Role of government in public health

PUBLIC HEALTH- ITS REGULATION

The practice of public health has been dynamic in India, and has witnessed many
hurdles in its attempt to affect the lives of the people of this country. Since
independence, major public health problems like malaria, tuberculosis, leprosy,
high maternal and child mortality and lately, human immunodeficiency virus
(HIV) have been addressed through a concerted action of the government. Social
development coupled with scientific advances and health care has led to a decrease
in the mortality rates and birth rates.[1]
This article is a literature review of the existing government machinery for public
health needs in India, its success, limitations and future scope.

CHALLENGES CONFRONTING PUBLIC HEALTH

The new agenda for Public Health in India includes the epidemiological transition
(rising burden of chronic non-communicable diseases), demographic transition
(increasing elderly population) and environmental changes. The unfinished agenda
of maternal and child mortality, HIV/AIDS pandemic and other communicable
diseases still exerts immense strain on the overstretched health systems.

Silent epidemics: In India, the tobacco-attributable deaths range from 800,000 to

900,000/year, leading to huge social and economic losses. Mental, neurological
and substance use disorders also cause a large burden of disease and disability. The
rising toll of road deaths and injuries (2—5 million hospitalizations, over 100,000
deaths in 2005) makes it next in the list of silent epidemics. Behind these stark
figures lies human suffering.

Health systems are grappling with the effects of existing communicable and non-
communicable diseases and also with the increasing burden of emerging and re-
emerging diseases (drug-resistant TB, malaria, SARS, avian flu and the current
H1N1 pandemic). Inadequate financial resources for the health sector and
inefficient utilization result in inequalities in health. As issues such as Trade-
Related aspects of Intellectual Property Rights continue to be debated in
international forums, the health systems will face new pressures.

The causes of health inequalities lie in the social, economic and political
mechanisms that lead to social stratification according to income, education,
occupation, gender and race or ethnicity.[3] Lack of adequate progress on these
underlying social determinants of health has been acknowledged as a glaring
failure of public health.

In the era of globalization, numerous political, economic and social events

worldwide influence the food and fuel prices of all countries; we are yet to recover
from the far-reaching consequences of the global recession of 2008.

ADDRESSING PUBLIC HEALTH ISSUES – THE STRATEGY

AND STAKEHOLDERS
To meet the formidable challenges described earlier, there is an urgent call for
revitalizing primary health care based on the principles outlined at Alma-Ata in
1978: Universal access and coverage, equity, community participation in defining
and implementing health agendas and intersectoral approaches to health. These
principles remain valid, but must be reinterpreted in light of the dramatic changes
in the health field during the past 30 years. Attempts to achieve “Health For All”
have been carried forward in the form of “Millenium Development Goals.”

Public health is concerned with disease prevention and control at the population
level, through organized efforts and informed choices of society, organizations,
public and private communities and individuals. However, the role of government
is crucial for addressing these challenges and achieving health equity. The Ministry
of Health and Family Welfare (MOHFW) plays a key role in guiding India's public
health system.

Contribution to health of a population derives from systems outside the formal

health care system, and this potential of intersectoral contributions to the health of
communities is increasingly recognized worldwide. Thus, the role of government
in influencing population health is not limited within the health sector but also by
various sectors outside the health systems.

ROLE OF GOVERNMENT WITHIN THE HEALTH SECTOR

Important issues that the health systems must confront are lack of financial and
material resources, health workforce issues and the stewardship challenge of
implementing pro-equity health policies in a pluralistic environment.[5] 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.

HEALTH INFORMATION SYSTEM

The Integrated Disease Surveillance Project was set up to establish a dedicated

highway of information relating to disease occurrence required for prevention and
containment at the community level, but the slow pace of implementation is due to
poor efforts in involving critical actors outside the public sector. Health profiles
published by the government should be used to help communities prioritize their
health problems and to inform local decision making. Public health laboratories
have a good capacity to support the government's diagnostic and research activities
on health risks and threats, but are not being utilized efficiently. Mechanisms to
monitor epidemiological challenges like mental health, occupational health and
other environment risks are yet to be put in place.

HEALTH RESEARCH SYSTEM

There is a need for strengthening research infrastructure in the departments of

community medicine in various institutes and to foster their partnerships with state
health services.

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.

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 community-wide 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 grassroot level.

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.

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.

SCOPE FOR FURTHER ACTION IN THE HEALTH SECTOR

School health, mental health, referral system and urban health remain as weak
links in India's health system, despite featuring in the national health policy.
School health programs have become almost defunct because of administrative,
managerial and logistic problems. Mental health has remained elusive even after
implementing the National Mental Health Program.

On a positive note, innovative schemes through public-private partnerships are

being tried in various parts of the country in promoting referrals. Similarly, the
much awaited National Urban Health Mission might offer solutions with regards to
urban health.

ROLE OF GOVERNMENT IN ENABLING INTERSECTORAL

COORDINATION TOWARD 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 70-80% 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.[6]
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.[7] 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.

Education
Elementary education has received a major push through the Sarva Siksha
Abhayan. 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 mini-Anganwadi centers in deprived areas are examples
of inclusive growth under the eleventh 5-year plan. The government needs to
strengthen ICDS in poor-performing 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 iron-fortified salt to address
the burden of anemia).[8] 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.[7]

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, anti-
erosion 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 Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana 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 Janasankhya Sthiratha Kosh 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.[10]

Gender mainstreaming and empowerment

Women-specific 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.[7]

Reducing the impact of climate change and disasters on health

Thermal extremes and weather disasters, spread of vector-borne, food-borne and
water-borne infections, food security and malnutrition and air quality with
associated human health risks are the public health risks associated with climate
change. Depletion of non-renewable 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.[11] 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.[7]

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 Rogi Kalyan
Samitis. 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 community-based 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 (public-private 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.[7] 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.
Go to:

CONCLUSIONS
“The health of people is the foundation upon which all their happiness and all
their powers as a state depend”
– Benjamin Disraeli, British Prime Minister.
In this changing world, with unique challenges that threaten the health and well-
being of the population, it is imperative that the government and community
collectively rise to the occasion and face these challenges simultaneously,
inclusively and sustainably. Social determinants of health and economic issues
must be dealt with a consensus on ethical principles – universalism, justice,
dignity, security and human rights. This approach will be of valuable service to
humanity in realizing the dream of Right to Health. The ultimate yardstick for
success would be if every Indian, from a remote hamlet in Bihar to the city of
Mumbai, experiences the change.
It is true that a lot has been achieved in the past: The milestones in the history of
public health that have had a telling effect on millions of lives – launch of
Expanded Program of Immunisation in 1974, Primary Health Care enunciated at
Alma Ata in 1978, eradication of Smallpox in 1979, launch of polio eradication in
1988, FCTC ratification in 2004 and COTPA Act of 2005, to name a few. It was a
glorious past, but the future of a healthy India lies in mainstreaming the public
health agenda in the framework of sustainable development. The ultimate goal of
great nation would be one where the rural and urban divide has reduced to a thin
line, with adequate access to clean energy and safe water, where the best of health
care is available to all, where the governance is responsive, transparent and
corruption free, where poverty and illiteracy have been eradicated and crimes
against women and children are removed – a healthy nation that is one of the best
places to live in.
PRIVATE HEALTH

The health services planning in India is characterised by its failure to take into
account the holistic picture of the health care services. In the mixed economy
model the social sector is planned with a view to provide for the externality and to
redistribute the services in favour of the underprivileged masses. In the post
independence period the growth of the private health sector has been tremendous.
This is inspite of the fact that the First Five Year Plan has clearly set out the
purposed of planned development vis-à-vis the private sector. The distinction
between the public and the private sector is, it will be observed, one of relative
emphasis, private enterprise should have a public purpose and there is no such
thing under present conditions as completely unregulated and free enterprise.
Private enterprise functions within the conditions created largely by the State.
Apart from the general protection that the state gives by way of maintenance of
law and order and the preservation of sanctity of contracts, there are various
devices by which private enterprise derives support from the government through
general or special assistance by way of tariffs, fiscal concessions and other direct
assistance, the incidence of which is on the community at large. In fact, as the
experience of recent years has shown, major extension of private enterprise can be
rarely undertaken except through the assistance of the state in one form or another
(First Five Year Plan 1951-56, Planning Commission, GOI pg. 33). Over the
period this has not happened in the planning process simply because the planning
commission never had a holistic picture of the size, distribution and growth trends
in the health care services. India has probably the largest private health sector in
the world. Even in the USA about half the resources of the health sector are
provided by the public exchequer. Right through the Seven Five-Year Plan the
planners and policy makers have never discussed the private health sector, which
provides two-thirds of the health care in the country. Hence plans and policies are
bound to be limited in their impact. The private health sector consists of, on the
one hand, private general practitioners and consultants of different systems
(allopathy, Indian system and homeopathy) and a variety of non-qualified
practitioners and on the other hand hospitals, nursing homes, maternity homes,
special hospital etc. In the hospitals, nursing homes, maternity homes etc, the
private sectors share is a **** over half of all such facilities in the country. Besides
this there is the pharmaceutical and medical equipment manufacturing industry,
which is overwhelmingly private and pre-dominantly multi-national. There are also
laboratories, which carry tests right from blood testing to CAT scans. The share of
the private health sector is between 4% to 5% of the gross domestic product
(GDP). This share at today's prices works out to between Rs.16,000 Crores and
Rs.20,000 Crores per year. This paper deals with regulation that exists in the
private health sector. The implementation of the Bombay Nursing Homes
Regulating Act in Bombay as a case in point is discussed and subsequently issues
relating to a comprehensive regulation system for the private sector are thrown up
for debate. Let us make it clear in the beginning that privatization and
liberalization are not synonymous with lack of monitoring or of regulation. Even in
the USA with a 'free market' operating there are stringent regulations for medical
practice and running hospitals and nursing homes.

1. Existing Regulations The private health sector consisting of general

practitioners, nursing homes and hospitals involve two thirds of the
medical human power in the country. Despite this there is hardly any
regulation of the practice of this sector of health. This is indeed surprising
because such activity cannot be carried out without registration. The
medical professional has to be registered with the Medical Council which
us a statutory body that sets the standard of medical practice, 'disciplines'
the professionals, monitors their activities and checks any malpractice's
The doctors who decide to set up their own clinics as well as hospitals,
nursing homes, polyclinics etc., have to register with the respective local
body. The problem with the above is that the controlling bodies are
virtually non-functioning. The reason for this is not only lack of interest
but also weak provisions in the various acts. They are also heavily
influenced by the private health sector. Another agent in the private health
sector which needs to be regulated further is the pharmaceutical industry.
As a chemical industry this agent is regulated to some extent but as a
participant in the health sector it operates virtually unregulated. Whereas
the public health sector due to bureaucratic procedures is forced to
maintain at least some minimum requirements (e.g. they will not employ
nonqualified technical staff, follow certain set procedures of use of
equipment or purchase of stores etc) and is subject to public audit, the
private health sector operates without any significant controls and
restrictions. As per existing law the health sector has provision for
regulation under three different authorities.
2. The Medical council: The Medical Council of India and the respective
state Councils have to regulate medical education and professional
practice. Presently beyond providing recognition to medical colleges the
Medical council does not concern itself with the practitioner, unless some
complaint is made and a prima facie case established. Even the list of
registered practitioners is not updated properly by the Medical Councils.
The national body at present concerns itself with only recognizing and de-
recognizing medical colleges whereas the State bodies function only as
registers for issuing a license for practicing medicine. ( The state Councils
 also facilitate recognition of private medical colleges which the National
Council has de-recognized!).
3. The Local Bodies (Muncipalities, Zilla Parishads, Panchayat Samitis etc.)
have the authority to provide a license to set up a nursing home or hospital
and regulate its functions. However, besides providing the certificate to set
up a hospital or nursing home the local bodies do not perform any other
function, inspite of provision in the Act.
4. The Food and Drug administration (FDA) has the jurisdiction to control
and regulate the manufacture, trading sale of all pharmaceutical products.
This is one authority which ahas been provided some teeth by the law. But
its performance is most embarrassing. It is ridden with corruption. Inspite
of the ridicule it faced as a result of the Lentin commission inquiry its
behaviour remains more or less unchanged. Given this state of affairs the
people of the country are left entirely to the whirns of the goodness of
doctors. With highly commercialized medical practice the latter is very rare
today. In view of the existing health situation and health practices,
regulation of those who provide health care is an urgent necessity.
Regulation exists in other sectors so why not in health? Hence there is an
urgent need for strong measures to control and regulate the private health
sector.

What should a comprehensive legislation seeking regulation include?

The following suggestions on regulation encompass the entire health sector.

However, they are not an exhaustive list but only some major important areas
needing regulation.

(a) Nursing Hoes and Hospitals

 Setting up minimum decent standards and requirements for each type of
unit; general specifications for general hospitals and nursing homes and
special requirements for specialists care, example: maternity homes,
cardiac units, intensive care units etc. This should include physical
standards of space requirements and hygiene, equipment requirements,
human power requirements (adequate nurse: doctor: bed ratios) and
their proper qualifications etc.

 Maintenance of proper medical and other records which should be

made available statutorily to patients and on demand to inspecting
authorities
 Fixing reasonable and standard hospital and professional charges.
 Filing of minimum data returns to the appropriate authorities e.g. data
on notifiable diseases details death and birth record, patient and
treatment data etc.
 Regular medical and prescription audits which must be reported to the
appropriate authority.
 Regular inspection of the facility by the appropriate authority with
stringent provisions for flouting norms and requirements.
 Periodic renewal of registration after a through audit of the facility