|DR. J. E. PARK MEMORIAL ORATION
|Year : 2011 | Volume
| Issue : 2 | Page : 88-91
Public health in India: Issues and Challenges
Director, National Centre for Disease Control, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt of India, New Delhi, India
|Date of Web Publication||22-Sep-2011|
L S Chauhan
Director, National Centre for Disease Control (NCDC), Govt of India, 22, Sham Nath Marg, New Delhi-110054
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Health is determined not only by medical care but also by determinants outside the medical sector. Public health approach is to deal with all these determinants of health which requires multi sectoral collaboration and inter-disciplinary coordination. Although there have been major improvements in public health since 1950s, India is passing through demographic and environmental transition which is adding to burden of diseases. There is triple burden of diseases, viz. communicable, non-communicable and emerging infectious diseases. This high burden of disease, disability and death can only be addressed through an effective public health system. However, the growth of public health in India has been very slow due to low public expenditure on health, very few public health institutes in India and inadequate national standards for public health education. Recent years have seen efforts towards strengthening public health in India in the form of launch of NRHM, upgradation of health care infrastructure as per IPHS, initiation of more public health courses in some medical colleges and public health institutions and strengthening of public health functional capacity of states and districts under IDSP.
Keywords: Public health, Health problems, India
|How to cite this article:|
Chauhan L S. Public health in India: Issues and Challenges. Indian J Public Health 2011;55:88-91
| Public Health and Health Determinants|| |
Age old definition of health given by WHO states that, "Health is a state of complete physical, mental and social well being and not merely the absence of disease". Medicine or curative services is not the only soul contributor to health and well being of population. There are several other determinants of health which include environmental, biological, socio-economic factors, information and communication, availability of health services, utilization of health services, age structure of the population etc. By influencing these factors or these determinants we may play quiet a substantial role in improving the health.
Public health, which is, "Art and Science of protecting and improving the health of a community through an organized and systematic effort that includes education, provision of health services and protection of the public from exposures that will cause harm".
Thus, public health approach is to deal with all these determinants of health which requires multi sectoral collaboration and inter disciplinary coordination. Health care includes medical care and care of the determinants of health (this collective approach will help to improve the health of the community).
Public Health approach is a holistic approach which encompasses all elements required for healthy living. It controls disease through health promotion, specific protection and by restoration and rehabilitation. In addition, disease surveillance which informs about ongoing as well as emerging public health issues is a core public health function. Other important functions are developing partnerships, formulation of regulations/laws, planning/policies and Human Resources Development.
| Health status of Indian Population|| |
India is passing through demographic and environmental transition which is adding to burden of diseases. The first half of the 20 th century witnessed a large number of communicable disease epidemics.
There have been major improvements in public health since 1950s. Affordable medicines and tools are now available which are highly effective, when used appropriately. Examples are: Anti-tubercular medicines, Anti-malarials, Insecticide-treated bednets, and condoms (to prevent HIV infection).
However, there have also been health consequences of urbanization and industrialization. There is persisting inequality in health status due to varying economic, social and political causes.
Developing countries like India currently face a TRIPLE BURDEN of diseases from:
- Unfinished agenda of Communicable Diseases.
- Emerging Non-communicable disease related to lifestyles, and
- Emerging Infectious Diseases.
This high burden of disease, disability and death can only be addressed through an effective public health system.
Ever increasing population with increasing geriatric population and changing lifestyle with more urbanization is putting pressure on environmental as well as on nutritional requirement resulting in nutritional deficiency, poor sanitation increasing communicable and non-communicable diseases etc.
| Disease Burden|| |
India has the highest number of TB cases in the world. Out of 9.2 million cases of TB that occur in the world every year, nearly 1.9 million occur in India which accounts for one-fifth of the global TB cases. Experts estimate that about 2.5 million persons have HIV infection in India. This is nearly 7.6% of the global burden of 33 million cases. More than 1.5 million persons are affected with malaria every year. Almost half of them suffer from falciparum malaria. One third of global cases infected with filarial disease live in India. Nearly half of leprosy cases detected in the world in 2007 were contributed by India. More than 300 million episodes of acute diarrhea occur every year in India in children below 5 years of age. Although data are limited, perhaps more than 35 million persons are carriers of viral hepatitis B.
Emerging infectious diseases are a major public health problem in developing countries like India. Because of the existing environmental, socio-economic and demographic factors, developing countries like India are vulnerable to rapidly evolving micro-organisms. During the past three decades more than 30 new organisms have been identified worldwide including HIV, Vibrio cholera O139, SARS, corona virus, highly pathogenic avian influenza virus A, and novel H1N1 influenza virus. Many of these organisms emerged in the developing countries of Asia.
Infectious diseases, especially the new emerging and re-emerging diseases, result in high morbidity and mortality and affect the public health and economy adversely. For example, plague which was not reported from any part of India for almost a quarter of the century, caused a major outbreak in Beed district in Maharashtra and Surat in Gujarat in 1994 and resulted in huge economic loss to the country.
In the recent times, avian influenza virus A H5N1 created pandemic scare by affecting birds/poultry in more than 60 countries including India and affecting human beings in 15 countries. But pandemic finally occurred due to novel H1N1 virus in 2009. As of 20 th of November 2009, more than 0.5 million cases and 6770 deaths due to lab confirmed novel H1N1 infections have been reported to WHO by more than 206 countries, although countries are no longer required to test and report all cases. During previous pandemics, influenza viruses took more than 6 months to spread as widely as the new influenza A H1N1 pandemic virus did in less than 6 weeks since the first cases started in Mexico in April 2009. Infection, first confirmed in India on 16 th of May 2009 in a traveler, has spread to 30 States in 6 months causing more than 46460 lab confirmed cases and 2735 deaths (data till March 2011).
Burden of non-communicable diseases is not less. Overall non-communicable diseases are the leading causes of death in the country, constituting 42% of all deaths. Communicable, maternal, perinatal and nutritional conditions constitute another 38% of deaths. Injuries and ill-defined caused constitute 10% of deaths each. However, majority of ill-defined causes are at older ages (70 or higher years) and most of ill-defined deaths are likely to be from non-communicable diseases.
Rural areas report more deaths due to communicable, maternal, perinatal and nutritional conditions (41%). The urban areas have a lower number of deaths from communicable, maternal, perinatal and nutritional conditions but a higher proportion from non-communicable diseases (56%). Their proportion is less in rural areas (40%). Injuries constitute about the same proportion in both rural and urban areas; however, the specific causes of injury vary.
Overall, the leading cause of death is cardiovascular disease (19%), followed by respiratory diseases (namely chronic obstructive pulmonary disease or COPD, asthma, other respiratory diseases; 9%), diarrhoeal diseases (8%), perinatal conditions (6.3%), respiratory infections such as acute pneumonia (6.2%), tuberculosis (6%), malignant and other neoplasms (5.7%), senility (5.1% - which is concentrated at ages 70 and higher), unintentional injuries: other (4.9%), and symptoms, signs and ill-define conditions (4.8%). (Source: Report on causes of death in India, 2001-03; Registrar General of India).
Besides, India has the highest number of blind persons in the world. An estimated 2-2.5 million persons in India have cancers at any given point of time. More than 7 lakh cases of cancer occur every year. National Family Health survey-III has revealed that more than 56% of the women in India have some degree of anaemia and about one-third are undernourished. Similarly, three-fourths of young children are also anaemic.
Despite high disease burden and shortage of funds, the country has achieved noteworthy successes. Smallpox and guineaworm have been eradicated; their last cases occurred in the country in May 1975 and July 1996 respectively. Yaws, which mainly occurs in remote tribal areas, has been eliminated. Prospects of polio eradication in the near future are very bright. Last case of Polio In January 2011 in west Bengal. UP and Bihar, the traditional pockets of pockets of polio, have not reported a case for a long time. Malaria which used to cause 75 million cases in early 1950s has been reduced to less than 2 million cases every year. Revised national tuberculosis control programme, launched in 1997, presently covers the entire country and detects over 70% of new sputum cases with treatment success rate of 87%. TB mortality has decreased from over 5 lakh deaths every year at the beginning of programme to about 2.8 lakh deaths presently despite growth in population. Leprosy has been eliminated as a public health problem from most of the states.
Life expectancy has increased from 36.5 years in 1951 to more than 63.1 years. While Crude birth rate declined from 40.8 in 1951 to 22.8 in 2008, crude death rate declined from 25.1 in 1951 to 7.4 in 2008. Infant Mortality Rate (IMR) declined from 146 per 1000 live births in 1951 to 53 per 1000 live births in 2008. Maternal Mortality Ratio (MMR) declined from 398 per 100,000 live births in 1997-98 to 254 per 100,000 live births in 2006. However, India has a long way to go in further reducing mortality among infants, mothers and the people in the most productive age-groups (15-45 years).
| Evolution of Public Health in India|| |
Many Expert Committees, dating back to the Bhore Committee in 1946, reviewed the existing health infrastructure/situation in the country and made recommendations needed to prevent and control diseases including communicable, non-communicable and emerging diseases. Based on these recommendations huge health care infrastructure has been created in the country. The health care has three tiers systems i.e. Primary, secondary and tertiary. A large number of primary health centers, community health centers and Sub-centers have been established in the country. More recently, the Expert Committee on Public Health system (1996) and the National Commission on Macroeconomics and Health (2005) examined these issues. National Five Year Plans, National Health Policy (1983, 2002) and many international initiatives such as Health for All by 2000, Calcutta Declaration on Public Health in south-East Asia (1999), UN Millennium Development Goals (2000), Global Commission on Macroeconomics and Health (2001), revised International Health Regulations (2005), an Asia Pacific Strategy for Emerging Diseases (2005) have also provided strong policy directives for the development of health care delivery system to control/prevent diseases. As a result of these efforts, a strong health infrastructure has been developed. Many national disease programmes to control/eliminate/eradicate diseases have been set up in the country. In the current Five-year Plan, pilot projects for leptospirosis and rabies control and pilot projects on non-communicable diseases have also been initiated.
Inspite of the efforts mentioned above, the growth of public health in India is very slow. The impeding factors for this include very few public health institutes in India, inadequate national standards for public health education including curriculum and methods. This results in inadequate public health workforce in the country. Over and above health care in the country more emphasis is on more curative services and with inadequate lab capacity in the system and poor participation of private sector in public health activities. As per NFHS III, the pattern of health care expenditure in India shows that more than 70% of expenditure is from out of pocket by house holds. Estimates suggests that in India the total health expenditure is around 6% of GDP, and is dominated by out of pocket spending i.e. around 5%. The government/public expenditure on health care is around 1% of GDP. Due to this low public expenditure the reach and quality of public health services are below the desired level.
However, many initiatives have been taken recently for the growth of public health in India which include National Rural Health Mission (NRHM) wherein thrust has been given to upgrade health care infrastructure as per IPHS, augmentation of human resources, flexible financing and involvement of the community in health care planning and utilization of services.
More public health courses are being started in the medical colleges and public health institutions like MPH course at NCDC, Delhi and NIE, Chennai as well as MPH course being conducted by PHFI. Public health functional capacity of states and districts is being developed under IDSP. Department of Health Research has been created in the Ministry of Health & Family Welfare. NICD has been upgraded to NCDC. Public Health Bill has been drafted and many programme on non-communicable diseases such as diabetes, cardiovascular disease and stroke have been initiated. To further give impetus to the growth of public health in India, the priority is to ensure access, availability and utilization of primary health care to all including urban slum population for which there is need to strengthen the health care infrastructure, increase public health workforce with a dedicated public health cadre, enhancing public private partnership, formulation and enforcement of public health laws and over and above increase public health financial allocation and expenditure as well as to strengthen disease surveillance and response system. All such efforts are being made under NRHM.
I would like to end the oration quoting a phrase from Laurie Garrett, "Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the floor continuously while leaving the tap running" and it is a never ending exercise. Thus the growth of public health is the need of the hour.