CHADHA

COMMITTEE

REPORT

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 I. INTRODUCTION
Malaria had till recently boon the first in the list of injury to the
community in India and in several other parts of the world. The anti-malaria
measures in the pre-DDT era consisted mostly of ant larval measures and
drainage schemes. On account of the extensive areas to be covered and very
heavy Costs involved, it had not been feasible to extend these operations to
rural areas. They were necessarily limited to a few urban areas only. The first
breakthrough for rural malaria control came when DDT proved its value that
malaria control could be brought within the economic feasibility of a
developing country.

Malaria eradication operates in four phases: the Preparatory, Attack.

Consolidation and Maintenance. A special organization is established for the
first three phases, while the activities under the maintenance phase are the
responsibility of the general health organization of a country. Under the Indian
programme, the preparatory phase was oriented 'because of the experience
gathered during a period' of 5 years when a nation-wide control programme
had been operative in the country from 1953 to1957. The special organization
for malaria eradication came into existence both at the Centre and the states
from 1958. The campaign has been operative for over 5 years and 228.3 units*
concerning about 251.5 million population, have completed' the task under
the Attack phase, are in the consolidation phase in 1963.

Some of the units that had entered consolidation phase in 1962 are
becoming ready to enter the final stage, the maintenance phase from next
year. Areas in various States will enter this phase by stages. Since the
activities under the maintenance phase will be the responsibility of the general
health organization in the country, it is necessary that the States be prepared
to take over such activities as and when the units are ready to enter the
maintenance phase.

It must be stressed that malaria eradication alone is not sufficient;

the gains achieved must be sustained. Before any unit is demobilized arid the
programme enters .the maintenance phase, it is necessary to ensure that
suitable machinery exists for vigilance services to prevent the resurgence, of
malaria. This requires certain preparation, administrative and technical. It is
also important to unsure correct procedures to be adopted to suit local
conditions.

It is therefore necessary (i) to study-not only the present position

regarding the malaria eradication-operation -but also the maturity of the
health organization to take over such activities as are required during the
maintenance phasg5 (ii) to assess measures necessary to ensure smooth
running of the vigilance services subsequent to the demobilization of the
special organization Established for eradication of the disease; and (iii) to
formulate plans for the maintenance phase.

* One-unit was designed to cover a population of about

1 million. However, "owing to the increase in population,
l Unit covers about 1.12 million population.

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 These points-were fully appreciated by malaria workers in the
country as early as June, 1962 when for the first time it was envisaged that
about 70to80 million population area should normally be ready to enter the
maintenance phase in 1964.

The Conference of State malariologists hold at Simla on 18th to 20th

June 1962 recommended that a sub-committee should.
1) review the rural health facilities,
2) apportion the priorities for establishment of rural health centers
in those unit areas which 5arcT likely to enter-the maintenance phase,
3) consider the requirement of additional staff for the rural
organization for vigilance operation under, the maintenance phase, and
4) consider the manner in which the staff of the N.M.S.P should be
deployed including the orientation1of-the personnel required for other public
health activities.

On the basis of the recommendation a Sub-Committee consisting of health

administrators and malariologists, formed by the Government of the India met
under the Chairmanship of the Director General of Health Services on the 3rd
and 4th September 1962. The Sub-Committee reviewed the National Hairy
Eradication Programme and recommended that a special committee should
study in detail the preparations that are to be made for the entry-into the
maintenance phase and formulate a plan. The Special Committee was
constituted, by, the Government of India under the, Ministry of Health letter
Nb.F.l-22/62-Instt., dated the 10th April, 1963. The term of reference-were:-
(l) The committee should go into the details of the requirement
related to the primary health centers, their .planning, the
necessary priority required according to the needs of the
maintenance phase of the Malaria Eradication Programme;
(2) The Committee should also consider the, Staffing, pattern
required for the primary he alt be centers not only for the malaria
eradication programme, but also for other health activities and
the, manner in which the technical and supervisory staff of the
N.M.E.P. Organization should be utilized after. Malaria ordination
has been achieved.
The committee was constituted of:-
1. The Director General of Health Services ,Chairman
2. The Director of-Health Services, Bihar.
3. The Director of Health Services, Kerala.
4. The Director of Medical Services, Madras.
5. The Director of Public Health Madras.
6. The Director of Public Health, Mysore-

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 7. The Director of Medical and Health Services, U.P.
8. A representative of the Union Ministry of Health.
9. A representative of the Directorate General of Health Services.
10. Chief, Health Division, Planning commission.
11. Dr. P. Dutt, Asstt. Director General of Health Services, Secretary.

The Special Committee held its first meeting on 16.4.63, the second
meeting on 3.8.1963 and the third meeting on 21st and 22nd November, 1963
at New Delhi under the chairmanship of the Director General of Health
Services. The Committee invited Regional Director World Health Organisation
South East Asia Regional Office; Director, National Institute of Communicable
Diseases; Director, National Malaria Eradication programme; Chief Health
Division, United States Agency for International Development, Adviser, Health,
Ford Foundation; Adviser, Health Ministry Community Development and Co-
operation, Director, Family Planning to participate in the deliberations. The
Secretary drew up a list of basic Kerala, Madras, Mysore and Uttar Pradesh
and made personal observations in the field on the existing facilities for the
vigilance operations and discussed with various health authorities and
workers. He also visited Bombay City to observe the working of surveillance
operations.

The interim report was placed before the Central Council of Health
during its eleventh session at Madras on 5-7th November, 1963. As
recommended by the Council, the Health Secretaries of the States of Kerala,
Mysore, Madras, Maharashtra, Uttar Pradesh, Punjab and Bihar and Director
of Public Health, Maharashtra and Director of Health Services, Punjab were
also invited to consider and finalise the report during the third meeting.

List of participants is at appendix 15.

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 II SUMMARY

Malaria, till recently, had been the greatest handicap to the

socioeconomic, development of the country. The only known methods of
control viz., anti-larval and drainage schemes were Expensive and as such it
had not been possible to include in the pre-DDT period the rural India in any
large scale control programme. The main activities had to be restricted in
certain, urban, areas. By 1952 DDT provided protection to about 8% of the
population at risk. The National Malaria Control Programme commenced in
1958 as a joint Indo-American co-operative effort, contemplating a progressive
has phasing starting from 84 endemic units to reach 200 units in 5 years
towards the end of 1957-58.
Meanwhile, malaria control programme undertaken in several
countries using DDT as a residual insecticide brought two technical points
into focus
(1) The possibility of fortuitous eradication of the disease even in
countries where such an aim was not in specifically planned in the first
Instance; and
(2) Precipitation of resistance in the mosquitoes to insecticides.

The risk of resistance urged countries to plan eradication which has

been shown to be possible before the resistance developed in malaria-carrying
mosquitoes. The newer concept of total eradication of the disease grew as a
result of impact of world opinion channeled through accredited International
Organizations like the W.H.O. and U.S. Agency’ for International Development.
In i95& £he Indian programme changed its objective from control’ to
eradication. In 1962 after 4 years of activities, 140.47 units entered the
consolidation phase and another 87.83 more units in 1963.

The preparation for entry into the maintenance phase has been
under Consideration since 19§2. A Sub-Committee formed by the Government
of India under the Chairmanship of the Director General of Health Services,
meeting on the 3rd and 4th September 1962, give consideration, to-
(a) the absorption of the activities of the maintenance
phase into the general health services; '
(b) Strengthening of the basic rural health services and
(c) training of personnel engaged in specialized mass campaigns to
become multi-purpose workers to that they can continue to
follow up the measures required for the maintenance phase as a
part of the routine health activities.

On the basis of the recommendations of the Subcommittee a Special

Committee was constituted in April 1963 under the chairmanship of Director
General of Health Services, The Committee met thrice. It considered that the
maintenance is the responsibility of the general health services, which should
be adequately strengthened, particularly the rural health services.

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 As the malaria eradication programme advanced towards
consolidation and maintenance, it become clear that eradication cannot be
sustained without the support of the general health services, capable of taking
over the entire responsibility for vigilance, during the maintenance phase.

This was realized in 1960 when the W.H.0. Recommended as an

essential requisite during the pre-eradication activations, the development of
rural health infra-structures which will ultimately take over the responsibility
for vigilance Phase.

Unless malaria has been eradicated from the world the risk of re-
establishment of malaria is far too great. Failure in Consolidation of
eradication will be disastrous to the country in general and to the health
organization in particular.

The health services in the areas entering the maintenance phase will
have to be suitably augmented to meet the needs for vigilance for sustaining
eradication. What is of utmost importance in the vigilance is the total coverage
of the population. It is thus necessary to consider not only the distribution’
and the number of the ‘static dispensaries, 'health centers, etc. but also what
proportion, of the population is at present, utilizing these facilities. In the
rural areas, except for the population within a radius of is to 2 miles from a
health centre, people generally seek treatment only for painful conditions and
ailments. That keeps them off from work. Even then, representation by friends
and relatives at health; centers, is high. It is therefore imperative that in
addition to, the: establishment of the rural health centers dispensaries and
hospitals me form of multipurpose domiciliary health service is necessary as
an intrinsic part of the basic health services to absurd total coverage such a-
domiciliary service will form the basic not only for integrating- other mass
campaigns such as smallpox’ eradication in their maintenance phase into the
general also, for undertaking newer health programmes. This will be an
investment towards building of rural health services particularly for
sustaining mass programmes It is also necessary to comply with those basic
needs of vigilance, viz.
(1) Prompt detection, radical treatment of parasite carriers and their
follow-up.
(2) Epidemiological, investigation; of positive cases and measures to
eliminate foci, and

(3) periodic review of the status of ordination and the adequacy of the
vigilance, system.

The recommendations of the Committee are:

(l) Vigilance-through medical institutions must be developed to the
fullest extent. All medical institutions Government or non-government, private
medical practitioners, irrespective of the system of medicine they practice and
all professional and other health workers should be harmessed,

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The members of panchayats, block development committees, mahila mandal
youth clubs, other voluntary agencies, to teachers, etc. should participate and
efforts should be so made that every village, hamlet or locality has one
'Voluntary collaborator;
(2) All efforts should be made to establish primary health centers
provided for in the current plan period particularly in the areas entering the
maintenance phase. The States that have a plan, programme for establishing
a certain number of midwifery or maternity and child health centers every
year should give priority to their establishment in the areas, deficient of
adequate medical coverage.
(3) In urban areas, institutional case detection should be the
mainstay. The major medical institutions with heavy out-patient attendance
should have a person specially detailed to take clinical samples including
blood smears.
These institutions should have a separate clinical side-room.
Additional staff will be required for -
(a) activation of institutional case detection,
(b) domiciliary case detection, in slum areas including collection of
blood smears and dispatch to laboratories, and
(c) Special investigation of foci.
(4) In rural areas owing to incomplete and uneven coverage by
medical institutions and liberal representation by proxy at primary health
centers and dispensaries, there should be facilities for detection of fever cases
and for taking blood smears from all suspected malaria and inadequately
explained fever cases through domiciliary services.
(5) Domiciliary services should be developed for all health
programmes including malaria, smallpox, control of other communicable
diseases, health education, etc.
(6) The basic service unit should cover not more than 5000
population. However, owing to limitations of financial and material resources
at present the basic service unit should cover about 10,000 populations. This’
may form a sub-centre of a primary health Centre. The number of such sub-
centers will naturally vary depending on the population and area covered by a
health centre.
(7) It should be staffed by a midwife or auxiliary nurses midwife and
a health assistant or auxiliary health worker. There should be a midwife or
auxiliary nurse mid-wife for every, 5,000 population. However, in view of the
limited number available, as an interim measure, only one is recommended
for entry 10,000 population. The staff required over and above that approved
in the family Planning Programme should be provided by the general health
services.
(8) The Extension Educator (Family Planning) should be, utilized in
strengthening education aspects of all programmes.

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 (9) The existing one Sanitary Inspector at the block level is very
inadequate. Although we should have one Sanitary Health inspector for10,000
populations, this may not be feasible at present. "In addition to the existing
one at the block level, there should be at least one Sanitary Health, Inspector,
for, 20,000‐25,000 population. He will provide supervision to all health activities
including domiciliary services. The senior-most of them may be designated as
Senior Sanitary/Health Inspector.
(10) Each primary health centre should have a microscope and
laboratory technician who shall conduct all simple laboratory examinations
giving particular attention to examination of blood smears for malaria
parasites. In the block whore there is no primary health centre, a suitable
dispensary may be, selected to have the facilities of a microscope and a
laboratory technician until such time a primary health centre is established.
(11) Wherever possible, there should be an extra-medical officer for a
Primary Health Centre.
(12) At the district level-there should be, in addition to the District
Health Officer another medical Officer trained in malaria. He will be in charge
of general epidemiology but during who next two to three years he should
concentrate mainly on malaria. He should be assisted by a reasonable number
of Health Supervisors approximately on the ratio of one- per six or seven
blocks.
(13) Existing State Regional or Division Health Officers should be
strengthened by a officer trained' in epidemiology and malaria. In the States
not having regional offices, the existing zonal level National Malaria
Eradication offices should be converted into regional offices.
(14) State levels: A state Malaria Officer preferably of the rank of
Deputy Director is required for overall guidance and supervision. He should
continue for at least two years after the entire state has entered the
maintenance Phase. Afterwards he will be in charge of control of
Communicable diseases including malaria. The State Malaria laboratory
should be merged into the State Public Health laboratory so that every Public
Health laboratory has a malaria section. The laboratory at the State level
should have at least one-medical officer for epidemiological work, one
entomologist, 2or3 entomological assistants and a number of microscopists for
undertaking-.special investigation and 'serve as’ the Central Intelligence
Bureau, for malaria in the State.
(15) Laboratory- services:- Facilities should be provided at each
district, headquarter hospital or district laboratory for examination of blood
smears which should be kept a separate entity under the direct supervision of
the assistant District-Health Officer for a period of two to three years. A
senior-laboratory technician should supervise the work of laboratory
technicians at lower levels.

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 (16) Central Levels The Regional Coordinating Organizations should
continue to provide inter-state coordination technical guidance, assistance, in
training and laboratory services. After the eradication has been achieved,
those organizations should be de-eloped into the regional offices of the
Directorate General of Health Services.

The Central organization of the National Malaria Eradication

Programme on a modified scale should be retained for least 2to8 years after
the eradication has been achieved ever the whole country.
(17) Logistics: Equipment and stores should remain at the district
level under the direct control of the District Health Officer. However, a few
sprayers and 9 small quantity of DDT should be kept at lower level.
(18) Transports: Transport- will be required for each:

State Malaria Officer …1

Regional Officer …1
District Health Officer …1
Assistant District Health Officer …1
Health Supervisors …1 each

The Senior- Health/Sanitary Inspector who will provide supervision in

the Block area should have an easy and quick means of independent
transport. A cycle is a must with suitable cycle allowance. A health inspector
and a health worker should be provided with a .cycle or at least provided with
adequate allowance to maintain a cycle.
(19) There should be a direct line of command from the State Health
Directorate downwards.
(20) Utilisation of the N.M.E.P staffs: National Malaria Eradicate on
programme staff, who will be available for re-employment have wide
experience in the field. They should, be utilised with necessary training
wherever re quirt in filling up the posts on a priority basis in the various
health and medical programmes.
(21) The training will be required for two broad categories of
personnel (a) the existing health personnel and (b) N.M.E.P. staff.
(a) Existing health personnel may be given a short .orientation for
about a week' in malaria.
(b) N.M.E.P. staff* Two types of training, short orientation and long
courses, are recommended. The personnel have wide, experience in the field
particularly in respect of the approach to the people and in basic down-to-the-
earth health education methods. Job Orientation in the programmes, current
at the moment, will make them suitable to undertake the responsibility under
proper supervision. Further orientation may be given as new programmes are
undertaken.

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 Facilities should also be provided every year for longer regular courses
as health inspectors, laboratory technicians, health Assistants, etc. for a
certain proportion of the workers.
The Central and State Governments should provide immediate
facilities for various types of training, short and long courses, in various
subjects so that we are ready to undertake the maintenance phase as soon as
the units are ready.
(22) Notifications:-Though notification for other diseases has not
worked satisfactorily' a beginning must be made for malaria at the
Commencement of the maintenance phase.
(23) Vulnerable areas and groups vulnerable areas and groups
should be delineated and strict vigilance observed.
(24) Other anti-malaria (mosquito) measures): Antimosquito
measures in urban areas, and in connection with roads, railways, bridges and
other Construction works should be strengthened.
(25) Each state should work-out in details
(1) the staff required.
(2) the number of persons in various, categories requiring further
orientation and training,
(3) existing facilities for training and further facilities required, and
(4) estimated expenditure including, how much State Governments
can bear.
(26) The committee was of the opinion that the extra expenditure
consequent on the augmentation of the Staff of the general, health services for
supposes of vigilance in the maintenance phase should be borne by the
Central Government and that assistance should be Outside the State Plan
ceiling.

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 III. THE MAINTENANCE PHASE

1. After malaria has been eradicated from country or its part, stops
must be taken to prevent its resurgence and maintain the’ area free from
malaria. This could only be done by vigilance and other measures, as in their
absence, the risk of re‐establishment of malaria is far too great and efforts and
heavy expenditure hither to hitherto incurred would be rendered totally in
fructuous. Failure in consolidating the gains will be expensive in terms of
money and costly to the health organization in terms of loss of prestige and
public confidence.
2. There is nothing new in this concept anything achieved in any field
has to be maintained. Perhaps the world maintenance. Perhaps as a part of
the malaria eradication programme is a misnomer as the maintenance of
freedom for malaria is a function of a malaria eradication programme
However, it is considered as one of the phases of the programme because the
maintenance of eradication is a conditioning qua non not only for stating but
even planning an eradication programme.
3. Maintenance is a state of continuous vigilance. Its purpose is to
maintain the malaria-free status of the areas from which malaria has been
eradicated. It's objectives remedial measures.
4. Since the possibility of recurrence of malaria cases will exist so long
as malaria is present within some parts of a State country or the world,
vigilance will be an essential activity to prevent importation or reintroduction
of the disease.
5. While certain technical and administrative criteria are required to be
fulfilled before an area could be permitted to enter from the consolidation to
the maintenance has, certification of malaria eradication through world Health
Organization could be sought at any time after an area has entered the
maintenance phase, provided that the area involved is not less than 50, 000
sq. kilo-meters or 20.000 sq. miles forming a complete block and that eradi-
cation is maintained-. V/.H.0. Lists the country or a part thereof in the official
Register. This is in accordance with the resolution passed in the Thirteenth
World Health Assembly., 1960. I

For the registration, it is necessary that the criteriarea fulfilled

(Appendix I). The criteria for confirmation of malaria eradication are based on
technical-and administrative, considerations. The administrative criteria
relate‐ to the maturity, ability and competence of the health organization to
underrate vigilance. Health services need facilities and personnel for the ready
detection of malaria cases, examination of blood smears, capacity and
competence t o organize epidemiological investigations and to deal effectively
and speedily with any importation of cases or re-establishment of
transmission. The special task force created for eradication has ultimately to be
abolished in the maintenance phase and the personnel utilized as far as
possible for the general health services.

I Thirteenth W.H.O Assembly Resolution No. 13,35, 1960.

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6. The risk during the maintenance phase is from an imported case. It
becomes important, therefore, to prevent the establishment of malaria in the
eradicated areas through any case (cases) that may be imported. It arrears
that the danger of re-introduction of malaria into the eradicated areas has not
yet been fully realized in many quarters.
7. Ideally, the best protection against re-introduction of a disease in a
country is to make it insusceptible to infection s o that even if a disease is
introduced, it cannot take root in the community The risks, consequent on any
imported case of malaria are different from these of smallpox or plague. The
introduction o case of smallpox in population protected by vaccination or
introduction of a case of bubonic plague in an environment where rodent and
please are under control is less dangerous than introducing a potent sources
of malaria infection in an area where Vectors are present, the season favorable
and potential reproduction rate high.

8. Activities.
8.1. The role of general health services in Malaria eradication has, in the
recent past, been over-shadowed by the massive malaria eradication
organization. This has boon the experience in most of the countries with
malaria eradication programmes. However as malaria eradication programme
advanced toward consolidation and maintenance, it become more and more'
apparent that eradication cannot be sustained without the support of the
general" health services, capable of actively participating in the consolidation
Phase activities and taking over the responsibility for vigilance during the
maintenance phase. Realizing this problem, the W.H.O. in I960, recommended
that, for all future programmes in developing countries with inadequate health
services pre-eradication activities are necessary before embarking on malaria
eradication programmed. One of the chief functions of the pre-eradication'
'programme is to develop a rural health infrastructure, which will in time
cooperate with the. Malaria eradication programme and Ultimately become
responsible for vigilance, for sustaining malaria eradication in the maintenance
phase.
In India, areas under malaria eradication will be progressively
entering maintenance phase starting with 70-80 units in 1964. The health
services in the areas entering the maintenance phase will have, to be suitably
augmented to meet the needs of vigilance for 'sustaining ordination.

The stage development of rural 'health, services varies from state to

State and even from area to area within the same state. "In considering the
adequacy of general health services in terms of total coverage it is necessary
not only consider the distribution and number of hospitals health centers and other
static curative centers, but also what proportion. Of the population is cit
present utilizing these facilities. This is important from the point of view of
maintenance of malaria eradication as vigilance has to be extended to the
entire population in order to prevent the re-establishment of endemicity through
Imported cases.

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Even in well developed areas it is a come-on knowledge that, except for a
population within a small radius of the curative institutions, people in rural
areas generally seek treatment only for painful conditions and for ailments
that keep them off from work While it is important to establish all the rural
health centre’s and hospitals as planned, this present stage of schematic
development or such institutions is not likely to provide a total coverage to the
community, in the circumstances, it is the considered that some of domiciliary
health care should be provided for the population as an intrinsic part of the
Basic the health services. Such a domiciliary services could from the basis for
integrating mass campaigns such as smallpox eradication in the maintenance
phase in to the general health services and also for “undertaking future health
programmes. This will be an investment towards building of rural health
services particularly for sustaining mass programmes.
8.2. In order to maintain malaria eradication on after
Eradication has boon achieved, vigilance has to be maintained over the entire
population. This vigilance will involve the following:
1. Prompt detection and radical treatment of parasite-carriers and
there, follow up:
2. Epidemiological investigation of positive cases and measures to
eliminate face; and
3. Periodic review of the status of malaria eradication and the
adequacy of the vigilance system.
8.2.1. Detection of cases: The prevention of re-establishment of endemicity
depends on the early detection and examination of infection. This must be
done preferably before transmission occurs.
In general, case detection should be undertaken
all Static medical institutions such as hospitals, dispensaries health centre’s,
private practitioners, etc, and in addition, by the rural domiciliary, health
workers.
8.2.1.1 Detection of cases in rural cases: As mentioned earlier, under
existing conditions in rural areas of the country, static medical institutions
cover only a small proportion of the population. In order to achieve total
coverage, it is necessary to provide a domiciliary health
services. This can be achieved by a multi-purpose domiciliary worker. It will
not be necessary for him to take blood smears from every fever case and
administer presumptive treatment as is done by malaria surveillance workers
during the consolidation phase. He will, however, as a part of his normal
duties, take blood smears from cases clinically, suspected as malaria or
inadequately explained fever cases. He will also record all cases of fever so
that any abnormal increase in un-explained fevers in his locality could be
investigated. It is reckoned that these domiciliary health workers could cover
on an average (10,000 population at monthly intervals.

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The supervision of the work of this domiciliary health worker should come
from the primary health centre. It would be advisable to have to have health
inspectors as intermediate supervisors between the medical officer of the
health centre and the peripheral worker.

8.2.1.2. Detection of cases- urban areas: Excepting for slum areas the
urban population can be expected to seek treatment in hospitals dispensaries
or from general practitioners as they have a higher standard of health
awareness. Domiciliary service is therefore not a primary need in cities.
However, in slum areas where the health consciousness of people is not
sufficiently awakened, domiciliary services will be required as in rural areas.
Diagnostic facilities for fevers in static institutions in urban areas will have to
be improved. This can be achieved by institutions. It should be emphasized
that this diagnostic service should also be made, available, free of cost, to
medical practitioners in urban areas.

8.2.1.3. Strategic points of importation of cases: Overland inter-country

routs, seaports, airports, etc. Will need special provision for the screening and
wherever necessary following and treatment of persons arriving from known
malarias areas.

8.2.1.4 Importance of providing diagnostic facilities for fever cases: The

medical profession in India, as a rule, relies mostly on clinical findings for the
diagnosis of fevers. This is partly because of the lack of facilities for prompt
microscopic examination of blood films. The provision of a technician, trained
in routine blood smear examination will improve the diagnosis of fevers and
incidentally help in the discovery of malaria cases that may be missed
otherwise.

The District laboratory/ Headquarters Hospital should have facilities

for examination of blood films. The facilities for examination of blood smoars
at rural health centre and district laboratories/ headquarters hospitals should
be available, free of charge, to private medical practitioners and to the public.

8.2.2 Epidemiological Investigation and Measures to eliminate foci:

Notification: It is of utmost importance that malaria must be declared a
notificable disease. It is fully realized that the implementation of notification of
even the existing notificable diseases like smallpox and cholera cholera are
spectacular diseases which may not remain n hidden for long even when
official notification is delayed. Their remedial action is also of short duration.
On the other hand, malaria can remain undected for long with consequent
years of malaria eradication effort. It is therefore important that malaria must
be facilitate notification. Stamped and self-addressed notification cards should
be available to all curative centre’s including private medical clinics.

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 The district health organization should be strengthened by the addition
of a medical officer responsible for all epidemiological investigation of malaria
and other diseases, within the district. It should be his duty to keep “track of
all malaria cases reported and carry out the necessary investigations and
direct remedial action.

8.2.3 Periodic, Review of the Status of Malaria Eradication and the

Adequacy of the Vigilanced System:

At State Headquarters it will, be necessary to maintain a close watch on

the status of the Malaria eradication. This should form a part of the State
epidemiological Intelligence Service. An adequately trained epidemiologist:
should be in charge, of the services and it should be his responsibility to
appraise the status of malaria eradication and the adequacy of the vigilance
system. This appraisal should be done at least once every six months. The
State Epidemiological service should also have a mobile epidemiological team,
fully staffed with trained entomologists and laboratory technicians to
undertake any special investigations in connection with foci of infection
reported from the districts.

8.3. The malaria eradication organization which has been developed with
considerable effort has stood the test of a high standard, of efficiency that are
required in implementing the eradication programme. The staff is disciplined
and used to hard field work. The experience of these workers is something
that the health services in the country can ill afford to lose. This pattern of
organization can be utilized with advantage in the future development of rural
Health services-for sustaining not only malaria, eradication but also many
other mass campaigns. It is therefore suggested that instead of totally
disbanding the malaria eradication service it should be suitably adapted to
form the matrix or the basis of future rural health organization.

14
 IV. STATUS OF NATIONAL MALARIA ERADICATION PROGRAMIS IN INDIA
AMP THE EXISTING SITUATION IN FIVE STATUS ENTERING
MANTENANCE PHASE IN 1964;

Shortly after the Independence, the Planning Commission considered in

1951 the recommendations of the Health Survey and Development Committee
popularly known as Shore Committee (1946) and recommended malaria
control programme on ah all India basis and give it a top priority.

2. The National Malaria Control Programme

The programme for nation-wide malaria control was drafted in 1952 by the
Director, Malaria Institute of India (now National Institute of Communicable
Diseases) in association with St-ate Health Authorities and international
agencies.

The plan envisaged a continuing programme consisting of:

1) an immediate Operational phase extending over 3 years; and
2) a "Maintenance" phase continuing indefinitely, requiring alert
watchfulness and continued control operations reduced in scale if
necessary.

Saturday December, l952 will be remembered as a landmark in the

history of malaria in India when the operational Agreement between India and
the United States of America was signed, stipulating assistance for malaria
control.
The National Malaria Control Programme was started in 1953 aiming at
progressive coverage of about two hundred million people living in endemic
malaria areas within a period of five years two hundred units, each designed
to cover about one million population, were allotted by l957. The year-wise
progress and malaria metric indices up to 1957-58 are given below-
Statement showing the progress of the National Malaria control programme
(1953-54 to 1957-58)

Year No. of Popula- Child Child Infant _ Proportionate

units tion pro- spleen para- parasite case rate.
function- tected in rate site rate
ing Million. rate
1953-54 84.00 49.51 15.7 3.9 l.6 10.8
1954-55 110.7.5 79.91 12.4 4.2 2.0 8.2
1955-56 133.75 112.00 7.7 1.8 0.7 6.2
1956-57 169.25 144.5 6.0 1.1 0.5 5.3
1057-58 192.50 165.57 4.2 0.8 0.6 4.4

15
The National Malaria Control Programme lasted for 5 years from 1953-54 to
1957-58 i.e. last three years in the first five year Plan and first two years in
the Second Plan period. By 1957-58 the reduction in child spleen, child
parasite and infant parasite rates, compared to the figures of 1953-54, was
the extent of 73.2, and 62.5% respectively. The proportional case rate
(percentage of clinical malaria cases to all diseases treated in dispensaries and
hospitals fell from 10.8 in 1953-54 to 4.4 in 1957-58 a redaction by 60
percent. Thus malaria toppled from its position as the leading public health
problem in India.

3. The progressive reduction in the incidence of malaria was so striking

that there was a population demand for its indefinite continuation. The
control programme, however apart from being costly (about Rs-5crores a year),
had its hazards like the appearance of resistance in mosquitoes to insecticides.
In consultation with the state Governments and international agencies such as
U.S. Agency for International Development and World Health Organization,
the Government of India, in 1958-59, decided to convert the control in to an
eradication programme, phased over a period of 8 years.

4. The National Malaria Eradication Programme

During the first year 1958-59, 30 more units were allotted bringing
the total to 230 endemic units. During the following year, 160 hypo-endemic
units were allotted; thus the whole country was covered by 390 units in 1960-
61 and in another 20.5 units in 1961-62. The remaining 25.5 units designed
and problem area units, neighboring countries and in some problem areas
justified the institution of surveillance.

The progress of the National Malaria Eradication programme is

shown in the following table:

Year No. of Child Child Infant Pro- No. of Found Positive

unit soleen Para- para- Per Blood Positive Rate per
func- Rate Site Site tional Smears 1000
tioning rate Rate Case Exa- amears
Rate Mined Examined.
Million
1958-59 225.25 3.2 0.5 0.2 4.0
1959-60 386.75 1.4 0.2 0.1 2.4
1960-61 390.00 0.7 0.1 0.04 1.3
1961 390 - - - 0.7 13.1 49151 3.75
1962 390 - - - 0.4 26.1 59675 2.30

16
 After 4 year of activities: on the recommendations of independent
appraisal teams, 140-47 units entered the consolidation, phase in 1962,
followed by 87.83 units in 1963. Thus, the total number of units in the
consolidation phases is 228.30 covering about 251 million population.

The number of units in the different phases of activities in 1963

and- projected till the end of the Third Five Year Plan is :-
Year No. of units No. of units Total
Attack Pre-con- Consolidation Maintenance
phase solidation phase phase
'phase

1962-63 134.53. 115.00 140.47 ‐ 390

1963-64 36.00 127.70 228.30 - 392

1964-65 19.25 54.05 248.70 70 392
1965-66 5,50 23.52 154.07 208.91 392

Distribution of units that have entered the consolidation stage in

1962 and 1963 is shown in the Appendix 2.

5. The areas that are likely to enter the maintenance phase next year
are in 2 blocks, one in-the South, consisting of contiguous' areas' of Kerala,
Madras and Mysore and the other in the North of Bihar and Uttar Pradesh.
They are separated and surrounded particularly in the north by areas still
under attack and pre-consolidation phases. A map is at appendix 3.

The possibility of some more units entering the maintenance phase

is being explored. It is likely that 3 . 5 - 4 units in Maharashtra and about 5
units in the Punjab may be ready to enter the maintenance phase from the
next year. However, much would depend on certain epidemiological studies
being undertaken.

6. The organisational and administrative facilities available at present,

in these areas are discussed below
6.1 Medical Institutions.

The number of; medical institutions varies from State to State and
also in the same State from district to district.

They include dispensaries and hospitals (modern or indigenous

medicine) run by government and non-government agencies other than the
private dispensaries, chambers or clinics of private medical practitioners and
special institutions level leprosy, cancer, tuberculosis, etc.

17
6.1.1. Urban Areas: Excepting some townships and notified areas
facilities for "medical aid including hospital and dispensaries are more
adequate and the number of the private medical practitioners more than in
rural areas. Number of cases represented by their friends and relatives for
taking medical aid cannot be precisely assessed but it appears to be precisely
assessed but it appears to be less than in rural areas.
6.1.2 Rural Areas: In Bihar, in the second year consolidation areas,
there is one medical institution other than sub-centre differs from those of the
rest of the country excepting in Rajasthan in having an auxiliary health
worker. The number of medical institutions including the sub-centre’s works
out to be on a ratio of 1 per about 24,000 population (Appendix 5)

In Mysore, the old Mysore area is mo.re generously served than

the newly integrated areas. On an average there is a medical institution for
every 15,600'population the ratio varies from 1 per 7,000 to 1 per 26,000
(Appendix 5). To ensure uniform coverage, since 1961, the, state is working on
plan to revile it least one medical institution for a block (not a Community
Development, Block) of about 15,000 population, and has divided each district
into such blocks ( Appendix 5) .

In Uttar Pradesh, there is one medical institution for every 50,0,00

population. In addition, there are 496 M.C.H. centre’s (Appendix 6).

In Kerala, there are more medical institution in the Tranvancore-

Cochin area than in the Malabar area and. more in coastal areas. On an
average, there is one medical institution for every 42,500. There are 673
M.C.H. centers. These are not attended by medical officers (Appendix 7.)

In Madras, there is one medical institution for every 35, 560

(Appendix8).

In Punjab, there is a medical institution for every 25,000

population (Appendix 9).
The distribution of various type of medical institutions is uneven
and they do not adequately cover the need of the people The effective physical
coverage with reference to people seeking medical, aid, appears to lie within a
radius of 2 miles. Though the effective radius of an institution for malaria
detection work cannot be estimated now, it may vary with the type and
popularity of an institution and other local conditions. Cases (fever cases
included) attending dispensaries are liberally represented by relatives and
friends. Although according to the present scheme of development, more
primary health centre’s are likely to be established these are not likely to
provide adequate coverage to the rural population.

18
 Medical practitioners are few and far between in rural areas. In
Mysore for example, the number of private medical practitioners varies from'1
for 4,586 people in South Kanara district to 1 for 42,408 in Gulbarga district.
The average for the State is Mysore is however 1 for 9,378.
Although private clinics arc, about twice the number of medical
institutions in rural areas, their contribution to medical welfare judged by the
number of the attending patients, is not proportionately large.
Only slightly less than one-third of doctors in rural areas practices
modern medicine. Compounders constitute about one-fifth of the .number of
practitioners of modern medicine.
The fact remains that large groups of population are not covered
by either medical institutions or medical practitioners and are not likely to be
covered for quite some thing to come,
6.2. Passive Surveillance:

The success of passive surveillance varies from State to state. The

percentage of slides collected in1962 under passive surveillance with respect
to active' surveillance varies from 6.7 to 30.5. The figure-is even be low 5 per
cent in nearly two-thirds of the units in one State. Pooled results of the five
State's indicate their the percentage of slides examined/collected through
passive surveillance in 1962 was less than 10 in nearly one-third of the units
and varied from 10, to 20 in another one-third of those units. In other words,
hardly one-third of the units examined/collected slides more than 20 per cent
through passive surveillance. During the first quarter of 1963 in only one
State there had been a district rise in passive surveillance slides.
Medical Officers of Government and municipal medical
institutions, barring a few exceptions, have yet to show active interest in the
case detection programme of the malaria eradication campaign. They have not
considered it as their normal responsibility. Whatever has been the response
is due to the presence of surveillance workers, who have taken blood smears
on their behalf, during the time when they were present.

I The National Sample Purvey Thirteenth Round:

September 1947 May 1958 No.64. The Cabinet Secretariat,
Governments of India, 1962.

19
 Most private medical practitioner’s arc also indifferent. The possible
causes are:
(1) Many doctors sincerely believe that malaria has disappeared
from the country and that there is no possibility for its reappearance.
(2) Most of them also do not realise the implications of passive'
surveillance operations. They resent taking blood, smears from cases other
than clinical and suspected malaria. It is surprising when it is realised that
16.620 malaria cases have been confer med from about 38 lakh blood smears
collected through passive surveillance and examined during 1961 and 1962
and that most of these cases are those that wore clinically not malaria.
(3) Yong doctors do not appear to be adequately oriented towards
malaria programme. Even many undergraduate students have had no chance
to stain blood slides for malaria parasites. Even orientation training centres
for rural health personnel have not been attaching sufficient importance.
(4) Medical institutions after understaffed and medical officers are
too busy.
6.3. Notification's

The list of notificable diseases varies in urban and rural areas. In

rural areas, cases are seldom notified and deaths incompletely.' The last of
notificable diseases varies in the urban areas from municipality to
municipality. Here again it is the deaths that are more completely notified.
Notification of malaria in rural areas is sufficient' but may not be impossible
organise.

6.4. Laboratory facilities:

Outside the malaria organisation diagnostic facilities are almost,

non-existent. Quite a few primary health centre’s have got microscopes but no
laboratory technician on the staff. Microscopes are seldom used.
Expecting in one State there is no laboratory technician or
microscopist at the sub-divisional level hospital.
Most of the States have got some sort of a district laboratory. They
are usually understaffed, ill-equipped and some of them form part of a district
hospital where they are functioning more as a clinical side room.

6.5. Facilities for epidemiological investments:-

At the State level, there is an epidemiological organisation excepting

in one State where it is likely to be established shortly. The epidemiological
organisation, where it exists is in a rudimentary stage and so inadequately
staffed that it is not possible to provide the general direction and guidance in
the control of communicable diseases nor do they have the staff to undertake
investigations except through whether few and untrained staff are available
either at the district or lower levels.

20
6.6 Organisational structure
6.6.1 State level

The organisational structure, necessary at the State level to provide

supervision, guidance and advice to the followed by the rural health services,
is incomplete. The fortunate' exception is of course the malaria organisation.

6.6.2 Intermediate- level

Districts: The weakest element of the structure seems to be at this
level. In fact, almost everywhere the basic responsibility of immediate
guidance and supervision of the local institutions is fulfilled incompletely or
not at all. The two supervisory senior officers (Civil Surgeon and District
Health Officers) are overburdened with multifarious activities in hospitals or in
other health and office work and no time is a available for periodic visits to or
for regularly chocking the records of not to speak of providing any guidance
to, the peripheral unite. In some States the supervision of peripheral-units is
divided between these two officers.
Added to their burden are the changes brought or being brought about
by the decentralisation of administration in rural areas, resulting in the dual
control of health activities and of the personnel. The 'difficulty will continue
unless the organizational changes are established and a clearer picture
emerges.
The State regional divisional organisation where they exist, are similarly
incompletely staffed and thus incapable of providing necessary supervision
and guidance.

6.6.3 Health Personnel’s:-

'
Operational level:- Health personnel at the periphery such as Sanitary
Inspector/Health Inspector /Health Assistant, midwife and lady health
visitors, vary in number from State to State and in the same State from area
to area. For example in Kerala there as a sanitary inspector or Health
Assistant for every 20,000 population and one midwife per 5,000 population,
in the old Tranvancore Cochin area. In Malabar area (3 districts) there is a
Health assistant for 75,000 and a midwife for 25,000 population.
In Mysore, in Malnad area, there is a sanitary Inspector for every 15,
000 population and midwife for every 5,000, population.
In Uttar Pradesh; there is a Sanitary - Inspector for a population of
about 40,000 to 6, 0,000.
In Bihar, there is a sanitary health inspector for a population of about
39,000 and a vaccinator for every 30,000 population. There is an auxiliary
health worker in each sub-centre and the" usual number of female personnel.

21
 In Madras, with democratic decentralization, Circle Inspectors have
disappeared. In a panchayat union, there and a Health Inspector and 1 to 2
health Assistants or vaccinators (l for a. Union with a population of 70,000 or
loss and 2 for a population of over 70,000) where a primary health centre
exists, there are four auxiliary nurse midwives /midwives and a Lady Health
Visitor.
In Punjab, there is a sanitary inspector for every 53,000 population. In
addition where there, is a primary health centre, there are 1 or 2 lady health
visitors and 4 auxiliary nurse midwives.
On scanning the existing National Health Programmes, namely, namely,
smallpox, malaria, tuberculosis, leprosy, venereal-diseases, etc, the only
programme that has near full complement of personnel is the Malaria
Eradication service, but taking all the services as a whole, the existing
personnel will be found to be grossly insufficient.
7. LSSSONS LEARNT ON AD MI NI STRATI ON AND ORGANISATION
FROM THE MALARIA ERADICATION PROGRAMME.

(1) The single most important administrative element that has

been demonstrated to be essential for the success of the programme is the
vertical channel of continuous Supervision from the central to the peripheral
level. The current progress malaria eradiction is almost exclusively due to the
checks and counter checks at various echelons.
(2) Decentralisation of administrative authority with retention of a
single central technical direction is another feature that has “proved to be
essential for efficiency.
(3) Continuous process of technical guidance and administrative
management, provided for in the malaria eradication service, is, such that no
single number of the service feels isolated in the technical field.
(4) Continuous evaluation in addition to periodic independent
evaluation has provided efficiency and at the same time necessary flexibility to
the programme.
An efficient service has already been built over a number of years. It
provides features which can be built into the existing national health
programmes. This may be useful in invigorating the philosophy and
broadening of the objective of the local health services by (l) extending the
services to cover the entire population beyond the usually heavily populated
and readily/accessible areas; (2) accepting responsibility for complete
prevention-of preventable disease on its programme and not being satisfied
with only maintaining each communicable disease below the level at which it
is considered, "an important, public health problem;" and (3) getting out of
the essentiality polyclinic services mentality.

22
 V. RECOMMENDATIONS
Vigilance through institutions

Institutional case detection should continue more extensively cod

intensively than ever before. All efforts should be dire cted to activate all
existing medical institutions Government and non-Government. All private
medical practitioners, irrespective of the system of medicine they "profess, and
all professional and other health workers should be harnessed. The members
of lock development committees, Panchayats, taluk boards, goan sabhas,
gram panchayats, panchayat samithis, mahila mandals, youth, clubs and any
other voluntary local body, school teachers and other should, participate and
efforts must be made to enlist their co-operation so that every village, hamlet
or locality has one voluntary collaboration. The interest of doctors requires to
be periodically stimulated through the academic conferences or personal
discussions. They must be kept continuously impressed that examination of
b lood smears is an essential part of accurate diagnosis of, fever cases which
constitute the largest groups of sickness and is a task of priority at-least for
2-3 years after an area enters maintenance phase. An offer of facilities for
simple laboratory investigations, free of-charge, may go a long way in the free
flow of blood smears. Medical officers of public institutions should ensure
that arrangements are available at all times for obtaining blood smears as and
when necessary.
Unfortunately there are already instances of clinicians overlooking the
possibility of malaria as a cause of fever. The fact that malaria is still a risk in
the country-should be instilled in the minds of all members of the medical
profession.
It is necessary to ensure that passive .surveillance institutions operate
fully and satisfactorily and. to give constant debriefings or retraining in such
matters as preparation of slides, their examination etc.

2. Domiciliary services:

Domiciliary service is a recognised well tried practice that has stood the
test of time it is this service that brings a health organisation into close touch
with the community and ultimately reduces-burden on the health
organisation itself. It brings services to the people at hone through a regular,
system of visits to villages/and: houses. The consensus of view is that, in the
present situation of the country institutional detection of cases cannot alone
be, depended upon for the detection of all cases and as such multipurpose
domiciliary services arc absolutely necessary. As a part of the normal duties, a
workers activities will include taking of blood slides from all suspected cases
of malaria and inadequately explained, fevers and timely detection of an
outbreak.
3. Screen in criteria: For institutional vigilance all over cases should
be screened, for at least- 2-3 years and subsequently only suspected malaria
including all intermittent and inadequately explained fever cases.

23
 4. Notification:-
An early notification is essential. Statutory notification helps is bringing
forth the awareness of the situation in the nines of the people and also help
the workers. Malaria should be declared as a notifiable disease. Facilities
should be provided to medical practitioners at least in the form of pre-paid self
addressed cards.
Every efforts should be made to obtain information regrind the
occurrence of fever cases from a many sources as possible. In addition to
whatever normal agencies exist, the services of school teachers, members of
gram panchayats and other voluntary agencies should be enlisted for
reporting to the nearest vigilance agencies.
5. Medical Institutions:
All efforts should be made to establish medical institutions particularly
dispensaries and primary health centre’s planned during the third plan
period, especially in the area entering the maintenance phase. The States that
have a plan programme of establishing every year, a certain number of
midwifery or M.C.H. centre’s should give priority to such areas.
6. Vigilance in different areas:

6.1 Urban areas

Institutional case detection should be the mainstay, however, slum

and fringe areas would require supplemental case detection programme
through domiciliary services. Major institutions, particularly those with an
average daily outpatients attendance of new cases of about 200 more should
have the services of a person for taking clinical samples including blood
smears. Those institutions, particularly those with a sizeable indoor
department should have separate clinical side-room for improved diagnostic
facilities. The services may be available for all private medical practitioners in.
the area.

6.2. Rural areas:

O wing to the incomplete-and uneven coverage by medical institutions

and liberal representation of cases by proxy at dispensaries institutional case
detection along will not be sufficient. It has to be supplemented by regular
domiciliary services for detection of fever cases and far taking blood smears
from all suspected cases including intermittent and inadequately explained
favor cases. So far, during the consolidation phase such visits are carried out
at fortnightly intervals. It is felt that monthly visit is 'the minimum essential to
ensure an effective check on detection of "cases.

7. Remedial measures

Remedial measures that may be required on the notification of a

confirmed case include
(a) epidemiological investigation,
(b) radical treatment,

24
 (c) Focal spray,
(d ) mass blood survey in as-short a period as possible, but in no case,
beyond one week,
(e) Parasitological follow-up and
(f) Health education.
8. Health Organisation needed for vigilance
8.1. The various activities during the maintenance phase necessitate that -
1) health services be adequate and properly distributed throughout
the area;
2) general health service maintain & nucleus of highly trained and
experienced malaria eradication personnel, strategically distributed all over
the country so that they can immediately deal with a sporadic outbreak. They
may be assigned to any public health work but they must be available for
specialized duties in relation to malaria ready to be dispatched wherever
necessary.
3) One or more epidemiological units, consisting of malaria
specialized members, be available for providing expert guidance.
4) Periodic review of the status, of freedom from malaria and the
adequacy of vigilance.

Besides malaria, the attach phase of the smallpox eradication

programme will be completed in about two years and its maintenance phase
necessarily devolves on the basic health services. Our hopes for a major
Advance against tuberculosis and leprosy based on domiciliary chemotherapy
depend, largely on the active participation of the network of health centre’s.
Failure in absorbing the special programmes in the health services,
particularly in rural areas will seriously delay the institution of other
programmes which are now on the waiting list.

Primarily health centres have been planned as a focal point from

which, all health services should radiate. Strengthening of, the staff and
reduction of population coverage become rid do by various Committees could
not be implemented on account of the shortage of trained personnel and folds.
Pooling of resources and their maximum utilization are indicated.

In order to strengthen family planning services in rural areas, each

primary health centres will have at least 6 sub-centres instead of 3, each
staffed by an auxiliary nurse-midwife or a family welfare worker, for a
population of about 10,000 and also one family planning field work (male) will
be assigned for 30,000 population. I t was felt that this basic structure should
be farther strengthened in such d way that current programmes be under
taken with more of efficiency than at present and that at present and that a
more stable base be laid -down. This will help in undertaking future public
health programmes with much less cost and additional personnel. Duties of a
family planning field worker (male) are at Appendix 10.

25
8.2 Primary Health centre Level :-

8.2,1 The Committee was of the view that the basic unit to have effective,
control over communicable diseases, and to provide preventive healthcare
should cover a population of not more than 5,000. However, in view of the
limitations of financial and material resources, such a unit should cover not
more than 10,000 populations, though the ultimate target should be 5,000.

The basic unit to cover about 10,000 populations for the

present should be considered as a sub centre. Number of such sub-centre’s
will naturally very' depending on the population and terrain of a block. Each
sub-centre will provide elementary medical care, detection and prevention of
communicable disease, maternity and child health family planning, basic
environmental sanitation and health education. Each sub-centre should be
staffed by a midwife or an auxiliary nurse-midwife or family welfare worker
and an auxiliary health assistant.

8.2.2. At this main centre, in addition to the existing post of sanitary

inspector, there will be under the Family Planning Programme, an Extension
Educator, who will be a graduate with six months training in general health
with emphasis on extension education on family welfare planning. He may be
utilized in strengthening education aspects of all types of programmes.

8.2.3. The importance of strict supervision of the work particularly of the

domiciliary services cannot be over- emphasised. Otherwise, in malaria for
example, cases may slowly build up without being detected. The existing one
Sanitary Inspector in-a block is very inadequate. He has a full time job for'
sanitation work, which is bound to increase more and more in future years.
Ideally there should be atleast 1 health inspector for 10,000 populations.
This may not be feasible at present. In addition to the existing one at the block
headquarters, there should be at least 1 health inspector for every 20,000 to
25,000 population. He should be responsible for all health activities. He will
also complement, guide and supervise, to the extent, possible all health
services including domiciliary services under the 'overall control of the medical
officer in charge. The senior most of the Inspectors “may be designated as-
Senior Health Sanitary inspector.

The basic staff should be in position by the 31st March, 1064 if

necessary, in rented buildings in areas where primary health centres have not
yet been established«

Coordination of the activities of the various auxiliary health

personnel working in the field, some of thorn having different responsibilities,
is absolutely necessary in the interest of economy and efficiency of work. The
working relations between Block development Officer and health staff should
be rationalized so that there is a direct line of command for all health-
personnel.

8.2.4. Facilities for blood - smear; examination should be adequate and the
results of the examination be communicated within 24-48 hours but not later
than 72 hours. The delay in communicating the results including negative
findings is

26
Probably one of the most important reasons for inactive cooperation medical,
practitioners. A confirmed case should be notified by the quickest means, if
necessary, by telephone or telegraph. These requirements would mean
decentralization of facilities. Each primary health centre should have a
microscope and a laboratory technician who will conduct simple laboratory
examinations living particular attention to examination of blood smears for
malaria parasites. Pending the establishment of "the primary health centre, a
microscope and CK a laboratory technician may be placed in a suitably selected
dispensary in a block or panchyat union area*

8.2.5. Wherever possible, there should be two medical officers for a primary
health centre.
8.2.6. For Urban areas:

Staff are required

1) domiciliary vigilance in slum areas; and

2) laboratory investigations.-

8.3. Intermediate levels:

8.3.1. District levels: Work load includes.

1) Close supervision of domiciliary, services.

2) activation of passive case detection through personal contact;
3) conduct of epidemiological investigations and remedial measures;
and
4) Supervision of laboratory work at district and low or levels. The
nature of work demands that the officer will have to tour 15-20
days a month.

8.3.1,1. The work load will be too heavy for the existing district health officer.
An additional officer is required to assist-the health officer in the discharge of
his responsibilities efficiently. He should be a medical officer trained in
malaria and may be selected from out of the unit medical officers. His main
job would be that of a district epidemiological officer. He should be in charge
of public health programmes, providing supervision, carrying out
epidemiological-investigations and remedial actions, .under the overall
supervision of the District Medical Officer of Health. For a period of about
three years subsequent to the entry of an area into the maintenance phase t,
he should concentrate mostly on malaria. He should be assisted by a
reasonable number of health supervisors approximately on the basis of one for
every 6or7 blocks.
8.3.1.2. Facilities should be provided at each district laboratory or district
headquarter hospital for examination of blood smears, which should be kept a
separate entity under the direct supervision of the assistant district health
officer for a period of at least 2to3 years after an area has entered the
eradication phase.

27
8.3.2. Zonal level:
Existing State regional or Divisional Health Offices should be strengthened by
a medical officer trained or having experience in epidemiology and' malaria.
Otherwise the existing N.M.E.P. zonal offices, should b 3 converted into
regional health offices.
8.4. State level:
A state Malaria Officer preferably of the rank of Deputy director in
charge of malaria and other communicable diseases will be required for
overall guidance and supervision. He should continue to be responsible
primarily for these duties for at least two to three years after the State has
entered the maintenance phase in entirety. He should be assisted, by a
medical officer for carrying out and< supervising epidemiological investigations
and remedial actions. The State Malaria laboratories should morgue into the
State Public Health laboratories so that every public health laboratory has a
malaria section. The laboratory at the State level should be staffed with, at cast
one ant on legist, one senior laboratory technician entomological assistants and
microscopists on a required basis (microscopists to cross-check 5 per cent, of
blood smears).
8.5. The above recommended organisation may be used as a guide and may
be suitably amended; to suit the local requirements but keeping the essentials
intact.

8.6. CENTRAL LEVEL:

8.6.1. Regional Coordinating Organisation.

Regional Coordinating Organisations under the Central Government

have contributed in a large measure to the success of the programme, by
efficient inter-state coordination, intra-State supervision and guidance-of
actual field operations and continuous training of personnel. In view of the
expansion of activities of health services and the necessity of decentralized.
Control, advice and guidance in the, various aspects of health development. It
will be desirable that this organisation should continue as nucleus which
should be developed into regional, office of the Directorate Central; of Health
Services. In a country like ours with large population and extensive .areas, it
is perhaps not possible, to exercise efficient coordination and guidance; from
the Centre only. It may be added that a similar arrangement; exists even in
advanced countries like United States of America where besides the
Headquarters, there are nine regional offices for inter- state Coordination and
technical guidance-and advice.
8.6.2. The Central organisation of Rational Malaria Eradication
Programme should be retained on a modified scale for at least 2 to 3 years
after the eradication has been achieved every the whole country. It may be
added that the countries that have achieved eradication are maintaining a
Central Organisation on a reduced scale. This is considered essential to review
periodically and evaluate the status of eradication of the country-to provide
technical guidance and to carry out epidemiological investigation and
coordinate logistics.

28
 Organisational charts showing the present National Malaria
Eradication organisations and the health organisation strengthened
particularly for sustaining mass programme and also showing the
development of staff from various sources are at Appendices 11 and 12.

9. Logistics

Equipment and stores should remain at the district leve1 under the direct
charge of District. Health Officer However a FEW sprayers and a small quantity
of DDT should be stored at lower level.
10. Transport.

Transport will be' required 'for:

Deputy Director Health Services in Charge,
Malaria and Communicable Diseases .... 1
Regional Health Officer .... 1
District Health Officer .... 1 if
he has no transport
Assistant District Health Officer .... 1
Health Supervisor .... 1

The Senior Health Inspector who will provide. Supervision in a block

area should have an easy and quick means of independent transport. A cycle
with a suitable allowance is a must. All health workers and inspectors should
be provided with or maintain cycles with cycle allowance.
11. Other anti-mosquito measures.
Now, since malaria is being eradicated no organisation must be allowed to
endanger or undo what has been achieved on such grounds as shortage of
dunds, etc. In fact, all anti-measures should be strengthened. These will have
a salutary effect on all mosquito-borne disease. Existing, rules, if any, should
be revised and where no rules exist, they should be framed. These refer to
Government institutions, municipalities zilla parishads. Private and public
undertaking and in connection with roads, railways, bridges, culverts, burrow
pits, impounded water storage, canals factories, etc. including the
establishment of factories.
The importance of undertaking ant larval work by municipalities
etc. cannot be over-emphasized in the interested various types of mosquito-
borne diseases.
12. Health education.
Success of vigilance operations depends to a large extent on the co-
operation of the various categories of people government officials, medical
professions both in Government and the private practice and above all the
public. It is needless to mention the importance of developing a sense of
participation and responsibility, in the implementation and success among all
groups of workers and above all the community.

29
13. International consideration:
The excising International Sanitary Regulations provided sufficient
protection against the importance of mosquitoes provided that they are rigidly
applied.
Article 103) of the I.S.R. permits special measures in respect or
"migrants, seasonal workers or persons taking part in periodic mass
congrations. The special measures have not been defined. Overland inter-
country routes, sea and airports may need special provision for screening,
following up and treatment of persons arriving, from known malarias areas.
This may be organized at ports through port health authorities. It may be
necessary to provide facilities for on-the- spot examination of blood smears at
larger ports. The Expert Committee on Malaria (in their 9th report) has
recommended that a special group of experts in malaria and international
quarantine should be convened at the earliest opportunity to consider and
make recommendations the methods to be employed as a protection against
the danger of importation of malaria by the groups listed in Article 103 of the
1.5. Rs. or by other groups or individuals net included tinker this regulation."
14. Inter-country coordination.
We are co-coordinating our programme with our three neighboring countries,
Burma, Pakistan and Nepal. Cooperation has been forthcoming from the
health organisations of the countries concerned, thanks to the good offices of
the W.H.O. We should continue to extend our efforts to our mutual benefits.
15. Utilisation of N.M.E.P. disbanded staffs

A large number of N.M.E.P. staff will be surplus.

Some of them are highly trained and experienced in epidemiological
investigation of malaria cases and all of them have wide experience in the field
particularly in the approach to the people and basic health education
methods. It is in the interest of the country’s health programmes that they
should be utilised with necessary training on a priority-basis. They will infuse
a new spirit of urgency of dealing with a problem as they did, with malaria,
provided that the same supervision and camaraderie continue to guide them.

16. Training,
16.1. Objectives:
To make health workers to undertake efficiently multipurpose
domiciliary health services. Priority should be given to job training of workers
at execution level and training in malaria, epidemiology and supervision to
supervisors.
16.2. Two bread categories of health staff will require training.
a) Existing health personnel; and
b) N.M.E.P. staff.

30
 a) The existing health personnel may be given a short orientation in
malaria.
b) For N.M.E.P. staff, two types of training are envisaged.

i) Short orientation on the health programme that are undertaken at

the time to make them fit to undertake the job immediately, Initially training
should be for a month followed by periodic seminar. Further orientation
courses should be given whenever now programmes are introduced.
ii) Long regular courses..

A certain percentage of the person of the should be given facilities

every year to undertake long regular courses as health inspectors, laboratory
technicians, auxiliary health workers, medical assistants etc.

16.3. In addition, the staff that does not find a place in the above
programme may be trained as optometrist's, leprosy paramedical personnel,
X-Ray technicians, laboratory technicians, pharmacists, etc. Because of their
wise courses will make them suitable as auxiliary personnel -required, for a
number of health programmes.

16.4. The Central and State Governments should make immediate

arrangements for various types of training short and long, so that we become
ready to undertake the responsibility as soon as the units are ready.
Arrangements are being made at the 'National Institute of Communicable
Diseases for medical professional personnel. Training of other personnel
should be undertaken in states.

IV. Orientation of future health personnel towards malaria:.

Malaria will remain a potent force to contend with for the next few
years. As such, in all training programmes at university level, undergraduate
and post-graduate, and at non-university level of our future health personnel,
doctors, public health engineers, post-graduates nurses, public health nurses
health inspectors and all type of auxiliary personnel, due importance should
continue to be given to malaria.

18. Delineation of vulnerable area and groups.

Areas may be vulnerable either because, they adjacent to territories

where eradication has not been achieved and are therefore especially liable to
invasion for because they arc centre’s for migrants, travelers and pilgrims.
Vulnerable groups include pilgrims, migrants, labor forces, military and
others. In a developing country like India, big construction work in connection
with hydro-electric, irrigation, river from time to time. As such, special care
will need to be taken to delineate vulnerable groups or areas at periodic
intervals.

31
19. The basic organisational structure needed for the maintenance of
freedom from malaria and smallpox and for the implementation of other
health programmes have been laid down. It is necessary that each state
should work out in detail.

a) The staff required.

b) the number of persons' in various categories requiring further

orientation training;

c) existing facilities for trails, and further facilities required;- and.

d) estimated expenditure, including how much the State

Governments can bear.-

20. Financial assistances

The foregoing recommendations would necessitate the State
Governments having to incur substantial sums on augmenting the staff at all
levels of the general health services of the State. It was' pointed out by all the
representatives of the State Governments -'-that, with their present resources,
it would not be possible for the State Governments to shoulder this burden. It
is. Therefore, necessary that a measures of Central assistance for this'
purpose is made available, in this context, it. Is tinder stood that the National
Development Council after a mid-term appraisal of the progress of' health
sachems at its meeting held on the 8th and 9th November, 1963, observed
that the maintenance phase of the Malaria: eradication Programme has to be
provided for in the annual plans of the States, he Committee was of the view
that the extra expenditure, consequent on the augmentation of the staff of 'the
Central Health Services, for purpose of Vigilance. In the maintenance phase
may be-borne by the Central Government and that this assistance should be
outside the State-plan coiling. The question of financing the health schemes in
the States had been discussed the meetings of the. Central Council of Health
held at Madras on the 5th to 7th November, 1963. All the States had
expressed considerate concern over the present pattern of assistance and
limitation of working within the State-financial ceilings.

21. Unless the vigilance services are established, the entry into the
maintenance phase and the disband meat of NMEP organization will have
disastrous effects' as has been the experience in some countries.

Criteria for Malaria Eradication-Extract from W.H.O. Expert

Committee on Malaria Eighth Report-1961.

4.1. Epidemiological criteria for the confirmation of malaria eradication.

Definitions:-

Malaria may be assumed to have been eradicated when adequate

surveillance operations have not reveled any evidence of transmission or
residual endemicity, despite careful search, during three conceptive years.

32
To establish this, claim in relation to a specific defined area the following
evidence is essential s-

(1) Proof of the adequacy of the surveillance mechanism:

In areas where no specific general measures of anopheline control or

other measures which might -obscure the presence of residual foci have been
in operation during the at least the last two of these three years, proof of
adequacy of surveillance can be based on detection mechanisms which are
largely passable, provided that facilities for accurate diagnosis and treatment
are readily available to and within easy access of the entire population and are
in fact utilized by them. When the accurate diagnostic facilities are less
universally utilized the surveillance, to be adequate must include a
considerable element of active detection.

When measure£ such as inopholine control or mass treatment, which

might obscure the presence of malarias foci, have boon practiced .during
these three years, the surveillance mechanism," to be adequate should be of "a
very high duality. Furthermore, the" microscopic examination of a number
blood slides' equivalent to at least 10% of the population of the area
concerned, should have been completed since the date when the last
indigenous case, other than, a proven relapse, was confirmed.

When malaria has not previously been endemic, i.e. has not been
present In a measurable incidence either of cases or of natural transmission
over a succession of years but has appeared only in' a small temporary focus,
the required proud could be based on local studies carried out by general
medical arid public health Institutions.

(2) Evidence that in this period of three years no indigenous cases

originating within that time have been-discovered.

(3) The evidence of a register of all malaria infections discovered during

that time, it being established beyond reasonable .doubt that, each case was
either.

(a) Imported, as shown by tracing the case to its origin, in an

acknowledged malarias area;

(b) a relapse of a pre-existing infection, as shown by the history of the

case and the absence of any associated cases in the neighborhood, of its
origin.

33
 Appendix -2
Statement showing number of units in consolidation
During 1962 and 1963.

SI. No. State Consolidation Consolidation

1996 1963
No. of units No. of unit

1. Andhra Pradesh 8.50 4.50

2 Bihar 19.75 7.00
3. Gujarat 10.34 3.87
4. Kerala 13.50 1.00
5. Madhya Pradesh , 7.00 3.75
6. Madras 23.00 7.45
7. Maharashtra 10.30 7.61
8. Mysore 10.33 3.65
9. Orissa 3.25 0.75
10. Pun jab 6.25 7.01
11. Rajasthan 6.00 2.62
12. Uttar Pradesh 22.25 25.75
13. West Bengal - 12.37
14. Himachal Pradesh - 0.50

Total 140.47 87.83

34
 BIHAR Appendix 4

Consolidated, list of Medical institutions or towns in the districts and the sub-
divisional rural areas of the subdivision forming para of 2nd year of
consolidation areas during 1962-63.

Sub Pensaries Hospitals Lepr Mobile

SI. District Population Divis Locks Primary MCH. T.B. osy Medic
No. ion Cent Cli- Cent other
Rural Govt. Non Govt. Govt. Non
al
Dis- res nics res unit
Govt.
centres
1.
Patna 29,12,614 5 2 25 30 47 12 4 9 1 ‐ - 1

2. Gcyt. 30,47,263 4 4 40 42 35 9 2 4 1 1 - ‐

3. Shantou 32,22,467 4 3 39 29 33 66 3 4 2 = ‐ ‐

4.
Saran 35,85,531 3 3 32 29 7 1 4 2 1 ‐ ‐
5

‐
5. Champaran 30,09,841 2 2 29 28 20 6 5 2 - ‐ ‐

6. Muzffarpur 41,16,320 3 3 25 37 23 6 1 3 1 1 ‐ -

7. Darbhang 44,23,363- 3 38 23 23 3 7 ‐ 5 1 1 - -

8. Moghyr 3,84,897 4 3 16 22 7 1 5 1 2 - -
12

9. Bhagalpur 17,15,128 2 17 17 21 17 6 - 3 1 3 - ‐

-
10. Purnea 30,87,428 4 33 9 14 4 7 2 5 2 - -

Total 3,31,31,852 34 318 253 275 201 71 14 45 14 9 - 1

35
 Consolidated list of medical institute District-wide (MYSORE) Appendix 5

Ayur P.W.
SI. District Population Taluk Block P.H Ci R.S R.S Co - Pl D Pv Ru Ho- HC Mobile
no .C vil Dis- L.F mb- Ved an Fore t. ral spit D Medic
Gov Di Pen- Dis- ine ic - st Di SN al Ce al
t. s- Sarie Pen d An Ta And s- P nt Units.
Of Pe s s- Dis d tio Rail Pe Di re
Ind ns Ari pen Una n Way ns s-
ia - es - ni Di Dis- - Pe
Typ ari sari Dis s- Pens Ar ns
e es es pen Pe - ies -
- ns Arie Ar
Sar - s ies
ies Ar
ies
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

1 Coorg 3,21,516 3 3 - 16 - - - - 1 - - - 24 3 1
1 - 6 6 4 - -
Bellary 9,74,483 7 12
2 - - 14 - 6 12 - - - 2 - -
3 Mandya 8,98,553 7 9 2 -
- - 6 - -
4 Chickmangalur 5,95,849 7 5 16 - - - 3 7 -
1 - 27 - - - 2 4
562,699 7 16 1 - - 28 8
5 South Kanaya 1,366,732 7 - - - - -
6
10 15 1 16 7 8 2 2 1
Turakur 1,229,633 11 16 - - 19 14 - - 2 10 8
7 Bangalore 1,094,128 - 7 2 26 - 1 - - 2 - -
-
8 Chitra-Durga 1,375,886 16 1 - - 21 - - - - - -
14 11 - - - - 2 10 -
Dharwar 1,416,350 11 1 - 10 3 1
9 18 9 - - - - 4 - -
Mysore 839,339 8 1 - 10 1 2
10 11 34 - - - 27 2 - 3
11 Hassan- 11 8 - 35 9 4 27 - - - - 3 16 1
1,145,022 15-
12 Kolre - - 2 10 1

Total 13,019,720 107 146 15 16 158 68 10 12 1 5 4 37 55 54 8

36
 APPENDIX-6

STATEMENT SHOWING CONSOLIDATED LIST OF MEDICAL INSTITUTE INCLUDED IN

THE AREAS PROJECTED FOR ENTRY INTO MAINTENANCE PHASE. UTTER PRADESH

No. Hos MCH T.B Lep Mobi Other Fam-

Sl. Name of Population Teh Block of Dis pit Cen- Non Clini - Le Indi- ily
no the Dis- sils pri pen Non als Non tres Govt ros M.U Gen- Plan-
trict m- Sari govt. Gov Govt Govt es y Ral ning
Ara es t. . Cen Disp- Cen-
y Gov - Ensa- tres
He t. tre ries
alt
h
Ce
ntr
es

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Allhabad 25,19,963 8 27.5 7 13 18 8 5 60 5 2 1 1 25 17

2 Baranbanki 14,46,287 4 16.5 7 12 9 4 - 34 n.a - 1 - 11 8

3 Deria 16,68,783 4 29.5 10 6 - 2 - 41 2 1 1 - 24 10

4 Gorakhpur 5,39,371 4 31,00 7 4 1 3 1 2 2 1 2 - 1 n.a

5 Kanpur 15,02,173 6 20.5 7 48 7 15 1 19 - 1 1 1 23 n.a

6 Lucknow 18,95,815 3 10.0 7 16 15 7 5 36 1 2 1 2 25 18

7 Unnao 12,63,859 4 16.0 6 10 3 5 - 31 n.a - - - 22 9

8 Varanasi 23,08,195 4 22.5 11 14 9 20 4 42 1 2 3 1 33 3

9 Azamgarh 12,48,032 6 29.5 6 6 - 4 - 33 n.a - - - 9 8

10 Faizabad 8,94,188 4 18.5 3 1 3 - - 19 n.a - - - 7 n.a

11 Fatehpur 11,16,350 3 13.0 6 12 3 5 1 29 n.a - - - 17 8

12 Ghazipur 13,62,445 4 11.6 4 9 3 4 - 29 n.a 1 - - 14 10

13 Jaunpur 17,76,402 5 20.0 9 9 6 5 2 38 n.a 1 - - 19 12

14 Pratapgarh 12,83,788 3 15.0 6 7 8 4 - 36 n.a - - - 14 12

15 Rai Bareli 13,52,832 4 16.5 6 7 13 3 - 32 n.a 1 - - 11 15

16 Sultanpur 17,75,634 4 16.5 5 12 1 6 3 33 n.a 1 - - 13 14

Total 107 185 99 95 22 514 11 13 10 5 268 154

Staff patterns: 1. Primary health centre, Government of India

2. Maternity & Child Health Centers. Midwife- 1, Dai- 1
3. Indigenous Dispensary. Doctor- 1, Compunder-1

37
 APPENDIX-7
CONSOLIDATED LIST OF MEDICAL INSTITUTE
DISTRICT-WISE-KERAL SATATE 1963

Sl Name of Tehsils Block Hos S.I.C P.H. Rural T.M M.C. T.B Lep B.w ITI Mo Mid Total
.no the Dis- - C/ .D H - dis b
trict (taluk Dis- CLI DIS Wife
Pit- ) P.H. CEN- - Ros pen uni ry
Pens- PE t
als U TRE NIC y Sar N cent
Aries y re
S Cen SA-
-
RA
Tre Y
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Trivendrum 4 12 12 2 15 13 8 1 1 - 1 - - 86 139

2 Quilon 6 17 8 - 13 16 1 - 3 - 1 1 - 80 122

3 Alleppy 7 18 9 1 14 13 - - 1 2 1 - - 73 113

4 Kottayam 8 13 6 1 7 17 1 1 - - 6 - - 64 103

5 Inakulam 7 20 12 1 14 26 - 1 1 - 5 - - 93 153

6 Trichur 5 18 10 1 11 15 - - - 2 4 1 - 94 138

7 Palghat 6 17 8 1 11 24 - - - 1 - 4 1 57 107

8 Kozhikode 6 23 11 - 12 20 - - - - - - 1 64 108

9 Cannanoro 6 12 5 1 8 23 - - - 2 2 - - 63 104

TOTAL 82 8 104 167 10 3 6 7 19 6 2 673 1087

Note:
P.H.C/ P.H.U= Primary Health centres/ Unit M.C.H= Maternity&child
S.H.C= Secondary Health centres Health centres.
T.M.D= Temporary Malaria Dispensary Iti. Dis= Itinerary
Dispensary.
Mob.Disp.=Mobile Dispensary.
* Merging to Hospitals Now only I.SM.C *Midwifery centres include
at Neyettinkara sub-centres.
** P.H.C.- L.M.O -1
Clerk -1
Coverage -25,000-30,000

38
 CONSOLIDATED LIST OF MEDICAL INSTITUTIONS MADRAS Appendix 8

SL. NAME Popul No. No, No. No.o No No. Non Mo Rura Non Lepr Panc Pri
NO District - of of of f n of Govt bile l sub- osy hayt nci
Latio Tal Blo Pri Hos gov Dis M.U Dipe sidis Sub- Unio pal
n uks cks ma pi- t. pen n- ed sidir n Ins
(in ry Tals - Sari y dis- tit-
milli Hea Govt Sar es Cent Pen- uti
on) lth . ies Medi res/ sarie ons
Cen Gov -cine Clini s
tres t Subs cs
idi- Etc.
sed
1 2 3 4 5 6 7 `8 9 10 11 12 13 14 15 16

1 -
North Arcot 2.86 10 36 10 14 6 3 1 8 - 3 111 3

2
South Arcot 2.78 7 35 10 13 6 4 2 - 5 - 5 18 5

3 Chingleput 1.85 7 37 11 6 1 5 2 1 8 - 2 13 4

4 Goimbatore 3.15 4 41 23 2 3 12 2 1 11 3 - 2 11

5 Kanyakumari 0.83 4 9 6 4 1 11 - - 2 1 2 15 -

6 Madurai 2.51 6 34 14 14 5 2 7 1 2 1 2 15 7

7 Milgiris 0.31 2 4 3 6 - 2 - 2 - - - 5 5

8 Ramanathapurm 2.08 7 32 15 21 3 6 3 1 - - 1 31 3

9 Salem 3.37 8 51 9 19 - 2 1 1 12 3 2 16 -

10 Thaniavur 2.98 9 36 14 15 2 28 - - 17 2 1 18 10
-
11 Tiruchirappalli 2.94 9 39 9 13 3 13 1 16 - 2 12 5

12 Tirunaveli 2.51 7 31 9 12 7 8 1 1 2 3 2 2 9

Total 2817 80 375 133 145 37 96 18 10 81 12 22 165 62

39
 Appendix-9

Consolidated List Of Medical Institutions in Rural and Urban Areas In the

Punjab

Popu- P.H Dispe Sch Tuber Em Hos Tube No. Areas Density
Lation Centr n- ool - plo pital rcul beds Sq. of
SI .No. 1961 es Sarie Hea clulos ym s osis mile Populat
s lth is ent Cent ion /
Units In- ral Sq.
Gener sur mile.
al anc
e
1
2 3 4 5 6 7 8 9 10 11 12

Ambala 1.37 10 39 1 1 1 1 - 1045 2134 644

Amirtsar 1.53 11 40 1 1 - 15 - 2517 1978 776

Bhatinda 1.06 10 20 - - - 8 - 340 2706 390

Ferojpur 1.62 17 38 - 2 - 9 - 600 3882 417

Gurdaspur 0.99 3 25 - 1 - 7 - 494 1360 726

Gurgaon 1.24 13 27 1 1 1 7 - 340 2367 524

Hissar 1.54 14 36 1 1 1 14 1 1247 5380 286

Hoshiarpur 1.23 13 34 - 1 - 5 1 517 2210 558

Jullundur 1.23 11 29 - - - 9 1 865 1335 919

Kangara 1.06 17 43 - - - 9 2 903 4904 217

Kapurthala 0.34 6 8 - 1 - 4 - 156 630 546

Karnal 1.49 14 27 - 1 1 5 - 432 3062 487

Ludhiana 1.02 8 24 1 1 - 8 - 1028 1324 712

Lahul spiti 0.02 2 7 - - - 1 - 18 4714 4

Mohindergarh 0.55 4 9 - 1 - 6 - 183 1343 408

Patiala 1.05 10 18 - 1 - 8 1 1126 2262 464

Rohtak 1.42 12 26 1 1 1 6 1 542 2330 610

Sangrur 1.43 14 18 - 1 - 8 1 280 3031 470

Simla 0.11 1 8 - 1 - 8 - 628 254 444

Total 20.30 195 476 6 16 5 149 6 13261 47208

40
 Appendix‐10

Talks for Mile Field Health Worker in

Family Planning ( 1 per 30,000)

1 To locate loaders for F.P. in each village.

2 To help leaders from health committees in each village with close

relationship to Panchayats.

3 To help health committees

(a) Determine how many stockiest of contraceptives there shall he in

each village and make plans for adequate storage and distribution
of contraceptives so that all married couples have access to needed
supplies.

(b) Determine what methods of education Panchayats wish to use in

teaching the people of the village about contraceptives.

(c) T0 visit Health Committee chairman once a week to discover

needs and problems in family planning programme-.
(d) T0 supply educational materials to chairman as are needed.

(e) To discuss F.P. programme with small groups of men at the

request of chairman of health committee.

(f) To work with auxiliary nurse-midwives in helping them to

arrange meetings with groups of women in the village.

(g) To help Block-Extension Educator and Senior Sanitary Inspector,

develop training camps and meetings for health committee
members and other leaders and workers in the village.

(h) To help in Block or district F.P. Programmes in special

campaigns, as for example, vasectomy or tubectomy camps.

4. To supplement .health --education activities in other health programmes.

41
 Appendix 11

ORGANISATIONAL CHART SHOWING THE PRESENT N.N.E.P. ORGANISATION

CENTRAL AND THE STRENGTHENED HEALTH ORGANISATION RECOMMENDED

N.N.E.P. ORGANISATION POLYVALENT HEALTH ORGANISATION

Director, NNEP CENTRAL MALARIA ADDESSMENT CP

Regional Co-ordinating Regional Co-ordinating

Organisation Organisation
Dy. Dir. NNEP

HEALTH DIRECTORATE HEALTH DIRECTORATE

State Malariologist Deputy Director
of Health Services.

ZONAL
Zonal M.O. State Regional
A.D.H.S.
A.D.P.H.

UNIT DISTRICT
Pop. I million D.H.O.
Medl. Officer A.D.H.O.
Asst. Unit Officer Health Supervise
Laboratory Senior Laboratory
Technicians Technician
SUB UNIT PRIMARY HEALTH CENTRE
Pop. 2,50,000 Pop. 75,000 Med Officer
Sen. Med. Inspr. I Senior Officer
Jun. Med. Inspr. I Inspector
Laboratory
technician
SECTOR SUB CENTRE- 6
STATE

Pop. 10,000 Pop. 10,000 – Polyvalent

Surveillance 12,000 health activities
Worker
H.I. H.I. H.I.
AHW* AHW AHW AHW AHW AHW
ANM ANM ANM ANM ANM ANM

* A.H.W. = Health Assistant or auxiliary Health Workers.

** A.N.M. = Auxiliary Nurse Midwife.
LINE OF COMMED
State Health Directorate - Deputy Director

State Regional Health Office - Regional Officer

District Health Officer - District Health Officer Asstt. District

Health Officer

Primary Health Centre - Medical Officer

Health Inspectors

Sub- Centres (Aux.) Health Worker/ Asstt.

42
 Appendix -12
Organisational chart in a District with deployment of staff

District Level Asst. Health Officer -1 Senior Lab. Technician -1

Health Supervisors. Driver -1

(i) Existing: Medical Officer -1 Auxiliary Nurse Midwife -1)

Public Health -1 Compounder -1) I
Nurse/L.H.V. -1 Driver -1)
Sanitary Inspector -1
(ii) Proposal: Medical Officer -1 Male Field Worker -2)
Under Auxiliary Nurse Computer -1) II
Family Midwife -4 Store Clerk-Cum
P.H.C. LEVEL
Planning Extension Accountant -1)
& MCH Educator -1

(iii) Additional Staff* Sanitary Inspector -3)

Polyvalent Laboratory technicians -1) III
Activities Health Worker -6-7)
Clerk -1)

* Suggested to make primary health centre and sub-centres

self-sufficient to deal with comprehensive health
activities including malaria.

S.C. S.C. S.C. S.C. S.C. S.C. S.C.

43
 Appendix-13
Content of the training course f o r the Peripheral Workers

Period - Initial one month (4 weeks)

Content:

1. Control of communicable diseases including vaccination,

immunisation-.

2. Environmental sanitation.

3. Health Education

4. Vital Statistics.

44
45
 1. EMILO PAMPANA - "A Text Book of Malaria Indication"
Oxford University Press, 1963.
2. U.H.O. Expert Committee on Malaria - Sixth Report
Technical Series No. 123,1957.

Appendix 14/

Contd. From prepage.

During the consolidation, phase, the activities are aimed at the

intensification of surveillance operation after the interruption of spray
programme. However much depends the ability of the unit to meet the
technical criteria specific for the purpose. Normally, malaria eradication
should be achieved 2-3 years after entry into the consolidation phase. This is
followed by the maintenance phase.

4. The introduction of synthetic residual insecticides thus halted the use

of expensive1 drainage works and costly larviciding eradication and led to the
control and eradication of malaria in rural areas.

46
 Appendix -15

PARTICIPANTS

1. Dr. M.S. Chadha

Director General of Health Services .... Chairman.
2. Dr. K . N . Rao,
Additional Director General of Health Services
3. Shri P.S. Appu,
Health Secretary, Bihar.
4. Shri A.S. Menon,
Health Secretary, Kerala.
5. Shri R. Ah and a Krishna,
Secretary, Public Health,
Labour and Municipal
Administration, Mysore.
6. Shri D.P. Devaprasad,
Deputy Secretary Health-Madras..
Shri S.L. Verma,
Under Secretary Health Punjab.
7. Dr. D. Bhatia,
Director of Health Services, 'Punjab.
8. S.M. Hassan,
Director of Health Services, Bihar.
10. Dr. T. Bhaskar Menon,
Director of Health Services, Kerala.
11. Dr.(Mrs.)H.M.Sharma,
Director of Public Health, Madras.
12. Dr. C Gopal Raj Chetty,
Director of Public Health
in Mysore, Bangalore.
13. Dr. P.D. Bhave,
Director of Public Health,
Maharashtra.
14. Shri A. P. Mathur,
Under Secretary, Ministry
of Health.
15. Dr. N. Jungalwalla,
Deputy Director General of
Health Services.
16. Dr. A.P. Ray,
Deputy Director General of Health Services,
(Public Health)
17. Dr. K.M. Lal,
Deputy Director General of Health Services.
18. Dr. S. Seshagiri Kau,
Chief, Health Division, Planning Commission.
19, Dr. K . K . Govil,
Joint Director of Medical and Health
Services, U.P.
47
APPX. 15( continued from prepage)

20. Dr. V.S. Gopalakrishnan.

Deputy Director of
Health Services, Kerala.
21. Dr. M.V. Singh,
Deputy Director (Malaria),
U.P. Lucknow.
22. Dr. K.C. Rastogi,
Deputy Director (Malaria),
U.P. Lucknow.
23. Dr. U.M. Rao,
Assistant Director
of Medical Services, -Madras.
24. Dr. B.K. Varna,
Chief Malaria Officer, Bihar.
25. Dr. Asa Singh,
State Malaria Officer, Punjab.
26. Dr. U.A.N. Iyengar,
Assistant Chief, Health Division,
Planning Commission. .
27. Dr. P.R. Dutt,
Assistant Director General
of Health Services secretary
Special invitees –

28. Dr. Eugene Campbell,

Chief, Health Division,
U.S.A. I.D. New Delhi.
29. Dr. H. Richards,
Assistants Director
of Health serivces W.H.O./SEARO.
30. Dr. G. Sannasivan,
Senior Regional Malaria
Adviser, VI.K.O./SEARO.
31. Dr.S.P.Ramakrishnan,
Director, National Institute,
of Communicable Diseases’.
32. Lt. Col. Barkat Narain,
AdviserHealth, Ministry
of Community Development,
Co-operation and Panchayati Raj.
33. Dr.M.W. Ereymann
Ford foundation.
34. Dr. V. Ramakrishna,
Director, CHEB.

OBSERVERS

35. Dr.B.l. Raina,

Director, Family Planning.
36. Dr. B. Mathews,
Ford foundation.
37. Dr. Edward S. McGauven,
Ford foundation.

48
APPENDIX- 15 (Contd. From prepage)

30. Dr. Hugh R. Leavell,

Ford Foundation.
39. Dr. .Malcolm H. Morrill,
Ford Foundation.
40. D r . S.L. Dhir,
Aassistant Director General
of Health Services, (Planning).
41. Dr. K.C Patnaik
Assistant Director General
of Health Services,
(Epidemiulegy)

42. D r . A.K.Krishnaswamy,
Deputy Director,
National Institute of
Communicable Diseases, Delhi-6.

44. Shri A.T. Seshadri,

Deputy Director
Administration (P.H.C.)

45. D r . W.C. Jolly,

Deputy Assistant Director General
( Health Services (Health Education)

46. Dr.B.C.Misra,
Assistant Director,
National Malaria Eradication
Programme, Delhi-6.

47. Dr.L.Ramachandran,
Officer-in-chargo,
Rural Health Training
Centre, Najafgarh (Delhi).

49