Paradigm Shift Public Health PULecture March2010

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Paradigm Shiftin

Indian Public Health Needs and Priorities:Issues and Challenges(Lecture at Panjab University, Chandigarh, India, on 23.03.2010)

V R Raman

9424207375, [email protected]

Associated With:

Public Health Resource Network

(upcoming) State Health Systems Resource Centre Jharkhand

Key Features of the CurrentPublic Health Paradigm Shift

Publicseemsto be back into the public health affairs across the world, people back toprimary health care, and community back in community health..

International: the world health report 2008- Primary Health Care: Now More than Ever,Report of the Commission on Social Determinants of Health- Closing the Gap in a

Generation: Health Equity Through action on Social Determinants of Health, reformstaking place in countries like US..

National:

National Rural Health Mission 2005-12, Draft Public Health Act

Many of the problems have been accepted and solutions looked at: Human resourcesfor health, public health planning, public health standards, technical assistance,community participation measures, health financing, systemic corrections

However, there are systemic, HR and infrastructure related, geographic limitations

Chronology of Paradigm Shift(s)

Prior to Alma Ata Declaration

Bhore Committee, 1946: peoples participation, spirit of self-help, health programme asservices, village health committees and voluntary health workers

Mudaliar Committee, 1961: importance of demand for higher stds of public health, healtheducation, prioritisation by govt..

ICMR and ICSSR: Alternative Approaches to Health Care, Health for All.

Community Health initiatives: Jamkhed, FRCH etc.., Janata CHV approach too..

Compulsary Family Planning treated as Health (!)..


Alma-ata and after

Defining health as the complete physical, mental, social well-being; health determinantsinto picture; Health For All by 2000 as the goal

In India- National Health Policy 1983NIHFW and SIHFWs- learning centres

CSSM-MCH-RCH programmes and vertical disease control programmes: target based toneed based approaches

Gradual retreat by the state: comprehensive primary health care to selective care, limited

interventions approach, Target based approaches, predicted/quantified outcomes, limitedcoverage and lesser scaling up, top-down and vertical approaches, SAP, currentreflections..

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Funders priorities vs. funding needs: impact at both public sector and community

Welfare approaches Vs. Rights approaches- even government services considered asmercy

Clinical approaches Vs. Social Health approaches


Widening community health initiatives- civil society initiatives and state-run programmeslike Jan Swasthya Rakshak (MP)

1st Peoples Health Assembly 2000- the birth of Peoples Health Movement (Jan SwasthyaAbhiyan), peoples health charter(s), campaign material, international health forum,international peoples health university, second PHA, liaison with WHO and getting a

favourable environment for peoples health, right to health care initiatives, peoples ruralhealth watch.. And the WHR 2008

MDGs emerging as the ultimate goal, replacing health for all and Comprehensive PrimaryHealth Care

Revised National Health Policy 2003, introduction of PPPs and passive privatisation, returnof medical centric approaches

Chhattisgarh SHRC and the Mitanin Programme: influencing the national public health

agenda

General Elections 2004, National Advisory Committee, Common Minimum Programme, anddeclaration of NRHM in 2005

Right to Food, Right to Employment initiatives and NREGA: another vital area

TSC and ICDS under scrutiny

Changes as part of NRHM

Public Health Planning- village, block, district and state plans

Community Participation: ASHA, VHSC, CBM etc

Flexible and decentralised financing, organisational frameworks

Demand side financing: RSBY, JSY etc

Quality of CARE concepts- structures like RKS and standards like IPHS Convergence: food and nutrition on the crossroads

Bringing indigenous systems into the public health mainstream

Public-Private Partnerships

Quest for technical capacities and technical assistance

HRH: introduction of state-district-block level managerial cadre for programme, finance,quality; additional hands for HSC and other facilities

Worlds largest Community Health Volunteer initiative- ASHA

Public Health Capacity Building- Public Health Foundation of India and Indian InstitutesPublic Health;

Public Health Resource Network and capacity building programme for district healthplanning as well as PG diploma in District Health Planning

NRHM: Challenges

Where do we stand after 4 years of NRHM?

Challenges of NRHM-

issues of mission spirit and vision

financial allocations and flow

HRH crisis- quantity and quality

infrastructure bottlenecks

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rural mission still is urban- tribal, conflict, difficult areas are not getting covered evenafter exclusive push for inclusion

Indian Systems or AYUSH- still on crossroads

evolving systems along with the mission

Corruption: leaderships under question mark, esp. in difficult states..

Making Access to Health Care as a fundamental right and health services as basicentitlements for all- Public Health Act

NRHM: Societal Issues

ASHAs and Village Committees: Lackeys or Liberators?

RKSs and RSBY: Where stand the poor patients?

Private Partnerships: Who gets benefited on whose costs?

Huge HRH crisis and outmigration- withering the services

Medical Education Reforms under scrutiny

Decentralised Planning and financing: issues of inclusion, transparency and accountability

Gender divide: doing ends and decisive ends

Sanitation: Still not a clean area De-centralisation: Whither PRIs

Convergence: everything around happen except it

Focus states: continuing to be amongst the weakest

Roles of concerned citizens and grassroots level structures

Quality of Public Health Education and levels of available public health skills

Expected and Potential roles of Public Health Professionals/ practitioners

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Paradigm Shift Public Health PULecture March2010