NATIONAL HEALTH POLICY
Item
- Title
- NATIONAL HEALTH POLICY
- extracted text
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GROUP DISCUSSION
- PROBABLE PROCESS
The group elects a Chairman and a rapporteur who will remain the
same for Sessions III and IV and the rapporteur will present the
deliberations of the group in session V (10/4/92 at 2.00 p.m.)
The group might like to follow the following schedule of activity:
Dnrinq Session III, (9/4/92) in the afternoon
* The grouj^hrough in detail the Policy Document
* Discusses the Policy statements referring to individual groups
* Discusses issue arising out of Policy statements
- Present status of implementation at State/District/PHC Level
- Are we going in line with the Policy?
- If not, what are the areas needing strengthening? - Govt.health
Set up
- Non-Govt.
Organisation
- What should be the approach at different levels of Health
Care - State/District/PHC
- What should be the approach by Health related sectors
- Any other aspect group likes to discuss.
During Session IV (10/4/92) in the morning
* Starts the discussion reviewing the activities of previous day.
v-x
4 cmectah and
oriH citportps
1 an focusing
Continue 4"
the
discussion
prepares an
an action
action oplan
focusing on
Orientation of Partners in Health Care on Health Policy
* Implementation of aspects discussed previous day at different
levels of Health care by Govt./NGO and People’s representatives.
*
*
Supervision, monitoring and evaluation of the implementation.
*
Need/otherwise of a State Health Policy
The group rapporteur presents in detail aspect of Health Policy
discussed, members participating in the discussion and detailed
action plan.
Focusses on Primary Health Care
I
Group
Focusses on Health Education
Group II
Focusses on Inter-sectoral co—cordination
Group III
Group IV Focusses on Heai-fch Information System
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Hp 7- * 3
CURilENT _ HEAL TH JTA1US . OF INDIA
(By Dr.J.P.GUPTA, Regional Director (H&FW) Sangalore)
According to WHOS ‘’the process of continuous progressive
improvement of the health status of a population reflects the
health development of the nation”. It is a product of rising
•f the level of human well-being marked by containment of
diseases and attainment of positive physical and mental healthrelated to satisfactory economic functioning and social
integration.
It is based ^n the fundamental principle that Governments have
., v. responsibility of their people and simultaneously people should
have the right as well as the duty, individually or collectively
to participate in the development of their own health.
1
■
The health status depends upon the over all social and ecenomic
development of the country.
There are a number of indicators to gauze health status of the
community to the extent to which the objectives and targets of
a programme are being attained.
racteristic of indicator ~
The ideal indicators .scientifically should be Valid, Reliable,
Sensitive, Specific and Quantifiable, There is presently no
available definition (including WHO definition) containing all
the ideal indicators as criteria for measuring the health.
Only the measurement of health have been dubbed in the frame
work of illness, the consequences of ill health (morbidity or
disability) and economic, occupational and domestic factors
that promote ill health.
Since health is multidimensional and each dimension is
influenced by numerous factors (known or unknown); thus the
health status may cover the following indicators
Mortality indicators. Morbidity indicators, Nutritional status
indicators, Health care delivery indicators, Utilisation rates,
Indicators of social and mental health, Environmental indicators.
Socio-economic indicators, Health policy indicators, Indicators
of quality of life and Other indicators.
- oOo
K* * M
^REFORMJIATED ..J^3AL_INDIC^T0
(As adopted with amendments by the Executive Board
by Resolution EB 85.R5)
No.1 - The number of countries in which health for all
all is
is
continuing to receive endorsement as policy at the
highest level.
No.. 2 — No., of countries in which mechanism for involving people
in the implementation of strategies are fully functioning
or are being further developed.
No.3 - The percentage of gross national product on health.
No .4 - The percentage cf National Health Expenditure devoted
to local health Services.
No.5 - The No.of countries in which resources for Primary
Health Care are becoming more equitably distributed.
No.6 - The amount of International Aid received or given for
health.
■
No.7 - The percentage cf the population covered by Primary
Health Care, with atleast the following —
(a) Safe water in the home or with reasonable access
and adequate excreta disposal facilities available.
(b) .Immunization
against Diphtheriaa , Tetanus,
.j.
t
Whooping-cough, measles, Poliomylitis and
Tuberculosis 7
(c) Local Health Services, including
■'
availability of
essential drugs, within one hour's walk or.,ttavel,
(d) Attendance by trained personnel for pregnancy and
child birth and caring for children upto atleast
one year of age.
(e) The percentage of each element should be qiven
fcr all identifiable subgroups.
(f) The percentage of women of child-bearing age using
family planning*
No. 8 - The percentage of newborns weighing, at least 2500 grams
at birth and the percentage of children whose weightfor-age and/or weight-for-height are acceptable.
No.9 - The
IMR,- MMR, and *probability
of sadying
before ui
the
_
— --------- 1
j .l
je age
of 5 years (U5MR), in all identifiable subgroups.
No. 10 - Life expectancy at birth, by sexx in all identifiable
subgroups.
No. 11 - The adult literacy rate, by sex, in all identifiable
subgroups.
Ne.12 - The per capita Gros.s National Product.
3
NATIONAL GOALS OF HEALTH
(Seurce:
National Health Policy Document)
GOALS
achievement
* INFANT MORTALITY RATE
(combined)
(per 1000 live births)
6*
80 (1990-prov.)
UNDER-5 MORTALITY
(per 1000 live births)
70
146 (1990 >
MATERNAL MORTALITY
(per lakh birth)
200
400 (1990)
PERINATAL MORTALITY
30-35
5C.1 (1987)
■-CRUDE DEATH RATE (Combined)
9/1000
9.6 (1990-Prov.)
*CRLJDE BIRTH RATE (Combined)
21/1000
29.9 (1990-Prov.)
**EFFECTIVE CPR
60%
44.1 (1991-Prov.)
1*0
1.6 (1981)
@9 FAMILY SIZE (Rural &
Urban combined)
2.3
4.1 (1987)
® EXPONENTIAL ANN GR.RATE
1.2
2.11 (1991)
(Source Census
Report 1991)
@% NEWBORN WITH 2500 Gms
Birth Weight.
10%
30% (1990)
@ % OF ANTENATAL CARE
100%
40-50%
@ % DELIVERIES BY TBA
100%
40.5% (1987)
*-* IMMUNIZATION - TT(PW)
100%
79% (1991)
!'TT School Children
100%
55.6% (1989)
DPT
100%
82% (1990)
POLIO
100%
82% (1990)
BCG
100%
89% (1990)
DT
85%
** MEASLES
100%
N.R.R
■
80%
(1990)
M.1% (1991)
- 4 OTh^JJ^ICATORS
GOALS
ACHIEyEMENT.
64.0
59.0 (1990)
100%
55% (1989)
T.B.(% of Disease arrested
out of those detected)
75%
65% (1989)
O INCIDENCE OF BLINDNESS (%)
0.3
0.7 (1990)
LIFE EXPECTANCY AT BIRTH
(persons)
.: c.-
LEPROSY (% of Disease arrested
out of those detected)
Female Literacy (1991) =39.4
© % of children sufferin
from
underweight (0-4 yrs.
(By Gomez - 8 States)
Moderate & severe = 61 (1980-91)
severe = 9 (1980-91)
© Average index of food produc
tion per capita (1979-81=100)
= 1^8 (1990)
@ Daily per capita calorie supply
as % of requirements (1988)
95
@ % of household income (1980-85)
Spent on - All foods
9
Cereals
52
18
@ % of Population with access to
safe water (1989-90)/
Total
Urban
Kural
= 75
= 79
= 73
@ O.R.T. use rate (1987-89)
= 13
@ GNP per capita (in US S) (1989)
340
Sources * - SRS Report 1990
@ - The State of the World’s children 1992 - UNICEF
- MCH&FW Quarterly report
@@ - 2nd Evaluation - Country report on strategies
4
for Health for all by the year
’®
2000-1991
r
5
LEVEL OF ACHIEVEMENT OF SOME NORMS
ALL INDIA POSITION AS ON 30.09.1991
■».
SI.
No.
..a. JU-*.*,.-, .ni-ax
Parameters/indicators
National
Norms
2
3
1. Population covered by a
Sub-centre
Norms'achieved/
established
(Approximate)
4
3000-5000 Pop.
4576 •
2. Population covered by a PHC
20,000-30,000 Pop.
27168
3. -Population covered
- _ ___ _by/ a
Community Health Centre
About 1 lakh Pop.
3.10 lakhs
4. No.of Sub-centres for each
PHC
.
6 sub-centres
5. No.of Primary Health Centres
for each Community Health
Centre
6.0 sub-centres
4 PHCs
11.4 PHCs
6. Trained Village Health ^uide
One for each
village/1000
population
1*42 villages/
VHG
1442 population/
VHG
7. Trained Dai
Atleast one for
each village
1.00 villages
1002 population
8, Population served by
Health Workers (Male and
Female)
M:3000-5000
F:3000-5000
7632
4953
9. Ratio of HA(M):HW(M)
1 :6
1 :3.4
10. Ratio of HA(F):HW(F)
1 :6
1:5.4
11. Average area covered by
Sub-Centre
12. Average Area covered by a PHC
13. Average area covered by a CHC
14. Max,radial distance covered
by a PHC (in km.)
15. Max.radial distance covered
by a Sub-centre (in km.)
16. Max.radial distance covered
by a CHC (in km)
1T. Average number of villages
covered by a sub-centre
24.00 sq.km.
142.45 sq.km.
1626.93 sq.km.
6.73 km.
2.76 km.
22,81 km
4-5
18. Average number of villages
covered by a PHC
26-27
19. Average number of villages
covered by a CHC
Source: Quarterly Bulletin on Rural Health Statistics
3C4
•Sep. 1991.
•%
- 6 HEALTH Ib^lSITOCTyi^
As.
A.
Buildings
to be con-structed.
Total
f unctioninq.
In Govt.
Build
ing.
Building
under con_ ..struct! on
SuB-Centres > 130983
51985
(39.7%)
7505 .
71093
(54.3%)
-jak --a rau -»
imh i.
‘wx-. •»
PHCs
22065
12500
(56.6%)
1389
8176
(37.0%)
CHCs
1932
1179
(61.»%)
284
469
(24.3%)
-» - •
Ba
••
II.Maax. ri
’ -
.wra
«v •»<■ xrr --r—rnt. ■
-ua
-*» ..
•• >
.*• <-■ .
-•
.r-
w
.
hi-
. .......... ;
No.of PHCs & Sub-Centres required and in position in
THbTCAFeT= Total Population in TSP Area = 776.84 lakhs
= r,{otal Population in Tribal pocket = 403.02 lakhs
= lotal PHCs required for Tribal Area = 3507
= Total PHCs in position in Tribal Area = 3198 (91.2%)
=
Sub-Centres required in Tribal Area = 23586
= Total Sub-Centres in position in Tribal Area = 18996 (80.5%)
C. Primary Health Cen^tres, with or without Doctors
TlnTormation ‘available for ’1’0787^ PHCs. (48.9/? only)
= PHCs with 4 or more Doctors
= PHCs with 3 Doctors
= PHCs with 2 Doctors
PHCs with 1 Doctor
PHCs without Doctors
= 427
= 450
= 3875
= 5048
= 987
D. = PHCs without Lab,.Technician
= PHCs without Pharmacist
3787
311
= 476
E. = Total No.of ANM Schools
=20337
= ANM admission capacity
= Total No.of LHV promotional schools = 46
= 3863
= ANM admission capacity
F, = Total Dais trained since inception
(as on 30-9-91)
= Village Health Guide Scheme
-PHCs covered under VHG Scheme
-Villages covered under VHG Scheme
-Total VHGs Trained
(including 948 AHGs)
- No.of working VHGs
597761
4220
531009
416672
335590
G* = Medical Ca r e St a t i sties - As on 1-1-1990
TSourcV"-'Tlealth Tnformation India - 1990)
Urban
^ural
7005
- No.of Hospitals
3137~
506768
- No.of beds
95722
15557
- NOiOf dispensaries
12747
9286
- No.of Beds
13642
Total
10T72
602490
28304
22928
H. = disabled population (as per 1981 Census report)
“
Lrrc~f^7Tn
ttural Area
Arpa
= 969401
- disabled
pe’rsons in ftural
7
= 149547
- Disabled person in Urban area
=1118948
- Total Disabled person
I. Percentage of Population below poverty._line (1987-88 Prcvj
“TS'oufce -Health information India - 1990)
- Rural
- Combined
= 32.66%
= 29.23%
7
J. HEALTH MAN.PpJRR IN RURAL AREAS Category
No.Sanctioned
No. in
Vacant
£osi±i°n
• -in 111 I ■■ 111 wi -Mi;-
1 . Surgeons
914
676
25.1
2. Obs.& Gyn.
627
362
42.4
3, Physicians
535
406
24.2
4* Paediatricians
512
274
46.4
5. Doctors at PHCs
25062
21278
15.1
6i Glock Extn, Educators
6154
5763
6.4
7. Health Asstts. (Male)
24891
23273
6.5
8. Health Worker (Male)/MPW 86713
78538
9.4
9. Health Asstts.(Fem)/LHVs 25044
22282
11.1
132449
121016
8.7
11.Pharmacists
19172
17578
8.4
12. Lab.Technicians
10189
8629
15.4
13. Nurses Mid-wives
13790
11969
13.3
14. Radiographer
658
509
22.7
Total category 1 to 4
2588
1718
33.6
Total of category (5 to 1.4) 344122
3H835
9.7
Grand total of all (1-14)
312553
9.9
10. Health Workers (Fem)/
’ ANMs
346710
PERCENTAGE OF GROSS NATIONAL ^PROpUCT . SPIENT^JIN HEALTH Estimation of total expenditure on Health and Family Welfare
have been taken into consideration on the following basis:-
(1) Expenditure of Ministry of Health and Family Welfare
(Centre and State - both Plan and Non-plan)‘
(2) Expenditure on Health and Family Welfare by other
government Departments (except Defence, Paramilitary
orces, Local bodies and P & T etc - since data are
not available;.
(3) For estimating private
expenditure
.
.... ------------- > on Health and
Family Welfare, the basic assumption is that the
private expenditure is double the amount of’Public
|ector
rector Expenditure (on the basis of National Sampl
Sample
Survey findings).
The’ findings are (A) uring Sixn^ and Seventh Plan the total expenditure
on Health and Family Welfare (from Departments of
Health and Family Welfare of States, UTs. and
Centre only) as percentage of GNP is between the
rate of 0.98% (1986-87) to 1.32% (1984-85)
X
For year 1984—85
National Health Expenditure
’ GNP
X 100
R3• 3018.36 ^Crores,
X 100 = 1.32%
Rs.228,1T8 Crores
(Source - Planning Commission)
“
(B) As percentage of HNP, the total public sector expenditure
(as per above information) has remained within the range
of 1.32% (1984-85) and 1.07% (1986-87).
(C) -^he total expenditure on Health and Family Welfare
including the Private Sector is within the range of
4.08% (1984-85) to 3-2% (in 1986-87).
MRCENTAGE_OF NATIONAL HEALTH EXPENDITURE ON LOCAL HEALTH SERVICES
Only outlays of Minimum Need Programmes (below district level)
has been considered. Therefore the following figures are not
showing realistic picture - rather it is an under estimate -
£°r J.985^1990
National Health Expenditure elevatedto local services^
National Health Expend’iture
(including F.W.)
“
63 Crores
Rs. 2495 Crores ■
X 100
X 100 = 42.6%
(Source - Planning Commission)
(It excludes Central Health outlay of Rs.897 crores,
Family Welfare outlay of Rs.3256 crores and outlays for
National Health Programmes ~ because expenditure below
district level is not available).
f.:
TX> P lx C
»
CURRENT HEAL TH JIAIV,S ..pF JNDIA
(By Dr.J.P.GUPTA, Regional Director (H&FW) Bangalore)
According to WHO, ;,the process of continuous progressive
improvement of the health status of a population reflects the
health development of the nation'*8. It is a product of rising
•f the level of human well-being marked by containment of
diseases and attainment of positive physical and mental health
related to satisfactory economic functioning and social
integration.
It is based *n the fundamental principle that Governments have
responsibility of their people and simultaneously people should
have the right as well as the duty, individually or collectively
to participate in the development of their own health.
The health status depends upon the over all social and ecenomic
development of the country.
There are a number of indicators to gauze health status of the
community to the extent to which the objectives and targets of
a programme are being attained.
Characteristic of indicator The ideal indicators scientifically should be Valid, Reliable,
Sensitive, Specific and Quantifitble• There is presently no
available definition (including WHO definition) containing all
the ideal indicators as criteria for measuring the health.
Only the measurement of health have been dubbed in the frame
work of illness, the consequences of ill health (morbidity or
disability) and economic, occupational and domestic factors
that promote ill health.
Since health is multidimensional and each dirhension is
influenced by numerous factors (known or unknown); thus the
health status may cover the following indicators:-
Mortality indicators, Morbidity indicators, Nutritional status
indicators, Health care delivery indicators, Utilisation rates,
Indicators of social and mental health, Environmental indicators,
Socio-economic indicators, Health policy indicators. Indicators
of quality of life and Other indicators.
- oOo -
- 2 -
.^FgjyyiuuxTED. glpjal_indicm
(As adopted with amendments by the Executive Board
by Resolution EB 85.R5)
No.1 ~ The number of countries in which health for all is
continuing to receive endorsement as policy at the
highest level.
No.2
No.of countries in which mechanism for involving people,
in the implementation of strategies are fully functioning
or are being further developed.
i
No.3 - T^e percentage of gross national product on health.
No. 4
The percentage cf National Health Expenditure devoted
to local health services.
No. 5 - The No.of countries in which resources for Primary
Health Care are becoming more equitably distributed
No. 6 - lhe amount of International Aid received or given for
health.
No.7 - The percentage ef the population covered by Primary
Health Care, with atleast the following (a) Safe water in the home or with reasonable access
and adequate excreta disposal facilities available.
(b) Immunization against Diphtheria, Tetanus,
Whooping-cough, measles, Poliomylitis and
Tuberculosis.
(c) Local Health Services, including availability of
essential drugs, within one hour’s walk or travql.
(d) Attendance by trained personnel for pregnancy and
child birth and caring for children upto atleast
one year ' of age.
(e) The percentage of each element should be given
fer all identifiable subgroups.
(f) The percentage of women of child-bearing age using
family planning*
No. 8
■ The percentage of newborns weighing at least 2500 gr
grams
at birth and the percentage of children whose weightfor-age and/or weight-for-height are acceptable.
No. 9
The IMR, MMR and probability of dying before the age
of 5 years (U5MR), in all identifiable subgroups.
No. 10 - Life expectancy at birth, by sex, in all identifiable
subgroups.
No. 11
The adult literacy rate, by sex, in all identifiable
subgroups.
N«.12 - The per capita Gross National Product.
3
NATIONAL GOALS OF HEALTH
(Seurce:
National Health Policy Document)
GOALS
ACHIEVEMENT
* 'INFANT MORTALITY RATE
(combined)
(per 1000 live births)
6«
80 (1990-prov.)
UNDER-5 MORTALITY
(per 1000 live births)
70
146 (1990)
MATERNAL MORTALITY
(per lakh birth)
200
400 (1990)
PERINATAL MORTALITY
30-35
5C.1 (1987)
■*CRUDE DEATH RATE (Combined)
9/1000
9.6 (1990-Prov.)
*CRUDE BIRTH RATE (Combined)
21/1000
29.9 (1990-Prov.)
**EFFECTIVE CPR
60%
44.1 (1991-Prov.)
@@ N.R.R
1.0
1.6 (1981)
@9 FAMILY SIZE (Rural 8.
Urban combined)
2.3
4.1 (1987)
@ EXPONENTIAL ANN GR.RATE
1*2
2.11 (1991)
(Source Census
Report 1991)
@% NEWBORN WITH 2500 Gms
Birth Weight.
10%
30% (1990)
@ % OF ANTENATAL CARE
100%
40-50%
@ % DELIVERIES BY TBA
100%
40*5% (1987)
« IMMUNIZATION - TT(PW)
100%
79% (1991)
"TT School Children
100%
55.6% (1989)
DPT
100%
82% (1990)
POLIO
100%
82% (1990)
BCG
100%
89% (1990)
DT
85%
80% (1990)
** MEASLES
100%
99.r/0 (1991)
- 4 OTHER.INDICATORS
goals
ACHIEVEMENT
’i ■
■»
u
-9 ■-J
•if-
LIFE EXPECTANCY AT BIRTH
(persons)
.■
.. •
64.0
59.0- (1990)
100%
55% (1989)
T.B. (% of Disease arrested
out of those detected)
75%
65% (1989)
@@ INCIDENCE OF BLINDNESS (%)
0.3
0.7 (1990)
@@ LEPROSY (% of Disease arrested
out of those detected)
Female Literacy (1991) =39.4
/o of children sufferin
underweight (0-4 yrs.
(By Gomez - 8 States)
f rom
Moderate & severe
61 (1980-91)
severe = 9 (1980-91)
@ Average index of food produc
tion per capita (1979-81=100)
= V8 (1990)
@ Daily per capita calorie supply
as % of requirements (1988)
= 95
@ % of household income (1980-85)
Spent on - All foods
Cereals
52
= 18
@ % of Population with access to
safe water (1989-90)
Total
Urban
Kural
= 75
= 79
= 73
@ O.R.T. use rate (1987-89)
= 13
@ GNP per capita (in US S) (1989)
= 340
r• iim.
wt
y"wi
■ i -. -i*
Sources * - SRS Report 1990
@ - The State of the World’s children 1992 - UNICEF
- MCH&FW Quarterly report
@@ - 2nd Evaluation - Country report on strategies
for Health for all by the year
2000-1991
5
LEVEL OF ACHIEVEMENT OF SOME NORMS
ALL INDIA POSITION AS ON 30.09.1991
■eaw.u »
si.
-■
-rwr?
^rnr—r —n
No.
Parameters/indicators
National
Norms
1
2
3
1. Population covered by a
Sub-centre
Norms "achieved/
established
(Approximate)
4
3000-5000 Pop.
4576
2. Population covered by a PHC
20,000-30,000 Pop.
27168
3. Population covered -by/ a
Community Health Centre
About 1 lakh Pop.
3.10 lakhs
4. No.of Sub-centres for each
PHC'
...
6 sub-centres
5. No.of Primary Health Centres
for each Community Health
Centre
6.0 sub-centres
4 PHCs
11.4 PHCs
6. Trained Village Health Guide
One for each
village/1000
population
1.42 villages/
VHG
1442 population/
VHG
7. Trained Dai
Alleast one for
each village
1.00 villages
1002 population
8. Population served by
Health Workers (Male and
Female)
M:3000-5000
F:3000-5000
7632
4953
9. Ratio of HA(M) :HVi/(M)
1:6
1:3.4
10. Ratio of HA(F):HW(F)
1:6
1 :5.4
11. Average area covered by
Sub-Centre
12. Average Area covered by a PHC
13. Average area covered by a CHC
14. Max.radial distance covered
by a PHC (in km.)
15. Max.radial distance covered
by a Sub-centre (in km.)
16. Max.radial distance covered
by a CHC (in km)
1T. Average number of villages
covered by a sub-centre
24.00 sq.km.
142.45 sq.km.
1626.93 sq4kin.
6.73 km.
2.76 km.
22.81 km
4-5
18. Average number of villages
covered by a PHC
26-27
19. Average number of villages
covered by a CHC
3C4
Source: Quarterly Bulletin on Rural Health Statistics
■Sep. 1991.
fNFRASTR^
- 6 .on 30-9x91...
A.
Total
func^ioniQa^
In ^ovt.
Build-
Sub^Centres
130983
PHCs
22065
CHCs
1932
B,
Building
under con. _ _st ruction.
Buildings
to be coa
structed.
51985
(39.7%)
790b .
71093
(54.3%)
12500
(56.6%)
T179
(61.0%)
1389
8176
(37.0%)
469
(24.3%)
284
IJo?ojL P-H.Cs_&.^_Sub-Centres required^ and in position in
Tribaf Area ~ Total Population in TSP Area = 776.84 lakhs *
r.
= jotal
Population in Tribal pocket = 403^02 lakhs
- ^tal PHCs required for Tribal Area = 3507
= Total PHCs in position in Tribal Area = 3198 (91.2%)
- Total Sub-Centres required in Tribal Area = 23586
- Total Sob-Centres in position in Tribal Area = 18996 (80.5%)
c* R£ija?.r.y- K031.^
without Doctors TTnformation ‘available’ for ”10787 PHCs’? (48.9^’only)
= PHCs with 4 or more Doctors
- PHCs with 3 Doctors
= PHCs with 2 Doctors
= PHCs with 1 Doctor
= PHCs without Doctors
427
450
3875
5048
987
D. - PHCs without Lab.Technician
= PHCs without Pharmacist
= 3787
= 311
E. = lotal No.of ANM Schools
= 476
= ANM admission capacity
=20337
= Total No.of LHV promotional schools = 46
= ANTA admission capacity
= 3863
F.
Total Dais trained since inception
(as on 30-9-91)
Village Health Guide Scheme
-PHCs covered under VHG Scheme
-Villages covered under VHG Scheme
-Total VHGs Trained
(including 948 AHGs)
- No.of working VHGs
597761
=
=
=
4220
531009
416672
335590
G. = Medical Care Statistics - As on 1-1-1990
TSource -^ealth^nformation India - 1990)
Total
Rural
- No.of Hospitals
7005
10T72
3167
- No.of beds
506768
95722
.602490
- No.of Dispensaries
28304
15557
12747
22928
- No.of Beds
13642
9286
H. = disabled population (
per 1981 Census report)
- disabled persons 1..
in Rural Area
969401
149547
- Disabled person in Urban area
=1118948
- Total Disabled person
er.£SDT42.e, of Population .below.. poverty line (1987-88 £rov.)
I.
^{Source - Health Information India T 1990*)
- Rural
= 32.66%
- Combined = 29.23%
7
.'f
J- HEALTH MAN POWER IN ,rural AREAS Category
No.Sanctioned
1 . Surgeons
No. in
Position
Vacant
914
676
26.1
2. Obs.& Gyn,
627
362
42.4
3. Physicians
535
406
24.2
4. Paediatricians
512
274
46.4
5. Doctors at PHCs
25062
21278
15.1
6. Elock Extn. Educators
6154
5763
6.4
7. Health Asstts. (Male)
24891
23273
6.5
8. Health Worker (Male)/MPW 86713
78538
9.4
9. Health Asstts.(Fem)/LHVs 25044
22282
11.1
10. Health Varkers (Fem)/
ANMs
132449
121016
8.7
11.Pharmacists
19172
17578
8.4
12. Lab.Technicians
10189
8629
15.4
13. Nurses Mid-wives
13790
11969
13.3
14. Radiographer
658
509
22.7
Total category 1 to 4
2588
1718
33.6
Total of category (5 to 14) 344122
3H835
9.7
Grand total of all (1-14)
312553
9.9
346710
PERCENTAGE OF GROSS_ NATIONAL PRODUCT SPENT ON HEALTH Estimation of total expenditure on Health and Family Welfare
have been taken into consideration on the following basis:-
(1) Expenditure of Ministry of Health and Family Welfare
(Centre and State - both Plan and Non-plan)'
^2) Expenditure on Health and Family Welfare by other
overnment Departments (except Defence, Paramilitary
orces, Local bodies and P & T etc - since data are
not available).
(3) For estimating private expenditure on Health and
Family Welfare, the basic assumption is that the
private expenditure is double the amount of Public
Rector
1
-- t e-- Sample
,
ector Expenditure (on
the basis of National
Survey findings).
The findings are (A) L uring Sj^th and Seventh Plan the total expenditure
on Health and Family Welfare (from Departments of
Health and Family Weifare of States, UTs. and
Centre only) as percentage of GNP is between the
rate of 0.98% (1986-87) to 1.32% (1984-85)
I
R
For yea2? 19S4—85
, -.^nr.Tr
m.T-« ataa:—WLfat
J waiK -
NationalJHealth Expenditure
J
=
X 100
“'GNP
l7®57tT8 IrSl
X
X 100
100
= 1.32%
(Source - Planning Commission)
(8) As percentage of HNP, the
ubllv sector eApe
the total H
public
expenditure
(as per above information) has remained within the range
of 1.32% (1984-85) and 1.07% (1986-87).
(C) ^he total expenditure on Health and Family Welfare
including the Private Sector is within the range of
4.08% (1984-85) to 3-2% (in 1986-87).
•PERCENJAGdEJOF NATIONAL J4EALTH EXPENDI^TUR^^JLpCAL HEALTH,:SERVLGES
Only outlays of Minimum Need Programmes (below district level)
has been considered. Therefore the following figures are not
showing realistic picture ~ rather it is an under estimate ~
£Q£.J985"199p
National Health Expenditure elevated
:=
local services^
National Health Expenditure
(including F.W.)
~ fc* 1063 Crores
Rs. 24$5 Crores
X 100
X 100 = 42.6%
(Source « Planning Commission)
(It excludes Central Health outlay of Rs.897 crores,
Family Welfare outlay of Rs.3256 crores and outlays for
National Health Programmes - because expenditure below
district level is not available).
H p 2- ’If*
VIEW
0 F
PEOPLES’
REPRESENTATIVE
I N
NATIONAL
HEALTH
POLICY
By
*
DR, M.V.
KULKARNI,
-fc-X-
DR0 G,N.
PR?iBHAKARA, M.D. ,
M.D. ,
Presented in the workshop on National Health Policy
by Voluntary Health Associati.n of Karnataka 9 Bangalore.
on 9-10 April 1992
Held at Institute for Social and Ec.nomlc Change, Nagarbhavi,
BANGALORE-560 072
Professor & Head
** Lecturer
Department .f Preventive 8. Social
Medicine , Government Medical College,
MYSORE.
4'
I
CONTENTS
1.
INTRODUCTION
2.
FUNDAMENTAL POLICY
3.
ELEMENTS TO BE CONSIDERED
4.
EXISTING PROBLEMS IN THE AREA
5.
GENERAL FORCE INVOLVED
6.
WOMEN FORCE INVOLVED
7.
NATIONAL PICTURE
8.
COMMUNITY EFFORT
9.
INTEGRATED ACTION
10.
COMMENT FROM THE PEOPLE
11.
CONCLUSION AND REMARKS
12,
REFERENCES.
■K
-K-
X—X-*
X.
nrrAQPycTiON
The charter for India’ s Soeio-Economic Develepment through
specific programmes , as a Health Policy was approved in 1983 by
Parliament, 7Lying greater stress on MCH care following targets
by 2000 A.D. were fixed.
I.M.R. - below 60
Perinatal Mortality Rate
30-35
Pre-School child mortality - 1*
(1-5 years)
M.M.R.
- Below 2
Babies with Birth weight
below 2500 g
- 10%
Birth rate
- 21
Family size
- 2.3
ANC to pregnant women
- 100%
Deliveries by TBA
- 100%
Immunization
- 100%
vVe have seen integration of Family Planning with ether sector and
also a change in the Organisational pattern •f MCH & FP Serviees,
both in Rural and Urban areas., Training of Dais, ICDS and UIP
have been best examples of effort in this regard.
People’s Representatives main objection has been that NHP never
takes Social Justice and only talks about poverty alleviation and
health care. Further, they are als« of opinion that there is
no -spirit of partnership by agencies.
People have the right and duly to participate .in the process for
the improvement and maintenance of their health.
•1
©
APPROPRIATE PLANNING STARTS WITH PEOPLE
I
A
They should recommend the Government encoufl?aging and ensuing
their participation.
2
2 »
/
Small political units or communities can take care of ’Whole
Person’s needs’ rather than by a Government which
--- take
--- ? compart
mentalised bureaucratic activities.
tv
2.
FUNPAIvIENTAL ..POLICY
The Fundamental policies for health that are to be considered
are as follows;
1. Health is a fundamental right and is a social goal
2. Inequality in Health is a concern.
3 • People should participate in planning implementing Health
care.
4. Government is responsible for adequate health of people
5 . Self reliance is possible by peoples active participation
6. Intersectoral co-ordination is the backbone.
7. Utilisation of available resources for health
3.
ELEMENTS_TO J3E CO^NSWERED
The elements that are to be mentioned for the people’s
Repres entative are;
*
. Awareness .f health problems
2. Means to solve health problems
3. Safe water, sanitary latrines affordable by the people
diverting rural quota t. rural instead of to an urban area
5. Legislative support gathering for above items there is a need
of more sub-centres, community health centres, Trained Health
guides and trained Dais.
Involvement of all category of People's Representatives from the
existing infrastructure have been there fr.m time immemorial.
These are (a) Corporation (b) Muncipality (c) Boards (d) Village
Panchyat (e) .Mandal panchyat (f) Zilla Parishat (g) Religi •us
Bodies (h) C.-.perative b.dies (i) District Health and F.'.'IOffices
(j) director of Health and Family Welfare (k) State Ministry
(1) Union Ministry (m) Voluntary Health Organisation.
People representatives should have a note of the following
elementaries.
1. All people in every country will have at least ready access
to essential health care and to first level referal facilities.
7
2*jAP pe°Ple will be actively involved in caring for themteelves
and for their families as far as they can and in community
action for health.
I ■
3. People shall share responsibility with Government for health
care of their members.
■
- 3 4. Government should assure overall responsibility for health
of their people.
sanitation facilities will be
5. Safe drinking water and
availabel to all.
6. All people to be adequately nourished.
7. All children and pregnant methers to get immunised
8. Communicable diseases shall no more be a public health problem
diseases3 and Mental Health by
9. Look int» non communicable
style and psychosocial environment.
controlling life !
.'
10. Availability of essential drugs.
Successful pursuit of health policy will depend on authority
being responsible for it, on behalf of Government. At present
those being (a) Ministry (b) Directorate (c) Corporation and
Municipality (d) Zilla Parishat at different levels. Here
ensuring political commitment is to channelling health
activities to the people.
4. EXISTING 'PROBLEMS__IN_THE_..AREA
Our great problems is not that of promoting the pursuit of.new
knowledge, it is the suitability and adoptability of existing
structure and functioning of Health Services at large that
matters in Health for All*
It is still being observed that —
a) Raising cost of Medical Treatment
b) No aminities for safe water and sanitation
c) Over reliance on Mass Media is becoming dangerous
d) Poor education becoming carrier for utilisation of knowledge*
A) PROBLEMS IN APPROACH^
S:
- LACK OF CLEAR NATIONAL HEALTH POLICY
- POOR LINKAGE OF HEALTH SERVICES WITH OTHER NATIONAL
DEVELOPMENT
- LACK OF CLEAR PRIORITY
- SOCIAL ASPECT OBSTRUCTS NATIONAL HEALTH POLICY
~ NO COMMUNITY INVOLVEMENT
- INAPPROPRIATE TRAINING OF HEALTH PERSONNEL
B) PROBL.E_MS_ IN_.RESOURCE,:
- INADEQUACY AND MALDISTRIBJTION
- NON-UTILISATION OF ACTUAL AND POTENTIAL RESOURCES
- RESTRICTED USE OF PUBLIC HEALTH WORK
- INCREASING COST
C) PROBLEMS- IN _GEI^ERAL STRUCTURE:
~ NO EFFECTIVE PLANNING
- WEAK DEVELOPMENT OF O3NCEPT OF TOTAL SYSTEM
.. .4
4
D) PROBLEM IN TECHNICAL ASPECT:
'«■« ■■ ■
IJI—
—•r-T
M.V4
■ I
L
~J1
- NO HEALTH EDUCATION
- NO BASIC SANITATION
- NO COMMUNICATION
- NO TRANSPORT
NO HEALTH INFORMATION
5. GENERAL FORCE INVOLVED:
Support by other related sectors viz., ^Agriculture, Housing, Water
supply, Sanitation, Public Works and Communication, Education,
Mass Media are at most important.
People’s Representatives in Local Government can ensure that
community interests are properly taken into account in planning
and implementation of programmes. Public services should be
accountable to the communities. The desirability of co-ordinating
at the local level, the activities of various sectors involved
in Socio-economic development and the crucial role of community
in achieving them, make peoples representatives as an essential
and effective component.
A clear national health policy is needed which will promote
community cohesion around efforts for health and related develop
ment, will fo/ster the co-ordination at the local level of all
sectors1 pregrammes that have a bearing on Health Care, will
build up the capacity of communities to make up their health
and other social aspirations known, and will ensure that the
community controls both the funds it invests and personnel
providing it. Mutual support between Government and people,
reinforced by mutual information feedback. It is the responsibi
lity of Government to stimulate this kind of support to set up
necessary intersectoral co-ordination and different administra
tive level to pass legislation, to provide sufficient human,
material technical and financial resources.
For public reach, it needs easy access to the right kind of
information concerning their health situation and how they
themselves can help to improve it. In certain area or situation,
peoples participation can be legislated.
Non—Government Organisations can make a very useful contribution
to health services, precisely because of working within the
community. They have same responsibility as Government Agencies
in the sense that they provide Technical and financial support
to nation and would do well to ensure that these are channelled
into the Health Service System.
....5
5
6. WOMEN FORCE INVOLVED:
imi
I rj-..
Tibi i
Women a force for renewal of Health Activities in a nature of
policy is attributed. Women influence health care in many ways,
as mothers bearing the main responsibility for family health, as
Agricultural workers, as Primary Health Centre? Workers
birth attendants, educators and members of community groups.
If an educational programme does not recognise women as important
agents of change and learning, it will not succeed in developing
full community involvement and cannot obtain the people’s
responsibility.
NATIOI^AL PICTURE;
In India, at least 3 forms of influential environment can be seen.
They are (a)Political environment (b) Religious environment and
(c)Social reform environment.
High technology, medicine is getting quite out of hand and leading
health systems in the wrong direction, i.e., away from health
promotion for the many, towards expensive treatment for the few*
Modern Medicine, is not accessible to the poorer social classes.
And most forms of disease are more prevalent among people living
in poverty, This show the link between health and socio-economi®
conditions.
Among the organisations that have been used or suggested for
mobilising support for Primary Health Care as National Health
Programme are (a)Political parties (b)Women Organisations
(c)Youth organisations (d^ Trade Unions and (e)Religious or
Ethnic bodies.
Whenever possible, local plans and priorities should be.based
on informations about the actual health needs and problems of
§11 members in the community. Groups at risk can be identified
along with special needs and priorities can be established and
progress monitered on the basis of information.
Individuals and families should assume responsibilities for
their own health and welfare. This entails penetration of
services to target population.
In our Society, stress is laid on overall political and economic
context. Power, Finance decision making all not by people, but
normally by people’s representatives. Hence countryside effort
is necessary for a common setting of peoples representatives
Elected bodies of citizens have been put incharge of local
boc.ltn and social services at District and Regional levels,
•».. 6
6
Here wide involvement of people in the improvement of their '
own health will not be there. Appointment
.
of representatives
to the advisory board of local health facilities is to be
geared up.
The financial contribution by voluntary organisation is relatively
small, but their contribution to health’ is often significant.
These local, National and International Organisations have their
own motives and provision in the allocation of resources. This
factor should be carefully considered when assessing that role
in health care. They direct their limited resources to the
most needy segment of population.
/
8. COmUiJITY EFFORT:
Cultural, Economic, and political circumstances of India influence
all aspect of support to Health services. There is a need for
understanding of the relations between effective community
involvement and propitious political and economic conditions.
The mobilisation of people for health development require their
participation.
The collective organisation in India Ihas been as follows:
Dia: 2
voluntary health
.PlES
ASSOCIATION
POLITICAL
PARTY
E
GOVT. AGENCY
EN
, REPRESENTATIVE
:BODY
RELIGIOUS BODYIn British ruling without any contribution people used to get
services. wow
Mow also that
tnat strong tradition has been seen in our
country. We have organisational disharmony. Various social
and political forces play in every Mandal Panchyat and Zilla
Parishad hampering the participation. Hence peoples involvement
is slow and halting. N’hat people see as their real need are
not seen by service givers. This amounts to ignoring peoples
need. A professional man always says that he is better
qualified and that he knew better than any one.
7
I
VMK'..'
7
9. INTEGRATED ACTION:
Discussions and conclusions at the Joint Conferences of the Central
Councils of Health and Family Welfare and the National Development
Council have always been directed towards a common pattern of
infrastructure in Health and Family Welfare Services in India.
Whether it is in Medical Education,- Legislation, Standard
maintenance of vaccine or drug; there has been common consensus
for a common pattern. Evolution of National Health Policy is one
such major step for an integrated action in achieving this goal.
Communication strategies to motivate a positive attitude could
have been another step in achieving a goal of National Health
Policy.
Thus all over departments, which contribute for socio-economic
development of India, relay upon intimately related sectors of
administration and 'politics. It is vital importance to ensure
effective co-ordination between Health and Peoplefs Representa
tives. Contents and prioiities of programmes are to be viewed
by people or peoplefs Representatives in their effective
implementation. Integrated Programme of Rural Development (IRDP)
is a standing example in this regard.
10. COMMENT FROM THE PEOPLE:
—
11, i ,-aaar.~^T»’
x—m -jwnm n. —— -» ianr
wm
Following upbridged comment demarcate people view in National
Health Policy.
- Health Facility to one and all, equal with Urban-Rural,
Male-Female , Young-Old.
- Poor to have free service, Rich to have paid service.
- Political unrest 9 violence and law breaking are by lack of
understanding. provide better understanding.
- Region, District and Urban should have programmes by Regional,
District and Corporation Offices.
-’Without potable water and sanitation is it health facility?
- India is not poor, money is going down the drain 9 use for
proper health care.
- Older have struggled,
of sweat and toil.
Younger are yet to realise the importante
- Administrators both Government and elected body have done
considerable harm by undermining the concept and need of
excellence in every sphere of action.
- Democracy run on present election procedure puts a premium
on powers.
- No Co-operative community care by Zilla Parishat
- No copying from USA or UK
their economic status.
Make Health available to all in
.... 8
- 8 - Health care is not just by doctors.
Say Health Board.
"
But by others alsoi
admission criteria is
why not policy common to all? priority to certain groups.
- Allow us to have Home , Herbai 02? Nature
even.
with chemicals.
Do not insist
workers of all department to help Health
services.
-
11 • INCLUSION AND REMARKS :
National Health Policy is an expression of our Health. Hence
national strategy should include broad' lines of action in all
sectors involved to give effect to that policy, what has to be
done? Who has to do it? ^uring what time?
With waht resources?
It is a framework leading to more detailed
programming, budgeting,
implementation and evaluation.
We mean Health that begine at home
, schools, factories. It is
there, where people live and work that health is made or broken,
It does mean people will i
use better approaches then they do now
for preventing diseases and. alleviating unavoidable disease and
disability and have better
ways of growing up, growing old and
dying gracefully.
Let this mean even distribution among population whatever
resources for Health are available.
Peoples Representative in Health Policy is a sober one.
But
related strategy appears good, clear cut and defined,
They
deserve giving effect to these action. Here achieving acceptable
evel of health as part of socio-economic development in the
spirit of social justice is to be indicated.
Why should we not involve General Practioners
and Link Insurance
Scheme? This can be answered m the policy
Simplified Medicine programme or elementary health by any body
should be envisaged in the policy.
Two way Radio scheme for advice and supervision seems to be
very good.
Dia:
M—WflW
| .mii M
3
,|
LL ’
FORMAL
HEALTH
SYSTEM
MAN ANQ^EALTH SYSTEM
-
w- .-wrrw-wt.v ’n-.
vrarmri ■
. ■
COMMON MAN
-> TRADITIONAL HEALTH SYSTEM
INFORMAL HEALTH SYSTEM
In the above figure it is pointed out how we. are driving behind
man, whereas Man is running behind Traditional and informal s
... .9
- 9
Hence we should think of
a C.—operative Rural Despensary
b Family Survival Assurance Plan
c Integrated Child Care
d; Integrated Health Nutrition
e Integrated Maternal Care
f Integrated Family Care
Dia:
4
PROCESS Cf ffiALTH DEVELOPMENT
programme
C
PEOPLE
I
1 v.
IMPLEMENT *■
RE PROGRAMME
EVALUATE
T
INFORMATION
SUPPORT
In each action involvement of people and/or peoples Representative
has an effect on any policy making.
In view of problems posed, we should make an endevour to provide
basic
aminities
—
------- >, to provide essential drugs, to provide basic
education.
Women force and community force is an asset in our endevour of
uniform pattern of Health Services.
Integrated Action is an injectable solution 9 which has a miracle
in community healing.
REFERENCES
1. Alma —Ata— Ten years after —WHO 1986 (New letter No.20)
2. Alternative Approaches to Health care - ICMR New Delhi 1977
3. Alternative approaches to meeting basic Health needs in
developing countries. UNICEF - WHO Joint Study -WHO 1975
4. Global strategy for HFA by the year 2000 - WHO 1981
5. Health for all by the year 2000 the role of Health Education
VTH Gunaratre Int. Journal of B.E. Vol.XXIII No.1, 1980.
6. Health System support for Primary Health Care - P.H.Paoer
No.80 WHO 1984.
7. Leadership for Primary Health Care- P.H.Paper No.82 WHO - 1986
8. Managerial process for National Health Development - WHO 1981
9. Medical Care, the cnanging needs and pattern
Sip Godber
Ciba Foundation Lecture -» 1970.
n. National Health Policy — Statement — Govt, of India Ministry
of Health and Family Welfare, New Delhi - 1982.
11. Planning India’s Health - K.S.Sanjivi, Orient Longman 1971.
12. Primary Health Care
Joint Report WHO & UNICEF - WHO 1978T
13. Primary Health Care - The Chinese Experience , WHO 1983
14. Text Book of Preventive and Social Medicine 9 8.K.Mahajan,
Jaypee Brothers 1991.
15. Text Book of Preventive and Social Medicine. J.E.Park.
12th Edtn. 1989.
x-*-a
'1
HP
c
oS
“OVERALL VIEW OF NATIONAL HEALTH POLICY"
* Dr.(Mrs.)M.K.Vasundhara
Introduction
-a*
4
>/
*
»—4.* :-UK*r.«
Since independence the nation has taken forward stride to improve
the health of its citizens. There has been a substantial success
in lowering the death rates and raising the life expectancy.
Smallpox has been eradicated. Plague almost eliminated and the
incidence of malaria is reduced. However, the surmounting
health problems still post a challenge. Our current infant
mortality rate (IMR) is 94 which does not compare favourably with
that of Japan which is 4. It is estimated that 3.deaths occur
every minute from dehydration due to diarrhoea while tuberculosis
claims one life. At any one time, 12-15% of the population is
sick mostly due to communicable diseases.
The major brunt of
these illnesses is borne by women and children. It is all
the
more tragic because most of this morbidity and mortality is
preventable as 75% of the illnesses are related to poor hygiene
and lack of sanitation. The resurgence of the repressed diseases
like kalazaar or malaria and emergence of new diseaseslike
AIDS pose a further challenge. To top it all, the rapidly
expanding population takes its own toll. It is estimated that
on the economic front, for every 5 points gained.., 2 points are
lost due to minimum demands of the growing population. It is
55tight rope walk exercise” to check the slide down and balance
the development because for the overall development, health
is a critical factor.
The Government’s concern regarding current situation and its
commitment to achieve ’’Health for All by 2000 A.D.” led to
evolvement of the National Health Policy in 1983. The
enunciation of policy highlights the Government’s efforts at
removing inequity in the health care delivery by reaching out
to the ‘’voiceless” vulnerable population with a health care,
technology which is appropriate, affordable and acceptable to
the community. For the first time, the time as an important
resource was realised and targets to be achieved by 2000 A.D.
have been clearly spelt out.
Strategy
The Strategy suggested for implementation of this policy is the
Care. i.9*
i.9.
same as that evolved for Primary Health Care,
1. Equity in distribution of health care
2. Appropriate Health Technology
3. Multisectoral Approach
4. Community Participation
Equity: had to be considered because the health care services
were concentrated in urban areas catering only to the minority
of the population. The vulnerable population were often
neglected. Inadequate referral services led to consumer
inconvenience, congestion, duplication and fragmentation o±
the services leading to increased cost.
Professor and Head of the Department of Community Medicine
bangalore Medical College, Bangalore - 560 002.
Paper presented at the ’’National Health Policy Workshop
organised by Voluntary Health Association of Karnataka on
April 9 and 10, 1992.
*
X ✓
2 •=•
Appropriate Health
^he curative bias led to wastage
of resourccTs in treating over again the diseases which were
preventable. A comprehensive health care consisting of.preventive,
curative, promotive and rehabilitative services was envisageu.^
The specialisation and hospital based services engulfed the major
chunk of the budget favouring the few while denying the essential
care to the majority of the community.
Appropriate Heajth^Technolo^y: The shift is.now from
specialisation to services which are appropriate, effective,
simple and feasible. Such technology promotes self reliance eg.
Oral rehydration therapy to combat dehydration.
Multisectoral approach: Health cannot be viewed in isolation as
botTT'health" and development are interdependent. Therefore, a
multisectoral approach with intersectoral co-ordination between
health and allied sectors like food and agriculture, education,
water supply and sanitation, social welfare etc., is.required
for balanced development. This calls for horizontal integration
of services at all levels.
(■
Community Partici^atipn: Sir Joseph Bhore in 1946 indicated the
need for ^comm'unTty ’“participation. This critical. need is not yet
realised. There have been some sporadic unorganised ventures
which have been shortlived. The dialogue between the planner,
and the consumer is lacking. Therefore, the envisaged community
participation in planning, implementation and evaluation of
•health care services is minimal.
Broad Guidelines
-hvT»'
• x-v.>
Certain broad guidelines have been identified in the National
Health Policy. They are:
1. Strengthen the heal,th _care_seryicres.,
2. Develop referra. 1 JAnkac^es.
3. Restructure me di .cal,, _e d u c_a t Aon
4. Exploit the potential of _Traditional
5. Promote action oriented healt-L.s^YA^^?AeAAc.h
6. Develop
alth\JjQ^rmatw_n
7. Attempt Population stabilisation
8. Provide for ^nvju^nme^
9. Involve Noj^ojyern^
Organisation jji..health .care_dej!iverx
10. Highlight- the role of health education
11. Reform he^alth^J-^.i.s^latipjj
4
Health Services: In order to make health care services appropriate,
the stress is on shifting the bias from ’’somewhere to everywhere”
by establishing a network of services to reach the remotest of
the areas. -his
ib4 takes into consideration the population density,
transport
and priority criteria like tribal, hilly,
topography, *
areas.
The
curative bias is shifted to comprehensive
and endemic areas,
health care.
—ti n
1 n- - --r
■"titt ■
-ut..
The lack of referral services leads to consumer inconvenience,
congestion at the specialist centres, duplication and fragmenta
tion of services which adds to the cost of the already
constrained resources. Therefore, ’’Back-up support” is provided
for by establishing Community Health Centres (C.H.C) with
specialist services. Each CHC will be catering to the needs of
4 to 5 Primary Health Centres.
*
3
The policy also envisages elimination of private practioners
by Government doctors. It focuses attention on the much
neglected occupational health services.
Critical analysis reveals that the above objectives are not yet
realised though there has been considerable expansion of health
infrastructure. Essential drugs are not yet available within
one. kilometer walking distance. The drug policy is topsy turvy
with a bias on its the price line than the health needs. Control
is still vested with Ministry of Petroleum and Industries though
drugs are critical for health- care needs.
Medical Education: Due to accultration, the Medical Education had
been “Western oriented’’’ creating a “Culture gapi? between the
training and health demands. The Policy indicated a need for
restructuring the syllabi and revise the training programmes.
Health Service Research:
•h'KMB —■■
♦
rr-j * -w- • -• J>a Mt* WJ.j-k —hm-tiWi
a v. -?■ ».
■IM
In order to seek optimal solutions to the existing problems
the stress is to be shifted from the fundamental research to
operation research.
Health Information System: Hard factual data are needed for
planning, evaluation and understanding of epidemiological trends
of diseases. Monitoring and evaluation process would permit
••midterm corrections” in the programmes and also ring a timely
warning bell in the event of emergence of a new problem. This
is how AIDS was detected in U.S.A. Our reporting system needs
revamping as the date available is often incomplete and
irrelevant. The person who gathers the data and the one who
transmits it are not oriented in the process and the relevance
of data generation. Further, there is lack of “feed back” of
data to the grass root level though communication is one of the
fundamental principles of management.
Involvement of Traditional Systems of Medicine: A vast potential
of available health manpower already practicing traditional system
of medicine as well as general practitioners of allopathic
medicine remain unexploited in the implementation of National
Health Programmes. Their contribution is neither recorded nor
recognised. ^t is hightime this manpower availability is
exploited to draw them in to national health stream in order
to achieve the Goal of Health For ^11 by 2000 A.D.
Non-Covernment Organisations (NGOS): have voluntarily contributed
a lot towards community health by extending their services to
outreach areas, educating the community; facilitating research;
sensiting Government about health needs of community e.g.Family
Planning Frogramme was first activated by the voluntary^
organisations. ‘It is indeed a welcome change that the Government
is^now inviting NGO’s to extend their role in National Health
Programmes.
/ s 1' a t' i on :
needs to be reviewed and revised to be
He a 1th J.1 e qi
relevant in context of the current knowledge. ^t needs to be
implemented uniformly throughout the country because diseases
or health problems recognise no geographical boundries.
4
4^
Hc^J^th ..Educati^qn: The unfortunate loss of limbs and life is
avoidable* if^ the community is educated about ways and means
to prevent the same. In any case, people have right to
information. Therefore the messages have to be meaningful
to promote self reliance. People have to realise their
rights, role and responsibilities for their health care.
Health education therefore should be the foundation stone
on which health care services should be built.
T^e **Count Down 2000 A.D.yj has already begun. It is
hightime, therefore, that we critically review our progress,
remove the impediments and reinforce our activities on
war-footing basis to convert the cherished ,5dreamis of
National Health Policy into a reality.
►
-x- -X- *
I
-X' -Jf-
a
HP ^*6
Some Policy Reflections
in the context
of
a) Health Policy for Karnataka
b) Perspective Planning for
Health Services
c) Approach Document for 8th Plan
Presented at a Dialogue of NGOs
including Community Health Cell
Team, with Director of Health
and Family Welfare Services and
Joint Director (Planning),
Directorate of Health and Family
Welfare Services, Government of
Karnataka, Bangalore.
July 1990
Bangalore
By
Dr.Ravi Narayan
Community Health Cell, Bangalore.
7°
nPERSPECTIVES IN HEALTH POLICY AND STRATEGIES1’ FOR THE STATE
OF KARNATAKA.
a response from the Community Health Cell, Bangalore*
A. GENERAL PERSPECTIVE
fl. As a background it is important to keep in mind ttiat the
health of people and populations is largely determined by
broader factors such as:
employment;
adequate income and purchasing power;
adequate food, housing and clothing;
availability of sanitation facilities and safe water,
education and opportunity for skill development;
accessible and effective health care services.)
This is examplified by the documented experience of several
developed countries where major public health problems like
tuberculosis, leprosy, cholera and other diseases were on
the decline prior to the medical are of antibiotics ano
vacci'hes. It is accepted that this change was due to general
socio-economic development.
2.
At an operational level, acceptance of the above ideas call
for effective intersectoral linkages in terms of planning
and coordination betweenTHe Departments of Health, Education,
'Water supply and Sanitation, Housing, Town and Country
Planning, Agriculture and Industries.
Keeping in mind the decentralised system adopted by the
state, this planning and coordination could be done at the
zilla parishad level.
3.
Regional HeaIth Planning
At present, in the health sector, we have national health
policies, programmes and targets for the country as a who e
while overall policies and thrusts are important, keeping
in mind the vastness and diversity of the country and even
within single States, health programmes and plans need to
be evolved at a more local level at District level to
start with. Two important factors to consider in this are:
a. the special needs of certain groups, who are
socially and economically marginalised —
dalits, tribals, slum dwellers, women and
children, the handicapped;
b. the dynamic nature of the health status of
populations which keeps changing in response to
factors in society—eg., environmental, economic,
cultural changes, life style changes etc., We
are faced simultaneously with the diseases of
poverty for large sections of the population,
viz., malnutrition, tuberculosis, leprosy,.water
related diseases etc., and diseases resulting from
industrialisation and modernisation—eg. , cancers,
cardio-vascular diseases and ill-defined new^
symptom complexes that are presenting in areas
of environmental pollution.
Health planning needs to move from a rather adhoc,
centralised, top down method to a more scientific basis.
For this, it is necessary to have good quality health
information, collected on an ongoing basis from
different geographical, social and economic strata
of society. Presently health statistics are largely
....2
2
compilatiens from various administrative reports, Greater
emphasis needs to be given to quality of information , its
validity and analytical interpretation of the date, Quantitative or hard data reflect some of the physical factors but
an interactive, participatory approach with people would
indicate the live social/human processes taking place.
There are presently more than 400 voluntary agencies working
in the field of health in the State. Involving'them in
planning exercises w»uld provide a ’window1 to what is happening
at the grass root level. Involving members of gram sabhas,
mandal panchayatS' and zilla parishads would play the same
role—they would in the process get better equipped to monitor
the functioning of the health care services.
4.
XU® ludge4,ary_a 1•lqc<ation for health, education and welfare
sVrvic'es needs ’to* be’’critically analysed in the context of
the health needs of the people. This could alse be the
subject of wider debate at various levels—State, District 9
Zilla Parishad, Mandal Panchayat, Gram Sabha etc.,
Broadly there .could be
a. a larger allocation to health - eg. 9 6-8%
b. a reduction in the present urban/rural
bias in health expenditure—eg. , Rs.30000
spent on drug purchases per annum, per
primary health centre presently covering a
population of 60-80000 (or even the prescribed
30000 population) is grossly inadequate, In
contrast the annual budgets of specialised,
elite institutions at State and District head
quarters is excessive.
5.
The Appian
Indian Systems of,
of Medicine (Aurveda, Siddha,
lil®
Siddha Unani,
UnaniI*,
Yoga etc.,) and other systems like homeopathy are widely
prevalent throughout the country. They are culturally
more acceptable and economically and geographically more
accessible. Though official recognition has now been
given to them, they are very marginalised in terms.of
State financial resources and in involvement with health
planning. By recognising them as partners, we would
increase the health infrastructure many fold.
6.
During the past decade and particularly so in the past
4-5 years* there is a very rapidly increasing trend towards
lLz..aAL°-Q....2.£
.se.£vlces,* Corporate sector business
houses are getting involved with the running of diagostic
centres, hospitals and even with medical education. Though
conducted under the name of increasing accessibility to the
latest in medical care and of self-reliance etc., the basic
logic is one of making profits. Unfortunately, they are
also receiving State encouragement. It is resulting in
the £omjner^cializatiq
with the ’selling’ of
high technology di’agnostic'^and’ therapeutic services not
all of which are beneficial and some of which are positively
hazardous and harmful to health.
H.
1E-1CIFI.C
• BllfelAc..11?Allh...2.a.c:h/.l£g i ni nq
Over the years, there has been a gradual erosion in t|he
role played by public health specialists in the sphere
of health planning. The discipline itself has unfortu
nately $lid into disrepute and has not been attracting
the best. This is in contrast to the increasing role
being played by such trained specialists in health
□
3
planning and organization and evaluation of health services in
several other countries to their benefit, This situation needs
to be rectified by providing better trainingj facilities and
job opportunities.
It would be benefical if all Govt. Medical Officers could undergo
some basic training in practical public health (more than that in
rhe undergraduate course), management, team work etc.,.as in
eir future role, they are also expected to function as team
leaders and planners. In the absence of such a :9staff colleqe"
ype training, they in effect offer only curative services to
those who manage to reach their clinics.
At the primary health centre level, ’team training1 orienting
all members as one group to the overall objectives of the work.
programmes, team functioning itself could be given. This could
be followed by regular meetings for sharing and feed back of
experiences, problem solving, team building and continuing
education. At present these exercises are more of a
coverages110’ policing nature mainly checking cut on target
’
necessary.
3. There is a great need for continuing education for doctors,
nurses and paramedical staff on an organized basis. Teaching
andresearch institutes from different disciplines including
sociology, management, economics etc., could be involved. This
shouldbe a two-way dialogue—much feed back from the field
evel is necessary to suitably modify teaching curriculum and
research priorities.
These experiments are also going on in teaching institutions and
coordinating bodies among voluntary agencies involved with health,
teaching, service and research.
4. Recently, there is a trend emphasising vertical health
programmes - eg., immunization, oral rehydration, child survival,
leprosy etc. as time bound, targetted efforts. This is going
full circle back to the days of malaria eradication and unipurpose
workers. India, infact has historically contributed the concept
2. ifniri—ed_health care approach and the
wisdom of this should not be lost sight of in spite of professional
A-/ ky kA
k- O
5. There is an urgent necessity
— 2 to
— evolve
---- o a rational ^drug £oliqy.
This would ensure an <adequate^supply of essential drugs' to meet '
the health needs of people and in^fact
--- - - - would also help conserve
scarce resources,
6. The system of medical jducat.iori itself needs critical
reappraisal. Several governmental committees have given very
relevant recommendations regarding this aspect of health
personnel training. But as yet no major dent has been made on
the system.
In Karnataka, private enterprise in medical education is playing
a questionable role. These money oriented practices are
etrimental to a profession which is so closely associated with
life and health of people.
(Some in Karnataka as well) have reported poor utiliza.government ~hea1th services. In the face of
expansion gf structures and numbers’* will not yield results.
1s * need to consolidate and strengthen the qualitative
aspeers ot the service.
...,4
4
8. As in many other spheres, there is corruption at*many
levels of the health service, This factor”has“to be addressed
if the goal of public service is
seriously by all concerned
c---co be realised.
’’PERSPECTIVES IN HEALTH POLICY AND STRATEGIES/^ FOR^THE _STATE
A_suMyvymY
A. Perspective Planning in Karnataka for health services must
keep in mind the goal for !HEALTH FOR ALL BY 2000 A.D. and in
this context reorient its focus:
a. From HRalTH as a medicalized PROVISION of curative
to Health as an enabling/empowering process
in"the community increasing individual, family and
community’s autonomy over health related means,
opportunities, knowledge and structure.
b. From Health Policy/ as infrastructural development tp
Health Policy as ’1 quality of life’ and ’quality of care 1
development.
c. From Health Planning as a top down bureaucratized
procedure to a participatoryj, community .based,
bottoms up exercised This is’ particularly relevant
in The^’Tontext of the decentralised system of
Panchayat Raj ushered into the State.
B. In keeping with the overall perspectives of the Ministty^of
Health & Family Welfare Services outlined in their March! 1988
Persnective Plan and the discussions with Sri.L.C.Jain, we
wish to highlight the following key issues:
1 . Health Policy must be closely interlinked with polity
of socio-economic development.
2# Health Policy must explore multi-sectoral linkages.
3. Health Policy must evolve regionally from local
level upwards taking into account
a. Special needs of certain groups - dalits 9 tribals
and slum dwellers;
b. Changing status of health, environment, socio
economic status;
c. Reliable and good quality health information.
d. Interaction with community perceptions and
needs.
4. Health budgets should be increased substantially and
rural urban disparity tackled seriously.
5. All systems of Medicines and existing alternatives
and options available to the community must be
involved and included in an attempt to create an
integrated Indian System of Medicine and Health
Policy.
.... 5
5
6.
Privatization and commercialisation of medicine must
becurbed and the State must continue to bear the
Jor resPonsibility to providing people with
afiordable and accessible services, NGO, Volags and
the private sector must be welcomed to complement
the services but not replace it.
7a. Public Health reorientation of all medical staff isan important strategy organized through a staff
college process and oriented to team traininq and
participatory approaches.
7b. Continuing Education programmes for doctors, nurses
and para-medicals based on multi-disciplinary and
participatory approaches are crucial investments
for the future. A community/social reorientation
of medical education and all existing h alth
manpower training programme is important.
8.
Stress on integrated community based health care
approaches and movement away from vertical
unipurpose health programmes is necessary.
9.
A Rational Drug and Technology Policy needs to
be outlined and implemented.
10. Health Practice Research geared to important basic
issues such as:
a* Poor utilisation of government health
services;
b. Corruption in health services; and
c. Participatory approaches in planning/management
should be organised.
Hp
NATIONAL HEALTH POLICY STATEMENT - 1982
From the viewpoint pf Voluntary Agencies.
by
Dr. Shirdl Prasad Tekur,
Cornmunity Health Cell#
326# V Main Road#
1cBlOtk# Koramangala,
Bangalore - 560 C34.
PATJONAL HEALTH POLICY STATEMENT - 1982
From the viewpoint of Voluntary Agencies
Tho Government of Indians National Health Policy Statement 1982
recognises the importance of community i ^rticlpation and its role
and relationship with voluntary agencies in the following areas a) for identification of health needs and priorities. as well as
in the implementation and management of various health and
related programmes. (P-4)
b) for providing universal comprehensive primary health care
services relevant to the actual needs and priorities at a cost
which the people can afford, ensuring that the planning and
implementation of the various health programmes is through the
organized involvement and participation of the community,
adequately utilising the services being rendered by private
voluntary organisations active in the health sector. (P-4)
J
c) at the community level, to devise arrangements for health and
all other developmental activities to be coordinated under an
Integrated programme of rural development. (P-17)
d) for offering organised logistical, financial and technical
support to voluntary agencies, while adequately utilizing and
enlarging the services rendered by them, and intermeshing it
with governmental efforts in an integrated manner. This,
especially for those which seek to serve the needs of rural
areas and urban slums. (P-6,9,10)
• •2
2.
e) for initiating organised measures to enable development of
various Indigenous and other systems of medicine and a phased
Integration in the overall health care delivery system, specially
in regards to preventive, promotive and public health
objectives.
(P-10,11)
The policy clearly emunclates what is desirable.
It also calls for
— decentralization of services like MCH services to the maximum
possible extent (P-14)
— efforts to establish herbal gardens and encourage low-cost,
indigenous herbal medicine which is easily available and of
certified quality (P-15); and
— for mobilising additional resources for health promotion, ensuring
that the community shares the costs of the services. (P-16)
All these, for providing adequate care and treatment to t- ose entitled
to free care. (P-9)
rrhe policy refrains from providing advice on how this can be done,
beyond the pointers it puts out.
This gives us a wonderful
opportunity to initiate measures to
take into account local realities in the area of health and
development;
- understand peoples priorities in health and the reasons thereof;
consider available resources and constraints, while designing a
flexible process suitable for implementation.
Voluntary agencies and their federations have been interacting with
the Government of Karnataka at meetings end workshops at various
levels, and different times, initiated both by the voluntary agencies
as well as the government, our experience in Karnataka in the last
5 years has shown that with adequate openness and enthusiasm on both
sides, this io a creative possibility and can be operationalised.
E;en though this may not have brought any miracles in Karnataka,
.3
3>
aB
the $tage is set for a close and meaningful collaborative
effort in the decade ahead. Some aspects of this collaboration arei
1. The Formation of a Consultative Committee by the Ministry of
Rural Development and Social Welfare comprising of secretaries
of all key government departments and representatives of NGOs in
Community Development, Education h Health. This was formed at
the Initiative of the Planning Commission and has been sustained
Dy the enthusiasm of a series of Development Coromisslonerfi and
Rural Development Secretaries.
✓
The Consultative Committee has sub committees Including one on
Health in which NGC’s dialogue with the Director of Health
tervices and his colleagues on health programmes •«•••«••
2. Dialogue of NGO’s with Perspective Planning Committee of
Government of Karnataka on Health, welfare and Educational
Programme.
3* Dialogue with NGO*s by Director of Health Services at various
levels
a) Sub cocnnltt.ce of consultative committee
b) Sth plan document preparation
c) Dialogue on government programmes organised by Voluntary
Health Association of Karnataka*
4. Steps to prepare a comprehensive directory.
5. There are steps to Increase such dialogue at the district level.
6* Exploration of collaborative efforts are also under way.
The key process in all this is frank discussion, feedback from
grassroots and mutual consultation in e non-threatening interactive
ethos and a general commitment to exploring the idea of working
together.
..4
4.
At thia juncture, a purposefully critical collection of impressions
of voluntary agencies in their interactions with the Government are
called for to understand the varying levels of success in the
process of Government—Voluntary agency collaboration.
a) Participation sought of Volags in government initiated meets are
at very short notice, on matters which have been already decided
upon and more for purposes of form than actual concern*
Also,
when government officials attend Volag sponsored meets, the
response is desultory, condescending and defensive if at all.
b) Voluntary agencies are seen by the government as only alternative
service providers or associates for implementation of their
demand
programmes. Tne
The voluntary agencjrM
agency?,® roles
roios as
a® Issue-raisers
xb»uo—
creators, builders of awarenass and alternative planners are
largely ignored if not also seen as threats to the Government plans.
c) The Government’s understanding is that involvement of voluntary
agency’s representatives in consultations automatically means
•peoples involvement8 or •community participation’•
It ignores the feedback and the elaborate process the voluntary
agency initiates to bring about peoples participation, since it
may mean modification of plans to suit peoples needs.
d) The Government tends to off-load many of its responsibilities on
to voluntary agencies, and puts remands and pressures beyond
voluntary agency resources and capabilities without adequate
support.
The top-down planning and issue of operation guidelines
stifle voluntary agency innovations and creative approaches.
Also, vertical programs and focus on selective primary health care
programs are at the cost of comprehensive primary health care.
c) The people’s image of the P.lhC. and Governmental Health staff
is very poor.
Corruption, inefficiency, political interference
and mismanagement are seen to hold sway.
They are unhappy with
<•5
- J3BSSJ
5.
functioning, attitudes, and quality of
services at Gov«nnent
Health Centres.
The voluntary agency plea to tone up the existing governmental
.y.t« and bring in greater accountability a. well .s qualitati
improvement in their services is largely Ignored.
I
A $tll-out of this was seen in the negative experiences of the
government health services with, the Panchayat Raj system.
been pre-occupied for
The Governmental Health Services has also
too long in infra-structural development, resulting in mere
structures ?nd no useful function.
in the Government’s perceptions about
f) There has been no change
--3 (NGCs/Volags) or about peoples
people working outside the system
implementation of programmes.
capabilities in planning and : .
Th. Vlllao. Health worker.. Heal thouIde.. Ang.nw.dl worker, and
other, who were poaelfallltle. In P«>pl.. p.rtlelpatloO h.v. been
co-opted fa, th. .y.t« and
l.ck.y. In th. gor.™.ntal
process, demanding recognition, wore aalerlea. perk., etc.
g) Dl.r.lti of
of local
local culture
cuiwr. and
ana tradition, and r.apact for It ha.
„av.r O^n a string
.trio, point
point in
In co^rnwotal
’
so. h... th. traditional and lndlq.no». ay.tw. of health ear
anff.r^ and failed to te rKcnl-d for th.lr potential In
.dominance of the Allopathic approach to health care.
people do not participat
Is it any wonder, then, that
desired?
- that privatisation and cofnrcercia' ization
e as much as
of medical services
is the norm?
- that people have to take up the cell for
Technology policies?
Rational Drug and
•nd that Health policies designed for the poor
do not reach them?
and marginalised
6.
If corannxnlty participation as envisaged in the National Health Policy
is to make an Impact on peoples health, it needs to include processes
that enhance -
Information transfer and awareness building programmes for the
people - probably the most important and credible step, considering
that this is the weakest link of the present system.
People need to know the whys and hows of each programme, and
also to discuss them to explore ideas of how to do them better.
Voluntary agencies have something to offer to the Government in
ways of interacting with the community as well as creative
low-cost communication, which considers people as participants in
a process of development rather than •target—groups• or *
•beneficiaries’.
b) Understanding that people are not a homogenous mass, and are
stratified by class, caste, education, culture, gender and other
factors. Positive discrimination towards groups who de not
benefit from existing progranxnes, bcause they do not participate
in local decision making should be a focus.
Voluntary agencies
have experience In working-with such groups and find that
supplementing participation with Education efforts coulu
strengthen building of healthy communities.
c) Peoples perceptions of the working of projects and programmes
j
or their own responses to problems must be seen as equally
important as statiatical/professional/technlcal situation analysis.
This can be sought for by informal focus group discussions rather
than formal surveys.
•'•hen facts are placed before people in an
understandable manner, it is seen that educatlon/technical
expertise is not a precondition to evolve innovative solutions.
These methodologies used by Voluntary agencies in their work
can easily be shared with governmental agencies.
d) Increasing involvement of voluntary agency sector in the role of
monitors, evaluators, issue raisers, demand creators and trainers
and not just “programme implementors1.
..7
7.
e) Reorientation proyraitjoea for staff at all
levels of the existing
Infrastructure about thia alternate concept of people as
participants, where voluntary agencies could share the approaches
they adopt*
f) Monitoring and record-keeping systems that are not only
quantitative, but also qualitative and allow feedback from people
and from lower level functionaries of the system who are in
closer contact with the people. The motivation of health staff
at the lower leveli> is at a low ebb as they face practical
difficulties in their work with people, which they do not seem
to have the required continuing education and support to deal with
effectively. Voluntary agencies could help re-orienting them.
All these call for moving away from top-down models to more
decentralized and flexible approaches to the diversity of options
likely to emerge. we can share the positive and negative experiences
of noth Governmental and Voluntary agency efforts especially in the
past two decades, learn from each other
methods towards health.
and evolve more effective
To conclude, we have
a positive approach to the National Health Policy,
— an opportunity to make our approaches flexible to meet peoples needs,
- a rich experience between ua to learn from. and.
— in Karnataka, a healthy trend of collaboration.
Let us make use of these and get down to making HEALTH FOP ALL by
2000 A.-D. a reality in Karnataka.
x-x x-x •x
) ,
7/ I v \
REFERENCES
!• Statement on National Health Policy — Government of India,
Ministry of Health & Family Welfare - 1982.
2. Perspectives in Health Policy and Strategies for the State of
Karnataka - a response from CHC-Bangalore.
3. People’s Involvement in Planning and Implementation Process a CHC’s reeponne to Planning Commission Initiative.
4. Beyond Policy Rhetoric, Statistics and Infrastructurae
Development : The tasks for the 1990’s — A working paper from
CHC for the Regional Review meeting on Primary Health Care
System Development for Southern Zone.
5. Specific ccnrments on Perspective plan for Karnataka - drawn up
for Department of Health and Family welfare Services, Karnataka.
6. Perspective Planning in Health * A report of the Expert group
of perspective planning, set up by the Government of Karnataka.
7. Building the New Paradigm - A study-Reflection-Action-experiB»ent
in Community Health in Inula - CHC.
8. Towards a People-Crlented Alternative Health Care System
Ravi Narayan.
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I0
ASSOCIATION OF KARNATAK.A. (VHAK)
Ha j ini Nil ay a, No. 60, Ramakrishna JjAut t JTo ad C^ro s s
Ulsoor, ’Bangalore
’’
During 1969 the leaders of Voluntary Hospitals and Health care
institutions of this country met at Bangalore and in their
deliberations they recomended formation of Voluntary Health
J° bring in all the Voluntary Health Institutions
ot ^tate m to its fold to supplement and augment the Primary
Health Services for the unreached community. It is
■ with this
background.the VHAK was established in 1974 as_ a non-Governmental
non-sectarian registered under Karnataka Society's Act i960?
After its formation VHAK started its activities intensively to
enroll all the Voluntary Health Institutions both in urban and
rural including teaching Hospitals in the VQiun-|;3ry Sector as
members to bring them together on various platforms through
regional meetings, seminars, workshops, training programmes
far all levels of Health functionaries to enable them to
perceive Health as a movement and to strengthen the existing
health care delivery system. The VHAK started with 25
Institutions and has grown to a big institution with a
membership strength of 150 institutions covering all the
regions, all the districts of Karnataka emphasising the need
for developing the most underdeveloped communities of such
districts. It has taken such programmes which would directly
oenefit the common man in the remotest part of the country
side through Dai Training programme, Teachers Training
programme, Health Volunteers Training Programme, Traditional
Medical healers Training programme, Health Workers Training
programme, RDT for Practicing and Teaching Medical personnel,
Seminars for personnel of Developmental Organisations and
designing programmes to the needs of the member institutions.
- VHAK is federal constituent of VHAI, New Delhi.
- Membership is open to all Health & Developmental
Institutions which are registered under Society’s
Act or any other act with a motive of n* profit
and non-sectarian.
- VHAK has divided ^arnataka into four regions Bangalore,
Mysore, Mangalore and Dharwad for convenience >f
bringing the respective institutions together and
closer for geographical convenience.
- The funds of VHAK are received from Membership fees
& Donations.
GOALS A.OBJECTI.VgS
The main goal of VHAK is to create a healthy community,
community. ^t
believes that health can became a reality for all people of the
country by ensuring social justice, equitable distribution and
reaching the unreached for prevention, promotion, curative and
rehabilitative Primary Health Care through concerted effort
both by Government and Voluntary Sector. This needs a
Comprehensive health plan enunciating all the basic principles
of justice dignity and human values woven into the fabric of
the ’comprehensive’ policy emphasising on Primary Health Care,
This may be ensured through mutual understanding and defining
the policy clearly both by Government and Voluntary Sector for
effective implementation of the programme to achieve the
enshrined goals of the health policy.
The Main objective of the VHAK is:
—To act as a liaison between the Voluntary and Government
Agencies at both Central and State levels.
—To aid in co-ordination of health care activities in the
Voluntary Sector.
2
--To help Member Institutions to collaborate wherever
feasible in order to conserve resources.
-To help in organising training programmes for different
levels of Institution Staff
--To encourage preventive and promotive health care
activities
—Diffusing information and recent trends in health care
Policies, Management and Technology.
—Studying, documenting and promoting alternative systems
of medicine and Traditional medicine.
-—-Promoting health care activities
— To mobilize the -resources of both Government and Voluntary
for effective utilization of available resources
Apart from conducting various programmes -the sharing of Health
information related to the programmes and latest developments
in the field of Health is an important task and to achieve this
goal circulars and bi-monthly newsletters are brought out.
ACTIVITIES:
— VHAIC organizes refresher and short term training programmes
according to the felt needs of member institutions from time
to time for Doctors, Nurses, Para-medical workers and
others.
!>
— Training programmes have been organized in the field of
Community Health, School Health, Rational Drug Therapy,
T 3 A (MCH) etc.,
Some of the programmes to mention that were organised both
intensively and extensively are as follows:
1.
Community & Health Care
2.
Problems encountered by Health Care institutions and
suggestions to over come the same.
3.
Materials Management
4.
Community Health Care for the needy
5.
New approaches to community Health Planning & Implementation
6.
Visions of Health Care
'7
Refresher course for Balasevikas
3.
Health priorities and difficulties in the practical
implementation of these priorities.
9.
Hospital
Health education programmes
10. T.B.in context to community health
11. National Health Policy & Role of Voluntary Health Institutions.
12. School Health & School Health education
13. Role of Nurses in community health
14. Management of Diarrhoeal Diseases
3
7
r
3
15. Innovative methods of Nutrition education in schools
16. Participatory dialogue on Government Health Programmes Government
Voluntary Organisation, Etc.,
VHAK has envisaged the following training programmes for the
years 1991 to 1994; The major areas are:
1.
Training of Traditional Birth Attendants:
This is a five.days programme, since the age old practices of
conducting deliveries by the untrained Dais give way for high
rate of infant mortality, morbidity and other complications
m some places leading to death, it is necessary that they
undergo training to conduct safe deliveries and acquire
knowledge to educate on various aspects of Maternal & Child
Health.
2.
Traditional Systems of Medicine:
This is three days workshop on Traditional Systems of Medicine
J-ms
to develop a system of Health Care in which all the different
systems can make their own uiique contribution and promotet
the same.
‘
3.
Training of Village Health Workers:
This is ten days Training Programme. Identify
Identify and
and train
train
dedicated, committed and service minded local personnel
who would take the initiative in a broader prospective
to improve the health status of the community.
4.
School Health:
The role of the School in the Community is to provide a
means for future development and growth through creative
education of its future citizenary. The emphasis of this
programme is Training the Teachers. This includes one day
orientation and 3 days Intensive Training Programme.
5.
Health for Non-Health:
Most of the Voluntary °rganisationa working in the field
of development do nc$ have either doctors, nurses or any
other so called Health personnel; all the same, in one
way or other they are contributing to health in all
rural masses with whom they are working. This 2 days
programme aims at strengthening their knowledge on
Health, broaden their definition of Health and help
them incorporate components of health so that, their
developmental programmes will be more comprehensive and
successful.
6,
Rational Drug Therapy:
VHAK Objectives regarding this are
s) To collect and disseminate the right information
on Drugs and Drug related issues.
b) To create awareness among masses
c) To involve health, education departments, lawyers
Medical workers and Journalists in the awareness compaign.
<fl) To pressurise Medical Professionals and the authorities
of Pharmacy & Pharmaceutical companies to realise the
irrational policies and practices existing.
. . .4
4
LIAISON WORK_WITH J?HE GOVERNMENT :
—VHAK maintains fruitful dialogue with the Health Ministry and
Directorate of Health Services on all matters of common interest.
It has good rapport with the Education department and Forest
department also.
--The cause of Voluntary health sector has been effectively
represented with the Government through meetings and presenta
tion of memoranda.
—VHAK encourages member institutions to co-operate with
Government agencies at local levels in a collaborative and
supportive manner with a view to maximize health care services.
—In light of the VII & VIII five year plans the Karnataka
Government is also involving Voluntary Organisations as
partners. A consultative committee has been constituted under
the Development Commissioner, representatives of Voluntary
Organisations and different heads of the Government departments,
VHAK is \/ery much part of this consultative Committee.
*—Helping the Member Organisations to have dialogue with district
level Health personnel.
—Collecting disseminating various Government Orders, Circulars
related to Voluntary Organisations to the member institutions.
—Helping the Members utilise the Government resources such as
training programmes and health education materials etc.,
LIAISON WITH OTHER VOLUNTARY AGENCIES:
—VHAK has good collaborative relationship with many other
Voluntary agencies engaged in diversely specialized yet allied
fields of activity such as FEVORD-K and the DAF-K etc.,
RELATIONSHIP WITH VHAI, NEW DELHI.
■’ is a federal constituent of Voluntary Health Association of
India and being committed to common goals and philosophy, maintains
< special relationship with it in all spheres of activity.
PUBLICITY AND INFORmTION SHARING:
Through our bi-monthly Newsletter and circulars, we keep our
members informed about latest developments in the health services
in areas of legislation, innovative projects, research
discoveries, refresher training programmes etc. 9
- To strengthen Collective fellowship of Voluntary Health Sector
- To strive for increased liaison and collaboration with the
Government for mutual benefit.
s To publish a health resources manual containing information on
local resources, Government facilities to voluntary sector etcJS
- To publish simple, health education material such as posters
and slides on good health, hygiene and nutrition.
- To offer on-the-field consultancy for developing community based
innovative health care programmes involving local resources.
To establish a legal consultancy service on all matters of
legislation affecting voluntary hospitals.
- To become financially self-sufficient with indigenous publiP
support through self-supporting services and fund-raising
programmes o
• To organise disaster relief from amongst its constituents.
■ ro offer consultancy service to organizations and companies
he wish to add health activities as a service,.
- X - X - X -
VOLUNTARY HEALTH ASSOCIATION OF7 KARNATAKA, BANGALORE
VOLUNTRY HEALTH ASSOCIATION OF INDIA, NEW DELHI
AND
DEPARTMENT OF H 1ALTH AND FAMILY WELFARE
GOVERNMENT OF KARNATAKA
WORKSHOP ON NATIONAL HEALTH POLICY
Venue : I S E C
Date : 9 & 10, April 1992
Bangalore - 72
PROGRAMME
.1
FIRST DAY
i
9.4.1992
Inagiirat Function :
Session - I
8.30 to 9.30 a.m
Registration
9.30 to 9.35 a.m
Invocation by Mrs.Joyce
9.35 to 9.45 a.m
Welcome by Dr.H.Sudarshan, Treasurer
VHAK
9.45 to 9.55 a.m
Role of VHAI in health <5c Context of
the workshop
by
Dr.Mira Shiva, Head
Public Policy Division
VHAI, NEW DELHI.
9.55 to 10.15 a.m
Lighting of the lamp & Inagural
address by Sri.Puttasame Gowda
Minister,
Hon.Health
Govt.
of
Karnataka.
10.15 to 10.30 a.m
Key Note Address
Mr.V.S.BADARI,
Population Centre.
Director
Asst.
10.30 to 10.40 a.m
Presidential address
10.40 to 10.45 a.m
Vote of thanks - Dr.Sona Kalyanpur Rao,
Hon.Secretary, VHAK
10.45 to 11.00 a.m
Coffee
Session II
•
Chair person
Dr.C.M.Francis
Co-Chair person
Dr.S.V.Rama Rao
Presentations :
11.00 to
11.15 a.m
Over view of NHP
Dr.M.K.Vasundhara
Prof. & Head, Dept of P&SM
Bangalore Medical College
of
India
Director
11.15 to 11.30 a.m
Current
Health status
Dr. J.P.Gupta,
regional
(H <5c FW) Bangalore
11.30 to 11.45 a.m
NHP - Point of view of
Dr.C.R .K rishnamur thy
Addl. Direc lor - MCI I M 'WZ
Govt, of Karnataka.
11.45 to I 2.00 noon
NHP - point of view of people's
representative
Dr.M.V.Kufkarni
Prof. <3c Head
Govt. Medical
Dept, of P & SM
College, Mysore.
Govt.
P T O
k
. JKi
- 2 -
12.00 to 12.15 p.m
NHP - Point of Voluntary Organisations
Dr.S.P.Tekur, Community
Community Health Cell, Bangalore.
12.15 to 1.00 p.m
Remarks & Reflection from
person & Co-chair person
1.00 to 1.45 p.m
LUNCH
Chair
Session - III
GROUP DISCUSSION :
Study & Analyse NIIP
Identifying lacunae & its
implementation
2.00 to 4.30 p.m
•
i
10.4.1992
SECOND DAY
Session - IV
8.00 to 9.00 a.m
Breakfast
9^00 to 9.15 a.m
Briefing of the Group Discussion
Report held the previous day.
9.15 to 11.00 a.m
Group discussion continued
(How to strengthen the implementation)
11.00 to 11.30 a.m
Tea Break
11.30 to 1.00 a.m
Action Plan (towards effective
implementation
of
NHP)
1.00 to 2.00 p.m
Lunch
Session V
2.00 to 4.00 p.m
*4
Gist
of
the deliberations
to
be
presented to
the
Health Secretary
Presentation
reports
Remarks
Vote of thanks
Tea
********* *************
of
Group
)—C’ J-
11
VOLUNTARY HEALTH ASSjXIAT IpN^ KARNATAKA
ANNUAL GENERAL BODY MEETING
DATE: Sunday 5, July 1992
VENUE: Conference Hall
St.Martha’s Hospital
Nrupathunga Road
BANGALORE, - 5,60.009.
JR P G R A MM,J.
WORKSHOP ON
’NATIONAL _ HEALTH POLICY.. - .A ..DECADE AFTER..,,.
9.00 to 9.30 a.m.
9.30 to 11.00 a;m.
1
?
Registration
INAGURATION
Invocation - By students, School of Nursing
St.Martha’s Hospital
Fr.Bernard Moras, President, VHAK
Welcome
Lighting of the Lamp Mr.A.K*M,Naik
Secretary
&
Health
& Family Welfare
Inagural Address
Govt, of Karnataka
Dr.Ranganath Achar
Key Note Address
director, H & F.W.
Gevt. of Karnataka
- Report of N H P ~ By Dr.H.Sudarshan
Treasurer, VHAK
- Vote of Thanks - Dr.(Mrs) Sons Kalyanpur Ran
Hon. Secretary, VHAK
11.00 to 11.30 a.m. - TEA
11.30 to 12.30 p.m. - Group Discussion
- Operationalisation of National Health Policy
Strategy at District level
Moderates - Dr.C.M.Francis
- Dr.SoV.Rama Rao
« Dr.C.R.Krishna Murthy
- Dr•C.Prasanna Kumar
12.30 t® 1.30 p.m.
1.3® to 2.30 p.m.
Presentation of Group reports
2.30 to 4.00 p.m.
ANNUAL GENERAL BODY MEETING.
LUNCH
» Prayer
2. Roll Call
3. Approval K Review of the Minutes of the previous E.C.Meeting
4. Points arising out of the minutes
5. Annual Report
1991-92
6. Audited Statement of Accounts
7. Appointment of Auditors
8. Review of the Constitution
9. Appointment of Nomination Committee
10. Release of the Book ’STATE OF INDIA’S HEALTH’
11s Future programmes
12. Any other matter with the permission of the Chair.
X- -Jr -x-
.
Ft
'u p
STATEMENT
0 N
NATIONAL HEALTH POLICY
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
NEW DELHI
1982
Introductory
1. -The Constitution of India envisages the establishment of a
new social order based on equality, freedom, justice and the
dignity of the individual. It aims at the elimination of poverty,
ignorance and illhealth and directs the State to regard the
raising of the level of nutrition and the standard of living of its
people and the improvement of public health as among its
primary duties, securing the health and strength of workers,
men and women, specially ensuring that children are given
opportunities and facilities to development in a healthy manner.
1.2 Since the inception of the planning process in the
country, the successive Five Year Plans have been providing
the frame work within which the States may develop their
health services infrastructure, facilities for medical education,
research etc. Similar guidance has sought to be provided
through the discussions and conclusions arrived at in the Joint
Conferences of the Central Councils of Health and Family
Welfare and the National Development Council. Besides,
Central legislation has been enacted to regulate standards of
medical education, prevention of food adulteration, main
tenance of standards in the manufacture and sale of certified
drugs, etc.
1
1.3
While the broad approaches contained in the successive
Plan documents and discussions in the forums referred to in
para 1.2 may have generally served the needs of the situation
in the past,
it is felt that an
integrated,
comprehensive
approach towards the future development of medical education
research and health services requires to be established to serve
the actual health needs and priorities of the country. It is in
this context that the need has been felt to evolve a National
Health Policy.
Our heritage
2. India has a rich, centuries-old heritage of medical and
health sciences. The philosophy of Ayurveda and the surgical
skills enunciated by Charaka and Shusharuta bear testimony to
our ancient tradition in the scientific health care of our people.
The approach of our ancient medical systems was of a holistic
nature, which took into account all aspects of human health
and disease. Over the centuries, with the intrusion of foreign
influences and mingling of cultures, various systems of
medicine has, in a relatively short period of time, made a
major impact on the entire approach to health care and pattern
of development of the health services infrastructure in the
country.
Progress
achieved
3. During the last three decades and more, since the attain
ment of Independence, considerable progress has been achieved
in the promotion of the health status of our people.
Smallpox
has been eliminated; plague is no longer a problem; mortality
from cholera and related diseases has decreased and malaria
brought under control to a considerable extent. The mortality
rate per thousand of population has been reduced from 27.4 to
14.8 and the life expectancy at birth has increased from 32.7
to over 52. A fairly extensive network of dispensaries, hos
pitals and institutions providing specialized curative care has
developed and a large stock of medical and health personnel
of various levels, has become available. Significant indigenous
capacity has been established for the production of drugs and
pharmaceuticals, vaccines, sera, hospital equipments, etc.
2
The existing
picture
I
4. In spite of such impressive progress, the demographic and
health picture of the country still constitutes a cause for
serious and urgent concern. The high rate of population
growth continues to have an adverse effect on the health of
our people and the quality of their lives. The mortality rates
for women and children are still distressingly high; almost one
third of the total deaths occur among children below the age
of 5 years; infant mortality is around 129 per thousand live
births. Efforts at raising the nutritional levels of our people have
still to bear fruit and the extent and severity of malnutrition
continues to be exceptionally high. Communicable and noncommunicable diseases have still to be brought under effective
control and eradicated. Blindness, Leprosy and T.B. continue to
have a high incidence. Only 31% of the rural population has
access to potable water supply and 0.% enjoys basic sanitation.
4.1 High incidence of diarrhoeal diseases and other preventive
and infectious diseases, specially amongst infants and children,
lack of safe drinking water and poor environmental sanitation,
poverty and ignorance are among the major contributory
causes of the high incidence of disease and mortality.
4.2 The existing situation has been largely engendered by the
almost wholesale adoption of health manpower development
policies and the establishment of curative centres based on
the Western models, which are inappropriate and irrelevant to
the real needs of our people and the socio-economic conditions
obtaining in the country. The hospital-based disease, and
cure-oriented approach towards the establishment of medical
services has provided benefits to the upper crusts of society,
specially those residing in the urban areas. The proliferation
of this approach has been at the cost of providing compre
hensive primary health care services to the entire population,
whether residing in the urban or the rural areas. Furthermore,
the continued high emphasis on the curative approach has led
to the neglect of the preventive, promotive, public healfh and
rehabilitative aspects of the health care. The existing approach
instead of improving awareness and building up self-reliance,
has tended to enhance dependency and weaken the community's
capacity to cope with its problems. The prevailing policies
in regard to the education and training of medical and health
personnel, at various levels, has resulted in the development
of a cultural gap between the people and the personnel provi
ding care. The various health programmes have, by and large,
failed to involve the individuals and families in establishing a
3
self-reliant community. Also, over the years, the planning
process has become largely oblivious of the fact that the
ultimate goal of achieving a satisfactory health status for all
our people cannot be secured without involving the commu
nity in the identification of their health needs and priorities as
well as in the implementation and management of the various
health and related programmes.
Need for
evolving a
health policy
-the revised
20-point
programme
5. India is committed to attaining the goal of "Health for all
by the year 2000 A.D." through the universal provision of com
prehensive primary health care services. The attainment of
this goal requires a through overhaul of the existing approa
ches to the education and training of medical and health
personnel and the reorganisation of the health serv.ces mfrastructure. Furthermore, considering the large variety of inputs
into health, it is necessary to secure the complete integration
of all plans for health and human development with the overall
national socio-economic development process, and specially in
the more closely health related sectors, e g. drugs and pharma
ceuticals, agriculture and food production, rural development,
education and social welfare, housing, water supply and sani
tation, prevention of food adulteration, maintenance of pres
cribed standards in the manufacture and sale of drugs and the
conservation of the environment. In sum, the contours of the
National health Policy have to be evolved within a fully inte
grated planning framework which seeks to provide universal
comprehensive primary health care services, relevant to the
actual needs and priorities of the community at a cost which
the people can afford, ensuring that the planning and imple
mentation of the various health programmes is through the
organ is ed involvement and participation of the communi ty,
adequately utilising the services being rendered by private
voluntary organisations active in the health sector.
5. 1 It is also necessary to ensure that the pattern of develop
ment of the health services infrastructure in the future fully
takes into account the revised 20-point programme. The said
programme attributes very high priority to the promotion of
family planning as a people's programme, on a voluntary basis,
substantial augmentation and provision of primary health
facilities on a universal basis; control of leprosy, T.B. and
Blindness; acceleration of welfare programmes for women and
children; nutrition programmes for pregnant women, nursing
mothers and children, especially in the tribal, hill and back
ward areas. The programme also places high emphasis on the
supply of drinking water to all problem villages, improvements
4
I
in the housing and environments of the weaker section of
society; increased production of essential food items; integ
rated rural developments; spread of universal elementary educ
ation, expansion of the public distribution systems, etc.
Population
stabilisation
6.
Irrespective of the changes, no matter how fundamental,
that may be brought about in the over-all approach to health
care and the restructuring of the health services, not much
headway is likely to be achieved in improving the health status
of the people unless success is achieved in securing the small
family norm, through voluntary efforts, and moving towards
the goal of population stabilisation.
In view of the vital
importance of securing the balanced growth of the population
it is necessary to enunciate, separately, a National Population
Policy.
Medical and
health
education
7. It is also necessary to appreciate that the effective delivery
of health care services would depend very largely on the nature
of education, training and appropriate orientation towards
community health of all categories of medical and health
personnel and their capacity to function as an integrated team,
each of its members performing given tasks within a coordi
nated action programme. It is therefore, of crucial importance
that the entire basis and approach towards medical and health
education, all levels, is reviewed in terms of national needs and
priorities and the curricular and training programmes restruc
tured to produce personnel of various grades of skill and
competence, who are professionally equipped and socialy
motivated to effectively deal with day-to-day problems, within
the existing constraints. Towards this end, it is necessary to
formulate, separately, a national medical and health education
Policy which (i) sets out the changes required to be brought
about in the curricular contents and training programme of
medical and health personnel, at various levels of functioning;
(ii) takes into account the need for establishing the extremely
essential inter-relations between functionaries of various grades
(iii) provides guidelines for the production of health personnel
on the basis of realistically assessed manpower requirments;
(iv) seeks to resolve the existing sharp regional imbalances in
their availability; and (v) ensures that personnel at all levels
are socially motivated towards the rendering of community
health services.
5
Need for
providing
primary
health care
with special
emphasis on
8. Presently, despite the constraint of resources, there is
disproportionate emphasis on the establishment of curative
centres-dispensaries, hospitals, institutions for specialist treat
ment—the large majority of which are located in the urban
areas of the country.
the preventive,
The vast majority of those seeking medical relief have to travel
long distance to the nearest curative centre, seeking relief for
ailments which could have been readily and effectively handled
at the community level. Also for want of a well established
referral system, those seeking curative care have the tendency
to visit various specialist centres, thus further contributing to
congestions, duplication of efforts and consequential waste
of resources. To put an end to the existing all-round unsatis
factory situation, it is urgently necessary to restructure the
health services within the following broad approach :
promotive
and
rehabiliative
aspects:
(1)
To provide within a phased, time-bound programme a
well dispersed network of comprehensive primary health
care services, integrally linked with the extension and
health education approach which takes into account
the fact that a large majority of health functions can be
effectively handled and resolved by the people them
selves, with the organised support of volunteers, auxilliaries, para-medicals and adequately trained multi-purpose
workers of various grades of skill and competence, of
both sexes. There are a large number of private, volun
tary organisations active in the health field all over
the country. Their services and support would require
to be utilised and intermeshed with the governmental
efforts, in an integrated manner.
(2)
To be effective, the establishment of the primary health
care approach would involve large scale transfer of
knowledge, simple skills and technologies to health
volunteers, selected by the communities and enjoying
their confidence. The functioning of the front line of
workers, selected by the community would require to be
related to definitive action plans for the translation of
medical and health knowledge into practical action,
involving the use of simple and inexpensive intervention
which can be readily implemented by persons who have
undergone short periods of training. The quality of
training of these health guides/workers would be of
crucial importance to the success of this approach.
6
(3)
The success of the decentralised primary haalth care sys
tem would depend vitally on the organised building up of
individual self-reliance and effective community partici
pation; on the provision of organised, back-up support
of the secondary and tertiary levels of the health care
services, providing adequate logistical and technical
assistance.
(4)
The decentralisation of services would require the estab
lishment of a well worked out referral system to provide
adequate expertise at the various levels to the organisa
tional set-up nearest to the community, depending upon
the actual needs and problems of the area, and thus ensure
against the continuation of the existing rush towards the
curative centres in the urban areas. The effective esta
blishment of the referral system would also ensure the
optimal utilisation of expertise at the higher levels of the
hierarchical structure. This approach would not only lead
to the progressive improvement of comprehensive health
care services at the primary level but also provide for
timely attention being available to those in need of
urgent specialist care, whether they live in the rural or
the urban areas.
(5)
To ensure that the approach to health care does not
merely constitute a collection of disparate health interv
entions but consists of an integrated package of services
seeking to tackle the entire range of poor health condi
tions, on a broad front, it is necessary to establish a na
tion-wide chain of sanitary-cum-epidemiological stations.
The location and functioning of these stations may be
between the primary and secondary levels of the hierar
chical structure, depending upon the local situations
and other relevent considerations. Each such station
would require to have suitably trained staff equipped to
identify, plan and provide preventive, promotive and
mental health care services. It would be beneficial,
depending upon the local situations, to establish such
stations at the Primary Health Centres. The district
health organisation should have, as an integral part ot
its set-up, a well organised epidemiological unit to
coordinate and superintend the functioning of the field
7
stations. These stations would participate in the inte
grated action plans to eradicate and control diseases,
besides tackling specific local environmental health
problems. In the urban agglomerations, the municipal
and local authorities should be equipped to perform
similar functions, being supported with adquate resour
ces and expertise, to effectively deal with the local
preventable public health problems. The aforesaid
approach should be implemented and extended through
community participation and contributions, in whatever
form possible, to achieve meaningful results within a
time-bound programme.
(6)
,The location of curative centres should be related to
the populations they serve' keeping in view the densi
ties of population, distances, topography, transport
connections.
These centres should function within
the recommended referral system, the gamut of the
general specialities required to deal with the local
disease patterns being provided as near to the comm
unity as possible, of the secondary level of the hierar
chical organisation. The concept of domiciliary level
and the field-camps approach should be utilised to
the fullest extent, to reduce the pressures on these
centres, specially in efforts relating to the control and
eradication of Blindness, Tuberculosis, Leprosy, etc.
To maximise the utilisation of available resources, new
and additional curative centres should bo established
only in exceptional cases, the basic attempt being
towards the upgradation of existing facilities, at
selected locations, the guiding principle being to
provide specialist services as near to the beneficiaries
as may be possible, within a well-planned network.
Expenditure should be reduced through the fullest
possible use of cheap locally available building mater
ials, resort to appropriate architectural designs and
engineering concepts and by economical investment
in the purchase of machineries and equipments,
ensuring against avoidable duplication of such acqui
sitions, It is also necessary to devise effective mech
anisms for the repair, maintenance and proper upkeep
of all bio-medical equipments to secure their maximum
utilisation.
8
(7)
With a view to reducing governmental expenditure and
fully utilising untapped resources, planned programmes
may be devised, related to the local requirments and
potentials, to encourage the establishment of practice
by private medical professional, increased investment
by non-governmental agencies establishing curative
centres and by offering organised logistical, financial
and technical support to voluntary agencies active in
health field.
(8)
While the major focus of attention in restructuring the
existing governmental health organisations would relate
to establising comprehensive primary health care and
public health services, within an integrated referral
system, planned attention would also require to be
devoted to the establishment of centres equipped to
provide speciality and super-speciality service, through
a well dispersed net work of centres, to ensure that the
present and future requirements of specialist treatment
are adequately available within the country. To reduce
governmental expenditures involved in the establish
ment of such centres, planned efforts should be made
to encourage private investments in such fields so that
the majority of such centres, within the governmental
set up, can provide adequate care and treatment to
those entitled to free care, the affluent sectors being
looked after by paying clinics. Care would also require
to be taken to ensure the appropriate dispersal of such
centres, to remove the existing regional imbalances
and to provide services within the reach of all, whether
rural or the urban areas.
*
(9)
Special, well coordinated programmes should be laun
ched to provide mental health care as well as medical
care and the physical and social rehabilitation of those
who are mentally retarded, deaf, dumb, blind, physically
disabled, infirm and the aged. Also, suitably organised
programmes would require to be launched to ensure
against the prevention of various disabilities.
(10)
In the establishment of the re-organised services, the
first priority should be accorded to provide service to
those residing in the tribal, hill and backward areas as
well as to endemic disease affected populations and the
vulnerable sections of the society.
9
(11)
In the re-organised health services scheme, efforts
should be made to ensure adequate mobility of personnel
at all levels of functioning.
(12)
In the various approaches, set out in (1) to (11) above
organised efforts would require to be made to fully
utilise and assist in the enlargement of the services
being provided by private voluntary organisations active
in the health field. In this context, planning encoura
gement and support would also require to be afforded
to fresh voluntary efforts, specially those which seek
to serve the need of the rural areas and the urban
slums.
Re orientation
of the
existing
health
personnel
9. A dynamic process of change and innovation is required
to be brought in the entire approach to health manpower
development, ensuring rhe emergence of fully integrated
bands of workers functioning within the '‘Health Team"
Private
practice by
governmental
functionaries
10. |t is desirable for the States to take steps to phase out
the system of private practice by medical personnel in govern
approach.
ment service, providing at the same time for payment of
appropriate compensatory nonexisting allowance. The State
would require to carefully review the existing situation, with
special reference to the availability and dispersal of private
practitioners, and take timely decisions in regard to this vital
issue.
Practitioners
of indigenous
and other
systems of
medicine and
their role in
health care
11. The country has a large stock of health manpower comp
rising of private practitioners in various systems, for example.
Ayurvedic, Unani, Sidha, Homoeopathy, Yoga, Naturopathy
etc. This resource has not so far been adequately utilised. The
practitioners of these various systems enjoy high local accep
tance and respect and consequently exert considerable influ
ence on health beliefs and practices. It is, therefore, neces
sary to initiate organised measures to enable each of these
various systems of medicine and health care to develop in
accordance with its genius. Simultaneously, planned efforts
should be made to dovetail the functioning of the practitioners
of these various systems and integrate their services, at the
appropriate levels, within specified areas of responsibility
and functioning, in the over-all health care delivery system,
10
specially in regard to the preventive, promotive and public
health objectives. Well considered steps would also require to
be launched to move towards a meaningful phased integration
at
1
of the indigenous and the modern systems.
Problems requiring urgent
attention
Besides the recommended restructuring of the health
services infrastructure, reorientation of the medical and health
manpower, community involvement and exploitation of the
services of private medical practitioners, specially those of
the traditional and other systems, involvement and utilisation
of the services of the voluntary agencies active in the health
field, etc., it would be necessary to devote planned, time
bound attention to some of the more important inputs requi
red for improved health care. Of these, priority attention
would require to be devoted to:
(i)
Nutrition: National and regional strategies should be
evolved and implemented, on a time-bound basis, to
ensure adequate nutrition for all segments of the popu
lation through a well developed distribution system,
specially in the rural areas and urban slums. Food of
acceptable quality must be available to every person in
accordance with his physical needs. Low cost, proce
ssed and ready-to-eat foods should be produced and
made readily available. The over-all strategy would
necessarily involve organised efforts of improving the
purchasing power of the poorer sections of the society.
Schemes like employment guarantee scheme, to which
the government is committed could yield optimal results
if these are suitably linked to the objective of
providing adequate nutrition and health cover to the
rural and the urban poor. The achievement of this
objective is dependent on integrated socio-economic
development leading to the generation of productive
employment for all those constituting the labour force.
Employment guarantee scheme and similar efforts
would require to be specially enforced to provide soci
al security for identified vulnerable sections of the
society. Measures aimed at improving eating habits,
inculcation of desirable nutritional practices, improved
and scientific utilisation of available food materials and
11
the effective popularisation of improved cooking practi
ces would require to be implemented.
Besides, a
nation-wide programme to promote breast feeding of
infants and eradication of various social taboos detri
mental to the promotion of health would need to be
initiated. Simultaneously, the problems of communi
ties afflicted by chronic nutritional disorders should be
tackled through special schemes including the organi
sation of supplementary feeding programmes directed
to the vulnerable sections of the population. The force
and effect of such programmes should be ensured by
delivering them within the setting of fully integrated
health care activities, to ensure the inculcation of the
educational aspects, in the over-all strategy.
(ii)
Prevention of food adulteration and maintenance
of the quality of drugs: Stringent measures are
required to be taken to check and prevent the adulter
ation and contamination of foods at the various stages
of their production, processing, storage, transport,
distribution, etc. To ensure uniformity of approach,
the existing law would require to be reviewed and
effective legislation enacted by the Centre. Similarly
the most urgent measures require to be taken to ensure
against the manufacture and sale of spurious and sub
standard drugs.
(Hi) Water supply and sanitation : The provision of safe
drinking water and the sanitary disposal of waters,
human and animal wastes, both in urban and rural
areas, must constitute an integrated package. The
enormous backlog in the provision of these services
to the rural population and in the urban agglomerations
must be made up on the most urgent basis. The provi
sion of water supply and basic sanitation facilities
would not automatically improve health. The availa
bility of such facilities should be accompanied by
intensive health education campaigns for the improve
ment of personal hygiene, the economical use of
water and the sanitary disposal of waste in a manner
that will improve individual and community health.
Ail water-supply schemes must be fully integrated with
12
I
efforts at proper water management, including the
drainage and disposal of waste waters. To reduce
expenditures and for achieving a quick headway it
would be necessary to devise appropriate technologies
in the planning and management of the delivery
systems. Besides, the involvement of the community
in the implementation and management of the systems
would be of crucial importance, both for reducing
costs as well as to see that the beneficiaries value and
protect the services provided to them.
(iv) Environmental protection: While preventive, pro
motive, public health services are established and the
curative services re-organised to prevent, control and
treat diseases, it would be equally necessary to ensure
against the haphazard exploitation of resources which
cause ecological disturbances leading to fresh health
hazards.
It is, therefore,
necessary that economic
developmeat plans, in the various sectors, are devised
.in adequate consultation with the Central and the State
Health authorities. It is also vitally essential to ensure
that the present and future industrial and urban develo
pment plans are centrally reviewed to ensure against
congestions, the unchecked release of noxious emiss
ions and the pollution
of air and water.
In
this
context, it is vital to ensure that the siting and
location of all manufacturing units is strictly regulated
through legal measures, if necessary. Central and
State Health authorities must necessarily be consulted
in establishing
locational policies for
industrial
development and urbanisation programmes. Environ
mental appraisal procedures must be developed and
strictly applied in according clearance to the various
developmental projects.
(v)
Immunisation programme : It is necessary to launch
an organised, nationwide immunisation programme,
aimed at cent percent coverage of targetted population
groups with vaccines against preventable and communi
cable diseases.
Such an approach would not only
prevent and reduce disease and disability but also bring
down the existing high infant and child mortality rate.
13
(vi) Maternal and child health service :
A vicious
relationship exists between high birth rates and high
infant mortality, contributing to the desire for more
children. The highest priority would, therefore, require
to be devoted to efforts at launching special progra
mmes for the improvement of maternal and child health,
with a special focus on the less privileged sections
of sections of society. Such programmes would require
to be decentralised to the maximum possible extent,
their delivery being at the primary level, nearest to the
doorsteps of the beneficiaries. While efforts should
continue at providing refresher training and orientation
to the traditional birth attendants, schemes and progra
mmes should be launched to ensure that progressively
all deliveries are conducted by competently trained
persons so that complicated cases receive timely and
expert attention, within a comprehensive programme
providing ante-natal, intra-natal and postnatal care.
(vii)
School health programme : Organised school health
services, integrally linked with the general, preventive
and curative service, would require to be established
within timelimited programmes.
(viii)
Health
education
Occupational health service : There is urgent need
for launching well-considered schemes to prevent and
treat diseases and injuries arising from occupational
hazards, not only in the various industries but also in
the comparatively un-organised sectors like agriculture.
For this purpose, the coverage of the Employees State
Insurance Act, 1948, may be suitably extended ensu
ring adequate coordination of efforts with the general
helth services. In their respective spheres of responsi
bility, the Centre and the States must introduce
organised occupational health services to reduce
morbidity, disabilities and mortality and thus promote
better health and increased welfare and productivity on
all fronts.
13. The recommended efforts, on various fronts, would bear
only marginal results unless nation-wide health education
programmes, backed by appropriate communication strategies
are launched to provide health information in easily under
standable form, to motivate the development of an attitude
14
for healthy living. The public health education programme
should be supplemented by health, nutrition and population
education programmes in all educational institutions at
various levels. Simultaneously, efforts would require to be
made to promote universal education, specially adult and
family education, without which the various efforts to organise
preventive and promotive health activities, family planning
and improved maternal and child health cannot bear fruit.
Management
information
system
14.
Appropriate decision making and programme planning in
the health and related fields is not possible without establi
shing an effective health information system. A nation-wide
organisational set-up should be established to procure essent
ial health information. Such information is required not only
for assisting in planning and decision making but to also
provide timely warnings about emerging health problems and
for reviewing, monitoring and evaluating the various on-going
health programmes. The building up of a well conceived
heakh information system is also necessary for assessing
medical and health manpower requirements and taking timely
decisions, on a continuing basis, regarding the manpower
requirement in the future.
Medical
industry
15.
The country has built up sound technological and manu
facturing capability in the field of drugs, vaccines, bio-medical
equipments, etc. The available know-how requires to be
adequately exploited to increase the production of essential
and life saving drugs and vaccines of proven quality to fully
meet the national requirement, specially in regard to the
national programmes to combat Malaria, TB, Leprosy,
Blindness, Diarrhoeal diseases, etc. The production of the
essential, life saving drugs under their generic names and the
adoption of economical packaging practices would considerably
reduce the unit cost of medicines bringing them within the
reach of the poorer sections of society, besides significantly
reducing the expenditures being incurred by the govern
mental organisation on the purchase of drugs. In view of the
low cost of indigenous and herbal medicines, organised
efforts may be launched to establish herbal gardens, producing
drugs of certified quality and making them easily available.
15. 1 The practitioners of the modern medical system rely
heavily on diagnostic aids involving extensive use of costly,
sophisticated biomedical equipment.
Effective mechanisms
15
indigenous manufacture, for such devices being readily avai
lable, at reasonable prices, for use of the health care centres.
Health
education
16. Besides mobilising the community resources, through its
active participation in the implementation and management of
national health and related programmes, it would be necessary
to device well considered health insurance schemes, on a
State-wise basis, for mobilising additional resources for
health promotion and ensuring that the community shares the
cost of lhe services, in keeping with its paying capacity.
Health
legislation
17. It is necessary to urgently review all existing legislation
and work towards a unified, comprehensive legislation in the
health field, enforceable all over the country.
Medical
research
18. The frontiers of the medical sciences are expanding at a
phenomenalpace. To maintain the country's lead in this field
as well as to ensure self-sufficiency and generation of the
requisite competence in the future, it is necessary to have an
organised programme for the building up and extension of
fundamental and basic research in the field of bio-medical and
allied sciences. Priority attention would require to be devoted
to the resolution of problems relating to the containment and
eradication of the existing, widely prevalent diseases as well
as to deal with emerging health problems. The basic objective
of medical research and the ultimate test of its utility would
involve the translation of available know-how into simple,
low-cost, easily applicable appropriate technologies, devices
and interventions suiting local conditions, thus placing the
latest technological achievements, within the reach of health
personnel, and to the front line health workers, in the remotest
corners of the country. Therefore, besides devotion ‘ to basic,
fundamental research, high priority should be accorded to
applied, operational research including action research for
continuously improving the cost effective delivery of health
services. Priorities would require to be identified and laid
down in collaboration with social scientists, planners and
decision makers and the public. Basic research efforts should
devote high priority to the discovery and development of more
effective treatment and preventive procedures in regard to
communicable and tropical diseases—Blindness, Leprosy, T.B.,
etc. Very high priority would also have to be devoted to
contraception research, to urgently improve the effectiveness
acceptability of existing methods as well as discover more
effective and acceptable devices. Equally high attention would
16
should be established to identify essential
equipments
required for extensive use and to promote and enlarge their
require to be devoted fo nutrition research, to improve the
health status of the community. The overall effort should aim
at the balanced development of basic, clinical problem-oriented
operational research.
Inter-sectoral
cooperation
1^.
All health
and
human
development
must ultimately
constitute an integral component of the overall socio-economic
•developmental process in the country.
It is thus of vital
importance to ensure effective coordination between the health
and its more intimately related sectors. It is, therefore, neces
sary to set up standing mechanisms, at the Centre and in the
States, for securing inter-sectoral coordination of the various
efforts in the fields of health and family planning, medical
education and research, drugs and pharmaceuticals, agriculture
and food, water supply and drainage, housing, education and
social welfare and rural development. The coordination and
review, committees to be set up, should review progress,
resolve bottlenecks and bring about such shifts in the contents
and priorities of programmes as may appear necessary to
achieve the overall objectives. At the community level, it
would be desirable to devise arrangements for health and all
other developmental activities being coordinated
integrated programme of rural development.
Monitoring
and review
of progress
under an
20. It would be of crucial importance to monitor and period
ically review, the success of the efforts made and the results
achieved. For this purpose, it is necessary to urgently identify
’ the base line situation and to evolve a phased programme for
the achievement of short and long term objectives in the
various sectors of activity. Towards this end, the current level
of achievement as well as the broad indicators for the achiev
ement of certain basic health and family welfare goals are set
out in the annexed tabular statement. These goals, as well as
other allied objectives, would require to be further worked
upon and specific targets for achievement established by the
Central and the State governments in regard to the various
functioning.
17
f
goals for health and family
WELFARE PROGRAMMES
GOALS
SI.
No
Indicator
1.
Infant mortality rate
Rural
Perinatal mortality
Urban 70(1978)
Total 125 (1978)
67 (1976)
106 87 below 60
30-35
2.
Crude death rate
Around 14
12
3.
Pre-school child
Current level
1985
136 (1978)
122
60
10.4
9.0
20-24 15-20
10
(1-5 yrs) mortality
24 (1976-77)
4.
Maternal mortality rate
4-5 (1976)
5.
Life expectancy at
birth (yrs)
Male
52.6 (1976-81) 55.1
Famale 15.6 (1976-81) 54.3
6.
1990 2000
3-4
2-3 below 2
57.6
57.1
64
64
Babies with birth
weight below
2500 gms (Percentage)
30
25
18
10
7.
Crude birth rate
Around 35
31
27.0
21.0
8.
Effective couple
Protection (Percentage)
23.6 (March 82)
37.0
42.0
60.0
Net Reproduction Rate
(NRR)
1.48 (1981)
1.34
1.17
1.00
10.
Growth rate (annual)
2.24 (1971-81)
1.90
1.66
1.20
11.
Family size
4.4 (1975)
3.8
12.
Pregnant mothers
receiving ante-natal (%)
40-50
9.
13.
2.3
50-60 60-75
1.00
Deliveries by trained
attendents (%)
30-35
18
50
80
100
14.
Immunisation status
(%) coverage
TT for pregnant women
60
100
100
5
65
40
60
70
50
70
100
100
85
70
80
100
100
85
85
85
20
80
85
85
2
70
85
85
20
40
60
80
50
60
75
90
1.4
1
0.7
0.3
20
TT for school children
10 years
16 years
20
DPT (children below 3 yrs) 25
Polio (infants)
BCG (infants)
DT (new school entrants
5-6 years)
Typhoid (new school
entrants 5-6 years)
15.
Leprosy - percentage of
arrested cases out of
those detected
16.
TB - percentage of
disease arrested cases
out of those detected
17.
Blindness Incidence
of (%)
r
19
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