Describe the national health programmes of India with their achievements and problems.

Classification and the Major Programmes

• The classification:
• Communicable disease programmes — the national TB elimination programme (NTEP), targeting elimination by 2025; the national vector borne disease control programme, covering malaria, dengue, chikungunya, filariasis, kala-azar and Japanese encephalitis; the national AIDS control programme; the national leprosy eradication programme; the universal immunization programme; the national viral hepatitis control programme; the integrated disease surveillance programme; and the national rabies control programme
• Non-communicable disease programmes — the national programme for prevention and control of non-communicable diseases (NP-NCD), covering cancer, diabetes, cardiovascular disease and stroke; the national programme for control of blindness and visual impairment; the national mental health programme with its district mental health programme; the national programme for prevention and control of deafness; the national oral health programme; the national tobacco control programme; and the national programme for health care of the elderly
• Nutrition programmes — anaemia MUKT BHARAT; the national iodine deficiency disorders control programme; vitamin A prophylaxis; ICDS and POSHAN abhiyaan; and the mid-day meal (PM POSHAN)
• Reproductive and child health — RMNCH+A with JSY, JSSK, PMSMA, RBSK and RKSK
• Other — the national water supply and sanitation programme, SWACHH BHARAT, the National Programme on Climate Change and Human Health, and the National Programme for Control and Treatment of Occupational Diseases
• The successes that should be named specifically:
• Smallpox eradication, declared in India in 1977 and globally in 1980 — the only human disease ever eradicated
• Polio, with India declared polio-free in 2014, which had been considered the most difficult country in the world in which to eliminate it
• Guinea worm and yaws eradication
• Maternal and neonatal tetanus elimination
• Leprosy elimination as a public health problem, achieved at national level in 2005
• The leprosy qualification is instructive and should be given — "elimination as a public health problem" means a prevalence below 1 per 10,000, which is not the same as eradication
• New cases continue to occur, some districts remain above the threshold, and declaring elimination led to a reduction in programme effort and vigilance — which is a general danger of announcing a milestone as though it were an end

Lessons, Problems and Principles

• Why smallpox eradication succeeded, which is the most instructive case in all of public health:
• The disease had features that made eradication biologically possible — NO animal reservoir; NO carrier state and no subclinical infection capable of transmitting; a characteristic rash making clinical diagnosis reliable without a laboratory; a short period of infectivity; and a stable, heat-resistant, effective vaccine giving lasting immunity in a single dose
• The strategy changed from mass vaccination to surveillance and containment (ring vaccination), on the reasoning that finding every case and vaccinating its contacts interrupts transmission far faster than raising overall coverage
• That change of strategy is the single most important lesson — the programme succeeded when it stopped counting vaccinations and started finding cases
• Also required — political commitment, international cooperation and funding, a case reward scheme encouraging reporting, and house-to-house search
• Why other diseases are harder — malaria has an animal and asymptomatic human reservoir, a vector, relapsing forms and no lasting immunity; tuberculosis has a vast latent reservoir and a long treatment; polio has subclinical infection with far more silent than paralytic cases, so transmission is invisible
• The malaria experience is the cautionary tale — the National Malaria eradication Programme achieved dramatic reduction in the 1960s, and effort and funding were then reduced, after which malaria resurged
• The lesson is that premature relaxation reverses gains, and this same pattern has since been seen with leprosy, kala-azar and, internationally, with measles
• The recurring problems of Indian national health programmes:
• Vertical structure, so that programmes duplicate infrastructure and compete for the same worker’s time — the ANM is answerable to a dozen programmes at once
• Target-driven reporting, which distorts activity toward what is counted and encourages falsification
• Neglect of quality in pursuit of coverage
• Weak surveillance and information systems, with delayed and incomplete reporting
• Poor integration with the private sector, which treats a large share of patients and reports almost none of them
• Interrupted drug and supply chains
• Inadequate community participation, with programmes designed centrally and delivered to people rather than with them
• Loss of momentum after an announced achievement
• Dependence on external funding for some programmes, with sustainability questions when it ends
• The principles that emerge, which is what an examiner is looking for at the end:
• 1. Integrate programmes into the general health service wherever possible, reserving vertical structure for a genuine elimination effort with an end point
• 2. Judge programmes by outcome rather than by activity — by cases prevented rather than tablets distributed
• 3. Build surveillance first, since a programme cannot control what it cannot see, and the last stage of any elimination effort is entirely a surveillance problem
• 4. Engage the private sector, since the patients it treats are invisible to the programme, and mandatory notification alone does not achieve engagement
• 5. Do not relax prematurely, since the final phase of elimination is the most expensive per case and the most easily abandoned
• 6. Address the social determinants alongside the technical intervention, since tuberculosis is a disease of crowding and undernutrition and no drug regimen alters that
• 7. Attend to community ownership, without which coverage is achieved once and not sustained
• The overall assessment — India’s national programmes have achieved genuinely remarkable things at enormous scale, including two eradications; and their persistent weakness is not technical knowledge but sustained, integrated, well-staffed delivery
• Smallpox succeeded by finding cases, not counting doses, which is the most transferable lesson in public health
• Malaria resurged after effort was relaxed, a pattern since repeated with leprosy and kala-azar
• Elimination as a public health problem is not eradication, and announcing it reduced vigilance and effort
• Ring vaccination beats raising coverage once transmission is focal, which is why the strategy changed
• Smallpox had no animal reservoir or carrier state, which is what made eradication biologically possible at all
• A characteristic rash allowed diagnosis without a laboratory, which made village-level case finding practicable
• Polio has far more silent than paralytic cases, which makes its transmission invisible and elimination harder
• Tuberculosis has a vast latent reservoir, which no case-finding strategy can reach directly
• The ANM answers to a dozen programmes, which is what vertical structure costs at the point of delivery
• Judge by cases prevented, not tablets distributed, which is the difference between outcome and activity
• Build surveillance first, since a programme cannot control what it cannot see
• The last stage of elimination is a surveillance problem entirely, and also the most expensive per case
• The private sector treats many and reports few, which leaves a large share of patients invisible to every programme
• Mandatory notification alone does not achieve engagement, which is why private sector involvement needs incentives too
• Tuberculosis is a disease of crowding and hunger, and no drug regimen alters that determinant
• India eradicated smallpox in 1977, three years before global certification, which is worth stating as a date
• India was declared polio-free in 2014, having been considered the hardest country in the world for it
• Target-driven reporting encourages falsification, which corrupts the data the programme depends on
• External funding raises sustainability questions when it ends, which should be planned for rather than discovered
• Reserve vertical structure for genuine elimination efforts that have a defined end point, and integrate the rest
• Community ownership sustains what campaigns achieve once, which is why coverage without it decays
• The weakness is delivery, not knowledge, which is the honest summary of Indian national programmes