems and their scientific knowledge of stakeholders interest in the area of education, health delivery, research and awareness building. Through this component of the scheme funding will be provided for IT application to AYUSH elements and to set up National and State web-portals encompassing information of registered practitioners, dispensaries, hospitals, teaching institutions, centres of excellence, R&D units, drug testing facilities, industrial units etc with their geographical details (Rs. 25 crore). the second component for covering acquisition-digitization-microfilming-editingtranslation and publication of manuscripts. An umbrella initiative is intended in the 12th Plan for listing, acquisition, micro-filming, digitization, editing, translation and publication of AYUSH manuscripts to be done in collaboration with National Manuscripts Commission & Indian Council of Historical Research to bring up targeted outcomes related to most important manuscripts of AYUSH usage and research. (Rs. 100 crore).

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(6)

International Co-operation In accordance with the National Policy, promotion and propagation of AYUSH abroad is facilitated through this scheme by supporting International exchange Programmes/Seminars/Workshops on AYUSH and International Cooperation activities including market development/workshops/seminars/conferences/exhibitions/trade fairs/Road shows etc. In the 11th Plan allocation of Rs. 40 crore was made for this scheme and the key achievements are Deputation of AYUSH experts and officers in 95 international events. 17 foreign delegations hosted to explore opportunities of international collaboration. Support provided to 38 experts for presentation of scientific papers in international conferences. AYUSH entrepreneurs were supported exhibitions/fairs, road shows etc. to participate in 17 international

12 conferences/research collaborations supported through Indian Missions. 16 fellowships granted to foreign students for studying AYUSH in India. One AYUSH Information Cell set up in Malaysia. 2 AYUSH books translated and published in foreign languages. Indo-US Centre for Research in Indian Systems of Medicine has been set up in the University of Mississippi, USA to undertake scientific validation and development of scientific information on ASU medicines through collaborative research and advocacy. MoUs drawn/entered in to with China, Russia, SAARC and ASEAN Countries. Eight community herbal monographs prepared and submitted to EU.

Mid-term appraisal of the scheme pointed out the need to take corrective measures regarding funding aspects of foreign-deputation of non-official experts and enhancement of upper limit of support for market development, collaborative research and promotional activities. Collaboration with premier Research & Development institutions abroad was emphasized to tackle the questionability of efficacy of ASU medicines. 12th Plan allocation for IC is proposed to be hiked to Rs. 160 crore with needful modification of the scheme to provide for and to facilitate the following additional activities International collaboration in AYUSH research on global health problems & needs;

20

Organising annual interactive meets with international medical schools & scientific organisations in potential countries to explore educational and research collaboration and development of institute-to-institute linkages in the interest of AYUSH promotion; Placing AYUSH Counsellors/Attaches in major Indian Embassies/Consulates to explore, coordinate, facilitate and guide AYUSH promotion, recognition, entrepreneurship, collaboration and other relevant activities; Establishing AYUSH chairs in major international universities to foster bilateral cooperation for promotion of AYUSH education, research, and exchange of expertise and recognition of qualifications.

(7)

Development of AYUSH Industry This scheme is meant for supporting development of common facilities for AYUSH industry clusters and for providing incentives to industry for participation in fairs and conduct of market studies. The 11th Plan provisioning for this purpose is to the tune of Rs. 505 crore and the major achievements are Development of common facilities of quality control, manufacturing and storage of drugs approved for industry clusters in Maharashtra, Karnataka, Tamilnadu, Kerala, Andhra Pradesh, Orissa, Rajasthan and Punjab and three others for Uttrakhand, Gujarat and Assam are targeted. 275 industrial units were given incentive to participate in fairs/exhibitions.

Mid-term appraisal of the scheme implementation brought out the need of doubling the initial outlay of Rs. 100 crore to Rs. 200 crore to cover adequate number of industry clusters in the country and recommended that the workshops/seminars/training programs on Quality Control and Quality Assurance of ASU drugs may be conducted for sensitization of drugs regulators and manufacturers. It is sought to provide allocation of Rs. 1010.50 in the 12th Plan for supporting the development of common facilities at least for one industry cluster in each state, for encouraging increased participation of industry in fairs/exhibitions for exposition of AYUSH and for conducting various relevant activities of industry interest.

(8)

Funding of NGOs engaged in local health traditions, midwifery practices etc. under NRHM 11th Plan provides an allocation of Rs. 25 crore for supporting project-based NGOs activities focused at revitalization, propagation, documentation and validation of local health traditions, midwifery practices etc. During the plan period 37 proposals have been supported. Department of AYUSH in its pursuit to implement policy directive for revitalization and promotion of local health traditions and needful engagement in their scientific 21

validation has accorded lot of importance to support the initiatives of NGOs in this direction. So as to cover the expected number of proposals, as the scheme has been widely circulated and known to various NGOs, it is proposed to allocate Rs. 100 crore in the 12th Plan amounting to four-time hike from the 11th Plan allocation.

(B)

Centrally Sponsored Schemes

This category of schemes is meant to fund proposals recommended by the State Governments for strengthening infrastructural facilities in the area of AYUSH education, health care and quality control and development of medicinal plants sector. Consequent upon their mid-term appraisal, the sub-schemes have been suitably modified in terms of eligibility criteria, funding pattern and ceiling limits and are proposed to be continued in 12th Plan with enhanced allocation but without making any structural changes. However, in order to achieve tangible outcomes of long term value, implementation aspects of the schemes will be modified to facilitate that elements of questionable utility are prevented. As the forthcoming demand of availing these schemes is likely to increase, it is proposed to provide an allocation of Rs. 20863 crore plus transfer of Rs. 10000 crore from NRHM flexi pool in the 12th Plan. Relevant details of each of the schemes with projected allocation and justification thereto is provided hereunder.

(9)

Promotion of AYUSH The elements included in this scheme for extending grant-in-aid are- (a) Development of Institutions, (ii) Hospitals & Dispensaries comprising of separate subschemes for strengthening of AYUSH hospitals and dispensaries and for facilitating mainstreaming of AYUSH under NRHM with creation of AYUSH facilities in primary health network and support for supply of medicines to state dispensaries and (iii) Drugs Quality Control. 11th Plan provides total allocation of Rs. 1400 crore under this head with break up as undera) Development of Institutions b) Hospitals & Dispensaries c) Drugs Quality Control Rs. 550 crore Rs. 625 crore Rs. 225 crore

The major achievements under these components during 11th Plan area) Development of Institutions: 120 proposals of AYUSH teaching institutions supported including mainly that for infrastructural development of UG/PG colleges, starting add-on pharmacy/paramedical courses and development of model colleges. b) Hospitals & Dispensaries: 1933 PHCs, 260 CHCs and 83 District Hospitals supported for setting up AYUSH facilities; 6359 state health units given financial support for meeting recurring costs; 31894 dispensaries/colocated AYUSH units supported for purchase of medicines, 370 AYUSH 22

hospitals given assistance for up-gradation of infrastructure and 394 for meeting recurring costs; and 23 State Program Management Units supported for meeting recurring expenditure. c) Drugs Quality Control: 12 State Drug Testing Laboratories, 17 Pharmacies, 34 State Drug Licensing Authorities, 62 proposals of strengthening enforcement mechanism for ASU drugs, 11 proposals of strengthening in-house quality control laboratories of drug manufacturers supported.

Mid-term appraisal of the individual schemes found certain implementation constraints and the needs of expanding the scheme-ambit and suggested following corrective measuresDevelopment of Institutions Eligibility criteria for releasing grant-in-aid to Govt/Govt.-aided AYUSH institutions may be revised in order to enable institutions to come up to meet CCIM/CCH norms. Ceiling of grant-in-aid for UG, PG and development of model institutions/centre of Advance Studies and similarly for starting add-on courses may be increased. Grant-in-aid to support setting up of AYUSH colleges/Universities in states devoid of them may be extended on 85:15 matching share basis (90:10 in case of Northern States), as applicable in NRHM.

Hospitals & Dispensaries o Up-gradation of infrastructural facilities in existing AYUSH hospitals may be done in a phased manner. Recurring grant for supply of essential medicines may be scaled up and provided to all existing AYUSH units. Admissible assistance may be provided to such PHCs/CHCs/District Hospitals, where AYUSH manpower has been provided under NRHM Flexipool, to create necessary infrastructure. Assistance may be provided to States for setting up Programme Management Units AND Health Information Management System (HMIS). Financial support as per the existing scheme with viability gap funding may be provided for setting up infrastructure in states, where AYUSH network of hospitals and dispensaries is poor and services be arranged in such facilities by supporting Non-governmental organizations of repute.

23

Provision may be made in the scheme to engage doctors in the State AYUSH dispensaries/hospitals, where NRHM does not provide for doctors.

Drugs Quality Control The limit of assistance to Drug Testing Laboratories may be increased. State Drug Testing Laboratories desirous of working in PPP mode may be supported on recurring basis for staff and consumables.

In view of the above and the intention of the Government to inculcate quality education, improved health care services and effective drug quality control & regulatory mechanism, it is proposed to increase the allocation for the scheme in 12th Plan to Rs. crore (including Rs. 10000 crore transfer from NRHM flexi pool allocation for mainstreaming of AYUSH related activities under the Hospitals & Dispensaries subscheme) with relevant justification for each sub-scheme as underi) Development of Institutions: Allocation of Rs. 7425 crore in 12th Plan is sought against this scheme with the aim to fulfil the perceived needs of AYUSH education sector and to enable enhanced scope of the schematic provisions on the basis of following justification(a) The present allocation of Rs. 2.00 Crores for UG Colleges, Rs. 3.00 Crores for PG Colleges and Rs. 5.00 Crore for Model Colleges is inadequate to develop the institutions to higher viable standards which may attract the students as well as the patients leading to real mainstreaming of AYUSH. Hence, it is proposed that the grant-in-aid limit may be increased to Rs. 8.00 Crore for UG colleges and Rs. 12.00 Crore for PG Colleges with the target of supporting 100 UG Colleges and 50 PG Colleges in 12th Plan. For this an allocation of Rs. 1400 crore is proposed. It is also recommended that the enhanced rate of grant-in-aid may cover the funding required for developing the Computer Laboratory, E-Library, Wi-Fi Campus, development of Research Laboratories in the colleges, Digital Records System for the attached hospitals, up-gradation cum modernization of the institutional hospitals by installation of modern diagnostic equipment under the umbrella of Development of AYUSH institutions scheme. (b) The rate of grant-in-aid for development of Model colleges may be increased to Rs. 20.00 Crore and one college in each state may be supported, for which an amount of Rs. 700 crore would be required to cover 35 eligible colleges across the country. It is proposed to establish separate Interdisciplinary Research Department in every model college which may be called Central Research Station wherein the experts from various science streams like Biochemistry, Biotechnology, Pharmacology, Molecular-Biology and Biostatistics could be available to undertake interdisciplinary research. All the Departments in the AYUSH Model College will have access to Central Research Station to carry out research in their specific subject. This approach will help to avoid unnecessary departmentalism and duplication of 24

facilities and will pave the way for an environment of focused scientific endeavors and outcomes. (c) The existing scheme provision of 3.00 cr for starting add on PG/Pharmacy/Paramedical courses may be increased to Rs. 6.00 cr and the colleges may also be supported for starting M.Sc. like master degree courses of Medicinal Plants, basic sciences with AYUSH specialty etc along with the courses already mentioned in the scheme under 11th Plan. The colleges running such courses may provide facility of elective and credit courses in related subjects to the UG & PG students of AYUSH during the course of their studies. The credit courses could be formulated in such a way that if a student undertakes a particular credit course every year throughout the academic career, in that case he would be able to have additional degree in the particular stream. This provision will open more job opportunities to the AYUSH doctors and will also attract meritorious students to ASUH courses. Model/PG colleges may also be considered for financial support to start additional new courses like M.Sc. (Medicinal Plant Chemistry) and other research training programs and credit courses with the available infrastructure. The provision of additional support mentioned above may also be extended to the institutes willing to start paramedical courses for therapists, pharmacists, nurses etc. in AYUSH systems. Under this subscheme allocation of Rs. 600 crore is sought. (d) Grant-in-aid to support setting up of AYUSH colleges/Universities in states devoid of them may be extended on 85:15 share basis (90:10 in case of Northern States), as applicable under NRHM. It is proposed to expand the ambit of the scheme provision to facilitate opening of AYUSH departments in health universities as well as conventional universities to give specific identity to AYUSH education in the university system, which so far is lacking. The funding rate of Rs. 10 cr per unit under the scheme may be increased to 30 cr and about 10-15 such entities would be supported in the 12th Plan, for which an allocation of Rs. 300 crore is proposed. (e) It is proposed to take up up-gradation of state level AYUSH Institutes (one in each state) as Centers of Excellence to the level of National Institutes with estimated funding @ Rs.135.00 crore per Institute (Rs. 60.00 crore as fixed cost and Rs. 15.00 crore per annum as recurring cost). Accordingly, the estimated expenditure amounting to Rs. 4425 cr has been included in the projected allocation of the scheme. ii) Hospitals & Dispensaries Scheme: Requirement of Rs. 22633 cr. including transfer of Rs. 10000 crore from NRHM Flexi-pool is proposed to continue with the existing provisions of the scheme and support/undertake the following additional initiatives in 12th Plan period-

a) AYUSH Program Implementation Plans (PIPs) of the states under NRHM including engagement of AYUSH manpower in PHCs/CHCs/District Hospitals, which are funded from NRHM-Flexi-pool, may be handled in the Department of AYUSH for better coordination with the State AYUSH 25

Directorates/Departments and to facilitate optimal implementation of mainstreaming of AYUSH strategy in right perspective. Transfer of Rs. 10000 cr from NRHM Flexipool to Hospitals & Dispensaries part of the Centrally Sponsored Scheme is therefore urged in 12th Plan to steer integration process in the states with a focused approach for gainful outcomes in health care delivery and improving AYUSH services with need-based integration interventions. The details of the proposal are given under the head New Components/Schemes in subsequent pages. b) The ambit of the scheme for Development of AYUSH Hospitals & Dispensaries, is proposed to be expanded to include (i) AYUSH hospitals & dispensaries run by local government bodies like Municipal Corporation/Committee etc, which are presently out of the scope of NRHM for extending support for up-gradation of infrastructural facilities and supply of essential drugs to teaching hospitals and (ii) establishment of independent AYUSH hospitals in PPP mode with support of Rs. 10 Cr. per hospital. About 35 such hospitals (one in each state) are proposed to be provided support in the 12th plan. The allocation sought under the respective components amounts to Rs. 300 cr and Rs. 350 crore respectively. c) Financial support as per the existing scheme with viability gap funding is proposed to be provided for setting up infrastructure in states, where AYUSH network of hospitals and dispensaries is poor and services be arranged in such facilities by supporting non-governmental organizations of repute.

d) Covering all PHCs/CHCs/District Hospitals for creation of infrastructure for co-location of AYUSH facilities. e) Implementation of National AYUSH Health Program (Rs. 1000 cr), details given under the head New Components/Schemes in subsequent pages.

(iii)

Drugs Quality Control scheme: An outlay of Rs 805 cr. has been proposed in the 12th Plan to continue with the existing scheme provisions and in addition respond to the requirements of Setting up Central Drug Controller for AYUSH, details given under New Components/Schemes)- Rs. 166 Crore. Further strengthening of the State Drug Testing Laboratories and Pharmacies (Rs. 400 cr.) Supporting the concept of AYUSH Janaushadhi retail outlets for promoting the availability and use of classical formulations in rural areas (Rs.100 Cr).

26

Increasing the limit of assistance to ASU&H manufacturing units for establishment of in-house quality control laboratory to Rs. 1.00 cr per unit. (Rs. 100 cr.)

In order to strengthen the enforcement of Drugs and Cosmetics Act and facilitating availability of quality medicines in the market, it is felt appropriate to continue the scheme with needful modifications as mentioned above and support relevant proposals from the states.

(10)

Development of Tertiary Care AYUSH Facilities in PPP mode Development of AYUSH health care facilities in PPP Mode has been accorded high priority and the allocation for this purpose in the 11th Plan amounts to Rs. 50.00 cr. In the mid-term appraisal of the Centrally Sponsored Scheme for Hospitals & Dispensaries, it was emphasised that the constraint of creating posts for setting up specialised AYUSH facilities needs to be overcome and the possibilities of public-private partnership should be explored regarding provision inter alia of quality health services with the involvement of private sector. Accordingly, it is proposed to enhance the scheme allocation to Rs. 350.00 cr in the 12th Plan to meet the emerging demand of entering in to Public-Private Partnership with reputed AYUSH institutions and encouraging private allopathic hospitals to create/widen specialized AYUSH-based health care for the benefit of people. The proposed hike in allocation is seven times from the 11th Plan allocation.

(11)

National Mission on Medicinal Plants Under this head the National Medicinal Plants Board is implementing a Centrally Sponsored Scheme during 11th Plan with an outlay of Rs. 485 crore. The scheme is primarily aimed at supporting market driven medicinal plants cultivation on private lands with backward linkages for establishment of nurseries for supply of quality planting materials and forward linkages for post-harvest management, processing, marketing infrastructure, certification and crop insurance in project mode. This is being achieved by cultivation of medicinal plants in identified zones/clusters within selected districts of States having potential for cultivation of certain medicinal plants and promotion of such cultivation following good agricultural practices through Farmers, Cultivators, Growers Associations/ Federations, Self Help Groups, Corporates, and Cooperatives. The achievements under the scheme include Setting up of 636 nurseries of medicinal plants Coverage of 51308 hectares of land for cultivation of medicinal plants Support provided to 25 post-harvest infrastructure units Putting in place 5 processing units and 2 market promotion units.

27

It was realised during mid-term appraisal of the scheme thati) State Medicinal Plants Boards, which are nodal agency for medicinal plants in the states, should be strengthened with Project Management Units in each state to step the implementation of the scheme.

ii) Minimal gross amount of subsidy for large-scale cultivation of medicinal plants should be increased to the limit prescribed under National Horticulture Mission. iii) Release of funds for cultivation assistance should be field-verification based instead of being credit linked.

As the commercial scale cultivation of medicinal plants is critical for assured supply of quality raw materials to the industry, the support being provided for this purpose needs to be enhanced for covering large projects and more species of medicinal plants. Also, facilities for supply of quality seedlings & saplings and processing of medicinal plants with forward & backward linkages, quality certification and support for collection and marketing of plant-based raw materials are essentially required to attract farmers towards cultivation of medicinal plants and promote the related trade. An allocation of Rs. 1710.00 cr with 3.53 times hike from the 11th Plan is, therefore, sought under the scheme in the 12th Plan to undertake the following interventions, break up of indicative requirement is given in bracket for each intervention to expand the cultivation status of medicinal plants over 2,00,000 hectares of land (Rs. 600 cr.), for induction of voluntary certification scheme for medicinal plants (Rs. 30 cr.), for expansion of organic produce certification scheme (Rs. 50 cr.), for development of 20 Medicinal Plants Processing Zones (Rs. 400 cr.), for raising 2000 nurseries (Rs. 480 cr), and for providing minimum support price to the collectors of medicinal plants and marketing support to the farmers (Rs. 150 Cr.).

The above initiatives overseen by NMPB are proposed to be taken up through State Medicinal Plants Boards, Forest Departments, Horticulture Missions, Special Purpose Vehicles of Industries, Quality Council of India and Agencies of Ministry of Tribal Affairs-Agriculture-Forests & Environment.

28

(C)

New Components/Schemes

Following new components/schemes are proposed for addition added in the projected 12th Plan to steer effective promotion of AYUSH for public benefit and addressing the quality issues of drugs, manpower and education(i) National Commission for Human Resources in AYUSH The Commission has been conceived as an institutional framework to address issues related to regulation, shortage, quality assurance and inequitable availability of AYUSH professionals & work force. This proposal is based on the lines for abolishing existing regulatory bodies for allopathic, dentistry, pharmacy and nursing education and practice by repealing the existing laws. The Commission shall undertake work force study, formulate action plans and ensure inter-sectoral coordination to promote availability of Quality Human Resources in AYUSH including that of Yoga & Naturopathy, which are so far not regulated /accredited in the country. The issues related to AYUSH paramedical education, HR development and regulation will also be dealt under this arrangement. The Commission shall provide two sets of autonomous bodies as (i) National Councils of professionals of each of Ayurveda, Unani, Siddha, Sowa-Rigpa, Homoeopathy, Yoga & Naturopathy and (ii) National Board for Education, Training and Examinations and Natural Evaluation & Assessment Committee for Indian Systems of Medicine, Homoeopathy, and Yoga & Naturopathy, Nursing in Indian Systems of Medicine / Homoeopathy and courses in pharmacy. Their head offices would be in Delhi with full time Chairpersons and Members and part time & nominated members. Appropriate infrastructure and manpower would be required to run the secretariats. This arrangement will help steering educational reforms in AYUSH as raised in the discussion note circulated by the Planning Commission for the Steering Committee. Financial Implication: About Rs. 125.00 crore.

(ii)

Setting up of Referral hospitals in 8 National Institutes The credibility of the AYUSH streams is impingent on evidence-based quality health care. The National AYUSH Institutes being the premier institutions in the country attract large number of patients, including the referred ones. Necessarily, these institutions should provide outstanding patient care services in their particular systems. The standards and upkeep of hospitals attached to National Institutes are not encouraging, mainly due to neglect & poor investment and they continue to be just like general hospitals. It is, therefore, proposed to upgrade the hospitals in eight National institutes like IPGTRA, NIA, NIUM, NIS, NIH, AIIA, NEIAH, NEIFM and two National Institutes of Yoga and Naturopathy with world class treatment facilities and conditions with NABH accreditation for secondary & tertiary level health care providing adequate diagnostic & investigative facilities, machineries, equipment, IT gadgets and manpower including specialised therapies & consultation services and infrastructure for clinical research. Financial Implication: About Rs. 100 crore per hospital for eight institutes and Rs. 10 crore each for Yoga and Naturopathy institutes totalling Rs. 820 Crore. This proposal along with estimated expenditure is included under the Educational Institutions allocation.

(iii)

Setting up Homeopathic Medicines Pharmaceutical Corporation Limited (HPCL) Presently, the Homoeopathic industries participating in Govt. supplies by and large are not GMP-compliant and are not equipped with qualified technical staff or quality control facilities. 29

This amounts to violation of Drugs & Cosmetics Act and it is very difficult to ensure that quality of medicines is supplied to Govt. dispensaries & hospitals. Other important factor is that private industries mainly manufacture patent & proprietary medicines discouraging classical pharmacopeial products. There is only one unit in Govt. sector i.e. Kerala Co-operative Homoeopathic Manufacturing Unit having annual turnover of Rs.10 crore which is not sufficient to meet the requirement of Government Departments and supplies under NRHM. It is, therefore, felt necessary to set up an IMPCL like public sector enterprise for manufacturing of homeopathic medicines to ensure quality & timely supplies to CGHS, State dispensaries and Homeopathic facilities under NRHM. Financial Implication: Rs. 75.00 cr are estimated to meet the expenditure on land & building construction (Rs. 30 cr), equipment & machinery (Rs. 15) and recurring costs of consumables/maintenance and manpower (Rs. 30 cr. ).

(iv)

Setting up of National Institute of Medicinal Plants The medicinal plants sector of India needs persons trained in all aspects of medicinal plants e.g. conservation, taxonomy, cultivation, processing, post harvest management, certification, trade, both domestic and international, biodiversity, TK related issues, protection of IPRs, HS codes, international agreements and treaties like CITES, Nagoya Protocol etc. Besides, there is a felt need to have an institutional mechanism for imparting training to the implementing agencies of NMPB schemes and design courses for training. There is also a need for an institute to undertake state of art research and act as a referral centre for all dimensions of medicinal plants. In order to fulfil these needs it is proposed to establish a National Institute of Medicinal Plants in 12th Plan period equipped with training facilities, herbal garden, demonstration site, raw materials processing & testing facilities, drugs repository and well-trained faculty. Financial Implication: Rs. 100.00 cr (including non-recurring & recurring costs), it is included in the Research and Development including Medicinal Plants allocation.

(v)

Setting up of Research and Quality Control Laboratories in 8 National Institutes There is a scarcity of accredited laboratories for quality testing in the country. Very few laboratories exist in the private sector, which are GLP compliant and have the mandate for testing of natural products like ASU&H medicines. In the Govt. sector there is only one NABL accredited laboratory for ASU drugs i.e. the laboratory of Capt. Srinivas Murthi Drug Research institute, Chennai under Central Council of Research in Ayurvedic Sciences (CCRAS). As such the National institutes are the ideal locations to have Quality laboratories in the concerned system to undertake drug testing and research. The facilities shall be of NABL standard. It is, therefore, proposed to develop laboratories for drug testing and research in National Institute of Ayurveda- Jaipur; National Institute of Homoeopathy-Kolkata; National Institute of Unani Medicine- Bangalore; National Institute of Siddha- Chennai; Institute of Post Graduate Training and Research in Ayurveda- Jamnagar, North Eastern Institute of Ayurveda & HomoeopathyShillong (one for Ayurveda and another for Homoeopathy); All India Institute of Ayurveda, New Delhi. Such an arrangement will help to expand the quality testing facilities in the country for ASU&H products as well as for their utilisation in research and training activities at institutional level. Financial Implication: It is estimated that Rs. 100.00 cr per laboratory for eight laboratories amounting to Rs. 800 cr. (inclusive of non-recurring & recurring costs) would be required. 30

Central Drug Controller for AYUSH drugs The Expenditure Finance Committee at its meeting held on 4.10.10 under the chairmanship of Secretary (Expenditure) has agreed to create infrastructure of Central Drug Controller for AYUSH drugs. Allocation of Rs.166.00 crore has been projected for this purpose in the 12th Plan. Under the Central Drug Controller for AYUSH Drugs, 40 posts including 25 regular and 15 contractual/outsourced posts will be created and in addition salaries of scientific manpower in 30 state govt. run Drug Testing Laboratories will be borne during 12th Plan period. This provision will be made under the Centrally Sponsored Scheme for Drugs Quality Control under the head - Promotion of AYUSH. Presently the demand for traditional Indian medicine i.e. Ayurveda, Siddha, Unani and other herbal products has increased tremendously in India and abroad. The world herbal market is estimated to be $62 billion out of which the share of China is $19 billion and that of India is only $1billion (PHARMAXECIL) There are around 10000 ASU Drugs manufacturing units in the country at present. To facilitate the increased acceptability of ASU medicines within the country and abroad, the core issue is the quality and standardization of ASU products and effective enforcement of the provisions of the Drugs & Cosmetic Act. It is recommended by the Ayurveda, Siddha and Unani Drugs Consultative Committee (ASUDCC) chaired by DCGI that a separate Central Drug Controller for ASU drugs may be created. The proposal along with required funds is incorporated in the Centrally Sponsored Scheme for Drug Quality Control.

(vi)

(vii)

Setting up All India Institute of Yoga In view of the emerging demand for Yoga training and education, a dedicated institute at national level is required to undertake teaching & research programs and project strengths of Yoga with scientific data and evidence-based approaches, particularly in the area of psychosomatic and lifestyle diseases, where conventional medical approach does not provide effective solutions. The space required for this purpose is neither adequate nor geographically conducive in the present premises of Morarji Desai National Institute of Yoga, New Delhi. It is, therefore, intended to set up another National level institute of Yoga with distinct mandate and state of the art infrastructure near to the national capital in 12th Plan. Financial Implication: Rs. 200.00 cr inclusive of non-recurring & recurring costs)

(viii)

Setting up All India Institute of Unani Medicine, Hyderabad Keeping in view the growing demand and interest of public in Unani System of Medicine, it is proposed to set up an All India Institute of Unani Medicine (AIUM) at Hyderabad with high class treatment facilities in Unani System, research facilities on modern parameters and good quality of U.G. and P.G. education. This Institute would have facilities for world class treatment in the system as per the Indian Public Health Standards (IPH), providing adequate diagnostic and investigative facilities through modern diagnostic equipments, machineries and manpower, specialist consultations services and upgraded research wing and thereby provide the status of a referral hospital. This will make the facilities comparable with the secondary/ tertiary health care hospitals in conventional system and will enhance the credibility of the Unani System of Medicine. Financial Implication: Rs. 250.00 cr (inclusive of recurring and non-recurring costs) are estimated for allocation in 12th Plan.

31

(ix)

Setting up All India Institute of Homeopathy Homeopathy in India has established itself more than anywhere else in the world. It is regulated through Central Acts and Statutory regulatory body and a large infrastructure in the form of registered practitioners, teaching institutions, dispensaries and hospitals exist in the country. Being cost effective, palatable, safe and effective for the management of such diseases/disease-conditions as are considered untreatable in other systems of medicine, the demand for homeopathy has grown phenomenally. To fulfil the emerging interest of scientists for research in homeopathy and inculcate interdisciplinary understanding for promoting evidence-based use of homeopathy, it is proposed to set up a premier institute equipped with postgraduate education and research facilities and tertiary care hospital services. This will help exploring the scientific basis of homeopathic medicine and building up its credibility for the benefit of masses and mainstreaming in health care delivery system. Financial Implication: Allocation of Rs. 250.00 cr (inclusive of recurring and non-recurring costs) is estimated for implementing the proposal in 12th Plan.

(x)

Setting up of 5 Hi-Tech Quality Control Labs under Research Councils at regional level with NABL accreditation The need for improving quality testing of ASU&H drugs has been raised from different forums. State Licensing Authorities have raised time and again where to send the samples picked up under the provisions of Drugs & Cosmetics Act for testing as the state laboratories are not equipped except in Maharashtra and Gujarat states, where the government drug-testing facilities are common for allopathic and ASU drugs. Drug Manufacturers, who are supplying medicines to Govt. dispensaries & hospitals and exporting to other countries, also find it difficult to get the products tested and certified from an authentic source. Drugs Consultative Committee has realized the need to address this problem. The Planning Commission in their discussion note for the Steering Committee on AYUSH for 12th Plan has also raised the issue of quality assurance mechanism and need of augmenting the drug testing facilities for AYUSH sector. Therefore, in order to expand the quality control base of highest standards as per the requirement of Drugs & Cosmetics Act, 1940 and for the testing of exported/imported ASU&H drugs and for R&D purpose, it is proposed to set up hi-tech quality control laboratories under AYUSH Research Councils in the 12th Plan. To start with five laboratories from amongst the four Research Councils (two of CCRAS and one each of CCRUM, CCRH and CCRS) will be identified to develop as the regional laboratories and notified as the extended arms of PLIM & HPL to fulfil the drug testing requirements at the regional level and facilitate quality research in drugs. The proposed laboratories will be equipped with hi-tech quantitative & qualitative analytical tools & machinery and adequately trained manpower to meet the drug testing requirement not only of the Research Councils but also for the purpose of development of pharmacopoeial standards and testing of drug samples received from industry and state licensing authorities. Five regional laboratories are proposed, two from CCRAS and one each from CCRUM, CCRH and CCRS for quality testing of Ayurveda, Siddha, Unani and Homeopathy drugs in Northern, Southern, Eastern, Western and Central parts of the country. Financial implication to the tune of Rs. 500 cr is estimated to materialise the proposed initiative in 12th Plan period. The required funds @ Rs. 100 crore per laboratory are included in the respective research councils allocation.

32

Setting up National AYUSH Library & Archives Planning Commission in its discussion note for 12th Plan Steering Committee on AYUSH has raised the need to create a contemporary museum of AYUSH on the past, present and future of Indias medical heritage. The idea is welcome and Working Group felt that instead of a stand-alone museum of AYUSH, a national library and archives with documentation centre & museum may be set up at a suitable place to preserve, project and disseminate important AYUSH articles of heritage including literary, official documents/records and tools/instruments of all systems and to undertake publication of AYUSH newsletter, journal etc. Considering the viability and importance of this concept, it is contemplated to house the proposed centre in one of the National Institutes, preferably under public-private partnership with a credible Trust or Foundation, selected on the basis of stipulated criteria by inviting expression of interest for specified terms & reference from capable organisations. Financial implication: An allocation of Rs. 50 crore has been projected to cover the nonrecurring & recurring costs of the proposal and it is included under the Central Scheme for

(xi)

system strengthening within the strengthening of Department of AYUSH.

(xii)

National Institute of Sowa-Rigpa The educational system of Sowa-Rigpa is presently in the hands of some institutes run by the Tibetan bodies in trans-Himalayan region of India. Some sort of financial support is provided to these institutions from Government. However, the infrastructural facilities there are not sufficient to meet the aspirations of the students who choose to study Sowa-Rigpa for a professional career. As Sowa-Rigpa has been accorded state patronage, a dedicated institute of the system is required that may lead to develop benchmark standards of education, patients care and postgraduate research and impart professional training to produce skilled manpower. Hence, a National Institute of Sowa-Rigpa is proposed to be set up in the 12th Plan period with facilities of UG & PG education, paramedical training and provision of clinical services through a well-equipped hospital. The possibility may be explored to acquire for upgrading the one SowaRigpa institute supported by the Department of Culture to the level of proposed National Institute. Financial implication: An allocation of Rs. 100 crore is indicated to set up the required infrastructure and meet the recurring costs. (xiii) Central Council for Research in Sowa-Rigpa Sowa-Rigpa system of medicine has recently been recognised as part of AYUSH and efforts are being made to strengthen its various aspects. Presently, an institute for research in Sowa-Rigpa with a limited mandate is functioning at Leh (Jammu & Kashmir) under the aegis of Central Council for Research in Ayurveda & Siddha. It does not have developed linkages and collaboration with other scientific institutions because of its geographical location and the activities there are not very contributory for the scientific development of the system. Unlike other Indian systems of medicine and homeopathy, the Sowa-rigpa has not been much explored scientifically and standards of drugs, therapies, procedures etc are lacking. It is, therefore, proposed to develop an organisational set up mandated with scientific validation and standardization of Sowa-Rigpa to facilitate research in literary, drug, clinical areas and medicinal plants. The Sowa-Rigpa Research Council can initially be started from the CCRAS headquarters with the present institute as the key unit to coordinate the implementation of the project till completion. The proposed institute may be enlisted under the Central Scheme for Research & Development including medicinal plants. 33

Financial implication: An allocation of Rs. 50 crore is proposed to meet the non-recurring & recurring costs. The proposal with its proposed allocation is included in the Central

scheme for Research Councils.

Setting up Indian Institute of AYUSH Pharmaceutical Sciences Ayurveda, Siddha, Unani and Homeopathy have specific peculiarities in the preparation of medicines and dosage forms, which are quite differentiated from each other in terms of properties, stability and mode of administration. Growing emergence of interest towards natural health products looks for development of pharmaceuticals keeping pace with the new trends and technological advancements. Scientific exploration of various dosage forms of ASU&H drugs and use of modern drug-manufacturing technology compatible with ASU&H principles of pharmaceutics are critically important areas to work in. Understanding the nature, properties and dynamics of ASU&H medicines in contemporary scientific language can lead to global acceptability and promote trade. To address this issue with a focused approach, a dedicated national level institute comparable to NIPER is required to engage in AYUSH pharmaceutical education & research and collaborate with other scientific institutes for modernising traditionally used pharmaceutics. It is intended to include the proposed institute in the Central Sector scheme for Educational Institutions. Financial implication: An allocation of Rs. 150 crore is proposed to establish the required infrastructure & related recurring costs. (xiv)

(xv)

AYUSH Gram AYUSH Gram is a concept wherein one village per block will be selected for AYUSH interventions of health care. The overall health checkup of the entire population will be done by AYUSH doctors based on AYUSH systems and they will be provided basic knowledge for promotion of health and prevention of diseases. The communities will be educated about healthy practices and advantages of traditional food items used locally and their medicinal properties. The AYUSH doctors will also undertake health checkup camps at schools in and around the selected villages. AYUSH training will also be imparted to ASHAs, Anganwadi workers, school teachers etc. Awareness building activities would be conducted through grampanchayats involving schools, anganwadis, self-help groups and other community organizations. The villages near to PHCs having road connectivity will be selected for this program. Treatment for sick people will be provided through the PHC. This kind of program is already being implemented in Chhattisgarh and Gujarat states and has been found successful in AYUSH and community health promotion. Based on best AYUSH practices being adopted in different states, it is intended to propagate the concept of AYUSH Gram nationwide and support the proposals through the central scheme of AYUSH and Public Health. AYUSH Telemedicine Services Medicine assisted with new communication technology i.e Telemedicine has facilitated the outreach of health services to remote rural populations settled particularly in difficult terrains. Department of AYUSH with the intention of increasing the outreach of AYUSH services facilitated a pilot project of Tele-Homoeopathy in Tripura to provide health care through 10 centers coordinated by the State Homoeopathic Hospital, Agarthala. There being no enabling provision in any of the 11th Plan Schemes to support such a project, the financial support was provided by the National Institute of Homoeopathy, Kolkata from its own funds. 34 (xvi)

Another such telemedicine project is being run in Bihar state where the patients with eye diseases are provided Ayurvedic treatment. The project is undertaken through CCRAS for the advantage of patients that any time of the day they can walk into the kiosk, take consultation on video with a doctor sitting either in the PHC or Hospital. The first line of treatment is thus immediately provided in this way to the patients. This project is going on for the last one and a half year and found to be viable and successful. The project was selected for Sindia Award given by Telecom Ministry and recentlyconferred with e-World 2011 Jury Choice Award under the Best Public Private Partnership initiative category jointly instituted by the Centre for Science, Development and Media Studies (CSDMS), Ministry of Communication & Information Technology, and Department of Telecom. Department has received such proposals from states like J&K, Punjab, Jharkhand, Orissa and West Bengal. Considering the huge utility of telemedicine facilities for rural and remote populations, particularly where even basic public health infrastructure does not exist, it is proposed to introduce AYUSH Telemedicine nationwide during the 12th plan for covering the remote areas of the country including NE and Hilly states. Given the provision of required financial resources about 1,00,000 nodes are aimed to be established during the plan and the projects will be supported through the AYUSH and Public Health scheme.

(xvii) AYUSH Fellowship Scheme The fellowships are integral part of professional education for supporting the meritorious students to encourage them to excel in their scientific endeavors on particular subjects. This provision is available for students taking education in other streams. However, this provision is lacking in AYUSH sector. It has been observed that the demand for AYUSH education and research is increasing and meritorious students are motivated to pursue AYUSH as a professional career. Even scholars of other streams of science have shown inclination to explore AYUSH in their postgraduate/doctoral training & research. Vaidya-Scientist fellowship program run by one of the Centres of Excellence supported by Department of AYUSH is a beginning in this direction and it needs to be expanded by identifying suitable institutions and scholars to undertake AYUSH-specific scientific training and research activities during their postgraduate/doctoral studies. In order to steer this proposal 100 scholars per year are proposed to be initially supported for two years during the 12th Plan period by selecting them on the basis of a national eligibility test. It is also intended to provide needful support to the host institute for strengthening/provisioning of the required research infrastructure & logistics. The initiative shall be implemented as a part of the Central Sector scheme to be anchored by a central institute for coordination and facilitation. A national panel of interdisciplinary experts will identify the institutions and research topics and the scholars admitted in the scheme will be subjected to rigorous mentoring by peer experts of the related subject. The approach shall be to encourage interdisciplinary research on specific AYUSH issues that may augment scientific basis of AYUSH and provide tangible leads for further work. A provision of Rs. 50 crore is proposed for this intervention in the 12th Plan and it is included in the central scheme for Research Councils. (xviii) National AYUSH Health Program AYUSH systems are culture-friendly and known for robust health promotive guidelines and holistic approach. This inherent potential of AYUSH needs to be tapped for the control of non-communicable diseases and their public health implications. During 11th Plan, the Department of AYUSH identified specific strengths of AYUSH and initiated national campaigns with the involvement of States on geriatric health care, anemia control, mother and child health 35

care, management of ano-rectal disorders through AYUSH systems. As a result of these campaigns peoples awareness has been built up about the role AYUSH can play in improving health status of populations with lifestyle interventions and management of chronic diseases. It is now proposed to launch National AYUSH Health Program mandated with the objective of promoting AYUSH practices of maternal & child health care, geriatric care, mental health, nutritional care and health promotion for the benefit of masses. The program would be implemented like a Centrally Sponsored Scheme involving State AYUSH Directorates, Public Health facilities, AYUSH colleges and reputed NGOs working in related areas. Needful linkages will also be attempted with the National Non-Communicable Disease Control Program in implementing health promotion strategies of AYUSH. The program will be steered with the help of a National Steering Committee chaired by Secretary (AYUSH) and appointment of nodal points at central, state and district levels to coordinate and monitor the implementation. It is proposed to provide an allocation of Rs. 1000 crore for this purpose in the 12th Plan as part of the Centrally Sponsored Scheme for promotion of AYUSH.

Mainstreaming of AYUSH under NRHM Mainstreaming of AYUSH under NRHM is one of the important thrust areas to improve the quality and outreach of health care and attain integration of health services. In the 11th Five Year Plan, public health facilities (PHCs, CHCs and District Hospitals) have been supported for co-location of AYUSH doctors, creation of necessary infrastructure and supply of AYUSH medicines. However, the coverage so far is not significant. Only 24.6% of the public health facilities could avail central assistance for AYUSH medicines and 8.7% PHCs, 5.8% CHCs and 13.9% District Hospitals availed the relevant centrally sponsored scheme for setting up infrastructure required for colocation of AYUSH facilities. In many of the cases the money has remained unspent in the states for the reason of not having dedicated AYUSH administrative setup under NRHM to monitor the progress. It has also come to notice that in many states AYUSH proposals under NRHM are not given attention and are not entertained while preparing the state PIPs. As a result mainstreaming of AYUSH could not make significant headway under NRHM except for colocation of AYUSH facilities in primary health network as there are no indicators for measuring the progress of integration and mainstreaming of AYUSH process. The AYUSH component under NRHM-Flexipool needs to be properly structured with specific indicators for progress evaluation and to facilitate examination of state proposals for evidencebased approval. It is also felt that administrative set up for AYUSH under NRHM needs to be established in the states with necessary infrastructure and required manpower. For all this a separate budget allocation is required for AYUSH in the NRHM-flexipool to support the state proposals with certain norms of funding for specific interventions, including creation of necessary administrative setup for AYUSH, support to PHCs/CHCs and DHCs in the country for collocation of AYUSH facilities/doctors, supply of medicines and other integration-facilitating activities. The program monitoring, training of ANMs, ASHAs etc, provisioning of AYUSH drug kits in sub-centres etc. are also intended under the proposed mainstreaming of AYUSH initiative under the NRHM. In the 11th Plan, a total of Rs. 967 crore approx. were invested from NRHM Flexipool for AYUSH mainstreaming activities, with which about 10% of the PHCs, CHCs and DHs could be covered. In order to complete the colocation of AYUSH services in all the units of the primary health network and support other mainstreaming of AYUSH activities in the states, budgetary requirement of Rs. 10,000 cr. is proposed in the 12th Plan with transfer of corresponding amount of funds from NRHM-Flexipool.

(xix)

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