|3rd Five Year Plan||
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The broad objective of the health and family planning programmes in the Third Plan is to expand health services, to bring about progressive improvement in the health of the people by ensuring a certain minimum of physical well-being and to create conditions favourable to greater efficiency and productivity. Increased emphasis will be laid on preventive public health services. As in the Second Plan, specific programmes have been formulated for the Third Plan for improvement of environmental sanitation, specially rural and urban water supply. control of communicable diseases, organisation of institutional facilities for providing health services and for the training of medical and health personnel, and provision of services such as maternal and child welfare, health education and nutrition. The Third Plan also accords very high priority to family planning.
2. As against outlays of Rs. 140 and Rs. 225 crores in the First and Second Plans respectively, programmes in the Third Plan involve a total outlay of about Rs. 342 crores, about Rs. 297 crores being in the States and the rest at the Centre. These amounts are distributed undei-difl'erent heads as follows :
Table 1 : Distribution of outlay
Progress And Programmes
3. During the past ten years, substantial progress has been made in various health programmes, and in several directions there have been notable advances. Measures adopted for ihe control of malaria have resulted in marked decline in the incidence of the disease. In 1958, in place of control, the programme of complete eradication of malaria was adopted. In controlling other communicable diseases like filaria, tuberculosis, leprosy and venereal diseases also appreciable progress has been made. The number of hospitals and dispensaries has increased from 8600 in 1950-51 to 12,600 in 1960-61 and of beds from 113,000 to 185,600. A basic type of health organisation providing an integrated preventive and curative service hw been established in 2800 development blocks with a population of about 200 million. At the end of the Second Plan, there were 78 institutions teaching indigenous systems of medicine, their annual intake being 1375. Facilities according to the indigenous systems arc at present available in 98 hospitals and 5372 dispensaries with a total bed strength of 2462. About 664 schemes of urban water supply and drainage entailing a total cost of Rs. 112 crores have been completed or are in progress. In addition to schemes of rural water supply implemented under the programmes for community development, locsil development works and welfare of backward classes, about 228 schemes with an estimated cost of Rs. 20 crores have been taken up under the Hcahh programme.
4. Statistics concerning birth and death rates arc subject to serious limitations, and for the period subsequent to 1951 only rough estimates can be made. Nevertheless, the following Table indicates in broad terms steady improvernent in Ihc health of the population:
Table 2 : Birth rates, death rates and expectation of life1941-61
5. Although there has been considerable development in the field of health and in the related services, at the end of the Second Plan, certain dencicndcs were specially marked. Thus. in relation to needs the institutional facilities were quite inadequate, specially in the rural areas. Doctors were not evenly distributed
HEALTH: FIRST AND SECOND PLAN ACHIEVEMENTS AND THIRD PLAN TARGETS
between urban and rural areas and, as against concentration in many urban areas, in the rural areas generally there were shortages, and the existing institutions did not have their full complement of personnel. Progress in the control of communicable diseases was hampered in several parts of the country on account of shortages of trained personnel and to some extent also of supplies of the equipment. Despite a measure of progress in rural water supply, there were large rural tracts which lacked safe drinking water. In many urban areas problems of drainage have been accentuated on account of the rapid growth of population.
6. The broad aim in the Third Plan will he to remove the shortages and deficiencies mentioned above. A major objective is that, to a-' large an extent as possible, supplies of good drinking water should be available in most villages in the country by the end of the Third Plan. Institutional facilities will be expanded so that medical and health services reach progressively larger numbers of persons, specially in the rural areas. The programme for the eradication of malaria will be completed and efforts will be made to eradicate siLall pox and to control filaria, cholera, tuberculosis, leprosy and other communicable diseases. Drainage programmes will be undertaken on a larger scale in the urban areas.
The specific physical targets proposed for the Third Plan along with statistics of progress in the First and the Second Plans are given in summary form in the Table below :
Table 3: Achievements and targets
@ Number indicates
the number in practice or in service.
Water Supply And Environmental Sanitation
7. Rural water supply.Problems of rural water supply vary from region to region and often within the same region. Rural water supply schemes have been taken up, in the main, under the programmes for community development, local development works and welfare of backward classes. These are supplemented by the national water supply and sanitation programme under Health which deals with the provision of wafer supply to groups of Villages through works requiring a measure of technical skill in design and, construction. The programme gives priority, to areas of great water scarcity and salinity and those in which water-borne diseases are endemic. The expenditure incurred on this scheme during the First .and Second Plans is estimated at about Rs. 33 crores and 11,000 villages were provided with water supply through pipes.
8. surveys to ascertain the present state of rural water supply are being undertaken in a number of States. Where such surveys have not been initiated, it is necessary to arrange for them, so that for every state a correct assessment of the extent of the problem may become available as a basis for detailed programmes to be implemented during the third Plan. To achieve the objective of making supplies of good drinking water available to most villages in the country by the end of the Third Plan. it will be necessary not only to make an intensive effort, but also to ensure that at every stage there is effective corrdination between all agencies concerned in carrying out the programme of rural water supply at the dirstrict and block levels and to mobilise local initiative and contribution to the utmilise local initiative and contribution to the utmost. Experience during the First and second plans has shown that great care is needed in preparing technical designs and estimates of urual water supply schemes and in keepint down their cost.
9. Under different programmes a provision of about Rs. 67 crores is available in the Third Plan for rural water supply. Th;s includes Rs. 35 crores for the Village Water Supply Programme, about Rs. 16 crores under the plans of the States under Health, about Rs. 12 to 13 crores under the community development programme and about Rs. 3 to 4 crores under the programme for the welfare of backward classes. The greater part of the amounts provided for ihe Village Water Supply Programme are intended to be available for (a) backward areas, (b) areas not covered by community development programme, (c) pro-extension blocks, and (d) blocks which have completed their first and second stage in the community development programme. The Village Water Supply Programme is intended primarily to deal with the rural water supply at the village level. As a rule. the ceiling of Rs. 10,000 per village is to be observed. The public contribution is generally expected to be about 50 per cent, but this proportion may be changed and modified in difficult areas or in backward areas. Schemes for groups of villages which involve provision of piped water supply and works of an engineering character are to be catered for by provisions under the Health programme, but for such schemes there could be a part contribution from funds available under the Village Water Supply Programme on the scale of Rs. 10,000 per village. The Village Water Supply Programme is to be undertaken at the block level through Panchayat Samitis and Village Panchayats, the funds being routed through the organisation at the block level. It is proposed that there should be a broadly agreed programme at the local level under which all the provisions available for water supply are effectively utilised. The programme should be based on careful surveys.
10. Along with rural water supply much greater attention should now be given to the programme of rural sanitation specially to the sanitary disposal of excreta in the villages. Problems relating to the proper design and construction of village latrines and the educational and organisational aspects of the programme for their promotion have been recently studied. The broad lines of an action programme in this field may be said to be fairly established. Although, in the beginning progress may be slow, it is important that in each development block an effort should be made to create greater awareness of rural sanitation problems and to introduce the use of sanitary latrines in schools and camps for groups of houses and, where possible, in individual houses. It would facilitate the introduction of latrines if the local sanitary inspectors are trained in casting the latrine sets. With the participation of the local people these latrines can be constructed at a fairly low cost. If this work is undertaken as a block programme it should be possible to achieve substantial results within a foreseeable period. Health education'is of course a most important aspect of the programme of rural sanitation. The advantages and convenience of clean, odourless and cheap latrines arc obvious. They are no less essential for conserving the fertilizer value of human wastes and enriching the soil.
11. Urban water supply.Urban water supply schemes are being executed by municipalities and corporations with loans provided by the Central and State Governments. The following priorities for the selection of areas for urban water supply programmes which were accepted for the Second Plan will also be observed in the Third Plan :
12. Urban water supply and sanitation schemes taken up in the first two Plans were designed to provide safe water supply and drainage facilities to a total urban population of 15 million. Of these, 450 schemes will be completed by the end of the Second Plan and the rest will continue into the Third Plan. Among the important schemes taken up during the First and the Sedond Plans are : Vaitama-cum-Tansa scheme of Bombay, schemes for the improvement of water supply and drainage in the cities of Delhi, Calcutta, Madras, Bangalore, Ahmc-dabad, Kaval Towns of Uttar Pradesh, and Visa-khapatnam in Andhra. In carrying out these programmes there were certain shortfalls. These were mainly due to shortage of trained personnel. inadequate organisation and planning, and lack of materials, particularly, galvanised iron pipes, pump sets and related accessories.
13. As a result of the experience of urban water supply schemes during the Second Plan, three main suggestions may be made. In the first place, urban water supply schemes, specially the larger ones, need to be phased carefully, so that different parts of a project are in the correc't sequence with one another and at each stage certain returns on the outlays incurred are realised. The technical scrutiny of plans and estimates is important if delays arc to be avoided. Secondly, to ensure that the funds available are used to. the best advantage it would be desirable to avoid dispersing them too thinly over a large number of schemes. This implies careful selection of urban water supply schemes on the basis of suitable criteria. Thirdly, once a project is accepted, the municipal body concerned should not only accept responsibility for maintenance but also contribute to the cost of construction to an extent which may be determined by the State Government. There is also need for well-organised Public Health Engineering Departments in all States. These DepartmenTs could ensure adequate coordination between the engineering and health aspects ef various water supply schemes, whether undertaken by the State Governments or by corpora-lions and municipalities. Where this coordination has been lacking, there have been delays in execution and maintenance has been unsatisfactory. Statutory water and sewage boards, empowered to float loans and levy cesses, and set up with the object of undertaking water supply and sewage schemes within their jurisdiction are likely to be helpful in the effective and efficient management of water supply schemes.
14. A sum of Rs. 89 crores has been provided for urban water supply and drainage schemes during the Third Plan period. The number of new schemes that can be taken up against the allocation for urban water supply is necessarily limited. Along with other water supply and drainage schemes to be taken up by the States, the following important schemes will be completed or taken up : water supply and drainage schemes of Madras, Jabalpur, Bangalore, Mangalore, Delhi, Calcutta, Bombay and Kaval Towns of Uttar Pradesh, Visakha-patnam and Manjecra Water Supply schemes of Andhra Pradesh, Ernakulam-Mattancherry and Trivandrum water supply and drainage schemes <»f Kerala.
15. The urgency and importance of providing drainage and sewerage and arranging for safe disposal of sewage in towns and cities need greater attention. These facilities are at present lagging behind the water supply facilities, and it is necessary that schemes of drainage and sewerage are considered simultaneously with those for water supply and are carried out under a coordinated programme. This would insure against the risk of increased breeding of mosquitoes and deterioration in the sanitary conditions of the towns as a result of water supply schemes. It would be desirable to set apart for sewerage schemes, say, 20 to 30 per cent of the estimated cost of water supply projects in cities with a population over 100,000.
Primary Health Units. Hospitals And Dispensaribs
16. By the end of the Second Plan, 2800 primary health units will have been established, covering most of the development blocks. The number of hospitals and dispensaries will increase from 8600 in 1951 to 12,600 in 1961 and during the same period the number of beds will increase from 113,000 to 185,600. The working of primary health units during the Second Plan shows that among factors affecting the progress of this programme were (i) shortage of heaJth personnel, (ii) delays in the construction of buildings and residential quarters for staff and (iii) inadequate training facilities for different categories of staff required for service in rural areas. The need has also been felt for strengthening the primary health units and to possibility of integrating as early as may be feasible services such as those for the control of malaria, tuberculosis, etc., with the normal activities of health units. Among other steps to b» taken to improve the efficiency of primary health units, are the provision of the minimum staff required, organisation of the necessary training facilities and the integration of the activity of primary health units with other health services available in the area.
17. Difficulties have been experienced in securing a sufficient number of doctors. In order to create the necessary climate and conditions for securing personnel for rural areas, I he following measures are suggested :
18. Further, to ensure that the standard of primary health units is maintained and special services are readily made available to them, it is necessary that these units are linked up with referral and district hospitals. Specialised services are at present concentrated in hospitals in the larger cities. To bring these services within easy reach of the population of small towns and villages, it is necessary that the bed strength of district and sub-divisional hospitals is suitably enlarged and X-ray and pathological diagnostic services -s.ad medical, surgical aad obstetrical specialist services are made available. Apart from the increase in hospital beds, out-patient departments should be organised as polyclinics, so that much of the technical equipment may be available and treatment afforded in the outpatient department itself.
19. The overall target for the Third Plan is the establishment of 2000 more hospitals and dispensaries and 54,500 additional beds.
Control of Communicable Diseases
20. Work on the control of communicable diseases, including malaria, filariasis, tuberculosis, smallpox, venereal diseases, leprosy, cholera and goitre will be undertaken on a larger scale in the Third Plan, special emphasis being placed on the eradication of malaria and smallpox. A total expenditure of Rs. 23 crores was incurred on the control of the communicable diseases in the First Plan and of Rs. 64 crores in the Second Plan. The Third Plan programmes entail a total outlay of about Rs. 70 crores.
21. Malaria eradication.Anti-malaria measures undertaken during the first two Plans have resulted in marked decline in the annual incidence of the disease from 75 million cases in 1952-53 to about 10 million cases in 1960-61. The child spleen rate diminished from 7.7 per cent in 1956 to 1.4 per cent in 1960. Similarly. the child parasite rate decreased from 1.8 per cent to 0.2 per cent and infant parasite rate from 0.7 per cent to 0.1 per cent. By the end of the Second Plan, 390 malaria eradication units were in position. Surveillance operations have been introduced simultaneously and, as the Third Plan progresses, these units will be gradually withdrawn and only a few units will be retained, if necessary, particularly in border areas.
22. Fihria control.Filariasis is prevalent mostly in coastal regions. Surveys conducted during the Second Plan have indicated that about 40 million persons are exposed to the infection in endemic areas. The method adopted for its control consists of mass chemotherapy, anti-mosquito measures and anti-larval measures. Filariasis is predominantly an urban problem and the essential effective long-term measure is the improvement of environmental sanitation. The number of control units was increased from 11 in 1956 to 48 in 1961. In the Third Plan, anti-filariasis measures will be continued, but priority will be given to drainage schemes in towns affected by this disease.
23. Smallpox.Smallpox is endemic in India and is a source for the spread of infection to other countries. There has been a decline in morbidity and mortality rates from smallpox due to the vaccination campaigns which have been undertaken, but smallpox cases continue to occur during certain seasons in a year and the disease appears in epidemic form onCe in five or six years.
As smallpox is a preventible disease and as vaccination is a potent weapon for eradicating it, it has been agreed that during the Third Plan an effort should be made to eradicate the disease. Pilot schemes were initiated in all States during 1960-61. The principal items of the programme in the Third Plan would be (1) an increase in the output of vaccine lymph, (2) recruitment and training of vaccinators, and (,3) undertaking mass vaccination to cover the entire population before the next outbreak ot the disease. Action has already been initiated to increase the output of vaccine lymph.
24. Tuberculosis.A sample survey conducted recently under the auspices of the Indian Council of Medical Research has shown that the total number of cases ol pulmonary tuberculosis in the country was roughly 5 million, ot which about 1.5 million might be infectious and that while mortality from tuberculosis is showing signs of decline, the incidence rate has remained more or less the same, both in rural and urban areas. During the Second Plan about 120 million persons were tested under the B.C.G. Vaccination Campaign. The number of tuberculosis clinics was increased from 160 in 1956 to 220 in 1961. Ten T.B. Demonstration and Training Centres were established and the number of beds for tuberculosis patients was increased from 22,000 in 1956 to 26,500 in 1961. A National T.B. Training Institute was established at Bangalore in 1959.
In the Third Plan, the B.C.G. Campaign will be intensified to cover another 100 million persons. The number of clinics will be increased from 220 to 420. In addition, 25 mobile clinics equipped with X-ray for miniature films and the mobile laboratory for collection of specimens and simple examinations will be set up for service in rural areas. Five more Tuberculosis Demonstration and Training Centres will be established. About 3500 more beds for tuber-culasis patients will be added bringing the total number of beds to 30,000 by 1966. Provision has also been made for the setting up of 7 After Care and Rehabilitation Centres.
25. Veneral diseases.The common venereal diseases prevalent in the country are syphi-ils and gonorrhoea and the incidence is fairly high in cities, ports, industrial areas and in some of the sub-Himalayan tracts and is likely to increase with urbanisation and industrialisation. By the end of the Second Plan period 75 district clinics and 8 headquarter clinics were set up. The introduction of effective methods for the rapid diagnosis and treatment of these diseases has made it possible to reduce the reservoir of infection in the population. In the .Third Plan, 100 district clinics and 6 headquarter clinics will be set up and Procain Aluminium Monostearate (PAM) and antigens will be supplied free of cost.
26. Leprosy.There are roughly 2 million persons suffering from leprosy in the country of whom abort 20 to 25 per cent are in the infectious stage. The incidence of disease varies from 0.5 per cent to 5.0 per cent. Leprosy is brought under control by intensive and extensive mas's scale treatment with modem drugs, especially the sulphones. By the end of the Second Plan, 135 Study and Treatment Centres ior leprosy had been set up. About 7 million persons had been surveyed and about 90,000 persons were given domiciliary treatment. The Central Leprosy Teaching and Research Institute at Chingleput has been carrying out research into various problems concerning leprosy and training the leprosy workers. The Leprosy Advisory Committee, set up in 1958, to review the leprosy control schemes has made a number of recommendations for intensifying (he leprosy control work in India such as grant of special allowance, free residential accommodation, improvement in service conditions and centralised training proarammes for workers in this field.
The programme for the control of leprosy during the Third Plan period includes the establishment of 100 more control units and the establishment of survey, education and treatment (SET) centres, besides continuing the existing programmes. A large number of voluntary organisations and social workers in antileprosy work will be associated in this programme. Every hospital and primary health unit in endemic areas would be organised as a nucleus for leprosy control work.
27. Cholera.India has been an endemic area for cholera for a very long period. As has been pointed out by a recent expert committee there are five endemic foci in the deltaic regions of the principal rivers in the States of West Bengal, Orissa, Andhra Pradesh and Madras of which West Bengal and Orissa, are the more erious. To prevent frequent recurrence of cholera epidemics, these endemic foci have to he eliminated. This caa be achieved only by providing adequate supply of safe water for the population, particularly in the endemic areas and by the adoption of modern methods of sewage disposal. As a practical measure attention should first be concentrated on towns and cities where the infection spreads much more easily than in the rural areas with their relatively sparse population. By tar, the largest and most important endemic focus in India is Greater Calcutta which is situated at the very centre of the main endemic area of West Bengal. The existing system for the supply of filtered river water is an old one and has to be considerably extended. Only two-thirds of the city area is at present covered by a sewerage system. Improvement and modernisation of the water s.upplv, sewerage and drainage systems of Greater Calcutta calls for careful planning and urgent action. Water supply and sanitary conditions in the Calcutta area were reviewed recently by a team from the World Health Organisation and various steps have been recently initiated.
28. For the complete eradication of cholera, water supply and sanitation have to be improved much more extensively than has yet been possible under the First and Second Plans. In ihe 7'hird Plan a substantial programme for providing protected water supply is being undertaken. It is suggested that in the States affected by cholera a large part of this programme should be concentrated in the endemic pockets. Specific programmes for these areas should be drawn up speedily and, if necessary, an effort should be made to supplement resources avail-;ihle under the Plan. There is no reason why it should not be possible to reduce the incidence of cholera significantly during the Third Plan ;ind lo eliminate it wholly by the end of the Fourth Plan.
29. Goitre.Goitre is endemic in the sub-Himalayan region. During the Second Plan period the Government of India, in collaboration with the UNICEF established a factory near Sambhar Lake in Rajasthan, to manufacture .'odised/iodatcd salt for distribution in some endemic districts of the Punjab. This factory is capable of producing iodised salt to meet the requirements of a population of 2.7 million, lhat is, about a third of the population at risk. To eliminate goitre completely, the production of iodised salt has to be increased and two more plants need to be installed.
30. Provision has been made in the Third Plan for the treatment and control of trachoma. Facilities for the early diagnosis of cancer and for research in this field will be expanded under the Third Plan.
Medical Education And Research
31. Statistics relating to the expansion of training facilities for medical and para-medical personnel during the first two Plans have been set out in table 3. In the Third P'an, training facilities in medical colleges and attached hospitals will be expanded further and 18 new medical colleges will be established, bringing the total number to 75. Separate Departments will he established in all medical colleges for the study of social and preventive medicine. The development programme of the All India Institute of Medical Sciences will be completed and m several' medical colleges certain departments will be upgraded and facilities for postgraduate training and research will be established.
32. The expansion of training facilities for doctors in the first two Plans has barely kept pace with the growth of population, the population-doctor ratio remaining at 6000 : 1 over the decade 1951-61. This ratio will remain unchanged under the programme for the Third Plan. in formulating which the shortage of feichers in the existing medical colleges has bad to be taken into consideration. Reference has already been made to the shortage of doctors for work in rural areas and to steps necessary for removing this deficiency. A further measure which is recommended is that a new short-term course for the training of "medical assistants" should be instituted at an early date. The trainees should work in primary health units in the rural areas for periods of 3 to 5 years after which they should be given special facilities to obtain the normal medical qualifications and continue in the public service.
33. Postgraduate medical education.With the rapid expansion of medical colleges and the establishment of new colleges, there will be increased demand for teachers. A larger number of students have to be trained in various subjects to the postgraduate level to take up teaching positions in medical colleges. The existing facilities available for postgraduate education arc adequate for an annual average intake of about 750 students and the out-turn may be of the order of 250. It is estimated that there is already a shortage of about 2000 teachers in the existing medical colleges. For the anticipated expansion of these colleges and the establishment of new medical colleges, about 2500 teachers will be needed so that the total requirement of teachers during the Third Plan will be of the order of 4500. A provision of Rs. 3.5 crores has been made in the Third Plan for the expansion of facilities for postgraduate education. This programme has a very high priority and should be completed in the early years of the .Third Plan.
34. Dental education.There are. at present 10 dental colleges with a total annual admission of about 280. During the Third Plan 4 new colleges will be established and some of the existing colleges will be expanded. This will raise the annual admission to 400 per year. Provision has also been made in the Third Plan for the opening of dental clinics and for dental research.
35. Medical research.Research; programmes in the Second Plan were drawn up on the basis of the recommendations of the Indian Council of Medical Research. These include research in communicable diseases, particularly tuberculosis, trachoma, leprosy, cholera and virus diseases, The study of nutritional disorders and diseases received special attention. Studies with- a view to developing methods for preventing pollution of rivers and streams by industrial wastes were carried out. Research on diseases of viral origin has also been undertaken. Programmes for medical research to be carried out in the Third Plan have been described in the Chapter on Scientific and Technological Research. Priority will be given to the study of problems of environmental sanitation and communicable diseases. Special attention will be devoted to training of research workers in different fields in sufficient number. Research on indigenous medicine will be intensified.
Training of Ancillary Personnel
36. Although since the beginning of the First Plan, steps have been taken to expand training facilities for nurses and other ancillary personnel, shortages have continued to be acute. The relevant statistics of the progress made and the targets for the Third Plan are set out in Table 3. The problem is proposed to be dealt with in the Third Plan along the following lines :
37. Public health engineers.In the Third Plan, training facilities are being expanded for public health engineers, subordinate personnel as well as water works operators. In these categories, personnel are required in increasing number on account of the programmes for urban and rural water supply.
The Plan also provides for training of Sanitary inspectors, laboratory technicians, refrac-tionists, opticians and radiographers and for workers in leprosy, venereal diseases and tuberculosis. Facilities for training in health statistics are also being arranged.
38. Pharmacists.The education of pharmacists is regulated under the Pharmacy Act, 1948, which was passed with the object of raising standards of training required for pharmacists who work in hospitals and dispensaries. The replacement of "compounders" who are now commonly employed for dispensing medicines by trained pharmacists will bs necessarily a long-term process. It is, however, important that of the additional personnel required in the Third Plan, estimated at about 6000, as large a proportion as possible should be trained pharmacists. On the present plans there appears to be a gap of about 2000, which can be mads up, in the main, through the further expansion of the existing training institution.
39. In its widest sense health education is the very foundation of a successful public health programme. As was suggested in the First Plan, a great deal of ill health is the result of ignorance of simple rules of hygiene or of indifference to their practical application, and no single measure is likely to give a greater return in proportion to the outlay than health education. To implement the programme of health education, the Central Health Bureau was established in 1956 in the Directorate General of Health Services and several States have also set up such Bureaux. Among the most important aspects of health education are personal hygiene, environmental sanitation, prevention of communicable diseases, nutrition, physical exercise, marriage guidance, pre-natal and post-natal care, maternity and child health, etc. Health education should be undertaken as a national programme and far greater stress should be placed upon it in the work of social education in community development blocks. The Third Plan provides for increase in facilities for training in health education and for demonstration and publicity. Both in urban and rural areas there is considerable scope for orienting the existing health programmes, so as to assure for them a sound base in widespread health education.
40. A beginning with health insurance has been made with the provision of health and medical facilities for industrial workers under the Employees' State Insurance Scheme and for the employees of the Central Government in Delhi under the Contributory Health Service Scheme. In the light of the experience gained, other schemes of this nature should be worked out by the Central and S<ate Governments, so that over a period a comprehensive system of contributory health insurance, which serves a large part of the population, can be established. It is proposed to study further various problems which arise in this connection with a view to evolving phased programmes for implementation.
41. At the end of the Second Plan. 44 million children were at school; in the Third Plan this number will go up by 20 million. About 50 million children of the age group 6-11 will be in school by the end of the Third Plan. Care of the health of such large numbers of children is not only vital in itself, but is a most important aspect of the health of the community as a whole. As the School Health Committee, which submitted its interim report about a year ago, pointed out, the incidence of sickness and disease among school children due to malnutrition and other preventive causes is extremely high. It is suggested that the Health programmes drawn up for the Third Plan in the States should ensure certain minimum services for the care of health in the schools. These are : (1) clean drinking water and sanitary facilities in schools, (2) arrangements for medical inspection, (3) follow up services in association with the primary health unit in the development block, and (4) instruction of teachers in health education.
In view of the importance of school midday meals for the health and nutrition of children, specially for those coming from the poorer homes, as suggested in the chapter on Education, this programme should be extended progressively as local communities come forward to contribute towards it. In due course the movement for midday meals should cover the bulk of the school population, specially in the lower age groups.
Maternal and Child Health
42. At the end of the Second Plan there were nearly 4500 maternity and child welfare centres, each serving a population varying between 10,000 and 25,000. One third of these centres are located in urban areas. As a result of improvements in maternity care affected during the first two Plans, the maternal mortality rate which was as high as 20 per thousand live births in 1938 is now estimated to have come down to 12.4 per thousand live births. There has also been a general reduction in the incidence of severe cases of anaemia in areas where antenatal services are well established and there has been a steady decrease in the infant mortality rate. During the Second Plan, maternity and child welfare services became an integral part of the over-all health services in rural areas. Maternity and Child Welfare Bureaux have been established in most of the Stales. Steps were also taken during the Second Plan to improve training in paediatrics. Facilit'es for the teaching of paediatrics in medical colleges have been expanded in recent years. Maternity and child welfare services provided by the primary health centres are supplemented by services provided by welfare extension projects and by voluntary organisations.
During the Third Plan it is proposed to link up the maternity and child health services associated with the primary health units with extended facilities in referral and district hospitals. Short orientation courses will be arranged at these hospitals for personnel engaged in maternity and child health work.
43. The recent constitution by the Central Government of an Advisory Committee on Mental Health points to the growing importance of mental health services in programmes for the development of public health and medical facilities. Besides making curative services available in mental hospitals to the extent feasible, greater attention has now to be given to the provision of preventive mental hygiene services and, in particular, to the introduction of a range of training programmes. Rapid industrialisation, technological changes and the movement of population from rural to urban areas bring in their train certain tensions and problems of maladjustment which are best dealt with in their early stages. There is need for mental health orientation of medical specialists, public health personnel and social workers, specially those working in maternity and child health centres. Mental health education is also an important aspect of the health education programme. Training facilities are required on a steadily increasing scale for child psychiatrists and psychiatric social workers. In the field of education, counselling for simple personal and emotional problems, mental health education of parents and teachers on sound principles of child upbringing and training in mental hygiene of school teachers should find an appropriate plac'e in the school health programme. In view of the role of psychological factors in social life, mental hygiene measures should be regarded as a necessary element in the administration of social welfare programmes. Since so little is known regarding the new social and psychos-logical problems which are coming up as India's economy develops and becomes ever more complex, facilities should also be provided for special surveys and studies in mental health. Voluntary organisations can help greatly in educating the general public?, in supporting the work of child guidance clinics and in other ways.
44. It has long been recognised that deficiencies in vital statistics are among the more serious weaknesses of the existing statistical system. The problem was discussed at length in the First Five Year Plan, but over the past decade comparatively little progress has been made. The subject was considered in all the aspects at an inter-State conference in April, 1961. It has recommended that Central legislation should be enacted for vital statistics, in which there should be common definition of vital events, provision for compulsory registration and duties of Registrars, forms for reporting vital statistics and penalties should be laid down, leaving it to State Governments and Union Territories to provide for the administrative machinery and other details of implementation. Suggestions were also made regarding arrangements appropriate to municipal areas, areas notified under the State Panchayat Acts and other rural areas,appointment of District Registrars, flow of returns and compilation of statistics. It was further proposed that in addition to an annual sample census to estimate the growth of population and other measures of demographic characteristics, a scheme of sample registration of areas should be worked out with a view to obtaining reliable estimates of birth and death rates for different States and regions. These recommendations are at present under consideration. It is essential that the programme for the improvement of vital statistics should be implemented in the States as speedily as possible with such further support from the Centre as might be found necessary.
45. The Third Plan envisages a large increase in the production of drugs in the country and replacement of imported drugs and raw materials by indigenous manufactures. In the past, quality and standards in drugs were based in the main on imported drugs but, with the virtual stoppage of imports and development of internal production, the Indian Pharmacopoeia and the National Formulary will become the basis of standards in drugs and the development of the industry. The quality of drugs, both imported and manufactured is controlled under the Drugs Act, 1940. This law is in force in all the States but generally, it is not being adequately implemented. In part this deficiency is due to inadequacy of staff and to want of proper facilities for analysing samples of drugs taken from manufacturers and traders. Under a recent amendment of the legislation. the Central Government has taken concurrent powers with the States over the manufacture of drugs. The services of the Central Drugs Laboratory at Calcutta, have been placed at the disposal of the State Governments, but it is also essential that the State Governments should themselves provide for the establishment of their own laboratories for analysis of samples. The Central Government has appointed a skeleton staff for the control of manufacture of drugs concurrently with the State Governments, but it will also be necessary for the State Governments to take early steps to augment their present personnel for the day to day administration of the legislation. At present too few samples are taken and long delays occur in their analysis.
While staff and facilities for analysis have to be made available, it is equally essential that manufacturers and trade associations should be induced to play a fully responsible role in maintaining quality and standards. Consumer associations, lodal bodies and voluntary organisations should bring deviations from standards and excessive prices to the attention of the general public and of the authorities concerned.
46. While the prices of many essential drugs are being maintained at reasonable levels, those of proprietory brands, specially of products of foreign origin or composition which are distributed by Indian agents or subsidiaries of manufacturers abroad, are often excessive, and large profits are made. This situation has to be remedied, as far as possible, with the help of the manufacturers and distributors concerned. It is also essential that Indian manufacturers, the medical' profession and the State Governments should follow the directions set out in the National Formulary, which will be revised at regular intervals and maintained up-to-date. To create confidence among the public in products marketed under non-propriecory names, State Governments should strengthen measures for quality control and ensure adequate arrangements for inspection.
A proportion of the drugs sold in the market, specially biologicals, are of sub-standard quality. Spurious drugs are also being frequently sold. The Drugs Act has been amended recently, and a minimum punishment of one year's imprisonment has been prescribed for the manufacture and sale of spurious drugs.
47. The supply of pure food is an obligation which all producers and distributors owe io the community and which can and must be enforced rigorously. Yet, from such evidence as is available, the position has tended to deteriorate, and adulteration in such articles of common consumption as ghee, milk, oils, and fats, spices and condiment, flour, pulses, etc. occurs all too frequently in the towns and also increasingly, in the rural areas. Indeed, methods of food adulteration tend to become progressively more elaborate and more difficult to detect. Problems of food adulteration have been recently considered by the Central Council of health and at a special seminar, and a series of suggestions have been put forward. These include proposals for deterrent punishment under the Prevention of Food Adulteration Act, 1954, strengthening of the machinery for inspection of foodstuffs and of the available laboratory facilities, and improvement and speeding up of administrative and other procedures connected with food offences. Recommendations have also been made regarding the standards to be observed in respect of different articles of consumption. Adulteration occurs at the point of production, in the stage of processing and in the course of distribution, both wholesale and retail. It is important that besides being dealt with where it touches the consumer, the problem should be followed up systematically for each commodity through each of the earlier stages, and all the parties concerned should be brought within the scope of legal and administrative action. Local bodies, voluntary organisations and consumer associations should be encouraged to expose the evildoers, and the authorities concerned should give the utmost attention to public complaints. It is also essential, as suggested in the Chapter on Cooperation, that cooperative consumer stores should be built up, specially in the towns, as a means of assuring the supply of pure foodstuffs.
Indigenous System of Medicine
48. Work on indigenous systems of medicine has developed steadily during the past decade. For the promotion of research in indigenous systems a sum of about Rs. 38 lakhs was spent during the First Plan. Research programmes in this field were considerably expanded in the Second Plan, the total expenditure incurred being about Rs. 4 crores. In 1959, the Central Council of Ayurvedic Research was set up to advise the Government of India on the formulation of a coordinated policy for research in Ayurveda throughout the country and on steps to be taken for stimulating research. Two advisory committees, one on Homoeopathy and the other on Unani, were also set up. The Central Institute of Research in Indigenous Systems of Medicine which was established at Jamnagar in 1953, has undertaken clinical research in certain selected diseases and identification of crude ayurvedic drugs, plants and herbs and problems connected with their cultivation. In addition to its ayurvedic and modern medical sections, the Institute also has a "Siddha" unit attached to it. The post-graduate training centre set up at Jamnagar in 1956 affords facilities for advanced and critical studies in Ayurveda.
49. Ayurveda.The present approach to education in Ayurveda has not produced satisfactory results and has become a matter for controversy. As suggested in the First Plan, a curriculum drawn up for the purpose has to be designed primarily to enable the student to attain full proficiency in the practice of the particular system. A large number of States have been running the "integrated" course of training while there are some States which have, in addition to such institutions, maintained "shuddha" ayurveda courses. Experience has, however, shown that the course of integrated medicine in India, wherever introduced, has not served the avowed object of producing practitioners of Ayurveda. Students thus qualified have a leaning towards the practice of modem medicine for which they are only partially trained. In fact, two of the colleges imparting training in integrated medicine have recently been converted into colleges of modern medicine. It has also been observed that some vaidyas have recourse to drugs occurring in modern medicine for the use of which they have not been trained.
50. There is lack of uniformity in various States in the matter of qualifications prescribed for admission, the curricula of studies, practical training given to the students in preclinical and clinical subjects, standards of qualifying examination and in the kinds of diplomas and degree awarded.
The Central Council of Ayurvedic Research appointed by the Ministry of Health has recommended that the curriculum for education in indigenous systems of medicine should comprise concurrent courses in Ayurveda and modern medicine. The recommendation of the Panel on Ayurveda appointed by the Planning Commission, on the basis of concensus of opinion of its members, was as follows :
"There should be a four-year diploma course in Ayurveda which will be devoted to an intense study of Ayurveda with the provision that elements of science, i.e., Physics, Chemistry and Biology, will be included in the pre-ayurvedic course of one year. This should aiso include preliminary training in Darshana, Padartna Vijnan, Sanskrit etc. in the first year. The pre-clinical subjects (first two years) should include Sharir Vijnan, Dravya Guna and Rasa Shastra. Those who wish to qualify themselves for degree course with a view to enter Government service should undergo an additional two years course. In the clinical subjects (last three years) arrangements should be made to teach Nidana, Chikitsa, Swasthya Vritta, Prasuti Tantra, Striroga, Bairoga, Shalya, Shala-kya and Vyavahara Ayurveda. Along with teaching these subjects there should be compulsory teaching of one of the 'Vridha Trayi', namely, Charaka Sam-hita, Sushruta Samhita or Vagbhatta Samhita during the period. At the end of the training of six years a degree of Ayurvedacharya should be awarded. The first four years should be devoted exclusively to the study of Ayurveda. For the purpose of the last two years the instruction will include the exposition of scientific aspects and provide necessary practical training. There will be also amplification in the teaching of Ayurveda with reference to the scientific advancement in allied sciences. Minor surgery, communicable diseases, midwifery, preventive medicine which would enable the Graduates to serve in the Health Organisation of the State will also be taught".
51. The panel on Ayurveda appointed by the Planning Commission and the Central Council of Ayurveda set up by the Ministry of Health have suggested, among other things, the following :
For promoting Ayurvedic system of medicine it is important that research work in it should be intensified. With this in view, research on the fundamental doctrines on Ayurveda, literary research, clinical research, drug research, etc. will be undertaken during the Third Plan. A sum of Rs. 9.8 crores has been provided in the Third Plan for the development of indigenous systems of medicine. The programme of development which has been drawn up includes the opening of five new colleges, expansion of 31 existing colleges, research in pharmaceutical products, opening and upgrading of 1800 dispensaries and hospitals, improvement of pharmacies and the establishment of herbaria. It is well known that a large number of indigenous drugs are in common use in the households. It is proposed during the Third Plan to establish herbaria with a few selected herbs locally available in the. first instance in individual development blocks.
52. Nature Cure.The Nature Cure treatment has been in vogue from times immemorial in India and in other countries. Modern medicine has incorporated many of its techniques for the treatment of several disabilities. This process can be continued even further. The significance of nature cure should be considered more as a way of life than as a system of medical treatment in the narrow sense. Its emphasis on the preventive aspect of disease, promotion of general health, vitality and spirit of self-help through simple ways of living deserves better appreciation. During the Third Five Year Plan the existing nature cure institutions will be assisted to equip themselves with Sathological laboratories, so that modern scienti-c methods can be utilised for placing nature cure treatment on a more sound footing.
53. Homeopathy.The Central Government have given grants for upgrading, improving and setting up homeopathic institutions and for research. An Advisory Committee on Homeopathy has been constituted by the Ministry of Health. The question of establishing facilities for the manufacture of homeopathic' drugs and of a laboratory for standardising the drugs is being considered in consultation with this Committee. In the Third Plan, provision has been made for giving grants to homoeopathic institutions and for carrying out research. The possibility of uWsing properly trained and qualified homoeopaths for service in urban and rural areas needs to be explored.
Proposals for the opening of homoeopathic colleges and hospitals have been made and should be considered further.
54. Vnani.The Government of India have constituted an Advisory Committee on the subject under the Ministry of Health. Grants are being given to institutions for the purpose of research, upgrading, improvement and establishment of unani institutions.
55. In plans for the improvement of health conditions better nutrition holds a crucial place. During the first two Plans there has been no concerted effort to improve nutrition, change food habits or create great awareness of the problem. With the increase in production and improvement in economic conditions envisaged for the Third Plan, a systematic approach to the problem of nutrition should now be feasible. It will doubtless take time to bring about substantial changes but, if programmes are conceived from the beginning on correct lines, the right priorities are set, and each community begins to realise the significance of nutrition and the contribution which it can itself make by its own effort and resources, over a period, considerable results can be achieved.
The broad features of the problem of nutrition are well known. Generally, in most parts of India, the diet is composed of cereals and is lacking in protective and body-building foods such as milk, meat, eggs, vegetables and fruit. Diet surveys undertaken at the instance of the Indian Council of Medical Research over two periods, 193548 and 195558, show that while there has been no appreciable change in the consumption of cereals and pulses, there may well have been a small reduction in the consumption per capita of some of the non-cereals foods. Food deficiencies bear most harshly on growing children among the poorer sections of the population. Over a large area at the foothills of the Himalayas endemic goitre results from iodine deficiency. Other important elements in the problem are the loss of nutritive elements in food, due to the adoption of wrong methods of cooking, as in rice and vegetables and of processing as in rice milling, waste of fruit and fish, on account of lack of transport and refrigeration facilities, and diversion to low priority uses as in the case of milk used in the preparation of sweets. Thus, over the first two Plans there has been no significant increase in the average per capita consumption of milk, which is at present estimated at 4.9 oz, per day as against the minimum requirement of 10 oz, for a balanced diet. The total production of fish has risen from about 700,000 tons to 1.4 million tons, and programmes in the Third Plan provide for increase in the production of fish to 1.8 million tons. Possibilities exist, however, of securing larger increases in production through more effective organisation of the fisheries industry, and efficient implementation of various development programmes. It should also be possible to bring into use to a much larger extent than at present subsidiary foods such as potatoes, sweet potatoes and tapioca, leafy and other vegetables and fruits like papaya and banana which are easily grown, products like palm gur and honey, and processed foods such as have been developed with success at the Central Food Technological Research Institute, Mysore.
56. At the present stage of development the programme for improving nutrition falls broadly under two heads, namely, education of the public and of various groups of workers in nutrition, and measures to meet the nutritional requirements of vulnerable groups within the community. Information and guidance about nutrition, about conserving the nutritive elements in food and avoiding wrong uses and wastage, should be made widely available through demonstrations and the work of voluntary organisations and mahila mandals in the villages as part of the community development programme. At the same time, groups such as doctors, nurses, health visitors, school teachers and others should receive special short-term training in nutrition. Among the vulnerable groups, those requiring the greatest attention are expectant and nursing mothers, infants, pre-school children and school children, specially in the lower age groups. School chidren are best catered for through the mid-day meal programme to which reference has been made earlier. For under-nourished children the provision of protective foods like milk and additions to the diet through nmJti-purpose food, vitamins, etc., are essential. Greater attention should also be given to the provision of cheap and balanced meals in canteens in industrial undertakings, hostels in schools and collages, and in restaurants and eating places for the general public.
To carry out programmes such as these, public health nutriton services at the Centre and in the States need to be better equipped. At the Centre there is already a National Nutrition Advisory Committee. The establishment of special sections for nutrition in the Public Health Departments in the States has been repeatedly urged. At the State level there must be the closest coordination, as in a vital common effort, on the part of the Departments of Health, Agriculture, Animal Husbandry, Dairying, Fisheries, Education, Social Welfare and Publicity. At the district and block level a well-designed programme for improving nutrition can secure increasing public support and appreciation as well as the help of voluntary workers and organizations. Proceeding on these lines, in the course of the Third Plan, it should be possible to lay solid foundations for popular and steadily growing effort to improve nutrition and the general health of the community, and especially of its vulnerable and weaker sections.
Planning for The Future
Far-reaching developments have occurred in the field of health since the
Health Survey and Development Committee (Bhore Committee) submitted its
comprehensive report fifteen years ago. It is important that, besides
being closely integrated with programmes in other fields, plans for the
development of health services should be conceived with a clear prospective
for the future, specially over the next three plan periods. In June 1959,
the Ministry of Health set up the Health Survey and Planning Committee
for assessing and evaluating developments in medical relief and public
health since Independence and formulating recommendations for the future
plan of health development. The Committee is at present engaged in a careful
study of the problems of rural and urban medical relief, pubic health,
including environmental hygiene, control of communicable diseases, professional
education and research, population and family planning, and drugs and
58. In recommending the programme of family planning, the First Five Year Plan stated: "It is apparent that population control can be achieved only by the reduction of the birth-rate to the extent necessary to stabilise the population at a level consistent with the requirements of national economy. This can be secure only by the realisation of the need for family limitation on a wide scale by the people. The main appeal for family planning is based on considerations of health and welfare of the family. Family limitation or spacing of the children is necessary and desirable in order to secure better health for the mother and better care and upbringing of children. Measures directed to this end should, therefore, form part of the public health programme".
In pursuance of the policy outlined above, there has been a steady expansion of activities in the field of family planning especially in the Second Plan. The programme for the Third Plan has been recently considered by a special committee appointed by the Ministry of Health and by the Planning Commission's Panel on Health.
59. In the Chapter on Long-term Economic Development, certain provisional estimates of increase in population over the next fifteen years have been cited, and it has been stated that the objective of stabilising the growth of population over a reasonable period must be at the very centre of planned development. In this context, the greatest stress has to be placed in the Third and subsequent Five Year Plans on the programme of family planning. This will involve intensive education, provision of facilities and advice on the largest scale possible and widespread popular effort in every rural urban community. In the circumstances of the country family planning has to be undertaken, not merely as a major development programme, but as a nation-wide movement which embodies a basic attitude towards a better life for the individual, the family and the community.
60. During the First Five Year Plan, 126 family planning clinics were set-up in urban areas and 21 in rural areas. In the course of the Second Plan, the number of clinics increased to 549 in urban and 1100 in rural areas. In addition to these clinics, family planning services are provided at 1864 rural and 330 urban medical and health centres. A number of sterilisation centres have also been established. The programme is guided by the Central and State Family Planning Boards. All States have set-up special units for family planning work. Considerable amount of research work is in progress at the Contraceptive Testing Unit at Bombay and elsewhere under the guidance of the Indian Council of Medical Research and at the All India Institute of Hygiene and Public Healh, Calcutta. Demographic research centres have been set-up in Bombay, Calcutta, Delhi and Trivandrum. A number of valuable field investigations have been carried out, such as the India-Harvard-Ludhiana population study and the studies undertaken at Ramanagaram in Mysore, in the Lodi Colony in Delhi, at Najafgarh near Delhi, and at Singur near Calcutta. A broad based training programme has been developed which includes centres for training of instructors, a rural training demonstration and experimental centre, development of training clinics into regional training centres, touring training teams and ad hoc training courses. Family planning has also been incorporated in the normal training programme of a number of teaching institutions for doctors and medical auxiliaries. As against Rs. 65 lakhs in the First Plan, a financial provision of Rs. 5 crores was made in the Second Plan.
61. The programme for family planning in the Third Plan provides for (a) education and motivation for family planning, (b) provision of services, (c) training, (d) supplies, (e) communication and motivation research, (f) demographic research, and (g) medical and biological research. The programme as approved, involves a total outlay of Rs. 50 crores. Clearly, the limitations of a programme of the nature of family planning arise not from finance, but essentially from considerations of organisation, and personnel, which affect the scale and intensity at which the programme can be implemented.
62. Various studies suggest that there is already considerable awareness of the need for family limitation and desire for practical help and guidance. This does not mean that the difficult problems of communication and motivation have been overcome or that in terms, of advice and- organisation much more than a beginning has been made, in particular, in.approaching rural communities. It is to these .aspects that. much greater attention should be given in the Third Plan. The intensification of the educational programme is crucial to the success of the entire movement. Family planning education, being part of education for a better life, has to be interwoven with other constructive activities, especially the work of the primary health centres, community development blocks and voluntary organisations. Information has to be made available on the largest possible scale and conditions created in which individuals can freely resort to family planning.
63. Family planning services have to be made available much more widely than at present. In this, the central feature must be the integration of family planning with the normal medical and health services, specially those rendered through the primary health centres. To an extent such services might also be made available through centres maintained by voluntary agencies, mobile units and industrial and other establishments. According to the tentative programmes drawn up for the Third Plan, the number of family planning clinics is likely to increase from about 1800 at the end of the Second Plan to about 8200. Of the latter, about 6100 clinics may be in rural areas and 2100 in urban areas. Distribution of simple contraceptives and general advice could be entrusted in a much larger measure to voluntary organisations, to para-medical personnel and to dais specially trained in family planning work. The additional personnel and other expenditure required for enabling every primary health centre to provide family planning services is proposed to be incorporated in an integral manner into the programme for primary health centres. The main difficulty here is of securing the, requisite trained personnel specially women workers. For expanding training facilities, it is essential to organise a large number of intensive short-term courses. In the urban areas it is proposed that greater use should be made of private medical practitioners in providing advice, distributing supplies and, to the extent possible, in undertaking sterilisation.
64. A large-scale family planning programme has to be supported necessarily by indigenous manufacture of contraceptives. In this respect, although there has been some progress, the situation cannot be said to be satisfactory. The estimates of supplies, which have been current hitherto, are based on a programme of very small dimensions. In view of the nature of the programme, it is considered that it will be necessary for the Government to take initiative in prescribing standards and specifications, determining prices, and also participa^ng increasingly in production. In the early stages and for certain sections of the population, the provision of supplies free of cost and at subsidised rates will also be necessary. It is recommended that detailed plans for the production of contraceptives, both by Government and by private firms,-should be drawn up as a matter of high priority, keeping: in view the objective that, as rapidly as possible, supplies will in fact become available on the scale needed.
65. An expanded programme of research is to be undertaken in the Third Plan. Amongst others, the following aspects are being investigated :
An expert committee on oral contraceptives has been appo-'nted to review periodically the developments in this field and to make recommendations. A committee to guide communication motivation and action-research in family planning has also been recently set up. Studies of the sociological problems involved in family planning need to be developed on more comprehensive lines than has been hitherto attempted.
66. Over the past five years, facilities for sterilisation operations have been extended in several States and about 125,000 operations have been carried out. Within the programme of family planning, sterilisation undertaken on the basis of voluntary choice has a valuable contribu^'on to make. It is visualised that during the Third Plan facilities for sterilisation will be extended to district hospitals, sub-divisional hospitals and to such primary health centres as have the necessary facilities for surgical work. With the he'p of mobile units, these facilities can be extended further.
67. The main task in the field of family planning in the Third Plan is to find effective solutions to certain basic problems and to mobilise all the available agencies for educational and extension work in support of family panning. Administrative arrangements at the Centre and in the States will need to be greatly strengthened. To equip thousands of primary health centres and in the due course their sub-centres as well, with personnel and supplies, and to be able to reach out to the villages not merely with advice but more positively with the means to practise family planning, are tasks whose magnitude and complexity should not be under-estimated. To utilise such diverse agencies as private medical practitioners, indigenous doctors and village dais for family planning work along with the family planning clinics and the primary health centres wHl call for most careful planning at the local leveL The organisation of production of contraceptives on the scale needed is another major undertaking. It is estenrial that the help of voluntary organisations, labour organisations and other associations in various fields of national life should be sought on as large a scale as possible and integrated into the practical programmes of work adopted in each area.
68. Finally, it should be added that besides the facilities which are undoubtedly needed, in any large-scale effort to limit families there should be the greatest emphasis oa moral and psychological elements, on restraint and on such social policies as education of women, opening up of new employment opportunities for them and raising of the age of marriage. In addition to advice on birth control the family planning programme should include sex and family life education and advice on such other measures as may be necessary to promote the welfare of the family.
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