Five Year Plans in Community Health Nursing

Overview

1st Five Year Plan (1951-1956)

• Established the basic framework of health services post-independence
• Set up the first Primary Health Centres (PHCs) - only 725 PHCs existed at the start
• Focused on control of epidemic communicable diseases: malaria, smallpox, tuberculosis, cholera, and leprosy
• Approach was techno-centric - health workers trained primarily to prevent and control disease spread
• Launched National Malaria Control Programme (NMCP)
• National TB Programme was initiated
• Only 18,500 registered nurses and 12,780 ANMs in the country
• International agencies (WHO, UNICEF) provided chemicals, medicines, and vaccines
• Limitation: Urban areas received the major share of resources; rural-urban health disparity was wide. By end of this plan, one hospital existed per 320,000 rural population vs. 1:36,000 in urban areas

2nd Five Year Plan (1956-1961)

• Continued expansion of PHC network, though still inadequate - by end of 2nd plan, one Primary Health Unit per 1,40,000 rural population (14 times less than Bhore Committee recommendation)
• National Filaria Control Programme launched
• National Leprosy Control Programme initiated
• Family planning services introduced as a national programme
• Health manpower training expanded - nursing schools and ANM training centres established
• Murlidhar Committee (1959) set up to evaluate progress and provide recommendations for health services
• Successes in controlling disease-specific deaths, improving life expectancy, and reducing death rates
• Limitation: Resource allocation remained heavily urban-skewed; structural inequities persisted

3rd Five Year Plan (1961-1966)

• PHC expansion continued; each PHC was meant to serve a population of approximately 80,000 (later revised to 30,000)
• Intensification of communicable disease control programmes
• Trachoma Control Programme started
• National Smallpox Eradication Programme launched
• Nutrition programmes initiated - National Goitre Control Programme
• Family planning received increased funding (Rs. 27 crores allocated, up from Rs. 5 crores in 2nd plan)
• Multipurpose health worker concept began to be discussed
• Community nursing roles extended to MCH (maternal and child health) services at sub-centre level

4th Five Year Plan (1969-1974)

• MCH and Family Planning services were formally integrated in this plan for better effectiveness - a landmark change in community health nursing practice
• Family planning infrastructure strengthened: PHCs, sub-centres, urban family planning centres, district and state family welfare bureaus
• National Programme for Prevention of Nutritional Anaemia launched during the 4th Plan - iron and folic acid supplementation to pregnant women and children became a nursing responsibility
• Special Nutrition Programme (SNP) started
• Mid-Day Meal programme initiated in some states
• Health visitor training programmes expanded
• Community health nurses began providing integrated services combining MCH, family planning, nutrition, and immunization

5th Five Year Plan (1974-1979)

• This plan was landmark as it formally acknowledged the widening rural-urban health gap and committed to correcting it
• Minimum Needs Programme (MNP) launched - ensured that basic health services were first provided to underserved areas to remove disparities
• Two core principles of MNP:
  1. Facilities to be provided first to underserved areas to remove disparities
  2. Facilities to be provided as a package through intersectoral area projects for greater impact
• Targets under MNP for rural health:
  • One PHC per 30,000 population in plains; 20,000 in tribal/hilly areas
  • One sub-centre per 5,000 people in plains; 3,000 in tribal/hilly areas
  • One Community Health Centre (rural hospital) per 1 lakh population or one CD block
• Drinking water supply and sanitation included as health priorities (water-borne diseases - diarrhoea, cholera, typhoid, jaundice were major burdens)
• Emergency declared mid-plan (1975-77): family planning received disproportionate attention
• ANM role became central - ANMs stationed at sub-centres became the frontline community health nurse

6th Five Year Plan (1980-1985)

• Strongly influenced by the international declaration "Health for All by 2000 AD" and the Primary Health Care (PHC) approach from Alma Ata
• Comprehensive Primary Health Care approach adopted
• Universal Immunization Programme (UIP) foundations laid
• National Diarrhoeal Diseases Control Programme
• National ARI (Acute Respiratory Infections) Control Programme
• Oral Rehydration Therapy (ORT) promoted through community nurses and ANMs
• Integrated Child Development Services (ICDS) expanded - Anganwadi workers complemented ANMs in community health delivery
• Safe drinking water and sanitation prioritized under the national rural drinking water mission
• First National Health Policy (NHP) announced in 1983 - aimed at universal, affordable, needs-based healthcare
• Radical measures were suggested but action at ground level remained minimal; privatization became an overarching trend in the 1980s

7th Five Year Plan (1985-1990)

• MCH programmes and Family Welfare programmes merged and strengthened
• Objectives: improve maternal and child health, reduce infant mortality, and expand immunization coverage
• Universal Immunization Programme (UIP) launched - one of the most significant community health nursing activities; ANMs and community nurses responsible for cold chain maintenance and vaccine delivery
• Child Survival and Safe Motherhood (CSSM) Programme
• National AIDS Control Programme initiated (1987) following the first HIV case in India
• Community health nursing roles expanded to include AIDS education and awareness
• Training of Lady Health Visitors (LHVs) and ANMs intensified
• Various MCH programmes converged under one umbrella - "all aimed at improving health of mothers and children"

8th Five Year Plan (1992-1997)

• Focus on health for underprivileged populations, but with a selective healthcare approach
• PHC infrastructure targets under MNP to be achieved:
  • One PHC per 30,000 in plains; 20,000 in tribal/hilly areas
  • One sub-centre per 5,000 in plains; 3,000 in tribal/hilly areas
• National Family Health Survey-I (NFHS-1) conducted in 1992-93 - gave baseline data for community health planning
• Expanded Programme on Immunization fully established
• Child Survival and Safe Motherhood (CSSM) programme major initiative
• Urban Family Welfare Centres established for slum populations
• Provision of PHC services in urban slums emphasized
• India became a member of WTO (1995) - opened economy, affecting health sector
• Community health nurses trained in newer areas: RTIs/STIs, nutrition rehabilitation

• Extend nutrition support to 11 million eligible persons
• Expand Special Nutrition Programme to all ICDS projects
• Consolidate mid-day meal programme linked to health, water and sanitation

9th Five Year Plan (1997-2002)

• Reproductive and Child Health (RCH) Programme launched in 1997 - replaced CSSM and FP programmes with a rights-based, client-centred approach; a major shift in community health nursing philosophy
• Referred back to Bhore Committee recommendations and came up with innovative strategies:
  • Evolving state-specific strategies for health
  • Integration of medical education and health services
  • PHC provision in urban slums
  • Horizontal and vertical integration of programmes
  • Improvement of disease surveillance systems
• National Family Health Survey-II (1998-99) conducted
• Despite novel ideas, the plan failed at ground level due to weak implementation mechanisms
• NFHS-II covered 90,000 women aged 15-49 for comprehensive baseline data

10th Five Year Plan (2002-2007)

• National Health Policy 2002 released (draft called for public feedback) with objective of achieving acceptable standards of good health for Indians
• Specific measurable health targets for the first time in planning history
• Integrated Disease Surveillance Programme (IDSP) launched
• Revised National Tuberculosis Control Programme (RNTCP) - DOTS strategy
• National Vector Borne Disease Control Programme
• Panchayati Raj institutions and local bodies involved in health planning - decentralization of community health responsibilities
• District health planning introduced
• Community nurses trained in DOTS supervision, vector control, and surveillance

11th Five Year Plan (2007-2012)

• Central theme: "Inclusive Growth" - health for all with special focus on marginalized groups
• National Rural Health Mission (NRHM) launched in 2005 (operational through this plan period)
  • Introduced ASHA (Accredited Social Health Activists) - female community health volunteers at village level (1 per 1000 population)
  • ASHAs work alongside ANMs and Anganwadi workers - the "three-pillar" model of community health
  • Rogi Kalyan Samitis (hospital management committees) set up
  • Untied grants to PHCs/sub-centres for local needs
• Indian Public Health Standards (IPHS) introduced for PHCs, CHCs, and sub-centres
• Major reduction targets for:
  • Maternal Mortality Ratio (MMR)
  • Infant Mortality Rate (IMR)
  • Total Fertility Rate (TFR)
• Community nursing roles: ASHA facilitation, immunization under National Immunization Schedule, institutional delivery promotion (JSY scheme - Janani Suraksha Yojana)
• Janani Suraksha Yojana (JSY) - cash incentive for institutional delivery - community nurses and ASHAs central to implementation

12th Five Year Plan (2012-2017)

• Universal Health Coverage (UHC) was the stated goal - "moving towards UHC is a key goal of the 12th Five Year Plan" and the National Health Mission (NHM) was the primary vehicle
• National Health Mission = NRHM + NUHM (National Urban Health Mission added in 2013)
• Essential Health Package defined
• Social determinants of health formally addressed in planning
• Major thrust areas:
  • Reducing out-of-pocket expenditure (OOP) on health
  • Ensuring accessibility of vaccines, medicines, and technology
  • Increasing health staff numbers and skill levels
  • AYUSH integration (Ayurveda, Yoga, Unani, Siddha, Homeopathy)
  • Disaster management and preparedness
  • Nutrition promotion
  • Improved sanitation and safe drinking water
• 12th Plan goals for RMNCH+A (Reproductive, Maternal, Newborn, Child, and Adolescent Health + Nutrition):
  • Reduction of Infant Mortality Rate (IMR)
  • Reduction of Maternal Mortality Ratio (MMR)
  • Reduction of Total Fertility Rate (TFR)
• National Development Council approved 8% growth target for the plan
• Community nurses/ANMs: central to delivering RMNCH+A services, JSY, JSSK (Janani-Shishu Suraksha Karyakram), immunization, ASHA support, VHND (Village Health and Nutrition Days)
• Mental health in community: management at community level through better training of community workers and primary care teams, especially in conflict zones
• Dedicated Public Health cadre recommended - public health nurses, epidemiologists, health inspectors, and multi-purpose workers (only Tamil Nadu had a dedicated public health cadre at the time)

Post-Plan Period: Three Year Action Agenda (2017-2020), NITI Aayog

Achievements Across Plan Periods (Park's Textbook data)

Role of Community Health Nurses Across Plans

Key Concepts in Community Health Nursing Planning (Evaluation Framework)

• Relevance - Is the service actually needed by the community?
• Adequacy - Is the scale of intervention sufficient for the problem?
• Accessibility - Can the target population physically, economically, and socially reach the service?
• Acceptability - Is the service culturally appropriate and accepted?
• Effectiveness - To what degree are predetermined objectives and health targets achieved?
• Efficiency - How well are resources (money, manpower, materials, time) used?
• Impact - What is the overall effect on health status and socioeconomic development?