India

Millennium Development Goals

Annex - 2

The progress made towards achievement of health related Millennium Development Goals is given here.

GOAL 4: REDUCE CHILD MORTALITY

I. STATUS AND TRENDS

Under-Five Mortality Rate

The health status of children is best evident from key indicators namely, under­-five mortality rate and Infant Mortality Rate (IMR). There have been considerable efforts to reduce under-five mortality rates in the country over the last three decades. In 2002, the average under-five mortality rate in India was 85 deaths per 1000 live births, a considerable reduction as compared to 202 in 1970. The rate of decline in the 90s, however, is about half of previous decade’s rate of decline, 4.7 percent. At the current rate, India would achieve under-five mortality of 64 per 1000 live births by 2015, which is well short of MDG goal of 41.

Infant Mortality Rate

In India, approximately 1.72 million children die each year before reaching their first birthday. Infant mortality has declined significantly in India from 129 in 1970 to 57 in the year 2005-06. The target for MDG 2015 is 27 per 1000 live births.

Immunization

Among all the indicators, immunisation is one, which lacks authentic information. The available figures vary according to different sources. While the Government of India statistic quotes a higher level of measles coverage as compared with other survey figures such as NFHS; the NFHS-III indicates coverage of 44 percent of children immunized by age one year in 2005-06. However, there has been a considerable improvement when compared to NFHS I during 1992-93. The measles coverage is 59% for the same years.

II. CHALLENGES

Sustaining the Past Performance

India's performance in reducing mortality rates, compared to similar Asian developing countries like China, Indonesia and Thailand, is poor. The level of IMR is much higher in India when compared even to some of the Southeast Asian countries like Bangladesh and Sri Lanka. Though the long term reduction in mortality rates is noteworthy, the concern is the decline in slowing down during the recent decade. In other words, the tempo has not been sustained during the recent years. There is urgent need for new approaches and priorities in the overall strategy to reduce mortality rates among children.

Inter-State Variations

There is a wide inter-state disparity in infant mortality rates and under-five mortality rates. The IMR varies from as low as 14 (Kerala) to as high as 96 (Orissa). The figures indicate the widespread disparity and performance when compared to national average. Weaker States like Uttar Pradesh, Rajasthan, Madhya Pradesh, Orissa and Assam have IMR higher than the national average. There are substantial differences not only in the IMR but also in the neonatal, and under-five mortality rates between States. There is need for more concentric and region specific policies and programmes.

The measles immunisation for children aged 12-23 months also show similar disparities. The immunisation coverage ranges from a high of 90 percent in Tamil Nadu to a low of 16 percent in Bihar. Performance of the weaker States like Uttar Pradesh, Bihar, Assam, Rajasthan, etc., is well below national average.

Causes of Child Mortality

It is estimated that under-nutrition and anaemia are contributory factors in over 50 percent of under-five deaths in the country. Malnutrition is an area to be tackled as studies have revealed a synergy between malnutrition and mortality. Major causes of infant mortality continue to be pre-maturity birth and low birth weight, poor intra-partum and newborn care, diarrhoeal diseases, acute respiratory infections and other infections.

Neonatal mortality accounts for more than two-thirds of infant mortality in India. Over the last decade, post-neonatal mortality has declined much faster than neonatal mortality. This is mainly due to increased programme interventions focussed on post neonatal stage such as immunisation, management of diarrhoea, ARI, etc.  Policies and programmes should emphasise on interventions to reduce perinatal and neonatal mortality. Antenatal care, safe delivery and quality of newborn care are key requirements for reduction of all types of mortality.

Gender Disparity

There are gender differences in IMR and under-five mortality rates. Though there is no biological reason for a higher mortality rate in females in the age group of 0-4 years, it is the social causes that adversely affect the mortality rate of girls, and this needs to be tackled. Girls have a higher mortality rates than boys during the post-neonatal period to five years. The risk of mortality is higher among girls than boys as their malnutrition levels are higher.

Urban-Rural Bias

Bridging the gap between urban and rural child mortality rates and immunisation coverage is another challenge to be tackled with. There is a large urban-rural disparity in the infant and under-five mortality rates and immunisation coverage for measles. One of the reasons is the lack of accessibility to services due to remoteness of the location and higher proportion of disadvantaged groups. Providing adequate services to specific vulnerable groups and those in the remote areas is the key to bring down the gap.

III. POLICIES AND PROGRAMMES

Reproductive and Child Health

The ongoing RCH programme comprehensively integrates interventions to improve child health and was initiated to address each of the major factors contributing to high IMR and under-five mortality. Components of child healthcare include:

      Essential newborn care

      Immunisation

      Nutrition

      Exclusive breastfeeding for 6 months

      Timely introduction of complimentary feeding

      Detection and management of growth faltering

      Vitamin A supplementation

      Iron supplementation

      Early detection and appropriate management of Acute Respiratory Infections, Diarrhoea and other infections

In order to accelerate the decline of IMR, essential newborn care was included as an intervention under the RCH Programme. Equipment for essential newborn care was supplied to districts, and skill up-gradation training for Medical Officers and other staff at the district hospitals was conducted. Medical colleges were envisaged to improve content, quality and coverage of essential newborn care. Collaboration with the National Neonatology Forum (NNF) for operationalisation of newborn care facilities at the primary level was initiated. In addition, Department of Family Welfare and ICMR are funding research studies on the feasibility, replicability and effectiveness of community based newborn care in reducing neonatal mortality in settings where access to primary healthcare institutions is suboptimal.

Focus during the Tenth Plan

Tenth Plan focuses on operationalisation of the appropriate essential newborn care in all settings so that there is substantial reduction in the early neonatal mortality, both in institutional deliveries and home deliveries.

Universal Immunization Programme (UIP)

The UIP was taken up in 1986 as National Technology Mission and became operational in all districts in the country during 1989-90. UIP became a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992 and Reproductive and Child Health (RCH) Programme in 1997. Under the Immunization Programme, infants are immunized against tuberculosis, diphtheria, pertussis, poliomyelitis, measles and tetanus. Universal immunisation against 6 Vaccine-Preventable Diseases (VPD) by 2000 was one of the goals set in the National Health Policy (1983). This goal however has not been achieved. Available data from service reporting indicate that there had not been any improvement in the coverage during the nineties. This has been a source of concern. However, reported cases of vaccine preventable diseases have declined over the same period.

One of the major reasons for not achieving 100 percent routine immunisation is the focus on campaign mode programmes in Health and Family Welfare. The Department of Family Welfare has now taken up a scheme for strengthening of routine immunization. A project on Hepatitis B immunization and injections safety has also been initiated.

National Polio Surveillance Programme (NPSP)

NPSP was started in 1997 with DANIDA and USAID assistance and is under the management of WHO. The programme has helped in detection of cases, case investigations, laboratory diagnosis and mop up immunization. Special efforts are being made to achieve high routine and campaign coverage in under-served communities, and remind families about need for routine immunization during the Pulse Polio Immunisation (PPI) campaigns. The medical goal of polio eradication is_- to prevent paralytic illness due to polioviruses by elimination of wild poliovirus so that the countries of the world need not continue to immunize all children perpetually.

The Oral Rehydration Therapy (ORT) Programme

ORT was started in 1986-87. The main objective of the programme was to prevent deaths due to dehydration caused by diarrhoeal diseases among children under 5 years of age due to dehydration. Health education, aimed at rapid recognition and appropriate management of diarrhoea, has been a major component of the CSSM.

Acute Respiratory Infections (ARI) Control

Pneumonia is a leading cause of death of infants and young children in India, accounting for about 30 percent of the under-five deaths. Under the RCH Programme, Tablet co-trimoxazole is supplied to each sub-centre in the country as part of Drug Kit-­A. Mothers and community members are being informed about the symptoms of ARI, which would require antibiotic treatment or referral.

Tenth Five Year Plan

Effort will be made to achieve 100 percent coverage for six vaccine-preventable diseases, eliminate polio and neonatal tetanus through strengthening routine immunisation programmes, and discourage campaign mode operations, which interfere with routine services. It is envisaged to bring in greater involvement of the private sector and improve awareness through all channels of communication.

GOAL 5: IMPROVE MATERNAL HEALTH

I. STATUS AND TRENDS

Maternal Mortality Ratio (MMR)

Maternal mortality in India continues to be a major concern given the reduced social, cultural and economic status of Indian women that inhibits them from adequate access to health facilities.  Though it is a major social concern, there are no reliable estimates available on maternal mortality. The estimates available are from the National Family Health Surveys (I and II) and the Sample Registration System (SRS) for few years. The maternal mortality ratio at the national level estimated for 1998 by SRS was 407 per 100,000 live births and 301 in 2001-03 (MMR-RGI). Though estimates are indicative, they reflect the relative neglect of women's health in India.

Regional Variations

There is clear evidence of high inter-state variations in MMR. The estimates of MMR in the weaker States in the north and central India are very high compared to southern and western region States.

Births Attended by Skilled Health Personnel

Safe deliveries, greatly reflected by births attended by skilled personnel, though have been increasing, and are still much below the desired level. NFHS III estimates that the proportion of births attended by skilled health personnel was 48 percent during 2005-06. Also, there is a wide gap in the proportion between rural and urban. While the proportion of births attended by skilled health personnel in urban area is 73 percent, the same in rural area is only 34 percent. The vulnerable groups such as schedule castes and schedule tribes are the most affected with only 39 percent and 23 percent of births attended by skilled health personnel, respectively.

Causes of Maternal Deaths

There are several causes attributed to maternal deaths. Some of the direct causes, such as haemorrhage, puerperal complications, obstructed labour, abortions and toxaemia account for more than three-fourths of the maternal deaths while other related causes such as anaemia, pregnancy with TB/malaria, viral hepatitis and others account for rest of the deaths. Studies have shown that haemorrhage, sepsis and anaemia are the major causes of maternal deaths, more so in rural areas. NFHS II reveals that moderate and severe anaemia among pregnant women (28%) is almost double that of non-pregnant women (16%).

Apart from these, there are several other intangible factors associated with maternal deaths. They are overall health status, reproductive status, access to health services and extent of utilisation of health services. Adoption or non-adoption of family planning service also in a way has an effect on maternal mortality. The high maternal death rate is further reflected with the performance of pregnancy related indicators. According to NFHS III, only 51 percent of mothers received antenatal check-up ( at least three visits), 71 percent received two or more doses of tetanus toxoid and contraceptive prevalence is 56.3% in 2005-06.

II. CHALLENGES

Establishing Database on MMR

Lack of information on maternal mortality levels in the states is the major detrimental factor in assessing the gravity of the issue and brining in awareness on the maternal mortality. A reliable database is critical to planning, priority setting, and advocacy for political commitment. Dissemination of regular and reliable statistics on maternal deaths at national and state levels will increase sensitivity to the issue. A good civil registration system recording all births and deaths is essential.

High Risk Pregnancy Behaviour

The pregnancy pattern in India - too early, too many, too close together - enhances the risk of maternal mortality. About one-fifth of fertility is contributed by women in the age group of 15-19 years. The birth interval in about one-fourth of this group is 18 months. Of the total births, about a quarter is higher order births, of order 4 or more.

Poor percentage of institutional deliveries

Institutional deliveries are a critical factor in determining maternal deaths. The NFH S II indicates that the institutional deliveries are low in the country (33.6%) and very low in rural areas (24.6%). Though various measures have been under implementation under RCH programme for promoting institutional deliveries, they still need to be seen for the better results.

Poor programme implementation

The RCH programme though has various provisions such as emergency transportation, supply of emergency obstetric care equipment and IFA tablets, and provision of hiring private gynaecologist by public health facilities, the RCH Facility Survey conducted in 2000 reveals poor availability and utilisation of these provisions. The programme implementation has to be improved for attaining set objectives.

III. POLICIES AND PROGRAMMES

CSSM and RCH Programmes

Indian MCH Programmes from as early as 60s and 70s have focused on antenatal care and safe deliveries. Despite all these, the MMR has remained high though there is an improvement. The major programme towards promoting safe motherhood and reducing maternal mortality in India is CSSM, now being integrated into Reproductive and Child Health programme. Prior to the CSSM, several programmes in various forms were under implementation aiming to control population, and promote safe motherhood and child survival. While these programmes did have a beneficial impact, the discrete and separate identity of each programme was causing problems in its effective management besides somewhat reducing the outcome. In the nineties, the CSSM programme was, therefore, drawn up and implemented from 1992-93 onwards.

The process of integration of related programmes initiated with the implementation of the CSSM Programme was taken a step further in 1994 when the International Conference on Population and Development at Cairo proposed the unification of programmes for RCH. The RCH Programme incorporates the components of the CSSM Programme and further includes two additional components - one relating to sexually transmitted diseases (STD) and the other relating to reproductive tract infection (RTI). The main highlights of the RCH programme are:

      Interaction of all interventions for fertility regulation and maternal and child health with reproductive health programmes for both men and women.

      Reorienting the provision of services to make these clients centred, demand driven, high quality, and based on the needs of the community, assessed through decentralized participatory planning and the target free approach.

      Upgradation of the level of facilities for providing various interventions with due care to quality. The First Referral Units (FRUs) being set up at sub-district level will hereafter provide comprehensive emergency obstetric and newborn care. Similarly, RCH facilities in PHCs will be substantially upgraded.

      All-round improvement in the access of the community to various services, which are commonly required by it. It is proposed to provide facilities for MTP at the PHCs, and counselling and IUD insertion at the sub-centres, in a phased manner.

      Provision of greater access to outreach services, particularly for the vulnerable groups of the population who have, till now, been left out of the planning process. For this, special programmes will be taken up for urban slum-dwellers, the tribal population and the adolescents.

      NGOs and Voluntary Organisations will be involved in a much larger way to improve the outreach and make it a people's programme.

      Practitioners of ISM will be trained and research and development in ISM will be supported to improve the range of RCH services.

      Panchayati Raj System will be assisted to play greater role in planning, implementation, and assessment of client satisfaction.

Maternal Health Component of RCH

The maternal health component of RCH services to be provided at the sub-centre, PHC, CHC/FRUs include the following:

1. Antenatal Care

      Registration of pregnancies

      Providing essential Antenatal care (at least 3 visits)

      Iron prophylaxis to pregnant and lactating mothers

      Detection and treatment of anaemic mothers

      Management/referral of high risk pregnant mothers

2. Natal Care

      Increasing proportion of deliveries by midwifery trained personnel

      Increasing proportion of institutional deliveries

3. Post-Natal Care

      Provision of at least 3 post-natal visits

      Monitoring and care of the newborn

      Referral/management of high risk newborn

4 Provision of care for unwanted pregnancies

      Referral/management of unwanted pregnancies through MTPs and safe abortion

IV. ATTAINING MDG TARGET

India's performance is poor even among the low and middle income countries in the region. Even based on conservative estimate of 407 maternal deaths per 100,000 by Sample Registration System in 1998, more than 100,000 women die of pregnancy related causes every year in India, which was about 18 percent of global maternal deaths.

With the current trends, both the national target 100 to be achieved by 2010 (National Health Policy - 2002) and the MDG target 106 by 2015 look unrealistic. Achieving these targets is largely dependent upon socio-economic conditions of women, besides efficient implementation of programme interventions. Among others, the following factors are critical in achieving the target:

      Reduction in fertility levels

      Promoting comprehensive antenatal care

      Screening and identification of anaemic women

      Active promotion of institutional deliveries

      Effective screening for high risk delivery cases

      Effective availability of emergency transportation

      Increase in the number of approved facilities for Medical Termination of Pregnancy

GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES

HIV/AIDS

I. STATUS AND TRENDS

India is burdened with a larger HIV/AIDS epidemic than any other country in the world. It accounts for almost 13 percent of the 40 million people living with HIV/AIDS globally and over 69 percent of the 7.4 million people living with HIV/AIDS in the Asia and Pacific region in 2003. Given the large population base, a rise of 0.1 percent in the prevalence rate would increase the numbers living with HIV by over a half a million. Since the first case was reported in Chennai in 1986 (capital of Tamil Nadu), HIV has spread rapidly from urban to rural areas and from high risk groups to general population. The number of HIV infected persons has increased to 5.1 million in 2003 from a small 0.2 million in 1990 (Fig 6.1).

The reported cases of full-blown AIDS to NACO, as of August 2004, are 86,028; of which 72.1 percent are males and 27.9 percent are females, indicating one woman among four AIDS cases reported. This is only a fraction of AIDS morbidity in the country, reflecting both the stigma and the ignorance surrounding the infection. Some of the estimates suggest that the number would range somewhere between 100,000 and 1,000,000 (HIV/AIDS Treatment and Prevention, World Bank 2004). Since the epidemic is more than a decade old, mortality due to AIDS is increasing; nearly 2 percent of all deaths are due to HIV/AIDS in 1998.  If current HIV/AIDS policies continue, by 2033 AIDS will account for an estimated 17 percent of all deaths and 40 percent of deaths from infectious diseases. Elaborate government-led machinery is in place and working in partnership with NGOs and private sector to prevent and control the spread of HIV/AIDS, the biggest public health challenge in Indian history.

Table 6.1: Status of HIV/AIDS Presence in India in 2003

Source: HIV Sentinel Survey 2003, NACO, GoI

Knowledge of HIV/AIDS

In India, knowledge about HIV is still scant and incomplete. About 82 percent of males and 70 percent females in general population have heard of HIV/AIDS, while it is more than 90 percent among high risk and bridge groups. Among females in general population, only 48 percent knew that using a condom every time would prevent them from HIV/AIDS and only 19.9 percent of females in this population have correct beliefs about HIV transmission. People's knowledge level on correct beliefs on HIV/AIDS is in general low among all categories of target groups. The knowledge and awareness levels are relatively higher among high risk groups compared to general population (Behavioural Surveillance Survey, 2002).

Condom use at last high-risk sex

The Behavioural Surveillance Survey 2002 indicates that nearly three fourths of female sex workers and their clients have used a condom during their last sexual intercourse with commercial partners. It is 60 percent among IDUs and only 39.3 percent among MSM. The condom use at last sex with non-regular sex partners was only 40 percent among females and 51 percent among males. The consistent condom use among all high risk groups is, however, low. Among males and females with regular sex partners, it is 33.6 percent and 26.6 percent respectively. Among FSWs it is 51.5 percent and IDUs, 31.8 percent.

Condom use rate of the contraceptive prevalence rate

Between the two NFH surveys (1992 and 1998), there has been no perceptible increase in the usage of condoms among the general population. The reported usage of condoms among married women of reproductive age (from 15 to 49 years) is a small 3.1 percent in 1998-99. It is very low in rural areas, 1.6 percent and in urban areas it is 7.2 percent. Among young age groups, 15-19 and 20-24 years the usage is 1.4 and 3.2 percent respectively.

II. CHALLENGES

Several factors increase Indian vulnerability to a devastating AIDS epidemic - widespread poverty, illiteracy, poor nutritional and health status, social inequalities based on caste and gender, inadequate health infrastructure, taboos about sex, lack of political commitment, and a persistent denial of the AIDS epidemic in many states. Without the immediate and sustained implementation of preventive and control measures, the adult HIV prevalence rate could be 5 percent by the year 2006 - a total of nearly twenty-five million HIV infected people, roughly equal to the number of current infections in sub­ Saharan Africa (India Health Report, 2003).

III. POLICIES AND PROGRAMMES

The Government of India has responded to the challenge of HIV with appropriate policies, strategies and programmes. The national AIDS Control and Blood Policies were adopted in 2002. The Policy envisages zero new infections by 2007. In the initial years of the epidemic, late 1980s, AIDS prevention efforts were confined to `hot spots' like Maharashtra, Tamil Nadu, Manipur, and select big cities. Since 1992, considerable efforts were being put to expand it to all parts of the country through the World Bank supported country-wide National AIDS Control Project. The first phase of this project (1992-99), with an IDA credit of $ 84 million, focused on preventing transmission through blood and blood products and on increasing awareness of the danger of risky sex and needle exchange. Phase II of the National AIDS Control Programme (NACP) began in 1999, supported by a World Bank credit of $ 191 million plus Indian government funding of $ 14 million, is a 100 percent centrally sponsored scheme implemented through State AIDS Control Societies. In addition to the World Bank, state-level AIDS control projects are also being implemented by several bilateral donors such as USAID of the US government in Tamil Nadu and Maharashtra, DFID of the UK government in Andhra Pradesh, Gujarat, Kerala, and Orissa, and Canadian International Development Agency (CIDA) of the Canadian government in Karnataka and Rajasthan. While the World Bank project, implemented through NACO, covers the whole range of prevention, care, and capacity building, bilaterally funded projects focus on the prevention of sexual transmission of HIV. More than 80 percent of the programme resources are financed by the government, with one fifth coming from government revenue and four fifths from a World Bank credit. About 20 percent of the budget is financed by grants from bilateral donors.

IV. ATTAINING MDG TARGET

The MDG targets to halt the growth of HIV/AIDS spread by 2015 and also targets to reverse the spread. The National Health and AIDS Control Policies proclaimed in 2002, however, planned to achieve the same goal by 2007. Attaining national goal appears to be unrealistic with the given capacities, programmes and shorter duration, while MDG could be possible if planned for.

Over the last decade there is a manifold increase in the number of HIV cases from a mere 0.2 million in 1990 to 5.1 million in 2003, which indicates an annual average growth of 0.37 percent between 1990 and 2003. Though this presents a low percentage of growth, a small 0.1 percentage growth would add an additional half a million new cases. The rate of growth was peak between 1990 and 1998 and slowed down thereafter at a growth rate of about 5 percent up to 2001 and increased to 15 percent between 2001 and 2002 and again declined to 11.6 percent between 2002 and 2003. Attaining zero level growth by 2015 would mean achieving immediate declines in the annual growth rates, at least by one percent every year. While continuing the present set of programmes, which resulted in decline in HIV infections caused by blood transfusion, should intensify the following activities:

      HIV/AIDS awareness and education, particularly among youth and students in school and colleges

      Involvement of the private health sector and building up public-private partnerships

      More support services for those living with HIV/AIDS

      Stronger political commitment

      Collaboration with various stakeholders such as other Government Departments, NGOs, CBOs for expanded response

      Transform HIV/AIDS from the image of a private problem to a public problem through IEC

MALARIA

1. STATUS AND TRENDS

Long implemented strategies effectively contained the incidence of malaria in India.

The incidence, which was estimated in the order of 75 million cases and 0.8 million deaths in 1947, was brought down to 0.32 million cases and 211 deaths in the year 2003. Malaria was almost eradicated by mid sixties but has staged a comeback thereafter. About 6.47 million malaria cases were reported in 1976, the highest since resurgence. During this period of resurgence of malaria, certain states of the Union of India like Uttar Pradesh, Bihar, Karnataka, Orissa, Rajasthan, Madhya Pradesh and Pondicherry were found to be worst affected, ­particularly with increasing incidence of P. falciparum infection.  Programmes since independence have however, reversed the growth of incidence since 1984 and registered a declining trend from 1987. On the whole, the country has been able to contain malaria incidence of 2 to 3 million cases annually since 1984 in spite of increased population at the rate of 2.1 percent annually.

Malaria transmission occurs in almost all areas of India except areas above 1800 metres sea level. About 95 percent of population in the country live in malaria-risk areas. Overall, ten states account for 93 percent of the total disease burden. While Madhya Pradesh, Orissa, Rajasthan, Bihar, Andhra Pradesh and Maharastra account for over 80 percent of total cases, Madhya Pradesh and Orissa alone account for 50 percent of mortality (India Health Report, 2003). Malaria in India is unevenly distributed. In most parts of the country, about 90 percent, malaria is unstable with relatively low incidence but with a risk of increase in cases of epidemic form every 7 to 10 or more years.

There are 4 species of malarial parasites, of which 3 species are found in India. These are a) Plasmodium Vivax that may cause relapsing malaria but seldom death (50­-55% of total reported cases), b) P. falciparum that causes malignant malaria and may lead to death (48-52% of total cases), c) P. malariae that may cause severe malaria (small numbers found in foothills in Orissa) and, d) P. ovale (not found in India). All malaria mortality in India is due to P. falciparum only.

II. CHALLENGES

Developmental activities, industrial growth, expansion of agriculture, deforestation and changing lifestyles have the potential of increasing the breeding sites of mosquitoes. At present, malaria continues to be a public health problem affecting around 20 percent population that lives largely in remote, inaccessible, forest and forest-fringe areas. These areas have poor infrastructure and large number of vacancies at key level functionary that contribute to operational difficulties in programme implementation. Further, technical obstacles like development of Chloroquine resistance in P.falciparum and insecticide resistance in malaria vectors in some areas also pose challenge to the malaria control efforts besides developmental activities leading to creation of mosquitogenic conditions, urbanization, migration and climate change serving as aggravating factors for malaria transmission.

III. POLICIES AND PROGRAMMES

The period after independence has witnessed several initiatives and measures to combat malaria, which effectively contained the growth of malaria.

National Malaria Control Programme/ National Malaria Eradication Programme/National Anti Malaria Programme

The first measure in the direction of control of malaria is the launching of National Malaria Control Programme by Government of India (NMCP) in 1953. The NMCP was highly successful and within five years the incidence dropped to 2 million from 75 million in 1947. Encouraged by this, the programme was changed to a more ambitious National Malaria Eradication Programme in 1958. By 1961 the incidence dropped to a mere 5000 cases a year. But since then the programme suffered set-backs due to technical, operational and administrative reasons, and the cases started rising again. In 1977, the Modified Plan of Operation (MPO) was launched with the immediate objectives to prevent deaths and to reduce morbidity due to malaria. The programme was integrated with primary healthcare delivery system. Selective indoor residual spray by stratifying areas based on cases per 1,000 populations in a year, i.e., the Annual Parasite Incidence (API) of 2 and above was recommended in the MPO. Malaria incidence declined to about 2 million cases by the year 1984 and thereafter. Realising the difficulties in controlling/eradicating malaria, the National Malaria Eradication Programme has been renamed as National Anti Malaria Programme (NAMP). The main control strategies under the programme are as follows:

      Early Case Detection and Prompt Treatment (EDPT) to provide relief to the patient, and reduce reservoir of the infection.

      Selective Vector Control by appropriate insecticidal spray in rural areas and recurrent anti-larval measures including biological methods like use of larvivorous fish.

      Promotion of personal prophylactic measures including use of Insecticide Treated Mosquito Nets (ITMN), etc., and promotion of bio-environmental control measures.

      Emphasis on Information, Education and Communication (IEC) to promote community participation in the programme and inter-sectoral collaboration.

      Capacity building of optimal utilization of the technical manpower for the programme.

Enhanced Malaria Control Project (EMCP)

The World Bank assisted Enhanced Malaria Control Project is in operation in 1045 malaria hardcore tribal PHCs of 100 districts covering 62 million population in the states of Andhra Pradesh, Chattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Rajasthan and Orissa. Nineteen towns of 10 States have also been included under EMCP. In these areas, attempts are being made to have an integrated strategy for malaria control, which includes providing for presumptive treatment to fever cases at each village; presumptive radical treatment at health facilities in high risk areas; promotion of use of insecticide treated bed nets; use of larvivorous fish in mosquito breeding sites; and selective indoor residual spray in high risk areas. The project was concluded in March 2004.

IV. ATTAINING MDG TARGET

The MDG targets to halt the growth of malaria incidence by 2015 and also targets to reverse the incidence. Malaria has been effectively controlled in vast areas covering almost 80 percent population of the country in spite of increased population, rapid and unplanned urbanization, increased migration and population aggregation. The growth in the incidence of malaria has been stable at 2-3 millions since 1984 and also registered declines from 2002. The incidence and mortality levels caused by malaria are 1.82 million and 902 respectively in the year 2002. The present performance levels suggest that the targets of MDG have largely been achieved but should strive for consistency in the declines. The National Health Policy 2002 has much higher target to reduce the mortality caused by malaria by 50 percent by 2010.

TUBERCULOSIS (TB)

I. STATUS AND TRENDS

India accounts for one-third of global TB and has more TB cases than any other country in the world. About 40 percent of the Indian population is infected with TB bacillus. Every year about 2.2 million persons are added to the existing load of about fifteen million active TB cases; of these, about 800,000 are smear positive (infectious), and about 450,000 die. TB is the leading cause of death among women in the reproductive age group of 25-44 years, more deaths than those due to all the causes of maternal mortality. Since every sputum-positive case has the potential to infect 10-15 individuals in a year, and since TB is one of the important opportunistic infections of HIV, it is feared that deaths due to TB can go up to four million in the next decade if not controlled. It is estimated that the economic loss to the country due to TB is Rs 12,000 crore (US $ 3 billion) (RNTCP Status Report, 2004).

As per Global TB Report 2003, two-thirds of the additional sputum positive cases, reported under DOTS in 2001, were found in India. In 2002, over 620,000 cases were placed on treatment of which nearly 250,000 were new smear positive cases. In the year 2003, more than 900,000 cases were placed on treatment - largest cohort of cases, more than any other country in the world. The success of DOTS in India would determine the success of TB control in the world.

II. CHALLENGES

TB and HIV

TB is the most common opportunistic infection in people living with HIV. As the Human Immuno-deficiency virus (HIV) breaks down the immune system, HIV- infected people are at greatly increased risk of TB. Without HIV, the lifetime risk of developing TB in TB-infected people is 10 percent, compared to at least 50 percent in HIV-infected. HIV is also the most powerful risk factor for progression from TB infection to TB disease. TB in turn accelerates the progression of HIV to AIDS and shortens the survival of patients with HIV infection. With an estimated 5.1 million HIV­ positive individuals in India, it is likely that HIV may worsen the TB epidemic. However, even among HIV-infected people, TB can be cured. DOTS is as effective among HIV-infected TB patients as among those who are HIV negative. The Government of India has undertaken several measures to strengthen collaboration between the TB and HIV.

III. POLICIES AND PROGRAMMES

National TB Programme and Revised National Tuberculosis Control Programme (RNTCP)

The National TB Programme (NTP) was launched in 1962, and an impressive infrastructure of 446 District TB centres, 330 TB clinics, 764 hospitals, and 47,600 beds were established. These hospitals diagnose nearly 1.3 million patients and treat 250,000 sputum positives every year. The outcome is, however, unsatisfactory as treatment completion is less than 40 percent of patients. Poor diagnosis, inappropriate regimens, and the lack of patient evaluations or follow-up are the major shortcomings of the programme. Despite expert committee reviews in 1975 and 1988, the TB programme languished for want of a credible strategy and political and administrative support, as well as low resource allocation not exceeding Rs 20 crore per year. An exhaustive review of the National TB Programme was taken up in 1992. In 1993, RNTCP, based on the DOTS strategy was introduced on a pilot basis to detect at least 70 percent of sputum positive patients, and cure at least 85 percent. It is planned that the RNTCP coverage will be extended to the entire country by 2005, The DOTS strategy is now implemented under the RNTCP in about 455 districts covering 829 million people (as on February 29, 2004). The NTP is implemented along with RNTCP in the remaining parts of the country with the Central government providing drugs for Short-Course Chemotherapy (SCC). The DOTS strategy is based on five principles.

      Case detection among patients spontaneously attending health facilities, primarily by the microscopic examination of sputum.

      Ensuring adequate drug supply.

      The administration of SCC under direct observation.

      Systematic monitoring and accountability for every patient diagnosed.

      Political will.

There has been a qualitative improvement in diagnosis, with a ratio of 1.2 smear negative pulmonary TB for every case of smear-positive TB. The cure rate has doubled from about 25 percent to 86 percent, though not uniformly. The death rate has also been reduced to 4 percent, compared to at least 20 percent under the NTP. These achievements of RNTCP are due to the quality training given to health staff, the increasing involvement of NGOs, improved management systems and the standardization of treatment regimens according to patient typology to ensure the uninterrupted supply of drugs in patient-wise boxes, increased availability of sufficient funds with district societies, and intensive monitoring.

Collaboration with other sectors

India has one of the largest private healthcare sectors in the world, with an estimated 8 million private practitioners. RNTCP has made a concerted effort to develop partnerships with the private health sector and NGOs, in order to widen access to quality TB care. To date, more than 3000 private practitioners and 750 NGOs are officially providing RNTCP services, 131 medical colleges out of 189 are collaborating with RNTCP in the implementing districts. The results of this collaboration are promising.

The Government of India has involved the Ministries of Labour, Railways, Mines and Steel by issuing directives to their respective health establishments in adopting the DOTS strategy as the standardized treatment for TB patients. This is necessary for creating an epidemiological impact, as all the cases will have uniform treatment with uninterrupted good quality drugs. GoI has initiated a Public Private Mix (PPM) pilot project with technical assistance from WHO in 14 sites across the country: Ahmedabad, Bangalore, Bhopal, Chandigarh, Chennai, Delhi, Jaipur, Kolkata, Lucknow, Patna, Pune, Bhubaneswar, Ranchi and Thiruvanthapuram. The project is an initiative to increase case detection by enhancing involvement of the private sector in RNTCP. Each of these sites is primarily an urban area with substantial presence of other sectors and weak public health infrastructures.

Central TB Division has collaborated with the World Economic Forum and Confederation of Indian Industries (CII) to facilitate the launch of The Indian Business Alliance with the objective of providing a platform to bring together companies to adopt RNTCP.

IV. ATTAINING MDG TARGET

Controlling TB in India is a tremendous challenge. The TB burden in India is still staggering. Every year, 2.2 million persons develop the disease, of which about 800,000 are infectious, and about 450,000 die of it - 1232 every day. The disease is a major barrier to social and economic development. An estimated 100 million workdays are lost due to illness. The present capacities and the huge presence of the disease would make it almost difficult to achieve the millennium goal. The millennium goal targets to halt the grouch of TB incidence by 2015 and also targets to reverse the incidence. The achievement of this goal will depend on how soon and how well the following constraints are overcome.

      Low coverage: DOTS covers only about 20-25 percent of TB patients

      Weak involvement of civil society and the community

      Weak health system, particularly in urban areas without primary healthcare infrastructure

      Unsupervised private practitioners following their own lines of treatment, contributing to drug resistance

      The implementation of multiple systems of TB control (conventional, SCC, and RNTCP), with different financing mechanisms

      The threat of a dual epidemic: HIV/AIDS and TB as an opportunistic infection with a potential to increase the number of cases substantially

This donor lending has gradually shifted from passive programmatic assistance to the Central Governm1ent, to a more direct, active role in influencing and building the capacity of governments to initiate health reform, reflecting the shift in the international environment from disease control to systems, issues and governance. Despite the constraints of the funding agencies like inadequate preparation of projects, multiple goals and sub goals in excess of capacity of the implementing agency, unrealistic time frames, inadequate matching of financing and scheduling of project activities, etc., India will continue to be dependent on donor aid, and external assistance will continue to serve as a catalyst to the improvement of systematic efficiencies and universal access to healthcare.