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5. DEVELOPMENT OF
THE HEALTH SYSTEM
5.1 Health policies
and strategies
Anaemia and malnutrition among women and children respectively has led
to serious problems of macro and micro nutrition capacities. Moreover, the
public health expenditure over the years has been less in India due to
which out-of-pocket expenditure is more. As a result of all this, a realistic
strategy was planned before making the NHP of 2002 according to the current
needs of the people. The main goal of NHP 2002 is to evolve a policy
structure to reduce the inequalities and to see that public health services
are acceptable to the disadvantaged sections of the people.
The main objective of this policy is to achieve an acceptable standard
of good health among the general population of the country. The approach
would be to increase access to the decentralized public health system by
establishing new infrastructure in deficient areas, and by upgrading the
infrastructure in the existing institutions. Overriding importance would be
given to ensuring a more equitable access to health services across the
social and geographical expanse of the country. Emphasis will be given to
increasing the aggregate public health investment through a substantially
increased contribution by the Central Government.
Emphasis will be laid on rational use of drugs within the allopathic
system. Increased access to tried and tested systems of traditional medicine
will be ensured. Within these broad objectives NHP 2002 shall achieve the
goals of eradicating Polio and Yaws by 2005, eliminate leprosy by 2005,
eliminate kala azar by
2010, eliminate lymphatic filariasis by 2015, achieve a zero level growth of
HIV/AIDS by 2007, reduce mortality
on account of TB, Malaria and other vector borne diseases by 2010, reduce
prevalence of blindness by 0.5 percent by 2010,
reduce IMR to 30/1000 and MMR to
100/100,000 by 2010, increase utilization of public health facilities from
less than 20 to more than 75 percent
by 2010, and establish an integrated system of surveillance.
The public health administration at the State level is to render
effective service delivery. The contribution of the private sector in providing
health services would be much enhanced, particularly for the population
group, which can afford to pay for services. Priority will be given to
preventive and first-line curative initiatives at the primary health level
through increased sectoral share of allocation.
National health Accounts and Health statistics by 2005 show increase
in the expenditure by government as a percentage of GDP from the existing 0.9
percent to 2 percent by 2010, increase share of central grant to constitute
at least 25 percent of total
spending by 2010, increase State sector health spending from 5.5 percent to 7
percent of the budget by 2005 and
further increase it by 8 percent by 2010. The policy places great reliance on
the strengthening of primary health structure for the attaining of improved
public health outcomes on an equitable basis.
Millennium Development Goals
The progress made towards achievement of health related Millennium
Development Goals is given in Annex-2.
Related Links
 National Health Policy 2002- India
Health
Policy WHO/HQ
5.2 Inter-sectoral cooperation
Inter-sectoral cooperation is very much for
the betterment of health services in India. Public health mainly
depends on adequate nutrition, safe drinking water, sanitation, a clean
environment, primary education, etc., which are all interconnected. There is
a need for policies to be interrelated. The Expert committee on Public Health
System (Bajaj committee) 1996 has rightly emphasized the need for
coordination with other sectors for better health outcomes. It has suggested
for two committees to be set up, i.e., cabinet committee on health and
committee of secretaries chaired by cabinet secretary comprising all
departments concerned with activities influencing health outcomes, like
education, sanitation, drinking water, environment, nutrition, etc.
Related Links
WHO - India
5.3 Organization of the health system
The healthcare services organization in the country
extends from the national level to village level. From the total organization structure, we
can slice the structure of healthcare system at national, state, district,
community, PHC and sub-centre levels.
National level The organization at the
national level consists of the Union Ministry of Health and Family
Welfare. The Ministry has three
departments, viz. Health, Family Welfare, and Indian System of Medicine and
Homeopathy, headed by two Secretaries, one for Health and Family Welfare and
the other for ISM and H. The
department of Health is supported by a technical wing, the Directorate
General of Health Services, headed by Director General of Health Services
(DGHS).
State level - The organization at State
level is under the State Department of Health and Family Welfare in each
State headed by Minister and with a Secretariat under the charge of
Secretary/Commissioner (Health and Family Welfare) belonging to the cadre of
Indian Administrative Service (IAS).
By and large, the organizational Structure adopted by the State is in
conformity with the pattern of the Central Government. The State Directorate of Health Services,
as the technical wing, is an attached office of the State Department of
Health and Family Welfare and is headed by a Director of Health
Services. However, the organizational
structure of the State Directorate of Health Services is not uniform
throughout the country. For example,
in some states, the Programme Officers below the rank of Director of Health
Services are called Additional Director of Health Services,
while in other states they are called Joint/Deputy Director, Health
Services. But regardless of the job
title, each programme officer below the Director of
Health Services deals with one or more subject(s). Every State Directorate has supportive
categories comprising of both technical and administrative staff.
The area of medical education which was integrated with
the Directorate of Health Services at the State, has
once again shown a tendency of maintaining a separate identity as Directorate
of Medical Education and Research.
This Directorate is under the charge of Director of Medical Education,
who is answerable directly to the Health Secretary/Commissioner of the
State. Some states have created the
posts of Director (Ayurveda) and Director
(Homeopathy). These officers enjoy a
larger autonomy in day-to-day work, although sometimes they still fall under
the Directorate of Health Services of the State.
Regional level
In the state of Bihar, Madhya Pradesh, Uttar
Pradesh, Andhra Pradesh, Karnataka and others, zonal or regional or
divisional set-ups have been created between the State Directorate of Health
Services and District Health Administration.
Each regional/zonal set-up covers three to five districts and acts
under authority delegated by the State Directorate of Health Services. The status of officers/in-charge of such
regional/zonal organizations differs, but they are known as
Additional/Joint/Deputy Directors of Health Services in different States.
District level - In
the recent past, states have reorganized their health services structures in
order to bring all healthcare programmes in a
district under unified control. The
district level structure of health services is a middle level management organisation and it is a link between the State as well
as regional structure on one side and the peripheral level structures such as
PHC as well as sub-centre on the other side.
It receives information from the State level and transmits the same to
the periphery by suitable modifications to meet the local needs. In doing so, it adopts the functions of a
manager and brings out various issues of general, organizational and
administrative types in relation to the management of health services. The district officer with the overall
control is designated as the Chief Medical and Health Officer (CM & HO)
or as the District Medical and Health Officer (DM & HO). These officers are popularly known as DMOs or CMOs, and are overall
in-charge of the health and family welfare programmes
in the district. They are responsible
for implementing the programmes according to
policies laid down and finalized at higher levels, i.e. State and
Centre. These DMOs/CMOs
are assisted by Dy. CMOs
and programme officers. The number of such officers, their
specialization, and status in the cadre of State Civil Medical Services
differ from the State to State. Due to
this, the span of control and hierarchy of reporting of these programme officers vary from state to state.
Sub-divisional/Taluka level At the Taluka
level, healthcare services are rendered through the office of Assistant
District Health and Family Welfare Officer (ADHO). Some specialties are made available at the taluka hospital.
The ADHO is assisted by Medical Officers of Health, Lady Medical
Officers and Medical Officers of general hospital. These hospitals are being gradually
converted into Community Health Centres (CHCs).
Community level
For a successful primary healthcare programme,
effective referral support is to be provided.
For this purpose one Community Health Centre (CHC) has been
established for every 80,000 to 1, 20,000 population, and this centre
provides the basic specialty services in general medicine, pediatrics,
surgery, obstetrics and gynecology.
The CHCs are established by upgrading the
sub-district/taluka hospitals or some of the block
level Primary Health Centres (PHCs)
or by creating a new centre wherever absolutely needed.
PHC level At
present there is one Primary Health Centre covering about 30,000 (20,000 in
hilly, desert and difficult terrains) or more population. Many rural dispensaries have been upgraded
to create these PHCs. Each PHC has one medical officer, two
health assistants one male and one female, and the health workers and
supporting staff. For strengthening
preventive and promotive aspects of healthcare, a
post of Community Health Officer (CHO) was proposed to be provided at each
new PHC, but most states did not take it up.
Sub-centre level
The most peripheral health institutional facility is the sub-centre manned by
one male and one female multi-purpose health worker. At present, in most places there is one
sub-centre for about 5,000 populations (3,000 in hilly and desert areas and
in difficult terrain).
The 73rd and 74th constitutional amendments have
given the powers to the local bodies in some states of India. In the process, different
states have adopted different stakeholders for the benefit of health
services, with the help of community participation, which gives stress on
safe drinking water and sanitation at village level. The Panchayats
are given the power to look after the welfare of the people.
Ministry
of health and Family welfare
Health System
- WHO/SEARO
5.5 Health information system
Census The census in India is a
decennial activity, which pools tremendous resources, and huge data
pertaining to many facets of population is generated. The census in India started on regular basis
from the year 1891 and last one was
conducted in the year 2001. The data
represents the situation as on 1st March (except 1971 census when
it was 1st April). It
normally provides age and sex structure and spatial distribution of
population. In addition, it also
provides information on some socio-economic factors. Occasionally some additional information is
also obtained like mortality, disability, etc. Among all sources of information, census
information reaches maximum accuracy.
Related Links
Census India
Civil Registration
System - It is a
continuous permanent systematic activity of enlisting vital events
countrywide. Considering its utmost
importance, this activity is given legal status through a special Act, Birth
and Death Registration Act 1969.
Authorities like local registrar, Registrar General under the act in
different areas like rural, urban have been designated from various
sectors. Normally, the local registrar
is from local self-government or from health department. General apathy leads to gross
under-registration from time to time and differs from place to place. There is often a considerable time lag
between collection of data and its compilation and publication. The data collected from urban area are
comparatively of better quality than from rural area.
Sample Registration
System In
1964-65, Government of India introduced Sample Registration System for
improving reliability of data pertaining to vital events and also to have
urban and rural break-up. Population
covered was 61,12,000 in 1998. Although initiated on pilot basis, it
covered 2,235 urban sampling units and 4,436 rural sampling units
selected. A Government servant,
usually a teacher, is selected and trained to function as enumerator. A baseline survey of sample unit is
conducted to obtain information about usual resident population of the same
sampling areas. The enumeration of
birth and deaths is continuously carried out pertaining to resident
population by him for his area. Every
six months, an official supervisor makes a visit and independently checks all
the households in the area of enumerator.
Thus, it functions as a continuous process and which is superimposed
by periodic retrospective surveys.
Unmatched or partially matched events after verification are added and
final estimates are worked out.
Sometimes, additional information is also collected through sub
samples. Presently, this is supposed
to be most accurate data source providing information about birth rate, death
rate, age specific death rates, Infant Mortality Rate, age and sex
composition, and seasonal and spatial variations in these statistics. It has been decided now to collect data
pertaining to causes of deaths on regular basis. Sample Registration System provides information by states and for the
country.
Related Links
Census
India
National Sample
Surveys
National Sample Survey Organisation regularly
conducts nation-wide surveys collecting information regarding social,
economical, demographic, industrial and agricultural conditions. The organisation
has many wings. One wing shoulders
responsibilities like designing the sample survey, improving quality of data,
etc. Another wing consists of well trained full time personnel who actually
conduct surveys. The organisation also obtains support from State statistical organizations. Normally, the surveys collect multi sectoral information.
The surveys are conducted in the form of rounds stretched over a
specific period, generally one year.
The first round was carried in the year 1951 and 55th round
in the year 1999-2000. The organisation has published extensive information through
456 reports. Sometimes, special
information directly pertaining to health is also collected.
Related Links
Ministry
of Statistics and Program Implementation
Service statistics - Information generated from Sub Centre level and above is also fed
into the health information system on specifically designed reporting formats
submitted monthly. The health and family welfare information is compiled at
district level and submitted to State level from where it goes to central
level (GoI).
Ministry of Health and Family Welfare brings out two publications
yearly (there is backlog currently) Family Welfare Yearbook and Health
Information Yearbook. These yearbooks compile all information available from
various sources and present by districts, states and country. However, most
of the information pertains to services provided by public sector.
In addition, all India
surveys are also conducted such as National Family Health Survey (I & II
have been done so far), RCH survey, etc.
India has national disease surveillance. The surveillance exists only for
polio and HIV/AIDS and it has been effective in getting information. However,
there is a need for a strong disease surveillance network in the whole
country for better information on diseases and better health initiatives
Related Links
Central
Bureau of Health Intelligence
Misitry of
Health and Family Welfare
5.6 Community action
A considerable change has happened in the last two decades towards
implementation of the government's action plans through the institutions of
civil society and NGOs. It is to be recognized that widespread debate on
various public health issues has, in fact, been initiated and sustained by
NGOs and other members of the civil society. Also, an increasing contribution
is being made by such institutions in the delivery of different components of
public health services. Certain disease control programmes require close
interaction with the beneficiaries for regular administration of drugs,
periodic carrying out of pathological tests, dissemination of information
regarding disease control, and other general health information.
5.7 Health research and technology.
Research in the private sector has assumed some significance only in the last decade. In our country, where the
aggregate annual health expenditure is of the order of Rs.
80, 000 corers, the expenditure on research, in both public and private
sectors in 1998-99, was only of the order of Rs.
1150 corers. It would be reasonable to infer that with such low expenditure
on research, it is virtually impossible to make any dramatic break-through
within the country, by way of new molecules and vaccines; also, without a
minimal backup of applied and operational research, it would be difficult to
assess whether the health expenditure in the country is being incurred
through optimal applications and appropriate public health strategies.
Related Links
Indian
Council of Medical Research
National
Documentation Center
Institute of
Health Management Research
Research WHO/HQ
Research
WHO/SEARO 
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