The main functions of the Department of Health are :

1. to undertake National Health Programmes in order to intensify measures for the prevention, control and eradication of communicable diseases and reduce mortality and morbidity due to all diseases;
2. to promote education, research and training in various medical disciplines to reorient the medical colleges in the delivery of health services in rural areas;
3. to prevent adulteration of food as well as drugs;
4. to give impetus to bio-medical research; and
5. to collaborate with member contries of United Nations & international agencies like WHO, UNICEF in matters relating to health promotion and development.

The Plan outlay for Central Sector Health Programme in the Annual Plan 1995–96 was Rs. 670.00 crore including a foreign aid component of Rs. 225.00 crore. A major portion of outlay is for the National Health Programmes for the Control of communicable and non-communicable diseases implemented through centrally sponsored programmes. The external assistance has been sought to get the enhanced quantum of funds for programmes in critical areas mainly diseases control programme viz. leprosy, tuberculosis, AIDs and blindness.
Another major component of the Central Sector Health Programme is Purely Central Schemes through which financial assistance is given to about 80 institutions. These institutions are responsible for contribution in the field of control of communicable and non-communicable diseases, medical education, training, research and patient care. During 1995–96 Rs. 245.00 crore allocation have been made under Purely Central Schemes.

Financial Assistance to Voluntary Organisations
The Government of India have been giving financial assistance to the Voluntary Organisations for encouraging them to set up new hospitals/dispensaries in rural areas or to expand and improve the existing hospital facilities. Financial assistance is available under the following grant-in-aid schemes :

1. Scheme for improvement of Medical Services;
2. Promotion and Development of Voluntary Blood Donation Programme; and
3. Special Health Scheme for Rural Areas. Grants-in-aid amounting to Rs. 22.13 lakh were released to 11 voluntary institutions during the year 1994–95. An amount of Rs. 18.63 lakh has been released to 8 voluntary institutions during 1995–96.

Health Minister’s Discretionary Grant
Financial assistance to the poor and indigent patients is given from the Health Minister’s Discretionary Grant to defray a part of the expenditure on hospitalisation / treatment in cases where free medical facilities are not available.
During 1994–95 assistance totalling Rs. 9.63 lakh was given to 104 individuals. A provision of Rs. 30 lakh has been made during the financial year 1995–96. The maximum ceiling of grant has been raised from Rs. 10,000/- to Rs. 20,000/- in each case. A sum of Rs. 29.97 lakh has been released to 257 patients during the financial year 1995–96.

Medical Relief and Supplies
Under the Central Government Health Scheme (CGHS), a number of new initiatives have been taken up. Expenses incurred on Intra Ocular Lens (IOL), Hearing Aids and Pacemakers have become reimbursable. In order to expedite disposal of reimbursement of medical expenses claims, powers to reimburse the cost of artifical appliances have been delegated to the administrative Ministries/Departments.
The Additional Directors/Deputy Directors of CGHS Organisations have also been delegated powers to reimburse the cost of artificial appliances to the pensioners.

National Health Programmes
The Central Government has taken certain steps to combat communicable, non-communicable and other major diseases which cause disability not only to improve the health status of India’s population but also to prevent and control disabilities. For this purposes, several National Health Programmes are directly run by the concerned ministers.

National Leprosy Eradication Programme :
National Leprosy Eradication Programme (NLEP) is implemented as a 100% Centrally sponsored scheme. The aim of NLEP is to achieve elimination of Leprosy by the year 2000 A.D. Free treatment services with combination of drugs, Multiple-Drug Therapy (MDT) are provided to all leprosy patients throughout the country through trained leprosy workers. Estimated number of persons requiring treatment for leprosy has declined from 4 million cases in 1985 to 0.54 million cases in March, 1996. More than 6.5 million leprosy patients have been cured with MDT and percentage of registered patients taking MDT treatment has increased from 10 per cent in 1985 to 96 per cent in 1996. The prevalence rate of leprosy has declined from 57.3 per thousand population in 1981 to 5.9 per thousand population in 1996. Number of new leprosy cases detected each year has remained about 0.45 million.
About 15-20 per cent children suffer with leprosy. Proportion of infectious cases varies from 15-20 per cent while 5 to 15 per cent patients suffer from various types of deformities.

Currently most of the leprosy patients are in the states of Uttar Pradesh, Bihar, Madhya Pradesh and West Bengal.

Programme Objectives :
The Government of India launched National Leprosy Eradication Programme in 1982–83 with an aim to achieve elimination of leprosy by 2000 A.D. and to reduce its prevalence to <1/10,000 population. In order to achieve this several strategies were adopted including :

1. Early detection of leprosy cases through health workers, trained in leprosy.
2. Provision of domiciliary Multi-Drug Treatment (MDT) by specially trained staff in leprosy to cover 201 districts with prevalence of 5 or more leprosy cases per 10,000 population, by specially trained staff in leprosy.
3. Provision of MDT Services through Mobile Leprosy Treatment Units with the help of existing health care services in moderate to low endemic areas/districts.
4. Intensification of health education activities; and
5. Appropriate rehabilitation.

Financial Targets and Achievements of NLEP

1. Eighth Plan (1992–97) - Approved Outlay - Rs. 140.00 crore.
2. Outlay and Expenditure during Annual Plans 1992–93 to 1996–97.

3. Eighth Plan (1992-97) - Anticipated Expenditure - Rs. 305.95 crore.
4. Ninth Plan (1997-2002) - Proposed Outlay Rs. 337.04 crore of which Foreign Aid is Rs. 294.04 crore.
5. Annual Plan (1997-98) - Proposed Outlay Rs. 82.28 of which Foreign Aid is Rs. 75.13.

Targets and Achievements of NLEP

The impact of MDT Services has been sustantial, where MDT epidemiological impact assessed in 40 districts, where MDT programme has been in progress for past four or more years, shows that there is a marked reduction in prevalence rate (approximately 85 per cent); in annual new case detection rate (30 per cent); and deformity rate (80 per cent). The World Bank assistance has further strengthened the programme. It is expected that there would remain just over 100,000 leprosy cases and by the end of 2000 A.D., not more than 20,000 cases. This would bring in an effective break in the transmission of the disease and the goal to bring it down to less than 1 per 10,000 population set by the World Health Organisation would be achieved year-wise.

National Programme for Control of Blindness :
National Programme for Control of Blindness (NCPCB) was launched in the year 1976 as a 100 per cent centrally sponsored programme. Various activities of the programme include establishment of Regional Institute of Ophthalmology, upgradation of Medical Colleges, district hospitals and Block Level Primary Health Centres, development of mobile units, recruitment of required ophthalmic manpower in eye care units for provision of various opthalmic services. The goal is to reduce the prevalence of blindness from 1.4 per cent to 0.3 per cent by 2000 A.D.

The infrastructure developed so far and targets for the year 1995–96 are as follows :

The assistance provided to the service components under this programme has been enhanced during 1995–96, with the budget allocation raised from Rs. 40 crore during 1994–95 to Rs. 72 crore during the current year 1995–96. There is a provision of Rs. 75 crore during 1996–97.

Performance of cataract operations has gone up. Target for the year 1994–95 was 24.50 lakh and 21.56 lakh operations were performed. A target of 26.20 lakh operations has been set for the year 1995–96 and 19.73 lakh operations have been performed so far.

Performance of Cataract Operations

Voluntary organisations are playing an important role in this programme. District Blindness Control Societies (DBCS) are being established throughout the country under the Chairmanship of District Magistrate/District Commissioner. Till now, about 456 DBCS have been established.

External Assistance :
The following agencies have been assisting (NPCB) since 1980 :

1. World Health Organisation (WHO) – WHO has been assisting NPCB in organising workshops and seminars at the national and state levels; sponsoring fellowship for regional and extra-regional countries; professional development of manpower and supply of sophisticated ophthalmic equipment.
2. Danish International Development Agency (DANIDA) – In 1978, an agreement was signed between the Government of India and the Government of Denmark to provide support for the development of services unde NPCB, viz supply of equipments to Mobile Units, Primary Health Centres and District Hospitals and covering part of recurring costs. It is also involved in the following activities :

1. Manpower development;
2. Establishment of Management Systems at State level;
3. Establishment and development of monitoring and evaluation systems;
4. Preparation of Health Education material, teaching and information aids; and
5. Training.

3. World Bank Assistance – A World Bank assisted Blindness Control project is under implementation since 1994–95. The proposed expenditure of the project is Rs. 554 crore during the project period of 7 years.

The project is being implemented in 7 major states of the country viz. Andhra Pradesh, Madhya Pradesh, Maharashtra, Tamil Nadu, Orissa, Uttar Pradesh and Rajasthan.
Major inputs of the project are upgrading the ophthalmic services expanding the coverage in rural and tribal areas, establishment and functioning of DBCS, training of ophthalmic manpower, improving the management information systems and creating awareness about the programme in the masses.
Under the World Bank project a sum of Rs 21 crore is being allocated for the year 1994–95. Assistance of Rs. 48.60 crore was earmarked for the year 1995–96.

National Iodine Deficiency Disorders Control Programme
Iodine deficiency manifests itself in a wide range of physical and mental disorders, the most extreme form being hypothyroidism. The survey conducted by the Central and the State Health Directorates, Indian Council of Medical Research (ICMR) and Medical Institutes have clearly demonstrated that no Indian State is free from the ill-effects of Iodine Deficiency Disorders and an estimated 63 million in the country have disorders attributable to this deficiency and about 167 million are at risk.

About 54.4 million persons are suffering from endemic goitre, about 8.8 million from mental handicap, about 2.2 million are cretins and about 6.6 million have mild neurological disorders. The survey results indicate that out of 255 districts surveyed, Iodine Deficiency Disorders are a major public health problem in 222 districts.

Realising the magnitude of the problem the Government of India launched a 100 per centrally assisted National Goitre Control Programme (NGCP) in 1962 with the following objectives :

1. Initial surveys to assess the magnitude of Iodine Deficiency Disorders.
2. Supply of Iodated Salt in place of common salt; and
3. Resurveys to assess the impact of Iodated Salt every 5 years.

In August 1992, the National Goitre Control programme (NGCP) was renamed as national lodine Deficiency Disorders Control Programme (NIDDCP) with a view of wide spectrum of lodine Deficiency Disorders. On the recommendations of central council of Health in 1984, the Government took a policy decision to iodate the entire edible salt in the country by 1992. The programme started in April, 1986 in a phased manner. To date, the annual production of iodated salt in our country is 34 lakh metric tonnes per anum.

Achievements :
The achievements made under the programme from its inception to date are as under :

1. The Policy of iodated salt production has been liberalised to private sector. 641 private manufacturers have been licensed by the Salt Commissioner, out of which nearly 532 units have commenced production so far. They have annual production capacity of iodated salt of more than 60 lakh metric tonnes (MT) for the entire country.
2. Annual production of iodised salt has been raised from 5.0 lakh MT in 1985-86 to 35 lakh MT in 1995-96. This is expected to be further raised to 50.00 lakh MT in near future.
3. The Salt Commissioner in consultation with the Ministry of Railways arranges for the transporatation of iodated salt from the production centres to the consuming States under priority category ‘B’, a priority second to that for defence.
4. In order to ensure use of only iodated salt, 26 States/UTs have completely banned the salt other than iodised salt while three other States have issued partial ban whereas three States have yet to issue the ban.
5. For effective monitoring and proper implementation of National Iodine Deficiency Disorders Control Programme, all the States/UTs have been advised to set up Iodine Deficiency Disorders Control Cells in the State Health Directorates and Central Government provide cash grants for this purpose. Presently, 25 States/UTs have established such types of cells. The States of Goa, Himachal Pradesh, Jammu and Kashmir, Punjab, Tamil Nadu, Union Territory of Pondicherry and Lakshadweep have not yet so far set up such IDD Control Cells.
6. For ensuring the quality control of iodated salt at consumption level, testing have been set at the Bio-Chemistry division of Institute of Communicable Diseases, Delhi for training both medical and para-medical personnel and monitoring salt and urinary iodine.
7. For ensuring the quality control of iodated salt at consumption level, testing kits for on the spot qualitative testing have been developed and were distributed to all District Health Officers in endemic States for awareness.
8. It has been proposed to set up district level IDD monitoring labs in all the States who have issued ban notification complete/partial for iodine content of salt and urinary iodine excretion which are the most effective tools for proper implementation of IDD Control Programme. Tentative allocation of Rs. 75,000 per lab have been provided for this purpose.
9. Cash grants are provided by the Central Government for conducting surveys/re-surveys of IDD; Health education and Publicity campaign to promote the consumption of iodated salt.
10. Realising the importance of iodine deficiency in relation of Human Resource Development, NIDDC has been included in 20 point Programme.
11. The standards for iodated salt have been laid down under PFA Act, 1954. These stipulate the iodine content of salt at the production and consumption level should be at least 30 and 15 ppm respectively, and
12. GOI-UNICEF Project 1992-95 is being implemented in 13 selected endemic States for extensive monitoring and Information Education & Communication (IEC) activities of National Iodine Deficiency Disorders Control Programme. The activities are to be strengthened in 10 selected districts of the 13 states including North-Eastern regions.

Information, Education and Communication (IEC) on lodine Deficiency Disorders
To intensify IEC activities, a communication package having the following highlights was finalised with UNICEF:

1. Radio/TV spots were prepared and their broadcast/telecast is being done.
2. A 10 minutes video film on Iodine Deficiency Disorders was made and distributed to the states.
3. Posters/Danglers have been developed.
4. Material for posters highlighting the storage technique of iodised salt for use by wholesaler and retailers has been prepared and distributed.

National Mental Health Programme :
The National Mental Health Programme was launched during Seventh Five Year Plan to ensure availability of Mental Health Care Services for all, specially for those at risk in under-privileged sections of the community. The basic emphasis was on the promotion of community participation in the Mental Health Services development as a measure of self-help and self-reliance. The National Advisory Group identified 11 institutions for the training of health workers under the programme. This training consist of imparting basic knowledge of mental health to the Primary Health Care Physicians and Para-Medical Personnel. During 1995–96, Rs. 5 lakh was allocated for this programme.

National Filaria Control Programme :
Filariasis is a major public health problem in many States of the country and about 420 million people are estimated to be living in 175 endemic districts of which about 109 million are in urban areas of which about 47 million urban population is being protected. The infection is transmitted through insect bites and results in a disabling disease causing swelling which results in tremendous enlargement of leg or foot, or other part of the body.
The National Filaria Control Programme was launched in 1955. Under the Programme the following measures were undertaken :

1. Delimitation of the problem in hitherto unsurveyed areas; and
2. Control in urban areas through recurrent anti-larval measures and anti parasitic measures by 206 control units and 198 clinics, giving treatment with diethyl carbamisine to clinical cases and microfilaria carriers.

During the Eighth Plan anti-filarial drugs were distributed through Primary Health Care Delivery System in the rural areas of endemic States.

Number of Microfilaria (Mf) carriers and disease cases detected during the last three years by the control units and filaria clinics are as follows :

Other Major Health Programmes
The care of mothers and children occupies a paramount place in the Indian health services delivery system. This is reflected from the fact that 9 out of the 17 goals listed in the National Health Policy (1983) relate to maternal and child health.

As an integral part of the overall strategy for reduction of infant mortality to below 60 per thousand live births; child mortality to below 10 per thousand under five, child population and maternal mortality to below 200 per 100,000 live births by 2000 AD, the followling specific programmes have been under implementation in the country as 100 per cent centrally sponsored Family Welfare Schemes :

1. Universal Immunisation Programme (UIP) for the control of vaccine preventable diseases namely, diphtheria, pertussis, neo-natal tetanus, tuberculosis, poliomyelitis and measles.
2. Oral Rehydration Therapy (ORT) Programme for control of deaths due to dehydration caused by diarrhoea.
3. Prophylaxis Schemes against nutritional anaemia among pregnant and lactating mothers and against blindness due to Vitmin A deficiency among children of under 5 years of age.

Child Survival and Safe Motherhood (CSSM) Programme:
The CSSM Programme, launched in 1992-93, is being implemented with the financial assistance of World Bank and UNICEF and has an outlay of Rs. 1125.5 crore over a seven year period. The Programme has the following components :

1. Sustaining and strengthening the ongoing Immunisation, Oral Rehydration Therapy (ORT) and Prophylaxis Schemes;
2. Improving maternal care at community level by providing training to the Traditional Birth Attendants (TBAs) and disposable delivery kits to the pregnant women;
3. Expanding, in a phased manner, the programme for control of Acute Respiratory Infections (ARI) for children below 5 years of age; and
4. Setting up in a phased manner, a network of sub-district level First Referral Units (FRUs) for improving emergency obstetric care in the States of Assam, Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh.

Universal Immunisation Programme (UIP)
Universal Immunisation Programme (UIP), launched in 1985, has been declared as one of the Technology Missions in 1986, as a part of the overall national strategy to bring down infant and maternal mortality in the country. At the beginning of the Programme in 1985-86, vaccine coverage levels ranged between 29 per cent for BCG and 41 per cent for DPT. During 1995-96 (upto February 1996) coverage levels ranged from 67 per cent for TT (PW) to 84 per cent for BCG.

Surveillance of Vaccine Preventable Diseases :
A reliable surveillance system has been developed. The immediate reporting of cases of neo-natal tetanus and poliomyelitis has been made mandatory. There has been a significant decline in the incidence of these diseases.

Impact on Infant Mortality Rate (IMR) :
The effective impact of the programme is reflected in the significant drop in the infant mortality rate from 129 in 1976 to 74 in 1993. In the States of Bihar, Madhya Pradesh, Orissa and Rajasthan, the IMR has steadily come down.

Oral Rehydration Therapy (ORT) for Diarrhoea Control Among Children
The Oral Rehydration Therapy Programme had started in 1986-87 in a phased manner with the objective to prevent diarrhoea associated deaths in children due to dehydration. Diarrhoea still remains one of the leading causes of death among children under 5 years. Oral Rehydration Salts (ORS) has been used as a drug of choice for proper case management of diarrhoea cases.

Prophylaxis Schemes

Anaemia Prevention and Control among Pregnant Women:
Anaemia, accounts for 20 per cent of the maternal deaths in the country. It is one of the major causes of maternal mortality and is an aggravating factor in hemorrhage, toxemia and sepsis. The CSSM programme, therefore, has prioritised pregnant women for Iron and Folic Acid (IFA) administration. During 1994-95, 208.00 lakh (85.8 per cent) pregnant women were provided with the recommended dosage of IFA tablets.

Prevention and Control of Vitamin A deficiency among Children :
Vitamin A deficiency, which can lead to blindness, is widely prevalent in the country, especially among the pre-school children. The CSSM programme sought to administer six-monthly doses of concentrated Vitamin-A to the children between 1 to 3 years of age. During 1994-95, 149.8 lakh (72.6 per cent) infants were administered the measles-linked dose while the DPT/OPV booster linked dose was administered to 98.6 lakh (54.8 per cent) children in the age group of 1-2 years.

Essential Maternal Care – Dais Training, Their Reporting Fees And Disposable Delivery Kits for Pregnant Women:
The data for 1992 indicates that the proportion of deliveries attended by untrained hands was high, particularly in the rural areas. With the goal to achieve 100 per cent deliveries by trained personnel the CSSM Programme accords a high priority to speed up the training of Traditional Birth Attendants (Dais). An amount of Rs. 7.50 crore has been allocated during 1994-95 for 500/250 Dais per district. The reporting fee offered to the Dais has also been enhanced from Rs. 3.00 per case to Rs. 10.00 per case. There is a provision for the supply of disposable delivery kits containing essential items for safe and hygienic delivery to pregnant women.

First Referral Units (FRUs) for Emergency Obstetric Care:
Upgrading of rural health facilities, with a post of a gynaecologist, an operation theatre, essential equipments and skill based training is being undertaken in certain districts. Easier accessibility to adequate medical care is essential for an effective referral system and for promoting timely and early referral.

Pulse Polio Immunization (PPI)
Government of India decided to implement the strategy of National Immunization Days i.e Pulse Polio Immunization, beginning in 1995 to achieve polio eradication by the year 2000A.D. In the first phase, Government decided to observe Pulse Polio Immunizaiton on the two fixed days, on these two days, Oral Polio Vaccine (OPV) was given to all children of 0 to 3 years of age in the entire country regardless of previous immunization. 8.7 crore children in the country, including 7.9 crore in the age group 0-3 years, were given a dose of Oral Polio Vaccine in the country on 9 December 1995 and equal number of 9.3 crore children including 8.5 crore in the age group 0-3 years were given a dose of Oral Polio Vaccine in the second round on 20 January 1996.

The public response to Pulse Polio Immunisation was overwhelming. Mothers made a beeline for the immunization posts since early in the morning. One hundred per cent of the target was achieved.

PPI was the biggest public health intervention ever to be carried out in India. All departments of the government and non-governmental organisations successfully coordinated and cooperated to achieve full coverage.
The second phase of Pulse Polio Immunization was implemented on two days i.e. on 7 December 96 and 18 January, 1997.

Rural Health Services
Several programmes and schemes are implemented under the Minimum Needs Programme to provide primary health care relevant to the actual needs of the community in the rural areas. The status of Sub-Centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs) under the Minimum Needs Programme is as follows :

Sub-Centre :
A Sub-Centre is established on the basis of one Centre for every 5,000 population in the plain areas and for every 3,000 population in the hilly and tribal areas. There were 1,31,900 sub-centres functiong during the year 1995-96.

Primary Health Centres (PHCs) :
Primary Health Centres are established on the basis of one PHC for every 30,000 population in the plain areas and for every 20,000 population in hilly, tribal and backward areas. The number of PHCs functioning in the country was 21,693 during the year 1995-96.

Community Health Centres (CHCs) :
Rural hospitals, with specialist facilities were established by upgrading PHCs having 30 beds to cover a population of 80,000 - 1.20 lakh. In 1995-96 the number of functioning CHCs was 2,385.

Other Causes of Disabilities
Apart from major causes of disabilities like blindness, leprosy, polio, iodine deficiency there are other causes which have also received attention from various agencies including :

Genetic Causes of Birth Defects
Abnormalities of structure, function and body chemistry result in physical, sensory or mental disabilities are caused by heredity factors, apart from environmental interference with a child’s development before, during and after birth. Heredity information, containing characteristics (including defects) is passed on from parents to a child. Many genetic disorders can be traced to modes of inheritance such as Huntington Disease (progressive deterioration of the central nervous system) or Dwarfism (retardation of bone growth). Some defects like Down’s Syndrome (popularly known as Mongolism) is present at birth and is the result of chromosomal imbalance or an error occuring during the process of cell formation at the time of conception. This is not a "heredity condition" in the sense that it is not transferred from parent’s defective genes. It is essentially a random mistake and can happen to anyone, but women over 35 years are at a greater risk than younger mothers.

Many genetic diseases are due to abnormal enzymes. Experts in human genetics and medicine maintain that there are over 3200 causes of heredity disorders and in at least half of them these causes can be identified. Advancement in this extremely important field has helped to identify foetus at risk. On the basis of such a diagnosis recommendation can be made for the termination of pregnancy. With the help of the techniques of genetic counselling parents can be forewarned. Without such expert advice there is a risk that all or several children in a family would either be born with disabilities or would become disabled as they get older.

Genetic counselling, genetic engineering and many other new techniques now can identify preconditions responsible for inherited disabilities. Such breakthrough have the potential of making an appreciable impact on the incidence of disability. Such expertise is as yet, available only at selected institutions in large cities and outside the knowledge and reach of ordinary people. There is a definite need to establish a network of services accessible to couples at risk and to para–medical, medical and health service personnel. Regular training and orientation of medical, health and social welfare staff is needed to advise the parents.

Fluorosis
A number of diseases can result from unsafe drinking water, fluorosis is one among these. It causes health problems such as stomach disorders, discolouration and loss of teeth, pain and stiffness in joints, backbone as well as muscles and even results in crippling a patient on a permanent basis. According to a report published by Government of India’s National Technology Mission on Drinking water, "In India today, millions of men, women and children are crippled and lead a vegetative life due to fluorosis".
For want of any proper survey the number of people who are suffering, or have been crippled, as a result of fluorosis is not precisely known. However, it has been roughly estimated that about 25 million people in the country, living in 150 districts in 15 States, are seriously affected. These 15 endemic States are : Delhi, Jammu and Kashmir, Kerala, Orissa, Bihar, Haryana, Karnataka, Madhya Pradesh, Maharashtra, Punjab, Andhra Pradesh, Gujarat, Rajasthan, Tamil Nadu and Uttar Pradesh.

According to the Bureau of Indian Standards (BIS) (1991), excess flouride intake can be prevented by non-consumption of high fluoride water and other food items and by increasing the intake of Calcium and Vitamin C which help in fighting against the harmful effects of fluoride.

Lathyrism
Lathyrism is a type of paralysis in the lower limbs. It is prevalent in Madhya Pradesh, Andhra Pradesh, Karnataka, Maharashtra, Bihar, Uttar Pradesh and also in parts of West Bengal. This is caused due to excess consumption of lathyrus sativus (Khesari Dal) and is irreversible and incurable. The disease occurs in four stages. The first stage is characterised by an awkward gait and the patient can walk without the help of a stick. The disease then advance to on-stick stage because of muscular stiffness, then due to excessive bending of knees and crossing legs, the individual is reduced to the crawling stage and eventually he becomes totally crippled. About four per cent of the total population is estimated to be affected by lathyrism in the affected areas.
The consumers of khesari dal are, of necessity, poverty stricken agricultural labourers and people belonging to socially disadvantaged and deprived groups. They have to depend on this dal for their survival and normally receive it as part of their wages from landlords. Except Bihar, Madhya Pradesh and West Bengal all State governments have prohibited the use of such dal for human consumption. The State Government of U.P. has even banned the cultivation of Khesari dal. Despite these government efforts and warnings about the risk, the dal is still being cultivated and is being consumed. The concerned government departments have drawn up value suggestions to reduce the danger of Khesari dal including ‘steeping process’ and ‘par boiling’ process which remove or reduce the poisonous substances in the dal. Some low-toxin varieties of the seeds have also been developed. Systematic research has resulted in setting up of a detoxifying plant in Rewa. However, the problems of cultivation and consumption of Khesari dal causing lathyrism continue.

Casualties from Accidents
All human activities–occupational, recreational, domestic or transportation – are subject to accident risk and therefore sustained efforts should be made to reduce accidents, particularly those resulting in partial or total disability or death. Owing to the rapid changes in the mode of living as well as the environment in India the rate of fatal and non-fatal accidents is on increase. It is extremely complex to calculate the economic loss which results from avoidable events. Accidents are caused by falls, inside or outside home, burns, drowning, transport (railways, road traffic, air travel, travel marine), poisonous gases, poisons, dangerous drugs, riots and violence, etc.

As per NSSO survey results, three to four per cent of visual disability as well as speech and hearing disability and 22 per cent of locomotor disabilities are due to injuries.
The Research Division of the National Society for Equal Opportunities for the Handicapped (NASEOH), Bombay, has estimated that about 25,000 industrial workers acquire permanent disability every year due to industrial accidents.

According to a publication entitled Statistics of Road Accidents in India (1983-1992), by the Ministry of Surface Transport, Government of India, 54,100 persons were killed and 2,44,100 persons were injured in road accidents in India in 1990 alone. There has been nearly four times increase in the number of deaths as well as injuries during 1970-1990. According to a guessetimate, nearly half a million persons acquire disability due to transportation accidents every year in India. Ownership of motorised vehicles in India is nearly one per cent of the world’s vehicle population, yet its share of road accidents in nearly six per cent.

Agricultural accidents could be largely prevented by redesigning the existing machines, like threshers and chaff cutters and also by stricter implementation of the Dangerous Machines Act and Bureau of Indian Standards (BIS) for the machines as well as by educating public with the help of print and electronic media. Accidents will always occur but their frequency and severity can be kept in check.

Nutritional Causes
Nutrition is essential for the body, its growth, health, maintenance and reproduction. Adequate food supply ultimately determines the nutritional status of an individual as well as the society in which he lives. Malnutrition adversely affects health, damages the supply of energy to the body and disrupts countless chemical reactions in the body. Nutrition is composed of energy factors such as calories, carbohydrates, proteins, fats and vitamins. Any imbalance or starvation in the supply, quality and quantity of these results in malnutrition and deficiency, often causing irreversible or permanent disabilities, visual impairment and mental retardation.
In recent years there has been a significant drop in the population below poverty line (56.8 per cent in 1960 to 29.0 per cent in 1987), but about 250 million out of 930 million still suffer from varying degrees of malnutrition in India.

According to the National Nutrition Policy, published in 1993 by the Department of Women and Child Development, Government of India, 43.8 per cent children were estimated to suffer from severe malnutrition in 1989-90, although there had been a decline during 1975-90 of 3.75 per cent in moderate malnutrition and 6.3 per cent in severe malnutrition.

Combating malnutrition has been one of the objectives of the Indian Government and along with overall rise in food production and reduction in poverty level in the country, specific interventions have been planned and implemented.
One such major step is the scheme of Integrated Child Development Services (ICDS) which has supplementary nutrition as its main component. ICDS had covered nearly 3000 blocks - roughly 60 per cent of the country by end of 1992-93. The Beneficiaries of this programme are children below six years of age, pregnant and lactating mothers and women in 15-44 age-groups.

Some other programmes to tackle the problem of malnutrition are Special Nutrition Programme, Balwadi Nutrition Programme, Wheat-based Supplementary Nutrition Programme and Mid-day Meals Programmes in certain States. International agencies such as Care-International and USAID also have programmes to tackle this problem.

The deficiency of vitamin A and protein energy malnutrition are major causes of childhood blindness. A Prophylaxis Programme Against Blindness due to Vitamin A deficiency was started by the Government in 1970. Under this programme children in 1-5 age-group are given an oral dose of 0.2 million IU of vitamin A in oil, every six months. The programme covers 30 million out of 80 million children in the target group. Over the years significant reduction in childhood blindness has been reported. Effective implementation of the programme continues.

In order to strengthen the thrust the Government of India have now adopted a National Nutrition Policy to cover the multiple aspects of nutritional programmes. Under the policy, National Nutrition Council and an Inter-ministerial Coordination Committee have been set up. Linkages between the food policy, the agricultural policy, the health policy, the education policy, the rural development programmes and the nutrition policy are established to effectively tackle the problems of malnutrition.

Ante-natal, Natal and Post-natal Causes
The 7th Plan had provided for a trained birth attendant for every 1000 population in 5,800,000 villages in India, and thus trained 5.8 lakh dais in the country (M.R. in India, A Contemporary Scene, NIMH). Low birth weight increases the risk of hazards in development for infants and children. One third of the babies born in India are of low birth weight. Early marriage, frequent pregnancies, poor nutrition and illiteracy are a few of the contributing factors. This vicious cycle, created by such factors results in harmful affects in adulthood and also in the next generation. Most government hospitals have post partum centres, yet women deliver their babies with the help of untrained dais. Many do not receive immunisation and ante/pre/post natal care. In Rajasthan, 67 per cent of mothers did not receive any ante–natal care either at home or outside. (National Family Health Survey).

Safe motherhood can prevent a number of disabilities, such as vision impairment, cerebral palsy, mental retardation and hearing impairment. There is a programme to provide iron and folic acid to the pregnant mothers. Although there is a programme of providing a trained mid-wife for every 5000 population, due to the inadequacy of training and lack of confidence of the people in the trained dais most of the deliveries in rural areas are still attended by traditional dais, who, by and large, do a good job but are unable to take care of the complications, if and when they arise. The Government of India has taken up a programme of Social Safety Net Scheme, with the assistance from the World Bank, under which, facilities at the Primary Health Centres will be upgraded in 90 ‘weak’ districts in the country. These facilities would include labour rooms, equipments, trained staff, regular water, electricity availability and facilities for education and information. The mothers would be encouraged with institutional deliveries and safe motherhood. The scheme has been taken up from 1992-93. The scheme is well-intentioned, no doubt. The results, however, are yet to be seen with the coverage not being universal.

Efforts Aimed at Prevention
According to WHO, the main causes of disability in India are INFECTION, NEGLECT and IGNORANCE. Among the underlying causes are low socio-economic conditions, inadequate health care and nutrition.

It is estimated that in the urban slums, 15 million children live in conditions of acute deprivation with inadequate access to basic health care, nutrition and safe drinking water (National Institute of Urban Affairs). Millions are affected by tetanus and have been disabled due to preventable causes and nutritional deficiencies, polio and acute respiratory infections. Present studies reveal differences in the disability prevalence rates between urban and rural areas with greater disparities for those disabilities which are nutrition related (55 per cent visual disability and 42 per cent for hearing disability).

The first National Family Health Survey conducted by the Ministry of Health and Family Welfare presented a dismal picture of malnutrition. Over 50 per cent of children under the age of 5 in several States had severe malnourishment. Only Kerala had shown malnutrition levels for children under five as less than 30 per cent. The survey had also revealed that the health objectives for women and children have not been achieved.

Immunisation
India has one seventh of the world’s population and one third of the disabled population of the world. Diseases which should have been eradicated by effective and total immunisation are still crippling or killing a large number of children. To note an example, a study of 15 class A, B and C cities in Rajasthan revealed that the percentage of fully immunised children in Jaipur, Jodhpur and Kota was only 21 per cent. Fully immunised children at two years of age were below 50 per cent in A, 60 per cent in B and 53 per cent in C towns. The coverage was better in smaller towns than in the larger cities.

The cold chain required by the live vaccine from the point of manufacture to the ultimate user-child, often becomes ineffective, particularly in rural areas when the cold chain breaks down and polio cases emerge even after vaccination (S.S. Varma). Between 3-5 lakh children are affected by polio every year. Government data shows 14,000 new cases in 1989 (National Covention).
The National Pusle Polio initiative launched in 1994 is an effort to prevent further incidence of it and is being implemented countrywide. The aim is to ensure that every child is given two doses of polio vaccine within the specified period.

Vitamin A
Despite the focus of preventive measures of the maternal and child health programmes, during past quarter of a century on Vitamin A, about 15,000 children go blind each year due to its deficiency (National Covention). The National Nutrition Monitoring Bureau has reported that prevalence of vitamin A deficiency in pre-school children is over 10 per cent in many states. The overall achievement of Vitamin A prophylaxis is 78.4 per cent. Vitamin A deficiency is also linked to child mortality and morbidity. Studies have shown that the mortality rate increases four times in children even with mild signs of Vitamin A deficiency. Complications due to measles, incidence of diarrhoea and respiratory diseases are also higher. Infections become more severe. Most of such ill-effects are because of the faulty distribution and monitoring system. Most children who suffer from Vitamin A Deficiency belong to the less privileged socio-economic groups. Specially affected are the urban poor because of non-availability of Vitamin A rich foods as they are seasonal as well outside their purchasing power. Vitamin A deficiency is also precipitated by a range of infections and illnesses including diarrhoea.

Integrated Child Development Services (ICDS)
The ICDS programme through an integrated package of services was instituted in response to the need to break the vicious cycle of malnutrition, disease/infection, resultant disability and mortality in the crucial early years of an infant’s life. In 20 years in the service of the pre-school child and the mother, the ICDS programme reached out to 3.8 million expectant and nursing mothers and adolescent girls, 17.8 million children (under 6) through nearly 300,000 anganwadi centres. Of these 10.2 million children (3-6 age-group) participated in centre based pre-school education activities.

The ICDS network consists of 3907 projects, covering nearly 70 per cent of the country’s community development blocks and 260 urban slum pockets. The population coverage through the anganwadi is approximately 1,000 in rural and urban areas and 700 in the tribal belts (Department of Women and Child, HRD Ministry).

The current focus of the ICDS is on reducing malnutrition in the young child, using immunisation contact points and mobilisation of women’s community groups, promoting complementary feeding and Oral Rehydration Therapy, thus ensuring the child’s right to healthy development.

Inspite of the conviction of the policy and the planners, children with disabilities remain marginalised in the ICDS programme and its activities. A sizeable number of children often remain undetected in the early stages. Possibilities of prevention/detection recede further when they are not taken to the health centres for immunisation. There is very little co-ordination between health and ICDS functionaries leading to sporadic efforts at immunisation, health check–ups or educational activities.

There is no integration in the anganwadis and the disabled children grow up in an environment indifferent to their real needs. The anganwadi worker has limited understanding, skill and knowledge in arranging pre-school activities and her limited sensitivity is unable to integrate the disabled children in the pre-school programme. Due to its reliance on voluntary efforts, ICDS has been able to keep down its implementational costs but the low honorarium paid to the anganwadi workers is a major impediment to sustaining motivation. They feel overburdened with responsibilities and tend to concentrate on services that are more closely monitored, such as supplementary nutrition distribution, immunisation, etc. A recent study of the National Institute of Nutrition indicated that 40-50 per cent of anganwadi workers in Andhra Pradesh could not distinguish backward children from normal with respect to their psychological development.

In the three month training of anganwadi workers, only two days are alloted to orientation on symptoms of disability, suitable play activities, availability of aids and appliances for them. However, the present arrangements of training remains localized to the areas which are serviced by the 11 institutes that handle such training. Disability training has been introduced into the second phase of the three phase sandwich programme. Bringing adolescent girls into the ambit of the service delivery system ensure that the prospective mothers are nutritonally sustained to deliver healthy babies, have learned appropriate mother-care skills and knowledge to meet the nurture needs to prevent disability (Samadhan News, April-June, 1995).

Delivery of Services
India has built up an impressive infrastructure of primary health care in terms of a network of health centres, hospitals and trained personnel. Sadly, the Primary Health Centres (PHCs) are in a deplorable state, a majority of them without essential medicines and trained staff (Minister for Health, Mr. A. R. Antulay).

The emphasis is on infrastructure development rather than on quality services. Even in urban areas where hospitals and health centres are within easier reach than in the rural areas, the basic health care is not provided as was indicated by the recent outbreak of plague and dengue epidemics in several cities.

The health system continues to emphasise the curative rather than the preventive measures. The hospitals are ill equipped to deal with the multifaceted problems of disability. Rehabilitation services are confined to medical aspects in the district hospitals. There is a shortage of E.N.T. experts and speech pathologists, and no genetic counseling or referral services are provided (S.S. Varma).

Family Welfare centres and health posts to improve the outreach of primary health care at all government hospitals, recommended by the Krishnan Committee, are not enough to cope with the growing needs of the rising population. In the urban areas, only 1,291 family welfare centres and 936 health posts in 10 States exist (Ministry of Health and Family Welfare).

There is an urgent need for the convergence of services through co-ordinated efforts of the different agencies involved. The 73rd and 74th Amendment Act, places on decentralised elected bodies, with representation from the community, the responsibility to prepare development plans, and to deal with related subjects such as health, social welfare, child development and women. This procedure should benefit disabled children as well. However, operational mechanisms need to be developed to evolve a system of effective co-ordination and the convergence of services between the Ministries of Health, Education and Welfare.

The Government of India is making efforts to improve the situation and to provide better services to the disabled through a range of programmes/actions/schemes. The India Population Projects in four metropolitan cities aim to strengthen basic health care services to women and children by establishing functional linkages with other government programmes such as the ICDS. The formulation of a National Rehabilitation Programme called for greater involvement of NGOs in the screening, detection, assessment, training, management and care, vocational training and job placement of people with disabilities, trained rehabilitation workers attached with the primary health centres.