Aalok Ranjan Chaurasia


Health and Public Health
Public Health in India
 Before the Colonial period
 During the Colonial period
 After the colonial period


Essential Public Health Functions
Mortality transition in India

The World Health Organisation defines
Health (of an individual) as the state of
complete physical mental and social well-being
and not merely the absence of disease or
infirmity.

World Health Organisation, however, does
not define Public Health.

Death, on the planet Earth, is inevitable.

A large number of deaths are premature.

A substantial proportion of deaths can be
avoided.

Public Health is related to preventing
premature and unavoidable deaths.
Exposure to Risk
Factors
Body resistance
Poor Health
Manifestation
Disease Condition
Disability
Death

If the disease condition is avoided, the
probability or the chance of death or
disability can be reduced.

Public Health is therefore described as the
science and art of preventing diseases,
prolonging life and promoting health (of
individuals) through organised efforts and
informed choices.


Public Health deals with the group of people
rather than individuals.
Dimensions of public health
 Health promotion
 Disease prevention
 Early diagnosis and prompt treatment
 Disability limitation
 Rehabilitation




The Indian approach to health is enshrined in
the concepts and principles of Ayurveda
which means the ‘science of life’.
Ayurveda is one of the oldest system of
health care in the World.
Ayurveda deals with both preventive and
curative aspects of health.
Health defined by WHO is very similar to
concepts of Ayurveda.

The western approach of avoiding diseases,
death and disability, traditionally focused on
personal hygiene and public sanitation during
the 19th Century.

This approach, combined with better food
availability, paid rich dividend in the
developed countries in reducing morbidity
and mortality.

Epidemiology
 Measurement of disease conditions in relation to
the population at risk.

Statistics
 Collection, presentation, analysis and
interpretation of epidemiological data.

Health Services
 Services directed towards meeting the health
needs of the people.




Little is known about public health activities
before the colonial period.
Main stream system of health care was
Ayurveda.
Home-based care appeared to be the
dominant feature.
There appeared little organised efforts or
institutional care to treat diseases and
prevent deaths.




Evolution of public health system during the
colonial period followed the same path that
was followed in Britain.
Public health efforts were focused largely on
protecting British civilians and army
cantonments.
Sanitation was given the top priority.
Focus was also on early detection and control
of contagious diseases – cholera and plague.



Training and research Institutions in public
health.
Public health legislation.
Sanitary departments





Ascertaining local sanitary conditions.
Vital registration.
Monitoring disease trends.
Vaccination programmes.
Technical advice on control of epidemics.




Restriction of public health efforts to British
civilians and military established was a major
constraint.
Majority of Indian masses remained deprived
of the dividends of these efforts.
At the time of Independence only 3 per cent
households in India had toilets.
Water, drainage and waste disposal services
were utterly lacking.

Although, public health efforts were
restricted to British civilian and military
establishment, they had impact on Indian
masses.
 Mortality spikes were sharply reduced.
 Mortality from cholera and plague was sharply
reduced.
 Diseases like malaria and gastro-enteritis
continued to take heavy toll.

Evolution of public health care system in
Independent India was shaped by two
important factors:
 The Report of First Health Survey and
Development Committee (Bhore Committee)
constituted during the colonial rule.
 Emergence of modern medical technology for the
prevention and control of diseases, especially
communicable diseases.


Appointed in 1943.
Recommended comprehensive remodeling of
health services.
 Integration of preventive and curative health
services at all levels.
 Hospital-based health care system.
 Development of primary health centres in two
stages.
 Training in Preventive and Social Medicine.

The short-term plan
 A PHC for every 40000 population.
 PHC to be manned by 2 doctors, 4 PHN, 4
Midwife, 1 Nurse, and others.

The long-term plan
 A primary health unit for every 10-20 thousand
population with 75 beds.
 Secondary unit with 650 bedded hospital.
 District unit with 2500 bedded hospital.


Mass production of antibiotics.
Availability of vaccines for diseases having
high mortality and disability rates
 Tetanus
 Diphtheria
 Pertussis (Whooping Cough)
 Measles
 Poliomyelitis



The recommendations of Bhore Committee
and the availability of preventive and curative
medical technology resulted in the evolution
of hospital-based public health system.
The public health arrangements created
during the colonial period were replaced by
hospitals and health centres.
Public health services were merged with the
medical services.

Bhore Committees recommendations were
accepted only partially.
 One primary health centre for every 30 thousand
population.
 Only 6 beds in each primary health centre.
 Only one doctor.
 Truncated paramedical staff.

The situation has remained largely
unchanged.



Since Bhore Committee, numerous
committees were constituted to evolve the
public health system.
Some of the recommendations of these
committees were adopted; some were not by
the government.
All committees retained the core of the
model recommended by the Bhore
Committee.

Mudalliar Committee(1962)
 Strengthen PHCs before establishing new ones.
▪ PHC should provide preventive, promotive and curative
services.
 Strengthen sub-divisional and district hospitals.
 Creation of All India Health Services.

Chaddha Committee (1963)
 Malaria worker to function as multipurpose
worker.

Mukherjee Committee (1965)
 Separate staff for family planning programme.
 Malaria activities to be de-linked from family
planning activities.

Jungalwala Committee (1967)
 A unified approach for all problems instead of a
segmented approach for different problems.
 Medical care and public health programmes to be
put under charge of a single administrator.

Kartar Singh Committee
 Concept of MPW(M) and MPW(F).
 One PHC to catre 50 thousand population.
 Each PHC should have 16 SHC (3-3.5 thousand
population).

Shrivastav Committee
 Creation of bonds of paraprofessional and
semiprofessional health workers from within the
community itself.
 Development of a “Referral Services Complex.”

Bajaj Committee
 Formulation of National Medical & Health Education






Policy.
Formulation of National Health Manpower Policy.
Educational Commission for Health Sciences.
Health Science Universities in various states.
Health manpower cells.
Vocationalisation of education at 10+2 levels as
regards health related fields.
Realistic health manpower survey.

A population based normative approach is
adopted for establishing hospitals and health
centres
 SHC – One for every 5000 (3000 in hilly/tribal
areas) population.
 PHC – One for every 30000 population (20000 in
difficult areas) with 4-6 indoor/observation beds.
 CHC – One for every 80-120 thousand population
with 30 beds.




The norms are for government institutions
and are for the rural areas only.
For the urban areas, no norms have been
defined.
Nearly all government civil and district
hospitals and most of the CHCs are located in
the urban areas.
No information is available about the private
health system.
Institution
Reference Number
SHC
2007
145272
More than 6 SHC for each PHC,
on average
PHC
2007
22370
More than 5 PHC for every CHC,
on average
CHC
2007
4045
Rural hospitals
2007
6298
Beds in rural
hospitals
2007
142396
Urban hospitals
2007
2774
Beds in urban
hospitals
2007
324206
About 23 beds per rural hospital
About 117 beds per urban
hospital




One fall out of the hospital-based public
health approach was the neglect of public
health legislation.
A Model Public Health Act was drafted in
1950 by the Government of India.
It was revised in 1987.
This Act is yet to be adopted by any of the
constituent state of the country.





The hospital-based public health system led
to the medicalisation of the system.
The focus has been on medical services.
Public health services have largely been
neglected.
Poor public health services result in high cost
of illness, debility and death.
The main sufferer are the people, especially
the poor and deprived.



The epidemiological and statistical
dimensions of public health have been
grossly neglected.
Lack of epidemiological and statistical
database affected public health planning.
In the absence of necessary information,
planning reduced to a normative, mechanical
exercise, often out of context to people’s
needs.


The problem gets complicated because of
social, economic, cultural and environmental
diversity that leaves normative planning
virtually redundant.
Decentralisation of the health system could
not succeed because of the lack of
epidemiological and statistical information
necessary for planning for public health
services.




Public health in India is ‘hospitalised.’
Health planning is concerned more with the
health of the health care delivery system
(hospitals and health centres) then the health
of the people.
The remedy was sought in terms of specific
National health and disease control
programmes.
There are numerous such programmes.







Reproductive and child health programme.
National tuberculosis control programme.
National malaria control programme.
National blindness control programme.
National water born disease control
programme.
National leprosy eradication programme.
National iodine deficiency control
programme.



All National disease control programmes are
implemented through the existing
government hospitals and health centres.
Over the years, a campaign approach has
been evolved to implement many of the
national health and disease control
programme.
Successful campaigns have often been
followed by unsuccessful maintenance.







Focus on medical services.
Neglect of public health services.
No modern public health regulation.
Lack of systematic planning.
Poor sustainability of public health efforts.
Absence of epidemiological and statistical
skills at district and below district level.
No micro-level planning, no public health
action.
Emergencies and Distasters
Management capacity
Research
Quality
Human resources
Evaluation
Policy and planning
Participation
Regulation
Health promotion
Epidemiological surveillance
Health situation
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
80
80
75
75
70
70
Observed
Very fast
Fast
Medium
Slow
Very slow
65
60
65
60
55
55
50
50
45
1973 1978 1983 1988 1993 1998 2003
Observed
Very fast
Fast
Medium
Slow
Very slow
45
1973 1978 1983 1988 1993 1998 2003
Widespread existence of preventable
diseases and deaths is a disgrace to
the society which tolerates it.
Thank You