1.1 PUBLIC HEALTH IN INDIA
INTRODUCTION: DEFINITION AND CONCEPT
World Health Organization (WHO) has quite popularized the definition of health among medical and allied fraternity. But this ideal definition by many scientists is considered as individual based. As a community, we desire achievement of positive health by all members. Attempts towards improvement of health of all the members of the community by doctor consultation, compliance to advise given by a physician, etc. can only be theoretical way of achievement of this objective. For various obvious reasons such approach is never thought or practiced. It may require very long time and may not be feasible also. In history also there are not any countries or states which have exclusively resorted to this approach. On the other hand history is full of examples where contribution of other than medical system is acknowledged. In history although there were no precise measures of community health various countries at different times have witnessed huge differences in health of their citizens. Almost across the world such observations of disparity between health statuses of their constituent members have resulted socio-political and technical turmoil. The concept of public health has emerged in this manner. Public health has been beautifully defined by Charles-Edward Amory Winslow as, ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.’ The definition envisages a chain of continuum of objectives and assumes interlinking of prevention of diseases, prolonging life and promoting health. The best part of the definition is the advocated way of achievement. The only reason for such advocating is the realization of inevitability of executing joint efforts willingly for the achievement of the objective in true sense. The prolonging of life is not extension of life in critical care units in hospitals with life support systems. It expects increasing life expectancy. Public health is an applied science pooling disciplines like medicine, epidemiology, biostatistics, demography, social sciences together. Public health across the world is involved in some basic functions. The set basic functions include assessment of health status in the geographical area, developing guidelines for actions and assuring some provisions. The assessment includes periodical surveys, monitoring systems and linkages with subsystems and other systems. Assessment of risk factors forms integral part of health assessment in well-developed systems.
SOCIO-CULTURAL AND ECONOMIC INFLUENCE
The history of public health is full of examples illustrating the influence of socio-cultural factors on health. In London in sixteenth century there was tradition to publish Bills of Mortality on weekly basis mostly to know the deaths particularly due to plague. The first bill of mortality was probably published in 1532. This was not a regular feature. The difference between mortality among lower and higher socio-economic class was vividly explained after analysis of Bills in London. John Graunt's a small vendor of sewing articles became the first demographer after publishing his book ‘Natural and Political Observations Made upon the Bills of Mortality (1662 Old Style or 1663 New Style)’. His attempt was towards creating a system of early warning for impending deaths due to plague. Sir Edwin Chadwick in 1842 published his report on, ‘The Sanitary Condition of the Laboring Population’. This report generated local as well national movement which formed basis of and resulted in promulgation of the Public Health Act 1848 in United Kingdom. The Report clearly showed the correlation between the lack of sanitation and high morbidity, mortality and low life expectancy. Similar story happened in United States of America. Lemuel Shattuck an active person in civic affairs and turned into a book seller was appointed as Chair of Commission in Massachusetts. His Report of the Sanitary Commission of Massachusetts published in 1850 was a benchmark in public health. He described very lucidly the appalling status of sanitary conditions existing then. He also gave solid recommendations for improvements. Therefore he is called Architect of American Public Health. In last century, Thomas McKeown a British physician interested in history of medicine aggressively published his opinions from about 1955 to 1980. McKeown argued that the population growth of the United Kingdom post-1700 was due to economic conditions rather than improved medicine and public health.1 This is popularly known as McKeown's thesis. Although vehemently opposed by medical fraternity, his contentions about role of socio-economic status in health and general improvement have been indirectly further expounded in another report. The Black report was a 1980 document published by the Department of Health and Social Security (now the Department of Health) in the United Kingdom. Sir Douglas Black was chairperson of the expert committee into health inequality. The report demonstrated that although overall health had improved since the introduction of the welfare state, there were widespread health inequalities, also found that the main cause of these inequalities was economic inequality. The report showed that the death rate for men in social class V was twice that for men in social class I and that gap between the two was increasing, not reducing as was anticipated.
In India the situation was more complex. Apart from socio-economic classes religion and casts also play major role. In NFHS 3 it was observed that among Jains 86.8% were from highest wealth quintile and only 1.6% were from lowest quintile. Whereas among scheduled tribes 5.2% were from highest wealth quintile and 49.96% were from lowest quintile.2 Considering wealth quintile as proxy of socio-economic classes the class wise disparity in selected health indicators as given in Table 1.1.
The influencing factors may be internal or external. Study of the internal factors is almost exclusively domain of internal medicine. The external influencer can be grouped into physical and social environment. Evolution is a process of adoption to the physical environment. The influence is so powerful that in long run it modifies the genomic spectrum.
The broad term social includes cultural as well as the economical factors. Socio-economic factors are self-created by the community prescribing behaviors in day to day life. Their influences are equally strong to modify health status. The community is having different classes mostly as the product monetary consideration and religion including cast. Cultural factors are mostly generated from traditions in the religion and cast. But they are also influenced by geographic area where most common practices may percolate to other classes. The traditions affect the way of understanding and response to the problem. These factors affect understanding of signs and symptoms of the diseases and relating them some intuitive etiology. Accordingly the responses are based on such understanding. Thus they influence utilization of available health services. The influence on day to day life even may generate health problems. All the traditions are surely not harmful. Leisurely walking after dinner, washing hand and feet returning home and massage with oil to neonates, breastfeeding for one to years are well acknowledged in modern medicine. Refraining eating papaya, eggs in pregnancy is very common practice which needs discouragement. Cultural practices also affect health seeking behavior. In all types of research the minimum age, sex and socio-economic status are the confoundable variables which are always considered.
Public health is solely function of economic system. There is always a competition among social sectors to grab largest pie in the financial allocation. In spite of recommendation of increasing health budget in national health policy, National Rural Health Mission (NHM) there is hardly any change. In Government budget social and community services are given code ‘B’ under revenue expenditure. As the investment in health sector does not generate any revenue, allocation to health is always comprised. About 1% GDP is allocated to public health sector. The overall health expenditure is about 4 to 5% of GDP and contribution of public sector is 20 to 25%.
Need for Public Health Response
The understanding and the redressal mechanisms for improvement in health status are really diverse. Moreover they may not be limited to health department. Apart from health system in the form resources, determinants of health include food supply, safe water supply and sanitation, air pollution. The obvious reflections are high morbidity and mortality due to gastroenteritis and subsequent dehydration due to consumption of contaminated water. Another set of vector borne disease like malaria and dengue are entirely due to mismanagement of stored/accumulated/stagnated collected water bodies. These problems are tackled through public health engineering. In 1972–73 Government of India initiated Accelerated Rural Water Supply Program (ARWSP) to improve the quantity and quality of drinking water supply. Later it was renamed National Drinking Water Mission (NDWM) in 1986. Lastly in 1991, it was again renamed after late Prime Minister of India as Rajiv Gandhi National Drinking Water Mission (RGNDWM). Almost all the states have water and sanitation departments. Safe water supply with widespread use of oral rehydration solution (ORS) has pushed the rank of diarrheal diseases to third or fourth position. Asthma and chronic obstructive pulmonary diseases (COPD) are emerging as leading cause of morbidity and mortality. These problems and solutions are beyond the scope of individualized curative medicine. The two main areas which need actions for overall betterment in health are behavioral communication and demand generation. Demand generation even compels government to device means and strategies for better behavioral communication. Persuasion from committed people directly or through courts sometimes has compelled government to enact health related Acts. Emerging chronic diseases and their complications directly affect productivity. The cost of treatment is very high and in most of the diseases the duration of treatment is long, may be lifelong. Many chronic diseases and their complications can be preventable through public health approach.
DEVELOPMENT OF HEALTH SYSTEM
Health sector planning is an integral part of social-economic development plan in all countries. In India the health sector planning has received inputs from various committees.
The first committee at the time of independence was named as, ‘Health Survey and Development Committee’. The committee was appointed by Government under chairmanship of Sir Joseph Bhore in 1943. The report was submitted in January 1946. The report runs in to four volumes.3
Observations of the Committee
The health status of the community was poor and is reflected in following indicators are as follows:
- Crude death rate 22.4/1000
- IMR 162/1000 live births
- MMR 20/1000 live births
- Life expectancy 27 years
The committee also observed that many of the health problems were preventable. The committee opined that investment in prevention would give high returns, in the form of increased productivity and development. The committee stated that health and development are interdependent. An improvement in the related sectors other than health will certainly lead to improvement in health. The sectors recommended for indirect improvement in health were as follows—housing, communication, water supply, sanitation, improvement in nutrition, elimination of unemployment, improvement in agriculture, industrial production.
- Integration of and curative services at all administrative levels
- Major changes in medical curriculum including 3 months training in preventive and social medicine to prepare social physicians
- Development of health institutions
- Recommended area approach establishing basic health unit as close to the people as possible providing comprehensive services
- Long-term plan
- First tier—75 bedded Primary Health Unit for 10,000–20,000 population, 6 medical officers, 6 public health nurses, 2 sanitary inspectors, 2 health assistants and other support staff
- Second tier—550 bedded Regional Hospital Unit, to serve referral center for 30–40 PHUs
- Third tier—2500 bedded District Health Unit to serve about 3 million population
- Good communication system between PHU, RHU and DHU.
- Short-term plan
- To be implemented in 5–10 years
- Establishment of PHCs for a population of 40,000.
Primary Health Unit was expected to provide preventive, curative and rehabilitative services. The recommended staff for PHU was; 2 medical officers, 2 sanitary inspectors, 5 nurses, 4 midwives and some support staff. It is an important landmark in public health in India. The recommendations initiated concept of integrated development and also comprehensive medicine. Although not implemented, the present three tiers pattern of PHC, RH and DH is based on the recommendations.
Primary Health Care
The next landmark was covenant by many countries including India about Health for All. This theme was based on an international conference at Alma Atta in erstwhile Russia. The consensus was resorting to Primary Health Care approach for seeing objective of Health for All. A working group was formed by Planning Commission in 1980 appointing Secretary Health as chairman to set goals and objectives. The working group fairly evolved specific indices and targets to be achieved in the country by 2000 AD.
National Health Mission
Government of India after thorough assessment of health status in 2005 accepted ‘mission mode’ as redressal mechanism and launched National Rural Health Mission. In 12th plan it was subsumed in National Health Mission. All the national programs are brought under one umbrella. Substantial weightage is given to management. Funds are enhanced and deposited directly in the accounts of state level society. Adequate emphasis has been given to quality aspects by evolving Indian Public Health Standards for different types of health care institutions. Most importantly many systems like Accredited Social Health Activist (ASHA), Village Health Nutrition and Sanitation Committees, Rugna Kalyan Samittees etc. have been initiated. Bottom to top approach for planning incorporating some flexibility is established now. NHM gives special focus on reproductive and child health. Accordingly many new initiatives like Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Rashtriya Bal Suraksha Karyakram (RBSK) have been started.
Policies and Strategies
The constitution had given directive principles, health is a state subject. After 73rd and 74th amendment decentralization and power transfer to local self-governments has taken place remarkably. Government of India can give guidelines particularly about the implementation of national health programs. India responds to most of the international calls particularly from WHO and UNICEF while framing policies and strategies. In all the states the services are almost free and almost to all. Even if the charges are there, they are grossly subsidized. There is nominal fees for registration, investigations, etc. Generally patients needing services under national health programs including Reproductive and Child Health (RCH) services are not charged. Maximum weightage is given to primary health care services through public sector. First National Health Policy was evolved in 1983. Next National Health Policy was framed in 2002 and third policy is in draft stage. Government has sought comments from public on the draft health policy. Some goals were set in NHP 2002 and infrastructure development and increase in budget was envisaged.4 In the same year National Policy on Indian Systems of Medicine and Homoeopathy (ISM&H) was also pronounced. Even before advent of NHM government always supported Non-Government Organizations (NGOs). All the policy documents mention involvement of NGOs. The most favorite areas for NGOs are family planning, leprosy and HIV/AIDS. Generally these policy documents clear guidelines of infrastructure development in rural areas. Hence in rural areas across the country there is uniformity in institutions.
Urban area has been only considered seriously in 12th Plan. In 12th Plan concept of Universal Health Coverage has been extensively deliberated. It is recommended that states may start Universal Health Coverage first as project in limited geographical areas and then extend gradually. The recommended norms for establishing institutions are given in Table 1.2.
The budget for various levels of care recommended by NHP is shown in Figure 1.1. The policy also recommended that share of health department should be 8% of total budget. Most of the states lag far behind. It also recommends that central share in public health expenditure should be around 25%.
Private sector is strong in India and there no strict regulations for monitoring the performance or fees structure. Clinical Establishment Act 2010 has invoked only by nine states/union territories. Similarly National Pharmaceutical Pricing Authority time to times issues Drug Price Control Orders (DPCO) under Essential Commodities Act, 1955, announcing maximum price for selected essential and lifesaving medicines. However the resources with Food and Drug Administration limit the effective implementation of the orders.
The epidemiological transition has compelled government to divert attention towards non-communicable diseases and conditions. National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in 2010–11.
The decisions to formulate policies, strategies are taken at highest level in Delhi or state capitals. The Central Council of Health and Family Welfare is the apex body consisting of Union Health Minister and Health Ministers from all the states with their secretaries. The council meets once in two years to formulate policies and strategies. Generally heterogeneous group consisting of people's representatives, administrators and senior technical experts evolve and shape the policies. The dissemination is executed in the form of resolutions, orders or gazettes from the Government. Generally vulnerable sections find some place in these guidelines.
India is a federation of 29 states and 7 territories. States are largely functioning independently usually following guidelines given by central government. There are multiple systems of medicine apart from modern medicine which is generally termed as Allopathy. The parallel systems under National Health Mission are grouped under AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy). India has mix health system private and public.
Health and Family Welfare ministry has separate wings for Family Welfare, Health Services, National AIDS Control division and National Health Mission. There is separate department for AYUSH and Medical Research. Cabinet and State Ministers are elected representatives from some political parties.
Fig. 1.2: Organogram of Health and Family Welfare Ministry, Government of IndiaSource: Adopted from website of Ministry of Health and Family Welfare, Government of India
The secretary and his administrative colleagues are from Indian Administrative Services. Directorate General is the executive technical wing headed by senior technical person but not necessarily from Public Health. Food Drug Administration is theoretically under Directorate General of Health Services. The organogram of ministry is given in Figure 1.2. The organogram of Directorate General of Health Services pertaining to technical wing is given in Figures 1.3 and 1.4. The Directorate General of Health Services also supervises various national programs. Each program usually is headed by an officer of the rank of Deputy Directorate General of Health Services. Similar arrangement exists in state governments. In most of the states medical education and health services are different departments which may be headed by one minister or two different ministers. In some states the in-charge of is called as Director of Health Services and in some states Director General of Health Services. In states like Gujarat, Madhya Pradesh Director is replaced by Commissioner, an administrative officer.
As per the norms for health care institutions are spread over in all the states. The subcenter is the most peripheral public sector institution manned by one female and male health worker. The female health worker Auxiliary Nurse Midwife (ANM) is trained in midwifery to enable her to conduct deliveries in subcenter.
Fig. 1.3: Organization chart of Directorate General of Health Services (Technical Matters)Source: Adopted from website of Ministry of Health and Family Welfare, Government of India
Fig. 1.4: Organization chart of Directorate General of Health Services (Technical Matters)Source: Adopted from website of Ministry of Health and Family Welfare, Government of India
The ANM is the real backbone of public sector services. In many subcenters after advent of NHM second ANM on contractual basis is also functioning. The next level is primary health center which manned by about 15 personnel and headed by a medical officer. Some medical officers are from AYUSH background. Almost all primary health care needs can be satisfied in these two types of institutions. Subcenter and primary health center have area concept in their development; the institutions are responsible for the health of the population in the designated area. The secondary level care is partly given by Community Health Centers and District Hospitals. Some rural hospitals considering the work load and location have been upgraded to subdistrict hospitals where the number of specialists increases from three to five/eight. The minimum bed strength in district general hospital is 200. The civil surgeon is overall in-charge of curative and administrative field. In Maharashtra community health centers are called Rural Hospitals and are brought under civil surgeon. Specialists’ services are available in these institutions. However there is acute shortage of specialists. Tertiary care is usually offered by medical colleges. In rural area the District Health Officer is overall in-charge. The Panchayat Raj System is well developed in rural area. Three tier system of Panchayat Raj exits in the form of Zilla Parishad, Panchayat Sammitte and Gram Panchayat. Parallel to this system in health, there is District Health Officer and Taluka Health Officer.
Although not a public sector functionary in each village Accredited Social Health Activists are playing major role of bridging gap between community and public health functionaries. The lady is resident of the village in reproductive age group and having schooling completed. She performs dual role. She is with the community for demanding regular and quality services from health personnel. She is with health personnel to peruse people to seek the available services. She is voluntary worker but gets some financial benefits based upon her performance. After selection ASHAs receive modular training for seven different aspect of health. More than nine lakhs ASHAs are functioning in the country.
HEALTH INFORMATION SYSTEM
Direct health information in details is available from health institutions. A large chunk of that information is collected through Health/Hospital Management Information System (HMIS). The hospitals also have their own HMIS. The National Programs were having and still have their own management health system and which still continue. Now as almost all the national programs are brought under single umbrella of National Health Mission since 2005 a unified HMIS across the country has been started. All the programs under national health mission are covered in Health Management Information System. The identification of indicators for monitoring is the crucial stage. Like objective the indicators should also be Specific, Measurable, Assignable, Realistic and Time-bound (SMART). Usually quantitative indictors are selected excepting exist interviews for quality assessment in hospitals. Steps involved in structuring or restructuring of HMIS can be summarized as follows:
Step 1: Identifying information needs and feasible indicators
Step 2: Defining data sources and developing data collection instruments for each of the indicators selected
Step 3: Developing a data transmission and processing system
Step 4: Ensuring use of the information generated
Step 5: Planning for HMIS resources
Step 6: Developing a set of organizational rules for health information system management.
While designing the HMIS some quality checks including validity are incorporated. The NHM present HMIS has 30 validity rules while monthly data are being entered.5 Any values of indicator X which cannot have value more than Y indicator is not accepted. For each indicator as validity measure outlier figures are also confirmed. HMIS monitors 255 indicators and many attributes from 17 major groups. Presently district wise information is available on the website of National Health Mission.5 Most of the hospitals both from public and private sector also have their own HMIS. Hospital generally requires slightly different information like Bed Occupancy Rate, Bed Turnover Rate, Average Length of Stay, Mortality, Turn-Around Time for Investigations, Down Time for Critical Equipment's, mortality rates, stocks of material supplies, financial indicators, etc.
Civil Registration System6
Apart from HMIS health related data is also generated through non-institutional sources. Some of the systems are briefly described here. Statistics about birth and deaths is collected by Registrar General Government of India. Although registration of births and deaths is mandatory under Registration of Births and Deaths Act 1969, the actual registration is far from satisfactory. This continuous system of registration of births and deaths is called Civil Registration System. Latest level of birth registration in year 2013 is about 85.6%, and death registration about 70.9% (Office of the Registrar General). Over and above this most of the countries conduct National Level Health Surveys. Surveys with specific objectives like measuring incidence of tuberculosis are intermittently conducted. In India following surveys and systems collect health pertaining information regularly conducted.
Sample Registration System6
Although birth and death are vital events in the community the registration is not hundred percent. In many states it is even less than 75%. Therefore Office of Registrar General, India, in 1964–65 started a system of collecting information on births and deaths through samples on pilot basis. Encouraged by the results the Sample Registration System (SRS) was extended across the country in 1969–70. The system has two phases; in first phase a part time enumerator collects information about births and deaths in the sampled units. Then a full time supervisor independently and six monthly confirms the events. The discrepancy if any is verified. Since 2014 a total of 8,861 are covered under the scheme. The details are given in Table 1.3. The statistics generated through SRS is considered the most valid information about vital events in India hence it is extensively used in planning and research.
National Family Health Survey2
In the absence reliable data about population health indicators, in most of the countries National Level surveys are conducted to generate the desired information. In India it named as National Family Health Survey (NFHS). It is a multi-round survey conducted across the country in a representative sample of households. For conduction of NFHS International Institute for Population Sciences (IIPS) is the nodal agency. NFHS receives financial support from international agencies. The first National Family Health Survey (NFHS-1) was conducted in 1992–93. The second was conducted in 1998–99 in 26 states of India. The third round was carried out in 2005–06 in 29 states. Fourth National Family Health Survey (NFHS-4) was recently carried out in 2014–15. The fourth round in addition to the 29 states included all six union territories for the first time. The most important feature is that it providing estimates of most indicators at the district level.
District Level Household Survey7
These surveys collect slightly different information then NFHS. The only difference was this system was giving district wise information. The first survey in this series was carried out in 1998–99. This was the only reliably valid data in public domain at district level. In addition the survey included assessment of public health institutions. In fact it is named as District Level Household and Facility Survey. The fourth round was conducted in 2012–13.
Annual Health Survey6
Annual Health Surveys have been started by Government of India 284 districts in nine states (eight Empowered Action Group and Assam). The single most reason for selection of these states was the extent of scope. These states have about 50% of India's population and have high birth and death rates. Reliable information for district level was not available. Total population covered is 1.82 crore constituting 36 lakhs households. The mean households covered per district are about 13 thousands. There are 20,694 sampling units; villages in rural areas and census enumeration blocks in urban areas.
Medically Certified Cause of Death (MCCD)6
The health care institutions are giving death certificate to relatives of deceased persons with mention of cause of death. Similarly even if the death occurs in home, the physician attending to the deceased fills the requisite form. A copy of the certificate is submitted to the Local Registrar of Birth and Deaths. This is in accordance with Registration of Birth and Death Act 1969. The statistics generated is of good quality as it is filled by a qualified doctor. But the compliance was not satisfactory. Only about 20% of reported deaths appear in the system. Hence from year 2014 submission of reports has been made mandatory to all health care institutions including from private sector. The sole purpose is generating statistics as per International Classification of Diseases, so that the data becomes comparable.
Some communitization mechanisms have been mentioned in National Health Mission. Community action has been built on two pillar concepts; people have right to health and health is significantly affected by social determinants. It is always envisaged that the people and communities will be active involved in the achievement of health. Community actions improve the access and quality of health services. The process passes through tackling social determinants of health. Nationally and internationally many women group are active particularly about Reproductive and Sexual Health and Rights. The pilot project of Community Based Monitoring which was launched in initial phase of NHM is well established now. This ambitious project was launched in 2007. This is a very large project implemented nine states (Assam, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Rajasthan and Tamil Nadu). In each state three to five districts are selected. The project is implemented by state level non-NGOs with the help of field level NGOs. The CBM is built on NHM structures like Village Health Sanitation Nutrition Committees and Rogi Kalyan Samiti (RKS), and having one or few representatives from the concerned NGOs. The NGOs have frequent dialogues including Jan Sunwai with health care system. They monitor and prepare report card for functioning of Primary Health Center. Presently CBM is covering 25 states.
NGOs like Centre for Enquiry into Health and Allied Themes (CEHAT), Mahila Sarvangeen Utkarsh Mandal (MASUM) and Dr Sabu George working in gender equality issues were worried by the declining child sex ratio in India and particularly in Maharashtra. They filed one Public Interest Litigation (PIL) in Supreme Court and thus were instrumental in finalizing the amendments in the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act. Similarly responding to another PIL by Ramadan Ray in an order Supreme Court directed Government of India to frame insurance scheme for unfortunate fatalities during or after sterilization operations and improve quality of services by way of formulating guidelines about operating procedures and quality assurance committees.
HEALTH RESEARCH AND TECHNOLOGY
Health and medical field have not only very vast scope but also experience fast expansion. Indian Council of Medical Research (ICMR) is the apex body for conducting and encouraging health/medical research in India. It had its roots in the erstwhile Indian Research Fund Association (IRFA) established in 1911. After independence in 1949 it was renamed as ICMR. The Government of India envisages role of coordinating and funding medical research in the country. It is headed by Director General and many scientists of different cadres. The post of Director General ICMR has been upgraded to secretary health research. It has institutions working dedicated towards important aspects in health research. National Institute of Virology, National AIDS Research Institute, National Institute of Malaria Research, National Institute of Nutrition, etc. are cherished internationally. ICMR offers grants to research proposals from individuals as well as institutions. Under graduate as well postgraduate students are also given grants for small projects under Short Term Research Studentship program and thesis support scheme. The focus areas include use of biotechnology, genetics, etc. Recently Department of Health Research (DHR) has been established under ICMR exclusively to promote health care or services. Health system research has been identified as one the priority areas. It has many collaborative projects with international institutions conducting research. The thrust areas are listed here:
- Communicable Diseases
- Tribal Health
- Reproductive and Child Health
- Non-Communicable Diseases
- Basic Medical Sciences
- Traditional Medicine
The horrible stories of torture under the disguise of research after Second World War and then the Tuskegee syphilis experiment in USA were highly criticized across the globe. As humanly response various codes of conduct of medical research have been formulated. The first was Nuremberg Code consisting of ten points. The Belmont report is a classical document guiding ethical issues. The report lucidly deliberates on three principles—respect for persons, beneficence and justice. In India also ICMR has issued guidelines for conducting biomedical research. The basic principles remain the same. In Ethical guidelines for Biomedical Research on Human Participants published in 2006 following twelve principles have been described.8
- Principles of essentiality
- Principles of voluntariness, informed consent and community agreement
- Principles of non-exploitation
- Principles of privacy and confidentiality
- Principles of precaution and risk minimization
- Principles of professional competence
- Principles of the maximization of the public interest and of distributive justice
- Principles of institutional arrangements
- Principles of public domain
- Principles of totality of responsibility
- Principles of compliance
ICMR as well as Central Drugs Standard Control Organization have given guidelines about ethics committee. Registration of all ethics committee is mandatory from 8th February 2013.9 Similarly all clinical trials must be registered. This decision was necessary to avoid about 500 deaths each year due to clinical trials.10
IDENTIFICATION OF ISSUE
Past experiences and literature exploration adequately define and describe the health problems in the community. But the usual systems of collecting health data like HMIS may not provide in depth information. In such circumstances larger surveys are planned and conducted. Many projects resort to surveys to study the desired variables. The national level surveys are described in brief above. Although health indicators like IMR, MMR are declining there is wide statewise gap and many states have unacceptably high rates. Even within the states generally tribal areas, slum population, the indicators are unfavorable. Malnutrition among children and anemia among women particularly pregnant women is about 50% and there are no signs of any decline. Diseases like pneumonia and diarrhea continue to take their toll in child population. Non communicable diseases like coronary artery disease, cerebrovascular stroke, depression, cancer, chronic obstructive pulmonary disease/asthma, etc. are increasing rapidly. The cost of treatment is increasing and many families find it difficult to afford medical care particularly in private sector which is poorly regularized. The total fertility is still high in Empowered Action Group (EAG) states adding to total population. In the total population of India geriatric population is increasing and child sex ration is declining. There is acute shortage of trained manpower and other resources including required budgetary provision.
Modes of Survey
Survey is non-interventional method of collecting detailed information which in generally not easily available from a comparatively larger population. While conducting survey the selection of the individual subjects from the population is a critical issue and standard statistical methods and formulas are used for estimation of sample size. Most of the surveys are observational and sometimes analytical. Census which is carried out every ten years is probably largest face to face carried out survey. Paper and Pencil Interviews (PAPI) is speedily decreasing and Computer Assisted Personal Interviews (CAPI) or Tablet Assisted Personal Interviews are in vogue. These methods avoid use of paper, time-saving and easier for analysis. The way of interaction has changed and has been made easy but the art of preparing questionnaire still requires thorough homework. In the context of literacy and willingness to participate schedule is used more frequently than questionnaire which expects people to fill the proforma. Both schedule and questionnaire may be structured (in a sequence) or unstructured and the responses may be close ended (designed choices) or open ended.11 For yield of standard scientific information the planning and implementation of the survey must rigorously follow the necessary steps. The survey instrument is usually tested for different types of validities. Whenever more than one person is involved inter-observer as intra-observer reliability needs to be minimized. Apart from face to face interviews telephone and web interviews are also in vogue; each method has its advantages and disadvantages.12
Planning and Implementation
All the information generate through census, HMIS, all types of national level surveys, estimates from national and international agencies is assessed and made use directly or indirectly in national level planning. In India Five Year Planning has been accepted as the major system to bring change. Presently 12th plan is in operation. Plan document deliberate existing situation, review last plan's performance and decide national level goals and objectives. In January 2015 Planning Commission was dissolved and National Institute for Transformation of India (NITI) Aayog was established. Prime Minister is Chairman of NITY Aayog. Apart from elected representatives subject experts are members of NITY Aayog. Health sector along with education is grouped under social sector. The states have Planning Boards which work with close liaison with planning department. The chairperson is Chief Minister and Executive Chairperson is political appointment. The state boards were formed in 1972 and reconstituted in 1995. District Planning District Planning Committees (DPC) constituted as per article 243 ZD of 74th Amendment of the Constitution. The District Planning Committee consolidates the plans prepared by the Panchayats and the Municipalities in the district and prepares a draft development plan for the district as a whole. The total number of members is proportionate to population but 4/5 are elected members. The planning as well implementation under NHM has been shifted to District Level Society.
Education and Training
Medical and allied sciences education is governed by constitutional bodies. For medical education there is Medical Council of India. Central Council for Indian Medicine governs systems like Ayurveda, Unani, Sidha and Sowa Rigpa. Homeopathy has a separate council. For dental education Dental Council of India takes the leading role. Similarly nursing education is governed by Indian Nursing Council. There is no separate council for physiotherapy and occupational therapy and professional associations develop guidelines and generally they are accepted. These are autonomous bodies. The members mostly elected persons and few are nominated. The President is elected among members. The foremost objective is to maintain consistently acceptable quality of medical education for postgraduate as well as undergraduate. It includes curriculum, manpower, infrastructure and the existence is confirmed by inspections; then only recognition is awarded to institution and qualification. The regulations are stringent but lately the role of MCI has become controversial due to alleged malpractices by the body. Similar objectives and systems have laid down for other councils.
Postgraduation in Public Health or Community Medicine is available in most of the medical colleges. Education in Public Health has percolated from doctors to non-doctors particularly from other systems of medicine and biological sciences. One of the reasons is students are more attracted to clinical specialties and later superspecialties. The earnings from these branches far exceed than public health in private sector. Some states including Maharashtra, Tamil Nadu, etc. have public health cadre; in these states public health specialties are preferred for senior administrative post. There are many institutions imparting education in public health like All India Institute of Health and Hygiene, Kolkata, National Institute of Health and Family Welfare (NIHFW), Delhi, etc. Public Health Foundation of India, Indian Institute of Health Management and Research, Jaipur, Tata Institute of Social Sciences, Shree Chitra Tirunal Institute of Medical Sciences, etc. offer public health qualifications which are not under the purview of MCI. All these institutions are also carrying out short-term trainings. NIHFW is the apex institute in public sector for conducting tailor-made training courses for government of officers. On similar lines most of the states have State Health and Family Welfare Training Centers. At regional levels they are named as Health and Family Welfare Training Centers (HFWTC). HFWTC mostly train medical officers, senior paramedicals and also conduct basic training courses for male multi-purpose workers. In most of the states there are District Training Centers and District Training Teams which conduct routine training for male and female health workers.
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Globally, 14.2 million people die prematurely every year from non-communicable diseases (NCDs) between 30 and 69 years of age. About 86% of these premature deaths from NCDs occur in developing countries. Deaths due to communicable diseases, maternal, perinatal conditions and nutritional deficiencies accounted for 27.2% of all deaths in 2008 (Table 1.1). It is projected that in the year 2030, this proportion would shrink to just 13.8%. NCDs on the other hand would rise from 63.2 to 76.1% in the same year. While deaths due to cancer, heart diseases and stroke will increase, deaths due to communicable diseases, perinatal conditions and injuries will reduce during the next 15 years.
NCD BURDEN IN INDIA
India is also going through a time bomb of chronic non-communicable diseases epidemic at present, with over 60% of the deaths in the country already attributable to non-communicable diseases, particularly the four biggest killers, namely cardiovascular diseases, diabetes, cancer and chronic obstructive lung diseases. The picture is worsening fast as evident in the Figure 1.1.
While the nation's priorities in terms of other longstanding health problems such as maternal and child health as well as various communicable diseases, have shown significant decline over the last two decades, there still seems to be a long way to go and the government has been consistently focusing on the challenges posing them. However, it also realizes that India is running against time in combating large epidemics of various chronic illnesses in the coming years due to an increasing lifespan besides rapid changes in lifestyle and the physical environment owing to economic progress and urbanization.
A WHO report has suggested that India is projected to spend $237 billion (1.5% of the GDP) as a result of heart disease, stroke and diabetes from 2005 to 2015. A World Economic Forum report (2014) reported that India is expected to lose $4.58 trillion before 2030 from expenses in the care for NCDs and mental health conditions. Of this, $2.17 trillion is expected to be consumed by cardiovascular diseases alone.
Fig. 1.1: Proportional mortality in India (% of all deaths, all ages, both sexes)Source: WHO NCD Country profiles
REASONS FOR RISE IN NCDS (TABLE 1.2)
Increase in life expectancy and unhealthy lifestyle behavior are two main reasons for this epidemiological transition. Tobacco use, both smoking and smokeless forms, unhealthy diet rich in salt, sugar and saturated/trans-fats, physical inactivity and alcohol use are key risk factors associated with this trend. Increasing levels of air pollution and mental stress have also been attributable to this trend.
RESPONSE TO THREAT OF NCDS IN INDIA
National response to NCD epidemic has been praiseworthy in recent times, though far from adequate, given the magnitude of the burden and the challenges in its control. A National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke was launched by the Ministry of Health and Family Welfare in 100 select districts in 21 states in 2010–11 and being expanded to all the districts in a phased manner. Key strategies of the program include health promotion for healthy lifestyles to reduce exposure to risk factors, early diagnosis through periodic/opportunistic screening of population and better diagnostic facilities, infrastructure development for management of NCDs, capacity building of human resources in public health facilities, facilitating rapid referral in medical emergencies (e.g. heart attack and stroke) to reduce mortality and providing treatment to persons with NCDs including rehabilitation and palliative care.
The government is also planning to introduce population-based interventions wherever applicable through multi-sectoral approach.
Long Term Targets
The Ministry of Health and Family Welfare has also prepared a monitoring framework to prevent and control NCDs and their risk factors by the year 2025 with some goals as shown in Table 1.3.
The Way Forward
To achieve these targets, it would be necessary to introduce healthy public policies, involve whole of Government, rope in Government, NGO and Private health sector and have massive campaign to make people realize to imbibe healthy lifestyle consisting of healthy and balanced diet, being physically active and abstain from use of alcohol and tobacco. Population-based intervention would require subsidies for healthy option, raising taxes on unhealthy food, tobacco and alcohol, controlling air pollution, providing clean energy in rural areas and bringing up children and adolescents in healthy lifestyles. Government should also realize that investment on health promotion and prevention and capacity building to manage NCDs will be cost-effective in the long run by means of averting premature deaths and disability in the productive age group and reducing out-of-pocket expenditure on these chronic diseases.
- ♦ World Health Organization: www.who.int/mediacentre/factsheets/fs310/en/index1.html
- ♦ World Health Organization: www.who.int/nmh/publications/ncd-profiles-2014
- ♦ Harvard Initiative for Global Health 2013. The Economic Impact of Non-communicable Diseases in China and India: Estimates, Projections and Comparisons. http://www.hsph.harvard.edu/pgda/WorkingPapers/2013/PGDA_WP_107.pdf
- ♦ World Health Organization: www.who.int/gho/publications/world_health_statistics/2012