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Community Book

The document outlines the role of nurses in India's National Health Programmes, focusing on the National Health Mission (NHM) and its components aimed at improving community health. It details various units covering topics such as communicable and non-communicable diseases, nutritional programs, and reproductive health strategies. The NHM aims to provide equitable, affordable, and quality healthcare services while addressing broader social determinants of health through community engagement and inter-sectoral coordination.

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Henry Massey

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Community Book

Uploaded by

Henry Massey

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 127

BNS-209 Emerging and Re-emerging

Infectious Diseases
Community Health
Indira Gandhi National Open University
School of Health Sciences Nursing

Block

3
National Health Programmes in India-Role of
Nurse
Unit 1
National Health Mission 11

Unit 2
National Health Programmes related to
Communicable Diseases 31

Unit 3
National Health Programme related to Non
Communicable Diseases 62

Unit 4
National Nutritional Programme 80

Unit 5
Reproductive, Mental, Newborn, Child and Adolescent
Health (RMNCH+A) Strategy 92

Unit 6
National Mental Health Programme 117

7
Health Problems in India:
Role of Nurse in prevention
and Management

8
Emerging and Re-emerging
BLOCK INTRODUCTION Infectious Diseases

Community Health is concerned with the study of health and disease in human
population and its goal is to provide comprehensive need based health care
services to the entire community to achieve the millennium development goals.
A community health nurse is a partner in health team who provides nursing
care, treatment to the sick, health counseling and carries out her services in the
natural environment of people such as home, school, industries and health
center in the community.
Community Health Service is primarily carried outside the therapeutic
institutions such as the hospital. However, the community health nurse links
the community with hospital by her early detection of “risk factors” and referring
the individuals to the hospital for treatment. When individuals are discharged
from hospital, to follow them up in their homes. Community nursing is a vital
component of health services. Community health services have been dynamic,
to keep up with the advancement in various disciplines. This course is built on
your first year courses and you may refer back whenever needed.
This Block on National Health Programmes in India-Role of Nurse is
divided into six units:
Unit 1: National Health Mission
Unit 2: National Health Programmes related to Communicable
Diseases
Unit 3: National Health Programme related to Non Communicable
Diseases
Unit 4: National Nutritional Programme
Unit 5: Reproductive, Mental, Newborn, Child and Adolescent Health
(RMNCH+A) Strategy
Unit 6: National Mental Health Programme
We are confident, that you have by now developed a positive attitude
towards gaining nursing knowledge and skill by distance education method,
particularly through printed materials. If you have find any gross
misinformation regarding printed material, please let us know, so that we
may be able to set right the information. Keep up your strong motivation to
your efforts in continuing education through self-study.
We hope the information given in this Block may help you in improving
your knowledge and skill, so as to provide effective health care to the
individuals, families and communities living in their natural environment.

9
National Health
Programmes in India-
Role of Nurse

10
National Health Mission
UNIT 1 NATIONAL HEALTH MISSION
Structure

1.0 Objectives
1.1 Introduction
1.1.1 Overview of NHM

1.1.2 Milestones of NHM

1.1.3 Vision of NHM

1.2 NUHM Guiding Principles

1.2.1 Goals of NHM

1.3 Components of NHM

1.3.1 Public Health Planning & Financing.

1.3.2 Human Resource strengthening

1.3.3 Health System strengthening.

1.3.4 RMNCH+A services

1.3.5 National Disease Control Programmes (NDCP’S)

1.3.6 Community Processes.

1.4 Organisational structure

1.4.1 National level

1.4.2 District level

1.5 Strategies to achieve targets

1.6 The Primary Care List of Assured Services
1.6.1 Reproductive and Child Health

1.6.2 Emergency and Trauma Care

1.6.3 Communicable Diseases

1.6.4 Non-Communicable Diseases

1.7 Monitoring And Evaluation

1.8 Service Delivery Strategies
1.9 Let Us Sum Up
1.10 Answers to Check Your Progress
1.11 References

1.0 OBJECTIVES
After going through this unit you will be able to:

 Explain the milestones and Vision of NHM

 Describe guiding Principles NUHM/NRHM-NHM

11
National Health  Explain Targets of NHM and Components of NHM
Programmes in India-
Role of Nurse  Explain the organisational structure at National and State level

 Discuss about Strategies to achieve targets

1.1 INTRODUCTION
This is the first unit of this block. In the previous block you have gone through
national health problems. Now, we will be covering various strategies under
related national health programmes to prevent and control these problems. The
National Health Mission (NHM) encompasses its two Sub-Missions, the National
Rural Health Mission (NRHM) and the newly launched National Urban Health
Mission (NUHM). In this unit in initial section emphasis is given on vision,
milestones, guiding principles, targets and components of NHM. In next section
on organisational structure is explained at National level and District level. You
will also read about Strategies to achieve targets in a section. The Primary Care
List of Assured Services including Reproductive and Child Health , Emergency
and Trauma Care , Non-Communicable Diseases , Monitoring And Evaluation,
Service Delivery Strategies are also discussed.

1.1.1 Overview of NHM

The NHM was launched by the government of India in 2013 subsuming the
national rural health mission and National urban health mission. It was further
extended in March 2018 to continue until March 2020. The NHM envisages
achievement of universal access to equitable, affordable & quality health care
services that are accountable and responsive to people’s needs.

NHM focuses on decentralized health planning, service delivery, creating

knowledge hubs with district hospitals, strengthening any rural area at district
hospitals, expanding outreach services, improving community processes and BCC.

The main aim is to create a fully functional decentralized and community owned
system with greater intersectoral coordination so that wider social determinants
factors affecting health of people like water sanitation, nutrition gender and
education are also equally addressed.

NHM is headed by mission director and monitored by national Level monitors

appointed by government of India. The main components of the program include
health system strengthening in rural and urban areas, reproductive – maternal –
new-born – child and adolescent health (RMNCH+A) and control of
communicable and non- communicable diseases.

1.1.2 Milestones of NHM

1992 : Child Survival and Safe Motherhood programme (CSSM)

1997 : RCH I : The programme was formally launched on 15th October 1997.
Phase 1 programme incorporated the 4 components-RCH package,
Family planning, Child survival and safe motherhood Client approach
to health care, Prevention and management of RTI/STDs/AIDS.

12
2005 : RCH II : began from 1st April 2005,the focus is to reduce maternal National Health Mission
and child mortality and morbidity with emphasis on rural health care.

2005 : National Rural Health Mission (NRHM) : The National Rural Health
Mission (NRHM) was launched by the Prime Minister on 12th April
2005, to provide accessible, affordable and quality health care to the
rural population, especially the vulnerable groups.

2013 : RMNCH +A strategy: India’s Reproductive, Maternal, Newborn,

Child and Adolescent Health (RMNCH+A) Strategy, launched in
2013, was a milestone in the country’s health planning.

2014 : India New-born Action plan (INAP): The India Newborn Action Plan
(INAP) is India’s committed response to the Global Every Newborn
Action Plan (ENAP), launched in June 2014 at the 67th World Health
Assembly, to advance the Global Strategy for Women s and Children’s
Health.

1.1.3 Vision of the NHM:

“Attainment of Universal Access to Equitable, Affordable and Quality health care
services, accountable and responsive to people’s needs, with effective inter-
sectoral convergent action to address the wider social determinants of health”.

Core Values of NHM are

• Safeguard the health of the poor, vulnerable and disadvantaged.

• Strengthen public health systems.

• Build environment of trust between people and providers of health services

• Empower community to become active participants in the process of

attainment of highest possible levels of health.

• Institutionalize transparency and accountability in all processes and

mechanisms.

• Improve efficiency to optimize use of available resources.

1.2 NUHM GUIDING PRINCIPLES

Let us now read the principles for the success of achieving the targets as given
below:

Several principles for the success of achieving the targets set by Government of
India were followed

• Build an integrated network of all primary, secondary and a substantial part of

tertiary care, providing a continuum of care from community level to the
district hospital, with robust referral linkages to tertiary care and a particular
focus on strengthening the Primary Health Care System including outreach
services in both rural areas and urban slums.

• Ensure coordinated inter-sectoral action

13
National Health • Ensure prioritization of services that address the health of women and children
Programmes in India- and the prevention and control of communicable and non-communicable
Role of Nurse
diseases, including locally endemic diseases.
• Ensure increased access and utilization of quality health services to minimize
disparity on account of gender, poverty, caste, other forms of social exclusion
and geographical barriers.
• Incentivize good performance of both facilities and providers.
• Address shortages of skilled workers in remote, rural areas, and other under-
served pockets through appropriate monetary and non-monetary incentives.
• Promote partnerships with private, for profit, and not for profit agencies
including civil society organizations to achieve health outcomes.
• Facilitate knowledge networks and create effective public health institutions.
• Encourage and enable the involvement of Panchayati Raj Institutions (PRIs) /
Urban Local Bodies • (ULBs) representatives in the governance and oversight
of health services
• Mainstream AYUSH, so as to enhance choice of services for users and to learn
from and revitalize local health care traditions.
• Expand focus beyond maternal and child survival to ensure quality of life for
women, children and adolescents.

1.2.1 Goals of NHM

• Reduce MMR to 1/1000 live births

• Reduce IMR to 25/1000 live births

• Reduce TFR to 2.1
• Prevention and reduction of anaemia in women aged 15–49 years
• Prevent and reduce mortality & morbidity from communicable, non-
communicable; injuries and emerging diseases
• Reduce household out-of-pocket expenditure on total health care expenditure
• Reduce annual incidence and mortality from Tuberculosis by half
• Reduce prevalence of Leprosy to <1/10000 population and incidence to zero
in all districts
• Annual Malaria Incidence to be <1/1000
• Less than 1 per cent microfilaria prevalence in all districts
• Kala-azar Elimination by 2015, <1 case per 10000 population in all blocks

Goals of this phase of NHM will be towards enabling and achieving the stated
vision.

Making the system responsive to the needs of citizens, building a broad based
inclusive partnership for realizing National health goals, focusing on the survival
and well-being of women and children, reducing existing disease burden and
ensuring financial protection for households.

14
Check Your Progress 1 National Health Mission

Q1) What are the milestones of NHM

1.3 COMPONENTS OF NHM

Let us read the components covered under NHM as given below:

1. Public health Planning & Financing.

2. Human resource strengthening.
3. Health System strengthening.
4. RMNCH+A services
5. National disease control programmes (NDCP’S)
6. Community Processes.

1.3.1 Public health planning & financing

 As pure health indicators facilities & differential planning & made for district
/cities /blocks.
 Planning for full spectrum of health services.
 Emphases on quality assurance in delivery points
 Strengthening of management
 Developing a separate & trained public health cadre of professionals
including Nurses & Doctors.

1.3.2 Human resource strengthening in health;

 Based on Cases arrangement of Health professionals
 HR accountability Performance based incentives & for working in difficult
areas
 Additional incentives to health professionals to serve in rural and remote
areas.
 Speedy recruitment to fill up vacancy, preferable decentralized.
 Amendments in medical colleges norms to ease availability of
heaths professionals
 Capacity building & training of staff at all levels.

15
National Health 1.3.3 Health System strengthening.
Programmes in India-
Role of Nurse  Construction of new building & renovation of existing one.
 Improving sanitation & Hygiene in Public facilities: Kavakalp Kayakalp is
new initiative launched in 2015 to increase the hygienic, sanitation, effective
waste management & infections control practices in public health facilities.
 It includes Certificate of commendation & Cash Awards of such public health
care facilities that show good performance & Compliance to protocol.
 Social protection:- Reducing out of pocket expense

A. Drugs:- Free drugs service initiatives.

- Essential drugs as per the defined Essential drugs list are given free of
cost.
- Central procurement of drugs as per various programme EDL & standard
& Guidelines
- Provision of local purchase of drugs & Supplies at lower level.

B. Diagnostics:- free diagnostics service initiative.

- free of cost diagnostic services (radiological & laboratory) are provided to

patients as per level of facilities

C. Diet:- free good quality Diet.

- It’s available to all inpatients including pregnant women

D. Transport:- emergency response system (ERS) / patient transport service /

National Ambulance services.

Based on Janani Suraksha Yojana, & Janani Sishu Suraksha Karyakram (JSSK)
these cashless basic services are provided

Ambulance Services

108 Ambulance 102 Ambulance

- It’s an Emergency response System - It’s basic patient transport System.

- These ambulance work to bring - They are located in govt. hospitals
& post delivery, drop back facility
1. victims of accidents to nearest govt. - They provide
hospital. 1. Facilities to all registered children
& mother from hospital to their
2. to shift patient to district hospital. homes.
3. pickup facilities for pregnant women 2. To bring critically ill neonatal
from their home to health care centre patients from homes to hospital to.
for institutional delivery

• Approximately l ambulance work for 1 lakh population.

Have 3 drivers + 3 paramedical emergency technician + 2 Supervisors for 15
vehicles

16
• Outreach Services - Mobile Medical Units: - National Health Mission

- In difficult terrain & remote areas vehicles are appointed to carry health
care to door step of patients & they carry drugs, supplies & laboratory &
diagnostics equipment.

1.3.4 Reproductive, Maternal, Newborn, Child Health &

Adolescent services (RMNCH+A).
- For reducing maternal & child health mortality,
- To improve in access & utilisation of health care services by vulnerable
population

Sub-Component of this scheme are :

A. Reducing maternal mortality rate : Maternal Health.

a) Incentives - Janani Suraksha Yojana.

- Incentives are paid to all pregnant women of both Urban & rural areas
for delivery in public institutions.
- It facilitate public institutional deliveries.

State Incentives under J SY. I

Rural Areas Urban Areas
Pregnant Women Asha Pregnant Women Asha
High performance 700 600 600 400
Status
Low performance 1,400 600 1,000 400
Status
At Home delivery 500 - 500 -

b) Free Patient entitlements: - Janani Sishu Suraksha Karyakram. (JSSK).

- This Scheme ensure the caseless delivery & c-section for pregnant women
& management of sick neonates upto a year to prevent incurring high out
of pocket expenses a exploitation by unwarranted people.

Pregnant women Sick newborn till 30 days of life

 free & Caseless delivery  free treatment

 free c-section  free dung & Consumables
 free dung & Consumables  free diagnostics
 free diagnosis  free provision of blood
 free diet during hospital stay  Exemption from other charges
 free provision of blood  free transport.
 Exemption from user charges
 Free transport – from home to hospital
From hospital to home in 48 hr
Referral to other facility
17
National Health c) Strengthening Infrastructure & MCH Services.
Programmes in India-
Role of Nurse - MCH separate wings can be established in District hospitals Sub-District
hospitals / CHC / FRU to overcome the constraints of the Caseloads &
institutional delivery at these facilities.
d) Reorienting Medical Education - Skill Labs
- Establish for competency based training & skill of professionals
e) Capacity building & Daksha Programme.
- for service providers in labour room
f) Promotive health: Mothers absolute Affection
- For promotion of breast feeding.
g) Improve access & Coverage & safe abortion services.
- MTP provided in FRU, 24x 7.
h) Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
- The 9th months of pregnant ladies are provided free health check-up
including BP, Sugar and other blood test etc. & treatment in all health
care facilities. Private sector Gynaecologist are encouraged to voluntary
participate & provide ANC services in these public health facilities.
i) NGO involvement
j) Monitoring & accountability of Services:- Maternal Wealth Review
- Purpose o facility based MDR & Community based MDR is to identify
the causes of maternal death & gap in Service delivery, for taking correct
action.
k) Reducing IMR & child mortality rate :-
i. Newborn care service, programme
Location Services
Newborn Care Corner All delivery points Essential newborn care, 0day
in communication.
Newborn stabilization CHCS/FRUs Stabilization & referral of
sick newborn
Special Newborn care DHs & tertiary care Management of sick newborn
units (SNC Us) hospital
ii. Universal Immunisation Programme (UIP) & Mission Indra Dhanush.
iii. Rashtriya Bal Swasthya Karyakaram (RBSK)
- To improve overall quality of life of children, 0-18 yrs.
- Early detection & intervention 4D’s - Defect at birth.
By management - Deficiency Diseases
Screening
Support -
Through medical referral to - Development delay
Health team /higher centre - Disabilities.
in every block/ in school/ Anganwadi
18
iv. IMNCI National Health Mission

v. Nutritional Rehabilitation Centers (NRC’S)

vi. Monitoring : Child health Review

B. Adolescent Health programme.

i. Rashtriya Kishor Swasthya Karya Karam (RKSK)

adolescent friendly health services are provide in District health facilities

to provide counselling on:- sexual & reproductive health substance
abuse, Violence - domestic Violence, Mental health, injury, NCD &
provide iron & folic acid tablets, condoms, pregnancy kits, OCP’S
through counselor.

ii. Reducing Fertility Rate - family planning services - (FPS)

FPS are delivered at district; all PHC’s CHC’s & DH, provides both
temporary & permanent methods

iii. Declining Sex Ratio: Govt. implement the Pre-conception & Pre-natal
Diagnostic Techniques (PCPNDT) Act, 1994

Preventing Communicable & Non Communicable disease: For details

refer Unit 2 and Unit 3 of this block.

1.3.5 National Disease Control Programmes (NDCP’S)

Non Communicable Disease Communicable Disease
Programmes Programmes
- National programme for prevention - - National Vector Borne Disease
& Control of diabetes, CVD- stroke Control Programme (NVBDCP)
- National programs for Prevention & - Revised National Tuberculosis
Control of Blindness. Control Programme (RNTCP)
- National Mental Health programme. - National Leprosy Eradication
programme
- NIDDCP - Integrated Disease surveillance
Programme
- NTCP
- National Oral Health programme.
- National programme for Health Care
of Elderly.

1.3.6 Community Processes

Various community processes are as given below:

Community - Led Action for health.

Community-Led Activities

a) Village Health Sanitation & Nutrition Committee (VHSNC).

b) ASHA

19
National Health c) Anganwadi workers
Programmes in India-
Role of Nurse d) Jan Sunwai & Jan Samvad:- Public dialogues / Public
Hearing taking direct feedback from the community members.

- IEC Activities:- Comprehensive communication strategy includes

BCC with IEC strategies to disseminate in villages lowest level.

- Participants and Govt. professionals agencies, Non govt.

agencies Specialized agencies, visible mass medias give efforts in
massive health communication.

1.4 ORGANISATIONAL STRUCTURE

Let us read the Organisational structure at National and District level as given
below:

*INSTITUTIONAL FRAME WORK:

- National Institute of Health & family welfare
1.4.1 National level

Implementation structure - Apex body for training &

Ministry of Health & skill development
family Welfare, Go1

Mission Director . National health system

resource Centre
- for technical support
Programme
Programme Divisions FM headed by Director
(Finance) National Programme
management Unit for
programme management &
State Health Society activities for policy support
Programmes.
 District hospital National ASHA mentoring
 General hospital District health society/City group
 Sub District hospital Health society
 Rogi Kalyan Samitri

Community Health Centre/ Sub Centres Village, Health sanitation

PHC’s of nutrition committee (VHSNC)

Rahikalya Samitri
(RKS)

20
1.4.2 District level structure National Health Mission

District Collector

CMO

Medical officer NRHM Nodal officer NVHM

District District District District District District

Programme Account Quality Early Community Urban
Manager Manager Assurance intervention process Health
Officer Centre Manager
Coordinator
Manager
District ASHA
District ASHA Training

1.5 STRATEGIES TO ACHIEVE TARGETS

Following strategies were adopted during NUHM

1. Support and supplement state efforts to undertake sector wide health system
strengthening through the provision of financial and technical assistance.

2. Build state, district and city capacity for decentralized outcome based
planning and implementation

3. Enable integrated facility development planning which would include

infrastructure human resources, drugs and supplies, quality assurance, and
effective Rogi Kalyan Samitis (RKS).

4. Create a District Level Knowledge Centre within each District Hospital

5. Improve delivery of outreach services

6. Strengthen the sub-centre/Urban Primary Health Centre (UPHC) with

additional human resources and supplies

7. Prioritize achievement of universal coverage for Reproductive Maternal,

Newborn, Child Health + Adolescent (RMNCH+A), National Communicable
Disease Control and Non Communicable Diseases programmes.

8. Expand focus from child survival to child development of all children 0-18
years through a mix of Community, Anganwadi, and School based health
services.

9. Achieve the goals of safe motherhood

10. Focus on adolescents and their health needs.

11. Ensure the control of communicable disease

21
National Health 12. Use primary health care delivery platforms to address the rising burden of
Programmes in India- Non- Communicable Diseases
Role of Nurse
13. Converge with Ministry of Women & Child Development

14. Empower the ASHA to serve as a facilitator, mobilizer and provider of

community level care.

15. Strengthen people’s organizations such as the Village Health Sanitation and
Nutrition Committees (VHSNC) and Mahila Arogya Samitis (MAS)

16. Create mechanisms to strengthen Behaviour Change Communication

17. Develop effective partnerships with private sector

18. Enhance use of Information & Communication Technology

19. Strengthen Health Management Information Systems

20. Ensure universal registration of births and deaths with adequate information
on cause of death

21. To ensure equitable health care and to bring about sharper improvements in
health outcomes

22. The government has already taken steps towards provision of free maternal,
and child health services, including newborn care, immunization, adolescent
health, and family planning.

23. Free diagnostic and treatment services

24. Focus on strengthening primary health care across the country.

1.6 THE PRIMARY CARE LIST OF ASSURED

SERVICES
Let us now read about the services assured in primary care as given below:

1.6.1 Reproductive and Child Health

a. Care in pregnancy- All care including identification of complications, but
excluding management of complications requiring surgery or blood
transfusion.

b. All aspects of Essential New-born Care.

c. Care for common illnesses of new-born and of children- identify, stabilize and
refer life threatening conditions beyond the approved skill sets of the mid
level care provider.

d. Immunization

e. Universal use of iodized salt.

f. All aspects of prevention and management of malnutrition, excepting those

that requiring institutional care.

g. All family planning services except female sterilization

22
h. Provision of safe abortion services - medical and surgical. National Health Mission

i. Identification and management of anaemia, Common sexual and urogenital

problems which can be treated syndromically, or diagnose with point of care
diagnostics, and identification of those which need referral.

j. All health education and individual counselling measures needed for

promotion of desirable health behaviours and health care practices and change
from inappropriate health care practices and behaviours, related to RCH.

k. All activities under the Rashtriya Bal Suraksha Karyakram- at Anganwadi and
school level

l. All laboratory support

m. Patient transport systems that can bring and drop back patients for example
sick infants up to one year of age, institutional delivery, for disability, and
address problems of access due to lack of transport.

1.6.2 Emergency and Trauma Care

a) Prevention and appropriate management for bites and stings- snakes,
scorpions, wild animals.

b) Management of poisoning, including food poisoning.

c) Complete first aid including management of minor injuries

d) Stabilization care in poisoning and major injuries and ensuring referral

through emergency response systems.

1.6.3 Control of Communicable Diseases

a) Screening for leprosy, referral on suspicion, and follow up of cases with
confirmed diagnosis and prescribed treatment.

b) Referral of suspect tuberculosis, family level screening of known patients, and

follow up of cases with confirmed diagnosis and prescribed treatment.

c) HIV testing, appropriate referral and follow up of specialist-initiated

treatment.

d) All measures for the prevention of Vector Borne Diseases; early and prompt
treatment for these diseases, with referral of complicated cases.

e) Control of helminthiasis.

f) Reduction in burden of waterborne disease

g) Reduction of infectious hepatitis B and identification and referral for the

same.

h) Primary care for other infectious diseases

1.6.4 Non-Communicable Diseases

a) Screening for breast and cervical cancers in all women over the age of 30.

b) Screening for mental disorders, counselling, and follow up to specialist

initiated care.
23
National Health c) Detection of epilepsy and stroke and follow up to specialist initiated drugs and
Programmes in India- rehabilitative measures.
Role of Nurse
d) Screening for visual impairments, correction of refractive errors and referrals
for the rest.

e) Screening for diabetes and hypertension in all population above 30 annually.

f) Ensuring follow up on doctor initiated drugs in diabetes and hypertension- and

secondary prevention – so that no complications develop.

g) Prevention – primary, secondary and tertiary preventive care in rheumatic

heart disease.

h) Primary and secondary prevention in COPD and bronchial asthma, with

provision of follow up care in patients put on treatment by specialists.

i) Counselling and support to victims of violence.

j) Preventive measures against all harmful addictive substances- tobacco in the

main, but also alcohol and addictive drugs

k) Community based geriatric care support.

l) Preventive and promotive measures to address musculo- skeletal disorders-

mainly osteoporosis, arthritis of different types and referral or follow up as
indicated.

m) Community based rehabilitative and disability care support.

Check Your Progress 2

Q1) What strategies are adopted to achieve the targets of NHM

Q2) What are the aims of reproductive and child health strategy
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

3) List the components of NHM

1.7 MONITORING AND EVALUATION

For monitoring and evaluation of NHM program several mechanisms were
adopted. The primary aim is to serve as a strong and harmonized M&E component
of the NHS, covering all major disease programmes as well as health system
actions through

 Use of data from large scale population surveys

 Commissioning implementation research or evaluation studies

24
 Use of HMIS data and field appraisals and reviews National Health Mission

 Health outcomes, output and process indicators

 Periodic Population Health Surveys and Demographic Information

 The Sample Registration Surveys (SRS)

 Death statistics

 National Sample Survey Organization (NSSO) data on cost of care and

morbidity, DLHS and NFHS.

1.8 SERVICE DELIVERY STRATEGIES

 Reproductive, Maternal, Newborn, Child Health and Adolescent
(RMNCH+A) Services
 Maternal Health – Comprehensive package of RMNCH+A services. – Janani
Suraksha Yojana (JSY) – Janani Shishu Suraksha Karyakram (JSSK)
 Access to safe abortion services
 Prevention and Management of Reproductive Tract Infections (RTI) and
Sexually Transmitted Infections (STI)
 Gender Based Violence
 New-born and Child Health
 Universal Immunization
 Health Screening and Early Intervention Services
 Adolescent Health
 Iron and Folic Acid (IFA) supplementation and Provision of Weekly Iron and
Folic acid Supplementation (WIFS) and National Iron Plus Initiative.
 Facility -based adolescent health services
 Community based health promotion activities
 Information and counseling on sexual and reproductive health (including
menstrual hygiene),
 Substance abuse
 Mental health
 Non-communicable diseases, injuries
 Adolescent Friendly Health Clinics (AFHC)
 Family Planning – Intra-Uterine Contraceptive Devices (IUCD).

Control of Communicable Diseases

 The National Vector Borne Diseases Control Programme (NVBDCP) is an

umbrella programme for prevention and control of vector borne diseases viz.
Malaria, Japanese Encephalitis (JE), Dengue, Chikungunya, Kala-Azar and
Lymphatic Filariasis. Of these, Kala-Azar and Lymphatic Filariasis have been
targeted for elimination by 2015. Please refer details in Unit 2 of this block.
25
National Health  Revised National Tuberculosis Control Programme (RNTCP)
Programmes in India-
Role of Nurse  National Leprosy Control Programme (NLEP)
 Integrated Disease Surveillance Programme (IDSP)
Non Communicable Diseases (NCD)
 National Programme for Prevention and Control of Cancer, Diabetes,
Cardiovascular Diseases and Stroke (NPCDCS)
 National Programme for the Control of Blindness (NPCB)
 National Mental Health Programme (NMHP)
 National Programme for the Healthcare of the Elderly (NPHCE)
 National Programme for the Prevention and Control of Deafness (NPPCD
 National Tobacco Control Programme (NTCP)
 National Oral Health Programme (NOHP)
 National Programme for Palliative Care (NPPC)
 National Programme for the Prevention and Management of Burn Injuries
(NPPMBI)
 National Programme for Prevention and Control of Fluorosis (NPPCF)

Check Your Progress 3

Q1) Explain Adolescent Health programme.

Reducing Fertility Rate - family planning services - (FPS)

Declining Sex Ratio:

Q2) what are the ways and means of monitoring and evaluation of NHM
services
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q3) Name three non communicable disease health programmes under

NHH
....................................................................................................................
.....................................................................................................................
.....................................................................................................................

26
National Health Mission
1.9 LET US SUM UP
In this unit we have discussed The NHM envisages achievement of universal
access to equitable, affordable & quality health care services that are accountable
and responsive to people’s needs.

1.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) The milestones of NHM

1992: Child Survival and Safe Motherhood programme (CSSM)

1997: RCH I : The programme was formally launched on 15th October 1997.
Phase 1 programme incorporated the 4 components-RCH package, Family
planning, Child survival and safe motherhood Client approach to health care,
Prevention and management of RTI/STDs/AIDS.

2005: RCH II : began from 1st April 2005,the focus is to reduce maternal and
child mortality and morbidity with emphasis on rural health care.

2005: National Rural Health Mission (NRHM) : The National Rural Health
Mission (NRHM) was launched by the Prime Minister on 12th April 2005, to
provide accessible, affordable and quality health care to the rural population,
especially the vulnerable groups.

2013: RMNCH +A strategy: India’s Reproductive, Maternal, Newborn, Child

and Adolescent Health (RMNCH+A) Strategy, launched in 2013, was a
milestone in the country’s health planning.

2014: India New-born Action plan (INAP): The India Newborn Action Plan
(INAP) is India’s committed response to the Global Every Newborn Action
Plan (ENAP), launched in June 2014 at the 67th World Health Assembly, to
advance the Global Strategy for Women s and Children’s Health.

2) Five guiding principles of NHM

1) Build an integrated network of all primary, secondary and a substantial

part of tertiary care, providing a continuum of care from community
level to the district hospital, with robust referral linkages to tertiary care
and a particular focus on strengthening the Primary Health Care System
including outreach services in both rural areas and urban slums.

2) Ensure coordinated inter-sectoral action

3) Ensure prioritization of services that address the health of women and

children and the prevention and control of communicable and non-
communicable diseases, including locally endemic diseases.

4) Ensure increased access and utilization of quality health services to

minimize disparity on account of gender, poverty, caste, other forms of
social exclusion and geographical barriers.

5) Incentivize good performance of both facilities and providers.

27
National Health Check Your Progress 2
Programmes in India-
Role of Nurse Q1) Strategies are adopted to achieve the targets of NHM

1. Support and supplement state efforts to undertake sector wide health

system strengthening through the provision of financial and technical
assistance.
2. Build state, district and city capacity for decentralized outcome based
planning and implementation
3. Enable integrated facility development planning which would include
infrastructure human resources, drugs and supplies, quality assurance,
and effective Rogi Kalyan Samitis (RKS).
4. Create a District Level Knowledge Centre within each District
Hospital
5. Improve delivery of outreach services
6. Strengthen the sub-centre/Urban Primary Health Centre (UPHC) with
additional human resources and supplies
7. Prioritize achievement of universal coverage for Reproductive
Maternal, Newborn, Child Health + Adolescent (RMNCH+A),
National Communicable Disease Control and Non Communicable
Diseases programmes.
8. Expand focus from child survival to child development of all children
0-18 years through a mix of Community, Anganwadi, and School
based health services.
9. Achieve the goals of safe motherhood
10. Focus on adolescents and their health needs.
11. Ensure the control of communicable disease
12. Use primary health care delivery platforms to address the rising
burden of Non- Communicable Diseases
13. Converge with Ministry of Women & Child Development
14. Empower the ASHA to serve as a facilitator, mobilizer and provider of
community level care.
15. Strengthen people’s organizations such as the Village Health
Sanitation and Nutrition Committees (VHSNC) and Mahila Arogya
Samitis (MAS)
16. Create mechanisms to strengthen Behaviour Change Communication
17. Develop effective partnerships with private sector
18. Enhance use of Information & Communication Technology
19. Strengthen Health Management Information Systems
20. Ensure universal registration of births and deaths with adequate
information on cause of death

28
21. To ensure equitable health care and to bring about sharper National Health Mission
improvements in health outcomes
22. The government has already taken steps towards provision of free
maternal, and child health services, including newborn care,
immunization, adolescent health, and family planning.
23. Free diagnostic and treatment services
24. Focus on strengthening primary health care across the country.
Q2) The aims of reproductive and child health strategy
- To reduce maternal & child health mortality,
- To improve in access & utilisation of health care services by
vulnerable population
Q3) The components of NHM
The components under NHM are:
 Public health Planning & Financing.
 Human resource strengthening.
 Health System strengthening.
 RMACHTA services
 National disease control programmes (NDCP’S)
 Community Processes.
Check Your Progress 3
1) Adolescent Health programme.
i. Rashtriya Kishor Swasthya Karya Karam (RKSK)
adolescent friendly health services are provide in District
health facilities to provide counselling on:- sexual & reproductive
health substance abuse, Violence - domestic Violence, Mental health,
injury, NCD & provide iron & folic acid tablets, condoms, pregnancy
kits, OCP’S through counselor.
ii. Reducing Fertility Rate - family planning services - (FPS)
FPS are delivered at district; all PHC’s CHC’s & DH, provides both
temporary & permanent methods
iii. Declining Sex Ratio: Govt. implement the Pre-conception & Pre-natal
Diagnostic Techniques (PCPNDT) Act, 1994
2) The ways and means of monitoring and evaluation of NHM services
For monitoring and evaluation of NHM program several mechanisms were
adopted. The primary aim is to serve as a strong and harmonized M&E
component of the NHS, covering all major disease programmes as well as
health system actions through
• Use of data from large scale population surveys
• Commissioning implementation research or evaluation studies

29
National Health • Use of HMIS data and field appraisals and reviews
Programmes in India-
Role of Nurse • Health outcomes, output and process indicators

• Periodic Population Health Surveys and Demographic Information

• The Sample Registration Surveys (SRS)

• Death statistics

• National Sample Survey Organization (NSSO) data on cost of care and

morbidity, DLHS and NFHS.

3) Three non communicable disease health programmes under NHM

• National Programme for Prevention and Control of Cancer, Diabetes,

Cardiovascular Diseases and Stroke (NPCDCS)

• National Programme for the Control of Blindness (NPCB)

• National Mental Health Programme (NMHP)

1.11 REFERENCES
• K.Park; Text Book of Preventive and Social Medicine; Bhanot Banarsidas
Publishers, 22nd Edition 2009

• Keshav Swarnkar, Community Health Nursing; 2nd Edition, Nr Brothers

Publications

• K.K Gulani ‘Community Health Nursing’ Kumar Publishers 1st Edition

• AH Suryakantha, Community Medicine With Recent Advances, 2nd Edition,

New Delhi: Jaypee Publishers, 2010

• www.keralahealht/gov.in

• www.who.in

• http://www.urban.health.resource.centre.in/module

• NRHMbulletin.vol7(4)july-aug2012

30
National Health Programmes
UNIT 2 NATIONAL HEALTH Related to Communicable
PROGRAMMES RELATED TO Diseases

COMMUNICABLE DISEASES
Structure

2.0 Objectives
2.1 Introduction
2.2 National Vector Borne Disease Control Programme (NVBDCP)
2.2.1 Malaria
2.2.2 Urban Malaria Scheme
2.3 Malaria Control Strategies
2.3.1 Surveillance and case management
2.3.2 Integrated vector management (IVM)
2.3.3 High-risk areas and populations
2.3.4 Behaviour change communication (BCC)
2.3.5 Interaction of malaria control with other health programmes
2.4 National Filarial control programme
2.5 Kala-Azar Control Programme
2.6 Japanese Encephalitis Control
2.7 Dengue Fever Control
2.8 Chikungunya fever
2.9 Revised National Tuberculosis Control Programme
2.9.1 Organization
2.9.2 Programmatic Management Of Drug Resistant TB (PMDT)
2.10 National Leprosy Eradication Programme
2.10.1 Disability prevention and medical rehabilitation (DPMR)
2.10.2 Services in the urban areas
2.10.3 ASHA involvement
2.11 National Aids Control Programme
2.11.1 HIV surveillance
2.11.2 Prevention of Parent-To-Child Transmission of HIV
2.11.3 HIV Testing of Tuberculosis Patients
2.11.4 Targeted Interventions for High-Risk Groups
2.12 Let Us Sum Up
2.13 Answers to Check Your Progress
2.14 References

31
National Health
Programmes in India- 2.0 OBJECTIVES
Role of Nurse
After completing this unit, you will be able to:

 describe the organizational set up of National Anti Malaria Programme;

 describe the treatment for malaria;

 narrate the provisions made by Government against mosquito borne disease;

 guide a tuberculosis patient for proper treatment and follow up;

 state the organizational set up of National Leprosy Eradication Programme

(NLEP);

 describe the health activities under NLEP;

 discuss the importance of prevention in the management of AIDS; and

 describe the health activities under NACP.

2.1 INTRODUCTION
In the previous unit you have read about National Health Mission in details. In
this unit , emphasis is given to the National health programmes related to
prevention and control of communicable diseases, namely National Vector Borne
Disease Control Programme (NVBDCP) Surveillance and case management ,
Parameters of malaria surveillance, High-risk areas and populations with
important strategy of Behaviour change communication (BCC). National filarial
control programme, Kala-Azar Control Programme, Japanese Encephalitis
Control Dengue Fever Control and Chikungunya fever control are covered. You
must be thorough and familiar with these diseases and related programme
strategies. A section each on Revised National Tuberculosis Control Programme,
National Leprosy Eradication Programme and National Aids Control Programme
are dealt in the unit.

2.2 NATIONAL VECTOR BORNE DISEASE

CONTROL PROGRAMME
The national Vector Borne Disease Control Programme (NVBDCP) was
implemented in the State/UT’s for prevention and control of vector borne diseases
namely malaria, Filariasis, Kala-azar, Japanese Encephalitis (JE), Dengue and
Chikungunya.

The vector borne diseases are major public health problems in India.
Chikungunya fever which has re-emerged as epidemic outbreaks after more than
three decades has added to the problem. The prevention and control of vector
borne diseases is complex; as their transmission depends on interaction of
numerous ecological, biological, social and economic factors including migration.

Under NVBDCP, the three pronged strategy for prevention and control of VBDs
is as follows:

32
(i) Disease management including early case detection and complete treatment, National Health Programmes
strengthening of referral services, epidemic preparedness and rapid response Related to Communicable
Diseases
(ii) Integrated vector management (IVM) for transmission risk reduction
including indoor residual spraying in selected high-risk areas, use of
insecticide treated bed-nets, use of larvivorous fish, anti-larval measures in
urban areas, source reduction and minor environmental engineering

(iii) Supportive interventions including behavior change communication (BCC)

public private partnership and inter-sectoral convergence, human resource
development through capacity building, operational research including
studies on drug resistance and insecticide susceptibility, monitoring and
evaluation through periodic reviews/ field visits, web based management
information system, vaccination against JE and annual mass drug
administration against lymphatic filariasis.

2.2.1 Malaria
The programme was launched originally as National Malaria Control Programme
in 1953, during the First Five Year Plan. The control programme, was later
converted in 1958 into an eradication programme, with the objective of
eradicating malaria once and for all from the country.

In 2002 the programme was renamed from NAMP to National Vector Borne
Disease Control Programme

The main activities of the programme are as follows:

1. Formulating policies and guidelines

2. Technical guidance

3. Planning

4. Logistics

5. Monitoring and evaluation

6. Coordination of activities through the States/Union Territories and in

consultation with national organizations such as National Centre for Disease
Control (NCDC), National Institute of Malaria Research (NIMR)

7. Collaboration with international organizations like the WHO, World Bank,

GFATM and other donor agencies

8. Training

9. Facilitating research though NCDC, NIMR, Regional Medical Research

Centres etc

10. Coordinating control activities in the inter-state and inter-country border

areas

Organization

There are 19 Regional Offices for Health and Family Welfare under Directorate
General of Health Services, Ministry of Health and Family Welfare, located in 19
states, which play a crucial role in monitoring the activities under NVBDCP.
33
National Health These offices are equipped with malaria trained staff.
Programmes in India-
Role of Nurse Every state has a Vector Borne Disease Control Division under its department of
Health and Family Welfare. It is headed by the State Programme Officer (SPO).
States are responsible for the procurement of certain insecticides for indoor
residual spray (IRS), spray equipment and certain anti-malarials, the central
government supplies DDT and larvicides.

Each state has established a State Vector Borne Disease Control Society, which
includes civil society and sometimes private sector representation.

At the divisional level, zonal officers have technical and administrative

responsibilities of the programme in their areas under the overall supervision of
Senior Divisional Officers (SDOs).

At the district level, the Chief Medical Officer (CMO)/ District Health Officer
(DHO) has the overall responsibility of the programme. At the district level,
DVBDC officer assists the CMO/DHO. There is one Assistant Malaria Officer
(AMO) and Malaria Inspector (MIs) to assist him.

The laboratories have been decentralized and positioned at the PHCs. The medical
officer of the PHC has the overall responsibility for surveillance and laboratory
services, and also supervises the spray. Case detection management and
community outreach services are carried out by MPWs as well as ASHAs and
other community health volunteers.

2.2.2 Urban Malaria Scheme

The urban malaria scheme was launched in 1971 to reduce or interrupt malaria
transmission in towns and cities. About 7.4 per cent of the total cases of malaria
and 10.9 per cent of deaths due to malaria are reported from urban areas.

Factors related to occurrence of cases of Malaria

The vector of malaria in the urban areas breeds largely in man-made containers
including overhead tanks and underground water storage tanks, water coolers,
cisterns, roof gutters, flowers vases, bottles and ornamental ponds, old tyres etc.,
which can collect water. Large construction activities provide suitable breeding
sites for the mosquitoes. Influx of migrant labour, from malarious zones
contribute to increase in incidence.

Measures to prevention and control

Control of urban malaria lies primarily in the implementation of civil bye-law to

prevent mosquito breeding in the domestic and peri domestic areas.

Use of larvivorous fish in the water bodies such as slow moving steams,
ornamental ponds etc. is recommended. Larvicides are used for water bodies such
as slow moving streams, ornamental ponds etc. is recommended. Larvicides are
used for water bodies which are unsuitable for fish use. The urban malaria scheme
under national vector disease control programme is presently protecting 116
million population from malaria and other mosquito borne diseases in 131 towns
in 19 states and Union Territories. The civic bye-laws have been enacted and
implemented in Delhi, Mumbai, Kolkata, Chandigarh, Bangalore, Chennai,
Ahmedabad and Goa etc.
34
Malaria control is now incorporated into the heath service delivery programme National Health Programmes
under the umbrella of NRHM. This provides opportunities for strengthening Related to Communicable
Diseases
malaria prevention and treatment services close to the community. All available
methods and means are being used to deliver these interventions, at entry level
facilities (e.g. CHCs, PHCs, and sub-centres), community outreach services using
village level, NGOs, private-sector providers and district and regional health
facilities and hospitals.

Objective

To achieve API<1 per 1000 population by the end of 2017 Goals

The national goals for strategic plan are:

1. Screening all fever cases suspected for malaria (60% through quality
microscopy and 40% by rapid diagnostic test.
2. Treating all P. falciparum cases with full course of effective ACT and
primaquine, and all P. vivax cases with 3 days chloroquine and 14 days
primaquine.
3. Equipping all health institutions (PHC level and above), especially in high-
risk areas, with microscopy facility and RDT for emergency use and
injectable artemisinin derivatives.
4. Strengthening all district and sub-district hospitals in malaria endemic areas
as per IPHS with facilities for management of severe malaria cases.

Outcome Indicators

The outcome indicators of strategic plan are:

1. At least 80% of those suffering from malaria get correct, affordable,

appropriate and complete treatment within 24 hours of reporting to the health
system, by the year 2017.
2. At least 80% of those at high risk of malaria get protected by effective
preventive measures such as ITN/LLIN or IRS by 2017.
3. At least 10% of the population at high-risk areas is surveyed annually (annual
blood examination rate>10%).

2.3 MALARIA CONTROL STRATEGIES

The strategies for prevention and control of malaria and its transmission are
discussed in details as given below:

1. Surveillance and case management

- Case detection (passive and active)
- Early diagnosis and complete treatment
- Sentinel surveillance.
2. Integrated vector management (IVM)
- Indoor residual spray (IRS)
- Insecticide treated bed nets (ITNs)/Long Lasting
35
National Health Insecticidal Nets (LLINs).
Programmes in India-
Role of Nurse - Antilarval measures including source reduction.

Epidemic preparedness and early response.

Supportive interventions

- Capacity building

- Behaviour change communication (BCC)

- Intersectoral collaboration

- Monitoring and evaluation

- Operational research and applied field research.

2.3.1 Surveillance and case management

Surveillance and case management are most important for management of cases,
The primary purpose of case management is to shorten the duration of illness,
prevent the development of severe disease and death, especially in falciparum
malaria. Therefore, case management for malaria is based on early diagnosis
followed immediately by effective treatment. Early effective treatment is also
important for limiting transmission of the disease.

Active case detection (ACD) is carried out in rural areas with blood smears
collected by MPWs during fortnightly house visits. Passive case detection (PCD)
is done in fever cases reporting to peripheral health volunteers/ASHAs and at sub-
centres, malaria clinic, CHC, and other secondary and tertiary level health
institutions that patients visit for treatment.

The new norms for case management emphasize quality care for patients. The
implementation of use of Rapid Diagnostic Tests (RDTs) and Artesunate
combination therapy (ACT) and the improvement in service delivery is expected
to attract greater number of fever cases to the programme in the coming years.

Parameters of malaria surveillance are:

a) Annual parasite incidence rate (API)

b) Annual blood examination rate (ABER)

c) Annual Falciparum incidence (AFI)

d) Slide Positivity rate (SPR)

e) Slide Falciparum Rate (SFR)

2.3.2 Integrated vector management (IVM)

The NVBDCP aims to achieve effective vector control by the appropriate
biological, chemical and environmental interventions of proven efficacy,
separately or in combination as appropriate to the area through the optimal use
resources. Efforts are made for collaboration with various public and private
agencies and community participation for vector control. The IVM includes sage
use of insecticides and monitoring of insecticide resistance. The measures of
vector control and protection include:
36
- Measures to control adult mosquitoes: Indoor Residual Spray (IRS) National Health Programmes
Related to Communicable
- Antilarval measures: Chemical, biological and environmental Diseases

- Personal protection: use of bed-nets, including insecticide treated nets.

2.3.3 High-risk areas and populations

Using local surveillance data vector control experience, including the knowledge,
habits and attitudes of the local community, district VBDC staff will be
responsible for identification and mapping of high risk areas and risk populations
as a basis for planning vector control.

As much as possible, the village is to be the unit of intervention, but in some

districts, data available with knowledge of ecological conditions may make it
more rational to classify whole sub-centre areas as high-risk areas. High risk areas
and populations will be re-defined at least annually. Such villages shall be
protected by indoor residual spray and insecticide treated nets and the coverage
will be more than 80 per cent, whatever may be the intervention.

2.3.4 Behaviour change communication (BCC)

BCC is a systematic process that motivates individuals, families and communities
to change their inappropriate or unhealthy behavior; or to continue a healthy
behavior.

BCC is directed at: (a) early recognition of signs and symptoms of malaria; (b)
early treatment seeking from appropriate provider; (c) adherence to treatment
regimens; (d) ensuring protection of children and pregnant women; (e) use of
ITNs/ LLINs; (f) acceptance of IRS, etc.

Anti-malaria month campaign

Anti-malaria month is observed every year in the month of June throughout the
country, prior to the onset of monsoon and transmission season.

2.3.5 Interaction of malaria control with other health

programmes
The other main public health programmes related to malaria control are:

1. Integrated Disease Surveillance Project (IDSP): The project, with weekly

fever alerts is increasingly providing the early warning signals on malaria
outbreaks.

2. Other vector borne diseases: Dengue and malaria control activities overlap in
many urban areas, malaria and kalaazar in a few districts of Jharkhand, and
malaria and filariasis in some areas including a few districts of Odisha.

3. Reproductive and child health: Antenatal care services are utilized in

distribution of LLINs to pregnant women in some areas of the country. Janani
Suraksha Yojana also makes provision of bed-nets distribution to pregnant
women. Changes in the malaria case management norms have been included
in the Integrated Management of Neonatal and Childhood Illness.

37
National Health Check Your Progress 1
Programmes in India-
Role of Nurse Q1) What are the objectives of malaria control programme
....................................................................................................................
....................................................................................................................
....................................................................................................................

Q2) List the strategies for malaria control

Q3) What is integrated vector management

2.4 NATIONAL FILARIAL CONTROL

PROGRAMME
Lymphatic filariasis is endemic in 20 states and union territories. The national
filarial control programme has been in operation since 1955. According to recent
estimate about500milion people are exposed to9 the risk of infection
19 million manifests the disease and 25millon have filarial parasites in their
blood. In June 1978, the operational component of the NFCP merged worth the
urban malaria scheme for maximum utilization of available resources.
The training and research components however continue to be with the director,
national institute of communicable disease, Delhi. Training in filarology is being
given at three regional filaria training and research centers situated at Calicut.
Rajahmundry and Varanasi under the national institute of communicable disease,
Delhi besides 12 headquarters bureau are functioning at the state level. Filarial
control strategy includes vector control through anti larval operations source
reduction. Detection and treatment of micro filaria carriers, morbidity
management. National filarial control program is being implemented through 206
filaria control units, 199 filaria clinics and 27survey units, primarily in endemic
urban towns. In rural areas anti filarial medicines and morbidity management
services are provided through primary health care system.

In India, the National Health Policy (2002), envisages elimination of lymphatic

filariasis (ELF) by 2015. The elimination is defined as “lymphatic filariasis ceases
to be public health problem, when the number of microfilaria carriers is less than
1 per cent and the children born after initiation of ELF are free from circulating
antigenaemia.

The strategy of lymphatic filariasis elimination is through:

a) Annual Mass Drug Administration (MDA) of single dose of antifilarial drug

for 5 year or more to the eligible population (except pregnant women,
children below 2 year of age and seriously ill persons) t interrupt
transmission of the disease.

38
b) Home based management of lymphoedema cases and up-scaling of hydrocele National Health Programmes
operations in identified CHCs/ district hospitals/ medical colleges. Related to Communicable
Diseases
The strategy follows the WHO recommendation of annual single doss mass drug
therapy with DEC/DEC with albendazole as supplement to existing NFCP
strategy for 5 years or more in highly endemic districts to reduce transmission of
filaria to a very significant low level. In pursuit of achieving the goal of
elimination of lymphatic filariasis by 2015, govt of India has launched nation
wide mass drug administration (MDA) of DEC in 202 endemic districts of the
country. To alleviate the sufferings of the patients, home based morbidity
management and hydro colostomy at identified hospital/ CHCs has been taken up.
For the year 2005, the mass drug administration was given, covering about 434.49
million populations showing a coverage rate of 79.8 %. During 2006 MDA was
given to 286.29 million populations in 179 districts with coverage rate of
83.67 %. All sectors including medical colleges, programme
implementers, private sector health care service providers and community
volunteers were involved.

2.5 KALA-AZAR CONTROL PROGRAMME

Kala- azar is now endemic in 32 districts of Bihar, 4 districts of Jharkhand, 11
districts of West Bengal and 2 districts of Uttar Pradesh, besides sporadic cases in
few other districts of Uttar Pradesh. A centrally sponsored prgramme was
launched in 1990-91. This has brought down the incidence and death rate of the
disease by 75% by the year 2007. The strategies for kala-azar elimination are:

a) Enhanced case detection and complete treatment including introduction of

PK 39 rapid diagnostic kits and oral drug Miltefosine for treatment of kala-
azar cases.
b) Interruption of transmission through vector control by replacing DDT with
pyrethroid for fogging to eliminate sandfly as the insect is becoming
resistance to DDT.
c) Communication for behavioral impact and intersect oral convergence
d) Capacity building
e) Monitoring, supervision and evaluation
f) Research guidelines on prevention and control of kala-azar have been
developed and circulated to the states.

In May 2005, a tripartite memorandum of understanding has been signed by

health ministers of India, Bangladesh, and Nepal to replace the annual incidence
of kala-azar to less than 1per 10000 populations at the sub district level by 2015
and to improve the health status of vulnerable groups and at risk population living
in kala-azar endemic areas.

The revised strategy of total eradication of kala azar was launched on 2nd
September 2014. The new strategy includes introduction of Rapid Diagnostic Kit
developed by ICMR into the programme and single dose treatment with
Liposomal Amphoterecin B, which is given intravenously in 10 mg dose. It is to
reduce the human reservoir of infection. WHO will supply the drug free of cost.
39
National Health
Programmes in India- 2.6 JAPANESE ENCEPHALITIS CONTROL
Role of Nurse
Japanese encephalitis is a disease with high mortality rate and those who survive
do so with various degrees of neurological complications. During the last few
years it has become a major public health problem. States of Andhra
Pradesh, West Bengal, Assam, Tamil Nadu, Karnataka, Bihar,
Maharashtra, Manipur, Haryana, Kerala, and Uttar Pradesh are
reporting maximum number of cases.

The strategies for prevention and control of Japanese encephalitis include

strengthening of the surveillance activities through sentinel sites in tertiary health
care institution, early diagnosis and proper case management, integrated vector
control particularly personal protection and use of larvivorous fishes, capacity
building and behavior change communication. As the JE vectors are outdoor
rester’s, indoor residual spray is not effective. The govt. of India provides need
based assistance to the states, including support for training programmes and
social mobilization.

As there is no specific cure for this disease, early case management is very
important to minimize the risk of complication and death. JE vaccination is
recommended for children between 1-15 years of age. In addition, health
education through different media an dinter personal communication for the
community is crucial. Emphasis should be given on keeping pigs away from
human dwellings, or in pigsties, particularly during dusk to dawn, which his the
biting time of vector mosquitoes. Uses of cloths which cover the body fully to
avoid mosquito bites are advocated. Use of bed nets is also very important
precaution. Since early reporting of case is important to avoid complications, the
community should be given full information about the signs and symptoms of the
disease, and the health facilities available at health centers / hospitals. The states
are advised to use malathion for out door fogging as out break control measure in
the affected areas.

Epidemiological monitoring of the disease for effective implementation of

preventive and control measure and technical support is provided on request by
the state health authorities.

2.7 DENGUE FEVER CONTROL

During 1996, an outbreak of dengue was reported in Delhi. Since then dengue has
been reported from other states also. In view of this major outbreak of the disease
a ‘Guideline of preparation of contingency plan in case of outbreak /epidemic of
dengue/dengue hemorrhagic fever’ was prepared and sent to all the states. It
includes all the major aspects of control measures like identification of outbreak
demarcation of affected area containment of outbreak, case management, vector
control, IEC activities about Do’s and Don’ts for prevent ion of dengue,
monitoring and reporting etc .

Technical assistance for investigation, prevention and control of dengue /DHF

outbreak is provided to the state through directorate of NAMP and NICD Delhi.

40
For early diagnosis ELISA based NSI kits have been introduced under the National Health Programmes
programme which can detect the cases from 1st day of infection. IgM capture Related to Communicable
Diseases
ELISA tests can detect the cases after 5th day of infection.

The GOI has taken the following steps for prevention and control of dengue.

- Monitoring the situation through reports received from state health

authorities.
- A mid-term plan for prevention and circulated to the states for
implementation. The main components of mid-term plan for prevention and
control of dengue are as follows:
a. Surveillance: Disease and entomological surveillance
b. Case management : Laboratory diagnosis and clinical management
c. Vector management : Environmental management for source reduction,
chemical control, personal protection and legislation
d. Outbreak response: Epidemic preparedness and media management
e. Capacity building: Training, strengthening human resource and operational
research
f. Behavioural change communication : social mobilization, and information,
education and communication (IEC)
g. Inter-sectoral coordination : with ministries of urban development, rural
development, Panchayati raj, surface transport and education sector
h. Monitoring and supervision: Analysis of reports, review, field visit and feed-
back

2.8 CHIKUNGUNYA FEVER

Chikungunya fever is a debilitating non-fatal viral illness, re-emerging in the
country after a gap of three decades. Govt. of India is continuously monitoring the
situation. Guidelines for prevention and control of the disease have been prepare.
Since same vector is involved in the transmission of dengue and chikungunya,
strategies for transmission risk reduction by vector control are also the same.

Check Your Progress 2

Q1) What are the strategies for Kala Azar elimination

41
National Health
Programmes in India- 2.9 REVISED NATIONAL TUBERCULOSIS
Role of Nurse CONTROL PROGRAMME
National Tuberculosis Programme (NTP) has been in operation since 1962.
Spread of multidrug resistant TB was threatening to further worsen the situation.
In view of this, in 1992 Government of India along with WHO and SIDA
reviewed the TB situation. In 1993, in order to overcome these lacunae, the
Government of India decided to give a new thrust to TB control activities by
revitalizing the NTP. The Revised National TB Control Programme (RNTCP) thus
formulated, adopted the internationally recommended Directly Observed
Treatment Short-course (DOTS) strategy, as the most systematic and cost-
effective approach to revitalize the TB control programme in India.

The objectives of the RNTCP are:

1. Achievement of at least 85 per cent cure rate of infectious cases of

tuberculosis; through DOTS involving peripheral health functionaries; and

2. Augmentation of case finding activities through quality sputum microscopy to

detect at least 70 per cent of estimated cases.

In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP. The
components are as follows: -

- Pursuing quality DOTS expansion and enhancement.

- Addressing TB/HIV and MDR-TB.

- Contributing to health system strengthening.

- Engaging all care providers.

- Empowering patients and communities.

- Enabling and promoting research (diagnosis, treatment, vaccine).

2.9.1 Organization
The profile of RNTCP in a state is as follows:

- State Tuberculosis Office —-- State Tuberculosis Officer

- State Tuberculosis Training and -—- Director Centre

Demonstration

- District Tuberculosis Centre —- District Tuberculosis Officer

- Tuberculosis Unit - Medical Officer TB Control

- Senior Treatment Supervisor

- Senior TB Laboratory Supervisor

- Microscopy Centres, Treatment Centres

- DOTS Providers

42
New Initiatives National Health Programmes
Related to Communicable
The RNTCP has completed the feasibility study of introducing GeneXpert in Diseases
RNTCP in 18 Tuberculosis Units in 12 states. RNTCP is currently using CB
NAAT for the diagnosis of tuberculosis and MDT-TB in high risk population like
HIV positive and paediatric groups

1. Nikshay: TB surveillance using case based web based IT system

Central TB Division in collaboration with National Informatics Centre has

undertaken the initiative to develop a case based web based application
named Nikshay.

This software was launched in May 2012 and has following functional
components.

- Master management

- User details

- TB Patient registration and details of diagnosis, DOT provider, HIV

status, follow-up, contact tracing, outcomes.

- Details of solid and liquid culture and DST, LPA, CBNMT details.

- DR-TB patient registration with details.

- Referral and transfer of patients.

- Private health facility registration and TB notification.

- Mobile application for TB notification.

- SMS alerts to patients on registration.

- SMS alerts to programme officers.

- Automated periodic reports

a. Case finding

b. Sputum conversion

c. Treatment outcome.

2. TB Notification

In order to ensure proper diagnosis and management of TB cases, and to

reduce TB transmission and the emergence and spread of MDR-TB, it is
essential to have complete information of all TB cases. According to the
Government of India notification dated 7th May 2012, it is now mandatory
for all healthcare providers to notify every TB case to local authorities i.e.
District Health Officer/Chief Medical Officer of a district and Municipal
health officer, every month in a given format. At present, 57,000 health
facilities have been registered and 35,000 patients have been notified.

3. Ban on TB Serology

The serological tests are based on antibody response, which is highly variable
in TB and may reflect remote infection rather than active disease. Currently

43
National Health available serological tests are having poor specificity and should not be used
Programmes in India- for the diagnosis of pulmonary or extra-pulmonary TB.
Role of Nurse
4. Direct benefit transfer schemes: Direct benefit transfer schemes are being
established by linking TB patients reported in NIKSHAY with AADHAR and
PEMS to effectively deliver benefits to TB patients and their providers.

Initiation of treatment

Under the RNTCP active case finding is not pursued. Case finding is passive.
Patients presenting themselves with symptoms suspicious of tuberculosis are
screened through 2 sputum smear examinations. Sputum microscopic examination
is done in designated RNTCP microscopy centres. They are located either in the
CHC, PHC, Taluka Hospitals or in the TB dispensary. Each centre has a skilled
technician to ensure quality control, a senior TB laboratory supervisor is
appointed for every 5 microscopy centres.

All patients are provided short-course chemotherapy free of charge. During the
intensive phase of chemotherapy all the drugs are administered under direct
supervision called Direct Observed Therapy Short-term (DOTS). DOTS is given
by peripheral health staff such as MPWs, or through voluntary workers such as
teachers, anganwadi workers, dais, ex-patients, social workers etc.

44
The drugs are supplied in patient-wise boxes containing the full course of National Health Programmes
treatment, and packaged in blister packs. For the intensive phase, each blister Related to Communicable
Diseases
pack contains one day’s medication. For the continuation phase, each blister pack
contains one weeks supply of medication. The combi pack drugs for extension of
intensive phase are supplied separately. The boxes· are colored according to the
category of the regimen, red for category I patients, blue for category II patients.

2.9.2 PROGRAMMATIC MANAGEMENT OF DRUG

RESISTANT TB (PMDT)
DOTS-Plus

The PMDT services for quality diagnosis and treatment of drug resistant TB cases
were initiated in 2007 in Gujarat and Maharashtra. These services since then have
been scaled up and currently these services are available across the country from
March 2013. As of 2013, about 20,000 (17,000-24,000) among new pulmonary
TB cases and 41,000 retreatment cases of MDR-TB have been reported in India,
and of these 32,622 confirmed cases were put on standard regimen for MDR-TB
under RNTCP.

Achievements of RNTCP

The RNTCP covers the whole country since March 2006. Phase II of the RNTCP
has been launched in the country from 1st October 2006. The treatment success
rate has more than trebled from 25 per cent in 1998 to 88 per cent in 2013. Death
rate has been brought down seven folds from 29 per cent to 4 per cent. 662 DTCs,
2,698 TB Units and 13,209 DMCs are functional in the country. More than 6 lacs
public health care providers have been trained under the programme. Master
trainers on TB/HIV have been trained on TB/HIV related issues in 12 states. More
than 16 million patients have been initiated in treatment, saving almost 2.8
million lives.

Check Your Progress 3

Q1) Enlist the objectives of RNTCP

Q2) Explain new initiatives under RNTCP

2.10 NATIONAL LEPROSY ERADICATION

PROGRAMME
The national leprosy control programme (NLCP) has been in operation since
1955, as centrally aided programme to achieve control of leprosy through early
detection of cases and DDS (dapsome) immunotherapy on an ambulatory basis.
The NLCP moved a head initially at a slow pace, presumably for want to clear-cut
policies or operational objectives for nearly two decades. The program gained
45
National Health momentum during the fourth five year plan after it was made a centrally
Programmes in India- sponsored program. In 1980 the govt. of India declared its resolve to eradicate
Role of Nurse
leprosy by the year 2000 and constituted a working group to advise accordingly.
The working group submitted its report in 1982 and recommended a revised
strategy based on multidrug chemotherapy aimed at leprosy eradication through
reduction in the quantum of infection in the population, reduction in the sources
of the infection, and breaking the chain of transmission of disease. In 1983 the
control programme was redesignated national leprosy eradication programme with
the goal of eradication the disease by the turn of the century of the century. The
aim was to reduce case load to one or less than one per 10000 populations.

The revised strategy was based on early detection of cases (by population surveys,
school surveys, contact examination and voluntary referral), short term multidrug
therapy, health education, and ulcer and deformity care and rehabilitation
activities. The regimens recommended by WHO have been adapted to suit the
operational and administrative requirements. NLEP provided free domiciliary
treatment in endemic districts through specially trained staff, and moderate to low
endemic districts it provided services through mobile leprosy treatment units and
primary health care personnel. Treatment of leprosy cases with MDT was taken
up in a phased manner.

The Programme has been integrated with general health system in 2002-03, since
then leprosy diagnosis and treatment services are available at all PHCs and
government hospitals.

The components of the programme are as follows:

1. Decentralized integrated leprosy services through general health care system;

2. Capacity building of all general health services functionaries:

3. Intensified information, education and communication;

4. Prevention of disability and medical rehabilitation; and

5. Intensified monitoring and supervision.

As a result the no of cases discharged as cured increased progressively over

the years.

URBAN LEPROSY CONTROL PROGRAMME

Urban leprosy control programme has been implemented since 2005 under which
assistance is being provided by govt of India to urban areas having population size
of more than one lakh. For the purpose of providing graded assistance, the urban
areas are grouped in four categories; town ship I, medium cities I, medium cities-
II, Mega cities.

Leprosy Elimination Monitoring (LEM). The LEM is required to assess the

performance of leprosy services and envisages to collect key information on
the issues like integration, quality of leprosy services like diagnosing and
treatment (MDT), drug supply management and IEC etc. The LEM exercise was
carried out with WHO assistance through the national institute of health
and family welfare (NIHFW), New Delhi, during June 2002 in the 12 priority
endemic states. The 2nd LEM exercise was carried out in May & June 2003 In 13
46
states, and the 3rd LEM was carried out in May & June 2004 in the same states. National Health Programmes
During the year 2002- 03 another such survey was carried out through Related to Communicable
Diseases
an independent agency leprosy mission, New Delhi in seven high endemic states
of Bihar, Uttar Pradesh , Madhya Pradesh , Orissa , West Bengal , Chhattisgarh,
Jharkhand with the funds of world bank supported second national
leprosy elimination project .

NLEP: National action plan for 2006 -07.

The national action plan for the year 2006-07 has been released by the central
leprosy division of the DGHS.

The main objectives of the plan for the period of April 2005 to march 2007 are:

a. To continue the efforts to achieve elimination of leprosy

b. To maintain the gains achieved and to continue the efforts to achieve
elimination at district and block levels
c. To make quality leprosy services available
d. Strategies as drawn up for the second NELP are:
e. Decentralization and institutional development
f. Strengthening and integration of service delivery
g. Disability care and prevention
h. Information, education and communication

2.10.1 Disability prevention and medical rehabilitation

(DPMR)
1. Implementation of DPMR activities eg. Treatment of leprosy reaction, ulcers,
physiotherapy, reconstructive surgery and providing MCR footwear.
2. Integrating DPMR services with Institutes and departments of medical
colleges and there is provision of services to person with disability by various
departments under different ministries.
3. To develop a referral system to provide prevention of disability services to all
leprosy disabled persons in an integrated set-up.

Programme Implementation Plan for 12th Plan Period (2012-13 to 2016-17)

As the disease is still prevalent with moderate endemicity in about 15 per cent of
the country, the plan objectives are set as follow.

a) Elimination of leprosy i.e. prevalence of less than 1 case per 10,000

population in all districts of the country.
b) Strengthen disability prevention and medical rehabilitation of persons affected
by leprosy.
c) Reduction in the level of stigma associated with leprosy.

Programme strategy

To achieve the objectives of the plan, the main strategies to be followed are:

- Integrated leprosy services through general health care system.

47
National Health - Early detection and complete treatment of new leprosy cases.
Programmes in India-
Role of Nurse - Carrying out house-hold contact survey for early detection of cases.

- Involvement of Accredited Social Health Activist (ASHA) in the detection and

completion of treatment of leprosy cases on time.

- Strengthening of disability prevention and medical rehabilitation (DOMR)

services.

- Information, Education & Communication (IEC) activities in the community

to improve self-reporting to Primary Health Centre (PHC) and reduction of
stigma.

- Intensive monitoring and supervision at block primary health centre/

community health centre.

2.10.2 Services in the urban areas

The health services in the urban areas differ from the rural areas because of non-
availability of infrastructure like PHC and manpower for providing services upto
domicilliary level. The services in urban areas are provided mainly through
institutional level.

Following additional activities are specific to the needs of the urban population:

1. Identify human resources available with Government, civil societies, NGOs

and private medical practitioners for leprosy services like suspect and
referral. Population groups may be allocated to each human resource, and for
follow-up of the cases.

2. Build capacity of the identified human resources at the time of induction and
periodically.

3. Examination of all household contacts of all new cases at least once before
the completion of treatment of index case.

4. Identify one referral centre in each urban location for diagnosis and to
manage leprosy with or without complications.

5. Supervision and monitoring of the programme is the responsibility of the

district leprosy officer, and medical officer of the referral centre.

6. Mobile health clinics of general health services include leprosy services on

their visit to slums, peri-urban villages and migrant agglomerations.

7. Develop a system of record keeping and reporting by each participating

centre.

8. Develop a system of regular MDT supply to each health centre.

9. Procure additional requirement of drugs, dressing material, aids and

appliances for inhabitants of leprosy colony requiring regular care for their
disabilities.

10. Organize sensitization meetings for IEC and advocacy, participate in

exhibitions, quiz competition for awareness to reduce stigma.

48
2.10.3 ASHA involvement National Health Programmes
Related to Communicable
Accredited Social Health Activists (ASHA) will be involved to bring out Diseases
suspected cases from their villages for diagnosis at PHC and after confirmation of
diagnosis, will follow up the patients for completion of treatment.

Information, education and communication (IEC/BCC)

The IEC strategy during the 12th plan period will focus on communication for
behavioural changes in general public against the stigma and discrimination
against the leprosy affected persons. Making the public aware about the
availability of MDT, correction of deformity through surgery and that the leprosy
affected person can live a normal life with the family.

Check Your Progress 4

Q1) List the components of national leprosy eradication programme

Q2) What are the activities carried out under disability prevention and
medical rehabilitation
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................

2.11 NATIONAL AIDS CONTROL PROGRAMME

National AIDS Control Programme was launched in India in the year 1987. The
Ministry of Health and Family Welfare has set up National AIDS Control
Organization (NACO) as a separate wing to implement and closely monitor the
various components of the programme. The aim of the programme is to prevent
further transmission of HIV, to decrease morbidity and mortality associated with HIV
infection and to minimize the socio-economic impact resulting from HIV infection.

The milestones of the programme:

1986 - First case of HIV detected.

1992 - NACP-1 launched to slow down the spread of HIV infection.
1999 - NACP-11 begins, focusing on behaviour change, increased
decentralization and NGO involvement.
2004 - Anti-retroviral treatment initiated.
2007 - NACP-III launched for 5 years (2007-2012).
2014 - NACP-IV launched for 5 years (2012-2017).

The national strategy has the following components establishment of surveillance

centres to cover the whole country; identification of high-risk group and their
screening; issuing specific guidelines for management of detected cases and their
49
National Health follow-up; formulating guidelines for blood bank, blood product manufacturers,
Programmes in India- blood donors and dialysis units; information, education, and communication
Role of Nurse
activities by involving mass media and research for reduction of personal and
social impact of the disease; control of sexually transmitted diseases; and condom
programme.

The package of services under NACP-IV are:

1. Prevention services –

- Targeted interventions for high-risk groups (female sex workers, men who
have sex with men, transgenders/ hijras, injecting drug users) and bridge
population (truckers and migrants)
- Needle-syringe exchange programme and opioid substitution therapy for
IDUs
- Prevention interventions for migrant population at source, transit and
destination
- Link worker scheme for HRGs and vulnerable population in rural areas
- Prevention and control of sexually transmitted infections/reproductive tract
infections
- Blood safety
- HIV counselling and testing services
- Prevention of parent to child transmission
- Condom promotion
- Information, education and communication and behaviour change
communication (BCC)
- Social mobilization, youth interventions and adolescence education
programme
- Mainstreaming HIV/AIDS response
- Work place interventions.

2. Care, support and treatment services

- Laboratory services for CD4 testing and other investigations

- Free first-line and second-line Anti-Retroviral Therapy (ART) through ART
centres and Link ART Centres (LACs), Centres of Excellence (CoE) and
ART plus centres
- Paediatric ART for children
- Early infant diagnosis for HIV exposed infants and children below 18
months
- Nutritional and psycho-social support through Care and Support Centres
(CSC)
- HIV/TB coordination (cross-referral, detection and treatment of co-
infections)
- Treatment of opportunistic infections
- Drop-in centres for PLHIV networks.

50
2.11.1 HIV surveillance National Health Programmes
Related to Communicable
Different types of surveillance activities are being carried out in the country to Diseases
detect the spread of the disease and to make appropriate strategy for prevention
and control viz., area specific targeted intervention and best practice approach.
The types of surveillance are : (a) HIV Sentinel Surveillance, (b) HIV Sero-
Surveillance, (c) AIDS Case Surveillance, (d) STD Surveillance, (e) Behavioural
Surveillance, and (f) Integration with surveillance of other diseases like
tuberculosis etc.

Counselling and HIV testing services

The Basic Service Division of the department of AIDS control provides HIV
counselling and testing services for HIV infection. The national programme is
offering these services since 1997 with the goal to identify as many people living
with HIV, as early as possible (after acquiring the HIV infection), and linking
them appropriately and in a timely manner to prevention, care and treatment
services.

The HIV counselling and testing services include the following components:

1. Integrated Counselling and Testing Centres (ICTC)

2. Prevention of parent-to-child transmission of HIV (PPTCT)
3. HIV/tuberculosis collaborative activities.

Integrated Counselling And Testing Centres: Diverse models of HIV counselling

and testing services are available to increase access to HIV diagnosis, these
include testing services in health care facilities, standalone sites and community-
based approaches at various levels of public health systems in India from state,
district, sub-district and village/community levels as depicted in Fig. 2.1

HIV screening using whole blood

finger prick test/mobile ICTCs
reaching vulnerable/ HRGs/
Community unreached population
level

Village level Standalone ICTCs & facility

Primary Health Centres, ICTCs
24 x 7 PHCs etc., Private
Hospitals/Labs/NGOs etc.

Sub-district level e.g. Civil Standalone ICTCs & facility

Hospitals, Community Health ICTCs
Centre etc.

State and District level e.g. Medical Standalone ICTCs

Colleges/District Hospitals etc.

Level of HIV counselling and testing services in India

51
National Health 2.11.2 PREVENTION OF PARENT-TO-CHILD
Programmes in India-
Role of Nurse TRANSMISSION OF HIV
The prevention of parent-to-child transmission of HIV/ AIDS (PPTCT) programme
was started in the country in the year 2002. Currently there are more than 15,000
ICTCs in the country which offer PPTCT services to pregnant women. The aim of
the PPTCT programme is to offer HIV testing to every pregnant woman (universal
coverage) in the country, so as to cover all estimated HIV positive pregnant women
and eliminate transmission of HIV from mother-to-child.

In India, PPTCT interventions under NACP was started in 2002, using SD-NVP
prophylaxis for HIV positive pregnant women during labour and .also for her new
born child immediately after birth. India has also transitioned from the single dose
Nevirapine strategy to that of multi-drug ARV prophylaxis from September 2012.
This strategy was executed in the three southern high HIV prevalence states of
Andhra Pradesh, Karnataka and Tamil Nadu. The national strategic plan for
PPTCT services using multi-drug ARVs in India was developed in May-June 2013
for nationwide implementation in a phased manner. Based on the new WHO
guidelines (June 2013) and on the suggestions from the technical resource groups
during December 2013, department of AIDS control has decided to initiate life-
long ART (using the triple drug regimen) for all pregnant and breast-feeding
women living with HIV, regardless of CD4 count or WHO clinical stage, both for
their own health and to prevent vertical’ HIV transmission, and for additional HIV
prevention benefits.

The key goal is to ensure the integrated PPTCT service delivery with the existing
Reproductive and Child Health (RCH) programme.

The essential package of PPTCT services in India are as follows (22): ·

1. Routine offer of HIV counselling and testing to all pregnant women enrolled
into antenatal care, with an ‘opt out’ option.
2. Ensuring involvement of spouse and other family members, and move from
an “ANC-Centric” to a “Family-Centric” approach.
3. Provision of life-long ART (TDF+3TC+EFV) to all pregnant and breast-
feeding HIV infected women, regardless of CD4 count and clinical stage of
HIV progression.
4. Promotion of institutional deliveries of all HIV infected pregnant women.
5. Provision of care for associated conditions (STI/RTI, TB and other
opportunistic infections).
6. Provision of nutrition, counselling and psychosocial support for HIV infected
pregnant women.
7. Provision of counselling and support for initiation of exclusive breast-feeds
within an hour of delivery as the preferred option and continued for 6
months.
8. Provision of ARV prophylaxis to infants from birth upto a minimum of 6
months.
9. Integrating follow-up of HIV-exposed infants into routine healthcare services
including immunization.

52
10. Ensuring initiation of Co-trimoxazole Prophylactic Therapy (CPT) and Early National Health Programmes
Infant Diagnosis (EID) using HIV-DNA PCR at 6 weeks of age onwards, as Related to Communicable
Diseases
per the EID guidelines.
11. Strengthening community follow-up and outreach through local community
networks to support HIV positive pregnant women and their families.

2.11.3 HIV TESTING OF TB PATIENTS

Detection of HIV by offering HIV tests to diagnosed TB patients is being
implemented by NACP and RNTCP jointly since 2007-08. NACP and RNTCP
have jointly decided to offer HIV testing upstream during evaluation of patients
for TB when they present with TB symptoms.

The four pronged strategy for HIV-TB coordination activity to reduce mortality
are summarized in Fig.
Prevention Early detection of TB/HIV
1. Isoniazid preventive treatment 1. 1003 coverage of PITC in TB
2. Air borne infection control patients
3. Awareness generation 2. PITC in presumptive TB cases
3. Rapid diagnostics for detection of
TB and DR-TB in PLHIV
4. ICF activities at all HIV settings
-ICTC, ART, LAC and TI settings
TB/HIV co-ordination to reduce mortality
Prompt treatment of TB/HIV Management of special TB/HIV
1. Early initiation of ART cases
2. Prompt initiation of TB 1. TB/HIV patients on Pl based
treatment ARV
2. TB/HIV in children
3. TB/HIV pregnant women
4. Drug resistant TB/HIV

Activities to reduce HIV-TB mortality

PITC - provider initiated HIV testing and counselling; CF - intensified case
finding;
LAC - link ART centres; TI Targeted interventions
Care, support and treatment
The care, support and treatment (CST) component of NACP aims to provide
comprehensive services to people living with HIV (PLHIV) with respect to free
Anti-Retroviral Therapy (ART), psychosocial support, prevention and treatment
of opportunistic infections (01) including tuberculosis, and facilitating home-
based care and impact mitigation.
CoE & Select medical college
ART Plus
Medical college and
ART Centres
District level hospital

Link ART Centres and LAC Sub-district level

Plus Centres hospitals & CHC

Model of HIV treatment services

53
National Health 2.11.4 TARGETED INTERVENTIONS FOR HIGH RISK
Programmes in India-
Role of Nurse GROUPS
The main objective of targeted interventions (Tl) is to improve health-seeking
behaviour of high risk groups (HRG) and reduce their risk of acquiring sexually
transmitted infections (STI) and HIV infections. High risk groups under TI
include female sex workers (FSW), men who have sex with men (MSM),
transgenders (TG)/hijras ·and injecting drug users (IDU), and bridge populations
include high risk behaviour migrants and long distance truckers.

The services offered through targeted interventions include:

- Detection and treatment for sexually transmitted infections

- Condom distribution (except in this for bridge population)
- Condom promotion through social marketing (for HRG and bridge
population)
- Behaviour change communication
- Creating an enabling environment with community involvement and
participation
- Linkages to integrated counselling and testing centres
- Linkages with care and support services for HIV positive HR Groups
- Community organization and ownership building Specific interventions for
IDUs
- Distribution of clean needles and syringes
- Abscess prevention and management Opioid substitution therapy
- Linkage with detoxification/rehabilitation services
- Specific interventions for MSM/TGs
- Provision of lubricants
- Specific interventions for trans gender (TG)/hijra populations
- Provision of project-based STI clinics

Link worker scheme: The Link worker scheme is a community-based outreach

strategy to address HIV prevention and care needs of HRG and vulnerable
population in rural areas. The specific objectives of the scheme include reaching
out to these groups with information and knowledge on prevention and risk
reduction of HIV and STI, condom promotion and distribution, providing referral
and follow-up linkages for various services.

Blood transfusion services: The division of blood safety has been renamed as the
division of blood transfusion services. Only licensed blood banks are permitted to
operate in the country and voluntary blood donation is encouraged.

Condom promotion: Condom promotion strategies will be strengthened through

free distribution and social marketing channels, non-traditional outlets, female
condoms, etc. aided by an effective communication strategy. The programme will
continue to link prevention with care, support and treatment.

54
STD CONTROL PROGRAMME: STD control is linked to HIV/AIDS control National Health Programmes
as behaviour resulting in the transmission of STD and HIV are same. HIV is Related to Communicable
Diseases
transmitted more easily in the presence of another STD. Hence, early diagnosis
and treatment of STD is now recognized as one of the major strategies to control
spread of HIV infection.

NACO has branded the STI/RTI services as “Suraksha Clinic”, and has
developed a communication strategy for generating demand for these services.

PRE-PACKED STJ/RTI COLOUR CODED KITS: Prepacked colour coded STl/

RTI kits have been provided for free supply to all designated STI/RTI clinics.
These kits are being procured centrally and supplied to all State AIDS Control
Societies.

Information, education and communication

Communication in NACP-IV is directed at:

a. To increase knowledge among general population (especially youth and

women) on safe sexual behaviour;
b. To sustain behaviour change in high risk groups and bridge populations;
c. To generate demand for care, support and treatment services; and
d. To make appropriate changes in societal norms that ·reinforce positive
attitude, beliefs and practices to reduce stigma and discrimination.

Adolescence Education Programme: This programme runs in secondary and senior

secondary schools to built up life skills of adolescents to cope with the physical and
psychological changes associated with growing up. Under the programme, 16 hour
sessions are scheduled during the academic terms of class IX and XI.

Red Ribbon Clubs: The purpose of Red Ribbon Club formation in colleges is to
encourage peer-to-peer messaging on HIV prevention and to provide a safe space
for young people to seek clarifications of their doubts and myths surrounding
HIV/AIDS.

Check Your Progress 5

Q1) Explain Prevention services provided as a package under National

AIDS control programme
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q2) List the components of Counselling and HIV testing services

Q3) What are the targeted interventions for high risk group for HIV
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

55
National Health
Programmes in India- 2.12 LET US SUM UP
Role of Nurse
In this unit we have emphasized on the National health programmes related to
prevention and control of communicable diseases, namely National Vector Borne
Disease Control Programme (NVBDCP) Surveillance and case management,
Parameters of malaria surveillance, High-risk areas and populations with
important strategy of Behaviour change communication (BCC). Other
communicable diseases related strategies under national health programmes
namely National filarial control programme, Kala-Azar Control Programme,
Japanese Encephalitis Control, Dengue Fever Control and Chikungunya fever
control are discussed. You must be thorough and familiar with these diseases and
related programme strategies so that you can actively participate as Community
Health Nurse in the community. A section each on Revised National Tuberculosis
Control Programme, National Leprosy Eradication Programme and National Aids
Control Programme were dealt in detals.

2.13 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

Q1) Objective

To achieve API<1 per 1000 population by the end of 2017 Goals

The national goals for strategic plan are:

1. Screening all fever cases suspected for malaria (60% through quality
microscopy and 40% by rapid diagnostic test.

2. Treating all P. falciparum cases with full course of effective ACT and
primaquine, and all P. vivax cases with 3 days chloroquine and 14 days
primaquine.

3. Equipping all health institutions (PHC level and above), especially in high-
risk areas, with microscopy facility and RDT for emergency use and
injectable artemisinin derivatives.

4. Strengthening all district and sub-district hospitals in malaria endemic areas

as per IPHS with facilities for management of severe malaria cases.

Outcome Indicators

The outcome indicators of strategic plan are:

2. At least 80% of those suffering from malaria get correct, affordable,

appropriate and complete treatment within 24 hours of reporting to the health
system, by the year 2017.

3. At least 80% of those at high risk of malaria get protected by effective

preventive measures such as ITN/LLIN or IRS by 2017.

4. At least 10% of the population at high-risk areas is surveyed annually (annual

blood examination rate>10%).

56
Q2) The strategies for malaria control National Health Programmes
Related to Communicable
The strategies for prevention and control of malaria and its transmission are Diseases
discussed in details as given below:
Surveillance and case management
- Case detection (passive and active)
- Early diagnosis and complete treatment
- Sentinel surveillance.
Integrated vector management (IVM)
- Indoor residual spray (IRS)
- Insecticide treated bed nets (ITNs)/Long Lasting
Insecticidal Nets (LLINs).
- Antilarval measures including source reduction.
Epidemic preparedness and early response.
Supportive interventions
- Capacity building
- Behaviour change communication (BCC)
- Intersectoral collaboration
- Monitoring and evaluation
- Operational research and applied field research.
Q3) What is integrated vector management
Integrated vector management (IVM) includes:
- Indoor residual spray (IRS)
- Insecticide treated bed nets (ITNs)/Long Lasting
Insecticidal Nets (LLINs).
- Antilarval measures including source reduction.
Check Your Progress 2
Q1) What are the strategies for Kala Azar elimination
The strategies for kala-azar elimination are:
a) Enhanced case detection and complete treatment including introduction of PK
39 rapid diagnostic kits and oral drug Miltefosine for treatment of kala-azar
cases.
b) Interruption of transmission through vector control by replacing DDT with
pyrethroid for fogging to eliminate sandfly as the insect is becoming
resistance to DDT.
c) Communication for behavioral impact and intersect oral convergence
d) Capacity building

57
National Health e) Monitoring, supervision and evaluation
Programmes in India-
Role of Nurse f) Research guidelines on prevention and control of kala-azar have been
developed and circulated to the states.

Q2) The prevention and control measures for dengue fever:

The GOI has taken the following steps for prevention and control of dengue.

- Monitoring the situation through reports received from state health

authorities.

- A mid-term plan for prevention and circulated to the states for

implementation. The main components of mid-term plan for prevention and
control of dengue are as follows:

a. Surveillance: Disease and entomological surveillance

b. Case management : Laboratory diagnosis and clinical management

c. Vector management : Environmental management for source reduction,

chemical control, personal protection and legislation

d. Outbreak response: Epidemic preparedness and media management

e. Capacity building: Training, strengthening human resource and

operational research

f. Behavioural change communication : social mobilization, and

information, education and communication (IEC)

g. Inter-sectoral coordination : with ministries of urban development, rural

development, Panchayati raj, surface transport and education sector

h. Monitoring and supervision: Analysis of reports, review, field visit and

feed-back

Q3)

Chikungunya. fever is a debilitating non-fatal viral illness, re-emerging in the

country after a gap of three decades.

Check Your Progress 3

Q1) The objectives of RNTCP

1. Achievement of at least 85 per cent cure rate of infectious cases of

tuberculosis; through DOTS involving peripheral health functionaries; and

2. Augmentation of case finding activities through quality sputum microscopy to

detect at least 70 per cent of estimated cases.

Q2) New initiatives under RNTCP

1. Nikshay: TB surveillance using case based web based IT system

Central TB Division in collaboration with National Informatics Centre has

undertaken the initiative to develop a case based web based application named
Nikshay.

58
This software was launched in May 2012 and has following functional National Health Programmes
components. Related to Communicable
Diseases
- Master management

- User details

- TB Patient registration and details of diagnosis, DOT provider, HIV status,

follow-up, contact tracing, outcomes.

- Details of solid and liquid culture and DST, LPA, CBNMT details.

- DR-TB patient registration with details.

- Referral and transfer of patients.

- Private health facility registration and TB notification.

- Mobile application for TB notification.

- SMS alerts to patients on registration.

- SMS alerts to programme officers.

- Automated periodic reports

a. Case finding
b. Sputum conversion
c. Treatment outcome.

2. TB Notification

In order to ensure proper diagnosis and management of TB cases, and to

reduce TB transmission and the emergence and spread of MDR-TB, it is
essential to have complete information of all TB cases. According to the
Government of India notification dated 7th May 2012, it is now mandatory for
all healthcare providers to notify every TB case to local authorities i.e.
District Health Officer/Chief Medical Officer of a district and Municipal
health officer, every month in a given format. At present, 57,000 health
facilities have been registered and 35,000 patients have been notified.

3. Ban on TB Serology

The serological tests are based on antibody response, which is highly variable
in TB and may reflect remote infection rather than active disease. Currently
available serological tests are having poor specificity and should not · be used
for the diagnosis of pulmonary or extra-pulmonary TB.

1. Direct benefit transfer schemes: Direct benefit transfer schemes are being
established by linking TB patients reported in NIKSHAY with AADHAR and
PEMS to effectively deliver benefits to TB patients and their providers.

Check Your Progress 4

Q1) The components of National Leprosy Eradication programme

1. Decentralized integrated leprosy services through general health care system;

2. Capacity building of all general health services functionaries:

59
National Health 3. Intensified information, education and communication;
Programmes in India-
Role of Nurse 4. Prevention of disability and medical rehabilitation; and
5. Intensified monitoring and supervision.
Q2) Activities under disability prevention and medical rehabilitation
1. Implementation of DPMR activities eg. Treatment of leprosy reaction, ulcers,
physiotherapy, reconstructive surgery and providing MCR footwear.
2. Integrating DPMR services with Institutes and departments of medical
colleges and there is provision of services to person with disability by various
departments under different ministries.
3. To develop a referral system to provide prevention of disability services to all
leprosy disabled persons in an integrated set-up.
Check Your Progress 5
Q1) Preventive services provided as a package under National AIDS control
programme
- Targeted interventions for high-risk groups (female sex workers, men who
have sex with men, transgenders/ hijras, injecting drug users) and bridge
population (truckers and migrants)
- Needle-syringe exchange programme and opioid substitution therapy for IDUs
- Prevention interventions for migrant population at source, transit and
destination
- Link worker scheme for HRGs and vulnerable population in rural areas
- Prevention and control of sexually transmitted infections/reproductive tract
infections
- Blood safety
- HIV counselling and testing services
- Prevention of parent to child transmission
- Condom promotion
- Information, education and communication and behaviour change
communication (BCC)
- Social mobilization, youth interventions and adolescence education
programme
- Mainstreaming HIV/AIDS response
- Work place interventions.

Q2) Components of Counselling and HIV testing services

The HIV counselling and testing services include the following components:

1. Integrated Counselling and Testing Centres (ICTC)

2. Prevention of parent-to-child transmission of HIV (PPTCT)
3. HIV/tuberculosis collaborative activities.

60
Integrated Counselling And Testing Centres: Diverse models of HIV counselling National Health Programmes
and testing services are available to increase access to HIV diagnosis, these Related to Communicable
Diseases
include testing services in health care facilities, standalone sites and community-
based approaches at various levels of public health systems in India from state,
district, sub-district and village/community levels

3) The services offered through targeted interventions include:

- Detection and treatment for sexually transmitted infections

- Condom distribution (except in this for bridge population)

- Condom promotion through social marketing (for HRG and bridge

population)

- Behaviour change communication

- Creating an enabling environment with community involvement and

participation

- Linkages to integrated counselling and testing centres

- Linkages with care and support services for HIV positive HR Groups

2.14 REFERENCES
• K.Park; Text Book of Preventive and Social Medicine; Bhanot Banarsidas
Publishers, 22nd Edition 2009

• Keshav Swarnkar, Community Health Nursing; 2nd Edition, Nr Brothers

Publications

• K.K Gulani ‘Community Health Nursing’ Kumar Publishers 1st Edition

• AH Suryakantha, Community Medicine With Recent Advances, 2nd Edition,

New Delhi: Jaypee Publishers, 2010

• K.Park; Text Book of Preventive and Social Medicine; Bhanot Banarsidas

Publishers, 26th Edition 2021

61
National Health
Programmes in India- UNIT 3 NATIONAL HEALTH
Role of Nurse
PROGRAMMES RELATED TO
NON COMMUNICABLE DISEASES
Structure

3.0 Objectives
3.1 Introduction
3.2 National programme for Control of Blindness
3.1.1 Strategies
3.1.2 Organization and structure
3.1.3 Vision 2020: The Right to Sight
3.1.4 Universal Eye Health : a Global action plan 2014-2019
3.3 National Immunization program
3.3.1 Pulse polio immunization programme
3.3.2 Introduction Of Hepatitis-B Vaccine
3.3.3 Introduction Of Japanese Encephalitis Vaccine
3.3.4 Introduction Of Measles Vaccine Second Opportunity
3.3.5 Introduction Of Pentavalent Vaccine (DPT + Hep-B + Hib)
3.3.6 Mission Indradhanush
3.4 National program for prevention and control of Diabetes, Cardiovascular
Disease and Stroke (DCS) Component under NPCDCS
3.4.1 Diabetes, Cardiovascular Disease and Stroke (DCS) Component under
NPCDCS
3.4.2 Cancer component under NPCDCS
3.4.3 Cancer services
3.4.4 Tobacco control legislation
3.4.5 National tobacco control programme
3.6 Integrate disease surveillance project (IDSP)
3.6.1 Components of surveillance activity
3.6.2 Syndromes under surveillance
3.7 National programme for control and treatment of occupational diseases
3.8 National Water supply and sanitation programme
3.8.1 Swajaldhara
3.8.2 Bharat Nirman
3.8.3 Rural sanitation programme
3.8.4 Nirmal bharat abhiyan
3.8.5 Swach bharat abhiyan

3.9 Let Us Sum Up

3.10 Answer to Check Your Progress

62
National Health Programmes
3.0 OBJECTIVES Related to Non
Communicable Diseases
After going through this unit you will be able to:

 Explain about National programme for prevention and control of Non

Communicable diseases
 Explain about National programme for control of blindness,
 Describe National Immunization program including
 Participate in the activities related to national program for prevention and
control of Diabetes, Cardiovascular Disease and Stroke (DCS) and learn
components under NPCDCS
 Ensure to carry out activities related to cancer prevention and control under
NPCDCS
 Strengthen Cancer services, creating awareness regarding Tobacco control
legislation, measures under National tobacco control programme.
 Participate in the activities related to National programme for control and
treatment of occupational diseases;
 Create awareness on schemes related to National Water supply and sanitation
programme among the general population.

3.1 INTRODUCTION
In the previous unit you have read in details about National programmes related
to communicable diseases. In this unit we will discuss National Health
programmes related to Non Communicable Diseases, Strategies, Organization and
structure. Various health programmes related specific activities are also dealt.
Such as for control of blindness Vision 2020: The Right to Sight, Universal eye
health: a global action plan 2014-2019. A section on National immunization
program covering Pulse polio immunization, Hepatitis-B Vaccine, Japanese
Encephalitis Vaccine, Measles Vaccine, Pentavalent Vaccine (DPT + Hep-B +
Hib) And Mission Indradhanush. Next section is about National program for
prevention and control of Diabetes, Cardiovascular Disease and Stroke, Cancer
(NPCDCS) is covered in sub sections depending upon the specific diseases such
as Diabetes, Cardiovascular Disease and Stroke, next sub section on Cancer
component including Tobacco control legislation, National tobacco control
programme. A section covers about Integrated disease surveillance project,
Components of surveillance activity and Syndromes under surveillance. We have
also discussed National programme for control and treatment of occupational
diseases and brief on National Water supply and sanitation programme.

3.2 NATIONAL PROGRAMME FOR CONTROL

OF BLINDNESS
The programme was launched with the goal to reduce the prevalence of blindness
from 1.4 to 0.3 per cent. As per 2006-07 survey the prevalence of blindness was
1.0 per cent. Objectives of the programme in the 12th Five Year Plan period are: ·

63
National Health 1. To reduce the backlog of avoidable blindness through identification and
Programmes in India- treatment of curable blind at primary, secondary and tertiary levels, based on
Role of Nurse
assessment of the overall burden of visual impairment in the country;
2. Develop and strengthen the strategy of NPCB for “Eye Health for All” and
prevention of visual impairment, through provision of comprehensive
universal eye-care services and quality service delivery;
3. Strengthening and up gradation of Regional Institutes of Ophthalmology
(RIOs) to become centre of excellence in various sub- specialties of
ophthalmology and also other partners like Medical Colleges, District
Hospitals, Sub district Hospitals, Vision Centres, NGO Eye Hospitals;
4. Strengthening the existing infrastructure facilities and developing additional
human resources for providing high quality comprehensive eye care in all
districts of the country;
5. To enhance community awareness on eye care and lay stress on preventive
measures;
6. Increase and expand research for prevention of blindness and visual
impairment, and
7. To secure participation of voluntary organizations/ private practitioners in
delivering eye care.

3.2.1 Strategies
1. Continued emphasis on free cataract surgeries through health care delivery
system and in collaboration with NGO
2. Emphasis on comprehensive eye care by covering diseases like diabetic
retinopathy, glaucoma, corneal transplantation, vitreoretinal surgery,
treatment of childhood blindness etc. Immediate attention to these diseases to
eliminate avoidable blindness.
3. Active screening of adults above 50 years of age by organizing eye screening
camps and transporting operable cases to eye facility.
4. Screening of children for identification and treatment of refractive errors and
provision of free glasses to the affected.
5. Coverage of underserved area through public private partnership
6. Capacity building of health personnel for improving their knowledge and
skill in delivery of quality care
7. IEC activities to create awareness on eye care within community through
regional Institutes of ophthalmology and medical colleges to be strengthened
in a phased manner with latest equipment’s and training of manpower so that
they can be upgraded as centres of excellence.
8. Strengthening district hospitals by upgrading infrastructure, equipment and
adequate manpower.
9. Continuing emphasis on Primary health care by establishing vision centres in
all PHC’s with a PMOA in position.
10. Multipurpose district mobile units for better coverage
64
3.2.2 Organization and structure National Health Programmes
Related to Communicable
To avoid duplicity of work, State Ophthalmic Cell has been merged with State Diseases
Blindness Control Society, and after the launch of NRHM, State Blindness
Control Societies have been further merged with State Health Society. Likewise,
District Blindness Control Societies have also been merged with District Health
Societies. Facilities for intra-ocular lense implantation have been expanded to
taluka level.

The organizational structure for the national programme for control of blindness
is as shown in Fig:3.1

Administration

Central Ophthalmology Section,

Directorate General of Health Services,
Ministry of Health & FW, New Delhi

State State Ophthalmic Cell,

Directorate of Health Services, State Health Societies

District District Blindness Control Society

Service Delivery and Referral System

Tertiary Level Regional Institutes of Ophthalmology & Centres of

Excellence in Eye Care Medical Colleges

Secondary District Hospital and Level NGO Eye Hospital

Primary Level Sub-district level hospitals/CHCs

Mobile Ophthalmic Units

Upgraded PHCs,
Link Workers/Panchayats

Fig: 3.1 Organizational structure for National programme for control of blindness
Strategies are:

School Eye Screening Programme: 6-7 per cent of children aged 10-14 years
have problem with their eye sight affecting their learning at school. Children are
being first screened by trained teachers. Children suspected to have refractive
error are seen by ophthalmic assistants and corrective spectacles are prescribed or
given free for persons below poverty line.

Collection And Utilization of Donated Eyes: Hospital retrieval programme is

the major strategy for collection of donated eyes, which envisage motivation of
relatives of terminally ill patients, accident victims and others with grave diseases
to donate eyes

3.2.3 Vision 2020: The Right to Sight

It is a global initiative to reduce avoidable (preventable and curable) blindness by
the year 2020. India is also committed to this initiative. The plan of action for the
country has been developed with following main features:

65
National Health 1. Target diseases are cataract, refractive errors, childhood blindness, corneal
Programmes in India- blindness, glaucoma, diabetic retinopathy.
Role of Nurse
2. Human resource development as well as infrastructure and technology
development at various levels of health system. The proposed four tier
structure includes Centres of Excellence (20), Training Centres (200), Service
Centres (2000), and Vision Centres (20,000).

Fig:3.2 Proposed structure for Vision 2020: The right to sight

3.2.4 Universal eye health: A Global action plan 2014-2019

Provision of effective and accessible eye care services is the key to control
measures. The preference should be given to strengthening eye care services
through their integration into the primary health care and health system
development, as almost all causes of visual impairment are avoidable, e.g.,
diabetes mellitus, smoking, premature birth, rubella, vitamin A deficiency etc.,
and visual impairment is frequent among older age groups.

Check Your Progress 1

Q1) Explain strategies adopted to achieve the objectives of National

Blindness Control programme
....................................................................................................................
....................................................................................................................
....................................................................................................................

Q2) Enlist the features of Vision 2020

Q3) Explain Universal Eye Health: A Global Action Plan 2014-2019

....................................................................................................................
....................................................................................................................
....................................................................................................................
66
National Health Programmes
3.3 NATIONAL IMMUNIZATION PROGRAMME Related to Communicable
Diseases
Experience with smallpox eradication programme showed the world that
immunization was the most powerful and cost-effective weapon against vaccine
preventable diseases. In 1974, the WHO launched its “Expanded Programme on
Immunization” (EPI) against six, most common, preventable childhood diseases, viz.
diphtheria, pertussis (whooping cough), tetanus, polio, tuberculosis and measles.
The Government of India launched its EPI in 1978 with the objective of reducing
the mortality and morbidity resulting from vaccine-preventable diseases of
childhood and to achieve self-sufficiency in the production of vaccines. Universal
Immunization Programme was started in India in 1985. It has two vital components:
immunization of pregnant women against tetanus, and immunization of children in
their first year of life against the six EPI target diseases. The aim was to achieve 100
per cent coverage of pregnant women with 2 doses of tetanus toxoid (or a booster
dose), and at least 85 per cent coverage of infants with 3 doses each of DPT, OPV,
one dose of BCG and one dose of measles vaccine by 1990.
A “Technology Mission on Vaccination and Immunization of Vulnerable
Population, specially Children” was set up to cover all aspects of the
immunization activity from research and development to actual delivery of
services to the target population.
The immunization services are being provided through the existing health care
delivery system (i.e., MCH centres, primary health centres and subcentres,
hospitals, dispensaries and I CD units). There is no separate cadre of staff for EPI.
Although the target was “universal” immunization by 1990, in practice, no
country, even in the industrialized world, has ever achieved 100 per cent
immunization in children. ‘Universal’ immunization is, therefore, best interpreted
as implying the ideal that no child should be denied immunization against
tuberculosis, diphtheria, whooping cough, tetanus, polio and measles. It is,
however, generally agreed that when immunization. Coverage reaches a figure of
80 per cent or more, then disease transmission patterns are so severely disrupted
as to provide a degree of protection even for the remaining children who have not
been immunized, because of “herd immunity”. It is also important that children
are immunized during the first year of life and that levels of immunization are
sustained so that each new generation is protected.
Significant achievements have been made in India. Since 2012 the coverage rates
have gone upto 87 % for TT among pregnant females, 87 % for BCG, 72% for
DPT, 74% for measles and 70% for OPV and Hep B. since then there is a
significant decline in the reported incidence of vaccine preventable diseases.

Decline in reported Vaccine

Preventable Diseases (VPD) from year 1987 to 2013

Disease 1987 2013

Poliomyelitis 28,257 0
Diphtheria 12,952 4,090
Pertussis 163,786 36,661
NNT 11,849 528
Measles 247,519 15,768

67
National Health 3.3.1 Pulse polio immunization programme
Programmes in India-
Role of Nurse Check Your Progress 2

Q1) Name vaccine preventable diseases

Q2) Explain about pentavalent vaccination

Q3) Enlist the aim of Mission Indradhanush

3.4 NATIONAL PROGRAMME FOR PREVEN-

TION AND CONTROL OF CANCER, DIABE-
TES, CARDIOVASCULAR DISEASES AND
STROKE (NPCDCS)
India is experiencing a rapid health transition with large and rising burden of
chronic non-communicable diseases (NCDs) especially cardiovascular disease,
diabetes mellitus, cancer, stroke, and chronic lung diseases. Considering the fact
that NCDs are surpassing the burden of communicable diseases in India and the
existing health system is mainly focused on communicable diseases, need for
National Programme on Prevention and Control of Diabetes, Cardiovascular
Diseases and Stroke was envisaged. Later on this programme was integrated with
National Cancer Control Programme, and National Programme for Prevention and
Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)
came into existence.

3.4.1 Diabetes, Cardiovascular Disease and Stroke (DCS)

Component under NPCDCS
The programme focuses on the health promotion, capacity building including
human resource development, early diagnosis and management of these diseases
with integration with the primary health care system.

The major objectives of the programme are as follows:

- Prevent and control common NCDs through behaviour and lifestyle changes.

- Provide early diagnosis and management of common NCDs.

- Build capacity at various levels of health care for prevention, diagnosis and
treatment of common NCDs.

68
- Train human resource within the public health set-up viz doctors, paramedics National Health Programmes
and nursing staff to cope with the increasing burden of NCDs, and Related to Communicable
Diseases
- Establish and develop capacity for palliative & rehabilitative care.

The programme is to be implemented in 20,000 sub-centres and 700 community

health centres (CHCs) in 100 districts across 21 States/UTs and the strategies
include promoting healthy lifestyle through massive health education and mass
media efforts at country level, opportunistic screening of persons above the age of
30 years, establishment of Non-Communicable Disease (NCD) Clinic at
Community Health Centre (CHC) and District level, development of trained
manpower and strengthening of tertiary level health facilities. For long-term
sustainability of the programme, service delivery will be through existing public
health infrastructure and systems. The various approaches such as mass media,
community education and interpersonal communication will be used for
behavioural change focusing on the following messages:

- Increased intake of healthy foods

- Increased physical activity

- Avoidance of tobacco and alcohol

- Stress management.

A) Activities at Sub-Centre

1. Opportunistic screening of population above 30 years.

2. The suspected cases of diabetes and hypertension will be referred to CHCs of

higher health facility.

B) Activities at CHC
1. NCD clinic at CHC shall do the diagnosis: blood sugar measurement, lipid
profile, ultrasound, X-ray and ECG etc.
2. Management and stabilization of common CVD, diabetes and stroke cases.
3. Home visits for bedridden cases, supervise the work of health workers by a
nurse.
4. Complicated cases of diabetes, high blood pressure etc. shall be referred from
CHC to the district hospital.
C) Activities at district hospital
1. NCD clinic at district hospital.
2. Provide regular management and annual assessment of persons suffering from
cancer, diabetes and hypertension.
3. People with established cardiovascular diseases shall also be managed at
district hospital.
4. Provide home based palliative care for chronic, debilitating and progressive
patients.
5. Involved in promotion of healthy lifestyle through health education and
counseling.

69
National Health 3.4.2 Cancer component under NPCDCS
Programmes in India-
Role of Nurse Cancer is an important public health problem in India, with nealy 10 lakh new
cases occurring every year in the country. It is estimated that there are 2.8 million
cases of cancer in the country at any given point of time. With the objectives of
prevention, early diagnosis and treatment, the national cancer control programme
was launched in 1975-76.

The programme was revised in 1984-85 and subsequently in December 2004:

a. Primary prevention of cancers by health education;

b. Secondary prevention i.e. early detection and diagnosis of common cancer
such as cancer of cervix, mouth, breast and tobacco related cancer by
screening/self examination method; and
c. Tertiary prevention i.e. strengthening of the existing institutions. of
comprehensive therapy including palliative care.

A) Regional Cancer Centre Scheme

The existing regional cancer centres are being further strengthened to act as
referral centres for complicated and difficult cases at the tertiary level. One time
assistance of Rs. 3 crores during the plan period is provided to Regional Cancer
Centres except TMH, Mumbai and JRCH (AIIMS) for strengthening and to the
CNCI, Kolkata on the approved pattern of funding.

B) Oncology Wing Development Scheme

This scheme had been initiated to fill up the geographic gaps in the availability of
cancer treatment facilities in the country. Central assistance is provided for
purchase of equipment, which include a cobalt unit besides other equipment

C) Decentralized NGO scheme

This scheme is meant for IEC activities and early detection of cancer. The scheme
is operated by the nodal agencies and the NGOs are given financial assistance for
undertaking health education and early detection activities of cancer.

D) IEC activities at central level

IEC activities at the central level are to be initiated in order to give wider
publicity about the Anti Tobacco Legislation for discouraging consumption of
cigarettes and other tobacco related products, and for creating awareness among
masses about the ill effects of consumption of tobacco and tobacco related
products.

E) Research and training

Following training manuals have been developed under the NCCP for capacity
building in cancer control at district level:

a. Manual for health professionals

b. Manual for cytology

c. Manual for palliative care

d. Manual for tobacco cessation

70
3.4.3 Cancer services National Health Programmes
Related to Communicable
Under this national programme for prevention and control of cancer, diabetes, Diseases
CVD and stroke the cancer services are:

1. Common diagnostic services, basic surgery, chemotherapy and palliative care

for cancer cases is being made available at 100 district hospitals.

2. Each district is being supported with Rs. 1.66 crores per annum for the
following.

- Chemotherapy drugs are provided for 100 patients at each district

hospital.

- Day care chemotherapy facilities is being established at 100 district

hospitals.

- Facility for laboratory investigations including mammography is being

provided at 100 district hospitals and if not available, this can be
outsourced at government rates.

3.4.4 Tobacco Control Legislation

A comprehensive tobacco control legislation titled “The Cigarettes and other
Tobacco Products. Act, 2003” was notified in Gazette of India on 25th Feb, 2004.
The provisions of the Act are:

 Prohibition of smoking in public places;

 Prohibition of direct and indirect advertisement of cigarette and other

products;

 Prohibition of sale of cigarette and other tobacco products to a person below

the age of 18 years,
 Prohibition of sale of tobacco products near the educational institutions;
 Mandatory depiction of statutory warnings (including pictorial warnings) on
tobacco packs; and
 Mandatory depiction of tar and nicotine contents alongwith maximum
permissible limits on tobacco packs.

3.4.5 National Tobacco Control Programme

In order to facilitate the implementation of the Tobacco Control Laws, to bring

about greater awareness about the harmful effects of tobacco, and to fulfill the
obligations under the WHO-Framework convention on tobacco control, Govt. of
India has launched a new National Tobacco Control Programme in the 11th Five
Year Plan.

The main components of the programme are:

1. Public awareness/mass media campaigns for awareness building and for

behavioural change;
2. Establishment of tobacco product testing laboratories, to build regulatory
capacity, as required under COTPA, 2003;

71
National Health 3. Mainstreaming the programme components as a part of the health delivery
Programmes in India- mechanism under the NRHM framework;
Role of Nurse
4. Mainstream research and training on alternate crops and livelihood, with other
nodal ministries;
5. Monitoring and evaluation, including surveillance, e.g. adult tobacco survey;
6. Dedicated tobacco control cells for effective implementation and monitoring
of anti-tobacco initiatives;
7. Training of health and social workers, NGOs school teachers etc;
8. School programme; and
9. Provision of tobacco cessation facilities.

Check Your Progress 2

Q1) Name vaccine preventable diseases

Check Your Progress 3

Q1) Name the chronic Non-Communicable Diseases (NCDs)covered under

one national health proramme
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q2) Enlist major objectives of the NPCDCS programme

Q3) List the activities at District Hospital for managing NCDs

72
National Health Programmes
3.6 INTEGRATED DISEASE SURVEILLANCE Related to Communicable
PROJECT (IDSP) Diseases

Integrated disease surveillance project is a decentralized state based surveillance

system in the country. This project is intended to detect early warning signals of
impending outbreaks and help initiate an effective response in a timely manner in
urban and rural areas. It will also provide essential data to monitor progress of
ongoing disease control programme and help allocate health resources more
efficiently. The project was launched in Nov. 2004. It is a 5-year project.

In this project, different types of integration are proposed. These include: (a)
Sharing of surveillance information of disease control programmes; (b)
Developing effective partnership with health and non-health sectors in
surveillance; ( c) Including non-communicable and communicable diseases in the
surveillance system; (d) Effective partnership of private sector and NGOs in
surveillance activities; (e) Bringing academic institutions and medical colleges
into the primary public health activity of disease surveillance.

The important information in disease surveillance are - who gets the disease, how
many get the disease, where did they get the disease, why did they get the disease,
and what needs to be done as public health response.

3.6.1 Components of the surveillance activity

a. Collection of data
b. Compilation of data
c. Analysis and interpretation
d. Follow-up action
e. Feedback.

The classification of surveillance in IDSP is as follows:

a. Syndromic diagnosis - diagnosis is made on the basis of clinical pattern by

paramedical personnel and members of the community;
b. Presumptive diagnosis - diagnosis made on typical history and clinical
examination by medical officer; and
c. Confirmed diagnosis - clinical diagnosis by a medical officer and or positive
laboratory identification.

3.6.2 Syndromes under surveillance

The reporting units for disease surveillance are:

Public Health Sector Private health sector

Rural CHCs, District Sentinel private practitioners,
Hospitals and Sentinel hospitals
Urban Urban hospitals, Sentinel private,
ESI/ Railway/ nursing homes,
Medical colleges hospitals. Sentinel hospitals, Medical colleges,
Private and NGO Laboratories.

73
National Health 1. Sub-centre-health worker/ANM reports all patients fulfilling the clinical
Programmes in India- syndrome from PHC, private clinic, hospital etc.
Role of Nurse
2. PHC/CHC medical officers report as probable cases of interest, where this
cannot be confirmed by laboratory tests at the peripheral reporting units, and
as confirmed when the laboratory information is available as in case of blood
smear +ve malaria and sputum AFB +ve tuberculosis.

3. Sentinel private practitioners, district hospitals, municipal hospitals, medical

colleges, sentinel hospitals, NGOs medical officers report as probable cases of
interest.
Check Your Progress 4

Q1) Enlist the aims and objectives of Integrated disease surveillance project.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q2) Explain the classification of surveillance in IDSP

3.7 NATIONAL PROGRAMME FOR CONTROL

AND TREATMENT OF OCCUPATIONAL
DISEASES
Government of India launched a scheme called “National Programme for Control
and Treatment of Occupational Diseases” in 1998-99.

The following research projects have been proposed by the government :

1. Prevention, control and treatment of silicosis and silico-tuberculosis in agate

industry.

2. Occupational health problems of tobacco harvesters and their prevention.

3. Hazardous process and chemicals, database generation, documentation, and

information dissemination.

4. Capacity building to promote research, education, training at National

Institute of Occupational Disease.

5. Health Risk Assessment and development of intervention programme in

cottage industries with high risk of silicosis.

6. Prevention and control of occupational health hazards among salt workers in

the remote desert areas of Gujarat and Western Rajasthan.

74
National Health Programmes
3.8 NATIONAL WATER SUPPLY AND SANITA- Related to Communicable
TION PROGRAMME Diseases

The National Water Supply and Sanitation. Programme was initiated in 1954. In
1972 a special programme known as the Accelerated Rural Water Supply
Programme was started as a supplement to the national water supply and
sanitation programme. During the Fifth Plan, rural water supply was included in
the Minimum Needs Programme of the State Plans. The Central Government is
supporting the efforts of the States in identifying problem villages through
assistance under Accelerated Rural Water Supply Programme. A “problem
village” has been defined as one where no source of safe water is available within
a distance of 1.6 km, or where water is available at a depth of more than 15
meters, or where water source has excess salinity, iron, fluorides and other toxic
elements, or where water is exposed to the risk of cholera.

Information, education and communication is an integral part of rural sanitation

programme to adopt proper environmental sanitation practices including disposal
of garbage, refuse and waste water, and to convert all existing dry latrines into
low cost sanitary latrines.

In 1999-2000, Sector Reform Project was started to involve the community in

planning, implementation and management of drinking water schemes which was
in 2002 scaled up as the Swajaldhara Programme.

3.8.1 Swajaldhara
Swajaldhara was launched on 25th Dec. 2002. Swajaldhara is a community led
participatory programme, which aims at providing safe drinking water in rural
areas, with full ownership of the community, building awareness among the
village community on the management of drinking water projects, including
better hygiene practices and encouraging water conservation practices along with
rainwater harvesting.

Swajaldhara has two components: Swajaldhara I (First Dhara) is for a gram

panchayat or a group of panchayats (at block I tahsil level) and Swajaldhara II
(Second Dhara) has district as the project area. District water and sanitation
mission sanctions swajaldhara I.

The programme was revised from 1st April 2009 and named as National Rural
Drinking Water Programme. It is now a component of Bharat Nirman which
focuses on the creati on of rural infrastructure.

3.8.2 Bharat Nirman

Bharat Nirman was launched by the Government of India in 2005 as a programme
to build rural infrastructure.

3.8.3 Rural Sanitation Programme

The rural sanitation programme in India was introduced in the year 1954 as a part
of the First Five Year Plan of the Government of India. The rural sanitation
coverage was only 1% as per census 1981. Government of India introduced the

75
National Health Central Rural Sanitation Programme (CRSP) in 1986 with the objective of
Programmes in India- improving the quality of life of the rural people and also to provide privacy and
Role of Nurse
dignity to women.

The program was reconstructed again in April, 1999 which focuses on demand
driven approach in a phased manner with a view to cover the wider range of rural
population by the end of 9th five year plan. The department of water supply and
sanitation is responsible for the sanitation in rural areas. The total sanitation
campaign (tsc) is a program to ensure sanitation facilities in rural areas to
eradicate open defecation.

• it was launched in the year 1999.

• the major goal is to stop open defecation by 2012.
• it follows principle of “no to low subsidy” where nominal subsidy is given in
form of incentives for construction of toilet. Financial incentives were
provided to Below Poverty Line (BPL) households for construction and usage
of individual household latrines (IHHL) in recognition of their achievements.

3.8.4 Nirmal Bharat Abhiyan (NBA)

In 2012, a paradigm shift was made il1 the Total Sanitation Campaign, by
launching the Nirmal Bharat Abhiyan, in the 12th Five Year Plan. The objective of
NBA is to achieve sustainable behavioural change with provision of sanitary
facilities in entire communities in a phased manner, saturation mode with “Nirmal
Grams” as outcomes.

3.8.5 Swachh Bharat Abhiyan

Prime Minister Shri Narendra Modi launched country’s biggest cleanliness drive
on 2nd October 2014. The campaign aims to accomplish a vision of clean India by
2nd October 2019.

Check Your Progress 5

Q1) Define a “problem village”.

Q2) Explain Information, education and communication as an integral part of

rural sanitation programme
....................................................................................................................
....................................................................................................................

Q3) Explain Swachh Bharat Abhiyan

3.9 LET US SUM UP

In this unit under first section we have discussed National Health programmes
related to Non Communicable Diseases, Strategies, Organization and structure.
Various health programmes related specific activities. Such as for control of
76
blindness Vision 2020: The Right to Sight, Universal eye health: a global action National Health Programmes
Related to Communicable
plan 2014-2019 are covered. A section on National immunization program Diseases
covering Pulse polio immunization, Hepatitis-B Vaccine, Japanese Encephalitis
Vaccine, Measles Vaccine, Pentavalent Vaccine (DPT + Hep-B + Hib) and
Mission Indradhanush. Next section has dealt with National program for
prevention and control of Diabetes, Cardiovascular Disease and Stroke, Cancer
(NPCDCS) in sub sections depending upon the specific diseases such as
Diabetes, Cardiovascular Disease and Stroke, and sub section on Cancer
component including Tobacco control legislation, National tobacco control
programme are discussed. A section covered Integrated disease surveillance
project, Components of surveillance activity and Syndromes under surveillance.
We have also discussed National programme for control and treatment of
occupational diseases and brief on various schemes related to National Water
supply and sanitation programme. Hope you will actively participate in all the
activities and play important role in creating awareness with innovative methods
to bring about desirable life style modifications to achieve the goals.

3.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

Q1) Strategies to achieve the objectives of National Blindness Control

programme:

1. Continued emphasis on free cataract surgeries through health care

delivery system and in collaboration with NGO
2. Emphasis on comprehensive eye care by covering diseases like
diabetic retinopathy, glaucoma, corneal transplantation, vitreoretinal
surgery, treatment of childhood blindness etc. Immediate attention to
these diseases to eliminate avoidable blindness.
3. Active screening of adults above 50 years of age by organizing eye
screening camps and transporting operable cases to eye facility.
4. Screening of children for identification and treatment of refractive
errors and provision of free glasses to the affected.
5. Coverage of underserved area through public private partnership
6. Capacity building of health personnel for improving their knowledge
and skill in delivery of quality care
7. IEC activities to create awareness on eye care within community
through regional Institutes of ophthalmology and medical colleges to
be strengthened in a phased manner with latest equipment’s and
training of manpower so that they can be upgraded as centres of
excellence.
8. Strengthening district hospitals by upgrading infrastructure, equipment
and adequate manpower.
9. Continuing emphasis on Primary health care by establishing vision
centres in all PHC’s with a PMOA in position.
10. Multipurpose district mobile units for better coverage
77
National Health Q2) The features of Vision 2020
Programmes in India-
Role of Nurse It is a global initiative to reduce avoidable (preventable and curable)
blindness by the year 2020. India is also committed to this initiative. The
plan of action for the country has been developed with following main
features:

1. Target diseases are cataract, refractive errors, childhood blindness,

corneal blindness, glaucoma, diabetic retinopathy.

2. Human resource development as well as infrastructure and technology

development at various levels of health system. The proposed four tier
structure includes Centres of Excellence (20), Training Centres (200),
Service Centres (2000), and Vision Centres (20,000).

Q3) Universal Eye Health: A Global Action Plan 2014-2019

Check Your Progress 2

Q1) Vaccine preventable diseases:

Tuberculosis, Poliomyelitis, Diphtheria, Pertussis, Tetanus, Hepatitis B,
Measles, Mumps and Rubella.
Q2) Pentavalent vaccination
India introduced pentavalent vaccine containing DPT, hepatitis B and Hib
vaccines in two states viz. Kerala and Tamil Nadu under routine
immunization programme from December 2011. With the introduction of
pentavalent vaccine, a new antigen, i.e., Hib has been added which protects
against haemophilus influenzae type B (associated with pneumonia and
meningitis) and the number of injections are reduced to 3.
Q3) Aim of Mission Indra Dhanush
The goal is to vaccinate all under-fives by the year 2020. The mission will
be technically supported by WHO, UNICEF, Rotary international and other
donor partners.

Check Your Progress 3

Q1) Cardio Vascular diseases (CVDs), Diabetes Mellitus, Cancer, Stroke.

Q2) The major objectives of the NPCDCS programme :
 Prevent and control common NCDs through behaviour and lifestyle
changes.
 Provide early diagnosis and management of common NCDs.
 Build capacity at various levels of health care for prevention, diagnosis
and treatment of common NCDs.
78
 Train human resource within the public health set-up viz doctors, National Health Programmes
paramedics and nursing staff to cope with the increasing burden of Related to Communicable
Diseases
NCDs, and
 Establish and develop capacity for palliative & rehabilitative care.
Q3) Strategies to manage NCD clinic at District Hospital
 Provide regular management and annual assessment of persons
suffering from cancer, diabetes and hypertension.
 People with established cardiovascular diseases shall also be managed
at district hospital.
 Provide home based palliative care for chronic, debilitating and
progressive patients.
 Involve in promotion of healthy lifestyle through health education and
counseling.
Check Your Progress 4
1) This project is intended to detect early warning signals of impending
outbreaks and help initiate an effective response in a timely manner in urban
and rural areas.
It will also provide essential data to monitor progress of ongoing disease
control programme and help allocate health resources more efficiently.
2) The classification of surveillance in IDSP
Syndromic diagnosis - diagnosis is made on the basis of clinical pattern by
paramedical personnel and members of the community;
Presumptive diagnosis - diagnosis made on typical history and clinical
examination by medical officer; and
Confirmed diagnosis - clinical diagnosis by a medical officer and or
positive laboratory identification.
Check Your Progress 5
1) A problem village is defined as one where no source of safe water is
available within a distance of 1.6 km, or where water is available at a depth
of more than 15 meters, or where water source has excess salinity, iron,
fluorides and other toxic elements, or where water is exposed to the risk of
cholera.
2) Information, education and communication are integral part of rural
sanitation programme to adopt proper environmental sanitation practices
including disposal of garbage, refuse and waste water, and to convert all
existing dry latrines into low cost sanitary latrines. The IEC activities would
help to involve the community in planning, implementation and
management of drinking water schemes and make population understand
importance of safe drinking water.
3) Prime Minister Shri Narendra Modi launched country’s biggest cleanliness
drive on 2nd October 2014. The campaign aims to accomplish a vision of
clean India by 2nd October 2019

79
National Health
Programmes in India- UNIT 4 NATIONAL NUTRITIONAL
Role of Nurse
PROGRAMMES
Structure

4.0 Objectives
4.1 Introduction
4.1.1 Policies to Overcome Nutritional Health Problems
4.2 Integrated childhood Development Services
4.2.1 Objectives
4.2.2 Services under ICDS
4.3 Kishori Shakti Yojna
4.3.1 Objectives
4.3.2 Services Provided
4.3.3 Importance
4.3.4 Components
4.3.5 Girl to girl approach (11-15 years age group)
4.3.6 Balika Mandal (15-18 years age group)
4.4 Vitamin A Prophylaxis Programme
4.4.1 Schedule for Vitamin A
4.5 National Nutritional Anamia prophylaxis programme
4.6 Mid-day meal programme
4.6.1 Aims
4.7 Iodine deficiency disorder programme (IOD)
4.8 Let Us Sum Up
4.9 Answers to Check Your Progress

4.0 OBJECTIVES
After going through this Unit, you will be able to:

 Explain the magnitude of nutritional problems affecting health

 Enlist policies pertaining to nutrition
 Describe ICDS services to overcome nutritional problems
 Discuss objectives, services provided, importance and components related to
Kishori Shakti Yojna
 Explain Girl to girl approach (11-15 years age group) and Balika Mandal (15-
18 years age group)
 State activities under Vitamin A Prophylaxis Programme
 Describe National Nutritional Anamia prophylaxis programme
 Explain and create awareness about Iodine deficiency disorder programme

80
National Nutritional
4.1 INTRODUCTION Programmes

In the previous unit you have gone through national health programmes related to
non communicable diseases in India. We have already discussed in details about
nutritional problems in Block 2 Unit 3. In this unit we will be focusing upon
national programme to prevent and control nutritional deficiencies.

India is the second most populated developing country in the world. Extensive
poverty results in chronic and constant hunger. The appearance of this constant
and re-occuring problem is the condition of under-nutrition which is more
common among poor communities, mostly children and women. Malnutrition is a
result of improper and inadequate diet or more essential nutrients that deteriorates
physical and mental growth and human health. The improper diet is related to the
food and other nutrients required to maintain a good health, for growth and to
allow a choice of physical activity and work levels, those are socially important.
Under- nutrition reduces the work efficiency and productivity.

It is the most important cause of illness and death globally accounting for 12% of
all deaths and 16% of disability-adjusted life years lost. It is well known that
undernutrition is a result of multiple unfavourable factors. It is a very important
factor which needs policies to overcome these problems.

4.1.1 Policies to overcome nutritional health problems

 Integrated Child Development Services Scheme
 Midday Meal Programme
 Special Nutrition Programme (SNP)
 National Nutritional Anemia Prophylaxis Programme
 National Iodine Deficiency Disorders Control Programme
 National Goitre Control Programme
 Applied Nutrition Programme
 Akshaya Patra Programme

4.2 INTEGRATED CHILDHOOD DEVELOP-

MENT SERVICES
The Integrated Child Development Service (ICDS) Scheme was launched on
October 2nd, 1975. The aim was to provide supplementary nutrition, immunization
and pre-school education to the children. It is one of the world’s largest
programme to provide an integrated package of services for the entire
development of a child. It is a centrally funded scheme executed by state
governments and union territories.

Beneficiaries of this programme are:

1. Children in the age group of 0-6 years;

2. Pregnant women and
3. Lactating mothers.
81
National Health 4.2.1 Objectives
Programmes in India-
Role of Nurse  To improve the nutritional and health status of children in the age- group 0-6
years.
 To lay the foundation for proper psychological, physical and social
development of the child.
 To reduce the incidence of mortality, morbidity, malnutrition and school
dropout.
 To achieve effective coordination of policy and implementation amongst the
various departments to promote child development; and.
 To enhances the capability of the mother to look after the normal health and
nutritional needs of the child through proper nutrition and health education.

4.2.2 Services under ICDS

 Supplementary Nutrition;
 Pre-school non-formal education;
 Nutrition & health education
 Immunization;
 Health check-up and
 Referral services.

Among the above mentioned three services viz. immunization, health check-up
and referral services are related to health and are provided through National
Health Mission and Public Health Infrastructure. And it was done by various
centres Anganwadi Centres through Anganwadi Workers (AWWs) and
Anganwadi Helpers (AWHS) at a basic level.

The delivery of services to the beneficiaries is as follows:

Services Target Group Service provided by

(i) Supplementary Children below 6 years, Anganwadi Worker and

Nutrition Pregnant & Lactating Anganwadi Helper
Mothers (P&LM) (Ministry of Women and
Child Development
(MWCD)

(ii) Immunization* Children below 6 years, ANM /MO Health

Pregnant & Lactating system, Ministry of
Mothers (P&LM) Health and Family
Welfare (MoHFW)

iii) Health Check-up* Children below 6 years, ANM/MO/AWW (Health

Pregnant & Lactating system, MHFW)
Mothers (P&LM)

iv) Referral Services Children below 6 years, AWW/ANM/MO (Health

Pregnant & Lactating system, MoHFW)
Mothers (P&LM)

82
v) Pre-School Children 3-6 years AWW (MWCD) National Nutritional
Programmes
Education

vi) Nutrition & Health Women (15-45 years) AWW/ANM/MO (Health

Education system, MoHFW &
MWCD)

*AWW assists ANM in identifying the target group.

The Supplementary Nutrition Programme component was funded through 50:50

ratios. The North East states have 90:10 ratios. Beneficiaries of SNP are given hot
meals along with take-home rations. For children, the number of rations and
meals received depends on their malnutrition levels.

SNP is provided for 300 days at the rate of Rs. 8 per day for children and Rs. 9.50
for pregnant and lactating mothers. Severely malnourished children are allocated
Rs 12 per day. Adolescent Girls (11-14 years out of school) are allocated Rs 9.50
per day.

There will be 1 Anganwadi centre (AWC) for a population of 400-800; 2 AWCs

for 800-1600; 3 AWCs for 1600-2400 and thereafter in multiples of 800 -1 AWC.
The norms for one AWC for Tribal/Riverine/Desert, Hilly and other difficult areas
will be 300-800 Norms for one Mini AWC will be 150-400. Norms for
Anganwadi on Demand (AOD) - Where a settlement has at least 40 children less
than 6 years of age but no AWC.

ICDS Systems imparts a project to strengthen and improve earlier programme was
Strengthening and Nutrition Improvement Project (ISSNIP). The aim of this
project was to improve nutritional and early childhood development outcomes of
children in India. Their main objectives of Phase 1 are to support the GOI and the
selected States to strengthen the ICDS policy framework, systems and capacities,
and facilitate community engagement, to ensure greater focus on children less
than three years of age in the project districts; and strengthen convergent actions
for improved nutrition outcomes in the stipulated districts.

The project will be implemented in identified 162 districts having a higher

proportion of child under nutrition across eight States, like Bihar, Chhattisgarh,
Jharkhand, Madhya Pradesh, Maharashtra, Rajasthan, Uttar Pradesh and Andhra
Pradesh. Besides, urban pilots will be undertaken in and around NCR of Delhi
and convergent nutrition actions pilots in some selected districts in two non -
project States like Odisha and Uttarakhand.

Check Your Progress 1

Q1) Name any four nutritional policies

Q2) Name the beneficiaries of ICDS programme

83
National Health .....................................................................................................................
Programmes in India- .....................................................................................................................
Role of Nurse
Q3) Enlist the Services under ICDS project
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

4.3 KISHORI SHAKTI YOJNA

The scheme is for adolescent girls and was initiated from 1st November 1991.
Now the scheme has been renamed as Kishori Shakti Yojna. Since no separate
budget is available for this scheme and nutrition is to be provided from the State
Sector, the beneficiaries are provided supplementary nutrition through ICDS
under the Supplementary Nutrition Programme.

Scheme for Adolescent Girls was sanctioned in the year 2010 and is implemented
in 205 districts across the country. The target group of this scheme was adolescent
girls (AGs) in the age group of 11 to 14 years.

4.3.1 Objectives
Kishori Shakti Yojana (KSY) aims to provide a facility to adolescent girls so that
they may become responsible citizens.

The broad objective of the scheme was to advance the nutritional, health and
development status of adolescent girls, support increasing knowledge of health,
hygiene, nutrition and family care, and to integrate them with opportunities for
learning life skills, going back to school, helping girls grow to understand their
society and become prolific members of the society.

This scheme works as the existing ICDS infrastructure.

4.3.2 Services provided

Under this scheme, adolescent girls are offered non-formal education in life
education aspects including physical, developmental and sex education at
Anganwadi centres. Girls can also be given basic health supplements such as IFA
and de-worming tablets. Girls can also be given vocational training at the centres.

4.3.3 Importance
Adolescence is a crucial phase in the life of the woman. At this stage, she stands
at the threshold of adulthood. This stage is intermediary between childhood and
womanhood and it is the most eventful for the mental, emotional and
psychological well being. The life-cycle approach for holistic child development
remains unaddressed if adolescent girls are excluded from the developmental
programmes aimed at human resource development.

The Adolescent Girls (AG) Scheme, put into practice by the Ministry of Women
and Child Development under Integrated Child Development Services (ICDS),
primarily aims at breaking the inter-generational life-cycle of nutritional and
gender disadvantage and providing a supportive environment for self-
84
development. The government has approved expansion and universalization of the National Nutritional
Scheme for Adolescent Girls in a phased manner i.e. in additional 303 districts in Programmes
2017-18 and the remaining districts in 2018- 19 with the simultaneous phasing out
of Kishori Shakti Yojana (KSY). Thus at present, 508 districts in the country are
covered under Scheme for Adolescent Girls. In the identified areas of remaining
districts, KSY is implemente.

4.3.4 Components
There are two main components of this Scheme

A. Nutrition- In Nutrition part Home Ration or Hot Cooked Meal for 11 14

years Out of school girls - Nutrition Provision was Rs. 9.50 per day (600
calories; 18 20 gram of protein and recommended daily intake of
micronutrients per day).

B. Non-Nutrition Part - In Non Nutrition part for school going Adolescent

Girls: (2 – 3 times a week) of 11 14 years, IFA supplementation, Health
check up and Referral services, Nutrition & Health Education (NHE),
Counselling/ Guidance on family welfare, ARSH, child care practices, Life
Skill Education and accessing public services should be provided. It was
decided to involve Panchayati raj institutions, NGOs and other institutions
for implementation of the Scheme.

4.3.5 Girl to girl approach (11-15 years age group)

In each selected Anganwadi area 2 girls in the age group of 11–15 years are
selected. These adolescent girls provided with a meal on the same scale as the
pregnant women or nursing mother namely one that would provide 500 calories of
energy and 20 g of protein. The 2 girls so identified are to receive in-service
training at the Anganwadi from the worker and supervisor over a period of six
months to become fully equipped individuals, capable of managing the centre on
their own, so as to fully realize the objectives in all aspects, of the Anganwadi
worker, including management of stores, the organization of the feeding
programme, immunization schedules, to take weight of children, home visits,
preschool activities etc.

4.3.6 Balika Mandal (15-18 years age group)

This scheme has more focus on the social and mental development of girls at age
group 15–18 years. Special focus was laid to motivate and involve the uneducated
groups belonging to this age group in non–formal education and improvement and
up gradation of home-based skills.

4.4 VITAMIN A PROPHYLAXIS PROGRAMME

The programme was launched in 1970 by the ministry of health and family
welfare with one objective to reduce the disease and preventing blindness due to
Vitamin A deficiency. It was started with seven states with severe problems later it
was extended country. Under this programme, children aged 6 months to 6 years
were to be administered a mega dose of vitamin A at 6 monthly intervals. To
prioritize Vitamin A administration, the programme was revised to give 5 mega

85
National Health doses at 6 months intervals to children 9 months to 3 years of age. In view of
Programmes in India- adequate supplies of Vitamin A, the target group has been revised to cover
Role of Nurse
children 9 months- 5 years, since 2007. The main objective of this programme
was to decrease the commonness of Vitamin A deficiency from current 0.6% to d”
0.5%. The Main strategy was given to provide health and nutrition education to
encourage colostrum feeding, exclusive breastfeeding for the first six months, the
introduction of complementary feeding thereafter and adequate intake of Vitamin
A rich foods.

4.4.1 Schedule for vitamin A

Prophylactic Vitamin A as per the following dosage schedule:

 100000 IU at 9 months with measles immunization

 200000 IU at 16-18 months, with DPT booster

 200000 IU every 6 months, up to the age of 5 years

A total of 9 mega doses are to be given from 9 months of age up to 5 years. All
children those are suffered from xerophthalmia are to be treated at health
facilities, given 1 dose of Vitamin A if they have not received it in the previous
month.

Check Your Progress 2

Q1) List the objectives of kishori Shakti yojana

Q2) Explain two main components of Adolescent Girls (AG) Scheme

Q3) Explain Benefits of Girl to girl approach (11-15 years age group)
....................................................................................................................
....................................................................................................................
....................................................................................................................

Q4) Write the Prophylactic schedule for Vitamin A

4.5 NATIONAL NUTRITIONAL ANAEMIA PRO-

PHYLAXIS PROGRAMME
This programme was launched during 4th 5-year plan in 1970 by Ministry of
health and family welfare for the prevention of nutritional anaemia in mothers and
children. Recently, the National Nutritional Anaemia Prophylaxis Programme is
operated as part of the RCH programme under the revised policy, the target group
86
has been expanded to include infants 6-12 months, school children 6-10 years and National Nutritional
adolescents 11-18 years of age, clinically found to be anaemic. For infants and Programmes
children, a liquid formulation having 20 mg elemental iron and 100 mgs folic acid
per ml, will be made available.

Dosage for various age groups are as follows:

Age Elemental iron Folic acid Duration

Children 6 - 59 20 mg 100 mg 100 days if the

months child is clinically
found to be anaemic

6-10 years 30 mg 0.250 mg 100 days

School going
children

Adolescents and 100 mg 0.500 mg 100 daysgirls are

adults given greater priority

Pregnant women one tablet of 0.500 mg prophylactically daily

100 mg 2 tabs for 100 days if
of 100 mg clinically anaemic for
100 days

Lactating mothers 100 mg 0.500 mg 100 days

and acceptors of
family planning

The programme also aimed to include health and nutrition education to improve
overall dietary intakes and encourage the use of iron and folic acid rich foods as
well as food items that help iron absorption.

4.6 MID DAY MEAL PROGRAMME

The Mid-day Meal Scheme was first started in Tamilnadu. It is also known as
School Lunch Programme. This programme was launched by Ministry of
Education in 1961.

4.6.1 Aims
 Provision of free lunch to school-children on all working days,

 Protecting children from classroom hunger;

 Increasing school enrolment and attendance;

 Improves socialisation among children belonging to all castes and

 Addresses malnutrition

Mid day meal programme also provides social empowerment through provision of
employment to women, reduce school drops outs, and improve the attendance.

As per the current norms, the primary children are provided with 30-gram pulses,
75-gram vegetables and 7.5 grams vegetables.

87
National Health
Programmes in India- 4.7 IODINE DEFICIENCY DISORDER
Role of Nurse PROGRAMME (IDD)
India commenced a goitre control programme in 1962, based on iodized salt. At
the end of three decades, the prevalence of the disease still remained high. As a
result, a major national programme “The IDD Control Programme” was initiated
in which nation-wide, rather than area-specific use of iodized salt is being
promoted. It was decided as a national policy to fortify all edible salt in a phased
manner by end of 8th Plan.

The objectives of the programme are:

1. Surveys to assess the magnitude of the Iodine Deficiency Disorders in

districts.
2. Supply of iodized salt in place of common salt.
3. Resurveys to assess iodine deficiency disorders and the impact of iodized salt
after every 5 years in districts.
4. Laboratory monitoring of iodized salt and urinary iodine excretion.
5. Health education and publicity.

Significant achievements

The production/supply of iodized salt from April 2013 to March 2014 was 58.64
lakh tonnes and 55.08 lakh tonnes.

Notification banning the sale of non-iodized salt for different human consumption
in the entire country is already issued under “Food Safety & Standards Act 2006
and Regulations 2011”.

Check Your Progress 3

Q1) Write the dosage for all age groups for anemia prevention
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q2) Explain the benefits of mid day meal program

Q3) Enlist the objective for Iodine deficiency disorder program

4.8 LET US SUM UP

We have already discussed in details about nutritional problems in Block 2 Unit 3.
In this unit we have focused upon National Health programmes to prevent and
control nutritional deficiencies. After briefing the magnitude of nutritional
88
problems affecting health , enlisted the policies pertaining to nutritional health, National Nutritional
described ICDS services to overcome nutritional problems and discussed Programmes
objectives, services provided, importance and components related to Kishori
Shakti Yojna. We also explained girl to girl approach between11-15 years age
group and Balika Mandal of 15-18 years age group. Stated activities under
Vitamin A Prophylaxis Programmeand described National Nutritional Anamia
prophylaxis programme. Knowledge of Iodine deficiency disorder programme

Would help you to create awareness about Iodine deficiency disorder programme

4.9 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) Four Nutritional policies

 Integrated Child Development Services Scheme

 Midday Meal Programme

 Special Nutrition Programme (SNP)

 National Nutritional Anemia Prophylaxis Programme

Beneficiaries of this programme are:

Children in the age group of 0-6 years;

Pregnant women and

Lactating mothers.

3) Enlist the services under ICDS project

 Supplementary Nutrition;

 Pre-school non-formal education;

 Nutrition & health education

 Immunization;

 Health check-up and

 Referral services.

Check Your Progress 2

1) Objectives of Kishori Shakti yojana

Kishori Shakti Yojana (KSY) aims to provide a facility to adolescent girls so

that they may become responsible citizens.

The broad objective of the scheme was to advance the nutritional, health and
development status of adolescent girls, support increase in knowledge of
health, hygiene, nutrition and family care, and to integrate them with
opportunities for learning life skills, going back to school, helping girls grow
to understand their society and become prolific members of the society.

89
National Health 2) There are two main components of this Scheme
Programmes in India-
Role of Nurse A. Nutrition- In Nutrition part Home Ration or Hot Cooked Meal for 11
14 years Out of school girls - Nutrition Provision was Rs. 9.50 per day
(600 calories; 18 20 gram of protein and recommended daily intake of
micronutrients per day).

B. Non-Nutrition Part - In Non-Nutrition part for school going Adolescent

Girls: (2 – 3 times a week) of 11-14 years, IFA supplementation, Health
check up and Referral services, Nutrition & Health Education (NHE),
Counselling/ Guidance on family welfare, ARSH, child care practices,
Life Skill Education and accessing public services provided with
involvement of Panchayati raj institutions, NGOs and other institutions
for implementation of the Scheme.

3) Benefits of Girl-to-girl approach (11-15 years age group)

The 2 girls after getting in-service training at the Anganwadi from the worker
and supervisor over a period of six months become fully equipped
individuals, Hence, they are capable of managing the centre on their own, so
as to fully realize the objectives in all aspects, of the Anganwadi worker,
including management of stores, the organization of the feeding programme,
immunization schedules, to take weight of children, home visits, preschool
activities

4) Prophylactic Vitamin A as per the following dosage schedule:

 100000 IU at 9 months with measles immunizati

 200000 IU at 16-18 months, with DPT booster

 200000 IU every 6 months, up to the age of 5 years

A total of 9 mega doses are to be given from 9 months of age up to 5 years.

Check Your Progress 3

1)
Age Elemental iron Folic acid Duration

Children 6 - 59 20 mg 100 mg 100 days if the child is

months clinically found to be
anaemic
6-10 years School 30 mg 0.250 mg 100 days
going children
Adolescents and 100 mg 0.500 mg 100 daysgirls are
adults given greater priority
Pregnant women one tablet of 0.500 mg prophylactically daily
100 mg 2 tabs for 100 days if clinically
of 100 mg anaemic for 100 days
Lactating mothers 100 mg 0.500 mg 100 days
and acceptors of
family planning

90
2) Mid-day meal programme provides social empowerment through provision Reproductive, Maternal,
of employment to women, reduce school drops outs, and improve the Newborn, Child And
Adolescent Health
attendance. (Rmnch+A) Strategy
As per the current norms, the primary children are provided with 30-gram
pulses, 75-gram vegetables and 7.5 grams vegetables.

3) The objectives of the programme are :

1. Surveys to assess the magnitude of the Iodine Deficiency Disorders in

districts.

2. Supply of iodized salt in place of common salt.

3. Resurveys to assess iodine deficiency disorders and the impact of

iodized salt after every 5 years in districts.

4. Laboratory monitoring of iodized salt and urinary iodine excretion.

5. Health education and publicity.

91
National Health
Programmes in India- UNIT 5 REPRODUCTIVE, MATERNAL,
Role of Nurse
NEWBORN, CHILD AND
ADOLESCENT HEALTH
(RMNCH+A) STRATEGY
Structure

5.0 Objectives
5.1 Introduction
5.2 Reproductive and Child Health – 1 Programme
5.2.1 Interventions under RCH phase I
5.3 RCH II
5.3.1 Essential obstetric care
5.3.2 Emergency obstetric care
5.3.3 Referral linkages
5.4 Janani Suraksha Yojana
5.5 Janani-Shishu Suraksha Karyakram (JSSk)
5.6 Child Health Components
5.6.1 Nutritional Rehabilitation Centres (NRCs)
5.6.2 Integrated Management of Childhood Illness (IMCI)
5.6.3 Integrated Management of Neonatal and Childhood Illness (IMNCI)
5.6.4 Facility Based Newborn Care
5.6.5 Newborn Care Corner (NBCC)
5.6.6 Newborn Stabilization Unit (NBSU)
5.6.7 Special Newborn Care Unit (SNCU)
5.7 Home Based Newborn Care (HBNC)
5.7.1 Navjat Shishu Suraksha Karyakram (NSSK)
5.7.2 Rashtriya Bal Swasthya Karyakram (RBSK)
5.8 Reproductive, Maternal, Newborn, Child and Adolescent Health
(RMNCH+A)
5.8.1 Adolescent Health Programme
5.8.2 Adolescent Reproductive and Sexual Health programme (ARSH)
5.8.3 Weekly Iron and Folic Acid Supplementation (WJFS)
5.8.4 Menstrual Hygiene Scheme
5.9 Care During Pregnancy And Childbirth
5.10 Newborn and Child Care
5.11 Care Through The Reproductive Years
5.12 Maternal and Child Health (MCH) Wing
5.13 Let Us Sum Up
5.14 Answers to Check Your Progress
92
Reproductive, Maternal,
5.0 OBJECTIVES Newborn, Child And
Adolescent Health
After going through this unit you will be able to: (Rmnch+A) Strategy

 Explain Interventions under Reproductive and Child Health – 1&II

Programme

 Describe Essential obstetric care , Emergency obstetric care and Referral

linkages

 Enlist the components of Janani Suraksha Yojana

 Enlist the activities under Jananl-Shishu Suraksha Karyakram (JSSk)

 Describe Child Health Components

 Explain Home Based Newborn Care (HBNC)

 State the strategies under Reproductive, Maternal, Newborn, Child and

Adolescent Health (RMNCH+A)

 Take care during of mother during pregnancy, and childbirth, newborn baby.

5.1 INTRODUCTION
In the previous unit we have discussed about nutrition health programmes. In this
unit emphasis will be given to Reproductive and child health related schemes and
strategies. Reproductive and child health approach has been defined as “people
have the ability to reproduce and regulate their fertility, women are able to go
through pregnancy and child birth safely, the outcome of pregnancies is successful
in terms of maternal and infant survival and well being, and couples are able to
have sexual relations, free of fear of pregnancy and of contracting disease”

We will discuss Interventions under Reproductive and Child Health – 1&II

Programme and describe Essential obstetric care , Emergency obstetric care and
Referral linkages in first section. You will be reading the components of Janani
Suraksha Yojana and activities under Janani-Shishu Suraksha Karyakram (JSSk)
at the end of the unit Child Health Components including Home Based Newborn
Care (HBNC) discussed. We have also emphasized the strategies under
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)
You have to play very important role of taking care of mother during pregnancy,
and childbirth and so on.

5.2 REPRODUCTIVE AND CHILD HEALTH-1

PROGRAMME
Let us now read the RCH phase-I

The RCH phase-I programme incorporated the components relating child survival
and safe motherhood and included two additional components, one relating to
sexually transmitted disease (STD) and other relating to reproductive tract
infection (RTI).

93
National Health 5.2.1 Interventions at District level under RCH Phase 1
Programmes in India-
Role of Nurse RCH phase-I interventions at district level were as follows:

Interventions in all districts

- Child Survival interventions i.e. Immunization, Vitamin A (to prevent

blindness), Oral Rehydration Solution (ORS) therapy and prevention of
deaths due to pneumonia.

- Safe Motherhood interventions e.g. Antenatal check-up, Immunization for

tetanus, safe delivery, Anemia control programme.

- Implementation of Target Free Approach.

- High quality training at all levels. - IEC activities.

- Specially designed RCH package for Urban slums and Tribal areas.

- District sub-projects under Local Capacity Enhancement.

- RTI/STD Clinics at District Hospitals (where not available)

- Facility for safe abortions at PHCs by providing equipment, contractual

doctors etc.

- Enhanced community participation through Panchayats, Women’s Groups and

NGOs.

- Adolescent health and reproductive hygiene.

The major interventions under RCH - Phase I

1. Essential obstetric care

Essential obstetric care intends to provide the basic maternity services to all
pregnant women through (1) early registration of pregnancy (within 12-16
weeks). (2) provision of minimum three antenatal check-ups by ANM or
medical officer to monitor progress of the pregnancy and to detect any risk/
complication so that appropriate care including referral could be taken in
time. (3) provision of safe delivery at home or in an institution, and (4)
provision of three postnatal check-ups to monitor the postnatal recovery and
to detect complications.

2. Emergency obstetric care

Complications associated with pregnancy are not always predictable, hence,

emergency obstetric care is an important intervention to prevent maternal
morbidity and mortality. Under the RCH programme the FRUs were
strengthened through supply of emergency obstetric kit, equipment kit and
provision of skilled manpower on contract basis etc.

3) 24-Hour delivery services at PHCs/CHCs

To promote institutional deliveries, provision has been made to give

additional honorarium to the staff to encourage round the clock delivery
facilities at health centres.

94
4) Medical Termination of Pregnancy (MTP) Reproductive, Maternal,
Newborn, Child And
The aim is to reduce maternal morbidity and. mortality from unsafe Adolescent Health
abortions. The assistance from the Central Government is in the form of (Rmnch+A) Strategy
training of manpower, supply of MTP equipment and provision for engaging
doctors trained in MTP to visit PHCs on fixed dates to perform MTP.

5) Control of Reproductive Tract Infections (RTI) / Sexually Transmitted

Diseases (STD)

Under the RCH programme, the component of RTI/STD control is linked to

HIV and AIDS control. It has been planned and implemented in close
collaboration with National AIDS Control Organization (NACO). NACO
provides assistance for setting up RTI/STD clinics upto the district level.

6) Immunization

The Universal Immunization Programme (UIP) became a part of CSSM

programme in 1992 and RCH programme in 1997. It will continue to provide
vaccines for polio, Tetanus, DPT, DT, measles and tuberculosis.

7) Essential newborn care

The primary goal of essential newborn care is to reduce perinatal and

neonatal mortality. The main components are resuscitation of newborn with
asphyxia, prevention of hypothermia, prevention of infection, exclusive
breast feeding and referral of sick newborn.

8) Diarrheal disease control

In the districts not implementing Integrated Management of Neonatal and

Childhood Illness, the vertical programme for control of diarrheal disease
will continue. India is the first country in the world to introduce the low
osmolarity Oral Rehydration Solution.

9) Acute respiratory disease control

The standard case management of ARI and prevention of deaths due to

pneumonia is now an integral part of RCH programme. Peripheral health
workers are being trained to recognize and treat pneumonia. Cotrimoxazole is
being supplied to the health workers through the drug kit.

10) Prevention and control of Vitamin A deficiency in children

It is estimated that large number of children suffer from sub-clinical

deficiency of vitamin A. Under the programme, doses of vitamin A are given
to all children under 5 years of age.

11) Prevention and control of Anemia in children

Iron deficiency anemia is widely prevalent in young children. To manage

anemia, the policy has been revised. Infants from the age of 6 months
onwards up to the age of 5 years are to receive iron supplements in liquid
formulation in doses of 20 mg elemental iron and 100 mcg folic acid per day
for 100 days in a year.

95
National Health 12) Introduction of Hepatitis B Vaccination
Programmes in India-
Role of Nurse Introduction of Hepatitis B in the National Immunization Programme has
been approved by the Government. Under this project hepatitis B .vaccine
will be administered to infants along with the primary doses of DPT vaccine.

5.3 RCH - PHASE II

After reading measure initiatives under RCH-1, Let us now go through
improvements accomplished with RCH II as discussed below:

RCH-phase II began from 1st April, 2005. The focus of the programme is to
reduce maternal and child morbidity and mortality with emphasis on rural health
care.

Objectives Of RCH Phase-II programme:

1. Reduction of Maternal Morbidity And Mortality

2. Reduction of Infant Morbidity And Mortality

3. Reduction of Under 5 Morbidity And Mortality

4. Promotion of Adolescent Health

5. Control of Reproductive Tract Infections and Sexually Transmitted

Infections.

The major strategies under the second phase of RCH are:

• Essential obstetric care

a. Institutional delivery

b. Skilled attendance at delivery

• Emergency obstetric care

a. Operationalizing First Referral Units

b. Operationalizing PHCs and CHCs for round the clock delivery services

• Strengthening referral system

The Government of India has given some broad guidelines and strategies for
achieving the reduction in maternal mortality rate and infant mortality rate. The
initiatives which have been planned are:

5.3.1 Essential obstetric care

a) Institutional delivery: To promote institutional delivery in RCH Phase II, it
was envisaged that fifty percent of the PHCs and all the CHCs would be
made operational as 24-hour delivery centres, in a phased manner, by the
year 2010. These centres would be responsible for providing basic
emergency obstetric care and essential newborn care and basic newborn
resuscitation services round the clock. The experience of RCH phase-I
indicates that giving incentive to health workers for providing round the
clock services did not function well in most of the states. On the contrary

96
there is the experience from government of Andhra Pradesh and Tamil Nadu, Reproductive, Maternal,
where round the clock delivery and new born care services could be ensured Newborn, Child And
Adolescent Health
by providing 3 to 4 staff nurses/ ANM at the PH Cs. (Rmnch+A) Strategy
b) Skilled attendance at delivery - It is now recognized globally that the
countries which have been successful in bringing down maternal mortality
are the ones where the provision of skilled attendance at every birth and its
linkage with appropriate referral services for complicated cases have been
ensured. The WHO has also emphasized that skilled attendance at every birth
is essential to reduce the maternal mortality in any country. Guidelines for
normal delivery and management of obstetric complications at PHC/CHC for
medical officers and for ANC and skilled attendance at birth for ANM/LHVs
have been formulated and disseminated to the states.

c) The policy decision: ANMs I, LHVs I, and staff nurse have now been
permitted to use drugs in specific emergency situations to reduce maternal
mortality. They have also been permitted to carry out certain emergency
interventions when the life of the mother is at stake.

5.3.2 Emergency obstetric care

Operationalization of FRUs and skilled attendance at birth are the two activities
which go hand in hand. In view of this, simultaneous steps have been taken to
ensure tackling obstetric emergencies. It has been decided that all the First
Referral Units be made operational for providing emergency and essential
obstetric care during the second phase of RCH. The minimum services to be
provided by a fully functional FRU are (41):

1. 24- hour delivery services including normal and assisted deliveries;

2. Emergency obstetric care including surgical interventions like caesarean

sections;

3. New-born care;

4. Emergency care of sick children;

5. Full range of family planning services including laproscopic services;

6. Safe abortion services;

7. Treatment of STl/RTI;

8. Blood storage facility;

9. Essential laboratory services; and

10. Referral (transport) services.

To be able to perform the full range of FRU function, a health facility must have
the following facilities: (a) A minimum bed strength of 20-30. However, in
difficult areas, as the North-East states and the underserved areas of eight referred
to as Empowered Action Group (EAG) states, which are socio economically
backward -Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan,
Uttaranchal and Utter Pradesh. this could initially be relaxed to 10-12 beds (b) A
fully functional operation theatre (c) A fully functional labor room (d) An area

97
National Health earmarked and equipped for newborn care in the labor room, and in the ward (e)
Programmes in India- A functional laboratory (f) Blood storage facility (g) 24 hour water supply and
Role of Nurse
electricity supply (h) Arrangements for waste disposal, and (i) Ambulance facility.

5.3.3 Strengthening referral system

During RCH I funds were provided through Panchayats for emergency obstetric
care but were underutilized. Therefore in RCH II different modes were of referral
linkages were proposed like NGO’s, self-help groups and women groups.

Several initiatives were also taken

 MBBS doctors were trained in life saving anesthetic skills for emergency
obstetric care.

 Setting up of blood storage centres at FRU’s according to government

guidelines.

5.4 JANANI SURAKSHA YOJANA

The National Maternity Benefit scheme has been modified into a new scheme
called Janani Suraksha Yojana (JSY). It was launched on 12th April, 2005. The
objectives of the scheme are - reducing maternal mortality and infant mortality
through encouraging delivery at health institutions, and focusing at institutional
care among women in below poverty line families.

The salient features of Janani Suraksha Yojana are as follows:

a) It is a 100 per cent centrally sponsored scheme;

b) Under National Rural Health Mission, it integrates the benefit of cash

assistance with institutional care during antenatal, delivery and immediate
post-partum care; This benefit will be given to all women, both rural and
urban, belonging to below poverty line household and aged 19 years or
above, up to first two live births The Accredited Social Health Activist
(ASHA) would work as a link health worker between the poor pregnant
women and public sector health institution in the low performing states.
ASHA would be responsible for making available institutional JANANI
SURAKSHA YOJANA antenatal as well as postnatal care. She would also be
responsible for escorting the pregnant women to the health centre.

The eligibility of cash assistance is as follows:

1. In low performing states (LPS) : All women, including those from SC and ST
families, delivering in government health centres like sub-centre, primary
health centre, community health centre, first referral unit, general wards of
district and state hospitals or accredited private institutions.

2. In high performing states (HPS): Below poverty line women, aged 19 years
and above and the SC and ST pregnant women.

The year 2006-07 was declared as the year for institutional deliveries. During
the year scope of the scheme was extended to the urban areas of high
performing states and restriction of age and birth order were removed in the

98
low performing states. The benefits of the scheme was also extended to all Reproductive, Maternal,
women belonging to SC/ST families for institutional deliveries. Newborn, Child And
Adolescent Health
During the year 2012-13, about 1.06 crore pregnant women were benefitted from (Rmnch+A) Strategy
the scheme

Vandemataram scheme

This is a voluntary scheme wherein any obstetric and gynae specialist, maternity
home, nursing home, lady doctor/MBBS doctor can volunteer themselves for
providing safe motherhood services. The enrolled doctors will display
‘Vandemataram logo’ at their clinic. Iron and Folic Acid tablets, oral pills, TT
injections etc. will be provided by the respective District Medical Officers to the
‘Vandemataram doctors/ clinics’ for free distribution to beneficiaries.

Safe abortion services: It provides affordable medicinal services to ladies in

general. In the case of abortions, all procedures are done by qualified
professionals or doctors, who are exceptionally prepared or trained to perform this
sort of procedure. They have vast knowledge in abortion medicine, which makes
them the best individuals to trust with the methodology.

Majority of abortions take place outside authorized health services and/or by

unauthorized and unskilled persons. Whether spontaneous or induced, abortion is
a matter of concern as it may lead to complications. Under RCH phase II
following facilities are provided:

a) Medical method of abortion: Termination of early pregnancy with two drugs

Mifepristone (RU 486) followed by Misoprostol. They are considered safe
under supervision, with appropriate counselling.

b) Manual Vacuum Aspiration (MVA): The department of family welfare has

introduced Manual Vacuum Aspiration (MVA) technique in the family
welfare programme. Manual Vacuum Aspiration is a safe and simple
technique for termination of early pregnancy, makes it feasible to be used in
Primary Health Centers (PHC) or comparable facilities.

Village Health and Nutrition Day

Organizing Village Health and Nutrition Day once a month at anganwadi centre to
provide antenatal/postpartum care for pregnant women, promote institutional
delivery, health education, immunization, family planning and nutrition services
etc.

Maternal death review

Maternal death audit, both facility and community based, is an important strategy
to improve the quality of obstetric care and reduce maternal mortality and
morbidity.
99
National Health Pregnancy tracking
Programmes in India-
Role of Nurse The link between pregnancy-related care and maternal mortality is well
established. RCH-11 stresses the need for universal screening of pregnant women
and providing essential and emergency obstetric care. Focused antenatal care,
birth preparedness and complication readiness, skilled attendance at birth, care
within the first seven days etc. are the factors that can reduce the maternal
mortality

5.5 JANANI-SHISHU SURAKSHA KARYAKRAM

(JSSK)
Government of India launched the Janani-Shishu Suraksha Karyakram (JSSK) on
1st June 2011, a new national initiative, to make available better health faculties
for women and child. The following facilities to the pregnant women:

- All pregnant women delivering in public health institutions to have absolutely

free and no expense delivery, including caesarean section. The entitlements
include free drugs and consumables, free diet upto 3 days during normal
delivery and upto 7 days for C-section, free diagnostics, and free blood
wherever required. This initiative would also provide for free transport from
home to institution, between facilities in case of a referral and drop back
home. Similar entitlements have been put in place for all sick newborns
accessing public health institutions for treatment till 30 days· after birth. The
scheme has now been extended to cover the complications during ANC, PNC
and also sick infants.

Check Your Progress 1

Q1) Explain essential obstetric care under RCH 1

Q2) List the purpose of conducting Institutional delivery under RCH II

Q3) Explain Safe abortion services

5.6 CHILD HEALTH COMPONENTS

The strategy for child health care, aims to reduce under five child mortality
through interventions at every level of service delivery.

100
5.6.1 Nutritional Rehabilitation Centres (NRCs) Reproductive, Maternal,
Newborn, Child And
Severe Acute Malnutrition (SAM) is an important contributing factor for most Adolescent Health
deaths among children suffering from common childhood illness such as (Rmnch+A) Strategy
diarrhoea and pneumonia.

The services provided at the NRCs include:

a) 24 hours care and monitoring of the child;

b) Treatment of medical complication;
c) Therapeutic feeding;
d) Sensory stimulation and emotional care;
e) Counselling on appropriate feed, care and hygiene; and
f) Demonstration and practice-by-doing on the preparation of energy dense food
using locally available, culturally acceptable and affordable food items.

5.6.2 Integrated Management of Childhood Illness (IMCI)

The extent of childhood morbidity and mortality caused by Diarrhoea, ARI,
Malaria, Measles and Malnutrition is substantial. Most sick children present with
signs and symptoms of more than one of these conditions. This overlap means that
a single diagnosis may not be possible or appropriate, and treatment may be
complicated by the need to combine for several conditions. IMCI is a strategy for
an integrated approach to the management of childhood illness as it is important
for child health programmes to look beyond the treatment of a single disease. This
is cost effective and emphasizes prevention of disease and promotion of child
health and development besides provision of standard case management of
childhood illness.

The Indian version of IMCI has been renamed as Integrated Management of

Neonatal and Childhood Illness (IMNCI). It is the central pillar of child health
interventions under the RCH II strategy. The major highlights of the Indian
adaptation are:

a) Inclusion of 0-7 days age in the programme;

b) Incorporating national guidelines on Malaria, Anaemia, Vitamin-A
supplementation and Immunization schedule;
c) Training of the health personnel begins with sick young infants upto 2
months;
d) Proportion of training time devoted to sick young infant and sick child is
almost equal; and
e) Skill based.

5.6.3 Integrated Management of Neonatal and Childhood

Illness (IMNCI)
IMNCI strategy is one of the main interventions under RCH-11/NRHM. It focuses
on preventive, promotive and curative aspects of the programme. The objective is
to implement IMNCI package at the level of household, and through ANMs at
sub-centre level; through medical officers, nurse and LHVs at PHCs level.

101
National Health The IMNCI clinical guidelines target children less than 5 years old — the age
Programmes in India- group that bears the highest burden of deaths from common childhood diseases.
Role of Nurse
The guidelines take an evidence-based, syndromic approach to case management
that supports the rational, effective and affordable use of drugs and diagnostic
tools. Evidence-based medicine stresses the importance of evaluation of evidence
from clinical research and cautions against the use of intuition, unsystematic
clinical experience, and untested pathophysiologic reasoning for medical
decision-making. In situations where laboratory support and clinical resources are
limited, the syndromic approach is a more realistic and cost-effective way to
manage patients. Careful and systematic assessment of common symptoms and
well-selected clinical signs provides sufficient information to guide rational and
effective actions.

THE CASE MANAGEMENT PROCESS

The case management process is presented on a series of charts, which show the
sequence of steps and provide information for performing them. The charts
describe the following steps:

• Assess the young infant or child

• Classify the illness

• Identify treatment

• Treat the infant or child

• Counsel the mother

• Give follow-up care

These steps are probably similar to the way you care for sick children now,
though you may have learned different words to describe them. The step called
“Assess the Young Infant or Child” means taking a history and doing a physical
examination. “Classify the Illness” means making a decision on the severity of the
illness. You will select a category, or “Classification,” for each of the child’s
major symptoms, which corresponds to the severity of the disease. Classifications
are not specific disease diagnoses. Instead, they are categories that are used to
determine treatment.

The charts recommend appropriate treatment for each classification. When using
this process, selecting a classification on the chart is sufficient to allow you to
“Identify Treatment” for a young infant or child. For example, a young infant
with the classification POSSIBLE SERIOUS BACTERIAL INFECTION could
have pneumonia, septicaemia or meningitis. The treatments listed for POSSIBLE
SERIOUS BACTERIAL INFECTION will be appropriate because they have been
chosen to cover the most important diseases included in this classification.

“Treat” means giving treatment in clinic, prescribing drugs or other treatments to

be given at home, and also teaching the mother how to carry out the treatments.
“Counsel the mother” includes assessing how the child is fed and telling her
about the foods and fluids to give the child and when to bring the child back to
the clinic.

102
Management of the young infant age up to 2 months is presented on two charts Reproductive, Maternal,
titled: Newborn, Child And
Adolescent Health
* ASSESS AND CLASSIFY THE SICK YOUNG INFANT AGE UP TO 2 (Rmnch+A) Strategy
MONTHS and

* TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER.

The case management process for sick children age 2 months up to 5 years is
some what different from young infants and is presented on three charts
titled:

* ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5

YEARS

* TREAT THE CHILD

* COUNSEL THE MOTHER

The charts are designed to help you to manage young infants and children
correctly and efficiently. This course trains you to use the charts and gives you
clinical practice managing sick young infants and children.

5.6.4 Facility based Newborn care

As more sick children are screened at the peripheries through IMNCI and referred
to the health facilities, care of the sick newborn and child at CHCs, FRUs, district
hospitals and medical college hospitals assumes priority. Equipping the facilities
to provide the requisite level of care and simultaneously enhancing the capacity of
the medical officers at these facilities to handle such cases thus becomes
important.

The newborn care facilities at different levels are as follows:

Health facility All newborns at birth Sick newborns

Primary health centre Newborn care corner in Prompt referral

(PHC)/Sub-centre (SC) labor rooms
Identified as MCH level I

Community health centre Newborn care corner in Newborn

(CHC)/First referral unit labor rooms and in stabilization unit
(FRU) identified as MCH operation theatre (SNBU)
Level II

District hospital identified Newborn care corner Special newborn

as MCH Level III in labor room and in care unit (SNCU)
operation theatre

5.6.5 Newborn Care Corner (NBCC)

NBCC is a space within the delivery room in any health facility where immediate
care is provided to all newborns at birth. This area is MANDATORY for all health
facilities where deliveries are conducted. As of March 2014, about 13,653 NBCCs
are operational in the country

103
National Health 5.6.6 Newborn Stabilization Unit (NBSU)
Programmes in India-
Role of Nurse NBSU is a facility within or in close proximity of the maternity ward where sick and
low bir.th weight new borns can be cared for during short periods. All FRUs/CHCs
need to have a neonatal stabilization unit, in addition to the newborn care corner:

5.6.7 Special Newborn Care Unit (SNCU)

SNCU is a neonatal unit in the vicinity of the labor room which is to provide special
care (all care except assisted ventilation and major surgery) for sick newborns. Any
facility with more than 3,000 deliveries per year should have an SNCU.

The minimum recommended number of beds for an SNCU at a district hospital is

12. However, if the district hospital conducts more than 3,000 deliveries per year,
4 beds should be added for each 1,000 additional deliveries.

5.7 HOME BASED NEWBORN CARE (HBNC):

Home based newborn care is aimed at improving newborn survival. The strategy
of universal access to home based newborn care must complement the strategy of
institutional delivery to achieve significant reduction in postpartum and neonatal
mortality and morbidity. The providers of service include anganwadi workers,
ANM, ASHA and the medical officer.

The major objective of HBNC is to decrease neonatal mortality and morbidity

through:

1. The provision of essential newborn care to all newborns and the prevention of
complications.
2. Early detection and special care of preterm and low birth weight newborns.
3. Early identification of illness in the newborn and provision of appropriate
care and referral.
4. Support the family for adoption of healthy practices and build confidence and
skills of the mother to safeguard her health and that of the newborn.
ASHA will make visits to all newborns according to specified schedule upto
42 days of life. The schedule of visit is as follows:
a) Six visits in the case of institutional delivery - Day 3, 7, 14, 21, 28, and
42.
b) Seven visits in the case of home delivery (Day 1, 3, 7, 14, 21, 28 and 42).
c) In cases of Caesarean section delivery, where the mother returns home
after 5-6 days, ASHAs are entitled to full incentive of Rs. 250 if she
completes all five visits starting from Day 7 to Day 42.

5.7.1 Navjat Shishu Suraksha Karyakram (NSSK)

NSSK is a programme aimed to train health personnel in basic newborn care and
resuscitation. It has been launched to address care at birth issue i.e. prevention of
hypothermia, prevention of infection, early initiation of breast-feeding and basic
newborn resuscitation. The objective of the new initiative is to have a trained
health person in basic newborn care and resuscitation unit at every delivery point

104
5.7.2 Rashtriya Bal Swasthya Karyakram (RBSK) Reproductive, Maternal,
Newborn, Child And
RBSK is a new initiative launched in February 2013. It includes provision for Adolescent Health
Child Health Screening and Early Intervention Services through early detection (Rmnch+A) Strategy
and management of 4 Ds, prevalent in children. These are defects at birth,
diseases in children, deficiency conditions and development delays including
disabilities. An estimated 27 crore children in the age group of 0-18 years are
expected to be covered across the country in a phased manner.

Child Health Screening and Early Intervention Services under NRHM envisage to
cover 30 identified health conditions for early detection, free treatment and
management.

Identified health conditions for child health screening and early intervention
services

1. Defects at Birth
1. Neural tube defect
2. Down’s Syndrome
3. Cleft Lip and Palate I cleft palate alone
4. Talipes (club foot)·
5. Developmental dysplasia of the Hip
6. Congenital cataract
7. Congenital deafness
8. Congenital heart diseases
9. Retinopathy of prematurity
2. Deficiencies
10. Anemia especially severe anemia
11. Vitamin A deficiency (Bitot’s spots)
12. Vitamin D deficiency (Rickets)
13. Severe acute malnutrition
14. Goitre Childhood
3. Diseases
15. Skin conditions (scabies, fungal infection and eczema)
16. Otitis media
17. Rheumatic Heart Disease
18. Reactive Airway Disease
19. Dental caries
20. Convulsive disorders
4. Developmental delays and disabilities
21. Vision impairment
22. Hearing impairment
23. Neuro-motor impairment.

105
National Health 24. Motor delay
Programmes in India-
Role of Nurse 25. Cognitive delay
26. Language delay
27. Behaviour disorder (Autism)
28. Learning disorder
29. Attention Deficit Hyperactivity Disorder.
30. Congenital Hypothyroidism, Sickle Cell Anemia, Beta Thalasemmia
(Optional)

Programme Implementation:

1. For newborn :
- Facility based newborn screening at public health facilities, by existing
health manpower.
- Community based newborn screening at home through ASHAs for
newborn till 6 weeks of age during home visits.
2. For children 6 weeks to 6 years :
- Anganwadi center based screening by dedicated Mobile Health Teams.
3. For children 6 years to 18 years :
- Government and Government aided school based screening by dedicated
Mobile Health Teams.

Facility based newborn screening

This includes screening of birth defects in institutional deliveries at public health

facilities, especially at the designated delivery points by ANMs, Medical Officers/
Gynaecologists.

Community based newborn screening (age 0-6 weeks) for birth defects

Accredited Social Health Activists (ASHAs) during home visits for newborn care
will use the opportunity to screen the babies born at home and the institutions till
6 weeks of age. ASHAs will mobilize caregivers of children to attend the local
Anganwadi Centers for screening by the dedicated Mobile Health Team. For
performing the above additional tasks, she would be equipped with a tool kit
consisting of a pictorial reference book having self explanatory pictures for
identification of birth defects.

Screening of children aged 6 weeks till 6 years attending Anganwadi Centers

Children in the age group 6 weeks to 6 years of age will be examined in the
Anganwadi Centres by dedicated Mobile Health Teams.

Screening of children enrolled in Government and Government aided schools

For children in the age group 6 to 18 years, who will be screened in Government
and Government aided schools, the block will be the hub of activity for the
programme, At least three dedicated Mobile Health Teams in each block will be
engaged to conduct screening of children. Villages within the jurisdiction of the
block would be distributed amongst the mobile health tea

106
Check Your Progress 2 Reproductive, Maternal,
Newborn, Child And
Q1) List the Child health strategies Adolescent Health
..................................................................................................................... (Rmnch+A) Strategy
.....................................................................................................................
Q2) List the screening criteria for child health under Rasthriya Bal
Suraksha Karykram
.....................................................................................................................
.....................................................................................................................

5.8 REPRODUCTIVE, MATERNAL, NEWBORN,

CHILD AND ADOLESCENT HEALTH
(RMNCH+A)
In June 2012, the Government of India, Ethiopia, USA and the UNICEF convened
the “Global Child Survival Call to Action : A Promise to Keep” summit in
Washington, DC to energize the global fight to end preventable child deaths
through targeted interventions in effective, life-saving interventions for children.
In February 2013, the Government of India held its own historic Summit on the
Call to Action for Child Survival, where it launched “A Strategic Approach to
Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) in
India.” Since that time, RMNCH +A has become the heart of the Government of
India’s flagship public health programme, the National Health Mission.
This approach is likely to succeed given that India already has a community
based programme with presence of 8.7 lakh ASHA workers, as well as the three
tiered health system in place. These provide a strong platform for delivery of
services. This integrated strategy can potentially promote greater efficiency while
reducing duplication of resources and efforts in the ongoing programme.
The RMNCH+A strategy is based on provision of comprehensive care through the
five pillars, or thematic areas, of reproductive, maternal, neonatal, child, and
adolescent health, and is guided by central tenets of equity, universal care,
entitlement, and accountability. The “plus” within the strategy focuses on:
- Including adolescence for the first time as a distinct life stage;
- Linking maternal and child health to reproductive health, family planning,
adolescent health, HIV, gender, preconception and prenatal diagnostic
techniques;
- Linking home and community-based services to facility based care; and
- Ensuring linkages, referrals, and counter-referrals between and among health
facilities at primary (Primary Health Centre), secondary (Community Health
Centre), and tertiary levels (District Hospital).
In developing the RMNCH+A strategy, the aim is to reach the maximum number
of people in the remotest corners of the country through a continuum of services,
constant innovation, and routine monitoring of interventions. Guidelines and tools
were developed and policies were adjusted.
1. High-Priority Districts: The RMNCH +A strategy addresses India’s inter-
state and inter-district variations. The RMNCH+A approach is a conscious
articulation of the GOI’s commitment to tailoring programmes to meet the
needs of previously underserved groups, including adolescents, urban poor,
and tribal populations.
107
National Health 2. Management tools and job aids: The RMNCH+A 5x5 matrix identifies five
Programmes in India- high-impact interventions as shown in Fig: 5.1 across each of the five
Role of Nurse
thematic areas, five cross-cutting and health systems strengthening
interventions, and, the minimum essential commodities across each of the
thematic areas. The 5x5 matrix is an important tool for explaining the
strategy in simple terms, organizing technical support, and monitoring
progress with the states and high priority districts.

Reproductive Maternal Health Newborn Health Child Health Adolescent Health

Health - Use MCTS to - Early initiation - Complementary - Address teenage
- Foeus on spacing ensure early and exclusive feeding, IFA pregnancy and
method registration of breast-feeding. supplementation increase
pregnancy and and focus on contraceptive
- Focus on interval - Home based
full ANC nutrition prevalence in
IUCD at all newborn care
adolescents.
facilities - Detect high risk through ASHA. - Diarrhoea
including sub pregnancies and management at - Introduce
- Essential
centres on fixed line list including community level community based
Newborn Care
days. severely anaemic using ORS and services through
and resuscitation
mothers and Zinc. peer educators.
- Home delivery of services at all
Contraceptives ensure delivery points. - Management of - Strengthen ARSH
(HDS) and appropriate pneumonia. clinics.
management - Special Newborn
Ensuring spacing Care Units with - Full immunization - Roll out National
at Birth (ESB) - Equip delivery highly trained coverage. Iron Plus
through ASHAs. points with human resource Initiative
highly trained - Rashtriya Bal
- Ensuring access and other including weekly
HR and ensure Swasthya
to Pregnancy infrastructure. IFA
equitable access Karyakram
Testing Kits supplementation.
to EmOC - Community level (RBSK) screening
(PTK “Nischay use of of children for - Promote
Kits”) and services through
Gentamycin by 2Ds’ (birth menstrual
strengthening FRUs, Add MCH
ANM. defects, hygiene.
comprehensive wings as per
need. development
abortion care delays,
services. - Review maternal, deficiencies and
Maintaining infant and child disease) and its
quality deaths for management.
sterilization corrective
services actions.
- Identify villages
with high
numbers of home
deliveries and
distribute
Misoprostol to
selected women
in 8th month of
pregnancy for
consumption
during 3rd stage
of labour;
Incentivize
ANMs for home
deliveries.

Fig 5.1 5x5 Matrix

108
Goals and Targets Reproductive, Maternal,
Newborn, Child And
While the country aims to set one collective goal towards reducing preventable Adolescent Health
maternal, newborn and child deaths by 2017, it is increasingly becoming apparent (Rmnch+A) Strategy
that there is varied and unequal rate of progress within the states and districts.

5.8.1 Adolescent Health Programme

Taking cognisance of the diverse nature of adolescent health needs, a
comprehensive adolescent health strategy has been developed. The priority under
adolescent health include nutrition, sexual and reproductive health, mental health,
addressing gender-based violence, non-communicable diseases and substance use.
The strategy proposes a set of interventions (Health promotion, prevention,
diagnosis, treatment and referral) across levels of care. These interventions and
approaches work towards building protective factors that can help adolescents and
young people develop ‘resilience’ to resist negative behaviours and operate at four
major levels: individual, family, school and community by providing a
comprehensive package of information, commodities and services.

The priority interventions are as follows:

1. Adolescent nutrition; iron and folic acid supplementation.

2. Facility-based adolescent reproductive and sexual health services (ARSH)

(Adolescent health clinics). Information and counselling on adolescent sexual
reproductive health and other health issues.

3. Menstrual hygiene.

4. Preventive health check-ups.

Coverage targets for key RMNCH +A interventions for 2017

- Increase facilities equipped for perinatal care (designated as ‘delivery

points’) by 100%.

- Increase proportion of all births in government and accredited private

institutions at annual rate of 5.6% from the baseline of 61 % (SRS 2010).

- Increase proportion of pregnant women receiving antenatal care at annual

rate of 6% from the baseline of 53% (CES 2009).

- Increase proportion of mothers and new born receiving postnatal care at

annual rate of 7:5% from the baseline of 45% (CES 2009).

- Increase proportion of deliveries conducted by skilled birth attendants at

annual rate of 2% from the baseline of 76% (CES 2009).

- Increase exclusive breast-feeding rates at annua1 rate of 9.6% from the

baseline of 35% (CES 2009).

- Reduce prevalence of under-five children who are underweight at annual

rate of 5.5% from the baseline of 45% (NFHS-3).

- Increase coverage of three doses of combined diphtheria-tetanus-pertussis

(DTP3) (12-23 months) at annual rate of 3.5% from the base life of 7%
(CES 2009).

109
National Health - Increase ORS use in under-five children with diarrhoea at annual rate of
Programmes in India-
Role of Nurse 7.2% from the baseline of 43% (CES 2009).

- Reduce unmet need for family planning methods among eligible couples,
married and unmarried, at annual rate of 8, 8% from the baseline of 21%
(DLHS3).

- Increase met need for modern family planning methods among eligible
couples at annual rate of 4.5 % from the baseline of 4 7% (DLH 3).

- Reduce anaemia in adolescent girls and boys (15-19 years) at annual rate of
6% from the baseline of 56% and 30%, respectively (NFHS-3).

- Decrease the porportion of total fertility contributed by adolescents (15-19

years) at annual rate of 3.8% per year from the baseline of 16% (NFHS-3).

- Raise child sex ratio in the 0-6 years age group at annual rate of 0.6% per
year from the baseline of 914 (Census 2011).

5.8.2 Adolescent Reproductive and Sexual Health

programme (ARSH)
Steps are being taken to ensure improved service delivery for adolescents during
routine sub-centre clinics and also to ensure service availability on fixed days and
timings at the Primary Health Centre, Community Health Centre and District
Hospital levels. Core package of services includes promotive, preventive, curative
and counselling services being made available for all adolescents married and
unmarried, girls and boys through adolescent friendly health clinics.

Approaches:

- Facility based health services-

- Adolescent Friendly Health Clinics;
- Counselling-Dedicated ARSH and ICTC counselling;
- Community based interventions-Outreach activities, and
- Capacity building for service providers.

I. Adolescent Friendly Health Clinics (AFHC): Through Adolescent Friendly

Health Clinics, routine check-up at primary, secondary and tertiary levels of
care is provided on fixed day clinics. At present 6,302 AFHCs are functional
across the country providing services, information and commodities to more
than 2.5 million adolescents for varied health related needs such as
contraceptives provision, management of menstrual problems, RTI/STI
management, antenatal care and anaemia.

II. Facility based counselling services: Counselling services for adolescents on

important issues such as nutrition, puberty, RTI/STI prevention and
contraception, delaying marriage and childbearing, and concerns related to
contraception, abortion services, pre-marital concerns, substance misuse,
sexual abuse and mental health problems are being provided through
recruitment and training of dedicated counsellors. At present 881 dedicated
ARSH counsellors are providing comprehensive counselling services to
adolescents across the country
110
III. Outreach activities: Outreach activities are being conducted in schools, Reproductive, Maternal,
colleges, teen clubs, vocational training centres, during Village Health Newborn, Child And
Adolescent Health
Nutrition Day (VHND), health melas and in collaboration with self help (Rmnch+A) Strategy
groups to provide adequate and appropriate information to adolescents in
spaces where they normally congregate.

5.8.3 Weekly Iron and Folic Acid Supplementation (WIFS)

Ministry of Health and Family Welfare has launched the Weekly Iron and Folic
Acid Supplementation (WIFS) Programme to meet the challenge of high
prevalence and incidence of anaemia amongst adolescent girls and boys. The long
term goal is to break the intergenerational cycle of anaemia, the short term benefit
is of a nutritionally improved human capital.

- Administration of supervised weekly iron-folic acid supplements of 100 mg

elemental iron and 500 μg folic acid using a fixed day approach.

- Screening of target groups for moderate/severe anaemia and referring these

cases to an appropriate health facility.

- Biannual de-worming (Albendazole 400 mg), six months apart, for control of
helminths infestation.

- Information and counselling for improving dietary intake and for taking
actions for prevention of intestinal worm infestation.

5.8.4 Menstrual Hygiene Scheme

The Ministry of Health and Family Welfare has launched scheme for promotion of
menstrual hygiene among adolescent girls in the age group of 10-19 years in rural
areas.

Key activities under the scheme include: -

- Community based health education and outreach in the target population to

promote menstrual health;
- Ensuring regular availability of sanitary napkins to the adolescents;
- Sourcing and procurement of sanitary napkins;
- Storage and distribution of sanitary napkins to the adolescent girls;
- Training of ASHA and nodal teachers in menstrual health, and
- Safe disposal of sanitary napkins.

Check Your Progress 3

Q1) List priority interventions of Adolescent Health Programme

Q2) Explain Weekly Iron and Folic Acid Supplementation (WIFS)

111
National Health
Q3) Discuss important features of Menstrual Hygiene Scheme
Programmes in India-
Role of Nurse ......................................................................................................................
......................................................................................................................
......................................................................................................................

5.9 CARE DURING PREGNANCY AND

CHILDBIRTH
It is estimated that about 15 per cent pregnancies may develop complications,
which cannot be predicted. Most of these complications can be averted by
preventive care, skilled care at birth, early detection of risk, appropriate and
timely management of obstetric complications and postnatal care.

The priority interventions are as follows ·:

1. Delivery of antenatal care package and tracking of high-risk pregnancies.

2. Skilled obstetric care.
3. Immediate essential newborn care and resuscitation.
4. Emergency obstetric and newborn care.
5. Postpartum care for mother and newborn.
6. Postpartum IUCD and sterilization.
7. Implementation of PC & PNDT Act.

Check Your Progress 4

Q1) List the areas under which RMNCH+ A interventions are implemented
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q2) Explain Adolescent Reproductive and Sexual Health (ARSH)

programme
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q3) Explain RMNCH+A 5x5 matrix

4) List the priority interventions to look after Reproductive health

112
Reproductive, Maternal,
5.10 NEWBORN AND CHILD CARE Newborn, Child And
Adolescent Health
The interventions in this phase of life mainly focus on children under 5 years of (Rmnch+A) Strategy
age.

Priority Interventions:

1. Home-based newborn care and prompt referral.

2. Facility-based care of the sick newborn.

3. Integrated management of common childhood illnesses (diarrhoea,

pneumonia and malaria).

4. Child nutrition and essential micronutrients supplementation.

5. Immunization

6. Early detection and management of defects at birth, deficiencies, diseases

and disability in children 0-18 years of age (Rashtriya Bal Swasthya
Karyakram).

5.11 CARE THROUGH THE REPRODUCTIVE

YEARS
Reproductive health needs to exist across the reproductive years and therefore
access to these services is required in various life stages starting from the
adolescence phase. Reproductive health services include the provision for
contraceptives, access to comprehensive and safe abortion services, diagnosis and
management of sexually transmitted infections, including HIV.

Priority interventions

1. Community-based promotion and delivery of contraceptives.

2. Promotion of spacing methods (interval IUCD).

3. Sterilization services (vasectomies and tubectomies).

4. Comprehensive abortion care (includes MTP Act).

5. Prevention and management of sexually transmitted and reproductive

infections (STI/RTI).

5.12 MATERNAL AND CHILD HEALTH (MCH)

WING
Dedicated Maternal and Child Health Wings will be established in high case load
facilities with adequate prov1s1on of beds. The new MCH wings will be
comprehensive units (30/50/100 bedded) with antenatal waiting rooms, labour
wing, essential newborn care room, SNCU, operation theatre, blood storage units
and a postnatal ward and an academic wing. This will ensure provision of
emergency maternal and newborn care services as well as 48 hours stay, i.e.,
quality postnatal care to mothers and newborns.

113
National Health
Programmes in India- 5.13 LET US SUM UP
Role of Nurse
In this unit we have covered programmes related to reproductive and child health
approach. Which has been defined as “people have the ability to reproduce and
regulate their fertility, women are able to go through pregnancy and child birth
safely, the outcome of pregnancies is successful in terms of maternal and infant
survival and well-being, and couple are able to sexual relations free of fear of
pregnancy and of contracting disease”. Interventions are discussed under RCH
phase I and RCH II. Such as Essential and Emergency obstetric care, Referral
linkages. Scheme like, Janani Suraksha Yojana, Janani-Shishu Suraksha
Karyakram (JSSK). The Child Health Components are Nutritional Rehabilitation
Centres (NRCs), Integrated Management of Childhood Illness (IMCI) and
Integrated Management of Neonatal and Childhood Illness (IMNCI), Facility
Based Newborn Care.

A section on Home Based Newborn Care (HBNC), Navjat Shishu Suraksha

Karyakram (NSSK), Rashtriya Bal Swasthya Karyakram (RBSK), Reproductive,
Maternal, Newborn, Child and Adolescent Health (RMNCH+A) along with
Adolescent Health Programme, Adolescent Reproductive and Sexual Health
programme (ARSH), Weekly Iron and Folic Acid Supplementation (WJFS),
Menstrual Hygiene Scheme are covered. A section on care during Pregnancy and
Childbirth and Newborn and Child Care , and care through the Reproductive
Years including Maternal and Child Health (MCH) Wing.

5.14 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress1

1) Essential obstetric care intends to provide the basic maternity services to all
pregnant women through (1) early registration of pregnancy (within 12-16
weeks). (2) provision of minimum three antenatal check-ups by ANM or
medical officer to monitor progress of the pregnancy and to detect any risk/
complication so that appropriate care including referral could be taken in
time. (3) provision of safe delivery at home or in an institution, and (4)
provision of three postnatal check-ups to monitor the postnatal recovery and
to detect complications.

2) Institutional delivery: To promote institutional delivery in RCH Phase II for

providing basic emergency obstetric care and essential newborn care and
basic newborn resuscitation services round the clock.

3) Majority of abortions take place outside authorized health services and/or by

unauthorized and unskilled persons. Whether spontaneous or induced,
abortion is a matter of concern as it may lead to complications. Under RCH
phase II following facilities are provided:

Medical method of abortion: Termination of early pregnancy with two drugs

Mifepristone (RU 486) followed by Misoprostol. They are considered safe
under supervision, with appropriate counselling.

114
Manual Vacuum Aspiration (MVA): The department of family welfare has Reproductive, Maternal,
introduced Manual Vacuum Aspiration (MVA) technique in the family Newborn, Child And
Adolescent Health
welfare programme. Manual Vacuum Aspiration is a safe and simple (Rmnch+A) Strategy
technique for termination of early pregnancy, makes it feasible to be used in
Primary Health Centers (PHC) or comparable facilities.

Check Your Progress 2

1) The List of Child health strategies

a) Nutritional Rehabilitation Centres (NRCs)

b) Integrated Management of Childhood Illness (IMCI)
c) Integrated Management of Neonatal and Childhood Illness (IMNCI)
c) Facility based Newborn care
d) Newborn Care Corner (NBCC)
e) Newborn Stabilization Unit (NBSU)
f) Special Newborn Care Unit (SNCU)

2) The screening criteria for child health under Rasthriya Bal Swasthya
Karykram(RBSK)

RBSK includes provision for Child Health Screening and Early Intervention
Services through early detection and management of 4 Ds, prevalent in
children. These are defects at birth, diseases in children, deficiency
conditions and development delays including disabilities. An estimated 27
crore children in the age group of 0-18 years are expected to be covered
across the country in a phased manner.

Check Your Progress 3

The priority interventions are as follows:

1 Adolescent nutrition; iron and folic acid supplementation.

2 Facility-based adolescent reproductive and sexual health services (ARSH)
(Adolescent health clinics). Information and counselling on adolescent
sexual reproductive health and other health issues.
3 Menstrual hygiene.
4 Preventive health check-ups.

- 2) Ministry of Health and Family Welfare has launched the Weekly Iron
and Folic Acid Supplementation (WIFS) Programme to meet the
challenge of high prevalence and incidence of anaemia amongst
adolescent girls and boys. The long term goal is to break the
intergenerational cycle of anaemia, the short term benefit is of a
nutritionally improved human capital. Administration of supervised
weekly iron-folic acid supplements of 100 mg elemental iron and 500 μg
folic acid using a fixed day approach.
- Screening of target groups for moderate/severe anaemia and referring
these cases to an appropriate health facility.
- Biannual de-worming (Albendazole 400 mg), six months apart, for
control of helminths infestation.
115
National Health - Information and counselling for improving dietary intake and for taking
Programmes in India- actions for prevention of intestinal worm infestation.
Role of Nurse
3) Menstrual Hygiene Scheme

The Ministry of Health and Family Welfare has launched scheme for
promotion of menstrual hygiene among adolescent girls in the age group of
10-19 years in rural areas.

Key activities under the scheme include: -

- Community based health education and outreach in the target population to

Check Your Progress 4

1) The RMNCH+A strategy is based on provision of comprehensive care

through the five pillars, or thematic areas, of reproductive, maternal,
neonatal, child, and adolescent health,

2) Steps are being taken to ensure improved service delivery for adolescents
during routine sub-centre clinics and also to ensure service availability on
fixed days and timings at the Primary Health Centre, Community Health
Centre and District Hospital levels. Core package of services includes
promotive, preventive, curative and counselling services being made
available for all adolescents married and unmarried, girls and boys through
adolescent friendly health clinics.

3) The RMNCH+A 5x5 matrix identifies five high-impact interventions across

each of the five thematic areas, five cross-cutting and health systems
strengthening interventions, and, the minimum essential commodities across
each of the thematic areas, is an important tool for explaining the strategy in
simple terms, organizing technical support, and monitoring progress with the
states and high priority districts.

4) Reproductive Health

- Foeus on spacing method

- Focus on interval IUCD at all facilities including sub centres on fixed
days.
- Home delivery of Contraceptives (HDS) and Ensuring spacing at Birth
(ESB) through ASHAs.
- Ensuring access to Pregnancy Testing Kits (PTK “Nischay Kits”) and
strengthening comprehensive abortion care services.
- Maintaining quality sterilization services

116
National Mental Health
UNIT 6 NATIONAL MENTAL HEALTH Programme
PROGRAMME
Structure

6.0 Objectives

6.1 Introduction

6.2 Mental Healthcare Act, 2017

6.3 Key features of the MHA 2017 Bill

6.3.1 Capacity to make mental healthcare and treatment decisions

6.3.2 Right to access mental healthcare

6.3.3 Right to community living

6.3.4 Right to protection from cruel, inhuman and degrading treatment

6.3.5 Right to equality and non-discrimination

6.4 National Mental Health Programme

6.5 District Mental Health Programme (DMHP)

6.6 Role of Nurse in community Mental Health Services

6.6.1 Primary Prevention

6.6.2 Secondary Prevention

6.6.3 Tertiary Prevention

6.7 Let Us Sum Up

6.8 Answers to Check Your Progress

6.9 Reference

6.0 OBJECTIVES
At the end of this unit students will be able to:

 explain the aims of the National Mental Health Programme

 explain key features of MHA 2017 Bill

 Know the components of the National Mental Health Programme

 Identify the activities of the National Mental Health Programme

 Discuss strategies to promote community participation in the mental health

services

 Alleviate stigma attached with seeking mental health services - Role of Nurse

117
National Health
Programmes in India- 6.1 INTRODUCTION
Role of Nurse
The National Mental Health Programme was launched during 1982 with a view to
ensure availability of Mental Health Care Services for all, especially the
community at risk and underprivileged section of the population, to encourage
application of mental health knowledge in general health care and social
development.

The aims of the NMHP are: (a) Prevention and treatment of mental and
neurological disorders and their associated disabilities; (b) Use of mental health
technology to improve general health services; and (c) Application of mental
health principles in total national development to improve quality of life (50).

The objectives of the programme are:

1. To ensure availability and accessibility of minimum mental health care for all
in the foreseeable future, particularly to the most vulnerable and
underprivileged sections of population.

2. To encourage application of mental health knowledge in general health care

and in the social development

3. To promote community participation in the mental health services

development, and to stimulate efforts towards self-help in the community.

6.2 MENTAL HEALTHCARE ACT, 2017

India’s new mental health legislation, the Mental Healthcare Act, 2017, was
commenced on 29 May 2018 and seeks explicitly to comply with the United
Nations Convention on the Rights of Persons with Disabilities. It grants a legally
binding right to mental healthcare to over 1.3 billion people, one sixth of the
planet’s population.

Key measures include:

(a) New definitions of ‘mental illness’ and ‘mental health establishment’;

(b) Revised consideration of ‘capacity’ in relation to mental healthcare

(d) Nominated representatives’, who need not be family members;

(e) The right to mental healthcare and broad social rights for the mentally ill;

(f) Establishment of governmental authorities to oversee services;

(g) Mental Health Review Boards to review admissions and other matters;

(h) Revised procedures for ‘independent admission’ (voluntary admission),

‘supported admission’ (admission and treatment without patient consent), and
‘admission of minor’;

(i) Revised rules governing treatment, restraint and research; and

118
(j) De facto decriminalization of suicide. Key challenges relate to resourcing National Mental Health
both mental health services and the new structures proposed in the Programme
legislation, the appropriateness of apparently increasingly legalized
approaches to care (especially the implications of potentially lengthy judicial
proceedings), and possible paradoxical effects resulting in barriers to care
(e.g. revised licensing requirements for general hospital psychiatry units).

There is ongoing controversy about specific measures (e.g. the ban on electro-
convulsive therapy without muscle relaxants and anesthesia), reflecting a need for
continued engagement with stakeholders including patients, families, the Indian
Psychiatric Society and non-governmental organisations. Despite these
challenges, the new legislation offers substantial potential benefits not only to
India but, by example, to other countries that seek to align their laws with the
United Nations’ Convention on the Rights of Persons with Disabilities and
improve the position of the mentally ill.

6.3 KEY FEATURES OF THE MHA 2017 BILL

Let us read the key features of the MHA 2017 Bill as discussed below:

6.3.1 Capacity to make mental healthcare and treatment

decisions:
(1) Every person, including a person with mental illness shall be deemed to
have capacity to make decisions regarding his mental healthcare or treatment
if such person has ability to:

(a) Understand the information that is relevant to take a decision on the

treatment or admission or personal assistance
(b) Appreciate any reasonably foreseeable consequence of a decision or
lack of decision on the treatment or admission or personal assistance; or
(c) Communicate the decision under sub-clause (a) by means of speech,
expression, gesture or any other means.

(2) The information referred to in sub-section (1) shall be given to a person

using simple language, which such person understands or in sign language
or visual aids or any other means to enable him to understand the
information.

(3) Where a person makes a decision regarding his mental healthcare or

treatment which is perceived by others as inappropriate or wrong, that by
itself, shall not mean that the person does not have the capacity to make
mental healthcare or treatment decision, so long as the person has the
capacity to make mental healthcare or treatment decision under sub-section

6.3.2 Right to access mental healthcare.

(1) Every person shall have a right to access mental healthcare and treatment
from mental health services run or funded by the appropriate Government.

(2) The right to access mental healthcare and treatment shall mean mental health
services of affordable cost, of good quality, available in sufficient quantity,

119
National Health accessible geographically, without discrimination on the basis of gender,
Programmes in India- sex, sexual orientation, religion, culture, caste, social or political beliefs,
Role of Nurse
class, disability or any other basis and provided in a manner that is
acceptable to persons with mental illness and their families and care-givers.

(3) The appropriate Government shall make sufficient provision as may be

necessary, for a range of services required by persons with mental illness.

(4) Without prejudice to the generality of range of services under sub-

section (3), such services shall include—

(a) Provision of acute mental healthcare services such as outpatient and

inpatient services;
(b) Provision of half-way homes, sheltered accommodation, supported
accommodation as may be prescribed;
(c) Provision for mental health services to support family of person with
mental illness or home based rehabilitation;
(d) Hospital and community based rehabilitation establishments and
services as may be prescribed;
(e) Provision for child mental health services and old age mental health
services.

(5) The appropriate Government shall—

(a) Integrate mental health services into general healthcare services at all
levels of healthcare including primary, secondary and tertiary healthcare
and in all health programmes run by the appropriate Government;

(b) Provide treatment in a manner, which supports persons with mental

illness to live in the community and with their families;

(c) Ensure that the long term care in a mental health establishment for
treatment of mental illness shall be used only in exceptional
circumstances, for as short a duration as possible, and only as a last
resort when appropriate community based treatment has been tried and
shown to have failed;

(d) Ensure that no person with mental illness (including children and older
persons) shall be required to travel long distances to access mental
health services and such services shall be available close to a place
where a person with mental illness resides;

(e) Ensure that as a minimum, mental health services run or funded by

Government shall be available in each district;

(f) Ensure, if minimum mental health services specified under sub-

clause (e) of sub-section are not available in the district where a person
with mental illness resides, that the person with mental illness is
entitled to access any other mental health service in the district and the
costs of treatment at such establishments in that district will be borne by
the appropriate Government:

Provided that till such time the services under this sub-section are made

120
6.3.3 Right to community living. National Mental Health
Programme
(1) Every person with mental illness shall—

(a) Have a right to live in, be part of and not be segregated from society; and

(b) Not continue to remain in a mental health establishment merely because

he does not have a family or is not accepted by his family or is homeless
or due to absence of community-based facilities.

(2) Where it is not possible for a mentally ill person to live with his family or
relatives, or where a mentally ill person has been abandoned by his family or
relatives, the appropriate Government shall provide support as appropriate
including legal aid and to facilitate exercising his right to family home and
living in the family home.

(3) The appropriate Government shall, within a reasonable period, provide for or
support the establishment of less restrictive community-based establishments
including half-way homes, group homes and the like for persons who no
longer require treatment in more restrictive mental health establishments
such as long stay mental hospitals.

6.3.4 Right to protection from cruel, inhuman and degrad-

ing treatment.
(1) Every person with mental illness shall have a right to live with dignity.

(2) Every person with mental illness shall be protected from cruel, inhuman or
degrading treatment in any mental health establishment and shall have the
following rights, namely: to —

(a) Live in safe and hygienic environment;

(b) Have adequate sanitary conditions;
(c) Have reasonable facilities for leisure, recreation, education and religious
practices;
(d) Privacy;
(e) For proper clothing so as to protect such person from exposure of his
body to maintain his dignity;
(f) Not be forced to undertake work in a mental health

6.3.5 Right to equality and non-discrimination.

(1) Every person with mental illness shall be treated as equal to persons with
physical illness in the provision of all healthcare which shall include the
following, namely: —

(a) There shall be no discrimination on any basis including gender, sex,

sexual orientation, religion, culture, caste, social or political beliefs,
class or disability;

(b) Emergency facilities and emergency services for mental illness shall be
of the same quality and availability as those provided to persons with
physical illness;

121
National Health (c) Persons with mental illness shall be entitled to the use of ambulance
Programmes in India- services in the same manner, extent and quality as provided to persons
Role of Nurse
with physical illness;

(d) Living conditions in health establishments shall be of the same manner,

extent and quality as provided to persons with physical illness; and

(e) Any other health services provided to persons with physical illness shall
be provided in same manner, extent and quality to persons with mental
illness.

(2) A child under the age of three years of a woman receiving care, treatment or
rehabilitation at a mental health establishment shall ordinarily not be
separated from her during her stay in such establishment:

Provided that where the treating Psychiatrist, based on his examination of the
woman, and if appropriate, on information provided by others, is of the
opinion that there is risk of harm to the child from the woman due to her
mental illness or it is in the interest and safety of the child, the child shall be
temporarily separated from the woman during her stay at the mental health
establishment:

F) Rights to the information

(1) A person with mental illness and his nominated representative shall have the
rights to the following information, namely: —

(a) The provision of this Act or any other law for the time being in force
under which he has been admitted, if he is being admitted, and the
criteria for admission under that provision;

(b) Of his right to make an application to the concerned Board for a review
of the admission;

(c) The nature of the person’s mental illness and the proposed treatment plan
which includes information about treatment proposed and the known
side effects of the proposed treatment;

(d) Receive the information in a language and form that such person
receiving the information can understand.

(2) In case complete information cannot be given to the person with mental
illness at the time of the admission or the start of treatment, it shall be the
duty of the medical officer or psychiatrist in-charge of the person’s care to
ensure that full information is provided promptly when the individual is in a
position to receive it:

Provided that where the information has not been given to the person with mental
illness at the time of the admission or the start of treatment, the medical officer or
psychiatrist in charge of the person’s care shall give the information to the
nominated representative immediately.

122
Check Your Progress 1 National Mental Health
Programme
Q1) List the key features of the MHA 2017 Bill
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q2) Explain the key features of Right to protection from cruel, inhuman and
degrading treatment.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

Q 3) Explain right to equality and non-discrimination

6.4 NATIONAL MENTAL HEALTH

PROGRAMME (NMHP)
The Government of India launched the National Mental Health Programme
(NMHP) in 1982, keeping in view the heavy burden of mental illness in the
community, and the absolute inadequacy of mental health care infrastructure in
the country to deal with it. The district Mental Health Program was added to the
Program in 1996. The Program was re-strategized in 2003 to include two
schemes, viz. Modernization of State Mental Hospitals and Up-gradation of
Psychiatric Wings of Medical Colleges/General Hospitals. The Manpower
development scheme (Scheme-A & B) became part of the Program in 2009.

3 main components of NMHP

1. Treatment of Mentally ill

2. Rehabilitation
3. Prevention and promotion of positive mental health.
Objectives -
1. To ensure the availability and accessibility of minimum mental healthcare
for all in the foreseeable future;
2. To encourage the application of mental health knowledge in general
healthcare and in social development;
3. To promote community participation in the mental health service
development; and
4. To enhance human resource in mental health sub-specialties.

Strategies -

1. Integration mental health with primary health care through the NMHP

2. Provision of tertiary care institutions for treatment of mental disorders

123
National Health 3. Eradicating stigmatization of mentally ill patients and protecting their rights
Programmes in India- through regulatory institutions like the Central Mental Health Authority, and
Role of Nurse
State Mental health Authority.

Mental Health care

1. The mental morbidity requires priority in mental health treatment

2. Primary health care at village and sub center level
3. At Primary Health Center level
4. At the District Hospital level
5. Mental Hospital and teaching Psychiatric Units

6.5 DISTRICT MENTAL HEALTH

PROGRAMME (DMHP)
Let us read the components of District Mental Health Programme, which
includes:

The central government launched the District Mental Health Programme (DMHP)
as a 100% centrally sponsored scheme for first five years, at the national level in
1996-97 during the 9th plan as pilot project. The DMHP was based on Bellary
model; initially launched in 4 districts at the end of the 9th year plan expanded to
27 districts of the country. Presently, the DMHP is being implemented in 123
districts of the country as part of the 11th five year plan.

Objectives

 To provide sustainable basic mental health services to the community and to

integrate these services with other health services.

 Early detection and treatment of patients within the community itself.

 To reduce stigma of mental illness through public awareness.

 To treat and rehabilitate patients within the community.

Components

(a) Training programmes of all workers in the mental health team at the
identified nodal institute in the state;

(b) Public education in mental health to increase awareness and to reduce

stigma;

(d) Providing valuable data and experience at the level of community to the
state and centre for future planning, improvement in service and research.

District Mental Health Programme has now incorporated promotive and

preventive activities for positive mental health which includes:

- School mental health services: Life skills education in schools, counselling

services.

124
- College counselling services: Through trained teachers/ councellors. National Mental Health
Programme
- Work place stress management: Formal & Informal sectors, including
farmers, women etc.

- Suicide prevention services: Counselling center at district level,

sensitization workshops, IEC, help lines etc.

Check Your Progress 2

Q1) List the objectives of mental health Programme

Q2) What are the components of district mental health programme

Q3) List the promotive and preventive activities for positive mental health
......................................................................................................................
......................................................................................................................
......................................................................................................................

6.6 ROLE OF NURSE IN COMMUNITY MENTAL

HEALTH SERVICES
CHN has very important role under NMHP

 Risk assessment to understand the root cause of occurrence of mental problem

in terms of physical, social,
 Complex interaction of biological factors socio-cultural, environmental
factors
 Precipitating or triggering factors, situations, which vary from condition to
condition or person to person, from place to place.
 It can be substance use related.
 Identify, refer and follow up
 Differentiate normal and abnormal
 Provide first aid during emergency
 Conduct awareness programmes in the community

Levels of Prevention and Role of a Nurse

Caplan describes the levels of prevention as follows:

1) Primary Prevention

It is concerned with reduction of incidence of new cases of mental disorders

in the population by combating harmful forces that operate in the community,
and by strengthening the capacity of the people to withstand stress.

125
National Health 2) Secondary Prevention
Programmes in India-
Role of Nurse It is defined as reduction of the duration of mental disorders.

3) Tertiary Prevention

This is defined as reduction of the rate of residual defects that follow mental
disorder in the affected population.

6.6.1 Primary Prevention

Primary prevention should have the following goals:

i) Ascertaining ‘at risk’ population and the high risk situations where stressful
life events are the precipitating factors.

ii) Providing services to strengthen coping resources of these groups to prevent

development of symptoms.

Concrete Measures in Prevention

1) Individual Centred Measures

Child care and child-rearing measures include:

 Antenatal care to mother and educating her regarding the adverse effects of
irradiation, drugs and prematurity.
 Ensuring timely and efficient obstetrical assistance to guard against the ill
effects of anoxia, injury at birth.
 Liberalization of laws regarding termination of pregnancy, when it is
unwanted.
 Counselling of the parents of physically and mentally handicapped children,
with particular reference to the nature of defects. The parents need to accept
and emotionally support the child and be satisfied with limited goals.
 Programmes to enrich child mother relationship by stressing the importance
of warm accepting intimate relationship, and avoiding the prolonged
separation of mother and child, are essential.

2) Programmes Oriented to the Child in the School

These programmes are essential, as the school plays an important role in the
child’s life next to the family, in moulding the child’s personality on healthy lines.
The quality of the child’s cognitive achievement has an enormous effect on his
capacity to adapt to the rapidly changing world. Early signs of learning
difficulties or behavioural abnormalities can be detected, and timely corrective
measures can be taken through professional help. The teachers should be taught to
identify the symptoms of abnormal conduct and behaviour in the children and
refer cases to appropriate agencies.

3) Family Centred Activities to Ensure Harmonious Relationship

Between various members of the family attitudes of mutual trust, love and respect
for one another need to be fostered. Attitudes of warmth, acceptance and love,
emotional support and facilitating growth of children to realise their full potential
go a long way in primary prevention.

126
4) Programmes Oriented to Keep Families Intact National Mental Health
Programme
 Educational services in the field of mental health and mental hygiene.

 Parent-teacher associations.

 Home maker services when there is absence of the mother from home due to
illness or other reasons for prolonged periods, the public health nurse can
arrange for the service.

 Child guidance clinics to guide the parents in proper child rearing practices,
and to clear their doubts on mental health issue of the child.

 Marital counseling for those having marital problems.

5) Programmes for Families in Crisis

Some normal developmental crises are:

 The children passing through adolescence.

 Birth of a new baby.

 Retirement or menopause.

 Death of a wage earner in the family.

 Desertion by the spouse.

These crises situations can be handled by attendance at mental hygiene clinics,

psychiatric first aid centers, walk-in-clinics, etc.

6) Programmes for Culturally Deprived Families

The deprived families need biological and psychosocial supplies, they need better
hygienic living conditions, proper food, education, health facilities, and
recreational facilities. Other wise, psychopathy, alcoholism, drug addiction, crime
and mental illnesses, will result in such situations.

7) Society-centred Preventive Measures

These can be categorized as follows:

 Community development

 Social administration

 Collection and evaluation of epidemiological, biostatistical data

 Budgeting

These measures require coordinated activities among persons belonging to

different norms and disciplines, legislators, planners, government departments,
philanthropic and welfare organizations, etc. in addition, the

 Crisis intervention

 Modification of contents and methods of education.

 Programmes for children in character building

 Anticipatory guidance and reassurance to women before child birth, and

127
National Health  To persons before surgical interventions could help humanity to cope with
Programmes in India- life situations.
Role of Nurse
As a nurse you will find yourselves in different situations in various roles of
counselor, educator, facilitator, role model, and advocate, while functioning in the
area of primary prevention.

The knowledge of health worker at the periphery should be enriched in the area of
mental health so that they can function effectively in all the area of prevention of
mental illness and promotion of mental health in the community.

Check Your Progress 3

1) Define the following terms:

a) Primary Prevention
...............................................................................................................
...............................................................................................................
...............................................................................................................

b) Secondary Prevention
...............................................................................................................
...............................................................................................................
...............................................................................................................

c) Tertiary Prevention
...............................................................................................................
...............................................................................................................
...............................................................................................................

2) List concrete measures in primary prevention.

6.6.2 Secondary Prevention

The various aspects of secondary prevention are:

1) Early Diagnosis and Case Finding

This can be achieved by educating the public and community leaders,

industrialists, Mahila Mandals, Balwadis workers in how to recognize early
symptoms of mental illness. Seek the help of the public health nurses. They
can play very important role in this area.

2) Early Reference

The community health care workers and the public should be educated to
refer the cases to proper hospitals as soon as they recognize early symptoms
of mental illness.

3) Screening Programmes

Simple questionnaires should be developed to identify the symptoms of

mental illness, and administration of the same in the community for early
128
identification of cases. These questionnaires can be simplified in local National Mental Health
languages, and used widely in the colleges, schools, industries, etc. Programme

4) Early and Effective Treatment

Early initiation and effective treatment will help in quick recovery and
prevent setting in of chronicity.

5) Mental Health Education

This could be carried out be conducting mass camps and through film shows,
flash cards, and also through mass media communication.

6) Training of Health Personnel

Orientation courses to enable the members of the care-giving profession to

detect cases early in the course of their routine work should be conducted.
They may be trained in early detection of mental health problems, so that
they can identify people with mental health problems and subsequently refer
them to appropriate agencies.

7) Crisis Intervention

Crisis is an inevitable aspect of human existence. Individuals are constantly

confronted with potentially crisis-producing events that threaten their level of
functioning. A crisis occurs ‘when a person faces an obstacle to important life
goals that is, for a time, insurmountable through the utilization of custmary
methods of problem solving.

Check Your Progress 4

1) List important aspects of secondary prevention.

2) Define Crisis Intervention.

6.6.3 Tertiary Prevention

In tertiary prevention, emphasis is placed on reducing disability resulting from
illness. Tertiary prevention often means long term care. Disability may result from
hospitalization and nurse must make every effort to preserve the hospitalized
client’s identify and self-esteem.

Programmes in the mental hospital should aim at prevention of chronicity by

helping in initiating treatment of the fundamental illness in all admitted patients
and plea for early discharge. Family members should be involved actively in the
treatment programme so that effective follow-up can be ensured.

Occupational and recreational activities should be organized in the hospital so

that idling is prevented.

129
National Health Community Based Programmes
Programmes in India-
Role of Nurse Community based programme can be launched through meeting with the family
members, when the need for discharge from the hospital should be emphasized.
These programmes can be implemented through day hospital, night hospital
aftercare clinics, half-way homes, ex-patient hostels, foster care homes, etc.
Follow up care can be handed over to the community health nurses. There should
be constant communication between the community health nurses and the mental
health institution regarding the follow up of the discharged patient. The ultimate
aim of the hospital and community based programmes is to resocialize and
remotivate the patient for a functional role in the community, consistent with his/
her resources.

6.7 LET US SUM UP

In this unit we have discussed about Mental Healthcare Act, 2017. Described key
features of the MHA 2017 Bill such as Capacity to make mental healthcare and
treatment decisions, Right to access mental healthcare, Right to community
living, Right to protection from cruel, inhuman and degrading treatment, Right to
equality and non-discrimination. The section on National Mental Health
Programme including objectives and components are covered. District Mental
Health Programme Objectives, components and at the end Role of

Community Health Nurse in NMHP has been explained.

6.8 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) Key features of the MHA 2017 Bill are

 Capacity to make mental healthcare and treatment decisions

 Right to access mental healthcare

 Right to community living

 Right to protection from cruel, inhuman and degrading treatment

 Right to equality and non-discrimination

2) Key features of Right to protection from cruel, inhuman and degrading

treatment.

(1) Every person with mental illness shall have a right to live with dignity.

(2) Every person with mental illness shall be protected from cruel, inhuman
or degrading treatment in any mental health establishment and shall have
the following rights, namely: to —

(a) Live in safe and hygienic environment;

(b) Have adequate sanitary conditions;

(c) Have reasonable facilities for leisure, recreation, education and

religious practices;

130
(d) Privacy; National Mental Health
Programme
(e) For proper clothing so as to protect such person from exposure of
his body to maintain his dignity;

(f) Not be forced to undertake work in a mental health

3) Explain right to equality and non-discrimination

(1) Every person with mental illness shall be treated as equal to persons
with physical illness in the provision of all healthcare which shall
include the following, namely: —

(a) There shall be no discrimination on any basis including gender, sex,

sexual orientation, religion, culture, caste, social or political beliefs,
class or disability;

(b) Emergency facilities and emergency services for mental illness shall
be of the same quality and availability as those provided to persons
with physical illness;

(c) Persons with mental illness shall be entitled to the use of ambulance
services in the same manner, extent and quality as provided to
persons with physical illness;

(d) Living conditions in health establishments shall be of the same

manner, extent and quality as provided to persons with physical
illness; and

(e) Any other health services provided to persons with physical illness
shall be provided in same manner, extent and quality to persons
with mental illness.

(2) A child under the age of three years of a woman receiving care,
treatment or rehabilitation at a mental health establishment shall
ordinarily not be separated from her during her stay in such
establishment:

Provided that where the treating Psychiatrist, based on his examination

of the woman, and if appropriate, on information provided by others, is
of the opinion that there is risk of harm to the child from the woman due
to her mental illness or it is in the interest and safety of the child, the
child shall be temporarily separated from the woman during her stay at
the mental health establishment:

Check Your Progress 2

1) Objectives of mental health Programme

1. To ensure the availability and accessibility of minimum mental

healthcare for all in the foreseeable future;

2. To encourage the application of mental health knowledge in general

healthcare and in social development;

3. To promote community participation in the mental health service

development; and
131
National Health 4. To enhance human resource in mental health sub-specialties.
Programmes in India-
Role of Nurse 2) What are the components of district mental health programme

(a) Training programmes of all workers in the mental health team at the
identified nodal institute in the state;

(b) Public education in mental health to increase awareness and to reduce

stigma;

(d) Providing valuable data and experience at the level of community to

the state and centre for future planning, improvement in service and
research

3) List the promotive and preventive activities for positive mental health

- School mental health services: Life skills education in schools,

counselling services.

- College counselling services: Through trained teachers/ councellors.

- Work place stress management: Formal & Informal sectors, including

farmers, women etc.

- Suicide prevention services: Counselling center at district level,

sensitization workshops, IEC, help lines etc.

Check Your Progress 3

a) Primary Prevention

It is concerned with reduction of incidence of new cases of mental

disorders in the population by combating harmful forces that operate in
the community, and by strengthening the capacity of the people to
withstand stress.

b) Secondary Prevention

It is defined as reduction of the duration of mental disorders.

c) Tertiary Prevention

This is defined as reduction of the rate of residual defects that follow mental
disorder in the affected population.

2) Concrete measures in primary prevention.

1) Individual Centred Measures

2) Programmes Oriented to the Child in the School

3) Family Centred Activities to Ensure Harmonious Relationship

4) Programmes Oriented to Keep Families Intact

5) Programmes for Families in Crisis

132
6) Programmes for Culturally Deprived Families National Mental Health
Programme
7) Society-centred Preventive Measures

Check Your Progress 4

1) Important aspects of secondary prevention.

a) Early Diagnosis and Case Finding

b) Early Reference

c) Screening Programmes

d) Early and Effective Treatment

e) Mental Health Education

f) Training of Health Personnel

g) Crisis Intervention

2) Crisis is an inevitable aspect of human existence. Individuals are constantly

6.9 REFERENCE
Source: Int. J Law Psychiatry. Jan-Feb 2019; 62:169-178.

doi: 10.1016/j.ijlp.2018.08.002. Epub 2018 Aug 16.

133

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