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 Security
(UNDP)
Except for the State of Jammu & Kashmir where UN
security phase two is in effect, the remainder of the country is in NO
PHASE. Permits are required from
Ministry of External Affairs (MEA) to visit some areas of the country
categorized as Protected/Restricted. Applications should be sent at least
four weeks in advance of travel date to the Ministry of External Affairs
(Bhutan Section, Northern Division, South Block, New Delhi) on a form
obtainable from MEA. Details of
Protected/Restricted areas can be obtained from the Field Security
Coordination Officer, India. Mr. David Pakes, tel: 91-11-4628877 ext
271 fax: 91-11-4627612, cell: 91-9810603142 email: david.pakes@undp.org. Ms. Brenda
McSweeney, the UN Resident Coordinator/UNDP
Resident Representative is the Designated Official, tel: 91-11-4628877, fax: 91-11-4627612/8330, email: brenda.mcsweeney@undp.org. Please email requests for security
clearance to FSCO and/or travel details to same agency office in India or FSCO if
no same agency in India Food supply and
nutritional status(source – WHO/SEARO)
Despite
food grains sufficient, its distribution specially
amongst vulnerable population has been the challenging task. Resultantly, the
proportion of newborns weighing less than 2500 grams at birth was reported as
30% in 1993. The proportion of children under five years whose weight-for-age
was less than minus 2 SD
below the median was 53.4% (1992-93). It is estimated that 200 million people
are exposed to the risk of iodine deficiency disorders (IDDs)
and that 63 million suffer from goitre. Surveys conducted in 275 districts
have revealed that 235 districts are endemic for IDDs.
In 1991, 87.5% of pregnant women were found to be anaemic (haemoglobin <
11g/dl). The National Institute of Nutrition in Hyderabad
reported that 56% of children under five years of
age had iron deficiency anaemia. The contribution of vitamin A deficiency to
blindness was estimated to be 2% in 1975 and 0.04% in 1990.
A
national IDD control programme was launched in 1992 which covers all states
and union territories. The strategy is the use of iodated salt and all
aspects of programme implementation are being addressed.
Anaemia
contributed to 20% of maternal deaths in 1991. An intervention programme that
commenced in 1992 prioritized pregnant women for iron and folic acid
administration. During 1994/95, 85.8% of pregnant women were covered with the
recommended daily dose of iron folate tablets.
The
most susceptible group for vitamin A deficiency blindness are preschool
children. The child survival programme seeks to administer five doses of
vitamin A to all children under three years. During
1994/95, 72.6% of infants and 54.8% of 1-2 year old children were
administered vitamin A.
Other
actions include the Integrated Child Development Service (ICDS) programme
which provides a package of services to 54 million beneficiaries comprising
preschool children, pregnant women and lactating mothers, and the mid-day
meal programme for primary school children. The following goals have been set
to be achieved by the year 2000: reduction by 50% of moderate and severe protein-energy
malnutrition (PEM) in preschool children, reduction of low birth weight to
less than 10%, elimination of blindness due to vitamin A, reduction of iron
deficiency anaemia among pregnant women to 25%, and reduction of IDDs to less than 10% in endemic districts Epidemiological Profile(source – WHO/SEARO)  Mortality
The infant mortality rate (IMR) was reported to be 74
per 1000 live births in 1995 and the maternal mortality ratio (MMR) for
1992-93 was estimated at 420 per 100,000 live births. Estimates for 1996 of
the number of deaths per year in children under five
years from diarrhoeal diseases was 840,000, from
acute respiratory infections 600,000 and from measles 330,000. Deaths from
malaria were reported to be 1061 (1995), cardiovascular diseases 2,386,000
(1990), traffic accidents 45,670 (1993), and work accidents 543 (1993).
Between 1986 and 1993 the crude death rate (CDR) declined from 11.1 to 9.2
per 1000 population (urban 9.3 and rural 5.8). Between 1980 and 1995 the IMR
declined from 114 to 74, the main causes of death being prematurity,
ARI and diarrhoea. The number of reported
accidental deaths in 1993 was 11,125. The main constraints are low literacy
and income levels, sociocultural beliefs and
practices, and suboptimal utilization of health facilities.
Morbidity(source –
WHO/SEARO)
The number of reported cases of the
following diseases are: leprosy 400,000 (1995), malaria 2,200,829
(1994), measles 26,986 (1991), neonatal tetanus 1896 (1995), polio 3406
(1995), and tuberculosis 1,249,000 (1994-95). The vaccine-preventable
diseases (referred to in Section 6) have declined significantly since
implementation of the EPI. In India about 14 million people are
estimated to be suffering from active tuberculosis and about 0.5 million die
of the disease each year. Currently, short term chemotherapy using DOTS has
been introduced and accessibility to tuberculosis treatment centres improved.
The prevalence of leprosy has declined from about 39 per 10,000 population in 1985 to about 7 per 10,000 in 1995. The
spectacular reduction in this disease has been due to the new regimen of
multi-drug therapy. The number of new cases detected annually has, however,
remained more or less the same, at about 0.5 million. Disability (source – WHO/SEARO)
Disability
prevalence rates per 100,000 population estimated in
1994 are as follows: physical disability 3574, visual disability 827, hearing
806, speech 510, and locomotors disability 2041. The incidence rates per
100,000 population of these disabilities are:
physical 173, visual 45, hearing 27, speech 10 and locomotors disability 105
(national sample survey). HEALTH SERVICES Health policies and strategies (source –
WHO/SEARO)
The health sector in India is characterized by:
 a government sector that provides publicly financed
and managed curative and preventive health services from primary to tertiary
level, throughout the country and free of cost to the consumer (these account
for about 22% of the overall health spending and 1.3% of the GDP), and
a fee-levying private sector that plays a
dominant role in the provision of individual curative care through ambulatory
services and accounts for about 78% of the overall health expenditure and
4.7% of the GDP. Nationwide health care utilization rates show that private
health services are directed mainly at providing primary health care and
financed from private resources, which could place a disproportionate burden
on the poor.
The convergence of services to provide a holistic
approach to population control has also been promoted. In March 1995 a
separate Department of Indian System of Medicine and Homeopathy (ISM & H)
was created within the Ministry of Health and Family Welfare.
Some of the specific health
services issues are mentioned below; Intersectoral
cooperation (source – WHO/SEARO)
In
order to meet current needs and emerging challenges, a number of working
groups were constituted in 1996 to comprehensively review the existing health
situation in its totality. The following areas are included: communicable
diseases, health systems and biomedical research development, ISM & H,
child development, environmental health, health education and IEC, women’s
development, and requirements for supportive and diagnostic services in
primary, secondary and tertiary care.
Consultations
have also been held with NGOs. Two other committees have been constituted,
namely an expert committee to comprehensively review the public health system
in the country and the National Mission on Environmental Health and
Sanitation. The recommendations of these consultations have been discussed by
the concerned ministries and were to be submitted as proposals for the 9th
FYP.
The
active promotion of the panchayati raj (local administration) system from the village
to the district is a measure directed towards ensuring intersectoral
collaboration. Specific health areas that have effectively made use of intersectoral collaboration include malaria control, AIDS control programme, blindness control,
nutrition, and water and sanitation to name a few. Organization of the health system(source –
WHO/SEARO)
The focus of the 8th plan has been to improve access to
health care for the underserved and underprivileged segments of society,
through consolidation and operationalization of the
health infrastructure at all levels with emphasis on primary health care. In
view of the high maternal mortality, upgrading of existing maternal health
facilities and establishing first referral units (FRUs)
have been prioritized. Many states have initiated major projects to upgrade
their health services with assistance from funding agencies. Andhra Pradesh
is implementing a Health Systems Project with World Bank assistance, and the
states of Karnataka, West Bengal and Punjab are to follow. In support of Safe Motherhood,
priority central assistance has been provided to establish FRUs in all 213 districts in six states where the
maternal mortality is two to three times more than the national average.
States in India have only recently begun to
address issues relating to the organization of their health systems. Their
capacity to bring about key policy reforms is still lacking. A substantial proportion of specialist posts in CHCs are vacant, and thus affects the functioning
of first referral units. Other constraints relate to shortage of paramedical
staff, support staff and inadequate involvement of NGOs. Managerial
process(source – WHO/SEARO)
The process has been initiated for decentralization of
authority to the various levels to enable decision making at the right time.
Besides this, the panchayati raj
bodies are also being revitalized. Training facilities for health management
are being augmented with the NIFHW playing a pivotal role. Health information
system(source – WHO/SEARO)
In
pursuance of the national health policy for the establishment of an efficient
and effective management information system, a computer-compatible health
management information system (HMIS version 2.0) has been designed in
collaboration with participating states, the national information centre
(NIC) and WHO. The system is being implemented in phases. Community action(source – WHO/SEARO)
The concept of community participation is contained in
national health policy. The broad areas of community participation at grass
roots level are seen in the village health services scheme, the Anganwadi
scheme of ICDS, and the formation of village level committees. Community
action has also been successfully used in disease control programmes such as
malaria and in areas such as the provision and maintenance of drinking water
schemes and sanitation. The main constraint to community action is the low
priority given to health by the community in contrast to schemes that provide
direct financial benefit. Immunization(source
– WHO/SEARO)
The proportion of infants reaching their first birthday
who were fully immunized according to national immunization policies in
1992-93 was 27.5% (urban 41.5% and rural 23.4%). By individual vaccines the
coverage was as follows: DPT3 46.9%, OPV3 48.3%, measles vaccine 32.7%, BCG
58.7%, and pregnant women who received two doses of TT 53.8%. HIV/AIDS
(source – NACO/GOI)
The first evidence of HIV infections in India was documented at the MadrasMedicalCollege, Chennai, in 1986. India is the most densely populated country in Asia and the second most populous country in the world, with 960
million people. India faces enormous public health problems including a high
prevalence of diarrheal disease, tuberculosis,
malaria, hepatitis and sexually transmitted diseases.
According to the National AIDS Control
Organisation (NACO) 22.73 per 1000 persons in India are HIV positive (March 31,1998:
screened 3298238 -+ve 74960). Projections using the
statistics of NACO indicate an infection rate of 25 per 1000 by the turn of the
century. In India as on March 31, 1998, 5204 persons have been diagnosed as having
AIDS of which 21.06% are women. Probable source of infection in India is:
74.73% through sex.
7.30% through injecting drug users.
7.05% through blood transfusion.
10.92% others.
Most information on the HIV epidemic is derived from limited
studies of groups such as sex workers, truck drivers, and injecting drug
users, who are regarded as most vulnerable to HIV. The Studies of Bombay
female workers, who number at least a few hundred thousands, estimate that
over 50% were infected with HIV by 1994. As the first to bear the burnt of
the epidemic, such groups were often mistakenly viewed as reservoirs of
infection, and stigmatised as core transmitters and were the only groups targeted
for intervention.
The virus has spread with great rapidity along India's western and eastern coasts, and inward to
reach all parts of the country. The epidemic varies widely from one region to
the next, reflecting the country's great diversity.
Reports from the National AIDS Control Organisation, New Delhi confirm the rapid growth of the HIV
infection, initially among women in prostitution and their male clients, STD
Clinic patients and Commercial Blood donors and subsequently among other
population groups that include voluntary blood donors and antenatal women.
Recent testing of pregnant women in Mumbai shows infection rates
around 2.4% in 1996. In Pondicherry, the rate among pregnant women is around 4%.
Among truck drivers in the state of Tamilnadu, HIV
infection quadrupled from 1.5% in 1995 to 6.2% just one year later. In the
North-eastern state of Manipur, where the epidemic took off quickly among
male drug injectors, some drug clinics registering HIV rates of as high as
73% in 1996. In some other states, by contrast, only a few cases of HIV and
no cases of AIDS - have yet been reported.
It is clear that many people are having unprotected sex with
non-monogamous partners. With effective mixing of population, there is now an
alarming spread of HIV among general population as well, mostly through sex
between people who do not realise they may be transmitting or acquiring the
infection during unprotected sexual intercourse. The virus does not
discriminate between the rich and the poor, caste nor
creed and knows no boundaries. It has penetrated through every strata of
Indian Society.
India is in the threshold of becoming the most affected
country in the world in terms of new infections, in terms of total number of
infections and in terms of persons living with AIDS.
Prevention
and control of locally endemic diseases(source – WHO/SEARO)
The national tuberculosis control programme has not
achieved the desired results. In 1992 the programme was reviewed and a
revised control programme formulated with short term course chemotherapy
using the DOTS strategy. The problem of protein-energy malnutrition (PEM) and
micronutrient deficiency disorders are quite significant and are being dealt
with through a number of national programmes with well defined goals. Diarrhoeal diseases, which are still a major cause of
morbidity and mortality in infants and children, are being addressed through
the promotion of exclusive breast-feeding, good child feeding practices, and
the timely use of ORT during episodes of diarrhoea.
Acute respiratory infections (ARIs) are a leading
cause of death due to pneumonia in children under five years. A strategy
aimed at early recognition of the signs of pneumonia and timely referral has
been very effective in reducing mortality. HIV/AIDS is predicted to be a
major problem in India. A total of 22,529 seropositive cases were reported up to March 1996, but
this number does not convey the actual magnitude of the problem. Of the noncommunicable diseases, cancer and cardiovascular
diseases are emerging as major health concerns that will require considerable
financial resources for case management.
Malaria(source – GOI)
In the
year 1999 (upto 25th October), a total 8,81, 716 malaria cases including 3,87,125 P. F. cases have
been reported. During 1999, malaria incidence in the country has shown a
decrease by (-) 3.16% in total malaria cases and an increase by (+) 2.60% in
Plasmodium Falciparum (PF) cases as compared to the
corresponding period of 1998.
National
Anti Malaria Programme (NAMP) is a centrally sponsored National Health
Programme, operating on 50: 50 cost sharing basis between the Central and
State Governments. The Centre provides material assistance to the States,
including anti- malarials, insecticides. In
addition 100% cash assistance is provided to the North- Eastern States for
programme implementation.
With
the implementation of Modified Plan of Operation (MPO) the total malaria
cases came down women 6.47 million in 1976 to 2.18 million cases in 1984. The
malaria situation since then has been contained around 2 to 3 million cases annually.
Filaria (source
– GOI)
The
National Filaria Control Program was launched in
1955. Following measures are undertake in the programme: (i)
Delimitation of the problem in hitherto unsurveyed
areas; and (ii) Control in urban areas through recurrent anti- larval
measures and anti parasitic measures by 206 control units and 199 clinics
giving treatment with diethylcarbamizine to
clinical cases and microfilaria carriers. During 1997, in view of the
recommendations made in support of revised single day DEC mass therapy as a
supplement to existing NFCP strategy in highly endemic areas, it was proposed
to implement this strategy in 13 districts on a pilot basis. However, eight
districts were covered in the States of Kerala,
Orissa, UP, and West Bengal during November, 1997 and in the month of August, 1997
in Tamil Nadu by observing Filaria
Day. Approximately 49.7% to 94% coverage (achievement) was observed in these
districts by giving single day DEC therapy. The Centre provides DEC tabs for
the mass therapy campaign and cash assistance for IEC to the States through
Regional Directors, Regional Offices for Health and Family Welfare. Failaria Day observance is a continuing 5 years project
implemented by the states in the high endemic districts.
Kala- Azar(source – GOI)
Kala- azar is a serious public
health problem in Bihar and West Bengal. After its resurgence in Bihar in the early seventies, the
diseases spread from the four districts to adjoining areas. Now about 36
districts of Bihar and 10 districts of West Bengal are affected by Kala- azar. The disease is
however present predominantly in the districts adjoining the Ganges. The increasing trend of the
disease is evident from the fact that
the total number of cases which were 17,806 with 72 deaths
in 1986 rose to a total of 77,102 cases with 1,419 deaths in 1992. During
1997 and 1998 total cases and deaths due to kala- azar have been 17,429 and 13,542 and 255 and 221
respectively. Total Kala- azar
cases of 6,694 and deaths 220 have been listed during 1999 till August, from
Bihar, Delhi, West Bengal and Sikkim, The strategy
of Kala- azar control
broadly includes three activities; (i) Interruption
of transmission for reducing vector population by undertaking indoor residual
insecticidal spray twice annually; (ii) Early diagnosis and complete
treatment of Kala- azar
cases; and (iii) Health education for community awareness.
During 1998- 99, a budgetary
provision of Indian Rs. 10 million (US $ 208,000
approximately). has
been made in respect of this programme. This provision is for supply of
insecticide DDT and drugs sodium antimony gluconate
and pentamidin
Japanese Encephalitis
(JE)(source – GOI)
The
disease is caused by a virus and manifests as high fever, convulsions, confusion,
stiffness of the neck and coma etc. The fatality rate of this disease is very
high and those who survive do so with various degrees of neurological
complications. JE is spread by a mosquito principally Culex
tritaeniorthynchus which usually breeds in rice
fields and swampy and marshy areas.
Of
late, JE has become a important public health
problem and has been reported from 24 States/ UTs.
Number of cases and deaths due to JE reported from the country are indicated:
4.5.3. Major activities to control Japanese Encephalitis include: (I) Case
Management; (ii) Development of a safe and standard indigenous vaccine; (iii)
Sentinel surveillance including clinical surveillance of suspected cases;
(iv) Studies to identify the high risk groups by measuring the bloods level
of antibodies; (v) Epidemiological monitoring of the disease for effective
implementation of prevention and control strategies; and (vi) Vector Control
including residual spraying of space spraying.
Dengue
fever(source – GOI)
Dengue
Fever is a viral disease which is transmitted through the bites of female Aedes mosquitoes. In India, the virus was first isolated
during the fifties. Outbreaks of dengue have been reported from various parts
of the country primarily from urban areas. There are four sero-types
of dengue virus and all the four are prevalent in India. Dengue viral infection may
remain asymptomatic or manifest either as undifferentiated febrile illness
(viral syndrome), Dengue fever (DF) or Dengue Hemorrhagic Fever (DHF). The
primary infection leads to classical dengue fever for that particular
serotype. Subsequent infection by any other serotype may sometimes
precipitate Dengue Hemorrhagic fever (DHF) which is usually more prevalent
among children and may cause fatality in some Cases.
During
1996, an outbreak of Dengue was reported in Delhi. The first suspected case was
admitted to All India Institute of Medical Sciences on 20th August, 1996 and
the first death was reported as on 22- 8- 1996. As per reports received from
Health Directorate of the Government of National Capital Territory 10,252
cases and 423 deaths due to dengue have been reported from the States like Haryana, Punjab, Uttar Pradesh, Karnataka, Maharashtra and Tamil Nadu
during 1996.
Leprosy (source – GOI)
A
steady increase in the number of leprosy cases through successive decades
occurred after independence in 1947 starting with 1.37 million in 1951
reaching 4.0 million estimated cases in 1981. The prevalence of disease was
57/ 10, 000 in 1981. The main factor to account for this progressive rise
were rapid increase in the population, better case detection activities and
greater community awareness leading to voluntary reporting.
With
the implementation of MDT services under the programme since 1983 a large
number of leprosy cases are being discharged as disease cured. For the first
time in 1987 the number of cured cases exceeded new cases detected. Since
then with rapid extension of MDT services to other endemic areas, the
percentage of discharged cases has been increasing. During the year 1998- 99
the number of discharged cases was 0.77 million as against new case detection of
0.78 million cases. So far the programme has been able to treat and discharge
from the registers about 12.19 million cases out of which 8.33 million are
due to cure with MDT.
In
March, 1999 there were in the country and the prevalence rate was 5.19/ 0000.
India today ranks foremost among the
countries saddled with leprosy sufferers accounting for 60.9% of the global
recorded leprosy patient level. About 14- 20 percent of the patients are
children. The proportion of multi- bacillary cases among total cases is 56%
and among new cases the same is 32%. The deformity among newly detected cases
in a year is 3.76%.
Distribution
of the disease is uneven, although it is present throughout the country. The
inter State variation in the prevalence rates and the percentage of
population at risk were quite substantial, High number of patients are now
present mainly in the State of Uttar Pradesh, Bihar, Orissa, West Bengal, and
Madhya Pradesh. At present these five States contribute 71% of the country's
caseload. Though the prevalence of disease was high earlier in Tamil Nadu, Andhra Pradesh, Pondicherry, Maharashtra, the same has reduced remarkably
in these States.
TB
Control Programme (source – GOI)
Tuberculosis
continues to remain one of the most pressing health problems in India. About 14 million population are
estimated to be suffering form active TB of whom 3 – 3.5. million
are highly infectious. India accounts for nearly one third of
Global T. B. burden and every year has more than 2 million new cases of
tuberculosis. Approximately 2.9 million people die from tuberculosis each
year World wide; about one fifth of them in India alone. Nearly 500,000 die from
the disease – more than 1, 000 per day- one every minute. The spread of HIV/ AIDs would increase number of TB cases as well as deaths.
India launched the National
Tuberculosis Control Programme (NTCP) in 1962 which was integrated with the
Primary Health Care Delivery system and implemented through District
Tuberculosis Centres (DTC) of which 446 have been established. In addition,
there are 47,600 TB beds in the country, 330 TB clinics in urban areas and 17
State TB Training and Demonstration Centres. The beds are utilized as adjunct
to domiciliary treatment programme mainly for serious cases. Now 100% requirement of anti TB drugs are provided from Central
Government and these are made available to patients free of cost.
Achievements: Under N. T. P. around 1.5 million
cases of tuberculosis are detected every year of which 25% are sputum
positive and rest are radiologically
active cases. Treatment completion is around 30%. The mortality rate of 80
per 100,00 of population in 70's has been reduced to
50 per 100,000 of population in 1993.
Revised
National Tuberculosis programme: In 1992 the NTCP was reviewed by
a committee of experts. The committee found that NTP has not made any
significant epidemiological impact on problem of Tuberculosis. Based on the
findings of this review committee, a Revised Strategy for National TB Control
Programme (RNTCP) was evolved with the objective of laying emphasis on cure
of infectious cases through administration of directly observed short course
chemotherapy to achieve a cure rate of over 85% and augmentation of case
finding activities to detect 75% of estimated cases, only after having
achieved the desired cure rate. This strategy was pilot tested with SIDA
assistance in 1993- 94 on a population of 2.35 million and thereafter was expanded
for assessing its technical and operational feasibility to 17 project sites,
covering a population of 13.85 million. These project sites demonstrated good
quality of diagnosis with sputum conversion rate of nearly 90% and a cure
rate of over 80%.
Having proven the technical and operational feasibility
of the revised strategy, Government of India decided to extend the revised
strategy in the country in a phased manner to 102 old districts covering a
population of 272.21 million over a period of 3 years in 15 States with World
Bank Assistance. This also included strengthening the NTP in 203 short course
chemotherapy (SCC) districts with a population of 447 million 4.8.10. Under RNTCP, so far, quality
of diagnosis in almost all expansion areas has been good and sputum
conversion rate remains high at 87%.
Water supply and sanitation
(source – WHO/SEARO)
The proportion of the population
with safe drinking water available at home or with reasonable access was
84.3% in 1993 for urban areas and 82.4% in 1995 for rural areas. The
proportion of the population with adequate excreta disposal facilities was
49.9% in 1993 in urban areas and 3.7% in 1995 in rural areas.
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