9th Five Year Plan (Vol-2)

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Human and Social Development
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Health Manpower Production

3.4.55 The changes in medical, dental and nursing personnel over the last five decade are given in Fig-1. The Eighth Plan clearly stated that "the existing facilities for training of medical graduates has outstepped the needs. No new medical college or an increase in the admission capacity of the existing colleges will be supported during the Eighth Plan". The Indian Medical Council Act was amended in 1993. According to this amendment "no person shall establish a medical college and no medical college shall open a new or a higher course of study or training including a post graduate course of study or training or increase in its admission capacity in any course of study or training, without the prior permission of the Central Government". The Central Government after due clearance from the Medical Council of India may grant permission for establishment of new Medical Colleges if there was a requirement for manpower in the field of practice of medicine and if other conditions specified in the enabling provisions of the Act are fulfilled. A strict compliance of these provisions is called for.

3.4.56 The current stock of medical, dental, nursing and para-professionals in the country and the number of training institutions for each category are given in Table-3.4.5. During the Ninth Plan, no new medical college will be opened nor will there be any expansion in the admission capacity of existing institutions as there are adequate number of doctors in the country. Already, over two third of the doctors are undergoing postgraduate training. Hence there is no need for any addition to existing number of seats in various post graduate institutions, except for identified specialities with unmet manpower needs.

3.4.57 There is an acute shortage of dental manpower in the country. There is a need to ensure that adequate number of dental professionals of appropriate quality is trained. The dental colleges are unevenly distributed in the country. As many as 41 out of 96 dental colleges are in one State. The quality of dental education needs to be reviewed and appropriate remedial measures instituted.

3.4.58 Nursing education and nursing services have been given a high priority in order to bridge the large gap between requirement and availability of nurses and ensure quality of nursing training. These efforts will be continued during the Ninth Plan. In addition, efforts will be made to meet the increasing demand for nurses with specialised training in speciality and sub-speciality areas intensive medical and surgical care in hospitals and for public health nurses in health care system.

3.4.59 Many programmes are faltering because of lack of critical para-professional manpower. Over the last three decades, there has been an increasing requirement of several categories of para-medical persons such as male multipurpose worker, laboratory technicians, radiographers. Their availability and requirement vary from State to State and from time to time. Till the Eighth Plan the medical colleges, dental colleges and nursing training institutions have been the major training institutions for para-professionals. During the Eighth Plan the Open University system and the vocational training courses at 10 + 2 stream have provided two additional mechanisms for education and training of para-medical manpower. During the Ninth Plan the State manpower cells will assess the changing requirements for para-professionals, preferably at the district level and take necessary steps to meet the requirement through all available training channels. The Universities of Health Sciences (UHS) will ensure that appropriate curricula are evolved and followed. The State Governments will make necessary amendments in recruitment rules for these posts so that those who qualify through vocational courses and open university system become eligible for the jobs in Government, voluntary and private sectors. The feasibility of introducing pre-vocational courses at the 9th and 10th standards will be explored.

Bio-Informatics, Telematics and Distance Education

3.4.60 As early as 1986-87, the Expert Committee on Health Manpower Planning, Production and Management (Bajaj Committee) recommended: "for an effective support to the health manpower management, information system is vital for managerial efficiency.

Ninth Plan priorities for Human Resources Development for Health include:

  • Creation of a district data base on requirement, demand and availability for health manpower in the Govt., Private and voluntary sectors
  • Periodic updating of information on:
    • Requirement of different categories of health manpower
    • Availability of health manpower
  • Health manpower production based on the needs
  • Improvement in quality of undergraduate/ postgraduate education
  • Efforts to promote appropriate health manpower distribution
  • Continuing medical education for skill upgradation and appropriate people and programme orientation
  • Continuing multiprofessional education for promoting team work and intersectoral co-ordination

The health manpower information should encompass all the components of the health manpower management. The Committee recommends development of national health manpower information system as an important support to the health manpower development strategies." While recommending the establishment of Universities of Health Sciences, it was further emphasized that "it is entirely likely that several new faculties will grow in the University of Health Sciences: It is expected that a faculty of health information systems shall also be established in the Health Science Universities".

3.4.61 In spite of these far reaching recommendations, necessary action plans have yet to the concretised. Information Technology (IT) is now becoming one of the major components of the technological infrastructure for health management. All sub-sectors dealing with the generation, transmission and utilisation of demographic and epidemiological data such as bio-informatics, bio-statistics, health management information system (HMIS) and decision support systems (DSS) are finding increasing use in health planning and management. With the nation-wide network, NICNET, under the Planning Commission, giving health information support through its MEDLARS, Bio Medical Informatics Programme and Tele-Medicine Programme, a viable nucleus has already been set up which will be enhanced during the Plan period to cover all the Primary Health Centres and district hospitals. MEDNET, when operational, may become a major tool of continuing multiprofessional education and distance learning. Policy initiatives shall be undertaken during the Ninth Plan with the aim of developing clinical leadership, deciding which applications are to be supported, providing the appropriate technology, gaining clinician acceptance, setting up in Universities of Health Sciences one or more clinician-driven academic unit(s) and network(s) that are multidisciplinary and multisite to provide support for new and existing biomedical applications.

Health Manpower Information System

3.4.62 At the moment only infrastructure and manpower at the primary health care institutions are monitored and information periodically updated. There is no mechanism for obtaining and analysing information on health care infrastructure and manpower in private and voluntary sectors in the district. Unless this information is available it will not be possible to undertake any effective area-specific microplanning so that the health manpower required to meet the local health needs of the population is provided. This exercise becomes even more important in the current context when the population is undergoing a demographic, health and economic transition and there are marked differences in the health profile between States and districts. There is also the need for aggregating this data at the State and Central level so that appropriate policy and programme initiatives can be undertaken and adequate resources allocated.

3.4.63 During the Ninth Plan, attempts will be made to create a district data base on health manpower belonging to various categories (including the ISM and H practitioners) working in Central and State Government, voluntary, private sectors, defense services and Railways and public sector undertakings. The District Manpower Cell will assess district manpower requirement and availability and assist the State in manpower planning at district level. District-based manpower profile data will be updated at least once a year. Health manpower planning exercise at district, State and regional level by the University of Health Sciences will be carried out utilising this data and the information on the health care needs of the population and health facilities available. The Education Commission for Health Sciences (ECHS) will act as the nodal agency for the exercise at the national level.

3.4.64 The Health Manpower Planning,Production and Management Committee in 1987 recommended that the ECHS must be established as a central organisation on the lines of UGC for professional and para-professional education in health sciences, inter alia to provide realistic projection for national health manpower requirement and suitable mechanism to continuously review the projections based on felt needs. During the Ninth Plan period, the ECHS will promote all educational activities for all categories of health manpower at all levels. The UHS will develop newer faculties such as health management, health economics, social and behavioural sciences. UHS will also initiate necessary steps to enhance computer literacy among medical students and expose them to emerging technologies of informatics and telematics which are likely to be the base and basis for 21st century mode of communication through telemedicine and distance learning by open learning system in medicine and health sciences. Health manpower cells in the States will coordinate collection of data on manpower at district level and implement the recommendations of UHS for health manpower production.

Quality of Education in Health Sciences

3.4.65 One of the important reasons for the sub-optimal performance of health care institutions is the poor quality and inappropriateness of the education and training of health care providers, resulting in a lack of problem-solving competencies and skills. During the Ninth Plan period, appropriate changes in syllabi, curricula, teaching methods and assessment system will be made through various professional Councils to improve the undergraduate and post-graduate training so that the medical and dental graduates as well as allied health professionals acquire necessary technical knowledge and managerial skills to solve health problems and implement ongoing major national health and family welfare programmes within the existing constraints.

3.4.66 Medical colleges are periodically inspected by the Medical Council of India (MCI) regarding both the physical facilities and training process. During the Ninth Plan, inspection by the MCI will be not only for initial recognition but also for continued recognition as medical colleges and admissions will not be permitted unless the college is recognised. Attempts will be made to reorient education in health sciences so that the health care system becomes more efficient and effective. The existing professional Councils and any other Council which may be established in the future, will be responsible for ensuring the quality of medical and para-medical education, training and ethics of conduct and practices as per the statutory requirements.

Continuing education for health professionals

3.4.67 In the context of the rapidly evolving technology, demographic transition, changing lifestyles and disease patterns it is imperative that the process of continuing education is internalised throughout the working career of all health professionals so that their knowledge and skills are updated. Currently, in-service training courses in various institutions, thematic CME programmes conducted by National Academy of Medical Sciences, National Board of Examinations, and various professional bodies and associations have played a major role in CME. All these programmes will be expanded and intensified during the Ninth Plan. In addition, Open Universities will play a major role in periodically updating the skills and knowledge of various categories of health personnel. The Open University mechanism can efficiently and cost effectively provide specific training programmes where there is a major component of didactic learning eg. epidemiology, hospital administration and health management. It is also likely to be one of the most effective, efficient and cost-effective method of CME involving practitioners in Government, private and voluntary sectors and hence requires increased utilisation.

3.4.68 During the Ninth Plan, a major programme of multi-professional and inter-professional education will be initiated for training the members of health care delivery team, so as to enable them to accomplish group tasks in providing health care in the community. At the national level there will be training of the trainers in newer technologies, national programmes on emerging diseases and their management. At the State level there will be a similar training of personnel with special reference to the State's requirement. At the district level two types of training programmes have to be undertaken: 1) the multi- professional health team training in delivery of integrated health and family welfare service at the primary health care level; and 2) the training of the multi-professional team for the delivery of evolving programmes eg. the delivery of RCH care programme.

3.4.69 In addition, there will be training of the health professionals working in the government, voluntary and the private sectors together as a team to tackle the identified health problems in the district. Inter-sectoral training of personnel from related sectors e.g., nutrition, agriculture , water resource management and environmental sanitation will be undertaken as and when necessary.

Operational strategy for the Ninth Plan

  1. Attempts will have to be made to create a district data base on health manpower belonging to various categories including ISM and H practitioners working for Govt., voluntary and private sectors. Based on the availability, need and demand appropriate policy and programme initiatives for manpower development have to be made at State/district level.
  2. Improvement in quality of pre-service and in-service training for medical and paramedical personnel.
  3. Periodic updating of knowledge/skill for all categories of health manpower throughout their working careers so that they are able to provide appropriate quality of health care is essential. In addition to available training programmes increasing use may have to be made of the distance learning.

Control of Communicable Diseases

3.4.70 At the time of independence commu- nicable diseases were the major cause of morbidity and mortality in the country. Efforts were therefore initially directed towards their prevention and control. Small pox, a major killer in pre-Independence era has been eradicated. In 1953, malaria affected over 75 million and killed 0.8 million people.

Strategies to improve performance of Disease Control Programmes during Ninth Plan:

  • Rectify identified defects in design and delivery
  • Fill critical gaps in infrastructure and manpower
  • Make service delivery responsive to user needs
  • Ensure skill upgradation, supplies, and referral services
  • Improve community awareness, participation and effective utilisation of available services

The National Malaria Control Programme, which was launched in 1953, successfully brought down the incidence of malaria to 0.1 million cases with no death by 1965. Subsequently, there has been a resurgence of malaria. The Modified Plan of Operation has, however, succeeded in keeping morbidity and mortality at relatively low levels. The use of antibiotics has resulted in a substantial reduction in deaths due to common infections. Effective therapy for infections and vaccines for prevention of infection were the major factors responsible for the steep fall in crude death rate from 25.1 in 1951 to 8.9 in 1996. However, the morbidity due to communicable diseases continues to be high. Deteriorating urban and rural sanitation, poor liquid and solid waste management and overcrowding have resulted in an increasing prevalence of common communicable diseases. The re-emergence of diseases like Kala Azar, and emergence of new infections like HIV have added to the existing disease burden due to communicable diseases. Control of communicable diseases is becoming more difficult because of emergence of drug-resistant pathogens and development of insecticide-resistant vectors.

3.4.71 Even though health is a State subject, the Central Government has over the last forty years provided additional funds through Centrally Sponsored Schemes (CSS) for control of some of the major communicable diseases. Of these, the National Leprosy Eradication Programme is likely to achieve its objective of reduction in leprosy prevalence to below 1 per 10000 by the end of the Ninth Plan. However, malaria, tuberculosis and HIV infection require vigorous and intensified efforts for their containment and control.

3.4.72 The performance in, and shortcomings of, these National Programmes have been evaluated during the Eighth Plan period by Expert Committees. Accordingly, following remedial measures will be taken during the Ninth Plan period to:

  1. rectify the identified defects in the design and delivery of these programmes;
  2. fill the critical gaps in infrastructure and manpower;
  3. improve the operational efficiency and the quality of services;
  4. make service delivery system more responsive to users needs;
  5. ensure that health care providers have the necessary skills and support, including referral facilities and supplies they need;
  6. improve the community awareness of the existing services through IEC efforts so that there is optimal utilisation of available services.

3.4.73 External assistance has been obtained to augment available funds for implementing these programmes. These National Programmes will continue as CSS during the Ninth Plan period.

New initiatives during the Ninth Plan

Horizontal Integration of Vertical Programmes:

3.4.74 Initially, when sufficient infrastructure and manpower were not available for management of major health problems, several vertical programmes eg. National Malaria Eradication Programme (NMEP), National Leprosy Eradication Programme (NLEP) were initiated. Subsequently, over the years a three-tier health care infrastructure has been established. During the Ninth Plan period, efforts will be made to integrate the existing vertical programmes at district level and ensure that primary health care institutions will provide comprehensive health and family welfare services to the population.

3.4.75 In order to assist the PHC/ CHCs officers to effectively implement such a horizontal integration, the middle level public health programme managers who are currently heading the vertical programmes at district level will be given the additional task of ensuring coordination and implementation of integrated Health and Family Welfare Programme at Primary Health Care institutions in defined blocks. Involvement of the public health specialists at the subdistrict level will also improve data collection, reporting, strengthening HMIS, improving the supply of essential drugs/devices for all programmes at PHCs/CHCs and enabling operationalisation of the disease surveillance and response at district level.

Disease Surveillance and Response

3.4.76 Given the existing conditions of poor environmental sanitation and the weakness of the public health system it may not be possible to completely prevent outbreaks of communicable diseases in the near future. Delays in recognition and reporting of focal outbreaks, absence of functioning HMIS and disease surveillance system result in delays in implementation of appropriate response and consequent high morbidity and even mortality. The Expert Committee on Public Health System chaired by Member (Health), Planning Commission recommended the establishment of an epidemiological surveillance system. During the Ninth Plan, establishment of a functioning system for early detection and prompt response for rapid containment and control of the disease outbreak will receive high priority. Disease surveillance and response will be at district level to ensure prompt, effective, efficient remedial action utilising the existing infrastructure. This system will be given the necessary back-up, laboratory and epidemiological support so that containment measures are based on sound data and scientific rationale. This back-up system will be evolved by strengthening and optimal utilisation of the facilities and expertise available in the national institutions/medical colleges.

3.4.77 The regulations governing notification of diseases vary widely between States. There is an urgent need to develop a uniform regulation for notification of diseases in all States. The diseases that are to be covered under the notification system should consider adequately the problems of new, emerging and re-emerging infections so that appropriate response could be generated to tackle the situation.

Hospital Infection Control and Waste Management

3.4.78 Increasing incidence of hospital-acquired infections and accidental infection in health care providers and waste disposers, renders it imperative that efforts are made to improve infection control and waste management through utilisation of appropriate, affordable technology at all levels of health care. During the Ninth Plan period, infection control and waste management in all health care institutions will receive due attention and adequate funding.

National Malaria Eradication Programme (NMEP)

3.4.79 In the early fifties, malaria was not only a major cause of morbidity and mortality in the country but also one of the constraints for ongoing developmental efforts. Illness due to malaria was a major cause of absenteeism in agricultural and industrial labour and in irrigation and construction workers in the fifties. The National Malaria Control Programme, the first of the Health Sector CSS, aimed at reduction of the morbidity and mortality due to malaria, was launched in 1953. It is noteworthy that even though there was no well established health infrastructure in rural areas, the number of cases came down from 70 million in 1950 to 0.1 million by 1965. However, subsequently, there was a resurgence of malaria. In 1976 over 6.7 million cases were reported. From 1977, the NMEP started implementing a Modified Plan of Operations for control of malaria. After the initial success the number of cases have remained at over 2 million (Fig-2).

3.4.80 Initially, malaria in India was mainly a rural disease. Subsequently, due to major ecological changes five more eco-types have been recognised viz., forest and forest fringe malaria; rural malaria; urban malaria; industrial malaria; border malaria and migration malaria.

3.4.81 The North Eastern (NE) States have high incidence of P.falciparum malaria. High morbidity, mortality due to malaria and emerging problem of drug resistance are reported. A major initiative during the Eighth Plan (1994) was to provide 100% Central Assistance for NMEP in NE States so that financial constraints do not come in the way of effective implementation of the NMEP. The performance of NMEP during the Eighth Plan period is indicated in Table-3.4.6. There has been an increase in the number of cases of malaria reported during the Eighth Plan period. The proportion of Pf infection has increased to 40 per cent. Many of the fever patients are not screened, diagnosed and effectively treated primarily because of lack of male multipurpose worker and laboratory technicians. Not all the diagnosed cases are reported to the programme authorities. Residual insecticide spraying is often not done at appropriate time. Community involvement in spray operations and the bioenvironmental measures for control of mosquito breeding are poor. Some of the vectors of malaria have developed resistance to one, two or three of the currently used insecticides.

3.4.82 There is an urgent need to intensify the malaria control activities during the Ninth Plan period especially in the States which had been reporting large number of malaria cases (Fig-3). The NMEP has, therefore, drawn up a programme for intensive and effective implementation of the Modified Plan of Operation (MPO) in malariogenic areas in the country during the Ninth Plan. Financial assistance has been procured from the World Bank for augmenting domestic funds available for implementation of the programme.

3.4.83 The criteria for selecting the areas for intensive implementation of MPO during the Ninth Plan are:

Modified Plan of operation for NMEP during the Ninth Plan

Intensification of control activities in areas with:

  • API of > 2 in the last three years
  • Pf rate of > 30%
  • Reported deaths due to malaria
  • > 25% of the population is tribal

Components of the Modified Plan of Operation

  • Early diagnosis and prompt treatment
  • Selective vector control and personal protection
  • Prediction , early detection and effective response to out breaks
  • IEC

Targets for 2002

  • ABER of over 10%
  • API <0.5%
  • 25% reduction in morbidity and mortality due to malaria
  1. annual parasite incidence of more than 2 for the last 3 years;
  2. Pf. rate of more than 30%; deaths due the malaria reported
  3. tribals form more than 25% of the population.

3.4.84 The areas identified on the basis of these criteria are the 7 North Eastern States and 100 districts spread over the States of Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa and Rajasthan.

3.4.85 The ongoing programme with 100 percent Central assistance in the seven North-Eastern States will be continued during the Ninth Plan. Additional inputs will be provided to the 100 hardcore and tribal districts identified on the basis of the above criteria. Enhanced malaria control programme will also be implemented in 19 cities/ towns which have rising slide-positivity rate and in areas where there have been focal outbreaks of malaria in the previous year.

The main components of MPO that will be strengthened in these areas are:

  1. early diagnosis and prompt treatment, through strengthening of active and passive surveillance and laboratory diagnosis;
  2. selective vector control by integrating various vector control approaches and, promotion of personal protection methods;
  3. prediction, early detection and effective response to malaria outbreaks;
  4. intensified information, education and communication campaign.

3.4.86 In spite of the reported increase in drug resistance, Chloroquin will remain the first line drug for presumptive treatment and Primaquine will be given for radical treatment. Sulpha pyrimethamine drug combination will remain as the second line of treatment especially for Pf cases in areas where drug resistance is reported and selective use of quinine will continue for treatment of severe and complicated malaria.

3.4.87 The village will be the unit for residual insecticide spray operations. DDT will continue to be the insecticide of choice in areas where vector is sensitive because of its efficacy and cost effectiveness. In areas where DDT is ineffective, Malathion may be used. Synthetic pyrethroids will be used only in areas where triple insecticide resistance is reported. Personal protection through use of insecticide impregnated bed nets will be advocated. In urban areas stringent measures to prevent stagnation of water, ensure covering of overhead tanks and drains and enforcing periodic cleaning will be attempted.

3.4.88 With effective implementation of the Programme, it is expected that by the end of the Ninth Plan the following targets will be achieved in malariogenic areas: 1. ABER of over 10%; 2. API less than 0.5% and 3. 25% reduction in morbidity and mortality due to malaria.


3.4.89 Available data indicates that Kala-azar is endemic in 36 districts in Bihar and 10 districts in West Bengal (population 75 million). Periodic outbreaks of Kala-azar with increase in morbidity and mortality continue to occur in these States. Over 90% of the reported cases and over 95% of the reported deaths are from Bihar. Over two third of the cases in Bihar are reported from 7 districts.

3.4.90 The Government of India is implementing a CSS for control of Kala-azar in Bihar and West Bengal. Following reported increase in the number of cases and deaths due to Kala azar in 1989-91, an intensive programme for containment of Kala-azar was launched in 1992.

3.4.91 The strategy for control of infection includes interruption of transmission through insecticidal spraying with DDT and early diagnosis and treatment of Kala-azar cases. The Government of India is providing insecticides and anti Kala-azar drugs. The State Governments meet the expenses involved in the diagnosis and treatment and insecticide spraying operations.

3.4.92 Effective implementation of the programme resulted in a decline in both Kala-azar cases and deaths during 1993-95. However, there were delays and inadequacy of the insecticidal spray operations during 1995-96 and the decline could not be maintained (Table-3.4.7).

3.4.93 During the Ninth Plan, the focus will be on ensuring effective implementation of the programme so as to prevent outbreaks and eventually to control infection. DDT will continue to be the mainstay for insecticide spray as the vector (Phlebotomus argentipes) is still susceptible to DDT.

Other Vector-borne Diseases


3.4.94 Filariasis is endemic in Southern, Eastern, Western and Central Indian States. It is estimated that about 428 million (113 urban, 315 rural) people are living in areas where filariasis is endemic. Reports from 13 States and UTs covering about 48 million population indicate that annually 6 million persons suffer from acute lymphangitis due to filariasis. Chemotherapy and vector control measures have succeeded in reducing microfilaria rate and disease rate in 94% of towns where control programmes have been in operation for more than 5 years.

3.4.95 During the Ninth Plan, the strategy for filariasis control would include:

  1. single dose DEC mass therapy once a year in identified 13 districts and selective DEC treatment in filariasis endemic areas;
  2. continuation of vector control measures;
  3. detection and treatment of microfilaria carriers, treatment of acute and chronic filariasis;
  4. IEC for ensuring community awareness and participation in vector control as well as personal protection measures.


3.4.96 Dengue outbreaks have been reported from urban areas from all States. All the four types of dengue virus exist in India. The vector Aedes Aegypti breeds in peridomestic fresh water collections and is found in both urban and rural areas. Analysis of available data from 54 dengue outbreaks between 1954 and 1995 indicate that:

  1. dengue outbreaks occur both in urban and rural areas; and
  2. over the years there has been an increase in reported cases of dengue, dengue haemorrhagic fever and dengue shock syndrome.

3.4.97 Diagnostic tests for dengue virus are not readily available in most parts of the country. At present, there is no mechanism for monitoring and surveillance for dengue. During the Ninth Plan efforts will be made to:

  1. establish an organised system of surveillance and monitoring;
  2. strengthen facilities for early diagnosis and prompt treatment;
  3. intensify IEC efforts to ensure that all households implement peridomestic measures to reduce breeding of Aedes.

Japanese Encephalitis

3.4.98 Japanese Encephalitis (JE) has been reported in the country since mid fifties. With increasing development of irrigation projects and changing pattern of water resource management there has been a progressive increase in number of States reporting cases in India. Twelve States/ UTs have reported outbreaks of JE in the last decade and 378 million population is exposed to risk of JE. The NMEP has been implementing the recommendations of the Expert Committee on JE control. However, implementation of the strategies for improving clinical management, vector control, disease surveillance and health education has been sub-optimal in most States. During the Ninth Plan efforts will be made to intensify all these activities.

3.4.99 Efforts to reduce morbidity and mortality due to vector-borne diseases by appropriate vector control measures aimed at reduction of disease transmission and strengthening of facilities for early diagnosis and treatment of cases in primary and secondary care settings will be continued in the Ninth Plan. Information, education and communication (IEC) activities to ensure community awareness and cooperation, in programmes for prevention, early detection and appropriate treatment of vector borne diseases will be intensified.

National Tuberculosis Control Programme (NTCP)

3.4.100 Tuberculosis is a major health problem in India. The aim of the fight against tuberculosis is at individual level to cure disease, to preserve and quickly restore work capacity, to allow the person to be within the family and community and in this way to maintain their socio-economic status and at the community level, to reduce the risk of tuberculosis infection through case finding and their appropriate management and care. Studies carried out by the Indian Council of Medical Research (ICMR) in the fifties and sixties showed that:

  1. unlike the situation in developed countries, BCG did not protect against adult TB and BCG given at/ soon after birth provided some protection against TB in infancy and early childhood.
  2. domiciliary treatment with anti TB drugs was safe and effective.

3.4.101 A National Tuberculosis Control Programme was initiated in 1962 as a CSS. The programme was aimed at early case detection in symptomatic patients reporting to the health system through sputum microscopy and X-ray and effective domiciliary treatment with standard chemotherapy. BCG vaccination at birth was incorporated into the immunisation programme. The Short Course Chemotherapy (SCC) which shortened the duration of treatment to nine months was begun in selected districts in 1983. Over the years, 293 districts were included for SCC.

3.4.102 During the last three decades, because of low case detection, case holding and cure rates, the Programme has not succeeded in bringing down the disease burden, in spite of availability of effective chemotherapy. Estimates based on available limited data from small-scale epidemiological studies indicate that the prevalence of active disease continues to be 1.4 per cent. It is estimated that there are about 14 million cases of active tuberculosis. Of these 3.5 million are highly infectious sputum positive tuberculosis cases. With the HIV-TB co-infection the incidence of tuber-culosis may increase significantly from the current 1.8 per thousand.

3.4.103 The performance under the NTCP during the Eighth Plan period is given in Table-3.4.8. About 1.5 million TB cases are detected and reported by the programme annually. Of these 25% are sputum positive. It is estimated that about 1.5 million cases are detected and treated by the private sector. Both under-diagnosis (missing sputum positive cases) and over-diagnosis (by X-Ray) occur. Under programme conditions completion of therapy is only 30 per cent. Long duration of treatment schedule (especially conventional therapy), irregular supply of drugs, poor follow-up of patients under treatment, lack of counseling regarding adverse consequences of incomplete therapy are some of the major factors responsible for the low treatment completion rates.

3.4.104 A major review of NTCP was undertaken during the Eighth Plan (1992) to identify inadequacies in the ongoing programmes and suggest remedial measures. A Revised National Tuberculosis Control Programme (RNTCP) was drawn up with the following aims: (1) to improve cure/ completion of therapy rates to 85% by providing drugs for short course chemotherapy (SCC) and strengthening monitoring and supervision of patients under treatment; and (2) to improve case detection to 70% by providing critical personnel and improving their skills through training.

3.4.105 The RNTCP has been pilot tested in 17 project sites (population of 13.85 million) in different parts of the country during the last three years. The cure rates achieved ranged between 60 and 80%. Encouraged by the results achieved in the pilot projects, it was decided to extend the strategy in a phased manner during the Ninth Plan period. Assistance from the World Bank has augmented the resources available for the Programme during the Ninth Plan period when:

Revised National Tuberculosis Control  Programme


  • RNTCP will be implemented in 102 districts
  • NTCP will be strengthened in 203 SCC districts
  • Strengthening of standard regime in remaining non SCC districts
  • Strengthening of Central institutions, State TB Cells and State TB training Institutions

Targets upto 2002

  • Enhance case detection to at least 70% of estimated incidence.
  • Achieve at least 85% cure rate among smear positive cases in 102 RNTCP districts and 60% cure rate in SCC districts.
  • Reduce proportion of smear negative detected to 50% or less of the total cases.
  • Ensure no. of TB suspects tested for smear positives is not less than 2.5% of OPD in PHIs and no. of smear tested is at least 3 per suspected patient.
  • RNTCP will be implemented in 102 districts;
  • NTCP will be strengthened in 203 Short Course Chemotherapy (SCC) districts as a transitional step to adopt the RNTCP;
  • standard regime will be strengthened in the remaining non SCC districts, and
  • the Central Institutions, State TB Cells, and State TB Training Institutions throughout the country will be strengthened.

The targets for the Ninth Plan are:

  1. to enhance case detection to at least 70% of the estimated incidence.
  2. to achieve at least 85% cure rate amongst smear positive patients of Tuberculosis in 102 districts implementing RNTCP and 60% cure rates in 203 SCC districts;
  3. to reduce the proportion of smear negatives detected under the programme to 50% or less of the total cases.
  4. to improve the aggregate smear positivity rate at least to 50%.
  5. to ensure that the number of TB suspects tested for smear examination is not less than 2.5% of the general OPD attendance of the PHIs and number of smears examined is at least 3 per suspected patient.

3.4.106 It is expected that with the implementation of this Programme over the next 5 years (a) the total number of patients cured will increase to 32.55 lakh (compared to estimated 22.89 lakh who will be cured if NTCP in its original form is continued) and (b) 1.8 lakh deaths will be prevented.

National Leprosy Eradication Programme (NLEP):

3.4.107 Leprosy has been a major public health problem in India. In 1984 it was estimated that there were nearly four million cases of leprosy in the country, 15% of which were children. Recognising that leprosy was a major cause of disability and the infected persons face social ostracism, several non-governmental organisations and social service/voluntary agencies had taken up treatment and rehabilitation of leprosy patients right from the pre-Independence period. However, the outreach of these services was very limited.With the availability of Multi Drug Therapy (MDT) it became possible to cure leprosy cases within a relatively short period (6-24 months) of treatment. The National Leprosy Eradication Programme was launched as a 100% Centrally funded CSS in 1983 with the goal of arresting disease transmission and bringing down the prevalence of leprosy to 1/10000 by 2000 AD.

The strategy adopted was:

  1. early detection of leprosy cases through active surveillance by trained health workers;
  2. regular treatment of cases with MDT administered by leprosy workers in endemic district and Mobile Leprosy Treatment Units and Primary Health Care Workers in moderate to low endemic areas/ districts;
  3. intensified health education and public awareness campaigns to remove social stigma attached to the disease.
  4. appropriate medical rehabilitation and leprosy ulcer care services.

3.4.107 The programme was initially taken up in endemic districts and was extended to all districts in the country from 1994 with World Bank assistance. The estimated number of persons requiring treatment for leprosy has declined from four million cases in 1984 to 0.54 million cases in March 1996. More than 6.98 million leprosy patients have been cured by MDT and the proportion of registered patients taking MDT treatment has increased from 10% in 1985 to 96% in 1997. The prevalence rate of leprosy has declined from 57.3 per ten thousand population in 1981 to 5.8 per ten thousand population in 1995. However, the number of new leprosy cases detected each year has remained about 0.45 million. The performance during the Eighth Plan is shown in Table-3.4.9.

3.4.108 The performance during the Eighth Plan has been satisfactory with respect to new case detection and treatment completion but less than optimal with respect to the reduction in total cases mainly due to treatment of backlog of cases. The incidence of the disease has not shown a marked decline. Earlier 50% of cases were in Andhra Pradesh and Tamil Nadu. Now over 50% of the cases requiring treatment are in UP, MP, Bihar and West Bengal. The laboratory support for diagnosis and assessing the success of treatment is sub-optimal. Available information on recurrence, relapse rates and reactions to drug therapy is inadequate. Even though leprosy infection has been cured, the deformities and disabilities associated with leprosy continue to require treatment and these have not been looked after.

3.4.109 During the Ninth Plan the strategy will be:

  1. strengthening laboratory services in PHC/CHC, establishing surveillance system for monitoring time trends in prevalence of the disease throughout the country
  2. accelerating the pace of activities, intensifying case detection and MDT coverage in high prevalence States and areas that are difficult to access;
    Strategies for NLEP during the Ninth Plan
    • Intensifying case detection and MDT coverage in high prevalence States and areas difficult to access
    • Strengthening laboratory services in PHC/CHC, establishing surveillance system for monitoring time trends
    • Preparing for and initiating horizontal integration of leprosy programme into primary health care system
    • Providing greater emphasis on disability prevention and treatment
    • Implementation of Modified Leprosy Elimination campaign
    • Ensuring rehabilitation of cured patients.
    • Repeal of discriminatory provision under marriage act where leprosy is ground for divorce

    Target for Ninth Plan:

    • Reduce prevalence of leprosy to 1/10000.
  3. maintaining activities in the previously highly endemic areas;
  4. preparing for and initiating horizontal integration of the leprosy programme into the primary health care system.
  5. greater emphasis on disability prevention and management through :(a) transfer of knowledge and technology to affected persons, families, community;(b) strengthening local treatment facilities for ulcers/leprosy related deformities; (c) supply of aids and appliances to prevent further impairment; (d) developing trained manpower resources and improving facilities for corrective surgery for deformities
  6. implementation of Modified Leprosy Elimination campaign and bringing mass public awareness, training of general health care staff and detection of hidden cases
  7. ensuring rehabilitation of cured patients.
  8. repeal of discriminatory provision under marriage act where leprosy is one of the grounds of divorce.

The target for the Ninth Plan will be to reduce prevalence of leprosy to 1/10000 by 2002 A.D.

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