UNIT' 6 NUTRITIONAL AND SCHOOL

HEALTH PROGRAMMES I

Structure I

6.0 Objectives , .
6.1 Introduction
6.2 National Nutrition Programme
6.2.1 Special Nutrition Programrne (SNP)
6.2.2 Balwadi Nutrition Programme (BNP)
6.2.3 Mid-day Meal Programme (MDM)
6.2.4 ICDS Scheme
6.2.5 Applied Nutrition Programme
6.2.6 Tamil Nadu Integrated Nutrition Programme (TJNP)
6.2.7 National Nutritional Anaemia Prophylaxis Programme
6.2.8 Vitamin AProphylnxis Programme
6.3 School Health Progranzme
6.3.1 Benefits of School Health Programme
5.3.2 Components of School Health Progranune
6.3.3 Role of Community Health Nurse
6.4 Let Us Sum Up
6.5 Answers to Check Your Progress

6.0 OBJECTIVES
After completing this unit, you will be able to:
list and describe various nutritional programmes in India;
describe the organization and functioning of ICDS Scheme;
*
identify the beneficiaries in an ICDS project;
describe components of school health programme; and
describe the role of community health nurse in school health programme.

6.1 INTRODUCTION
You have read the principle of nutrition and dietetics in Block 5 of Applied Sciences,
BNS-102. Community programmes on nutrition are aimed at translating these
principles into practice. As nutrition has a wide implication, v ~ i o u Ministries
s have
2
started their programmes. The nutritional health programmes are basically three i,e.,
programme related to suppIementation of Vitamin A, Iron and Iodine. The Vitamin
A and Iron supplementation are covered under CSSM programme and has been
discussed in Unit 1. Provision of Iodine to check iodine deficiency disorders is
discussed in Unit 4.
The Ministry of Human Resource Development runs programmes for dietary
supplementation and the Ministry of Agriculture, Ministry of Food and Civil Supply
runs prograrnines for more availability of food. All these are described'in this unit.
As you will be directly involved with ~ntegratedChild Development Services
1 (ICDS) Scheme, a separate section has been devoted for this. Water supply and
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sanitation is also included in the supportive services component of ICDS, Hence,
i this national programme has been also dealt here, separately. Hope, after reading
I
these programmes, you will be able to guide your patients in utilizing the nutritional
/ services in a better way. 129
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Role of Nurse in National
Health Prnrrrnrnrne~ 6.2 NATIONAL NUTRITION PROGRAMME
1 . We shall discuss about various Nutritional Programmes iqfollowing sub-sections.

6.2.1 Special Nutrition Programme ( S N P )

The programme was initiated in 1970 to provide supplementary nutrition to below 6
L'
years age group and to pregnant and lactating mothers. Provision was made for
supply of Vitamin A to children and Iron (IFA) tablets to pregnant ladies.
Supplements were provided for 300 days a year. The beneficiaries of this
programme are gradually transferred to the ICDS progrqmme which will be
discussed later on. Indeed, the beneficiaries of both the programmes are of similar
type.

6.2.2 Balwadi Nutrition Programme (BNP)

This is being implemented through voluntary agencies like the Central Social
Welfare Board (CSWB), Indian Council of Child Welfa~e(ICCW), Harijan Sevak
Sangh, Adimjati Sevak Sangh, Kasturba Gandhi National Memorial Trust, etc. The
target group are preschool children of 3 years to 5 years. The provision for diet
supplementation is for 270 days a year. The diet contains 300 calorie and 10 gm
proteinlday. The children are also given preschool education. Provision is made to
take care of emotional and social development of children.

6.2.3 Mid-Day Meal Programme (MDM) ,

This is also called 'Noon Meal Programme' which means meals are served around
mid-day or noon. The target group is 6-11 years of children who are attending the
school. This was also launched in 1962 and aimed at increasing the school
attendance in addition to taking care of their health. Mid-day meal programme was
launched mainly in primary schools with the objective of:
Improving school attendance,
Reduce dropout, and
Child nutrition.
This programme covers 21.1 million children of class I to V standard. Food grains
are pvovided at the rate of 3 kg per mnontll. Provision is made for 300 calorie and
8-12 gm of proteidday to beneficiary. This is provided for 200 days in each year,
Central government supplies all requirement of cost for its implementation in rural ;
areas. Panchayats and Nagarpalika are involved fox setting up necessary
infrastructure for preparing cooked Eood. NGO, women's group and parent teacher
, ~ p n c i l scan be also utilized. In several areas supplelnentary feeding programme
are assisted by Cooperative American Relief Everywhere (CARE) and world food
programme, I
 6.2.4 ICDS Scheme Nutritional and School
Health Programmes
other and child forms more than 60 per cent of Indian Population. Out of this is
underfive children and pregnant women are the most vulnerable in terms of
morbidity and mortality. In addition, early childhood forms the foundation of
physical, psychological and social development of future citizen. Realizing the
implication of the development of mother and child on the future of country the
Government of India launched the ICDS Scheme in 1975 in 33 experimental project
areas. Success of scheme lead to it's expansion to 2996 projects and now goal is
universalization of ICDS throughout the country.

The ICDS scheme aims at improving the nutritional and health status of children 0-6
year age group, laying the foundation for all round development of child including .
reduction of the school dropout and enhance the capability of mothers to look after
their children.

Objectives of ICDS. '

- Improve nutrition and health status of children in the age group of 0 - 6 years
- Lay foundation of proper psychological, physical and social development of the
child
- Effective coordination and implementation of policy amongst the various
departments
- Enhance the capability of mother to look after the normal health and nutritional
needs through proper nutrition and health education.

The objectives of the 'ICDS scheme is realized through a package of services.

Package includes:

i) Supplementary nutrition, Vitamin A, Iron and Folic Acid

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ii) Irmnt~nization

iii) Health check up

iv) Referal services

v) Tsedtment of minor ailments

vi) Nutrition and health education to women and children

vii) Non-formal education and pre-school education of children.

The beneficiaries of the services are the children below 6 yc5ars age, expectant and
nursing mothers and women in the 15-45 years age group and adolescent girls in
selected blocks.

Scheme of Adolescent Girls

There was gap in between women and child age group which was not covered by
any health ,and social welfare programmes where girls in the crucial groups need
special attention. They need appropriate nutrition, education and health education,
training for motherhood etc., training for acquiring skills as the base f o i earning an
independent livelihood. A scheme for adolescerit girls in ICDS was launched by
Department of Women and Child Development, Minisixy of Human Resource
Development in 1991, I

Common services for all adolescent girls in the age group of 11 to 18 years were
131
planned, These were:
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 Role of Nurse in National
Health Programmes - Watch over menarche
- Immunization
- General health checkup once in evely six months
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-. 7 Dewordng
- Prophylactic measures against anemia, goiter and vitainin deficiency
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- Referral to PHC and district hospital.

This scheme is extended to 3.5 1 lakh adolescent girls in 507 ICDS blocks covering
all states and UTs. It is proposed to extend to 2b00 community development blocks
covering 12.8 lakhs adolescent girls?

The service delivery unit is knbwn as a Project and the In-charge is called child
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Development Project Officer (CDPO). The projects are identified as RuraWrban
or Tribal. Each rurallurban project covers a population of 1 lakh whereas the tribal
projects cover only 35,000 population.

Each project is subdivided into smaller &ts. The smallest unit is known as
Anganwadi which covers a population cf 1000 in ruralturban projects and a
population of 750 in tribal projects. lie, In-charge of the Anganwadi is called
Anganwadi Workers (AWW) who is usually selected from the community and is
wkll versed in cooking the traditional 1 cal preparations. Helper is given a training of
8 days. , P
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The A"WW is supervised by the Supervisor called 'Mukhya Sevika' (MS). One MS
is appointed for 25 u r b d 2 0 rural/l7 tribal Angawadi. The cluster of Anganwadi
under one MS is known as a Sector. Thus, each project has about 4-5 sectors. The
relationship of these divisions with health set up is discussed in next sub-section.

Organizational Set Up

The primary responsibility lies with the Department Of Women and Child
Development (DWCD) in Ministry of Human Resource Development. But the
health and nutrition component is being monitored by the health ministry, The
coordination between the two different ministries at different levels is shown in
Fig. 6.1.

The health personnel involved in the ICDS scheme are desipated as 'Advisor' for
their contribution towards the ICDS scheme. The M.0, of PHC is called as Sector
Advisor (SA), the M.O. I/C of Community Health Centre is called Project Advisor
,(PA), the DistrictlSub-district medical officer supervising activity of PA is called
District Advisor (DA) and the Chief District Medical Officer is called Chief District
Advisor (CDA). The Director of Health Services coordinates the ICDS activity of
the state and are called state coordinators. The Deputy Director of Health Services
is also designated as Senior Advisor. He helps the state coordinator in his
functioning.

The M,O. of PHC along with LHV and MPW (F) discharges his responsibility ,
towards ICDS in the area. There is some overlap of area between the Sector ahb
the PHC. It is because the serving population of each are different. However, for
the purpose of ICDS, one M.O. is identified (irrespective of his place of duty a
PHCICHC) for each sector and thus under one PA, there would be about 4 Sector
Advisors.

The hierarchy from social welfare side is as shown in Fig. 6.1 i.e. AWW CDPO
Project Officer.
 Nutritional and School
Health Progranlmes

DirectorIProjectOfficer In-

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N.0.of PHC (SA)
Lady Health Visitor (LHV)
4
Multipurpose Worker MPW (F)

Fig. 6.1: Organisational Chart

Programme Activity
i) Service Delivery
The activities in health comnponent of the package of services is same as the
National Health Programmes i.e. Immunization, is same as UIP. Health check up '

covers antenatal, postnatal, newborn care and general health check up of child
under five years. IFA, deworming tablets, Vitamin A, etc., is made available. ,
Patients are given referral advice to attend higher health set up as and when
required. The MPW (F) and the LHV provide the check up under guidance of
M.O. of PHC,
Supplementarynutrition is given to all children attending the non-fonnal edi~cation,
to at-risk children and moderately malnourished children. The severely
malnourished children are given therapeutic nutrition. The calorie and protein
supplement is as mentioned below:
 Role of Nurse In National The grading of nutritional status is done by measuring the weight of the child and
Health Progra~nmes
plotting the weight against the growth card.
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1 The aim of therapeutic nutrition for severely malnourished is to provide 1000-1200
calorie and 20 gm protein. These are to be provided in 4 feeds out of which 2 feeds
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are provided at anganwadi. Usually, the food is made available for 300 days a year.
Nutrition and health education to mother covers all possible message aimed at
healthy child, proper diet, hygiene, safe motherhood, etc.
The non-formal preschool education (NFPSE) aims at foundation for proper
physicaI, psychological, cognitive and social development of the child, around 40 -
50 children between 3 to 5 years are enrolled and about 2 hours per day is spent by
the AWW for this purpose. The programme starts with a prayer. The children are
informally exposed toalphabets, few rhymes, etc. Chalk, models, blocks, cut papers,
paints, toys, clay, etc. are usually used in teaching.
ii) Monitoring
Monitoring of the implementation of activities is carried out by respective ministries.,
The Anganwadi worker makes a monthly report and submits one copy to SA and '
the other copy to CDPO kough the MS. Every month a meeting of SA is held with
the 'AWW of his sector along with the MS. At the end of the meeting a sector level a

reorientation training session is taken by the SA, The reports of performance by

AWW of each sector is compiled at project level after discussion in a meeting and
the PA sends a report to Central Technical Committee located at Delhi. This
meeting is usually also attended by the DA of the district and an orientation training
session is also taken by the DA. One DA is responsible for 3 to 4 projects. Thus
cvery month PA, DA and CDA compile the activity reports separately at respective
level and send to CTC. These reports are known as PA report, DA reporl and CDA
report respectively.
Central Technical Committee (CTC) on health monitors and evaluates the health ,

and nutrition component of ICDS. CTC was started in 1976 and was located in All
India Institute of Medical Sciences (AIlMS). Since August 1995, CTC is renamed
as CTC-IMCD (Central Technical Committee - Integrated Mother and Child
Development) and is registered as a semi autonomous organization.
iii> Training . .
Training of CDPO is carried out by the National Institute of Public Cooperation and
Child Development (NIPCCD) which is an autonomous organization wder Deptt.
of Women and Child Development. The training is for 2 months. Refresher training
is given at NIPCCD and also by the ICDS consultants.
The Mukhya Sevika (MS) is trained for 3 months at NIPCCD or in Middle Level
Training Centre (MLTC)identified by NIPCCD. The AWW is trained in
Anganwadi Training Gentes (AWTC) which are managed by Indian Council for
Child Welfare (ICCW), Home Sciences Colleges, Schools of Social Sciences, etc.
The training of SA, PA, DA, CDA is done by the ICDS Consultant, ICDS
Consultants are usually the faculty of Obstetric and Gynae. PaediatsicsPSM deptt. ,
of medical colleges who are identified by the state coordinator for this purpose.
Each consultant is given the responsibility for few districts. The ICDS consultant
carries our. training for all types of medical officers of.the allotted area and also
conducts surveys to help CTC assess the impact of ICDS services periodically.
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iv) Achievements 1
New ICDS is effective in 5171 community development blocks and major urban :
slums through out the country. As against 2.27 crore beneficiaries until arch 1997,
there were 3.4 crore beneficiaries in April 2001. Today the scheme reached out to i
about 54 lakh expectant and nursing mother and 288 lakh children under six years Nutritional and School
Health Programmes
of age belonging to the disadvantaged groups.
Implementation is closely monitored at regular intervals. Department of Women and
Child Development has'installed a microcomputer and a special software has been
developed for ICDS for periodic monitoring and quarterly status reports.
Performance reports are sent to the states nodal departments. Copies of reports are
sent to the Planning Commission, PM Office, Department of Programme
Implementation.
In spite of big infrastructure developed under ICDS programme the nutritional
status of the women and children remain. almost same as of previous years.
Reasons for lack of improvement in nutritiohal status in ICDS areas include:

1) Inadequate coverage below 3 years of age who are at greatest risk of

malnutrition. It is provided in the programme that 0-6 years children will be '
covered however in reality only 3-6 years age group is covered. Very little is
done to cover the 0-3 years age group children. Similarly pregnant and lactating
women hardly benefite from this programme.

2) Irregularity of food deliveries to anganwadis and hence irregular feeding and

inadequate rations

3) Poor nutrition education to improve feeding practices at home

4) . Inadequate training of workers in nutrition, growth monitoring and

, communication

5 ) Poor supervision

6 ) Poor coordination and linkage with health workers

7) Lack of community ownership and participation

8 ) Poor quality of feed which is not well accepted by majority of children.

URBANmURAL PROJECT
(1,00,000 population, 100 villages)
 . .
Role of Nurse in National TRIBAL PROJECT
Health Programmes
(35,000 population, 590 villages)

................................................

Though ICDS scheme is a responsibility of Department of Wolne~land CIlild

~evelb~rnent,
the health personnel has an,imporlant role to play. The health
 persannel should consider this as an extra manpower and resource input for the i School
~ r ~ t r i t i o n aand
Health Programmes
betterment of health care deliiery to mother and child. Thus they should work with
a team spirit and cooperate with each other at every step for a better functibning.
The following points may be emphasized by the PHN during her visits:

i) The supplemental nutrition at anganwadi should not replace the normal food of
the child or pregnant ladies

ii) The growth chart should be maintained for all children and grading of
nutritional states be done accordingly
iji) All the severely malnourished should be referred to doctor to rule out other
medical causes of failure to thrive like tuberculosis, systemic diseases, etc.
iv) At least, 4 physical examinations to be carried out during antenatal period out
. of which one should be after 36 weeks of pregnancy

v) Two visits must be made within 10 diys of delivery. Mother must be told to
practice absolute breastfeeding.

6.2.5 Applied Nutrition Programme

The Applied Nutrition Programme (ANP) was introduced as a pilot scheme in
Orissa in 1963 which later on extended to Tarnil Nadu and Uttar Pradesh with the
objectives of : a) promoting production of protective food such as vegetables and
fruits and b) ensure their consumption by pregnant and nursing mothers and
children. During 1973, it was extended to all the states of the country. The
Nutritional Education was.l.he main focus and efforts were directed to teach rural
communities through demonstration how to produce food for their consumption
through their own efforts. The beneficiaries are children between 2-6 years and
prignant and lactating mothers. Nutrition worth of 25 paise per child per day and 50.
paise per woman per day ase provided for 52 days in a year. But this prog~amme
did not produce any impact. The conmunity kitchens and school gardens could not
function properly due to lack of suitable land, irrigation facilities and low financial
investment.

6.2.6 Tamil Nadu Integrated Nutrition Programme (TUVP)

The Tmnil Nadu Integratyd Nutrition Project was started in 1980 targeting at 6-36
months old cl~ildren,and pregnant and lactating women. TINP aimed at:
To reduce malnutrition LIP to 50 per cent among children under 4 years of age;
To reduce infant inortality by 25 per cent;

To reduce i it am in^ deficiency in the under 5 year from about 27% to 5%;
, and
' TOreduce anemia in pregnant and nursing women from about 55% to about

1 The project has four major compon6nts:

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1) Nutrition services,
/ 2) Health services,
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3) Comn~unication,and

'i 4) Monitoring and evaluation.

/ TINP-II was designed to cover in a phased manner, 316 of the total of 385 rural
blocks in Tamil Nadu. The.Goals of the p r o g s m e s were:
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Role of Nurse in National 1) To increase the proportion of children classified as "nutrit:ionally normal" by 50
Health Programmes
, ' per cent in new and 35 per cent in TINP-I areas;
2) ' To reduce the infant mortality to 55 per 1000 live births; and

3) To 50 per cent reduction in incidence of low birth weight.

The projects are assisted by World Bank and with the goal of universalization of
ICDS all the TINP blocks will be converted into TCDS bloclts.

6.2.7 National Nutritional Anaemia Prophylaxis Progrm~me

Available studies on prevalence of nutritional anemia in India show that 65% infant
and toddlers, 60% 1-6 years of age, 88% adolescent girls (3.3%has hemoglobin <7
gmtdl; severe anemia) and 85% pregnant women (9.9% having severe anemia).
The prevalence of anemia was marginally higher in laclating women as' compared
to pregnancy. The commonest is iron deficiency ane~nia.
The programme was launched in 1970 to prevent nutritiolial anemia in mothers and
children. Under this programme, the expected and nursing mothers as well as
acceptors of farnily planning are given one tablet of iron and folic acid containing
60 mg elemental iron which was raised to 100 mg elemental iron, however folic acid
content remained same (0.5 mg of folic acid) and child in the-age group of 1-5
years are given one tablet of iron containing 20 mg elen~cnialiron (60 mg of ferrous
sulphate and 0.1 mg of folic acid) daily for a period of 100 days. This programme is
being taken up by Maternal and Child Health (MCH) Division of Ministry of Health
and Family Welfare. Now it is the part of RCH programme.
Under this programnle, fortification of salt with iron, has bee11 identified ns a
measure to control anemia. Pilot pro-ject of salt,fortification with iron has bee11
started in Tamil Nadu. National programmes to control and prevcnt anemia have
not been successful. Experience from other countries in conlrolling moderat~l;
severe anemia guide to adopt long term measuresi.e., fortification of h o d iteins
like, milk, cereal, sugar, salt with iron. Nutrition education to improve dietary intakes
in family for receiving needed rnacro/micro nutrients as protein, iron and vitamins ,
like folic acid, B12, B, C, etc., for hemoglobin synthesis is important. Nutritional
Anemia conti-01Programme should be comprehensive and incorporate nutrition
education tlwough school health and ICDS infrastl-uctureto promole regular intake
of ironlfolic acid rich foods, to promote int;ake of food which helps in absorption of
iron and folic acid and adequate intake of food.

6.2.8 Vitamin A Prophylaxis P r o g r m e

Prevalence of Bitot's spot is 0.7% in children which has not gone down since 1988-
90. In all age groups it is 0.21%.Night blindness in children and women has bem
found maximum in Bihar, Assam, Uttarpradesh. Uncler the National Prog~.arnmefor
Prophylaxis against Blindness in Children caused due Lo Vitamin A deficiency, every
 child has been provided Prophylaxis against Vitamin A deficiency in the form of 5 ~ u t r i t i o n a land School
Health Programmes
oral doses stafling at 9 months along with measles vaccirne as a-first dose (1 lakh
IU) then at 15 months a second dose (2 lakh IU), then every 6 monthly (2 lakh IU)
. are given till the age of 3 yeas. The programme has been implemented through
RCI-I programme.
Check Your Progress: 4
1) The National Nutritional Anaemia Prophylaxis prograrmne was launched in
...............
2) The beneficiaries of this psogrtmme are ................................................
3) The psophylactic vitamin A is given in the dose of ..................................

6.3 SCHOOL HEALTH P R O G U M M E

More than half of the worltl's population is below the age of 25 years and majority
in the age group of 10-25 years from developing countries. If we fail to nurture their
health, it will have impact on achieving their goals in life. It is also obscrved that "to
learn effectively children need good health. Health is also th!: key factor in school
entry as well as continued school participation and attainment in school. The health
benefits of education are profound especially with regard to women or girls. School
health programmes have a beneficial impact on students family, nation and d l
people at large. School health programmes are those that promote health through
schools. School health progralnrne activities include all school based activities that
contl-ibute to understanding, maintenance and improvement of health of school
population including health services, health educat~onand healthful school
environment.
6.3.1 Benefits of School Health Prograrnnie
=
Investment in school health programme is the most efficient and cost effective
way to improve students' health and consequently their academic performance
a
School and healthy school children reduce morbidity and mortality rates. More
years of schooling a girl receives, it is more IikeIy that her children will survive
and will be healthy
School food programme have marked effect on school attendance and
performance
Co~i~prehensive health education car1 prevent certain adverse behaviour like
tobacco use, drug abuse, unhealthy dietary practices, unsafe sexual behaviour
and physical inactivity.
School is best channel for putring health information at the disposal of it's
citizens.

6.3.2 Components oTSehool Health Programme

A comprehensive school health programme must be implenlet~tedin an organized ..
and stxategic manner consisting of following conlponents:
School health services include preventive, promotive curative and referral services.
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Health appraisal should include:
1

Regular Periodical Medical Examination: It should be carried out by medical

officer or health worker once in a yew. Health worker should be able to handle any
emergency health need of school staff. The initial examination should be thorough
with appropriate laboratory tests to detect most comrnon preventable diseases.
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Daily Inspection: Daily inspection by school teacher brings a change in thek day
! to day hygienic practices and also early detection of any behavioural or physical
 Role of Nurse in National disprder. Teacher should look into following aspects such as general appearance,
Health Programmes
any rash or skin eruption, change in face colour, running nose, cough, fever and
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neck rigidity or any abnormal sign and symptoms.
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Health Record: Health record maintained by teacher will help in effective
treatment and follow up specialist services like dental, eyes, ENT, mental health
clinics. Dental health and eye care need special emphasis in health care delivery in
school health programme.
First Aid and Emergency: care should be part of school services. Teachers and
students must undergo firsf aid training.
School Health Education: Include academic education, health and nutrition
education, first aid, life skill education. Good personal hygiene, physical exercise,
sitting and standing posture, interest in play activities and maintaining healthy body.
Students should be involved in regular vaccination, environmental sanitation.
Students should learn prevention of injuries and traffic rules.
School Health Environment: Physical and psychosocial environment include safe
environment which means safe water supply and sanitation. Space should be 10 sq
feet per person. Classroom should have sufficient cross ventilation, lighting,
furniture of safe design, eating facilities, lavatory facilities and all these should help
in further development of health of environment.
Health Promotion for School Personnel: Teacher should understand that
students copy them as role model.
Nutrition and Food Safety: Improving nutrition like mid day meal programme help
in improving school attendance and academic performance.
Physical Education, Recreation, Mental Health Counseling and Social
Support: These will help children in improving self confidence, friendship,
maladjustment, drug addiction and unsafe sexual practices that are common
problems among children.
School Health Programme: Should focus on needs of adolescent boys and girls in
meaningful manner. Educators, teachers, health workers must acquire information
skills and resources nepssary for effective implementation of school hcalth
programme.

6.3.3' Role of Community Health Nurse

Community health nurse may be posted as school health nurse in school health
scheme. She is a team member in this team. She will:

Conduct regular periodical checkup

Recognize sign and symptoms and help in early detection of defects and
diseases
- Refer to special clinics like eye, ENT and dental etc. and follow up

: Growth monitoring for young children at the primary level

Health education and counseling

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Treatment of minor ailments

- Help in rehabilitation services like spectacles, hearing aids etc.

Dewosrning in the areas where worm infestation is common public health

problem

Immunization for preventable diseases

 Training of teachers for first aid and minor ailments Nutritional and School
Health Programmes
Guidance and counselling.

6.4 LET US SUM UP

In this unil, various llutritional programmes and School Health Programme has been
briefly discussed. ICDS schenle is the biggest supple~nentarynutrition programme
covering pregnant and lactating mothers and 0-6 year child. It has ~nainly3
componints i.e. training, ~nonitoringof activity m d evaluation in the form of survey:
The program~neactivity of ICDS is a package of 6 aclivities. The supplementary
nutrition aims at providing 300 calorie and 10 gnl protein to children in addition to
their normal diet at home. All malnourished children are detected by growth
monitoring and appropriate intervention in forin of therapeutic n~~trition/relerral
health services etc.

6.5 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress X
6- 1 2 year old children.
Check Your Progress 2
1) The beneficiaries of the services are the children below 6 y e a s age, expectant
and nursing molhers and women in the 15-45 years age group and ridolescent
girls in selected blocks.
2) a) Supplementary nutrition, Vitamin A, Iron and Folic Acid
b) Immunization

c) Health check up
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1 d) Rpferral services

el Treatment of minor ailments

f) Nutrition and health education to women and cl~ildren

g) Non-formal education and pre-school education of children.

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3) Child Development Project Officer
 Role of Nurse in National Check Your Progress 3
Health Programmes
1) Orissa; 1963

t 2) Nutritional Education was the main focus and efforts were directed to teach
1 rural communities through demonstration how to produce food for their
I consumption through their own efforts.
I 3) 1980

4) The project has four major components:

a) Nutrition services,
b) Health services,
c) Communication, and
d) Monitoring and evaluation.
Check Your progress 4

2) Mothers ( ~ x ~ k c t aand
n t Nursing) and'children
3) 5 oral doses starting at 9 months along with measles vaccime as a first dose (1
lakh IU)then at 15 months a second dose (2 lakh IU), then every 6 monthly (2
lakh IU) are given till the age of 3 years.
Check Your Progress 5

1) Investment in school health rogramme is the most efficient and cost

P health arid consequently their academic
effective way to improve students'
performance
.. School and healthy school children reduce morbidity and mortality rates.
More years of schooling a girl receives, it is more likely that her children
will survive and will be healthy
%
~ c h o dfood
l programme have marked effect on school attendance and
performance
Comprehensive health education can prevent certain adverse behaviour
like tobacco use, drug abuse, unhealthy dietary practices, iinsafe sexual
behaviour and physical inactivity.
- School is best channel for putting health information at the disposal of it's
citizens.
2) a) physical and psychosocial environinenl
b) school attendance
 I Appendix J

NATIONAL RURAL WEALTH MISSION:

THE VISION
9 The National Rural Health Mission (2005-12) seeks to provide effective
healthcare to rural population throughout the country with special focus on 18
states, which have weak public health indicators and/or weak infrastructure.
a These 18 States are Arunachal Pradesh, Assam,l Bihar, Chhattisgarh,
Himachal Pradesh, Jharkhand, J a m u and Kashmir, Manipur, Mizoram,
Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura,
Uttaranchal and Uttar Pradesh.
o The Mission is an articulation of the commitment of the Government to r i s e
- public spending on health from 0.9 per cent of GDP to 2-3 per cent of GDP.
o It dins to undertake architectural co~reclionof the health system to enable it
to effectively h i d l a increased allocations as promised under the National
Common Minimum Programme and promote policies that strengthen public
health inanagement and service delivery in the country.
o It has as its key components provision of a female health activist in each
village; a village health plan prepared through a local team headed by the
Health and Sanitation Cornnittee of the Panchayat, strengthening of the rural
llospital for effective curative care and made measurable and accounLable to
the corninuni.ty through Indian Public Health Standards (IPHS); and integration
of vertical Health and Family Welfare Programmes and Funds for optimal
utilization of funds and infrastructure and strengthening delivery of primary
healthcare.
o It seeks to revitalize local health traditions and mainstream AYUSH into thc
public health system.
e It aims at el'fective integration of health concerns with determinants of health
like sanitation and hygiene, nutrition, and safe drinking water through a District
Plan for Health.

I, o It seeks decentxalization of programmes for district management of health,

0 It seeks to address the inter-state and inter-district disparities, especially
among the 18 high focus States, including unmet needs for public health
r infrastructure.

( 0 It &all define time-bound,goals and report publicly on their progress.

1 0 It seeks to improve access of mal people, esp.ecially poor women and chil-
dren, to equitable, affordable, accountable and effective primary healthcare.
I Goals
I
o Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio
(MMR). .',.
' . a Universal access to public health services such as women's health, child
! , health, water, sanitation and hygiene, imrnu~iization,andnutrition.
i
\
* ' Prevention and co&ol of communicable and non-communicable diseases,
I
including locally endemic diseases. '
j
t @ Access to integrated comprehensive primary healthcare.
P
e Population,stabilization, gender and demographic balance.
@ Revitalize locjh'ialth traditions and mainstream AYUSH.
0 Proination of herdthy life styles.
 Role of Nurse in National Strategies
Health Programmes
A) Core Strategies
I
I
I
e Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own
I
cbntrol and manage iublic health services.
I

m Promote access to improved healthcare at household level through th'e female

I health activist (ASI-IA).
1 m Health Plan for each village through Village Health Committee of the
9'
Pan ayat.
e Strenkthening sub-centre through an untied fund to enable local planning and
action'land more Multi Purpose Workers (MPWs).
e Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC.
per Ir?kh population for improved ccr'ative care to a nonnative standard (Indian
Public qealth standads defining personnel, equipment and manage~nent
standards).
e . Preparationland Implementation of an inter-sectoral District Health P1'a.n
prepared by the District Health Mission, including drinking water, sanitation
and hygiene and nutrition.
e l&egrating vertical Health and Family Welfare progra~nmesat National, Statq
. . Blocl~and District levels.
'
0 ~echnicdSupport to National, State and District Health Missions, for Public
Health. Management.
'a Strengthening capacities for data collection, assessment and rgview for evi-
dence based planning: monitodng and supervision.
o or mu la ti on of transparent policies for deploy~nentand career development of
'Human Resources for health.
., a Developing capacities for preventive health care at all levels for promoting
healthy life styles, reduction in consumnption of tobacco and hlcohol etc.
e Promoting non-profit sector particularly in underserved areas.
Plan of Action
. ,

Component (A): Accredited Sucial Health Activists

e Every villagellarge habitat will havk a female Accrcdited Social Health Activist
, (ASHA) - chosen by and accountable to the panchayat - to act as the
. interface between the community and the public health system. States to.
choose State specific models.
act as.a bridge between the ANN and the .village and be
ASHA wOulf
accountable o the Pandhayat..
0 Shewill be an hondrary volunteer, receiving pkformance-based cornpeksatioD
L
for promoting universa~~mmunization, refpal and escort services for RCH,
construction of household toilets, and other healthcare delivery
.ri - programmes.
a She will be trained on a pedagogy of public health developed and mentioned
-through a Standing Mentoring Group at National level incorporating best ,
practices qnd implemented through active involvement of c o ~ n f h ~hqaith
~ i t ~'
resource organizations. I

She will facilitate preparktion and implementation of the Village Health Plan
along with Angajlwadi woi-ker, ANM, functioniries of other ~ e ~ a & e n t sand
,
~k1f::helpGroup mkrnbers, under the leadership of the Vil1age.Hedt.h
Committee of the Parichayat.
 6 She will be promoted all over b e country, with special emphasis on the 18 high Appendices
focus States. The Government of India will bear the cost of training, incentives
and medical kits. The remaining components will be funded under Financial
Envelope given to the States under the programme.
0 She will be given a Drug KIT containing generic AYUSH and allopathic
formulations for common ailments. The drug kit would be replenished from
time to time.
e ~nductiontraining of ASWA to be of 23 days, in all, spread over 12 months.
On the job training would continue throughout the year.
. Prototype training material to be developed at National level subject to State
level modifications.

a Regulation of Private Sector including the informal rural practitioners to ensure

availability of quality service to citizens at reasonable cost.

1 + Promotion of Public Private Partnerships for achieving public health goals.

I e Mainstreaming AYUSH - revitalizing local health traditions.

a Reorienting medical education to support rural health issues including
regulation of Medical Care and Medical Ethics.
0 Effective and viable risk pooling and social health insurance to provide health
security to the poor by ensuring accessible, affordable, accountable and good
quality hospital care.
6 Cascade model of training proposed through Training of Trainers including
contract plus distaice learning model.
e Training would require partnership with NGOsiICDS Training Centres and
State Health Institutes.

1 Component (B) Strengthenitzg Sub-Centres(SC)

Each sub-centre will have an Untied Fund for local action @ 10,000 per
annum, This Fund will be deposited in a jaint Bank Account of the ANM and
Sarpanch and operated by the ANM, in consultation with the Village Health
Coinmitree.
@ Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres.
I In case of additional Outlays, Multipurpose Workers (Male)/AdditionalANMs
wherever needed, sanction of new Sub-centres as per 2001 population norm,
I
and upgrading existing Sub-centres, including buildings for Sub-centres
functioning in rented premises will be considered.
Component (C) Strengthening Primary Health Centres(PUC)
Mission aims at strengthening PHCs for quality preventive, promotive, curative,
supervisory and outreach.serviees, through:
0 Adequate and regular supply of essential quality drugs and equiprnents
(including Supply of Auto Disabled Syring~sfor imunization).to PHCs.
I

,
0 Provision of 24 hour service in at least 50 per cent PHCs by addressing
shortage of doctors, lespecially in high focus States, thraugh mainstreaming
AYUSH manpower.

1 I
i
@ Observance of Standard treatment guidelines and protocols.
145 1
 i
Role of Nurse in National 0 In case of additional Outlays, intensification of ongoing communicable disease
Health Programmes
control programmes, new programmes for control of non-communicable
I diseases, upgradation of 100 per cent PHCs for 24 hour referral service, and
I
provision of 2nd doctor at PHC level (1 male, 1 female) would be undertaken
3 I on the basis of felt need.
Component (D):Strengthening Community Health Centrs (CHCS) for First
Referral Care

I A key strategy of the Mssion is:

e 0~erationalisin~'3,222 existing Community Health Centres (30-50 beds) as 24
hour First Referral Units, including posting of anaesthetists.
e Codification of new Indian Public Health Standards, setting norms for
infrastructure, staff, equipment, management etc. for CHCs.
e Promotion of Stakeholder Cormnittees (Rogi Kalyan Sarnitis) for hospital
management.
e Developing standards of services and costs in hospital care.
Develop, display and ensure compliance fo Citizen's Charter at CI-TClPHC
level.
In case of additional Outlays, creation of new Community Health Centres
(30-50 beds) to meet the population norm as per Census 2001, and bearing
their recurring costs for the Mission period could be considered.
Component (E): District Health Plan
e District Health Plan would be an amalgamation of field responses through
Village Health Plans, State and National piiorities for Health, Water-Supply,
Sanitation and Nutrition.
Health Plans would form the core unit of action proposed in areas like water
supply, sanitation, hygiene and nutrition. Implementing Departments would
integrate into District Health Mission (DHM) for monitoring.
r, District becomes core unit of planning, budgeting and implementation.
9 Centrally Sponsored Schemes could be rationalized/modified accordingly in ,

consultation with States.

Concept of "tunneling' funds to dishict for effective integration of
programmes.
All vertical Health and Family Welfare Programmes at District and State level
merge into one common "District Health Mission" at the District level and the
I
"State Health Mission" at the state level.
Provision of Project Management Unit for all dislricts, through contractual
engagement of MBA, Inter Charterhter Cost and Data Entry Operator, for
@proved programme management.
Component (F). Converging Sanitation and Hygiene urzdcr NRHM I

e Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and :

is proposed to cover all districts in 10th Plan.
e Components of TSC include IEC activities, rural sanitary marts, individud ,
household toilets, women sanitary complex, and School Sanitation Programme.
I

9 Similar to the DHM, the TSC is also implemented through Panclzayati Raj
. Institutions (PRls). I
I

I
1
I
 a The Districl Health Mission would therefore guide activities of sanitation at Appendices
district level, and promote joint IEC for public health, sanitation and hygiene,
though Village Health and Sanitation Committee ,and promote household.
toilets and School Sanitation Programme. ASHA would be incentivised for
promoting household toilets by the Missioa.
Component (G): Strengthening Disease Control Programmes
e National Disease Control Programmes for Malaria, TB, Kala Azar, Filaria.
Blindness and lodine Deficiency and Integrated Disease Surveillance
Programme shall be integrated under the Mission, for improved programme
delivery.
0 New Initiatives would be launched for control of Non Communicable
Diseases.
e Disease surveillance system at village level would be strengthened.
Supply of generic drugs (botgh AYUSH and Allopathic) for common ailments
at village, SC, PHCICHC level.
e Provision of a mobile medical unit at District level for improved Outreach
services.
Component (H): Public Private Partnership for Public Health Goals including
Regulation of Private Sector
a Since almost 75 per cent of health services are being currently provided by the
private sector, there is a need to refine regulation.
0 Regulation to be transparent and accountable.
e Reform of regulatory bodieslcreation where necessary.
e District Institutional Mechanism for Mission must have representation of
private sector.
Need to develop guidelines Tor Public-Private Partnership (PPP) in health
sector, Identifying areas of partnership, which are need based, thematic and
geographic.
a I

0 Public sector to play the lead role in defining the framework and sustaining the
parhersllip. ,

Management plan for PPP initiatives: at DistsicVState and National levels.

Component (I): New Health Fimznrzcirzg Mechanislns
ATask Group to exaxline new health financing mnechanisrns, inclucling Risk Pooling .
for Hospital Care as follows:
Progressively the District Health Missions to move towmds paying hospitals
for services by way of reimbursement, on the principle of "money follows the
patienl".
Standardizntion of services - outpatient, in-patient, laboratory, surgical
interventions - and costs will be done periodically by a committee of experts in
each state,
A National Expert group to monitor these standards and given suitable advice
and guidance on protacols and cost comparisons.
All existing CHCs to have wage component paid on monthly basis. Other
I
I recurrent costs may be reirnbclrsed for services rendered from District Health
i Fund. Over the Mission period, the CHC may move towards all costs,
i
1
including wages reimbursed t'ar services rendered:
Role of Nurse in National rr A district health accounting system, and an ombudsman to be created to
Health Programmes
monitor the District Health Fund Management, and take corrective action,
Adequate technical managerial and accounting support to be provided to DHM
in managing risk-pooling and health security.
e Where credible Community Based Health Insurance Schemes (CBMI) exist'
are launched, they will be encouraged as part of the Mission.
m The Central government will provide subsidies to cover k part of the premiums
for the poor, and monitor the schemes.
r The IRDA will be approached to promote such CBHIs, which will be
periodically evaluated for effective delivery.
Component (J): Reorienting HealtWMedical Education Support Rural Health
Issues
a e While district and tertiary hospitals are necessarily located in urban centres,
they form an integral part of the referral care chain serving the needs of the
rural people.
0 Medical and para-medical education facilities need to be created in states,
based on need assessment.
0 Suggestion for Commission for Excellence in Hedth Care (Medical Grants
Commission), National Institution for Public Health Management etc.
9 Task Group to improve guidelines/details,
Instutional Mechanisms
e Village Health and Sanitation Sarniti (at village level consisting of Panchayat
RepresentativeJs, ANM/MPW, Anganwadi worker, teacher, ASHA,
community health volunteers). '

0 Hospital Management CommitteeiRogi Kalyan Samiti for community

management of public hospitals,
.: District Health Mission, under the leadership of Zila Parishad with district
Health Head as Convenor and all relevant departments, NGOs, private
professionals'etc. represented on it.
a State Health Mission, Chaired by Chief Minister and co-chaired by Health
* Minister and with the State Hedth Secretary as Convenor-representation of
related Departments, NGOs, private professionals etc.
@ Integration of Departments of Health and Family Welfare, as National and
State level.
9 National Mission $tee* Group chaired by Union Minister for Health and
Family Welfare with Deputy Chairman Planning Commission, Ministers d
Panchayat Raj, rural Development and Human Resource De~elopment:and
public healtb professionals as members, to provide policy support and guidmce ,
to the Mission.
e Empowered Programme Committee chaired by Secretary, HFW,to be the
Executive Body of the Mission.
I

e Standing Mentoring Group shall guide and oversea the implementation'of

ASHA initiative. I

e Task Grou&~for Selrscted Tasks (time-bound).

 Appendix 2

GUIDELIllaJESAS PER GSSM PROGRAM

Table 1
CLINICAL CLASSIFICATION OF PNEUMONIA 1
AGE 2 MONTHS- 5 YEARS
Therapy Where to treat
.r
PNEUMONIA
Respiratory Age Can be treated at
rate (per minute) (months) hornelhealth facility
a 50 or more 2-12 Cotrimoxatols Oral
'40 or more 12-60

I SEVERE PNEUMONIA,
e Chest lndrawing kritibiotics
Intramuscular
' Patient should be
hospitalized.
VERY SEVERE ILLNESS
e Inability to drink
e Excessive drowsiness
r Stridor in calm child Must always be admitted
r Respiratory grunting Chloramphenicol and treated at a health
e History of apnoea cyanosls, Intramuscular facility with provlsion of
convulsions. oxygen.
e Severe malnutrition
e Hypothermia '
Note:Childred less than two months who have fast breathing are alwnys treated as 'for fievera
pneumonia and their assessment and management is discussed separately.

Table 2
TREATMENT OF PNEUMONIA
Dally dose schedule of COTRIMOXMOLE for five days -
AGEWEIGHT Paedlatrlc Tablet Paedlatrlc syrup
Each tablet: Each spoon (5 ml):
Sulphamethoxazole 100 mg Sulphamethoxazole 200 mg
and Trimethoprlm 20 mg and Trimethoprlm 40 mg,
< 2 months* One tablet twice a day Half sp oon (2.5 ml) twice a
(Wt. 3-5 kg) day,
Two tablets twice a day. One spoon (5ml) twice a day,

1-5 years 'Three tablets twice a day One and half spoon (7.5 ml)
(Wg. 10-19 kg) twioe a day.
Notc:

a) If paedintric tablets are not available the daily dose of adult single doae tablet (containing
Sulphamethoxazole400 rng and Trimethoprim 80 mg), is a quarter, half and three-fourths of a
tablet per dose, to be given twice a day, for the b e age-groups, respectively.

b) * In a chlld less than mu months,cotrimoxazole is not routinely recommended. These children

art: to be treated as for severe pneumonia, However, in case of delay in referral contrimoxazole
may be initiated.

C) Cotrimoxazoleshould not be given to premature babies and cnses o f neonatal jaundice. Such
children when seen by a health workor must be referral to a health facility.

d) In small children the tablar should be crushed and mixed with milk or other fluids. The mixhxre
should be given to the child with a 8poon,
!
Role of Nurse in National Table 3
i Health Programmes
HOW MUCH ORS TO GIVE FOR REPLACEMENT OF ONGOING
I STOOL LOSSES TO PREVENT DEHYDRATION
I Age
c 6 months
After each liquid stool 1
-
7 months 2 years
2 to 5 years Half to one glass (100-200 ml)

e Mothers &st be told to continue giving additional quantities of home available

fluids (HAF) or ORS solution as long as diarrhoea lasts.
f

e Breastfeeding must be continued (if in the appropriate age group). In

exclusively breastfed babies frequent breastfeeding is usually enough to
prevent dehydration.
e If milk other than the mother's rnik is being consumed, this should not be
diluted.
o Food norlnally taken by the chld should be continued.
If the child is brought to the health facility check far signs of dehydration and start
fluid therapy. Give prepared solution of ORS.
A packet of ORS should be given to the mother before she goes home and she
should be told how to prepare ORS solution. DO NOT FORGET TO ADVISE
THE MOTHER TO GIVE ORS, HAF, TO CONTINUE FEEDING THE CWILD
AND TO LOOK FOR EARLY DANGER SIGNS OF DEHYDRATION.
Table 4
REHYDRATION THERAPY
Approximate amount of QRS solution to be given in the first 4 hours*
Age** €4 4-11 12-23 2-4 5-14
months months months years years
Weight (kg) 43 5-8 8-11 11-16 16-30
ORS(ml) 200-400 400-600 600-800 800-1200 1200-2200
Measure 1-2 2-3 3-4 4-6 6-1 1
I (Glass) A
* If the child wants mire QRS than shown, give morc.
** In- mother to give the child'breast tnilk in between the feeds of ORS.

*** For infants who are not brcastfed, also give 100-200 ml. clean water during this period.

If the child vomits, wait for lominutes and then continue to give ORS, but
more slowly.
e If the child develops puffiness of eyelids, stop ORS, continue ro give plain
water {or breast milk). Give ORS as for maintenance therapy (Table 1) after
the puffiness disappears.
After 4-6 hours of treatment with ORS solution, the child should be reassessed.
Source: Nntional Child Survival and Safe Motherhood Progrmme, Programme i~tervet~tions,
child I

survival, MCH Division, Ministry of Health & Family Welfare, Govt., of India, 1994.
 Appendix 3

~ ~ ~ r o d u c tand
i v echild health approach has been defined as "people have the a b i l i ~
to reproduce and regulate their fertility, women are able to go through pregnancy
and child birth safely, the outcome of pregnancies is successful in terns of maternal
and infant survival and well being, and couples are able to have sexual relations free
of feu of pr.egnancy and of contracting disease".

he concept is in keeping with the evolution of an integrated approach to the

programmes aimed at improving the health status of young women and young
children which has been going on in the country namely family welfare progr-e,
universal iinin~~tlization
programme, oral dehydration therapy, child survival and safe
programme and acute respiratory infection control etc. It is obviously
sensible that integrated RCH programme would help in reducing the cost inputs to
some extent because overlapping of expenditure would not be necessary and
integrateditnplemcntation would optimize outcomes of field level.
The RCI-I progrimme incorporates the components relating child survival and safe
motherhood ancl includes two aclditional components, one relating to sexually
transmitted disease (STD) and other relating to reproductive tract infection (RTI).
Fig. 1 represents the vwious conlponents of RCH programme.
Family Planning Child Survival and Safe Motherhood component
Client approach to healtll care PreventionManagement of RTYSTDIAIDS
Pig. 1: RCH Package

RCH Package
The main highlights of the RCE-I progamme are:

1) The progmlxlrnc integrritcs all interventions of fertility regulation, maternal and

child health with seprocluctive health for both men and women.

2) T11e services to be provided will be client oriented, demand driven, high quality
and based on necds of community through decentralized participatory planning
I and target free approach. \

3) The programme envisages upgradation of the level of facilities of providing

various interventions and quality of care. The First Referral Units (FR'CTs)
being set-up at sub-district level will provide comprehensive emergency
obstetric and new born ciue, Similasly RCH facilities at PHCs will be
a substantially upgraded,
ii 4) It is proposed tu improve facilities of obstetric care, MTP and IUD insertion in
the PlCs, Also for IUD insertion at sub-centres.
5) Specialist facilities for STD and RTI will be available in all district hospitals
and in a fair number of sub-district level hospitals.
6) The progsamlne aims at improving the out-reach of services primarily for the
Vulnertble group ofipopulafion who h a b been, till now, effectively left out of
planning process, e.g. special progrmme will be taken up for urban slums,
tribal population and adolescents. NGOs and v o l u n q organizations will be
jnvolved in a much larger way to impfove out-reach and make it people's
Programme; practitioners of Indian System of Medicine will be trained and
1
and development in Indian System of Medicine will be suppo~edto
~t%m.~c1-1 151
I improve range of RCH services; the Panchayat Raj functionaries will have a
Bole of Nurse in National central role in determining the need of the local population for RCI-I services
Health Programmes ,
generally and for contraceptives particularly- under the target free approach,
The Panchayat will also be the agency for iniplementing the programme and
for extending financial support to women for taking them to specialist at sub-
divisional hospitals for delivery.
The RCH programme is based on a differential approach. Inputs in all the districts
have not been kept uniform. While the care components are the same for all
districts, the weaker districts will get more support and sophisticated facilities are
proposed for relatively advanced disltricts. On the basis of crude birth rate and
female literacy rate, all the districts have been divided into three categories.
Category A having 58 districts, category B having,184 districts and category C
having 265 districts. All the districts will be covered in a phased manner over a
period of three years. The programme was formally launched on 15th October,
1997.
RCH interventions at district level will be as follows:
Interventions in All Districts
o Child Survival interventions i.e. immunization,Vitamin A (to prevent blindness),
oral rehydration therapy and prevention of deaths due to pneumonia.
8 Safe Motherhood interventions e.g. antenatal check up. Immunization for
tetanus, safe delivery, anemia confsol programme.
a Implementation of Target Free Approach.
a High quality training at all levels.
9 IEC activities.
a Specially designed RCH package for urban slums and tribal areas.
District sub-projects under ~ o c a Capacity
l Enhancement.
a RTIISTD Clinics at District Hospitals (where not available),
e Facility'for safe abortions at PHCs by providing equipment, contractual
doctors etc.
8 Enhanced community participation through Panchayats, Women's Groups and
NGOs.
@ Adolescent health and reproductive hygiene.
Interventions in Selected ,States/Districts
9 Screening and treatment of RTI/STD at sub-divisional level.
@ Emergency obstetric care at selected FRUs by providing drugs.
0 Essential obstetric care by providing drugs and PHN/Staff Nurse tit PHCs. ,
e Additional ANM at sub-centres in the weak districts for ensuring MCH care.
e Improved delivery service and emergency care by providing equipments kits,
IUD insertions and ANM kits at sub-centres.
0 Facility of referral transport for pregnant women during emergency to the
nearest referral centre through Panchayat in weak districts.
. ,
Maternal health care was a part of ~ & y Welfare ~rogrammbfrom its inception.
Interventions were introduced as vertical schemes, namely the National Nutritional
Anaemia Control P r o g r m e , TT immunization of pregnant women (part of
immunization prograrmne) and Dais training progiramme etc. Family Planning
remained a separate intervention. In 1992, the Chief Survival and Safe Motherhood
Programme integrated all the schemes far better compliance. This programme had I
the following components:
i
 a) Early registration of pregnancy. Appendices

b) To provide minimum three antenatal check-ups

c) Universal coverage of all pregnant women with 'IT immunization.
d) ~ d $ i c eon food, nutrition and rest
e) Detection of high risk pregnancies and prompt referral
f) Clean deliveries by trained personnel
g) Birth spacing, and
h) Promotion of institutional deliveries
The current RCH programme has integrated these services and the major
interventions are essential obstetric care, 24 hours delivery services at PHCsI
CHCs, emergency obstetric care, Medical Termination of pregnancy, prevention of
reproductive tract infection (RTI) and sexually transmitted diseases (STD), and
District Surveys.
Essential Obstetric Care
Essential obstetric care intends to provide the basic maternity services to all
pregnant women through (1) early registration of pregnancy (within 12-16 weeks),
(2) provision of minjinurn three antenatal check ups by ANM or medical officer to
monitor progress of the pregnancy and to detect any risk/complication so that
appropriate care including referral could be laken in time, (3) provision of safe
delivery at home or in an institution, (4) provision of three postnatal check ups to
monitor the postnatal recovery and to detect comnplications.
This component in RCH programme is more relevant for Assam, Bihar, Rajasthan,
Orissa, Uttar Pradesh and Madhya Pradesh as most of the deliveries in these states
are conducted at home in unclean environment causing high maternal morbidity and
mortality.
Emergency Obstetric Care
Complications associated with pregnatlcy are not always predictable, hence,
emergency obstetric care is an imporlint interven~ionto prevent maternal morbidity
and mortality. Under the CSSM progran~me1748 Refe'errd Units were identified
and supported with equipment kit E to kit l? However, these FRUs are not fully
operational because of lack of man power and adequate infrastructul'e. Under the
RCH programme the FXiUs will be strengthened through supply of emergency
obstetric kit, equipment kit and provision of skilled manpower on contract basis elc.
Traditional Birth Attendant still plays an important sole during deliveries in our
society. Under the CSSM programme, Dai training was a uniform country-wide . .
activity. However, it was observed that the delivery practice adopted vary Erom
state to state, e.g., in Kerala and Goa more than 90 per cent deliveries take place in
health institutions, whereas in most northern states majority of deliveries take place
at home, Therefore:, the current RCH programme decided to decentralize this
activity by involvirlg NGOs to make it more local specific.
24-hour Deliver~yServices at PHCs/CHCs
To promote institutional deliv~des,provision has been made to give additional
honorarium to the staff to encourage round the clock delivery facilities at health
centres.
'Medical Termination of Pregnancy
MTP is a reprodurctive health measure that enables a woman to opt out of an
unwanted or unintended pregnancy in certain specified circumstances without
' 153
endangering her Ilife, through MTP act 1'971. The aim is to reduce m a m a 1
-
Role of Nurse in Ka. ..:a! morbidity and mortality from unsafe abortions. The assistance from the C,-
Health Programmes
Government is in the form of training of manpower supply of MTP equipment a,,.
provision for engaging doctors trained in MTP tb visit PHCs on fixed dates to
perform MTP.
Control of Reproductive Tract Infections (RTI) and Sexually Tkansmitted
Diseases (STD)
Under the RCH programme, the component of RTMTD control is linked to HIV
and ADS control. It has been planned and implemented in close collaboration with
National AIDSaControlOrganization (NACO). NACO will provide assistance for
setting up RTI/STD clinics up to the district level. The tksistance from the Central
Government is in the form of training of the manpower and drug kits including .
disposable equipment. Each district will be assisted by two laboratory technicians
on contract basis for testing blood, urine and RTUSTD tests.
Immunization
The Universal .Immunization Programme (UIP) became a part of CSSM
programme in 1992 and RCH programme in 1997. It will continue to provide
vaccines for polio, tetanus, DPT, DT, measles and tuberculosis. The cold chain
established so far will be maintained and additional items will be provided to new
health facilities.
Drug and Equipment Kits
The drug and equipment kits supplied at various levels are as follows:
At sub-cetltre level:
e Drug kit A
e . Drug kit B .
e Mid-wifery kit
o Sub-centre equipment kit
At PHC level:
a PHC equipment kit
At CUCFRU level:
6 Equipment kits fiom lit E to kit P.
In addition, a drug kit for essential obstetric care will be supplied to PHCs in-
category C districts.
Essential Newborn Care
The primary goal of essential newborn care is to reduc* perinatal and neonatal
mortality. The main components are resuscitation of newborn with asphyxia,
prevention of hypothermia, prevention of infection, exclusive breast feeding and
reIerral of sick newborn. The strategies are to train medical and other health
personnel in essential newborn care, provide basic facilities for care of low birth
weight and sick new borns in FRU and district hospitals etc.
Oral Rehydration.Therapy
Diarrhoea is one of the leading cause of child mortality. Oral Rehydration Therapy
i
Programme started in 1986-87 is being implemqnted through RCM programme,
Supplies of ORS packets to the state are being organized by Central Government.
Twice a year 150 packets of ORS are provided as p a t of drug kit supplied to all
sub-centres in the country. The programme emphasizes the rational use of drugs ,
for the managenlent of diml~oea.~dequate'nutritionalcarp of the child with
diarrhoea and proper advice to mothers on feeding are two important areas of this
programme.
Acute Respiratory Disease Control Appendice!

The standard case management of ARI and prevention of deaths due to pneumonia
is now an integral part of RCH programme. Peripheral health workers are being
trained to recognize and treat pneumonia. Cotrimoxazole is being supplied to the
health workers through the CSSM drug kit.
Prevention and Control of Vitamin A Deficiency in Children
It is estimated that large number of children suffer from sub-clinical deficiency of
vitamin A. Under the programme, 5 doses of vitamin A are given to all children
under three years of age. The first dose (llakh units) is given at nine months of age
along with measles vaccination. The second dose (2 lakh units) is given along with
DPT/OPV booster doses: Subsequent three doscs (2 lakh units each) are given at
six months intervals.
Initiatives taken after Adoption of National Populatio~lPolicy 2000
1

RCH Cainps
In order to nmke the services of specialists like gynaecologists and paediatricians
available to people living in remote areas, a scheme for holding cmps have been
initiated in 102 districts covering 17 states from January, 2001. Camps are being
organized in Haryana, Madhya Pradesh, Ra~astl~an, Amnachd Pradesh, Uttar
Pradesh and Meghalaya.
RCH Out-reach Scheme
During 2000-200 1, an RCH, out-reach schenle was initiated to strengthen the
delivery of immuniztitiort and other materl~aland child health services in remote and
comparatively weaker districts and urban slums in Utrar Pradcsh, Madhya Prdcsh,
Rajastlian, Bihar, Assarn, Orissa, Gujarat and West Bengal.
OperationaliZation of District Newborn Care
Sixty districts have been provided cquiprnents to up-date neonatal Fdcilities.
Home Based Neortatal Care
The Department of Family Welfare llns approved two proposals lor introducing
home based neonatal care. The first is based on thc Gadchiroli lllodel and second is
proposal from ICMR in selected centres locatecl in Bihar, Mcihzrashtm, Orissu, .
Rajasthan and Uttar Pradesh, The objective is to evolve a nntional programme for
provision of neonatal care a1 the grassroots level.
Bordet District Cluster Strategy (BDCS)
Under this initiative 49 districts spread over 17 states have heel1 selccted for
providing focuscd interventions for reducing the iix~htmortality .y~d maternal
mortality rates by at least SO per cent over the next two to three yews. It is a
UNICEF assisted activity. UNICEF releases funds directly to the states.
The activities of the project. are: developinent and wdrzing of health and nutrition
teams: physical up-gradation of primary I~ealthcentres and sub-centres, additional
supply of drugs and equiplnents; support for mobility of staff; development of local
IEC for social mobilization; training of medical officers; up-gradation of First
Referral Units and fillin; of vacant posts through contractual hppointments,
Integrated Management of ChiMhood lllrzas (IMCI)
The extent of childhood morbidity and mortality caused by diarrhoea. ARI, malaria,
measles and malnutrition is subitantial. Most sick children present with signs and
Symptoms of more than one of ihese conditions. This overlap means that a single
diagnosis may not be possible or appropriate md treatment may be complicated by 155
Role of Nurse in National the need to combine for several conditions. An integrated approacli to manage sick
Health Programmes
children is, therefore, necessary. IMNCI is a strategy for an integrated approach to
the management of childhood illness as it is important for child health programmes
to look beyond the treatment of a single disease. This is cost effective and
emphasizes prevention of disease and promotion of,childhealth and development
besides provision of standard case management of childhood illness.
It has been decided to launch IMNCI in selected BDCS districts. In the Indian
context this strategy is quite pertinent considering the recent evidence from
NFHS-II report highlighting that ARI (17 per cent), diarrhoea (13 per cent), fever
(27 per cent) and under-nutrition (43 per cent) were the commonest morbidities
observed in: the children aged under 3 years. Coverage of measles vaccination in
children between 12-23 months is also low. An integrated approach to address
these major childhood illnesses seems to be an effective strategy to promote child
health in this country.
The Indian version of IMCI has been renamed as Integrated Management of
Neonatal and Childhood Illness (IMNCI). The major highlights of the Indian
adaptation are:

a) Inclusion of 0-7 days age in the programme

b) Incorporating national guidelines on malaria, anaemia, vitamin-A.

supplementation and immunization schedule.

c) Training of the health personnel begins with sick young infants up to 2 months.

d) Proportion of training time devoted to sick young infant and sick child is almost
equal.
Introduction of Hepatitis B Vaccination Project
A pilot project for introduction of Hepatitis B in the National Immunization
Programme has been approved by the Government. Under this project hepatitis B
i
vaccine will be administered to infants along with the primary doses of DPT
vaccine. The project will be implemented in 33 districts and slums of 15
metropolitan cities.
Training of Dais 1

A scheme for training of Dias was initiated during 2001-2002. The scheme is being
implemented in 156 districts in 18 statesNTs of the country. The districts have been
selected on the basis of the safe delivery rates being less than 30 per cent.
New initiatives
1) Training of MBBS doctors in anaesthetic skills for emergency obstetric care at.
FRUs.

2) Training of MBBS doctors in obstetric management skills.

3) Setting up of blood storage centres at FRUs.

4) Development of cadre of community level skilled birth attendants, I

5) Janani Suraksha Yojana (National Maternity Benefit Scheme). ,
I

6) Vandemataram Scheme.
I

Empowered Action Group (EAG)

An Empowered Actian Group has been constituted in the Ministry of Health and , j
Family Welfare, with Union M i s t e r for Health and Family Welfare as chairman on
20th March, 2001. As 55 per cent of the increase in the population of India is
anticipated in the states of Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Appendices
Orissa, Chhattisgarh, Jharkhand and Uttaranchal, these states are perceived to be
most deficient in critical socio-demographic indicates. Through EAG, these states
will get foccused attention for different health and family welfare programmes.
District Surveys
There is no regular source of data to indicate the reproductive health status of
women. The RCH programme conducted district based rapid household survey to
assess the reproductive health status of women. The survey was conducted in two
phases covering 252 districts. The outcome of the survey is as shown in Table I.
Table 1: Key Indicators of Reproductive Health in India
(Survey Report September to December, 1999)

L I
Male age 20-54 years
* N t h symptdms RTIJSTD 12.7
* Aware of AlUS 57.4

Key:
1 CMW refers to currently married women who had the last livc/still biflh since January, 1995.

2) Safe delivery refers to institutional delivery and honzc delivery attended by doctorlnurse1ANM.

3) Full ANC refers to 3 ANC check up + at least one TT injecdon .t la)tablets of IFA.

4) Pregnancy complications: Percent women wha reported any of the following complications:
swelling of hands and feet, visual disturbnnce, bleeding, convulsions, weak or no movement of
foetus and abnormal presentofion.

5) Delivery complications: per cent of women who reported my OF the following complications:
premature labour, obstructed labour, prolonged labour.
 S AS PER NATIONAL FAMILY
LFARE PRQG
Check-list for Selection of Oral Pills Acceptors by Village Health Guides/
ANM
A village health guide/ANM should fill the following points before selecting an
acceptor for oral pills:
Is the woman:
1) Above 35 years Yes No
2) Married for more than 2 years have no children Yes No
3) Poorly nourished Yes No
4) Fat (overweight) Yes No
5) Yellow colour of skin and eyes in last 6 months Yes No
6) Smoker Yes No
7) History of diabetes (Sugar in urine) Yes No
8) Complaint of prolongedfrequent headache Yes No
9) Visual disturbances Yes No
10) Fits Yes No
11) Lump in breast Yes No
12) Swelling of arms and legs Yes No
13) Palpitations Yes No
14) Breathlessness on exertion -Yes No
15) Irregular vaginal bleeding Yes No
16) History of swelling of feet andlor fits during pregnancy Yes No

If all the above are answered in negative the patient may be selected for oral
contraceptives. If any of the above are answered in positive the patient must be
seen by.a physician before oral contraceptives are prescribed. .
Guidelines for Deciding Eligibility for Terminal Methods
Ministry of Health and Family Welfare vide circular No. N. 11011-1-84-Ply dated
18-03-1986,has issued following guidelines for deciding eligibility for terminal
methods:
i) The age of husband should not ordinarily be less than 25 years.
ii) The age of wife should not be less than 20 years .and more than 45 years.
iii) If the couple has two or more living children, the lower limit of age of husband
and wife may be relaxed at the discretion of the operating surgeon.
iv) Sterilization services be provided to couples with at least two living children,
irrespective of the age of the second child. However, in respect of highly
motivated couples who voluntarily want sterilization after one living child, the
StateNTs may take a conscious decision in ths regard, keeping in view the
local circuinstances of the respective State~UTs.
v) As a general rule, very old and very young persons should not be sterilized
unless there are other reasons justifying such operations. In case of old
people the age of the wife should not be one of the considerations for
I
performing the operation and should be recorded in the application/
consent form. In case of young people, the existing number ol' living children
may be taken into consideration before performing the operation. I

vi) Before selecting a person for sterilization operation, the operating surgeon I

InLrst interview thc person to assess if the person concerned i s suffering

from psychiatric inslabiiity and is fully convil~cedand n~irti\.i;i.;.dahoert
- getting the operatiosa pc-
-"--~..~'kosmed. ---
Sunrce: Officer, G~r\iurnmentof Inclin,
Guidelines I'or Chc District Ilcalih Offic~a~s/ChiefMedicsll
Ministry of Health & Family Welfiire, 1986,