Health care infrastructure in India

India’s National Health Policy (NHP) was last formulated in 1983, and since then there have been marked changes in the determinant factors relating to the health sector. Some of the policy initiatives outlined in the NHP-1983 have yielded results, while in several other areas the outcome has not been as expected. [MOHFw India, 2002] The noteworthy initiatives under that policy were:

(i) A phased, time-bound programme for setting up a well-dispersed network of comprehensive primary health care services, linked with extension and health education, designed in the context of the ground reality that elementary health problems can be resolved by the people themselves;

(ii) Intermediation through ‘Health volunteers’ having appropriate knowledge, simple skills and requisite technologies;

(iii) Establishment of a well-worked out referral system to ensure that patient load at the higher levels of the hierarchy is not needlessly burdened by those who can be treated at the decentralized level;

(iv) An integrated net-work of evenly spread speciality and super-speciality services; encouragement of such facilities through private investments for patients who can pay, so that the drain on the Government’s facilities is limited to those entitled to free service.

Government initiatives in the public health sector have recorded some noteworthy successes over time. Smallpox and guinea worm disease have been eradicated from the country. Polio is on the verge of being eradicated. Leprosy, kala azar, and filariasis are likely to be eliminated in the near future. There has been a substantial drop in the total fertility rate and IMR. The success of the initiatives taken in the

public health field is reflected in the progressive improvement of many demographic, epidemiological and infrastructural indicators over time (Table 1.1). [MOF India, 2008; MOHFw India, 2002; RGI, 2007]

Table 1.1 Achievements through the years 1951–2008 as a result of the policy initiatives of the National Health Policy -1983 Infant mortality rate (/1000 live births)

36.7 CbHI: Central bureau of Health Intelligence; NHP: National Health Profile;

RGI: Registrar General of India; RHS: Rural Health Statistics;

SC/PHC/CHC: Sub Centres/Primary Health Centres/Community Health Centres;

UNDP: United Nations Development Programme

while noting that the public health initiatives over the years have contributed significantly to the improvement of these health indicators, it is to be acknowledged that public health indicators and disease-burden statistics are the outcome of several complementary initiatives under the wider umbrella of the developmental sector, covering rural development, agriculture, food production, sanitation, drinking water supply, education, etc. Despite the impressive public health gains as revealed in the statistics in Table 1.1, there is no gain considering the fact that the morbidity and mortality levels in the country are still unacceptably high. These unsatisfactory health indices are, in turn, an indication of the limited success of the public health system in meeting the preventive and curative requirements of the general population.

The period after the announcement of NHP-1983 has not only seen the persistence of some communicable diseases such as malaria, tuberculosis, some common

water-borne infections (gastroenteritis, cholera, and some forms of hepatitis) and a new and extremely virulent communicable disease, HIv/AIDS, but also seen an increase in mortality from some non-communicable diseases like diabetes, cancer and cardiovascular diseases. The increase in life expectancy has increased the requirement for geriatric care. Similarly, the increasing burden of trauma cases is also a significant public health problem.

Another area of grave concern in the public health domain is the persistent incidence of macro and micro nutrient deficiencies, especially among women and children. In the vulnerable sub-category of women and the girl child, this has the multiplier effect through the birth of low birth weight babies and serious ramifications of the consequential mental and physical retarded growth.

In the health care sector, stagnant public spending on health (less than 1 percent of gross domestic product) places India among the bottom 20 percent of countries.

Most low-income countries spend more than India, where current levels are far below what is needed to provide basic health care to the population. The bulk of public spending on primary health care has been spread too thinly to be fully effective, while the referral linkages to secondary care have suffered. As in other countries, preventive health services take a back seat to curative care.

Over the last five decades, India has built up a vast health infrastructure and manpower at primary, secondary and tertiary care in government, voluntary and private sectors. These institutions are manned by professionals and para-professionals trained in the medical colleges. Currently, private sector health services range from those provided by large corporate hospitals, smaller hospitals and nursing homes to clinics and dispensaries run by qualified personnel.

while there is a general shortage of medical personnel in the country, this shortfall impacts disproportionately on the less-developed and rural areas. No incentive system attempted so far has induced private medical personnel to go to such areas; and even in the public health sector the effort to deploy medical personnel in such under-served areas, has usually been a losing battle. In such a situation, the possibility needs to be examined of entrusting some limited public health functions to nurses, paramedics and other personnel from the extended health sector after providing them with adequate training.

India has a vast reserve of practitioners in the Indian systems of medicine and homoeopathy, who have undergone formal training in their own disciplines.

The possibility of using such practitioners in the implementation of state/central government public health programmes in order to increase the outreach of basic health care in the country is addressed in the NHP-2002.