Textbook of Community Medicine Preventive and Social Medicine, 8e [Eight Edition] 9789354667237

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Eighth Edition

Textbook of

Community Medicine Preventive and Social Medicine As per the latest CBME Guidelines |Competency Based Undergraduate Curriculum for the Indian Medical Graduate adopted by National Medical Commission

Key Features of Eighth Edition Unique features: The eighth edition is in line with the competency-based undergraduate curriculum for the Indian Medical Graduate mandated by National Medical Commission. It has revised/updated 20 Chapters, addresses 107 core competencies with special emphasis on 18 skill-based competencies. In addition, this edition incorporates Attitude, Ethics, and Communication (AETCOM) skills (soft skills) to be integrated into UGs curriculum. Methods of acquisition of these skills have been indicated. The revised chapters on concept of health and disease, ethics in medicine and doctor–patient relationship, social and behavioural sciences (humanities), principles of health promotion and education, counselling and social marketing, healthcare of community and community diagnosis, gender issues and women empowerment, healthcare delivery systems, health planning and management, laws pertaining to practice of medicine focus on: ‘Real-life issues’ as illustrated in problem-based learning, various case studies focus on building communication skills, eliciting healthcare seeking behaviours, barriers in healthcare, doctor–patient and community relationship, communication need assessment of community, comprehensive community diagnosis, therapy and prognosis, role of physician in healthcare system and responsibility to society and community, working in a healthcare team as leader and member of health team, health legislations pertaining to practice of medicine in outbreak and pandemic situation. All these chapters focus on ‘community as patient’, community diagnosis and community therapy. Whole of the Government and whole of the society approach, leaving no one behind is the emphasis in all the revised chapters. Feedback and comments received from learned and experienced teachers, like Director-Professor Dr DK Taneja, Late Prof AK Sharma, Late Prof RK Sachar, Director-Professor Suneela Garg, Prof Lahiri, Prof Dominic Misquich, Prof Dara S Amar, Prof MK Sudershan, Prof Rajesh Kumar, Prof Sandeep Kumar Ray, Prof SC Mohapatra, and Dr Madhumita, have been included in appropriate chapters to make the book more comprehensive and learner-friendly. Part I Part I of this comprehensive textbook on community medicine covers: Basic sciences related to the discipline of community medicine—application of social and behavioural sciences, clinico-social case review, pedagogy, group dynamics, behaviour change communication, counselling in health and disease, health economics, demography and population sciences, applied nutrition, environmental health, epidemiology and its application, and applied biostatistics, research methodology and ethics in medicine medical entomology and medical genetics. The subject of epidemiology is covered in chapters on epidemiology and its application in epidemiology of CCDs and NCDs and research methodology, applied statistics and national health programmes, planning, monitoring and evaluation of health systems. The reproductive and child health, policy and programmes in India has been intentionally linked with demography and population problem and included in this part for the purpose of continuity and sequential learning. Generally, part I conforms to the Paper 1 in theory, excluding maternal and child health. However, demarcation of theory Paper 1 and Paper 2 varies from university-to-university but generally it covers the above mentioned areas. Part II Part II of the text covers epidemiology of communicable and non-communicable diseases, national health programmes, health management—healthcare delivery systems, health management functions—planning, monitoring and evaluation of services/ programmes, healthcare financing and hospital statistics. It also incorporates occupational health, geriatrics, disaster management, hospital waste management and international health regulations apart from international statistical classification of diseases and related health problems (ICD-11). These areas generally form the contents of theory Paper 2 of community medicine which also includes reproductive, maternal and child health but may differ from university-to-university.

Eighth Edition

Textbook of

Community Medicine Preventive and Social Medicine As per the latest CBME Guidelines |Competency Based Undergraduate Curriculum for the Indian Medical Graduate adopted by National Medical Commission

Dr (Brig) Sunder Lal MBBS, DPH, MD Former Professor and Head, Department of Social and Preventive Medicine Pt BD Sharma Postgraduate Institute of Medical Sciences, Rohtak and AIMSR, Bathinda (Punjab) Professor, Community Medicine, MM University—Mullana (Ambala) Deputy Director-General, TA (Medical) Chairman, Board of Studies of Medicine and Allied Sciences, MDU, Rohtak Member, National Commission on Population, GoI; Consultant, ICDS Member, National Technical Advisory Group on Immunization and Child Health Member, Technical Resource Group on Women, Children and ICDS NSS Programme Officer Honorary Professor, IMACGP and President of IAPSM

Adarsh MBBS Former Senior Medical Officer, HCMS (I) Medical Officer-incharge, Postpartum Centre, PGIMS, Rohtak Medical Officer-incharge, Urban Family Welfare Centre, Rohtak Urban Health Centre attached with PGIMS, Rohtak

Pankaj MDS Ex-Professor, Department of Public Health Dentistry Rajasthan Dental College, Jaipur (Rajasthan)

CBS Publishers & Distributors Pvt Ltd New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Lucknow • Mumbai Hyderabad

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Disclaimer Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies.

eISBN: 978-93-546-6723-7 Copyright © Authors and Publisher Eight eBook Edition: 2024

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Representatives Hyderabad Pune Nagpur Manipal Vijayawada Patna

Foreword

I

t is a matter of great privilege for me to write the Foreword to the eighth edition of Textbook of Community Medicine by Prof (Dr) Sunder Lal, Dr Adarsh and Dr Pankaj. It is a unique book that not only imparts theoretical concepts but also lays strong emphasis on the applied and practical aspects of the preventive concepts and their practical applications. The book fulfils the tenets of Miller’s pyramid in developing competence in community medicine in terms of knows, knows how, shows, shows how, and does. While being precise, the book has not compromised on the essential information. The book has received immense popularity of earlier editions, especially amongst students of community medicine, the everchanging public health scenario in the country has made it necessary to revise and update the earlier edition to suit the present-day requirements. Authors have incorporated all the recent developments in the field of community medicine. They have been successful in presenting the information in a lucid and engaging manner. The authors have also adhered to the current global trends in medical education of integration of clinical disciplines with the preventive medicine with focus on the integrated information on different domains of primary healthcare. This will provide proper perspective to the reader of the book. This apart, the eighth edition integrates Attitude, Ethics and Communication (AETCOM) competencies with existing community-based curriculum of undergraduates (UGs). I hope this book will be of a great interest and be equally useful to students and professionals of community medicine and public health. I am quite confident that this book will be widely referred to and most importantly facilitate academic brilliance with social relevance. I congratulate the authors for bringing out the eighth edition of Textbook of Community Medicine. I am confident and hope that like the earlier editions, this edition will also be a great success.

Dr Chandrakant S Pandav MBBS, MD, MSc, FAMS, FIAPH, FIAPH, FIAPSM • • • •

President, Indian Coalition for Control of Iodine Deficiency Disorders (ICCIDD), India Former Professor and Head, Centre for Community Medicine, AIIMS, New Delhi World Health Organization (WHO), Public Health Champion, 2017 Padmashri Awardee-2021

Book Review Dr. Sushila Nayar School of Public Health Incorporating Department of Community Medicine Mahatma Gandhi Institute of Medical Sciences Sewagram 442 102 Wardha District, Maharashtra, India Phone: (91) 7152-284341 to 284355

T

he eight edition of the Textbook of Community Medicine authored by Dr Sunder Lal, Adarsh and Pankaj, published by CBS Publishers & Distributors Pvt Ltd., Delhi, is a very interesting texbook for undergraduate students and it is as per latest competency-based curriculum and regulations by National Medical Commission. It has 20 chapters, 812 pages with affordable price. This book has covered the desired competencies in chapters wherever it is appropriate which will be very useful for undergraduate students to get an idea about learning objectives. However, in certain competencies related to epidemiology and biostatistics, having some more real-life examples would have been more impactful. Prof Sunder Lal, main author of the book, has vast experience in the field of community medicine and contributed significantly to the promotion of speciality specially in the field of RMNCH, epidemiology and, healthcare planning and management. The book is the reflection of his vast experience in the form of various chapters. The book has been divided in two parts. The part I has basic sciences related to community medicine while part II has covered applied sciences related to community medicine making it easier to understand and develop linkage between basic and applied aspects. In part I, all important aspects of community medicine like basic understanding of concepts, environment, health promotion, nutrition, epidemiology, biostatistics, demography, hospital waste management and medical genetics are covered. It also includes a chapter on RMNCH + A which relates to part II, since it is linked with demography and population problems, for this reason covered in part I to maintain continuity. In part II, epidemiology of communicable and non-communicable diseases along with national programmes have been covered in detail and it will act as a reference to both undergraduate and postgraduate students. The healthcare of the community as well as health planning and management and international health have been described keeping in view the various developments in the country like National Health Mission, Ayushman Bharat and international health regulations. The natural disasters have increased in the country and book has included a chapter on that. The health of the elderly, workforce and mental challenges have also been described in detail and included their national and global relevance.

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Textbook of Community Medicine

I would like to congratulate the authors for inclusion of a chapter on recent advances in community medicine which incorporates various Public Health Acts pertaining to practice of medicine as well as Covid pandemic. The format of the chapters is very well prepared; especially presenting important factors in tabular format is very appealing. The language of the text is very easy to understand for the target audience and the flow of the information is logically sequenced. This book covers all important aspects of public health which are mentioned in the revised undergraduate curriculum. However, a chapter on health inequity would have been added to sensitize undergraduate students on important aspects of public health. Similarly, further details on the concept of health financing, in various country examples with different models of health insurance could have been added. This textbook will definitely help undergraduate students to get an overall idea of various important concepts of community medicine, competencies related to it and practical aspects of community medicine.

BS Garg

ix

Preface to the Eighth Edition

A

lot has changed since the seventh edition of Textbook of Community Medicine published in 2022. Many of new initiativies, programmes and national guidelines have come up. The introduction of comprehansive primary healthcare through upgraded sub-health centres and PHCs (now known as health and wellness centres) and similarly in urban areas urban health and wellness centres, speciality UPHCs (polyclinics) and block public health units are some of the new additions in eighth edition. This has changed the landscape dramatically. To keep the book relevant to the newer developments the eighth edition has incorporated: Revised public health standards of 2022, revised health management information system version 2.0, revised mother and child protection card with red flag signs on development, National Family Health Survey-5, special bulletin on maternal mortality 2018–20, national guidelines on rabies prophylaxis 2019, integrated RCH register version 2.0 of 2022, HIV estimates in India-2021, WHO air quality guideline values of 2021, global hunger index, UNDPhuman development index of 2021, National TB Survey of India 2019–21, National Immunization Schedule of 2022, introduction of qHPV for cervical cancer elimination, midwifery initiative of Govt of India—nurse practitioner, SAANS, SUMAN, MusQan, Rural Health Statistics 2022, National Health Accounts 2018–19. Kartz index of daily living of activities , India hypertension control initiative second phase 2019, A-BHIM, PM Atmanirbhar Swasth Bharat, International Year of Millets, introduction of WHO weight for height charts, India’s demographic profile, how to build skill pyramid of core competencies in the new curriculum of UGs and how to integrate the AETCOM into competency based curriculum in different phases,‘one health one planet’, besides updating of all the national health programmes and progress of SDGs of United Nations, global current situation of Covid-19 and situation in India. Further it incorporates Medical Termination of Pregnancy Act-revised in 2021, ECD for 1000 days, essential medicine list of 2020 for HWC, new threats to human security in the anthropocene 2022, Global TB Report 2022, status of National AIDS Response 3rd ed 2021, Guidelines for programmatic management of TPT in India, July 2021, Guidelines in programmatic Management of Drug Resistant TB in India-2019, causes of death statistics 2015–2017, vital statistics in India based on the Civil Registration System 2020, electronic nicotine delivery system (ENDS) and WHO stand on typhoid vaccines, monkeypox disease—A-PHE IC and various recent advances in public health. Part I covers basic sciences relevant to the subject of community medicine. It covers Chapters 1 to 7 and 9 and forms part of theory paper one. Part II covers applied sciences relevant to the subject of community medicine. It covers Chapters 8 and 10 to 20 and forms part of theory paper two in general with some unavoidable overlaps. Various case studies in almost all chapters enriches the learning of various competencies in live situations. Sunder Lal Adarsh Pankaj

Preface to the First Edition

T

o write quality textbook on community medicine (preventive and social medicine) is a challenging task, however, this challenge was accepted by the authors. Departure has been made from conventional textbooks to accommodate the requirements of Medical Council of India as also to incorporate newer challenges, hitherto not attempted by most textbooks available in the market. The authors have incorporated the most recent advances in the field of community medicine besides the practical field experiences in the form of case studies. Field experiences/observations cannot be substituted by any textbook material; the authors have made a bold and conscious attempt to bring back live situations and field experiences into the textbook, which is the unique feature of this book. Another unique feature is to restrict to the specific areas of concern to public health (epidemiology, application of biostatistics, health management, communication and biosocial and sciences of humanity) to avoid duplication of areas/concerns of other specialities. The sequencing of chapters is purposeful to highlight the priority health problems and concerns of community medicine (preventive and social medicine). Hopefully, the textbook will meet the needs of health managers and decision-makers at various levels besides the teachers of community medicine, postgraduate students and predominantly the undergraduates (MBBS and BDS students), and teachers of community medicine, graduate nurses, general nursing students in the discipline of community medicine. It would indeed be a pleasure to get positive as well as negative feedback from the readers to effect improvement in future editions of the book. Sunder Lal Adarsh Pankaj

Acknowledgements

T

he support, guidance, encouragement and material help received from learned colleagues and friends like Late Prof AK Sharma of LHMC, New Delhi; Prof Rajesh Kumar, PGI, Chandigarh; Dr DK Taneja, Professor, MAMC, New Delhi; Late Prof RK Sachar, DMC, Ludhiana; Prof AS Sekhon, Head, Department of Community Medicine, Government Medical College, Patiala; Prof AS Wantamutte, Head, Department of Community Medicine, JLNMC, Belgaum (Karnataka); Prof Sandip Kumar Ray, KPC Medical College and Hospital, Jadavpur, Kolkata; Dr SC Mohapatra, Professor, Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi (UP) and Dr Madhumita, Associate Professor, Community Medicine, Government Medical College, Patna, are sincerely acknowledged. The authors owe deep sense of gratitude to World Health Organization which has kindly permitted us to use the valuable published material, and to UNICEF, NCDC-DGHS, MoHFW, New Delhi, ICMR, PHFI, and IHME, whose published material was used extensively to enrich the contents of the book for dissemination of scientific information to the teachers and the students. Help received from Dr Kuldip, Civil Surgeon, Yamuna Nagar; Dr Manish Goyal, Associate Professor, LHMC, New Delhi and Dr Shankar Prinja, Additional Professor, PGI, Chandigarh, is sincerely acknowledged. Sunder Lal Adarsh Pankaj

Contents Foreword by Chandrakant S Pandav

v

Book Review by BS Garg

vii

Preface to the Eighth Edition

ix

Preface to the First Edition

xi

Index of Competencies

xxv

Abbreviations

xxix

Part I Basic Sciences Related to Community Medicine (Topics 1 to 7 and 9) 1.

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship Competency-based Learning in Community Medicine 1 Pedagogy and Problem-based Learning 2 A case Study on Clinico-social Case Review 4 Concept of Health and Holistic Health 4 Dimensions of Health—Physical, Mental, Social and Spiritual Health 5, 6 Concept of Public Health 7 Relativeness of Health 7 Determinants of Health 8 Social Determinants of Health, VHSNC and Convergent Action on Social Determinants of Health 11 Characteristics of Agent, Host and Environmental Factors in Health and Disease and Multifactorial Etilogy of Disease 12 Natural History of Disease 12 Application of Interventions at Various Levels of Prevention 12 Levels of prevention 13 Concept of Health Promotion and Education, IEC and BCC 15 Health Indicators 17 Human Development Index 18 Demographic Profile of India and its Impact on Health 21 Role of Effective Communication Skills in Health and Disease 22 Doctor–Patient Relationship 24 Ethics in Medicine (Moral Principles) 25 Consumer Protection Act (CPA) 26 Clinical Establishment Act, 2010 26 Hippocratic Oath 26 World Medical Association Declaration of Geneva—“The Physician’s Pledge” 26 Nuremberg Code of Ethics in Medical Research 27 Declaration of Helsinki 27 Euthanasia 28 Duties of Physicians to their Patients 29 Major Health Problems in India 33 Principles and Practice of Medicine in Hospital and Community 33

1–34

xiv 2.

Textbook of Community Medicine

Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease

35–59

Historical Development of Medicine and Social Sciences, from Symptoms to Universal Health Coverage 35 Concept of Rural, Urban and Tribal Communities 35–37 Community Participation in Health Management and Development 37 Types of Family and its Role in Health and Disease 38 Steps in Assessment of Clinico-social Cultural and Demographic Profile of Individual, Family and Community 41 Correct Methods of Assessment of Socio-economic Status (SES) of Individual and Family 43 Socio-economic and Caste Census (SECC) 44 Family Medicine 46 Family-retained Household Records (Mother and Child Protection Card) 46 Family Adoption Programme and Yoga Meditation 47 Social and Cultural Factors in Health, Disease and Disability 50 Socio-cultural Factors with Social Problems and their Behavioural Components 51 Social Phychology and Community Behaviour 51 Community Relationship and its Impact on Health and Disease 52 Barriers to Good Health and Health-seeking Behaviour 53 Poverty and Social Security Measures and its Relationship to Health and Disease 54 Principles of Health Economics 55

3.

Environmental Health Problems

60–111

Concept of Safe and Wholesome Water 60 Water Requirement Norms for Rural Areas 61 Norms of Water Supply for Urban Areas 61 Sanitary Sources of Water 61 Health Hazards of Water Pollution 63 Aetiology and Basis of Waterborne Diseases (Jaundice, Hepatitis and Diarrhoeal Diseases) 63 Water Purification Processes 63 Case Studies on Drinking Water, Chlorination, Storage Practices 68 Water Quality Standards 69 Arsenic Contamination 71 Endemic Fluorosis 71 National Programme for Prevention and Control of Fluorosis 73 Concept of Water Conservation and Rainwater Harvesting 74 National Rural Drinking Water Supply and Sanitation Programme 75 Urban Water Supply System 76 Standards of Housing and Effect of Housing on Health 77 Solid Waste, Human Excreta and Sewage Disposal (Borehole, Pit and VIP Latrines) 78 Social Factors Related to Excreta Dispossal—“Easing for Diseases”: A Case Study 79 Safe Dispossal of Human Excreta in Rural Areas 80 Case Study of a Dug Well Latrine 81 Composting, Gobar Gas Plant and TSC 82 Total Sanitation Campaign/Swachh Bharat Abhiyan 82, 83 Urban Sanitation 83 Health Hazards of Soil Pollution 85 Health Hazards of Air Pollution 87 Health Hazards of Noise Pollution 93 Role of Vectors in Transmission of Diseases and Integrated Vector Managment 94 Identification of Features and Life Cycle of Vectors of Public Health Importance and their Control Measures Commonly Used Rodenticides, their Mode of Action and Applications 108 National Vector-borne Disease Control Programme (NVBDCP) 110

4.

Principles of Health Promotion and Education Health Education—Definition and Aim 112 Behaviour Change Communication 113 Health Information to People—Information for all 114 Information Revolution 114 Various Methods of Health Promotion/Education their Merits and Demerits 115 Effects of Communication 117 Methods of Organizing Health Promotion, Education at Individual, Family and Community Settings 118

95

112–131

Contents

xv

Communication Skills in Health 119 Case study in Communication 121 Steps in Planning, Organizing, Implementation and Evaluation of Health Communication/Education Programme 121 Steps in Evaluation 122 National Communication Strategy in RCH 124 Counselling in Health and Disease 124 GATHER Approach to Counselling about IUDs 126 Social Marketing Programme in Health and Family Welfare—An Education Method 130

5.

Nutrition Global Targets on Nutrition 132 Sustainable Development Goals for Nutrition 132 Major Nutrition-related Public Health Problems 133 Common Sources of Various Nutrients and Recommended Dietary Allowances According to Age, Sex, Activity and Physiological Conditions 133–137 Dietary Fibre 134 Visible and invisible fats 139 Trans Fats (Hidden Fat) 140 Characteristic of an Average Indian Diet 140 Planning and Recommending Suitable Diet for Individual and Family Based on Local Availability of Foods and Economic Conditions 141 Balanced Diet for Moderately Active Man 141 Common Dietary Beliefs and Practices in Infants, Young Children, Pregnant and Lactating Mothers—A Case Study 143 Undernutrition during Infancy and its Prevention 144 Exclusive Breastfeeding 145 Ten Steps to Successful Breastfeeding (WHO, UNICEF and Baby Friendly Hospital Initiative) 146 Infant Milk Substitutes Act, 2000 and 2016 146 National Guidelines on Promotion of Infant and Young Child Feeding 148 Common Nutrition-related Health Disorders 148 Macronutrient Deficiency Disorders or Protein Energy Malnutrition (PEM) 148 Correct Methods of Performing a Nutritional Assessment of Individuals, Families and Community Prevention, Control and Management of PEM 152 Nutrition Rehabilitation Centres and Sneha Shivirs 153 Principles of Nutrition Education 155 Growth Monitoring (A Preventive Strategy) and Nutrition Surveillance 156 Methods of Nutritional Surveillance 163 Micronutrient Deficiency Disorders 166 Nutritional Anaemia 166 National Nutritional Anaemia Control Programme 169 National Iron Plus Initiative 169 Anaemia Mukt Bharat 170 Vitamin A Deficiency (VAD) 170 National Programme for VAD 172 Iodine Deficiency Disorders 174 National IDD Control Programme 176 Zinc Nutrition 179 Dietary (Food Consumption) Surveys 180 National Nutritional Programmes 183 National Nutrition Policy 185 National Nutrition Mission 2018 187 Prevention of Food Adulteration Act 188 The Food Safety and Standards Act 188 National Survey on Milk Adulteration 189 Food Fortification 190 Neurolathyrism 191 Epidemic Dropsy 191 Food Hygiene and Food Poisoning 191 Genetically Modified Crops 193 ICDS (Integrated Child Development Services) Mission 193

132–199

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Textbook of Community Medicine

xvi 6.

Basic Statistics and its Applications and Research Methodology Variables and Scales of Measurements 200 Classification or Types of Statistical Data 201 Sources of Health Data 202 Methods of Data Collection 203 Data Analysis and interpretation 203 Presentation of Statistical Data—Visibility of Data 204 Application of Simple Elementary Statistical Methods 207 Summarization of Data, or Data Reduction (Measures of Central Tendency) 208 Frequency Distribution or Counts 211 Normal Distribution and Normal Curve 213 Measures of Variability (Dispersion) 213 Common Probability Sampling Techniques 217 Confidence Interval 222 Probability 223 Tests of Significance in Various Studies 225 Life Table Method of Analysis 232 Research Methodology 234 Research: Fundamental and Basic, Applied, Action-oriented and Operational Research Focus Group Discussions 239 Framing a Research Question for a Study 239

7.

Epidemiology

200–241

234

242–306

Principles, Concepts and uses of Epidemiology 242 Definition 242 Sources of Epidemiological Data 243 Epidemiology of Communicable Diseases (CCDs) 243 Changing Pattern of Infectious/Communicable Diseases in India 244 Emerging and Re-emerging Infectious Diseases and Neglected Tropical Diseases 244 Modes of Transmission 245 Levels of Disease Occurence 251 Prevention and Control of Communicable Diseases 253 Notification of Diseases 255 Epidemiology of Non-communicable Diseases (NCDs) 255 Prevention and Control of NCDs 256 Measuring Disease and Death Frequency 256 Measuring the Burden of Disease 256 Defining, Calculating and Interpreting Morbidity Indicators 257 Defining, Calculating and Interpreting Mortality Indicators 260 Million Death Study (Causes of Death Statistics) 263 Disability: Measurement 263 Common Impairments 264 Risk Measurement in Epidemiology 265 Need and Evaluation of Screening Tests 267 Principles of Public Health Surveillance 270 Integrated Disease Surveillance Programme 275 Analysis and Interpretation of Data by TPP 277 Principles and Measures to Control an Epidemic 279 Surveillance of Risk Factors of Non-communicable Diseases 280 WHO Stepwise Approach for Surveillance of Risk Factors in NCDs 280 Steps in the Investigation of an Epidemic of CCD—Jaundice and Principles of Control Measures 281 Epidemiological Study Designs 285 Observational Studies 285 Descriptive Studies 285 Analytical Studies 289 Ecological Studies 289 Cross-sectional Studies 290 Case Control Studies 290 Cohort Studies 292

Contents Experimental Studies 294 Randomized Controlled Trials (RCTs) 295 Field Trials 298 Community Trials 299 Principles of Causation and Association in Epidemiological Studies Biases in Epidemiological Studies 302 Applications of Computers in Epidemiology/Health Sciences 303 Epidemiological Basis of National Health Programmes 303 List of 20 Notifiable CCDs 305 List of National Health Programmes 305

8.

xvii

299

Epidemiology of Communicable and Non-Communicable Diseases and Related Disease Specific National Health Programmes (Part of Applied Sciences Part II)

307–507

Principles of Planning, Implementation and Evaluating Control Measures of a Disease at Community Level 307 Natural History of HIV/AIDS—Window Period 310 Epidemiology of HIV/AIDS Epidemic 310 Prevalence and Burden of HIV Epidemic in India—Current Status of Epidemic 311 National Surveillance Systems in HIV, Viral Hepatitis B and C 2023 314 National Biennial HIV Sentinel Surveillance (HSS) Plus in India 314 National Integrated Bio-behavioural Surveillance (IBBS) Model 314 National AIDS Control Programme (NACP) 315 National Strategic Plan and Mission Sampark 2017–24 for HIV/AIDS (NACP) 315 Female Sex Work Patterns—A Case Study 319 Reproductive Tract Infections/Sexually Transmitted Infections 319 Syndromic Case Management of STI/RTI 321 National Guidelines on Prevention, Management and Control of RTIs/STIs 2014 322 National Strategic Plan for STI/RTI 2017–24 Vision 324 Epidemic of Tuberculosis in India 324 Epidemiology and Natural History of Tuberculosis 324 National TB Prevalence Survey in India 2019–21 325 Burden of TB Disease in India (2021) 325 National Tuberculosis Control Programme (NTCP) 1962 327 Revised National Tuberculosis Control Programme (RNTCP) 1992 Renamed as National TB Elimination Programme 327 National Strategic Plan (NSP) 2017–25 327 National Policy for Diagnosis of TB 328 Integrated DR–TB Diagnostic and Resistant TB Algorithm 330 Drug Regimen for Treatment—Daily Regimen 331 Programmatic Management of Drug Resistant TB (PMDT)—Erstwhile Dots Plus 331 Magnitude of DR-TB in India 331 All Oral H Mono/Poly DR-TB Regimen 332 Shorter MDR-TB Regimen from April 2018 332 All Oral Longer MDR-TB Regimen 333 New Initiatives and Policy Changes from 2020–22 333 Guidelines for Tuberculosis Preventive Treatment (TPT) 334 Leprosy 335 Epidemiology 335 National Leprosy Eradication Programme (NLEP) 338 Primary Prevention of Leprosy among Contacts 340 Vector-borne Diseases 340 National Vector-borne Disease Control Programme (NVBDCP) 340 Malaria 341 Epidemiology of Malaria 341 National Malaria Control Programme in India 343 National Framework for Malaria Elimination in India 344 Strategic Approaches 347 Early Diagnosis by Epidemiological Surveillance and Case Management in Malaria 345 Case-based and Focus-based Surveillance in Category 1 346 National Drug Policy on Malaria (2013) 347 Drug Schedule for Treatment of P. vivax and P. falciparum Malaria 348 Integrated Vector Management (IVM) 350 Monitoring and Evaluation in Malaria 354

xviii

Textbook of Community Medicine Urban Vector-borne Disease Scheme (Urban Malaria Scheme) 355 Programme Planning and Management 356 Lymphatic Filariasis 356 Epidemiology 356 National Filaria Elimination Programme 358 New Initiatives—Tripple Drug (IADC) 360 Kala-azar (VL) Epidemiology 360 National Kala-azar Elimination Programme 361 Dengue Fever/Dengue Haemorrhagic Fever 362 Epidemiology 362 National Mid-term Plan for Prevention and Control of Dengue and Chikungunya (2011–13) and Beyond Dengue Case Classification and Management Clinical Criteria for DF/DHF/DSS 364 Entomological Surveillance and Larval Indices 364 Chikungunya Fever 366 Japanese Encephalitis (JE)—Acute Encephalitis Syndrome 367 Epidemiology 367 National Programme for Prevention and Control of JE/AES 368 Kyasanur Forest Disease 370 Epidemiology 370 Yellow Fever 370 Waterborne Diseases (WBD) 372 Epidemiology of Diarrhoeal Diseases 372 Classification of Diarrhoea 373 Oral Rehydration Salt (ORS): Reduced Osmolarity ORS 373 Classification of Dehydration 374 Management of Dehydration 374 Prevention of Acute Diarrhoeal Diseases 376 Rotavirus Vaccine in Prevention of Diarrhoea 376 National Diarrhoeal Diseases Control Programme 376 Intensified Diarrhoea Control Fortnights (IDCF) from 2014–22 377 Cholera 377 Epidemiology of Cholera 377 Methods of Prevention and Control of Cholera 378 Epidemic Disease Act, 1897 379 Management of Outbreaks of Cholera 379 Ending Cholera—A Global Roadmap to 2030 380 Use of Oral Vaccine in Cholera Outbreaks 380 Viral Hepatitis 381 Hepatitis A 381 Epidemiology 381 Hepatitis E 382 Epidemiology 382 Hepatitis B—A Silent Killer 383 Epidemiology 383 Prevention of Perinatal HBV Transmission 384 Hepatitis C—the Silent Killer 385 Epidemiology 385 National Viral Hepatitis Control Programme 386 Guinea Worm Disease (Eradicated from India) 387 Enteric Fevers—Neglected Tropical Disease 388 Epidemiology 388 Policy Guidelines on Typhoid Immunization in India 391 WHO Recommended Typhoid Vaccines 391 Newer Vaccines Against Typhoid 391 Zoonotic Diseases 392 Rabies 392 Epidemiology of Rabies 392 Revised National Guidelines on Rabies Prophylaxis (2019) 393 National Rabies Control Programme (NRCP) 398 National Programme for Control of Rabies in Dogs 399 Plague 399

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Contents

xix

Epidemiology 399 Brucellosis—Neglected Tropical Disease 403 Epidemiology, Prevention and Control 403 Hydatid Disease—a Neglected Tropical Disease 404 Taeniasis and Cysticercosis—Neglected Tropical Diseases 405 Epidemiology, Prevention and Control 405 Toxoplasmosis: Epidemiology, Transmission, Prevention and Control 405 Leptospirosis 406 Programme for Prevention and Control of Leptospirosis—National Guidelines 2015 406 Anthrax: Epidemiology, Prevention and Control 408, 409 Q-Fever 409 Mad Cow Disease and Creutzfeldt-Jakob Disease (CJD) 410 Epidemiology of Vaccine Preventable Diseases 411 Measles 411 Epidemiology 411 Measles Mortality Reduction—India's Multi-year Strategic Plan 2010–2017 414 Measles Rubella Campaign in 2017 414 Rubella and Congenital Rubella Syndrome 415 Road Map to Measles and Rubella Elimination in India by 2023 415 Mumps 416 Chickenpox (Varicella) 416 Pertussis (Whooping Cough): Epidemiology and Prevention 416 Tetanus: Epidemiology and Prevention 417 Maternal and Neonatal Tetanus Eliminated 418 Diphtheria (A Re-emerging Threat) 419 Tuberculosis: Epidemiology and Prevention 420 Epidemiology of Poliomyelitis 420 National Polio Eradication Programme and Key Strategies of National Polio Eradication Programme 421 The Polio Eradication Endgame Strategy 2013–18: Three Steps 423 Introduction of Inactivated Polio Vaccine (IPV) 424 Withdrawal of Type 2 Component of OPV: Switch from Trivalent OPV to Bivalent OPV 424 Endgame Strategy 424 Acute Respiratory Infections (ARIs) 425 Epidemiology of ARI 425 National Policy on ARI Control 426 Meningococcal Disease 430 Epidemiology 430 Managing Patients with MD and Control of Epidemics 432, 433 Yaws and its Eradication Programme (YEP) 433 Severe Acute Respiratory Syndrome (SARS) 435 Influenza 437 Avian Influenza and Human Health (New Threat) 438 Pandemic Influenza A (H1N1) 2009 (Swineflu) 440 Middle East Respiratory Syndrome (Coronavirus) 443 Ebolavirus Disease (EVD) 443 NIPAH: Epidemiology and Prevention 444 Zika Virus Infection/Disease and its Prevention 444 Monkeypox—Declared by WHO as PHEIC 445 Epidemiology of Non-communicable Diseases and Related Disease Specific National-Health Programmes 446 A Case Study on Unhealthy Life Styles 446 Epidemiology of Cardiovascular Diseases (CVDs) (Unhealthy Lifestyle Diseases) 446 Disease Burden 446 Natural History and Levels of Prevention of CVDs 447 Modifiable Risk Ractors of CVDs 449 Surveillance of Risk Factos 452 Obesity (an Epidemic in India) 452 Epidemiology 452 Measuring Obesity 452 Consequences of Obesity 454 Prevention and Control of Obesity 454 Diabetes 455

xx

Textbook of Community Medicine Epidemiology 455 Criteria for the Diagnosis of Diabetes Mellitus 456 Types of Diabetes 456 Prevention of Diabetes 458 Screening Programmes for Diabetes 459 Hypertension (a Silent Killer) 460 Epidemiology of Hypertension 460 Rules of Halves in Hypertension 460 What Constitutes Hypertension 460 Prevention of Hypertension 462 Rheumatic Heart Disease (RHD) 463 Epidemiology of RHD 463 Prevention of Rheumatic Fever and RHD 464 National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Strokes (NPCDCS) 467 Disease Burden due to NCDs in India 467 Components of NPCDCS 468 Levels of Prevention in NCDs 469 Primordial Prevention in NCDs 469 Population-based Screening for NCDs 471 Cancer—Screening of Common Cancers and Referral 472 Package of Services for NCDs 475 New Initiatives for Control and Prevention of NCDs 475 WHO Global Action Plan and Monitoring Framework for Prevention and Control of NCDs by 2025 476 National NCD Monitoring Survey 2017–18 476 Accidents and Injuries: Hidden Epidemic 477 Pandemic of Road Traffic Accidents (RTA) 477 Epidemiology of RTA 478 Prevention of Accidents 481 Motor Vehicle Act, 2019 481 National Programme for Prevention and Management of Trauma and Burn Injuries 482 National Programme for Prevention and Management of Burn Injuries (NPPMBI) 483 Blindness 484 Epidemiology of Blindness 484 National Blindness Survey in Population—2019 485 National Programme for Control of Blindness and Visual Impairment (NPCBVI) 486 District Blindness and Visual Impairment Control Programme (DBVICP) 487 Global Trachoma Mapping Project and Elimination by 2020 489 New Initatives during 12th Five-Year Plan 489 Cancers 490 Epidemiology of Cancers 490 Common Cancers in India 490 An Atlas of Cancer in India 490 National Cancer Control Programme in India 492 Cost Effective Strategies—Best Buys as per WHO 492 Vaccines Against Cancer 492 National Cancer Registry Programme (NCRP) 493 National Oral Health Programme (NOHP) 494 Oral Disease Burden 494 Objectives of National Oral Health Programme (NOHP) 495 Strategies for Implementation 495 National Programme for Prevention and Control of Deafness 497 National Organ Transplant Programme (NOTP) 498 Educating and Training of Health Workers in Disease Surveillance, Control, Treatment and Health Education for CCDs and NCDs 498 Health Management Information System (HMIS) 499 Development of HMIS in India—A Case Study 500 Records and Registers at Sub-centre 502 Integrated Reproductive and Child Health Register (IRCHR) 502 Civil Registration System (CRS) 505 Sample Registration System (SRS) 506 Model Registration Survey of Cause of Death 507

Contents

9.

xxi

Demography, Vital Statistics, Population Stabilization and Medical Genetics (Part I) Principles of Demography 508 Demographic Transition/Cycle 508 Population Explosion 510 Population Dynamics and Consequences of Population Explosion 510, 511 Demographic Indices (Demographic Indicators and Vital Statistics) Population Statistics Causes of Declining Sex Ratio and their Social and Health Implications 514 Vital Statistics 516 Fertility Rates/Indicators 518 Methods of Population Control 521 National Population Policy 522 Sources of Vital Statistics (Census, NFHS, NSSO and SRS) 526–528 Medical Genetics 529 Chromosomal Abnormalities 530 Epidemiology of Genetic Disorders and Services 531 Birth Defects Surveillance System 531 The Human Genome Project and Human Genome Diversity Project 535 The Preconception and Prenatal Diagnostic Techniques (PC-PNDT) (Prohibition of Sex Selection) Act, 1994 and Amended Rules, 2021 536 The Medical Termination of Pregnancy Act, 1971 537

508–538

511

Part II Applied Sciences Related to Community Medicine (Topics 8 and 10 to 20) 10. Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A)— Part of Applied Sciences Current Status of RMNCH + A 539 Major Health Problems of Women and Children 539, 540 Local Customs and Practices during Pregnancy Childbirth, Lactation and Child Feeding Practices Child Survival and Safe Motherhood (CSSM) Interventions 541 Reproductive and Child Health Phase 1 and Phase 2 541 RMNCH + A Approach 543 Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A) Interventions 545 Tracking Every Pregnant Women by Name, Methods of Screening of High Risk Pregnant Women and Newborns and Young Children 547 India’s Maternal Mortality on Decline 551 National Strategies/Interventions for Reduction of MMR 555 Neonatal, Infant and Child Mortality 557 National Strategies Interventions to Reduce IMR and U5MR 562 India Newborn Action Plan 565 Universal Immunization Programme 567 Integrated Management of Neonatal and Childhood Illness 578 School Health Programme 583 Rashtriya Bal Swasthya Karyakram 587 Physiology, Clinical Management and Principles of Adolescent Health 588 National Programmes and Policy for Adolescent Health and Development 590 Rashtriya Kishor Swasthya Karyakram (RKSK) 590 Kishori Shakti Yojna 593 Rajiv Gandhi Scheme for Empowerment of Adolescent Girls—SABLA 593 Various Family Planning Methods—their Advantages and Shortcomings 594 Basis and Principles of National Family Planning/Welfare Programme and Organization and Operational Aspects 595 Gender Issues and Women Empowerment 598 Beti Bachao Beti Padhao Scheme 603

539–603

540

Textbook of Community Medicine

xxii 11.

Occupational Health

604–622

Occupational/Workplace Safety and Health 604 Specific Occupational Health Hazards, their Risk Factors and Preventive Measures 605 Pneumoconioses, Silicosis, Asbestosis, Anthracosilicosis 605–607 Presenting Features of Patients with Occupational Illness 607 Byssinosis and Extrinsic Allergic Alveolitis 608 Diseases Caused by Lead and its Toxic Compounds 609 Effects of Heat, Radiation, Compressed Air, Noise and Vibration 610–613 Occupational Dermatosis 613 Carbon Monoxide Poisoning 614 Coal Mines and other Mines—Health Problems 614 Industrial Accidents 615 Prevention and Control of Occupational Hazards 615 Principles of Ergonomics in Health Preservation 616 Role, Benefits and Functioning of Employees State Insurance Scheme of India 619 Employees State Insurance (ESI) Act, 1948 619 Occupational Disorders of Health Professionals, their Prevention and Management 621

12.

Geriatrics—“Add Life to the Years”

623–632

Concept of Geriatric Services 623 Gerontology 623 Health Problems of Elderly/Geriatric People 624 Prevention of Health Problems of Aged 625 Action Towards Active Ageing 626 Kartz index on Independence in Daily Living Activities 628 A Young Man of Hundred Years (1997)—A Case Study 629 National Policy on Older Persons (1999) 630 National Programme for Healthcare of Elderly (NPHCE) 631

13.

Disaster Preparedness and Management

633–640

Concept of Disaster Management 633 Global Phenomenon 633 Disaster Management Cycle 634 National Disaster Management Plan 634 Disaster Management Act 634 Disaster Preparedness 634 Response to Disaster 635 Natural Disasters in India 635 Types of Disasters in India 636 Man-made Disasters in India and World 636 National Disaster Management Authority 637 Bioterrorism 640

14.

Hospital Waste Management Definition of Waste 641 Biomedical Waste Generation and Classification 641 Hazards of Biomedical/Healthcare Waste 642 National Guidelines for Hospital Waste Management/Laws for Hospital Waste Management Biomedical Waste Categories and their Segregation, Collection, Treatment, Processing and Disposal Options 644 Biodegradable Plastic and Medical Waste 647 Hazards of Plastic 648

15.

Mental Health Concept of Mental Health 649 Burden of Mental Disorders in India 649 Beliefs—Attitudes and Practices in Relation to Mental Disorders—A Case Study 650 Warning Signals of Mental Health Disorders 651 National Mental Health Programme 651

641–648

643

649–664

Contents District Mental Health Programme 651 Mental Healthcare Act 653 National Mental Health Policy of India 2014 654 Substance Use Disorders (Drug Abuse) 655 Social Problem of Drug Abuse—A Case Study 656 Tobacco Pandemic 658 Global Adult Tobacco Survey (GATS) 2010 and 2016–2017 658 Global Youth Tobacco Survey 658 Cigarettes and Other Tobacco Products Act (COTPA), 2003 660 National Tobacco Control Programme (NTCP) 660 Intellectual Disability (ID) or Intellectual Development Disorders (IDDs) Intelligence 662 Juvenile Delinquency (JD) 662 Juvenile Justice Act of 1986 663 Child Marriage 663 Child Marriage Restraint Act of 1976 663 Child Guidance Clinic/Centre 663

16.

661

Health Planning and Management Health Planning in India 665 National Health Policy 1983 665 NITI Aayog 665 National Health Policy, 2017 666 Concept of Health Planning 669 Planning Cycle 670 Assessment of Health Service Needs CHNA for 2020–21—a Case study Health Management 676 Different Levels of Management 677 Health Management Techniques 679 Hierarchy 679 Delegation and Decentralization 679 Convergence 680 Methods of Convergence—A case Study 680 Organizational Behaviour 680 Good Leadership and Motivation of Health Team 680 Motivation—A Management Technique 682 Health Team (Public Health Team) Job Responsibilities 684 Supervision as Management Tool 688 Training and Continuing Education of Health Teams 690 Training Needs Assessment (TNA) 690 Controlling 691 Health System Monitoring 691 Evaluation of Health Programme or Health Services 693 Programme Evaluation and Review Technique (PERT) 695 Healthcare Financing in India at a Glance 695 Catastrophic Health Expenditure 698 Hospital Management 700 Preventive and Promotive Health Services in Hospitals 702

17.

xxiii

Healthcare of the Community Concept of Community Healthcare 703 Community Diagnosis and Treatment 703 National Rural Health Mission, 2005–2012 706 National Health Mission 708 Universal Health Coverage Model 709 Primary Healthcare, its Principles and Components (Elements) 710 Selective Primary Healthcare 711 Comprehensive Primary Healthcare (CPHC) 711 Healthcare Delivery Systems in India 712 Primary Healthcare System in Rural Areas 712 Primary Healthcare Organization: At Village Level—VHSNC 713

665–702

671

703–738

xxiv

Textbook of Community Medicine Revised Indian Public Health Standards (IPHS) 2022 713 Primary Healthcare in Rural and Urban Areas 713 Sub-health Centres in Rural Areas 714 Health and Wellness Centres 715 Urban Health and Wellness Centres (UHWC) 715 Health and Wellness Centres Primary Health Centre (PHC) Rural 717 Community Health Centre 721 Block Public Health Unit 721 Urban Primary Healthcare Services 725 National Urban Health Mission, 2013 725 Urban Primary Health Centre (U-PHC) Model 726 Specialist UPHC (Polyclinic) (Urban) 728 Primary Healthcare in Tribal Areas 729 Secondary and Tertiary Healthcare 729, 730 Referral System 730 Private Health Sector 731 Employees State Insurance Scheme (ESIS) 732 Health Policy and Health Insurance 732 Ayushman Bharat 732 Ex-servicemen Contributory Health Scheme 733 Central Government Health Services Scheme 733 Railway Health Services 734 Armed Forces Health Services 734 Indian System of Medicine or AYUSH 734 Other Sectors—NGOs and Voluntary Sectors/Agencies 734 Partnership with NGOs 735 Human Resources in Health 735 Healthcare Utilization 735 Millennium Development Goals (MDGs) 736 Sustainable Development Goals (SDGs) versus MDGs 737 Health Related SDGs 737

18.

International Health and International Health Regulations

739–747

International Health Regulations 739 Concept of International Health 739 Global Health Security 739 International Statistical Classification of Diseases and Related Health Problems 742 International Form of Medical Certificate of Cause of Death 743 Role of Various International Health Agencies 744 WHO, UNICEF, Colombo Plan, TCM, Rockefeller Foundation, FAO CARE, Ford Foundation, DFID, USAID, IRCS and DANIDA 744–747

19.

Essential Medicines and Rational Use of Drugs

748–753

Concept of Essential Medicines List 748 Role of Essential Medicines in Primary Healthcare 750 Counterfeit or Fradulent Medicines in India 751 Prevention of Counterfeit Medicines in India 751 National Programme for Containment of Antimicrobial Resistance 752

20.

Recent Advances in Community Medicine Important Public Health Events of Last Four Years 754 Various Issues during Outbreaks and their Prevention 755 Laws Pertaining to the Practice of Medicine 756 a. Human Organs and Tissues Transplantation Act and its Implications b. Clinical Establishment Act, 2010 757 Covid-19 Pandemic 763 Behaviour of Host—A Case Study 763

Index

754–774

756

775

xxv

Index of Competencies Code

Competencies addressed

Chapter no.

Page no.

Topic 1: Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship CM CM CM CM CM CM

1.2: 1.2: 1.1: 1.2: 1.2: 1.3:

Define health and describe the concept of holistic health Describe the concept of spiritual health Define and describe the concept of public health Define and describe the relativeness of health Define and describe determinants of health Describe the characteristics of agent, host and environmental factors in health and disease and multifactorial etiology of disease CM 1.4: Describe and discuss the natural history of disease CM 1.5: Describe the application of interventions at various levels of prevention CM 1.6: Describe and discuss the concepts, the principles of health promotion and education, IEC and BCC—behaviour change communication CM 1.7: Enumerate and describe health indicators CM 1.8: Describe the demographic profile of India and discuss its impact on health CM 1.9: Demonstrate the role of effective communication skills in health in a simulated environment CM 1.10: Describe the important aspects of the doctor–patient relationship in a simulated environment

1 1 1 1 1 1, 7

4 6 7 7 8 12, 245–51, 300

1 1 1, 4, 10

12 12–14 15, 112–115, 584

1 1 1, 4 1

17 21 22, 119 24

Topic 2: Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease CM 2.2: CM 2.1: CM 2.2: CM 2.2: CM 2.4: CM 2.3: CM 2.5:

Describe family types, its role in health and disease Describe the steps and perform clinico-social cultural and demographic assessment of the individual, family and community Demonstrate in simulated environment the correct assessment of socio-economic status Describe social and cultural factors in health, disease and disability Describe social psychology, community behaviour and community relationship and their impact on health and disease Describe and demonstrate in a simulated environment, the assessment of barriers to good health and health-seeking behaviour Describe poverty and social security measures and its relationship to health and disease

2 2

38 41

2 2 2

42 50 50, 51

2

53

2

54

3 3 3 3 3 3 3 3 3 3 3 11 3 3

60 62 63 63–68 69 73, 74 77 78, 82 85 87–93 93 611 94, 110 95

3, 8 3

109, 350 110

Topic 3: Environmental Health Problems CM 3.2: CM 3.1: CM 3.3: CM 3.2: CM 3.2: CM 3.2: CM 3.5: CM 3.4: CM 3.1: CM 3.1: CM 3.1: CM 3.1: CM 3.6: CM 3.7: CM 3.8: CM 3.6:

Describe the concepts of safe and wholesome water and sanitary sources of water Describe health hazards of water pollution Describe the aetiology and basis of waterborne disease (jaundice/hepatitis/diarrhoeal diseases) Describe water purification processes Describe water quality standards Describe concept of water conservation and rainwater harvesting Describe the standards of housing and effect of housing on health Describe the concept of solid waste, human excreta and sewage dispossal Describe health hazards of soil pollution Describe health hazards of air pollution Describe health hazards of noise pollution Describe health hazards of radiation pollution Describe the role of vectors in transmission/causation of diseases Identify and describe the identifying features and life cycle of vectors of public health importance and their control measures Describe mode of action and application cycle of common rodenticides and insecticides Discuss National Vector-borne Disease Control Programme

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Textbook of Community Medicine

Topic 4: Principles of Health Promotion and Education CM 4.1: CM 4.2: CM 4.3: CM 4.3: CM 4.2: CM 4.1:

Describe various methods of health education with their advantages and limitations Describe the methods of organizing health promotion and education activities at individual, family and community settings Demonstrate and describe the steps in planning, organizing, implementation and evaluation of health communication/education programme Demonstrate and describe the steps in evaluation of health promotion and education programme Describe concept and method of health counselling Social marketing programme—A method of health eduction

4 4

115–18 118–19

4

121, 122

4 4 4

122–124 124–129 130

5

133

5

140

5

146

5

151, 180

5 5 5 5 5 5 5 5 5

153 155 163 168–179, 183–185 185–87 188 190 191 193

Topic 5: Nutrition CM 5.1: CM 5.4: CM 5.3: CM 5.2: CM 5.5: CM 5.5: CM 5.5: CM 5.6: CM 5.6: CM 5.8: CM 5.8: CM 5.7: CM 5.6:

Describe the common sources of various nutrients and special nutritional requirements according to age, sex activity and physiological conditions Plan and recommend a suitable diet for the individuals and families based on local availability of foods and economic status, etc. in a simulated environment Define and describe common nutrition-related health disorders including macro-protein energy malnutrition (PEM), micro-iron, Vit A, iodine, Zn and their control and management Describe and demonstrate correct methods of performing a nutritional assessment of individuals, families and community by using the appropriate method Describe the principles of nutrition rehabilitation Describe the principles of nutrition education in the context of socio-cultural factors Describe the methods of nutritional surveillance Enumerate and discuss important national nutritional programmes Enumerate and discuss the National Nutrition Policy/policies Describe and discuss the effects of food additives and adulteration Describe and discuss the importance and methods of food fortification Describe food hygiene Enumerate and discuss Integrated Child Development Service (ICDS) Scheme

Topic 6: Basic Statistics and its Applications and Research Methodology CM 6.2: CM 6.2: CM 6.2: CM 6.3: CM 6.4: CM 6.4: CM 6.4: CM 6.4: CM 6.3: CM 6.1:

Describe, discuss and demonstrate classification of statistical data Describe and discuss principles and demonstrate the methods of collection of data Describe and discuss analysis, interpretation, and presentation of statistical data Describe and discuss, demonstrate the application of elementary statistical methods Describe measures of central tendency Describe and discuss frequency distributions Describe and discuss measures of dispersion Enumerate, discuss and demonstrate common sampling techniques Describe, discuss and demonstrate test of significance in various study designs Formulate a research question for a study

6 6 6 6 6 6 6 6 6 6

201 202, 203, 237, 238 203 207 208 211 213 217 225 239

7

242

7 7 7 7 7 7 7 7

243 245 253 255–56 256 260 267 281

7 7 7 7

285 299 302 303

Topic 7: Epidemiology CM 7.1: CM CM CM CM CM CM CM CM

7.3: 7.2: 7.2: 7.2: 7.4: 7.4: 7.6: 7.7:

CM 7.5: CM 7.8: CM 7.8: CM 7.9:

Define epidemiology and describe and enumerate the principles, concepts and uses of epidemiology Enumerate, describe and discuss the sources of epidemiological data Enumerate, describe and discuss the modes of transmission of communicable diseases Enumerate, describe and discuss measures for prevention and control of communicable diseases Describe and discuss measures for prevention and control of non-communicable diseases Define, calculate and interpret morbidity indicators based on given set of data Define, calculate and interpret mortality indicators based on given set of data Enumerate and evaluate the need of screening tests Describe and demonstrate steps in the investigation of an epidemic of communicable disease and the principles of control measures Enumerate, define, describe and discuss epidemiological study designs Describe the principles of association, causation in epidemiological studies Describe biases in epidemiological studies Describe and demonstrate the application of computers in epidemiology

Index of Competencies

xxvii

Topic 8: Epidemioogy of Communicable and Non-Communicable Diseases and Related Disease Specific National Health Programmes CM 8.5: CM 8.1: CM 8.3: CM 8.4: CM 8.2:

CM 8.6: CM 8.7:

Describe and discuss the principles of planning, implementing and evaluating control measures 8 for disease at community level bearing in mind the public health importance of the disease Describe and discuss the epidemiology and control measures including the use of essential laboratory tests at the primary care level of communicable diseases 8 Enumerate and describe disease-specific national health programs including their prevention and treatment of a case of CCD Describe the principles and enumerate the measures to control a disease epidemic 7, 8 Describe and discuss the epidemiology and control measures including the use of 8 essential laboratory tests at the primary care level for non-communicable diseases (diabetes, hypertension, stroke, obesity and cancer, etc.) Educate and train health workers in disease surveillance, control and treatment and health education 8 Describe the principles of management information system 8

307

310–446 279, 379 446–498

498 499

Topic 9: Demography, Vital Statistics, Population Stabilization and Medical Genetics CM 9.1: CM 9.1: CM 9.4: CM 9.4: CM 9.2: CM 9.3: CM 9.2: CM 9.2: CM 9.5: CM 9.6: CM 9.7:

Define and describe principles of demography, demographic cycle and vital statistics Describe demographic cycle Describe the causes and consequences of population explosion and population dynamics in India Describe population dynamics of India Define, calculate and interpret demographic indices including birth rate, death rate, fertility rates Enumerate and describe the causes of declining sex ratio and its social and health implications Define, calculate and interpret death rate Define, calculate and interpret fertility rates Describe the methods of population control Describe National Population Policy Enumerate sources of vital statistics including, SRS, NFHS, NSSO, civil registration system and census

9 9 9 9 9 9 9 9 9 9 9

508 508 510 510 511 514 516 518 521 522 526–528

Topic 10: Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A) CM 10.1: Describe the current status of reproductive, maternal, newborn and child health (RMNCH) and common health problems CM 10.3: Describe local customs and practices during pregnancy, childbirth, lactation and child feeding practices CM 10.4: Describe child survival and safe-motherhood interventions CM 10.4: Describe the reproductive, maternal, newborn, child health interventions CM 10.2: Enumerate and describe the methods of screening high-risk groups CM 10.5: Describe universal immunization programme CM 10.5: Describe integrated management of neonatal and childhood illness CM 10.5: Describe school health programme CM 10.2 and CM 10.5: Describe Rashtriya Bal Swasthya Karyakram and screening newborn and children 0–18 years CM 10.8: Describe the physiology, clinical management and principles of adolescent health including ARSH CM 10.8: Describe Rashtriya Kishor Swasthya Karyakram including ARSH CM 10.6: Enumerate and describe various family planning methods, their advantages and shortcomings CM 10.7: Enumerate and describe the basis and principles of the family welfare programme including the organization, technical and operational aspects CM 10.9: Describe and discuss gender issues and women empowerment

10

539

10

540

10 10 8, 10 10 10 10

541 545 471, 546 567 578 583

10 10 10 10 10

587 588 590 594 595

10

598

11

605

11

607

11 11 11

615 619 621

Topic 11: Occupational Health CM 11.3: Enumerate and describe specific occupational health hazards, their risk factors presenting features and preventive measures CM 11.1: Enumerate and describe the presenting features of patients with occupational illness including agriculture CM 11.4: Describe the principles of ergonomics in health preservation CM 11.2: Describe the role, benefits and functioning of employees state insurance scheme CM 11.5: Describe occupational disorders of health professionals, and their prevention and management

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Textbook of Community Medicine

Topic 12: Geriatrics—“Add Life to the Years” CM 12.1: CM 12.2: CM 12.3: CM 12.4:

Define and describe the concept of geriatric services Describe health problems of aged population Describe the prevention of health problems of aged population Describe national program for elderly

CM 13.1: CM 13.2: CM 13.3: CM 13.4:

Define and describe the concept of disaster management Describe disaster management cycle Describe man-made disasters in the world and in India Describe the details of the national disaster management authority

12 12 12 12

623 624 625 631

13 13 13 13

633 633 636 637

14 14 14

641 643 644

15 15 15

649 651 651

16 16 16 16

665 669 670 676

17 17 17 17 17

703 703, 706, 708 710 712 736

18 18

739 744

19 19 19

748 750 751

20 20 9, 20

754 755 536, 756

20

757

Topic 13: Disaster Preparedness and Management

Topic 14: Hospital Waste Management CM 14.1: Define and classify hospital waste CM 14.3: Describe laws related to hospital waste management CM 14.2: Describe biomedical waste categories and their segregation, collection, treatment, processing and disposal options

Topic 15: Mental Health CM 15.1: Define and describe the concept of mental health CM 15.2: Describe warning signals of mental health disorders CM 15.3: Describe National Mental Health Programme

Topic 16: Health Planning and Management CM 16.4: CM 16.1: CM 16.2: CM 16.3:

Describe health planning in India and national policies related to health and health planning Define and describe the concept of health planning Describe planning cycle Describe health management techniques

Topic 17: Healthcare of the Community CM 17.1: CM 17.2: CM 17.3: CM 17.5: CM 17.4:

Define and describe the concept of healthcare to community Describe community diagnosis, NHM and IPHA Describe primary healthcare, its components and principles Describe healthcare delivery systems in India Describe national policies related to health and health planning Millennium development goals and sustainable development goals

Topic 18: International Health and International Health Regulations CM 18.1: Define and describe the concept of international health CM 18.2: Describe roles of various international health agencies

Topic 19: Essential Medicines and Rational Use of Drugs CM 19.1: Define and describe the concept of essential medicines list (EML) CM 19.2: Describe role of essential medicines in primary healthcare CM 19.3: Describe counterfeit medicine and its prevention

Topic 20: Recent Advances in Community Medicine CM 20.1: List important public health events of last four years CM 20.2: Describe various issues during outbreaks and their prevention CM 20.4: Demonstrate awareness about laws pertaining to the practice of medicine such as: Clinical Establishment Act and Human Organ Transplantation Act and its implications CM 20.3: Describe any event important to health of the community

xxix

Abbreviations ACD

Active Case Detection

FSSA

Food Safety and Standards Act

AEFI

Adverse Events Following Immunization

FSWs

Female Sex Workers

AETCOM

Attitude, Ethics and Communication

GDP

Gross Domestic Product

AIDS

Acquired Immunodeficiency Syndrome

GNI

Gross National Income

AKD

Acetone Killed and Dried Typhoid Vaccine

GoI/GOI

Government of India

ANC

Antenatal Care/Clinic

HBPNC

Home-based Postnatal Care

ANM

Auxiliary Nurse Midwife

HDI

Human Development Index

APL

Above Poverty Line

HIV

Human Immunodeficiency Virus

ARSH

Adolescent Reproductive and Sexual Health

HLEG

High Level Expert Group

ASHA

Accredited Social Health Activist

HWC

Health and Wellness Centre

AWW

Anganwadi Worker

IAP

Indian Association of Paediatrics

BCC

Behaviour Change Communication

IAPH

Indian Association of Public Health

BObC

Basic Obstetric Care

IAPPD

BPL

Below Poverty Line

Integrated Action Plan for Pneumonia and Diarrhoea

IAPSM

Indian Association of Preventive and Social Medicine

CBHI

Central Bureau of Health Intelligence

CBR

Crude Birth Rate

CCDs

Communicable Diseases

IBBS

Integrated Bio-behavioural Surveillance Survey

CDR

Crude Death Rate

ICDRI

CHC

Community Health Centre

International Conference on Disaster Resilient Infrastructure

CNA

Communication Needs Assessment

ICD

International Classification of Diseases

CNAA

Community Need Assessment Approach

ICDS

Integrated Child Development Services Scheme

Covid-19

Corona Virus Disease

ICF

CPHC

Comprehensive Primary Health Care

International Classification of Functioning, Disability and Health

CRS

Congenital Rubella Syndrome

ICMR

Indian Council of Medical Research

CSW

Commensal Sex Workers

ICTC

Integrated Counselling and Testing Centre

DGHS

Director-General of Health Services

IDD

Iodine Deficiency Disorders

DHAP

District Health Action Plan

IDSP

Integrated Disease Surveillance Programme

DMO

District Malaria Officer

IDU

Injecting Drug Users

DOTS

Directly Observed Treatment Short-course

IEAG

India Expert Advisory Group

DST

Drug Sensitivity Test

DVBDCO

District Vector-borne Disease Control Officer

EAG

Empowered Action Group

EC

Eligible Couple

ECHS

Ex-servicemen Contributory Health Services

EHP

Essential Health Package

EMObC

Emergency Obstetric Care

EObC

Essential Obstetric Care

FOGSI

Federation of Obstetric and Gynaecological Societies of India

FP

Family Planning

IEC

Information, Education and Communication

IHR

International Health Regulations

IHME

Institute for Health Metrics and Evaluation

ILO

International Labour Organization

IMA

Indian Medical Association

IMNCI

Integrated Management of Newborn and Childhood Illness

IMR

Infant Mortality Rate

INAP

India Newborn Action Plan

IPHS

Indian Public Health Standards

IPV

Injectable Polio Vaccine

Textbook of Community Medicine

xxx IRS

Indoor Residual Spray

IUCD

Intrauterine Contraceptive Device

IUGR JSY

PC–PNDT

The Pre-conception and Prenatal Diagnostic Technique Act

Intrauterine Growth Retardation

PHC

Primary Health Centre/Primary Health Care

Janani Surakshya Yojna

PHFI

Public Health Foundation of India

PMJAY

Pradhan Mantri Jan Arogya Yojna

LBW

Low Birth Weight

MAA

Mother Absolute Affection

MB

Multi-bacillary Leprosy

MCH

Maternal and Child Health

MCI

Medical Council of India

MCPC

Mother and Child Protection Cared

MCTS

Mother and Child Tracking System

MDG

Millennium Development Goals

MGNREGA

Mahatma Gandhi National Rural Employment Guarantee Act

MLHP

Mid-level Health Provider

MMR

Maternal Mortality Ratio

MNA

Management Needs Assessment

MOHFW

Ministry of Health and Family Welfare

MPHW

Multipurpose Health Worker

MSM

Men Having Sex with Men

MTPA

Medical Termination of Pregnancy Act

NCD

Non-communicable Diseases

NGOs

Non-governmental Organizations

NHM

National Health Mission

SkBA

Skilled Birth Attendance

NHP

National Health Policy

SRS

Sample Registration System

NIDs

National Immunization Days

SSA

Sarva Shiksha Abhiyan

NIPCCD

National Institute of Public Cooperation and Child Development

STDs

Sexually Transmitted Diseases

NITI Aayog

National Institute for Transforming India Aayog

STIs

Sexually Transmitted Infections

NMMU

National Mobile Medical Unit

TAS

Transmission Assessment Surveys

NMR

Neonatal Mortality Rate

Td

Tetanus and Diphtheria Toxoid

NRHM

National Rural Health Mission

TGR

Total Goitre Rate

NSP

New Sputum Smear Positive

NSS

National Service Scheme

NSSK

Navjat Shishu Swasthya Karyakram

NTAGI

National Technical Advisory Group on Immunization

NUHM

National Urban Health Mission

UIP

Universal Immunization Programme

NVDCP

National Vector-borne Disease Control Programme

UN

United Nations

NVHCP

National Viral Hepatitis Control Programme

UnHC

Universal Health Coverage

NYVK

Nehru Yuva Vikas Kendra

UVBD

Urban Vector-borne Diseases

OOP

Out of Pocket Expenditure

VHND

Village Health and Nutrition Day

ORS

Oral Rehydration Salt

VHSNC

Village Health Sanitation and Nutrition

ORT

Oral Rehydration Therapy

PB

Paucibacillary Leprosy

WBD

Water-borne Diseases

PCD

Passive Case Detection

WHO

World Health Organization

PNMR

Post-neonatal Mortality Rate

PPP

Public–Private Partnership

PPTCT

Prevention of Parent to Child Transmission

RBSK

Rashtriya Bal Swasthya Karyakram

RCH

Reproductive and Child Health

RDA

Recommended Dietary Allowances

RDT

Rapid Diagnostic Test

RGJAY

Rajiv Gandhi Jeevandayee Arogya Yojna

RMNCH + A Reproductive, Maternal, Newborn, Child and Adolescent Health RPR

Rapid Plasma Reagin

RSOC

Rapid Survey of Children

RSPM-10

Respirable Suspended Particulate Matter-10

RTI

Reproductive Tract Infection

SBA

Swachh Bharat Abhiyan

SBR

Stillbirth Rate

SDG

Sustainable Development Goals

SES

Socio-economic Status

SHC

Sub Health Centre

TFR

Total Fertility Rate

TNA

Training Needs Assessment

TSC

Total Sanitation Campaign

UHC

Urban Health Centre

UID

Unique Identity Number

Committee

Part I Basic Sciences Related to Community Medicine

1 Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship In community medicine, ‘patient’ is ‘community’ “Analysis of healthcare problems of community is one of the most effective ways of competency based learning in community medicine”

regulations. Specific core competencies to be acquired, span over the years. Domains of learning, methods of learning as well as methods of formative and sumative assessment have been explicitly stated.1

“A teacher can never truly teach unless he is still learning himself. A lamp can never light another lamp unless it continues to burn its own flame. A teacher who has come to the end of his subject, who has no living traffic with his own knowledge, but merely repeats his lessons to his students can only load their minds. He cannot quicken them. Truth not only must inform, but also must inspire. If the inspiration dies out, and the information only accumulates, then truth loses its —Rabindranath Tagore infinity.”

Suggested Methods of Aquisition of Various Competencies

In community medicine “the patient” is “the community” not an individual, hence the focus of learning should be: ‘Community diagnosis and Community therapy’. To arrive at community diagnosis, the student should be able to listen to chief complaints of community, directly observe, interact with community, and analyse health practices, health seeking behaviours, community structure, analyse and interprets a household survey, and facility survey data, live data of surveillance, service delivery and routine health reports/data of facility. Apart from this the student should be able to identify the root causes/ determinants of health problems and be able to communicate effectively with community and organized listening groups. Some of the methods of active and participatory learning are being explained in this chapter. The teacher acts as a facilitator and provides learning material to learner. Revised curriculum provides a unique opportunity to medical faculty of 596 Medical Colleges to restructure their teaching program, to develop learning resource material, promote problem-based learning, prepare relevant case studies, integrate teaching and learning with healthcare delivery system, use real life situations and live data, exploit modern technologies, develop field practice areas to bring field experiences to classroom setting, involve program officers of state/district in teaching program to achieve competency-based learning. Further, it provides an opportunity to transform conventional field visits to specific skills to be acquired with clear cut

The following four part saying is about knowledge and self-knowledge: • He who knows not, and knows not he knows not, is a fool; shun hin • He who knows not, and knows he knows not, is simple; teach him. • He who knows, and knows not he knows, is asleep; awaken him. • He who knows, and knows he knows, is wise; follow him. —Bruce Lee

COMPETENCY BASED LEARNING IN COMMUNITY MEDICINE

In the subject of community medicine, the new MBBS regulations identified 20 broad topics with 107 core competencies. Out of these, 89 (83%) are related to domain of knowledge (knows and knows how) focusing on didactic learning, while 18 (17%) are related to skill domain (shows and shows how and performs) focusing on skill learning. At the end of the course, student should be able to demonstrate and/or perform these skills himself or herself. Building these skills in community medicine is an enormous task and a challenge indeed. New regulations give an impetus to improved doctor– patient relationship and acquisition of effective communication skills. They encourage self-directed learning by choosing a subject of interest by the learner and exposure to clinical experience in the very first year of the MBBS course. Clear directions are there for integrated teaching by way of horizontal and vertical integration. Learning is outcome based under new 1

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objectives and ensuring achievement of relevant learning objectives. The pivotal responsibility of faculty is to develop positive attitude in students towards community.2, 3 Essential Skills for Community Medicine Practice

The most essential skills/competencies include: 1 Positive attitude of mind to work for community. 2 Ability to communicate effectively with people/patient and family on health and disease. 3 Ability to organize community or groups in the community. 4 Ability to generate resources from community. 5 Ability to elicit community participation. 6 Give responsibility to community (sanitation, birth and death registration, reporting outbreaks, maintenance of wells—chlorination of water—disposal of human excreta, animal excreta, and garbage). 7 Ability to assess community health needs. 8 Ability to meet community health needs. 9 Ability to share the health information with community. 10 Ability to lead health team and of training of community volunteers (birth attendants, health guides, Anganwadi workers, ASHAs, school teachers, Mahila Swasthya Sanghs and others). The teachers/faculty must reinvent themselves to refine and practice these competencies. Teaching vs Learning

People resent being taught. Nobody wishes to be taught but everyone wishes to learn and people have strong desire to learn. Emphasis should be on learning. Learning is a lifelong process. Child learning and adult learning differs. There are four ways of learning: 1 Trial and error: By trying for oneself (trial and error) and learning from each trial (experiential learning). 2 Being told: By receiving instructions either orally or in writing or by demonstration. 3 Imitation: By copying the actions of another person usually an instructor or a skilled person. 4 Thinking: By organizing one’s thoughts about a topic or problem to arrive at an explanation or solution. Best way of learning is learning by doing. Common saying is: “I hear, I forget, I see, I remember, seeing is believing, I do, I know.” Adult learning should be problem-centered and experience-centered.

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Pedagogy

The art and science of learning/teaching is known as pedagogy. It includes different teaching/training methods

and technology to change the knowledge, attitude and behaviour of learner. Curriculum: It is “a sum total of all planned educational experiences which include four components—learning objectives, content areas or subject matter, instructional strategies, methods of learning and evaluation.” Emphasis should be on learning. Lesson plan should include learning objectives, methods of learning, learning aids, contents, feedback and evaluation. Pedagogic methods: Teaching technology and methods in medical education are—lecture, lecture discussion, demonstration, return demonstration, tutorial, clinical teaching, group discussion, brain storming, buzz session, problem-based learning, panel discussion, symposia, seminar, workshop, conference, convention, institute, completion of project, focus group discussion and case study methods, role play, reflection, cinema, narratives, comics, and skill lab. Teaching aids: Include audio–visual and other aids, such as—tape recorder, over-head projector, mike, transparencies, video-tapes/cassettes, pictorials, blackboard, computer, laptop, etc. Problem-based Learning/Participatory Learning

Education is a process to bring about change in behaviour of the students. Three domains—cognitive (knowledge), affective (attitudes) and psychomotor (practical skills) are the main focus of competency based medical education. Behaviour change can be done by conventional methods of teacher-centred training in which the knowledge and skills are imparted to students by traditional methods of lectures and demonstrations; it is a passive process. The second method is, in which the students participate and take active part in self-directed learning. Here, the teacher acts as a facilitator. The learning here is student-centred and active. At present, undergraduate medical education is subjectbased teaching in various semesters. One course is not related to other. In the traditional subject-based curriculum, it is assumed that the knowledge gained in pre- and paraclinical periods will be remembered and will be transferred to illness situations. Both assumptions are unsupported. Forgetting is massive and rapid. Cause to Effect and Effect to Cause Approach

Basic science teachers present material in cause–effect logic, in which they organise their own knowledge and in which most of the textbooks are written. The students as clinician have to relearn it in the effect–cause sequence within which clinical problems must be worked out. That is, the clinical problem start with an effect of a disease process. The student must work backwards from effects through possible explanation to identify what is likely to cause. This can be best achieved by integrated curriculum and integrated teaching. Various techniques have been used

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

to have integrated curriculum, like system-based learning, community-based and problem-based learning. Problem-based learning is defined as learning that results from the process of working towards the understanding or evaluation of a community health problem. Problems are used as spring board for learning. The health problem is encountered first. It serves as a stimulus for the application and development of problemsolving skills and search for knowledge to understand the mechanisms (root causes) responsible for the health problem and its solution. The process involved facilitates self-directed independent learning. Once the information has been gathered, digested and understood, the knowledge obtained can be used to solve other problems. The key features of problem-based learning are: 1 Analysis of healthcare problems in community as main method of acquiring and applying knowledge. 2 Self-directed lifelong learning. 3 Use of small tutorial groups. 4 Develop an epidemiological reasoning process. The problem-based learning creates an atmosphere which encourages active participation, emphasizes the personal nature of learning, accepts the differences between the learners, recognizes the learner’s right to commit mistakes, tolerates imperfection, encourages openness of mind and trust in self, facilitates discovery, puts emphasis on selfevaluation and accepts confrontation of ideas. Problem

The problem selected should be major public health problem. The entire subject may be taught on the basis of problems. a Problems are presented to the students as written cases or live simulations or actual cases. b The students analyse these problems and discuss these problems and generate issues which may be basic or clinical. c These issues are framed into objectives of learning by the students. d The teacher has a list of learning objectives for that health problem with him. He helps the students to identify the objectives of learning by themselves. e The students seek the information from library, books, journals and resource persons in different disciplines in the college and wards of the hospitals. f In subsequent tutorials, the students appraise the information; share it with other students in the group and discuss all aspects of the problem. They critically evaluate their own performance. g Once the students and tutor are satisfied that the predetermined objectives have been met, the students write down the summary of discussions. Later on other problems are taken up in the same sequence.

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h Assessment: The evaluation of students performance is based on their achievement of the programme objectives and their performance in problem-based learning exercises, self-evaluation, peer evaluation and the evaluation by the tutor. Objective-structured clinical examination (OSCE) and objective-structured practical examination (OSPE) and special exercises can be given for evaluation of competency-based learning. (Source: Souvenir-Diamond Jubilee celebration, MCI) Recently, MCI (2018 Regulations) has revised the curriculum of UGs wherein horizontal (elements in the same phase) and vertical (elements from other phases) integration of teaching and training have been structured. MCI has been replaced by National Medical Commission in 2020.

Clinico–social Case Review (CSCR)

This is yet another method to learn and comprehend the natural history of disease and effective interventions (levels of prevention). This approach has two distinct components. One—the clinical review—which consists of standard case management (history taking, examination, clinical diagnosis, confirmative diagnosis, treatment, counselling and follow-up). This is best done by treating physicians and their teams in the outdoor or indoor set-up. Objective here is to treat the illness and reduce its prevalence. Second part is social review: Social review essentially consists of identification of specific social factors and their analysis in respect of presenting disease with the objective: a To recognize the sufficient causes or risk factors or underlying determinants of presenting disease. b To treat the cause by effective intervention in order to prevent the disease, reduce its incidence, prevalence and ultimately elimination of disease. The social review thus begins with a disease and searches for its causes which are often multiple—host factors, environmental factors and factors relating to causative agent of disease (multifactorial etiology). Example: Host factors—age, sex, habits, personal hygiene, marital status, age of marriage, birth interval, migrant worker/labourer, social class (determined by income, education, housing and occupation), immunity and heredity may predispose a person to an illness. Social and Cultural Factors/Practices of Host

Similarly, use of tobacco, harmful use of alcohol, physical inactivity, high speed driving and not obeying traffic rules (unhealthy lifestyles), unprotected sex with multiple sex partners (lifestyles), non-utilization of available health services or delay in seeking care, incomplete treatment, faulty choice of food—junk food, fast food, inadequate food, delayed initiation of breastfeeding, and weaning, large-sized family, lack of information and knowledge, wrong beliefs and

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attitudes, are other factors which could initiate a disease, help in its progression or precipitate a disease or an event. Many harmful cultural practices may worsen a disease. Environmental Factors

• Unsafe environments, such as unsafe water, indiscriminate defecation, soil pollution, air pollution, overcrowding, urban slums, breeding of mosquitoes, flies, rodents, insects, presence of stray dogs, animals and pets, bad working environment/occupational hazards, could be sufficient causes for disease occurrence. • Economic loss due to an illness to individual, family, community and nation and cost of treatment and care. • Impacts of illness on individual, family, community and nation or state are other dimensions of CSCR. In essence, social and cultural factors have their significant role in either initiating a disease, its progression, recovery or cure. Example: Inadequate breastfeeding and delayed weaning initiates malnutrition in young children, and an episode of diarrhoea in malnourished child precipitates malnutrition. Girl child or lesser child is predisposed to malnutrition. Causative Agent Factors—see Chapter 7

much occupied. Similarly, antenatal care visits to sub-centre located at a distance of 2 km could not happen. At last, Maya was brought to sub-centre with swollen face and legs with labour pains. Female health worker with the help of ASHA arranged free transport up to first referral unit (FRU). Free medicines and material were provided at FRU for safe delivery and incentive money was given to Maya from funds under Janani Suraksha Yojana (JSY) under the umbrella of National Rural Health Mission. Several issues can be identified out of this clinical-social case review, such as girl child—the lesser child, deprivation of education to girls, undernutrition, age of marriage and teenage pregnancy, workload, anaemia in pregnancy, toxaemia, below poverty line family, health seeking behaviour, incentives for safe delivery, missed opportunities, causes of low birth weight babies, breastfeeding and management of low birth weight babies, weight gain pattern in low birth weight babies, etc. It could be a part of problem-based learning and learning of epidemiological methods. These reviews can be an opportunity for vertical integrated teaching by the departments of paediatric, obstetric and gynae and community medicine, to identify causes of low birth weight and occurrence of repeated episodes of illness in young children as also integrated management of childhood illness (IMCI) apart from gender disparity.

A CASE STUDY ON CLINICO-SOCIAL CASE REVIEW Clinical Review

A low birth weight (1.8 kg) male baby was born to Maya at first referral unit. Baby could not suck the breast milk and expressed milk was given to this baby by nurses. Baby was kept with mother for 10 days when the breastfeeding got established and baby started thriving on breastfeeds. Thereafter, the mother and baby were sent home. This baby started having episodes of cough and difficult breathing requiring hospitalization on two occasions. At the age of 10 months, the hospital admission was on account of difficult and fast breathing and the child recovered after 7 days time and sent home after counselling. The baby was due for measles vaccine and this opportunity was missed in the hospital. Weight-for-age at the time of discharge was 6 kg. Social Review

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Maya was lesser child and most of her time got spent in care of younger brother and sister and household chores. She could not be enrolled in school and got married around 16 years of age, she looked very weak and pale, and got easily tired after household work, became pregnant after 2 months of marriage. She had to work in farm and family, to bring fodder, fuel and cook meals. Anganwadi worker registered Maya as pregnant women around fifth month and this family was identified as below poverty line family, but Maya could never go to Anganwadi because she was too

Competency addressed: The student should be able to: CM 1.2: Define health and describe the concept of holistic health.

CONCEPT OF HEALTH AND HOLISTIC HEALTH SDG-3 “Ensure healthy lives and promote well being for all at all ages”. WHO at 70 has chosen the theme of world health day on 7 April 2019 ‘universal health coverage: everyone, everywhere’. There is renewed focus on the “One Health” which proposes to take measures to protect the health of animals, environment and humans. “Health should be seen and believed as development function.” Health is difficult to define but easier to understand. To many of us, it may mean absence of disease or infirmity and to many it may mean sound body and sound mind and sound function of the body: A concept close to holistic health. ‘Holistic health’ can be defined as an approach to life. Rather than focusing on illness or specific parts of the body, this ancient approach to health considers the whole person and how he or she interacts with his or her environment. Holistic health emphasises the connection of mind, body, and spirit.

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

ATTAINING HOLISTIC HEALTH

Well-being is made up of physical health, social and emotional nurture, mental stimulation, focus clarity and spiritual nourishment. Therefore, in order to feel at our very best we need to start a holistic self care path to create a personal well-being plan. Start by categorising the physical, mental, emotional and spiritual parts and then choose one or more activity that will serve you in the most enjoyable and meaningful way. For example

Physical—a daily 45 minute walk Mental—commit to a 15 minute morning meditation Spiritual—rediscover a passion, interest or hobby by making time to incorporate in your week. ‘India is a Centre of World Holistic Healthcare’—“PM Modi”. “Good health is the most precious thing anyone can have. When people are healthy, they can learn, earn, work and support themselves and their families. When they are sick, nothing else matters (Dr Tedros Adhanom Ghebreyesus WHO Director General 2019)”.4 To an anatomist: Healthy body means it should confirm to normal anatomical structures. To a physiologist: Health means normal body functions. To a biochemist: It means normal biochemical levels/values. To a pathologist: It means normal cellular make-up. To a geneticist: It means full realization of genetic potential. Similarly, to a clinician it means no abnormality in structure and function and usually when a clinician fails to detect anything in a person by his clinical wisdom and laboratory tests, he/she labels a person no abnormality detected (NAD). To a psychiatrist: It means well adjusted and a balanced personality. Definition

World Health Organization (WHO) has given a comprehensive definition of health which includes important dimensions, such as physical, mental and social health. WHO in its constitution has defined health in the largest sense of the term that states: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” WHO’s 199 member states have endorsed this statement.1 The Executive Board of the World Health Organization (WHO) proposed redefining ‘health’ as “a dynamic state of complete physical, mental, social and spiritual well-being, and not merely the absence of disease or infirmity” (WHO 1998). WHO recognizes “health as a fundamental human right of an individual, family and community and it sets a most important social goal of the enjoyment of highest attainable standard of health by all nations or countries “without

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distinction of race, religion, political belief, economic or social condition”. Realization of this goal requires the action of many other social and economic sectors in addition to health sector. Health is thus a multisectoral subject. Inter- and intra-sectoral coordination is essential to achieve the goal of health for all. “One health” has been defined by WHO as “an approach to designing and implementing, programs, policies, legislations and research in which multiple sectors communicate and work together to achieve better public health outcomes”. In the international conference on primary healthcare jointly organized by the WHO and UNICEF in Alma Ata, USSR, in September 1978, fundamental principles of health were enunciated and a declaration was made; this declaration endorsed the earlier resolution of 30th World Health Assembly (1977). “The attainment by all citizens of the world by the year 2000 of a level of health, that will permit them to lead a socially and economically productive life.” This is popularly known as ‘Health for all’ (HFA) and it is to be achieved through primary healthcare approach, in a spirit of social justice and as a part of overall development. Development of health is to be based on self-determination and self-reliance in health on the part of individual, the community and the nation. Ottawa Charter (1986) further lends support to health promotion. DIMENSIONS OF HEALTH

There are three dimensions of health: Physical, mental and social. A fourth dimension of spiritual health has been added. Physical Well-being

It means adequate body weight, height and circumferences as per age and sex with acceptable level of vision, hearing, locomotion or movements, acceptable levels of pulse rate, blood pressure, respiratory rate, chest circumference, head circumference, and waist–hip ratio. The body structures and functions confirming to laid down standards within the range of normal development and functions of all the systems. Some of the physical health standards are: • Birth weight should range between 2.7 and 2.9 kg ‘cutoff ’ level of low birth weight is 2.5 kg. • Standard growth charts have been evolved to monitor growth of young children. Body mass index: Normal range is 18.5–25 and waist– hip ratio normal range is 0.6–0.9 and triceps skinfold thickness 12–15 mm and sub-scapular skinfold 18–20 mm. Similarly, ideal weights as per age and height for male and female have been worked out. Reference Indian adult man and woman have been defined. Reference Indian Adult Man and Woman (NNMB)

Reference man is in age group 19–39 years and weighs 65 kg with a height of 1.77 m with a BMI of 20.75 and is

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free from disease and physically fit for active work; on each working day, he is engaged in 8 hours of occupation which usually involves moderate activity, while when not at work he spends 8 hours in bed, 4–6 hours in sitting and moving about, 2 hours in walking and in active recreation or household duties. Reference woman is in age group 19–39 years, nonpregnant non-lactating (NPNL) and weighs 55 kg with a height of 1.62 m and a BMI of 20.95, is free from disease and physically fit for active work; on each working day she is engaged in 8 hours of occupation which usually involves moderate activity, while when not at work she spends 8 hours in bed, 4–6 hours in sitting and moving about, 2 hours in walking and in active recreation or household duties. Reference Body Weight and Height

Reference body weights and heights of Indians as under physical health are easier to understand and easier to measure. Periodical health examination and preplacement health examination determine the level of health of an individual. We want best of physical health standards to be attained by all individuals and we are most particular for recruitment in army for physical standards apart from mental health. Mental Well-being

The positive dimension of mental health is stressed in WHO’s definition of health as contained in its constitution. Mental health is defined as “a state of well-being in which the individual realizes his or her own abilities, can cope with normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community”. A mentally normal person has the ability to mix-up with others, he/she makes friendship, behaves in a balanced manner, keeps himself tidy and observes adequate personal hygiene, well oriented to time, place and person and environments and is unduly not suspicious of others, he is cheerful and happy and enjoys life with a purpose and he thinks positively and has normal development and contributes fully and is useful and productive to society and nation. He/she is a balanced person and emotionally stable and realizes his/her shortcomings and strengths and abilities. People are judged by others. The friend circle or family members are the one’s who can endorse the mental health status of an individual first of all. Social Well-being

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It is third dimension of health. It means ability of a person to adjust with others in his social life, at home, at workplace and with people. Men interact with men and they inter-relate and interdepend on each other and play their effective role in accordance with a situation. Essentially, social well-being includes harmonius inter-relation and interaction of human beings.

Social well-being is a composite function of income level, literacy, occupation and working conditions, marital harmony, institution of family, social groups and cultural and behavioural pattern of the society and stressful situation. Social well-being is conditioned by the influence of environments as well. Social well-being can be measured on a scale by taking into consideration indicators like income, literacy and occupation (as discussed under socio-economic status of family). Competency addressed: The student should be able to: CM 1.2: Describe the concept of spiritual health.

Spiritual Well-being

The WHO at its 37th World Health Assembly has added the spiritual dimension to health. The recognition of this dimension speaks of the importance of multidimensional well-being of swasthya (health). Spiritual health has been defined as “that part of the individual which reaches out and strives for meaning and purpose in life. It includes integrity, principles and ethics, the purpose in life, commitment to some higher beings and beliefs in concepts that are not subject to the state-ofthe-art explanation”. Positive health: A person who enjoys all the four dimensions of health (physical, mental, social and spiritual) is said to be in a state of positive health. The concept of perfect positive health cannot become a reality because a person can never be in perfect state of all the four dimensions. Medical Classification: Officers

Health of serving officers is continuously monitored through periodical medical check-ups during the entire length of their service. Similarly, periodical medical examination of industrial workers is done regularly. Medical Classification

Medical classification of serving officers is done by medical board after assessing his fitness under five factors, indicating by the code word ‘SHAPE’ which represents the following factors: S Psychological H Hearing A Appendages P Physical capacity E Eyesight Medical classification under the system is based on functional capacity of the individual as a whole for military duties. Thus, classification done under this system enables the administrative authorities to assign appropriate assignment to officers depending upon their employment capacity. Functional capacity of an officer under each factor is denoted by numerals 1–5 against each code letter, indicating declining functional efficiency. The numerals

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

are written next to the code letter, except that where an officer is in grade 1 in all factors, his categorization may be denoted by writing SHAPE-1 instead of writing S1 H1 A1 P1 E1. General evaluation of numerals is as under. 1 Fit for all duties anywhere. 2 Fit for all duties but may have limitations as to type of duties of employability. Employment restrictions are given separately by the medical board. 3 Excepting for ‘S’ factor fit for routine or sedentary duties but may have limitations of employability at high altitude (above 2700 meter), extreme cold area/ hilly terrain and for lone assignments for which specific recommendations are given. 4 Temporary unfit for military duties on account of hospitalization/sick leave. 5 Permanent unfit for military duties. Competency addressed: The student should be able to: CM 1.1: Define and describe the concept of public health.

CONCEPT OF PUBLIC HEALTH I. Public Health

• Winslow defined public health as “the art and science of preventing diseases, prolonging life, and promoting health through organized community efforts and informed choices of society organizations, public and private communities, and individuals.” It means organizing healthcare systems, resources and infrastructure. Health management is an example of public health. • WHO and Acheson report defined public health as, “the science and art of preventing diseases, prolonging life and promoting health through organized efforts of society.” • Focus of public health is total population (healthy and sick both). How to Achieve Goal of ‘Health’?

Public health system achieves goal of health by: 1 Providing organized health services (promotive, preventive curative and rehabilitation services) 2 Promoting healthy behaviours and lifestyles (universal exclusive breastfeeding, handwashing, physical activity and avoid tobacco and alcohol). 3 Promoting healthy environments (household and external) water supply and sanitation, prevent indoor and outdoor air pollution, accidents and mosquito breeding or vector breeding. 4 Implementing health legislations against tobacco use, food adulteration, epidemic/pandemic, etc. II. Concept of Preventive Medicine

“It is the science and art of preventing diseases, prolonging life and promoting health”.

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Generally the preventive medicine focuses on individual health or groups, such as high-risk groups and advocates screening of high-risk groups/individuals. The concept can be extended to general population. This term and concept became popular in the United States of America. In India we adopted the term of ‘social and preventive medicine’ or ‘preventive and social medicine’ and subsequently the term ‘community medicine’ has been adopted. III. Concept of Social Medicine

“Social medicine is the study of socio-economic, cultural, environmental and health services and genetic factors and conditions which influence the health of population”. This term and concept became popular in United Kingdom during the industrial revolution. IV. Community Medicine/Community Health

Last JM defined community medicine as “the field concerned with the study of health and disease in the population or a defined community or group. Its goal is to identify the health problems and needs of defined populations (community diagnosis) and to plan, implement and evaluate the extent to which health measures effectively meet these needs”. The Ottawa Charter (1986) is the pivot of principles and practices of health promotion. It recognizes the fundamental conditions and resources for health—peace, shelter, education, food income, a stable ecosystem, sustainable resources, social justice of equity. The Ottawa Charter on health promotion advocates five key strategies: 1 Building healthy public policy 2 Create supportive environments 3 Strengthen community action 4 Develop personal skills 5 Reorient health services. Competency addressed: The student should be able to: CM 1.2: Define and describe the relativeness of health.

RELATIVENESS OF HEALTH

Health is a relative phenomenon. It is biological ‘normal’ state based on statistical norms/standards. The use of reference values to diagnose or screen for disease implies that health is relative concept. Clinical examination, evaluation of laboratory data and diagnostic imaging findings all require comparison to ‘normal’ standard. Normality itself is also relative. Very often normal values differ between geographical areas, between sexes or age groups. For example, ‘normal’ blood pressure differs between sexes, and also varies with age and its pattern is not the same in all human populations. A statement of normal values must indicate the population referred to similarly, pulse rate, heart rate, height, weight, serum

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cholesterol and haemoglobin levels vary from person to person. The establishment of ‘normal’ values permits the selection of appropriate actions in medical practice. Variability is inherent in biomedical measurements upon which decision on individual patient care or community health programmes are based. It is therefore necessary to establish standards on which decision can be made. These standards are often referred to as normal values and are generally based on measurements made on healthy population in statistical reasoning. What occurs most frequently is considered as normal. The problem is often where to draw a cut off line between normal and abnormal. Two types of normal values are usually required for medical decisions: i Point normal values, and ii Normal range • Point normal values are derived from population/ sample mean values (mean, median or mode). • Normal range in medical sciences is as mean ±1.96 SD, which ensures 95% of randomly selected healthy people would fall within the limits in a normal distribution. It is easy to compute normal range in term of the mean and standard deviation by using the property of normal distribution. Competency addressed: The student should be able to: CM 1.2: Define and describe determinants of health.

DETERMINANTS OF HEALTH

Determinants of health are underlying causes of illhealth and development. These are—“the causes for the causes” these can be addressed by collective action across multiple sectors—health, education, nutrition, water and sanitation, poverty reduction, etc. ‘Health in all Public Policies’ and healthy public policies can be effective interventions. Health is a development function. Much more health comes through sectors other than health sector, such as water and sanitation (environments) nutrition, literacy women and child development and healthy lifestyles (behaviours). These are also known as determinants of health. Hence, integration of health services with determinants of health achieves better health. The National Health Mission adopts a synergistic approach by effective integration of Health concerns with determinants of good health, viz. nutrition, sanitation, hygiene and safe drinking water through district action plan for health. 1. Environment

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This is considered to be the most important determinant and input to health. The environment is defined as “the aggregate of all external conditions and influences affecting the life and development of an organism, human behaviour and society”. A composite of physical, economic

pressures, culture and education contributes largely to the background to which one’s genetic apparatus reacts. Harmonious environment relationship to man contributes to an improved state of health (Fig. 1.1). Rightly so the national health planners have included in their agenda to control and improve the natural physical environments, e.g. air, water, soil, and noise. Man-made Environment

In man-made environment or artificial environment included items are housing, transport, industries and communication (roads, rail, air and sea). Environment forms the fulcrum in the chain of transmission (epidemiological triad) as shown in Fig. 1.2. There is continuous interaction between agent, host and environment: Agent  Environment  Host. If there is an equilibrium between agent, host and environment, the balance is maintained and the individual, family and community enjoy perfect health. If the environments become favourable for agent (disease producing stimulus/factors/conditions/microorganisms) the balance is tilted, health is disturbed and the result is disease or bad outcome. Treating and modification of environments favourable to human host promotes health and prevents diseases. Over 80% of diseases are due to bad environments like unsafe water supply, wide spread insanitary conditions due to indiscriminate defecations, poor disposal of waste water, garbage and refuse apart from air pollution leads to wide spread filthy conditions and are perpetual threat to endemic diseases and outbreaks. Mosquitoes and fly breed enormously and pose threat to occurrence of several diseases. Environment is a global concern and all energies are now focused to save the planet (our earth) by improving the deteriorating environments. While talking of environments, community treatment has been successful by handling the environment by three methods: i Socio-economics (poverty): The term social and economics although susceptible to different definitions are completely interdependent in relation to environment. Economic life is chief determinant of social existence, hence the term socio-economics. The poor governments do not have enough money and so are the people of that government. Poverty affects the health in that productivity is lost due to partial disability. There is vicious circle because people are poor as they are sick and sick because they are poor. However, the high economics does not always assure good health. They may purchase things which impair health. ii Wealth distribution (employment): Remunerating jobs, freedom from unemployment provides for improving living standards which in turn can help provide personal and environmental health, these are considered purchasable commodities. Wealth ensures

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Fig. 1.1: Determinants of health (WHO*) * The direction of the arrow indicates the direction of impact while the width of the arrow indicates the relative weight or importance of the input to health (WHO). “One health approach”: Focuses on measures to protect the health of animals, environment and humans.

iii

iv.

• •

good housing facility, nourishment, clothing, recreation, good use of leisure, and all these contribute to health. Education: Besides socio-economics education is another variate for contribution to health. Educational progress conditions biological, domestic and technical progress. Its positive contribution to economic growth including health is recognized by all. Planning for education is thus considered planning for health and vice versa. ‘Education for all’ and universal elementary education are the thrust areas which will contribute substantially to improved health for all including environments besides healthseeking behaviour. The Environment (Protection) Act of 1986 is an Umbrella Act for the protection of the environment. Relevant to the water environment, this Act has among others the following features: Nationwide programme for prevention, control and abatement of environmental pollution. Empower any person to enter, inspect, sample and test.

Fig. 1.2: Characteristics of agent, host and environmental factors

• Establish/recognize environmental laboratories. • Regulate, close, prohibit industries, processes, and operations. • Require Government organizations to furnish information, etc. The Central Pollution Control Board (CPCB) is the national apex body for assessment, monitoring and control of water and air pollution. Well-managed and integrated water and sanitation programmes are crucial to health and development. A clean environment and adequate safe water are essential prerequisites for all children to grow, develop and attain good health. There is now distinct change in the strategy for promoting sanitation by the government. The Central Rural Sanitation Programme now promotes sanitation as a seven-component package: Handling of drinking water, disposal of waste water, disposal of human excreta, disposal of garbage and animal excreta, home sanitation and food hygiene, personal hygiene and village sanitation. Investments for ensuring access to safe drinking water will bring the desired health benefits only when complemented by investment in all the seven components of sanitation. A staggering 29% of Indians defecate in open risking the environments and leaving the excreta to seep through the soil and contaminate the water table and water bodies with pathogens which come back into food chain. This is a key causative factor behind the high prevalence of soil and waterborne diseases in rural India as also in urban slums. According to World Health Organization, 80% of all diseases, such as diarrhoea, cholera, typhoid fever

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infective hepatitis, vector-borne diseases, etc. are caused due to lack of safe water and sanitation. END OPEN DEFECATION BY 2030

As per UNICEF 2020 data, 71% of households have toilets. This percentage is lower in villages where 67% use toilet (Table 1.1). Total sanitation campaign (TSC)/ Swachh Bharat Abhiyan (Gramin and Urban) is a sound beginning. Its objectives are to bring about improvement in the general quality of life in rural areas, accelerate sanitation coverage and generate demand for toilets in all schools and Anganwadis in rural areas through awareness and behaviour change through education involving Panchayati Raj Institutions (PRIs). Nirmal Gram Puraskar a National Award under total sanitation campaign has been launched on Feb. 24, 2005 by the Government. PRIs can look forward to get cash prizes ranging from 50,000 to 5,00,000 if:5–7 • All households in the village have access to toilets with full usage. • There is no open defecation. • All Anganwadi centres have access to sanitation facilities. • There is general cleanliness all around. • Kerala is the first state to end open defecation. • India was declared open defecation free in Oct 2020.

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Table 1.1: Households basic sanitation services 2021 Country

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Improved sanitation coverage (%) Urban

Rural

Total

China

95

88

92

India

79

67

71

Iraq

100

100

100

Pakistan

82

60

68

Sri Lanka

93

94

94

World

88

66

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Environment being Compulsory Subject

50 hours compulsory core module course in Environmental studies, spread over to 6 months, at undergraduate level in all streams has been introduced by various universities in view of direction of the Hon’ble Supreme Court of India; with effect from 2004 to 2005. This course will enhance knowledge, skills and attitudes to environment. The syllabus is divided into eight units covering 50 lectures including field work activities of five lecture hours. 2. Behaviour of Host (Fig. 1.1)

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i It is considered second largest area or determinant/ input to one’s health and at some places it is even higher than environment. Like most personally held values and beliefs, certain habits are first learnt from family, community and school, all of these play an important role in general behaviour pattern. In terms of

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satisfactory survival, one’s behaviour may not be the most rational and will therefore require modification through effective behaviour change communication (BCC) in most of non-communicable diseases. Each society and indeed individual has cultural values, ideologies and interests relating to health and health services. The beliefs inimical to survival indicate need for health promoting changes in cultural pattern. But it may also be determined whether such changes are desirable or even tolerable. Behaviour change communication is to create healthy lifestyles, healthy habits, responsible reproductive behaviour, values of traditional and indigenous foods, safe sex and practice of personal hygiene to promote health and prevent diseases. Proper evaluation of beliefs, social values and motivation should determine the needed changes and in which way the services are to be provided to be acceptable. Attitude change is a major change and may bring about permanent behavioural change (feeding young children, promotion of universal exclusive breastfeeding, feeding and eating habits—a core cultural variable, adequate diet for physical and mental alertness). Primary values are respected and self-image is not destroyed. Geographical social mobility and dissatisfaction foster change. Attitudes are also related to utilization of services provided. Even for the existing services, the utilization rates are low at 50% or even less for antenatal care, use of iron and folic acid and vitamin A prophylaxis. Habits (habit means repetitive behaviour in an individual): Habits die very hard. In the word ‘HABIT’ if you remove ‘H’ ABIT of it is there, if you further remove ‘A’ BIT of it is there, if you remove ‘B’ IT is still there. Habits do not change by sheer will power. It demands change in beliefs and attitudes and it requires practice and skills.

3. Health Services

Availability, accessibility, affordability and acceptability of health services are considered an important determinant/ input to health. Health services utilization depends on quality of services offered as also faith and satisfaction derived from services apart from accessibility. Health services include promotive, preventive, curative and rehabilitative services available through various health systems. Utilization of health services depends upon health behaviour and socio-economic conditions (income, literacy and occupation of a person). 4. Heredity

Genetic inheritance may provide the initial significant contribution to one’s state of health, may be modified by

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

environments and specifically by health services. Even before individual’s birth, comprehensive health planning will need to include such aspects of healthcare as prenatal counselling and prenatal care apart from marriage and genetic counselling. Ecology of health: Ecology is defined as mutual relationship between living organisms and their environment. Ecology of health is the study of relationship between variations in man’s environments and his state of health. Social Determinants of Health8

Social determinants of health are the ‘causes for the causes’. Social determinants of health are the conditions in and under which people are born, grow, live, work and age, and broader set of forces, and systems that shape the conditions of daily life are referred to as social determinants of health (WHO). These include early year’s experiences, education, economic status, employment and decent work, housing and environment and effective systems of preventing and treating ill health. Actions on these determinants, such as eradicating poverty and hunger, ensuring food security, access to safe drinking water and sanitation, employment and decent work and social protection, protecting environments and delivering equitable economic growth will ensure economically productive and healthy society. It requires ‘Health in all policies’ with action by sectors outside the purview of health to attain better health and development. Village Health Sanitation and Nutrition Committees (VHSNC), Urban Health Sanitation and Nutrition Committes and Mahila Arogya Samiti in Urban Slums

Following the launch of revised guidelines for VHSNCs, as a part of guidelines for community processes VHSNCs are envisaged as a standing/subcommittee of the Panchayat and the role of ASHA as member secretary has been strengthened. Village Panch has been made the chairperson and VHSNC has been reconstituted. Over 5.55 lakh VHSNCs have been constituted by March 2021. Composition of VHSNC • Minimum of 15 members, chairperson—mahila panch— scheduled caste preferred. • Member secretary—ASHA. • Members: Elected Gram Panchayat members—5, ANM, AWW, school teacher, PHED, NGO members/ self-help groups volunteers 10, including users of health services. Untied grant: `10,000 per annum for local actions, e.g. village sanitation and reduction of breeding of mosquitoes. Objectives VHSNC: To provide a platform for convergent actions on social determinants and all public services directly or indirectly related to health.

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Convergent Actions on Social Determinants of Health

A year-long campaign—VISHWAS (village based initiative to synergise health water and sanitation) has been launched which will be conducted by each VHSNC/ UHSNC in its village across all the states. ASHA will play key role in facilitating this process, but the campaign will be led by VHSNC members, and core group of volunteers from community. Eleven monthly campaigns will be conducted on selected themes, viz. • Open defecation free village day, school and Anganwadi sanitation day, liquid and solid waste management, healthy lifestyles/health promotion, vectors control day— dengue and malaria, safe water and personal hygiene, integrated diarrhoea control fortnight, breast-feeding week. National Nutrition week/month in September. • Each of these monthly campaigns days will aim at building a platform for convergence of all programmes, resources and community action on the day’s theme. A manual for the campaign has been prepared. The campaign has been rolled out in October 2017. These activities are part of strategic information, education and communication (IEC) plan of Ministry of Health and Family Welfare (MOH and FW) using mass media along with mid-media, social media and inter-personal communication. National Urban Health Mission (NUHM) envisaged a woman collective/Samiti in urban slums/slum-like settlements as a leadership platform for community level actions. As per guidelines, Mahila Arogya Samiti (MAS) has been constituted at the level of 50–100 households. MAS is expected to generate demand, ensure optimal utilization of services, increase community ownership and sustainability, and to establish community-based monitoring system. Over 62000 MAS have been formed in urban slums as part of urban health centres under NUHM. International classification of functioning, disability and health (ICF) recognizes the role of environmental factors, more than biological or medical, in creation of disability. In doing so, it takes into account body functions and structures, activities of people, participation and their involvement in all areas of life, as well as environmental factors which affect these experiences. Against this background, measuring or assessing individual functioning involves systemic recording and mapping of various qualifiers, facilitators or barriers in relation to impairment, activity limitation and participation restriction. The term ‘capacity’ refers to what an individual can do in a standard environment and ‘performance’ refers to what a person actually does in his/her current or usual environment. The gap between the two provides useful guide to what can be done to the environment of the individual to improve the performance. Apart from the scope of using ICF model into legislation and social policy, it has abundant application value in clinical settings for rehabilitation programming.

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Rather than enlist behaviours through assessment on “what an individual cannot do”, following ICF the focus has shifted to “what they can do”. Concept of Disease

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The WHO has defined health, but not disease because of its variations, e.g. mild, moderate, severe, fatal, and disease without clinical manifestations. Definition, given by Webster, “A condition in which the body health is impaired, a departure from a state of health, an alteration of human body interfering in performance of vital functions”. Morbidity: Any departure, subjective or objective, from a state of physiological or mental well-being, whether due to diseases, injury or impairment. Disease means ‘lack of ease’ or ‘disorder of structure or function’. Disease produces specific symptoms or that affects a specific part of the body. Examples: Fever, cough, diarrhoea, vomiting, convulsion, injury to any part of the body that may result in loss of body part or may affect the function of the body parts such as loss of vision, hearing, etc. Extent: Overall 7.5% of people are sick at any given point of time, 6.8% in rural and 9.1% in urban areas, respectively (NSSO 75th Round 2018). Pattern: Occurrence of disease varies by time, places, and persons. Spectrum: Disease has a spectrum, it may be subclinical with no symptoms or signs or it may be early disease with mild symptoms and signs or it may be in advance or at severe stage with frank signs and symptoms. The outcome of disease may be full recovery with or without treatment, recovery with sequelae or disability or a person may die of fatal disease. Those who recover may become carriers of that disease (infectious disease). Duration: A disease may be of short duration lasting for a few days less than a week or 2 weeks or it may be of long duration. A disease of short duration is called acute disease, e.g. acute diarrhoea fever, cough or a disease may have longer duration and we call it a chronic disease such as tuberculosis, leprosy, typhoid fever. Symptoms of ailment persisting more than one month or if a course of treatment of an ailment continuing for a month or more is called a chronic ailment. Some diseases such as diabetes, hypertension, HIV are lifelong and require lifelong continuous treatment and follow-up. Major categories: A disease may be communicable, i.e. spreads from person to person or may spread by or transmitted by a vector or a common source such as unsafe drinking water or food. These diseases are caused by microorganisms. Other categories of diseases are noncommunicable diseases (NCDs) which are chronic in nature, expensive to treat and are caused by unhealthy behaviours or lifestyles and are multifactorial.

Measuring disease burden: Disease burden is measured by disability adjusted life years (DALYs). One DALY equals to 1 year of healthy life lost due to premature death or disability. Other measures of disease are incidence and prevalence rates, spells of sickness and duration of sickness. Competency addressed: The student should be able to: CM 1.3: Describe the characteristics of agent, host and environmental factors in health and disease and multifactorial etiology of disease.

Figure 1.2 displays the characteristics of agent, host and environments in health and disease. The detail of characteristics of agent, host and environment is described in Chapter 7 on pages 245–251. Causes—single or multifactorial: A disease may be caused by a single agent or specific micro-organism (bacteria, viruses, protozoa, rikettsial, spirochaetes and fungi, etc.) or may result from combination of several risk factors, we call it a multifactorial disease, e.g. cardiovascular diseases, diabetes, cancers, etc. are multifactorial (see pages 256, 300 and 468). Ayurveda propagated disease theory based on ‘Imbalance of Tridosha’—Vata (air), Pita (bile) and Kapha (mucus). Competency addressed: The student should be able to: CM 1.4: Describe and discuss the natural history of disease.

The natural history of any disease refers to the phases through which the disease passes, in the absence of any intervention. Clear knowledge of natural history of a disease helps in identifying the stages vis-à-vis appropriate intervention to prevent and control the disease or eliminate and eradicate a disease. The natural history of any disease begins as soon as the organism of a disease (infectious (disease) enters the body of a susceptible host or else a disease provoking stimulus or accumulation of risk factors or condition/exposure/circumstance or combination of these factors start operating in the susceptible host. Pre-pathogenic phase: During this period the host stays healthy without any disease and the agent, host and environment remain in balance. Pathogenic phase: This begins/starts as soon as the disease producing organism or stimulus enters the human body, the body of host reacts and chain of events follow as depicted in Fig. 1.3. If the natural history of a disease is known and most probable risk factors/exposures are known then appropriate levels of prevention/interventions can be applied in healthy population or in sick persons to promote health, to prevent disease, cure disease, limit disability and to rehabilitate persons. Competency addressed: The student should be able to: CM 1.5: Describe the application of interventions at various levels of prevention.

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Fig. 1.3: Natural history of disease and levels of prevention

LEVELS OF PREVENTION The word ‘prevention’ is derived from Latin ‘praevenire’ means ‘to come before’. The prevention is anticipatory medicine. It comes before the disease occurs. Anticipatory actions or proactive measures are preventive in nature. Preventive actions can be taken at any stage of the spectrum of health and disease. Most of the preventive measures are focused on ‘healthy people’, to ensure that they stay healthy and do not contract or develop disease or diseases. The goal of prevention is to ‘achieve health for all’ or ‘health in all’9 to ensure adequate level of health which permits them to lead a productive and socially useful life (Fig. 1.4).

Fig. 1.4: Proportion of ailing persons in a 15 days period

Clearly, the concern and focus of prevention is on 92.5% ‘healthy people’ to ensure that they stay healthy but the concept of prevention can be applied to 7.5% of unhealthy

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or sick also to restore their health at the earliest and to prevent deaths and disability in sick persons. LEVELS OF PREVENTION—APPLICATION OF INTERVENTIONS AT VARIOUS LEVELS

Following levels of prevention are applicable: 1. 2. 3. 4.

Primordial Primary Secondary Tertiary



Focus on healthy people/total population



Focus on sick people (who have already developed a disease)

All these levels are important and complementary, although primordial prevention and primary prevention have the most to contribute to the health and well-being of the whole population. 1. Primordial Prevention

This is the real prevention, which does not allow the people to fall sick. The goal of primordial prevention is healthy nations, healthy population, healthy cities, towns and villages, healthy homes, healthy environments, and work place. Aim

The aim of primordial prevention is to prevent the emergence of ‘unhealthy lifestyles’ in population or to prevent the emergence of ‘risk factors’ in the community. Primordial prevention is a strategy to reduce risks and promote healthy lifestyles. In developing countries with high mortality, 10 selected leading risk factors have been identified for appropriate actions, these are: i Underweight/malnutrition ii Unsafe sex iii Unsafe water, sanitation and hygiene iv Indoor smoke from solid fuels v Zinc deficiency vi Iron deficiency vii Vitamin A deficiency viii High blood pressure ix Tobacco use x Cholesterol

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The policy and legislation on tobacco and smoking have been adopted by many governments in the world including India. Tobacco epidemic can be prevented by effective legislation against tobacco. WHO global initiative has motivated many countries to adopt effective policy on tobacco. People should not take onto smoking (tobacco use) or adopt unhealthy lifestyles in relation to diet, exercise, and physical activity. The world is living dangerously either because it has little choice or because it is making wrong choices. Today

there are more than 8 billion people coexisting on this fragile planet. On the one side there are many millions who dangerously face high and heavy concentrated burden from poverty, undernutrition, unsafe sex, unsafe water, poor sanitation and hygiene, iron deficiency and indoor smoke from solid fuels. On the other side lies unhealthy consumption, particularly tobacco and alcohol. The risks from blood pressure and cholesterol, strongly linked to heart attacks and strokes are also closely related to excessive consumption of fatty, sugary and salty foods. They become even more dangerous when combined with deadly forces of tobacco and excessive alcohol consumption. Obesity a result of unhealthy consumption coupled with lack of physical activity is itself a serious health risk. India is facing a double burden of disease, i.e. infectious diseases due to lack of safe water, sanitation, and chronic non-communicable diseases due to unhealthy lifestyles. Primordial Prevention Strategies (a) At Government Level: Healthy Public Policies

The Government especially Health Ministry should play a stronger role in formulating risk prevention strategies which are population- or community-based strategies. • Provision of safe water and ensuring sanitation to rural, tribal and urban areas (The Swachh Bharat Abhiyan). • Policy on nutrition to improve nutrition by effective agriculture policy on “food for all and good nutrition for all” particularly improving the nutrition of most vulnerables: Infants, young children, adolescent girls, pregnant women and lactating mothers. • Revised National Nutrition Policy on promotion of healthy diets. • Controlling food industry to prevent production and sale of junk foods, salt and trans-fats reduction in processed foods. • Healthy foods through mid-day meal in schools. • Tobacco, alcohol and substance abuse: Tobacco of course is a major risk factor for cardiovascular diseases. In terms of intervention, the greatest tobacco-related improvements in population health would be a combination of tobacco taxation (Sin tax), comprehensive ban on advertising and restriction of smoking in public places and sale of cigarettes/bidis to children should be implemented. ‘Legislations on tobacco’ by all nations has been adopted in view of great health risks of tobacco. • Policy on crop alternative to tobacco. • Controlling/regulating behaviour of road users through Road Safety Motor Vehicle Act—licensing for driving, use of safety belts and helmets. • Prevention of air pollution (indoor and outdoor). • Promoting non-health sectors involvement in developing policies for control of NCDs and intersectoral coordination—agriculture, education, food industry,

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

women and child development, ministry of sports, etc. (multisectoral action plan for NCDs). • Protection of environments. • Improved safety at workplace. Thus, the primordial prevention can be achieved by combination of education and legislation on tobacco and food, promotion of physical activity, healthy and clean eating and observing personal hygienic practices. These measures should begin right during childhood period, continued during adolescence, and maintained in youth, adulthood and old age. These measures will reduce emergence of risk behaviours in the population. Competency addressed: The student should be able to: CM 1.6: Describe and discuss the concepts, the principles of health promotion and education, IEC and BCC.

This competency overlaps with Chapter 4, hence also covered in Chapter 4. Health education is an important mean of health promotion and prevention of diseases. (b) At Community Level

• IEC and BCC for healthy lifestyles. • Education: Health education for adopting healthy behaviours through mass media and inter-personal communication focusing on predominant risk factors— undernutrition, unsafe sex, unsafe water and bad sanitation, high blood pressure, high cholesterol, overweight and tobacco use. 2. Primary Prevention

Once the risk factors have emerged in the community or unhealthy behaviours are practiced on large scale, the primary prevention has prime place. Aim

The aim of primary prevention is to limit the incidence of disease by controlling underlying causes/risk factors. or To prevent the development of disease/diseases in population, by modification of risk factors. Strategies of Primary Prevention (Fig. 1.3)

A Health promotion. B Specific prevention/protection against disease, trauma and accidents. A. Health Promotion

Health promotion means improving positive health in general by observing time honoured ‘best practices’ like personal hygiene, brushing teeth, handwashing, avoiding smoking and alcohol, regular physical exercise, adopting healthy habits of eating, etc. Best health practices (lifestyles) are established and practiced in the family first

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of all and at school and workplace and with peers in later life. Measures for health promotion: Health promotion can be achieved through health education programmes, which could be formal and non-formal. Health education should be part and parcel of general education. Adequate nutrition, Universal exclusive breastfeeding improving environmental sanitation (safe water, safe disposal of human and animal excreta, reduction of air pollution), regular physical exercise and yoga promotes health and prevents diseases in population. B. Specific Protection

• Immunization, against vaccine preventable diseases prevents many diseases. Most of the countries including India have national immunization programmes to prevent diseases. Immunization against polio is an important strategy for polio eradication. Smallpox was eradicated by effective vaccination programme. Hep B vaccine prevents liver cancer. • HPV vaccine prevents cervical cancer. • Specific nutrients like mega doses of vitamin A and iron and folic acid tablets to young children, pregnant and lactating women and adolescent girls prevent blindness due to vitamin A deficiency and anaemia, respectively. Iodine consumption by salt iodization prevents goitre/iodine deficiency disorders. • Contraception: To prevent births, contraceptives are used widely. This is the priority number one in India to limit the size of population by spacing and terminal methods of contraception. • Prevention of HIV and AIDS as also STIs, hepatitis B by condom use are examples of specific protection. • Accidents prevention: Use of helmets and safety belts prevents head injuries and fatal accidents. Safety devices used in industries to prevent injuries and accidents are also an example of specific protection against accidents and injuries. • Avoidance of allergens, radiation by specific protection. Approaches

We have two approaches in primary prevention, which are population-based and high-risk approach. (a) Population-based Approach

In population-based approach, the intention is to cover the whole population for adopting healthy lifestyles through behaviour change communication. Universal immunization focuses on coverage of all infants. Similarly, safe water for all, the focus is whole population; universal elementary education is also population-based strategy. Other population-based approaches are legislation against smoking and tobacco and fixing legal age for marriage

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and risk reduction against HIV/AIDS, universal salt iodization are the examples of population-based strategies to prevent diseases or epidemic prone diseases. Regulating salt content and trans-fats in manufactured foods, maintenance of healthy diets, reduction of salt intake and saturated fats, promoting physical activities and control of tobacco use are key population-based strategies. Advantages

• Population-based approaches are useful and these make high impacts in reducing the incidence of diseases and are sustainable and cost effective. • The population approach does not require any screening programme to identify high-risk groups. • Population-based approaches are more rewarding in risk reduction in population and treating underlying cause. (b) High-risk Approach

The focus of primary prevention in this approach is select individuals who have high risk such as commercial sex workers or bridge population who practice high-risk sexual behaviour, and people with sexually transmitted infection (STD clinic attendees). This strategy is being followed in National AIDS Control Programme in the country. Smokers are also high-risk individuals and similarly persons having family history of diabetes and hypertension are high-risk individuals. Individual screening programmes for identification of high-risk individuals for coronary heart disease, hypertension and obesity have not met with much success. Screening is a costly affair and very few can afford it. Focus on high-risk individuals will deal with only margin of the problem as it covers small number of persons and will not have much impact on reduction of disease incidence or underlying cause in population. Individual measures to reduce risk-like screening for blood pressure, cholesterol, diabetes and weight and height measurement, may produce small effects as these involve lot of cost, and effect of individual approach pays least. Advantages

High-risk approach seems to be attractive as some argue that scarce resources should be used for high-risk people but this does not yield much results. Implications

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The distribution and determinants of risks in a population have major implications for strategies of prevention. Geoffrey Rose observed that in vast majority of diseases “natural history of disease presents us with continuum, not a dichotomy”. Risk typically increases with across the spectrum of a risk factor. Use of dichotomous labels such as ‘hypertensive’ and ‘normotensive’ are therefore not a description of natural order, but rather an operational convenience. Following this line of thought, it becomes

obvious that the ‘deviant minority’ (e.g. hypertensive) who are considered to be high-risk are only part of risk continuum; rather than a distinct group. This leads to one of the most fundamental axioms in preventive medicine “a large number of people exposed to a small risk may generate many more cases than a small number of exposed to high-risk”. Rose pointed out that wherever this axiom applies, a preventive strategy focusing on high-risk individuals will deal with only margin of the problem and will not have any impact on the large proportion of disease occurring in large proportion of people who are at moderate risk. For example, people with slightly raised blood pressure; suffer more cardiovascular events than the hypertensive minority. While the high-risk approach may appear more appropriate to individuals and their physicians, it can have only little effect at a population level. It does not alter the underlying cause of illness, relies on having adequate power to predict future disease, and requires continued and expensive screening for few high-risk individuals. The relation between risk factors and disease events is continuous and most events occur in people in the middle range of risk factors distribution who are not normally judged as at high risk. The effort expended on measuring risk factors in individuals is, therefore questionable (Robert Beaglehole). Screening for risk factors in individuals (checking blood pressure, overall check-up, check-up for diabetes and monitoring of cholesterol, etc.), cost time and lot of money and resources should be directed towards primary prevention based on population strategies of risk reductions. In contrast, population-based strategies that seek to shift the whole distribution of risk factors have the potential to control population incidence. Such strategies aim to make healthy behaviours and reduced exposure into social norms and thus lower the risk in entire population. The potential gains are extensive, but the challenges are great as well, a preventive measure that brings large benefits to the community appears to offer little to each participating individual, this may adversely affect motivation of population at large (known as prevention paradox). Population-based approach is most often applied to prevention of cardiovascular diseases. Population-based strategies to reduce salt content of manufactured food, maintenance of healthy diets, promotion of physical activity and control of tobacco industry should be priority to control epidemic of cardiovascular diseases. 3. Secondary Prevention

This level of prevention is directed towards those individuals who have developed disease. Early detection and prompt treatment at any stage can alter the course/outcome of disease. Aim

Aim of secondary prevention is to reduce prevalence of disease in the community by curing that disease.

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

The secondary prevention is valid in our country for early detection and prompt treatment of tuberculosis, leprosy, malaria, blindness and cancer in the country. Strategies (Early Diagnosis and Prompt Treatment)

• The strategy of secondary prevention is to detect the disease at early stage and ensure prompt treatment to reduce its severity and duration. Example: Detection of malaria by active and passive fever surveillance offers prompt treatment in homes, similarly sputum examination of those persons having cough of 2 weeks or more helps early detection of tuberculosis and prompt treatment with DOTS strategy. • By having population-based screening programmes, for persons above 30 years of age, we can detect the diseases at early stage. Screening of vision to detect refractive errors, to detect cataract, to detect precancerous lesions, diabetes, blood pressure measurement for treatment of hypertension in middle-aged and elderly people. Similarly, growth monitoring of children and birth weighing can detect growth faltering at the earliest to treat it at an early stage. • Surveillance and screening programmes help early case detection and prompt treatment. Periodic medical examination of industrial workers and army personnel helps in early detection of disease and its prompt treatment. This aims at detect susceptible persons/ factory workers and remove them from exposure before they suffer any permanent incapacitation. 4. Tertiary Prevention (Disability Limitation and Rehabilitation)

The tertiary prevention is the last level of prevention. It is applied when the individual has reached an advanced stage of disease. It indicates that the first two levels have failed. Aim

• To limit the progress and development of complications of established disease. • To reduce impairment and disability. • To provide rehabilitation measures. • To prolong life. • To prevent deaths. Disability Limitation

Once a disability (impairment, activity limitation, participation restriction) has occurred, measures can be taken to prevent its progression to handicap. Disability can be limited to minimum by advanced treatment at referral centres or established clinics by physiotherapy, and by training of disabled for self-care. Rehabilitation

Once the disability has progressed to the stage of handicap, then attempt is made to rehabilitate the

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individual. It is a restorative medicine using the remaining capacities of an individual and making him/her selfreliant and useful member in the community. The rehabilitation consists of physical, occupational and social rehabilitation measures. These are very costly. Examples of rehabilitation: Rehabilitation of paraplegics, amputees (those who have lost limbs), blinds, deaf, mentally retarded, leprosy cases and polio cases. These persons are being provided support for rehabilitation at established centres either by government or by voluntary organizations. Example: Artificial limbs and foot, hearing aids, spectacles, wheelchair for mobility, speech therapy, crutches, etc. Community-based rehabilitation (CBR) is the preferred approach wherein family and community takes responsibility and government provides support. CBR programmes are designed and run by local communities. CBR seeks to ensure that people with disabilities have equal access to rehabilitation and other services and opportunities—health, education, and livelihoods. Developed by WHO in 1980s CBR is practiced in more than 90 countries and represents move away from institutions towards community self reliance. Tertiary prevention is a costly and a challenging task. Competency addressed: The student should be able to: CM 1.7: Enumerate and describe health indicators.

HEALTH INDICATORS

It is somewhat easier to define health for an individual or person or child or adolescent or youth but to define ‘community health’ is somewhat more difficult. ‘Community health’ parameters are different from health parameters of an individual. Community health can be measured through indicators of economics (gross national product, gross national income and per capita income), life expectancy, under five mortality, infant mortality, literacy level, composite index like human development index, maternal mortality, etc. The other indicators of community health are environmental indicators, demographic, access to health services, healthcare utilization and health policy indicators. A community is healthy when it enjoys sound health where disease and death rate is acceptably low, it is not threatened with bad environments and its economy is sound and the health practices are sound and based on scientific evidences. Its literacy levels are high and demographically it has balanced sex ratio and people live long, quality of life is good and human development index is high. A village is said to be healthy if it has safe source of improved water supply, safe method of waste water disposal, paved streets, disposal of garbage, refuse and animal excreta by manure pits, people use sanitary latrines, female literacy is high, girls enrolment is universal, deliveries are conducted by trained persons,

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birth rate and death rate are within acceptable limits, immunization coverage is high, children are wellnourished and housing condition is good. INDICATORS OF QUALITY OF LIFE Gross National Income (GNI) Per Capita

Definition: The gross national income (GNI), formerly referred to as gross national product (GNP) measures the total domestic and foreign value added claimed by the resident producers, at a given period in time, usually a year expressed in constant 2017 international dollars converted using purchasing power parity (PPP) conversion rates. Limitations of GNI

Growth of GNP does not necessarily ‘trickle down’ to the poor and governments often struggle to intervene to ensure the distribution of economic progress to the poor but it percolates very slowly. The GNI is concerned with production which is traded or monetarized, it does not reflect such factors as growing of food for family consumption or the unpaid labour of women or do it yourself building of homes, or local collection and consumption of water or firewood and varieties of activities in home settings in rural and urban areas. Average income statistics fail to reflect real levels of ‘social income’ provided by such government financed services as health and education. Large proportion of GNI does not enter world trade, official exchange rate cannot reflect domestic purchasing power. Moreover, GNI is an average figure. GNI of India was International $ 6590 per annum per person in the year 2021. Gross Domestic Product (GDP) Per Capita

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Definition: The average per capita market value of the sum of gross values added of all resident institutional units engaged in production, for a given national economy, at a given period in time, usually a year, expressed in international dollars using purchasing power parity rates. GDP measures the total output of goods and services for final use occurring within the domestic territory of a given country, it provides an aggregate measure of production. GDP for the year 2021 in India was $6590. Life expectancy in India: In India as a result of Covid19 pandemic the life expectancy of 69.7 years in 2019 has declined to 67.2 years in 2021, which is now 68.9 years for women and 65.8 years for men. Healthy life expectancy (free from disability): Reflects overall health of country’s population in India from 2000 (54.2 years) to 2019 (59.3 years) improved by 6.1 years. Lost healthy life expectancy (HALE) represents equivalent years of full health lost through years lived with morbidity and disability.

HUMAN DEVELOPMENT INDEX

The human development index (HDI) remains an aggregate measure of progress in three dimensions—health, education and income. Inequities in human development persist According to the revised human development report (HDR) methodology, HDI includes following parameters in three dimensions. 1 Life expectancy at birth. 2 Mean years of schooling and expected years of schooling. 3 Gross national income (GNI) per capita. In the revised methodology, the health dimension is still assessed by life expectancy at birth and is calculated using a minimum value of 20 years and maximum value of 85 years, with the data provided by the UN Population Division. In the calculation of revised education component, education index is measured by mean years of schooling for adults aged 25 years and older and expected years of schooling for children of school-entry age. It is preferred over literacy rate as mean years of schooling are measured more frequently in most of the countries, and can better discriminate between countries. The mean years of schooling are estimated by the United Nations Educational, Scientific and Cultural Organization (UNESCO), institute for statistics, based on educational attainment data from various census and surveys. The expected years of schooling are based on enrolment by age at all levels of education, capped at 18 years, and are produced by the UNESCO, institute for statistics. Further, in the revised methodology, standard of living is being measured by gross national income (GNI) which is a better measure than gross domestic product for globalized economies, as significant difference may be there between income of a country and its residents. Also, some residents who live abroad send their income back to the country and some living in a country send their income abroad, which gets covered in GNI. Following indices are used to represent aforementioned parameters: 1. Life expectancy index (LEI)

Life expectancy index =

Life expectancy  20 85  20

85 and 20 are maximum and minimum assumed values of life expectancy at birth, respectively. LEI is 1 when life expectancy at birth is 85 and 0 when life expectancy at birth is 20. 2. Education index (EI): Mean years of schooling index + Expected years of schooling index Education index = 2

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Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

A. Mean years of schooling index (MYSI)

Mean years of schooling 15 15 is projected as maximum value of mean years of schooling in any country till 2025. MYSI =

Human development index is geometric mean of all three indices works out 0.633 for the year 2021 in India (Tables 1.2 and 1.3). Table 1.2: Ranking of countries based on HDI scores (Human Development Report 2021—UNDP)

B. Expected years of schooling index (EYSI)

Rank

Name of country

Expected years of schooling 18 18 is equivalent to achieving master’s degree in most countries. 3. Income index (II): In  GNIpc   In 100  Income index = In  75000   In 100 

1

Switzerland

0.962

2

Norway

0.961

5

Australia

0.951

132

India

0.633

191

South Sudan

0.385

EYSI =

The value of income index is 1 when GNI per capita is $75,000 and 0 when GNI per capita is $100. The higher the GNI per capita of a country, the higher would be the value of its income index. Finally, the HDI is calculated as geometric mean of these three normalized indices, with equal weightage to all, which though is often criticized as all these dimensions not necessarily contribute equally in human development. HDI of India in 2021

Life expectancy at birth Mean years of schooling Expected years of schooling GNI per capita

= 67.2 years = 6.7 years = 11.9 years = 6590$.

1. Life expectancy index (LEI)

Life expectancy index =

67.2  20  0.726 85  20

2. Education index (EI)

MYSI =

6.7 = 0.447 15

11.9 = 0.661 18 0.447  661 Education index =  0.554 2 EYSI =

3. Income index (II)

Income index =

In  6590   In 100 

In  75000   In 100  Income index = 0.626 Geometric mean of 1, 2 and 3 indices  3 0.726  0.554  0.686  0.633

HDI score

Between 1990 and 2019, India’s HDI value increased from 0.434 to 0.645, an increase of nearly 50%, an indication of country’s remarkable achievement in lifting 271 million of people out of poverty. However in 2021 the HDI declined to 0.633 due to Covid-19 pandemic Table 1.3. Table 1.3: Trend of HDI in India Year

1990

2000

2010

2015

2019

2020 2021*

HDI

0.434

0.491

0.575

0.629

0.645

0.642 0.633

* However in 2021 the HDI decilined to 0.633 due to Covid-19 pandemic.

The Covid pandemic has infected and killed millions of people worldwide. It has upended the global economy, interrupted education dreams, health services and treatment, and disrupted lives and livelihood. The Covid crisis deepened in health, with a drop in life expectancy at birth. For the first time, indicators of human development have declined—drastically, unlike anything experienced in other recent global crises. (UNDP special Report 2022— New threats to human security in the Anthropocene. “Demanding greater solidarity”). Covid-19 pandemic has caused unprecedented decline in human development index values in the last two years—2019 to 2021. The HDI adjusted for Covid-19 had yet to recover about five years of progress. Revised Multidimensional Poverty Index (MPI)

Revised and updated global MPI in September 2018 includes three dimensions—health, education and standard of living and 10 indicators (nutrition, child mortality, years of schooling, school attendance, cooking fuel, improved sanitation, drinking water, electricity, housing and assets). Based on this index nearly 27.9% of people in India were poor in 2015–16.10 PHYSICAL QUALITY OF LIFE INDEX

Physical quality of life index (PQLI) is one of the indicators used to measure the level of human development.

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This index takes into consideration of the following components: • Infant mortality rate • Life expectancy at age one • Literacy rate For the lowest level of IMR of Kerala of 16 against the 90 of UP or MP, the score for Kerala would be 100 and for UP it would be only 5.6 where zero score is allotted to absolutely defined lowest performance and score of 100 denotes absolutely defined highest performance. After allocating the scores to each component, aggregate score of three components is averaged out. Each component has equal weightage. The PQLI is a composite index and measures social well-being of human development of a defined geographical territory. The PQLI does not include the component of GNP meaning thereby that economic development is not a pre-requisite for human development. PQLI is not totally dependent upon economic development. MEASUREMENT OF HEALTH STATUS THROUGH HEALTH INDICATORS

Since morbidity and mortality only relate to sick persons and persons who die. What about those who survive? The objective of nations all over the world is to improve the quality of life (physical, social and mental well-being). Therefore, the population or community health and development is judged through other indicators in addition to morbidity and mortality indicators. The quality of life of survival is judged through some of the following indicators, positive and negative both. Policy Indicators

• Allocation of financial resources for health, e.g. allocation of percentage of budget on health and percentage of GDP spent on health. • Percentage of public health investment on primary healthcare, secondary and tertiary healthcare. • Policy on social insurance and coverage of most vulnerables and poor people, e.g. ‘Ayushman Bharat’. • Equitable access to health services and equity in medical education and human resource development. • Decentralized management of health institutions and delegation of authority to Panchayati Raj Institutions. • Convergence and intersectoral coordination. • Public–private and NGOs partnership. • Use of rational drugs and drug policy. • Population norms for health facility and IPHS. 1. Basic Indicators

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Under-five mortality (negative indicator). India ranks at 53rd place with under-five mortality of 32 (2021). • Infant mortality rate (negative indicator) • Neonatal mortality rate

• • • •

Gross national income (positive indicator) Life expectancy at birth (positive indicator) Total adult literacy (positive indicator) Net primary school enrolment ratio

2. Nutrition Indicators

• • • •

Percentage of infants with low birth weight Early initiation of breastfeeding (%) Exclusively breastfed up to 6 months (%) Introduction of solid, semisolid or soft foods at 6–8 months (%) • Malnutrition prevalence in under-five (underweight, wasting and stunting). • Vitamin A supplementation coverage • Households consuming iodized salt. 3. Health Indicators

• Population using improved drinking water source. • Percentage of population using adequate sanitation facilities. • Percentage of routine vaccines financed by government. • Immunization status of pregnant women and infant. • ORS use rate and ARI management rate at health facility. • Children sleeping under impregnated bed nets (%). • Percentage of under-five with fever receiving antimalarial drugs. 4. HIV/AIDS

• • • • • •

HIV incidence per 1000 uninfected population. Adults (15–49 years) prevalence rates. Estimated number of people living with HIV/AIDS. HIV prevalence among young people (15–24 years). Comprehensive knowledge of HIV (%). Women living with HIV (%).

5. Education

• • • • •

Adult literacy rate Primary school gross enrolment ratio Net primary school enrolment ratio Primary school entrants reaching grade 5 Secondary school gross enrolment ratio.

6. Demographic Indicators

Population, population annual growth rate, crude birth and death rate, life expectancy, total fertility rate, percentage of urban population, average annual growth rate of urban population (%). 7. Economic Indicators

GNI per capita, GDP per capita average annual growth rate, percentage of central government expenditure

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

allocated to health, education and defence, and percentage of population below $ 1.5 a day. 8. Women

Life expectancy of female, women literacy, gross enrolment ratio for girls, contraceptive prevalence, antenatal care coverage, skilled attendant at delivery (%) and maternal mortality ratio and lifetime risk of maternal death. 9. Child Protection

Child labour (5–14 years), birth registration, female genital mutilation, and child marriage. 10. Adolescents

Adolescents indicators include adolescents as proportion of total population, marital status, age at first birth, adolescent birth rate (15–19 years), attitudes towards domestic violence, secondary education and comprehensive HIV knowledge. 11. Equity

Equity indicators include birth registration, skilled attendance at birth, underweight prevalence in children, immunization—measles coverage and use of improved sanitation facilities in poorest and richest 20%. Competency addressed: The student should be able to: CM 1.8: Describe the demographic profile of India and discuss its impact on health.

DEMOGRAPHIC PROFILE OF INDIA AND ITS IMPACT ON HEALTH Size of Population and its Implications on Health

• Large size of population over 1412 million in July 2022 poses a challenge for universal health coverage. To set up health facilities, such as number of sub-centres, PHCs, CHCs and required manpower, physical infrastructure and finances as per Indian Public Health Standards and population norms, it becomes an uphill task. • Nearly 66% of population is rural and 34% urban and half of urban population may be living in urban slums, which have high density of population and consequently high risk of respiratory infections and TB and Covid-19. Disparity or divide between rural and urban population/urban slums persists, as most of health resources are concentrated in favour of urban areas (hospitals, doctors, private nursing homes and big hospitals). Universal coverage of health for this much population remains a big challenge.

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Sex Ratio—Demographic Implications

The demographic divide between women and men continues to exist till date. Out of total population of 1210 million in 2011, we had 587 million females against 623 million males, which means 36 million females are missing in India. Overall female sex ratio was 943 per 1000 men. Many well to do states like Haryana and Punjab have low female sex ratio, indicating high mortality in female. The overall female sex ratio has improved to the level of 1020 in 2019–21 for the first time in India. Thus survival rates in women have improved. a. Most Disturbing Sign of Demography: Declining Female Child Sex Ratio (CSR) Census 2011

The population of 0–6 years girls is declining. At national level this ratio is 914. Most worrisome feature of low child sex ratio of 830, 846, 886 and 867 was observed in the prosperous states of Haryana, Punjab, Delhi, and Chandigarh, respectively. Jhajjar district in Haryana had the lowest child sex ratio of 774. This is significant pointer towards sex selective abortions, this needs to be curbed by stringent implementation of PNDT Act. CSR has improved to 928 due to implementation of PNDT. Population Structure

a. Infant and Young Children (0–4 Years)

The overall 0–4 year population which forms the base of pyramid is shrinking due to fall in fertility rate and success of F.P prog. currently it is 8.2% of total population. Newborns, infants and young children below 5 years of age constitute 8.2% of total population. They are most vulnerable to diseases and deaths. High infant mortality of 28 and under 5 mortality of 32 is a problem. Their prime health needs are survival, feeding (breastfeeding, exclusive breastfeeding, complementary feeding), early childhood care and education, growth and development, immunizations and management of childhood illness like diarrhoea, ARIs and fevers. They are supreme assets and future human resource of the country. Hence, the health services provision should be over-riding priority. Invest in their education and health. b. Population of 5–14 Years (School Going Children)

These children constitute nearly 18.3% of India’s population. They are vulnerable age group. Major health implications for this population are supervision and monitoring of their growth and development, adequate diet, universal enrolment and retention in schools, screening and correction of 4Ds— common defects (visual and hearing impairment, dental caries), developmental delays and learning disorders, diseases and deficiencies. Major intervention includes health education to promote ‘healthy lifestyles’, healthy

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behaviours and habits (eating healthy foods, avoiding tobacco use, promoting physical activities, using toilets, handwashing and personal hygiene, drinking clean water) besides health protection by immunizations, iron folic acid supplementation and deworming. Major challenge is coverage of all schools (government and private) under universal health coverage and RBSK and RKSK prog. Adolescent Age 10–19 Years

Adolescents constitute Nearly 18.3 to 20% of population of India. Health implications in this age group are to provide them correct and complete information on ‘healthy lifestyles’ menstrual hygiene, reproductive and sexual health, prevention of RTI, STDs, and HIV, adequate and healthy diet, avoiding drugs, alcohol and tobacco use, prevention of accidents road safety, right age of marriage and child bearing, contraception and prevention of noncommunicable diseases. Main health intervention is health education and counselling by peer educators, through curriculum and education system and implementation of RKSK.

Competency addressed: The student should be able to: CM 1.9: Demonstrate the role of effective communication skills in health in a simulated environment.

Objective of this skill is to arrive at community diagnosis and communication needs assessment. Role of Effective Communication Skills in Health and Disease

This is economically productive population. They constitute nearly 62% of India’s population.

Communication skills of health managers (Doctors) and workers, ASHAs and Anganwadi volunteers are crucial, critical and much depends on their training. Good communication skills are essential to elicit correct history (chief complaints), effective counselling and to enhance patient satisfaction.

Health Implications

Communication

The health needs of this age group is a necessity for economic development. They must be healthy at home and at workplace, and do not fall sick and should have safeguards in terms of financial security in the event of sickness to prevent catastrophic expenditure. Nearly 60 million people are pushed to poverty every year in India due to catastrophic health expenditure. Health protection schemes and workplace safety for this segment of population is an imperative need for national economy and productivity. Men and women in reproductive age group (15–49 years) constitute nearly 52% of population in India. The health implications in this age bracket are to address reproductive and sexual health of men and women—to reduce high fertility, to control STI/RTI and HIV, to reduce high maternal morbidity and mortality due to anaemia, unsafe abortions, repeated pregnancies, besides problem of oral, breast and cervical cancers and other lifestyle chronic diseases—NCDs.

Communication is a core competency for Indian medical graduates. Communication skills are necessary for community and patient diagnosis, satisfaction, building good relationship of trust and respect, speedy recovery and improved health outcomes besides health promotion and adopting healthy lifestyles.

Population of 15–59 Years—Working Population

How to achieve this skill

Demographic transition in India has led to increased population of older persons above the age of 60 which now constitute nearly 12% of total population of India. People live longer and life expectancy has increased to 69.7 years a sign of socio-economic development.

a. Listening to community or client: In community medicine “the patient” is ‘community’ not an individual. Listening to community you serve is the most important skill in communication. Active listening means analysing the mind of community/client. It is first step in community diagnosis and patient diagnosis. Student listens to rural/urban community, their chief complaints and priority demands, interacts with elected leaders (formal) and informal leaders and organized groups such as village/urban health sanitation and nutrition committee, Mahila Arogya Samiti in urban areas, AWWs, health workers, school teachers, NGOs and family members in allotted families. Transact walk in community helps mapping of sources of water supply, excreta disposal practices, breeding places, housing, health facilities, schools, electricity and market places. Information collected by listening and direct observation is recorded in diary/practical Logbook and analysed to arrive at community diagnosis.

Health Implications

Active Listening

Due to demographic shift of ageing population India has to address the health problems of aged people in terms

“You can’t learnin’ nothin’ you’re doin’ all the takin.”

Population of 60+ (Geriatric Population)

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of chronic non-communicable diseases and degenerative diseases which require expensive lifelong treatment and care. To address health and social problems of elderly people is a challenging task in universal health coverage. Population of 30–65 constitutes 37% of total population. This age group is being targeted for population-based screening of common cancers (oral, breast and cervical) and non-communicable diseases, and lifestyles management.

—Lyndon B Johnson, US President

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

Listening actively is different from hearing. Hearing is physiological function while active listening is analysis of what is being said, how it is being said, and body language of person or client/patient/community. Listening is the key skill to effective communication. Active listening analyses the mind of persons, their profile, helps to assess their health and communication needs and community diagnosis. Listen attentively, show that you are listening, by maintaining eye contacts, nodding your head and reflecting feelings. Active listening is a part of participatory leadership and management. Most health managers spend around 50% of their time to listening, talking, writing and reading (communication). Too much of the communication between provider and client is one way. Field workers need to spend more time listening to them, than talking, discussing their health and family planning needs. Training in listening and counselling is necessary. Interpreting Body Language

Listen to what is not being said. Communication is not only verbal, everyone communicates their feelings “non-verbally”, though what is popularly called “body language”, learn how to interpret body language. Learn to pay attention to body language, and be sensitive to what your staff and colleagues are trying to communicate to you non-verbally. It can help you to identify problems. Body language examples: • Touching face frequently means anxiety, and discomfort • Rubbing nose means anxiety, wishes to avoid • Foot tapping means impatience, anger • Elbow on table, hands forming steeple—confident, secure • Hand over mouth means playing, wishes to hide, anxiety • Avoiding eye contact means anxiety, distrust, discomfort, hiding. Empathy

Empathy is part of being human in active listening. Through empathy we connect with other’s emotions and share in their felt health needs/experiences. Key component of empathy is emotional connection with the person/client or community. Empathy is an experience of understanding another person’s condition from their perspective by placing yourself in another’s shoes and feeling what they are feeling. It is known to increase helping behaviour. Empathy includes mirroring what a person is feeling, to identify and understand another person’s emotions (being happy, sad, angry, shy, nervous). b. Speaking is another important skill. What to speak, how to speak, when to speak and whom to speak are essential elements. It means, the communicator should have latest knowledge and speak scientifically. Convey message which is sense making and has proven scientific evidence.

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Speaking/Talking

Most of communication in our life is verbal/oral communication. Verbal communication by doctors to patients builds a relationship of trust and works more than healing with medicines or other interventions. Use sympathetic/empathic tone, easy to understand language, addressing or focusing on concern of audience/community talk with people not at them, people do not learn much from telling. They learn from what they think, feel, discuss, see and do together. Skill of group formation, group discussion, focus group discussion is most rewarding in gathering information. Other communication skills are reading, writing and reasoning. c. Reading: It means acquiring latest knowledge on health-development, health system policies and services to inform people to enhance utilization of services. d. Writing: It means developing clear and precise health messages in local dialects, facts for health and their critical analysis. Clear and concise written job descriptions and instructions with health teams helps them to perform what is expected of them. Writing skills: Learn to write effectively. clear writing is clear thinking. Writing effectively means your thoughts are clear, and concise. Write clear instructions for health workers. Updated, written job descriptions must be available with the health workers so that workers understand what is expected out of them. Technical directions are best written so there is no possible misinterpretation and so there is a ready reference later on. Quite often, medical officers are required to write a brief note for district collector for supporting plans of action and intersector coordination. Similarly, drafting a press release for clearance and health messages for actions or adopting healthy behaviour/lifestyle by people are other examples of writing skills. Always write in active voice; short sentences. Because of need to communicate to illiterate persons, familiar pictures/pictorials are used to convey messages. The term “visual literacy” has been used for a Person’s familiarity with pictures and conventions of graphic design. e. Reasoning: A sound skill of reasoning in communication is imperative. It involves creative thinking. Good reasoning for adopting healthy lifestyles/best practices helps promoting health, preventing diseases and health seeking behaviours and utilization of services by community. Expected outcomes: Student contacts and interacts with community, its elected and non-formal leaders and organised groups of men and women and allotted families and households record his/her observations in logbook. Minimum frequency of contacts to be determined locally.

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Competency addressed: The student should be able to: CM 1.10: Demonstrate the important aspects of the doctor– patient relationship in a simulated environment.

Objective of this skill is to abide by the prescribed ethical and legal codes of conduct and practice to improve quality of relationship between providers and the community. Doctor is bound by medical ethics of “The physician’s pledge”. Nuremberg code of ethics in medical research, Declaration of Helsinki and duties of physician to their patients as per Medical Council of India. In public health, the patient is “Community”. A typical rural health centre is responsible to a defined population of 30,000 and urban health centre to 50,000 population. The way in which providers of public health services are connected with community they serve is known as community relationship. The households, families, community, Village and Urban Health Sanitation and Nutrition Committees, ASHAs, AWWs are connected with dynamic health system of subcentres (health and wellness centres), PHCs, CHCs and district hospitals for continuum of comprehensive primary healthcare across lifecycle. The system maintains sustained contacts with the families and the community by regular home visits and outreach services, leading to community participation and satisfaction and also increased use of public health services at all these levels. How?: “These interactions and sustained contacts must be demonstrated to the students. Students observe the ethical practices of honourable role models—faculty of medical college silently to emulate in their life later on. Thus ‘faculty must practice what they teach on ethics’. Most textbooks on community medicine do not have a chapter on medical ethics. Hence, the UGs and faculty are deprived of this information”. DOCTOR–PATIENT RELATIONSHIP (DPR)

DPR as derived from “The physician’s pledge” is one to one, rational, based on mutual trust, value system and is reciprocal, give and take and each one has a specific role to play. DPR is the cornerstone to patient care. Good interaction and contacts between doctor and patient enhances satisfaction. Empathy (sharing feelings of patient) and effective communication (providing correct information) builds mutual trust and avoids litigation. Types of DPR

1

1 Paternalistic model: In this model the doctor should make all the decisions. Assumption her is doctor knows the best. 2 Informative model: Here doctor provides all the relevant information for the patient to make decision. 3 Deliberative model: Here doctor deliberates through dialogue and discussions and helps the patient to select the best treatment among alternatives.

4 Interpretive model: Here doctor helps the patient to articulate his/her values through interpretation and provides interpretation which is truly wanted. Empathy and effective communication is part of therapy and is linked to outcomes of care through sustained DPR on treatment adherence, satisfaction and improved health status. Consent: Voluntary agreement by patient to allow medically trained person to touch, examine and perform treatment. The consent is implied, or expressed consent and best is informed consent. Duty of Care for Doctor

Qualified in modern system of medicine, is competent for giving medical advice and treatment, duty of care in deciding what treatment to give, update his/her knowledge and skills, maintain medical records, medical certificate register, display details and observe all statutory laws and regulations. Negligence is an offence under consumer protection Act. Know Your Patient Well

• His/her health literacy and socio-economic status. • His prime concern, perception of illness, outlook and attitude, health seeking behaviour, coping mechanism, his/her expectation and expectation of patient’s attendants. Patients autonomy and dignity decisions must be respected. Patients have right to seek second opinion and can withdraw from a research study anytime rights should be ensured. Duty of Patient

As laid down by government of India and various health Acts and regulations. Responsibilities of Patients

To keep the facility clean, avoid spitting in corners, avoid over-crowing by attendants, respecting visiting hours, not causing any harm to public property including violence against healthcare professionals. Expected Outcomes

The student interacts with health workers and health volunteers (ASHAs, AWWs), identifies their nature and frequency of contacts with the community they serve. Students observe their acceptability and ability to organize community and documents his/her observations in the logbook for self directed learning.10 The new MBBS curriculum has a course called Attitudes, Ethics, Communication (AETCOM) which runs across years. It has 27 modules of 140 hours spreadover 4 years. Students will be assessed for how they communicate

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

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with patients, how they counsel people for organ donations or other challenging procedures, how sensitively do they offer care and obtain informed consent. All these will count along with competencies. It is an ambitious course, hopefully it gets implemented. Medical faculty must demonstrate to students “the humane approach to patient and community”. AETCOM cannot be taught merely by lectures/sermons, its practice must be seen to be believed. The Medical College faculty must practice it first of all. AETCOM must be integrated with different phases—pre, para and clinical phases rather than a separate disintegrated modular, course in isolation. One such approach is clinico-social case review, problem-based learning and sustained community and family contacts as explained under pedagogy (Fig. 1.5).11, 12

Learning Modules for Professional Year IV—44 Hours

LEARNING OF AETCOM

The programme suggests a hybrid problem oriented approach to explore the various facets of “Real Life Issues” that will confront students in their careers see (Fig. 1.5). Attitude: A human attribute indicating a particular mental state or an outlook to life. It mainly includes affective domain chiefly related to feelings, moods, settled way of thinking, thoughts and emotions and inclinations.

Learning Modules for Professional Year I—34 Hours

Module 1.1: Module 1.2: Module 1.3: Module 1.4: Module 1.5:

What does it mean to be a doctor? What does it mean to be a patient? The doctor–patient relationship. The foundation of communication—1. The cadaver as our first teacher.

Module 4.1: The foundation of communication—IV. Module 4.2: Case studies in medico-legal and ethical situations. Module 4.3: Case studies in medico-legal and ethical situations. Module 4.4: Case studies in ethics, empathy and doctor– patient relationship. Module 4.5: Case studies in ethics the doctor–industry relationship. Module 4.6: Case studies in ethics and doctor–industry relationship. Module 4.7: Case studies in ethics and patient autonomy. Module 4.8: Dealing with death. Module 4.9: Medical negligence–consumer protection Act.

Learning Modules for Professional Year II—37 Hours

ETHICS IN MEDICINE (MORAL PRINCIPLES)13

Module 2.1: Module 2.2: Module 2.3: Module 2.4: Module 2.5:

Ethics is the branch of philosophy dealing with the distinction between right and wrong with the moral consequences of our actions (last 1989); it refers to moral issues involved in statistical investigations in medicine, the scientific integrity of the investigator and the obligations implicit in the doctor–patient relationship. Doctor is at the central stage bound by medical ethics of “The physician pledge”. (WMA Declaration Geneva) Doctor is responsible for care of sick individuals, healthcare of community and training of health teams. The ethical responsibilities extend to very large domain and in particular the area of medical ethics has become much more important in view of recent advances in medicine like: • Genome project: Genetic counselling in hereditary diseases, in vitro fertilization, growing foetus in the womb of surrogate mothers are important areas. • Termination of pregnancy on medical grounds (MTP Act).

The foundation of communication—II. The foundation of bioethics. Healthcare as a right. Working in a healthcare team. Bioethics continued—case studies on patient autonomy and decision making. Module 2.6: Bioethics continued. Module 2.7: Bioethics continued. Module 2.8: What does it mean to be a family member of sick patient. Learning Modules for Professional Year III— 25 Hours

Module 3.1: The foundation of communication—III Module 3.2: Case studies on bioethics—Disclosure of medical errors. Module 3.3: The foundation of communication—IV Module 3.4: Case studies on bioethics—Confidentiality. Module 3.5: Case studies in bioethics—Fiduciary duties

Fig. 1.5: Hybrid problem based learning suggested for AETCOM cases

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• Ethics in contraceptives and family planning practices. • HIV/AIDS. • Legal and ethical conflicts under Human Organs and Tissues Transplantation Act. • Vaccine and drug trials and medical research. • Distribution and allocation of resources according to health needs of masses in urban and rural areas. • Doctor–patient relationship. • Health policies. • Policies of care of terminal ill patients and voluntary passive euthanasia. It is mandatory that every medical institution should have an ethical committee to approve the plan of research work in relation to human beings and animals. LAWS PERTAINING TO PRACTICE OF MEDICINE Consumer Protection Act—Avoid Negligence (Relates to AETCOM 4.9)

• The doctors must practice medicine ethically in terms of doctor–patient relationship, avoid unnecessary investigations and consultation and avoid negligence in care. Consumer Protection Act (CPA) safeguards the rights of client and it improves the quality of medical care. Under CPA, the negligence in medical care is an offence. Negligence means that a person who holds himself ready to give medical advice and treatment implied, undertakes that he is possessing skill and knowledge for the purpose. Such a person, who is consulted by a patient, owes him certain duties, namely a duty of care in deciding what treatment to give or a duty of care in the administration of that treatment. A breach of any of these duties gives a right of action for negligence to the patient. Doctors in private practice, hospitals, clinics who charge for patient care/hospital paid by an insurance firm for treatment/hospitals having free as well as paying patients come under the purview of this Act. Clinical Establishment Act, 2010

Main Features

• Grading of clinical establishment. • Standard treatment guidelines. • Protection of patient rights—such as rights to information, access to medical records informed consent, second opinion and confidentiality. – Standard of care and prices/fees of services. – Negligence and unfair practice. – Organ and tissue transplantation. HIPPOCRATIC OATH

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Modern Version

I swear to fulfil, to the best of my ability and judgement, this covenant (solemn agreement):

• I will respect the hard-won scientific gains of those physicians in whose steps I walk and gladly share such knowledge as is mine with those who are to follow. • I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of over treatment and therapeutic nihilism. • I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug. • I will not be ashamed to say “I know not”, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery. • I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I treat with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. • I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. • I will prevent disease whenever I can, for prevention is preferable to cure. • I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. • If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May, I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. WORLD MEDICAL ASSOCIATION (WMA) DECLARATION OF GENEVA—OCTOBER 2017 The Physician’s Pledge

As a member of the medical profession:

• I solemnly pledge to dedicate my life to the service of humanity. • The health and well-being of my patient will be my first consideration. • I will respect the autonomy and dignity of my patient. • I will maintain the utmost respect for human life. • I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient. • I will respect the secrets that are confided in me, even after the patient has died.

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

• I will practise my profession with conscience and dignity and in accordance with good medical practice. • I will foster the honour and noble traditions of the medical profession. • I will give to my teachers, colleagues, and students the respect and gratitude that is their due. • I will share my medical knowledge for the benefit of the patient and the advancement of healthcare. • I will attend to my own health, well-being, and abilities in order to provide care of the highest standard. • I will not use my medical knowledge to violate human rights and civil liberties, even under threat. • I make these promises solemnly, freely, and upon my honour. NUREMBERG CODE OF ETHICS IN MEDICAL RESEARCH

1 The voluntary consent of the human subject is absolutely essential. This means that the consent should be free and without force, fraud, deceit duress or any other ulterior motive. The person giving consent should have the legal capacity to do so. It should be intelligent and given only after understanding the nature of experiment, its purpose, duration, methods, its hazards and after effects that may arise out of the experiment. 2 The experiment should be such as to yield fruitful results for the good of society, unprocurably by other methods or means of study, and not random and unnecessary in nature. 3 The experiment should be so designed and based on the results of animal experimentation and a knowledge of the natural history of the disease or other problems under study that the anticipated results will justify the performance of the experiment. 4 The experiment should be conducted to avoid all unnecessary physical and mental suffering and injury. 5 The experiment should be conducted where there is a prior reason to believe that death or disabling injury will occur; except, perhaps in those experiments where the experimental physicians also serve as subjects. 6 The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment. 7 Proper preparations should be made and adequate facilities provided to protect the experimental subject against even remote possibilities of injury, disability or death. 8 The experiment should be conducted only by scientifically qualified persons. The highest degree of skill and care should be required through all stages of the experiment of those who conduct or engage in the experiment. 9 During the course of the experiment, the human subject should be at liberty to bring the experiment to an end if he has reached the physical and mental state where continuation of the experiment seems to him to be impossible.

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10 During the course of the experiment, the scientist in charge must be prepared to terminate the experiment at any stage, if he had probable cause to believe, in the exercise of good faith, superior skill and careful judgement required of him, that a continuation of the experiment is likely to result in injury, disability, or death to the experimental subject. This code got to the subjects of consent the voluntariness of consent, the right of a patient to withdraw if he wished, and the basic question of doing things in accordance with proper medical standards and safeguards. However, among other limitations, it did not explicitly deal with the subject of children. Probably nobody at that time, thought it would be necessary. Administer the assent form if the respondent is less than 18 years old and take informed consent from the respondent parent/guardian/care-giver. DECLARATION OF HELSINKI (it Relates to AETCOM Modules 2.5 and 2.7)

World Health Association has prepared the following recommendations as a guide to every doctor in biomedical research involving human subjects. They should be kept under review in future. It must be remembered that these are only a guide to physicians all over the world. Doctors are not relieved from criminal, civil and ethical responsibilities under the laws of their own countries. I. Basic Principles

1 Biomedical research involving human subjects must conform to generally accepted scientific principles and should be based on adequately performed laboratory and animal experimentation and on a thorough knowledge of the scientific tradition. 2 The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experiment protocol which should be transmitted to specially appointed independent committee for consideration, comment and guidance. 3 Biomedical research involving human subject should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the subject has given his or her consent. 4 Biomedical research involving human subjects cannot legitimately be carried out unless the importance of the objective is in proportion to the inherent risk to the subject. 5 Every biomedical research project involving human subjects should be proceeded by careful assessment of predictable risks in comparison with foreseeable benefits to the subject or to others. Concern for the interests of the subjects must always prevail over the interest of science and society.

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6 The right of the research subject to safeguard his or her integrity must always be respected. Every precaution should be taken to respect the privacy of the subject and to minimize the impact of the study on the subject’s physical mental integrity and on the personality of the subject. 7 Doctors should abstain from engaging in research projects involving human subjects unless they are satisfied that the hazards involved are believed to be predictable. Doctors should cease any investigation if the hazards are found to outweigh the potential benefits. 8 In publication of the results of his or her research, the doctor is obliged to preserve the accuracy of the results. Reports of experimentation not in accordance with the principles laid down in this declaration should not be accepted for publication. 9 In any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study and the discomfort it may entail. He or she should be informed that he or she is at liberty to abstain from participation in the study and that he or she is free to withdraw his or her consent to participation at any time. The doctor should then obtain the subject’s freely given informed consent, preferably in writing. 10 When obtaining informed consent for the research project the doctor should be particularly cautious if the subject is in a dependent relationship to him or her or may consent under duress. In that case, the informed consent should be obtained by a doctor who is not engaged in the investigation and who is completely independent of the official relationship. 11 In case of legal incompetence, informed consent should be obtained from the legal guardian in accordance with national legislation. Where physical or mental incapacity makes it impossible to obtain informed consent, or when the subject is a minor, permission from the responsible relative replaces that of the subject in accordance with national legislation. 12 The research protocol should always contain a statement of the ethical considerations involved and should indicate that the principles enunciated in the present declaration are complied with. II. Medical Research Combined with Professional Care (Clinical Research)

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1 In the treatment of the sick person, the doctor must be free to use a new diagnostic and therapeutic measure, if in his or her judgement it offers hope of saving life, re-establishing health or alleviating suffering. 2 The potential benefits, hazards and discomfort of the new method should be weighed against the advantages of the best current diagnostic and therapeutic methods.

3 In any medical study, every patient including those of a control group, if any should be assured of the best proven diagnostic and therapeutic methods. 4 The refusal of the patient to participate in a study must never interfere with the doctor–patient relationship. 5 If the doctor considers it essential not to obtain informed consent, the specific reasons for this proposal should be stated in the experimental protocol for transmission to the independent committee. 6 The doctor can combine medical research with professional care, the objective being the acquisition of new medical knowledge, only to the extent that medical research is justified by its potential diagnostic or therapeutic value for the patient. III. Non-therapeutic Biomedical Research Involving Human Subjects (Non-clinical Biomedical Research)

1 In the purely scientific application of medical research carried out on human beings, it is the duty of the doctor to remain the protector of the life and health of that person on whom biomedical research is being carried out. 2 The subjects should be volunteers—either healthy persons or patient for whom the experimental design is not related to the patient’s illness. 3 The investigator or the investigating team should discontinue the research if in his/her or their judgement it may, if continued, be harmful to the individual. 4 In research to man, the interest of science and society should never take precedence over consideration related to the well-being of the subject. EUTHANASIA (Relates to AETCOM Modules 2.6 and 4.8)

‘Thanatology’ is a branch of science that deals with scientific study of death and practices associated with it. Euthanasia has its origin from Greek word, the term Eu means well and Thanatos means death and it literally means an easy death.2 It is a form of peaceful or dignified death which is specially advocated when life becomes a punishment and dying comes as pleasure to patient, suffering from some incurable disease like cancer with severe intolerable and uncontrollable pain. Honourable SC permits ‘living will’ for passive euthanasia: The supreme court recognises right to die with dignity and allows an individual to execute an ‘advance directive’ or ‘living will’ authorising someone to widhdraw his/her life support if he/she went into a permanent vegetative state (PVS) because of an incurable and irreversible medical condition. Life support could be widhdrawn only after a medical board approved it. With this verdict India joins nations such as UK, Germany and the Netherlands which have advance directive laws allowing an individual to execute a ‘living will’.

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

But active euthanasia which involves administering some medicines or lethal injection to end life, continues to be illegal in India. Advantages of legal recognition of brain death in terminal injury: • It will facilitate organ transplantation. • It will ensure economy of intensive care resources. • It will have maximum impact in the matter of property rights, negligence claims, insurance and workers compassionate. INDIAN MEDICAL COUNCIL (PROFESSIONAL CONDUCT, ETIQUETTE AND ETHICS) REGULATION, 2002

(Amended upto 8th October 2016 Medical Council of India Duties of Physicians to their Patients13 (Medical Council of India)

Obligations to Sick (Relates to AETCOM Modules 1.1, 3.4 and 3.5)

2.1.1 Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high/ character of his mission and the responsibility he discharges in the course of his professional duties. In his treatment, he should never forget that the health and the lives of those entrusted to his care depend on his skill and attention. A physician should endeavour to add to the comfort of the sick by making his visits at the hour indicated to the patients. A physician advising a patient to seek service of another physician is acceptable, however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient. However, for good reason, when a patient is suffering from an ailment which is not within the range of experience of the treating physician, the physician may refuse treatment and refer the patient to another physician. 2.1.2 Medical practitioner having any incapacity detrimental to the patient or which can affect his performance vis-à-vis the patient is not permitted to practice his profession. 2.2 Patience, delicacy and secrecy: Patience and delicacy should characterize the physician. Confidences concerning individual or domestic life entrusted by patients to a physician and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the state. Sometimes, however, a physician must determine whether his duty to society requires him to employ knowledge, obtained through confidence as a physician to protect a healthy person against a

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communicable disease to which he is about to be exposed. In such instance, the physician should act as he would wish another to act toward one of his own family in like circumstances. 2.3 Prognosis: The physician should neither exaggerate not minimize the gravity of patient’s condition. He should ensure himself that the patient, his relatives or his responsible friends have such knowledge of the patient’s condition as will serve the best interests of the patient and the family. 2.4 The patient must not be neglected: It relates to AETCOM module 4.9. A physician is free to choose whom he will serve. He should however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not wilfully commit an act of negligence that may deprive his patient or patients from necessary medical care. 2.5 Engagement for an obstetric case: When a physician who has been engaged to attend an obstetric case is absent and another is sent for and delivery accomplished, the acting physician is entitled to his professional fees, but should secure the patient’s consent to resign on the arrival of the physician engaged. 3. DUTIES OF PHYSICIAN IN CONSULTATION Unnecessary Consultations should be Avoided

3.1.1 However, in case of serious illness and in doubtful or difficult conditions, the physician should request consultation, but under any circumstances such consultation should be justifiable and in the interest of the patient only and not for any other consideration. 3.1.2 Consulting pathologists/radiologists or asking for any other diagnostic laboratory investigation should be done judiciously and not in a routine manner. 3.2 Consultation for patient’s benefit: In every consultation, the benefit to the patient is of foremost importance. All physicians as engaged in the case should be frank with the patient and his attendants. 3.3 Punctuality in consultation: Utmost punctuality should be observed by physicians in making themselves available for consultations. 3.4 Statement to patient after consultation: All statements to the patient or his representatives should take place in the presence of the consulting physicians, except as otherwise agreed. The disclosure of the opinion to the patient or his relatives or friends shall rest with the medical attendant.

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3.4.2 Differences of opinion should not be divulged unnecessarily but when there is irreconcilable difference of opinion the circumstances should be frankly and impartially explained to the patient or his relatives or friends. It would be open to them to seek further advise as they so desire. 3.5 Treatment after consultation: No decision should restrain the attending physician from making such subsequent variations in the treatment if any unexpected change occurs, but at the next consultation, reasons for the variations should be discussed/explained. The same privilege, with its obligations, belongs to the consultant when sent for in an emergency during the absence of attending physician. The attending physician may prescribe medicine at any time for the patient, whereas the consultant may prescribe only in case of emergency or as an expert when called for. 3.6 Patients referred to specialists: When a patient is referred to a specialist by the attending physician, a case summary of the patient should be given to the specialist, who should communicate his opinion in writing to the attending physician. 3.7 Fees and other charges: 3.7.1 A physician will clearly display his fees and other charges on the board of his chamber and/or the hospitals he is visiting. Prescription should also make clear if the physician himself dispensed any medicine. 3.7.2 A physician will write his name and designation in full along with registration particulars in his prescription letter head. Note: In government hospital where the patient load is heavy, the name of the prescribing doctor must be written below his/her signature. 4. Responsibility of physicians to each others 5. Duties of physician to public and to paramedical profession 6. UNETHICAL ACTS

A physician will not aid or abet or commit any of the following acts which shall be construed as unethical.

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6.1 Advertising: Soliciting of patients directly or indirectly by a physician, by a group of physicians or by institutions or organizations is unethical. A physician will not make use of his/her (or his/her name) as subject of any form or manner of advertising or publicity through any mode either alone or in conjunction with others which is of such a character as to invite attention to him or to his professional position, skill, qualifications, achievements, attainments, specialities, appointment, associations, affiliations or honours and/or of such character as

would ordinarily result in his self-aggrandizement. A physician will not give to any person, whether for compensation or otherwise, any approval, recommendation, endorsement, certificate report or statement with respect of any drug, medicine, nostrum remedy, surgical, or therapeutic article, apparatus or appliance or any commercial product or article with respect of any propriety, quality or use thereof or any test, demonstration or trial thereof, for use in connection with his name, signature, or photograph in any form or manner of advertising through any mode nor shall he boast of cases, operations, cures or remedies or permit the publication of report thereof through any mode. A medical practitioner is, however, permitted to make a formal announcement in press regarding the following: – On starting practice – On change of type practice – On changing address – On temporary absence from duty – On resumption of another practice – On succeeding to another practice – Public declaration of charges. 6.1.2 Printing of self-photograph or any such material of publicity in the letter head or on signboard of the consulting room or any such clinical establishment will be regarded as acts of self-advertisement and unethical conduct on the part of the physician. However, printing of sketches, diagrams, picture of human system shall not be treated as unethical. 6.2 Patent and copyright: A physician may patent surgical instruments, appliances and medicine or copyright applications, methods and procedures. However, it will be unethical if the benefits of such patents or copyrights are not made available in situations where the interest of large population is involved. 6.3 Running an open shop (dispensing of drugs and appliances by physicians): A physician should not run an open shop for sale of medicine for dispensing prescriptions prescribed by doctors other than himself or for sale of medical or surgical appliances. It is not unethical for a physician to prescribe or supply drugs, remedies or appliances as long as there is no exploitation of the patient. Drugs prescribed by a physician or brought from the market for a patient should explicitly state the proprietary formulae as well as generic name of the drug. 6.4 Rebates and Commission

6.4.1 A physician will not give, solicit or receive nor will he offer to given solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

6.4.2

6.5

6.6

6.7

patient for medical, surgical or other treatment. A physician will not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee for medical, surgical or other treatment. Provisions of para 6.4.1 shall apply with equal force to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study/work. Nothing in this section, however, will prohibit payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision. Secret remedies: The prescribing or dispensing by a physician of secret remedial agents of which he does not know the composition, or the manufacture or promotion of their use is unethical and as such prohibited. All the drugs prescribed by a physician should always carry a proprietary formula and clear name. Human rights: The physician will not aid or abet torture nor will he be a party to either infliction of mental or physical trauma or concealment of torture inflicted by some other person or agency in clear violation of human rights. Euthanasia: Practising euthanasia will constitute unethical conduct. However on specific occasion, the question of withdrawing supporting devices to sustain cardiopulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone. A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor-incharge of the patient, CMO/MO in-charge of the hospital and a doctor nominated by the incharge of the hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organ Act, 1994.

7. MISCONDUCT

The following acts of commission or omission on the part of a physician will constitute professional misconduct rendering him/her liable for disciplinary action: 7.1 Violation of the regulations: If he/she commits any violation of these regulations.

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or the Medical Council of India in his clinic, prescriptions, certificates, etc. issued by him/her or violates the provisions of regulation. 7.4 Adultery or improper conduct: Abuse of professional position by committing adultery or improper conduct with a patient or by maintaining an improper association with a patient will render a physician liable for disciplinary action as provided under the Indian Medical Council Act, 1956 or the concerned State Medical Council Act. 7.5 Conviction by court of law: Conviction by a court of law for offences involving moral turpitude/ criminal acts. 7.6 Sex determination tests: On no account sex determination test shall be undertaken with the intent to terminate the life of a female foetus developing in her mother’s womb, unless there are other absolute indications for termination of pregnancy as specified in the Medical Termination of Pregnancy Act, 1971. Any Act of termination of pregnancy of normal female foetus amounting to female foeticide shall be regarded as professional misconduct on the part of the physician leading to erasing from panel, besides rendering him liable to criminal proceedings as per the provisions of this Act. 7.7 Signing professional certificates, reports and other documents: Registered medical practitioners are in certain cases bound by law to give, or may from time to time be called upon or requested to give certificates, notification, reports and other documents of similar character signed by them in their professional capacity for subsequent use in the courts or for administrative purposes, etc. 7.8 A registered medical practitioner will not contravene the provisions of the Drugs and Cosmetics Act and Regulations made thereunder. Accordingly, prescribing steroids/psychotropic drugs when there is no absolute medical indication; selling schedule ‘H’ and ‘L’ drugs and poisons to the public except to his patient; in contravention of the above provisions shall constitute gross professional misconduct on the part of the physician. 7.9 Performing or enabling unqualified person to perform an abortion or any illegal operation for which there is no medical, surgical or psychological indication.

7.2 If he/she does not maintain the medical records of his/her indoor patients for a period of 3 years as per regulation 1.3 and refuses to provide the same within 72 hours when the patient or his/her authorized representative makes a request for it as per the regulation 1.3.2.

7.10 A registered medical practitioner will not issue certificates of efficiency in modern medicine to unqualified or non-medical person.

7.3 If he/she does not display the registration number accorded to him/her by the State Medical Council

Note: The foregoing does not restrict the proper training and instruction of bonafide students,

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midwives, dispensers, surgical attendants, or skilled mechanical and technical assistant and therapy assistants under the personal supervision of physicians. 7.11 A physician should not contribute to the lay press articles and give interviews regarding diseases and treatments which may have the effect of advertising himself or soliciting practices; but is open to write to the lay press under his own name on matters of public health, hygienic living or to deliver public lectures, give talks on the radio/TV/internet chat for the same purpose and send announcement of the same to lay press. 7.12 An institution run by a physician for a particular purpose such as a maternity home, nursing home, private hospital, rehabilitation centre or any type of training institution, etc. may be advertised in the lay press, but such advertisements should not contain anything more than the name of the institution, type of patients admitted, type of training and other facilities offered and the fees. 7.13 It is improper for a physician to use an unusually large signboard and write on it anything other than his/her name, qualifications obtained from a university or a statutory body, titles and name of his speciality, registration number including the name of the State Medical Council under which registered. The same should be the contents of his prescription papers. It is improper to affix a signboard on a chemist’s shop or in places where he does not reside or work. 7.14 The registered medical practitioner will not disclose the secrets of a patient that have been learnt in the exercise of his/her profession except: – In a court of law under order of the presiding judge; – In circumstances where there is a serious and identified risk to a specific person and/or community; and – Notifiable diseases. In case of communicable/notifiable diseases, concerned public health authorities should be informed immediately.

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7.15 The registered medical practitioner will not refuse on religious grounds alone to give assistance in or conduct of sterility, birth control, circumcision and medical termination of pregnancy when there is medical indication, unless the medical practitioner feels himself/herself incompetent to do so. 7.16 Before performing an operation the physician should obtain in writing the consent from the husband or

wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed. 7.17 A registered medical practitioner will not publish photographs or case reports of his/her patients without their permission, in any medical or other journal in a manner by which their identity could be made out. If the identity is not to be disclosed, the consent is not needed. 7.18 In the case of running of a nursing home by a physician and employing assistants to help him/ her, the ultimate responsibility rests on the physician. 7.19 A physician will not use touts or agents for procuring patients. 7.20 A physician will not claim to be specialist unless he has a special qualification in that branch. 7.21 No act of in vitro fertilization or artificial insemination will be undertaken without the informed consent of the female patient and her spouse as well as the donor. Such consent will be obtained in writing only after the patient is provided, at her own level of comprehension, with sufficient information about the purpose, methods, risks, inconveniences, disappointments of the procedure and possible risks and hazards. 7.22 Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this regard will constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines will also be construed as misconduct.12 7.23 If a physician posted in rural area is found absent on more than two occasions during inspection by the head of the district health authority or the chairman, Zila Parishad, the same will be construed as a misconduct if it is recommended to the Medical Council of India/State Medical Council by the state government for action under these regulations. 7.24 If a physician posted in a medical college/institution both as teaching faculty or otherwise will remain in hospital/college during the assigned duty hours. If he is found absent on more than two occasions during this period, the same will be construed as a misconduct if it is certified by the principal/medical superintendent and forwarded through the state government to Medical Council of India/State Medical Council for action under these regulations.

Concept of Health and Disease, Ethics in Medicine and Doctor–Patient Relationship

Table 1.4 gives major health problems in India Table 1.4: Major health problems in India Total projected population in July 2022

1412 million

Total fertility rate

2

Crude birth rate 2020

19.5

Sex ratio NFHS-5 (2019–21)

1020

Female illiteracy 2011

31.6%

People below poverty line 2012

21.9%

Human development index rank 2021

132

Disease burden COVID-19 pandemic-India 2nd hard hit country globally India’s share in global disease burden 2015

19%

India’s share in global incidence of TB 2020

26%

Burden of TB in India 2019–21 (prevalence)

4.3 million

Leprosy—new cases per year

1.27 lakh

HIV burden—people living with HIV/AIDS 2021

2.40 million

STI/reproductive tract infections—episodes

30 million

per year Malaria incidence per year 2020

338494 cases

Filaria cases—line—listed cases 2019

654013 cases

Iodine deficiency disorders-Endemic dist

348

Any mental morbidity in adults

10.6%

Anaemia in pregnancy

52%

Maternal mortality ratio (2018–20)

97

Infant mortality rate 2020

28

Under-five mortality rate 2020

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necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner. Deletion from the register will be widely publicized in local press as well as in the publications of different medical association/ societies/bodies. Other Attributes for Good Doctor–patient Relationship

Being Kind

• A friendly word, a smile, a hand on shoulder or some other sign of caring often means more than anything else you can do. Treat others as your equals. • Treat the sick as person/people: Be especially kind to those who are sick or dying, and be kind to their families. Let them see that you care. • Have compassion: Kindness often helps more than medicine. Never be affraid to show you care. • Practice what you teach (or who will listen to you) people are more likely to pay attention to what you do than what you say. Note: Ten competencies of Chapter 1 are thematic in nature, applicable to the entire subject of community medicine and rest of the topics/chapters and national health programmes. These competencies build a theme on the subject. Most of these competencies are overlapping and inter-related. Challenge for teacher is to organize lesson plans in such a manner that it links a competency to specific national health programme as described in the textbook.

Low birth weight babies

22%

Underweight children below 5 years

32%

Proportion of deaths due to NCDs

62%

PRINCIPLES AND PRACTICE OF MEDICINE IN HOSPITAL AND COMMUNITY

Communicable, maternal, perinatal and nutritional

27%

Injuries

11%

The approaches in clinical medicine and community medicine are distinct. The purpose of this elucidation is not to undermine the discipline of clinical medicine or hospitals, but to emphasize that the ‘medicine as a social science’ has much wider scope and bigger responsibility. The preventive and social medicine/community medicine specialists have to be best physician first to accomplish the tasks in the community. The areas and skills of two disciplines are clear cut and distinction has been drawn between the two to enhance the understanding of students of community medicine. Clinical medicine and preventive and social medicine (community medicine) need each other and interdepend and inter-relate in many of the critical areas; however, the approach differs (Table 1.5). The prevention is not the monopoly of preventive and social medicine alone the ‘preventive outlook and attitude of mind’ applies equally to all branches of medicine and its specialities. All branches of clinical medicine—surgery, obstetrics and gynaecology, paediatrics or any of their subspecialities, aim at early diagnosis and prompt treatment and application of health promotive and preventive aspects in their respective speciality.

Proportion of deaths due to CCDs, maternal

Outbreaks—dengue, chikungunya, H1N1, JE Frequent Tobacco use in adults

28.6%

Diabetes in adults (NFHS-5)

Women 13.5% Men 15.6%

Hypertension in adults (NFHS-5)

Women 21.3% Men 24.0%

Overweight and obese

Women 24.7% Men 23%

Coronary heart disease

1.6 to 7.4% in rural and 6.5 to 13.2% in urban areas

Chronic obstructive resp. diseases

3.3 to 5.4%

8.1 to 8.7 Punishment and Disciplinary Action

If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed

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Textbook of Community Medicine

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Table 1.5: Principles of practice of medicine in hospital and community Areas/outlook

Clinical medicine

Community medicine/preventive and social medicine/public health

Focus

Treats individual/disease

Treats community (holistic approach), prevents spread of disease

Concern

Sick persons (individual)

Both sick and healthy people (community)

Responsibility

Of those who come to seek help

Whole community (defined community)

Goal

To relieve symptoms, signs and to cure patient

• To eliminate and eradicate disease • To reduce incidence and prevalence of diseases

Skills/competence

Clinical skills

Epidemiological, biostatistic and managerial skills

Treatment/prescription

Treats patients with pills, drugs, injections and therapeutics

• • • •

Workstation

Hospitals and special clinics

Health centres, community/institutions

Teaching training

Bedside—patient side

In community

Diagnostic and evaluation tools

Uses clinical parameters (treatment success rate)

• Uses epidemiological tools: – Surveys, surveillance and outbreak investigations – Health records and epidemiological studies – Reduction of disease, death, and disability rates

Requirement

Patient compliance and cooperation

Community participation/community organization

Intersectoral coordination

Mainly health sector

Intersectoral coordination is essential between health, ICDS, education, development and agriculture

Results

Quickly achieved and visible

Takes longer time to see the results

Laboratory

Hospital wards

Community

REFERENCES 1 Medical council of India. Competency based undergraduate curriculum for Indian Medical Graduate. Vol. 1. Dwarka. New Delhi ICI—2018. 2 Lal S. Strengths, weaknesses, opportunities and threats analysis of competencies and building skill pyramid in the subject of Community Medicine. Indian Community Med 2021; 46: 173–7. 3 Lal S, Integration of medical education with healthcare delivery system in India for competency based Learning. Indian J Community Med 2018; 43:251–4. 4 WHO: WHO at 70-working for better health for everyone, everywhere. News release, 5 April 2019/GENEVA. 5 UNICEF the state of the world’s children 2017 and 2019. Children in a digital world UNICEF for child.

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6 Ministry of Drinking Water and Sanitation 2018 Swachh Bharat Mission—Gramin.

Treats causes through national health programmes Treats environments—safe water—safe excreta disposal Raises community immunity by mass immunization Mass treatment like MDA for filaria—mass deworming, vitamin A prophylaxis • Iodized salt • DOTS (directly observed treatment, short course chemotherapy) • Health legislation and behaviour change communication

7 Ministry of Housing and Urban Affairs 2018 Swachh Bharat Abhiyan—Urban. 8 WHO world conference on social determinants of health. Rio political declaration on social determinants of health. Rio de Janeiro, Brazil, 21 October 2011. 9 GOI National Health Policy 2017. MOH and FW, Government of India, New Delhi. 10 UNDP. Human Development Report 2021 and special Report of 2022. 11 Lal S, Sehgal P. Integration of attitude, ethics and communication competencies into competency-based UG curriculum. Indian J of Community Med 2022; 47:4–7. 12 Lal S, Sehgal P. Learning Practice of health management through existing health action plans under National Health Mission (NHM). Indian J Community Med 2022; 47:309–12 13 Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations (Amended upto 8th October 2016). MCI, Pocket-14 Sector 8, Dwarka New Delhi.

2 Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease “Know the community you serve before knowing medicine” “In community medicine the concern is community”

1950–1977: COMMUNITY MEDICINE/COMMUNITY HEALTH OR PUBLIC HEALTH ERA

HISTORICAL DEVELOPMENT OF MEDICINE AND SOCIAL SCIENCES FROM SYMPTOMS TO UNIVERSAL HEALTH COVERAGE

Focus—shifted from individual patient diagnosis and treatment to community diagnosis and treatment or community health or public health. Whole community should be the concern of medicine as social science.

BEFORE 1850: EMPIRICAL ERA

Focus during this era was on symptoms. Accordingly the art of medicine revolved around treatment of symptoms only.

1978 ONWARDS HEALTH FOR ALL ERA

World Health Organization in the year 1977 adopted a strategy of ‘health for all by 2000 AD’ through ‘comprehensive primary healthcare approach’ which holds the ground even today. Focus remains to achieve good health in all—whole India. Now the nation is committed to achieve ‘universal health coverage’ by adopting revised National Health Policy of 2017.1 “Nation’s greatest asset is its people”. Have a Good Look at your Community. “Know community before knowing medicine”

1850 TO 1900: BACTERIOLOGICAL ERA (BASIC SCIENCE ERA)

Focus—in this era basic sciences of medicine developed and focus shifted to causative organisms and disease. Medicine became science and microorganisms of various diseases were discovered and grown on cultures. Koch’s postulates were developed, stating that: a The micro-organism must be present in every case of disease as a necessary cause. b One should be able to isolate the organism on culture. c The isolated organism when inoculated should be able to produce disease in susceptible host. d The organism must then be recovered from the host and identified. The Koch’s postulates are not wholly true in all circumstances as we may not be able to isolate Mycobacterium tuberculosis from all those persons who have TB disease.

What is Community?

Definition: There is no universal definition of community. “Community often refers to a group of people residing in a specific geographical area, who have common interests, heritage, common bonds and shared assets and common socio-economic patterns”. Community size could be a village, a group of villages or as big as a country—like India. Community could be rural, urban or tribal community. For the practice of community medicine/community health/public health, understanding and knowledge of community is essential. “Know the community you serve before knowing medicine”.

1900–1950: PREVENTIVE MEDICINE AND CLINICAL SCIENCE ERA

This was an era of preventive medicine, social and clinical sciences. Focus—shifted to diagnosis and treatment of a patient. The whole approach became patient centred (Table 2.1).

Concept of Rural Community: A Case Study 2

India is a land of diversities. It has 28 states and 8 union territories. Nearly 66% of population lives in rural areas 35

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Textbook of Community Medicine Table 2.1: Historical development of medicine as social science from symptoms to universal health coverage

Period    

Before 1850

Eras      

Empirical health Bacteriological or era basic science era

Focus    

Symptoms 

Bacteria or disease  Individual  Community  Community

Sciences 

Unknown

Basic sciences

1850–1900

1900–1950

1950 –1977

Preventive medicine Community health or and clinical science era public health era Social sciences and clinical sciences (Humanities)

in 663049 villages. Rural communities are scattered in small villages, or hamlets which may be difficult to reach. Rural people are engaged primarily in agriculture or farm work, nearly 40% are landless labourers and work as manual casual labourers. About 85% of the farmers are small (with 1–2 hectare land) and marginal (with up to 1 hectare land) farmers. Their relationships are intimate, kinship is very strong and most families are joint families and caste system is very strong. The system of governance is by local self government (Panchayati Raj Institutions— PRIs), which is a three-tier structure—village, block and district (as recommended by Balwant Rai Mehta Committee in 1957 elaborated in Table 2.2). All adult members, above 18 years of the village constitute Gram Sabha who have voting rights and they keep a watch over the functions of village Panchayat. Village Panchayat has a responsibility to register births and deaths and is responsible for village development. State Government has transferred the funds, functions, and functionaries to village Panchayat for health developmental activities. Block development and Panchayat officer (BDPO) is an executive officer of Panchayat Samiti at the block headquarter who executes the development activities planned by PRIs. Village Panchayat gives land for construction of sub-centres, schools, Anganwadis and other institutions. Over 5.55 lakh VHSNC are functional. Khap Panchayat

Khap Panchayat is the union of few villages. Generally there are 10–15 members who constitute the Khap panchayat. Khap Panchayat is concerned with the affairs of the Khap it represents. Lately, they have emerged as

Community health sciences (social and managerial sciences)

1978–2017 and beyond Health for/in all era ‘universal coverage’ Community health sciences, behavioural sciences, and management sciences

Qasi-Judicial bodies that pronounce harsh punishments based on age-old customs, and traditions often bordering on regressive measures to modern problems. These institutions have no official government recognition or authority and not governed by law, but it can exert significant social influence within a community. These exist mostly in North India—UP, Haryana and Rajasthan. Rearing cattle is almost universal in a village. Cattle sheds are located near dwellings and animal excreta is disposed of or dumped near to dwellings. Many people defecate in open (33%) and do not have toilet/use toilet which lead to soil pollution, worm infestation and water pollution. Sources of water supply are hand-pumps, wells and piped water supply. Inequities in Mortality and Fertility

Rural community has high birth rate of 21.1, per 1000, high death rate of 6.4 per 1000 population and high infant mortality rate of 31 per 1000 live births (SRS 2022). Density of population is low. Each village has common land (shamlat) meant for generating revenue for village Panchayat. Concept of Urban Community: A Case Study

Census of India defines urban area as: (a) All areas with municipality, corporation, cantonment board or notified area committee; (b) place satisfying the following three criteria simultaneously—a minimum population of 5000, at least 75% of males working population engaged in non-agricultural vocations and density of population at least 400 per square km. In India, 34% of population lives in urban areas. Urban community is different from rural community. In urban

Table 2.2: Three-tier system of local self government (PRIs)* local rural bodies

2

Levels

System of administration/Governance

Membership

Village

Gram Panchayat

Sarpanch (village headman) and members of Panchayat who are directly elected from village, one-third seats are reserved for women

Block

Panchayat Samiti

All Sarpanches and president

District

Zila Parishad

All presidents of Panchayat Samitis

*PRIs (Panchayati Raj Institutions), under the landmark 73 constitutional amendment Act of 1992 PRIs are local self governments, delegated and made responsible for 29 subjects including primary healthcare, education and family planning.

Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease

areas, class rather than caste is a stronger system. People are primarily engaged in non-agricultural vocations. Density of population is very high and land cost is very high. The system of governance is by municipal committees/ corporations, or cantonment board. Urban Local Bodies

Each census ward elects a municipal commissioner/ counsellor. Each municipal committee or corporation elects its president/mayor. One-third of urban population or even more than that lives in urban slums with deplorable or sub-human conditions; living in households of poorly built localities usually with inadequate infrastructure and unhygienic environments lacking in proper sanitary and drinking water facilities. Urban dwellers have less interaction with each other and live in isolation. Most families are nuclear families. The occupation is business, service or industrial work. Urbanization is inevitable. Most health parameters for urban areas are much better except in urban slums which may be worse than rural areas. Urban birth rates are low at 16.1 per thousand, death rate is 5.1 per thousand population and infant mortality rate of 19 per thousand live births (SRS 2022). Health facilities in urban areas are well developed in terms of hospitals, nursing homes, private practitioners and public health services. Tribal Community

About 8.2% of population of India is tribal population. These people live in forest areas, hilly area which are difficult to reach, without much civic amenities. Their socio-economic status is poor and they are marginal communities with minimum access to health facilities. Health facilities and health infrastructure in these areas are poorly developed and so is the road infrastructure. Tribals are marginal farmers and practice shifting cultivation. Health facility norms for population coverage have been relaxed for tribal areas. Tribal areas are most vulnerable to—falciparum malaria, with problem of drug resistance, tuberculosis, sickle cell anaemia, thalassaemia and glucose-6phosphatase deficiency (G6PD). Their customs and cultural practices have profound effect on health. Female sex ratio is better in tribal areas, breastfeeding practices are universal. Thus, knowing your community is an imperative need for the practice of community medicine. Take a good look at your community, respect your people, their traditions, ideas and culture and help them build on the knowledge and skills they already have. It is a common proverb: “Go in search of your people Love them, learn from them Plan with them, serve them Begin with what they know Build on what they have.”

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Assess Felt Needs

What things in your people’s daily lives (living conditions, lifestyles, ways of doing things, beliefs, etc.) do they feel help them to be healthy? What do people feel to be their major problems, concerns and needs—not only those related to health but also in general? 1 Felt-needs: Means what people feel are their biggest problems? 2 Real needs: As determined by experts and steps people can take to meet these problems in lasting way. 3 Willingness or readiness of people to plan and take the needed steps. 4 Resources: ‘People’ themselves are the biggest resource. People count first in resources, their skills, materials, and/or money needed to carry out the activities decided upon. Example: Let us suppose that a man who smokes a lot comes to you complaining of cough that has been steadily getting worse: 1 His felt—need is to get rid of cough. 2 His real need is (to correct the problem) to give-up smoking. 3 To get rid of his cough will require his willingness to give-up smoking. For this he must understand how much it really matters. 4 One resource that may help him to give-up smoking is information about the harm it can do to him and his family. Another is the support and encouragement of his family, his friends and you. Self-help

For how many of their problems, can people care for themselves? How much outside help is required? Are people ready to generate resources and cooperative to solve their problems? Do people work together to meet common needs? Do they share or help each other when needs are great. What are their opinions to make the village better and healthier place to live? Where might you and your people begin?

COMMUNITY PARTICIPATION IN HEALTH MANAGEMENT AND DEVELOPMENT 3–5 Goal of ‘health’ cannot be achieved without community participation as the people are the most important resources for health and development. Community is the ‘heart’ of health system. What is Community Participation?

“Community participation is a process by which individuals and families assume responsibility for their own health and welfare and for those of community and develop capacity to contribute to their and the community’s development”.

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Textbook of Community Medicine

Types of Community Participation

i Community takes the responsibility to manage health services at village level, e.g. management of sub-centres by village Panchayat (women members of PRIs). ii Community generates its own resources to maintain the building of a sub-centre and construction of subcentres and schools. iii Community itself plans or determines their health needs and priorities and work hard to meet these needs. iv Community organises the programme and implements the programme with their own resources plus resources provided by the government. v Community monitors the government run programmes and provides feedback to the system. vi Community evaluates the health programmes and gives its report card to government for necessary corrective actions. Rogi Kalyan Samiti at PHC, CHC, Mahila Arogya Samitis in urban health centres, village and Urban health sanitation and nutrition committee and Mahila Mandals at village level have been constituted to enhance community participation in health and development. Competency addressed: The student should be able to: CM 2.2: Describe family types, its role in health and disease.

How?

Student interacts with family regularly and follows it longitudinally.

TYPES OF FAMILY AND ITS ROLE IN HEALTH AND DISEASE

2

Family is a universal institution in all the cultures. In India, family occupies a pivotal position and is a significant system in the social fabric. The family thus is a biological unit, or a social unit and a universal institution in every society. Several definitions of family have been given from time to time; some of these are being reproduced: • McLver defines family as “a group defined by a sex relationship, sufficiently precise and enduring to provide for the procreation and upbringing of children”. • According to Burgess and Locke, a family is “a group of persons united by ties of marriage, blood or adoption, constituting a single household, interacting and inter-communicating with each other in their respective social roles of husband and wife, mother and father, son and daughter, brother and sister, creating a common culture”. • Ninkoff defines a family as “a more or less a durable association of husband and wife with or without children or a man or woman along with children”.

• Elliot and Merrill define family as “the biological social unit composed of husband, wife and children”. • The definition given by Bureau of Census (USA) is easier. According to Bureau, the family is “a group of two or more persons related by blood, marriage or adoption and residing together.” Household

The term family differs from household, in that, all members of household may not be blood related, e.g. servants. House and Household6

The term ‘house’ means a structure with a single roof, where one or more than one family may be residing during the enumeration of population. The number of households in a house is determined according to number of kitchens (Chulahs) in a house. For examples, if there are four families living in a house and their food is being cooked in three kitchens, the total number of households will be three. In a house, there may be more than one household and each should be assigned a separate identity number. Definition (NFHS-5): A person or group of related or unrelated persons who live together in the same dwelling unit (S), who acknowledge one adult male or female as the head of the household, who share the same housekeeping arrangements, and who are considered as single unit. Characteristics of Family

Out of these definitions, the following characteristic can be summed-up: • A mating relationship: The family comes into existence when a man and woman establish mating relationship between them. The relation may be of shorter duration or lifelong. When a marital relation breaks down, the family disintegrates. • A form of marriage: Mating relationship is established through the institution of marriage, it may take one of the several forms, monogamous or polygamous, partners may be selected by the parents or elderly persons in the family in arranged marriages or an individual himself/herself may select the partner. • A common habitation: Family lives in home or household for child bearing and rearing. • System of nomenclature: Every family is known by name and it has its own system of reckoning and descent. The descent may be reckoned through the male line or through the female line. Usually the wife goes and joins her husband’s relatives but sometimes husband also may go and join his wife’s relatives (in North-east India). • An economic provision: There is some source of income to sustain economic needs of the family. Head of the family performs certain vocation to earn money.

Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease

Types or Forms of Families

The families can be classified on the basis of authority or else on the basis of structure. On the basis of authority vested the families can be either: • Patriarchal: Where male member as head of family is authority in decision-making and controlling the family affairs and the female is subordinate. Patriarchy defines life patterns and culture and even way men and women think about one another. The descent is recokned through the male line. • Matriarchal: The authority is vested in female head of the family. Now 18% of households are headed by women. On the basis of marriage pattern, the family may be classified as: • Monogamous in which one man marries one woman. Only such a marriage where there is only one regular trusted sexual partner and both are free from HIV infection have no chance of acquiring sexually transmitted infections like HIV and other STDs. • Polygamous family: Husband has more than one wife or multiple sexual partners, such a marriage relationship in these families involves the greater risk of transmission of STDs and HIV infections. • Polyandrous family: In this kind of family, one woman marries many men and lives with all of them or with each of them alternatively. This also involves the risk of multiple sexual partnership. If it is regular partnership the risk of HIV transmission is somewhat less but certainly it carries more risk if the partnership is irregular and involves multiple sexual partnership behaviour. Similarly, the family could belong to various groups as per sanctions of marriage. An endogamous family is one which sanctions marriage only within members of in-groups. Consanguineous marriages, i.e. marriages amongst cousins have more risk of transmission of genetic disorders. An exogamous family is one which sanctions or allows marriages of in-groups with members of an out-group. Such a marriage carries low risk of transmission of genetic disorders. On the basis of the structure, the family has been classified as nuclear, joint or extended family.

39

away from their parental house. Industrialization, urbanization and employment pattern are some of the compelling reasons for development of nuclear family. In a nuclear family, both the parents may be employed for the job or work for wages, children are left under the care of some agency or at home under the care of servant. The strain and stress of bringing up children (feeding and care) is real in nuclear family. If the wife is housewife, the worry of care of child gets reduced. The development of children in such families is a challenge. The extrafamilial institutions, such as creches, child care centres, balwadi centres or nurseries are utilised for the care and development of young children by most nuclear families. Joint or Extended Family

The culture of joint family is widely prevalent in rural India and even in urban areas. Married couple/couples live with their parents. The children of these couples are looked after by the grandparents as the men and women are away for field work or are in the job. The joint family shares the common kitchen. All the property is held in common; including land. To save the land from division or fragmentation, joint families played their pivotal role. The authority is vested in the eldest member who is the head of the family/household. Joint family is characterised by large size, common residence, common purse, common kitchen and common land and there is great degree of interdependency. The merits of joint family are—it provides social and economic security to all its members—working, nonworking, old age people and young children, sick people, widows and handicapped/disabled. The widow’s remarriage is common and it is a kind of rehabilitation to save the property in the name of joint family. Apart from merits, there are several demerits of joint family, such as it hinders the development of personality, privacy to couple is least, and it leads to uncontrolled births. Merits overweigh demerits. Three Generation Family

It is also a joint family but it denotes that three generations stay together and share common house and kitchen. Grandparents, their married sons and their offsprings are an example of three generation family. Functions of Family/Roles in Health and Disease

Nuclear Family Socio-cultural Factors

Biological Function

Nuclear family is one which consists of the husband, wife and their children who stay together. These types of families are common in urban settings when the male adult members get married, they leave their parental home and start their life as an independent unit. Compelling reasons for development of nuclear family are—the male member getting an employment in urban settings far away from parental house or the newly married couples wish to stay

The basic/essential function of family is to bear children and propagate its progeny. Bearing and rearing children is to preserve its species. In the process of bearing children, there may be too many children, which add to the size of family and in some states like Bihar, Rajasthan, Uttar Pradesh and Madhya Pradesh, the family size tends to be large and acceptance of contraception may be low. Biological function should have emphasis on quality of life.

2

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Textbook of Community Medicine

The total fertility rate has declined from 6.0 (1951) to 2.0 in 2021, which is below the replacement level of fertility of 2.1. Interruption of biological function by contraception adds on, the essential responsibility of ensuring the survival of the children born as also adequate quality of life by health services. Rear Children

Rearing children is another essential or obligatory function. Rearing children means nurturing; transmitting values and culture till such period the children attain adulthood and become independent. Rearing practices vary from culture to culture and family to family. Child learns moral values and develops ‘lifestyle’ within the family as family and parents are eternal and first school of learning for a young child. The basic values and practices are transmitted from parents and family members to their children/offsprings. In this process, the parents and other family members have to be good role models for their children. Child may acquire the habit of smoking from parents or grandparents, habit of use of toilet, brushing teeth, washing hands and personal hygiene is acquired in the family. Family needs to be supported in this function by all other social institutions like Anganwadi centres, creches, Balwadis and formal system of schools. The total child development and growth is family-based but conditioned by the environments. Seeds of NCDs are sown during childhood period. Culture Transmission

The family is an institution that transmits traditional values, ideals, beliefs, practices and traditions. The child who is born in the family is a ‘clean slate’ and he imbibes and learns the values, beliefs, practices from his family. Some of the things which cannot be taught by any other institution are best learnt within the family. Security

Family provides social and income security to its members. It provides shelter, food, clothing and other necessities of life to dependent members. Similarly, family provides security to old age person, to sick and disabled person. Mentally retarded and other disabled are best cared for in the family. Old age homes are homes away from home and do not provide family environments hence family in Indian set-up is the best institution for care of the elderly people. All efforts should be directed to sustain and maintain the institution of family.

develops in the milieu of family. Children learn by imitation and this learning can be further enhanced by extra-familial institutions like non-formal education imparted through ICDS Anganwadi workers and continued through the formal education system of school. Thus, family is sheet anchor for sustaining and providing social and economic security, developing life styles, personality traits and transmission of values and culture to its members. Family Size

In general, the family size means total number of persons in a family, however demographically it means the number of children a woman has born at a point in time. The total fertility rate (TFR) means the average number of children born to a woman during her lifetime or else the number of children that would be born per woman if she was to live to the end of her child-bearing years (15–49 years) and bear children at each age in accordance with prevailing age-specific fertility rate (see measures of fertility). 15  49

TFR =

5  Age-specific fertility rate 15 19

1000 During the year 1951, the TFR was 6.0. The current level of TFR is 2 (2019–21), which is below the replacement level of 2.1, this in other words means two child norm. In states like Bihar, Meghalya, UP, Jhharkhand and Rajasthan it is still higher than national level. The large size of the families in these states is attributable to early marriages, lack of practice of contraception due to illiteracy, ignorance and poverty, unfavourable attitudes and disbelief in contraception. These states are very high focus states for Family Planning Programme. Large-sized family means where the number of children are more than average of the nation, these families are high risk families. Broken Family

These are those families where the parents have separated or divorced due to disharmony or else one or both parents have died and the children become orphans. Such a situation profoundly affects the physical, social and mental development of children since the family support is lost or it is partial. Children of such families may drift to abnormal development and likely to develop behavioural problems. Orphanages provide support to such children. Broken homes are due to inter- and intra-family quarrels and is the bed rock on which personality and psychological breakdown starts in children.

Shaping Personality and Lifestyles of an Individual

2

Family takes pride in shaping of personality of an individual. Behaviour pattern of a person, obedience, respectfulness, cooperativeness, truthfulness, discipline, self-reliance, ability to stand against stress, gender respect,

Problem Families or High-risk Families

Such families like large-sized families, families below poverty line, broken families, addiction in husband, and long illness of child or in any other member are called

Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease

problem families and these families need to be targeted as priority families for healthcare, social development and poverty alleviation. Children in these families run the risk of poor health, development problems and social problems. Role of Family in Health and Disease—Gender Inequities

The family would be referred and quoted in all ‘lifestyle diseases’, ‘chronic non-communicable diseases’ and ‘behavioural problems’ because all have their origin at the place of living and in the family and the natural history of disease can be traced to the setting of family. The first response to an illness of young children or any other falling ill comes from family. It is the family response which matters most in child survival may it be initiation of breastfeeding, exclusive breastfeeding, infant and young child feeding practices, administration of home available fluids (HAF) in diarrhoea, continuing feeding during diarrhoea, smokeless kitchen, supplementary feeding, spacing and limitation of births, home delivery/institutional delivery, seeking antenatal care, immunisation services and treatment of tuberculosis, the decisions of family are critical. Therefore, the families need to be empowered and well informed and supported by all the primary health centres, sub-centres, ICDS system, education and development department. How this support comes is a matter of national, state, district and local policy of village Panchayat. Disparity between boys and girls and adverse sex ratio (gender discrimination) is ultimately family or at the most a community choice. Food availability at the household level is seldom a problem for children between the ages of 6 and 24 months, the amounts required are small, the issue is proper care and attention to child’s need and attitudes of the family which deliberately denies food (cereals) to children, due to wrong beliefs. Social attitudes at the family level are at heart of environmental concerns. Much of the hygiene and sanitation is in the mind, rooted in conceptions of purity, pollution, and dignity of labour. Family level storage of drinking water and its use, protection from contamination by use of clean hands are decisions of the family. Safe disposal of garbage, refuse, waste water and excreta disposal are ultimately the decisions of the family. Sanitation costs nothing when people cooperate and take it by themselves. People’s programme on sanitation succeed but government programmes on sanitation quite often fail. Sanitation and hygiene is essentially a way of life deep rooted in the cultural practices and only determined efforts of families can make it successful. What people do with their lives and those of their children affect their health far more than anything that governments do but what they can do is determined, to a great extent, by their income and knowledge—factors that are not completely within their control.

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Poverty reduction programmes and universal elementary education and education for all especially for girls (Sarva Shikhsha Abhiyan) by the government if pursued and implemented vigorously can change the scenario. Similarly, primary healthcare for all can make the difference. Competency addressed: The student should be able to: CM 2.1: Describe the steps and perform clinico-social cultural and demographic assessment of the individual, family and community.

Objective

The main objective of this competency is to assess community health needs, cultural and demographic profile of community and its implications on health How?

The student uses household survey register data and village/urban ward information to assess clinico-social, cultural and demographic profile of individual, family and community. Steps in Assessment of Clinico-social Cultural and Demographic Profile of Individual, Family and Community

Household Surveys (HHS) and Village Health Survey

The primary healthcare is reaching families through network of Sub-centres, PHCs, CHCs, Anganwadis and ASHAs. This appears to be the major means of reaching families. It is mandatory for health workers female, ASHA and Anganwadi workers to maintain family records of each household. This household survey register (family register) connects families to the system of sub-centres and Anganwadis under ICDS. Household register is updated once every year and it forms the basis of formulation of village and sub-centre action plan and community health needs assessment. The health needs and health practices of each family and family member are assessed by the health workers by establishing contacts with each family. The household survey register provides wealth of information relevant to the health and action to be initiated/undertaken by the worker. The objectives of household survey are: i To assess community health services needs ii To assess the clinico-social, cultural and demographic profile and health status of each individual in the household and its environment and for identifying beneficiaries for initiating relevant healthcare activities/services. iii To identify high risk households or families. The information of household survey register consists of—household information and individual information.

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The household information consists of: Household no. House no. Resident/ migrant Religion

Family type

Caste

Source of drinking water Above poverty Below poverty line line Katcha–pucca– Ownership of semi-pucca house Separate Type of fuel kitchen used TV–radio Other assets

Monthly income Type of house Number of rooms Assets

Breeding places of mosquitoes and flies

Land holding

Cattle wealth

Nuclear/ joint Storage practices Type of latrine used Own/ rented Electricity Motor vehicle, tractor Garbage and waste water disposal

• The information on individual is given in Table 2.3. Village Health Register/Census Ward Register

Household surveys are carried out village wise by health team. This generates information on socio-cultural and demographic profile of each village. Village Health Sanitation and Nutrition Committee is responsible for preparation of Village Health Action Plan based on village health register data/information. Essentially village health register provides information on demography—total population, agewise population structure, total number of households and families, eligible couples,, infants, pregnant and lactating mothers, sources of drinking water and sanitation facilities, health facilities, health teams (ANMs AWW, ASHA, male worker) formal and informal leaders, schools, village practitioners, major health problems, health behaviour/practices and health seeking behaviour, of community besides births and death data. Urban ASHAs and AWWs prepare census ward register under the supervision of urban health centre ANMs and supervisors. Armed with this information the health workers, Anganwadi workers and ASHAs are required to visit 10 families per day and to cover the entire area within 3 months period. The priority houses where visit is required are chosen and priority includes:

• Eligible couples. Large-sized families. • Pregnant women—unregistered. • Registered pregnancy with any complications or not turning-up for second dose of tetanus toxoid/or IFA tablets. • Postnatal case not seen after delivery. • A low birth weight neonate. • A new acceptor of oral pill/IUD. • Child with suspected pneumonia. • Child with diarrhoea with some dehydration. • Child with vitamin A deficiency not turning up for second therapeutic dose. • An infant not turning up for immunisation. • Follow-up after tubectomy and follow-up of referred to PHC/CHC/hospital by you. • A person acutely and seriously ill. • A child who has had an adverse reaction to any immunisation. • Maternal, neonate or child death. • A recent case of acute flaccid paralysis. • Severely malnourished child. • Follow-up patients of diabetes and hypertension. In summary, it includes priority houses of ‘scheduled caste, below poverty line families or landless families’, and families having either infant or pregnant woman. Before making home visits, the workers are required to look into the relevant individual mother and child protection card, immunisation card, or family record and note the urgency of the health needs. The workers review any procedures to be carried out, specific advice to be given or demonstration to be done. Workers carry the required articles and records with them and visit the priority houses/ families. Expected outcomes: The student analyses the household survey data and prepares demographic profile of community/family. He/she enlists observed way of life such as garbage and excreta disposal, cooking fuel used, water storage practices and food distribution within the family, literacy, occupation, income and common illnesses suffered in the last one month and healthcare utilized. Competency addressed: The student should be able to: CM 2.2: Demonstrate in simulated environment the correct assessment of socio-economic status.

Table 2.3: Individual information at household level (demographic and socio-cultural assessment)

2

1

2

3

4

Name of head of household

Name of Age in Sex members years of DOB household

5

6

7

Relation Marital Occupation to head status and of houseliteracy hold

8

9

10

11

12

Immunization Illness Disability Marriages, Healthstatus of in last if any pregnancy, care children 1 month births, utilization (under deaths in and 2 years) the last expenditure year

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Relationship of Social and Behavioural Sciences (Humanities) to Health and Disease

Objective

Prasad’s Method (1961) Modified in 2018 8

The objective of this competency is to identify the deprived households/families and vulnerable populations and priority groups for health services.

Socio-economic status of family can also be known by criteria proposed by BG Prasad in 1961, which includes per capita monthly income of an individual as given in Table 2.6.

Correct Methods of Assessment of Socio-economic Status (SES) of Individual and Family

Standard of living index (SLI) based on household amenities and possession of some selected household items, the SLI can be developed by allocating scores to items. The total of scores may vary from lowest of 0 to maximum of 40. On the basis of total score, households are divided into three categories as: a Low—if total score is less than or equal to 9. b Medium—if total score is greater than 9 but less than or equal to 19. c High—if the score is greater than 19.

How?

The socio-economic status of family can be determined by the student on the basis of education, occupation and income level. Based on these variables, socio-economic status has been measured by following methods. Kuppuswami’s Method (for Urban Area)

Kuppuswami’s method takes into consideration the education, occupation and monthly income of family to classify or determine socio-economic status. Each component is given a weighted score and then the total score is summed-up and the individual/family can be classified into a socio-economic class I, II, III, IV and V as illustrated in Table 2.4. The level of income is generally updated on the basis of consumer price index (CPI). Udai Pareek’s Method (for Rural Areas)

Pareek has evolved to determine socio-economic scale and class for rural area. It takes into consideration—caste, occupation, education, land holding, social participation, family size, housing and farm power and material possession. Each of these components is given weighted score and by summing-up all the components the SES can be determined and categorised into several classes, as given in Table 2.5. This way individuals and families can be classified into a socio-economic class. Income may be concealed and it may not be easy to determine. To determine the level of poverty, these criteria can be adopted to classify the family as below poverty line (BPL) or above poverty line (APL).

These three categories of SLI have been used in district level household surveys and NFHS in India (Table 2.7). Socio-economic criteria determine the level of ‘wellbeing’, lifestyles, and utilization of services apart from social status and recognition and position in the society. Wealth does not ensure or guarantee good health as wealthy may adopt unhealthy lifestyles. Poor may spend money on alcohol or tobacco and wealthy persons may smoke, drink and consume unhealthy diets (more saturated animal fats, animal food, etc.). Income level or socioeconomic status of families can be assessed by rapid observation methods in community and family can be described as economically well-off or economically weaker or middle class family. Middle class income families in India are under transition and obesity, hypertension, coronary heart disease and diabetes (all lifestyle diseases) are emerging in this socio-economic class, while poor families bear the brunt of malnutrition, repeated infections due to diarrhoeal diseases, acute respiratory infections, TB and worm infestation, due to overcrowding, poor housing and insanitary conditions.

Table 2.4: Revised Kuppuswami’s method of social classification of an individual (urban areas), updated Jan 20187 Components (A) Completed educational qualification of head • Professional or honors • Graduate or postgraduate • Intermediate/post high school diploma • High school certificate • Middle school certificate • Primary school certificate • Illiterate (B) Occupation of head • Legislators, senior officials and managers • Professionals • Technicians and associate professionals • Clerks • Skilled workers and shop and market sales workers • Skilled agricultural and fishery workers • Craft and related trade workers • Plant and machine operators and assemblers • Elementary occupation • Unemployed

Weighted score 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1

Components

Weighted score

(C) Monthly income of family (2018) • >1,26,360 12 • 63,182–1,26,356 10 • 47,266–63,178 6 • 31,591–47,262 4 • 18,953–31,589 3 • 6,327–18,419 2 • 6,323 1 Calculation Total score = A+ B + C Social class* • 26–29 Upper class I • 16–25 Upper middle class II • 11–15 Lower middle class III • 5–10 Upper lower class IV • Below 5 Lower class V

*Class I is the highest socio-economic class; while class V is the lowest economic class.

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Textbook of Community Medicine Table 2.5: Pareek’s method of socio-economic classification (rural areas)

Components

Weighted score

(A) Caste • Scheduled caste • Lower caste • Artisan caste • Agriculture caste • Prestige caste • Dominant caste (B) Occupation • None • Labourer • Caste occupation • Business • Independent profession • Cultivation • Service (C) Education • Illiterate • Can read only • Can read and write • Primary • Middle • High school • Graduate and above (D) Land • No land • Less than 1 acre • 1–5 acre • 5–10 acre • 10–15 acre • 15–20 acre • 20 and above (E) Social participation • None • Member of one organization (like Panchayat member, Nambardar, etc.) • Member of more than one organization • Office holder in such organization • Wider public leader

Components

Weighted score

(F) Family members • Up to 5 • Above 5 (G) House • No house • Katcha house • Mixed house • Pucca house • Mansion (H) Farm power • No draught* (buffalo/cows) animal • 1–2 draught animals • 3–4 draught animals • 5–6 draught animals or tractor (I) Material possession • Bullock cart • Cycle • Radio • Chairs • Improved agriculture equipment • None Socio-economic class Total score Score more than 43 Score 33–42 Score 24–32 Score 13–23 Score less than 13

1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6

1 2 1 2 3 4 6 1 2 3 6 1 1 1 1 2 0 Grading I II III IV V

0 1 2 3 6

* Draught animal—animal used for pulling heavy load.

Table 2.6: Modified Prasad’s social classification8 for may 2021 Social class

Per capita monthly income limits ( `) Prasad’s classification 1961

Modified classification* for may 2021

100 and above 50–99 30–49 15–29 Below 15

7863 3931–7862 2359–3930 1179–2358 25 (obese) 18.9

20.6

23

24

Delhi BMI > 25 (obese)

24.6

34.9

38

41.3

Punjab BMI > 25 (obese)

27.8

31.3

32.2

40.8

Haryana BMI > 25 (obese)

20.2

21.0

28.3

33.1

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women in urban area were obese or overweight against 20% in rural area. Similarly 30% of men were obese or overweight in urban area against 19% in rural India (NEHS-5).5 Levels of obesity have (in adults 15–49) increased in men and women in India over the last 5 years. Prevalence has increased in men from 18.9% to 23% and in women from 20.6% to 24% while in women. Obesity is maximum in prosperous states like Delhi, Punjab and Haryana. Delhi and Punjab with obesity levels of 41.3% and 40.8% in women respectively being the heaviest states in India. Socioeconomic Status

Upper socioeconomic classes and affluents are more affected as compared to urban poor; however, it all depends on lifestyles of eating and exercise. NNMB data observed high obesity levels in urban slums indicating that obesity is now affecting urban poor. Ethnicity

People of Indian origin living in USA, UK and Malaysia have high incidence and prevalence of obesity as compared to local people. Physical Inactivity

Consequences of Obesity

With increase in prosperity, the lifestyles have changed because of urbanization, industrialization and mechanization. The physical activity much reduced due to use of automobiles, long hours of watching of television and playing computer games and load of books which confines the children, adolescents and adults in homes. The energy spending is less and energy consumption is much higher with higher use of junk foods (refined carbohydrates). Eating junk foods and television watching go together, due to excessive use of mobile telephones, the mobility is further reduced. Urban surveys from Indian cities have indicated low level of physical activities in 61–66% of men and 51–75% of women. Nearly 41% of adults in India fail to meet minimal levels of physical exercise (WHO ICMR study 2020) or 41% of adults lead inactive lifestyles, are at risk of lifestyle diseases.

Overweight and obesity is a risk factor for development of various non-communicable diseases (NCDs), over the years epidemiological data has proved that obesity and overweight leads to increased mortality and increased risk of chronic diseases like cardiovascular diseases, diabetes, hypertension, osteoarthritis, osteoporosis, gallbladder diseases, gallstones and certain cancers like breast and uterine and infertility. Obesity is a major risk factor for non-insulin dependent diabetes mellitus also apart from non-alcoholic fatty liver disease. Diabetes together with obesity is often referred as diabesity.

Risk Factors

Primordial Prevention

Physical inactivity, unhealthy eating, consumption of alcohol are the risk factors for overweight and obesity and other NCDs. New Trend

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malnutrition continues to be a major health concern in many parts of the world, excess of food consumption and sedentary lifestyles are leading to an epidemic of obesity and chronic non-communicable diseases (NCDs). Obesity is strongly linked to low physical activity and a major cause for insulin resistance. Insulin resistance is a characteristic feature of Asian Indians even with non-obese body mass index. A genotype which provided metabolic defence at times of famine has probably placed the present generation at a higher risk of developing metabolic disorders when exposed to constant overnutrition and physical inactivity. Hitherto, our concern remained on undernutrition in young children. Long-standing malnutrition in India exposes these children during adulthood period to the consequence of degenerative metabolic disorders even at low BMI when they indulge in overeating and physical inactivity. Currently, the dietary transition (of overeating and physical inactivity) has affected the urban rich and adults; however, obesity and metabolic disorders have affected the urban poor as well as rich in India. India is currently fighting against undernutrition as well as impending outbreak of overweight and obesity.

Obesity is emerging as a problem of younger age groups, i.e. younger children in urban affluent areas have the tendency towards overweight due to more amenities and less of physical activities as also overeating tendencies. A study of 4000 Indian children in 15 cities indicated that 25% of children in 5–14 years age in urban schools being overweight, while nearly 11% kids were obese. While

Prevention and Control of Obesity

Since overweight and obesity is an emerging epidemic and significant public health problem, its prevention and control strategies are important. Following strategies can be applied.

It involves prevention of development of obesity risk factors in population/persons not known to have the risk factors of the disease. The aim is to avoid emergence and establishment of the social, economic and cultural pattern of “lifestyles” that are known to contribute to an increased risk of obesity. In obesity, primordial prevention consists of physical activity and regulating dietary pattern. WHO says obesity cannot be prevented or managed or physical activity promoted, solely at the level of individual governments. The food industry, international agencies, the media and the community all need to work together to modify the environments so that it is less conducive to weight gain.

Epidemiology of Communicable and Non-communicable Diseases and Related Disease Specific NHPs

Lifestyles

Lifestyles such as eating pattern, overweight and taking onto physical activity begins early in life during childhood period. Hence, the primordial prevention of obesity begins during childhood period. Developing healthy lifestyles is the responsibility of parents, school teachers, media, industrial establishment and the government (regulating town planning and eating establishments). Let us give our future generation a healthy start. During this transition period when we are faced with undernutrition on one hand and overnutrition on the other, we have to strike a balance. PHYSICAL ACTIVITY

Habit of regular physical exercises can be inculcated during childhood at home by parents, in schools by school teachers and at workplace by peers and the management. Any amount of physical activity helps at any age. The minimum amount of physical activity required for prevention of obesity is at least 30 minutes of moderate activity every day or to spend 150 calories or energy per day. Therefore, 30 minutes of moderate activity every day is helpful. Half an hour is a minimum recommendation, of course, more time you spend moving for health, the more you gain. Walking 2.34 km in 30 minutes; or walking 3.12 km in 30 minutes, basketball game for 15 minutes, cycling, gardening, dancing fast for 30 minutes and washing a car or motorcycle, etc. help and keep away obesity. Exercise to your capacity. Everybody above 2 years of age should undertake for a cumulative duration of 30 minutes moderate physical activity. Persons with medical problems should consult a physician and take medical advice before starting a vigorous exercise. Avoid extremes and inappropriate or excessive physical activities. One can have interrupted physical activity of 10 minutes session or two sessions of 15 minutes each.6 Diet—Curb on “Junk Foods” Regulatory Measures

Improve nutrition knowledge of people and eating sensibly and avoiding excess of eating. Caloric excess and physical inactivity lead to obesity. Avoidance of eating junk foods helps to reduce calories. Curb sale of junk foods in the vicinity of schools. The left front Government in Kerala has imposed 14.5% of tax on restaurants selling foods high on saturated fats such as Pizzas, burgers and tacos. Eating more of protective foods like green leafy vegetables and fruits in place of sweets is beneficial. Have only 20 g of visible fats in the food and right proportion of saturated, monosaturated and polyunsaturated fatty acids in diets to maintain optimum level of HDL in the blood. Derive 60–65% of energy from carbohydrates with emphasis on complex carbohydrates of whole grain cereals which are good sources of fibre. Sugar should provide less than 10% of total energy. 10–15% of energy should be obtained from

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proteins and 20–30% from fats. Vegetarian diets based on complex carbohydrates, edible oil such as groundnut oil, sesame oil with moderate level of linoleic acid and GLV (green leafy vegetables) and fruits are helpful and better than animal foods. Fish and lean meat are good. Primary Prevention by Periodical Check-up

Primary prevention in obesity involves preventing the development of obesity in those who are overweight. Know your weight by checking your weight periodically at home or at workplace. Regular weighing at an interval of 1 to 3 months helps screening of persons for risk factor of overweight. If a person is overweight, regular programme of diets and physical activity can be chalked out and results can be monitored by the individual himself. Secondary Prevention

If one has developed obesity, attempts are made to avoid further progression of obesity to morbid obesity and its complications. Graduating physical activity and dietary regimens can still be useful. Physical activity reduces stress and promotes active life. Tertiary Prevention

It involves treating of advanced obesity and associated illnesses with obesity to reduce mortality and morbidity by advocating combination of drugs, physical activity, diet regulation, avoidance of tobacco, alcohol and weight loss bariatrics surgery procedures for “morbid obesity”. Different strategies have to be adopted in rural and urban areas in the light of National Nutritional Policy and action plan on nutrition. REFERENCES 1 WHO. Obesity prevention and managing the global epidemic. Technical Report Series 894. Geneva: WHO; 2000. 2 Shetty PS. Body mass index: Is it the ideal universal weight for height index? NFI 2002 Oct; 23(4). 3 Shetty PS. Obesity: an emerging public health problem in Asia. NFI 2003 July; 24(3). 4 WHO. Global report on diabetes 2016. Executive summary WHO. Geneva. 5 IIPS-2006, NFHS-2 to NFHS-5 Mumbai, India. 6 WHO. World health day 2002: Move for health. Regional office for South East Asia, New Delhi: WHO; 2002.

DIABETES EPIDEMIOLOGY

World Health Day 7th April 2016—“Halt the rise beat diabetes”. Diabetes as a non-communicable disease is significant public health problem. The prevalence rate all the world over is rising.

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Diabetes mellitus is characterized by hyperglycaemia and disturbance of carbohydrate, fat and protein metabolism that are associated with absolute or relative deficiency of insulin action and/or insulin secretion. Therefore although diabetes is an endocrine disease in origin its major manifestations are those of metabolic diseases (WHO). The body needs insulin to convert starches and other foods into energy. “Cut-off” level for diabetes (Table 8.42). Table 8.42: Criteria for diagnosis of type 2 diabetes Fasting glucose (mg/dl)

2 hours postglucose load (mg/dl)

Diabetes mellitus

126 or

200

Impaired glucose tolerance

140 to 5.6 % and  6.4 % Life style change interventions in pre-diabetics are essential to prevent development of diabetes These “cut-off” levels help in making decisions to manage diabetes and also help in determining the disease burden and prevalence level of diabetes in population. Capillary blood glucose value is also sufficient. Where capillary blood glucose measured by glucometer is used in the fed state (i.e. post-food/post-glucose/post-meal), the >200 mg/dl cut off may be revised to >220 mg/dl. Criteria for the Diagnosis of Diabetes Mellitus

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1 Symptoms of diabetes plus casual plasma glucose concentration 200 mg/dl (11.1 mmol/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. OR 2 Fasting plasma glucose (FPG) 126 mg/dl (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours. OR 3 Two hours post-load glucose 200 mg/dl (11.1 mmol/L) during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. In the absence of unequivocal hyperglycaemia, these criteria should be confirmed by repeat testing on a different day. The third measure-oral glucose tolerance test (OGTT) is not recommended for routine clinical use. Glycosylated haemoglobin (HbA1C): It measures blood sugar control in diabetics. Level should be less than 7%.

Types of Diabetes

Type 1 (Due to autoimmune destruction of beta cells)

Formerly known as insulin-dependent diabetes mellitus (IDDM). Proportion of IDDM is less than 15% mostly in children and below 30 years, i.e. in younger persons. Type 2

Formerly known as non-insulin-dependent diabetes (NIDDM). Proportion of NIDDM is over 85% mostly above 40 years of age. This is the predominant type of diabetes in India. This classification has significance because etiology and management of these 2 types of diabetes are different. In type 1, the definite risk factors are obscure while in type 2, the environmental risk factors are known and therefore these can be minimized or reduced to control the prevalence and incidence of diabetes. Most preventive programmes are against type 2 diabetes. Type 2 is much more prevalent as compared to type 1. Prevalence and incidence of type 2 has risen all the world over. Gestational diabetes mellitus (GDM): It is defined as diabetes first recognized during pregnancy. The degree and severity of hyperglycaemia in this form of diabetes vary considerably. Following delivery, some women revert to normal glucose tolerance. About 10–25% of pregnant women have GDM. (GTT more than 140 mg/dL). All pregnant women are screened for GDM. Impaired glucose tolerance test (IGT) and impaired fasting glucose (IFG): Fasting plasma glucose (FPG) 110–125 mg is called impaired fasting glucose (IFG) and 2 hours post-load glucose 140–199 mg/dl is called Impaired glucose tolerance (IGT). IFG and IGT are associated with the metabolic syndrome. Malnutrition-related diabetes: This develops in young persons who were low birth weight babies and infants who were malnourished, and when they grow as adults they develop insulin resistant diabetes. Such adults are below 30 years with body mass index less than 18.5. Such adults are prone to develop metabolic disorders. Prevalence

World over the prevalence of adult diabetes was around 4.7% in the year 1980 and has risen to 8.5% in 2014. In India, prevalence was estimated to be 4.0% in 2000 and this has risen to 7.8% in 2014 in adults, indicating that diabetes was a major public health problem and epidemic of non-communicable diseases (Table 8.43). According to NFHS-5 (2019–2021) 13.5% women and 15.6% of men age 15 years and above were diabetic in India. Overall prevalence of pre-diabetes in India is 10.3%. One in ten school-age children and adolescents were prediabetic with fasting plasma glucose >100 mg/dl and 126 mg/dl.

Epidemiology of Communicable and Non-communicable Diseases and Related Disease Specific NHPs Table 8.43: Estimated prevalence of diabetes in adults (18 + years) in WHO regions 1, 2 WHO regions

Prevalence (%) 1980

1990

2014

African region

3.1

7.1

Region of the Americas

5.0

8.3

Eastern Mediterranean region

5.9

13.7

European region

5.3

7.3

South East Asian region

4.1

8.6

Western Pacific region

4.4

8.4

India

4.1

5.5

2019–21

4.7

7.8

13.5 to

8.5

Global Burden

Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980.1 The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4.7 to 8.5% in the adult population. This reflects an increase in associated risk factors such as being overweight or obese. Over the past decade, diabetes prevalence has risen faster in low- and middle-income countries than in high-income countries. With the current rates of prevalence, it is projected that India along with China and US will be “top three” countries to have most diabetics in terms of numbers. Thus, most of the burden will fall on developing countries and India would be home to 123.5 million cases of diabetes (Table 8.44).3,4 Currently 77 million Indians are living with diabetes (year 2020) with prevalence level of 13.5 to 15.6%. The number of people with diabetes is mounting due to rapid population growth, ageing, urbanization and increasing prevalence of obesity and physical inactivity. Table 8.44: Top ten countries for number of adults (20–79 years) with diabetes (2015–2040) Country China

Number of people with diabetes (million) 2015 2040 109.6

150.7

India

65–69.2

123.5

USA

29.3

35.1

Brazil

14.3

23.3

Russian Federation

12.1

12.4

Mexico

11.5

20.6

Indonesia

10.0

16.2

Egypt

7.8

15.1

Japan

7.2

–

17.1

13.6

Bangladesh

Deaths due to Diabetes

In India, 63% of all deaths were due to non-communicable diseases. During the base year of 1998 mortality due to Diabetes was to the extent of 0.2% which has now risen ten folds (2%) in the year 2014. Globally diabetes caused over 4 million deaths in 2019. Risk factors

15.6 World

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Source: IDF Diabetes Atlas, 7th edition, 2015 and ICMR 2016

1 2 3 4

Physical inactivity Overweight (BMI >23 kg/m2), and obesity Family history of diabetes High blood glucose, impaired fasting glucose, impaired glucose tolerance. 5 High cholesterol 6 High triglycerides. People have adopted sedentary life and have become inactive and have put on weight on account of excessive consumption of food. For hours, people watch TV, are busy with computers and use vehicles and contact people on telephones and mobile phones and thereby they have become inactive. Physical inactivity has added a new dimension of iatrogenic problem or self-created problem of obesity and diabetes. Rapid urbanization and reduced playground space and excessive load of books and reading have reduced physical activities of children. Age

The prevalence increases as the age advances. The type I diabetes which is more severe diabetes occurs mostly in younger people while type II diabetes prevalence is much more in middle and old age group. As the life expectancy is increasing, the people above the age group 60 and 65 will have to bear the brunt of diabetes. Data on diabetes in younger age group below 20 and above 65 is limited. In developing countries, the majority of people with diabetes are in 45–64 years age range while in developed countries most people have diabetes above the age of 64. Sex

The prevalence of diabetes is higher in men than women. Rural and Urban Distribution

For most developing countries in rural areas, the prevalence is assumed to be one-half that of urban areas. Urbanization leads to increased risk of diabetes because of altered diet, obesity and physical inactivity and other factors such as stress. In India, the prevalence of diabetes in rural area was 4.3% against 11.2% of urban areas in the year 2017. Economic Status

Diabetes is more prevalent in higher income brackets, because of unhealthy lifestyles and physical inactivity leading to problem of overweight and obesity.

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Example: Punjab has highest prevalence level at 10% against 4.3% in Bihar Family History of Diabetes

It is a strong risk factor and indicates genetic predisposition. Person who has family history of diabetes needs to observe precaution and undergo regular check-ups. Nutritional Status

Low birth weight babies and severely and moderately malnourished children, when they grow-up as adults suffer from metabolic disorders including insulin resistant diabetes. These persons when they develop diabetes have BMI less than 18.5 and require large doses of insulin for glycaemic control. In Indian context, this is quite significant in view of widespread childhood malnutrition. Prevention of Diabetes

Over 80% of type 2 diabetes is preventable. Primordial prevention: It consists of prevention of emergence and establishment of risk factors (physical inactivity, overweight and obesity). Initiate actions to prevent people becoming overweight and obese beginning before birth and in early childhood. Promote universal breastfeeding and consumption of healthy foods and discourage the consumption of unhealthy foods such as sugary sodas and promote physical activity.

Overweight and Obesity

Voluntary weight reduction improves insulin sensitivity maintaining optimum BMI, i.e. striving for BMI at the lower end of normal range. For adult population, this means keeping BMI in the range of 21–23 kg/m2 and maintaining waist hip ratio of less than 0.9 is good for health. It is more important for Indians because abdominal/ central obesity is predominant obesity in India and they are more susceptible to develop insulin resistant diabetes and syndrome X (insulin resistance syndrome). Syndrome X consists of abdominal obesity, insulin resistance, hypertriglyceridaemia, hyperinsulinaemia and hypertension. Syndrome X and insulin resistance syndrome have been renamed by WHO in 1998 as “Metabolic syndrome”. The modified adult treatment panel (ATP) III and third report of National Cholesterol Education Programme criteria works better for the diagnosis of metabolic syndrome in Indians. Physical Activity

Adoption of healthy lifestyles (dietary modification and physical activity) are the corner stones of both primordial and primary prevention of diabetes. These are beneficial for the total population, hence the focus should be on total population. Healthy lifestyles are not only beneficial for diabetes alone but are generally good for prevention of other non-communicable diseases like obesity, coronary heart disease, strokes, hypertension and some cancers. Hence, integrated preventive programmes for noncommunicable diseases are called for because most of the risk factors are common.

Increased physical activity which has a major beneficial effect on insulin sensitivity independent of its effect on weight. Moderate level of physical activity of half an hour brisk walking, cycling or jogging or running, jumping, dancing or intense physical activity depending upon one’s physical capacity is good for maintaining appropriate weight and helps reduction of weight. Physical activity should be done on regular basis and on most days per week. Physical activity means you move for your health. Moderate to intense physical exercise enhances insulin sensitivity. Voluntary weight loss in overweight and obese people decreases the risk of diabetes because of improved insulin sensitivity.

Prevention of Type I Diabetes

Diets

Primary Prevention: Population-based Approach

It occurs much less frequently and it results from autoimmune destruction of the  cells of the pancreas. Though the environmental and genetic factors appear to be involved, but there is no convincing evidence of role for lifestyle factors which can be modified to reduce the risk. The primordial and primary prevention for type I diabetes, is not practical for want of evidence.

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factors play a major role and are the main risk factors. Overweight and obesity are associated with an increased risk of type II diabetes and the evidence is convincing. Increased BMI and increased waist–hip ratio and obesity are important determinant of insulin resistance which is the underlying abnormality in most cases of type II diabetes.

Prevention of Type II Diabetes

Type II diabetes results from an interaction between genetic and environmental factors, however, the environmental

High-saturated fat intake and excess of refined carbohydrates has been associated with a higher risk of impaired glucose tolerance, higher fasting glucose, insulin levels, and risk of type II diabetes. Consumption of unsaturated fatty acids and polyunsaturated fatty acids from vegetable sources are associated with reduced risk of type II diabetes. MUFA and PUFA increase the insulin sensitivity and improve glucose tolerance. Total visible fat intake should not exceed 20–40 g per day and not more than 20–30% of total calories or energy be derived from fats, lesser the better.

Epidemiology of Communicable and Non-communicable Diseases and Related Disease Specific NHPs

Dietary Fibre (DF)

Dietary fibre (DF) or complex carbohydrates have beneficial effect on weight reduction. Adequate intake of dietary fibre prevents obesity. Achieving adequate intakes of DF by regular consumption of whole grain cereals, legumes, pulses, fruits and vegetables (particularly green leafy vegetables) are most probably helpful in prevention of development of type II diabetes. Indian diets which are predominantly cereal-based provide adequate quantities of dietary fibre. We need to promote intakes of green leafy vegetables, fruits and pulses by adopting healthy dietary and agriculture policies to be saved from type II diabetes. Recommended intake of DF is 20–35 g per day. Fenugreek seeds (Methi seeds) which have high level of insoluble dietary fibre (28%) and soluble dietary fibre (20%) is very effective in reducing blood glucose and cholesterol levels. Secondary Prevention

This involves early diagnosis and prompt treatment of type II diabetes, to prolong life or to live full life. Make essential medicines such as human insulin made available and affordable to all who need them. The primary purpose of secondary prevention is early detection or identification of individuals without symptoms who either already have a disease or are clearly at high-risk of developing it, through screening programme. Screening programme have two approaches: Populationbased screening programme for type II diabetes remains controversial, it involves high cost and is not feasible for whole population. However, it is done for epidemiological research purposes to determine prevalence and trends of diabetes for the purpose of planning and measuring the impact. Population-based screening is not recommended to screen children and young adults for NIDDM (noninsulin-dependant diabetes mellitus). Selective screening: This is feasible and undertaken for high-risk individuals. The possible high-risk groups are: • Persons above the age of 30 years at the point of primary contact with health facility. • Those with a strong family history of diabetes. • Migrant Asians and Indians, other ethnic groups who show high prevalence and those changing traditional to westernized lifestyles. • Obese and overweight persons and women with history of gestational diabetes mellitus (GDM) or high birth weight babies. • Those with other elements of chronic metabolic syndrome, e.g. hypertension, obesity, dyslipoproteinaemia. Opportunistic screening: This is most practical way, when high-risk people present themselves to healthcare facility, they are screened for diabetes and hypertension.

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This is highly cost-effective and no extra resources are used to organize the screening programme. Screening of TB in diabetes and diabetes in TB has been initiated in 2015 for integrated management of diabetes, TB and HIV/AIDS. Screening strategies include testing of casual blood glucose, measurement of blood pressure, BMI, physical activity, tobacco and alcohol use. Diabetes increases the risk of tuberculosis by 3 folds and is estimated to be responsible for 10% of cases of TB in India. Screening for diabetes and hypertension as on December, 2020–2021 more than 46 million adults persons have been screened for diabetes and hypertension. 8.05% were found suspected to be diabetic and 9.47% found to be hypertensive. Tertiary Prevention

When the diabetes is established; all attempts should be made to keep it under control. Aim here is to prevent complications such as blindness, kidney failure, foot ulceration which may lead to gangrene and subsequent amputation, increased risk of infection, coronary heart disease and stroke. Education of individual to observe practice of personal hygiene to prevent infection and trauma and seek early treatment of infection and trauma. Life can be prolonged and full life despite diabetes is possible. Life-threatening complications can be avoided by effective treatment. Diet regulation, physical exercise and regular drugs including cheaper human insulin ensure effective control of diabetes. Main lifestyle changes that reduce insulin resistance and prevent NIDDM: • Increased physical activity • Voluntary weight reduction • Correction and prevention of obesity • Limit fat intake and saturated fats • Increase PUFA and MUFA in diet • Encourage dietary fibre. National Diabetes Control Programme was launched as Pilot Programme in the 7th Five-Year Plan. The project was initiated in two districts in Tamil Nadu and one district in Jammu and Kashmir. Now the national programme for prevention and control of cancer, diabetes, CVD and strokes has been launched in India. Population-based screening programme has been launched for adults above the age of 30 years. REFERENCES 1 WHO (2016). Global report on diabetes. WHO Geneva. 2 IDF Diabetes Atlas, seventh edition, 2015. 3 King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025. Prevalence, numerical estimates and projection. Diabetes Care 1998;21:4–31.

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4 Wild SH, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes care 2004;27:1047–53.

HYPERTENSION (A SILENT KILLER) “High blood pressure” was chosen as Theme of World Health Day, 7th April 2013. Hypertension is a “silent killer”. Hypertension is a complex public health problem. The higher the blood pressure in the community, the higher is the prevalence of cardiovascular diseases, strokes and renal diseases. Hypertension constitutes an important risk factor for ischaemic heart disease or coronary heart disease, stroke, eye and renal complications. EPIDEMIOLOGY OF HYPERTENSION Rules of Halves in Hypertension

Majority of the persons suffering from hypertension are unaware of the disease. In accordance with the “rules of Halves”, 50% of persons do not know about their higher blood pressure; only 50% of cases who are aware of the disease are on medication. These patients who are being treated, 50% are on proper antihypertensive therapy with their BP regularly monitored. It is, therefore, estimated that BP of only 10–12% hypertensive is controlled with appropriate treatment. There are on estimated 200 million adults with hypertension in India, but less than 10% of them have their blood pressure under control (IHCI–2022). Cardiology Society of India reports 33% of adults tested had high blood pressure, over 60% had no clue of having high BP, while 42% had controlled BP. In developed and developing countries with low mortality, higher blood pressure is the second most important risk factor in terms of DALYs losses. Over 11% of DALYs lost in developed countries are attributable to high blood pressure.1 In India 8.5% of DALYs are lost due to high blood pressure. In developed countries of North America, Europe and Asian Pacific at least one-third of disease burden is attributable to tobacco, alcohol, blood pressure, cholesterol and obesity. Suboptimal blood pressure causes 7.1 million of deaths annually worldwide.1 Rural/urban distribution: Hypertension is a risk factor for coronary heart disease and stroke and is three times more prevalent in urban areas as compared to rural, this may be because of different lifestyles in two populations.2 But hypertension level of >140/90 is almost equal in two populations indicating low prevalence of risk factors in majority population of rural areas. Epidemiological survey by Chadha et al indicated prevalence rate of 12.75% in adult population (25–64 years) of urban area in Delhi in the year 1989–1992.

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PREVALENCE IN INDIA—NFHS-5

Results of several community-based studies in India indicate prevalence of hypertension in 25% of urban and

10% of rural population. NFHS-5 data reported rising trend of hypertension prevalence of 24% in men and 21.3% in women in adults age 15 years and above. ICMR-NCDIR study carried out in 2021, indicates that 28.0% of adults in India were hypertensive and 72 % were unaware of their status of high BP. Prevalence was higher in urban areas (34%) than in rural areas (25.7%). Treatment adherence was low at 59.2% in Rural areas (2019–21). What Constitutes Hypertension

The distribution of blood pressure values differ considerably among various populations. For example, the 90th percentile of systolic blood pressure varies between 146 and 176 mmHg resulting in wide differences in the proportion of people having “hypertension” in various parts of world. The worldwide projects like MONICA, INTERSALT and INTERHEALTH and India hypertension Control Initiative (IHCI) have contributed on the subject of hypertension substantially. The question is—What is most appropriate level at which the treatment should begin? This “cut-off” level determines the burden of hypertension in the community. Level of >140/90 has been chosen as “cut-off” point for classifying person into hypertensive and normal. Classification of blood pressure into various categories such as normal, prehypertension, stage 1 and stage 2 hypertension is depicted in Table 8.45.3,4 Table 8.45: Classification and management of blood pressure for adults4 BP classification

DBP mmHg

Lifestyle modification

Normal Prehypertension

4 score)

1170

• Hypertensives 172

(7.6%)

• Diabetics 198

(8.8%)

• Hypertensive and Diabetics

90

• Cancer 9

(4/1000)

• TB 5

(2.2/1000)

(6 deaths) respectively. These indicate priority problems for planning service needs in the community at the level of health and wellness centre (Table 16.4). However 4 infant and 2 maternal deaths is a cause of concern in this HWC-SC. Disease burden was assessed from the past year records of persons who were attended at sub-health centre and attended during outreach sessions conducted in the community. C. Prioritization of Health Needs/Problems and Norms for Each Service

Prioritization of Health Needs

Data based following priority health needs emerged at this sub-health centre-HWC: Care during pregnancy, delivery and after delivery, neonatal and infant care services to reduce maternal and infant deaths. The other priority is services for NCDs, communicable diseases particularly tuberculosis and prevention of accidents. These priorities were determined based on causes of deaths, their magnitude and severity and amenability to existing low cost interventions besides acceptability by community. Coverage of pregnant women, infants, eligible couples, may be low in your area. That becomes an urgent need

Table 16.4: Assessment of disease burden—vital events at sub-health centre 2020–21 Age groups

Male

Female

Total

0–1 year

0

4

4

Infant deaths

4

1–5 year

0

0

0

Maternal deaths

2

Fever

12

Heart attacks

17

5–14 year 15–49 year 50 + year

16

All ages

0 9 24

33

0 3 17

24

0 12 41

57

Cause of death

Sugar (Diabetes)

3

Old age

7

Accidents

6

Brain Haemorrhage

1

Paralysis

2

Tuberculosis

3

Total

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or priority for ensuring high level of coverage of care to antenatals, infants and eligible couples. The coverage norms are laid down by state/district/or CHC incharge. Coverage norms for immunization is 100% and same is true for antenatal examination (at least four check-ups). Priority clients are: Poorest and needy, below poverty line families having infants, under fives, pregnant women, postnatal mothers, sick children and acceptors of contraceptives, adolescents and old people, etc. and Persons with NCDs and chronic diseases (leprosy-TB, filaria, kala azar, etc.). Goal/vision—Where do we wish to go?

Goal is purpose towards which effort is directed or the desired destination where you want your institution to be in future. or The goal is a broad, direction-setting, positive statement, describing what we want to achieve through our efforts. The goal usually cannot be objectively measured. The Goal is ‘health for all’ through primary healthcare. Example: To achieve ‘health for all’, to stabilize population and to improve quality of life. D. Objectives or What we Want to Achieve?

National population policy, Health Policy 2002, and 2017 and universal health coverage have laid down measurable objectives/indicators to be achieved by 2030 and beyond. These are measurable actions to be achieved. An objective is a brief statement specifying the desired impact or effect of a health promotion programme (i.e. how much of what should happen to whom by when) or objective is the aim or the end of an action. Objectives can be measured in terms of accomplishment. Definition: Objectives are the specific results that are expected from a programme or activities. Good objectives are: SMART

S: Specific (clear and precise): So that everyone involved interpret them in the same way. M: Measurable (amenable to evaluation): To monitor progress or evaluate performance. A: Appropriate and relevant: These should be appropriate and relevant to your organisation’s policies, goals and strategies. R: Realistic: The objectives should be realistic in view of limited resources (money, manpower and material). T: Time-bound: The objectives should be achieved within time frame. Examples of objectives at the level of health and wellness centre (HWC) • To register all pregnant women, births and deaths. • To provide minimum four antenatal check-ups to all registered pregnant women in sub-centre area. • To cover all infants for primary immunization. • To have 90% of all deliveries in institutions.

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These objectives are specific and measurable and feasible or realistic: Every month we get report on coverage of antenatals and infants. In a way, these are short-term or ‘operational objectives’ for a programme or service. At the end of the year, we can assess the level of coverage of antenatals and infants for antenatal care and immunization respectively, from regular reports to a reasonable extent or by coverage evaluation surveys. The second set of objectives like: • Reduction of infant mortality to 25 by the year 2025. • Reductions of total fertility rate to 2.1 by the year 2025 in all states are long-term objectives at national and state levels. These are achievable over a long period of time by effective interventions. These are also known as impact objectives. E. Resources at Health and Wellness (HWC) (Men, Material and Money)

• Organizing resources at village and HWC level include ‘people’ themselves and elected representatives, especially woman members of Panchayat, Mahila Swasthya Sangh and Mahila Mandals and nongovernmental voluntary organizations count first in resources. Besides these, there are ‘honorary and voluntary workers’ like AWW, ASHA, traditional birth attendants, village chowkidar, health guides and school teachers and private practitioners of various systems. Development functionaries like Gram Sevikas are also available in a few villages. At the HWC level, Community Health Officer—CHO, ‘health workers male and female’ and ASHAs are available and accountable to medical officer or in some situations to village Panchayats. VHSNC has been constituted in each village under NHM. • Besides manpower, the other resources include building—community centre, vocational centre and Anganwadi centres; Essential list of 105 ‘medicines’ and ‘equipment’ for maternal and child healthcare and NCDs are also available. Drug kits are also available at Anganwadi centre. • At sub-centre level, untied grant of ` 10,000 per year is available for local health actions, such as purchase of emergency medicines, repairs of equipment, and cleanliness. Besides this incentive money to be paid to ASHA (performance-based incentive) is also available. • These resources must be marshalled and used by the sub-centre health teams to provide various health services. The medical officers and supervisors are responsible to ensure proper utilization of available services at sub-centre by the community. The available services must be depicted and made known to the people of the HWC area, especially to village panchayats and women groups (citizen’s charter).

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• Time is also an important resource and hence time management is critical. Time devoted by medical officers for management and technical jobs should be balanced to ensure that management functions are not neglected. • Information (health records, reports/data) is also an important resource at HWC. F. Programming (Work Plan)—How we will get there?

A programme is grouping of continuous and related activities designed to achieve the set objective. Activities include home visits (for identification, updating, tracking of eligible couples, antenatals, children and programme beneficiaries), immunization, MCH and FP clinic, growth monitoring, communication and counselling and visit to Anganwadi, recording and reporting, group meetings, screening of non-communicable diseases (NCDs), etc. Preparation of Sub-Centre Annual Action Plan

The preparation of the sub-centre annual action plan is the first step in the process of decentralized planning. It provides basis for determining the service requirements of the sub-centre population. Hence the sub-centre team makes a plan for provision of essential services. Having assessed the health service needs the female health worker prepares annual action plan. This plan addresses the felt health needs of Local Community with assured Community Participation. The health plan specifies the activities to be carried out and the resources required to carry out these activities. The health action plan is reflected in a matrix form (in specified frame). Based on the performance of last year the planned performance for the current year for each service package is worked out and annual targets for package of services are set. The current position and additional quantities requirement of drugs, contraceptives, equipment, manpower and other material is worked out and indent is prepared for supply. All the annual sub-centre action plans are compiled to get PHC action plan which converge to form a CHC and district health action plan (DHAP). Hence the planning process starts at village and urban ward level with local bodies to cover diversity.

A fixed work schedule of visits is planned-daywise and village wise as shown in Table 16.5. This schedule covers the entire population of HWC-sub-centre or 5–6 Anganwadi workers area/area of 5 AHSAs. It is flexible enough to readjust to evolving problems like unusual events or outbreaks and intensive activities/campaigns for specific programme. • Mothers meetings and home visits can be held jointly with AWW and ASHA of the area. That will have more impact and provide security to health worker female. • On open days, the immunization sessions in hamlets or mothers meetings or Health and Nutrition Day or PHC meetings can be held. Any missed activity can be done on open day. • One home visit should cover at least 10–15 households and part of that day could be spent at Anganwadi. The events of birth/death/pregnancy and marriage can be collected through home visits or at Anganwadi centre or on Health and Nutrition Day at Anganwadi centre. Home visits are meant for tracking of beneficiaries or follow-up as also identification of new beneficiaries and for counselling and group meetings. The planned work schedule should be linked with Anganwadi workers and ASHAs. G. Implement the Chosen Plan of Activities (Table 16.6)

A plan is only as good as its implementation. Implementation is the key step in the planning process, which needs special attention. The work plan prepared by workers must be implemented. Work schedule must be made more efficient. The field workers should spend more time with priority clients especially the poorest and needy. The home visit/ contact programme should focus on: 1 Young eligible couples (20–29 years). 2 Pregnant and lactating women of weaker section. 3 Children below one year of age. 4 Households having NCDs and elderly. The implementation plan illustrates as to who will do what activity, at what time and at which place. When all the activities are worked out and time line defined with responsibility, it gives an overview of activities against which monitoring can be undertaken. In other words, this

Table 16.5: Monthly work plan of health worker, female (MPHW, female)

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Week

Monday

Tuesday

Wednesday*

Thursday

Friday*

Saturday

First

NCDs village-1

MCH and FP clinic

Immunization village-3

MCH and FP clinic

AW visit-1

Open day

Second

NCDs village-2

-do-

Immunization village-4

MCH and FP clinic

AW visit-2

Open day

Third

NCDs village-3

-do-

Immunization village-1

-do-

AW visit-3

Open day

Fourth

NCDs village-4

-do-

Immunization village-2

-do-

AW visit-4

Open day

Fifth

NCDs village-5

-do-

Immunization village-5

-do-

AW visit-5

Open day

*Village health sanitation and nutrition day with ASHA and AWW once a month and fixed screening day for NCDs in villages NCDs—Non communicable diseases. MCH—Maternal and child health. AW—Anganwadi.

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Table 16.6: Matrix of implementation of action plan covering major activities Activities

Inputs/resource required

Person responsible

Supporting staff

Time from to

1. Household survey

Training, HH register

ASHA and AWW

ANM

Feb to March every year

2. Antenatal care

Integrated RCH register, weighing scale, preg. test kit, BP appratus, IFA tablets HB meter, TT, exam table

ANM

ASHA, AWW

One outreach session per AWW per Month on Tuesday and Thursday at SC

3. Screening of NCDs

Registers, glucometer, BP appratus

ANM

ASHA, AWW

On every Monday at village level

4. Immunization

Vaccines, Vit. A, Vaccine carrier, syringes and needles emergency kit, MCPC and registers, reporting format

ANM

ASHA, AWW

Outreach session on every Wednesday at AW

matrix facilitates in not only providing information on when the activities have to be initiated and completed but can be effectively used for tracking the status of each of the defined activities along with monthly monitoring reports. This helps to assess the performance of health worker. H. Monitoring and Supervision of Activities

How do we know we are on right track?

Monthly monitoring reports (MMR) on revised format: Monthly monitoring reports provide useful information on monitoring of services of HWC. Any deviation detected are brought to the notice of health workers for corrective actions by better planning and implementation of the programme. Monitoring measures the progress of work each month and serves a useful tool to know the performance level of the worker against the norms or standards. The purpose of monitoring and supervision is to improve work/service standards. The health supervisors will ensure monitoring of work and spot supervision. Health supervisors ensure supervision and supporting the service in difficult areas and upgrading the skills of workers by on the job training/continued induction. I. Coordination of Activities “Coming together is a Beginning, Keeping together is Progress, Working together is Success”

Convergence of work and services with Anganwadi workers, traditional birth attendant and ASHA can enhance the coverage of antenatal mothers. Health worker female works with and works through Anganwadi workers and ASHA, ensure joint home visits, joint survey, meeting with antenatals and women groups. Anganwadi centre is a hub or convergence point of all services for women, children and screening of NCDs. Further all these health team members must know their assigned role and work schedule of sub-centre and Anganwadi as also available services. Coordinating the work between AWW and health worker female, as also between health workers (female and male), TBAs, ASHAs and NGOs is essential for convergence on the village health sanitation and nutrition day.

J. Evaluation of Sub-centre Performance

What are the Outcomes?

The evaluation means, how far the stated objectives of sub-centre action plan have been met and reasons for not meeting the objectives are identified for replanning of programme/services. Performance reports (monthly monitoring reports) provide useful information for monitoring and evaluation of services. The purpose of evaluation is to improve the services by mechanism of feedback to the programme and providers. Simple indicators have been evolved for rapid evaluation and medical officer and health supervisors can use these indicators to assess the services at sub-centre. Much of the information is obtained through regular supervisory field visits and by looking into the routine reports. Some of the suggested indicators are mentioned below: • Total number of outreach sessions planned and number of sessions actually held in sub-centre area. • % of antenatal mothers provided four check-ups. • % of home deliveries/institutional deliveries and deliveries done/supervised by health worker female. • % of traditional birth attendants trained. • % of infants fully immunized or immunized against measles. • % of antenatals referred. • % of neonates referred. • % of village health and nutrition days organized. • % of over 30 years of age screened for NCDs and common cancers • % of Hypertensives and diabetics on treatment K. Replanning

The evaluation discovers gaps in the planning process. It also pin points shortcomings in the planning process. The replanning takes care of these gaps and shortcomings in the planning cycle: Assessing needs  resources  defining objective/ outcomes  carry out activities  monitor, coordinate and supervise  evaluate  replan.

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HEALTH MANAGEMENT Competency addressed: The student should be able to: CM 16.3: Describe health management techniques.

The simplest definition of management is ‘getting things/ work done’. The health management is defined as ‘purposeful and efficient use of health resources’ (manpower, money, material and time) to achieve predetermined goals/goal. The senior medical officers and medical officers have to perform essential managerial functions besides technical functions. HEALTH MANAGEMENT TRAINING OF UGs—A MISSED OPPORTUNITY!

The objectives of UGs medical education have been clearly defined. At the end of undergraduate program, the Indian Medical Graduate (IMG) should be able to recognize “Health for All” as a national goal, learn every aspect of national policies on health, achieve competency in holistic medicine, develop scientific temper and observe medical ethics. In consonance with the national goals, each medical institution should evolve institutional goals to define the kind of trained manpower they intend to produce. The Indian Medical Graduate coming out of medical colleges be familiar with the basic factors which are essential for the implementation of national health programs, acquire basic management skills in the area of human resources, material and resource management related to healthcare delivery system, general and hospital management, principal inventory skills and counselling. He must be able to identify community health problems and learn to resolve these by designing, instituting corrective steps and evaluating the outcome of such measures. Such a graduate should be able to provide leadership to healthcare team in primary and secondary healthcare setting, educate and motivate other members of the team and accountable to patients, community and the profession (MCI 2018). All these competencies are relevant and relate to effective training of UGs in basic health managerial skills by whole of the college faculty (as institutional reponsibility) and more so by the department of community medicine.4, 5 Technical Functions (Clinical Functions)

Technical functions include diagnosis and treatment of patients, their follow-up and referrals besides, preventive and promotive services. These functions are most satisfying to doctor, much more rewarding and results can be achieved within short period. In most situations, doctor works alone and has one-to-one relations with his patient and client. Public health needs qualified managers and not merely clinicians.

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Essential Management Functions of Medical Officer and their Use in Decision Making

The important management functions of medical officer are as under:

P: Planning, organizing, implementing and evaluating the health activities (what needs to be done and methods of doing). O: Organizing resources (men, money and material) and assignment of tasks and responsibility. S: Staffing: Training and continuing education of staff and their supervision, besides recruitment of staff. Delegation: Transferring work/responsibility and authority downwards to subordinates. D: Directing: Day-to-day direction to subordinates— making decisions and issuing specific orders and instructions. Co: Coordination of work of health teams and other health-related sectors like ICDS, school teachers and village panchayats. R: Reporting: Submission of regular reports of performance to higher level. B: Budgeting: Spending contingencies and maintenance of accounts and preparation of budget. C: Controlling: Through monthly and annual performance reports, regular supervision, sanction of leaves, rewards and punishment. I: Innovation: New work methods and eliciting community support. R: Representation: Representing the organization at various levels. The acronym to reproduce these components is POSDCORB-CIR. A Case Study on Health Management

Management functions are required at each level but at the lower levels of organization more of technical functions as also human relations and lesser of managerial functions, conversely higher an officer’s position in a health organization, the greater is the need for managerial skills and the lesser is the need for technical skills. One has to strike a balance between technical and managerial functions. Management functions have been neglected or are poorly performed because of lack of training in management functions during undergraduate medical education or lack of interest or both. The management functions are more important in Indian settings because of scarce resources. The best health manager is one who is able to achieve maximum within limited resources. Most management responsibilities are seldom taken and enjoyed by doctors and they attach low value to these functions and have seldom been trained to perform these functions. Medical officer is responsible to plan and organize the health activities for 30,000 population of defined geographical area. His concern is “total community” of 30,000 people (sick and healthy both). This is one of the important job functions of medical officer. “People themselves are important resources.” The job of medical officer is to organize people and use people’s organization (Panchayati Raj institutions) and their resources and plan

Health Planning and Management

health activities with them and involve them in village health activities and consult them periodically to have their opinions and reactions to improve the services. The plan of work must start from the bottom, i.e. from people, who are the most important resources and users of health services. Community mobilization and ensuring its participation is heavy responsibility and a challenging task. Doctor is accountable responsible to ‘community’ “patients and” “profession” and his job is to ensure health to all people; 30,000 population under his charge. This is the community, he serves and he must organize ‘community healthcare’ for this much population. He alone cannot look after such a large community and essentially he will use health auxiliaries or health workers to do the job in the community. The doctor must delegate the work responsibilities to health workers. In order that these health workers do the job well and provide quality services, they must have appropriate ‘skills’ and doctor is responsible to upgrade their skills from time to time and support them to do their job. He continuously undertakes management needs assessment (MNA). Management needs assessment is critical function. The health manager (medical officer) is a leader of the health team in a primary health centre and community health centre, he is responsible to plan and organize the health work with health teams, motivate them, impart skill training; delegate the work, supervise and coordinate their work, assess their performance, improve their work performance, develop health team, involve community in promoting health functions and report the activities to higher levels on regular basis, evaluate the performance of health centre and keep on innovating the things at local level and come out with new model/models of healthcare delivery in his area and learn from people and health teams to solve their problems. In short, the performance of health centre depends upon the health work done by the health teams at sub-centre and village level volunteers/honorary workers. Therefore, the health teams must perform well and plan their activities meticulously to ensure high level of coverage and quality of services. Medical officer is also ‘responsible for patient care’ and his decisions are vital to save lives. Management functions in relation to patient care include organization of outdoor, indoor and emergency care, referral arrangement, laboratory services, indenting drugs including essential drugs, maintenance of equipment, material management besides control and prevention of outbreaks, notification of diseases, keeping records of vital statistics, etc. Quality of medical care will depend upon quality of management functions related to such care. DIFFERENT LEVELS OF MANAGEMENT Base of Pyramid—Health System Organization

The organization (structure) of health system is pyramidal in nature. The organization is the structure or anatomy,

677

while the management is the physiology of the system of health services/care. People (1412 million) are the most important resource in India. People themselves and large number of auxiliaries and health volunteers with lesser skills form the base of pyramidal organization, who work in the community and are accessible to people for primary healthcare. These auxiliaries and Anganwadi workers besides health guides and ASHA constitute strong community-based human resources to respond to the preventive, promotive and curative health needs of people (Fig. 16.2). We have 161829 (157935 Rural and 3894 urban) subcentres, 180769 MPHWs (female) and 52696 male health workers besides 13 lakhs Anganwadi workers, traditional birth attendants and over 10.72 lakhs ASHAs, which form the strong base of pyramid. The effectiveness of services in India largely depends upon the auxiliaries and their skills and competence. Their basic training and continuing education will determine their skills and competence and quality of service they render in the community. Healthcare functions of community health centre and primary health centre rest on the shoulders of health auxiliaries. First Level Managers

They are called supervisors. These managers function at the lowest level of the organization and are in contact with the workers whom they supervise. No other managerial personnel are placed below them. The health supervisor male and female supervise the work of health workers male and female who are operating workers providing or delivering services. Such supervisors are often called first line managers. Middle Level of Pyramid 6

This is constituted by health professionals who hold the responsibility of health team leaders/managers. At this level, we have 31053 (24935 rural and 6118 urban) primary health centres, 6064 (5480 rural and 564 urban) community health centres to provide referral services to sub-centres. Apart from referral support, this level is responsible for planning, programming, implementation, monitoring and supportive supervision, continuing education, coordination, and evaluation of health services and health programmes in the assigned community of 1,20,000 for each CHC. The challenging task is to attain reasonable and acceptable level of health status for whole community and their success is measured not by number of patients cured or treated but how much the disease rate, death rate and disability rate have been reduced. The impact indicators of performance of these health centres and CHCs are reduction in fertility rate, infant mortality rate, maternal mortality rate, reduction of disease rate (diarrhoea, respiratory infection, malaria, tuberculosis). The ultimate goal remains to eradicate diseases and achieve health for all. At this level of the organization, the medical officers and senior medical

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officers have to devote 50–60% of their total time for health management functions and to ensure achievement of the goals of organization: ‘Health for/in all’. Middle Level Managers

These groups of managers comprise a few levels. They supervise other managers and operating workers. They look after the activities necessary for implementation of organizational plans for achievement of its goals. The medical officers and district programme officers are middle level managers who supervise the first line managers and managers of PHC and CHC respectively and can also supervise the operating workers in the field. Top of Pyramid

At the top level of the organization, the senior level managers are entrusted with the function of directing, monitoring and control of the health services and health

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programmes. District and state level programme officers supervise the assigned area, besides coordinating the health activities and ensure that plans of work are prepared and implemented at various levels. This level is also responsible to arrange for in-service training of various cadres, besides sending progress reports to higher formation and represent their organization at district, state and central levels. It also controls the budget, posting, promotion and transfers of employees. This level continuously undertakes management needs assessment (MNA) to improve the services/system. Top Level Managers

These managers are at the highest level of hierarchy and are in overall charge of the organization. The district civil surgeon and director health services may be called top level managers (Fig. 16.2).

Fig. 16.2: Health system organization *HWC—Health and wellness centre, **MLHP—Mid-level health provider Source: Rural Health Statistics in India, and National Health Profile, 31st March 2022.

Health Planning and Management

Top level manager spends more time in planning and organizing than a lower level manager. Higher is the level in the organization, the greater is the need for managerial skills and lesser is the need for technical skills. Conversely the lower is the level in the organization, the more is the need of technical and human relations skills and lesser the need of managerial skills (Fig. 16.3).

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and referral support is a weak link. Most of the investments in medical education have been made on doctors, whereas training and continuing education of health auxiliaries have been neglected. Therefore, it is most essential to invest in these auxiliaries and support them adequately to enhance coverage and quality of health services. Since 66% of population lives in rural areas, the capacity of auxiliaries needs to be strengthened. Recently, it has been clearly stated in the National Population Policy that health services and planning should begin from below, i.e. from people. All sub-centre action plans should be evolved in consultation with the people; however, this has not taken off well and needs to be done on emergency basis. Here comes the role of health manager to perceive the needs of training and support to health auxiliaries. Participatory management should be encouraged at all the levels of organization. Decentralization

Fig. 16.3: Levels of organization and skills required

The general policies, plan and the guidance of Indian health system have been laid down by National Population Policy (2000) and National Health Policy (2002) and more recently by National Health Mission (2013) and National Health Policy 2017. Objectives and plan of National Disease Control Programme have been defined by the Ministry of Health and Family Welfare. The role of primary health centre/community health centre, doctors, health supervisors and workers is to interpret policies at local level, plan their implementation and see that these are implemented. HEALTH MANAGEMENT TECHNIQUES7

Hierarchy: Whenever a group of people is involved in the accomplishment of a task, some form of organization emerges and hierarchy develops. Hierarchy means a ranking system ordered according to status or authority. (Who is responsible to whom?) Hierarcy describes relationship and responsibility within an organization. Hierarchy consists of levels of responsibility, chain of command, recognition and span of control (number of subordinates who can be supervised effectively) and respecting authority, not supersede authority, upward, downward and lateral relationships in an organization. Delegation: It means downward transfer of work/ functions, responsibility and authority for decision making and problem solving to subordinates. Delegation does not release the delegator from the final responsibility for outcomes. It results in additional relationship between functionaries and responsibilities, authority and accountability. Most of the functions of primary healthcare (RMNCH + A and National Health Programmes) have been delegated to auxiliaries (health workers and their supervisors). However, the support system and supportive supervision

Devolution of authority (powers) and responsibility to local levels—Panchayati Raj institutions and Nagarpalikas, in rural and urban areas respectively. Under constitutional provision ‘States’ have the primary responsibility to provide healthcare to its people. However, the healthcare delivery system in many states remain largely centralized at the departmental level in spite of strong and effective presence of institutions of local self government at village, block and district levels. Decentralized management of health institutions especially those at primary level through Panchayati Raj institutions (PRIs) has been strongly— advocated by National Heath Policy. The 73rd and 74th Constitutional Amendment Act, 1992, made health family welfare and eduction a responsibility of village Panchayats and Nagarpalikas, respectively. Local self-governments are an important means of furthering decentralized planning and programme implementation. However, in order to realize their potentials, they need strengthening by further delegation of administrative and financial powers including powers of resource mobilization. Decentralized programme management should also be reinforced by convergence of all vertical Public Health Programmes at the district level and below. This would avoid duplication of efforts in areas like information, eduction and communication, training and supervision. Examples of Decentralization of Planning and Programme Implementation

National Health Mission (NRHM and NUHM) under its umbrella integrates all related and stand alone health programmes in health sector. • Funds, functions and functionaries have been transferred to Panchayati Raj Institutions like untied funds to Village Health Sanitation and Nutrition Committees, for local action and planning, increased role of PRIs in ASHA programme, Constitution of Rogi Kalyan Samitis/hospital development committee,

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district health society for decentralized district, CHC, PHC, SC and village health planning with PRIs and people, community monitoring system and greater space for NGOs participation. • Provision of untied funds at every level and contractual appointment route to immediately fill human resource gaps as well as ensuring locally resident health staff/ workers are other examples of decentralization. • Village health plans, sub-centre, PHCs, CHCs and district action plans are examples of decentralized participatory planning. Convergence—A Case Study

Convergence means working together or coming together or coordinating two or more sectors to produce a combined effect greater than the sum of their separate effects. Indicators of health depend as much on drinking water, sanitation, nutrition, female literacy, early childhood development, women empowerment, etc. as they do on hospitals and functional health systems. Realising the importance of wider determinants of health, coordination and convergence between health sector and other sectors such as ICDS, water and sanitation (Swachh Bharat Abhiyan), eduction, nutrition, PRIs and rural and urban development sectors is an imperative need. Anganwadi centres and school system at the village level are the principal hubs for health and development actions. Village is the first level of convergence of programmes of all the ministries, hence best achieved by VHSN committee. Methods of Convergence—A Case Study

At Village Level

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• Co-location of Anganwadi centres with sub-centres/in schools—a best management practice. • Joint home visits by AWWs, ANMs and ASHAs, and joint household surveys—a best practice. • Immunization outreach sessions with AWWs at Anganwadi centre—a best practices. • Village Health Sanitation and Nutrition Day at Anganwadi centre once a month. • Sharing of information between ANM, AWW and school teachers and development functionaries. • Microplanning and screening of NCDs. At sector level: Geographical area co-terminus for supervision between health supervisors and ICDS supervisors, joint touring, and preparation and sharing of monthly monitoring/progress reports and planning of work and review of work together at sector level meeting besides problem-solving and continuing education of ICDS and health teams and their development. At block level: Joint planning by medical officer, CDPO and Block Samiti and block development and Panchayat offices and block education officer.

Supplementary nutrition will have little effect if diarrhoeal diseases in children remain unchecked. Provision of safe water and sanitation at Anganwadi centre/at village in convergence with Swachh Bharat Abhiyan makes more sense/impact. Hence, convergence actions with other sectors are essential to reduce morbidity and mortality and improvement of nutritional status as also to achieve high coverage level of all services. All national health programmes—School Health Programme, Adolescent Health Programme, National Anaemia Control Programme, Mental Health Programme, Rashtriya Bal Swasthya Karyakram, National Tobacco Control and National Oral Health Programme are being implemented by convergence with education department and district early intervention centre. At District Level

District Health Action Plans, block, PHC, sub-centre and Village Health Action Plans are important means to enhance inter-sectoral and intra-sectoral convergence. GOOD LEADERSHIP AND MOTIVATION OF HEALTH TEAM: A MANAGEMENT TECHNIQUE Organizational Behaviour (OB)

OB means ‘better understanding and managing people at work’. The medical officer incharge of CHC or PHC works with health volunteers and honorary workers (Anganwadi workers, traditional birth attendants, health guides and ASHAs), health workers, health supervisors and above all with Panchayati Raj institutions (elected representatives of people) and village leaders formal and informal both. Since manpower for primary healthcare is of varied background and around 70% of the total budget and sometimes more than that is spent on manpower alone, hence to understand the behaviour of health teams, predicting their behaviour, and controlling their behaviour becomes an important task, in the hospital and community setting. Health Organization

The health organization, which is constituted by abovementioned group of people who all work towards some common goal. Bringing positive change in their behaviour is an important job function of health manager (or health team leader). Knowing health teams intimately, their personality, aptitudes, attitudes, family responsibility, training background, motivational level and job satisfaction is essential. The leader must analyze after collecting these attributes about each member of the health team and this analysis provides him useful information for making decision. In order to influence others’ behaviour, the best way is to understand and know each other well.

Health Planning and Management

Good Leadership and Motivation of Health Team: A Health Management Function

The medical officer is a leader of health teams, who by virtue of his position in the health organization influences the behaviour of others. Wherever the leadership is effective, the performance of health team has been much better. Who is a Leader?

A leader is best when people barely know he exists. “But of the best leaders when their task is accomplished their work is done, the people all remark “We have done it ourselves”. Any person or an individual in an organization who influences the behaviour of others is a health team leader. A medical officer is a leader to health workers and health assistants and other persons in the organization. A health worker and supervisor is a leader to health guides, Anganwadi workers, ASHAs, and traditional birth attendants. Each individual in health team plays the role of health leader at various levels and influences the behaviour of others who come in contact with him in day-to-day activities. A school teacher is a leader to his class students. Individuals differ in their degree of leadership. There are two prime concerns: 1 Concern for the ‘people’ (humanistic approach) 2 Concern for the ‘task’ (mechanistic approach). Balanced leadership has equal concern for both ‘people’ and the ‘task’ or ‘work’. Appropriate Leadership Styles

The manner in which the leader influences the behaviour of health team is known as leadership styles. There are four styles of leadership but there is no one best leadership style. It all depends upon the development levels of the followers (D1–D4). Style 1: Directing (Directive Behaviour)

This involves telling people what to do, how to do it, where and when to do it and then supervising their performance closely. The leader in this situation provides specific instructions (written job description and tasks to be done) and closely supervises the task accomplishment. This style is applied to health workers who have low competence (newly recruited persons) but high commitment (eager to perform or are enthusiastic) i.e. Development level—D1. Style 2: Coaching

It involves directing and supporting the workers. The leader continues to direct and closely supervises the task accomplishment, but also explains decisions, solicits suggestions and supports progress. This style of leadership is observed for workers or supervisors who have some competence but low commitment. (Development level—D2)

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Style 3: Supporting

Supportive behaviour involves listening to people, providing support and encouragement for their efforts and then facilitating their involvement in problem-solving and decision-making. The leader facilitates and supports subordinate’s efforts towards task accomplishment and shares responsibility for decision-making with them. This style is applicable in a situation where the subordinates have high competence but variable commitment. (Development level—D3.) Style 4: Delegating

It means turn over responsibility for day-to-day decisionmaking. The leader hands over responsibility and authority for decision-making and problem-solving to subordinates. This style is applicable for those subordinates who have high competence and high commitment. (Development level—D4) There is no best way to influence others. The leader needs to assess the situation in the organization and accordingly choose a style of leadership. One has to become situational leader. The most important criterion in deciding the leadership style is the characteristics of the subordinates or health teams. There is no one best leadership style. You need to adapt your style to fit the needs of each person. Leadership style is how a manager behaves when trying to influence the behaviour of someone else. The appropriate styles will vary for each person but will be a combination of directive and supportive behaviours with a shift from “ME to WE”. • Competence means sound scientific knowledge and skills. • Commitment means highly motivated and confident person. Medical officer is a leader of health team at primary health centre and he provides day-to-day directions to his subordinates, provides supportive supervision, and conducts continuing education to improve their skills. Maternal and child health activities (antenatal care, deliveries, postnatal care and immunization, etc.) have been delegated to health workers. Untied money of ` 10,000 per annum has been given to female health workers for local action—an example of delegation of financial powers—a best practice. How to Lead?

Apply LEAD model. Leaders can use a simple four-step model to ensure their participation and increase productivity. 1 Lead with clear purpose. 2 Empower to participate. 3 Aim for consensus. 4 Direct the process. The LEAD model includes key leadership functions— setting clear goals and objectives, getting people involved, reaching consensus on important items and paying attention to both tasks (the work) and relationship (the team).

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Best Way to Influence others: Lead by Examples

Observe high standards and lead by examples. Learn to lead yourself first practice what you teach or who will listen to you. If you smoke yourself and advise others not to smoke that is bad example. Set examples first for yourself and then the followers will follow you. If you set an example of coming in time the others will follow. A good leader does not tell people what to do, he sets examples. Qualities of a Leader/Facilitator: Best Practices

1 2 3 4

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Sets examples for correct behaviour. Facilitates work. Actively listens and solves problems. Takes responsibility for both, his actions and the people he supervises. 5 Knows himself and his limits and constantly seeks to improve himself. 6 Is available 7 Looks after the welfare of his employees. 8 Makes sound and timely decision. 9 Sets goals that are achievable. 10 Knows his job and stays abreast with current events. Some other attributes of a good leader: • He makes decision based on information and data and his own observations and facts. • Gives credit to team members for high performance and gives them recognition for high performance. • Encourages different view points. • Teaches and coaches others without telling them what to do. • Organizes information and data so that others can understand and act on it. • Models the behaviour he or she would like to see in others. • Knows how to bring the right people together for a task. • Is aware of his own limitations and knows who is better qualified to make a decision or complete a task. • Understands that diversity can affect teamwork in a positive way. • Understands that different people are motivated by different things and are willing to work hard to address their individual needs. • Shares powers and authority with others. • Encourages team members to take responsibility for issues, problems, actions and projects. • Looks for ways to help the team achieve its goals. • Finds opportunities to reward appropriate behaviour, minimizes punishment for inappropriate behaviour. • Is firm about goals, but flexible about the process used to reach those goals. • Is not afraid to address conflict. • Understands and acknowledges that people’s, individuals’ needs (social, personal career, lifestyle,

work preferences), may affect teamwork and accordingly works with and not against these needs. The health system is adequately designed to provide a comprehensive, high coverage of promotive, preventive and curative services throughout India. A large trained staff of workers and health volunteers ASHAs and Anganwadi workers, with task appropriately defined to meet the major public health needs of poor are in place. There remains a question of motivated leadership of each health team, their continued education, supervision and encouragement, if the potential is to be fulfilled. Wherever the leadership has been good dramatic improvement in the health can be seen in poor Indian rural population. Most medical officers are unwilling or unable to assume the role of effective leadership. They have most probably been not trained well, not prepared or motivated to take this role. MOTIVATION—A MANAGEMENT TECHNIQUE

The health team leader or manager motivates health team for better efficiency of work at SC, PHC/CHC and hospital. People are most important resource of an organization. What is Motivation?

Motivation is goal-directed or goal-oriented behaviour. The motives are driving forces, which arouse and maintain activity and hence they determine the direction of behaviour of an individual. The concept of motivation must be understood by health team leaders and members because they are concerned with modification of people’s behaviour. Recently the emphasis of whole science of communication has shifted to ‘behaviour change’. Behaviour change communication is the crux. Changing reproductive behaviour and sexual behaviour are the key areas to limit the size or space children and to protect oneself against HIV and AIDS, respectively. “Why do people behave the way they do?” The answer of this question lies in people’s motivation. The driving force responsible for directing the behaviour of individuals is motivation. It is, therefore, important to understand and predict, and thereby control and modify their behaviour. Definition

Motivation is a process that starts with a felt need, want, drive or impulse within an individual. Once the individual is able to satisfy the need/want, in the form of an incentive the drive is reduced and a new need is felt. This process continues throughout life as needs and wants keep on occurring and changing in life process (Fig. 16.4). Motives are driving forces such as felt-needs, wants, drives and impulses. That simply means something within an individual that prompts behaviour. Strategies for Motivation

People are the most important resources of an organization. Unlike non-human resources, such as equipment and fin-

Health Planning and Management

Fig. 16.4: Basic motivation process

ances, people want to participate, achieve, and want recognition and be motivated. Motivate people to get best out of them. Learn what motivates them. The seven main motivators are: 1 Achievement: Most people like to do things well. They like to succeed. Achievement or success is very important matter for an individual (success begets success). Satisfaction in success and in getting things done well comes largely from achieving, hence achievement is a big motivating factor. A good team leader helps the team members to achieve by giving them clear instructions, suitable training, facilities, and supplies they need for their work. Success has lot many fathers failure has none. If the health team fails to achieve, leader must share failures. Leader helps people to achieve work objectives. 2 Recognition: Giving recognition to people ensures them that their work is noticed and appreciated. Praise makes people feel good. It also makes them want to do a better job—so they can get more praise. “Give praise where praise is due.” Acknowledging good performance by rewards to motivate people. 3 The work itself: The old saying that “work is worship” holds true for motivation. People like to do work that is constructive, that in their opinion is worthwhile and helpful to other people. Leader explains the value of work to his team repeatedly and supports them on the job. 4 Responsibility: Most people welcome responsibility, some people fear it. Most people like to make decisions about their lives and to accept the responsibility for doing so. Leader should delegate responsibility to subordinates (health workers for maternal and child health work at sub-centre and in the village) and always help them to take responsibility to sustain their interest. 5 Advancement: Advancement or promotion in career is a form of recognition. Recognition without reward is not very convincing. People want recognition that comes in tangible form, such as an increase of salary or more responsibility, with freedom to use their own initiative, which leads to job satisfaction. Leader helps others to train for promotion and encourages increasing their knowledge and skills so that they are ready for promotion.

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6 Self-improvement: People like to become mature, to develop as people. Many people make great sacrifices to improve themselves or to offer such opportunities to other members or their family. Team leader should ‘give opportunities for self-development’ by giving them learning resource material and help to improve and upgrade their skills by—on the job training and continuing education. 7 Job satisfaction and security: Job satisfaction is also a motivating factor. Job should be enriched from time to time, as the technology advances, to improve the quality of work and the job. All these factors help in retention of manpower. Maslow’s Hierarchy of Needs

A motive, which has highest strength, is met first. People work on satisfying needs in an orderly fashion. The need that has the highest motive strength receives attention first. Maslow presents a theory that designates categories of needs and strengths when unsatisfied (Fig. 16.5). According to ‘Maslow’s theory’, the physiological needs at the bottom of the pyramid given in Fig. 16.5 are top priority motive strengths when unsatisfied. Physiological needs have highest priority until satisfied. Once physiological needs are satisfied, safety needs take priority. This format follows as the pyramid climbs to self-actualization, which is a priority only when other four needs are satisfied. It must be noted that all needs are present within an individual, the priority of needs, however, shifts. The old saying “you can lead a horse to water, but you cannot make it drink” is very true in case of motivation. The health leader may not be able to make someone behave in certain way. If the individual has an internal need, the sight of external goal increases the

Fig. 16.5: Maslow’s hierarchy of needs

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probability that behaviour aimed at goal attainment will follow, no guarantee, however, exists. For example, if the health worker is provided with facilities, and is also well trained to perform his/her responsibilities, it is probable that he/she will be motivated to carry out the task effectively and efficiently but one cannot be absolutely sure. A motivated person accomplishes goal in shorter time and produces quality work at lower cost. If the individual has positive experience, it serves as stimulus for motivating her/him to accomplish the task. Common causes of dissatisfactions: 1 2 3 4 5 6 7

Inefficient administration Incompetent supervision Poor personal relationship Poor leadership qualities Low pay Bad working conditions Non-participation in plans of work.

TEAM-BUILDING

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A health team at sub-centre consists of health workers (male and female), traditional birth attendant, Anganwadi workers and health guides and in most situation other link workers (ASHAs) or NGO workers (social workers). The team building is the responsibility of health manager. The team needs to meet together at regular interval for organized in-service training and review of progress of their work. Under the present circumstances, the sector meeting day or village and urban health sanitation and nutrition day (UHSND) is fixed in the block. On sector meeting day, 25–30 Anganwadi workers, 6 female health workers and equal number of male workers, health supervisor and Mukhya Sevika or ICDS supervisor, child development and project officer (CDPO) and medical officer meet at sector headquarter once a month on fixed date. This is a unique opportunity to develop team or building teamwork, holding a continuing education session on a chosen problem observed by the supervisor or medical officer. This occasion is used to achieve maximum coordination and joint planning. In the group, all team members have a chance to express their feelings, narrate the successful experiences as also failures. The health manager (medical officer) and child development project officer participate and solve the problems to the extent possible and plan jointly the activities for the next month. The shortcomings as observed through routine monthly monitoring reports are discussed with health team, the work is coordinated and information of monthly report is shared between team members. The health team finds a great opportunity to learn from peers experience, share the problems, and come out with solution. It is a great occasion for building team and mutual learning.

Further health team exists for the community health at village level (AWWs, health workers, TBAs and ASHAs). The community has health needs and it is the function of the health team to respond to their health needs. No one person can acquire all the necessary skills, or have enough time to do everything that must be done to satisfy the needs of even a small community. Therefore, people have to work in team to get the work done. Functions of Health Team at Village Level

• To promote community participation. • To consult the community or contact them on regular basis say once a month meeting with Panchayat or Mahila Swasthya Sangh to assess their health needs. • To give responsibility to community of the problems which families and community can resolve themselves, such as sanitation and personal hygiene and improving their dietary habits. • To elicit cooperation from other sectors or other functionaries, such as village Chowkidar (for birth and death registration), school teachers and Mahila Mandals and Sakshar Mahila Smooh (SMS). • The health team learns from community by listening and observing, by talking with community leaders to have first hand information on health practices—child rearing and feeding practices, health attitudes, values, beliefs and customs, family life and decision-making process in the family. Ultimately, health team prepares village action plan or sub-centre action plan to help people to meet their feltneeds and organize community efforts to solve a problem. Health teams are not well trained to organize village community for self-help and the health manager must build capacity of health team in this area.

HEALTH TEAM (PUBLIC HEALTH TEAM) JOB RESPONSIBILITIES: A MANAGEMENT TECHNIQUE To deliver health services to community ‘Teamwork’ is essential. Professionals (doctors and nurses) and paramedicals work as a team to accomplish the public health goals. Job responsibilities and functions of various members of health team are being described hereunder.6–8 After the launch of NRHM, NHM, NCDs Programme, Health Policy 2017, and Ayushman Bharat, IPHS–2022 the job description and functions of health functionaries and facilities have been redefined. Most medical officers and health workers do not know what is expected of them because they have no written job descriptions, or guidelines are out of date, or supervisors do not tell providers what they should do.8

Health Planning and Management

JOB RESPONSIBILITIES OF MEDICAL OFFICER, AT PRIMARY HEALTH CENTRE Job Responsibilities of Medical Officer-PHC

The Medical officer of Primary Health Centre (PHC) is responsible for implementation of all activities grouped under health and family welfare delivery system in PHC area. He/she is responsible in his individual capacity as well as an overall in charge.

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1. Clinical Work

• The Medical Officer will be organizing and performing duties necessary for the routine Outpatient services and also ensure emergency cases are attended and taken care of. • He/she will screen cases needing specialized medical attention, refer them to referral Institutions and will cooperate and coordinate with other institutions providing medical care services in his/her area. • He/she will attend all calls from the in-patients, while He/she is ‘on-call duty’. • As a member of the healthcare team, he/she will exemplify an example in attitude toward patients and staff, thereby, performing duties with respect, dignity, privacy and modesty to the patients. • He/she will be friendly, courteous and sympathetic while working with patients and ensure privacy and confidentiality of the patients. • He/she will perform any other duties which a Medical Officer is expected to perform in view of his position and any other duties which will be assigned as and when required. 2. Public Health Work

• He/she will make arrangements and provide guidance for rendering healthcare services at the community level and at the PHC through the Health Assistants, Health Workers and others. • The Medical Officer will ensure that all the members of the his/her Health Team are fully conversant with the various National Health and Family Welfare Programs including NHM to be implemented in the area allotted to each health functionary. • He/she will prepare operational plans and ensure effective implementation of the same to achieve the laid down targets under different National Health and Family Welfare Programmes. • Any service, speciality or otherwise, being rendered in the hospital, its quality delivery and other necessary coordination will be ensured by the MO. • The MO will ensure the effective implementation of all National Health Programmes-Reproductive and Child Health Programme, Universal Immunization Programme, National Vector Borne Disease Control Programme, National Programme for control of

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Blindness, Non-Communicable Diseases Programmes, National Mental Health Programme, Control of Communicable Diseases, Leprosy, Tuberculosis, Sexually Transmitted Diseases and Ayushman Bharat. He/she will be responsible for proper and successful implementation of the Programmes in PHC area, including education, motivation, delivery of services and aftercare. He/she will be responsible for all administrative and technical matters regarding the operations of National Health Programmes in his/her PHC area. He/she will be responsible for all Health Education activities in his/her area. He/she will take the necessary steps for institutionalizing public health surveillance and undertake timely actions in case of any outbreak or epidemic in his/her area.

3. Administrative Work

• He/she will supervise the work, scrutinize the programmes of his/her staff and suggest changes if necessary to suit the priority of work of staff working under him/her. • He/she will hold monthly staff meetings to evaluate the progress of work and suggest steps to be taken for further improvements. • He/she will ensure the maintenance of the prescribed records and registers at PHC level and will issue various kinds of certificates in the capacity of a medical officer. • He/she will ensure that the problems and grievances of the staff are solved promptly. • He/she will ensure the confidentiality of the patients. • He/she will take actions timely for legal matters, medico-legal cases, RTIs, court cases and expeditious implementation of order of the courts. • He/she will organize training programmes including continuing education for the staff of PHC and ASHA under the guidance of the district health authorities and Health and Family Welfare Training Centres and will ensure that the staff working under his office regularly gets appropriate training. • He/she will assess the performance of the staff and arrange for retraining if required. • He/she will ensure appropriate utilization of funds as per the guidelines and GFR (General Financial Rules) provisions. • He/she will ensure auditing procedures are completed well in advance and audit reports are furnished to all the concerned authorities. • He/she will dispose of all of the obsolete/condemned items and vehicles as per the government orders in force. • He/she will monitor and guide the activities of Hospitals/PHC/CHC committees, patient welfare societies of hospitals, village health and sanitation committees.

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• He/she will ensure inter-sectoral/inter-departmental coordination; involvement of community leaders, various social welfare agencies and people for effective provision of patient centric healthcare. • He/she will be involved in ‘performance audit’ of staff as per the guidelines of ‘performance Audit’. • He/she will facilitate, coordinate, supervise, monitor and implement the provisions of all the health sector Acts and the Rules. JOB RESPONSIBILITIES OF HEALTH EDUCATOR7

The health educator will function under the technical supervision and guidance of the block extension educator. However, he/she will be under the immediate administrative control of the PHC medical officer. He/she will be responsible for providing support to all health and family welfare programmes in the block. His/her main responsibilities are • Develop, plan, organize, implement and evaluate health education activities/behaviour change communication (BCC) activities in PHC area, under the guidance of MO and block extension educator. JOB RESPONSIBILITIES OF HEALTH ASSISTANT FEMALE (LHV—LADY HEALTH VISITOR): FEMALE SUPERVISOR

Under the multipurpose workers scheme, a health assistant female is expected to cover a population of 30,000 (20,000 in tribal and hilly areas) in which there are 6 sub-centres, each with at least one health worker female. The health assistant female will carry out the following duties: Supportive Supervision and Guidance

• Visit each sub-centre at least once a week on fixed day to provide supportive supervision and guidance to health workers female, birth attendants and ASHAs and cover all the six sub-centres in a month. Use checklist system for supervision and home visits on sample basis. JOB RESPONSIBILITIES OF HEALTH ASSISTANT (MALE SUPERVISOR)

Under the Multipurpose Workers Scheme, a health assistant (male) is expected to cover six sub-centres, each with one health worker (male). The health assistant (male) will carry out following duties. Supportive Supervision and Guidance

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• Provide supportive supervision and guidance to all health workers (males) by visiting each health worker at least once a week on fixed day. Health assistant male can use a checklist system for supportive supervision. • Carry out supervisory home visits on sample basis in the area of health worker (male) to assess the performance of health worker and his quality of work.

• Help and guide the health worker (male) in planning and organizing his programmes of activities. Job Description of Community Health Officer (CHO)— Mid-Level Health Provider

The CHO would broadly be expected to carry out public health functions, ambulatory care, management and provide leadership at the HWC-SHC. They would be responsible for the following: 1 Ensure that all households in the service area are listed, empaneled and a database is maintained-in digital format/paper format as required by the state. 2 Provide clinical care as specified in the care pathways and standard treatment guidelines for the range of services expected of the SHC. 3 Clinical care provision would include coordinating for care/case management for chronic illnesses based on the diagnosis and treatment plan made by the Medical Officer/specialists who will initiate treatment for chronic diseases, dispense drugs as per standing orders by the medical officer. 4 Such coordination could be facilitated through processes such as telehealth. However, CHOs can also provide medicines as per the provisions of Schedule K, Item 23. 5 Focus attention in screening for chronic conditions, enabling suspected cases confirmed and initiating treatment based on appropriate STGs or on basis of plans made by medical officer/specialists. As a team, ensure adherence, along with counselling and support as needed for primary and secondary prevention efforts. Such chronic conditions would include both noncommunicable diseases and the chronic communicable diseases of tuberculosis, leprosy and HIV. 6 Coordinate and lead local response to diseases outbreaks, emergencies and disaster situations and support the medical team or joint investigation teams for disease outbreaks. 7 Support the team of MPWs and ASHAs in their tasks, including on the job monitoring, support and supervision and undertaking the monitoring, management, reporting and administrative functions of the HWC such as inventory management, upkeep and maintenance and management of untied funds. 8 Support and supervise the collection of populationbased data by frontline workers, collate and analyse data for planning and reporting of data to the next level in an accurate and timely fashion. Use HWC and population data to understand key causes of mortality, morbidity in the community and work with the team to develop a local action plan with measurable targets, including a particular focus on vulnerable communities. 9 Coordinate with community platforms such as the VHSNC/MAS/SHGs and work closely with PRI/ULB, to address social determinants of health and promote behaviour change for improved health outcomes.

Health Planning and Management

10 Address issues of social and environmental determinants of health with extension workers of other departments related to gender based violence, education, safe potable water, sanitation, safe collection of refuse, proper disposal of wastewater, indoor air pollution and specific environmental hazards such as fluorosis, silicosis, arsenic contaminations, etc. JOB FUNCTIONS OF HEALTH WORKER (FEMALE) OR AUXILIARY NURSE MIDWIFE (ANM)

Under the Multipurpose Workers Scheme, a health worker (female) is available at sub-centre covering 5,000 population or five Anganwadis areas in plain and 3,000 population in hilly/tribal/desert and difficult areas. She is supervised by health assistant (female). Her job functions are as under: 1 Maternal and child health services: This includes essential obstetrical care and child services in allocated 5,000 population. 2 Family planning services: This includes identification, registration and motivation of all eligible couples in her area and providing conventional contraceptives. 3 Training and continuing education to dais and ASHAs and organize Village Health and Nutrition Day at Anganwadi centre once a month, for at least 4 hours of contact time between ANMs, AWWs, ASHAs and beneficiaries. 4 Communicable diseases: Implement Integrated Diseases Surveillance Programme (IDSP) in her area and notify regularly occurrence of syndromes. 5 Prevention and control of non-communicable diseases (NCDs): (Health promotion and community based screening of NCDs and common cancers). 6 National health programmes: Services for all national health/disease control programmes (NVBD, tuberculosis, blindness, HIV/AIDS, IDDs, leprosy and Universal Immunization Programme and NCDs). 7 Treatment of common ailments and health education. 8 Vital events: Regularly record and report pregnancies, births and deaths in her area. 9 Records and reports: Maintain essential records and prepare and submit performance report every month. 10 Team activities: Coordinate the work with health worker (male), Anganwadi workers, ASHAs, block development functionaries, Panchayati Raj Institutions, school teachers, self-help groups and NGOs. 11 To undertake community needs assessment for workload assessment and prepare sub-centre action plan with the help of PRIs, ASHAs and AWWs. Role of ANM as Facilitator of ASHA and AWW

ANM holds monthly/fortnight meeting with ASHAs and AWWs, acts as resource person for training, informs date,

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time, place of outreach session, takes their help in updating eligible couples, utilizes ASHA in motivating pregnant women and married couples for utilizing services at subcentre. AWW guides ASHA in organizing health day once a month. JOB RESPONSIBILITIES OF HEALTH WORKER (MALE)

Health worker (male) is available at sub-centre which covers a population of 5,000 in plain and 3,000 in hilly/ tribal/desert area. The health worker (male) will make a visit to each family once a fortnight. He will record his visit on the main entrance to the house according to the instructions of the state/UT. His duties pertaining to different national health programmes are: 1 Active case detection (active surveillance for malaria): By visiting each family once a fortnight (100 houses per day), preparing thick and thin blood smears of all fever cases and giving full treatment to clinically suspected/confirmed cases of malaria as per guidelines/ policy. Nearly 63% of male health worker posts are vacant. 2 Where kala-azar is endemic: Carry out surveillance for kala-azar in each family and refer and guide the suspected cases to nearest PHC. • He will assist spray operation in his area. 3 Where Japanese encephalitis (JE) is endemic: From each family he shall enquire about presence of any fever case with altered sensorium (encephalitis) and guide these suspected cases of JE for diagnosis and treatment to medical officer. 4 Where filaria in endemic: He will identify cases of lymphoedema/elephantiasis and hydrocele and their referral to PHC/CHC for appropriate management. 5 Environmental sanitation: Chlorinate the public drinking water source including wells at regular interval. 6 Prevention and control of non-communicable diseases in the area: (Health promotion and opportunistic screening.) • Communicable diseases: Recognize and report diseases under integrated disease surveillance for rapid response in outbreak situation at local level, with the help and guidance of MO of PHC and district teams. Also educate people on prevention and control of communicable diseases and non-communicable diseases. 7 Universal Immunization Programme: Assist health worker female in organizing outreach session on immunization day at Anganwadi centre ‘or’ organize himself outreach session in remote and difficult area. 8 School health: Assist the health supervisor male and female in the school health programme. 9 Reproductive and Child Health Programme (RCH): Distribute conventional contraceptives and oral

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contraceptives to the couples and help prospective acceptors of sterilization in obtaining the services. • Identify male community leaders in each village and assist health supervisor male in training leaders in the community and ensure participation of community. • Identify women requiring help in medical termination of pregnancy and refer them to nearest approved institution. • Identify and refer cases of genital sore or urethral discharge or non-itchy rash over the body to MO. • Primary medical care: Provide treatment for common ailments, first aid and emergencies and refer cases beyond his competence to nearest facility. • Health education: He is a part of sub-centre team for nutrition and health education activities. • Vital events: Record births and deaths of his area and share/coordinate this information with ANM and report these events to health assistant male. • Records and reports: Maintain the records of activities performed and report the activities performed on the prescribed monthly report/ proforma to health supervisor. • Functions of ASHAs and AWWs: Explained under ICDS and NRHM, respectively.

What is Supportive Supervision?

Supervision is a helping process. i The supervision means guidance, supporting and facilitating the work. ii Its objective is to improve the quality of work and health services. It also aims at development of health worker and health teams to improve or upgrade their skills by—on the job training and guidance. iii The supervisors should make use of management information system and field visits to identify unmet health needs of community and help health workers to evolve action plans to meet these needs. Definition

Supervision is described as: “A process by which a designated individual or a group of individuals, oversee the work of others and establish such controls and procedures as will improve that work through development of worker and working group or through manipulation of the conditions under which the work takes place.” Supervisors must facilitate the work and motivate the workers to perform better and render quality services as per standards. The problems of the workers must be solved by their supervisors and deficiency be rectified by rapid action to sustain the interest of workers. Methods of Supervision

ACTIVITIES OF DAI (BIRTH ATTENDANT)

Traditional birth attendants (TBA) have been trained to conduct safe home deliveries. From now on they are being retrained as skilled birth attendants which include care of mother and newborn. TBA is a village level functionary who is helpful in early recognition and registration of all pregnant women, promotion of institutional deliveries and conducting safe home deliveries and provides care after delivery to mothers and newborn as also registration of births and deaths with health worker female. She refers high risk women and difficult deliveries to sub-centre or PHC or CHC. She is depot holder for contraceptives and motivates eligible couples for acceptance of contraceptives. She refers unwanted pregnancies for medical termination of pregnancy to recognized facility.

SUPERVISION AS MANAGEMENT TECHNIQUE/TOOL What is Not Supervision?

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The supervision is often misused and misunderstood by many. It is not an inspection or fault-finding mission. It is also not a checking or marking only presence or absence of subordinates or just signing the registers.

There are various methods of supervision: 1. Observing workers on the job (concurrent supervision): When the workers are doing their job the designated supervisor oversees that they are doing the work as per laid down standards. This gives an opportunity to judge the quality aspect of services. There is no other method to judge the quality of services provided to people but for on the job observation. This is an opportunity to train the worker on the job concurrently. Supervisor also gets a chance to see the relationship of worker with client and community and accessibility and acceptability of services. You can look whether the pieces of equipment are functional and being used. Once the worker is being observed directly they may try to overdo or the situation may be abnormal on that particular day, or the workers may become nervous, these should be guarded and taken care of. No judgement should be passed for an abnormal situation. 2. Meeting clients and community leaders (consecutive supervision): Consumer or client is a ‘king’ in health service delivery system. The supervisors can meet users/clients and community. A sample of 10 households can be observed to elicit their reactions and satisfaction about services. Their unmet health needs can be assessed and reasons of dissatisfaction can be ascertained for rectification. The whole purpose is to improve the system of health services. Clients’ views and consultation always help to improve

Health Planning and Management

the system. Action plans should incorporate the view points and suggestions of consumer. Involvement of community and leaders in health system can be worked out by meeting the leaders and organized women groups apart from their demand and satisfaction about services. 3. Review of records and reports and work diaries: The records and reports are evidence of work done or work performed by the workers. The accuracy and completeness of records can be assessed by supervisors. Similarly, unmet needs also can be assessed through records and reports. How the workers are using these records for preparing the sub-centre action plans, can also be assessed by supervisors. Whether records are being shared with community and community leaders can be judged. Again, the purpose is to encourage workers to maintain essential records and use that information to improve their work and quality of services and coverage, besides planning. 4. By checklist: Health supervisors are required to maintain a ‘checklist’ for each sub-centre/village to ensure adequate supportive supervision. Use of checklist helps observing performance and identification of deficiencies in standard inputs (as per IPHS), actual performance, and procedures and causes of poor performance. The supervisors must make a note of deficient skills and rectify these through on the job training. The supervisors must be able to use the management information system to identify the unmet client needs and deficient skills in the workers; client satisfaction and quality of services. Whole machinery of supervision (medical officers and health supervisors and district supervisors) would focus on development of health teams at the sub-centre level. Ensure availability of all supplies for services by regularly supervising these through checklist system. Data on sub-centre, PHC and CHC facility checklist and survey helps better planning/decision-making. 5. Staff meetings: Staff meetings with health workers provide an opportunity to get information and to give information to health teams. It also helps to coordinate the work between health workers male and female as also ASHAs and Anganwadi workers. It is an occasion to review the deficiencies in work performance and ways and means to improve the work. Some of the pressing problems can be solved in these meetings. It is also a best forum to plan the work for the next month. During review meetings, continuous education session can be organized to improve the skills of health teams. 6. Feedback to worker and higher levels: Give feedback to workers about your supervision. Give positive as well as negative feedback about his/her work performance with a view to improve the performance in future. Sector meeting provides an opportunity to provide feedback to the workers on their performance and problems are solved on the spot and joint plan is made, for the next month.

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7. Solve problem: Solving problems related to work and worker or the systems are a part of supportive supervision. Functions of Supervisor

The functions of supervisors include 1 Facilitation of work, guidance and training. 2 Establishing qualitative and quantitative control of the work and improve quality of service. 3 Promoting effectiveness of the individual worker. 4 Promoting effectiveness of the group. 5 Serving a link between field and administrative staff at higher level. 6 Monitoring and evaluation of performance. Obstacles in Supervision

Lack of training, poor understanding of concept of supervision and its objective, lack of mobility and transport, no fixed schedule of visits, lack of accountability of supervisors are the major obstacles in the supervision. There is no account of work supervised or assessed. It should be built into the system of monthly reporting. The accountability of the system right now is to the bureaucracy. It should be reversed to the client and community plus health and family welfare staff. Adequate mobility or advance money for supervisory visits should be ensured. Adequate management training to health supervisors, workers during undergraduate and internship period must be strived. The criteria for measuring the performance of supervisors should focus on their success in using the health management information system and field visits to identify unmet client needs and deficient skills and to rectify these through on the job training. Present Scenario

The health workers do not have written job description, and do not get the guidance for improving their deficient skills. Medical officer spend 80% of his time on curative work at the health centre and not available to supervise and support their work with the result the workers are left to themselves to perform and continue to do their job what they know and seldom know whether they are doing things right or as per standard. In the past, the whole focus of supervision was on targets achieved and there was no concern to improve the quality of work, worker and group performance. The supervisors must have a fixed schedule of visit to sub-centre, it should be known to both people and the health workers of the area. The supervisors must go well prepared to meet the situation and have all the facts and figures with him/her of that sub-centre. If the supplies were deficient, the supplies must be ensured in that visit. Reaching supplies and material to workers is part of the job of supervisors. Workers should not run all the times to collect supplies.

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The best example is sustaining outreach sessions on immunization: The vaccines in vaccine carrier, syringes, needles and necessary cards and reporting formats must be reached to the worker by supervisors and reports and left over vaccines are collected on the same day. Ensure that immunization sessions are held along with Anganwadi workers, preferably at Anganwadi centre or sub-centre as per standard; and high level of coverage and quality is ensured. Examples: Supervisor observes that planned session of outreach immunization has been missed by the worker. Reason was supplies (vaccines) had not reached to location. Action by supervisor/manager: To ensure that session is held on subsequent week or on open day of work schedule for the next month. Similarly, supervisors ensure availability of necessary supplies for quality antenatal care. • Securing and maintenance of sub-centre buildings. • Involving people in the healthcare delivery system. • Helping workers to prepare and implement efficient work schedule. These are some examples cited to develop the concept and method of supervision. All the supervisors must use checklist system for supervision and keep a record in their diaries for followup action. Supervision without actions is useless exercise. Training and Continuing Education of Health Teams: A Management Responsibility

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Since the health workers have been trained at district level and at institutions for their initial training of 1 year for male and one and a half year for female, they need a system of continuing education to upgrade their skills. These health workers have been imparted some skill training but it is inadequate by all standards. Training schools impart less of community-based training and focus more on theoretical training based in the hospital and in the institutions far away from the community. Basic training faculty is poorly trained and training is a last priority with the state governments. Basic training of health workers— the syllabus and contents are much more than MBBS or doctorate in community medicine, the implementation of training is faulty in many ways. In our opinion and experience whole of the basic training of health workers and health team must be based in the community and their teachers should be traditional birth attendants, experienced health workers and Anganwadi workers, ASHAs and senior medical officers of CHC. Given this situation, the medical officer and senior medical officers are responsible to provide on the job training to health workers, continuing education and orientation training. Of late, quite a transformation of family welfare training system has occurred during the past three decades. A new

infrastructure of state institutes of health and family welfare, regional and divisional training centres, and district training centres (DTCs) and district training teams has been created. States are beginning to recognize the critical importance of training for improving service quality. Most staff at the periphery now have received inservice training under CSSM, RCH, IDSP, NRHM and NCDs programmes. However, by and large the training and continuing education has been neglected. The skills of trainers and method of training need to be improved. Field staff need more training in; how to plan their work routines and help them preparing an efficient work schedule. The training, particularly in-service training of health workers can be best carried out at PHC and CHC and at sub-centre level, it gives them an opportunity of hands on training and practice. Major emphasis should be to improve the quality of technical care delivered by auxiliary nurse midwife (female health workers) especially in clinical skills like pelvic examination, IUD insertions, abdominal examination and safe deliveries. Training in work planning and preparing efficient work schedule and interpersonal communication can be best provided at block level. The role of medical officer as manager is to ensure that all the workers and health teams are adequately trained in skills. Deficient skills are to be identified and upgraded during supervisory visits and continuing education sessions at sector meeting or monthly meetings. Worker to worker training can be arranged by medical officer in PHC or CHC area where better skilled and experienced health workers can impart training to their fellow colleagues. Health supervisors and lady medical officer can ensure skill training at the level of PHC/CHC. Integrated skill training under RCH leaves much to be desired. The role of medical officer becomes critical in the area of training and continuing education of health teams under his/her charge. Usually this role is not accepted well. Whatever medical officer knows he just lectures on that subject. The training has to be skill-based, need-based, and deficiencies in skills observed during field visits, must be rectified. The training has to be learning by doing and focus on skills of the trainees rather than on the subject. Method should be demonstration; return demonstration and no lectures are needed. Audiovisual methods would be used maximally. Training needs are assessed through supervisory visits and if a new technology/policy or programme has come, that becomes the focus of training. Maternal and child healthcare (antenatal check-ups, deliveries, postnatal care, neonatal care, immunization, IUD insertion, treatment of diarrhoeal diseases, pneumonia and other common ailments) have been delegated to health workers. Health workers can best discharge this responsibility when trained adequately and supported by supervisors and on the job training. Therefore, team leader and health supervisors are responsible for hands on training of health workers for pelvic and cervical examination by

Health Planning and Management

speculum and copper T insertion and conduct of normal delivery as also give safe injections. Coverage and quality of maternal and child health services will largely depend on the skills of health workers and their continuous training. Training and continued education on non-communicable diseases, inter-sectoral co-ordination and interaction and involvement of people in planning is an imperative need, apart from communication skills and data management. Controlling: A Management Technique

The work done or outputs of various activities are reported online to primary health centre once a month by fixed date. The sector or monthly meeting day is used to collect and compilation of reports. The supervisors ensures compiling and collection of reports of each sub-centre area in the sector meeting, where 25–30 Anganwadi workers assemble along with 5–6 health workers female and as also health workers male once every month. The deficiencies are rectified on the spot and performance for the month is assessed. Reasons for short falls are discussed and rectified. The workers and supervisors are assessed on the basis of their annual work performance. The performance of every worker is assessed annually by way of annual confidential reports. Grades of performance are assigned. The objective of this exercise is to improve the performance of workers and health teams as also to establish control by setting performance standards.

HEALTH SYSTEM MONITORING: A MANAGEMENT TECHNIQUE Health system is a set of elements, which function together to accomplish an objective or purpose. The digestive system, e.g. consists of mouth, gullet, stomach, small intestine and large intestine, all of which function together to digest food. The elements in the system are those components, which function, belong together, and work in a synchronized manner, to achieve a common goal, purpose or objective. The health system requires inputs to carry out programme activities, which result in outcomes. These outcomes are in the form of outputs (immediate products and services produced by the programme), effectschanges in knowledge, attitudes, and behaviour/practice

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that result from outputs and impacts (changes in health or fertility status due to the effects).9 • Programme inputs are resources (men, money and materials) that are invested in the health programme. • Processes (activities): Inputs are processed in several ways, which include discrete actions such as weighing, counselling, diagnosis, treatment, referral, immunization, home visit, educating, antenatal check up, delivery, training and laboratory tests as also surveillance, screening, chlorination, and preparation of reports. How often an activity occurs against planned one? • Outcomes: The processes (activities and tasks) lead to results which are called outcomes. The outcomes are of three types: (i) Outputs, (ii) effects, and (iii) impacts. – Outputs (results): The activities lead to some results. The immediate results are called ‘outputs’ and these are products and the services, growth monitoring and immunization cards (mother and child protection card) and iron folic acid tablets distributed are: Products and the number of children weighed and pregnant women contacted and examined are: Services. Other examples of services are number of deliveries conducted; number or postnatal mothers and neonates provided required services. – Effects: The outputs produce effects on client’s knowledge, attitude, skills and behaviour and individual gets motivated to use service, e.g. use of ORT, contraceptive, use of antenatal clinic, immunizations, quit smoking, and improved service coverage. – Impact: Ultimate result is impact of effects, which is reduction in morbidity, mortality, fertility or disability or malnutrition. The system framework and planning evaluation cycle is shown in Fig. 16.6. Thus, the system approach converts men, money and material resources into activities, which lead onto outputs in the form of services or products and which produce effects on person and ultimately results into improved health status in the form of reduced disease, fertility, death and disability rates (like reduction in diarrhoea, malaria, decreased infant mortality, decreased birth rate, etc.).

Fig. 16.6: Place of monitoring and evaluation in planning cycle

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692 Indicator

How?

An indicator is a measurable variable that helps to measure change. Indicator is an indirect/direct measure of an event or condition. An indicator is constructed from a set of measurements but is more than the measurement itself. Example: A child’s weight is a measurement or indicator. If this weight is compared to a ‘standard’ or reference weight’, it indicates the child’s nutritional status. Thus for each indicator a standard is set. Weight-for-age is a measurement and if it is expressed in terms of percentage of children above or below –2SD of reference value it becomes an ‘indicator’. Weightfor-age is an indirect measure of nutritional status of a child. Best example of monitoring is growth monitoring of young children on WHO standard growth charts.

Monitoring information is generated from i Routine reports are used for monitoring of the programme or health services. Monthly monitoring reports of sub-centre, PHC, CHC are used as good tools for monitoring of progress of activities and to observe any deviation or changes or alterations from the accepted levels or path or direction and corrective actions are ensured at the earliest. ii Field visits—observations made by supervisors. iii By Gantt chart. iv Community monitoring.

Target: Reduce prevalence of underweight in children below 5 years of age to the level of 25% by 2025. Indicator weight for age

Children aged 0  59 months who are below  2SD from median weight-for-age of WHO child growth standards 100 Total number of children 0  59 months of age weighed Uses

Indicators can be used to measure achievement of targets, assess changes/trends in health status and compare the level of achievement between sub-centres, PHCs and CHCs by setting standard for each indicator. Monitoring

Definition

Monitoring is the periodic continuous collection and analysis of selected indicators to enable managers to determine whether key activities are being carried out as planned and are having the expected effects on the target population. Monitoring provides feedback to project management in order to improve operational plans and to take corrective actions. The monitoring involves collection and analysis of information of actual operation to detect deviation from planned operation, to ensure mid-course corrections. Purpose

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The main purpose of monitoring is to detect changes or deviations soon after they occur and action taken at the earliest to correct the root causes of deviations. Monitoring is usually carried out at inputs and processes stages.

Types of Indicators for Monitoring

Health system consists of model of inputs, processes, outputs, effects and impacts. Accordingly, the indicators of monitoring are (Fig. 16.6): • Input indicators • Process indicators • Output indicators • Effect indicators • Impact indicators In addition to selecting an indicator, performance standards for each indicator are set. Input indicators

Inputs are resources needed to carry out activities or programme. The common input indicators would monitor the availability of: i Personnel (available number of doctors, health supervisors, workers, traditional birth attendants) against the sanctioned posts or against the population norms or against Indian public health standards. ii Supplies are sufficient or insufficient, e.g. ORS packets, essential drugs, equipment and other material for activities, e.g. percentage of sub-centres without essential drugs. iii Equipment: Number or percentage of sub-centres without weighing machines and BP apparatus and, copper T insertion equipment. iv Money: Budget—untied money, maintenance grant, JSY money, etc. money spent against sanctioned budget. v Physical facilities—building, space for services. The manager must monitor all these to ensure supplies wherever these are deficient before you expect the results or service or performance. Adequate inputs should be ensured and should be in place. Whether SC, PHC, CHC is accessible, population covered by each of these set-up against the norms or standards (Indian Public Health Standards).

Health Planning and Management

Process indicators

These are activity indicators, how often an activity happens against the planned, e.g. no. of outreach sessions planned and actual numbers held. Number of antenatal clinic days/ sessions held against planned and how often the workers make home visits and contact the Panchayati Raj Institutions (Village health sanitation and nutrition day) against the planned schedule. Output indicators (service utilization indications)

The most important types of outputs in health services are: i Utilization of services ii Quality of services provided as per standards iii Contacts, of those in need of or eligible for the service and frequency of contacts with target groups. iv Access to the service and unit cost. Health services utilization data is collected through routine monthly reports—clinic and outreach reports which indicate simple counts such as: i Number of patient served/seen per month ii Number of antenatals registered iii Number of antenatals provided 4 check ups iv Infants, children, and antenatals immunized v Eligible couples provided contraceptives vi ORS packets/iron folic acid tablets, vitamin A doses distributed. vii Persons above 30 years screened for NCDS and common cancers viii Number of eligibles contacted or informed on services. The service utilization data gives information on number only (numerator). The Judgement about the effectiveness of service can be made based on a comparison between what was planned and what actually happened. This type of monitoring requires collecting numerator (number) and denominator data, for example, 60 of 100 eligible children vaccinated (60% coverage) and 30 out of 60 antenatals given 4 check-ups (50% coverage). Effect indicators (behaviour indicators)

Effect indicators include change in knowledge attitude and behaviour or practices observed as a result of activity. Percentage of ECs using contraceptives, proportion of mothers initiating breastfeeding within one hour of birth are examples of practices/behaviour indicators. Behaviour indicators also include coverage level: Coverage means proportion of target group that has received the prescribed treatment/service in a correct and complete manner, e.g. fully immunized children, mothers who had full antenatal care, proportion of institutional deliveries, and coverage of eligible couples. Impact indicators

These indicators include: i Decline in incidence of diarrhoea, acute respiratory infection and other diseases of national significance.

ii iii iv v

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Decline in malnutrition in young children (0–3 years). Decline in birth rate/fertility rate. Decline in death rate. Decline in infant and child mortality rate.

The impact indicators such as improvement of nutritional status, birth rates, death rates, and infant mortality rates are available through routine records/ reports, but these reports are incomplete most of the times. The system generates lot of data and impact indicators can become available through routine reports if the quality of data is improved by regular monitoring. In the absence of good routine reports, these data are collected by special surveys, or through national data of sample registration system, National Family Health Surveys Data, and District Level Household Survey Data or Annual Health Surveys.

EVALUATION OF HEALTH PROGRAMME OR HEALTH SERVICES: A MANAGEMENT TECHNIQUE Evaluation may be defined as the process of assessing the results of the programme to determine whether the stated goals and objectives have been achieved. The evaluation is done to know if we have achieved what we planned. It is normally done at the end of programme/project. Evaluation is usually done at the outputs, and outcomes (effects and impacts) level. Evaluation also answers some critical questions • To what extent the stated objectives have been achieved? • At what cost the objectives have been achieved? • Should the programme be continued as such? • Should the programme be modified in view of results/ observations of evaluation? • Should the programme be abandoned? • Should the programme and objectives be modified? Purpose: The whole purpose of the evaluation is to improve the health system/programmes and the health infrastructure development and to guide the allocation of resources in current and future programmes. Components of Evaluation

The evaluation of programme has the following components: 1 What? Be clear as to what is to be evaluated? Is it a programme, service or health centre or hospital, which is being evaluated? 2 Information: What information support is available on the subject? These could be monitoring reports, i.e. data on service outputs and field observations on client

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satisfaction/reactions, work diaries or some official published reports. 3 Verify relevance: Are the health policies relevant to country’s overall social and economic policies? Is it directed towards defined national health goals? Does it contribute in improving health of population concerned? Frequency of Evaluation

While monitoring is a continuous process the evaluation is a terminal activity or final step in the programme implementation. It is better to assess the progress and efficiency once a year at least and to assess the impact of programme longer time is required and evaluation should be done at least 5 years from the start of programme. Indicators and Criteria for Evaluation

Indicators are variables that help to measure changes. They are evaluation tools, which can measure the change directly or indirectly. Keep it short and specific (KISS), i.e. list of indicators should be short and specific. The indicator should be ‘valid’, i.e. indicator actually measures what it is supposed to measure. It should be ‘reliable’, it means that even if the indicator is used by different people at different times and under different circumstances the result should be the same or consistent. It should be ‘sensitive’, it means it should measure the changes as soon as these occur. It should be ‘specific’ it means that the indicator reflects changes only in a situation or phenomenon concerned. It should be ‘feasible’ it means it should be simple to collect and analyse the data for it and lastly it should be ‘precise’, i.e. it should have sufficient details (e.g. age, sex and geographical area). Various indicators for evaluation have been explained in National Health Programmes. Design of Evaluation

There are 57 research designs to conduct evaluation however, most practical, simple and basic designs are given below. 1 The one time study: This is expressed as EXO, where ‘E’ is the experimental group, ‘X’ is the programme intervention and ‘O’ is the observation. It is the most common, fast, and inexpensive design, but there is no baseline data, nor is there any control group. Therefore, it is weakest design.

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2 One group: Before and after study or baseline/ repeat observation. It may be expressed as EOXO where: E is the experimental group (beneficiaries) O is the baseline observations (before programme intervention)

X is programme intervention O is repeat survey observation (after programme intervention). This design is also fast and inexpensive but there is no control group and there is no random selection. 3 Time series study: It may be expressed as: EOOOXOOO E is experimental group (beneficiaries) O O O are observations or surveys in time series. X is programme intervention O O O—before and after programme intervention. This design is time consuming, but it determines the impact of the programme over a period of time. However, there is no control group to eliminate extraneous variables, and there is no random selection in the design. 4 Non-equivalent baseline/repeat observation study (with and without study). It may be expressed as: EOXO COO where E is experimental group C is control group O is baseline observation in experimental group. O is baseline information in control group (O and O are conducted simultaneously) X is programme intervention O is repeat observation in experimental group after programme intervention and O is repeat observation in control group at the time O is conducted. This is quasi-experimental design, where baseline and repeat observations are conducted on experimental group as well as on the control group. There is no random selection. 5 Post-programme observations—control group study: It may be expressed as: ERXO CRO where E is experimental group C is control group R stands for random selection X is programme intervention O is post-programme observation in experimental group. O is observation on control group at the time O is conducted. This is true experimental design; it has control group as well as random selection. But there is no baseline data for comparing the impact of the programme. 6 Baseline/repeat observation control group study: It may be expressed as: EROXO CROO

Health Planning and Management

where E is experimental group C is control group R stands for random selection O is baseline observation in experimental group O is baseline observation in control group (O and O are conducted simultaneously) X is programme intervention O is repeat observation in experimental group after programme intervention, and O is repeat observation in control group at the time O is conducted. This is true experimental design. It has control group, it involves random selection; and baseline as well as repeat observation are available. (Adapted from Manual on Integrated Management Information System for ICDS, 1986 Ist Ed. MOHRD, New Delhi).

Examples of evaluation: Coverage evaluation survey for immunization in children of 12–23 months of age. Improvement of nutritional status of under 5 years by weight-for-age at 1 year interval. Using annual data of sample registration survey to collect birth rate, death rate, and infant mortality rate to know the impact of interventions. Other examples: HIV sentinel surveillance surveys, surveillance of AFP, goitre surveys, apart from evaluation of National Health Programmes by base-line and repeat surveys—NFHS and SRS in India.

PROGRAMME EVALUATION AND REVIEW TECHNIQUE (PERT) One technique of control in the planning process highly applicable is PERT (programme evaluation and review technique), sometimes called critical path method (CPM), which means to: 1 Identify key activities in a project. 2 Devise the sequence of activities and arrange them in a flow diagram. 3 Assign duration of time for performance of each phase of the work to be done. 4 Develop PERT network: List the activities horizontally on paper. To make this look like a formal PERT chart put circles at the beginning and end of each activity. Draw lines between beginning and ending circles. These circles are events representing the beginning and completion of each activity. The line represents the activity. Add other circles for other events not related to activities. 5 Identify the critical path: Begin at the right side where the large task has been completed. Choose the last task that has taken the most time. Now connect that activity

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with the precedent activity that required the most time, continue this process across the page from right to left. Review this carefully by reading left to right. The objective is to identify a sequence of activities which will accomplish the larger task in the shortest amount of time. 6 Perform network time calculations: Add up the time allotments along the critical path. The sum will indicate the total time required to complete the project. 7 Re-plan: Try other routes through the activities always ensuring that no activity commences before the precedents are completed, e.g. training of Anganwadi workers cannot occur unless they are recruited and appointed. The point of this exercise is to identify the activity/ activities which need manager’s keenest interest. The biggest disadvantage of PERT is overemphasis on time and almost no attention to cost. Critical path analysis is effective and powerful method of assessing • What tasks must be carried out? • Where parallel activity can be performed. • The shortest time in which you can complete a project • Resources needed to execute a project. • The sequence of activities, scheduling and timings involved • Task priorities. • The most efficient way of shortening time on urgent projects.

HEALTHCARE FINANCING: A MANAGEMENT TECHNIQUE The financing of healthcare in India is based on two basic tenets. First, the provision of healthcare service to people is the responsibility of the state government and secondly, comprehensive healthcare should be available to entire population irrespective of their ability to pay. Health investments bring benefit to economic development. Since independence healthcare has been recognized as an essential social sector investment, it was therefore initially envisaged that health services in government institutions will be provided free of cost to all. During 1990s, it was recognized that given the increasing awareness and expectations of the people, and the escalating cost of healthcare, this policy could not continue. The ninth plan envisaged that major public health priorities such as essential primary healthcare, emergency life-saving services, services under the Disease Control and Family Welfare Programme will be provided free of cost to all. The ninth plan advocated that the centre and state government should work out appropriate norms for levying user charges on people above the poverty line for other services and hospitalization and evolve mechanisms for

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collection and utilization of funds. Kerala experimented the user charges model at district level and under European Commission assistance several states introduced users charges for select services and most of the states were allowed to retain user charges for effecting improvement in quality of services. The WHO has estimated that India at present is spending 5.2% of gross domestic product (GDP) on health of which 0.9% is public expenditure and the rest of three-fourths is out of pocket spending. India ranks 13th from the bottom in terms of public spending on health (World Health Report, 2000), being lowest in the world. Based on the need and broad goals of National Health Policy, 2002, a national health accounts and health statistics was established. Emphasis should shift from financial allocation to outcomes.10 SPENDING ON HEALTHCARE

Despite years of strong economic growth in India the total spending on healthcare in 2018–19 was about 3.16% of GDP. Global evidence on health spending shows that unless a country spends at least 5–6% of its GDP on health, and the major part of it is from government expenditure, basic healthcare needs are seldom met. The governement spending on healthcare in India is only 1.28% of GDP, i.e. nearly 40.6% of total health spending. Perhaps the single most important policy pronouncement of the National Health Policy, 2002 articulated in the 10th, 11th and 12th Five-Year Plans and the NRHM framework was the decision to increase public health expenditure to 2–3% of GDP. Public health expenditure rose briskly in the initial years of the NRHM, but at the peak of its performance it started stagnating at about 1.04% of GDP. The failure to attain minimum levels of public health expenditure remain the single most important constraint. While it is important to recognize the growth and potential of rapidly expanding private sector, international experience shows that health outcomes and financial protection are closely related to absolute and relative levels of public health expenditure. Brazil, Thailand and Sri Lanka have achieved close to universal health coverage. Thailand has almost the same total health expenditure as India but its proportion of public health spending is 77.7% of total expenditure, and this is spent through a form of strategic purchasing in which about 95% is purchased from public healthcare facilities which is what gives it such a high efficiency. Brazil spends 9% of its GDP on health but of this public health expenditure constitute 4.1% of the GDP (45% of total health expenditure).

HEALTHCARE FINANCING IN INDIA AT A GLANCE

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Health Accounts describe health expenditures and flow of funds in the country’s health system over a financial

year of India. It answers important policy questions such as what are the sources of healthcare expenditures, who manages these health goods and services, who provides healthcare services and which services are utilized. Key health financing indicators are as under: Total Health Expenditures (THE)

Total health expenditures constitute current and capital health expenditures incurred by government and Private sources including external funds of donors. Current Health Expenditures (CHE)

CHE constitutes only recurrent expenditures for healthcare (goods and services) used up in the course of one year and are usually purchased regularly, (i.e. recurrent cost), such as expenditures on salaries, rent, petrol, oil and lubricants, electricity, water, medicines and diagnostics and other consumables. CHE indicates operational expenditures on healthcare that impact the health outcomes of the population in that particular year. Main focus is on CHE which constitutes over 91% of the total health expenditures (THE) in India. Capital Health Expenditures or Capital Costs

These are expenditures on items/goods that last longer than one year such as buildings, equipment, vehicles, machinery, etc. The capital health expenditures constitute nearly 9% of THE in India. Revenues of Healthcare Financing Schemes (Sources)

There are five major sources of health financing in India as elaborated below and illustrated in Fig. 16.7. 1 Household revenues including insurance contributions 2 State government funds 3 Central government funds 4 Enterprises, NGO and external donors funds 5 Social health insurance, government finance health insurance schemes besides private insurance schemes. Who Contributes to Current Health Expenditures (CHE)?

Household revenues including insurance contributions which finances healthcare system is the single largest component contributing over 60% of CHE and out of pocket expenditure being 53.23%, followed by state government funds 19.63%, Central government funds 11.71% and enterprises 5.51% (Fig. 16.7). The 15th FC recommends health spending by states be increased to 8% of their budget by 2022 and 67% of total health expenditure be on primary healthcare. Who Provides Healthcare Services?

Over 17% of current health expenditure (CHE) is attributed to Government Hospitals and 28.7% to private

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percentage of GDP indicates health spending relative to the country’s economic development. It also indicates government priority towards healthcare. Total health expenditure as percentage of General domestic product (GDP) has further declined from a low of 3.31% in Financial year 2017–18 to 3.16% in 2018–19 which translates to ` 4470 per capita per annum. It is woefully low when compared with WHO recommendation of 5% of GDP (Table 16.7). 2. Government Health Expenditure (GHE) on Healthcare as Percent of THE

Fig. 16.7: Sources of health financing in India (NHA 2018-19)

hospitals. Nearly 7.75% of CHE is attributable to PHCs, dispensaries and family planning services and 4.73% of CHE goes to other private providers (private clinics). Thus private sector dominates in providing healthcare services. What Services are Consumed?

About 34.5% of CHE is being attributed to inpatient curative care, 18.9% to outpatient curative care and 0.77% to day curative care. Current health expenditure (CHE) attributed to Primary healthcare is 55.2%, (against 67% recommend by 15th FC), on secondary care 30.5% and for tertiary care is 5.9%. For Preventive care CHE is 9.44%. KEY HEALTH FINANCING INDICATORS (TABLE 16.7) 1. Total Health Expenditure (THE) as Percentage of GDP

Total health expenditure constitutes current and capital expenditures incurred by government and private sources including external funds. Total health expenditure as a

The government health expenditure constitutes spending under all schemes funded by central, state and local governments. It has an important bearing on the health system as low government health expenditures may mean high dependence on household out of pocked expenditures. Government spending on healthcare over the last 14 years has increased from 22.5 to 40.61% of total health expenditure (THE). It forms 1.28% of gross domestic product (GDP). However, government health expenditure on healthcare in India is the lowest in the world. It has an important bearing on health system as low government spending on healthcare means high dependence on household’s OOPE. National Health Policy 2017 Commits 2.5% of GDP as government spending on health by 2025. 3. Household’s Out of Pocket Expenditure (OOPE) on Health as Percent of THE

OOPE on health indicates the extent of financial protection available for households towards healthcare payments. OOPE are expenditures directly made by households at the point of receiving healthcare. The burden of OOPE falls on poor people who spend their savings or get loan to pay towards healthcare. Over the years household’s OOPE burden has decreased from a high of 69.4% of total health expenditure (THE) in 2004–05 to 48.21% in 2018–19—a good sign of progress

Table 16.7: Expenditure on health in India 2004–05 to 2018–19 Selected national health accounts indicators

2004–2005

2013–14

2016–2017

2017-2018

2018-2019

1. Total health expenditure (THE) as % of GDP

4.20

4.02

3.8

3.31

3.16

2. Government health expenditure as % of GDP

0.94

1.15

1.2

1.35

1.28

3. Government health expenditure as % of THE

22.5

28.6

32.4

40.8

40.6

4. Private expenditure on health as % of THE

78.05

72.9

67.6

59.2

59.4

5. Out of packet expenditure as % of THE

69.4

64.2

58.7

48.8

48.21

6. Per capita government expenditure on health

` 242

1042

1415

1753

1815

7. Households OOPE per capita

` 959

2596

2570

2097

2155

8. Total per capita expenditure on health

1201

3638

4381

4297

4470

Source: World health report 2007, NCMH-2005 and National Health Accounts 2005 to 2019

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indeed. However OOPE in India is the highest in the world; it constitutes 1.52% of GDP and Rs. 2155 per capita per year. Hopefully health protection measures such as Ayushman Bharat (PMJAY) and Ayushman Bharat health infrastructure mission (ABHIM) and universal health protection for all reduces OOPE to a minimum acceptable level. 4. Financial Protection

Financial protection is measured through two indicators– Impoverishment and catastrophic health expenditure. Impoverishment: Around 4.2% or approximately 50 million people are being pushed to poverty every year in India because of high OOPE on healthcare. Catastrophic Health Expenditure

Healthcare costs of household exceeding 10% of total monthly consumption expenditure or 40% of its non-food consumption expenditure is designated as catastrophic health expenditure and is declared as an unacceptable level of healthcare cost. Impoverishment due to healthcare cost is of course even more unacceptable. About 17.3% of people spent more than 10% of their household’s total expenditures on healthcare between 2012–20 which has declined to 7% in 2022. 5. Social Security Expenditures on Health as Percent of THE

This indicator indicates the extent of pooled funds available for specific categories of population. These expenditures include finances allocated by the government towards payment of premiums for health insurance schemes (PMJAY, RSBY, social health insurance schemes–CGHS, ESIS and ECHS employee benefit schemes). Around 9.6% of total health expenditure goes to social security expenditure on health while private health insurance expenditure of total health expenditure is 6.6% (voluntary payment to provide financial protection). Private Health Sector

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With 80% of doctors, 25% of nurses and 49% beds, private sector is dominant provider of curative services. This sector is financed primarily by OOPE. Major challenge of ailing government health sector is to increase its utilization in favour of poor. Healthcare utilization in India is predominantly through private sector for curative care and towards government sector for preventive care. Government health sector is dominant provider of preventive and promotive health services to over 95% of the population of the country. Health financing is critical for planning allocation of resources to develop strategies that protect people from catastrophic health expenditure and reduce inequities.

Hospitalization Expenditure

a Average medical expenditure per hospitalization case: On an average, a much higher amount was spent for treatment per hospitalized case by people in the private (`31, 845) than in public (`4450). The average medical expenditure for treatment per hospitalized case, if treated in private hospital was around 7 time higher than if treated in government hospital. b. Average medical and other related non-medical expenditure per hospitalization case in rural area was `16, 676 against `26, 475 in urban areas. Strategic Purchasing of Secondary and Tertiary Care

Free primary healthcare by government sector, supplemented by strategic purchase of secondary care hospitalization and tertiary care services from both public and private sector will be main financial strategy of assuring health services. Strategic purchasing means government acting as a single payer, purchasing care from private and government hospitals for district health system development. (NHP, 2017 commits 2.5% of GDP on public health). Compulsory Social Insurance

Coverage of health insurance in India is pathetically limited. Compulsory social insurance schemes include the Central Government Health Scheme (CGHS), Employees’ State Insurance Scheme (ESIS) and Ex-servicemen Contributory Health Scheme (ECHS). Social health insurance expenditure has increased from 4.2 to 16.2% over the past 14 years. Coverage of Health Expenditure Support (Social Insurance)

The government was able to bring about 12% of urban and 13% of rural population under health protection coverage through Rashtriya Swasthya Bima Yojana (RSBY) or similar plan only 12% households of upper class of urban area had some arrangement of medical insurance from private providers. It is, thus, seen that as high as 86 % of rural population and 82% of urban population were still not covered under any scheme of health expenditure support. On the whole, poorer households appear not to recognize the efficacy of coverage, both in rural and urban areas. With the implementation of ‘Ayushman Bharat’ the scenario has changed. Now 35% of population is covered for health protection including PMJAY. To bridge the gap, it is envisaged to cover all for health protection by 2025. A. Outpatient/Ambulatory Care Services

It is observed that private doctors were the most important single source of treatment in both urban and rural areas (Fig. 16.8). More than 70% (67.5% in rural and 73.8% in the urban areas) spells of ailment (outdoor care) were treated in the private sector-consisting of private doctors,

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Fig. 16.8: Percentage distribution of spells of ailments treated in OPD during the last 15 days in rural and urban areas by private sector and government sector (NSSO 2017–18)

Fig. 16.9: Indoor care services

nursing homes, private hospitals, charitable institutions. Only 32.5% in rural and 26.2% in the urban areas, spells of ailments were treated in government sector consisting of government hospitals, clinics, dispensaries, subcentres, primary health centres, community health centres, mobile medical units, ESI hospitals and dispensaries. B. Inpatient/Hospitalized Care Services

Private institutions dominate in the field in treating the inpatients, (nearly 60% of all hospitalizations) both in rural and urban areas. A steady decline in use of government sources and corresponding increase in private sources was evident (Fig. 16.9), over the last five NSS rounds.11, 12 REFERENCES 1 GOI. Manual on target free approach in family welfare programme. New Delhi: MOH and FW, GOI; 1996. 2 GOI. Manual on community needs assessment approach (formerly target free approach) in family welfare. New Delhi: MOH and FW, GOI; 1998.

3 GOI. National health policy (revised) 2002. New Delhi: MOH and FW, GOI; 2002 and 2017. 4 Lal S, Sehgal P, Learning practice of health management through existing health action plans under National Health Mission (NHM) Ind J Community Med 2022; 47:1–4. 5 Arole RS, Rhode JE. Organization of health services and training of physicians for child health services. A consultant report to USAID. New York: USAID; 1983. 6 WHO. On being in charge—a guide for middle level management in primary healthcare. Geneva: WHO; 1980. 7 NIHFW. Management training modules for medical officers primary health centre. New Delhi: NIHFW; 1987. 8 GOI. IPHS for Sub-centre, Primary Health Centre and Community Health Centre, NRHM, MOH and FW. GOI; New Delhi, 2007 and 2012. 9 GOI. Management of integrated management information system for ICDS. New Delhi: Ministry of human resource development; 1986. 10 National Health Accounts Estimates for India 2013–14. and 2017–18 NHA Technical Secretariat, National Health System Resource Centre, MOHFW Government of India.

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11 GOI. Ministry of Statistics and programme implementation key indicators of social consumption in India health—2018 NSS 75th Round. 12 Aga Khan Foundation. Primary healthcare management advancement programme modules (1,4,5). Washington (USA): Aga Khan Foundation; 1993.

HOSPITAL MANAGEMENT Hospital Administration/Management

Hospital has an organization to organize and manage high quality patient care services (medical and nursing) which include acute patient care or emergency services, OPD, indoor, laboratory services besides supportive services (blood bank, laundry CSSD, dietary, waste-management and infection control, maintaining patient records, cleanliness and dispensing of drugs, materials, etc.). The hospital management comprises planning of preventive, promotive, curative and rehabilitative services, managing human resources, materials and logistics and financial resources. Hospital designs and hospital engineering services are other important areas. Medical care in the hospitals is very costly inspite of government policy of free essential drugs, free diagnostics, free emergency and trauma services and free maternal and child care services and services for national health programmes. Hospital morbidity and mortality data is quality data for planning and evaluation of services. HOSPITAL STATISTICS/MEDICAL RECORDS

Hospital statistics are used as a measure of evaluation of quality of medical care and its utilization. It also helps in planning and allocation of resources in different areas.

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The major uses of hospital statistics are to • Evaluate quality of medical care rendered, • Identify the deficiencies at various levels, i.e. input process and outcome of the services, and • Evaluate the effectiveness and efficiency of the hospital administration/management. The generation of hospital statistics should be purely on the basis of administrative requirement of the hospital. Hence, these vary with the type of hospital. It may be generated daily, weekly, monthly, quarterly and annually depending upon the requirement. Still broadly it can be divided into following types:1,2 1 Patient movement statistics: Number of admissions/ discharges/deaths, OPD patients. 2 Morbidity statistics: Number of patients under various diagnoses. 3 Management/administrative statistics: Manpower, material, money finances, etc. 4 Hospital services statistics: Number of operation theatres (OTs), number of surgeries (major/minor), number of specialities, their utilization indicators, etc.

Patient Movement Statistics

Average Daily Census

Average daily census is the average number of patients in the hospital at a given time per day; and is expressed as: Sum of daily census for a given period Number of calendar days in the period HOSPITAL UTILIZATION INDICES 1. Turnover (T) Interval

T interval is the mean number of days a bed remains vacant between two admissions, and is expressed as: Number of vacant bed days in a defined period T Total number of discharges, deaths and transferrs during that period The value of T may be negative or positive. i A negative T is indicative of scarcity of beds and overutilization. ii A long positive T is indicative of under-utilization because of either defective admission procedures or poor quality medical care. iii A short positive T is indicative of optimum utilization. T interval is a very sensitive index of hospital utilization. It can also be used to measure the demand for or pressure on beds. 2. Bed (Turn Over) Rate

It is an important measure of hospital utilization indices. It gives the net effect of changes in occupancy rate and AVLS (average length of stay): Number of discharges for a given period of time Average bed count for that period of time

× 100

Percentage of Occupancy or Bed Occupancy Ratio

This is the ratio of occupied bed days to the available bed days as determined by bed capacity, during any given period of time. Calculation Actual number of occupied bed days  100 Available bed days

Bed occupancy ratio is used to measure the utilization of health facility beds. 80–85% occupancy is considered ideal for good quality of patient care. A hospital has always some beds vacant for emergency, maternity, isolation, intensive care units, etc. This space is called ‘dead bed

Health Planning and Management

space’. This accounts for 15–20% of beds in a hospital. That is why 80–85% occupancy indicates full utilization of hospital beds. 100% occupancy means over-utilization which leads to fall in the quality of care. Occupancy of more than 100 means patients on floors, overtaxed hospital, physical facilities and over worked staff. All this adds up to substandard medical care. The bed occupancy rate for different units can be monitored to plan hospital services and evaluate the efficiency/ utilization. An occupancy of less than 80% is uneconomical and indicates lack of response from the public. Too rigid compartmentation of hospital wards does not afford flexibility and may result in under-utilization of one department while another department may be short of beds. Built in flexibility is desirable for proper and optimum utilization of hospital beds.

Indices of Quality of Care

3. Average Length of Stay in Health Facility

III. Consultation Rate

Average length of stay is the average number of days of service rendered to each discharged patient (including deaths and transfers) during a given period of time (exclusive of newborn babies). Inpatient days are compiled from the discharge summary of discharged patients. In computing the length of stay, the day of admission is counted but the day of discharge is not counted. Admission and discharge on the same day is counted as one day.

Calculation

Calculation Total inpatient days during a given period Total discharges (including deaths and transfers) during the same period

In teaching hospital (PGIMS, Rohtak) during the year 2007, the average length of stay was 6.02 days. If the admission procedures are streamlined, time is not wasted in investigations, early diagnosis and treatment will help bring down the average length of stay of inpatients. On one bed 36 patients can be taken care of in a year if the average length of stay is 10 days. If it is 20 days then only 18 patients can be admitted on this bed. Projecting this principle to 1000 beds indicates the importance of reduction in the average length of stay. At the same time, care should be taken against too early discharge of patients. For this purpose readmission rate should also be calculated and watched. This index may be used to plan a waiting list. Average daily OPD attendance Total number of outpatient attended Number of working days during that period

Average OPD attendance per patient, i.e. the number of time on an average, a patient attends OPD. Total number of OPD attendance during a given period Total number of new OPD cases during that period

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I. Autopsy Rate

Number of pathological autopsies performed Number of deaths during a period

× 100

Autopsy rate of more than 15–20% indicates enquiry type of medical staff, progressive in outlook. II. Caesarean Section (CS) Rate

Calculation Total CS performed Total number of deliveries

× 100

The normal value of this rate is 3–4%. A higher CS rate should be enquired into.

Total written consultations during a period

× 100 Total discharges (including deaths) during that period

A consultation rate of more than 15–20% is indicative of high quality of medical care. IV. Hospital Infection Rate (Postoperative Infection Rate)

All infections in clean surgical cases in a year × 100 Total number of surgeries in that year V. Death Rates

Gross Death Rate Total number of hospital deaths during a given period

× 100 Total discharges (including deaths and transfers) during the same period

Net Death Rate Total deaths of inpatients after 48 hours or more after admission Total discharges (minus deaths occurring within 48 hours after admission)

× 100

Specific Death Rate Number of net deaths in a ward or department during a given period Total discharges (including deaths) in that department during the same period

× 100

Net death rate is used as an indicator of quality of patient care in an institution. In advanced countries, the value of

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this rate is about 4%. Excessive death rates of hospital should be investigated. VI. Anaesthesia Death Rate

Calculation Number of deaths due to anaesthesia Number of patients anaesthetized during a period

 5000

An anaesthesia death rate of more than 1 in 5000 calls for scrutiny of the staff, equipment and procedures in this department. VII. Postoperative Death Rate (POP Death Rate)

Calculation POP deaths (within 10 days after surgery) Total operations during a given period

× 100

The usual value of this rate is 1–2%. But it varies greatly with the type of surgery being undertaken in an institution. VIII. Maternal Death Rate

Calculation Total deaths of obstetric patients Total discharges (including deaths) of the obstetric patients

× 100

The usual value is less than 0.25%. Excessive rate should be enquired into. IX. Neonatal Death Rate

Calculation Total deaths of neonates during a given period Total viable newborns discharged (including deaths) during the same period

× 100

A neonatal death rate of more than 2% should be investigated. Beds and Death Rate

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An extensive study of vital statistics and hospital data of different areas has revealed that a close relationship exists between the deaths in a population and number of hospital beds needed. It has been found that 0.5 general beds are needed per annual death in a population of 100. In a population having 10 deaths per 1000, 5 beds per 1000 are needed in the acute general hospitals for optimum medical care. If total number of annual deaths in a region are 200, then this population needs 100 general beds. This formula is used extensively for planning medical care

facilities in a region. In India, current death rate is 6% per 1000, hence we need 3 beds per 1000 population but we have only 1.17 bed per 1000 population. In government sector, we have 8,18,396 beds and estimated beds in private sector are 7,86,302 which makes total bed strength of 16,04,698 for population of 1361 million.3 Only 36% all governmental hospital beds are available in rural areas as compared to 64% for urban population— a paradox.4 National Health Policy goal is to have 2 beds per 1000 population. There has been steady decline in utilization of public health facilities for inpatient care.

PREVENTIVE AND PROMOTIVE HEALTH SERVICES IN HOSPITALS Promotive and preventive health services in hospital set up, such as eduction on health for general public and waiting patients and their attendants in OPD/indoor, counselling on health and disease through various speciality clinics, ICTC, PPTCT, comprehensive immunization clinic, trauma centre (prevention of injuries and accidents), contraceptive services, family planning sterilization, adolescent friendly health clinics, clinics for non-communicable diseases and reproductive and child health services can be linked with referral stations (district, sub-district, CHC, PHC and sub-centre), homes and community for continuum of health services. Hospital data on morbidity and mortality (causes of death) can be most useful for planning of health services. Sentinel surveillance of diseases in hospital (malaria, dengue and chikungunya, STI, RTI, HIV, acute flaccid paralysis, vaccine preventable diseases, and epidemic prone and notifiable diseases can provide warning signal for early response and action. Geographical pathology can be mapped based on hospital morbidity. Hospitals can take responsibility for a defined geographical area for community-based services. Teaching hospitals produce human resources for health and provide referral support for specialist services/national health programme besides continuing education of human resources and support of laboratory services for validating the surveillance data. REFERENCES 1 NIHFW. Training Module for Medical Officers (PHC). New Delhi: NIHFW; 1987. 2 GOI. RCH II family planning programme implementation plan (PIP). New Delhi: Dept. of Family Welfare, MOH and FW; 2004. 3 GOI. National Health Profile 2018. CBHI, DGHS, MOH and FW—Nirman Bhavan, New Delhi. 4 Yadav K, Jarhyan P, Gupta V, Pandav. CS. Revitalizing Rural Healthcare Delivery: Can rural health practitioners be the answer? IJCM 2009, 34, 1 view point.

17 Healthcare of the Community “In community medicine, the patient is community, hence a need for community diagnosis and community therapy”

Competency addressed: The student should be able to: CM 17.1: Define and describe the concept of healthcare to community.

COMMUNITY DIAGNOSIS AND TREATMENT There are two objectives of community diagnosis

1 To determine the priority health needs of people and resources to meet these needs. 2 To elicit community participation.

CONCEPT OF COMMUNITY HEALTHCARE It was realized that medicine as a “social science” could not solve a health problem by treating and caring of sick individuals in the hospitals or dispensaries. The focus in the second half of the 20th century shifted to community and community diagnosis and treatment. The whole community should be the focus of health. Ensure health coverage to total community and meet the health needs of the “community” through universal health coverage. Accordingly, the approach to medicine shifted from treatment to care, coverage, reduction of incidence and disease burden and disability and “development of community” to achieve positive ‘health in all’. During the year 1952, India adopted a strategy and National Policy of all round community development through “Community Development Block”. This was a unique approach and unique movement wherein “health” was considered as a part and parcel of all round development. “Health” became an integral part of agriculture, industrial, social and human development. One Community Development Block (CDB) with population of 1,00,000 was considered as the smallest development unit for all round development including health. Competency addressed: The student should be able to: CM 17.2: Describe community diagnosis, IPHS and NHM.

Steps involved in community diagnosis include:

1 2 3 4 5 6 7 8 9

Listen to people—their chief complaints/demands Observation on community Investigations in community Tentative diagnosis Final diagnosis Treatment of community (therapy) Follow-up of community Evaluation of therapy Replanning of services.

1. LISTENING TO PEOPLE—THEIR CHIEF COMPLAINTS

Public health approach puts people first. Listen to demands expressed by elected local leaders of local self government, informal leaders, organized women groups, youth groups, elderly people, self help groups, and NGOs as also school teachers, ASHAs and AWWs. Regular contacts and dialogue with people are most essential to get their top of mind (feelings and felt needs) as also demands to assess their health needs. People identify their own health needs and priorities and work hard to meet these needs. The experts determine the real health needs based on scientific evidence. People express their felt health needs in the form of demands. It is always wise to begin with areas where there is an overlap of health demands (felt needs) expressed by people and real needs identified by the experts. In the second stage take those areas which are 703

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significantly determined by experts and left out by people through sustained education programme (Fig. 17.1). Generally people demand, water, roads, electricity, veterinary hospitals, schools and health comes as last priority. Felt needs

1

Needs felt by people (demands)

Overlap

2

Needs determined by both people and experts

Real needs

3

Needs determined by experts

Fig. 17.1: Felt needs and real needs

Listening can be organized in several ways such as by informal interviews, conversations, unstructured, semistructured, and structured interviews (questionaire); group and focused group discussions besides narratives and brain storming to capture information or data on community diagnosis. Brainstorming

Brainstorming is a technique used by small group of 6–8 persons to generate variety of ideas, to identify problems, theories for causes of problems, proposed remedies or obstacles to problem solutions. The list of ideas generated are processed by combining and grouping similar ideas. Brainstorming along with supportive data and review helps identifying threats and opportunities. 2. OBSERVATIONS ON COMMUNITY (DESCRIPTIVE EPIDEMIOLOGY)

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Observe: The geographical area to be covered, terrains, roads and accessibility of areas, the size of population to be served, number of villages, households and families, number of sub-centres health staff in position, resources available in terms of Village Health and Sanitation Committees, ASHAs, Anganwadi workers, schools, village Panchayat and their members, private practitioners, and NGOs. Rapidly assess the sanitary conditions, sources of drinking water, excreta disposal practices, health practices major occupations, leadership pattern, community organization, cropping pattern, health customs and practices and health seeking behaviour as also age and sex composition of population in terms of sex ratio, infants, preschool children, school age, adolescents, eligible couples, and elderly populations, etc. Always involve health workers and their supervisors in diagnosis of community. Observations provide direct evidence of the extent of health problems/needs of the area, these can be analysed and interpreted together with the chief complaints. Careful documentation of observed events/ health practices provide valuable cues as to what is actually

occurring. Participant observation is the best way to elicit their socio-cultural patterns, customs and health, nutrition, water and sanitation practices. Rapid rural appraisal and participant rural appraisal techniques can enrich the data or information collection for community diagnosis. These methods include direct observation, participant observations, and transact walk. 3. EXAMINATION OF COMMUNITY (ANALYTICAL EPIDEMIOLOGY)

Examination of community consists of examination of health service data, health records and reports of sub-centres, PHC as also surveillance data—such as number of pregnant women, births and deaths and diseases occurring in the area, causes of deaths, OPD records for common morbidities in the area, coverage of children for immunization and eligible couples for contraceptive services from integrated RMNCH + A register. Similarly, national health programmes data/ reports, their compilation, analysis and interpretation can provide a good lead for diagnosis of health needs of the people. Nutritional status can be assessed from records of growth charts, thus health and nutritional status can be assessed and the probable causes or risk factors or determinants of such status can be ascertained to a reasonable extent apart from core-health indicators—birth rate, death rate and CPR. 4. SURVEYS AND INVESTIGATION IN COMMUNITY

Annual household surveys and eligible couple surveys and their regular updates provide a wealth of information on number of beneficiaries and in which households these beneficiaries are located. Healthcare utilization can be worked out. Household survey data provides information on age and sex of all members, their marital status, literacy level, economic status (BPL and APL families), source of drinking water, use of sanitary latrines,—excreta disposal practices, and cooking fuel which forms the basis of health needs assessment of each and every household and community diagnosis. Household data help preparation of village register for village health action plan by village health and sanitation and nutrition committee (VHSNC). It also helps in identification of at risk households for priority health services. The other survey includes facility survey to discover gaps in resources as also meetings with health staff to corroborate the observations and the health problems faced by them in the field work. • Investigations consist of water samples testing for coliform count, stool examination, blood smear examination for malaria, dietary surveys, mass fever surveys, outbreak investigations, population-based screening of risk factors for non-communicable diseases, by point of care tests—sputum examination for TB and testing of salt samples for iodine content (by spot testing kits) and haemoglobin estimation.

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5. TENTATIVE DIAGNOSIS AND FINAL DIAGNOSIS

The information derived from chief complaints—listening to people, direct observations, examination of community, the tentative community diagnosis can be made to a reasonable extent. Tentative diagnosis can be changed to final diagnosis with the supportive evidence of investigations/facility survey and interviews and meetings. Comprehensive Community Diagnosis

Community diagnosis not only includes diagnosis of community illness but it must also include diagnosis of underlying cause/causes or determinants of presenting illness such as environments—water and sanitation, unhealthy behaviours, dietary practices, poor knowledge and lack of information, negative attitudes, poor hygienic practices, healthcare utilization, access to comprehensive primary healthcare, income/poverty, and illiteracy. As and when a patient from community comes to seek healthcare services from a designated health facility (government or private); the direct service providers diagnose illness based on the presenting clinical signs/ symptoms or by syndromic approach and with the support of laboratory tests. Direct service providers most often ignore the diagnosis of underlying cause/causes or determinants of presenting illness. Thus, the diagnosis most often is incomplete. The mindset and diagnosis practices must change for holistic diagnosis. The underlying cause/causes or determinants of illness must be part of patient diagnosis, and become universal practice as part of curriculum of UGs and PGs. Sick person can be classified as individual risk, e.g. NCDs, family risk, e.g. scabies worm and louse infestation and community risk such as TB, Covid-19, SARS, influenza, malaria, etc. (epidemic prone diseases) accordingly the therapy differs for individual, family and community. Example: Acute watery diarrhoea in children is an environmental related problem—infection comes from contaminated water, food, poor hand hygiene or poor nutrition or poor immunity status. The holistic diagnosis of diarrhoea should be: i. Diarrhoea: Related to environment factors—specify (poor hand hygiene, open defecation, unsafe water and food hygiene). The focus should be on identifying the source or exposure that caused diarrhoea and the number of other persons who may have been similarly exposed, the potential for further spread in the community and interventions to prevent additional cases or recurrence. ii. Malaria and dengue: Related to vector breeding and poor management of waste water, and solid waste, necessitating source control. iii. NCDs: Related to unhealthy lifestyles. iv. Road accidents: Related to behaviour of road users, high speed, non-use of helmet, seat belts and use of alcohol.

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6. COMMUNITY THERAPY (TREATMENT OF COMMUNITY/INTERVENTION EPIDEMIOLOGY)

Community therapy includes • Prescription or treatment of presenting illness to reduce disease incidence and mortality/disability • Treatment/prescription for determinants or underlying cause/causes of presenting illness. Doctors seldom prescribe treatment for underlying causes or determinants. Example in malaria we treat malaria—the disease. Community therapy—includes control of mosquitoes—elimination of breeding and personal protection by ITN. Intervention epidemiology/public health therapy includes treatment of determinants as well as treatment of presenting illness: a Treatment of environments—such as treatment of water and chlorination to provide safe water, safe disposal of human and animal excreta as also garbage treatment, solid waste disposal and waste water management. b Universal salt iodation to prevent IDD c Enhance community immunity by immunization. d Prevention of births, HIV and STDs/RTIs by use of condoms. e Organize health services for people. f Early diagnosis and complete treatment of diseases and determinants under national health programmes. g Health education and behaviour change communication adoption of healthy lifestyles. h Legislations for tobacco control, sex determination and helmet, seat belt use, etc. i Mass deworming and mass drug administration (MDA). Universal health coverage (UHC) must build on universal access to determinants of health such as safe drinking water and sanitation, wholesome nutrition, basic education, hygienic environments, safe housing. To aim at achieving UHC without ensuring access to determinants of health would be a strategic mistake and plainly unworkable. 7. FOLLOW-UP COMMUNITY

Follow-up of community in their homes or at clinic at subcentres and PHCs is essential to motivate people to continue the treatment or prophylaxis, to complete the immunization, space births at least 3 years apart, early breastfeeding and universal exclusive breastfeeding. Regular follow-up ensures regular contacts, development of trust, and increased utilization of services. Follow-up also ensures the progress of antenatal period, weight gain pattern of antenatals, growth of young children and corrective actions in case of growth failure and danger signs in pregnant women and neonates and young children.

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Regular home visits ensures follow-up of community as also it provides an opportunity to get feedback from people and to sustain behaviour change and drug adherence. 8. EVALUATION OF THERAPY OR INTERVENTIONS

The impact of intervention or services can be assessed by monitoring of activities through annual reports, annual household surveys and rapid methods of assessment by eliciting client satisfaction, reduction in malnutrition, birth rate, reduction in morbidity and mortality (infant mortality and maternal mortality) reduction of anaemia and malaria incidence, etc. 9. REPLANNING OF SERVICES

The results of evaluation can be fed back to the system to fill the gaps and improvement of organized health services. Community involvement is essential in community diagnosis and community therapy as also in replanning of health services.

NATIONAL RURAL HEALTH MISSION (NRHM), 2005–2012

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The National Rural Health Mission seeks to provide effective and affordable healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure.1 NRHM is a flagship programme of government of India. Under its umbrella it integrates all related and stand alone National Health Programmes in the health sector. Thrust areas under NRHM: ASHA, Village Health Sanitation and Nutrition Committees, strengthening of sub-centres, PHCs, CHCs, sub-district and district hospitals, untied grant at village, SC, PHC, CHC, besides annual maintenance grant, state and district health societies, community monitoring, essential drugs at SC, PHC, CHC, intersectoral convergence, mobile medical units and facility and household surveys, District Health Action Plan, etc. Aim: The NRHM aims to provide accessible, affordable, accountable quality healthcare through a functional public health system. It also seeks to reduce maternal mortality ratio, infant mortality rate and total fertility rate. The key features of NRHM include: Making the public health delivery system fully functional and accountable to the community, human resources management, community involvement, decentralization, rigorous monitoring and evaluation against Indian Public Health Standards, convergence of health and related programmes from village level upwards, innovations and flexible financing as also interventions for improving the health indicators.1

The NRHM represents a major departure from the past, in that central government health financing is now directed to the development of state health systems rather than being confined to a select number of national health programmes. NRHM provides a unique opportunity to states to build a partnership and carry out necessary reforms in health sector with more resources. District and State Programme Implementation Plans (PIPs) form the basis to suit the diverse needs of states and regions. NRHM has set a new standard of partnership with states where it is the state that determines what is needed to reform the public sector health system. The architectural corrections envisaged under NRHM are organized around five pillars each of which is made-up of a number of overlapping core strategies. NRHM—5 MAIN APPROACHES/PILLARS OF NRHM

a Increasing participation and ownership by the community (decentralization): This means transfer of funds, functions and functionaries to Panchayati Raj Institutions (PRIs). Further this is sought to be achieved through (i) an increased role for PRIs in the ASHA programme, (ii) village health sanitation and nutrition committee, (iii) constitution of Rogi Kalyan Samitis/ hospital development committee or users groups, (iv) district health society for decentralized district and village health planning with PRIs and people, and (v) community monitoring system and through a greater space for NGO participation. b Indian Public Health Standards (IPHS) 2006: Setting of standards and norms helps in monitoring and evaluation. The prescription of the IPHS marks one of the most important core strategies of the NRHM. Once the norms and standards are in place, the challenge lies in identifying facility wise gaps in infrastructure, human resources, equipment, drugs supplies and above all service outcomes. The facility survey identifies the gaps and funding is directed to closing the gaps so identified. IPHS have been adopted for sub-centres, primary health centres and community health centres and district hospitals in 2006 and revised in 2012, and further revised in 2022. c Improved programme management through capacity building: The core of this is professionalizing management by building up management and public health skills in the existing workforce, supplemented by inclusion of management personnel into the system (states/district programme manager, IT professionals and accounts professionals). Programme management units at state, district and block levels have been set up by engaging programme managers with MBA, qualification, chartered accountant and data entry operators for improved programme management—right from the national level, NRHM visualizes a sustained process of

Healthcare of the Community

capacity development of management of programme through, National Health System Resource Centre, and State Health System Resource Centre, who help as technical resource for capacity building in district planning process and improving service delivery in health sector. d Flexible financing: “The supply side financing” means government spends on health as being provider of health services, creates infrastructure and manpower and pays salaries to deliver services to people “free” of cost. In NRHM flexible financing is the hallmark so that service guarantee as spelled out in IPHS can be made available. The central strategy of this pillar is the provision of untied funds to every level—to the village health and sanitation committee, to the subcentre, to the PHC, to the CHC and district hospital. Even the strategy of providing resource envelope to each district and state which the district/state is to use against an approved plan that it develops is an unprecidented level of financial flexibility. Financial packages for demand side financing and various forms of risk pooling where money follows the patient are also major strategies declared by the NRHM. The Janani Suraksha Yojana is one major, almost overwhelming example of “demand side financing option” where the funding is to the user of services. The beneficiary is free to choose between private sector provider or public sector provider. e Innovations in human resources management for health sector: Contractual appointment route to immediately fill human resource gaps as well as ensuring availability of locally resident health staff/ workers, incentives to staff posted in difficult and underserved areas, multi-skilling of doctors and staff, mainstreaming and integration with AYUSH are examples of innovations that seeks to find new solutions to old problems for optimal use of human resources. Accreditation and developing public–private partnership in healthcare is yet another approach under NRHM. Expansion of technical and professional education and increasing access to weaker sections to such education is also a core strategy. Component (A): Accredited Social Health Activist (ASHA)—Community Health Volunteers

• Every village to have a native female accredited social health activist (ASHA) 25–45 years of age, educated up to 8th class; chosen by and accountable to village Panchayat to act as the interface between the community and the public health system.3 • ASHA would be trained women community health volunteer at village level for 1000 population. • Her work schedule is flexible. She works 3–4 hours per day on about 4–5 days a week.

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• She will be honorary volunteer, receiving performancebased compensation for promoting universal immunization, referral and escort services for RCH, construction of household toilets, and services for other national health programmes. • As a member secretary of VHSNC she will facilitate preparation and implementation of the village health action plan along with Anganwadi worker, ANM, and functionaries of other departments and self-help group members under the leadership of village Panchayat. • ASHA will take steps to create awareness and provide information to the community on determinants of health, such as nutrition, basic sanitation and hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilization of health and family welfare services. • She will counsel women on birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including reproductive tract infection/sexually transmitted infection (RTI/STI, HIV/AIDS) and care of the young children. • ASHA will mobilize the community and facilitate them in accessing health and health-related services available at the village/sub-centre/primary health centres such as immunization, antenatal check-up (ANC), postnatal check-up (PNC), family planning services, ICDS, sanitation and other services being provided by the Government on VHSN day once a month. • She will arrange escort/accompany pregnant women and children requiring treatment/admission to the nearest pre-identified health facility, i.e. primary health centre/community health center/first referral unit. She provides home-based newborn care (HBNC) by 6–7 home visits for newborn and postnatal care up to 42 days after delivery, besides Home based care for young child (HBCYC) by home contacts on first week of 4th, 7th, 10th, 13th and 16th month of age of child. • ASHA will provide primary medical care for most common ailments, such as diarrhoea, fevers, and first aid for minor injuries. She will be a provider of directly observed treatment short-course (DOTS) under national tuberculosis elimination programme. She will also act as a depot holder for essential provisions being made available to every habitation like oral rehydration therapy (ORT), iron folic acid tablets (IFA), disposable delivery kits (DDK), oral pills and condoms, etc. A drug kit has been provided to each ASHA. • She will record and report all births and deaths in her village and any unusual health problems/disease outbreaks in the community to the sub-centres/primary health centre. • Participation in National Filaria Day. • Identify the cases of skin patch with loss of sensation

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and bring them to the notice of health worker male/ females ensure that all the patients of leprosy are taking regular treatment. • Fulfillment of all these roles by ASHA is envisaged through continuous training and upgradation of her skills. Mobile Academy

It is free audio training course designed to expand and refresh knowledge base of ASHAs and improve their communication skills. It is any time any where training course via their mobile phones in 16 states of India. Component (B): District Health Action Plan (DHAP)

One of the core strategy of NRHM is preparation and implementation of an intersector District Health Action Plan by District Health Mission, including drinking water, sanitation, hygiene and nutrition, early childhood development, female literacy, women empowerment, etc. The District Health Action Plan would be the main instrument for planning, intersectoral convergence, implementation and monitoring of activities under NRHM. Rather than funds being allocated to the states for implementing programmes designed and approved by the Government of India level the states have been encouraged to prepare their perspective and annual plans which in turn would be based on the district plans. Household and facility survey should provide basis for mapping diversity and defining baseline, periodic surveys would thereafter be taken up on annual basis to track the improvements in the facility as well as improvements in the health indicators. Village health register is a tool for planning regarding all incidents and people’s health needs round the year. Village health plans, reflecting local health needs have to be aggregated at Gram Panchayat, cluster and block levels to ultimately feed into district health plan. Component (C): Convergence or Synergies with other Departments

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Convergence means working together or coming together or coordinating two or more sectors to produce a combined effect greater than the sum of their separate effects. The indicators of health depend as much on drinking water, sanitation, nutrition, female literacy, early childhood development, women empowerment, etc. as they do on hospitals and functional health systems. Realizing the importance of wider determinants of health, NRHM seeks to adopt a convergent approach for intervention under the umbrella of district plan. The Anganwadi centre under ICDS and school system at the village level will be the principal hubs for health action. Likewise, wherever village committees have been effectively constituted for drinking

water, sanitation, ICDS, etc. NRHM will attempt to move towards one common village health and sanitation committee covering all these activities. Panchayati Raj Institutions will be fully involved in this convergent approach to coordinate various functions and functionaries at the village level (ICDS, education, agriculture rural development, and self-help groups). Village action plan and district action plan will be major instruments for intersectoral convergence actions. Component (D): Strengthening Disease Control Programmes

i Integrated disease surveillance programme for CCDs and NCDs. ii Supply of essential medicines at SC, PHC and CHC. iii Mobile medical unit at district level. Component (E): People Public–Private Partnership (PPPP) for Public Health Goals

The non-governmental health sectors account for nearly 70% of health expenditure in India. In the absence of effective public health system majority of the households seek healthcare from non-governmental sector. A variety of partnerships are being pursued under the existing programmes of the Ministry, especially the RCH II and independently by the states with their own resources. Contracting is the predominant model of PPPP in India. Under this system states are trying contract in, contract out, outsourcing, management of hospital facilities by leading NGOs, hiring staff, service delivery, including family planning services, MTP, treatment of STI/RTI, etc.

NATIONAL HEALTH MISSION (NHM) • The NHM is the primary vehicle to move towards universal health coverage. It has two sub-missions— National Rural Health Mission and National Urban Health Mission. To address health needs of the urban poor, mission document on National Urban Health Mission has been approved in January 2008. Theme of World Health Day 2010 “Urban Health Matters” is a strong advocacy for urban health. After the success of the NRHM, the nation now wants to expand the scope of health services in towns also (for urban poor in urban areas). The NRHM has been reorganized in 2013 into National Health Mission, which would cover all villages and towns in the country. The NHM now extends all over the country both in urban and rural areas and promotes universal access to continuum of cashless health services from primary to tertiary care. Services will be delivered with seamless integration between primary, secondary and tertiary levels of care. The

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gains of the flagship programme of NRHM will be strengthened under the umbrella of NHM which will have universal coverage. The focus or thrust on covering rural areas and rural population will continue. • 12th Plan envisaged increase in public spending on core health from 1.04% of GDP in 2011–12 to 1.87% of GDP by the end of 12th Plan with 70% of the budget to be spent for primary healthcare (HLEG). Principle source of financing would be general tax revenues, supplemented by partnership with private sector and contribution by corporate as a part of their Corporate Social Responsibility (CSR). The NHM incorporates the following core principles: Universal Health Coverage, achieving quality standards by adopting revised Indian Public Health Standards, Continuum of Care by networking of institutions like Medical Colleges, District Hospitals, CHC, PHC and SCs linked with each other, decentralized planning at District, Block, CHC, PHC and Village. The main programmatic components of NHM include—Health system strengthening of rural and urban areas for RMNCH and adolescent health (RMNCH + A), communicable and non-communicable diseases. It will focus on Dedicated Public Health Cadre in States. UnHC must build on universal access to services related to determinants of health safe water, sanitation, nutrition, eduction and gender equality. To aim at achieving UnHC without ensuring access to determinants of health would be a strategic mistake. Universal Health Coverage 2

Rolling out Universal Health Coverage (UnHC)—a new strategy. 12th Plan strives to establish system of UnHC over the next two plans periods which will “ensure equitable access for all Indian citizens in any part of the country, regardless of income level, social status, gender, caste or religion to affordable, accountable and appropriate, assured quality health services (promotive, preventive, curative and rehabilitative) as well as services addressing wider determinants (water, sanitation, nutrition and education) of health delivered to individuals and population with the government being guarantor and enabler, although not necessarily the only provider of health and related services”. • Critical components of UnHC include—coverage, capacity building, continuum of services, convergence, community involvement, communication for behaviour change, comprehensiveness, client satisfaction, besides quality of services. UNIVERSAL HEALTH COVERAGE (UnHC) MODEL

Universal health coverage (UnHC) entails three dimensions (Fig. 17.2): a. Breadth: It means 1412 million population need to be covered. Address health needs of whole population

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Fig. 17.2: Attaining universal coverage (Source: WHO, 2009)

with priority to poor/vulnerables by targeting mechanism. b. Depth: Service packages—promotive, preventive, curative and rehabilitative or primary, secondary and tertiary levels of care or public health services and personal health services (clinical services). c. Height: Direct cost: Proportion of costs covered or costs sharing mechanisms. Development of risk pooling mechanism to protect all from the impoverishment effect of healthcare (social insurance). Ayushman Bharat—National Health Protection Mission provides protection to 100 million BPL families; ` 5 lakh per family per annum. Raising public health expenditure on health from 1.28 to 2.5% of GDP by the end of 2030. National Health Policy and UnHC3

National Health Policy 2017 assures availability of free comprehensive primary healthcare (CPHC) services, for all aspects of reproductive, maternal child and adolescent health, and for most prevalent communicable and non-communicable and occupational diseases in the population. The policy envisages that every family would have health card that links them to primary healthcare facility and eligible for a defined package of services anywhere in the country. To provide comprehensive healthcare the policy recommends a matching human resources development strategy, effective logistics support system and referral back up. This would also necessitate upgradation of existing sub-centres to “health and wellness centres” and reorienting primary health centres to provide comprehensive set of preventive, promotive, curative and rehabilitation services. Every family will have access to doctor of his choice. • The secondary and tertiary care will be made accessible and affordable by strategic purchase mechanism from public and private set-up. • Reduction of catastrophic health expenditure and significant reduction of OOP expenditure.

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• Health centres will be established on geographical norms apart from population norms. Ayushman Bharat (AB) with its two inter-related Components of AB Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojna (PM-JAY) represents a paradigm shift towards India’s Path to Universal Health Coverage (UnHC). While PM-JAY is the largest health protection scheme in the world which caters to BPL and certain other categories of Indian population for Secondary and Tertiary care hospitalization. The ABHWCs are envisaged to deliver an expanded range of 12 comprehensive Primary Healthcare Services (that includes preventive, promotive, curative, palliative and rehabilitative services, which are universal free and closer to community) which address the basic primary healthcare needs to the entire population in their areas. The two combined expand access, universality and equity in healthcare service delivery in the country. The revised IPHS 2022 define the norms for public health facilities to set benchmark towards achieving goal of universal health coverage in India.

Principles of Primary Healthcare

1 Equitable distribution of health services to all sections with priority to weaker sections. Achieve equity between rural–urban, rich–poor and gender—male and female. 2 Active community participation: People must be part of planning, programming, implementation, management and evaluation of health services. 3 Multi-sectoral approach: Health is not only the function of health sector alone but much more health comes through many other sectors like water supply and sanitation, literacy and education, nutrition and agricultural development, etc. hence health is a multisectoral subject. 4 Appropriate scientifically sound technology: Which is socially acceptable and directed against relevant health problem, e.g. growth monitoring, ORS, breastfeeding, immunization, family planning, female literacy and food supplements—vitamin A, iodized salt and IFA (GOBIFFF as advocated by UNICEF). Basic Components/Elements of Primary Healthcare

Competency addressed: The student should be able to: CM 17.3: Describe primary healthcare, its principles and components.

PRIMARY HEALTHCARE, ITS PRINCIPLES AND COMPONENTS (ELEMENTS)

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“Primary healthcare is an essential healthcare, based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community, through their full participation and at a cost that the community and the country can afford ....”. It forms an integral part both of country’s health system of which it is the central function and main focus and of overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing healthcare as close as possible to where people live and work and constitutes the first element of a continuing healthcare process. Thus, primary healthcare is not an inferior healthcare. It is based on sound scientific methods. The hallmarks of PHC are universal availability, accessibility, acceptability and affordability and community participation. Primary healthcare addresses the main health problems in the community providing promotive, preventive, curative and rehabilitative services. Accordingly, it attempts to intervene at all levels of the natural history of disease. India has played a leading role in planning and establishing primary healthcare system in the country ever since health survey and development committee (Bhore Committee) submitted its report in 1943–1946.

The PHC gives primacy to following essential elements: i Education concerning prevailing health problems and the methods of preventing and controlling them. ii Promotion of food supply and adequate nutrition. iii An adequate supply of safe water and basic sanitation. iv Maternal and child healthcare including family planning. v Immunization against the major infectious diseases. vi Prevention and control of locally endemic diseases. vii Appropriate treatment of common diseases and injuries. viii Provision of essential drugs. It reflects clearly that goal of Health for All is to be achieved through 8 components, which belong to not just one sector but to many inter-related sectors, and sectors other than health sector. It necessitates achieving inter- and intra-sectoral coordination. Health cannot be attained by health sector alone. Supportive Activities for Primary Healthcare

These include following in order to successfully implement primary healthcare. WHO has identified the following supportive activities: 1 Community involvement and participation. 2 Intra- and inter-sectoral coordination. 3 Provision of effective referral support. 4 Development and mobilization of resources. 5 Managerial processes (policy, goals and objectives). 6 Medical and health services research, including innovative approaches. 7 Development and application of appropriate technology 8 Health manpower development.

Healthcare of the Community

India had a rich experience in the field of primary healthcare and has been a world leader in developing primary healthcare strategies. Most significant strategy was to initiate movement of community development since 1952 onward of which health was an integral part. India established network of primary health centres in rural areas one in each of the smallest administrative unit, i.e. community development block of 1,00,000 population. The global strategy of health for all was formulated in 1981 and global targets were set. Despite many benefits of primary healthcare, its implementation suffered from unfavourable economic conditions. Many developing countries could not provide healthcare, safe water and sanitation and adequate food and nutrition. Selective Primary Healthcare

It is an interim strategy for disease control in developing countries. • It targets/focuses on most important problems or causes of morbidity or mortality such as pneumonia, diarrhoea, in children leading to high mortality. Child survival and safe motherhood (CSSM) programme and GOBI FFF are examples of selective primary healthcare models. • Selective primary healthcare is more feasible than primary healthcare. • Selective PHC model uses appropriate technologies such as use of ORS and immunization to achieve high coverage and impacts on reduction of mortality. Comprehensive Primary Healthcare (CPHC)

Comprehensive primary healthcare is similar to primary healthcare approach as adopted in 1978 after Alma-ata declaration to achieve health for all. Comprehensive primary healthcare follows a “life cycle approach” covering all phases of life. It includes the delivery of a packages of preventive, promotive, curative and rehabilitative services delivered close to communities. Healthcare providers who are sensitive, have an understanding of local health needs, cultural traditions and socio-economic realities, and are able to provide care for most common ailments, enable referral for doctor or specialist consultations and can undertake follow-up. Examples of CPHC–RMNCH + A, IMNCI, etc. Service Delivery System (Modes) of CPHC

i Household/family/community-based services by regular home visits by ASHAs and AWWs. ii Outreach services/outpatient—by ANMs. iii Facility based services—at SC, PHC, CHC and hospitals. Background

National Health Mission focused on selective primary healthcare interventions, targeting RCH, communicable

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diseases, and national health programmes interventions. These interventions led to improvements in key indicators related to RCH and select communicable diseases. Noncommunicable diseases were not covered under NHM. NCDs account for 62% total deaths in India. Low utilization of public health facilities were obvious as only 32% of rural and 26% of urban population sought healthcare in public sector. Private sector remains the major provider of health services in the country and caters to 70 and 60% of outpatient and inpatient care, respectively. Catastrophic health expenditure is pushing 63 million people below poverty line per annum (NSSO 75th Round). Comprehensive Healthcare through Health and Wellness Centres 4 (HWCs)

Health and wellness centre (HWC) is a key component of the Ayushman Bharat—PMJAY; which is a flagship programme of the government of India. HWCs are envisaged to provide comprehensive primary healthcare (CPHC); comprising a package of 12 services. In order to ensure delivery of CPHC services closer to people the existing sub health centers covering a population of 3000 in tribal and 5000 in rural areas are being transformed to Health and Wellness Centres (HWC), with the principle being “time to care” no more than 30 minutes of travel. Similarly, primary health centres in rural and urban health centres in urban areas are also being transformed to HWCs in phased manner. Comprehensive Primary Healthcare Package of 12 Services at HWC5—see Page 718

Inputs for Health and Wellness Centres Key Inputs Provided at a HWC are as under

a. At the upgraded SHC At sub-centre level, HWC team will consist of ASHAs, ANMs led by mid-level service provider (BAMS physician/BSc nurse). A key addition to the primary healthcare team at the SHC–HWC, would be: A Mid-level Health Provider (MLHP) who would be a community health officer (CHO)—a BSc in community health or a nurse GNM with BSc or an Ayurveda practitioner trained and certified in a six months certificate programme in community health through IGNOU/other state public health universities for a set of competencies in delivering public health and primary healthcare services. ` 7 lakh per HWC is provided for repairs/renovation of existing sub-centre for transformation all HWCs should have branding as per GoI guidelines and national ID number. b. At PHC level (rural and urban) HWC team will consist of staff as per IPHS norms led by existing medical officer I/C. Other inputs are access to technologies, essential medicines, vaccines, diagnostics,

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sufficient space, tablets/smart phones, referral support system, capacity building, community mobilizations and intersectoral convergence to support delivery of expanded range of services. Outputs of HWCs (Service Utilization)

i HWC data base—population enumeration and empanelment and maintenance of database of all families and individuals by HWCs. ii Individual Health Records and Family Health folders for service users to ensure access to healthcare entitlement. iii Increase access to services—access to expanded range of services. Improved utilization of services: Percentage of antenatals registered, antenatal provided 4 ANC, 180 IFA tablets, institutional deliveries. No. of infants immunized, couples protected with contraceptives, persons screened for hypertension and diabetes, persons utilizing government services/private services, OPD attendance, indoor admissions. Quality of services: Percentages of children correctly weighed, per abdomen examination and blood pressure measured as per standards. Recently National Quality Assurance Standards for HWC—SHC were launched to ensure the provision of 12 packages of services. Outcomes of HWC (Coverage Indicators)

1 Improved coverage of population or population subgroups, e.g. • Proportion of eligible couples using contraceptives. • Proportion of fully immunized infants. • Proportion of completed immunization. • Proportion of mothers who initiated breastfeeding within one hour of birth. • Percentage of households using sanitary latrines. • Percentage of households using improved source of drinking water. 2 Reduced out of pocket and catastrophic health expenditure. 3 Decongestion of secondary and tertiary health facilities. 4 Risk factors mitigation. Impact of HWCs

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Improved population health indicators in term of reduction in disease incidence, prevalence, reduction in mortality, improved contraception rate, improved nutrition, improved RCH services, etc. Impact data is gathered by routine monthly monitoring reports or by periodical surveys such as coverage evaluation surveys, National Family Health Survey, etc.

Competency addressed: The student should be able to: CM 17.5: Describe healthcare delivery systems in India.

HEALTHCARE DELIVERY SYSTEMS IN INDIA “Health” in India is the responsibility of state government. Under the constitution, state government is responsible to provide health services to its people (population). Article 21 of the constitution requires the state to ensure the health and nutritional well-being of all people. The role of central government is to give financial support to states to implement national health programmes including reproductive and child health programme. Broad policies on health and population are laid by the central government, which are adopted by the state governments for implementation. It is the state health infrastructure, which translates the policy into actions at various levels. The healthcare delivery systems in India comprise mix of public and private providers of health services. VARIOUS HEALTHCARE SYSTEMS

1 Government run services and municipal health services (municipal corporation) in urban areas. 2 Private health sector. 3 Industrial organizations, corporate sector, Employees State Insurance (ESI) Scheme–Health Insurance. 4 Central Government Health Services (CGHS) Scheme. 5 Railway health services. 6 Armed forces health services. 7 Indian system of medicine (AYUSH). 8 Non-governmental organizations (NGOs) and philanthropic organizations (charitable).

PRIMARY HEALTHCARE SYSTEM IN RURAL AREAS HEALTHCARE OF THE COMMUNITY

The primary healthcare system infrastructure has been developed as a three-tier system (consisting of sub-centre, primary health centre, and community health centre (non FRU) being the three Pillars of Primary Healthcare System) based on the population norms. The norms for tribal areas are different (Table 17.1). Nearly 66% of population of India lives in rural areas. Healthcare of rural India has been reorganized ever since the launch of National Health Policy, 1983. The primary healthcare has been universalized in the country to realize the goal of health for all in India. Over the years, India has established the vast public health infrastructure in the country which includes 161829 rural and urban sub-centres, 31053 rural and urban primary health centres and 6064

Healthcare of the Community Table 17.1: Three tier system of primary healthcare organization* Level

Population norms

Village

Sub-centre

1000

5000

PHC

30,000

CHC

1,20,000

Functionaries • Health volunteers or health guides (female) • Anganwadi workers • Trained birth attendants • Accredited social health activist (ASHA) Multipurpose health workers (male and female) Health professionals (doctors) Specialists

* People themselves are the biggest resource of health organization.

community health centres to provide health services to 66% of the country’s population living in rural areas. The primary healthcare organization at various levels is depicted in Table 17.1. PRIMARY HEALTHCARE ORGANIZATION At Village Level—Village Health Sanitation and Nutrition Committee (VHSNC)

At village level, we have trained birth attendants, Anganwadi workers and health volunteers (village health guide) at the rate of 1:1000 population and now accredited social health activist (ASHA) has been introduced by National Rural Health Mission (NRHM). A village health sanitation and nutrition committee (VHSNC) (consisting of PRIs, ANM, AWW, ASHA, teacher and NGOs) has been constituted under NRHM for village health action plan and its implementation with untied money of `10,000 per annum. Over 5.55 lakh village health and sanitation committees have been established. Village Health Nutrition and Sanitation Day is organized every month at the Anganwadi centre in each village for RMNCH + A (reproductive maternal, newborn, child health and adolescent) services and for convergent actions on determinants of health. VHSNC monitors the services provided by AWW, ASHA and Sub-centre. Anganwadi Workers (AWWs)

Anganwadi workers are honorary village-based locally resident workers under Integrated Child Development Services (ICDS) Scheme, chosen by village people. One AWW works for 400–800 population in plain area and for 300–800 in tribal and difficult areas. AWW guides ASHA in organizing health day at Anganwadi once a month and other activities at village level. Mahila Swasthya Sangh (MSS), Mahila Arogya Samiti (MAS) and ASHAs

At present, 79, 512 MSS are working at village level. ASHAs (accredited social health activists) at village

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level (one per 1000 population) have been introduced under NHM. Over 10.72 lakh ASHAs are currently working. REVISED INDIAN PUBLIC HEALTH STANDARDS (IPHS)6 2022

Indian Public Health Standards for various government health facilities were released in 2006 after the launch of NRHM and revised in 2012. Since the last revision of IPHS in 2012 a number of new initiatives, interventions and programmes have come up. The introduction of Comprehensive Primary Healthcare through upgraded subhealth centres and PHCs (now known as Health and Wellness Centres) and similarly in urban areas Urban Health and Wellness Centres, speciality Urban PHCs, (Polyclinics) and universal screening of Non Communicable diseases are some of the new additions. Since then seven key policy shifts (see page 667) under National Health Policy 2017 for public healthcare delivery system were launched. Objectives of IPHS

1 To define a uniform standard to ensure high quality services. 2 To specify the minimum assured (Essential) and achievable (Desired) services to be provided at different levels of government health facilities—at SC, PHC, CHC, sub dist and district 3 To specify adequate workspace (buildings), human resources, for health, drugs, diagnostics, equipment, administrative and logistical support to deliver services for expected outcomes 4 To achieve and maintain acceptable quality of care. 5 To facilitate monitoring and supervision of health facilities. 6 A tool for governance, leadership and evaluation. Once the norms and standard are in place, the challenge lies in identifying facility wise gaps in infrastructure, human resources, equipment, drugs, supplies and above all service outcomes. IPHS now specify what essential services would be delivered, what physical infrastructure and health manpower, equipment and essential drugs are needed to provide services. IPHS now lays down performance standards for health facilities and healthcare providers.

PRIMARY HEALTHCARE IN RURAL AND URBAN AREAS In government sector in India the delivery of health services follows three-tier structure of Primary, Secondary and Tertiary healthcare services in rural and urban areas. Primary healthcare services in rural areas have been well structured and well organized and are provided through sub-health centres and Primary Health Centres.

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Primary healthcare services in urban slums and urban vulnerable population were not well organized. Under National Urban Health Mission, Launched in 2013 the Urban Health Centres and Urban Community Healthcentres were set up for providing primary healthcare in urban areas.

SUB-HEALTH CENTRES IN RURAL AREAS

Essential Health Services Provided at SHC

• Reproductive maternal newborn child and adolescent health and family planning services • Services for all national health programmes of communicable and non-communicable diseases besides IEC and BCC services • Basic curative services for common diseases free of cost • Free diagnostics and essential drugs • Disease surveillance under/DSP and recognition of outbreaks at incipient stage and first response to outbreak. • Recording and reporting of births, deaths and causes of death statistics.

Over the years the sub-health centres (SHC) established in rural areas have served the needs of rural community. Since the launch of NRHM in 2005 services of SHCs have been upgraded. The sub-health centre (SHC) is the most vital Peripheral and first contact point between the primary healthcare system and the community. It is the first formal ladder of Primary healthcare and forms the base of health system pyramid. It serves a rural population of 5000 in plain and 3000 in tribal, hilly and desert area. SHC is manned by health workers female and male. It provides Primary healthcare services mostly preventive and promotive and basic level of curative services. The Ministry of Health and Family Welfare—Government of India provides 100% central assistance to all the SHCs in the country. Government of India bears the salary of female health workers (ANMs) and LHVs besides rent liability and contingency as also drugs and equipment, whereas salary of male health workers is borne by the state government. As on 31st March 2022 there were 157935 SHCs functional is the country.

Desirable Services

Strengthening of SHCs

Supervision and Support

The SHCs were strengthened under National Health Mission for construction of building, providing one additional Auxiliary Nurse Midwife (ANM) on contractual basis and untied funds of Rs. 10,000. Additional SHCs were set up to meet the population norms. The SHCs were further strengthened under Prime Minister Ayushman Bharat Health Intrastructure Mission (PM-ABHIM) and 15th Finance Commission (FC-XV) for their upgradation to Health and Wellness Centres (HWCs).

The sub-health centre health workers are periodically supervised by Health Assistant Female (LHV) and Health Assistant Male. One supervisor provides supportive supervision to 6 SHCs. Major role of supervisor is to ensure supplies—vaccines, drugs, contraceptives equipment and helping health team at SHC to plan and implement efficient work schedule and on the job continued education and training as also preparation of SHC annual health action plan. Medical officer is also required to supervise the SHC at least once a month.

Services at SHCs

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desirable. One of the two ANM must stay at subcentre to provide services and they should divide the 5000 population of subcentre among themselves to provide outreach services and effective coverage of population.

SHCs continued to provide mainly promotive, preventive and limited basic curative services. Over the years emphasis remained on providing selective primary healthcare in the areas of Reproductive Maternal Newborn and Child Health Services, Family Planning, Management of communicable diseases and services related to various National Health Programmes. The SHC provides services at subsentre clinic or by its outreach activity in the community of 5000 population spread over in several villages. Minimum of 6 hours of routine subcentre OPD clinic by ANM per day is

• Provide AYUSH treatment as per guidelines • Disinfection of drinking water sources and promotion of sanitary latrines Referral Services

SHC refers the patients to its attached primary health centre or community Health Centre for diagnostics and initiation of treatment as also for institutional deliveries and MTPs, apart from patients requiring emergency services after providing initial first aid services at SHC.

Work Plan at SHC

Annual SHC plan is prepared to meet health services needs of population. The SHC team prepares (health worker female and male along with ASHAs and AWWs) their fixed work schedule for covering the total population for envisaged services. This schedule is known to the community and the supervisors. Service Utilization

Over 95% of people used preventive and promotive health services provided free of cost by the government (public sector).

Healthcare of the Community

These services included immunizations, maternal and child health services (Delivery Services) and health education and information. Despite a steady increase in number of SHCs and strengthening of subcentres the utilization of government health facilities by people for outpatient and inpatient care has not improved. Healthcare utilization is predominantly through private sector for curative services and government sector for preventive services. Over 70% of people turn to private sector for outpatient ambulatory care and 58% for hospitalization or inpatient care (NSS 75th Round). In view of selective primary healthcare provided by SHCs these SHCs are being restructured and reorganized as Health the Wellness Centres (HWCs) to provide comprehensive primary healthcare (CPHC).

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Population Norms for Health and Wellness Centres

i HWC-SHC (rural): In rural areas, one Sub Health Centre is established for every 5000 population in plain areas and 3000 population in hilly/tribal/desert areas. ii UHWC (Urban): In urban areas one Urban-HWC per 15,000–20,000 population caters predominantly to poor and vulnerable populations, residing in slums or other such pockets (Table 17.2). Table 17.2: Population norms for HWC-SHC/UHWC S. No. Type of facility

Plain area (population)

Hilly/Tribal area (population)

1.

HWC-SHC

5000

3000

2.

UHWC

15,000–20,000

–

HEALTH AND WELLNESS CENTRES

Comprehensive primary healthcare (CPHC) through Ayushman Bharat Health and Wellness Centres (HWCs)– were launched in 2018. Ayushman Bharat (AB) makes a paradigm shift to move from sectoral and selective primary healthcare to comprehensive range of healthcare services. It covers prevention, promotion and ambulatory healthcare at primary, secondary and tertiary level by adopting a ‘life cycle’ or continuum of care approach through different phases of life. (adolescence, pregnancy, birth, infancy, preschool, school, reproductive, adult and ageing). It has two components. The first component of AB pertains to transforming/upgradation of all existing 150,000 SubHealth Centres and all PHCs into HWCs. All SHC-HWCs have branding as per GoI guidelines and national ID number and renovated buildings. Nearly 1.1 lakh SubHealth Centres have been transformed to AB—Health and Wellness Centres by March 2022 and all remaining SHCs are to be upgraded as HWCs by Dec. 2022. The second component of AB is PM-JAY which is the largest health protection scheme the world over for poor. Types and Categories of Health and Wellness Centres

The revised Indian Public Health Standards 2022 Classify the Health and Wellness Centre into two types: a Health and Wellness Centre—Sub-Health Centre in rural area (HWC-SHC) b Health and Wellness Centre in Urban area (UHWC)

Human Resources for Health

In rural areas, Health and Wellness Centre-Sub-Health Centre has been provided with Community Health Officer (CHO) as the leader of health team-consisting of Auxiliary Nurse Midwife (ANM) and a multipurpose health worker (MPHW male) or two ANMs, along with support staff (Table 17.3). In urban HWC the health team is lead by medical officer as shown in Table 17.4. Urban Health and Wellness Centres (UHWC)

National Urban Health Mission (NUHM) was launched in 2013 with the aim to provide affordable primary healthcare through urban PHCs, Urban CHCs and outreach services to the urban slum population in India. Now Based on the learning from management of COVID-19 Pandemic, which has affected urban areas disproportionally a Paradigm shift in Urban Primary Healthcare is envisaged. As a part of this shift, Universal Comprehensive Primary Healthcare is planned to be provided through Urban Health and Wellness Centres (UHWC) and Polyclinics. Urban Health and Wellness Centres (UHWC) have been planned with population norm of 15000 to 20000 for each UHWC. It enables robust decentralized delivery of basic Primary Healthcare services closer to people in urban slums. In the Public Health Sector the Health and Wellness Centres—SHCs and Urban Health and Wellness Centres are the first point of contact between the Primary Healthcare system and the Community in rural and urban

Table 17.3: Human Resources at rural HWC-SHC as per IPHS 2022 S. No.

Human resources

Number

1.

Community health officer (CHO) or Mid Level Health Provider

1

2.

Multipurpose health workers one male + one female

2

3.

AHSA @ 1 per 1000 population

5

Beds

Minimum performance standards

2 Day care beds with oxygen support

OPD = 20 patients per day

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Table 17.4: Human Resources at Urban Health and Wellness Centre (UHWC) as per IPHS 2022 S. No.

Human resources

Number

Beds

Minimum performance standards

1.

Medical officer

1

2 Day care beds

OPD 75 patient per day by MO

2.

Staff nurse/pharmacist

1

with oxygen delivery

• Clinical, emergency and other

3.

Male multipurpose worker

1

• B Type (1500 L to oxygen

4.

ANM—one per 10000 Pop*

1–2

capacity cylinder 3)

5.

ASHA one per 2000 Pop*

5–8

• Oxygen concentrator

6.

Sanitary staff

1

7.

Security staff

1

10 LPM – 1

duties. Supervision of public health and health programmes related activities • 120 Dispensions of prescriptions per day by pharmacist

* ANM and ASHA responsible for catchment area of a UPHC will be drawn from HWC—UPHC/UCHE

areas respectively. These health facilities act as an interface with the community at the grass root level, providing basic primary healthcare services/packages. Purpose: The purpose of Rural HWC–SHCs and UHWCs is largely preventive and promotive, but they provide a basic level of curative services as well. The FC-XV proposes to provide support for setting up of Urban HWCs in close collaboration with urban local bodies with human resources as per Table 17.4. The HWC would deliver expanded range of packages of services. The urban HWC should be located preferably within 1 kilometer radius of under-served population in urban slums accessible to people within 30 minutes of reach. It can function in rented building or building constructed or renovated by Government or at Government Health facility. The Urban-HWC would be the first port of call for residents in urban areas. It would be linked to the UPHCHWC for administrative financial, reporting, supervisory and referral purposes. Key Delivery Modes for CPHC Services (Fig. 17.3)

1 Care at family, household and community level by ASHAs, AWWs and ANMs by regular home visits and sustained community contacts with VHSNC/UHSNC and target groups for health promotion and prevention of disease by promoting healthy behaviours/life styles. • Outreach services—by ANMs and Health Workers who offer standardized treatment/interventions by organizing VHSNDs/UHSNDs once a month. 2 At facility level—Health and Wellness Centres

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3 At first referral level—at PHC, CHC and secondary referral at FRU, Sub-district and District HospitalPhysically or through teleconsultation. SERVICE PROVISION

The healthcare services to be provided at these Centres include: health promotion, early identification, ensuring treatment adherence, follow-up care, ensuring continuity of care by appropriate referrals, optimal home and community follow-up, disease surveillance and health promotion and prevention for the expanded range of Comprehensive Primary Healthcare (CPHC) services. HWC also conducts screening programme for NCDs and chronic CCDs, hold camps and special health drives, outbreak investigations and first response to epidemic/pandemic and awareness generation besides community participation. • Health and wellness centres mainly provide promotive and preventive services and basic or limited curative services. They provide standardized treatment. Besides providing reproductive, family planning, maternal, newborn, child and adolescent health services and services for various national disease programmes, HWCs now carry out population based screening cum eduction and awareness generation for most common non communicable diseases, to identify risk factors and early detection. All men and women age group 30 to 65 years are screened for hypertension, diabetes, obesity once a year and for common cancers—breast, oral and cervix once in 5 years. Screening for NCDs is now integral part of comprehensive primary healthcare.

Fig. 17.3: Key delivery modes of comprehensive primary healthcare services

Healthcare of the Community

Health team at HWC follows up all confirmed cases of diabetes and hypertension every month for treatment adherence and life style management to promote wellness and health behaviours—eating RIGHT and SAFE, physical activity, yoga sessions and meditation, tobacco cessation and no alcohol use are regular activities at HWCs. Screening for blindness, anaemia and chronic communicable diseases such as leprosy, TB, filara, HIV is also being done. About 14 diagnostic tests/point of care tests for Hb, urine test, malaria, dengue, blood sugar, HIV, syphilis, hepatitis B, iodine in salt, water samples, sputum for TB, filaria, sickle cell rapid tests are done free of cost. Essential medicine list of 105 medicines is there for each HWC. • In addition to providing basic clinical services, HWCs are also to be utilized as a platform for teleconsultation and expanding the range of diagnostics. All the 1,50,000 Health and Wellness Centres are connected for providing consultation of specialist and superspecialist services. • The services to be provided at both types of facilities are identified as ‘essential’ and ‘desirable’. The former includes those ‘minimum assured services’ that every facility at that level must provide. ‘Desirable services’ are those that a facility should aspire to ultimately achieve (if not already being provided) over a period of time depending on the needs of community. Thus, desirable services will be over and above the essential services. • Collaboration with other sectors have also been identified and listed for certain services such as nutritional support with the WCD department, school health with the education department and vector control activities with the ULBs/PRIs. Telemedicine eSanjeevani National Telemedicine Services

There are two variants of eSanjeevani telemedicine service: i eSanjeevani AB-HWC (Doctor to Doctor teleconsultation) over 1.5 lakh HWCs in the country are being connected for Tele-medicine consultation service of specialists and superspecialists. ii eSanjeevani OPD (Patient to Doctor teleconsultation): In the Wake of COVID-19 pandemic MOHFW upgraded eSanjeevani application to enable patient to doctor tele-consultation to ensure continuum of care and facilitate health services to all citizens in the confines of their homes free of cost.

HEALTH AND WELLNESS CENTRE PRIMARY HEALTH CENTRE (PHC) RURAL Health survey and development committee popularly known as Bhore committee gave the concept of primary health centre (PHC) way back in 1946. One PHC was recommended for 40,000 rural population in short-term

717

perspective and for 10,000 to 20,000 population in the long run. PHCs were designed to provide comprehensive primary healthcare—including promotive, preventive and curative health services to rural population. Now each PHC covers 30,000 population in plain rural area and 20,000 in tribal, hilly, desert and difficult areas. The PHC and sub-centre should not be set up on rigid population norms, it should be accessible using “time to care” approach, within 30 minutes of travel time. At this level of primary healthcare—services of professionally qualified medical officer, male and/or lady medical officer are available. These PHCs are established and maintained by the state governments under the minimum needs programme (MNP), and basic minimum service programme (BMSP). PHCs are primarily state funded. One PHC acts as a referral unit for 6 sub-centres. Each PHC has 6 indoor/ observation beds, it has operation theatre complex, a labour room and a laboratory. All the existing PHCs are being transformed to health and wellness centres (HWCs-PHCs) in phased manner. All “Minimum assured services” or essential services as envisaged in PHC should be available. The services which are indicated as “desirable” are for the purpose that all the states should aspire to achieve. Types/Categories of PHC/UPHC

The revised IPHS 2022 guidelines classify the rural and urban Primary Health Centres (PHCs) as: a. HWC-PHCs: Ideally, for rural areas, the states should aspire to make all PHCs functional as 24 × 7 facilities. However, there is a need to prioritize PHCs conducting deliveries to function as 24 × 7 HWC-PHCs. All other PHCs should continue to provide routine care along with preventive and promotive health interventions and function as PHCs-HWCs. b. Urban HWC-PHCs: In urban areas, assured roundthe-clock emergency and secondary care services are readily available, so primary health centres are expected to provide routine OPD care along with preventive and promotive health interventions and function as UPHCs-HWCs. However, the UPHCs with indoor beds already conducting deliveries can continue to function as 24 × 7 UPHCs-HWCs. c. Specialist UPHC/Polyclinic (urban): “Multispecialty UPHC/Polyclinics” in urban areas should be established with the aim to further reduce morbidity and mortality by providing specialist services on ambulatory/day care basis, closer to the urban community. Such polyclinic services would be limited to outpatient care (see UPHC-HWC on page 728). Population Norms for HWC-PHC

Normally, a PHC in rural areas is to be established for a population of 20,000 (in hilly and tribal areas) and 30,000 (in plains) (Table 17.5). A Primary Health Centre (PHC)

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Table 17.5: Population norms for HWC-PHC S. No.

Type of PHC facility

Plain area (population)

1.

Rural PHC

30,000

2.

Urban PHC

50,000

3.

Polyclinic in urban area

2.5 lakh-3 lakh

that is linked to a cluster of Sub Health Centres—HWCs would be strengthened as HWC to deliver the expanded range of primary care services with complete 12 package of services. In addition, it would also serve as the first point of referral for all the SHC-HWCs in its jurisdiction. In urban areas, usually the population density is high and there are various types of healthcare facilities which provide inpatient care. So, the approach in urban areas for establishing PHCs shall be different from that in rural areas. UPHCs are established for every 50,000 population and in close proximity to urban slums. Multispecialty Polyclinics provide specialist healthcare services to a population of 2.5 to 3 lakhs, encompassing the catchment area population of 5–6 UPHCs, depending upon geographic location, population density, available infrastructure, etc. In-Patient Ward/Day Care Room

There should be two essential and four desirable beds in a PHC while six essential and four desirable beds in a 24 × 7 PHC/UPHC. UPHC and multispecialty polyclinic will have two essential and four desirable day care beds to provide care to patients requiring stabilization, observation and/or monitoring. After stabilizing the patients, adequate referral to higher centres for further management, if required, should be done. Every bed should be provided with an IV stand, a bed side locker and a stool for attendants. Oxygen cylinder and Ambu bags should be easily accessible and functional (Table 17.6). UPHCs are not expected to provide in-patient care. However, such UPHCs that continue to provide delivery services, need to provide infrastructure as per 24 × 7 PHC. Oxygen Support

The COVID-19 pandemic has affected not only secondary or tertiary level of care but also the primary level. Thus,

oxygen support at PHC/UPHC and 24 × 7 UPHCs through cylinder or concentrator is essential as per GoI guidelines (Table 17.6). Minimum Performance Standards

In OPD 75 patients per day by Medical Officer. Dentist OPD 20 patients per day. Lab technician 100 tests per day. Pharmacist 120 dispensions of prescriptions per day. Staff Nurse one per 6 beds as per Indian Nursing Council norms. Staffing pattern of HWC-PHC is indicated in Table 17.7. Service Provision by HWC-PHC

Presently even a well-functioning primary health centre provides services that are limited to reproductive, sexual and child health along with some of the National Disease Control Programmes. Together these conditions, for which people seek healthcare, represent less than 15% of all services. For all the rest, people have no option but to resort to either the local private care provider or travel to the crowded District Hospital or Medical College hospital. The HWC-PHC plays a major role in delivering comprehensive set of services as mentioned below. In addition to the basic curative services of primary care level, health and Wellness Centres PHCs have an important role in the prevention of several disease conditions, including both communicable and non-communicable diseases. The twelve packages snvisaged under comprehensive primary healthcare services (CPHC) at HWC-PHC are: 1 Care in Pregnancy and Childbirth 2 Neonatal and Infant Healthcare Services 3 Childhood and Adolescent Healthcare Services 4 Family Planning, Contraceptive Services, and other Reproductive Healthcare Services 5 Management of Communicable Diseases: National Health Programmes 6 General Out-patient Care for Acute Simple Illnesses and Minor Ailments 7 Screening, Prevention, Control and Management of Non-communicable Diseases 8 Care for Common Ophthalmic and ENT Problems 9 Basic Oral Healthcare 10 Elderly and Palliative Healthcare Services

Table 17.6: Bed requirement and oxygen delivery systems in Primary Health Facility-HWC S. No.

17

Facility type

Bed capacity

B type (1500 L oxygen capacity) cylinder

Oxygen concentrator (10 liters)

1.

Primary Health Centre (Rural)

6 (2 E + 4 D)

4

1

2.

Primary Health Centre (Urban) and Polyclinic

6 (day care) 2E+4D

4

1

3.

Primary Health Centre/UPHC (24 × 7)

10 (6 E + 4 D)

5

1

Note: E: Essential, D: Desirable

Healthcare of the Community

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Table 17.7: Human resource for health at PHC, UPHC, polyclinic and 24 × 7 PHC and UPHCs as per IPHS 2022 Human Resource for Health MO MBBS

PHC

UPHC

Polyclinic

24 × 7 PHC*

24 × 7 UPHC*

E

D

E

D

E

D

E

D

E

D

1

1

2

–

2

–

2

1

2

1

MO AYUSH

–

1

–

–

–

–

–

1

–

–

Dentist

–

1

–

1

1

–

–

1

–

1

*Specialist for medicine, obstetrics and gynecology, pediatrics, ophthalmology, dermatology and psychiatry (6 core specialists)

–

–

–

–

–

–

–

–

Staff nurses

2

1

1

1

7

–

7

–

6 – On rotational Basis—only for outpatient services 2

–

Pharmacist and store keeper

1

–

1

–

1

1

1

1

1

1

Medical laboratory technologist/ Lab technician

1

–

1

–

1

–

2

1

2

1

Optometrist/Ophthalmic Assistant/Vision technician

–

1

–

–

1

–

–

1

–

1

Health worker (female) ANM

1*

–

5

–

5

–

1

–

5

–

Health worker/Health assistant (male)

1

–

–

–

–

–

1

–

–

–

Health assistant (female)/ Lady health visitor

1

–

1

–

1

–

1

–

1

–

Health educator counsellor

–

1

–

1

1

–

–

1

–

1

Dental assistant*

–

1

–

1

–

1

–

1

–

1

Cold chain/Vaccine logistic assistant

–

1

–

1

–

1

1

–

1

–

Physiotherapist

–

–

–

–

1

–

–

1

–

1

Public health manager

–

–

1

–

1

–

–

–

1

–

Dresser

1

–

1

–

–

–

1

–

1

–

LDC-1/Accountant

1

–

1

–

1

–

1

–

1

–

Data entry operator

1

–

1

–

1

–

1

–

1

–

Cleaning staff

1

–

1

–

2

–

4

–

4

–

Note: These specialists are on rotational basis 1. The number of HR indicated as desirable (D) is over and above the HR indicated as essential (E). 2. All the HR indiciated under the support staff is to be only hired in-house, if the related services are not outsourced. 3. Meaning thereby, for outsourced services, the HR is to be provided by the outsourcing agency.

11 Emergency Medical Services Including Burns and Trauma 12 Screening and Basic Management of Mental Health Ailments 172 Essential medicine list is recommended as per IPHS for HWC–PHC and over 50 plus diagnostic services are available. • In Addition to 12 packages envisaged under comprehensive primary healthcare services (CPHC) the HWC-PHCs Rural and UHWC-PHC provide referral services for managing complicated cases referred from Health and Wellness Centres. The level of complexity of care of services delivered at PHC would be higher than at SHC-HWC. In fact PHC supports referral services for diagnostics, initiation of

treatment, supervision and guidance, administrative, and financial control over HWC-PHC. • Besides providing curative/clinical services, the PHCs in rural and urban areas will also support in provision of preventive and promotive services to the community. • These PHCs also play an important role in undertaking public health functions in the community leveraging the frontline workers and community platforms. • They go beyond first contact care and hence are expected to mediate a two-way referral support to primary and secondary level facilities as well as ensure follow up support for individual and population health interventions. PHCs/UPHCs have a critical role in referral and follow up and should establish strong upward (CHC/UCHC) and downward (community and outreach) linkages.

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• Outreach services to the community will also be a part of the service package at PHCs/UPHCs (e.g. VHNDs, UHNDs, special outreach sessions). • HWC-PHC should also be utilized as a platform for teleconsultation (eSanjeevani) and expanding the range of diagnostic services in hub and spoke model. • Collaboration with other sectors have also been identified and listed for certain services such as nutritional support with the Department of Women and Child Development, school health with the education department and vector control activities with the ULBs/ PRIs. Minimum Assured Services at PHC—HWC

PHCs are cornerstone of rural health services—a first port of call to a qualified doctor of public health sector in rural areas for the sick and those who directly report or referred from sub-centres for curative, preventive and promotive healthcare. Major functions of PHC happen at sub-centres to cover 30,000 population. Desirable services

• Safe abortion services (MTP) using manual vacuum aspiration • Counselling services in schools • ICTC services • Issue disability certificates • Blood cholesterol and ECG. A. Technical Functions (Clinical Functions)

1 Medical care: Medical care consists of curative services through routine outdoor, indoor and 24 hours emergency services for patient. Essential drugs, vaccines and diagnostics are provided free of cost to all. Outdoor services—4 hours in the morning and 2 hours in the evening/afternoon with minimum OPD attendance of 75 patients per day per MO. PHC provides referral medical care services to all its subcentres. It is desirable that MO PHC HWC shall spend at least 2 hours per day twice a week for field duties and monitoring. 2 Monitoring and supervision of SHC-HWC. Once a month clinic at sub-centre by medical officer. 3 Arrange referral transport. B. Management Functions

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Medical officer is the leader of health team at the PHC. He is responsible for planning (sub-centre action plans and PHCs plans), organizing, implementation, coordination, decision-making monitoring and supervision as also evaluation of services, personnel management, reaching material and supply to sub-centres, training and continuing education of health teams, financial

management and ensuring inter- and intra-sectoral coordination and also reporting the performance to higher level, i.e. community health centre. Holding staff meetings to get information and give information to staff and also to solve their problems. Planning of work in sector or monthly meeting with AWWs, ASHA and health workers and their supervisors is also an essential function. Thus, the medical officer is not only a doctor to provide curative, preventive and promotive services but he is a manager as well to perform essential managerial tasks as listed above apart from leadership role. Above all, challenging management task under NRHM is to utilize the budget for improving quality of services and functions of PHC. Functioning of PHC is critical to implement all the national health programmes in rural areas as also to support referral services. As on 31 March 2021, a total of 31053 PHCs (24935 rural and 6118 urban) were functioning. 16635 rural PHCs have been converted into HWC PHCs. There are no functional PHCs in many remote areas in dire need of healthcare. As of now 94.5% of the PHCs are running in government buildings. Majority of PHCs lack essential infrastructure and inputs. Essential drugs for the treatment of common ailments are not available in majority of PHCs. No more than one-third of PHCs provided delivery services in them and on an average 26 deliveries occurred in the last 3 months. Thus, the PHCs are functioning suboptimally. Every PHC now have a Rogi Kalyan Samiti/Primary Health Centre’s Management Committee for improvement of the management and service provision at the PHC. This committee has the power to generate its own funds and utilize the same for service improvement of the PHC besides monitoring the functions of PHC. Strengthening of HWC–PHCs under NRHM and Support under A—BHIM

i PHCs have been strengthened by adequate and regular supplies of essential drugs and equipment. ii Round the clock services (24 × 7) in all PHCs of the country, in phased manner. iii Upgrading single doctor PHC to 3 doctors PHC by posting AYUSH practitioners at PHC level and 3 staff nurses. iv Observing standard treatment protocols and Indian Public Health Standards (IPHS 2022). v Untied grant of `25,000 for local health planning and action and maintenance grant of `50,000 per annum. vi PHCs are proposed to be transferred to the local elected Panchayati Raj institutions for management and control. Rogi Kalyan Samiti (RKS) has been constituted at each PHC to increase community control and participation. vii Citizen charter at PHC—services and rights of citizens and grievance redressal system.

Healthcare of the Community

COMMUNITY HEALTH CENTRE (CHC) The government healthcare delivery in India has been at three levels, namely—primary, secondary and tertiary. The secondary level of healthcare essentially includes community health centres (CHC) constituting First Referral unit (FRU) and the sub-district and the district hospital. The CHCs were established and maintained by the state government under minimum needs programme/basic minimum service programme for rural population. The CHCs are designed to provide referral healthcare for cases from primary health centres HWCs level and for cases in need of specialist care approaching the centre directly. CHCs is a referral centre for four primary health centres (HWCs). CHC is responsible for 1,20,000 population in plain and 80,000 in tribal area. Generally, it covers the population of one community development block geographical area. A total of 6064 CHCs (5480 rural and 584 urban) were functioning as on 31st March 2022. CHC is a 30 bedded hospital providing specialist care in Medicine, Obstetrics and Gynaecology, Anaesthesia, Surgery and Pediatrics. It has facility of labour room, operation theatre, X-ray and laboratory. It provides emergency obstetric care besides specialist services. Types/Categories of CHC/UCHC

The revised IPHS 2022 guidelines classify the rural and urban CHCs as: A. Non-RFU CHCs (rural): Non-FRU CHCs are those that provide essential services including preventive, promotive, curative, palliative and rehabilitative services, etc. Curative services include normal delivery, stabilization of common emergencies, etc. Non-FRU CHCs in rural areas have 30 essential beds. B. FRU CHCs (rural and urban): FRU CHCs, in addition to the above services, provide specialised care which can be rendered through specialists (physicians, surgeons, obstetricians, paediatrician and anaesthesiologists) and the accompanying infrastructure (functional operation theatre and blood storage unit). Both elective and emergency surgical services of secondary level care shall be provided. FRU-CHCs will provide surgical services and go beyond obstetric services. Thus, while CHCs in rural areas can be either nonFRU CHC or FRU CHC, the UCHC in urban areas will function only as FRU UCHCs. Non-FRU CHCs will have 30 essential beds. For FRU CHCs in rural areas, 30 beds, maternity and surgical services will be essential while in a 50 bedded FRU CHC, additional ophthalmic, orthopaedic and ENT services will be desirable. Similarly, for FRU UCHCs 50 beds, maternity and surgical services will be essential in all the cities. The same with 100 beds

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(in metropolitan cities/cities with population of more than 1 million), will have additional ophthalmic and orthopaedic services as desirable. Out of 30 beds 20 FRU-CHC and 18 non-FRU-CHC beds will be oxygen supported beds with adequate D type 7000 litres cylinder-20 and B type 1500 litres cylinder10 and 5 oxygen concentrators (10 litres). Block Public Health Unit (BPHU)

All CHCs at block headquarters level (in rural and urban areas) are to be developed as Block Public Health Units (BPHU). Every block in the county is envisaged as having a CHC/ Block PHC/SDH at the Block Headquarter (HQ) which serves as a hub for referral from the SHCs and PHCs of the block. However, the situation across states is variable, with the Block CHC functioning as just another PHC in some states, while in some other states, the block CHC also serves as a First Referral Unit. Currently, the block health facility is only equipped to provide selected clinical services, a limited range of public health functions and administrative control of the health institutions within the block. The BPHU are expected to have four functional areas: Clinical service delivery, public health functions, block public health laboratory to serve both clinical, public health functions (disease surveillance) and HMIS unit. The clinical and diagnostic services will be delivered as per Indian Public Health Standards (IPHS) and efforts will be made to improve the quality and timeliness of reporting of service delivery and public health related data. The BPHUs will also promote decentralised planning and the preparation of block health plans that feed into district health plans. BPHU has area co-terminus with Panchayat Samiti (Block Panchayat, it facilitates convergent actions on social determinants with ICDS, PRIs, and Education). BPHU is supported by XV Finance Commission funds. Objectives

The objectives of block public health unit will be to: • Promote decentralized planning of public health activities with rural and urban local bodies through participatory process. District Plan will be inclusive of Block plans, Panchayat/urban local body plans. • Serve as the referral point for the HWC-PHC and HWC-SHC in the block, in order to reduce crowding at higher level facilities and provide comprehensive primary healthcare (delivery of clinical and public health services). • Strengthen disease surveillance (both human and animal) to support evidence generation/forecast of potential outbreaks through robust data reporting using HMIS.

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• To create a platform for collaboration, coordination among multi-disciplinary sectors to address social determinants of health. • Ensure accountability for health outcomes within the block. Population Norms for CHCs

Normally, a Community Health Centre in rural areas (CHC) is to be established for a population norm of 80,000 (in hilly and tribal areas) and 1,20,000 (in plains) and/or time to care approach. To establish effective convergence and linkages with citizen centric services, a CHC should be established at the Community Development Block/ Taluka/Tehsil/Circle Level. This will also supplement the three-tier Panchayati Raj System (Gram Panchayat, Block Panchayat and Zila Panchayat). The Community Health Centre in urban areas (UCHC) is set up as a secondary care referral centre in metro cities with a population of 5 lakh and above and population of 2.5 lakh in non-metro cities. These facilities are in addition to existing facilities (SDH/DH) that cater to the urban population in the locality. A UCHC is a 50 bedded facility that provides in-patient medical and surgical services and facilities for institutional delivery. For the metros and million plus cities, the

UCHCs are established at 5 lakh population and are 100 bedded facilities. The revised manpower for CHC as per revised IPHS 2022 is depicted in Table 17.8. Standard treatment protocols for all national health programmes and locally common diseases have been made available at all CHCs. Standard treatment protocols is the “Heart” of quality and cost of care. All the support services (lab, transport, nursing, diet, CSSD, laundry and blood storage) have been strengthened at the CHC level. The IPHS for CHC have been projected on the basis of assumption that there will be average bed occupancy of 60%. The strength may be further increased if the occupancy increases. Distressingly there is considerable shortfall (80%) of specialists at the level of CHCs in India and occupancy of beds is low in most situations. Some of the CHCs have been upgraded to the level of first referral units (FRUs) by providing blood transfusion service and a part-time/on contract basis services of an anaesthetist. A majority of the CHCs do not function as FRUs because they either do not have any specialist or the posted specialists are not from the specified specialities. • To fill the gap of specialists, multiskilling of doctors by offering short courses to doctors in lifesaving anaesthetic skills, and obstetric skills are being offered.

Table 17.8: Human resources for health at non-FRU-CHC and FRU-CHC as per IPHS 2022 Staff

Non FRU CHC 30 essential beds Essential Desirable

FRU-CHC 30 essential beds Essential Desirable

Specialists and medical officers • Physician/family medicine specialist

1

1

1

1

• Surgeon

–

1

1

–

• Obstetrician and gynaecologist

–

1

1

–

• Paediatrician

–

1

1

–

• Anaesthesiologist

–

1

1

–

• Microbiologist

-

–

–

1

GDMO

3

1

6

2

MO AYUSH

–

1

–

1

MO Dental

1

–

1

–

Staff nurses

29

–

46

–

5

2

6

1

Technicians (LT, OT, ECG radiology and assistants)

9

4

13

4

Pharmacist and store keeper

2

1

2

2

Administrative staff*

7

3

10

1

Cleaning staff

5

4

8

1

Allied health professionals Dietician, social worker counselor, physiotherapist and clnical psychologist Other allied health professionals

17

* Hospital Manager, Nursing I/C, accountant, DEO, sanitary inspector, registration clerk, IA.

Healthcare of the Community

Due to shortage of manpower at CHC, doctors of primary health centres are being located at CHCs on shift duties after attending to routine OPD duties at primary health centre, in order to provide round the clock clinical services. • A microscopy centre has been established at each CHC for diagnosis of sputum smear positive cases of tuberculosis. Over 99% of CHCs are in Govt buildings. • Citizen’s charter for CHCs: All CHCs now have the charter of citizen’s health rights and entitlements prominently displayed at the entrance. It enables the citizens to know the availability of services at CHC, their rights and entitlement. Service Provision

• Secondary care specialist services closer to the community are envisaged to be delivered at the two types of CHCs (FRU and non-FRU) with assured multidirectional linkages (for referral and follow-up). • Apart from curative services, there should a strong focus on health promotion, prevention, palliation and rehabilitation at both primary and secondary levels of facilities. • Non-FRU CHCs are envisaged to deliver services related to maternal and child health (including normal delivery), infectious diseases, nutritional disorders including iron-deficiency anaemia, mental health conditions, non-communicable diseases, Eye, Oral and ENT care. Early identification and treatment of these disease coupled with prevention, promotion and risk reduction at community level is the only way to address disease burden at the population level. • Services at FRU CHCs include specialist care, operative services and blood transfusion facilities in addition to maternal and child healthcare services. • All the CHCs are to be expanded by integrating the functions of clinical services and public health surveillance for improved public health actions. It will also strengthen the diagnostic capacity of the laboratory both for clinical conditions and public health surveillance and serve as the hub for health-related reporting through a robust HMIS. • To ensure continuum of care, assured referral with facility readiness to manage referred cases must be established. The referral transport network should have the requisite number of equipped ambulances (depending on population norms) with adequately trained manpower. Follow-up care at the community level/primary healthcare centre level should also be linked. • Collaboration with other sectors have been identified and listed for certain services such as nutritional support with the Women and Child Development (WCD) department, school health with the education and safewater and sanitation with Environment department (Jal-Shakti).

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Assured Services/Functions of CHC—Clinical Functions

• All essential or “Assured services” besides desirable service as envisaged in the CHC should be available, which include—routine and emergency care in surgery, medicine, obstetrics and gynaecology and paediatrics, in addition to services for the National Health Programmes and OPD and indoor services. • To provide specialist services and referral services to four primary health centres area. • 24-hour delivery services (normal and assisted delivery). • Provides essential and emergency obstetric care including caesarean section. • Full range of family planning services including laparoscopic service and no scalpel vasectomy. • RTI/STI services and ICTC for HIV/AIDS. • Medical termination of pregnancy (safe abortion services) MTP facility approved for 2nd trimester of pregnancy (desirable service). • Newborn care (newborn care stabilizing unit) • Routine and emergency care of sick children • School health services/adolescent health services. • Referral transport services—round the clock • Cold chain maintenance for vaccines • Designated microscopy centre for TB. • Essential laboratory and X-ray services • Indoor (admission) services • Dental health services • Blood storage facility • Training and continuing education of health teams • Integrated disease surveillance and control of outbreaks • Ensure inter-sectoral convergence • To elicit community participation • To enhance public–private partnership • Services for National Health Programmes of CCDs and NCDs. Desirable services

• • • •

Link antiretroviral therapy centre. Intraoccular pressure by tonometer. Biopsy services. Public–private partnership for lab services.

Strengthening of CHCs under NRHM

• National Rural Health Mission (NRHM) aims at operationalization of all existing CHCs as 24 hours first referral units (FRUs). • Opening up of additional CHCs to meet population norms and develop standards of services. • Two specialists, namely anaesthetist and public health programme manager have been provided on contractual basis. • Provision of Untied money ` 50,000 per annum for local health actions.

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• Provision of maintenance grant of ` 1 lakh per year. • Adoption of Indian Public Health Standards for CHCs. Initial funds of ` 20 lakh per CHC provided for its upgradation to achieve Indian Public Health Standards. • Rogi Kalyan Samiti for every CHC for accountability ownership and monitoring of functions of CHC. • Multiskilling of doctors to close specialists gap. • Public–private partnership to close specialists gap. First Referral Unit (FRU) or Comprehensive Emergency Obstetric and Neonatal Care Centre

Essential requirement of fully operational first referral unit (FRU) is an existing facility (CHC, or district or subdistrict hospital) can be declared a fully operational FRU only if it is equipped to provide round the clock services for comprehensive emergency obstetric and newborn care (CEmONC), in addition to all of following: • 24 hours delivery services including normal and assisted deliveries. • Emergency obstetric care including surgical interventions like caesarean sections* and other medical interventions • Newborn care* (newborn care stabilization unit). • Emergency care of sick children. • Full range of family planning services including laparoscopic services. • Safe abortion services. • Treatment of STI/RTI. • Blood storage facility* on a 24-hour basis. • Essential laboratory services. • Referral transport services. The foundation of FRUs was laid in the country in 1992 by Child Survival and Safe Motherhood Programme (CSSM). Out of designated. 3559 FRUs 1685 were functional in 2022. *Critical determinants of functionality.

Purpose: Purpose of FRU is to reduce/prevent maternal and neonatal deaths. Management Functions at CHC

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CHC, which is responsible for 1,20,000 population, has 40–60 skilled and trained technical staff in 20–25 rural sub-centres, in addition to health guides, trained birth attendants, ASHAs and over 100 Anganwadi workers and their supervisors under ICDS programme, who are responsible for women and child development. Thus, the senior medical officer I/C of CHC is endowed with large resources of manpower at CHC, besides funds from NRHM. His job functions and responsibilities fall into the broad areas of curative, preventive, promotive and managerial tasks. 1 He is first and foremost manager of extensive resources available at his command; both manpower and material, which is a major means of reaching 1,20,000 population under his care. The managerial tasks consist

of providing effective leadership to health teams, planning of health services (community needs assessment) of all sub-centres, PHCs and the CHC, organizing, finding out community resources, implementation action plans, decision-making, supervision, monitoring, coordination of teams, intersectoral coordination, and eliciting community participation. 2 Trainer for continuing education: In view of large number of para-professional personnel under his control/charge, he is responsible for continuing education and training, monitoring, motivation and progressive improvement of technical skills of his teams, in order to improve the quality of services and client satisfaction. 3 Clinical care: He is a clinician whose decision is critical in the care of sick/patients and the decision in their management, either by him or his delegates. 4 He is responsible to the communities (1,20,000 people). In short, the SMO of CHC is a leader of large team of personnel and is responsible both to his team and to the communities they serve. 5 Leadership role: Health team building. It is widely recognized that the managerial functions of the CHC and PHC are badly neglected and doctors are generally not adequately prepared and are seldom interested in management functions. In particular leadership role of the PHC/CHC doctors is proving to be a weak link, placing the success of the other elements of the health system in great jeopardy. Doctors are seen to be playing almost exclusively clinical curative role, spending 80% of their time in daily clinics and unable or unwilling to take on management functions and important liaison with the community which is necessary for substantial improvement in community health. Thus, medical doctors (SMO and MO) are key facilitating figures in the national strategy of ‘Health in all’. The health system is adequately designed to provide comprehensive, high coverage of promotive, preventive and curative services throughout India. A large trained staff of workers with tasks appropriately defined to meet the major public health needs of the rural poor is in place. There remains a question of motivated leadership of each health team, their continued education, supervision, motivation is essential if the potential is to be fulfilled. Most medical officers are unwilling to assume this role. Wherever this leadership is good, the results are dramatic in improvement in health of poor rural population in India. Supervision and Support to CHC

The CHCs are linked to district health organization for supportive supervision and referral services. CHCs refer cases to district hospitals and district health organization

Healthcare of the Community

helps support mass camps and campaigns at CHC level including training activities. District programme officers periodically visit CHC for supervision and support. Each CHC reports its performance to chief medical officer. Accessibility of Primary Healthcare

Instead of population norms “time to care” approach should be followed. A travel time of 30 minutes to reach a primary healthcare facility and a total of 2 hours to reach FRU could be a reasonable goal or secondary care should be distributed such that within what is known as the golden hour—a secondary care facility can be accessed. National Mobile Medical Units/Health Camps

With the objective to take healthcare to the door step of the public in the rural areas, especially in under-served areas, national mobile medical units (NMMUs) have been provided, one per district under NMMUs. The states can adopt more suitable and sustainable model for the MMU to suit their local requirements. Two kinds of MMUs are envisaged, one with diagnostic facility for the states other than North-East states, Himachal Pradesh and J & K. In addition, for the NorthEast states, Himachal Pradesh and J & K, specialized facilities and services such as X-ray, ECG and ultrasound are provided in MMUs due to their difficult hilly terrain. District health society will decide the operation of MMUs locally. To increase visibility, awareness and accountability all MMUs have been repositioned as “National Mobile Medical unit Service” with universal colour and design. Functioning of Primary Health Care System (SCs, PHCs and CHCs)

• The system of primary healthcare functions at sub-optimal level because of poor leadership and poor management. • Absence of healthcare providers particularly of doctors and other caregivers (43%). • Poor accessibility of facilities to difficult areas and underserved poor people. • Utilization of facilities is poor—no more than 20–30% of people utilize the primary healthcare system curative services and many turn to private practitioners. • Equipment and medicines are in short supply. • Panchayati Raj institutions have been marginally involved in the system. Community participation lacks. • Most of CHCs do not function as first referral units. • Lack of integration of services. • Referral support system is weak. • Indoor beds at PHCs and CHCs remain under-utilized (occupancy rate is low).

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URBAN PRIMARY HEALTHCARE SERVICES Nearly 34% of India’s population lives in urban areas and nearly one third of this population lives in urban slums, which have sub-human living conditions. Over 75% of dispensaries, 60% of hospitals, 80% of doctors and para-professionals are in urban areas. Urban population is most aware and has ready access to healthcare. Data from SRS, NFHS and other surveys indicate that the health indices of urban areas are better than those in rural population. A large number of private practitioners, nursing homes, hospitals, specialists and super-specialists are available in urban areas, besides NGOs and religious organizations, yet the urban poor have poor access to healthcare. Thus, there is “Poverty in Plenty” in urban slums in terms of primary healthcare. WHO Choice of Theme of World Health Day on 7th April 2010: “Urban Health Matters” was most timely and apt. coverage of urban population and reporting of work is a big challenge.9 Migration

Migration has resulted in rapid unplanned growth of urban slums. The slum population faces greater health hazards due to overcrowding, poor sanitation, lack of access to safe drinking water and environmental pollution. Health indices of urban slums dwellers in some areas are worse than those of rural population. Unlike the three-tier rural health services there have been no efforts to provide well-planned and organized primary, secondary and tertiary care services in geographically delineated urban slum areas. As a result in many areas, primary healthcare facilities are not available. The 1083 urban family welfare centres were revamped into 871 urban health posts in 1983 to cover urban slum population. System/Structure of Primary Healthcare in Urban Area

It consists of HWCs, urban PHCs, urban CHCs and polyclinics.

NATIONAL URBAN HEALTH MISSION (NUHM), 2013 Rapid urbanization has led to rapid increase in number of urban poor population; majority of them live in slums. The need for improving the healthcare for the urban poor has been recognized as “thrust area” by the National Health Policy (2002), the National Population Policy (2000), Eleventh Five-Year Plan and RCH-2. Urban poor population have been recognized as “vulnerable and underserved communities” in RCH-2. The challenges: These are—rapid urbanization, degraded environmental conditions, poor health indicators of urban poor

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population, inadequate and sub-optimal functioning of urban primary health infrastructure, overcrowding at secondary level, multiplicity of service providers with weak or almost missing coordination, sub-optimal utilization of the strength of private and charitable service providers and weak community capacity. All these indicate imperative need of different strategies. NUHM was set up in 2013. The NUHM aims to address essential primary healthcare needs of urban poor in 779 cities with population of 50,000 and above in all the districts and state headquarters with active involvement of urban local bodies (ULB). The NUHM would be covering 375 million urban population with a special focus on 76.6 million urban poor living in slums and beyond spread over in 779 cities. Now it covers 1000 cities and towns. Urban population may reach to 534 million by 2026. The existing urban health posts and urban family welfare centres, urban RCH centres, etc. will be strengthened and upgraded as urban primary health centres (U-PHCs). Focus of NUHM, 2013: The NUHM would have high focus on: • Urban poor population living in listed and unlisted slums. Only 49% of the slums have been notified. • All other vulnerable population as homeless, rag pickers, street children, rickshaw pullers, construction and brick and lime kiln workers, sex workers and other temporary migrants and pavement dwellers. • Public health thrust on sanitation, clean drinking water and vector control. • Strengthening of public health capacities of urban local bodies (municipal corporations, municipalities, notified area committees.

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Aim

The NUHM aims to improve the health status of urban population in general, but particularly of the poor and other disadvantaged sections. Service Delivery System Core Strategies

i Public–private partnerships, i.e. with private service providers or with NGOs or faith based organizations. ii Through public-public partnership, i.e. partnership with railways hospitals, employee state insurance corporations and public sector companies hospitals. An optimal mix of these strategies is desirable. With the launch of NUHM the existing urban health posts/urban family welfare centres/dispensaries would cease to exist and these will be strengthened and revamped into “Urban primary health centres”. The national urban health service delivery model would make a concerted effort to rationalize and strengthen the existing public health system through various partnerships as per core strategies. The components for urban healthcare delivery model is shown in Fig. 17.4.

URBAN PRIMARY HEALTH CENTRE (U-PHC) MODEL The urban health delivery model basically comprises Urban Health and Wellness Centre-PHC and urban Polyclinics for provision of comprehensive primary healthcare with outreach and referral linkages as described below.7 By 31st March 2022, there were 6118

Fig. 17.4: Urban healthcare delivery model—various components, coverage of urban population is a challenge

Healthcare of the Community

U-PHCs, of these 3350 have been upgraded to Urban health and wellness centres PHC. Components of U-PHC Model

Community Level

i Each slum/community would have frontline community worker called Urban Accredited Social Health Activist (U-ASHA) similar to ASHA under NRHM, covering about 1000 to 2500 population, of 200–500 households based on spatial considerations preferably co-located at the Anganwadi centre functional at the slum level. U-ASHA will be a link between the UPHC and the urban slum community to generate demand for services and behaviour change communication to promote healthy practices and help ANMs in delivering outreach services. ASHAs will be provided with photo ID cards to boost her self-esteem. U-ASHA will be entitled for performance based incentive fixed by states. U-ASHA will perform 5 major activities—home visits up to 2 hours per day, attend monthly Health Sanitation and Nutrition Day, accompany pregnant women and children to urban health centre, holding ward level meeting and record keeping. ii Mahila Arogya Samiti (MAS): MAS is a women’s health committee of 10–12 members for 50–100 urban slum households having population between 250 and 500. The MAS acts as community based peer educator group in slums involved in generating community awareness through interpersonal communication, undertakes community based monitoring and promotes linkage with services and referrals. MAS elects its chairperson and a treasure, supported by U-ASHA to manage revolving fund. Annual grant of ` 5000 to each MAS every year will be provided for conducting fortnightly/monthly meetings of MAS. Capacity of MAS would be built by orientation workshops. iii Outreach session by ANM for slum dwellers vulnerable population in the form of health and nutrition days: a The purpose of outreach session is to provide preventive, promotive and curative healthcare services at household level by regular visits and outreach sessions. Each ANM will organize minimum of one routine outreach session in every area every month (monthly Health, Sanitation and Nutrition Day). For improving routine outreach services ANM will be provided with mobility support of ` 500 per month. 4–5 ANMs are posted in one UPHC and each ANM covers about 10,000 population. b Special outreach sessions (for slum and other vulnerable population) once a weak/fortnight in partnership with other health professionals (doctors/ pharmacist/technician/nurses—government or private specialists at the community level. It will include screening and follow-up, basic lab investigations, drug dispensing and counselling.

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Urban Health Centre

Population covered by U-PHC: Each U-PHC functions for a population of 50,000, located preferably within a slum or near a slum within half kilometer radius, catering to slum population of approximately 25,000–30,000 with provision for OPD services from 12 noon to 8 pm in the evening. The cities based upon the local situation may establish a U-PHC for 75,000 for areas with very high density and can also establish one for around 5000–10000 slum population for isolated slum clusters. Unlike rural areas, sub-centres have not been established in urban areas. Now Urban Health and Wellness Centres (UHWC), one UHWC for 15000 to 20000 population are being set up. Beds: Two day care beds are essential and aspire to have 4 day care beds to provide care for stabilization/ observation. Beneficiaries of U-PHCs: Primary healthcare through U-PHCs and U-CHCs will be universally available to all citizens residing in urban areas; whereas the outreach services will be targeted for slum dwellers and other vulnerable population. Targeting is needed especially for secondary and tertiary care to all. It can be provided free only to those who cannot afford it otherwise. Urban poor will be identified by household surveys conducted through community organizations/NGOs under supervision of ULB (urban local bodies). Services

At the U-PHC level the services provided will include OPD (consultation), basic laboratory diagnosis, drugs/ contraceptives apart from distribution of health education material and counselling for all communicable and noncommunicable diseases. In order to improve access to urban slum population at convenient timings, the U-PHC may provide services from 12 noon to 8 pm in the evening. UPHCs will not provide in-patient care. However, such UPHCs that continue to provide delivery services, need to provide infrastructure as per 24 × 7 PHC. Broadly the services include: • 12 Packages envisaged under comprehensive primary healthcare services • Medical care: OPD services/consultation • Services prescribed under RCH-II • National health programmes services • Collection and reporting of vital events and IDSP • Referral services • Basic laboratory services • Counselling services • Essential medicines • Services for communicable and non-communicable diseases • Social mobilization and community level activities.

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Specialist UPHC/Polyclinic (Urban)

Multispecialty Urban Primary Health Centre/Polyclinics, in addition to services provided by UPHC, would provide day care/ambulatory specialist care to urban population. Fixed day rotational multispecialty OPD at UHWC-PHC or at Urban CHC for a minimum of SIX specialties, viz. Medicine, OBG, Paediatrics, Ophthalmology, Dermatology and Psychiatry would be provided at the polyclinic. States could start with 2–3 specialties services and gradually expand the range to 6 services. Polyclinic should plan and provide oral, Physiotherapy and and/or optometrist services also along with diagnostic and point of care testing for all the specialties concerned. Human Resources at Polyclinic

Essential—MO MBBS 2, Dentist 1, Specialists 6, Staff nurses 2, Pharmacist 1, LT 1, Optometrist 1, Health Workers Female 5, Health assistant Female 1, Health educator/ counsellor 1, Physiotherapist 1, Public Health Manager 1, Dresser 1 (desirable) LDC/Accountant 1, Data entry operator 1 and cleaning staff 2. Population Norms for Polyclinic

Multispecialty Polyclinics provide specialist healthcare services to population of 2.5 to 3 lakh covering catchment area of 5–6 UPHCs. Performance Standards

Each specialist provides services to 60 patients per day except Psychiatrist who provides services to 20–30 patient per day, for a dentist 20 patients per day with 8–10 dental procedures; counsellor 20–25 counselling sessions, physiotherapist 15–20 interventions per day, ophthalmic assistant 30–40 cases per day, pharmacist 120 dispensations of prescription per day and Medical Officer 75 OPD Patient per day. Specialists conduct 10 invasive procedures per week. Ophthalmic assistant—30 to 40 cases per day each specialist looks after 20 indoor patients. The government facilities strengthened as U-PHC will also be provided annual financial support in the form of Rogi Kalyan Samiti/Hospital Management Committee Untied Fund of ` 75,000 to ` 1,25,000 per U-PHC per year. The recurrent cost support provided to U-PHCs of ` 20 lakh per year would include cost of all contractual staff of 6118 urban PHCs. All U-PHCs are being converted in phased manner to HWCs. Referral Unit

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Urban community health centre (U-CHC) may be set up as a satellite hospital for every 4–5 U-PHCs to support U-PHC for referral specialist services. The U-CHC would cover a population of 2,50,000. It would provide inpatient services and would be 30–50 bedded facility. U-CHCs would be set up in cities with a population of

above 5 lakh wherever required. These facilities would be in addition to the existing health facilities (district hospital and sub-district hospital). 350 U-CHC have been set up so far. For metro cities, the U-CHCs may be established for every 5 lakh population with 100 beds. Indian Public Health Standards of 2022 will be observed for U-PHCs and U-CHCs. The Community Health Centre in urban areas (UCHC) is set up as a secondary. Care referral centre in Metro cities with a population of 5 lakh and above and for population of 2.5 lakh in non Metro cities. It is 50 bedded facility that provides in-patient medical and surgical services and facility for institutional deliveries. In metro cities bed strength is 100. These facilities are in addition to existing facilities. Quality Assurance Standards for U-PHCs

To measure the quality of services. Quality standards for U-PHCs were released by MOHFW in 2016 to help in planning and improving quality of services. 7 Now “Operational Guidelines for improving quality in Public Healthcare Facilities under IPHS 2022” are in place.8 Referral Linkages

The existing hospitals including urban local body maternity homes, state government hospitals and medical colleges, apart from private hospitals will be empanelled/accredited to act as referral points for different types of health, services, diabetes, trauma care, orthopaedic, dental surgeries, mental health, critical illness, deafness control, cancer management, tobacco counselling, and cessation, etc. School Health Services (SHS)

In urban areas, the scheme of SHS would cover government and private schools located in slums (U-PHC catchment area) or government schools near slums to promote healthy lifestyles and other preventive and promotive services. Cost Sharing

Under the National Urban Health Mission the centre–state funding pattern will be 60:40 for all states except North Eastern states and other special category states of J & K, Himachal and Uttarakhand where it would be 90:10. Convergent action in urban areas: Because of multiple agencies working in urban areas, the convergence (coordination) is essential for better outcomes. Convergence with other sectors like urban local bodies, department of education, ICDS, HIV and AIDS control, national health programmes, Ministry of Urban Development and Ministry of Housing, Jawaharlal Nehru National Urban Renewal Mission, basic services for urban poor, water and sanitation (public health); Rajiv Awas Yojna, women and child development and other stakeholders is essential.

Healthcare of the Community

Community Participation

The NUHM encourages effective participation of the community in planning and management of healthcare services. It promotes a community health volunteer: UASHA, or link worker in urban poor settlements, creation of community-based institutions like Mahila Arogya Samiti (MAS) and Rogi Kalyan Samitis. Planning Process

The urban local bodies become the units of planning with its own approved norms. The district health society will function as the coordinating body at the district level for urban health also. NUHM will be implemented through the health department in the urban local bodies except in very large municipal corporations, which will receive funds from state health society.

PRIMARY HEALTHCARE IN TRIBAL AREAS Tribal people (about 106 million) in India are considered to be socio-economically the most disadvantaged group. They constitute 8.2% of the country’s total population. National Health Policy 1983, 9th Plan as well as National Population Policy (2000) and RCH-2 have given primacy to tribal areas for primary healthcare services. Some of the problems of accessibility and utilization of health services unique to tribal areas are because of difficult terrain and sparsely distributed population in forest and hilly regions. There are locational disadvantage of sub-centres, PHCs and CHCs, non-availability of service providers due to vacant posts and lack of residential facilities, lack of suitable transport facilities for quick referral of emergency cases. Lack of appropriate human resources development and policies to encourage/motivate the service providers to work in tribal areas, inadequate mobilization of NGOs, and lack of integration with other health programmes. IEC activities are not tuned to the tribal vocabulary, beliefs and practices, services not being clientfriendly in terms of timings and cultural barriers and non-involvement of local traditional faith healers. Tribal areas are most vulnerable to falciparum malaria, with problem of drug resistance, tuberculosis, yaws, sickle cell anaemia, thalassaemia and G6PD deficiency. Infant mortality rate is higher in tribal population and only 26% of children receive all vaccines. Sex ratio is better in tribal areas. Sickle cell anaemia elimination programme has been launched. The norms for population coverage have been relaxed for tribal areas (Table 17.9). Tribal areas need special attention. Most of the centrally sponsored disease control programmes have a focus on the tribal areas. Under the National Anti-Malaria Programme (NAMP), 100 identified predominantly tribal districts in Andhra Pradesh, Bihar,

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Table 17.9: Norms for tribal areas for primary healthcare8 Institution

Population covered

One sub-centre One PHC One CHC

3000 20,000 80,000

Gujarat, Madhya Pradesh, Maharashtra, Odisha and Rajasthan are covered. In spite of all these, the access to and utilization of healthcare remains suboptimal and health and nutrition indices in the tribal population continue to be poor.

SECONDARY HEALTHCARE Healthcare delivery in India has been envisaged at 3 levels, namely primary, secondary and tertiary levels. The secondary level of healthcare essentially includes community health centres (CHCs) constituting the first referral units (FRUs) and private hospitals and nursing homes. The secondary healthcare is available in FRUs, subdivisional/sub-district, district hospitals and urban hospitals in government as also in private sector. Strengthening of the sub-divisional/sub-district, and district hospital is an approved activity under NRHM. The secondary healthcare infrastructure at the CHC and district hospital, today functions both as primary healthcare infrastructure for taking care of the needs of the population in the city/town in which it is located and also as secondary care centre. This dual role dilutes its effectiveness. Purpose of secondary care at district level is to support referral services by establishing linkages between PHC-CHC and 764 district hospitals. There should be two-way flow of patients, specialists, services and records but unfortunately, the referral linkage is absent or very poor. Strengthening of secondary care services was identified as priority area in 9th plan period. In addition to state government funding, 7 states have taken World Bank loan to initiate projects to build up FRUs/district hospitals. During the 10th plan period, efforts were made to strengthen the physical infrastructure, functional improvement in terms of patient care, organization of referral linkages between CHCs, district hospitals and tertiary care institutions; improvement in different components of care such as hospital waste management, disease surveillance and rapid response and health management information system and these would continue in 12th plan period and beyond. The government expenditure on secondary healthcare is 31.15% of total health expenditure. Cost

Since the cost of secondary care is going high, operationalization of cost recovery through user charges from

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people above poverty line has been started. Public– private partnership has also begun. Most of secondary care is made available in district through private sector, which includes nursing homes, private hospitals and private practitioners, charitable hospitals, dispensaries and NGOs. The rising cost of healthcare is pushing 60 million of people into poverty every year on account of catastrophic expenditure. District Health Plan and District Health Organization

Under National Rural Health Mission (NRHM), district becomes core unit of planning, budgeting and implementation of health services. All vertical health and family welfare programmes at the district and state level merge into common “district health mission” at the district level and the “state health mission” at state level. Progressively the district health mission to move towards paying hospital for services by way of reimbursement, on the principle of “money follows the patient”. The services will be standardized as per Indian Public Health Standards. Hospital Management Committee/Rogi Kalyan Samiti for community management of public hospitals has been setup. Public–private partnership for secondary and tertiary care have been promoted. Annual health survey data and NFHS-5 can be used for district planning. National Rural Health Mission has allocated grant to upgrade district hospital services as per Indian public health standards. Besides efficient ambulance services, this step will improve secondary healthcare at district level. District Health Organization

Civil surgeon/chief medical officer is the leader of health organization at district level. Several programme officers/ health programme managers work under him for implementation of various national health programmes in the district. Rapid response teams (RRT) for outbreak investigation and rapid response exist at district level. Secondary healthcare should be accessible within one hour of travel time. National ambulance services have been provided for referral support.

TERTIARY HEALTHCARE

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Tertiary care is available through medical college hospitals, superspeciality institutions and bigger hospitals set-up by private organizations. Many state governments are facing resource crunch and have not been able to obtain funds for equipment, maintenance, supply of consumables and upgrading the infrastructure to meet the rapidly growing demand for complex diagnostic and treatment modalities. Therefore, private organizations have taken a lead to set-up big hospitals, in most of metropolitan cities there are

reputed institutes providing quality tertiary care at cost beyond the reach of many. The government intends to open up regional institutes on the pattern of All India Institute of Medical Sciences, New Delhi, in various parts of the country; these would strengthen the tertiary care services. User charges from people above poverty line have been the mechanism to recover cost and retain it locally to upgrade the services and infrastructure and to sustain the system of tertiary care. Some states have provided land, water and electricity at lower cost to private organizations. The private organizations in return hold the responsibility to provide free care to certain proportion of people below poverty line as per agreement with the state governments (30% inpatient facilities and 40% of the outpatient/diagnostic services). Tertiary healthcare services are being strengthened under Pradhan Mantri Swasthya Suraksha Yojana (PMSSY). The PMSSY comprises establishment of 22 new AIIMS like institutions and upgradation of 75 Medical Colleges to the level of AIIMS to correct regional imbalances in the availability of affordable tertiary healthcare services and also to augment facilities for quality medical eduction in the country. Government expenditure on tertiary healthcare is 13% of total health expenditure. Six AIMS are already functional and remaining 16 are in progress. PM ATMANIRBHAR SWASTH BHARAT SCHEME

It aims at to develop capacities of primary, secondary and tertiary healthcare systems even in the last mile of the nation and developing modern ecosystem for research, testing, and treatment in the country itself. REFERRAL SYSTEM

The referral system is poorly developed in India. Primary healthcare is three-tier system. It is expected that patients from sub-centres are referred to PHCs and from PHCs to CHCs and from CHCs to district hospital and district hospital to tertiary level of care. It is free for all affair, any one can walk into secondary and tertiary levels of care directly and that increases the load of patients at these levels. The diseases/ailments which can be dealt with at primary healthcare level are being treated at district and even at higher level of care. An ideal referral system means regionalization of health services (accepting responsibility for healthcare for a defined geographical area and population), developing strong linkages between SCs and PHCs; CHCs, district and tertiary level of care, two-way flow of patients, two-way flow of specialists, two-way flow of records, two-way flow of services to avoid duplication of efforts and resources. First referral units (FRUs) have been developed for emergency obstetric and newborn care services but most of FRUs are not functioning well.

Healthcare of the Community

Referral system needs to be strengthened to support primary healthcare. Success of integrated management of neonatal and childhood illness (IMNCI) and Integrated Disease Surveillance Project (IDSP) will largely depend upon strong support of referral system. A good referral system could reduce the patient load at secondary and tertiary care levels, apart from saving precious lives. It would also reduce cost and avoid duplication of efforts and time. The referrals should not be automatic to the next higher level, instead the referring institution should be free to refer the cases to the institution, which in their opinion has the necessary facilities for providing competent services, required by the case (Fig. 17.5).

Fig. 17.5: Referral system

Telemedicine

Telemedicine is an essential part of the Health and Wellness Centres functions. Over 87000 HWCs are telemedicine enabled for regular consultation at higher facilities for treatment, referral and follow up. Tablets are being provided to CHOs, ANMs and Smart Phones to ASHAs. Ayushman Health Tele-Consultation

India has launched the largest Tele-Medicine Programme (e-Sanjeevani) in the world to connect all 150000 Ayushman Bharat Health and Wellness Centres (ABHWCs) from April 16, 2022. This provides online consultation of specialist/superspecialist health services to common citizens in the confines of their homes at no cost. It facilitates doctors-to-doctors and doctor to patients consultations. By the end of 31st March 2022 over 1.17 lakh AB-HWC have been operationalized in the country. National ambulance services: Referral transport services have been provided through dial 112 ambulance services by emergency service response vehicles.

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PRIVATE HEALTH SECTOR Over 80% of doctors, 26% of nurses and 49% of beds are available in private sector. The private sector accounts for nearly 80% health expenditure in India. It consists of private practitioners, solo-practitioners, polyclinics, nursing homes, general and speciality hospitals of allopathy system and Indian system of medicine, mostly in urban areas and some in rural areas. Many unqualified practitioners (compounders, RMPs, traditional healers, herbalists, faith healers, dais, etc.) are also available in rural and urban areas. The curative services provided by them are of variable quality. Private sector provides around 70% of ambulatory outdoor services and over 60% of indoor patient care. Both rich and poor people seek services from private sector. Private sector is the dominant provider of curative healthcare services with substantial share of outpatient treatment and inpatient care, but the quality of care is variable. The regulatory mechanism by the government can lay standards for service and charges and can involve the private sector in secondary and tertiary care. The private sector/practitioners can be paid for the services rendered by them. Tertiary care can largely be left to private sector after the regulatory mechanism. Similarly, private sector can be involved in national healthcare programmes and primary healthcare in urban slums on the basis of payment for service by the government, to fill the gap of urban primary healthcare. The rural and urban poor of India have limited resources to meet their health needs despite the big network of primary healthcare services. Most often they have to bear out of pocket (OOP) expenses for various unforeseen situations. These put them into the never ending debt trap. The problem is further aggravated as they resort to medical treatment only when faced with loss of wages due to illness. The preventive and promotive healthcare is almost nonexistent for them because of their preoccupation in field/labour for daily wage during the working hours of health institutions in the public sector. In the absence of an effective public health system most people (70%) in India turn first to the private sector for curative care and even poor people are prepared to pay substantial sums for it. Private sector limitations are that it primarily focuses on curative services because that is what the clients are prepared to pay for, that a poorest person cannot always afford services, that quality of services as in the public sector is variable. The private sector accounts for three-quarters of all health expenditure in India. Around 60% of current expenditure on health tends to be OOP expenditure in India. Direct consumer education on quality care and cost information could help patients when they seek providers. The public sector should take responsibility to guide private providers on standard regimens of diagnosis and

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treatment through training programmes to improve their practices. Regulatory mechanism for private sector as proposed in NHP 2002 may be difficult to implement on the ground situation—public–private partnership (PPP) within these limitations can be mobilized for enhancing access to healthcare. Employees State Insurance Scheme (ESIS)

Health insurance means you pay a premium out of your salary or income and get agreed upon services. The Government of India passed Employees State Insurance (ESI) Act in 1948. Under this Act, the employer–employee and the state and central government contribute and provide specified medical and healthcare besides social security to the employee. Focus

The focus of the programme is “employee” and his family. The employees of factories are covered in the scheme and it is primarily urban-based scheme where the factories are located. Coverage

It covers those non-seasonal factories or institutions, which employ 10 or more persons for wages. Under the Act, various factories and institutions are covered. Benefits

The medical benefits include medical care (outdoor, indoor and emergency services) as also maternity benefits, preventive and promotive and rehabilitative services including family planning services to employees and their families (read Chapter 11 for detail.) Establishment

The ESIS provides services through dispensaries, ESI hospitals and through arrangements of beds in hospitals and services of private practitioners. It has the provision of reimbursing the cost of treatment or provides free medical and health services against the contribution and eligibility of employees.

poverty every year, still remains a concern. In order to address this and provide health cover of ` 5 lakh perfamily per year for secondary and tertiary care hospitalization to poor and vulnerable section of the population, Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched, subsuming the erstwhile Rashtriya Swasthya Bima Yojana. The scheme aims to improve affordability, accessibility and quality of care for the poor and vulnerable section of the population. Launched with two pillars: (a) PMJAY (b) HWCs. a. Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (PMJAY)

It is the largest government funded health protection scheme of the world Salient features • Health insurance to cover 107 million poor and vulnerable families (500 million people) are entitled under AB-PMJAY for cashless and paperless access to services at empanelled hospitals. The health cover includes 3 days of Pre-hospitalization and 15 days of post hospitalization expenditures. • Coverage up to ` 5 lakhs/family/year to protect the poorest from catastrophic healthcare spending for secondary and tertiary care hospitalization in all government and private empanelled hospitals. All hospitals will deploy Ayushman Arogya Mitra. Ambitious plan can prevent 60 million Indians from slipping below poverty line annually due to catastrophic health expenditure. • More than 40% population to get benefit. Funding: The funding of scheme is shared between state and central governments. The ratio of central share to state share is 60:40 for all states except NE states where this ratio is 90:10. PMJAY will be expanded to 80% of the population on a voluntary contribution basis. • Ayushman Bharat Digital Mission: A digital health ID to every citizen to facilitate access to personal health records to doctors anywhere in India, was launched in Sept 2021. Salient Features

HEALTH POLICY AND HEALTH INSURANCE WHY: Close to 86% of rural and 82% of urban population was not covered under any health expenditure support and catastrophic health expenditure. AYUSHMAN BHARAT—PRADHAN MANTRI JAN AROGYA YOJANA

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Over the past few decades there has been improvement in various health indicators of India. However, the Out-ofPocket Expenditure, which pushes millions of people into

1 Cashless and paperless access to services for the beneficiary at the point of service in any (both public and private) empanelled hospital across India. 2 No family size limit, ensuring all family members, specifically the girl child and senior citizens, get coverage. It is suggested to preferably make the women as the head of the family. 3 The scheme is entitlement based. Every family figuring in defined SECC (socio-economic cast census) database and RSBY will be entitled to claim benefit under the scheme. The beneficiaries will be encouraged to bring Aadhaar for the purpose of identification but

Healthcare of the Community

no person will be denied benefits in the absence of Aadhaar card. 4 A well-defined complaint and public grievance redressal mechanism with robust safeguards to prevent misuse/fraud/abuse by providers and users is in place. Pre-authorisation will be made mandatory for all tertiary care and selected secondary care packages. All ongoing health protection or insurance schemes in various Ministries and Government will be merged with National Health Protection Mission. Health protection plan offers 1592 medical procedures covering secondary and tertiary procedures at fixed rates for each of these across 23 specialities. Institutional Structure

An independent autonomous body—National Health Authority at national level and State Health Authority at state level has been set up to implement the scheme. Modes of Implementation

1 Trust model/assurance model: The state health agency (SHA) reimburses healthcare providers directly without intermediation of insurance company. 2 Insurance model: State health agency pays premium to insurance company per eligible family. 3 Mixed model: Under this, the state health agency engages both trust and insurance models. b. Pradhan Mantri Health and Wellness Centres (HWCs)

• 1.5 lakhs sub-centres and primary health centres are being transformed to HWCs, so far 1.17 sub-centres have been transformed to HWC-SC. • HWCs will provide comprehensive primary healthcare services • Services being provided close to homes/community. Expanded range of health services at HWCs for:

• Pregnancy and child-birth • Neonatal and infant health • Childhood and adolescent health • Family planning and reproductive health • Common ophthalmic and ENT problems • Oral health • Mental health ailments • Elderly and palliative health • Emergency medical services • Management of communicable diseases • General outpatient care • Non-communicable diseases Each of these services has promotive, preventive and curative component and it follows a life cycle approach for continuum of healthcare.

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Supported with

• • • • •

Health promotion including yoga Free essential medicines and diagnostics Teleconsultation Robust IT system Electronic health records

Ex-servicemen Contributory Health Scheme (ECHS)

This scheme is meant for ex-army personnel. They have to contribute as per laid out norms and they are entitled for specified services in lieu of contributions. ECHS was launched with effect from April 1, 2003, with an objective to provide quality medicare to its members and their authorized dependents through 227 ECHS polyclinics (106 in military stations and 121 in non-military stations) across the country and a network of empanelled hospitals/ nursing homes and diagnostic centres. The scheme covers 20 lakh ex-servicemen and around 10 million beneficiaries. Periodical check up/screening tests as per age appropriate categories—once in five years for 40–50 years, once in two years for 60–79 years and every year for above 80 years will be conducted. The aim is early detection of chronic diseases and their effective management.

CENTRAL GOVERNMENT HEALTH SERVICES (CGHS) SCHEME It is a contributory health scheme. The CGHS was started in 1954 with the objective of providing comprehensive medical care facilities to the central government employees and their family members. Now besides central government employees, the scheme also provides services to members and ex-members of parliament, judges of supreme court, high court (sitting and retired), freedom fighters (free of cost); central government pensioners, employees of certain autonomous bodies/ semi-government organizations, accredited journalists and ex-Governors and ex-Vice Presidents of India. The scheme was initially started in Delhi and now extended to 72 cities. Set-up under CGHS

329 allopathic dispensaries (now named as wellness centres), 86 AYUSH dispensaries, 34 homeopathic and 9 unani, 2 siddha and 3 yoga dispensaries have been set-up in different parts of the country. In addition to above, 19 polyclinics, 73 laboratories, 74 dental clinics, 2 geriatric clinics and 4 hospitals and 19 postal dispensaries were functioning under CGHS. It has empanelled 1403 hospitals. Contribution: Monthly contribution for availing CGHS services ranges from ` 250 to 1000. Per capita expenditure is ` 11331.

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Facilities

The facilities of outpatient care and emergency inpatient care, free supply of drugs, lab and radiological investigations, domiciliary visit to seriously ill patients and specialists consultation are being provided to beneficiaries, through the above set up. Recognized private hospitals and diagnostic centres provide specialized treatment and investigation facilities. There are special facilities for the convenience of pensioners and senior citizens entitled to CGHS. Pensioners can obtain a ‘whole life’ CGHS card by paying 10 years subscription. Recognized hospitals also provide credit facilities to valid card holder. Beneficiaries

As on August 2020, there were 1250515 card holders and 3669224 beneficiaries of CGHS. Each beneficiary has to contribute part of pay on regular basis. RAILWAY HEALTH SERVICES

The organization of railways maintain 613 dispensaries, health centres and 125 hospitals with 13,702 beds for their employees to provide primary, secondary and tertiary level of care. There is comprehensive networking of services. ARMED FORCES HEALTH SERVICES

Armed forces run well-organized comprehensive healthcare for their personnel during peace and war situation. The services include preventive, promotive, curative and rehabilitation services through network of military hospitals, military and specialized centres. Military hospitals provide wide range of services for army personnel and their dependents. Well-organized rehabilitation services are in place to provide artificial limbs besides provision of vocational and occupational rehabilitation services. INDIAN SYSTEM OF MEDICINE OR AYUSH

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AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Sidha and Homeopathy). There are over 7,71,468 practitioners of AYUSH all over India. They are also important source of medical care to vast majority of population in rural and urban areas. These Indian systems have established institutions, hospitals and dispensaries for health services. People have faith in concepts and practices of indigenous system of medicine. AYUSH system has been involved in national healthcare programmes like family planning, malaria; and tuberculosis. They have the potentials to support primary healthcare in rural and urban slum areas. The government intends mainstreaming of AYUSH for reproductive and child health programme. This is an additional resource of trained medical manpower in India to support medical care. This potential resource can be

used at PHC for 24 hours service as envisaged under National Rural Health Mission 2005. Under NRHM, AYUSH practitioners are co-located in 40% of PHCs, 65% of CHCs and 69% of district hospitals. International Yoga Day of United Nations is celebrated in India on 21st June every year to popularise Yoga in the world. Department of AYUSH has been made Ministry of AYUSH. “Global centre for Traditional Medicine” is being set up in India in collaboration with WHO at Jam-Nagar in Gujarat.

OTHER SECTORS NON-GOVERNMENTAL ORGANIZATIONS (NGOS) AND VOLUNTARY SECTOR/AGENCIES

This sector provides services on non-profit basis. They supplement the efforts of governmental health services. They work in difficult and underserved and unserved areas with voluntary zeal. Apart from purely private providers of healthcare, the NGOs and voluntary sector have been providing healthcare services to community both in urban, rural and tribal areas. It is estimated that more than 7,000 voluntary agencies are involved in health-related activities. A wide inter-state differential exists in the coverage of villages by NGOs. NGOs providing a variety of services are relatively, unevenly distributed across and within states and have limited area of operation. Some implement government programmes of the department of family welfare and health, others run integrated or basic health services programme or provide special care/ rehabilitation to people suffering from specific diseases, e.g. leprosy patients; blinds and handicapped. Healthcare activities are also carried out by agencies like the RedCross, industrial establishments, Lion’s Club, Helpage India, etc. The National Rural Health Mission seeks to build greater ownership of the programme among the community through involvement of NGOs. Promotion of public–private partnership for achieving public health goals is one of the strategies initiated by the department in this regard. This partnership will reinforce the strategy of involvement of NGOs already spelt out in the National Population Policy, 2000. The Government of India is committed to voluntary and informed choice in family planning, reproductive and child healthcare services. Towards this end, the government, the corporate sector, voluntary and nonvoluntary sector are expected to work together in partnership. The professional bodies like Indian Medical Association, F e d e r a t i o n o f O b s t e t r i c i a n s a n d Gynaecologists are also involved in the partnership to achieve the desired goal.

Healthcare of the Community

PARTNERSHIP WITH NON-GOVERNMENTAL ORGANIZATIONS

The Government of India envisages collaboration with NGOs through enhanced participation by the state governments also. Under RCH II, the ownership of the program has been decentralized to the state governments. The planning process now starts from the district level. The scheme has been included in the state PIP for NRHM under RCH II. NGOs in particular, have been assigned supplementary or complementary role to that of the government healthcare delivery, thus aiding them in reaching the masses meaningfully. They have a comparative advantage of flexibility in procedures, rapport building with communities and are at the cutting edge of programme implementation. NGOs have been involved in ASHAs’ training, activities relating to National Disease Control Programmes, PNDT Act and service delivery in addition to health education and awareness programmes. Human Resources in Health (Health Manpower in India): Human resources in health are identified as one of the core building blocks of health system. They include physicians, nursing professionals, pharmacists, midwives, dentists and technicians. Over 10.72 lakh ASHAs and 5.53 lakh VHSNC are available at grass root level. Total number of allopathic doctors registered up to 2019 were 12,34,205 (1:1445 population), 7,99,879 AYUSH doctors (1:1682 population), 2,77,428 dental surgeons (1:10120 population), total number of ANM were 8,79,508, and registered nurses and midwives were 21,17,649. Nurse population ratio was 1:482. Human resources in health consume over 50–70% of the budget hence their role in the system of healthcare delivery is critical at all the levels. At sub-centres, 52696 male health workers and 1,80,769 ANMs were available. Quality of Health Services

Definition of quality: “Service delivery according to standards” or doing right things the right way. WHO-1988 definition by Roemer and Aguilar: “Proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question and that have the ability to produce an impact on morbidity, mortality, disability and malnutrition”. National Strategies to Improve Quality of Health Services in India

The various strategies adopted address all the dimensions of quality, to achieve client satisfaction, enhance demand for public health services and increase utilization of government health services. These strategies are: • Skill based training to enhance technical competencies of providers, Job aid tools and online training any time any where training, besides telemedicine are available now. • Standard treatment guidelines have been provided.

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• Indian Public Health Standards for health service delivery at sub-centres, PHCs, CHCs, UHCs district/ sub-district hospital have been implemented. • Community/client participation has been enhanced in planning, implementation and evaluation of health services. Health planning process now starts from village level with people consultation. VHSNC, RKS, district health societies have been created to oversee the health system. Target free approach has been adopted. • Regular quality assurance standards in PHCs, CHCs, UHC and HWCs district hospitals have been implemented. • Clinical Establishment Act is in place in some states. • Death review or mortality audit is in place to improve services and prevent avoidable mortality/premature mortality. (Like infant and maternal deaths review), • Operational Guidelines of 2013 and 2022 for quality Assurance Public Health Facilities are in place. HEALTHCARE UTILIZATION10, 11

Despite a steady increase in public healthcare infrastructure, utilization of public health facilities by population for outpatient and inpatient care has not improved. The NSSO (1996–2018) data clearly show a major decline in utilization of public health facilities for inpatient care and corresponding increase in utilization of same from private healthcare providers in both rural and urban areas as over 70% of people turn to private sector for outdoor patient care. In rural areas, 45.7% hospitalization took place in public hospitals and 54.3% in private hospitals the corresponding figures in urban India were 35% and 65% respectively. With the exception of a few states there has been a very low utilization of outpatient care as well (26–32%). Despite higher costs in private sector, this shift shows the people’s growing lack of trust in the public system. Reasons for low utilization—critical shortage of health personnel, inadequate incentives, poor working conditions, absenteeism, long wait, inconvenient clinic hours, poor outreach, insensitivity to local needs, inadequate planning, management and monitoring of service/facilities were the main reasons, besides poor quality of services lack of community participation; Lack of information, poor referral support and supervision and stock outs. This leads us to identify service delivery and management problems and their root causes. Root causes of health service delivery and management problems can be analysed by: i System framework analysis ii Cause effect analysis diagram—fishbone diagram or Kaoru Ishikawa diagram iii Flowcharts iv Why tree analysis.

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1 National Rural health Mission (NRHM). Meeting peoples health needs in rural areas. Framework for implementation 2005–2012. 2 12th five year plan 2012–2017. Health sector, Government of India. 3 National Health Policy 2017. MOHFW. Government of India. 4 GOI, NHSRC, NHM. Ayushman Bharat Comprehensive primary healthcare through Health and Wellness Centres. operational guidelines—2018. 5 Report of the task force on comprehensive primary healthcare rollout, MOHFW, Government of India 2015. 6 Revised Indian Public Health Standards (IPHS). Guidelines for Sub-centres, Primary Health Centres and Community Health Centres 2012 and 2022 DGHS, MOHFW. Government of India. 7 Quality standards for urban primary health centre, NHM. January 2016. MOHFW, Government of India. 8 Government of India MOHFW “Operational Guidelines for Improving Quality in Public Healthcare Facilities 2021”. 9 Lal S, Mathur SC. Poverty in Plenty. Editorial, IJCM April–June 1998;23:(2). 10 Key indicators of social consumption in India on Health, national Sample Survey 71st and 75th Round, 2014 and 2018. Ministry of Statistics and Programme Implementation, Government of India. 11 Government of India, MOHFW, NHM: Operational Guidelines for Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (A-BHIM) October 2021. Competency addressed: The student should be able to: CM 17.4: • Describe national policies related to health and health planning. This part of competency overlaps with 16.4 competency and discussed in Chapter 16 on page 665. • Describe Millennium Development Goals and Sustainable development goals.

MILLENNIUM DEVELOPMENT GOALS (MDGS)1

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These goals have been evolved in 2000 as a result of several global summits that took place in 1990s. The MDGs place health at the heart of development and represent commitments by governments throughout the world to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degradation. Three of the eight goals are directly health related, all the others have important indirect effects on health.1 1 Eradicate poverty and hunger by 2015. 2 Achieve universal primary education. 3 Promote gender equality and empower women.

4 Reduce child mortality. • Under-five mortality rate, and infant mortality rate 5 Improve material health. • 5B: Universal access to reproductive health. 6 Combat HIV/AIDS, malaria and other major diseases. 7 Ensure environmental sustainability. 8 Develop a global partnership for development. The revised Millennium Development Goals framework agreed by the United Nations General Assembly at the 2005 World Summit, effective from 15th Jan 2008 included specific target on reproductive health: MD Goal 5, Target B, which seeks to “Achieve, by 2015, universal access to reproductive health”. This new target falls within the goal of “improving maternal health”. The new indicators have been evolved for monitoring. Further most of the objectives/indicators relate to reproductive and child health (RCH) framework. The programmes to attain MDG are already in hands through RCH and other national health programmes as also National Population Policy 2000 (immediate and medium term goals) and Revised National Health Policy 2002 apart from National Rural Health Mission (NRHM). Countdown to 2015 was formed in 2005 by a group of scientists, policymakers, activists and institutions to track progress toward Millennium Development Goal 4. New official list of indicators and of key maternal, newborn and child health policies have been stressed.2 Progress of MDGs in India so far (2015)

Base Year 1990

India could reduce its IMR to the level of 40 under-five mortality from 123 to the level of 48 per thousand live births—a good progress indeed. Nearly 81% of deliveries were safe in India and the MDG 5, has made the least progress and India’s maternal mortality of 167 stays at high level. Similarly, adolescent birth rate stays at high level of 39. Nearly 33% of the under-three-children are underweight. Nearly 90% of population use improved drinking water source but only 40% of population use improved sanitation facilities (2015). HIV prevalence in adult population is stable at low level of 0.26% and DOTS programme is making rapid progress as high cure rate of over 85% is being achieved. Tuberculosis prevalence, and incidence has come down to the level of 195 and 167 per lakh population and mortality reduced to 17 per lakh. Vector-borne diseases including malaria continues as high morbidity, and pose continuous threat of outbreaks and epidemics in different parts of the country. Sustainable Development Goals (SDGs) of UNs

The MDGs have been reframed as “sustainable development goals”. The SDGs provide a framework to shape policies and agenda for next 15 years.

Healthcare of the Community

SUSTAINABLE DEVELOPMENT GOALS (SDGS) OF UNS VERSUS MDGS On 25th September 2015, the UN general assembly adopted the new development agenda “transforming our world—the 2030 agenda for sustainable development”. The 17 goals of the new development agenda integrate all three dimensions of sustainable development (economic, social and environmental) around the themes of people, planet, prosperity, peace and partnership (5 Ps).

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The SDGs seek to continue to prioritize the fight against poverty and hunger, while also focussing on human rights for all, and empowerment of women and girls as part of push to achieve gender equality. They also build upon, and extend, the MDGs in order to tackle the unfinished agenda/business of the MDGs era. One of the 17 goals is to “ensure healthy lives and promote well-being for all at all ages”. The health goal is associated with 13 targets including 4 means of implementation of targets (Tables 17.10 and 17.11).

Table 17.10: Sustainable development goals Goal 1

End poverty in all its forms everywhere

Goal 2

End hunger, achieve food security and improved nutrition and promote sustainable agriculture

Goal 3

Ensure healthy lives and promote well-being for all at all ages

Goal 4

Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.

Goal 5

Achieve gender equality and empower all women and girls

Goal 6

Ensure availability of water and sanitation for all

Goal 7

Ensure access to affordable, reliable, sustainable modern energy for all

Goal 8

Full and productive employment and decent work for all

Goal 9

Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation

Goal 10

Reduce inequality within and among countries

Goal 11

Make cities and human settlements inclusive, safe, resilient and sustainable

Goal 12

Ensure sustainable consumption and production patterns

Goal 13

Take urgent action to combat climate change and its impacts

Goal 14

Conserve and sustainable use of the oceans, seas and marine resources for sustainable development

Goal 15

Protect, restore and promote sustainable use of terrestrial ecosystems

Goal 16

Promote peaceful and inclusive societies

Goal 17

Global partnership for sustainable development

Table 17.11: Health-related sustainable development goals laid by United Nations, 2015 Targets of goal 3

Levels to be reached by 2030

• Stunting and wasting in children under 5 years of age

• By 2025 end all forms of malnutrition

• • • • •

• • • • •

Under-five mortality rate Neonatal mortality Reduce maternal mortality ratio Halve the number of deaths and injuries due to road traffic accidents Tuberculosis malaria and HIV/AIDS combat hepatitis, water-borne and other communicable diseases • Water and sanitation for all—end open defecation

25 per 1000 live births 12 per 1000 live births 70 per lakh live births By 2020 End the epidemics of TB, malaria and HIV and other communicable diseases • Universal access to safe drinking water and sanitation for all • Reduce by one-third By 2030 Do

• Premature mortality due to non-communicable diseases • Promote mental health—prevention and treatment of substance abuse • Universal health coverage, affordable essential medicines and vaccines for all • Ensure universal access to sexual and reproductive healthcare services • Reduce number of deaths and diseases due to air, water and soil pollution Strengthen the implementation of tobacco control (FCTC), essential medicines Substantially increase health financing and workforce, strengthen national capacity

Do Do Means of implementation

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Overall the SDGs have 169 targets and 230 indicators. It can be noted that the MDGs on maternal mortality, child mortality and infectious diseases have been retained in the SDGs framework, augmented by new and more ambitious targets for 2030, and expanded to include neonatal mortality, and more infectious diseases such as hepatitis and water-borne diseases. The targets on reproductive and sexual healthcare services and access to vaccines and medicines are also closely related to the MDG targets. The heart of SDGs is equity, which is founded on the concept of “Leaving no one behind”, i.e. reduction of inequality within and among countries. MDGs were focused on mothers and children and people affected by HIV, TB and malaria. In contrast the health SDGs address health and well-being at all ages including newborn and children, adolescents, adult women and men and older persons (lifecycle approach). SDGs also lay stress to achieve universal health coverage and reduce the burden of non-communicable diseases and promote health equity to build a fairer, healthier world.

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achieving the targets is largely driven by exemplary countrywide performance in Goal 6 (clean water and sanitation) and Goal 7 (affordable and clean energy) where the composite scores are 83 and 92 respectively. India has become open defaecation free in 2019. India’s SDG Goal 3 shows encouraging results—maternal mortality is reduced to 97, under 5 mortality reduced to 32, institutional deliveries 94.4%, fully immunized children between 9 and 11 months 91%, and incidence of HIV, malaria reduced considerably, however TB notification in India declined by 41% in 2020 due to Covid pandemic (services disruption). Covid-19 has reversed years of progress. However as per SDG report 2021 India’s ranking fell to 120 from 117 among 193 countries since its performance on hunger, stunting, wasting, anaemia, gender equality remained dismal. REFERENCES

Sustainable Development Goals (SDGs) India’s Index

1 MDGs, India country report 2015, New Delhi Central Statistical Organization 2015.

Country’s overall SDG score improved by 6 points from 60 in 2019 to 66 in 2020–21. This positive stride towards

2 United Nations—Transforming our world: The 2030 Agenda for Sustainable Development, September 2015.

18 International Health and International Health Regulations “Disease pandemic requires co-ordinated global response” GLOBAL HEALTH SECURITY AGENDA (GHSA)

INTERNATIONAL HEALTH REGULATIONS (IHR)

GHSA is global effort to strengthen core capacity of countries to prevent, detect and respond to infectious diseases outbreaks in animals and humans.

Competency addressed: The student should be able to: CM 18.1: Define and describe the concept of international health.

International Health Regulations (IHR), May 2005

The purpose of the revision of IHR is to develop regulations that are adapted to the present volume of international traffic and trade and take account of current trends in the epidemiology of communicable diseases, including emerging disease threats. IHR have been revised in May 2005 and have come into effect from June 2007. The revision and updating of IHR on Global Health Security, epidemic alert and global public health response to natural occurrence, accidental release or deliberate use of biological and chemical agents or radionuclear material that affect health, has enlarged the scope of public health emergencies to be notified to the WHO for rapid response (Flowchart 18.1). Major uses of IHR are: • IHR is the key global instrument for protection against the international spread of diseases.1 • IHR encourages the nations to establish effective National Health and Disease surveillance system and build capacity at various levels. • Ensures prompt notification of events that may constitute public health emergency of international concern, to WHO within 24 hours. • Provides appropriate public health emergency response. In each country, the national focal point has been established. In India, National Centre for Disease Control (NCDC) has been identified as national focal point for IHR. Toll free telephone no. 1075 is set-up to encourage lay reporting to health authorities for recognition and response to an unusual event or outbreak. Rapid response teams (RRTs) have since been constituted at national level

CONCEPT OF INTERNATIONAL HEALTH

The purpose of the International Health Regulations, adopted by the World Health Assembly in 1969, is to help prevent the international spread of diseases, and in the context of international travel, to do so with the minimum of inconvenience to the passenger. This requires international collaboration in the detection, reduction and elimination of the sources from which infection spreads rather than attempts to prevent the introduction of disease by legalistic barriers that over the years have proved to be ineffective. Ultimately, however, the risk of an infective agent becoming established in a country is determined by the quality of the national epidemiological services, and in particular, by the day-to-day national health and disease surveillance activities and the ability to implement prompt and effective control measures.1 No regulations can be expected to foresee every disease eventuality, and in certain situations, diseases and conditions other than those covered by the International Health Regulations may be of concern to national health authorities and the travelling public. The International Health Regulations obviously cannot refer specifically to diseases that were not known at the time they were last revised; this is the case with acquired immunodeficiency syndrome (AIDS), SARS (severe acute respiratory syndrome) and COVID-19. Nevertheless, any requirement of an HIV antibody test certificate (AIDS-free certificate) is contrary to the regulations. 739

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and checklist for central rapid response teams for disease outbreak investigations have been prepared. Core Capacity Requirements for Surveillance and Response2

1. At the Local Community Level and/or Primary Public Health Response Level Capacities

a To detect events involving disease or deaths above expected levels for the particular time and place in all areas within the territory of the state. b To report all available information to appropriate level of health care response. c To implement preliminary control measures. 2. At the Intermediate Public Health Response Levels Capacities

a To confirm the status of reported events and to support or implement additional control measures. b To assess reported events immediately and, if found urgent, to report all essential information to national level. The criteria for urgent events include serious public health impact and/or unusual or unexpected nature with high potential for spread. 3. At National Level—Assessment and Notification Capacities

a To assess all reports of urgent events within 48 hours. b To notify to WHO immediately through the national focal point for IHR. Public health response, the capacities: To determine rapidly the control measures required to prevent domestic and international spread, to provide support through specialized staff and laboratory, rapid dissemination of information and recommendations received from WHO and to establish, operate and maintain emergency response plan (Flowchart 18.1). Quarantine measures have been prescribed under IHR. Specific measures for vector-borne diseases like disinsecting, derating, disinfection of aircraft and ship have been specified and similarly core capacity requirements for airports, ports and ground crossing have been laid out. International Vaccination Requirements

Smallpox

The eradication of smallpox was confirmed by WHO nearly 45 years ago (1978). Smallpox vaccination is no longer indicated, and may be dangerous to those who are vaccinated and those in close contact with them.

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Plague

• Vaccination against plague shall not be required as a condition of admission of any person to a territory.

• For the purposes of these regulations, the incubation period of plague is 6 days for quarantine purpose. Cholera

Vaccination against cholera cannot prevent the introduction of the infection into a country. The World Health Assembly therefore, amended the International Health Regulations in 1973 so that cholera vaccination should no longer be required of any traveller. The traditional parenteral cholera vaccine conveys incomplete, unreliable protection of short duration and its use is, therefore, not recommended (WHO-official record no. 209, 1973). For the purpose of these regulations, the incubation period for cholera is 5 days. Yellow-fever Vaccination Certificate

Urban and jungle yellow fever occurs only in parts of Africa and South America. Urban yellow fever is an epidemic viral disease of humans transmitted from infected to susceptible persons by the Aedes aegypti mosquito. Jungle yellow fever is an enzootic viral disease transmitted among non-human primate hosts, and occasionally to humans, by a variety of mosquito vectors. For the purpose of these regulations, the incubation period of yellow fever is 6 days. A yellow-fever vaccination certificate is now the only certificate that should be required in international travel, and that only for a limited number of travellers. Many countries require a valid international certificate of vaccination from travellers arriving from infected areas or from countries with infected areas, or who have been in transit. Although there is no epidemiological justification for this latter requirement, which is clearly in excess of the International Health Regulations, travellers may find that it is strictly enforced, particularly for people arriving in Asia from Africa or South America. On the other hand, vaccination is strongly recommended for travel outside the urban areas of countries in the yellowfever endemic zone, even if these countries have not officially reported the disease and do not require evidence of vaccination on entry. The vaccination has almost total efficacy, while the case-fatality rate for the disease is more than 60% in adults who are not immune. Tolerance of the present vaccine is excellent. The only contraindication to its use, apart from true allergy to egg protein, is cellular immunodeficiency (congenital or acquired, the latter sometimes being only temporary). The period of validity of an international certificate of vaccination against yellow-fever is 10 years, beginning 10 days after vaccination. If a person is revaccinated before the end of this period, the validity is extended for a further 10 years from the date of revaccination. If the revaccination is recorded on a new certificate, travellers are advised to retain the old certificate for 10 days until the new certificate becomes valid. Meningococcal vaccine—for Haj pilgrims.

International Health and International Health Regulations

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Flowchart 18.1: Decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern

a

As per WHO case definitions.

b

The disease list shall be used only for the purposes of these regulations.

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INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES (ICD) AND RELATED HEALTH PROBLEMS A classification of diseases may be defined as a system of categories to which morbid entities are assigned according to some established criteria. ICD is used to translate diagnoses of disease and cause of death from words into an alphanumeric code which permits easy storage, retrieval and analysis of data. ICD-10 accepted as a WHO standard came into effect from 1993. The purpose of ICD is to compare the disease burden with different areas, states and countries and to compare the disease burden over different time periods within the same country. This helps to plan and evaluate the impact of health services and health programmes. ICD was formalized in 1893 as the Bertillon classification or international list of causes of death. The 11th revision of international statistical classification of diseases and related health problem is the latest in the series (ICD-11).3 ICD-11 contains 26 chapters or major groups of diseases, which are shown in Table 18.1, against XXI in ICD-10. Each chapter has categories and subcategories.

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Table 18.1: ICD-11 Mortality and Morbidity Statistics 2018 Version • 01 Certain infectious or parasitic diseases • 02 Neoplasms • 03 Diseases of the blood or blood-forming organs • 04 Diseases of the immune system • 05 Endocrine, nutritional or metabolic diseases • 06 Mental, behavioural or neurodevelopmental disorders • 07 Sleep-wake disorders • 08 Diseases of the nervous system • 09 Diseases of the visual system • 10 Diseases of the ear or mastoid process • 11 Diseases of the circulatory system • 12 Diseases of the respiratory system • 13 Diseases of the digestive system • 14 Diseases of the skin • 15 Diseases of the musculoskeletal system or connective tissue • 16 Diseases of the genitourinary system

The main innovations of ICD 10th revision: It replaced numerical system of coding frame with alphanumeric coding frame. Chapters have been assigned a unique letter or group of letters, each capable of providing 100 threecharacter categories. It uses an alphanumeric coding scheme of one letter followed by two or three numbers at the threecharacter categories and four-character categories, respectively. This has resulted in large coding frame and a stable coding frame (doubling the size of coding frame in comparison with 9th revision). The ICD is revised at an interval of 10 years period and accordingly ICD-10 which came into force in Jan 1993 was revised in 2018. International form of medical certificate of cause of death is mandatory.

• 17 Conditions related to sexual health

Major Changes from ICD-10 to ICD-11

• 26 Traditional medicine conditions—module I

Coding Scheme

• V Supplementary section for functioning assessment

Chapter numbering in ICD-10 was Roman which has been changed to Arabic in ICD-11. • Stem code (category) is 4 characters and there are 2 levels of sub-categories. • An alphanumeric code with a letter in the second position and a number in the third character position to differentiate the codes of ICD-10. The inclusion of a forced number at the third character position prevents spelling ‘undesirable words’. A letter in the second character position allows for clear distinction between a code from ICD-11 and one from ICD-10.

• 18 Pregnancy, childbirth or the puerperium • 19 Certain conditions originating in the perinatal period • 20 Developmental anomalies • 21 Symptoms, signs or clinical findings, not elsewhere classified • 22 Injury, poisoning or certain other consequences of external causes • 23 External causes of morbidity or mortality • 24 Factors influencing health status or contact with health services • 25 Codes of special purposes

• X Extension code

• Alphanumeric codes cover the range from 1 A 00.00 to ZZ9Z.ZZ. • Codes starting with an ‘X’ indicate an extension code. • The letters ‘0’ and ‘I’ are omitted to prevent the confusion with the number ‘0’ and ‘1’ • The first character of the code always relates to the chapter number. It may be number or a letter.

International Health and International Health Regulations

• A first character of 1–9 is used for Chapters 1 through 9 and for Chapters 10 through 26, the first character is a letter. The code range or a single chapter always has the same character in the first position. For example, 1 AOO is a code in Chapter 1 and B AOO is the code in Chapter 11.

INTERNATIONAL FORM OF MEDICAL CERTIFICATE OF CAUSE OF DEATH Cause of death

• The terminal letter ‘Y’ is reserved for the residual category ‘other specified’ and the terminal letter ‘Z’ is reserved for the residual category ‘unspecified’. Blocks are not coded within this code structure.

I

• Code cluster concept does not exist in ICD-10, whereas ICD-11 supports post-coordination and the linking codes within a code cluster.

Antecedent causes Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last

In its latest ICD, the WHO has included new emerging challenges of antibiotic resistance more closely in line with the global antimicrobial surveillance system (GLASS), gaming disorders (game addiction), has been added to section on addictive disorders besides ensuring sleep disorders. The focus on antimicrobial resistance is of special interest to India that has world’s largest burden of antibiotic resistance. New Chapters

Chapters 7 and 17 are new chapters on sleep-wake disorders and conditions related to sexual health. Similarly Chapter 4 on diseases of immune system and Chapter 26 on traditional medicine conditions are new. Chapter codes for special purpose included in Chapter 25. ICD-11 is also able to better capture data regarding safety in health care, which means that unnecessary events that may harm health—such as unsafe workflows in hospitals—can be identified and reduced. The new ICD also includes new chapter, one on traditional medicine: Although millions of people use traditional medicine worldwide, it has never been classified in this system. Another new chapter on sexual health brings together conditions that were previously categorized in other ways (e.g. gender incongruence was listed under mental health conditions) or described differently. Gaming disorders have been added to the section of addictive disorders. ICD-11 was presented to World Health Assembly in May 2019 for adoption by member states and is now available for implementation with effect from January 2022. The ICD is the foundation for identifying health trends and statistics worldwide, and contains around 55,000 unique codes for injuries, diseases and causes of death. It provides a common language that allows health professionals to share health information across the globe.

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Disease or condition directly leading to death*

Approximate interval between onset and death

(a) ........................ due to (or as a consequence of)

...........................

(b) ........................ due to (or as a consequence of) (c) ........................ due to (or as a consequence of)

...........................

...........................

(d) ........................ due to (or as a consequence of) II Other significant conditions contributing to the death, but not related to the disease or condition causing it

.........................

...........................

.........................

...........................

*This does not mean the mode of dying, e.g. heart failure, respiratory failure. It means the disease, injury, or complication that caused death.

Causes of Death

The causes of death to be entered on the medical certificate of cause of death are all those diseases, morbid conditions or injuries, which either resulted in or contributed to death and the circumstances of the accident or violence, which produced any such injuries. Death certificates are the main source of mortality data. They help in assessing the effectiveness of public health programmes, health planning and management and for deciding health priorities. Underlying Cause of Death

The underlying cause of death is defined as: a Disease or injury which initiated the train of morbid events leading directly to death. b ‘The circumstances of the accident or violence which produced the fatal injury’. Underlying cause of death is used for tabulation purpose. Example

A 67-year-old male admitted with retention of urine died of uraemia in the hospital. The chain of events followed were: a Uraemia b Hydronephrosis

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c Retention of urine d Hypertrophy of prostate 1 The immediate cause of death in this case is uraemia and underlying cause of death was hypertrophy of prostate. 2 Other significant conditions contributing to death: Old age. When an HIV positive person dies from TB disease the underlying cause is classified as HIV in ICD-10 regulations. While auditing deaths in lab confirmed cases of Covid-19, many states in India assigned the cause of death as underlying co-morbidity such as asthma, diabetes, hypertension and heart disease not the Covid-19. Thus, Covid-19 deaths were under-reported. Case Study

A 63 years old man had been treated for some years for malignant hypertension and developed hypertensive heart disease and chronic renal failure. While seriously ill with heart condition, he developed acute appendicitis and appendix ruptured. Appendicectomy was carried out successfully, but the heart condition deteriorated further and he died two weeks later. Student is asked to fill the standard format of death certificate—Part I and Part II and document in his/her practical log book. REFERENCES 1. WHO. International Health Regulations (2005). Second Edition. 2. GOI, NICD, DGHS, MOH and FW—Checklist for Central Rapid. Response team for disease outbreak investigation including Avian Influenza, 2005. 3. WHO. International Statistical Classification of Diseases and Related Health Conditions. Tenth Revision Volume 2, ICD10 and ICD-11. Competency addressed: The student should be able to: CM 18.2: Describe role of various international health agencies.

ROLE OF INTERNATIONAL HEALTH AGENCIES UNITED NATIONS

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Before the conclusion of the Second World War, some of the important powers decided to set-up an organization for the purpose of more effectively consolidating the forces for order and for the prevention of any likely recrudescence of the unfortunate trends that led to the Second World War. As a result of an appeal by the four great powers Britain, France, USA and the Union of Soviet Socialist Republic, a conference was held in 1945 at San Francisco and an organization called the United Nations emerged therefrom. It is significant that one of the first acts of the United Nations Organization through its Economic and Social

Council was resolution adopted for the constitution of a World Health Organization as one of the specialised agencies of the United Nations. The activities of this organization are now well-known throughout the world and the influence it has exercised on many problems of health in different countries has materially helped in the tackling of some of the major and urgent problems on a global scale. United Nations has laid down MDGs and SDGs to ensure Global Partnership for Sustainable Development as also promote peaceful and inclusive societies (Goal-16). WORLD HEALTH ORGANIZATION (WHO)

WHO turns 75, calls for renewed drive for “health equity” on the eve of its 75th anniversary. The WHO is one of the specialized agencies of the United Nations and came into being in 1948. This organization has more than 199 member states, which collaborates in the task of achieving the highest possible level of health throughout the world. The WHO deals with problems of health like malaria, cholera, plague, yellow fever and other communicable and non-communicable diseases which have an international as well as a national impact. Advice and assistance are given to countries requesting for such help in the fields of maternal and child health, nutrition, environmental sanitation, professional education, nursing, health, education of the public, mental health, etc. The WHO was established on 7th April 1948 and since then 7th April of every year is observed as “World Health Day”. The World Health Day 2020 chose theme ‘year of the nurse and midwife’ Health Care Workers face greater risk of infection such as Covid-19 and other nosocomial infections. The WHO is a non-political, international health organization of United Nations committed to promotion of attainment of highest standard of health by all citizens of the world. Over the years, its membership has grown and it has 199 countries as its members. The Constitution of the WHO defines ‘health’ as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and goes on to say that one of the fundamental rights of every human being without distinction of race, religion, political belief, etc. is the enjoyment of the highest attainable standard of health. The objective of the WHO being the “attainment by all people, the highest possible level of health”, its functions are described inter alias as given below. Functions of WHO

• It coordinates international health through International Health Regulations of 1969 which are amended from time to time. New regulations are in place since 2005. • It collects and disseminates the information on an international notifiable diseases through weekly epidemiological reports; thereby serves as a warning centre for epidemics, and pandemics.

International Health and International Health Regulations

• Helps in establishment of national surveillance system of diseases of public health significance. • It strives for ‘health for all’ through primary health care systems. • It publishes weekly epidemiological reports, world health statistics quarterly, world health statistics annually, world health reports on public health problems. • For the purpose of uniformity and comparison, WHO has brought out international classification of diseases and gives standard definition of various morbid conditions and events. This system helps to achieve comparison and uniformity in reporting and recording. The latest international classification of diseases (ICD) is ICD-11 released in 2018. • It promotes and supports biomedical research at national, regional and international levels. Notably MONICA research on cardiovascular diseases is an example worth citing. • WHO helps certify eradication of diseases/disease from a territory-based on established international criteria. It certified eradication of smallpox way back in 1978 and it also certified eradication of guinea worm disease from India in the year 2000. Polio-free India Certified by WHO on 27th March 2014. • It establishes international reference laboratories for research and identification of emerging diseases. • It supports the Nations by providing health experts in different fields. • Supports fellowship programmes. • Helps/supports eradication of diseases and national health programmes to control diseases of public health significance (communicable and non-communicable). WHO has established 6 regional offices 1 2 3 4 5 6

South–East Asia with HQ at New Delhi (India). Africa with HQ at Harare (Zimbabwe). The American HQ at Washington DC (USA). Europe HQ at Copenhagen (Denmark). Eastern Mediterranean HQ at Alexandria (Egypt). Western Pacific HQ at Manila (Philippines).

UNITED NATIONS INTERNATIONAL CHILDREN’S EMERGENCY FUND (UNICEF)

The UNICEF is one of the specialized agencies of the United Nations created for the purpose of providing aid, primarily in the fields of health, welfare and nutrition of the mothers and children. It works in close cooperation with other specialized agencies of the United Nations like the WHO, FAO and UNESCO. The UNICEF provides and supplies equipment not available within the country when asked for such help. It gives material help for the training of national personnel and technical advice is provided by the WHO and the FAO. Every type of UNICEF assistance

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has, as its basic purpose—the improvement of maternal and child health. United Nations International Children’s Emergency Fund (UNICEF) was born in 1946 to deal with the problems of children after Second World War; many of them left as orphans and suffered increased morbidity and mortality after war. Though the emergency functions are over it continues to retain its old name UNICEF and the new name is ‘United Nations Children’s Fund’. Functions

It plays the role of advocacy for mother and child and supports the programmes and services for mother and child development all over the world. Initially, it focused its attention on children only and mothers were forgotten. Its concern for mother developed subsequently. Major functions and supports provided in all the areas of women and child development covers the areas of feeding and nutrition, immunization, water and sanitation, education, integrated child development services, programme for adolescent, literacy, integrated management of childhood illness and many welfare programmes. UNICEF supports training, research and service programmes in the area of mother and child. It provides equipment, machinery and other materials to support the health and development of mothers and children. Salt iodation plants have been set-up with the assistance of UNICEF. The assistance given falls into the following major categories. 1 Basic maternal and child health services including health centres and training of national personnel. 2 Disease control including control and eradication of diseases such as malaria, TB, leprosy, etc. which affect large number of children. 3 Nutrition including supply of milk for child feeding. 4 Social services for children. 5 Emergency aid to mothers in time of disasters— earthquakes, famine, etc. India, which has undertaken intensive rural health development work by the establishment of primary health centres in collaboration with the community development centres, has received aid from the UNICEF in the shape of technical equipment, midwives and nurses kit, drugs, milk, vitamins, motor vehicles, bicycles, etc. The major underlying cause of infant and child mortality being malnutrition, the UNICEF has been donating powdered skimmed milk for distribution to infants and children through the maternal and child welfare centres, schools, clinics, etc. They have gone one step forward and have set-up milk conservation plants for the production and distribution of safe milk in larger quantities. Aid for nine dairy plants have also been executed. This has increased production, processing and distribution of pure milk, as cheaply as possible. They train the national staff

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to plan, supervise and carry-out the nutrition programmes. In collaboration with the FAO, the UNICEF is helping to increase the production and consumption of protective foods (applied nutrition programme) besides iodation of salt to control iodine deficiency disorders. COLOMBO PLAN

The Colombo Plan is cooperative enterprise of member governments of the commonwealth countries in order to further economic and social progress and to make these countries self-reliant. The Colombo Plan has contributed to the higher training of a large number of medical and auxiliary personnel in all fields. The All India Institute of Medical Sciences at Delhi was established with the financial assistance from one of the Colombo Plan countries, viz. New Zealand. The plan provides for visits to countries by experts who can offer advice on local problems and train the local people, and supply of equipment, especially to teaching institutions. Mention may also be made of the contribution by the New Zealand Government of a Dairy Plant to Delhi under the Colombo Plan. The contribution of Canada in supplying cobalt therapy units to medical institutions in India is another important item of aid under the Colombo Plan. TECHNICAL COOPERATION MISSION (TCM)

The programme commenced in the first year of the first 5-Year Plan and is based on an agreement signed between the Governments of US and India on the 5th January 1952, with the view of promoting and accelerating integrated economic development of India. Under this agreement, projects of technical cooperation mutually agreed upon between the two countries are executed. A separate agreement is again signed for each of the projects in question. The schemes are jointly financed by both the governments. The contribution of the TCM is for meeting overseas’ costs of equipment and materials, freight exports and training facilities. The US International Cooperation Administration provides the financial assistance for the TCM programmes. The following projects under the TCM are included in the field of health: i Malaria control and malaria eradication. ii National water supply and sanitation. iii Assistance of medical colleges and allied institutions. iv Health institutions training centres. v Control of filaria. vi Medical education. vii General nursing. viii Vector-borne disease control.

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ROCKEFELLER FOUNDATION

The Rockefeller Foundation has been operating in India since 1920. It began with a scheme for the prevention and

control of Hookworm disease in the Madras Presidency. Later the foundation was associated with several health and medical programmes in India. In the beginning the foundation had treated fields of public health and medical education as two separate issues. Since 1951, however, the two have been combined under a single programme with wide objectives. The establishment of the All India Institute of Hygiene and Public Health at Calcutta was in a large measure due to the cooperation of the Rockefeller Foundation. The foundation’s programme included the training of competent teachers and research workers in a certain number of selected medical colleges, training abroad of candidates from India through fellowships and travel grants, research on fundamental health problems and the adoption of research as an integral part of the medical course and the sponsoring of visits of a large number of medical specialists from the USA. Mention should also be made of the establishment of the Virus Research Centre in Pune by the ICMR in collaboration with the Rockefeller Foundation. The foundation has not only provided equipment and supplies, but also provided some of the staff members and facilities for the training of research work on insect-borne viral diseases. The ICMR has been receiving financial aid from the Foundation for the implementation of their fellowship programme for training junior medical teachers in Indian institutions. The Christian Medical College and Hospital at Vellore, The Seth GS Medical College, Bombay, The Christian Medical College, Ludhiana, The KG Medical College, Lucknow, are some of the institutions which have been constantly helped by the Rockefeller Foundation over a period of years. Mention should also be made of the contribution of the Rockefeller Foundation to the All India Institute of Medical Sciences, New Delhi, for the purchase of equipment and for construction work. Fellowships and travel grants in the fields of public health, medical education, research, and nursing have been awarded by the Rockefeller Foundation. International Clinical Epidemiology Network (INCLEN) was started by the Rockefeller Foundation to build-up critical mass of researchers in clinical epidemiology. FORD FOUNDATION

This is another agency from which India has received aid for the implementation of some of its national health programmes. Their contribution has been mainly in the public health field. For instance, the Foundation has helped in the establishment of public health orientation training centres, research-cum-action projects in environmental sanitation, pilot projects in rural services at Gandhigram and the Rural Latrine Programme. The orientation Training Centres at Singur, Poonamallee and Najafgarh provide training courses in public health for doctors, nurses, health visitors, sanitary inspectors, midwives and other public health personnel all over India. The basic public health principles and health education techniques are emphasized

International Health and International Health Regulations

in the training of such personnel. The Ford Foundation has also made available a large sum of money to support programmes of education and family planning for the action-cum-research centres. FOOD AND AGRICULTURE ORGANIZATION (FAO)

The FAO is mostly concerned with the problem of increased food production and banishment of hunger from the face of the earth. Herein comes the nutritional aspect of the people of India and the impairment of health through undernutrition and malnutrition. In this respect, the FAO has been working in close collaboration with other international organizations and with the Ministries of Food and Agriculture and Health through Government of India. The FAO had recommended at its conference in Rome in 1957 that due attention should be paid to the nutritional status of the people while formulating policies of food production in all countries. COOPERATIVE FOR AMERICAN RELIEF EVERYWHERE (CARE)

The CARE is a non-profit, non-sectarian and nongovernmental organization of the United States created in 1946 with the primary objective of sending food from American donors to people of war-devastated Europe. Today this organization serves many countries and supplies food packages and kits for use in vocational training, agriculture, health and education programmes. Mid-day school meal programme in India was supported by CARE. WORLD BANK

World Bank assists the developing countries to improve the quality of life by advancing loans. The areas/domain where World Bank has provided assistance include: Education, control of communicable diseases, water supply and sanitation, communication, population control, malaria, and HIV/AIDS. Notably in India roll back malaria kala-azar, IDSP, RCH programme, blindness control and construction of roads have been supported by World Bank apart from state health systems development projects to improve secondary health care. DEPARTMENT FOR INTERNATIONAL DEVELOPMENT (DFID)

This is the bilateral agency of United Kingdom (UK). In India, this organization has supported the programme on

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reproductive and child health, financing of National Family Health Survey-3 as also Revised National Tuberculosis Control Programme (RNTCP) phase II, besides HIV/AIDS, and polio eradication. Globally, it works for elimination of world poverty, illiteracy and gender inequality. UNITED NATIONS POPULATION FUNDS (UNFPA)

The UNFPA assisted 6th Country Programme (CP-6). It supports the programme activities on reproductive health, population and development strategies and advocacy in India. The four complementary interventions included in CP-6 were: HIV/AIDS, adolescent health, gender issues and monitoring through result based programming. UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID)

This agency supports the innovations in family-planning services (IFPS) project in Uttar Pradesh and now extended to Uttarakhand and Jharkhand. The project includes reproductive health, child survival and HIV/AIDS with emphasis on increasing public/private partnership, catalytic role for technical assistance, integrated client centred services and sustainability. INTERNATIONAL RED CROSS SOCIETY (IRCS)

It works on the principle of “Peace through humanity”. The primary activities of IRCS are, evacuation of war casualties, disaster relief, promotion of voluntary blood donation and collection of blood for transfusion, maternity and child welfare, medical relief and rehabilitation, community services, ambulance and nursing services, and training courses in first aid/rescue operations, promotion of junior/youth red cross, establishment of working women hostels, homes for aged and mentally retarded, and destitutes apart from HIV/AIDS prevention programme. This is the largest humanitarian organization which strives towards the creation of better society. DANISH INTERNATIONAL DEVELOPMENT AGENCY (DANIDA)

This agency has supported the National Blindness Control Programme in India in terms of development and training of manpower, funding equipment and material apart from establishment of district blindness societies. Another thrust area of DANIDA is poverty reduction in developing nations.

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19 Essential Medicines and Rational use of Drugs “Vast Majority of cough and cold and acute watery diarrhoea need no antibiotics”

India is pharmacy of the developing world, but about half of its population does not have access to essential lifesaving medicines and the situation is worse when it comes to medical devices and in vitro diagnostics. Currently, private service providers are treating large number of patients (70%) at the primary level for major diseases. However, the treatment regimens followed are diverse and not scientifically optimal, leading to an increase in the incidence of drug resistance. Such practices need to be curbed by training and by providing adequate information to private practitioners on drug regimens to be followed under national health programmes for major endemic diseases. Competency addressed: The student should be able to: CM 19.1: Define and describe the concept of essential medicines list (EML).

CONCEPT OF ESSENTIAL MEDICINES LIST (EML)

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Drugs and medicines form a substantial portion (almost 72%) of the out of pocket spending on health by households. Components of drugs and medicines form 10% of the overall health budget. Share of drug expenditure to total household health expenditure is 70%. Over 60,000– 80,000 brands of medicines are available in India but only 350 are considered essential or required to meet the needs of majority of population. WHO has its essential list of drugs known as “Model list” of 312 medicines of 2003 and 2011 has been revised and released in 2015. WHO in 2017 (WHO technical report series 1006) has added 30 new medicines to essential medicines list of 376 drugs. Now WHO model list of essential medicines 22nd list (2021) is in place. The National List of Essential Medicines (NLEM) 2022 includes 384 medicines against 376 of year 2015 NLEM. It has added 34 and deleted 26 medicines. Four new

cancer drugs have been added now, these have to get cheaper now. New list deletes Ranitidine because of cancer concerns. The Government of India has opened Jan Aushadhi Kendras—a countrywide chain of 7500 medical stores to make quality generic and other drugs available at reasonable affordable prices. Most states have adopted an essential drugs list for public health system selected from model list of WHO. Availability of essential drugs in every HWC, PHC and CHC will increase people’s confidence in public health system and increase utilization of services. The states are promoting: • Use of generic drugs. • Rational use of drugs by adopting standard treatment guidelines and prescription audit. • In 2020 Ministry of Health and FW has recommended facility wise Essential Medicines list (EML) to be made available at the Public Healthcare facilities. List of 105 essential medicines at SHC-HWC, 172 at PHC-HWC and 455 at CHC and 544 at District Hospitals has been recommended. • Use of standard treatment guidelines: These have been adopted in the country for National Programmes on malaria, tuberculosis, STI/RTI, IMNCI, ARI, AIDS and diarrhoeal diseases control programme. Standard case management protocols are available. Essential Drugs, and Medicines at Subcentre (HWC)

The essential list of medicines at subcentre and urban wellness centre is indicated in Table 19.1. Emergency drug kit at sub-centre Inj. adrenaline, Inj. hydrocortisone, Inj. dexamethasone, Glyceryl trinitrate sublingual tablet 0.5 mg. 748

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Table 19.1: List of essential medicines for HWC–SHC/UHWC—(IPHS 2022) S. No.

Name of medicine

1–2

Anaesthetic agents, oxygen gas, lignocaine topical form 5%/injection

3–6

Analgesics, antipyretics, NSAID Tab aspirine 75 mg, diclofenac 50 mg and injection, ibuprofen 200 mg, paracetamol 250 mg

7–10

Anti-allergic and medicines used for anaphylaxis Tab levacetirizine 5 mg, hydrocortisone injection 100 mg, pheniramine injection 22.75 mg adrenaline injection 1 mg/ml

11–12

Antidotes and other substances used in poisoning Activated charcoal, injection atropine 1 mg/ml

13–18

Anti-convulsant/anti-epileptic/anti-psychotic Magnesium sulfate injection 2 ml ampoule; tab diazepam 5 mg, midazolam nasal spray, tab phenobarbitone 30 mg, sodium valproate

19

Intestinal anthelomentics Tab albendazole 400 mg/oral liquid 200 mg/5 ml

20

Antifilarial—Diethylcarbamazine tablet 100 mg/oral liquid

21–26

Antibacterial Amoxicillin capsule 250 mg/500 mg, gentamicin injection 10 mg/ml, Tab co-trimoxazole 80 mg, + trimethoprim 400 mg, capsule doxycycline, tab metronidazole 200 mg, norfloxacin tablets

27

Anti-tuberculosis medicines

28

Anti-leprosy drugs

29–31

Anti-fungal medicines Clotrimazole ointment, miconazole ointment, fluconazole tab 150 mg

32

Anti-malarial medicines

33–34

Medicines used in palliative care Lactulose oral liquid, povidone iodine lotion and ointment

35–37

Anti-anaemic medicines Ferrous salt 100 mg + folic acid 500 µg (large and small tablets) Folic acid tablet 5 mg, vitamin K injection 1 mg/ml

38–41

Cardiovascular medicines used in angina Tab Isosorbide—S—Mononitrate 5 mg, atenolol 50 mg, metroprolol 25 mg, isosorbide dinitrate 5 mg (sublingual)

42–45

Antihypertensive medicines Tablet ambodipine 2.5 mg, enalapril 40 mg, telmisartan 40 mg, hydrochlorothiazide 12.5 mg

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Hypolipidemic medicines—atorvastatin 10 mg

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Medicnes used in dementia—alprazolam tab 0.25 mg

48–54

Dermatological medicines (tropical) Silver Sulphadiazine cream 1%, betamethasone cream 0.05%, calamine lotion, benzyl benzoate ointment, mupirocin cream, potassium permanganate 0.1%, zinc oxide cream 10%

55–60

Disinfectants and antiseptics Ethyl alcohol solution 70%, hydrogen peroxide 6%, gentian violet, bleaching powder with 30% available chlorine, gamabenzene hexochloride, framycetin sulphate ointment

61–63

Ear, nose and throat medicines Cipro floxacin drops 0.3% and tablets, borospirit ear drops, ear wax solvent drops and turpentine oil

64–74

Gastrointestinal medicines Ondansetron 4 mg, omeprazole capsule 20 mg, Ispaghula granules/husk, ORS, zinc sulphate 20 mg, dicyclomine 10 mg, dioctyl sulfosuccinate sodium, magnesium hydroxide, sena powder and domperidone tablet/syrup

75–81

Contraceptives Ethinylestradiol (A) + levonorgestrel tablet, IUCD 380 and 375 male condom, ormeloxifene tablet 30 mg, EC pill-Levonorgestrel 1.5 mg medoxyprogestrone acetate injection 150 mg, pregnancy testing kits Contd…

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Table 19.1: List of essential medicines for HWC–SHC/UHWC—(IPHS 2022) (Contd…) S. No.

Name of medicine

82–84

Medicines used in diabetes mellitus Levothyroxine tablet 25 mcg, 50 mcg, 100 mcg

86–87

Vaccines—As per national prog and rabies vaccine

88

Oxytocics and abortificent medicine Misoprostol tablet 200 mcg

89–93

Medicines acting on respiratory tract Budesonide 0.5 mg/ml (nebulizer), salbutamol tablet 2 mg, normal saline drops, dextromethorphan oral syrup, hyoscinebutylbromide 10 mg Tablet

94–96

Solutions correcting water electrolyte and acid base disturbances Ringer Lactate injection, sodium chloride injection 0.9%, dextrose 25% and 5%

97–102

Vitamins and minerals Tab B complex, vitamin C tablets 100 mg, calcium carbonate tab 500 mg, cholecalciferol tablet 60000 IU, Pyridoxine 25 mg and 50 mg, vitamin A solution 100000 IU/ml

103–104

Ophthalmological medicines Sodium cromoglycate 2% eye drops, methyl-cellulose eye drops

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Diuretics Furosemide injection (Lasix) and tablet 40 mg

Now the essential list of medicines at subcentre/health and wellness centre is as under: ANMs have been trained under IMNCI and they can administer first dose of antibiotic in cases of suspected sepsis in neonates before referral (injection gentamicin for sepsis). ANMs can give pre-referral dose of antenatal corticosteroids in preterm labour, Vitamin K at birth, antibiotics for pre-mature rupture of membranes and advance distribution of tablets misoprostol for prevention of post-partum haemorrhages similarly ANMs are responsible for managing adverse events following immunization (AEFI) by use of adrenaline injection provided in emergency kit. Mid level health provider can indent essential drugs for treating non-communicable diseases (diabetes and hypertension, COPD, epilepsy, etc.) from PHC. Competency addressed: The student should be able to: CM 19.2: Describe role of essential medicines in primary health care.

diseases like diarrhoea and pneumonia and malaria and other endemic diseases. Availability of uninterrupted supplies of essential medicines at SC, PHC and CHC enhance service utilization and continuity of service. Misuse of drugs reduces their efficacy, making the microbes resistant.

LIFE-SAVING COMMODITIES IN RMNCH + A PROGRAMME With a strong focus on the reproductive, maternal, newborn and child health (RMNCH) ‘continuum of care’, the UN Commission identified and endorsed an initial list of 13 overlooked life-saving commodities that, if more widely accessed and properly used, could save the lives of more than 6 million women and children. RMNCH continuum of care

Commodity

Usage

Reproductive health

• Female condoms

Family planning/ contraception Family planning/ contraception Family planning/ contraception

Role of Essential Medicines in Primary Health Care

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Essential drugs at sub-centres and primary health centre like ORS, cotrimoxazole, vitamin A, IFA tablets, vaccines, contraceptives, mebendazole, chloroquine, paracetamol, methylergometrine and chlorine tablets are life-saving drugs. National Rural Health Mission supports provision of essential drugs and equipment to all PHCs of 18 high focus states. These drugs save life and disability and help in management of life-threatening

• Implants • Emergency contraception Maternal health

• Oxytocin • Misoprostol

Postpartum haemorrhage Postpartum haemorrhage Contd…

Essential Medicines and Rational use of Drugs Contd…

RMNCH continuum of care

Commodity

Usage

• Magnesium sulfate

Eclampsia and severe preeclampsia, toxaemia of pregnancy

Newborn health

• Injectable antibiotics • Antenatal corticosteroids (ANCS) • Chlorhexidine • Resuscitation equipment

Newborn sepsis Respiratory distress syndrome for preterm babies Newborn cord care Newborn asphyxia

Child health

• Amoxicillin • Oral rehydration salts (ORS) • Zinc

Pneumonia Diarrhoea Diarrhoea

Competency addressed: The student should be able to: CM 19.3: Describe counterfeit medicine and its prevention.

Counterfeit or Fraudulent Medicines in India

“A counterfeit medicine is defined as one that either contains the wrong ingredient, or none of the specified active ingredient, or the correct active ingredient at the wrong dose”. India is one of the leading global producers of low cost generic medicines due to high domestic demands and inexpensive manufacturing cost. India is global pharmacy of the world. Manufacturing and sale of counterfeit or faque medicine is a global problem but much more prevalent in developing countries like India. Nearly 20% of drugs in India are proven to be faque, while in developed countries the rate of faque medicines is quite low at 1% only. Consequences of this practice could be life-threatening as these drugs may not produce the desired effects in severe diseases (life-threatening diseases). It is estimated that 3/4 of counterfeit medicines produced globally originate from India.

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2 Regulatory control over drugs. 3 Implementing innovative counterfeiting measures such as mass serialization and forensic markers. The Central Drugs Standard Control Organization (CDSCO) headed by Drugs Controller General of India regulates quality of drugs marketed in the country under the Drugs and Cosmetic Act. The mission of this organization is to safeguard and enhance public health by assuring safety, efficacy and quality of drugs, medical devices and cosmetics. • The manufacture, sale and distribution of drugs in the country is primarily regulated by the state drug control authority while control over drugs imported for the first time in the country is by the CDSCO. State government appoints drug inspectors who lift samples of drugs for quality testing by designated state laboratory. • Seven central drug testing laboratories under CDSCO have been accredited. • Standards for drugs: The Indian Pharmacopeia Commission (IPC) sets the standards and quality specification of drugs and pharmaceuticals in the form of Indian Pharmacopeia (IP), and it promotes rational use of drugs. To ensure drug safety IPC runs pharmacovigilance Programme of India (PVPI) to protect the health of citizens of India. Now nebulisers, BP apparatus, glucometers and thermometers have been included in the list of essential medicines/equipment under Drugs and Cosmetics Act. Medical Stores Organization (MSO)

• Lack of consumer awareness • Self medication • High cost of genuine medicines • Weak enforcement of legislations • Prevalence of internet pharmacies—online selling • Difficult to detect counterfeit medicines According to WHO, 50% of drugs sold online are fraudulent.

Under the DGHS, MOH and FW Govt of India finalizes rate contracts and procurement and supply of medicines at the right time, with right quantity and right quality to various health institutions of the country through seven Government Medical Store Depots (MSDs). MSO also procures supply of medicines in natural calamities/disasters as also vaccines (yellow fever and meningococcal vaccine). The MSO through MSD accepts drugs from various manufacturers, duly inspects each and every batch of drugs and gets tested from government approved laboratories. Supply of generic medicines at low cost through AMRIT stores (affordable medicines and reliable implants for treatment): To address the rising out of pocket expenditure the government has opened chain of affordable medicines and reliable implants for treatment (AMRIT) stores selling life-saving drugs at half of the market price. Over 9000 Jan Aushadhi Kendras have been opened across the country to make available essential medicines at 50 to 90% cheaper prices than the medicines available in the market.

Prevention of Counterfeit Medicines in India

Cost-Effective Treatment Rules for 40 killer Diseases

Reasons for Counterfeit Medicines

1 Education of people—to raise the level of awareness of faque drugs.

With affordable health care out of bounds for commoners, the government has decided to issue guidelines on cost-

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effective treatments for top killer diseases. The move involves publishing standard treatment guidelines and best technologies for the management of priority diseases on the line of UK’s National Institute for Health Care and Excellence. Fifteen top priority diseases identified include—cancers, cardiovascular diseases, diabetes, TB, malaria, mental disorders, suicides and substance use, diarrhoeal diseases, neurological diseases including epilepsy, dementia, schizophrenia, HIV/AIDS, dengue and other vector-borne diseases, hepatitis, snake and scorpion bites and malnutrition. Patients will be able to make choices about the treatment technologies. Conclusion

Standard treatment protocols and use of EML for treatment can reduce drug resistance in India besides saving money (economic benefits). Anti-microbials should be prescribed only when necessary after a clear diagnosis.1, 2 Need to End unsafe Medication Practices

Under a new ‘Global Patient Safety Action Plan’ 2021– 2030 the WHO aims to advance policies, strategies and actions to eliminate all sources of avoidable risk and harm to patients and health workers by addressing counterfeit and substandard products and enhancing patient safety and reporting systems. The WHO has several focus areas: • The first is to establish patient safety incident reporting and learning systems. • Second is to develop and implement standard operating procedures (SOP), for safe medication use. Third help health workers to stay updated on safe medication practices. And fourth increase awareness about the importance of using medication safely. Unsafe medication practices contributes 134 million adverse events annually resulting in around 2.6 million deaths.

Indian Scenario

The focus of AMR is of special interest to India that has the world’s highest burden of AMR. The published reports in the country reveal an increasing trend of drug resistance in common diseases like cholera, enteric fever, malaria kala-azar, ARIs, etc. Based on AMR surveillance data of ICMR in 2016 as part of global antimicrobial surveillance system (GLASS) coordinated by WHO it was estimated that 50% or more of hospital antimicrobial use was inappropriate. A recent study in the Lancet Microbe and Global burden of bacterial antimicrobial in 2019 indicated 4.95 million deaths across the world were attributed to AMR. The AMR is facilitated by: • Irrational use of drugs. • Self medication and over the counter drugs. New Lancet Study indicates that unapproved antibiotic formulations constituted 47% in India. Azithromycin 500 mg tablet was the most consumed antibiotic formulation. Cephalosporin was the most used antibiotic class followed by Penicillin and macrolide. After Jaipur declaration on AMR and in view of grave problem of AMR, National Programme on AMR containment was launched in 2013. National Centre for Disease Control (NCDC) is the nodal agency. Objectives

• To generate data for common bacterial pathogens. • To determine magnitude and trends of AMR in India. • To update and standardize treatment guidelines on infectious diseases. • To promote rational use of antibiotics. • Spreading knowledge on infection control. • To standardize national treatment guidelines for practitioners and various health facilities. Activities

NATIONAL PROGRAMME ON CONTAINMENT OF ANTIMICROBIAL RESISTANCE Antimicrobial resistance is a global public health threat with serious health, economic and political implications. NATIONAL PROGRAMME FOR ANTIMICROBIAL RESISTANCE (AMR) CONTAINMENT

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AMR is well recognized a global threat to human health. Infections caused by antimicrobial resistant organisms in hospitals are associated with increased morbidity, mortality and healthcare costs. AMR has emerged even to newer and more potent antimicrobial agents such as carbapenems. ICD 11 revision includes new emerging challenges of AMR and gaming disorders as new diseases.

• Surveillance: To generate AMR data for common bacterial pathogens through network of ten laboratories across the country. • Development and implementation of national infection control guidelines. • Information education and communication activities to build awareness. • To develop unified national treatment guidelines for treatment of different infectious diseases. • Development of national repository of bacterial strains/ cultures. Achievements

• National treatment guidelines for antimicrobial use in infectious diseases version 1.0 (2016) have been formulated and disseminated for use.

Essential Medicines and Rational use of Drugs

• Besides standard treatment guidelines under various national health programmes of control/elimination of diseases, standard treatment guidelines for 227 medical conditions belonging to 21 specialities have been issued. • These guidelines will be further refined and reviewed based on new scientific evidences. • National policy document on AMR evolved in India. Very High Prevalence of Antimicrobial resistance to 7 most common bacteria, viz, Escherichia coli, Klebsiella species, Pseudomonas species, Acinetobacter species, Staphylococcus species and Salmonella enterica serotype typhi and paratyphi and Enterococcus species is worrisome in India. The resistance to 3rd and 4th generation cephalosporins among E. coli is 77% and 63% respectively, similar to that observed in Klebsiella spp, 79% to 3rd and 69%

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to 4th generation cephalosporins. 60% isolates of Pseudomonas spp. are resistant to ceftazidine. Emergence of resistance to Linezolid in gram-positive and Colistin resistance to gram-negative pathogen is matter of concern for public health. REFERENCES 1. National Treatment Guidelines for Antimicrobial use in Infectious diseases version 1.0 (2016) NCDC, DGHS, MOHFW. Government of India. 2 MOH and FW Essential Medicine list of SHC, PHC CHC— ABHWC NHM—2020 3 GOI, MOHFW, DGHS, NCDC, National Programme on AMR Containment. Annual Report – 2021 (NARS-Net India).

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20 Recent Advances in Community Medicine “A teacher must keep on learning” On 23-7-2022 WHO declared monkeypox as Public Health emergency of International concern over 85,756 cases and 261 deaths spread over in 110 countries have been reported. India reported 23 cases from Kerala and Delhi with one death.

Competency addressed: The student should be able to: CM 20.1: List important public health events of last four years.

IMPORTANT PUBLIC HEALTH EVENTS FROM 2019 TO 2022

National Events

I. International Events

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India gets new education policy after 34 years in 2020. It makes school education compulsory from 3 years (ECCE).

• ICD-11 released in 2018 and implemented from Jan 2022. • Ebolavirus disease—declared as Public Health Emergency of International concern in July 2019 by WHO. • Novel coronavirus pandemic (Covid-19) with epicentre at Wuhan in China spreading to 220 other countries of the world. • World Health Day 2021—Building a fairer healthier world for everyone to eliminate health inequities. • Vaccines against Covid-19 developed and launched in 2020. • Global Strategy for Cervical Cancer Elimination launched by WHO in 2020. • WHO revised Global Air Quality standards in 2021. • UNDP-Human Development Report in 2021—HDI of India at 0.663. • WHO Global centre for Traditional medicine at JamNagar in Gujarat—India • First malaria vaccine—‘MOSQUIRIX’ approved by WHO in October 2021. • WHO approved Covaxin for emergency use on 3rd Nov 2021. • Omicron variant of SARS-CoV-2 emerged on 24th Nov 2021. Sub-variants of Omicron BA 1 and BA 2 and their combination—‘XE‘ sub-variant is responsible for Covid surge in Asia and Europe and China. It evades immunity. XBB.1.16 spikes cases in India Variant XBB.1.16

II. Natural Disasters

• Unprecedented floods in Kerala in 2018 and 2019, killing 86 people, in Assam, Bihar, Karnataka, Maharashtra, Gujarat and MP in July–Aug 2019. • Cyclone Fani Struck Odisha on 3rd May, 2019. • Supercyclone—Amphan struck West Bengal and Odisha with massive destruction, killing 92 people in West Bengal in May 2020. • Severe cyclone—NISARGA struck Mumbai and Gujarat in June 2020. Devastating flood in Assam, Bihar and Kerala in June–July 2020. • Cyclone “Gulab” hit Andhra, Telengana and Odisha in September 2021. • Flash flood in Kerala and Uttarakhand in October 2021 killed over 100 persons. • Flash floods in Assam, Maharashtra, Gujarat Telengana and Karnataka affected million in June-July 2022 over 300 people died. III. Outbreaks/Epidemics

• Covid-19 pandemic in 2020. • Outbreak of Nipah virus in 2018 in Kerala at Kozhikode and Malappuram districts killing 16 of 18 confirmed cases with CFR of 88.8% and visited again in 2019 and 2021. • Avian influenza in 12 states of India in Jan 2021. 754

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• Vaccines against Corona-19 developed. India developed three vaccines—Covishield, Covaxine and Zycov-D. • First human case of bird flue (H5N1): An 11-year-old child from Gurugram, Haryana died at AIIMS 2021 on July 12 confirmed by NIV Pune. • Zika virus disease outbreak in Kerala, and Maharashtra— 65 confirmed cases were reported in July 2021 and at Kanpur in UP in October 2021 reported 10 cases. • National Covid vaccination drive launched on 16th Jan 2021. • NIPAH outbreak in Kerala in Sept 2021, one child died. IV. New Programmes and Policies

• Giudelines on programmatic management of drug resistant TB in India 2019. • All oral H mono/poly, shorter, and longer MDR-TB regimen started in 2020. • Magnitude of substance use in India (MOSJE GOI, Feb 2019). • Updated guidelines on PMDT (drug-resistant TB) and diagnostic algorithm revised in 2019. • Historic Triple Talaq Act of July 2019 for women empowerment. • NFHS-5 report released in Dec 2021. • National Medical Commission Act, 2019. • National TB Disease Survey, 2019–2021 completed. • ICMR-NIN, GOI, Recommended dietary allowances for Indians and estimated average requirements 2020. • Competency based Undergraduate Curriculum rolled out along with AETCOM course in 2019–20. • State of Global Air/2020 released key statistics for India, estimated 1.67 million deaths in India due to air pollution in 2019. • WHO revised Air Quality Guidelines levels released in 2021. • Longitudinal Ageing Study in India (LASI) wave-1 India report released in 2020. • National integrated HIV, viral hepatitis B and C sentinel surveillance survey conducted in Jan 2021, and 2023. • ICMR data on fourth sero-survey-Covid-19 conducted in June-July 2021 released. • PM Digital Health Mission (PM-DHM)—provision of healthcare with unique ID to all to facilitate access to health data of individual anywhere in India. • New HMIS version 2.0 launched in December 2020. • Operational guidelines 2020 on active case detection and regular surveillance for leprosy released. • India slipped to 101 rank in Global Hunger Index in 2021 (FAO) behind Pakistan, Bangladesh and Nepal. • For termination of pregnancy, gestational period has been increased from 20 to 24 weeks under the MTP (Amendment) Act 2021. • Phase 2 of India hypertension control initiative launched in 2019. • Revised national guidelines for rabies prophylaxis— 2019.

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• Ayushman Bharat Health Infrastructure Mission (ABHIM) launched in October 2021. • TPT guidelines released in India in July 2021. • First quadrivalent human papilloma vaccine (qHPV) CERVAVAC by SII Pune is under review of NATAGI. • Global health Leader Award for ASHAs of India in 2022 by WHO. • Indian Public Health Standards Revised in 2022 by MOHFW. • Overall population sex ratio (females per 1000 males) went up from 991 to 1020. Between NFHS-4 and 5 crossing 1000 mark for the first time in India. • 125 year old woefully inadequate Epidemic Disease Act of 1897 being replaced by Public Health Act 2020. • Prohibition of child marriage amended bill to raise the age of marriage of girls from current 18 years to 21 years is pending in parliament. • Birds flu in Maharashtra in Feb 2022 and at Alappuza in Kerala in December 2021. • GYTS-4 National fact sheet released in 2021. • Influenza subtype H3N2 circulating in India January to March 2023 causing rise in cases. • H3N2 influenza caused 3038 cases in India Competency addressed: The student should be able to: CM 20.2: Describe various issues during outbreaks and their prevention.

VARIOUS ISSUES DURING OUTBREAKS AND THEIR PREVENTION 1. Issues Related to Detection of an Outbreak

Denial and Under-reporting

The number one obstacle is to fight denial. The important reasons for hiding and denying outbreaks could be: • No skills to investigate • Additional work for everyone • Press pressure • Fear of sanctions. Outbreaks are only investigated when there is a large cluster—which shows that the system is reactive only or the system acts under pressure when most cases have occurred or else the system never investigates and denies the occurrence of outbreak, e.g. occurrence of JE cases in Bihar, recently. Prevention by

Technical training, guidance and motivation of staff. Investigation methods/detection methods can be learned and detection becomes easier with practice as data guides prevention measures and good investigations impress the press besides leaders appreciate signs that situation is under control through visible actions.

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2. Preparedness for Outbreak Investigations and Control Preparedness Tends to be Weak in the System

Mock exercised by RR team are essential to test preparedness 3. Weak or Inadequate Surveillance System for Early Detection of Outbreaks

Though the IDSP is in place since 2004, the surveillance system for epidemic prone diseases tends to be very weak on ground situation, despite the presence of district epidemiological unit. Medical officers do not write the diagnosis in the OPD register. i Data is not compiled and not looked into before transmission to district surveillance officer (weekly reports on forms P, S and L). ii Data is not analysed locally to detect outbreaks and seasonal variations at early stage. Early warning signals such as clustering of cases or deaths, increase in cases or deaths, two or more epidemiologically linked cases of disease with outbreak potential, e.g. measles, cholera, dengue, Japanese encephalitis are most often ignored. Workers are not encouraged to report such incidences. iii Reports on surveillance by various units are not in time and are incomplete. Laboratory support needs to be improved to make surveillance more lively. Setting up of Block Public Health Unit at Block/CHC level is under way to strengthen disease surveillance and decentratized planning. Setting up of integrated public health labs in all the districts under PMABHIM is welcome. iv Local communities participation and informants system is poorly developed. Village health and sanitation committees, PRIs and ASHAs involvement can be most effective. Prevention

i IDSP register with diagnosis has been provided to them but entries in this register seldom match with outpatient register and reports. Heavy rush of OPD is cited as most often excuse. ii Strengthen surveillance system by supportive supervision, motivation and use of data collected locally for planning of programme and early response. 4. Issues Related to Health Systems

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i The IDSP works through existing health system of village, Sub-centres, PHCs and CHCs, Urban Health Posts/centres and Sentinel hospitals. In many of the areas/states the health workforce/human resources are deficient to the extent of 50% of doctors, nurses and paramedical workers. Thus, the system is functioning sub-optimally and early detection of outbreaks and quick response is absent. Recent JE outbreak in Bihar at Muzaffarpur is live example. Besides human

resources poor logistics, monitoring and supervision are inadequate. Health being state subject, the primary responsibility of prevention and control of outbreaks lies with state governments, which do not spend sufficient budget on health (low budget for health). Spending by states be increased to more than 8% of their budget by 2022. District epidemiological units are weak and not pro-active. ii Involvement of private health providers/practitioners: Because of inefficient Government Health System people turn to private health providers and these providers treat over 70% of spells of sickness, hence their capacities for early detection of outbreaks, disease notification and control and prevention must be fully utilized. They need to be provided updated national guidelines on control and prevention of outbreaks by organizing shortterm training through various professional bodies. 5. Poor Data-management: Covid Epidemic

Hopefully improved infrastructure under PM Ayushman Bharat Health Infrastructure Mission (ABHIM) ensures better preparedness for effective response to current and future outbreaks/Epidemics. Competency addressed: The student should be able to: CM 20.4: Demonstrate awareness about laws pertaining to the practice of medicine such as: Clinical Establishment Act and Human Organ Transplantation Act and its implications.

TRANSPLANTATION OF HUMAN ORGANS AND TISSUES ACT (THOTA) IT RELATES TO AETCOM MODULE 4.3

Transplantation of Human Organs Act, 1994, amended in 2011 and 2014, now known as THOTA. Implications

A large number of persons suffer from end-stage organ failure; they require transplantation. There is huge gap between the requirement of organs and their availability. There is also a threat of commercial dealing in organs. Transplantation of Human Organs Act, 1994 was, therefore, enacted to regulate removal, storage and transplantation of human organs for therapeutic purposes and for prevention of commercial dealings in human organs. The Act has been adopted by all states and UTs except J and K, Andhra Pradesh and Telangana. The amended Act and Rules thereunder provide for inclusion of tissues in the Act along with organs. Act expands the definition of ‘near relative’ to include grand children, and grand parents. There is provision for—‘Transplant coordinator’ in all registered hospitals under the Act, provision of higher penalties for trading in organs, to protect vulnerable and poor, simplification of brainstem death, certification committee and permission for enucleation of corneas by a trained technician.

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Implementation of Act

The Government of India is implementing National Organ Transplant Programme (NOTP) to retrieve, store and transplant of organs, training of manpower and awareness generation to promote organ donation from deceased persons. There is need to promote organ donation from deceased (cadaveric) donors rather than relying on living donors, because of commercial trading and increased risk to health of living donors. Under the programme an apex level organization, viz. National Organ and Tissue Transplant Organization (NOTTO) has been set up at Safdarjang Hospital at Delhi with its main activity to formulate policy, guidelines for organ donation and transplantation, establish national network of organ retrieval, transplant centres and tissue banks through a dedicated online system. Five regional level organizations called Regional Organ and Tissue Transplant Organization (ROTTO) have been established at Chennai, Chandigarh, Guwahati and Kolkata. Similarly, State Organ and Tissue Transplant Organizations (SOTTO) are being set up. Anyone above 18 can donate. Age cap of 65 years removed. Clinical Establishment Act (CEA), 2010

A. What is it?

The Act is for registration and regulation of the clinical establishments (except those of Armed Forces), with a view to prescribe minimum standards of facilities and services which may be provided by them. Recognized qualifications of person incharge of clinical establishment have been specified. The Ministry of Health and Family Welfare has notified clinical establishments. B. Application

The Act is applicable to 11 states and 6 UTs. C. National Council for Clinical Establishment (NCCE)

Under the Chairmanship of DGHS this body performs the following functions. State councils for clinical establishments have been also constituted. i Compiling and Publishing National Register of clinical establishments. ii Classify the clinical establishment into different categories. iii Develop the minimum standards for establishment and their periodic review. iv Determine the first set of standards for ensuring proper healthcare. v Collect statistics on regular basis. D. Implementation

• Facility for online registration for clinical establishments. • Operational guidelines in respect of minimum standards have been issued to implementing states. • Standard treatment guidelines (STGs) of 227 medical conditions in respect of 21 clinical specialities for provision of proper care have been uploaded on website.

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• STGs prescribed under National Health Programmes have been compiled and uploaded. • STGs for Ayurveda have been compiled. • Advocacy-cum-training workshops conducted. • List of medical treatment and standard template of costing of procedures and services has been prepared and states have been advised to use it. • Consumer Protection Act, see Chapter 1. • Medical termination of Pregnancy Act, see Chapter 9. Competency addressed: The student should be able to: CM 20.3: Describe any event important to health of the community.

RECENT EVENT IMPORTANT IN HEALTH OF COMMUNITY CORONAVIRUS DISEASE (COVID-19) PANDEMIC 2020–23

The emergence of the novel coronavirus SARS-CoV-2 at Wuhan in China in December 2019 followed by its rapid spread first in China and then to 220 countries of the world. WHO declared it Public Health Emergency of International Concern on 30th January, 2020 and subsequently pandemic on 11th March, 2020. Covid-19 is a new disease. There is still much to discover about disease and its impact. Preparedness, response and actions will continue to be driven by rapidly accumulating scientific and public health knowledge. In the natural history of Covid-19, there are two most important key factors: i Behaviour of VIRUS (mutation) and ii Behaviour of HOST—COVID-Appropriate Behaviours. Data/information presented on Covid-19 is to be interpreted cautiously as the epidemic is still evolving. Population-based data on morbidity and mortality is awaited. Reported Covid-19 data is nowhere nearer to actual numbers CHARACTERISTICS OR BEHAVIOUR OF THE VIRUS

New coronavirus is an RNA virus; genetically distinct from the one that causes SARS and MERS. The virus responsible for Covid-19 is different from SARS with respect to community spread and severity. It causes illness ranging from common cold to much more serious cases of pneumonia and deaths. The virus spreads much faster than SARS but causes less severe disease; with case fatality of 3–5%, compared to 11% in SARS and 50% for MERS. Mutant Strains of Virus

The original virus—SARS-CoV-2 has undergone mutation. to survive. The virus survives only in humans.

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WHO so far has flagged and classified six variants of concern (VOC), namely—Alpha, Beta, Gamma, Delta and Omicron and its sub-lineage BA. 1 and BA. 2 (Stealth variant) and six variants of interest (VOI), namely—Eta, Iota, Kappa, Lambda, Mu, and XBB.1.16. XE is hybrid of BA. 1 and BA. 2 omicron variants and similarly BF. 7 which caused surge in China, Japan, South Korea, US and Brazil is variant of Omicron. BF. 7 variants of Omicron are highly transmissible with short I.P and high ‘R’ of 10–16. It evades immunity. It is unlikely to cause IVth wave in India because 90% of Indian population has developed hybrid immunity. Cases of Alpha variant have been reported in 172, Delta in 170, Beta in 141, Mu in 40 and Gamma in 91 countries. Omicron variant has been detected in over 110 countries. Omicron’s infectivity is nearly 4–5 times higher than Delta variant. Omicron is thus highly transmissible, less severe and milder so far, most often asymptomatic or mild; does not invade lung, causes less hospitalization sheer number of omicron infections may overwhelm healthcare systems. Omicron causes, Tsunami of cases so huge and quick. It has now outpaced Delta strain in many parts of the Globe. Viral Replication Rate—‘R’

Level of infectiousness is denoted by ‘R’ effective. It means average number of new cases directly generated by one infected person during the entire infectious period in population. If ‘R’ is = 2, it means one infected person can infect 2 others, in the absence of control measures such as wearing masks and social distancing, one infected person can infect half of household members. Secondary attack rate of Covid is 75% within 5 days of onset. Transmission

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I Covid-19 is primarily airborne transmission. Airborne transmission is different from droplet transmission as it refers to the presence of microbes (viruses) within droplet nuclei—smaller particle less than 5 µm in diameter and which remain in air for a long time as aerosols and be transmitted to other over distances greater than one meter. Coronavirus in droplet nuclei can be carried over to 10 meters distance (New Lancet Study). Airborne transmission occurs rapidly in crowded places. II This is also transmitted through respiratory droplets and close contact. Droplet transmission occurs when one has close contact within one meter with a person having respiratory symptoms—coughing or sneezing which may spread these potential droplets typically 5–10 µ in size. III Transmission may also occur touching surfaces or objects in immediate environment’s around that infected person, and then touching nose, mouth or eyes. The virus can survive on surfaces from 2 hours to 9 days. Air pollution and Covid-19 is double whammy.

Airborne spread of virus is quite common in indoor croweded places and overerowded markets and in large gatherings (festivals, religious, election, farmers rallies and revenge tourism). These events are called superspreader events. Mass reverse migration of labourers from cities because of loss of livelihood caused by extended lockdown enhanced transmission and spread of Covid to local population in India. Hence, keep potential superspreader events under check for now to prevent next surge. Wearing mask has become important more than ever to prevent infection and transmission. It spreads faster in indoor crowded spaces (WHO), hence improved ventilation can reduce transmission. Air pollution and Covid-19 is double whammy in urban slum areas. Covid-19 spreads very very rapidly in densely populated areas like slums of Dharavi in Mumbai, Chennai and Delhi hence urban slums are high-risk areas. Transmission Pattern/Scenarios

Category 1: No reported cases Category 2: Sporadic cases—countries or territories/ areas with one or more cases imported or locally detected. Category 3: Cluster of cases—countries or territories/ areas experiencing cases clustered in times, geographic location and/or by common exposures. Category 4: Community transmission—countries/territories/areas experiencing larger outbreaks of local transmission. Incubation Period

Incubation period ranges from 1 to 14 days, average being 5–6 days Symptoms and Long-term Sequelae

Common symptoms of delta variant are: Cough, shortness of breath or difficult breathing and high fever, along with muscle pain, new loss of taste and smell, chills, repeated shaking with chills, headache and sore throat, nausea and diarrhoea. Patients are infectious a few days before the symptoms, during the illness and a few days after the recovery. Variable proportion (50 to 70%) of asymptomatic cases have been reported in India. They are potential spreaders of infection in the community. Data suggests that if someone had an infection, 80% of them remain protected at least 7 months. Long Covid

Long-term effects of Covid-19 are: Nearly 80% of recovered cases face Covid issues including fatigue,

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bodyache, inability to concentrate, dry cough which resolves in 6–8 weeks and some develop permanent lung fibrosis, breathlessness, cardiac damage, stroke, kidney disease, neurological and psychological complications. ‘Long Covid’—about 10% of adults show persistent symptoms 6 months after initial infection—most commonly lingering cough, shortness of breath, persistent fatigue, dizziness and insomnia. SUSCEPTIBILITY AND IMMUNITY

No one is immune to novel corona virus. All are susceptible to infection. However, infections are more in young people in India, which constitute 65% of population below 35 years of age. Covid-19 is a mild disease in younger age groups and severe in people above 60 years with comorbidity. WHO has declared that corona infection does not provide absolute protection from reinfection and antibody test is not “immunity passport”. Reinfection, though rare, is possible. Reinfections are mild and mostly asymptomatic, can spread to other persons. GEOGRAPHIC SPREAD UP TO 31st MARCH 2023 Global Situation

Although over 220 nations have been affected, it is an uneven pandemic. Ten nations made up 81% of all cases and deaths. The US, India, Brazil, UK and Russia account for half of world’s cases (Table 20.1). Countries across the world are currently at different phases in the evolution of Covid pandemic. Pandemic will continue to evolve, future will depend on choices we make. Number of confirmed Covid-19 cases across the planet surpassed 761 million and over 6.8 million have died. In India, UK and US, the situation was explosive. The US continues to be worst hit country with world’s highest number of 102 million cases and 11 lakh deaths. In terms of infections, India follows in the second place with 44.7 million cases. In terms of deaths, Barzil comes at second place with 6.99 lakh deaths (Table 20.1). Experts say it is only the tip of iceberg when it comes to true impact of the pandemic that has affected life and livelihood around the world (John Hopkin University) in critical ways. The actual worldwide Table 20.1: Global scenario of Covid-19 Jan 2020 to 31st March 2023 Country

Cumulative number of cases reported in million

Cumulative Deaths in (lakh)

US India France Brazil Germany UK Italy

102.6 44.7 38.6 37.2 38.3 24.2 25.6

11.17 5.30 1.61 6.99 1.70 2.10 1.88

World total

761.4

68.87

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tally of Covid-19 cases is likely to be far higher as the testing has been variable. Many people have had no symptoms and some governments have concealed the true number of cases. To date, over 6.79 million confirmed deaths have been reported which may be undercount. Global increase has been driven by surge in India, Europe and US due to emergence of mutated strain of virus in UK, India, Brazil, and Mexico. Although the global level trends in cases and deaths have been declining over the recent weeks. The global situation remains highly fragile. “There is significant variations by region, by country and within countries. “In all WHO regions, there are countries reporting sharp increase in cases and hospitalizations. In the past 3 years, substantial progress has been made towards ending the acute phase of the Covid-19 pandemic. However, the combination of more transmissible variants, increasing social mixing and suboptimal vaccination coverage will delay the end of the pandemic”. China driven Omicron variant-BF. 7 surge triggered a global alert in Dec 2022. China’s zero Covid policy proved counter-productive. Indian Scenario

Real burden of disease and deaths is not known precisely as the epidemic is still evolving. India is the 2nd hard hit country with 44.7 million Covid cases and 5.30 lakh deaths (Table 20.1). India reported its first case of Covid-19 on 30th January, 2020 from Kerala. By 6th March, only 29 confirmed cases were reported including 16 Italians. All had history of travel to Italy and Dubai. Since then, the trend is rising and there is linear growth of confirmed cases. Exponential growth of daily surge was observed in August and September 2020, as first wave, second wave in AprilMay 2021 was most furious and deadly and 3rd wave in Jan–Feb 2022 was mild. Maharashtra state was the worst affected state in India followed by Kerala, Karnataka and Tamil Nadu. These four states contributed over 50% of Covid-19 cases and 56% of deaths in India (Table 20.2). Table 20.2: Worst affected states in India due to Covid-19 cumulative cases and deaths up to 31st March 2023 States

Cases

Deaths

1. Maharashtra

81,43,686

1,48,441

2. Kerala

68,35,918

71,620

3. Karnataka

40,77,103

40,322

4. Tamil Nadu

35,96,651

38,050

5. Andhra Pradesh

23,39,186

14,733

6. Uttar Proadesh

21,28,776

23,650

7. West Bengal

21,19,004

21,533

8. Delhi

20,09,656

26,526

4,47,15,786

5,30,867

India

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Mumbai (Maharashtra) was the worst affected area in India. Four metros and big cities, namely Mumbai, Ahmedabad, Chennai and Delhi almost contributed 60% of infections in India. Maharashtra alone contributed almost 19% of total infections and 28% of deaths. Covid infection in India was largely concentrated in urban slums of metros and big cities. Covid-19 pandemic has affected urban areas disproportionately. Accordingly a paradigm shift in urban primary healthcare through urban health and wellness centres and polyclinics was planned in 2022. Over 80% of cases in big metros during 3rd wave were due to Omicron infections. Virulence

The virulence and impact of Covid-19 in different geographical regions varies. Therefore, predictions based on mathematical models and trajectories of infection and deaths in one part of the world do not hold good for all countries. Impact of Covid-19 in India is related to its younger population (65% being less than 35 years of age), with lesser lifestyle-related susceptibilities, infection were restricted and concentrated to small population in metros and big cities in first wave. Rural areas did not report any significant hotspots.2 PROFILE OF CASES/SPECTRUM OF COVID-19

In India about 92% of Covid cases were reported to be mild and managed at home isolation, in only 5.8% of cases oxygen therapy was required and 1.7% of severe cases required intensive care unit support. Oxygen is needed when saturation falls below 94%. Over 90% omicron infections were mild or asymptomatic Age and Sex Morbidity and Mortality

• Analysis of limited data revealed that 76% of infections were in men against 24% in women. Nearly half—47% of infected were below 40 years of age; 34% between 40 and 60 years and 19% were above the age of 60 years. • Data suggests that 64% of deaths occurred in males and 36% in females. In terms of age distribution, 0.5% were in less than 15 years age group, 2.5% in 15– 30 years, 11.4% in 30–45 years, 35.1% in 45–60 years and 50.5% in persons above 60 years of age. Further, 73% deaths had underlying co-morbidities. Elderly people above 60 years of age with co-morbidities remained high-risk groups for Covid-19. Mortality

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Overall case fatality rate due to Covid-19 in India was consistently low between 2% and 3% as compared with average high of 5.53% in other counties of the world. It is because young people are affected most in India in comparison to older persons in other countries. It indicates the impact of stringent, timely National Lockdown strategy early in the epidemic. However, Covid

morbidity and mortality in India varied from state-to-state and district-to-district. India has one of the lowest deaths per million–374, much lower than US–2920, Brazil–3092 and Mexico 2498. Certain reports and studies have reported excess deathshigher than the official reported number of deaths. Covid19 pandemic has drawn the attention of nation for improving the cause of death statistics in India. In most of deaths the cause of death is not available-both in rural and urban areas, despite presence of robust Sample Registration and civil Registration System in the country. Only 22% of deaths were medically certified in India in 2020 (CRS–2020). There is a concern of under-reporting of Covid-19 lab confirmed deaths by many states. While auditing deaths, many states assigned the cause of death as underlying comorbid conditions like asthma, hypertension, diabetes, heart disease rather than Covid-19. New estimates from WHO suggest that full death toll associated directly or indirectly with Covid between Jan 2020 and December 2021 was approximately 14.9 million, representing 9.49 million more deaths than 5.42 million globally reported as directly attributable to SARS–COV 2 virus. WHO estimates of Covid deaths for India were 4.7 million almost 10 time higher than 4.81 Lakh of official reported deaths directly attributable to covid. WHO data on deaths include, besides the deaths attributable directly to Covid-19, deaths due to complications following infection, delay in treatment of cancers and other diseases, disruption in essential health services, postponement of surgeries and lack of lifesaving medicines. Deaths data reported by official agencies donot reflect these indirect deaths. That explains the huge difference between WHO estimates and official reported deaths in India. Management of Covid-19

There is no specific medicine/drug against coronavirus. The management is symptomatic. Over 80–85% of Covid are mild cases can be managed at home, 15–20% may need hospitalization and 5% may need ICU support. Standard precautions for all patients for infection prevention and control are observed. World Health Organization study in 30 countries including India in over 405 hospitals says currently there is no specific drug for Covid-19. The widely used remdesivir, hydroxychloroquine, lopinasivir, interferon or integeron plus lopinasivir, ivermectin and plasma therapy has all been ineffective in preventing Covid deaths or reducing their recovery time in severely sick. Oxygen is life saving. Pulse oxymeter measures level of oxygen saturation; which can be monitored along with temperature and pulse rate by patient at home to spot danger and seek timely help. Corona takes away your breath and causes death due to hypoxia—when oxygen saturation falls below 94%, the mortality risk increases.

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Role of BCG vaccine: BCG vaccine slows down spread of Covid-19. It has potential to enhance immunity among the elderly (ICMR). Risk Profiling of Districts of the Country

All the 733 districts in the country were categorized into three zones—Red, Orange and Green, based on critical parameters. Red Zones or Hotspot Districts—130 Districts

The government has classified Red Zones or hotspots as areas with total active cases more than 200; over 15 active cases per lakh population, less than 14 days case doubling rate, calculated over 7 days, over 6% case fatality rate, over 6% sample positivity rate and number of tests per lakh less than 65. Green Zones—319 Districts

Green zones shall be defined as districts with zero confirmed case till date or districts with no confirmed case in the last 21 days. Orange Zones—284 Districts

Districts which are neither defined as red nor as green zones shall be orange zones. Zoning was done to focus containment strategies and review the situation every week. STRATEGY FOR COVID-19 TESTING IN INDIA (VERSION 5, DATED 18/5/2020)

Initially India was testing only three categories of highrisk people 1 All symptomatic (ILI symptoms) individuals with history of international travel in the last 14 days. 2 All symptomatic (ILI—influenza like illness symptoms) contacts of laboratory confirmed cases. 3 All symptomatic (ILI symptoms) healthcare workers/ frontline workers involved in containment and mitigation of Covid-19. Revised strategy widened to cover additional categories 1 All patients of severe acute respiratory infection (SARI) 2 Asymptomatic direct and high-risk contacts of a confirmed case to be tested once between day 5 and day 10 of coming into contact. 3 All symptomatic ILI within hotspots/containment zones. 4 All hospitalized patients who developed ILI symptoms. 5 All symptomatic ILI among returnees and migrants within 7 days of illness. NB

• ILI case is defined as one with acute respiratory infection with fever 38°C and cough.

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• SARI case is defined as one with acute respiratory infection with fever 38°C and cough and requiring hospitalization. • All testing in the above categories is recommended by real-time RT-PCR test only which has 80% sensitivity. Test protocol: RT-PCR is the gold standard test for Covid, which uses throat and nasal swab samples. It is highly specific. Antigen will not be detected, if the test is too late or if virus load is low. Test must be performed early in symptomatic phase. Variations in sample collection techniques also influence the result. What makes matter worst is that high proportion of rapid antigen tests (RAT) are being used currently. RAT gives false negative results thus a large number of infections being missed. A large number of those not detected by RAT roam around freely and infect others. National guidelines say that proportion of RT-PCR tests should be 70% at least. Track at least 30 contacts for every positive case within 72 hours and manage them effectively. Initially case detection/and testing rates were low in India. Subsequently aggressive testing strategy was adopted to reach 10 to 20 lakh tests per day which resulted in improved rate of detection, contact tracing, timely management of cases and low case fatality rate of 1.2%. To date, over 921 million have been tested with an overall average positivity rate of 4.9% and varying weekly positivity rate based on 7 days moving average. Tests are restricted mainly in big cites and metros. In rural areas, testing facilities are not available or are of very limited scale.2,3 CONTAINMENT MEASURES/INDIA’S RESPONSE

Since Covid is a global epidemic, it requires a global coordinated response. It seems that only virus has globalized not the response. 1 India declared Covid-19 as National Disaster and states were allowed to spend disaster relief funds fearlessly under Disaster Management Act, (DMA) of 2005. 2 States invoked Epidemic Disease Act of 1897 to contain epidemic and its spread. 3 Timely and effective National Lockdown was enforced under DMA for about 8 weeks and extended further for 2 weeks with some relaxations. 4 Information, education, communication and community participation to prevent spread of Covid-19: Massive campaign of IEC was mounted using multimedia approach to encourage protective behaviours such as social distancing, hand hygiene and respiratory etiquette. For community engagement, special Gram Sabhas were organized, village Panchayats were mobilized to generate awareness and people participation and actions by people themselves, to avoid panic and stigma and encourage self reporting. “Be careful, not fearful”. 5 To prevent entry of Covid-19 in India: The government initiated several measures for early detection of

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imported cases with universal fever screening at all air and seaports of incoming passengers even before first case was detected. Those with symptoms were tested for Covid-19. International and domestic flights were banned in India with effect from 22.03.2020 to Mid April 2022. 6 Capacity building of health workforce and chain of over 2542 laboratory facilities across the country were set-up. 7 Isolation of sick persons (source control): To prevent spread of infection, the system of clinical triage for assessing all patients at admission, and immediate isolation of patient with suspected disease in an area separate from other patients (source control). Over 600 dedicated Corona hospitals were set-up. This approach stigmatized Covid patients. 8 Contact tracing and quarantine: In India mandatory 14 days quarantine for those arriving in India from infected countries on or after 16.03.2020 was enforced. Quarantine of persons is the restriction of movements or separation from rest of population of healthy persons who may have been exposed to Corona virus infection. Its objective is monitoring their symptoms and ensuring early detection of cases. Quarantine is different from isolation, which is separation of ill or infected persons from others to prevent the spread of infection and reduce human-to-human transmission. Introduction of quarantine measures early in an outbreak may delay the introduction of disease in a country. Duration: WHO recommends that contacts of patients with laboratory confirmed Covid-19 be quarantined for 14 days from the last time they were exposed to the patient. Quarantine can be done in hotels, schools or at home; preferably in a single room and maintain a distance of at least 1 meter from other household members. Daily follow-up of persons for screening of body temperature and symptoms for the duration of quarantine is essential. At the end of quarantine period respiratory samples should be sent for lab testing. 9 National lockdown: Janata Curfew followed by total timely World’s most stringent lockdown of 1380 million people in India from 25.03.2020 extended up to 31.05.2020 under Disaster Management Act 2005; with total duration of almost 10 weeks was enforced. Aim was to break the transmission cycle and prevent community spread. This move united India to defeat Covid pandemic. National lockdown has delayed the peak load, pushed the peak to September and geared up the health system. The lockdown did slow the spread but could not lock the virus. Half the global population was under lockdown. All regular health services were closed/shut. 10. Social distancing—physical distancing: People stayed at home, avoided large social gatherings, maintained

safe distance of at least 1 meter between persons, avoided contact with sick persons. Hand hygiene, cough etiquette, using homemade face masks was adopted on massive scale by people. Janata curfew, national lockdown and social distancing reduced transmission significantly. Post-lockdown period was most critical to consolidate the gains or achievements so far, however, virus spread exponentially after lockdown was lifted. Wearing masks has become more important than ever. Without social distancing, one infected parson can infect 406 persons in one month, with 50% reduction in exposure, 15 persons will be infected and with 75% reduction in exposure 2.5 persons will be infected per month. Unfortunately only 50% of people in India were wearing masks and only 30% wore it correctly. Mask prevents infection and transmission while vaccination prevents deaths and serious Covid disease and reduces chances of hospitalization to the extent of 96%. 11. Food security: Under Pradhan Mantri Garib Kalyan Ann Yojna, food security was provided to migrants who lost income due to Covid-19. Over 800 million persons were provided free of cost, additional 5 kg grains per person per month up to November 2021 under National Food Security Act. and further extended up to December 2023. 12. National 24 × 7 help line was set up at NIMHANS for psychological support. Impact of Intervention Strategies

National lockdown and intensive IEC activities prevented sudden spike of cases that would have overwhelmed our fragile healthcare system, causing panic and helplessness. It delayed the first peak by 175 days. It provided a window period to prepare the health system. It created massive behaviour change among people who adopted best practices—physical distancing, wearing masks, hand hygiene and respiratory etiquette. Communication Strategy—Perils of Bad Messaging

Communication strategy on Covid-19 focused on “Mahamari” (will kill everyone) which frightened people of death. Lockdown and policing was used as “Brahamastra” (ultimate weapon) against virus. This strategy led to unprecedented exodus of migrants from metros to their home. Stigma was attached to Covid-19. Subsequently government changed its communication strategy to “how people must learn to live with virus”. It is imperative to urgently remove stigma attached to virus, treat it like any other infectious disease and restore regular health services. Prevent infodemic and rumours to avoid panic.

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Economic impact: Covid-19 pandemic has impacted economic growth negatively. The poverty will rise sharply as many people lose jobs/become jobless as a consequence of “lockdown”. Nearly, 90% of workforce in India is employed in informal unorganized sector. Labourers, migrants and daily wagers have been hit hard by pandemic. IMF has downgraded India’s economic growth rate from 12.5 to 9.5% for the fiscal year 2021–22.

controlling, monitoring and surveillance of Covid-19 pandemic.

Education: Massive school dropouts led to increase in child labour.

1 Monitor trends in Covid-19 disease at district, state national and global levels. 2 Rapidly detect new cases in countries where the virus is not circulating, and monitor cases in countries where the virus has started to circulate. 3 Provide epidemiological information to conduct risk assessments at the district, state, national, regional and global levels. 4 Provide epidemiological information to guide preparedness and response measures. 5 To estimate Covid-19 infection in population. 6 To provide early warning signals.

Behaviour of Host/Community: A Case Study of Biggest Covid Cluster in Nizamuddin and Nanded

At the headquarter of Tablighi Jamaat Markaz—a religious organization at Nizamuddin at Delhi, thousands of devotees from different states of India and abroad held annual congregation from 13th to 15th March 2020. The devotees defied the directives of government of Delhi and did not observe social distancing, cough etiquette and lived in dormitories full to their capacity. After the event, most of the followers left to their homes in different states of India; Many of them stayed back at headquarter. Many of them developed fever and respiratory symptoms. Following their dispersal to different states of India, there was biggest spike in Covid cases to the extent of 40% in 18 states of India (Tablighi related spread). Many Covid cases in the state of Telangana, AP, Delhi, Tamil Nadu, Punjab, Haryana and UP were epidemiologically linked to these devotees who participated at Nizamuddin gathering. The police evacuated 2361 residents of Tablighi Jamaat. Of these, 1800 were quarantined at nine facilities and 617 taken to hospital for testing. The followers and their contacts linked to Jammat, 25000 in number, were traced in different states and put under quarantine, after a “mega contact tracing operation”. Despite all these efforts, many of the followers went underground to escape the wrath of stigma. This organization has been banned by several countries. Similarly, many migrants from different states left in panic to their homes. 4046 pilgrims returned from Hazur Sahib in Nanded (Maharashtra) on 1st May to Punjab. Of 1932 cases in Punjab, 1225 cases were linked epidemiologically to pilgrims of Nanded. Similarly, migrants returning to their native places (reverse migration) spiked the cases in various states—UP, Bihar, and MP. States were hard pressed to trace them and their contacts. Thus social distancing is a challenging task to hold back migrants and religious congregation. It requires community mobilization on massive scale in pandemic situation. Similar gatherings (superspreader events) during Holi festival, Kissan rallies, and Baisakhi Jatha crossing lndo-Pak border and ‘revenge tourism’, election rallies, world’s largest gathering in Maha Kumbh Mela at Haridwar led to spike of cases in 2021. Legislative measures seldom control the spread of epidemic; strong epidemiological measures and public health system is necessary for

SURVEILLANCE OF COVID-19 THROUGH IDSP

Surveillance means—“Information for action” Objectives of the Surveillance

The objectives of the global surveillance are to:

Goals in India

• To achieve case fatality rate of less than 1%. • To achieve positivity rate of less than 5% WHO flags positivity rate above 5% for active containment and Covid protocol. • To achieve testing capacity of 10 lakh tests per day. Case Definitions for Surveillance

Suspect Case

A A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath), and a history of travel to or residence in a location reporting community transmission of Covid-19 disease during the 14 days prior to symptom onset; OR B A patient with any acute respiratory illness and having been in contact with a confirmed or probable Covid19 case (see definition of contact) in the last 14 days prior to symptom onset; OR C A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath; and requiring hospitalization) and in the absence of an alternative diagnosis that fully explains the clinical presentation. Probable Case

A A suspect case for whom testing for the Covid-19 virus is inconclusive. OR B A suspect case for whom testing could not be performed for any reason.

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Confirmed Case

A person with laboratory confirmation of Covid-19 infection, irrespective of clinical signs and symptoms. Contact

A contact is a person who experienced any one of the following exposures during the 2 days before and the 14 days after the onset of symptoms of a probable or confirmed case: 1 Face-to-face contact with a probable or confirmed case within 1 meter and for more than 15 minutes; 2 Direct physical contact with a probable or confirmed case; 3 Direct care for a patient with probable or confirmed Covid-19 disease without using proper personal protective equipment; OR 4 Other situations as indicated by local risk assessments. Note: For confirmed asymptomatic cases, the period of contact is measured as the 2 days before through the 14 days after the date on which the sample was taken which led to confirmation. Antibody test is recommended for detection of community spread. Regular epidemiological surveillance and genome sequencing is the key for effective control of current epidemic and to predict future spread. Huge data collected by district and states must be analysed locally to generate information for action. Epidemic Curve—First Wave in India (15.7.20 to 15.2.21)

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India’s effective Covid lockdown delayed first peak by 175 days. Epidemic continued to build up in India ever since the first Covid-19 case was reported on 30th January 2020. The progression of pandemic in India was monitored on daily tracker. Daily incidence reporting from all the districts of country like India was a herculean task because of its population size and geography. Under-reporting of cases and Covid deaths is a universal global problem. Only laboratory confirmed cases were reported. Covid incidence curve was plotted weak wise and month-wise to know where we are in the course of epidemic, as also to know the impact of various interventions. The first wave of Covid-19 started building up in mid July 2020 and gradually attained its peak on 17th September 2020 and subsided in middle of Feb 2021 (Fig. 20.1 and Table 20.3). As the first wave receded the daily Covid cases load fell to its lowest level on 12-2-21 at 9110 new cases (Fig. 20.1) and 78 deaths. The government declared that country was in the ‘endgame’ of pandemic in February 2021. The impression from the government was that India has beaten Covid-19 after months of low case count/load, which encouraged complacency. The nation paid heavy cost for its complacency. People and the government alike thought that worst was over and all Covid appropriate

norms were thrown to wind. The National Supermodel Committee suggested falsely that India has achieved ‘herd immunity’ and made incorrect assessment of pandemic which encouraged complacency. Despite the danger of warning of second wave and emergence of mutant strains, the system and the people became complacent. State after state started dismantling the antiCovid infrastructure in the mistaken belief that pandemic has come to an end. Make and shift Covid centres and hospitals folded up, temporary staff was laid off, and little attempt was made to ramp up critical health infrastructure like-ventilators, medical O 2 , ICU beds, staff and additional temporary hospitals. National and state plans were not developed against Covid-19. The first wave was primarily due to original virus SARS-CoV-2 and confined mainly to urban areas. Second wave—One Year of Pandemic In India

Second wave witnessed spread from urban areas to periurban and rural areas. The second wave started building itself in early March 2021. India witnessed intense and furious second wave exactly a year after the stringent lockdown. The lockdown did not succeed taming the epidemic. Mass vaccination and Covid appropriate behaviour held the key. India squandered its early successes in controlling Covid-19 pandemic. We expected a ‘second wave’ but it turned out to be a ‘Tsunami’ in India. Second wave was most brutal and terrifying. The second wave started building itself in mid March 2021 and rapidly reached to its peak on 7th May 2021 and subsided at the end of June 2021 (Fig. 20.1). Alarming rise in incidence of cases to 10.5 lakh in the month of March 2021, escalating to 66 lakh new cases in April 2021, reaching to peak level at 93 lakh new cases in May 2021 produced a grim situation (Fig. 20.2). Single day incidence in India skyrocketted at over 4 lakh cases on 7-5-21 (Fig. 20.1) and a deadliest day on 19-5-21, set a grim record of 4529 deaths on a single day. Highest incidence of cases and deaths were reported in the months of April and May 2021. Nearly 93 lakh cases and 1.20 lakh deaths (4000 per day) were added in the month of May 2021 alone—the highest ever logged by any nation in the world. At the peak of second and first wave, around 9.7% of hospitalized persons died. Nearly 70% of hospitalized were over 40 years old. Healthy and young people died more in second wave. Only 2% of adults could be vaccinated by the first week of April 2021, i.e. before second wave in India. The second surge was due mainly to Delta variant accounting for 83% of new cases. Hospital beds fell short of the requirement, oxygen demand escalated beyond imagination, life saving medicines ran short, patients died outside hospital, playgrounds turned into mass cremation centers, as mortality level increased, recovery rate dipped to a low level of 82% death rate spiked to 8.3% and active case load spiked up to 37 lakh (Table 20.4) cases needing treatment at home/hospitals,

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Fig. 20.1: First and second wave of Covid-19 in India—2020 and 2021 weakly incidence of cases on specified dates

and viral replication (R) rose to highest level of 1.37. As the second wave hit hard, states started making huge demands but critical supplies were not available to match the spike.

Sudden surge led to panic all around and people even with mild infection, fearing death rushed for hospital admission, stocked oxygen and medicines at home unnecessarily.

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Table 20.3: Monthwise reported frequency/incidence of Covid-19 cases and deaths in India from 30th Jan 2020 to 28th Feb 2023 Months (at the end of month)

Reported frequency of lab positive cases in a month

Cumulative deaths

30th Jan 2020

1 in Kerala

1

February

2

3

0

July

1072030

1638870

35747

Agust

1982375

3621245

64469

September

2604518 (First wave peak)

6225763

97497

October

1911356

8137119

121641

November

1294572

9431691

137139

Feb 2021

350548

11096731

157051

0

162468

March 2021

1052604

12149335

April 2021

6613641

18762976

208330

May 2021

9284558 (Second wave peak)

28047534

329100

Jun 2021

2315314

30362848

398454

July 2021

1251145

31613993

423810

Dec 2021

264803

34861579

469724

Jan 2022

6607920 (Third wave peak)

41469499

496242

Feb 2022

1461546

42931045

514023

March 2022

94730

43025775

521181

31 Oct 2022

66285

44653592

529024

31 Nov 2022

18755

44672347

530620

31st Dec 2022

6033

44678384

530698

31st Jan 2023

4400

44682784

530740

28.2.2023

3567

44686371

530771

31.3.2023

29415

44715786

530867

Main Reasons for Second Wave Were

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Cumulative frequency

i Covid pandemic fatigue was one of the most important causes of the surge. As the lockdown was lifted and the number of cases declined to lowest level, it led to massive Covid inappropriate behaviour—no masks, no social distancing at market places, at religious social gathering events and revenge tourism. ii Large scale superspreader events like—festivals, Kumbh Mela at Haridwar, Baisakhi Jatha to Pakistan, farmers and election rallies resulted in spike of cases. iii The second surge of cases in India was linked to the emergence of the Delta variant of coronavirus. Delta variant reported first from India was primarily responsible for the second wave accounting for over 80% of new cases in India. This strain proved to be 70% more transmissible than UK variant—Alpha, more severe and deadly, more intense and also led to breakthrough infections in India and other countries. iv Lack of containment measures together with pandemic fatigue spiked the trajectory of cases in India. v Data management: Multiple agencies like ICMR, NITI Aayog, IIT Kanpur, Tamil Nadu, DGHS, NTAGI, and NCDC were involved for Covid 19 data collection and analysis. There were divergent views and lack of

coordination. Partial information was available in public domain in bits and pieces. Comprehensive information for action was the imperative need to mitigate the impact of epidemic. India’s Response to Contain Covid-19 in Second Wave and Beyond

A Special five-pronged campaign was launched including— aggressive testing, tracking, treatment, vaccination and promoting covid appropriate behaviour in the community. National guidelines were issued in the first week of April 2021 focusing on: • Aggressive testing with RT-PCR accounting for 70% of all the tests, and reduce positivity rate below 5%. • Trace and test 30 close contacts of every positive case in the first 72 hours. • Reduce case fatality below 1% by prompt treatment. • Optimal use of vaccines to enhance coverage levels. • Special campaign for promoting Covid appropriate behaviour was launched using multi-media to check the spike. Home and community-based isolation: Nearly 80– 85% of Covid-19 cases are asymptomatic or mildly symptomatic, do not require hospitalization and may

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Fig. 20.2: Epidemic curve of India—monthwise incidence of Covid-19 from April 2020 to Jan 2023 (cases in lakh)

be managed at home or in Covid-care isolation facility set-up at village level. Monitoring of active case in home-isolation: To monitor oxygen saturation and pulse rate and temperature, people were provided home isolation kits having pulse oximeter, thermometer and medicines. Patients under home isolation stand discharged and end isolation after at least 10 days have passed from onset of symptoms and no fever for 3 days. There was no need for testing after the home isolation period was over. Healthcare infrastructure for managing Covid in rural areas Covid care centres (CCC) at village level, dedicated covid health centres (DCHC) at PHC/CHC and dedicated Covid hospitals (DCH) were set up to manage Covid in rural areas. Opening up of lockdown revolved on 3 pillars: • Area must attain positivity rate of less than 5% for more than 2 weeks. • Community must own covid appropriate behaviour. • Achieve 70% vaccination in 60+ and 45+ with comorbidity. The process of unlocking in 2021 was left to states. State government must adopt aggressive containment measures to localize the transmission. Insurance cover: Government provided insurance cover to Covid warriors in addition to Covid allowance.

3rd Wave of Covid-19 in India–Jan–Feb 2022

The third wave started building up very rapidly in Jan 2022 and quickly attained its peak on 21st Jan 2022 and subsided rapidly by the end of Feb 2022. The 3rd wave was so quick and huge lasting for about a month. The 3rd wave in India was driven by Omicron superspreader variant. It outpaced Delta Variant in all the metropolis and big cities in India. Its infectivity was 4–5 times higher than delta strain but it carried 50–70% reduced risk of hospitalization rate, ICU and oxygen demand. Hospitalization rate during 3rd wave was 5–10% in comparison to 20–30% during second wave caused by delta strain. Omicron thus proved to be less severe and mild but fast spreader in the community. It proved to be fastest spreading virus in World’s history. Though the number of cases rapidly increased the hospitalization and mortality rate did not rise at the same rate as the case fatality rate was low at 1.19% During the height of 3rd wave in Jan–Feb 2022 Omicron resulted in 80 Lakh new cases and 32500 deaths in these 2 months. After hitting the peak with 347275 cases on a single day on 21st Jan 2022 (Fig. 20.3) the 3rd wave plateued on 11th April 2022 with record two years low daily incidence of 796 new cases and active case load declined to 11000 with lower rate of hospitalization, ICU beds and use of oxygen in 3rd wave. This could be attributed to combination of high level of vaccine induced immunity as 72% of adults were fully vaccinated with two doses besides natural infection over

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Fig. 20.3: 7 days average incidence during three waves of Covid-19 in India—2020 to 2023 peaks and waves at regular interval of 8 months (NDTV tracker MOHFW) First wave: 15-07.2020 to 12.02.2020 Second wave: Mid March to June 2021 Third wave: Jan to Feb 2022

the two years of pandemic in India plus fundamental properties of new variant. Risk of re-infections or breakthrough infections was 5 times higher with Omicron as compared to Delta variant and doubling time was 1.5 to 3 days and its ‘R’ factor or replication rate was much higher as Omcron spread like wild fire by air transmission. Most cases of Omicron recovered after 7 days and over 90% of Omicron cases were asymptomatic or had mild symptoms of fever, cough, nasal congestion and scratchy throat as it does not invade lungs and causes upper respiratory infection. It is highly transmissible less severe and mild and most often asymptomatic. The 3rd wave of Covid-19 is practically over in India and overall normalcy has returned but pandemic is far from over. Amid growing concern posed by “XE” (a mix of BA.1 and BA.2–Sub-lineage of Omicron) India has decided to extend paid booster dose of Covid vaccine facility to all adults from 18–59 years of age, 6 months after the administration of second dose. This facility was made available in all private vaccination centres. In view of hesitancy and poor response and very low coverage the government of India has initiated free of cost booster/ precautionary dose to all adults 18–59 years of age from 15th July 2022 in campaign mode lasting for 75 days. The vaccine induced immunity after July–August 2021 schedule and Omicron induced antibodies have long waned as it has been over 6 months after the Omicron outbreak. People are vulnerable again. Vaccines Against COVID-19 for Emergency Use

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Dozens of highly effective vaccines produced in record time with breakthrough technologies. Following vaccines are approved in India for emergency use: 1 Covishield vaccine: Developed by Serum Institute of India (SII) in collaboration with British firm Oxford-

2

3 4 5 6

7 8 9

AstraZeneca. It is a recombinant vaccine based on viral vector technology. It comes in liquid form. Covaxin: Developed in India by Bharat Biotech Hyderabad in collaboration with ICMR and Viral Research Institute Pune. Covaxin is whole viron inactivated coronavirus. It comes in liquid form. Sputnik V: It is a Russian vaccine based on viral vector technology, supplied as freezed dried vaccine. Moderna vaccine: It is based on the new mRNA platform approved in India for emergency use. Johnson and Johnson vaccine—single shot vaccine is approved for emergency use. ZyCoV-D3 dose schedule (on day 0, 28 and 56) gets nod for emergency use in India with 66.6% efficacy. It is world’s first plasmid DNA based indigenous vaccine for adults and children above 12 years age. Covovax produced by S11 in collaboration with novavax is approved in India. Corbevax produced by Bharat Biotech is approved in India. Intranasal vaccine (INCOVACC) by Bharat Biotech: For the primary 2 dose schedule with an interval of 4 weeks between first and second dose and a heterogenous booster dose for subjects who have received previously 2 doses of Covishield or Covaxin. Heterogenous booster shot provides better response/immunity.

Vaccines were designed to cover initial version of SARS-CoV-2, not for variants. Objectives of vaccination programme are:

• Vaccines are intended to prevent severe disease, not infection. • To prevent severity or reduce severity of Covid-19 disease and reduce hospitalization.

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• To protect the health system (health workforce). • To prevent deaths and save lives. • To induce greater herd immunity. Storage of vaccines: These vaccines are stored at 2°– 8°C. Dose Schedule

Two dose schedule, i.e. two doses with an interval of 28 days between first and second dose in case of Covaxin. Each dose is of 0.5 ml by intramuscular route in deltoid muscle of left arm. • Interval between two doses of Sputnic V is 21 days. • Interval between two doses of Covishield vaccine is increased from 6–8 weeks to 12–16 weeks for enhanced immune response and greater protection as per global evidence. Interval between two doses reduced to 8–16 weeks on 20 March 2022. Age of Administration

Persons above the age of 12 years are given these vaccines. Shelf life of vaccine: Shelf life is 6 months. Shelf life for covaxin increased to 12 months and for Covishield to 9 months. Open vial policy: It is not applicable for these vaccines. Open vial must be used within 4 hours. Beneficiaries and Policy of Covid Vaccination in India

Free of cost national vaccination drive began in India on 16th of January 2021. Priority in first phase was to cover all health workers and frontline workers, followed by most vulnerables—persons above 60 years of age and persons between 45 and 59 years having co-morbidity. In second phase from Ist April 2021, policy to vaccinate all above the age of 45 was adopted and in phase three policy to vaccinate all above 18 years of age from 21st June 2021 was implemented in India. The vaccination is voluntary but advisable. Vaccination is recommended for lactating mothers any time after delivery. It is safe to give vaccine to pregnant women. Government of India has approved covid vaccination for pregnant women. In view of Omicron spike world over and India the policy of free vaccine to adolescents (15–18 years age) was implemented in India on 3rd Jan 2022. Schedule of 2 doses of Covaxin with an interval of 28 days between first and second dose. Precautionary dose (booster dose) for health and front line workers and every one aged 60 years and above started on 10th Jan 2022 in India upon completion of 9 months from the date of administration of second dose with same vaccine. Now the interval between second and booster or precautionary dose has been reduced from 9 month to 6 months. On 16.3.22 free of cost vaccine drive for 12–14 year age children was initiated, with corbevax of Biological E’s two dose schedule with an interval of 28 days between first and second dose. Corbevax of Biological

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E’s India’s first heterogenous (different from primary dose) vaccine. Booster dose of corbevax to individuals 18 years and above fully vaccinated with either 2 doses of covaxin of Covishield, has been approved by the centre and Drug Controller General of India. Vaccine Coverage levels—Jan 2023

Over 2207 million doses of Covid vaccine has been administered in India so far. Over 90% of adult population is covered with two doses of covid vaccine and around 96% of adult population in India has received at least one dose, which is one of the highest coverage in the world. India with 90% of population already infected and 90% of adults covered with 2 doses engoys HYBRID immunity. Children between 12–14 years of age, 96% have received 2 doses. However, dismal 28% of adults have received booster or precautionary dose. Now the Govt of India has revised its policy from paid booster dose to free booster dose for all adults 18 to 59 year of age. The free booster dose campaign will last for 75 days starting from 15th July 2022. India scripted history of administering 2000 million doses of Covid vaccine within 18 months of drive—a marvels in history of delivery of vaccines. Global Coverage

Globally on an average 75% of health workers and people above 60 years of age have been vaccinated. These rates are much lower in low income countries. nearly 64% of population in SEAR is fully vaccinated and 68 countries have not yet achieved even 40% coverage. Cases are surging again in many countries, thus Covid threat persists. Expand vaccination coverage as vaccine provides high level of protection against severe disease and deaths Contraindications

Sick persons and persons who give history of allergy will not be administered vaccine. Adverse Events Following Vaccination (AEFV)

Minor events after vaccination such as pain, swelling and mild fever, headache and bodyaches can occur but subside of their own within a day or two. No major serious side effects have been reported. Many European countries stopped the use of Covishield fearing blood clots in recipients which could not be attributable to vaccine. Vaccines are safe to use. Benefits of vaccines overweight a rare risk of clot as affirmed by WHO. The reporting rate of thromboembolic events in India is around 0.61 per million doses, much lower than 4 cases per million doses in UK. Only one vaccine-related death in 68-year-old man was reported who suffered anaphylaxis. Coverage Level

Nearly 70% of population must be fully vaccinated to generate vaccine-induced herd immunity that will allow

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normal activities to resume. In Israel, 60% of population has been covered and similarly in UK and US nearly 50% population has been covered with two doses resulting in drastic reduction of cases followed by resurgences. Target in India

Target is to vaccinate 950 million adults above 18 years of age by July 2022. In India, over 2207 million-doses have been administered, which translates to 96% of persons covered with at least one dose and 90% of persons have been fully vaccinated with 2 doses up to Dec 2022. Effectiveness of Vaccines

The effectiveness of vaccines in preventing serious disease and death is 96.6% after first dose and 97.5% after second dose. Mortality rate in unvaccinated was high (ICMR Sept 2021). However, mutant strains may decrease the efficacy of vaccines. Over 90% of India’s population has hybrid immunity (vaccine + natural infection induced immunity). Immunity after Vaccination

Immunity develops two weeks after receiving two doses of vaccine. How long the immunity lasts after two doses is not known yet. However, ICMR says protection against Covid-19 by natural infection or by vaccination (two doses) could last up to 9 months. People including elderly are overall protected from severe disease and deaths at 80–95%. Persons acquiring immunity after natural infection or by vaccination can still get (though rare) infected (breakthrough infection) with mutated variants of virus. Humoral immunity of vaccine wanes with time as the titre of antibodies goes down. Nonetheless protection through cellular immunity against severe disease and death would remain effective. Breakthrough or Reinfection after Vaccination

Only 2–4 per 10000 inoculated with Covishield and Covaxin respectively reported breakthrough infection after receiving 2 doses of vaccine (ICMR). Even if the Covid reinfection occurs after the first or second dose, it does not cause severe disease. The chances of hospitalization gets reduced by 75% after two doses. Delta variant is behind 86% of breakthrough infections in vaccinated persons. The overall interim clinical efficacy of vaccines is 78% and 100% efficacy against asymptomatic infections (ICMR). Both Covishield and Covaxin work against Delta+ variant (Lambda) and Delta variant and have been approved by WHO.

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Booster Dose

Vaccine policy shift: Precautionary or booster dose for health workers and front line workers as well as for elderly

with co-morbidity above 60 year age has begun with effect from 10th Jan 2022. Booster dose is designed to help people to maintain level of immunity for longer. Vaccine nationalism is not helping Covid fight due to inequity in vaccination. Variants are winning the race due to unequal access to vaccine. Too many countries are seeing spikes in cases due to fast moving variants and shocking inequity in vaccination. As on August 2021, over 50% were fully vaccinated in richest nations and only 2% in poorest. No one is safe until everyone is safe hence ensure equity. Repeated booster doses of original vaccines against emergent variants is not a viable strategy (WHO). WHO on vaccines coverage: Achieve 10% full coverage by September, 40% by December 2021 and 70% coverage by July 2022. Low vaccination coverage areas are prone to get intense transmission and infection with mutant strains. Two doses give better protection than one. In US, over 90% of infections are with Delta virus; 90% hospitalized were unvaccinated, 98–99% who died of Covid in US were unvaccinated and only 0.8% vaccinated died, breakthrough infections in fully vaccinated were only 1.1%, hence vaccines against Delta variants are working. Over 99.5% of Covid deaths from Jan 2021 to June 2021 in India occurred among unvaccinated persons. CDC has described Covid-pandemic as “Pandemic of unvaccinated” in 3rd wave. Vaccine for Children

Children are at very low risk of Covid infection. Children younger than 12 years donot require covid vaccine. two shots are recommended for children 12 and 17 years, a third or booster shot is not needed for this age group. Vaccine Hesitancy

World Health Organization defines vaccine hesitancy as “delay in acceptance or refusal of vaccination”, despite the availability of vaccine, due to any reason. Vaccine hesitancy is a growing problem world over. Nearly 29% of healthcare workers in US, 40% in UK were hesitant to get Covid vaccine and over 60% of persons in India were unsure of taking any of the two Covid vaccines. Vaccine hesitancy could arise because of apprehensions around vaccine safety, efficacy and side effects as well as myths and misconception. Ministry of Health and Family Welfare addressed the problem of hesitancy in its communication strategy prior to launch of campaign to build trust among people. States were directed to invoke the provision of the Disaster Management Act and engage community leaders. Covid vaccine is no silver bullet. Covid vaccine prevents serious disease, death, hospitalization, besides protecting the health system. We do not know the impact of vaccines on transmission. The vaccinated may still transmit or spread deadly virus as it takes at least 2 weeks

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time to kick on and develop vaccine-related immunity. Vaccine alone will not wipe out covid virus. Wearing masks correctly, social distancing and hand washing remain norms despite vaccination. Epidemic can persist and it may take longer time to wipe out the virus. A high level of vaccine-induced immunity at district, national and global level is necessary. No country is safe unless all are safe. Deaths Averted by Vaccination

Between December 8, 2020 and December 8, 2021 Covid Vaccination prevented 14.4 million deaths in 185 countries. Covid vaccination has substantially altered the course of pandemic saving millions of lives in the world. It averted 4.2 million potential deaths in India alone (Lancet Oliver Watson Imperial College London UK). Epidemic of Covid Associated Mucormycoses (CAM) or Black Fungus in India

Mucor-mould (a fungus) exists in environment—soil, manure, and decaying organic matter. It is an opportunistic infection in Covid-19 patients. It is occurring most commonly in diabetics and misuse of steroids therapy in Covid-19 apart from wide-spread practice of multiple antibiotics. Many states have made it a notifiable disease under Epidemic Disease Act of 1897. Amphotericin-B is effective drug against mucormycosis. A majority of CAM cases have uncontrolled diabetes. It affects face, nose, eyes and brain, can cause blindness and even removal of jaw bone besides affecting lungs. Common symptoms are: Headache, nose secretions, bleeding from nose, blood in cough, lack of sensation on face and swelling on one side of face. In some cases, it proves to be fatal. Over 45432 cases and 4333 deaths (till July 15th 2022) have been reported from 28 states of India with maximum cases from Maharashtra and Gujarat states. Monitoring Indicators for Covid–19

Government of India MOH and FW is continuously tracking and releasing the following indicators on daily tracker. i Daily incidence and single day growth/decrease rate ii Active cases requiring home/hospital treatment and isolation. iii Positivity rate based on 7 days moving average and daily positivity rate and average cumulative positivity rate since 23rd April 2020. iv Case fatality rate (CFR)—total deaths in lab confirmed cases per 100. v Recovery rate—proportion of lab confirmed cases— improved/discharged/migrated. vi Doubling rate of cases over time period in days. vii Viral replication rate ‘R’—moving average per week

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viii Tests performed per million and total tests performed ix Infrastructure—Covid beds, O2 supported beds, ICU and ventilator beds. x In addition, ICMR released periodically the prevalence of infection rate in community by serosurveys, and genomic sequence surveillance to detect mutant strains. xi Hospitalization rate due to Covid-19. xii Genomic surveillance. Daily Incidence of Covid-19

This indicator measures the impact of interventions. The epidemic trajectory peaked at different times in various states. The worst affected states/UTs were Maharashtra, Kerala, Telengana, Tamil Nadu, Karnataka, West Bengal and Delhi. Daily incidence peaked up in September 2020 (First Wave), in April–May 2021 (second wave) which proved to be most furious and deadly and in Jan–Feb 2022 (third wave). In terms of total number of reported cases India is second hard hit country in the world after US. Positivity Rate

Overall cumulative positivity rate in India varied between 5 and 8%. Currently it has declined to 4.9% (Feb 2023). India adopted a policy to test 5% of all positive samples for genomic sequencing to detect mutant strains of virus. However india could test only 1% of positive samples. Genome sequencing of all positive Covid-19 cases in India was stepped up in Dec 2022 to detect any new variant of concern/interest in view of BF. 7 surge in China and rising number of cases in Japan South Korea, US and France. Results indicated 11 sub-variants of Omicron in circulation and nothing alarming or new. Thus India continues in safe zone. Cases Fatality Rate and Recovery Rate

Case fatality rate in India was lowest in the world between 1.2 and 1.8% and recovery rate of over 98% being highest in the world. Low CFR in India is due to its demographic structure as most persons affected were of young age groups below the age of 60. Case fatality rate is influenced by total number of tests performed in population. With aggressive testing and identification of asymptomatic and mildly symptomatic cases, the CFR would reduce. Deaths per million is more reliable index while comparing the spread, mortality and effectiveness of interventions. India had lowest deaths per million at 374 much lower than US at 2920. Target

India’s target is to achieve positivity rate of less than 5%, case fatality rate of below 1%, sustain viral replication rate (R) at low level of less than 1 and achieve high recovery rate near to 99%.

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772 Viral Replication Rate—“R” Factor

R value is a critical marker of Covid-19. It denotes virus reproduction rate. It means expected number of cases directly generated by one infected person during his/her entire period of infection in population. The R factor indicates the speed at which the Covid-19 infection spreads in the community. If R is 2 it means one infected person can spread infection to 2 other persons, hence it should be kept below one. R factor was very high at 1.37 to 1.69 during April and May 2021 and Jan–Feb 2022 coinciding with second and 3rd wave. R is based on weekly moving average, it was at low level of 1.06 on 28th Feb 2023. Active Case Load

Over 80% of active cases in India were reported from Kerala, Maharashtra, Tamil Nadu, West Bengal and Karnataka. Active case load is critical for management of cases in homes and hospital isolation and requirement of beds, etc. During the peak of first wave in September 2020 total active case load peaked to 9 lakh and in second wave in May 2021 total active case load increased to unmanageable level of 36 to 37 lakh cases when Hospitalization rate increased and beds fell short of requirement. Similarly in third wave total active case load increased to the level of 20–22 lakh in Jan 2022 but majority of cases were mild and hospitalisation rates were low in 3rd wave (Table 20.4). Current level of active case load as on Feb 2023 was low at 2257 cases. Children under 20 years of age comprise 1–2% of all covid cases world over. A majority of them—over 90% are asymptomatic and mild can be treated with standard home isolation protocols.

Among the confirmed cases of covid in India, less than 12% were children and young adults under 20 years of age and 3–4% were children under 10 years. Agewise impact of covid was more or less the same across two waves and children and youngster were not affected disproportionately as believed (Table 20.5). Among hospitalized children, mortality rate in below 10 years was 2.4% and 40% of those who died had co-morbidities. Table 20.5: Age-wise Covid-19 cases in India in percentages Age groups in years

Ist wave July to December 2020

Second wave 15 March to 25th May 2021

Below 20

11.30

11.62

21–40

42.44

45.49

41–50

32.36

30.62

61 plus

13.89

12.58

Children are not at additional risk of contracting covid disease in any subsequent wave. The evidence from various sero-surveys across states indicates that children have been infected at a similar rate as adults; however, their developing disease in the severe form is low. Children immune system can ward off the virus before it replicates, which explains why they get mild disease unlike adults. Their T cells are relatively naive and untrained, they produce antibodies specific to spike proteins. Adults produce antibodies—nucleocaspid (n-antibodies) which is key for viral replication in the body. Sero-surveillance Studies in India

Table 20.4: Trend of active cases from July 2020 to Feb 2023 in India Dates and month

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Number of active cases

31 July 2020

545318

31 Agust 2020

781975

30 September 2020 (peak)

940441

31 October 2020

582649

30 April 2021

3170228

10 May 2021 (peak)

3745237

31 May 2021

2026092

31 Dec 2021

104781

30 Jan 2022 (peak)

1831268

28 Feb 2022

92472

31 March 2022

13672

30 Nov 2022

4855

31 Dec 2022

3653

28th Feb 2023

2257

31 March 2023

15208

Purpose—to determine transmission of Covid-19 in population or to determine prevalence of Covid-19 infection (antibodies) in population. Four national serosurveys were conducted by ICMR. First in May, second in August to September 2020—during first wave, third from December 17th to 8th Jan 2021 just before the second wave. The fourth survey conducted in June–July 2021 covered 28,975 persons across 70 districts of 21 states. The prevalence levels of antibodies from first to 4th sero-survey were at 0.7, 7.1, 21.4 and 67.6%, respectively. The fourth national sero-survey estimated overall prevalence of antibodies in persons above 6 years of age at 67.6% up from 21.4% of third survey. Two-thirds of country’s population have developed antibodies to virus indicating past infection. It means one-third of India’s population was still susceptible to Covid-19 disease. Seropositivity was 62.3% among the unvaccinated, 80% in those with one dose and 89.8% in persons with two doses of vaccine. Over 50% of 8691 children between 6 and 17 years surveyed were seropositive. Seropositivity among 6–9 years children was 57.2%.

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The level of exposure of children is almost same as adults. Children can ward off infection due to underdeveloped Ace-2 receptors which SARS-CoV-2 needs to enter lungs, hence most children—over 90% get mild disease. Implications of sero-surveys: Primary schools can reopen first and secondary schools can reopen in staggered manner. All school staff must be fully vaccinated. The vaccination policy can be modified based on the findings of sero-survey. Rural and urban areas had almost same levels of prevalence. Each state must carry out sero-survey and use data for planning of Covid strategy. Waste generated due to excessive use of gloves and PPE during Covid pandemic is threatening human health. Herd Immunity

Herd immunity is nebulous concept and we cannot pin our hopes on herd immunity by natural infections. It is not at all an option in the programme. High prevalence of Covid-19 infection rate in community could be one of the reasons for decline of new cases and deaths, particularly in urban slums and dense population in urban areas. Nearly 70–80% of people need to have been infected for the population to reach herd immunity. That has not happened in India. Brazil saw massive covid resurgence at seroprevalence of 75%. Likewise Delhi, Dharavi and Mumbai saw massive surge, with seropositivity rate of over 56%, due to Delta strain. Covid resurgence cannot be ruled out in India as long as susceptible population is there. MUTANTS INCREASE THE THRESHOLD LEVEL OF HERD IMMUNITY Current Situation of Covid-19 in India—31st March 2023

Overall 2207 million doses of vaccines have been administered (first dose 922 million, second dose 866 million) by the end of March 2023. Impressive recovery rate of 98.5% with lowest case fatality of 1.19% has been achieved in India, with national average positivity rate of 5.5%. Low level of coverage of booster/precautionary dose around 27% is worrisome, leaving large proportion of adults as vulnerable. Three waves of Covid-19 at 8 months regular successive interval probably indicate waning vaccine induced or natural infection immunity in population (Fig. 20.3). Thus overall population immunity is down and people are again vulnerable. Booster doses are best reserved for elderly people with co-morbidity to protect them from severe infection and death even if they catch Covid reinfection. Considering that India’s 3rd wave was driven by Omicron in Jan–Feb 2022, there in no epidemiological reason to believe that “XE” (mixture of BA.1 and BA.2) and new sub-variant of Omicron-BA.2.75 found in India in June 2022 will cause fresh wave. “XE” and BA.2.75

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and XBB are sub-variants of Omicron unlikely to cause 4th wave in India. Because of high level of vaccine induced immunity in adults in India (90% of adults fully vaccinated with two doses and 96% have received at least one dose) besides natural infection immunity in second and third wave, the severity of Covid disease, hospitalization and ICU bed has decreased substantially. However SARS Cov-2 is going to stay with us far long and we have learned to live with it. The public health emergency of international concern is yet not over as many low income countries have low level of vaccine coverage-barely 40%. After a lowest daily case count in Feb 2023 the Covid case incidence is rising again in different parts of the country since early March 2023. The current Covid surge is being driven by Omicron sub-variant XBB.1.16. Overall the country has witnessed a steady increase in cases surging to 13000 daily Covid cases on 20th April 2023. The daily positivity rate of 4.7%, with an average positivity rate of 5.5% and “R” (reproductive rate) of 1.17, and consistent rise of active case load reaching to over 67806 is a cause of concern. Against 29415 Covid cases in the month of March 2023 India’s cases spiked to 176203 in April 2023 thus there was nearly six time rise of cases in April 2023, with an average of 7660 cases per day. Currently there are eight high burden states with high positivity rates and rise of cases. These states are UP, Tamil Nadu, Rajasthan, Kerala, Karnataka, Haryana and Delhi. High positivity rate of 29.65% was observed in Delhi, followed by Kerala 28.25% and Haryana 19.28% against the national average of 5.5% in the weak ending April 19, 2023. The Covid surge is driven by Omicron sub-variant XBB categorized as variant under monitoring (VUM) by WHO. However, most of the cases are mild and self limiting not resulting in increased hospitalization, being managed at home. States are conducting mock drills to ensure preparedness along with adequate testing to identify hotspots besides strengthening healthcare system. Case based and focus based surveillance now is an imperative need to identify vulnerable areas and persons as also pattern of spread to prevent surge and another Covid wave. The five pronged strategy of testing, tracking, treatment, vaccination and Covid appropriate behavior is to be continued as pandemic is far from over. India continues to be second hard hit country in the world with 44.8 million cases and 5.31 lakh deaths until 23.04.23. India is probably entering into endemic phase of Covid-19. Short and Medium Term Strategies for “One Health” Driven by Covid-19 “Pandemic in India”

The renewed focus on ‘one World, one Health’ states that Animals, Environment and Humans health is linked to each other and is impossible to separate. It is imperative to protect the health of animals, humans and environment. Disease producing organisms of infectious disease (CCDs) live/survive, multiply and develop in animal and human host or in environment.

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Strategies for “One World One Health” in India

To develop core capacity to deliver the “One Health Approach” to prevent, detect and respond to infectious disease outbreaks in animals and humans, following strategies are to be in place under PM–ABHIM by 2025–26. PM–ABHIM is pan India scheme to strengthen healthcare infrastructure, developing core capacities of health systems and institutions, to build IT enabled disease surveillance system, networking of labs and strengthening health units at the point of entry for effective detecting, investigating, preventing and combating outbreaks and PH emergencies’. i Setting up of national institute for “One Health”. ii Four new national Institutes for virology and a regional research platform for WHO–SEAR and 9 Bio-safety Level–III laboratories. iii Setting up of health and wellness centres (HWCs) in rural and Urban areas for CPHC. Over 1.1 lakh SHCs are transformed to HWCs upto March 2022. iv Block Public Health Units at CHCs for strengthening of surveillance and decentralized planning. v Setting up of Integrated Public-Health labs in all districts. vi Establishing critical care-hospital blocks in all districts with population more than 5 lakh. vii 12 central institutions for training and monitoring sites with 150 bedded critical care hospital blocks. viii Strengthening of National Centre for Disease Control (NCDC), 5 New Regional CDCs and 20 metropolitian surveillance units. ix Expansion of the Integrated Health Information Portal (IHIP) to all states/UTs to connect all public health labs.

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x Operationalisation of 17 new Public-Health-Units and strengthening of 33 existing Public-Health units at points of entry, that is at 32 Airports, 11 seaports and 7 landcrossings. xi Setting up of 15 health emergency operation centres and 2 container based hospitals. Conclusion

Covid-19 is a new disease. It provided an opportunity to learn all aspects of epidemiology, clinical trials, RCTs, preparedness, planning and management, disaster management, Epidemic Disease Act, International health regulations, inter-sectoral coordination, community mobilization/participation and above all adoption of healthy behaviours by people and how to live with virus. Covid-19 crisis has exposed India’s health system inadequacies and challenges to strengthen public health system. Let us build, back better (BBB) sustainable public health system in recovery phase of pandemic. Ayushman Bharat Health Infrastructure Mission (ABHIM) launched in October 2021, hopefully prepares all 733 districts for effective response to current and future pandemic diseases. REFERENCES 1. WHO critical preparedness, readiness and response actions for Covid-19. Interim guidance 22.03.2020 World Health Organization. 2. Indian Council of Medical Research, Department of Health Research. Strategy for Covid-19 testing in India (Version 5, dated 18.05.2020). 3. The Tribune Chandigarh/Wednesday/13 May 2020. Let’s not lower our guard against Covid, Ashok Bhan, Ex-DGP, Former member National Security Advisor Board.

Index A bate

351 Abattoirs 405 Abbreviated regimen 396 A-BHIM 773 Abortion 551 Accidents and injuries 477 Accredited social health activist (ASHA) 707 Acculturation 53 Acrodermatitis enteropathica 180 Action research 234, 235 Activated sludge 85 Active ageing 625 Active case detection 345 Active listening 22, 23, 125 Activities of dai 688 Activities of daily living 628 Acute encephalitis syndrome (AES) 367 Acute flaccid paralysis (AFP) 421 Acute respiratory infections 425 AFHCs 592 Adolescent health 588 Adoption process 118 Adverse child sex ratio 515 Adverse events following immunization 574 Adverse sex ratio 514 Aedes aegypti 97 AETCOM 24, 25 Age of pandemics 435 Age and sex composition of population 512 Age specific death rates 262 Age specific fertility rate 519 Agmark 190 AIDS 310 Air pollution 87 Airborne transmission 248 Air quality guidelines 92 Alzheimer’s disease 628 Ambient air pollution 88 Anamnestic responses 398 Anaemia Mukt Bharat 170 Analytical studies 289 Anganwadi 194 Anganwadi workers 194 Animal birth control 399 Animator 121 Annual blood smears examination rate 354 Annual falciparum incidence 354 Annual parasite incidence 259 Anopheles mosquitoes 94 Anthracosilicosis 607 Anthrax 408 Antioxidants 135 Anthropological research 47 Anthropology 52 Antigenic drift 438

Antigenic shift 438 Antimicrobial resistance 752 Anti-retroviral therapy (ART) 318 Applied nutrition programme 184 Applied research 234 AQI 93 Arithmetic mean 208 Armed forces health services 734 Arsenic contamination 71 ARSH 590 Artesunate combination therapy 348 ARTI (annual risk of tuberculous infection) 326 Asbestosis 606 Asbestos bodies 607 Ascaris lumbricoides 87 ASHA 707 Ashramas 623 Assessing dehydration 372 Assisted reproductive techniques 596 Attack rate 260 Attitude 25 Attributable fraction 267 Attributable risk 266 Auger 80 Averages 207 Average cost 57 Average Indian diet 140 Average length of stay 701 Avian influenza 438 Avoidable blindness 485 A young man of 100 years 629 AYUSH 734 Ayushman Bharat 732 Ayushman ambassadors 119

Baby-friendly hospital initiative

146

Bacteriological era 35 Bacteriological quality of drinking water 69 Bagassosis 607 Balanced diet 141 Barriers to good health 53 Barriers in communication 123 Basic science era 35 BCG vaccine 420 Beat elbow 614 Beat knee 614 Bed occupancy rate 700 Bed population ratio 701 Behaviour 9, 10 Behaviour change communication 113 Below poverty line families 54 Best buy’s 471, 492 Beti bachao beti padhao 603 Bhore committee 665 Biases in epidemiology 302

775

Bioactive phytochemicals 134 Bio-behavioural surveillance survey 314 Biochemical oxygen demand 85 Biodegradable plastics 647 Biofeedback 451 Biomedical waste management rules 641 Biostatistics 200 Bioterrorism 640 Birth control methods 594 Birth defects surveillance 531 Birth interval 520 Birth rate 518 Birth weight 144 Biting mites 105 Bitot’s spot 171 Blindness 484 Blocked flea 402 Body mass index 452 Borehole latrine 80 Bottle feeding 145 Bottom up approach 542 Breastfeeding 145 Breastfeeding promotion network of India (BPNI) 147 Breast milk 145 Broken family 40 Brill-Zinsser disease 104 Breteau index 365 Bridge population 312 Brucellosis 403 Brugia malayi 356 Bti 351 Bubonic plague 401 Byssinosis 608

Case-based surveillance

346 Caissons disease 612 Cancer 490 Canine rabies 392, 399 Caplan syndrome 607 Carbohydrates 136 Carbon monoxide poisoning 614 Cardiovascular diseases 446 CARE 747 Capital cost 57 Case control studies 290 Case fatality 262 Case study 4 Catch-up campaign 414 Categories of biomedical waste 644 Causation in epidemiology 299 Cause of death certificate 743 CBNAAT 329 Cell culture vaccines 396 CEmONC 549 Centchroman 594

776 Census 508, 629 Central tendency 207, 208 Cereals 133 CGHS 733 Chain of transmission 245 Characteristic of an Indian diet 140 Channel of communication 120 Checklist in supervision 690 Chemoprophylaxis 349 Chickenpox 416 Chikungunya fever 366 Child guidance clinic/centre 663 Child health services 539 Child Marriage Restraint Act 663 Child mortality rate 561 Child sex ratio 515 Chi-square test 229, 230 Chlorine demand 66 Chloroquine resistance 343 Cholera 377 Cholera vaccines 379, 380 Cholesterol 449 Chronic energy deficiency 165 Chronic lung diseases 90 Chunk 221 Citizen’s charter 723 Civil registration system 505 Classification of degree of PEM 152 Clinical medicine and community medicine 34 Clinical science era 35 Clinical social case review 4 Cluster sampling 219 Clinical establishment Act 743 Coagulation 64 Codex 190 Coefficient of variation 217 Cohort studies 292 Cohort studies in leprosy 294 Cohort studies in malaria 294 Cold chain system 573 Colombo plan 746 Colostrum 147 Commercial sex workers 313 Common impairments 264 Common screening tests 270 Communication in health 119 Communication needs assessment (CNA) 122 Communication skills 22, 119 Community 35 Community-based rehabilitation 17 Community development 703 Community development block 703 Community diagnosis 703 Community behaviour 51 Community healthcare 703 Community health centre 721 Community health era 35 CNAA 543, 671 CPHC 711 Community medicine 7 Community participation 37 Community relationship 51 Community trials 299 Composting—Bangalore and Indore methods 82 Competency-based learning 1 Concept of health planning 669 Condiments and spices 136

Textbook of Community Medicine Condom 594 Confidence interval 222 Confirmed by laboratory (L) 276 Confounding bias 302 Congenital rubella syndrome 575 Consanguineous marriages 39, 532 Consecutive sampling 219 Consumer Protection Act 26 Contraceptives 594 Contraceptive prevalence rate 521, 596 Contagion index 392 Control of communicable diseases 253 Copper-T 594 Core life skills 591 Cost benefit analysis 58 Cost effective analysis 57 Cost minimization analysis 57 Cost utility analysis 58 Costs 57 Counselling in health and disease 124 Covid-19 pandemic 767 Cross-sectional studies 290 Crude birth rate 518 Crude death rate 261, 516 CSSM 541 Culex mosquitoes 97 Cumulative incidence 259 Curable blindness 485 Cyclical variations 287 Cyclops 110 Cysticercosis 405

Dai training

548

Daksh 545 DANIDA 747 Data 200 Data triangulation 278 Day carriers 574 Deafness 93 Death by breath 89 Decentralized participatory planning 666 Declaration of Helsinki 27 Decompression sickness 613 Deep freezer 573 Deep wells 62 Defluoridation of water 74 Dehydration 372 Delegation 679 Delphi method 237 Demographic gap 510 Demographic profile of India 21 Demographic transition 508, 515 Demography 508 Dengue fever 362 Dengue haemorrhagic fever 365 Dengue shock syndrome 365 Density of population 515 Dental fluorosis 72 Dependency ratio 516 Depression 650 Descriptive studies 285 Determinants of health 8, 9 DFID 747 Diabetes mellitus 455 Diarrhoeal diseases 372 Diastolic blood pressure 460 Dietary beliefs and practices in India 143 Dietary fibre 134

Dietary surveys 152, 180 Dimension of health 5 Diphtheria 419 Direct mode of transmission 246 Directly observed treatment and shortcourse (DOTS) 327 DOTs plus 323 Disability 264 Disability adjusted life years 59 Disability limitation 17 Disability measurement 263 Disaster Management Act 633 Disaster preparedness 633 Discrimination and stigma 340 Disinfection of water 65 Disinfection of wells 67 Dispersion 213 District blindness control society 487 District health action plan 708 District mental health programme 651 DNA technology 534 Doctor–patient relationship 24 Domestic violence 600 Down syndrome 530 Drop in centre (DIC) 316 Drug deaddiction centres 657 Drug resistance in malaria 343 Drug resistance in typhoid fever 390 Dug well latrine 81 Dysentery 373

Early childhood care and education

195 Early diagnosis and complete treatment 17 Early marriages 554 Early neonatal death rate 507 Easing for diseases 79 Ebola virus disease 443 Ecological studies 289 Economic blindness 486 Economic impact of tuberculosis 56 Effects of communication 117 Efficacy of vaccine 413 Elements of surveillance 271 Eligible couples 521 Elimination of tetanus neonatorum 418 Emergency contraception 594 Emergency obstetric care (EmOC) 549 Emerging and re-emerging infectious diseases 244 Empathy 23 Empirical era 35 Employee State Insurance Scheme 732 Endemic 251 Endemic fluorosis 71 Enteric fevers 388 Entomological inoculation rate 342 Environmental health 60 Environmental sanitation in schools 585 Environments in chain of infection 8, 251 Epidemic 252 Epidemic curve 252 Epidemic Disease Act 255 Epidemic dropsy 191 Epidemic typhus 104 Epidemiological transition 255 Epidemiological study designs 285 Epidemiological surveillance of diseases 270 Epidemiological basis of NHP 303 Epidemiological triad or triangle 245

Index Epidemiology 242 Epilepsy 650 Eradication of poliomyelitis 421 Eradication of yaws 433 Ergonomics 615 eSanjeevani 717 ESI Act 1948 619 Essen regimen 396 Essential fatty acids 139 Essential newborn care 563 Essential medicines 748 Essential obstetric care 546 Ethics in medicine 25 Ethnographic research 47 Eugenics 536 Euthanasia 28 Euthenics 536 Evaluation of health programme 693 Exclusive breastfeeding 145 Expectation of life 517 Experimental studies 294 Experiential learning 2 Ex-servicemen contributory health scheme 733 Extended family 39 Extended sickness benefit 621 Extensive drug resistant TB 332 Extrinsic allergic alveolitis 608 Extrinsic incubation period 341

Factories Act

615 Falciparum malaria 341, 348 Family types 39 Family-based household records 46 Family medicine 46 Family size 40 Family studies 47 FAO 747 Farmer’s lung 456 Fats 138 Feedback in communication 121 Felidae 406 Felt need 704 Female condom 594 Fertility indicators 518 Field trials 298 Filaria 356 F-IMNCI 583 First referral unit 549 Fish bowl 117 Fixed sites 570 Flea index 101, 403 Fleas 101 Focus-based surveillance 346 Focus group discussion 117, 239 Fomite transmission 248 Food additives 189 Food fortification 190 Food for work programme 185 Food poisoning 191 Food pyramid 142 Food Safety and Standard Act 188 Ford foundation 746 Framingham study 447 Frequency distributions 205, 211 Frequency table 205 Fruits 134 Fundamental research 234

GATHER approach

125 Gaussian (normal) distribution 213 Gender issues and women empowerment 598 Gender inequality index 599 Gene therapy 535 General fertility rate 519 Genetic counselling 534 Genetically modified crops 193 Genetics 529 Genital herpes ulcer 323 Genital ulcer 323 Genome project 535 Genotoxic waste 642 Genotoxicity 642 Geographic information system 504 Geometric mean 209 Geriatrics 623 Gerontology 623 Gestational diabetes 456 Global adult tobacco survey 658 Global health security 739 Global warming 91 Glucose-6-phosphate dehydrogenase deficiency 531 GOBIFFF 711 Golden crescent 656 Golden triangle 656 Good samaritan 483 Grades of goitre 179 Greenhouse gases 91 Green leafy vegetables 134 Gross domestic product 18 Gross national income 18 Groundwater 61 Group communication 115 Group discussion 115 Group dynamics 117 Growth charts 159 Growth monitoring 156 Growth rate of population 516 Guinea worm disease 387

Habit

10 Haemoglobinopathies 532 H1N1-influenza 440 Hand hygiene 249 Handicap 264 Hard ticks 106 Harm reduction centres 657 Harmonic mean 209 Health 5 Healthcare of community 703 Health and wellness centres 715 Healthcare delivery systems in India 712 Healthcare financing 695 Healthcare utilization 735 Health economics 55 Health education 112 Health for all era 35 Health indicators 17 Health legislation 7 Healthy life expectancy 18, 232 Health management 676 Health management functions 679 Health management information system 499 Health problems of children 540 Health problems of women 539 Health planning in India 665 Health promotion 15, 112

777 Health services 9, 10 Health seeking behaviour 53 Health system monitoring 691 Health system organization 678, 712 Hearing impairment 613 Heat cramps and exhaustion 611 Heat stroke 611 Hepatitis A 381 Hepatitis B 383 Hepatitis C 385 Hepatitis E 382 Hepatitis A vaccine 582 Hepatitis B vaccine 384 Heredity 9, 10 Hib vaccine 577 Hidden epidemic 310 High density lipoprotein 449 High-risk approach 16 Hippocratic oath 26 HIV and breastfeeding 147 HIV burden 311 HIV positive 310 HIV sentinel surveillance 314 HIV trends 311 HIV/AIDS 310 Holistic health 4 Home available fluids 375 Home-based newborn care 563 Home-based records 45, 46 Home delivery practices 540 Hookworm disease 87 Hospital acquired infections 246 Hospital statistics 700 Hospital waste management 641 Host factors 249 Host in chain of infection 249 House and household 38 Housing standards 77 Household 38 Household surveys 41 Household survey register/family register 41 House index 365 Housefly 100 Household food security 132 Human development index 18 Humanities 50 Human diploid cell vaccine 396 Human genome project 535 Human genome diversity project 535 Human papillomavirus/vaccine 492 Human resource development 193 Human resources in health 735 Hydatid disease 404 Hydrofluorosis 73 Hypertension 460 Hyperendemic 252 Hypothesis 225

ICD-10 and 11

742 ICF 742 Iceberg phenomenon 310 Ice-lined refrigerator 573 Ice-packs 574 ICPD (International Conference on Population and Development) 595 ICTC 128, 317 IDD (goitre) survey 178 IDSP 275

778 IEC 113 Illegal abortions 554 IMNCI 578 Impaired glucose tolerance test 456 Impairment 264 Improvident maternity 520 Inactivated polio vaccine (IPV) 422 Incidence of a disease 259 Incident response system 638 Incineration 646 Incremental cost 57 Incubation interval 342 Indian AQI 93 India newborn action plan 565 Indian public health standards (IPHS) 713 Indirect method of standardization 262 Indirect mode of transmission 246 Indoor air pollution 90 Indoor residual spray 350 Industrial accidents 615 Industrial fluorosis 73 Inequities in health/gender 599 Infant and child mortality 557 Infant Milk Substitutes Act 146 Infant mortality causes 559 Infant parasite rate 294 Infectious agents 300 Infectious waste 642 Infertility 596 Influenza 437 Information for all 114 Injectable contraceptives 594 Injecting drug users 656 Insecticide resistance in malaria 343 Insecticide treated nets (ITN) 351 Integrated action plan for P and D 564 Integrated biological and behavioural survey 314 Integrated child development services 193 IRCHR 502 Integrated teaching 4 Integrated vector management 350 Intelligence 662 Intelligent quotient 662 Intensified diarrhoea control fortnight 377 Intentional injuries (suicide) 481 International classification of functioning, disability and health 11 International health 739 International health regulations 739 International Red Cross Society 747 International statistical classification of diseases 742 Interpersonal communication 115 Interviews 237 Intradermal regimens 397 Intrinsic incubation period 341 Invisible fats 139 Iodine deficiency disorders (IDDs) 174 Iodization of salt 177 Ionizing radiation 611 Itch mite 104 IUCD 594 IYCF 148

Jal Shakti Ministry

76 Janani Suraksha Yojana 549 JSSK 549 Japanese encephalitis 367

Textbook of Community Medicine Jery Lynn strain 416 JE vaccine 369 Job description of ASHAs 707 Job description of health supervisors 686 Job description of health workers 687 Job description of MO 685 Job description of mid-level health provider 686 Joint family 39 Judgement sampling 221 Junk foods 144 Juvenile delinquency 662 J.J. Act 663

Kala-azar

350 Kaoru ishikawa diagram 735 Kangaroo mother care 566 Kartz index 628 Keratomalacia 171 Khap panchayat 36 Kishori Shakti Yojana 199 Klinefelter’s syndrome 530 Koch’s postulates 35, 300 Kopliks spots 401 Kuppuswami’s method of SES 43 Kyasanur forest disease 379 Kilkari 548 Kartz index 618

L ate neonatal mortality 560 Laqshya programme 557 LEAD model 681 Lead and its toxic effects 609 Leadership styles 681 Legumes 134 Leishmaniasis 360 Leprosy 335 Leptospirosis prevention and control 406 Level of significance 225 Levels of prevention 13 Lice 102 Life expectancy 18, 19, 233, 517 Life skills 652 Life table 232 Likert scale 122 Line listing 204 Linoleic acid 139, 140 Linolenic acid 139, 140 Link workers scheme 317 Literacy rates 517 Long-lasting insecticidal bednets 351 Lot quality assurance sampling 221 Louse-borne epidemic typhus 104 Low birth weight babies 144 Low cost sanitation 83 Low density lipoproteins 449 Lower abdominal pain 323 Low utilization of govt health services 711, 735 Lymphatic filariasis 356 Mad cow disease

410 Mahila Mandals 38 Mahila Swasthya Sangh 48 Major health problems in India 33 Mala-D 594 Mala-N 594 Malaria 341 Mahila Arogya Samiti 38, 115

Malaria in India 341 Malaria prophylaxis 350 Malnutrition in adolescents 164 Malnutrition in adults 165 Malnutrition in young children 148, 149 Man-made disasters 636 Man-made environments 8 Mansonioides 98 Marginal costs 57 Maslow’s hierarchy of needs 683 Mass communication 117 Mass drug administration in filaria 358 Maternal health 539 Maternal death review 550 Maternal mortality 551 Maternal mortality rate 553 Maternal mortality ratio 553 Matriarchal 39 Matrix of communication for behaviour change 123 Measles 411 Measures of variation 213, 215 Measure of central tendency 208 Measles multiyear strategic plan 414 Measles elimination by 2023 416 Measles rubella vaccine 575 Measurement of maternal mortality 553 Median 209 Medical Council of India 29 Medical entomology 94 Medical genetics 529 Medical sociology 49 Medical social worker 664 Medical Termination of Pregnancy Act 537 Meningococcal disease 430 Meningococcal vaccine 431 Mental disorders 649 Mental health 649 Mental (well-being) 6 Mental Health Act 653 Mental retardation (IDD) 661 Message 120 Meta-analysis 301 Methods of screening of high risk groups 547 Metabolic syndrome 456 Methods of population control 521 Micronutrient deficiency disorders 166 Middle East respiratory syndrome 433 Mid-level health provider 711, 715 Mid upper arm circumference 152 Mid-day meal programme 185 Milk and milk products 135 Millennium development goals 736 Million death study 263 Mission Indradhanush 571 MGNREGA 185 MMR vaccine 575 Mobile academy 702 Mode 210 Mode of transmission 245 Model registration survey of causes of death 507 Molecular genetics 534 Monkeypox 445 MONICA project 447 Monogamous 39 Mono-unsaturated fatty acids 139 Monthly blood examination rate 354 Mop up rounds 422

Index Mortality statistics 260 Mosquito larvicidal oil (MLO) 356 Mother absolute affection 146 Mother and child tracking system (MCTS) 504, 548 Mother and child protection card 45, 46, 158 Motivation 683 Multidimensional poverty index 55 Multidrug resistant TB 332 Multifactorial diseases 256, 300 Multi-stage sampling 221 Mumps 416 Mutation of gene 530 Mutagens 530

Nalgonda technique

74 Narcotic and Psychotropic Drug Act 657 National Cancer Control Programme 492 National cancer registry programme 493 National centre for disease control 739 National child survival and safe motherhood programme 541 National clean air programme 92 National communication strategy in RCH 124 National demographic goals 509 National ambulance services 551 NDMA 637 National Diarrhoeal Disease Control Programme 377 National digital health 505 National Digital Health Mission 501 National drug deaddiction programme 657 National drug policy on malaria 347 National family health survey 527 National Family Planning Indemnity Scheme 596 National Family Planning Programme 595 National Filaria Elimination Programme 358 National framework for malaria elimination 344 National Food Security Act 132 National guidelines for hospital waste management 643 National guidelines on rabies prophylaxis 393 National guidelines on infant and young child feeding 148 National Rabies Control Programme 398 National guidelines on prevention management and control of RTI/STI 322 National guinea worm eradication programme 379, 388 National Health Mission 706, 708 National Health Policy 1983 and 2002 665 Naional Health Policy 2017 666 National HIV/AIDS control programme 315 National iron + initiative 169 National immunization schedule 568 National institute of occupational health 606 National iodine deficiency disorders control programme 176 National programme for containment of antimicrobial resistance 752 National programme of prevention and control of JE/ AES 368 National strategic plan for TB-elimination 327 National kala-azar elimination programme 361 National leprosy eradication and elimination programme 338 National Malaria Control Programme 343 National Malaria Eradication Programme 343 National Mental Health Programme 651

National Mid-Day Meal Programme 183 National mid-term plan for prevention and control of dengue 363 National policy for empowerment of women 602 National Nutrition Mission 187 National Nutrition Monitoring Bureau (NNMB) 164 National nutritonal programmes 183 National Nutrition Policy 185 National nutritional anaemia control programme 169 National Oral Health Programme 494 National Organ Transplantation Programme 757 National policy on ARI 426 National policy on older persons 630 National polio eradication programme 421 National population policy 522 National programme and policy for adolescent health 590 National programme for control of blindness 486 National programme for control of cancer diabetes, cardiovascular diseases and strokes 467 National programme for health care of elderly 631 National programme for prevention and control of deafness 497 National programme for prevention and managment of trauma and burn injuries 482 National programme for prevention of parent to child transmission 313 National programme for prevention and control of fluorosis 73 National programme for VAD 172 National programme on prevention and control of viral hepatitis 386 National reproductive and child health programme 539 National Rural Health Mission 706 National rural water supply and sanitation programme 75 National Safety Council of India 615 National strategy on SMP 131 National tobacco control programme 660 National tuberculosis control programme 327 National Health Mission 706 National Urban Health Mission 725 National vector-borne disease control programme 110, 341 Natural history of disease 12, 13 Necessary cause 300 Neglected tropical diseases 244 Negative predictive value 269 Neonatal mortality 560 Newborn care corner 563 Newborn stabilization unit 563 Net reproduction rate 520 NIPAH 444 NITI Aayog 60, 665 Neural tissue vaccine 395 Neurolathyrism 191 New leprosy case 337 Newer vaccines in UIP 575 Non scalpel vasectomy 595 Noise pollution 93 Non-communicable diseases 255, 446 Non-formal pre-school education 195 Non-Governmental Organizations 734 Non-parametric tests 230 Non-verbal communication 120 Normal distribution 213

779 Normal distribution curve 213 Normal range 214 Normal value 215 NRR 520 Nosocomial transmission 246 Notifiable diseases 255 Nuclear family 39 Null hypothesis 225 Nuremberg code of ethics 27 Nutrition 132 Nutrition education 155 Nutrition intervention programmes 183 Nutrition rehabilitation centre 153 Nutritional anaemia 166 Nutritional surveillance system 163 Nuts and oil seeds 134

Obesity

452 Observational studies 285 Obese class I, II and III 453 Occupational lung diseases 605 Occupational asthma 609 Occupational dermatosis 613 Occupational safety and health 604 Odds ration 290 One health approach 5 One-way communication 121 Operational research 234, 235 Opportunistic infections 317, 327 Opportunity cost 57 Open defecation free 9, 83 Open birth interval 521 Oral pills 594 Oral polio vaccine 422 Oral rehydration salt 373 Oral rehydration therapy 373 Organization behaviour 680 Orphanages 40 Orthotoluidine test 67 Ottawa charter 7 Outbreak investigations 274 Outbreak of plague 400 Outbreak response immunization 421 Outdoor air-pollution 88 Outreach sessions 571 Overweight 450 Oxidation pond 85 Ozone 65

P value

226 P. falciparum proportion 355 Panchayati Raj Institutions (PRIs) 36 Pandemic 253 Pandemic influenza 440 Paradigm shift in FP 597 Parent to child transmission 313 Parenteral transmission 248 Participation bias 302 Particulate matter 88 Partography 548 Passive case detection 345 Passive surveillance 345 Pasteurization 404 Pathogenic and prepathogenic periods 13 Pathogenicity 245 Patriarchal 39 PC-PNDT Act 536, 551 Pearl index 597

780 Pedagogy 2 Pediculosis 103 Peer counselling 129 Pentavalent vaccine 577 Perinatal mortality 561 Period prevalence 258 Periodical health examination 617 Persistent organic pollutants 62, 350 Persistent diarrhoea 373 Person distribution 288 Pertussis 416 Phossy jaw 417 Physical inactivity 454 Physical quality of life index 19 Physical well-being 5 Pie diagram 205 Pit latrine 80 Place distribution 287 Plague 399 Plague surveillance 403 Planning of health services 669 Plasmodium falciparum 341 Plasmodium malariae 341 Plasmodium ovale 341 Plasmodium vivax 341 PM 10, PM 2.5 92 PM-JAY 732 PM Ujwala Yojna 92 Pneumococcal conjugate vaccine 577 Pneumoconioses 605 Pneumonia 427, 428 Pneumonic plague 401 Point prevalence 258 Poker’s back 73 Poliomyelitis 420 Polio eradication 421 Polio endgame strategy 423 Polyandrous 39 Polygamous 39 Polyunsaturated fatty acids (PUFA) 139 Population at risk 257, 266 Population attributable risk 267 Population-based approach 15 Population education 119 Population dynamics 510 Population explosion 510 Population policy 522 Population pyramid 513 Population stabilization 508 Population problem 508 Positive predictive valve 269 Post-exposure prophylaxis 394 Potable water 60 Poverty line 54 Prasad’s method of SES 44 PC-PNDT Act 536 Pre-exposure prophylaxis 318 Prefered private providers 323 Pre-obese 453 Pre-patent period 357 Pre-placement examination 616 Pre-test and post-test counselling 127 Pre-transition stage 509 Prevalence 257 Preventable blindness 458 Prevention of Food Adulteration Act 188 Prevention of parent to child transmission 317

Textbook of Community Medicine Prevention paradox 16 Preventive medicine era 34 PRAI 80 Primary health care 712 Primary health centre 717 Primary prevention 15, 448 Primordial prevention 14, 447 Private health sector 731 Probability 223 Probability proportion to size (PPS) 219, 220 Probable cases (P) 276 Problem families 40 Problem-based learning 2 Programme evaluation and review technique 695 Proportion 257 Proportional mortality ratio 262 Protein energy malnutrition 148 Proteins 136 Public distribution system 185 Public health 7 Public Health Act 255 Public health emergencies 281 Public–private partnership 698, 731 Pulmonary tuberculosis 325 Pulse polio immunization 422 Pulses 134 Purified chick embryo vaccine 396 Purified duck embryo vaccine 396 Purposive sampling 221

Q fever

409 Qualitative data 201 Qualitative methods of research 238 Quality adjusted life years 58 Quality and standards of water 69 Quality of health services 735 Quality of life 19 Quantitative data 201 Quarantine 255 Quartile 211 Questionnaire 238 Quota sampling 221

Rabies

392 Rabies immunoglobulin (RIG) 393 Radiation 611 Railway health services 734 Rain water harvesting 74 Rajiv Gandhi National Drinking Water Mission 73 Randomized controlled trials 295 Range 215 Rapid diagnostic test 347 Rapid sand filter 64 Rashtriya Bal Swasthya Karyakram 587 Rashtriya Kishor Swasthya Karyakram 590 Rate 257 Ratio 257 Rattus norvegicus 108 Rattus rattus 108 Raynaud’s phenomenon 613 RCA latrine 80 RCH phase 1 541 RCH phase 2 53 Real need 37 Receiver 121 Recommended dietary allowances (RDA) 136, 137 Reduced osmolarity ORS 374 Reduviid bugs 110

Re-emerging infectious diseases 244 Reference adult man 5, 6 Reference adult woman 5, 6, 136 Referral system 730 Regression analysis 231 RHIME 263 Rehabilitation 17 Relativeness of health 7 Relative risk 267 Relaxation techniques 451 Released from treatment 337 Reproductive and child health programme 539 RMNCH + A 539 Reproductive tract infections 319 Re-registered case 337 Research question 239 Research methodology 234 Reservoir and source of infection 249 Residual chlorine 66 Revised Jones criteria 465 Revised national tuberculosis control programme 327 Rheumatic fever 463 Rheumatic heart disease 463 Right to Education Act 118 Risk factors 265, 447 Risk measurement in epidemiology 265 Road traffic accidents 477 Rockfeller foundation 746 Rodents 108 Root causes analysis 735 Root vegetables 134 Rotavirus vaccine 376, 577 Routine reports 471 Rubella 415 Rural community 35

SABLA

199, 593 Safe abortion 554 Safe blood 318 Safe deliveries 548 Safe disposal of human excreta 78 Safe injection 551 Safe pregnancy 547 Safe purpeurium 549 Safe water 60 Simple random sampling 218 Sample registration system (SRS) 506 Sample vaccine 395 Sampling 217 Sampling fraction 218 Sampling frame 218 Sampling unit 218 Sanitary sources of water 61 Sandflies 98 Sarva Shiksha Abhiyan (SSA) 583 Saturated fatty acids 139 Scabies 105 Schizophrenia 650 Scales of measurements 200 Scatter diagram 231 School health programme 583 Screening tests 267 Seasonal distribution 286 Second-hand smoke (SHS) 449, 659 Secondary attack rate 260 Secondary healthcare 729 Secondary prevention 16, 448 Secular trends 285

Index Sedimentation 64 Segregation of waste 643 Selection bias 302 Self-help groups 523 Senescence 623 Sensitivity of test 268 Sentinel surveillance 272 Septic tank 81 Severe acute respiratory syndrome 435 Sewage 84 Sewage treatment process/human excreta 84 Sex ratio 514, 599 Sex ratio at birth 515 Sexually transmitted infections 319 Shallow open wells 62 Silicosis 605 Simple random sampling 218 Skeletal fluorosis 73 Skilled attendance at birth 548 Skin fold thickness 452 Slide positivity rate (TPR) 354 Slow sand filters 64 Sludge digestion 85 Smallpox eradication/vaccine 740 Social blindness 486 Social distancing 761, 762 Social determinants of health 11 Social empowerment of women 602 Social and cultural factors 50 Social health problems 50 Social marketing programme 130 Social medicine 7 Social mobility 45 Social psychology 51 Social review 4 Social therapy 50 Social well-being 6 Socio-economic status (SES) of family 43 Socio-economic and caste census 44 Sociogram 117 Soft ticks 108 Soil pollution 85 Soil transmitted helminths 87 Solar water disinfection 65 Solid waste management 78 Source of communication 120 Sources of health data 202 Sources of nutrients 133 Sources of vital statistics 526 Special newborn care unit 563 Specificity 268 Spiritual well-being 6 Sporadic 251 Spot map 207 Spot testing kits 177 Specific protection 15 Stable malaria 343 Stable population 511 Standard case definitions 277 Standard deviation 216 Standard of living index 45 Standard error of mean 216 Standard error of proportion 223 Standard million 261 Standard normal distribution 212 Standard normal deviate 217 Standard treatment guideline 752 Standardization of crude death rate 261

781

Stationary population 511 Steps in outbreak investigation of CCD 279, 281 Sterilization (female) 594 Strength of association 301 Sterilization (male) 594 Stillbirth rate 560 Strategic action plan for malaria control in India 344 Strategic information management system 319 Stratified random sampling 219 Stress management 451 Student’s ‘t’ test 228 Stunting 152 Subcentre action plan 670, 674 Subcentre registers 503 Subcentres 714 Substance use disorders 655 Sufficient cause 300 Sugar and jaggery 135 Sugar salt solution 373 Suicide rate 651 Supervision as management tool 688 Supplementary feeding 196 Supplementary nutrition programmes 151, 184 Surface water 62 Surveillance of AFP 421 Surveillance methods 271 Surveillance of communicable diseases 254 Surveillance of malaria 345 Surveillance of risk factors of non-communicable diseases 280 Surveillance of STI 324 Suspected/syndromic (S) case 276 Suspended particulate matter 88 Sustainable development goals 737 Swachh Bharat Abhiyan 83 Swasth Nagric Abhiyan 54 Switchover from tOPV to bOPV 424 Syndrome X 458 Syndromic approach 321 Systematic random sampling 218

Three-generation family 39 Thresher’s disease 608 Ticks 106 Time distribution 285 ‘t’ test 228 Test of significance 225 THOTA 756 Tobacco control legislation 660 Tobacco pandemic 658 Top down approach 542 TORCH test 406 Total fertility rate 519 Total sanitation campaign 82 Toxoplasmosis 405 Trachoma 489 Trans-fats 140 Training needs assessment 690 Ttansfusion transmissible infections 246 Transmission assessment surveys 359 Trauma centre 483 Trends in population growth 516 Tribal areas primary healthcare 729 Tribal community 37 Tuberculin test 326 Tuberculosis 324 Tuberculous infection 326 TPT 334 Tube wells 62 Turner’s syndrome 530 Turnover interval 700 Twin pit water seal latrine 80 Two-way communication 121 Ty21a vaccine 391 Type I and 2 diabetes 456 Type I error 226 Type II error 226 Typhoid carrier 389 Typhoid fever 389 Typhoid conjugate vaccine 392 Typhoid vaccines 390

Tabulation of data

Udai Pareek’s method of SES

204 Target audience 121 Taeniasis 405 Transplacental transmission 246 Target-free approach (CNAA) 542 Targeted intervention 316 Targeted public distribution system 154, 185 Tatera indica 400 Teaching vs learning 2 Technical cooperation mission 746 Teenage pregnancies 554 Telemedicine (e-Sanjeevani) 717 Temporal relationship 301 Teratogen (mutagen) 530 Tertiary healthcare 730 Tertiary prevention 17 Tertiary treatment of sewage 85 Test falciparum rate 355 Test positive rate 354 Testing of hypothesis 225 Tests of significance 225 Tetanus 417 Tetanus neonatorum 418 Thai Red Cross schedule 397 The final push strategy 339 Therapeutic nutrition 197 Thermotolerant coliform bacteria 69

43 Ujwala Yojana 92 Ultraviolet radiation 611 Uncertainties 202 Under-5 mortality 561 Undernutrition 133 Undernutrition during infancy 144 Underweight 152 Unethical acts 30 Unhealthy lifestyle diseases 446 UNICEF 745 Universal DST in TB 329 Universal elementary education programme 583 Universal health coverage 709 Universal immunization programme 567 Universal precautions 255 Universal salt iodation 176 Universalization of ICDS 199 Unmet needs of family planning 598 Unsafe abortions 554 Unsaturated fatty acids 139 Unstable malaria 343 Untied funds 714 Unwanted pregnancies 554 Urban community health centre 728 Urban community 36 Urban health 725

782 Urban malaria scheme 355 Urban primary health care services 725 Urban primary health centre 726 Urban sanitation 83 Urban vector-borne diseases 355 Urban water supply and sanitation 76 Urethral discharge 323 Urinary iodine excretion (UIE) 177 USAID 747

Vaccine associated paralytic polio

423 Vaccine carriers 574 Vaccine derived poliovirus 423 Vaccine hesitancy 770 Vaccine preventable diseases 567 Vaccine vial monitor 424 Vagabond disease 103 Vaginal discharge 323 Validity of test 269 Variability 213 Variance 216 Variables 200 Variation 202 Varicella 416 Varicella vaccine 416 VCTC 128 Vector-borne diseases 340 Vector-borne transmission 247 Vehicle-borne transmission 247 Ventilated improved pit latrine 81 Verbal autopsy 274 Verbal communication 119 Vertical transmission 246 Very low density lipoprotein 449 Village health and nutrition day 198

Textbook of Community Medicine Village health register 42 Village health, sanitation and nutrition committee 11 Village Panchayat 36 Viral hepatitis 381 VISHWAS 11 Vivax malaria 343 Virulence 245 Visible fats 139 Vision 2020 489 Vit A deficiency 170 Vital statistics 516

Waist circumference

452 Waist hip ratio 452 Walk in cold rooms 573 Walk vision 486 Wasting 152 Water-based diseases 63 Water-borne diseases 63, 372 Water conservation 74 Water pollution problem 62 Water purification 63 Water quality standards 69 Water quality surveillance 70 Water related vector-borne diseases 63 Water scarce diseases 63 Weighted mean 209 Weil-Felix test 104 Weil’s syndrome 407 Wholesome water 60 Whooping cough 416 Window period 310 Women status 600 Women workload 600 Wolff Chaikoff’s effect 175

Work vision 486 World Bank 747 World Health Organization 744 WHO air quality guidelines 92 WHO stepwise approach 280

XDR-TB

332 Xenopsylla astia 101, 402 Xenopsylla braziliensis 101, 402 Xenopsylla cheopis 101, 402 Xerosis corneal 171 X-linked disorders 531 X-linked inheritance 531 X-rays 611

Yaws eradication programme

443

Years lived with disability 497 Yellow fever 370 Yellow fever vaccine 372 Yersinia pestis 400, 402 Yoga and medication 451 Young old 623 Young people 588 Youth 588 Y tree analysis 735

Zika virus infection

444 Z-score lines 217 Zagreb schedule 396 Zero population growth 511 Zinc nutrition 179 ZOE gynaecologic simulator 597 Zoogleal layer 64 Zoonotic diseases 392 Zoophilic 96