Lecture series

GS F332
Health
• The World Health Organization 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.
• Public Health is the science and art of preventing
diseases, prolonging life and promoting health (of
individuals) through organized efforts and
informed choices.
• Dimensions of public health- Health promotion,
Disease prevention, Early diagnosis and prompt
treatment, Disability limitation and Rehabilitation
• Impacts of poor public health conditions
a) Reduced attraction for investors and tourists
b) continued expenditures on combating diseases which
should have become history
c) labor productivity foregone.
• Evolution of public health services- triggered
partly by military concerns, cure was uncertain
and massive business losses.
• The “sanitary movement”-radical changes in
citizens’ health behaviors and private lives
• Effort devoted to building the organizational and
technical infrastructure of public health services,
and public health engineering
• Institutions and procedures for preventing
exposure to communicable diseases became
well-established in the developed world
• Non-communicable diseases
• Public health services broadened to control
these through lifestyle changes and controlling
environmental pollution
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 in India before Colonial period
• Main stream system of health care was
Ayurveda.
• Home-based care appeared to be the
dominant feature.
• There appeared little organized efforts or
institutional care to treat diseases and prevent
deaths.
• Public health in India during Colonial period
• Public health measures focused largely on protecting
British civilians and army cantonments
• The services were focused largely on early detection
and control of outbreaks of contagious diseases with
high fatality rates
• Institutions for public health training and research,
were built - All-India School of Public Health and
Hygiene, and the Calcutta School of Tropical Medicine
• Public Health legislation along lines then current in
Europe
• Sanitary Departments at national and provincial levels
for civilian public health services
• Policy making and planning for public health services,
• During the first half of the twentieth century,
the mortality spikes from epidemics were
sharply reduced.
• By the end of the colonial era mortality from
diseases such as cholera and the plague had
fallen sharply
• Diseases such as malaria and gastro-enteric
infections continued to take heavy tolls
• First Five Year plan noted only 3 percent of households in
India had toilets, and that much of the population lacked basic
water, drainage and waste disposal services
• The capacity to prevent outbreaks from occurring atrophied
i. mass-production of antibiotics refined during the 1940s.
ii. main causes of death shifted from communicable to non-
communicable diseases
iii. separate institutional structures and programs for controlling
specific communicable diseases
iv. preference for public funds to be used to provide private
goods (such as medical care), rather than public goods (such
as sanitary measures to protect the health of the population
as a whole)
v. elite capture
• Public health services were designated as the
responsibility of the state governments, except for
issues such as port quarantine and provisions
relating to the spread of diseases between states
• Neglect of public health regulations and their
implementation
• Diversion of funds from public health services
• Organizational changes inimical to maintaining public
health
• The bulk of the funds allocated by the central Health
Ministry to the states are tied to specific programs
• Public health cannot be sustained on a “campaign”
basis
• The epidemiological and statistical dimensions
of public health have been grossly neglected
• Planning reduced to a normative, mechanical
exercise, often out of context to people’s
needs
• Social, economic, cultural and environmental
diversity leaves normative planning virtually
redundant
 Child health
• As per Census 2011, the share of children (0-6 years)
accounts 13% of the total population in the Country.
• As per latest Sample Registration System, 2016 Report; The
Under Five Mortality Rate in India is 39/1000 live births.
• As per latest Sample Registration System, 2016 Report;
Infant Mortality Rate is 34/1000 live births.
• Child Health programme under the Reproductive,
Maternal, Newborn, Child and Adolescent (RMNCH+A)
• The National Population Policy (NPP) 2000, the National
Health Policy 2002, Twelfth Five Year Plan (2007-12),
National Health Mission (NRHM - 2005 – 2017), Sustainable
Development Goals (2016-2030) and New National Health
Policy, 2017 have laid down the goals for child health.
• The major causes of child mortality in India as per the
SRS reports (2010-13) are:
I. Prematurity & low birth weight (29.8%),
II. Pneumonia (17.1%),
III. Diarrheal diseases (8.6%),
IV. Other non-communicable diseases (8.3%),
V. Birth asphyxia & birth trauma (8.2%),
VI. Injuries (4.6%),
VII. Congenital anomalies (4.4%),
VIII. Ill-defined or cause unknown (4.4%),
IX. Acute bacterial sepsis and severe infections (3.6%),
X. Fever of unknown origin (2.5%), a
XI. all other remaining causes (8.4%)
• The major causes of infant mortality in India as per the
SRS reports (2010-13) are:
I. Prematurity & low birth weight (35.9%),
II. Pneumonia (16.9%),
III. Birth asphyxia & birth trauma (9.9%),
IV. Other no communicable diseases (7.9%),
V. Diarrheal diseases (6.7%),
VI. Ill defined or cause unknown (4.6%),
VII. Congenital anomalies (4.6%),
VIII.Acute bacterial sepsis and severe infections (4.2%),
IX. Injuries (2.1%),
X. Fever of unknown origin (1.7%),
XI. all other remaining causes (5.4%).
• Neonatal Health
a) Essential new born care (at every ‘delivery’ point at time of birth)
b) Facility based sick newborn care (at FRUs & District Hospitals)
c) Home Based Newborn Care and Home Based Young Care (HBYC)
Programme
• Nutrition
a) Promotion of optimal Infant and Young Child Feeding Practices under
Mother’s Absolute Affection (MAA) Programme
b) Micronutrient supplementation (Vitamin A, Iron Folic Acid)
c) Management of children with severe acute malnutrition
d) National Deworming Day
• Immunization
a) Intensification of Routine Immunization
b) Eliminating Measles and Japanese Encephalitis related deaths
c) Polio Eradication
• Immunization is one of the most cost effective public health
interventions since it provides direct and effective
protection against preventable morbidity and mortality.
• It has been a major contributor in the decline of under-5
mortality rate from ~ 233 to ~63 (per 1000) in last five
decades in India.
• Modern immunization developed in India in 19th century,
parallel to the Western world
• BCG in 1962 as a part of National Tuberculosis Program.
• Extended Programme on Immunization was launched in
India in 1978
• In 1985, the program was converted into Universal
Immunization Program (UIP) with a goal to cover ‘all’
eligible children in the country, immunization of ‘all’
pregnant women with TT and to improve quality of
services.
 The barriers to achieve 100%
immunization coverage
1. Huge population with relatively high growth rate
2. Geographical diversity, cultural diversity and Political
instability
3. Reaching out to mobile/migrant population
4. Low levels of education and lack of awareness
5. Inadequate delivery of health services (supply
shortages, vacant staff positions, lack of training)
6. Lack of accountability, inadequate supervision and
monitoring
7. Lack of micro planning at district level
8. General lack of inter-sectoral coordination and lack of
coordination between state and central governments
9. Weak VPD surveillance system in the country.
 Nutrition
• Higher proportion of underweight children
• Nutritional deficiencies across children as well
as adult population
• South Asian enigma
• Under nutrition in children is closely
associated with poor nutritional status of
women
 Insurance based health care
• Rashtriya Swasthya 1. Efficiency issues
Bima Yojna (2008)- BPL 2. Distortion issues
families are enrolled 3. Targeting issues
with private insurance
companies 4. Equity issues
• Health improvement 5. Irreversibility issues
model or a business
model
• Private insurance
becoming backbone of
Indian health system
 Ayushman Bharat Yojna (2018)
• Aimed at providing 1. National Health
insurance cover to Protection Scheme
economically backward • cashless benefits from any
people in rural and urban public or private empaneled
areas hospitals across the country
• Identified on the basis of
data from the Socio- 2. Wellness centres
Economic Caste Census
(SECC) 2011. • Upgrading Public Health
• The cover will be Rs 5 lakh Centres to Wellness Centres
per family per year.
• Mostly for secondary and
tertiary care hospitalization.
 Integrated child development scheme
Objectives
1. To improve the nutritional and health Target Population
status of children in the age-group 0-6 1. Children in the age group of 0-6 years
years; 2. Pregnant women and
2. To lay the foundation for proper 3. Lactating mothers
psychological, physical and social
development of the child; Services
3. To reduce the incidence of mortality, 1. Supplementary Nutrition
morbidity, malnutrition and school 2. Pre-school non-formal education
dropout; 3. Nutrition & health education
4. To achieve effective co-ordination of 4. Immunization
policy and implementation amongst 5. Health check-up and
the various departments to promote
6. Referral services
child development; and
5. To enhance the capability of the
mother to look after the normal
health and nutritional needs of the
child through proper nutrition and
health education.
Population Norms
• There will be 1 Anganwadi centre
(AWC) for population of 400-800;
2 AWCs for 800-1600; 3 AWCs for
1600-2400 and thereafter in
multiples of 800 -1 AWC.
• The norms for one AWC for
Tribal/Riverine/Desert, Hilly and
other difficult areas will be 300-
800
• Norms for one Mini AWC will be
150-400.
• Norms for Anganwadi on Demand
(AOD) - Where a settlement has
at least 40 children under 6 years
of age but no AWC
Funding pattern
• All components of ICDS except
Supplementary Nutrition
Programme (SNP) are financed
through a 60:40 ratio (central :
state).
• The Supplementary Nutrition
Programme (SNP) component
was funded through a 50:50 ratio.
The North East states have a
90:10 ratio
 Strengths Weakness
1. ICDS Scheme is the only 1. The focus and coverage of
program in the country which is children in 0-3 years of age is
aimed at the holistic inadequate.
development of the child.
2. The referral system is weak.
2. It serves the extreme
underprivileged communities of 3. Lack of adequate
the backward and remote areas decentralization.
of the country 4. AWW has not been accorded
3. It delivers services right at the the dignity and prestige as a
doorsteps of the beneficiaries to voluntary worker.
ensure their maximum
participation. 5. Inadequate emphasis on
Nutrition and Health
4. It utilizes local women as
honorary village level workers Education (NHE) activities for
for the delivery of the package Behaviour change
of services.
5. The implementation of ICDS
program has made it possible for
the health services to reach the
most remote and difficult areas
of the country.
 Tamil Nadu story
• Based on extensive network of Primary health centres,
visited by patients form diverse social background
• Focus on public heath
• Extensive initiatives in child nutrition, health care and
social security
• Increased women autonomy- increased involvement of
women in health provision services
• Increased impetus to good quality health- primary
health centres are well supplied by basic drugs,
• Increased coordination between health workers and
medical offices, 24 hrs. open health centres
• Low social distance between medical officers and
patients.
 Basic components of Tamil Nadu model

• it separates the medical officers into public health

and medical tracks,
• requires those in public health track to secure a
public health qualification,
• orients their work toward managing public health
services while those in medical tracks are
involved in hospital care, and
• greater authority is vested on the medical officers
in charge of the rural health facility for providing
health services to the people
• ICDS are government owned
• Longer working hours for anganwadis
• Daycare facilities for small children
• Integrated training for the anganwadi workers
with other health workers
• Regular monitoring
• Creative activism in designing social programmes
• Comprehensive and universalistic social policies
 Accessible

Equitable Universal
Improved
health
delivery
Accountable
system Participatory

Affordable