Schemes/Activities of the Department

The Health Services perform the chief function of delivery of primary health care in a wholesome manner. Preventive and promotive health care in addition to the routine curative services and rehabilitation aspects of health care constitute the main activities of the department. The activities include the establishment and maintenance of medical institutions with necessary infrastructure, control of communicable diseases, rendering of Family Welfare services including Maternal and Child Health Services, implementation of National Control / Eradication programmes providing curative services and administration. The Analytical Laboratories and Public Health Laboratory function as a single-purpose units under the department with independent controlling officer for each.

Minimum needs programme (Basic minimum services)
The programme gives priority to the development of Rural Health Services. The concept of Minimum Needs Programme was introduced during Fifth Five Year Plan. The establishment of Sub-Centre, Primary Health Centre, upgradation of PHCs and construction of building of PHC / Sub-Centre and staff quarters are included in the programme.

Objective
The objectives to be achieved in a phased manner through successive plan periods by 2000 AD are as follows.

2. One PHC for every 30000 population (20000 population in Tribal and Hilly area)

3. One CHC / upgraded PHC for every 80000 – 1.20 lakh population with 30 beds (with specified service in medicine, surgery, pediatrics, gynecology and obstetrics and public health)

Multipurpose Workers Scheme
The Multipurpose Workers Scheme has been implemented in all Districts. The total number of multipurpose workers male and female at present (1996-97) is 5911 and 4505 respectively. There are 13 Training Centres and 18 private Training institutions with an intake capacity of 515 and 505 respectively for females (JPHN). There are 4 Training schools for JHI with an intake capacity of 160 and 9 Nursing schools with an intake capacity of 294. There are two Health and Family Welfare Training Centres with an intake capacity of 110 and 2 Health Supervisors Training school with an intake capacity of 90.

National Programme for Control of Blindness
The Programme envisages comprehensive eye health care services to rural and urban people by adopting eye camp approach and eye care services at various levels and by intensification of eye health education including eye donation awareness programme. The following measures were undertaken to achieve the above objective.

i. Mobile Ophthalmic units
At present there are 15 mobile units of which 13 units are attached to District Hospitals and 2 are Central mobile units attached to Medical Colleges at Kottayam and Kozhikode.

Central Mobile Unit
1. Medical College Kottayam
2. Medical College Kozhikode

District Ophthalmic Unit
1. District Hospital Manjeri
2. District Hospital, Kanhangad
3. District Hospital, Kollam
4. District Hospital, Thrissur
5. District Hospital, Alappuzha
6. District Hospital, Palakkad
7. District Hospital, Ernakulam
8. District Hospital, Pathanamthitta
9. District Hospital, Thiruvananthapuram
10. District Hospital, Kannur
11. District Hospital, Idukki
12. District Hospital, Mananthawady
13. District Hospital, Kozhikode

ii. District Hospitals
There are 14 district level eye units one in each district hospital, where the services of one ophthalmic surgeon and one ophthalmic assistant each are available. The following 14 hospitals have already been strengthened with additional eye units.
1. Government Hospital, Peroorkada
2. District Hospital Kollam
3. District Hospital, Alappuzha
4. General Hospital, Pathanamthitta
5. District Hospital, Painavu (Idukki)
6. General Hospital, Ernakulam
7. District Hospital, Thrissur
8. District Hospital, Manjeri
9. District Hospital, Kannur
10. District Hospital, Kannur
11. District Hospital, Palakkad
12. General Hospital, Kozhikode
13. District Hospital, Kanhangad
14. District Hospital, Kottayam

iii. Primary Health Centres
care services to rural people.
Among the PHCs, 214 have been provided with ophthalmic equipment and one ophthalmic assistant to deliver primary eye care services to rural people.

Medical Colleges
Ophthalmic departments have been upgraded in 5 Medical Colleges and gave been provided with equipments and additional teaching staff for better eye care and for the man power training. The total seats available for ophthalmic assistants are 75.
Ophthalmic departments have been upgraded in 5 Medical Colleges and gave been provided with equipments and additional teaching staff for better eye care and for the man power training. The total seats available for ophthalmic assistants are 75.

Eye Banks
There are 12 Eye banks in the Government sector, 5 in 5 medical colleges, 5 in district hospitals and 1 in Thodupuzha taluk hospital and 1 in Kollam. They are
1. Medical College / Government Ophthalmic Hospital, Thiruvananthapuram
2. Medical College Hospital, Kozhikode
3. Medical College Hospital, Kottayam
4. Medical College Hospital, Alappuzha
5. Medical College Hospital, Thrissur
6. General Hospital, Ernakulam
7. District Hospital, Kannur
8. District Hospital, Manjeri
9. District Hospital, Pathanamthitta
10. District Hospital, Kanhangad
11. Taluk Headquarters Hospital, Thodupuzha
12. District Hospital,Kollam.

In private sector, 2 eye banks are functioning. They are
1. Little Flower Hospital, Angamaly
2. District Co-operative Hospital, Kozhikode
Besides, 2 collection centres were established in District Hospital Palakkad,
and District Hospital, Mananthawady.

The Mobile units are conducting eye operation camps, organised by various
voluntary organisations and grants are given to them through the concerned District Blindness Control Societies.
For effective decentralisation and speedy implementation of various activities at the district level, District Blindness Control Societies were constituted in all districts as per Government of India guidelines with District Collector as Chairman.

Revised National TB Control Programme
This programme is implemented through 100 % World Bank assistance and was first implemented in Pathanamthitta district in 1994.
The prime aim is to achieve 85% cure rate. Now the programme is being extended to eight more districts. Treatment organisers are appointed for the supervision and laboratory technicians for cross checking the results in microscopic camera.

National Filaria Control Programme
Filariasis is prevalent in the entire coastal belt and in some pockets of Kerala. About 6.3 million people are exposed to the risk Filarisis and 2.8 million people are protected by NFCP.
The programme was launched in the State during 1955-56. Now it is implemented through 16 NFCP units, 2 Filaria Survey Units and the Filaria control works at Cherthala. Attached to the Filaria Units, 11 Filaria clinics are functioning. The Filaria Survey Unit at Thrissur was shifted to Thiruvananthapuram in May 95 and continues to function as main central unit at Valiyathura in Thiruvananthapuram.

Activities:
A. Control – Mosquito larvicidal spraying operation, pistia removal and anti parasitic (DEC) treatment.
B. Assessment – Entomological and parasitological (filaria survey)

Monitoring Agency
The State Headquarters Bureau of Filariasis under the Assistant Director (Filaria) attached to the Directorate of Health Services is monitoring and assessing the work at the State level.

Achievement
A total number of 93811 persons were examined during 1996-97

The performance during the last three years is as follows

National Malaria Eradication Programme
Kerala state entered the maintenance phase of NMEP in 1965. The malaria free status was maintained till 1968. As a result of imported cases, small outbreaks of malaria occurred in 1976 with 1951 cases in Kannur district and it was effectively controlled by immediate containment measures. The modified plan of operations under NMEP was implemented in 1977. One zonal malaria organisation was sanctioned in 1977 with 50% of central assistance. The zonal malaria organisation with 50% central assistance which helped in coordinating the NMEP work in the state. There are at present 14 District Malaria Officers in the state. The Zonal Malaria organisation carried out detailed entomological studies in vulnerable areas of various districts. The programme is implemented under Multipurpose Workers scheme since 1983.

Present Stage
The Ministry of Health and Family Welfare, Government of India appointed an expert committee in 1994 to identify the problem areas and formulate specific strategies to tackle problems in such areas. As per the suggestions “ The malaria action programme “ has been launched from 1995 and was implemented with the Deputy Director of Health Services (Malaria) as the Programme Officer.

Activities
Detection of malaria cases through active and passive surveillance and remedial operation through radical treatment plan and contract survey, follow up of positive cases and DDT focal spray.

Malaria positive and PF cases and Deaths during 1990 to 1996 in Kerala

National Leprosy Eradication Programme
The National Leprosy Eradication Programme was started in 1959. The main strategy of the programme was continuous case detection of leprosy cases and its treatment with dapsone and also health education of the patient family and the community. The system was later found to have drawbacks, because of the enormous number of defaulters due to the prolonged nature of treatment and also the emergence of Dapsone resistant leprosy.
In view of the high incidence of resistant leprosy, the Government of India constituted a committee in 1981 and in pursuance of the suggestions in the report the National Leprosy Control Programme was redesignated as National Leprosy Eradication Programme. With a view to wiping out leprosy from India by 2000 AD, it was brought under a 20 point programme and was subsequently made 100 % centrally sponsored scheme.
The most significant feature of the National Leprosy Eradication Programme is the introduction of a specialized form of treatment for leprosy known as M.D.T (Multi Drug Therapy) in all endemic districts, step by step. In Kerala M.D.T was implemented in Alappuzha (1987, Thrissur and Palakkad (1990), Kollam and Thiruvananthapuram (1991) and Ernakulam, Kannur, Kasargod, Malappuram and Kozkikode (1993) and later in the other districts.

As a result, the prevalence rate in these districts was reduced considerably as given below:

Physical Target and achievement (1996)

	Target	Achievement	Percentage
New cases detected	4000	5765	144
Cases brought under treatment	4000	5720	143
Cases detected	5500	7903	144

Components of National Leprosy Eradication Programme

Magnitude of the problem

Sexually Transmitted Diseases Control Programme
Sexually Transmitted Diseases (STDs) are known to be one of the major health problems. As women are major reservoirs of infection in syphilis, screening of all pregnant women and subsequent treatment will not only lead to decrease in the incidence of the disorders, but will also reduce the incidence of congenital syphilis, arising from untreated cases besides that of abortions, miscarriages, still births, deafness and blindness. In the state there are STD clinics attached to district / taluk hospitals, which are known as Skin and V.D departments.

National AIDS Control Programme
Considering the gravity of increasing prevalence of HIV / AIDS the state Government has intensified and started a control programme. An AIDS surveillance centre was established in 1986 at Medical College, Thiruvananthapuram. Here screening of blood donors and blood products are carried out.
National AIDS Control Programme was implemented in the state from September 1993. The AIDS cell was created under an Additional Director of Health Services. There is also a State AIDS Committee and State Technical Advisory Committee to oversee the programme implementation of prevention and control of HIV/AIDS. The main activities are surveillance, modernisation of blood banks, establishment of zonal blood testing centres, component separation unit and incineration, strengthening and establishment of STD clinics, training of staff, IEC activities including adolescent education.
The reports from hospitals, blood banks and laboratories in the state indicate that the incidence of HIV infection in the state is steadily increasing. The reported case of HIV positive and AIDS cases till 31-12-1997 is 1791 and 166 respectively. The incidence shows that even though there is a fair degree of awareness among the public it has not lead to the desired behavioural changes.
The IEC activities are conducted in a moderate way using print media, electronic media and other arts form. Awareness programme for the public is done through All India Radio and Doordarshan. The Government of Kerala has decided to appoint a Communication agency of IEC consultant to give target specific IEC activities to the public. Both Government and private doctors were trained in HIV/AIDS. Training is also given to staff nurses and other paramedical staff and high school teachers and head masters. Both blood bank officers and technicians were trained, a workshop on syndromic management of STDs for 22 medical officers was conducted and counseling training for HIV/AIDS was also given.
The 23 licensed blood banks in Government section have been modernised and in the state there are 83 modernised and licensed blood banks including those in private, autonomous and central Government institutions. The 3 component separation units attached to blood banks in the Medical Colleges are nearing completion. A large incinerator has been installed in the Medical College campus of Thiruvananthapuram.
Since the surveillance centre in Medical College alone is inadequate steps are being taken to start 5 more centres.
Kerala State AIDS cell has conducted three workshop for eminent Doctors, Educationalists, Social Workers, Director of Public Instructions, Director of Collegiate Education, Head Masters and Principals of colleges for evolving a strategy to give sexual health education to high school students from 8th standard onwards. A module named Family Life Education for training the teachers of high schools to impart training for their students was formed and was printed and supplied by UNICEF.
In order to streamline the work of different Non Governmental Organisations (NGOs) the AIDS Cell is conducting a meeting every year viz. AIDS Circle Meet. Representatives from important NGOs in other states, nominees send by WHO, NACO, UNAID and DFID also are participating in this meet.

State Mental Health Programme
The State has a Mental Health Programme of its own and the first District Psychiatry unit was opened in 1970 attached to District Hospital, Ernakulam. Initially psychiatric services were provided through the 3 Mental Hospitals. Stress in now on domicilliary care and secondary prevention of major mental disorders. Drug de-addition programme is also incorporated into it. There are 3 Mental Health Centres, 5 psychiatric units and district psychiatric units (in teaching hospitals) in the public sector, besides hospital / wards / rehabilitation centres in private hospitals and voluntary organisations. They provide OP and IP care and give training to medical students and nurses. A suicide prevention clinic has been started in the General Hospital, Thiruvananthapuram. The doctors and paramedical staff of Taluk Hospitals and Primary Health Centres are being trained and it is proposed to distribute the Psychiatric drugs through selected PH Centres. A project viz. “The Need Assessment of Severe Mental Morbidity of Kerala State” has been launched and an office of the State Mental Health Authority was opened in pH laboratory campus on 29-7-1997.
Facilities are available in the three Mental Health Centres to the relatives of the patients for staying with them if they desire so. The Social Welfare Department is running a rehabilitation centre for ex-female mental patients of Mental Health Centre.

Physical Medicine and Rehabilitation
The physical medicine and rehabilitation units are started with the main objective of providing maximum care to the physically disabled for the treatment of disability producing diseases and rehabilitation of the disabled.
The first Department of Physical Medicine and Rehabilitation in Kerala was established in the Medical College, Thiruvananthapuram in 1968. A state level advisory committee on Medical Rehabilitation Science to advise the Government in the implementation of Physical Medicine and Rehabilitation in the state was constituted in 1975. The Deputy Director of Health Services (PM&R) was also included as member of the committee.
Under the Department of Health Services, 11 Physical Medicine and Rehabilitation units are functioning in major hospitals in all districts except Pathanamthitta, Idukki and Kasargod.
Three limb fitting centres are functioning in G.H.Ernakulam, District Hospitals at Kollam and Kannur. A fourth one is being set up at District Hospital, Palakkad.
The Welfare Society for the Locomotor Disabled has been formed for the rehabilitation of locomotor disabled. The society augmented Government activities in the field of medical rehabilitation by conducting medical camps for the locomotor disabled and supplying sufficient artificial appliances tot he selected.

National Iodine Deficiency Disorder Control Programme
This is a centrally sponsored scheme with 100 % central assistance. Under the programme a Goiter cell was sanctioned in the Directorate of Health Services in 1988 and was fully established in 1990. The programme envisages imparting health education regarding goiter, conduct of goiter prevalence surveys and awareness creation for the use of iodised salts instead of common salt. Various publicity activities such as the preparation of folders, posters, cinema slides, stickers, exhibition sets on IDD, slides on IDD etc were done under the Directorate of Health Services. A series of seminars, workshops, operational training and state level meetings on IDD also were conducted. The activities were organised by various voluntary organisations, women’s associations, youth clubs, Civil Supplies Officers, representatives from Social Welfare Department & medical officers of Primary Health Centres. The IDD cell started iodine monitoring system on iodized salt by distributing MBF kits to District Medical Officers, supplied by UNICEF, Madras.
From 1989-94, the IDD cell conducted 30 Goiter prevalence surveys in 14 districts of Kerala and found out that prevalence rate is 4.7 to 20 %.
Government of Kerala has not issued notification for banning the sale of non-iodized salt.

Family Welfare Programme
The Family Planning Programme was officially implemented in India in 1952. During the first and second plan periods (1951-61) the programme was taken up in a very modest way. It was reorganised in the third plan period and it gathered momentum with the starting of full fledged department in 1966. During the fourth plan period, it was implemented as a target-oriented, time-bound, incentive-based programme. During the fifth plan period it was integrated with maternal health and child care and nutrition and was implemented as a package programme, which include health, family planning, maternal and child health and nutrition.
The beginning of the programme in Kerala in 1955 was with 11 clinics attached to Medical institutions. But over the years, the state has evolved innovative strategies like mass camps, which were later adopted in other parts of the country. The course of development falls into three distinct phases. First a period of slow growth during 1955-64, second a period of reorganisation and establishment os State Family Planning Centres during 1964-70 and lastly a period of intensified maternal and child health services from mid 70’s onwards. During the period 1956-61, of the first phase. 70 family planning clinics were opened in the state with facilities for sterilization in 53 institutions. During the next four years, which was a period of slow growth, 50 more clinics were started and family planning clinics were opened in 93 panchayats. Subsequently more infrastructure facilities were provided and incentives for promoters and doctors were introduced to boost up the programme. At various levels, committees were constituted to promote the activities of Family Planning clinics. In 1964 on the basis of the recommendation of the Mukharjee Committee, a network of service units was established and it was a period of recoganisation till 1970. From 1970-1973 conduct of mass sterilization camps was the hallmark of the programme. Since 1970 the state has stepped up the pace and reached several milestones in the implementation of the various family welfare programmes.
Delivery of various Family Planning services is undertaken through the sub centres, Primary Health Centres, Taluk Hospitals, District Hospitals and Medical Colleges. People’s participation was sought through local self government including voluntary organisations and opinion leaders at various levels. Imaginative use of mass media and inter personal communication were made for highlighting the benefit of small family norm and removal of socio-cultural barriers for adoption of family limitation programme.
The Junior Public Health Nurses located at the sub-centre along with Junior Health Inspectors are the front line workers providing services in the community. For skill upgradation of medical and paramedical personnel at the subcentre, PHC’S and CHC’S two Health and Family Welfare Training Centres are functioning in the state.
In the mid 1970’s, MCH services were integrated with FP and the programme was renamed Family Welfare Programme. Since then Kerala has made rapid strides in the implementation of Family Welfare Programmes. The programme seek to promote responsible and planned parenthood through voluntary and choice of methods best suited to individual acceptors.
In Kerala from 1957 to 1973 as in other states the number of vasectomies out numbered tubectomies, accounting for as much as 76% of the total sterilization conducted by the state. But since, then, there was a reversal of the trend, tubectomies outstanding vasectomies in all the years except in 1976. Male sterilization declined from 14% in 1980-81 to about 2% in 1990-91 and to as low as 0.3 % in 1996-97. In the case of IUD insertions, OP & CC uses also, a decreasing trend was noticed indicating clearly that the people of Kerala prefer permanent methods for Family Planning.
One redeeming feature of the implementation of the Family Welfare Programme in Kerala was that since 19980-81 it was able to maintain consistently an achievement of over 90% of the target under sterilization and could even excel the targets consistently for two years in 1980-81 and 1981-82 in 1984-85 and again from 1988-89 to 1994-95 except to 1990-91. For the creditable performance during 1986-87 the state secured the second prize of an award of Rupees one crore among group A states and first prize during 1987-88 of a cash award of Rupees 2.5 crores. In 1997, Population Foundation of India has adjusted Kerala as the best performing state in India in terms of population and reproductive health programmes for a cash award of Rs. 10 lakhs and a running trophy. Similarly Palakkad district was adjusted as the best performing district for a cash of RS 2 lakhs.
One of the important tools to assess the impact of the performance of the Family Welfare Programme on birth rate is the couple protection rate. In Kerala the percentage of effectively protected couples is higher than the All India average. According to the Government of India estimates the couple protection rate as on 31-3-1994 i 51.5 % for Kerala, while the all India rate is 45.4 %.
In fact the true measure of effectiveness of the Family Welfare Programme is neither the number of sterilization conducted nor that of IUDs inserted or - OP and CC users, - but the demographic impact to the extend that the birth rate is reduced. The birth rate registered a decline from 23.2 in 1985 to 17.7 in 1995.
As a result of the fall in birth rates the TFR also declined from 2.3 in 1986 to 1.8 in 1991 and GRR from 1.1 to 0.9.

Table 1
Some fertility indicators for Kerala

TFR Total Fertility Rate
GRR Gross Reproductive Rate
CBR Crude Birth Rate
Source : Family Welfare Year Book 1992-93.
The long term demographic goals, as laid down in the National Health Policy (1983) was to achieve the net reproduction rate of unity by the year 2000 AD. The state has achieved this goal ahead of the targeted year. Kerala’s achievements in the Family Welfare front have been impressive in terms of major indicators viz. birth rate, death rate, neonatal mortality rate, infant mortality rate, couple protection rate etc.
The social factors such as high female literacy, higher age at marriage of girls, status of women, effective role played by non Governmental Organisations and the general socio-economic consciousness of the people have contributed to this unique position.

Immunisation Programme
Immunisation plays a vital role in the control of infectious diseases, by building up immunity among immunised persons against some specific vaccine preventable diseases and by helping to decrease the transmission of diseases from one person to another. In Kerala the EPI started in 1978 as a phased programme to cover 33 NES blocks every year. T.T immunisation to pregnant women started in 1975-76 was integrated with EPI in 1978 itself. Polio and typhoid vaccinations were included in 1979-80 and T.T immunisation for school children in 1980-81, while BCG vaccination was brought under the purview of EPI during 19981-82. Measles vaccination was initiated only in 1985-86. By the year 1982 all the then 151 NES blocks in the state were covered under the EPI and from 1983 onwards it became a permanent ongoing programme.

Universal Immunisation Programme
With a view to improving vaccine coverage and quality of service, a major shift in emphasis and strategy was adopted by the Government of India in 1985. The Universal Immunisation Programme was thus launched under National Immunisation Mission. The main objective of the programme is immunisation of all children below one year of age (infants) against 6 vaccine preventable diseases and 100 % coverage of pregnant women with T.T maintenance of universal prophylaxis against anaemia in women and children and also better management of diarrhoeal diseases.
In Kerala UIP was launched in 1985, in the selected districts of Palakkad and Idukki and by 1988 all the 14 districts were covered. Infant below 1 year are immunised against six killer diseases viz. Diphtheria, Whooping cough, Tetanus, child hood TB, Poliomyelitis and Measles.

Cold Chain Programme
Under the UIP the cold chain system of storage of vaccines is maintained. Vaccines are generally sensitive to heat. Hence the shortage and transport of vaccines should be done at the required low temperature levels. The system of storage and transport of vaccines at low temperature from manufacturer to the point of use is called the Cold Chain System.
The allocation and supplies of all vaccines to the immunisation programme are done by the Government of India. The supplies of vaccine to the state are made to the regional vaccine stores at Thiruvananthapuram, Ernakulam and Kozhikode. The regional vaccine store at Thiruvananthapuram also functions as a state store. The supply of vaccines to District Stores is made from Regional vaccine stores and from District stores to PHC, CHCs, PP units etc.
A wide range of equipments including walk in coolers, Deep freezer, ice lined refrigerator, cold boxes, vaccine carriers, day carriers etc are used in the cold chain system. In order to ensure the potency of vaccines at all levels and quality of the cold chain system samples of vaccine from all levels are collected and sent to Coonoor regularly for potency testing.

Oral Rehydration Therapy (ORT)
ORT was launched as a national child health programme from 1985 along with UIP. The ORT was introduced in 1971 by WHO on a part of improving the management of diarrhoeal diseases, so as to control deaths due to these diseases. Oral fluid therapy is based on the observation that glucose given orally enhances the intestinal absorption of salt and water and is capable of correcting the electrolyte and water deficit. The aim of the programme is to prevent diarrhoeal deaths due to dehydration among children under five years.
In Kerala the programme was started in 1987 in a phased manner. By 1988-89 Diarrhoeal Treatment Units were established in all Medical Colleges and in seven district hospitals. ORS depots are being established in all villages and urban areas at he rate of one per thousand population to increase ORS accesses rate.
The 25th year of ORS discovery was celebrated in 1994-95. Kerala is having a unique phenomenon of high morbidity and low mortality. As a result of effective implementation of this programme the IMR and child morbidity rate have declined remarkably.

Child Survival and Safe Motherhood Programme (CSSM)
The CSSM programme was launched in 1992-93 in a phased manner with the assistance of World Bank and UNICEF. The programme seeks to sustain the high coverage levels of immunization achieved through UIP in good performing areas, and strengthening the immunisation services where the coverage is still not satisfactory. The programme also provides for augmenting services under oral rehydration therapy, universalising the prophylaxis scheme for control of anaemia in pregnant women and control of blindness due to vitamin A deficiency in children and initiating a programme for control of acute respiratory infection in children and strengthening of FRUs to deal with risk obstetric cases and obstetric emergencies.
Immunisation camps are arranged in sub-centres, anganwadies and other suitable locations as per pre-arranged plan of action. Due importance is given to education of mothers, motivation and in reminding mothers for second and third doses of vaccination. Vaccine is supplied to private hospitals free of cost. The state has made tremendous achievements like elimination of neonatal tetanus and polio and reduction of other vaccine preventable diseases and many districts have become polio free. After s series of polio mop-up rounds, Kerala state along with the entire nation is conducting the pulse polio immunisation in December 7th and January 18th every year. 71 FRUs have been already been identified in the state and measures are being taken to strengthen them for emergency obstetric care and neonatal care.