Despite these differences the World Health Assembly in 1977 declared that all citizens of the world should attain a level of health that will permit them to lead a socially and economically productive life. This culminated in the international objective of HEALTH FOR ALL by the year 2000 as the social goal of all governments. Health for all means that health is to be brought within the reach of every one in a given community. It implies the removal of obstacles to health–that is to say, the elimination of malnutrition, ignorance, disease, contaminated water supply, unhygienic housing etc. It depends on continued progress in medicine and public health.
IndiaPrimary health care
Kerala and primary health care
Kerala is a state worth mentioning as it has achieved landmark Kerala milestones in achieving an almost 100% literacy. In addition it has one of the lowest infant mortality rate, a higher life expectancy and a lower death rate. On the other hand if one looks at population statistics, Kerala has a high population density (total population around 30 million) and a lower per capita income than the national average. In addition Kerala has a higher doctor: population ratio. The noteworthy factor is that literacy is a very important determinant of health.
Comparison of Kerala and All India Health Statistics
|Death rate (1993)||6.0||9.2|
|Infant mortality rate (1993)||13||74|
|Life expectancy at birth (1993)||66.5||61.5|
|Literacy rate (%) (1991)||90.59||52.11|
|Per capita income (1989–90)||INR 3389||INR 5670|
|Doctor Population ratio (1991)||1:7213||1:2148|
Overall Health Situation in India
IndiaLet us now turn our attention to the overall health situation in India. We will look at some basic statistics impacting health, review health care delivery systems and critique the achievements as well as the unfulfilled targets of health care delivery.
Population Profile: The work on the next census (2001) has already started. Even without it, it can be said that India is heading towards a population explosion. It is one of the most populous nations in the world–second only to China. Nature has only finite resources and the consequences of an ever expanding population to mankind as a whole are grave. Let us look at some of these demographics or should we say “Demographics”.
High fertility both in terms of birth rate and family size.
Illiteracy rate of about 40%
Dependency ratio of 0.9, that is, every economically productive member has to support almost one dependent. This table summarizes the most recent
demographic information available:
India: Demographic profile
|Total Population (eatimated1996)||952||Million|
|Population rural% (1995)||73.2||–|
|Adult literacy rate % (1995)||52||–|
|Density of population per sq.km (1995)||283||–|
|Sex ratio female per 1000 male (1991)||929||–|
|Average family size (1988)||34.8||–|
|Age at marriage, female (1991)||19||Years|
|Annual per capita GNP
(at current prices 1994–95)
When we compare some of the available statistics to that prevalent in the west the following is the observation.
Selected health and socioeconomic indicators
|Other developing Countries||Developed Countries|
|Life expectancy at birth (years) 1996||66||77|
|IMR (per 1000 live births)||55||6|
|Maternal mortality per 100,000 live births 1990||350||13|
|Doctor population ratio per 10,000 (1993)||8.4||25.2|
|Nurse population ratio per 10,000||9.6||74.2|
|GNP per capita (US $)(1994)||1133||24414|
|Adult Literacy rate||73||99|
A Look at Mortality Statistics
During the last few decades, there has been a notable improvement in the health status of the population. The death rate has steadily declined. The life expectancy at birth has gone up considerably since 1951, recording an estimated 62 years during 1995. Many of the infectious diseases have shown a decline, e.g. plague and malaria.
There is still a lot that needs to be done. India’s health standards are still low compared to those in developed countries. The infant mortality rate (IMR) India is still high (about 74) as compared to a low of about 6 in developed countries. It does not compare even favorably to some countries in the African continent. Even among underdeveloped countries the IMR is considerably higher. The life expectancy rate in India is at least 10–15 years behind the western life expectancy.
A look at some morbidity profiles
Although some diseases have been brought under control many diseases like tuberculosis, filariasis, leprosy, malaria, diarrhea diseases continues to be a major health problem. Small pox has been eradicated. But measles and polio are still widely prevalent. Bacterial meningococccal meningitis has been on the increase. We still have not controlled viral hepatitis infections. AIDS may become one of the most deadly diseases in the near future. Diarrheal diseases still are a major cause of morbidity and mortality in children. Malnutrition occurs very commonly in children, especially in the rural areas.
About 30 per cent of babies are born with a birth weight of less than 2.5. kg. Vitamin A deficiency is a major cause of preventable blindness. India is home to almost half the cases of tuberculosis in the world. Not so encouraging is the widespread occurrence of leprosy. People continue to be afflicted by malaria. Many deaths occur due to Paramoecium falciparum infections. Kala–azar has made a resurgence. An estimated 20,000 cases occur annually. Lastly sexually transmitted diseases are widely prevalent.
In addition to the above the so called slow epidemics of diseases such as diabetes, cancer, heart diseases also affect people in third world countries. Smoking is decreasing in many developed countries due to health fears, but it is on the rise in developing countries. It is estimated that in certain developed countries as high as 60% of the men smoke. Heart attacks occur at a younger age in South Asia as compared to the rest of the world. With the adoption of western lifestyle, diabetes is increasingly seen in India.
What has been done so far to tackle these health problems?
1. Establishment of primary health care centers:
The establishment of primary health care centers started earnestly after independence in 1952. Over the years, a network of primary health centers and sub–centers have been established. The primary health centers are the major health care providers in the rural areas. At the village level, a band of voluntary health workers (e.g. village health guides and trained dais) has been created. They are selected by the local community and trained to deliver primary health care. Secondary health care is provided by the district hospitals and newly created community health care.
Tertiary health care is provided by the teaching hospitals and institutions and other apex hospitals. Both in the rural and urban areas, the public and private sectors exist side by side. A large number of voluntary organizations are also involved in providing health care to the people.
2. Establishing a health care work force
Major requirement in developing an adequate health infrastructure is health manpower which must be adequate both as regards quality and quantity. Many medical colleges (allopathic) and nursing schools were started soon after independence. There are about 400,000 allopathic doctors. In addition the alternative forms of medicine also contribute to the workforce e.g. Ayurvedic system, Homeopaths, Unani system, they number approximately 6 lakhs and are actually more than the existing allopaths. When all doctors are included the ratio of doctor: patient population is roughly 1:2100.
3. Health care and insurance
As compared to the West, health care insurance does not exist in a big way. As part of the public sector health services, there are a number of schemes such as Central Govt. Health scheme (CGHS) and the Employees State Insurance Scheme (ESIS) under which comprehensive health care services are provided to the families of employees. The beneficiaries covered by these schemes work out to a little less than 6 per cent of the Indian population. Some private sectors provide insurance to their employees. With the government opening up the insurance sector to international competitors the insurance scenario will undergo a dramatic change in the coming years.
Primary Health Care
Another important declaration was the Alma Ata (erstwhile USSR) joint conference of WHO–UNICEF. It was declared that “The existing gross inequality in the health status of people particularly between developed and developing as well as within countries is politically, socially and economically unacceptable”. The Alma–Ata conference called for acceptance of the WHO goal of Health for all by 2000 A.D. and proclaimed “Primary health care as a way to achieving health for all”.
This slogan was adopted and incorporated into delivery of health services by many countries including India. India is a signatory to the Alma–Ata Declaration of 1978. The National Health Policy, approved by the parliament in 1983 clearly indicates India's commitment to the goal of health for all by the year 2000 AD.
The Declaration of Alma Ata stated that primary health care includes at least:
- Education about prevailing health problems and methods of preventing and controlling them.
- Promotion of food supply and proper nutrition.
- An adequate supply of safe water and basic sanitation.
- Immunization against infectious diseases.
- Prevention and control of endemic diseases.
- Appropriate treatment of common diseases and injuries.
- Provision of essential drugs.
- Crude death rate
It is defined as the number of deaths per 1000 population per year in a given community.
- Expectation of life
Life expectancy at birth “The average number of years that will be lived by those born alive into a population if the current age–specific mortality rates persist”. Life expectancy is a good indicator of socio–economic development in general.
- Infant mortality rate
Infant mortality rate is the ratio of deaths under 1 year of age in a given year to the total number of live births in the same year, usually expressed as a rate per 1000 live births. It is one of the most universally accepted indicators of health status not only of infants, but also of whole populations.