Public Health in India

Outline

 Health and Public Health

 Public Health in India
 Before the Colonial period
 During the Colonial period
 After the colonial period
 Essential Public Health Functions
 Mortality transition in India
Health

 The World Health Organisation defines

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

 World Health Organisation, however, does

not define Public Health.
Death

 Death, on the planet Earth, is inevitable.

 A large number of deaths are premature.

 A substantial proportion of deaths can be

avoided.

 Public Health is related to preventing

premature and unavoidable deaths.
A Model of Health
Exposure to Risk Body resistance
Factors

Poor Health
Manifestation

Disease Condition

Disability Death
Public Health

 If the disease condition is avoided, the

probability or the chance of death or
disability can be reduced.

 Public Health is therefore described as the

science and art of preventing diseases,
prolonging life and promoting health (of
individuals) through organised efforts and
informed choices.
Public Health

 Public Health deals with the group of people

rather than individuals.
 Dimensions of public health
 Health promotion
 Disease prevention
 Early diagnosis and prompt treatment
 Disability limitation
 Rehabilitation
Traditional Indian Approach

 The Indian approach to health is enshrined in

the concepts and principles of Ayurveda
which means the ‘science of life’.
 Ayurveda is one of the oldest system of
health care in the World.
 Ayurveda deals with both preventive and
curative aspects of health.
 Health defined by WHO is very similar to
concepts of Ayurveda.
Western Approach

 The western approach of avoiding diseases,

death and disability, traditionally focused on
personal hygiene and public sanitation during
the 19th Century.

 This approach, combined with better food

availability, paid rich dividend in the
developed countries in reducing morbidity
and mortality.
Components of Public Health

 Epidemiology
 Measurement of disease conditions in relation to
the population at risk.
 Statistics
 Collection, presentation, analysis and
interpretation of epidemiological data.
 Health Services
 Services directed towards meeting the health
needs of the people.
Public Health before the Colonial
Period
 Little is known about public health activities
before the colonial period.
 Main stream system of health care was
Ayurveda.
 Home-based care appeared to be the
dominant feature.
 There appeared little organised efforts or
institutional care to treat diseases and
prevent deaths.
Public Health during the Colonial
Period
 Evolution of public health system during the
colonial period followed the same path that
was followed in Britain.
 Public health efforts were focused largely on
protecting British civilians and army
cantonments.
 Sanitation was given the top priority.
 Focus was also on early detection and control
of contagious diseases – cholera and plague.
Public Health during the British
Period
 Training and research Institutions in public
health.
 Public health legislation.
 Sanitary departments
 Ascertaining local sanitary conditions.
 Vital registration.
 Monitoring disease trends.
 Vaccination programmes.
 Technical advice on control of epidemics.
Public Health during the British
Period
 Restriction of public health efforts to British
civilians and military established was a major
constraint.
 Majority of Indian masses remained deprived
of the dividends of these efforts.
 At the time of Independence only 3 per cent
households in India had toilets.
 Water, drainage and waste disposal services
were utterly lacking.
Public Health during the British
Period
 Although, public health efforts were
restricted to British civilian and military
establishment, they had impact on Indian
masses.
 Mortality spikes were sharply reduced.
 Mortality from cholera and plague was sharply
reduced.
 Diseases like malaria and gastro-enteritis
continued to take heavy toll.
Public Health in Independent India

 Evolution of public health care system in

Independent India was shaped by two
important factors:
 The Report of First Health Survey and
Development Committee (Bhore Committee)
constituted during the colonial rule.
 Emergence of modern medical technology for the
prevention and control of diseases, especially
communicable diseases.
Bhore Committee

 Appointed in 1943.
 Recommended comprehensive remodeling
of health services.
 Integration of preventive and curative health
services at all levels.
 Hospital-based health care system.
 Development of primary health centres in two
stages.
 Training in Preventive and Social Medicine.
Bhore Committee

 The short-term plan

 A PHC for every 40000 population.
 PHC to be manned by 2 doctors, 4 PHN, 4
Midwife, 1 Nurse, and others.
 The long-term plan
 A primary health unit for every 10-20 thousand
population with 75 beds.
 Secondary unit with 650 bedded hospital.
 District unit with 2500 bedded hospital.
Bhore Committee
The Committee visualised the development of primary health
centres in 2 stages
(a) As a short term measure, it was proposed that each primary health
centre in the rural areas should cater to a population of 40,000 with
a secondary health centre to serve as a supervisory, coordinating and
referral institution. For each primary health centre two medical
officers, four public health nurses, one nurse, four midwives,
two sanitary inspectors, two health assistants, one pharmacist and
fifteen other Class Four workers were recommended

(b) a long term plan (also called the Three Million Plan) of setting up
primary health units with 75 bedded hospitals for each 10,000 to
20,000 population and secondary units with 650 bedded hospitals,
again reorganised around district hospitals with 2500 beds.
Medical Technology

 Mass production of antibiotics.

 Availability of vaccines for diseases having
high mortality and disability rates
 Tetanus
 Diphtheria
 Pertussis (Whooping Cough)
 Measles
 Poliomyelitis
Public Health in Independent India

 The recommendations of Bhore Committee

and the availability of preventive and curative
medical technology resulted in the evolution
of hospital-based public health system.
 The public health arrangements created
during the colonial period were replaced by
hospitals and health centres.
 Public health services were merged with the
medical services.
Public Health in Independent India

 Bhore Committees recommendations were

accepted only partially.
 One primary health centre for every 30 thousand
population.
 Only 6 beds in each primary health centre.
 Only one doctor.
 Truncated paramedical staff.
 The situation has remained largely
unchanged.
Public Health in Independent India

 Since Bhore Committee, numerous

committees were constituted to evolve the
public health system.
 Some of the recommendations of these
committees were adopted; some were not by
the government.
 All committees retained the core of the
model recommended by the Bhore
Committee.
Public Health in India

 Mudalliar Committee(1962)
 Strengthen PHCs before establishing new ones.
▪ PHC should provide preventive, promotive and curative
services.
 Strengthen sub-divisional and district hospitals.
 Creation of All India Health Services.
 Chaddha Committee (1963)
 Malaria worker to function as multipurpose
worker.
Public Health in India

 Mukherjee Committee (1965)

 Separate staff for family planning programme.
 Malaria activities to be de-linked from family
planning activities.
 Jungalwala Committee (1967)
 A unified approach for all problems instead of a
segmented approach for different problems.
 Medical care and public health programmes to be
put under charge of a single administrator.
Public Health in India

 Kartar Singh Committee (1973)

 Concept of MPW(M) and MPW(F).
 One PHC to cater 50 thousand population.
 Each PHC should have 16 SHC (3-3.5 thousand
population).
 Shrivastav Committee (1975)
 Creation of bonds of paraprofessional and
semiprofessional health workers from within the
community itself.
Public Health in India
 Bajaj Committee (1986)
 Formulation of National Medical & Health Education Policy.
 Formulation of National Health Manpower Policy.
 Educational Commission for Health Sciences.
 Health Science Universities in various states.
 Health manpower cells.
 Vocationalisation of education at 10+2 levels as regards
health related fields with appropriate incentives, so that
good quality paramedical personnel may be available in
adequate numbers.
 Realistic health manpower survey.
Public Health System in India

 A population based normative approach is

adopted for establishing hospitals and health
centres
 SHC – One for every 5000 (3000 in hilly/tribal
areas) population.
 PHC – One for every 30000 population (20000 in
difficult areas) with 4-6 indoor/observation beds.
 CHC – One for every 80-120 thousand population
with 30 beds.
Public Health System in India

 The norms are for government institutions

and are for the rural areas only.
 For the urban areas, no norms have been
defined.
 Nearly all government civil and district
hospitals and most of the CHCs are located in
the urban areas.
 No information is available about the private
health system.
Public Health System in India
Institution Reference Number
SHC 2007 145272 More than 6 SHC for each PHC,
on average
PHC 2007 22370 More than 5 PHC for every CHC,
on average
CHC 2007 4045
Rural hospitals 2007 6298
Beds in rural 2007 142396 About 23 beds per rural hospital
hospitals
Urban hospitals 2007 2774
Beds in urban 2007 324206 About 117 beds per urban
hospitals hospital
Public Health in Independent India

 One fall out of the hospital-based public

health approach was the neglect of public
health legislation.
 A Model Public Health Act was drafted in
1950 by the Government of India.
 It was revised in 1987.
 This Act is yet to be adopted by any of the
constituent state of the country.
Public Health in Independent India

 The hospital-based public health system led

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

 The epidemiological and statistical

dimensions of public health have been
grossly neglected.
 Lack of epidemiological and statistical
database affected public health planning.
 In the absence of necessary information,
planning reduced to a normative, mechanical
exercise, often out of context to people’s
needs.
Public Health in India

 The problem gets complicated because of

social, economic, cultural and environmental
diversity that leaves normative planning
virtually redundant.
 Decentralisation of the health system could
not succeed because of the lack of
epidemiological and statistical information
necessary for planning for public health
services.
Public Health in India

 Public health in India is ‘hospitalised.’

 Health planning is concerned more with the
health of the health care delivery system
(hospitals and health centres) then the health
of the people.
 The remedy was sought in terms of specific
National health and disease control
programmes.
 There are numerous such programmes.
Public Health in India

 Reproductive and child health programme.

 National tuberculosis control programme.
 National malaria control programme.
 National blindness control programme.
 National water born disease control
programme.
 National leprosy eradication programme.
 National iodine deficiency control
programme.
Public Health in India

 All National disease control programmes are

implemented through the existing
government hospitals and health centres.
 Over the years, a campaign approach has
been evolved to implement many of the
national health and disease control
programme.
 Successful campaigns have often been
followed by unsuccessful maintenance.
Public Health in India

 Focus on medical services.

 Neglect of public health services.
 No modern public health regulation.
 Lack of systematic planning.
 Poor sustainability of public health efforts.
 Absence of epidemiological and statistical
skills at district and below district level.
 No micro-level planning, no public health
action.
Mortality Transition in India
Public Health in India

Widespread existence of preventable

diseases and deaths is a disgrace to
the society which tolerates it.