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Ans 1: The Reproductive and Child Health (RCH) Programme was launched in October 1997.
The main aim of the programme is to reduce infant, child and maternal mortality rates. The main
objectives of the programme in its first phase were:

To improve the implementation and management of policy by using a participatory planning

approach and strengthening institutions to maximum utilization of the project resources
To improve quality, coverage and effectiveness of existing Family Welfare services
To gradually expand the scope and coverage of the Family Welfare services to eventually come
to a defined package of essential RCH services.
Progressively expand the scope and content of existing FW services to include more elements of
a defined package of essential
Give importance to disadvantaged areas of districts or cities by increasing the quality and
infrastructure of Family Welfare services

RCH-I had a number of successful and unsuccessful outcomes. Base line statistics were recorded
in 1998-99 and compared to 2002-03. Percentage of women receiving any ANC rose by about 12
% to reach 77.2%. But use of government health facilities has declined. Use of contraceptives
increased by 3.3 % to 52.0 %, while family planning due to spacing method rose by 3.3% to 10.7
%. Use of permanent methods did not change. Infant mortality came down from 71(SRS 1997)
to 63 (SRS 2002) but the aim of universal immunization was far from reach. Polio though
reduced has not met the eradication target. Not enough attention was paid to awareness of
diarrhoea management and Acute Respiratory Infection danger signs hence resulting in a rise of
case incidents.

The child health programmes is now its second phase: RCH-II. Following are the aims of the programme:

Expand services to the entire sector of Family Welfare beyond RCH scope
Holding States accountable by involving them in the development of the programme
Decentralization for better services
Allowing states to adjust and improve programmes features according to their direct needs.
Improving monitoring and evaluation processes at the District, state and the Central level to
ensure improved program implementation.
Give performance based funding, by rewarding good performers and supporting weak
performers.
Pool together financial support from external sources
Encourage coordination and convergence, within and outside the sector to maximize use
resources as well as infra structural facilities

In 2007 a Joint Review Mission (JRM), under the Ministry of Health and Family Welfare,
reviewed the progress of RCH-II and found with a number of key concern areas. The JRM found
that child health was being limited to immunization and other aspects were being ignored. Proper
guidelines for implementation needed to be put in place for the states. There need to be more
training programmes to meet the need for qualified personnel. Many innovative techniques and
methods that are being implemented need to be evaluated before expansion takes place. Uttar
Pradesh requires additional attention with regard to infrastructure and implementation of RCH
and NHRM. There is a need to increase family planning services to meet the target of on average
only 2.1 children in each family/household.

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Ans 2: Health information management (HIM) is information management applied to health and
health care. It is the practice of acquiring, analyzing and protecting digital and traditional
medical information vital to providing quality patient care. With the widespread computerization
of health records, traditional (paper-based) records are being replaced with electronic health
records (EHRs). The tools of health informatics and health information technology are
continually improving to bring greater efficiency to information management in the health care
sector. Both hospital information systems and health human resources information systems
(HRHIS) are common implementations of HIM.

Health information management professionals plan information systems, develop health policy,
and identify current and future information needs. In addition, they may apply the science of
informatics to the collection, storage, analysis, use, and transmission of information to meet
legal, professional, ethical and administrative records-keeping requirements of health care
delivery. They work with clinical, epidemiological, demographic, financial, reference, and coded
healthcare data. Health information administrators have been described to "play a critical role in
the delivery of healthcare in the United States through their focus on the collection, maintenance
and use of quality data to support the information-intensive and information-reliant healthcare
system".

The World Health Organization (WHO) stated that the proper collection, management and use of
information within healthcare systems "will determine the system's effectiveness in detecting
health problems, defining priorities, identifying innovative solutions and allocating resources to
improve health outcomes".[

Information systems, particularly at lower levels of the health system (closer to the collection
source), need to be simple and sustainable and not overburden health delivery staff or be too
costly to run. Staff need feedback on how the routine data they collect can be used and also need
to understand the importance of good quality data for improving health. Capacity building is
required to ensure policymakers at all levels have the ability to use and interpret health data,
whether it originates from routine systems, health surveys or special operational research. It is
also important that health system staff understand the significance of local data for local program
management, and that their needs for strengthened capacity for critical health statistical analysis
are met. Local use of data collected at lower levels of the health system is a key step for
improving overall data quality. Furthermore, aggregate patient information collected at various
points of service delivery and made interoperable with routine HIS improves the quality and use
of health information.

The electronic health record has been continually expressed as an evolvement of health record-keeping.
Because it is electronic, this means of record keeping has been both supported and debated in the
health professional community and within the public realm.

In the United States, 89% of those who responded to a recent Wall Street Journal poll described
themselves as "Very/Somewhat Confident" in their health care provider who used electronic health
records compared to 71% of respondents who responded positively about their providers who didn't or
don't use electronic health records.[10] As of 2008, more than fifty-percent of Chief Information Officers

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polled listed that they wanted ambulatory electronic health records in order to have the health
information record available to move across each stage of health care.

Health information managers are charged with the protection of patient privacy and are responsible for
training their employees in the proper handling and usage of the confidential information entrusted to
them. With the rise of technology's importance in healthcare, health information managers must remain
competent with the use of information databases that generate crucial reports for administrators and
physicians.

Education is an important aspect in being successful in the world of health information management.
Aside from initial credentials, health information professionals may wish to pursue a Masters of Health
Information Management, Masters of Business Administration, Masters of Health Administration, or
other Masters programs in health data management, information technology and systems, and
organization and management. Gaining further education advances the health professional's career and
qualifies the individual for upper-management positions.

Ans 3 a): Rural Sanitation Programme envisages promoting "Environmental Sanitation" as a package
aiming to address the issues to reduce the probability of people's exposure to diseases and providing
hygienic environment and taking measures to break the cycle of diseases by improved management of
human, animal and domestic wastes.

This includes but is not limited to :-

i. hygienic management of human and animal excreta

ii. safe disposal of waste water and storm water

iii. safe disposal of garbage

iv. safe handling of drinking water

v. domestic and food hygiene

vi. personal hygiene including promotion of hand washing

vii. village cleanliness

APHED has been involved in promoting demand responsive participatory sanitation programme as self-
help programme without any subsidy with UNICEF support since 1993. Social marketing is adopted as
the key strategy for promotion.

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Promotion of sanitation as a package without any subsidy and developing alternate delivery mechanism
initially piloted in Assam through UNICEF supported 'Intensive Sanitation Project in Kamrup District'. The
strategy has been similar as followed in Medinipur district in West Bengal.

Capitalising on the lessons learned from pilot initiatives similar strategy has been replicated in more and
more districts and because of good acceptability activities spread to sixteen districts out of twenty three
districts of Assam.

Presently 50 Nos. of Sanitation Mart (SM) have been set up in sixteen districts with UNICEF support
which are managed by NGOs. Setting up of more SMs through UNICEF support in other districts are in
the pipe line. Through these SMs about 27,000 Improvised House Hold Latrines (IHHL) are being
constructed annually without any subsidy.

A good number of options with cost ranging from Rs. 475.00 to Rs. 5000.00 per unit of latrine are being
offered by the SMs. However, about 60% of the household units constructed so far are of the options
below Rs. 500.00 without superstructure.

People movement for better sanitation has been taking shape and large numbers of latrine are also
constructed by the individuals utilising outlets developed by individual initiatives

According to sample study conducted about 60% of the households of the rural Assam have been using
latrines.

Ans 3 b): The practice of medicine as we know today, has had a long and winding history in
India, which can be traced through the civilisations, who have ruled the land. Be it the Greek
influence from Alexandria or the Moghal flavour from Persia, all the different rulers added to the
already existing curative knowledge of the natives. Evidence of medical practices has been
discovered in the ruins of the ancient Harrapan civilisation confirming our belief that some form
of healthcare services existed in the pre-historic era.

The first documented evidence of the emergence of modern system of medicine is from the
Royal Hospital, Goa. Founded by Alfonso de Albuquerque in 1510, it was the first hospital
established in India and was one of the best-managed hospitals in the world at that time. The first
native Goan to have successfully obtained the diploma of fisico, appears to have been Inacio
Caetano-Afonso, a native of Piedade. He was examined by the fisico-mor in 1735 and his
success in practice earned him the title `Aesculapius of Goa'.

Subsequently, when the East India Company came to India, it also paved way for the Indian
Medical services (IMS). Established in 1612, IMS comprised British surgeons, who were
recruited to take care of the British troops and their families in India. The Government General
Hospital, Chennai was started by them on November 16, 1664 as a small hospital to treat the sick
soldiers of the East India Company. Later, in 1750, it was declared open to the native population.
In Mumbai, the first hospital was opened in 1676 and in Calcutta in 1707-08. During the same
era, French rulers had built a hospital at Pondicherry in 1701. Hence, Chennai was the first city
to establish the first present day hospital in India. INHS Asvini, Mumbai, established in 1756
was the first of all naval hospitals in India, which started off in the barracks as Kings Seamen

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Hospital for in-patients. All these hospitals were started with either the rich and elite or the
troops in mind and therefore the native Indians did not find treatment here.

It was John Underwood, the Company surgeon, who established the first medical facility in 1799
at Monegar Choultry in Chennai for the Indians and called it Native Infirmary. It consisted of a
cluster of buildings with the government-maintained asylum for lepers among others.

In the north, Lady Willingdon Hospital was inaugurated on November 20, 1935 with a major
donation by Lady Willingdon, the then Vicerene, to serve the people of Kullu valley. In Delhi
hospitals of repute were St. Stephens (1908) started as a small dispensary in 1867 in Old
Delhi and Irwin Hospital (1938).In Ahmedabad, the oldest indigenous hospital called Seth
Vadilal Sarabhai General hospital was started in 1931. A hospital for lunatics was established on
May 17, 1918 at Ranchi called the Ranchi European Lunatic Asylum. Albert Edward Hospital
from Kolhapur, Lady Dufferin hospital, Kolkata were also well known. The All India Institute of
Hygiene and Public Heath (AIIH&PH), Kolkata, was established in 1932 with the assistance of
Rockfeller Foundation.

In the pre-independence India, Kolkata was the hub of medicine, Chennai was the nucleus of
obstetrics and gynaecology and Mumbai was the focal point for surgeries.

Ans 4 a): A traditional model of infectious disease causation, known as the Epidemiologic Triad
is depicted in Figure 2. The triad consists of an external agent, a host and an environment in
which host and agent are brought together, causing the disease to occur in the host. A vector, an
organism which transmits infection by conveying the pathogen from one host to another without
causing disease itself, may be part of the infectious process.

In the traditional epidemiologic triad model, transmission occurs when the agent leaves its
reservoir or host through a portal of exit, is conveyed by a mode of transmission to enter
through an appropriate portal of entry to infect a susceptible host. Transmission may be direct
(direct contact host-to-host, droplet spread from one host to another) or indirect (the transfer of
an infectious agent from a reservoir to a susceptible host by suspended air particles, inanimate
objects (vehicles or fomites), or animate intermediaries (vectors)).

Figure 1: Epidemiologic Triad of Disease Causation (Historical)

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Ans 4 c): Vector control is any method to limit or eradicate the mammals, birds, insects or other
arthropods (here collectively called "vectors") which transmit disease pathogens. The most
frequent type of vector control is mosquito control using a variety of strategies. Several of the
"neglected tropical diseases" are spread by such vectors.

For diseases where there is no effective cure, such as Zika Virus, West Nile Virus and Dengue
fever, vector control remains the only way to protect human populations.

However, even for vector-borne diseases with effective treatments the high cost of treatment
remains a huge barrier to large amounts of developing world populations. Despite being
treatable, malaria has by far the greatest impact on human health from vectors. In Africa, a child
dies every minute of malaria; this is a reduction of more than 50% since 2000 due to vector
control. In countries where malaria is well established the World Health Organization estimates
countries lose 1.3% annual economic income due to the disease. Both prevention through vector
control and treatment are needed to protect populations.

As the impacts of disease and virus are devastating, the need to control the vectors in which they
carried is prioritized. Vector control in many developing countries can have tremendous impacts
as it increases mortality rates, especially among infants. Because of the high movement of the
population, disease spread is also a greater issue in these areas.

Ans 4 d): Certification of India as a Guinea Worm disease free country by the World Health Organisation
in February 2000 is a major milestone in the history of disease eradication in India. Guinea worm is the
second communicable disease after smallpox, which has been eradicated from the country, by the
efforts of NICD and the concerned states.

Guinea Worm disease (Dracunculiasis) was an important public health problem in many states of India
before it was eradicated in 2000. It is caused by a large nematode, Dracunculus medinensis, which
passes its life cycle in two hosts Man and Cyclops. Man harbours the adult parasites in the
subcutaneous tissues, especially of legs, arms and back, which are likely to come in contact with water.
A blister appears on the skin when the gravid 60-100 cm long adult female worm is ready to discharge
its larvae. The escape of larvae into the water takes place in batches and the parturition is usually
complete in about 2-3 weeks. These larvae are ingested by Cyclops and develop into infective stage in
about 2 weeks. People swallow the infected Cyclops in drinking water from step wells or ponds. The
larvae are liberated in the stomach, cross the duodenal wall, and enter the retro-peritoneal connective
tissues where they grow and mature.

Ans 4 e): The specific objectives of an investigation are to define the parameters of the epidemic
(i.e., time of illness onset and conclusion of the epidemic, number of cases, and morbidity and
mortality), to identify control or prevention measures, and possibly to identify new data relative
to the epidemiology of the health problem. Epi-Aids always are performed collaboratively with
partners domestically or internationally.

Justification for investigating epidemics include

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increased disease or injury severity (e.g., its morbidity or mortality or other determinants of
severity);
occurrence of a rare or unknown disease or a change in the pattern of the disease's occurrence;
opportunity to identify new information (e.g., risk factors previously unassociated with that
disease or a change in transmission method);
occurrence among a particular population (e.g., children or older persons);
public or political concern;
opportunity to conduct research on a specific disease; and
opportunity to train personnel (e.g., EISOs or state and local field investigators) in the
methodology of field investigations.

The 13 steps in an epidemic field investigation (Box) are adaptable to the circumstances of the
problem, resources available, or cause or suspected cause of the disease. Altering the order of the
steps might be necessary (e.g., possibly instituting control measures before completing data
analyses), but all of the steps should be completed. These steps are as valid today as they were
during the first field investigations over a half century ago, but the methodology of field
investigations has evolved, as has the complexity of epidemics.

Ans 5 a): Mortality rate, or death rate,[1] is a measure of the number of deaths (in general, or due to a
specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality
rate is typically expressed in units of deaths per 1,000 individuals per year; thus, a mortality rate of 9.5
(out of 1,000) in a population of 1,000 would mean 9.5 deaths per year in that entire population, or
0.95% out of the total. It is distinct from "morbidity", a term used to refer to either the prevalence or
incidence of a disease, and also from the incidence rate (the number of newly appearing cases of the
disease per unit of time).

Ans 5 b): Proteinenergy malnutrition (PEM) or proteincalorie malnutrition refers to a form of

malnutrition where there is inadequate calorie or protein intake.

Types include:

Kwashiorkor (protein malnutrition predominant)

Marasmus (deficiency in calorie intake)

Marasmic Kwashiorkor (marked protein deficiency and marked calorie insufficiency signs present,
sometimes referred to as the most severe form of malnutrition)

PEM is fairly common worldwide in both children and adults and accounts for 6 million deaths annually.
In the industrialized world, PEM is predominantly seen in hospitals, is associated with disease, or is often
found in the elderly.

Note that PEM may be secondary to other conditions such as chronic renal disease or cancer cachexia in
which protein energy wasting may occur.

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Ans 5 d): A cold chain is a temperature-controlled supply chain. An unbroken cold chain is an
uninterrupted series of refrigerated production, storage and distribution activities, along with associated
equipment and logistics, which maintain a desired low-temperature range. It is used to preserve and to
extend and ensure the shelf life of products, such as fresh agricultural produce, seafood, frozen food,
photographic film, chemicals, and pharmaceutical drugs. Such products, during transport and when in
transient storage, are called cool cargo. Unlike other goods or merchandise, cold chain goods are
perishable and always en route towards end use or destination, even when held temporarily in cold
stores and hence commonly referred to as cargo during its entire logistics cycle.

Ans 5 e): Multi-drug therapy (MDT)

MDT treatment is provided in blister packs, each containing four weeks treatment. Specific blister packs
are available for multibacillary (MB) and paucibacillary (PB) leprosy as well for adults and children.

Standard adult treatment regimen for MB leprosy:

Rifampicin: 600 mg once a month

Clofazimine: 300 mg once a month, and 50 mg daily

Dapsone: 100 mg daily

Duration: 12 months (12 blister packs)

Standard adult treatment regimen for PB leprosy:

Rifampicin: 600 mg once a month

Dapsone: 100 mg daily

Duration: six months (six blister packs)

Ans 5 h): Kala-azar is a slow progressing indigenous disease caused by a protozoan parasite of
genus Leishmania

In India Leishmania donovani is the only parasite causing this disease

The parasite primarily infects reticuloendothelial system and may be found in abundance in bone
marrow, spleen and liver.

Post Kala-azar Dermal Leishmaniasis (PKDL) is a condition when Leishmania donovani invades
skin cells, resides and develops there and manifests as dermal leisions. Some of the kala-azar
cases manifests PKDL after a few years of treatment. Recently it is believed that PKDL may
appear without passing through visceral stage. However, adequate data is yet to be generated on
course of PKDL manifestation.

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