SPECIAL ARTICLE

Year : 2014  |  Volume : 58  |  Issue : 4  |  Page : 261-266

An alternative model of health delivery system to improve public health in India

Faruqueuddin Ahmed
Integral Institute of Medical Sciences and Research, Integral University, Lucknow, Uttar Pradesh, India

Correspondence Address:
Faruqueuddin Ahmed
Integral Institute of Medical Sciences and Research, Integral University, Dasauli, PO Bas ha, Kursi Road, Lucknow - 226 026, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0019-557X.146287

Abstract

Three distinct groups of people, the sick, at risk and a healthy population constitute the beneficiaries of any health services. Available health care packages are based on the paradigm of the "natural history of the disease and the five levels of the prevention." Patient-centric "personal care services" and community centric "public health care" are the two packages universally provided to a community. A health care system can only be effective and efficient if there is balanced mix of the personal and public health care delivered as a comprehensive package in a regionalized graded manner by a well-trained manpower. The current health care delivery system is mostly personal care centered and public health component is in the fringes and being delivered as vertical programs through the multipurpose health worker. The alternative model speaks about bi-furcating the two types of services and delivering both as a comprehensive package to the community. As per the constitution of India health services including major public health services are state subject but the nature of emerging public health problems relates to mass movement of people and goods, environmental changes due industry and other developmental activities etc. resulting in the spread of the same beyond the manmade geographical boundary, some public health activity may be included in the union/concurrent list. To deliver the packages a public health cadre may be created at the state and center and be equipped with public health knowledge and skill to deliver well-defined evidence-based service package to control the existing problem and keep strict vigilance to prevent entry/emergence of new health problems.

Keywords: Personal health care services, public health care services, public health care package, evolution of health care in India, India′s five year plan, policy reform and system reforms in health care, governance, system vs mission mode.

Introduction

1. Service need for diseased, disabled and at risk with overt symptoms and sign: This group needs immediate medical care to detect their disease or disability and treat at the onset or take protective measure to prevent the onset. This type of care is defined as personal health care (clinical care), package of services mostly contains curative, preventive, promotive and rehabilitative care. The knowledge and skill required to deliver the services at the community or the institutional level is unique. At the primary level, the worker should be proficient to provide primary clinical care as well as referral to a higher center and maintain patient records for future purposes. In some cases, other family members may also need clinical or other health package. The focus of attention in providing personal services is an individual and the family.
2. Service need for healthy or apparently healthy: The services required for these groups are to improve environmental condition and also intervention against specific determinants of health affecting the community. All these interventions are contents of an effective public health package.
3. The 10 essential public health service package defined by the American Public Health Association, ^[1] which are universally accepted and are as follows:
   1. Monitor health status to identify community health problems.
   2. Diagnose and investigate health problems and health hazards in the community.
   3. Inform, educate and empower people about health issues.
   4. Mobilize community partnerships to identify and solve health problems.
   5. Develop policies and plans that support individual and community health efforts.
   6. Enforce laws and regulations that protect health and ensure safety.
   7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
   8. Assure a competent public health and personal health care workforce.
   9. Evaluate effectiveness, accessibility and quality of personal and population-based health services.
   10. Research for new insights and innovative solutions to health problems.
4. Training needs for delivery of clinical personal care and public health care: To address needs under clinical care, and public health, the specific type of service packages and trained manpower is necessary. The requirement for delivering both clinical and public health services should be competence-based and encapsulate modern information and communication technology.
   1. To deliver clinical care, the provider should be able to diagnose and treat the patient at the earliest, prevent complications and promote healthy practices and behavior in the patient and the family members to avoid future episodes. As our clinical care delivery system is graded, the other important competence is an effective referral.
   2. The package of public health services is quite different from clinical care. Required skill is epidemiological, managerial, on communication and on community organization. Knowledge on Health, Natural History of Diseases, Ecology, environment, behavioral science, Health economics, Public health administration and management, etc. are also required .

1. The "Bhore Committee" report included five distinct areas of services:
   1. Public Health,
   2. Medical Relief,
   3. Professional Education,
   4. Medical Research, and
   5. International Health.
2. The staffing pattern for a primary health center, included two streams of health personals, which were - four public health nurse, two sanitary inspectors and one vaccinator for public health activity and one nurse, four midwives, two health assistants, and one pharmacist for clinical care. Two medical officers (MOs) were also included, one for personal care and the other for public health. ^[2] However, in 1967, the Jungalwalla Committee recommended that there should be an "Integrated health services" in all levels, organization and personnel and suggested a unified cadre. ^[3] As a corollary to this change, in 1973 the Kartar Singh Committee on "Multipurpose Worker Under Health and Family Welfare" introduced the concept of multi skilling training of peripheral health worker and recommended the structure for integrated services at the peripheral and supervisory level and suggested the present population norms for subcenter and primary health care (PHC) and its staffing pattern. ^[4] The above sequence of events completely changed the health care delivery system in the country and stalled the growth of public health services. One can argue that the existing health care delivery system in India is efficient, which has resulted in eradication of diseases like small pox and guinea worm, controlling diseases like HIV, leprosy, tuberculosis, and also containing effectively the emerging diseases like SARS, bird flu etc. This success is attributable to not only the existing health care delivery system, but also to special vertical programs, which was executed in campaign mode and not system mode. Of course, the ever-expanding health care infrastructure supported the effort by providing clinical and surveillance support.
3. Health services and related constitutional provisions: ^[5]
4. 1. In the preamble, all the broad principles enunciated in it have an indirect bearing on health. The fundamental characterization of Indian polity is based on three pillars "socialist, secular, democratic." Socialist would mean that health as a necessary human resource should be subject to societal control and made a public/collective responsibility, meant in practice the responsibility is of the state. Secular dimension suggests that health should be made available irrespective of caste/community/religion. The "democratic" should promote the welfare of the people, which include physical welfare and thus health of the population. Three cardinal principles of Justice, Liberty and Equality mentioned in the preamble imply that health must be provided by the public authority to live in dignity, equally and impartially, to all individuals and sections.
   2. Under Directive Principles of State Policy: The provisions under this head are largely normative stipulations left to the will of the rulers. In formulating the policies and programs, the state is supposed to keep them in view and noncompliance with this does not attract judicial action. "Article 21 of the constitution of India confers the fundamental right to life and personal liberty." Bhagwati J held that the right to live with human dignity and all that goes along with it, namely the bare necessaries of life such as adequate nutrition, clothing and shelter above the head." He also adds that as Right to live with human dignity enshrined in Article 21 derives its life breath from the Directive principles of state policy and particularly clause (e) and (f) of article 39, 41 and 42. Therefore, it must include protection of health and strength of men, women and children against abuse. Opportunities must be there for children to develop in a healthy manner, in freedom and dignity and educational facilities, just and human conditions to work in and for maternity relief. Article 47 also refers to raising the standard of living of the rural population, and has included health and improved sanitation which are associated with health.
   3. Center-state relations: This is the most crucial aspect in the delivery of health care services of the country, since the different public authorities - the Union Government and the State Governments derive their power and functions from the constitutional provisions defining and regulating these relations. Of the 97 items mentioned in the union list, item number 28 related port quarantine, item number 58 related to manufacturing and distribution of salt and item 81 related to interstate migration and quarantine, is of relevance to public health. Majority of the personal care and public health services are included in the state list. Of the 66 items, 5 items are relevant to the health services. They are item number 6 (public health and sanitation, hospitals and dispensaries), item number 8 (intoxicating liquors - production, manufacture, possession, transport, sale and purchase), item number 10 burial 7 cremation and grounds, item number 15 prevention of animal diseases (indirectly related to zoonotic disease control) item 17 (water-supplies irrigation and canals). Of the 47 items included in the concurrent list 9 important domains of public health is included, item 16, lunacy and mental deficiency - reception and treatment, item 18 (adulteration of foodstuffs), item number 19 (drugs and poison-related to opium), item 20 (economic and social planning), item 23 (social security including employers liability, workmen's compensation and maternity benefit), item 25 and 26 (medical education and professions medical and legal), item number 29 (prevention of extension from one state to another of infectious or contagious diseases or pests affecting man, animal and plants), item number 30 (vital statistics including registration of births and deaths). But possessing jurisdiction over items by the state is not the same as possessing the financial power to make good that jurisdiction in practice. To address imminent health needs many a times the union government wants to start national health programs with 100% finance. Though the intention may be based on legitimate epidemiological facts but much state government feels that the union is imposing/curving its autonomy. The planning commission is the platform for a collective decision in this regard, but many feel it is not based on the constitution.
5. Current scenario: The recommendation of Jungalwalla Committee and Kartar Singh Committee was appropriate for addressing the health needs based on the demographic, epidemiological, available technical and resources. However, over the decades the scenario has changed. With the persistent population growth and ever increasing newer habitations and the country's inability to keep pace in providing adequate safe water and sanitation was responsible for the diseases such as cholera, typhoid, and malaria. Lack of any specific public health program to address the other determinants like changing lifestyle, food habit and ecology due to de-forestation, recent developments in industrial, agricultural and rearing of livestock practices and migration of rural to urban area have changed the morbidity pattern and its interventions. Besides the existing morbidities, the newer ones are added - the emerging infectious diseases and lifestyle diseases. In addition to these physical health problems, there are social and mental health problems which also come under the purview of public health services. The present day health care delivery system is not staffed with adequately trained personnel and is not equipped with equipments necessary to deliver the specific public health programs to contain the emerging morbidity.
   
   Government of India in its different five year plans tried to address the emerging health problems by prioritizing different strategy from implementing single disease control through program mode to the PHC approach in service delivery and to the latest strategy through Mission mode. A brief summary of the 9 ^th , 10 ^th , 11 ^th and 12 ^th five year on health is scripted hereunder.
6. 1. During the Ninth Plan, beside the policy of strengthening the service infrastructure, policies were introduced on integration of vertical program, programs on disease surveillance and response, control of noncommunicable disease, Health Impact Assessment of developmental projects, appropriate management systems for organizing the emergency, disaster, accident and trauma care at all levels of health care and improvement of Health Management and Information System. ^[6]
   2. In the Tenth Plan, the emphasis was on restructuring the existing infrastructure, upgradation of skill of the personnel, and providing good quality integrated RCH services by improving the logistics of supply, operationalizing the referral system through the and involvement of Panchayati Raj Institutions (PRI) in planning, monitoring and midcourse correction of the program at local level through inter-sectoral coordination. ^[7]
   3. Eleventh Plan highlighted on improving health equity through implementation of National Rural Health Mission (NRHM) and National Urban Health Mission by adopting a system-centric approach rather than a disease-centric approach and decentralizing governance, establishing e-health and improving access to and utilization of essential and quality health care. ^[5]
   4. The objective stated in the 12 ^th Five Year Plan is to "put in place a basic architecture for health security of the nation, which will be built on what has been achieved through NRHM and expand it into a comprehensive National Health Mission." It speaks of the primary responsibility of the state Governments to improve the public health care system, while regulating the private, so that they can work towards addressing the management of delivery of preventive, promotive, curative and rehabilitative health intervention. ^[8]

1. Policy reform: In earlier days public health problems used to be confined to a geographical domain. Due to easy movement of people and globalization, epidemiological situation is different, the spread of any modern epidemic is ubiquitous and not limited to the manmade boundaries of states or countries, and in fact, some public health measures needs global cooperation. Therefore, strategy of public health intervention should also be uniform throughout the country. For effective planning and implementation of public health program, we require a health care delivery system with defined responsibilities of a defined area of operation, trained manpower and effective public health legislation. The other important aspect is to keep uniformity in the delivery of public health services is a centralized monitoring system. This organ of the service may also the state in rapid response and provide technical and other operational support in combating Public Health program affecting several states. The following steps may be considered:
   • In view of the epidemiological and contemporary social and demographic changes some more domains of public health service package may be considered to be included in the union/concurrent list of the Constitution of India, for a unified strategy of implementing public health interventions.
   • The other measure to be considered is the introduction of a Model Public Health Act in all the states as many of the public health intervention can only be implemented with legislative support viz. food security, industrial pollution, etc.
2. System reform: Two distinct streams of services viz. Clinical care and Public Health services under two separate divisions with two separate cadres of health personnel is to be organized which should start from the community level and end at the state level. The divisions will have well defined service responsibility. The domain of services of the clinical and public health is different, but for a better outcome it needs active coordination for converging different types of service packages to the targeted beneficiaries or area at all levels of service delivery system starting from sub-center to the state level. Instead of multipurpose worker each sub-center should have a pair of nursing and clinical care worker and public health worker. In the primary health center level, the supervisors of each stream should be Nursing and Clinical Care Assistant and Public Health Assistant. At the Community Health Centre (CHC) level, the supervisor staff will be known as the Community Nursing and MO and Community Public Health Officer (CPHO). Currently, in the block PHCs, there is a post of Block Extension Educator under FW program that can be converted to CPHO. For this, at least graduate degree in Public Health is essential. At the district level, there should be two district level managers, one District MO and the other District Public Health Officer. One additional post of Entomologist at the District level is also necessary for the public Health stream. At the state level, there will be one post each for Director of Medical Services and Director of Public Health. This is in addition to the existing medical service providers like Pharmacist, General Nurse Midwife, Lab Technician, Doctors, etc. The overall in-charge of the primary health center is the Medical and Health Officer and in the CHC Community Health Officer. The in-charges of PHC and CHC will coordinate and monitor the two streams of activities. The Public Health specialist will be posted coterminous to the officers of other service departments in the community viz. Agriculture, education, rural development. Emphasis will be given to incorporating the modern electronic recording and transmission technology in the service delivery system, both for personal patient care and public health care. Network of web-based monitoring system will be established for real time follow up of epidemiological trend of diseases in different section of the community by utilizing the satellite maps available for the individual PHC/CHC/and district. This will be useful to make need-based district health plans and its implementation.
3. Training program: Three types of training program, which are vocational, graduate and post graduate would be essential. Vocational training program for the community level worker, graduate level for the PHC level and post graduate level (diploma/degree) for the district and above level posts. To discourage people to join at the community level, lateral entry should not be allowed up to the CHC level. Only experienced individuals in service or special course and obtained the requisite training will be promoted to the higher posts and may be able to go up to the highest posts in the state. The existing training programs are standalone training program and are not structured. Consequently, the standard cannot be maintained, and the evaluation system is poor and there is no innovation in the program. Accordingly, it is suggested that in the long run the training should be under the supervision of a university or higher training institution, which has classroom and workplace training with formative and summative evaluation. The system of training program may take innovative measures as per the evaluation results. To equip the existing staff of the Sub center and PHC, the short term measure will be restructuring the training program into clinical and public health and through a reorientation program. As a long term measure, there should be provision to start graduate and masters courses in public health. The master course has already been initiated by many institutes including PHFI. The Indian Academy of public health has already developed a Bachelor course of Public Health. As a short term measure the existing Block Extension Educator or Health Assistant, having graduate degree in biology may undergo a short-term course of 1΍ years to be able to work as Community Health Officer. To augment the clinical services in the sub center and PHC, a graduate course of Nurse Practitioner of 4 years (including internship) is envisaged. As a short term measure, interested graduate nurses can be oriented for 6 months and may be posted at primary health center and later to Sub Center level to provide clinical care.
4. Issues of Governance: Regionalization of graded health services and convergence: While in principle our health care is graded and regionalized, but there exists confusion also. During the launching of community development (CD) program in 1952, provision of medical relief and preventive health services was a part of the CD program. Unfortunately, only the Health Department came out of the CD Blocks and started working as a standalone department, but remained physically near the Block Headquarter. Till the concept of CHC was not introduced, the block primary health centers worked in tandem with other block activities. The process of site selection for the construction of CHC was one of the main reasons for the present status of nonconvergence of Health and other block activities. All other service departments except health are coterminous with block infrastructure. The activities of health are institution based viz. Sub-center, PHC, CHC, District hospital. As we have already started a mechanism of coordination with the PRI under National Health Mission, the strategy of convergence of different service packages to the targeted beneficiaries needs some administrative and managerial maneuver so that inter-sectoral coordination at different levels of decision become effective. For a smooth and time bound change the health care reform program should be implemented in "Mission Mode rather than System Mode"

References

1.	Available from: http://www.apha.org/programs/standards/performancestandardsprogram/resexxentialservices.htm. [Visited on 2014 Jul 23].
2.	Govt. of India. Report of Health Survey and Development Committee. Simla: Govt. of India Press; 1946.
3.	Govt. Of India. Report of the Committee on Integration of Health Services. New Delhi: Directorate General of Health Services, Ministry of Health; 1967.
4.	Govt. of India. Report of the Committee on Multipurpose Workers Under Health & Family Planning Program. New Delhi: Department of Health Family Planning, Ministry of Health & Family Planning; 1973.
5.	Mahendra P, Singh VN. Shukla's Constitution of India. 10 th ed. Lucknow: Eastern Book Company; 2007.
6.	http://planningcommission.gov.in/plans/planrel/fiveyr/9th/vol2/v2c3-4.htm. [Visited on 2014 Jul 23].
7.	Available from: http://www.planningcommission.nic.in/plans/planrel/fiveyr/11th/11_v2/11th_vol2.pdf. [Visited on 2014 Jul 23].
8.	http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol3.pdf. [Visited on 2014 Jul 23].