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Public Health in India Aalok Ranjan Chaurasia

Public health

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Public Health in India

Public Health in IndiaAalok Ranjan ChaurasiaOutlineHealth and Public HealthPublic Health in IndiaBefore the Colonial periodDuring the Colonial periodAfter the colonial periodEssential Public Health FunctionsMortality transition in India

HealthThe World Health Organisation defines Health (of an individual) as the state of complete physical mental and social well-being and not merely the absence of disease or infirmity.

World Health Organisation, however, does not define Public Health.DeathDeath, on the planet Earth, is inevitable.

A large number of deaths are premature.

A substantial proportion of deaths can be avoided.

Public Health is related to preventing premature and unavoidable deaths.A Model of HealthExposure to Risk FactorsBody resistancePoor HealthManifestationDisease ConditionDisabilityDeathPublic HealthIf the disease condition is avoided, the probability or the chance of death or disability can be reduced.

Public Health is therefore described as the science and art of preventing diseases, prolonging life and promoting health (of individuals) through organised efforts and informed choices.Public HealthPublic Health deals with the group of people rather than individuals.Dimensions of public healthHealth promotionDisease preventionEarly diagnosis and prompt treatmentDisability limitationRehabilitationTraditional Indian ApproachThe Indian approach to health is enshrined in the concepts and principles of Ayurveda which means the science of life.Ayurveda is one of the oldest system of health care in the World.Ayurveda deals with both preventive and curative aspects of health.Health defined by WHO is very similar to concepts of Ayurveda.Western ApproachThe western approach of avoiding diseases, death and disability, traditionally focused on personal hygiene and public sanitation during the 19th Century.

This approach, combined with better food availability, paid rich dividend in the developed countries in reducing morbidity and mortality.Components of Public HealthEpidemiologyMeasurement of disease conditions in relation to the population at risk. StatisticsCollection, presentation, analysis and interpretation of epidemiological data.Health ServicesServices directed towards meeting the health needs of the people.Public Health before the Colonial PeriodLittle is known about public health activities before the colonial period.Main stream system of health care was Ayurveda.Home-based care appeared to be the dominant feature.There appeared little organised efforts or institutional care to treat diseases and prevent deaths.Public Health during the Colonial PeriodEvolution of public health system during the colonial period followed the same path that was followed in Britain.Public health efforts were focused largely on protecting British civilians and army cantonments.Sanitation was given the top priority.Focus was also on early detection and control of contagious diseases cholera and plague.

Public Health during the British PeriodTraining and research Institutions in public health.Public health legislation.Sanitary departmentsAscertaining local sanitary conditions.Vital registration.Monitoring disease trends.Vaccination programmes.Technical advice on control of epidemics.

Public Health during the British PeriodRestriction of public health efforts to British civilians and military established was a major constraint.Majority of Indian masses remained deprived of the dividends of these efforts.At the time of Independence only 3 per cent households in India had toilets.Water, drainage and waste disposal services were utterly lacking.Public Health during the British PeriodAlthough, public health efforts were restricted to British civilian and military establishment, they had impact on Indian masses.Mortality spikes were sharply reduced.Mortality from cholera and plague was sharply reduced.Diseases like malaria and gastro-enteritis continued to take heavy toll.Public Health in Independent IndiaEvolution of public health care system in Independent India was shaped by two important factors:The Report of First Health Survey and Development Committee (Bhore Committee) constituted during the colonial rule.Emergence of modern medical technology for the prevention and control of diseases, especially communicable diseases.Bhore CommitteeAppointed in 1943.Recommended comprehensive remodeling of health services.Integration of preventive and curative health services at all levels.Hospital-based health care system.Development of primary health centres in two stages.Training in Preventive and Social Medicine.

Bhore CommitteeThe short-term planA PHC for every 40000 population.PHC to be manned by 2 doctors, 4 PHN, 4 Midwife, 1 Nurse, and others.The long-term planA primary health unit for every 10-20 thousand population with 75 beds.Secondary unit with 650 bedded hospital.District unit with 2500 bedded hospital.Medical TechnologyMass production of antibiotics.Availability of vaccines for diseases having high mortality and disability ratesTetanusDiphtheriaPertussis (Whooping Cough)MeaslesPoliomyelitisPublic Health in Independent IndiaThe recommendations of Bhore Committee and the availability of preventive and curative medical technology resulted in the evolution of hospital-based public health system.The public health arrangements created during the colonial period were replaced by hospitals and health centres.Public health services were merged with the medical services.Public Health in Independent IndiaBhore Committees recommendations were accepted only partially.One primary health centre for every 30 thousand population.Only 6 beds in each primary health centre.Only one doctor.Truncated paramedical staff.The situation has remained largely unchanged.Public Health in Independent IndiaSince Bhore Committee, numerous committees were constituted to evolve the public health system.Some of the recommendations of these committees were adopted; some were not by the government.All committees retained the core of the model recommended by the Bhore Committee. Public Health in IndiaMudalliar Committee(1962)Strengthen PHCs before establishing new ones.PHC should provide preventive, promotive and curative services.Strengthen sub-divisional and district hospitals.Creation of All India Health Services.Chaddha Committee (1963)Malaria worker to function as multipurpose worker.Public Health in IndiaMukherjee Committee (1965)Separate staff for family planning programme.Malaria activities to be de-linked from family planning activities.Jungalwala Committee (1967)A unified approach for all problems instead of a segmented approach for different problems.Medical care and public health programmes to be put under charge of a single administrator.Public Health in IndiaKartar Singh CommitteeConcept of MPW(M) and MPW(F).One PHC to catre 50 thousand population.Each PHC should have 16 SHC (3-3.5 thousand population).Shrivastav CommitteeCreation of bonds of paraprofessional and semiprofessional health workers from within the community itself.Development of a Referral Services Complex.Public Health in IndiaBajaj CommitteeFormulation of National Medical & Health Education Policy.Formulation of National Health Manpower Policy.Educational Commission for Health Sciences.Health Science Universities in various states.Health manpower cells.Vocationalisation of education at 10+2 levels as regards health related fields.Realistic health manpower survey.

Public Health System in IndiaA population based normative approach is adopted for establishing hospitals and health centresSHC One for every 5000 (3000 in hilly/tribal areas) population.PHC One for every 30000 population (20000 in difficult areas) with 4-6 indoor/observation beds.CHC One for every 80-120 thousand population with 30 beds.Public Health System in IndiaThe norms are for government institutions and are for the rural areas only.For the urban areas, no norms have been defined.Nearly all government civil and district hospitals and most of the CHCs are located in the urban areas.No information is available about the private health system.Public Health System in IndiaInstitutionReferenceNumberSHC2007145272More than 6 SHC for each PHC, on averagePHC200722370More than 5 PHC for every CHC, on averageCHC20074045Rural hospitals20076298Beds in rural hospitals2007142396About 23 beds per rural hospitalUrban hospitals20072774Beds in urban hospitals2007324206About 117 beds per urban hospitalPublic Health in Independent IndiaOne fall out of the hospital-based public health approach was the neglect of public health legislation.A Model Public Health Act was drafted in 1950 by the Government of India. It was revised in 1987.This Act is yet to be adopted by any of the constituent state of the country.

Public Health in Independent IndiaThe hospital-based public health system led to the medicalisation of the system.The focus has been on medical services.Public health services have largely been neglected.Poor public health services result in high cost of illness, debility and death.The main sufferer are the people, especially the poor and deprived.

Public Health in IndiaThe epidemiological and statistical dimensions of public health have been grossly neglected.Lack of epidemiological and statistical database affected public health planning.In the absence of necessary information, planning reduced to a normative, mechanical exercise, often out of context to peoples needs.Public Health in IndiaThe problem gets complicated because of social, economic, cultural and environmental diversity that leaves normative planning virtually redundant. Decentralisation of the health system could not succeed because of the lack of epidemiological and statistical information necessary for planning for public health services.Public Health in IndiaPublic health in India is hospitalised.Health planning is concerned more with the health of the health care delivery system (hospitals and health centres) then the health of the people.The remedy was sought in terms of specific National health and disease control programmes.There are numerous such programmes.

Public Health in IndiaReproductive and child health programme.National tuberculosis control programme.National malaria control programme.National blindness control programme.National water born disease control programme.National leprosy eradication programme.National iodine deficiency control programme.Public Health in IndiaAll National disease control programmes are implemented through the existing government hospitals and health centres.Over the years, a campaign approach has been evolved to implement many of the national health and disease control programme.Successful campaigns have often been followed by unsuccessful maintenance.Public Health in IndiaFocus on medical services.Neglect of public health services.No modern public health regulation.Lack of systematic planning.Poor sustainability of public health efforts.Absence of epidemiological and statistical skills at district and below district level.No micro-level planning, no public health action.Essential Public Health Functions

Essential Public Health Functions in IndiaMortality Transition in India

Public Health in IndiaWidespread existence of preventable diseases and deaths is a disgrace to the society which tolerates it.

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