National Health Programmes

next time. The reason for high absence rates is seen in the lack of accountability of the public personnel (Devarajan/ Shah 2004: 911).

Figure 3.18: Absence Rates in Government Facilities

Lack of medicines and doctors, inadequate quality of service, and individual access and utilization barriers are responsible for the underutilization of public services in rural areas.

Public health policies and management have failed to address these issues. Insufficiency at the Ministry of Health (see above) affects all sub-national levels. Sub-national levels also do not appear to work effectively. The next section will look into the management and performance of National Health Programmes and into the status of primary health care in India.

Figure 3.19: Expenditure for National Health Programmes 2003-04

3.2.3.1. Family Welfare Programme

The Family Welfare Programme includes all other programmes concerned with reproductive and child health such as the ICDS Scheme. The Family Welfare Programme was adopted in India as early as 1951 under the name of Family Planning Programme. It was the first population control programme worldwide, introduced in the knowledge that rapid population growth poses a socio-economic problem for the country. The programme was renamed in 1974 and more components were included. Sterilization rates were abolished in 1996 under the target-free approach which became the Community Needs Assessment Approach (CNAA) in 1997 (Kishore 2002: 16). The motivation fee for sterilization was withdrawn. The CNAA envisions that the female MPW prepares an action plan for Sub-Centre which draws on the information collected through her household survey and discussions with other health workers, women groups and the panchayat. The data is compiled at the PHC and later at the CHC, which prepare their action plans accordingly. According to the achievements from the last year, the health staff has to accomplish 5 to 10 % higher rates for mother and child health services, antenatal care visits, and immunization (Ibid.: 20). This decentralized participatory planning strategy tries to involve community and opinion leaders in the formulation of decentralized family welfare and health care plans (MoHFW 2005: 124). The programme is supported through funds from United Nations Fund on Population Activities (UNFPA: Rs. 3.65 billion in 2003-2007), World Health Organization (WHO: US$ 505,000 in 2004-2005) and United States

Actual Expenditure for National Health Programmes 2003-04 (in Million Rupees)

49,2 61,3 102,4

251,9 500,9

864,3 1177,6

2001,6 2286,2

0 500 1000 1500 2000 2500 3000

National Mental Health Programme Drug De-addiction Programme including assistance to

States

National Iodine Deficiency Disorders Control Programme

National Cancer Control Programme including Tobacco Free Initiatives National Leprosy Eradication Programme National Blindness Control of Programme National Tuberculosis Control Programme National Vector Borne Disease Control Programme National AIDS Control Programme and National S.T.D.

Control Programme

Source: own design; data: Ministry of Health and Family Welfare 2005 [http://health.nic.in/CSS.htm]

Agency for International Development (USAID: US$ 325 million in 1992-2004) (Ibid.: 156).

Special programme components like the Border District Cluster Strategy for child health is sponsored by UNICEF releasing its funds directly to the states (Ibid.: 165). The World Bank has also given large loans through its population projects since 1972. During 1998-2003 US$ 248.3 million for reproductive and child health care and US$ 300 million for women and child development were granted (World Bank 1999: 7).

The goal of the Family Welfare Programme is the reduction of Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) and Crude Birth Rate (CBR). Higher coverage with antenatal and prenatal care services as well as higher immunization coverage, more institutional deliveries, higher female literacy, more services for scheduled castes and slums, and more eligible couples who use permanent or temporary contraceptive methods are the steps towards these goals (see Kishore 2002, MoHFW 2005). Although IMR, MMR and CBR sank throughout the last decades, the rates are still high (see 3.1.1.).

Inequalities in antenatal care services and immunization coverage prevail (see above).

3.2.3.2. Participation in the Family Welfare Programme

Non-governmental organizations (NGOs) are involved in several parts of the programme as are village community groups. In the Information, Education and Communication (IEC) Programme NGOs were used to sensitize, mobilise and involve elected representatives and the general public in reproductive and child health through workshops and newsletters (MoHFW 2005: 126, 170). The Mother NGO (MNGO) scheme introduced during the 9^th five year plan (1997-2002) is another important component of Public Private Partnership (PPP) within the Family Welfare Programme. Currently, 102 MNGOs receive grants from the government for the promotion of reproductive and child health (Ibid.: 173).

The MNGOs in turn issue grants to smaller Field NGOs (800 FNGOs) in 439 districts throughout the country, who exercise the mainly educational tasks according to the goals of the programme. Under the new NGO guidelines they are also supposed to complement and supplement public-private health care infrastructure in un-served and underserved areas (Ibid.: 175). MNGOs control and supervise FNGOs. While FNGOs are accountable to them, MNGOs have to report back to the government.

Another scheme is the Service NGO (SNGO) scheme, which will be implemented in un-served and underun-served areas. The SNGOs are supposed to deliver a variety of clinical and non-clinical services as an integrative package of reproductive and child health services (Ibid.: 174). Documentation and training activities are included in the non-clinical services. To carry out these services, SNGOs need appropriate staff (doctors, paramedical staff) and infrastructure (ambulance, hospital, clinic). Tamil Nadu and Karnataka also want NGOs to adopt PHCs.

The changes as envisioned under the revised NGO guidelines are as follows:

• “decentralization of the schemes to the state and district level;

• shift from exclusive IEC and awareness generation to service delivery;

• delivery of RCH services by NGOs in un-served and under served areas;

• clearly defined eligibility criteria for registration, experience, assets and jurisdiction;

• rationalization of the jurisdiction area serviced by the NGO to provide in depth service and optimize resources, mainstreaming gender issues in all intervention areas;

• enhanced male participation and involvement in delivery of all RCH services;

• emphasis on measurable qualitative and quantitative performance indicators;

• selection, approval, funding and monitoring of MNGO/SNGO projects by State and District RCH Committees.

• increased interface of NGOs with local government bodies.” (Ibid.: 173).

Community participation is tried through establishment of Mahila Swasthya Sangh (MSS).

The MSS are women groups in the villages, whose members are five grass-root level volunteers, ten prominent women from the community, the MPW female, and field level functionaries from the Education Department. Since 1990 79,512 MSS were established in the country, of which each receives Rs. 1,200 per year for conducting their monthly meetings (Ibid.: 169). Education and motivation of the community to participate in reproductive and child health programmes are the main tasks of MSS.

3.2.3.3. National Programmes for Communicable and Non-Communicable Diseases The National AIDS Control Programme was initiated in 1999 to reduce the spread of HIV/AIDS and to strengthen the response of the public system to the disease. In India 5.1 million people were infected with HIV in 2004 (NACO 2005). Although this is only 0.9 % of the adult general population, it means that India has an equal number of infected people like in South Africa, where the prevalence is 21.5 % (UNAIDS 2005: 9). Prevention, care and surveillance are the three dimensions of the programme. Treatment of sexually transmitted diseases (STD), awareness raising, voluntary counselling and testing, and condom programming are part of the preventive programme. The Gates Foundation supports the programme with US$ 200 million (Ibid.: 43). The World Bank group provided an interest free credit of US$ 191 million in 1999 (World Bank website). Other UN organizations and bilateral development agencies also support the programme. The Programme is carried out by the National Aids Control Organization (NACO) and its sub-national State Aids Control Societies. In the prevention programme 150 NGOs are involved.

Knowledge concerning the prevention of HIV grew. The programme managed to increase the condom use of commercial sex workers. The number of centres for voluntary testing and counselling increased to 628 in 2004 (MoHFW 2005: 43). However, HIV is still on the rise in India and awareness in rural areas is low.

The National Vector Borne Disease Programme encompasses the prevention and control of Malaria, Kala-Azar, Filaria, Japanese Encephalitis, and Dengue Fever (Kishore 2002:

98). Among them Malaria has the highest prevalence with 1.65 million cases in 2003, followed by Kala-Azar (17,321) and Dengue Fever (12,750) (MoHFW 2005: 23-28).

Strategies for Malaria prevention and control are early diagnosis and prompt treatment, integrated vector control through indoor residual spray, promotion of bednets, use of larvivorous fish, IEC and capacity building. The number of Malaria cases has fluctuated

between 2 and 3 million cases per year since 1984, a small decline can be noticed since 1997 (Ibid.: 23). Filaria is endemic in 20 states, “control strategies include vector control through anti larval operations, source reduction, detection and treatment of microfilaria carriers, morbidity management and IEC.” (Ibid.: 25). Indoor residual spray is also one main strategy against Kala-Azar and its vector the sand fly. Its elimination is envisaged for 2010. Reduction of vector density and personal protection against mosquito bites are the prevention measures for Japanese Encephalitis. The measures for Dengue Fever are similar, personal protection, source reduction and IEC are employed. The number of Dengue cases shows a stark increase from 1998 (707) to 2003 (12,750) (Ibid.: 28). Kalar-Azar cases also went up and Japanese Encephalitis did not significantly decline (MoHFW 2003: 189-190). Hence, the measures taken for prevention of vector-borne diseases have not been very successful.

The National Tuberculosis Control Programme does not receive as much funds as the AIDS or Vector Borne Disease Control Programme, although Tuberculosis kills more people in India than HIV, STD, Malaria, Leprosy, and tropical diseases combined (417,000 per year; Ibid.: 33). The programme tries to cure 85 % of all detected cases through Directly Observed Treatment, Short Course (DOTS) as recommended by WHO.

The programme is supported by World Bank, UK Department for International Development (DFID), Danish International Development Agency (DANIDA), USAID and Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) (Ibid.). The programme was able to reach nearly 76 % of population and to treat 2.8 million since its start in 1993.

However, Tuberculosis remains a serious threat with 2.2 million new cases every year of which 1 million are infectious smear positive pulmonary cases (GFATM website).

The National Blindness Control Programme exists since 1976. Prevalence of blindness was 1.1 % in 2001-2002 (MoHFW 2005: 35). The improvement of eye care services is the major programme component. Cataract surgeries steadily increased up to 3.9 million in 2002-2003. School eye screening was introduced and training and IEC activities implemented. The voluntary sector plays an important role in the establishment of District Blindness Control Societies, furthermore, 45 NGOs receive assistance under this programme. World Bank (US$ 85 million from 1994 to 2002), DANIDA and WHO assist the programme.

The National Leprosy Control Programme came into existence in 1955 (Kishore 2002:

133). Early detection and regular treatment with Multi-Drug Therapy are as important in the programme as public awareness campaigns to remove the social stigma associated with Leprosy. The prevalence of the disease has come down from 57.6 cases per 10,000 population in 1981 to only 2.3 cases MoHFW 2005: 29). Leprosy is eliminated in 16 states of India. The Leprosy elimination campaign was successful. The programme is supported by the World Bank, the International Federation of Leprosy Elimination, WHO and DANIDA. NGOs are involved in the programme and have helped to reduce the prevalence (Ibid.: 32).

The National Cancer Control Programme was established in 1975. Prevention of cancer through education, early detection and treatment as well as strengthening of institutions to improve therapy are modules of the programme. India currently has 150,000-200,000

cancer cases, 70,000 new cases come up every year (Ibid.: 44). Regional cancer centres and district cancer control programmes have been initiated with central funds. Health education through voluntary organizations is again a major focus of the programme.

The National Iodine Deficiency Disorder Programme assesses the magnitude of Iodine Deficiency, supplies iodated salt, and carries out IEC activities for prevention. The Drug De-addiction Programme and the National Mental Health Programme receive relatively small funds. Both programmes started in the 1980ies. Integration of mental health with primary health care, provision to tertiary care institutions, and eradicating stigmatization of mentally ill patients are steps taken under the National Mental Health Programme. District Mental Health Programmes, with a community based approach to the problem, began 1996 in four districts. The programme will be expanded to cover the entire country.

3.2.3.4. National Programmes Related to Health

The Basis Minimum Service Programme introduced in 1974 mainly focuses on “100 % coverage of provision of safe drinking water in rural and urban areas, elementary education and adult education; 100 % coverage of primary health services facilities in rural and urban areas; universalization of primary education; provision of public housing to all shelterless poor families; extension of midday meal programme in primary schools, to all rural blocks and urban slums and disadvantaged sections; provision of connectivity to all unconnected villages and habitants; and streamlining of the public distribution system with focus upon the poor.” (Kishore 2002: 231). The rural primary health care network has already been described in details above (see 3.2.1.3.). The status of India’s public services in view of access to drinking water, primary schools, health care, public transport and public distribution shows that the programme has not been successful so far (see 3.1.2.; Paul et al. 2004).

The National Water and Sanitation Programme was introduced in 1954 and aims at the protection of environment and health through management of water resources and solid waste. A community-based approach was adopted in 1990, trying to mobilise community and build their capacity as well as to enhance community share in capital investment, ownership and control (Kishore 2002: 237). Since the 73^rd Amendment of the Constitution of India (1992) PRIs have been involved in reviewing the implementation and management of drinking water sources. Private bodies and NGOs are engaged in the rural sanitation programme, focussing on low cost sanitation. In 2000 only 14 % of the rural population had access to safe sanitation (World Bank 2000: 2). The demand for sanitation among the rural population is low, it is difficult to convince them to built latrines.

The sanitation coverage has not risen significantly till today, it is 23.7 % (Ministry of Rural Development 2005).

The National Programme of Improved Chulha (cook stove) has the purpose to conserve fuelwood and to care for women’s health which is severely affected by indoor air pollution through traditional cooking habits with open fire. Access to electricity in rural India is 44 % (Chaurey et al. 2004: 1693), gas is not easily available and also costly, therefore, the use of fuelwood for cooking is widespread, especially among the poor.

The Integrated Rural Development Programme is one of the Poverty Alleviation Programmes. It can be perceived as an employment scheme, promoting self-employment as an additional income source and offering training programmes to unemployed or underemployed men and women in rural areas (Kishore 2002: 235).