HEALTH CARE SERVICES I

PUBLIC HEALTH
The term "public health" came into general use around 1840. It arose from
the need to protect "the public" from the spread of communicable diseases.
Later, it appeared in 1848 in the name of a law, the Public Health Act in
England to crystallize the efforts organized by society to protect, promote
and restore the people's health.
In 1920, C.E.A. Winslow, a former professor of public health at Yale
University, gave the oft-quoted definition of public health. The WHO Expert
Committee on Public Health Administration, adapting Winslow's earlier
definition has defined it as :
"the science and art of preventing disease, prolonging life, and
promoting health and efficiency through organized community
efforts for the sanitation of the environment, the control of
communicable infections, the education of the individual in personal
hygiene, the organization of medical and nursing services for early
diagnosis and preventive treatment of disease, and the
development of social machinery to ensure for every individual a
standard of living adequate for the maintenance of health, so
organizing these benefits as to enable every citizen to realize his
birthright of health and longevity".
Whereas in developing countries such as India, public health has not made
much headway in terms of sanitary reforms and control of communicable
diseases, it has made tremendous strides in the industrialized western
countries resulting in longer expectation of life and significant decline in
death rates. As a result of improvements in public health during the past 50
or 60 years, public health in the developed countries has moved from
sanitation and control of communicable diseases (which have been largely
controlled) to preventive, therapeutic and rehabilitative aspects of chronic
diseases and behavioural disorders.
A EURO symposium in 1966 suggested that the definition of public health
should be expanded to include the organization of medical care services.
This was endorsed by another Expert Committee of WHO in 1973. Thus
modern public health also includes organization of medical care, as a means
of protecting and improving the health of people. Since the organization of
public health tends to be determined by cultural, political and
administrative patterns of the countries, there is a wide mosaic of
organizational arrangements.
Public health, in its present form, is a combination of scientific discipliness
(e.g., epidemiology biostatistics, laboratory sciences, social sciences,
demography) and skills and strategies (e.g. epidemiological investigations,
planning and management, interventions, surveillance, evaluation) that are
directed to the maintenance and improvement of the health of the people.
Health
Health is a state of complete physical, mental and social well-being
which is essential for leading a productive life, and is not merely the
absence of disease or infirmity. Provision for health should be
considered a fundamental human right and attainment of highest
level of health is a most important social goal. Concept of Health
Care
Since health is influenced by a number of factors such as adequate food,
housing, basic sanitation, healthy life styles, protection against
environmental hazards and communicable diseases; the frontiers of health
extend beyond the narrow limits of medical care. It is thus clear that
"health care" is not synonymous with "medical care". Health care covers a
broad spectrum of personal health services ranging from health education
and information through prevention of disease, early diagnosis and
treatment and rehabilitation.
This health care services may be defined as "all those personal and
community health services, including medical care and related
education and research directed towards the protection and
promotion of the health of the community."
The term "health services" implies organization, delivery, staffing.
The major themes have emerged in the recent years in the delivery of
health services :
(a) First, that health services should be organised to meet the needs of
entire population and not merely selected groups. Health services should
cover the full range of preventive, curative and rehabilitation services.
Health services are now seen as part of the basic social services of the
community; (b) secondly, it is now fully realised that the best way to
provide health care to the vast majority of underserved rural people and
urban poor is to develop effective "primary health care" services supported
by an appropriate referral system. The current social policy throughout the
world is to build up health systems based on primary health care, towards
the policy objective of Health for All by 2000AD.
Basis for Health Care in India in Modern Time
India gained independence in August, 1947, after a long colonial rule.
Although, the National Health Policy in India was not framed and announced
until 1983. The basis for organisation of health services in India through the
primary health care approach in modern time was laid by recommendations
and guidance provided by the `Health Survey and Development Committee'
(Bhore Committee) in 1946. The community development was launched in
October 1952, as the first integrated all round rural development
programme. It was proposed to establish one primary health centre (PHC)
for each community development block. At that time, the operational
responsibilties of the PHC were to cover medical care, control of
communicable diseases, maternal and child health (MCH), nutrition, health
education, school health, environmental sanitation and the collection of
vital statistics. Each PHC had three sub-centres, being looked after by a
trained midwife for providing MCH services.
Subsequently, over the past decades the health services organization and
infrastructure have undergone extensive changes and expansion in stages
following a review by a number of expert committees, namely the Mudaliar
Committee (1961), the Mukherjee Committee (1966), the Kartar Singh
Committee (1974), and the Srivastava Committee (1975). Progressive
changes have been introducted into the programme over the six five-year
plan periods. The first five-year plan (1951-56) initiated a process of all-
round balanced development to ensure a steady improvement in the living
standard over a period of time. New programmes for control of
communicable diseases such as Malaria, filaria, tuberculosis, leprosy etc.
was instituted. Health and medical care infrastructure and facilities, and
water supply and sanitation were expanded with a view to improve the
accessibility and availability of services.
The subsequent five-year plans aimed at expanding health and
family planning services to bring these services within the reach of
all people for improving their health status. During the fifth plan
(1974-80), removal of poverty and achievement of self-reliance on
the part of the community were given emphasis. For preventing and
correcting nutritional deficiencies, supplementary feeding
programmes for children and expectant mothers were initiated on a
country-wide basis. The family planning programme was integrated
with the MCH and Nutrition programmes.
India is a signatory to the Alma Ata Declaration of 1978, as is committed
to attaining the goals of "Heath for All" (HFA) by the year 2000 A.D., through
the primary health care approach. Consequently, while formulating the sixth
five-year plan (1980-85), a critical review was made of the approaches in
the first five-year plans. Based on these, a long term perspective plan was
outlined by the Government for achieving the HFA goals. Also efforts were
initiated for the formulation of the National Health Policy keeping in view
the HFA principles and strategies.
HEALTH FOR ALL
Since 1975, the WHO has been developing the concept of achieving health
for all by 2000 AD. In the 30th World Assembly in 1977, it was decided that
the main social goal of the governments and the WHO should be "the
attainment by all the people of the world by the year 2000, of a
level of health that will permit them to work productively and to
participate actively in the social life of their community." This was
popularly known as "Health for All (HFA) by 2000 AD."
In the International Conference on Primary Health Care, jointly organised by
WHO and UNICEF in Alma Ata, USSR in 1978, this concept of HFA by 2000 AD
was endorsed and it was further stated that primary health care would be
the key to attaining this target. These also spelt out the minimum essential
components of primary health care and the supportive activities needed for
their successful implementation.
To achieve the goal of Health for All, a number of immediate goals or
milestones had been planned in between as below:
1985— Providing right kind of food for all
1986— Providing essential drugs for all
1990— (a) Providing basic sanitation for all
(b) Providing adequate supply of drinking water for all
(c) Immunization of children against six common diseases, viz. measles,
whooping cough, tetanus, diptheria, polio and tuberculosis.
Besides the above, a number of indicators (e.g. health status indicators,
health care indicators, social and economic indicators and health policy
indicators) have also been developed to enable countries to measure and
monitor as they work towards the goal. However, it was left to each country
to decide its own norms, while suggesting a minimum life expectancy of 60
years and maximum infant mortality rate of 50 per 1000 live births.
Most recent estimates indicate that some 83% habitations are `fully
covered', 15% are `partially covered' and only 2% of habitations are not
covered.
There has been marked impovement in the health status of the
people in the country. Life expectancy has increased to 64.6 years
during 2000. Crude birth rate has reduced to 26.1 during 1999.
Crude death rate has declined to 8.7 and infact mortality rate to 70
during the same period. Planned initiatives taken in the public
health field have also resulted in improvement in epidemiological
scenario in the country. Small pox and Guinea worm diseases have
been eradicated, Polio is on the verge of eradication, Leprosy, Kala-
Azar and Filariasis can be expected to the eliminated in the
foreseeables future. Incidence of malaria which showed resergence
during early seventies has reduced to 2.2 million cases during 2000.
Primary Heath Care
The term "primary health care" was first used to mean the care given to the
patient by the health worker who saw him first. It was also called FIRST
CONTACT CARE. If the patient was referred to the hospital, it was called
"secondly care." More recently, the Alma Ata Conference in 1978 gave
primary health care a wider meaning. The Alma Ata Conference defined
primary health care as follows:
"Primary health care is essential health care made universally
accessible to individual and acceptable to them, through their full
participation and at a cost the community and country can afford."
For achieving success in HFA development at least eight components of
primary health care need to be properly implemented. For this, the
cooperation and support of other social and economic development sectors,
such as education, social and women's welfare, food and agriculture, animal
husbandry, water resources, housing, rural development, energy,
environmental protection, industry, communication, etc. would be vital.
Level of Care
Health services are usually organised at various levels (a) Primary
level: The first level is the point of contact between individuals and the
health system, where primary health care is delivered. The primary health
centres and their sub-centres constitute this level of care in India,
(b) Intermediate level: At this level, more complex problems are dealt
with. The sub-divisional/district hospitals usually constitute the second
level. They provide support to the primary health care institutions,
(c) Central level: The central level institutions (viz. Regional hospitals,
Medical College Hospitals, specialised Hospitals) not only provide highly
specialised care but, also to sustain primary health care as part of
comprehensive national health system.
Principle underlying Primary Health Care
Primary health care is based on four principles:
1. Equitable distribution: Health service should be accessible to all the
sections of the society with special attention to the needy and vulnerable
groups. It is well known, that rural population, in most developed countries,
are widely scattered and do not have adequate transportation facilities. City
hospitals are beyond the reach of most rural people and are usually
patronised by those in their immediate vicinity. Primary health care aims to
correct this imbalance and bring health services as near people's home as
possible and is supported by a higher level of health care, to which the
patient can be referred.
2. Community participation: The involvement of individual families and
communities in promotion of their health and welfare, including self-care, is
an essential ingredient of primary health care. Community involvement also
implies that the community should participate in the planning,
implementation and maintenance of health services.
3. Multisectorial approach: Joint effort of the health sector and other health
related sectors viz. education, food and agriculture, social welfare, animal
husbandry, housing and public works, rural reconstruction etc. are needed
for attainment of health.
4. Appropriate technology: Appropriate technology is not cheap
primitive technology for poor, primitive people. It calls instead for
scientifically sound materials and methods that are socially
acceptable, directed against relevant health problems. Health
System Infrastructure
The country is divided into 22 major States and 9 smaller union territories,
which in turn are divided into administrative districts. At present, there are
431 districts. Each district is divided into sub-districts or talukas, under
which are situated the community development blocks. There are about
6,000 community development blocks in the country.
As mentioned earlier, over the past three decades the health services
infrastructure and health care facilities have been expanded considerably. It
is aimed to further improve the facilities as noted below:
Facilities at Village Level: In a village, for about 1,000
population, there will be one health guide and one trained dai or
traditional birth attendant (TBA), both will be selected from the
community. They will be trained at the level of the primary health
centre (PHC) and the sub-centre. These two village level
functionaries are to receive technical support and continuing
education from the multi-purpose health workers (male and female)
posted at the sub-centre. Other administrative control and
supervision should ideally be carried out by the village health
committee or the village panchayat.
Facilities at Sub-centre Level : The most peripheral health
institutional facility will be at the sub-centre, manned by one male
and one female multi-purpose health workers. At present, in most
places there is one sub-centre for about 10,000 population. It is,
however, aimed to have one sub-centre per 5,000 population
(3,000 population in hilly and desert areas, and difficult terrain) by
the end of the Seventh Five Year Plan i.e. 1990. To date, about
83,000 sub-centre (both on the old and new patterns mentioned
above) have been established.
Facilities at PHC Level : At present there is one PHC in each
community development block, which covers about 1,00,000 or
more population. It was aimed to establish one PHC for every
30,000 population by the year 1990. Many rural dispensaries are
being upgraded to create the subsidiary health centres or these new
PHCs. Each new PHC will have one medical officer, two health
assistants—one male and one female, and the health workers and
other supporting staff. For strengthening preventive and promotive
aspects of health care, a new non-medical post called community
health officer (CHO) will be provided at each new PHC. To date,
there are about 11,000 PHCs (both old and new combined).
Facilities at Community Health Centre : For a successful primary
health care programme, effective referral support to be provided.
For this purpose one community health centre (CHC) will be
established for every 1,00,000 population, and this centre will
provide the main specialist services. The CHCs will be established
either by upgrading the sub-district/taluka hospitals or some of the
block level PHCs, or by creating a new centre wherever absolutely
needed.
Facilities at District Level : District health organisation is to be
appropriately strengthened to cater to the needs of the expanding
rural health and family welfare programmes. Not only the planning
and implementation and monitoring of health and family welfare
programmes are to be carried out at the district level (preferably on
a decentralised basis), all the referral services from the periphery
i.e. PHCs, community health centres and taluka hospitals, are to be
attended to satisfactorily.
The primary contact care will be provided by the health
functionaries at the village level and by the multipurpose workers at
the sub-centres level. The cases needing further help will be
dealt with at the PHC, and those needing referral support by the
specialist would be referred to the community health centre. The
second and third level referral supports will be provided at the
district hospital and the medical college/specialised hospitals
respectively.
Organisation at State Level
Under the Ministry of Health and Family Welfare in each State, there is one
technical directorate functioning under the Director(s) of Health Services,
and one executive wing headed by the Health Secretary, who has also the
overall administrative control.
Organisation at National Level
Under the Union Ministry of Health and Family Welfare, there are two
technical departments— the Health Department is headed by the Director
General of Health Services and Family Welfare Department is headed by the
Commissioner, Family Welfare. The executive wing as well as the technical
departments are under the overall administrative control of the Secretary to
the Government of India.