3.4 HEALTH

3.4.1 India was one of the pioneers in health service Planning with a focus on primary health care. In 1946, the Health Survey and Development Committee, headed by Sir Joseph Bhore recommended establishment of a well-structured and comprehensive health service with a sound primary health care infrastructure. This report not only provided a historical landmark in the development of the public health system but also laid down the blueprint of subsequent health planning and development in independent India.

3.4.2 Improvement in the health status of the population has been one of the major thrust areas for the social development programmes of the country. This was to be achieved through improving the access to and utilization of Health, Family Welfare and Nutrition Services with special focus on under served and under privileged segment of population. Main responsibility of infrastructure and manpower building rests with the State Government supplemented by funds from the Central Government and external assistance. Major disease control programmes and the Family Welfare Programmes are funded by the Centre (some with assistance from external agencies) and are implemented through the State infrastructure. The food supplementation programmes for mothers and children are funded by the State and implemented through the ICDS infrastructure funded by the Central Government. Safe drinking water and environmental sanitation are essential pre-requisites for health. Initially these two activities were funded by the Health Department, but subsequently Dept. of Urban and Rural Development and Dept. of Environment fund these activities both in the State and Centre.

3.4.3 At the time of Independence, the country's health care infrastructure was mainly urban and clinic based. The hospitals and clinics provided curative care to patients who came to them. Outreach of services in the rural areas was very limited; there were very few preventive and rehabilitative services available. From the First five-year Plan, Central and State Governments made efforts to build up primary, secondary and tertiary care institutions and to link them through appropriate referral systems. The private and voluntary sector also tried to cater to the health care needs of the population (Table 3.4.1). Efforts to train adequate number of medical, dental and paramedical personnel were also taken up. National Programmes for combating major public health problems were evolved and implemented during the last fifty years. Efforts to further improve the health status of the population by optimising coverage and quality of care by identifying and rectifying the critical gaps in infrastructure, manpower, equipment, essential diagnostic reagents, drugs and enhancing the efficiency of the health system are underway.

3.4.4 Improvement in coverage and quality of health care and implementation of disease control programmes resulted in steep decline in the crude death rate (CDR) from 25.1 in 1951 to 9.0 in 1996. Life expectancy rose from 32 years in 1947 to 61.1 years in 1991-96 with female life expectancy (61.7 yr.) higher than the male (60.6 yr.). However, the morbidity due to common communicable and nutrition - related diseases continue to be high. Morbidity due to non-communicable diseases is showing a progressive increase because of increasing longevity and alterations in life style. During the Ninth Plan efforts will have to be made to tackle this dual disease burden effectively so that there is sustained improvement in the health status of the population.

3.4.5 India today has a vast network of governmental, voluntary and private health infrastructure manned by large number of medical and paramedical persons.

Current problems faced by the health care services include:

3.4.6 The Special Action Plan for Health envisages expansion and improvement of the health services to meet the increasing health care needs of the population; no specific targets have been set.

3.4.7 During the Ninth Plan efforts will be further intensified to improve the health status of the population by optimising coverage and quality of care by identifying and rectifying the critical gaps in infrastructure, manpower, equipment, essential diagnostic reagents and drugs. Efforts will be directed to improve functional efficiency of the health care system through:

Approach During the Ninth Plan:

3.4.8 The approach during the Ninth Plan will be:

1. An absolute and total commitment to improve access to, and enhance the quality of, primary health care in urban and rural areas by providing an optimally functioning primary health care system as a part of the Basic Minimum Services;
2. To improve the efficiency of existing health care infrastructure at primary, secondary and tertiary care settings through appropriate institutional strengthening, improvement of referral linkages and operationalisation of Health Management Information System (HMIS);
3. To promote the development of human resources for health, adequate in quantity and appropriate in quality so that access to essential health care services is available to all so that there is improvement in the health status of community, periodically organise programmes for continuing education in health sciences, update knowledge and upgrade skills of all workers and promote cohesive team work;
4. To improve the effectiveness of existing programs for control of communicable diseases to achieve horizontal integration of ongoing vertical programmes at the district and below district level; to strengthen the disease surveillance with the focus on rapid recognition, reporting and response at district level; to promote production and distribution of appropriate vaccines of assured quality at affordable cost; to improve water quality and environmental sanitation; to improve hospital infection control and waste management
5. To develop and implement integrated non-communicable disease prevention and control program within the existing health care infrastructure;
6. To undertake screening for common nutritional deficiencies especially in vulnerable groups and initiate appropriate remedial measures; to evolve and effectively implement programmes for improving nutritional status, including micronutrient status of the population;
7. To strengthen programmes for prevention, detection and management of health consequences of the continuing deterioration of the ecosystems; to improve linkage between data from ongoing environmental monitoring and that on health status of the population residing in the area including health impact assessment as a part of environmental impact assessment in developmental projects;
8. To improve the safety of the work environment and worker's health in organised and unorganised industrial and agricultural sectors especially among vulnerable groups of the population;
9. To develop capabilities at all levels for emergency and disaster prevention and management; to implement appropriate management systems for emergency, disaster, accident and trauma care at all levels of health care;
10. To ensure effective implementation of the provisions for food and drug safety; strengthen the food and drug administration both at the Centre and in the States;
11. To increase the involvement of ISM and H practitioners in meeting the health care needs of the population;
12. To enhance research capability with a view to strengthening basic, clinical and health systems research aimed at improving the quality and outreach of services at various levels of health care;
13. To increase the involvement of voluntary, private organisations and self-help groups in the provision of health care and ensure inter-sectoral coordination in implementation of health programmes and health-related activities;
14. To enable the Panchayati Raj Institutions (PRI) in planning and monitoring of health programmes at the local level so that there is greater responsiveness to health needs of the people and greater accountability; to promote inter-sectoral coordination and utilise local and community resources for health care.

Health Care Infrastructure

Primary Health Care

3.4.9 The primary health care infrastructure provides the first level of contact between the population and health care providers upto and including primary health care physicians and forms the common pathway for implementation of all the health and family welfare programmes in the country. It provides integrated promotive, preventive, curative and rehabilitative services to the population close to their hearth and home. Majority of the health care needs of the population is taken care of by the trained health personnel at the primary health care level. Those requiring specialised care are referred to secondary or tertiary care. Thus, the three-tier system consisting of Primary, Secondary and Tertiary care facilities with adequate referral linkages will provide essential health and family welfare services to the entire population.

Rural Primary Health Care Infrastructure

3.4.10 At the time of Independence, Health Care services were mainly urban-centered and hospital-based. Realising the importance of creating a functional Primary Health Care infrastructure, national norms for the primary health care infrastructure were drawn up. These take into account the population, population density and terrain. Earmarked funds were provided under the Minimum Needs Program in the State Plan allocations. The funds received from the Department of Family Welfare and through the Externally Assisted Projects (EAPs) were utilised to build up the Rural Health infrastructure. The current functional status of Primary Health Care infrastructure (Sub Centres, Primary Health Centres and the Community Health Centres), and the additional requirements, wherever necessary, to meet the norms for population as per 1991 census are given in Table-3.4.2.

3.4.11 At the national level the total number of functional Sub centres and the PHCs nearly meets the set norms (one sub-centre for 3000-5000 population, one Primary Health Centre for 20,000- 30,000 population; one Community Health Centre for four PHCs) for the population in 1991 (Table-3.4.2). However, there are marked disparities at the State and district level. It is a matter of concern that many of the districts with poor health indices do not have adequate health infrastructure. There is considerable backlog in terms of construction of the buildings for Sub Centres and PHCs. Some States have adopted innovative measures including mobilisation of local resources to clear this backlog. Taking cognizance of the widening disparities among the States in the availability of Basic Minimum Services (BMS), the Conference of the Chief Ministers in July 1996, recommended that Additional Central Assistance (ACA) may be provided to the States for correcting the existing gaps in the provision of seven Basic Minimum Services (BMS). The modalities of implementation of the programme are discussed in detail in the section on Basic Minimum Services. Of these, access to primary health care, safe drinking water and primary education were given higher priority with the mandate that universal access to these services is to be achieved by 2000 AD. Increasing involvement of the people's representatives, voluntary organisations and the people themselves in these activities will be further encouraged during the Ninth Plan.

3.4.13 In some areas, the existing Primary Health Care Institutions (PHIs) are functioning sub-optimally because of one or more of the following factors:

3.4.14 These problems need urgent resolution at the local level through adequate provision of resources and intervention of the Panchayati Raj Institutions (PRI).

3.4.15 Unlike the SC and PHCs, the number of functioning CHCs, which form the First Referral Unit (FRU), is far below the projected requirement. This gap should be filled quickly so that the PHCs and Sub Centres do have a nearby referral hospital for the management of `high-risk patients' who are referred. In most of the States there are functioning sub-district and taluk hospitals. With the restructuring of the Primary Health Care Institutions in the Seventh Plan, these institutions were to be redesignated as CHCs and suitably strengthened. The Eighth Plan had also reiterated this strategy. States that had implemented this suggestion report that these FRUs are well utilised, as they are located in towns that are well connected with villages by transport and are well known.

3.4.16 During the Ninth Plan, all the States will restructure the existing sub-district, taluk hospitals and block level PHCs into functioning CHCs (FRUs); it is expected that once this restructuring is completed, the current large gaps in functioning CHCs will be narrowed substantially. Similarly existing rural hospital and dispensaries have to be restructured wherever possible to meet the requirements in PHC. Earmarked funds under BMS could be utilised for completing the restructuring and strengthening of these hospitals/dispensaries.

Health Manpower in Rural Primary Health Care Institutions

3.4.17 Health manpower position in Primary Health Care Institutions in the last year of the Eighth Plan period is indicated in Table-3.4.3.

3.4.18 As per the national norms, one male and one female multi-purpose worker should be available at the Sub-Centre catering to the Health needs of 3000 to 5000 population. The number of sanctioned posts of male multi-purpose workers is only half the number required. This has been cited as one of the major factors responsible for the sub-optimal performance in health sector programmes. There are large numbers of male-workers employed in the malaria, leprosy and TB Control programmes. These workers need be trained and redeployed as male multipurpose workers and given the responsibility of looking after health and family welfare programmes in their sub-centre area. The availability of the female multi-purpose workers in adequate number has been the major factor for the near universal coverage under the immunisation Programme and improvement in ante-natal care; however the quality of care provided needs improvement. The vacancies as well as the lack of sanctioned posts of radiographers, lab-technicians and other para-professionals have adverse impact on ongoing Health and Family Welfare Programmes. These need be rectified as rapidly as possible and funds provided under BMS in 1996-97 have been utilised by some States to fill the critical gaps in health manpower.

3.4.19 During the Ninth Plan, several of the Centrally Sponsored Schemes including Family Welfare Programme, Revised National Tuberculosis Control Programme (RNTCP), National Malaria Eradication Programme (NMEP) will provide funds for recruitment of appropriate manpower. Funds provided under ACA for BMS may also be utilised to fill the critical gaps in health manpower. Every district will undertake district-level manpower survey and planning, so that funds from all these sources are optimally utilised to fill the existing gaps in vital manpower and unnecessary duplication is avoided.

3.4.20 So far, the national norms for manpower requirement have been computed on the basis of the population. During the Ninth Plan the requirement of personnel will be computed not only on the basis of population, but also on the basis of workload, distance to be covered and difficulties in delivery of Health Services. A flexible approach to recruitment of staff, if necessary on part time basis, will be adopted to ensure that the programmes do not suffer due to lack of key personnel.

Physicians in PHCs

3.4.21 The number of PHC doctors at the national level exceeds the requirement as per the norms. However, there are marked differences in their distribution. About 10% of the PHCs are without doctors, while a similar number have three or more doctors. The PHCs without doctors are mostly located in remote areas where health care facilities under voluntary or private sector are also limited. The State Governments are taking steps to redeploy the PHC doctors so that the needs of the population in under-served areas are met on a priority basis. Some of the innovative approaches to fill the vacancies in under-served areas currently being tried in some States include:

3.4.22 During the Ninth Plan, the feasibility and usefulness of these approaches will be evaluated and those found useful in any area will be utilised as a part of local area- specific micro planning for effective delivery of essential Primary Health Care.

Specialists at CHCs

3.4.23 A substantial proportion of specialist’s posts even in the functioning CHCs is vacant. Hence, these CHCs are unable to function as First Referral Units. In view of the serious implications of this lacuna in the establishment of referral system, as well as effective provision of health, MCH/FP care, there is an urgent need to rectify this. Improving the service conditions and providing a conducive environment are essential to ensure that specialists in CHCs do stay and provide the needed services. At the moment, there is no post of Public Health Specialist or Anaesthetist, in the CHCs. Services of Anaesthetist are vital because without an Anaesthetist, emergency/routine surgery in CHCs will not be possible. Efforts will be made to provide this critical manpower, if necessary on part-time basis. As a long-term measure, sufficient number of in-service candidates may be trained in this speciality. It is vital to provide inter linkage between preventive, promotive and curative services in the CHCs so that health and family welfare programmes, disease surveillance and response mechanisms get strengthened. Until the specialists in public health get posted in CHCs, the existing specialists in these Centres who presently are mainly responsible for curative services, will have to be given Public Health orientation, training in Epidemiology and Health Management so that each one of them assumes the responsibility of looking after the Disease Control Programme in their respective specialities e.g. Immunisation by paediatrician and FP by the obstetrician. This would also improve the linkages between the CHC and the PHCs.

Tribal Health

3.4.25 The tribal population is not a homogeneous one. There are wide variations with regard to education and health status, access and utilisation of health services among the tribal populations. The tribal populations in North Eastern States have high literacy levels, they access available health facilities, and hence their health indicators and demographic indices are better than national level inspite of the fact that the region is endemic for malaria. On the other hand, the Onges in Andaman and Nicobar remain a primitive tribe with very little access to either education or health care. Differential area-specific strategies will therefore have to be developed for each of the tribal areas to improve access and utilisation of health services.

3.4.26 The National Health Policy accorded a high priority to provision of health services to those residing in the tribal, hilly and backward areas as well as to detection and treatment of endemic diseases affecting the tribal population. The strategy adopted for meeting the health care needs during the Eighth Plan period included provision of preventive, promotive and curative services through the primary health care institutions, and at the village level through link health workers and trained Dais. Keeping in view the far-flung areas, forest land, hills and remote villages, where most of the tribal habitations are concentrated, the population coverage norms for PHIs is relaxed to one PHC for every 20,000 population and one Sub Centre for 3,000 population. While choosing the villages for establishments of sub centres the States have been advised to set up at least 15% of these in Scheduled Castes' habitations or villages having 20% or more Scheduled Caste population and 7.5% in tribal areas.

3.4.27 Till June 30, 1996 there were 20097 sub-centres functioning against a requirement of 28383 sub-centres for tribal areas. The number of functioning PHCs were 3260 against a requirement of 4180 and functioning CHCs were 446 against a requirement of 492. There are also 1122 Dispensaries and 120 Hospitals in Modern Medicine, 78 Mobile Clinics in Modern Medicine, 1106 Dispensaries and 24 Hospitals in Ayurveda, 251 Dispensaries and 28 Hospitals in Homeopathy, 42 Unani Dispensaries, 7 Siddha Dispensaries functioning in the tribal areas in the country. As many as 16,845 Sub Centres, 5987 PHCs and 373 CHCs have been established in Scheduled Caste Basties/Villages having 20% or more Scheduled Caste population. In addition 980 Dispensaries in Modern Medicine, 1042 Ayurvedic Dispensaries, 480 Homeopathic Dispensaries, 68 Unani/Siddha Dispensaries are functioning in the Scheduled Caste concentrated areas in the country. Mobile dispensaries and camps were organised to provide health facilities wherever feasible.

3.4.28 Even though efforts have been made to create primary health care infrastructure and sanction necessary manpower both under modern medicine and under ISM and H, there is lack of both professional and paraprofessional manpower, mainly because the State Govt. personnel do not prefer to work in these areas. The State Governments are trying to minimise vacancies by taking even part time staff in tribal areas. A Central Planning Committee has been set up to review the health care activities in 39 districts of 12 States with pockets of extremely backward tribal population.

3.4.29 Priority was also accorded to research in diseases to which Scheduled Tribes/ Scheduled Castes are prone. The Indian Council of Medical Research has set up five regional medical centres in tribal areas in the country one each at Jabalpur, Bhuvaneshwar, Jodhpur, Dibrugarh and Port Blair to carry out research on health problems of people in these regions, especially the scheduled tribes. The All India Institute of Hygiene and Public Health has also initiated a project "Integrated Health Development of Scheduled Castes and Scheduled Tribes of Sunderbans area of West Bengal." The Central Council for Research in Ayurveda and Siddha has set up research projects, and conducted service- oriented survey to provide medical aid to Scheduled Tribes and Scheduled Castes.

3.4.30 A review of all these activities will be undertaken in the Ninth Plan so that information generated so far is transformed into well-structured action programme. During the Ninth Plan period priority action will be:

Operational strategy for the Ninth Plan

State specific strategies

3.4.31 States have to prioritise and utilise funds available for primary health care on the basis of the existing infrastructure and the performance indices as follows:

Rural Primary Health Care

1. Ensure that geographically delineated rural areas are covered by the three tier primary health care institutions as per the norms defined above through integration of the existing hospitals/dispensaries in rural areas into the appropriate tier of the rural primary health care infrastructure.
2. Accord high priority to filling the reported large gap in the vital CHC/FRU by redesignating and appropriately strengthening the existing block level PHCs, subdistrict/ subdivisional hospitals, rural hospitals, subdistrict post partum centres.
   
   

   Ninth Plan Strategies for improving Urban Primary Health Care: Create and strengthen primary health care infrastructure through: Re-organisation and restructuring of existing institutions Re-deploy existing manpower to operationalise these institutions Link primary health care infrastructure with existing secondary and tertiary care institutions in the same geographically delineated areas Establish effective referral services Involve Nagar Palikas in effective inter-sectoral co-ordination and improving community participation

3. In all FRUs:
   1. ensure that there are specialist/trained doctors in the following specialities: Medicine, surgery, obstetrics, paediatrics and anaesthesia;
   2. ensure that there are no vacancies (if necessary by providing for part time appointments) and that referred patients and those requiring emergency care do receive the treatment they need; until such time that there are qualified PSM personnel to monitor progress in ongoing national programmes, the specialist available in the CHC may be given the additional responsibility of monitoring these programmes (e.g., paediatrician will monitor the immunisation programme); enable the staff to stay and provide good quality services to the population by improving the service conditions and providing a conducive work environment to doctors (including specialists) and paramedical personnel.
      
4. Ensure that there are no vacancies in the critical para professional posts by skill development and redeployment of already available manpower; where absolutely necessary manpower gaps may be filled through part time appointments.
5. Available funds to be utilised on priority basis for purchase of equipment, consumables, drugs required for improving quality of services; funds may be provided for construction only when absolutely necessary.
6. Strengthen the referral services

Urban Health and Family Welfare Services

3.4.32 Nearly 30% of India's population lives in urban areas. Urban migration over the last decade has resulted in rapid growth of people living in urban slums. The massive inflow of the population has also resulted in the deterioration of living conditions in the cities. Some of the available data on health and related indices in urban and rural population is given in Table-3.4.4. From the data it would appear that the urban population has better health facilities and health indices than the rural population. However in many towns and cities the health status of urban slum dwellers is worse than that of the rural population. The urban health facilities provide health care, especially tertiary care to both the urban and rural population. The available urban health care infrastructure is insufficient to meet the health care needs of the growing urban population.

3.4.33 Realising this the municipalities, State Governments and the Central Government have tried to provide funds for building up urban health care. Unlike the rural health services, there have not been any well-planned and organised efforts to provide primary, secondary and tertiary care services in geographically delineated areas in urban health care. As a result, there is either non-availability or substantial under utilisation of available primary care facilities along with an over-crowding at secondary and tertiary care centres.

3.4.34 During the Ninth Plan period, efforts will be made to evolve a well-structured organisation of urban primary health care to remedy the existing situation. A health care delivery system aimed at providing basic health and family welfare services to the population within 1 - 3 kms. of their dwellings will be made available by establishing Urban Health and Family Welfare Centres manned by medical and para-medical persons. These Centres will have:

1. adequate outpatient facility;
2. in-patient facility (at least 10 beds of which four will be for maternity care and the remaining beds will be for medical, surgical and paediatric care);
3. supportive services including laboratory and radiology facilities and pharmacy;
4. provision for referral/ transport of patients.

The essential services, to be provided, will include

1. medical and surgical services including eye and ENT care;
2. obstetric care and new-born care and child health;
3. counseling for reproductive health and contraception
4. dental services;
5. emergency and trauma care;
6. prevention and control of communicable and noncommunicable diseases;

Secondary Health Care: Priorities in the Ninth Plan Provide adequate diagnostics, consumables and drugs Strengthen emergency services Provide care for high risk cases Establish effective, credible linkages with primary and tertiary care facilities in geographically delineated areas.

This step is expected to reduce the burden on the tertiary care hospitals, besides providing a credible and effective linkage with Primary Health Care Institutions. In order to raise resources to meet the recurring costs of good quality diagnostic and curative services, the feasibility of collecting user charges from patients (except those below the poverty line) is also being explored. These experiences will enable the States to evolve and implement appropriate schemes for strengthening these hospitals so that they cater to the increasing need for secondary care services during the Ninth Plan period. Increasing involvement of private and voluntary sector in secondary health care has been reported from many states. The mechanisms by which secondary health care services could be made readily available and affordable through collaboration between Government, private and voluntary sector will be explored during the Ninth Plan period.

Tertiary Health Care Problems: Growing demand for complex, costly diagnostic and therapeutic modalities lack of skilled manpower, equipment and consumables to meet the demand overcrowding Ninth Plan priorities Provide funds for capacity building Levy user charges to people above poverty line Explore alternative modalities to meet the growing cost of care

3.4.41 Along with the emphasis on enhancing the outreach and quality of primary health care services and the strengthening of linkages with secondary care institutions, there is a need to optimise the facilities available in the tertiary care centres. At this level, there is an ever-widening gap between what is possible and what is affordable either for the individual or for the country. Majority of the tertiary care institutions in governmental sector lack adequate manpower and facilities to meet the rapidly growing demand for increasingly complex diagnostic and therapeutic modalities. Over the last two decades these institutions have been facing increasing resource crunch and have not been able to obtain spares for equipment maintenance, to replace obsolete equipment, to maintain supply of consumables and to upgrade the infrastructure necessary to provide high technology, high quality care at affordable cost to meet the ever increasing needs and rising expectation of the population. Several States have started levying user charges for the diagnostic and curative services offered in these institutions from people above the poverty line, to meet some of the recurring costs in providing such services. During the Ninth Plan, efforts will be made to provide a one time support to selected tertiary care institutions in each State and Union Territory to update their technical capabilities and to evolve and implement a rational user charge policy that would enable these institutions to provide high quality tertiary care at affordable cost. Some of the States are also taking up experimental projects of establishment of pay clinics/ pay cabins for generating funds required by the institutions. Other States are exploring the feasibility of providing land, water and electricity at lower cost to private entrepreneurs for setting up tertiary care/ super speciality institutions if these entrepreneurs agree to provide 30% in-patient facilities and 40% of the out-patient /diagnostic services free of cost for people below poverty line. Exemption from import duty for import of diagnostic equipment has been given in the past to private/ voluntary agencies that had agreed to provide diagnostic services to poor patients free of cost. The advantages, disadvantages in these experiments need to be documented and those found useful replicated in other settings.