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Chapter: Sociology of Health : Health services

Role of government within the health sector with few suggested majors

Health forms a major criteria in the evaluation of the developmental status of a country. The Constitution of India envisages the establishment of a new social order based on equality, justice and dignity of the individual.

Role of government within the health sector with few suggested majors:


Health forms a major criteria in the evaluation of the developmental status of a country. The Constitution of India envisages the establishment of a new social order based on equality, justice and dignity of the individual. The Preamble, Directive Principles of State Policy and Fundamental Rights in the Constitution of India stand testimony to the commitment of the State to its people in this regard. The commitment made by the nation has found expression in the various developmental activities undertaken by the Government since independence.


Various government departments are contributing to the well being and healthy development of the people, either directly or indirectly. While the Ministry of Health & Family Welfare is the nerve center of all health related activities, other Ministries like Human Resource Development, Rural Development, Agriculture, Food and Civil Supplies and Urban Affairs also contribute substantially.


Ministry of Health & Family Welfare has the constitutional obligation to guide, regulate, assist and finance State Governments in the area of population control, family planning, medical education, adulteration of food, drugs and poisons, medical profession, vital statistics and mental deficiency, leaving the other areas of public health, sanitation and nutrition to the State Governments' exclusive jurisdiction. The central Government evolves broad policies and plans through Central Council of Health & Family Welfare for implementing various health programme in the country.


1. Scenario around 1950s and onwards:

At the time of independence the health situation in the country was dismal with millions of people succumbing to the scourge of Malaria, Plague, Influenza, Pneumonia, Tetanus,and Tuberculosis. Added to this misery was the frequent occurrence of droughts.


With the inception of planning in the country, the Government took concerted measures to control/eradicate communicable and non communicable diseases through various National Health Programmes. These are being implemented as centrally sponsored schemes aimed mainly at reduction of mortality and morbidity caused by major diseases.



The major health schemes include the National programmes for Eradication/Control of Malaria, Blindness, Leprosy, Tuberculosis, AIDS including Blood safety measures and STD control, Cancer control, Iodine Deficiency Disorders Control, Mental Health and Guineaworm Eradication programme.



The National Rural Health Mission (NRHM) launched by the Government of India is a leap forward in establishing effective integration and convergence of health services and affecting architectural correction in the health care delivery system in India.



India is a signatory to the AlmaAta declaration of Health for All by 2000 A.D. through primary health care approach. In 1983, the National health Policy was adopted to give effect to this commitment. It laid stress on the provision of preventive, promotive and rehabilitative health services to the people representing a shift from medical care to health care, and from urban to rural population.



To achieve this a huge network of rural health infrastructure comprising of 1,36,339 sub centres, 22,010 Primary health Centres and 2,622 community health centres have been set up throughout the country. The Common Minimum Programmes of the Government also attaches importance to primary health care and envisages to provide 100% coverage both in the rural and urban areas. Health Care Institutions.


Over the years the country has expanded the health care delivery system and has adequate availability of health manpower and training institutes. At present there are about 489189 allopathic doctors, 11,300 Dental Surgeons and 5,59,896 Nurses in the country. Every year about 18,000 medical graduates and post graduates are passing out of nearly 164 medical colleges and other institutions.


India has many premier educational and research institutes like AIIMS, New Delhi; PGI, Chandigarh, JIPMER, Pondicherry, NIMHANS, Bangalore, ICMR, New Delhi; NTI, Bangalore; NICD New Delhi; CLTRI Changalpattu; NBE, New Delhi and All India Institute of Hygiene and Public Health, Calcutta, attached to the Ministry of health & Family Welfare.


India has attained selfsufficiency in the manufacture of many drugs and vaccines and a chain of laboratories are working in this area. Many institutes of Department of Science & Technology like Centre for Cellular & Molecular Biology, Hyderabad; National Institute of Immunology, New Delhi and DRDO, Bangalore have been contributing usefully towards health sector.



2. Pilot Projects:


To strengthen the secondary health care development system, Government has started State Health Systems Development projects in Andhra Pradesh, Karnataka, West Bengal, Orissa and it is being extended to six more States with World Bank's assistance.


To strengthen disease surveillance system in the country, especially at District and State level a pilot project has been started. Two districts each in Madhya Pradesh, Gujarat, Maharashtra, Bihar, Andhra Pradesh, Rajasthan, karnataka, Haryana, Uttar Pradesh, Kerala and Delhi have been selected under this project. Pilot projects have also been initiated on Cancer, Oral health, Diabetes and Micro nutrients. Realising the importance of Information, Education and Communication (IEC) strategy in India, Government has taken measures to utilise all forms of media to propagate and advocate health messages.



3. Regulation and enforcement in public health:


A good system of regulation is fundamental to successful public health outcomes. It reduces exposure to disease through enforcement of sanitary codes, e.g., water quality monitoring, slaughterhouse hygiene and food safety. Wide gaps exist in the enforcement, monitoring and evaluation, resulting in a weak public health system. This is partly due to poor financing for public health, lack of leadership and commitment of public health functionaries and lack of community involvement. Revival of public health regulation through concerted efforts by the government is possible through updation and implementation of public health laws, consulting stakeholders and increasing public awareness of existing laws and their enforcement procedures.



4. Health promotion:


Stopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco smoking and promoting physical activity. These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of communitywide education programs and other health promotion activities need to be strengthened. Much can be done to improve the effectiveness of health promotion by extending it to rural areas as well; observing days like “Diabetes day” and “Heart day” even in villages will help create awareness at the grass root level.




5. Human resource development and capacity building:


       There are several shortfalls that need to be addressed in the development of human resources for public health services. There is a dire need to establish training facilities for public health specialists along with identifying the scope for their contribution in the field. The Public Health Foundation of India is a positive step to redress the limited institutional capacity in India by strengthening training, research and policy development in public health. Preservice training is essential to train the medical workforce in public health leadership and to impart skills required for the practice of public health. Changes in the undergraduate curriculum are vital for capacity building in emerging issues like geriatric care, adolescent health and mental health. Inservice training for medical officers is essential for imparting management skills and leadership qualities. Equally important is the need to increase the number of paramedical workers and training institutes in India.


6. Public health policy:


Identification of health objectives and targets is one of the more visible strategies to direct the activities of the health sector, e.g. in the United States, the “Healthy People 2010” offers a simple but powerful idea by providing health objectives in a format that enables diverse groups to combine their efforts and work as a team. Similarly, in India, we need a road map to “better health for all” that can be used by states, communities, professional organizations and all sectors. It will also facilitate changes in resource allocation for public health interventions and a platform for concerted intersectoral action, thereby enabling policy coherence.


7. Role of government in enabling intersectoral coordination towards public health issues:


The Ministry of Health needs to form stronger partnerships with other agents involved in public health, because many factors influencing the health outcomes are outside their direct jurisdiction. Making public health a shared value across the various sectors is a politically challenging strategy, but such collective action is crucial.




·              Social determinants of health


Kerala is often quoted as an example in international forums for achieving a good status of public health by addressing the fundamental determinants of health: Investments in basic education, public health and primary care.


Living conditions


Safe drinking water and sanitation are critical determinants of health, which would directly contribute to 7080% reduction in the burden of communicable diseases. Full coverage of drinking water supply and sanitation through existing programs, in both rural and urban areas, is achievable and affordable.



Urban planning


Provision of urban basic services like water supply, sewerage and solid waste management needs special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities works to develop financially sustainable cities in line with the Millenium Development Goals, which needs to be expanded to cover the entire country.Other issues to be addressed are housing and urban poverty alleviation.


Revival of rural infrastructure and livelihood


Action is required in the following areas: Promotion of agricultural mechanization, improving efficiency of investments, rationalizing subsidies and diversifying and providing better access to land, credit and skills.




Elementary education has received a major push through the SarvaSikshaAbhayan. In order to consolidate the gains achieved, a mission for secondary education is essential. “Right of children to Free and Compulsory education Bill 2009” seeks to provide education to children aged between 6 and 14 years, and is a right step forward in improving the literacy of the Indian population.


Nutrition and early child development


Recent innovations like universalization of Integrated Child Development Services (ICDS) and setting up of miniAnganwadi centers in deprived areas are examples of inclusive growth under the eleventh 5 year plan. The government needs to strengthen ICDS in poorperforming states based on experiences from other successful models, e.g., Tamil Nadu (upgrading kitchens with LPG connection, stove and pressure cooker and electrification; use of ironfortified salt to address the burden of anemia). Micronutrient deficiency control measures like dietary diversification, horticultural intervention, food fortification, nutritional supplementation and other public health measures need intersectoral coordination with various departments, e.g., Women and Child Development, Health, Agriculture, Rural and Urban development.


Social security measures


The social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee Scheme (MREGS) has the potential to change the complexion of rural India. It differs from other poverty alleviation projects in the concept of citizenship and entitlement.[9] However, employment opportunities and wages have taken the center stage, while development of infrastructure and community assets is neglected. This scheme has the necessary manpower to implement intersectoral projects, e.g., laying roads, water pipelines, social forestry, horticulture, antierosion projects and rain water harvesting. The unlimited potential of social capital has to be effectively tapped by the government.



Food security measures


Innovations are required to strengthen the public distribution system to curb the inclusion and exclusion errors and increase the range of commodities for people living in very poor conditions. It is essential that the government puts forth action plans to increase domestic food grain production, raise consumer incomes to buy food and make agriculture remunerative.


Other social assistance programs


The RashtriyaSwasthiyaBimaYojana and AamAdmiBhimaYojana are social security measures for the unorganized sector (91% of India's workforce). The National Old Age Pension scheme has provided social and income security to the growing elderly population in India.


·              Population stabilization


There is all round realization that population stabilization is a must for ensuring quality of life for all citizens. Formulation of a National Policy and setting up of a National Commission on Population and JanasankhyaSthirathaKosh reflect the deep commitment of the government. However, parallel developments in women empowerment, increasing institutional deliveries and strengthening health services and infrastructure hold the key to population control in the future.


·              Gender mainstreaming and empowerment


Womenspecific interventions in all policies, programs and systems need to be launched. The government should take steps to sensitize service providers in various departments to issues of women. The Department of Women and Child Development must take necessary steps to implement the provisions of “Protection of Women from Domestic Violence Act, 2005.” Training for protection officers, establishment of counseling centers for women affected by violence and creating awareness in the community are vital steps. Poverty eradication programs and microcredit schemes need to be strengthened for economic and social empowerment of women.


·              Reducing the impact of climate change and disasters on health


Thermal extremes and weather disasters, spread of vectorborne, foodborne and waterborne infections, food security and malnutrition and air quality with associated human health risks are the public health risks associated with climate change. Depletion of nonrenewable sources of energy and water, deterioration of soil and water quality and the potential extinction of innumerable habitats and species are other effects. India's “National Action Plan on Climate Change” identifies eight core “national missions” through various ministries, focused on understanding climate change, energy efficiency, renewable energy and natural resource conservation. Although there are several issues concerning India's position under UNFCCC, it has agreed not to allow its per capita Greenhouse gas emissions to exceed the average per capita emissions of the developed countries, even as it pursues its social and economic development objectives.


The Ministry of Health, in coordination with other ministries, provides technical assistance in implementing disaster management and emergency preparedness measures. Deficient areas include carrying out rapid needs assessment, disseminating health information, food safety and environmental health after disasters and ensuring transparency and efficiency in the administration of aid after disasters. Implementation of Disaster Management Act, 2005 is essential for establishing institutional mechanisms for disaster management, ensuring an intersectoral approach to mitigation and undertaking holistic, coordinated and prompt response to disaster situations.


·              Community participation

Community participation builds public support for policies and programs, generates compliance with regulations and helps alter personal health behaviors. One of the major strategic interventions under NRHM is the system of ensuring accountability and transparency through people's participation – the RogiKalyanSamitis. The Ministry of Health needs to define a clear policy on social participation and operational methods in facilitating community health projects. Potential areas of community participation could be in lifestyle modification in chronic diseases through physical activity and diet modification, and primary prevention of alcohol dependence through active communitybased methods like awareness creation and behavioral interventions.


·              Private sectors, civil societies and global partnerships


Effective addressing of public health challenges necessitates new forms of cooperation with private sectors (publicprivate partnership), civil societies, national health leaders, health workers, communities, other relevant sectors and international health agencies (WHO, UNICEF, Bill and Melinda Gates foundation, World Bank).


·              Governance issues


In order to ensure that the benefits of social security measures reach the intended sections of society, enumeration of Below Poverty Line families and other eligible sections is vital. Check mechanisms to stop pilferage of government funds and vigilance measures to stop corruption are governance issues that need to be attended. The government should take strict action in cases of diversion of funds and goods from social security schemes through law enforcement, community awareness and speedy redressal mechanisms. Social audits in MREGS through the Directorate of Social Audit in Andhra Pradesh and Rajasthan are early steps in bringing governance issues to the fore. This process needs strengthening through separate budgets, provisions for hosting audit results and powers for taking corrective action. Similar social auditing schemes can be emulated in other states and government programs like ICDS, which will improve accountability and community participation, leading to effective service delivery.


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