Health status of special groups

By:Alka Mishra

M. Sc. Nursing 1st year

index• Introduction• Health care delivery • Special groups

» Women» Children» Tribal» Aged» Disabled» Migrant» Scheduled caste

• Summary• Conclusion

introductionHealth is…..

……..a state of complete Physical, Mental and Social well being and not merely an absence of disease or infirmity…. …..which allows a person to live a socio-economically productive life.

Illness is…..

…a state in which a person’ s physical, emotional, intellectual, social or spiritual functioning is diminished or impaired.

Conted....Health care is...

…….multitude of services rendered to individuals or communities by the agents of health services or professional for the purpose of

Promoting Restoring andMaintaining health

Embraces all the goods and services designed for “prevention, promotion and rehabilitation interventions” includes Medical Care

Health care providerA person or organization that provides services

and/or health care personnel….  ….to deliver proper health care in a systematic way to any individual in need of health care services.

Could be a government…or… ….the health care industry, ….a health care equipment company, ….an institution such as a hospital or laboratory.

Health care professionals may include  physicians, dentists ,nurses and other support staff.

Health services

Permanent countrywide system of established institutions with the objective of…….coping with the various health needs and

demands of population……thereby provide health care to individuals and

community with preventive and curative activities….utilizing health care workers

Components of healthcare delivery system

1. Structure of health system

Aspects of the design of health services that influences the way in which they are delivered Includes….

Number and type of personnel and staff

Way of these personnel organized to work

Nature and extend of facility and equipment

Range of services offered

System of management and amenities

Financing

Enumeration and determination of the eligible population for these services

Governance and decision making

2. Process of health care delivery Consists of two partsBehavior of professionals

Recognition of the problem i.e. diagnosisDiagnostic procedureRecommendation of treatment or managementAppropriate follow up

Participation of peopleUtilization of servicesUnderstanding the recommendationsSatisfaction with the servicesParticipation in decision making

Conted....3. Outcomes of health care

Aspects of health that results from interventions provided by the health system

4. Flow of patients in health care system

Varies from country to country India harbors a multistage (three tier) system, where majority of health

care is delivered by community health care worker Indian system is more cost effective if health workers are skilled and

effectively supervised Such system could one of the reason to reduced cost of health care in

developing countries

Levels of health care Primary Health care Provided at the community level

Secondary health care Provided at PHC, CHC, DH etc.

Tertiary health care Provided at hospitals

Tertiar

y care

Secondary health care

Primary health care

Health Care Delivery System in India India is a union of 28 states and 7 union territories.

States are largely independent in matters relating to the delivery of health care to the people.

Each state has developed its own system of health care delivery, independent of the Central Government.

The Central Government’s responsibility policy making , planning , guiding, assisting, evaluating and coordinating the work of the State Health

Ministries.

Health system in India

Local or peripheral

State

Central

At centreThe official “organs” of health system at

national level areThe Ministry of Health and Family

welfare

The directorate general of Health Services

The central council of health and family welfare

Mohfw organizational chart

Functions of mohfwUnion list International health relations and administration of port quarantine

Administration of Central Institutes

Promotion of research

Regulation and development of medical, pharmaceutical, dental and nursing professions

Establishment and maintenance of drug standards

Census and collection and publication of other statistical data

Coordination with states

Conted.....Concurrent List:

Prevention of Communicable disease

Prevention of food adulteration

Control of drug and poison

Vital statistics

Labor welfare

Economic and social planning

Population control and family planning

Dghs organizational chart

Functions of dghsGeneral functions Surveys Planning Coordination Programming and appraisal of all health matters

Specific function International health relations and quarantine of all major ports in

country and international airport. Control of drug standards Maintain medical store depots Administration of post graduate training programmes

Conted..... Administration of certain medical colleges in India

Conducting medical research through Indian Council of Medical Research ( ICMR )

Central Government Health Schemes.

Implementation of national health programmes

Preparation of health education material for creating health awareness through Health Education Bureau

Collection, compilation, analysis, evaluation and dissemination of information

National Medical Library

Central council of health

functionsTo consider and recommend broad outlines of policy

related to matters concerning health like environment hygiene, nutrition and health education.

To make proposals for legislation relating to medical and public health matters.

To make recommendations to the Central Government regarding distribution of grants-in-aid.

State level

District level• Districts

Tehsils /Talukas (200-600 villages)

Community Development Blocks (approx 100 Villages & 80,000 -1.2 Lac Pop)

Municipalities & Corporations

Villages

Panchayats

Town Area Committee (5,000-

10,000 Pop)

Municipal Board (10,000- 2 Lac

Pop)Corporations (> 2

lac pop)

Health care system Intended to delivery healthcare services and represented by five major sectors

different from each other by health technology

Public health sector a. Primary health care

Primary health centre Sub centre

b. Hospitals/Health centre Community health centre Rural hospitals District hospitals/health centre Specialist hospitals Teaching hospitals

c. Health insurance schemes Employees State Insurance Central Govt. Health Schemes

d. Other agencies Defense services Railways

Conted.....2. Private sectora. Private hospitals, polyclinic, nursing homes and dispensariesb. General practitioners and clinics

3. Indigenous system of medicine a. Ayurveda and Siddhab. Unani and Tibbic. Homeopathyd. Unregistered practitioners

4. Voluntary health agencies

5. National health programmes

Special groups• Special groups are the groups which would be

vulnerable under any circumstances (e.g. where the adults are unable to provide an adequate livelihood for the household for reasons of disability, illness, age or some other characteristic), and groups whose resource endowment is inadequate to provide sufficient income from any available source.

Special groups• Women• Children• Tribal• Aged• Disabled• Migrant• Scheduled caste

Factors affecting healthLack of job

Low paid unorganised labour

Lack of health services

Poor nutrition

IllitrecyDiscrimination

Women• Gender is one of many

social determinants of health—which include social, economic, and political factors—that play a major role in the health outcomes of women in India. Therefore, the high level of gender inequality in India negatively impacts the health of women.

Status of healthThe low status of—and subsequent

discrimination against—women in India can be attributed to

o cultural norms.o Societal forces of patriarchy,o hierarchy o multigenerational families

Conted......• Highest rate of malnourishment• 50% of pregnant /non pregnant anaemic• A 2012 study by Tarozzi have found the

nutritional intake of early adolescents to be approximately equal. However, the rate of malnutrition increases for women as they enter adulthood.

• Furthermore, Jose et al. found that malnutrition increased for ever-married women compared to non-married women.

Key Reproductive & child health indicatorsIndicator (%)• Female literacy 59.1• Women with BMI below normal 38.8• Women who had at least 3 ANC visits 42.8• Women consumed IFA for 90 or more days 18.1• Institutional births 31.1• Deliveries by TBA 39.1• Life expectancy at birth 68.3• TFR Rural 2.7

Urban 1.9Total 2.4

• Initiation of breast feeding with in 1 hr 21.5• Exclusive breast feeding(0-6 Months) 48.3• Complementary feeding (6-9 Months) 53.8

Other indicators

• Anaemia & malnutrition• Reproductive health & rights• HIV/AIDS• Mental health• Breast cancer• Domestic violence

Trend of Birth rate, Death rate, Infant Mortality rate, Total Fertility rate,Sex ratio at Birth and Sex ratio of children (0-4 age group), India

16.0

18.0

20.0

22.0

24.0

26.0

28.0

2008 2009 2010 2011 2012 2013

Birth rate

Total Rural Urban

6.26.46.66.87.07.27.47.67.88.08.2

2008 2009 2010 2011 2012 2013

Death rate

Total Male Female

35

40

45

50

55

60

2008 2009 2010 2011 2012 2013

Infant mortality rate

Total Male Female

1.5

2.0

2.5

3.0

3.5

2008 2009 2010 2011 2012 2013

Total fertility rate

Total Rural Urban

890

900

910

920

2007-09 2008-10 2009-11 2010-12 2011-13

Sex ratio at birth

Total Rural Urban

890

900

910

920

2007-09 2008-10 2009-11 2010-12 2011-13

Sex ratio of children (0-4 age group)

Total Rural Urban

Causes of maternal deaths in india

Haemorrhage37%

Sepsis11%

Abortion8%

Ob-structed labour

5%

Hyper-tensive disorder

5%

others 34%

Govt initiativeAll the elements of RCH- II integrated in NHM• Essential Obstetric Care• Quality Ante Natal care• Post natal care for mother and newborn• Skilled Attendance at Birth• Provision of Emergency Obstetric and Neonatal

Care at FRUs• Augmentation of skilled human resources for

Maternal Health

Conted.....• Safe Abortion Services/ Medical termination

of Pregnancy (MTP)• Supply of Nischay Pregnancy detection kits to

sub centres• Maternal Death Review• MCTS• A Joint MCP Card• JSSK

Conted.....,• Gender Based Violence (detection & support)• Setting up of Blood Storage Centre (BSC) at

FRUs• Scheme for promotion of menstrual hygiene

among adolescent girls in rural India

Children• A person between birth and full growth; a boy

or girlNeonateUnder 5 yrs of age

Health status indicators

• Neonatal mortality rate 2012 31• Immunization coverage (%) 2012, BCG 87• Immunization coverage (%) 2012, DPT1 88• Immunization coverage (%) 2012, DPT3 72• Immunization coverage (%) 2012, polio3 70• Immunization coverage (%) 2012, MCV 74• Child marriage (%) 2002-2012*, married by 15 18.2• Child marriage (%) 2002-2012*, married by 18 47.4

• Low birth weight (%) 2008-2012* 28• Early initiation of breastfeeding (%), 2008-2012*

40.5• Exclusive breastfeeding <6 months (%), 2008-2012*

46.4• Introduction of solid, semi-solid or soft foods 6-8

months (%), 2008-2012* 56.1• Breastfeeding at age 2 (%), 2008-2012*

76.8• Underweight (%) 2008-2012*, moderate & severe

42.5• Underweight (%) 2008-2012*, severe 15.8

• Stunting (%) 2008-2012*, moderate & severe 48

• Wasting (%) 2008-2012*, moderate & severe 19.8

• Overweight (%) 2008-2012*, moderate & severe 1.9

• Vitamin A supplementation full coverage (%) 2012 59

• Iodized salt consumption (%) 2008-2012* 71.

Conted.....pnuemonia

8%

preterm18%

asphyxia10%

sepsis8%

others2%

congenital5%

diarrhoea1%

diarrhoea11%

measles3%

meningitis2%

injuries4%

others12%

pnuemonia15%

CONTED.....· It is estimated that 14% of the 4.2 million HIV/AIDS cases are children below the age of 14.

· A study conducted by the ILO found that children of infected parents are heavily discriminated-35% were denied basic amenities and 17% were forced to take up petty jobs to augment their income.

· Child labor in India is a complex problem and is rooted in poverty.

· Data suggests that there are 11.28 million working children in India.

· Over 85% of this child labor is in the country’s rural areas and this number has risen in the past decade.

Govt initiativePriority interventions:1. Home-based newborn care and prompt referral2. Facility-based care of the sick newborn3. Integrated management of common childhood illnesses (diarrhea, pneumonia and malaria)4. Child nutrition and essential micronutrients supplementation & ICDS5. Immunization6. Early detection and management of defects at birth, deficiencies, diseases and disability in children (0–18 years)

Conted......• Other Schemes Include:

– Balika Samriddhi Yojana (BSY)– Kishori Shakti Yojana (KSY)– Nutrition Programme for Adolescent Girls (NPAG)– Early Childhood Education for 3-6 Age Group Children

Under the Programme of Universalization of Elementary

– Scheme for welfare of Working Children in need of Care and

– An Integrated Programme for Street children

Conted....– Child line Services– Central Adoption Resource Agency – Rajiv Gandhi National Crèche Scheme For the Children

of Working Mother – Programme for Juvenile Justice– General Grant-in-Aid Scheme– Pilot Project to Combat the Trafficking of Women and

Children for Commercial Sexual Exploitation in Destination Area

– Mid-day Meal Scheme– National Crèche Fund

• NEW COMPONENT• IFA to be distributed by

ASHA during doorstep delivery of contraceptives; IFA tablets to be given for 52 weeks each year

• As part of the antenatal care package, at all levels of health facilities , sub centre and outreach

•NEW COMPONENT•Weekly IFA supplementation (WIFS) for both adolescents boys & girls in Government/Government aided/municipal schools

• 6-60 months: IFA administered biweekly, on fixed days , under direct supervision of ASHAs ; 5-10 years: at AWC & through schools

Children Adolescent

Reproductive Age group

Pregnant & lactating women

Tribal healthINTRODUCTION: • Being among the poorest and most

marginalised groups in India, tribals experience extreme levels of health deprivation.

• The tribal community lags behind the national average on several vital public health indicators, with women and children being the most vulnerable

Conted....Definition:• A tribe is a distinct people, dependent on their

land for their livelihood, who are largely self-sufficient, and not integrated into the national society

Features of scheduled tribes• Show primitive traits• Have distinct culture• Shyness of contact with public at large• Geographical isolation• Social & economic backwardness• Pre- Agrarian technology• Stagnant or declining population

• Tribal constitute 8.61% of the total population (2011 Census) and cover about 15% of the country’s area.

• 75% of them reside in central India

Key indicators of tribal health

Sex ration & child sex ratioIndicator Sex Ratio (/1000 Female) Child Sex Ratio (/1000 Female)

2001 2011 2001 2011

Total populationTotal 933 943 927 919

Rural 946 949 934 923

Urban 900 929 907 905

Scheduled tribesTotal 978 990 973 957

Rural 981 991 974 959

Urban 944 980 951 940

Literacy rate

Conted.....

Nutritional status• Nutritional Status: • 46.6% ST women have BMI below 18.5, indicating a

high prevalence of nutritional deficiency.• 68.5 % (55%)of women and 39.6 % (25%) of men

are anemic – highest among all social groups • Only 21% of ST children age 12-35 months received

vitamin A supplements • Among children age 6-59 months, the figure drops

further to only 14.6%.

• 76.8% of ST children are anemic - 26.3 % mild, 47.2 % moderate & 3.3 % severe

Disease encounter

Communicable Disease:• Water borne and communicable diseases:• Gastrointestinal disorders are very common,

leading to marked morbidity and malnutrition.• Malaria and tuberculosis. • Spectrum of viral and venereal diseases.

Genetic disorders• High prevalence of genetic disorders mostly

involving red blood cells: Genetically transmitted disorders like sickle cell anemia.

• G6PD deficiency and different forms of Thalassaemia are also common

Mental health issues• 20/1000

• 11/1000 Depression • 3/1000 Hysteria

• 2/1000 Phobia

• 1/1000 Schizophrenia

• 0.4/1000 Mania

aids• 2.9/1000 per among tribes (2.8)

Govt initiative• Till June 30, 2006 there were 20097 sub-centre

functioning against a requirement of 28383 sub-centre for tribal areas.

• The number of functioning PHCs were 3260 against a requirement of 4180 and functioning CHCs were 446 against a requirement of 492.

• There are also 1122 Dispensaries and 120 Hospitals and 78 Mobile Clinics in Modern Medicine .

• 1106 Dispensaries and 24 Hospitals in Ayurveda.• 251 Dispensaries and 28 Hospitals in Homeopathy.

St welfare schemes• . Integrated Tribal Development Project• 2. Nursery-cum-Women Welfare Centre;• 3. Mid Day Meal Scheme• 4. Janshala Programme• 5. Tribal Alternate Education Programme 2002-2007• 6. Scheme of strengthening education among scheduled tribe girls in low• literacy districts• 7. Incentives for education• 8. Ashram schools• 9. Pre matric hostels• 10. Post matric hostels• 11. Grant in aid schemes for welfare of scheduled tribes• 12. Scholarships• 13. Tribes India• 14. National Overseas Scholarships• 15. Book Bank Scheme• 16. Central Sector Scheme for up gradation of merit of SC/ST students• 17. Tribal research centre

Mobile medical unitThe mobile medical unit comprises a doctor, lab

technician, nurse, auxiliary mid wife and driver. The vehicle is fitted with all necessary equipment, including, microscope and a mini-lab.

• Doctors will screen tribal people for diabetes, cardiac diseases, hypertension, symptoms of tuberculosis

Geriatric health• Most developed world countries have accepted

the chronological age of 65 years as a definition of 'elderly' or older person.

• it is many times associated with the age at which one can begin to receive pension benefits.

• At the moment, there is no United Nations standard numerical criterion, but the UN agreed cut off is 60+ years to refer to the older population.

CONTED.....• Elderly or old age consists of ages nearing or

surpassing the average life span of human beings. The boundary of old age cannot be defined exactly because it does not have the same meaning in all societies. Government of India adopted ‘National Policy on Older Persons’ in January, 1999. The policy defines ‘senior citizen’ or ‘elderly’ as a person who is of age 60 years or above.

CONTED.....• Both the share and size of elderly population

is increasing over time. From 5.6% in 1961 it is projected to rise to 12.4% of population by the year 2026. •

Health Status indicators

CONTED.....

CONTED.....

CONTED.....

CONTED.....

CONTED.....• Ministry of Social Justice & Empowerment -

nodal Ministry for policies and programmes for the Senior Citizens.

• Legislations The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 was enacted in December 2007.

• National Policy on Older Persons (NPOP), 1999• National Council for Older Persons

CONTED....• Central Sector Scheme of Integrated Programme

for Older Persons (IPOP) • Assistance for Construction of Old Age Homes • International Day of Older Persons • Ministry of Health & Family Welfare :Separate queues for older persons in

government hospitals.2 National Institutes on Ageing at Delhi and

Chennai have been set up Geriatric Departments in 25 medical colleges

have been set up.

disabled• A disability may be generally defined as a

condition which may restrict a person's mental, sensory, or mobility functions to undertake or perform a task in the same way as a person who does not have a disability.

• Disabled population in India 2.31%• (census- 2001)

Conted......• Types of disability:Physical - affects a person's mobility or dexterity Intellectual - affects a person's abilities to learnPsychiatric - affects a person's thinking processesSensory - affects a person's ability to hear or seeNeurological - results in the loss of some bodily

or mental functions

Conted...• People with disabilities have • same health needs • immunization,• cancer screening etc.• They may experience a narrower margin of health, because of

poverty and social exclusion.• vulnerable to secondary conditions, such as pressure sores or

urinary tract infections. • Evidence suggests that people with disabilities face barriers in

accessing the health and rehabilitation services they need in many settings.

Health status

Health status• Type of loco motor disability (% distribution)• Male Female All persons• Deformity of limb

46 44 45• Dysfunction of joints of limb

21 26 23 Paralysis 14 15 15 • Other (deformity of body)

9 10 10 Loss of limb 8 9 5

CONTED....• Prevalence of blindness per 1,00,000

population (NSS 58th round)• Male Female Person

• Rural 276 326 296• Urban 163 228 194

CONTED....• More than 60% reason of blindness acquired disability

due to three reasons –• old age (nearly 25%), • cataract (21%) • other eye diseases (more than 15%). Similarly about 70% of the persons with low vision also

acquired disability due to these same three reasons• cataract • and old age (nearly 30% each) and • other eye diseases (more than 10%).

Government Initiatives for ReAdressal of Disability in India

• National Policy for Persons with Disabilities, 2006

• Salient features– i) Physical Rehabilitation, which includes early detection and

intervention, counselling and medical interventions and provision of aids and appliances. development of rehabilitation professionals;

– ii) Educational Rehabilitation which includes vocational training; and

– iii) Economic Rehabilitation, for a dignified life in society.

CONTED.....• Disability Certificates• Components of Rehabilitation of Persons with

Disabilities : (i) provision of assistive aids and appliances (ii) education (iii) vocational training (iv) assistance for employment (v) training in or assistance for independent living

CONTED.....• Deen dayal Disabled Rehabilitation Scheme• Grant to NGOs under FYP (working for disabled)

MIGRANTS• India has a large number of international

migrants. About 5.1 million persons are migrants by last residence from across the international border in India (2001 census). Neighbouring countries are the main sources of origin of the international migrants to India with the bulk of these migrants coming from Bangladesh, followed by Pakistan and Nepal. But these are migrants who have entered the country legally

MIGRANTSEmployed in • cultivation and plantations,• brick-kilns,• quarries, • construction sites • and fish processing (NCRL, 2001).• urban informal manufacturing construction,

Conted....• services or transport sectors • casual labourers,• head loaders, • rickshaw pullers and• hawkers.

Conted.....• The rapid change of residence due to the

casual nature of work excludes them from the preventive care and their working conditions in the informal work arrangements in the city debars them from access to adequate curative care.

Health status• Poverty is a universal determinant of health • malnutrition,• a poor overall health status,• poor access to preventive and curative health

services, • and higher mortality and morbidity rates.

CONTED....• Migrants and mobile people become more vulnerable to

HIV/AIDS. By itself, being mobile is not a risk factor for HIV/AIDS. It is the situations encountered and behaviours possibly engaged in during the mobility or migration that increases vulnerability and risk. Migrant and mobile people may have little or no access to HIV information, prevention (condoms, STI management), health services.

• Source: International Organisation for Migration (2005), Health And Migration: Bridging the Gap, Geneva: International Organisation for Migration

Unique health problems of migrants

• Communicable diseases• Reproductive and child health• Violence against women• Child labour• 3-D jobs – dangerous, dirty and degrading. • Maladjustment – social & psychlogical

Govt initiatives• There is no specific schemes targeting the

migrant population• Though there are some NGOs working for

migrants e.g.

STATUS OF DALITS• Dalits one-sixth of the Indian population (160 million

approx).• Literacy rate 24 per cent.• meagre purchasing power; • poor housing conditions; • lack or have low access to resources and entitlements.• In rural India they are landless poor agricultural

labourers attached to rich landowners from generations or poor casual labourers doing all kinds of available work.

CONTED.....• In the city they are the urban poor employed as

wage labourers at several work sites, beggars, vendors, small service providers, domestic help, etc.,

• living in slums and other temporary shelters without any kind of social security.

• The members of these groups face systemic violence in the form of denial of access to land, good housing, education, health and employment.

Health status indicatorsIndicator value

Neonatal mortality

Infant mortality rate

Under 5 MR

% of children vaccinated with card

Home delivery

Disability proportion

46

66

88

34.8%

57.1%

2.20

Govt initiatives• Rashtriya swasthya bima yojana• Subsidized lone• Overseas education loans• Free health services for BPL family in public

and private sector hospitals

Conclusion• Looking upon the given facts we can very well

make out that the health status of an individual is significantly affected by his status in family, society, & community. Thus changing the social status of an individual or family will bring the change in health status of community.