Public Health Sector in India consists of Referral hospitals, Teaching hospitals, District hospitals, and rural health sector. Backbone of rural health care is the Sub-centers, Primary Health Centers (PHCs), Community Health Centers (CHCs), and the district hospitals. There are about 137,311 Sub-centers, 22,842 PHCs, 3043 CHCs, and over 1000 District Hospitals. Each PHC is intended to provide primary health care to a population of 20,000 to 30,000. Sub-Centers cater to a population of about 5,000 each, and are the first contact point between a patient & health care system. Laid down ratio of population to a Sub Center, PHC or CHC have all been overtaken by population growth, and as it stands today the services at these health care facilities fall far short of the targets & indicators.
Health is all pervasive and healthy body & mind is an asset to any society. Any measure which falls short of achieving this aim may be termed as a deficiency or shortfall. Second rate health of people will give rise to only second rate people. One often hears criticism that with one billion people we do not have world class athlete or scientist. But we tend to forget that in that one billion hardly 30 % or 30 million enjoy proper physical & mental health.
National Health Policy aimed to achieve ‘Health for all by 2000 AD’ was declared in the year 1983 (1). The same slogan has been repeated in a recent announcement by the Vice Chairman Planning Commission aiming to achieve the same aim by the year 2020 (2). The only difference is the time interval of two decades. There is no road map. With budgetary support ranging between 3-5% in different Five Year Plans and 3-9 % expenditure on health in different States for the last many decades how this is going to be accomplished is difficult to envision. The investment in health care sector has in fact declined from 1.3 % to 0.97 % of GDP (in 1999) (3). 13 to 15 % of Indians do not have access to health care facility. Rural health infrastructure remains in a very poor state. The situation is further complicated by health being a State Subject. The functions of the Central Govt are set out in accordance with the Article 246 of the Constitution, under Union List & Concurrent list. Regulation and development of medical, pharmaceutical, dental, and nursing professions fall under the Central jurisdiction, so does the Control of Drugs and Poison within the Concurrent list. Prevention of extension of communicable diseases from one unit to another also falls under the Concurrent list (4). Rest of the functions relating to health care comes under the State function. Therefore parameters, results, inputs, and indicators differ from sate to state and at times widely. Realistic and enforceable policies are required to upgrade health care facilities.
There are stringent rules and procedures, and standards laid down for drugs and pharmaceuticals but not for equipments. Functions of the Drug Controller of India are limited to certifying new drugs, regulating import of new drugs, and laying down pharmaceutical procedures. Procurement policies are elaborate, and in detail. Under the Drug & Cosmetic Act 1940 (as amended) the regulation of manufacture, sale & distribution of drugs is primarily the concern of the State authorities (5). Thus it is obvious that implementation very much depends upon on the State authorities.
There are no standards, for equipments. One has to rely on declared parameters of the manufacturers. So far sophisticated electro-medical equipments are concerned this may not be a problem area as the standards may be verifiable and known. But for other equipments (including equipments for bio-medical waste treatment) it is an area of acute problem. There are no laid down standards for incinerator, hydroclave, or shredder. It must be appreciated that improper waste disposal is the root cause for most of environmental degradation, and communicable diseases with mutated variants of microbes. SARS is one example. Recent epidemic of viral disease which has affected a large number of children in Andhra Pradesh recently is another example. Experts are now convinced that around 30 % of incidence of AIDS is caused by improper disposal of infected syringe waste.
Equipment maintenance is so poor that at any given time about 40 % of these equipments remain unserviceable for want of proper maintenance (6).
Technical services have to be necessarily provided by the health care professionals – doctors, nurses, paramedics, but the non-technical services may be managed by others. Health care establishments in the public sector find themselves seized with the problem of looking after the non-professional services also. This affects the quality of patient care. Services like cleanliness, laundry, patient food, security, IT etc can always be outsourced. Outsourcing is the ‘in thing’ in the private health care facilities.
As per the WHO 45 to 50 % of all injections given in the developing world are either unsafe or unnecessary (7). Main cause of hospital acquired infection (HAI) is improper hospital waste disposal resulting in higher morbidity demanding increased facilities & resources of the society. Proper disposal of bio-medical waste as the core issue is still to be recognized with due importance. HAI is a matter of great concern to all health care planners. A study in UK (and since expenditure in patient care in UK is all funded by the public sector there cannot be any more accurate indicator) indicates clearly that ‘in excess’ expenditure on account of treating HAI costs the state exchequer an additional amount of about one billion pounds per year. It amounted to an estimated loss of 8.7 million man days (8). Manifest illness, sub-clinical affliction, infection control, environmental health, pollution & waste management, all have to be viewed together. Only then one can aspire to achieve a healthy society with improved health care. Therefore establishing a Waste Management Authority of India (WMAI)’ will not be a bad idea (9).
As per Mr Theo Colborn a wild life expert, the human body carries 500 more chemicals than it carried before 1920s (10). This reflects on the health and behavior pattern of individuals. Definition of ‘positive health’ must change to include absence of pollutants in the body and aim should be to achieve ‘Total Health’. The apt definition therefore would be “A state of complete physical, mental and social well being, where life thrives on in healthy environment devoid of pollutants; and not merely absence of disease and infirmity.”
Therefore there is a necessity of reviewing the statutory rules in order to improve its applicability, and effectiveness.
Health being a State subject, it is not possible for the Central authorities to intervene effectively and at will. Sale and distribution of spurious drugs, fluids, and blood is everyday news. The State machineries, for some reason have not proved effective. It is necessary to establish federal authority for periodic monitoring, & empowered to issue directives overriding the State’s directive in case it is at a conflict.
Health care in India has many shortcomings. It needs a general revamping. Specific weaknesses have to be identified, and strengthened. There are weaknesses in the statutory provisions, regulatory rules, and control mechanisms. These need to be studied and corrected.
May 14, 2003 (LK Verma)
1. National Health Policy Document
2. ‘Vision 2020’ released by Shri KC Pant, Vice Chairperson Planning Commission – Times of India, Jan 24, 2003
3. National Health Report-1997
4. Park’s textbook of Preventive & Social Medicine, 15th edition, page 601
5. Indian Pharmacopoeia, 1994
6. Paper presented during ‘QUEST – 2001’ Conference – Lt Col RK Chaturvedi, Associate Professor, Department of HA, AFMC
7. Hospital Waste in Latin America – J Monreal (1991), WHO/PEP/RVD/94.1
8. ‘The Socio-economic Burden of Hospital Acquired Infection’ – Rosalind Plowman et al, Apr 1994 to May 1995
9. Article ‘Needed: a National Waste Management Authority’ –Verma LK, Pharmabiz Hospital Review, Nov 16 – 30, 2002
10. Indian express Nagpur, Jun 22, 1997