good health is fundamental to living a productive life

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AN OVERVIEW OF HEALTH AND NUTRITIONAL SERVICES IN INDIA

BRIEF CONTENTS

PreambleImportance of health and nutrition

Definition of health and nutritionWho standards of health and nutritionHealth and nutritional problemsMalnutritionHealth and nutritional schemes in IndiaHealth and nutritional policies and legislationsInstitutional mechanism for health and nutritionFinancial budgets for health and nutritional programmes

³It is health that is real wealth and not pieces of gold and silver´.

Mahatma Gandhi, Father of Nation (India).

³The doctor of the future will no longer treat the human frame with drugs, but rather will

cure and prevent disease with nutrition.´

Thomas Edison.

1. Preamble

R esearch in Health and Nutritional services provided to human being is so important to

underpin both policy making and project designing. Though there has been progress in

improving health and nutrition of people in India; some challenges remain and new ones have

emerged India. The social, economic, and cultural factors influence human¶s health and

nutritional status. The major health problems of the 21st century include nutritional deficiencies

and dietary changes in both rural and urban settings. The research in Health and Nutritional

services can help to identify the biological and socio-cultural components of solutions to

nutrition and health problems. Favorable health policies and effective and equitable health

services are critical to the broader development goal of breaking the cycle of poverty, high

fertility, poor health, low productivity and slow economic growth.

1.1 The Concept of Health

Health is primarily a personal responsibility and demands personal care to enjoy it. It is

an essential requirement of all irrespective age, caste, creed, race, religion and economic

standard. Health of an individual can be affected by general health condition of the society and

vice-versa. Therefore, health of the community needs higher attention while considering the



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development of a region or a country. It is a precious asset for everyone. It is the crown of all

possessions and untheft treasure. It is certain that health is a basic need of all human beings from

womb to tomb. Good nutrition is a firm foundation for human happiness, and sound health and

skilled performance. It constitutes the most important readily improved environmental influence

of health.

The advances in medical sciences have the treatment of many diseases possible and

simple. And yet the benefits of modern medicines have not reached the vast majority of people

in poverty groups and rural areas, especially women. But it is the women who are the prime

producers of the necessities of the life, women on whom the society depends so heavily for

economic support and family health care.

According to the census 2011 of India about 68.84 percent of Indian population is living

in rural areas as against 31.16 percent in urban areas. There are nearly 6, 40, 867 villages in India

which are scattered over larger areas as compared to urban areas (Census of India, 2011)

1. Urban

areas are not only concentrated but are also attracting centres for economic activities and for

services like health, transport. As a result, large population of hospitals, dispensaries clinics and

medical centers are found in urban areas than in rural areas. On the contrary, villages being

smaller size, most of the health services like hospitals, dispensaries and clinics became

uneconomical as their capacities remain under utilized. Moreover, health problems are rampant

in rural areas, not merely because of lack of medical facilities but because of general poverty,

lack of balanced and nutritious diet to large proportion of rural population, and more over lack of

knowledge with regard to health and hygiene.

1.2 Importance of Health and Nutrition

Health and nutrition are the most important contributory factors for human resource

development in the country. Food consumption, which largely depends on production and

distribution, determines health and nutrition of the population. Accessing by the poor to

services that improve health, nutrition and fertility outcomes is one of the three pillars of the

World Bank's Health, Nutrition, and Population Sector Strategy (Anne Tinker, 2000, p.7)2.

Health and nutrition are vital for livelihood of the human being on the earth. Especially, it

requires during the childhood to sustain thereafter. A good health and nutrition can reduce the

risk of chronic diseases in later life. Nourishing well balanced diets are essential for proper

growth of immunity, physical, and mental development. A women¶s health and nutrition status



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have important implications for her wellbeing. A Poor nutritional status of women affects not

their health but also the health of their offspring. Maternal nutrition is so important determinant

of pregnancy outcomes, nutrition outcomes and indicators of women¶s health.

Nutrition is critical for health and well-being and is important at every stage of life. Good

nutritional status is widely accepted as an important indicator of national development. Foods

provide energy, nutrients and other substances needed for health. Optimal nutritional status helps

ensure a healthy child hood, pregnancy and a robust newborn. Food consumption, both in terms

of quantity and quality, plays a major role in determining nutritional status. Healthful nutrition

reduces stress, enhances immunity, affects longevity and improves outlook and the quality of

life. The prevalence of malnutrition and infectious disease among the young has important

implications for the health and well-being of the population, because ill health in childhood can

affect an individual¶s physical and mental development, susceptibility to disease, and capacity

for work.

Good health and nutrition is fundamental to live a productive life, meeting basic needs

and contributing to community life. It is an enabling condition for the development of human

potential. The components of health are multiple and their interactions are complex. The health

of an individual is strongly influenced by genetic make-up, nutritional status, access to health

care, socioeconomic status, relationships with family members, participation in community life,

personal habits and lifestyle choices. A healthy population can lead the nation better in all the

frontiers.

Adolescence is the future generation of any country. Their nutritional needs are critical

for the well being of a society. If the adolescence are well-nourished, they can make optimal use

of their skills, talents and energies and would be healthy and responsible citizens. Adolescence,

a second period of rapid growth cycle may serve as an opportunity for compensating faltered

early childhood growth though a good health and nutritional components. Poor nutrition starts

before birth and goes up to death and can spam into generation.

1.3 Definition of Health

The most acceptable definition of health is given by the WHO (1978): Health is the state

of complete physical, mental, social and spiritual well-being, and not merely an absence of

disease or infirmity. It is a significant departure from the medical model. It is a definition of

positive health and goes beyond the mere absence of a disease: the focus being on maintaining



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good health, rather than on the treatment of different diseases. This comprehensive definition

has made it necessary to define the health of a community in a broad perspective, and not merely

in terms of the individual demographic indicators such as Infant Mortality R ate (lMR ), Life

Expectancy at Birth (LEB), Mortality R ate by Causes, and so on. A community could be healthy

if almost every individual in it were healthy. The primary requirements for anyone to be healthy

are availability of adequate food, shelter and clothing.

This definition tells us that health is a positive state of human life. In other words, it is a

state of complete well-being not just the absence of disease. A person may not be suffering from

any disease and yet may not enjoy complete well-being. There are many times when one feel

tired or exhausted and incapable of concentrating on their work. At such times they are not

enjoying complete well-being, even though at other times they do. There are also times when

one suffers from an infection or periods of ill health. This means no person enjoys full health all

the time. However, a person can be called healthy if he or she enjoys good health most of the

time. Another dimension which is also gaining prominence is spiritual health. Health relates to

physical well-being, who people are as individuals, how people relate to their environment, what

they know value and believe how they make decisions and behave. The dimensions of health as

described in figure 1.

F ig. The dimensions of Health

1.3.1 Physical Health is easy to detect and describe. A person is physically healthy if he or she

looks alert, is responsive, energetic, and vigorous. Physical health is discussed in terms of

wellness of the body and absence of bodily disorders. It includes the characteristics such as one¶s

weight, susceptibility to disease, nutritional status, fitness and powers of recovery from illness.



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1.3.2 Social health is one¶s ability to get along with other people in one¶s life and have a

productive role in one¶s family or community. It relates to social abilities, skills and insights.

Positive social interaction can be seen both as a means of achieving health and as a part of health

itself.

1.3.3 Mental or emotional health is expressed in terms of understanding one¶s emotions,

coping with everyday problems and handling stress in a non-destructive way. The mental

components of health are related to one¶s self-esteem, self-confidence and the way you cope with

problems.

1.3.4 Spiritual health may involve a religious belief, or it may simply relate to that sense of

being part of a larger environment or world.

1.4 The social construct of health

It recognizes that a person¶s cultural background, religion, family structure, support

networks, level of education and income all interrelate to affect their view of health status as

shown in figure 2. Cultural factors may influence dietary patterns. This, in turn, may bring into

question the relevance of the standard dietary pyramid. R eligious factors may determine whether

immunisation occurs or a potentially lifesaving blood transfusion is allowed. Family and culture

may determine the type and amount of physical activity which people, especially females,

engage in. Health status is affected by gender; education; income and social status; successful

social relationships; and culture. Understanding this social view of health enables to realize that

health does not mean the same to all people and as society changes.

Access to

Services Peers

Gender

Culture

Education

Media

Income

HEALTH



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Environment Religion Family

Fig 2: Social construct of health

1.5 Definition of Nutrition

Nutrition refers to the availability of energy and nutrients to the body¶s cells in relation to

body requirements. It is a basic human need and a prerequisite to a healthy life. Nutrition can be

defined as ³The science of foods, the nutrients and other substances therein; their action,

interaction and balance in relationship to health and disease; the processes by which the

organism ingests, digests, absorbs, transports and utilizes nutrients and disposes of their end

products. In addition, nutrition must be concerned with the social, economic, cultural and

psychological implications of food and eating´. Household nutrition involves physical and

economic access to balanced diets and safe drinking water for the children, women and men of every family. Nutritional status is the condition of health of an individual as influenced by the

utilization of nutrients. Nutrition is essential from the very early stages of life for proper growth,

development and to remain active along with the human growth cycle as shown in figure.



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Nutrition throughout the life cycle

Source: Prepared by Nina Seres f or the ACC/SCN-appointed Commission on the Nutr ition Challenges of the 21st

Centur y.

BABY

LBW

CHILD

STUNTED

ADOLESCENT

STUNTED

WOMEN

MALNOURISHED

PREGNANCY LOW

WEIGHT GAIN

MALNUTRITION

ELDERLY

INADEQUATE FOOD

HEALTH & CARE

INADEQUATE FOOD

HEALTH & CARE

INADEQUATE FOOD

HEALTH & CARE

INADEQUATE

CATCHUP GROWTH

MENTALLY RETARD RISK OF

CHRONIC DISEASES IN

ADULT HOOD

INADEQUATE FEEDING, FREQUENT

INFECTIONS INADEQUATE FOOD HEALTH

& CARE

GROWTH FAILURE

REDUCED MENTAL CAPA

HIGH MMR



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A proper diet and good nutrition targeted to many solutions to the health and nutritional

problems of mankind as shown in the figure.

S ource: Anonymous author

1.6 Current Nutritional Status

The National Family Health Survey 05-06 (NFHS-3) gives statistics of the nutritional status of

women and children of India. According to the NFHS-3, 43 percent of children under age five

years are underweight for their age (WAZ<-2SD) and 48 percent of children under age five years

are stunted (HAZ<-2SD). NFHS-3 shows that 36% of all women age 15-49 in India are

underweight (BMI <18.5). And that girls and boys 0-35 months were about equally likely to be

underweight. The girls having slightly better health status2.

Table1: Child Mortality Statistics

Countries

Per

Capita

GDP

Under-fivemortality rate

MDG

target

Average annual rate of Reduction (%)

Progresstowardsthe MDG

target1990 2006Observed Required

1990 2006 2007 - 2015

Er itrea 271 147 74 49 4.3 4.6on track

Bangladesh 428 149 69 50 4.8 3.6 on track

India 976 115 76 38 2.6 7.6 insufficient

Pakistan 996 130 97 43 1.8 9.0 insufficient

Niger ia 1,169 230 191 77 1.2 10.1 insufficient

Philippines 1,639 62 32 21 4.1 4.8 on track



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Sr i Lanka 1,676 32 13 11 5.6 2.2 on track

Egypt 1,770 91 35 30 6.0 1.6 on track

Indonesia 1,869 91 34 30 6.2 1.3 on track

S ource: Unicef

Table1 demonstrates how countries with comparable per capita GDP like the Philippines,

Sri Lanka and Egypt have made better progress towards at reducing child mortality. In fact,

Bangladesh and Eritrea, which have approximately half and quarter of India¶s per capita GDP,

respectively, and had higher infant mortality rates to start with, have made commendable

progress between 1990 and 20063.

1.7 Malnutrition

Malnutrition refers to any imbalance in satisfying nutrition requirements. It is the

condition that results from taking an unbalanced diet in which certain nutrients are lacking, in

excess (too high an intake), or in the wrong proportions (Dorland's Medical Dictionary and

Sullivan, Arthur; Steven M. Sheffrin, 2003). A number of different nutrition disorders may arise,

depending on which nutrients are under or overabundant in the diet. Malnutrition infection

complex are shown in the figure.

Malnutrition

Weak education

and Health S stemImpaired Child

Develo ment

Weak education

and Health S stemCompromised

Immunit

Infection Poverty

Disease R educed

Productivit

Energy Loss



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Fig: Malnutrition-Infection Complex

S ource: S chaible, U., Kaufmann, S ., Malnutrition and Infection: complex mechanisms and Global Impact. PLoS

Medicine. May 2007.

India has one of the highest rates of malnutrition in the world. Nearly one in every two of

India¶s 120 million children is underweight, almost double the prevalence in Sub-Saharan Africa.

An undernourished child will fail to reach her human potential in her adult years ± in terms of

educational attainment, health and productivity ± perpetuating a vicious cycle of poverty and

malnutrition.

India has a serious problem of child undernutrition. R eduction of child undernutrition is

imperative, since it has enormous consequences for child and adult morbidity mortality, as well

as productivity. Undernutrition directly affects many aspects of children¶s development,

retarding physical and cognitive growth and increasing susceptibility to disease. Improved policyand programs are needed if India is to reach the nutrition MDG (Millennium Development Goal)

target of halving the figures for malnutrition by the year 2015 (from in 1990 to in 2015).

The nutritional status of young children is an important indicator of health and

development²it is not only a reflection of past health insults but an important indicator of future

health trajectories4. Malnutrition plays a key role in maternal mortality, just as in infant and

child deaths. In 1965, a World Health Organization Expert Committee on Nutrition in

Pregnancy and Lactation wrote, ³Next to young children, pregnant and lactating women are

nutritionally the most vulnerable group, especially in the developing regions of the world, and

yet comparatively little is known of their special nutritional needs´. R egrettably, little has

changed since then and maternal malnutrition remains a major problem in India and Pakistan. In

this two countries the majority of women are in a constant state of nutritional stress, beginning in

childhood, then adolescence, and continuing through the childbearing period which often

commences before growth has ceased, and consists of a continuous cycle of pregnancy and

lactation, all too often resulting in premature death. Chronic protein-energy malnutrition, iron-

deficiency anaemia, and deficiencies of iodine and vitamin A are among the common nutritional

deficiencies that affect women in the two countries5.

Almost 50% of pre-school children in rural India are malnourished6. An adequate intake

of calories does not ensure that the need for micronutrients has been met. Being underweight

due to wasting (i.e., low weight-for-height, indicating acute weight loss) or stunting (i.e., low



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height-for-age, indicating chronic restriction of a child¶s nutrition), micronutrient deficiencies, as

well as being overweight, are forms of malnutrition. Approximately 852 million people around

the world are unable to obtain enough food to lead healthy and productive lives. Undernutrition

in children is responsible for an increased risk of illness and death from many infectious

diseases, causing nearly 3.6 million deaths, including some attributed to diarrhea, pneumonia,

measles and malaria. Poor nutrition can result from either inadequate or excessive levels of

nutrient intake and influences the development of chronic disease.

Malnutrition is a condition where there is insufficient or inadequate consumption of basic

nutrients required by the body which leads to the manifestation of various diseases and disorders.

According to the World Health Organization, malnutrition is the biggest contributor to child

mortality, as it directly or indirectly leads to various deficiency disorders. Thus, these

malnutrition facts speak for themselves. So, to deal with this worldwide menace, it is important

to know all about the various kinds of malnutrition diseases that exist and what are the symptoms

that they show.

1.8 Consequences of Poor nutrition

A women with poor nutritional status, as indicated by a low body mass index, short

stature, anemia, other micro-nutrient deficiencies, has a greater risk on abstracted labour, having

a baby with a low birth weight, having adverse pregnancy outcomes, producing lower quality

breast milk, death due to post partum haemortag and illness for herself and her baby.

1.9 Reasons for Malnutrition

In communities or areas that lack access to safe drinking water, these additional health risks

present a critical problem. Lower energy and impaired function of the brain also represent the

downward spiral of malnutrition as victims are less able to perform the tasks they need to in

order to acquire food, earn an income, or gain an education.

Since the common assumption is that food insecurity is the major cause of malnutrition,

almost completely ignoring the contribution of infection and inappropriate feeding practices,

policy inputs have been skewed towards food-based interventions.

Malnutrition among children is often caused by the synergistic effects of inadequate or

improper food intake, repeated episodes of parasitic or other childhood diseases such as

diarrhoea, and improper care during illness (Pelletier 1994; R uzicka and Kane 1985)[7] [8].



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factors such as lower levels of household wealth and maternal education are important causes of

childhood undernutrition (UNICEF 1998)19.

1.10 List of Malnutrition Diseases

Malnutrition increases the risk of infection and infectious disease; for example, it is a major risk

factor in the onset of active tuberculosis (Schaible UE, Kaufmann SH, 2007)20.

1.10.1 Marasmus is a disease that results from severe deficiency of both proteins and calories

and is one of the most common malnutrition diseases in children. Thus, this condition results in

overall energy deficiency. In this condition, a person looks emaciated and the body weight of the

person maybe lower than 80% of the normal required weight of the person. The occurrence of

this disease is higher in infants below the age of one. This disease is rampant in African countries

and certain other third world countries. In this disease, there is extensive muscle wasting. There

might also be edema, dry and scaly skin, loose skin, etc. Furthermore, the adipose tissue reserves

of the person get severely depleted, especially from the buttocks and thighs. The person is also

seen to be very irritable, fretful and voraciously hungry. The person also becomes very

susceptible to contracting infectious diseases, which further increases the mortality rate of this

disease. The treatment of this disease will not only consist of providing the person with all the

required nutritional supplements that he is deficient of but will also entail treating dehydration

and any other infections that he may be suffering from.

1.10.2 Kwashiorker is one of the most acute protein malnutrition diseases in the world. It is also

said to be protein-calorie malnutrition similar to marasmus, but what sets it apart from marasmus

is the presence of edema, that is typically seen in the feet. Other signs of this disease include a

distended abdomen, an enlarged liver, thinning hair which is normally coarse in texture, loss of

teeth, skin depigmentation, and dermatitis. Children suffering from this condition normally end

up developing irritability and anorexia as well. Although it was believed for long that this disease

was caused by protein deficiency, it is now being said that other factors, like vitamin and mineral

deficiency also play a very important role in causing this disease. Once again, as is seen in

marasmus, due to the severe deficiency of various essential nutrients, the person has an increased

susceptibility to contracting diseases and even developing diseases after getting vaccinated for

that particular disease.



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1.10.3 Anemia is one of the most common malnutrition diseases seen the world over. Anemia

can be caused due to a variety of reasons, but one of the main reasons for anemia is a diet that is

deficient in iron and vitamin B12. A diet deficient in iron leads to a type of anemia known as

iron deficiency anemia. This kind of anemia is one of the most common malnutrition diseases in

the world and is especially rampant in developing countries. It is also particularly seen in

pregnant women in these regions. It leads to various problems like shortness of breath, tiredness

and fatigue, pallor and other symptoms that point towards a low hemoglobin count. Deficiency

of vitamin B12 leads to a type of anemia known as megaloblastic anemia.

1.10.4 Goiter is a disease that is mostly caused due to deficiency of iodine in the diet. This leads

to typical goiter symptoms like swelling of the thyroid gland which is visible as a large swelling

in the neck. Other symptoms present in goiter will be similar to those seen in hypothyroidism,

like lethargy, weakness, low metabolic rate, increased susceptibility to cold, ptosis, etc.

Sometimes, the swelling in the neck may be so large, that it may lead to compression of the

windpipe or the larynx, which may cause difficulty in breathing and speaking. This disorder is

typically seen in countries that have deficient iodine in their soil, or in countries where the food

supplements available are not iodized. Goiter treatment will depend on the size and cause of

goiter. If the swelling is small and is only due to slight iodine insufficiency, then providing

iodine supplements can help treat the disorder. However, if the swelling is large and is causing

pressure on the windpipe or larynx, then it is best to do an emergency partial or complete

thyroidectomy, depending on the case.

1.10.5 Hyponatremia is a condition that is caused due to deficiency of sodium in the blood and

diet. This is a serious type of electrolyte disturbance that is normally seen in people who have

high levels of antidiuretic hormone. In this disease, the concentration of sodium in the plasma is

less than 135mEq/L. This condition is often seen as a result of a complication of some other

serious medical illness, like diarrhea, excessive vomiting, polydipsia, etc. Typical symptoms

include nausea, vomiting, headache, etc. If the symptoms are not treated in time and worsen

further, there may even be mental clouding, confusion, convulsions, stupor and the person may

even eventually go into coma. The treatment for this disease depends on the underlying cause. In

cases of severe volume depletion, there may be need of intravenous administration of saline.

Serious symptoms like seizures normally require treatment using hypertonic saline.



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1.10.6 Hypokalemia is caused due to deficiency of potassium in the diet. Normally, the

symptoms to start showing, there needs to be not only insufficient consumption of potassium but

also excessive loss of potassium from the body. Thus, it is often seen as a complication of

dehydration or diarrhea and malnutrition. The signs and symptoms of this include myalgia,

muscle cramps, tetany, slight change in blood pressure, constipation, etc. Serious effects of it

include respiratory depression and cardiac arrhythmias. The most important approach to treat this

disease is to include foods high in potassium in the diet. If the person is also suffering from

dehydration or diarrhea, then he will need fluid replenishment and treatment with antibiotics as

well.

1.10.7 Vitamin Deficiency is also commonly seen in many malnutrition diseases. Given below

is a list of the various vitamins and what their deficiency leads to:

1.10.7.1 Vitamin A Deficiency of it is relatively common in developing countries, though it is

rarely seen in developed countries. One of the most common symptoms causing due to the

deficiency of this vitamin is night blindness it can even lead to complete blindness if there is

severe depletion in the levels of this vitamin. Causing blindness due to vitamin A deficiency

among malnourished children can be seen all over the world. Other symptoms are increased

susceptibility to infections, lack of appetite, dry and rough skin and hair, and poor wound

healing. This Vitamin can be restored in the body with the help of including foods that are rich in

vitamin A in the diet.

1.10.7.2 Vitamin B1 or thiamine is a nutrient that is available in many sources, like yeast and

pork, which are obviously a rarity in malnourished environments. One of the most common

symptoms of this vitamin deficiency is the manifestation of beriberi. It is a nervous system

disorder, which leads to symptoms like severe lethargy and fatigue, inability to derive energy,

difficulty in walking, loss of muscle with muscle wasting and eventual complications of the

cardiovascular, nervous, muscular and gastrointestinal systems. It is also commonly seen in

alcoholics. The treatment of this will involve administration of thiamine in the form of thiamine

hydrochloride tablets or injections.

1.10.7.3 Vitamin B2 or R iboflavin deficiency is normally seen in conjunction with protein-

energy malnutrition diseases and is also seen in alcoholics. The signs and symptoms this vitamin

deficiency includes sore throat with swelling and redness of the mouth, cheilosis, angular



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stomatitis, glossitis, seborrhic dermatitis, etc. The deficiency symptoms can be reversed with the

help of including foods rich in riboflavin, like meat, eggs, cheese, yogurt, etc.

1.10.7.4 Vitamin B3 or niacin deficiency leads to a disease called pellagra. It often results from

alterations of protein metabolism in the body. People who have a staple diet of maize also often

end up suffering from pellagra. The signs and symptoms of it includes photosensitivity,

dermatitis, dementia, diarrhea, alopecia, insomnia, weakness, ataxia, etc. Cases of pellagra that

are left untreated have a high mortality rate, as the person can die within four to five years of

being diagnosed. To prevent this from happening, it is important to include niacin rich foods in

the diet.

1.10.7.5 Vitamin B12 deficiency is one of the most common deficiencies seen in the spectrum of

vitamin B deficiencies. It is found only in animal products; hence, a deficiency of this vitamin is

often seen in vegetarians. Signs of the vitamin deficiency include tingling sensation of tongue,

white spots on skin, mouth sores, shortness of breath, memory loss, headaches resembling

migraine attacks, etc. However, one of the most important and prominent symptoms of the

vitamin is megaloblastic anemia. This is the type of anemia where the red blood cells are large

and immature in nature.

1.10.7.6 Vitamin C or ascorbic acid is a vitamin that is found in citrus fruits. Although an

overdose of the vitamin is rare and the deficiency can be seen in developing countries habitually.

Deficiency of this vitamin leads to a condition known as scurvy and the symptoms like bleeding

gums, delayed wound healing, spots on skin and increased susceptibility to infections. This

vitamin can be obtained by eating fruits like oranges, lemon, lime, grapefruit, etc.

1.10.7.7 Vitamin D deficiency normally occurs due to inadequate intake of calcium coupled

with inadequate sunlight exposure. The symptoms of the deficiency of it include impaired bone

formation, thus, causing bone softening diseases like osteomalacia. It is also a major

contributing factor towards the development of osteoporosis in women living in developing

countries. To help prevent this from occurring, one needs to have a diet that is high in calcium

and foods with vitamin D. The Deficiency and Excess of Nutrients narrated in the table 2.

Table 2: Deficiency and Excess of Nutrients

Nutrients Deficiency Excess

Food energy Starvation, Marasmus Obesity, diabetes mellitus, Cardiovascular



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disease

Simple

carbohydratesnone diabetes mellitus, Obesity

Complex

carbohydratesnone Obesity

Saturated fat low sex hormone levels Cardiovascular disease

Trans fat none Cardiovascular Disease

Unsaturated fat none Obesity

Fat

Malabsorption of Fat-soluble

vitamins, R abbit Starvation (If

protein intake is high)

Cardiovascular Disease (claimed by some)

Omega 3 Fats Cardiovascular Disease Bleeding, Hemorrhages

Omega 6 Fats none Cardiovascular Disease, Cancer

Cholesterol none Cardiovascular disease

Protein kwashiorkor R abbit starvation

Sodium hyponatremia Hypernatremia, hypertension

Iron Anemia Cirrhosis, heart disease

Iodine Goiter, hypothyroidism Iodine Toxicity (goiter, hypothyroidism)

Vitamin A

Xerophthalmia and Night

Blindness, low testosterone

levels

Hypervitaminosis A (cirrhosis, hair loss)

Vitamin B1 Beri-Beri

Vitamin B2

Cracking of skin and Corneal

Ulceration

Vitamin B3

(Niacin)Pellagra dyspepsia, cardiac arrhythmias, birth defects

Vitamin B12 Pernicious anemia



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Vitamin C Scurvy diarrhea causing dehydration

Vitamin D R icketsHypervitaminosis D (dehydration, vomiting,

constipation)

Vitamin E nervous disorders Hypervitaminosis E (anticoagulant: excessive

bleeding)

Vitamin K Haemorrhage

Calcium

Osteoporosis, tetany,

carpopedal spasm,

laryngospasm, cardiac

arrhythmias

Fatigue, depression, confusion, anorexia,

nausea, vomiting, constipation, pancreatitis,

increased urination

Magnesium HypertensionWeakness, nausea, vomiting, impaired

breathing, and hypotension

PotassiumHypokalemia, cardiac

arrhythmiasHyperkalemia, palpitations

1.11 Health and Nutritional Programmes in India

1. 11.1 Programmes on Health Sector

Department of Health and Family Welfare, Government of India is administering the

various programmes/schemes and enacted various legislations on health sector and some of the

important are:

1. 11.1.1 National Diarrhoeal Diseases Control Programme was launched in 1981 to reduce

the mortality in children below five years due to diarrhoeal diseases through introduction of Oral

R

ehyderation Therapy (OR

T). The high priority accorded to the Programme is part of the package of services rendered under the MCH programme which was initiated during 1980-85

has now been strengthened extensively. The Anganwadi Centres of the ICDS Scheme have

served as nucleus for the propagation of this programme which has been found to be an effective

measure to prevent dehydration.



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1.11.1.2 Cancer Control Programme bridges the geographical gaps in the availability of cancer

treatment facilities across the country, the programme launched in 1975-76 was revised in 1984-

85 and subsequently in December 2004. At any point of time, it is estimated that there are nearly

25 lakh cancer cases and about 4 lakh deaths occurs every year in this country. In view of the

magnitude of the problem and the requirement this was initiated.

1.11.1.3 Mental Health Programme was started in 1982 with the objectives to ensure the

availability and accessibility of minimum mental health care for all, to encourage mental health

knowledge and skills and also to promote community participation in mental health service

development and stimulate self-help in the community. There was a shift in approach of mental

health care services from hospital based care to community based mental health care.

1.11.1.4 Emergency Facilities of State Hospitals located on National Highways for up

gradation & strengthening of Emergency Trauma Care Facility in State Government Hospitals

located on National Highways under the scheme ³Assistance for Capacity Building´ with a view

to provide immediate treatment to the victims of road traffic injury. The network of trauma care

facilities along the corridors will bring down the morbidity and mortality on account of

accidental trauma by observing the golden hour concept.

1.11.1.5 Prevention and Control of Diabetes, Cardiovascular Disease and Strokes a pilot

scheme has been launched in January, 2008 with the aim of prevention and control of non-

communicable diseases (NCDs) using health promotion and health education advocacy. The

early detection of persons with high level of risk of developing disease through opportunistic

screening and capacity building of health system at all levels to tackle NCDs and improvement

of quality of care. A well developing trained manpower at various health care set-ups in

Districts/States. The pilot scheme encompasses 10 States with one District each namely,

Kamrup, Assam; Jalandhar, Punjab; Bhilwara, R ajasthan; Jabalpur, Madhya Pradesh; Shimoga,

Karnataka; Kancheepruam, Tamil Nadu; and Thiruvananthapuram, Kerala. Under the Pilot

project, Health promotion activities were undertaken in 300 schools (30 in each district) and at

15 workplaces (1-2 workplace per district) in all the 10 States.

1.11.1.6 Central Government Health Scheme (CGHS) is a scheme for providing health care to

serving Central Government employees and their dependant family members. Over the years, the

scheme has bee extended to cover central government pensioners, their dependant family

members and certain other categories like members of parliament and ex-members of parliament,



20

freedom fighters etc., The membership of this scheme stood at 9.35 lakhs with 32 lakh

beneficiaries as on 31.3.2009. The beneficiaries are being provided health service through a huge

network of: Dispensaries (247 Allopathic, 82 Ayush), Yoga Centres (4), Polyclinics (19),

Laboratories (66), Dental Units (21) and Gynae±maternity Hospital (1). In addition, beneficiaries

enjoy medical facilities in around 400 private empanelled hospitals and around 170 diagnostic

centres, all over the country.

1.11.1.7 Health Minister¶s Discretionary Grant is a Financial Assistance to the poor and

indigent patients is given from the Health Minister¶s Discretionary Grant to defray a part the

expenditure on hospitalization/treatment in Govt. Hospital as these patients cannot be considered

for financial assistance under R ashtriya Arogya Nidhi due to income of above poverty line, but

less than R s.50,000/- per annum.

1.11.1.8 National Vector Borne Disease Control Programme is a comprehensive programme

for prevention and control of vector borne diseases namely Malaria, Filaria, Kala-azar, Japanese

Encephalitis (JE), Dengue and Chikungunya which is covered under the overall umbrella of

NR HM. The States are responsible for implementation of programme whereas the Directorate of

NVBDCP, Delhi provides technical assistance, policies and assistance to the States in the form

of cash & commodity, as per approved pattern.

1.11.1.9 Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was approved by

Government of India in March, 2006 with the objective of correcting regional imbalance in the

availability of affordable and reliable tertiary healthcare services and also to augment facilities

for quality medical education in the country. It has two components in its first phase - (i) setting

up of six AIIMS-like institutions and (ii) upgradation of 13 existing Government medical college

institutions.

1.11.1.10 Other Health Programmes are Prevention and Control of Deafness; Prevention and

Control of Fluorosis; National Filaria Control Program, R ashtriya Arogya Nidhi, Leprosy

Eradication Programme (NLEP); TB Control Programme (R NTCP); Programme for Control of

Blindness (NPCB); Iodine Dificiency Disorders Control Programme, National AIDS Control

Program, National Program for Prevention and Control of Deafness, Tobacco Control Program

and School Health Programs.

1.11.2 Rural Health Services



21

The health and family welfare programme in the country is being implemented through

primary health care system. In rural areas, primary health care services are provided through a

network of 146036 Sub-Centres, 23458 Primary Health Centres and 4276 Community Health

Centres as on March 2008 based on the following norms of population case load/work load and

distance. The population norms for SC/PHC/CHC are as follows:

1.11.2.1 Sub-Centre is the first peripheral contact point between Primary Health Care system

and the community. It is manned by one Female (ANM) and one Male Health Worker and one

LHV for six such Sub-Centres. These are assigned task relating to maternal health child health,

family welfare, nutrition, immunization, diarrhea control and control of communicable diseases.

These centers facilitated with basic drugs for minor ailments needed for taking care for essential

health need for women and children.

1.11.2.2 Primary Health Centre (PHC) is the first contact point between village community

and the Medical Officer. It is manned by a Medical Officer and 14 other staff. It acts as a referral

Unit for 6 Sub-Centres and has 4-6 beds for patients. It performs curative, preventive, promotive

and Family Welfare services. There are 23, 458 PHCs functioning in the country. These are

being strengthened under NR HM to provide a package of essential public health programmes

and support for outreach services to ensure regular supplies of essential drugs and equipment,

round the clock services in all PHCs across the country, upgrading single doctor PHC to 2

doctors PHC by posting AYUSH practitioners at PHC level, provision of 3 Staff Nurses in a

phased manner.

1.11.2.3 Community Health Centre (CHC) is established and maintained by the State

Governments and as per standards it is supposed to be manned by four Medical specialists i.e.

Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff.

It has 30 in-door beds with one OT, X-ray, and Labour room and Laboratory facilities and serves

as a referral centre for 4 PHCs. It provides facilities for emergency obstaetrics care and specialist

consultations. At present 4276 CHCs are functioning in the country. Indian Public Health

Standards lays down that this CHC is to be manned by 6 Medical Specialists including

Anaesthetics and an eye surgeon (for 5 CHCs) supported by 24 paramedical and other staff with

inclusion of two nurse midwives in the present system of seven nurse midwives.

1.11.2.4 Mobile Medical Units/Health Camps initiated with the objective to take health care to

the door step of the public in the rural areas, especially in under-served areas, these, have been



22

provided, one per district under NR HM. Two kinds of MMUs are envisaged, one with diagnostic

facility for the States other than North-East States, Himachal Pradesh and J&K. In addition, for

the North- Eastern States, Himachal Pradesh and J&K, specialized facilities and services such as

X-ray, ECG and ultrasound are proposed to be provided in MMUs.

1.11.3 Maternal Health Programmes

The promotion of maternal and child health has been one of the most important

objectives of the Family Welfare Programme in India. Under the NR HM and the R CH

Programme, the Government of India is actively pursuing the goals of reduction in Maternal

Mortality by focusing on the 4 major strategies of essential obstetric and new born care for all,

skilled attendance at every birth, emergency obstetric care for those having complications and

referral services. The other major interventions are provision of Safe Abortion Services and

services for R TIs and STIs. The National Population Policy 2000 and National Health Policy

2002 have set the goal of reducing MMR to less than 100 per 100000 live births by the year

2010.

1.11.3.1 Schemes for Improving Obstetric Care Services initiatives are under implementation

to achieve the goal of reduction in Maternal Mortality. These interventions are Essential

Obstetric Care; Quality Ante Natal care; Prophylaxis and treatment of Nutritional Anemia; Post

natal care for mother and newborn; Skilled Attendance at Birth; Provision of Emergency

Obstetric and Neonatal Care at FR Us; and R eferral Services at both Community and Institutional

level.

1.11.3.2 Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National

R ural Health Mission (NR HM) being implemented with the objective of promoting institutional

delivery among the poor pregnant women. It launched on 12th April 2005, is being implemented

in all states and UTs. It is a 100 % centrally sponsored scheme and it integrates the benefits with

delivery and post delivery care. Besides the maternal care, the scheme provides cash assistance

to all eligible mothers for delivery care. This programme has identified, the Accredited Social

Health Activist (ASHA) as an effective link between the Government and the poor pregnant

women. Here the main role is to facilitate pregnant women to avail Services of maternal care and

arrange referral transport. The Yojana subsidizes the cost of Caesarean Section or for the

management of Obstetric complications, up to R s. 1500 per delivery to the Government



23

Institutions, where Government specialists are not in position. All BPL pregnant women aged 19

years and above, preferring to deliver at home is entitled to cash assistance of R s. 500 per

delivery, up to two live births.

1.11.3. 3 Village Health and Nutrition Day (VHNDs) Organizing at Anganwadi centre at least

once every month to provide ante natal and post partum care for pregnant women, promote

institutional delivery and health education apart from other various services.

1.11.3.4 1odine Prophylaxis Programme was initiated by realizing the serious health and social

implications of the problem of iodine deficiency disorders Government of India launched a

National Goitre Control Nutrient Deficiency Control Programmes Programme (NGCP) in 1962.

This programme is now called the Iodine Prophylaxis Programme. The basis of the programme

was a study conducted in the mid-fifties in the Kangra Valley, by the Scientists of All India

Institute of Medical Sciences. The study showed that the prevalence of goitre comes down

considerably when the common salt supply to the population is replaced by iodized salt. In

keeping with the results of this study the control programme was initiated. The main objectives

of the control programme are to identify goitre endemic regions, supply iodized salt in place of

ordinary common salt in goitre endemic areas and assess the impact of the programme over a

period of time.

1.11.4 Child Health Programmes

Since the inception of the family planning Programme in 1951, and subsequent inclusion

of maternal and child health, focus has been on reducing the commonest cause of mortality

among the under fives in the country. The Infant Mortality R ate has declined from 134 per

thousand live births in 1947-50 to 53 per thousand live births in 2008, which is still high. There

is hence a firm commitment for the reduction of the MMR , IMR and the TFR under the National

R ural Health Mission (NR HM).

Some important child health programme are Navjaat Shishu Suraksha Karyakram

(NSSK); Integrated Management of Neonatal and Childhood Illness; Facility Based Integrated

Management of Neonatal and Childhood Illness (F- IMNCI); Sick New Born Care (SNCU);

Infant and young child feeding; Nutrition R ehabilitation Centres (NR Cs); School Health

Programme; and Home Based New Born Care.



24

1.11.4.1 Scheme of Oral Rehydration Therapy¶s main objectives of the scheme of oral

rehydration therapy is to reduce the incidence of death due to dehydration from diarrhoea

diseases, particularly among young children by promoting the use of oral rehydration solution

(OR S) to prevent dehydration and by educating mothers in this regard. Diarrhoea is a serious

health problem in our country, afflicting millions of young children every year. Children

exposed to poor environmental sanitation and hygiene, without access to safe drinking water; in

particular suffer from repeated episodes of diarrhoea. If immediate remedial measures are not

taken, it may even lead to the child's death.

1.11.4.2 Universal Immunization Programme was introduced in 1978 as Expanded

Programme of Immunization. This gained momentum in 1985 as Universal Immunization

Programme (UIP) and implemented in phased manner to cover all districts in the country by

1989-90. UIP become a part of Child Survival and Safe Motherhood Programme in 1992. Since,

1997, immunization activities have been an important component of National R eproductive and

Child Health Programme. Immunization is one of the key areas under National R ural Health

Mission (NR HM) launched in 2005. Under the Universal Immunization Programme Government

of India is providing vaccination to prevent six vaccine preventable diseases i.e. Diphtheria,

Pertussis, Tetanus, Polio, Measles and severe form of Childhood Tuberculosis.

1.11.4.3 Pulse Polio Immunization was initiated in the pursuance of the World Heath Assembly

resolution of 1988; this Programme was started nation-wide from 1995 to eradicate polio in India

covering children in the age group 0-3 years. In order to accelerate the pace of polio eradication,

all children under the age of 5 years were targeted since 1996-97. From 1999-2000 house to

house vaccination of missed children was also introduced to vaccinate children missed during the

fixed booth based vaccination of children.

1.12 Nutritional Programmes

1.12.1 Special Nutrition Programme was launched in the country in 1970-71. It provides

supplementary feeding to the extent of about 300 calories and 10 gm. of proteins to pre-school

children and about 500 calories and 20 gm. of protein to expectant and nursing mothers for 300

days a year. At present SNP is operated, as a part of the Minimum Needs Programme in the

various states. The nutrition component of the ICDS programme is funded by States and Union



25

Territories from the SNP budget. At present about 21.5 million beneficiaries are covered under

this programme.

1.12.2 Balwadi Nutrition Programme is being implemented since 1970-71 through five

national level voluntary organisations. The Central grant is given for. supplemerltary feeding of

children. It consists of 300 calories and 10 gm. of p' Aein per child per day for 270 days a year.

During 1991-92, about 0.23 million children in the age group 3-5 years in 5640 balwadis were

covered by the scheme.

1.12.3 Goitre Control Programme was initiated by the GoI in 1962 to identify goiter endemic

regions and to assess the impact of goitre control measures. The availability and production of

iodized salt and strengthening of administrative machinery controlling the entry of noniodized

salt in the endemic regions have been recommended as measpres to improve the implementaion

of the programme.

1.12.4 National Nutritional Anaemia Control Programme results from deficiency of iron and

folic acid in the body. A person suffering from anaemia feels weak and has a low capacity to

work. Nutritional anaemia is a widely prevalent problem in our country. It is especially affects

women in the reproductive age and young children. It is estimated that more than 50 per cent of

pregnant women in our country are anaemic. This is directly or indirectly responsible for about

one fifth of maternal deaths and is a major cause of premature births and low birth weight babies.

This programme aims at significantly decreasing the prevalence and incidence of anaemia in

women in the reproductive age group, particularly pregnant and lactating women, and preschool

children by giving them iron and folic acid tablets.

1.12.5 National Prophylaxis Programme for Prevention of Nutritional Blindness aims at

protecting children, between 6 months and 5 years of age, from vitamin A deficiency by giving

them large doses of vitamin A on periodic basis. An estimated 5 to 7 per cent children in our

country suffer from eye problems resulting from vitamin A deficiency. Night blindness and other

mild deficiency symptoms in the eye, for instance lack of luster, haziness and other changes such

as dry, foamy, triangular spots on the white part of the eye, can be cured with vitamin A therapy.

However, if the condition is untreated, the cornea in the eye gets severely damaged and blindness

results which condition cannot be reversed.

1.12.6 Nutritional Programme for Adolescent Girls (NPGA) was launched by the Planning

Commission initially for a period of two years i.e. 2002-03 and 2003-04 in 51 identified



26

disctricts i.e. in two of the backward districts in each of the major states and most populous

disctrict (excluding the capital district) in remaining smaller states/UTS in the country. This

scheme was restarted in 2005-06. The Ministry of Women and Child Development administers

the scheme at the central level and State/UT Governments implement the scheme. The

Department of Food and Public Distribution provides food grains at BPL rates to the States/UT

Government for implementing the programme through M/o Human R esources as shown in the

table 3.

Table3: Food Grains distributed for the programme (lakh tone)

Year Allocation Off take

Rice Wheat Total Rice Wheat Total

2002-03 0.40 0.22 0.62 0.11 1.01 1.12

2003-04 2.22 0.29 2.51 0.63 0.00 0.632004-05

2005-06 0.68 0.35 1.03 0.40 0.08 0.48

2006-07 0.41 0.07 0.48 0.16 0.05 0.21

S ource:

1.12.7 Reproductive and Child Health Second Phase project for India will help reduce

maternal mortality, child mortality and morbidity, lower fertility and the rate of population

growth through expanding the use of essential R CH services. The Project cost USD 2232

millions include funding from Work Bank and non-bank sources. 1.12.8 Integrated Child Development Services (ICDS) scheme integrates several aspects of

early childhood development and provides supplementary nutrition, immunisation, health check-

ups, and referral services to children below six years of age as well as expecting and nursing

mothers. Additionally, it offers non-formal pre-school education to children in the 3-6 age group,

and health and nutrition education to women in the 15-45 age groups.

1.11.9 Ayusmati Scheme the goal of this scheme is to reduce the incidence of Maternal

Mortality and Morbidity. The major objectives of the scheme are to increase the number of

institutional deliveries and to ensure the quality of services.

1.12.10 Central Rural Sanitation Programme was launched in 1986 with an objective of

improving the quality of the life of rural people and provides privacy and dignity to women. The

components of the programme households below the poverty line conversion of the dry latrines



27

to water pour flush toilets, construction of village sanitary complexes for women, setting up of

sanitary marts, intensive campaign for awareness creation and health education etc.

1.12.11 Nutrition Friendly Schools Initiative (NFSI) the main aim is to provide a framework

for designing integrated school based intervention programmes. It addresses the double burden

of nutrition-related ill-health and building on add interconnecting on-going school-based

programmes being implemented by various partner agencies like UNESCO, WHO, WOR LD

BANK etc.

1.12.12 Infant and Young Child Feeding Project (IYCF) the major objectives of the

programme are to create knowledge on Breastfeeding, Timely and appropriate complementary

child feeding, safe infant feeding communities affected by HIV, better maternal nutrition, and the

lactation. This programme was funded by USAID.

1.13 World Health Organisation Child Growth Standards (2011)

1.13.1 Anthropometric Indices

y For children the anthropometric indices were: Body mass index for Age Z-scores (BAZ),

Height-for-Age Z-scores (HAZ), and Weight-for-Age Z-scores (WAZ). These indices

allow comparison between children of different ages.

y Low Height-for-Age Z score (HAZ) indicates µstunting.¶ It is a good indicator for chronic

undernutrition as it does not vary according to short term factors, such as illness. Itsignifies poor environmental conditions.

y Body Mass Index (BMI) is used to compare weight to height ratio of different

individuals. BMI is calculated by dividing the weight in kilograms by the height in

meters squared.

y BMI±for-Age Z score (BAZ), compares BMI of child with the BMI of children of the

same age. Children who have low BAZ are described as being µwasted¶. Wasting is also

sometimes called global undernutrition or global acute malnutrition (GAM).

y Low weight-for-age (WAZ) indicates the child is underweight. Low WAZ may reflect

wasting or stunting. This general property makes WAZ a good indicator for nutritional

status (Onis & Blössner, 2003)20.

Z scores are in reference to The WHO Child Growth Standards (2011) median values as follows

BAZ <-2 SD indicates wasting.



28

BAZ <-3 SD indicates severe wasting.

HAZ <-2 SD indicates stunting

HAZ <-3 SD indicates severe stunting

WAZ <-2 SD indicates undernutrition.

WAZ <-3 SD indicates severe undernutrition.

The WHO growth reference is based on an international group of children. This is appropriate as

a comparison group, as all children grow similarly when their health needs are met. Also any

difference in growth between ethnicities is minor compared to the effect of environment.

(Physical Status...,1995).

For women body mass index (BMI) was used. BMI indicates an adult¶s health status. BMI was

calculated by dividing the weight in kilograms by the height in meters squared. For adults BMI

values are age-independent and the same for both sexes. However different populations have

different body proportion which means the same BMI of people in different nations may have

different nutritional status (WHO Global Database).

BMI classifications for Asian adults are as follows:

Severe thinness, BMI<16.00 (kg/m2)

Moderate thinness, BMI = 16.00 - 16.99 (kg/m2)

Mild thinness, BMI = 17.00 - 18.49 (kg/m2)

Healthy weight, BMI = 18.5-22.9 (kg/m2)

Overweight, BMI>23 (kg/m2)

The WHO international cut-offs are the same with the exception of the cut-off for overweight

being >25 (kg/m2)

1.14 Indian Public Health Standards (IPHS): Indian Public Health Standards (IPHS), which

detail the specifications of standards so that the citizen is confident of getting public health

services in the hospital. These standards are lain down in sub-centers, PHCs, CHCs,

Subdivisional/ Sub-district Hospitals and District Hospitals not only for personal and physical

infrastructure, but also for delivery of services and management. Each Hospital would, as part

of IPHS, be required to set up a R ogi Kalyan Samittee (R KS)/Hospital Management Committee)

which will bring in community control into the management of public hospitals.



29

1.15 Goals and Strategies for Eleventh Five Year Plan

1.15.1 Reducing Malnutrition

y Virtual elimination of acute severe malnutrition and reduction in malnutrition among

children under 3 years of age up to at least 25.3% by the end of XIth five year plan.

Malnutrition in children upto 5 years is to be brought down to atleast 30% by 2011.

y Exclusive breast-feeding to be increased to 75%. Complete feeding of infants aged 6-9

months to be increased to at least 80%.

y IYCF practices to be given priority for promotion of feeding best practices.

y Mission mode approach to combat malnutrition among children under 3 years in tribal

areas to be introduced.

y Expansion of Management of Child Malnutrition Scheme throughout the State including

establishment of Malnutrition Treatment Centres (MTCs) in district hospitals.

y Training component for management malnutrition to be strengthened.

1.15.2 Reducing Infant Morbidity & Mortality

y R eduction in Infant Mortality R ate atleast to 32/1000 by the end of XIth five year plan.

Complete immunization coverage to be increased to 90% of children.

y Strengthening Integrated Management Child hood Illness (IMCI) system.

y Empowering families for child care and development.

1.15.3 Reducing Maternal Mortality Ratio

y MMR to be brought down to atleast 148 per one lac of live births by the end of the XIth

five year plan.

y Promotion of institutional deliveries.

y Iron and Folic Acid supplementation to pregnant women.

y

Anemia in women to be reduced to 24.3% by the end of the XIth

five year plan.y Improvement in antenatal services to cover all pregnant women.

y Expansion in emergency delivery services.

y Efforts will be made to provide atleast one medical facility available for 24 hours within

15-20 km radius.



30

1.15.4 Goals and Strategies for Adolescent Girls in Eleventh Five Year Plan

y Issues concerning adolescent girls will be addressed keeping in mind the life cycle

approach.

y Kishori Shakti Yojana to be strengthened.

y School health check up programme to be initiated and expanded to all the schools

including educational institutions for girls.

y Programme on the lines of National Nutrition Mission for providing food grain to

adolescent girls upto 18 years weighing less then 35 k.g. needs to be promoted

throughout the state.

y Mid-Day-Meal programme for girls to be extended upto 10th class.

y Adolescent girls clubs to be formed and supported.

y Specific scheme for non-school going girls in 6 to 11 years of age to be formulated and

implemented.

1.15.5 Goals and Strategies for Nutrition in Eleventh Five Year Plan

y Separate department for food security and nutrition to focus on food security in an

integrated manner is recommended.

y Food and nutrition security and safety policy be developed and implemented.

y Special food and nutrition cell on the lines of Food & Nutrition Board to be setup.

y A system of demonstration in proper cooking methods including counseling on

nutritional requirements to be developed for creating awareness.

y The services of graduate/post-graduates of home science colleges to be utilized in

creating awareness regarding food security and nutrition.

y R egular inspections and quality checks to ensure clean and healthy foods for the

customers at each and every eating place.

y Food and Nutrition visitors proposed to be appointed. Participation of NGOs could be

promoted.y Supply chain under TPDS to be improved to ensure availability of food stock at FPSs.

y Department of Food & Civil Supplies to be strengthened in terms of manpower and

mobility.

y Civil Supplies Corporation recommended to be set up.



31

y Strict enforcement of Food Adulteration Act is to be ensured.

y Sufficient stock of food grain and other essential commodities to be maintained at

strategic points particularly in areas frequently facing drought situation.

y Grain Banks could be set up through women SHGs.

y Assessment of poverty levels need to be assessed regularly for appropriate management

of supplies.

1.16 Health and Nutritional Policies and Legislations

1.16.1 Constitutional provisions

Various ministries of the government of India have developed policies related to Health

and Nutrition. Some of the policies deal explicitly with adolescent health and development

issues, whereas others have done so implicitly. Important relevant policies and plans that have

been developed in India include:

1.16.1.1 The Children¶s Code Bill, 2000 presented to the former Prime Minister of Inida, Shri

Atal Behari Vajpayee at a high level meeting attended by Union Ministers and Child R ights

experts on November 14 by Mr. Justice CR Krishna Iyer, Chairperson of the National Expert

Group on Child R ights. The day was observed as the millennium's first children's day.

1.16.1.2 National Health Policy, 1983 (the draft National Health Policy 2000 is in the process

of finalization) aimed at attaining health for all through primary health care. While the policydid not mention adolescence specifically, it emphasized safe motherhood and child survival as

well as the need for the provision of health care for school-going children through the school

health program.

1.16.1.3 National Plan of Action for Children (Planning Commission of India), 1992

commits itself to ensure all rights to all children upto the age of 18 years. The Government shall

ensure all measures and an enabling environment for survival, growth, development and

protection of all children, so that each child can realize his or her inherent potential and grow up

to be a healthy and productive citizen.

1.16.1.4 Decade of the Girl Child, 1991±2000 Department of Women and Child Development

has formulated a National Plan of Action for the SAAR C Decade of the Girl Child (1991-2000

A.D.). The plan of Action is to ensure survival, protection and development of the girl child with

the ultimate objective of building up a better future for the girl child.



32

1.16.1.5 National Policy on Child Labor, 1987 scheme was started in 1988 to rehabilitate child

labour. The Scheme seeks to adopt a sequential approach with focus on rehabilitation of children

working in hazardous occupations & processes in the first instance. Under the Scheme, after a

survey of child labour engaged in hazardous occupations & processes has been conducted,

children are to be withdrawn from these occupations & processes and then put into special

schools in order to enable them to be mainstreamed into formal schooling system.

1.16.1.6 National Population Policy, 1997 & 2000 have developed by Indian states for

themselves. Where applicable, these have included concerns about adolescent health and

development. Adolescent health is the domain of the Ministry of Health and Family Welfare and

the Departments of Health and Family Welfare of the states. The Ministry is significantly

involved with the issues of nutrition and development of children, particularly girl children. The

major thrust to adolescent health, however, was given in the Policy. R ecognizing that the needs

of adolescents, including the need for protection from unwanted pregnancies and STIs, have not

been specifically addressed in the past, This Policy underscored adolescent health as a strategic

focus in achieving socio-demographic goals. It aims at ensuring that adolescents¶ need for

information, counseling, population education, and contraceptive services are accessible and

affordable; food supplements and nutrition services are available; and the legislation on restraint

of child marriage is enforced. It also emphasized that reproductive health services for adolescent

girls and boys are especially needed in rural areas, where adolescent marriage and pregnancy are

most prevalent.

1.16.1.7 National Education Policy, 1974 initiative was identified in this Policy, which

recognized the right to education for all segments of the population and made elementary

education for all children compulsory, including adolescent boys and girls. The programs have

been developed and implemented to universalize education and reduce school dropouts,

especially among adolescent girls. In many states, the education of girls is free until the graduate

and postgraduate levels.

1.16.1.8 National Youth Policy, 1986 and Draft New National Youth Policy, 2000 placed

adolescent health as a subsection under the health sector. Youth empowerment and gender justice

were recognized as the major thrust areas of the policy. Apart from various policies, several

legislative provisions have also been introduced that directly or indirectly protect the rights of

adolescents.



33

1.16.1.9 National Health Policy-2002 (NHP-2002)

The National Health Policy-2002 (NHP-2002) gives prime importance to ensure a more

equitable access to health services across the social and geographical expanse of the country. The

policy outlines the need for improvement in the health status of the people as one of the major

thrust areas in the social sector. It focuses on the need for enhanced funding and organizational

restructuring of the public health initiatives at national level in order to facilitate more equitable

access to the health facilities. An acceptable standard of good health amongst the general

population of the country is sought to be achieved by increasing access to the decentralized

public health system by establishing new infrastructure in deficient areas, and by upgrading the

infrastructure in the existing institutions. Emphasis has been given to increase the aggregate

public health investment through a substantially increased contribution by the Central

Government. Priority would be given to preventive and curative initiatives at the primary health

level through increased sectoral share of allocation.

1.16.1.10 National Health Policy -1983

The NHP, 1983, was the first attempt to synthesise recommendations of three important

earlier committees, the Bhore Committee of 1946 (Government of India, 1946), the Mudaliar

Committee of 1962 (Government of India, 1962), and the Shrivastav Committee of 1975

(Government of India, 1975, 1976) and the Alma Ata declaration of global demand of Health for

All by 2000. It was largely dictated by global slogans and the field realities in India. All targets

were set to be achieved by 2000, as was in Alma Ata declaration, IMR of 60 by 2000, MMR of

200 by 2000 etc. It also reiterated the resolution of taking health services to the doorstep of the

people and ensuring fuller cooperation of the community, it failed to even declare health care as

a fundamental right of the people and quieted the WHO preamble of 1948 that states, µThe

enjoyment of the highest attainable standard of health is one of the fundamental R ights of every

human being without distinction of race, religion, political belief, economic or social condition¶

None of the health impact goals set in NHP 1983 were achieved by 2000.

1.16.1.11 National Health Policy 2002 and NRHM 2005

The second major policy endeavor is National Health Policy 2002 (NHP 2002) and it closely

followed on the heels of the National Population Policy 2000 ( NPP 2000). Both policies grew

in the context of liberalization and globalization. The concept of Health for All and Health is a

Fundamental Human R ight that was the corner stone of the Soviet Health Policy was given a go



34

bye. After the collapse of the Soviet Union the health programs were also gradually privatized.

However ambitious health goals were set in NHP 2002. NHP 2002 was followed by a massive

National R ural Health Mission launched by the Prime Minister in 2005.

The National Health Policy-2002 (NHP-2002) gives prime importance to ensure a more

equitable access to health services across the social and geographical expanse of the country. The

policy outlines the need for improvement in the health status of the people as one of the major

thrust areas in the social sector. An acceptable standard of good health amongst the general

population of the country is sought to be achieved by increasing access to the decentralized

public health system by establishing new infrastructure in deficient areas, and by upgrading the

infrastructure in the existing institutions. Emphasis has been given to increase the aggregate

public health investment through a substantially increased contribution by the Central

Government. Ministry of Health and Family Welfare is responsible for ensuring safe food to the

consumers. This is done through the Prevention of Food Adulteration (PFA) Act 1954 and the

PFA R ules 1955 made there under. The Food Safety & Standards Act, 2006, a new law

encompassing the domains of various food related laws in the country has been enacted to

revamp the food safety requirements in keeping with modern day needs as well as the

international trend towards modernization. The new law aims to ensure safe, hygienic and

wholesome food for the citizens of the country. It bestows responsibility on the Food

manufacturers, traders etc. to manufacture and supply safe, hygienic and wholesome food. The

Act also provides for compensation to the victim or the legal representative to be paid by vendor

/manufacturer, in case of injury or death of consumer by adulterated / injurious food article. The

Food Safety and Standards Authority of India has been established to implement the provisions /

mandate of this new law, for laying down science based standards for articles of foods and to

regulate their manufacture, storage, distribution, sale and import to ensure the availability of safe

and wholesome food for human consumption.

1.16.1.12 The National Nutrition Policy

The National Nutrition Policy adopted by the Government of India in 1993 under the aegis

of the Depart ment of Women a nd Child Deve lopment, advocated a multi-sectora l

st rategy for eradicating malnutrition and achieving optimum nutrition for all. The

implementation strategy involves setting up Inter Sectoral Coordination mechanism at Centre,

State and District levels, Advocacy and sensitisation of policy makers and programme



35

managers, intensifying micronutrient malnutrition control activities, reaching nutrition

information to people, establishing nutrition monitoring and mapping at State,

District and Community level, and developing district-wise disaggregated data on

nut rit ion. Develop ment of S ta te Pla ns o f Acton on Nutrition by respective States was also

an important mandate. The Objectives of the Policy are:

y To reduce the incidence of severe (8.7 per cent) and moderate (43.8 per cent)

malnutrition by half by the year 2000 A.D.

y All adolescent girls from poor families to be covered through the ICDS by 2000 A.D. in

all CD blocks of the country and 50% of urban slums.

y To increase per capita availability of 215Kg, for that, to achieve production targets of 230

MT by 2000.

y At least 100 days of employment created for each rural landless family, employment

opportunities in urban slum dwellers and urban poor.

y Distribution of iodized salt to cover all endemic areas.

y Nutritional blindness to be completely eradicated by 2000 A.D.

y To expand the Nutrition intervention net through ICDS so as to cover all vulnerable

children in the age group 0 to 6 years.

1.16.1.13 National Rural Health Mission (NRHM) launched in 2005, the difficult areas with

unsatisfactory health indicators were classified as special focus States to ensure greatest attention

where needed. The thrust of the Mission is on establishing a fully functional, community owned,

decentralized health delivery system with inter-sectoral convergence at all levels, to ensure

simultaneous action on a wide range of determinants of health like water, sanitation, education,

nutrition, social and gender equality. The mission is shifting the focus to a functional health

system at all levels, from the village to the district. The architectural correction envisaged under

NR HM is organized around five pillars, each of which is made up of a number of overlapping

core strategies. These five fillers are: (1) Increasing Participation and Ownership by the

Community, (2) Improved Management Capacity (3) Flexible Financing (4) Innovations in

human resources development for the health sector, and (5) Setting of standards and norms with

monitoring.

1.17 National Health Legislative Acts



36

Besides constitutional provisions, some other legislative acts have been promulgated to

safeguard the health and some of the National Health Legislative Acts are:

y Workmen¶s Compensation Act 1912

y The Child Marriage R estraint Act 1929

y The R ed Cross Society Act (Allocation of Property) 1936

y The Drugs and Cosmetic Acts 1940

y The Indian Nursing Council Act 1947

y The Dentist Act 1948

y The Pharmacy Act 1948

y The Drugs (Control) Act 1948

y The Minimum Wages Act 1948

y The Factors Act 1948

y The Employees State Insurance (ESI) Act 1948

y The Plantation Labor Act 1951

y The Mines Act 1952

y The Prevention of Food Adulteration Act 1954 (Amended 1956, 1964,

1971, 1976, 1986)

y The Indian Air Craft (Public Health) R ules 1954

y The Indian Medical Council Act 1956 (Amended 1964, 1993 and 2001)

y The Children Act 1960

y The Maternity Benefit Act 1961

y The Atomic Energy Act 1962

y The R egistration of Birth and Death Act 1969

y The Medical Termination of Pregnancy (MTP) Act 1971 (R ules 1975)

y The Water (Prevention and Control Pollution) Act 1974

y The Air (Prevention and Control Pollution ) Act 1981

y The Dangerous Machines (R egulation) Act 1983

y The Narcotic Drugs and Psychotropic Substance Act 1983

y Juvenile Justice Act 1986

y The Child Labor (Prohibition and R egulation) Act 1986



37

y The Environment (Protection) Act 1986

y The Consumer Protection Act (CPA) 1986

y The Epidemic Diseases Act 1987

y The Mental Heath Act 1987

y The R ehabilitation Council of India Act 1992

y The Transplantation of Human Organs Act 1994

y The Pre-natal Diagnostic Techniques (R egulation and prevention of misuse) Act 1994

y The Persons with Disabilities (Equal Opportunity, Protection of R ights and Full

Participation) Act 1995

y The National Environmental Tribunal Act 1995

y The Biomedical Waste (Management and Handling) R ules 1998

y Immoral Traffic (Prevention) Act, 1956

y The Prenatal Diagnostic Techniques (R egulation and Prevention of Misuse) Act of 1994.

1.18 Committees on Health and Nutrition

1.18.1 Sir John Bhorewas Committee ± 1943 for the first time a committee headed by Sir John

Bhorewas appointed to study the existing health conditions and make recommendations to

prevent communicable diseases, promote health and provide basic health care. It submitted its

report in 1946; the major recommendations therein still form the basis of the Indian public health

system. The committee concentrated on preventive medicine and tried to link health with social

justice. It gave some pragmatic directions recommending population based national net work of

maternity sub-centers (SC-one for 20,000 population), a primary health center ( PHC-one for one

lakh population) and a secondary center , also called the referral center ( SHC-one for each

taluka or teshil) and a specialized hospital with teaching facilities at the district level.

1.18.2 The Mudaliar Committee ± 1962 gave its report in 1962 concentrated on medical

education and development of training infrastructure for static medical units.1.18.3 The Shrivastav Committee ± 1975 gave its report in 1975 urged the training of a cadre

of health assistants to serve as links between qualified medical practitioners and multipurpose

workers (e.g. school teachers, post masters, gram-sevaks, etc.).

1.19 Institutional mechanism for Health and Nutrition



38

1.19.1 National Nutrition Monitoring Bureau (NNMB) was established under the aegis of

Indian Council of Medical R esearch in the year 1972, with the Central R eference Laboratory at

the National Institute of Nutrition (NIN), Hyderabad. It carries out surveys under the guidance

of a Steering Committee and has been generating dynamic database on diet and nutritional status

of the communities regularly, since inception and it has the following objectives:

To collect, on a continuous basis, on representative segments of population in each of the

States, data on dietary pattern and nutritional status adopting standardized and uniform

procedures and techniques, and

To periodically evaluate the ongoing national nutrition programmes to identify their strengths

and weaknesses and to recommend appropriate corrective measures.

1.19.2 Food and Nutrition Board as reconstituted on 26 July 1990, advises Government,

coordinates and reviews the activities in regard to food and nutrition extension/education;

development, production & popularization of nutritious Foods and Beverages; measures required

to combat deficiency diseases; and 'Conservation and efficient utilization as well as

augmentation of food resources by way of food preservation .and processing.

1.19.3 National Family Health Survey (NFHS) has undertaken height and weight measurement

in a representative sample of children and women at state level. NFHS (I, II &III) provides valid

state level estimates of under nutrition and comparable state level estimates at two time points

i.e. 1992-93, 1998- 99 and 2005-06.

1.19.4 National Sample Survey Organization (NSSO) Conducts every five years the

information on expenditure on food at family level is collected on a statistically adequate and

representative sample all over the country. This information is used to calculate poverty levels

based on expenditure on calories. The disadvantages are that this does not provide information

on dietary consumption at the family and individual level and does not assess nutritional status;

the survey is done only once in 5 years. However, if coupled with the NNMB survey, the data

may provide excellent insights into changing dietary patterns in India.

1.19.5 The Nutrition Society of India (NSI), Hyderabad established in 1967 is an association of

nutrition professionals, programmers and policy makers from India and abroad. It is dedicated to

disseminate the results of the latest research in nutrition ± basic and applied aspects; analyse the

current status of nutrition programmes in the country and recommend appropriate strategies to

promote nutrition of the community at large. The NSI, through its annual meetings provides a



39

forum for young scientists to present their research findings. It is the recognized Indian

representative of

y International Union Nutritional Sciences (IUNS), through the adhering body, Indian

National Science Academy (INSA), and

y Federation of Asian Societies of Nutrition

1.19.6 National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide

accessible, affordable and accountable quality health services to the poorest households in the

remotest rural regions.

i. Establishment of New Born Care facilities and Facility Based Integrated Management of

Neonatal and Childhood Illnesses (F-IMNCI)

ii. Navjaat Shishu Suraksha Karyakram

iii. Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and Pre-Service

IMNCI

iv. Home Based Care of Newborns

v. Universal Immunization

vi. Early detection and appropriate management of Acute R espiratory Infections, Diarrhoea

and other infections

vii. Infant and young child feeding including promotion of breast feeding

viii. Management of children with malnutrition

ix. Vitamin A supplementation and Iron and Folic Acid supplementation School Health

Programme.

1.20 Trends in Policy Development

Although the National Health Policy (NHP) in India was not framed until 1983, India has

built up a vast health infrastructure and initiated several national health programmes over last five

decades in government, voluntary and private sectors under the guidance and direction of various

committees (Bore, Mudaliar, Kartar Singh, Srivastava), the Constitution, the Planning Commission,

the Central Council of Health and Family Welfare, and Consultative Committees attached to the

Ministry of Health and Family Welfare. The period after 1983 witnessed several major

developments in the polices impacting the health sector - adoption of National Health Policy in

1983, 73rdand 74th Constitutional Amendments in 1992, National Nutrition Policy in 1993,



40

National Health Policy in 2002,National Policy on Indian System of Medicine and Homeopathy in

2002, Drug Policy in 2002, introduction of Universal Health Insurance schemes for the poor in

2003, and inclusion of health in Common Minimum Programme of the UPA Government in 2004.

The first National Health Policy in 1983 aimed to achieve the goal of `Health for All' by

2000 AD, through the provision of comprehensive primary healthcare services. It stressed the

creation of an infrastructure for primary healthcare; close co-ordination with health-related services

and activities (like nutrition, drinking water supply and sanitation); the active involvement and

participation of voluntary organisations; the provision of essential drugs and vaccines; qualitative

improvement in health and family planning services; the provision of adequate training; and medical

research aimed at the common health problems of the people. The main objective of the revised

National Health Policy, 2002 is to achieve an acceptable standard of good health among the

general population of the country and has set goals to be achieved by the year 2015. The major

policy prescriptions are as follows:

y Increase public expenditure from 0.9 percent to 2 percent by 2010.

y Increase allocation of public health investment in the order of 55 percent for the primary

health sector; 35 percent and 10 percent to secondary and tertiary sectors respectively.

y Gradual convergence of all health programmes, except the ones (such as TB, Malaria,

HIV/AIDS, R CH), which need to be continued till moderate levels of prevalence are

reached.y Need to levy user charges for certain secondary and tertiary public health services, for

those who can afford to pay.

y Mandatory two year rural posting before awarding the graduate medical degree.

y Decentralising the implementation of health programmes to local self governing bodies

by 2005.

y Setting up of Medical Grants Commission for funding new Government Medical and

Dental colleges.

y Promoting public health discipline.

y Establishing two-tier urban healthcare system - Primary Health Centre for a population of

one lakh and Government General Hospital.

y Increase in Government funded health research to a level of 2 percent of the total health

spending by 2010.



41

y Appreciation of the role of private sector in health, and enactment of legislation by 2003

for regulating private clinical establishments.

y Formulation of procedures for accreditation of public and private health facilities.

y Co-option of NGOs in national disease control programmes.

y Promotion of tele medicine in tertiary healthcare sector.

y Full operationalisation of National Disease Surveillance Network by 2005.

y Notification of contemporary code of medical ethics by Medical Council of India.

y Encouraging setting up of private insurance instruments to bring secondary and tertiary

sectors into its purview.

y Promotion of medical services for overseas users.

y Encouragement and promotion of Indian System of Medicine.

Through the 73rdand 74th Constitutional Amendment Acts (1992), the local bodies

(Municipalities and Panchayat) have been assigned 29 development activities, which have a direct

and indirect bearing on health. These include health and sanitation (covering hospitals, PHCs and

dispensaries), family welfare, drinking water, women and child development, the public distribution

system and poverty alleviation programmes.

The Common Minimum Programme announced by the UPA government in 2004 has

proposed to raise public spending on health to at least 2-3 percent of the Gross Domestic Product

(GDP) over the next five years, with focus on primary healthcare. The present Government has

proposed to take all steps to ensure availability of life saving drugs at reasonable prices through

revival of Public Sector Units in the manufacture of critical bulk drugs. The budget 2004-05 has

proposed three major initiatives in the health sector. They are: (i) redesigning the Universal

Health Insurance scheme introduced in 2003 to make it exclusive for below poverty level people

with a reduced premium (ii) introduction of Group Health Insurance scheme for members of Self

Help Groups and Credit Link Groups at a premium of R s 120 per person for an insurance cover

of R s 10000, and (iii) exemption of income tax for the hospitals working in rural areas.

1.21 Health Expenditure

The amount allocated during five year plans in India for health and family welfare and total

investment can be seen in the table 4.



42

Table 4: Status of Expenditure in F YPs (Rs. in Crores)F YPs Total Plan Investment Health Family Welfare

I 1960.0 65.2 0.1

II 4672.0 140.8 2.2

III 8576.0 225.0 24.9

IV15778.8 335.5 284.4

V 39322.0 682.0 497.4

VI 97500.0 1821.0 1010.0

VII 180000.0 3392.0 3256.2

VIII 798000.0 7575.9 6500.0

IX 859200.0 10818.0 15120.2

X 1484131.3 31020.3 27125.0

XI 2156571.0 136147.0

(S ource: S tate Institute of Health and F amily Welfare, Jaipur)

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Websites

www.wcd.nic.inwww.nipccd.nic.in

www.worldbank.org

www.cag.gov.in

www.wcd.nic.in/icds.htm

good health is fundamental to living a productive life

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