1.

Public Health: Definition & Concept

1.0 Introduction
The term “public health” came into general use around 1840. It arose from the need
to protect “the public” from the spread of communicable disease. Later, in 1848 it
became an act of a law in England and was named the „Public Health Act‟. This
shapeup the efforts organised by society to protect, promote, and restore people‟s
health. A historic milestone was achieved with the rise of public health, which came
in the form of a “great sanitary awakening” and which took place in the mid 19th
century. The cholera epidemic of 1832 in England led to an investigation of the
health of people in large towns, with a view to improve the conditions in which they
lived. It had a tremendous impact on modifying the behaviour of people and ushering
in an era of public health. Public health during the 19th century was largely a matter
of sanitary legislation and sanitary reforms, aimed at the control of man‟s physical
environment, for example, water supply, sewage disposal, and so on.

1.1 Public Health: Meaning and Concepts

1.1.1 Public Health: Meaning

There have been many definitions and explanations of public health. Some of
the most influential or interesting definitions of public health are:

“Public health is the art and science of preventing disease, prolonging life, and
promoting health and efficiency through organised community efforts for the
sanitation of the environment, the control of community infections, the
education of individuals, in principles of personal hygiene, the organisation of
medical and nursing services for the early diagnosis and prevention of
disease, and the development of social machinery, which will ensure to every
individual of the community, a standard of living adequate for the maintenance
of health, so organising these benefits as to enable every citizen to realise his
birthright of health and longevity”.

- Winslow‟s definition -AAPHP, 2010

“Public health consists of organized efforts to improve the health of

communities. The operative components of this definition are that public
health efforts are organized and directed to communities rather than to
individuals. Public health practice does not rely on a specific body of
knowledge and expertise but rather relies on a combination of science and
social approaches. The definition of public health reflects its central goal – the
reduction of disease and the improvement of health in a community.”

- Defining public health historical and contemporary development

1.1.2 Public Health: Concepts

Public health promotes and protects the health of people and the communities
where they live, learn, work and play. It also promotes wellness by
encouraging healthy behaviours. Public health is defined as the science of
protecting the safety and improving the health of communities through
education, policy making and research for disease and injury prevention.

From conducting scientific research to educating about health, people in the

field of public health work to assure the conditions in which people can be
healthy. That can mean vaccinating children and adults to prevent the spread
of disease or educating people about the risks of alcohol and tobacco. Public
health sets safety standards to protect workers and develops school nutrition
programs to ensure kids have access to healthy food.

Public health works to track disease outbreaks, prevent injuries and shed light
on why some of us are more likely to suffer from poor health than others. The
many facets of public health include speaking out for laws that promote
smoke-free indoor air and use of seatbelts in four wheeler vehicles, spreading
the word about ways to stay healthy and giving science-based solutions to
problems. Public health saves money, improves our quality of life, helps
children thrive and reduces human suffering.

Public health is the science of protecting and improving the health of families
and communities through promotion of healthy lifestyles, research for disease
and injury prevention and detection and control of infectious diseases.
Overall, public health is concerned with protecting the health of entire
populations. These populations can be as small as a local neighbourhood, or
as big as an entire country or region of the world.

Public health refers to "the science and art of preventing disease, prolonging
life and promoting health through organized efforts and informed choices of
society, organizations, public and private, communities and individuals.” It is
concerned with threats to health based on population health analysis. The
population in question can be as small as a handful of people, or as large as
all the inhabitants of various continents.

Public health incorporates the interdisciplinary approaches of epidemiology,

biostatistics and health services. Environmental health, community health,
behavioural health, health economics, public policy, insurance medicine,
mental health and occupational safety and health are other important
subfields.

The focus of public health intervention is to improve health and quality of life
through prevention and treatment of disease and other physical and mental
 health conditions. This is done through surveillance of cases and health
indicators, and through promotion of healthy behaviours. Examples of
common public health measures include promotion of hand washing,
breastfeeding, delivery of vaccinations, and distribution of condoms to control
the spread of sexually transmitted diseases.

1.1.3 Functions of Public Health

To accomplish its task of ensuring the well-being of the population, public

health must perform a wide range of functions as mentioned below:
1. Prevent diseases and injuries.
2. Promote healthy lifestyles and good health habits.
3. Identify, measure, monitor, and anticipate the health needs of
community.
4. Formulate, promote, and enforce essential health policies.
5. Organise and ensure high-quality and cost-effective public health and
healthcare services.
6. Reduce health disparities and ensure access to healthcare for all.
7. Promote and protect a healthy environment.
8. Disseminate health information and mobilise communities to take
appropriate action to maintain their health.
9. Plan and prepare for natural and man-made disasters.
10. Reduce interpersonal violence and aggressive wars.
11. Conduct research and evaluate health-promoting and disease
preventing strategies.
12. Develop new methodologies for research and evaluation.
13. Train and ensure a competent public health workforce.

1.1.4 Role of Public Health

The focus of public health interventions is to prevent and manage diseases,

injuries and other health conditions through surveillance of cases and the
promotion of healthy behaviour, communities, and environments. Its aim is to
prevent health problems from happening or re-occurring by implementing
educational programs, developing policies, administering services and
conducting research.

In many cases, treating a disease or controlling a pathogen can be vital to

preventing it in others, such as during an outbreak. Vaccination programs and
distribution of condoms to prevent the spread of communicable diseases are
examples of common preventive public health measures, as are educational
campaigns to promote vaccination and the use of condoms (including
overcoming resistance to such).
 Public health also takes various actions to limit the health disparities between
different areas of the country and, in some cases, the continent or world. One
issue is the access of individuals and communities to health care in terms of
financial, geographical or socio-cultural constraints to accessing and using
services. Applications of the public health system include the areas of
maternal and child health, health services administration, emergency
response, and prevention and control of infectious and chronic diseases.

The great positive impact of public health programs is widely acknowledged.

Due in part to the policies and actions developed through public health, the
20thcentury registered a decrease in the mortality rates for infants and children
and a continual increase in life expectancy in most parts of the world.

Since the 1980s, the growing field of health in general has broadened the
focus of public health from individual behaviours and risk factors to
population-level issues, such as inequality, poverty and education. The new
public health seeks to address the health inequalities by advocating
population based policies that improve health in an equitable manner (Park,
2002).

1.1.5 Public Health Policy of India

In view of the federal nature of the Constitution, areas of operation have been
divided between Union Government and the State Governments. Seventh
Schedule of Constitution describes three exhaustive lists of items, namely,
Union list, State list and Concurrent list. Though some items like public health,
hospitals, sanitation etc. fall in the State list, the items having wider
ramification at the national level like Family Welfare and Population Control,
Medical Education, Prevention of Food Adulteration, Quality Control in
manufacture of Drugs etc. have been included in the Concurrent list. The
Union Ministry of Health & Family Welfare is instrumental and responsible for
implementation of various programmes on a national scale in the areas of
health and family welfare, prevention and control of major communicable
diseases and promotion of traditional and indigenous systems of medicine. In
addition, the Ministry also assists States in preventing and controlling the
spread of seasonal disease outbreaks and epidemics by providing technical
assistance.

The policy lays stress on the preventive, promotive, curative and rehabilitative
aspects of health care and on establishing comprehensive primary health care
services to reach the population in the remotest area of the country. In the
context of the size of the population, the socio- economic development and
the existing health status of the people, the National Health Policy in India hag
the following notable elements:
 1. A greater awareness of health problems and means to solve these in
and by the communities;
2. Supply of safe drinking water and basic sanitation, using technologies
that the people can afford;
3. Reduction of existing imbalance in health services by concentrating on
rural health infrastructure;
4. Establishment of a dynamic health management information system to
support health planning and health programme implementation;
5. Concerted action to combat wide spread malnutrition.
6. Provision of legislative support to health protection and promotion.
7. Promotion of alternative methods of health care delivery system and
low cost health technologies
8. Greater co-ordination of different system of medicine as Homeopathic,
Ayurvedic, Unani etc.

The health policy is supported by components of wider socio-economic

development policies addressed to the reduction of regional disparities, fuller
employment, elementary education, integrated rural development, population
control, welfare of women and children etc.

The health strategy includes restructuring of the health infrastructure,

developing of health man-power, research and development. Specific goals
for developing health infrastructure and manpower are given below:

a) To establish one health sub-centre for every 5000 rural population

(3000 in tribal and hilly area) with one male and one female health
worker.
b) To establish one primary health centre for every 30,000 population in
rural area (20,000 in hilly and tribal areas)
c) To establish community health centre for one lakh population.
d) To train village health guides selected by the community for every
village or 1000 population
e) To train traditional birth attendants or Dais in each village or 1000
population Training of various categories of other staff e.g. multi-
purpose health workers, Mahila Sawasthya Sangh (MSS).

National Health Policy 1983

A National Health Policy was last formulated in 1983, and since then there
have been marked changes in the determinant factors relating to the health
sector. Some of the policy initiatives outlined in the NHP-1983 have yielded
results, while, in several other areas, the outcome has not been as expected.
The NHP-1983 gave a general exposition of the policies which required
recommendation in the circumstances then prevailing in the health sector.
The noteworthy initiatives under that policy were:-
(i) A phased, time-bound programme for setting up a well dispersed network
of comprehensive primary health care services, linked with extension and
health education, designed in the context of the ground reality that elementary
health problems can be resolved by the people themselves;

(ii) Intermediation through „Health volunteers‟ having appropriate knowledge,

simple skills and requisite technologies;

(iii) Establishment of a well-worked out referral system to ensure that patient

load at the higher levels of the hierarchy is not needlessly burdened by those
who can be treated at the decentralized level;

(iv) An integrated network of evenly spread speciality and super-speciality

services; encouragement of such facilities through private investments for
patients who can pay, so that the draw on the Government‟s facilities is
limited to those entitled for free use.

National Health Policy 2002

The objective of public health policy-2002 is to achieve an acceptable

standard of good health amongst the general population of the country. The
approach would be to increase access to the decentralized public health
system by establishing new infrastructure in deficient areas, and by upgrading
the infrastructure in the existing institutions.

Overriding importance given to ensuring a more equitable access to health

services across the social and geographical expanse of the country.
Emphasis given to increasing the aggregate public health investment through
a substantially increased contribution by the Central Government. It is
expected that this initiative will strengthen the capacity of the public health
administration at the State level to render effective service delivery. The
contribution of the private sector in providing health services much enhanced,
particularly for the population group which can afford to pay for services.
Primacy will be given to preventive and first-line curative initiatives at the
primary health level through increased sectoral share of allocation. Emphasis
laid on rational use of drugs within the allopathic system. Increased access to
tried and tested systems of traditional medicine will be ensured.

National Health Policy 2015

The primary aim of the National Health Policy, 2015, is to inform, clarify,
strengthen and prioritize the role of the government in shaping health systems
in all its dimensions- investment in health, organization and financing of
healthcare services, prevention of diseases and promotion of good health
through cross sectoral action, access to technologies, developing human
resources, encouraging medical pluralism, building the knowledge base
 required for better health, financial protection strategies and regulation and
legislation for health.

1.1.6 Public Health Programs

Most governments recognize the importance of public health programs in

reducing the incidence of disease, disability, and the effects of aging and
other physical and mental health conditions, although public health generally
receives significantly less government funding compared with medicine.

The World Health Organization (WHO) identifies core functions of public

health programs including:

 Providing leadership on matters critical to health and engaging in

partnerships where joint action is needed;
 Shaping a research agenda and stimulating the generation, translation and
dissemination of valuable knowledge;
 Setting norms and standards and promoting and monitoring their
implementation;
 Articulating ethical and evidence-based policy options;
 Monitoring the health situation and assessing health trends.

In particular, public health surveillance programs can:

 Serve as an early warning system for impending public health
emergencies;
 Document the impact of an intervention, or track progress towards
specified goals;
 Monitor and clarify the epidemiology of health problems, allow priorities to
be set, and inform health policy and strategies; and
 Diagnose, investigate, and monitor health problems and health hazards of
the community.
 Public health surveillance has led to the identification and prioritization of
many public health issues facing the world today, including HIV/AIDS,
diabetes, waterborne diseases, zoonotic diseases, and antibiotic
resistance leading to the re-emergence of infectious diseases such as
tuberculosis. Antibiotic resistance, also known as drug resistance, was the
theme of World Health Day 2011.

1.1.7 Major Public Health Programs running in India

National Health Mission (NHM): The National Health Mission (NHM)

encompasses its two Sub-Missions, the National Rural Health Mission
(NRHM) and the National Urban Health Mission (NUHM). The main
programmatic components include Health system strengthening in rural and
urban areas, Reproductive-Maternal-Neonatal-Child and Adolescent Health
(RMNCH+A) and Communicable and Non-Communicable Diseases. The
NHM envisages achievement of universal access to equitable, affordable &
quality healthcare services that are accountable and responsive to people‟s
needs.

(a) National Rural Health Mission (NRHM): NRHM seeks to provide quality
healthcare to the rural population, especially the vulnerable groups. Under the
NRHM, the Empowered Action Group (EAG) States have been given special
focus. The thrust of the mission is on establishing a fully functional,
community owned, decentralized health delivery system with inter-sectoral
convergence at all levels, to ensure simultaneous action on a wide range of
determinants of health such as water, sanitation, education, nutrition, social
and gender equality.

(b) National Urban Health Mission (NUHM): NUHM seeks to improve the
health status of the urban population particularly urban poor and other
vulnerable sections by facilitating their access to quality primary healthcare.
NUHM covers all State capitals, district headquarters and other cities/ towns
with a population of 50,000 and above (as per census 2011) in a phased
manner. Cities and towns with population below 50,000 will continue be
covered under NRHM.

Under the umbrella of National Health Mission, Ministry of Health and Family
Welfare, Govt. of India is running following public health care programs:

1. Maternal and Adolescent Healthcare: Sustained development of the

country can be achieved only if we take holistic care of our women and
children. Massive and strategic investments have been made for the
improvement of Maternal Health. Rashtriya Kishor Swasthya Karyakram
aims to implement programmes in order to ensure holistic health and
development of adolescents of our country, by addressing needs related to
sexual and reproductive health, nutrition, injuries and violence (including
gender based violence),prevention of non-communicable diseases, mental
health and substance misuse among adolescents.

2. Child Health Programme: Rashtriya Bal Swasthya Karyakram (RBSK)

has been launched to provide child health screening and early
interventions services by expanding the reach of mobile health teams at
block level. These teams will carry out screening of all the children in the
age group 0–6 years enrolled at Anganwadi Centres at least twice a year.
Government of India is providing vaccination free of cost against nine
vaccine preventable diseases i.e. Diphtheria, Pertussis, Tetanus, Polio,
Measles, severe form of Childhood Tuberculosis, Hepatitis B across the
country and Japanese Encephalitis in selected districts and Meningitis &
 Pneumonia caused by Hemophilus Influenza type B in selected
states/districts.

3. Disease Control Programmes [NHM]: Several National Health

Programmes such as the National Vector Borne Disease Control
Programme, Leprosy Eradication, TB Control, Blindness Control and
Iodine Deficiency Disorder Control Programmes have come under the
umbrella of National Health Mission (NHM). The National Vector Borne
Disease Control Programme (NVBDCP) for prevention and control of
vector borne diseases viz. Malaria, Japanese Encephalitis (JE), Dengue,
Chikungunya, Kala-azar and Lymphatic Filariasis.

4. National Leprosy Eradication Programme (NLEP): Since the inception

of National Leprosy Eradication Programme (NLEP) in the year 1983
spectacular success have been made in reducing the burden of Leprosy.

5. The Revised National TB Control Programme (RNTCP) based on the

internationally recommended Directly Observed Treatment Short-course
(DOTS) strategy, was launched in1997 expanded across the country in a
phased manner. The Goal of TB Control Programme is to decrease
mortality and morbidity due to TB and cut transmission of infection until TB
ceases to be a major public health problem in India.

6. National Iodine Deficiency Disorders Control Programme (NIDDCP):

Deficiency of Iodine can cause physical and mental retardation, cretinism,
abortions, stillbirth, deaf, mutism, squint, loss of IQ, compromised school
performance & various types of goiter etc. Objectives of the programme
are - surveys to assess the magnitude of the Iodine Deficiency Disorders
in districts; supply of iodized salt in place of common salt; resurveys to
assess iodine deficiency disorders and the impact of iodized salt after
every 5 years in districts; laboratory monitoring of iodized salt and urinary
iodine excretion and health education and publicity.

7. Family Planning: India has expected increase of population of 15.7% in

next 15 years from 1210 million in 2011 to 1400 million in 2026. Therefore,
India is the first country in the world to have launched a National
Programme for Family Planning in 1952. With its historic initiation in 1952,
the Family Planning Programme has undergone transformation in terms of
policy and actual programme implementation. There occurred a gradual
shift from clinical approach to the reproductive child health approach and
further, the National Population Policy (NPP) in 2000 brought a holistic and
a target free approach which helped in the reduction of fertility.
8. National Programme For Prevention And Control Of Cancer,
Diabetes, Cardio Vascular Disease And Stroke (NPCDCS): India is
experiencing a rapid health transition with a rising burden of Non-
Communicable Diseases (NCD). The major Non-Communicable Diseases
like cardiovascular diseases, cancer, chronic respiratory diseases,
diabetes and other. Losses due to premature deaths due to heart
diseases, stroke and Diabetes are also projected to increase over the
years. In order to prevent and control major NCDs. The NPCDCS was
launched in 2010 with focus on strengthening infrastructure, human
resource development, health promotion, early diagnosis, management
and referral.

9. National Tobacco Control Programme (NTCP): India is the second

largest consumer of tobacco in the world. The tobacco epidemic in India is
notable for the variety of smoked and smokeless tobacco products that are
used and for their production by entities ranging from the loosely
organized manufacture of bidi and smokeless products to multi-national
corporations. An estimated one million Indians die annually from tobacco-
related diseases. The extent of use of smokeless tobacco products (SLT)
is particularly alarming.

10. National Mental Health Programme (NMHP): Mental Health disorders/

Mental illnesses are emerging as a major cause of morbidity in the
country. These illnesses include depression, bipolar mood disorders,
anxiety disorders, personality disorders, delusional disorders, substance
use disorders, psycho-sexual disorders and sleep disorders among others.
NMHP was started in 1982 with the objectives to ensure availability and
accessibility of minimum mental healthcare for all, to encourage mental
health knowledge & skills and to promote community participation in
mental health service development and to stimulate self-help in the
community.

11. National Programme for Control of Blindness (NPCB) was launched in

the year 1976 as a 100% centrally sponsored scheme with the goal of
reducing the prevalence of blindness to 0.3% by 2020.

12. National Programme For Prevention And Control Of Deafness

(NPPCD): This program was launched for Prevention and Control of
Deafness (NPPCD) on the pilot phase basis in the year 2006-07(January,
2007) covering 25 districts. Current burden of disease as per NSSO
survey is that 291 persons per one lac population are suffering from
deafness.

13. National Programme For Prevention & Control Of Fluorosis (NPPCF):

Fluorosis is a public health problem, caused by excess intake of Fluoride
 through drinking water/food products/industrial pollutants over a long
period. It results in major health disorders like Dental Fluorosis, Skeletal
Fluorosis and Non-Skeletal Fluorosis. NPPCF was initiated in the 11th
Five Year Plan (2008-09) with the aim to prevent and control Fluorosis in
the affected States.

14. National Programme For Healthcare Of The Elderly (NPHCE): This

program addresses health related problems of elderly people. The basic
aim of the NPHCE Programme is to provide separate, specialized and
comprehensive healthcare to the senior citizens at various level of State
Healthcare Delivery System including outreach services. Preventive and
promotive care, management of illness, health manpower development for
geriatric services, medical rehabilitation and therapeutic intervention and
Information Education &Communication (IEC) are some of the strategies
envisaged in the NPHCE.

15. National Oral Health Programme (NOHP): NOHP is a new initiative by

Government of India with the objectives - improvement in the determinants
of oral health e.g. healthy diet, oral hygiene improvement etc. and to
reduce disparity in oral health accessibility in rural & urban population;
reduce morbidity from oral diseases by strengthening oral health services
at sub district/district hospital.

16. Capacity Building For Development Trauma Care Facilities In

Government Hospitals: Road traffic injuries are one of the leading
causes of deaths and disabilities. Deaths and disabilities due to accidents
are gradually rising in the country. Through the scheme, the designated
hospitals were to be upgraded for providing trauma care facilities. It was
envisaged that the network of trauma care facilities along the corridors will
bring down the morbidity and mortality on account of accidental trauma on
the roads in India by providing trauma care within the ambit of golden hour
concept.

17. National Programme On Prevention And Management Of Burn

Injuries (NPPMBI): The main objectives of the Programme are - to reduce
incidence, mortality, morbidity and disability due to Burn Injuries; to
improve awareness among the general masses and vulnerable groups
especially the women, children, industrial and hazardous occupational
workers; to establish adequate infrastructural facility and network for
Behaviour Change Communication, burn management and rehabilitation
interventions and to carry out research for assessing behavioural, social
and other determinants of Burn Injuries in our country for effective need
based programme planning for Burn Injuries, monitoring and subsequent
evaluation.
18. Food Fortification: Food fortification is a public health measure aimed at
reinforcing the usual dietary intake of nutrients with additional supplies to
prevent/control some nutritional disorders. It is the process whereby
nutrients are added to foods in relatively small quantities to maintain or
improve the quality to the diet of population. Ministry is working on Food
Fortification of Essential food items in coordination with other Ministries
like the Ministry of Woman and Child Development (MWCD) and Ministry
of Science and Technology.

19. National Organ Transplant Programme (NOTP): Transplantation of

Human Organs Act, 1994 provides a system of removal, storage and
transplantation of human organs for therapeutic purposes and for
prevention of commercial dealings in human organs. There is a huge gap
between demand for and supply of human organs. However, a number of
steps have been taken by the Government to promote organ donation and
simplify the process of such donation. Website of NOTTO for providing
updated information to general public has been operationalized a 24x7 call
centre with toll free helpline number (1800114770) for providing
information has been established, provision of facility for both Online and
Offline pledging of organs has been made.

20. National Commission on Population (NCP): The National Commission

on Population was constituted in May 2000 to review, monitor and give
directions for the implementation of the National Population Policy(NPP)
2000, with a view to meet the goals set-out in the Policy, to promote inter-
sectoral coordination, involve the civil society in planning and
implementation, facilitate initiatives to improve performance in the
demographically weaker states in the country and to explore the
possibilities of international cooperation in support of the goals set out in
the National Population Policy.

21. Adverse Child Sex-Ratio in India: The Child Sex Ratio (CSR) for the age
group of 0-6 years as per the 2011 Census has dipped further to 918 girls
as against 927 per thousand boys as recorded in the 2001 Census. This
negative trend reaffirms the fact that the girl child is at higher risk than ever
before. Some of the reasons commonly put forward to explain the
consistently low levels of Sex Ratio are a preference for sons, neglect of
the girl child resulting in higher mortality at younger age, female
infanticide, female foeticide, higher Maternal Mortality and male bias. Easy
availability of the sex determination tests and abortion services may also
be a catalyst in the process, which may be further stimulated by pre-
conception sex selection facilities. These techniques were widely misused
to determine the sex of the foetus and subsequent elimination, if the foetus
was found to be a female.
22. Central Government Health Scheme (CGHS): The Government of India
(Allocation of Business) Rules, 1961 has entrusted the responsibility of
providing medical care to the Central Government Servants, to the
Department of Health and Family Welfare, Ministry of Health and Family
Welfare. Central Government Health Scheme (CGHS) is a health scheme
mainly for serving/retired Central Government employees and their
families.

23. The Information, Education & Communication (IEC) strategy aims to

create awareness and disseminate information regarding the benefits
available under various schemes/programmes of the Ministry and to guide
the citizens on how to access them. The objective is also to encourage
build-up of health seeking behaviour among the masses in keeping with
the focus on promotive and preventive health. The IEC strategy has
catered to the different needs of the rural and urban masses through the
various tools used for communication. The Ministry designed a strategic
framework for targeted IEC activities encompassing mass media, along
with mid-media and inter-personal activities so as to disseminate
information about the various health schemes in the masses.

24. Gender Issues: Major component of Health & Family Welfare Programme
is related to Health problems of women and children, as they are more
vulnerable to ill health and diseases. Since women constitute about half of
population, it is essential to know the health status of women so that the
causes of ill health are identified, discussed and misconceptions removed.
Ill health of women is mainly due to poor nutrition, gender discrimination,
low age at marriage, risk factors during pregnancy, unsafe, unplanned and
multiple deliveries, limited access to family planning methods and unsafe
abortion services. The Government seeks to provide services in a lifecycle
approach. Under the RCH Programme, the need for improving women
health in general and bringing down maternal mortality rate has been
strongly stressed in the National Population Policy 2000.

25. National Aids Control Organization (NACO): NACP has been

implemented by Government of India as100% centrally sponsored scheme
through State AIDS Control Societies in the states for prevention and
control of HIV/AIDS. The first National AIDS Control Programme was
launched in 1992, which focused on the national HIV surveillance system,
prevention activities among High Risk Groups(HRGs) including information
on HIV and the blood safety programme. NACP-II launched in 1999
focused on the scale-up of targeted interventions for HRGs, especially
prevention, out-reach, HIV testing & counselling and fostered greater
involvement of People Living with HIV(PLHIV) and community networks.
The treatment programme was also launched under NACP II.
 Institutionalization of decentralized programme management through State
AIDS Control Society was a key thrust in phase II. NACP-III launched in
2007, showed a rapid expansion of prevention, care, support and
treatment efforts across the country with a focus on increasing service
access points through institutional scale-up and out-reach.

1.1.8 Public Health Professionals

Public health professionals try to prevent problems from happening or

recurring through implementing educational programs, recommending
policies, administering services and conducting research – in contrast to
clinical professionals like doctors and nurses, who focus primarily on treating
individuals after they become sick or injured. Public health also works to limit
health disparities. A large part of public health is promoting healthcare equity,
quality and accessibility.

Modern public health practice requires multidisciplinary teams of public health

workers and professionals including physicians specializing in public health,
specialist doctors, psychologists, epidemiologists, biostatisticians, medical
assistants or Assistant Medical Officers, Health educators

Scientists and researchers, public health nurses, midwives, medical

microbiologists, environmental health officers, public health inspectors,
pharmacists, dentists, dieticians, and nutritionists, veterinarians, public health
engineers, public health lawyers, sociologists, community planners,
community development workers, communications experts, social workers,
health safety professionals, public policy makers, sanitarians, bioethicists, and
others.

Public Health Professionals or workers may be the –

• First responders
• Restaurant inspectors
• Health educators
• Scientists and researchers
• Nutritionists
• Community planners
• Social workers
• Epidemiologists
• Public health physicians
• Public health nurses
• Occupational health and safety professionals
• Public policymakers
• Sanitarians
 2. Health Awareness and
Role and Importance of Yoga
2.0 Introduction
Health is one of the fundamental rights of every human being. Various dimensions
i.e. Physical, Mental, Social and Spiritual well-being and factors which determine the
health of an individual like Heredity, Environment and Life style etc. Health
maintenance is a basic need of human being. A big section of population of our
country is illiterate and pursuing old traditions to maintain health. Therefore, number
of health problems facing by them. To make aware the masses about their health
issues health awareness contents are increasing in media day by day. In addition to
the number of news stories appearing in main space of newspaper, number of
newspapers assigned a full page for health issues articles.

Yoga is another vital topic in these days. World Health Organisation has fixed a date
„21st June of each year‟ devoting to Yoga. It shows the importance of Yoga to
maintain our health. In this lesson you will also know about various health issues due
to changing lifestyle of the people. You will understand about various health issues
and problems in rural and urban India and health care system in India. Medical
tourism is another significant issue now days. In this section you will take an
overview of medical tourism in India.

2.1 Health: Definition & Concept

2.1.1 Definition of Health

Health is a dynamic condition resulting from a body's constant adjustment and

adaption in response to stresses and changes in the environment for
maintaining an inner equilibrium called homeostasis. Health is the level of
functional or metabolic efficiency of a living organism. In humans it is the
ability of individuals or communities to adapt and self-manage when facing
physical, mental or social challenges.

The widely accepted definition of health is the one given by the World Health
Organisation in the preamble to its constitution:

“Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”.
- WHO, 1946

"The extent to which an individual or group is able to realize aspirations and

satisfy needs, and to change or cope with the environment. Health is a
resource for everyday life, not the objective of living; it is a positive concept,
emphasizing social and personal resources, as well as physical capacities"

- WHO‟s revised definition of health in 1984

Health is "A state characterized by anatomic, physiologic, and psychological

integrity; ability to perform personally valued family, work, and community
roles; ability to deal with physical, biologic, psychological, and social stress".

Following three types of definition of health can also be used:

1. „Health is the absence of any disease or impairment‟.

2. „Health is a state that allows the individual to adequately cope with all
demands of daily life (implying also the absence of disease and
impairment)‟.

3. „Health is a state of balance, an equilibrium that an individual has

established within himself and between himself and his social and
physical environment‟.

But, these have some consequences. If health is defined as the absence of

disease, the medical profession is the one that can declare an individual
healthy. With the progress of medical science, individuals who are declared
healthy today may be found to be diseased tomorrow because more
advanced methods of investigations might find signs of a disease that was not
diagnosable earlier.

There can be a person, who has abnormalities that can be counted as

symptoms of a disease but do not feel ill. There are others whose body
tissues do not demonstrate changes but who feel ill and do not function well.

The third definition makes health depend on whether a person has

established a state of balance within oneself and with the environment. This
means that those with a disease or impairment will be considered as being
healthy to a level defined by their ability to establish an internal equilibrium
that makes them get the most they can from their life despite the presence of
the disease.

Health would thus be a dimension of human existence that remains in

existence regardless of the presence of diseases, somewhat like the sky that
remains in place even when covered with clouds. Thus, health referred to the
ability to maintain homeostasis.

The dimensions of health i.e. Physical, Mental/Psychological, Intellectual,

Spiritual, Emotional, and social health referred to a person's ability to handle
 stress, to acquire skills, to maintain relationships, all of which form resources
for resiliency and independent living.

Therefore, it can be said that, health is the level of functional or metabolic

efficiency of a living organism. In humans it is the ability of individuals or
communities to adapt and self-manage when facing physical, mental or social
challenges.

Thus, health referred to the ability to maintain homeostasis. Mental,

intellectual, emotional, and social health referred to a person's ability to
handle stress, to acquire skills, to maintain relationships, all of which form
resources for resiliency and independent living.

It can be said that, health is the level of functional or metabolic efficiency of a

living organism. In humans it is the ability of individuals or communities to
adapt and self-manage when facing physical, mental or social challenges.

2.1.2 Concept of Health

Health is considered as an important part of human life. But, its concept or the
meaning differs with each community and each individual in a community,
depending upon their socio-cultural and environmental conditions. It is also
seen that the concept of health changed over time depending upon scientific
and socio-economic developments and advancements.

Ancient Indian history during Vedic period reveals the practice of

comprehensive concept of health. It emphasized on health promotion and
health maintenance through practice of good environmental sanitation and
personal rules and regulations. Health also included physical, mental, social
and spiritual aspects of life.

Over the years, this concept was lost under the influence of changing socio-
cultural and environmental conditions. Health from there onwards was viewed
as absence of disease. This concept still prevails among under privileged and
underdeveloped communities. Health is usually neglected until disease/
sickness occurs.

However, for the past few decades there has been a change in the concept of
health. Now, Health is considered as a fundamental human right. It is also
considered a social goal to be achieved by all to lead economically productive
and useful life. This goal is popularly known as "Health For All" (HFA) which
was adopted by WHO in 1977 and accepted by all the member countries.
Changing Concepts of Health

Concept of health is not constant. It changes from time to time under the
influence of continuous changes throughout the world. A brief description of
changing concepts of health is given as under:

a) Biomedical Concept: The human body is considered as a machine and

disease is due to breakdown of this machine. The Doctors or any other
health worker‟s work is to repair this machine. According to this concept
health is viewed as freedom from disease i.e. individual is considered
healthy only if he does not have any disease. It also stresses that ill health
is caused by disease producing organisms e.g. typhoid is caused by
salmonella typhosa, cholera by cholera vibro.

This concept of health ignored the role of social, environmental and

cultural factors in disease causation. This model was found to be
inadequate to solve the problems of malnutrition, chronic diseases like
diabetes, peptic ulcer, drug abuse and accidents. Since these diseases
are not caused by disease producing organisms, but by other causative
factor e.g. inadequate nutrition, lack of exercise, over exertion, emotional
stress and pollutants etc.

b) Ecological Concept: According to this concept health is viewed as a

harmonious relationship between man and his environment, and disease
as maladjustment of the man to his environment. There is a continuous
adaptation and adjustment of human being to his environment. There is a
feeling of wellbeing, relative absence of pain and discomfort when man is
able to adjust with his environment and feeling of ill-health when he is not
able to adjust. It means as long as human being follow desirable natural
principles of healthful living they can live healthy and Happy life.

Once this balance between man and his environment is disturbed, there is
maladjustment and it can cause various diseases. For example
industrialization and urbanization, increasing population and overcrowding,
transport etc. have resulted in pollution off air, water and soil.

c) Psychological Concept: According to this concept health gets affected by

various other factors such as social, psychological, cultural, economical
and political. For example many health problems like peptic ulcer, high
blood pressure, diabetes, heart problems and mental health problems are
mainly due to various psycho-social and cultural factors. Therefore, all the
factors including biomedical, environmental and psycho-social-cultural and
economical factors need to be considered while assessing health status of
people at any time.
 d) Holistic Concept: The concept says that human being is considered as a
whole person comprising of body, mind and soul. He lives under the
influence of various factors in his environment or community. These
factors include biological, physical, environment, social, psychological,
cultural, economical and political resources available in the community.
These factors influence and determine total health of body, mind and soul
i.e. physical, mental, social and spiritual health. This concept emphasized
on promotion and maintenance of health. Holistic concept of health is
comprehensive concept.

2.1.3 Determinants of Health

Generally, the context in which an individual lives is of great importance for

both his health status and quality of their life. It is increasingly recognized that
health is maintained and improved not only through the advancement and
application of health science, but also through the efforts and intelligent
lifestyle choices of the individual and society. According to the World Health
Organization, “the main determinants of health include the social and
economic environment, the physical environment, and the person's individual
characteristics and behaviours”.

A person‟s health is as much a product of the degree of prosperity,

opportunity and control people have in their lives as it is the medical services
they receive. Many factors, such as socio-economic status, productivity, the
health service system, environmental conditions and genetic endowment,
influence the health of persons, families and communities. These factors are
frequently referred to as the determinants of health. (Public Health Agency of
Canada, 2003).

The health of an individual may be affected by various factors. The factors

within the individual and the factors within the society are as follows:

i) Heredity (Biological)
ii) Environmental factors
iii) Life style (Behavioural)
iv) Personal Health Practices
v) Socio-economic conditions
vi) Health Welfare Services
vii) Healthy Child Development
viii) Gender and Equity
ix) Socio-Culture factors
x) Other factors
i) Heredity (Biological)

Heredity refers to transmission of physical and mental characteristics from

parents to their children e.g. general appearance, height, weight, natural
immunity, intelligence etc. These inherited characteristics will determine
individual's physique and mental constitution as he grows and develops while
in womb and after birth under the influence of environmental factors. The
genetic endowment of the individual, the functioning of various body systems,
and the processes of development and aging are a fundamental determinant
of health. Genetic endowment may predispose some people to certain health
problems.

This also contain diseases which are inherited from parents to their children
because of some problems in the genes and chromosomes e.g. haemophilia
in male children, downs‟ syndrome, infantile diabetes and mental retardation
and so on. The state of health, therefore, depends partly on the genetic
constitution of an individual. Thus, genetic inheritance does influence health of
people.

ii) Environmental factors

Centuries later, Pettenkofer in Germany revived the concept of disease and

its association with the environment. Environment can be classified as
“internal” and “external”. The internal environment of an individual pertains to
each and every component of bodily parts, every tissue, organs, their system,
and their harmonious functioning within the system. The external environment
consists of those things which an individual is exposed to after conception. It
can be divided into physical, biological and psycho-social components. All the
three components of environment are inter-related and environment is
considered as a whole in identifying its affect on health.

The healthy environment can help people develop their physical and mental
capabilities. A society‟s values and norms contribute to the health of its
members. Risks to good health are lessened in communities where social
stability, recognition of diversity, safety and cohesion exists.

iii) Life Style (Behavioural)

The way people live is reflected in a whole range of social values, attitudes,
and activities. It is composed of cultural and behavioural patterns and lifelong
personal habits that are developed through the process of socialisation.

Life style is the aggregation of personal decisions (i.e. over which the
individual has control) that can be said to contribute to or cause illness or
death. Focusing on lifestyle issues and their relationships with functional
health, that people can improve their health via exercise, enough sleep,
maintaining a healthy body weight, limiting alcohol use, and avoiding smoking.
Health and illness can co-exist, as even people with multiple chronic diseases
or terminal illnesses can consider themselves healthy.

Healthy lifestyle promotes positive health. Poor life style has ill effects on
health. For example, good personal hygiene, adequate nutrition and safe
dietary practices, adequate education and suitable work, and self care
promote good health, whereas unhygienic practices may cause scabies,
worm infections, trachoma etc. Defective dietary practices may cause
malnutrition and deficiency diseases. Smoking, alcoholism, inactive life may
cause cardio-vascular diseases, diabetes, cancer etc.

iv) Personal Health Practices

People‟s knowledge, intentions, behaviour and coping skills are key

influences on health. Although individuals can choose to behave in ways that
promote health, it must be recognized that the social environments in which
they live also influence individual life choices.

v) Socio-economic Conditions

The health status of the majority of the world‟s population is determined

primarily by their level of socio-economic development, such as Gross
National product (GNP) per capita, education, nutrition, employment, housing,
the political system of the country, and so on. Developments in socio-
economic status improves living standard and results in reducing death rates,
disease rates, and increase longevity. Such as, economic status, education,
occupation political system etc.

VI) Health Welfare Services

The purpose of health services is to promote health status of the population.

The provision of safe drinking water can prevent mortality and morbidity from
water-borne diseases. The care of pregnant women and children will
contribute to the reduction of maternal and child mortality, immunization to
children can reduce the incidence of communicable diseases in them.
Maternal and child health services can reduce the morbidity and mortality rate
in mothers and children and promote their health. The health services are
essential for improving the health of people, but healthcare alone does not
produce good health. It is strongly believed that no matter how technically
superior and cost-effective health services are, ultimately they are pertinent
only if they are accessible, affordable and acceptable to people.

The purpose of Health and Family Welfare Services is to promote and

improve the health status of the population, prevent diseases and prolong life.
Therefore, health services are essential to improve the health of the people,
provided the people avail these services.

VII) Healthy Child Development

Prenatal and early childhood experiences have a powerful effect on

subsequent health, well-being, coping skills and competence. Increasing
evidence shows there are critical stages where intervention has the greatest
potential to positively influence health. These stages are the period before
birth, early infancy, the beginning of school and the transitions to adolescence
and to adulthood.

VIII) Gender and Equity

Gender refers to the array of socially-determined roles, personality traits,

attitudes, behaviours, values, and relative power and influence that society
ascribes to the sexes. “Gendered” norms influence the health system‟s
practices and priorities. Many health issues are a function of gender-based
social status or roles.

As one of the determinants of health you need to understand that gender

discrimination influences the health of girls and women. Gender influences:

 Exposure to risk factors

 Access to and understanding of information about disease
management, prevention and control
 Subjective experience of illness and its social significance
 Attitudes towards the maintenance of one‟s own health and that of the
other family members
 Patterns of service use
 Perceptions of quality of care

IX) Socio Culture factors

Socio-Cultural factors are also a determinant of health. Dominant cultural

values contribute to marginalization and stigmatization for some minority
groups, including loss or devaluation of language and culture. For some, there
is lack of access to culturally appropriate health care services.

X) Other factors

The other factors are those that influence health of the population, but are
outside the formal health care systems, such as food, agriculture, education,
industry, social welfare, rural development, and so on. The policies and
provisions under these heads assist in raising the standards of living. They
 also have an impact on employment opportunities, wages, medical
programmes, family support systems, and so on.

Hence, you must understand that medicine alone is not a contributor to the
health and well-being of a population. The potential of inter-sectoral
contributions to health of communities is being recognised increasingly.

2.1.4 Essentials of Good Health

Requisites of good health which could be identified at three levels:

i) Individual and Family Level
ii) Community Level
iii) State Level

i) At individual and family level: The requirements of health at the

individual and family level include:
• Following of personal hygiene practice, care of body parts, cleanliness
• Taking enough rest, sleep, exercises and recreation
• Well-balanced diet
• Regular health screening and immunization
• Reporting early when sick and taking regular treatment
• Avoidance of unhealthy practices – over-eating, smoking, drug abuse
etc.
• Good social relationship and working conditions in the family,
neighbourhood and community people and work place

ii) At Community Level: Requisites of health at the community level include:

• Proper housing and sanitation

• Safe water supply
• Clean air, proper light and sound
• Safe surroundings to avoid accidents
• Proper disposal of excreta, waste water and sewage
• Good placement of school, health centers, hospital, market and
recreation facilities
• Plantation and vegetation
• Good social relationship among the neighbourhood and community
participation

iii) At State level: Requisite of optimum healthcare at the state level includes:
• Political will and desire to implement healthcare policies
• Desired healthcare delivery system
• Adequate and accessible infrastructure; health related services include
nutrition, environmental sanitation, education, right to work etc.
• Desired manpower development
 • Maintenance of health records, reports and health statistics
• Research & Evaluation of health care services and feedback

2.1.5 Parameters of Health

Achieving and maintaining health is an ongoing process, shaped by both the

evolution of health care knowledge and practices as well as personal
strategies and organized interventions for staying healthy.

1. Diet: A healthy diet includes a variety of plant-based and animal-based

foods that provide nutrients to the body (i.e. Protein, Fat, Carbohydrates,
Minerals & Vitamins and Water). Such nutrients give energy and keep the
body running. Nutrients help build and strengthen bones, muscles, and
tendons and also regulate body processes. Making healthy food choices is
important because it can lower your risk of heart disease or diabetes and
developing some types of cancer, and it will contribute to maintaining a
healthy weight.

2. Physical Exercise: Physical exercise enhances or maintains physical

fitness and overall health and wellness. It strengthens muscles and
improves the cardiovascular and respiratory system.

3. Sleep: Sleep is an essential component to maintaining health. In children,

sleep is also vital for growth and development. Ongoing sleep deprivation
has been linked to an increased risk for some chronic health problems. In
addition, sleep deprivation has been shown to correlate with both
increased susceptibility to illness and slower recovery times from illness.
Due to the role of sleep in regulating metabolism, insufficient sleep may
also play a role in weight gain or, conversely, in impeding weight loss.

4. Self-care strategies: Personal health depends partially on the active,

passive, and assisted cues people observe and adopt about their own
health. These include personal actions for preventing or minimizing the
effects of a disease, usually a chronic condition, through integrative care.
They also include personal hygiene practices to prevent infection and
illness, such as bathing and washing hands with soap; brushing and
flossing teeth; storing, preparing and handling food safely; and many
others.

The information gleaned from personal observations of daily living – such

as about sleep patterns, exercise behaviour, nutritional intake and
environmental features – may be used to inform personal decisions and
actions (e.g., "I feel tired in the morning so I am going to try sleeping on a
different pillow"), as well as clinical decisions and treatment plans (e.g., a
patient who notices his or her shoes are tighter than usual may be having
 exacerbation of left-sided heart failure, and may require diuretic
medication to reduce fluid overload).

Personal health also depends partially on the social structure of a person's

life. The maintenance of strong social relationships, volunteering, and
other social activities have been linked to positive mental health and also
increased longevity. One American study among seniors over age 70,
found that frequent volunteering was associated with reduced risk of dying
compared with older persons who did not volunteer, regardless of physical
health status. Another study from Singapore reported that volunteering
retirees had significantly better cognitive performance scores, fewer
depressive symptoms, and better mental well-being and life satisfaction
than non-volunteering retirees.

Prolonged psychological stress may negatively impact health, and has

been cited as a factor in cognitive impairment with aging, depressive
illness, and expression of disease. Stress management is the application
of methods to either reduce stress or increase tolerance to stress.
Relaxation techniques are physical methods used to relieve stress.
Psychological methods include cognitive therapy, meditation, and positive
thinking, which work by reducing response to stress. Improving relevant
skills, such as problem solving and time management skills, reduces
uncertainty and builds confidence, which also reduces the reaction to
stress-causing situations where those skills are applicable.

5. Occupational health: In addition to safety risks, many jobs also present

risks of disease, illness and other long-term health problems. Among the
most common occupational diseases are various forms of
pneumoconiosis, including silicosis and coal worker's pneumoconiosis
(black lung disease). Asthma is another respiratory illness that many
workers are vulnerable to. Workers may also be vulnerable to skin
diseases, including eczema, dermatitis, urticaria, sunburn, and skin
cancer. Other occupational diseases of concern include carpal tunnel
syndrome and lead poisoning.

As the number of service sector jobs has risen in developed countries,

more and more jobs have become sedentary, presenting a different array
of health problems than those associated with manufacturing and the
primary sector. Contemporary problems, such as the growing rate of
obesity and issues relating to stress and overwork in many countries, have
further complicated the interaction between work and health. Many
governments view occupational health as a social challenge and have
formed public organizations to ensure the health and safety of workers.
6. Healthy lifestyle management: A healthy lifestyle means maintaining a
balanced and nutritious diet as well as engaging in sports or other fitness
related activities. A healthy diet alone however is inadequate to ensure a
healthy body as physical activity helps to keep one in shape and free of
sickness and disease.

According to the World Health Organization, only one in ten people

exercise regularly and a majority does not follow a healthy diet. The main
culprit is our penchant for junk food as can be seen from the popularity of
fast food chains and other western eateries. Even local foods such as fried
noodles, friend rice and snacks and savouries are laden with fat and
calories. Thus, consuming this type of food on a daily basis can contribute
to weight gain. Overweight and obese people suffer from many health
complications such as diabetes, high blood pressure, high cholesterol and
even cancer.

Hence, the emphasis on healthy lifestyle should start at a young age.

Parents must urge their children to eat more vegetables, fruits, juices,
whole meal and wholegrain foods. Many parents, due to time constraint,
usually find the easy way out by cooking two-minute noodles or heading
towards the nearest fast food joint for quick meal. They do not realize
however that sets the stage for an unhealthy lifestyle for their children who
quickly become addicted to such foods. Thus, parents can counter this
problem by cooking or preparing meals that do not take up time such as
cheese sandwiches, soup, stir friend vegetables or buy pre-packed meals
from supermarkets which can be warmed up in the microwave oven.

Dining out usually involves eating heavily and unhealthily. Most of us are
prone to ordering deep fried food and oily dishes as opposed to steamed
or baked food. Thus, though eating out are unavoidable, parents of
children and adults as a hole should order fresh food and foods that are
nutritious and not laden with oil, fat or sugar. Once a pattern of healthy
eating is established, it would be easier to carry through such a lifestyle
and for the children to follow suit.

Daily exercise is vital. Most students are sedentary and prefer to

concentrate on their studies as they consider indulging in physical
activities a waste of time. By enforcing regular exercise daily, these
students would be exposed to the importance and benefits of exercise.
Therefore, schools should implement physical education on a daily basis.

Many parents and adults do not allocate time for physical activity. A large
number of them work long hours and return home late thereby depriving
themselves of the benefits of exercise. Parents must lead an exemplary
life which can benefit their children by increasing awareness on the health
 benefits of exercising regularly. Bringing their children for walks in the
morning or evening is a good start to achieve this goal. They should
become members of clubs which have swimming pools and gym facilities.
During the weekend, the family can strengthen their bond by adjourning to
clubs for exercise and a healthy meal after that.

In short, leading a healthy lifestyle is a conscious decision. One can ignore

that and lead a life that exposes one too many health hazards. It is
important to recognize that a healthy living ensures a longer life span as
well as a life free of disease and complications.

2.1.6 Health Awareness

India is a densely populated country where a large number of people live

without access to the basic education and primary health facilities. The
situation is more complex in rural villages comparing to the urban areas. Their
houses are poorly established and do not have proper supply of water and
electricity. They somehow manage little water from resources available at the
distant places and hardly think of having shower, clean their cloths and
renovate their shelters. In addition to their poor socio-economic condition,
another major cause of their sufferings is lack of education and public
awareness. Health related awareness programmes content the following
objectives:

1. To increase public awareness that disease are significant public health

problem.

2. To increase public awareness of symptoms and signs of disease.

3. To improve the knowledge and attitudes of patients about detection,

treatment and control of disease.

4. To promote the family and community educational material essential for

positive lifestyle habits.

5. To create public awareness about the ill-effects of alcohol, smoking and

drugs, etc.

These health awareness programs are also focus to develop a panel of local
people who can handle any critical situation. These programs help local
community:-

1. To increase knowledge, attitude and skills of all health professionals

regarding sign, symptoms and management strategies for health hazards
to improve disease control.
 2. To encourage health professionals to treat patients carefully.

3. To develop resource and material for use of health professionals.

4. To promote research all over the world to curb health hazards.

5. To encourage continuing educational programmes on accurate information

on diagnosis and treatment of diseases.

A few examples of organizations that are involved in public health are:

• Centers for Disease Control (CDC)

• World Health Organization (WHO)

• National Institute for Health (NIH)

• Food and Drug Administration (FDA)

• Occupational Safety and Health Agency (OSHA)

• Department of Health and Human Services (HHS)

2.2 Yoga: Meaning and Concept

The word 'yoga' means "to join or yoke together". It brings the body and mind
together to become a harmonious experience. Yoga is a method of learning
that aims at balancing "Mind, Body and Spirit". Yoga is a practice with
historical origins in ancient Indian philosophy.

Modern lifestyle has lost the harmony in mind-body relationship which has
caused several stress-based diseases such as hypertension, coronary heart
diseases and cancer. An attempt to prevent and treat these diseases
triggered a search for better lifestyles and better strategies that converged on
the rediscovery of ancient disciplines such as Yoga, combining lifestyles with
potent infallible prescriptions for lasting mental peace as confirmed by clinical
studies.

Yoga is the science of modern living, of right living, and should be

incorporated into our daily lives. Yoga has technical systems to help calm the
mind, maintain resilience, harness physical and mental energies and to
develop an integrated personality. It‟s a way of balancing the emotions and
establishing the harmony between the mind and body. A person can choose
one or a combination of two or more from the many paths of yoga according
to need of his lifestyle. One can practice pranayama, asanas, relaxation,
meditative and pratyahara techniques, as well as follow personal and social
disciplines where possible. It is up to the individual to find which path best
 suits his/her needs, lifestyle and personality. Yoga can be practiced while
leading a normal lifestyle, but with different aspirations, mentality and attitude
towards oneself and the interactions in life.

The art of practicing yoga helps in controlling an individual‟s mind, body and
soul. It brings together physical and mental disciplines to achieve a peaceful
body and mind, helps manage stress and anxiety and keeps you relaxed. It
also helps in increasing flexibility, muscle strength and body tone. It improves
respiration, energy and vitality. Practicing yoga might seem like just
stretching, but it can do much more for your body from the way you feel, look
and move.

The practice of Yoga does not only deal with developing the body but also
covers all the aspects of a person's life. It is about the physical, mental and
spiritual well-being of an individual as well as his environment and relationship
with other creatures. Real practice of the principles of yoga leads to deeper
self-knowledge, love and respect towards other people and creatures, cleaner
environment, healthy diet, and union with the Divine.

2.2.1 The basics of Yoga

The philosophy and practice in all forms of YOGA is embedded in the

following eight principles

1. Yama - Control of the Mind

2. Niyama - Follow rules
3. Asana - Postures of exercise
4. Pranayama - Controlled Breathing
5. Pratyahara - Complete relaxation
6. Dharana - Attain consciousness of the body
7. Dhyana - Concentration and Awareness
8. Samadhi - State of Absolute Awareness

Yogic exercises recharge the body with cosmic energy and facilitates -

• Attainment of perfect equilibrium and harmony

• Promotes self- healing
• Removes negative blocks from the mind and toxins from the body
• Increases self-awareness
• Helps in attention, focus and concentration; especially important for
children
• Reduces stress and tension in the physical body by activating the
parasympathetic nervous system
 Various forms of Yoga practice

 Health yoga: is the path of physical fitness or yoga of postures.

 Bhakti Yoga: is the path of the heart or the yoga of devotion.
 Dhyana Yoga:is the path of meditation and contemplation
 Gyana Yoga : is the path of learning and knowledge
 Karma Yoga: is the path of action or selfless service.
 Nada Yoga: is the Yoga of inner sound. The sound of the Universe.
 Yoga Nidra: is the yoga to achieve perfect sleep

2.2.2 Role of yoga in human’s health and fitness

Yoga makes the human being disease & medicine free through a scientific
approach on the knowledge base of our great saints & sage and more on
yoga. Yoga views the human body as a composite of mind, body and spirit.
Yoga relates to health such as Yoga Improves blood circulation and over all
organ functioning; Bring down stress, enhances power of relaxation & stamina
and bestows greater power of concentration and self-control; Regulation and
transformation of blood chemistry through proper synthesization of neuro-
endocrinal secretions, dispassionate internal vibrations leads one to attain the
power to control the mind and to become free from the effect of external
forces compelling one to lose to equanimity; and Yoga practitioner become
cheerful enjoys talking to people, shares problems with friends and can
realize that there are other also who are sailing in same boat, so that one can
easily mix-up in group by happier nature.

Yoga takes place main role in three areas that are physical, mental and
spiritual being. Therefore, yoga helps to promote a balanced development of
all the three.

1. Physical

 Flexibility: Yoga helps the body to become more flexible, bringing greater
range of motion to muscles and joints, flexibility in hamstrings, back,
shoulders, and hips.

 Strength: Many yoga poses support the weight of own body in new ways,
including balancing on one leg (such as in Tree Pose) or supporting with
arms increases strength.

 Better Breathing: Most of us breathe very shallowly into the lungs and
don't give much thought to how we breathe. Yoga breathing exercises,
called Pranayama, focus the attention on the breath and improve lung
capacity and posture, and harmonize body and mind which benefits the
entire body. Certain types of breath can also help clear the nasal
 passages and even calm the central nervous system, which has both
physical and mental benefits.

 Disease Eliminator: Yoga has the power to prevent and eliminate various
chronic health conditions in women similar to men.

 Heart Disease: With less stress and blood pressure chances of

cardiovascular diseases are prevented. Increasing blood circulation and
fat burning results in lowering cholesterol.

 Diabetes: Yoga stimulates insulin production and reduces glucose to

prevent diabetes.

 Gastrointestinal: Yoga improves the gastrointestinal functions in women

effectively.

 Metabolism: Yoga helps women to stay healthy by balancing metabolism

results by controlling hunger and weight.

 Pain Prevention: Increased flexibility and strength can help prevent the
various instances of back pain, chronic pain, neck pain can be lessened
with yoga practice.

 Blood circulation: Yoga postures can help improve circulation and

eliminate toxic waste substances from the body.

2. Psychological

 Mental Calmness: Yoga asana practice is intensely physical.

Concentrating so intently on what body is doing has the effect of bringing
calmness to the mind.

 Stress Reduction: Physical activity is good for relieving stress, and this is
particularly true of yoga. Yoga provides a much-needed break from
stressors, as well as helping put things into perspective. Yoga controls
breathing, which reduces anxiety. It also clears all the negative feelings
and thoughts from mind leading to reduction of depression.

 Concentration: Yoga increases concentration and motivation in quick

time. This is why women from all aspects of life practice yoga since better
concentration can result in better focus on life and profession.

 Memory: Yoga stimulates better blood circulation especially to the brain,

which reduces stress and improves concentration leading to better
memory.
  Body Awareness: Doing yoga will give an increased awareness of own
body. It increase level of comfort in own body. This can lead to improved
posture and greater self-confidence.

3. Spiritual

 Inner Connection: Yoga can help to create a bond, a relation between

body and mind apart from all other benefits.

 Inner Peace: Yoga is the only method known to us for better and quicker
inner peace. The inner peace generated increases and improves our
capability in making effective decisions even at serious circumstances.

 Purpose of Life: Yoga is a simple exercise method that has numerous

benefits, psychologically and physically apart from allowing us to attain
inner. It helps to find the purpose of life and secrets to healthy longer life.

2.2.3 Yoga for prevention of disease

Scientific studies have shown that the practice of Yoga has curative abilities
and can prevent disease by promoting energy and health. That is why more
and more professionals have started using Yoga techniques in patients with
different mental and physical symptoms, such as psycho-somatic stresses
and different diseases.

Our bodies have a tendency to build up and accumulate poisons like uric acid
and calcium crystals, just to mention a few. The accumulation of these
poisons manifests in diseases and makes our bodies stiff.

A regular Yoga practice can cleanse the tissues through muscle stretching
and massaging of the internal organs and brings the waste back into
circulation so that the lungs, intestines, kidneys, and skin are able to remove
toxins in a natural way.

Yoga asana is recommended for the treatment of both high and low blood
pressure.

Yoga provides exercise to all the organs of the body so as to regulate the
overall metabolism rate in the body.

There are several causes of high blood pressure like increased stress, anger
and anxiety or other mental and cognitive disorders.

Yoga helps to free one's mind from the negative thoughts and provides
complete rest to the mind and the body. This increases the metabolism of the
body and brings the mind at rest. Excessive thinking about something also
increases the pressure with which the blood flows in various organs of the
body.

The practice of yoga helps the individual achieve a sense of balance and
relaxation in life. Yoga works on physical and mental aspects of the individual.
Thus yoga for strength also helps individual's live healthy lives that will show
on the skin.

The overall improvements in the body of an individual will lead to the

improvement in the skin quality as the skin will be well nourished.

The same applies to yoga for hair. This is simply because improved
circulation of blood will nourish the hair follicles better.

The ultimate goal of yoga is, however, to help the individual to transcend the
self and attain enlightenment. As the Bhagavad-Gita says, “A person is said to
have achieved yoga, the union with the Self, when the perfectly disciplined
mind gets freedom from all desires, and becomes absorbed in the Self alone.”
Yoga is a way of living with the aim is 'a healthy mind in a healthy body'.

The art of practicing yoga helps in controlling an individual's mind, body and
soul. It brings together physical and mental disciplines to achieve a peaceful
body and mind; it helps manage stress and anxiety and keeps you relaxing. It
also helps in increasing flexibility, muscle strength and body tone. It improves
respiration, energy and vitality. Practicing yoga might seem like just
stretching, but it can do much more for your body from the way you feel, look
and move.

Surya Namaskar is a complete body exercise. It keeps all internal organs,

stomach, intestines, pancreas, spleen, heart and lungs, healthy and strong;
muscles of external body parts, chest, shoulders, hands, thighs, legs
becomes healthy and strong. It makes spine and waist flexible by removing
disorders. It improves blood circulation in the body which removes skin
diseases. These are the best twelve steps of Surya Namaskar yoga positions
in sequence to burn calories, weight loss and complete health, fitness.
 3. Major Public Health and Lifestyle Issues
in India

3.0 Introduction

Health is determined not only by medical care but also by determinants

outside the medical sector. Public health approach is to deal with all these
determinants of health which requires multi sectoral collaboration and inter-
disciplinary coordination. Although there have been major improvement in
public health since 1950s, India is passing through demographic and
environmental transition which is adding to burden of diseases. There is triple
burden of diseases, viz. communicable, non-communicable and emerging
infectious diseases. This high burden of disease, disability and death can only
be addressed through an effective public health system. However, the growth
of public health in India has been very slow due to low public expenditure on
health, very few public health institutes in India and inadequate national
standards for public health education. Recent years have seen efforts towards
strengthening public health in India in the form of launch of National Rural
Health Mission (NRHM) and National Urban Health Mission (NUHM) under
the one umbrella of National Health Mission (NHM).

3.1 Public Health Issues

While noting that the public health initiatives over the years have contributed
significantly to the improvement of these health indicators, it is to be
acknowledged that public health indicators/disease-burden statistics are the
outcome of several complementary initiatives under the wider umbrella of the
developmental sector, covering Rural Development, Agriculture, Food
Production, Sanitation, Drinking Water Supply, Education, etc. Despite the
impressive public health gains, there is no gainsaying the fact that the
morbidity and mortality levels in the country are still unacceptably high. These
unsatisfactory health indices are, in turn, an indication of the limited success
of the public health system in meeting the preventive and curative
requirements of the general population.

Out of the communicable diseases which have persisted over time, the
incidence of Malaria staged a resurgence in the1980s before stabilising at a
fairly high prevalence level during the 1990s. Over the years, an increasing
level of insecticide-resistance has developed in the malarial vectors in many
parts of the country.
In respect of TB, the public health scenario has not shown any significant
decline in the pool of infection amongst the community, and there has been a
distressing trend in the increase of drug resistance to the type of infection
prevailing in the country.

An extremely virulent communicable disease HIV/AIDS has emerged on the

health scene since the declaration of the NHP-1983. As there is no existing
therapeutic cure or vaccine for this infection, the disease constitutes a serious
threat, not merely to public health but to economic development in the
country. The common water-borne infections – Gastroenteritis, Cholera, and
some forms of Hepatitis – continue to contribute to a high level of morbidity in
the population, even though the mortality rate may have been somewhat
moderated.

The period after the announcement of NHP-83 has also seen an increase in
mortality through „life-style‟ diseases, diabetes, cancer and cardiovascular
diseases. The increase in life expectancy has increased the requirement for
aged care. Similarly, the increasing burden of trauma case is also a significant
public health problem. Another area of grave concern in the public health
domain is the persistent incidence of macro and micro nutrient deficiencies,
especially among women and children. In the vulnerable sub-category of
women and the girl child, this has the multiplier effect through the birth of low
birth weight babies and serious ramifications of the consequential mental and
physical retarded growth.
 NHP-1983, in a spirit of optimistic empathy for the health needs of the people,
particularly the poor and underprivileged, had hoped to provide „Health for All
by the year 2000 AD‟, through the universal provision of comprehensive
primary health care services. In retrospect, it is observed that the financial
resources and public health administrative capacity which it was possible to
marshal, was far short of that necessary to achieve such an ambitious and
holistic goal. Against this backdrop, it is felt that it would be appropriate to
pitch NHP-2002 at a level consistent with our realistic expectations about
financial resources, and about the likely increase in Public Health
administrative capacity. The recommendations of NHP-2002 will, therefore,
attempt to maximize the broad-based availability of health services to the
citizenry of the country on the basis of realistic considerations of capacity. The
changed circumstances relating to the health sector of the country since 1983
have generated a situation in which it is now necessary to review the field,
and to formulate a new policy framework as the National Health Policy-2002.
NHP-2002 will attempt to set out a new policy framework for the accelerated
achievement of Public health goals in the socioeconomic circumstances
currently prevailing in the country.

3.1.1 Major public health issues in India

Malnutrition: Malnutrition can be described as the unhealthy condition that

results from not eating enough healthy food. A well-nourished child is one
whose weight and height measurements compare very well within the
standard normal distribution of heights and weights of healthy children of
same age and sex. Protein-energy malnutrition (PEM); Iron deficiency;
Vitamin A deficiency; Iodine deficiency; Foliate deficiency are the major forms
of malnutrition.

Malnutrition impedes the social and cognitive development of a child. These

irreversible damages result in lower productivity. As with serious malnutrition,
growth delays hinder a child‟s intellectual development. Sick children with
chronic malnutrition, especially when accompanied by anaemia, often suffer
from a lower learning capacity during the crucial first years of attending
school. Also, it reduces the immune defence mechanism, which heightens the
risk of infections.

Due to their lower social status, girls are far more at risk of malnutrition than
boys their age. Partly as a result of this cultural bias, up to one third of all
adult women in India are underweight. Inadequate care of these women
already underdeveloped, especially during pregnancy, leads them in turn to
deliver underweight babies who are vulnerable to further malnutrition and
disease.
High Infant Mortality Rate: Despite health improvements over the last thirty
years, lives continue to be lost to early childhood diseases, inadequate new-
born care and childbirth-related causes. More than two million children die
every year from preventable infections.

Poor sanitation As more than 122 million households have no toilets, and
33% lack access to latrines, over 50% of the population (638 million) defecate
in the open.(2008 estimate). This is relatively higher than Bangladesh and
Brazil (7%) and China (4%). Although 211 million people gained access to
improved sanitation from 1990–2008, only 31% use the facilities provided.
Only 11% of Indian rural families dispose of stools safely whereas 80% of the
population leave their stools in the open or throw them in the garbage. Open
air defecation leads to the spread of disease and malnutrition through
parasitic and bacterial infections.

Unsafe drinking water: Several million people suffer from multiple episodes
of diarrhoea and still others fall ill on account of Hepatitis A, enteric fever,
intestinal worms and eye and skin infections caused by poor hygiene and
unsafe drinking water. This problem is exacerbated by falling levels of
groundwater caused mainly by increasing extraction for irrigation. Insufficient
maintenance of the environment around water sources, groundwater pollution,
excessive arsenic and fluoride in drinking water pose a major threat to India's
health.

Bodily injuries: Bodily injuries are also a common health issue in India.
These injuries, including broken bones, fractures, and burns can reduce a
person's quality of life or can cause fatalities including infections that resulted
from the injury or the severity injury in general.

Poor lifestyle health issue: Some contributing factors to poor health are
lifestyle choices. These include smoking cigarettes, drug addiction, over
consumption of alcohol etc. It also can include a poor diet, whether it is
overeating or an overly constrictive diet. Inactivity can also contribute to health
issues and also a lack of sleep, stress and neglect of oral hygiene.

Genetic disorders: There are also genetic disorders that are inherited by the
person and can vary in how much they affects the person and when they
surface.

Mental illness: Having a mental illness can seriously impair, temporarily or

permanently, the mental functioning of a person. Other terms include: 'mental
health problem', 'illness', 'disorder', 'dysfunction'. Examples include,
schizophrenia, ADHD, major depressive disorder, bipolar disorder, anxiety
 disorder, post-traumatic stress disorder and autism. Mental health issues in
response to the pressures of society and social problems they encounter.
Some of the key mental health issues are: depression, eating disorders, and
drug abuse. There are many ways to prevent these health issues from
occurring such as communicating well with suffering from mental health
issues.

3.1.2 Communicable Diseases

The occurrence of most of these diseases is associated with poor awareness,

poor hygiene and poor sanitation. Mortality related to them is usually for not
being able to avail of services. Communicable diseases are also known as
infectious diseases. Infectious pathogens include some viruses, bacteria,
fungi, protozoa, multi-cellular parasites, and aberrant proteins known as
prions. These pathogens are the cause of disease outbreaks, epidemics, and
common health problems.

The term infectivity describes the ability of an organism to enter, survive and
multiply in the host, while the infectiousness of a disease indicates the
comparative ease with which the disease is transmitted to other hosts.
Transmission of pathogen can occur in various ways, including physical
contact, contaminated food, body fluids, objects, airborne inhalation, or
through vector organisms.

Infectious diseases are called “contagious” when they are easily transmitted
by contact with an ill person or their secretions (eg, influenza). Thus, a
contagious disease is a subset of an infectious disease that is especially
infective or easily transmitted. Other types of
infectious/transmissible/communicable diseases with more specialised routes
of infection, such as vector transmission or sexual transmission, are usually
not regarded as “contagious,” and often do not require medical isolation
(sometimes loosely called quarantine) of victims.

Emerging infectious diseases are a major public health problem in India result
in high morbidity and mortality and affect the public health and economy
adversely. Because of the existing environmental, socio-economic and
demographic factors, India is vulnerable to rapidly evolving micro-organisms.
During the past three decades more than 30 new organisms have been
identified worldwide including HIV, Vibrio cholera, SARS, corona virus, highly
pathogenic avian influenza virus A, and novel H1N1 influenza virus. In the
recent times, avian influenza virus A H5N1 created pandemic scare by
affecting birds/poultry in India and affecting human beings.

The top three single killer agents/diseases are HIV/AIDS, TB and malaria.
While the number of deaths due to nearly every disease has decreased,
 deaths due to HIV/AIDS have increased fourfold. Childhood diseases include
pertussis, poliomyelitis, diphtheria, measles and tetanus. Children also make
up a large percentage of cases of lower respiratory and diarrhoeal
deaths.(Kishore, 2009)

Malaria: Intermittent fever, with high incidence during the rainy season,
coinciding with agriculture. Malaria is a major public health problem in several
parts of the country. The case load, though a steady around 2 million cases
annually in the late 1990s, has shown a declining trend since 2002.

Dengue: Dengue is a viral disease. It is transmitted by the infective bite of

Aedes aegypti mosquito. Humans develop disease after 5-6 days of being
bitten by an infective mosquito. Dengue Fever is a severe, flu-like illness.
Dengue is a severe form of the disease, which may cause death.

Leprosy: Leprosy is a chronic infectious disease caused by Mycobacterium

leprae. It usually affects the skin and peripheral nerves, but has a wide range
of clinical manifestations. The disease is characterised by long incubation
period – generally of 5-7 years. Leprosy is a leading cause of permanent
physical disability. Timely diagnosis and treatment, before nerve damage has
occurred, is the most effective way of preventing disability due to leprosy.

Tuberculosis: Tuberculosis (TB) is an infectious disease caused by the

bacteria, Mycobacterium tuberculosis. It is the world‟s biggest single infectious
cause of death among adults. India has the largest number of tuberculosis
cases in the world, accounting for more than one-third of the global burden;
TB is the leading cause of death among adults in the country. Nearly 1.8
million new cases occur each year. TB has killed more people than any other
infectious disease in India.

HIV/AIDS: India reported its first case of HIV in India was among the
commercial sex workers in 1986. From 3-5 million infected cases in India the
government‟s efforts have led to a declining trend in recent years.

3.1.3 Non Communicable Diseases

Burden of Non-communicable (not contagious) disease including

cardiovascular disease, cancer, diabetes, chronic respiratory disease and
stroke is not less. Overall non-communicable diseases are the leading causes
of death in the country. These diseases killed millions of people in previous
years, and a large proportion of these deaths occurred during the most
productive period of life.

The modifiable behavioural risk factors such as dietary habits, physical activity
levels, tobacco and alcohol abuse and high stress levels precipitate the
development of physiological risk factors like obesity, raised blood pressure,
deranged blood glucose and dyslipidemia, leading to the ultimate progression
to disease outcomes like coronary heart disease, stroke, diabetes,
etc.(Kishore, Kohli, Sharma, & Sharma, 2012) These diseases are largely
preventable through effective interventions that tackle common risk factors
including tobacco use, unhealthy diet and physical inactivity.

Other NCDs of public health importance are blindness, deafness and mental
disorders. Malnutrition among children is a cause of great concern, especially
in developing countries.

Cardio-vascular diseases (CVDs), Coronary artery disease (CAD) or

Coronary heart disease (CHD) – often broadly referred to as ischaemic heart
disease (IHD) – is primarily myocardial infarction and sudden coronary death.
They are leading cause of mortality due to changing lifestyles. They have a
major impact on life expectancy and significantly contribute to morbidity.

Rheumatic heart diseases: Rheumatic fever usually follows an untreated beta-

haemolytic streptococcal throat infection in children. As a consequence, the
heart valves are permanently damaged which may progress to heart failure.
Today, it mostly affects children in developing countries, linked to poverty,
inadequate healthcare access.

Stroke: If the flow of blood is obstructed, by a blood clot moving to the brain,
or by narrowing or bursting of blood vessels, the brain loses its energy supply,
causing damage to tissues leading to stroke. Stroke is uncommon in people
under 40 years; when it does occur, the main cause is high blood pressure.
The major risk factors for stroke are similar to those for coronary heart
disease, with high blood pressure and tobacco use the most significant
modifiable risks. Atrial fibrillation, heart failure and heart attack are other
important risk factors.

Diabetes mellitus: Diabetes Mellitus is a metabolic disorder characterised by

hyperglycaemia, glycosuria and defective carbohydrate, fats, and protein
metabolism. Diabetes is a chronic condition that occurs when the pancreas
does not produce enough insulin or when the body cannot effectively use the
insulin it produces.

Cancers: Cancer is predicted to be an increasingly important cause of

morbidity and mortality in the next few decades, in all regions of the world.
Within upper-middle-income and high income communities, prostate and
breast cancers are most commonly diagnosed in males and females,
respectively, with lung and colorectal cancers representing the next most
common types in both sexes.
In India the leading causes of cancers are cancers of oral cavity, lungs,
oesophagus and stomach in men. Cancers of cervix, breast and oral cavity in
women are common. Cancer of oral cavity and lungs in males and cervix and
breast in females are more than 50% of all cancer deaths in India.

Deafness: Hearing impairment refers to complete or partial loss of the ability

to hear from one or both ears (mild, moderate, severe). Deafness refers to the
complete loss of ability to hear from one or both ears.

Blindness: The WHO has defined blindness as “visual acuity of less than 3/60
(Snellen) or its equivalent”, and for non-specialised personnel it is further
described as “inability to count fingers in daylight at a distance of 3 metres”.
Causes of blindness are – Cataract, Refractive errors, Corneal scar,
Trachoma, Glaucoma, Vitamin A deficiency, and Other rate causes.

Mental disorders: Mental health is defined as a state of well-being whereby

individuals recognise their abilities, are able to cope with the normal stresses
of life, work productively and fruitfully and are able to make contributions to
their community. Common mental disorders are – Depression, Anxiety
disorders, Substance abuse, Manic depression, Schizophrenia, Hysteria,
Hyperactive disorders in children, Mental retardation etc.

Nutritional deficiency disorders: According to UNICEF, under-nutrition is

defined as the outcome of insufficient food intake and repeated infectious
diseases. It includes being underweight for one‟s age, too short for one‟s age
(stunted), dangerously thin for one‟s height (wasted) and deficient in vitamins
and minerals (micronutrient malnutrition). India has the largest number of
children in the world who are undernourished.
Causes of malnutrition are - Inadequate food security, Infection, Low birth-
weight, Low weight of adolescent girls, Low immunisation coverage, Maternal
anaemia, Poor sanitary conditions and poor hygiene, Low literacy rate, Lack
of knowledge regarding normal growth of children, Incorrect child rearing
practices, Inaccessible and inadequate health services, Lack of
comprehensive child health care programme, Lack of political will.
 4. Public Health Care System in India:
Issues & Problems in Rural and Urban
India

4.0 Introduction

Since its independence, India has become a world leader in medical

advancement due to its incredible medical education system and state-of-the-
art private medical facilities. It is now a major provider of health services and
contains some of the most highly skilled and qualified medical providers in the
world. Quality health care, however, remains inaccessible for many
undeveloped Indian regions. For example, in rural communities it is estimated
that only 18 hospital beds are available per 100,000 people. Even when
medical treatment is available, public hospitals are frequently understaffed
and undersupplied. The poor are forced to rely on overburdened, unsanitary
facilities as their only source of health care.

4.1 Health Care

Health care is the act of taking preventative or necessary medical procedures

to improve a person‟s wellbeing. This may be done with surgery, the
administering of medicine, or other alterations in a person's lifestyle. These
services are typically offered through a health care system made up of
hospitals and physicians. Systematic activities to prevent or cure health
problems and promote good health in humans are undertaken by health care
providers.

Primary Health Care is defined as "Essential Health Care" based on practical,

scientifically sound and socially acceptable methods and technology, made
universally accessible to individuals and families in the community through
their full participation at a cost that the community and country can afford to
maintain at every stage of their development and in the spirit of self-reliance
and self-determination. If you look at the definition, it has big concepts which
are here to understand its full meaning.

It is an appropriate practical approach because majority of the problems are

preventable and curable at the community level with simple, economical and
acceptable technology and self-efforts of the people with some guidance and
supervision of health workers. It also promotes people's self-confidence, trust
and abilities to manage their own health matters. It includes education of
people which will not only improve their health knowledge, attitudes and skills
 but also build up their outlook on socio-economic development. This will result
in better health and quality life.

4.2 Public Healthcare System in India

Since independence in 1947, the pace of development in India has unequally

registered commendable speed in a number of sectors including health.
Efforts made by the Union and State Governments in response to the call
“Health for All by 2000” emanating out of the historical Alma-Ata conference in
1978, have resulted in considerable gains.

A gross look at demographic and epidemiological features since then

distinctly reflect successes in vital indicators viz. life expectancy at birth, crude
birth rate, crude death rate, maternal/infant mortality rates, etc. In addition,
these decades have also witnessed achievements like eradication of
smallpox, dracontiasis, Yaws and elimination of leprosies while prevalence
and incidences of diseases like HIV, Malaria, Polio, Cholera and
Gastroenteritis have declined considerably. Encouraged by the aforesaid
achievements in the health sector, the country has set to herself ambitious
goals to be achieved by 2015 that include eradication of Polio, Kalazar while
also aiming to achieve zero level incidence of HIV/AIDS by 2007.

On the infrastructure front, the nation has created an impressive network of

Sub-centers, Primary Health Centers, Community Health Centers,
dispensaries and hospitals of various sizes to effectively implement the
cherished goals as per the National Health Policy 2002 and NRHM. Taking
clue from ICPD Cairo in 1994, the country responded to the need for
paradigm shift in delivery of healthcare services which inter-alia aims at
decentralization and devolution, outcome linked funding support, upgrading
the infrastructure/workforce as per IPHS, community need-based planning,
client-centered healthcare delivery, inter-sectoral coordination and public
private partnership, which are the mandate under National Rural Health
Mission (NRHM).

At the Government Health Sector, operationally, the Chief Medical Officers

(CMOs) at district level is the nodal for delivery of services supported by
Deputy CMOs and respective programme officers.

Within a few years after induction into service, the prospective incumbents
usually get promotion to higher berths, but more often than not find
themselves amidst administrative indecision, because of considerable lack of
proficiency, related to management aspects of health care services like
General Management, Human Resource Management, Financial
Management, Materials Management, Disciplinary/Vigilance matters and
 more importantly the management of on-going projects related to health,
which are not taught in the medical colleges.

The Government of India in consultation with the respective State

Governments started implementing the reform process within the country in a
phased manner and towards capacity building of district level officers and now
also from the blocks as part of it. This was reinforced in a landmark national
resolve, at the 8th conference of Central Council of Health and Family Welfare
held in New Delhi (28th-29th August, 2003), where it was unanimously
resolved that “the professional training of medical officers in 12-16 years‟
service bracket in Public Health, Management and Health Sector Reforms,
should be made a pre-requisite for promotion to CMOs/Civil
Surgeons/Hospital Superintendents to equip them to handle their
responsibilities better”.

Since the 1980‟s, India has become one of the fastest growing nations of the
world. Between 1980 and 2010, India achieved a growth of 6.2 per cent, while
the world as a whole showed a growth rate of 3.3 per cent. It is now
recognised as a global power in key economic sectors. Currently, the private
sector is booming as India has been constantly expanding its information
technology (IT) sector and liberalising its foreign investment laws.

According to an article in the Economic Times, India‟s medical tourism sector

is expected to experience an annual growth rate of 30%, making it a $2 billion
industry by 2015. People from the US, UK, and the Middle East are coming to
India for their treatment. Today, the private Indian hospitals are well equipped
with the latest technology and have highly qualified staff that can provide
quality medical treatment to patients. Sadly, a huge percentage of India‟s
population has little or no access to these facilities.

Despite these economic advances, issues such as poverty and poor health
still plague the country. Here, growth and increase in income have not
automatically translated to a higher standard of living for a majority of the
Indian population. While there have been positive trends in healthcare such
as the eradication of the new wild type polio infections, the provision of quality
health care services is insufficient at best. India spends about 4% of its GDP
on health (the government currently spends 1.4% on health). The government
aims to increase its investment in healthcare to 2.5 percent by the end of 12th
five-year plans. (Source: Planning Commission)

4.2.1 Public Healthcare delivery system in India

Healthcare delivery system is the organisation of people, institutions and

resources to promote, restore or maintain health of the people, according to
their needs and demands, with equitable distribution. This includes efforts to
 influence determinants of health as well as more direct health-improving
activities. A health system is therefore more than the pyramid of publicly
owned facilities that deliver personal health services. It includes healthcare
activities at home; private providers; behaviour change programmes; vector-
control campaigns; health insurance organisations; occupational health and
safety legislation.

The Indian Constitution stipulated that for every state “raising the level of
nutrition and the standard of living of its people and the improvement of public
health as among its primary duties”. The states are largely independent in
matters relating to the delivery of healthcare to the people. The Central
Government‟s responsibility consists mainly of policy making, planning,
guiding, assisting, evaluating and coordinating the work of the state health
ministries. Healthcare in India features a universal healthcare system run by
the constituent states and territories of India. However, the private sector
delivers the bulk of the healthcare.

As India consists of different cultures and beliefs, the healthcare system is

also varied and complex – from highly specialised to most traditional.

4.3 Public Healthcare delivery system in Government sector

The public health system at the state level is funded and managed by state
governments. Since health is a state subject, according to the Constitution,
the Central ministry provides only technical support to states; this support is
not binding on the state.
 Organisational structure of public healthcare delivery system of India:

Public Healthcare delivery system

in Government sector

Center level State level District level Village level

Ministry of Ministry of State District Community

Health & AYUSH Health Hospitals Health Center
Family (Ayurved, Directorate headed by (CHC)
welfare Yoga, Unani, Chief 30 Bed referral
Siuddha, unit of 4 PHCs
Medical
Homoeopathy)
Officer

Deptt. Of Deptt. Of 1. Public 1. District Family Primary

Health & Health & Health Deptt. Welfare Officer, Health Center
Family Research 2. Medical 2. District Health (PHC) 4-6
Welfare Education Officer bed referral
3. District
Deptt. unit of 6 sub-
Malaria Officer
3. Municipal centers
Administration
Deptt.
1. Dte. General of
Health Service;
2. Central Govt. Sub-District
Health Service Hospitals Sub-Center
3. Govt. Of (SC)
National Capital Most
peripheral
Territory contact point
Urban Family
Welfare Center community
or Dispensaries manned with
1 ANM (F)
and 1 HW
(M)
Health Workers
1. Urban Social
Health Activists
(USHA)
2. Mahila
Arogya Samiti
(MAS)
However, India‟s public healthcare system consists at following three levels:

A. Central
B. State
C. District level

A. CENTRAL LEVEL

The Ministry of Health & Family Welfare is headed by Union Minister of Health
& Family Welfare.

Since 10th November, 2014 Shri Jagat Prakash Nadda is the Union Minister
of HFW and Minister of State for Health & Family Welfare Shri Shripad Yesso
Nai.

In view of the federal nature of the Constitution, areas of operation have been
divided between Union Government and the State Governments. Seventh
Schedule of Constitution describes three exhaustive lists of items, namely,
Union list, State list and Concurrent list. Though some items like public health,
hospitals, sanitation etc. fall in the State list, the items having wider
ramification at the national level like Family Welfare and Population Control,
Medical Education, Prevention of Food Adulteration, Quality Control in
manufacture of Drugs etc. have been included in the Concurrent list.

The Union Ministry of Health & Family Welfare is instrumental and responsible
for implementation of various programmes on a national scale in the areas of
health and family welfare, prevention and control of major communicable
diseases and promotion of traditional and indigenous systems of medicine. In
addition, the Ministry also assists States in preventing and controlling the
spread of seasonal disease outbreaks and epidemics by providing technical
assistance.

Expenditure is incurred by Ministry of Health & Family Welfare either directly

under Central Schemes or by way of grants-in-aid to the
autonomous/statutory bodies etc. and NGOs. In addition to the Central
Government sponsored programmes, the Ministry is implementing several
multi-lateral/international NGO supported programmes in association with the
State Governments.

On August 7, 2014 vide extraordinary gazette notification Department of AIDS

Control has been merged with Department of Health & Family Welfare and
now be known as National AIDS Control Organization (NACO).

As per the amendment, dated December 8, 2014; Department of AYUSH has

been made a separate Ministry of Ayurveda, Yoga & Naturopathy, Unani,
Siddha and Homeopathy (AYUSH).
It has different departments which are headed by the secretary and assisted
by a joint secretary (JS), deputy secretary (DS) and assistant secretary (AS).

Ministry of Health & Family Welfare comprises two departments i.e.

A) Department of Health & Family Welfare (DHFW)

B) Department of Health and Research (DHR)

Central health services: The Central Health Service was restructured in1982
to provide medical manpower to various participating units like

a) Directorate General of Health Services (Dte. GHS),

b) Central Government Health Service (CGHS),
c) Government of National Capital Territory (GNCT) of Delhi etc.

Functions of Ministry of Health and Family Welfare

1. International health relations and administration.

2. Administration of central health institutions such as All India Institute of

Medical Science, All India Institute of Hygiene and Public Health, National
Institute of Mental Health and Neurosciences (NIMHANS), etc.

3. Encourage research

4. Development and regulation of nursing education, dentistry education,

pharmacology and medical education.

5. Establish and maintain standards related to drugs.

6. Collection and publication of census and other demographic data.

7. Health status of immigrants and emigrants

8. Coordination between state and central ministries

9. Social and economic planning

10. Activities related to labour welfare

11. Control over drugs and poison

The Central Council of Health and Family Welfare

It was set up in 1952 to promote coordinated and concerted action between

the Centre and states. Its chairman is Union Health minister and State Health
ministers are other members. Functions of the council are:
1. Preparing proposals in making laws in areas of medicine and health.

2. Making plans for development throughout the country.

3. Lay down recommendations for grants and financial assistance to state for
medical services and review the activities

4. Encourage medical education and training

B. STATE LEVEL

Every state has a Ministry of Health; it is headed by a minister for health and
family welfare or a deputy minister for health and family welfare. The health
secretariat is the official organ which is headed by a secretary, who is
assisted by a deputy secretary and a large administrative staff. All activities of
the health secretariat are governed by State Health Directorate, which is
headed by Director of Health Services and assisted by a number of deputies
and assistant directors of health.

Functions of state health secretariat are:

1. Planning for health services in the state

2. Implementation of national health programmes
3. Providing all types of health services in the state
4. Food sanitation and hygiene
5. Vital statistics
6. Promote maternal and child health
7. Training of health workers, nurses, etc.

There are three departments under a state government

1. Public health department

2. Medical education department
3. Municipal administration department (Under local government)

C. DISTRICT LEVEL

Pay attention to the administrative structure because the health communicator

needs to work with officials at the district level and below. The district health
and family welfare structure is headed by the Chief Medical Officer-Health
(CMO-H) and is assisted by two deputies CMO-H, district Family Welfare
Officer (DFWO), District Health Officer (DHO), District Malaria Officer (DMO).
The DHO is in charge of health administration and all national health
programmes except the family welfare programme.

Sub-Divisional/Sub-District and District Hospitals: Strengthening of sub-

divisional/sub-district and district hospitals is also an approved activity under
 NHM. The States propose their requirement in their Programme
Implementation Plans (PIPs), which are approved by the National Programme
Coordination Committee (NPCC) and approvals are generated in light of the
appraisal.

Besides, funds for carrying out approved activities Untied Grant per Sub-
Divisional/Sub-District and District Hospitals is also provided for local health
action to Rogi Kalyan Samiti (RKS) to undertake and supervise improvement
and maintenance of physical infrastructure.

4.3.1 Urban Health Infrastructure

Government hospitals: These are mainly run by state governments.

Urban Family Welfare Centres: At present there are 1,083 such centres
functioning in various urban areas. They provide outreach services, primary
healthcare, maternal and child health services and contraceptive distribution.

Urban areas are usually covered with health centres or dispensaries at the
50,000-100,000 population level. There will be district hospitals which usually
fall in urban areas and act as tertiary care level for the rural health system.
Some districts hospitals could be specialty or super-specialty hospitals. One
of the district hospitals is also located in the capital of that state.

Health delivery model for urban poor proposed under the National Urban
Health Mission
Health personnel in urban areas

At the community level: 1. Urban Social Health Activist (USHA) for 1,000-
2,500 beneficiaries between 200-500households.

2. Mahila Arogya Samiti (MAS): a community-based institution comprising 20-

100 households to encourage participation. Proposed staff at Primary Urban
Health Centre (PUHC) is – Doctor-1, Lab technician-1; Pharmacist-1; Staff
nurse-2; Up to 4 ANM; Programme manager/Community mobilisation officer-
1, Other clerical and support staff (Peon, Sweeper).

Private sector

The private healthcare system in India is well established and flourishing; it

has grown enormously over the years. A weak government healthcare
delivery system, coupled with its poor quality of care (QoC), is a major
contributing factor to the growth of the private healthcare system. Data from
the National Family Health Survey (NFHS) III, 2005-06, also confirms that the
private medical sector remains the primary source of healthcare for the
majority of households in urban (70 per cent) as well as rural areas (63 per
cent).

The number of corporate hospitals and nursing homes is going on increasing

in the country. The government too offers a number of financial concessions
to corporate hospitals in the form of subsidised sale of land and tax
concessions for medical research. It also encourages public-private
partnership at different levels. Indian and foreign companies have also come
forward to set up tertiary care/super-specialty hospitals.

The private healthcare delivery system (PHCDS) in India is made up of three

major sub-systems: (a) individual practitioners; (b) secondary level institutions
such as nursing homes and smaller hospitals and (c) tertiary care hospital
such as specialty and super-specialty hospitals.

Therefore, the private sector too can be grouped into three levels of care:

1. Primary level – GP (Allopathic/AYUSH) and traditional practitioners

2. Secondary level – Nursing homes
3. Tertiary level – specialty and super-specialty hospitals

The range of private healthcare providers:

(a) private practitioners

(b) for-profit hospitals and nursing homes,
(c) corporate hospitals
(d) not-for-profit, NGO and missionary hospitals and
(e) Ayurveda, Yoga, Unani, Sidhha and Homoeopathy private practitioners.
(f) Traditional healers

During the last two decades, the number of private hospitals has increased
significantly, especially corporate chains like Apollo, Fortis, Max, among
others.

Then there are the voluntary healthcare agencies (VHAs), which play an
important role. A voluntary health agency is defined as an organisation that is
administered by an autonomous board, which holds meetings and raises
funds from private sources. It runs public health programmes that provide
health services or health education or programmes that support research or
legislation for health or a combination of all these.

1. Voluntary sector Indian Red Cross Society: established in 1920 under the
Act run the programmes which can be grouped into four main core areas:
Promoting humanitarian principles and values; Disaster response; Disaster
preparedness and Health and Care in the Community.

2. Hind Kusht Nivaran Sangh (Indian Leprosy Association): is an old and

prestigiousbody of people committed to treatment, rehabilitation of leprosy
patients andelimination of leprosy from India.

3. Indian Council for Child Welfare works for child welfare and advocacy for
children‟srights.

4. Tuberculosis Association of India: is a voluntary organisation set up in 1939

with the objective of prevention, control, treatment and relief of tuberculosis;
encouragement of and assistance in the establishment throughout India of
State Associations and undertaking research and investigation on subjects
concerning tuberculosis and allied chest diseases.

5. Bharat Sevak Samaj is a voluntary organisation set up to promote India‟s

development and to build its economic strength.

6. Central Social Welfare Board is working for welfare of disadvantage

sections of society.

7. The Kasturba Memorial Fund is a trust that engages in a number of

activities such as health services, leprosy eradication, health workers‟ training
and educational programmes.

8. Family Planning Association of India, established in 1949, works in the field

of reproductive and sexual health. It provides information on sexuality
education and family life and a wide range of services in sexual and
reproductive health, including family planning.
 9. All India Blind Relief Society works in the field of blindness prevention,
control and rehabilitation.

10. All India Women‟s Conference is a voluntary organisation dedicated to the

uplift and betterment of women and children and diversified into various social
and economic activities involving women.

11. Professional bodies such as Indian Public Health Association, Indian

Association of Preventive and Social Medicine, Indian Medical Association,
etc.

4.3.2 Rural Health Infrastructure

The healthcare infrastructure in rural areas has a three-tier system and is

based on the following population norms as shown in Table 1 and Figure 4.

Source:
1. Sub Centers (SCs): Sub-Centre is the most first peripheral and first
contact point between primary healthcare system and the community. It
is required to be manned by at least one Auxiliary Nurse Midwife
(ANM)/ Female Health Worker and one Male Health Worker. One Lady
Health Visitor (LHV) is entrusted with the task of supervision of six Sub-
Centers. Sub-Centers are assigned task relating to maternal and child
health; family welfare; nutrition; immunisation; disease control and
health counselling. The sub-centres are also provided with basic drugs
for minor ailment needed for taking care of essential health needs.
Government of India bears the salary of ANM and LHV, while the
salary of the Male Health Worker is borne by the State Governments.

2. Primary Health Centre (PHC): PHC is the first contact point between
village community and the Medical Officer. It is manned by a Medical
Officer and other support staff. It acts as a Referral Unit for 6 Sub-
Centres and has 4-6 beds for patients. It provides curative, preventive,
promotive and Family Welfare services. The PHCs are being
strengthened under NHM (National Health Mission) to provide a
package of essential public health services and support for outreach
services including for regular supplies of essential drugs and
equipment, upgrading single doctor PHC to 2 doctors PHC by posting
 AYUSH practitioners at PHC level, provision of 3 Staff Nurses in a
phased manner based on patient load and delivery load. The
States/UTs have to incorporate their proposals and requirement of
funds in their Programme Implementation Plans (PIP) under NHM.
Untied Grant per PHC for local health action to Rogi Kalyan Samiti
(RKS) is provided to undertake and supervise improvement and
maintenance of physical infrastructure.

Functions of PHC

1. To provide integrated curative and preventive healthcare to the rural

population with emphasis on preventive and promotive aspects of
healthcare.
2. PHCs are established and maintained by state governments under
the Minimum Needs Programme (MNP).

3. Community Health Centre (CHC): Community Health Centres are the

first referral unit under the RCH (rural community health) programme
where emergencies, operations and blood transfusion can be handled.
A CHC is established and maintained by the state government and as
per the standards it is supposed to have 4 medical specialists –
surgeon, physician, gynaecologist and paediatrician – supported by
paramedical and other staff. It has 30 in-door beds with one OT, X-ray,
and labour room and laboratory facilities and serves as a referral
centre for 4 PHCs. It is supposed to provide facilities for emergency
obstetrics care and specialist.

Funds are being provided every year as requested by the States in

their Programme Implementation Plan under NHM to strengthen CHCs
and make them First Referral Unit (FRU). Untied Grant per CHC for
local health action to Rogi Kalyan Samiti (RKS) is also provided to
undertake and supervise improvement and maintenance of physical
infrastructure.

Health personnel and staffing pattern in rural India: At the village

level, there are three main health workers:

1. Village health guide (VHG) is working in some states, but is being by

ASHA.

2. Trained birth attendant (TBA) is still working in many places to assist

the deliveries at home. However, training of dais has stopped to
promote institutional delivery, the traditional birth attendants continue to
provide antenatal, intra-natal and postnatal care.
 3. Accredited Social Health Activist (ASHA) is a female community
health worker chosen by and accountable to the panchayat and acts as
the interface between the community and the public healthcare system.
An ASHA must primarily be a married/widowed/divorced woman
resident of the village and preferably in the age-group of 25-45 yrs. She
should be a literate woman, with formal education up to at least the
8thclass, and have communication and leadership qualities. After 23
days of training she will be providing the following services:

a) Spread awareness about the determinants of health such as

nutrition, basic sanitation and hygienic practices, healthy living and
working conditions, information on existing health services and need
for utilisation of health and family welfare services;

b) Counsel women on birth preparedness, importance of safe delivery,

breast feeding and complementary feeding, immunisation, family
planning and contraception, prevention of common infections including
RTIs/STIs and care of the young child;

c) Mobilize the community and facilitate them in accessing health and

health related services available at the Anganwadi/sub centre/ PHCs.

d) Work with Village Health and Sanitation Committee (VHSC)

e) Escort to pregnant women and children requiring

treatment/admission to the nearest pre-identified health facility;

f) Medical care for minor ailments such as diarrhoea, fever and first aid.
She will also be a provider of DOTS treatment for TB;

g) Act as depot holder for essential provisions being made available to

every habitation like ORS, Iron & Folic Acid tablets, Disposable
Delivery Kit, Oral pills, condoms, etc;

h) Inform the sub-centre/PHC about births and deaths;

4.3.3 Basic Infrastructural Status (as on 31st March 2015):

(Resource: Rural Health Statistics 2014-15, Statistics Division, Ministry of

Health and Family Welfare, Government of India)

Basic Infrastructure

(a) Sub District/sub divisional hospitals in India (SDH): 1022

(b) District Hospitals in India (DH): 763
(c) Mobile Medical Units (MMU): 1253
(d) Working Doctors in Sub divisional hospital in India: 10018
(e) Working Doctors in District Hospital in India: 18436
(f) Para-medical staff in Sub District/sub divisional hospitals in India:
26717
(g) Para-medical staff in District Hospitals in India: 55642
(h) Sub centers: 153655
(i) Health worker (Female) ANM (Auxiliary Nurse Midwife) at sub center:
193191
(j) Health worker (Male) at sub center: 55657
(k) Primary Health Centers (PHCs): 25308
(l) Health worker (Female) ANM (Auxiliary Nurse Midwife) at PHCs
(Primary Health Centers): 19066
(m) Health Assistants (Female) LHV (Lady Health Visitors) at PHCs: 13372
(o) Health Assistants (Male) at PHCs: 12646
(p) Allopathic Doctors at PHCs: 27421
(q) Block Extension Educators at PHCs: 2934
(r) PHCs with AYUSH facilities: 10237
(s) Community Health Centers (CHCs): 5396
(t) Specialists (surgeon, OB&GY, Physicians and Pediatricians at CHCs:
4078
(u) General Duty Medical Officers (GDMOs) allopathic at CHCs: 11822
(v) Nursing staff at CHCs: 65039

Basic administrative structural data of India

(i) Districts in India: 672 (as per census 2011)
(ii) Villages in India: 640867 (as per census 2011)
(iii) Rural Area in India: 3115202.65 sq. km. (as per census 2011)
(iv) Urban Area in India: 78091.61 (as per census 2011)
(v) Rural Population of India: 833748852
(vi) Urban population of India: 377106125
(vii) Estimates of Birth Rate of India: 21.4
(viii) Estimates of Death Rate of India: 7.0
(ix) Infant Mortality Rate of India: 40 per thousand
Average rural population covered by health facility (based on the rural
population of 2011 Population Census):
i) Each Sub Center: 5426
ii) Each Primary Health Center: 32944
iii) Each Community Health Centers: 154512

Average rural area (Sq. Km) covered by

(i) Each Sub Center: 20 sq km

(ii) Each Primary Health Center: 123 sq km
(iii) Each Community Health Centers: 577 sq km
 Average radial distance (Km) covered by

(i) Each Sub Center: 2.5 sq km

(ii) Each Primary Health Center: 6.3 sq. Km
(iii) Each Community Health Centers: 13.5 sq. km

Average number of villages covered by

(i) Each Sub Center: 4

(ii) Each Primary Health Center: 25
(iii) Each Community Health Centers: 119

4.3.4 Growth of public healthcare system in India:

More recently, the Expert Committee on Public Health system (1996) and the
National Commission on Macroeconomics and Health (2005) examined these
issues. National Five Year Plans, National Health Policy (1983, 2002) and
many international initiatives such as Health for All by 2000, Calcutta
Declaration on Public Health in south-East Asia (1999), UN Millennium
Development Goals (2000), Global Commission on Macroeconomics and
Health (2001), revised International Health Regulations (2005), an Asia
Pacific Strategy for Emerging Diseases (2005) have also provided strong
policy directives for the development of health care delivery system to
control/prevent diseases. As a result of these efforts, a strong health
infrastructure has been developed. Many national disease programmes to
control/eliminate/eradicate diseases have been set up in the country. In the
current Five-year Plan, pilot projects for leptospirosis and rabies control and
pilot projects on non-communicable diseases have also been initiated.

Therefore, resulting the efforts, life expectancy has increased from 36.5 years
in 1951 to more than 63.1 years. While Crude birth rate declined from 40.8 in
1951 to 22.8 in 2008, crude death rate declined from 25.1 in 1951 to 7.4 in
2008. Infant Mortality Rate (IMR) declined from 146 per 1000 live births in
1951 to 53 per 1000 live births in 2008. Maternal Mortality Ratio (MMR)
declined from 398 per 100,000 live births in 1997-98 to 254 per 100,000 live
births in 2006. However, India has a long way to go in further reducing
mortality among infants, mothers and the people in the most productive age-
groups (15-45 years).

4.3.5 Issues and Problems in Rural and Urban India:

In spite of the efforts mentioned above, the growth of public health in India is
very slow. The impeding factors for this include very few public health
institutes in India, inadequate national standards for public health education
including curriculum and methods. This results in inadequate public health
workforce in the country. Over and above health care in the country more
emphasis is on more curative services and with inadequate lab capacity in the
system and poor participation of private sector in public health activities. As
per NFHS III, the pattern of health care expenditure in India shows that more
than 70% of expenditure is from out of pocket by households. Estimates
suggests that in India the total health expenditure is around 6% of GDP, and
is dominated by out of pocket spending i.e. around 5%. The
government/public expenditure on health care is around 1% of GDP. Due to
this low public expenditure the reach and quality of public health services are
below the desired level.

However, many initiatives have been taken recently for the growth of public
health in India which includes National Rural Health Mission (NRHM) wherein
thrust has been given to upgrade health care infrastructure as per IPHS,
augmentation of human resources, flexible financing and involvement of the
community in health care planning and utilization of services.

More public health courses are being started in the medical colleges and
public health institutions like MPH course at NCDC, Delhi and NIE, Chennai
as well as MPH course being conducted by PHFI. Public health functional
capacity of states and districts is being developed under IDSP. Department of
Health Research has been created in the Ministry of Health & Family Welfare.
NICD has been upgraded to NCDC.

Public Health Bill has been drafted and many programme on non-
communicable diseases such as diabetes, cardiovascular disease and stroke
have been initiated. To further give impetus to the growth of public health in
India, the priority is to ensure access, availability and utilization of primary
health care to all including urban slum population for which there is need to
strengthen the health care infrastructure, increase public health workforce
with a dedicated public health cadre, enhancing public private partnership,
formulation and enforcement of public health laws and over and above
increase public health financial allocation and expenditure as well as to
strengthen disease surveillance and response system. All such efforts are
being made under NRHM.

There is also a large gap in the healthcare system between urban and rural
areas. This inequity is due to a lack of healthcare resources and infrastructure
in the rural region. Complicating the issue, 68 percent of the population
resides in the rural areas, which implies that only a quarter of the Indian
population has access to quality healthcare. Those who have access are not
necessarily able to afford it. This is because poor government services calls
for the private sector to fill the gap. This leads to provision of services at a
higher cost, which creates an even wider gap between the rich and the poor.
Much needed public private partnerships that can provide solutions have not
really come into play.
This inequity has shaped the current market environment and created serious
concerns for India which are highlighted by following facts:

1) According to UNICEF, around 46 per cent of all children below the age of
three are too small (less height) for their age and 47 per cent are underweight.
About one-third of all adult women are underweight. Inadequate care of
women and girls, especially during pregnancy, results in low birth weight
babies. Nearly 30 per cent of all newborns have a low birth weight, making
them vulnerable to further malnutrition and disease.

2) Sanitation and hygiene are still a major concern, especially in the rural
areas. According to UNICEF India (2008), only 31 per cent of India‟s
population use improved sanitation. According to the Public Health
Association, only 53 per cent of the population wash hands with soap after
defecation, 38 per cent wash hands with soap before eating and only 30 per
cent wash hands with soap before preparing food. WASH Interventions
significantly reduce diarrhoeal morbidity as it is well known that poor WASH
causes diarrhoea, which is the second biggest cause of death in children
under-five years.

3) Infectious diseases such as dengue, tuberculosis, diarrhoea, hepatitis, and

malaria continue to plague the country. According to a recent article, in the
Hindustan Times, India is at the top of any table for the most vaccine-
preventable deaths yet ironically over half of all vaccines produced in the
world are made in India. In 2012, pneumonia and diarrhoea claimed the lives
of over 500,000 children in India.

4) Lifestyle diseases such as heart disease and diabetes are on the rise in
India. According to the International Diabetes Federation (IDF), India is
presently home to 62 million people living with diabetes and by 2030 India‟s
diabetes numbers may cross the 100 million mark. Diabetes includes Type 1
diabetes – insulin-dependent, usually first diagnosed in children or young
adults; Type 2 diabetes-adult onset diabetes or noninsulin-dependent
diabetes which results from being overweight and inactive and Gestational
diabetes – affecting women during the later stages of pregnancy. Diabetes
affects not only the urban population in India but also the rural population as
they have a poor diet consistent of low quality meat, inadequate protein and
lack of fibre. Recent studies have also shown that South Asians in general are
at higher risk for Type 2 diabetes, up to four times higher than other ethnic
groups probably due to a combination of genetics and environment and diets
high in refined carbohydrates.

5) India has a population of almost 1.2 billion people. 55% of this population
(nearly 600 million people) has no access to toilets. Most of these numbers
are made up by people who live in urban slums and rural areas. A large
populace in the rural areas still defecates in the open. Slum dwellers in major
metropolitan cities, reside along railway tracks and have no access to toilets
or a running supply of water. The situation in urban areas in terms of scale is
not as serious as rural areas.

The entire Indian population has greater access to mobile phones than toilets,
according to a recent United Nations study. Highlighting the country‟s
hazardous sanitation issues, a study conducted by the United Nations
University said, only 366 million people (36% of the population) had access to
proper sanitation in 2008.

Most Indian‟s still do not have access to modern sanitation. For example, rural
sanitation coverage was estimated to have reached only 21% by 2008
according to the UNICEF/WHO joint monitoring programme. There continue
to be a number of innovative efforts to improve sanitation including the
community led Total Sanitation Campaign and the monetary rewards under
the Nirmal Gram Puraskar.

School Water and Sanitation Towards Health and Hygiene (SWASTHH) was
born to spearhead School Sanitation and Hygiene Education (SSHE) in the
country. This book is meant for managers and trainers involved in school
sanitation and hygiene education (SSHE) programmes operating at different
levels, such as state, district or block level. It was developed in the context of
the SWASTHH programme in India and it provides many guidelines and
activities.

Poor sanitation is something that not only affects the health of the people of
the country, but also affects the development of the nation. In fact, women are
most affected by the hazards of lack of proper sanitation. For instance, in
India majority of the girls drop out of school because of lack of toilets. Only
22% of them manage to even complete class 10. On economic grounds,
according to the Indian Ministry of Health and Family Welfare, more than 12
billion rupees is spent every year on poor sanitation and its resultant illnesses.

India‟s healthcare sector certainly presents a dichotomy with its numerous

health challenges. In the aspects of growth and innovation, India remains a
beacon for other developing countries but it is still far behind in providing high-
quality healthcare for its people.

The purpose of Health Issues India is simple to follow critical stories and
issues that emerge as this rapidly developing economy copes with its health
challenges. It is our mission to present high-quality coverage of health care
and policy in India. The website features the latest trends, research and
summaries of health care news from across the nation.
 5. India as Medical Tourism Destination

5.0 Introduction

Medical Tourism in India is one of the best options available to people across
the globe. Millions come every year to get treated and then enjoy their
recuperative holidays across India. People from different walks of life cut
across the entire span of the globe come to India to have their treatments
done with peace of mind. India provides world class medical facilities with
hospitals and specialized multi specialty health centers providing their
expertise in the areas of Cosmetic Surgery, Dental care, Heart Surgeries,
Coronary Bypass, Heart Check up, Valve replacements, Knee Replacements,
Eye surgeries.

The Indian traditional systems of medicine like Ayurveda, Yoga,

Panchakarma, Rejuvenation Therapy are among the most ancient systems of
medical treatment, of the world. India practically covers every aspect of
medicine combining modern treatments with traditional experience.

5.1 India as a Medical Tourism Destination

India is renowned for ancient alternative therapies such as Ayurveda, Yoga

and Meditation, and Therapeutic Massage. India is an exotic tourist
destination offering everything from beaches, mountains, cosmopolitan cities,
quaint villages and pilgrimages to suit every palate. Rich in history and
culture, India has proved to be an oasis in the modern world, providing
complete health and well being, while providing the latest in technology.

The concept of Medical Tourism India refers to visit by overseas patients for
medical treatment and relaxation. The opportunities in Indian Healthcare
sector in medical infrastructure and technology are just as good as those in
the West.

Over the years, India has grown to become a top-notch destination for
medical value travel because it scores high over a range of factors that
determines the overall quality of care. Imagine a complex surgical procedure
being done in a world class global hospital by acclaimed medical specialists at
a fifth to tenth of what it normally takes in India. From quality of therapy, range
of procedural and treatment options, infrastructure and skilled manpower to
perform any medical procedure with zero waiting time, the list of benefits of
travelling for medical treatment in India are many.
 India has one of the best qualified professionals in each and every field, and
this fact has now been realized the world over. Regarding Medical Facilities
India has the most competent doctors and world class Medical Facilities. With
most competitive charges for treatment, India is a very lucrative destination for
people wanting to undergo treatment of certain medical problems who do not
need immediate emergency treatment.

As Indian healthcare sector develops, a new term has been coined called
'Medical Tourism', which is the process of people from all corners of the world
visiting India to seek medical and relaxation treatments. The most common
treatments sought are heart surgery, knee transplant, cosmetic surgery and
dental care.

Medical tourists choose India as their favourable destination because of the

key opportunities in Indian healthcare sector in the form of efficient
infrastructures and technology. The health insurance market and National
medical systems here are well developed, which is convenient for visitors
from the West and the Middle East.

Southern states of India, especially, Kerala has developed Health Tourism as

one of the products for the promotion of tourism in Kerala. Most hotels and
resorts are coming up with the Yoga, Panchakarma, Rejuvenation, Spas and
Ayurveda Centers as an integral part in Kerala. India has an international
reputation of being a knowledge-based economy.

5.1.1 Advantages for healthcare solutions in India

Facilities: The high-end healthcare system in India is as good as the best in

the world. India maintains not only a robust accreditation system but also a
large number of accredited facilities (about 275 such facilities that match any
global infrastructure). India has a good number (22) of JCI (Joint Commission
International) accredited hospitals and compares well with other countries in
Asia. These set of approved hospitals in India can provide care at par or
above global standards.

Frontier technologies: Cutting edge technology to support medical

diagnostics and medical procedures are employed by specialists in medical
facilities. All recognized hospitals have invested a lot in supportive technology
and operative techniques. Complicated heart surgeries, cancer care and
surgeries, neuro and even general surgeries require high-end technology to
continually better outcomes, minimize complications, enable faster recovery
and reduce length of hospital stay. The recent advancements in robotic
surgeries, radiation surgery or radio therapies with cyber knife stereotactic
options, IMRT / IGRT, transplant support systems, advanced neuro and spinal
options are all available in India. India‟s medical management and acclaimed
specialists are quite comfortable in challenging themselves to new frontiers to
provide solutions, always building on their expertise.

Finest doctors: India has not only hospitals with world-class facilities but
skilled world-class doctors and medical personnel too. The country has the
largest pool of doctors and paramedics in South Asia. Many of them have
established their credentials as leaders around the world. India‟s medical
history spans thousands of years through Ayurvedic and alternate medicine
forms. With a large number of doctors, there is a high level of competency
and capability in adoption of newer technologies and innovation and fresh
treatment methods. It is a wonderful example of higher quantity leading to
higher quality and vice versa. Communicate, talk to the doctors in the
accredited facilities prior to your visit and they will study your needs and
customize the treatment for you!

Financial Savings: Quality of care is attracts people. However, quality

services should not be beyond the affordability of the patient who requires it. If
quality comes at an affordable cost it is an unbeatable advantage. This
confluence of highest quality and cost advantage is unique for India. The
benefit is unimaginable when it comes to major treatments such as for
leukemia where the difference in cost is 10 to 20 times. For other treatments,
it could be anything from a fifth to a tenth when compared to Western
countries and 80 to 90 per cent of what is charged in other South Asian
medical destinations.

The estimated 600,000 people who step into India from other countries do not
do so for not only cheap healthcare but for quality healthcare at an affordable
cost. They are not compromised at any level, but regain health at a fraction of
the cost.

Fast Track – Zero Waiting Time: Quick and immediate attention for
surgeries and all interventions are assured in India. Getting an appointment
for bypass surgery or a planned angioplasty in certain countries takes almost
3-6 months. And there these treatments are very costly too. It‟s zero waiting
time in India for any procedure, be it heart surgery, kidney care, cancer
treatment, neuro-spinal procedure, knee/hip/joint replacements, dental,
cosmetic surgeries, weight loss surgery etc.

Feeling the pulse: For greater understanding between patients and

healthcare personnel, the warmth and hospitality of Indian hospitals is a big
factor in choosing India as a healthcare destination. Among the top medical
destinations of the world, India has the highest percentage of English
language speaking people. Amidst the variety of culture and traditions, if there
is one thing that is common in India, that is the English language. If other
 language options are essential, there are expert interpreters who will be
arranged by the hospitals.

Indian Corporate Hospitals: Indian corporate hospitals have a large pool of

doctors, nurses, and support staff ensuring individualized care. The highly
skilled personnel, with wide experience and international exposure excel in
Cardiology and Cardiothoracic surgery, Orthopedic surgery, Bariatric or
Obesity surgery, Gastroenterology, Ophthalmology, Dentistry, and Urology, to
name a few. Our hospital partners have exclusive Cosmetic/Plastic surgery
departments. Our alliance partners have Centers of Excellence in their
specialty areas.

5.1.2 Government pushes medical tourism in India

Seeing the huge potential in the sector, the government has also started
issuing M (medical) visa to the medical patients, and MX visas to the spouse
accompanying him, which are valid for a year. Two lakh medical tourists
visited India last year, and the figure will grow by 50% this year.

India is being promoted as a healthcare destination in the ongoing 'Incredible

India campaign,' being run by the tourism ministry. The campaign would
promote Indian hospitals abroad as centers offering best medical services. In
addition, availing medical services in India costs about a tenth of what it is in
US, and one-sixth in UK. Not only this, the National Accreditation Board for
Hospitals (NABH), a body set up to ensure safety and hygiene norms for
hospitals, has already started the process of granting accreditation.

India now offers the latest techniques such as robotic surgery, and gamma-
knife treatment for brain tumors. The efficacy of treatment compares with that
in the West, with the death rate from coronary bypasses at 0.8% compared to
2.35% in the US.