TABLE OF CONTENTS
1.	Public Health - Primary Health Care Services
2.	Rural Primary Health Care Services
3.	Health Manpower in Rural Primary Health Care Institutions
4.	Urban Primary Health Care Services
5.	Tribal Areas
6.	Secondary Health Care
7.	Tertiary Health Care
8.	Suggestions for Improvement in the Functioning of Primary Health Care Infrastructure
9.	Statewise/Systemwise Number of Hospitals and Dispensaries
10.	RIES under Modern System and ASM&H
11.	Infrastruture providing Family Welfare Services
12.	Statement Showing Statewise Staff Position Under MAMP
13.	Position of Vertical Staff by March 2000
14.	CCH&PW
15.	Nutrition
16.	The National Population Policy 2000 envisages improvement in the Health and nutritional Status of Women and Children
17.	Nutritional Implication of Changing Food Production Patterns
18.	Food Production
19.	Prevention and Management of Chronic Energy Deficiency
20.	CED in Pregnant and Lactating Women
21.	Current Situation CED
22.	Ninth Plan Strategy
23.	CED in Pre-School Children
24.	Interstate Differences in Dietary Intake, Undernutrition and Infant Mortality
25.	Operational Strategy during the Ninth Plan to improve health and Nutritional Status of Pre-school Children
26.	Nutritional Component of the Integrated Child Development Scheme (ICDS)
27.	World Bank - GOI Review
28.	Suggestions made by GOI-WB Review Group
29.	Review of Funding of Nutritional Component of ICDS
30.	ICDS during 9th Plan
31.	Monitoring of ICDA Programme
32.	Emerging Nutritional Problem: Adolescent Nutrition
33.	Geriatric Nutrition
34.	Overeating and Obesity
35.	Micronutrient Deficiencies: Anaemia
36.	Ninth Plan Strategy
37.	Iodine Deficiency Disorders
38.	National Prophylaxis Programme against Nutritional Blindness
39.	National Nutrition Policy
40.	Summary and Recommendations: Health
41.	Nutrition
42.	Currently the Major Nutrition Related Public Health Problems are:
43.	Paradigm Shift Required
44.	Recommendations: Food Production and Distribution
45.	Public Distribution System
46.	Improving Maternal Nutrition
47.	Improving Child Nutrition
48.	Monitoring of Nutrition Status

PART II - PUBLIC HEALTH & NUTRITION

Primary Health Care Services

The primary health care infrastructure provides the first level of contact between the population and health care providers. Realising the importance of the primary health care infrastructure in delivery of health services, States, Centre and several agencies simultaneously started creating primary health care infrastructure and manpower. This has resulted in substantial amount of duplication of the infrastructure and manpower; inspite of this there are under served areas where the need for the health services is very great. The problem is mainly one of inequitable distribution of existing institutions and manpower as well as poor functional status due to:

Over and above all these there are the voluntary organizations and the private sector providing heath care.

The statewise information with regard to the government hospitals and dispensaries in modern system of medicine and ISM&H, rural primary health care infrastructure as well as the institutions being maintained by the Department of Family Welfare for providing family welfare services is given at Annexure-I.

It is important to take into account all these before estimating the gaps in infrastructure and manpower. It is possible to achieve substantial improvement in coverage and quality of health services by appropriately restructuring the existing infrastructure making them responsible for health care for the population in a defined in geographic area. Similarly substantial proportion of the manpower problems can be sorted out by appropriate reorientation and re-deployment of existing manpower.

Rural Primary Health Care Services

At the national level the total number of functional Sub centres and the PHCs nearly meets the set norms (one sub-centre for 3000-5000 population, one Primary Health Centre for 20,000-30,000 population) for the population in 1991. The requirement of primary health care infrastructure (as of 1991 population) and the current status of primary health care infrastructure and manpower in rural areas is given in Table I.

Even though a vast infrastructure has been created, it is functioning sub-optimally. The factors responsible for the sub-optimal functioning of rural Primary Health Care Institutions are:

In spite of the fact that the norms for creation of infrastructure and manpower are similar throughout the country, there are substantial differences between States and between districts in the same state in the availability and utilization of health care services and health indices of the population. Attempts are being made to minimise these gaps. It is a matter of concern that many of the districts with poor health indices do not have adequate health infrastructure.

In addition to the classical PHC, States have a large no. of rural hospitals and dispensaries in modem system of medicine and ISM&H. In addition to CHCs there are block level PHCs, Taluk Hospitals, Sub Divisional Hospitals & Sub District Post Partum Centres. Earmarked funds under BMS could be utilized for completing the restructuring and strengthening of these hospitals/dispensaries. Several states have initiated action to improve access to primary health care services. Some of the ongoing initiatives to improve access to Primary Health Care include:

Currently, in addition to funding through the earmarked basic minimum services in the State Plan Budget, funding from Additional Central Assistance under PMGY externally assisted projects for strengthening health infrastructure and centrally sponsored programmes in Health and Family Welfare provide funding for strengthening infrastructure, covering critical gaps in manpower, equipment, consumable and drugs. Under PMGY, an allocation of Rs.2500 crores has been provided to the States for 5 sectors comprising primary health, primary education, shelter, drinking water and nutrition. A minimum of 15% of this allocation is to be spent by the States on each of the five sectors. However, the states do have the flexibility to determine the utilization of the remaining 25% of funds. Funds from PMGY under primary health care may be utilized for strengthening of existing and functioning primary health care institutions (50%) by procurement of drugs and essential consumables and contingency for travel costs for ANMs, repair of essential equipment, repair/replacement of furniture and 50% for strengthening repair and maintenance of infrastructure in sub-centre, PHC and CHC (priority will be given to ensure portable water supply, adequate toilet facilities and waste management).

Poor maintenance and consequent deterioration of the buildings and equipment has been a major factor responsible for sub-optimal functioning. Many States are unable to provide funds for these critical activities from the Non Plan funds. Under the Reproductive and Child Health Care Programme, Rs. 10 lakh per district has been released to the States for minor repair and maintenance of buildings, especially for operation theatre, labour rooms and for improvements in water and electric supply. Rs. 10 lakh per CHC/district hospital is also released to all States for major civil works to improve facilities for essential obstetric services through construction/repair of operation theatre, labour rooms or to provide/improve facilities for water/electric supply in PHCs, CHCs & district hospitals. A total of Rs. 49 crores for minor civil works and Rs. 21 crores has been released in the Ninth Plan upto 1998-99.

Health Manpower in Rural Primary Health Care Institutions

The number of PHC doctors at the national level exceeds the requirement as per the norms. However, there are marked differences in their distribution. The PHCs without doctors and paraprofessionals are mostly located in remote areas where health care facilities provided by the voluntary or private sector is also limited. Some of the innovative approaches to fill the vacancies in under-served areas currently being tried in some States include local recruitment of doctors, if necessary on part-time basis; adoption of a village/PHC/district by industrial establishments, cooperatives, self-help groups and charitable institutions; permitting local practitioners to pay a rental and practice in the PHCs after OPD hours. The usefulness of these approaches is being assessed. Substantial proportion of specialist posts even in functional CHCs are vacant, hence these CHCs are unable to function as First Referral Units (FRUs). It is necessary to ensure that specialists are available in the CHCs so that referral patients and those requiring emergency care receive the treatment they need. There are gaps in some of the critical para professional personnel such as the lab technicians and male multi purpose workers. Efforts are under way to provide the required posts of lab technicians under various CSS to fill the gap within this plan period. The number of sanctioned posts of male multi-purpose workers is only half the number required. This has been cited as one of the major factors responsible for the sub-optimal performance in health sector programmes. There are large numbers of male-workers employed in the malaria, leprosy and TB Control programmes. They have to be given appropriate retraining and skill upgradation, redeployment as male multipurpose workers and given the responsibility of looking after all health and family welfare programmes in their sub-centre area. Funds for these activities are available under States Annual Plan Health Sector Basic Minimum Services (BMS) Outlays, for BMS and Externally Aided Projects; some of the states have state specific Externally Assisted Projects to improve primary health care infrastructure/manpower.

Urban Primary Health Care Services

Nearly 30% of India's population lives in urban areas. There is either non - availability or substantial under utilization of available primary care facilities along with an over-crowding at secondary and tertiary care centres. There is a plethora of personnel and beds in public, private, voluntary agencies but these are not geographically linked with clear assignment of responsibilities or referral linkages. The innate difficulty in restructuring of infrastructure is that there are multiple funding agencies.

Nagar Palikas, State Govts., Central Ministries and EAPs provide funding for building upgradation and re-structuring urban primary health care infrastructure and establishing effective linkages. Earmarked funds under BMS and the ACA for BMS, funds from the urban RCH project and from urban component of IPP project can be utilized for the development of urban primary health care. Planning Commission has provided an ACA of Rs. 1.5 crores for strengthening of urban health care services in Municipal Council, Malgaon, Nasik district, Maharashtra in Annual Plan 1999-2000. Though there are several small success stories, the progress in the overall task of restructuring, reorganising the urban primary health care linked to secondary and tertiary care and appropriate retraining and redeployment of personnel has been very slow.

Tribal Areas

The population coverage norms for primary health care institutions is 1 PHC per 20,000 population, 1 SC for 3000 population in hilly/tribal areas as against 1 PHC per 30,000 population and 1 SC for 5000 population for the general rural population, in view of distances and sparse population. There are at present 20,799 SCs, 3,306 PHCs and 469 CHCs in tribal areas in addition there are 1122 Allopathic dispensaries, 120 Allopathic hospitals, 78 Allopathic mobile clinics, 1106 Ayurvedic dispensaries, 24 Ayurvedic hospitals, 251 Homeopathic dispensaries, 28 Homeopathic hospitals, 42 Unani dispensaries, 7 Siddha dispensaries functioning in tribal areas. Similarly, 16,845 SCs, 5987 PHCs & 373 CHCs have been established in Scheduled Caste Basties/Villages having 20% or more SC population; another 980 Allopathic dispensaries, 1042 Ayurvedic dispensaries, 480 Homeopathic dispensaries and 68 Unani/Siddha dispensaries are functioning in schedule caste concentrated areas.

Most of the Centrally Sponsored Disease Control Programmes have a focus on tribal areas. Under the NAMP 100 identified districts that are predominantly tribal in Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa & Rajasthan are covered.

Several states have had successful experiments in improving primary health care to Tribals:

The problems with such experiments are that the:

A new scheme titled Medical Care for Remote and Marginalised Tribal and Nomadic Communities has been initiated in the Ninth Plan. Under this scheme, a research project on 'Intervention Programme for Nutritional Anemia and Haemoglobinopathies amongst some primitive tribal population of India' has been initiated by ICMR.

Secondary Health Care

The secondary health care infrastructure at the district hospitals and urban hospitals are currently taking care of the primary health care needs of the population in the city/town in which it is located and also act as secondary care centres; this inevitably leads to overcrowding and under utilization of the specialized services.

Strengthening secondary health care services is an identified priority in the Ninth Plan. In addition to the provision of funds from State Plan several States have been seeking External Assistance to build up FRU/District Hospitals. So far six states have initiated such projects with external assistance from World Bank. The States have initiated construction works, procurement of equipments increased availability of ambulances, drugs; improvement in services following training to improve skills in clinical management, attitudes and behaviour of health care providers reduction in vacancies and mismatches in health personnel/infrastructure and improvement in Hospital Waste Management, disease surveillance and response system have been reported.

All the six States have attempted introduction of user charges for diagnostics and therapeutics from people above the poverty line. Initial problems have been sorted out. Some States are still unable to ensure retention of collected charges in the same institute. This problem need be speedily resolved.

Tertiary Health Care

Majority of the tertiary care institutions in the governmental sector lack adequate manpower and facilities to meet the rapidly growing demand for increasingly complex diagnostic and therapeutic modalities. On the other hand, there is overcrowding in tertiary care hospitals due to a lack of a referral system from primary and secondary care levels. There is a need to optimize facilities in the tertiary care centres. The Ninth Plan priorities for tertiary care centres includes provision of funds for capacity building levying user changes to people above poverty line and exploring alternative modalities to meet the growing cost of care.

Several States (e.g. Rajasthan, UP) are trying out innovative schemes to give greater autonomy to these institutions, allowing them to generate resources and utilise them effectively. Some States e.g. Rajasthan and Kerala have been levying user charges and attempting to utilise the funds to improve hospital services.

Suggestions for Improvement in the Functioning of Primary Health Care Infrastucture

There is adequate primary health care infrastructure in rural areas. In order to improve the primary health care services, it is important that:

No new infrastructure needs to be created and only existing infrastructure should be strengthened and operationalised. The access to primary health care should be improved and quality of primary health care in urban and rural areas should be enhanced through optimally functioning primary health care system. The following measures are suggested which would help in optimal and efficient functioning of the existing primary health care infrastructure:

The PHCs should function as curative care centres and also provide preventive and promotive health care services. CHCs with 25-30 beds should provide back up curative, referral and inpatient facilities. Specialists from CHCs/ FRUs should visit to PHCs on specified days. Non-overlapping geographical areas should be earmarked for provision of services by PHCs/CHCs/Taluk Hospitals. Civil Surgeons/District Hospital In-charge should be made responsible for developing referral linkages between PHCs/CHCs/Taluk Hospitals functioning in the area.

Availability of medical and para-medical manpower should be improved through contractual appointment of doctors/ para-professionals. Anaestheist should be appointed at FRUs/CHCs on contractual basis.

States must be provided earmarked funding under health sector allocations in Annual Plan proposals for primary health care services under Rural/urban areas. There is a need to have state specific strategies and within the states district specific strategies especially for backward areas. Over and above the national norms for establishment of infrastructure for providing basic health care facilities the state governments should formulate separate policy/ strategy/ demographic norms for establishment of the infrastructure in the backward areas depending upon their specific requirements.

A number of states have started implementing the Secondary Health System Project for strengthening of the health care infrastructure at the district level. There is an urgent need for making the health care institutions at district level to be self sustainable so that these institutions are able to function in a financially independent way and are also able to provide good quality health care facilities. There is also a need to define the role of public sector hospitals. The district level hospitals and other institutions providing referral back-up need to be restructured and the state governments may be given flexibility to evolve their own strategies for making these institutions self- sustainable. The States must introduce user charges for the persons who can afford to pay.

The district should have specialists in epidemiology/ public health/bio-statistics so that monitoring of ongoing health/family welfare programmes through Health Management Information System (HMIS), ensuring appropriate supplies, disease surveillance and responding to the immediate requirements become insult in the public health system. Wherever epidemiologists are not available, the existing clinical specialists should be trained in public health and epidemiology. Planning Commission has provided an additional central assistance for development of a self - sustainable district hospital model and the progress in this effort will be monitored.

Suitable programmes under Continuing Medical Education (CME) should be planned for the professional/paraprofessional in public/private/voluntary sector so as to keep them abreast with the latest developments in the field. Suitable policy needs to be developed for the rational use of drugs and the use of only the generic drugs so that cost of drugs becomes affordable.

Connectivity of villages with the villages having primary health care facilities should be improved utilizing funds available under PMGY.

ISM&H institutions in rural/remote areas to provide preventive/ promotive services and also health counseling.

A cadre of mid-wife may be formed for better management of maternal and child health activities in the rural areas.

Nutrition

At the time of Independence the country faced two major nutritional problems - one was the threat of famine and acute starvation due to low agricultural production and lack of appropriate food distribution system. The other was chronic energy deficiency due to poverty, low-literacy, poor access to safe-drinking water, sanitation and health care; these factors led to wide spread prevalence of infections and ill health in children and adults. Kwashiorkor, marasmus, goitre, beriberi, blindness due to Vitamin-A deficiency and anaemia were major public health problems. The country adopted multi - sectoral, multi-pronged strategy to combat the major nutritional problems and to improve nutritional status of the population.

During the last 50 years considerable progress has been achieved. Famines no longer stalk the country. There has been substantial reduction in moderate and severe under nutrition in children and some improvement in nutritional status of all segments of population. Kwashiorkor, marasmus, pellagra, lathyrism, beriberi and blindness due to severe Vitamin-A deficiency have become rare. While much of this change is attributable to improvement in dietary intake, sometimes the changes were unforeseen and incidental to ongoing developmental processes. However, it is a matter of concern that milder forms of chronic energy deficiency and micronutrient deficiencies continue to be widely prevalent in adults and children. The last three decades have witnessed emergence of newer nutritional problems. Unforeseen factors, unleashed by developmental process have brought about changes in environment and dramatic changes in epidemiology of nutrition related disease such as flurosis. There had been major alterations in the life styles and dietary intake especially among urban middle and upper income group population resulting in increasing incidence of obesity in adolescents and adults and increasing risk of non- communicable diseases; under nutrition associated with HIV /AIDS is emerging as a newer public health problem.

The National Population Policy 2000 envisages improvement in the Health and nutritional status of women and children through :