|2nd Five Year Plan||
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The general aim of health programmes during the second five year plan is to expand existing health services, to bring them increasingly within the reach of all the people and to promote a progressive improvement in the level of national health. The specific objectives are:
2. In providing hospital facilities the aspects to be kept in view are quantity, distribution, integration, and quality. An effective regional system of hospitals would include four distinct elements, namely the teaching hospital, the district hospital, the tehsil hospital, and the rural medical centre associated with a health unit. Each element in such a system would be linked administratively with the others. A coordinated hospital system with its free flow of medical services and patients should help to provide satisfactory medical care both in urban and rural areas.
3. The creation of more hospital facilities is needed but, in view of the high cost of these services, it is equally important to develop existing hospital services and to make them both efficient and economic. In existing hospitals questions relating to staffing, accommodation, equipment and supplies should receive special attention. Further, a long-range programme of action should be promoted by
4. It is estimated that in 1951 there were 8,600 medical institutions in the country with about 113,000 beds; in 1955-56 the number of institutions may be about 10,000 with about 125,000 beds. These figures represent an increase during the first plan of 16 per cent in institutions and of 10 per cent in beds. At the end of the second plan the number of institutions is likely to be about 12,600 and the number of beds about 155,000, providing thus for an increase of about 26 per cent in institutions and of about 24 per cent in hospital beds. The plan provides about Rs. 43 crores for augmenting and improving hospital services, including staff, accommodation, equipment and supplies.
5. The povision of adequate health protaction to the rural population is by far the most urgent need to be met in the second five year plan. In view of the programme for extending the national extension service to the entire rural population, the establishment of primary health units in as many development blocks as possible is a necessary step towards providing an integrated preventive and curative medical service in rural areas. The population of an average development block is too large to be catered for by the proposed health unit staff, but the scheme has the advantage of providing an elementary type of health organisation throughout the country. In later plans, progressive improvements in the scheme' of medical care provided by health units can be undertaken.
6. The ultimate success of the health unit programme depends upon the extent to which essential services are provided. These are:
the early stages, certain services such as those for the control of malaria,
filaria, tuberculosis, veneral diseases and leprosy may have to be rendered
by special staff but, after adequate control has been attained, such services
should form part of and be integrated with the normal activities of a
health unit This integration will be greatly facilitated if during the
period of the second plan full co-ordination of activities can be established
between such specialised services and the health units. The staff employed
in each health unit should ultimately be such as to enable the unit to
provide the basic services as well as specialised services relating to
malaria and other diseases. In order that these services may reach the
public throughout the area which a health unit serves, the provision of
transport has considerable practical importance. It will also facilitate
the removal of urgent cases to hospitals. It is desirable that a broad
uniform pattern for the structure and functions of a health unit
7. The difficulty in obtaining doctors and other health personnel in rural areas is due less to lack of trained personnel especially in the case of doctors, as to the present unsatisfactory position in respect of housing conditions, facilities for the education of children and other amenities. An essential step in securing a large flow of health workers into rural areas is to make conditions of service in these areas more attractive.
8. As against 725 health units set up during the first plan, it is proposed to establish over 3,000 health units in national extension and community projects and other areas. State Governments also propose to convert 131 existing dispensaries into primary health units and to set up a number of secondary health units. The plan provides about Rs. 23 crores for this programme.
9. The number of medical colleges has increased from 30 in 1950-51 to 34 in 1954-55 and 42 in 1955-56. Annual admissions have increased from about 2,500 in 1950-51 to about 3,500 by 1955. The present training facilities provide for an annual out-turn of about 2,500 doctors during the second plan. There are at present 70,000 qualified doctors in India and about 12,500 doctors will qualify during the second plan. As against this, the number of doctors needed will be about 90,000. It is considered essential that more training facilities should be provided during the second plan so that this gap may be filled.
10. As new medical colleges will take some time to function fully, the expansion of existing colleges should be given the first priority. The plan provides about Rs. 20 crores for the expansion of medical colleges and attached hospitals, establishment of Preventive Medicine and Psychiatric Departments in medical colleges, completion of the All-India Institute of Medical Sciences and schemes for upgrading certain departments of medical colleges for post-graduate training and research. The annual admissions are likely to be increased by about 400 as a result of these expansion schemes. This would, however, cover only a part of the shortfall in the number of available doctors. It would, therefore, be necessary to start some new colleges during the second plan period. An amount of Rs. 6.5 crores has been provided in the plan of the Ministry of Health for establishing new medical colleges.
11. Medical colleges in India are now staffed by teachers who are permitted private practice. This concession is an important reason for low standards of teaching and for the small amount of attention which medical research has received. To remedy this situation, the Medical Council of India has recommended that every department of a medical college should have a full-time non-practising unit consisting of a professor and other teachers. The strengthening of medical colleges by the inclusion of whole-time units is essential for raising standards of undergraduate and post-graduate medical education and for developing research. The additional cost involved in this proposal in respect of each college is expected to be Rs. 2 lakhs per year. The provision necessary for about 35 medical colleges will be about Rs. 3.5 crores in the course of the second plan period.
DENTAL EDUCATION AND DENTAL SERVICES
12. There are only 600 to 700 qualified dental surgeons in the country. Thus, the country has only a fraction of the dental surgeons it needs. The need for a substantial increase of the facilities for training dental personnel is therefore obvious. There are, at present, only six dental colleges in the country and even these are not properly staffed, equipped or housed. The first step should be to bring the existing dental colleges to the required standards of efficient functioning and to double the number of admissions. Bombay has two dental colleges and Punjab, Uttar Pradesh, West Bengal and Madras one each. A dental college is to be established at the All-India Institute of Medical Sciences at Delhi. During the second plan Andhra, Bihar, Madhya Pradesh and PBPSU propose to open new dental colleges and West Bengal and Punjab have provided for the expansion oŁ existing colleges. The plan provides Rs. 2 crores for dental education.
13. In order to expand dental services it is suggested that medical men attached to rural dispensaries should be trained for emergency dental treatment. There are about 6,000 to 7,000 dentists who are registered in Part 'B' of the Dentists' Register and they are practising dentistry. They should be given additional courses of training. It is necessary to arrange for the training of adequate numbers of dental hygienists, dental mechanics and dental technicians. They will assist in increasing the efficiency of the limited dental services at present available. During the second plan period dental clinics are to be established in several district headquarter hospitals.
NURSING AND OTHER TRAINING PROGRAMMES
14. Shortages in personnel other than doctors have been more marked and are likely to persist longer than in Ae case of doctors. At the end of 1954 the numbers registered in different categories in the States were 20,793 nurses, 24,290 midwives, 756 health visitors, 4,468 dais and 946 nurse-dais. As norms to aim at, there should be one hospital bed for 1,000 population, one nurse and one mid-wife for every 5000 population and one health visitor and one sanitary inspector for 20,000 population. For ancillary categories of personnel, figures given in the last column in the statement below are still somewhat distant. They illustrate, however, the character of the present shortages and the need for accelerated and sustained action if even elementary services are to reach the mass of the people in any adequate degree:
During the second plan, arrangements are being made for the training of increased numbers of nurses, mid wives, pharmacists, sanitary inspectors and other technicians at medical colleges and at the larger hospitals which are not in use as teaching hospitals. A provision of about Rs. 6 crores has been made for these training programmes.
15. Nurses. At present, nursing education of different types and at varying standards is being imparted. It is desirable to standardise the training, so that maximum use is made of existing and new facilities for training. The two existing nursing colleges which train candidates for the B.Sc. degree in nursing can continue to provide training for the higher grades of nursing personnel. A great deal of expansion is needed in respect of facilities for the basic nursing course of three years' duration, to which is generally added a course in midwifery for six months or one year. On this depends the development of nursing services. The number of admissions to existing training institutions for nurses should be increased, and every large hospital should be used as a training centre, The basic training course should also be given a bias towards the public health aspect of nursing including family planning.
16. Auxiliary nurse-midwives.In view of the large development programmes that are being undertaken all over the country, large numbers of auxiliary nurse-midwives are needed. They have a shorter course of training than nurses. Provision for this type of training should be expanded and use should also be made of hospital facilities. It is suggested that institutions at present utilised for'1 training midwives may be upgraded into auxiliary nurse-midwives' training centres and hospitals at headquarters of districts as well as other hospitals in which fifty or more beds are available may be utilised for such training.
17. It is desirable that adequate facilities should be provided to enable nurses belonging to any particular class to get successively higher types of training until they become graduates in nursing if they desire to do so. A method by which the maximum use of all available nursing personnel is promoted, is to supplement full-time nurses by the use of part-time workers wherever possible. Nurses often leave the profession after marriage if full-time service is insisted upon. Many married nurses would, however, be willing to take up part-time v/ork provided they do not have to move out of station. If local candidates are selected for training and are later employed in their own areas, without being moved into distant places,- many more candidates for nursing would become available.
18. DaisThe training of dais should be undertaken in those areas in which they are needed urgently. Preference should be given to women from the dai-class. The course should be of six months' duration and training should be given by public health nurses or health visitors who are qualified midwives.
19. Health visitors.-There is at present a marked shortage of candidates for health visitors' courses. The reason for this lies partly in inadequate facilities for midwifery training which is a prerequisite for the health visitors' course. Another factor is the lack of prospects of promotion for health visitors who do not have a certificate in general nursing also. Supervisory and teaching posts are so few in number that even health visitors possessing higher qualifications have small prospects of advancement in their own field. It is difficult to get health visitors for work in small towns and rural areas because quarters are not always provided for those who are not attached to hospitals. Yet another handicap for these personnel is disparity in emoluments. Allowances for food, uniform and washing are not admissible to health visitors.
20. There would be many advantages if all categories of nursing personnel (nurses, mid-wives and health visitors) should belong to a single service. At present public health nurses, health visitors and domiciliary mid-wives are not always part of a well-integrated nursing cadre. An integrated cadre assumes to some extent the same basic training for all members of the service. Already, there is a growing body of opinion that the nursing service for hospitals and for public health should be integrated into one service and that all nurses and midwives should also have adequate training in public health and domiciliary practice. In course of time this will certainly obviate the necessity of training a separate category of health visitors. Though the long-term objective may be to replace health visitors by nurses with public health training and midwives by auxiliary nurse-midwives, in view of the present acute shortage of health visitors, it is not advisable to discontinue training of health visitors. It is therefore essential that the existing facilities for the training of this category of personnel should be strengthened and broadened suitably so as to meet adequately the present needs and to facilhate the transition.
21. Auxiliary personnel.In considering the training programmes for auxiliary personnel, certain general principles may be stated. All training programmes should be closely related to the problem of employing the persons trained as soon as possible after training. Recruitment for training should be from amongst those who are resident in locaLareas, as far as possible, and provision for stipends should be made in order to enable deserving students from the lower income groups to avail of opportunities for training. The task of the auxiliary health worker is to supplement the contribution made by doctors and other highly trained personnel for promoting preventive and curative health activities in their various branches. The main purpose of training and employing auxiliary workers is to promote a speedy and relatively cheap expansion of health protection to the people. In most cases, corresponding to each of the main categories of fully trained personnel, there is room for an auxiliary worker. Thus, a sanitary inspector is an auxiliary worker in relation to public health engineer, a radiographer to the radiologist, a laboratory technician to the trained research worker in the laboratoiy. Similarly, to the doctor who is engaged in the ministration of preventive and remedial medical care, an auxiliary worker who is able to carry out a variety of preventive functions and is able at the same time to administer treatment of an elementary kind, can prove to be of real assistance. In the interests of ensuring health administration and medical care on sound lines, it is essential that auxiliary personnel should work under the supervision of fully trained professional people. Specific and well-defined functions should be laid down for each type of auxiliary worker. The main principle in the production of such a worker should be that within the limited field of work prescribed for him he should acquire a high degree of competence. It is not the ' intention that a type of auxiliary worker should be developed who is taught a smattering of a number of different types of health functions and becomes proficient in none.
22. Training programmes have to be based on certain minimum standards to be attained throughout the country. The Medical, Dental, Nursing and Pharmacy Councils of India ensure this in their respective fields of professional training. For sanitary inspectors, health assistants and certain other types of workers, such as laboratory technicians, such coordinating bodies with tlie necessary powers to promote the attainment of uniform minimum standards do not exist at-oresent. It is also essential that different types of auxiliary workers should have opportunities to rise in their own respective branches to higher grades of professional and administrative posts. Provision for enabling them to undertake further training, both general and professional, is therefore necessary.
23. The entire field of medical research was reviewed ten years ago by the Health Survey and Development Committee. The Committee drew attention to the lack of research in medical teaching institutions and viewed with concern the increasing attention given in research institutes to routine work such as manufacture of essential biologicals instead of to the development of research as such. It also expressed the view that research institutions needed additional personnel, material and equipment. Since these observations were made the situation has not improved.
24. In recent years a large number of new institutions for medical research have come into being. There is .now an institute for drug research as well as institutes for research in chest diseases, leprosy, cancer and mental health. Adequate facilities and funds should be provided to these institutions. Research institutions should also perform another essential function, namely, the training of workers in specialised fields of medical sciences. To achieve this object, research institutes should be brought into intimate association with universities.
25. An essential pre-requisite for promoting medical research is the provision of an adequate number of workers equipped for research. Since medical colleges are the main source for the recruitment of research workers in medical sciences, an atmosphere of research must be developed in these institutions. Association of research with teaching will improve the quality of teaching and foster a spirit of research among medical students, and also stimulate a proportion among them to take up research careers. In 1946 the Health Survey and Development Committee drew attention to 'the almost complete absence of organised medical research in the different departments of medical colleges'. A number of factors have contributed to this unsatisfactory position, such as excessive teaching loads, shortage of trained personnel, lack of the practice of team-work between the different departments in medical colleges and inadequacy of equipment During the past few years the Indian Council of Medical Research has given considerable support to research work in ntedical colleges. The Council has now the following programmes in view:
26. Next to creating a climate of research in medical colleges, the important step is to provide young and promising medical graduates with opportunities for training in research methods. It is proposed to provide junior members of the staff of non-clinical and clinical departments of medical colleges training in methods of teaching and research. One of the principal problems in medical administration is to attract and retain young and promising men to research as a vocation for life. The Indian Council of Medical Research has therefore worked out proposals for establishing a research cadre.
27. Before a new institute in any particular subject is thought of, it is necessary first to create a broad base in that subject in the country by supporting research units under competent workers, preferably in university departments. The Indian Council of Medical Research has established nine research units in certain specialised fields in different institutes. During the second five year plan new research units are to be developed" for the study of mycology, parasitology, paediatrics etc., which have not received enough attention in the past In some fields new institutes are required. Accordingly, it is proposed to set up an Institute of Biology, arid Institute for Research into Occupational Health and to expand the existing Virus Research Centre into a full-fledged Virus Research Institute. A number of specific research projects are also proposed to be carried out during the second plan. These pertain to the fields of nutrition, drug research, industrial health, maternal and child health, tuberculosis and environmental hygiene. A total provision of over Rs. 4 crores has been made for medical research programmes in the second plan.
28. Laboratory facilities for clinical and public health purposes are assuming an increasingly important place in health administration. In order to facilitate the setting up of and, where necessary, expanding existing laboratories in the States at all levels, a total provision of about Rs. 2.5 crores has been made. These laboratories will assist measures for disease control as well as those directed against adulteration of food and drugs.
29. There is at present a dearth of qualified statisticians in the field of health. Short courses in health statistics are provided in some medical institutions. It is recommended that such courses should be provided by all teaching medical institutions. There is need also for a sufficient number of persons with advanced training in statistics, with special reference to health statistics. The necessary arrangements are being made.
INDIGENOUS SYSTEMS OF MEDICINE
30. As against a provision ofRs. 37.5 lakhs made by the "Central Government in the first plan, the second plan provides Rs. 1 crore at the Centre and -Rs. 5.5 crores in the States for developing the indigenous systems of medicine. The plan provides for the development of the research centre and post-graduate institute at Jamnagar, the opening of five Ayurvedic colleges, expansion of thirteen existing colleges as well as for the starting of 1100 Ayurvedic dispensaries, herbaria and aushadhalayas. and improvement of 255 existing dispensaries. These schemes are expected to bring Ayurvedic institutions to a standard which would enable them to take up research programmes.
CONTROL OF COMMUNICABLE DISEASES
31. During the first plan some advance has been made in the attack on communicable diseases. The principal diseases in this group are malaria, filariasis, tuberculosis, leprosy and venereal diseases. For effective control of these diseases it is essential to have nation wide programmes for all the affected areas. As compared to Rs. 22 crores allotted in the first pain for the control of communicable diseases, the second plan provides about Rs. 58 crores.
32. Malaria Control.The malaria control programme has been one of the principal health programmes during the first five year plan. In the areas served by 162 units which have been established so far, 84 units have been in operation for three years. In areas served by these units, against an estimated incidence of about 60 million cases of malaria, there has been a reduction of about 20 million cases in the first year of operation. Proposals for the malaria control programme for the second five year plan are based on the following considerations:
It has been the general experience that a period of three years is required to reach the peak of operational efficiency. Control operations should be maintained at this level for a further period of at least two years before the programme is changed over to the maintenance phase.
33. The question arises as to the end point in the operational phase, the beginning of maintenance phase and the level at which measures are to be kept up during the latter period. The criteria for determining the end point of active operation, as now generally accepted, are:
The extent to which operations are to be kept up during the maintenance phase would be determined by the degree of fulfilment of the criteria mentioned above. If these criteria are met, three possible lines of action are:
In a sufficiently large area it may be possible to adopt one or more of the above alternatives, to watch the results and, in the event of no untoward happenings taking place, to stop further spraying.
34. So far there is no evidence of the development of resistance to D.D.T. in anophelines in this country, but there are a few reports of lowered susceptibility amongst the culicines. Further, in the experience of other countries both anophelines and culicines^ are reported to have developed resistance or lowered susceptibility to insecticides. It has however been noticed that it takes much longer for resistance to develop than to establish successful malaria control. It is therefore vital to achieve national coverage through adequate control measures and to maintain it before anophelines have a chance to develop resistance. A lowering of susceptibility to insecticides among anophelines and culicines is under active observation in this country both in the laboratory and in the field. The change-over from the operational phase to the maintenance phase requires not only a careful appraisal of the situation but also sustained vigilance which should be continued during the period of maintenance. It is considered that, in addition to routine checks by the staff members of each malaria control unit, special teams of competent workers should also carry out test checks from time to time.. Appraisal of results should be based on accepted malariometric data which are regularly collected. These have to be recorded, compiled and studied at the unit and State levels and for the country as a whole at the Malaria Institute. A total provision ofRs. 28 crores has been made in the plan for malaria control.
35. Filaria control. Experimental control of flla-riasis by adopting a single method of control, such as (a) drug administration (b) anti-adult mosquito measures and (c) anti-larval measures, was carried out for a period of four years in Orissa State. The results of these studies show that while, by and large, no single method yielded an adequate measure of control over the disease, anti-larval operations tended .to show a reduction in the rate of infection in the community from the end of the second year onwards, while measures against the adult mosquito demonstrated such a reduction only a little later. In the case of drug treatment 'there was considerable reduction in the infection rate in the first two years which was, however, followed by an increase in the rate thereafter. It is therefore expected that the proposed programme, for combining these measures will produce substantial results within a shorter period of time. Proposals included in the second plan comprise:
The plan has been prepared on the basis that about 25 million people are exposed to the risk in the country. The survey units which are operating in different parts of the country will no doubt provide more precise data on which to base an effective campaign against the disease. The plan ensures that in rural areas where malaria and fuariasis are both prevalent overlapping of effort is avoided: In India W. bancrofti is the more prevalent type of infection and in a large measure it is urban in distribution. As the vector is C. fatigans and as the permanent method of control against this vector would be by the provision of underground drainage, top priority should be given to drainage schemes in urban areas where fuariasis exists as a health problem. It is particularly important that simultaneously with the introduction of water supply in such areas drainage should also be provided. The plan provides about Rs. 9 crores for the continuance of 13 control units established during the first plan and for the setting up of 65 new units.
36. Tuberculosis: A programme of tuberculosis control, based on the following priorities with primary emphasis on prevention was initiated during the first five year plan:
It is proposed to expand tuberculosis control measures during the second plan period as a national programme.
37. To ensure that mass BCG vaccination campaign is completed according to schedule during the second plan period. States have been requested to draw up definite schemes, taking into consideration the size of the population to be covered, the number of teams needed for this purpose and the cost involved. As BCG vaccination is to be carried out as a part of the public health programme in the States, even after the termination of the present mass campaign, it is necessary that a certain number of persons employed in BCG work should be retained by the States on the permanent strength of the Public Health Department. By the end of the first plan over 70 million persons will be tuberculin tested and about 24.5 millions vaccinated with BCG. The target for the second plan is to complete the first round of the campaign by covering the entire susceptible population below 25 years of age.
38. As new anti-biotics make it possible to have a large number of tuberculosis patients treated in their homes, clinics have gained an importance. A clinic is ordmarily intended to function as a diagnostic, advisory and prevention unit, and to be able to offer some measure of specific treatment Clinics cannot serve their purpose effectively unless they are sufficient in number and of a certain minimum standard. Most of the existing clinics are of poor standard; few of them are equipped or staffed adequately to do preventive work or to provide an effective domiciliary service. During the second plan it is proposed to establish and expand about 200 clinics as against 166 set up during the first plan. The object is to provide one clinic at least in each district, preferably at its headquarters. For the successful working of these clinics it is necessary that they should have full-time doctors with a staff of health visitors and other ancillary personnel, the numbers depending on the area and the population to be served. These clinics should also have, as far as possible, a few beds at their disposal either directly attached to them or in nearby institutions for isolating and treating cases which cannot be treated in homes because of overcrowding or unhygienic conditions.
39. The establishment of a number of model tuberculosis centres, which would be useful for teaching and demonstration, has considerable importance because 3f shortage of personnel for manning T.B. services. These centres should preferably be attached to medical colleges and should be equipped with four main sections, namely, an epidemiological section for mass X-ray survey and BCG vaccination, a clinical .section for diagnosis and treatment, a bacteriological section and a domiciliary service under the direction of a public health nurse. The work of these sections .should be coordinated, emphasis being placed on preventive aspects. There are, at present, three such centres in New Delhi, Pataa and Trivandrum, and two more are likely to be established in the near future, at Madras and Nagpur. There is need for establishing many more such centres. It is therefore proposed to provide for ten such centres during the period of the second plan.
40. Stress is to be laid on providing simply designed and cheaply constructed institutions for the isolation of infective patients, especially in cases where isolation or treatment at home is impossible. These should, in the first instance, be in or near crowded areas where T.B. is most prevalent. Those who need advanced surgical treatment will be moved to institutions where the necessary facilities exist. About 4000 beds are likely to be added during the second plan.
41. Opening of after-care colonies and rehabilitation centres for persons who had suffered from tuberculosis needs no emphasis. There has been in existence an after care colony at Madanapalle for over 30 years where over 40 ex-patients are employed. Such facilities scarcely existed at other places prior to the first plan. A few centres were established during the first plan period- It is proposed to set up about ten such centres during the second plan and to provide facilities for teaching ex-patients suitable handicrafts which can be continued by them in their homes as a cottage industry.
42. A total provision of about Rs. 14 crores has been made for measures for the control of T.B. during the second plan.
43. Leprosy.According to estimates made by a committee appointed by the Government of India in 1953 for the control of leprosy, there are not less than 1.5 million persons suffering from leprosy. The incidence of the disease varies from region to region and is between 2 to 4 per cent rising to 10 per cent in certain districts and may be as high as 15 to 20 per cent in certain villages. The belt of highest incidence includes the whole of the east coast and south peninsula including West Bengal, South Bihar, Orissa, Madras, Travanpore-Cochin, Hyderabad and Madhya Pradesh. Treatment and prevention of infection in children is a basic step in the control of leprosy. The number of clinics, dispensaries or leprosaria for treatment of leprosy patients is extremely inadequate at present There is also lack of co-ordination between different agencies working in this field. The problem is to make treatment available in villages and as far as possible in homes. The eradication of leprosy calls for a nation-wide programme.
44. During the first plan, two main steps were taken for combating these disease. The first was the establishment of a Central Leprosy Teaching and Research Institute at Chingleput in Madras for the training of leprosy workers and for research on problems relating to leprosy. The second step was to launch a leprosy control programme. The futility of attempting isolation of leprosy cases in special leprosy homes, v/hich was taken in the past to be the main method of control in endemic areas, is recognised. With the discovery of sulphone therapy in leprosy a new approach is available for the control of the disease. The objective of the scheme is proper treatment and follow-up of all patients in the whole of the area under control together with case finding and preventive and educational work. Apart from clinical improvement, sulphone therapy brings about a gradual reduction in infectivity in patients. As it is not possible to initiate sulphone therapy on a mass scale simultaneously over all the endemic areas in the country, two types of control units, namely, study and treatment centres meant for research and evaluation, and subsidiary centres for survey and treatment were initiated in the first plan period. Four treatment and study centres and thirty-six subsidiary centres were approved during the first plan. It is proposed to continue the existing treatment and study centres and subsidiary centres as well as to open about eighty-eight new subsidiary centres. Provision has also been made for establishing beds for the isolation of acute cases, for the oorrection of deformities, and for setting up rehabilitation centres. A sum of about Rs. 4 crores is provided under the second plan for leprosy control programmes.
45. Venereal diseases:In the past the' problem of V.D. in the country as a whole, especially syphilis, has not received the attention it deserves from the public, from administrators and even from the medical profession, even though effective tools for rapid diagnosis and treatment exist The-methods now available for the rapid cure of syphilis and other major venereal diseases make it possible to bring down effectively the reservoir of infection in the population provided certain public health techniques are used in the programme of venereal diseases control. Venereal diseases have to be fought on three frontseducational, epidemiological and therapeutic. There are no accurate statistics regarding the prevalence of these diseases among the population. Such information as exists relates to surveys conducted in a certain number of places, as in Madras and Calcutta. Systematic serological screening of expectant mothers in maternal and child health centres shows that the incidence of syphilis varies from 5 to 8 per cent. of the adult population. In urban centres its incidence is higher than in rural areas. Generally speaking, hitherto, the procedure has been to establish treatment centres which carry a considerable load of patients. There is no indication as to how far such centres have contributed towards an effective campaign against V.D. A proper programme should lay stress on epidemiological investigation, education of the patients and their follow-up as well as case-finding activity. Special stress should be laid on the prevention of parental syphilis by routine serological screening of every pregnant woma,n and treatment of positive reactors.
46. As regards rural areas, the problem of organising a satisfactory campaign against V.D. is more difficult in view of the sparsely distributed population and inadequacy of the health stall in those areas. It is suggested that a V.D. control Programme should be started in health units at their headquarters and that it should be extended in due course, as and when more funds and trained personnel become available in the areas served by the health units. There is, however, a belt of rural territory along the foothills of the Himalayas where the prevalence of venereal diseases, particularly of syphilis, is known to be high. Concentrated efforts must therefore be made in these areas for a radical treatment of the V.D. problem.
WATER SUPPLY AND SANITATION
47. Waterbome and other allied diseases are responsible for a large incidence of mortality'and morbidity in the community, which can be brought under control by establishing protected water supplies and sanitary methods of excreta disposal. In the first five year plan, about Rs. 24 crores were provided by the States for urban and rural water supply and sanitation. Towards the end of 1954 a water supply and sanitation programme was formulated by the Central Government, under which Rs. 12 crores as loans for urban water supply schemes and Rs. 6 crores as grants towards rural water supply schemes were made available. The second plan makes a tentative provision ofRs. 53 crores for urban water supply and sanitation, Rs. 28 crores for rural water supply and a special provision of Rs. 10 crores for urban areas which have Corporations.
48. The schemes included in the first plan did not make satisfactory progress on account of shortage of material, inadequate transport facilities and the absence of adequate public health engineering Staff in the States to plan and execute the schemes. The rural portion of the work is not making satisfactory progress primarily due to lack of trained personnel and organisation. Rural works have been frequently executed by a variety of agencies and have become purely construction projects with little public health education of the villagers in the need for and use of sanitary facilities. Large numbers of villages have, however, improved their water supply through local development works and through the national extension and community development programme.
49. Progress in the implementation of water suppiy piogrammes depends a great deal on the availability of pipes, pumps and other equipment The requirements of cast iron and galvanised iron pipes for urban water supply during the last year of the first plan amounted to about 100,000 tons and will increase to about 125,000 tons per year during the second plan. As against this, the present production is in the neighbourhood of 60,000 tons per year of which about 50,000 tons is for water pipes.
50. During the first plan public health engineering organisations were set up at the Centre and in several States, but most of these organisations are not adequately staffed. Public health engineering organisations are needed in all States and they should have staff with special training in public health matters. Training facilities for public health engineers, overseers, sanitary inspectors etc., have to be greatly expanded. Accordingly, a provision of Rs. 50 lakhs has been made for this purpose in the second plan.
51. Nutrition is the most important single factor in the maintenance of health. With improvement in the production of cereals during the first plan, there will be greater stress now on increasing the production of protective foods such as milk, eggs, fish, meat, fruits and green vegetables. As it will not be possible to provide nutrition at optimum level to every body, priority in improving nutrition should be given to vulnerable groups of the population, namely, expectant and nursing mothers, infants, toddlers, pre-school children and children of school-going age. It is well known that any damage to proper growth and development, which may occur in these age groups owing to under-nutrition or mal-nutrition, cannot be entirely made good even by providing adequate nutrition at a later age. To the extent milk powder and food supplements like cod liver oil and vitamins are available for distribution, this consideration should be specially kept in view. Efforts to provide mid-day meals for school-going children should also be made. Provision has been made in the plan for schemes of nutrition research, nutritional surveys in national extension and community development areas, opening of diet kitchens in hospitals and establishment of nutritional laboratories and museums. Some of the important problems of nutrition taken up for study by the Indian Council of Medical Research are:
MATERNAL AND CHILD HEALTH
52. States have provided about Rs. 3 crores for the setting up of about 2,100 maternity and child health centres. These centres will be integrated with the primary health unit services. The need for proper training of medical and ancillary personnel to be employed in maternal and child health programmes is recognised and the plan makes the necessary provision.
53. At present paediatrics is the weakest link in maternal and child health services. It is essential to provide paediatric training to personnel incharge of maternal and child health centres in the paediatric departments of medical colleges and to equip and staff tbem suitably. Each paediatric department will select six existing maternal and child health centres and augment the staff of each with a doctor trained in paediat-ricts, public health nurse and other auxiliary staff. Their functions will be to take up combined preventive and curative paediatric care of children and to attend to school health in the elementary schools of the area, in addition to the ante-natal and obstetric service already being done. Protective protein foods, essential drugs and prophylactic vaccines will also be made available to each of the centres. To begin with, it is proposed to set up at least 5 paediatric training centres. These centres will arrange for the regular training of maternal and child health personnel and also give periodic refresher courses.
54. The problem of regulating India's population from the dual standpoint of size and quality is of the utmost importance to national welfare and national planning. The objectives set out in the first five year plan were:
The family planning programme was primarily directed to the building up of an active public opinion in favour of family planning and the promotion of family planning advice and service on the basis of existing knowledge. At the same time demographic as well as medical and biological studies were taken up. Assistance in the shape of subsidies or grants was given to States, local authorities, voluntary organisations and scientific institutions for about 115 family planning clinics and for 19 research schemes relating to biological and demographic problems. It is proposed to develop this programme further during the second plan.
55. The family planning programme has now gone far enough to call for its further development on systematic lines, for continuous study of population problems and for a suitable central board for family planning and population problems. Such an organisation should be more or less autonomous in its working. The main constituents in the Central Board's programme will be :
56. It is proposed to establish clinics, one for 50,000 population, in all big cities and major towns. As regards small towns and rural areas, clinics will be opened gradually, in association with primary health units. These clinics -are intended to create a general awareness of the problem and to provide advice and service. The establishment of a central training and clinical institute ' and a rural training unit near Bangalore are under consideration. A contraceptive testing and evaluation centre is being developed at Bombay. It is necessary that training in family planning should be imparted to all medical and nursing students. All hospitals and an increasing number of dispensaries should develop in due course a family planning service. It is also proposed to promote actively medical, biological and demographic research. A provision of nearly Rs. 5 crores has been made for family planning programmes. It is expected that about 300 urban and 2,000 rural clinics will be set up in the course of the second plan.
57. The medical and public health facilities which are provided will achieve their objective in the measure in which the people take full advantage of these facilities and change their own attitudes and practices. This calls for a special effort in support of health education. The primary object of health education is to help the people to achieve health by their own action and efforts. It therefore begins with the interest of the people in improving their conditions of living and aims at developing a sense of responsibility for their own health betterment as individuals and as members of local communities. The interests, needs and aspirations of the people themselves provide the starting point and the main motive force for enlisting their good-will and participation in local planning as well as in action. The guidance and help of experts is of course necessary. Health .education bureaux which and r being established at the Centre and iA the State Health Departments will attempt to provide inservice training for health workers, educational aids and consultative services in educational methodology as well as improved interpretation of health services.
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