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293Introduction to Health Systems
Components of Programme
1. Manpower training and development
Training and development of manpower including state
medical college experts, audiologists, medical officers,
obstetricians and pediatricians multipurpose workers,
Functionaries at grass root level such as anganwadi workers,
Accredited Social Health Activist (ASHA), Trained Birth
Attendants (a) for prevention, early identification, rehabilitation
and management of hearing impaired and deafness cases, (b)
to make the personnel aware of the existing facilities available
for deafness to facilitate appropriate referral, (c) to sensitize
the healthcare personnel regarding their specific roles in the
program, (d) to enable the health providers to provide a
leadership role in creating awareness about hearing
impairment, and (e) to facilitate the development of suitable
manpower, to be able to implement this program in the entire
nation, in a phased manner.
2. Capacity building
Capacity building at the district hospital, community health
centers, and primary health center in respect of ENT/
audiology infrastructure for screening of ear morbidity and
detection of hearing loss.
3. Service provision including rehabilitation
This means the provision of service for early detection, ear
screening camps, treatment, management, and rehabilitation
of hearing and speech impaired cases at different levels of the
healthcare delivery system.
4. Awareness creation among parents/community
Community-level health workers and doctors form a part of
the IEC activities at various levels to generate awareness for
early identification of hearing impairment, especially among
children so that such cases are managed and the stigma
attached to deafness can be removed.
294 Social Pharmacy
Program Execution and Expansion
The programme was a 100% centrally sponsored scheme during
the 11th Five-Year Plan. However, in the 12th Five-Year Plan,
the Centre and the States have pooled resources as per the
financial norms of NRHM. The programme was initiated in
the year 2006–2007 in pilot mode in 25 districts of 11 states/
UTs and later expanded to 228 districts of 27 states/UTs.
Expected Benefits of the Program
The programme is expected to generate the following benefits:
1. Availability of various services like prevention, early
identification, treatment, referral, rehabilitation, etc. for
hearing impairment and deafness as the primary health
center/community health centers/district hospitals
largely cater to their need.
2. Decrease in the magnitude of hearing-impaired persons.
3. Decrease in the severity/extent of ear morbidity or hearing
impairment.
4. Improved service network/referral system for persons
with ear morbidity/hearing impairment.
5. Creation of awareness among the health workers/grass-
roots level workers through the primary health center
medical officers and district health officers.
6. Capacity building at the district hospitals to ensure better
care.
UNIVERSAL IMMUNIZATION PROGRAMME
History of Immunization Program in India
After the success of global smallpox eradication in the 70s, it
was realized that immunization is the most effective tool for
the prevention, control, and even eradication of a disease. The
Immunization Programme in India was introduced in 1978 as
the expanded programme of immunization (EPI) for
immunizing all children during the first year of life with DPT,
OPV, BCG, and typhoid–paratyphoid fever vaccines to reduce
mortality and morbidity. Immunization of pregnant mothers
295Introduction to Health Systems
with the TT vaccine was introduced in 1983. The program
gained momentum in 1985 and was expanded as the Universal
Immunization Programme (UIP) and implemented in a phased
manner to cover all corners of a country’s districts by 1989-90.
The stated objectives of UIP are:
1. To rapidly increase immunization coverage.
2. To improve the quality of services.
3. To establish a reliable cold chain system at the health
facility level.
4. To introduce a district-wide system for monitoring
performance.
5. To achieve self-sufficiency in vaccine production.
UIP has two vital components: (a) Immunization of pregnant
women against tetanus, and (b) immunization of children in
their first year of life against the six EPI target diseases. In 1992,
UIP became a part of the Child Survival and Safe Motherhood
(CSSM) Programme. Since, 1997, immunization activities have
been an important component of the National Reproductive
and Child Health Programme. It was recommended to cover
100% among infants also. In 1995, the Pulse Polio Immunization
Program was launched as a strategy to eradicate poliomyelitis.
Since 2005 immunization has been one of the key areas under
the National Rural Health Mission (NRHM).
Diseases Protected by Vaccination under UIP
Under the Universal Immunization Programme, the Govern-
ment of India is providing vaccination to prevent the following
vaccine-preventable diseases:
1. Diphtheria
2. Pertussis
3. Tetanus
4. Polio
5. Tuberculosis
6. Measles
7. Hepatitis B
8. Japanese encephalitis (commonly known as brain fever)
296 Social Pharmacy
9. Meningitis and pneumonia caused by Haemophilus
influenzae type b.
Vaccines under UIP
Under UIP, the following vaccines are provided:
1. BCG (Bacillus Calmette-Guerin)
2. DPT (Diphtheria, pertussis and tetanus toxoid)
3. OPV (oral polio vaccine)
4. Measles
5. Hepatitis B
6. TT (Tetanus Toxoid)
7. Japanese Encephalitis (JE) vaccination (in selected high
disease-burden districts)
8. HiB containing Pentavalent vaccine (DPT + HepB + Hib)
(in selected States)
Guiding Principles of UIP
The services provided are guided by the following principles:
1. Universal immunization coverage: Sustaining demand
and ensuring that all pregnant mothers, children, and
adolescents are immunized as per the national schedule in
line with the principles of universal health coverage.
2. Equitable access: Ensuring that the immunization services
reach out to the underserved, needy, and most vulnerable
populations while addressing regional inequalities across
states
3. High-quality services and innovation: Maintaining the
highest possible quality in vaccine procurement, storage,
distribution, and delivery services innovatively and safely.
4. Sustainability and partnerships: Committing resources—
financial, human, and technical, that sustain immunization
benefits to the people at all times and promoting
partnerships across different sectors and organizations
build synergies and expand the overall coverage of the
program.
5. Governance: Decentralized planning through a bottoms-
up approach to improve operational efficiency.
297Introduction to Health Systems
6. Management excellence and accountability: Implemen-
tation, oversight, and accountability of interventions that
optimize efficient use of resources.
The vaccination schedule under the UIP is given in
Table 5.7.
NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS AND
VISUAL IMPAIRMENT (NPCB&VI)
Introduction
The National Programme for Control of Blindness and Visual
Impairment (NPCB&VI) was launched in the year 1976 as a
100% centrally sponsored scheme (now 60:40 in all states and
90:10 in NE states) to reduce the prevalence of blindness to
0.3% by 2020. Rapid survey on avoidable blindness conducted
under NPCB during 2006–07 showed a reduction in the
prevalence of blindness from 1.1% in 2001–02 to 1% in
2006–07.
The prevalence rate of blindness and targets are as follows:
• Prevalence of blindness—1.1%. (Survey 2001–02).
• Prevalence of blindness—1.0%. (Survey 2006–07).
• Current survey (2015–18) in progress. The projected
rate of prevalence of blindness is 0.45%.
• Prevalence of blindness target—0.3% (by the year
2020).
Main causes of blindness include cataract (62.6%), refractive
error (19.70%), corneal blindness (0.90%), glaucoma (5.80%),
surgical complication (1.20%), posterior capsular opacification
(0.90%), posterior segment disorder (4.70%), others (4.19%).
The estimated National Prevalence of Childhood Blindness/
low vision is 0.80 per thousand.
The five diseases identified for global elimination include
cataract blindness, trachoma blindness and transmission,
onchocerciasis, avoidable causes of childhood blindness,
refractive errors, and low vision.
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Table 5.7: Vaccination schedule under the UIP
National Immunization Schedule
Vaccine When to give Dose Route Dose
For infants
BCG At birth or as early as possible 0.1 ml (0.05 ml until Intradermal Left upper arm
till one year of age 1 month of age)
Hepatitis B At birth or as early as possible 0.5 ml Intramuscular Anterolateral side
birth dose within 24 hours of mid-thigh—Left
OPV birth dose At birth or as early as possible 2 drops Oral –
within the first 15 days
OPV 1, 2 and 3 At 6, 10, and 14 weeks 2 drops Oral –
DPT 1, 2 and 3 At 6, 10, and 14 weeks 0.5 ml Intramuscular Anterolateral side of
mid-thigh
Hepatitis B 1, 2 At 6, 10, and 14 weeks 0.5 ml Intramuscular Anterolateral side
and 3 of mid-thigh
IPV (inactivated 14 weeks 0.5 ml Intramuscular Anterolateral side
polio vaccine) of mid-thigh—Right
HIB containing At 6, 10, and 14 weeks 0.5 ml Intramuscular Anterolateral side
Pentavelant 1, 2 of mid-thigh—Left
and 3
Rota virus vaccine At 6, 10, and 14 weeks 5 drops Oral –
Measles 1st dose 9 completed months–12 months 0.5 ml Subcutaneous Right upper arm
(give up to 5 years if not
received at 9–12 months of age)
Vitamin A, At 9 months with measles 1 ml (1 lakh IU) Oral –
1st dose
(Contd.)
299Introduction to Health Systems
National Immunization Schedule
Vaccine When to give Dose Route Dose
For infants
For children
DPT 1st
booster 16–24 months 0.5 ml Intramuscular Anterolateral side of
mid-thigh—Left
OPV booster 16–24 months 2 drops Oral
Measles 2nd dose 16–24 months 0.5 ml Subcutaneous Right upper arm
Vitamin A (2nd to 16 months with DPT/OPV 2 ml (2 lakh IU) Oral –
9th dose) booster; then, one dose every
6 months up to the age of
5 years)
DPT 2nd booster 5–6 years 0.5 ml Intramuscular Left upper arm
TT 10 years and 16 years 0.5 ml Intramuscular Upper arm
For pregnant women
TT-1 Early in pregnancy 0.5 ml Intramuscular Upper arm
TT-2 4 weeks after TT-1 0.5 ml Intramuscular Upper arm
TT-Booster If received 2 TT doses in a 0.5 ml Intramuscular Upper arm
pregnancy within the last 3 years
Give TT-2 or booster doses before 36 weeks of pregnancy. However, give these even if more than 36 weeks have passed.
Give TT to a woman in labor, if she has not previously received TT.
**Pentavalent vaccine contains a combination of DPT, HepB and HiB. In the states where it has been introduced, it will
replace DPT 1, 2 and 3 and hepatitis B 1, 2 and 3. Hepatitis B birth dose and booster doses of DPT will continue as before.
*** JE Vaccine (SA 14-14-2) is given in select endemic districts after the campaign is over in that district.
**** The 2nd to 9th doses of vitamin A can be administered to children 1–5 years old during biannual rounds, in collaboration with
ICDS.
300 Social Pharmacy
Main Objectives
1. To reduce the backlog of avoidable blindness through
identification and treatment of curable blindness at
primary, secondary, and tertiary levels based on
assessment of the overall burden of visual impairment in
the country.
2. To develop and strengthen the strategy of NPCB for “Eye
Health for All” and prevention of visual impairment
through the provision of comprehensive universal eye-
care services and quality service delivery.
3. Strengthening and up-gradation of Regional Institutes of
Ophthalmology (RIOs) to become centers of excellence in
various sub-specialties of ophthalmology and also other
partners like medical colleges, district hospitals, sub-
district hospitals, vision centers, and NGO eye hospitals.
4. Strengthening the existing infrastructure, and equipment
and developing additional human resources for providing
high-quality comprehensive eye care in all districts of the
country.
5. To enhance community awareness of eye care and
especially preventive measures.
6. To increase and expand research for the prevention of
blindness and visual impairment.
7. To assist voluntary organizations/private practitioners in
delivering eye care services including cataract operations
and eye banking.
Strategies
1. Information Education Communication (IEC) activities for
creating awareness of eye care within the community.
2. Active screening of the population and referral of operable
cases to fixed eye care facilities.
3. Effective implementation of a school screening program
for all children aged 10 to 14 years for identification and
treatment of refractive errors and provision of free
spectacles to those affected and belonging to poor socio-
economic strata.
301Introduction to Health Systems
4. Capacity building of health workers for improving their
knowledge and skill in the delivery of high-quality eye
care services.
5. Provision of eye-care services, and multipurpose district
mobile ophthalmic units in the district hospitals
throughout the country.
6. Emphasis on comprehensive eye-care coverage by
covering emerging diseases other than cataracts like
diabetic retinopathy, glaucoma, corneal transplantation,
vitreoretinal surgery, treatment of childhood blindness
including retinopathy of prematurity (ROP), etc.
7. Funding of tertiary eye-care center for the purchase of
sophisticated modern ophthalmic equipment.
8. Ensure the setting up of super specialty clinics for all major
eye diseases including diabetic retinopathy, glaucoma,
retinopathy of prematurity, etc. in state-level hospitals and
medical colleges all over the country.
9. Integration of teleophthalmology centers at PHC/Vision
centers with superspecialty eye hospitals to broaden access
of people to the best possible facility for diagnosis and
treatment of eye diseases, especially in hilly terrains and
difficult areas.
10. Development of a network of eye banks and eye donation
centers linked with medical colleges and the Regional
Institute of Ophthalmology (RIOs) to promote the
collection and timely utilization of donated eyes in a
transparent manner.
11. Provision of eye care services and free cataract surgery
through the healthcare delivery system, by the involve-
ment of NGO sector and public-private partnership.
Plan
1. Setting up more PHC/vision centres to broaden access of
people to eye care facilities.
2. To extend financial support to NGOs for treatment of other
eye diseases like diabetic retinopathy, glaucoma
management, laser techniques, corneal transplantation,
302 Social Pharmacy
Vitreoretinal surgery, and treatment of childhood blind-
ness, free of cost to poor people.
3. Integration of existing ophthalmic surgical/non-surgical
facilities in each district by associating a few units to the
next higher unit.
4. The inclusion of modern ophthalmic equipment in eye care
facilities makes it more versatile to meet modern-day
requirements.
5. Upgradation of software for management information
systems for better implementation and monitoring and
monitoring.
6. Digitalization of eye care services—IEC messages,
WhatsApp groups for stakeholders, etc.
7. Provision for setting up Multipurpose District Mobile
Ophthalmic Units in District Hospitals for better coverage.
PULSE POLIO IMMUNIZATION PROGRAM
Introduction
In India, vaccination against polio was started in 1978 under
Expanded Programme on Immunization but it failed to
eradicate poliomyelitis. In 1985, the Universal Immunization
Program (UIP) was launched to cover all the districts of the
country. In December 1995, the Government of India launched
the Pulse Polio Immunization (PPI) program, also known as
National Immunization Days (NIDs) along with the Universal
Immunization Program to eliminate poliomyelitis from India.
The program was launched under the World Health
Organization’s (WHO) Global Polio Eradication Initiative and
is conducted twice in the early part of each year.
The main aim of PPI was to immunize every child under the
age of 5 years through improved social mobilization and the
setting up of large networks of booths throughout the country.
Under this program, all children in the age group of 0-5 years
are given two doses of oral polio vaccine (OPV) in January and
December every year. Additionally, multiple rounds (at least
two) of Sub-National Immunization Days (SIDs) have been