Block-6

Skin, Eye And
Ear Infections
Block
6
PUBLIC HEALTH AND RELATED ISSUES
UNIT 19
Primary Health Care-I: Concept and Organisation 69
UNIT 20
Primary Health Care-II: Current Status in India 80
UNIT 21
Primary Health Care-III: Delivery of Services 107
UNIT 22
Health Programmes 127
UNIT 23
Income Generation Programmes 165
UNIT 24
Environmental Protection 199
65
Common
Infectious COURSE DESIGN (ORIGINAL)
Diseases
Prof. V.C. Kulandai Swamy Prof. H.P. Dikshit Prof. A.B. Bose
Vice Chancellor Pro-Vice-Chancellor Director
IGNOU, New Delhi IGNOU, New Delhi SOCE, IGNOU, New Delhi
Prof. P.R. Reddy Dr. Mehtab Bamji Prof. B.N. Koul
Vice-Chancellor National Institue of Executive Director
Sri Padmasvathi Mahila Nutrition STRIDE
Vishwa Vidyalyam, Tirupathi Hyderabad New Delhi
Mrs. Mary Mammen Mrs. Arvind Wadhwa Prof. Prabha Chawla
CMC Hospital Vellore Lady Irwin College School of Continuing
New Delhi Education, IGNOU
Dr. Mrs. S.R. Mudambi
New Delhi
W-163 'A', 'S' Block Dr. Annu J. Thoma
MIDC Pmpri, Bhosari School of Continuing Dr. Deeksha Kapur
Pune Education School of Continuing
IGNOU, New Delhi Education, IGNOU
New Delhi
BLOCK PREPARATION (ORIGINAL)
Block Coordinator Course Editor
Dr. K.V.R. Sarma Dr. Annu J. Thoma Prof. P.R. Reddy
National Institue of Nutrition School of Continuing Vice-Chancellor
Hyderabad Education Sri Padmasvathi Mahila
IGNOU, New Delhi Vishwa Vidyalyam,Tirupathi
COURSE REVISION TEAM (2014)
Prof. Deeksha Kapur Ms. Rajshree
Discipline of Nutritional Sciences Ms. Kusum Bhatt
SOCE, IGNOU, New Delhi Consultant, SOCE
IGNOU, New Delhi
COURSE REVISION TEAM (2022)
Prof. Deeksha Kapur Dr. Namrata Singh
Discipline of Nutritional Sciences Discipline of Nutritional Sciences
SOCE, IGNOU, New Delhi SOCE, IGNOU, New Delhi
PRINT PRODUCTION
Mr. Rajiv Girdhar Mr. Hemant Pardia
Asstt. Registrar Section Officer
MPDD, IGNOU, New Delhi MPDD, IGNOU, New Delhi
March, 2022
© Indira Gandhi National Open University, 2022
ISBN :
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or
any other means, without permission in writing from the Indira Gandhi National Open
University.
Further information about the School of Continuing and Indira Gandhi National Open
University courses may be obtained from the University’s Office at Maidan Garhi, New
Delhi-110 068.
Printed and published on behalf of the Indira Gandhi National Open University, New Delhi,
by Prof.Neerja Chadha, Director, School of Continuing Education, IGNOU, New Delhi.
Laser Typeset by: Tessa Media & Computers, C-206, Shaheen Bagh, Jamia Nagar, New Delhi-110025
Print at:
66
BLOCK 6 INTRODUCTION Skin, Eye And
Ear Infections
This block brings you to the end of course 2. In blocks 2-5, you have already
been exposed to common health problems existing in the community setting
– their nature, causes, treatment and preventions. Now, we bring a holistic
perspective to public health and related issues.
Units 19-21 focus on different aspects of the primary health care approach
and its application in our country. The concept, organisation and delivery of
services are discussed in detail alongwith information as out of the current
status of primary health care in India. Unit 22 talks about health programmes.
In Block 1 of this course, we had discussed one issue which is obviously
linked to public health – population. In this block some other issues related to
health are explored. Income is a major determinant of quality of life. Access
to bealth services may often be dependent on income. Therefore, programmes
which improve the purchasing power of people can influence health status of
communities. This is the theme of Unit 23.
Environmental protection is another crucial area which influences health.

Health and disease are, as you know, intimately related to environmental
factors such as water supply, sanitation and pollution. Unit 24 deals with
aspects of how man has damanged the environment in many ways due to
domestic and commercial activities. The implications of this for our health
are expanded upon along with possible solutions to environmental problems.
67
Common
Infectious
Diseases
68
UNIT 19 PRIMARY HEALTH CARE-I: Primary Health
Care-I:
CONCEPT AND ORGANISATION Conceptand
Organisation
Structure
19.1 Introduction
19.2 Health and Responsibility for Health
19.2.1 Different Levels of Health Care
19.2.2 Alma Ata Declaration
19.2.3 National Health Policy
19.3 Primary Health Care

19.3.1 Characteristics of Primary Health Care
19.3.2 Primary Health Care and Development
19.4 Let Us Sum Up

19.5 Glossary
19.6 Answers to Check Your Progress Exercises
19.1 INTRODUCTION
This unit tells about the traditional and modern concepts of health. Reading
through this unit will help you to know about the concept of Primary Health
Care, it’s characteristic features and how the concept is related to
development. The main points of Alma Ata Declaration, in which several
countries in the world committed themselves to make efforts to achieve a
minimal level of health care for their citizens by 2000 A.D. through the
Primary Health Care approach in the delivery of health care services is the
highlight of the unit.
Objectives
After studying this unit, you would be able to :
• define health and Primary Health Care, and

• describe main characteristics of Primary Health Care concept.
19.2 HEALTH AND RESPONSIBILITY FOR

HEALTH
Traditionally health has been viewed in its narrow connotation—an absence
of disease. However, with growing advancement and understanding of
various spheres, it has now been universally acknowledged that health has
much wider ramifications and should be perceived in its holistic perspective.
This has been reflected in the definition of health given by the World Health
Organisation as “Health is a state of complete physical, mental and social
well-being and not merely an absence of disease or infirmity”.
69
Public Health You might remember reading about the different components of health
and Related earlier. Let us quickly go through them again. Physical health is an important
Issues
component of total health. In good physical health the individual has a good
complexion, clean skin, bright eyes, lustrous hair, firm flesh, good appetite,
sound sleep, regular activity of bowel and bladder, and coordinated
movements of body. Mentally healthy person feels satisfied with himself, he
is well adjusted and has good self control. The concept of social health
connotes abilities such as those of making satisfying and lasting friendships,
assuming responsibilities in accordance with one's capacities, showing
socially considerate behavior and living effectively with others.
The constitution of India envisages that the state shall regard the raising of
the level of nutrition and standard of living of its people and the improvement
of public health as among its primary duties. This has resulted in a greater
degree of state involvement in the establishment of nationwide health system
of health care services in the country. The term health care services includes
not only the public health services, but also medical care, and related
education and research.
The health care services developed correspond to the health problems of the
community. This brings us to the crucial question what are the common
health problems in our country? By now you should be able to enlist them.
Let us briefly discuss each one of them.
Common Health Problems in India

The common health problems in India include :
i) Nutritional Disorders : Nearly 80 per cent of the children below the age
of five years are undernourished. 50 per cent of all pregnant and
lactating women have nutritional anaemia. Vitamin A deficiency is a
major problem in 1-3 years age group children. Iodine deficiency
disorders affect nearly 54 million people in India.
ii) Communicable Diseases : Malaria, Tuberculosis, Leprosy, Filaria,
Cholera etc. are few of communicable diseases which causes illnesses
in the community.
iii) Environmental Sanitation Problems: Lack of safe drinking water in
many areas of the country and unsafe methods of excreta disposal
increases the risk of infection and infestation. Unsanitary practice are
the most common causes of disease and death specially among
children and women.
We have just gone through the common health problems affecting people in
our country. In addition to these problems the increasing population of our
country is posing yet another health problem. Every year nearly 15 million
people are added to our population.
What is the government’s response to these problems? What are the health
care facilities provided? Who are the health care functionaries working
towards improving health? The following discussion answers these questions:
70
19.2.1 Different Levels of Health Care Primary Health
Care-I:
Health care is provided at three levels namely : Conceptand
Organisation
i) Primary level of Health Care : The most peripheral level of health care is
called primary level health care (Figure 19.1). In India a team of village
level functionaries namely village guide, trained dai, male and female
multipurpose worker provide primary level health care services to the
community. Most of the common health problems in the developing
countries can be managed by appropriately trained para-medical workers
like those mentioned above functioning at the village level. You will
learn about these functionaries in unit 20 section 20.3.
ii) Secondary level of Health Care : There are only few health problems
which require the services of professionals. This level of health care is
called secondary level of health care. These services are provided
through primary health centers, Community health centers, district
hospitals etc. Figure 19.1 gives information regarding the population
covered by this level of health care and corresponding expenditure
incurred on it.
iii) Tertiary level of Health Care : Very few health conditions requires
highly specialised type of health care services which are provided
through sophisticated hospitals like state hospitals and medical college
hospital, national institutes etc. This level of healthcare is called tertiary
level of health care which covers only one per cent population (Figure
19.1).
Fig 19.1: Levels of Health Care

From our discussion above it is evident that the effort of our government is to
provide effective and comprehensive health care for all segments of the
population. To improve on their services the government has adopted the
Alma Ata Declaration and is working towards providing health for all by the
year 2000 A.D. What is Alma Ata Declaration? Read the following
discussion to gain knowledge on this.
71
Public Health 19.2.2 Alma Ata Declaration
and Related
Issues The Health Assembly of the World Health Organisation (WHO) adopted
resolutions in 1976, concerning the provision and promotion of effective
comprehensive health care for all people and expressed the need to hold an
international conference to exchange experiences on the development of
Primary Health Care. The conference was held in Alma Ata, the capital of the
erstwhile Kazakh state of Soviet Socialist Republic in 1978. The
Intergovernmental conference was attended by delegations from 134
governments and by representatives of 67 United Nations Organisations,
specialised agencies, and nongovernmental organisation.
The conference ended with the following declaration:

i) The conference strongly reaffirms that health, which is a state of
complete physical, mental and social well being, and not merely the
absence of disease or infirmity, is a fundamental human right and the
attainment of the highest possible level of health is a most important
worldwide social goal.
ii) The existing gross inequality in the health status of the people is
politically, socially, and economically unacceptable and is, therefore, of
common concern to all countries. .
iii) Economic and social development is of basic importance to the fullest
attainment of health for all and to the reduction of the gap between the
health status of the developing and developed countries.
iv) The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.
v) Governments have a responsibility for the health of their people which
can be fulfilled only by the provision of adequate health and social
measures. A main social target of Governments, international
organisations and the whole world community in the coming decades
should be the attainment of a level of health by all people of the world by
the year 2000 that will permit them to lead a socially and economically
productive life.
vi) Primary health care is the key to attain this target.
vii) All governments should formulate national policies, strategies and plans
of action to launch and sustain primary health care as part of
comprehensive national health system.
viii) All countries should cooperate in a spirit of partnership and service to
ensure primary health care for all people.
ix) An acceptable level of health for all the people of the world by the year
2000 can be attained through a fuller and better use of the world’s
resources.
Our government abides by this declaration. Based on this, a national health

policy has been formulated. The policy is described in the following sub-
section.
72
19.2.3 National Health Policy Primary Health
Care-I:
To achieve the optimal utilization of resources and co-ordinate efforts of Conceptand
Organisation
different departments and ministries participating in promotion of health of
community members, the Government of India developed a National Health
Policy in 1983. The policy was revised in the year 2002, in view of the
developments in field of health and improvement in the national economy,
Ministry of Health and Family Welfare modified the NHP. The main strategy
advocated continues to implementation of the Primary Health Care approach.
It emphasizes that decentralized public health system should be implemented
with convergence of all health programs under one umbrella. The salient
highlights of the new national health policy are as follows:
• Improving Public Health Infrastructure

• Extending Public Health Services to community
• Human Resource Development for delivery of health care
• Increase in number of Medical and Dental Colleges
• Increase in facilities for specialization in Public Health and Family
Medicine
• Increase in Nursing Personnel
• Efficient Delivery of National Public Health Programmes
• Involvement of Non-Government Organizations for delivery of health
care
• Involvement of Private Sector for delivery of health care
• Improving supplies of Drugs and Vaccines
• Participation of Supportive Sectors in delivery of health care
• Priority for Population stabilization
• Inter-sectoral Contribution to Health
• Improving Information Education Communication in delivery of health
care
• Improvement in Medical Ethics and Legislation to improve health
• Developing Norms for Health Care Personnel
• Regulation of Standards in Education of personnel in Paramedical
Disciplines
• Enforcement of Quality of Standards for Food and Drugs
• Development of National Disease Surveillance System and
documentation of Health Statistics
• Improving Health research
• Improving Urban Health
• High priority to be accorded to Mental Health and Women's Health
• Environment Health and Occupation Health to be given priority 73
Public Health • Development of Medical Facilities for Overseas Users
and Related
Issues • Developing medical facilities and health care in country keeping global
development in the world
Check Your Progress Exercise 1

1) List the different dimensions of health.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) What are the three main health problems in our country?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
3) List the health workers involved at the primary levels of health care.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
4) List any five highlights of the National Health Policy.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
19.3 PRIMARY HEALTH CARE

The Alma Ata Declaration, you learnt, strongly recommended the
development of primary health care for all people. What is the concept of
Primary Health Care? We will learn about this in the next section.
There is wide gap between the health status of population in the different
countries and the developing world. This gap is also evident within the
individual developing countries between the health of “haves” and “have
nots”.
A better health status of community can be achieved with the technical

74 knowledge available. Unfortunately in most countries this knowledge is not
being put to the best advantage. Health resources are being allocated mainly Primary Health
to sophisticated medical institutions in the urban areas. Indeed, the Care-I:
Conceptand
improvement of health is being equated with the provision of medical care Organisation
through sophisticated hospitals. At the same time, disadvantaged groups have
no access to any permanent form of health care. Even when the health
facilities are located within easy reach, they are unable to pay or the cultural
taboos put them out of bounds. Moreover, most of the developing countries
have developed their health care delivery system based on the western model.
Thus most conventional health care systems are becoming increasingly
complex, costly and have doubtful social relevance.
So what is the alternative with the limited money available? The primary
health care is the answer to this problem. The Primary Health Care approach
is cost-effective, and has great impact on the health problems of the
community but it is difficult to introduce, On the other hand the specialized
health care is easy to introduce but it is expensive and has little effect on the
health problems. Let us understand the primary health care approach.
Primary Health Care is an approach to achieve an acceptable level of health

at reasonable cost throughout the world in a foreseeable future (Figure 19.2).
The World Health Organization defines primary health care as: "Essential
health care, made universally accessible to individuals and families in the
community in an acceptable and affordable way with their full participation".
This approach has evolved over the years, partly in light of the experiences,
positive and negative, gained in delivery of health care services in a number
of countries.
Primary Health Care addresses to the main health problems in the

community, providing promotive, preventive, curative and rehabilitative
services. In order to make health care universally accessible, involvement of
communities in planning, organization and management is essential and this
mobilization can be done through appropriate education.
The primary health care is most effective and economical, if it is delivered
through health workers selected from the local community and trained
properly considering the community health problems and its expressed health
needs. These community health workers should have the support of the
existing Government health system.
Since health cannot be attained by the health sector alone appropriate

measures are required from other sectors for economic development, food
production, water, sanitation, housing and education.
75
Public Health
and Related
Issues
Fig. 19.2 ; The Price of Health
Political commitment of Primary Health Care should also be forthcoming

which implies support from the government and community leaders. It also
requires reorientation of the national health development strategies and
transfer of a greater share of health resources to the underserved majority of
the population.
The basic characteristics of Primary Health Care are listed in the following
section.
19.3.1 Characteristics of Primary Health Care

Given below are the characteristic features of the primary health care :
i) It is essential health care which is based on practical scientifically sound

and socially acceptable methods and technology.
ii) It should be rendered universally acceptable to the individuals and
families in the community through their full participation.
iii) Its availability should be at a cost which the community and country can
afford.
iv) It addresses to the main health problems in the community, providing
preventive, promotive, curative and rehabilitative services.
v) It requires, in addition to the health sector, all related sectors of
community development.
vi) It requires and promotes maximum community and individual self-
reliance and their participation in the planning, organisation and
implementation, making full use of local resources.
vii) It has the integrated and functional referral system.
76
viii) It relies on local referral to health workers and community workers, Primary Health
suitably trained to work as health team and to respond to the expressed Care-I:
Conceptand
health needs of the community. Organisation
After understanding the concept of primary health care, you can very well
visualise how providing good health can go a long way in improving life and
good living. The discussion in the next Section 19.3.2 further highlights the
relationship between health and development.
19.3.2 Primary Health Care and Development

Development implies progressive improvements in the living conditions and
quality of life enjoyed by society and shared by its members. It is a
continuous process. Only when people have an acceptable level of health
they can enjoy the benefits, of development. Since primary health care is the
key to attaining an acceptable level of health by all, it helps people to
contribute to their own social and economic development.
As an example, the control of diseases by primary health care approach

would help to promote development in general. Proper nutrition and
reduction of sickness would increase work productivity. Breaking the vicious
cycle of malnutrition and infection improves the physical and mental
development of the child.

1) Define Primary Health Care.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
77
Public Health 2) List the four services to be provided by primary health care.
and Related
Issues ……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
19.4 LET US SUM UP

In this unit you have learnt the concept of health and primary health care.
Health has much wider dimensions in the areas of physical, mental and social
well-being rather than merely the absence of disease. The primary health care
concept is an alternative approach to the delivery of health services to the
community, in a much more economic and effective manner with full
involvement of local communities.
The unit also discussed the various characteristics of Primary Health care and
it described the international efforts made in this concept as Alma Ata
declaration.
19.5 GLOSSARY
Community A group of people living in a defined geographical area.

Community It is a process in which the people living in a defined
Participation geographical area identify goals, plan and implement
programmes to meet the decided goals..
Community The main health problems of the community.
Health Problems
Curative Services The services which are provided to the diseased person to
cure his disease, for example services provided in
hospitals to patients.
Essential health The minimal level of health care provided to a person
care which would enable him to lead a socially and
economically productive life.
Health care The health care services provided to the community. It
delivery services may be governmental or nongovernmental.
Preventive, The health care services provided to the community
service which prevent the occurrence of diseases, such as
vaccinations given to children.
Promotive The services provided to the members of the community
services to promote health and healthy habits.
Referral Services The services available at the next higher level health
institutions.
World Health The United Nations Agency working in the area of health
Organisation with headquarters at Geneva.
78
19.6 ANSWERS TO CHECK YOUR PROGRESS Primary Health
Care-I:
EXERCISES Conceptand
Organisation

i) Physical, Mental, Social.
ii) Nutritional deficiency disorders, Communicable diseases, Environmental
Sanitation
iii) ASHA
Trained Dai
Village health guide

Multipurpose worker (male and female)
iv) Increase in nursing personnel

Priority for population stabilization
Improving health research
Improving urban health

1) Essential health care made universally accessible to individuals and
families in the community in an acceptable and affordable way with their
full participation
2) Promotive, preventive, curative and rehabilitative.
79
Public Health
and Related UNIT 20 PRIMARY HEALTH CARE-II:
Issues
CURRENT STATUS IN INDIA
Structure
20.1 Introduction
20.2 Historical Perspective of Development of Health Care Delivery
Services
20.3 Current Status of Development of Primary Health Care Services
20.3.1 Multipurpose Worker (MPW) Scheme
20.3.2 Village Health Guide Scheme
20.3.3 Training of Village Dais
20.3.4 Accredited Social Health Activist (ASHA) scheme
20.4 Health Care Services at Different Levels

20.4.1 Village Level
20.4.2 Sub-centre Level
20.4.3 PHC Level
20.4.4 Community Health Centres
20.4.5 Taluka Hospital
20.4.6 District Level
20.5 Status of Health Infrastructure in India

20.6 Let Us Sum Up
20.7 Glossary
20.1 INTRODUCTION
This unit describes the historical development of health care delivery services
and the current status of Primary Health Care Services in India. It also
discusses the health delivery services available at the village sub-centre,
primary health centre, community health centre, taluka and district level.
Objectives
After studying this unit, you will be able to:
• describe the providers of primary health care services in India, and
• enumerate the institutions providing health services at different levels.
80
20.2 HISTORICAL PERSPECTIVE OF Primary Health
Care-II:
DEVELOPMENT OF HEALTH CARE Current Status
In India
DELIVERY SERVICES
The concern in health development and primary health care in India dates
back to the vedic period. In the Indus Valley Civilisation as back as 3000
B.C. one finds evidence of well developed underground drains, public baths,
etc. in the cities. Health was given high priority in daily life and this concept
of health included physical, mental, social and spiritual well-being. The life
style was conducive to health promotion and in the advocated daily activities
of life called the “Dina Charya”. The following essentials of health care were
emphasised: health education, personal hygiene, exercise, dietary practices,
food sanitation, environmental sanitation, code of conduct, self-discipline,
civic and spiritual values etc. Unfortunately, for various reasons particularly
due to foreign aggressions, Ayurvedic system failed to develop because of
lack of state patronage and recognition. During the middle of the 18th century
the British Government in India established medical services which were
primarily meant for the benefit of the British armed forces and a few
privileged civil servants. But the vast majority of the population was denied
access to the western medicine. Some preventive measures were provided for
control of epidemics and dispensaries were opened in some remote villages.
Provincial Health Departments were established in 1919, but neither health
planning nor medical education was related to the health needs of the people.
After Independence in 1947, the health care delivery services in health survey
and development committee (Bhore Committee) was appointed by the
Government to survey the existing health conditions and health organisation
in the country and to make recommendations for future development. The
Committee suggested the delivery of preventive, promotive and curative
health services to the rural masses through the Primary Health Centres.
A community development programme was launched in October 1952, for
the integrated all-round rural development. It was proposed to establish one
Primary Health Centre (PHC) for each Community Develpment Block. At
that time the operational responsibilities of the PHC were to provide medical
care : control of communicable diseases, Maternal and Child health, Nutrition
and Health Education, School Health, Environmental Sanitation and the
collection of vital statistics (Figure 20.1)
81
Public Health
and Related
Issues
Subsequently, the health services organisation and infrastructure has

undergone extensive changes and expansion following the review by a
number of expert committees, namely the Mudaliar Committee (1962), the
Mukherjee Committee (1965), and the Srivastava Committee (1975).
In 1978, India signed Alma Ata declaration and committed itself to attain a
minimum level of health care for all the citizens by 2000 A.D. The National
Health Policy of India was adopted in 1983, which has provided for
necessary political commitment to reorganise and reorient the health
infrastructure on the Primary Health Care Approach (Figure 20.2)
82 Fig. 202 : Primary Health Care Approach

20.3 CURRENT STATUS OF DEVELOPMENT OF Primary Health
Care-II:
PRIMARY HEALTH CARE SERVICES Current Status
In India
Keeping in view various recommendations of different committees, the

Government of India has introduced several innovative changes in the health
care delivery infrastructure. The various schemes introduced include:
20.3.1 Multipurpose Worker (MPW) Scheme

The MPW Scheme has been introduced in 1974 with the primary objective of
making the vertical unipurpose programmes into integrated multipurpose
ones. At the PHC level the para-medical staff has been redesignated as Health
Assistants— male and female. They act as supervisors for the multi-purpose
Health Workers—male and female, VHGs (health guides), dais and ASHA
posted at the sub-centres. The roles and responsibilities and the job
descriptions of these workers have been accordingly modified. Appropriate
training programmes under MPW scheme has also been organised for
reorientation of these workers at different levels about the various health
activities to be undertaken.
Under the multipurpose workers scheme, a health worker (male/female) is

expected to cover a population of 5,000 wherein he/she carries out the
responsibilities as indicated.
Job Responsibility of Multi purpose Health Worker (Male)

• MALARIA
o Identify fever cases
o Make thick and thin blood films of all fever cases ...
o Send the slides for laboratory examination
o Administer presumptive treatment to all fever cases
o Record the results of examination of blood film
o Refer all cases of positive blood films to the health assistant (male)
for medical treatment
o Educate the community on the importance of blood film
examination for fever cases, treatment of fever cases, insecticidal
spraying of houses, larviciding measures, and other measures to
control the spread of malaria.
• COMMUNICABLE DISEASES
o Identify cases of notifiable diseases, i.e. cholera, plague,
poliomyelitis, and persons with continued fever, or prolonged cough,
or spitting of blood, which he comes across during his home visits
and notify the health assistant (male) and primary health centre
about them.
o Carry out control measures until the arrival of the health assistant
(male)
83
Public Health o Educate the community about the importance of control and
and Related preventive measures against communicable diseases including
Issues
tuberculosis.
o Report the presence of stray dogs to the health assistant (male)
• ENVIRONMENTAL SANISTATION
o Chlorinate public water sources including wells at regular intervals
o Educate the community on (a) the method of disposal of liquid
wastes; (b) the method of disposal of solid wastes; (c) home
sanitation; (d) advantages and use of sanitary type of latrines; (e)
construction and use of smokeless chulhas.
o Help the community in the construction of (a) soakage pits; (b)
kitchen garden; (c) manure pits (d) compost pits; (e) sanitary
latrines.
• IMMUNISATION
o Administer DPT, BCG, measles and oral poliomyelitis vaccination
to all eligible children.
o Assist the health assistant (male) in the school immunisation
programme.
o Educate the people in the community about the importance of
immunisation against the various communicable diseases.
• TRAINING
o Organise and conduct training for dais with the assistance of the
health worker (female).
• MATERNAL AND CHILD HEALTH
o Conduct weekly MCH clinics at each sub-centre with assistance of
the health worker (male).
o Respond to calls from the health worker (female) and trained dais
and from the health worker (male) in the twilight, and render
necessary help.
• FAMILY WELFARE
o Conduct weekly family welfare clinics (alongwith the MCH clinics)
at each sub-centre with the assistance of the health worker (female).
o Motivate resistant cases for family planning.
o Provide information on the availability of services for medical
termination of pregnancy and refer suitable cases to the approved
institutions.
o Guide the health worker (female) in establishing female depot
holders for the distribution of contraceptives and train the depot
holders with the assistance of the health worker (female).
84
• NUTRITION Primary Health
Care-II:
o Identify cases of malnutrition among infants and young children Current Status
In India
(zero to five years), give the necessary treatment and advice and
refer serious cases to the primary health centres.
• PRIMARY MEDICAL CARE
o Provide treatment for minor ailments, provide first aid for accidents
and emergencies, and refer cases beyond her competence to the
primary health centre or nearest hospital.
• HEALTH EDUCATION
o Carry out educational activities for MCH, family planning, nutrition
and immunisation with the assistance of the health worker (female).
o Arrange group meeting with leaders and involve them in spreading
the message for various health programmes.
o Organise and conduct training of women leaders with the assistance
of health worker (female).
o Organise and utilise mahila mandals, teachers and other women in
the community in the family welfare programme.
• Job Responsibility of Multipurpose Health Worker (Female)
She will carry out the following functions :
• MATERNAL AND CHILD HEALTH
o Register and provide care to pregnant women throughout the period
of pregnancy.
o Test urine of pregnant women for albumin and sugar during her
home visits and at the clinic.
o Refer cases of abnormal pregnancy and cases with medical and
gynaecological problems to the health assistant (female) or the
primary health centre.
o Conduct about 50 per cent of total deliveries in her area.
o Supervise deliveries conducted by dais and assist them whenever
called in.
o Refer cases of difficult labour and newborns with abnormalities and
help them to get institutional care and provide follow-up care to
patients referred to or discharged from hospital.
o Make up at least three postnatal visits for each delivery conducted in
the intensive area and render advice regarding care of the mother
and care of feeding of the newborn. .
o Assess the growth and development of the children and take
necessary action.
o Help the medical officer and health assistant (female) in conducting
MCH and family planning clinics at the sub-centres.
85
Public Health o Educate mothers individually and in groups for better family health
and Related including MCH, family planning, nutrition, immunisation, control of
Issues
communicable diseases, personal and environmental hygiene and
care of minor ailments.
• FAMILY PLANNING
o Utilise the information from the Eligible Couple Register for the
family planning programme.
o Spread the message of family planning to the couples and motivate
them for family planning individually and in groups.
o Distribute conventional contraceptives to the couples, provide
facilities and help the prospective acceptors in getting family
planning services, if necessary, by accompanying them or arranging
for the dais to accompany them to hospital.
o Provide follow-up services to female family planning adopters,
identify side- effects, give treatment on the spot for side-effects and
minor complaints and refer those cases that need attention by the
physician to the PHC/hospital.
o Establish female depot holders, help the health assistant (female) in
training them, and providing a continuous supply of conventional
contraceptives, to the depot holders.
o Build rapport with acceptors, village leaders, dais and others and
utilise them for promoting family welfare programmes.
o Participate in mahila mandal meetings, and utilise such gatherings
for educating women in family welfare programmes.
• FAMILY WELFARE
o Conduct weekly family welfare clinics (alongwith the MCH clinics)
at each sub-centre with the assistance of the health worker (female).
o Motivate resistant cases for family planning.
o Provide information on the availability of services for medical
termination of pregnancy and refer suitable cases to the approved
institutions.
o Guide the health worker (female) in establishing female depot
holders for the distribution of contraceptives and train the depot
holders with the assistance of the health worker (female).
• MEDICAL TERMINATION OF PREGNANCY
o Identify the women requiring help for medical termination of
pregnancy and refer them to the nearest approved institution.
o Educate the community of the availability of services for medical
termination of pregnancy.
86
• NUTRITION Primary Health
Care-II:
o Identify cases of malnutrition among infants and young children (0-5 Current Status
In India
years), give the necessary treatment and advice and refer serious
cases to the PHC.
o Distribute iron and folic acid tablets as prescribed to pregnant and
nursing mother, infants and young children (0-5 years) and family
planning acceptors.
o Administer vitamin A solution as prescribed to children (from 1 to 5
years).
o Educate the community about nutritious diet for mothers and
children.
o Identify cases of notifiable diseases i.e. cholera, plague,
poloimyelitis, and persons with continued fever of prolonged cough,
or spitting of blood, which she comes across during her home visits
and notify the health worker (male) about them.
• IMMUNISATION
o Administer DPT, CG, measles and oral poliomyelitis vaccination to
all eligible children.
o Immunise pregnant women with tetanus toxoid.
o Assist the health assistant (male) in the school immunization
programme.
o Educate the people in the community about the importance of
immunization against the various communicable diseases.
• DAI TRAINING
o List dais in area and involve them in promoting family welfare.
o Help the health assistant (female) in the training programme of dais.
• VITAL EVENTS
o Record births and deaths occurring in the area in the births and
deaths register and inform them to the health worker (male).
• RECORD KEEPING
o Register (a) pregnant women from three months of pregnancy
onward; (b) infants zero to one year of age; and (c) women aged 15-
44 years through systematic home visits.
o Maintain the prenatal and maternity records and child care records.
o Assist the health worker (male) in preparing the Eligible Couple
Register and maintaining it up-to-date.
o Prepare and submit the prescribed periodical reports in time to the
health assistant (female).
87
Public Health o Prepare and maintain maps and charts for her area and utilise them
and Related for planning her work.
Issues
• TRAINING
o Organize and conduct training for dais with the assistance of the
health worker (female).
• PRIMARY MEDICAL WORK
o Conduct weekly MCH Clinics at each sub-centre with assistance of
the health worker (male).
o Provide treatment for minor ailments, provide first aid for accidents
and emergencies, and refer cases beyond her competence to the
primary health centre or nearest hospital.
• HEALTH EDUCATION
o Carryout educational activities for MCH, family planning, nutrition
and immunization with the assistance of the health worker (female).
o Arrange group meeting with leaders and involve them in spreading
the message for various health programmes.
o Organize and conduct training of women leaders with the assistance
of health worker (female). Organise and utilise mahila mandals,
teachers and other women in the community in the family welfare
programme.
• TEAM ACTIVITIES
o Attend and participate in staff meetings at primary health
centre/community development block or both.
o Coordinate her activities with the health worker (male) and other
health workers including the health guides and dais.
o Meet with the health assistant (female) each week and seek her
advice and guidance whenever necessary.
o Maintain the cleanliness of the sub-centre.
o Participate as a member of the team in camps and campaigns.
20.3.2 Village Health Guide Scheme

This scheme was introduced as Community Health Volunteers (CHVs)
Scheme in the year 1977. The designation of the CHVs has recently been
changed to Health Guide (HG). The HGs are chosen/selected from the
community and they work part-time on voluntary basis (Figure 20.3).
88
Primary Health
Care-II:
Current Status
In India
Fig. 20.3 : Health Guide—a part time worker
Their main role is to assist in the preventive and promotive aspects of health
care and to provide curative services for minor ailments and to make referrals
of problem cases either to the sub-centre or to the visiting mobile medical
team (Figure 20.4).
A health guide is expected to cover the population of a village or if the village is a

large one, a population of about 1,000. He/She receives technical guidance from the
health worker (male/female).
Fig. 20.4: Health guide – working in a community
Job Functions Of Health Guide

• MALARIA
o Identify fever cases.
o Make thick and thin blood films of all fever cases. 89
Public Health o Send the slides for laboratory examination. '
and Related
Issues o Administer presumptive treatment to fever cases.
o Keep a record of the persons given presumptive treatment.
o Inform health worker (male) of the names and addresses of cases
from whom blood slides have been taken.
o Assist health worker (male) and the spraying teams in spraying and
larvicidal operations.
o Educate the community on how to prevent malaria.
o Inform the health worker (male) immediately when epidemic occurs
in his/her area.
o Take immediate precautions to limit the spread of disease.
o Educate the community about the prevention and control of
communicable diseases.
• ENVIRONMENTAL SANITATION AND PERSONAL HYGIENE
o Chlorinate drinking water sources at regular intervals.
o Keep a record of the number of wells chlorinated.
o Assist the health worker (male) in arranging for the construction of
the following:
 Soakage pits
 Kitchen gardens
 Compost pits
 Sanitary latrines
 Smokeless chulhas
• Educate the community about the following :
o Safe drinking water
o Hygienic methods of disposal of liquid waste
o Hygienic methods of disposal of solid waste
o Home sanitation
o Kitchen gardens
o Advantages and use of sanitary latrines
o Advantages of smokeless chulhas
o Food hygiene
o Control of insects, rodents and stray dogs
o Educate the community about the importance of personal hygiene.
90
• IMMUNISATION Primary Health
Care-II:
o Assist the health worker (male/female) in arranging for Current Status
In India
immunisation.
o Educate the community about immunisation against diphtheria,
whooping cough, tetanus, tuberculosis, poliomyelitis.
• FAMILY PLANNING
o Spread the message of family planning to the couples in his/her area
and educate them about the desirability of the small family norm.
o Educate the people about the available methods of family planning
o Act as a depot holder, distribute nirodh to the couples, and maintain
the necessary records of nirodh distributed.
o Inform the health worker (male/female) of those couples who are
willing to accept a family planning method so that he/she can make
necessary arrangements.
o Educate the community about the availability of services for medical
termination of pregnancy (MTP).
• NUTRITION
o Identify cases with signs and symptoms of malnutrition among pre-
school children (one to five years) and refer to the health worker
(male/female).
o Identify cases with signs and symptoms of anaemia in pregnant and
nursing women and children and refer them to health worker
(male/female) for treatment.Assist health worker (male/female) in
administering vitamin A solution as prescribed to children.
o Teach families about the importance of breastfeeding and the
introduction of supplementary weaning foods.
o Educate the community about nutritious diet for mothers and
children.
• VITAL EVENTS
o Report all births and deaths in his/her area to the health worker
(male).
o Educate the community about the importance of registering all births
and deaths.
• FIRST-AID IN EMERGENCIES
o Give emergency first-aid for the following conditions. Refer these
cases to the primary health centre as necessary and inform the health
worker (male/ female).
 Dressing
 Electric shock
 Heat stroke
91
Public Health  Snake bite
and Related
Issues  Scorpion sting
 Insect stings
 Dog bite
 Accidents
o Carry out first aid procedures in dealing with accidents.
o Keep a record of first-aid given to each patient.
• TREATMENT OF MINOR AILMENTS
o Give simple treatment for the following signs and symptoms and
refer cases beyond his/her competence to the sub-centre or primary
health centre :
 Fever
 Headache
 Backache and pain in the joints
 Cough and cold
 Diarrhoea
 Vomiting
 Pain in the abdomen
 Constipation
 Toothache
 Ear-ache
 Sore eyes
 Boils, abscesses and ulcers
 Scabies and ringworm
o Keep a record of the treatment given to each patient.
• MENTAL HEALTH
o Recognise signs and symptoms of mental illness and refer these
cases to health worker (male/female).
o Give immediate assistance in emergencies associated with mental
illness.
o Educate the community about mental illness.
20.3.3 Training of Village Dais

The Government of India launched a scheme in 1976 for training the
Traditional Birth Attendants (TBAs) i.e. the dais working in the villages. The
aim of the scheme is that at least one trained dai should be available in every
village having 1,000 population. More than 3,50,000 of village dais have so
far been trained for conducting safe and aseptic deliveries, in addition to
92
providing other MCH care. (Source : Annual Report 1990-91, Ministry of Primary Health
Health and Family Welfare, Government of India). They are expected also to Care-II:
Current Status
motivate women for acceptance of family planning. The dais spend 2 days In India
per week in either the PHC or in the sub-centre. They accompany the female
health worker to the village.
Job functions of trained dais _

The Dai is an important person in her village. She serves as a link between
the families in her village and the health worker (female). The responsibilities
assigned to improve mother and child health in village are following :
i) She should contact every pregnant woman in her area and ensure that she
is registered at the sub-centre or primary health centre.
ii) She should attend the weekly prenatal clinic and assist the health worker
(female)
iii) She should try to ensure that every pregnant woman in her area attends
the prenatal clinic at least three times, i.e. after the third month to
confirm pregnancy, during the seventh month, and during the nine
month.
iv) She should try to ensure that every pregnant woman is immunised
against tetanus (two doses—the last dose at least one month before the
delivery and the first dose one month before the last).
v) She should try to ensure that every pregnant woman takes iron and folic
acid tablets as prescribed.
vi) If any abnormal pregnancy is detected she should show the case
immediately to the female health worker/ANM or health assistant /LHV
or refer the case to the PHC.
vii) She should ensure that preparations for delivery are made either at home
or at the PHC or hospital.
viii) If she finds any abnormality during labour she must seek medical aid
without delay.
ix) When she receives a call for delivery.
• She should take her kit with her. ‘
• She should watch the progress of labour carefully.
• She should allow labour to progress normally without any
unnecessary interference.
• She should observe aseptic techniques while conducting the
delivery.
x) She should see that her kit is always replenished, clean, and ready for use
during a delivery.She should make the mother and baby comfortable and
attend to the nutrition of both.
xi) She should instruct the mother and the relatives as to when she should be
called immediately, e.g. in case the mother has excessive bleeding or
there is bleeding from the baby’s cord. 93
Public Health xii) In the postnatal period if she finds any complications in the mother, e.g.
and Related fever or foul discharge from vagina, or in the baby cord infection or
Issues
jaundice, she should immediately inform the health worker (female) /
ANM or refer the mother or baby to the PHC.
xiii) She should try to ensure that all infants in her area are immunised with
BCG, DPT and poliomyelitis vaccine.
xiv) She should motivate the eligible couples in her area to use a
contraceptive method or to undergo sterilisation.
xv) She should distribute nirodh, foam tablets, and jelly to those couples who
require these contraceptives.
xvi) She should report all birth and deaths in her area to the health
worker/ANM.

1) List any five services provided by the PHC.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) Enlist the five job responsibilities of multipurpose workers.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
3) Mention five job responsibilities of health guide.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
4) Mention five important activities of trained dais.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
94
20.3.4 Accredited Social Health Activist (ASHA) Scheme Primary Health
Care-II:
The Government of India has decided to launch a National Rural Health Current Status
In India
Mission (NRHM) to address the health needs of rural population, especially
the vulnerable sections of society. Presently, the ANM is heavily
overworked, which impacts outreach services in rural areas. A new band of
community based functionaries, named as Accredited Social Health Activist
(ASHA) has been created to fill this void.
Job Functions of ASHA

ASHA is the first port of call for any health related demands of deprived
sections of the population, especially women and children, who find it
difficult to access health services. ASHA is health activist in the community
who will create awareness on health and its social determinants and mobilize
the community towards local health planning and increased utilization and
accountability of the existing health services. She would be a promoter of
good health practices. ASHA will also provide a minimum package of
curative care as appropriate and feasible for that level and make timely
referrals.
ASHA roles and responsibilities are as follows:

1. ASHA will take steps to create awareness and provide information to the
commmity on determinants of health such as nutrition, basic sanitation &
hygienic practices, healthy living and working conditions, information
on existing health services and the need for timely utilization of health &
family welfare services.
2. ASHA will counsel women on birth preparedness, importance of safe
delivery. breast-feeding and complementary feeding, immunization,
contraception and prevention of common infections including
Reproductive Tract Infection/Sexually/Transmitted Infection (RTIs/
STIs) and care of the young child.
3. ASHA will mobilize the community and facilitate them in accessing
health and health related services available at the village/sub-
center/primary health centers such as Immunization, Ante Natal Check-
up (ANC), Post Natal Check-up (PNC), ICDS, sanitation and other
services being provided by the government.
4. ASHA will work with the Village Health & Sanitation Committee of the
Gram Panchayat to develop a comprehensive village health plan.
5. ASHA will arrange escort/accompany pregnant women & children
requiring treatment/ admission to the nearest pre-identified health facility
i.e. Primary Health Centre/ Community Health Centre/ First Referral
Unit (PHC/CHC/FRU).
6. ASHA will provide primary medical care for minor ailments such as
diarrhoea, fevers, and first aid for minor injuries. She will be a provider
of Directly Observed Treatment Short-course (DOTS) under Revised
National Tuberculosis Control Programme.
95
Public Health 7. ASHA will also act as a depot holder for essential provisions being made
and Related available to every habitation like Oral Rehydration Therapy (ORS), Iron-
Issues
Folic Acid Tablet (IFA), chloroquine, Disposable Delivery Kits (DDK),
Oral Pills & Condoms, etc. A Drug Kit will be provided to each ASHA.
8. ASHA will inform about the births and deaths in her village and any
unusual health problems./disease outbreaks in the community to the Sub-
Centres/Primary Health Centre.
9. ASHA will promote construction of household toilets under Total
Sanitation Campaign
20.4 HEALTH CARE SERVICES AT DIFFERENT

LEVELS
The overall health infrastructure in the country has been expanded
considerably in the past 60 years. According to the decision of the
Government, the following types of infrastructure facilities and health
functionaries have been developed.
Health care facilities/Health functionaries at different levels :
Village level VHG, Trained Dais

Sub-centre level Male and female multipurpose workers
PHC level Medical officers. Health assistants–male and female
Taluka level Specialists in important disciplines of, medical
sciences
Community Health Specialists in important disciplines of medical
Centre level sciences
District level Specialists in important disciplines of medical
sciences
20.4.1 Village Level

For 1,000 population in a village, there can be at least one HG and one
trained dai. They are to be trained at the level of PHC and sub-centre and
their technical and supportive supervision including continuing education is
done by Health Worker— male and female—posted at the sub-centre. Other
administrative control and supervision of these health functionaries are to be
ideally carried out by Village Health committee and the Village Panchayat.
The Health Guide and Trained Dais and ASHA work under the supervision
and support of Health Workers (male and female).
The organisation of primary health care at the village level is summarised in

Table 20.1
96
Table 20.1: Facilities at Village Level Primary Health
Care-II:
Current Status
Population Manpower Services provided In India
covered provided
1,000 1 health guide Treatment of minor ailments, MCH and
family planning, Environment Sanitation
1 Village 1 trained dai Conducting safe deliveries, family
planning advice
1,000 1 ASHA Maternal and Child Health
20.4.2 Sub-Centre Level

There is one multipurpose Health Worker — male and female — in each sub-
centre. He/She carries out in addition to her own activities supporting
supervision of the trained dais as well as the HGs. The cases which need the
higher medical skills are referred to the PHCs or to the visiting medical team
from the PHC. To provide the effective coverage, additional sub-centres have
been created or established to achieve a target of 1 per 5,000 (1 for 3000-
5000 population in hilly, desert and difficult terrain). The health workers at
the sub-centre provide treatment of minor ailments, provide first-aid for
accidents or emergencies and refer cases beyond their competence to Primary
Health Centre. In addition they carry out health education activities,
chlorination of water sources, implementation of various National Health
Programmes and Family Planning Services to the rural masses. Table 20.2
presents the primary health care system at sub-centre level
Table 20.2: Facilities at Sub-Centre Level
Population Manpower provided Services Provided

covered
5000/unit 1 Male Multipurpose Worker Health education
1 Female Multipurpose Worker activities Chlorination of
water, Implementation of
National Health
programmes Family
Planning
20000/unit 1 Male and female Health Supportive, supervision
Assistants and assistance of
multipurpose workers
activities
20.4.3 PHC Level

Primary Health Centre provides not only provide basic health services, but
also referral. PHC is the peripheral and yet most vital outpost around which
rural health care services are built and delivered to the community.
The numbers of PHCs have been increased to achieve a target of 1 per 30,000
population. In addition, in selected places in rural areas, there are
dispensaries to provide curative services. Majority of these dispensaries are 97
Public Health being upgraded to form subsidiary health centres to bring them at par with
and Related PHCs.
Issues
At the PHC level there are medical officers (2 to 3), Block Extension
Educator (BEE)-1, Health Assistants—male and female. Health Workers—
male and female—and other supportive staff. At PHCs curative services,
preventive and promotive aspects of health care, organisation of training
programmes and continued education activities for the sub-centre staff and
health functionaries at the village level are provided. The Health Assistants
supervise the activities of the Health Workers and the village functionaries
i.e. HGs and Dais. The BEE is responsible for the IEC (Information
Education and Communication) programme in the area covered by the PHC
Table 20,3 presents the organisation of health facilities at PHC level.
Table 20.3: Facilities at the PHC level
Population Manpower provided Services provided

covered
30,000 Medical Officer Leadership and Monitoring,
Supervising preventive, promotive
and curative services
Block extension IEC activities
educator
Health Assistant Preventive , promotive and curative
(male, female) services, supportive supervision to
village level functionaries
Health workers Preventive , promotive and curative

(male, female) services
ASHA Preventive , promotive and curative
services
Recently, Government of India has created a post of Community Health

Officer (CHO). The main responsibility of the CHO will be the organisation
of preventive and promotive aspects of health care services. The BEE are
being trained to provide health education to masses.
20.4.4 Community Health Centres

For a successful primary health care programme, effective referral support is
to be provided. To achieve this, it has been decided that to establish one
community health centre for 100,000 population. At CHC all the speciality
services including Medicine, Surgery, Gynecology and Obstetrics and
Pediatrics would be available. The cases which could not be dealt with at the
Primary Health Centre, would be referred to the Community Health Centre. It
is proposed that every 4th PHC would be upgraded to community health
centres having 30 beds.
98
20.4.5 Taluka Hospital Primary Health
Care-II:
Some of the taluka hospitals have been strengthened by providing a post- Current Status
In India
partum centre alongwith its infrastructure inputs. These hospitals are to
provide referral services support to the peripheral centres.
20.4.6 District Level

District hospital have been strengthened to cater to the needs of the
expanding rural health and family welfare programmes. Not only the
planning and implementation and monitoring of Health and Family Welfare
Programmes are carried out at the District level, but all the referral services
from the periphery i.e. PHCs, Community Health Centres, Taluka hospitals
are to be attended to satisfactorily. Services of specialists of all major
disciplines of medicines are made available. Figure 20.5 summarises the
health service delivery system in India.
Fig. 20.5 : Health Service Delivery System
Table 20.4,20.5 and 20.6present the existing and recommended staffforthe

population covered at the sub centre, PrimaryHealth Centre and Community
Health Centre.
Table 20.4: Staff at the Sub Centre (3000-5000 Population)
Manpower Existing
Health Worker (F) 1
Health Worker (M) 1
ASHA 1
Trained Dai 1
99
Public Health Table 20:5: Staff at the Primary Health Centre (20,000-30,000
and Related
Issues
Population)
Staff Existing Recommended

Medical officer 1 3 (At least 1 female)
AYUSH Practitioner Nil (AYUSH or any ISM
system prevent locally)
Account Manager Nil 1
Pharmacist 1 2
Nurse – midwife (F) 1 5
Health worker (F) 1 1
Health Educator 1 2
Health Asstl (Male and 1 each 1 each
Female)
Clerks 2 2
Laboratory Technician 1 1
Driver Optional/vehicles may be
outsourced
Class IV 4 4
Total 15 24/25
Table 20.6: Staff at the Community Health Centre (80,000-120,000

Population)
Staff Existing Recommended

Medical Officer 1 3 (At least 1 female)
AYUSH Practitioner Nil (AYUSH or any ISM system prevalent
locally)
Account Manager Nil 1
Pharmacist 1 2
Nurse-midwife (F) 1 5
Health Workers (F) 1 1
Health Educator 1 2
Health Asstt (Male & 1 each 1 each
Female)
Clerks 2 2
Laboratory Technician 1 1
Driver 1 Optional/vehicles outsourced
Class IV 4 4
Total 15 24/25
You have just learnt ahout the health services provided by the government at
100
different levels. Primary Health
Care-II:
Current Status
In India
Figure 20.6: Health systems in less developed countries
The indicators of health achieved by the Government in the past years

are as follows.
INDICATOR 1951 1981 2000 2010-

11
I. DEMOGRAPHIC
CHANGES
Life Expectancy 36.7 54 64.6 65.96
Crude Birth Rate 40.8 33.9 25 20.22*
(SRS)
Crude Death Rate 25 12.5 8.5 7.4*
(SRS)
IMR 146 119 68 44
II. EPIDEMIOLOGICAL
SHIFTS
Malaria (cases in million) 75 2.7 2.2 -1.31
Leprosy cases per 10,000 57.3 3.74 0.69
population
Small Pox (No, of cases) 44,887 Eradicated Eradicated —
Guineaworm (No. of cases) 39,792 Eradicated —
Polio (No, of cases) 29,709 265 Polio
Free
101
Public Health
and Related
20.5 STATUS OF HEALTH INFRASTRUCTURE
Issues IN INDIA
The status of health infrastructure in our country is as follows:
Status of Health Infrastructure in India
1st Plan 10th Plan 11th Plan

1951-56 2002-2007 2007-2012.
(March (March
2007) 2012)
1. Primary Health Centres 725 22,370 24448
(PHC)
2 Subcentres (SC) NA 145,272 151684
‫د‬٠ Community health centres - .4,045 5187
4. Total beds (2002.) 125,000 914,543 628708
5. Medical colleges 42 270 381
6. Annual admissions in medical 3,500 30,408 42576
colleges
7. Dental colleges 7 205 301
8. Allopathic doctors 65,000 767,500 106813
9. Nurses (pegcelered Nurse and 18,500 928,149 1562186
Mid/wife)
10. ANMs 12,780 526,242 726557
11. Lady Health visitors 578 50,393 55498
12. Health workers (F) (in - 147,439 188715
position) at SC
13. Health Workers (M) (in - 62,881 51705
position) at SC
14. Block Extension Educator (in - 4,068 2269
position)
15. Health Assistant (M) at PHCs - 20,234. 14648
(in position)
16. Health Assistant (F)/LHV at - 17,919 16109
PHCs (in position)
17. Village Health Guides (2002) - 323,000 -
Source: Rural Health Statistics 2012 (MOHFW2013)’

http://mohfw.nic.in/WriteReadData/1892s/492794502RHS%202012.pdf
(accessed 11-11-14) 2) National Health Profile of India 2013
http://cbhidghs.nic.in/index2.asp?slid=1284&sublinkid=1166(accessedllll,20
14)
A brief definition of common indicators utilized to describe achievements in

102 field of health are mentioned in box 20.1 below to understand their concept.
Box 20.1: UNDERSTANDING THE TECHNICAL TERMS Primary Health
Care-II:
Simple definition of indicators used to assess health status are given below: Current Status
In India
1. The crude death rate, the annual number of deaths per 1000 people.
2. Perinatal mortality (PNM), also perinatal death: The number of infant
deaths occurring between the foetal viability (28 weeks gestation or
1000g) and the end of the 7th day after delivery per 1000 live births per
year.
3. The crude birth rate, the annual number of live births per 1000 people.
4. Natural Reproduction Rate: It is a measure of population growth from
one generation to another under constant conditions.
5. The Net reproduction rate, the number of daughters who would be born
to a woman completing her reproductive life at current age-specific
fertility rates.
6. Maternal Mortality Rate: Total number of deaths of women from
pregnancy related causes (including up to 6 weeks of post partum period)
per 100,000 live births in a given year.
7. The infant mortality rate, the total number of deaths of children less than
1 year old per 1000 live births in a given year.
8. Preschool Death Rate: Number of deaths of children aged 1-5 years in a
given year per 1000 children in this age group.
9. The expectation of life (or life expectancy): the number of years which
an individual at a given age could expect to live at present mortality
levels.

1) What are the facilities available at the following?
a) Sub-Centre
…………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
b) PHC
…………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
c) Village Level
…………………………………………………………………….............
…………………………………………………………………….............
103
Public Health 2) Enlist the referral health institutions up to the district hospital.
and Related
Issues …………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
…………………………………………………………………….............
To improve the quality of health care the following national health

programmes have been initiated by the government. A detail review of these
programmes is presented in Unit 22
i) National Family Welfare Programme

ii) National Inmunisation Programme
iii) National Malaria Eradication Programme
iv) National Tuberculosis Control Programme
v) National Leprosy Eradication Programme
vi) National Filaria Control Programme
vi) National Programme for Prevention of Anaemia and Vitamin A
Deficiency
vii) National Programme for Prevention of Blindness
ix) National Programme for Control of AIDS
20.6 LET US SUM UP

In this unit you learnt that the concept of Primary Health Care had been
operational in India since the vedic time. However due to repeated foreign
invasions there had been relative neglect of the traditional Ayurvedic System.
After Independence special efforts were made to provide modern health
services to the majority of rural population through the Primary Health
Centres. The National Health Policy which was approved by the Parliament
in 1983 and modified in 2002, provided the necessary political commitment
to reorganise and reorient the health care delivery system on the Primary
Health Care Approach. The Primary Health Care functionaries in our
country’s health care delivery system are: Trained Dais and Community
Health Guides, who are selected from the local community and after initial
training work as honorary community health workers. They get support from
the governmental health functionaries, multipurpose health workers (male
and female). The Primary Health Centres, Community health Centres,
Taluka, District and state hospitals are envisaged to provide the referral
support.
104
20.7 GLOSSARY Primary Health
Care-II:
Current Status
In India
ASHA A health activist in the community who will create
awareness on health and its social determinants and
mobilize the community toward local health planning
and increased utilization and accountability of the
existing health services
Community Government Health Institution, with 30 beds and

Health Centre specialists services available to provide referral support
to Primary Health Centres.
Health Assistants The supervisory cadre of health personnel to provide

(Male and support to multipurpose health workers (Male and
Female) Female).
Health Guide A volunteer from the community, given orientation

training in health, to act as community level worker.
Multipurpose The peripheral health functionaries providing

Health Worker preventive, promotive and curative services through
sub-centres.
Primary Health : The governmental health institution which provides

Centre preventive, promotive and curative services ١to rural
populations. The national norm is to have one Primary
Health Centre for 20,000-30 00 population.
20.8 ANSWERS TO CHECK YOUR PROGRESS

EXERCISES
1) Any five of the following : Medical care, Mother and Child care, Family
Planning, Maintenance of Safe water, Prevention and control of locally
endemic diseases, Collection of vital statistics, Education about health,
Referral services, Training of health guide, National Health Programme.
2) Any five of the following :
i) Identification of fever cases and making blood slide of all fever
cases
ii) Chlorination of wells
iii) Health education of community
iv) Family planning education and distribution of nirodhs
v) First-aid-in emergencies and treatment of common ailments 105
Public Health vi) To get pregnant women (in her area), registered at the sub-centre
and Related
Issues vii) To ensure hygiene during delivery
viii) To provide first-aid-in difficult labour conditions and to refer such
cases
ix) To provide Family Planning education and health education.
• Treatment fo minor ailments
• First aid for accidents or emergencies
• Health Education activities
• Chlorination of water sources
• Assist in preventive, promotive health services
• Assist in MCH and family planning
• Environmental sanitation.
Contact with every pregnant woman and ensure her registration; attend
the weekly prenatal clinic; assist in tetanus immunisation; distribution of
iron and folic acid tablets; refer difficult cases to PHC; insruct the
mother and the relatives as to when she should be called; immediately
undertake the postnatal visits, assist in immunisation of infants, motivate
the eligible couples to accept FP; distribute nirodh, foam tablets, and
jelly; report all birth and deaths in her area.
1) a) • Treatment of minor ailments.

• First aid for accidents or emergencies
• Health Education activities
• Chlorination of water sources
• Implementation of National Health Programmes
• Immunisation and family planning services.
b) • Monitor, guide, supervise preventive, promotive health services.
• Undertake medical and surgical work
• Function as a referral centre
c) • Treatment of minor ailments

• MCH and family planning
• Environmental sanitation.
2) i) Primary Health Centres
ii) Community Health Centres
iii) Taluka hospitals
iv) District hospitals.
106
UNIT 21 PRIMARY HEALTH CARE-III: Primary Health
Care-III:
DELIVERY OF SERVICES Delivery of
Services
Structure
21.1 Introduction
21.2 Essential Components of Primary Health Care
21.2.1 Education of the People about Prevailing Health Problems and Method of
Preventing and Controlling them
21.2.2 Promotion of Food Supply and Adequate Nutrition
21.2.3 Adequate Supply of Safe Water and Basic Sanitation Measures
21.2.4 Maternal and Child Health Care and Family Planning
21.2.5 Immunisation Against Infectious Diseases
21.2.6 Prevention and Control of Endemic Diseases
21.2.7 Appropriate Treatment of Common Diseases and Injuries
21.2.8 Provision of Essential Drugs
21.3 Supportive Activities Required for the Success of Primary Health Care
21.4 Let Us Sum Up
21.5 Glossary
21.1 INTRODUCTION
You have learnt about the concept and organisation of primary health care in
the Unit 19. This unit will tell you about the various components of Primary
Health Care and the current level of achievement for them in India. The unit
also highlights the other important supportive activities which must also be
undertaken alongwith the operationalisation of the Primary Health Care
concept.
Objectives
After studying this unit, you will be able to :
• enlist various components of primary health care,

• describe the achievement level of the components of primary health care
and probable measures to enhance the achievements, and
• discuss the supportive activities essential for successful implementation
of primary health care.
107
Public Health
and Related
21.2 ESSENTIAL COMPONENTS OF PRIMARY
Issues HEALTH CARE
Primary Health Care is an essential health care which should be accessible to
all individuals. In the Alma Ata Declaration, it is stated that at least the
following components should be included in primary health care (Figure
21.1):
i) Education of the people about prevailing health problems and methods of
preventing and controlling them.
ii) Promotion of food supply and proper nutrition
iii) Adequate supply of safe water and basic sanitation
iv) Maternal and child health care and family planning
v) Immunisation against major infectious diseases
vi) Prevention and control of locally endemic diseases
vii) Appropriate treatment of common diseases and injuries
viii) Provision of essential drugs.
A brief discussion on the various components of primary health care in India

and their activities is presented in the following sub-section. A write-up on
the remedial measures which need to be adopted or are being adopted to
improve the components of primary health care is also presented. We begin
with the first component—educating the people about the prevailing health
problems.
Fig. 21.1: Components of Primary Health Care
108
21.2.1 Education of the People about the Prevailing Health Primary Health
Care-III:
Problems and Methods of Preventing and Controlling Delivery of
them Services
People in general, particularly in rural areas and urban slums, are not
knowledgeable about health matters, such as what are the prevailing health
problems in the community and how to prevent and control them; what are
the needs for the maintenance and promotion of health; what are the
resources available and how and when to utilise them etc. Socio-economic
backwardness, ignorance, traditions and superstitions have been acting as
constraints to progressive thinking including development of the concept of
positive health.
Educating the people about the prevailing health problems and methods of
preventing and controlling them is therefore one of the main task of primary
health care functionaries (health guide, trained dais and multipurpose
workers). The government has initiated an Information, Education and
Communication (IEC) Programme for women. This programme is
operational in the states of Uttar Pradesh, Bihar and Rajasthan. Under the
programme women volunteer from the local community are identified as
link-women as Accredited Social Health Activist (ASHA), which provide
health education messages to the other women in the village. Health
education activities are conducted as an integral part of routine health care
delivery system.
Health education and population education topics are also being conversed in
text books for school children.
Inspite of the best of the efforts put in by the government, health education
efforts have been very inadequate. Illiteracy, particularly of the women, has
acted as barriers to communication in health and related matters. Health
functionaries cannot therefore provide services which are acceptable and
inexpensive.
Remedial Measures : Appropriate educational programmes are to be
organised for different groups of people. Health education to the community
should be a prime function of the health workers and village level
functionaries. In this endeavour, functionaries of other sectors such as social
and women’s welfare, education, agriculture and animal husbandry,
panchayats and voluntary agencies like mahila mandals and youth clubs can
contribute very significantly. Health education in schools and adult education
sessions should incorporate topic on various health problems, and methods
for their prevention and control.
21.2.2 Promotion of Food Supply and Adequate Nutrition

The Integrated Child Developmental Services (ICDS) scheme has been one
of the largest programme, which attempts to improve the nutritional status of
pregnant, lactating women and children below six years, especially those
belonging to underprivileged sections of the society (for details refer to Unit
22).
109
Public Health Vitamin A solution and folifer tablets are being given under the vitamin A
and Related and anaemia prophylaxis programmes. (Refer to Unit 22). The Integrated
Issues
Rural Development Programme, Jawahar Rojgar Yojna are the other
important National programmes implemented by the Government, to ensure
promotion of food supply and proper nutrition.
Inspite of all these efforts, nutritional deficiency states of varying degrees in
regard to protein-energy malnutrition, vitamin A and iodine deficiency and
nutritional anaemia are still prevalent in a wide section of our population.
Nutritional deficiency disorders are particularly noticeable among pregnant
and nursing mothers, and in infants and children. Available statistics indicate
that of the total deaths occurring among the age group of 0 to 5 years, about 7
per cent of deaths are due to malnutrition and in another 46 per cent it is an
associated factor.
Remedial Measures : This dismal condition can be substantially improved
by organising and conducting nutrition education in the community and in
the schools; encouraging people to make kitchen gardens and community
gardens; and educating the people on food hygiene. Steps also need to be
taken to encourage growing locally nutritious foods such as cereals, pulses,
vegetables, fruits, milk, fish and poultry products through cooperative and
other efforts so as to make these easily accessible and affordable to the
people. Simultaneously, the purchasing capacity of the families should be
improved through a variety of income generating schemes. In addition, for
the moderately and severely malnourished groups, supplementary nutrition
programmes are to be organised.
In these endeavours functionaries from other sectors such as agriculture,

animal husbandry, irrigation, banks and cooperatives, social and women’s
welfare, panchayat and voluntary organisations can play a very significant
role.
21.2.3 Adequate Supply of Safe Water and Basic Sanitation

Measures
Providing adequate supply of safe drinking water and basic sanitation
measures is one of the major components of primary health care. A national
water supply and sanitation programme has been initiated by the government
which aims to provide safe drinking water and sanitation facilities to rural
and urban population.
Many health problems have their roots in various aspects of community life
and cannot be influenced by medical or health interventions alone. Safe and
potable water is not available to a majority section of the population. Many of
the waterborne diseases prevalent in the country are preventable, but the
importance of the use of safe water as well as the personal hygiene are not
properly appreciated. Environmental sanitation is very poor, particularly in
rural areas and in urban slums. In most of the places, there are no proper
arrangements for disposal of human and animal wastes, sewage, sullage etc.
Remedial Measures : Systematic approach should be made to survey and
110 identify sources of safe water and to carry out proper analysis of water.
Arrangements should be made for regular treatment of water through Primary Health
chlorination before using it for drinking and cooking purposes. People at all Care-III:
Delivery of
levels including the village leaders, women, and children at schools should be Services
educated (on continuous basis) about the importance of proper maintenance
of water resources, simple method of treatment of water and the use of safe
water. Observation of personal hygiene practices should be emphasised.
It would be important to organise the people and the resources for

constructing household and community latrines, and making arrangements
for collection and disposal of human and animal wastages. Proper disposal of
waste water is also very important. Construction of soakage pits and use of
some of the waste water in kitchen gardens should be encouraged and helped.
Educating the women about the proper maintenance of water sources and the
importance of kitchen garden would be helpful. Proper educational
programmes on all these aspects for the children, youths, adults and the
mothers should be organised in a systematic manner.
In improving safe water supply and sanitation programmes, cooperation of
the workers of other sectors such as irrigation, engineering department,
village industries, agriculture, education, social and women’s welfare, rural
development, panchayats and cooperative are most vital.
21.2.4 Maternal and Child Health Care and Family Planning

An important component of primary health care is provision of MCH care.
Under this provision maternal care, infant care, care of young children and
family welfare services are provided. In spite of these services, the health
status of women and children is rather poor. Why is it so? What can be done
to improve these services? Read the following discussion to get an answer to
these questions.
A) Maternal Care : Compared to developed countries as well as some
developing countries, the current maternal mortality rate of 4 to 5 per
1000 live births in India is high. No valid information on morbidity data
on mothers is available. Maternal care—antenatal, natal and post-natal—
in rural areas and urban slums, is totally inadequate. In rural areas,
majority (about 80 per cent) of births are occurring outside the
institutions, and are being attended by untrained birth attendants.
Some of the important causes of maternal mortality are infection,
haemorrhage, toxaemia, illegal abortion and malnutrition. Liberalisation
of abortion laws and enactment of medical termination of pregnancy
(MTP) act in 1971 were the direct outcome of the realisation of the fact
that induced abortion performed by unqualified persons under
unhygienic conditions significantly increased maternal mortality and
mobidity.
Remedial Measures : Systematic efforts are to be made to progressively
increase antenatal registration and care of pregnant women from the
present level of 35 per cent to 100 per cent. It is also to be ensured that
progressively almost all deliveries are conducted under aseptic
conditions by trained health personnel i.e. the dais or female 111
Public Health multipurpose workers. Pregnant and nursing mothers should get
and Related prophylactic doses of tetanus toxoid and iron and folic acid supplement.
Issues
During post-natal check-ups, mothers are to be educated on breast
feeding, growth monitoring, weaning and immunisation of the child and
on personal hygiene exercises, diet and family planning.
B) Infant Care : The infant mortality rate (IMR) of 77 per 1000 live births
(as per estimates of SRS in 1992) in India is very high and this figure is
much higher for rural areas. About 50 to 60 per cent of this is caused by
mortality during the neonatal period (0-28 days) and particularly in the
first week of life. Several factors contribute to this mortality and these
include poor maternal health during pregnancy, frequent child births,
inadequate care of ‘at risk’ mothers, poor infrastructure facilities, lack of
care of newborn at birth and practically no facilities to newborn care
from primary to tertiary levels.
Low birth weight infants, either due to prematurity or due to intra-uterine
growth retardation, result from various factors such as low maternal
weight and height, frequent pregnancies, maternal malnutrition and
anaemia, chronic maternal diseases and pregnancy complications. Low
birth weight if particularly associated with prematurity is a major
underlying factor for neonatal or infant mortality.
Remedial Measures : For dealing with these problems, the dais and
female health workers and health assistants have to be properly trained in
prenatal and neonatal care adopting ‘high-risk’ approach. Proper
facilities for referrals to the secondary and tertiary levels are to be
developed and organised. Communities are to be properly educated
about the importance of antenatal and neonatal care, and be encouraged
to actively participate in these programmes.
C) Care of Young Children : Among the children aged 0-5 years (i.e. the
preschool children) the morbidity and mortality is mainly due to
malnutrition, diarrhoeal diseases, respiratory infections and other
preventable infections. Malnutrition predisposes the children to infection
(the morbidity rates being three times higher in malnourished children)
Remedial Measures : Two types of intervention programmes would be
needed (a) prevention and treatment of malnutrition, and (b) reduction
mortality due to diarrhoea, respiratory infections and other infections
preventable by immunisation.
The strategies for reduction of prevalence rate of malnutrition in pre-
school children would be : (a) to provide nutrition education to the
mothers; (b) to detect the cases of malnutrition and to grade them (c) to
rehabilitate grades I and II cases by supplementary feeding from home
resources; (d) supplementary feeding of grade III and IV cases at health
institutions; and (e) referral of grade III cases associated with diarrhoea
or infection of secondary level of care i.e. the community health centres
or district or taluka level hospitals.
The strategies for reduction in infant mortality due to diarrhoeal diseases
and respiratory infections would be (a) to educate the mothers on how to
112
prevent and treat diarrhoeal and respiratory diseases, (b) to train the Primary Health
health functionaries about how to recognise and treat these disorders, and Care-III:
Delivery of
to judge which patients would need referral to higher levels of health Services
services, (c) to create facilities or secondary level care for referred cases;
and (d) to provide drugs, oral rehydration salts (ORS) and other
supportive measures.
All children, preferably below the age of one year must be immunised
against tuberculosis, poliomyelitis, diptheria, tetanus, whooping cough
and measles.
D) Family Planning : Even though India was the first country in the world
to take up family planning as an official programme in 1952, the
achievements over the past 60 years have not been as good as would be
desirable. Currently, the crude birth rate is around 30 per 1000
population. For reducing the birth rate to 25 per 1000 population and to
achieve a net reproduction rate (NRR) of one by 2000 A.D, 60 per cent
of the eligible couples in the reproductive age are to be effectively
protected through contraceptive method. Presently it is estimated that
about 43 per cent of the couples in the reproductive age group have been
protected by contraceptive measures. Out of this nearly 38 per cent have
been protected by sterilisation alone, and only 5 per cent by spacing
methods. More than 80 percent of the acceptors of sterilisation have
three or more living children. Obviously, we may not expect the desired
demographic gain from such contraceptive measures.
Remedial Measures : More concentrated attention needs to be given to
younger couples with low parity i.e. the newly married couples need to
be the educated about spacing methods and one-child and two-child
couples for contraceptive protection with permanent methods.
The acceptance and continued use of contraceptives are influenced by
several factors such as the character of the method including its
advantages and disadvantages; individual and social acceptability,
providers’ knowledge, skill and attitude, effective communication,
motivation and counseling. The nature and quality of delivery services
including supply logistics and follow-up care; and the cost needs are
important considerations.
Small family norm has to become a way of life for this purpose,
organisation of population education in the schools, colleges, and in
adult education programmes would be most vital.
For creating favourable atmosphere conducive to adoption of small
family norm, and acceptance and practice of effective contraception, the
following approach may be adopted.
i) For educating the community, the family and the individual couples,
systematic and coordinated use of mass media, group oriention and
interpersonal communication would be important. The goal of the family
welfare workers would be to (a) supply necessary information for
education and motivation; (b) assist the client to evaluate contraceptive
information and services, and to make an informed choice and decisions
113
Public Health about these, and (c) to encourage them for continued contraceptive use;
and Related the
Issues
ii) Health personnel should be properly trained with a view to strengthen
their knowledge and skills in educating and motivating the prospective
users, and to develop in themselves a proper attitude and faith in the
programme;
iii) The health care service agency should be properly geared for effective
implementation, monitoring and evaluation of contraceptive services;
and the logistics for procurement and to ensure continued regular supply
of contraceptive;
iv) Effective delivery of contraceptive services at the door-steps of the
people is considered to be an important measure for promotion of small
family norm;
v) For promoting acceptance of family planning the infant mortality rate
has to be brought down speedily and the chances of child survival have
to be substantially improved;
vi) Enforcement of universal primary education and prevention of drop-outs
would be an important step towards acceptance of small family norm;
special attention needs to be given to education of the girls and women.
vii) Optimum age of the mothers for reproductive outcome is between
twenties. Therefore, enforcement of the law on the minimum age of
marriage as well as counseling the women not to bear any child before
the age of 20 would be an important strategy; and
viii) Since women have been found to be important instruments for social
change, raising the social status of women and involving them in various
welfare activities including family planning would be important.

1) List the eight essential components of primary health care.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) Name the programme initiated by the government to educate women
about the prevailing health problems in the country. How is the message
transmitted ? Present graphically.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
114 ……………………………………………………………………………
3) List any three remedial measures which can be adopted to ensure Primary Health
promotion of food supply and proper nutrition. Care-III:
Delivery of
Services
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
4) What are the services provided under MCH care ?List the two
intervention programme needed to improve health status of preschool
children.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
21.2.5 Immunisation against Major Infectious Diseases

India has a long history of vaccination programmes. In the sixties vaccination
against smallpox and tuberculosis was started and in mid-seventies
vaccination against diphtheria, pertussis and tetanus was taken up. Polio
vaccination was initiated in 1980 and the measles vaccination in 1985 in
limited scale. Presently the package of immunisation services for infants
includes vaccination against tuberculosis, diphtheria, pertussis, tetanus,
poliomyelitis and measles. Expectant mothers are to be given two doses or
one booster dose of tetanus toxoid.
According to the new initiative on Universal Immunisation by 1990 (which

has been dedicated to the memory of late Mrs. Indira Gandhi) it is planned to
immunise 85 per cent infants and 100 per cent expectant mothers against
vaccine-preventable diseases. For achieving these goals, it is estimated that
approximately 22 million infants and 24 million expectant mothers are to be
covered annually. Presently the coverage is not adequate and some of the
major states are lagging behind. Furthermore, even among those children
who are being immunised there are dropouts and a significant proportions of
children do not complete the multi-dose schedules.
Remedial Measures : Tor successful immunisation programme regular
supply and proper storage of vaccines with effective maintenance of cold
chains for preservation of the potency of the vaccines must be ensured.
Considerable amount of ingenuity and innovative approaches are required for
adopting appropriate logistics and supply management considering the
locally prevailing conditions. For expanding the coverage as well as for
preventing the dropouts, there is a need for educating the people and
particularly the mothers; and motivating active community involvement and
participation. 115
Public Health For the organization of immunization activities, appropriate educational
and Related activities as well as for providing services and follow-up support and care,
Issues
the help and cooperation of other sectors such as Education, Social and
Women’s Welfare, Panchayati and Voluntary Organisations would be
valuable.
21.2.6 Prevention and Control of Endemic Diseases

Although the prevalence of endemic diseases will vary from one region to
another, some of the important diseases prevalent in our country are:
tuberculosis, malaria, leprosy, filaria,, iodine deficiency disorders, etc.
The Government has launched various national programmes for the control
or eradication of these endemic disorders. A few of these include leprosy
eradication programme, tuberculosis control programme, programme for
control of blindness. (The details of these Programmes have been described
in the Unit 22. People are being trained for early detection and treatment and
follow up care of cases. However, inadequate data on prevalence of the
locally endemic diseases is available thus the decision makers cannot take the
judicious decision.
Remedial Measures : There is need to develop an information system which
should emphasise on the monitoring of the different locally prevalent
endemic diseases. This data should be available at the district level and
feedback should be given to the primary health care units in the districts. The
people should be educated about the significance of each disease and simple
methods to prevent and control them through the locally available resources.
The community members should be motivated to utilise the services of
various national health programmes implemented by the government.
21.2.7 Appropriate Treatment of Common Diseases and

Injuries
The government has set up institutions at the primary health care level—sub-
centre, primary health centre; at secondary level—districl/zonal hospital, and
at tertiary level state hospital/medical college hospital. The appropriately
trained staff is available at each of the health unit. However the system of
referral is not satisfactory which is leading to chaotic situation, dilution of
health care and duplication efforts.
About 80 per cent of diseases can be managed by appropriately trained

paramedical functionaries at the village level. This management of these
common ailments at the peripheral level reduces load on the referral
institutions which are to provide the specialised health care to more seriously
ill individuals. At present all the individuals suffering from minor or major
health ailments attend the hospitals at primary, secondary or tertiary level
leading to dilution of specialised health care meant for the specific age group.
Remedial Measures : Treatment of minor ailments and first aids may be
given at village level. Treatment of common diseases and injuries are to be
provided at the sub-centres and PHCs, and appropriate referral services are to
116 be organised. People need to be educated about the availability of local
remedies and other facilities to meet these health needs. Other sectors such as Primary Health
Education, Social and Women’s Welfare, Panchayat, Voluntary Care-III:
Delivery of
Organisations can play an important role in educating the people and school Services
teachers can help in organising of resources.
21.2.8 Provision of Essential Drugs

The government has made a list of drugs to be made available at the primary,
secondary and tertiary level of health care. The drugs to the primary health
care workers are replenished at the monthly interval. However the health
being the state subject, in the process of replenishment at times the
interruptions occurs which causes break in health care services.
As mentioned earlier about 80 per cent of diseases can be managed by

appropriately trained staff at the peripheral level by simple medicines
available with them. However these medicines should be provided to the
functionaries in adequate amount and should be periodically replenished to
maintain the continuity of services. Presently 90 per cent of budget for drugs
is spent for diseases which affect only 10 per cent of population residing in
the urban areas.
Remedial Measures : For local health care and treatment of common
diseases and disorders, at least 20 drugs should be available within one hour’s
walk and travel. Utilising locally available remedies and indigenous system
of medicines should be utilised. In view of the financial constraints of
Government resources, community’s participation through cooperative
funding etc., may be explored.
1) List the package of immunisation services included for infants in the

primary health care.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) List any two remedial measures that need to be adopted for control or
eradication of endemic disorders.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
3) List the health institutions set-up by the government at the following
levels:
Primary health care ……………………………………………………….
Secondary health care …………………………………………………….
Tertiary health care ……………………………………………………….
117
Public Health
and Related
21.3 SUPPORTIVE ACTIVITIES REQUIRED FOR
Issues THE SUCCESS OF PRIMARY HEALTH
CARE
The WHO has identified a number of supportive activities essential for
successful implementation of primary health care which are:
i) Community involvement and participation

ii) Intra and inter-sectoral coordination
iii) Development of effective referral support
iv) Development and mobilization of resources
v) Involvement of managerial processes
vi) Health manpower development
vii) Medical and Health Services Research including innovative approaches
viii) Development and application of appropriate technology for health.
A brief discussion on each of these activities is presented below:
I) Community Involvement and Participation

For the success of primary health care, community involvement and
participation is most vital. So far meaningful community
participation in various programmes has been largely lacking, except
in certain parts of the country where village panchayats and vohuntary
agencies have been taking some interest.
Ideally true participation means that the people should be knowledgeable
about the health problems; they should identify their needs. draw out
plan their action according to the priority, and the resources available,
organise and implement programmes, monitor and control the progress,
and periodically evaluate and do the re-programming. Initially, there may
be passive involvement which has to be gradually and progressively
made more active participation. Some developments initiatives could be
conducive to increasingly greater participation of the community in the
health care programme like selection of health guides, ASHA and trained
dais from local communities. With the activation of the village health
committees, mahila mandals, youth clubs, etc., it should be possible to
get greater active participation of the community.
The community should be able to mobilize resources and gradually try to
become self-reliant in matters of health and family welfare in a spirit of
self-development. Health and family welfare personnel working within
the community have to develop credibility among the people and act as
catalytic agents. Although, in the primary health care approach emphasis
has to be given to preventive and promotive aspects of health care,
curative services which are the felt-need of the community are to be
provided satisfactorily. This intervention will serve as an entry point for
establishing credibility of health personnel.
118
Primary Health
Care-III:
Delivery of
Services
Some of the advantages of community participation are as follows:

i) it can significantly contribute to bringing about general development
and to health development in particular;
ii) it increases the understanding of the user's-perspective in the
management of health. It also renders the services more accessible
and acceptable to the people;
iii) it promotes and strengthens self-reliance in matters of delivery of
health services. Participation also develops a sense of responsibility
for the health care programme;
iv) it also brings down the cost of the health care, as the indigenous
knowledge and local resources are utilised by the community for the
preventive and promotive aspects of health care, the people in the
community have to play the main role;
v) it is important to recognise that the integration and coordination of
different sectoral activities is necessary for making adequate and
sustained impact on health status of the community This can be
brought about only at the community level and through community
actions and organization.
II) Intra and Inter-Sectoral Coordination
Within the health sector, besides the national health system, a number of
non-governmental agencies are functioning and catering to the health
needs of a large proportion of the population. These agencies include
voluntary organisations, non-governmental organisations, professional
bodies, private practitioners of modern medicine and indigenous system
of medicine. Studies have shown that in specific rural areas as much as
60-70 percent of the health care is being provided by such non-
governmental sector. Unfortunately no systematic efforts have been
made for establishing proper linkages and coordination with these non- 119
Public Health governmental agencies. There is an urgent need to evolve process for
and Related effectively linking their efforts and activities in the national health care
Issues
delivery system for ensuring coverage of all sections of the population
through primary health care (Figure 21.2)
Figure 21.2: Disciplines that need to work together for health
Even within the existing health system itself, there is a great scope for
integrated and coordinated efforts. In many situations, it is observed that
separate .vertical health programmes are in operation without
establishing any linkage among themselves. In some places, even the
health and family welfare programmes are being run independently
without any integration
III) Development of Effective Referral Support
For the success of primary health care, one of the essential requisites will
be development of proper referral support at secondary and tertiary
levels. This has to be built in a systematic manner. Adequate two-way
referral support is to be provided. For this, a system needs to be devised
linking various relevant institutions, starting from individuals and
simplest of health institutions in small communities and continuing
through increasingly complex institutions along with the health system
chain. Particular attention has to be given to those institutions which
provide direct support to primary health care. For organising a proper
and effective referral system, it would be useful to review the functions,
staffing, plan design, available equipment etc. and the organisation and
management of health centres and district hospitals, in order to prepare
these for their wider function in support of primary health care.
IV) Development and Mobilization of Resources
For obtaining relatively larger investments in health development
programmes some public resources, strong political commitment is
necessary (Figure 21.3). It is often noted that due to lack of knowledge
and inconsistent efforts, available funds for many Tevelopment projects
remain unutilised. Furthermore, from the community liscil, whstantial
financial and human resources can be mobilised: some of these, such as
enthusiasm and the energy of the youth and the women for community
action, thay otherwise remain unutilized.
120
Communities with institutional structures, such as local body or Primary Health
council/cooperative etc. can mobilise resources for community more Care-III:
Delivery of
easily than those relying on individual and voluntary contributions. In Services
some voluntary projects, small regular contributions made by rural
families have served as a kind of group insurance schemes and have
substantially covered the cost of primary health care in the community.
Such an approach may bring out a radical improvement in the quality
and coverage of health care among the rural people.
Figure 21.3: National Resources for Health
V) Involvement of Managerial Processes

Management is a process for purposeful and effective utilisation of
resources i.e. manpower, material and money, for accomplishing a pre-
determined objective. The managerial processes involve the following
steps:
(i) Situation analysis: (ii) Policy formulation; (iii) Setting goals/objectives
/targets; (iv) Framing of strategy, (v) Making plan of Action; (vi) Broad
programming; (vii) Budgeting; (viii) Detailed programming; (ix)
Implementation-organisation of resources, initiation and directing of
activities; (x) Monitoring and control; (xi) Evaluation and feedback; and
(xii) Reprogramming. Proper information support is needed for all these
steps.
In the organisation and development of national health care delivery
system, the application of different components of the above-mentioned
managerial processes will vary with different categories of personnel
working at different levels. Functioning at different levels would also
require blending of varying degrees managerial and technical skills. 121
Public Health Higher is the level in the organization, the greater is the need for
and Related managerial function and lesser the need for technical skill. Conversely,
Issues
the lower is the level in the organisation, the lesser is the need for
managerial function and higher the need for application of technical skill.
However, even at the grass-root level development of well coordinated
and systematic style of functioning by various categories of personnel
would be very important for proper management of the programme.
Furthermore, in participatory management the principles and different
components of managerial processes, should be well understood by
members.
It is being increasingly realised that management training alone for the
health personnel may not be sufficient for achieving the objectives. What
is needed is management development. According to this concept,
besides improving the managerial capabilities of the manager,
management practices and culture of the organisation system are also to
be changed and improved.
VI) Health Manpower Development
Vigorous action is to be taken to ensure availability of adequate numbers
of appropriate health personnel required to devise and implement the
plans of action. This would require reorientation of the existing health
workers, development of new categories of workers in health and related
sectors, and motivation and training of all manpower to serve the
community. For social orientation of all categories of health workers, to
serve the people as well as to improve their technical skill, the
cooperation of the Ministry of Education and of all training institutions
has to be ensured. This may need reform of educational curriculum and
training programmes.
While dealing with manpower, the useful role of the traditional medical
practitioners, the birth attendants, and even the family members needs to
be considered. The last category assumes importance particularly from
the point of self-care as a part of primary health care i.e. taking of
responsibility to the individuals and families for their own health care.
Obviously keeping in view the above considerations, three main types of
approaches are to be made:
i) pre-service and in-service training of the newly recruited and
existing health and family welfare personnel respectively as a part of
continuing education;
ii) appropriate basic professional training of medical, nursing and other
paramedical personnel keeping in view the contemporary needs
reform of educational curriculum may be required;
iii) development of new categories of workers, as exemplified by the
health guides, ASHA, community health workers etc.
Continuing education provides means of equipping workers to perform
competently in their current and future jobs with the objective of
increasing the efficiency of the individual as well as the organisation. It
122
is the planned provision for systematic learning in the job. and is an Primary Health
essential element for personal and organisational development. An Care-III:
Delivery of
important factor for achieving health for all would be the ability of the Services
individual and the organisation to recognise and respond to changes in
advancing technology for health maintenance and promotion, new
pattern of diseases, disabilities etc., new social policies, expectations and
programmes for better health services.
New competencies are to be developed at different levels to be able to
observe, analyse, interpret realistically and react intelligently to human
behaviour, events and environments, be able to effectively perform as a
member of the team, and to address to the priority community problems
and concerns, and to develop proper attitude for continuous learning. The
concept of life-long education is being increasingly accepted as an
indispensable supplement to basic education. Although in the country,
there exist some programmes of continuing education, these are
piecemeal, largely ineffective and sometimes inappropriate.
For maintaining high level of competence and performance and to
strengthen national will to achieve Health For All through primary health
care, development of adequate systems for continuing education and to
integrate it with supervision at all levels would he most vital for proper
Health Manpower Development. Such education or systems should be
based on identified real community problems and felt needs; the task to
be performed; the methods, techniques and equipment to be used; and
continuing education should be provided to all health workers and their
supervisors. The responsibility of providing competency based
continuing education should be shared by the individuals, the health care
system, the educational system and the professional bodies.
VII) Medical and Health Services Research
A network of comprehensive health care system based on primary health
care approach and integrating preventive, promotive, curative and
rehabilitative aspects is to be developed for catering to all sections of the
population. Although, there are some micro level experiences of
successful implementation of all the components and principles of
primary health care approach, these have not been developed
systematically within the health system and not been extended to larger
areas of districts or state. There is a need for evolving, through
appropriate operations, research programmes, replicable and viable
models that could be adapted in the health system in an incremental
fashion.
The health services infrastructure has been expanded and manpower is
being deployed on arbitrary basis. There is an urgent need for
undertaking systematic work studies at different levels such as sub-
centre, primary health centre, community health centre, etc. for evolving
a more rational basis for determining job functions, staffing patterns etc.
Many of the existing programmes under the health services are not
progressing properly. There is a need for systematic evaluation of these
123
Public Health programmes with the object of improving the existing model or
and Related developing suitable alternatives, wherever needed.
Issues
VIII) Development and Application of Appropriate Technology for
Health
While formulating the strategies and programmes and designing the
services, it would be helpful to review the existing technologies and
identifying those that are appropriate; and to indicate and promote the
type of research required to develop alternatives to replace inappropriate
technologies. In this endeavour, it would be useful to promote
participation of the government departments, research and academic
institutions, the industry and the non-governmental organizations, both in
health and health related sectors.

1) How can community participation help in improving primary health
care? Give any two points.
a) ………………………………………………………………………
b) ………………………………………………………………………
2) Enlist the supportive activities for successful implementation of Primary
Health Care concept.
i) ………………………………………………………………………
ii) ………………………………………………………………………
iii) ………………………………………………………………………
iv) ………………………………………………………………………
v) ………………………………………………………………………
vi) ………………………………………………………………………
21.4 LET US SUM UP

In this unit you have learnt the eight essential components of Primary Health
Care. The reasons for poor achievements in these components have been
mentioned. The unit also specifies the eight important supportive activities
which must be undertaken for the successful implementation of the Primary
Health approach.
21.5 GLOSSARY
Basic sanitation Safe disposal of human and household waste.

Crude Birth Rate The crude birth rate is the annual number of births per
1000 people.
Endemic diseases The diseases which are constantly present in an area.
Essential drugs The expert committee of World Health Organization
has identified specific drugs which must be available at
124
sub-centre and primary health centres. Primary Health
Care-III:
Health manpower Development of the working potentialities of health Delivery of
development personnel to the fullest possible extent. Services
Mobilization of Reallocation and re-organization of resources so as to

resources ensure optimal utilization of resources.
Net Reproduction The net reproduction rate is the expected number of
Rate daughters, per newborn prospective mother, who may
or may not survive to and through the ages of
childbearing.
Parity The number of liveborn children a woman has
delivered
Safe Water Provision of water for drinking and cooking purposes
Supply which is free from the health hazards.

EXERCISES
1) i) Health education
ii) Promotion of nutrition
iii) Safe water supply and basic sanitation
iv) Maternal and child health and family planning
v) Immunisation
vi) Prevention and control of locally endemic diseases
vii) Management of common diseases
viii) Provision of essential drugs
2) Information, Education and Communication Programme link
women......... Other women.
3) a) Organizing and conducting nutrition education in the community
and the school.
b) Encouraging people to make kitchen gardens and community
gardens.
c) Improving the purchasing capacity of the families through variety of
income generating schemes.
4) Maternal care, infant care, care of young children and family planning.
5) Prevention and treatment of malnutrition.
Reduction of mortality due to diarrhoeal and other infections.

1) Vaccination against tuberculosis, diphtheria, pertusis, tetanus,
poliomyelitis, measles. 125
Public Health 2) Develop an information system which emphasize on the monitoring of
and Related the different locally prevalent endemic disease.
Issues
Educate people about the significance, promotion and control of endemic
disease through locally available resources.
3) Sub-centre, primary health centre
District / Zonal hospital
State hospital / medical college hospital.

1) a) It increases the understanding of the users perspective in the
management of health and renders the services more accessible and
acceptable to the people.
b) It helps to utilize indigenous knowledge and local resources thereby
reducing cost on health care.
2) i) Community participation
ii) Inter and intra-sectoral coordination
iii) Effective referral system
iv) Mobilization of resources
v) Improvement of managerial processes
vi) Health manpower development
126
UNIT 22 HEALTH PROGRAMMES Health
Programmes
Structure
22.1 Introduction
22.2 Health Programmes
22.2.1 National Immunisation Programme
22.2.2 National Family Welfare Programme
22.2.3 National Programme for Prevention of Nutritional Blindness Due to

Vitamin A Deficiency
22.2.4 National Nutritional Anaemia Control Programme (National Iron Plan

Initiative (NIPI))
22.2.5 National Iodine Deficiency Disorders Control Programme
22.2.6 National Vector Borne Disease Control Programme
22.2.7 National Leprosy Eradication Programme .
22.2.8 National Programme for Control of Blindness
22.2.9 National AIDS Control Programme.
22.2.10 National Mental Health Programme.
22.2.11 National Diabetes Control Programme
22.2.12 Revised National Tuberculosis Control Programme
22.2.13 National Rural Health Mission
22.3 Other Programmes for the Promotion of Mothers and Child Health
and Nutritional Status
23.3.1 Integrated Child Development Services Scheme
23.3.2 Mid day Meal Programme
23.3.3 Special Nutrition Programme
22.3.4 Applied Nutrition Programme
22.3.5 Wheat-based Supplementary Nutrition Programme
22.3.6 Balwadi Nutrition Programme
22.4 Let Us Sum Up

22.5 Glossary
22.1 INTRODUCTION
This unit describes some of the important health and health-related
programmes operational in the country. It gives an overview of the National
Health Programmes in terms of the programme infrastructure, activities and
beneficiaries. An attempt is also made to critically analyse the programme 127
Public Health functioning.
and Related
Issues Objectives
After studying this unit, you will be able to:
• enlist important National Health Programmes operational in the country.
• describe important activities and services available under the various
National Health Programmes.
22.2 HEALTH PROGRAMMES

During the last six decades, since the attainment of Independence,
considerable progress has been achieved in India in the promotion of the
health status of its population. You know that small pox has been completely
eliminated. Plague is no longer a problem and the expectancy of life at birth
has increased significantly. This progress could be achieved due to several
steps taken by the National Government. Among such measures, one is
implementation of number of health programmes. These programmes are
normally referred to as National Health Programmes. These programmes arc
financed by the Government of India. Several of these programmes are
assisted by international health agencies such as WHO and UNICEF (United
Nations Children's Fund). A brief discussion on the major health programmes
is presented in the following sub-sections.
22.2.1 National Immunisation Programme

The major causes of morbidity and mortality in children are infectious
diseases. In addition to those who become ill or die, many children are
disabled for life by the complications following these diseases. Neonatal
tetanus remains a major cause of neonatal mortality in many parts of the
country especially in the rural areas. Poliomyelitis is the single major cause
of lameness in children below the age of five years. A large number of cases
of diphtheria, pertussis, tetanus, tuberculosis and typhoid are reported
annually. In India about 1.3 million children die every year due to diseases
preventable by immunisation. A full course of immunisation which costs
very little can protect a child against measles, diphtheria, whooping cough,
tetanus, tuberculosis and polio, yet in the developing world 3 million children
die and another 5 million are left disabled due to these vaccine preventable
diseases of childhood, which can be saved by timely immunisation.
Infrastructure : The Government of India, started the Universal
Immunisation Programme (UIP) in 1986, with the objective of reducing the
mortality and morbidity in children by immunisation of all eligible children
and pregnant women, against the common and dangerous infectious diseases,
by the year 2000 A.D. The programme is being implemented in the rural
areas through the existing infrastructure of primary health centres through the
multipurpose health workers, trained dais, HG. The procurement of the
vaccine and the other equipment is made from the District Health Authorities.
Activities : Immunisation in the broadest sense consists of administration of
128
the vaccine, for reduction of the diseases in the community. This requires a Health
considerable amount of preparatory work in the community, planning the Programmes
procurement of vaccines and the supplies, their storage and distribution, and
development of the information system and the feedback.
Strategies of Operation : This programme is an integral part of primary
health care and services are provided through the existing health
infrastructure. There is no separate cadre of staff. Since it is a long-term
programme, the services are continued even in the absence of the diseases in
the area. Thus high levels of immunisation coverage arc to be sustained over
the years. The National Immunisation Schedule followed is presented in
Table 22.1.
Table 22.1: Indian National Immunization Schedule
a) For Infants At birth - BCG and OPV - 0 dose

(for institutional
deliveries)
At 6 weeks - BCG (if not given at birth)

- DPT-1, OPV-1 and Hepatitis B-l
At 10 weeks - DPT- 2, OPV-2 and Hepatitis B-2
At 14 weeks - DPT- 3, OPV-3 and Hepatitis B-3
At 9 months - Measles
b) At 16-24 months . - DPT and OPV
c) At 5-6 years - DT- the second dose of DT should be given at an

interval of one months if there is no dear history or
documented evidence of previous immunization
with DPT
d) At 10 and at 16 - Tetanus Toxiod - The second dose of TT vaccine

years should be given at an interval of one month if there
is no clear history or documented evidence of
previous immunization with DPT, DT or TT
vaccines
For Pregnant - TT -1 or Booster

Women, Early in - TT - 2
Pregnancy, One
month after TT— 1
Note –
i) Interval between 2 doses of DPT, OPV and Hepatitis B should not be
less than one month.
ii) Minor cough, colds and mild fever are not a contraindication to
vaccination, 129
Public Health iii) In some states, Hepatitis B vaccine is given as routine immunization at
and Related
Issues 6th, 10th and 14th weeks.
iv) Vitamin A is given at 9th, 18th, 24th, 30th, 36th 42nd, 48th, 54th and 59th
month.
v) If the child has diarrhoea, give a dose of OPV, but do not count the dose
and ask the mother to return in 4 weeks for the mission dose.
Immunisation services are provided by taking vaccines to fixed centres in the

villages (outreach operations). In more difficult areas special teams are sent
to cover children and pregnant women.
Depending upon convenience and facilities available, different strategies are

adopted. Whatever be the strategy it is aimed to cover all pregnant women
and children under one year.
Vaccination sessions are organised daily, bi-weekly, fortnightly or monthly,

depending upon the attendance at the clinics. All vaccines are made available
at each health centre so that the beneficiaries do not have to visit different
places for different vaccines.
The day and time of vaccination session are fixed and prominently displayed.
All efforts are made to hold the sessions regularly as scheduled.
The Government of India has set a goal of achieving about 85 per cent
coverage of children under the immunisation programme by the year 2000
A.D. However, by the turn of the century 100 per cent of pregnant women are
expected to be covered under tetanus toxoid immunisation. Currently only
about 50-60 per cent of children are immunised. What are the reasons for
poor coverage? Let’s consider.
Reasons for poor coverage

1) Lack of Accessibility ; One of the reasoas for poor coverage is that
villages are not within easy reach from the fixed centre, especially those
with poor communication and transport facilities. In such cases
arrangements need to be made for carrying vaccines and other supplies to
the villages and organising sessions at site. The involvement of village
health guides, trained birth attendants, anganwadi workers and other field
level workers is necessary for the success of the programme.
The village leaders, elders, teachers and others should be encouraged to

collect the eligible children, keep them ready at the vaccination site on
the pre-fixed day and time. Arrangement for repeat visits must be made
at an interval of 4 to 8 weeks.
1) Lack of adequate Community Participation : This may be due to the lack
of the knowledge of the masses about the diseases preventable by
immunisation; cultural beliefs which decrease the acceptability; or the
previous bad experience with the immunisation due to abscess or other
complication. Sometimes the mothers may not be aware of the time,
place, or day of immunisation or the time may clash with the work at
home or in the fields. Community participation is very vital for a
130
successful vaccination campaign and every effort should be made to Health
elicit this. The community leader should be explained the urgency of Programmes
early immunisation of pregnant women and children. Further, the worker

should inform the beneficiaries well in advance, their fears and
misconceptions be removed by health education and group discussion;
sometimes the involvement of local leaders, mahila mandals, may prove
to be useful.
2) Inadequate Recording System : An effort should be made to have a
vaccination register at the worker level, on which the names of children,
infants and the pregnant women should be entered and this should be
updated every month. The worker should record the exact date of
immunisation on the register. The mothers should also have a record of
the immunisation and the immunisation cards should be given to them.
3) Inadequate Equipment for Immunisation : Adequate supplies of syringes,
needles, vaccine carriers, means of sterilisation of equipment are very
vital for the success of immunisation programme. An ill-equipped
worker can do more harm to the programme. The unsterilised injections
given may result in complications.
22.2.2 National Family Planning Programme

India with a population of nearly 1260 million, (2011 census), is the second
most populous country in the world, next to China. With only 2.4 per cent of
the world's land area, India is supporting 15 per cent of the world's
population. India's population is increasing at the rate of nearly 15 million per
year. If the current growth rate continues unchecked the population of India
at the turn of the century may well reach one billion. India at present is facing
a population explosion crisis.
Infrastructure: India was among the first of the few Governments in the
world to adopt Family Planning as a National Policy. The Family Planning
Programme was launched in 1953. During 1972, liberalization of abortion
was allowed under the Medical Termination of Pregnancy Act.
The programme is implemented by the existing health infrastructure. At
village level, health workers render the services to the masses.
Activities: The workers carry out the activities like the preparation and
maintenance of the 'Eligible Couple' register; distribution of conventional
contraceptives, introduction and follow up of intra uterine contraceptive
devices (IUCD) and follow up of the sterilisation cases. For motivation of the
eligible couples the cafeteria approach is adopted, in which the couple is
given the choice regarding use of the family planning method.
The National Family Planning programme activities are based on national
population policy. The salient features of the policy are as follows:
i) Raising the legal age at marriage for girls to 18 years and for boys to 21
years.
ii) Making the acceptance of various family planning methods totally 131
Public Health voluntary and no coercion of any type to be used.
and Related
Issues iii) Freezing the population at 1971 Census for representation in the
Parliament.
iv) Linking a part of the central plan assistance to states with their family
planning achievement.
iv) Seeking inter-sectoral coordination in the family planning programme.
vi) Involvement ofnon-governmental organisations in family planning
programme.
vi) Raising the educational status of women.
22.2.3 National Programme for Prevention of Nutritional Blindness

due to Vitamin A Deficiency
Vitamin A deficiency is a major public health problem among pre-school
children in India. The National Programme for prevention of nutritional
blindness due to vitamin A deficiency was launched in 1970 and presently
covers 30 million beneficiaries. According to rough estimates, every year
thirty to forty thousand children may become victims of nutritional blindness.
(Source : Text Book of Preventive & Social Medicine, B.K. Mahajan & M.C.
Gupta 1991). The programme comprises a long-term and a short-term
strategy. The short-term intervention focuses on administration of megadoses
of Vitamin A on periodic basis, while long-term emphasises is on dietary
intervention to increase the intake of foods which are rich in Vitamin A.
Objective : The specific objective of the programme is to reduce the
deficiency and prevent blindness due to Vitamin A deficiency.
Acitivities : A massive dose of Vitamin A is given every 6 months to
children between ages of 6 months to 5 years. The scheme gives priority to
children between 6 months to 3 years as the highest prevalence of clinical
signs of Vitamin A deficiency are reported in this age group. The
recommended schedule megadose administration for children is as follows:
6 — 11 months — one dose of 1,00,00 01.U.
1 — 5 years — 2,00,000 I.U. (every 6 months).
A child is expected to receive a total of 9 doses of Vitamin A before his fifth

birthday.
The long-term strategy emphasises on improvement of dietary intake of

vitamin A through regular consumption of Vitamin A rich foods such as dark
green leafy vegetables, yellow vegetables and fruits, dairy products and the
promotion of breast feeding.
Ornganisation : The programme is implemented through the existing
network of primary health centres and sub-centres. The female multipurpose
worker and other paramedics of the primary health centres are responsible for
administering Vitamin A concentrates to children and for imparting nutrition
education to mothers. The services of ICDS functionaries are utilised for the
132 implementation of the programme.
22.2.4 National Nutritional Anaemia Control Programme Health
Programmes
(NNACP) National Iron Plus Initiative (NIPI)
Recently the NFHS-4 (2015-16) data revealed that 59% of children (6-59
months) had heamoglobin levels below 11 ug/dl, 28% mild, 29% moderate
and 2% had sever anaemia. Anaemia is a major contributory cause of high
incidence of premature births, low birth weight and perinatal mortality: To
reduce the prevalence of anaemia in pregnancy the National Nutritional
Anaemia prophylaxis programme of iron and folic acid distribution to
pregnant mothers was initiated by Government of India in 1972.
More recently a comprehensive set of actions have been identifici in national
guidelines for control of iron deficiency aneamia in the form of National Iron
+ Initiative (NIPI). The NIPI is an attempt to look at iron deficiency
comprehending across all life stages including adolescents and women in
reproductive age groups,
Let us look at the objectives of the programme.
Objectives
The National Nutritional Anaemia Control Programme aimed at significantly
decreasing the prevalence and incidence of anaemia in women in
reproductive age group, especially pregnant and lactating women, and
preschool children. Let us look at the target group of the programme.
Target Group
The beneficiaries of the programme included :
• Women in the reproductive age group, particularly pregnant and

lactating mothers
• Children 1-5 years of age
• Adolescent Girls
• Family planning acceptors (women who accept family planning
measures like intrauterine devices (IUD) and tubectomy)
We will now look at the programme strategies. Programme Strategy
Distribution Strategy
Following recommendations doses of iron and folic acid are given under
NIPI: (Table 22.2)
Table 22.2 : Recommended doses of iron and folic acid supplement
Age Group Intervention Regime Service Delivery

/Dose
6-60 Iml of IFA syrup Biweekly Through ASHA
containing 20 throughout the Inclusion in MCP
mg 0f elemental period 6-60 card
iron and 100 months of age
133
Public Health mcg of folic acid and de-worming
and Related
Issues
for children 12
months and
above.
5-10 years Tablets of 45 mg Weekly In school through
elemental iron throughout the teachers and for
and 400 mcg of period 6-10 out of school
folic acid years of age and children through
biannual de- Anganwadi centre
worming (AWC)
Mobilization by
ASHA
10-19 years 100 mg Weekly In school through
elemental iron throughout the teachers and for
and 500 mcg of period 10-19 those out of school
folic acid years of age and through AWC
biannual de- Mobilization by
worming ASHA
Pregnant and 100 mg I tablet daily for ANC/ANM/ASHA
lactating card elemental iron 100 days, Inclusion in MCP
women and 500 mcg of starting after the
folic acid first trimester, at
14-16 weeks of
gestation. To be
repeated for 100
days post-
partum.
Women in 100 mg Weekly Through ASHA
reproductive age elemental iron throughout the during house visit
(WRA) and 500 mcg of reproductive for contraceptive
folic acid period distribution
Source: Guidelines for control of Iron Deficiency Anaemia, NRHM, 2013
22.2.5 National Iodine Deficiency Disorders Control

Programme (NIDDCP)
At present, in India about 200 million people are estimated to have been
exposed to the risk of IDD (Iodine Deficiency Disorder). The IDD problem
continues to exist and especially in the sub-himalayan belt. Recent studies
however, have shown that there are pockets with IDD in other parts of the
country too. In all, till 2008, 324 districts have been surveyed in country and
263 have been found to be endemic for IDD. Looking at the magnitude of the
problem the Government of India (GOI) launched the National Goitre
Control programme in 1962. This programme is now renamed as the
National Iodine Deficiency Control Programme.
Objectives : The major objectives of the programme are :
134
1) to conduct the initial surveys to assess the magnitude of the iodine Health
deficiency disorders. Supply of iodised salt in place of common salt to Programmes
the entird country.

2) to conduct resurveys to assess the impact of iodised salt after 5 years.
Beneficiaries : All people residing in endemic and non-endemic areas for

IDD. The endemic area is to be given priority.
Activities : The following activities are conducted under the scheme :
i) lodisation of Salt: In order to control the problem of IDD, the GOI has
initiated steps since 1.4.86 for universal iodisation of edible salt in a
phased manner by the year 1995.
Initially, in order to meet the requirements of iodised salt in the endemic

areas, 12 iodisation plants were set up. Against the installed capacity of
production of 8-10 lakh MT of iodised salt per annum, the actual
production was only around 2.0 lakh MT. In 1986, GOI issued licenses
to nearly 500 units to produce iodised salt. Till 2008, 368 units have
started functioning with a production capacity of 50 lakh MTs. The
estimated annual requirements is about 50.00 lakhs M.T. to provide all
endemic areas with iodised salt.
ii) Notification for banning the use of non-iodised salt: The sale of non-
iodised salt has been banned completely in majority of states and
partially in remaining states The Government stands committed to
universal iodisation of salt.
iii) Establishment of Goitre Cell: To ensure adequate monitoring and
effective implementation of the NIDDCP states and UTs have
established a Goitre Cell in their state health directorate.
iv) Information education and communication activities : Cash grants
have been provided by the Central Government to states and Union
Territories for production of health education material and carrying out
health education activities on IDD as well as for undertaking surveys.
v) Intersectoral Co-ordination : It has been realised that NIDDCP
activities require integrated efforts of multiple agencies like Industry,
Railways, Health, etc. The focus of NIDDCP activities has-now been
shifted from health department to multi and interdisciplinary
participation.
Check Your Progress Exercise 1 .

1) Who are the beneficiaries of National Nutritional Iron Plus Initiative
programme?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
135
Public Health 2) What prophylactic dose of Vitamin A is given to the following children?
and Related
Issues 6 months to 1 year ………………………………………………………
1 year to 5 year ………………………………………………………….
3) What are two important reasons of poor coverage under national
immunization programme in India ?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
4) Name 4 diseases against which immunisation is given under National
Immunisation Programme.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
22.2.6 National Vector Borne Disease Control Programme

The National Vector Borne Disease Control Programme (NVBDCP) is an
umbrella programme for prevention and control of vector borne diseases.
Earlier the vector borne disease such as Malaria, Filaria, Chikungunya, Kala-
azar, Dengue and Japanese Encephalitis (JE) were managed under separate
National Health Programmes but now NVBDCP covers all the six vector
borne diseases namely: Malaria, Filaria, Chikungunya. Kala-azar, Dengue
and Japanese Encephalitis (JE). NVBDCP is an integral part of the India's
National Rural Health Mission (NRHM). In the following section we will dea
with each ofthe vector borne disease control programmes in detail.
A. National Anti Malaria Control Programme:

Among the vector borne diseases malaria continues to pose serious public
health threa in different parts of the country, particularly due to Plasmodium
falciparum, as it is sometimes prone to complications if not treated in time.
The National Health Policy (2002) has set the goal of reduction in mortality
due to malaria by 50%by 2010 and efficient morbidity control Reduction of
malaria morbidity and mortality is also included in Millenium Development
Goals.
Around 1.5 million laboratory confirmed cases of malaria are annually
reported in India.
About 80% of malaria cases and deaths are reported from Northeastern (NE)
states, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Andhra Pradesh,
136 Maharashtra, Gujarat and Rajasthan, West Bengal and Karnataka. However,
other states are also vulnerable and have local and focal outbreaks. Health
Programmes
Infrastructure: The programme is implemented in the rural areas through
the existing infrastructure of primary health centres, through the multipurpose
workers, (MPW). In areas where the communication is poor and the problem
is high, anti-malaria drug centres (DDC), and fever treatment depot (FTD),
are established.
At the district level, the District Malaria Officer, (DMO), assisted by
Assistant malaria officer, Assistant unit officer, Senior laboratory technician,
and Statistical assistant, monitor and supervise the malaria control activities.
Activities: The following measures are taken under the programme to reduce
the incidence of malaria. Currently a three pronged strategy is being
implemented through, Primary Health Care for prevention and control. This
includes:
1) Disease Management:
• Early case detection and prompt treatment: Confirmed cases of

malaria are treated with oral Chloroquin and Primaquine. To learn
more about the effective treatment of malaria you may refer to
Highlight 1 which provides detail information on National Drug
Policy on Malaria (2010).
• Strengthening of referral system.
• Epidemic preparedness and rapid response.
2) Integrated Vector Control
• Indoor residual insecticide spray in rural areas in selected high risk

pockets.
• Use of insecticide treated bednets.
• Use of larvi-vorus fishes.
• Antilarval measures in urban areas including use of biolаrvicides.
• Environmental and minor engineering measures like de-weeding and
de-silting.
3) Supportive Interventions
• Behaviour change communication.
• Human resource development through capacity building.
• Public Private Partnership and intersectoral collaboration.
• Operational research including studies on drug resistance and
insecticide susceptibility.
• Monitoring evaluation through periodic reviews, field visits and web
based Management Information System up to the district level.
Anti-Parasite Measures: This involves the surveillance of the population by
conducting house visits by the health workers (active surveillance) and the
137
Public Health passive surveillance which includes the services provided at the malaria
and Related clinics, fever treatment depots, drug distribution centres. All patients are
Issues
given anti-malarial treatment to decrease the load of parasites.
HIGHLIGHT 1 National Drug Policy on Malaria (2010)

Early diagnosis and complete treatment is one of the strategies ofthe National
Malaria Control Programme. The National Drug Policy on Malaria has
recently been revised in 2010. Effective treatment of Malaria under the
National Drug Policy aims at:
• Providing complete cure (clinical and parasitological) of malaria cases

• Prevention of progression of uncomplicated malaria into severe malaria
and thereby reduce malaria mortality
• Prevention of relapses by administration of radical treatment
• Interruption of transmission of malaria by use of gametocytocidal drugs
• Preventing development of drug resistance by rational treatment of
malaria cases
Drug and chemoprophylaxis schedule for treatment of malaria
A. Drug Schedule
I) Treatment of P. vivax cases
1) Chloroquine: 25 mg/kg body weight divided over three days i.e.
10mg/kg on day 1, 10mg/kg on day 2 and 5mg/kgon day 3.
2) Primaquine: 0.25 mg/kg body weight daily for 14 days.
Age-wise dosage schedule for treatment of P.vivax cases
Age (Years) Tablet Chloroquine Tablet

Primaquine1
Day-1 Day-2 Day-3 (2.5 mg base)
Day-1 to Day
14
<1 ½ ½ ¼ 0
1-4 1 1 ½ 1
5-8 2 2 1 2
9-14 3 3 1½ 4
15 & above 4 4 2 6
1
Primaquine is contraindicated in infants, pregnant women and individuals
with G6PD deficiency. 14 day regimen of Primaquine should be given
138 under supervision.
II) Treatment of uncomplicated P.falciparum Cases Health
Programmes
1) Artemisinin based Combination Therapy (ACT)2
• Artesunate 4 mg/kg body weight daily for 3 days Plus.

• Sulfadoxine (25 mg/kg body weight) -Pyrimethamine (1.25
mg/kg body eight) on first day.
Age-wise dosage schedule for treatment of P. falciparum cases
Age (in 1st Day 2nd Day 3rd Day 2nd Day
years)
Artesunate SP3 Artesunate Artesunate Primaquine
(50 mg) (50 mg) (50 mg) (7.5 mg base)
<1 ½ ¼ ½ ½ 0
1-4 1 1 1 1 1
5-8 2 1 2 2 2
½
9-14 3 2 3 3 4
15 & 4 3 4 4 6
above
III) Treatment of uncomplicated P. falciparum cases in pregnancy
1st Trimester: Quinine salt 10mg/kg 3 times daily for 7 days.
Note: Quinine may induce hypoglycemia; pregnant women should not
start taking quinine on an empty stomach and should eat regularly, while
on quinine treatment.
2nd and 3rd trimester: ACT as per dosage given above.
Treatment of mixed infections (P.vivar + P.falciparum) cases

All mixed infections should be treated with full course of ACT and
Primaquine 0.25 mg per kg body weight daily for 14 days.
IV) Treatment of severe malaria cases

Severe malaria is an emergency and treatment should be given as per
severity and associated complications which can best be decided by the
treating physician. The guidelines for specific antimalarial therapy is as
follows:
• Artesunate: 2.4 mg/kg body weight IV or IM given on adinission
(time=0h); | then at 12 h and 24 h and then once a day.
(or)
2 ACT is not to be given in 1st trimester of pregnancy.

3
Each Sulphadoxine-Pyrimethamine (SP) tablet contains 500 mg
sulphadoxine and 25 mg pyrimethamine. 139
Public Health • Artemether: 3.2 mg/kg body weight IM given on admission and then
and Related 1,6 mg/ kg body weight per day.
Issues
(or)
• Arteether:. 150 mg IM daily for 3 days in adults only (not recommended

for children).
(or)
• Quinine: 20 mg/kg4 body weight on admission (IV infusion or divided

IM injection) followed by maintenance dose of 10 mg kg body weight 8
hourly. The infusion rate should not exceed 5 mg salt/kg body weight per
hour.
Note:
The parenteral treatment in severe malaria cases should be given for
minimum of 24 hours once started (irrespective of the patient's ability to
tolerate oral medication earlier than 24 hours).
After parenteral artemisinin therapy, patients will receive a full course of oral
ACT for 3 days. Those patierts who received parenteral Quinine therapy
should receive:
• Oral Quinine 10 mg/kg body weight three times a day for 7 days
(including the days when parenteral Quinine was administered) plus
Doxycycline 3 mg/kg body weight once a day or Clindamycin 10mg/kg
body weight 12-hourly for 7 days (Doxycycline is contraindicated in
pregnant women and children under 8 years ofage).
(or)
ACT as described before.
B. Chemoprophylaxis
Chemoprophylaxis should be administered only in selective groups in high
P.falciparum endemic areas. Use of personal protection measures including
Insecticide Treated Bed Nets (ITN)/Long Lasting Insecticidal Nets (LLIN)
should be encouraged for pregnant women and other vulnerable population
including travellers for longer stay. However for longer stay of Military and
Para-military forces in high Pf endemic arzas, the practice of
chemoprophylaxis should be followed wherever appropriate e.g. troops on
night patrol duty and decisions oftheir Medical Administrative Authority
should be followed.
I) Short term chemoprophylaxis (up to 6 weeks)
Doxycycline: 100 mg once daily for adults and 1.5 mg/kg once daily for
children | (contraindicated in children below 8 years). The drug should be
4(Loading dose of Quinine i.e. 20mg/kg body weight on admission may

not be given if the patient has already received quinine or ifthe clinician
140 feels inappropriate).
started 2 days before travel and continued for 4 weeks after leaving the Health
malarious area. Programmes
Note: It is not recominended for pregnant women and children less than
8 years.
II) Chemoprophylaxis for Longer stay (more than 6 weeks)
Mefloquine: 250 mg weekly for adults and should be administered two
weeks before, during and four weeks after exposure.
Note: Mefloquine is contraindicated in individuals with history of
convulsions, neuropsychiatric problems and cardiac conditions.
Therefore, necessary precautions should be taken and all should undergo
screening before prescription of the drug.
Source: National Drug Policy on Malaria (2010). DMA News Bulletin,
10th July, 2010. Delhi Medical Association.
B. National Filaria Control Programme

Filariasis is a major public health problem in India. Filariasis is a disease
caused by the presence of parasitic worm in the lymph vessels. Whenever the
disease becomes chronic, it is irreversible. The disease has been prevalent
throughout India except Jammu & Kashmir, Punjab, Himachal Pradesh,
Mizoram, Meghalaya, Tripura, Manipur, Rajasthan, Arunachal Pradesh,
Delhi, Haryana, Sikkim and Nagaland.
Cases of filariasis have been recorded from Andhra Pradesh, Assam, Bihar,
Chhattisgarh, Goa, Jharkhand Karnataka, Gujarat, Kerala, Madhya Pradesh,
Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh, West Bengal, Pondicherry.
Andaman & Nicobar Islands, Daman & Diu, Dadra & Nagar Haveli and
Lakshadweep.
Objectives:
• To reduce and eliminate transmission of lymphatic filariasis by Mass
Drug Administration (MDA) of DEC (Diethyl carbamizine) in endemic
areas. About 85.92 % of the population was covered under MDA in
2008;
• To reduce and prevent morbidity in affected persons; and
• To strengthen the existing health care services.
• For the control offilariasis, the National Filaria Control Programme was
launched in 1955. Under the programme, the following activities are
being undertaken:
i) defining the problem in the surveyed area and unsurveyed areas.
ii) control of disease in Urban areas through; a) recurrent anti-larval
measures, and b) anti-parasitic measures.
Infrastructure:
There are 27 survey units, 206 control units, 199 filaria clinics and 3 Rural
Filaria Control Projects.Filaria Survey Units carry out initial survey. in the 141
Public Health endemic districts on a sample basis to assess the prevalence, type of infection
and Related and vectors. Filaria Control Units carryout antilarval measures. They are also
Issues
responsible for monitoring mosquito breeding places for larvae, pupae and
vector density. Filaria Clinics are responsible for the population survey,
treatment of cases and carriers. Total population covered by a Filaria Clinic is
about 50,000.
At present, about 42.6 million people in urban areas are being protected
through anti larval measures by 204 control units. About 192 clinics are
giving treatment to clinical! cases and microfilaria carriers. It is observed that
in 90 per cent of the towns where control measures are in operation for more
than five years, marked reduction in microfilaria rates have been reported.
Activities: Salient features of the strategy observed under National Filaria
Control Programme are as follows:
• Recurrent anti-larval measures at weekly intervals,

• Environmental methods including source reduction by filling ditches,
pits, low lying areas, deweeding, desilting, etc.,
• Biological controlofmosquito breeding through larvivorous fish.
• Anti-parasitic measures through 'detection' and 'treatment'ofmicro filaria
carriers and disease person with Anti Filarial Drugs (DEC+Albendazole)
for 5 years or more by Filaria Clinics in towns covered under the
programme to the population excluding children below two years,
pregnant women and seriously ill persons in affected areas to interrupt
transmission of disease.
C. Kala-azar Elimination Programme

Kala-azar is a slow progressing indigenous disease caused by a protozoan
parasite.. The parasite primarily infects reticuloendothelial system and may
be found in abundance in bone marrow, spleen and liver.
Kala-azar is endemic in castem states of India namely Bihar, Jharkhand, Uttar
Pradesh and West Bengal. 165. million population is estimated to be at risk in
these four states. Mostly poor socio-economic groups of populations
primarily living in rural areas are aflected. As per the provisional data
reported upto July, 2009 a total of 14619 cases of Kala-azar have been
detected and 41 deaths have been reported.
Infrastructure:
Goverument of India provides kala-azar medicines, insecticides and technical
support and the State governments implement the programme through
primary health care system and district zonaland State malaria control
organizations and provide other costs involved in strategy implementation.
Activities: The other programme strategy includes:
• Vector control
• Early Diagnosis and Complete treatment
142
• Information Education and Conumunication Health
Programmes
• Capacity Building
Dengue:
It is transmitted by the infective bite of Aedes Aegypti mosquito. Man
develops disease after 5-6 days ofbeing bitten by an infective mosquito.It
occurs in two forms: Dengue Fever and Dengue Haemorrhagic Fever
(DHF).Dengue Fever is a severe, flu-like illness. Dengue Haemorrhagic
Fever (DHF) is a more severe for of disease, which may cause death. In 2008,
12561 cases of dengue were detected and 80 deaths were reported. As per the
provisional data reported upto July 2009, 2901 cases of dengue have been
detected and 13 deaths have been reported.
Infrastructure:
The Government of India has established 110 Sentinel Surveillance Hospitals
with laboratory support for augmentation of diagnostic facility for dengưe in
endemic State(s) in 2007 which has been increased to 170 in 2009. All these
are linked with 13 Apex Referral Laboratories. Information on the list of
hospitals and referral laboratories can be obtained from the following
website: http://nvbdcp.gov.in/dengue-goi-activities.html.
Activities:
• Treatment Management
No drug or vaccine is available for the treatment of Dengue/Dengue
Haemorrhagic fever (DHF). With early detection and proper case
management and symptomatic treatment, mortality can be reduced
substantially. In dengue shock syndrome, the following treatment is
recommended:
 Replacement of plasma losses;
 Correction of electrolyte; and
 metabolic disturbances blood transfusion.
• Preventive Vector control measures

1) Personal prophylactic measures:
• Use of mosquito repellent creams, liquids, coils, mats etc.
• Wearing of full sleeve shirts and full pants with socks.
• Use of bednets for sleeping infants and young children during day
time to prevent mosquito bite
2) Biological control:
• Use of larvivorous fishes in ornamental tanks, fountains, etc.
• Use of biocides
3) Chemical control:
• Use ofchemical larvicides like abate in big breeding containers
143
Public Health • Aerosol space spray during day time
and Related
Issues 4) Enviromental management and source reduction methods:
• Detection & elimination of mosquito breeding sources
• Management of rooftops, porticos and sunshades
• Proper covering of stored water
• Reliable water supply
• Observation of weekly dry day
5) Health education:
• Impart knowledge to common people regarding the disease and
vector through various media sources like T.V., Radio, Cinema
slides, etc.
6) Community participation:
• Sensitilizing and involving the community for detection of Aedes
breeding places and their elimination. The control of Aedes Aegypti
mosquito is the only method of choice.
D. Japanese Encephalitis
Japanese Encephalitis (JE) is a viral disease. It is transmitted by infective
bites of female mosquitoes mainly belonging to Culex tritaeniorhynchus,
Culex vishnui and Culex pseudovishnui group. However, some other
mosquito species also play a role in transmission under specific conditions.
Man is an accidental host of JE primarily affects central nervous system.
Japanese encephalitis is a major problem in Uttar Pradesh, Assam, Andhra
Pradesh, Goa, Haryana, Karnataka, Kerala, Manipur, Tamil Nadu,
Maharashtra, Bihar and West Bengal. During year 2008, total3839 cases and
684 deaths due to JE. It were reported from 16 States/Union Territories.
Infrastructure:
The state governments make provisions for medicines, equipment and
accessories as well as sufficient number of trained medical, nursing and
paramedical personnel in the endemic districts. Technical support is also
provided on request by the state health authorities for outbreak investigations
and control.
Activities:
• Preventive measures: The preventive measures are directed at reducing
the mosquito breeding and taking personal protection against mosquito
bites using insecticide treated mosquito nets.
• Treatment/ management: JE vaccine is produced in limited quantities
at the Central Research Institute, Kasauli: Vaccination is not
recommended as an outbreak control measure as it takes at least one
month after second dose to develop antibodies at protective levels and
the outbreaks are usually short lived. So there is no specific anti-viral
medicine available against JE virus. The cases are managed
144
symptomatologically. Clinical management of JE is supportive and in the Health
acute phase is directed at maintaining fluid and electrolyte balance and Programmes
control of convulsions, if present. Maintenance of airway is also crucial.
Chikungunya Fever
Chikungunya is a non-fatal, viral illness that is spread by the bite of aedes
aegypti mosquito. It resembles dengue fever. Human beings are the major
source or reservoir of chikungunya virus for mosquitoes.
The states effected by chikungunya are Andhra Pradesh, Karnataka,
Maharashtra, Madhya Pradesh, Tamil Nadu, Gujarat and Kerala, In the year
2006, the total number of 1390322 suspected chikungunya fever cases come
reported from the country.
Activities :
• Treatment/management:There is no specific treatment for chikungunya
as there is neither chikungunya virus vaccine nor drugs are available to
cure the infection. Supportive therapy that helps ease symptoms, such as
administration of non steroidal anti-inflammatory drugs, and getting
plenty of rest, may be beneficial. Infected persons should be isolated
from mosquitoes in as much as possible in order to avoid transmission of
infection to other people.
• Preventive measures: Prevention centres on avoiding mosquito bites.
Eliminating mosquito breeding sites is another key prevention measure.
To prevent mosquito bites, the following measures should be observed:
 Use of mosquito repellents on skin and clothing.
 Use of bed nets if sleeping in areas that are not screened or air-
conditioned.
 When working outdoors during day times, wear long-sleeved shirts
and long pants to avoid mosquito bite.
22.2.7 National Leprosy Eradication Programme

In India, leprosy was first described in the Susruth Samhita and treatment
with 'chaulmoogra' oil was known at that time. It is said that leprosy was
referred to as Kusht in the Vedic writing, which is how the disease is known
as even to this day.
Leprosy is caused by Mycobacterium Leprae, which morphologically
resembles Mycobacterium Tuberculosis. The reservoirs of leprosy is/are
infectious leprosy patient (s) who are not taking Multi Drug Therapy (MDT)
and is in prolonged contact with healthy persons. Only less than 20% of
leprosy patients are of infectious type and with modern Multi Drug Therapy,
these patients become non-infectious very rapidly Even single dose of MDT
kill 99.9% leprosy bacilli under laboratory conditions. There is no threat of
disease transmission in the patient is taking treatment at home.
Govt of India started National Leprosy Control Programme in 1955 based on
Dapsone domiciliary treatment, through vertical units, implementing survey 145
Public Health education and treatment activities. Since the early 1980s, MDT has
and Related revolutiontred the treatment of leprosy. It is a combination of the drugs-
Issues
Rifampicin, Clofazimine and Dapsone and is virtually a guaranteed cure of
leprosy as even a single dose of MDT kills 99.9% of leprosy germs. There
are no significant side effects of MDT within prescribed doses and a leprosy
patient ceases to be infectious within a few months of starting the course of
treatment. MDT is now available free-of-cost on all working days at all Sub-
centres, Primary Health Centres, Govt. Dispensaries and Hospitals in the
country.
Though the disease is found throughout the country, it is not equally
distributed. There as wide variation in the prevalence. Even in the low
endemic areas there are pockets of high prevalence.
The areas of high prevalence are now found mainly in the south-eastern part
of the country which includes the States of Tamil Nadu, Orissa, Bihar,
Pondicherry and Andaman and Nicobar Islands.
The areas of moderate prevalence are found mostly in the central and south-
western part, castern part and the himalayan foot hills of the country. The
areas of low prevalence are found mainly in the north-western parts of the
country.
Activities: The main activities under NLEP include early detection of cases
by house to house surveys, school surveys, slum surveys, and to bring all the
detected cases under regular treatment as near to their house as possible.
Emphasis is given on education of the patients, their families and the
community on facts about leprosy and its curability etc.
Active involvement of the non-governmental organisations is encouraged in
all these programme activities. Basic training is provided to leprosy staff and
general orientation and training is provided to the routine health care staff.
Infrastructure: The magnitude of the case load and high endemicity in the
country needed the deployment of especially trained vertical staff for
rendering leprosy services. In endemic areas, one Leprosy Control Unit
(LCU) covers 4 to 5 lakh rural population and is manned by 4 non-medical
supervisors and 20 para-medical workers. The urban leprosy centre is
manned by a paramedical worker who covers 50,000 urban population. At the
district level, the office of the District Leprosy Officer is set up. There are
244 district units functioning at present and there are 49 leprosy training
centres which are engaged in training of manpower required for carrying out
the programme activities. Important services provided under the programme,
include: i) case detection and treatment; i) health education; community
participation; ii) maintenance of records; iv) training: iv) monitoring; v)
rehabilitation and vi) administering multidrug treatment.
Out of 596 districts in the country, as on 31st March 2006, a total of 439
districts (73.7%) achieved elimination. For elimination in the remaining
districts, special focus of the programme is on endemic blocks with
prevalence rate of more than 2/10,000 population. As on 31st March 2006,
leprosy cases on record came down to 0.95 lakh.
146
Current Strategy: Although leprosy elimination has been achieved at Health
national level, efforts will continue at the same pace as at present to achieve Programmes
leprosy elimination in the remaining districts and avoid any possible

recurrence of disease in areas where success has already been achieved.
New Paradigms under the programme:

• More focus on new case detection and treatment completion.
• Improvement of quality of leprosy services.
• Strengthening referral services with more focus on long term care of
leprosy affected persons.
• Support of NRHM for improving delivery of leprosy services by
involvement of ASHA, Village Health & Sanitation Committees, Rogi
Kalyan Samitis.
• Community based rehabilitation of leprosy affected persons.
• Renewed focus on reduction of stigma and discrimination against leprosy
affected persons and their family members.
22.2.8 National Programme for Control of Blindness (NPCB)

Blindness is one of the most significant social problems in our country. It is
estimated that there are 30 million people completely blind in the world.
India alone accounts for 12 million totally blind (in both eyes) and 8 million
partially blind (in one eye). This means 32 million blind eyes are there in
India out of which 3 million need corneal transplantation (implantation of
cornea) (Source : Annual report 1991-92, Ministry of Health and Family
Welfare, Government of India, 1992).
The latest studies have revealed that 81 per cent of blindness is due to
cataract (opacity in the lens of the eye, resulting in blurred vision) which is
curable by surgical interventions.
Today, there is a backlog of 22 million cataract cases and adding 2 million
every year, whereas, the present rate of cataract operation is 1.2 million per
year resulting in an additional load of 0.8 million cataract cases every year.
Thus the country needs to perform 2.7 million cataract operations per year to
clear the backlog.
Realising the importance of technical manpower for effective implementation

of programme, the priority for manpower development is being given. Some
of the important training programmes are :
i) Training of para-medical ophthalmic assistance (PMOA)
ii) Training of medical graduates and ophthalmologists oriented to the needs
of NPCB.
iii) Orientation/Refresher training of medical officers of primary health
centres and hospitals.
iv) Continuing medical education for eye specialists.
147
Public Health The para-medical ophthalmic assistants are trained in 37 training schools
and Related attached to selected medical colleges/regional institutes/national institute.
Issues
Training of primary health centre medical officers (7-15 days) is conducted in
medical college's/ district hospitals/selected eye hospitals to prepare them to
integrate eye health care into comprehensive health care delivery services and
to guide and supervise the work of the ophthalmic assistant. The medical
officers of primary health centres in turn carry out orientation training of the
primary health centre staff to ensure that they have adequate knowledge and
skills to know their roles and responsibilities— clearly and discharge their
respective responsibilities.
22.2.9 National AIDS Control Programme

AIDS (acquired immuno deficiency syndrome) is a disease characterised by
loss of the cell medialed immune response due to decreased number of
certain T- lymphocyte. The causative agent has not been identified, but the
disease is of virus origin.
The National AIDS Control Programme was initiated in the year 1986. The
three major components of the programme include :
i) Surveillance
ii) Screening of blood and blood products to ensure blood safety; and
iii) Information, Education and Communication.
Objectives : The main objective of the programme was to arrest the pace of
infection by stepping up (survey surveillance) activities amongst the
promiscuous individuals and providing the scope of social mobilisation
through health education. The main objective of the programme is :
1) Prevention of new infection in high risk groups and general population
through:
a) Saturation of coverage of high risk group with targeted
interventions; and
b) Scaled up interventions in the general population.
2) Providing greater care, support and treatment to a large number of people
living with HIV/AIDS.
3) Strengthening the infrastructure, system and human resources in
prevention, care, support and treatment programmes at the district, state
and national levels.
4) Strengthening a nation-wide Strategic Information Management System.
To achieve the objectives the following activities are carried out:
a) Information, education and communication to groups practising high
risk behaviour and general public;
b) prevention and treatment of sexually transmitted diseases (STD);
c) prevention and treatment of transmission through intravenous drug
abusers;
148
d) prevention of transmission through blood and blood products; Health
Programmes
e) strengthening of clinical management capabilities; and
f) programme management.
Government of India have already taken the needed precautions by issuing

strict guidelines for all manufacturing units producing blood and blood
products for strict compliance. Instructions have also been issued to all blood
banks to screen all pooled plasma for HIV, Syphilis, Hepatitis and Malaria
and any sample detected positive for the virus should be discarded forthwith.
Necessary hospital infection control guidelines to all medical institutions and
establishments in the country have been issued for strict observance.

1) List any three activities of the national leprosy eradication programme.
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
2) What are the three major components of national AIDS control
programme.
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
22.2.10 National Mental Health Programme (NMHP)

The Government of India launched the National Mental Health Programme
during the 1982. The objectives were:
1) To ensure availability and accessibility of minimum mental health care
for all in the foreseeable future, particularly to the most vulnerable and
underprivileged section of population.
2) To encourage application of mental health knowledge in general health
care and in the social development.
3) To promote community participation in the mental health services
development, and to stimulate efforts towards self-help in the
community.
Medical Colleges are providing training in basic knowledge and skills in the
field of mental health to the primary health care physicians and para-medical
personnel. These centres are also coordinating various Mental Health
activities in the region and supply the health education materials to the 149
Public Health training centres in their respective regions and coordinate with the Ministry
and Related of Health and Family Welfare.
Issues
The programme strategies are:

1) Integration of mental health with primary health care through the
NMHP;
2) Provision of tertiary care institutions for treatment of mental disorders;
3) Eradicating stigmatization of mentally ill patients and protecting their
rights through regulatory institutions like the Central Mental Health
Authority, and State Mental Health Authority.
District Mental Health Programme Components are:
a) Training programmes for all workers in the mental health team at the
identified nodal institute in the state;
b) Public education in mental health to increase awareness and to reduce
stigma;
c) For early detection and treatment, the OPD and indoor services are
provided; and
d) Providing valuable data and experience at the level of community to the
state and centre for future planning, improvement in service and
research.
22.2.11 National Diabetes Control Programme

The National Diabetes Control Programme was included in the 7th Five Year
Plan as one of the central health sector programmes and was allocated a sum
of Rs. 25 lakh to initiate District Diabetes Control Programmes. The
programme developed in Tamil Nadu and Jammu and Kashmir, has provided
a model for integration of diabetes care and control in the primary health care
programme.
Objectives : The objectives of the programme are :

a) Identification of high risk subjects at early stages and imparting
appropriate health education with focus on primary prevention of
diabetes.
b) Early diagnosis of the disease and institution of appropriate management
so as to reduce morbidity and mortality (secondary prevention) with
emphasis on vuInerable groups e.g. gestational diabetes; (diabetes during
pregnancy)
c) Prevention, arrest or slowing of acute metabolic as well as chronic
cardio- vascular-renal complications of the disease.
d) Provision of equa! opportunities to ensure scholastic achievements as
well as physical attainment and thus ensuring social and emotional
adaptation leading to an improved quality of life, and
150 e) Identification of those with partial or total physical handicaps owing to

diabetes to ensure their rehabilitation with emphasis on optimal organ or Health
body function. Programmes
The programme interventions have been grouped into the following three
components.
A) Health promotion for the general population: Targeted to healthy, risk
free population and involves development of an effective communication
strategy to modify individual, group and community behavior through
media. It consists of community based interventions, workplace
interventions and school based interventions.
B) Disease prevention for the high risk group: Interventions aimed at early
diagnosis and appropriate management for reducing morbidity and
mortality targeting people who suffer from elevated risks demonstrated
through hypertension, obesity, high blood lipid and glucose levels and
those who have suffered from a previous cerebral or coronary event and
are at high risk.
C) Assessment of prevalence of risk factors: Through surveillance of risk
factors that predict many non-communicable diseases, and research into
causal association will also be carried out
22.2.12 Revised National Tuberculosis Control Programme

Tuberculosis is a communicable, bacterial disease which results from
infection with ID bacilli.
Tuberculosis is a major public health problem in the country. As per the
National Tuberculosis Sample Survey, conducted by the ICMR in 1955-
1958, nearly 1.5 per cent of the total population is estimated to be suffering
from active tuberculosis of lungs, of which one-fourth are infectious. The
prevalence is same in urban as well as in the rural areas. Nearly 3.2 lakh
persons die of the disease every year. It is estimated that about 80 per cent of
the cases of tuberculosis reside in the rural areas.
Organization: The National Tuberculosis Control Programme has been
functioning since 1962 and the district tuberculosis centre forms its
functioning unit. The district tuberculosis officer (DTO) is the overall
incharge of the programme at district level. He is assisted by a team,
consisting or laboratory technician, X-ray technician, treatment organiser and
statistical assistant. All other health institutions of the district assist DTO in
programme implementation.
Case Finding: All the patients reporting at the Peripheral Health Institutions
with symptoms of cough, fever, hemoptysis, chest pain are offered sputum
examination and if this is negative patient is kept under observation, sputum
examination is repeated or patient sent for X-ray.
Programme Goals:
• To reduce mortality and morbidity form tuberculosis; &
• To interrupt chain of transmission.
151
Public Health Objectives:
and Related
Issues • To cure at least 85% of all newly detected infectious cases of pulmonary
tuberculosis (new sputum smear-positive).
• To detect at leas: 70% of estimated new smear positive pulmonary
tuberculosis cases.
Directly Observed Treatment Strategy (DOTS):

DOTS is a systematic strategy having the following five components:
1) Political and administrative commitment
2) Good quality diagnosis, primarily by sputum smear microscopy
3) Uninterrupted supply of good quality drugs
4) Directly Observed Treatment (DOT)
5) Systematic monitoring and accountability
TB is completely curable if full course of treatment is taken by the patient.

Treatment facilities are available free of cost for TB cases in all District TB
centres. Block PHCs, Taluk Hospitals, Primary Health Centres and other
Govt. Health Institution.
Though the programme has been in operation since 1962, it had not made any
significant epidemiɔlogical impact on problem of TB. The Programme was
reviewed by an Expert Committee in 1992. Based on the findings and
recommendations of the review, the Government of India evolved a revised
program based on Directly Observed Treatment Short course Strategy
(DOTS) with the objective of curing at least 85% of new sputum positive
patients and detecting at least 70% of such patients.
Under the DOTS Strategy, patients swallow the drugs under direct
observation of the health worker viz. the DOT provider. The selection of the
DOT provider is not restricted to medical personnel Any responsible person
of the locality/community except a family member can function as DOTS
provider. The patient is required to visit the designated DOTS centre and
consume the medicine in the presence of the DOT provider. In case the
patient drops out/fails to attend the health facility in the scheduled day, then it
is the responsibility of the DOT provider to retrieve the patient to the system
and ensure completion of the treatment regimen.
One of the unique features of this programme is the fact that patient wise
treatment boxes are available with the DOT provider with the full regimen of
drugs needed to complete the treatment. This facility ensures uninterrupted
supply of medicines to any patient.
22.2.13 National Rural Health Mission (NRHM)

Government of India has committed itselfto provision of improved public
health services under the Common Minimum Programme, Drawbacks of the
current health system include, centralised planning instead of decentralised
planning using locally relevant strategies, institutions based on population
152
norms rather than hantations, fragmented disease specific approach rather Health
than comprehensive health care and inability of the system to mobilise action Programmes
in areas of safe water, sanitation, hygiene and nutrition, the key determinants
of health in context of our country.
National Rural Health Mission (NRHM) is proposed to cover the entire
country with special focus on 18 states including 8 EAG (Empowered Action
Group) states viz., U.P., M.P., Bihar, Orissa, Rajasthan, Uttarakhand,
Jharkhand and Chattisgarh; & North Eastern states viz., Assam, Arunachal
Pradesh, Manipur, Mizoram, Meghalaya, Nagaland, Sikkim and Tripura
besides Himachal Pradesh and Jammu & Kashmir. The mission has been
conceived for rural areas and health care needs of urban poor will be covered
through a proposed National Urban Health Mission. NRHM has been
launched on 12th April 2005.
Goals
• Universal access to public health services such as women's health, child
health, water, sanitation and hygiene, immunisation and nutrition.
• Prevention and control of communicable and non-communicable
diseases, including locally endemic diseases.
• Access to integrated comprehensive primary health care.
• Reduction in Infint Mortality Rate (IMR) and Maternal Mortality Ratio
(MMR).
• Population stabilisation, gender and demographic balance.
• Revitalise local health traditions and mainstream AYUSH.
• Promotion of healthy life styles.
The expected outcome of NRHM

• IMR reduced to 30/1000 live births.
• Maternal mortality reduced to 100/100,000 live births.
• TFR reduced to 2.1.
• Raising the sex ratio (0-6 year) to 935,
• Malaria mortality reduction-50% up to 2010, additional 10% by 2012.
• Kala azar mortalty reduction-100% by 2010 and sustaining elimination
until 2012.
• Filaria/microfilaria reduction-70% by 2010, 80% by 2012 and
elimination 2015.
• Dengue mortality reduction-50% by 2010 and sustaining at that level
until 2012.
• Cataract operations-increasing to 46 lakh.
• Leprosy prevalence rate-reduce to less than 1 per 10,000.
• Tuberculosis DOTS-maintain 85% cure rate and also sustain planned
case detection, rate. 153
Public Health • Upgrading all health establishments in the districts to Indian Public
and Related Health Standards.
Issues
• Increase utilisation of First Referral Units-bed occupancy by referred
cases of more than 20% to over 75%.
Key Strategies
Providing an Accredited Social Health Activist (ASHA): Currently Health
Worker Female (HWF) is heavily overworked as she is to cater to more than
5000 population especially in EAG states, with only 50% MPW(M) being
available. This adversely affects the outreach Services in the rural areas, Job
responsibilities of Anganwadi Worker (AWW) like supplementary nutrition,
preschool education and other support activities leave little time for her to
take up the responsibility to bring about a change in health in the village. This
void is proposed to be filled through new community based functionaries,
named Accredited Social Health Activists (ASHA).
It is proposed to have one ASHA per 1000 population However, there can be
one ASHA per habitatior. in tribal, hilly and desert areas, depending on the
workload.
• Integration of ongoing disease control programmes, RCH II, and

Integrated Disease Surveillance Programme. The Budget of various
National Health Programmes except AIDS and Cancer Control
Programme will be integrated to form a comprehensive budget head. In
addition there will be convergence of major determinants of health ie.
water supply, sanitation, hygiene and nutrition.
• Decentralised planning: Planning will start at the level of village where
Village Health and Sanitation Cominittee will be formed to prepare
intersectoral village health plan that includes provision of safe water,
sanitation, hygiene and nutrition.
Strengthening of Primary Health Care Infrastructure:

Sub-Centres: An untied grant of Rs. 10,000/- will be provided at sub-centre
level to set in motion an autonomous action for health at local level. This will
enable the health workers to respond to local needs.
Primary Health Centres: Provision will be made for 24 hour services in at
least 50% PHCs by addressing shortage of doctors in high focus states.
Supply of essential drugs and equipment will be ensured.
Community Health Centres: CHĆs will be upgraded as 30-50 bedded
hospitals. In addition to existing specialists, two more specialists viz.
anaesthetist and public health manager will be provided. The support
manpower will include one more Public Health Nurse and HW (F).
Supplementary Strategies
• Regulation of private sector including the informal rural practitioners to
ensure availability of quality services to citizens at reasonable cost.
154
• Promotion of Public-Private Partnerships for achieving public health Health
goals. Programmes
There are many models of public-private partnerships such as provision

of land for setting up health facilities at concessional rates to
private/charitable organizations by the government. In turn they are
required to provide free OPD services and a given proportion of free
beds for poor patients. In some places private organizations provide
investigation facilities for patients attending government hospitals at
rates fixed by the government. Central Government Health Scheme
provides for investigation and treatment facilities from selected private
providers. Some of the recent models of Public-Private Partnerships for
maternal health are given in annexure I.
• Mainstreaming AYUSH-revitalising local health traditions.
• Reorienting Medical Education to support rural health issues including
regulation of Medical Care and Medical Ethics.
• Effective and viable risk pooling and social health insurance to provide
health security to the poor by ensuring accessible, affordable,
accountable and good quality hospital care.
Indian Public Health Standards (IPHS):

Objectives of Indian Public Health Standards (IPHS) are:
• To provide optimal care to the community.

• To achieve and maintain an acceptable standard of quality of care.
• To make the services more responsive and sensitive to the needs of the
community.
These standards indicate minimum requirements and cover infrastructure,
staff, equipment, drugs, and investigation facilities.
IPHS have been prepared for sub-centres, PHCS, CHCs, sub divisional and
district hospitals. These standards also provide criteria for location, layout
and space for buildings and details of other infrastructure facilities. IPHS for
sub-centres, PHCs and CHCS describe the services available at these centres
and job responsibilities of various functionaries. To ensure quality, every
institution shall have standard operative procedures and standard treatment
protocols for common diseases and National Health Programmes.
Mainstreaming of AYUSH
AYUSH interventions initiated under NRHM:
• Co-location of AYUSH dispensaries in 3528 PHCs in different states.

• Appointment of 452 AYUSH doctors and pharmacists on contractual
basis in the primary health care system.
• Inclusion of AYUSH modules in training of ASHA.
• Inclusion of Punarnavdi Mandoor' in the ASHA kit for management of
anaemia during pregnancy. 155
Public Health • Inclusion of seven Ayurvedic and five Unani medicines in the RCH
and Related programme.
Issues
• Establishment of speciality clinics, specialised therapy centres and
AYUSH wings in district hospitals supported through Centrally
Sponsored Scheme.
During the eleventh five year plan pilot action research projects will be
supported to evolve viable models of integration of AYUSH with NRHM.
Public-Private Partnership for Maternal Health

Janani Suraksha Yojna
Janani Suraksha Yojna (JSY) has been proposed under NRHM by modifying
the existing National Maternity Benefit Scheme (NMBS). The existing
scheme provides for cash assistance to pregnant women from Below Poverty
Line (BPL) families for better diet. While under JSY cash assistance is linked
to antental care during pregnancy, institutional care during delivery and
immediate post-partum period in a health centre. This will be coordinated by
a village level health worker. JSY is a 100% centrally sponsored scheme.
Goals:
• To reduce maternal mortality ratio and infant mortality rate.
• To increase institutional deliveries among BPL families.
Cash assistance is available for births

1) List the objectives of the national mental health programme.
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
2) List three important activities under national TB Control Programme.
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
3) What three major activities are conducted under the National Malaria
Eradication Programme?
…………………………………………………………………………
…………………………………………………………………………
156
22.3 OTHER PROGRAMMES FOR THE Health
Programmes
PROMOTION OF MOTHER AND CHILD
HEALTH AND NUTRITIONAL STATUS
Women and children constitute the vulnerable section of the society. They
are most prone to disease and infection leading to ill-death. To overcome
these problems the government has initiated a number of programmes with
the sole objective of improving the nutritional and health status. You might
recall reading about some of these programmes in the previous course. Can
you list them down? For your reference, here is a list of the programmes
targeted at women and children. They are Integrated Child Development
Services (1CDS) programme, Mid-day Meal Programme (MDM), Special
Nutrition Programme (SNP), Applied Nutrition Programme, Wheat based
supplementary nutrition programme and Balwadi Nutrition Programme.
Since you have already learnt about ICDS and Mid-day meal programme in
Course 1, Block 6, Unit 24, we shall not spend much time on them. We
suggest you go back to Course 1 and read them once again. Here we will
concentrate more on the other programmes. But, we begin with ICDS
Scheme, a brief review.
22.3.1 Integrated Child Development Services Scheme (ICDS)

Integrated Child Development Services (ICDS) was launched on 2nd October
1975, in pursuance of the national policy for children in 33 experimental
blocks. Success of the scheme stimulated the expansion of scheme to 2499
projects by the end of March 1991. During the year 1991-92, 75 new projects
were sanctioned. It is the largest nutrition programme implemented by
Government of India. At present about 1.85 lakhs anganwadis are providing
supplementary nutrition (SN) to 142.52 lakhs children, pregnant and nursing
mothers.
Beneficiaries : The beneficiaries are children below 6 years, pregnant and
lactating mothers and women in the age group of 15 to 44 years.
Objectives : The objectives of the scheme are:
• to improve the nutritional and health status of children in the age group
of 0-6 years
• to lay the foundations for proper psychological, physical and social
development of the child
• to reduce the incidence of mortality, morbidity, malnutrition and school
dropouts
• to achieve effective co-ordination of policy and implementation amongst
the various departments to promote child development; and
to enhance the capability of the mother to look after the normal health and
nutritional needs of the child through proper nutrition and health education.
Activities : The following services are provided under the programme :
157
Public Health • Supplementary nutrition (SN)
and Related
Issues • Immunisation
• Health check-up
• Referral services
• Treatment of minor illnesses
• Nutrition and health education to women
• Pre-school education to children in the age group of 3-6 years
• Convergence of other supportive services like water supply, sanitation
etc.
Supplementary nutrition is provided for 300 days a year. On the spot feeding
is done as far as possible at the Anganwadi. All children eligible beneficiaries
receive daily ration of 500 calories with 12 to 15 g protein. Severely
malnourished children, receive 800 calories and 20-25g protein, pregnant and
lactating mothers receive daily supplementary nutrition providing 600
calories and 18-20 g protein.
The eligible beneficiaries are provided iron and folic acid tablets and massive
dose of vitamin A through the health infrastructure existing in the ICDS
project area.
The Cost of Supplementary nutrition provided is

i) Children (6 months to 72 months) Rs. 4 per child per day
(grade I & II children)
ii) Severely malnourished Rs. 6 per child per day
(6 months to 72 months)
iii) Pregnant and nursing mother Rs. 5 per beneficiary per day
(Source : Central Technical Committee, Ministry of Welfare 1991)

Organisation : ICDS is a multisectoral programme and involves several
government departments and their services are co-ordinated at the village,
block, district, state and central levels. The primary responsibility for the
implementation of the programme lies with the Department of Women and
Child Development, Ministry of Welfare at the centre and the nodal
department at the state, which may be Social Welfare, Rural Development,
Tribal Welfare or Health etc. The anganwadi worker is the most peripheral
functionary who implements the programme services at the
village/corhmunity level.
22.3.2 Mid Day Meal ( MDM) Programme

Mid-day meal programıne is also known as ‘noon meal programme'. MDM
was started in 1962-63. With a view to enhancing enrollment, retention and
attendance and simultaneously improving nutritional levels among children,
this program was modified and implemented from 1995 as the National
158 Programme of Nutritional Support to Primary Education (N.P-NSPE) as a
Centrally Sponsored Scheme in 2408 block in the country. By the year 1997- Health
98 the NP-NSPE was introduced in all blocks of the country. It was further Programmes
extended in 2002 to cover children in classes I-V of government, government

aided, local body schools and EGS (Education Guarantee Scheme) and AIE
(Alternative and innovative Education Scheme) centers.
From 2004 the scheme was revised to provide cooked mid day meal with 300
calories and 8-12 grams of protein to all children studying in classes I-V in
Government and aided schools.
From 2006, in addition to free supply of food grains, the revised scheme
provided Central Assistance for (a) cooking cost at the rate of(a) Rs 1.80 per
child/school day for States in the North Eastern Region ( NER), provided the
NER states contribute Rs. 0.20 per child/school day, and (b) Rs 1.50 per child
school day for other States and UTS, provided that these States and UTs
contribute Rs 0.50 per child/school day (c) Management, monitoring and
evaluation costs @2% of the cost of food grains, transport subsidy and
cooking assistance, (d) Provision of mid day meal during summer vacation
in drought affected areas.
In 2007, GOI announced the revised nutritional norms and extended the Mid-
Day Meal Scheme to cover children in Upper Primary Classes in 3479
Educationally Backwards Blocks (EBBs).
In 2021, MDM was renamed PM POSHAN (POshan SHAkti Nirman)
scheme providing one hot cooked meal to school children.
Objectives
The objectives of the mid day meal scheme are:
• To retain and improve attendance in school of children studying in class 1-8
• Improving the nutritional status of children in classes I-VIII in
Government, Local Body and Government aided schools,
• Encouraging poor children, belonging to disadvantaged sections, to
attend school more regularly and help them concentrate on classroom
activities.
• Providing nutritional support to children of primary stage in drought
affected areas during summer vacation.
Beneficiaries: The beneficiaries are children attending the preprimary,
primary and upper primary school (6 to 14 years of age). The children
belonging to backward classes; scheduled caste and scheduled tribe families
are given priority.
Activities: Cooked nutritions meal is given to students in pre primary,
primary and upper primary. Children in the primary stage receive per day 450
calories and 12g protein while children in the upper primary stage receive
700 calories and 20 g of protein.
Organisation : The programme is implemented through the existing network
of schools and one of the school teacher is designated as the ‘organiser’ and
is responsible for the implementation of the scheme.
159
Public Health 22.3.3 Special Nutrition Programme
and Related
Issues The Special Nutrition Programme (SNP) was launched in 1970-71 by the
Ministry of Social Welfare, Government of India. It was initially launched as
a Central Programme but was transferred to the state sector during the fifth
five year plan. During the sixth and seventh five year plans, steps were taken
to convert the SNP centres on the pattern of ICDS scheme by strengthening
them with health and other inputs.
Objectives : The objectives of the programme is to improve the nutritional
status of preschool children, pregnant and lactating mothers of poor socio-
economic groups in urban slums, tribal areas and drought prone rural areas.
Beneficiaries : The programme caters to :
i) Preschool children
ii) Pregnant and lactating mothers.
The beneficiaries are selected on the basis of their socio-economic groups.

The pregnant mother in the last trimester and lactating mothers during the
first four months are given priority. The malnourished children are also given
priority.
Activities : The activities of the programme include:
• to provide supplementary nutrition.

• to provide health care services including supply of Vitamin A solution
and iron and folic acid tablets. (This component has been added during
sixth five year plan.)
Organisation : The programme is implemented through a network of

balwadis, which are located at the village/community level. The balwadi
worker and the helper is most peripheral functionaries implementing the
scheme.
22.3.4 Applied Nutrition Programme (ANP)

This programme is now of historical importance as it is no longer in
operation. The ANP was first implemented in Orissa and Andhra Pradesh in
1962. By 1973, the whole country was covered by the scheme. This
programme till date is the best conceived nutrition programme but it could
not achieve the desired results due to management failure. The programme
was initiated as a centrally sponsored scheme but now is being implemented
by the states. Due to shift in thrust in the recent years, the ANP is at present a
non-expandable, low priority programme as compared to other nutrition
programmes implemented by the states.
Objectives : The objectives of the programme are:
• to make people conscious of their nutritional needs,

• to increase production of nutritious foods and its consumption, and
160
• to provide supplementary nutrition to vulnerable groups through local Health
production of foods. Programmes
The programme aimed at the approach of “self reliance” to be developed at

the community and individual level.
Beneficiaries : The programme reaches out to :
• Children between 3-6 years

• Pregnant and lactating mothers.
Activities : ANP envisaged production of nutritious food by people
themselves and to be consumed by them to improve their own nutritional
status. Poultry farming, horticulture, beehieve keeping, kitchen gardening and
nutrition education were main activities in the programme.
The supplementary nutrition was provided to children and women
beneficiaries.
Organisation : The programme is implemented under the supervision of
block development officer. The Balsevikas with a helper undertake the
programme activities at the village/community level.
22.3.5 Wheat-Based Supplementary Nutrition Programme

(WNP)
The wheat-based supplementary nutrition programme is a centrally sponsored
scheme started in 1986. This scheme was initiated to enlarge the scope of
existing nutrition programmes by covering additional beneficiaries: The
children, pregnant and lactating mothers, primarily in tribal areas, urban
slums and backward areas. Initially, this scheme was meant to cover
additional beneficiaries (mother and child) who could not be covered by
ICDS projects.
Objectives : The programme aims to enlarge the scope of existing nutrition
programme by covering additional beneficiaries i.e. pre-school children and
nursing and expectant mothers through wheat-based supplementary nutrition.
Beneficiaries : Children of pre-school age, nursing and expectant mothers in
disadvantaged areas with high IMR or high concentration of scheduled
castes, particularly in urban slums and backward rural and tribal areas.
Activities : Under this scheme supplementary nutrition is provided to the pre-

school children and pregnant and expectant mothers. The scheme consists of
2 components, viz. Centrally funded component and state funded component.
i) Centrally funded component: Under the centrally sponsored WNP,
the supplementary food given to children and expectant and nursing
mothers.
ii) State funded component: Under this component, the wheat was
initially provided to the state governments at a subsidy to provide
supplementary nutrition to the beneficiaries covered by the state
government nutrition programmes.
161
Public Health 22.3.6 Balwadi Nutrition Programme (BNP)
and Related
Issues The Balwadi Nutrition Programme (BNP) was started in 1970-71. It is
operated through Balwadis and day-care centres which are being run by the
five national voluntary organisations. There are about five thousand Balwadis
implementing the programme. It is a non-expanding and non-plan activity of
the government of India.
Objectives : The programme aims to supply about one-third of the calorie
and half of the protein requirements of the pre-school child as measure to
improve their nutritional and health status.
Beneficiaries ; Beneficiaries are pre-school children between the age of 3 to
5 years. Priority is given to children belonging to low income group.
Activities : The supplementary nutrition is given to children for 270 days a
year. Apart from nutritional supplementation, the activities for social and
emotional development are undertaken at balwadis.
Organisation : The Balwadi worker is the most peripheral worker
implementing the programme at the village/community level.

1) List three programmes providing supplementary nutrition services to
children.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) How many days supplementary nutrition is distributed in (i) ICDS
scheme (ii) Balwadi Nutrition Programme.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
22.4 LET US SUM UP

In this unit you learnt about all the important National Health programmes
and other programmes aimed at mother and child development. You learnt
about the organisation activities and functionaries implementing each
programme. After reading this unit, you would have got a clear idea on how
to effectively control the common diseases, and what support is required for
successful implementation of National Health Programmes.
162
22.5 GLOSSARY Health
Programmes
Drug In rural areas where Malaria is highly prevalent and health

distribution infrastructure is under-developed, the teachers or other
centre local leader is trained to give drugs to suspected cases of
malaria. These are called drug distribution centres.
Vaccine The diseases like Diphtheria, Pertusis (Whooping Cough),
preventable Tetanus, Tuberculosis, Poliomyelitis and Mea&les which
diseases can be prevented by vaccination.
Cold-chain The vaccines require to be stored at low temperature from
their production till their consumption. During this period
low temperature is ensured through maintaining the cold-
chain system.
Health Development of the working potentialities of health
manpower personnel to the fullest possible extent.
development
Community It is a process in which the people living in a defined
Participation geographical area identify goals, plan and implement
programmes to meet the decided goals.

EXERCISES
1) Children in 1-5 years of age, pregnant mothers, nursing mothers, female
acceptor of terminal methods of family planning and IUDs.
2) i) 1,00,000 I.U. of vitamin A between 6 months to 1 year.
ii) 2,00,000 I.U. Of vitamin A between 1-5 year every 6 month.
3) Any two of the following :
i) inadequate community participation
ii) inadequate recording system
iii) inadequate equipment for immunisation
iv) lack of accessibility
4) Any four of the following :
i) Tuberculosis
ii) Poliomyelitis
iii) Whooping cough
iv) Diphtheria
v) Measles
vi) Tetanus
163
Public Health Check Your Progress Exercise 2
and Related
Issues 1) Any three of the following:
i) Early detection of cases
ii) Encourage participation of Non-Governmental Organisation.
iii) Treatment of cases
iv) Training of functionaries
v) Rehabilitation of patients.
2) Any three of the following:
i) Surveillance of disease
ii) Screening of blood and blood products
iii) Information dissemination
iv) Guidelines for manufacturing blood products
v) Screening of blood at blood banks.

1) To ensure availability of minimum mental health care, to encourage
application of mental health knowledge in general health care, to
promote community participation, to stimulate efforts towards self-help
in the community.
2) Any three of the following: (i) case findings, (ii) treatment and case
retention, (iii) health education, (iv) BCG vaccination.
3) (i) Anti-parasite measures, (ii) anti-mosquito measures and (iii) anti-
larval measures.
Check Your Progress Exercises 4

1) Any three of the following:
i) ICDS
ii) MDM
iii) Balwadi Nutrition Programme -
iv) Wheat-based Nutrition Programme
v) Applied Nutrition Programme
vi) Special Nutrition Programme.
2) ICDS: 300 days/year BNP: 200 days/year
164
UNIT 23 INCOME GENERATION Income
Generation
PROGRAMMES Programmes
Structure
23.1 Introduction
23.2 Evolution of Special Programmes
23.2.1 Types of Programmes
23.2.2 The Pre-income Generation Programme Period
23.2.3 Change in Thinking and Genesis of the Income Generation Programmes
23.3 The Minimum Needs Programme

23.3.1 The Concept of Minimum Needs and Basic Needs
23.3.2 Evolution of the Minimum Needs Programme
23.4 Area Development Programmes

23.4.1 Command Area Development Programme
23.4.2 Drought Prone Areas Programme
23.4.3 Desert Development Pfogramme
23.4.4 Hill Area Development Programme
23.5 Employment Generation Programmes

23.5.1 Employment Generation Schemes Prior to the Sixth Plan
23.5.2 National Rural Employment Programme
23.5.3 Rural Landless Employment Guarantee Programme
23.5.4 Jawahar Rozgar Yojana
23.6 Anti-Poverty Programmes for the Rural Poor

23.6.1 Anti-poverty Programmes before Sixth Plan
23.6.2 Integrated Rural Development Programme
23.6.3 Development of Women and Children in Rural Areas (DWCRA) Programme
23.6.4 Training of Rural Youth for Self Employment (TRYSEM) Programmes
23.7 Anti Poverty and Employment Generation Programmes Since the

1990s
23.7.1 Self – Employment and Poverty Alleviation Programmes
23.7.2 Wage – Employment Programmes
23.8 Let Us Sum Up

23.9 Glossary
165
Public Health
and Related
23.1 INTRODUCTION
Issues
The previous units would have given you some ideas about health
programmes as well as immunisation programmes in the country. The quality
of life of individuals would include social inputs as well as economic ones.
Food, housing, education, health, sanitation are some of the items that go to
determine the quality of life. Apart from the Government providing some or
most of these services, people’s ability to purchase goods and services, is
important in determining people’s command over goods and services. Hence
income becomes a kind of index to measure how much of what commodities
people can purchase. Now, the Government has to focus on the poorest
people and most of the poorest people live in villages. Hence in this unit we
will deal mainly with anti-poverty programmes, employment programmes,
and income generation programmes for the rural poor.
Food and nutrition are basic to the survival of individuals. For a person to
acquire food, as well as other goods and services like education, housing,
there can be several methods. The person can buy these or perhaps the
Government can provide these. There can be other ways too, like children
getting food within the family. One way can often lead to another. For
example, private systems of buying and selling can collapse during a drought
or famine and the Government has to step in to provide food. Whichever way
the person acquires food and the other basic need items like education and
health, there is no getting away from the fact that basic needs form important
elements of individual and social development and capabilities. An important
way to acquire food and health services is to acquire them in exchange for
money out of one’s income. Hence having a source of income acquires
importance. People can get income out of some asset, or work on their own,
for themselves, or hire out their labour to someone else.
For poorer people, who typically own little to no assets, employment offers
almost the only scope for income. However, employment is not always
available. There may be little demand for hired labour. Moreover,
employment is often seasonal. These vagaries of the employment situation
provides a reason for the Government to step in and take steps to provide
employment, and try to reduce poverty.
Some of the main providers of employment in the country are the

Governmental undertakings and public sector companies. The Indian
Railways, for instance, is one of the biggest providers of employment. In
villages, however, there are no Government companies or departmental
undertakings. Hence the need arises to develop programmes and schemes
which help to give employment to the rural poor and to lessen their poverty.
These schemes form the topic of this unit. At the end of the block, Annexure
I explains the meaning of some of the more technical terms used in the text of
the unit.
Objectives
After going through the unit, you should be able to :
166
• describe the income generation and employment programmes launched Income
by the government; Generation
Programmes
• trace the development and evolution of the anti-poverty strategies in
India;
• describe the minimum needs and area based development programmes in
rural India, and
• evaluate and assess the working of these programmes. '
23.2 EVOLUTION OF SPECIAL PROGRAMMES

There are, as we mentioned, several programmes for the rural poor and
unemployed. There are also programmes which are aimed at ecologically
backward areas. But these programmes were not in existence right from the
time that India became independent. How did they evolve? What policy or
philosophy did they spring from? These are some of the questions we will
consider in this section.
23.2.1 Types of Programmes

Various types of economic and social programmes can be identified. There
are purely social programmes, which are ‘consumption’ oriented in that they
do not seek to help or enhance production. An example is the Integrated
Child Development Services Scheme (ICDS). Also in this category would be
included various health programmes, immunisation programmes and
nutrition programmes.
Another type or set of programmes has to do with increasing production.

These programmes seek to make the land, the labourers and farmers more
productive. Irrigation programmes would be of this type. So would the
Integrated Areas Development Programme (IADP) launched in the early
1960s to improve productivity in agriculture. It was a precursor of the Green
Revolution, introduced in the mid-1960s on a much wider scale and included
a package of inputs consisting of high yielding variety of seeds, nitrogenous
fertilizers, more intensive use of water, and so on.
A third set of programmes can be called institution oriented programmes.

These programmes seek to bring about changes and improvements in overall
institutional patterns and arrangements. Community Development
Programme and the Panchayati Raj arrangements are examples of this type of
programmes. Land reform seeking to bring about, among other things,
changes in the ownership pattern of land could also be considered as an
example of this type of programme.
Sometimes some programme cannot be categorized as one type or the other.

For example, we would normally think of a nutrition programme as a
‘consumption’ type of programme. But insofar as adequate nutrition helps to
increase productivity of labour, nutrition programmes can also be considered
as a ‘production’ type of programme. Similarly, land reforms, an institutional
programme, can help in improving overall productivity of land and hence
could be considered a production type programme. 167
Public Health The kind of programmes that we would be considering in this unit broadly
and Related fall in the category of consumption programmes in so far as they help to raise
Issues
the nutritional status and consumption, education and health levels. But
primarily they are production type programmes as they seek to provide assets
and employment, increase productivity and generate income. The area based
programmes that we consider seek to increase productivity of ecologically
disadvantaged land areas.
23.2.2 The Pre-Income-Generation Programme Period

Immediately after Independence, there was no income generation
programme. The existing programmes were mainly in the nature of food and
irrigation programmes designed more to increase production than to alleviate
poverty and generate employment as such. In the 1950s, in the first Five Year
Plan, two important things were done. One was the incorporation into the
plan of the earlier Grow More Food Campaign which had its origin in the
efforts to increase food production during the second world war. The other
was the initiation of a major institutional programme called the Community
Development Programme in 1952. This had as its precursors some earlier
efforts at rural development programme projects like the Sriniketan Project of
Tagore or the Marthandam Project started by Spencer Hatch. In the second
Five Year Plan another important institutional programme was started. This
was the Panchayati Raj institution. The Community Development
Programme and the Panchayati Raj Programme were not directly designed to
raise the consumption and production levels. There was the National
Extension Services started in 1953, which sought to provide an integrated
package of information, knowledge, seeds, credit and so on, to the farmers so
that primarily the benefits of research in agriculture could be passed on to the
farmers. It was a ‘lab-to-land’ programme. This programme was a
production-type programme. But again there was no direct effort at
increasing consumption and directly generating income. That was to come
later.
The main effort at reducing inequalities in the rural areas was articulated
through land reforms which sought to bring about changes in the ownership
of patterns of land and to provide security of tenure, among other things. But
there was, till then, no other direct attempt to focus on poverty or rural
unemployment or even in redistribution of land.
At the beginning of the planning process a variety of possibilities regarding

growth and redistribution were considered. There could be redistribution
before growth; there could be growth with redistribution; and there could be
growth before redistribution. It was the last which was opted for. It was felt
that in a poor country there was only poverty to redistribute. Before the
‘cake’ could be recarved into various sizes and portions, the size of the cake
itself had to grow. There was an urgent need for the economy of the country
as a whole to grow, it was felt, rather than try to redistribute existing
incomes.
This strategy was articulated in the strategies of the first two plans,
particularly the second Five Year Plan. This plan focused on heavy industry.
168
Moreover, the Government was envisaged to play a leading role and control Income
or regulate important sectors of the economy like infrastructure. Generation
Programmes
A major assumption of this thinking was that the benefits of growth would
automatically reach even the poorest sections of the population. It was felt
that once the country as a whole grew, everybody would reap the benefits of
growth. This was not to be.
The first cracks in the strategy appeared in the 1960s. In 1963-64 and 1964-
65 two successive droughts occurred. This led to fall in production of food
grains. Heavy imports had to be resorted to. On the industrial side, it was
evident that the industrial strategy had led to increased concentration of
economic power, to inefficiencies in production, and to a slowdown in
investment by the Government.
The shortfall in agriculture led to the adoption of the Green Revolution

strategy in 1966-67. The Green Revolution, as we mentioned earlier, was a
production oriented strategy. By the turn of the decade, however, certain
factors and circumstances led to a change in thinking in official circles and
the initiation of income generation and employment.
23.2.3 Change in Thinking and Genesis of the Income

Generation Programmes
By the late 1960s it was clear that the benefits of even the Green Revolution
had not percolated to all in the villages. Although the Green Revolution had
helped to make the country self-sufficient in foodgrains there were still poor
peasants who were net buyers of foodgrains. The Green Revolution also did
not have a significant effect on employment generation. Mechanisation did
not come down in the farms.
In the early 1970s and indeed, since the late 1960s, there were attempts at
statistical estimation of the magnitude of poverty, about determination of a
suitable poverty line, and the trend in rural poverty. Although the various
estimates differed in details, they all underscored the point that a significant
number of the rural populace was below any suitably defined poverty line.
Most experts regarded that the poverty line should be defined in view of an
adequate minimum level of nutrition by an individual or family and the
expenditure thereon. These measurement attempts were indicative of the
emerging general concern regarding poverty.
Another source of the change in thinking that took place around the same
time was the change that was occurring in the discipline of Development
Economics and Development Studies. Three points were stressed. First,
instead of simply focusing on the relative backwardness of developing
countries or a developing country like India compared to advanced countries
like America and Britain, what was needed, it was felt, was to focus on
inequality and poverty within a developing country like India. Second, a
distinction was sought to be made between growth and development—the
former focusing exclusively on GNP and its size, while the latter was seen as
growth plus change: a change in attitudes, in institutions, in income
distribution and standard of living. The third was including non-economic 169
Public Health indicators like health, education, mortality and so on as indicators of
and Related development as well as laying stress on certain basic and minimum needs
Issues
required by everyone. The last entailed stressing a minimum standard of
living and an absolute level of poverty.
These thoughts found their echoes in India, as in several developing

countries. In the following section we discuss in turn, minimum needs
programme, anti-poverty programmes, employment generation programmes,
and area based programmes. All these, except perhaps the minimum needs
programme, seek directly or indirectly to generate income for the people. Our
stress throughout will be on rural areas.

1) Explain the types of economic and social programmes. Which type of
programme would an employment guarantee programme be?
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
2) Why did a change in thinking occur towards the end of the sixties and
lead to the income generation programmes?
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
23.3 THE MINIMUM NEEDS PROGRAMME

The main goal of India’s development policy has been, till now, growth with
social justice. The main instrument through which this was sought to be
realised were the successive Five Year Plans.
By the late 1960s and 1970s it was realised that the benefits of growth did not
trickle down entirely to the poorer sections of society. At the time when the
Fifth Five Year Plan was being formulated in the early 1970s, more than half
the rural population lived below the poverty line. Hence the concept of
minimum needs was given a formal shape in the plan. It was conceived as an
important tool of rural development.
23.3.1 The Concept of Minimum Needs and Basic Needs

Although the minimum needs concept was formally articulated in the Fifth
Five Year Plan in 1974, it was not entirely new. Way back in 1957, the
170 Fifteenth Indian Labour Conference had recommended that minimum wages
be need based. In 1962, under the direction of Pitamber Pant, the Planning Income
Commission prepared a document setting the requirement for the minimum Generation
Programmes
level of consumption to reach a minimum target rate of growth. It also set out
the approach to a minimum level of living or minimum needs. The
International Labour Office (ILO) in 1976 put forward the basic needs
concept formally at the Tripartite World Conference on Employment, Income
Distribution and Social Progress. The basic needs concept is also set out in
the ILO document Employment, Growth and Basic Needs : A One World
Problem published in 1977. According to the ILO, satisfaction of basic needs
included two elements:
• meeting the minimum requirements of a family for private consumption

of food, shelter, clothing are obviously included in this; also, certain
household equipment and furniture, and
• access to essential services such as safe drinking water, sanitation, public
transport, health and education i.e. items of social consumption.
Other important constituents of basic needs according to ILO are people’s

participation in decision-making; putting basic needs in the broader
framework of basic human rights, fuller employment, rapid rate of economic
growth, improvement in quality of employment and in conditions of work,
and redistribution on considerations of social justice.
In India, the approach paper to the Fifth Five Year Plan stated that alleviation
of poverty required a multi-pronged attack and suggested a separate National
Programme for Minimum Needs. It observed that employment will not
suffice in enabling the poor to buy all the essential items of consumption
required for a minimum standard of living. Hence employment and income
generation measures would have to be supplemented by social consumption
and investment in the form of education, health, nutrition, drinking water,
housing, communications and electricity.
The basic needs programme as provided by ILO is wider as it includes

private and social consumption as well as human rights, people’s
participation, employment, and growth with justice. Minimum needs focusses
on social consumption.
23.3.2 Evolution of the Minimum Needs Programme (MNP)

Here we see how the MNP works and is implemented in India. Let us state at
the outset that MNP is not a separate and a single programme. Rather,
minimum needs is a concept which has been formalised through an integrated
set of objectives, strategies and targets. The programmes of MNP are part of
the several programmes concerned and there are no outlays for the MNP in
addition to the sectoral outlays.
In the Fifth Plan, the MNP aimed at:

i) Providing facilities for universal elementary education for children upto
the age of 14 at places nearest to their homes.
ii) Ensuring in all areas a minimum uniform availability of rural public
171
Public Health health facilities including preventive medicine, family planning,
and Related nutrition, early detection of morbidity and referral services.
Issues
iii) Supplying drinking water to problem villages suffering from chronic
scarcity of safe sources of water.
iv) Providing of all-weather roads to all villages having a population of
1,500 persons or more.
v) Providing developed home sites for landless labour in rural areas.
vi) Carrying out environmental improvement in slums.
vii) Ensuring spread of electrification in rural areas to cover about 30-40 per-
cent of the rural population.
In the Draft Fifth Five Year Plan, Rs. 2,803 crore were set aside for MNP. Of
the seven components, five were specifically for the rural population,
elementary education was for both rural and urban, though primarily rural
population, and one, namely, improvement of slums was specifically for
urban population.
The sixth Five Year Plan (1980-85) saw the concept of minimum needs and
the MNP essentially as an investment in human resource development. The
Plan saw the MNP as raising the consumption level of the poor and thereby
improving the productive efficiency of workers. Thus MNP was seen both as
a consumption type programme, as well as, indirectly, as a production type
programme. The Sixth plan retained the same components as the Fifth Plan
but gave a separate and distinct identity to nutrition. Nutrition was thus a
separate component. Moreover, elementary education in scope was
broadened to include adult education; there was separate allocation for adult
education. The total outlay on MNP in the Sixth Plan was Rs. 5807 crore of
which Rs. 4927 crore was in State plans and Rs. 833 crore in the Central
plan.
In the Seventh Five Year Plan (1985-90), three more components were added
to the MNP package. These were: rural domestic cooking energy, public
distribution system and rural sanitation. A total provision of Rs. 11,546 crore
was originally made in the Seventh Plan for MNP of which Rs. 164 crore was
in the Central Plan. For the three components added later, outlays were
provided on a year-to-year basis.

1) How does the concept of minimum needs differ from that of basic
needs.
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
172 …………………………………………………………………………
2) List the main MNP components for rural areas in the Seventh plan. Income
Which were added since the Fifth Plan? Generation
Programmes
…………………………………………………………………………
23.4 AREA DEVELOPMENT PROGRAMMES

In 1952 the Community Development Programme (CDP) was launched.
By the end of the sixties it was realised that this multipurpose
programme had not fulfilled all the expectations that it raised. Hence,
among other programmes, some area based development programmes
were launched in the seventies. These area development programmes
are what we discuss in this section.
23.4.1 Command Area Development Programme

The Command Area Development Programme (CADP) was launched to
bring about efficient utilisation of water, as water is an essential requirement
for agricultural production. This programme is important in the development
of backward areas. ’
The CADP was launched in 1975, in 50 selected irrigation projects in 13

states, as a Central Government sponsored scheme. Its main aim was to bring
about greater utilisation of irrigation potential and stepping up agricultural
production in selected areas requiring major and medium irrigation. A unified
approach was desired and States were asked to set up Command Area
development authorities for the projects. The National Commission on
Agriculture in its report in 1976 emphasised the need for developing the land
in the Command areas in an integrated manner.
The main objectives of the CADP are to :

i) maximise agricultural production through better management of land and
water use in the command areas of irrigation projects where there was a
gap between potential and actual use;
ii) ensure that inputs are supplied;
iii) provide institutional finance to farmers.
The programme covers items like on-farm development works comprising

field irrigation channels, field drains, land leveling, consolidation of land
holding and realignment of field boundaries where necessary; introduction of
rotational system of water distribution within the outlet; adoption of suitable
cropping patterns, strengthening agricultural extension services; provision of
drainage network; development of ground water; arrangement and supply of
credit and other agricultural inputs; and development of infrastructure such as
roads, markets and warehousing facilities within the command area.
The main sources of finance for CADP are Central assistance to the States on
a matching basis for certain selected items, the State Governments, own
resources, and institutional credit. In the seventh plan, priority was accorded
to economically backward states in the disbursement of the Central scheme of
the CAD Project. In the fifth plan, an expenditure of Rs. 66.5 crore in the 173
Public Health Central sector, Rs. 56 crore in the State sector and Rs. 8.2 crore from
and Related institutional sources was incurred. In the sixth plan an expenditure of Rs. 287
Issues
crore in the Central sector and Rs. 560 crore in the State sector was incurred.
The CADP has performed quite well particularly in the improvement in

utilisation of irrigation potential. The potential utilised went up from 6.88
million hectares (mha), in 1979-80 to 10.19 mha in 1986-87. Gross irrigated
area has increased significantly. Water distribution and availability has gone
up. Emphasis has been laid on modernisation of the earlier irrigation systems.
The CADP, however, has suffered from a number of shortcomings such as

slow implementation, inadequate financial and organisational support,
inadequate motivation, unwillingness of farmers to provide land for CAD
activities, problems of floods affecting CAD works, slow progress in
consolidation of land in which field channels were to be constructed, lack of
extension support and uncertainty in the supply of irrigation water.
23.4.2 Drought Prone Areas Programme

Drought is not uncommon in India. Areas prone to drought and desert
conditions are often characterised by soil erosion and environmental
degradation.
The Indian meteorological department defines drought as a situation

occurring in any part of the country when the annual rainfall is less than 75
per cent of the normal. If rainfall is deficient by 25 to 30 per cent of the
normal, it is moderate drought and if the deficiency is more than 50 per cent
it is chronic drought. Severity of drought depends on the aridity or degree of
moisture deficiency, duration of the dry spell and the size of the affected area.
The Drought Prone Areas Programme (DPAP) was started in 1973 during the
Fourth Five Year Plan as an integrated area programme. Starting such a
programme was felt necessary because 19 per cent of the total area of the
country is drought prone and 12 per cent of the total population lives in such
areas.
The main objectives of DPAP are :
• promoting a more productive dryland agriculture by water resources and

agro-climatic factors, with suitable cropping patterns;
• developing productive use of water resources of the area, soil and
moisture conservation including water harvesting, and promoting proper
land Use;
• promoting afforestation, including farm forestry;
• .developing livestock including development of pasture and fodder
resources; and
• promoting other diversified activities such as horticulture, sericulture,
fisheries etc.
The major components of the programme are :

174
• soil and water conservation and land shaping Income
Generation
• afforestation and pasture development Programmes
• water resources development.
Seventy five per cent of annual allocations are earmarked for the core
components (30 per cent for land shaping and soil conservation, 25 per cent
for afforestation and pasture development, and 20 per cent for water
resources development).
During the Fourth Plan, the DPAP was in operation in 54 districts in 13

states. In the Sixth Plan Rs. 350 crore were allocated for DPAP out of which
88 per cent, that is Rs. 310 crore, was spent. The Seventh Plan recommended
continuing the Sixth Plan strategy of stress on activities which directly
contribqte to the restoration of ecological balance, and its implementation as
an integrated areas programme. The major shortcoming of the programme
has been lack of planning and linkages with ongoing schemes of the state
plan. Sometimes the availability of infrastructure was not surveyed before the
plan was implemented.
23.4.3 Desert Development Programme

Nearly 218,000 square km. in western Rajasthan and adjacent areas in
Gujarat and Haryana make up the great Indian desert. This desert is hot.
Besides this there is a cold desert in the northern part of the country in
Ladakh and parts of Himachal Pradesh. Groundwater in desert areas is saline
and not always fit for drinking or cultivation. Moreover, rangelands are often
overgrazed. Consequently top soil cover is severely depleted and there are
serious erosion problems.
To develop the desert areas a Desert Afforestation Centre was set up in

Jodhpur in 1951-52. In 1957 the Centre was renamed the Desert
Afforestation and conservation station. Later the Central Arid Zone Research
Institute was set up. A Desert Development Board was constituted in 1966
and several pilot projects were launched in four districts of Rajasthan,
Gujarat and Haryana. In 1974, in it: interim report, the National Commission
on Agriculture stated that the desert areas faced different problems compared
to those faced by semi-arid and dry sub-humid regions and stressed a
different set of measures. On the recommendations of the National
Commission on Agriculture, the Desert Development programme was
launched in 1977-78.
The main objectives of the Desert Development programme are :

• controlling desertification;
• restoring ecological balance of certain desert and semi-desert areas;
• creating conditions for raising the level of production, income; and
• employing the people of these areas by increasing the productivity of
land, water, livestock and human resources.
The major components of the programme are afforestation, grassland 175
Public Health development and sand dune stabilisation; optimum exploitation and
and Related conservation of ground water; construction of water harvesting structures;
Issues
rural electrification for energising tube-wells and pump sets, and
development of agriculture, horticulture and animal husbandry.
In 1989-90 the programme was in operation in 132 blocks in 21 districts in

five states. The area was covered by about 0.36 million sq. km. and a
population of 15 million was covered. The Centre bore the entire financial
burden of the programme, which started as a central sector scheme, till 1978-
79. In the Sixth Plan the cost was shared equally by the centre and the states.
In the first two years allocations were made mainly on ad-hoc basis. From
1979-80 onwards funds were allocated on the basis of Rs. 15 lakhs per block
per year with the Central and State governments each giving 7.5 lakhs.
Rajasthan has shown a low utilisation of funds—merely 67 per cent.
23.4.4 Hill Area Development Programme

Hill areas make up 21 per cent of the total area of the country, and 9 per cent
of the population of the country lives in these areas. The ecosystem in these
areas is fragile. In order to protect the ecosystem and foster the basic life
giving natural resources of these areas the Hill Area Development
Programme (HADP) was initiated in 1974-75 under the Fifth Five Year Plan.
The programme also sought to address the neglect faced by the people in hill
areas as compared to people in the plains.
The basic objectives of the HADP are :

• restoring, preserving and developing the ecosystem in hill areas of the
country;
• tackling the special problems in the hill areas relating to the terrain and
the variable nature of the agro-climatic conditions in these areas;
• investing in infrastructure facilities in hill areas characterised by high
unit costs; and
• supplementing the efforts of the State governments in the development
of hill areas.
In states such as Jammu and Kashmir, Himachal Pradesh, Sikkim, Manipur,
Meghalaya, Nagaland, Tripura, Arunachal Pradesh and Mizoram where hills
cover almost the entire geographical area of the states (these states are called
special category states), funds are allocated for hill area development while
formulating their state plans. In other states where hills form only part of the
geographical area of the state, the states form a subplan under which special
funds are earmarked for expenditure to develop these areas. The central
government supplements these efforts by earmarking funds under HADP for
the development of hills.
In states like Maharashtra, Karnataka, Goa, Kerala, Tamil Nadu, a number of

smaller administrative Units (talukas) benefit from a scheme called Western
Ghats Development Programme (WGDP).
176
In the Fifth Plan Rs. 170 crore were allocated for HADP including Rs. 20 Income
crore for WGDP. In the sixth plan allocation was raised to Rs. 560 crore and Generation
Programmes
in the seventh plan to Rs. 870 crore (including Rs. 75 crore and Rs. 116.50
crore for WGDP in the two plans respectively).The HADP has sought to
address the problems of ecodegradation, the prevalence of shifting cultivation
called jhum in the North Eastern states, soil erosion and deforestation, loss of
forest cover to meet firewood requirements. It has been felt necessary to
support HADP with energy programmes, and livestock and cattle
development programmes.
It is important that programmes in hill areas are implemented carefully

because the ecosystem in these areas is very vulnerable. Horticulture and
plantation crops can promote environmentally sound development in hill
areas, and because of their links with the food processing industry, help to
generate income. Another important thing to bear in mind is that transport
and infrastructure facilities are developed adequately but in a non-
environment friendly manner in the hill area.
Check Your Progress Exercise 3 '

1) What are the main problems faced in the implementation of CADP?
What have been its main achievements?
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
2) What are the main objectives of DPAP?
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
3) List the main objectives of DDP.
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
4) What are the basic objectives of HADP?
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
177
Public Health
and Related
23.5 EMPLOYMENT GENERATION
Issues PROGRAMMES
Much of the Indian population is poor. Since labour is abundant and jobs
scarce, unemployment is high and wages low even in rural areas. Over the
period since Independence, moreover, growth in labour force has outstripped
growth in employment. Hence the Governmen. has striven to devise and start
programmes which would help to generate employment. Higher pay would
help to pull people out of poverty. This section discusses some such
programmes.
23.5.1 Employment Generation Schemes Prior to the Sixth

Plan
During the Third Plan the Rural Manpower Programme was started to give
employment opportunity and covered 1,000 community Blocks by the end of
1964-65.
In the Fourth Plan, the government introduced a special scheme called the
Crash Scheme for Rural Employment (CSRE) for creating employment. It
was introduced as a non-plan programme with the following objectives:
• generating, on average, employment for 1,000 persons per year in every

district, and
• creating durable and productive assets related to local development
plans.
CSRE was included in the Fourth Plan for the years 1972-73 and 1973-74
with an outlay of Rs. 50 crore for each year. As part of the CSRE, a Pilot
Intensive Rural Employment Project (PIREP) was launched. This project
aimed to collect data on the dimensions of CSRE in terms of its ability to
provide employment to everyone who was willing to work. The CSRE was
implemented over a three year period, and spilled over to the first year of the
Fifth Plan. The main drawback with CSRE was that resources were spread
thinly over a large number of small projects and works instead of being
concentrated on a few small ones.
In 1977, a new programme called Food For Work (FFW) was started. It
aimed at providing employment to the rural poor by paying wages in return
for building and developing infrastructure and durable community assets. It
was a non-plan scheme to augment the funds of State Governments for
maintenance of rural public works which included minor irrigation works,
soil and water conservation, afforestation on existing highways, construction
of drains etc.
23.5.2 National Rural Employment Programme

The National Rural Employment Programme (NREP) was launched in 1980
to increase employment in villages. In the process it sought to redistribute
income and consumption in the rural areas; this was viewed as a crucial step
178 towards poverty alleviation. In 1981, NREP replaced the FFW programme
and was made a part of the Sixth Plan. Income
Generation
NREP had the following objectives: Programmes
• generating additional gainful employment for unemployed and

underemployed persons (both men and women) in rural areas;
• creating productive community assets for direct and continuous benefits
to the poor, and for strengthening rural economic and social
infrastructure which would lead to rapid growth of the rural economy
and steady rise in the incomes of the rural poor, and
• improving the overall quality of life in rural areas.
In all works under NREP preference was given to landless labour and among
the landless labour, those belonging to scheduled castes and scheduled tribes
were preferred. Both individual and community works could be taken up
under NREP, during any time in the year. Under NREP, contractors could not
be engaged. There could be no middleman.
Under NREP wages were paid partly in cash and partly as foodgrains—about
1 to 2 kilos of foodgrains per head per day being the norm. The advantage of
having foodgrains as part of wages was that rural labourers were protected
from the fluctuations in prices of foodgrains. Another advantage was that
workers were assured of a minimum quality of foodgrains. Also, this was an
effective way of utilising surplus foodstocks. Wages under NREP were to be
given as stipulated under the Munimum Wages Act.
The NREP was implemented by the District Rural Development Agencies

(DRDA). Panchayati Raj institutions and voluntary organisations were also
sought to be involved in the programme. At the State level the programme
was planned, implemented and monitored by the State Level Coordination
Committees (SLCCs). At the Centre, a Committee for NREP had been set up
to provide overall guidance, give guidelines and undertake continuous
monitoring of the programme. NREP was a centrally sponsored programme
with the Centre and the states sharing expenditure equally. The central share
was released in two equal instalments. The state governments released the
entire amount of central assistance to the DRDA. They added the matching
contributions to the central share. Training facilities were provided at the
Central, State and Block levels. At the State level organisations like Council
for Advancement of People’s Action and Rural Technology (CAPART) and
National Building Organisation (NBO), were involved in imparting training.
NREP has had a mixed record. Among its benefits were stabilising wages and
prices of foodgrains in rural areas, creating different kinds of community
assets, and raising the living standards of the rural people. It also helped to
raise wages and strengthened the rural infrastructural base. In many cases,
most of the works under NREP was being executed by Gram Panchayats
(about 90 per cent). Voluntary agencies and block agencies executed about 8
per cent of the work.
Among the areas of concern regarding NREP was that productive use of
labourers has not gone up substantially. There has also been lack of
179
Public Health systematic planning, as well as lack of coordination among various agencies.
and Related There has often been mismatch of projects and manpower. The roads built
Issues
under NREP have been kutcha in many cases. Popular support for the
programme has been lacking.
23.5.3 Rural Landless Employment Guarantee Programme

(RLEGP)
This programme was launched in 1983 with three basic objectives:
• improving and expanding scope for employment for the rural people,
particularly landless labour, so as to be able to guarantee employment to
at least one member of every landless household up to 100 days in a
year,
• creating productive and durable assets for direct and continuing benefits
to the poor and for strengthening rural economic and social infrastructure
which would lead to rapid growth of the rural economy and raise
employment opportunities and income levels of the poor, and
• to improve the overall quality of life in rural areas.
This programme gave preference to rural landless households and among
them, to women, scheduled castes and scheduled tribes. Labour intensive
projects were emphasised, particularly during lean agricultural seasons. The
RLEGP aimed to stabilise agricultural labour supply by guaranteeing
employment to one member of each landless labour household.
The works taken up under RLEGP were the ones considered relevant to the
Minimum Needs Programme and the 20-point programme, like construction
of rural link roads, land development reclamation of wastelands, construction
of sanitary latrines and so on. Also small sized dwellings under another
programme called Indira Awaas Yojana could be part of works taken up
under RLEGP.
RLEGP, unlike NREP was funded entirely by the Centre. Funds were
released under RLEGP in two half yearly installments, except that for social
forestry, which was released in the first installment itself. The Centre released
RLEGP funds to the States which in turn released them to the District Rural
Development Agencies (DRDAs) within a month of receiving central funds.
The DRDAs are the district level agencies for implementing employment
generation and poverty alleviation programmes.
Wages in RLEGP too were paid according to the Minimum Wage Act.
Moreover, wages were paid partly in foodgrains. Resources for RLEGP were
allocated by the Centre to the States according to prescribed criteria giving 50
per cent weightage to the number of agricultural labourers, marginal farmers
and landless labourers, and 50 per cent weightage to the incidence of poverty.
DRDA was the main agency implementing and monitoring RLEGP.
Moreover, Panchayati Raj institutions and voluntary organisations were
sought to be involved. At the State level the State Level Coordination
180
Committee was in charge of the programme and at the Centre, the Central Income
Committee for NREP and RLEGP acted as the apex body. Generation
Programmes
Let us go over some of the points of similarity and dissimilarity between

NREP and RLEGP. The two programmes were similar to the extent that both
were target oriented employment generation programmes and were directed
at the rural poor; both aimed at creating durable community assets, both paid
part of the wages in foodgrains, had wages statutorily fixed and had similar
mode of payment of wages, both were implemented through the DRDA,
contractors were not permitted under both programmes; and both sought to
involve the Panchayati Raj institutions and voluntary organisation. The main
points where RLEGP differed from NREP was that the RLEGP focused
primarily on the rural landless; unlike under NREP, expenditure under
RLEGP was fully funded by the centre; and while RLEGP aimed at giving
guarantee of employment to one member of each landless rural household
upto 100 days in a year, NREP did not give any such specific guarantee.
If we turn to the performance of RLEGP the first thing to be kept in mind is
that the guarantee part of the programme could not be put into operation due
to scarcity of resources. Contribution of microhabitat for SC/ST under the
Indira Awaas Yojana has been the more successful areas under RLEGP. The
Seventh Plan envisaged the construction of one million micro habitats. The
second important component of RLEGP was social forestry. In 1985-86, 20
per cent of the funds were set aside for this component and was raised to 25
per cent in subsequent years. Another important component of RLEGP was
the Million Wells Scheme. This scheme was started in 1988-89 to provide
open irrigation wells free of cost to small and marginal farmers belonging to
SCs and STs and free bonded labourers. For that year a target of 95, 930 units
of wells was fixed. This necessitated an investment of Rs 154 crore for that
year.
An outlay of Rs. 500 crore was made when the programme was launched in
1983. In the period 1983 to 1985, the employment generation target was 360
million mandays. However, only 260.18 million mandays of work could be
generated. The Seventh Plan proposed to provide a limited guarantee of
providing 80 to 100 days employment to landless labourers. The Seventh
Plan provided an outlay of Rs 1,774 crore for RLEGP. Given a wage material
cost ratio of 50:50, it envisaged generation of 1,013 million mandays of
employment under RLEGP.
23.5.4 Jawahar Rozgar Yojana.

We have discussed some schemes of employment prior to the Sixth Plan. We
have also discussed two main employment generation programmes, namely
NREP and RLEGP launched in the Sixth Plan. In this sub-section we will
talk about a new employment generation programme launched in the Seventh
Plan.
The NREP, which was launched as a modified form of the Food for Work
Programme had as one of its main characteristics, payment of a part of the
wages in foodgrains. The main focus of RLEGP was on providing
181
Public Health employment with special stress on landless labourers. It aimed to generate
and Related employment to at least one member from each rural labour household upto
Issues
100 days in a year. A need was, however, felt to devise a new programme
which would aim to provide intensive employment in backward areas. The
emphasis was on attacking unemployment in economically backward
villages.
A new scheme for employment generation was announced by the then

finance minister in his budget speech in 1989-90. This new scheme was
named Jawahar Rozgar Yojana. A provision of Rs. 500 crore was made for
this scheme in that year’s budget. The funds allotted for this were to be in
addition to those allotted under NREP and RLEGP. Another thing which was
stated was that NREP and RLEGP would be merged and implemented as a
centrally sponsored scheme with a 75:25 sharing of funds between the Centre
and the States.
Later the whole matter was reconsidered. The new programme called
Jawaharlal Nehru Rozgar Yojana, as well as NREP and RLEGP, would be
merged into a single programme to be called Jawahar Rozgar Yojana. The
expenditure under this programme is to be shared on a 80:20 basis between
the Centre and the States.The central share under this programme is released
directly to the DRPAs which are the district level implementing agencies for
this programme. Not less than 80 per cent of the share received by the
DRDAs are to be released to the village panchayats.
Let us now look at this programme in somewhat greater detail. The main
objective of the programme is to generate gainful additional employment for
the unemployed and underemployed in the rural areas. Other objectives
include creating productive community assets to help the poor and thus
strengthening infrastructure, and improving overall quality of life in rural
areas.
The target group for the programme consists of persons living below the
poverty . line, with preference given to those poor who belong to scheduled
castes and scheduled tribes. Moreover, it is required that 30 per cent of the
beneficiaries be women.All works leading to creation of durable community
assets can be taken up under the programme, with works helping the poor and
being amenable to use as infrastructure in anti-poverty programmes being
given priority. Indira Awaas Yojana and Million Wells Scheme have been
retained under JRY. For social forestry, participation of NGOs is sought.
Wages under JRY can be paid partly in foodgrains. But the distribution of
foodgrains is not to exceed 1.5 kg per manday. Wages are paid, as far as
possible, according to the Minimum Wages Act.
The financing of JRY is shared by the Centre and the States on a 4:1 basis.
The central assistance is allocated on the basis of percentage of rural poor in
the State/ Union Territory out of the total rural poor in the country. The States
allocate their share to the districts on the basis of an index of backwardness.
This index is worked out on the basis of the percentage of agricultural
labourers to main workers in rural areas, percentage of scheduled castes and
182
scheduled tribes in the total rural population, and inverse of agricultural Income
productivity. Generation
Programmes
At the district level, the main agencies responsible for implementation of the
JRY are DRDAs and Zilla Parishads and at the village level, gram
panchayats. Thus for the JRY, the Panchayati Raj institutions are directly
involved in the implementation process.
The central funds are given directly to the DRDA or Zilla Parishads, These
funds are released in two instalments. In the first, the entire amount for Indira
Awaas Yojana and social forestry, and 50 per cent of the balance is released.
The second instalment is released on the request of the DRDA/Zilla parishad
on their fulfilling certain conditions like the following :
• Fifty per cent of the available funds should have been utilised by the
district;
• The opening balance in the district is not less than 25 per cent of the
district allocation of the year; and
• Audit and progress reports of the district have been sent directly.
The State governments are required to release their funds to the DRDAs
or Zilla parishad within a month of the release of the Central share.

1) What were the objectives in launching CSRE?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
…………………………………………………………………………….
2) What were the objectives in launching FFW? What was its unique
feature?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
…………………………………………………………………………….
3) What were the objectives of NREP? What were the main benefits of
paying part of the wages in foodgrains under NREP?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
183
Public Health …………………………………………………………………………….
and Related
Issues 4) List three important points of difference between NREP and RLEGP.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
…………………………………………………………………………….
5) Describe the main features of JRY.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
…………………………………………………………………………….
23.6 ANTI-POVERTY PROGRAMMES FOR THE

RURAL POOR
We have discussed area based programmes and employment generation
programmes apart from Minimum Needs Programme. Now we discuss
specific anti-poverty programmes.
In the earlier phase of planning in India, till about the midsixties it was
assumed that the benefits of economic growth would trickle down to the
poorest segments of the population. Actual experience did not conform to this
expectation. Moreover, by the end of the 1960s it was seen that the benefits
of the Green Revolution did not accrue to the poorest groups. The numbers of
the landless, small and marginal farmers, and agricultural labourers were
increasing throughout the 1960s.
Two other factors gave an impetus to the attempts at attacking poverty

directly. The first was peasant agitations in certain parts of the country. The
second was the idea, steadily gaining currency even in international circles,
that developing countries ought to pay attention to absolute poverty and try to
remove it.
It is in this context that poverty received a direct attack since the early 1970s,
beginning with the slogan of Garibi hatao (remove poverty) in 1971. The
main programme for alleviating poverty has been the Integrated Rural
Development Programme (IRDP). We shall discuss it presently but first let us
get down to discussing some anti-poverty programmes in existence before
IRDP.
23.6.1 Anti-poverty Programmes before Sixth Plan

The principal programmes were launched in the Fourth and the Fifth Five
184 Year Plans. Following the views expressed in the Report of the All India
Credit Review Committee (1969) that the normal benefits of development Income
had tended to bypass the poorer section of the rural population. The Fourth Generation
Programmes
Five Year Plan devised two sets of programmes : one for small farmers and
the other for marginal fanners and agricultural labourers.
Special agencies registered under the Societies Registration Act, 1860, were
set up for these programmes—Small Farmers Development Agencies
(SFDAs) and the Marginal Farmers and Agricultural Labourers Development
Agencies (MFALs) for marginal farmers and agricultural labourers.
Membership in each agency was small, consisting mainly of representatives
of institutional agencies and district administrations, with the Collector or
Deputy Commissioner as Chairman. Forty six SFDAs were started during the
Fourth Five Year Plan.
The main objectives of the SFDAs were :
• to identify the target group beneficiaries i.e. small fanners;

• to study and identify their problems;
• to formulate suitable schemes;
• to seek institutional support and to induce credit sources to provide
credit; and
• to arrange for extension services and supplies.
The basic objective was to help the rural poor to increase their incomes. The
principal methods were to help the poor to adopt improved technology,
provide greater access to irrigation and diversify farm economy through
subsidiary activities like dairy, animal husbandry and horticulture.
MFALS were started on the same lines as SFDAs. In the Fourth Plan forty
one MFALs were started on a pilot basis. The main objectives of the MFALs
were to identify eligible marginal farmers and small farmers and investigate
their problems; to formulate suitable economic programmes; to give gainful
employment; to promote rural industries; to help to create common facilities
to process, store and market products, and to evolve adequate institutional,
financial and administrative arrangements for implementing various
programmes.
MFALs and SFDAs were to act as catalysts and were not to directly
administer any economic programmes. These were to be implemented
through institutions sponsored by them. MFALs mainly aimed to generate
gainful employment. SFDAs were launched in 1969. SFDA and MFALs
were fully operationalised in 1971-72. On the recommendation of the
National Commission on Agriculture (1976), MFALs were merged with
SFDAs and all agencies were called SFDAs.
At the time when the Sixth Plan came into operation in 1980, the SFDAs,
then in existence in 1818 blocks, were merged with IRDP. You will read
about IRDP in the subsequent sub-section.
Although the SFDAs and MFALs had some success in generating

employment— the main employment coming from road— works, these 185
Public Health programmes had some shortcomings. First, funds were limited. Second,
and Related identification of beneficiaries was slow. Little attention was paid to the
Issues
identification of agricultural labourers. Third, little was done to draw up
specific projects to ensure supply of inputs. Fourth, input loans were often
misutilised. Fifth, cooperative infrastructure continued to be weak 'in many
areas.
23.6.2 Integrated Rural Development Programme

The Integrated Rural Development Programme (IRDP) has come to be the
main anti-poverty programme for the benefit of rural poor. Now we discuss
this programme in some detail.
To begin with let us pause to explain the term integrated. Basically the term
implies provision of a package of interrelated projects supporting and
reinforcing one another, so as to avoid a one-dimensional approach.
The Draft Sixth Plan (1978-83) emphasised four dimensions of integration:

integration of sectoral programmes, spatial integration, integration of social
and economic process, and integration of the policies to ensure a better
coordination between growth, employment generation, and poverty
alleviation.
The concept of integration was seen as a method of rising above a project or a
sectoral approach. It involved a sharp focus on target groups made up of
small and marginal farmers, agricultural labourers and artisans. Integrated
Rural Development (IRD) was sought to be made area-specific as the
distribution of poverty and employment varied across regions. Ecological and
environmental balance was also aimed at.
Various kinds of programmes were proposed to be included, like programmes
of agricultural development including efficient land utilisation and water
resources, programmes of animal husbandry as a subsidiary occupation for
small and marginal farmers, programmes of fishery, programmes of social
forestry and farm forestry, village and cottage industry programmes.
Programmes to develop the service sector of villages, and programmes to
develop skill and make labour mobile.
IRDP emphasised grassroots level plans at the block level which would be
linked to the District and State plans. People's participation was actively
sought, as was the help of voluntary agencies.
The concept of IRD was put into actual application on an experimental basis
in twenty selected blocks, in 1976. The IRDP programme was launched, after
some modification, in 1978-79 in 2,300 blocks, of which 300 blocks were
coterminous with SFDA, DPAP, and CADP. In 79-80 another 300 blocks
were added making the programme operational in 2,600 blocks by 31 March
1980. It was extended to all blocks in the country from 2nd October 1980.
Simultaneously, SFDAs were merged with IRDP.
IRDP mainly aims at providing assistance (subsidy and institutional credit) to

selected families for income generating assets in order to raise their incomes
186
through self-employment so that they can move above the poverty line. The Income
poor were defined as those families which had an annual income of less than Generation
Programmes
Rs. 6,400. IRDP follows the antyodaya (poorest of the poor first) principle
and hence assists only those families with an annual income of Rs. 4,800 or
less.
Moreover, those with an annual income of less than Rs. 3,500 are assisted
first. The main poor groups include small and marginal farmers, agricultural
labourers and rural artisans. Apart from these stipulations, there are other
guidelines such as :
At least 30 per cent of the families are to be drawn from scheduled castes and
scheduled tribes (SCs and STs). This is applicable to both the District and
State levels. Also, at least 30 per cent of the beneficiaries should be women.
Among these, women headed households are to be given priority.
As we mentioned, with the launching of IRDP all over the country, SFDAs
were merged with IRDP. Also, different agencies implementing diverse
programmes like SFDAs, DPAP, DDP etc. were merged, and the District
Rural Development 90 Agency (DRDA) was treated to function at the district
level as a single agency for the implementation of IRDP, DPAP, DDP etc.
IRDP was launched as a Centrally sponsored scheme with the allocations to

be equally shared by the Centre and the States. The Ministry of Rural
Development is the apex level agency responsible for overall guidance,
policy making and monitoring of the programme.
At the State level, the State Level Coordination Committee (SLCC) monitors
the programme. At the district level are the DRDAs, which are societies
registered under the Societies Registration Act, 1860.
The block level staff is responsible for the implementation of the programme
at the grassroots level. The chief coordinator at the block level is the Block
Development Officer (BDO), who is assisted by extension officers. Below
the BDO is the village level worker (VLW) at the village level. Voluntary
agencies and voluntary action groups concerned with socio-economic
activities pertaining to rural development are also associated with the
programme. The funds for voluntary agencies are channeled through the
Council for Advancement of People’s Action and Rural Technology
(CAPART).
The VLW/Block staff prepares the list of the beneficiaries. Families with
annual income of less than Rs.3,500 are assisted first. Then various projects
are chosen for the family, keeping in mind the preference of the family and
its skills, aptitude and ability. Different rates of subsidy are given for
different activities and categories of beneficiaries, ranging from 25 per cent
to 66.66 per cent. The subsidy is linked to loans and is given in kind to the
beneficiaries for projects which are economically viable. It is usually sought
to be ensured that the subsidy : credit ratio is 1:2. The main part of the credit
component comes from institutional finance. Loans are provided at a 10 per
cent concessional rate of interest. Loan applications are sponsored by BDOs.
On this basis, bank managers process applications and sanction loans. In 187
Public Health April 1988, a group life insurance scheme for IRDP beneficiaries between the
and Related ages of 18 years and 60 years was introduced. Insurance cover applies from
Issues
the date on which the loan is disbursed to the beneficiaries and is operative
till the date on which the beneficiaries attains the age of 60 years, or three
years from the commencement of asset distribution, whichever is earlier. The
cost of insurance cover is provided entirely by the government of India.
Under IRDP, the beneficiaries are given a package of subsidy and credit. The
subsidy element is provided by the government (shared equally by the
Central and State government concerned). The loan is provided by the
banking system which includes commercial banks, cooperative banks and
regional rural banks.
Let us discuss the peformance of IRDP. Studies have shown that in the Sixth
Plan, achievements with respect to allocation, expenditure, mobilisation of
credit and investment, the number of scheduled caste and scheduled tribe
beneficiaries, have exceeded the targets over the plan period. There have
been shortfalls in other areas such as per capita credit subsidy credit ratio etc.
Various other evaluation studies have indicated that around 40 per cent of the
people had crossed the income level of Rs 3,500 and around 55 per cent to 90
per cent (varying from study to study) had experienced some increase in their
incomes. However, the extent of wrong identification was around 15 to 20
per cent, a substantial number of whom were above the poverty line. The
financial allocation as well as physical targets were determined uniformly on
per block basis leading in come cases to ineligible families being selected.
Morever, there were complaints of leakages of funds due to corruption and
malpractices. Also, selection of projects under the programme showed a bias
towards animal husbandry, particularly milch cattle. Often the quality of
these animals was inferior. Very little was done to provide institutional
support for the supply of raw materials and marketing. In many areas banking
services were inadequate. In some cases, staff was not trained and qualified;
also there was absence of coordination and integration between different
departments.
In the Seventh Plan, some changes were sought to be made in the light of the
Sixth Plan experiences. One of these was the adoption of the household
approach over the group approach in view of the low absorbing capacity of
the poor. This meant that not only would the total package of benefits be
provided to identified households but assistance in the form of more than one
project of asset creation would also be provided to different members of the
same households. This would generate capacity for productive absorption of
credit and generation of income. The Seventh Plan also sought to step up
activities in the Industries Services and Business (ISB) sector.
An outlay of Rs 2,643 crore was provided for IRDP in the seventh plan. The
target was to cover 20 million beneficiaries (10 million existing and 10
million new beneficiaries). In the Seventh Plan period the allocation of
finance on a uniform block basis was given up and in its place was
substituted a method whereby the quantum of financial allocation was linked
to the incidence of poverty in the block.
188
In the Seventh Plan, the financial and physical targets were by and large Income
achieved. There has, moreover, been diversification of activities. Also, the Generation
Programmes
targets for SC/ST were exceeded. However, in the case of women, only some
states like Gujarat, Karnataka, Tamil Nadu, Punjab and West Bengal
achieved the target of 30 per cent.
The main criticism against IRDP was that the concept of integration as spelt
out was almost entirely given up in actual operation. Another criticism has
been regarding the fairly high incidence of ineligible beneficiaries. The
disbursement of bank credit to beneficiaries under IRDP has shown some
weaknesses. The quantum of loan disbursed has been less than that required
to meet the poverty problem in its entirety. There have been delays in
providing loans. Moreover, there were middlemen who have been known to
siphon off part of the loans. There have also been problems with follow up
and recovery of loans. The organisational aspects of IRDP have also shown
certain weaknesses.
Where IRDP has assisted the poorest of the poor, the investment made has
not been sufficient to bring these categories of the poor above the poverty
line. It has been ineffective where complementary linkages have not been
provided or the assets obtained as a result of IRDP loan and subsidy have
been deficient. For example, in many cases, the poor have received inferior
quality of milch cattle whose upkeep has been so expensive that the poor
villager has been forced to sell them off. Weak coordination between
different agencies, bureaucratic inertia, and lack of infrastructure are other
problems which the programme has not been able to successfully resolve.
23.6.3 Development of Women and Children in Rural Areas

(DWCRA) Programme
A few years after IRDP was fully operationalised, it was realised that women
did not reap as much benefit as they were expected to. Hence it was felt
neessary to devise special programmes for women in rural areas. The basic
idea was to provide skills and training and access to rural credit so that
income is generated. Higher incomes are supposed to help to provide better
nutrition so that productivity of women at work will increase.
Thus the basic objective of DWCRA is to provide rural women with assets
and credit and enhance their skills. It also seeks to provide an effective
organisational support structure so that women can receive assistance in the
production of goods. The target group in DWCRA is the same as that under
IRDP but here the group and not the family receives assistance. The
programme envisages that groups of 15 to 20 women will be formed and
these groups will come together for mutually beneficial activities. Each group
receives a one time grant of Rs 15,000, contributed in equal measure by the
Central government, the State government and UNICEF. This grant may be
used for marketing purposes, as working capital, for infrastructural output
and childcare facilities. The group organisers also get a travelling allowance
of Rs.2,000 per year.
DWCRA was launched in 1982-83 as a pilot project in 50 districts, chosen

189
Public Health according to the criteria of high infant mortality rate and low female literacy,
and Related by 1989-90, the programme was being implemented in 106 districts.
Issues
DWCRA is not limited to providing economic benefits. It includes supportive
services like mother and child care, adult education, immunisation etc. To
this end, coordination is maintained with various other departments such as
Education, Health and Family Welfare, and Women and Child Development.
At the State level, a woman of the rank of Deputy Secretary to the State
Government is in charge of the programme. At the district level, a woman
officer may be appointed as Assistant Project Officer (APO) (Women’s
Development) to assist the Project Officer of the DRDA. At the block level a
team comprising one woman BDO (Mukhya Sevika), two women VLWs
(Gram Sevika) and one Gram Sevika per DWCRA block. The main financial
assistance for the programme is provided by the Central Government. The
Central Government releases its own share as well as that of the UNICEF.
Under DWCRA, training is provided by various agencies at different levels.
The organiser of each group helps the women to derive maximum benefit
from the training programme. Moreover, Gram Sevikas, Mukhya Sevikas and
APOs help to identify enable activities and projects for the group.
DWCRA has suffered from shortage of functionaries at almost all levels, lack
of infrastructural facilities and credit problem in selecting projects and lack of
clarity regarding the role of the groups and low motivation of the members of
the group.
23.6.4 Training of Rural Youth for Self-Employment

(TRYSEM) Programme
The TRYSEM programme was launched in 1979 as a separate scheme for
training rural youth for self-employment, as there was a huge backlog of
unemployment. The main objective was to provide rural youth (18-35 years)
from families below the poverty line with training and technical skills to
enable them to take up self employment. Forty youth, both men and women,
were to be selected from each block and trained in both skill development
and entrepreneurship to help them become self-employed. Training is
provided not only by imparting physical skills, but attitudes are changed,
motivation is enhanced etc. Self-employment means gainful employment on
a full time basis resulting in income sufficient for the family of the youth to
cross the poverty line. In 1980 when IRDP was extended to all blocks in the
country, TRYSEM became the self-employment-for-youth component of
IRDP. Since 1981-82 separate funds for TRYSEM were discontinued.
The youth identified for the programme are put through a period of training,
either with a master craftsman.or a training institute. TRYSEM trainees are
given a stipend and tool kit. On successful completion of the training they
become eligible to receive a subsidy/credit/income generating asset under
IRDP. TRYSEM has usually put emphasis on industries and services. The
objective of TRYSEM includes wage employment (since 1982-83) in case of
certain specific projects. These projects, selected by the State Level
Coordination Committee were to satisfy certain condition like being
190 integrated ones, and the beneficiaries were to be from IRDP target groups.
The BDO selects the eligible youth belonging to the target group with the Income
help of VLWs. The identification of the vocations is done by the DRDA in Generation
Programmes
consultation with district level officers of the different departments, keeping
in view their sectoral plan. After this the DRDA prepares a resource
inventory of training facilities like ITIs, polytechnics, khadi and village
industries (KVIs), Krishi Vigyan Kendras etc. No educational qualification
for the trainees has been prescribed. The syllabus is expected to include
training in working skills as well as managerial skills.
The DRDA is responsible for the implementation of TRYSEM. The Assistant

Project Officer (Industries) and Extension Officers (Industries) are
responsible for the extension of TRYSEM, in addition to their normal duties.
At the state level there is a sub-committee of the State Level Coordination
Committee (SLCC) exclusively for TRYSEM. At the apex level which is the
central level, the policy guidelines are provided by and overall monitoring
done, by the Central Committee on IRDP and related programmes. This
committee is presided over by the Ministry of Rural Development. ,
Once the youth complete their training and are to be self-employed, the basic
support system, infrastructural facilities and backward and forward linkages
assume importance. Backward linkages are essentially provision of inputs
and infrastructural facilities and support to the students whereas forward
linkages related mainly to the demand for and marketing of the product
produced by training. For the trainees, the DRDA is responsible for the
provision of these linkages. The infrastructure for training itself is provided
by a network of organisations at the National/State level, including the
National Institute of Rural Development (NIRD) at Hyderabad with a
regional sub-centre at Guwahati, the State Institutes of Rural Development
(SIRDs), the Extension Training Centre (ETCs) and other institutes of
Management Development and Rural Management. These institutes basically
aim at training the trainers who, in turn, train the TRYSEM candidates as
well as assist in various areas of rural development.
When we study the performance of TRYSEM, we must focus on two aspects:

to what extent the target set in terms of the member of youth to be trained, the
financial allowances made were realised. The second is how easily the
trained youth have been able to gain access to self-employment opportunities.
In the latter aspect we must examine whether self-employment has helped in
ameliorating the conditions of poverty of the families of the youth.
In the Sixth Plan period the targets (physical and financial) were exceeded in
the last four years of the plan. In the Seventh Plan, targets for the number of
youth trained were not fixed. In the Sixth plan, the percentage of youth
trained who were self-employed was 47.1 and in the Seventh Plan it was 46.6
per cent. Since 1982-83, when wage-employment was included in the
scheme, the number of trained youth employed on wages as a percentage of
total youth trained has varied between 9 per cent and 17 per cent. Thus,
although TRYSEM was initially conceived as a self-employment programme,
the wage employment supplement has also contributed in augmenting
employment opportunities of trainees. The percentage of employed youth to
the total number of trained youth has never been more than 71 per cent. The 191
Public Health percentage of SC/ST and women among the trained youth has shown a rising
and Related trend.
Issues
TRYSEM has had several shortcomings, some of which are mentioned

below:
• Implementation is uneven across areas.

• Although the programme imparted training it has not, in some cases,
instilled the candidates with confidence to take up self-employment
ventures.
• Training lacked appropriate technology in the package provided.
• There are deficiencies in training arrangements and in the syllabus
prescribed by various training institutes.
• In the selection of trades, self-employment possibilities and financial
viability were not adequately assessed.
• Assistance in the provision of raw materials and marketing has been
lacking.
• Not every district has training centres for TRYSEM.
• In many cases, the assistance provided to TRYSEM trainees from IRDP
for projects had no link with the training they had received.

1) Why were SFDAs and MFALs set up?
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
……………………………………………………………………….......
2) What does the term ‘integrated’ in integrated rural development signify?
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
…………………………………………………………………………...
3) Who are the target beneficiaries of IRDP?
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
192
4) List two major shortcomings of IRDP. Income
Generation
………………………………………………………………………… Programmes
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
5) List four positive elements of TRYSEM.
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
6) List the main features of DWCRA.
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
23.7 ANTI-POVERTY AND EMPLOYMENT

GENERATION PROGRAMMES SINCE THE
1990S
In this section we discuss the anti-poverty and employment generation
programmes started since the 1990s. In 1991, as you are aware, India
changed the course and structure of the basic macro-management of the
economy, going in for liberalization and also experiencing the effects of
globalization. In this era, there has been a greater faith and reliance on
economic growth to take care of and ameliorate economic woes. This has not
been much different in the case of poverty alleviation. The Planners have
clearly recognized the role of economic growth in providing employment
avenues for the population, even for the poor. The growth-oriented approach
has been supplemented by focusing on particular sectors that enhance
people's capabilities. Poverty also is. now seen as a multi-dimensional
phenomenon and various aspects of these dimensions like education and
health have been made part of the planning process.
23.7.1 Self-employment and Poverty Alleviation Programmes

The IRDP, which was introduced in selected blocks in 1978-79 and launched
throughout the country from October 2, 1980, was successful in providing
assistance to rural poor in the form of subsidy and bank credit for productive
employment. Subsequently, as we have seen in previous sections, TRYSEM
and DWCRA were launched. Moreover, sub-programmes like Supply of
Improved Tool Kits to Rural Artisans (SITRA) and Ganga Kalyan Yojana 193
Public Health (GKY) were launched to take care of the specific needs of the people. All
and Related these programmes were implemented as stand-alone programmes, and by the
Issues
middle of the Ninth Plan it began to be felt that these were multiple
programmes that did not have the desired linkages. This less-than-desired
impact of the self employment programmes led the Planning Commission to
appoint a committee in 1997 to look into the working of the self employment
and wage employment programme. The committee made two important
recommendations: first, that the various self-employment programmes for the
rural poor should be merged, and secondly, that there should be a shift from
the individual beneficiary approach to a group-based approach. The
committee emphasized the identification of cluster of activities in relevant
areas and laid stress on training and marketing.
In the light of the committee's recommendations, the IRDP and allied

programmes including the Million Wells Scheme were merged on 1 April
1999 into a single programme called the Swarnajayanti Gram Swarozgar
Yojana (SGSY). This programme was conceived as a holistic programme of
micro enterprise development in rural areas. It emphasizes the organizing of
the rural poor into self-help groups, capacity building, planning of activity
clusters, infrastructure support and linkages for technology, credit and
marketing. Unlike previous programmes, this programme did not aim to rely
only on the DRDA for its implementation but had a cluster of organizations
like the DRDAS, relevant departments of state governments, NGOs etc. The
SGSY oriented the thinking of policy at the grassroots towards formation of
self-help groups.
23.7.2 Wage Employment Programmes

Wage employment programmes have had multiple objectives. They not only
provide jobs but also help to create rural infrastructure. Also, they aim to
create employment in lean agricultural season, as well as during natural
disasters. One effect of wage employment programmes is to push wages
upwards by expanding the demand for labour, mainly in public works. After
the attainment of self-sufficiency in foodgrains, wage employment
programmes for rural areas received a boost in the 1970s. In 1977 there was
the Food-for-Work programme. Later there were programmes like NREP and
RLEGP. We have discussed these earlier. As we have seen, the NREP and
RLEGP were merged in April 1989 under the Jawahar Rozgar Yojana (JRY).
This programme aimed to employment opportunities in rural areas by
creating economic infrastructure and social assets. Initially the JRY also
included the Indira Aawas Yojana (LAY) and the Million Wells Scheme
(MWS). In 1996 these were made independent schemes. During the Ninth
Plan central allocation for the JRY fell. Also, the cost of creating
employment opportunities went up. Hence, employment generation declined
over the years. Much of the funds for JRY had been spent on roads and
buildings.
Since 1 April, 1999, the JRY was revamped as the Jawahar Gram Samridhi
Yojana (JGSY). The primary objective of the JGSY was the building of rural
infrastructure. Employment generation was a secondary objective. The
194
programme has been implemented by the Gram Panchayats. It provided for Income
special benefits for SC/STs. Generation
Programmes
On 2 October 1993, the Employment Assurance Scheme (EAS) was launched

in 1778 drought-prone, desert, tribal and hill area blocks. In 1997-98, it was
extended to all blocks. The EAS aimed to provide employment during the
lean season, in the form of manual labour. This manual labour was to be
utilized for the construction of rural infrastructure based on the felt needs of
the people. The EAS was a centrally sponsored scheme, with the Centre
providing 75 per cent of the funds and the states 25 per cent. The zilla
parishads and the panchayat samitis were the implementing agencies.
The programme benefited the rural poor by creating community assets, but
the impact on employment general was limited.
23.8 LET US SUM UP

This unit aimed at familiarising you with various income generating
programmes for the rural poor. We discussed three broad types of
programmes: the Minimum Needs Programme, area based programme, and
target group beneficiary oriented programmes.
We began the unit by mentioning the inputs to the quality of life particularly
social inputs. Income, as we saw becomes an index of the purchasing power
of the people to buy those commodities which go to determine quality of life.
We focused on the rural poor people for this purpose. We saw how income
from employment fluctuates because employment opportunities are limited.
There being few large scale providers of employment in rural areas, as also
employment being seasonal, the government has to step in to take steps for
generating employment.
We talked about three types of programmes-consumption, production, and

institution oriented programmes. In this unit we focused on consumption type
programmes and some production type programmes. We gave a brief sketch
of the evolution of the thinking on and strategy of anti-poverty and income
generation programmes.
We considered four types of programmes in detail; the Minimum Needs

Programme, the area based programmes, employment generation
programmes, and anti-poverty programmes. The area based programmes
considered were the Drought prone Areas Programme, Command Area
Development Programme, the Desert Development Programme and Hill
Areas Development Programme. In the discussion on employment generation
programmes we discussed the early schemes like PIREP and CSRE, the food
for work programme, and NREP, RLEGP and JRY. In anti-poverty
programmes we provided a discussion of early attempts like setting up
SFDAs and MFALs, following this we discussed in detail the IRDP,
TRYSEM and DWCRA.
195
Public Health
and Related
23.9 GLOSSARY
Issues
Afforestation The process of planting trees to make a forest.
Subsidy The difference between the market price and the lower
price paid by the consumer beneficary. This difference is
met by the government.
Manday cost The cost required to generate one manday of labour.
Wage material The ratio of total amount spent on wages to the total
ratio amount spent on non-wage materials for the works.

EXERCISES
1) Consumption type, production type and institution oriented type.
Employment generation programmes would be a combination of
consumption and production type programmes.
2) i) Efforts of Green Revolution did not spread to the poor
ii) Attempts to measure magnitude of poverty
iii) Change in Development Economics—focus on absolute poverty and
distribution justice.

1) Basic needs concept covers both personal and social consumption,
human rights, people’s participation etc. and provides a wider conceptual
framework. The Minimum needs concept, on the other hand, covers only
items of social consumption and assumes that other consumption are
covered through the other planning strategies.
2) In the Seventh Plan, MNP had eleven components relevant to rural areas.
These are :
Elementary education, Adult education, Rural Health
Rural water supply
Rural roads
Rural electrification
Housing assistance to rural landless labourers
Nutrition
Rural domestic cooking energy
Rural sanitation and
Public distribution system.
196
The following three components were added after the Fifth Plan : Income
Generation
Rural domestic cooking energy Programmes
Rural sanitation and

Public distribution system.

1) Slow pace of implementation;
Lack of adequate financial and organisational support for maintenance of
the workers.
2) slow progress in consolidation of land; and
lack of extension support.
Its main achievements have been: increase in extent of utilisation of
potential, increase in areas in gross irrigated areas and irrigation
intensity, and improvement in water distribution and water availability.
3) Answer based on subsection 23.4.3

1) The main objectives were: to generate additional gainful employment for
the unemployed and underemployed men and women in rural areas; to
create durable community assets and social infrastructure in rural areas
and raise incomes; and to improve overall quality of life in rural areas.
2) The main benefits of paying a part of wages in foodgrains was that it
helped to stabilise prices of foodgrains, it provided workers with a
minimum quantity of foodgrains, and it effectively used surplus
foodstocks.
3) Answer based on Subsection 23.5.2
4) The main points on which RLEGP differed from NREP were:
• RLEGP specifically focused on the landless labourers among the
unemployed;
• RLEGP gave a guarantee of work to one member of each landless
family for at least 100 days in a year, and
• expenditure for RLEGP, unlike that for NREP, was fully funded by
the Centre.

1) These agencies were set up to raise the income of the rural poor by
providing them better access to improved technology, better irrigation
facilities and other productivity increasing measures, and by helping
them to diversify their farm economy through activities like dairying,
horticulture, sericulture etc. The agencies also aimed at making the
197
Public Health farmers members of credit cooperatives to facilitate credit supply.
and Related
Issues 2) Answer based on section 23.6.2
3) Answer based on section 23.6.2
4) The two major shortcomings of IRDP have been that the concept of
‘integrated’ as initially thought of has not been applied and used in its
true sense, and that there have been many ineligible beneficiaries.
5) Four positive features of TRYSEM are:
• it has been able to augment employment in rural areas
• it has contributed to works developing both skill formation and
entrepreneurial abilities among rural youth
• it has also provided training in non-formal settings
• its integration with IRDP has helped the beneficiaries to get access
to subsidy, credit and income generating assets.
198
UNIT 24 ENVIRONMENTAL Environmental
Protection
PROTECTION
Structure
24.1 Introduction
24.2 Concept of Environment
24.3 Impact of Human Activities on the Environment
24.4 Health and Environment
24.5 Environmental Economics
24.6 Approaches in Solving Environmental Problems
24.7 Your Role in Environmental Protection
24.8 Let Us Sum Up
24.9 Glossary
24.1 INTRODUCTION
You may have come across headlines like this in your daily newspaper. Have
you ever thought about the implications of issues such as these for yourself
and your family? If you have, you would have realised the importance of
protecting the environment.
Today, we face the severe problem of environmental degradation. It has been

realised in recent times that unless we take appropriate measures, our health
and well-being and even our survival is at stake.
We begin this unit by explaining the concept of environment. We, then, trace
the process whereby man shaped the environment and gradually began
destroying it. It is an established fact that environmental degradation has now
assumed alarming proportions. The air around us is polluted, water is unfit
for drinking and the food we eat is contaminated with chemicals resulting in
poor health. The pressure of increasing population is shrinking our already
limited resources. This highlights how man’s excessive, unthoughtful
interference with nature has brought about the degradation of the
199
Public Health environment and how this continues to adversely affect our quality of life.
and Related
Issues Efforts made by the Government, non-governmental organisations and by
individuals/communities are essential to ensure protection of the
environment. In many ways we need to challenge the manner in which
resources are currently used at both domestic and commercial levels.
Practices promoting waste minimisation and waste utilisation are very
important, as this unit tells you.
The message that comes across to us is that we can make a difference by

spreading
information, generating awareness and exerting pressure. So, as a community
educator this area requires your special attention.
Objectives
After studying this unit, you should be able to :
• explain the relationship between environment and health

• describe the health problems arising from environmental degradation in
India
• discuss the need for environmental legislation
• describe the various programmes launched by the Government for
protecting the environment
• discuss the role played by non-govemmental/voluntary organisations in
protecting the environment
• list reasons for lack of awareness of people, in general, towards
environmental protection
• suggest ways to disseminate information about environment among the
different segments of the population
24.2 CONCEPT OF ENVIRONMENT

Our survival, success, progress, health and happiness are intimately related
with the environment we live in. Environment literally means
“surroundings”. However, for considering various current issues related to
environmental protection it is necessary that you understand the concept of
environment in a broader sense and in a holistic manner.
So let us first try to understand the nature of our environment.

The thin layer on the crust of earth where life exists is called the biosphere.
Life forms flourish here because they come across favourable conditions.
Two components of the environment are distinguished in the biosphere :
i) the non-living (abiotic) component of the physical environment which
includes land, soil, water and air and
ii) the living (biotic) component or biological environment which includes
200
all plants, animals (including human beings) and microorganisms. Environmental
Protection
The physical and biological environment interact with one another. A change
in physical environment brings about a change in biological environment and
vice versa. The following three kinds of interactions can be recognised in the
biosphere :
i) Interaction among living beings : This is because of competition for
food, shelter and other necessities of life. Interaction is also due to
interdependence for elements and compounds that constitute the form of
an organism about which we will explain later in this section.
iii) Interaction between the physical and biological environment: The
physical factors such as temperature, water and sunshine can affect an
organism favourably or adversely. The biological factors also affect the
physical environment. For example, lichens produce acids that corrode
the rock and sand together.
iii) Interaction among physical factors : A change in temperature, for
example, may limit the availability of water for the organisms or a cloud
cover may limit incoming solar radiations for plants.
“No part of life can be considered apart from any other; there is no such
thing as an organism without an environment ”, Lewis Mumford
The growth and survival of organisms in the biosphere is made possible by

transfer of matter and energy between the components of the environment.
Matter is derived from the minerals present in the soil, water, on land and in
oceans as well as the oxygen and carbon dioxide present in the lower layers
of the atmosphere. The energy from the sun enables conversion of inorganic
chemicals into organic matter. You may be aware that the variety of life
forms, from the smallest like amoeba and bacteria to the largest like elephants
or whales are composed mainly of the same kind of organic matter, water and
relatively small amounts of minerals. The main basic constituents of organic
matter are carbon, hydrogen, oxygen, nitrogen, phosphorus and sulphur.
Minute quantities of some other mineral ions are also essential for life forms.
All the elements and water recycle between organisms and their physical
environment. In fact, no new chemicals enter the earth from outside (except
meteors) and we cannot get rid of hazardous chemicals out of the earth
(except in spaceships)! However, energy is being constantly added from the
sun. Thus, the earth is a closed system with respect to chemicals but an open
system in terms of energy.
Let us now try to understand the recycling of matter by considering a smaller

unit of the biosphere — the ecosystem.
The organism of a particular habitat such as a pond, lake, farm, forest or

ocean together with the non-living environment with which they interact
constitute an ecosystem. An ecosystem may be as small as an aquarium or as
big as a forest or an ocean. There is regulated transfer of energy and an
orderly controlled cycling of nutrients in ecosystems (Fig. 24.1).
201
Public Health In an ecosystem, green plants harness the energy of the sun and convert
and Related carbon dioxide and water into starches and sugars. Also, materials such as
Issues
minerals from weathered rocks are incorporated into the plants. Therefore,
plants are called the producers of an ecosystem. Next the chemicals move in
herbivores — the animals that survive on plants and then they move in
carnivores — the animals that survive on herbivores (Plants herbivores
carnivores). The carnivores and animals are called the consumers of an
ecosystem. When plants die, the microbes act on dead organic matter and
decompose it into inorganic matter. Thus, microbes are the decomposers in
an ecosystem. In this way, elements return back into the soil and atmosphere
and once again, the inorganic matter is available for recycling from living
beings back to the physical environment. The elements oxygen, carbon,
hydrogen, nitrogen and also sulphur move in the gaseous cycle (Fig. 24.2)
while other elements present in life forms move in the earth crust only. This
is called the sedimentary cycle.
Fig. 24.1: Naturally balanced ecosystem
Fig. 24.2 : The process of photosynthesis and respiration cause the balanced cycling of
oxygen and carbon in the biosphere
202
There exists a delicate balance between organisms and their environment Environmental
(unless some catastrophe like a volcanic eruption or a flood occurs). Only Protection
human beings as a species have been able to intervene and change the
delicate balance of the environment. In the next section, we trace the changes
brought about in the environment by human activities since the beginning of
the cultural evolution.

1) In the following sentences choose the appropriate word(s) from those
given in brackets:
a) The non-living components of an ecosystem are called
(biotic/abiotic) factors.
b) The area of earth where life exists is called (atmosphere/biosphere).
c) The living components of an environment (do/do not) influence the
non-living components.
d) An ecosystem includes (living/nonliving/both living and nonliving)
components of the environment.
2) Animals obtain food from the plants. Do they give something to the
plants?
………………………………………………………………………….....
………………………………………………………………………….....
………………………………………………………………………….....
………………………………………………………………………….....
………………………………………………………………………….....
24.3 IMPACT OF HUMAN ACTIVITIES ON THE

ENVIRONMENT
Our environment today is very different from that of early man who lived
60,000 years ago. Like other organisms he lived in a natural environment and
felt dominated by it As man possessed greater intelligence than other
organisms, he gradually changed his environment to suit his needs and to
ensure his survival. So, a new phase in human evolution began— the cultural
evolution. Since then man has changed the environment to a great extent. In
fact, it has deteriorated and the consequences are so alarming that man fears
his own extinction from the earth.
We feel that it would be appropriate here to consider briefly the impact of

human activities on the environment since the beginning of the cultural
evolution so that you can comprehend the problem and plan your action at the
community level.
To do this we must look back in time—peep into our past. You would find it
interesting to trace changes in the environment from the earliest times till
today. As you read, it would immediately strike you how much our capacity
203
Public Health to change (more often harm) our environment has increased.
and Related
Issues The cultural evolution is divided into the following three major stages :
i) The hunter-gatherer stage
ii) Rise in agriculture
iii) Industrial revolution
The hunter-gatherer stage dates as far back as 60,000 years ago and its
decline began somewhere between 20,000 to 15,000 years ago. Two main
reasons are suspected for its decline:
i) the killing of many more animal than required for food and clothing thus
creating an ecological imbalance and
ii) a rapid increase in human population.
It is probable that the practice of agriculture and domestication of animals

had evolved for finding more dependable sources of food and this was
probably accompanied by the origin of metallurgy so that an array of
improved tools for developing agriculture was evolved. Gradually, the
population increased and human settlements spread into newer areas. People
cleared forests and burned surface vegetation for planting crops. The tools
also enabled them to cut trees to build their houses with logs. However, they
could not use the same land for agriculture for a long period. This was
because the repeated farming depleted the land of nutrients essential for the
growing of crops. Therefore, they abandoned the place, moved to new areas
and cleared more and more forests. This lead to the destruction of cultivable
land and formation of deserts. The cutting of native forest and subsequent
over farming of land has been shown to be responsible for the spread of
deserts in India and elsewhere in historic times. There is good evidence that
the Sahara desert in Africa was once a lush green forest where the ancestors
of the Egyptians had lived. The decline in early civilisations, e.g.
Mesopotamia, Incan and Indus Valley has been attributed to deforestation on
a large scale. The subsequent soil erosion, floods and silting of irrigation
canals resulted in famines, death and desertion of villages.
The most severe and rapid degradation of the environment occurred in the
last 200 years during the industrial resolution. The present generation is
witness to its disastrous effects. Before the industrial revolution most of the
population of the world lived in villages and were engaged in farming. With
industrialisation, there was mass movement from villages to cities which
became the manufacturing and trade centres. This movement of people from
rural to urban societies continues even today.
The industrial revolution sharply increased pressure on the land and other
resources. One example is the fossil fuels which began to be consumed at a
very fast rate. This has continued to the extent that we now fear that they will
last for not more than 200 to 300 years. The industrial revolution has caused
the world-wide pollution of air, water and land.
204 Can you now list the kinds of changes brought about by cultural evolution
which have affected the environment? Which one of these is a major factor Environmental
responsible for the rapid degradation of the environment? Protection
…………………………………………………………………………............
…………………………………………………………………………............
…………………………………………………………………………............
…………………………………………………………………………............
…………………………………………………………………………............

Answer questions from 1 to 6 using information given in the following
growth curve of human population (cig. 24.3).
Fig. 24.3: Growth of human population, a) In the last half million years; b) From 1960
to 2000.
1) What was the population of the world when agriculture was first
developed about 11,000 years ago?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) How much has population increased from the development of agriculture
to 1 A.D.?
……………………………………………………………………………
……………………………………………………………………………
3) Compare the population of the world in 1650 and 1930.
205
Public Health ……………………………………………………………………………
and Related
Issues ……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
4) What was the population of the world by 1975?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
5) What are the reasons for such rapid increase in population for past 300
years?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
6) What is the expected population at the end of this century?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
Let us now look at the major human activities which have led to degradation
of our environment. We begin with deforestation.
DEFORESTATION
In our discussion on cultural evolution we talked about how deforestation
began with the rise in agriculture and grazing of pastures. The process is
continuing till today but at a much faster rate. The other causes for
deforestation are shifting cultivation, practised in some regions of India, use
of wood as fuel, for production of paper pulp and commercial timber. Large-
scale deforestation was also the result of construction of large dams on rivers
which require clearing of several hectares of forest. For example, estimates
show that the construction of Tehri dam near the Tehri town in the Garhwal
Himalayas, a little downstream at the junction of Bhagirathi and Bhilganga
rivers has submerged 4,000 hectares of good forest land.
So, what has been the extent of destruction of forest cover? Data show that
206
the total forest area of the world has reduced to less than 30 per cent within Environmental
this century. In India, of the total geographical area only 19 per cent of the Protection
land is under forest cover. Out of this, forest cover of good quality is only 8
per cent. While nearly 80 per cent of India was covered with forests around
3,000 B.C., it reduced to 23 per cent at the time of Independence. The main
reason for this reduction was the overexploitation of forests for timber and
fuel.
We have so far talked about the rapid rate at which our forests are
disappearing. But what is the effect of this? Deforestation leads to loss of soil
structure, soil erosion and depletion of soil nutrients. Once the plant cover is
removed, the top soil layer is exposed to direct impact of rain torrents, water
flow, strong surface winds and unstable air temperature. When water gushes
down the slopes the fine soil particles are removed from the entire surface.
This process of soil erosion reduces the fertility of the soil and forms steep
slopes, gullies and ravines. In some areas, soil erosion increases the volume
of run-off water resulting in floods. Silting of rivers, lakes and large
reservoirs particularly of dams results due to soil erosion.
Deforestation also leads to habitat destruction and thus affects biodiversity
and wild life adversely. The destruction of any one plant or animal species
can have an impact on many other organisms living in the Forest. You may
know that many animals have been declare as endangered species and some
are already extinct.
POLLUTION
With the beginning of the industrial revolution there has been a rapid increase
in industrial activities. There is considerable increase in production of coal,
petrochemicals, fertilisers, pesticides as well as energy generation. This has
resulted in generation of large quantities of gaseous, liquid and solid wastes
which have polluted our air, water and land.
We will talk about air pollution first.
Air pollution
Air pollution is increasing rapidly especially in large cities like Delhi,
Bombay, Calcutta and Madras because of increase in the number of transport
vehicles—cars, buses, trucks, three wheelers etc. During peak hours of traffic
it is so high that one can notice people wearing face masks to protect
themselves. Air pollution is also experienced by people working for
industries which release toxic pollutants. People living close to such
industries are also affected. You may know that thousands of people died,
many while sleeping, during the Bhopal disaster in 1984. In this case, a
poisonous gas escaped from a pesticide plant run by Union Carbide. In 1986,
an accident occurred at the Chernobyl Atomic Power plant in USSR. Though
only 31 people died immediately after the explosion, a few thousands to more
than a million were suspected to be exposed to nuclear radiations. The
disastrous effect of radiation is yet to be seen in the coming generation.
However, we know from the Hiroshima experience that these effects are
inevitable. 207
Public Health The two examples we have just talked about show you that air is polluted not
and Related just by gases but also by nuclear radiations. The various causes of air
Issues
pollution are depicted in Figure 24.4.
The major cause of air pollution is excessive use of fossil fuels — coal, petrol
and gas used in automobiles, industries and for household purposes.
Automobiles release carbon dioxide, carbon monoxide, oxides of nitrogen,
lead and smoke which contains unburnt carbon. Some of you may have
experienced dizziness when caught in heavy traffic. This is due to carbon
monoxide which is a poisonous gas and is fatal at high concentrations.
Fig. 24.4 : Air pollutants released from various sources make air toxic
The oxides of nitrogen can create many ailments such as gum inflammation,
internal bleeding and even lung cancer. Oxides of nitrogen also produce
photochemical smog and ozone when they react with hydrocarbons present in
the atmosphere in the presence of sunlight. Photochemical smog appears as a
yellowish brown haze in the air and is harmful especially for plants. Ozone
causes respiratory problems and watering of eyes.
Among the suspended particulate matter in the atmosphere, coal, cement and
silica dusts are the major pollutants. Coal based power plants generate fly ash
which amounts to a total of 30 million tonnes annually in India. The 10,000
stone crushers in the country together let out 1,000 tonnes of stone dust daily.
In addition a large amount of dust is also blown out by transport vehicles.
The level of dust particulates measured in 10 large Indian cities shows that its
concentration in Bombay, Calcutta, Delhi, Kanpur and Hyderabad exceeds
the allowable limits. In Delhi, the total calculated vehicular pollution doubled
during 1980-81 to 1986-87. Consequently the occurrence of respiratory
problems is increasing particularly in children living in the large cities.
208
Another severe effect of air pollutants is acid rain, i.e. rain water which Environmental
brings along with it acids from the atmosphere. In fact, oxides of nitrogen and Protection
sulphur released into the air from automobiles and industry respectively, react
with water and form sulphuric and nitric acid. These acids come down along
with rain. As you might expect, acidic water is extremely harmful for crops
and other vegetation as well as for terrestrial organisms. If acidic water finds
its way into lakes or rivers, aquatic organisms die. In Sweden alone 3,000
lakes are dead due to acid rain.
Let us now consider the problem of pollution at the global level. Air pollution
has no political boundaries. The pollutants can travel to far off places along
with prevailing winds. That is why the effects of the Chernobyl disaster were
observed as far away as Switzerland. The two major pollutants that need to
be controlled at the global level are carbon dioxide and chlorofluorocarbons
(CFCs). The excessive burning of fossil fuels for running automobiles and
industries has resulted in a rapid increase in the carbon dioxide level in the
atmosphere.
You know that carbon dioxide is not a poisonous gas; it is necessary for
plants to carry out photosynthesis. It also has a special role in keeping the
earth warm and maintaining its temperature. It stops the outgoing warmth
from escaping into space. This is called the green house effect because carbon
dioxide and some other gases work like the glass walls of a green house. The
glass walls of the green house prevent all the heat from escaping into the
atmosphere.
It is estimated that the average global temperature has increased between
0.3°C to 0.7°C in the last hundred years. It is anticipated that by 2050 the
earth’s temperature would increase by 20°C if the present trend of increase of
gases continues. This would cause thermal expansion of oceans and melting
of land based antarctic ice packs and glaciers. Consequently, a rise of one and
a half metres in sea level is anticipated. Can you guess what could happen?
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
It is predicted that average sea level will rise between 30 to 213 cm by 2073.
Over the past century the increase in the average global sea level was much
less — about 15 cms. An anticipated rise of one and a half metres will
submerge coastal areas, accelerate erosion of shore line, damage estuaries
and increase the salinity of drinking water aquifers. It is estimated that it
would flood about 11.5% land area of Bangladesh, flood some areas of the
Nile Delta and submerge 30 to 80% of the coastal wetlands of United States
and many other coastal areas of the world. It is feared that the Maldives
islands would be submerged within a decade.
The increase in the temperature would affect regional climate, shift climatic
zones and rainfall. This would also lead to increase in temperature of certain
209
Public Health areas of the world; death of forests; loss or failure or major cereal crops
and Related including paddy; massive heat wave and drying of lakes.
Issues
You may have heard about global depletion of the ozone layer. The layer of ozone
above the atmosphere shields life on earth from harmful radiations of the sun. This is
getting damaged because of the use of chlorofluorocarbons or CFCs as refrigerants,
aerosols, can propellants, solvents and foam plastics used in making coffee cups and
containers for fast foods. If this shield is damaged, harmful radiation would reach
the earth and cause severe skin cancer.
Ozone Hole: At the South Pole a thinner layer of ozone, about 60% only was
detected by scientists. This is spread over an area of the size of United States. It is
referred to as the ozone hole.
Water Pollution
For centuries human settlements have dumped their sewage and other wastes
into streams, lakes, rivers, oceans or other water bodies. A limited amount of
biodegradable waste can get decomposed by the activity of organisms and
water bodies get purified by themselves in course of time. But this capacity
of selfpurification is limited. With increase in population our rivers Ganga,
Yamuna, Mahi, Narmada and others as well as lakes, for example the
beautiful Dal lake in Kashmir are loaded with sewage and wastes. The rivers
also supply domestic and drinking water. Consumption of sewage polluted
water causes diseases like typhoid, dysentery or other gastric problems about
which you have learnt earlier in this course.
The quality of water bodies has further deteriorated because the effluents
from paper and steel mills, sugar mills, tanneries, distilleries, DDT factories,
automobile workshops are also let into the rivers. Most industrial waste is
non-biodegradable.
It may contain poisonous metals like mercury, cadmium, arsenic and

pesticides such as DDT. The metals and pesticides get into the bodies of
aquatic organisms and slowly accumulate in them. These chemicals reach
human beings if they eat poisoned organisms, for example fish. The well
known episode of Minimata disease in Japan was caused due to eating of fish
which were caught from a river contaminated with mercury. Figure 24.5
summarizes the sources of water pollution.
210
Environmental
Protection
Fig. 24.5 : The various sources of water pollution
pesticides, fertilisers or other chemicals used in agriculture also find their

way into nearby water bodies. They may seep through the ground and
contaminate ground water sources. Unlike rivers, ground water cannot be
purified. Our ground water resources have been found to be contaminated
with nitrate. Nitrates are converted to nitrites in the body and the latter cause
a kind of anaemia especially in bottle fed infants called
methaemoglobinaemia. Highlight 1 tells you about some instances of ground
water pollution in India.
HIGHLIGHT 1
Ground Water Pollution
Pali in Rajasthan has more than 450 textile units where dyeing and bleaching
of clothes is carried out. The coloured effluents containing sulphuric acid and
toxic carcinogenic substances were indiscriminately discharged onto large
areas in the city. During the monsoon, the chemicals seeped through the
ground and polluted ground water.
Similarly, ground water in industrial areas of Punjab and Haryana is polluted
with high concentrations of poisonous metals like nickel, copper, chromium
as well as cyanide. This is due to effluents from bicycle and woollen
manufacturing units located in the cities of Ambala, Ludhiana and Sonepat.
Domestic effluents contain chemicals such as disinfectants, soaps and

detergents. They also contain waste food. Detergents are rich in phosphate, a
plant nutrient. Thus the water body which receives the effluents also get rich
in nutrients which promote the growth of algae. Excessive growth of algae
211
Public Health causes depletion of dissolved oxygen. Consequently, aquatic organisms cease
and Related to survive in such water.
Issues
Our discussion has highlighted the different ways in which rivers or other
water bodies get polluted. Such polluted rivers finally run into the oceans,
polluting them as well. Besides this, oceans are also polluted because of
discharge of sewage and industrial effluents from the factories along the coast
line. In addition, frequent oil spills from tankers also pollute the oceans and
adversely affect marine life.
Land Degradation
We have told you how deforestation is linked to soil erosion and
desertification. Intensive cultivation, mining and other developmental
activities also accelerate soil erosion. Mining in Doon Valley has caused
silting of rivers and instability of land masses. Besides, waste material from
mining centres render the land unsuitable for any use.
Industries generate a lot of wastes. These wastes go on accumulating unless

disposed off promptly and properly. Some of the industrial wastes are
hazardous and need to be treated before disposal. Otherwise, they can cause
serious contamination of natural resources, posing a threat to the quality of
the environment and adversely affecting human health. Untreated hazardous
wastes remain a permanent threat even in land fills. The case of Love Canal
near Niagara falls in USA is discussed in Highlight 2.
HIGHLIGHT 2
Lessons from Love Canal
A few decades ago, an abandoned canal near Niagara Falls, New York was
dumped with approximately 19,000 tonnes of chemical wastes packed into 55
gallon steel drums by a chemical factory. Later, the site was covered with dirt
and an elementary school and playground was built on this site. After two
decades, when it rained heavily, the area became a muddy swamp of
chemicals because of increase in the level of ground water. The poisonous
chemicals had leaked out of the drums and spread on the playground and
reached the basements of houses. Soon children and adults of the area
suffered from illnesses such as severe headache, skin sores, rectal bleeding,
liver malfunctions and epilepsy. later, miscarriages and birth defects were
also reported.
Toxic chemicals from wastes may seep through the ground and poison
ground water. Open waste dumps create unsanitary surroundings and ruin the
appearance of the area. But solid waste management in India has traditionally
been given low priority by civic authorities, although the amount of solid
waste is increasing proportionally to the rise of affluence in the cities.
DEPLETION OF RESOURCES
Human population has doubled in the last 50 years. The demand for resources
such as food, fossil fuels and space has increased. There is rapid consumption
212
of resources. Our resources are both living and non-living. Some of the Environmental
resources once used cannot be regenerated again. For example, mineral Protection
deposits and fossil fuels. These are called non-renewable resources. Our
forests, pastures, wild life, aquatic life can be regenerated again and are
called renewable resources. However, owing to the pressure of population
and the excessive demand, the consumption of these resources is taking place
at such a fast rate that renewal cannot keep pace. These renewable resources
are gradually becoming non-renewable. Formation of soil is a very slow and
long-term process and takes thousands of years. It is estimated that the world
is losing 7 per cent of top soil per decade. If timely measures like
afforestation are not taken up, it is feared that cultivated land will become
degraded in a few decades.
The depletion of non-renewable resources is even more serious.
Social Degradation of The Environment

Since Independence many large scale developmental projects for irrigation,
production of chemical fertilisers, energy generation, steel etc. were planned
and many of them are now completed. Generally, wherever a developmental
project is initiated, some agricultural and forest land is requisitioned for it.
The population living there is displaced. The affected persons have to leave
their homes and professions and look for new jobs and new places to live.
This brings vast changes in living conditions, employment patterns and social
organisation of large populations. Developmental projects have provided
some people with energy, food, water, goods and employment on the one
hand while on the other they have displaced millions of people and many of
them have migrated to cities. The large cities themselves are overcrowded.
Hence the migrants live in slums, footpaths, jhuggis under the most
unhygienic conditions which pose a threat to their health.It is estimated that
by the year 2000 A.D. the slum population in India will rise to about 78
million. The slums represent the worst type of environmental degradation.
Although developmental projects are a must for all round development of our
country, problems have arisen due to lack of planning and poor management.

1) List causes of deforestation.
a) ………………………………………………………………………..
b) ………………………………………………………………………..
c) ………………………………………………………………………..
2) List three types of renewable and three types of non-renewable
resources.
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
213
Public Health 3) Why are renewable resources endangered in the present century?
and Related
Issues …………………………………………………………………………….
…………………………………………………………………………….
4) How can deforestation lead to floods? Explain.
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
5) List four air pollutants.
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
6) Name the pollutants responsible for acid rain. What are their sources?
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
7) List the sources of water pollution. What type of pollutants do they
contain?
a) ………………………………………………………………………..
b) ………………………………………………………………………..
c) ………………………………………………………………………..
24.4 HEALTH AND ENVIRONMENT

We have discussed in detail how various human activities have caused
irrepairahle damage to land, air, water and organisms that inhabit them. Man
is mercilessly exploiting the planet that nurtures him and provides life and
sustenance. The increasing concern now for the protection of the environment
is not because of man’s love for nature but to a great extent to protect directly
or indirectly human health, well-being, comfort and to avoid illness and
diseases.
Although ancient civilizations were aware of the effects of environment on

health, the importance of clean environment in modem times was realised
214 after the industrial revolution. Since then a great deal of success has been
achieved in understanding health problems and solving them. Environmental
Protection
An individual’s health is the result of the interaction of a large number of
influences upon him or her. These influences fall into three categories: (i)
genetic (ii) behavioural and (iii) environmental. Genetic influences refer to
the features a person inherits from his or her parents like appearance,
intellect, even abnormalities or diseases. Haemophilia, mongolism, sickle-cell
anaemia and thalassaemia are genetic diseases. But allergies, hypertension,
schizophrenia, asthma and diabetes are not entirely caused by genetic factors,
since these diseases may be triggered or get affected by nutrition, stress,
emotions, hormones, drugs or other environmental interactions. In other
words, they would not occur if the environment is favourable for a person
and the person will remain unaffected and healthy. Behavioural influences
include the effects of habits such as smoking, drugs, alcoholism, chewing
tobacco or pan masala or food habits that influence our health.
Environmental Protection
Various components of the environment exert influences on our health. These
components are physical, chemical, biological, sociological and
psychological. Various factors under these categories are illustrated in Figure
24.6.
Fig. 24.6 : Environmental influences that affect our health
The psychological environment is a unique creation of man himself. Social

and medical scientists have clearly established an association between
psychological environment and prevalence of certain diseases. For example,
it has been shown that lung cancer is caused by chemical substances but the
habit of smoking is often due to psycho-social causes.
As you know, certain environmental conditions like air, water and food are
necessary for man’s survival. Apart from their availability, their quality and
quantity must be assured according to man’s natural and acquired capacity to 215
Public Health sustain himself. Progress in industrialization has brought pollution and
and Related consequently health hazards. We have mentioned some of the health
Issues
problems earlier. As you learnt in Block 4 of Course 1, food is adulterated
with non- permitted or substandard chemicals used as artificial colours,
preservatives, flavouring agents, sweeteners or for other reasons. Toxic
metals poison food during canning or while cooking in inappropriate metal
utensils. Our water is polluted with biological contaminants (from sewage) or
chemical contaminants (from industries). Respiratory diseases and diseases
due to inhalation of coal dust, talc, fibres of cotton, flax, hemp and asbestos
are on the increase.
Developmental activities especially irrigation projects have contributed to the

spread of diseases like malaria, dengue fever, Japanese encephalitis and the
problem of genu valgum (knock-knees) in large areas. It was reported that
accumulation of DDT in the body tissues is the highest among Indians. This
is. because of high residues of this pesticide in our food. A few people
severely affected by pesticides were found to suffer from pain in the hip and
knee joints and later they could hardly stand up.
People suffer from occupational health problems also. People sitting

continuously at the desk in offices often suffer from spondylitis of the neck
and back.
Noise pollution is another problem which affects health. It has become an

important stress factor in modern life. Exposure to high noise levels results in
varying degrees of deafness. In general, the stress associated with modern
living leads to anxiety, depression, sadness, fear and anger which may result
in physical illnesses like headache, sleeplessness, stomach upset and
muscular tension.

1) Which of the following genetic diseases are triggered by environmental
interactions?
a) Haemophilia
b) Diabetes
c) Schizophrenia
d) Asthma
e) Mongolism
2) List three diseases that got introduced in our country due to
developmental activities.
a) ………………………………………………………………………..
b) ………………………………………………………………………..
c) ………………………………………………………………………..
216
24.5 ENVIRONMENTAL ECONOMICS Environmental
Protection
So far, we have discussed at length the problem of pollution and its adverse
consequences. In this section, we will discuss the control of pollution and its
economic dimensions. It is said, “it costs to control pollution but it also costs
if it is not controlled”. Cost due to damages and cost of pollution control both
can be quantified strictly in monetary terms and a cost-benefit analysis can be
obtained. This can guide a country in preparing a plan of action. To illustrate
this point we will consider data available from some industrialised countries
because such data are virtually non-existent in our country.
The system used for the control of emissions of particulate matter are
cyclones, bag filters, electrostatic precipitators and scrubbers. These are
installed according to the volume of gases to be handled and may cost from a
few thousands to a few lakh rupees. However, installation of large filter bags
may cost from several lakhs to a few crore rupees. Cost benefit data available
from Japan, Germany and USA show that investments made towards air
pollution control are worthwhile because their costs were paid back and there
was a net gain. Pollution induced economic damages as a percentage of GNP
(Gross National Product) amount to 3% in UK, 2% in USA and 1% in
Canada. Considering the gross saving from clean-up and cost of clean-up, the
cost benefit analysis for USA shows that each dollar spent for clean up results
in benefit of two dollars. So we can conclude that it is prudent to control
pollution as it prevents losses and provides benefit.
If we consider environmental losses which occurred in other countries when
they were as industrialised as we are today, the losses ranged from 2 to 3% of
GNP. This means a country should spend about half i.e. 1 to 1.5% of GNP in
control of pollution. This amounts to 3000 crores of rupees annually for
India. At present about 600 crores are spent for pollution control efforts.
Since our country has meagre resources, some alternatives have to be worked
out for pollution control. The two most effective and complementary
strategies suggested are:
i) Waste minimisation and
ii) Waste utilisation
There is a difference between pollution control through control devices and
pollution control through waste minimisation. Control devices are used to
either stop further damage or repair the damages that have already occurred.
Waste Minimisation
First of all you must understand that wastes are inevitable. Human and other
living beings produce wastes due to their natural activity. Wastes are
generated due to agricultural activities. They amount to over 600 million
tonnes (crop residues and agrochemical wastes) annually in our country. In
technological processes alongwith useful products wastes are also generated.
Wastes always cost. In the manufacturing process they are produced at the
cost of the product. Excessive wastes indicate inefficiency. Often, wastes are
due to carelessness and bad habits. At an individual level we can minimise 217
Public Health wastes as well as wastage.
and Related
Issues
Waste is Wealth
Save water and energy. Reduce unnecessary consumption.
An expense of about 2600 million rupees was estimated, for instance, in the
first phase of Ganga Action Plan — for cleaning the holy river in 262
different schemes. So you can imagine how expensive it is to clean a “dirty”
environment! Isn’t it better, then, to prevent waste accumulation wherever
possible?
Waste Utilisation
It is technologically feasible to recycle many of the wastes. This makes good
sense in economic terms for most industries as well as an individual level.
Highlight 3 illustrates the potential for using wastes as raw materials for
various industries.
HIGHLIGHT 3
Making Profit Out of Waste
For the first time waste products are being used on a large scale for
manufacturing useful products in India. These products are also finding a
substantial market which makes them high profit ventures. Here are some
prominent examples:
• Strains of bacteria are mixed with garbage from city dumps. The bacteria
break down the waste into simpler chemicals. Thus they cut short the
rotting time and remove the foul smell, eventually producing manure.
Manure, as you know, is much better than the chemical fertilisers now in
use.
• Flyash is emitted by thermal power plants in large amounts because
Indian coal has a high ash content. This flyash is now being used to make
bricks. When flyash is mixed with lime, calcinated gypsum and water, a
cement-like substance is formed. This substance is moulded into bricks
and panels which are stronger than those of clay. These bricks are of
such high quality that even big hotels and embassies have placed order
for these bricks.
• Waste plastic soft drink bottles can be melted and shaped into chips to
make polyester fibre. The bottles otherwise create a big waste problem.
• Distilleries release effluents or "spent wash". Industries are now being
set up to use this effluent to generate methane gas with the help of
bacteria. Methane gas is used as fuel. The gas generated is used by
distilleries in their furnaces or boilers replacing kerosene or coal. Some
industries are, hoping to use the same technology for turning household
wastes into energy.
• Wastes from canteens and hatcheries is being used to grow earthworms.
The castings of these earthworms then form excellent manure.
218
• Stalks of the cotton plant are bound with resins to create a teak-like Environmental
Protection
board. This costs only half as much as real teak board. Rice husk has also
been similarly used.
Note: You can find such examples of innovative enterprises presented in
newspapers particularly related to economics.

1) Differentiate between pollution prevention and pollution control. Which
of these is more beneficial? Why?
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2) “Wastes are indeed misplaced resources.” Comment.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
24.6 APPROACHES IN SOLVING

ENVIRONMENTAL PROBLEMS
In the previous sections we have already discussed the ways in which man’s
activity has damaged or altered the fragile global ecosystem. Our country’s
environmental problems have also been highlighted in the subsections on air,
water and land pollution as well as the discussion on deforestation.
Now, we come to the question — What can we do to solve environmental

problems? There are two ways in which we can attempt this:
i) Organising environmental awareness and education campaigns at the
community level.
ii) Environmental action at the following levels:
• Government
• Non-governmental organisations
• Community / Individual level
It must be emphasised that people act in order to protect their environment

only when they become aware of its importance. Hence promoting action at
the individual/community level involves spreading information about the
environment, the ways in which it gets deteriorated or degraded and also the 219
Public Health way in which this can harm our health and well-being. Awareness about these
and Related aspects then makes peqple act in order to prevent and solve environmental
Issues
problems in their area.
As we mentioned earlier, the Government, Non-governmental organisations

and individual/community level action all play an important role in
environmental protection. We begin with Governmental schemes, campaigns
and also explore the role of Government in enacting legislation.
The Role of the Government in Environmental Protection

The Government has played the role of a catalyst in promoting awareness
campaigns. It has also established a legal framework for taking action against
offenders through environmental legislation. The National Environmental
Awareness Campaign being organised by the Ministry of Environment and
Forests is one example of a programme which spreads the message of
environmental protection. People are encouraged to think about various
issues and take up activities such as afforestation and other schemes related
to regeneration of ecosystems, pollution control and conservation of flora
(plants) and fauna (animals).
Another interesting scheme started by the Ministry is called the “Paryavaran
Vahini” scheme. These Vahinis are groups of people (20 per vahini) who
include individual activists as well as members and are involved in:
• creation of environmental awareness and promotion of active
participation of people in environmental programmes;
• reporting illegal acts related to cutting of forests, poaching, pollution and
degradation of the environment due to commercial activities (e.g.
mining);
• providing feedback regarding afforestation and restoration of plant
cover;
• monitoring of air and water quality.
This scheme illustrates the useful cooperation emerging between the
Governmental and non-governmental organisations (NGOs) in imparting
environmental education.
We have already discussed some of the activities undertaken by the
Government in spreading knowledge, providing information and taking up
environmental action. It would be obvious to you that such action at the local
level may not always be enough. A system of checks and controls is also
needed which is effective all over the country in a uniform manner. Such a
system must involve legislation and its enforcement particularly to control
pollution and degradation of the environment. Various Acts passed by the
Government of India are as follows:
• Water (Prevention and Control of Pollution) Act

According to the provisions of this Act, Water Pollution Boards have
been set up at the Central and State level. These Boards have the power
220 to advise, coordinate and provide technical assistance in the prevention
and control of water pollution. They also monitor water pollution levels Environmental
and lay down permissible levels of pollution. Protection
The Water Act prohibits dumping of poisonous, noxious or polluting

matter into streams, rivers and other water bodies. It also prohibits any
activity which can block or decrease water flow leading to accumulation
of pollutants.
• Air (Prevention and Control of Pollution) Act
The Air Act regulates emissions from automobiles and industries. The
Central Board for Prevention and Control of Water Pollution implements
and enforces this Act also. In addition it lays down standards for air
quality.
• Environment (Protection) Act
The coverage of the Act is very wide and includes handling of.hazardous
substances, prevention of environmental accidents, research, inspection
of polluting industries, establishment of laboratories, providing
information. The Act provides the Central Government with considerable
powers. It also enables individuals to file cases in court. Before the
implementation of this Act, this could only be done by the Boards we
have talked about earlier.
• Wildlife (Protection) Act
This Act governs wildlife conservation and protection of species of
animals and plants which are threatened with extinction. The Act
prohibits trade in rare and endangered species. Under the provisions of
this Act, the Government gives financial assistance for maintaining
national parks and sanctuaries; protecting wildlife and control of
poaching and illegal trade in wildlife products; captive breeding
programmes for endangered animals; wildlife education and
development of related zoos.
We have so far talked about only some of the major laws in existence.
However, how effective are these laws? Have they been implemented
properly? What are the problems that still remain unsolved? Some of the
drawbacks in environmental legislation and difficulties in enforcement are
discussed in Highlight 4.
HIGHLIGHT 4
Implementing Laws
Given below are some instances whereby the environmental legislation alone
finds it difficult to bring out intended outcomes.
• The Environment (Protection) Act provides for putting a check on
pollution of rivers. But 90 per cent of the pollution of the Ganga results
from municipalities dumping their waste in the river. The municipalities
have no money to install treatment plants to treat the wastes before
dumping in the river.
221
Public Health • The Forest Bill could not be approved because of public protest. The
and Related
Issues proposed Bill would have posed great difficulties for tribals living in and
off forests because it prohibited the taking of all the forest produce
including leaves and fruits from the forest. The proposed Bill gave forest
officers significant powers which was again resented by people.
• Can individuals or even groups of individuals who file a case in court be
expected to submit authoritative proof of an extremely high radiation
level or high water pollution level?
• In 1984, the Bhopal Tragedy (due to leakage of a poisonous gas) claimed
the lives of 5000 people and affected a quarter of the city’s population.
Compensation claims are only beginning to be settled now. Here the law
had to contend with a powerful multinational corporation.
• Small industries may not be able to install treatment plants to reduce
pollution because such plants are very expensive.
Highlight 4 clearly brings out the following problems in implementation of

laws:
• managing infrastructure
• applying pressure on governmental agencies and private enterprises who
are “big polluters”.
• covering the costs of cleaning up
• inability in some cases for individuals to fight and win cases
• covering the costs of litigation (fighting cases)
• conflicts with people who need and use resources at the local level who
see such legislation as a threat.
The Role of NGOs in Environmental Action

We have discussed the role of the Government in promoting environmental
protection. In the case of the Paryavaran Vahini Scheme we hinted at the
potential of cooperation between the Government and non-governmental
organisations. Let us now study the role of non-governmental organisations
(NGOs) in greater detail.
NGOs play one or more of the following three roles: .
The role of NGOs as pressure groups and action groups is illustrated by the
Dashauli Gram Swarajya Sangh (DGSS) which pioneered the Chipko
Movement in the district of Chamoli in the early 70’s. The movement
222
originated with the local people realising that they were suffering the ravages Environmental
of floods because of the rapid destruction of forests. This was happening Protection
because of the large-scale commercial felling of trees over several years. So,
DGSS took on the role of mobilising people in several villages to protect
their trees by the unique action of “chipko” — clinging to trees even if they
were threatened with death by the contractors. They thus pressed for the
defense of their traditional forest rights and sought to protect themselves from
the devastating effects of deforestation. The Chipko Movement successfully
exerted pressure on powerful people to act in favour of retaining the forest
cover in the villages of the Himalayan region.
On the other hand, the Delhi-based Kalpavriksh and the Kerala Sastra Sahitya
Parishad illustrate the role of NGOs in generating awareness, conducting
research, developing educational materials. Kalpavriksh has concentrated on
(i) opposing destruction of Delhi’s green areas, (ii) assessment of the
Narmada Valley Project, (iii) pesticide use, (iv) air pollution, (v) impact of
mining activities. The Kerala Sastra Sahitya Parishad has helped to create
awareness about conserving water and energy resources. The Parishad’s use
of folk arts in its educational programmes is of special interest.
Our discussions so far have concentrated on mechanisms evolved by the
Government and NGOs for preventing environmental damage and promoting
environmental protection. We have also talked about the problems
encountered. It must be emphasised that social, political and economic
factors have to be considered in implementing legislation, installing pollution
control measures or modifying existing industrial or domestic practices.
Now, let us turn to. the aspect of how environmental crises can be handled. In
simple words, how do we clean up our rivers or land, for example? This
requires action at various levels — Government, NGOs and local
communities.
In this context, it would be useful to give you a few details about the Ganga
Action Plan (GAP) which we mentioned in the previous section. This plan
was launched in 1986 for improving the quality of the river Ganga, by
reducing the pollution load and establishing self-sustaining sewage treatment
plant systems. What does this mean? You may be aware that the sewage from
towns and cities as well as effluents (wastes) discharged from factories pours
into the river. This is called the “pollution load”. In order to reduce this load,
factories have to control the amount of wastes which are released by them
and also treat them so that they become less toxic and harmful for the
environment. In addition, pollution load has to be reduced by appropriate
sewage treatment plants for treating municipal sewage before discharge into
the river.
Out of 264 polluting industries which discharge their effluents into the river
Ganga and its tributaries 68 grossly polluting units have been monitored for
installation of effluent treatment plants. Prosecution has been launched
against offending industries as well. About 45-50 units have installed
treatment plants. In addition, infrastructure capable of intercepting and
diverting 485 million tonnes/day and treating 223 million tonnes/day of
223
Public Health municipal sewage has been created.
and Related
Issues Various practical suggestions have been made to solve the problem
particularly of small industries who for various reasons cannot abide by the
norms laid down. It has been proposed, for example, that a few industries
situated close together could share the costs of installing a common treatment
plant. Governmental subsidies have also been suggested in order to protect
the interests of small industries.
Our discussions in this unit must have led you to think more deeply about
issues related to environmental protection. We should perhaps be asking
ourselves questions like these:
• Can we afford to make money without judiciously using the resources

which keep our factories going—coal, petroleum, water, land, air ?
• Should we not evolve technologies which are appropriate at the local
level and may even use recycled materials so that we do not accumulate
waste?
• Can we evolve ways in which waste can be converted into useful
products?
• Can we (as individuals) not reject products made by destroying the
environment and encourage products which are “environment friendly”?
• Should we not prevent ourselves from becoming a part of the “throw
away culture”, as practiced in the West? Can we decide not to buy or
encourage products such as disposable bags or packs which add to the
pile of waste?
• Can we utilise our resources in the most economical way?
• Should there be a change in the way society takes decisions? Can
environmental considerations be made to count in decision making?
• Can we assess and modify technology which already exists so that no
further damage is done to the environment?
What would be your opinion on these questions? Think about these issues
and write down what you feel in the space provided.
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
24.7 YOUR ROLE IN ENVIRONMENTAL

PROTECTION
As you read this unit you must have identified some points of interest for you
as well as for the community. You could list some of these in the space
provided. We have mentioned a couple of possibilities to give you an idea.
224
Environmental
Protection
Environmental Concerns in Your Community
• Contaminated drinking water supply (biological or chemical?)
• Waste disposal
•
•
•
Our discussions in Block 2 of this course and in this unit on environmental

protection must have shown you clearly how much the environment
influences our health. This is an important message you could take to your
community.
Such a message is linked to encouraging community members to initiate

action on cleaning up their immediate surroundings. However, the broader
scope of this unit would have indicated to you that a particular community
may not always be responsible for environmental degradation. In many cases,
commercial enterprises working in the area may be responsible. Forming
action and pressure groups becomes very important in such cases. You could
find out more about NGOs working in your area and try to link up with their
ongoing programmes.
The idea of launching a “Paryavaran Vahini” in your village or town or the

city where you live could be a good one. If you live in a city, NSS volunteers
in colleges might be willing to help. Similarly, schools also run outreach
programmes in which you could participate.
In addition to this, it is worthwhile considering the possibility of conducting

detailed discussions with community leaders or other members in order to
decide on what kind of programmes would best highlight the problems being
faced and the solutions which could be found.
Some of the simple messages you could promote are:
PRESERVE NATURE
GROW MORE TREES AND NURTURE THEM
FIGHT POLLUTION
CREATE PRESSURE GROUPS FOR PREVENTION OF

ENVIRONMENT DEGRADATION
PREVENT WASTE AND WASTAGE
RECYCLE WASTES AND UNUSED OBJECTS
PROTECT YOUR ENVIRONMENT OR YOU'LL HAVE TO PAY 225

Public Health There may be several others you could think of in order to add to the list.
and Related
Issues Check Your Progress Exercise 6
1) Explain the following terms :
a) Waste minimization
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
b) Waste recycling
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
c) Wastage
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
……………..……………………………………………………………
2) a) “Environmental protection is a complex issue”. Justify this statement
giving examples.
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
b) What measures could be undertaken in your community to promote
environmental protection? List any five measures.
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
……………………………………………………………………….
226
24.8 LET US SUM UP Environmental
Protection
The following major points emerged from this unit :
• Living beings interact with each other and their environment. The
environment provides matter necessary for life and the sun provides
energy. There is a cyclic flow of matter between organisms and the
environment.
• Human activities have been adversely changing the environment since
the beginning of the cultural evolution. Deforestation and overgrazing of
pastures had increased with the rise of agriculture and domestication of
animals.
• The industrial revolution accelerated changes in the environment at an
alarming rate. The present day problems of pollution of air, water and
land are mainly the result of excessive consumption of fossil fuels for
automobiles and industry and over utilisation of renewable and non-
renewable sources.
• The dramatic increase in world population from half billion in 1650 to 45
billion can be explained due to increase in food production, the rise in
industry and advances in medicine. The death rate has decreased.
• Our health is closely linked with the environment we live in. Due to
growing pollution various toxic chemicals get into our body daily
through food, water and air. Health problems like respiratory diseases,
cancer, stress-related problems such as hypertension, heart diseases are
on the rise in present times.
• The cost-benefit analysis of pollution control measures indicates that
purely in monetary terms the gain is double compared to the money
spent. Pollution is the result of waste accumulation. Waste minimisation
and utilisation are strategies which can reduce cost and maximise benefit.
• The Government has enacted legislation in order to protect the
environment and punish offenders responsible for pollution or other
types of environmental degradation. It has also collaborated with NGOs
in launching education/information campaigns and schemes.
Regeneration programmes such as the Ganga Action Plan have also been
launched. The impact of these programmes/ legislation can be further
improved.
• Our approach as individuals and as communities should be to create
awareness and build pressure groups which can work for the cause of
environmental protection.
24.9 GLOSSARY
Aerosol Suspension of small liquid or solid particles in a gas for

e.g. smoke. Aerosol sprays are widely used for
insecticides, air fresheners, paints, cosmetics.
227
Public Health
and Related Biodegradable A substance that can be broken down into simple
Issues chemicals by living beings such as microorganisms.
Captive Raising plants or animals in zoos or other controlled

breeding conditions to produce stock for subsequent release
into the wild.
Carnivores Those animals that eat other animals.
Consumers Organisms which obtain their nourishment by

consuming the producer.
Decomposers The organisms which obtain their nutrients by feeding

upon dead organisms, breaking them down into
simpler substances and in doing so making other
nutrients available for the producer.
Ecosystem A self-contained and perhaps small unit or area such as

woodland which would include all the living and
nonliving parts of that unit.
Green house Glass enclosed, climate controlled structure in which

young or out of season plants are grown and protected.
Gully Ravine formed due to action of water.
Haemophilia A genetic disease, marked by defective blood clotting.
Ions Atoms or group of atoms carrying positive or negative

charge.
Japanese A fatal brain fever caused by a virus with symptoms

encephalitis such as headache and drowsiness leading to coma.
Lichen A symbiotic association of an algae and a fungus to

form a slow-growing plant which colonises such
inhospitable environments as rocks in mountainous
areas or the trunks of trees.
Metallurgy The process of obtaining metals from their primary
sources.
Mongolism Genetic disease, caused by the presence of an extra

chromosome, resulting in an incurable condition of
idiocy (mental deficiency), abnormal growth
Pollutant Substance or agent introduced into the natural

environment which may have a harmful effect.
Pollution The act of introducing into the natural environment

any substance or agent which may harm that
228 environment and which is added more quickly than
the environment is able to render it safe. Environmental
Protection
Producers The organisms especially green plants and some
bacteria which are able to manufacture food from
inorganic sources by such processes as photosynthesis
Propellant A combustible substance that produces heat and

supplies ejection particles as in a rocket engine
Ravine Deep narrow valley
Schizophrenia A mental disease marked by a breakdown in the

relation between thought, feeling and actions,
frequently accompanied by delusions and retreat from
social life
Sickle cell An inherited disease of the blood in which

anaemia haemoglobin is altered so that red blood cells become
sickle-shaped so that the normal functioning of blood
is hampered.
Silting Deposit of sediment by water in a channel, harbour or

water reservoir.
Soil erosion The detachment and movement of top soil by the

action of wind or flowing water
Spondylitis A disorder of the spine or vertebrae which causes

inflammation, rigidity or deformity
Thalassaemia A hereditary disease resulting in severe anaemia in

children. Frequent blood transfusion is required;
children do not live upto adulthood.
Top soil The layer of soil which is rich in nutrients
Weathering The process of wearing down of a land mass by the

action of wind, living agents or chemical action.

EXERCISES
1) a) abiotic
b) biosphere
c) do
d) both living and non-living
2) Animals replenish carbon dioxide in the atmosphere used by plants for
photosynthesis, whereas inorganic chemicals are released from dead 229
Public Health animals on decay and are used by plants.
and Related
Issues Check Your Progress Exercise 2
1) About 2 to 5 million people lived throughout the world when agriculture
was first developed about 11,000 years ago.
2) The world population increased during the 9000 years from the
development of agriculture to 1 A.D. It was estimated to be 250 million
people.
3) By 1650 the world population had reached 500 million and by 1930 it
was 2000 million.
4) The population was more than 4000 billion people.
5) The death rate has been falling steadily because of better sanitation,
medical facilities like vaccination and medicine.
6) It may reach well over 6000 million people by 2000.

1) a) Need for wood to produce paper, building material and furniture.
b) Clearing of forests for agriculture.
c) Use of wood as fuel.
2) Renewable: forest, wild life and soil.
Non-renewable: fossil fuels, mineral deposits and water.
3) Due to increase in human population the renewable resources are
consumed at a much faster rate than can be replenished.
4) See section 24.3
5) Air pollutants - oxides of sulphur and nitrogen, carbon monoxide, carbon
dioxide, ozone, dust, etc.
6) Oxides of sulphur and nitrogen. Oxides of sulphur are released from
metallurgical processes during smelting of ores and oxides of nitrogen
are released from automobiles and the fertilizer industry.
7) a) Industrial effluents.— toxic metals and chemicals,heat.
b) Agricultural run off — pesticides and nitrates.
c) Domestic waste water — sewage and some toxic chemicals.
Diabetes, schizophrenia, asthma.
1) Diabetes, schizophrenia, asthma.
2) a) Dengue
b) Japanese encephalitis
c) Fluorosis.
230
Check Your Progress Exercise 5 Environmental
Protection
1) Pollution Prevention : Measures taken to safeguard environment from
possible damages by use of technology or other human activities.
Pollution Control: Use of devices or other means to stop further
damage to the environment or to repair the damage that has already
occurred.
Pollution prevention is beneficial because it involves waste
minimisation and waste utilisation by recycling. The money used for
the control of pollution is returned in the form of efficiency and
increase in production.
2) Refer to Section 24.2 to 24.4.

1) a) In industrial or domestic activities, considerable waste is generated.
Often this is due to inefficiency, carelessness or poor habits. We can
reduce expenditure (and increase profit in industry) by finding ways
and means whereby less waste is generated.
b) Waste recycling is one way of minimising “waste”. In this way, the
so- called waste becomes a resource which can be used in productive
ways. In other words, waste recycling is a form of utilising waste.
c) Wastage refers to generation of waste due to improper use.
Excessive levels of use of resources also indicates wastage, e.g.
using electricity or water when not required such as leaving lights on
or taps open.
2) a) Enviromental protection often involves conflict between making
money or promoting developmental activities and destroying the
environment. It is often more convenient to continue polluting the
environment for example rather than to install treatment plants or
other pollution control measures. Similarly, people may oppose
protection measures because this clashes with their livelihood, e.g.
opposition to a strict forest bill. So both economic and political
factors play a key role — the influence of personal greed and vested
interests cannot be
b) Answer based on your experience.
ANNEXURE 1
Arid A region deficient in rainfall, with rainfall barely

enough to sustain vegetation.
Asset Financial and physical items like land, machines,
etc., which are owned.
Command area Area which is under control, or at one’s disposal,
or within reach.
231
Public Health Coterminous Having the same boundary or extent or limits.
and Related
Issues Credit Loan, or the obtaining of goods on loan.
Ecologically Usually used for an area which is in an
disadvantaged unfavourable circumstance ecologically, that is, it
is not very fertile or easy to grow crops in, or has
little vegetation.
Economic growth The steady process by which the productive
capacity of the economy, and hence its income,
increases.
Gross irrigated The total land area over which artificial
area distribution of water takes place in order to
increase or help in crop cultivation.
Gross national The total value of all goods and services produced
product (GNP): within the economy plus the net income from
abroad accruing to domestic residents.
Jhum A method of shifting cultivation, where a plot of
land is cultivated for a few years, and when crop
declines because of reduced soil fertility and
effects of pests and weeds is abandoned for
another area where the ground is cleared for
cultivation by “slash and burn” methods, and the
procedure is repeated.
Microhabitat Very small dwelling like a hut.
Outlay Total money spent or set aside for expenditure.
Private Consumption by individuals.
consumption
Productive assests Assets which help to increase production and
hence income.
Redistribution Bringing about a change in the existing
distribution pattern.
Social Consumption by groups, or use of goods which
consumption are used by the public in general and not by single
individuals.
Social forestry Management, preservation and extension of
forests by groups such as villagers.
232

Block-6

Uploaded by

Copyright:

Available Formats

Block-6

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Block-6

Uploaded by

Copyright:

Available Formats

Skin, Eye And

Primary Health Care-I: Concept and Organisation 69

Environmental protection is another crucial area which influences health.

19.3 Primary Health Care

19.4 Let Us Sum Up

• define health and Primary Health Care, and

19.2 HEALTH AND RESPONSIBILITY FOR

Common Health Problems in India

Fig 19.1: Levels of Health Care

The conference ended with the following declaration:

Our government abides by this declaration. Based on this, a national health

• Improving Public Health Infrastructure

Check Your Progress Exercise 1

19.3 PRIMARY HEALTH CARE

A better health status of community can be achieved with the technical

Primary Health Care is an approach to achieve an acceptable level of health

Primary Health Care addresses to the main health problems in the

Since health cannot be attained by the health sector alone appropriate

Fig. 19.2 ; The Price of Health

Political commitment of Primary Health Care should also be forthcoming

19.3.1 Characteristics of Primary Health Care

i) It is essential health care which is based on practical scientifically sound

19.3.2 Primary Health Care and Development

As an example, the control of diseases by primary health care approach

Check Your Progress Exercise 2

19.4 LET US SUM UP

Community A group of people living in a defined geographical area.

Check Your Progress Exercise 1

Village health guide

iv) Increase in nursing personnel

Check Your Progress Exercise 2

20.3.2 Village Health Guide Scheme

20.3.3 Training of Village Dais

20.3.4 Accredited Social Health Activist (ASHA) scheme

20.4 Health Care Services at Different Levels

20.4.2 Sub-centre Level

20.4.3 PHC Level

20.4.4 Community Health Centres

20.4.5 Taluka Hospital

20.4.6 District Level

20.5 Status of Health Infrastructure in India

Subsequently, the health services organisation and infrastructure has

82 Fig. 202 : Primary Health Care Approach

Keeping in view various recommendations of different committees, the

20.3.1 Multipurpose Worker (MPW) Scheme

Under the multipurpose workers scheme, a health worker (male/female) is

Job Responsibility of Multi purpose Health Worker (Male)

20.3.2 Village Health Guide Scheme

Fig. 20.3 : Health Guide—a part time worker

A health guide is expected to cover the population of a village or if the village is a

Fig. 20.4: Health guide – working in a community

Job Functions Of Health Guide

20.3.3 Training of Village Dais

Job functions of trained dais _

Check Your Progress Exercise 1

Job Functions of ASHA

ASHA roles and responsibilities are as follows:

20.4 HEALTH CARE SERVICES AT DIFFERENT

Health care facilities/Health functionaries at different levels :

Village level VHG, Trained Dais