Introduction Combating different health problems and living and leading a healthy life has been a continuous struggle of man since time immemorial. His involvement as the priest, the magician, the traditional faith healer, the herbalist and the medicine man all undertook the various means to cure man's health problems and disease and to bring relief to the sick. Earlier, medicine was practiced in an almost complete absence of scientific medical knowledge. In India, medicine was practiced on the basis of experience with natural herbs, which resulted in a good literature named Charak Samhita, the base of the Ayurvedic system of medical treatment. Similarly, Greek/Unani medicine, Chinese medicine, Egyptian medicine and treatment methods were also popular. In the course of its evolution, which proceeded by stages, with advances and halts, medicine has drawn a lot from the traditional cultures of which it is a part and later from biological and natural sciences. To its more recent approaches, medicine is also covered through social and behavioural sciences. |
The period following 1500 A.D. was marked by revolutions in the political, industrial, religious and medical fields. Political revolutions took place in France and America, where people started claiming their just rights. The industrial revolution in the West brought about great benefits, leading to an improvement in the standard of living among people. The 16–18th centuries saw numerous exciting discoveries in the field of medical science, which is based on scientific medical knowledge. The 20th century, marked by the ‘explosion’ of knowledge, has made medicine and medical treatment more complex and costly. This resulted in the glaring contrasts in the state of health between the developed and developing countries and between the rich and the poor. This has become a serious concern for all who are responsible for providing health services to the people in general and more so to the needy. The inability of the central government as well as state governments to provide effective and sufficient health services has attracted criticism of the present administrative and political systems in terms of their ability in delivery of welfare services to the people, including health services. |
The provision for sufficient and effective healthcare services to a billion-plus population of India is indeed a challenging task. The challenge that exists today to reach the total population with adequate healthcare services and to their utilisation raises certain questions such as:
What is the status of healthcare services in India? Are the healthcare services accessible to the whole population including poor and marginalised sections? What are the bottlenecks and constraints faced in the delivery of healthcare services? How far we are able to develop a proper, effective and efficient healthcare system suited to our need and to provide sufficient infrastructure to ensure good health?
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The present healthcare system in India is based on the recommendations of the Health Survey and Development Committee appointed in 1943 under the chairmanship of Sir Joseph Bhore. The committee's recommendations for the development of the health sector were based on the following main principles:
No individual should fail to secure adequate medical care because of the inability to pay for it. The health programme must, from the very beginning, lay special emphasis on preventive work with consequential development of environmental hygiene. The health services should be placed as close to the people as possible to ensure the maximum benefit to the communities to be served. It is essential to secure the active cooperation of the people in the development of the health programmes, and active support of the people is to be sought through the establishment of a Health Committee in every village. The doctor, who is the leader of the health team, should be a ‘social Physician’ who should combine remedial and preventive measures to confer maximum benefits on the community.
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The Bhore committee also laid special emphasis for facilities of safe drinking water, sanitation and housing. The committee insisted that ‘medical relief and preventive healthcare must be urgently provided as soon as possible to the vast rural population of the country’. The recommendations of Bhore committee based on the socioeconomic conditions of India helped policymakers and planners in developing the national healthcare services for the future. |
Healthcare System before Adoption of National Health Policy, 1983 At the time of independence, India inherited a health system devised during the British imperial rule, essentially to provide services to defence forces and the colonial administrators and to the local gentry. By and large, the health system was urban based, elite biased and curative oriented and did not cover the large rural-based population of the country to provide minimum healthcare services (Sapru R.K., 1997). The system suffered largely in terms of both adequacies of health institutions and facilities and the manpower for health services1.The position of medical personnel in India in 1947 compared with the United Kingdom is given in Table 1. Before the 1970s, basic healthcare was delivered through health centres, posts or subcentres, but these services were not able to meet the healthcare needs of the large population because of poor accessibility, inadequate infrastructure, lack of professional experts and paramedical staff in all areas of healthcare. A new approach to healthcare system was introduced in the development of health services in India with the signing of the Alma-Ata Declaration (WHO-UNICEF-sponsored International Conference on Primary Health Care) on 12 September 1978, recommending ‘Health for all by 2000’ through the primary healthcare approach. The Alma-Ata Conference defined primary healthcare as ‘Primary healthcare is essential healthcare made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford’. The concept of primary healthcare has been accepted by all countries (including India) as the key to the attainment of health for all by 2000. It has also been accepted as an integral part of India's health system. The essential components of primary healthcare outlined by the Alma-Ata Declaration are (i) education concerning prevailing health problems and the methods of preventing and controlling them, (ii) promotion of food supply and proper nutrition, (iii) an adequate supply of safe drinking water and basic sanitation, (iv) maternal and child healthcare, including family planning, (v) immunisation against major infectious diseases, (vi) prevention and control of locally endemic diseases, (vii) appropriate treatment of common diseases and injuries and (viii) provision of essential drugs. Health Planning in India Health Planning in India is an integral part of national socioeconomic planning. The guidelines for national health planning were provided by a number of committees dating back to the Bhore committee report in 1946 (see Table 2). These committees were appointed by the Government of India from time to time to review the existing health situation and recommend measures for further action. The recommendations of these committees are important landmarks in the history of public health in India based on which healthcare system in India is developed. The Alma-Ata Declaration on Primary Health Care and the National Health Policy of the Government of India gave a new direction to health planning in India, making primary healthcare the central function and main focus of its national health system. The five-year plans were covered to rebuild rural India, and health was recognised as an important contributory factor for the development and utilisation of manpower. The broad objectives of the health programmes during five-year plans have been:
Control or eradicate major communicable diseases Strengthen the basic health services through the establishment of PHCs and sub centres Population control Develop health manpower resources
Health Status and Health Problems The success of health plan depends on numerous factors, among which the choice of the correct policy is very important. The term ‘health policy’ may be defined as an expression of goals for improving the health situation, the priorities among those goals and the general directions for achieving them (Sapru, R.K., 1997)2. An assessment of the health status and health problems is the first requisite for any planned effort to develop healthcare services. The data required for analysing the health situation and for defining the health problems comprise the following aspects:
Demographic conditions of the population Morbidity and mortality statistics Environmental conditions, which have a bearing on health Socioeconomic factors, which have a direct effect on health Cultural background, attitudes, beliefs, and practices, which affect health Availability of medical and health services Other services available.
In Indian context, the health problems may be grouped under the following heads: (i) communicable disease problems, (ii) nutritional problems, (iii) environmental sanitation problems, (iv) medical care problems and (v) population problems. Mortality and morbidity statistics reveal that a diverse set of factors are associated with maternal mortality: factor that influence delay in deciding to seek medical care, in reaching a place where care is available and in receiving appropriate care. The Tenth Five-Year Plan document of India has targeted to reduce the IMR to 45 per 1,000 live births by 2007 and 28 per 1,000 live births by 2012. The main causes of high maternal mortality rate (MMR) being socioeconomic status of women, inadequate antenatal care, the low proportion of institutional deliveries, birth and the non-availability of skilled birth attendants in two-thirds of cases. The World Health Report (1999) gives the main causes of death in India as non-communicable diseases (48 percent), communicable disease (42 percent) and injuries (10 percent). The dominant communicable diseases are infectious and parasitic diseases, respiratory diseases, maternal conditions, perinatal conditions and nutritional deficiencies. Non-communicable diseases are malignant neoplasm, diabetes mellitus, neuropsychiatric disorders, sense organ disorders, cardiovascular diseases, respiratory diseases, digestive diseases, musculoskeletal diseases, congenital anomalies, oral diseases and other non-communicable diseases. National Family Health Survey-II (NFHS-II) conducted a study on four major diseases prevailing in India – asthma, tuberculosis, jaundice and malaria. In India, around 2,468 persons per 1,00,000 populations were reported to be suffering from asthma at the time of survey. The prevalence of asthma is high in rural areas than in urban areas and is slightly higher in males than in females. The overall prevalence of tuberculosis in India is 544 per 100,000 populations. This is 16 percent higher than the survey conducted by NFHS-I (467 per 100,000). It is more in rural areas than in urban areas and that too more in males than in females. It is more in males because men are in contact with more people who might have tuberculosis (TB) and smoking. The prevalence of tuberculosis (TB) increases with age. The cases of jaundice were reported to be 1,361 persons per 100,000 populations. This is more prevalent in rural areas than in urban areas. However, it decreases with age. Thus, the highest numbers of jaundice patients are in the age-group of 0–14. As many as 3,697 persons per 100,000 populations were reported to have suffered from malaria (NFHS II). People of rural areas suffer twice than that of urban areas, and it is slightly high in males than in females. All these diseases, however, vary and differ from state to state depending on the climate and geographical locations of the areas. With regard to the prevalence of disability, 4–14 million people are blind, 3.2 million people have hearing impairment, 16 million people are affected by locomotor disabilities and 3 percent of India's children are mentally retarded (WHO, 2011). According to the Indian Council of Medical Research (ICMR), cataract is the primary cause for 55 percent of blindness. The major causes of blindness as seen in the survey conducted by the National Programme for Control of Blindness (NPCB) included cataract, refractive errors, corneal opacity, glaucoma, trachoma and vitamin A deficiency. Health is influenced by a number of factors such as adequate food, housing, basic sanitation, and healthy lifestyles, and all these factors are not adequately and satisfactorily covered by the present healthcare system. The Government of India has policies related for the disabled, rehabilitation schemes, and grant-in-aid schemes run through NGOs; however, the implementation part of these policies and programmes is not satisfactory. Hence, it is imperative that the insufficient provisions to cover these factors will affect the health status of the individual and then ultimately of the state. The burden of disease estimation (2005) in Table 3 clearly shows the need of care and attention needed for healthcare services in India. Healthcare Services The purpose of healthcare services is to improve the health status of the population. The scope of health services varies widely from country to country. There is now broad agreement that health services should be comprehensive, available and accessible, and acceptable at a cost the community and country can afford. How far our healthcare system is satisfying these requirements is a serious question to judge and evaluate. The health status of the common man and the availability of health services to him at an affordable cost are very far from the objectives of health planning in India. Some of the indicators of the poor health status of the country are the increase in suffering and death from various diseases (accounting for about 20 percent of the world's disease burden), about 46 percent of our children are malnourished and more than half the women (56 percent) in the age of 15–49 years are anaemic (TOI, 10 June 2011). Sufficient progress was made in controlling infectious diseases such as diarrhoea, diphtheria, tuberculosis, malaria and other vector-borne diseases in the early decades after independence. However, after the 1980s, due to lack of sufficient resources and infrastructure required for the population of India and the weakening of the public and preventive health system, there has been a resurgence of many of these diseases such as malaria, TB, chikungunya, dengue and diphtheria. The war against infectious disease has become a serious challenge before the healthcare system; non-communicable diseases such as diabetes, cancer, hypertension and various types of mental disorders also lead to morbidity and mortality. This double burden of communicable and non-communicable diseases demands a more effective and efficient healthcare system and an adequate number of health manpower with increase in budget provisions on health in our five-year plans. But the provisions made are far from satisfactory compared with the increasing needs of the Indian population. Inadequate Resources Resources such as health manpower, money and material required to meet the vast healthcare needs of India are not sufficient. An analysis of increasing burden of diseases (refer back to Table 3), the availability of resources for healthcare needs and budget allocations for health provide a very dismal picture about the health concerns and programmes of the government. Irrational political interference, increasing corrupt practices, degenerating values and deviated work culture are the precipitating factors leading to the big gap between the healthcare needs of the people and the services available to them at the grassroot levels. Table 4 shows the suggested norms for health personnel prescribed for the Indian population and conditions. It is generally said that no nation, however rich, has enough resources to meet all the needs of healthcare. Therefore, an assessment of available resources and the proper allocation and efficient utilisation of resources are important considerations for providing efficient and effective healthcare services. However, in India, neither the proper steps are made to create adequate resources as per the changing needs nor serious efforts are made for proper allocation and management of available resources to utilise them optimally. Table 5 shows the national averages of the doctor–population ratio, the medical/psychiatric social worker ratio, the population–bed ratio and the nurse– doctor ratio in India, and Table 6 explains the availability of doctors in PHCs and specialists in community health Centres (CHCs) in India during March 2009. A careful study of the available data and sufferings of people clearly indicate the maldistribution of health manpower between rural and urban areas within the states. These studies have shown that there is a concentration of doctors up to 73.6 percent in urban areas where only 26.4 percent of population live. A latest survey of health ministry reveals that there is a shortfall of 20,903 (13.16 percent) subcentres, 40,803 (18.46 percent) PHCs and 2,653 (40.87 percent) CHCs in India as per the 2001 population (see Table 7). Shortfall means an unbearable load on the available services; hence, these scant available services are also not properly distributed to the needy, thereby increasingly worsening the situation. During the past few decades, professional social work has witnessed many changes and has proven its credibility to deal with different problems related to health (Ghosh, 2004)3. The professional social worker plays a pivotal role as a guide, educator enabler and facilitator. But in practical, this part in health manpower is ignored in India. Despite the guidelines given by the ICMR and WHO, medical social workers and psychiatric social workers are not appointed in hospitals except in some institutes of national importance. These posts have been lying vacant for many years in these institutes and never care has been taken to appoint them for local-level hospitals. The Millennium Development Goals In September 2000, representatives of 189 countries met at the millennium summit in New York to adopt the United Nations Millennium Declaration. The world leaders made specific commitments in seven areas: peace; security and disarmament; development and poverty eradication; protecting our common environment, human rights, democracy and good governance; protecting the vulnerable; meeting the special needs of Africa; and strengthening the United Nations. Governments set a target of 2015 by which they would meet the Millennium Development Goals (MDGs) in which health was placed at the heart of development and represent commitments 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. Thus, 3 of the 8 goals are directly related to health; all other goals have important indirect effects on health. Of the 18 targets, 8 are required to achieve these goals, and 18 of the 48 indicators of the progress are health related (Tables 8 and 9). It means that more emphasis should be provided to the health sector by the governments, especially in developing countries. But the targets achieved till 2007 are not encouraging because on the basis of the midterm evaluation, Secretary-General, United Nations, emphasised in the report that there is a clear need for political leaders to take urgent and concerted action, or many millions of people will not realise the basic promises of MDGs in their lives. In India, there is a slow progress in the improvement of health indicators related to mortality, morbidity and various environmental factors contributing to poor health conditions. An important indicator of health status is IMR, which is reported at 53 per 1000 live births in 2008. It is projected that at the current rate of decline, by 2015, India would have an IMR (under 5 years) of 64 per 1000 live births, which is very far from the target of MDGs. The United Nation's Millennium Development Goals report, 2012, assessed the regional progress and found that India is likely to miss the MDG's target related to maternal health. The report indicated that there is a marginal improvement from maternal death in every 6 min in 2010 to 10 min now, but it is far away from the target set to achieve the goal. In India, at present, MMR is 212 per one lakh live births, whereas the target is 109 per lakh live births by 2015. Therefore, one can conclude that with this speed achieving the MDGs will be a challenging task, especially for the poor states in India. A member of interventions, including improved infrastructure especially water and sanitation, health, electricity, roads, will be needed to attain the MDGs. Top Conclusion The above analysis indicates that ‘health’ a major component of any welfare state and has not been given proper attention by the Government of India. The steps taken time to time by the government to provide health services suffered with major gaps such as irrational and insufficient budget allocations to the health sector, inefficient management of resources, ignoring importance of education and training, imbalance in stress on curative and preventive aspects, lack of proper attention to public health services like pure drinking water and sanitation, poor administration of services and lack of honest political will. |
In the changing scenario, there is a need to think more carefully and gear up to face the challenge. The present conditions of the country such as increase in population, imbalance in demographic map, poverty, the impact of globalisation, liberalisation and privatisation on our social, economic, political structure has affected the basic characteristics of our society. Hence, there is an urgent need to take up the issue of health more carefully, seriously, scientifically and rationally at the local and central levels. Health being an important constituent of human development must be at the top priority and immediate steps should be taken to increase government spending on health and family welfare, nutrition, sanitation and elementary education. There is a need to rethink the strategy of implementation of primary healthcare services for which the present approach of last priority and residual concern needed to be changed to first priority and main focus. It can be done by empowering people through community participation in identifying the priorities. |
Top Footnotes Government of India, Planning Commission. The First Five Year Plan, New Delhi, 1952, PD.490-92. TopBack Sapru, R.K., Health Care Policy and administration in India, The Indian Journal of Public Administration, New Delhi, July-Sept.1997. TopBack Ghosh, Raja, Work in Health: Scope and experiences with special emphasis to Rabindranath Tagore's Creativity, Perspectives in Social Work Vol. XIX, No. 1, Jan.-April 2004. TopBack Tables | Table 1:: Availability of medical personnel in India, 1947
| | Medical Personnel | India | United Kingdom | | Doctor | 6,3001 | 1,000 | | Nurse | 43,000 | 300 | | Health visitor | 4,00,000 | 4,710 | | Midwife | 60,000 | 618 | | Dentist | 3,00,000 | 2,700 | | Pharmacist | 40,00,000 | NA |
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| | | Table 2:: Committees/Programmes to Promote Healthcare System in India
| | Name of the Committee/Programme | Year | | Bhore Committee | 1946 | | Mudalian Committee | 1962 | | Chadha Committee | 1963 | | Mukherji Committee | 1965 | | Mukherji Committee | 1966 | | Jungalwalla Committee | 1967 | | Kartar Singh Committee | 1973 | | Shrivastava Committee | 1975 | | Rural Health Scheme | 1977 | | Health for all by 2,000 A.D. | 1981 | | National Health Policy | 1983 | | Universal Immunization Programme | 1985 | | National Diabetes Control Programme | 1987 | | National AIDS Control Programme | 1987 | | Child Survival and Safe Motherhood Programme | 1992 | | Revised National Tuberculosis Programme with DOTS | 1993 | | Pulse Polio Immunization | 1996 | | Reproductive and Child Health Programme | 1997 | | National Population Policy | 2000 | | National Health Policy | 2002 | | National Rural Health Mission | 2005 |
| | | Table 3:: Disease Burden Estimation, 2005
| | Disease/Health Condition | Estimate of cases (lakh) | Projected number (2015) of cases (lakh) | | Communicable Diseases | | | | Tuberculosis | 85 (2000) | 544 (NFHS-II) | | HIV/AIDS | 51 (2004) | 190 | | Diarrhoeal diseases episodes per year | 760 | 880 | | Malaria and other vector -borne diseases | 20.37 (2004) | NA | | Leprosy | 3.67 (2004) | Expect to be eliminated | | Otitis media | 3.57 | 4.18 | | Non-communicable conditions | | | | Cancers | 8.07 (2004) | 9.99 | | Diabetes | 310 | 460 | | Mental Health | 650 | 800 | | Blindness | 141.07 | 129.96 | | CVDs | 290 (2000) | 640 | | COPD and Asthma | 405.20 (2001) | 596.36 | | Other Non-communicable conditions | | | | Injuries deaths | 9.8 | 10.96 | | Number of hospitalisations | 170 | 220 |
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| | | Table 4:: Suggested norms for health personnel
| | Category of personnel | Norms | | Doctors | 1 per 3,500 population | | Nurses | 1 per 5,000 population | | Health workers (female and male) | 1 per 5,000 population (in plain areas) 1 per 3,000 population (in hilly and tribal areas) | | Trained dai | One for each village | | Health assistants | 1 per 30,000 population in plain areas and 20,000 in hilly and tribal areas | | Pharmacists | 1 per 10,000 population | | Lab technicians | 1 per 10,000 population |
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| | | Table 5:: Health manpower in India
| | Manpower | Number | | Doctors per 1,00,000 population | 56 | | Beds per 10,000 population | 9.3 | | Nurses and midwives per 1,00,000 population | 78 | | Medical social worker | 0.03 per 1000 population |
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| | | Table 6:: Availability of Doctors, March 2009.
| | State | PHCs | Specialists in CHCs | | Andhra Pradesh | 2214 | 480 | | Arunachal Pradesh | 87 | 09 | | Assam | 344 | 142 | | Bihar | 1565 | 104 | | Chhattisgarh | 1100 | 145 | | Goa | 44 | 14 | | Gujarat | 1019 | 76 | | Haryana | 427 | 79 | | Himachal Pradesh | 361 | 00 | | Jammu & Kashmir | 550 | 138 | | Jharkhand | 1678 | 341 | | Karnataka | 3146 | 691 | | Kerala | 1063 | 794 | | Madhya Pradesh | 541 | 245 | | Maharashtra | 2065 | 438 | | Mizoram | 51 | 00 | | Manipur | 117 | 02 | | Meghalaya | 128 | 04 | | Nagaland | 144 | 02 | | Orissa | 866 | 371 | | Punjab | 349 | 254 | | Rajasthan | 1523 | 598 | | Sikkim | 51 | 07 | | Tamil Nadu | 1271 | 00 | | Tripura | 109 | 04 | | Uttarakhand | 126 | 39 | | Uttar Pradesh | 2001 | 618 | | West Bengal | 932 | 175 | | Union Territories of India | 1/0 | 19 |
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| | | Table 7:: Shortfall in Health Infrastructure in India
| | Required | Existing | Shortfall | %Shortfall | | Sub-Centres | 158792 | 144998 | 20903 | 13.16 | | PHCs | 026022 | 022669 | 04803 | 18.46 | | CHCs | 006491 | 003910 | 02653 | 40.87 |
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| | | Table 8:: Health-related Millennium Development Goals and Indicators
| | | | Table 9:: Health-related Millennium Development Goals in India
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