Health has been declared a fundamental human right. This implies that the State has a responsibility for the health of its people. National governments all over the world are striving to expand and improve their health care services. The current criticism against health care services is that they are (a) predominantly urban-oriented (b) mostly curative in nature, and (c) accessible mainly to a small part of the population. The present concern in both developed and developing countries is not only to reach the whole population with adequate health care services, but also to secure an acceptable level of Health for All, through the application of primary health care programmes.
Concept of health care
Since health is influenced by a number of factors such as adequate food, housing, basic sanitation, healthy lifestyles, protection against environmental hazards and communicable diseases, the frontiers of health extend beyond the narrow limits of medical care. It is thus clear that "health care" implies more than "medical care". It embraces a multitude of "services provided to individuals or communities by agents of the health services or professions, for the purpose of promoting, maintaining, monitoring, or restoring health" (1). The term "medical care" is not synonymous with "health care". It refers chiefly to those personal services that are provided directly by physicians or rendered as the result of physicians's instructions. It ranges from domiciliary care to resident hospital care. Medical care is a subset of health care system.
Health care is a public right, and it is the responsibility of governments to provide this care to all people in equal measure. These principles have been recognized by nearly all governments of the world and enshrined in their respective constitutions. In India, health care is completely or largely a governmental function.
Health system
Health services are designed to meet the health needs of the community through the use of available knowledge and resources. It is not possible to define a fixed role for health services when the socio-economic pattern of one country differs so much from another. The health services are delivered by the "health system", which constitutes the management sector and involves organisational matters.
Two major themes have emerged in recent years in the delivery of health services: (a) First, that health services should be organised to meet the needs of entire populations and not merely selected groups. Health services should
cover the full range of preventive, curative and rehabilitation social services of a country (2); (b) Secondly, it is now full realised that the best way to provide health care to the vas majority of underserved rural people and urban poor is to develop effective "primary health care" services supported by an appropriate referral system. The social policy throughout the world was to build up health systems based on primary health care, towards the policy objective t Health for All by 2000 A.D.
Community participation is now recognized as a major component in the approach to the whole system of health care treatment, promotion and prevention esison the provision of these services to the people representing a shift from medical care to health care and from urban population to rural population.
Levels of health care
It is customary to describe health care service at 3 levels, viz. primary, secondary and tertiary care levels. These levels represent different types of care involving varying degrees of complexity.
1. Primary care level
It is the first level of contact of individuals, the family and community with the national health system, where "primary health care". ("essential" health care) is provided. As a level of care, it is close to the people, where most of their health problems can be dealt with and resolved. It is at this level that health care will be most effective within the context of the area's needs and limitations (3).
In the Indian context, primary health care is provided by the complex of primary health centres and their subcentres through the agency of multipurpose health workers, ANM, ASHA, Anganwadi worker, village health guides and trained dais. Besides providing primary health care, the village "health teams" bridge the cultural and communication gap between the rural people and organised health sector. Since India opted for "Health for All" by 2000 AD, the primary health care system has been reorganized and strengthened to make the primary health care delivery system more effective.
2. Secondary care level
The next higher level of care is the secondary (intermediate) health care level. At this level more complex problems are dealt with. In India, this kind of care is generally provided in district hospitals and community health centres which also serve as the first referral level (4).
3. Tertiary care level
The tertiary level is a more specialized level than secondary care level and requires specific facilities and (5) This care provided by the regional or central level institutions, ed. Medical College Hospitals. All India Institutes, Regional Hospitals, Specialized Hospitals and other Apex Institutions
A fundamental and necessary function of health care system is to provide a sound referral system. It must be a two way exchange of information and returning patients to those who referred them for follow-up care (6) It will ensure continuity of care and inspire confidence of the consumer in the system For a large majority of developing countries (including India) this aspect of the health system remains very weak.
Changing concepts
With political independence, there was a national commitment to improve health in developing countries. Against this background different approaches to providing health care came into existence. These are:
1. Comprehensive health care
The term "comprehensive health care" was first used by the Bhore Committee in 1946. By comprehensive services, the Bhore committee meant provision of integrated preventive, curative and promotional health services from womb to tomb to every individual residing in a defined geographic area. The Bhore Committee defined. comprehensive health care as having the following criteria:
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(a) provide adequate preventive, curative and promotive health services;
(b) be as close to the beneficiaries as possible;
(c) has the widest cooperation between the people, the service and the profession,
(d) is available to all irrespective of their ability to pay:
(e) look after specifically the vulnerable and weaker sections of the community; and
(f) create and maintain a healthy environment both in homes as well as working places.
The Bhore Committee suggested that comprehensive health care should replace the policy of providing more medical care. This concept formed the basis of national health planning in India and led to the establishment of a network of primary health centres and sub-centres.
The Government of India, during the successive 5 year plans has built up a vast infrastructure of rural health services based on primary health centres and subcentres. However, experience during the past 60 years has indicated hat the primary health centres were not able to effectively cover the whole population under their jurisdiction, and Their sphere of service did not extend beyond a 2-5 km radius. These facilities often did not enjoy the confidence of the people because they were understaffed and poorly applied with medicines and equipment; as a result, there Jas growing dissatisfaction with the delivery of health services.
2. Basic health services
In 1965, the term "basic health services" was used by NICEF/WHO in their joint health policy (7). They defined me term as follows "A basic health service is understood to e a network of coordinated, peripheral and intermediate health units capable of performing effectively a selected group of functions essential to the health of an area and assuring the availability of competent professional and auxiliary personnel to perform these functions.
The change in terminology from comprehensive to basic health services did not affect materially the quality of content of health services The handicaps or drawbacks of the basic health services are those shared by the comprehensive health care services, vie, lack of community participation, lack of intersectoral coordination and dissociation from the socio-economic aspects of health.
3. Primary health care
A new approach to health care came into existence in 1978, following an international conference at Alma-Ata (USSR) This is known as "primary health care It has all the hallmarks of a primary health care delivery, first proposed by the Bhore Committee in 1946 and now espoused worldwide by international agencies and national governments (8)
Before Alma-Ata, primary health care was regarded as synonymous with "basic health services", "first contact care" "easily accessible care", "services provided by generalists", etc. The Alma-Ata international conference gave primary health care a wider meaning. The Alma-Ata Conference defined primary health care as follows (9)-
"Primary health care is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford"
The primary health care is equally valid for all countries from the most to the least developed, although it takes varying forms in each of them. The concept of primary health care has been accepted by all countries as the key to the attainment of Health for All by 2000 AD. It has also been accepted as an integral part of the country's health system.
Elements of primary health care
Although specific services provided will vary in different countries and communities, the Alma-Ata Declaration has outlined 8 essential components of primary health care (9). 1. education concerning prevailing health problems and the methods of preventing and controlling them: 2. promotion of food supply and proper nutrition; 3. an adequate supply of safe water and basic sanitation; 4. maternal and child health care, including family planning: 5. immunization against major infectious diseases; 6. prevention and control of locally endemic diseases; 7. appropriate treatment of common diseases and injuries; and 8. provision of essential drugs.
Principles of primary health care
1. Equitable distribution
The first key principle in the primary health care strategy is equity or equitable distribution of health services, i.e., health services must be shared equally by all people irrespective of their ability to pay, and all (rich or poor, urban or rural) must have access to health services. At present, health services are mainly concentrated in the major towns and cities resulting in inequality of care to the people in rural areas. The worst hit are the needy and vulnerable groups of the population in rural areas and urban slums. This has been termed as social injustice. The failure to reach the majority of the people is usually due to inaccessibility. Primary health care aims to redress this imbalance by shifting the centre of gravity of the health care system from cities (where three-quarters of the health budget is spent) to the rural areas (where three-quarters of the people live), and bring these services as near people's homes as possible.
2. Community participation
Notwithstanding the overall responsibility of the Central and State Governments, the involvement of individuals, families, and communities in promotion of their own health and welfare, is an essential ingredient of primary health care. Countries are now conscious of the fact that universal coverage by primary health care cannot be achieved without the involvement of the local community. There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services, besides maximum reliance on local resources such as manpower, money and materials. In short, primary health care must be built on the principle of community participation (or involvement).
One approach that has been tried successfully in India is the use of village health guides and trained dais. They are selected by the local community and trained locally in the delivery of primary health care to the community they belong, free of charge. By overcoming cultural and communication barriers, they provide primary health care in ways that are acceptable to the community. It is now considered that ASHA and Anganwadi workers are an essential feature of primary health care in India. These concepts are revolutionary. They have been greatly influenced by experience in China where community participation in the form of bare-foot doctors took place on an unprecedented scale.
3. Intersectoral coordination
There is an increasing realization of the fact that the components of primary health care cannot be provided by the health sector alone. The Declaration of Alma-Ata states that "primary health care involves in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communication and others sectors" (9). To achieve such cooperation, countries may have to review their administrative system, reallocate their resources and introduce suitable legislation to ensure that coordination can take place. This requires strong political will to translate values into action. An important element of intersectoral approach is planning-planning with other sectors to avoid unnecessary duplication of activities.
4. Appropriate technology
Appropriate technology has been defined as "technology hat is scientifically sound, adaptable to local needs, and acceptable to those who apply it and those for whom it is used, and that can be maintained by the people themselves keeping with the principle of self-reliance with the resources the community and country can afford" (10). The term "appropriate" is emphasized because in some countries, large, luxurious hospitals that are totally Inappropriate to the local needs, are built which absorbs major part of the national health budget, effectively blocking any improvement in general health services. This also applies to using costly equipment, procedures and techniques when cheaper, scientifically valid and acceptable ones are available, viz, oral rehydration fluid, standpipes which are socially acceptable, and financially more feasible than house-to-house connections, etc.
It will be seen from the above discussion that primary care is qualitatively a different approach to deal with the It will be seen from the above discussion that primary health problems of a community. Unlike the previous approaches (e.g. basic health services, integrated health care, vertical health services) which depended upon taking care approach starts with the people themselves. This health services to the doors of the people, primary health approach signifies a new dynamism in health care and has been described as Health by the people, placing people's health in people's hands (11). The ends of the primary health care approach are the same as those of earlier approaches (Le., attainment of an acceptable level of health by every individual), but the means adopted are different (12), that is, more equitable distribution and nation-wide coverage, more intersectoral coordination and more community involvement in health related matters. In short, primary health care goes beyond the conventional health services. It forms part of the larger concept of Human Resources and Development.
HEALTH FOR ALL
In 1977, it was decided in the World Health Assembly to launch a movement known as "Health for All by the year 2000". The fundamental principle of HFA strategy is equity, that is, an equal health status for people and countries, ensured by an equitable distribution of health resources. The Member countries of WHO at the 30th World Health Assembly defined Health for All as : "attainment of a level of health that will enable every individual to lead a socially and economically productive life."
In 1978, the Alma-Ata International conference on Primary Health Care reaffirmed Health for All as the major social goal of governments, and stated that the best approach to achieve the goal of HFA is by providing primary health care, especially to the vast majority of underserved rural people and urban poor. It was envisaged that by the year 2000, at least essential health care should be accessible to all individuals and families in an acceptable and affordable way, with their full participation. The Alma-Ata Conference called on all governments to formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a national health system. It is left to each country to develop its norms and indicators for providing primary health care according to its own circumstances. In 1981, a global strategy for HFA was evolved by WHO (13). The global strategy provides a global framework that is broad enough to apply to all Member States and flexible enough to be adapted to national and regional variations of conditions and requirements. This was followed by individual countries developing their own strategies for achieving HFA, and synthesis of national strategies for developing regional strategies. The WHO has established 12 global indicators (13) as the basic point of reference for assessing the progress towards HFA, as for example, a minimum life expectancy of 60 years and maximum IMR of 50 per 1000 live births.
National strategy for HFA/2000
As a signatory to the Alma Ata Declaration in 1978, the provide HEA to its citizens bu 2000 AD. In pursuance of this objective various attempts were made to evolve suitable strategies and approaches. In this connection two important reports appeared (1) Report of the Study Group on "Health for All an alternative strategy", sponsored by ICSSR and ICMR. and (ii) Report of the Working Group on "Health for All by 2000 AD sponsored by the Ministry of Health and Family Welfare, Government of India (14, 15). Both the groups considered in great detail the various issues involved in providing primary health care in the Indian context. These reports formed the basis of the National Health Policy formulated by the Ministry of Health and Family Welfare, Government of India in 1983 (16) which committed the Government and people of India to the achievement of HFA.
The National Health Policy echoes the WHO call for HFA and the Alma-Ata Declaration. It had laid down specific goals in respect of the various health indicators by different dates such as 1990 and 2000 AD. Foremost among the goals to be achieved by 2000 AD were: (1) Reduction of infant mortality from the level of 125 (1978) to below 60. (2) To raise the expectation of life at birth from the level of 52 years to 64. (3) To reduce the crude death rate from the level of 14 per 1000 population to 9 per 1000. (4) To reduce the crude birth rate from the level of 33 per 1000 population to 21. (5) To achieve a net reproduction rate of one. (6) To provide potable water to the entire rural population.
THE MILLENNIUM DEVELOPMENT GOALS
During September 2000, representatives from 189 countries met at the Millennium Summit in New York, to adopt the United Nations Millennium Declaration. The goals in the area of development and poverty eradication are now widely referred to as "Millennium Development Goals" (MDGs). The MDGs placed health at the heart of development and represent commitments by governments throughout the world to do more to reduce poverty and hunger and to tackle ill-health; gender inequality; lack of education; access to clean water; and environmental degradation. They were an integral part of the road map towards the implementation of the UN Millennium Declaration. Three of the 8 goals, 8 of the 18 targets required to achieve them, and 18 of the 48 indicators of progress, were health related. They assist in the development of national policies focussing on poor, and help track the performance of health programmes and systems. Although, the MDGs do not cover the whole range of public health domains, a broad interpretation of the goals provides an opportunity to tackle important cross cutting issues and key constraints to health and development. Governments had set a date of 2015 by which they would meet the MDGs, i.e, eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality, improve maternal health combat HIV/AIDS malaria and other communicable diseases, ensure environmental sustainability, and develop a global partnership for development (17,18,19). For details, please refer to chapter 2.
THE SUSTAINABLE DEVELOPMENT GOALS
On 25th September 2015, the UN General Assembly adopted a new development agenda Transforming our world the 2030 agenda for sustainable development. The 17 goals of the new development agenda integrates all three dimentions of sustainable development (economic, social and environmental) around the theme of people, planet, prosperity, peace and partnership. The SDGs aim to be universal, integrated and interrelated in nature. For details, please refer to chapter 14.
HEALTH CARE DELIVERY
The challenge that exists today in many countries is to reach the whole population with adequate health care services and to ensure their utilization. The "large hospital" which was chosen hitherto for the delivery of health services has failed in the sense that it serves only a small part of the population, that too, living within a small radius of the building and the services rendered are mostly curative in nature. Therefore, it has been aptly said that these large hospitals are more ivory towers of diseases than centres for the delivery of comprehensive health care services. Rising costs in the maintenance of these large hospitals and their failure to meet the total health needs of the community have led many countries to seek 'alternative models of health care delivery with a view to provide health care services that are reasonably inexpensive, and have the basic essentials required by rural population.
THE MODEL
A number of models have been developed for the delivery of health care services (20). One of the simplest models is shown in Fig. 1. In actual practice the model is more detailed and complex. The INPUTS are the health status or health problems of the community; they represent the health needs and health demands of the community. Since resources are always limited to meet the many health needs, priorities have to be set. This envisages proper planning so that resources are not wasted. An account of the health planning has already been given in the preceding chapter. The HEALTH CARE SERVICES are designed to meet the health. needs of the community through the use of available knowledge and resources. The services provided should be comprehensive and community-based. The resources must be distributed according to the needs of the community. The HEALTH CARE SYSTEM is intended to deliver the health care services; in other words, it constitutes the management sector, and involves organisational matters. The final outcome or the OUTPUT is the changed health status or improved health status of the community which is expressed in terms of lives saved, deaths averted, diseases prevented, cases treated, expectation of life prolong
ed, etc. Models such as these are being employed for improving health care services. A discussion of the application of the model (Fig. 1) in the Indian context is given in the following pages.
HEALTH STATUS AND HEALTH PROBLEMS
An assesment of the health status and health problems is the first requisite for any planned effort to develop health care services. This is also known as Community Diagnosis. The data required for analyzing the health situation and for defining the health problems comprise the following: 1. Morbidity and mortality statistics 2. Demographic conditions of the population. 3. Environmental conditions which have a bearing on health. 4. Socio-economic factors which have a direct effect on health. 5. Cultural background, attitudes, beliefs, and practices which affect health. 6. Medical and health services available. 7. Other services available.An analysis of the health situation in the light of the above data will bring out the health problems and health needs of the community. These problems are then ranked according to priority or urgency for allocation of resources. A brief description of current demographic and mortality profile and the health problems of India is given in the following pages.
1. Demographic profile
A major concern today is population explosion. The demographic profile is characterised by: a. large population base; b. high fertility both in terms of birth rate and family size; c. low or declining mortality; d. "young" population (about 26.2 per cent of the population) is below the age of 15 years; e. the proportion of illiterate population is close to 34.62 per cent: this explains why the decline in birth rate has been so slow; and f. dependency ratio of 48.73 per cent for the year 2020; that is, every economically productive member has to support almost one dependant. Table 1 summarizes the most recent demographic information available. TABLE 1 India: Demographic profile Total population (2022) Crude birth rate (2022) Crude death rate (2022) Annual growth rate % (2022) Population doubling time (at current growth rate) Population rural % (2020) Adult literacy rate % (2011) Density of population per sq.km (2020) Sex ratio female per 1000 male (2018-20) Population below 15 years % (2020) Population above 65 years % (2020) Average family size (2020) Age at marriage, female (2020) Annual per capita GNP (at current prices 2018-19) 1,412 million 18.7 7.2 1.3 30 years 65.0 74.04 464 907 26.2 6.6 1.8 22.7 years Rs. 126,521 Source : (21, 22, 23)2. Mortality profile
During the last few decades, there has been a notable improvement in the health status of the population. The death rate has steadily declined from 21 (1965) to 7.2 (2022). The life expectancy at birth has gone up considerably since 1951, recording an estimated 67 years for males and 70 years for females during 2020. The diseases have also registered a decline (e.g., cholera, mortality rates for a number of infectious and communicable tuberculosis, malaria). However, a deeper study reveals distressing situation. India's health standards are still low compared to those in developed countries. While in the world as a whole, the IMR for the year 2019 is about 28 per 1000 live births, and in the developed countries as low as 5, in India it is as high as 28. Our life expectancy of about 67 years lags behind by almost 12-15 years compared to that in developed countries where it is currently between 71 and 80 years. The current urban death rate (during 2022) was 5.1 and the rural death rate 6.4 per 1000 of population. There were also considerable interstate variations in death rate, as for example, during 2020 the death rate in Chhattisgarh was highest, about 7.9 as compared to the national average of 73. and 3.6 in Delhi. Among the states, Kerala had the lowest IMR of 6 per 1000 live births and Madhya Pradesh had the highest IMR of 43 per 1000 live births (24). Table 2 shows that the death rate is the highest in the age infection. 15 to 25 per cent of total deaths are attributed to group 0-4 years. This is as a result of malnutrition and infectious and parasitic diseases.
Health problems
The HEALTH PROBLEMS of India may be conveniently grouped under the following heads: 1. Communicable disease problems; 2. Non-communicable disease problems; 3. Nutritional problems; 4. Environmental sanitation problems; 5. Medical care problems; and 6. Population problems.1. Communicable disease problems
Communicable diseases continue to be a major problem in India. Diseases considered to be of great importance today are: (a) Malaria: Malaria continues to be a major health problem in India. Although total malaria cases has declined. compared to previous years, the proportion of P. falciparum has increased. Malaria cases have increased in North-East states, Madhya Pradesh, Chhattisgarh, Jharkhand, Orissa, Andhra Pradesh, Maharashtra etc. During 2021 there were 0.16 million cases of malaria (which included 63.1% cases of Pf malaria) and 73 deaths. (b) Tuberculosis: Tuberculosis remains a public health problem, with India accounting for one-fifth of the world incidence. Every year about 2.2 million persons develop tuberculosis, of which about 0.62 million are new smear positive highly infectious cases and about 0.24 million people die of TB every year. The emergence of HIV-TB co-infection and multidrug resistant TB has increased the severity and magnitude of the disease. In March 2006 RNTCP has achieved nation-wide coverage. (c) Diarrhoeal diseases: Diarrhoeal diseases constitute one of the major causes of morbidity and mortality, specially in children below 5 years of age. They are responsible for about 7.2 million cases of diarrhoea each year. Outbreaks of diarrhoeal diseases (including cholera) continue to occur in India due to poor environmental conditions. (d) ARI: Acute repiratory diseases are one of the major causes of mortality and morbidity in children below 5 years of age. During 2020, 23.67 million episodes of ARI were reported with 5,160 deaths. (e) COVID-19: India had its share of COVID-19 cases during the pandemic, as of 20th Sept. 2022, India reported 44.52 million cases with 528 million deaths due to COVID-19. Large scale vaccination drive is going on in the country. (1) Leprosy: Leprosy is another important public health problem in India. During the year 2020-2021, total of 65,147 new cases were detected, out of which child cases were 9.49% and deformity grade II and above was 4.14%. 51.48 per cent of these cases are estimated to be multibacillary. All the States and Union Territories report cases of leprosy. However, there are considerable variations not only between one State and another, but also between one district and another. With the prevalence rate of about 0.68 per 10.000 population, India has achieved the goal of leprosy elimination at national level. (g) Filaria: The problem of filaria remains endemic in about 272 districts in 16 States and 4 UTs. The population at risk is over 670 million. To achieve elimination of LF, the Govt. of India has launched nationwide Annual Mass Drug Administration (MDA) with annual single recommended dose of diethylcarbamazine citrate tablets in addition to scaling up home based foot care and hydrocele operations. In 2014, 250 endemic districts implemented MDA targeting a population of about 554 million. (h) AIDS: The problem of AIDS is stable. It is estimated that by the end of year 2021 there were about 2.4 million HIV positive cases in the country. (1) Others: Kala-azar, meningitis, viral hepatitis, Japanese encephalitis, dengue fever, enteric fever and helminthic infestations are among the other important communicable disease problems in India. The tragedy is that most of these diseases can be either easily prevented or treated with minimum input of resources. In fact most of the developed countries of the world have overcome many of these problems by such measures as manipulation of environment, practice of preventive medicine and improvement of standards of living.
2. Non-communicable diseases (NCDs)
India is experiencing a rapid epidemiological transition with a large and rising burden of chronic diseases, which were estimated to account for 63 per cent of all deaths in 2016. NCDs, especially diabetes mellitus, CVDs, cancer, stroke, and chronic lung diseases have emerged as major public health problems due to an ageing population and environmentally driven changes in behaviour.
Cancer has become an important public health problem in India with an estimated 1.1 million cases occurring every year. At any point of time, it is estimated that there are nearly 3.9 million cases in the country. In India, tobacco related cancers account for about half the total cancers among men and 20% among women. About one million tobacco related deaths occur each year, making tobacco related health issues a major public health concern. In India, more then 12 million people are blind. Cataract (62.6 per cent) is the main cause of blindness followed by Refractive Error (19.70 per cent). There has been a significant increase in proportion of cataract surgeries with Intra Ocular Lens (IOL) implantation from per cent in 1994 to 95 per cent in 2016-17. Oral Health Care has not been given sufficient importance in our country. Most of the district hospitals have a post of dental surgeon but they lack equipment, machinery, and material. Even where the equipment exists, the maintenance is poor, hence service delivery is affected.
3. Nutritional problems
From the nutritional point of view, the Indian society is a dual society, consisting of a small group of well fed and a very large group of undernourished. The high income groups are showing diseases of affluence which one finds in developed countries.
The specific nutritional problems in the country are :
(a) Protein-energy malnutrition : Insufficiency of food - the so-called "food gap appears to be the chief cause of PEM, which is a major health problem particularly in the first of life. The great majority of cases of PEM, nearly 80 percent are mild and moderate cases. The incidence of severe cases is 1 to 2 per cent in preschool age children. The problem exists in all the States and the nutritional marasmus is more frequent than kwashiorkor. (b) Nutritional anaemia India has probably the highest prevalence of nutritional anaemia in women and children. About one-half of non-pregnant women an suffer from an anaemic. 19 per cent of maternal deaths are attributed to anaemia. 52.2 per cent of pregnant women are and young children are estimated to anaemia. According to NFHS-5, about 52.2 per cent women are anaemic of which 45.5 per cent are in urban areas and 54.3 per cent in rural areas. The survey also shows that the incidence of anaemia in children aged 6-59 months is 67.1 per cent with 64.2 per cent in urban areas and 68.7 per cent in rural areas. By far the most frequent cause of anaemia Is iron deficiency, and less frequently folate and vitamin B, deficiency, (c) Low birth weight: This is a major public health problem in India. About 28 per cent of babies born are of low birth weight (less than 2.5 kg). Maternal malnutrition and anaemia are mainly responsible for this condition. (d) Xerophthalmia (nutritional blindness): About 0.04 per cent of total blindness in India is attributed to nutritional deficiency of vitamin A. Keratomalacia has been the major cause of nutritional blindness in children usually between 1-3 years of age. Subclinical deficiency of vitamin A is also widespread and is associated with increased morbidity and mortality from respiratory and gastro-intestinal infections. (e) lodine deficiency disorders: Goitre and other iodine deficiency disorders (IDD) have been known to be highly endemic in sub-Himalayan regions. Reassessment of the magnitude of the problem by the Indian Council of Medical Research showed that the problem is not restricted to the "goitre belt" as was thought earlier, but is extremely prevalent in other parts of India as well. It has been found that out of 324 districts surveyed in 29 states and all UTs, 263 districts are endemic i.e. where the prevalence of IDD is more than 10 per cent. It is also estimated that more than 71 million people are suffering from goitre and other IDD (25). (f) Others: Other nutritional problems of importance are lathyrism and endemic fluorosis in certain parts of the country. To these must be added the widespread adulteration of foodstuffs.
4. Environmental sanitation
The most difficult problem to tackle in this country is perhaps the environmental sanitation problem, which is multifaceted and multifactorial. The twin problems of environmental sanitation are lack of safe water in many areas of the country and sanitary way of excreta disposal. Besides these, there has been a growing concern about the impact of "new" problems resulting from population explosion, urbanization and industrialization leading to hazards to human health in the air, in water and in the food chain. As of year 2017 safe water is available to 97 per cent of the urban and 93 per cent of the rural population; and adequate facilities for waste disposal to 63 per cent of the urban and 28 per cent of the rural population. The problem is gigantic.
5. Medical care problems
based, disease-oriented health care model has provided India has a national health policy. The existing hospital. health benefits mainly to the urban elite. Approximately 80 per cent of health facilities are concentrated in urban areas Even in urban areas, there is an uneven distribution of doctors. With large migrations occurring from rural to urban areas, urban health problems have been aggravated and Include overcrowding in hospitals, inadequate staffing and scarcity of certain essential drugs and medicines. The rural areas where nearly 65 per cent of the population live, do not health services. Many villages rely on indigenous systems of enjoy the benefits of the modern curative and preventive medicine. Thus the major medical care problem in India is inequable distribution of available health resources between urban and rural areas, and lack of penetration of health services to the social periphery. The primary health care approach which lays stress on equity, intersectoral coordination and community participation seek to redress these imbalances.
6. Population problem
The population problem is one of the biggest problem facing the country, with its inevitable consequences on all aspects of development, especially employment, education. housing, health care, sanitation and environment. The country's population has already reached one billion mark by the turn of the century. Currently, the country's growth rate is 1.3 per cent. This calls for the "two child family norm". The population size and structure represent the most important single factor in health and manpower planning in India today where the law of diminishing returns, among other factors, plays an important role in the economic development of the country.
RESOURCES
Resources are needed to meet the vast health needs of a community. No nation, however rich, has enough resources to meet all the needs for all health care. Therefore an assessment of the available resources, their proper allocation and efficient utilization are important considerations for providing efficient health care services. The basic resources for providing health care are:
(i) Health manpower; (ii) Money and material; and (iii) Time.Health manpower
The term "health manpower" includes both professional and auxiliary health personnel who are needed to provide the health care. An auxiliary is defined by WHO as "technical worker in a certain field with less than full professional training". Health manpower requirements of a country are based on (i) health needs and demands of the population; and (ii) desired outputs. The health needs in turn are based on the health situation and health problems and aspirations of the people. Health manpower planning is an important aspect of community health planning. It is based on a series of accepted ratios such as doctor-population ratio, nurse-population ratio, bed-population ratio, etc. They are given in Table 3. The country is producing annually, on an average 31,298 allopathic doctors; 9,865 Ayurvedic graduates: 1525 Unani graduates; 320 Siddha graduates and 12785 Homoeopathic graduates (26).
TABLE 3
Suggested norms for health personnel Category of personnel Norms suggested 1. Nurses 2. Health workers female and male 3. Trained dai 4. Health assistants (male and female) 5. Pharmacists 6. Lab. technicians 7. ASHA 1 per 5,000 population 1 per 5,000 population in plain area and 3,000 population in tribal and hilly areas. One for each village 1 per 30,000 population in plain area and 20,000 population in tribal and hilly areas. Provides supportive super-vision to 6 health workers (male/female). 1 per 10,000 population 1 per 10,000 population 1 per 1,000 population Source : (25)Although the averages are satisfactory on a national basis, they vary widely within the country. There is also maldistribution of health manpower between rural and urban areas. Studies in India have shown that there is a concentration of doctors (upto 73.6 per cent) in urban areas where only 26.4 per cent of population live. This maldistribution is attributed to absence of amenities in rural areas, lack of job satisfaction, professional isolation, lack of rural experience and inability to adjust to rural life. The national averages of doctor-population ratio, population-bed ratio and nurse to doctor ratio in some countries are shown in Table 4.
Health manpower requirements are subject to change, both qualitatively and quantitatively, as new programmes, projects and philosophies are introduced into the health care system. For example, there has been a change from unipurpose to multipurpose strategy. Then came the goal of Health for All. In addition, national health programmes such as tuberculosis control, leprosy eradication and control of blindness needed more trained workers and technicians. Thus during the past decade many new categories of health manpower have been introduced. They include village health guides, multipurpose workers, technicians, ophthalmic assistants, etc. Table 5 gives the total health manpower current stock under the "rural health scheme".
Money and material
Money is an important resource for providing health services. Scarcity of money affects all parts of the health delivery system. In most developed countries, average government expenditure for health is about 18 per cent of GNP. In developing countries it is less than 1 per cent of the GNP and it seldom exceeds 2 per cent of the GNP. This translates into an average of a few dollars per person per year in the underdeveloped countries as compared to several hundred dollars in developed ones. To make matters worse, much of the spending is for services that reach only a small fraction of the population. At present India is spending about 3 per cent of GNP on health and family welfare development. Since money and material are always scarce resources they must be put to the most effective use, with an eye on maximum output of results for investment. Since deaths from preventable diseases such as whooping cough, measles, tuberculosis, tetanus, diphtheria, acute respiratory infection, diarrhoea, malaria and malnutrition frequently occur in developing countries, the case is strong for investing resources on preventing these diseases. Management techniques such as cost-effectiveness and cost-benefit analysis are now being used for allocation of resources in the field of community health.
Time
"Time is money", someone said. It is an important dimension of health care services. Administrative delays in sanctioning health projects imply loss of time. Proper use of man-hours is also an important time factor. To summarize, resources are needed to meet the many health needs of a community. But resources are desperately short in the health sector in all poor countries. What is important is to employ suitable strategies to get the best out of limited resources.
HEALTH CARE SERVICES
The purpose of health care services is to improve the health status of the population. The goals to be achieved have been fixed in terms of mortality and morbidity reduction, increase in expectation of life, decrease in population growth rate, improvements in nutritional status, provision of basic sanitation, health manpower requirements and resources development and certain other parameters such as food production, literacy rate, reduced levels of poverty, etc. The scope of health services varies widely from country to country and influenced by general and ever changing national, state and local health problems, needs and attitudes as well as the available resources to provide these services. There is now broad agreement that health services should be (a) comprehensive (b) accessible (c) acceptable (d) provide scope for community participation, and (e) available at a cost the community and country can afford. These are the essential ingredients of primary health care which forms an integral part of the country's health system, of which it is the central function and main agent for delivering health care (9).
HEALTH CARE SYSTEMS
The health care system is intended to deliver the health care services. It constitutes the management sector and involves organisational matters. It operates in the context of the socioeconomic and political framework of the country. In India, it is represented by five major sectors or agencies which differ from each other by the health technology applied and by the source of funds for operation. These are:
2. PRIVATE SECTOR
(a) Private hospitals, polyclinics, Nursing homes, and dispensaries (b) General practitioners and clinics 3. INDIGENOUS SYSTEMS OF MEDICINE Ayurveda and Siddha Unani and Tibbi Homoeopathy Unregistered practitioners 4. VOLUNTARY HEALTH AGENCIES 5. NATIONAL HEALTH PROGRAMMESPRIMARY HEALTH CARE IN INDIA
Scheme, based on the principle of "placing people's health in In 1977, the Government of India launched a Rural Health people's hands". It is a three tier system of health care Shrivastav Committee in 1975. Close on the heels of these recommendations an International conference at Alma-Ata in 1978, set the goal of an acceptable level of Health for All the people of the world by the year 2000 through primary health care approach. As a signatory to the Alma-Ata Declaration, the Government of India was committed to achieving the goal of Health for All through primary health care approach which seeks to provide universal comprehensive health care at a cost which is affordable.
Keeping in view the WHO goal of "Health for All" by 2000 AD, the Government of India evolved a National Health Policy based on primary health care approach. It was approved by Parliament in 1983. The National Health Policy laid down a plan of action for reorienting and shaping the existing rural health infrastructure with specific goals to be achieved by 1985, 1990 and 1995 within the framework of the Sixth (1980-85) and Seventh (1985-90) Five Year Plans and the new 20 point Programme. Steps were taken to implement the National Health Policy objectives towards achieving
Health for All by the year 2000. During the last decade further development of rural health infrastructure took place in view to implement National Health Policy 2002 and 2017, National Population Policy 2000 and more recently National Rural Health Mission, National Urban Health Mission and Health and Wellness Centres with formulation of Indian Public Health Standards.
VILLAGE LEVEL
One of the basic tenets of primary health care is universal coverage and equitable distribution of health resources. That is, health care must penetrate into the farthest reaches of rural areas, and that everyone should have access to it. To implement this policy at the village level, the following schemes are in operation:
a. ASHA Scheme; b. ICDS Scheme; and c. Training of Local Dais.a. ASHA
ASHA must be resident of the village - a woman (married/widow/divorced) preferably in the age group of 25 to 45 years with formal education up to eight class, having communication skill and leadership qualities. Adequate representation from the disadvantaged population group will ensure to serve such groups better. The general norm of selection is one ASHA for 1000 population. In tribal, hilly and desert areas the norm could be relaxed to one ASHA per habitation.
Role and responsibilities of ASHA
ASHA will be a health activist in the community who will create awareness on health. Her responsibilities will be as follows (29):
1. ASHA will take steps to create awareness and provide Information to the community on determinants of health such as nutrition, basic sanitation and hygienic practices, healthy living and working conditions, information on existing health services, and the need for timely utilization of health and family welfare services.
2. She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception and prevention of common infections including reproductive tract infection/sexually transmitted infection and care of the young child.
ASHA will mobilize the community and facilitate them in accessing health and health related services available at the anganwadi/subcentre/primary health centres, such as immunization, antenatal check-up, postnatal check-up, supplementary nutrition, sanitation and other services being provided by the government.
4. She will work with the village health and sanitation committee of the gram panchayat to develop a comprehensive village health plan.
5. She will arrange escort/accompany pregnant women and children requiring treatment/admission to the nearest pre-identified health facility i.e. primary health centre/community health centre/First Referral Unit.
6. ASHA will provide primary medical care for minor ailments such as diarrhoea, fevers, and first-aid for minor injuries. She will be a provider of directly observed treatment short-course (DOTS) under revised national tuberculosis control programme.
7. She will also act as a depot holder for essential provisions being made available to every habitation like oral rehydration therapy, iron folic acid tablet, chloroquine, disposable delivery kits, oral pills and condoms etc. A drug kit will be provided to each ASHA. Contents of the kit will be based on the recommendations of the expert/technical advisory group set up by the government of India, and include both AYUSH and allopathic formulations.
8. Her role as a provider can be enhanced subsequently. States can explore the possibility of graded training to her for providing new-born care and management of a range of common ailments, particularly childhood illnesses.
9. She will inform about the births and deaths in her village and any unusual health problems/disease outbreaks in the community to the sub-centre/primary health centre.
10. She will promote construction of household toilets under total sanitation campaign.
Role and integration with Anganwadi (29)
Anganwadi worker will guide ASHA in performing following activities: (a) Organizing Health Day once/twice a month. On health day, the women, adolescent girls and children from the village will be mobilized for orientation on health related issues such as importance of nutritious food, personal hygiene, care during pregnancy, importance of antenatal check-up and institutional delivery, home remedies for minor ailment and importance of immunization etc. AWWs will inform ANM to participate and guide organizing the Health Days at anganwadi centre; (b) AWWs and ANMs will act as resource persons for the training of ASHA; (c) IEC activity through display of posters, folk dances etc. on these days can be undertaken to sensitize the beneficiaries on health related issues; (d) Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA. The replacement of the consumed drugs can also be done through AWW; (e) AWW will update the list of eligible couples and also the children less than one year of age in the village with the help of ASHA; and (f) ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition supplement. She would also take initiative for bringing the beneficiaries from the village on specific days of immunization, health check-ups/health days etc. to anganwadi centres.
Role and integration with ANM (29)
Auxiliary Nurse Midwife (ANM) will guide ASHA in performing following activities: (a) She will hold weekly/fortnightly meeting with ASHA and discuss the activities undertaken during the week/fortnight. She will guide her in case ASHA had encountered any problem during the performance of her activity; (b) AWWs and ANMs will act as resource persons for the training of ASHA; (c) ANMs will inform ASHA regarding date and time of the outreach session and will also guide her for bringing the beneficiary to the outreach session; (d) ANM will participate and guide in organizing the Health Days at anganwadi centre; (e) She will take help of ASHA in updating eligible couple register of the village concerned; (f) She will utilize ASHA in motivating the pregnant women for coming to sub-centre for initial check-ups. She will also help ANMs in bringing married couples to sub-centres for adopting family planning; (g) ANM will guide ASHA in motivating pregnant women for taking full course of iron and folic acid tablets and tetanus toxoid injections etc.; (h) ANMs will orient ASHA on the dose schedule and side effects of oral pills; (i) ANMs will educate ASHA on danger signs of pregnancy and labour so that she can timely identify and help beneficiary in getting further treatment; and (j) ANMs will inform ASHA on date, time and place for initial and periodic training schedule. She will also ensure that during the training ASHA gets the compensation for performance and also TA/DA for attending the training.
b. Anganwadi worker
Angan literally means a courtyard. Under the ICDS (Integrated Child Development Services) Scheme, there is an anganwadi worker for a population of 400-800. There are about 100 such workers in each ICDS Project. As of date over 7,067 ICDS blocks are functioning in the country. The anganwadi worker is selected from the community she is expected to serve. She undergoes training in various aspects of health, nutrition, and child development for 4 months. She is a part-time worker and is paid an honorarium of Rs. 1500 per month for the services rendered, which include health check-up including maintenance of growth chart, immunization, supplementary nutrition, health education, non-formal pre-school education and referral services. The beneficiaries are especially nursing mothers, pregnant women, other women (15-45 years), children below the age of 6 years and adolescent girls (30). Along with Village Health Guides, the anganwadi workers are the community's primary link with the health services and all other services for young children.
c. Local dais (31)
A scheme for training of Dais was initiated during 2001-02. The scheme was implemented in 156 districts in 18 states/UTs of the country. The districts selected were on the basis of the safe delivery rate being less than 30 per cent. The scheme was extended to all the districts of EAG states. The aim was to train at least one Dai in every village with the objective of making deliveries safe.
INDIAN PUBLIC HEALTH STANDARDS AT PRIMARY HEALTH CARE LEVEL (2022)
Focus on urban health came during RCH-I and continued in RCH-II as part of NRHM. Since the last revision of the Indian Public Health Standards in 2012, a number of new initiatives, interventions and programmes have been introduced in the public health system of India. The introduction of comprehensive primary health care through upgraded sub-centres and PHCs (now known as Health and Wellness Centres), and similarly, in urban areas, Urban Health and Wellness Centres, speciality UPHCs (polyclinics). Are some of the new additions, with special focus on people living in listed and unlisted slums, homeless, rag-pickers, migrants and other vulnerable population. Since then, some key policy shifts have been proposed under the National Health Policy (2017) for public health care delivery system in the following areas (32):
• Clinical care - from stand-alone curative to a preventive, promotive and rehabilitative approach for achieving comprehensive wellness in health. • Primary care - from selective care to assured comprehensive care with linkages to referral hospitals. • Drugs, diagnostics, and emergency services - from user fees and cost recovery to assured free drugs, diagnostic and emergency services to all in public hospitals. • Infrastructure and human resource development - from. Normative approach to targeted approach to reach under-served areas with "time to care approach". • Urban health - from token interventions to on-scale assured interventions to organize Primary Health Care delivery and referral support for urban poor. Collaboration with other sectors to address wider determinants of urban health is advocated. • National health programmes - integration with health systems for programme effectiveness and in turn contributing to strengthening of health systems for efficiency.In the public health sector, the sub health centre (SHC) and urban health and wellness centre (UHWC) are the most peripheral and first point of contact between the primary health care system and the community in rural and urban areas respectively. These health facilities act as an interface with the community at the grass-root level, providing all the comprehensive primary health care services.
Revised IPHS guidelines 2022 also define the components specific to urban health facilities to set benchmarks to achieve the goal of universal health coverage.
• The 2022 IPHS guidelines have been framed for: • Sub-District Hospitals (SDH) & District Hospitals (DH), • Community Health Centres (CHC) - rural and urban, • Health and Wellness Centre - Primary Health Centres (PHC) - rural and urban, including Multispeciality UPHC (Polyclinics) in urban areas, • Health and Wellness Centre - Sub Health Centre (SHC) - rural and urban.The 2022 revised quidelines emphasize on the services to for each level of health facility will be the basis for be delivered at each level of facility. Service delivery defined developing other health system strengthening components viz. infrastructure, human resources, drugs, diagnostics equipment, quality improvement, monitoring/supervision, governance, and leadership.
The 2022 IPHS norms supports government health facilities to attain a minimum acceptable functional standard (indicated as 'essential') while striving and aspiring for improvement (indicated as 'desirable') so as to accelerate India's progress towards achievement of Universal Health Coverage (UHC) and Sustainable Development Goal - 3 (SDG-3) in alignment with the National Health Policy 2017.
In comparison with the IPHS guidelines of 2012, the revised IPHS 2022 guidelines classify the HWCs as: 1. Health and Wellness Centres - Primary Health Centre: a. HWC-PHC in rural areas b. HWC-UPHC in urban areas 2. Health and Wellness Centres - Sub Health Centre: a. Health and Wellness Centre Sub Health Centre in rural areas b. Urban Health & Wellness Centre in urban areas Depending on the services provided at a particular facility, it may be deemed as a primary or secondary care service provider facility: • Health and Wellness Centres (HWC-SHC, UHWCs and PHCs), in both rural and urban areas will provide primary care services. • Multispeciality polyclinics nearer to the community will provide ambulatory specialist services, particularly in urban areas. • Community Health Centres in rural areas can be either FRU or non- FRU, depending on the range of services provided. In urban areas, CHCs will provide services at par with FRU. • District and Sub-District Hospitals will provide secondary care services. Implementation of all national programmes at individual facilities must be in line with the latest Gol/state guidelines developed for that programme. All Rural and Urban-HWCS should have a National Identification Number (NIN-Id) and register on the AB-HWC portal.
A Citizen's Charter should be prominently displayed near the entrance of the facility. This should provide information about the various services being offered, timings, responsibilities of patients and providers, details of referral vehicles and facilities, the number of free drugs and diagnostics being provided and other citizen friendly information. Patient's rights should be ensured, and they should also be made aware of their responsibilities (e.g., to keep the facility clean and avoid spitting in corners, avoiding over-crowding by attendants, respecting visiting hours, not causing any harm to public property or indulging in violence against healthcare professionals, etc.). A sample of citizen's charter for the level of HWC-PHC is shown below (33).