Public health system in India

The modern public health system in India evolved due to a number of influences from the past 70 years, including British influence from the colonial period.[1] The need for an efficient and effective public health system in India is large. 20% of all maternal deaths and 25% of all child deaths in the world occur in India. 69 out of 1000 children are dead by the time they reach the age of 5.[2] 58% of Indians are immunized in urban areas compared to only 39% in rural areas. Communicable disease is the cause of death for 53% of all deaths in India.[2]

Public health initiatives that affect people in all states, such as the National Mental Health Program, are instilled by the Union Ministry of Health and Family Welfare.[1] There are multiple systems set up in rural and urban areas of India including Primary Health Centres, Community Health Centres, Sub Centres, and Government Hospitals. These agencies must follow the standards set by Indian Public Health Standards documents that are revised when needed.[3] ter

History

Public health systems in the colonial period were focused on health care for British citizens that were living in India. The period saw research institutes, public health legislation, and sanitation departments, although only 3% of Indian households had toilets at this time.[4] Annual health reports were released and the prevention of contagious disease outbreaks was stressed. At the end of the colonial period, death rates from infectious diseases such as cholera had fallen to a low, although other diseases were still rampant.[4]

In modern day India, the spread of communicable diseases is under better control and now non-communicable diseases, especially cardiovascular diseases, are major killers.[4] Health care reform was prioritized in the 1946 Bhore Committee Report which suggested the implementation of a health care system that was financed at least in part by the Indian government.[1] In 1983 the first National Health Policy (NHP) of India was created with the goals of establishing a system with primary-care facilities and a referral system. In 2002, the updated NHP focused on improving the practicality and reach of the system as well as incorporating private and public clinics into the health sphere.[1]

Public health funding has been directed to helping the middle and upper classes, as it targets creating more health professional jobs, expanding research institutions, and improving training. This creates unequal access to health care for the lower classes who do not receive the benefits of this funding.[4] Today, states pay for about 75% of the public healthcare system but insufficient state spending neglects the public health system in India.[5]

Facilities

The healthcare system is organised into primary, secondary, and tertiary levels. At the primary level are Sub Centres and Primary Health Centres (PHCs). At the secondary level there are Community Health Centres (CHCs) and smaller Sub-District hospitals. Finally, the top level of public care provided by the government is the tertiary level, which consists of Medical Colleges and District/General Hospitals.[1] The number of PHCs, CHCs, Sub Centres, and District Hospitals has increased in the past six years, although not all of them are up to the standards set by Indian Public Health Standards.[3]

Sub Centres

A Sub Centre is designed to serve extremely rural areas with the expenses fully covered by the national government. Mandates require health staff to be at least two workers (male and female) to serve a population of 5000 people (or 3000 in a remote, dangerous location). Sub Centres also work to educate rural peoples about healthy habits for a more long-term impact.[1]

Primary Health Centres

Primary Health Centres exist in more developed rural areas of 30,000 or more (20,000 in remote areas) and serve as larger health clinics staffed with doctors and paramedics. Patients can be referred from local sub centres to PHCs for more complex cases.[1] A major difference from Sub Centres is that state governments fund PHCs, not the national government. PHCs also function to improve health education with a larger emphasis on preventative measures.[1]

Community Health Centres

A Community Health Centre is also funded by state governments and accepts patients referred from Primary Health Centres. It serves 120,000 people in urban areas or 80,000 people in remote areas.[1] Patients from these agencies can be transferred to general hospitals for further treatments. Thus, CHC's are also first referral units, or FRUs, which are required to have obstetric care, new born/childcare, and blood storage capacities at all hours everyday of the week.[1]

District Hospitals

District Hospitals are the final referral centres for the primary and secondary levels of the public health system. It is expected that at least one hospital is in each district of India, although in 2010 it was recorded that only 605 hospitals exist when there are 640 districts.[6] There are normally anywhere between 75 to 500 beds, depending on population demand. These district hospitals often lack modern equipment and relations with local blood banks.[6]

Medical Colleges and Research Institutions

All India Institutes of Medical Sciences is owned and controlled by the central government. These are referral hospitals with specialized facilities. All India Institutes presently functional are AIMS New Delhi, AIIMS Bhopal,[7] AIIMS Bhubaneshwar, AIIMS Jodhpur, AIIMS Raipur, and AIIMS Rishikesh. A Regional Cancer Centre is a cancer care hospital and research institute controlled jointly by the central and the respective state governments. Government Medical Colleges are owned and controlled by the respective state governments and also function as referral hospitals.

Government Public Health Initiatives

In 2006, the Public Health Foundation of India was started by the Prime Minister of India as both a private and public initiative. The goal of this organisation is to incorporate more public health policies and diverse professionals into the healthcare sphere. PHFI is also collaborating with international public health organisations to gather more knowledge and direct discussions around needs and improvements to the current system.[8] Often times officials in policy making positions have a gap in their education about public health, and MPH and PhD programs in public health are lacking in their number of students and resources. PHFI aims to further these programs and educate more people in this field. The research discovered would be made transparent to the Indian public at large, so that the entire nation is aware of health standards in the country.[8]

Drawbacks

Drawbacks to India's public health system today include low quality care, corruption, unhappiness with the system, a lack of accountability, unethical care, overcrowding of clinics, poor cooperation between public and private spheres, barriers of access to services and medicines, lack of public health knowledge, and low affordability.[3][9] These drawbacks push wealthier Indians to use the private healthcare system, which is less accessible to low-income families, creating unequal medical treatment between classes.[3]

Low quality care

Low quality care is prevalent due to misdiagnosis, under trained health professionals, and the prescription of incorrect medicines. A study discovered a doctor in a PHC in Delhi who prescribed the wrong treatment method 50% of the time.[9] Indians in rural areas where this problem is rampant are prevented from improving their health situation.[2] Enforcement and revision of the regulations set by the Union Ministry of Health and Family Welfare IPHS is also not strict. The 12th Five-Year Plan (India) dictates a need to improve enforcement and institutionalize treatment methods across all clinics in the nation in order to increase the quality of care.[3] There is also a lack of accountability across both private and public clinics in India, although public doctors feel less responsibility to treat their patients effectively than do doctors in private clinics. Impolite interactions from the clinic staff may lead to less effective procedures.[9]

Corruption

Healthcare professionals take more time off from work than the amount they are allotted with the majority of absences being for no official reason.[9] India's public healthcare system pays salaries during absences, leading to excessive personal days being paid for by the government. This phenomenon is especially heightened in Sub Centres and PHCs and results in expenditure that isn't correlated to better work performance.[9]

Overcrowding of clinics

Clinics are overcrowded and understaffed without enough beds to support their patients. Statistics show that the number of health professionals in India is less than the average number for other developing nations.[5] In rural Bihar the number of doctors is 0.3 for every 10,000 individuals. Urban hospitals have twice the number of beds than rural hospitals do but the number is still insufficient to provide for the large number of patients that visit.[2] Sometimes patients are referred from rural areas to larger hospitals, increasing the overcrowding in urban cities.[10]

Poor cooperation between public and private spheres

5% of visits to health practitioners are in private clinics or hospitals, many of which are paid for out of pocket. Money is spent on improving private services instead of on funding the public sector.[9] Governmental failure to initiate and foster effective partnerships between the public and private healthcare spheres results in financial contracts that aren't negotiated to help the common man. These contracts would allow the private sector to finance projects to improve knowledge and facilities in the public sphere.[3]

Barriers of access

Both social and financial inequality results in barriers of access to healthcare services in India. Services aren't accessible for the disabled, mentally challenged, and elderly populations.[3] Mothers are disadvantaged and in many rural areas there is a lack of abortion services and contraception methods. Public clinics often have a shortage of the appropriate medicines or may supply them at excessively high prices, resulting in large out of pocket costs (even for those with insurance coverage).[3] Large distances prevent Indians from getting care, and if families travel the far distance there is low assurance that they will receive proper proper medical attention at that time.[2]

References

  1. 1 2 3 4 5 6 7 8 9 10 Chokshi, M; Patil, B; Khanna, R; Neogi, S; Sharma, J; Paul, V; Zodpey, S (December 2016). "Health systems in India". Journal of Perinatology. 36. doi:10.1038/jp.2016.184. PMC 5144115.
  2. 1 2 3 4 5 Balarajan, Yarlini; Selvaraj, S; Subramanian, S (11 January 2011). "Health care and equity in India". Lancet. 377 (9764): 505–515. PMC 3093249.
  3. 1 2 3 4 5 6 7 8 "20". Twelfth Five Year Plan (2012-17) (PDF) (Vol-III, ed.). Planning Commission, Government of India, New Dehli.
  4. 1 2 3 4 Gupta, Monica (December 2005). "Public Health in India: Dangerous Neglect". Economic and Political Weekly. 40 (49): 5159–5165. JSTOR 4417485.
  5. 1 2 Peters, David (Jan 1, 2002). "2". Better Health Systems for India's Poor: Findings, Analysis, and Options. World Bank Publications.
  6. 1 2 "Guidelines for District Hospitals" (PDF). Indian Public Health Standards. Ministry of Health and Family Welfare, Government of India. 2012. Retrieved 9 March 2018.
  7. ↑ AIIMS Bhopal.
  8. 1 2 Reddy, K; Sivaramakrishnan, Kavita (16 September 2016). "Unmet National Health Needs: Visions of Public Health Foundation of India". Economic and Political Weekly. 41 (37): 3927–3933. Retrieved 15 February 2018.
  9. 1 2 3 4 5 6 Hammer, Jeffrey; Aiyar, Yamini; Samji, Salimah (6 October 2017). "Understanding Government Failure in Public Health Services". Economic and Political Weekly. 42 (40): 4049–4057. JSTOR 40276648.
  10. ↑ Bajpai, Vikas (13 July 2014). "The Challenges Confronting Public Hospitals in India, Their Origins, and Possible Solutions". Advances in Public Health. 2014: 27.

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